Every finding on record at Crestpark Wynne, LLC

Based on interview, the facility failed to provide Provider Enhanced Reporting Payroll Based Journal (PBJ), mandatory staffing data in a uniform format to the Center for Medicare and Medicaid Services (CMS) for the 2nd Quarter 2025. The findings include: The PBJ Staffing Data Report was not available upon request during a recent annual recertification survey. The Administrator revealed the facility's PBJ data for January 2025, February 2025, and March 2025 was not submitted to the state, nor to CMS. According to CMS regulations, long-term care facilities must electronically submit to CMS complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS, but no less frequently than quarterly. During an interview on 07/23/2025 at 9:26 AM, the Administrator confirmed she was responsible for completing the staffing reports and sending the information to the state and CMS. She also verified she did not get the PBJ for the 2nd quarter done because she got an error with the data entry, then lost track of time, and forgot to submit it. The Administrator revealed the facility did not have a policy regarding PBJ data and reporting.

Based on observation, record review, and interview, the facility failed to ensure Enhanced Barrier Precautions (EBP) were implemented for one (Resident #11) of three residents reviewed for wounds. The findings include: Resident #11: During an observation on 07/24/2025 at 9:12 AM, this surveyor observed Licensed Practical Nurse (LPN) #10 provide wound care to Resident #11. LPN #10 performed hand hygiene, prepare the supplies, then put on gloves, but failed to put on a gown prior to performing the wound treatment. This surveyor also observed there was no EBP signage or Personal Protective Equipment (PPE) noted outside Resident #11's room. A review of Resident #11's Face Sheet indicated the facility admitted the resident on 05/24/2022, with diagnoses which included a urinary tract infection, dehydration, and chronic obstructive pulmonary disease. A review of Resident #11's annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/20/2025, revealed a Brief Interview for Mental Status (BIMS) score of 06, which indicated the resident had severely impaired cognition. The MDS also indicated Resident #11 was dependent on staff for transfers and required substantial/maximal assistance with dressing and required set up or clean up assistance with personal hygiene. A review of Resident #11's Physician Orders revealed the resident had wound treatment orders for their left buttock. A review of Resident #11's Resident Summary assessment dated [DATE], indicated a pressure ulcer to the resident's left buttock. During an interview on 07/24/2025 at 9:20 AM, LPN #10 confirmed she was not familiar with EBP. When asked what PPE should have been worn while performing high contact care to a resident with open wounds, she stated, Gloves for sure. If they have a PEG tube, a gown too if there would be any splashing. LPN #10 confirmed she did not wear a gown during the wound treatment for Resident #11. During an interview on 07/24/2025 at 9:28 AM, Certified Nursing Aide (CNA) #5 was asked if she was familiar with EBP, she stated, No. CNA #5 was then asked what PPE would be worn during high contact care for a resident with open wounds. She stated, Gloves unless there would be splashing then gown, shoe covers, mask, and goggles. During an interview on 07/24/2025 at 9:38 AM, CNA #6 was asked if she was familiar with EBP. She stated, No. Is that where you put something down before your supplies? CNA #6 was then asked what PPE would be worn during high contact care for a resident with open wounds. She stated, Gloves. During an interview on 07/24/2025 at 10:00 AM, CNA #8 was asked if she was familiar with EBP. She stated, Is that putting something down to protect something? CNA #8 was then asked what PPE would be worn during high contact care for a resident with open wounds. She stated, I guess all of it, mask, gloves, gown, shoe covers to protect me. During an interview on 07/24/2025 at 10:23 AM, the Director of Nursing/Infection Preventionist (DON/IP) was asked if she was familiar with EBP. She stated, I think I've heard of that, but I can't tell you what it is. The DON/IP was then asked what PPE would be worn during high contact care for a resident with open wounds. She stated, You would need at least gloves. I know with PEG tubes; we wear a gown. I'm not sure about everything else. If there is a possibility of splashing, you would want to wear a gown, and possibly shoe covers in case they have an infection. This surveyor requested a policy or procedure for isolation. The DON/IP stated the facility did not have one. This surveyor asked about previous in-services or training provided regarding EBP. The DON/IP stated she thought there was but could not provide any previous in-services or training. During an interview on 07/24/2025 at 10:40 AM, LPN #11 was asked if she was familiar with EBP. She stated, I don't know. LPN #11 was then asked what PPE would be worn during high contact care for a resident with open wounds. She stated, gloves and maybe a gown if it's a PEG tube. During an interview on 07/24/2025 at 11:00 AM, the Administrator was asked if the facility had a policy or procedure regarding EBP or isolation. She stated, No, not that I know of. During an interview on 07/24/2025 at 1:44 PM, the Advanced Practice Registered Nurse was asked if she was familiar with EBP and what residents it should be implemented for. She stated, Yes, for residents with wounds, PEG tubes, PICC lines, any unusual openings to the body. On 07/24/2025 at 12:00 PM, the DON/IP provided the Skin/Wound Log and confirmed it was an updated list. In addition, she verified Resident #11 had an open, active wound. A review of the Skin/Wound Log dated 07/09/2025, indicated Resident #11 was listed with active wounds.

Based on observation, interview, and facility policy review, the facility failed to ensure stored foods were properly covered, proper placement of meats, seasoning container lids were closed, and expired food items were promptly removed and discarded on or before the expiration or use by date, for one of one kitchen. The findings include: During a tour of the freezer on 07/21/2025 at 10:15 AM, this surveyor and the Dietary Manager (DM) observed the following: a. An open plastic bag with two beef patties was stored on a shelf, unsealed, exposing it to cross contamination. The DM stated, If it is not sealed, it could dry it out and it does not taste as good. b. A box of frozen fruit juice cups, with an expiration date of 05/05/2024, was on a shelf. c. A box of four-ounce chocolate shakes, with an expiration date of 06/11/2025was on a shelf. d. A bag of sausage patties was on a shelf, opened and unsealed. e. A bag of catfish was on a shelf, opened and unsealed. f. A box of pork steak was on a shelf, opened and unsealed. During a tour of the dry storage area on 07/21/2025, the following observations were made: a. Two 25-pound self-rising flour paper bags were on top of a table. This surveyor observed a brownish soiled area on both bags. The DM stated, I will throw it away in the trash. I don't know what it is. It's no longer good. b. Twenty-three, 46-fluid ounce containers of moderately thick honey consistency beverages were stored on a shelf. Sixteen of the containers had a best by date of 04/29/2025, and seven of the containers had a best by date of 05/28/2025. The DM stated they should have been thrown away, and this surveyor observed the DM throw all of the containers into the trash. c. A container of BBQ sauce was stored on a shelf, with a best by date of 03/05/2025. The DM confirmed out of date products should go in the trash. This surveyor observed the DM throw the BBQ into the trash. During a tour of the refrigerator on 07/21/2025, this surveyor and the DM observed the following: A box of uncooked pork was stored on a shelf, on the shelf below were eggs and tomatoes. The DM stated, the juice can leak on to the eggs and tomatoes and contaminate them. During a tour of the cooking area on 07/21/2025, this surveyor and the DM observed the following: Three seasoning containers were stored on a shelf near the kitchen stove; the lids were open and unsealed. The DM stated, Stuff can get inside, and cross contamination could happen. A review of the facility policy and procedural manual titled, Food Storage, indicated date marking should be visible on all high-risk food to indicate the date by which a ready-to-eat TCS food should be consumed, sold or discarded. The facility policy and procedural manual also indicated that all frozen foods should be covered, labeled and dated. All frozen foods will be checked to assure that foods will be consumed by their use by dates or discarded. Meat, fish and poultry should be stored on loser shelves, while fruits, vegetables, juices and breads should be stored on upper shelves. 1

Based on observation, interview, and record review, the facility failed to ensure food items were sealed after opening, food items were used prior to their use by date, equipment was maintained in good condition, and pans and other containers were stored in a manner to minimize the risk of contamination. The findings are: On 04/09/2024 at 10:27 AM, a carton of potato flakes was observed on the top shelf, above the worktable in the kitchen. The mouth of the carton was open, exposing the food product to air and contaminants. On the lowest shelf a container of paprika was observed with the top open exposing the product to air and contaminants. On 04/09/2024 at 10:35 AM, 1 package of hot dog buns and 1 package of hamburger buns were observed on the top tray of the bread rack with a use by date of 04/05/2024. On the second tray there were 4 full loaves of sliced bread with a use by date of 04/05/2024. On 04/09/2024 at 10:40 AM, 4 stainless steel mixing bowls, 5 skillets, 4 sheet trays, 7 large trays, 3 1/2 steam table pans, 2 1/4 steam table pans and 9 large steam table pans were stored right side up in a manner which allow dust and contaminants to collect prior to use. The shelf was observed to contain multiple food particles which extended down the length of the shelf and were beside the pots, trays, and other items on the shelf. On the upper shelves a stack of 11 divided plates, 5 gallon pitchers and one large beverage dispenser were observed to be right side up allowing for the collection of dust and contaminants. On 04/08/2023 at 10:45 AM, 2 wire baskets used for deep frying were observed hanging from a pot rack in the middle of the room. The entire circumference of each basket was coated in a tan substance that was thick and sticky to touch. The substance extended 1 to 1.5 inches down the side and all the way up the handle of each basket. Several pots were observed to be dented and blackened on the bottom. On 04/08/2024 at 11:36 AM, Dietary Aide #1 was observed inserting a digital thermometer into a full steam table pan of baked beans. The thermometer was inserted into the beans all the way to the handle of the thermometer, the plastic end extending into the bean mixture 1/2 inch. On 04/08/2024 at 12:00 PM, seven tables were observed in the dining room. The legs of each table were observed to be covered in varying amounts of rust. On 04/11/2024 at 10:45 AM, the Director of Nursing (DON) provided a Food Safety and Sanitation Policy and Procedure. On page 2, the policy directs that stored food is handled to prevent contamination and growth of pathogenic organisms. When a food package is opened, the food item should be marked to indicate the open date; perishable foods with expiration dates are used prior to the use by date on the package. Note: .all food and dining areas should be inspected on a regular basis. On 04/11/2024 at 11:15 AM, the Dietary Manager (DM) was asked how pots, pans and utensils should be stored. She replied that the items would typically be stored face down but the facility has a large rack for storing pots and pans. The DM was asked about the items on the bottom shelf and confirmed that the items are stored right side up but stated that the items should be face down. The DM identified the risk of gathering debris as the reason for storing these items bottom up. When asked how long the rust had been present on the shelves and legs of the worktables, the DM reported that the rust was present when she started working in the facility [AGE] years ago. The DM described how the staff took several pieces outside last year and painted the rusted shelves with paint designed for metal. However, the attempt at refurbishing isn't holding up as they had expected. She continued that the primary worktable located in the middle of the room that had the heaviest rust coverage, they were not able to get the table outside because the screws which hold the pot rack started to break when they attempted to take the rack down. The screws were corroded with grease and rust. When addressing the rack located beside the steam table that was rusted, the DM expressed that they would have been better served with a rubber coated rack versus the rack that is all metal. The DM confirmed that she was aware of the rust on the tables in the dining room. She was uncertain as to when the rust had developed, just that the rust had covered the legs of the tables for some time. When asked to describe the substance covering the circumference of the deep fryer the DM said the substance was a buildup of grease, a little crusty and slick. The DM reports that the facility has never had a deep fryer, as that would require the hood to be enlarged. Ensuring an item is dated and sealed was identified by the DM as the primary task when a food item is brought into the kitchen. On 04/12/2024 at 08:24 AM, the Administrator was asked if she was aware of the issues concerning the presence of rust on the kitchen equipment and on the legs of the dining room tables. The Administrator reported that they have been intending to take the tables outside to paint the legs. The Administrator was asked how long the tables had been in the facility, and the Administrator reported as long as she had been here, [AGE] years.

Based on observation, interview and record review, the facility failed to ensure hand rolls were applied to prevent further decline in range of motion (ROM) for 2 (Residents #13 and #28) of 3 sampled residents. The findings are: 1. A review of Resident #13's Care Plan dated 05/26/2023 did not document the contracture to the left hand. a. A review of Resident #13's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/21/2024 noted the resident was impaired on one side of the upper extremities. b. On 04/09/2024 at 11:17 AM, the Surveyor observed Resident #13 lying in bed at a fifteen (15) degree angle on his/her left side with legs elevated under the blanket. Resident #13 had a left hand contracture with no device present. c. On 04/09/2024 at 02:24 PM, the Surveyor observed Resident #13 lying on his/her back in bed at a fifteen (15) degree angle. The left hand remained contracted with no device present. d. On 04/10/2024 at 12:58 PM, the Surveyor observed Resident #13 lying in bed. The left hand was contracted with no device present. e. On 04/10/2024 at 01:04 PM, Certified Nurse Assistant (CNA) #3 confirmed that Resident #13's left hand was contracted with no device present to prevent the contracture from getting worse. f. On 04/10/2024 at 01:17 PM, the Director of Nursing (DON) confirmed that Resident 13's left hand was contracted with no device present to prevent the contracture from getting worse. 2. A review of Resident #28's Care Plan dated 12/19/2023 did not document the contracture to the left hand. a. A review of Resident #28's Quarterly MDS with an ARD of 02/14/2024 noted the resident was impaired on both sides of the upper extremities. b. On 04/10/2024 at 01:10 PM, the Surveyor interviewed CNA #3 at Resident #28's bedside and had her pull the residents blanket back to expose the extremities. CNA #3 confirmed the resident had a left hand contracture with no device present to prevent the contracture from getting worse. c. On 04/10/2024 at 01:20 PM, the Surveyor interviewed the DON at Resident #28's bedside. The DON confirmed the resident had a left hand contracture with no device present to prevent the contracture from getting worse. d. On 04/11/2024 at 09:22 AM, the Surveyor interviewed the Minimum Data Set (MDS) Coordinator and asked, If a resident is admitted to the facility with a contracture should it be documented on their comprehensive care plan? She stated, Yes, ma'am. When asked, Why should a contracture be on the care plan? She stated, It has to do with ADLs [activities of daily living] and help they may need. They may need a hand roll to prevent it from getting worse.

Based on interview and record review, the facility failed to ensure a Quarterly Minimum Data Set (MDS) was transmitted in a timely manner to promote individualized care for 2 (Residents #7 and #13) of 2 sampled residents. The findings are: On 04/10/2024 at 11:10 AM, a Quarterly Minimum Data Set (MDS) for Resident #7 and Resident #13 were identified as being 120 days late. On 04/10/2024 at 01:30 PM, the MDS Coordinator was asked to review the last MDS assessments which were submitted for Resident #7 and #13. The MDS Coordinator reported Resident #7 had a Quarterly MDS which was submitted on 02/01/2024 and Resident #13 had a Quarterly assessment submitted on 02/21/2024. The MDS Coordinator describes the facility computer system as revealing the assessments were submitted and received. The MDS Coordinator displayed paper confirmation which confirmed the submission and receipt. The MDS Coordinator shared that another person was responsible for completion and submission of MDS assessments during the month of February. The MDS Coordinator verbalized her plan to look on the CMS website to ensure the submissions were complete. On 04/11/2024 at 08:10 AM, the MDS Coordinator reported that CMS (Centers for Medicare & Medicaid Services) was contacted, and it was determined that the MDS assessments in question were not submitted/accepted as previously thought. The MDS Coordinator confirmed that the assessments were late and were resubmitted on the evening of 04/10/2024. The MDS Coordinator provided an MDS 3.0 NH (Nursing Home) Final Validation Report which confirmed reception, receipt, and acceptance on 04/11/2024. When the MDS Coordinator was asked how the facility would have known that there had been an issue with the transmission of assessments completed in February. The MDS Coordinator stated that she wouldn't have known until the next assessment was completed had it not been for the attention called to the problem during this survey. On 04/11/2024 at 02:21 PM, the Director of Nursing (DON) provided, Ch [Chapter] 5: Submission and Correction of the MDS Assessments, page 5-3. It documented, Assessment Transmission: Comprehensive assessments must be transmitted electronically within 14 days of the Care Plan Completion Date. All other MDS Assessments must be submitted within 14 days of the MDS completion Date.

Based on observation, interview, and record review, the facility failed to ensure fall mats at the bedside were properly positioned for 1 (Resident #13) of 1 sampled resident who required fall mats and call lights were maintained with no exposed wires for 1 (Resident #11) of 1 sampled resident. The findings are: 1. Resident #13 was admitted on [DATE] with a diagnosis of Alzheimer's disease and Convulsions. a. A facility in-service titled, 'Falls: Reduce the Risks' dated 05/19/2023 documented, .Intervention & Documentation Tickler for Falls . Padding on floor- landing mat(s) . b. The facility provided an Incident and Accident (I&A) Report dated 03/05/2024 that noted Resident #13 had fallen and hit the right side of their forehead on the floor. The twenty-four (24) hours follow up noted fall mat placed, staff re-educated to lower head of bed (HOB). c. Review of Resident #13's Care Plan dated 05/26/2023 did not document a fall. d. On 04/09/24 at 11:17 AM, the Surveyor observed Resident #13 lying in bed. Resident #13 had a fall mat that was positioned underneath the bed. e. On 04/10/2024 at 12:55 PM, the Surveyor observed Resident #13 lying in bed. Resident #13's fall mat was underneath the bed. f. On 04/10/2024 at 01:04 PM, Certified Nursing Assistant (CNA) #3 confirmed the resident was at risk for falls and the fall mat was underneath Resident #13's bed and should be located on the side of the resident ' s bed. g. On 04/10/2024 at 01:13 PM, the Director of Nursing (DON) confirmed the resident was a fall risk and the fall mat was underneath Resident #13's bed and should be located on the side of the resident's bed. h. A facility policy titled 'Accidents' documented, .The intent of this requirement is to ensure the facility provides an environment that is free from accident hazards over which the facility has control and provides supervision and assistive devices to each resident to prevent avoidable accidents. This includes: Identifying hazard(s) and risk(s); evaluating and analyzing hazard(s) and risk(s); Implementing interventions to reduce hazard(s) and risk(s) . 49689 2. On 04/09/2024 at 12:48 AM, the Surveyor observed a gray call light laying across Resident #11's bed, part of the plastic was missing exposing wires. The Surveyor then observed a cable cord hanging from the right-hand corner near the bathroom door. The cable was touching the floor. a. On 04/09/2024 at 02:22 PM, the Surveyor observed the resident moving around the room, no changes had been made to observations earlier. b. On 04/09/2024 at 02:33 PM, the Surveyor asked CNA #1 to describe the call light and what the issue could be for the resident. CNA #1 said that a plastic piece is missing, and that it could be a fire hazard. The Surveyor asked what the protocol for reporting issues like this was. CNA #1 said it should be written down on the maintenance log. The Surveyor then observed the CNA #1walk to the maintenance log for east hall and state it had not been reported, the Surveyor then observed them writing in it about the call light having wires exposed. c. On 04/09/2024 at 02:37 PM, the Surveyor asked the Maintenance Employee to observe the call light and asked what the issue could be for the resident. The Maintenance Employee said it has plastic broken off, and that it's an electrical issue. The Surveyor asked if it had been reported to them. The Maintenance Employee said it had not. The Surveyor asked about the cable in the corner of the room. The Maintenance Employee said that it was supposed to be covered and tucked into the ceiling. The Surveyor asked what the issue is with the cable being down. The Maintenance Employee said that it could be hazardous as they believe it's a live wire. The Surveyor asked if it has been reported to them. The Maintenance Employee said no it has not been reported. d. A facility policy titled Maintaining Call Lights documented, .Maintenance is responsible for ensuring that call lights are working/functioning properly. Call lights should be checked once a week. Staff should report any call lights that are not functioning properly to maintenance so that the issue can be resolved. Call light Checklist: C. Call light cords in good condition-no fraying or tears on cord .

Based on interview and record review, the facility failed to ensure a resident's individualized plan of care was revised to reflect the current needs of the resident and updated to include falls for 1 (Resident #13); oxygen therapy for 1 (Resident #19); and Hospice services for 1 (Resident #30) sampled residents. The findings are: 1. Resident #13's Care Plan dated 05/26/2023 did not document the contracture to Resident #13's left hand. a. A review of Resident #13's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/21/2024 noted the resident was impaired on one side of both the upper and lower extremities and had had no falls. b. An Incident report dated 03/05/2024 noted Resident #13 was found lying on the floor next to the bed. 2. A review of Resident #19's Care Plan dated 05/19/2023 did not document oxygen use. a. A review of Resident #19's Physician Orders dated 02/06/2024 noted oxygen saturation QS (as frequently as needed) keep at or above 93%. No specific order for quantity of oxygen in liters. b. A review of Resident #19's Medication Administration Record (MAR) for April 2024 documented oxygen usage at two (2) liters as needed for shortness of breath or below 93% O2 (oxygen) on 04/01/2024; 04/02/2024; 04/05/2024; 04/06/2024; 04/08/2024; and 04/09/2024. 44852 3. Resident #30 had a diagnosis of Unspecified dementia without behavioral disturbance. a. A Physician's Order for admission to Hospice was received on 03/26/2024. The order also included the discontinuation of all medications except PRN (as needed) and comfort. On 04/10/2024, a review of Resident #30's medical record revealed a physician's order for admission to Hospice was received on 03/26/2024. A review of Resident #30's care plan revealed that the care plan had not been revised to include Hospice services. b. On 04/11/2024 at 08:20 AM, the MDS Coordinator was asked when a care plan should be updated. The MDS Coordinator reported that a comprehensive care plan should be updated quarterly and as needed. When asked for as needed examples, the MDS Coordinator cited falls, major medication changes. When asked if the discontinuation of all medications which included antidepressants and antipsychotics would be considered a major medication change, the MDS Coordinator confirmed it would. When asked why updating the care plan would be important in this instance, the MDS Coordinator described that the staff would need to know to look for changes in mood or behavior. 4. The facility provided a policy titled, 'CMS's [Centers for Medicare & Medicaid Services] RAI [Resident Assessment Instrument] Version 3.0 Manual,' dated October 2023, that documented, .Following the decision to address a triggered condition on the care plan, key staff or the IDT [Interdisciplinary Team] should subsequently: Review and revise the current care plan, as needed; and Communicate with the resident or their family or representative regarding the resident, care plans, and their wishes .

Based on observation, interview and record review, the facility failed to ensure hand rolls were applied to prevent further decline in range of motion (ROM) for 2 (Residents #13 and #28 ) of 3 sampled residents. The findings are: 1. A review of Resident #13's Care Plan dated 05/26/2023 did not document the contracture to the left hand. a. A review of Resident #13's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/21/2024 noted the resident was impaired on one side of the upper extremities. b. On 04/09/2024 at 11:17 AM, the Surveyor observed Resident #13 lying in bed. Resident #13 had a left hand contracture with no device present. c. On 04/09/2024 at 02:24 PM, the Surveyor observed Resident #13 lying in bed. The left hand was contracted with no device. d. On 04/10/2024 at 12:58 PM, the Surveyor observed Resident #13 lying in bed. The left hand was contracted with no device present. e. On 04/10/2024 at 01:04 PM, the Surveyor interviewed Certified Nursing Assistant (CNA) #3 at Resident #13's bedside. CNA #3 confirmed the resident's left hand was contracted with no device present to prevent the contracture from getting worse. f. On 04/10/2024 at 01:17 PM, the Surveyor interviewed the Director of Nursing (DON) at Resident #13's bedside. The DON confirmed the resident's left hand was contracted with no device present to prevent the contracture from getting worse. 2. Resident #28's Care Plan dated 12/19/2023 did not document the contracture to the left hand. a. A review of Resident #28's Quarterly MDS with an ARD of 02/14/2024 noted the resident was impaired on both sides of the upper and lower extremities. b. On 04/10/2024 at 01:10 PM, the Surveyor interviewed CNA #3 at the resident's bedside and had her pull the residents blanket back to expose the extremities. CNA #3 confirmed Resident #28 had a left hand contracture with no device present to prevent the contracture from getting worse. c. On 04/10/2024 at 01:20 PM, the Surveyor interviewed the DON at the resident's bedside. The DON confirmed that Resident #28 had a left hand contracture with no device present to prevent the contracture from getting worse. 49689 3. A review of the facility policy titled, Restorative/Rehab [Rehabilitation] Care stated in part, the goals of rehab/restorative care are to maintain the present level of function and to improve or restore physical function.

Based on observation, interview and record review, the facility failed to ensure residents were shaved to promote good personal hygiene for 2 (Residents #13 and #3) of 2 sampled residents and residents' fingernails were kept clean for 1 (Residents #3) of 1 sampled resident. The findings are: 1. A review of Resident #13's Plan of Care dated 05/26/2023 noted the resident required total assistance with activities of daily living (ADLs). a. The facility provided a policy titled, 'Please Be Careful When Shaving Residents. Do Not Rush Through, As This Can Lead To Nicks & Cuts', dated 12/15/2023, which documented, Overview: Shaving may help a person feel good. b. A review of Resident #13's Physician Orders dated 02/09/2024 documented, Shower 6-2 bed baths daily may give shower if needed/ as tolerated. c. A review of Resident #13's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/21/2024 noted the resident was dependent for showers/baths. d. On 04/09/2024 at 11:17 AM, the Surveyor observed Resident #13 lying in bed. The resident needed to be shaved. e. On 04/09/2024 at 02:24 PM, the Surveyor observed Resident #13 lying in bed. The resident's face was not shaven. f. On 04/10/2024 at 12:57 PM, the Surveyor observed Resident #13 lying in bed. Resident #13 was unshaven. g. On 04/10/2024 at 01:04 PM, the Surveyor interviewed Certified Nursing Assistant (CNA) #3 at Resident #13's bedside. CNA #3 confirmed the resident was not clean shaven and should have been shaved on bath day. h. On 04/10/2024 at 01:15 PM, the Surveyor interviewed the Director of Nursing (DON) who confirmed the resident was not clean shaven and should have been shaved on bath day. 2. Resident #3 had diagnoses of Unspecified sequelae of cerebrovascular accident and Unspecified atrial fibrillation. a. A Quarterly MDS with an ARD of 01/15/2024 documented Resident #3 scored 13 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status (BIMS) and was dependent for care. b. Resident #3's Care Plan documented, The resident is at risk of developing complication r/t [related to] needing total assistance in the following ADLS [activities of daily living]: bed mobility, transfer, locomotion, dressing, personal hygiene, bathing, and toilet use . Approaches. Nailcare every two weeks per nurse . c. On 04/09/2024 at 12:26 PM, Resident #3's chin had hair that was stubble like in appearance. The Surveyor observed the fingernails of both hands had a brown substance under them, and the nails were long, jagged, and chipped in appearance. Resident #3 said they do not pluck my hair on bath days, and I would like that. Resident #3 also stated that the resident would like their fingernails cleaned and clipped. e. On 04/09/2024 at 02:21 PM, the Surveyor asked Resident #3 if nail care and plucking had been provided. Resident #3 showed the Surveyor the resident's chin and hands. The Surveyor observed no changes. Resident #3 stated it had not. f. On 04/10/2024 at 01:34 PM, the Surveyor asked CNA #2 to described Resident #3's hands. CNA #2 said that the nails were long and dirty and that they needed to be clipped. The Surveyor asked for CNA #2 to describe Resident #3's chin. CNA #2 said that the hair needs to be plucked or shaved. The Surveyor asked what the issue for the resident could be. CNA #2 said that it could be a dignity issue. The Surveyor asked when should nail care and shaving be done. CNA #2 said as needed, and to tell the nurse if the resident is diabetic. g. On 04/10/2024 at 01:43 PM, the Surveyor asked Licensed Practical Nurse (LPN) #1 to describe Resident #3's hands. LPN #1 said that the nails need clipping and are dirty. The Surveyor asked what the issue for the resident could be. LPN #1 said that the resident could scratch herself. The Surveyor asked LPN #1 to describe Resident #3's chin. LPN #1 said that yes, they need plucked or shaved. The Surveyor asked when should nail care and shaving be done. LPN #1 said when you see it and bathe them. 49689

According to observation, interview and record review, the facility failed to ensure incontinence care waste was disposed of properly for one (Resident #26) sampled resident. The findings are: 1. A Face Sheet documented Resident #26 had diagnoses of Dementia, Delusional disorder, and Cognitive communication deficit. 2. A Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/02/2024 documented Resident #26 scored a 2 (0-7 indicates severe cognitive impairment) on the Brief Interview for Mental Status (BIMS). 3. A Care Plan for Resident #26 documented, Behavior, [Resident #26] wanders thru [through] out the facility, [Resident #26] will remove urostomy and emptied in different places, rummages through clothes in [Resident #26's] room. 4. On 04/09/2024 at 10:25 AM, the Surveyor observed Resident #26 wandering the halls, then enter the resident's room and began to rifle through the trash. The Surveyor observed that in the trash can was a soiled brief with a blue wetness indicator visible. Resident #26 touched the soiled brief. The Surveyor then observed Resident #26 leave the room and walk down the hall. Resident #26 touched the handrails in the hallways being utilized by other residents, interacted with staff members, and touched a chair by the nurse's station before sitting in it. The Surveyor observed two residents going by in wheelchairs, stopped to take breaks and touch the handrails in the hallway. Registered Nurse (RN #1) redirected Resident #26 to the resident's room, holding the Resident ' s hand while walking down the hall. 5. On 04/09/2024 at 10:30 AM, the Surveyor asked Registered Nurse (RN) #1 what was in Resident #26's trash can by the bed. RN #1 said there is a brief in the trash can and it should have been changed already after incontinence care was performed. The Surveyor observed RN #1 pulling the trash bag containing the soiled brief out and put a new one in. The Surveyor asked what the issue could be for soiled incontinence care products being left in the room with a cognitively impaired resident. RN #1 said the resident could get into it; the resident has severe dementia. 6. On 04/10/2024 at 01:35 PM, the Surveyor asked Certified Nursing Assistant (CNA) #2 if soiled briefs should be left in the trash can after incontinence care was performed. CNA #2 said that the brief should not have been left in there, as it's an infection control issue. 7. A facility training titled Incontinent Care/Foley Care Observation documented, .21. Clean-up workstation and place everything in appropriate bags .

Based on record review and interview, the facility failed to ensure a change of condition assessment was completed no later than 14 days after the significant change for 1 (Resident #30) of 1 sampled resident. The findings are: 1. Resident #30 had a diagnosis of Unspecified dementia without behavioral disturbance. a. The resident's medical record revealed a Physician's Order for admission to Hospice was received on 03/26/2024. The last Minimum Data Set (MDS) completed was a Quarterly assessment with an Assessment Reference Date (ARD) of 12/04/2023. No Significant Change assessment was present in the medical record. b. On 04/11/2024 at 08:20 AM, the MDS Coordinator was asked if she was aware Resident #30 was admitted to Hospice. The MDS Coordinator reported that she hadn't reviewed the dates and claimed responsibility for the oversight. The MDS Coordinator was asked how she was made aware of changes in a resident's status. The MDS Coordinator described reviewing the orders every day along with the 24 hour reports. The MDS Coordinator confirmed that the facility does not have a daily stand up meeting to discuss changes in resident status. c. The Centers for Medicare & Medicaid Services (CMS) Resident Assessment Instrument (RAI) Version 2.0 manual documented, .Chapter 2: The assessment Schedule for RAI .Significant change in status assessments (SCSA)-Comprehensive Assessment .If the condition does not return to baseline, the assessment should be completed as soon as needed to provide appropriate care to the resident, but in no case later than 14 days after the determination was made that a significant change occurred .

Based on observation and interview, the facility failed to ensure the kitchen and dry storage area floors were free of debris, dirt, and stains and the kitchen vent were maintained in clean condition to provide a clean and sanitary environment for food preparation and to prevent the potential for food borne illness for residents who received meals from 1 of 1 kitchen; foods stored in the freezer, refrigerator, and dry storage area were covered, sealed and dated to minimize the potential for food borne illness for residents who received meals from 1 of 1 kitchen; food items were promptly removed and/or discarded on or before the expiration or use by date to prevent the growth of bacteria; food items that contained dairy products and other food items were used by its use-by date to maintain maximum freshness and taste and prevent potential food borne illness for residents who received a meal trays from 1 of 1 kitchen; dietary staff washed their hands between dirty and clean tasks and before handling clean equipment or food items to prevent potential for cross contamination; failed to ensure 3 of 3 ice machines were maintained in a clean and sanitary condition to prevent potential contamination of residents' beverages. These failed practices had the potential to affect 22 residents who received ice from the ice machine on the North Hall, 15 resident residents who received ice from the ice machine on the East Hall and 36 residents who received meals from the kitchen (total census 38), as documented on a list provided by Dietary Supervisor on 03/14/23 at 11:42 AM. The findings are: 1. On 03/13/23 at 10:17 AM, in the Kitchen, there was black residue on the panel of the ice machine. The Dietary Supervisor was asked to wipe the residue from the panel of the ice machine. The black residue easily transferred to the paper towel. The Surveyor asked the Dietary Supervisor how often the ice machine was cleaned and who uses the ice from the ice machine. She stated, We clean it every week and we use it to fill beverages for the residents at mealtimes. That's the ice the CNAs [Certified Nursing Assistants] use for the water pitchers in the residents' rooms and to fill beverages served to the residents at mealtimes. 2. On 03/13/23 at 10:19 AM, the following spices were observed on a shelf above the food preparation counter: a. Ground Celery Seed. b. Ground White Pepper. c. Meat Tenderizer. d. Taco Seasoning. e. Chili Powder. f. Ground Cumin. g. Ground Black Pepper. h. Montreal Steak Seasoning. i. Ground Cinnamon. j. Lemon and Pepper Seasoning Salt. k. Rubbed Sage. l. Smoked Sweet Paprika. m. Ground Mediterranean Seasoning. n. Dillweed. o. Thyme Leaves. p. Mediterranean Seasoning q. Oregano. The spices had no date when they were opened or when received. 3. An opened bag of sandwich bread was on the food preparation counter and had an expiration date of 3/10/2023. 4. On 03/13/23 at 10:21 AM, the following were observed on the bread rack in the Storage Room: a. Eight bags of bread dated 3/4/2023. b. One bag of bread had an expiration date of 3/9/2023. c. Two bags of bread had an expiration date of 2/25/2023. d. Sixteen bags of bread had expiration date of 3/10/2023. 5. On 03/13/23 at 10:49 AM, the following food items were on a shelf in the walk-in freezer in the Storage Room: a. An opened box of sausage, had no opened date on the box. b. An opened box of biscuits had no opened date on the box. c. An opened box of okra had no opened date on the box. d. An opened box of boneless pork chop fritters. The box was not covered or sealed. 6. On 03/13/23 at 10:53 AM, the following food items were on a shelf in the walk-in refrigerator: a. An opened bag of biscuits. The bag was not completely sealed. b. An opened bag of cheese slices had no date to indicate when it was opened. 7. On 03/13/23 at 11:21 AM, Dietary Employee (DE) #1 picked up the water hose with her bare hand and used it to spray off leftover food items from the blender contaminating her hands. She placed the blender, the lid, and the blade in the dirty rack of the dishwasher and pushed it into the dish washing machine. After the dishes stopped washing, she moved to the clean side and without washing her hands picked up the clean blade and attached it to the base of the blender to be used in pureeing foods to be served to the residents for lunch. At 11:26 AM, when she was ready to place cornbread into a blender to puree, the Surveyor stopped her and asked, What should you have done after touching dirty objects and before handling clean equipment? She stated, I should have washed my hands. I will go back and rewash the blade and the blender. 8. On 03/13/23 at 11:33 AM, DE #2 turned on the hand washing sink faucet and washed his hands. With his bare hands he turned off the faucet contaminating his hands. Without washing his hands he placed gloves on his hands contaminating the gloves. He untied a bread bag and used his contaminated gloved hand to remove slices of bread from the bag and placed them on the tray. He used a spatula to remove pimento cheese from the container and spread on the bread to be served to the residents for lunch. The Surveyor asked, What should you have done after touching dirty objects and before handling clean equipment? He stated, I rewash my hands and redo the pimento cheese sandwiches. 9. On 03/13/23 at 11:39 AM, the ceiling vent leading to the dish washing machine, extending towards the plate warmer had greasy cobweb/lint inside the slats with an accumulation of corroded black residue on them. 10. On 03/13/23 at 11:41 AM, DE #3 turned on the hand washing sink faucet and washed her hands. She turned off the faucet with her bare hands contaminating her hands. She removed gloves from the glove box and placed them on her hands contaminating the gloves. She picked up bowls with her contaminated gloved fingers inside of the bowls and placed them on the counter by the steam table to be used in portioning foods to be served to the residents on for lunch. 11. On 03/13/23 at 11:55 AM, the refrigerator temperature on the East Hall was 50 degrees Fahrenheit. The freezer was set on cool. The ice cream in the freezer was soft to touch. The Surveyor asked the Dietary Supervisor if the ice cream was still frozen solid. She stated, It was soft. On a shelf in the refrigerator was a plate with a pimento cheese sandwich dated 2/18/2023. On 3/14/23 at 3:38 PM, the Surveyor asked the Dietary Supervisor how long you keep a leftover sandwich. She stated, Two days maximum. 12. On 03/14/23 at 8:14 AM, the ice machine on the North Hall had a wet black residue on the left side of the panel. The panel area where the ice forms before dropping to the ice collector had a wet brown residue on it. The Surveyor asked the Dietary Supervisor to wipe the residue from the panel of the ice machine. The black residue easily transferred to the paper towel. The Surveyor asked how often the ice machine was cleaned and who uses the ice from the ice machine. She stated, We clean it every week, That's the ice the CNAs use for the water pitchers in the residents' rooms. 13. On 03/14/23 at 8:22 AM, the ice machine on the East Hall had a wet pink residue on the panel. The Surveyor asked the Dietary Supervisor to wipe the residue from the panel of the ice machine. The pink residue easily transferred to the paper towel. The Surveyor asked how often the ice machine was cleaned and who uses the ice from the ice machine. She stated, They clean it every Thursday. That's the ice the CNAs use for the water pitchers in the residents' rooms. 14. The facility policy titled, Hand Washing, provided by the Dietary Supervisor on 03/14/23 at 11:42 PM documented, . Policy: Employees will wash hands as frequently as needed throughout the day . Procedure: 1. When to wash hands: a. When entering the kitchen at the start of a shift . f. After handling soiled equipment or utensils. g. During food preparation, as often as necessary to remove soil or contamination and to prevent cross contamination when changing tasks . i. Before donning disposable gloves for working with food and after gloves are removed. j. After engaging in other activities that contaminates the hands .

Based on observation, record review, and interview, the facility failed to ensure an effective pest control program was in place to keep the kitchen free of pests to prevent the potential of cross contamination or bacteria growth. The failed practice had the potential to affect 36 residents who received meals from the kitchen (total census 38), as documented on a list provided by the Dietary Supervisor on 03/14/23 at 11:42 AM. The findings are: 1. On 03/13/23 at 10:48 AM, 3 roaches were crawling on the floor by the bread rack in the Storage Room. The Surveyor showed them to the Dietary Supervisor, she stepped on them and killed them. 2. On 03/13/23 at 10:55 AM, 8 dead roaches were on the floor in the Storage Room and 12 dead roaches were in the kitchen. The Surveyor asked the Dietary Supervisor how long they have had problems with pests. She stated, Not long. We changed companies and they come more often to spray. 3. On 03/13/23 at 10:56 AM, one roach was crawling on the floor by the door close to the Mop Room. The Surveyor showed it to Dietary Employee (DE) #3, who stepped on it and killed it. 4. On 03/13/23 at 10:57 AM, one roach was crawling down the wall above the rack where the plate holders and a tray that contained clean glasses was kept. The Surveyor showed it to the Dietary Supervisor. 5. On 03/13/23 at 11:44 AM, one roach was on the floor in the kitchen. The Surveyor showed it to DE #2, who stepped on it and killed it. 6. On 03/14/23 at 7:48 AM, one roach was crawling on the outside door of the walk-in refrigerator. The Surveyor showed it the Dietary Supervisor, she pushed it down and killed it. She stated, They came last night to spray. They come out when we have a heavy rain and when it's cold. 7. On 03/14/23 at 8:08 AM, one roach was crawling on the floor in the kitchen towards the oven. The Surveyor showed it to the Dietary Supervisor, and she stepped on it and killed it. 8. On 03/14/23 at 2:13 PM, the Surveyor asked the Dietary Supervisor, How many dead roaches did you observe in the Storage Room and in the Kitchen? She stated, I will say about 20 dead roaches. 9. The Pest Elimination Service logs dated 01/04/23 to 03/03/23 provided by the Dietary Supervisor on 03/13/23 at 2:12 PM documented: a. Date 01/04/23 Time In 9:28 AM - Time Out 11:11 AM, .Services Provided Exterior Rodent Trap Service, Pest Elimination - Monthly Service Notes and Recommendations The monthly pest control service and inspection was performed today. All exterior bait stations were inspected, cleaned, dated, and bait was replaced where needed . b. Date 01/05/23: Time In 8:30 PM - Time Out 9:47 PM, .Services Provided Trouble Call. Service Notes and Recommendations Treated the kitchen for roaches will treat again next week . c. Date 01/20/23: Time In 8:56 PM - Time Out 10:10 PM, .Services Provided Trouble Call. Treated the kitchen for roaches . d. Date 02/04/23: Time In 9:14 AM - Time Out 10:39 AM, .Services Provided Exterior Rodent Trap Service, Pest Elimination - Monthly. The monthly pest control service and inspection was performed today. All exterior bait stations were inspected, cleaned, dated and bait was replaced where needed . e. Date 02/07/23: Time In 7:52 PM - Time Out 9:06 PM, .Services Provided Trouble Call Treated the kitchen for roaches . f. Date 02/22/23: Time In 7:43 PM - Time Out 8:58 PM, .Services Provided Trouble Call Treated the kitchen for roaches . g. Date 03/01/23: Time In 10:42 AM - Time out 12:03 PM, .Services Provided Exterior Rodent Trap Service, Pest Elimination - Monthly. The monthly pest control service and inspection was performed today. All exterior bait stations were inspected, cleaned, dated and bait was replaced where needed . h. Date 03/03/23: Time In 8:04 PM - Time Out 9:14 PM, .Services Provided Trouble Call. Treated the kitchen for roaches .

Based on interview, and record review, the facility failed to ensure pneumococcal immunizations were administered to eligible residents to help protect against pneumococcal bacteria which can cause serious infections and is potentially fatal and immunization records were accurately documented for 5 (Residents #12, #13, #22, #31 and #189) of 5 sampled residents whose immunization records were reviewed. This failed practice had the potential to affect 38 residents as documented on the Resident Matrix provided by the Minimum Data Set (MDS) Coordinator on 03/13/23. The findings are: 1. Resident #12 had a diagnosis of Chronic Respiratory Disease. The Quarterly MDS with an Assessment Reference Date (ARD) of 02/22/23 documented the resident was moderately impaired in cognitive skills for daily decision-making per a Staff Assessment of Mental Health (SAMS) and was up to date on his Pneumococcal Vaccinations. a. A Vaccination Form in the medical chart documented, Vaccine not given . Pneumococcal vaccine previously immunized 11-10-11 . b. A Consent for Vaccination form dated 10/23/12 in the medical chart documented, I have had the pneumococcal vaccination within the past five years . 2. Resident #13 had diagnoses of Chronic Obstructive Pulmonary Disorder and Asthma. The Admission MDS with an ARD of 02/09/23 documented the resident scored 15 (13-15 indicates cognitively intact) on a Brief Interview of Mental Status (BIMS), was not up to date on his Pneumococcal Vaccinations and the vaccination was offered and declined. a. The Resident Vaccination Status Form in the medical chart documented, .Pneumococcal Vaccination Vaccine not given due to refusal . No declination was found in the chart. 3. Resident #22 had a diagnosis of Alzheimer's Disease. The Annual MDS with an ARD of 02/14/23 documented the resident was moderately impaired in cognitive skills for daily decision-making per a SAMS and was up to date on her Pneumococcal vaccinations. a. The Flu/Pneumonia Vaccination Status at the bottom of the Face Sheet in the medical chart documented Resident #22 received a Pneumococcal vaccine on 02/27/20 and the next vaccine was due 02/28/21. 4. Resident #31 had diagnoses of Atrial fibrillation and Hyperlipidemia. The Quarterly MDS with an ARD of 12/14/22 documented the resident scored 10 (8-12 indicates moderately cognitively impaired) on a BIMS and was not up to date on her Pneumococcal Vaccinations and the vaccination was offered and declined. a. The medical chart contained a consent for a Pneumococcal vaccine. No documentation of the administration of the vaccine was found in the medical chart. 5. Resident #189 had a diagnosis of Diabetes Mellitus. The Admission MDS with an ARD of 11/03/22 documented the resident scored 14 (13-15 indicates cognitively intact) and was not up to date on her Pneumococcal Vaccinations and was not eligible - medical contraindication. a. The medical chart did not contain documentation a Pneumococcal vaccine had been administered or declined. The Face Sheet documented, .Reason: Not eligible . 6. On 03/14/23 at 10:44 AM, the Surveyor asked the DON/ICP if immunization records in the resident charts should be accurate and kept up to date. The DON/ICP stated, Yes ma'am. The Surveyor asked what she utilized to know when residents needed immunizations. The DON/ICP stated, [Electronic Records System]. The Surveyor asked the DON/ICP to review Resident #12's vaccination documentation in his chart and asked if it was complete. The DON/ICP stated, No, it does not say if he wants Pneumo [Pneumococcal] or not. The Surveyor asked if Resident #12 was due for another Pneumococcal vaccine. The DON/ICP stated, I don't know. The Surveyor asked how often they are given. The DON/ICP stated, Every five years, I think. I will get a new form and have the refusal marked right. The Surveyor asked the DON/ICP to review Resident #13's vaccination documentation in his chart and asked if his Pneumococcal documentation was complete. The DON/ICP stated, No, his doesn't say it either. The Surveyor asked what was marked at the bottom of his Face Sheet. The DON/ICP stated, Offered and declined. That's got to be wrong. That's for COVID. I'll fix it. I'm sorry. The Surveyor asked if Resident #13 was due for a Pneumococcal vaccination. The DON/ICP stated, I will have to check [Immunization Information System]. He might have verbally refused. The Surveyor asked if that was documented in the nurses notes in the medical records. The DON/ICP stated, No ma'am. The Surveyor asked the DON/ICP to review Resident #22's vaccination documentation in her chart and asked if her documentation showed the correct Pneumococcal documentation. The DON stated, No, her Pneumo should not be due in 1 year. That was put in wrong too. The Surveyor asked the DON/ICP to review Resident #31's vaccination documentation in her chart and asked if there was a consent signed for the pneumococcal vaccine. The DON/ICP stated, Yes ma'am. The Surveyor asked if the DON/ICP had documentation of the Pneumococcal vaccine being administered. The DON/ICP stated, No, I do not see any. The Surveyor asked if Resident #31 was due for her Pneumococcal vaccine. The DON stated, I will have to check [Immunization Information System] for her too. The Surveyor asked the DON/ICP to review Resident #189's vaccination documentation in her chart and asked for the documentation for the reason it was documented she was not eligible for the Pneumococcal vaccine. The DON/ICP stated, I put it in wrong. I must have hurried. I will check on it and fix it. The Surveyor asked what possible negative outcomes could occur if the immunizations records were not kept accurate and up to date. The DON/ICP stated, They could be double immunized, or they could be given a shot that they don't want. 7. On 03/14/23 at 11:01 AM, the Surveyor asked the Administrator if a resident ' s immunizations should be accurate and kept up to date in the electronic records and in the resident's charts. The Administrator stated, Yes, ma'am. The Surveyor asked what a possible negative outcome could be if the records were not kept accurate and up to date. The Administrator stated, They would possibly catch the flu or get sick if we failed to provide them. If it was not accurate, they might receive a double dose. 8. On 03/14/23 at 12:16 PM, the DON/ICP informed the Surveyor that Resident #13 wanted a Pneumo vaccination and was overdue. The DON/ICP stated she would not have caught this. and thanked the Surveyor for bringing this to her attention. 9. On 03/14/23 at 1:40 PM, the DON/ICP provided the following documents: a. Resident #31 - an [Immunization Information System] printout. The printout documented a pneumococcal vaccine was due. The DON/ICP stated the [Immunization Information System] did not have any dates for Pneumococcal for Resident #31 and she had called Resident #31's Doctor's Office for the date the first one was given. If the Doctor's Office stated it was due the Pharmacy would bring it in a few days to administer. b. Resident #13 - a new completed consent form for the Pneumococcal vaccine. She stated, The pharmacy will be coming this afternoon to give it. 10. A completed vaccination status form provided by the DON/ICP on 03/14/23 at 3:41 PM for Resident #13 documented Resident #13 received a pneumococcal vaccination on 03/14/23. 11. The facility policy titled, Nursing Home Residents and Employee Requirements for Influenza, Pneumococcal and COVID-19 Vaccine Administration , provided by the DON/ICP on 03/14/23 at 9:00 AM documented, .6. If a resident is not vaccinated, the reason must be provided in the medical record . 7 .If administration of vaccine is requested by resident . facility will have 14 days to administer . Documentation: 1. After administration of a vaccine, the lot number and manufacturer name must be documented - this is done immediately after administration. 2. If a resident refuses, the refusal must be documented on the Vaccination Status form as well as documented in the nursing notes. 3. All records of documentation related to administration or refusal of . pneumococcal . vaccines must be kept in the resident's permanent medical record . 12. On 03/15/23 at 9:47 AM, the Surveyor asked the DON/ICP how often she checked the resident's immunization status. The DON/ICP stated, During Flu season once we put that [influenza immunizations] in and print that out. [Resident #31] needs hers and I found another lady too. The Surveyor asked if she checked on pneumococcal vaccinations at other times besides Flu season. The DON/ICP stated, No, I can't say that I have. The Surveyor asked how often medical records are checked for accuracy. The DON/ICP stated she did know but, I also put in my records to print a new face sheet for updated medical records.

Based on observation, and interview, the facility failed to ensure pureed food items were blended to a smooth, lump-free consistency to minimize the risk of choking or other complications for residents who required pureed diets for 2 of 2 meals observed. This failed practice had the potential to affect 8 residents who received pureed diets as documented on the Diet List provided by the Dietary Supervisor on 03/14/23 at 11:42 AM. The findings are: 1. On 03/13/23 at 11:11 AM, Dietary Employee (DE) #1 placed 8 servings of ham into a blender, added broth and pureed. She added thickener and pureed the mixture some more. At 11:15 AM, she poured the pureed meat into a pan on the steam table. The consistency of the pureed meat was lumpy and not smooth. There were pieces of ham in the mixture. 2. On 03/13/23 at 11:40 AM, DE #1 placed 8 servings of cornbread into a blender and added 2 cartons of whole milk and pureed. DE #1 used a #16 scoop (blue) to portion pureed cornbread into 8 individual bowls. The consistency of the pureed cornbread was thick. 3. On 03/13/23 at 12:19 PM, the Surveyor asked the Dietary Supervisor to describe the consistency of the pureed food items served to the residents for the lunch meal. She stated, The pureed ham has pieces of ham in it and the pureed cornbread was thick. 4. On 03/14/23 at 7:44 AM, the pureed sausage served to the residents on pureed diets for the breakfast meal, was gritty and not smooth. The Surveyor asked Certified Nursing Assistant (CNA) #1 to describe the consistency of the pureed sausage served to the residents for the breakfast meal. She stated, It was ground up. 5. On 03/14/23 at 7:51 AM, the Surveyor asked the Dietary Supervisor to describe the consistency of the pureed sausage served to the residents who required pureed diets. She stated, It needed to be pureed a little longer.

Based on observation and interview the facility failed to ensure the kitchen was maintained in a clean condition to prevent potential contamination and prevent food borne illnesses for residents who received trays from the kitchen. This failed practice had the potential to affect 36 residents who received a tray from the kitchen according to the list provide by the Administrator on 10/28/22 at 11:10 am. The findings are: a. On 10/28/22 at 9:38 am, the 2-door oven had a buildup of grease and grime on the top of it. There was one dead roach on the top in the back right hand corner of the oven. On the wall behind the oven, it had food particles on the wall with a brown substance running down the wall. The Surveyor asked the Dietary Manger (DM), Can you tell me what is on top of the oven? The DM stated, I can't really tell. I can't see it. The Surveyor asked the DM, Is the top of the over clean? The DM stated, No, it needs to be cleaned. b. On 10/28/22 at 9:41 am, there was water in the floor in front of the table used for pureeing food. Staff grabbed towels and placed in the floor to soak up the water. The DM stated, Oh my we have a water leak somewhere. I will call the plumber now. It looks like the water is coming from the drainpipe from the handwashing sink. c. On 10/28/22 at 9:42 am, a large plastic tote with long metal sheet pans, metal lids, and pots was under the prep table used for pureeing food. The items were covering in food particles. The Surveyor asked the DM, Are these pans clean? The DM stated, Yes, they are. The Surveyor asked the DM to remove the plastic tote from under the table and she pulled it out. The Surveyor asked the DM again, Would you say all of these items are clean? The DM stated, No, they are not. The DM instructed the dishwashing personnel to wash all the items in the plastic tote. d. On 10/28/22 at 9:43 am, the backsplash behind the steam table had food remnants and white and brown substances running down the backsplash. The steam from the steam table had landed on the backsplash and was drying on the backsplash sealing the food particles and backsplash. The Surveyor asked the DM, Would you say the backsplash behind the steam table is clean? The DM stated, No ma'am. It needs to be cleaned. e. On 10/28/22 at 9:45 am, the top and the bottom shelf of the plate warmer had food particles on it. The Surveyor asked the DM, Would you say the plate warmer is clean? The DM stated, No, it needs to be cleaned. f. On 10/28/22 at 9:46 am, the top of the dishwasher had particles of dirt and food. The Surveyor asked the DM, Is the top of the dishwasher clean? The DM stated, No, it has some kind of debris on it. g. On 10/28/22 at 9:47 am, The Surveyor asked the DM, How often do you deep clean the kitchen? The DM stated, We try to do sections at a time every week. We need a good weekend to do it all. The bad thing is she just cleaned it a week or so ago. h. On 10/28/22 at 11:10 am, The Administrator provided a policy labeled Dietary Cleaning Policy. The policy documented, The cleanliness of the kitchen, pantry, freezers/refrigerators, and food preparation area is the responsibility of all dietary employees from all shifts .Floors, walls, and fans should also be always kept neat and clean. These areas should be cleaned daily .Dishes, trays, glasses, pots and pans, etc.; should be washed immediately after use. Inspect these areas as you wash them to make sure these is no debris left on any surface. If any is found, the item should be re-washed immediately .Stove burner should be cleaned and clear from build-up, this should be done weekly .

Based on observation, record review and interview, the facility failed to ensure food items were dated when received and when opened; the ice scoop bucket was maintained in clean condition; dented cans were removed from stock; and kitchen appliances were maintained in clean condition to decrease the potential for food borne illness for residents who received meals from 1 of 1 kitchen. These failed practices had the potential to affect 36 residents who received a tray, as documented on a list provided by the Dietary Manager (DM) on 10/14/21. The findings are: 1. On 10/12/21 at 11:35 A.M., the following items in the walk-in cooler did not have an opened date: a. 1 bottle of thickened iced tea b. 4 cartons of thickened juice c. 1 half-gallon carton of Almond Milk d. 1 bottle of thickened coffee The DM was asked if all food items should have an opened date. She replied, Yes. 2. On 10/12/21 at 11:40 A.M., there was an opened roll of bologna in the walk-in cooler with no received (shelf) date or opened date. The DM was asked if all food times should also have a shelf date. She replied, Yes. 3. On 10/12/21 at 11:45 A.M., the following items were sitting on the floor in the walk-in freezer: a. 2 boxes of egg product b. 1 box of soup c. 1 box of Italian vegetables d. 1 box of pork tenderloin The DM was asked if food items should be placed on the floor in the freezer. She replied, No. 4. On 10/12/21 at 11:45 A.M., there was 1 box of pork tenderloin in the walk-in freezer with no shelf date. 5. On 10/12/21 at 11:50 A.M., there was a bread rack with 54 loaves of white bread, 9 packages of hot dog buns and 8 packages of hamburger buns. The DM was asked if the bread should have a shelf date. She replied, Yes. Normally, I just hang a sign on the rack. These came in yesterday and I just haven't done it yet. She was asked how long bread is good on the shelf. She replied, Seven days. 6. On 10/12/21 at 11:53 A.M., there was 1 dented can of cherry pie filling on a rack in the dry goods area. The DM was asked if dented cans should be stored for use. She replied, No. We are having a problem with [food distributor] delivering dented cans and foods we didn't order. 7. On 10/12/21 at 11:53 A.M., there was a glue trap with 10 roaches stuck to it, sitting on the bottom shelf of the prep table. The DM was asked if that trap should be there. She replied, No, someone must have sat it up there when we mopped the floors yesterday. 8. On 10/12/21 at 12:00 P.M., the top of the stove had a thick, black crusty appearing substance around all burners to the edges of the stove top. The DM was asked to describe the stove top. She replied, It's oil buildup; we don't have a fryer. She was asked if the stove top should be clean. She replied, Yes. 9. On 10/12/21 at 12:13 P.M., the ice scoop bucket for the ice machine on the Old West Wing, which Certified Nurse Assistants used to service ice to residents, had a black trash bag down in the bottom of it. When the DM pulled the bag out, there was water dripping on the floor. She was asked to wipe the bottom of the scoop bucket. She did so with a white paper towel, which became soiled with a black residue. She was asked what the black substance was. She replied, I don't know if it's mold, dirt, or debris. She was asked if this was sanitary. She replied, No. 10. A Food Storage policy provided by the DM on 10/14/21 at 8:08 A.M. documented, .Procedure: .Food should be dated as it is placed on the shelves . c. Date marking will be visible on all high-risk food to indicate the date by which a ready-to-eat, TCS [Time and Temperature Control] food should be consumed, sold, or discarded. 12. Refrigerated food storage: .f. All foods should be covered, labeled, and dated.i. All foods will be stored off the floor. 13. Frozen Foods: . c. All foods should be covered, labeled, and dated. All foods will be checked to assure that foods will be consumed by their safe use by dates or discarded. g. All foods will be stored off of the floor . 11. Cleaning Instructions: Ranges/Griddles policy provided by the DM on 10/14/21 at 8:08 A.M. documented, Policy: The cook/chef on each shift is responsible for keeping the range and/or griddle as clean as possible during the preparation of the meal. The range/griddle will be cleaned after each use. Spills and food particles will be wiped up as they occur .

Based on observation and interview, the facility failed to ensure the lids were closed on 2 of 2 dumpsters to minimize the presence of foul odors and decrease the potential for pest infestation. This failed practice had the potential to affect all 38 residents who resided in the facility, according to the Resident Census and Conditions of Residents provided by the Administrator on 10/12/21. The findings are: On 10/12/21 at 12:03 P.M., the lids were open on 2 of 2 dumpsters. The Dietary Manager (DM) was asked if the lids should be left open. She replied, No. She was asked why it is important to keep the lids closed. She replied, Because it could cause problems with flies and vermin.

Based on observation, record review and interview, the facility failed to ensure 2 of 2 clothes dryers remained free of excessive lint build-up to decrease the potential for fire in 1 of 1 laundry room. This failed practice had the potential to affect all 38 residents due to the proximity of the laundry room to the common dining areas, according to the Resident Census and Conditions of Residents provided by the Administrator 10/12/21. The findings are: 1. On 10/13/21 at 2:32 P.M., there were 2 electric dryers in the clean area of the laundry room behind the kitchen. Dryer #1 had lint built up around the lint compartment of the dryer approximately 3 inches wide by 1 inch thick. Laundry Employee (LE) #1 was asked to describe what she saw. She replied, A lot of lint. She was asked, What could happen with lint build-up? She replied, It could catch fire. At 2:35 P.M., dryer #2 had lint build-up around the thermostat wire approximately 1 inch wide by ½ inch thick and a pile of white strings in the bottom of the dryer. LE #1 was asked to describe what she saw. She replied, Lint buildup and this looks like string from towels [pointing to the white strings.] 2. The facility's Policy and Procedure for Cleaning Dryers, provided by the Administrator on 10/13/21 at 3:35 P.M., documented, .In order to maintain the safety of all residents . housekeeping and maintenance personnel will be responsible for the upkeep and cleaning of the dryers. This will be done per schedule to reflect optimal cleanliness which will reduce the risk of major injury through disasters such as fire . Cleaning items, such as a broom, may be used for any lint . behind / under the trap itself to ensure no lint residue remains .

Complaint # (AR 110) was substantiated, all or in part, with these findings. Based on record review and interview, the facility failed to ensure a resident's lap and shoulder restraints were attached and secured in the facility transport van, which allowed a resident's wheelchair to tip over and resulted in injury for 1 (Resident #1) of 5 (Residents #1 - #5) case mix residents who were transported in the facility van in the last 6 months. This failed practice resulted in past noncompliance at the level of immediate jeopardy to Resident #1, whose wheelchair tipped over during transport, resulting in the resident sustaining injury to the right arm, and had the potential to cause more than minimal harm to 20 residents who were transported in the facility van in the last 6 months, according to a list provided by the Administrator on 6/20/19. The Administrator was informed of the past noncompliance at the level of immediate jeopardy condition on 6/20/19 at 2:10 p.m. The findings are: 1. Resident #1 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set with an Assessment Reference Date of 3/18/19 documented the resident scored 14 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status, was independent with transfer and locomotion on and off the unit and had no functional limitation in range of motion. a. The Facility Investigation Report for Resident Abuse, Neglect, Misappropriation of Property & (and) Exploitation of Residents in Long Term Care Facilities, Division of Medical Services (DMS) form 762, documented, .Date & (and) Time of Incident (if known): 6/17/19 noon . Date Incident Reported/Faxed to OLTC (Office of Long Term Care) 6/17/19 Time: 1355 (1:55 p.m.) . Name of Involved Resident: (Resident #1) . Complete Description of Incident . (Resident #1) & (and) another resident were being transported in facility van by (Certified Nursing Assistant (CNA) #1) and (CNA #2) from doctor appointments this morning. (CNA #1) is the transportation aid & (CNA #2) was assisting due to (2) residents being transported. Residents requested to go by (fast food restaurant #1) after their appointments, so van drivers took them. When leaving (fast food restaurant #1), (CNA #1) heard one of the floor locks come out of the track & (Resident #1's) wheelchair turned over to the right side & resident hit the wheel well on the right side of the van. (CNA #1) pulled into the (fast food restaurant #2) parking lot (first space available) to assess the resident & to call in to the office to report incident. (Resident #1's) right elbow was bleeding, resident stated she did not hit her head. Facility personnel went to where van was parked to assist in getting resident back in wheelchair. (Resident #1) was transported to the emergency room for evaluation . (Resident #1) came back from the ER (emergency room ) with bruising & a contusion to right arm. X-rays were negative for any fractures. (Resident #1) is in stable condition. (Resident #1) is able to move her arm & has no problems eating . b. An OLTC Witness Statement Form dated 6/17/19 documented, .Witness Full Name: (CNA #1) . I (CNA #1) was taking 2 residents to (fast food restaurant #1) for lunch after their appointment .we were leaving (fast food restaurant #1) and the floor track came out of the floor and (Resident #1) turned over. I pulled into (fast food restaurant #2) and called for help asap (as soon as possible)! Made sure everything was alright . c. An OLTC Witness Statement Form dated 6/17/19 documented, .Witness Full Name: (CNA #2) . I (CNA #2) do not have knowledge of the (Resident #1) not being strap in properly. Because I raise up the lift close the door and got in the front seat. I didn't think that needed to go behind the van driver. I heard a scream and turn and (Resident #1) was on the floor on her side. We call (facility) and they sent up help. And we got (Resident #1) up . d. An OLTC Witness Statement Form dated 6/17/19 documented, .Witness Full Name: (CNA #3) . (CNA #1) called me on cell phone, stating that she had 2 residents in the big van + (and) one of them had fallen out of their w/c (wheelchair). She asked me to go get our supervisor (and) come to her as soon as possible. When the supervisor and I arrived, we saw (Resident #2) fully strapped in + (and) (Resident #1) was on the floor w (with) w/c pushed out of the way. We lifted her back into her w/c + our supervisor told the van driver + her rider (help) to make sure the resident was locked down properly + good. Van driver stated that she did not have all the pieces necessary. She then went to the other van, which was unoccupied w/a (with a) resident @ (at) the time, to get all of the correct straps. Which was the prior agreement made between our supervisor, the other van driver, + myself. We made sure . that (Resident #1) was strapped down the correct way, and we proceeded to the hospital . e. The Hospital Record dated 6/17/19 documented, .admitted : 06/17/19 . 1337 (1:37 p.m.) . van driver states PT (patient) was leaving wound care when her W/C flipped over on right side in van, C/O (complaint of) pain to right upper ext (extremity), dried blood noted to right sleeve of shirt, small skin tear with hematoma noted to right arm, denies hitting head or L[NAME] (loss of consciousness) . Imaging Studies Done: Yes . X-ray Interpreted by (Physician): Rt (right) elbow: reported neg (negative for fracture) . Departure Time of Disposition: 15:16 (3:16 p.m.) Disposition: Home Discharge Problem/Impression: Contusion of elbow, right . f. On 6/20/19 at 9:50 a.m., the Administrator was asked about the van accident on 6/17/19. We initially determined that the CNA did not properly secure the latch to the track on the floor of the van. We went step by step with securing the restraints and found that they were all in good working condition. We later found out that she didn't do the lap belt or shoulder restraint. She said they were not in the van. g. On 6/20/19 at 10:05 a.m., LPN #1 was asked about the van accident on 6/17/19. LPN #1 stated, I train all the CNAs on van transport. I have for the last two years. They are all trained to use the lap and shoulder restraints before going anywhere with residents in the van. (CNA #1) did not hook the seat belt or shoulder belt. I don't know why she didn't. She was not trained to do it that way. (CNA #2) excuse was that (CNA #1) was the official van driver and she didn't think she needed to check behind her plus she said she was doing the lift. h. On 6/20/19 at 11:17 a.m., Resident #1 was asked about the van accident on 6/17/19. Resident #1 stated, I don't know how it happened. I was slammed against the side and it hurt and I screamed and I screamed. Resident #1 was asked if the facility staff had put her lap and shoulder belt on before going to her appointment. Resident #1 stated, I had a belt on. I don't know where it is at now. I can't remember. I fell over in my wheelchair. That's all I know. i. On 6/20/19 at 11:22 p.m., Resident #2, whose MDS with an ARD of 5/7/19 documented the resident was cognitively intact, was asked about the van accident on 6/17/19. Resident #2 stated, I do not know what happened. I was turned the other way. I never seen her laying down. I didn't see what happened. I heard her screaming. They have always locked my wheelchair down. I have never had a problem. I have always felt safe. They take me to (city) all the time. Resident #2 was asked if transport staff always applied his lap and shoulder belt before taking him to [MEDICAL TREATMENT] or his appointments. Resident #2 stated, Nobody has ever had them on me. Oh, maybe the two girls up here (ADON and DON). They have put them on me. Most of the time, I did not have a lap belt or shoulder belt on. They have always locked my wheelchair down to the floor. j. On 6/20/19 at 12:11 p.m., CNA #3 was asked about the van accident on 6/17/19. CNA #3 stated, When I got there (Resident #2) was completely strapped down. (Resident #1) did not have her lap or shoulder belt on. k. On 6/20/19 at 2:22 p.m., the DON was asked how long CNA #1 had been doing van transports and if there had been any prior concerns or van-related incidents. The DON stated, She has been doing van transports since probably, middle of (YEAR). The van maintenance was done in (MONTH) of this year. She has not had any write-ups. She was a good worker and the residents loved her. The last incident involving the van was in 2011 or 2012. 2. The van restraint manufacturer's instructions, provided by the Administrator on 6/20/19, documented, .Section 5: Securing the Occupant . Lap Belts . 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, with the buckle of the lap belt placed opposite to the side where the shoulder belt is attached to the wall . Shoulder Belts: The last belt to attach before you're on your way is the shoulder belt. Bring the triangular fitting of the shoulder belt over the passenger's shoulder, past the collar bone, and diagonally across the upper chest. Attach it to the stud of the lap belt latch plate. Pull on the loose end through the adjuster to achieve firm yet comfortable tension. Pull on the belt to ensure that everything is properly attached . a. The facility's Van Procedure and Maintenance form documented, .SECURING RESIDENT IN WHEELCHAIR . Attach lap belt first, should be firm yet comfortable fit across pelvic area. Apply shoulder strap past the collar bone diagonal across chest. Buckle should be at hip opposite of shoulder strap side. Tighten straps to ensure a firm yet comfortable fit. DO NOT place straps across abdomen, neck or face . b. Van Check Off forms dated 5/6/19 documented Certified Nursing Assistant (CNA) #1 demonstrated loading and transporting a resident safely in the facility transport van, following proper procedures. The evaluator was (LPN #1). 3. The facility self-reported the incident to OLTC and removed the immediate jeopardy on 6/17/19 by suspending the CNAs, removing the vans from service, and initiating in-servicing and monitoring. By 6/20/19 when surveyors entered to conduct a complaint investigation survey, the facility had taken the necessary corrective actions to demonstrate compliance, as evidenced by the following: a. The DMS form 762 dated 6/17/19 documented, .Findings and Actions Taken: .Van drivers (CNA #1) and (CNA #2) were suspended during the investigation. The van will not be used for transport of residents until it has been thoroughly checked out by maintenance to ensure the tracts are in good working condition. No resident will be transported in either van until all staff who drive the van have been re-in serviced & have shown return demonstration of proper procedures by (Licensed Practical Nurse (LPN) #1). Both vans will be sent to (van conversion company) in (city) . Appointments have been scheduled on 6/21/19 for the 2010 van & 6/24/19 for the (YEAR) van. All staff who drive the van will be in-serviced about proper van procedures and checked off by (LPN #1)/Director of Nurses (DON)/ Assistant Director of Nurses (ADON) to ensure proper procedures are followed before being allowed to transport residents. Investigation into this incident revealed that (CNA #1) did not use the lap or shoulder belts to secure (Resident #1) properly. (CNA #1) will be terminated . b. A Facility Monitoring Form dated as initiated 6/17/19 documented the facility was conducting ongoing monitoring of transport staff adherence to manufacturer's instructions for application of the van's safety restraint system: .6/17/19 . Employee Monitored . Action Monitored . Corrections Required if applicable . 0 (none) . adjusted straps until R (resident) secured in place. 0 (No) movement noted during transport . 06/18/19 . 0 corrections required . 06/19/19 . 0 corrections required @ this time . c. An In-service form dated 6/18/19 documented the van restraint system training video was reviewed by the facility's current transport drivers. d. On 6/20/19 from 9:15 a.m. to 10:45 a.m., the surveyor observed staff applying the safety restraints in both vans. The restraints were applied per manufacturer's instructions, and no concerns were identified.

Based on observation, record review and interview, the facility failed to ensure gas-powered clothes dryers were maintained in safe operating condition, as evidenced by failure to ensure the ignition box (area around the burners) and the lint filters / lint compartments were free of excessive dust and lint build-up which could cause a fire and failure to ensure staff members responsible for maintenance / cleaning of dryers were aware of the need to periodically clean the burner compartments for the dryers in 1 of 1 laundry room. This failed practice resulted in Immediate Jeopardy, which could have caused serious harm, injury or death to 3 residents who resided in the area adjacent to or across the hall from the laundry room, as observed by the surveyor during rounds on 5/7/19. The Director of Nursing (DON) was informed of the Immediate Jeopardy condition on 5/7/19 at 3:30 p.m. The findings are: 1. The Operator's Manual - Installation and Operations Instructions on the (Brand Name) Industrial Dryer, provided by the Administrator on 5/7/19, documented, .14. PREVENTIVE MAINTENANCE INSTRUCTIONS: DAILY 1. Clean the lint screen . 2. Check the lint screen for tears. Replace if necessary. 3. Clean lint from the lint screen compartment. MONTHLY .2. Remove lint accumulation from front control area. 3. Remove lint and dirt accumulation from the top of the dryer and all areas above, below and around the burners and burner housing. Failure to keep this portion of the dryer clean can lead to a build-up of lint creating a fire hazard.QUARTERLY .8. Remove lint accumulation from the primary air ports in the burners.SEMI-ANNUALLY 1. Remove and clean the main burners. 2. Remove all orifices and examine for dirt and hole obstruction. 3. Remove all lint accumulation. Remove the front panel and the lint screen housing and remove lint accumulation. ANNUALLY 2. Check and remove any lint accumulation from the exhaust system . 2. On 5/07/19 at 10:06 a.m., a tour of the laundry room was completed, and the surveyor asked Laundry Aide #1 to assist with checking the lint compartments of the gas-powered clothes dryers. The aide opened the first dryer lint compartment, and there was a copious amount of dryer lint, which was packed into the areas on both sides of the metal casing of the lint compartment, from the bottom of the compartment up to the metal lip below the drum. Laundry Aide #1 was asked, How often are the dryers cleaned of lint? Laundry Aide #1 stated, Every morning and night-time . The lint screen itself, was completely covered by a ¼-inch build-up of lint. The second dryer's lint compartment contained copious amounts of lint on both sides of the metal casing and dryer drum, above the level of the metal lip of the lint compartment, and there was a large pile of lint approximately 4 inches x (by) 6 inches x 2 inches in the bottom of the compartment. The dryer screen had an L-shaped tear, approximate 4 inches x 2 inches. The surveyor took multiple photographs of both dryers, the laundry room, the lint in the dryer and the lint collected / bagged after removal from the dryers. Per surveyor rounds conducted on 5/7/19, the facility has four hallways. The laundry room is located in the back half of the facility, in the middle hallway. There are three dryers located in a 13 x 5-foot area; three of the walls are mason brick and the wall behind the dryers and ceiling is drywall. There are two resident rooms adjacent to the laundry / dryer room and two resident rooms across from these rooms. The distance from the closest occupied resident room to the laundry entrance door was 16 feet. A total of 3 residents resided in the nearby rooms. The Minimum Data Set (MDS) assessments for the 3 residents who lived in close proximity to the laundry room (assessment reference dates of 2/25/19, 4/18/19 and 5/10/19) documented 1 resident required supervision and set-up for walking in the corridor, 1 required limited assistance, and 1 was totally dependent on 2-plus people for transfer and locomotion; 1 of the residents had functional limitation in range of motion to the upper and lower extremities on one side. (Note: The specific room numbers and identifiers were left out of this paragraph to avoid exposing the residents' identity and personal health information). 4. On 05/07/19, the following interviews were conducted: a. At 10:28 a.m., the Maintenance Director was asked, How often do you maintain the dryers? He stated, I maintain back behind wall, the combustion chamber, usually the people in here (laundry personnel) do that. He was asked, How often do you clean the combustion chamber? He stated, I go every week and clean it out, once or twice a year, I clean it real good. He was asked, What is the wiring hanging down in the first dryer? He stated, Looks like a thermostat wire, not sure. He was asked, If the wire is impacted with lint, is there a potential for fire? He stated, Don't know if it's a potential for fire. The Maintenance Director was shown the lint build-up on the sides and back of first dryer and was asked, Is there a potential for fire? He stated, I know it needs to be cleaned out. b. At 10:40 a.m., the Housekeeping Supervisor was asked, Do you have a lint cleaning schedule? She stated, Supposed to clean it every morning before the shift and when I come in at 11 (11:00 a.m.) or 12 (12:00 noon). c. At 2:40 p.m., Laundry Aide #2 was asked, Are the dryers gas or electric? She stated, Gas. She was asked, How are the dryers lit? She stated, I'll show you. Laundry Aide #2 retrieved a key and opened the door to the ignition housing. She stated, It lights itself when you turn it on. The ignition housing had a build-up of dust and lint that was hanging and covering the electrical wiring and the manifold. The aide opened the ignition housing on the second dryer, and it was in the same condition as the first dryer. The surveyor took photographs of both dryers at this time. Laundry Aide #2 stated, We clean the lint screen and bottom of the dryer twice a day and twice at night. We do not clean anywhere else; we do not touch this area up here where it ignites. d. At 2:44 p.m., the Laundry Supervisor was asked about the maintenance of the dryers and stated, The only time the dryers are worked on is when we call them (repair service). The Laundry Supervisor was asked, When was the last time the dryers were maintained? She stated, I think about a month. The paperwork of the last service maintenance was requested. On 5/07/19 at 3:02 p.m., the Laundry Supervisor stated, I'm unable to get the paperwork; the Administrator is out. 5. On 05/07/19 at 3:30 p.m., the Director of Nursing was asked how often the dryer service company came to the facility and stated, I think once a month; my understanding is that it was a person that deals with the supplies. 6. On 05/08/19 at 10:40 a.m., the Administrator was asked for documentation of the monthly maintenance that complied with the manufacturer's operation manual. The Administrator stated, It is not being done. The Administrator provided a Check Combustion behind dryer wall log. This log documented weekly dates and times from 1/7/19 to 5/7/19 with the Maintenance Director's initials. 7. On 5/8/19, the following interviews were conducted: a. At 3:30 p.m., the Maintenance Director was asked, Have you been trained on preventive maintenance and minor repairs on the dryers? He stated, I was trained on cleaning behind the dryer wall, the combustion chamber. (Previous Maintenance Director), the old maintenance person trained me. I was not trained on cleaning the dryers. I was under the impression that the service technician for the washers and dryers comes periodically for repairs and maintenance. Yesterday, was the first time I seen (sic) inside the ignition box. The laundry supervisor and staff clean the lint daily from the bottom compartment and lint screen. b. At 3:42 p.m., the Administrator was asked, Are the laundry personnel/aides trained prior to working in the laundry room? She stated, Yes. When asked, Do you have documentation of that? The Administrator stated, I will call the Laundry Supervisor about that; she has left for the day. The Administrator was asked, Do you have a contract with a company for preventive maintenance and repairs for your dryers? She stated, Yes, (Company Name) . The Administrator was asked, Do you have any invoices on their last visit that detail the service that was provided? The Administrator stated, Yes, I have two here, one for (MONTH) and the other in March. I just noticed they are from (YEAR). I tried to call him (company representative) to get the other invoices, but his mailbox is full. When asked, How often does (Company Name) come to the facility for dryer maintenance? She stated, I don't know. The Administrator was asked, Can you recall the last time (Company Name) was here? She stated, No, I cannot. He may come before I arrive or after I leave. The Administrator was asked, Does (Company Name) service technician come monthly to maintain the dryer? She stated, No, they only come when we call them for repairs or troubleshooting. She was asked, If (Company Name) only comes when you call them, who is responsible for doing the Daily, Monthly, Quarterly, Semi Annual and Annual preventive maintenance on the dryer, as instructed by the operator's manual? The Administrator stated, Daily, the laundry personnel for lint removal, our maintenance and (Company Name) is responsible for the preventive and repairs. The Administrator was asked, Has your maintenance person been trained on preventive maintenance on the dryers? She stated, Yes and minor repairs. When asked, Do you have any documentation of that training? She stated, No, he was trained by the prior maintenance person that he replaced. The Administrator was asked, How often does maintenance clean the inside of the dryers and the ignition housing? The Administrator stated, I thought he was doing it weekly, the combustion chamber, but I found out yesterday, he was only cleaning behind the wall of the dryers. The combustion chamber, I thought, was the ignition housing of the dryer. I'm trying to contact (representative) from (Company Name) to come and in-service the laundry staff and maintenance on the dryers and the correct verbiage. The Administrator was asked, Who is responsible for ensuring that maintenance is trained and performing his duties in the facility? She stated, I am. c. At 3:49 p.m., Laundry Aide #2 was asked, Were you trained for your position and duties in the laundry room? She stated, Yes. She was asked, Do you recall the last time the dryers were repaired or had maintenance on them? She stated, No, I've seen the service man maybe twice and that was last year, none this year. She was asked, When do you clean the dryer lint screens? She stated, I clean the screens and under the screens twice when I work. If I work 5 a.m.-12 noon, I do it at 9 a.m., and at 12 noon and if I work 12 noon to 7 p.m., I do it at 4 p.m., and 7 p.m. d. At 3:55 p.m., the Laundry Supervisor was asked, When was the last time a service technician was here for maintenance in the laundry room? She stated, He came yesterday and before that, he was here around a month ago. She was asked, What did he do when he was here a month ago? She stated, He did repairs on a washing machine. When asked, When was the last time the service tech did maintenance or repairs on any of the dryers? The Laundry Supervisor stated, 3 or 4 months ago. I don't recall. She was asked, Is monthly maintenance completed on the dryers? She stated, They are supposed to. When asked, Who does it? She stated, (Representative) from (Company Name); he services the washers and dryers. She was asked, Is he scheduled to come monthly? She stated, No, he comes when we call him for repairs. She was asked, Who is responsible for cleaning inside the dryer? She stated, The laundry aides - vents and bottom of the compartment. She was asked, How often? The Laundry Supervisor stated, Twice a shift. When asked, Who is responsible for cleaning the inner sides, around the dryer drum and the ignition box? She stated, (Representative) the service tech, he checks and cleans everything when doing repairs. 8. The Immediate Jeopardy was removed, and the scope and severity lowered to E on 5/08/19, when the facility implemented the following Plan of Removal: l. Upon being informed of the failed practice, the maintenance staff immediately turned off the burner in the dryer and cleaned all lint and dust from around the burner on (MONTH) 7, 2019. The dryer was kept out of service until cleaning was completed. 2. Immediately removed all lint and/or dust from around flame. 3. DON/Designee in-serviced laundry and maintenance staff on (MONTH) 7, 2019 regarding how and when it will be cleansed after each load: Ensuring dryers are maintained in safe operating condition which will be evidenced by absence of excessive dust and lint build-up. Ensuring staff members that will be held accountable for ensuring cleanliness of dryer vents and burner compartments are doing so through monitoring. Knowledge in importance of cleanliness in regards to possible fire hazards and life-threatening injury to residents, staff, and visitors. *Laundry staff must be in-serviced before they are allowed to return to work. 4. Dryer vents, lint compartments, and burner compartments will be cleaned at the beginning of each shift and after each use/load on both shifts (0530 & (and) 1130 (5:30 a.m. and 11:30 a.m.)). 5. Laundry staff will document that cleaning is complete by initialing on their monitoring log on their shift under the correct day for when they clean the lint compartments and burner compartments. 6. This log will be monitored by Administrator and Housekeeping Supervisor/Designee as follows: Daily X (times) 30 days by 2 separate designees. If compliance met - 3 X week for 2 weeks. If compliance met - Twice a week for 2 weeks. If compliance met - Once a week indefinitely. This does not include random rounds made by supervisor and/or Administrator. Maintenance will perform visual monitoring of the burner compartments weekly to ensure it is kept free of lint build-up. 7. Laundry equipment services (Company Name) will perform an audit on the dryer (including dryer vents and burner compartments) and in-service the maintenance department on proper cleaning techniques on (MONTH) 7, 2019. 8. Any negative findings will be corrected immediately and reported to the QA (Quality Assurance) committee. QA will review on Monday, Wednesday, and Friday during the department head/QA meeting X 4 weeks then weekly to ensure compliance is met and sustained.

Complaint # (AR 673) was substantiated, all or in part, with these findings: Based on record review and interview, the facility failed to ensure the facility's abuse prohibition policies and procedures were implemented, as evidenced by failure of staff to immediately report an incident of possible resident-to-resident sexual abuse to the Administrator, failure to ensure a thorough investigation was conducted, failure to immediately and consistently implement protective measures to prevent further potential abuse and failure to report the incident to the Office of Long Term Care (OLTC) and other state agencies in accordance with state law for 1 of 1 (Resident #48) sampled female resident who was severely cognitively impaired and was allegedly involved in sexual activity with Resident #38, a cognitively intact male resident. These failed practices resulted in Immediate Jeopardy, which caused or could have caused serious harm, injury or death to Resident #48, who was allegedly observed engaging in sexual activity with Resident #38, and had the potential to affect 45 residents who were cognitively impaired according to the list provided by the Administrator on 7/26/18. The Administrator was informed of the Immediate Jeopardy situation on 7/12/18 at 3:55 p.m. The findings are: 1. The facility's Abuse/ Neglect Policy, provided by the Administrator on 7/9/18, documented, Definitions of Abuse . Sexual Abuse is defined as non-consensual sexual contact of any type with a resident . Sexual abuse includes but is not limited to: Unwanted intimate touching or (sic) any kind especially of the breast and perineal area .It is the policy of (facility) to take appropriate steps to prevent the occurrence of abuse, (Verbal, mental physical, sexual, involuntary seclusion), . and to ensure that all alleged violations of Federal or State Laws which involve . abuse . are reported immediately to the Administrator of the facility. Such violations will also be reported to State agencies in accordance with existing State Law. The facility will investigate each such alleged violation thoroughly and report the results of all investigations to the Administrator or his/her designee, as well as to State agencies as required by State and Federal Law . Reporting: Any employee who suspects an alleged violation shall immediately notify the Administrator or his/her designee. The Administrator/designee shall also notify the appropriate State and Local agencies immediately but not later than 1) 2 hours - if the alleged violation involves abuse or results in serious bodily injury 2) 24 hours - if the alleged violation does not involve abuse and does not result in serious bodily injury. The results of all investigations must be reported to the Administrator or his/her designee and appropriate state agency, as required by State Law, within 5 working days of the alleged violation . Investigation All investigations shall be conducted by the Administrator or DON (Director of Nursing). In the event an alleged violation occurs when neither of these people is in the Facility, the charge nurse is responsible for initiating the investigation procedure. The investigation shall include interviews of employees, visitors or residents who may have knowledge of the alleged incident. Factual information only should be documented, not assumptions or speculation. Written statements from involved parties should be taken and placed with all state required reports. The documentation of the investigation shall be kept in the Administrator's office in an administrative file. The medical record should be reviewed to determine the resident's past history and condition and its relevance to the alleged violation. Federal Law requires the Facility to have evidence of investigation alleged violations. This form shall be reviewed by member of the Quality Assurance Committee and attached to the copy of the reports. This form shall be maintained in the Administrator's office as an administrative file. It is not part of the medical record . Documentation All written reports will be completed and faxed to OLTC according to Arkansas State Law. Documentation in the medical record shall be made necessary for continuity of care for the resident. Separate incident reports or other written reports, when required, shall be maintained and produced according with State Law . Protecting Residents During a Suspected Abuse (Facility) must protect residents from abuse (verbal, mental, physical, and sexual), neglect, involuntary seclusion, and misappropriation of their property . Residents who have voiced an abuse compliant (sic) will be protected from further harm during the period of the investigation. This will be accomplished by QA (Quality Assurance) members appointing a supervisor or trusted employee to observe resident continually thru out the time period involved in this investigation . 2. Resident #48 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/5/18 documented the resident scored 2 (0-7 indicates severely impaired) on a Brief Interview for Mental Status (BIMS) and required limited assistance of one staff member with bathing, personal hygiene and toilet use, set-up help only with meals, was independent with transfers and locomotion, and had behaviors of rejecting care on 1-3 of the past 7 days. a. The Care Plan, dated as last reviewed on 6/5/18, did not address concerns with sexual behaviors and did not address whether the resident had the capacity to consent to sexual activity. b. A Social Progress Note dated 6/14/18 at 11:10 a.m. documented, (Resident's) (daughter) is upset because daughter caught her mother out on the patio yesterday (6/13/18) (with) a male (resident) friend (Resident #38) doing some inappropriate things to him. Daughter demanded that her mother stay away from male (resident). On 7/11/18 at 9:32 a.m., the Social Director was asked, Are you familiar with (Resident #38)? She stated, Yes. She was asked, Are you aware that he sometimes exhibits sexually inappropriate behaviors? She stated, Yes. She was asked are you aware of the incident on the patio with (Resident #48) on 6/14/2018? She stated, Yes. Surveyor asked her what did she know about incident and she stated, They were out on the patio and (Resident #38's) daughter walked in on her ' giving him a blow job out on the patio ' . The DON and I talked to him and informed him that the daughter was very upset and didn ' t want them around each other anymore. He said he understood and would cooperate and that he didn ' t want to do anything to get in trouble. He ' s been cooperative and has made an effort to keep his distance, but (Resident #48) has attempted to seek him out. She has actually had a decline since they have been separated. She was asked, Do you have knowledge or have you heard of (Resident #38) being inappropriate with any other residents? She stated, No. c. A Social Progress Note dated 6/14/18 at 1:39 p.m. documented, DON (Director of Nursing) & (and) myself sat down w (with) R (Resident) & asked questions such as if R had a 'special' friend. (Resident) at one point made the comment 'no, but I wish I did.' We also asked (Resident) if she was ever afraid or if she felt unsafe, if anyone had done anything to hurt her. (Resident) stated 'hell no, I mean heck.' (Resident) would often state things such as 'what business is it of yours. These questions are just damn stupid. I'm not ignorant, yet.' When and if she was in a relationship and family didn't approve would she continue to see them? (Resident) stated 'I don't have that kind of family. I would not, I'm a Christian & wouldn't want to do anything wrong. But if I ever had that opportunity, it might change things'. (Resident) openly voiced she knows what sexual behaviors, touching .etc. (et cetera) by stating 'I'm not ignorant. These questions are personal, too personal and just damn stupid'. This note was signed by the Social Director. A typed statement provided by the DON on 7/11/18 at 12:16 p.m. documented, 6/14/18 When I (Administrator) arrived at work this morning, (DON), informed me that last night (Resident #38) & (and) (Resident #48) were on the patio & were having oral sex. (Resident #48's) daughter walked up on them & was very upset. (Resident #48's daughter) called me this morning to discuss the matter. I went to DON's office where (DON) & (CNA (Certified Nursing Assistant) supervisor) could be in on the conversation. (Resident #48's daughter) stated that she fussed at her mother about the behavior & had told her to stay away from (Resident #38). (Resident #48's daughter) stated that she wanted us to keep them away from each other. We discussed patient rights & said that if both parties consented to being intimate that it was their right to do so. (Resident #48's daughter) questioned that with her mother's dementia that she's not able to make that kind of decision . (Resident #48's daughter) was very adamant that we keep her mother away from (Resident #38). We told her that we would respect her wishes in this matter. I called (Resident #38's daughter) back at 3:20 p.m. to give her an update on our course of action. l. Staff have been told to redirect (Resident #48) & (Resident #38) if they are seen together. 2. (Resident #38) has been told he needs to stay away from (Resident #48). 3. We can't guarantee that we be will able to keep them totally apart during meals & activities, but that they would be monitored during these times. (Resident #48's daughter) stated she was ok with these actions . d. On 7/11/18 between 11:26 a.m. and 3:37 p.m., the following questions were asked of Licensed Practical Nurses (LPN's) #1 and 2 and Certified Nursing Assistant (CNA's). Do you have knowledge of or have you ever witnessed (Resident #38) exhibit sexually inappropriate behaviors with residents? They all stated that he had been sexually inappropriate with only one resident at times, (Resident #48). But now they are being monitored and kept apart . They were asked, How do you monitor them? They all stated, We watch them and make sure they ' re not together. 3. Resident #38 had [DIAGNOSES REDACTED]. The Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/15/18 documented the resident scored 14 (13-15 indicates cognitively intact) on the Brief Interview for Mental Status (BIMS), was independent with locomotion on and off the unit, used a walker/wheelchair for mobility, required limited assistance of one person for dressing and had no behaviors. a. The Care Plan dated developed 2/16/18 documented, .Behavior: Sexually inappropriate. Resident makes inappropriate remarks to staff at times. Approaches: Encourage resident to assume responsibility for own behavior but verbalize staff willingness to assist in maintaining appropriate behavior such as reorientation and redirecting .If reasonable, discuss behavior with resident, explain / reinforce why behavior is unacceptable . The care plan did not address inappropriate behaviors toward other residents. b. A Social Progress Note dated 6/14/18 at 4:30 p.m. documented, .DON and myself spoke (with) (Resident) regarding his relationship (with) his female friend who is also (Resident #48) at our facility. (Resident) was told it was in his best interest to keep his distance from the female (Resident #48). (Resident) stated he understood and that she was driving him crazy. (Resident) even stated he was told by (Resident #48's) daughter to keep his eye on her and take care of (Resident #48). (Resident) stated he would do what they ask of him . c. A Nurses Note dated 7/7/18 (not timed) documented, .(Resident #38) asked another to suck his (expletive - slang for penis) out on the patio. I inform (Resident) that was wrong and not to do it again. This note was signed by Licensed Practical Nurse (LPN) #2. The 24 hour Report dated 7/7/18 documented on the 6:00 a.m. to 2:00 p.m. shift Resident #48 asked Resident #38 to suck his (expletive - slang for penis). On 7/11/18 at 2:03 p.m., LPN #2 was asked, When did you report the incident involving sexually inappropriate behavior between (Resident #38) and (Resident #48) that occurred on 7/7/18? She stated, I wrote it on the 24-hour report board, because it was the weekend. She was asked, Did you verbally report to anyone? She stated, I think I told the weekend Supervisor, but we put everything on the 24-hour report. She was asked, Have you had abuse prevention training? She stated, Yes. She was asked, When should you report abuse or possible sexual abuse? She stated, Immediately to the DON or Administrator. On 7/12/18 at 2:32 p.m., the DON and Administrator were asked about the incident that occurred on 7/7/18 between Resident #38 and Resident #48. They both stated that they were unaware of the incident that occurred on that date. 4. On 7/11/18 at 10:55 a.m. the DON was asked, Was an investigation done after you were informed of the sexual incident on the patio on 6/13/18? She stated, Yes, we talked to both of them and we made sure we kept them apart and told the staff to watch them closely. She was asked, What else was done? She stated, We notified the families and the doctors . She was asked, Was the Care Plan updated to address this behavior? She stated, We already had a care plan addressing (Resident #38's) behavior towards staff, but he has not been inappropriate with any other residents. He and (Resident #48) were sort of in a little relationship that was consensual and going well. Her daughter even knew about it. (Resident #48) didn't feel that she was doing anything wrong. She was doing what she wanted to do. We feel she was cognitive and consensual and, based off of that, we didn't feel the need to do anything other than keep them separated as the daughter had requested. And he has been cooperative in keeping his distance. She has been chasing him. She was asked, How are you monitoring? She stated, Everyone has been informed of the incident, so they all know to watch them closely. She was asked, What criteria did you use to assess (Resident #48's) capacity for consent in sexual situations? She stated, Her mood, her affect, her behaviors, and her ability to verbalize/understand yes and no. Regardless of the diagnosis, if they are able to understand what yes and no means, I feel they know what they want and what they don't want. She was asked, Do you know what her BIMS score is? She stated, No. She was asked if she considered looking at Resident #48's BIMS and stated, I don't; her BIMS isn't correct, because she gets a low score, because she gets upset and refuses to answer all of the questions. 5. On 7/12/18 at 9:55 a.m., the Administrator was asked, Did you report the incident (6/13/18) with (Resident #38 and Resident #48) to the proper authorities? She stated, No, I just did an internal investigation. She was asked, Who did the daughter tell about the incident? She stated, The nurse or CNA that night (6/13/18). She was asked, After she (daughter) told them about the incident was anything done? She stated, The daughter separated them and the staff monitored them to make sure that it didn't happen again. She was asked, Is there any documentation of this monitoring? She stated, Since they didn't call and tell us about this probably not . She was asked, When were you informed of the incident? She stated, The DON told me about it the next morning (6/14/18) when I got to the facility. She was asked, When did the DON find out about the incident? She stated When she came in (6/14/18). 6. On 7/12/18 at 5:25 p.m., the physician was asked in a telephone interview, Does (Resident #48) have the cognitive capacity to consent to sexual behaviors? He stated, No, she has terrible dementia. I would say no, her dementia is pretty advanced. She does not have the cognitive capacity to consent. 7. The Immediate Jeopardy was removed and the scope and severity lowered to H on 7/12/18, when the facility implemented the following Plan of Removal: a. Beginning at 4:15 p.m. on 7/12/18, all staff on duty will be in-serviced by DON/Designee on the following subjects: Abuse & neglect & reporting any incidents to supervisor, immediate monitoring for signs/symptoms of abuse. All staff - including weekend staff and those who are on vacation or medical leave will be in-serviced prior to providing care. b. Resident #48 will be monitored every (q) 15 minutes by staff to ensure that he has maintained distance from all other residents. Monitoring will continue indefinitely. Resident#38 will be monitored q 15 minutes by staff to ensure she maintains distance from Resident #48. Monitoring will continue indefinitely. c. Beginning at 4:15 p.m. on 7/12/18, all residents will be assessed by DON/Designee/Charge Nurse for evidence of sexual abuse. Audits will be completed by 8:00 a.m. on 7/13/18. d. Beginning at 4:15 p.m. on 7/12/18, all residents who are able to respond will be interviewed and witness statements obtained by Administrator/Designee to ensure that no other episodes of sexual abuse have occurred e. Beginning at 4:15 p.m. on 7/12/18, statements from staff currently working will be obtained to identify if they have witnessed any of these incidents. f. DON/Designee will make random rounds every shift to observe resident to resident interactions to ensure all residents are safe and free from abuse. g. On 7/12/18 the DON/Designee will obtain witness statements from the 2 residents involved in the identified incident and other interviewable residents who may have knowledge of the alleged incident. h. For any cognitively impaired resident who wishes to engage in sexual activity, the nursing home will have the resident evaluated by the physician to determine if they have the capacity to consent and the issue will be care planned accordingly. i. Any negative findings will be corrected immediately and reported to the QA (Quality Assurance) committee. QA will review on Monday, Wednesday and Friday during the department head/QA meeting x (times) 4 weeks then weekly to ensure compliance is met and sustained.

Complaint # (AR 673) was substantiated, all or in part, with these findings: Based on record review and interview, the facility failed to ensure an incident of possible resident-to-resident sexual abuse was immediately reported to the Administrator to prevent a delay in initiating protective measures to prevent further potential abuse and failed to ensure the incident was reported to the Office of Long Term Care (OLTC) and other state agencies in accordance with state law for 1 of 1 (Resident #48) sampled female resident who was severely cognitively impaired and was allegedly involved in sexual activity with Resident #38, a cognitively intact male resident. These failed practices resulted in Immediate Jeopardy, which caused or could have caused serious harm, injury or death to Resident #48, who was allegedly observed engaging in sexual activity with Resident #38, and had the potential to affect 45 residents who were cognitively impaired according to the list provided by the Administrator on 7/26/18. The Administrator was informed of the Immediate Jeopardy situation on 7/12/18 at 3:55 p.m. The findings are: 1. Resident #48 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/5/18 documented the resident scored 2 (0-7 indicates severely impaired) on a Brief Interview for Mental Status (BIMS) and required limited assistance of one staff member with bathing, personal hygiene and toilet use, set-up help only with meals, was independent with transfers and locomotion, and had behaviors of rejecting care on 1-3 of the past 7 days. a. The Care Plan, dated as last reviewed on 6/5/18, did not address concerns with sexual behaviors and did not address whether the resident had the capacity to consent to sexual activity. b. A Social Progress Note dated 6/14/18 at 11:10 a.m. documented, (Resident's) (daughter) is upset because daughter caught her mother out on the patio yesterday (6/13/18) (with) a male (resident) friend (Resident #38) doing some inappropriate things to him. Daughter demanded that her mother stay away from male (resident). On 7/11/18 at 9:32 a.m., the Social Director was asked, Are you familiar with (Resident #38)? She stated, Yes. She was asked, Are you aware that he sometimes exhibits sexually inappropriate behaviors? She stated, Yes. She was asked are you aware of the incident on the patio with (Resident #48) on 6/14/2018? She stated, Yes. Surveyor asked her what did she know about incident and she stated, They were out on the patio and (Resident #38's) daughter walked in on her ' giving him a blow job out on the patio ' . The DON and I talked to him and informed him that the daughter was very upset and didn ' t want them around each other anymore. He said he understood and would cooperate and that he didn ' t want to do anything to get in trouble. He ' s been cooperative and has made an effort to keep his distance, but (Resident #48) has attempted to seek him out. She has actually had a decline since they have been separated. She was asked, Do you have knowledge or have you heard of (Resident #38) being inappropriate with any other residents? She stated, No. c. A Social Progress Note dated 6/14/18 at 1:39 p.m. documented, DON (Director of Nursing) & (and) myself sat down w (with) R (Resident) & asked questions such as if R had a 'special' friend. (Resident) at one point made the comment 'no, but I wish I did.' We also asked (Resident) if she was ever afraid or if she felt unsafe, if anyone had done anything to hurt her. (Resident) stated 'hell no, I mean heck.' (Resident) would often state things such as 'what business is it of yours. These questions are just damn stupid. I'm not ignorant, yet.' When and if she was in a relationship and family didn't approve would she continue to see them? (Resident) stated 'I don't have that kind of family. I would not, I'm a Christian & wouldn't want to do anything wrong. But if I ever had that opportunity, it might change things'. (Resident) openly voiced she knows what sexual behaviors, touching .etc. (et cetera) by stating 'I'm not ignorant. These questions are personal, too personal and just damn stupid'. This note was signed by the Social Director. A typed statement provided by the DON on 7/11/18 at 12:16 p.m. documented, 6/14/18 When I (Administrator) arrived at work this morning, (DON), informed me that last night (Resident #38) & (and) (Resident #48) were on the patio & were having oral sex. (Resident #48's) daughter walked up on them & was very upset. (Resident #48's daughter) called me this morning to discuss the matter. I went to DON's office where (DON) & (CNA (Certified Nursing Assistant) supervisor) could be in on the conversation. (Resident #48's daughter) stated that she fussed at her mother about the behavior & had told her to stay away from (Resident #38). (Resident #48's daughter) stated that she wanted us to keep them away from each other. We discussed patient rights & said that if both parties consented to being intimate that it was their right to do so. (Resident #48's daughter) questioned that with her mother's dementia that she's not able to make that kind of decision . (Resident #48's daughter) was very adamant that we keep her mother away from (Resident #38). We told her that we would respect her wishes in this matter. I called (Resident #38's daughter) back at 3:20 p.m. to give her an update on our course of action. l. Staff have been told to redirect (Resident #48) & (Resident #38) if they are seen together. 2. (Resident #38) has been told he needs to stay away from (Resident #48). 3. We can't guarantee that we be will able to keep them totally apart during meals & activities, but that they would be monitored during these times. (Resident #48's daughter) stated she was ok with these actions . d. On 7/11/18 between 11:26 a.m. and 3:37 p.m., the following questions were asked of Licensed Practical Nurses (LPN's) #1 and 2 and Certified Nursing Assistant (CNA's). Do you have knowledge of or have you ever witnessed (Resident #38) exhibit sexually inappropriate behaviors with residents? They all stated that he had been sexually inappropriate with only one resident at times, (Resident #48). But now they are being monitored and kept apart . They were asked, How do you monitor them? They all stated, We watch them and make sure they ' re not together. 2. Resident #38 had [DIAGNOSES REDACTED]. The Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/15/18 documented the resident scored 14 (13-15 indicates cognitively intact) on the Brief Interview for Mental Status (BIMS), was independent with locomotion on and off the unit, used a walker/wheelchair for mobility, required limited assistance of one person for dressing and had no behaviors. a. The Care Plan dated developed 2/16/18 documented, .Behavior: Sexually inappropriate. Resident makes inappropriate remarks to staff at times. Approaches: Encourage resident to assume responsibility for own behavior but verbalize staff willingness to assist in maintaining appropriate behavior such as reorientation and redirecting .If reasonable, discuss behavior with resident, explain / reinforce why behavior is unacceptable . The care plan did not address inappropriate behaviors toward other residents. b. A Social Progress Note dated 6/14/18 at 4:30 p.m. documented, .DON and myself spoke (with) (Resident) regarding his relationship (with) his female friend who is also (Resident #48) at our facility. (Resident) was told it was in his best interest to keep his distance from the female (Resident #48). (Resident) stated he understood and that she was driving him crazy. (Resident) even stated he was told by (Resident #48's) daughter to keep his eye on her and take care of (Resident #48). (Resident) stated he would do what they ask of him . c. A Nurses Note dated 7/7/18 (not timed) documented, .(Resident #38) asked another to suck his (expletive - slang for penis) out on the patio. I inform (Resident) that was wrong and not to do it again. This note was signed by Licensed Practical Nurse (LPN) #2. The 24 hour Report dated 7/7/18 documented on the 6:00 a.m. to 2:00 p.m. shift Resident #48 asked Resident #38 to suck his (expletive - slang for penis). On 7/11/18 at 2:03 p.m., LPN #2 was asked, When did you report the incident involving sexually inappropriate behavior between (Resident #38) and (Resident #48) that occurred on 7/7/18? She stated, I wrote it on the 24-hour report board, because it was the weekend. She was asked, Did you verbally report to anyone? She stated, I think I told the weekend Supervisor, but we put everything on the 24-hour report. She was asked, Have you had abuse prevention training? She stated, Yes. She was asked, When should you report abuse or possible sexual abuse? She stated, Immediately to the DON or Administrator. On 7/12/18 at 2:32 p.m., the DON and Administrator were asked about the incident that occurred on 7/7/18 between Resident #38 and Resident #48. They both stated that they were unaware of the incident that occurred on that date. 3. On 7/11/18 at 10:55 a.m. the DON was asked, Was an investigation done after you were informed of the sexual incident on the patio on 6/13/18? She stated, Yes, we talked to both of them and we made sure we kept them apart and told the staff to watch them closely. She was asked, What else was done? She stated, We notified the families and the doctors . She was asked, Was the Care Plan updated to address this behavior? She stated, We already had a care plan addressing (Resident #38's) behavior towards staff, but he has not been inappropriate with any other residents. He and (Resident #48) were sort of in a little relationship that was consensual and going well. Her daughter even knew about it. (Resident #48) didn't feel that she was doing anything wrong. She was doing what she wanted to do. We feel she was cognitive and consensual and, based off of that, we didn't feel the need to do anything other than keep them separated as the daughter had requested. And he has been cooperative in keeping his distance. She has been chasing him. She was asked, How are you monitoring? She stated, Everyone has been informed of the incident, so they all know to watch them closely. She was asked, What criteria did you use to assess (Resident #48's) capacity for consent in sexual situations? She stated, Her mood, her affect, her behaviors, and her ability to verbalize/understand yes and no. Regardless of the diagnosis, if they are able to understand what yes and no means, I feel they know what they want and what they don't want. She was asked, Do you know what her BIMS score is? She stated, No. She was asked if she considered looking at Resident #48's BIMS and stated, I don't; her BIMS isn't correct, because she gets a low score, because she gets upset and refuses to answer all of the questions. 4. On 7/12/18 at 9:55 a.m., the Administrator was asked, Did you report the incident (6/13/18) with (Resident #38 and Resident #48) to the proper authorities? She stated, No, I just did an internal investigation. She was asked, Who did the daughter tell about the incident? She stated, The nurse or CNA that night (6/13/18). She was asked, After she (daughter) told them about the incident was anything done? She stated, The daughter separated them and the staff monitored them to make sure that it didn't happen again. She was asked, Is there any documentation of this monitoring? She stated, Since they didn't call and tell us about this probably not . She was asked, When were you informed of the incident? She stated, The DON told me about it the next morning (6/14/18) when I got to the facility. She was asked, When did the DON find out about the incident? She stated When she came in (6/14/18). 5. On 7/12/18 at 5:25 p.m., the physician was asked in a telephone interview, Does (Resident #48) have the cognitive capacity to consent to sexual behaviors? He stated, No, she has terrible dementia. I would say no, her dementia is pretty advanced. She does not have the cognitive capacity to consent. 6. The Immediate Jeopardy was removed and the scope and severity lowered to H on 7/12/18, when the facility implemented the following Plan of Removal: a. Beginning at 4:15 p.m. on 7/12/18, all staff on duty will be in-serviced by DON/Designee on the following subjects: Abuse & neglect & reporting any incidents to supervisor, immediate monitoring for signs/symptoms of abuse. All staff - including weekend staff and those who are on vacation or medical leave will be in-serviced prior to providing care. b. Resident #48 will be monitored every (q) 15 minutes by staff to ensure that he has maintained distance from all other residents. Monitoring will continue indefinitely. Resident#38 will be monitored q 15 minutes by staff to ensure she maintains distance from Resident #48. Monitoring will continue indefinitely. c. Beginning at 4:15 p.m. on 7/12/18, all residents will be assessed by DON/Designee/Charge Nurse for evidence of sexual abuse. Audits will be completed by 8:00 a.m. on 7/13/18. d. Beginning at 4:15 p.m. on 7/12/18, all residents who are able to respond will be interviewed and witness statements obtained by Administrator/Designee to ensure that no other episodes of sexual abuse have occurred e. Beginning at 4:15 p.m. on 7/12/18, statements from staff currently working will be obtained to identify if they have witnessed any of these incidents. f. DON/Designee will make random rounds every shift to observe resident to resident interactions to ensure all residents are safe and free from abuse. g. On 7/12/18 the DON/Designee will obtain witness statements from the 2 residents involved in the identified incident and other interviewable residents who may have knowledge of the alleged incident. h. For any cognitively impaired resident who wishes to engage in sexual activity, the nursing home will have the resident evaluated by the physician to determine if they have the capacity to consent and the issue will be care planned accordingly. i. Any negative findings will be corrected immediately and reported to the QA (Quality Assurance) committee. QA will review on Monday, Wednesday and Friday during the department head/QA meeting x (times) 4 weeks then weekly to ensure compliance is met and sustained.

Complaint # (AR 673) was substantiated, all or in part, with these findings: Based on record review and interview, the facility failed to ensure a severely cognitively impaired female resident (Resident #48) was protected from possible resident-to-resident sexual abuse, as evidenced by failure to ensure the resident was evaluated by the physician to determine her capacity or incapacity to consent to sexual activity with a cognitively intact male resident (Resident #38), failure to investigate an incident of possible resident-to-resident sexual abuse, and failure to immediately and consistently implement protective measures to prevent further contact with the cognitively intact male resident for 1 of 1 (Resident #48) sampled female resident who was severely cognitively impaired and was allegedly involved in sexual activity with Resident #38. These failed practices resulted in Immediate Jeopardy, which caused or could have caused serious harm, injury or death to Resident #48, who was allegedly observed engaging in sexual activity with Resident #38, and had the potential to affect 45 residents who were cognitively impaired according to the list provided by the Administrator on 7/26/18. The Administrator was informed of the Immediate Jeopardy situation on 7/12/18 at 3:55 p.m. The findings are: 1. Resident #48 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/5/18 documented the resident scored 2 (0-7 indicates severely impaired) on a Brief Interview for Mental Status (BIMS) and required limited assistance of one staff member with bathing, personal hygiene and toilet use, set-up help only with meals, was independent with transfers and locomotion, and had behaviors of rejecting care on 1-3 of the past 7 days. a. The Care Plan, dated as last reviewed on 6/5/18, did not address concerns with sexual behaviors and did not address whether the resident had the capacity to consent to sexual activity. b. A Social Progress Note dated 6/14/18 at 11:10 a.m. documented, (Resident's) (daughter) is upset because daughter caught her mother out on the patio yesterday (6/13/18) (with) a male (resident) friend (Resident #38) doing some inappropriate things to him. Daughter demanded that her mother stay away from male (resident). On 7/11/18 at 9:32 a.m., the Social Director was asked, Are you familiar with (Resident #38)? She stated, Yes. She was asked, Are you aware that he sometimes exhibits sexually inappropriate behaviors? She stated, Yes. She was asked are you aware of the incident on the patio with (Resident #48) on 6/14/2018? She stated, Yes. Surveyor asked her what did she know about incident and she stated, They were out on the patio and (Resident #38's) daughter walked in on her ' giving him a blow job out on the patio ' . The DON and I talked to him and informed him that the daughter was very upset and didn ' t want them around each other anymore. He said he understood and would cooperate and that he didn ' t want to do anything to get in trouble. He ' s been cooperative and has made an effort to keep his distance, but (Resident #48) has attempted to seek him out. She has actually had a decline since they have been separated. She was asked, Do you have knowledge or have you heard of (Resident #38) being inappropriate with any other residents? She stated, No. c. A Social Progress Note dated 6/14/18 at 1:39 p.m. documented, DON (Director of Nursing) & (and) myself sat down w (with) R (Resident) & asked questions such as if R had a 'special' friend. (Resident) at one point made the comment 'no, but I wish I did.' We also asked (Resident) if she was ever afraid or if she felt unsafe, if anyone had done anything to hurt her. (Resident) stated 'hell no, I mean heck.' (Resident) would often state things such as 'what business is it of yours. These questions are just damn stupid. I'm not ignorant, yet.' When and if she was in a relationship and family didn't approve would she continue to see them? (Resident) stated 'I don't have that kind of family. I would not, I'm a Christian & wouldn't want to do anything wrong. But if I ever had that opportunity, it might change things'. (Resident) openly voiced she knows what sexual behaviors, touching .etc. (et cetera) by stating 'I'm not ignorant. These questions are personal, too personal and just damn stupid'. This note was signed by the Social Director. A typed statement provided by the DON on 7/11/18 at 12:16 p.m. documented, 6/14/18 When I (Administrator) arrived at work this morning, (DON), informed me that last night (Resident #38) & (and) (Resident #48) were on the patio & were having oral sex. (Resident #48's) daughter walked up on them & was very upset. (Resident #48's daughter) called me this morning to discuss the matter. I went to DON's office where (DON) & (CNA (Certified Nursing Assistant) supervisor) could be in on the conversation. (Resident #48's daughter) stated that she fussed at her mother about the behavior & had told her to stay away from (Resident #38). (Resident #48's daughter) stated that she wanted us to keep them away from each other. We discussed patient rights & said that if both parties consented to being intimate that it was their right to do so. (Resident #48's daughter) questioned that with her mother's dementia that she's not able to make that kind of decision . (Resident #48's daughter) was very adamant that we keep her mother away from (Resident #38). We told her that we would respect her wishes in this matter. I called (Resident #38's daughter) back at 3:20 p.m. to give her an update on our course of action. l. Staff have been told to redirect (Resident #48) & (Resident #38) if they are seen together. 2. (Resident #38) has been told he needs to stay away from (Resident #48). 3. We can't guarantee that we be will able to keep them totally apart during meals & activities, but that they would be monitored during these times. (Resident #48's daughter) stated she was ok with these actions . d. On 7/11/18 between 11:26 a.m. and 3:37 p.m., the following questions were asked of Licensed Practical Nurses (LPN's) #1 and 2 and Certified Nursing Assistant (CNA's). Do you have knowledge of or have you ever witnessed (Resident #38) exhibit sexually inappropriate behaviors with residents? They all stated that he had been sexually inappropriate with only one resident at times, (Resident #48). But now they are being monitored and kept apart . They were asked, How do you monitor them? They all stated, We watch them and make sure they ' re not together. 2. Resident #38 had [DIAGNOSES REDACTED]. The Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/15/18 documented the resident scored 14 (13-15 indicates cognitively intact) on the Brief Interview for Mental Status (BIMS), was independent with locomotion on and off the unit, used a walker/wheelchair for mobility, required limited assistance of one person for dressing and had no behaviors. a. The Care Plan dated developed 2/16/18 documented, .Behavior: Sexually inappropriate. Resident makes inappropriate remarks to staff at times. Approaches: Encourage resident to assume responsibility for own behavior but verbalize staff willingness to assist in maintaining appropriate behavior such as reorientation and redirecting .If reasonable, discuss behavior with resident, explain / reinforce why behavior is unacceptable . The care plan did not address inappropriate behaviors toward other residents. b. A Social Progress Note dated 6/14/18 at 4:30 p.m. documented, .DON and myself spoke (with) (Resident) regarding his relationship (with) his female friend who is also (Resident #48) at our facility. (Resident) was told it was in his best interest to keep his distance from the female (Resident #48). (Resident) stated he understood and that she was driving him crazy. (Resident) even stated he was told by (Resident #48's) daughter to keep his eye on her and take care of (Resident #48). (Resident) stated he would do what they ask of him . c. A Nurses Note dated 7/7/18 (not timed) documented, .(Resident #38) asked another to suck his (expletive - slang for penis) out on the patio. I inform (Resident) that was wrong and not to do it again. This note was signed by Licensed Practical Nurse (LPN) #2. The 24 hour Report dated 7/7/18 documented on the 6:00 a.m. to 2:00 p.m. shift Resident #48 asked Resident #38 to suck his (expletive - slang for penis). On 7/11/18 at 2:03 p.m., LPN #2 was asked, When did you report the incident involving sexually inappropriate behavior between (Resident #38) and (Resident #48) that occurred on 7/7/18? She stated, I wrote it on the 24-hour report board, because it was the weekend. She was asked, Did you verbally report to anyone? She stated, I think I told the weekend Supervisor, but we put everything on the 24-hour report. She was asked, Have you had abuse prevention training? She stated, Yes. She was asked, When should you report abuse or possible sexual abuse? She stated, Immediately to the DON or Administrator. On 7/12/18 at 2:32 p.m., the DON and Administrator were asked about the incident that occurred on 7/7/18 between Resident #38 and Resident #48. They both stated that they were unaware of the incident that occurred on that date. 3. On 7/11/18 at 10:55 a.m. the DON was asked, Was an investigation done after you were informed of the sexual incident on the patio on 6/13/18? She stated, Yes, we talked to both of them and we made sure we kept them apart and told the staff to watch them closely. She was asked, What else was done? She stated, We notified the families and the doctors . She was asked, Was the Care Plan updated to address this behavior? She stated, We already had a care plan addressing (Resident #38's) behavior towards staff, but he has not been inappropriate with any other residents. He and (Resident #48) were sort of in a little relationship that was consensual and going well. Her daughter even knew about it. (Resident #48) didn't feel that she was doing anything wrong. She was doing what she wanted to do. We feel she was cognitive and consensual and, based off of that, we didn't feel the need to do anything other than keep them separated as the daughter had requested. And he has been cooperative in keeping his distance. She has been chasing him. She was asked, How are you monitoring? She stated, Everyone has been informed of the incident, so they all know to watch them closely. She was asked, What criteria did you use to assess (Resident #48's) capacity for consent in sexual situations? She stated, Her mood, her affect, her behaviors, and her ability to verbalize/understand yes and no. Regardless of the diagnosis, if they are able to understand what yes and no means, I feel they know what they want and what they don't want. She was asked, Do you know what her BIMS score is? She stated, No. She was asked if she considered looking at Resident #48's BIMS and stated, I don't; her BIMS isn't correct, because she gets a low score, because she gets upset and refuses to answer all of the questions. 4. On 7/12/18 at 9:55 a.m., the Administrator was asked, Did you report the incident (6/13/18) with (Resident #38 and Resident #48) to the proper authorities? She stated, No, I just did an internal investigation. She was asked, Who did the daughter tell about the incident? She stated, The nurse or CNA that night (6/13/18). She was asked, After she (daughter) told them about the incident was anything done? She stated, The daughter separated them and the staff monitored them to make sure that it didn't happen again. She was asked, Is there any documentation of this monitoring? She stated, Since they didn't call and tell us about this probably not . She was asked, When were you informed of the incident? She stated, The DON told me about it the next morning (6/14/18) when I got to the facility. She was asked, When did the DON find out about the incident? She stated When she came in (6/14/18). 5. On 7/12/18 at 5:25 p.m., the physician was asked in a telephone interview, Does (Resident #48) have the cognitive capacity to consent to sexual behaviors? He stated, No, she has terrible dementia. I would say no, her dementia is pretty advanced. She does not have the cognitive capacity to consent. 6. The Immediate Jeopardy was removed and the scope and severity lowered to H on 7/12/18, when the facility implemented the following Plan of Removal: a. Beginning at 4:15 p.m. on 7/12/18, all staff on duty will be in-serviced by DON/Designee on the following subjects: Abuse & neglect & reporting any incidents to supervisor, immediate monitoring for signs/symptoms of abuse. All staff - including weekend staff and those who are on vacation or medical leave will be in-serviced prior to providing care. b. Resident #48 will be monitored every (q) 15 minutes by staff to ensure that he has maintained distance from all other residents. Monitoring will continue indefinitely. Resident#38 will be monitored q 15 minutes by staff to ensure she maintains distance from Resident #48. Monitoring will continue indefinitely. c. Beginning at 4:15 p.m. on 7/12/18, all residents will be assessed by DON/Designee/Charge Nurse for evidence of sexual abuse. Audits will be completed by 8:00 a.m. on 7/13/18. d. Beginning at 4:15 p.m. on 7/12/18, all residents who are able to respond will be interviewed and witness statements obtained by Administrator/Designee to ensure that no other episodes of sexual abuse have occurred e. Beginning at 4:15 p.m. on 7/12/18, statements from staff currently working will be obtained to identify if they have witnessed any of these incidents. f. DON/Designee will make random rounds every shift to observe resident to resident interactions to ensure all residents are safe and free from abuse. g. On 7/12/18 the DON/Designee will obtain witness statements from the 2 residents involved in the identified incident and other interviewable residents who may have knowledge of the alleged incident. h. For any cognitively impaired resident who wishes to engage in sexual activity, the nursing home will have the resident evaluated by the physician to determine if they have the capacity to consent and the issue will be care planned accordingly. i. Any negative findings will be corrected immediately and reported to the QA (Quality Assurance) committee. QA will review on Monday, Wednesday and Friday during the department head/QA meeting x (times) 4 weeks then weekly to ensure compliance is met and sustained.

Complaint # (AR 673) was substantiated, all or in part, with these findings: Based on record review and interview, the facility's administration and nursing administration failed to ensure facility policies on abuse prohibition were operationalized; failure to ensure a severely cognitively impaired female resident (Resident #48) was protected from possible resident-to-resident sexual abuse by failing to ensure the resident was evaluated by the physician to determine her capacity or incapacity to consent to sexual activity with a cognitively intact male resident (Resident #38); failure to investigate an incident of possible resident-to-resident sexual abuse; failure to immediately and consistently implement protective measures to prevent further contact with the cognitively intact male resident; and failure to ensure the incident of possible resident-to-resident sexual abuse was immediately reported to the Office of Long Term Care (OLTC) and other agencies in accordance with State Law for 1 of 1 (Resident #48) sampled female resident who was severely cognitively impaired and was allegedly involved in sexual activity with Resident #38. These failed practices resulted in Immediate Jeopardy, which caused or could have caused serious harm, injury or death to Resident #48, who was allegedly observed engaging in sexual activity with Resident #38, and had the potential to affect 45 residents who were cognitively impaired according to the list provided by the Administrator on 7/26/18. The Administrator was informed of the Immediate Jeopardy situation on 7/12/18 at 3:55 p.m. The findings are: 1. The Job Description for the Administrator, provided by the Administrator on 7/13/18 at 8:55 a.m., documented, .Position Summary: To ensure the internal operation of the facility is functioning in accordance with established policies and procedures and is responsible for any non-compliance with regulations found in the facility . Essential Job Functions: .Will be responsible for the day to day operation of the facility. Must be knowledgeable of state and federal regulations and guidelines pertaining to long-term care facilities . 2. The Job Description for the Director of Nursing, provided by the Administrator on 7/13/18 at 8:55 a.m., documented, . Position Summary: Responsible for ensuring the nursing department is functioning as to provide optimum care for the residents and meets minimum state and federal standards. Responsible for developing and maintaining all nursing services in accordance with accepted standards. Assuring that nursing care plans are established for each resident and that his/her plan is reviewed and modified as necessary. 3. The Facility's Abuse/ Neglect Policy provided by the Administrator on 7/9/18 documented, Definitions of Abuse . Sexual Abuse if defined as non-consensual sexual contact of any type with a resident . Sexual abuse includes but is not limited to: Unwanted intimate touching or (sic) any kind especially of the breast and perineal area; .It is the policy of (Facility) to take appropriate steps to prevent the occurrence of abuse, (Verbal, mental physical, sexual, involuntary seclusion), . and to ensure that all alleged violations of Federal or State Laws which involve . abuse . are reported immediately to the Administrator of the facility. Such violations will also be reported to State agencies in accordance with existing State Law. The facility will investigate each such alleged violation thoroughly and report the results of all investigations to the Administrator or his/her designee, as well as to State agencies as required by State and Federal Law . Reporting: Any employee who suspects an alleged violation shall immediately notify the Administrator or his/her designee. The Administrator/designee shall also notify the appropriate State and Local agencies immediately but not later than 1) 2 hours - if the alleged violation involves abuse or results in serious bodily injury 2) 24 hours - if the alleged violation does not involve abuse and does not result in serious bodily injury. The results of all investigations must be reported to the Administrator or his/her designee and appropriate state agency, as required by State Law, within 5 working days of the alleged violation . Investigation All investigations shall be conducted by the Administrator or DON. In the event an alleged violation occurs when neither of these people is in the Facility, the charge nurse is responsible for initiating the investigation procedure. The investigation shall include interviews of employees, visitors or residents who may have knowledge of the alleged incident. Factual information only should be documented, not assumptions or speculation. Written statements from involved parties should be taken and placed with all state required reports. The documentation of the investigation shall be kept in the Administrator's office in an administrative file. The medical record should be reviewed to determine the resident's past history and condition and its' relevance to the alleged violation. Federal Law requires the Facility to have evidence of investigation alleged violations. This form shall be reviewed by member of the Quality Assurance Committee and attached to the copy of the reports. This form shall be maintained in the Administrator's office as an administrative file. It is not part of the medical record . Documentation All written reports will be completed and faxed to OLTC according to Arkansas State Law. Documentation in the medical record shall be made necessary for continuity of care for the resident. Separate incident reports or other written reports, when required, shall be maintained and produced according with State Law . Protecting Residents During a Suspected Abuse (Facility) must protect residents from abuse (verbal, mental, physical, and sexual), neglect, involuntary seclusion, and misappropriation of their property . Residents who have voiced an abuse compliant (sic) will be protected from further harm during the period of the investigation. This will be accomplished by QA (Quality Assurance) members appointing a supervisor or trusted employee to observe resident continually thru out the time period involved in this investigation 4. Resident #48 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/5/18 documented the resident scored 2 (0-7 indicates severely impaired) on a Brief Interview for Mental Status (BIMS) and required limited assistance of one staff member with bathing, personal hygiene and toilet use, set-up help only with meals, was independent with transfers and locomotion, and had behaviors of rejecting care on 1-3 of the past 7 days. a. The Care Plan, dated as last reviewed on 6/5/18, did not address concerns with sexual behaviors and did not address whether the resident had the capacity to consent to sexual activity. b. A Social Progress Note dated 6/14/18 at 11:10 a.m. documented, (Resident's) (daughter) is upset because daughter caught her mother out on the patio yesterday (6/13/18) (with) a male (resident) friend (Resident #38) doing some inappropriate things to him. Daughter demanded that her mother stay away from male (resident). On 7/11/18 at 9:32 a.m., the Social Director was asked, Are you familiar with (Resident #38)? She stated, Yes. She was asked, Are you aware that he sometimes exhibits sexually inappropriate behaviors? She stated, Yes. She was asked are you aware of the incident on the patio with (Resident #48) on 6/14/2018? She stated, Yes. Surveyor asked her what did she know about incident and she stated, They were out on the patio and (Resident #38's) daughter walked in on her ' giving him a blow job out on the patio ' . The DON and I talked to him and informed him that the daughter was very upset and didn ' t want them around each other anymore. He said he understood and would cooperate and that he didn ' t want to do anything to get in trouble. He ' s been cooperative and has made an effort to keep his distance, but (Resident #48) has attempted to seek him out. She has actually had a decline since they have been separated. She was asked, Do you have knowledge or have you heard of (Resident #38) being inappropriate with any other residents? She stated, No. c. A Social Progress Note dated 6/14/18 at 1:39 p.m. documented, DON (Director of Nursing) & (and) myself sat down w (with) R (Resident) & asked questions such as if R had a 'special' friend. (Resident) at one point made the comment 'no, but I wish I did.' We also asked (Resident) if she was ever afraid or if she felt unsafe, if anyone had done anything to hurt her. (Resident) stated 'hell no, I mean heck.' (Resident) would often state things such as 'what business is it of yours. These questions are just damn stupid. I'm not ignorant, yet.' When and if she was in a relationship and family didn't approve would she continue to see them? (Resident) stated 'I don't have that kind of family. I would not, I'm a Christian & wouldn't want to do anything wrong. But if I ever had that opportunity, it might change things'. (Resident) openly voiced she knows what sexual behaviors, touching .etc. (et cetera) by stating 'I'm not ignorant. These questions are personal, too personal and just damn stupid'. This note was signed by the Social Director. A typed statement provided by the DON on 7/11/18 at 12:16 p.m. documented, 6/14/18 When I (Administrator) arrived at work this morning, (DON), informed me that last night (Resident #38) & (and) (Resident #48) were on the patio & were having oral sex. (Resident #48's) daughter walked up on them & was very upset. (Resident #48's daughter) called me this morning to discuss the matter. I went to DON's office where (DON) & (CNA (Certified Nursing Assistant) supervisor) could be in on the conversation. (Resident #48's daughter) stated that she fussed at her mother about the behavior & had told her to stay away from (Resident #38). (Resident #48's daughter) stated that she wanted us to keep them away from each other. We discussed patient rights & said that if both parties consented to being intimate that it was their right to do so. (Resident #48's daughter) questioned that with her mother's dementia that she's not able to make that kind of decision . (Resident #48's daughter) was very adamant that we keep her mother away from (Resident #38). We told her that we would respect her wishes in this matter. I called (Resident #38's daughter) back at 3:20 p.m. to give her an update on our course of action. l. Staff have been told to redirect (Resident #48) & (Resident #38) if they are seen together. 2. (Resident #38) has been told he needs to stay away from (Resident #48). 3. We can't guarantee that we be will able to keep them totally apart during meals & activities, but that they would be monitored during these times. (Resident #48's daughter) stated she was ok with these actions . d. On 7/11/18 between 11:26 a.m. and 3:37 p.m., the following questions were asked of Licensed Practical Nurses (LPN's) #1 and 2 and Certified Nursing Assistant (CNA's). Do you have knowledge of or have you ever witnessed (Resident #38) exhibit sexually inappropriate behaviors with residents? They all stated that he had been sexually inappropriate with only one resident at times, (Resident #48). But now they are being monitored and kept apart . They were asked, How do you monitor them? They all stated, We watch them and make sure they ' re not together. 3. Resident #38 had [DIAGNOSES REDACTED]. The Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/15/18 documented the resident scored 14 (13-15 indicates cognitively intact) on the Brief Interview for Mental Status (BIMS), was independent with locomotion on and off the unit, used a walker/wheelchair for mobility, required limited assistance of one person for dressing and had no behaviors. a. The Care Plan dated developed 2/16/18 documented, .Behavior: Sexually inappropriate. Resident makes inappropriate remarks to staff at times. Approaches: Encourage resident to assume responsibility for own behavior but verbalize staff willingness to assist in maintaining appropriate behavior such as reorientation and redirecting .If reasonable, discuss behavior with resident, explain / reinforce why behavior is unacceptable . The care plan did not address inappropriate behaviors toward other residents. b. A Social Progress Note dated 6/14/18 at 4:30 p.m. documented, .DON and myself spoke (with) (Resident) regarding his relationship (with) his female friend who is also (Resident #48) at our facility. (Resident) was told it was in his best interest to keep his distance from the female (Resident #48). (Resident) stated he understood and that she was driving him crazy. (Resident) even stated he was told by (Resident #48's) daughter to keep his eye on her and take care of (Resident #48). (Resident) stated he would do what they ask of him . c. A Nurses Note dated 7/7/18 (not timed) documented, .(Resident #38) asked another to suck his (expletive - slang for penis) out on the patio. I inform (Resident) that was wrong and not to do it again. This note was signed by Licensed Practical Nurse (LPN) #2. The 24 hour Report dated 7/7/18 documented on the 6:00 a.m. to 2:00 p.m. shift Resident #48 asked Resident #38 to suck his (expletive - slang for penis). On 7/11/18 at 2:03 p.m., LPN #2 was asked, When did you report the incident involving sexually inappropriate behavior between (Resident #38) and (Resident #48) that occurred on 7/7/18? She stated, I wrote it on the 24-hour report board, because it was the weekend. She was asked, Did you verbally report to anyone? She stated, I think I told the weekend Supervisor, but we put everything on the 24-hour report. She was asked, Have you had abuse prevention training? She stated, Yes. She was asked, When should you report abuse or possible sexual abuse? She stated, Immediately to the DON or Administrator. On 7/12/18 at 2:32 p.m., the DON and Administrator were asked about the incident that occurred on 7/7/18 between Resident #38 and Resident #48. They both stated that they were unaware of the incident that occurred on that date. 6. On 7/11/18 at 10:55 a.m. the DON was asked, Was an investigation done after you were informed of the sexual incident on the patio on 6/13/18? She stated, Yes, we talked to both of them and we made sure we kept them apart and told the staff to watch them closely. She was asked, What else was done? She stated, We notified the families and the doctors . She was asked, Was the Care Plan updated to address this behavior? She stated, We already had a care plan addressing (Resident #38's) behavior towards staff, but he has not been inappropriate with any other residents. He and (Resident #48) were sort of in a little relationship that was consensual and going well. Her daughter even knew about it. (Resident #48) didn't feel that she was doing anything wrong. She was doing what she wanted to do. We feel she was cognitive and consensual and, based off of that, we didn't feel the need to do anything other than keep them separated as the daughter had requested. And he has been cooperative in keeping his distance. She has been chasing him. She was asked, How are you monitoring? She stated, Everyone has been informed of the incident, so they all know to watch them closely. She was asked, What criteria did you use to assess (Resident #48's) capacity for consent in sexual situations? She stated, Her mood, her affect, her behaviors, and her ability to verbalize/understand yes and no. Regardless of the diagnosis, if they are able to understand what yes and no means, I feel they know what they want and what they don't want. She was asked, Do you know what her BIMS score is? She stated, No. She was asked if she considered looking at Resident #48's BIMS and stated, I don't; her BIMS isn't correct, because she gets a low score, because she gets upset and refuses to answer all of the questions. 7. On 7/12/18 at 9:55 a.m., the Administrator was asked, Did you report the incident (6/13/18) with (Resident #38 and Resident #48) to the proper authorities? She stated, No, I just did an internal investigation. She was asked, Who did the daughter tell about the incident? She stated, The nurse or CNA that night (6/13/18). She was asked, After she (daughter) told them about the incident was anything done? She stated, The daughter separated them and the staff monitored them to make sure that it didn't happen again. She was asked, Is there any documentation of this monitoring? She stated, Since they didn't call and tell us about this probably not . She was asked, When were you informed of the incident? She stated, The DON told me about it the next morning (6/14/18) when I got to the facility. She was asked, When did the DON find out about the incident? She stated When she came in (6/14/18). 8. On 7/12/18 at 5:25 p.m., the physician was asked in a telephone interview, Does (Resident #48) have the cognitive capacity to consent to sexual behaviors? He stated, No, she has terrible dementia. I would say no, her dementia is pretty advanced. She does not have the cognitive capacity to consent. 9. The Immediate Jeopardy was removed and the scope and severity lowered to H on 7/12/18, when the facility implemented the following Plan of Removal: a. Beginning at 4:15 p.m. on 7/12/18, all staff on duty will be in-serviced by DON/Designee on the following subjects: Abuse & neglect & reporting any incidents to supervisor, immediate monitoring for signs/symptoms of abuse. All staff - including weekend staff and those who are on vacation or medical leave will be in-serviced prior to providing care. b. Resident #48 will be monitored every (q) 15 minutes by staff to ensure that he has maintained distance from all other residents. Monitoring will continue indefinitely. Resident#38 will be monitored q 15 minutes by staff to ensure she maintains distance from Resident #48. Monitoring will continue indefinitely. c. Beginning at 4:15 p.m. on 7/12/18, all residents will be assessed by DON/Designee/Charge Nurse for evidence of sexual abuse. Audits will be completed by 8:00 a.m. on 7/13/18. d. Beginning at 4:15 p.m. on 7/12/18, all residents who are able to respond will be interviewed and witness statements obtained by Administrator/Designee to ensure that no other episodes of sexual abuse have occurred e. Beginning at 4:15 p.m. on 7/12/18, statements from staff currently working will be obtained to identify if they have witnessed any of these incidents. f. DON/Designee will make random rounds every shift to observe resident to resident interactions to ensure all residents are safe and free from abuse. g. On 7/12/18 the DON/Designee will obtain witness statements from the 2 residents involved in the identified incident and other interviewable residents who may have knowledge of the alleged incident. h. For any cognitively impaired resident who wishes to engage in sexual activity, the nursing home will have the resident evaluated by the physician to determine if they have the capacity to consent and the issue will be care planned accordingly. i. Any negative findings will be corrected immediately and reported to the QA (Quality Assurance) committee. QA will review on Monday, Wednesday and Friday during the department head/QA meeting x (times) 4 weeks then weekly to ensure compliance is met and sustained.

Complaint # (AR 796) was substantiated, all or in part, with these findings: Complaint # (AR 804) was substantiated, all or in part, with these findings: Based on observation, record review, and interview, the facility failed to ensure necessary treatment and services were provided for management of existing pressure ulcers, as evidenced by failure to ensure pressure ulcer wound care was provided at the frequency ordered by the physician to promote healing and prevent further potential deterioration for 4 (Residents #1, #2, #3, and #5) of 5 (Residents #1, #2, #3, #4, and #5) case mix residents who had pressure ulcers. This failed practice resulted in immediate jeopardy, which caused or could have caused serious harm, injury or death to Resident #5, whose Stage IV pressure ulcer failed to heal, became infected, and deteriorated to the point where it was too large to debride to healthy margins and had exposure of bone. The facility also failed to ensure loose or missing wound dressings were promptly reported to licensed nursing staff and replaced to promote healing and minimize the potential for infection for 2 (Residents #2 and #3) of 5 (Residents #1, #2, #3, #4, and #5) case mix residents who had pressure ulcers. The failed practices had the potential to cause more than minimal harm to 11 residents who had pressure ulcers, according to a list provided by the Administrator on 12/12/17 at 6:00 p.m. The Administrator was informed of the immediate jeopardy condition involving Resident #5 on 12/12/17 at 4:12 p.m. The findings are: 1. Resident #5 had [DIAGNOSES REDACTED]. The Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/19/17 documented the resident scored 5 (0-7 indicates severe cognitive impairment) on the brief interview for mental status (BIMS), was totally dependent on the physical assistance of two-plus persons for transfers, was totally dependent on the physical assistance of one person for bed mobility, toilet use, and personal hygiene, was incontinent of bowel and bladder, was at risk for the development of pressure ulcers and had no existing pressure ulcers. a. A Nurse's Note dated 8/25/17 at 10:30 a.m. and signed by Licensed Practical Nurse (LPN) #1 documented, (Resident) has (an) unstageable full thickness decubitus to coccyx. Unstageable (due to) slough. Wound is 80% slough and 20% granulation tissue. Scant amount of serosanguineous drainage noted. (No) (signs and symptoms) of infection noted. Measures 2.5 cm (centimeter) (length) (by) 2.5 cm (width) (by) UTD (unable to determine depth). A Physician order [REDACTED].Cleanse coccyx (with) wound cleanser or normal saline. Apply Santyl and cover (with) secondary dressing (every) day until resolved . b. A Weekly Pressure / Non-Pressure Skin Condition Report form documented, .Date First Observed: 8/25/17 . The form further documented, .8/31/17 . 2.5 (cm) (by) 2.5 (cm) (by) UTD . Exudate Type . Serosanguineous . Exudate Amount: Small . Odor: None . Wound Bed: Granulation Tissue . Slough . Surrounding Skin Color . Pink . The August 2017 Treatment Record documented initials to indicate LPN #1 performed the ordered treatment to the resident's coccyx wound on 8/25/17 (Friday). There were no initials on the Treatment Record for 8/26/17 (Saturday) and 8/27/17 (Sunday) to indicate the treatments were provided on those dates. A Physician order [REDACTED].D/C (discontinue) current (treatment) to coccyx . Start new (treatment) to coccyx as follows: Cleanse wound on coccyx (with) (wound cleanser) or (normal saline), Pat dry, Apply Santyl, then apply Hydrogel, then cover (with) secondary dressing (every) day until resolved . c. A Weekly Pressure / Non-Pressure Skin Condition Report form documented, .9/7/17 . 2 (cm) (by) 2 (cm) (by) UTD . Exudate Type . Serosanguineous . Exudate Amount . Small . Odor . None . Wound Bed . Granulation Tissue . Slough . Surrounding Skin Color . Pink . The September 2017 Treatment Record was not initialed by a licensed nurse to indicate the physician-ordered treatments were provided on 9/10/17 (Sunday), 9/11/17 (Monday) and 9/13/17 (Wednesday). d. A Weekly Pressure / Non-Pressure Skin Condition Report form documented, .9/14/17 . 2 (cm) (by) 2 (cm) (by) UTD . Exudate Type . Serosanguineous . Exudate Amount . Small . Odor . None . Wound Bed . Granulation Tissue . Slough . Surrounding Skin Color . Normal for Skin . Remains unstageable (due to) slough. Wound bed is now 70% slough (and) 30% granulation tissue . The September 2017 Treatment Record contained no documentation to indicate the physician-ordered wound treatment was provided on 9/17/17 (Sunday). The Quarterly MDS with an ARD of 9/18/17 documented the resident scored 7 (0-7 indicates severe cognitive impairment) on the BIMS, was totally dependent on the physical assistance of two-plus persons for transfers, was totally dependent on the physical assistance of one person for bed mobility, toilet use, and personal hygiene, had limitation in range of motion of a lower extremity on one side, was incontinent of bowel and bladder, and had an unstageable pressure ulcer measuring 2.5 cm by 2.5 cm by an unknown depth. A Physician order [REDACTED].Add Juven (one) pack mixed (with) 8 oz (ounces) of water or juice BID (twice daily) (times) 60 days . Glucerna (one) can BID for additional protein and calories . e. A Weekly Pressure / Non-Pressure Skin Condition Report form documented, .9/21/17 . 2 cm (by) 2 cm (by) UTD . Exudate Type . Serosanguineous . Exudate Amount . Scant . Odor . None . Wound Bed . Slough . Surrounding Skin Color . Pink . The September 2017 Treatment Record had no documentation to indicate the physician-ordered wound treatments were provided on 9/23/17 (Saturday), 9/24/17 (Sunday) and 9/27/17 (Wednesday). f. A Weekly Pressure / Non-Pressure Skin Condition Report form documented, .9/28/17 . 2 cm (by) 2 cm (by) UTD . Exudate Type . Serosanguineous . Exudate Amount . Scant . Odor . None . Wound Bed . Slough . Surrounding Skin Color . Pink . The September 2017 Treatment Record had no documentation to indicate the physician-ordered wound treatment was provided on 9/30/17 (Saturday). The October 2017 Treatment Record had no documentation to indicate the physician-ordered wound treatments were provided on 10/1/17 (Sunday) and 10/2/17 (Monday). g. A Weekly Pressure / Non-Pressure Skin Condition Report form documented, .10/5/17 . 2 cm (by) 2 cm (by) UTD . Exudate Type . Serosanguineous . Exudate Amount . Scant . Odor . None . Wound Bed . Granulation Tissue . Slough . Surrounding Skin Color . Pink . Wound bed granulation tissue and slough. Surrounding skin color pink. Wound bed is now 60% slough and 40% granulation tissue . The October 2017 Treatment Record had no documentation to indicate the physician-ordered wound treatments were provided on 10/7/17 (Saturday) and 10/8/17 (Sunday). h. A Weekly Pressure / Non-Pressure Skin Condition Report form documented, .10/12/17 . 2 cm (by) 2 cm (by) UTD Exudate Type . Serosanguineous . Exudate Amount . Small . Odor . None . Wound Bed . Granulation Tissue . Slough . Surrounding Skin Color . Pink . A Physician order [REDACTED].Increase protein supplement to 30 ml (milliliter) QID (four times daily) . The October 2017 Treatment Record had no documentation to indicate the physician-ordered wound treatments had been provided on 10/14/17 (Saturday) and 10/15/17 (Sunday). A Nurse's Note dated 10/16/17 at 12:00 p.m. and signed by LPN #1 documented, (Resident) has unstageable pressure ulcer to coccyx. (Resident) has satellite pressure ulcers surrounding wound. Wound has stalled in resolving. (Increase) in serosanguineous drainage. (Resident) afebrile. Message left (with) (Physician) concerning oral antibiotic. A physician's orders [REDACTED].[MEDICATION NAME] 300 mg (milligram) (one) PO (by mouth) QID (four times per day) (times)10 days . Acidophilus 1 mg (one) PO (every) day (times) 10 days . Wound Center consult . i. A Weekly Pressure / Non-Pressure Skin Condition Report form documented, .10/19/17 . 3 cm (by) 3 cm (by) UTD . Exudate Type . Serosanguineous . Exudate Amount . Small . Odor . None . Wound Bed . Granulation Tissue . Slough . Surrounding Skin Color . Pink . Appt (Appointment) (at) (wound care center) 10/25/17 . The October 2017 Treatment Record had no documentation the wound treatments were provided on 10/21/17 (Saturday) and 10/22/17 (Sunday). A Nurse's Note dated 10/23/17 at 10:00 a.m. documented, Called to (resident's) room. Voiced slurred (with) AMS (altered mental status) noted . NO (new order) to send to ER (emergency room ) for eval (evaluation) and tx (treatment) . (10:05 a.m.) Amb (Ambulance) here for transport . A Nurses Note dated 10/24/17 at 5:00 a.m. documented, .Resident admitted to (hospital) . A Re-admitting Nursing Assessment form dated 10/27/17 at 1:15 p.m. documented, .(Resident) has unstageable - full thickness - 6 cm (by) 5 cm (by) UTD (with) slough covering the area . k. A Weekly Pressure / Non-Pressure Skin Condition Report form dated 10/27/17 documented, .6 cm (by) 5 cm (by) UTD . Exudate Type . Serosanguineous . Exudate Amount . Moderate . Odor . None . Wound Bed . Slough . Surrounding Skin Color . Pink . (Resident) returned from (hospital). Pressure (ulcer) (increased) in size . 100% slough. Rescheduled (appointment) (with) (wound care center) for 1:30 p.m.on 10/30/17 . The October 2017 Treatment Record had no documentation the wound treatments were provided on 10/28/17 (Saturday) and 10/29/17 (Sunday). l. A Weekly Pressure / Non-Pressure Skin Condition Report form documented, .10/30/17 . 5 cm (by) 4.5 cm (by) UTD . Exudate Type . Serosanguineous . Exudate Amount . Small . Odor . Slight . Wound Bed . Granulation Tissue . Slough . Black / Brown (eschar) . Surrounding Skin Color . Pink . New (treatment) . A Nurse's Note dated 10/30/17 at 3:30 p.m. and signed by LPN #1 documented, (Resident) returned from (appointment) (with) wound center (with) (new orders) as follows . D/C (discontinue) previous (treatment) to pressure ulcers . Start (new order). Cleanse coccyx (with) (wound cleanser), pat dry, apply a nickel thin layer of Santyl to wound bed only, then cover (with) secondary dressing (every) day . m. A Weekly Pressure / Non-Pressure Skin Condition Report form documented, .11/2/17 . 5 cm (by) 4.5 cm (by) UTD . Exudate Type . Serosanguineous . Exudate Amount . Small . Odor . Slight . Wound Bed . Granulation Tissue . Slough . Black / Brown (eschar) . Surrounding Tissue / Wound Edges . Maceration . The November 2017 Treatment Record had no documentation the wound treatments were done on 11/4/17 (Saturday) and 11/5/17 (Sunday). A Nurse's Note dated 11/6/17 at 12:00 p.m. and signed by LPN #1 documented, (Resident) returned from (appointment) (at) (wound care center). (No) new orders noted . n. A Weekly Pressure / Non-Pressure Skin Condition Report form documented, .11/9/17 . 8 cm (by) 8 cm (by) UTD . Exudate Type . Serosanguineous . Exudate Amount . Moderate . Odor . Slight . Wound Bed . Granulation Tissue . Slough . Black / Brown (eschar) . Surrounding Skin Color . Black / Brown . Surrounding Tissue / Wound Edges . Maceration . (Resident) has had [MEDICAL CONDITION]. Decline in condition . A Nurse's Note dated 11/13/17 at 1:30 p.m. and signed by LPN #1 documented, (Resident) returned from (appointment) (with) (physician at wound care center) (with) new orders as follows . (Discontinue) current (treatment) to coccyx . Start new (treatment) to coccyx as follows: Cleanse coccyx (with) wound cleanser, then apply Dakins 0.125% wet-to-dry packing and cover (with) foam dressing (with) border BID (twice daily) . The November 2017 Treatment Record documented, .Cleanse coccyx wound (with) wound cleanser, then apply Dakins 0.125% wet-to-dry packing and cover (with) foam dressing (with) border BID . 11-13-17 . Time . 8-4 (8:00 a.m. to 4:00 p.m.) . There was no other time slot on the Treatment Record to document a second treatment each day. o. A Weekly Pressure / Non-Pressure Skin Condition Report form documented, .11/16/17 . 8 cm (by) 8 cm (by) UTD . Exudate Type . Serosanguineous . Exudate Amount . Moderate . Odor . Moderate . Wound Bed . Granulation Tissue . Slough . Black / Brown (eschar) . Surrounding Skin Color . Black / Brown . Surrounding Tissue / Wound Edges . Maceration . A Nurse's Note dated 11/20/17 at 1:25 p.m. and signed by LPN #1 documented, (Resident) returned from MD (medical doctor) (appointment). (No) new orders . The November 2017 Treatment Record contained no documentation the wound treatment was done on 11/21/17. p. A Nurse's Note dated 11/22/17 at 10:00 a.m. documented, Called to (resident) room regarding (change) in MS (mental status). On assessing (resident) LLE (lower left extremity) has dark purple color. (Left) foot cold to touch. Unable to obtain pedal pulses. B/P (blood pressure) hard to hear . (Decreased) alertness compared to 0630 (6:30 a.m.) assessment . (New order) to send to ER for (evaluation) / (treatment) . 1) A patient face sheet from Hospital #1 documented the resident was admitted there on 11/22/17 at 11:23 a.m. 2) A patient face sheet from Hospital #2 documented the resident was admitted on [DATE] at 4:46 p.m. The Emergency Department Note dated 11/22/17 from Hospital #2 documented, .Clinical Impression / Problem . Decubitus ulcer . A Critical Care Consult dated 11/23/17 at 2:13 a.m. from Hospital #2 documented, .In addition, she has an extensive decubitus ulcer to the coccyx / sacral area that is very malodorous and obviously infected . present on admission . Very deep and I believe has exposed bone. Obvious infection with yellow and black slough, black eschar. Extremely malodorous. Packing with [MEDICATION NAME] until wound care and surgery can consult on her . A Discharge Summary dated 11/23/17 from Hospital #2 documented, .The patient has a history of [MEDICAL CONDITION] is unable to communicate at this time. She was found at her nursing home this morning with a cold left lower extremity . patient is septic secondary to UTI (urinary tract infection) versus decubital ulcer versus ischemic left lower extremity . A Certificate of Transfer from Hospital #2 documented, This is to certify the following information concerning the transfer of the above name patient . from (Hospital #2) on this 23 day of November, 2017 at (3:45 a.m.) . 3) A History and Physical dated 11/23/17 from Hospital #3 documented, .Plan: .Stage 4 decubitus ulcer appears to be infected. We will start the patient on broad-spectrum antibiotics, [MEDICATION NAME] . A Discharge Summary dated 12/8/17 from Hospital #3 documented, .We also note on the patient's arrival that she had an extremely large stage 4 decubitus ulcer to the sacrum. Bone was clearly visible through this wound. We had Wound Care see the patient and it was the feeling from our Wound Care that this needed debridement. There was purulence draining from the wound including necrotic tissue at its edges . The wound was extremely large, greater than 20 centimeters in diameter. He debrided as much of the necrotic tissue as he felt that he was able to do it safe. However, there were areas still that were necrotic and needed debridement. That could not be pursued given the (sheer) size of this ulcer. At this point, his frank recommendation with Palliative Care is a wound that will not be able to heal and will at some point in the relatively near future become re-infected and likely make the patient septic . On 12/12/17 at 12:40 p.m., a physician who provided care to Resident #5 at Hospital #3 was asked during a telephone interview what she remembered about the resident. She stated, She had a long standing history of Dementia, [MEDICAL CONDITION], was bed bound for several years. She went to an outside hospital and was sent to us for possible neurosurgery because they felt she may have had a subarachnoid hemorrhage, which wound up not being the case. She had developed an ischemic leg and it could not be bypassed, so she had to have it amputated. As far as her decub (decubitus ulcer) . it was a stage 4 with bone exposed. Quite large. And she came here like that. She had not been in a hospital for months . I can't say what happened, or didn't happen, at the nursing home, but obviously if you don't relieve pressure off of that area, it won't get better. It was a terrible wound. When she went into surgery to have it debrided, the surgeon said it was one of the worst he had ever seen, and he's seen a lot of them. It could not even be debrided to healthy margins because of the size of it. q. On 12/12/17 at 2:00 p.m., Registered Nurse (RN) #1 was asked why Resident #5's treatment was not done over the weekend (12/9/17 and 12/10/17). She stated, There was some confusion for me, because I had been off for about four weeks. Before, the supervisors weren't doing the treatments on the weekends, but that apparently changed. I didn't know I was supposed to do it. She was asked about all of the blanks on the Treatment Records for weekend treatments, and specifically about Resident #5. She stated, I think I done (sic) her treatment one time, and that was because the nurse asked for help. I'm just being honest. That was during the time the floor nurses were supposed to be doing them. I didn't take care of her wounds until after she came back from the hospital (10/27/17). Then I only did it like once. When I do the treatments, I usually initial the TAR (Treatment Administration Record). r. On 12/12/17 at 3:58 p.m., the Treatment Nurse was asked if he saw Resident #5's wound on the day she left to go to the hospital (11/22/17). He stated, Yes. I did the treatment on her wound before she went out. He was asked if he documented anything that day about how the wound looked. He stated, I don't think I did. I remember it didn't have a dressing on it, so I was trying to make sure I put one on it before she left. He was asked if he remembered seeing bone when he observed the wound that day. He stated, I couldn't see any bone, but there was a lot of slough. And it did have an odor. He was told what the hospital papers documented regarding the wound being infected. He was asked if the resident was on antibiotics at the time she left on 11/22/17. He stated, No she wasn't. She had been on some previously. He was asked about the Physician order [REDACTED]. He stated, Oh man . I know better than that. I can't believe I documented it like that. I was actually doing the treatment twice a day, but only put it in one time slot. s. On 12/12/17 at 4:48 p.m., the Director of Nursing (DON) was asked if anyone had reported to her that Resident #5's coccyx wound looked infected, or if bone was exposed. She stated, No. She was asked if anyone had identified that treatments were not being done on the weekends. She stated, There was a comment made about two weeks ago about who was supposed to be doing treatments on the weekends. I told them the RN (Registered Nurse) Supervisor. They said, 'Well, they're not. So I did it.' So I left a note in the RN Supervisor folder to inform them that RN Supervisors are the ones to do treatments on the weekends. The floor nurses have enough to do already. t. On 12/13/17 at 1:45 p.m., the Medical Director was asked during a telephone interview if he remembered Resident #5. He stated, I just remember the wound was pretty bad and we initiated care and sent her to the wound clinic. Then she got sick because of her leg. He was asked what the wound looked like the last time he saw it. He stated, The last time I saw it, it didn't look infected, but there was a little bit of exudate. He was asked if he was aware there had been a problem with treatments being done on the weekends in the facility. He stated, They just switched Treatment Nurses so there might have been a period of time where someone dropped the ball . 2. Resident #1 had [DIAGNOSES REDACTED]. The Quarterly MDS with an ARD of 10/10/17 documented the resident scored 7 (0-7 indicates severely cognitively impaired) on the Brief Interview for Mental Status (BIMS), required no assistance with transfers or bed mobility, was frequently incontinent of bladder, was occasionally incontinent of bowel, and had one stage 3 pressure ulcer (PU) measuring 0.5 centimeters (cm) by 0.3 cm by 0.0 cm. a. A Care Plan with a revised date of 8/25/17 documented, .At risk for pressure sore related to episodes of incontinence . report changes in skin status . to physician . Treatment per Treatment Nurse . b. A Nurse's Note dated 11/2/17 at 2:30 p.m. signed by LPN #1 documented, Pressure ulcer to coccyx has resolved . c. A Nurse's Note dated 12/8/17 at 2:30 p.m. signed by LPN #1 documented, Stage 3 pressure ulcer to left buttock / coccyx has reopened. Wound measures 1 cm (by) 1 cm (by) (less than) 0.2 cm. Periwound fragile, measures 6 cm (by) 6 cm. Treatment as follows: Cleanse PU (pressure ulcer) on left buttock / coccyx with WC (wound cleanser), pat dry, moisten collagen with hydrogel, apply to wound, then cover with secondary dressing every day until resolved . d. The December 2017 Treatment Record documented, with LPN #1's initials, the treatment was performed on 12/8/17. There were no initials on the Treatment Record for 12/9/17 (Saturday) and 12/10/17 (Sunday) to document provision of the treatment. e. On 12/11/17 at 11:33 a.m., the resident ambulated down the hall and into her room, accompanied by Certified Nursing Assistant (CNA) #2. The CNA removed the resident's wet incontinent brief; there was a dressing dated 12/8/17 on the resident's coccyx area. The dressing had a reddish yellow drainage on it that had soaked through. At 12:29 p.m., the Treatment Nurse, LPN #1, removed the 12/8/17 dressing, which revealed two open areas. The LPN measured the first area as 0.6 cm by 0.5 cm by less than 0.1 cm. The wound bed was pink. There was no odor; there was a small amount of bloody drainage. The LPN measured the second area as 1.0 cm by 1.0 cm by less than 0.1 cm. The wound bed was pink. There was no odor; there was a small amount of bloody drainage. The peri-wound was purple in color. According to the resident, the entire area was very tender to touch. When asked how the area looked in comparison to when he saw it last Friday (12/8/17), he stated, It looks worse. There was only one open area Friday. Now there's two. 3. Resident #2 had [DIAGNOSES REDACTED]. The Significant Change MDS with an ARD of 8/14/17 documented the resident was severely impaired in cognitive skills per a Staff Assessment of Mental Status (SAMS), was totally dependent on the physical assistance of two-plus persons for bed mobility and transfer, was totally dependent on the physical assistance of one person for toilet use and personal hygiene, was incontinent of bladder and of bowel, and was at risk for development of pressure ulcers. a. A Care Plan with a revised date of 10/23/17 documented, .Resident at risk for pressure ulcer due to immobility and incontinence . report changes in skin status to physician . notify nurse immediately of any new areas of skin breakdown, redness, blisters, bruises, discoloration noted during bathing or daily care . wound care as ordered, see current treatment record and physician orders; monitor effectiveness of / response to treatment as ordered . pressure ulcer on coccyx . Treatment per MD (physician) orders . Low air mattress . b. A Physician order [REDACTED].Cleanse Stage 3 pressure ulcer to coccyx with wound cleanser, pat dry, moisten collagen with hydrogel and apply to wound, then cover with secondary dressing every day until resolved . c. A Weekly Pressure / Non-Pressure Skin Condition Report dated 12/7/17 documented, .0.5 cm (by) 0.5 cm (by) 0.1 cm, no exudate, no odor, surrounding skin color pink, normal . d. The December 2017 TAR documented LPN #1 performed the treatment on 12/8/17, however, there were no initials on the TAR for 12/9/17 (Saturday) or 12/10/17 (Sunday) to document provision of the treatment. e. On 12/11/17 at 11:50 a.m., the resident was lying in bed on her right side. The Director of Nursing (DON) and Surveyor observed a wound on the coccyx area. There was no dressing covering the wound. f. On 12/11/17 at 1:55 p.m., the resident was lying in bed. CNA #1 was in the room. When asked if the resident had a dressing on her wound early this morning when she first began providing care for the resident, the CNA stated, No. The Treatment Nurse entered the room. When asked if anyone had reported to him that the wound had no dressing on it, he stated, No, but (Registered Nurse (RN) #1) has put one on there since you and (Director of Nursing (DON)) found her without one. The resident was rolled to her left side. The Treatment Nurse measured the area as 1 cm by 1 cm by 0.2 cm. There was no odor or drainage. Collagen and Hydrogel was applied and the area covered with an absorbent dressing. 4. Resident #3 had [DIAGNOSES REDACTED]. The Quarterly MDS with an ARD of 9/21/17 documented the resident was moderately impaired in cognitive skills per a staff assessment for mental status, was totally dependent on two-plus persons physical assistance for transfers, was totally dependent on one person physical assistance for bed mobility, toilet use, and personal hygiene, had limitation in range of motion of the lower extremities on both sides, was incontinent of bladder and of bowel, and had a Stage 2 pressure ulcer. a. A Care Plan with a revised date of 10/26/17 documented, .At risk for skin breakdown, related to incontinent episodes and decreased mobility . provide skin care, monitor skin and report any change of condition promptly . Stage II to Gluteal Crease . Treatment per MD (physician) orders . b. A Physician order [REDACTED].Cleanse gluteal crease with wound cleanser, pat dry, moisten collagen with hydrogel and apply to wound and then cover with a secondary dressing every other day until resolved . The November 2017 Treatment Record contained initials in the sections to document administration of the treatment every other day, except 11/21/17 (Tuesday) and 11/25/17 (Saturday). c. A Weekly Pressure / Non-Pressure Skin Condition Report dated 12/7/17 documented, .0.5 cm (by) 0.5 cm (by) (less than) 0.2 cm . Exudate Type . None . Odor . None . Wound Bed . [MEDICATION NAME] Tissue . Surrounding Skin Color . Pink . Surrounding Tissue / Wound Edges . Maceration . d. The December 2017 Treatment Record documented with initials LPN #1 performed the treatment every other day up to 12/7/17. There were no initials on the Treatment Record for 12/9/17 (Saturday). e. On 12/11/17 at 12:20 p.m., the resident was lying in bed. The resident was rolled to her left side by CNA #2. No dressing was covering the wound, and no open areas were visible due to a thick layer of barrier cream on the resident's buttocks. f. A Nurse's Note dated 12/13/17 at 6:30 a.m., and signed by LPN #1, documented, Resident has new stage 2 pressure ulcer to gluteal crease measuring 1 cm (by) 0.3 cm (by) 0.1 cm. Periwound red but blanches. PU from gluteal crease from 10/26/17 has increased in size. Measures 1.5 cm (by) 0.3 cm (by) (less than) 0.2 cm . g. On 12/13/17 at 10:06 a.m., the resident was lying in bed. The resident was rolled to her left side by LPN #1. Two open areas were visible on the coccyx area. LPN #1 stated, There was just one area. I found another one this morning. He measured the areas and stated the original area was now 1.5 cm by 0.4 cm by 0.2 cm. The second area measured 1.0 cm by 0.3 cm by 0.1 cm. He was asked if anyone made him aware on 12/11/17 that the wound had no dressing, and he stated, No. 5. The Immediate Jeopardy was removed and the scope and severity lowered to H on 12/12/17 at 5:00 p.m., when the facility implemented the following Plan of Removal: Beginning at 5:00 p.m. on 12/12/17, all staff on duty will be in-serviced by DON / Designee on the following subjects: abuse and neglect, turning and repositioning residents every 2 hours, reporting any changes in condition immediately to Charge Nurse, nurses regarding doing treatments, following physician orders, and documentation. All staff, including weekend staff and those who are on vacation or medical leave, will be in-serviced prior to providing care. Beginning at 5:00 p.m. on 12/12/17, body audits will be done by DON / Designee / Charge Nurse on all residents. Audits will be completed by 7:00 a.m. 12/13/17. TARs will be audited by DON / Designee to ensure documentation is being done: daily x (times) 7 days, weekly x (times) 3 weeks until compliance is met & (and) sustained. Pressure ulcer treatments will be monitored every weekend x (times) 4 weeks, then every 2 weeks indefinitely until compliance is met and sustained by DON / Designee to ensure these treatments are being done per physician orders. Pressure ulcer treatments will be monitored daily x (times) 7 days, weekly x (times) 3 weeks until compliance is met and sustained by DON / Designee to ensure treatments are being done per physician orders. Resident #5 was discharged to the hospital on [DATE] and is not expected to return to the facility. Resident #2's pressure ulcer area was cleaned and the dressing replaced on 12/11/17 at 1:00 p.m. by the Charge Nurse. Resident #1's pressure ulcer area was cleaned and the dressing replaced on 12/11/17 at noon by the Treatment Nurse. New treatment order obtained & (and) initiated by the Treatment Nurse. The Weekend RN will be in-serviced by DON / Designee upon return to work on responsibilities to ensure the weekend treatments are completed as ordered. Any negative findings will be corrected immediately and reported to the QA (Quality Assurance) Committee. QA will review on Monday, Wednesday, and Friday during the Department Head / QA meeting x (times) 4 weeks then weekly to ensure compliance is met & (and) sustained.

Based on observation, record review and interview, the facility failed to ensure nutritional status was maintained within acceptable parameters to prevent further weight loss as evidenced by failure to ensure interventions to address a severe weight loss were developed and promptly implemented and failure to ensure dietary needs were evaluated by the Registered Dietician to allow for improved caloric intake and nutritional adequacy for 1 of 1 (Resident #9) case mix resident who had a severe weight loss. The facility also failed to ensure the physician was consulted regarding the Registered Dietician's recommended interventions to decrease the potential for further weight loss for 1 of 1 (Resident #4) case mix resident who had a severe weight loss and received nutrition via Percutaneous Endogastrostomy (PEG) tube. This failed practice resulted in actual harm for Resident #9 who experienced a severe weight loss and had the potential to cause more than minimal harm for 11 residents who had a significant weight loss, according to a list provided by the Administrator on 3/27/15 and for 6 residents who received tube feedings, according to the Resident Census and Conditions of Residents form dated 3/24/15. The findings are: 1. Resident #9 had [DIAGNOSES REDACTED]. The 30 Day Minimum Data Set with an Assessment Reference Date of 2/26/15 documented the resident had severely impaired cognitive skills for daily decision making per a staff assessment of mental status; was independent for eating with set up help only; was on a therapeutic diet; had no swallowing problems; and had no weight loss. a. The March 2015 physician's orders [REDACTED]. b. The Annual Weight Report for 2014 / 2015 documented the following weights for the resident: 1) September 2014: 108 pounds 2) October 2014: 104 pounds 3) November 2014: 104 pounds 4) December 2014: 97 pounds 5) January 2015: 94 pounds 6) February 2015: 87 pounds The resident's March 2015 weight was provided by the Administrator on 3/24/15 at 10:50 a.m. and documented the resident weighed 87 pounds. This was a weight loss of 21 pounds from September 2014 to March 2015 (19.4%) and 10 pound weight loss from December 2014 to March 2015 (10.3%). c. The Dietary Progress Notes signed by a Registered Dietician (RD) and dated 12/3/14 documented, "...Back pain present (at) all times. Will not eat due to pain. Continues to lose wt (weight). Encouragement (at) all meals. Does not eat as many snacks as usual. Self fed. Staff continues to encourage snacks / meals." d. The Medical Nutrition Therapy Assessment form dated 1/5/15 documented, "Nutrition Diagnosis - At risk for nutritional def (deficit) R/T (related to) disease process AEB (as evidenced by) wt (less than) 100... Nutrition Prescription (and) Intervention - Continue encourage intake... Nutrition Monitoring... Rec (Recommend): Add 1 can glucerna to 2:30 (p.m.) snack..." 1) A handwritten physician's orders [REDACTED]. 2015 and March 2015 printed Physician order [REDACTED]. 2) On 3/25/15 at 10:30 a.m., the Director of Nursing (DON) was asked, "Where would a supplement such as Glucerna be documented showing the resident had received it and how much they had consumed?' She stated, "Usually on the MAR (Medication Administration Record)." 3) The resident's January 2015 and February 2015 MARs (copied on 3/26/15 at 3:30 p.m.) did not document the resident was receiving Glucerna. e. The monthly Consultant Dietician reports dated 9/25/14, 10/28/14, 11/17/14, 1/31/15 and February 2015 did not document a dietary assessment by the Registered Dietician for the resident. The Resident Plan of Care dated 2/9/15 did not address weight loss. 1) On 3/26/15 at 9:55 a.m., the Registered Dietician (RD) was asked, "When is the last time you saw (Resident #9)?" The RD stated, "I don't remember. I gave a copy of my report to the DM (Dietary Manager), the Administrator and the DON." The RD was asked, "Are you aware of (Resident #9)'s weight loss?" She stated, "Yes. Weight reports are not always available when I come in." The RD further stated the resident was in the hospital in January 2015 and did not show up on the January 2015 Weight Report. The RD was asked, "What is the procedure for you to get that information from the facility?' She stated, "I get the weight report from the DM. I haven't seen the weight report for March (2015)." 2) On 3/26/15 at 10:45 a.m., the DM was asked what her role was in getting information to the Registered Dietician. She stated, "I go into (computer software program) and print out the weight list for the current month, 3 months and 6 months." The DM was asked when the RD came to the facility. She stated, "Normally she comes around the third week in the month or she'll come back. This winter it's been the first week." The DM was then asked, "Did you print out a weight list on her last visit?" She stated, "Didn't give her a weight list. The monthly weights were not in yet, so I didn't have a current one to give her. She already had the last one. She worked on assessments. I did not mention (Resident #9). That's on me. I don't know why I did not." f. A physician order [REDACTED]." As of 3/26/15 at 3:30 p.m., the resident's March 2015 MAR indicated [REDACTED] g. The March 2015 Food and Hydration Intake Record documented: 1) Breakfast from 3/1/15 through 3/27/15 - the resident refused breakfast 4 times and ate 25% or less at 11 breakfast meals. Of the 23 meals she did eat, she consumed an average of 41.7% of her breakfast meals, 2) Lunch from 3/1/15 through 3/26/15 - the resident refused lunch 1 time and ate 25% or less at 10 lunch meals. One meal was not documented, but of the 24 meals she did eat, she consumed an average of 39.8% of her lunch meals. 3) Supper from 3/1/15 through 3/26/15 - the resident refused no supper meals and ate 25% or less at 3 supper meals. One meal was not documented, but of the 24 meals documented, she consumed an average of 67.3% of her supper meals. h. The following observation was made of the residents meals: 1) On 3/24/15 at 8:10 a.m., the resident was sitting in a chair in her room. An over bed table was in front of the resident and her breakfast tray was on the table. The resident was alone in her room at this time. The Food and Hydration Intake Record documented the resident ate 25% of the breakfast meal. 2) On 3/24/15 at 12:35 p.m., the resident was served Chicken supreme, mashed potatoes, peas and carrots, dinner roll with margarine, bread pudding with lemon sauce, chicken noodle soup, 6 ounces of tea and 4 ounces of water. LPN #5 was in the resident's room attempting to feed the resident. The resident consumed one bite of mashed potatoes and one sip of tea and requested to be left alone. 3) On 3/24/15 at 4:50 p.m., the resident was in bed with her eyes closed. On the over bed table, within reach of the resident, was an 8 ounce opened can of chocolate Glucerna with a straw inside. The can was approximately 3/4 full. 4) On 3/24/15 at 5:20 p.m., the resident was served the evening meal but refused to eat or drink. 5) On 3/25/15 at 8:15 a.m., the resident was lying in bed with her breakfast tray on the over bed table. The DON was in the room trying to feed the resident. The DON stated, "She's eaten a few bites." i. On 3/25/15 at 3:30 p.m., the DON was informed of the resident's weight loss and asked if she was aware of the severity resident's weight loss. She stated, "I was unaware that her weight loss was that severe. I found out approximately one month ago. Our ADON (Assistant Director of Nursing) that left February 19 (2015), was doing weights. She was to notify me when a resident was having a weight loss." The DON was asked, "Can you tell me when the RD and DM were made aware the resident was having a weight loss?' Don stated, "I can't give you a date when the dietary department was made aware. I just don't know." j. On 3/25/15 at 4:00 p.m., the DON was asked, "Have any other interventions been put in place for weight loss for (Resident #9)?" The DON stated, "I think I told one of the nurses to call the doctor and get an appetite stimulant and we started having a nurse feed her." k. On 3/26/15 at 8:40 a.m., the DON was asked if she remembered which nurse she told to call the doctor about the appetite stimulant. She stated, "It would be (LPN #3) and (LPN #4)." The DON was then asked if she remembered when having a nurse feed the resident was implemented. She stated, "Thursday (3/19/15) or Friday (3/20/15) of last week." The DON was asked if this intervention was documented anywhere. She stated, "I'm sure it's not." 1) On 3/26/15 at 9:00 a.m., LPN #4 was asked if she was told by the DON to call the doctor for an appetite stimulant for the resident. The LPN stated, "No, I don't recall her telling me to do that." 2) On 3/26/15 at 9:40 a.m. and again at 10:15 a.m., attempts made to contact LPN #3 via phone were unsuccessful. l. On 3/25/15 at 4:10 p.m., the DM was asked, "Are you aware of (Resident #9)'s weight loss and when were you made aware of it?" DM stated, "Yes. In the last couple of weeks, at the department head meeting that we have about 3 times a week." The DM was asked, "What is your role in the weight loss protocol and how does the RD get informed?" The DM stated, "I give her a weight list monthly. She goes through it and looks at residents' weights. I don't have a specific list that I give her. If a resident needs a supplement added, I add them to the list of those that receive supplements." m. On 3/26/15 at 11:20 a.m., the DON was asked, "Has there been any discussions regarding weight loss problems in the QA (Quality Assurance) meetings?" She stated, "I think there might be." The DON was asked, "Do you have any documentation from those meetings that you want to share with me?" The DON stated, "I'll check with the Administrator and make sure it's okay to give that to you." At 11:45 a.m., the DON stated, "We don't have anything to give you from the QA minutes." n. An RD Assessment Summary dated 3/24/15 and copied on 3/27/15 at 10:40 a.m. from the clinical record documented, "Food / Nutrition Related Hx (History) Information from Resident / Staff: Resident hospitalized ,[DATE]. Monthly weights have not been reported to RD. Resident is noted with a SWL (severe weight loss) for 180 days... Weight Change: Resident has gradually lost weight, current intakes show approximately 50% intake... Lab: No recent labs to review... Nutrition Diagnosis / Problem: Weight loss r/t (related to) lower intake caused by back pain as evidenced by SWL in 180 days... Interventions: Add med pass 2 ounces QID (four times a day) with med (medication) pass. Encourage intake, try SF (sugar free) house shake at snack times. Report all weight losses / weights after hospitalization to RD by fax or phone call... Goal: Inhibit further weight loss." o. The following Certified Nursing Assistants (CNA) were asked, "How much does a resident have to eat before you report it?" 1) On 3/26/15 at 10:19 a.m., CNA #6 stated, "If they don't eat greater than 25% or nothing." The CNA was asked, "Where do you document meal consumption for each meal?" She stated, "In the ADL (Activities of Daily Living) book. That's where the food and hydration intake records are." 2) On 3/26/15 at 10:14 a.m., CNA #7 stated, "If they eat less than 25% or nothing at all." 3) On 3/26/15 at 10:15 a.m., CNA #9 stated, "If I feed breakfast and they refuse, then I report it. Not matter what percentage is eaten, we put it in the food and hydration 24-hour report book. That's food and liquid." 4) On 3/26/15 at 4:15 p.m., CNA #10 stated, "If they eat under 25% I will report to the charge nurse." 5) On 3/26/15 at 10:08 a.m., CNA #8 stated, "25%. I tell the charge." 6) On 3/27/15 at 9:58 a.m., CNA #4 stated, "Less than 50% to the nurse. We put it in the book. I think dietary checks the book. This book is the food and hydration intake record book." 2. Resident #4 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set with an Assessment Reference Date of 1/2/15 documented the resident reentered from an acute care hospital 12/5/14, had moderately impaired cognitive skills for daily decision making per staff assessment of mental status; was totally dependent on the physical assistance of one person for eating; and received more than 51% of nutrition via feeding tube. a. The physician's orders [REDACTED]." b. The Annual Weight Report was provided by the Administrator on 3/24/15 at 10:00 a.m. and documented the following weights for the resident: 1) 9/8/14 - 165 pounds 2) 10/9/14 - 164 pounds 3) 11/10/14 - 159 pounds 4) 12/10/14 - 147 pounds 5) 1/6/15 - 149 pounds 6) 2/18/15 - 146 pounds The resident's March 2015 weight was provided by the Administrator on 3/24/15 at 10:50 a.m. and documented the resident weighed 145 pounds. This was a weight loss of 20 pounds from September 2014 to March 2015 (12.1%). c. The Medical Nutrition Therapy Re-Assessment form documented, "...3/3/15 ...Wt (weight) (down) Severely impacted (with) hosp (hospital) recently ...Change formula to Jev ([MEDICATION NAME]) 1.5... 6 cans (per) day." The res-assessment was signed by the Registered Dietician. d. On 3/24/15 at 12:50 p.m., Licensed Practical Nurse (LPN) #3 administered one can of [MEDICATION NAME] 1.2 via the resident's percutaneous endogastrostomy (PEG) tube. e. On 3/25/15 at 10:00 a.m. the Director of Nursing (DON) was asked to describe the process used to relay the information from the Dietary Consultant's reports to the physician and to follow through with (or document the doctor's refusal) an order related to the consultant's recommendations. The DON stated, "It will be the responsibility of the charge nurse to get that information to the physician. The charge nurse is to take the order and note it. I will be made aware when the pink slips are reviewed the next morning. To tell the truth, I have never seen the form (Medical Nutritional Therapy Re-Assessment). The previous DON was responsible for this. When she left it was passed on to the Assistant Director of Nursing (ADON) in February and she quit on 2/18/15. At this time, no one is responsible for the RD (Registered Dietitian) recommendations." The DON then stated the March physician's orders [REDACTED]. The DON stated, "The RD's recommendations most likely were sent over there at that time." It was then brought to the DON's attention that the resident had missed 22 days of receiving additional calories to prevent weight loss. 3. The facility's policy titled 'Nutrition (Impaired) / Unplanned Weight Loss Clinical Protocol' provided by the DON on 3/26/15 documented, "...Assessment and Recognition: The nursing staff will monitor and document the weight... The threshold for significant unplanned and undesired weight loss will be based on the following criteria... 1) 5% weight loss is significant, greater than 5% is severe for 1 month... 2) 7.5% weight loss is significant, greater than 7.5% is severe for 3 months... 3) 10% weight loss is significant, greater than 10% is severe for 6 months... 4) The Physician will consider whether any assessment including additional diagnostic testing is indicated to help clarify the severity or consequences of weight loss and/or impaired nutrition. Cause Identification... 1) The physician will review possible causes of weight loss with the nursing staff and/or Dietician before ordering interventions... 2) The Dietician will estimate calorie, nutrient and fluid needs and, with the Physician, will identify whether the resident's current intake is adequate to meet his or her nutritional needs... 3) The Physician, with the help of the multidisciplinary team, will identify conditions and medications that may be causing anorexia, weight loss or increasing the risk of weight loss. Treatment / Management... 1) The staff and physician will identify pertinent interventions based on identified causes and overall resident condition, prognosis, and treatment wishes... 2) The Physician will authorize and the staff will implement appropriate general or cause-specific interventions, as indicated, with careful consideration of the following: a. Resident choice... b. Nutritional needs: The Dietitian will help the Physician determine the appropriate diet for the resident based on the resident's degree of nutritional impairment, expressed wishes and underlying causes and conditions. If the resident's nutritional or caloric need have changed, but the diet has not, this may help to clarify the appropriate interventions. c. Hydration needs. d. Functional factors. e. Environmental factors. f. Chewing and swallowing abnormalities. g. Diet Modifications. h. Medications. i. Supplementation: Strategies to increase a resident's intake of nutrients and calories may include fortification of foods (for example, protein added to mashed potatoes), increasing portion sizes at mealtimes, and providing between-meal snacks and / or nutritional supplementation. j. Appetite stimulants: The Physician will limit prescribing of "appetite stimulants" to situations in which underlying causes cannot be identified or treated, other interventions have not worked or are not feasible, and the use of such medications is relevant to the individual's condition, prognosis, and wishes... Monitoring... 1) The Physician and staff will closely monitor residents who have been identified as having impaired nutrition or risk factors for developing impaired nutrition. Such monitoring may include: a. Evaluating the care plan to determine if the interventions are being implemented and whether they are effective in attaining the established nutritional and weight goals... 1) Evaluating the resident's response to interventions should be based on defined criteria for improvement / worsening of nutritional status; for example, stabilization of weight, laboratory values, or food / fluid intake... 2) The Physician, with input from the staff, will determine the most appropriate intervals for weight assessments. b. Recognizing the emergence of complications associated with certain interventions; further weight loss due to diet restrictions. c. Recognizing the emergence of new risk factors; for example, pressure ulcers, fever, or acute illness.

Based on observation, record review and interview, Nursing Administration failed to ensure nutritional status was maintained within acceptable parameters to prevent further weight loss as evidenced by failure to ensure interventions to address severe weight loss were developed and promptly implemented and failure to ensure dietary needs were evaluated by the Registered Dietician to allow for improved caloric intake and nutritional adequacy for 1 of 1 (Resident #9) case mix resident who had a severe weight loss. Nursing Administration also failed to ensure the physician was consulted regarding the Registered Dietician's recommended interventions to decrease the potential for further weight loss for 1 of 1 (Resident #4) case mix resident who had a severe weight loss and received nutrition via Percutaneous Endogastrostomy (PEG) tube. This failed practice resulted in actual harm for Resident #9 who experienced a severe weight loss and had the potential to cause more than minimal harm for 11 residents who had a significant weight loss, according to a list provided by the Administrator on 3/27/15 and for 6 residents who received tube feedings, according to the Resident Census and Conditions of Residents form dated 3/24/15. The findings are: 1. The job description for the Director of Nursing (DON) was provided by the DON on 3/26/15 at 10:55 a.m. and documented, "...Position Summary: Responsible for ensuring the nursing department is functioning as to provide optimum care for the residents and meets minimum state and federal standards. Responsible for developing and maintaining all nursing services in accordance with accepted standards... Essential Job Functions... Supervising all nursing personnel... Participating in planning for nursing care... Coordinating nursing services with other resident care services to ensure continuity of care... Assuring that nursing care plans are established for each resident and that his/her plan is reviewed and modified as necessary... Coordinates nursing assessment of each resident and assures that it is reviewed and modified as necessary... To serve as a member of the QA Committee to give reports within the nursing department... Provide direct patient care when needed... Visits all nursing units analyzing and evaluation nursing and related services rendered to residents... Maintains and reviews all records and reports required in nursing service department... 2. The facility's policy titled 'Nutrition (Impaired) / Unplanned Weight Loss Clinical Protocol' provided by the DON on 3/26/15 documented, "...Assessment and Recognition: The nursing staff will monitor and document the weight... The threshold for significant unplanned and undesired weight loss will be based on the following criteria... 1) 5% weight loss is significant, greater than 5% is severe for 1 month... 2) 7.5% weight loss is significant, greater than 7.5% is severe for 3 months... 3) 10% weight loss is significant, greater than 10% is severe for 6 months... 4) The Physician will consider whether any assessment including additional diagnostic testing is indicated to help clarify the severity or consequences of weight loss and/or impaired nutrition. Cause Identification... 1) The physician will review possible causes of weight loss with the nursing staff and/or Dietician before ordering interventions... 2) The Dietician will estimate calorie, nutrient and fluid needs and, with the Physician, will identify whether the resident's current intake is adequate to meet his or her nutritional needs... 3) The Physician, with the help of the multidisciplinary team, will identify conditions and medications that may be causing anorexia, weight loss or increasing the risk of weight loss. Treatment / Management... 1) The staff and physician will identify pertinent interventions based on identified causes and overall resident condition, prognosis, and treatment wishes... 2) The Physician will authorize and the staff will implement appropriate general or cause-specific interventions, as indicated, with careful consideration of the following: a. Resident choice... b. Nutritional needs: The Dietitian will help the Physician determine the appropriate diet for the resident based on the resident's degree of nutritional impairment, expressed wishes and underlying causes and conditions. If the resident's nutritional or caloric need have changed, but the diet has not, this may help to clarify the appropriate interventions. c. Hydration needs. d. Functional factors. e. Environmental factors. f. Chewing and swallowing abnormalities. g. Diet Modifications. h. Medications. i. Supplementation: Strategies to increase a resident's intake of nutrients and calories may include fortification of foods (for example, protein added to mashed potatoes), increasing portion sizes at mealtimes, and providing between-meal snacks and / or nutritional supplementation. j. Appetite stimulants: The Physician will limit prescribing of "appetite stimulants" to situations in which underlying causes cannot be identified or treated, other interventions have not worked or are not feasible, and the use of such medications is relevant to the individual's condition, prognosis, and wishes... Monitoring... 1) The Physician and staff will closely monitor residents who have been identified as having impaired nutrition or risk factors for developing impaired nutrition. Such monitoring may include: a. Evaluating the care plan to determine if the interventions are being implemented and whether they are effective in attaining the established nutritional and weight goals... 1) Evaluating the resident's response to interventions should be based on defined criteria for improvement / worsening of nutritional status; for example, stabilization of weight, laboratory values, or food / fluid intake... 2) The Physician, with input from the staff, will determine the most appropriate intervals for weight assessments. b. Recognizing the emergence of complications associated with certain interventions; further weight loss due to diet restrictions. c. Recognizing the emergence of new risk factors; for example, pressure ulcers, fever, or acute illness." 3. Resident #9 had [DIAGNOSES REDACTED]. The 30 Day Minimum Data Set with an Assessment Reference Date of 2/26/15 documented the resident had severely impaired cognitive skills for daily decision making per a staff assessment of mental status; was independent for eating with set up help only; was on a therapeutic diet; had no swallowing problems; and had no weight loss. a. The March 2015 physician's orders [REDACTED]. b. The Annual Weight Report for 2014 / 2015 documented the following weights for the resident: 1) September 2014: 108 pounds 2) October 2014: 104 pounds 3) November 2014: 104 pounds 4) December 2014: 97 pounds 5) January 2015: 94 pounds 6) February 2015: 87 pounds The resident's March 2015 weight was provided by the Administrator on 3/24/15 at 10:50 a.m. and documented the resident weighed 87 pounds. This was a weight loss of 21 pounds from September 2014 to March 2015 (19.4%) and 10 pound weight loss from December 2014 to March 2015 (10.3%). c. The Dietary Progress Notes signed by a Registered Dietician (RD) and dated 12/3/14 documented, "...Back pain present (at) all times. Will not eat due to pain. Continues to lose wt (weight). Encouragement (at) all meals. Does not eat as many snacks as usual. Self fed. Staff continues to encourage snacks / meals." d. The Medical Nutrition Therapy Assessment form dated 1/5/15 documented, "Nutrition Diagnosis - At risk for nutritional def (deficit) R/T (related to) disease process AEB (as evidenced by) wt (less than) 100... Nutrition Prescription (and) Intervention - Continue encourage intake... Nutrition Monitoring... Rec (Recommend): Add 1 can glucerna to 2:30 (p.m.) snack..." 1) A handwritten physician's orders [REDACTED]. 2015 and March 2015 printed Physician order [REDACTED]. 2) On 3/25/15 at 10:30 a.m., the Director of Nursing (DON) was asked, "Where would a supplement such as Glucerna be documented showing the resident had received it and how much they had consumed?' She stated, "Usually on the MAR (Medication Administration Record)." 3) The resident's January 2015 and February 2015 MARs (copied on 3/26/15 at 3:30 p.m.) did not document the resident was receiving Glucerna. e. The monthly Consultant Dietician reports dated 9/25/14, 10/28/14, 11/17/14, 1/31/15 and February 2015 did not document a dietary assessment by the Registered Dietician for the resident. The Resident Plan of Care dated 2/9/15 did not address weight loss. 1) On 3/26/15 at 9:55 a.m., the Registered Dietician (RD) was asked, "When is the last time you saw (Resident #9)?" The RD stated, "I don't remember. I gave a copy of my report to the DM (Dietary Manager), the Administrator and the DON." The RD was asked, "Are you aware of (Resident #9)'s weight loss?" She stated, "Yes. Weight reports are not always available when I come in." The RD further stated the resident was in the hospital in January 2015 and did not show up on the January 2015 Weight Report. The RD was asked, "What is the procedure for you to get that information from the facility?' She stated, "I get the weight report from the DM. I haven't seen the weight report for March (2015)." 2) On 3/26/15 at 10:45 a.m., the DM was asked what her role was in getting information to the Registered Dietician. She stated, "I go into (computer software program) and print out the weight list for the current month, 3 months and 6 months." The DM was asked when the RD came to the facility. She stated, "Normally she comes around the third week in the month or she'll come back. This winter it's been the first week." The DM was then asked, "Did you print out a weight list on her last visit?" She stated, "Didn't give her a weight list. The monthly weights were not in yet, so I didn't have a current one to give her. She already had the last one. She worked on assessments. I did not mention (Resident #9). That's on me. I don't know why I did not." f. A physician order [REDACTED]." As of 3/26/15 at 3:30 p.m., the resident's March 2015 MAR indicated [REDACTED] g. The March 2015 Food and Hydration Intake Record documented: 1) Breakfast from 3/1/15 through 3/27/15 - the resident refused breakfast 4 times and ate 25% or less at 11 breakfast meals. Of the 23 meals she did eat, she consumed an average of 41.7% of her breakfast meals, 2) Lunch from 3/1/15 through 3/26/15 - the resident refused lunch 1 time and ate 25% or less at 10 lunch meals. One meal was not documented, but of the 24 meals she did eat, she consumed an average of 39.8% of her lunch meals. 3) Supper from 3/1/15 through 3/26/15 - the resident refused no supper meals and ate 25% or less at 3 supper meals. One meal was not documented, but of the 24 meals documented, she consumed an average of 67.3% of her supper meals. h. The following observation was made of the residents meals: 1) On 3/24/15 at 8:10 a.m., the resident was sitting in a chair in her room. An over bed table was in front of the resident and her breakfast tray was on the table. The resident was alone in her room at this time. The Food and Hydration Intake Record documented the resident ate 25% of the breakfast meal. 2) On 3/24/15 at 12:35 p.m., the resident was served Chicken supreme, mashed potatoes, peas and carrots, dinner roll with margarine, bread pudding with lemon sauce, chicken noodle soup, 6 ounces of tea and 4 ounces of water. LPN #5 was in the resident's room attempting to feed the resident. The resident consumed one bite of mashed potatoes and one sip of tea and requested to be left alone. 3) On 3/24/15 at 4:50 p.m., the resident was in bed with her eyes closed. On the over bed table, within reach of the resident, was an 8 ounce opened can of chocolate Glucerna with a straw inside. The can was approximately 3/4 full. 4) On 3/24/15 at 5:20 p.m., the resident was served the evening meal but refused to eat or drink. 5) On 3/25/15 at 8:15 a.m., the resident was lying in bed with her breakfast tray on the over bed table. The DON was in the room trying to feed the resident. The DON stated, "She's eaten a few bites." i. On 3/25/15 at 3:30 p.m., the DON was informed of the resident's weight loss and asked if she was aware of the severity resident's weight loss. She stated, "I was unaware that her weight loss was that severe. I found out approximately one month ago. Our ADON (Assistant Director of Nursing) that left February 19 (2015), was doing weights. She was to notify me when a resident was having a weight loss." The DON was asked, "Can you tell me when the RD and DM were made aware the resident was having a weight loss?' Don stated, "I can't give you a date when the dietary department was made aware. I just don't know." j. On 3/25/15 at 4:00 p.m., the DON was asked, "Have any other interventions been put in place for weight loss for (Resident #9)?" The DON stated, "I think I told one of the nurses to call the doctor and get an appetite stimulant and we started having a nurse feed her." k. On 3/26/15 at 8:40 a.m., the DON was asked if she remembered which nurse she told to call the doctor about the appetite stimulant. She stated, "It would be (LPN #3) and (LPN #4)." The DON was then asked if she remembered when having a nurse feed the resident was implemented. She stated, "Thursday (3/19/15) or Friday (3/20/15) of last week." The DON was asked if this intervention was documented anywhere. She stated, "I'm sure it's not." 1) On 3/26/15 at 9:00 a.m., LPN #4 was asked if she was told by the DON to call the doctor for an appetite stimulant for the resident. The LPN stated, "No, I don't recall her telling me to do that." 2) On 3/26/15 at 9:40 a.m. and again at 10:15 a.m., attempts made to contact LPN #3 via phone were unsuccessful. l. On 3/25/15 at 4:10 p.m., the DM was asked, "Are you aware of (Resident #9)'s weight loss and when were you made aware of it?" DM stated, "Yes. In the last couple of weeks, at the department head meeting that we have about 3 times a week." The DM was asked, "What is your role in the weight loss protocol and how does the RD get informed?" The DM stated, "I give her a weight list monthly. She goes through it and looks at residents' weights. I don't have a specific list that I give her. If a resident needs a supplement added, I add them to the list of those that receive supplements." m. On 3/26/15 at 11:20 a.m., the DON was asked, "Has there been any discussions regarding weight loss problems in the QA (Quality Assurance) meetings?" She stated, "I think there might be." The DON was asked, "Do you have any documentation from those meetings that you want to share with me?" The DON stated, "I'll check with the Administrator and make sure it's okay to give that to you." At 11:45 a.m., the DON stated, "We don't have anything to give you from the QA minutes." n. An RD Assessment Summary dated 3/24/15 and copied on 3/27/15 at 10:40 a.m. from the clinical record documented, "Food / Nutrition Related Hx (History) Information from Resident / Staff: Resident hospitalized ,[DATE]. Monthly weights have not been reported to RD. Resident is noted with a SWL (severe weight loss) for 180 days... Weight Change: Resident has gradually lost weight, current intakes show approximately 50% intake... Lab: No recent labs to review... Nutrition Diagnosis / Problem: Weight loss r/t (related to) lower intake caused by back pain as evidenced by SWL in 180 days... Interventions: Add med pass 2 ounces QID (four times a day) with med (medication) pass. Encourage intake, try SF (sugar free) house shake at snack times. Report all weight losses / weights after hospitalization to RD by fax or phone call... Goal: Inhibit further weight loss." o. The following Certified Nursing Assistants (CNA) were asked, "How much does a resident have to eat before you report it?" 1) On 3/26/15 at 10:19 a.m., CNA #6 stated, "If they don't eat greater than 25% or nothing." The CNA was asked, "Where do you document meal consumption for each meal?" She stated, "In the ADL (Activities of Daily Living) book. That's where the food and hydration intake records are." 2) On 3/26/15 at 10:14 a.m., CNA #7 stated, "If they eat less than 25% or nothing at all." 3) On 3/26/15 at 10:15 a.m., CNA #9 stated, "If I feed breakfast and they refuse, then I report it. Not matter what percentage is eaten, we put it in the food and hydration 24-hour report book. That's food and liquid." 4) On 3/26/15 at 4:15 p.m., CNA #10 stated, "If they eat under 25% I will report to the charge nurse." 5) On 3/26/15 at 10:08 a.m., CNA #8 stated, "25%. I tell the charge." 6) On 3/27/15 at 9:58 a.m., CNA #4 stated, "Less than 50% to the nurse. We put it in the book. I think dietary checks the book. This book is the food and hydration intake record book." 4. Resident #4 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set with an Assessment Reference Date of 1/2/15 documented the resident reentered from an acute care hospital 12/5/14, had moderately impaired cognitive skills for daily decision making per staff assessment of mental status; was totally dependent on the physical assistance of one person for eating; and received more than 51% of nutrition via feeding tube. a. The physician's orders [REDACTED]." b. The Annual Weight Report was provided by the Administrator on 3/24/15 at 10:00 a.m. and documented the following weights for the resident: 1) 9/8/14 - 165 pounds 2) 10/9/14 - 164 pounds 3) 11/10/14 - 159 pounds 4) 12/10/14 - 147 pounds 5) 1/6/15 - 149 pounds 6) 2/18/15 - 146 pounds The resident's March 2015 weight was provided by the Administrator on 3/24/15 at 10:50 a.m. and documented the resident weighed 145 pounds. This was a weight loss of 20 pounds from September 2014 to March 2015 (12.1%). c. The Medical Nutrition Therapy Re-Assessment form documented, "...3/3/15 ...Wt (weight) (down) Severely impacted (with) hosp (hospital) recently ...Change formula to Jev ([MEDICATION NAME]) 1.5... 6 cans (per) day." The res-assessment was signed by the Registered Dietician. d. On 3/24/15 at 12:50 p.m., Licensed Practical Nurse (LPN) #3 administered one can of [MEDICATION NAME] 1.2 via the resident's percutaneous endogastrostomy (PEG) tube. e. On 3/25/15 at 10:00 a.m. the Director of Nursing (DON) was asked to describe the process used to relay the information from the Dietary Consultant's reports to the physician and to follow through with (or document the doctor's refusal) an order related to the consultant's recommendations. The DON stated, "It will be the responsibility of the charge nurse to get that information to the physician. The charge nurse is to take the order and note it. I will be made aware when the pink slips are reviewed the next morning. To tell the truth, I have never seen the form (Medical Nutritional Therapy Re-Assessment). The previous DON was responsible for this. When she left it was passed on to the Assistant Director of Nursing (ADON) in February and she quit on 2/18/15. At this time, no one is responsible for the RD (Registered Dietitian) recommendations." The DON then stated the March physician's orders [REDACTED]. The DON stated, "The RD's recommendations most likely were sent over there at that time." It was then brought to the DON's attention that the resident had missed 22 days of receiving additional calories to prevent weight loss.

Complaint # (AR 779) was substantiated (all or in part) in these findings: Based on record review and interview, the facility failed to ensure alarms were working or attached, falls were thoroughly investigated to determine causative factors in order to develop the most effective interventions, failed to ensure planned interventions were consistently implemented and evaluated for effectiveness and ineffective interventions were promptly revised to decrease the potential for further falls for 1 (Resident #6) of 5 (Residents #1, #2, #3, #5 and #6) case mix residents with a history of falls; 1 (Resident #6) of 2 (Residents #3 and #6) case mix residents who used bed alarms; and for 1 of 1 (Resident #6) case mix resident who used a seat belt alarm. The failed practice resulted in a pattern of actual harm for Resident #6 who, after multiple falls, suffered a right hip fracture that required surgical intervention and had the potential to cause more than minimal harm to 29 residents with a history of falls, according to a list provided by the Administrator on 1/7/15 and 13 residents who used bed alarms and 5 residents who used seat belt alarms, according to the Administrator on 1/6/15. The findings are: Resident #6 had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) with an assessment reference date of 11/24/14 documented the resident scored 2 (0-7 indicates severe cognitive impairment) on the Brief Interview for Mental Status, required limited assistance with transfers and was independent with bed mobility, used a wheelchair for mobility and had a history of [REDACTED]. a. An Admission Nursing Evaluation dated 11/17/14 at 11:45 a.m. documented, "admitted : 11/17/14...confused... (scar) to L (left) outer (thigh) from recent ORIF..." b. A Fall Risk assessment dated [DATE] (no time) documented the resident scored "14." The form further documented that a total score of 10 or above represented a high risk for falls. c. A Daily Skilled Nurse's Note dated 11/18/14 documented the following: " 7:30 p.m. A&O (alert and oriented) (times) 1 (person or self only). ...PT (Physical Therapy)/OT (Occupational Therapy) to evaluate (and) Tx (treat) ...4:30 a.m. ...bed low..." d. A Physical Therapy (PT) Evaluation and Plan of Treatment form dated 11/19/14 documented the resident had been hospitalized between 10/30/14 and 11/17/14 and PT rehabilitative services started 11/19/14. e. On 1/7/15 at 10:30 a.m., the Administrator provided a copy of a handwritten note to the facility from the family of the resident that documented, "...family ...requests that alarms be placed on her wheelchair and her bed; because she has a history of falls. We understand that she has had no falls since admission to this facility as of this date 11-19-14." f. The Daily Skilled Nurse's Note entry dated 11/19/14 at 1:30 p.m. documented, "...Alert (and) (oriented) (times) 1 (with) confusion..." g. A Nurses Note dated 11/20/14 at 2:00 p.m. documented, " ...(Name) and myself heard (residents) body / chair alarm going off, (name) entered room first she stated (resident) was standing in front of w/c (wheelchair) then (resident) sat down in floor on bottom. It appears she was going to sit back in w/c and wheels were unlocked. (Resident) did not hit head. (resident) denies any pain ..." 1) An I&A (Incident and Accident) Report dated 11/20/14 at 5:00 p.m. documented, "...CNA (Certified Nursing Assistant) (CNA #2) states she heard (resident) chair alarm going off and witnessed (resident) standing up from w/c (wheelchair), then (resident) sat down in floor. I also heard alarm... and entered room right after (CNA #2). (Resident) did not hit head. (No) visible injuries. (No) c/o (complaint of) injuries noted... DON (Director of Nursing) / ADON (Assistant Director of Nursing) Review... (resident) cued to ask for help before getting up." 2) A Rehabilitation Screening form dated 11/21/14 documented, "Pt (patient) educated in call light use and returned demo (demonstration) ability to use call light. Pt / staff educated in weight bearing and safety." Note: The MDS dated [DATE] documented the resident had severely impaired mental status. h. A Nurses Note dated 11/22/14 at 2:00 p.m. documented, "Called to (Resident) room per CNA (Certified Nursing Assistant) received (resident) lying on floor on (right) side. (Resident) attempting to stand up from floor several times. (Resident) assisted to w/c per staff. (No) visible injuries noted. (Resident) able to MAE (move all extremities) WNL (within normal limits). Denies pain at this time. (No) distress noted. Neuro (neurological) checks initiated per protocol. MD (Medical Doctor) notified (1) Monitor (and) send to ER (emergency room ) if condition worsens (2) Apply seat belt check (every) 30 min (minutes) (and) release (every) 2 hours for ROM (range of motion) ..." 1) An I&A Report dated 11/22/14 at 2:00 p.m. documented, "...called to (resident's) room... (resident) lying on (right) side on floor... no visible injuries." The I&A report documented the physician was consulted and a new order for a seat belt with alarm was ordered. The manufacturer's directions for the seat belt alarm documented, "When the buckle is opened, an alarm is activated." On 1/6/15 at 3:45 p.m., DON #1 stated the resident, "could undo seat belt alarm." There were no new interventions documented to help reduce the potential for further falls. 2) A form titled Permission for Restraint use dated 11/22/14 (no time) documented, "...use safety restraints as authorized by a physician as necessary to protect the resident from injury to himself or others, for the named resident ...check restraint / restraints below that will be used: (the area checked was other and seat belt was handwritten) ..." 3) A Rehabilitation Screening form dated 11/24/14 documented, "Pt found on floor on 11/22/14, Pt continues to receive skilled OT/PT (occupational therapy / physical therapy) (due) to inability to follow weight bearing and hx (history) of falls, self-release seat belt is recommended ..." i. Nurse's Notes dated 11/28/14 at 11:00 p.m. documented, "Resident in bed resting quietly (at) this time. (Resident) has attempted to get out of bed multiple times. (Resident) knows how to turn bed alarm off ..." j. Nurse's Notes dated 11/29/14 at 3:20 p.m. documented the resident was found on the floor lying next to wheelchair and, "...seat belt alarm not going off (at) this time." There was no documentation of an investigation for the cause of the seat belt alarm not functioning at that time and no new interventions were developed in an attempt to prevent further falls for this resident. An I&A Report dated 11/29/14 at 3:50 p.m. documented, "...hearing screaming coming from room. (Resident) was found on floor next to wheelchair. (Resident) was talking (and) did not know what happened. Blood noticed coming from back of head (at) this time..." There was no documented assessment of the resident's environment for possible contributing factors. k. The Plan of Care dated 12/2/14 documented, "At risk for falls due to unsteady gait... Approaches... Provide / monitor use of adaptive devices: wheelchair... Referral for screen (and) treatment as needed: PT OT. Seat belt with alarm to w/c. Bed alarm to bed to alert staff when resident is getting up... Restraint... Resident requires physical restraint to protect him/her from harm. Seatbelt with alarm to w/c... Monitor for and report to the physician the following restraint related issues: Development of or increase in behavior / mood problem. Decreased mobility. Development of contractures. Development of skin problems. Development of or increased incontinence..." l. Nurse's Notes dated 12/3/14 (not timed) documented, "Spoke (with) (name of physician) nurse concerning (resident) behavior (and) recent falls. T.O (telephone order) send (resident) to (name of geriatric behavioral health unit)..." A Nurse's Note dated 12/3/14 (not timed) and signed by Licensed Practical Nurse (LPN) #1, documented the resident, "...has had multiple falls since admit. We have applied an MD (medical doctor) ordered seat belt to her w/c (and) she releases it (and) attempts to stand (and) ambulate unassisted." m. Nurse's Notes dated 12/21/14 (not timed) documented the resident was readmitted to the facility and was alert and oriented to self only. Nurse's Notes dated 12/23/14 at 2:00 a.m. documented, "(resident) in w/c. Agitated because of seat belt..." As of 1/6/14 there were no revisions made to the plan of care with new interventions to prevent falls. There was no documentation in the new orders to indicate the resident continued to receive PT services upon readmission and none was provided by the facility as of 1/9/15 at 12:45 p.m. n. A Nurses Note dated 12/26/14 at 7:20 a.m. documented, "Called to (resident) room per CNA this nurse received (resident) sitting on floor on buttocks (with) back against dresser. (Resident) leaning to (left) side (with) (right) buttock slightly lifted off floor. This nurse asked (resident) what happened (resident) states "I just fell .' (Resident ) A/O (alert and oriented) (times) 1. Reoriented to place (and) time. Confusion noted Physical assessment performed (no) visible injuries noted. (Resident) denied hitting head (resident) able to MAE (move all extremities) upon ROM (range of motion) (resident) c/o (complained of) (right) hip / thigh pain. (Resident) able to bend (right) leg however yells 'it hurts' upon bending (right) leg bed alarm checked per (name) to ensure working properly. Bed alarms on / working properly (resident) known to turn bed alarm off ... 7:42 a.m. (resident) out of facility to (name) ER (emergency room ) ..." An I&A Report dated 12/26/14 at 7:20 a.m. documented, "...(resident) found sitting on floor on buttocks (with) back against dresser. (resident) leaning to left side (with) (right) buttock slightly lifted off floor... (complained of) pain to (right) hip / thigh." Nurse's Notes dated 12/26/14 at the same time, and signed by LPN #1, documented, "Bed alarms on / working properly. (resident) known to turn bed alarms off." Nurse's Notes documented the resident was sent to a local emergency room for evaluation. On 1/7/15 at 12:09 p.m., LPN #1 was asked if the resident's bed alarm sounded, on 12/26/14, at the time of the resident's fall. She stated, "alarm wasn't sounding." o. Local hospital emergency room records included radiology reports dated 12/26/14 for a CAT (Computed Tomography) Scan of the pelvis without contrast that documented an Impression, "1. Acute subcapital right femoral neck fracture. 2. Comminuted intertrochanteric left femoral neck fracture, which has undergone fixation. Multiple displaced bone fragments are present adjacent to the left femoral neck. There is no significant bony bridging as of yet. The degree of comminution appears greater on the current examination, suggesting that the patient has suffered an acute on chronic injury (possible further injury to left hip in comparison with x-rays from an earlier date)." Hospital records documented the resident was transferred to another hospital. On 1/8/15 at 6:51 p.m., a family member of the resident stated the resident had an ORIF of the right hip on 12/26/14. p. On 1/6/15 at 3:45 p.m., DON #2 was asked for documentation by nursing staff of alarm checks done and the frequency of them by the facility for residents who required the use of an alarm to ensure they were operable. DON #2 stated there was no documentation by nurses or CNAs of alarm checks or actual use of alarms, unless in nurses notes entries. A request was made at that time for evidence of any checks of all types of alarms in use for residents in the facility. On 1/7/15 at 10:30 a.m., the Administrator provided copies of a log and a written statement from the Maintenance Director. The logs, dated for December 2014, documented weekly checks that alarms were working and batteries changed every 2 weeks for residents in the facility who used any type of alarm device. The logs documented 2 alarms were checked for this resident on 12/11/14 and 12/25/14. The written statement documented the Maintenance Director's checks were done on a weekly basis. As of 1/9/15 at 12:45 p.m., there was no evidence of more frequent, routine checks for alarms' operations and placements were provided by the facility.

Complaint # was substantiated, all or in part, with these findings: Based on observation, record review, and interview, the facility failed to ensure the appropriate safety shoulder/lap straps were in use to secure the resident in a wheelchair during a van transport; failed to have the availability of manufacturer's guidelines for securement of a resident in a wheelchair during van transport; failed to educate van drivers in the usage of the van resident securement system and failed to ensure that all drivers had current driver's license with said driving records reviewed for citations to reduce the risk of accidents and resident injuries for 1 (Resident #4) of 1 case mix residents who were transported in the facility van per a wheelchair. This failed practice resulted in Immediate Jeopardy which likely caused or could have caused serious harm, injury or death for Resident #4 who suffered a fall from the wheelchair during transport and had a potential to affect 39 residents who were transported in the facility van per a wheelchair according to a list provided by the Director of Nursing on [DATE] at 2:14 p.m. The facility was informed of the Immediate Jeopardy on [DATE] at 1:55 p.m. The findings are: 1. Resident#4 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set with an Assessment Reference Date of [DATE] documented the resident had moderately impaired cognitive skills for daily decision making per a Staff Assessment for Mental Status, was dependent for transfer, required supervision for locomotion on or off unit and used a wheelchair for mobility. a. An Incident and Accident (I & A) Report dated [DATE] documented: "Status: Alert, Mobility: Wheelchair, ... Witness: Certified Nurse Assistant (CNA) #1, Employee. ... Location I&A: (facility van). ... CNA #1 stated that (Resident #4) was being very combative and that the W/C (wheelchair) was fastened into the van, but (Resident #4) slid out of w/c causing 2 skin tears to LLE (left lower extremity). ... DON (Director of Nursing)/ADON (Assistant Director of Nursing) Review: ... Inserviced this staff member on van. Monitoring van drives 3 X wk (week) for 1 month." On [DATE] at 3:50 p.m., CNA #1 was asked if she had been trained in the use of the van safety equipment. The CNA stated, "I am not trained to drive the van. The first time I ever did it, I didn't know how to adjust the straps. The CNA was asked to tell what happened on [DATE]. CNA #1 stated, "It was the first time I had transported anyone in the white van and I had to figure out how to use the belts. ... I took (Resident #4) to the doctor. I locked the wheelchair down and put belts on the resident. I did not attach shoulder straps going or coming. I was in the turning lane and turned off the highway and the resident fell out of the wheelchair. I drove to the facility and ran in to get help to get (Resident #4) out of the van." The CNA stated that she drove half a block to the facility with the resident on the floor of the van. b. The van schedule calender received from the Director of Nursing on [DATE] at 1:25 p.m. documented 21 transports via the white van from [DATE] through [DATE]. c. On [DATE] at 4:25 p.m., CNA #1 was asked to demonstrate how Resident #4 was secured in the white van the day of the incident that occurred on [DATE]. With a Surveyor in the wheelchair, the CNA secured the wheelchair to the floor attachments. Safety straps from each side of the van were placed through the arms of the wheelchair and attached in front of the surveyor at the waist. No shoulder straps were used. The CNA was asked where the shoulder straps were. CNA #1 was examining the straps when the Administrator came into the van and the Administrator was asked where the shoulder straps were. The Administrator began examining the straps when CNA #2 entered the van at 4:32 p.m. CNA #2 was also unable to secure the surveyor in the van using a shoulder strap. CNA #2 stated, "There is a strap missing." Both CNAs were asked if they had ever used a shoulder strap to secure residents in a wheelchair in this van. Both stated, "No." d. On [DATE] at 1:45 p.m., CNA #3 was interviewed. The CNA stated that she had been driving the van ever since they had it. She stated, "I was not taught to use the shoulder strap and do not know how to use it." e. On [DATE] at 10:40 a.m., CNA #5 was asked how long he had been driving the white van. The CNA stated, "Since we got it." The CNA proceeded to demonstrate how a resident in a wheelchair was secured with safety belts in the van. Licensed Practical Nurse (LPN) #2 was in the wheelchair. After the wheelchair was secured to the floor, CNA #5 pulled the straps from each side of the van and placed through each arm of the wheelchair and attached in front of the LPN. No shoulder strap was used. The surveyor asked where the shoulder strap was. Both the CNA and the LPN stated, "There is no shoulder strap." The CNA stated that he had not used a shoulder strap in this van. f. On [DATE] at 4:48 p.m., Licensed Practical Nurse (LPN) #2, who was the CNA Supervisor and Van Driver Educator, was asked what she taught about the shoulder straps in the van. The LPN stated, "The straps go across the shoulder and the waist. Straps go through the arms of the wheelchair. Both sides of the straps are secured to the van. The LPN was asked what was used to train the drivers on how to secure the resident in the wheelchair and the wheelchair to the floor. The LPN stated, "The Van Policy and the video for the use of the lift." The LPN also stated, "(The residents) should have a shoulder and a lap restraint." g. The facility's van protocol adopted [DATE] documented for resident's in wheelchairs "...j. Using the seatbelt provided ensure that each end of the seat belt is secured to the floor and place the other end of the seat belt through the arms of the wheel chair and buckle in front of the resident." (There was no documentation of the necessity of utilizing a shoulder restraint.) h. On [DATE] at 8:20 a.m., the DON was informed of the incorrect use of safety straps by CNA #1 and #2 on [DATE] during a demonstration with the surveyor. The DON stated, "I have shown them myself, how to use the shoulder and lap straps in the van." At 9:55 a.m., the DON was asked if she had the Manufacturer's Guidelines for the use of the safety equipment in the van for residents in wheelchairs. The DON stated, "All I have is the Owner's Guide." The DON was asked to show the surveyor where the safety recommendations were in this guide. The DON stated, "It doesn't show anything about wheelchairs." The DON stated that LPN #2 was responsible for training the drivers regarding van safety transport and that the Ford E-Series 2010 Owner's Guide, the Van Protocol, and the DVD for appropriate use of the van lift was the material used for training. i. On [DATE] at 10:10 a.m., LPN #2 stated that when the white van was delivered she was given the Van Protocol and the Lift Video to use for training. She stated that she had not used the Owner's Guide for training. LPN #2 was asked if she had trained the drivers to use the shoulder straps. The LPN stated, "No, I told them to put the straps through the arms of the wheelchair and fasten in front of the resident." The LPN stated that this information was from the Van Protocol and that there was no picture or diagram to teach from. j. On [DATE] at 10:30 a.m., in the presence of the surveyor, the Director of Nursing received via fax the Sure-Lok Wheelchair Securement and Occupant Restraint System manufacturer guidelines. k. The Sure-Lok Wheelchair Securement and Occupant Restraint System manufacturer guidelines in Section 5, pages ,[DATE] documented "Start by attaching the lap belt. Place the ends of the lap belt around the passenger. Thread them down 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 with the buckle of the lap belt placed opposite to the side where the shoulder belt is attached to the wall. The last belt to attach before you're on your way is the shoulder belt. Bring the triangular fitting of the shoulder belt over the passenger's shoulder, past the collar bone and diagonally across the upper chest. Attach it to the stud of the lap belt latch plate. Pull on the loose end through the adjuster to achieve firm yet comfortable tension. Pull on the belt to ensure that everything is properly attached." l. On [DATE] at 11:00 a.m., utilizing the safety strapping system in the van, the Director of Nursing, Maintenance Director, C.N.A. #5 and LPN #2 disengaged all straps utilized for occupant securement. The Sure-Lok Wheelchair Securement and Occupant Restraint System manufacturer's guidelines were reviewed by these four individuals. The strapping system was realigned and a demonstration of appropriately securing an occupant utilizing the lap belt and shoulder belt ensued. All equipment was available in the van for appropriate securement of the wheelchair occupant. m. On [DATE] at 11:07 a.m., an interview was conducted with the DON, LPN #2, the Maintenance Director, and CNA #5. All agreed that prior to receiving the Manufacturer's Guidelines for the safety lap/shoulder belts today, they were unable to safely secure a resident in the white van. n. On [DATE] at 11:10 a.m., the Administrator was asked what she had done following the incident with Resident #4 in the van to ensure that transporting residents in the van would be safe. The Administrator stated, "I had the DON and (LPN #2) in-service the drivers from the DVD and the Owner's Guide. The Administrator was asked if she was aware that the Owner's Guide did not have anything related to safety securement with a wheelchair. She stated, "No." 2. On [DATE] at 10:27 a.m. the Administrator provided the current driver's licenses of the drivers of the van. The drivers were CNAs #1, 2, 3, 4, 5, and #7. The Administrator stated that she did not have a current driver's license for CNA #6. The one on file expired in 2009." The Administrator also stated that she had not added any drivers to the insurance since January of 2011 (to ensure that drivers driving history could be reviewed for driving citations). a. The facility's van protocol adopted [DATE] documented general guidelines of "Any staff member that drives the van will have a valid Arkansas driving license. Any staff member that drives the van will be either certified or licensed as a healthcare provider in Arkansas. Any staff member that drives the van must complete and pass all components of the "transporting by van" competency test before transporting any resident. It is the responsibility of the staff member driving the van to provide a valid driver's license and maintain a current copy in their personnel file." b. On [DATE] at 1:20 p.m., the Administrator provided a document dated [DATE] and titled Disclosure Under Fair Credit Reporting ACT and Consent to Procurement of Consumer Report For Employment Purposes - Driving Record, that listed the van drivers for the facility. CNA #6 and #7 were not on that list. The Administrator was asked how she monitored to ensure the criteria was met for each person driving the van. The Administrator stated, "One time a year I send a list of drivers to the insurance company and the insurance company lets us know if they have a bad driving record." 3. The Immediate Jeopardy was removed and the scope/severity reduced to "E" on [DATE] at 3:53 p.m. when the facility implemented the following Plan of Removal: Vans were taken out of service on [DATE] at 4:00 p.m. Vans will remain out of service until drivers are trained properly regarding the safety features of the shoulder and lap belts as approved by the manufacturer ' s guidelines. Manufacturer's Guidelines were received on [DATE] from the manufacturer. Maintenance supervisor will review the guidelines on [DATE] to ensure he is knowledgeable of the proper procedures for fastening the safety belts. In order to ensure safety of our residents via van transport, the following will be implemented: All potential candidates to be van drivers will be in-serviced on safety procedures on [DATE] by 10:00 p.m. to drive the vans by Maintenance/Designee. Return demonstration will be observed by Nursing Designee and a score test rating of 100% must be achieved. All new candidates for van drivers will follow the same protocol. List of drivers who have been added to the driving list since [DATE] and a copy of their driver ' s license was faxed to (Name of insurance company) on [DATE] at 2:20 p.m. to ensure driving history meets industry standards. No employee will be allowed to drive the van if the insurance company and facility does not approve their driving history. A data base of approved drivers with their driver ' s license number and expiration date was created on [DATE] to ensure that all drivers have a current driver's license. No employee will be allowed to drive the van until current license is validated. Final approval of van drivers will be given by the Administrator post in-service, appropriate return demonstration and 100% test scores relative to van security safety. The adherence to the safety seating security system will be monitored at point of entry into the van for 20% of residents to be transported each day by the Administrator/Designee until compliance is achieved. Final approval of van drivers will be given by the Administrator.

Complaint # was substantiated, all or in part, with these findings: Based on record review and interview, the facility Administration failed to ensure the facility was administered in a manner that enabled it to use its resources effectively and efficiently to maintain the highest practicable physical well-being for Resident #4 during van transportation. The Administrator failed to ensure the appropriate safety shoulder/lap straps were in use to secure the resident in a wheelchair during a van transport; failed to have the availability of manufacturer's guidelines for securement of a resident in a wheelchair during van transport; failed to educate van drivers in the usage of the van resident securement system and failed to ensure that all drivers had current driver's license with said driving records reviewed for citations to reduce the risk of accidents and resident injuries for 1 (Resident #4) of 1 case mix residents who were transported in the facility van per wheelchair. This failed practice resulted in Immediate Jeopardy which likely caused or could have caused serious harm, injury or death for Resident #4 who suffered a fall from the wheelchair during transport, and had a potential to affect 39 residents who were transported in the facility van by use of a wheelchair as documented on a list provided by the Director of Nursing on [DATE] at 2:14 p.m. The facility was informed of the Immediate Jeopardy on [DATE] at 1:55 p.m. The findings are: 1. The Administrator's Job Description provided by the Administrator on [DATE] at 9:00 a.m. documented: "... Position Summary: To ensure the internal operation of the facility is functioning in accordance with established policies and procedures and is responsible for any non-compliance with regulation found in the facility. ...". 2. Resident#4 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set with an Assessment Reference Date of [DATE] documented the resident had moderately impaired cognitive skills for daily decision making per a Staff Assessment for Mental Status, was dependent for transfer, required supervision for locomotion on or off unit and used a wheelchair for mobility. a. An Incident and Accident (I & A) Report dated [DATE] documented: "Status: Alert, Mobility: Wheelchair, ... Witness: Certified Nurse Assistant (CNA) #1, Employee. ... Location I&A: (facility van). ... CNA #1 stated that (Resident #4) was being very combative and that the W/C (wheelchair) was fastened into the van, but (Resident #4) slid out of w/c causing 2 skin tears to LLE (left lower extremity). ... DON (Director of Nursing)/ADON (Assistant Director of Nursing) Review: ... Inserviced this staff member on van. Monitoring van drives 3 X wk (week) for 1 month." On [DATE] at 3:50 p.m., CNA #1 was asked if she had been trained in the use of the van safety equipment. The CNA stated, "I am not trained to drive the van. The first time I ever did it, I didn't know how to adjust the straps. The CNA was asked to tell what happened on [DATE]. CNA #1 stated, "It was the first time I had transported anyone in the white van and I had to figure out how to use the belts. ... I took (Resident #4) to the doctor. I locked the wheelchair down and put belts on the resident. I did not attach shoulder straps going or coming. I was in the turning lane and turned off the highway and the resident fell out of the wheelchair. I drove to the facility and ran in to get help to get (Resident #4) out of the van." The CNA stated that she drove half a block to the facility with the resident on the floor of the van. b. The van schedule calender received from the Director of Nursing on [DATE] at 1:25 p.m. documented 21 transports via the white van from [DATE] through [DATE]. c. On [DATE] at 4:25 p.m., CNA #1 was asked to demonstrate how Resident #4 was secured in the white van the day of the incident that occurred on [DATE]. With a Surveyor in the wheelchair, the CNA secured the wheelchair to the floor attachments. Safety straps from each side of the van were placed through the arms of the wheelchair and attached in front of the surveyor at the waist. No shoulder straps were used. The CNA was asked where the shoulder straps were. CNA #1 was examining the straps when the Administrator came into the van and the Administrator was asked where the shoulder straps were. The Administrator began examining the straps when CNA #2 entered the van at 4:32 p.m. CNA #2 was also unable to secure the surveyor in the van using a shoulder strap. CNA #2 stated, "There is a strap missing." Both CNAs were asked if they had ever used a shoulder strap to secure residents in a wheelchair in this van. Both stated, "No." d. On [DATE] at 1:45 p.m., CNA #3 was interviewed. The CNA stated that she had been driving the van ever since they had it. She stated, "I was not taught to use the shoulder strap and do not know how to use it." e. On [DATE] at 10:40 a.m., CNA #5 was asked how long he had been driving the white van. The CNA stated, "Since we got it." The CNA proceeded to demonstrate how a resident in a wheelchair was secured with safety belts in the van. Licensed Practical Nurse (LPN) #2 was in the wheelchair. After the wheelchair was secured to the floor, CNA #5 pulled the straps from each side of the van and placed through each arm of the wheelchair and attached in front of the LPN. No shoulder strap was used. The surveyor asked where the shoulder strap was. Both the CNA and the LPN stated, "There is no shoulder strap." The CNA stated that he had not used a shoulder strap in this van. f. On [DATE] at 4:48 p.m., Licensed Practical Nurse (LPN) #2, who was the CNA Supervisor and Van Driver Educator, was asked what she taught about the shoulder straps in the van. The LPN stated, "The straps go across the shoulder and the waist. Straps go through the arms of the wheelchair. Both sides of the straps are secured to the van. The LPN was asked what was used to train the drivers on how to secure the resident in the wheelchair and the wheelchair to the floor. The LPN stated, "The Van Policy and the video for the use of the lift." The LPN also stated, "(The residents) should have a shoulder and a lap restraint." g. The facility's van protocol adopted [DATE] documented for resident's in wheelchairs "...j. Using the seatbelt provided ensure that each end of the seat belt is secured to the floor and place the other end of the seat belt through the arms of the wheel chair and buckle in front of the resident." (There was no documentation of the necessity of utilizing a shoulder restraint.) h. On [DATE] at 8:20 a.m., the DON was informed of the incorrect use of safety straps by CNA #1 and #2 on [DATE] during a demonstration with the surveyor. The DON stated, "I have shown them myself, how to use the shoulder and lap straps in the van." At 9:55 a.m., the DON was asked if she had the Manufacturer's Guidelines for the use of the safety equipment in the van for residents in wheelchairs. The DON stated, "All I have is the Owner's Guide." The DON was asked to show the surveyor where the safety recommendations were in this guide. The DON stated, "It doesn't show anything about wheelchairs." The DON stated that LPN #2 was responsible for training the drivers regarding van safety transport and that the Ford E-Series 2010 Owner's Guide, the Van Protocol, and the DVD for appropriate use of the van lift was the material used for training. i. On [DATE] at 10:10 a.m., LPN #2 stated that when the white van was delivered she was given the Van Protocol and the Lift Video to use for training. She stated that she had not used the Owner's Guide for training. LPN #2 was asked if she had trained the drivers to use the shoulder straps. The LPN stated, "No, I told them to put the straps through the arms of the wheelchair and fasten in front of the resident." The LPN stated that this information was from the Van Protocol and that there was no picture or diagram to teach from. j. On [DATE] at 10:30 a.m., in the presence of the surveyor, the Director of Nursing received via fax the Sure-Lok Wheelchair Securement and Occupant Restraint System manufacturer guidelines. k. The Sure-Lok Wheelchair Securement and Occupant Restraint System manufacturer guidelines in Section 5, pages ,[DATE] documented "Start by attaching the lap belt. Place the ends of the lap belt around the passenger. Thread them down 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 with the buckle of the lap belt placed opposite to the side where the shoulder belt is attached to the wall. The last belt to attach before you're on your way is the shoulder belt. Bring the triangular fitting of the shoulder belt over the passenger's shoulder, past the collar bone and diagonally across the upper chest. Attach it to the stud of the lap belt latch plate. Pull on the loose end through the adjuster to achieve firm yet comfortable tension. Pull on the belt to ensure that everything is properly attached." l. On [DATE] at 11:00 a.m., utilizing the safety strapping system in the van, the Director of Nursing, Maintenance Director, C.N.A. #5 and LPN #2 disengaged all straps utilized for occupant securement. The Sure-Lok Wheelchair Securement and Occupant Restraint System manufacturer's guidelines were reviewed by these four individuals. The strapping system was realigned and a demonstration of appropriately securing an occupant utilizing the lap belt and shoulder belt ensued. All equipment was available in the van for appropriate securement of the wheelchair occupant. m. On [DATE] at 11:07 a.m., an interview was conducted with the DON, LPN #2, the Maintenance Director, and CNA #5. All agreed that prior to receiving the Manufacturer's Guidelines for the safety lap/shoulder belts today, they were unable to safely secure a resident in the white van. n. On [DATE] at 11:10 a.m., the Administrator was asked what she had done following the incident with Resident #4 in the van to ensure that transporting residents in the van would be safe. The Administrator stated, "I had the DON and (LPN #2) in-service the drivers from the DVD and the Owner's Guide. The Administrator was asked if she was aware that the Owner's Guide did not have anything related to safety securement with a wheelchair. She stated, "No." 3. On [DATE] at 10:27 a.m. the Administrator provided the current driver's licenses of the drivers of the van. The drivers were CNAs #1, 2, 3, 4, 5, and #7. The Administrator stated that she did not have a current driver's license for CNA #6. The one on file expired in 2009." The Administrator also stated that she had not added any drivers to the insurance since January of 2011 (to ensure that drivers driving history could be reviewed for driving citations). a. The facility's van protocol adopted [DATE] documented general guidelines of "Any staff member that drives the van will have a valid Arkansas driving license. Any staff member that drives the van will be either certified or licensed as a healthcare provider in Arkansas. Any staff member that drives the van must complete and pass all components of the "transporting by van" competency test before transporting any resident. It is the responsibility of the staff member driving the van to provide a valid driver's license and maintain a current copy in their personnel file." b. On [DATE] at 1:20 p.m., the Administrator provided a document dated [DATE] and titled Disclosure Under Fair Credit Reporting ACT and Consent to Procurement of Consumer Report For Employment Purposes - Driving Record, that listed the van drivers for the facility. CNA #6 and #7 were not on that list. The Administrator was asked how she monitored to ensure the criteria was met for each person driving the van. The Administrator stated, "One time a year I send a list of drivers to the insurance company and the insurance company lets us know if they have a bad driving record." 4. The Immediate Jeopardy was removed and the scope/severity reduced to "E" on [DATE] at 3:53 p.m. when the facility implemented the following Plan of Removal: Vans were taken out of service on [DATE] at 4:00 p.m. Vans will remain out of service until drivers are trained properly regarding the safety features of the shoulder and lap belts as approved by the manufacturer ' s guidelines. Manufacturer's Guidelines were received on [DATE] from the manufacturer. Maintenance supervisor will review the guidelines on [DATE] to ensure he is knowledgeable of the proper procedures for fastening the safety belts. In order to ensure safety of our residents via van transport, the following will be implemented: All potential candidates to be van drivers will be in-serviced on safety procedures on [DATE] by 10:00 p.m. to drive the vans by Maintenance/Designee. Return demonstration will be observed by Nursing Designee and a score test rating of 100% must be achieved. All new candidates for van drivers will follow the same protocol. List of drivers who have been added to the driving list since [DATE] and a copy of their driver ' s license was faxed to (Name of insurance company) on [DATE] at 2:20 p.m. to ensure driving history meets industry standards. No employee will be allowed to drive the van if the insurance company and facility does not approve their driving history. A data base of approved drivers with their driver ' s license number and expiration date was created on [DATE] to ensure that all drivers have a current driver's license. No employee will be allowed to drive the van until current license is validated. Final approval of van drivers will be given by the Administrator post in-service, appropriate return demonstration and 100% test scores relative to van security safety. The adherence to the safety seating security system will be monitored at point of entry into the van for 20% of residents to be transported each day by the Administrator/Designee until compliance is achieved. Final approval of van drivers will be given by the Administrator.

Based on record review and interview, the facility failed to ensure the Physician was immediately consulted following a significant change in a resident's physical status on [DATE] and the resident's continued digression through [DATE] for 1 (Resident #3) of 5 case mix residents (Resident's #1, #2, #3, #4 and #5) case mix residents who resided at the facility. The failed practice likely caused a pattern of harm for Resident #3 who exhibited a decline in condition and expired on [DATE] and had the potential to cause more than minimal harm for 1 resident who was unstable had a significant change in condition according to a list received from the Director of Nursing on [DATE] at 2:14 p.m. The findings are: 1. The facility's policy "Change in a Resident's Condition or Status" documented in part "The Nurse Supervisor/Charge Nurse will notify the resident's Attending Physician or On-Call Physician when there has been "...d. A significant change in the resident's physical/emotional/mental condition, e. A need to alter the resident's medical treatment significantly...." 2. Resident #3 had [DIAGNOSES REDACTED]. The Minimum Data Set with an assessment reference date of [DATE] documented the resident scored 15 (13 - 15 cognitively intact) on a Brief Interview of Mental Status, required limited physical assistance of one person for transfer, ambulation in corridor and on/off unit, dressing, personal hygiene, and bathing, was independent with eating with set up help only, had no functional limitations in upper or lower extremities and was continent of bowel and bladder. a. Nurses ' Notes dated [DATE] at 7:25 a.m. documented, "Called to R (Resident) room per CNA (Certified Nursing Assistant). R found lying next to bed in large amount of blood. A & O (Alert and Oriented), denies any pain or discomfort. 1" (One inch) laceration above L (left) eye. PERRL (Pupil equal, round, and reactive to light) ER (emergency room ) notified. Family notified. Sending R to ER for eval due to blood loss." The Incident and Accident (I & A) Report dated [DATE] at 7:25 a.m. documented, "R found lying in floor next to bed. 1" (One inch) lac (laceration) above L eye. A & O x (times) 3 (three), PERRL. No c/o (complaints), pain or discomfort." b. The I & A report attachment for neuro checks with an initial date of [DATE] documented the following: 1) [DATE] ...1:15 p.m., "Return from ER ,[DATE], 74, 18, 98.4, A & O" ,[DATE] (2:00 p.m. - 10:00 p.m. shift) " ,[DATE], 100, 20, 97 (recorded blood pressure, heart rate, respirations and temperature), alert, right eye pupil reacts, blind in left eye." ,[DATE] (10:00 p.m.- 6:00 a.m. shift) " ,[DATE], 92, 20, 98.4, alert and oriented x 3, pupil right eye reactive." 2) [DATE] ,[DATE] (6:00 a.m. - 2:00 p.m. shift) " ,[DATE], 86, 18, 98.8, A & O, PERRL." ,[DATE] (2:00 p.m. - 10:00 p.m. shift) " ,[DATE], 72, 22, 99, R eye reacts, equal, alert." ,[DATE] (10:00 p.m. 6:00 a.m. shift) " ,[DATE], 81, 20, 98.2, PERRL, alert." 3) [DATE] ,[DATE] (6:00 a.m. - 2:00 p.m. shift) " ,[DATE], 76, 22, 18, 97.8, (positive) PERRL." ,[DATE] (2:00 p.m. - 10:00 p.m. shift) " ,[DATE], 123, O2 (oxygen) 84, 95.4, alert off (and) on." ,[DATE] (10:00 p.m. - 6:00 a.m. shift) B/P (blood pressure),[DATE], P (Pulse) 130, O2 sat (oxygen saturation) 98%, 97.9 asleep." c. The physician progress notes [REDACTED]. Went to ER this weekend after fall. Had laceration of L (left) eyebrow. He has declined in last 2 weeks. He is not very responsive. He does open his eyes to stimulation. O2 Sat (oxygen saturation) 87%. Lungs clear. Multiple bruises. Abdomen soft and nontender. He appears terminal. Family is at bedside aware that he appears to be dying. " d. Nurse's Notes dated [DATE] at 1:30 p.m. documented, "(Attending Physician) here with NO (new orders) for O2 (oxygen) at 2LPM BNC (2 liters per minute by nasal canula) consult hospice if R requires." Nurse's Notes dated [DATE] at 6:36 p.m. documented, "Pt (patient) checked. Temp (temperature) noted 99.6. Was given Tylenol ES (extra strength) Liquid 10 cc (cubic centimeters) po (by mouth). Pt became nauseated and had mod (moderate) amt (amount) of dark liquid. Will cont (continue) to monitor." On [DATE] at 8:50 a.m., Licensed Practical Nurse #1 (charge nurse on [DATE] on 2:00 p.m. -10:00 p.m. shift), when asked about the resident ' s condition on that shift, stated, "There was a significant change on [DATE] from the 6:00 a.m. to 2:00 p.m. to my shift. I did not notify the physician. I did not begin monitoring his vital signs more frequently. I should have called the doctor." e. Nurse's Notes dated [DATE] at 10:40 p.m. documented, "R in bed with HOB (head of bed) up 45 degrees with call light in reach and his daughter at bedside. Skin w/d (warm and dry). Resp (respirations) fast but non labored at 40. Bed in the down position. Call light in reach. Color pale. Dark red urine in bag approx (approximately) 50 cc. Monitored frequently. Family offered support. O2 at 2 LPM BNC." f. Nurse's Notes dated [DATE] at 4:00 a.m. documented, "Repositioned. VS BP ,[DATE], T 96.1, P 101, R 34, O2 Sat 91%. Daughter remains with R. Monitored frequently." Nurse's Notes dated [DATE] at 5:30 a.m. documented, "VS (Vital signs) taken T (temperature) 97.4, Pulse 130. Resp (respirations) 28, BP (blood pressure) ,[DATE]. Turned and repositioned. Daughter in the room with pt (patient). O2 at 2 LPM per NC. Opened eyes and states 'I'm o.k.' Monitored freq (frequently)." On [DATE] at 3:00 p.m., Registered Nurse #1 (charge nurse on [DATE] on 10:00 p.m. through 6:00 a.m. shift), when asked about the resident condition on that shift, stated, "I did not call the physician at that time of night. I wasn't surprised at the vital signs but I noticed the prior vital signs. We were expecting him to pass away. His condition had worsened. He was ambulatory for short distances. He had taken a turn for the worse. The changes were expected by me because I felt it was the process he would go through before his death. His fluid intake had diminished. The vital sign changes would be considered a change of condition. With a change of condition on most patients we call the doctor and report the changes. I felt this was part of his dying process. The dark red urine in his [MEDICATION NAME] bag was normal for him. In hindsight, I should have called the doctor." h. On [DATE] at 2:15 p.m., the Medical Director stated, "I came to the facility on [DATE] at the facility's request to meet with (Resident #3's) family regarding the [DATE] fall. I answered questions regarding the care the facility was providing. I am also the ER Medical Director (community hospital) and had spoken to (ER Physician on duty on [DATE]) regarding his condition relative to the fall. I came as the Medical Director, not to care for the resident. I only make rounds on my patients. He is (Attending Physician's) patient. I did not examine him." i. Nurse's Notes dated [DATE] at 8:00 p.m. documented, ",[DATE]-123-O2 (saturation) 84." The Nurse's Notes dated [DATE] at 10:30 p.m. documented, "R in bed with eyes closed. Skin w/d. Resp nonlabored at 28 with moist O2 at 2 LPM BNC. Abd (abdomen) non-distended. Urine bag in place. HOB up 45 degrees. Occ (occasional) attempt to cough. Allowed to continue to rest at this time." Nurse's Notes dated [DATE] at 11:00 p.m. documented, "Pt repositioned by CNA's (Certified Nursing Assistants). VS-BP ,[DATE], Pulse 109, R 28, Temp 96.8, O2 sat at 96%, monitored every one hour. Daughter at bedside." j. Nurse's Notes dated [DATE] at 10:21 a.m. documented, "Repositioned-urine bag emptied with 200 cc dark red urine. VS BP ,[DATE], Pulse 91, O2 Sat 99%, Temp 94.8. Daughter at bedside. No acute distress observed." Nurse's Notes dated [DATE] at 1:00 p.m. documented, "R turned and reposition q (every) 2 hr (hours). BP ,[DATE], O2 98%, P 72, Temp 96.9. Family at bedside. No s/s (signs or symptoms) of distress noted. Will cont to monitor and report to oncoming nurse." k. Nurse's Notes dated [DATE] at 6:00 a.m. documented, "Repositioned. O2 at 2 LPM. O2 sat 100%. BP ,[DATE], P 100, R 24. Daughter with R. No extreme distress." Nurse's Notes dated [DATE] at 6:30 a.m. documented, "R resting. CL (Call light) in reach. Family at bedside. BP ,[DATE], T 96.0, P 101, O2 99. No s/s of distress noted. Will cont monitor R cond (condition) and report." Nurse's Notes dated [DATE] at 9:00 a.m. documented, "...BP ,[DATE], O2 sat 99, T 95.9, Pulse 90." l. Nurse's Notes dated [DATE] at 7:00 a.m. documented, "VS ,[DATE], P 101, R 30, O2 sat 98 on 2 LPM BNC. R resting quietly in bed. No s/s of distress noted." Nurse's Notes dated [DATE] at 7:59 a.m. documented, "Was called to pt's (patients) room per dtr. (daughter). She stated that 'Daddy had stopped breathing at one time.' Checked on pt and vs was taken, results noted ,[DATE], R 8, 96.4." Nurse's Notes dated [DATE] at 9:00 a.m. documented, "VS ,[DATE], P 98, R 26, Temp 97.2, P ox (pulse oxygen) 92." l. The first documented notation that the physician was consulted since [DATE] regarding the resident ' s deteriorating condition: Nurse's Notes dated [DATE] at 8:05 a.m. documented, "Notified (Attending Physician) that pt vs is very low and no new orders given." On [DATE] at 1:27 p.m., the Attending Physician stated, "I don't think they called me after I left on the ninth ([DATE] at 1:30 p.m.) I called them to check on him the next day. They said (Medical Director) had been there to meet with the family so I didn't ask any more questions." m. Nurse's Notes dated [DATE] at 8:30 a.m. documented, "Notified MD (Medical Doctor) on call no vs. Orders noted to call coroner and release remains to funeral home of family's choice."