Every finding on record at Creekside at the Springs

Based on observation, record review, and interview, it was determined that the facility failed to ensure a call light was kept within a resident's reach to allow the resident to summon assistance, and to provide prompt assistance to address a resident ' s pain and discomfort once requested for one (Resident # 62) of one sampled resident dependent on staff for assistance. The findings are: A review of an Admission Record indicated Resident #62 was admitted to the facility with diagnoses, which included heart attack and type 2 diabetes with diabetic neuropathy (a type of nerve damage that often affects feet and legs). The admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/25/2025, revealed Resident #62 had a Brief Interview for Mental Status (BIMS) score of 15, indicating Resident #62 was cognitively intact. The MDS revealed the resident had impairment in both lower extremities and used a walker and wheelchair for mobility. A review of Resident #62's Care Plan, initiated 04/22/2025, revealed the resident had an Activities of Daily Living self-care performance deficit related to limited mobility and weakness and required dependent assistance by two staff, via mechanical lift, during transfers. Interventions included to encourage Resident #62 to use their call light to alert staff if assistance was needed. A review of Resident #62's Care Plan initiated 04/23/2025 revealed the resident was at risk for falls related to gait/balance problems and weakness. Interventions included encouraging the resident to use the call light, or ask for assistance as needed, and to keep personal items within reach. The care plan indicated the resident had limited physical mobility due to weakness, and indicated Resident #62 required dependent assistance from one staff member for locomotion using their wheelchair. On 05/14/2025 at 8:32 AM, Resident #62 was overheard from the hallway, moaning and crying. Resident #62 was observed seated in a wheelchair in the resident ' s room. The resident was approximately three feet from the bed, with the bedside table placed in front of the resident. The resident was saying, I want to lay down. I'm hurting. The call light was observed wrapped around the bedrail. The surveyor asked if the resident was able to reach their call light to call for assistance. Resident #62 said, I don ' t even know where it is. The surveyor indicated where the call light was located, and Resident #62 reported they were unable to reposition themselves in order to reach the call light. The surveyor observed Resident #62 attempt and fail to reach the call device. On 05/14/2025 at 8:35 AM, when asked about Resident #62 moaning and crying, Licensed Practical Nurse (LPN) #2 said that (Resident #62) moans and cries out a lot. On 05/14/2025 at 9:00 AM, the surveyor observed Resident #62 continuing to cry out and ask for help getting back in bed. The resident said, I've been sitting here since 6:30 or 7:00 this morning. I want to go back to bed. LPN #2, who was present during this observation, said that the resident was able to use the call light and took the call light from around the side rail and placed it in the resident's lap. Resident #62 pushed the call light for assistance. At 9:20 AM Certified Nursing Assistant (CNA) #3 came into the resident's room. CNA #3 said that the resident's call light should have been within reach, but she did not get Resident #62 up this morning. During an interview on 05/14/2025 at 3:08 PM, Physical Therapy Assistant (PTA) #4 said their main goal was working on transferring so Resident #62 could discharge home. The resident had a fear of falling and would not even try to stand. During an interview on 05/14/2025 at 3:23 PM, LPN #2 said that Resident #62 would not help by standing, and required total assistance. During an interview on 05/14/2025 at 3:24 PM, CNA # 3 said that Resident #62 required a lift and was dependent on two staff. Review of a facility policy titled Answering the Call Light revised March 2021 indicated The purpose of this procedure is to ensure timely responses to the resident ' s requests and needs .5. When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident.

Based on record review and interview, the facility failed to ensure necessary care and services were provided including the monitoring of lab orders to ensure results were obtained in a timely manner, the physician was notified of results and treatment provided accordingly which resulted in hospitalization and subsequent death for 1 (Resident #70), as evidenced by: failure to monitor for return lab results; failure to appropriately assess and diagnose the symptoms of a urinary tract infection; failure to provide adequate treatment and services to reduce symptoms including confusion, disorientation, delusions, weakness, poor gait/imbalance, irregular heart rhythm and nausea which resulted in hospitalization and subsequent diagnosis of Sepsis for 1 (Resident #70) of 1 sampled resident with UA (urinalysis) culture orders. The failed practice resulted in Past Immediate Jeopardy, which caused or could have caused serious harm, injury, or death to Resident #70, who had a physician's order for lab including a urinalysis on 10/25/23. The failure to obtain the results caused a delay in treatment for 13 days which resulted in actual harm for Resident #70. The Administrator was notified of the Past Immediate Jeopardy on 2/7/23 at 4:05 PM. This failed practice had the potential to affect all residents residing in the facility. The findings are: 1. On 2/6/24 at 2:30 PM, a review of the electronic medical record revealed that on 10/24/23 the Advanced Practice Registered Nurse (APRN) placed a new order for an A1C (a blood test that measures your average blood sugar levels over the past 3 months), CBC (complete blood count, a blood test that measures many different parts and features of your blood), BMP (basic metabolic panel, a test that measures eight different substances in your blood), and an UA (urinalysis). The lab was sent to (Hospital) for processing. 2. On 2/6/24 at 2:50 PM, the Director of Nursing (DON) was asked to provide the results of the above ordered lab as they could not be found in the electronic medical record. The DON reported that the facility had made multiple attempts to obtain the results including multiple telephone calls with no results. That the APRN who ordered the lab did not have access to the electronic system used by the hospital which meant that she couldn't get the results. The Surveyor requested that action be taken to obtain the results on this date. The results were provided at 3:24 PM. The documentation revealed that on 10/28/23 the Culture results as determined by the hospital revealed Resident #70 had Escherichia coli (E coli). The lab results were not known by the facility until the resident was admitted to the hospital on 11/07/23. 3. On 11/1/23 a Nurses Note recorded: Resident not feeling well. Confused, disoriented, delusional, weak, poor gait and imbalance. Heart rhythm irregular. Pale pallor and fair turgor. Later reported nausea. Zofran admin per standing orders. Hydration encouraged frequently throughout the shift. Started Metformin on previous shift. CBG checked and resulted at 259. 4. On 11/1/23 at 16:29 a Nurses Note recorded: Verbal order for one liter of Sodium Chloride 0.9% solution at 80ml per hour times one bag. 5. On 11/1/23 at 16:34 a Nurses Note recorded: New order for NS 0.9% 1000ml intravenous @ 80ml/hr. 22 Cath to right forearm x 1 attempt. Patent to flush. Tolerated well. 6. On 11/5/23 at 15:22 a Nurses Note recorded: Resident continues to eat and drink very little 7. On 11/6/23 at 13:40 a Nurses Note recorded: Green drainage noted to bil [bilateral] eyes - clear nasal drainage noted - resident leaning forward with head down - is eating and drinking less - staff has tried to spoon feed resident with only a small amount 8. On 10/24/23 APRN new orders for A1C, CBC, BMP, and UA 9. On 10/31/23 a Nurses Note recorded: APRN new orders 1. Metformin 500 mg BID [2 times daily] with meals. 2. FSBS [Fasting Blood Sugar] daily times 14 then weekly times 4. 10. On 11/1/23 a Nurses Note recorded: Resident not feeling well. Confused, disoriented, delusional, weak, poor gait and imbalance. Heart rhythm irregular. Pale pallor and fair turgor. Later reported nausea. Zofran admin per standing orders. Hydration encouraged frequently throughout the shift. Started Metformin on previous shift. CBG checked and resulted at 259. 11. On 11/1/23 at 16:29 a Nurses Note recorded: Verbal order for one liter of Sodium Chloride 0.9% solution at 80ml per hour times one bag. 12. On 11/1/23 at 16:34 Nurses Note recorded: New order for NS 0.9% 1000ml intravenous @ 80ml/hr. 22 Cath to right forearm x 1 attempt. Patent to flush. Tolerated well. 13. On 11/5/23 at 15:22 a Nurses Note recorded: Resident continues to eat and drink very little 14. On 11/6/23 at 13:40 a Nurses Note recorded: Green drainage noted to bil [bilateral] eyes - clear nasal drainage noted - resident leaning forward with head down - is eating and drinking less - staff has tried to spoon feed resident with only a small amount eaten - very weak - often doesn't want to get out of bed - [Name] APRN saw resident with new orders noted. 15. On 11/6/23 at 15:26 a Nurses Note recorded: ZyrTEC Allergy Oral Tablet 10 mg 1 tablet by mouth one time a day for allergies. 16. On 11/6/23 at 19:05 a Nurses Note recorded: New skin condition. 17. On 11/6/23 APRN Note: sick visit CC/HPI THIS VISIT Chief Complaint/Reason for this Visit Sick visit HPI Relating to this Visit [resident's name] is in her room, supine on her bed. She has not been eating or drinking over the weekend. Her order for Zofran stopped the day after I started her on Metformin. She has BLE 2+ pitting edema with scattered fluid filled blisters on the dorsum of her feet. She does not feel well today. I am restarting her Zofran today and instructed [Name] to monitor the edema and blisters. Assessment & Plan: Malaise- monitor behavior and report deterioration; DM II - monitor dietary intake and check BG daily, report abnormal; Dehydration - Encourage free water intake. 18. ON 11/7/23 Hospital Admitting Note: Admit to [Hospital] Chief Complaint: Sepsis Sent to hospital due to increasing weakness and being sick for past month c/o weakness and body aches. No fever reported. Altered mental status decreased blood pressure. Vancomycin, IVPB (11/07/23 12:12 CST) Lactated Ringer Bolus, 1000 ML, IV Diagnoses: Sepsis, UTI FINAL REPORT from Hospital: Assessment/Plan: a. Sepsis likely due to UTI, awaiting culture results, provide IV hydration, currently on norepinephrine. Will begin IV merrem and vancomycin, stress dose steroids. b. UTI Patient had a previous urine culture 10/25 that results ESBL e.coli that she was not treated for at Creekside. c. Metabolic encephalopathy Likely secondary to sepsis d. Metabolic acidosis e. Hypocalcemia severe. Calcium 5.2, We will replete. Repeat CMP in AM f. Hypernatremia Sodium 148, will hydrate and repeat labs in AM. 19. On 2/7/24 at 7:46 AM, the DON was asked who is responsible for following up on ordered lab. The DON stated, ADON is responsible for the lab we have sent in. This went to the hospital. We never got the results. We called multiple times, but it wasn't written down. APRN is no longer with us. She did not have access to [hospital electronic records], which is the hospital's system. The DON was asked if anyone went to the hospital to get results. The DON stated, Not that I know of, I guess we didn't think of that. The DON reported that the Staff and APRN attributed increasing confusion to Dementia. The DON stated, [Resident #70] had been having a decline. The DON was asked when the staff became aware the lab/culture results were not in. The DON stated, We discussed it every day in stand up that we didn't have results. 20.On 2/8/24 at 10:00 AM the QAA plan was provided by the DON which was implemented on 11/9/23. Goal/Objective: To ensure timely receipt of UA C & S results; SPECIFIC ACTION STEPS: 1. New process for implementation of UA orders-will stay on order listing x 7 days; Person responsible: Nursing Team; Target Date of Completion: ongoing 2. Audit all UA orders x 2 months to ensure results received Person Responsible: DON/Designee; Target Date of Completion: ongoing 3. Request for UA results will be faxed and documented in clinical record; Person Responsible: Nursing Team; Target Date of Completion: ongoing 4. UA orders reviewed in morning start up to ensure timely receipt of results -will be followed up daily until results received; Person responsible: IDT team; Target Date of Completion: ongoing. 21. On 2/7/24 at 11:27 AM, the DON provided a Clinical Protocol for Lab and Diagnostic Test Results which documented, 1. When test results are reported to the facility, a nurse will first review the results. 3. A nurse will identify the urgency of communicating with the Attending Physician based on physician request, the seriousness of any abnormality, and the individual's current condition. IDENTIFYING SITUATIONS THAT WARREANT IMMEDIATE NOTIFICATION: 1. Nursing staff will consider the following factors to help identify situations requiring prompt physician notification concerning lab or diagnostic test results: 3. Whether the resident/patient's clinical status is unclear or he/she has signs and symptoms of acute illness or condition change and is not stable or improving, or there are no previous results for comparison. 22. On 2/7/24 at 4:21 PM a verbal plan of removal was provided by the Chief Nursing Officer. 23. On 2/8/24 at 8:53 AM the Plan of Removal was presented by the Administrator and the Director of Nursing. IJ- Plan of Removal for F 684 The facility failed to ensure lab results were obtained and treatment provided accordingly.'' Step #1: Corrective Action: A. Upon notification to the facility on [DATE] that an immediate jeopardy existed, the facility began auditing all resident charts @ 5:05pm to ensure that all current UA orders had results obtained and treatment provided accordingly and completed 2/7/2024. Step #2: Identification of others with the potential to be affected: On 2/7/2024, the facility IDT team pulled an order listing report @ 5:10pm for all UA orders from 10/25/2024 to 2/7/2024 to ensure results were obtained and treatment provided accordingly and completed 2/7/2024. Step #3: To ensure deficient practice does not occur: On 2/7/2024 @ 5:05p, the DON initiated an inservice for all licensed nursing personnel on duty and will continue ongoing inservice for all licensed staff prior to reporting for their next assigned shift to include: a. New process initiated on 11/9//23 regarding inputting UA orders in EHR [Electronic Health Records] With a 7 day stop date to ensure results were obtained. b. Obtaining UA/lab results after collection to ensure treatment if applicable. Step 4: Monitoring: DON/designee will audit UA/lab orders, using order listing report, daily to ensure results from UA/lab are obtained timely and treatment accordingly. Negative findings will be corrected immediately by DON/designee. Step 5: QA: A QAPI was first initiated on 11/9/2023. A second QAPI has been initiated to report on the above monitoring and auditing procedures. All findings from the QAPI will be presented at the monthly QAA meeting. Monitoring/auditing and reporting will continue for a minimum of three months. 24. On 2/9/24 at 9:10 AM, the Administrator was asked when she first became aware of the problem with receiving the lab results for Resident #70. She described that she is not always made aware of issues with lab, that lab is discussed in the morning nursing start up meeting but that those issues may not carry over into the full stand-up meeting which is attended by all of the facility department heads. The Surveyor asked who is responsible for ensuring that lab results are received. She stated, The ADON has been responsible, and the DON is ultimately responsible. Now the ADON will be responsible for routine lab and the Infection Nurse will be in charge of monitoring anything other than routine. I will also be attending the nurses meeting from now on. The Administrator confirmed that the in-serving of all licenses staff has been completed. 49071

Based on observation and interview the facility failed to ensure kitchen employees washed their hands and changed gloves between clean and dirty tasks; utilized food items were used prior to their expiration date to prevent food borne illness; the kitchen was clean and free of excess trash, grease, grime, and dust. The findings are: On 02/05/24 at 10:11 AM, two trays of cookies for the lunch meal were on the counter uncovered. On 02/05/24 AM at 10:12 AM, a large hard plastic container containing 4 one-pound packets of sliced turkey was in the 3-door refrigerator. The use by date located on the package was 1/19/23. Located on the same shelf was a resealable plastic bag containing 3 chicken strips. The bag had no date on it. On 2/5/24 at 10:17 AM, the top of a rack over the main worktable, which had skillets and other items hanging down from it, had a film of grease and grime to which dust had adhered. On 2/5/24 at 10:27 AM, upon entering the walk in freezer, the motor was observed on the top and to the left of the door. A large cascade of ice, 2 to 3 inches thick, was stuck to a hose that runs from the motor out of the top of the freezer. Water was observed in the bottom of the freezer. The floor of the freezer and the bottom shelf of the middle rack were covered in rust. On 2/5/24 at 10:40 AM, Dietary Aide #1 used gloved hands to obtain large cooking trays. She then retrieved a box of bread sticks from the walk-in freezer. She opened the box and placed the bread sticks on the tray with the same contaminated gloves. On 2/6/24 at 11:13 AM, the trash can adjacent to the hand washing sink was overflowing onto the floor. The lids of the receptacle remained open due to excess trash. Paper towels and discarded gloves were on the floor. On 02/07/24 at 10:58 AM, a large rectangle pan containing cinnamon peaches was on the worktable. The pan was uncovered and opened to air and contaminants. On 2/7/23 at 11:02 AM, a large, uncooked pork loin was laying on a cutting board on the worktable. Dietary Aide #1 picked up the raw meat with her gloved hands. Wearing the same gloves, Dietary Aide #1 placed the meat into a resealable plastic bag and then determined the bag was too small. Dietary Aide #1 removed the pork from the bag with the same gloves and placed it in a larger resealable plastic bag. Dietary Aide #1, wearing the same gloves contaminated with raw pork, sealed the bag, and placed it in a pan. Dietary Aide #1 then opened the door to the walk-in refrigerator with the same gloves and placed the pork into the refrigerator. On 2/8/23 at 11:09 AM, the hood above the range was covered in a film of grease and grime. Dust had adhered to the grease, giving the hood a textured appearance. The shelf above the range was also covered in dust and grime. On 2/8/24 at 11:14 AM, the floor between the deep fryer and the oven was shiny and covered in a layer of oil. Dust and food particles were to be stuck in the oil. On 2/8/24 at 11:50 AM, Dietary Aide #1 used gloved hands to obtain a can of chicken base from the shelf above the worktable. Dietary Aide #1 then retrieved a pitcher, carried it to the sink and added water. Dietary Aide #1 opened the container of chicken base and added some to the water. A spatula was then used to mix the chicken broth. Dietary Aide #1 then obtained two 1/4 steam table pans which contained pork loin. Dietary Aide #1 picked up tongs and used them to pick up the pork loin and place in the food processor. The pitcher was picked up by the handle and broth was added through the top of the food processer. The gloves were changed after the meat was poured from the food processor into a pan for the steam table. On 2/8/24 at 12:00 PM, Dietary Aide #1 opened the door to the range and removed a large tray of sweet potatoes from the oven using her gloved hands. After placing the tray on the worktable Dietary Aide #1 obtained a 1/2 steam table pan to hold the potatoes. With the same gloves, Dietary Aide #1 picked up a sweet potato and removed the skin and was then cut into fourths and placed into the pan. On 2/8/24 at 12:05 PM, Dietary Aide #2 with gloved hands opened the right door of the 3-door refrigerator and retrieved a clear plastic container which contained packages of deli ham and a container of sliced cheese. After placing the ham and cheese on the worktable Dietary Aide #2 returned to the refrigerator, opened the flap of a box containing 16-ounce blocks of butter. Dietary Aide #2 then reached into the box and brought out a block of butter. Dietary Aide #2 closed the door, moved to the first door, opened it, reached in, and retrieved a bag of bread. After placing the bread on the worktable, Dietary Aide #2 opened the bread bag, reached in, and got two slices of bread with the contaminated gloves. Dietary Aide #2 continued to assemble the sandwich, placing butter and bread in a skillet. Upon completion of the cooking process the sandwich was wrapped in aluminum foil. The sandwich was completed using contaminated gloves. Two boxes of frozen beef patties were observed on the worktable. Dietary Aide #2 continued to use the contaminated gloved hands to open the top of the box and retrieve the frozen beef patties and place them on a tray. On 2/8/24 at 12:30 PM, the lid of the trash can adjacent to the hand washing sink was held open by an excess of trash. The trash was overflowing, and paper towels and discarded gloves littered the floor. The large trash can next to the 3-compartment sink had trash protruding from the top, preventing the top from closing. On 2/8/24 at 12:34 PM, Dietary Aide #1 with gloves on carried a pan containing sweet potatoes to the worktable for pureeing. With the same gloves Dietary Aide #1 opened the right door of the 3-door refrigerator, reached in, pushed aside the flaps of a cardboard box, and retrieved a 16 ounce block of butter. Dietary Aide #1 then unwrapped the butter and placed it in a clear plastic container, opened the door to the microwave and placed the butter inside. After the butter was melted in the microwave, Dietary Aide #1 placed large pieces of baked sweet potato into the bowl of the food processor. Without removing the contaminated gloves, Dietary Aide #1 used a finger to push the sweet potatoes down into the bowl, so that the lid would close. On 2/8/24 at 12:50 PM, Dietary Aide #3 was filling plates on the tray line, with gloved hands. Dietary Aide #3 obtained insulated plate bases and insulated domes. Dietary Aide #3 held the plate with the thumb on the surface of the plate adjacent to the food items. Contaminated fingers were placed in the top of each insulated dome prior to being placed over the plate. On 2/8/23 at 12:55 PM, Dietary Aide #3 used contaminated gloves to break a dinner roll into small pieces and place it on a plate. When the Surveyor asked why the bread was broken into small pieces, Dietary Aide #3 stated, We do this for the mechanical softs. Sometimes when the bread isn't real soft, we break it up into pieces for them. This bread isn't very soft. On 2/8/24 at 1:20 PM, the Dietary Manager (DM) was asked to address the issue of breaking the dinner roll into small pieces for the residents who received a mechanical soft diet. The DM reported that the practice began some time ago and the Director of Nursing (DON) was where the instruction originated. On 2/8/24 at 2:12 PM, the Dietary Manager was asked when hands should be washed in the kitchen. The DM replied, When you first come in, whenever you change your gloves or after going from one thing to another. When the Surveyor asked when gloves should be changed. The DM described the need to change gloves between tasks. When the Surveyor asked about the importance of keeping the kitchen clean. The DM described her attempts to implement a new cleaning schedule. When the Surveyor asked who was responsible for taking out the trash in the kitchen. The DM identified the cook or the cook's aide.

Based on observation, record review, and interview, the facility failed to ensure call lights were within reach to enable residents to call for assistance to meet their needs for 2 (Residents #2, #37) of 20 residents who were able to use a call light on the 400 Hall. The findings are: a. On 02/5/24 at 10:21 AM, Resident #2, and Resident #37 had their call lights pinned to the curtain in between both residents. Resident #37's call light was clipped on the opposite side of the curtain not within sight of the resident. b. On 02/05/24 at 12:18 PM, Resident #2, and Resident #37 were both lying in their beds with their call lights pinned to the curtain separating the residents. Resident #37's was clipped on the opposite side of the curtain. c. On 2/5/24 at 3:57 PM, Resident #2, and Resident #37's call lights were both clipped to the dividing curtain and Resident #37's was clipped on the opposite side of the curtain not in sight of resident. d. On 2/6/24 at 10:34 AM, Resident #2, and Resident #37's call lights were both clipped to the dividing curtain and Resident #37's was clipped on the opposite side of the curtain not in sight of resident. e. On 2/8/24 at 9:14 AM, Licensed Practical Nurse (LPN) #1 was asked, where should a call light be located for a resident. LPN #1 confirmed, in their reach. The Surveyor asked if a call light should be clipped to the divider curtain out of both of the resident's reach. LPN #1 confirmed, no it should be in their reach. The Surveyor asked why is it important to have the call light in reach. LPN #1 confirmed, so they can ask for help, or if they are having an emergency they can alert staff, to let the staff know if they need them to do something for them. f. On 2/8/24 at 9:19 AM, the Surveyor asked LPN #2, where should a call light be located for a resident. LPN #2 confirmed, within their reach at all times. The Surveyor asked should a call light be clipped to a curtain. LPN #2 confirmed, no it is not ok. It should be in their reach. The Surveyor asked why is it important for the call light to be in the resident's reach. LPN #2 confirmed, so they can receive the assistance from staff that they need. g. On 2/8/24 at 9:33 AM, the Surveyor asked the Director of Nursing (DON) where should a call light be located for a resident. The DON confirmed, in their reach. The Surveyor asked should a resident's call light be clipped to a curtain out of reach of the resident. The DON confirmed, no it should not. The Surveyor asked why should a resident's call light be kept in reach. The DON confirmed, so they will have access to staff for care and needs. h. On 2/8/24 at 2:03 PM, a policy titled, Answering the Call Light, was provided by the Nurse Consultant. The policy documented, .General Guidelines .5. When the resident is in the bed or confined to a chair be sure the call light is within easy reach of the resident .

Surveyor: Young, [NAME] Based on observation and interview, the facility failed to provide a sanitary, uncluttered, odor free, and homelike physical environment to enhance quality of life for the residents in Rooms #102, #108, #109, #111 and #115 and 1 (Resident #417) of 1 sampled resident. The findings are: 1. On 02/05/24 at 11:05 am, room [ROOM NUMBER] had a television (TV) mounted on the wall. A white cable and 2 electrical wires were tangled together and hanging 2 feet down the wall to the electrical outlet above the counter where the sink is. 2. On 02/05/24 at 11:12 am, room [ROOM NUMBER] had a TV on the counter under the wall mounted soap dispenser. A white cable and an electrical wire ran under the mirror, over the paper towel dispenser into the cable outlet on the other side of the counter. A black metal box had various cords screwed into it. 3. On 02/05/24 at 11:15 am, room [ROOM NUMBER] had 3 black electrical cords hanging from the TV and down the wall 3 feet. A white cable was hanging from the ceiling and a white plastic hanger was hanging from the white cable. 4. On 02/08/24 at 08:36 am, room [ROOM NUMBER] had black electrical wires running from the back of the wall mounted TV to the electrical outlet 3 feet away. 5. On 02/08/24 at 08:47 am, room [ROOM NUMBER] had a black electrical wire running from the back of the TV down the wall 3 feet to the electrical outlet below the paper towel dispenser; a black cable running from the back of the TV down the wall and over the paper towel dispenser; and a white cable running over and to the other side of the mirror to a cable outlet on the wall. 6. On 02/08/24 at 02:17 pm, Certified Nursing Assistant (CNA) #1 was asked to come to Rooms #102, #108, #109, #111 and #115. CNA #1 was asked would you like cable and electrical wires running down the walls in your home? CNA #1 stated, No. The Surveyor asked would you consider these rooms to be homelike with cable and electrical wiring stretched across the wall? CNA #1 stated, I wouldn't think so. 7. On 02/08/24 at 02:25 pm, the Maintenance Supervisor was asked to come to Rooms #102, #108, #109, #111 and #115. The Maintenance Supervisor was asked, would you like cable and electrical wires running down the walls in your home? The Maintenance Supervisor stated, No. The Surveyor asked, would you consider these rooms to be homelike with cable and electrical wires running down the walls? The Maintenance Supervisor stated, I wouldn't consider them homelike, but it is something that we are working on. We are putting shelves up in the rooms. We just haven't gotten around to it yet. 46723 8. On 02/05/24 at 10:23 am, when entering the Secured Unit a very strong urine odor was noted. When entering room [ROOM NUMBER], the odor was stronger. 9. On 02/06/24 at 09:17 am, when entering the Secured Unit a very strong urine odor was noted. 10. On 02/07/24 at 01:53 pm, the Secured Unit continues to have a very strong urine odor. 11. On 02/08/24 at 09:35 am, the Secured Unit continues to have a very strong urine odor. 12. On 02/08/24 at 09:42 am, the Surveyor asked Registered Nurse (RN) #1, how do you ensure a room is free of any foul odors for the residents? RN #1 stated, When finished changing the resident's briefs we take the brief out of the room and dispose of it, sanitize mattresses, and use odor eliminator. The Surveyor asked how often are the resident's rooms cleaned and deep cleaned? RN #1 stated, The resident's rooms are cleaned daily by the CNAs and nurses. The deep cleaning is done monthly or as needed by housekeeping. 13. On 02/08/24 at 10:08 am, the Surveyor asked Licensed Practical Nurse (LPN) #3 how do you ensure a room is free of any foul odors for the residents? LPN #3 stated, Go into the room, smell it, and clean it. The Surveyor asked how often are residents rooms cleaned and deep cleaned? LPN #3 said housekeeping cleans weekly. 49071 14. On 02/05/24, during initial rounds the following observations were made: a. On 02/05/24 at 11:41 am, Resident #29 expressed that she felt like the walls were caving in on her and that her room was not like a homelike environment. b. On 02/06/24 at 08:44 am, Resident #29 was talking to the Social Worker about her room not being homelike and that she felt like the walls were caving in on her. c. On 02/07/24 at 11:45 am, Resident #29 voiced in the Resident Council meeting to that she felt like her room was not homelike, there are no pictures on the walls and no clock in my room or personal items in my room and I feel like the walls are just caving in on me. d. On 02/08/24 at 09:14 am, the Surveyor asked LPN #1, what should be in a resident's room to make it feel like a homelike environment? LPN #1 confirmed, their personal belongings. The Surveyor asked, if a resident tells you that they don't feel like their room is homelike and the walls are caving in, what should you do? LPN #1 confirmed, talk with the resident, and ask what can be done to make you feel like it is more homelike for you. e. On 02/08/24 at 09:21 am, the Surveyor asked LPN #2, what should be in a resident's room to make it feel more homelike? LPN #2 confirmed, pictures, stuffed animals, their personal items, blankets. The Surveyor asked, if a resident tells you they don't feel like their room is homelike and the walls are caving in on them, what would you do? LPN #2 confirmed, first I would take them out of the room to talk to them. I would also get the Social Worker involved, to see what we as a facility could do to make them feel like their room was more homelike. f. On 02/08/24 at 09:30 am, the Surveyor asked the Director of Nursing (DON), what should be in a resident's room to make it feel more homelike? The DON confirmed their personal belonging, family pictures and anything they bring from their home. The Surveyor asked, what if they don't come from home, or don't have a home? The DON confirmed we would talk to them about what the facility could do to make it more homelike for them. 15. On 02/05/24 at 10:21 am, Residents #2 and #37's room had a strong urine odor in the room and in the bathroom. a. On 02/05/24 at 12:18 pm, Residents #2 and #37's room had a strong urine odor in the room and in the bathroom. b. On 2/6/24 at 10:34 am, Residents #2's and #37's room had a strong urine odor in the room and in the bathroom. c. On 2/8/24 at 09:14 am, the Surveyor asked LPN #1, how do you ensure that a resident's room is kept free of foul smelling odors? LPN #1 confirmed, by cleaning it daily and making sure trash is taken out. The Surveyor asked, how often is a resident's room cleaned? LPN #1 confirmed, daily. The Surveyor asked, how often is a resident's room deep cleaned? LPN #1 confirmed, they have a deep cleaning schedule they go by, and I think it is weekly. d. On 2/8/24 at 09:21 am, the Surveyor asked LPN #2, how do you ensure that a resident's room is kept free of foul smelling odors? LPN#2 confirmed, make sure the trash is taken out, no food is left open, and that they have clean linen in place. The Surveyor asked, how often does housekeeping clean the resident room? LPN#2 confirmed, daily. The Surveyor asked, how often are the resident rooms deep cleaned? LPN#2 confirmed, they have a schedule they go by. e. On 2/8/24 at 09:30 am, the Surveyor asked the DON, how do you ensure that a resident's room is kept free of foul smelling odors? The DON confirmed, we do angel rounds, and me, and the Administrator, make several rounds throughout the day to ensure there are no odors. The Surveyor asked, how often are the resident rooms cleaned? The DON confirmed, daily. The Surveyor asked, how often are the rooms deep cleaned? The DON confirmed, they go by a schedule. f. On 2/8/24 at 09:35 am, a policy titled, Homelike Environment, was provided by the Nurse Consultant. The policy documented, Policy Statement Residents are provided with a safe, clean, comfortable, and homelike environment and encouraged to use their personal belongings to the extent possible. Policy Interpretation and Implementation .2. The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: .c. inviting colors and decor; d. personalized furniture and room arrangements; .3.b. institutional odors .

Based on observation, interview, and record review, the facility failed to ensure the resident's individualized care plan was updated to ensure appropriate care was received for 1 (Resident #24) of 1 sampled resident who did not have an intervention updated in the care plan. The findings are: 1. On 02/05/24 at 11:14 am, Resident #24 was sitting in a (specialized) chair with head leaned completely forward and to the right side. No support was provided to help support the resident's head and neck. 2. On 02/05/24 at 2:03 pm, surveyor observed Resident #24 was sitting in a (specialized) chair with head leaned forward and tilted to the right. No support was provided to help support the resident's head and neck. 3. The Care Plan with a revision date of 01/31/2024 did not address interventions for Resident #24's head leaning forward/ neck tilting to the right. 4. On 02/08/23 at 2:30 pm, the Surveyor asked Licensed Practical Nurse (LPN) #5, should Resident #24 have something to help support the head and neck? LPN #5 confirmed, yes, however we have tried pillows and towel rolls, but the resident keeps pulling them off. The Surveyor asked has this been care planned so staff would be aware? LPN #5 confirmed, well, I don't know, I haven't looked to see. The Surveyor asked who is responsible for care planning? LPN# 5 confirmed, the nurses and management team. 5. On 2/08/24 at 9:25am, the Surveyor asked the Director of Nursing (DON), should a resident's care plan be updated when interventions are put in place or if an intervention doesn't work? The DON confirmed, yes of course. The Surveyor asked who is responsible for making sure the care plan is updated? The DON confirmed, the Minimum Data Set (MDS) Coordinator and myself. 4. On 01/25/24 at 8:50 am, The Surveyor asked the Minimum Data Set (MDS) Coordinator, how do you know when to care plan something when it is added to a resident's care? The MDS Coordinator confirmed, in our morning meetings we discuss it. Also, I print out new orders, fall summary and risk data sheets each day. The Surveyor asked, who is responsible for care planning new interventions? The MDS Coordinator confirmed, I am. The Surveyor asked if a resident has a new intervention/order related to care put in place should it be care planned? The MDS Coordinator confirmed, yes it should. 5. On 02/09/24 at 08:46 am, the Administrator provided a policy titled, Care Plans, Comprehensive Person-Centered, which documented, .Policy Interpretation and Implementation .11. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change .

Based on observation, interview, and record review, the facility failed to ensure oral care was provided for 1 (Resident #3) of 5 (Residents #3, #10, #36, #39, and #65) sampled who were dependent for oral care. The findings are: a. On 2/5/2024 at 11:12 AM, Resident #3 was sitting in the geriatric chair. When Resident #3 talked, a thick buildup of gummy white residue on the resident's teeth and gums was visible. b. On 02/6/2024 at 10:13 AM, Resident #3 was taken to their room by a family member and received oral care. c. On 02/06/24 at 10:53 AM, Resident #3 was sitting up in geriatric chair eating a stuffed oatmeal cookie. Resident #3 had a thick gummy white residue on the teeth and gums. d. On 02/6/2024 at 10:13 AM, Resident #3 was taken to their room by a family member and received oral care. e. On 2/7/2024 at 9:47 AM, Resident #3 was sitting up in geriatric chair talking. Resident #3's teeth and gums had a thick gummy residue on them. f. Resident #3's Care Plan with an initiated date of 10/05/2022 documented Resident #3 required extensive assistance with personal hygiene and mouth care/oral care was to be provided every shift and as needed. Report any abnormal findings. Observe and report as needed for any signs/symptoms of oral/dental problems needing attention. Coordinate arrangements for dental care and transportation as needed/ordered. g. On 2/8/2024 at 9:30 AM, the Surveyor asked Registered Nurse (RN) #1 who was in charge of brushing teeth. RN #1 said, the floor nurses. The Surveyor asked how often is oral care done on the residents. RN #1 stated, First thing in the AM, after meals, and break, bedtime or once daily. The Surveyor asked why is oral care and teeth brushing done. RN #1 stated, Could cause gingivitis, need periodontal care, cause thrush, break teeth, cause pain, and cavities. h. On 2/8/2024 at 9:40 am, the Surveyor asked Licensed Practical Nurse (LPN) #3, who was in charge of brushing the resident's teeth. LPN #3 stated, The floor nurses. The Surveyor asked how often is oral care performed on residents. LPN #3 stated, Once daily. The Surveyor asked why is oral care and brushing teeth done. LPN #3 stated, Could cause infection that could get in the blood. i. On 2/8/2024 at 8:55 am, the facility policy titled, Teeth, Brushing, provided by the Administrator documented, .The purpose of this procedure is to assist the resident with oral hygiene . Preparation 1. Review the resident's care plan to assess for any special needs of the resident .

Based on observation, interview and record review, the facility failed to provide a pressure relieving device to 1 (Resident #29) of 1 sampled resident who did not have a pressure relieving device in the wheelchair. The findings are: 1. On 2/5/24 at 11:41am, Resident #29 was sitting in a wheelchair in the resident's room. Resident #29 said that the resident had previously had a wound on their bottom. It was healed now however, when the resident sits in the wheelchair it hurts the residents bottom. Resident #29's wheelchair did not have a cushion in it. The Surveyor asked, have you told anyone that you wanted a cushion in your wheelchair, and that your bottom hurt when you sat in your wheelchair? Resident #29 confirmed, yes, I told a nurse and I told someone in therapy, but they haven't gotten me a cushion yet. 2. On 2/7/24 at 12:40 pm, the Surveyor asked the Wound Care Nurse, if a resident who had previously had a wound on their bottom that is now healed complains that when they sit in their wheelchair that it hurts their bottom, should they have a cushion in their wheelchair? The Wound Care Nurse confirmed, absolutely, especially if they had breakdown previously however, everyone should have a cushion in their wheelchair. 3. On 2/8/24 at 9:33 am, the Surveyor asked the Director of Nursing (DON), should a pressure relieving device be in a wheelchair for a resident who has history of skin breakdown on their bottom, or is at risk for skin breakdown? The DON confirmed, absolutely, everyone should have a cushion in their wheelchair. 4. On 2/9/24 at 8:46 am, the Administrator provided a policy titled, Prevention of Pressure Injuries, which documented, .Support Surfaces and Pressure Redistribution 1. Select appropriate support surfaces based on the resident's risk factors, in accordance with current clinical practice. Device-Related Pressure Injuries 1. Review and select medical devices with consideration to the ability to minimize tissue damage, including size, shape, its application and ability to secure the device .3. For prevention measures associated with specific devices, consult current clinical practice guidelines .

Based on observation, interview, and record review, the facility failed to ensure expired medications were removed from the medication carts and medication rooms on 2 (Rose Hall and Green Hall) halls. The findings are: On 2/7/24 at 8:42 AM, the following observations were made in the [NAME] Hall Medication Room: i) One Foaming Hand Wash with an expiration date of 11/23. ii) One Hydrogen Peroxide 3% with an expiration date of 11/23. iii) One Peri Guard Ointment with an expiration date of 10/23. On 2/7/2024 at 8:50 AM, the Surveyor asked Licensed Practical Nurse (LPN) #4, what do you do with expired medications? LPN #4 stated, We enter them into the blue book with description, quantity, and expiration date. Then we put the expired medications in a locked container. Periodically, the Director of Nursing (DON) will come down and empty the container. On 2/7/2024 at 8:57 AM, the following observations were made in the [NAME] Hall Medication Cart: i) BindxNOW with an expiration date of 7/24/23, ii) Two Arginaid Powder with an expiration date of 1/21/24. iii) Deep Sea Saline with an expiration date of 8/23. On 2/7/2024 at 9:35 AM, the following observations were made in the Green Hall Medication Room: i) Wound Cleanser with an expiration date of 1/24. ii) Hand Sanitizer with an expiration date of 10/29/23. On 2/7/2024 at 9:42 AM, the Surveyor asked Registered Nurse (RN) #1, how often do you go through the medication room? RN #1 stated, Thoroughly once a month, and spot check weekly. On 2/7/24 at 9:47 AM, the Surveyor asked LPN #3, how do you dispose of narcotics when they expire? LPN #3 said, we contact the DON, and she comes to get them from us. Until she does, we keep them locked in the narcotic medicine drawer. On 2/8/2024 at 9:35 AM, the Nurse Consultant provided a Policy titled, Storage of Medications, . 3. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. 4.Discontinued, outdated, or deteriorated drugs or biological are returned to the dispensing pharmacy or destroyed .

Based on observation, interview, and record review, the facility failed to ensure the medication error rate remained below 5%. The findings are: On 02/07/2024 at 07:45 AM, the Surveyor observed Licensed Practical Nurse (LPN) #5 administer medication to Resident #17. LPN #5 applied arthritis cream to Resident #17's left knee as ordered. The Physicians Order failed to include an amount to be applied to the left knee for pain. LPN #5 gave two Acidophilus tablets to Acidophilus #17. The Physicians Order read to give 2 Acidophilus tablets but did not include a strength for the Acidophilus. LPN #5 administered a Multivitamin to Resident #17. The Physicians Order read to give a Multivitamin with minerals. The Surveyor asked how do you know how much of the arthritis cream to apply? LPN #5 said I just put an amount in my hand and rub it on the resident's knee. The Surveyor asked should there be a specific amount that you put on? LPN #5 confirmed, I guess but the order doesn ' t state an amount, so I just put some in my hand and apply it. The Surveyor asked, should an order have a dosage on it? LPN #5 confirmed, yes it should. The Surveyor asked if an order doesn ' t have a dosage on it what should the nurse do? LPN #5 confirmed, we should call the physician to get an amount and add it to the order. On 02/07/2024 at 08:41 AM, the Surveyor observed LPN #2 administer two medications. Acidophilus tablets to Resident #39. The Physicians Order read to give two Acidophilus tablets, but the order did not have a strength on it. On 02/08/2024 at 9:35 AM, the Nursing Consultant provided a document titled, Administering Medications, which documented, Policy heading Medications are administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation . 4. Medications are administered in accordance with prescriber orders .

Based on observation, record review and interview, the facility failed to ensure meals were served at temperatures that were acceptable to the residents to improve palatability and encourage good nutritional intake during 1 of 1 meal observed. The findings are: On 2/5/23 at 10:30 AM, during initial rounds, 3 residents complained that the food they receive is cold. They reported that breakfast is usually ok, but the other meals were cold. On 2/7/24 at 10:45 AM, a Resident Council meeting was held. During the meeting all 6 residents in attendance expressed dissatisfaction with the food and described it as poorly prepared and consistently cold. That it didn't matter if you eat in your room or in the dining room the food is cold. On 2/7/23 at 12:55 PM, Dietary Aide #3 was breaking a dinner roll into small pieces and placing the pieces on a plate. When the Surveyor asked why the bread was being pinched into small pieces, Dietary Aide #3 stated, We do this for the mechanical softs. Sometimes when the bread isn't soft, we break it up into pieces for them. This bread is kind of hard. On 2/7/24 at 1:12 PM, a test tray was filled and taken by this Surveyor and the Dietary Manager directly to the Conference Room. Upon entrance, the Dietary Manager removed the insulated dome and took the temperature of the food. The temperature of the roasted red potatoes was 123 degrees Fahrenheit; the baked sweet potato was 106 degrees Fahrenheit; the baked pork loin was 115 degrees Fahrenheit; the green bean casserole was 144 degrees Fahrenheit; and the green beans were 106 degrees Fahrenheit. On 2/7/23 at 1:15 PM, the Dietary Manager and 2 members of the Survey Team sampled the test tray. The items were room temperature. The pork loin was thin, dry, and over cooked. The meat was difficult to cut with the butter knife provided and was difficult to chew. The sweet potato was undercooked with a hard spot in the middle. On 2/8/23 at 2:12 PM, the Dietary Manager (DM) was asked to address the resident complaints concerning the temperature of the food. The DM was uncertain as to why the food was cold when served. The DM described checking the temperature of the food just prior to serving and reheating any item that wasn't hot enough. The DM was asked if the dietary department delivers the trays in carts or if the nursing staff comes for them. The DM described a system that frequently changed, and she could not identify how long it took for the trays to be delivered once they arrived on the hall.

Based on observation and interview, the facility failed to ensure residents with a physician's order for a pureed, or a mechanical soft diet, received food of the correct consistency to prevent choking. The findings are: On 2/7/24 at 11:35 AM, Dietary Aide #1 placed boneless pork loin in the bowl of the food processor, then placed the lid on the bowl and proceeded to chop the meat. After several minutes Dietary Aide #1 removed the lid and peered into the bowl. The meat in the bowl had been reduced to pieces, bite size or smaller. Dietary Aide #1 reached into the bowl and retrieved one large piece of pork that had failed to be chopped. Dietary Aide #1 placed the large piece in the bottom of the bowl and continued to blend the pork. When the food processor was stopped, the pork was in tiny, granular size pieces and looked like powder. On 2/7/24 at 12:55 PM, Dietary Aide #3 was breaking a dinner roll into small pieces and placing them on a plate. When the Surveyor asked why the bread was broken into small pieces, Dietary Aide #3 stated, We do this for the mechanical softs. Sometimes when the bread isn't real soft, we break it up into pieces for them. On 2/7/24 at 1:00 PM, Dietary Aide #3 filled bowls for a resident receiving a pureed diet. Dietary Aide #3 placed a scoop into the pan containing the pureed bread. Dietary Aide #3 brought the scoop out of the pan, careful to keep the scoop upright to prevent the pureed bread from pouring from the scoop prior to reaching the bowl. The pureed bread was poured from the scoop and into the bowl. The substance did not hold its shape. On 2/7/24 at 1:03 PM, Dietary Aide #3 placed a scoop into the pan containing pureed green beans. Dietary Aide #3 carefully brought the scoop up from the pan so that the serving of pureed green beans would remain in the scoop. As the scoop was held over the bowl the green bean mixture was poured into the bowl. The substance did not hold its shape. On 2/7/23 at 1:10 PM, Dietary Aide #3 placed a scoop of pork onto the plate which had been prepared for the residents who received a mechanical soft diet. The dry particles of meat scattered across the plate and required Dietary Aide #3 to use the scoop to scrape the meat particles back into a pile so that gravy could be put on top. On 2/7/23 at 1:20 PM, The Dietary Manager (DM) was asked to address the practice of pinching the dinner roll into small pieces for the residents who received a mechanical soft diet, and if it was the Registered Dietitian who instructed her to pinch/break the bread into small pieces for the residents who receive a mechanical soft diet. The DM reported that there was an email conversation concerning bread and that she believed the final instruction came from the Director of Nursing. The DM was asked what the correct consistency of pureed food was. She stated, Pudding. The DM was asked how large the pieces of meat should be for a resident receiving a mechanical soft diet. The DM described, Small, not ground but small. The DM was asked why it is important to provide residents who receive a pureed diet or a mechanical soft diet food that is the correct consistency. The DM stated, Because they could choke.

Based on observation, record review and interview, the facility failed to ensure the Quality Assurance and Performance Improvement Program (QAPI) Committee developed and implemented appropriate plans of action to prevent repeated deficiencies for: (F801) having qualified Dietary Staff; (F804) ensure meals were served at a temperature that were acceptable to residents to improve palatability and encourage good nutritional intake; (F805) ensure residents who have a physician order for a puree diet and a mechanical soft receive food in the correct consistency to prevent choking; and (F812) ensure kitchen staff wash their hands between clean and dirty task, and utilize food items prior to expiration date, to prevent food borne illness. These failed practices had the potential to affect 72 residents excluding Resident #39 who was an enteral feeding, as identified on the Midnight Census Report provided by The Administrator on 02/05/24 at 10:00 am. The findings are: 1. A Recertification survey was conducted on 02/09/24. During the survey, F801 was cited for the facility's failure to ensure qualified Dietary Staff. A review of the facility's Plan of Correction, with a correction date of 11/10/22 indicated: Step #1: Corrective Action: On 11/7/22, upon notification of deficient practice, the Administrator/Designee assessed qualifications of Dietary Manager. The Dietary Manager was swiftly enrolled in a CDM (Certified Dietary Manager) course by 11/14/2022, and she possesses 2+ years of dietary management in both the SNF (Skilled Nursing Facility) and restaurant setting. The facility's Registered Dietician was also put on notice to provide extra visits for additional support of the dietary department. No additional negative findings were noted. Step #2: Identification of others with the potential of being affected: On 11/7/2022, upon notification of deficient practice, Administrator/Designee through census audit identified that all residents have the potential to be affected by the deficient practice and immediately ensured that the current dietary manager was enrolled in a CDM course. Any negative findings were immediately corrected, and notification made to Administrator. Step #3: To ensure deficient practice does not recur: On 11/7/2022 Administrator/Designee and Dietary Manager signed an in-service provided by a corporate consultant regarding dietary manager educational requirements and qualifications. Step #4: Monitoring: Administrator/Designee will monitor CDM course progression, ensure completion, and will ensure that the facility's Registered Dietician visits regularly to provide additional support by observation and documenting on a monitoring form four times weekly until compliance is verified by OLTC (Office of Long Term Care). Any negative findings will be corrected immediately, and Administrator/Designee will be notified. Step #5: QA (Quality Assurance): Administrator/Designee will present any negative findings to the monthly QA committee for further review and recommendations. 2. A Recertification survey was conducted on 02/09/24. During this survey, F804 was cited for the facility's failure to ensure meals were served at a temperature that were acceptable to residents to improve palatability and encourage good nutritional intake. A review of the facility's Plan of Correction, with a correction date of 11/10/22 indicated: Step #1 Corrective Action: On 11/8/2022, upon notification of deficient practice, the Dining Service Director/Designee immediately ensured the following in order to prevent potential food borne illnesses and to improve palatability and encourage good nutritional intake: 1. Meals aren't left on steam table so long as to lose nutritive value, flavor & appearance. 2. Meals are held and served at acceptable temperatures. 3. Hot foods are maintained at or above a temperature of 135 degrees Fahrenheit, and cold foods are maintained at or below 41 degrees Fahrenheit. No additional negative findings were found. Step #2: Identification of others with the potential of being affected: On 11/8/2022, Dining Service Director/Designee through census audit immediately identified that all residents could be potentially affected by the deficient practice and immediately ensured the aforementioned Step 1 actions were taken. Any negative findings were corrected immediately. Step #3: To ensure deficient practice does not recur: On 11/8/2022, the Administrator/Designee in-serviced dietary staff on ensuring the following: 1. Ensuring meals aren't left on the steam table too long as to use nutritive value, flavor, or appearance. 2. Meals are being held and served at appropriate temperatures. 3. Hot foods are maintained at or above 135F (Fahrenheit), and cold foods are maintained at or below 41F Step #4: Monitoring: Dining Services Director/ Designee will monitor to ensure meal temping procedures and proper steam table procedures are followed appropriately by observation and documenting on a monitoring form 4 times weekly for 8 weeks or until compliance is verified by OLTC. Any negative findings will be corrected immediately, and Administrator/Designee notified. Step #5: QA: Dining Services Director/Designee will present any negative findings to the monthly QA committee for further review and recommendations. 3. A Recertification survey was conducted on 02/09/24. During this survey, F805 was cited for the facility's failure to ensure residents who have a physician order for a puree diet and a mechanical soft received food in the correct consistency to prevent choking. A review of the facility's Plan of Correction, with a correction date of 11/10/22 indicated: Step #1: Corrective Action: On 11/9/2022, upon notification of deficient practice, the Dining Service Director/Designee immediately ensured that puree food was blended to the correct consistency in order to promote good nutritional intake and prevent potential choking for residents requiring pureed diets. No additional negative findings were found. Step #2: Identification of others with the potential of being affected: On 11/9/2022, Dining Service Director/Designee through census audit immediately identified 5 residents on puree diet that could be potentially affected from the deficient practice and ensured that pureed food was blended to the correct consistency to prevent any complications. Any negative findings were corrected immediately. Step #3: To ensure deficient practice does not recur: On 11/9/2022, the Administrator/Designee in-serviced dietary staff on ensuring that pureed food items are blended to the correct consistency to promote good nutritional intake and to minimize the risk of choking or other complications for resident receiving a puree diet. Step #4: Monitoring: Dining Services Director/ Designee will monitor to ensure Puree food items are blended to an appropriate pureed consistency as required by observation and documenting on monitoring form 4 times weekly for 8 weeks or until compliance is verified by OLTC. Any negative findings will be corrected immediately, and Administrator/Designee notified. Step #5 QA: Dining Services Director/Designee will present any negative findings to the monthly QA committee for further review and recommendations. 4. A Recertification survey was conducted on 02/09/24. During this survey, F812 was cited for the facility's failure to ensure kitchen staff washed their hands/changed gloves between clean and dirty task, and utilized food items were used prior to the expiration date to prevent food borne illness. A review of the facility's Plan of Correction, with a correction date of 11/10/22 indicated: Step #1: Corrective Action: On, 11/7/2022, upon notification of deficient practice, the Dining Service Director/Designee immediately ensured the following in order to prevent potential contamination and potential food borne illnesses: 1. Foods stored in the kitchen freezer, refrigerators, and dry storage area were labeled and dated properly. 2. Foods in unit refrigerators were labeled and dated. 3. Clean dishes were stored properly. 4. Ice machines were maintained in a clean and sanitary condition. 5. Hot foods were maintained at or below 41 degrees F while awaiting service. No additional negative findings were found. Step #2: Identification of others with the potential of being affected: On 11/7/2022, the Dining Service Director/Designee through a census audit, immediately identified that all residents could potentially be affected by the deficient practice and ensured the above stated step 1 actions were immediately taken. Any negative findings were corrected immediately. Step #3: To ensure deficient practice does not recur: On 11/7/2022, the Administrator/Designee in-serviced all dietary staff on the following: 1. Foods stored in the kitchen freezer, refrigerators, and dry storage area must be labeled and dated properly. 2. Foods in unit refrigerators must be labeled and dated appropriately. 3. Clean dishes must be stored properly. 4. Ice machines must be maintained in a clean and sanitary condition. 5. Hot foods must be maintained at or below 41 degrees F while awaiting service. Step #4 Monitoring: Dining Services Director/ Designee will monitor to ensure the following through observation and documenting on monitoring form 3 times weekly for 8 weeks or until compliance is verified by OLTC. 1. Foods stored in the kitchen freezer, refrigerators, and dry storage area are labeled and dated properly. 2. Foods in unit refrigerators are labeled and dated. 3. Clean dishes are stored properly. 4. Ice machines are maintained in a clean and sanitary condition. 5. Hot foods are maintained at or below 41 degrees F while awaiting service. Any negative findings will be corrected immediately, and Administrator/Designee notified. Step #5: QA: Dining Services Director/Designee will present any negative findings to the monthly QA committee for further review and recommendations. 5. A QAPI policy provided by the Administrator on 02/05/24 at 10:30 am documented, .The objectives of the QAPI program are to .2. provide a means to establish and implement performance improvement projects to correct identified negative or problematic indicators . 6. On 02/09/24 at 10:57 am, the Administrator was asked, when a deviation from expected performance or a negative trend occurs how does the Quality Assessment and Assurance (QAA) committee know? The Administrator stated, The IDT [Inter Disciplinary Team] addresses potential problems in stand up [morning meeting to discuss what happened the day before] and stand down [afternoon meeting to talk about everything that happened that day]. The Surveyor asked, is there a mechanism for staff to report quality concerns to the QAA committee? The Administrator stated, They usually come tell me and then I discuss it with other members. The Surveyor asked, how does the facility decide which issues to work on? The Administrator stated, Our DON [Director of Nursing] was the one that came up with plan, she presents them to me, I agreed upon it, then take the concern to the rest of the committee. The Surveyor asked, how does the facility know that the corrective action has been implemented, is effective, and improvement is occurring? The Administrator stated, This week for our Immediate Jeopardy [IJ], our DON is monitoring daily. We have two assigned nurses to routine labs, and for infections. The DON is monitoring them and then I am monitoring the DON, and I will be in their start up meeting.

Based on observation and interview, the facility failed to ensure after eating lunch, 1 (Resident #24) of 1 sampled resident's face was cleaned and clothing changed before going into the sitting area to promote dignity and respect. The findings are: 1. On 2/5/24 at 11:02 am, Resident #24 was sitting in a specialized chair in the sitting area with the neck bent over and drainage coming from the mouth and nose running down onto the shirt. 2. On 2/5/24 at 12:27 pm, observed staff taking Resident #24 into the Dining Room for lunch. 3. On 2/5/24 at 1:11 pm, observed staff giving Resident #24 a bowl of spaghetti to begin eating. Resident #24 proceeded to spill spaghetti on the front of the shirt until a Certified Nursing Assistant (CNA) went by and placed a clothing protector on the resident. 4. On 2/5/24 at 1:28 pm, observed a CNA come and sit by Resident #24 to help assist in feeding the remainder of lunch. 5. On 2/5/24 at 1:43 pm, Resident #24's face was dirty with spaghetti sauce and the shirt had been wiped but had spaghetti sauce on the front of it with a wet spot on the right front from the drainage from the mouth and nose when a CNA pushed Resident #24 into the sitting area. 6. On 2/5/24 at 2:03 pm, a staff came into the sitting area to get Resident #24. Staff took Resident #24 to the bathroom and then took the resident to their room to lay down to rest. Resident #24's clothing was not changed, or face cleaned. 7. On 2/8/24 at 9:13 am, the Surveyor asked Licensed Practical Nurse (LPN) #1, if you observe a resident with food and drool on their face and clothing, what should you do. LPN #1 confirmed, take them to their room, wash their face and change their clothing. The Surveyor asked should a resident be left in a sitting area with other residents and visitors with food and drool on them. LPN #1 confirmed, no, they should not. 8. On 2/8/24 at 9:33 am, the Surveyor asked the Director of Nursing (DON) if you observe a resident with food on their face and drool and food on their clothing what should you do. The DON confirmed, take them to their room and change their clothing and clean them up. The Surveyor asked should a resident be left in a sitting area with other residents and visitors while having food on their face and clothing and drool on their shirt. The DON confirmed, absolutely not, never should that happen. 9. On 2/9/24 at 8:46 am, the Administrator provided a policy titled, Dignity, which documented, Policy Statement Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem . Policy Interpretation and Implementation 1. Residents are treated with dignity and respect at all times .

Based on observation, interview, and record review, the facility failed to ensure enteral feeding bags and containers were dated, and timed, when feeding was initiated for 2 (Resident #2 and #3) of 3 (Resident #1, #2, and #3) sampled residents who received nutrition via enteral tube feedings as documented on the Resident Matrix provided by the Administrator on 06/05/23 at 11:07 AM. The findings are: 1. Resident #2 had a diagnosis of Gastrostomy Status, Dysphagia, and Pneumonitis. The Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/02/23 documented Section K0510 Feeding Tube .while a resident . a. The Care Plan with a revision date of 03/05/23 documented, .ADL [activities of daily living] self-care performance deficit r/t [related to] CVA [Cerebral Vascular Accident] with left sided weakness .totally dependent on staff for eating .require tube feedings r/t Dysphagia .the resident depends on percutaneous endoscopic gastrostomy (peg tube) feeds and water flushes . b. The Physician Order with a start date of 05/04/23 documented, .enteral feed order every shift [named supplement] 1.5 @ [at] 65 ML/HR [milliliters per hour] continuous with 45 ML H20 [water] flushes Q Hour [every hour] . and .enteral feed order in the morning for weight loss 90 ml per peg . c. On 06/05/23 at 10:07 AM, Resident #2 was lying in bed, with a peg tube connected to a feeding pump and was running. A container labeled [named supplement] 1.5 containing 650 cc [cubic centimeters] of liquid was hanging with no name, rate, or date displayed on the bottle label. A clear bag containing 100 cc of clear fluid was hanging and running and was not labeled with Resident #2's name, rate, or date when the bottles were hung. d. On 06/05/23 at 11:45 AM, Resident #2 was lying in his bed, with a peg tube connected to a feeding pump and running. A container of [named supplement] 1.5 was hung and not labeled with a date, time, or rate. A clear bag with less than 100 cc's of clear fluid was hung and not labeled with a date, time, or rate. e. On 06/05/23 at 11:53 AM, the Surveyor asked Licensed Practical Nurse (LPN) #1, Is Resident #2's container of liquid nutrition/bag labeled and dated? LPN #1 replied, No, I've got to get new bags. 3. Resident #3 had diagnoses of Gastrostomy Status and Dysphagia. The Quarterly MDS with an ARD of 04/27/23 documented Section K0510 Feeding Tube .while a resident . a. The Care Plan with a revision date of 02/26/23 documented, . ADL self-care performance deficit r/t Cerebral Infarction and right sided hemiplegia and hemiparesis .NPO [nothing by mouth], totally dependent on staff for nutrition/hydration via (peg tube) . [named nutrition supplement] @ 60 ml/hr continuous .is dependent with tube feeding and water flushes .see md orders for current feeding orders . b. The Physician Order with a start date of 04/20/23 documented, .enteral feed order every shift for [named nutrition supplement] 1.5 .if [named nutrition supplement] unavailable . @ [at] 60 ML/HR with H20 [water] @ 75 ML Q2H [every 2 hours] continuous via dual flow pump . NPO diet NPO texture, for swallowing difficulties . c. On 06/05/23 at 10:06 AM, Resident #3 was lying in his bed with a peg tube connected to feeding pump and running. A container labeled [named nutrition supplement] containing 900 cc of liquid was hanging with no name, rate, or date displayed. The feeding pump was beeping and read .Feeding Complete. A clear bag containing 800 cc of clear fluid was hanging and running. The clear bag with clear fluid was not labeled with Resident #3's name, rate, or the date the containers were hung. d. On 06/05/23 at 11:43 AM, Resident #3 was lying in his bed, with a peg tube connected to a feeding pump and running. The feeding pump display read pump on hold-error and was beeping. A container of [named nutrition supplement] 1.5 with 900 ccs of liquid was hung and was not labeled with a date, time, or rate. A clear bag with 600 ccs of clear fluid was hung and was not labeled with a date, time, or rate. e. On 06/05/23 at 11:50 AM, the Surveyor asked LPN #1, Why was Resident #3's feeding pump beeping/on hold? LPN #1 replied, The pump wasn't cleared, it was on hold. The Surveyor asked, Was Resident #3 receiving nutrition while the pump was on hold? LPN #1 replied, No. The Surveyor asked, Are the containers of liquid nutrition and bags supposed to be labeled? LPN #1 replied, Yes. The Surveyor asked, What information are the containers of nutrition/bags supposed to be labeled with? LPN #1 replied, The time I hang it, the patient's name, the rate and room number. The Surveyor asked, Why should containers of formula/nutrition/bags be labeled and dated? LPN #1 replied, So we know when they are hung up. The Surveyor asked, Who is responsible for ensuring containers of liquid nutrition/bags are labeled and dated? LPN #1 replied, Nurses. The Surveyor asked, Is Resident #3's container of liquid nutrition/bag labeled? LPN #1 replied, No, it's not labeled. f. On 06/05/23 at 2:36 PM, the Surveyor asked the Director of Nursing (DON) what the peg tube container, bags and liquid nutrition be labeled with. The DON stated, The feeding, date, time and initials or signature. The Surveyor asked why they are to be labeled. The DON stated, So we know how long it has been hanging and when we need to change it. The Surveyor asked who was responsible for ensuring they were dated and labeled. The DON stated, The charge nurses on the hall. The Surveyor asked if staff had been trained in labeling feeding tube containers, bags, and liquid nutrition. The DON stated, We learn this in nursing school. The Surveyor asked what the expectation was of staff regarding following CMS guidelines and the facility policies and procedures. The DON stated, All staff are to abide by all policies and procedures at all times. g. On 06/05/23 at 2:43 PM, the Surveyor asked the Administrator what the expectations were for the staff regarding following the facility's policies and procedures. The Administrator stated, I am pretty black and white. I want them to follow it to a T. h. The facility policy titled, Enteral Tube Feeding via Continuous Pump provided by ADON on 06/05/23 at 11:05 AM documented, .5. On the formula label document initials, date and time the formula was hung/administered, and initial that the label was checked against the order . i. The facility policy titled, Enteral Feedings - Safety Precautions, provided by the ADON on 06/05/23 at 11:05 AM documented, .5. On the formula label document initials, date and time the formula was hung, and initial that the label was checked against the order .

Based on observation, interview, and record review, the facility failed to ensure the kitchen staff wore hairnets to keep hair from contacting exposed food, clean and sanitized equipment, utensils and linens, or unwrapped single-service articles in 1 of 1 kitchen. This failed practice had the potential to affect 77 residents who received meals from the kitchen as documented in the Resident Matrix provided by the Administrator on 06/05/23 at 11:07 AM. The findings are: a. On 06/05/23 at 9:17 AM., Dietary Assistant #1 was at the stainless preparation table in the kitchen wearing a ball cap and no hair net. The Surveyor asked, Do you have a hair net on? Dietary Assistant #1 replied, No. The Surveyor asked, Are you supposed to wear hair nets in the kitchen? Dietary Assistant #1 replied, Yes, I'm new. b. On 06/05/23 at 9:23 AM, Dietary Assistant #1 was cutting tomatoes without a hair net. c. On 06/05/23 at 9:24 AM, the Surveyor asked the Dietary Manager (DM), Are you supposed to wear hair nets while in the kitchen? The DM replied, I do not know. d. On 06/05/23 at 1:14 PM, the Surveyor asked the Infection Preventionist (IP) via a phone call when hair nets are to be utilized in the kitchen. The IP stated, At all times while in the kitchen. The Surveyor asked why hair nets were to be utilized. The IP stated, So you don't get hair and stuff in the residents' food. The Surveyor asked if kitchen staff had been trained or in-serviced on wearing hair nets. The IP stated, I personally have not done one. I did one on proper PPE [Personal Protective Equipment] and having it there, but it's been a while. e. On 06/06/23 at 2:43 PM, the Surveyor asked the Administrator when hair nets were to be worn in the kitchen. The Administrator stated, During preparation, but I want them on when they come in the door whether they are prepping or not. The Surveyor asked if the kitchen staff had been trained on wearing hair nets. The Administrator stated, Yes they have. The Surveyor asked what the expectations were for the staff regarding to following policy and procedures. The Administrator stated, I am pretty black and white. I want them to follow it to a T. f. The facility policy titled Cleaning and Sanitizing and Proper Hair Restraints, provided by the Administrator on 06/05/23 at 11:18 AM documented, .6. Employees must wear hair restraint when in food preparation areas.

Based on observation, interview, and record review, the facility failed to ensure privacy was provided during enteral bolus tube feedings to promote dignity for 1 (Resident #1) of 3 (#1, #2, and #3) sampled residents who received enteral tube feedings as documented on the Resident Matrix provided by the Administrator on 06/05/23 at 11:07 AM. The findings are: 1. Resident #1 had diagnoses of Anxiety Disorder and Bipolar Disorder. The Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/18/23 documented Section B0700 .rarely/never understood . and Section K0510 .Feeding tube .while a resident . a. On 06/05/23 at 2:05 PM, Licensed Practical Nurse (LPN) #1 administered medication and a bolus tube feeding to Resident #1 in his room with Registered Nurse (RN) #1 and Hospice RN/CM (RN/Case Manager) present. Staff/LPN/RN did not close the door or pull the privacy curtain during medication/nutrition administration, leaving Resident #1 exposed to the hallway. b. On 06/05/23 at 2:11 PM, the Surveyor asked RN #1, Why should the door be closed, or the privacy curtain be drawn when administering medications/liquid nutrition through a residents peg tube? RN #1 replied, It's their right and for dignity. The Surveyor asked, How are residents provided privacy during Activities of Daily Living (ADL's)/medication/nutrition administration through a peg tube? RN #1 replied, Door closed, and the privacy curtain drawn. The Surveyor asked, Did you close the door or pull the privacy curtain during the medication/nutrition administration for Resident #1? RN #1 replied, No, we did not. c. On 06/05/23 at 2:16 PM, the Surveyor asked the Hospice RN/CM why the door should be closed, or curtain drawn when administering medications and liquid nutrition. The Hospice RN/CM stated, For Privacy. The Surveyor asked if there was a reason the door remained open during Resident #1's administration of liquid nutrition. The Hospice RN/CM stated, No, one of us should have shut it. The Surveyor asked why a resident should be provided privacy during the administration of liquid nutrition. The Hospice RN/CM stated, Common respect. d. On 06/05/23 at 2:36 PM, the Surveyor asked the Director of Nursing (DON) why the door should be closed, or curtain drawn, when administering medications and liquid nutrition. The DON stated, To provide privacy. The Surveyor asked why residents should be provided privacy during the administration of liquid nutrition. The DON stated, It's a dignity issue. e. On 06/05/23 at 2:43 PM, the Surveyor asked the Administrator why doors should be closed, or curtains drawn, when administering medications and liquid nutrition. The Administrator stated, For privacy. The Surveyor asked what the expectations were for the staff regarding the following policies and procedures. The Administrator stated, I am pretty black and white. I want them to follow it to a T. f. The facility policy titled, Enteral Tube Feeding via Syringe (Bolus) provided by the ADON on 06/05/23 at 11:05 AM documented, .The purpose of this procedure is to provide nutritional support to residents unable to obtain nourishment orally .if the resident desires, return the door and curtains to the open position .

Based on observation and interview the facility failed to ensure the Dietary Manager (DM) had the necessary education and qualifications to meet the Centers for Medicare and Medicaid Services (CMS) minimum requirements to ensure nutritional needs and food safety needs were met for the 74 residents who resided in the facility and received trays from the kitchen. The findings are: a. On 11/07/22 at 09:03 AM, Dietary Employee (DE) #2 walked into the kitchen and the Surveyor introduced herself and asked if the Dietary Manager (DM) would be in later. DE #2 stated the facility did not have a DM and the Administrator was currently filling in as the DM until they found one. b. On 11/08/22 at 03:18 PM, The Surveyor asked the Administrator, When the DM would be available? The Administrator stated, We do not have a certified Dietary Manager. (Named) is the DM, but she is in training through [named] university. The Surveyor asked when the DM worked. The Administrator stated, She has been filling in in the evenings. The Surveyor asked the Administrator if they had a full time Dietician. The Administrator stated they have one that they could call if the Surveyor needed to ask her any questions. c. On 11/09/22 at 02:23 PM, the Surveyor asked the DM How often do dietary staff receive training for proper preparation of foods? The DM stated, I just took over. I am not sure. I was trained in the beginning. I ran everything past him [previous DM]. The DM explained that she is currently in training and has been covering the evening shift and has not had time to train the kitchen staff or oversee what they are doing.

Based on observation, interview, and record review, the facility failed to ensure a sufficient number of competent staff were employed to carry out the functions safely and effectively for 1 of 1 kitchen in the facility which fed 74 residents according to the Diet List provided by the Administrator on 11/7/22. The findings are: 1. On 11/07/22 at 08:58 AM, the Surveyor asked Dietary Employee (DE) #1 if the Dietary Manager (DM) was available. DE #1 stated DE #2 (the Cook), was available once she returned from taking out the trash. 2. On 11/07/22 at 09:03 AM, there was a sandwich in an open plastic bag with no date on the prep table. 3. On 11/07/22 at 09:03 AM, DE #2 walked into the kitchen, the Surveyor asked if the DM would be in later. DE #2 stated the facility did not have a DM and the Administrator was currently filling in as the DM until they found one. The Surveyor asked DE #2 to complete the kitchen tour with the Surveyor. DE #2 stated she was available if the Surveyor needed, but there was only two of us and one dish washer in the kitchen. 4. On 11/07/22 at 09:05 AM, there were 6 open plastic containers of spices on a shelf above a stainless-steel prep table with no designated received or opened date on the container. 5. On 11/07/22 at 09:09 AM, the Surveyor observed a plastic jug of vanilla dated 11/5, with no designation of a received date or open date, a plastic container of [NAME] Enchilada sauce with no lid and no date, a plastic container of tartar sauce dated 10/7, with no designation of a received date or open date, two plastic containers of [NAME] sauce marked opened 3/22, with no received date, and five cottage cheese plastic containers that did not contain cottage cheese and were not labeled or dated with the ingredients. 6. On 11/7/22 at 09:17 AM, there were open box of peas dated 8/30 with the bag not tied/sealed and whiteish grey ice crystals on the peas 7. - open box of pie dough dated 8/28 with the bag not tied/sealed and whiteish grey ice crystals on the dough 8. - open box of strawberries dated 9/27 with the bag not tied and whiteish grey ice crystals on the strawberries 9. - open box of cauliflower pieces dated 10/31 with the bag not tied and whiteish grey ice crystals on the cauliflower 10. - open box of cinnamon rolls dated 11/1 with the bag not tied and whiteish grey ice crystals on the rolls 11. - open box of roll dough dated 11/3 with the bag not tied 12. - plastic bag of tator tots with a black clip holding bag closed and not dated open boxes of food in the walk-in freezer with the enclosed bags not tied/sealed and whiteish grey ice crystals on the food. 13. On 11/7/22 at 09:23 AM, there was a plastic package of sliced ham and two bags of hotdog buns not dated, and a Ziploc bag of French toast dated 11/6 with no received date in the walk-in refrigerator. 14. On 11/7/22 at 09:28 AM, there was food in five plastic bins, in the original bags, with the tops cut off, not dated. 15. On 11/7/22 at 09:31 AM, there were two plastic containers of macaroni and rice with no date in the dry storage room. 16. On 11/7/22 at 09:36 AM, there were 3 open boxes of meat with the enclosed bags not tied/sealed and whiteish grey ice crystals on the foods, 1 Ziploc bag of undiscernible meat labeled chicken dated 10/19 covered in whiteish grey ice crystals, and five Ziploc bags of undiscernible meats dated 10/18 that were covered in whiteish grey ice crystals in the meat freezer of the dry storage room. 17. On 11/7/22 at 09:39 AM, The Surveyor used a white napkin to wipe a brown substance from the inside of the ice machine and showed DE #2. The Surveyor asked the DE #2 to describe the substance on the napkin and on the plastic divider in the ice machine. The DE #2 stated, It looks like brown mold. 18. On 11/7/22 at 09:45 AM, The Surveyor wiped the inside of the ice machine in the Blue Hall Dining Room with a white napkin, there was a thick, pink substance on it. No staff witnessed or commented. 19. On 11/08/22 at 03:18 PM, the Surveyor asked the Administrator, When would the DM be available? The Administrator stated, We do not have a certified Dietary Manager. (Named) is the DM, but she is in training through the [named University] of (named state). The Surveyor asked when the DM worked. The Administrator stated, She has been filling in in the evenings. 20. On 11/09/22 at 11:25 AM, DE #1 placed a wet sheet pan against other sheet pans under the prep counter and a wet pot turned upside down on top of another pot under the prep counter. 21. On 11/09/22 at 11:27 AM, DE #1 placed a wet stainless colander upside down on top of another colander under the prep counter. 22. On 11/09/22 at 11:29 AM, the Surveyor observed DE#2 puree the spaghetti, the meat sauce, and the breadstick all combined and not as separate foods, per the recipes. 23. On 11/09/22 at 11:41 AM, DE #1 removed a white plastic container with a lid, not sealed or closed, from the stainless standing refrigerator and removed the lid the remainder of the way and scooped chocolate pudding into cups. 24. On 11/09/22 at 12:23 PM, DE #2 poured the pureed cheesecake into bowls, she did not measure the pureed cheesecake. 25. On 11/09/22 at 12:40 PM, the Surveyor asked if the consistency of the mixed vegetable puree was too runny, DE #2 responded with I think it's ok. 26. On 11/09/22 at 12:44 PM, DE #2 placed the mixed vegetables puree in a steam table and checked the temperature. The puree was 106 degrees Fahrenheit (F). The Surveyor asked DE #2 What is the appropriate temperature for food to be held in the steam table? DE #2 stated, 140 degrees. The Surveyor asked, Were all foods the appropriate temperatures? DE #2 stated, Yes. The Surveyor asked the appropriate temperature for cold foods. DE #2 stated, 41 degrees. DE #2 took the temperature of a carton of milk which was 45.1 degrees F and left the milk cartons in the stainless pan on the line. 27. On 11/09/22 at 02:23 PM, the Surveyor asked the Dietary Manager (DM), How often do dietary staff receive training for proper preparation of foods? The DM stated, I just took over. I am not sure. I was trained in the beginning. I ran everything past him [named previous DM]. I think DE #1 was just nervous. The DM explained that she was currently in training and had been covering the evening shift and had not had time to train the kitchen staff or oversee what they were doing. 28. The Surveyor asked the DM, How should dishes, pots and pans be dried? The DM stated, Maybe with a certain chemical that dries them after they are clean. 29. On 11/7/22 at 03:20 PM, the two-week Dietary schedule for November, provided by the Infection Control Preventionist, designated which staff would perform the following tasks and functions of a kitchen which served 74 residents: a. the DM was scheduled as the DW [Dishwasher] on 11/10/22, 11/12/22, 11/17/22, and 11/22/22. b. a cook was assigned as the DW on 11/11/22, 11/15/22, 11/18/22, and 11/21/22. c. 3 staff (1 cook, 1 aide, and 1 DW) were scheduled 6a to 1p and 3 staff were scheduled 1p to 8p on 11/10/22,11/15/22, 11/18/22, 11/21/22, and 11/22/22. d. 3 staff (1 cook, 1 aide, and 1 DW) were scheduled 6a to 1p and 2 staff (1 cook and 1 aide) were scheduled 1p to 8p on 11/14/22, 11/16/22, and 11/23/22. e. 2 staff (1 aide and 1 DW) were scheduled 6a to 1p and 2 staff (1 cook and 1 DW) were scheduled 1p to 8p 11/12/22 and 11/17/22. f. 2 staff (1 cook and 1 DW) were scheduled 5a/7a to 1p and 4 staff (1 cook, 1 aide, and 2 DW) were scheduled 1p to 8p/7p on 11/13/22. g. No staff was scheduled prior to 1p, and 3 staff (1 cook, 1 aide, and 1 DW) were scheduled 1p to 8p on 11/11/22. h. 1 cook was scheduled 5a to 1p and 3 staff (1 cook, 1 aide and 1 DW) were scheduled 1p to 8p on 11/19/22. i. 1 DW was scheduled 7a to 1p and 3 staff (1 cook, 1 aide, and 1 DW) were scheduled 1p to 8p/7p on 11/20/22. j. A statement at the bottom of the schedule documented Employees get 2/15-minute breaks and 1/30 break which left no or 1 staff in the kitchen, for 1 or 2 hours, on 9 of the 14 days of the schedule provided (11/11/22, 11/12/22, 11/13/22, 11/14/22, 11/16/22, 11/17/22, 11/19/22, 11/20/22, and 11/23/22).

Based on observation, interview, and record review, the facility failed to ensure meals were not prepared and held on the steam table losing nutritive value, flavor, and appearance; meals were held and served at acceptable temperatures, hot foods were maintained at or above a temperature of 135 degrees Fahrenheit (F.), and cold foods were maintained at or below 41 degrees (F.) while awaiting service to prevent potential food borne illness and to improve palatability and encourage good nutritional intake during 1 of 1 meal observed for residents who received meals from 1 of 1 kitchen. These failed practices had the potential to affect 74 residents who received a tray from the kitchen, as documented on a list provided by the Administrator on 11/7/22. The findings are: 1. On 11/09/22 at 11:33 AM, Dietary Employee DE #2 placed the mechanical soft spaghetti mixture and mixed vegetables on the steam table. The Dietary Manager (DM) entered the kitchen. 2. On 11/09/22 at 11:43 AM, the DE #2 made a grilled cheese sandwich on the stove, (wrapped the grilled cheese sandwich) in foil and placed it on the steam table. 3. On 11/09/22 at 12:28 PM, DE #2 checked the steam table line temperatures. The pureed spaghetti, meat and bread mixture was 136.3 degrees F. DE #2 left it on the steam table. 4. On 11/09/22 at 12:30 PM, The lemon cheesecake was 48.3 degrees (F) and DE #2 threw it away and left the rest of the servings on the trays to be served. 5. On 11/09/22 at 12:44 PM, DE #2 placed the mixed pureed vegetables on the steam table and checked the temperature. They were 106 degrees (F). The Surveyor asked DE #2 What is the appropriate temperature for food to be held in the steam table? DE #2 stated, 140 degrees. The Surveyor asked, Were all foods at the appropriate temperatures? DE #2 stated, Yes. The Surveyor asked the appropriate temperature for cold foods. DE #2 stated, 41 degrees. DE #2 took the temperature of a carton of milk which was 45.1 degrees (F) and left the milk cartons in the stainless pan on the line to be served. 6. On 11/09/22 at 12:46 PM, DE #2 and DE #1 prepared food trays.

Complaint # (AR 694) was substantiated, all or in part with these findings. Based on observation, record review and interview, the facility failed to ensure supervision was provided to prevent accidents for 1 (Resident #1) of 6 (Residents #1 - #6) case mix residents who were transported in the facility van in the last 30 days. The facility failed to ensure staff correctly secured Resident #1 in the facility van, which resulted in the resident sliding out of the wheelchair when the driver braked suddenly. This failed practice resulted in Immediate Jeopardy, which caused or was likely to cause serious harm, injury or death to Resident #1, who fell out of his wheelchair on his face and abdomen, resulting in facial abrasions, and had the potential to cause more than minimal harm to 17 residents who were transported in the facility van in the last 30 days. The facility removed the Immediate Jeopardy situation prior to the survey entrance; however, current underlying deficient practice existed at the time of the survey. The facility was informed of the removed Immediate Jeopardy situation on 10/14/19 at 5:50 p.m. The findings are: 1. Resident #1 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/2/19 documented the resident scored 13 (13-15 indicates cognitively intact) on the Brief Interview for Mental Status (BIMS), was totally dependent on the assistance of two plus people for transfer, required extensive assistance of 2 plus people with bed mobility, and had functional limitation in range of motion to the upper and lower extremities on both sides. a. A Nurse's Note dated 10/9/19 at 11:42 a.m. and signed by the Assistant Director of Nursing (ADON) documented, This resident was being transported from the facility in the van to doctor appointment. Resident in wheelchair with seatbelt and secured straps in place. Transport CNA (Certified Nursing Assistant) reported to this nurse that a vehicle slammed on its brakes in front of her causing her to slam on her brakes to avoid impact. When she slammed on her brakes the resident slid out of his seat belt sliding down the middle aisle of the van coming to rest on his stomach and face . Transport CNA immediately checked the resident and called this nurse. She was advised to call 911 for assistance and to have the resident transported to ER (emergency room ) for evaluation. Transport CNA checked resident for any obvious injuries with abrasions noted to his face . Resident transported to (hospital) for eval (evaluation) and treatment as indicated. b. An Office of Long-Term Care (OLTC) Incident and Accident Report (I&A), Division of Medical Services (DMS) form 7734 dated 10/9/19 documented, (Resident #1) was being transported from the facility in the van to doctor appointment. Resident in wheelchair with seat belt and secured straps in place. Transport CNA (CNA #1) reported to this nurse that a vehicle slammed on its brakes in front of her causing her to slam on her brakes to avoid impact. When (CNA #1) slammed on her brakes the resident slid out of his seat belt sliding down the middle aisle of the van coming to rest on his stomach and face. Transport CNA immediately checked the resident and called this nurse. She was advised to call 911 for assistance and to have the resident transported to ER for evaluation. Transport CNA checked resident for any obvious injuries with abrasions noted to his face . Resident transported to (hospital) for eval and treatment as indicated. Witness statement being obtained from staff. (CNA #1) suspended pending investigation of this incident . c. An OLTC Witness Statement Form dated 10/9/19 and signed by CNA #1 documented, I was transporting (Resident #1) to his appt (appointment). The vehicle in front of me slammed on their brakes causing me to slam on mine to avoid impact. Upon pulling the facility van over safely, the resident was found towards the front of the van on his stomach. He had some abrasions to the left side of his face, but no other obvious injuries were noted at the time. ADON was notified and I was advised to call EMS (Emergency Medical Services). I stayed with the resident until EMS arrived and they transported him to (hospital) for evaluation. d. The hospital Emergency Department (ED) Physician Note dated 10/9/19 documented, (Patient) with [MEDICAL CONDITION] was being transported in a van (and was in a wheelchair). The van had to stop suddenly, and the patient reportedly fell forward out of the wheelchair and 'slid down the aisle of the van.' No L[NAME] (loss of consciousness). He has some pain over right facial area. Denies neck pain. No other area of reported pain . CT (Computed [NAME]ography) Facial bones: No fractures noted. e. On 10/14/19 at 9:47 a.m., CNA #1 was observed securing Resident #2 in a wheelchair in the facility van. The wheelchair was secured to the floor of the van using a restraint system with 4-point attachment hooks. A shoulder belt was attached at the back corner of the van, with the retracted portion of the belt coming out of a floor casing, and a lap belt portion that was separate. Two different shoulder belts were observed: one on the left side of the back of the van and one on the right. Signs were posted in both back corners of the van, which documented, Wheelchair Securement Location. The CNA placed the resident on the right side (driver side) of the van and properly secured her and the wheelchair. While doing this, the CNA began describing to the surveyor where she placed Resident #1 in the van when the incident occurred. She stated she placed him in the center of the back of the van instead of on the side. f. On 10/14/19 at 10:32 a.m., CNA #1 was asked to describe the incident involving Resident #1. She stated, I was taking him to a wound care appointment close to (Town #1). A vehicle in front of me slammed on their brakes, so I had to slam on mine. An EMT (Emergency Medical Technician) was behind me and saw me pull over to the side of the road and he assessed him . She was asked how long she had been doing transports for the facility and she stated, Since (MONTH) 2019. She was asked if she had been involved in any transport incidents before and she stated, No. She was asked how she was trained for the position of transport CN[NAME] She stated, (Maintenance Director) trained me on how to hook people up. She was asked if she was trained to hook people up in the middle area of the back of the van. She stated, No, and he will straight up tell you, 'I did not teach her to put someone in the middle.' And he's right. But when I came back from being off, the hook ups were set up in the middle, so I thought . hey, that's not a bad idea. At this time, the CNA and surveyor went back out to the facility van and the CNA obtained Resident #1's wheelchair to demonstrate how she secured it on the day of the incident. She stated, I am going to hook it up exactly like I had him hooked up. I'm just being honest. She placed the wheelchair in the middle area of the back of the van and secured it with the 4 securement hooks. She then placed the lap belt on what would be the resident's left side at the top of the arm piece, which prevented the belt from resting snug against the resident's pelvic area. She placed the lap belt on the resident's right side, also in a position high enough to where it could not rest on the pelvic area. She then pulled the shoulder belt from the back corner of what would be the resident's right side and connected it to the lap belt. The surveyor sat in the wheelchair to check the placement of the belts. The lap belt rested just below the Xiphoid process of the sternum, and the shoulder belt rested across the right upper Humerus area. (Photos were taken at this time.) g. On 10/14/19 at 10:54 a.m., the Maintenance Director was asked if CNA #1 was trained on hooking residents up in the middle section of the back of the van. He stated, No. Hooking somebody up in the middle never crossed my mind. I told her after this, 'don't do that because it's too far away from the shoulder strap'. Regardless, if the lap belt is properly placed, this would not happen. Even if you come to a sudden stop, you will bend at the waist instead of sliding out of the chair on the floor, if the belt is placed where it's supposed to be. At this time, the surveyor went to the maintenance office to watch the training video on the van's restraint system and how to secure residents in the wheelchair. The video stated, .The lap belt should never go over or around the arm rests, side panels or any other object that would hold the belt away from the passenger . It should be positioned low, across the front of the pelvis . Securement belts should follow a straight path from its retractor to its J-hook without bending around any part of the wheelchair . h. On 10/14/19 at 11:00 a.m., the Administrator provided a Driver Assessment Sheet dated 1/8/19 that documented CNA #1 had been checked off on driving skills, such as: .follows 1 sec (second) / 10 ft (feet) of vehicle length plus 2 secs identify / react time . maintains a space cushion around vehicle . does not exceed speed limit nor impede flow of traffic . demonstrates smooth acceleration and braking . i. On 10/14/19 at 12:15 p.m., CNA #1 was asked if she had ever used something like a check list to go by when hooking residents up in the van, as a safety check. She stated, I found some checklists in the desk. The guy that was the driver prior to me didn't tell me about a checklist. This guy trained me like in a day, but then (Maintenance Director) trained me better. I followed the other guy for one day and he didn't show me a whole lot. I just kind of rode with him. He didn't tell me about any paperwork. When we cleaned out his stuff, I found these check offs. I found these in the desk, and I think you do these with each resident, but I'm not sure. She was asked if she was ticketed by the police after the incident. She stated, No. The police never came because there was no impact or accident. Just the ambulance. She was asked if she watched a training video on the van's restraint system that went over how to properly secure residents in the wheelchair and van back in (MONTH) when she took the transport position. She stated, Yes, I watched the videos on YouTube on how to hook people up when I was trained. She was asked why she positioned the lap belt at the top of the arm rest on the resident's left side and she stated, Because his arm rest piece was close enough to the back of the wheelchair on that one side that it held the lap belt tight. At this time, the CNA and surveyor went back out to the van, and the CNA showed the surveyor where the resident was lying after on the van floor after falling out of the wheelchair. Based on where she stated his head was, the resident's head came to rest approximately 8 feet from the front of his wheelchair. (A photo was taken at this time). She was asked how fast she was going at the time of the incident and stated, I try not to ever speed in this thing, so I was going through a 45 (mile-per-hour) zone and I was doing no faster than 50. j. On 10/14/19 at 12:58 p.m., the Administrator provided a copy of the Transportation: Automobile/Van Safety Program Policy, which documented, .Make sure the resident has a lap belt/seat belt around them that is pulled across the resident's lap under the wheelchair armrest to fit snugly. k. On 10/14/19 at 3:18 p.m., the Director of Nursing (DON) and Administrator returned to the facility from transporting Resident #2 from school. The resident was observed secured in a wheelchair in the facility van. The resident's wheelchair was properly secured using the 4 attachment points; however, the lap belt was brought under the arm rest, between it and the side panel, then brought around the outside of the wheelchair wheels before being secured in the floor securement point. l. On 10/14/19 at 3:34 p.m., the DON was asked how she became aware of the incident involving Resident #1. She stated, (ADON) texted us. We were all headed to (Town #2) to a meeting. She told me there was an incident on the van, that (Resident #1) slid out of his wheelchair onto the van floor and that he was on his way to the ER. We were in a group text and they started talking to the (Administrator) after that . We suspended (CNA #1) . we are still doing the investigation. Friday, we called (CNA #1) up here and had her strap me into a wheelchair and we went on a trip around the block. I was secured. (Maintenance Director) watched her do this. As far as I know, she secured me properly. Before she took us on the trip, she had to re-watch the training videos and be checked off again by (Maintenance Director). She was asked if she had been trained on how to properly secure a resident in the van. She stated, Yes. She was asked about her positioning of the lap belt earlier on Resident #2, with it being between the arm rest and side panel of the wheelchair, and then around the outside of the wheels before being attached at the floor of the van. She gave the surveyor a copy of an instruction sheet on how to secure residents in the wheelchair in the van. She stated, This came out of the van book and it says it's okay to run the lap belt under the arm rest. She was asked if she was trained by the video produced by the van restraint manufacturer, or by this paper. She stated, Both, but it's been a while, and I've never had to actually secure someone without another person being with me that has been trained. m. On 10/14/19 at 4:15 p.m., the Administrator provided an Authorized Driver Basic Skills Validation form dated 3/3/18 that documented the DON had been checked off on skills that included: .Demonstrate ALL resident securement steps . n. On 10/14/19 at 5:34 p.m., Resident #4 was observed to be properly secured in the facility van by the Maintenance Director. The Maintenance Director was asked if CNA #1 watched the training video back in (MONTH) when she first took over the position of transport CN[NAME] He stated, Yes. I don't have anything that says she did, but she watched them. He was asked if the CNA actually had to go out and place a resident in the van and secure them, so he could see if she did it correctly and he stated, Oh yes. She strapped me in the wheelchair and drove me to (local department store). She did fine. He was asked if he or anyone else had made it a point to monitor the CNA since her initial training, to make sure she was consistently doing it correctly. He stated, No. Not since the initial training. o. On 10/15/19 at 9:37 a.m., the Administrator was asked how he became aware of the incident involving Resident #1. He stated, The ADON called us and told us what had happened. That (CNA #1) had called her, and she was on the side of the road and I believe she had already called EMS at that point. (ADON) was calling to tell us what had happened and to ask if it was a reportable. Of course, I said yes. The Business Office Manager and someone else went there to meet her on the side of the road because she was so upset. They brought the van back. I was in communication with (ADON) because she was in charge of handling it. I told her to suspend (CNA #1) and send in the reportable . We started gathering her witness statement before she left that day. The resident came back that afternoon without injury. Then we started our investigation. Got with (Maintenance Director) about the training. Pulled (CNA #1) in Friday to go over that with her, just to have her show us how she did it. (Maintenance Director) and (DON) went with her that day. That was part of our investigation. [NAME]orrow is the end of my 5-day investigation time frame. p. On 10/15/19 at 10:34 a.m., a representative for the van restraint manufacturer was contacted and asked about proper placement of the restraints. He stated, .We should always get the belt on the pelvic bone. That makes it difficult for the person to come out of the chair . The biggest reason people come out of the wheelchair is the lap belt being off the hip bone. q. On 10/15/19 at 12:16 p.m., the ADON was asked how she became aware of the incident involving Resident #1. She stated, (CNA #1) called me and let me know that a car had stopped in front of her and she had to slam on the brakes and that he was on the floor. I immediately told her to check him and call 911 and get the ambulance there. Then I let (Administrator) and (DON) and the doctor know immediately. (CNA #1) called me back several times telling me he was breathing fine and that she had an EMT sitting with them waiting for the ambulance . We just waited for the hospital to contact us and they called and said he was ready to come back . I did the reportable and sent it in. And since then, they have handled the rest of the paperwork. r. A facility policy titled, Doing It Right provided by the Administrator on 10/15/19 at 1:38 p.m., documented, .Securing the Occupant . Start by attaching the lap belt. Place the ends of the lap belt around the passenger. Thread them down through the opening between the side panel or the seat back and the seat cushion. Remember to position the lap belt around the occupant's pelvic zone near the hip . 2. On 10/14/19 at 5:40 p.m., the Administrator provided a list of interventions the facility had implemented to prevent recurrences related to the van incident: 1. Suspended van driver. 2. Started Abuse, Neglect, Misappropriation in-service. 3. Maintenance Supervisor is acting van driver. 4. DON, Maintenance Supervisor and van driver went on the van so van driver could show exactly what happened. 5. During investigation, it was determined that van driver placed resident in middle of back of van and not to the sides, therefore, we are including in our training that residents never be placed toward the middle of the van, but rather to the left or right side so that belts will fit better. 6. We are also implementing a check-off list to be filled out daily on van procedures and given to the Administrator daily. 7. Re-educated van driver on videos, policy and procedure, for proper wheelchair placement, locking, securing, as well as all other aspects of resident transportation.

Complaint # (AR 081) was substantiated with these findings: Complaint # (AR 117) was substantiated with these findings: Based on record review and interview, the facility failed to ensure a severely cognitively impaired resident with a history of agitation and combative behavior was free from staff-to-resident abuse for 1 (Resident #1) of 4 (Residents #1, #2, #4 and #5) case mix residents who resided on the facility's secure wing. The facility failed to ensure staff received training on dementia management and appropriate interventions to deal with aggressive and / or catastrophic reactions of residents, which resulted in a licensed nurse utilizing a takedown hold on Resident #1, an elderly resident with [MEDICAL CONDITION] and a history of aggressive behaviors. The failed practice resulted in immediate jeopardy which caused or could have caused serious harm, injury or death to Resident #1, and had the potential to cause more than minimal harm to 9 cognitively impaired residents with behaviors who resided on the facility's secure wing, as documented on a list provided by the Medical Records Clerk on 6/9/17. The facility was notified of the Immediate Jeopardy condition on 6/8/17 at 12:30 p.m. The findings are: Resident #1 was [AGE] years of age and was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Admission Minimum Data Set with an assessment reference date of 5/9/17 documented the resident scored 0 (0-7 indicates severe impairment) on a Brief Interview for Mental Status (BIMS); had signs and symptoms of [MEDICAL CONDITION] including inattention and disorganized thinking that were continuously present and did not fluctuate; exhibited physical behaviors toward others, verbal behaviors toward others and other behaviors not directed toward others on 1 to 3 of the last 7 days that significantly interfered with the resident's participation in activities or social interactions, significantly intruded on the privacy or activities of others and significantly disrupted care or living environment; exhibited rejection of care and wandering behaviors on 1 to 3 of the last 7 days, which significantly intruded on the privacy or activities of others; and required supervision with bed mobility, eating and toilet use. a. The Plan of Care dated as initiated on 5/4/17 documented, .Resident is at risk for behavioral issues due to DX (diagnosis) of Dementia, Alzheimer's. Resident has outburst of agitation, anger, aggressive at times and increased anxiety . If he/she becomes combative or resistive, stop task and/or leave the room, allowing time to calm, Observe resident closely during episode of behavior to keep resident and others safe and when he/she appears restless/agitated, observe for possible contributors, (pain, unmet physical need to void, hunger) through simple questioning, gestures, cues and assist with same. b. Nurses Notes dated 5/3/17 at 1:03 a.m. documented, Resident very confused. Can be combative, sits in floor, and gets up ad lib. Rubs the floor as if leaning. Up in hallway with pull-up only on. Very hard to redirect. Attempted to get in another resident's bed. Seldom speaks. Likes to get into everything. c. Nurses Notes dated 5/3/17 at 11:21 p.m. documented, Resident has been wandering up and down halls. In and out of other residents' rooms. No agitation noted. d. Nurses Notes dated 5/8/17 at 8:56 a.m. documented, Resident pacing hallways, opening all closed doors she can. She is going in and out of residents' rooms and am not able to redirect. When redirection is attempted she becomes agitated and started to swing her fist at staff. She also attempts to bite staff. Klonopin and [MEDICATION NAME] given. e. Nurses Notes dated 5/17/17 at 2:49 a.m. documented, Resident was trying to open snack and this nurse reached out to help but resident thought this nurse was trying to take it from her & (and) resident attacked this nurse. Was trying to hit and bite. This nurse was able to avoid being injured. Must explain what you are doing before trying to assist resident. f. Nurses Notes dated 5/28/17 at 3:36 p.m. documented, At 8:05 a.m., resident given [MEDICATION NAME] 0.5 mg (milligram) for increase signs of anxiety. Rapidly pacing up and down hallway. Getting agitated with staff looking for something but could not remember what it was. Not easily redirect. g. Nurses Notes dated 5/30/17 at 7:01 p.m. documented, Resident ambulating the hallways going in and out of other residents' rooms. She is wearing other residents' clothes. The CNA (Certified Nursing Assistant #1) came to her to help her get out of the others' clothes. And this resident slapped the CNA on the face and started screaming at the CNA. Was removed by this LPN (Licensed Practical Nurse) from CNA and sat her in the nearest chair and she started scratch and trying to bite me and the other CNA on the unit. Was taken out of the chair and placed on the floor on her tummy for resident safety. Called Dr. (name of Physician #1) and he said he couldn't help, to call (name of Physician #2). TC (telephone communication) made. (Physician #2) and a referral to a behavioral unit that has an available bed. h. A Witness Statement dated 5/31/17 by the Assistant Director of Nursing (ADON) documented, I was called up to Green Wing, upon arrival I heard a commotion. (CNA #1) was very upset holding the left side of her face with an ice pack. When I came around the Nurses' station I saw (LPN #1) sitting on the resident's buttocks with her hand on her back. She (resident) was able to twist her head . I knelt to assess the resident and found no injuries. (LPN #1) aide she had it under control but she needed assistance to get her an order for [REDACTED].#1), (LPN #4) came down from Green Wing crying stating 'I'm out of here'. I stopped (LPN #4) and asked her to talk to the DON, once again I call the DON and had her talk to (LPN #4) and 10 minutes later, I found out that she (LPN #4) had keys to Green Hall (medication) carts. The DON advised to call her back to finish out her shift. I got the keys from her and she left. When up on Green Wing, at some point, I threw my arms up in the air in disgust and said, 'This is not normal, this is not right'. An addendum dated 6/3/17 documented, On 5/30/17 at 6:51 p.m., I called my DON and I said, 'Hi, we have a situation up on Green Wing, where I have (LPN #1) sitting on a resident's back with her hand on her back, holding the resident to the floor. I have a CNA that was slapped and she was very upset and I need help with calming her down'. DON said she knew what was going on because she had already called her and after speaking with (CNA #1), I remained on the phone with the DON and told her about the abnormal maneuver and how wrong I thought it was and she said, 'Don't worry about it, this is part of the CPI training', both the DON and (LPN #1). (LPN #5) overheard my conversation with the DON and none of her instructions were to clock and walk the (LPN #1) (out of the building). After conversation with DON, (LPN #5) stated to me that 'I don't believe that was proper CPI training. (LPN #1) should've been clocked and walked out the door.' (LPN #5) then stated 'You have to do what your supervisor said to do'. i. On 6/1/17 at 3:39 p.m., the Director of Nursing was asked about the incident that occurred on 5/30/17 with Resident #1, LPN #1 and CNA #1. The DON stated that LPN #1 called her and stated that she had, .used a CPI (Crisis Prevention Intervention) hold and that the CNA was curled in the fetal position behind the Nurses' station. She stated she advised LPN #1 that she could not do that and that she needed to leave the building. j. On 6/1/17 at 3:40 p.m., LPN #2 stated she was working another wing when the incident occurred on 5/30/17. She stated she was told that the nurse up there was, getting beat up by (Resident #1). She stated when she walked into the secure wing, she saw the resident on the floor with the nurse sitting on her back. She stated she asked LPN #1, What do you need me to do? She stated LPN #1 asked her to assist the 7:00 p.m. to 7:00 a.m. (7p-7a) nurse to call the physician. She stated at this time, she could hear CNA #1 sobbing, so she took her out of the unit and down to her station. k. On 6/1/17 at 3:45 p.m., the Assistant DON was asked about the incident that occurred on 5/30/17 between Resident #1, CNA #1 and LPN #1. The ADON stated she was working on another hall and was paged to go the Nurses' station on the Blue Wing. She stated she could hear CNA #1 crying. She stated when she went to the Green Wing (secure wing) she saw LPN #1 sitting on the resident's back and using her hands to hold the resident's upper torso down. She stated she asked LPN #1 what she was doing and the LPN told her she was trained to do this. The ADON stated she then left the unit and called the DON. l. On 6/1/17 at 3:46 p.m., footage from the facility's security cameras was viewed, with the following findings (note: the footage does not include audio): According to the time stamp on the footage, on 5/30/17 at 5:36 p.m., Resident #1 approached the Nurses' Station and stood with her left arm and hand extended outward, grasping and slightly leaning on the door frame to the Nurses' Station. Within a few seconds, CNA #1 approached Resident #1 from behind and, instead of walking around the resident's right side to speak to the resident, the CNA grasped the resident's forearm from behind, removed the resident's hand from the doorframe, positioned herself between the resident and the doorframe, and began speaking to the resident. The resident turned and slapped the CNA on the left side of her face. The CNA went into the Nurses' station and LPN #1, who had been sitting at the Nurses' station, immediately got up, approached the resident and grasped the resident's upper arms with her hands, placed her face less than 1 foot away from the resident's face and began speaking to the resident. The resident pointed upward toward the LPN's chin, then pointed to her own chest, then pointed toward the Nurses' Station. As the resident pointed toward the Nurses' Station with her right hand, LPN #1 grasped the resident's right wrist and placed the resident's arm back down to the resident's side. The resident was not gesturing or resisting LPN #1 at this time. The LPN began to lead the resident toward a chair. The resident did not initially resist, then stopped, looked at the chair, said something to the LPN, turned toward the end of the hall and began to walk away. The LPN grabbed the resident's left arm and forcefully swung her around, back toward the chair. As the resident swung around, her upper back made contact with the wall, then the LPN forcibly placed the resident into the chair, with the resident's left leg and buttock making contact with the wooden chair arm as she descended into the seat. The resident attempted to get up, and LPN straddled the resident's legs, preventing her from rising. Another staff member assisted LPN #1 with keeping the resident in the chair. The resident was positioned with her right side over the right arm of the chair, with her ribcage resting on the chair arm and her buttocks in the seat of the chair. As the resident attempted to sit up, the LPN placed her elbow to the resident's left, posterior ribcage and prevented her from doing so. The resident continued to resist and the LPN placed her face directly in front of the resident's face, speaking to the resident. At 5:41 p.m., after the resident had been held in the chair for 5 minutes, the resident began to try to push the LPN away with her feet. The LPN attempted to take the resident down to the floor, causing the chair to flip onto its side. The resident's upper buttocks / coccyx area impacted the floor. The LPN forcibly rolled the resident onto her side, used her left knee to push the back of the resident's left leg down to the floor, and then straddled the resident. The LPN positioned herself over the resident's lower torso as she attempted to force the resident's upper torso into a prone position. After the resident was in a prone position, the LPN placed her own buttocks against the resident's lower back / upper buttocks and held the resident in place. The LPN placed her hands on the resident's upper back to keep the resident's upper torso pinned against the floor. The resident was held in this position for 13 minutes, until 5:54 p.m., when LPN #1 got off of the resident and sat on her knees, just to the right of the resident. At 5:55 p.m., LPN #1 patted the resident twice on the left hip / upper buttock area, then picked up the chair and placed it in an upright position against the wall. LPN #1 and another staff member then assisted the resident to get up off of the floor, placing their hands under the resident's axillary area and lifting the resident upward. They placed the resident in the chair and LPN #1 went to the computer behind the Nurses' Station at this time. At 5:57 p.m., the resident continued to sit in the chair with her head slumped forward toward her chest, as another staff member, LPN #4, stood next to the resident, rubbing the resident's back and hair, and speaking to the resident. LPN #4 then went behind the Nurses' Station and appeared to be crying. At 5:59 p.m., Resident #1 bent forward and placed her head on her hands, which were resting in her lap. The resident remained in this position until 6:03 p.m. At 6:15 p.m., the resident stood up and walked down the hall. She was stopped by a male resident in a wheelchair, who held the resident's hand and spoke to her. Resident #1 bent down and appeared to kiss the male resident on the cheek, then went into a room on the right side of the hall. The male resident in the wheelchair continued to sit outside the room, looking back and forth from the room to the staff at the Nurses' Station. At 6:17 p.m., the male resident entered the same room. At 6:23 p.m., LPN #1 and 3 additional staff entered the room, then 2 of the staff escorted Resident #1 out of the room and down the hall, into a room on the left side of the hall, with the 2 other staff members following behind. The resident did not appear to resist the staff as she was led down the hall. All 4 staff exited the room and returned to the area in or near the Nurses' Station at 6:26 p.m. m. A Witness Statement dated 6/2/17 by LPN #4 (the 7p-7a nurse) documented, I walked up to Green Wing and (LPN #1) was holding (Resident #1's) hands across over sitting in the chair, (LPN #1) was standing to the side of her. I went to clock in and came back up to the Green Wing (LPN #1) had (Resident #1) was laying on her belly and (LPN #1) was sitting on her back. She asked me to call (physician) but he didn't answer. Then (Dietary Employee #1) came up from kitchen and she took them into storage room and she hand me both sets of nurses' keys. We had not counted. I stayed and checked on (Resident #1) and she was breathing, and when I saw that she was ok, I became emotional and started crying and I had to leave. n. A Witness Statement dated 6/3/17 by LPN #2 documented, At approximately 6:00 p.m., (LPN #4) . informed me that she needed (ADON) and I stated 'she went that way' and pointed to the outside door. I asked (LPN #4) if she needed anything and she said 'the nurse on Green Wing is getting beat up by (Resident #1)'. I paged the ADON and handed (LPN #4) the phone. I went to Green Wing to see if I was needed. I saw a lot of residents gathered in the common area as I entered and as I rounded the corner I saw (LPN #1) across the resident's back. I asked (LPN #1) what I needed to do. I had been informed this Nurse was to be on Green Wing because she had CPI training by my supervisor. I went to help (LPN #4) call the doctor and heard screaming, which was (CNA #1) that had been hit by the resident I went to try to calm her with no success. I felt like she was causing more agitation among other residents and my ADON was on the unit so I felt I needed to get (CNA #1) off the unit. As I was walking out with the CNA, the ADON came by and she stated 'She can't do that in a nursing home.' I felt she was talking about (LPN #1) but unsure of procedures as I had been instructed that (LPN #1) was to be on Green Wing secondary her CPI training. I took (CNA #1) off of unit and ADON left unit to call the DON, the ADON asked me to listen to conversation and we attempted to calm (CNA #1). (LPN #5) was drawing up [MEDICATION NAME] and he and ADON was discussing protocols and what to do. (LPN #4) walked by crying as we were counting (narcotics). I had two of my Supervisors on the situation and both supervisors stated, 'She can't do that in a nursing home' and were discussing getting (LPN #1) out of the building. o. A Witness Statement dated 6/3/17 by LPN #5 documented, .The ADON came to me and talked to me briefly about what to do. I quickly told her to contact the DON and within a few minutes she was on the phone with the DON. I was handed the phone and I told the DON that what needed to happen was the LPN needed to be escorted to my office and given a drug screen and placed on administrative leave, pending an investigation, and relieved of her duties. I was then told by the DON that the nurse did nothing wrong, she used standard CPI procedures to de-escalate the situation. I was also told that the nurse (LPN #1) was trained in CPI and knew how to handle these situations. I then handed the phone back to the ADON. Then ADON, after getting off the phone, asked if I would assist her with an IM (intramuscular) injection with the resident (Resident #1) who punched the CNA. She then turned to me crying and said, 'I don't know what to do.' I told her that she needs to do what the DON instructed her to do and she told me that (LPN #1) had sat on the resident to subdue her . (LPN #1) repeatedly told her that this is what she does, that she is used to dealing with situations like this and that she had it under control. By this time, we arrived on the green wing, escorted the combative resident to her room and gave her 2 IM injections that the DON had received verbal orders for [MEDICATION NAME] 20 mg IM and [MEDICATION NAME] 2 mg IM. p. A Witness Statement dated 5/31/17 by the DON documented, May 30 at 6:37 p.m., I received a call for (CNA #1) who was crying hysterically I could not understand what she was saying at first all I heard was that she was slapped by a resident and she was hurting. When I asked her to calm down because it was difficult to understand her she became upset and hung up on me. At 6:39 p.m., I call the nurse on duty on Green (LPN #1) and asked her what was going on she stated 'I have it under control I will call you later and explain' and she hung up. I didn't feel good about it so I called the facility and (CNA #8) answered the phone and stated 'All hell has broke loose up here (Resident #1) slapped (CNA #1) in the face and she is crying and (LPN #1) is having to hold (Resident #1) down. I then asked to speak to (ADON) who was passing meds on another hallway. I asked (ADON) to go up to green and assess what was happening. (ADON) then called me back and said (CNA #1) is very upset she says her face hurts and she won't calm down. I spoke via conference call to (CNA #1). I then spoke to (ADON) and told her that I needed to know more about situation and she told me (LPN #1) was performing a CPI hold as (LPN #1) called it on (Resident #1) and some of the staff were very upset about it. I told (ADON) that we could not do CPI holds in a nursing home and she (LPN #1) would have to count narcotics and go home, The night nurse (LPN #4) had come in for report and I was told was upset . I called (LPN #1) and told her that she would have to count and go home and would be suspended until an investigation could be done. She was upset and stated 'I didn't do anything wrong I did a CPI hold.' I explained to her that those holds could not be performed in the nursing home. She stated 'I didn't know that sorry ok I understand I will count and go home'. q. LPN #1's time card documented the nurse clocked out on 5/30/17 at 9:01 p.m., over 2 hours after the incident occurred, based on the time of the incident as noted on the facility's video footage. On 6/1/17, LPN #1's personnel file was reviewed, and there was no documentation of any dementia care training or instruction on dealing with combative residents prior to being placed on the Green Wing to work with residents with severe cognitive impairment. There was also no documentation of reference checks with former employers. LPN #1's resume documented, .Worked at a regional women's community correction and men work release center from 2011 to 2017. r. On 6/8/17 at 2:25 p.m., CNA #2 was asked if she received training on dementia care and dealing with combative residents prior to being assigned to work on the secure wing. She stated, They did some training before they opened this wing, about 2 years ago. s. On 6/8/17 at 2:27 p.m., CNA #4 was asked if she received training on dementia care and dealing with combative residents prior to being assigned to work on the secure wing. She stated, The only training I got was when they opened this wing, about 2 years ago. t. On 6/8/17 at 11:55 p.m., CNA #5 was asked if she received training on dementia care and dealing with combative residents prior to being assigned to work on the secure wing. She stated, No, they gave me a pamphlet last week. u. On 6/8/17 at 12:10 p.m., CNA #6 was asked if he received training on dementia care and dealing with aggressive residents prior to being assigned to work on the secure wing. He stated, I have had training with Dementia and Alzheimer's, but not aggressive residents. v. At 12: 47 p.m., CNA #7 (employed with the facility for [AGE] years) was asked Have you received any training on how to deal with aggressive residents? She stated, Not really. w. On 6/8/17 at 11:20 a.m., LPN #2 (employed with the facility for 1 and 1/2 years) was asked, Have you had any training on how to care for patients with Dementia and aggressive behaviors? She stated, No, not until recently. x. On 6/8/17 at 12:45 p.m., LPN #6 was asked, Have you had any training on how to care for patients with Dementia and aggressive behaviors? She stated, Before they opened the Green Wing, about 2 years ago. y. On 6/8/17 at 9:55 a.m., the Interim Administrator (Regional Director of Operations) was asked if the facility provided dementia care training to CNAs and LPNs assigned to the secure wing. She stated, I don't know the answer to that. She was asked to provide documentation of any training at this time. As of 6/9/17 at 2:00 p.m., the facility had provided no documentation of dementia care training or education of staff on dealing with combative residents. z. The Immediate Jeopardy was removed and the scope/severity lowered to E on 6/8/17 at 2:30 p.m., when the facility initiated the following plan of removal: 1.) Beginning at 2:30 p.m., on June 8, 2017, staff will not clock in for work until training has been completed. All staff will be trained related to abuse / neglect/ misappropriation of resident property, reporting, protecting & investigating and behavioral management of agitated, combative residents including proper physical restraint use prior to the beginning of their shift. 2.) All nurses notes, incident reports, 24 hour reports and body audits will be reviewed by 5 p.m. Friday June 9th to ensure injuries of unknown origin, allegations of abuse, neglect misappropriation of resident property documented will be reported, residents protected and investigation initiated. 3.) All folders containing 7734s (forms for reporting abuse) and 762s (forms for documenting investigation results) will be reviewed for complete investigation and will be reopened if resident (s) were not protected, or investigation thorough by 5 p.m. Friday 9th. 4.) All residents will have a completed body audit within 48 hours to identify any injuries which might be consistent with abuse and any negative findings will be reported, the resident protected and investigation initiated. 5.) All staff will be interviewed to determine any knowledge of abuse / neglect / misappropriation of resident property by 5 p.m. Friday, June 9th. 6.) All residents with BIMS scores of 10 or above will be interviewed to determine any knowledge of abuse / neglect / misappropriation of resident property by 5 p.m., Friday, June 9th. 7.) All nurses notes, 24 hour reports, incident reports and body audits will be reviewed at clinical stand up and again at daily stand up meeting 5 times per week to ensure any potential abuse is not documented. 8.) Grievance / concern forms and monthly resident council meeting minutes will be reviewed for 6 months prior by noon on Friday, June 9th for any potential abuse documentation that needs action. All grievance / concern forms will be reviewed by the Administrator at daily stand up meeting 5 x (times) weekly and resident council meeting minutes will be reviewed each month by the Administrator. 9.) The Regional Clinical Manager will monitor all nurses notes, incident reports, 24 hour reports, body audits, grievance / concern forms, and resident council meeting minutes monthly to ensure any allegations of abuse / neglect / misappropriation of property is reported, the resident protected and the investigation initiated. 10.) The Regional Director of Operations will complete a review of each 7734, 762 and complete investigation prior to being sent to OLTC (Office of Long Term Care) to ensure protection and investigation was prompt and complete. 11.) All staff will receive specialized training for the unique needs and behaviors on the safe unit by June 17 by an outside consultant who specializes in dementia and behaviors. 12.) All staff who work on the safe unit will have competency checklists completed by June 17th and any new staff hired will receive the specialized training and competency checklist prior to their working on the safe unit.

Complaint # (AR 081) was substantiated with these findings: Complaint # (AR 117) was substantiated with these findings: Based on record review and interview, the facility failed to ensure staff implemented immediate protective measures to protect a resident from further potential abuse when multiple staff witnessed a licensed nurse utilizing a takedown hold on a severely cognitively impaired resident with a history of agitation and combative behavior for 1 (Resident #1) of 4 (Residents #1, #2, #4 and #5) case mix residents who resided on the facility's secure wing. The failed practice resulted in immediate jeopardy which caused or could have caused serious harm, injury or death to Resident #1, an elderly resident with [MEDICAL CONDITION] upon whom a licensed nurse utilized a takedown hold, and had the potential to cause more than minimal harm to 9 cognitively impaired residents with behaviors who resided on the facility's secure wing, as documented on a list provided by the Medical Records Clerk on 6/9/17. The facility was notified of the Immediate Jeopardy condition on 6/8/17 at 12:30 p.m. The findings are: Resident #1 was [AGE] years of age and was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Admission Minimum Data Set with an assessment reference date of 5/9/17 documented the resident scored 0 (0-7 indicates severe impairment) on a Brief Interview for Mental Status (BIMS); had signs and symptoms of [MEDICAL CONDITION] including inattention and disorganized thinking that were continuously present and did not fluctuate; exhibited physical behaviors toward others, verbal behaviors toward others and other behaviors not directed toward others on 1 to 3 of the last 7 days that significantly interfered with the resident's participation in activities or social interactions, significantly intruded on the privacy or activities of others and significantly disrupted care or living environment; exhibited rejection of care and wandering behaviors on 1 to 3 of the last 7 days, which significantly intruded on the privacy or activities of others; and required supervision with bed mobility, eating and toilet use. a. The Plan of Care dated as initiated on 5/4/17 documented, .Resident is at risk for behavioral issues due to DX (diagnosis) of Dementia, Alzheimer's. Resident has outburst of agitation, anger, aggressive at times and increased anxiety . If he/she becomes combative or resistive, stop task and/or leave the room, allowing time to calm, Observe resident closely during episode of behavior to keep resident and others safe and when he/she appears restless/agitated, observe for possible contributors, (pain, unmet physical need to void, hunger) through simple questioning, gestures, cues and assist with same. b. Nurses Notes dated 5/3/17 at 1:03 a.m. documented, Resident very confused. Can be combative, sits in floor, and gets up ad lib. Rubs the floor as if leaning. Up in hallway with pull-up only on. Very hard to redirect. Attempted to get in another resident's bed. Seldom speaks. Likes to get into everything. c. Nurses Notes dated 5/3/17 at 11:21 p.m. documented, Resident has been wandering up and down halls. In and out of other residents' rooms. No agitation noted. d. Nurses Notes dated 5/8/17 at 8:56 a.m. documented, Resident pacing hallways, opening all closed doors she can. She is going in and out of residents' rooms and am not able to redirect. When redirection is attempted she becomes agitated and started to swing her fist at staff. She also attempts to bite staff. Klonopin and [MEDICATION NAME] given. e. Nurses Notes dated 5/17/17 at 2:49 a.m. documented, Resident was trying to open snack and this nurse reached out to help but resident thought this nurse was trying to take it from her & (and) resident attacked this nurse. Was trying to hit and bite. This nurse was able to avoid being injured. Must explain what you are doing before trying to assist resident. f. Nurses Notes dated 5/28/17 at 3:36 p.m. documented, At 8:05 a.m., resident given [MEDICATION NAME] 0.5 mg (milligram) for increase signs of anxiety. Rapidly pacing up and down hallway. Getting agitated with staff looking for something but could not remember what it was. Not easily redirect. g. Nurses Notes dated 5/30/17 at 7:01 p.m. documented, Resident ambulating the hallways going in and out of other residents' rooms. She is wearing other residents' clothes. The CNA (Certified Nursing Assistant #1) came to her to help her get out of the others' clothes. And this resident slapped the CNA on the face and started screaming at the CNA. Was removed by this LPN (Licensed Practical Nurse) from CNA and sat her in the nearest chair and she started scratch and trying to bite me and the other CNA on the unit. Was taken out of the chair and placed on the floor on her tummy for resident safety. Called Dr. (name of Physician #1) and he said he couldn't help, to call (name of Physician #2). TC (telephone communication) made. (Physician #2) and a referral to a behavioral unit that has an available bed. There was no documentation in the Nurses' Notes that the resident was assessed for injury until 6/1/17 at 3:19 p.m., at which time the Nurses' Notes documented, Upon further evaluation, resident has bruise noted . 3 cm (centimeter) x (by) 3.5 cm circular right hip area. Nurses Notes dated 6/2/17 at 4:10 p.m. documented, Head to toe assessment performed. 2 cm purplish discolored area noted to right lateral forehead. 1 cm purplish colored bruise noted to posterior right upper extremity. 4 x 3 cm purplish bruise to anterior right hip. h. A Witness Statement dated 5/31/17 by the Assistant Director of Nursing (ADON) documented, I was called up to Green Wing, upon arrival I heard a commotion. (CNA #1) was very upset holding the left side of her face with an ice pack. When I came around the Nurses' station I saw (LPN #1) sitting on the resident's buttocks with her hand on her back. She (resident) was able to twist her head . I knelt to assess the resident and found no injuries. (LPN #1) aide she had it under control but she needed assistance to get her an order for [REDACTED].#1), (LPN #4) came down from Green Wing crying stating 'I'm out of here'. I stopped (LPN #4) and asked her to talk to the DON, once again I call the DON and had her talk to (LPN #4) and 10 minutes later, I found out that she (LPN #4) had keys to Green Hall (medication) carts. The DON advised to call her back to finish out her shift. I got the keys from her and she left. When up on Green Wing, at some point, I threw my arms up in the air in disgust and said, 'This is not normal, this is not right'. An addendum dated 6/3/17 documented, On 5/30/17 at 6:51 p.m., I called my DON and I said, 'Hi, we have a situation up on Green Wing, where I have (LPN #1) sitting on a resident's back with her hand on her back, holding the resident to the floor. I have a CNA that was slapped and she was very upset and I need help with calming her down'. DON said she knew what was going on because she had already called her and after speaking with (CNA #1), I remained on the phone with the DON and told her about the abnormal maneuver and how wrong I thought it was and she said, 'Don't worry about it, this is part of the CPI training', both the DON and (LPN #1). (LPN #5) overheard my conversation with the DON and none of her instructions were to clock and walk the (LPN #1) (out of the building). After conversation with DON, (LPN #5) stated to me that 'I don't believe that was proper CPI training. (LPN #1) should've been clocked and walked out the door.' (LPN #5) then stated 'You have to do what your supervisor said to do'. i. On 6/1/17 at 3:39 p.m., the Director of Nursing was asked about the incident that occurred on 5/30/17 with Resident #1, LPN #1 and CNA #1. The DON stated that LPN #1 called her and stated that she had, .used a CPI (Crisis Prevention Intervention) hold and that the CNA was curled in the fetal position behind the Nurses' station. She stated she advised LPN #1 that she could not do that and that she needed to leave the building. j. On 6/1/17 at 3:40 p.m., LPN #2 stated she was working another wing when the incident occurred on 5/30/17. She stated she was told that the nurse up there was, getting beat up by (Resident #1). She stated when she walked into the secure wing, she saw the resident on the floor with the nurse sitting on her back. She stated she asked LPN #1, What do you need me to do? She stated LPN #1 asked her to assist the 7:00 p.m. to 7:00 a.m. (7p-7a) nurse to call the physician. She stated at this time, she could hear CNA #1 sobbing, so she took her out of the unit and down to her station. k. On 6/1/17 at 3:45 p.m., the Assistant DON was asked about the incident that occurred on 5/30/17 between Resident #1, CNA #1 and LPN #1. The ADON stated she was working on another hall and was paged to go the Nurses' station on the Blue Wing. She stated she could hear CNA #1 crying. She stated when she went to the Green Wing (secure wing) she saw LPN #1 sitting on the resident's back and using her hands to hold the resident's upper torso down. She stated she asked LPN #1 what she was doing and the LPN told her she was trained to do this. The ADON stated she then left the unit and called the DON. l. On 6/1/17 at 3:46 p.m., footage from the facility's security cameras was viewed, with the following findings (note: the footage does not include audio): According to the time stamp on the footage, on 5/30/17 at 5:36 p.m., Resident #1 approached the Nurses' Station and stood with her left arm and hand extended outward, grasping and slightly leaning on the door frame to the Nurses' Station. Within a few seconds, CNA #1 approached Resident #1 from behind and, instead of walking around the resident's right side to speak to the resident, the CNA grasped the resident's forearm from behind, removed the resident's hand from the doorframe, positioned herself between the resident and the doorframe, and began speaking to the resident. The resident turned and slapped the CNA on the left side of her face. The CNA went into the Nurses' station and LPN #1, who had been sitting at the Nurses' station, immediately got up, approached the resident and grasped the resident's upper arms with her hands, placed her face less than 1 foot away from the resident's face and began speaking to the resident. The resident pointed upward toward the LPN's chin, then pointed to her own chest, then pointed toward the Nurses' Station. As the resident pointed toward the Nurses' Station with her right hand, LPN #1 grasped the resident's right wrist and placed the resident's arm back down to the resident's side. The resident was not gesturing or resisting LPN #1 at this time. The LPN began to lead the resident toward a chair. The resident did not initially resist, then stopped, looked at the chair, said something to the LPN, turned toward the end of the hall and began to walk away. The LPN grabbed the resident's left arm and forcefully swung her around, back toward the chair. As the resident swung around, her upper back made contact with the wall, then the LPN forcibly placed the resident into the chair, with the resident's left leg and buttock making contact with the wooden chair arm as she descended into the seat. The resident attempted to get up, and LPN straddled the resident's legs, preventing her from rising. Another staff member assisted LPN #1 with keeping the resident in the chair. The resident was positioned with her right side over the right arm of the chair, with her ribcage resting on the chair arm and her buttocks in the seat of the chair. As the resident attempted to sit up, the LPN placed her elbow to the resident's left, posterior ribcage and prevented her from doing so. The resident continued to resist and the LPN placed her face directly in front of the resident's face, speaking to the resident. At 5:41 p.m., after the resident had been held in the chair for 5 minutes, the resident began to try to push the LPN away with her feet. The LPN attempted to take the resident down to the floor, causing the chair to flip onto its side. The resident's upper buttocks / coccyx area impacted the floor. The LPN forcibly rolled the resident onto her side, used her left knee to push the back of the resident's left leg down to the floor, and then straddled the resident. The LPN positioned herself over the resident's lower torso as she attempted to force the resident's upper torso into a prone position. After the resident was in a prone position, the LPN placed her own buttocks against the resident's lower back / upper buttocks and held the resident in place. The LPN placed her hands on the resident's upper back to keep the resident's upper torso pinned against the floor. The resident was held in this position for 13 minutes, until 5:54 p.m., when LPN #1 got off of the resident and sat on her knees, just to the right of the resident. At 5:55 p.m., LPN #1 patted the resident twice on the left hip / upper buttock area, then picked up the chair and placed it in an upright position against the wall. LPN #1 and another staff member then assisted the resident to get up off of the floor, placing their hands under the resident's axillary area and lifting the resident upward. They placed the resident in the chair and LPN #1 went to the computer behind the Nurses' Station at this time. At 5:57 p.m., the resident continued to sit in the chair with her head slumped forward toward her chest, as another staff member, LPN #4, stood next to the resident, rubbing the resident's back and hair, and speaking to the resident. LPN #4 then went behind the Nurses' Station and appeared to be crying. At 5:59 p.m., Resident #1 bent forward and placed her head on her hands, which were resting in her lap. The resident remained in this position until 6:03 p.m. At 6:15 p.m., the resident stood up and walked down the hall. She was stopped by a male resident in a wheelchair, who held the resident's hand and spoke to her. Resident #1 bent down and appeared to kiss the male resident on the cheek, then went into a room on the right side of the hall. The male resident in the wheelchair continued to sit outside the room, looking back and forth from the room to the staff at the Nurses' Station. At 6:17 p.m., the male resident entered the same room. At 6:23 p.m., LPN #1 and 3 additional staff entered the room, then 2 of the staff escorted Resident #1 out of the room and down the hall, into a room on the left side of the hall, with the 2 other staff members following behind. The resident did not appear to resist the staff as she was led down the hall. All 4 staff exited the room and returned to the area in or near the Nurses' Station at 6:26 p.m. m. A Witness Statement dated 6/2/17 by LPN #4 (the 7p-7a nurse) documented, I walked up to Green Wing and (LPN #1) was holding (Resident #1's) hands across over sitting in the chair, (LPN #1) was standing to the side of her. I went to clock in and came back up to the Green Wing (LPN #1) had (Resident #1) was laying on her belly and (LPN #1) was sitting on her back. She asked me to call (physician) but he didn't answer. Then (Dietary Employee #1) came up from kitchen and she took them into storage room and she hand me both sets of nurses' keys. We had not counted. I stayed and checked on (Resident #1) and she was breathing, and when I saw that she was ok, I became emotional and started crying and I had to leave. n. A Witness Statement dated 6/3/17 by LPN #2 documented, At approximately 6:00 p.m., (LPN #4) . informed me that she needed (ADON) and I stated 'she went that way' and pointed to the outside door. I asked (LPN #4) if she needed anything and she said 'the nurse on Green Wing is getting beat up by (Resident #1)'. I paged the ADON and handed (LPN #4) the phone. I went to Green Wing to see if I was needed. I saw a lot of residents gathered in the common area as I entered and as I rounded the corner I saw (LPN #1) across the resident's back. I asked (LPN #1) what I needed to do. I had been informed this Nurse was to be on Green Wing because she had CPI training by my supervisor. I went to help (LPN #4) call the doctor and heard screaming, which was (CNA #1) that had been hit by the resident I went to try to calm her with no success. I felt like she was causing more agitation among other residents and my ADON was on the unit so I felt I needed to get (CNA #1) off the unit. As I was walking out with the CNA, the ADON came by and she stated 'She can't do that in a nursing home.' I felt she was talking about (LPN #1) but unsure of procedures as I had been instructed that (LPN #1) was to be on Green Wing secondary her CPI training. I took (CNA #1) off of unit and ADON left unit to call the DON, the ADON asked me to listen to conversation and we attempted to calm (CNA #1). (LPN #5) was drawing up [MEDICATION NAME] and he and ADON was discussing protocols and what to do. (LPN #4) walked by crying as we were counting (narcotics). I had two of my Supervisors on the situation and both supervisors stated, 'She can't do that in a nursing home' and were discussing getting (LPN #1) out of the building. o. A Witness Statement dated 6/3/17 by LPN #5 documented, .The ADON came to me and talked to me briefly about what to do. I quickly told her to contact the DON and within a few minutes she was on the phone with the DON. I was handed the phone and I told the DON that what needed to happen was the LPN needed to be escorted to my office and given a drug screen and placed on administrative leave, pending an investigation, and relieved of her duties. I was then told by the DON that the nurse did nothing wrong, she used standard CPI procedures to de-escalate the situation. I was also told that the nurse (LPN #1) was trained in CPI and knew how to handle these situations. I then handed the phone back to the ADON. Then ADON, after getting off the phone, asked if I would assist her with an IM (intramuscular) injection with the resident (Resident #1) who punched the CNA. She then turned to me crying and said, 'I don't know what to do.' I told her that she needs to do what the DON instructed her to do and she told me that (LPN #1) had sat on the resident to subdue her . (LPN #1) repeatedly told her that this is what she does, that she is used to dealing with situations like this and that she had it under control. By this time, we arrived on the green wing, escorted the combative resident to her room and gave her 2 IM injections that the DON had received verbal orders for [MEDICATION NAME] 20 mg IM and [MEDICATION NAME] 2 mg IM. p. A Witness Statement dated 5/31/17 by the DON documented, May 30 at 6:37 p.m., I received a call for (CNA #1) who was crying hysterically I could not understand what she was saying at first all I heard was that she was slapped by a resident and she was hurting. When I asked her to calm down because it was difficult to understand her she became upset and hung up on me. At 6:39 p.m., I call the nurse on duty on Green (LPN #1) and asked her what was going on she stated 'I have it under control I will call you later and explain' and she hung up. I didn't feel good about it so I called the facility and (CNA #8) answered the phone and stated 'All hell has broke loose up here (Resident #1) slapped (CNA #1) in the face and she is crying and (LPN #1) is having to hold (Resident #1) down. I then asked to speak to (ADON) who was passing meds on another hallway. I asked (ADON) to go up to green and assess what was happening. (ADON) then called me back and said (CNA #1) is very upset she says her face hurts and she won't calm down. I spoke via conference call to (CNA #1). I then spoke to (ADON) and told her that I needed to know more about situation and she told me (LPN #1) was performing a CPI hold as (LPN #1) called it on (Resident #1) and some of the staff were very upset about it. I told (ADON) that we could not do CPI holds in a nursing home and she (LPN #1) would have to count narcotics and go home, The night nurse (LPN #4) had come in for report and I was told was upset . I called (LPN #1) and told her that she would have to count and go home and would be suspended until an investigation could be done. She was upset and stated 'I didn't do anything wrong I did a CPI hold.' I explained to her that those holds could not be performed in the nursing home. She stated 'I didn't know that sorry ok I understand I will count and go home'. q. LPN #1's time card documented the nurse clocked out on 5/30/17 at 9:01 p.m., over 2 hours after the incident occurred, based on the time of the incident as noted on the facility's video footage. On 6/1/17, LPN #1's personnel file was reviewed, and there was no documentation of any dementia care training or instruction on dealing with combative residents prior to being placed on the Green Wing to work with residents with severe cognitive impairment. There was also no documentation of reference checks with former employers. LPN #1's resume documented, .Work at a regional women's community correction and men work release center from 2011 to 2017. r. On 6/8/17 at 2:25 p.m., CNA #2 was asked if she received training on dementia care and dealing with combative residents prior to being assigned to work on the secure wing. She stated, They did some training before they opened this wing, about 2 years ago. s. On 6/8/17 at 2:27 p.m., CNA #4 was asked if she received training on dementia care and dealing with combative residents prior to being assigned to work on the secure wing. She stated, The only training I got was when they opened this wing, about 2 years ago. t. On 6/8/17 at 11:55 p.m., CNA #5 was asked if she received training on dementia care and dealing with combative residents prior to being assigned to work on the secure wing. She stated, No, they gave me a pamphlet last week. u. On 6/8/17 at 12:10 p.m., CNA #6 was asked if he received training on dementia care and dealing with aggressive residents prior to being assigned to work on the secure wing. He stated, I have had training with Dementia and Alzheimer's, but not aggressive residents. v. At 12: 47 p.m., CNA #7 (employed with the facility for [AGE] years) was asked Have you received any training on how to deal with aggressive residents? She stated, Not really. w. On 6/8/17 at 11:20 a.m., LPN #2 (employed with the facility for 1 and 1/2 years) was asked, Have you had any training on how to care for patients with Dementia and aggressive behaviors? She stated, No, not until recently. x. On 6/8/17 at 12:45 p.m., LPN #6 was asked, Have you had any training on how to care for patients with Dementia and aggressive behaviors? She stated, Before they opened the Green Wing, about 2 years ago. y. On 6/8/17 at 9:55 a.m., the Interim Administrator (Regional Director of Operations) was asked if the facility provided dementia care training to CNAs and LPNs assigned to the secure wing. She stated, I don't know the answer to that. She was asked to provide documentation of any training at this time. As of 6/9/17 at 2:00 p.m., the facility had provided no documentation of dementia care training or education of staff on dealing with combative residents. z. The Immediate Jeopardy was removed and the scope/severity lowered to E on 6/8/17 at 2:30 p.m., when the facility initiated the following plan of removal: 1.) Beginning at 2:30 p.m., on June 8, 2017, staff will not clock in for work until training has been completed. All staff will be trained related to abuse / neglect/ misappropriation of resident property, reporting, protecting & investigating and behavioral management of agitated, combative residents including proper physical restraint use prior to the beginning of their shift. 2.) All nurses notes, incident reports, 24 hour reports and body audits will be reviewed by 5 p.m. Friday June 9th to ensure injuries of unknown origin, allegations of abuse, neglect misappropriation of resident property documented will be reported, residents protected and investigation initiated. 3.) All folders containing 7734s (forms for reporting abuse) and 762s (forms for documenting investigation results) will be reviewed for complete investigation and will be reopened if resident (s) were not protected, or investigation thorough by 5 p.m. Friday 9th. 4.) All residents will have a completed body audit within 48 hours to identify any injuries which might be consistent with abuse and any negative findings will be reported, the resident protected and investigation initiated. 5.) All staff will be interviewed to determine any knowledge of abuse / neglect / misappropriation of resident property by 5 p.m. Friday, June 9th. 6.) All residents with BIMS scores of 10 or above will be interviewed to determine any knowledge of abuse / neglect / misappropriation of resident property by 5 p.m., Friday, June 9th. 7.) All nurses notes, 24 hour reports, incident reports and body audits will be reviewed at clinical stand up and again at daily stand up meeting 5 times per week to ensure any potential abuse is not documented. 8.) Grievance / concern forms and monthly resident council meeting minutes will be reviewed for 6 months prior by noon on Friday, June 9th for any potential abuse documentation that needs action. All grievance / concern forms will be reviewed by the Administrator at daily stand up meeting 5 x (times) weekly and resident council meeting minutes will be reviewed each month by the Administrator. 9.) The Regional Clinical Manager will monitor all nurses notes, incident reports, 24 hour reports, body audits, grievance / concern forms, and resident council meeting minutes monthly to ensure any allegations of abuse / neglect / misappropriation of property is reported, the resident protected and the investigation initiated. 10.) The Regional Director of Operations will complete a review of each 7734, 762 and complete investigation prior to being sent to OLTC (Office of Long Term Care) to ensure protection and investigation was prompt and complete. 11.) All staff will receive specialized training for the unique needs and behaviors on the safe unit by June 17 by an outside consultant who specializes in dementia and behaviors. 12.) All staff who work on the safe unit will have competency checklists completed by June 17th and any new staff hired will receive the specialized training and competency checklist prior to their working on the safe unit.

Complaint # (AR 081) was substantiated with these findings: Complaint # (AR 117) was substantiated with these findings: Based on record review and interview, the facility failed to ensure a policy and procedure was developed and implemented to provide staff training on dementia management, to include appropriate interventions to deal with aggressive and / or catastrophic reactions of residents, in order to prevent an incident of staff-to-resident abuse for 1 (Resident #1) of 4 (Residents #1, #2, #4 and #5) case mix residents who resided on the facility's secure wing. The facility also failed to ensure the facility's abuse prohibition policies and procedures were followed after the incident involving Resident #1, as evidenced by failure to immediately suspend the employment of a licensed nurse who utilized an inappropriate takedown hold on the resident. The failed practices resulted in immediate jeopardy, which caused or could have caused serious harm, injury or death to Resident #1, an elderly resident with [MEDICAL CONDITION] and a history of aggressive behaviors, and had the potential to cause more than minimal harm to 9 residents who resided on the facility's secure wing and had a history of [REDACTED]. The facility was notified of the Immediate Jeopardy condition on 6/8/17 at 12:30 p.m.The findings are: 1. The facility's policy and procedure titled, Abuse and Neglect Policy and Procedures investigation and reporting, provided by the Administrator on 6/8/17, documented, .Mandatory In-Service programs will be held at least annually for all facility staff regarding the facility's policies . In-service programs may include the following information: Resident rights, Abuse and neglect policies . Understanding resident abusive conduct, understand differences that lead to conflict, resolving conflict . How and to whom incidents of mistreatment, neglect, and abuse should be reported, recognizing signs and symptoms of abuse. In an effort to protect a resident who has allegedly been abused, neglected, mistreated, or has had property misappropriated, the suspected employee(s) will be suspended immediately from employment until an investigation has determined that the employee is no longer a suspect . The Administrator or Facility Compliance Officer will track all abuse related Incident and Accident reports. Findings will be submitted to the Quality Assurance Committee during quarterly meetings. The facility will undertake other Protective and Preventive measures as follows: Staff working with difficult or abusive residents may be rotated as circumstances require; Management will be alert to employees stress through observation of change in behavior; Periodic in-service training programs regarding protecting resident rights will be conducted; Management will strive to provide adequate staffing by attempting to meet and exceed minimum staffing requirements; Staff and residents will be supervised in an effort to identify inappropriate behaviors that could signal possible signs of abuse, employee burnout or unreasonable stress. The policy and procedure did not address staff training on dementia care and intervening with combative residents. 2. Resident #1 was [AGE] years of age and was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Admission Minimum Data Set with an assessment reference date of 5/9/17 documented the resident scored 0 (0-7 indicates severe impairment) on a Brief Interview for Mental Status (BIMS); had signs and symptoms of [MEDICAL CONDITION] including inattention and disorganized thinking that were continuously present and did not fluctuate; exhibited physical behaviors toward others, verbal behaviors toward others and other behaviors not directed toward others on 1 to 3 of the last 7 days that significantly interfered with the resident's participation in activities or social interactions, significantly intruded on the privacy or activities of others and significantly disrupted care or living environment; exhibited rejection of care and wandering behaviors on 1 to 3 of the last 7 days, which significantly intruded on the privacy or activities of others; and required supervision with bed mobility, eating and toilet use. a. The Plan of Care dated as initiated on 5/4/17 documented, .Resident is at risk for behavioral issues due to DX (diagnosis) of Dementia, Alzheimer's. Resident has outburst of agitation, anger, aggressive at times and increased anxiety . If he/she becomes combative or resistive, stop task and/or leave the room, allowing time to calm, Observe resident closely during episode of behavior to keep resident and others safe and when he/she appears restless/agitated, observe for possible contributors, (pain, unmet physical need to void, hunger) through simple questioning, gestures, cues and assist with same. b. Nurses Notes dated 5/3/17 at 1:03 a.m. documented, Resident very confused. Can be combative, sits in floor, and gets up ad lib. Rubs the floor as if leaning. Up in hallway with pull-up only on. Very hard to redirect. Attempted to get in another resident's bed. Seldom speaks. Likes to get into everything. c. Nurses Notes dated 5/3/17 at 11:21 p.m. documented, Resident has been wandering up and down halls. In and out of other residents' rooms. No agitation noted. d. Nurses Notes dated 5/8/17 at 8:56 a.m. documented, Resident pacing hallways, opening all closed doors she can. She is going in and out of residents' rooms and am not able to redirect. When redirection is attempted she becomes agitated and started to swing her fist at staff. She also attempts to bite staff. Klonopin and [MEDICATION NAME] given. e. Nurses Notes dated 5/17/17 at 2:49 a.m. documented, Resident was trying to open snack and this nurse reached out to help but resident thought this nurse was trying to take it from her & (and) resident attacked this nurse. Was trying to hit and bite. This nurse was able to avoid being injured. Must explain what you are doing before trying to assist resident. f. Nurses Notes dated 5/28/17 at 3:36 p.m. documented, At 8:05 a.m., resident given [MEDICATION NAME] 0.5 mg (milligram) for increase signs of anxiety. Rapidly pacing up and down hallway. Getting agitated with staff looking for something but could not remember what it was. Not easily redirect. g. Nurses Notes dated 5/30/17 at 7:01 p.m. documented, Resident ambulating the hallways going in and out of other residents' rooms. She is wearing other residents' clothes. The CNA (Certified Nursing Assistant #1) came to her to help her get out of the others' clothes. And this resident slapped the CNA on the face and started screaming at the CNA. Was removed by this LPN (Licensed Practical Nurse) from CNA and sat her in the nearest chair and she started scratch and trying to bite me and the other CNA on the unit. Was taken out of the chair and placed on the floor on her tummy for resident safety. Called Dr. (name of Physician #1) and he said he couldn't help, to call (name of Physician #2). TC (telephone communication) made. (Physician #2) and a referral to a behavioral unit that has an available bed. There was no documentation in the Nurses' Notes that the resident was assessed for injury until 6/1/17 at 3:19 p.m., at which time the Nurses' Notes documented, Upon further evaluation, resident has bruise noted . 3 cm (centimeter) x (by) 3.5 cm circular right hip area. Nurses Notes dated 6/2/17 at 4:10 p.m. documented, Head to toe assessment performed. 2 cm purplish discolored area noted to right lateral forehead. 1 cm purplish colored bruise noted to posterior right upper extremity. 4 x 3 cm purplish bruise to anterior right hip. h. A Witness Statement dated 5/31/17 by the Assistant Director of Nursing (ADON) documented, I was called up to Green Wing, upon arrival I heard a commotion. (CNA #1) was very upset holding the left side of her face with an ice pack. When I came around the Nurses' station I saw (LPN #1) sitting on the resident's buttocks with her hand on her back. She (resident) was able to twist her head . I knelt to assess the resident and found no injuries. (LPN #1) aide she had it under control but she needed assistance to get her an order for [REDACTED].#1), (LPN #4) came down from Green Wing crying stating 'I'm out of here'. I stopped (LPN #4) and asked her to talk to the DON, once again I call the DON and had her talk to (LPN #4) and 10 minutes later, I found out that she (LPN #4) had keys to Green Hall (medication) carts. The DON advised to call her back to finish out her shift. I got the keys from her and she left. When up on Green Wing, at some point, I threw my arms up in the air in disgust and said, 'This is not normal, this is not right'. An addendum dated 6/3/17 documented, On 5/30/17 at 6:51 p.m., I called my DON and I said, 'Hi, we have a situation up on Green Wing, where I have (LPN #1) sitting on a resident's back with her hand on her back, holding the resident to the floor. I have a CNA that was slapped and she was very upset and I need help with calming her down'. DON said she knew what was going on because she had already called her and after speaking with (CNA #1), I remained on the phone with the DON and told her about the abnormal maneuver and how wrong I thought it was and she said, 'Don't worry about it, this is part of the CPI training', both the DON and (LPN #1). (LPN #5) overheard my conversation with the DON and none of her instructions were to clock and walk the (LPN #1) (out of the building). After conversation with DON, (LPN #5) stated to me that 'I don't believe that was proper CPI training. (LPN #1) should've been clocked and walked out the door.' (LPN #5) then stated 'You have to do what your supervisor said to do'. i. On 6/1/17 at 3:39 p.m., the Director of Nursing was asked about the incident that occurred on 5/30/17 with Resident #1, LPN #1 and CNA #1. The DON stated that LPN #1 called her and stated that she had, .used a CPI (Crisis Prevention Intervention) hold and that the CNA was curled in the fetal position behind the Nurses' station. She stated she advised LPN #1 that she could not do that and that she needed to leave the building. j. On 6/1/17 at 3:40 p.m., LPN #2 stated she was working another wing when the incident occurred on 5/30/17. She stated she was told that the nurse up there was, getting beat up by (Resident #1). She stated when she walked into the secure wing, she saw the resident on the floor with the nurse sitting on her back. She stated she asked LPN #1, What do you need me to do? She stated LPN #1 asked her to assist the 7:00 p.m. to 7:00 a.m. (7p-7a) nurse to call the physician. She stated at this time, she could hear CNA #1 sobbing, so she took her out of the unit and down to her station. k. On 6/1/17 at 3:45 p.m., the Assistant DON was asked about the incident that occurred on 5/30/17 between Resident #1, CNA #1 and LPN #1. The ADON stated she was working on another hall and was paged to go the Nurses' station on the Blue Wing. She stated she could hear CNA #1 crying. She stated when she went to the Green Wing (secure wing) she saw LPN #1 sitting on the resident's back and using her hands to hold the resident's upper torso down. She stated she asked LPN #1 what she was doing and the LPN told her she was trained to do this. The ADON stated she then left the unit and called the DON. l. On 6/1/17 at 3:46 p.m., footage from the facility's security cameras was viewed, with the following findings (note: the footage does not include audio): According to the time stamp on the footage, on 5/30/17 at 5:36 p.m., Resident #1 approached the Nurses' Station and stood with her left arm and hand extended outward, grasping and slightly leaning on the door frame to the Nurses' Station. Within a few seconds, CNA #1 approached Resident #1 from behind and, instead of walking around the resident's right side to speak to the resident, the CNA grasped the resident's forearm from behind, removed the resident's hand from the doorframe, positioned herself between the resident and the doorframe, and began speaking to the resident. The resident turned and slapped the CNA on the left side of her face. The CNA went into the Nurses' station and LPN #1, who had been sitting at the Nurses' station, immediately got up, approached the resident and grasped the resident's upper arms with her hands, placed her face less than 1 foot away from the resident's face and began speaking to the resident. The resident pointed upward toward the LPN's chin, then pointed to her own chest, then pointed toward the Nurses' Station. As the resident pointed toward the Nurses' Station with her right hand, LPN #1 grasped the resident's right wrist and placed the resident's arm back down to the resident's side. The resident was not gesturing or resisting LPN #1 at this time. The LPN began to lead the resident toward a chair. The resident did not initially resist, then stopped, looked at the chair, said something to the LPN, turned toward the end of the hall and began to walk away. The LPN grabbed the resident's left arm and forcefully swung her around, back toward the chair. As the resident swung around, her upper back made contact with the wall, then the LPN forcibly placed the resident into the chair, with the resident's left leg and buttock making contact with the wooden chair arm as she descended into the seat. The resident attempted to get up, and LPN straddled the resident's legs, preventing her from rising. Another staff member assisted LPN #1 with keeping the resident in the chair. The resident was positioned with her right side over the right arm of the chair, with her ribcage resting on the chair arm and her buttocks in the seat of the chair. As the resident attempted to sit up, the LPN placed her elbow to the resident's left, posterior ribcage and prevented her from doing so. The resident continued to resist and the LPN placed her face directly in front of the resident's face, speaking to the resident. At 5:41 p.m., after the resident had been held in the chair for 5 minutes, the resident began to try to push the LPN away with her feet. The LPN attempted to take the resident down to the floor, causing the chair to flip onto its side. The resident's upper buttocks / coccyx area impacted the floor. The LPN forcibly rolled the resident onto her side, used her left knee to push the back of the resident's left leg down to the floor, and then straddled the resident. The LPN positioned herself over the resident's lower torso as she attempted to force the resident's upper torso into a prone position. After the resident was in a prone position, the LPN placed her own buttocks against the resident's lower back / upper buttocks and held the resident in place. The LPN placed her hands on the resident's upper back to keep the resident's upper torso pinned against the floor. The resident was held in this position for 13 minutes, until 5:54 p.m., when LPN #1 got off of the resident and sat on her knees, just to the right of the resident. At 5:55 p.m., LPN #1 patted the resident twice on the left hip / upper buttock area, then picked up the chair and placed it in an upright position against the wall. LPN #1 and another staff member then assisted the resident to get up off of the floor, placing their hands under the resident's axillary area and lifting the resident upward. They placed the resident in the chair and LPN #1 went to the computer behind the Nurses' Station at this time. At 5:57 p.m., the resident continued to sit in the chair with her head slumped forward toward her chest, as another staff member, LPN #4, stood next to the resident, rubbing the resident's back and hair, and speaking to the resident. LPN #4 then went behind the Nurses' Station and appeared to be crying. At 5:59 p.m., Resident #1 bent forward and placed her head on her hands, which were resting in her lap. The resident remained in this position until 6:03 p.m. At 6:15 p.m., the resident stood up and walked down the hall. She was stopped by a male resident in a wheelchair, who held the resident's hand and spoke to her. Resident #1 bent down and appeared to kiss the male resident on the cheek, then went into a room on the right side of the hall. The male resident in the wheelchair continued to sit outside the room, looking back and forth from the room to the staff at the Nurses' Station. At 6:17 p.m., the male resident entered the same room. At 6:23 p.m., LPN #1 and 3 additional staff entered the room, then 2 of the staff escorted Resident #1 out of the room and down the hall, into a room on the left side of the hall, with the 2 other staff members following behind. The resident did not appear to resist the staff as she was led down the hall. All 4 staff exited the room and returned to the area in or near the Nurses' Station at 6:26 p.m. m. A Witness Statement dated 6/2/17 by LPN #4 (the 7p-7a nurse) documented, I walked up to Green Wing and (LPN #1) was holding (Resident #1's) hands across over sitting in the chair, (LPN #1) was standing to the side of her. I went to clock in and came back up to the Green Wing (LPN #1) had (Resident #1) laying on her belly and (LPN #1) was sitting on her back. She asked me to call (physician) but he didn't answer. Then (Dietary Employee #1) came up from kitchen and she took them into storage room and she hand me both sets of nurses' keys. We had not counted. I stayed and checked on (Resident #1) and she was breathing, and when I saw that she was ok, I became emotional and started crying and I had to leave. n. A Witness Statement dated 6/3/17 by LPN #2 documented, At approximately 6:00 p.m., (LPN #4) . informed me that she needed (ADON) and I stated 'she went that way' and pointed to the outside door. I asked (LPN #4) if she needed anything and she said 'the nurse on Green Wing is getting beat up by (Resident #1)'. I paged the ADON and handed (LPN #4) the phone. I went to Green Wing to see if I was needed. I saw a lot of residents gathered in the common area as I entered and as I rounded the corner I saw (LPN #1) across the resident's back. I asked (LPN #1) what I needed to do. I had been informed this Nurse was to be on Green Wing because she had CPI training by my supervisor. I went to help (LPN #4) call the doctor and heard screaming, which was (CNA #1) that had been hit by the resident I went to try to calm her with no success. I felt like she was causing more agitation among other residents and my ADON was on the unit so I felt I needed to get (CNA #1) off the unit. As I was walking out with the CNA, the ADON came by and she stated 'She can't do that in a nursing home.' I felt she was talking about (LPN #1) but unsure of procedures as I had been instructed that (LPN #1) was to be on Green Wing secondary her CPI training. I took (CNA #1) off of unit and ADON left unit to call the DON, the ADON asked me to listen to conversation and we attempted to calm (CNA #1). (LPN #5) was drawing up [MEDICATION NAME] and he and ADON was discussing protocols and what to do. (LPN #4) walked by crying as we were counting (narcotics). I had two of my Supervisors on the situation and both supervisors stated, 'She can't do that in a nursing home' and were discussing getting (LPN #1) out of the building. o. A Witness Statement dated 6/3/17 by LPN #5 documented, .The ADON came to me and talked to me briefly about what to do. I quickly told her to contact the DON and within a few minutes she was on the phone with the DON. I was handed the phone and I told the DON that what needed to happen was the LPN needed to be escorted to my office and given a drug screen and placed on administrative leave, pending an investigation, and relieved of her duties. I was then told by the DON that the nurse did nothing wrong, she used standard CPI procedures to de-escalate the situation. I was also told that the nurse (LPN #1) was trained in CPI and knew how to handle these situations. I then handed the phone back to the ADON. Then ADON, after getting off the phone, asked if I would assist her with an IM (intramuscular) injection with the resident (Resident #1) who punched the CNA. She then turned to me crying and said, 'I don't know what to do.' I told her that she needs to do what the DON instructed her to do and she told me that (LPN #1) had sat on the resident to subdue her . (LPN #1) repeatedly told her that this is what she does, that she is used to dealing with situations like this and that she had it under control. By this time, we arrived on the green wing, escorted the combative resident to her room and gave her 2 IM injections that the DON had received verbal orders for [MEDICATION NAME] 20 mg IM and [MEDICATION NAME] 2 mg IM. p. A Witness Statement dated 5/31/17 by the DON documented, May 30 at 6:37 p.m., I received a call for (CNA #1) who was crying hysterically I could not understand what she was saying at first all I heard was that she was slapped by a resident and she was hurting. When I asked her to calm down because it was difficult to understand her she became upset and hung up on me. At 6:39 p.m., I call the nurse on duty on Green (LPN #1) and asked her what was going on she stated 'I have it under control I will call you later and explain' and she hung up. I didn't feel good about it so I called the facility and (CNA #8) answered the phone and stated 'All hell has broke loose up here (Resident #1) slapped (CNA #1) in the face and she is crying and (LPN #1) is having to hold (Resident #1) down. I then asked to speak to (ADON) who was passing meds on another hallway. I asked (ADON) to go up to green and assess what was happening. (ADON) then called me back and said (CNA #1) is very upset she says her face hurts and she won't calm down. I spoke via conference call to (CNA #1). I then spoke to (ADON) and told her that I needed to know more about situation and she told me (LPN #1) was performing a CPI hold as (LPN #1) called it on (Resident #1) and some of the staff were very upset about it. I told (ADON) that we could not do CPI holds in a nursing home and she (LPN #1) would have to count narcotics and go home, The night nurse (LPN #4) had come in for report and I was told was upset . I called (LPN #1) and told her that she would have to count and go home and would be suspended until an investigation could be done. She was upset and stated 'I didn't do anything wrong I did a CPI hold.' I explained to her that those holds could not be performed in the nursing home. She stated 'I didn't know that sorry ok I understand I will count and go home'. q. LPN #1's time card documented the nurse clocked out on 5/30/17 at 9:01 p.m., over 2 hours after the incident occurred, based on the time of the incident as noted on the facility's video footage. On 6/1/17, LPN #1's personnel file was reviewed, and there was no documentation of any dementia care training or instruction on dealing with combative residents prior to being placed on the Green Wing to work with residents with severe cognitive impairment. There was also no documentation of reference checks with former employers. LPN #1's resume documented, .Worked at a regional women's community correction and men work release center from 2011 to 2017. r. On 6/8/17 at 2:25 p.m., CNA #2 was asked if she received training on dementia care and dealing with combative residents prior to being assigned to work on the secure wing. She stated, They did some training before they opened this wing, about 2 years ago. s. On 6/8/17 at 2:27 p.m., CNA #4 was asked if she received training on dementia care and dealing with combative residents prior to being assigned to work on the secure wing. She stated, The only training I got was when they opened this wing, about 2 years ago. t. On 6/8/17 at 11:55 p.m., CNA #5 was asked if she received training on dementia care and dealing with combative residents prior to being assigned to work on the secure wing. She stated, No, they gave me a pamphlet last week. u. On 6/8/17 at 12:10 p.m., CNA #6 was asked if he received training on dementia care and dealing with aggressive residents prior to being assigned to work on the secure wing. He stated, I have had training with Dementia and Alzheimer's, but not aggressive residents. v. At 12: 47 p.m., CNA #7 (employed with the facility for [AGE] years) was asked Have you received any training on how to deal with aggressive residents? She state, Not really. w. On 6/8/17 at 11:20 a.m., LPN #2 (employed with the facility for 1 and 1/2 years) was asked, Have you had any training on how to care for patients with Dementia and aggressive behaviors? She stated, No, not until recently. x. On 6/8/17 at 12:45 p.m., LPN #6 was asked, Have you had any training on how to care for patients with Dementia and aggressive behaviors? She stated, Before they opened the Green Wing, about 2 years ago. y. On 6/8/17 at 9:55 a.m., the Interim Administrator (Regional Director of Operations) was asked if the facility provided dementia care training to CNAs and LPNs assigned to the secure wing. She stated, I don't know the answer to that. She was asked to provide documentation of any training at this time. As of 6/9/17 at 2:00 p.m., the facility had provided no documentation of dementia care training or education of staff on dealing with combative residents. z. The Immediate Jeopardy was removed and the scope/severity lowered to E on 6/8/17 at 2:30 p.m., when the facility initiated the following plan of removal: 1.) Beginning at 2:30 p.m., on June 8, 2017, staff will not clock in for work until training has been completed. All staff will be trained related to abuse / neglect/ misappropriation of resident property, reporting, protecting & investigating and behavioral management of agitated, combative residents including proper physical restraint use prior to the beginning of their shift. 2.) All nurses notes, incident reports, 24 hour reports and body audits will be reviewed by 5 p.m. Friday June 9th to ensure injuries of unknown origin, allegations of abuse, neglect misappropriation of resident property documented will be reported, residents protected and investigation initiated. 3.) All folders containing 7734s (forms for reporting abuse) and 762s (forms for documenting investigation results) will be reviewed for complete investigation and will be reopened if resident (s) were not protected, or investigation thorough by 5 p.m. Friday 9th. 4.) All residents will have a completed body audit within 48 hours to identify any injuries which might be consistent with abuse and any negative findings will be reported, the resident protected and investigation initiated. 5.) All staff will be interviewed to determine any knowledge of abuse / neglect / misappropriation of resident property by 5 p.m. Friday, June 9th. 6.) All residents with BIMS scores of 10 or above will be interviewed to determine any knowledge of abuse / neglect / misappropriation of resident property by 5 p.m., Friday, June 9th. 7.) All nurses notes, 24 hour reports, incident reports and body audits will be reviewed at clinical stand up and again at daily stand up meeting 5 times per week to ensure any potential abuse is not documented. 8.) Grievance / concern forms and monthly resident council meeting minutes will be reviewed for 6 months prior by noon on Friday, June 9th for any potential abuse documentation that needs action. All grievance / concern forms will be reviewed by the Administrator at daily stand up meeting 5 x (times) weekly and resident council meeting minutes will be reviewed each month by the Administrator. 9.) The Regional Clinical Manager will monitor all nurses notes, incident reports, 24 hour reports, body audits, grievance / concern forms, and resident council meeting minutes monthly to ensure any allegations of abuse / neglect / misappropriation of property is reported, the resident protected and the investigation initiated. 10.) The Regional Director of Operations will complete a review of each 7734, 762 and complete investigation prior to being sent to OLTC (Office of Long Term Care) to ensure protection and investigation was prompt and complete. 11.) All staff will receive specialized training for the unique needs and behaviors on the safe unit by June 17 by an outside consultant who specializes in dementia and behaviors. 12.) All staff who work on the safe unit will have competency checklists completed by June 17th and any new staff hired will receive the specialized training and competency checklist prior to their working on the safe unit.

Complaint # (AR 081) was substantiated, with these findings: Complaint # (AR 117) was substantiated, with these findings: Based on record review and interview, the facility failed to ensure the facility's Administration / Nursing Administration failed to ensure nursing staff were trained and competent to safely provide care to a severely cognitively impaired resident with a history of agitation and combative behavior to prevent potential injury for 1 (Resident #1) of 4 (Residents #1, #2, #4 and #5) case mix residents who resided on the facility's secure wing. The facility failed to ensure staff received training on dementia management and appropriate interventions to deal with aggressive and / or catastrophic reactions of residents, which resulted in a licensed nurse utilizing a takedown hold on Resident #1, an elderly resident with [MEDICAL CONDITION] and a history of aggressive behaviors, with no staff attempting to intervene to stop the inappropriate treatment of [REDACTED]. The failed practice resulted in immediate jeopardy, which caused or could have caused serious harm, injury or death to Resident #1, and had the potential to cause more than minimal harm to 9 cognitively impaired residents with behaviors who resided on the facility's secure wing, as documented on a list dated 6/9/17. The facility was notified of the Immediate Jeopardy condition on 6/8/17 at 12:30 p.m. The findings are: 1. The Director of Nursing (DON) job description documented, The Director of Nursing is responsible for effective overall management of the Nursing Department and coordination with other disciplines to provide quality care to all patients/residents. She/he supports and practices the philosophy, objectives and standards of the Department of Nursing and participates in the revision of these as necessary to ensure quality care to all patients/residents. She/he also monitors the outcomes of nursing service activity by evaluating the performance of nursing staff, ensuring compliance with all facility and regulatory agency standards, policies and procedures . 2. Resident #1 was [AGE] years of age and was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Admission Minimum Data Set with an assessment reference date of 5/9/17 documented the resident scored 0 (0-7 indicates severe impairment) on a Brief Interview for Mental Status (BIMS); had signs and symptoms of [MEDICAL CONDITION] including inattention and disorganized thinking that were continuously present and did not fluctuate; exhibited physical behaviors toward others, verbal behaviors toward others and other behaviors not directed toward others on 1 to 3 of the last 7 days that significantly interfered with the resident's participation in activities or social interactions, significantly intruded on the privacy or activities of others and significantly disrupted care or living environment; exhibited rejection of care and wandering behaviors on 1 to 3 of the last 7 days, which significantly intruded on the privacy or activities of others; and required supervision with bed mobility, eating and toilet use. a. The Plan of Care dated as initiated on 5/4/17 documented, .Resident is at risk for behavioral issues due to DX (diagnosis) of Dementia, Alzheimer's. Resident has outburst of agitation, anger, aggressive at times and increased anxiety . If he/she becomes combative or resistive, stop task and/or leave the room, allowing time to calm, Observe resident closely during episode of behavior to keep resident and others safe and when he/she appears restless/agitated, observe for possible contributors, (pain, unmet physical need to void, hunger) through simple questioning, gestures, cues and assist with same. b. Nurses Notes dated 5/3/17 at 1:03 a.m. documented, Resident very confused. Can be combative, sits in floor, and gets up ad lib. Rubs the floor as if leaning. Up in hallway with pull-up only on. Very hard to redirect. Attempted to get in another resident's bed. Seldom speaks. Likes to get into everything. c. Nurses Notes dated 5/3/17 at 11:21 p.m. documented, Resident has been wandering up and down halls. In and out of other residents' rooms. No agitation noted. d. Nurses Notes dated 5/8/17 at 8:56 a.m. documented, Resident pacing hallways, opening all closed doors she can. She is going in and out of residents' rooms and am not able to redirect. When redirection is attempted she becomes agitated and started to swing her fist at staff. She also attempts to bite staff. Klonopin and [MEDICATION NAME] given. e. Nurses Notes dated 5/17/17 at 2:49 a.m. documented, Resident was trying to open snack and this nurse reached out to help but resident thought this nurse was trying to take it from her & (and) resident attacked this nurse. Was trying to hit and bite. This nurse was able to avoid being injured. Must explain what you are doing before trying to assist resident. f. Nurses Notes dated 5/28/17 at 3:36 p.m. documented, At 8:05 a.m., resident given [MEDICATION NAME] 0.5 mg (milligram) for increase signs of anxiety. Rapidly pacing up and down hallway. Getting agitated with staff looking for something but could not remember what it was. Not easily redirect. g. Nurses Notes dated 5/30/17 at 7:01 p.m. documented, Resident ambulating the hallways going in and out of other residents' rooms. She is wearing other residents' clothes. The CNA (Certified Nursing Assistant #1) came to her to help her get out of the others' clothes. And this resident slapped the CNA on the face and started screaming at the CNA. Was removed by this LPN (Licensed Practical Nurse) from CNA and sat her in the nearest chair and she started scratch and trying to bite me and the other CNA on the unit. Was taken out of the chair and placed on the floor on her tummy for resident safety. Called Dr. (name of Physician #1) and he said he couldn't help, to call (name of Physician #2). TC (telephone communication) made. (Physician #2) and a referral to a behavioral unit that has an available bed. There was no documentation in the Nurses' Notes that the resident was assessed for injury until 6/1/17 at 3:19 p.m., at which time the Nurses' Notes documented, Upon further evaluation, resident has bruise noted . 3 cm (centimeter) x (by) 3.5 cm circular right hip area. Nurses Notes dated 6/2/17 at 4:10 p.m. documented, Head to toe assessment performed. 2 cm purplish discolored area noted to right lateral forehead. 1 cm purplish colored bruise noted to posterior right upper extremity. 4 x 3 cm purplish bruise to anterior right hip. h. A Witness Statement dated 5/31/17 by the Assistant Director of Nursing (ADON) documented, I was called up to Green Wing, upon arrival I heard a commotion. (CNA #1) was very upset holding the left side of her face with an ice pack. When I came around the Nurses' station I saw (LPN #1) sitting on the resident's buttocks with her hand on her back. She (resident) was able to twist her head . I knelt to assess the resident and found no injuries. (LPN #1) aide she had it under control but she needed assistance to get her an order for [REDACTED].#1), (LPN #4) came down from Green Wing crying stating 'I'm out of here'. I stopped (LPN #4) and asked her to talk to the DON, once again I call the DON and had her talk to (LPN #4) and 10 minutes later, I found out that she (LPN #4) had keys to Green Hall (medication) carts. The DON advised to call her back to finish out her shift. I got the keys from her and she left. When up on Green Wing, at some point, I threw my arms up in the air in disgust and said, 'This is not normal, this is not right'. An addendum dated 6/3/17 documented, On 5/30/17 at 6:51 p.m., I called my DON and I said, 'Hi, we have a situation up on Green Wing, where I have (LPN #1) sitting on a resident's back with her hand on her back, holding the resident to the floor. I have a CNA that was slapped and she was very upset and I need help with calming her down'. DON said she knew what was going on because she had already called her and after speaking with (CNA #1), I remained on the phone with the DON and told her about the abnormal maneuver and how wrong I thought it was and she said, 'Don't worry about it, this is part of the CPI training', both the DON and (LPN #1). (LPN #5) overheard my conversation with the DON and none of her instructions were to clock and walk the (LPN #1) (out of the building). After conversation with DON, (LPN #5) stated to me that 'I don't believe that was proper CPI training. (LPN #1) should've been clocked and walked out the door.' (LPN #5) then stated 'You have to do what your supervisor said to do'. i. On 6/1/17 at 3:39 p.m., the Director of Nursing was asked about the incident that occurred on 5/30/17 with Resident #1, LPN #1 and CNA #1. The DON stated that LPN #1 called her and stated that she had, .used a CPI (Crisis Prevention Intervention) hold and that the CNA was curled in the fetal position behind the Nurses' station. She stated she advised LPN #1 that she could not do that and that she needed to leave the building. j. On 6/1/17 at 3:40 p.m., LPN #2 stated she was working another wing when the incident occurred on 5/30/17. She stated she was told that the nurse up there was, getting beat up by (Resident #1). She stated when she walked into the secure wing, she saw the resident on the floor with the nurse sitting on her back. She stated she asked LPN #1, What do you need me to do? She stated LPN #1 asked her to assist the 7:00 p.m. to 7:00 a.m. (7p-7a) nurse to call the physician. She stated at this time, she could hear CNA #1 sobbing, so she took her out of the unit and down to her station. k. On 6/1/17 at 3:45 p.m., the Assistant DON was asked about the incident that occurred on 5/30/17 between Resident #1, CNA #1 and LPN #1. The ADON stated she was working on another hall and was paged to go the Nurses' station on the Blue Wing. She stated she could hear CNA #1 crying. She stated when she went to the Green Wing (secure wing) she saw LPN #1 sitting on the resident's back and using her hands to hold the resident's upper torso down. She stated she asked LPN #1 what she was doing and the LPN told her she was trained to do this. The ADON stated she then left the unit and called the DON. l. On 6/1/17 at 3:46 p.m., footage from the facility's security cameras was viewed, with the following findings (note: the footage does not include audio): According to the time stamp on the footage, on 5/30/17 at 5:36 p.m., Resident #1 approached the Nurses' Station and stood with her left arm and hand extended outward, grasping and slightly leaning on the door frame to the Nurses' Station. Within a few seconds, CNA #1 approached Resident #1 from behind and, instead of walking around the resident's right side to speak to the resident, the CNA grasped the resident's forearm from behind, removed the resident's hand from the doorframe, positioned herself between the resident and the doorframe, and began speaking to the resident. The resident turned and slapped the CNA on the left side of her face. The CNA went into the Nurses' station and LPN #1, who had been sitting at the Nurses' station, immediately got up, approached the resident and grasped the resident's upper arms with her hands, placed her face less than 1 foot away from the resident's face and began speaking to the resident. The resident pointed upward toward the LPN's chin, then pointed to her own chest, then pointed toward the Nurses' Station. As the resident pointed toward the Nurses' Station with her right hand, LPN #1 grasped the resident's right wrist and placed the resident's arm back down to the resident's side. The resident was not gesturing or resisting LPN #1 at this time. The LPN began to lead the resident toward a chair. The resident did not initially resist, then stopped, looked at the chair, said something to the LPN, turned toward the end of the hall and began to walk away. The LPN grabbed the resident's left arm and forcefully swung her around, back toward the chair. As the resident swung around, her upper back made contact with the wall, then the LPN forcibly placed the resident into the chair, with the resident's left leg and buttock making contact with the wooden chair arm as she descended into the seat. The resident attempted to get up, and LPN straddled the resident's legs, preventing her from rising. Another staff member assisted LPN #1 with keeping the resident in the chair. The resident was positioned with her right side over the right arm of the chair, with her ribcage resting on the chair arm and her buttocks in the seat of the chair. As the resident attempted to sit up, the LPN placed her elbow to the resident's left, posterior ribcage and prevented her from doing so. The resident continued to resist and the LPN placed her face directly in front of the resident's face, speaking to the resident. At 5:41 p.m., after the resident had been held in the chair for 5 minutes, the resident began to try to push the LPN away with her feet. The LPN attempted to take the resident down to the floor, causing the chair to flip onto its side. The resident's upper buttocks / coccyx area impacted the floor. The LPN forcibly rolled the resident onto her side, used her left knee to push the back of the resident's left leg down to the floor, and then straddled the resident. The LPN positioned herself over the resident's lower torso as she attempted to force the resident's upper torso into a prone position. After the resident was in a prone position, the LPN placed her own buttocks against the resident's lower back / upper buttocks and held the resident in place. The LPN placed her hands on the resident's upper back to keep the resident's upper torso pinned against the floor. The resident was held in this position for 13 minutes, until 5:54 p.m., when LPN #1 got off of the resident and sat on her knees, just to the right of the resident. At 5:55 p.m., LPN #1 patted the resident twice on the left hip / upper buttock area, then picked up the chair and placed it in an upright position against the wall. LPN #1 and another staff member then assisted the resident to get up off of the floor, placing their hands under the resident's axillary area and lifting the resident upward. They placed the resident in the chair and LPN #1 went to the computer behind the Nurses' Station at this time. At 5:57 p.m., the resident continued to sit in the chair with her head slumped forward toward her chest, as another staff member, LPN #4, stood next to the resident, rubbing the resident's back and hair, and speaking to the resident. LPN #4 then went behind the Nurses' Station and appeared to be crying. At 5:59 p.m., Resident #1 bent forward and placed her head on her hands, which were resting in her lap. The resident remained in this position until 6:03 p.m. At 6:15 p.m., the resident stood up and walked down the hall. She was stopped by a male resident in a wheelchair, who held the resident's hand and spoke to her. Resident #1 bent down and appeared to kiss the male resident on the cheek, then went into a room on the right side of the hall. The male resident in the wheelchair continued to sit outside the room, looking back and forth from the room to the staff at the Nurses' Station. At 6:17 p.m., the male resident entered the same room. At 6:23 p.m., LPN #1 and 3 additional staff entered the room, then 2 of the staff escorted Resident #1 out of the room and down the hall, into a room on the left side of the hall, with the 2 other staff members following behind. The resident did not appear to resist the staff as she was led down the hall. All 4 staff exited the room and returned to the area in or near the Nurses' Station at 6:26 p.m. m. A Witness Statement dated 6/2/17 by LPN #4 (the 7p-7a nurse) documented, I walked up to Green Wing and (LPN #1) was holding (Resident #1's) hands across over sitting in the chair, (LPN #1) was standing to the side of her. I went to clock in and came back up to the Green Wing (LPN #1) had (Resident #1) was laying on her belly and (LPN #1) was sitting on her back. She asked me to call (physician) but he didn't answer. Then (Dietary Employee #1) came up from kitchen and she took them into storage room and she hand me both sets of nurses' keys. We had not counted. I stayed and checked on (Resident #1) and she was breathing, and when I saw that she was ok, I became emotional and started crying and I had to leave. n. A Witness Statement dated 6/3/17 by LPN #2 documented, At approximately 6:00 p.m., (LPN #4) . informed me that she needed (ADON) and I stated 'she went that way' and pointed to the outside door. I asked (LPN #4) if she needed anything and she said 'the nurse on Green Wing is getting beat up by (Resident #1)'. I paged the ADON and handed (LPN #4) the phone. I went to Green Wing to see if I was needed. I saw a lot of residents gathered in the common area as I entered and as I rounded the corner I saw (LPN #1) across the resident's back. I asked (LPN #1) what I needed to do. I had been informed this Nurse was to be on Green Wing because she had CPI training by my supervisor. I went to help (LPN #4) call the doctor and heard screaming, which was (CNA #1) that had been hit by the resident I went to try to calm her with no success. I felt like she was causing more agitation among other residents and my ADON was on the unit so I felt i needed to get (CNA #1) off the unit. As I was walking out with the CNA, the ADON came by and she stated 'She can't do that in a nursing home.' I felt she was talking about (LPN #1) but unsure of procedures as I had been instructed that (LPN #1) was to be on Green Wing secondary her CPI training. I took (CNA #1) off of unit and ADON left unit to call the DON, the ADON asked me to listen to conversation and we attempted to calm (CNA #1). (LPN #5) was drawing up [MEDICATION NAME] and he and ADON was discussing protocols and what to do. (LPN #4) walked by crying as we were counting (narcotics). I had two of my Supervisors on the situation and both supervisors stated, 'She can't do that in a nursing home' and were discussing getting (LPN #1) out of the building. o. A Witness Statement dated 6/3/17 by LPN #5 documented, .The ADON came to me and talked to me briefly about what to do. I quickly told her to contact the DON and within a few minutes she was on the phone with the DON. I was handed the phone and I told the DON that what needed to happen was the LPN needed to be escorted to my office and given a drug screen and placed on administrative leave, pending an investigation, and relieved of her duties. I was then told by the DON that the nurse did nothing wrong, she used standard CPI procedures to de-escalate the situation. I was also told that the nurse (LPN #1) was trained in CPI and knew how to handle these situations. I then handed the phone back to the ADON. Then ADON, after getting off the phone, asked if I would assist her with an IM (intramuscular) injection with the resident (Resident #1) who punched the CNA. She then turned to me crying and said, 'I don't know what to do.' I told her that she needs to do what the DON instructed her to do and she told me that (LPN #1) had sat on the resident to subdue her . (LPN #1) repeatedly told her that this is what she does, that she is used to dealing with situations like this and that she had it under control. By this time, we arrived on the green wing, escorted the combative resident to her room and gave her 2 IM injections that the DON had received verbal orders for [MEDICATION NAME] 20 mg IM and [MEDICATION NAME] 2 mg IM. p. A Witness Statement dated 5/31/17 by the DON documented, May 30 at 6:37 p.m., I received a call for (CNA #1) who was crying hysterically I could not understand what she was saying at first all I heard was that she was slapped by a resident and she was hurting. When I asked her to calm down because it was difficult to understand her she became upset and hung up on me. At 6:39 p.m., I call the nurse on duty on Green (LPN #1) and asked her what was going on she stated 'I have it under control I will call you later and explain' and she hung up. I didn't feel good about it so I called the facility and (CNA #8) answered the phone and stated 'All hell has broke loose up here (Resident #1) slapped (CNA #1) in the face and she is crying and (LPN #1) is having to hold (Resident #1) down. I then asked to speak to (ADON) who was passing meds on another hallway. I asked (ADON) to go up to green and assess what was happening. (ADON) then called me back and said (CNA #1) is very upset she says her face hurts and she won't calm down. I spoke via conference call to (CNA #1). I then spoke to (ADON) and told her that I needed to know more about situation and she told me (LPN #1) was performing a CPI hold as (LPN #1) called it on (Resident #1) and some of the staff were very upset about it. I told (ADON) that we could not do CPI holds in a nursing home and she (LPN #1) would have to count narcotics and go home, The night nurse (LPN #4) had came in for report and I was told was upset . I called (LPN #1) and told her that she would have to count and go home and would be suspended until an investigation could be done. She was upset and stated 'I didn't do anything wrong I did a CPI hold.' I explained to her that those holds could not be performed in the nursing home. She stated 'I didn't know that sorry ok I understand I will count and go home'. q. LPN #1's time card documented the nurse clocked out on 5/30/17 at 9:01 p.m., over 2 hours after the incident occurred, based on the time of the incident as noted on the facility's video footage. On 6/1/17, LPN #1's personnel file was reviewed, and there was no documentation of any dementia care training or instruction on dealing with combative residents prior to being placed on the Green Wing to work with residents with severe cognitive impairment. There was also no documentation of reference checks with former employers. LPN #1's resume documented, .Worked at a regional women's community correction and men work release center from 2011 to 2017. r. On 6/8/17 at 2:25 p.m., CNA #2 was asked if she received training on dementia care and dealing with combative residents prior to being assigned to work on the secure wing. She stated, They did some training before they opened this wing, about 2 years ago. s. On 6/8/17 at 2:27 p.m., CNA #4 was asked if she received training on dementia care and dealing with combative residents prior to being assigned to work on the secure wing. She stated, The only training I got was when they opened this wing, about 2 years ago. t. On 6/8/17 at 11:55 p.m., CNA #5 was asked if she received training on dementia care and dealing with combative residents prior to being assigned to work on the secure wing. She stated, No, they gave me a pamphlet last week. u. On 6/8/17 at 12:10 p.m., CNA #6 was asked if he received training on dementia care and dealing with aggressive residents prior to being assigned to work on the secure wing. He stated, I have had training with Dementia and Alzheimer's, but not aggressive residents. v. At 12: 47 p.m., CNA #7 (employed with the facility for [AGE] years) was asked Have you received any training on how to deal with aggressive residents? She stated, Not really. w. On 6/8/17 at 11:20 a.m., LPN #2 (employed with the facility for 1 and 1/2 years) was asked, Have you had any training on how to care for patients with Dementia and aggressive behaviors? She stated, No, not until recently. x. On 6/8/17 at 12:45 p.m., LPN #6 was asked, Have you had any training on how to care for patients with Dementia and aggressive behaviors? She stated, Before they opened the Green Wing, about 2 years ago. y. On 6/8/17 at 9:55 a.m., the Interim Administrator (Regional Director of Operations) was asked if the facility provided dementia care training to CNAs and LPNs assigned to the secure wing. She stated, I don't know the answer to that. She was asked to provide documentation of any training at this time. As of 6/9/17 at 2:00 p.m., the facility had provided no documentation of dementia care training or education of staff on dealing with combative residents. z. The Immediate Jeopardy was removed and the scope/severity lowered to E on 6/8/17 at 2:30 p.m., when the facility initiated the following plan of removal: 1.) Beginning at 2:30 p.m., on June 8, 2017, staff will not clock in for work until training has been completed. All staff will be trained related to abuse / neglect/ misappropriation of resident property, reporting, protecting & investigating and behavioral management of agitated, combative residents including proper physical restraint use prior to the beginning of their shift. 2.) All nurses notes, incident reports, 24 hour reports and body audits will be reviewed by 5 p.m. Friday June 9th to ensure injuries of unknown origin, allegations of abuse, neglect misappropriation of resident property documented will be reported, residents protected and investigation initiated. 3.) All folders containing 7734s (forms for reporting abuse) and 762s (forms for documenting investigation results) will be reviewed for complete investigation and will be reopened if resident (s) were not protected, or investigation thorough by 5 p.m. Friday 9th. 4.) All residents will have a completed body audit within 48 hours to identify any injuries which might be consistent with abuse and any negative findings will be reported, the resident protected and investigation initiated. 5.) All staff will be interviewed to determine any knowledge of abuse / neglect / misappropriation of resident property by 5 p.m. Friday, June 9th. 6.) All residents with BIMS scores of 10 or above will be interviewed to determine any knowledge of abuse / neglect / misappropriation of resident property by 5 p.m., Friday, June 9th. 7.) All nurses notes, 24 hour reports, incident reports and body audits will be reviewed at clinical stand up and again at daily stand up meeting 5 times per week to ensure any potential abuse is not documented. 8.) Grievance / concern forms and monthly resident council meeting minutes will be reviewed for 6 months prior by noon on Friday, June 9th for any potential abuse documentation that needs action. All grievance / concern forms will be reviewed by the Administrator at daily stand up meeting 5 x (times) weekly and resident council meeting minutes will be reviewed each month by the Administrator. 9.) The Regional Clinical Manager will monitor all nurses notes, incident reports, 24 hour reports, body audits, grievance / concern forms, and resident council meeting minutes monthly to ensure any allegations of abuse / neglect / misappropriation of property is reported, the resident protected and the investigation initiated. 10.) The Regional Director of Operations will complete a review of each 7734, 762 and complete investigation prior to being sent to OLTC (Office of Long Term Care) to ensure protection and investigation was prompt and complete. 11.) All staff will receive specialized training for the unique needs and behaviors on the safe unit by June 17 by an outside consultant who specializes in dementia and behaviors. 12.) All staff who work on the safe unit will have competency checklists completed by June 17th and any new staff hired will receive the specialized training and competency checklist prior to their working on the safe unit.

Complaint # (AR 081) was substantiated, with these findings: Complaint # (AR 117) was substantiated, with these findings: Based on record review and interview, the facility's Quality Assessment and Assurance (QAA) Committee failed to identify and develop a plan to correct deficiencies with regard to the training and competency of nursing staff to safely provide care to severely cognitively impaired residents with a history of agitation and combative behaviors to prevent potential injury for 1 (Resident #1) of 4 (Residents #1, #2, #4 and #5) case mix residents who resided on the facility's secure wing. The facility failed to ensure staff received training on dementia management and appropriate interventions to deal with aggressive and / or catastrophic reactions of residents, which resulted in a licensed nurse utilizing a takedown hold on Resident #1, an elderly resident with [MEDICAL CONDITION] and a history of aggressive behaviors, with no staff attempting to intervene to stop the inappropriate treatment of [REDACTED]. The failed practice resulted in immediate jeopardy, which caused or could have caused serious harm, injury or death to Resident #1, and had the potential to cause more than minimal harm to 9 cognitively impaired residents with behaviors who resided on the facility's secure wing, as documented on a list dated 6/9/17. The facility was notified of the Immediate Jeopardy condition on 6/8/17 at 12:30 p.m. The findings are: Resident #1 was [AGE] years of age and was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Admission Minimum Data Set with an assessment reference date of 5/9/17 documented the resident scored 0 (0-7 indicates severe impairment) on a Brief Interview for Mental Status (BIMS); had signs and symptoms of [MEDICAL CONDITION] including inattention and disorganized thinking that were continuously present and did not fluctuate; exhibited physical behaviors toward others, verbal behaviors toward others and other behaviors not directed toward others on 1 to 3 of the last 7 days that significantly interfered with the resident's participation in activities or social interactions, significantly intruded on the privacy or activities of others and significantly disrupted care or living environment; exhibited rejection of care and wandering behaviors on 1 to 3 of the last 7 days, which significantly intruded on the privacy or activities of others; and required supervision with activities of daily living. a. The Plan of Care dated as initiated on 5/4/17 documented, .Resident is at risk for behavioral issues due to DX (diagnosis) of Dementia, Alzheimer's. Resident has outburst of agitation, anger, aggressive at times and increased anxiety . If he/she becomes combative or resistive, stop task and/or leave the room, allowing time to calm, Observe resident closely during episode of behavior to keep resident and others safe and when he/she appears restless/agitated, observe for possible contributors, (pain, unmet physical need to void, hunger) through simple questioning, gestures, cues and assist with same. b. Nurses Notes dated 5/3/17 at 1:03 a.m. documented, Resident very confused. Can be combative, sits in floor, and gets up ad lib. Rubs the floor as if leaning. Up in hallway with pull-up only on. Very hard to redirect. Attempted to get in another resident's bed. Seldom speaks. Likes to get into everything. c. Nurses Notes dated 5/3/17 at 11:21 p.m. documented, Resident has been wandering up and down halls. In and out of other residents' rooms. No agitation noted. d. Nurses Notes dated 5/8/17 at 8:56 a.m. documented, Resident pacing hallways, opening all closed doors she can. She is going in and out of residents' rooms and am not able to redirect. When redirection is attempted she becomes agitated and started to swing her fist at staff. She also attempts to bite staff. Klonopin and [MEDICATION NAME] given. e. Nurses Notes dated 5/17/17 at 2:49 a.m. documented, Resident was trying to open snack and this nurse reached out to help but resident thought this nurse was trying to take it from her & (and) resident attacked this nurse. Was trying to hit and bite. This nurse was able to avoid being injured. Must explain what you are doing before trying to assist resident. f. Nurses Notes dated 5/28/17 at 3:36 p.m. documented, At 8:05 a.m., resident given [MEDICATION NAME] 0.5 mg (milligram) for increase signs of anxiety. Rapidly pacing up and down hallway. Getting agitated with staff looking for something but could not remember what it was. Not easily redirect. g. Nurses Notes dated 5/30/17 at 7:01 p.m. documented, Resident ambulating the hallways going in and out of other residents' rooms. She is wearing other residents' clothes. The CNA (Certified Nursing Assistant #1) came to her to help her get out of the others' clothes. And this resident slapped the CNA on the face and started screaming at the CNA. Was removed by this LPN (Licensed Practical Nurse) from CNA and sat her in the nearest chair and she started scratch and trying to bite me and the other CNA on the unit. Was taken out of the chair and placed on the floor on her tummy for resident safety. Called Dr. (name of Physician #1) and he said he couldn't help, to call (name of Physician #2). TC (telephone communication) made. (Physician #2) and a referral to a behavioral unit that has an available bed. There was no documentation in the Nurses' Notes that the resident was assessed for injury until 6/1/17 at 3:19 p.m., at which time the Nurses' Notes documented, Upon further evaluation, resident has bruise noted . 3 cm (centimeter) x (by) 3.5 cm circular right hip area. Nurses Notes dated 6/2/17 at 4:10 p.m. documented, Head to toe assessment performed. 2 cm purplish discolored area noted to right lateral forehead. 1 cm purplish colored bruise noted to posterior right upper extremity. 4 x 3 cm purplish bruise to anterior right hip. h. A Witness Statement dated 5/31/17 by the Assistant Director of Nursing (ADON) documented, I was called up to Green Wing, upon arrival I heard a commotion. (CNA #1) was very upset holding the left side of her face with an ice pack. When I came around the Nurses' station I saw (LPN #1) sitting on the resident's buttocks with her hand on her back. She (resident) was able to twist her head . I knelt to assess the resident and found no injuries. (LPN #1) aide she had it under control but she needed assistance to get her an order for [REDACTED].#1), (LPN #4) came down from Green Wing crying stating 'I'm out of here'. I stopped (LPN #4) and asked her to talk to the DON, once again I call the DON and had her talk to (LPN #4) and 10 minutes later, I found out that she (LPN #4) had keys to Green Hall (medication) carts. The DON advised to call her back to finish out her shift. I got the keys from her and she left. When up on Green Wing, at some point, I threw my arms up in the air in disgust and said, 'This is not normal, this is not right'. An addendum dated 6/3/17 documented, On 5/30/17 at 6:51 p.m., I called my DON and I said, 'Hi, we have a situation up on Green Wing, where I have (LPN #1) sitting on a resident's back with her hand on her back, holding the resident to the floor. I have a CNA that was slapped and she was very upset and I need help with calming her down'. DON said she knew what was going on because she had already called her and after speaking with (CNA #1), I remained on the phone with the DON and told her about the abnormal maneuver and how wrong I thought it was and she said, 'Don't worry about it, this is part of the CPI training', both the DON and (LPN #1). (LPN #5) overheard my conversation with the DON and none of her instructions were to clock and walk the (LPN #1) (out of the building). After conversation with DON, (LPN #5) stated to me that 'I don't believe that was proper CPI training. (LPN #1) should've been clocked and walked out the door.' (LPN #5) then stated 'You have to do what your supervisor said to do'. i. On 6/1/17 at 3:39 p.m., the Director of Nursing was asked about the incident that occurred on 5/30/17 with Resident #1, LPN #1 and CNA #1. The DON stated that LPN #1 called her and stated that she had, .used a CPI (Crisis Prevention Intervention) hold and that the CNA was curled in the fetal position behind the Nurses' station. She stated she advised LPN #1 that she could not do that and that she needed to leave the building. j. On 6/1/17 at 3:40 p.m., LPN #2 stated she was working another wing when the incident occurred on 5/30/17. She stated she was told that the nurse up there was, getting beat up by (Resident #1). She stated when she walked into the secure wing, she saw the resident on the floor with the nurse sitting on her back. She stated she asked LPN #1, What do you need me to do? She stated LPN #1 asked her to assist the 7:00 p.m. to 7:00 a.m. (7p-7a) nurse to call the physician. She stated at this time, she could hear CNA #1 sobbing, so she took her out of the unit and down to her station. k. On 6/1/17 at 3:45 p.m., the Assistant DON was asked about the incident that occurred on 5/30/17 between Resident #1, CNA #1 and LPN #1. The ADON stated she was working on another hall and was paged to go the Nurses' station on the Blue Wing. She stated she could hear CNA #1 crying. She stated when she went to the Green Wing (secure wing) she saw LPN #1 sitting on the resident's back and using her hands to hold the resident's upper torso down. She stated she asked LPN #1 what she was doing and the LPN told her she was trained to do this. The ADON stated she then left the unit and called the DON. l. On 6/1/17 at 3:46 p.m., footage from the facility's security cameras was viewed, with the following findings (note: the footage does not include audio): According to the time stamp on the footage, on 5/30/17 at 5:36 p.m., Resident #1 approached the Nurses' Station and stood with her left arm and hand extended outward, grasping and slightly leaning on the door frame to the Nurses' Station. Within a few seconds, CNA #1 approached Resident #1 from behind and, instead of walking around the resident's right side to speak to the resident, the CNA grasped the resident's forearm from behind, removed the resident's hand from the doorframe, positioned herself between the resident and the doorframe, and began speaking to the resident. The resident turned and slapped the CNA on the left side of her face. The CNA went into the Nurses' station and LPN #1, who had been sitting at the Nurses' station, immediately got up, approached the resident and grasped the resident's upper arms with her hands, placed her face less than 1 foot away from the resident's face and began speaking to the resident. The resident pointed upward toward the LPN's chin, then pointed to her own chest, then pointed toward the Nurses' Station. As the resident pointed toward the Nurses' Station with her right hand, LPN #1 grasped the resident's right wrist and placed the resident's arm back down to the resident's side. The resident was not gesturing or resisting LPN #1 at this time. The LPN began to lead the resident toward a chair. The resident did not initially resist, then stopped, looked at the chair, said something to the LPN, turned toward the end of the hall and began to walk away. The LPN grabbed the resident's left arm and forcefully swung her around, back toward the chair. As the resident swung around, her upper back made contact with the wall, then the LPN forcibly placed the resident into the chair, with the resident's left leg and buttock making contact with the wooden chair arm as she descended into the seat. The resident attempted to get up, and LPN straddled the resident's legs, preventing her from rising. Another staff member assisted LPN #1 with keeping the resident in the chair. The resident was positioned with her right side over the right arm of the chair, with her ribcage resting on the chair arm and her buttocks in the seat of the chair. As the resident attempted to sit up, the LPN placed her elbow to the resident's left, posterior ribcage and prevented her from doing so. The resident continued to resist and the LPN placed her face directly in front of the resident's face, speaking to the resident. At 5:41 p.m., after the resident had been held in the chair for 5 minutes, the resident began to try to push the LPN away with her feet. The LPN attempted to take the resident down to the floor, causing the chair to flip onto its side. The resident's upper buttocks / coccyx area impacted the floor. The LPN forcibly rolled the resident onto her side, used her left knee to push the back of the resident's left leg down to the floor, and then straddled the resident. The LPN positioned herself over the resident's lower torso as she attempted to force the resident's upper torso into a prone position. After the resident was in a prone position, the LPN placed her own buttocks against the resident's lower back / upper buttocks and held the resident in place. The LPN placed her hands on the resident's upper back to keep the resident's upper torso pinned against the floor. The resident was held in this position for 13 minutes, until 5:54 p.m., when LPN #1 got off of the resident and sat on her knees, just to the right of the resident. At 5:55 p.m., LPN #1 patted the resident twice on the left hip / upper buttock area, then picked up the chair and placed it in an upright position against the wall. LPN #1 and another staff member then assisted the resident to get up off of the floor, placing their hands under the resident's axillary area and lifting the resident upward. They placed the resident in the chair and LPN #1 went to the computer behind the Nurses' Station at this time. At 5:57 p.m., the resident continued to sit in the chair with her head slumped forward toward her chest, as another staff member, LPN #4, stood next to the resident, rubbing the resident's back and hair, and speaking to the resident. LPN #4 then went behind the Nurses' Station and appeared to be crying. At 5:59 p.m., Resident #1 bent forward and placed her head on her hands, which were resting in her lap. The resident remained in this position until 6:03 p.m. At 6:15 p.m., the resident stood up and walked down the hall. She was stopped by a male resident in a wheelchair, who held the resident's hand and spoke to her. Resident #1 bent down and appeared to kiss the male resident on the cheek, then went into a room on the right side of the hall. The male resident in the wheelchair continued to sit outside the room, looking back and forth from the room to the staff at the Nurses' Station. At 6:17 p.m., the male resident entered the same room. At 6:23 p.m., LPN #1 and 3 additional staff entered the room, then 2 of the staff escorted Resident #1 out of the room and down the hall, into a room on the left side of the hall, with the 2 other staff members following behind. The resident did not appear to resist the staff as she was led down the hall. All 4 staff exited the room and returned to the area in or near the Nurses' Station at 6:26 p.m. m. A Witness Statement dated 6/2/17 by LPN #4 (the 7p-7a nurse) documented, I walked up to Green Wing and (LPN #1) was holding (Resident #1's) hands across over sitting in the chair, (LPN #1) was standing to the side of her. I went to clock in and came back up to the Green Wing (LPN #1) had (Resident #1) was laying on her belly and (LPN #1) was sitting on her back. She asked me to call (physician) but he didn't answer. Then (Dietary Employee #1) came up from kitchen and she took them into storage room and she hand me both sets of nurses' keys. We had not counted. I stayed and checked on (Resident #1) and she was breathing, and when I saw that she was ok, I became emotional and started crying and I had to leave. n. A Witness Statement dated 6/3/17 by LPN #2 documented, At approximately 6:00 p.m., (LPN #4) . informed me that she needed (ADON) and I stated 'she went that way' and pointed to the outside door. I asked (LPN #4) if she needed anything and she said 'the nurse on Green Wing is getting beat up by (Resident #1)'. I paged the ADON and handed (LPN #4) the phone. I went to Green Wing to see if I was needed. I saw a lot of residents gathered in the common area as I entered and as I rounded the corner I saw (LPN #1) across the resident's back. I asked (LPN #1) what I needed to do. I had been informed this Nurse was to be on Green Wing because she had CPI training by my supervisor. I went to help (LPN #4) call the doctor and heard screaming, which was (CNA #1) that had been hit by the resident I went to try to calm her with no success. I felt like she was causing more agitation among other residents and my ADON was on the unit so I felt I needed to get (CNA #1) off the unit. As I was walking out with the CNA, the ADON came by and she stated 'She can't do that in a nursing home.' I felt she was talking about (LPN #1) but unsure of procedures as I had been instructed that (LPN #1) was to be on Green Wing secondary her CPI training. I took (CNA #1) off of unit and ADON left unit to call the DON, the ADON asked me to listen to conversation and we attempted to calm (CNA #1). (LPN #5) was drawing up [MEDICATION NAME] and he and ADON was discussing protocols and what to do. (LPN #4) walked by crying as we were counting (narcotics). I had two of my Supervisors on the situation and both supervisors stated, 'She can't do that in a nursing home' and were discussing getting (LPN #1) out of the building. o. A Witness Statement dated 6/3/17 by LPN #5 documented, .The ADON came to me and talked to me briefly about what to do. I quickly told her to contact the DON and within a few minutes she was on the phone with the DON. I was handed the phone and I told the DON that what needed to happen was the LPN needed to be escorted to my office and given a drug screen and placed on administrative leave, pending an investigation, and relieved of her duties. I was then told by the DON that the nurse did nothing wrong, she used standard CPI procedures to de-escalate the situation. I was also told that the nurse (LPN #1) was trained in CPI and knew how to handle these situations. I then handed the phone back to the ADON. Then ADON, after getting off the phone, asked if I would assist her with an IM (intramuscular) injection with the resident (Resident #1) who punched the CNA. She then turned to me crying and said, 'I don't know what to do.' I told her that she needs to do what the DON instructed her to do and she told me that (LPN #1) had sat on the resident to subdue her . (LPN #1) repeatedly told her that this is what she does, that she is used to dealing with situations like this and that she had it under control. By this time, we arrived on the green wing, escorted the combative resident to her room and gave her 2 IM injections that the DON had received verbal orders for [MEDICATION NAME] 20 mg IM and [MEDICATION NAME] 2 mg IM. p. A Witness Statement 5/31/17 by the DON documented, May 30 at 6:37 p.m., I received a call for (CNA #1) who was crying hysterically I could not understand what she was saying at first all I heard was that she was slapped by a resident and she was hurting. When I asked her to calm down because it was difficult to understand her she became upset and hung up on me. At 6:39 p.m., I call the nurse on duty on Green (LPN #1) and asked her what was going on she stated 'I have it under control I will call you later and explain' and she hung up. I didn't feel good about it so I called the facility and (CNA #8) answered the phone and stated 'All hell has broke loose up here (Resident #1) slapped (CNA #1) in the face and she is crying and (LPN #1) is having to hold (Resident #1) down. I then asked to speak to (ADON) who was passing meds on another hallway. I asked (ADON) to go up to green and assess what was happening. (ADON) then called me back and said (CNA #1) is very upset she says her face hurts and she won't calm down. I spoke via conference call to (CNA #1). I then spoke to (ADON) and told her that I needed to know more about situation and she told me (LPN #1) was performing a CPI hold as (LPN #1) called it on (Resident #1) and some of the staff were very upset about it. I told (ADON) that we could not do CPI holds in a nursing home and she (LPN #1) would have to count narcotics and go home, The night nurse (LPN #4) had come in for report and I was told was upset . I called (LPN #1) and told her that she would have to count and go home and would be suspended until an investigation could be done. She was upset and stated 'I didn't do anything wrong I did a CPI hold.' I explained to her that those holds could not be performed in the nursing home. She stated 'I didn't know that sorry ok I understand I will count and go home'. q. LPN #1's time card documented the nurse clocked out on 5/30/17 at 9:01 p.m., over 2 hours after the incident occurred, based on the time of the incident as noted on the facility's video footage. On 6/1/17, LPN #1's personnel file was reviewed, and there was no documentation of any dementia care training or instruction on dealing with combative residents prior to being placed on the Green Wing to work with residents with severe cognitive impairment. There was also no documentation of reference checks with former employers. LPN #1's resume documented, .Worked at a regional women's community correction and men work release center from 2011 to 2017 . r. On 6/8/17 at 2:25 p.m., CNA #2 was asked if she received training on dementia care and dealing with combative residents prior to being assigned to work on the secure wing. She stated, They did some training before they opened this wing, about 2 years ago. s. On 6/8/17 at 2:27 p.m., CNA #4 was asked if she received training on dementia care and dealing with combative residents prior to being assigned to work on the secure wing. She stated, The only training I got was when they opened this wing, about 2 years ago. t. On 6/8/17 at 11:55 p.m., CNA #5 was asked if she received training on dementia care and dealing with combative residents prior to being assigned to work on the secure wing. She stated, No, they gave me a pamphlet last week. u. On 6/8/17 at 12:10 p.m., CNA #6 was asked if he received training on dementia care and dealing with aggressive residents prior to being assigned to work on the secure wing. He stated, I have had training with Dementia and Alzheimer's, but not aggressive residents. v. At 12: 47 p.m., CNA #7 (employed with the facility for [AGE] years) was asked Have you received any training on how to deal with aggressive residents? She stated, Not really. w. On 6/8/17 at 11:20 a.m., LPN #2 (employed with the facility for 1 and 1/2 years) was asked, Have you had any training on how to care for patients with Dementia and aggressive behaviors? She stated, No, not until recently. x. On 6/8/17 at 12:45 p.m., LPN #6 was asked, Have you had any training on how to care for patients with Dementia and aggressive behaviors? She stated, Before they opened the Green Wing, about 2 years ago. y. On 6/8/17 at 9:55 a.m., the Interim Administrator (Regional Director of Operations) was asked if the facility provided dementia care training to CNAs and LPNs assigned to the secure wing. She stated, I don't know the answer to that. She was asked to provide documentation of any training at this time. As of 6/9/17 at 2:00 p.m., the facility had provided no documentation of dementia care training or education of staff on dealing with combative residents. z. On 6/9/17 at 2:00 p.m., LPN #5 was asked about any efforts by the facility's QAA Committee with regard to staff training. He stated he was unaware of anything being discussed at the QAA meetings related to resident behaviors, or anything regarding abuse. aa. The Immediate Jeopardy was removed and the scope/severity lowered to E on 6/8/17 at 2:30 p.m., when the facility initiated the following plan of removal: 1.) Beginning at 2:30 p.m., on June 8, 2017, staff will not clock in for work until training has been completed. All staff will be trained related to abuse / neglect/ misappropriation of resident property, reporting, protecting & investigating and behavioral management of agitated, combative residents including proper physical restraint use prior to the beginning of their shift. 2.) All nurses notes, incident reports, 24 hour reports and body audits will be reviewed by 5 p.m. Friday June 9th to ensure injuries of unknown origin, allegations of abuse, neglect misappropriation of resident property documented will be reported, residents protected and investigation initiated. 3.) All folders containing 7734s (forms for reporting abuse) and 762s (forms for documenting investigation results) will be reviewed for complete investigation and will be reopened if resident (s) were not protected, or investigation thorough by 5 p.m. Friday 9th. 4.) All residents will have a completed body audit within 48 hours to identify any injuries which might be consistent with abuse and any negative findings will be reported, the resident protected and investigation initiated. 5.) All staff will be interviewed to determine any knowledge of abuse / neglect / misappropriation of resident property by 5 p.m. Friday, June 9th. 6.) All residents with BIMS scores of 10 or above will be interviewed to determine any knowledge of abuse / neglect / misappropriation of resident property by 5 p.m., Friday, June 9th. 7.) All nurses notes, 24 hour reports, incident reports and body audits will be reviewed at clinical stand up and again at daily stand up meeting 5 times per week to ensure any potential abuse is not documented. 8.) Grievance / concern forms and monthly resident council meeting minutes will be reviewed for 6 months prior by noon on Friday, June 9th for any potential abuse documentation that needs action. All grievance / concern forms will be reviewed by the Administrator at daily stand up meeting 5 x (times) weekly and resident council meeting minutes will be reviewed each month by the Administrator. 9.) The Regional Clinical Manager will monitor all nurses notes, incident reports, 24 hour reports, body audits, grievance / concern forms, and resident council meeting minutes monthly to ensure any allegations of abuse / neglect / misappropriation of property is reported, the resident protected and the investigation initiated. 10.) The Regional Director of Operations will complete a review of each 7734, 762 and complete investigation prior to being sent to OLTC (Office of Long Term Care) to ensure protection and investigation was prompt and complete. 11.) All staff will receive specialized training for the unique needs and behaviors on the safe unit by June 17 by an outside consultant who specializes in dementia and behaviors. 12.) All staff who work on the safe unit will have competency checklists completed by June 17th and any new staff hired will receive the specialized training and competency checklist prior to their working on the safe unit.

Complaint # (AR 330) was substantiated (all or in part) based on these findings: Based on record review and interview, the facility failed to ensure the physician was immediately consulted and provided with complete and accurate information regarding a fall with head injury and failed to ensure the physician was informed of subsequent complaints of shoulder pain after the fall occurred to prevent a delay in treatment for 1 (Resident #4) of 7 (Residents #2, #3, #4, #5, #6, #7 and #8) case mix residents who were at risk for falls. The failed practice resulted in Immediate Jeopardy, which caused or could have caused serious harm, injury or death to Resident #4, who experienced a fall that resulted in a head injury and fractured clavicle, had the potential to cause more than minimal harm to 24 residents who had falls in the past 60 days, as documented on a list provided by the Registered Nurse Consultant on 7/1/16. The facility was informed of the Immediate Jeopardy condition on 7/1/16 at 2:15 p.m. The findings are: 1. The facility's policy titled, Falls Management, provided by the Registered Nurse Consultant on 7/1/16 at 10:35 a.m., documented, .9. If injury, severe pain or abnormal assessments observed, call 9-1-1 for transfer . 12. Contact physician . and document in the medical record, including time and person spoken with . 2. Resident #4 had [DIAGNOSES REDACTED]. The Admission Minimum Data Set with an assessment reference date of 5/4/16 documented the resident scored 14 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status; required extensive assistance of 2-plus persons for bed mobility, transfers and toileting; was not on a scheduled pain medication regimen; had experienced occasional pain in the past 5 days; rated her worst pain during the 5 days prior to the assessment as a 2, on a scale of 0 to 10, with zero indicating no pain, and 10 indicating the worst pain imaginable; and had no falls since admission. a. Physician order [REDACTED].#3 (Tylenol #3) 300-30 mg (milligram) tablet: Give 1 tab (tablet) by mouth every 6 hours as needed for pain . [MEDICATION NAME] 37-5-325 mg tablet: Give 1 tab by mouth twice a day as needed . b. A Care Plan dated 4/26/16 documented, Problem: I am at risk for falls . Goal: I will not experience any injuries related to falls . Approaches: Monitor for changes in my condition that may warrant increased supervision / assistance and notify the physician . Problem Onset 4/26/16: I am experiencing the presence of pain in back . Approaches . Administer my pain medication as ordered . Observe for worsening of my pain . and report to physician . c. A Pain Management Flowsheet for May 2016 documented the resident complained of back pain, leg pain or headache one to three times daily throughout the month of May 2016 and received Tylenol #3 or [MEDICATION NAME] as ordered. There was no documentation of any complaints of shoulder pain. d. A Resident Incident Report dated 5/25/16 at 5:45 a.m. and signed by Licensed Practical Nurse (LPN) #5 documented, Incident Type: Fall w/ (with) inj (injury) - unwitnessed .Type of Injury: Bruise, Location: Resident room . Incident Level: . Event (with) Mild injury . Narrative of incident and description of injuries: CNA (Certified Nursing Assistant) found resident in floor, laying (sic) on left side between BSC (bedside commode) (and) bed. CNA reported fall to nurse. Raised bruised area to forehead. Immediate Actions Taken: Head to toe (and) pain assessment completed. Raised bruised area on forehead. Ice pack applied to forehead. Note Tylenol #3 approx (approximately) 30 minutes prior to fall. Neuros (neurological checks) initiated. Neuros, rom (range of motion) (and) prom (passive range of motion) wnls (within normal limits). Encourage resident to use call light for needs . strips next to bed on floor (and) PT (physical therapy) screening. PCP (Primary Care Physician), RP (responsible party) (and) DON (Director of Nursing) notified. Actions Taken: First Aid by: (LPN #5) Type of Aid: Head to toe (and) pain assessment, ice pack applied .Physician notified: (physician's name) Date/Time 5/25/16 . The form did not specify whether the physician was informed of the raised, bruised area to the resident's head. There were no Nurse's Notes dated 5/25/16 that documented the incident or what the physician was told when notified of the incident. The fax cover sheet that was faxed to the physician's office after the above incident was dated 5/25/16 and was signed by LPN #5. The sheet documented, Please be advised that (Resident #4) had a non-injury fall this morning (at) 0530 (5:30 a.m.) trying to transfer herself from bed to BSC . The form incorrectly stated that there was no injury and had no documentation regarding the raised, bruised area to the resident's head. There was no indication on the form that the physician was contacted by telephone and informed of the incident in more detail. An Incident Investigation form dated 5/25/16 and signed by the Director of Nursing (DON) documented, .What: Fall with Injury . When: 5/25/16 . Where: Fall occurred in resident room . Why: Resident states that she had self-transferred to her bedside commode without any issues and felt that she could safely transfer back to her bed, but as she stood up, she became weak and fell to the floor landing on her left side and hitting her head on the floor. New Intervention: Orthostatic blood pressures BID (twice a day) x (times) 7 days, Oxygen saturations q (every) shift x 7 days, PT screening requested . There was no documentation to indicate the physician was informed of the injury to the resident's head. e. A Departmental Notes entry dated 5/25/16 at 3:24 p.m. and signed by LPN #6 documented, .Knot with light blue bruising to right temple related to recent fall . f. A Departmental Note dated 5/25/16 at 3:40 p.m. and signed by LPN #6 documented, Received new telephone order (Attending physician): (1) Orthostatic blood pressures BID at 0500 (5:00 a.m.) and 1700 (5:00 p.m.) times 7 days . (2) O2 (oxygen) saturation levels (every) shift times 9 days . There was no documentation to indicate the physician was informed of the injury to the resident's head. g. A handwritten Care Plan update dated 5/25/16 documented, Fall (with) injury; Raised bruised area on (right) side of forehead; Neuro checks initiated; Orthostatic BP (times) 7 days; O2 Sats (times) 7 days; PT screen; Nonskid strips placed on floor in front of BSC (and) by bed. MD (Medical Doctor) (and) Family notified . h. Departmental Notes dated 5/26/16 at 12:10 a.m. and signed by LPN #3 documented, Resident sitting up in bed unable to lay down R/T (related to) back pain resident c/o (complains of) left side pain in shoulder and left hip resident believes it is related to her fall. PRN (as needed) [MEDICATION NAME] given per orders and resident stated it was not helping then PRN Tylenol #3 given . There was no documentation that the physician was consulted regarding the new complaint of shoulder and hip pain that was unrelieved by [MEDICATION NAME] administration and that the resident felt the pain was related to the fall on the previous day. i. A Departmental Note dated 5/28/16 at 3:17 p.m. and signed by LPN #4 documented, .bruising to left back area and facial area still continues from recent fall, c/o (complains of) lower back pain attempted to reposition but not effective, then given prn Tylenol #3, within an hour resting comfortably, this was at 8 am this morning, then at 1 pm resident c/o neck and headache, requested prn [MEDICATION NAME] migraine . j. A Physician's General Progress Note dated 6/2/16 (8 days after the fall with injury occurred) documented, .Visit Information . Date of Service: 6/2/16 . Chief Complaint: new complaints of chest pain post fall History of Present Illness: Patient is seen today along with nursing home staff on rounds. Patient is resting in bed when seen on rounds today. Patient states that she had a fall about one week ago. Patient reports pain in her left upper chest area. Patient states the pain started after the fall. Bruising is noted on the left side of patient's upper chest in the area of her pacemaker. Patient has healing bruise above right eye as well. Patient states that her chest pain is her only concern at this time.Physical Examination .Musculoskeletal: .healing bruising above right eye, dark purple and red bruising on left upper chest. Patient with complaints of pain in upper left chest.Impression and Plan .Pain in chest. Patient with complaints of pain in upper left chest post fall one week ago. Patient with dark purple and red bruising to upper left chest. New order CXR and x-ray of left rib detail . k. A Departmental Note dated 6/2/16 at 10:06 a.m. and signed by LPN #6 documented, (Physician) here on rounds and received new order: CXR (chest x-ray) and X-ray left rib detail STAT (immediately). l. A CXR Report dated 6/2/16 at 11:22 a.m. documented, .Impression: Left clavicular fracture. m. A Departmental Note dated 6/2/16 at 5:41 p.m. and signed by LPN #6 documented, Received new telephone order . Ortho consult for left clavicle fx (fracture). n. On 6/30/16 at 3:26 p.m., LPN #5 was asked what was done for the resident after she fell on [DATE]. The LPN stated, Head to toe assessment, checking the head; check if can squeeze both hands, can speak, pupils equal. Complained of a little bit of a headache. The LPN was asked when the doctor was notified of the fall and stated, You know, I'm not sure. I figure I faxed that morning; I did. The LPN was asked if there were any injuries and stated, At that time, a small lump on head. We iced it. The LPN was asked how a determination was made on whether to call the physician after a fall. The LPN stated, .if (resident) can move, state their name, like neuro (checks). Non-injury protocol is what they use, like, if the resident not acting right. LPN #5 was asked if she informed the physician that the resident had a raised, bruised area on her head. The LPN stated, I did not. The LPN was asked why and stated, Because it was a small lump. Maybe a quarter in size. We put ice on it and end of shift, checked her. o. On 6/30/16 at 10:50 p.m., LPN #3 was asked if the physician was consulted on 5/26/16 when the resident complained of pain in the left shoulder and left hip and told the nurse she felt it was related to the fall on 5/25/16. The LPN stated, I don't know. The LPN was asked what should be done when a resident complains of pain after a fall. The LPN stated, I assume administer pain med (medication). The LPN was asked what should be done when a resident had a change of condition and stated, Notify the physician. p. On 7/1/16 at 10:15 a.m., the resident was asked if the pain she experienced after the fall on 5/25/16 was severe and stated, Yes, very bad. q. On 7/1/16 at 10:40 a.m., LPN #4 was asked about the Departmental Notes entry dated 5/28/16 at 3:17 p.m., which documented the resident had bruising to the left side of her back and to her facial area. The LPN stated, .she had some bruising to her left shoulder and temple area. The LPN was asked where the bruising was located and the LPN stated, Up on this area (pointing to left shoulder), her left shoulder and right temple, it was fading. You could still see it. r. On 7/1/16 at 11:45 a.m. the DON was asked when the physician was initially notified of the 5/25/16 fall. The DON referred to the 5/25/16 incident report and stated, She (nurse) has the date, but she didn't put the time, on 5/25/16. The DON was asked what time the incident occurred and stated, 5:45 a.m. The DON was asked what method was used to notify the physician, but gave no response. The DON was then shown the fax cover sheet documented by LPN #5 and was asked if that was a fax notification. The DON stated, It would appear so. The DON was asked what the fax documented and stated, That it was a non-injury fall at 5:30, which is not true, because she had a raised area on her head. The DON was asked if the resident had hit her head. The DON referred to the Incident Investigation attached to the incident report and stated, The resident hit her head. The DON was asked, If the resident had a raised area to the head, should the physician have been notified of the injury? The DON stated, Absolutely. The DON was asked if she had notified the physician on 5/25/16 and stated, Yes, I don't know the exact time. The DON was asked what was told to the physician and stated, That's when I left a message and asked if we could do orthostatic blood pressure and oxygen sats (saturation levels) because of weakness. The DON was asked if she thought that the information about the fall had already been communicated to the doctor and if it should have been. The DON stated, Yes. The DON was asked if the nurse who worked during the incident on 5/25/16 should have notified the physician and stated, That nurse should have notified the physician right then. That nurse, I feel, should have called. The DON was asked, When the physician saw the resident on 6/2/16, was that for routine rounds? The DON stated, Yes. The DON was asked if the physician should have been called after the resident complained of shoulder pain and due to the raised area on her forehead. The DON stated, Yes. 3. The immediate jeopardy was removed, and the scope / severity was reduced to H on 7/1/16 at 4:37 p.m., when the facility implemented the following Plan of Removal: a. On 7/1/16, DON will review all fall incident reports for the past 7 days to ensure policy and procedure was maintained. b. DON/designee will immediately question all nursing staff present today if they have any knowledge of any unreported resident falls or injury. Any reports of injury or falls will be reported to MD (Medical Doctor) immediately. c. Beginning 7/1/16, DON/designee will monitor PRN pain scales/records, resident assessments, the MAR (Medication Administration Record), nurses notes and all incident reports for consistency. Monitoring will be daily (times) 2 weeks, 5 (times) week (times) 2 weeks, 3 (times)/week (times) 2 weeks, then weekly thereafter. Any negative findings will be immediately addressed and monitoring schedule will resume if needed. All negative findings will be added to monthly QA (Quality Assurance). Beginning 7/1/16, all nurses will be in-serviced on administering and recording PRN pain medication, utilizing the pain scale, documenting the resident's pain rating and documenting the pain medication's effectiveness. Facility will ensure that any and all nurses who are not present today will be in-serviced regarding these issues prior to returning to work. d. Beginning 7/1/16, DON/designee will immediately begin to in-service all nurses on proper MD notification of all falls and reporting injury to the MD in a timely manner per policy and procedure. Facility will ensure that any and all nurses who are not present today will be in-serviced regarding these issues prior to returning to work for their next shift.

Complaint # (AR 330) was substantiated (all or in part) with these findings: Based on record review and interview, the facility failed to ensure necessary care and services were provided after a fall with injury, as evidenced by failure to ensure new onset shoulder pain was evaluated to rule out a serious fall-related injury; failure to ensure the severity of pain was thoroughly assessed prior to and after the administration of pain medication; and, failure to ensure the physician was immediately provided with complete and accurate information regarding fall-related injuries and complaints of pain after a fall occurred to prevent a delay in treatment and potential exacerbation of any existing injury for 1 (Resident #4) of 7 (Residents #2, #3, #4, #5, #6, #7 and #8) case mix residents who were at risk for falls. The failed practice resulted in Immediate Jeopardy, which caused or could have caused serious harm, injury or death to Resident #4, who experienced a fall that resulted in a head injury and fractured clavicle, had the potential to cause more than minimal harm to 24 residents who had falls in the past 60 days, as documented on a list provided by the Registered Nurse Consultant on 7/1/16. The facility was informed of the Immediate Jeopardy condition on 7/1/16 at 2:15 p.m. The findings are: 1. The facility's policy titled, Falls Management, provided by the Registered Nurse Consultant on 7/1/16 at 10:35 a.m., documented, .9. If injury, severe pain or abnormal assessments observed, call 9-1-1 for transfer . 12. Contact physician . and document in the medical record, including time and person spoken with . 14. The Director of Nursing will be notified immediately for falls resulting in injury and/or transfer . 2. Resident #4 had [DIAGNOSES REDACTED]. The Admission Minimum Data Set with an assessment reference date of 5/4/16 documented the resident scored 14 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status; required extensive assistance of 2-plus persons for bed mobility, transfers and toileting; was not on a scheduled pain medication regimen; had experienced occasional pain in the past 5 days; rated her worst pain during the 5 days prior to the assessment as a 2, on a scale of 0 to 10, with zero indicating no pain, and 10 indicating the worst pain imaginable; and had no falls since admission. a. Physician order [REDACTED].#3 (Tylenol #3) 300-30 mg (milligram) tablet: Give 1 tab (tablet) by mouth every 6 hours as needed for pain . [MEDICATION NAME] 37-5-325 mg tablet: Give 1 tab by mouth twice a day as needed . b. A Care Plan dated 4/26/16 documented, Problem: I am at risk for falls . Goal: I will not experience any injuries related to falls . Approaches: Monitor for changes in my condition that may warrant increased supervision / assistance and notify the physician . Problem Onset 4/26/16: I am experiencing the presence of pain in back . Approaches . Administer my pain medication as ordered . Observe for worsening of my pain . and report to physician . c. A Pain Management Flowsheet for May 2016 documented the resident complained of back pain, leg pain or headache one to three times daily throughout the month of May 2016 and received Tylenol #3 or [MEDICATION NAME] as ordered. There was no documentation of any complaints of shoulder pain. d. A Resident Incident Report dated 5/25/16 at 5:45 a.m. and signed by Licensed Practical Nurse (LPN) #5 documented, Incident Type: Fall w/ (with) inj (injury) - unwitnessed .Type of Injury: Bruise, Location: Resident room . Incident Level: . Event (with) Mild injury . Narrative of incident and description of injuries: CNA (Certified Nursing Assistant) found resident in floor, laying (sic) on left side between BSC (bedside commode) (and) bed. CNA reported fall to nurse. Raised bruised area to forehead. Immediate Actions Taken: Head to toe (and) pain assessment completed. Raised bruised area on forehead. Ice pack applied to forehead. Note Tylenol #3 approx (approximately) 30 minutes prior to fall. Neuros (neurological checks) initiated. Neuros, rom (range of motion) (and) prom (passive range of motion) wnls (within normal limits). Encourage resident to use call light for needs . strips next to bed on floor (and) PT (physical therapy) screening. PCP (Primary Care Physician), RP (responsible party) (and) DON (Director of Nursing) notified. Actions Taken: First Aid by: (LPN #5) Type of Aid: Head to toe (and) pain assessment, ice pack applied .Physician notified: (physician's name) Date/Time 5/25/16 . The form did not specify whether the physician was informed of the raised, bruised area to the resident's head. There were no Nurse's Notes dated 5/25/16 that documented the incident or what the physician was told when notified of the incident. The fax cover sheet that was faxed to the physician's office after the above incident was dated 5/25/16 and was signed by LPN #5. The sheet documented, Please be advised that (Resident #4) had a non-injury fall this morning (at) 0530 (5:30 a.m.) trying to transfer herself from bed to BSC . The form incorrectly stated that there was no injury and had no documentation regarding the raised, bruised area to the resident's head. There was no indication on the form that the physician was contacted by telephone and informed of the incident in more detail. An Incident Investigation form dated 5/25/16 and signed by the Director of Nursing (DON) documented, .What: Fall with Injury . When: 5/25/16 . Where: Fall occurred in resident room . Why: Resident states that she had self-transferred to her bedside commode without any issues and felt that she could safely transfer back to her bed, but as she stood up, she became weak and fell to the floor landing on her left side and hitting her head on the floor. New Intervention: Orthostatic blood pressures BID (twice a day) x (times) 7 days, Oxygen saturations q (every) shift x 7 days, PT screening requested . There was no documentation to indicate the physician was informed of the injury to the resident's head. e. A Departmental Notes entry dated 5/25/16 at 3:24 p.m. and signed by LPN #6 documented, .Knot with light blue bruising to right temple related to recent fall . f. A Departmental Note dated 5/25/16 at 3:40 p.m. and signed by LPN #6 documented, Received new telephone order (Attending physician): (1) Orthostatic blood pressures BID at 0500 (5:00 a.m.) and 1700 (5:00 p.m.) times 7 days . (2) O2 (oxygen) saturation levels (every) shift times 9 days . There was no documentation to indicate the physician was informed of the injury to the resident's head. g. A handwritten Care Plan update dated 5/25/16 documented, Fall (with) injury; Raised bruised area on (right) side of forehead; Neuro checks initiated; Orthostatic BP (times) 7 days; O2 Sats (times) 7 days; PT screen; Nonskid strips placed on floor in front of BSC (and) by bed. MD (Medical Doctor) (and) Family notified h. The Pain Management Flowsheets with the May and June 2016 Medication Administration Records (MARs) documented the following entries for Tylenol #3 from 5/25/16 through 6/2/16: 5/25/16 at 5:00 a.m. and 11:00 p.m., pain rating: 8; 5/27/16 at 12:00 MN (midnight), pain rating: 8; 5/27/16 at 9:00 a.m., (no pain rating documented); 5/28/16 at 8:00 a.m., (no pain rating documented); 5/28/16 at 11:50 p.m., (no pain rating documented); 5/29/16 at 8:00 a.m., pain rating: 8; 5/30/16 at 9:00 a.m., (no pain rating documented); 5/30/16 at 11:00 p.m., pain rating: 8; 6/1/16 at 12:10 a.m., (no pain rating documented); 6/2/16 at 12:15 a.m., (no pain rating documented); 6/2/16 at 11:00 p.m. (no pain rating documented). i. The Pain Management Flowsheets with the May and June 2016 Medication Administration Records (MARs) documented the following entries for [MEDICATION NAME] administration from 5/25/16 through 6/2/16: 5/25/16 at 8:35 p.m., pain rating: 8; 5/27/16 at 4:15 a.m. (no pain rating documented); 5/28/16 at 8:00 p.m. (no pain rating documented); 5/29/16 at 6:30 a.m. (no pain rating documented); 5/29/16 at 9:00 p.m. (no pain rating documented); 5/31/16 at 9:00 p.m. (no pain rating documented); 6/2/16 at 6:15 a.m. (no pain rating documented). j. Departmental Notes dated 5/26/16 at 12:10 a.m. and signed by LPN #3 documented, Resident sitting up in bed unable to lay down R/T (related to) back pain resident c/o (complains of) left side pain in shoulder and left hip resident believes it is related to her fall. PRN (as needed) [MEDICATION NAME] given per orders and resident stated it was not helping then PRN Tylenol #3 given . There was no documentation that the physician was consulted regarding the new complaint of shoulder and hip pain that was unrelieved by [MEDICATION NAME] administration and that the resident felt the pain was related to the fall on the previous day. k. A Departmental Note dated 5/28/16 at 3:17 p.m. and signed by LPN #4 documented, .bruising to left back area and facial area still continues from recent fall, c/o (complains of) lower back pain attempted to reposition but not effective, then given prn Tylenol #3, within an hour resting comfortably, this was at 8 am this morning, then at 1 pm resident c/o neck and headache, requested prn [MEDICATION NAME] migraine . l. A Physician's General Progress Note dated 6/2/16 (8 days after the resident's fall with injury) documented, .Visit Information . Date of Service: 6/2/16 . Chief Complaint: new complaints of chest pain post fall History of Present Illness: Patient is seen today along with nursing home staff on rounds. Patient is resting in bed when seen on rounds today. Patient states that she had a fall about one week ago. Patient reports pain in her left upper chest area. Patient states the pain started after the fall. Bruising is noted on the left side of patient's upper chest in the area of her pacemaker. Patient has healing bruise above right eye as well. Patient states that her chest pain is her only concern at this time.Physical Examination .Musculoskeletal: .healing bruising above right eye, dark purple and red bruising on left upper chest. Patient with complaints of pain in upper left chest.Impression and Plan . Pain in chest. Patient with complaints of pain in upper left chest post fall one week ago. Patient with dark purple and red bruising to upper left chest. New order CXR and x-ray of left rib detail . m. A Departmental Note dated 6/2/16 at 10:06 a.m. and signed by LPN #6 documented, (Physician) here on rounds and received new order: CXR (chest x-ray) and X-ray left rib detail STAT (immediately). n. A CXR Report dated 6/2/16 at 11:22 a.m. documented, .Impression: Left clavicular fracture. o. A Departmental Note dated 6/2/16 at 5:41 p.m. and signed by LPN #6 documented, Received new telephone order . Ortho consult for left clavicle fx (fracture). p. On 6/30/16 at 3:26 p.m., LPN #5 was asked what was done for the resident after she fell on [DATE]. The LPN stated, Head to toe assessment, checking the head; check if can squeeze both hands, can speak, pupils equal. Complained of a little bit of a headache. The LPN was asked when the doctor was notified of the fall and stated, You know, I'm not sure. I figure I faxed that morning; I did. The LPN was asked if there were any injuries and stated, At that time, a small lump on head. We iced it. The LPN was asked how a determination was made on whether to call the physician after a fall. The LPN stated, .if (resident) can move, state their name, like neuro (checks). Non-injury protocol is what they use, like, if the resident not acting right. LPN #5 was asked if she informed the physician that the resident had a raised, bruised area on her head. The LPN stated, I did not. The LPN was asked why and stated, Because it was a small lump. Maybe a quarter in size. We put ice on it and end of shift, checked her. q. On 6/30/16 at 10:50 p.m., LPN #3 was asked if the physician was consulted on 5/26/16 when the resident complained of pain in the left shoulder and left hip and told the nurse she felt it was related to the fall on 5/25/16. The LPN stated, I don't know. The LPN was asked what should be done when a resident complains of pain after a fall. The LPN stated, I assume administer pain med (medication). The LPN was asked what should be done when a resident had a change of condition and stated, Notify the physician. r. On 7/1/16 at 10:15 a.m., the resident was asked if the pain she experienced after the fall on 5/25/16 was severe and stated, Yes, very bad. s. On 7/1/16 at 10:40 a.m., LPN #4 was asked about the Departmental Notes entry dated 5/28/16 at 3:17 p.m., which documented the resident had bruising to the left side of her back and to her facial area. The LPN stated, .she had some bruising to her left shoulder and temple area. The LPN was asked where the bruising was located and the LPN stated, Up on this area (pointing to left shoulder), her left shoulder and right temple, it was fading. You could still see it. t. On 7/1/16 at 11:45 a.m. the DON was asked when the physician was initially notified of the 5/25/16 fall. The DON referred to the 5/25/16 incident report and stated, She (nurse) has the date, but she didn't put the time on 5/25/16. The DON was asked what time the incident occurred and stated, 5:45 a.m. The DON was asked what method was used to notify the physician, but gave no response. The DON was then shown the fax cover sheet documented by LPN #5 and was asked if that was a fax notification. The DON stated, It would appear so. The DON was asked what the fax documented and stated, That it was a non-injury fall at 5:30, which is not true, because she had a raised area on her head. The DON was asked if the resident had hit her head. The DON referred to the Incident Investigation attached to the incident report and stated, The resident hit her head. The DON was asked, If the resident had a raised area to the head, should the physician have been notified of the injury? The DON stated, Absolutely. The DON was asked if she had notified the physician on 5/25/16 and stated, Yes, I don't know the exact time. The DON was asked what was told to the physician and stated, That's when I left a message and asked if we could do orthostatic blood pressure and oxygen sats (saturation levels) because of weakness. The DON was asked if she thought that the information about the fall had already been communicated to the doctor and if it should have been. The DON stated, Yes. The DON was asked if the nurse who worked during the incident on 5/25/16 should have notified the physician and stated, That nurse should have notified the physician right then. That nurse, I feel, should have called. The DON was asked, When the physician saw the resident on 6/2/16, was that for routine rounds? The DON stated, Yes. The DON was asked if the resident should have been assessed for injury and the doctor called after the resident complained of shoulder pain and due to the raised area on her forehead. The DON stated, Yes. 3. The immediate jeopardy was removed, and the scope / severity was reduced to H on 7/1/16 at 4:37 p.m., when the facility implemented the following Plan of Removal: a. On 7/1/16, DON will review all fall incident reports for the past 7 days to ensure policy and procedure was maintained. b. DON/designee will immediately question all nursing staff present today if they have any knowledge of any unreported resident falls or injury. Any reports of injury or falls will be reported to MD (Medical Doctor) immediately. c. Beginning 7/1/16, DON/designee will monitor PRN pain scales/records, resident assessments, the MAR (Medication Administration Record), nurses notes and all incident reports for consistency. Monitoring will be daily (times) 2 weeks, 5 (times) week (times) 2 weeks, 3 (times)/week (times) 2 weeks, then weekly thereafter. Any negative findings will be immediately addressed and monitoring schedule will resume if needed. All negative findings will be added to monthly QA (Quality Assurance). Beginning 7/1/16, all nurses will be in-serviced on administering and recording PRN pain medication, utilizing the pain scale, documenting the resident's pain rating and documenting the pain medication's effectiveness. Facility will ensure that any and all nurses who are not present today will be in-serviced regarding these issues prior to returning to work. d. Beginning 7/1/16, DON/designee will immediately begin to in-service all nurses on proper MD notification of all falls and reporting injury to the MD in a timely manner per policy and procedure. Facility will ensure that any and all nurses who are not present today will be in-serviced regarding these issues prior to returning to work for their next shift.