Every finding on record at Evergreen Living Center at Stagecoach

Number of residents sampled: Number of residents cited: Based on observation, interview and facility document review, the facility failed to ensure that the waste was properly contained in the dumpsters, and the area was free from debris. During a concurrent observation and interview on 06/03/2026 at 10:32 AM of the dumpster area with Dietary Manager (DM) the following was observed:-The dumpster lid was open-A clear bag of trash was lying on the ground in front of the dumpster-The fencing around the dumpster was open- Approximately fourteen pallets were stacked and leaning on the fencing. The DM indicated the lid and gates to the dumpster area were to be closed and the trash needed to be in the dumpster. The DM also stated the area needed to be clean to prevent pests and rodents that would spread the trash. During a follow up interview on 06/04/2026 at 12:06 PM, the DM indicated the whole facility used the dumpsters. The DM also indicated it was on the maintenance rounds to check the area daily. During an interview on 06/04/2026 at 12:37 PM, the Maintenance Director indicated he was responsible for the dumpster area, and he did trash pick up every morning. The Maintenance Director also indicated the dumpster area needed to be kept clean to prevent rodents and disease. The Maintenance Director stated he had only been employed with the facility for a week and had not used the Maintenance Inspection Checklist yet. During an interview on 06/04/2026 at 10:02 AM, the Administrator stated the dumpster area was to be clean and indicated that in-services had been completed in the past concerning the dumpster area. Review of the Maintenance Inspection Checklist revealed the waste area was to be checked; no time or frequency of required checks were indicated. Review of a facility policy titled, Food Related Garbage and Refuse Disposal with a revision date of October 2017 revealed, Garbage and refuse containing food wastes will be stored in a manner that is inaccessible to pest. Outside dumpsters provided by garbage pick-up services will be kept closed and free of surrounding litter.

Number of residents sampled: Number of residents cited: Based on observation, interview and facility document review, the facility failed to ensure that the food preparation equipment and environment were maintained in a clean and sanitary condition to prevent contamination and the potential development of food borne pathogens, specifically, not cleaning the drip pans, conveyor toasting system and the oven. In one of one kitchen The findings include: During a concurrent observation of the kitchen and interview with Dietary Manager (DM), the following was observed: On 06/02/2026 at 2:00 PM, the drip pan was covered in thick crusty patches particularly in the center, much of the surface was coated in an amber to dark brown substance, brighter orange and yellow areas with dried peas and zucchini. The conveyor toasting system, fine, dry particulates are scattered throughout the internal chamber and resting on the front ledge with a dark residue on the conveyor mechanism. The exterior was covered in visible smudges and grease stains. DM states toaster is wiped down after ever use and it does not come apart to clean the inside. On 06/04/2026 at 8:45 AM, the oven was heavily soiled with black and gray substances covering it and a yellowish-brown residue was visible on the area where the door closes on the oven. The wire rack had a black and gray substance on it. During an interview on 06/02/2026 at 2:05 PM the DM stated the drip pan was cleaned every Sunday, this week it was cleaned on Saturday due to staffing issues. The conveyor toasting system was wiped down after ever use and, but it did not come apart to clean the inside. During an interview on 06/03/2026 at 9:05 AM the [NAME] verbalized the task involved with keeping the kitchen area clean. I make sure my area is wiped down with sanitizer water, I wipe down the seasoning area and clean the can opener daily, I clean the toaster by taking the crumb tray out and wipe it with sanitizer water and clean the microwave daily. The oven is cleaned once a week on Sundays. The [NAME] did not mention cleaning of the drip pans or the oven. During an interview on 06/03/2026 at 9:00 AM the Dietary Aide verbalized what task were done to keep the kitchen clean. I clean the aid side of the kitchen which has a mixer, slicer, drink machine and the ice machine by wiping down my table with sanitizer water and mopping the floor with bleach. The Dietary Aide did not mention cleaning of the drip pans or the oven. During an interview on 06/04/2026 10:02 AM the Administer indicated the kitchen was to be deep cleaned weekly. Review of the Week 1 menu for the week of 06/01/2026 indicated seasoned Zucchini was served on Monday 06/01/2026. Review of the Week 4 menu for the week of 05/25/2026 noted peas were served on Monday 05/25/2026. Review of in-services for the last year did not show any in-services for cleaning and sanitization. Review of the weekly task sheets did not show any task for cleaning the drip trays or conveyor toaster system. The task sheet indicated the Morning [NAME] duty included: Clean range, oven and grill top after each use. This was initialed as completed for the week of 05/25/2026 and the days of 06/01/2026 and 06/02/2026. Review of the manufacturer's manual for the conveyor toaster system indicated, Wipe the exterior of the toaster with a damp sponge or cloth soaked in hot or warm detergent. Remove the reflector/crumb tray, toaster drawer and wire bread feeder from the unity and empty them. Wash them in warm detergent water and rinse them. Review of the [name brand] Gas Range Instruction Manual , Cleaning, item number 2 indicated; Please clean the burners and drip tray of all debris and spillage daily. Review of the facility policy for Suggested Cleaning Procedures- Major Equipment stated, Daily Empty and wash range drip pans. Helpful tip: wipe off oven spills and splatters as they occur. Weely clean the interior of the oven with commercial oven cleanser.

Based on observation, interview and record review, it was determined the facility failed to ensure staff followed a care planned intervention requiring two staff members to perform a mechanical lift transfer for 1 (Resident # 43) of 4 sampled residents reviewed for accidents. The findings are: 1. The quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/14/24 revealed the resident scored a 0 on a Brief Interview for Mental Status (BIMS) (0-7 indicates severe impairment) and was on hospice care. The MDS revealed diagnoses of Alzheimer's disease, Non-Alzheimer's dementia, and Parkinsonism. a. A Care Plan, dated 1/14/2025, indicated Resident #43 required a mechanical lift with 2 staff member ' s assistance for transfers. b. Review of Resident #43's Hospital records for hospital admission with a date of 1/27/2025 revealed an operation note with date of service of 1/28/2024 that indicated a preoperative diagnosis of right distal femur fracture, operative procedure open reduction and internal fixation of right distal femur. This patient with advanced dementia and Parkinson's disease. Patient is on hospice but now lives in a geriatric care facility, was found to have a right femoral fracture. There was no reported fall. Clearly something happened as she had a displaced right femur shaft fracture. Details of the procedure indicated there was a lot of hematoma (pooled blood) at the fracture site, and the fracture was very displaced, and muscle was interposed in the fracture site. c. An OLTC (Office of Long-Term Care) Witness Statement dated 1/28/2024 and signed by Certified Nursing Assistant (CNA) #1 revealed on 1/26/2024 at 4:45 am Certified Nursing Assistant (CNA) # 1 log rolled Resident # 43 to tuck and get the lift pad under Resident # 43, I used a crank lift to lift [Resident #43] out of bed and into [the resident ' s] chair .I didn't have help and didn ' t ask anyone on another hall because we were short staffed , without assistance and did not report the improper transfer. d. On 1/29/2025 at 4:14 pm, the surveyor interviewed CNA #2 regarding Resident #43. CNA #2 stated while placing Resident # 43 back in bed on Sunday 1/26/2025 at 1:30 pm, it was noticed the resident ' s knee was swollen, the resident was grimacing and not smiling, which was reported to Licensed Practical Nurse (LPN) #3. e. A Nsg-Hot Rack progress note dated 01/26/2025 at 7:36 pm read, [Resident #43] has some swelling in her right knee that has not always been there and when move [the resident] grimaces in pain. f. A progress note dated 01/26/2025 at 10:03 pm read, Resident given morphine for swelling to knee. Hospice nurse made aware by day shift nurse, and they said they will evaluate resident tomorrow. g. A form titled, Radiology Results Report documented, .Examination Date: 1/27/25 .Procedure: Knee RT 2 V . Impression: Acute angulated spiral fracture of the distal right femur without prosthetic involvement . h. On 1/29/2025 at 4:16 pm, the surveyor interviewed LPN # 3 regarding Resident #43. LPN # 3 reported being called into Resident #43 ' s room by CNA # 2 on Sunday 01/26/2025 at 1:30 pm regrading a swollen right knee with pain. After assessing Resident #43, LPN #3 notified Baptist hospice of the findings and an x-ray was ordered, and instructions given to put some ice on the leg. LPN #3 stated Hospice said that they will notify the primary nurse to come out the next day to assess the resident and to give further instructions. i. On 1/29/2025 at 4:25 pm, the Director of Nursing (DON) stated that she had done competencies on all CNA staff that have worked, and she began the training on 1/27/2025. The DON reported about 7 staff members that still needed to be trained who had not worked as they were mostly PRN staff j. On 1/29/2025 at 4:39pm, the surveyor interviewed the DON and received an Inservice Education Report indicating staff were to refer to closet care plans prior to transferring resident. 2 staff (licensed staff) must transfer residents when using a (mechanical) lift with no exceptions. The DON reported having conducted the Lift Training Competency training. k. On 1/29/2025 at 5:35 pm, the DON provided a QAA (Quality Assurance) plan showing what she had done once she identified that the transfer was done incorrectly. The DON also provided a monitoring sheet where she watched mechanical lift transfers on 1/27/2025, 1/28/2025 and 1/29/2025. l. On 1/29/2025 at 5:44 pm, the surveyor interviewed Registered Nurse #4 who reported working the 7pm to 7am shift on 1/26/2025 and stated they had given Resident #43 morphine for exhibited signs of pain. m. On 1/30/2025 at 9:00 am, the surveyor spoke with LPN #3, who stated the Hospice nurse was notified of Resident #43 ' s swelling at 3:00 pm on Sunday (1/26/25). LPN #3 stated the DON and Administrator were notified on Sunday (1/26/2025) at 3-4pm of the findings. n. 01/30/25 5:30PM, The surveyor spoke with the Medical Director by telephone and the Medical Director stated that she did not feel that Resident 43 ' s fracture came to the level of IJ (Immediate Jeopardy). The Medical Director stated that she felt the resident ' s fracture was spontaneous. The Medical Director stated Resident #43 was a hospice patient with poor nutrition, had osteoporosis and had lost 10lbs in weight that was why she was put on hospice. The stated that there was no indication of an injury. I explained to the Medical Director that according to the witness statements the Certified Nursing Assistant (CNA) that worked nights had done a two person lift transfer with the mechanical lift by herself on Sunday morning (01/16/2025) about 4:45am when getting the resident up into the chair and at 1:30pm that day the aide who put the resident to bed noted the resident ' s knee was swollen. The nurse who looked at the resident also noted the knee was swollen and the resident grimaced when moved. The Medical Director asked if the aide said anything had happened and I said her statement said nothing unusual happened, but I had not been able to speak with her. The medical director again stated she felt that the fracture was most likely spontaneous. o. On 1/30/2025 at 5:45 pm, CNA #1 was interviewed by telephone and asked how much assistance Resident #43 needed with ADL's (activities of daily living). CNA #1 stated Resident #43 was totally dependent on staff for ADL's. CNA #1 was asked how many staff are required to transfer Resident #43 and CNA #1 stated the care plan stated two. CNA #1 was asked how Resident #43 was on the night of 1/26/2025 and she stated that the resident was their normal self. CNA #1 stated she cleaned the resident up, did incontinence care, and put the lift pad under the resident and then transferred the resident to the chair. When asked if she got help for the mechanical lift transfer, CNA #1 stated she was on the hall by herself, they were short staffed, and she did all the care herself. When asked if she tried to get a second person to help with the lift transfer CNA #1 stated no, she just tried to get the work done. She had residents that needed to get up and they (staff) got coachings if they did not get their work done. CNA #1 stated nothing unusual happened during the transfer and the only thing she reported to the nurse was that the resident had been coughing. CNA #1 was asked if she had done any other mechanical lift transfer by herself and she stated, to be honest they do it all the time CNA #1 confirmed she did not work after 1/26/2025 and she was suspended on 1/27/2025 after she received a call from the facility regarding the incident. CNA #1 confirmed that the closet care plan and the residents electronic record documented how much assistance the resident's needed with transfers. She also confirmed she had been trained on mechanical lift transfers on hire, but she did not recall whether she had been in-serviced on following the care plan at that time. CNA #1 confirmed she was in-serviced on the lift and following policies on 1/28/24 after the incident occurred. p. A policy titled, Care Plans, Comprehensive Person Centered (revision March 2022) indicated the care plan describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. q. A policy titled Lifting Machine, using a Mechanical (Revised July 2017) indicated the purpose of this procedure was to establish the general principles of safe lifting using the mechanical lifting device and included at least two (2) nursing assistants are needed to safely move a resident with a mechanical lift.

Based on observation, interview, and record review, the facility failed to ensure the Comprehensive Care Plan contained the necessary information to fully provide and coordinate care and services for a resident with physician's orders for Hospice Services for 1 (Resident #192) of 3 sampled residents that were reviewed for Hospice Services. The findings are: 1. The admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/29/2024 indicated Resident #192 had diagnoses of cancer of the colon, coronary artery disease, chronic obstructive pulmonary disease, scored 11 (8-12 indicated moderate impairment) on the Brief Interview for Mental Status (BIMS), required substantial to maximum assistance with activities of daily living (ADL's), and was on hospice services. a. A physician's order dated 01/05/2025 indicated Resident #192 was admitted to (Name of Hospice Company) hospice for malignant neoplasm (cancer) of colon. b. Review of the care plan with a revision date of 01/11/2025 revealed it did not address Resident #192 receiving hospice services. c. On 01/29/2025 at 10:00 AM, the MDS Coordinator confirmed during an interview that Resident #192 had been receiving hospice services since admission to the facility. The MDS Coordinator was asked if Resident #192's care plan addressed that the resident was receiving hospice services. The MDS Coordinator looked in the resident's electronic record and stated not yet, but it will. When asked why the care plan should address that the resident is receiving hospice services, the MDS Coordinator stated it should be included so staff know which hospice the resident is using and what care is to be provided. d. On 01/29/25 at 10:05 AM, during an interview the Director of Nursing (DON) confirmed Resident #192 was receiving hospice services and the resident's care plans should include that they are receiving hospice services because care plans should be individualized. The DON was asked if the facility had a policy on care plans. e. On 01/29/25 at10:10 AM, the policy titled Care Plans, Comprehensive Person-Centered (Revised March 2022) indicated a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident' physical, psychosocial and functional needs is developed and implemented for each resident and describes the services that are to be furnished

Based on observation, interview, and record review, the facility failed to post and make readily accessible to residents and visitors daily nurse staffing in a clear and readable format to include the facility name, date, total census and total number and actual hours worked by nursing staff. This failed practice had the potential to affect all 98 residents residing in the facility. The findings are: During an interview on 01/28/2025 at 4:20 pm, the Director of Nursing (DON) was asked for the location the nurse staffing was posted, and stated it was on the wall over by the nurse's station in a display case. The posted schedule only showed the daily schedule. The title of staff scheduled was not included. The schedule did not show the hours worked, the total hours, the census, or the name of the facility. The DON was asked what kind of information should be included on the nursing staffing and stated, The date, number of hours actually worked, and the hours scheduled. The DON was asked if the facility name and the census be on the nurse staffing posting and stated, Yes, they should. The DON was asked who makes the nurse staffing schedule and stated, Our HR (Human Resources) person does this. The one we had before wasn't doing it so she was terminated. We lost the key to the case and haven't been able to open it. The Maintenance man has ordered a new one and it hasn't come in yet so that's one reason it is not up to date. During an interview on 01/29/2025 at 1:58 pm, the Administrator was asked what information is required to be included on the posted nursing staffing schedule and stated, The date, census, hours scheduled, hours actually worked, facility name, schedule hours and shifts.

Based on observation and interview, the facility failed to ensure clean dishes and glasses were stored in a manner to prevent cross contamination; thickened liquids were dated when opened to prevent the potential for food borne illness; refrigerator temperature was maintained at 41 degrees Fahrenheit or below to prevent the potential for food borne illness; foods stored in the refrigerator and freezer were covered or sealed prevent the potential for food borne illness and employees washed their hands and changed gloves when contaminated to decrease the potential for food borne illness for residents receiving food from 1 of 1kitchen. The failed practice had the potential to affect 85 residents who received meal trays from the kitchen (total census 89), as identified on the list received from the Dietary Supervisor on 01/11/2024 at 11:20 AM. The finding are: 1. On 01/08/2024 at 10:45 AM, the racks where clean dishes and coffee mugs were stored by the door leading to the dish machine were not covered, exposing them to dust particles. 2. On 01/10/24 at 09:57 AM, the following observations were made in the walk-in refrigerator: a. The temperature in the walk-in refrigerator was 45 degrees Fahrenheit. The Surveyor asked the Dietary Supervisor to check the internal temperature of the milk. She did so and stated, It was 45 degrees Fahrenheit. b. An opened reusable, re-sealable zipper plastic bag that contained slices of cheese was on a shelf in the refrigerator. The bag was not sealed. c. An opened reusable, re-sealable zipper plastic bag that contained slices of ham was on a shelf in the refrigerator. The bag was not sealed. 3. On 01/10/24 at 10:00 AM, the following observations were made on a shelf in the walk-in freezer: a. An opened box of biscuits. The box was not covered, and the bag was not completely sealed. b. An opened box of fish was not covered, and the bag was not sealed. 4. On 01/10/24 at 11:27 AM, Dietary Employee (DE) #1 picked up a pan of beef sauce from the stove and placed it on the grill. DE #1 then picked up a pan from under the food preparation counter and placed it on the counter. She removed gloves from the glove box and placed them on her hands, then untied a bag of dinner rolls, contaminating the gloves. Without changing the gloves and washing her hands she removed dinner rolls from the bag and placed them into a pan to be served to the residents for the lunch meal. 5. On 01/10/24 11:33 AM, DE #2 pushed an empty dirty foil pie pan on the shelf on the steam table. She removed gloves from the glove box and placed them on her hands, contaminating the gloves. She picked up a spatula and used it to slice pies. She used the spatula to pick up sliced pieces of pie and then used her contaminated gloved hand to push the slices of pie into individual plates to be served to the residents for lunch. The Surveyor asked DE #2 what should you have done after touching dirty objects and before handling clean equipment? DE #2 stated, I should have washed my hands. 6. A facility policy titled, Employee Cleanliness and Handwashing Technique documented, .Dietary department employees are required to wash their hands on the occasions listed below. Before beginning shift and any other time deemed necessary . 47916 7. Resident #12 had diagnoses of hemiplegia and hemiparesis, cerebral infarction, and dysphagia. The Quarterly Minimum Data set (MDS) with an Assessment Reference Date (ARD) of 11/17/2023 documented a Brief Interview for Mental Status (BIMS) of 06 (0-7 indicates severe cognitive impairment). and required supervision for eating and oral hygiene, moderate assistance for dressing, maximal assistance with toileting and moderate assistance for personal hygiene. a. A Physicians Order dated 02/15/2023 documented, Regular Diet .Nectar consistency . b. A Care Plan with a revision date of 08/14/2023 documented .The resident has nutritional problem or potential nutritional problem r/t unspecified severe .Regular mechanical soft diet with nectar thick liquids . c. On 01/08/24 at 03:47 PM, Resident #12 asked the Surveyor for tea. The Surveyor observed a small ice chest with the lid elevated on a night table across the room from the foot of the bed in Resident #12's room. The ice chest contained a thawed ice pack, and thickened lemon water at room temperature. The thickened lemon water had a received date of 12/16/2023, there was no open date. d. On 01/10/24 at 09:59 AM, in Resident #12's room, the Surveyor observed a closed ice chest containing an opened 46 ounce container of thickened lemon water dated 12/16/2023, and it is sitting on a large, blue, thawed ice pack. There was no open date on the thickened lemon water. Resident #12 was sitting at the bedside with a full cup of thickened lemon water. The Surveyor asked Resident #12 how her drink tasted. Resident #12 told the Surveyor the drink was not cold, and she prefers it cold, because it tastes better and is easier to drink. e. On 01/10/24 at 10:10 AM, the Surveyor asked Certified Nursing Assistant (CNA) #5 what the process was for dispensing thickened liquids to residents that have an order. CNA #5 told the Surveyor that it would come from the kitchen. CNA #5 called over CNA #6 and asked her where the freezer packs come from. CNA #6 told the Surveyor that freezer packs come from the nutrition room. The Surveyor asked how often the 46 ounce containers of thickened lemon water are changed out. CNA #6 told the Surveyor she thinks it is every three days. The Surveyor asked how to identify the date it was opened, and CNA #6 said she did not know. The Surveyor pointed out the container was dated 12/16/2023. CNA #6 told the Surveyor that is a good question, I think I will start writing the open date on the container. f. The Certified Dietary Manager told the Surveyor that there is not a policy or procedure in place for dating thickened liquids with an open date when it leaves the kitchen. The kitchen places a received date on food and beverages when they are delivered to the facility, but they would not place an open date on thicken liquids that leave the kitchen because they do not know when staff would open the product.

Based on observation, interview, and record review, the facility failed to ensure Personal Protection Equipment (PPE) was available to prevent the spread of infection and staff sanitized their hands appropriately when assisting residents with meals. This failed practice had the potential to affect all 89 residents in the facility. The findings are: 1. On 01/08/2024 at 10:10 AM, the Administrator told the Surveyors there were 15 COVID residents, and mask were mandatory. The Surveyors observed surgical mask at the door, and the Administrator offered a N-95 mask if Surveyors wanted one, but everyone had a choice. a. On 01/08/2024 at 01:40 PM, the Surveyor was looking for personal protective equipment to don for interviews. Certified Nursing Assistant (CNA) #4 was asked to accompany the Surveyor to look at the isolation carts on the 400 Hall. The following PPE was missing: i) Cart outside room [ROOM NUMBER]: had food service hair protection, and two surgical mask, gowns, red and yellow bags. CNA #4 was asked should there be a droplet precautions sign on the door. CNA #4 pointed out the contact precaution sign, and looked on top of the isolation cart and found the droplet precaution signage. CNA #4 said, It looks like it came off the door. CNA #4 told the Surveyor there were no eye shields or protective eyewear, and no N-95 mask in the isolation cart. ii) Cart outside room [ROOM NUMBER]: CNA #4 was observed checking isolation cart and agreed there were no eye shields or eye protective equipment. iii) Cart outside room [ROOM NUMBER]: CNA #4 checked the isolation cart with the Surveyor and said, There are no N-95 mask. iv) Cart outside room [ROOM NUMBER]: CNA #4 checked the isolation cart with the Surveyor and told the Surveyor there were no N-95 mask. v) Cart outside room [ROOM NUMBER]: CNA #4 checked the isolation cart with the Surveyor and agreed no N-95, or protective eye shields or eye protection equipment was in the cart. vi) Cart outside room [ROOM NUMBER]: CNA #4 checked the isolation cart with the Surveyor and agreed no N-95, or protective eye shields or eye protection equipment were in the cart. vii) Cart outside room [ROOM NUMBER]: CNA #4 checked the isolation cart with the Surveyor and agreed there were no N-95 masks, or eye protection shields or equipment on the cart. b. On 01/08/2024 at 02:00 PM, the Surveyor asked CNA #4 who was responsible for isolation carts. CNA #4 said there had been recent changes and she did not want to tell the Surveyor the wrong thing. The Surveyor asked about the procedure for putting on PPE for resident care because no staff have been observed going in and out of isolation rooms. CNA #4 told the Surveyor that there are precautions signs on the doors, and the isolation carts should be stocked with everything to put on before entering a COVID-19 room. The Administrator approached and CNA #4 told the Administrator that the carts were missing eye protection and N-95 mask. The Administrator told the Surveyor and CNA #4 that he had supplies in his office. The Surveyor asked the Administrator what staff were expected to maintain the isolation carts and the Administrator told the Surveyor housekeeping, and environmental services. The Administrator told the Surveyor he was leaving to take care of the PPE. c. On 01/08/2024 at 03:00 PM, the Director of Nursing (DON) was asked for a policy on isolation precautions, and COVID-19. d. On 01/08/2024 at 03:30 PM, the Assistant Administrator provided a policy titled Isolation-Categories of Transmission-Based Precautions which documented, .Policy Interpretation and Implementation 1. Transmission-Based precautions will be used whenever measures more stringent than Standard Precautions are needed to prevent or control the spread of infection .Droplet Precautions .4. Masks a. In addition to Standard Precautions, put on a mask when entering the room or cubicle. e. On 01/08/2024 at 03:30 PM, the Administrator in Training provided a policy titled, Isolation-Initiating Transmission-Based Precautions which documented, .Policy Interpretation and Implementation .5. When Transmission-Based Precautions are implemented, the Infection Preventionist (or designee) shall; a. Ensure that protective equipment (i.e., gloves, gowns, masks, etc.) is maintained near the resident's room so that everyone entering the room can access what they need. f. On 01/11/2024 at 10:29 AM, The DON provided a policy titled Coronavirus Disease (COVID-19) Infection Prevention and Control Measures which documented, .Policy Statement This facility follows recommended standard and transmission-based precautions, environmental cleaning and social distancing practices to prevent the transmission of COVID-19 within the facility .Policy Interpretation and Implementation .2. While in the building, personnel are required to strictly adhere to established infection prevention and control policies, including: .c. Appropriate use of PPE .10.b. For a resident on Droplet Precautions: staff don a facemask within six feet of a resident .11. For a resident with known COVID-19 or symptoms of COVID-19: a. Staff don prior to entering the units or resident room gloves, isolation gown, eye protection and a N-95 or higher level respirator if available (a facemask is an acceptable alternative if a respirator is not available) . g. On 01/12/2024 at 08:10 AM, the Infection Preventionist (IP) was asked what role she plays in maintaining the isolation carts. The IP told the Surveyor that she makes sure the carts have hairnets, gowns, gloves, masks, and eye shields. The Surveyor asked who was responsible for filling the isolation carts. The IP said that everyone is responsible. If staff, see they are running out of PPE they should let someone know or get more from the Medical Supply Closet. The Surveyor asked if they had any in-services on maintaining the isolation carts and the IP told the Surveyor not to her knowledge. 48977 2. On 01/09/24 at 07:50 AM, the Surveyor observed CNA #2 feeding both Resident #45 and Resident #66 with her right hand without using hand sanitizer between giving each resident a bite of food. a. On 01/09/24 at 07:53 AM, the Surveyor asked CNA #2 do you have any hand sanitizer in your pocket? CNA #2 said no. The Surveyor asked between feeding Resident #45 and Resident #66 what should you have done? CNA #2 stated Sanitize my hands. b. On 01/10/24 03:15 PM, the Surveyor asked the Director of Nursing (DON) if a Certified Nursing Assistant is feeding multiple residents at the same time, between giving each resident a bite of food what should the CNA do? The DON said that's easy to forget but sanitize their hands. c. On 01/09/24 at 07:51 AM, the Surveyor observed CNA #1 pulling Resident #83's wheelchair up to the table with the right hand, then give Resident #24 a bite of food with the same hand without sanitizing. d. On 01/09/24 at 07:54 AM, the Surveyor asked CNA #1 do you have hand sanitizer in your pocket? CNA said no. The Surveyor asked after you pulled Resident #83's wheelchair up to table but before you gave Resident #24 a bite of food what should you have done? CNA #1 stated Sanitize my hands. e. On 01/10/24 at 03:15 PM, the Surveyor asked the DON if a Certified Nursing Assistant pulls a resident's chair to the table with her right hand, then give another resident a bite of food with her right hand what should she have done prior to giving the other resident a bite of food? The DON said sanitize her hands. The Surveyor asked why it is important to use proper hand hygiene. The DON said to keep down the spread of germs and infection. f. On 01/11/24 at 10:29 AM, the DON provided a policy titled, Handwashing/Hand Hygiene which documented, .Administrative Practices to promote Hand Hygiene 1. All personnel are trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections .

Based on observation, record review and interview, the facility failed to ensure meals were served in a method that maintained the appearance of food items that were acceptable to the residents to improve palatability and encourage good nutritional intake during 1 of 1 meal observed. This failed practice had the potential to affect 58 residents who had regular diets; 20 residents who received mechanical soft diets; and 7 residents who received pureed diets as documented on a list provided by the Dietary Supervisor on 01/11/2024 at 1:58 PM. The findings are: 1. On 01/08/2024 at 11:30 AM, Resident #44 told the Surveyors the food sucks, 90% is cold and 20% can't tell what you're eating. 2. The facility recipe for beef stroganoff for 100 residents documented, Used 20 1/2 lb [pound] of beef stew meat, 1/4 #10 can of mushroom pieces and stems, 11 oz [ounces] of yellow onion, 1 tablespoon of iodized salt, 3 cups of 2% reduced fat milk, 11/4 cups of sour cream, 3 cups of reconstituted beef base and 1 teaspoon of ground black pepper. a. [NAME] stew meat according to manufacturer's instructions. Cook to an internal temperature of 145 degrees Fahrenheit for 4 minutes. Maintain at an internal temperature of > (Greater than) 140 degrees Fahrenheit for only 4 hours. b. Add onions and mushrooms during last 5 minutes. Drain fat. Transfer to counter pans. c. Mix beef broth, milk, sour cream, salt, and pepper. Pour over beef cube mixture the bake. Cook to an internal temperature of 155 degrees Fahrenheit for 15 seconds. Maintain at an internal > (Greater than) 140 degrees Fahrenheit for only 4 hours. 3. On 01/10/24 at 01:24 PM, the following observations were made during the noon meal service: a. Egg noodles with beef sauce served to the residents on regular diets were watery. The water was separated from the food mixture. b. The egg noodles with ground beef sauce served to the residents on mechanical soft diets was watery. Water was separated from the food mixture. c. The pureed bread served to the residents on pureed diets was thick. The surveyor asked the Dietary Supervisor to describe the appearance of the foods served to the residents. She stated, Egg noodles with beef sauce was watery, and pureed bread was thick. 4. 01/10/24 01:25 PM, the Surveyor asked Dietary Employee (DE) #1 how she prepared the beef stroganoff. DE #1 stated, I sauteed onion, beef, and mushroom. Added salt, pepper, broth, and 4 cups of sour cream. She did not mention adding milk in the mixture. 5. 01/11/24 at 01:45 PM, the Surveyor asked DE #3 to describe the appearance of the food served to the residents for lunch on 01/10/2024. DE #3 stated, The egg noodles were watery. I kept draining the water off the noodles, before putting them on the plates, but still watery. Ground beef tips look like water down gravy. We don't know what it was. Pureed bread was thick.

Based on observation, interview, and record review, the facility failed to ensure fingernails were trimmed, cleaned, and free of jagged edges to promote good personal hygiene and grooming for 1 (Resident #18) of 7 (Residents #11, #18, #24, #41, #78, #83 and #191) sampled residents who were dependent on staff for nail care on the 100 Hall according to a list provided by Assistant Director of Nursing on 01/12/2024 at 3:40 PM. The findings are: 1. Resident #18 had diagnoses of Stroke, Dysphagia, and Pain in Right Shoulder. The Significant Change in Condition Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/16/23 documented that the resident scored 3 (indicating severely cognitively impaired) on a Staff Assessment for Mental Status (SAMS). a. The care plan with a revision date of 12/12/23 documented, .Focus: The resident has an ADL [Activities of Daily Living] self-care performance deficit r/t [related to] Activity Intolerance, Limited Mobility, Pain to right shoulder, Stroke . Intervention/Task: BATHING/SHOWERING: Check nail length and trim and clean on bath day and as necessary. Report any changes to the nurse . The care plan did not document the resident refuses care. b. On 01/08/24 at11:06 AM, Resident #18 was sitting up in bed watching television. His left hand was on top of the covers. The resident's fingernails were ungroomed with a dark substance under the nails and around the cuticles. Some of the nail edges were jagged and uneven. c. On 01/09/24 at 08:35 AM, Resident #18 was sitting up in bed eating breakfast. The fingernails on both hands had a dark substance under them and around the cuticles. Some of the nail edges were jagged and uneven. d. On 01/10/24 at 08:35 AM, Resident #18 was lying in bed with eyes closed with his left arm and hand outside of the covers. His fingernails on the left hand appeared ungroomed with a dark substance under the nail and around the cuticles. Some of the edges of the nails were jagged and uneven. e. On 01/11/24 at 08:35 AM, Resident #18 was lying in bed with eyes open. His fingernails had a dark substance under the nails and around the cuticles. Some of the edges of the fingernails were jagged and uneven. f. On 01/11/24 at 09:25 AM, the Surveyor asked Licensed Practical Nurse (LPN) #3 to accompany her to Resident #18's room. LPN #3 entered the room and spoke with the resident prior to looking at his fingernails. The Surveyor and LPN #3 then exited the room and LPN #3 was asked, Can you describe [Resident #18's] fingernails to me? LPN #3 stated, There is an unknown substance around his nail bed. His fingernails need to be cleaned. LPN #3 was asked, How much assistance does [Resident #18] require with activities of daily living? LPN #3 stated, He's total assistance of two people with care. LPN #3 was asked, Who is responsible for providing nail care to the resident? LPN #3 stated, All nursing staff on the hall are responsible for doing nail care. LPN #3 was asked, How often should nail care be done? LPN #3 stated, Every day. LPN #3 was asked, Does the resident refuse care? LPN #3 stated, Yes. He does sometimes refuse. LPN #3 was asked, What do you do if the resident refuses care? LPN #3 stated, Most of the time we call his [family member] and she will talk to him on the phone, and he will allow us to do the care. If he refuses, we back off and give him his space though, because he does have the right to refuse. LPN #3 was asked, How do you ensure that staff are providing the care that the residents need? LPN # stated, I stay on my hall. The CNA [Certified Nursing Assistant] can find me and report any refusals or concerns to me. We all work together as a team to make sure care is provided. LPN #3 was asked, Is it in the residents care plan that he refuses care? LPN #3 stated, I am pretty sure that it is, but we document any refusals anyway. LPN #3 was asked, Where is it documented in the chart when the resident refuses? LPN #3 stated, The nurse documents in the nurses notes and the aide also documents the refusal in the chart. g. On 01/11/24 at 09:55 AM, the Surveyor asked CNA #3, How much assistance does [Resident #18] require with activities of daily living? CNA #3 stated, We do everything for him. He is total care. He is on hospice services. CNA #3 was asked, Who is responsible for nail care? CNA #3 stated, The aides are unless the resident is a diabetic and then the nurse does the care. Hospice does his showers. CNA #3 was asked, How often should nail care be done? CNA #3 stated, Every day if they are nasty, but usually every other day when they are getting their shower. CNA #3 was asked, Does [Resident #18] refuse care? CNA #3 stated, He will refuse. He usually does not refuse for me, but if he does, they [aides] will tell the nurse and will try two more times. CNA #3 was asked, Do you document when the resident refuses care? CNA #3 stated, Yes. We document in the [database] so it goes into the residents record. h. On 01/11/24 10:08 AM, Resident #18's Progress Notes from 12/12/23 to 01/12/24 contained no documentation of Resident #18 refusing care. i. On 1/11/24 at 10:24 AM, Resident #18's activities of daily living care sheets provided by the Director of Nursing (DON) did not document any provision of nail care from 1/1/24 to 1/11/24 that Resident #18 refused care. j. On 01/11/24 at 02:10 PM, the DON was asked, Who is responsible for nail care? The DON stated, The CNAs on the floor unless the resident is diabetic and then the nurse should cut the nails. The DON was asked, How often should nail care be done? The DON stated, Nail care should be done on bath days and as needed. The DON was asked, What should staff do if a resident refuses nail care? The DON stated, The staff member should notify the nurse and make sure that they document it. The DON was asked, Where should the refusal be documented? The DON stated, The CNA should document the refusal where they document the ADL (care was provided. The DON was asked, Should refusal of care be documented on the residents care plan? The DON stated, Yes, it should be if it is continuous refusals of care. k. On 1/12/23 at 8:10 AM, the policy titled, Fingernails/Toenails, Care of , provided by the Assistant Director of Nursing (ADON) documented, .Purpose: The purpose of this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infect .General Guidelines: 1. Nail care includes daily cleaning and regular trimming. 2. Proper nail care can aid in the prevention of skin problems around the nail bed .

Based on interview and record review, the facility failed to ensure the comprehensive resident centered care plan for 1 (Resident #22) of 1 sampled resident addressed generalized anxiety, and major depression diagnoses and medications. The findings are: 1. Resident #22 had diagnoses of transient cerebral ischemic attack, anxiety disorder, and major depressive disorder. The Quarterly Minimum Data set (MDS) with an Assessment Reference Date (ARD) of 12/14/2023 documented a Brief Interview for Mental Status (BIMS) of 13 (13-15 indicates cognitively intact) and had received antianxiety and antidepressant medication during the 7 day lookback period. b. A Physician Order dated 08/16/2023 documented, Sertraline HCl [Hydrochloride] Oral Tablet 100 MG [milligram] .Give 1 tablet by mouth one time a day related to MAJOR DEPRESSIVE DISORDER, SINGLE EPISODE, UNSPECIFIED . c. A Physician Order Dated 06/16/2023 documented, busPIRone HCl Oral Tablet 15 MG .Give 15 mg by mouth two times a day related to GENERALIZED ANXIETY DISORDER . d. On 01/12/2023 at 09:05 AM, the Surveyor asked Licensed Practical Nurse (LPN) #2 for assistance finding antianxiety and antidepression medication interventions on Resident #22's care plan. LPN #2 said, Let's just look at the orders. [Resident #22] is on Buspar for anxiety and Sertraline for depression. The Surveyor asked for assistance finding documentation on the care plan. LPN #2 told the Surveyor that she does not use the care plan, and just goes and asks another nurse. e. On 01/12/2024 at 09:05 AM, the Surveyor asked the MDS nurse who puts in care plans and revises them. The MDS nurse said that she was responsible for care plans. The Surveyor asked for assistance finding antianxiety and antidepression medication interventions on the care plan for Resident #22. The MDS nurse said she could not find anxiety or depression on the care plan. The Surveyor asked why psychiatric diagnoses, and treatment medications are documented on the care plan. The MDS nurse said so nursing can see that Resident #22 has these diagnoses and how to care for them. The Surveyor asked if nursing is expected to use care plans, and if they are in-serviced on how to navigate the care plans. The Assistant Director of Nursing (ADON) told the Surveyor that nursing is expected to use care plans, and during orientation the nurse consultant shows them how to use care plans.

Based on observation, interview and record review, the facility failed to ensure a residents oxygen tubing was dated for 1 (Resident #10) of 4 sampled residents who required oxygen to reduce the risk of infection. The findings are: 1. Resident #10 had diagnoses of chronic obstructive pulmonary disease (COPD). The Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/25/2023, documented a Brief Interview of Mental Status (BIMS) of 15 (13-15 indicates cognitively intact). a. A Care Plan with a revision date of 03/13/2022 documented Resident #10 was to receive .OXYGEN SETTINGS: O2 [oxygen] @ [at] 2L/min [liters per minute] via nasal cannula PRN [as needed] . Physician Orders dated 10/16/23 noted Resident #10 was to have the oxygen tubing changed every Sunday on night shift and the CPAP cleaned daily on day shift. b. On 01/08/24 at 11:36 AM, Resident #10 was lying in bed with Continuous Positive Airway Pressure (CPAP) in place with 3 liters of oxygen via nasal cannula. The oxygen tubing was not dated and was sticky. c. On 01/08/24 at 02:30 AM, Resident #10 was resting with eyes closed with CPAP in place and oxygen at 3 liters per minute. The oxygen tubing not dated and sticky to the touch. d. On 01/09/2024 at 11:30 AM, Resident #10 was resting with eyes closed wearing the CPAP with oxygen at 2 liters. No date was seen on the oxygen tubing connected to the CPAP. e. On 01/10/24 at 09:45 AM, the Surveyor asked Registered Nurse (RN) #1 to check the oxygen and CPAP machine and tubing for Resident #10. Resident #10's oxygen was set at 2 liters, and the oxygen and CPAP tubing were undated. RN #1 looked and found a blue sticker dated 01/08/2023 and told the Surveyor it fell off of the oxygen tubing. RN #1 told the Surveyor there was not a date on the oxygen tubing that is connected to the CPAP. Resident #10 told RN #1 that it had been a while since the CPAP tubing was changed. f. On 01/10/24 at 02:45 PM, the Surveyor asked the Director of Nursing (DON) what procedure do you expect staff to follow for oxygen and CPAP tubing. The DON said, Tubing is to be changed once a week. The Surveyor asked why it is important to change oxygen and CPAP tubing weekly. The DON said to prevent bacteria growth. g. On 01/10/2024 at 03:28 PM, Nurse Consultant #1 provided a policy titled, Oxygen Administration, which documented, .Purpose The purpose of this procedure is to provide guidelines for safe oxygen administration . The documentation did not address dating oxygen tubing. h. On 01/11/2024 at 10:29 AM, the DON provided a policy titled, CPAP/BIPAP [Bilevel Positive Airway Pressure] Support, which documented, .7. Masks, nasal pillows and tubing: Clean daily by placing in warm, soapy water . The policy did not address labeling tubing.

Based on observation, interview and record review, the facility failed to ensure the shower door on the 400 Hall was locked and a cabinet on the 100 was locked to prevent accidental ingestion harmful chemicals contained in both areas. The findings are: 1. On 1/8/2023 at 11:00 AM, the Surveyor touched the handle to the shower door on the 400 Hall. The shower door opened. a. Upon entering the Shower Room a bottle of Ammonia Lactate 12% lotion was left in the chair by the door. b. An open bottle of (Brand) Professional Hair and Body wash was left on the floor in Shower #2. c. On 1/8/23 at 11:12 AM, Registered Nurse (RN) #2 was overheard telling a staff member the shower door was left unlocked. The Surveyor asked RN #2 what the procedure was for the shower room. RN #2 said that the door was supposed to remain locked. The Surveyor asked why do they keep the shower room locked? RN #2 said that not all residents are allowed in the shower room. The Surveyor asked are there any residents allowed in the shower room by themselves? RN #2 said that no residents were allowed in the shower room by themselves. d. On 1/10/24 at 02:45 PM, the Surveyor asked the Director of Nursing (DON) what is the policy for shower doors? The DON said the doors were to be locked. The Surveyor asked what is the reason for this? The DON said the Certified Nursing Assistants (CNA) have soaps and lotions to give residents baths in there. Residents may wander in and get them. The Surveyor asked what is to be done with the Ammonia Lactate 12% (lotion) The DON said she will find out and provide MSDS [Material Safety Data Sheet]. The Surveyor asked if the open bottle of (Brand) Body wash was to be kept on the shower floor. The DON said I doubt it is to be kept there. It is ok to keep it in the shower room as long as the doors are locked. The Surveyor asked why would you not want to keep it there? The DON said residents may wander in and think it is something to drink. e. 1/10/2023 3:35 PM, the Nurse Consultant provided a Safety Data Sheet for the Ammonium Lactate 12% Moisturizing Lotion which documented, .First Aid Measures: Skin Contact: Remove contaminated clothing and wash immediately with soap and water. Eye Contact: Rinse immediately with plenty of water and seek medical advice. Ingestion: Do not induce vomiting. If patient is conscious, give 2 glasses of water or milk. Contact a physician or poison Control Center immediately. Inhalation: Move person to fresh air. If breathing is difficult get medical attention. Important symptoms: None Special treatment: If swallowed get immediate medical attention or contact a Poison Control Center f. On 1/10/2024 at 3:28 PM, the Nurse Consultant provided a policy titled, Bath, Shower/Tub, which documented, General Guidelines .Never leave the resident unattended in the tub or shower . 48977 2. On 01/09/24 at 10:24 AM, the Surveyor observed a cabinet on the 100 Hall with an unlocked lock hanging on the handle. The Survey asked CNA #3 if she could open the unlocked cabinet. A bottle of Hydrogen Peroxide 3% was observed in the unlocked cabinet. a. On 01/09/24 at 10:24 AM, the Surveyor asked CNA #3 if Hydrogen Peroxide should be in the unlocked cabinet. CNA #3 stated, No, it shouldn't be in the cabinet. I am taking it out right now. b. On 01/10/24, at 3:38 PM, the Surveyor asked the DON if Hydrogen Peroxide should be in the unlocked cabinet on the 100 Hall? The DON was not familiar with the referenced cabinet, and accompanied the Surveyor and Nurse Consultant #1 to the 100 Hall. Upon arrival, the cabinet had an unlocked lock hanging on the handle. The Surveyor asked the DON and Nurse Consultant #1 should there be hydrogen peroxide in this cabinet? Nurse Consultant #1 stated No. The Surveyor asked the DON and Nurse Consultant #1 why should hydrogen peroxide not be in the unlocked cabinet? Nurse Consultant #1 stated, It's a hazard. The Surveyor asked who is it a possible hazard to? Nurse Consultant #1 stated To demented and confused residents. c. On 1/11/24 at10:51 AM, The DON provided a policy titled, Hazardous Areas, Devices and Equipment. The Policy Statement stated, All hazardous areas, devices, and equipment in the facility will be identified and addressed appropriately to ensure resident safety and mitigate accident hazards to the extent possible. Identification of Hazards 1. A hazard is defined as anything in the environment that has the potential to cause injury or illness. Examples of environmental hazards include, but are not limited to: d. Open areas or items that should be locked when not in use; g. Access to toxic chemicals .

Based on observation and interview, the facility failed to ensure only licensed staff had access to keys to the medication room to prevent the potential of misappropriation of resident property. This failed practice had the potential to affect all 89 residents in the facility that get medications from the medication room. The findings are: a. On [DATE] at 02:09 PM, the Surveyor asked to see the medication room. Staff at the nursing station pointed to the medication room, and Licensed Practical Nurse (LPN) #1 handed the medication room keys to Certified Nursing Assistant (CNA) #4. The Surveyors observed CNA #4 unlock the door, and stand holding the door open. The Surveyors did not enter the medication room and stood waiting for licensed staff while the door was being held open. b. On [DATE] at 02:11 PM, LPN #2 came to the medication room, and entered with the Surveyors. c. On [DATE] at 02:50 PM, the Surveyor asked the Director of Nursing (DON) if unlicensed personnel are supposed to be given keys to the medication room, and why do they not allow unlicensed personnel to have access to the medication room. The DON said that no unlicensed personnel should have keys to the medication room because there were medications in the refrigerator; over the counter medications; and expired and discontinued medications were in there as well. d. On [DATE] at 10:29 AM, the DON provided a policy titled, Storage of Medications, which documented, .Policy Statement The facility shall store all drugs and biologicals in a safe, secure, and orderly manner .10. Only persons authorized to prepare and administer medications shall have access to the medication room including any keys .

Based on record review and interview, the facility failed to coordinate with the State Agency for a Pre-Admission Screening and Resident Review (PASARR) to ensure the resident received appropriate mental health services for 2 (Residents #59 and #40) of 2 sampled residents. The findings are: 1. Resident #59 had a diagnosis of Schizophrenia and was taking the medication Olanzapine 2.5 milligrams twice a day for psychotic disorder. The Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/16/23 documented Resident #59 had a Brief Interview for Mental Status (BIMS) of 13 (13-15 indicates cognitively intact) and had diagnosis of schizophrenia, and was not considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition. a. On 1/10/24 at 8:45 AM, the Surveyor requested Resident #59's PASARR. b. On 1/10/24 at 9:15 AM, the Administrator provided the Surveyor with the following forms: i) Arkansas Department of Health and Human Services Evaluation of Medical Need Criteria (703), submitted in October 2022. ii) Arkansas Department of Health and Human Services Division of Medical Services Dementia Diagnosis Substantiation (780), submitted in October 2022. iii) Arkansas Department of Health and Human Services Division of Medical Services pre-admission screening (787), submitted in October 2022 2. Resident #40 had a diagnosis of schizoaffective and was taking Citalopram Hydrobromide for anxiety. The Annual MDS with an ARD of 02/22/23 documented Resident #40 had a BIMS of 15 (13-15 indicates cognitively intact) and was not considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition. a. On 1/10/24 at 8:45 AM, the Surveyor requested an Arkansas Department of Health and Human Services Division of Medical Services pre-admission screening (787). b. On 1/10/24 at 2:15 PM, the Administrator provided the following forms: i) Arkansas Department of Health and Human Services Evaluation of Medical Need Criteria (703), submitted in February 2022. ii) Arkansas Department of Health and Human Services Division of Medical Services Dementia Diagnosis Substantiation (780), submitted in February 2022. iii) Arkansas Department of Health and Human Services Division of Medical Services pre-admission screening (787), submitted in February 2022. c. On 1/10/24 at 10:30 AM, the Surveyor requested documentation of the response from the state designated authority for Resident 59's PASARR from October of 2022 and Resident #40's level II screening. Nurse Consultant #1 stated, I keep a binder for PASARR, but I do not have the response for those two residents. I remember when the level II was done. Nurse Consultant #1 was asked to pull up Resident #59's Annual MDS and go to section A 1500. What is documented? Nurse Consultant #1 said no. The Surveyor asked what should be documented? Nurse Consultant #1 stated, Yes. d. On 1/10/24 at 3:30 PM, the Surveyor asked the Director of Nursing (DON) who was responsible for the PASSAR? The DON stated, MDS Coordinator, but she is out. The Surveyor asked the DON without the response for the PASSAR, how can you incorporate any recommendation into the Resident's care? The DON opted to get Nurse Consultant #2. Nurse Consultant #2 gave the DON the detailed in-service on PASSAR mentioning the (State Designated Professional Associates) may suggest recommendation for care and/or therapy. The Surveyor asked the DON without the response from the state-designated authority how can the facility incorporate any possible recommendations into the resident's care? Nurse Consultant #2 stated to the DON, She wants you to say you can't because we can't. e. On 1/10/24 at 4:00 PM, a policy titled, Admission Criteria, revised March 2019, provided by the DON, documented, .9. All new admission and readmission are screened for mental disorders (MD), intellectual disabilities (ID) or related disorders (RD) per the Medicaid Pre-Admission Screening and Resident Review (PASARR) process. A. The facility conducts a Level I PASARR screen for all potential admission, regardless of payer source, to determine if the individual meets the criteria for MD, ID, or RD. B. If the level I screen indicates that the individual may meet the criteria for a MD, ID, or RD, he or she is referred to the state PASARR representative for the level II (evaluation and determination) screening process. (1) The admitting nurse notifies the social service department when a resident is identified as having a possible (or evident) MD, ID, or RD. (2) The social worker is responsible for making referrals to the appropriate state designated authority. C. Upon completion of the level II evaluation, the state PASARR representative determines if the individual has a physical or mental condition, what specialized or rehabilitative services he or she needs, and whether placement in facility is appropriate. D. The state PASARR representative provides a copy of the report to the facility. E. The interdisciplinary team determines whether the facility is capable of meeting the needs and services of the potential resident that are outlined in the evaluation. F. Once a decision is made, the state PASARR representative, the potential resident and his or her representative are notified .

Based on record review and interview, the facility failed to ensure the plan of care was reviewed and revised to address tube feedings for 1 (Resident 43) of 1 sampled resident who had a physician's order for tube feedings. The findings are: 1. Resident #43 had a diagnosis of Alzheimer's Dementia, Malnutrition, and Dysphagia. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/22/23 documented the resident scored 2 (0-7 indicates severe cognitive impairment) on a Brief Interview for Mental Status (BIMS), and received a mechanically altered diet and had a feeding tube. a. A Physician's Order dated 8/23/23 documented, .Enteral Feed: in the afternoon [Nutritional Supplement] 1.5 Cal 237 cc [cubic centimeters] with 60cc H2O [Water] flush before and after . b. The Care Plan with a revision date of 07/28/23 did not address the Resident #43 received tube feedings. c. On 01/11/24 at 2:15PM, the MDS Coordinator was asked, Does [Resident #43] have a feeding tube? The MDS Coordinator stated, Yes. The MDS Coordinator was asked, Does [Resident #43's] care plan address the that she has a feeding tube? The MDS Coordinator stated, I will have to look in her record and see. She had the tube feeding prior to my coming to work at the facility. The MDS Coordinator looked in the electronic record and stated, The care plan talks about talking to family about tube feeding placement, but it does not address that she has a feeding tube. The MDS Coordinator was asked, Should the care plan address the fact that the resident has a feeding tube? The MDS Coordinator stated, Yes. It should. The MDS Coordinator was asked, Why is it important that the care plan addresses that the resident has a feeding tube? The MDS Coordinator stated, It is important so that everyone knows how to take care of the feeding tube. d. On 01/12/2024 at 8:10 AM, the policy titled, Care Plan, Comprehensive Person-Centered, provided by the Assistant Director of Nursing (ADON) documented, .Policy Statement: A Comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical. psychosocial and functional needs is developed and implemented for each resident .8. The comprehensive, person-centered care plan will: .b. Describe the services that are to be furnished to attain or maintain the residents highest practicable physical, mental and psychosocial well-being .

Based on observation, record review and interview, the facility failed to ensure Intravenous (IV) tubing was dated and ports were capped for 1 (Resident #3) sample mix resident to prevent microbial growth and infectious organisms from entering the ports, and that linen carts were kept closed and lift slings and sheets were not stored on top of the cart to prevent cross contamination of the clean linen carts on 200 Hallways. 1. Resident #3 was admitted on [DATE] with a diagnosis of Diabetes Mellitus with Complications. The Nursing Admit/ Readmit Assessment with an effective date of 02/04/23 documented the residents' orientation to person, place, time, and situation. a. The Physician Orders dated 02/23/2023 documented, . Ceftazidime Intravenous Solution Reconstituted 1 GM [gram] (Ceftazidime) Use 1 gram intravenously every 8 hours for infection/post-surgical amputation for 113 Administrations Start Date 02/23/2023 . b. Resident #3's full Care Plan not due until 03/01/23. c. On 02/27/23 at 09:50 AM, the Surveyor made observations on the two hundred (200) hallway and a clean linen cart on the hallway was open and lift slings and sheets were sitting on top of the clean linen cart. d. On 02/27/23 at 09:52 AM, the Surveyor asked the Director of Nursing (DON) on the two hundred (200) hallway, should the clean linen cart be open? She stated, no, it shouldn't. The Surveyor asked, should lift pads and sheets be sitting on top of the clean linen cart? She stated, no, they shouldn't be. The Surveyor asked, why should the linen cart be kept closed with no linens, or lift pads on top of it? She stated, for contamination reasons. e. On 02/27/23 at 09:53 AM in Resident #3's room, the Intravenous Tubing (IV) connected to IV antibiotic Ceftazidime 1 GM was reconstituted. IV tubing was not dated, and IV port ends were not capped. Old IV antibiotic bag and tubing were lying on the residents' table. f. On 02/27/23 at 10:45 AM, the Surveyor asked the DON, should IV tubing be dated? She stated, yes. The Surveyor asked, why? She stated, to show the date it was used. The Surveyor asked, should the IV port ends be capped? She stated, yes. The Surveyor asked, why should they be capped? She stated, for infection control. The Surveyor asked, should old IV antibiotic with old tubing attached be lying on the residents' table in his room? She stated, no, it should've been pulled. The Surveyor asked, why? She stated, because it is an old used medication. g. The facility policy titled, Infection Control provided by the Administrator on 02/28/23 at 10:59 AM documented, . Policy Statement . This facility's infection control policies and practices are intended to facilitate maintaining a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections The objectives of our infection control policies and practices are to: . maintain a safe, sanitary, and comfortable environment . All personnel will be trained on our infection control policies and practices upon hire and periodically thereafter . h. The facility policy titled, Administration Set/Tubing Changes provided by the Administrator on 02/28/23 at 10:59 AM documented, . The purpose of this procedure is to provide guidelines for aseptic administration set changes to prevent infections associated with contaminated IV therapy equipment . Label new tubing with date, time, and initials. If facility requires, label may include the date and time that tubing was initialed and when tubing should be discontinued . All IV equipment, including administration sets, shall be managed using aseptic technique and observing standard precautions . All tubing is labeled with start and change date and time. Any tubing that is observed not to have a label must be changed and then labeled accordingly . Primary tubing should have a sterile end cap applied to end of tubing when it is disconnected from the catheter . Label administration set and tubing with date, time, and initials .

Based on observation, record review, and interview, the facility failed to ensure residents' adult briefs were changed when wet to promote good personal hygiene and prevent skin breakdown for 1 (Resident #3) of 2 (Resident #1, and R #3) sample mix residents who were dependent for pericare. The findings are: 1. Resident #3 was admitted on [DATE] with a diagnosis of Diabetes Mellitus with Complications. The Nursing Admit/ Readmit Assessment with an effective date of 02/04/2023 documented the residents' orientation to person, place, time, and situation. a. The Plan of Care dated 02/27/23 documented, . The resident has (specify: Urge, Stress, Functional, Mixed) bladder incontinence r/t [related to] Change resident Q2 [every 2 hours] and as needed peri-area with each incontinence episode. Encourage fluids during the day to promote prompted voiding responses . b. On 02/27/2023 at 09:53 AM, resident #3 sat in the doorway of his room, his brief was full of urine. Resident #3 stated to the Director of Nursing (DON), hey can you get someone to come down here and change me I'm wet, and I've been waiting about forty-five minutes and can't get an assistant to help me. The DON stated, hold on, we will get someone down here right away to come help you. c. On 02/27/23 at 10:16 AM, Certified Nursing Assistant (CNA) #1 went to Resident #3's room with a Physical Therapist to transfer the resident back to bed with a Hoyer lift. CNA #1 stated, I'll be right back I have to go get someone to help me change you. d. On 02/27/23 at 10:25 AM, CNA #1 and Licensed Practical Nurse (LPN) #1 changed Resident #3 and performed peri care on him. e. On 02/27/23 at 10:41 AM, the Surveyor asked LPN #1, how long does it for you to assist a wet resident to be changed? She stated, I don't change the residents the assistants do. The Surveyor asked, should a resident wait forty-five minutes for someone to help him, then be told someone will be right there to help them, and still wait another thirty minutes before care can be performed? She stated, no, but I think he was only waiting a few minutes. f. On 02/27/23 at 10:43 AM, the Surveyor asked CNA #1, how long does it take for you to assist a wet resident to be changed? She stated, usually 3-5 minutes. The Surveyor asked, are you aware the resident stated he was waiting for forty-five minutes to the Director of Nursing (DON), and then proceeded to wait approximately 30 more minutes until you were able to change him? She stated, no, I was giving another resident a shower when they asked me to come here and change him. The Surveyor asked, should a resident wait forty-five minutes for someone to help him, then be told someone will be right there to help them, and still wait another thirty minutes before care can be performed? She stated, no, ma'am. g. On 02/27/23 at 10: 51 AM, the Surveyor asked the DON, how long should it take staff to change a resident who is wet? She stated, we had to send an Assistant on that hallway home this morning over an allegation of abuse, but generally ask quick as we possibly can. Depending on time and if we are in the middle of meal service. The Surveyor asked, how long should it take to change the resident? She stated, it should be within ten minutes. The Surveyor asked, is it acceptable when a resident states to you they have been trying to get an assistant to assist them for forty-five minutes and you tell them you will get someone right away to come help and the resident ends up waiting another thirty minutes until staff come to the room to change them? She stated, no, but we did have to send a CNA home. h. The facility policy titled, Activities of Daily Living (ADLs), Supporting provided by the Administrator on 02/28/2023 at 10:59 AM documented, Policy Statement . Residents will provided with care, treatment and services as appropriate to maintain or improve their ability to carry out ADLs . Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal an oral hygiene . Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support with assistance with: . Elimination (toileting) .

Based on observation, interview, and record review, the facility failed to ensure wound care was provided for 1 (Resident #3) of 3 (Residents #1, #2 and #3) sampled residents who had a wound to prevent the potential for infection and failed to ensure weekly skin assessments were completed for 1 (Resident #3) of 3 (Residents #1, #2 and #3) sampled residents who required weekly skin assessments. The findings are: Resident #3 had diagnoses of Type 2 Diabetes Mellitus with Diabetic Nephropathy, Paralytic Syndrome and Other Abnormalities of Gait and Mobility. The Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/11/2022 documented the resident scored 15 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status (BIMS) and required extensive physical assistance of two plus persons for personal hygiene, transfers, and bed mobility. a. The Baseline Care Plan with a completion date of 12/15/22 documented, .Monitor/document location, size and treatment of skin injury. Report abnormalities, failure to heal, s/sx [signs and/or symptoms] of infection, maceration etc. [etcetera] to MD [Medical Doctor] . b. The Physicians Order dated 12/22/22 documented, .Paint friction rub/abrasion on right thigh with Betadine and leave open to air daily and as needed . c. The last Skin Assessment documented in the electronic record for Resident #3 was dated 07/11/22. d. On 12/19/22 at 3:45 PM, Resident #3 was in his room with his eyes closed. He had on shorts. Above his right knee was a cluster of blisters approximately 3 1/2 inches long. Redness was observed around the blisters, and the area was wet. e. On 12/20/22 at 10:45 AM, the Surveyor asked Resident #3, Do you have any pressure ulcers, or open sores? He stated, Right leg above knee has bruise. The Surveyor asked, How did you get the bruise on your leg? He stated, I rubbed it on the exercising machine in therapy. It happened two weeks ago. She put some cream and a bandage on it this morning. The Surveyor asked, How often do the staff help you with your care? He stated, They don't come in unless you ring for them. f. On 12/20/22 at 11:12 AM, the Surveyor asked the Director of Rehab, How did [Resident #3] burn his right leg? He stated, He was in a wheelchair on the exercising bike, and I didn't realize his leg was sticking out. It's a friction rub. The Surveyor asked, When did it happen? He stated, 12/14. The Surveyor asked, Did you complete an incident report? He stated, Yes, the [Director of Nursing (DON)] should have it. I have a copy of the witness statement on my desk. g. On 12/20/22 at 12:30 AM, the Surveyor asked Licensed Practical Nurse (LPN) #1, Does he have any pressure ulcers, or open sores? She stated, Not that I'm aware of. The Surveyor asked, How did [Resident #3] get the burn area on his right leg? She stated, I'm not sure, but the DON put a dressing on there this morning, but he pulled it off. The Surveyor asked, When was the last time [Resident #3] had a skin assessment? She stated, I don't know, but I can check and find out. The Surveyor asked, What kind of treatment were you doing to the burn on his right leg before I entered the facility on yesterday? She stated, I don't know. I haven't worked over there in months. The Surveyor asked, Who's responsible for doing the skin assessments? She stated, The nurses. h. On 12/20/22 at 3:07 PM, the Surveyor asked LPN #2, How did [Resident #3] get the burn area on his right leg? She stated, I don't know. The Surveyor asked, What kind of treatment were you doing to the burn on his right leg before I entered the facility on yesterday? She stated, Don't know. The Surveyor asked, Who's responsible for doing the skin assessments? She stated, Usually the treatment nurse would, but we're doing our own as far as I know. I think the DON is doing them, otherwise she would let us know. The Surveyor asked, When was the last time [Resident #3] had a skin assessment? She stated, I have no idea. i. On 12/21/22 at 1:05 PM, the Surveyor asked the DON, How did [Resident #3] get the burn area on his right leg? She stated, On the 15th, I was making rounds and I asked him what happened. He stated, 'I was in therapy and my leg leaned over and it did a friction rub.' I said in the morning meeting that he had an abrasion on his leg. The Director of Rehab said it was just red. When I saw it, the scab had started, [Resident #3] told me what happened and I told the Director of Rehab to get me a witness statement. We were just watching it. He asked me to come to his room yesterday and to look at his leg. I told him I was going to put a dressing on it and he let me put it on him. The Surveyor asked, Do you know why the nurses weren't aware that he had the burn to his right leg? She stated, I don't know. The Surveyor asked, What kind of treatment were you doing to the burn on his right leg before I entered the facility on Monday? She stated, We were not treating it we were just monitoring it. The Surveyor asked, Who's responsible for doing the skin assessments? She stated, The floor nurses in the absence of the treatment nurse. The Surveyor asked, How long has the facility been without a treatment nurse? She stated, She left I think the end of October. The Surveyor asked, How often should the skin assessments be completed? She stated, Weekly. The Surveyor asked, Why was a skin assessment not completed for [Resident #3] when he received the burns to his legs? She stated, In the I&A [Incident and Accident report] I referenced the area.

Based on observation and interview, the facility failed to ensure the environment was maintained in a safe condition for residents on the Secured Unit. This affected all 27 residents on the unit according to the Daily Census provided by the Administrator on 10/24/22. The findings are: 1. On 10/24/22 from 10:43 AM until 11:30 AM, during rounds on the unit, numerous chemicals were left in every resident's bathroom including but not limited to: (Germicidal Disposable) wipes, Perineal wash, skin lotion, and hair conditioner. 2. On 10/24/22 at 10:45 AM, the Surveyor asked the Social Director, Should these be in out in the bathrooms for the resident's to possibly get into? She stated, No, I'll take care of it. 3. On 10/28/22 at 11:04 AM, the Surveyor asked the Administrator for a policy regarding the storage of chemicals in the facility. She stated, We don't have one.

Based on observation, interview, and record review, the facility failed to ensure residents were free from physical restraints as evidenced by the wheels of the Dyn-Ergo chair being double locked while sitting in the Dayroom and/or Dining Room with a lap top tray attached for 1 (Resident #46) of 1 sampled resident who had a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The findings are: 1. Resident #46 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/26/22 documented the resident scored 0 (0-7 indicates severely cognitively impaired) on a Brief Interview of Mental Status (BIMS) and has 2 or more falls since admission and required a physical restraint daily when in chair of out of bed. a. The Care Plan with a revision date of 09/12/22 documented, .The resident is Moderate risk for falls r/t [related to] Gait/balance problems .Anticipate and meet the resident's needs . The Care Plan does not address the Dyn-Ergo and lap tray or interventions when in the chair. b. The Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Release Q [every] 2 hours for 15 minutes to perform range of motion, activities of daily living (ADLs), etc. [etcetera] Table top tray with strap while in wheelchair for repeated attempts to rise unattended. Release every 2 hours for 15 minutes and as needed to perform ROM [range of motion], repositioning and ADLs . c. On 10/24/22 at 11:38 AM, Resident #46 was sitting in her Dyn-Ergo chair with a lap tray attached to the chair. d. On 10/24/22 at 3:30 PM, Resident #46 was still sitting in her Dyn-Ergo chair with a lap tray attached to the chair. e. On 10/25/22 at 7:45 AM, Resident #46 was in the Dining Room sitting in her Dyn-Ergo chair with a lap tray attached. f. On 10/25/22 at 8:30 AM, Resident #46 was sitting in her Dyn-Ergo chair in the Day Room in front of the TV with a tray on the chair and the wheels of the chair were locked. g. On 10/25/22 at 9:35 AM, 10:30 AM, 11:15 AM, 11:40 AM Resident #46 was sitting in her Dyn-Ergo chair in the Day Room in front of the TV with the tray on the chair and the wheels of the chair were locked. h. On 10/25/22 at 11:45 AM, Resident #46 was pushed into the Dining Room with the tray on her chair. i. On 10/25/22 at 12:30 PM, Resident #46 was in the Dining Room with the tray on her Dyn-Ergo chair. j. On 10/25/22 at 1:10 PM, Resident #46 was being fed lunch sitting in her Dyn-Ergo chair with the tray attached. k. On 10/25/22 at 1:45 PM, Resident #46 was still in the Dining Room sitting in her Dyn-Ergo chair with the tray attached. l. On 10/25/22 at 2:10 PM, 2:45 PM and 3:30 PM, Resident #46 was in the Day Room sitting in her Dyn-Ergo chair with the tray attached. m. On 10/26/22 at 7:45AM, Resident #46 was in the Dining Room being fed with the tray attached to her Dyn-Ergo chair. n. On 10/26/22 at 8:15AM, Resident #46 was moved to the Day Room with the tray still attached to her Dyn-Ergo chair and the wheels locked. o. On 10/26/22 at 8:30 AM and 9:00 AM, Resident #46 remained in the Day Room in front of the TV, in her Dyn-Ergo chair with the tray still attached. p. On 10/26/22 at 9:10AM, Resident #46 was moved to her room in her Dyn-Ergo chair with the tray attached. q. On 10/26/22 at 12:35 PM, Resident #46 was taken to the Dining Room in her Dyn-Ergo chair with the tray attached to be fed lunch. r. On 10/26/22 at 1:30 PM, Resident #46 was still at the Dining Room in her Dyn-Ergo chair with tray attached. s. On 10/26/22 at 1:50 PM, Resident #46 was taken to her room and was sitting in the doorway in her Dyn-Ergo chair with the tray attached with her feet on the door. t. On 10/27/22 at 8:16 AM, Resident #46 was sitting in her Dyn-Ergo chair in the Day Room with the lap tray attached and the wheels locked. u. On 10/27/22 at 8:35 AM, 9:05 AM, 9:15 AM, 9:30 AM, 9:45 AM, 10:00 AM and 10:45 AM, Resident #46 was sitting in the Day Room in her Dyn-Ergo chair with the tray on her wheelchair and the chair locked. v. On 10/27/22 at 10:15 AM, the Surveyor asked CNA #6, Why is the device on [Resident #46] being used? CNA #6 stated, She falls a lot. The Surveyor asked, Have you been trained on a lap tray? She stated, No, just keep it on her as long as she's up by maintenance and a nurse. The Surveyor asked, What is the rationale in using this device? She stated, She may fall. The Surveyor asked, How often do you remove this device? She stated, Don't know. The Surveyor asked, Should the chair that rolls ever be locked when a resident is in it? She stated, No w. On 10/27/22 at 10:35 AM, the Surveyor asked Licensed Practical Nurse (LPN) #2, How do you supervise staff to ensure the lap tray is being released as ordered? She stated, I monitor her. The Surveyor asked, I noticed you document every two hours that she is being released and exercised. Have you monitored her today to ensure its being done? She stated, Today I haven't. The Surveyor asked, Should the chair that rolls ever be locked when a resident is in it? She stated, No. x. On 10/27/22 at 10:45 AM, the Surveyor asked the Director of Nursing (DON), Should the chair that rolls ever be locked when a resident is in it? She stated, No The Surveyor asked, How often should a resident be released from a restraint and checked? The DON stated, Every 2 hours. The Surveyor asked, What is the plan for reducing this restraint? She stated, I'll be right back, I'm new. The DON returned in 15 minutes and stated, On 12/21/22, we will look during our quarterly meeting. y. On 10/27/22 at 10:56 AM, Certified Nursing Assistant (CNA) #5 came to Dayroom, proceeded to [Resident #46], and unlocked the breaks on the Dyn-Ergo chair. The Surveyor asked CNA #5, What did you just do? She stated, I unlocked her breaks. The Surveyor asked, Should they have been locked? She stated, No. The Surveyor asked, What are your job duties? She replied, I'm the Staffing Coordinator. The Surveyor asked, Are you a LPN or a CNA? She replied, CNA. The Surveyor asked, Why were you coming to get [Resident #46]? She replied, Because I know she probably needed changed. The Surveyor asked, Why do you think she needed changed? She replied, Because she's been out here since she was gotten up before breakfast.

Based on observation, record review, and interview, the facility failed to ensure there were two staff members present to assist with bed mobility for 1 (Resident #4) of 1 resident who required 2-person assistance with care to prevent potential accidents and or injuries. This failed practice resulted in actual harm for Resident #4 who fell out of bed and sustained a fractured left tibia and fibula and had the potential to cause more than minimal harm to 5 residents who required 2 people for bed mobility according to a list provided by the Administrator on 2/24/22 at 11:30 AM. The findings are: Resident #4 diagnoses of [CONDITION(S)] of Right and Left Lower Legs, Morbid (Severe) Obesity, Body Mass Index (BMI) 70 or Greater, Need for Assistance with Personal Care, and Muscle Wasting Atrophy. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/31/21 documented that the resident scored 15 (13-15 indicates cognitively intact) on the Brief Interview for Mental Status and required extensive assistance of two plus people for bed mobility, transfer, toileting, and personal hygiene. a. The Care Plan documented, Focus [Resident #4] has an ADL [activity of daily living] self-care performance deficit r/t [related to] morbid obesity and weakness. Date Initiated: 09/27/2021 Date Initiated: 01/24/2022. The Care Plan did not document how much assistance the resident needed with turning and repositioning. b. The form titled, Closet Care Plan with an updated date of 12/15/2021 for Resident #4, documented, . ADL (Activity of Daily Living) CARE/ASSISTANCE . Turning and Repositioning . Bed: Assist x 2 . c. A Nursing I&A (Incident and Accident) Note in the electronic record dated 2/10/22 at 8:00 AM documented, . Therapy report to writer that resident was in the floor. Upon entering room, resident noted to be lying in the floor alongside bed with feet at head of bed and head at foot of bed. CNA [Certified Nursing Assistant] on site holding resident head off the floor with pillow for comfort. CNA report that while changing resident, resident lost balance while on side, started to roll out of the bed and CNA was unable to stop resident from rolling. CNA report resident had fallen and become wedged between bed and wheelchair in a standing position, CNA assisted resident from this position to the floor. Resident did not hit head. Resident complaining of pain to left leg from the knee down. DON (Director of Nursing, ADON (Assistant Director of Nursing), APRN (Advanced Practice Registered Nurse) All on site. Other nurse on site contacted ambulance with need of emergency transport to hospital and need for additional assist from floor by other crew. Nurse also called resident emergency contact and printed paperwork. Writer assisted by ADON and CNA cleaned resident of bowel and placed 2 bath blankets under resident at this time. While assisting resident with rolling while on floor to clean bowel, resident left ankle noted to be limp, resident was able to move toes, resident noted with swelling and bruising to affected area. Ambulance arrived on site with another crew for lift assist. Resident lifted from floor by 3 nursing home staff and 4 ambulance staff by bath blanket from floor to stretcher. Report given to ambulance crew. Resident left facility via stretcher to [Memorial Hospital] ER (emergency room ). d. Hot Rack Charting Note in the electronic record dated 2/10/2022 at 16:20 documented, .Is alert and oriented, Resident also with broken ankle - To See [Physician] at [Name of Clinic] on Monday for eval [evaluation] for tx [treatment] . e. On 02/22/22 at 9:55 AM, Resident #4 was lying in a bariatric bed (supports increased weight) watching television. The resident was asked, Do you have any concerns? She stated, I recently fell out of bed and broke my ankle. It happened because staff were not following the doctor's orders. She was asked, What happened that resulted in you falling? She stated, An aide was changing me by himself. There are supposed to be two aides at all times. The doctor's order is for two, so they were not following orders. My legs fell off the bed and this caused the fall. I ended up going to the hospital. They did x-rays and put on a splint for 4 days. I then went to an orthopedic doctor, and he put on a cast. The resident had a below knee cast on the left leg. The resident stated, I have to go back to the doctor, and they may have to put in rods. f. On 2/23/22 at 1:55 PM, CNA #1 was asked, How many aides usually work on 200 hall on the day shift? CNA #1 stated, Usually 2 aides. CNA #1 was asked, Are you familiar with caring for [Resident #4]? CNA #1 stated, Yes, I am familiar with her care. CNA #1 was asked, How much assistance does [Resident #4] need with her ADL's [Activities of Daily Living]? CNA #1 stated, She needs a lot of help with her ADL's. She can feed herself. She can wash her face and some of her upper body, but we have to do the rest. CNA #1 was asked, How many people are needed for bed mobility? CNA #1 stated, It takes 2 people now. CNA #1 was asked, Why do you say it takes two people now, when did that change? CNA #1 stated, About 2 weeks ago she used to roll and hold herself really well, but then she got weak. It's better to have two people now since she got weak. CNA #1 was asked, How do you know how much assistance with ADL's the resident needs? CNA #1 stated, The residents' have a closet care plan that tells us how much help they need. CNA #1 was asked, Does [Resident #4] get up out of bed? CNA #1 stated, She used to get up, but getting up began to cause too much pressure on her legs when she was sitting in the wheelchair. She was too uncomfortable, so she really doesn't get up anymore. CNA #1 was asked, When [Resident #4] got up in a wheelchair, how did staff get her up? CNA #1 stated, Ever since she came to the facility, we have used a lift to get her up. g. On 2/23/22 at 2:05 PM, the surveyor went into Resident #4's room and asked, Can I look in your closet for your closet care plan? She stated, Yes. You can look, but there is not one in there. There was one in there until December [2021], but there has not been one there since then. The surveyor looked in both closets in the resident's room and there was no closet care plan in either closet. The resident was asked, Do you remember when in December you saw the care plan? Resident #4 stated, I do not remember exactly, I just remember there was one until December. h. On 2/23/22 at 2:25 PM, Licensed Practical Nurse (LPN) #1 was asked, How much assistance with ADL's does [Resident #4] need? LPN #1 stated, She can feed herself. She can wash her upper body and face and arms. She is dependent for transfer with a lift. LPN #1 was asked, Can [Resident #4] move in the bed? LPN # 1 stated, She can, but she has to have assistance to move her legs. LPN #1 was asked, How many people does it take for bed mobility? LPN #1 stated, Two people. LPN #1 was asked, How long has she required two people for bed mobility? LPN #1 stated, Since I've worked here, it has been two people. LPN #1 was asked, Does [Resident #4] get up in a wheelchair? LPN #1 stated, It is very rare because it is very uncomfortable for her to get up. LPN #1 was asked, Were you working the day [Resident #4] fell ? LPN #1 stated, Yes I was working, but I was not in the room when it happened. A CNA was helping her change. LPN #1 was asked, Who was the CNA? LPN stated, The CNA was [CNA #2]. LPN #1 was asked, Can you tell me what happened that resulted in the fall? LPN #1 stated the CNA was rolling her to change her brief and her Chux pad. Her legs continued to roll and neither the aide nor [Resident #4] could stop the legs from rolling. [Resident #4] was standing in upright position [CNA #2] assisted her to the ground. I was notified and we went from there. LPN #1 was asked, Was there another aide in the room assisting with the care? LPN #1 stated, Not that I am aware of. LPN #1 was asked, Did [Resident #4] appear to be hurt? LPN #1 stated, She was complaining of pain in the left leg below the knee. There was bruising and swelling. I called the Nurse Practitioner, and she was sent to the hospital. The resident did say that when [CNA #2] was helping her to the ground, she heard a pop on her left side. LPN #1 was asked, Did the resident stay at the hospital? LPN #1 stated, She went to [Hospital] and came back. She came back on my shift. She went out at 2:30 PM she came back at 6:56 PM. LPN #1 was asked, What did they do for [Resident #4] at the hospital? LPN #1 stated, They did x-rays. She came back with a brace and suspected fracture. She had a follow up appointment with an orthopedic doctor. She went to the doctor and the leg was put in a cast. She has another appointment with the orthopedic doctor. LPN #1 was asked, Had [Resident #4] ever fallen before? LPN #1 stated, Not that I am aware of. LPN #1 was asked, How do the CNAs know how much assistance the resident need with care? LPN #1 stated, From the closet care plan and from report from the staff from the previous shift. LPN #1 was asked, Who is responsible for doing the closet care plans? LPN #1 stated, I believe Social Services, is. LPN #1 was asked, Is she a nurse? LPN #1 stated, No she is a CNA. i. The Nursing follow-up note dated 2/23/22 documented, .resident rolled out of bed during peri-care resulting in l [left] tib [tibia]/fib fibula] fx [fracture] ortho [Orthopedic] follow up scheduled per ER [emergency room ] visit. Cast applied at ortho appointment with follow-up scheduled. Long Term Intervention: Staff to ensure 2 staff members provide peri-care/turning in bed . j. On 2/24/22 at 3:15 PM, CNA #2 was contacted via telephone and was asked, Have you provided care to [Resident #4]? CNA #2 stated, Yes. CNA #2 was asked, How much assistance with ADL's does [Resident #4] require? CNA #2 stated, She is extensive assistance of two people. CNA #2 was asked, Has she always been extensive assistance of two people? CNA #2 stated, Yes. CNA #2 was asked, How do you know how much assistance the resident need with ADL's? CNA #2 stated, It is on the closet care plan. We can also look in the chart. CNA #2 was asked, Did they instruct you when you were first hired that you would find the information about how much assistance with care a resident will need on the closet care plan? CNA #2 stated, Yes. CNA #2 was asked, Can you tell me what happened the day [Resident #4] fell ? CNA #2 stated, Due to her weight and when she adjusted in the bed her legs went over the side of the bed. She is on a Bariatric bed and there is no siderail on the bed, just a handle at the head of the bed. CNA #2 was asked, Which way was [Resident #4] turning? CNA #4 stated, She was turning to the left side of the bed. CNA #2 was asked, What side of the bed were you on? CNA #2 stated, I was on the right side of the bed performing peri-care. CNA #2 was asked, Could you reach the resident's legs when they started to fall off the bed? CNA #2 stated, No. CNA #2 was asked, What did you do when you could not reach her legs? CNA #2 stated, I went to the other side of the bed. Her legs were off the bed up to her upper thighs. I tried to catch her legs, but I was unable to. She had turned almost 180 degrees. I reached under her arms and tried to position her on her back on the floor. CNA #2 was asked, Did she complain of anything hurting? CNA #2 stated, She said her legs hurt. They were touching the floor and her back was in the middle of the bed and she was sliding out. CNA #2 was asked, When you assisted the resident to the floor what position was she in? CNA #2 stated, She ended up with her head at the bottom of the bed. CNA #2 was asked, What did you do once she was on the floor? CNA #2 stated, Once I got her to the ground, I went to the door and asked someone to get the nurse. The nurse then notified the DON [Director of Nursing] and EMS [Emergency Medical Services]. CNA #2 was asked, Was anyone with you at the time this happened? CNA #2 stated, No not with peri-care. CNA #2 was asked, Should someone else have been with you to assist? CNA #2 stated, Peri-care was not normally a problem. She was extensive assist of one person for peri-care. CNA #2 was asked, Do you know what the closet care plan said at that time about bed mobility for the resident? CNA #2 stated, I am not certain what it said as of that day. CNA #2 was asked, Had you done peri-care by yourself on [Resident #4] before that day? CNA #2 stated, Yes. CNA #2 was asked, Had her legs ever gone out of the bed before? CNA #2 stated, No. Never before. k. On 2/23/22 at 3:50 PM, the Minimum Data Set (MDS) Coordinator was asked, Did you update [Resident #4] care plan after she fell ? She stated, Yes I did update the care plan that she had fallen. She was asked, How much assistance does [Resident #4] need with bed mobility? She stated, She is totally dependent of two people. She was asked, When you were a floor nurse, how much assistance did she need with bed mobility? She stated, I want to say she was one person assist, occasionally two person assist. She was asked, Is there a way to see on her care plan any previous entries to do with the amount of care she needed? She stated, You can use the filter and it will show what has been resolved. The filter was used on [Resident #4] electronic medical record to show care plan entries prior to 2/10/22. The MDS Coordinator was told that bed mobility was not addressed on the care plan. The MDS Coordinator did not comment. She was asked, Where do you get your information to update the care plan? The MDS Coordinator stated, I get the information from the initial nursing assessment, the quarterly assessments, and the weekly nursing assessments and other information from the chart. The MDS Coordinator was asked, How do the aides know how much assistance the resident need with ADL's? She stated, They find out from the closet care plan, and they can ask the nurses. She was asked, Who makes out the closet care plan? She stated, The ADON, does I believe. l. On 2/23/22 at 4:08 PM, the Assistant Director of Nursing (ADON) was asked, Do you keep a record of the closet care plans? The ADON stated, Yes we sure do. The ADON handed the surveyor a binder title Evergreen Living Closet Care Plans. The ADON was asked, Who makes the closet care plans? The ADON stated, I do. The ADON was asked, Where do you get the information for the care plan? The ADON stated, I go through the resident's information in the computer and get it from there. I update the care plans as needed. m. On 2/23/22 at 4:15 PM, the Director of Nursing (DON) was asked, Who does the follow up the Incidents and Accidents? The DON stated, I do. The DON was asked, Can you tell me what happened when [Resident #4] fell ? The DON stated, I was called to the room when it happened. The resident rolled a little too far and went out of the bed. The DON was asked, How many people were assisting [Resident #4] when it happened? The DON stated, I do not know. The DON was asked, When you did the follow up, did you ask how many people were assisting the resident? The DON stated, I know [CNA #2] was in the room for sure. The DON was asked, How many people did it require for bed mobility for [Resident #4]? The DON stated, One to two. The DON was asked, How do the aides know how many staff are needed to assist with ADL's? The DON stated, From the Closet Care Plan. The DON was asked, What was the intervention that was put in place after [Resident #4] fell ? The DON stated, To make her a two person assist at all times. The DON was asked, Was the Closet Care Plan updated at that time? The DON stated, As far as I know. The DON was asked, Who is responsible for updating the Closet Care Plan? The DON stated, One of the ADON. The DON was asked, How long has the ADON been responsible for updating the Closet Care Plans. The DON stated, 3 months. The DON was asked, After you changed [Resident #4] to a two person assist with bed mobility all the time did you do any additional in-services to ensure the staff were aware of this? The DON stated, I don't think that I did. n. The policy titled Activities of Daily Living (ADLs), Supporting provided by the Administrator on 2/24/22 at 11:15 AM documented, . Policy Statement: Resident will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs) . Policy Interpretation and Implementation: 5. A resident's ability to perform ADLs will be measured using clinical tools, including the MDS. Function decline or improvement will be evaluated in reference to the Assessment Reference Date (ARD) and the following MDS definitions: Extensive Assistance - While resident performed part of the activity over the last 7 days, staff provided weight bearing support .

Complaint # (AR 728) was substantiated, all or in part, with a deficiency cited at F689. Complaint # (AR 773) was substantiated, all or in part, with a deficiency cited at F689. Based on observation, record review and interview, the facility failed to provide adequate supervision to prevent accidents for 1 (Resident #1) of 2 (Residents #1 and #2) case mix residents who were at risk [MEDICAL CONDITION] hot liquids. The facility failed to ensure staff provided coffee that was at a safe temperature in order to prevent injury in case of accidental spillage. The facility failed to ensure staff notified the physician after discovering a coffee burn had occurred, which resulted in a delay in treatment to the wound. These failures resulted in past non-compliance and actual harm for Resident #1 when she sustained a second degree burn to her thigh due to spilling coffee in her lap. This failed practice had the potential to affect 32 residents who were at risk [MEDICAL CONDITION] hot liquids according to a list provided by the Director of Nursing (DON) on 8/7/2020 at 2:10 p.m. The facility corrected the deficient practice on 5/11/2020 prior to the survey entrance date. The findings are: Resident #1 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/03/2019 documented the resident scored 4 (0-7 indicates severe impairment) on the Brief Interview for Mental Status (BIMS), had adequate vision, had no behaviors and had no upper extremity impairment. a. A Nsg (Nursing) Admit/Readmit Assessment with Care Plan effective date 11/12/2019 documented, . Hot Liquid Risk . Care Planning: Resident is at risk [MEDICAL CONDITION] hot liquids. Resident to drink hot liquids while sitting at table only. Resident to use cup with a lid. Temperature of liquids is not to exceed 140 degrees. b. The Care Plan documented in the Focus section, Resident is at risk [MEDICAL CONDITION] hot liquids. Revision on: 11/25/2019 . The Intervention section documented, Resident to drink hot liquids while sitting at table only . Revision on 11/25/2019. c. A Nsg Admit/Readmit Assessment with Care Planning effective date 04/28/2020 documented, .Hot Liquid Risk . Care Planning: Resident is at risk [MEDICAL CONDITION] hot liquids. Resident to drink hot liquids while sitting at table only. Temperature of liquids not to exceed 140 degrees. This assessment was signed by the Care Plan Coordinator on 05/12/2020. d. The Care Plan documented in the Focus section, Resident is at risk [MEDICAL CONDITION] hot liquids.Revision on 5/12/2020. The Intervention section documented, Resident to use cup with lid for hot liquids. Date Initiated: 05/12/2020. Temperature of liquids not to exceed 140 degrees. Date Initiated: 05/12/2020. The Care Plan also documented in the Intervention section, RESOLVED: Resident to use cup with lid for hot liquids. Resolved 5/12/2020. e. A Late Entry Nurse's Note written on 05/13/2020 by Licensed Practical Nurse (LPN) #1 documented, 5/9/2020 - 10:30 a.m. - Note Text: called to resident room. Resident with burn to left inner thigh. Resident stated that she spilled coffee on her lap while trying to place cup on overbed table. Instructed resident and staff to not drink hot beverages unless they were in a covered container. f. A Late Entry Nurse's Note dated 05/13/2020 by LPN #1 documented, 5/9/2020 - 10:30 a.m. - Hot Rack Charting: called to resident room. Resident with burn to left inner thigh. Resident stated she was trying to place cup of coffee on overbed table and spilled some on her lap. Instructed staff and resident to ensure containers were covered when resident consuming hot liquids. g. A Late Entry Nurse's Note dated 05/15/2020 by LPN #3 documented, 5/15/2020 - 10:47 a.m. Note Text: Resident was noted to have a 2nd degree burn to left lateral thigh r/t (related to) coffee spill. This area was observed by this treatment nurse Monday 5-11-2020. This nurse called (Advanced Practice Nurse) and notified her as well as DON and Administrator. All above noted. Assessed burn and notified POA (power of attorney), this nurse had a video teleconference call with (wound doctor) and received new treatment orders. Today this area is improving ruptured blister has [MEDICATION NAME] tissue and the small clear fluid filled blister is drying out. There is no drainage and resident states it feels a lot better. h. A Division of Medical Service (DMS)-762 dated 05/18/2020 documented, Received a call from . OLTC (Office of Long-Term Care) on 5/18/2020 stating we had an allegation that resident (Resident #1) got a coffee burn one day in May. On 5/8/2020 at approximately 10:15 a.m., (Activity Director) provided coffee in styrofoam cup from her personal coffee maker. Resident was up in chair with bedside table beside her. About 11:30 a.m., Activity Director went and got the resident to take her to the beauty shop. (Activity Director) stated initially she did not notice the resident was wet. (Certified Nursing Assistant (CNA) #2) was leaving beauty shop as (Activity Director) was pushing resident into the beauty shop. (CNA #2) asked resident did she wet herself and resident stated she spilled something on herself. The resident did not report to them what she spilled. After completing hair, Activity Director took the resident to the hall and reported to (CNA #1) that resident was wet and needed changing. (CNA #1) went and changed the resident and did not note any redness at that time. On 5/9/20 at approximately 9:30 a.m., (CNA #3) removed resident's brief and noted what she initially described as a scratch on her leg. (CNA #3 and CNA #4) were providing resident a shower. (CNA #4) described area as a burn mark. (CNA #4) reports he went to notify (LPN #1) and another resident was telling (LPN #1) of the resident's burn. (CNA #4) confirmed to (LPN #1) that there was a burn mark. (CNA #3) stated she was going to report to the nurse (LPN #1). (CNA #3 and CNA #4) also told (CNA #1). (CNA #4) stated that (CNA #1) also reported to (LPN #1). (LPN #1) reports he was notified of the burn on 5/10/2020 and he assessed the area and applied zinc. On 5/11/2020, (LPN #2) was notified by (CNA #5 and CNA #6) that resident had spilled coffee on her left inner thigh. (LPN #2) notified (LPN #3) treatment nurse of the burn and blisters on resident's leg. (LPN #3) went and assessed the area. The resident had an elongated area where the blister had burst, and a second fluid filled blister intact. The area was described as a second-degree burn measuring 10.4 cm x (by) 5 cm. (LPN #3) then notified Administrator and DON. (LPN #3) notified (APN) and did a teleconference with (wound physician) concerning the burn to the left thigh and received treatment orders at 11:50 a.m. (DON) and (Administrator) went to interview the resident. Resident stated that she spilled the coffee in her lap. She stated she was trying to sit the cup of coffee on the over bed table and missed the table and dropped it in her lap . On 5/11/2020, individual coffee pot was removed from service. Full facility observation completed to ensure there were no other individual coffee pots. (Activity Director) was suspended pending investigation, allowed to return on 5/18/2020. Upon notification from OLTC, the investigation was reopened and (Activity Director) was again suspended pending further investigation. (LPN #1) was suspended pending investigation, allowed to return on 5/13/2020. Pain interview completed on resident. Stated she has had some pain. Did not report how much. Stated it did not keep her awake at night. Rated pain 2/10. (Rated 2 out of 10, indicative of mild pain) All resident's hot liquid assessments were updated by 5/13 with no negative findings. Staff in-serviced that all coffee served to residents must come from the kitchen. Staff in-serviced on abuse and neglect. 1 on 1 in-service with (LPN #1) along with charge nurse in-service on documentation needed for change of condition, treatment order must be obtained for skin impairments with appropriate notifications. 1 on 1 in-service CNA #1) and in-service charge nurses and CNAs, zinc requires physician order [REDACTED]. Upon discovery, the chart was reviewed, and it was determined there was no deviation from the POC (Plan of Care). In conclusion, the facility can't substantiate abuse, however, due to overall job performance and concern in judgement, (Activity Director) was terminated. (Resident #1) has had no complaint of pain. Wound is completely resolved. i. A Late Entry physician progress notes [REDACTED]. Resident is . being seen today for a skin burn to her left inner thigh. Per report, she spilled coffee in her lap. No s/s (signs or symptoms) of infection noted on exam . Skin: Burn to left inner thigh . Wound #1 Date identified: 5/10/2020. Location: Left inner thigh. Type of wound: Burn. Stage: N/A. (not applicable) Measurement/Size: 8.29 cm (centimeters) x 2.05 cm < (less than) 0.1 cm in depth. Undermining/Tunneling: No. Drainage/Exudate: No. Odor: No. Tissue/Wound Bed: Granulation %: 70. [MEDICATION NAME] % 30. Edges: Attached. Peri-wound: Normal. Intact. Progress: Improving . Diagnosis (and) Assessment: 1. Burn to left inner thigh-Silver [MEDICATION NAME] cream 1% to be applied Q shift (every shift) . j. A Late Entry Nurse's Note dated 05/21/2020 by the DON documented, 5/11/2020 - 11:00 a.m. - Spoke with resident's son regarding resident spilling coffee on her leg. Explained the incident, described she had a blister on her left thigh area. (Son) asked was the burn severe enough to require skin grafts. This nurse explained the burn is a second degree and should not require any surgical interventions. He thanked me for the call and stated he appreciates all that we are doing for our residents. k. On 08/05/2020 at 2:50 p.m., the surveyor went into the kitchen with the Dietary Manager (DM) to observe the dietary department's coffee machine. The DM was asked what temperature the coffee would be when it came out of the machine to give to a resident. She stated, This machine is pre-set to 130-134 degrees. She was asked if she or the kitchen staff could change the temperature range. She stated, No. We don't adjust nothing. If it needs to be adjusted, we have to call the company. At this time, the DM was asked to get a cup of coffee from the machine and check the temperature. She did and the temperature was 135.6. She was asked if she had a routine of checking the temperature of the coffee that comes out of that machine and she stated, I check it pretty much every morning. She was asked if she documented it on a log and she stated, No, I don't write it down. l. On 08/06/2020 at 10:40 a.m., the Care Plan Coordinator was asked what the 'effective date' meant that was located at the top of the Nsg Admit/Readmit Assessment forms, and why it would be different than the date that he signed it. He stated, The effective date .that's the date it's scheduled for or started. The date beside the signature is the date the assessment is locked. He was asked when the hot liquid assessment on Resident #1 was done if the effective date was documented as 04/28/2020 and the date beside his signature was documented as 05/12/2020, with the incident occurring on 05/08/2020. He stated, The assessment could have been done before the incident or after it. It could have been done anytime in that date range. m. On 08/06/2020 at 12:21 p.m., LPN #1 was asked about the incident involving Resident #1 and the coffee burn. He stated, I think it was on a weekend. The aides told me about a spot on her leg. I didn't know about a coffee spill. I put some ointment on it, but I forgot to chart on it, and I had to go back and put some notes in on it. He was asked about the CNAs stating they reported the incident to him on 05/09/2020, yet he documented he assessed the area on 05/10/2020. He stated, The best I can remember is when they told me about it, I went and looked at it. He was asked about giving the CNA Zinc to apply to the wound. He stated, I don't remember if I gave it to her or if she had it available. He was asked about not notifying the physician or the family of the incident. He stated, I didn't. I didn't notify the doctor at that time, but when they talked to me about it, they told me they notified the doctor. He was asked why he did not report the injury to anyone. He stated, The best I can say is maybe I was busy and .I'm not making excuses. I should have stopped what I was doing and taken care of it. n. On 08/06/2020 at 12:55 p.m., CNA #1 was asked what she remembered about Resident #1 and the coffee spill. She stated, I remember putting her on the toilet. It was round time. Her clothes were dry. She had a little red spot on her inner thigh, and I reported it to the nurse. I got her off the toilet. He gave me some cream and I put that on her. She was asked if the nurse looked at the area when she told him about it. She stated, No, he just took my word for it. She was asked what type of cream he gave her, and she stated, I don't remember that. She was asked if she changed the resident's clothes the day the Activity Director asked her to and she stated, No ma'am. By the time I got to her, she already had dry clothes on, and I don't know who changed her. She was asked if she saw the resident anymore that day. She stated, I saw her the next day. My old coworkers got her up for a shower and they saw her leg was blistered up. They came and got me, so I went and found (LPN #1) and he gave them cream that time. I don't know if he looked at it at that point or not. She was asked if the resident complained of any pain. She stated, In the shower room, she was complaining of the inside of her leg hurting. And then on the next round she was complaining about it . o. On 08/07/2020 at 9:18 a.m., LPN #3 was asked what she remembered about the incident involving Resident #1 and the coffee burn. She stated, That Monday, the 11th of May, a CNA grabbed me and told me the resident's leg was hurting from a coffee burn. I didn't know anything about it, so I went down there. It was on her inner thigh and it was blistered in some areas. On the upper portion, the blister had started to seep out. She was asked if she knew how the resident had gotten the burn. She stated, The Activity Director gave her coffee from her personal coffee pot and the resident spilled it. I didn't check the temperature from her coffee pot, but we went and temped the coffee from the kitchen and it wasn't even hot enough to drink in my opinion. She was asked if there had been any other hot [MEDICAL CONDITION] the facility. She stated, Not since I have been here. p. On 08/07/2020 at 9:20 a.m., the Resident's May and June 2020 Treatment Administration Record (TAR) documented treatment to the left thigh started on 05/11/2020 (3 days after the incident) with Silver [MEDICATION NAME] cream every shift and PRN (as needed) and stopped on 06/01/2020 due to the wound being healed. q. On 08/07/2020 at 9:33 a.m., Resident #1 was sitting in her wheelchair in her room. The DON assisted the resident to a standing position so the surveyor could observe her leg. A dark purplish area was observed to the left inner thigh. The resident was asked if she remembered what happened to her leg and she stated, Of course I remember. I was given a cup of coffee and when I went to sit it on my table, I bumped it and it spilled in my lap. I had on thick pants, so it took a little while for it to soak in. It sure did get sore. Somebody said, 'why didn't you holler?' Well there wasn't no need to holler after it already happened. She told me it was hot. It sure itches around the outside edge of it. r. On 08/07/2020 at 12:24 p.m., the DON was asked what she could remember about Resident #1 and the coffee burn incident. She stated, Monday morning (5/11/2020), it was reported to the treatment nurse that she had had a coffee spill with a burn to her leg. So, we began the investigation there. That was the first I heard about it. I went and looked at her leg. She had a blister to her inner left thigh. She told me what happened. She said she had a cup of coffee, reached over to sit it on the table, bumped it on the table and it spilled on her leg. She was asked if there had been any other hot liquid burns. She stated, I'm not aware of any spills prior to that. We went back and searched previous I/As (incident and accidents) and there were no other incidents like that. She was asked about the Nursing Admit/Readmit Assessment forms and the interventions with a box that can be checked. She was asked if a box is checked, did that automatically go over to the care plan as an intervention. She stated, Yes. The system is built to where when you check one of the interventions on the Nursing readmit form, it goes over to the Care Plan. She was asked how an intervention could get removed from a care plan. She stated, You can go edit a Care Plan and delete it, but you can still see that it was there. You can look at resolved interventions. And an intervention is supposed to be current until it is resolved. She was asked why the intervention of having a cup with a lid, that was checked on the 11/29/19 hot liquid assessment, wasn't on the Care Plan at the time of the incident. She stated, I don't know that. It wasn't even on the Care Plan back in November when the assessment was done. s. The facility's Safety of Hot Liquids Policy and Procedure provided by the DON on 8/7/20 documented, Residents will be evaluated for safety concerns and potential for injury from hot liquids upon admission, readmission and on change of condition. Appropriate precautions will be implemented to maximize choice of beverages while minimizing the potential for injury . Once risk factors for injury from hot liquids are identified, appropriate interventions will be implemented to minimize the risk from burns. Such interventions may include: .Serving hot beverages in a cup with a lid; Encouraging residents to sit at a table while drinking or eating hot liquids . Food service staff will monitor and maintain food temperatures that comply with food safety requirements but do not exceed recommended temperatures to prevent scalding. t. The facility identified the deficient practice and put corrective action in place on 5/11/2020. The corrective action was as followed: -The Activity Director was placed on administrative leave during investigation. -The coffee maker in activities was removed from service. -Full facility observation to ensure there were no more individual coffee makers. -Occupational Therapy performed a screen to validate hot liquid risk. -All staff were in-serviced that the only coffee that is to be given to residents is to come out of the dietary department. -A list of residents who require a lid for hot liquids was developed and placed in the dietary department, activity department and on each hall cart. -Administrator performed observation rounds 4 days a week x (times) 8 weeks to ensure there were no coffee makers in the department managers offices. -DON/Designee performed observation rounds in resident rooms to ensure there were no coffee makers present. -The Administrator/designee monitored 3 activities a week to ensure hot liquids was provided from the dietary department. -One on one in-services were done with CNA #1 and LPN #1 to educate that CNAs are not to apply zinc oxide. In-service for LPN #1 included documenting on a change in condition and obtaining a treatment order for any skin impairment with proper notification. -LPN #1 was suspended pending investigation. -CNAs and nurses were in-serviced that zinc requires a physician order [REDACTED]. In-service for nurses included documenting on a change in condition and obtaining a treatment order for any skin impairment with proper notification. -The DON/Designee checked zinc storage 3 times a week x 8 weeks. -The DON/Designee monitored clinical alerts 5 days a week to ensure any changes were followed up on. -The DON/Designee did 2 body audits daily x 5 days a week to monitor for possible skin impairments that were not reported.

Complaint # (AR 851) and # (AR 859) was substantiated, all or in part, in these findings. Based on record review and interview, the facility failed to ensure transfers were conducted as per the plan of care to decrease the potential for injury for 1 (Resident #11) of 12 (Residents #1 through #12) case mix residents who were dependent on staff for transfers. The failed practice resulted in past noncompliance actual harm to Resident #11, who was transferred manually, instead of by sit-to-stand mechanical lift, and sustained a dislocated shoulder, and had the potential to cause more than minimal harm to 18 residents who required a lift for transfers, according to a list provided by the Director of Nursing (DON) on 1/10/17 at 8:50 a.m. The findings are: Resident #1 had [DIAGNOSES REDACTED]. A Quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 11/15/17 documented the resident was severely impaired in cognitive skills for daily decision-making per a staff assessment of mental status (SAMS), required extensive assistance of 2-plus people for bed mobility, transfer, toileting, dressing and personal hygiene, was totally dependent on 2-plus people for bathing, and had no functional limitation in range of motion. a. The Plan of Care dated as initiated 8/12/14 documented the resident had an activities of daily living (ADL) self-performance deficit related to weakness with an intervention of, .The resident uses assist X (times) 2 (people) with sit to stand (mechanical lift) . b. The MDS Kardex Report (Closet Care Plan) dated as printed 12/9/16 documented a handwritten note dated 2/13/17, Sit to stand, with the Director of Nursing's initials. c. The Progress Note dated 12/16/17 at 4:01 p.m. documented, I was asked by (Licensed Practical Nurse (LPN) #1) to come and assess resident. Resident was in room with daughter and daughter state she thinks something is wrong with her mother's Right shoulder. Assessed shoulder and it does appear to be a difference in the right shoulder versus the left shoulder. Resident moans when anything is done to the right arm . The right hand is swollen and purple . Notified . (Advanced Practice Nurse (APN)) and orders for STAT xray right shoulder and elbow . d. The hospital Emergency Record dated 12/16/17 at 9:11 p.m. documented, [AGE] year-old female presents from nursing home with possible shoulder dislocation . multiple attempts to reduce the shoulder were unsuccessful . have consulted the orthopedic surgeon . He attempted reduction . unsuccessful . talk with the family about further care . patient will be sent back to nursing home with a sling and some pain medication . follow up with (orthopedic surgeon) in the office next week to discuss further options . e. The OLTC (Office of Long Term Care) Incident and Accident Report submitted to OLTC on 12/17/17 at 8:44 a.m. documented, Date of discovery: 12/17/17 at 1:31 a.m . (Resident #1) had an x-ray conducted to right shoulder showing dislocation. In the initial investigation, doing interviews, (Certified Nursing Assistant (CNA) #1) stated that her (sic) and (CNA #2) did not follow the Closet Care Plan of using a 'sit-to-stand' lift. Both CNAs suspended pending outcome of investigation . f. The Facility Investigation Report for Resident Abuse, Neglect, Misappropriation of Property, and Exploitation of Residents in Long Term Care Facilities documented the date and time of incident as 12/16/17 at 6:30 a.m. and the Type of Incident as Neglect. The report documented, .X-ray results were obtained at 7:49 p.m. and order to transfer to hospital to confirm results was given. Notified ambulance of transfer and sent to ER (emergency room ) at approximately 9:00 p.m. Dislocation was confirmed at 1:40 a.m. and investigation of unknown origin started. During the initial investigation, doing interviews at approximately 7:15 a.m., (Certified Nursing Assistant (CNA) #1) stated that herself and (CNA #2) did not follow the Closet Care Plan of using a sit-to-stand lift. Both CNAs were immediately suspended pending outcome of the investigation. In-services started immediately to ensure staff is properly following Closet Care Plans . Section III - Findings and Actions Taken . During Initial stages of the investigation into injury of unknown origin, (CNA #1) stated that on the morning of 12/16/2017 at approximately 6:30 a.m. that herself (sic) and (CNA #1) transferred (Resident #1) with a gait belt instead of a 'sit to stand' lift . (CNA #1) wrote (witness statement) the transfer was completed using a gait belt and resident did not express pain or discomfort and that she was on the resident's left side . (CNA #2) stated that her and (CNA #1) transferred (Resident #1) without the use of a gait belt and placed their hands under the resident's arms and grabbed the back of her pants . The OLTC Witness Statement form dated 12/17/17 at 10:55 a.m. and signed by CNA #2 documented, .on Saturday morning (12/16/17) at around 6:30 a.m. we got her up . During this time I do not remember using a gait belt. I got on the left side of (resident) and grabbed the back of her britches and lifted her mainly by her pants and pivited (sic) her to the chair while barely holding on to her forearm with the help of another CNA on the other side . The OLTC Witness Statement form date 12/18/17 (not timed) and signed by CNA #1 documented, I wasn't aware until this morning to use a stand-up lift on this resident. I always transfer her on her left side . We transfer (sic) her at approximately between 6:30 a.m. and 7 a.m. and there was no report of pain or any known discolorations Saturday morning . g. A Significant Change Minimum (MDS) data set [DATE] documented the resident was severely impaired in cognitive skills per a Staff Assessment Mental Status (SAMS); required extensive assistance from two-plus people for bed mobility, transfers, dressing, personal hygiene, and bathing; and had functional limitation in range of motion of one upper extremity. h. The resident was no longer in the facility at the time of the complaint investigation survey. Nursing Progress Notes dated 1/8/18 at 9:27 a.m. documented, Discharge Assessment Note - The resident discharged out to (inpatient hospice facility). She had a decline in health and met criteria for inpatient. She is not expected to return . i. On 1/10/18 at 3:42 p.m., CNA #3 stated she had worked the night shift on 12/16/17, going over routine care with CNA #1. The CNA was asked if she had ever seen Resident #1 transferred without a sit-to-stand lift prior to the 12/16/17 incident and stated no. j. On 1/11/18 at 4:55 a.m., CNA #5 was asked if he had worked with Resident #1 prior to her discharge and stated yes. The CNA was asked how they transferred the resident and stated, .sometimes a gait belt and 2 staff and sometimes a sit-to-stand lift. The CNA was asked if he had ever transferred the resident with another staff member without using the sit-to-stand lift and stated, Yes. k. The facility provided the following evidence of corrective actions that were initiated after the 12/16/17 incident, but prior to the complaint investigation survey: 1.) An In-service Education Report dated 12/17/17 documented, You must review the closet care plan before providing care to a resident. You must follow the closet care plan at all times . Further, you are responsible for knowing what the closet care plan says, do NOT take someone else's word for it. Failure to follow the care plan is considered NEGLECT and will be reported to OLTC . 2.) A form titled Transfer Training with Return Demonstration documented, Started return demos (demonstrations) 12/17/17 to 12/20/17. The form was signed by a total of 54 CNAs. 3.) The final report by the Administrator, Findings and Actions Taken dated 12/22/17 documented, .12/17/17 . (Registered Nurse (RN) #1) and (LPN's #1 and #2) began body audits for residents on 100 Hall or those who use a lift to transfer with no negative findings . Staff in-services on appropriate use and following of closet care plans started. Nursing management in-servicing with return demonstrations (with) all CNAs on proper transfer techniques with the use of gait belt, sit-to-stand lift, and Hoyer lift. Facility recommends substantiating allegation of neglect against CNAs #1 and #2 for failing to follow the care plan and doing an improper transfer. CNAs #1 and #2 to be terminated for their actions . 4.) Resident Safety Skills Checklists and Transfer Belt Skill Checklists dated 12/23/17 through 1/5/18 documented that ongoing monitoring of gait belt transfers and mechanical lift transfers continued at a frequency of 3 times weekly, with different staff members through the week the complaint investigation survey was initiated. 5.) During the complaint investigation survey conducted from 1/6/18 through 1/11/18, the surveyors observed staff providing transfer assistance to Resident #3 (mechanical lift transfer from bed to geri-chair), Resident #6 (mechanical lift transfer from bed to geri-chair) and #7 (mechanical lift transfer from bed to geri-chair). All transfers were conducted with 2 staff present and with proper technique - no current problems with mechanical lift transfers were identified.

Complaint # (AR 415) was substantiated (all or in part) in these findings: Based on observation, record review and interview, the facility failed to ensure a [DEVICE] dressing was consistently implemented as per the physician order [REDACTED].#2); pressure ulcer dressings were performed at the frequency ordered by the physician to promote healing and decrease the potential for infection for 2 (Residents #4 and #5); and wound dressings were promptly replaced and pressure relief was provided to promote healing of existing pressure ulcers and decrease the potential for further skin breakdown for 1 (Resident #3) of 5 (Residents #1 through #5) case mix residents who had pressure ulcers. The failed practices resulted in actual harm for Resident #2, whose Stage IV coccyx pressure ulcer increased in size and developed undermining and who developed an additional pressure ulcer in an adjacent area of the skin, and had the potential to cause more than minimal harm to 13 residents who had pressure ulcers, according to a list provided by the Director of Nursing (DON) on 8/17/16 at 10:13 a.m. The findings are: 1. Resident #2 had [DIAGNOSES REDACTED]. and [MEDICAL CONDITION]. The Significant Change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/15/16 documented the resident scored 9 (8-12 indicates moderately impaired) on the Brief Interview for Mental Status (BIMS), required extensive assistance from two-plus people for bed mobility, transfer, toilet use, and personal hygiene, required extensive assistance of one person for dressing, was incontinent of bowel and bladder, received scheduled and as needed pain medication, was at risk for the development of pressure ulcers, and had an unstageable pressure ulcer that was not present upon admission. a. The Care Plan with a review date of 7/15/16 documented, .The resident has a Stage 4 pressure ulcer to sacrum related to disease process . Monitor dressing to coccyx to ensure it is intact and adhering . Charge Nurse to change dressing if loose, soiled, missing, or saturated . Administer treatments as ordered . Follow facility policies / protocols for the prevention / treatment of [REDACTED]. b. A list of wounds provided by the Nurse Consultant on 8/17/16 at 10:15 a.m. documented the resident's original wound to the coccyx measured 4.1 cm by 1.7 cm by 0.9 cm on 8/9/16. c. A Physician order [REDACTED].Clean pressure ulcer to coccyx with normal saline and pat dry. Apply Pensar negative pressure wound therapy at 125 mmHg (millimeter mercury) continuous as needed for loose, soiled, wet or missing dressing and every day shift every Monday, Wednesday and Friday related to pressure ulcer of sacral region, stage 4 . d. A Nursing Progress Note dated 8/12/16 at 12:59 p.m. documented, . (Physician) here this morning and examined resident and pressure ulcer to the coccyx and he states there is some improvement and continue current orders. Negative pressure wound therapy system reapplied . The wound physician progress notes [REDACTED].Wound . Left coccyx is a pressure ulcer . Measurements are 3.5 cm length (by) 2.5 cm width (by) 1 cm depth . Negative pressure wound therapy, 125 mmHg (millimeter of mercury) continuous . change MWF (Monday Wednesday Friday) and PRN . There was no documentation of any undermining to the wound at this time. e. On 8/15/16 at 12:42 p.m., the resident was lying in bed. LPN #2 rolled the resident to her left side. A large deep pressure ulcer was on the coccyx area. There was no dressing present to cover the wound; the wound vac was not attached to the wound and there were no loose dressing materials in the bed. Bloody drainage was visible on the resident's bed sheet. A wound vac pump was on the floor next to the bed with the tubing draped over a chair arm. There was a dark, reddish brown substance in the tubing. The resident was asked when she last had a dressing on the area and she stated she didn't know. f. On 8/15/16 at 5:25 p.m., LPN #2 stated when she came to work 8/15/16, she was pulled to work the floor on this resident's hall. She was asked how long the resident's wound vac had been off. She stated, I didn't even know the pump was still off of her (until) you and I went in there this morning. She was asked if she knew the resident's dressing was not in place. She stated, No. I just know (Treatment Nurse) put one on there when she removed the pump late Saturday night or early Sunday morning. g. On 8/15/16 at 5:40 p.m., the resident was lying in bed. The resident was rolled to her left side. The coccyx wound was measured, by the Treatment Nurse, as 4.2 cm by 2.3 cm by 1.3 cm with undermining from 7 to 4 o'clock, the deepest portion being 1.8 cm at 3 o'clock. The wound bed was red with a small amount of slough present. A small hole was just below the wound that measured 0.4 cm by 0.4 cm by 0.9 cm. Another area was noted just to the right of the large wound. The Treatment Nurse stated this was a new area. It was open and measured 3.3 cm by 1.4 cm. The areas were cleaned with normal saline and a wound vac was applied. h. On 8/16/16 at 9:45 a.m., the resident was lying in the bed. The wound vac was not on. The Treatment Nurse stated, The pump is not working properly. (Wound Vac Provider) is sending a new one . At 3:50 p.m., the resident was repositioned in the bed on her back. The wound vac was not on. 2. Resident #4 had [DIAGNOSES REDACTED]. The Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/10/16 documented the resident scored 15 (13-15 indicates cognitively intact) on the Brief Interview for Mental Status (BIMS), required extensive assistance from two-plus people for bed mobility, dressing, toilet use, personal hygiene and bathing, received as needed pain medication, occasionally experienced pain, was at risk for the development of pressure ulcers and was admitted with two unstageable pressure ulcers with suspected deep tissue injury. a. The Care Plan dated 8/8/16 documented, .The resident has pressure ulcer UTD (unable to determine) to right posterior thigh . Administer treatments as ordered and monitor for effectiveness . Monitor dressing every shift and prn (as needed) to ensure it is intact and adhering . b. A Physician order [REDACTED].Clean unstageable pressure ulcer to the right upper thigh / buttock with normal saline . Pat dry and apply Santyl to the wound bed . Cover with [MEDICATION NAME] 2 (by) 2 and apply [MEDICATION NAME] Border 4 (by) 4 every day shift . c. A physician progress notes [REDACTED].Pressure Ulcer is located on the right buttock gluteal fold . Medical Necessity: The ulcer base is non-granulating, hypoxic, slough / necrotic . A skin / subcutaneous tissue level excisional debridement was performed by (physician) . Post Debridement Measurements: 2.8 cm length (by) 4 cm width (by) 0.3 cm depth with percentage debrided at 80% . post debridement stage noted as Unstageable Pressure Injury . Cleanse wound with Saline, apply Santyl to wound bed . change daily, and change prn (as needed) for soiling and / or saturation . d. The August 2016 Treatment Administration Record (TAR) documented, .Clean unstageable pressure ulcer to right the upper thigh / buttock with normal saline . Pat dry and apply Santyl to the wound bed . Cover with [MEDICATION NAME] 2 (by) 2 and apply [MEDICATION NAME] Border 4 (by) 4 every day shift . Order date . 8/12/16 . On the TAR, spaces were provided next to the wound care order for nurses to initial to indicate the wound care was provided each day; the spaces for 8/13/16 (Saturday) and 8/14/16 (Sunday) were blank. e. On 8/15/16 at 3:50 p.m., the resident was in bed. He was rolled to his left side by the Treatment Nurse and Registered Nurse (RN) Consultant #1. A discolored, soiled dressing, dated 8/12 (8/12/16), was observed to the right gluteal fold. The Treatment Nurse was asked if those were her initials on the dressing. She stated, Yes. The Treatment Nurse removed the dressing. The wound had a dark-colored substance that was dried onto the wound bed. The Treatment Nurse stated, That's calcium alginate stuck there. The wound was cleaned with normal saline, Santyl was placed in the wound bed and Calcium Alginate was placed over that. The area was covered with [MEDICATION NAME]. 3. Resident #3 had [DIAGNOSES REDACTED]. The Quarterly MDS with an ARD of 5/16/16 documented the resident scored 10 (8-12 indicates moderately impaired) on the BIMS, required extensive assistance from one person for bed mobility, eating, dressing, toilet use, personal hygiene and bathing, required extensive assistance from two-plus people for transfer, was totally dependent for bathing, received scheduled pain medication, experienced pain frequently, was at risk for the development of pressure ulcers, and had no pressure ulcers since admission or prior to admission. a. The resident's Care Plan dated 8/3/16 documented, .The resident has a potential for pressure ulcer development related to immobility . Eschar to 2nd toe right foot . and SDTI (Suspected Deep Tissue Injury) to right foot plantar under toes . Follow facility policies / protocols for the prevention / treatment of [REDACTED]. Treatment per orders . b. A Progress Note dated 8/11/16 at 4:02 p.m. documented, .While applying TAO (Triple Antibiotic Ointment) to resident's toe per orders this nurse observed small pea sized brown area to second toe. Tender to touch, no discharge, no bleeding. (Physician's Assistant) stated to offload great toe from second toe. I cleaned area to second toe and covered with TAO and 4 (by) 4. I wrapped foot with Kerlix anchoring great toe off of second toe. Resident stated that felt much better . A Physician order [REDACTED].Clean abrasion to the right second and third toes with normal saline and pat dry. Apply TAO (Triple Antibiotic Ointment) to the wound bed and cover with 1 (by) 1 bordered gauze. Keep great toe off loaded from second toe every day and evening shift on odd days . c. A Progress Note dated 8/12/16 at 3:41 p.m. documented, .Noted eschar to the second toe. Great toe rests on top of second toe. Order obtained to clean eschar to the left second toe with normal saline and pat dry. Apply 2 (by) 2 [MEDICATION NAME] plus between toes to keep the area dry. Place foam between great toe and second toe and apply roll gauze (bunny wrap) and secure every day shift on even days and as needed for loose, soiled, wet or missing dressing . Physician order [REDACTED].Clean eschar to the left second toe with normal saline and pat dry. Apply 2 (by) 2 [MEDICATION NAME] plus between toes to keep the area dry. Place foam between great toe and second toe and apply roll gauze (bunny wrap) and secure every day shift on even days and as needed for loose, soiled, wet or missing dressing . d. On 8/15/16 at 12:35 p.m., the resident was lying in the bed. A small area of eschar was noted to the top of the right second toe. The great toe was crisscrossed over, on top of the second toe. When the great toe was slightly pulled back off of the second toe by LPN #2, a small amount of dried, slough pulled away from the eschar. No dressing was present on the wound and no loose dressing materials were in the bed. 4. Resident #5 had [DIAGNOSES REDACTED]. The Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/5/16 documented the resident scored 13 (13-15 indicates cognitively intact) on the Brief Interview for Mental Status (BIMS), required extensive assistance of one person for bed mobility, transfer, dressing, toilet use, personal hygiene and bathing, received scheduled and as needed pain medication, was occasionally incontinent of bowel and bladder, was at risk for the development of pressure ulcers and was admitted with one Stage III pressure ulcer and one Stage II pressure ulcer. a. The Weekly Wound Observation (Treatment Nurse) dated 8/1/16 at 10:01 p.m. documented, .Upper right buttock . Pressure Ulcer Stage . Original . (Stage) II . Stage at highest level, do not down-stage as the wound heals . Current (Stage) III . Overall Impression . Visible Tissue . Worsening . Slough tissue present . Moist . Wound Measurements . Length (cm) (centimeter) 0.7 . Width (cm) 1.5 . Depth (cm) 0.2 . Describe the extent of any tunneling and or undermining . none . Comments . Slough to wound bed is newly noted and treatment regimen was changed . b. The Care Plan dated 8/2/16 documented, .The resident has pressure ulcers related to acute illness, malnutrition, incontinence and immobility . Follow facility protocols for treatment of [REDACTED]. c. A Physician order [REDACTED].Clean Stage 3 pressure ulcer to the right buttock with normal saline and apply [MEDICATION NAME] AG. Cover with [MEDICATION NAME] Border Sacral every day shift; both pressure ulcers to right buttock may share [MEDICATION NAME] Border Sacrum . d. The Nursing Weekly Wound Observation (Treatment Nurse) dated 8/8/16 documented the wound on the upper right buttock was a Stage III that measured 0.7 cm by 0.5 cm by 0.2 cm. The form documented, Pressure Ulcer Stage . Original (Stage) III . Stage at the highest level, do not down-stage as the wound heals . Current . (Stage) III . Wound Progress . Improved . Smaller and shallower . e. The August 2016 Treatment Administration Record (TAR) documented, .Clean stage 3 pressure ulcer to the right buttock with normal saline and apply [MEDICATION NAME] AG. Cover with [MEDICATION NAME] Border Sacral every day shift .Order date . 8/3/16. On the TAR, spaces were provided next to the wound care order for nurses to initial to indicate the wound care was provided each day; as of 8/15/16, the spaces for 8/13/16 (Saturday) and 8/14/16 (Sunday) were blank. f. On 8/15/16 at 12:47 p.m., the resident was lying in bed. She was asked about her skin. She stated, They ain't been changing my dressing like they're supposed to. It ain't been changed in two days. She was asked if the area caused her any pain. She stated, I know it's there. g. On 8/15/16 at 3:00 p.m., the resident was lying in bed. The Treatment Nurse rolled the resident to her left side. A dressing dated 8/12 (8/12/16) was on the right upper buttock area. The dressing was removed by the nurse and revealed a small red area that measured 1.3 cm by 1.4 cm and had a small, pinpoint-sized open area in the middle of the red area. The area was cleaned with normal saline. [MEDICATION NAME] AG was applied and the area was covered with [MEDICATION NAME]. 5. On 8/16/15 at 9:59 a.m., RN #1 was asked if she worked the weekend, 8/13/16 and 8/14/16. She stated she worked Saturday and Sunday 7:00 a.m. to 3:00 p.m. She was asked which hall she worked. She stated she worked the hall where Resident #4 and Resident #5 resided, but that she did not do the treatments because she was doing weekend duties and helping another nurse do her medication pass. She stated, (Licensed Practical Nurse (LPN) #1) was assigned to that hall. On 8/16/16 at 5:05 p.m., LPN #1 was asked if she worked the 8/13/16 and 8/14/16 weekend. She stated, Yes, I worked Saturday and Sunday 7:00 a.m. to 7:00 p.m. She was asked about the residents on her hall, which included Resident #4 and Resident #5, and if the wound treatments were done. She stated, I didn't do the treatments because I took that hall over in the evening time. (RN #1) had that hall during the day. 6. On 8/16/16 at 2:15 p.m., Registered Nurse Consultant #1 provided a statement from the Wound Care Physician that documented, When measuring wounds on wound patients I tend to measure open wound or in case of eschar, just eschar part of the wound. Measurements are usually head to toe - length, and width - widest part perpendicular to head to toe. Measurements can be affected by person doing measurement, pt (patient) position, i.e. one patient may stand one week during measurement and next week may want to stay in bed (and refuse to stand) or in case of sacral wound, be on one side one week, and other side next week, all this can affect measurements, therefore, interpretation should be used with caution. Many times wound appearance is best predictor if wound is healing. Occasionally periwound can be marked and measured but this can give ambiguous results, so caution should be used . 7. The facility's Prevention of Pressure Ulcers Policy and Procedure revised October 2010, received from the Registered Nurse Consultant #1 on 8/17/16, documented, .Pressure ulcers are usually formed when a resident remains in the same position for an extended period of time causing increased pressure or a decrease of circulation (blood flow) to that area and subsequent destruction of tissue . Once a pressure ulcer develops, it can be extremely difficult to heal. Pressure ulcers are a serious skin condition for the resident . When in bed, every attempt should be made to 'float heels' (keep heels off of the bed) by placing a pillow from knee to ankle or with other devices as recommended by therapist and prescribed by the physician .

Complaint # (AR 573) substantiated, all or in part, in these findings. Based on record review and interview, the facility failed to ensure an allegation of staff to resident abuse involving Certified Nursing Assistant (CNA) #1 was immediately reported to the Administrator/Designee to assure an investigation was promptly initiated and residents were protected from the potential of further abuse for 1 (Resident #1) of 7 case mix residents (Resident #s ,[DATE]), who required assistance with bed mobility and had reported an allegation of staff to resident abuse. This failed practice resulted in Immediate Jeopardy which caused or could have caused serious harm, injury or death to Resident #1, who alleged CNA #1 beat her up and who sustained skin tears to left arm and fracture of right arm. This failed practice had the potential cause more than minimal harm to 70 residents who required assistance with bed mobility in the facility according to a list provided by the Administrator on [DATE] at 11:36 a.m. The facility removed the Immediate Jeopardy prior to the survey entrance date. However, all the underlying deficient practices had not been corrected. The facility Administration was informed of the Immediate Jeopardy removed on [DATE] at 4:05 p.m. The findings are: 1. Resident #1 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] documented the resident scored 12 (8 - 12 indicates moderately impaired) on the Brief Interview for Mental Status (BIMS), required limited assistance of one person for bed mobility, was occasionally incontinent, and had limited range of motion of both upper extremities. a. The nurse's notes dated [DATE] at 10:15 p.m. and signed by Licensed Practical Nurse (LPN) #1 documented, .was notified per CNAs that res (resident) had wound to l (left) forearm upon entering res room res was noted to have large open area to l forearm. Res stated that black CNA in the morning was trying to roll res over and the CNA grabbed her wrists and started hitting them together and beating her up. This nurse then called (LPN #2) to room to look at wound and we decided that res needed to go to ER (emergency room ) d/t (due to) being able to see bone in some places. This nurse then called (DON (Director of Nursing)) to let her know what was going on and she stated to go ahead and send her to ER attempted to call on MD (medical doctor) and never received call back. (DON) also stated at this time to call res. dtr. (daughter).(DON) called back and stated to have all black CNAs go in res room to see if she could identify anyone of them. The only one that was close was (CNA #4) but res stated that she was not big enough res stated that it was a big girl and she had normal hair.This nurse and (LPN #3) looked res room over and res shirt had fresh blood on her cup and baby powder bottle, on the bedside table and on opposite handrail and under her nails, on her chin and forehead and wound still had fresh active bleeding noted at 10:35 p.m.After res left this nurse notified (Administrator) and he stated that it would be a reportable and to get witness statements and to call police and let him know of findings when CNAs went to res room and he asked if anyone matched her description and let her know that there is one on days that does and he stated not to let that CNA clock-in in the morning until he gets here . b. The nurse's notes dated [DATE] at 12:07 a.m. and signed by LPN #1 documented, .was notified per CNAs (CNA #1 and CNA #2) to come to res room that res had wound to L arm. Upon entering res room res was noted to have Lg (large) open area/skin tear to L forearm. Res stated that a black female CNA was helping her roll over and she was trying to help CNA roll and the CNA grabbed her wrists and started hitting then together and beating her up. Res had app. (approximately) 3.5 inch long and app. 2.5 inch wide open area/skin tear to l forearm and deep enough that it looked like bone in some areas and wound was bleeding large amount of blood . c. The hospital discharge summary dated [DATE] documented, .The patient told her daughter that there was a staff member that was moving her in the bed in a vigorous fashion and that her arms were being pushed together, and that the fracture occurred that way . d. The hospital x-ray results dated [DATE] documented, The bones are severely osteopenic, limiting assessment for detection of acute fracture. There is a [MEDICATION NAME] minimally impacted [MEDICAL CONDITION] right ulnar metadisphysis. On the lateral view, there is appearance of a nondisplaced [MEDICAL CONDITION] metaphysis of the radius with cortical step-off volarly and sclerotic linear density obliquely. Vascular calcifications are present. Impression: Fractures of the distal right radius and ulna. Ulnar fracture was noted by the emergency room physician at the time of examination. e. Staff interviews were conducted: 1) On [DATE] at 9:51 a.m., CNA #2 stated, ([DATE]) It was about 7:08 p.m. I was walking down the 400 hall toward the nurse's station, I heard a yell from a room, then I turned around to go into (Room Number) room. (CNA #1) was on the other side of (Resident #1's) bed facing the door. (Resident #1) was mad. (Resident #1) said, 'get her off me. I just calmed her down. This lady (Resident #1) can turn herself. I didn't see any blood, I would've reported it. App. 10:20 p.m., during last round, (CNA #1) asked me to change (Resident #1). I went to (Resident #1's ) bed. This is when I saw blood. It was all over her hand, under her finger nails. (Resident #1) said the nurse beat her up and she grabbed me. But she calls everybody nurse.(CNA #1) works with (Resident #1) all the time. (Resident #1) can turn herself, she will get upset with staff if she thinks they are going to force her. I didn't see anything, I don't think she meant to do anything. I think (CNA #1) did it by accident. I believe that's what happened. I never thought the resident did this to herself. CNA #2 stated when she heard the resident yell out it concerned her enough to turn around to go back into the room. CNA #2 was asked if she reported what the resident had said regarding, get her off me. CNA #2 stated, No, because she didn't see anything wrong with the resident when she first walked into the room. CNA #2 stated that it was not until the last round app. 10:20 p.m., when we called the nurse into the room when we saw the blood. 2) On [DATE] at 11:25 a.m., CNA #3 stated, I worked that night ([DATE]). I fed the resident that evening between 5:30 and 6:00 p.m I know there was nothing wrong with (Resident #1) at the time I fed her, because I gave her a drink in one hand and candy bar in her other hand. I know nothing was wrong because she was reaching to get the drink and candy bar. She had no complaints of anything. CNA #3 stated, The resident will let you know right then if you touch her to roll her over, she will yell. That's her way of letting you know don't touch me or you're hurting her. If you ask her to turn over, she will roll herself. The only time I can recall her yelling out that evening, it was around the 8 o'clock (round) window. I heard her yell, 'No, No stop, leave me alone.' When I heard that I was in another patient's room. I thought in my head, someone was changing her. CNA #3 stated, She's (Resident #1) not the type of resident that would do that to herself. It's not physically possible. Her hands do not have ability to cause a gash like that in her arm. I saw it. It was a bad opening. 3) On [DATE] at 12:50 p.m., LPN #1 stated, I was down the 400 hall passing meds. (medications) around 8:30 - 8:45 p.m I did her (Resident #1) meds. I handed her her bottle of water. She was able to hold it. She asked me to put cream on her arm. LPN #1 was asked about her statement which documented the resident asked you at app. 8:30 - 8:45 p.m. to put cream on her right arm because her right arm and wrist were hurting because a black CNA had twisted her arm while changing her. LPN #1 was asked did you report the allegation? LPN #1 stated, No, I was trying to do my med. pass and get the treatments done. I didn't see anything out of the ordinary, no swelling or bruising or anything like that. I saw red specks on her top and next to her mouth but I thought it was from supper. LPN #1 stated, Later in the evening, around 10:15 p.m., the CNAs hollered at me to come down to (Resident #1's) room. Her (left) sleeve was saturated with blood. I saw the gaping wound on her left arm. I asked (LPN #2) what she thought we should do with it? We both decided to send the resident to the hospital. We found smears of blood on her baby powder bottle, the bedside table and the side rail. When they (CNAs) started cleaning the blood off of her right hand she started screaming and I noticed a little scratch on the right wrist. LPN #1 stated she called the DON at 10:25 p.m. to report the wound to the left arm. At that time, the DON instructed her to get witness statements. LPN #1 stated she did not report to the DON any injury to the right arm because she did not see issues with the right arm. LPN #1 was asked, Did you have any idea that night that the two CNAs (CNA #2 and CNA #3), thought (CNA #1) might have caused those injuries? LPN #1 stated, No. LPN #1 was asked did you read the witness statements that night? LPN #1 stated, No, I didn't because it was so late and I was trying to fill out the I/A (Incident and Accident) and I had to talk to the police officer. 4) On [DATE] at 1:55 p.m., LPN #2 stated, .at 10:00 p.m. ([DATE]) I was finishing my med. pass. (LPN #1) was on 400 hall called me to bring the treatment cart. She took me into (Resident #1's) room and showed me the wound to the resident's left arm. It was awful. I asked the resident how it happened. (Resident #1) stated, one of those colored girls twisted my arm. I asked (LPN #1) was her arm this way earlier? She said I'm not sure. I don't see how I would've missed that. LPN #2 was asked if she believed the resident when she made the allegation that someone had twisted her arm? LPN #2 stated, I did believe her. You can't make something like that up. 5) On [DATE] at 12:12 p.m., LPN #3 (,[DATE] shift), stated, I came in to relieve (LPN #1) on 400 hall at 10:35 p.m. ([DATE]). As soon as I got here, (LPN #2) told me to go see the resident's arm. I went to (Resident #1's) room and she told me there were two nurses that grabbed her arm when she was trying to roll over. She said they grabbed her arms. LPN #3 stated there was no way that it (the injury) was consistent with her doing that to herself. LPN #3 was asked if Resident #1 had a routine of yelling when staff provided care. LPN #3 stated, No, not at night. f. The DMS (Division of Medical Services) -7724 (Incident and Accident Reporting) form dated [DATE] at 10:15 p.m. documented, On the evening of [DATE], LPN was called to (Resident #1's) room by CNAs. Upon entering resident room, resident was noted to have a large open area/skin tear to the left forearm. When asked what might have happened. (Resident #1) stated that 'a black female CNA was helping to roll her over and she was trying to help CNA roll and the CNA grabbed her wrists and started hitting them together and beating her up.' (Resident #1) was presented with all African American CNAs on the ,[DATE] shift for possible identification. Resident unable to identify any positive match. (Resident #1) sent to (hospital) for further evaluation and treatment. Investigation continued at this time. 1) The DMS-762 (Facility Investigation) witness statement dated [DATE] at 11:45 a.m. and signed by LPN #1 documented, This nurse had passed bedtime meds. to res around 8:30 - 8:45 p.m. on [DATE]. At that time res had reached for meds in med cup as she always does and used hands and arms to get drinks. No blood or cuts or scratches was noted to arms. Res did ask this nurse to rub her R (right) arm with Voltren Cream that is used on her knees and legs because her R arm and wrist are hurting because a black CNA had twisted her arm while she was changing her. (LPN #1) rubbed her arm and did not notice any scratches or cuts to either arm and res was using L arm and hand to show this nurse where to rub cream and explained to res that ,[DATE] shift wasn't here, but this nurse would investigate what res had stated happened. At this time this nurse did notice the front of res shirt was dirty and she had spot on corner of her mouth on L side, but this nurse thought it was from supper because they had something red for supper. At app. (approximately) 10:15 p.m. was notified by (CNA #1 and CNA #2) that res had wound to her arm. Upon entering res room this nurse noted Lg (large) open area to L (left) forearm.Res. did have large amount of blood on R sleeve of shirt from wound bleeding. No blood was on bed or on blanket that res covered up with and when this nurse questioned res about what happened to arm. Res stated it happened when the CNA twisted her arm. This nurse then called for (LPN #2) to come to room and bring treatment cart. When (LPN #2) entering she also asked nurse what had happened and res then stated that black CNA was trying to roll her over this morning and res stated she was trying to help her roll her and CNA grabbed her wrists and started hitting then together and beating her up. (LPN #2) and this nurse then left room and decided res needed to go to ER (emergency room ) d/t (due to) how deep wound was and possibly bone was visible. This nurse then called (DON) at app. 10:30 p.m. let her know what happened. She then said to send res to ER and call dtr. first. (LPN #3) on ,[DATE] shift had arrived and this nurse asked her to come to res room and when we entered (LPN #3) asked res what happened. Res then stated that 2 black CNAs had beat her up while white male had watched.Also when (LPN #3) and CNA was cleaning res R (right) arm up to get her ready for transport res was hollering in severe pain . 2) The DMS-762 witness statement dated [DATE] at 10:20 p.m. and signed by CNA #2 documented, Was doing last round and was helping (CNA #1) change (Resident #1). She checked (Resident #1's roommate) and I went to (Resident #1's) bed to check her. Noticed blood on her shirt. Notified (CNA #1) quickly to get LPN for 400 hall. (Earlier) At 7:45 p.m. I heard (Resident #1) yell and went into room, at this time (CNA #1) was about to change her so I assisted her. She was upset but nothing to alarm me she wasn't hurt in anyway. I didn't see any blood at this time. The 2nd DMS-762 witness statement dated [DATE] and signed by CNA #2 documented, I need to add to my report - when finding the skin tear and reporting I never believed or thought for once that (Resident #1) did this to herself. 3) The DMS-762 witness statement dated [DATE] at 10:20 p.m. and signed by CNA #1 documented, I, (CNA #1) did my rounds at 7:45 p.m. with the help of (CNA #2) as I always get another aide to assist me because of the screaming she does. There was nothing wrong with her or her arm. At 10:20 we getting ready to do the last round (CNA #2) and I went into (Rm.) 414 together and I went to check on (roommate) and (CNA #2) said come here and look at this, (Resident #1) have a skin tear on her arm. So, I notified (LPN #1) of what we saw. She came down to the room. 4) The DMS-762 witness statement dated [DATE] at 10:20 p.m. and signed by CNA #3 documented , I was in (Resident #1's) room around dinner time to feed her there were no tears on her arms, because I gave her juice in her left hand and her candy bar in her right head. The only time I recall her shouting and fussing was when she was getting changed during the 8pm rounds, and that's when (CNA #1) said (CNA #2) came in to assist her. At that time at 10:20 p.m. was when she brought it to the other CNAs attention that she had a skin tear on her left arm. g. Additional staff interview information: 1) On [DATE] at 11:25 a.m., CNA #3 stated she had a discussion in the break room with CNA #2 regarding the incident involving Resident #1 after the resident had been sent to the hospital. CNA #3 stated that CNA #1 was trying to say that the resident had done that to herself. CNA #3 stated, I told (CNA #2) it does not add up. She (Resident #1) can't do that to herself. She can't. I told (CNA #2) that she's heard people say (CNA #1's) mean just like I have and I told her I was just written up (three days after incident on [DATE]) and if she don't go tell (Administrator) her suspicions then I would. CNA #3 stated, I don't think (CNA #1) did it intentionally. But she did it. Even if you didn't intentionally do it, don't try to cover it up. CNA #3 stated, Her (CNA #1) tone is demanding. She has a deep voice. I've been told she's mean. She was asked what about the resident's fracture to her right arm? CNA #3 stated, I couldn't see the resident doing that to herself either. She's not capable of the movement. Someone would have to literally hold her arm. CNA #3 stated, That night CNA #1 was saying that the resident did it to herself. I told (CNA #1), I don't know who your trying to convince, but it's not me. CNA #3 was asked if she reported her suspicions that night ([DATE]) to the Administration. CNA #3 stated, No. CNA #3 was asked about her write up. She stated, I accept that. I have heard she's (CNA #1) aggressive. I have heard residents say she's mean. Did you report that residents had told you (CNA #1) was mean? CNA #3 stated, No, they (Administration) know their employees. There's no way (Administrator) hasn't heard that. 2) On [DATE] at 12:29 p.m., CNA #1 stated, It was between 7:07 - 7:12 p.m. ([DATE]), I asked the resident if she was wet.Anytime you touch her she screams, she yells. I told her to turn to the right, she grabbed the side rail. I reached across the resident and pulled on the draw sheet. She yelled out when I was pulling her over. When (CNA #2) came into the room the resident said, 'You're hurting me.' (CNA #2) started helping and the resident said, 'She's killing me.' (CNA #2) said to the resident, 'No, she's just trying to change you.' I never had a problem with (Resident #1). There was nothing wrong with her. At 10:20 p.m., I was going to do my last round. I told (CNA #2) we need to change her. We both went into the room, (CNA #2) went to (Resident #1) and I was with (Roommate). CNA #2 saw the resident's arm and called me over to resident. That's when we saw the blood. Her nails were full of blood. I told (LPN #1). I said it was a skin tear, but I had no idea it was that bad. 3) On [DATE] at 12:00 p.m., the DON stated, On [DATE] at 10:24 p.m., LPN #1 called me and all she said was that they (CNAs) had gone into the room. She had a skin tear, well it's worse than a skin tear. She has a 3 inch gash on her arm. I think I can see bone, it's deep. I can't get a hold of the doctor. I told (LPN #1) to send her anyway. Call the daughter and send her to the ER. (LPN #1) said the resident is digging in it. DON stated she told (LPN #1) that it probably hurts. The DON was asked if LPN #1 had reported to her Resident #1 had made an allegation that a black CNA had twisted her arm? The DON stated, No. The DON stated it was not until mid day on [DATE] when she became aware Resident #1 had sustained a fracture to the right arm, after the resident had been sent to the hospital. h. On [DATE] at 10;15 a.m., the Administrator stated CNA #1 was allowed to work the entire ,[DATE] shift on [DATE] and a full ,[DATE] shift on Tuesday [DATE]. He also stated that he was not aware that CNA #2 and CNA #3's had suspected CNA #1 had caused the resident's injuries until [DATE]. 2. Resident #6 had [DIAGNOSES REDACTED]. The Quarterly MDS with an ARD of [DATE] documented the resident scored 13 (13 - 15 indicates cognitively intact) on a BIMS and required limited assistance of one person for bed mobility. On [DATE] at 3:15 p.m., Resident #6 was asked if CNA #1 had been mean, rude or inappropriate to her? Resident #6 stated, Yes, she is, never been to me. But I've seen and heard. I have seen her grab a women's wrist. She's grouchy. I think that some people, she can do that to and some she can't. There was a woman in the next room, Room (Room number). I was a friend to that lady. She had bruises to her arms and chest. She died . She's (CNA #1) hateful. She's not too patient with a lot of them. Resident #6 was asked you're certain it was (CNA #1)? Resident #6 stated, Yes, she's short, broad. Most of the time her hair is balled up on top of her head and most of time she's on this end of the hall working. 3. Resident #7 had [DIAGNOSES REDACTED]. The Quarterly MDS with an ARD of [DATE] documented the resident scored 11 (8 - 12 indicates moderately impaired) on a BIMS and required extensive assistance of one person for bed mobility. a. On [DATE] at 2:45 p.m., Resident #7 was asked about staff treatment, specifically CNA #1. She stated, I know her. She's never done anything to me, but she's not one of the nicest ones. Just not real friendly. 4. The facility removed the Immediate Jeopardy and reduced the scope/severity to H on [DATE] (prior to the initiation of the survey) by taking the following actions. 1) At approximately 10:24 p.m. [DATE], DON instructed nurse to have all African American CNAs to come to room for possible identification. a. No positive identification given for current staff b. All direct care staff to write witness statements 2) At 10:35 p.m. on [DATE], notify (ambulance service) to transport resident to ER (remove resident from facility) 3) Closest possible morning shift employee was held from starting shift on Aug. 17, 2015, until interview with DON and Administrator. a. Witness statement that was given reports that possible resembled CNA was not assigned to resident room. b. Witness statement given by CNA (CNA #5) confirmed he was only CNA to assist resident c. Further statement review, indicates no signs/symptoms of pain given by resident during day shift. 4) On [DATE], at approximately 8:00 a.m. after review of witness statements, all Alert/Oriented residents were interviewed as to if any employee had been abusive to them in the recent time. a. All residents stated no. 5) Inservice began on Aug. 17, 2015, at 8:00 a.m. on the policy and procedure for the reporting and prevention of abuse. 6) Investigation of resident's surrounding in bedroom conducted by Admin and DON at approximately 8:30 am a. Side rail found to have missing plastic protector at base. b. Maintenance repaired plug shortly after 7) Due to witness statements given by employee and residents, as of 9:00 am on [DATE], no suspicious finding of possible abuse from employee. 8) On [DATE], due to family concern on suspected abuse, the option was given for resident to be transferred to another hall. a. family did not want to move resident at that time. 9) On [DATE], at approximately 5:00 p.m. (CNA #3) reported to Admin and DON the feeling of possible abuse to resident by (CNA #1) a. (CNA #3) inserviced on the immediate reporting of suspected abuse at 5:30 p.m. 10) CNA #1 immediately put onto administrative leave on [DATE], at 5:30 p.m. 11) Due to further reporting of suspected abuse via DHS, CNA #2 and LPN #1 also inserviced on the immediate reporting of suspected abuse on [DATE]. 5. On [DATE] at 3:50 p.m., the Administrator and the DON was asked how did the facility monitor the effectiveness of these inservices, how did the facility know if the staff understood the information covered in the inservices to prevent reoccurrences. They stated they did not have a monitoring system in place.

Complaint # (AR 573) substantiated, all or in part, in these findings. Based on record review and interview, the facility failed to ensure staff implemented the facility's abuse policy and procedure as evidenced by the facility's failure to ensure an allegation of staff to resident abuse involving Certified Nursing Assistant (CNA) #1 was immediately reported to the Administrator/Designee to assure an investigation was promptly initiated and residents were protected from the potential of further abuse for 1 (Resident #1) of 7 case mix residents (Resident #s ,[DATE]), who required assistance with bed mobility and had reported an allegation of staff to resident abuse. This failed practice resulted in Immediate Jeopardy which caused or could have caused serious harm, injury or death to Resident #1, who alleged CNA #1 beat her up and who sustained skin tears to left arm and fracture of right arm. This failed practice had the potential cause more than minimal harm to 70 residents who required assistance with bed mobility in the facility according to a list provided by the Administrator on [DATE] at 11:36 a.m. The facility removed the Immediate Jeopardy prior to the survey entrance date. However, all the underlying deficient practices had not been corrected. The facility Administration was informed of the Immediate Jeopardy removed on [DATE] at 4:05 p.m. The findings are: 1. The facility's Abuse Investigation & Reporting Policy and Procedure (no effective date given) documented, .All incidents of alleged or suspected resident mistreatment, neglect, or abuse, including injuries of unknown source, and misappropriation of resident property must be reported immediately to the Administrator or the Administrative Designee by a facility employee. 2. Resident #1 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] documented the resident scored 12 (8 - 12 indicates moderately impaired) on the Brief Interview for Mental Status (BIMS), required limited assistance of one person for bed mobility, was occasionally incontinent, and had limited range of motion of both upper extremities. a. The nurse's notes dated [DATE] at 10:15 p.m. and signed by Licensed Practical Nurse (LPN) #1 documented, .was notified per CNAs that res (resident) had wound to l (left) forearm upon entering res room res was noted to have large open area to l forearm. Res stated that black CNA in the morning was trying to roll res over and the CNA grabbed her wrists and started hitting them together and beating her up. This nurse then called (LPN #2) to room to look at wound and we decided that res needed to go to ER (emergency room ) d/t (due to) being able to see bone in some places. This nurse then called (DON (Director of Nursing)) to let her know what was going on and she stated to go ahead and send her to ER attempted to call on MD (medical doctor) and never received call back. (DON) also stated at this time to call res. dtr. (daughter).(DON) called back and stated to have all black CNAs go in res room to see if she could identify anyone of them. The only one that was close was (CNA #4) but res stated that she was not big enough res stated that it was a big girl and she had normal hair.This nurse and (LPN #3) looked res room over and res shirt had fresh blood on her cup and baby powder bottle, on the bedside table and on opposite handrail and under her nails, on her chin and forehead and wound still had fresh active bleeding noted at 10:35 p.m.After res left this nurse notified (Administrator) and he stated that it would be a reportable and to get witness statements and to call police and let him know of findings when CNAs went to res room and he asked if anyone matched her description and let her know that there is one on days that does and he stated not to let that CNA clock-in in the morning until he gets here . b. The nurse's notes dated [DATE] at 12:07 a.m. and signed by LPN #1 documented, .was notified per CNAs (CNA #1 and CNA #2) to come to res room that res had wound to L arm. Upon entering res room res was noted to have Lg (large) open area/skin tear to L forearm. Res stated that a black female CNA was helping her roll over and she was trying to help CNA roll and the CNA grabbed her wrists and started hitting then together and beating her up. Res had app. (approximately) 3.5 inch long and app. 2.5 inch wide open area/skin tear to l forearm and deep enough that it looked like bone in some areas and wound was bleeding large amount of blood . c. The hospital discharge summary dated [DATE] documented, .The patient told her daughter that there was a staff member that was moving her in the bed in a vigorous fashion and that her arms were being pushed together, and that the fracture occurred that way . d. The hospital x-ray results dated [DATE] documented, The bones are severely osteopenic, limiting assessment for detection of acute fracture. There is a [MEDICATION NAME] minimally impacted [MEDICAL CONDITION] right ulnar metadisphysis. On the lateral view, there is appearance of a nondisplaced [MEDICAL CONDITION] metaphysis of the radius with cortical step-off volarly and sclerotic linear density obliquely. Vascular calcifications are present. Impression: Fractures of the distal right radius and ulna. Ulnar fracture was noted by the emergency room physician at the time of examination. e. Staff interviews were conducted: 1) On [DATE] at 9:51 a.m., CNA #2 stated, ([DATE]) It was about 7:08 p.m. I was walking down the 400 hall toward the nurse's station, I heard a yell from a room, then I turned around to go into (Room Number) room. (CNA #1) was on the other side of (Resident #1's) bed facing the door. (Resident #1) was mad. (Resident #1) said, 'get her off me. I just calmed her down. This lady (Resident #1) can turn herself. I didn't see any blood, I would've reported it. App. 10:20 p.m., during last round, (CNA #1) asked me to change (Resident #1). I went to (Resident #1's ) bed. This is when I saw blood. It was all over her hand, under her finger nails. (Resident #1) said the nurse beat her up and she grabbed me. But she calls everybody nurse.(CNA #1) works with (Resident #1) all the time. (Resident #1) can turn herself, she will get upset with staff if she thinks they are going to force her. I didn't see anything, I don't think she meant to do anything. I think (CNA #1) did it by accident. I believe that's what happened. I never thought the resident did this to herself. CNA #2 stated when she heard the resident yell out it concerned her enough to turn around to go back into the room. CNA #2 was asked if she reported what the resident had said regarding, get her off me. CNA #2 stated, No, because she didn't see anything wrong with the resident when she first walked into the room. CNA #2 stated that it was not until the last round app. 10:20 p.m., when we called the nurse into the room when we saw the blood. 2) On [DATE] at 11:25 a.m., CNA #3 stated, I worked that night ([DATE]). I fed the resident that evening between 5:30 and 6:00 p.m I know there was nothing wrong with (Resident #1) at the time I fed her, because I gave her a drink in one hand and candy bar in her other hand. I know nothing was wrong because she was reaching to get the drink and candy bar. She had no complaints of anything. CNA #3 stated, The resident will let you know right then if you touch her to roll her over, she will yell. That's her way of letting you know don't touch me or you're hurting her. If you ask her to turn over, she will roll herself. The only time I can recall her yelling out that evening, it was around the 8 o'clock (round) window. I heard her yell, 'No, No stop, leave me alone.' When I heard that I was in another patient's room. I thought in my head, someone was changing her. CNA #3 stated, She's (Resident #1) not the type of resident that would do that to herself. It's not physically possible. Her hands do not have ability to cause a gash like that in her arm. I saw it. It was a bad opening. 3) On [DATE] at 12:50 p.m., LPN #1 stated, I was down the 400 hall passing meds. (medications) around 8:30 - 8:45 p.m I did her (Resident #1) meds. I handed her her bottle of water. She was able to hold it. She asked me to put cream on her arm. LPN #1 was asked about her statement which documented the resident asked you at app. 8:30 - 8:45 p.m. to put cream on her right arm because her right arm and wrist were hurting because a black CNA had twisted her arm while changing her. LPN #1 was asked did you report the allegation? LPN #1 stated, No, I was trying to do my med. pass and get the treatments done. I didn't see anything out of the ordinary, no swelling or bruising or anything like that. I saw red specks on her top and next to her mouth but I thought it was from supper. LPN #1 stated, Later in the evening, around 10:15 p.m., the CNAs hollered at me to come down to (Resident #1's) room. Her (left) sleeve was saturated with blood. I saw the gaping wound on her left arm. I asked (LPN #2) what she thought we should do with it? We both decided to send the resident to the hospital. We found smears of blood on her baby powder bottle, the bedside table and the side rail. When they (CNAs) started cleaning the blood off of her right hand she started screaming and I noticed a little scratch on the right wrist. LPN #1 stated she called the DON at 10:25 p.m. to report the wound to the left arm. At that time, the DON instructed her to get witness statements. LPN #1 stated she did not report to the DON any injury to the right arm because she did not see issues with the right arm. LPN #1 was asked, Did you have any idea that night that the two CNAs (CNA #2 and CNA #3), thought (CNA #1) might have caused those injuries? LPN #1 stated, No. LPN #1 was asked did you read the witness statements that night? LPN #1 stated, No, I didn't because it was so late and I was trying to fill out the I/A (Incident and Accident) and I had to talk to the police officer. 4) On [DATE] at 1:55 p.m., LPN #2 stated, .at 10:00 p.m. ([DATE]) I was finishing my med. pass. (LPN #1) was on 400 hall called me to bring the treatment cart. She took me into (Resident #1's) room and showed me the wound to the resident's left arm. It was awful. I asked the resident how it happened. (Resident #1) stated, one of those colored girls twisted my arm. I asked (LPN #1) was her arm this way earlier? She said I'm not sure. I don't see how I would've missed that. LPN #2 was asked if she believed the resident when she made the allegation that someone had twisted her arm? LPN #2 stated, I did believe her. You can't make something like that up. 5) On [DATE] at 12:12 p.m., LPN #3 (,[DATE] shift), stated, I came in to relieve (LPN #1) on 400 hall at 10:35 p.m. ([DATE]). As soon as I got here, (LPN #2) told me to go see the resident's arm. I went to (Resident #1's) room and she told me there were two nurses that grabbed her arm when she was trying to roll over. She said they grabbed her arms. LPN #3 stated there was no way that it (the injury) was consistent with her doing that to herself. LPN #3 was asked if Resident #1 had a routine of yelling when staff provided care. LPN #3 stated, No, not at night. f. The DMS (Division of Medical Services) -7724 (Incident and Accident Reporting) form dated [DATE] at 10:15 p.m. documented, On the evening of [DATE], LPN was called to (Resident #1's) room by CNAs. Upon entering resident room, resident was noted to have a large open area/skin tear to the left forearm. When asked what might have happened. (Resident #1) stated that 'a black female CNA was helping to roll her over and she was trying to help CNA roll and the CNA grabbed her wrists and started hitting them together and beating her up.' (Resident #1) was presented with all African American CNAs on the ,[DATE] shift for possible identification. Resident unable to identify any positive match. (Resident #1) sent to (hospital) for further evaluation and treatment. Investigation continued at this time. 1) The DMS-762 (Facility Investigation) witness statement dated [DATE] at 11:45 a.m. and signed by LPN #1 documented, This nurse had passed bedtime meds. to res around 8:30 - 8:45 p.m. on [DATE]. At that time res had reached for meds in med cup as she always does and used hands and arms to get drinks. No blood or cuts or scratches was noted to arms. Res did ask this nurse to rub her R (right) arm with Voltren Cream that is used on her knees and legs because her R arm and wrist are hurting because a black CNA had twisted her arm while she was changing her. (LPN #1) rubbed her arm and did not notice any scratches or cuts to either arm and res was using L arm and hand to show this nurse where to rub cream and explained to res that ,[DATE] shift wasn't here, but this nurse would investigate what res had stated happened. At this time this nurse did notice the front of res shirt was dirty and she had spot on corner of her mouth on L side, but this nurse thought it was from supper because they had something red for supper. At app. (approximately) 10:15 p.m. was notified by (CNA #1 and CNA #2) that res had wound to her arm. Upon entering res room this nurse noted Lg (large) open area to L (left) forearm.Res. did have large amount of blood on R sleeve of shirt from wound bleeding. No blood was on bed or on blanket that res covered up with and when this nurse questioned res about what happened to arm. Res stated it happened when the CNA twisted her arm. This nurse then called for (LPN #2) to come to room and bring treatment cart. When (LPN #2) entering she also asked nurse what had happened and res then stated that black CNA was trying to roll her over this morning and res stated she was trying to help her roll her and CNA grabbed her wrists and started hitting then together and beating her up. (LPN #2) and this nurse then left room and decided res needed to go to ER (emergency room ) d/t (due to) how deep wound was and possibly bone was visible. This nurse then called (DON) at app. 10:30 p.m. let her know what happened. She then said to send res to ER and call dtr. first. (LPN #3) on ,[DATE] shift had arrived and this nurse asked her to come to res room and when we entered (LPN #3) asked res what happened. Res then stated that 2 black CNAs had beat her up while white male had watched.Also when (LPN #3) and CNA was cleaning res R (right) arm up to get her ready for transport res was hollering in severe pain . 2) The DMS-762 witness statement dated [DATE] at 10:20 p.m. and signed by CNA #2 documented, Was doing last round and was helping (CNA #1) change (Resident #1). She checked (Resident #1's roommate) and I went to (Resident #1's) bed to check her. Noticed blood on her shirt. Notified (CNA #1) quickly to get LPN for 400 hall. (Earlier) At 7:45 p.m. I heard (Resident #1) yell and went into room, at this time (CNA #1) was about to change her so I assisted her. She was upset but nothing to alarm me she wasn't hurt in anyway. I didn't see any blood at this time. The 2nd DMS-762 witness statement dated [DATE] and signed by CNA #2 documented, I need to add to my report - when finding the skin tear and reporting I never believed or thought for once that (Resident #1) did this to herself. 3) The DMS-762 witness statement dated [DATE] at 10:20 p.m. and signed by CNA #1 documented, I, (CNA #1) did my rounds at 7:45 p.m. with the help of (CNA #2) as I always get another aide to assist me because of the screaming she does. There was nothing wrong with her or her arm. At 10:20 we getting ready to do the last round (CNA #2) and I went into (Rm.) 414 together and I went to check on (roommate) and (CNA #2) said come here and look at this, (Resident #1) have a skin tear on her arm. So, I notified (LPN #1) of what we saw. She came down to the room. 4) The DMS-762 witness statement dated [DATE] at 10:20 p.m. and signed by CNA #3 documented , I was in (Resident #1's) room around dinner time to feed her there were no tears on her arms, because I gave her juice in her left hand and her candy bar in her right head. The only time I recall her shouting and fussing was when she was getting changed during the 8pm rounds, and that's when (CNA #1) said (CNA #2) came in to assist her. At that time at 10:20 p.m. was when she brought it to the other CNAs attention that she had a skin tear on her left arm. g. Additional staff interview information: 1) On [DATE] at 11:25 a.m., CNA #3 stated she had a discussion in the break room with CNA #2 regarding the incident involving Resident #1 after the resident had been sent to the hospital. CNA #3 stated that CNA #1 was trying to say that the resident had done that to herself. CNA #3 stated, I told (CNA #2) it does not add up. She (Resident #1) can't do that to herself. She can't. I told (CNA #2) that she's heard people say (CNA #1's) mean just like I have and I told her I was just written up (three days after incident on [DATE]) and if she don't go tell (Administrator) her suspicions then I would. CNA #3 stated, I don't think (CNA #1) did it intentionally. But she did it. Even if you didn't intentionally do it, don't try to cover it up. CNA #3 stated, Her (CNA #1) tone is demanding. She has a deep voice. I've been told she's mean. She was asked what about the resident's fracture to her right arm? CNA #3 stated, I couldn't see the resident doing that to herself either. She's not capable of the movement. Someone would have to literally hold her arm. CNA #3 stated, That night CNA #1 was saying that the resident did it to herself. I told (CNA #1), I don't know who your trying to convince, but it's not me. CNA #3 was asked if she reported her suspicions that night ([DATE]) to the Administration. CNA #3 stated, No. CNA #3 was asked about her write up. She stated, I accept that. I have heard she's (CNA #1) aggressive. I have heard residents say she's mean. Did you report that residents had told you (CNA #1) was mean? CNA #3 stated, No, they (Administration) know their employees. There's no way (Administrator) hasn't heard that. 2) On [DATE] at 12:29 p.m., CNA #1 stated, It was between 7:07 - 7:12 p.m. ([DATE]), I asked the resident if she was wet.Anytime you touch her she screams, she yells. I told her to turn to the right, she grabbed the side rail. I reached across the resident and pulled on the draw sheet. She yelled out when I was pulling her over. When (CNA #2) came into the room the resident said, 'You're hurting me.' (CNA #2) started helping and the resident said, 'She's killing me.' (CNA #2) said to the resident, 'No, she's just trying to change you.' I never had a problem with (Resident #1). There was nothing wrong with her. At 10:20 p.m., I was going to do my last round. I told (CNA #2) we need to change her. We both went into the room, (CNA #2) went to (Resident #1) and I was with (Roommate). CNA #2 saw the resident's arm and called me over to resident. That's when we saw the blood. Her nails were full of blood. I told (LPN #1). I said it was a skin tear, but I had no idea it was that bad. 3) On [DATE] at 12:00 p.m., the DON stated, On [DATE] at 10:24 p.m., LPN #1 called me and all she said was that they (CNAs) had gone into the room. She had a skin tear, well it's worse than a skin tear. She has a 3 inch gash on her arm. I think I can see bone, it's deep. I can't get a hold of the doctor. I told (LPN #1) to send her anyway. Call the daughter and send her to the ER. (LPN #1) said the resident is digging in it. DON stated she told (LPN #1) that it probably hurts. The DON was asked if LPN #1 had reported to her Resident #1 had made an allegation that a black CNA had twisted her arm? The DON stated, No. The DON stated it was not until mid day on [DATE] when she became aware Resident #1 had sustained a fracture to the right arm, after the resident had been sent to the hospital. h. On [DATE] at 10;15 a.m., the Administrator stated CNA #1 was allowed to work the entire ,[DATE] shift on [DATE] and a full ,[DATE] shift on Tuesday [DATE]. He also stated that he was not aware that CNA #2 and CNA #3's had suspected CNA #1 had caused the resident's injuries until [DATE]. 3. Resident #6 had [DIAGNOSES REDACTED]. The Quarterly MDS with an ARD of [DATE] documented the resident scored 13 (13 - 15 indicates cognitively intact) on a BIMS and required limited assistance of one person for bed mobility. On [DATE] at 3:15 p.m., Resident #6 was asked if CNA #1 had been mean, rude or inappropriate to her? Resident #6 stated, Yes, she is, never been to me. But I've seen and heard. I have seen her grab a women's wrist. She's grouchy. I think that some people, she can do that to and some she can't. There was a woman in the next room, Room (Room number). I was a friend to that lady. She had bruises to her arms and chest. She died . She's (CNA #1) hateful. She's not too patient with a lot of them. Resident #6 was asked you're certain it was (CNA #1)? Resident #6 stated, Yes, she's short, broad. Most of the time her hair is balled up on top of her head and most of time she's on this end of the hall working. 4. Resident #7 had [DIAGNOSES REDACTED]. The Quarterly MDS with an ARD of [DATE] documented the resident scored 11 (8 - 12 indicates moderately impaired) on a BIMS and required extensive assistance of one person for bed mobility. a. On [DATE] at 2:45 p.m., Resident #7 was asked about staff treatment, specifically CNA #1. She stated, I know her. She's never done anything to me, but she's not one of the nicest ones. Just not real friendly. 5. The facility removed the Immediate Jeopardy and reduced the scope/severity to H on [DATE] (prior to the initiation of the survey) by taking the following actions. 1) At approximately 10:24 p.m. [DATE], DON instructed nurse to have all African American CNAs to come to room for possible identification. a. No positive identification given for current staff b. All direct care staff to write witness statements 2) At 10:35 p.m. on [DATE], notify (ambulance service) to transport resident to ER (remove resident from facility) 3) Closest possible morning shift employee was held from starting shift on Aug. 17, 2015, until interview with DON and Administrator. a. Witness statement that was given reports that possible resembled CNA was not assigned to resident room. b. Witness statement given by CNA (CNA #5) confirmed he was only CNA to assist resident c. Further statement review, indicates no signs/symptoms of pain given by resident during day shift. 4) On [DATE], at approximately 8:00 a.m. after review of witness statements, all Alert/Oriented residents were interviewed as to if any employee had been abusive to them in the recent time. a. All residents stated no. 5) Inservice began on Aug. 17, 2015, at 8:00 a.m. on the policy and procedure for the reporting and prevention of abuse. 6) Investigation of resident's surrounding in bedroom conducted by Admin and DON at approximately 8:30 am a. Side rail found to have missing plastic protector at base. b. Maintenance repaired plug shortly after 7) Due to witness statements given by employee and residents, as of 9:00 am on [DATE], no suspicious finding of possible abuse from employee. 8) On [DATE], due to family concern on suspected abuse, the option was given for resident to be transferred to another hall. a. family did not want to move resident at that time. 9) On [DATE], at approximately 5:00 p.m. (CNA #3) reported to Admin and DON the feeling of possible abuse to resident by (CNA #1) a. (CNA #3) inserviced on the immediate reporting of suspected abuse at 5:30 p.m. 10) CNA #1 immediately put onto administrative leave on [DATE], at 5:30 p.m. 11) Due to further reporting of suspected abuse via DHS, CNA #2 and LPN #1 also inserviced on the immediate reporting of suspected abuse on [DATE]. 6. On [DATE] at 3:50 p.m., the Administrator and the DON was asked how did the facility monitor the effectiveness of these inservices, how did the facility know if the staff understood the information covered in the inservices to prevent reoccurrences. They stated they did not have a monitoring system in place.

Complaint # (AR 438) and # (AR 445) were substantiated (all or in part) in these findings. Based on observations, record review and interviews, the facility failed to ensure policies and procedures to prohibit neglect were implemented to assure necessary care and services were consistently provided for oral and denture care to prevent infections of the oral cavity for 1 of 1 (Resident #6) case mix resident who required the use of dentures, was dependent on staff for oral care, and was cognitively impaired. This resulted in a pattern of harm for Resident #6 who was hospitalized with a [DIAGNOSES REDACTED]. This failed practice had the potential to cause more than minimal harm to 15 residents who required the use of dentures, were dependent for oral care, and cognitively impaired as per a list provided by the Medicare Manager on 7/15/15 at 12:45 p.m. The findings are: 1. The facility's Resident Abuse policy documented, .1. Neglect-Failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. Neglect occurs on an individual basis when a resident does not receive care in one or more areas. 2. Resident #6 had [DIAGNOSES REDACTED]. The Annual Minimum Data Set with an Assessment Reference date of 6/10/15 documented the resident was severely impaired in cognitive skills for daily decision making per the Staff Assessment for Mental Status and required extensive assistance with personal hygiene. a. A dental report dated 1/21/15 documented, Cleaned upper partial -very very dirty-covered in thick buildup [MEDICATION NAME] on lower teeth. b. A grievance report dated 1/21/15 documented, Resident went to dentist today. Upon arrival, dentures were noted to be unclean with food on them. The action taken documented, Denture/oral care in-service started on 1/21/15 for oral/denture care to be done every shift. c. A physician orders [REDACTED]. d. A grievance report, not dated, documented, (Name of daughter) the daughter of resident (Resident #6) reported to the interim DON (Director of Nursing) that when her mother went to the ER (emergency room ) following a fall the resident's toenails were excessively long. Her mother is a diabetic. She further states that other times when has had issue with the resident's teeth being unclean. The response documented, The DON had a lengthy conversation with the family member. (Treatment Nurse) the tx (treatment) nurse is to get the toenails trimmed immediately. I will speak to the housekeeping supervisor as well as the nursing staff in regards to the other issues. The form had the Administrator's signature at the bottom of the form with a date of 3/17/15 e. An in-service dated 3/20/15 documented the topics covered as Checking orders/24 hour chart checks, Responsible for admit, Bagging linens, peri-care -supplies on cart down hallway, nail care, handwashing, in-service book, charge nurse; CNA roles, meal service/meal monitoring, meals for employees, documentation and Incentive program. There was no documentation on this form that indicated the staff was in-serviced regarding oral/denture care. The in-service was signed as being conducted by the Administrator. f. Progress Notes dated 7/9/15 at 4:33 a.m., documented, Send to ER for eval (evaluation) due to swelling of nose, cheeks and upper lip. There was no other documentation in the nurses notes regarding this issue. g. A Incident report dated 7/9/15 at 4:44 a.m., documented the description as: CNA (Certified Nursing Assistant) brought this writer to rm (room) 105 to observe res (resident's) face. Noted her face seems swollen around mouth, nose seems swollen, also cheeks and under eyes. Small amt (amount) of old blood seen in mouth, dried around lips. Mouth care done but res is very tender in mouth, has trouble opening mouth and also very tender to touch on cheeks, nose and upper lip is also swollen. The notes section documented, Noted res had old blood in mouth and dried on lips. Mouth care done but res has difficulty opening mouth due to pain. On close exam found face to be swollen and very tender to touch around mouth, nose, both cheeks and under eyes. Res is able to answer yes and no questions but cannot elaborate as to anything that may have happened to her face. She can say 'yes' that it hurts, Given APAP ([MEDICATION NAME]) 650 mg (milligrams) crushed in applesauce, which she did get down with difficulty. h. The emergency room report dated 7/9/15 at 4:47 a.m., documented, Patient has a small amount of facial swelling noted to right side of her face over the maxillary sinus region. This area is tender to palpation. It is slightly [DIAGNOSES REDACTED]tous. The oral pharynx is this patient to have upper dentures which have not been removed for quite some time and are firmly in place. She has a fetid odor to her breath. There does not appear to be any intraoral trauma. The Radiology interpretation documented, CT (computerized tomography) of the facial bones reveal this patient to have some bony like destruction noted to the maxillary portion of her face on the right side which could be consistent with an [DIAGNOSES REDACTED]. This patient will be admitted to the hospital for IV (intravenous) antibiotics and further care. The ER notes documented, I spoke with the patient's daughter concerning the findings of the CT. The daughter did help keep the patient, while I removed the patient's dentures. There was a lot of foul-smelling odor to this and the patient's gum on the right maxillary side of her mouth is bleeding and broken down from infection. i. The ENT (Ears, Nose and Throat) specialist report dated 7/9/15 at 5:20 p.m., documented, CT showed some bony erosion of the maxilla on the right. Apparently ER had a hard time getting dentures out. Granulation tissue along the right Gingofabial groove along the right maxilla. The [DIAGNOSES REDACTED]. On 7/14/15 at 4:45 p.m., the ENT specialist stated that based on the history that he received her dentures had to have been there a long time. He further stated that he did not see her with her dentures, but was in the area that the dentures fit and it had to have been there a long time. j. The July 2015 Medication Administration Record [REDACTED]. This was documented, with nurses' initials, as being completed at 7:00 p.m. from 7/1 - 8/15. k. On 7/15/15 at 7:55 p.m., Licensed Practical Nurse (LPN) #1 was asked, Did you visually see the dentures in the cup when you initialed it being completed on 7/8/15? She replied, No, the CNA's told me that it was done. l. On 7/15/15 at 8:30 p.m., LPN #2 was asked, Did you visually see the dentures in the cup when you initialed it being completed on 7/3/15 and 7/6/15? She replied, No, I asked the CNA's and they told me they were. m. On 7/15/15 at 8:10 p.m., CNA #1 stated that she had worked for the facility for 7 months and that she floats. She stated that sometimes the resident would refuse to have her dentures removed but she did oral care on her. n. On 7/15/15 at 8:15 p.m., CNA #2 stated that she had worked at the facility since February 2015 and she did not know the resident even had dentures. o. On 7/15/15 at 8:25 p.m., CNA #3 stated that if the resident had her dentures in her mouth she removed them. She stated that she only works the hall where the resident resides two nights a week and that she did put the resident's dentures in a cup on those two nights. p. A form titled, Oral Care/Denture Care Completed was utilized by the CNA's to document the date and shift that they completed the care on the individuals who had dentures. There were forms documenting oral/denture care for January through May 2015. On 7/15/15 at 10:10 a.m., the Administrator stated that she started here in February 2015 and the form was already in place. She did not know why. She was asked to locate any documentation of this form being completed for this resident. As of 7/15/15 at 2:00 p.m., the Administrator did not provide any more forms that documented oral care for this resident. q. The plan of care initiated on 6/8/14 documented a problem of The resident has limited physical mobility r/t (related to) disease process ([MEDICAL CONDITION]) with interventions initiated on 7/13/15 of Clean teeth/partial dentures every morning, bedtime and PRN (as needed). Place dentures in cup with cleaner every bedtime. There was no documentation on the plan of care regarding denture care until 7/13/15. r. On 7/15/15 at 1:10 p.m., the Administrator stated that she was not here when the January 2015 grievance was filed and she did not know what the facility did. She stated she was here when the March 2015 grievance report was submitted and staff were in-serviced but did not know if she talked about oral care or not. She stated that she did not document it on the in-service sheet and she usually does. The Administrator was asked, What system did you put in place to prevent this re-occurring again? She stated, I didn't put any system in place. She stated that now she has in-serviced the staff regarding denture care with return demonstrations and that the CNA's were to report to the nurse if anyone refuses and that the LPN will visually check to make sure the dentures were in a cup at night.

Complaint # (AR 438) and # (AR 445) were substantiated (all or in part) in these findings. Based on observations, record review, and interviews, the facility failed to ensure necessary care and services were consistently provided for oral and denture care to prevent infections of the oral cavity for 1 of 1 (Resident #6) case mix resident who required the use of dentures, was dependent on staff for oral care, and was cognitively impaired. This resulted in a pattern of harm for Resident #6 who was hospitalized with a [DIAGNOSES REDACTED]. This failed practice had the potential to cause more than minimal harm to 15 residents who required the use of dentures, were dependent for oral care, and cognitively impaired as per a list provided by the Medicare Manager on 7/15/15 at 12:45 p.m. The findings are: Resident #6 had [DIAGNOSES REDACTED]. The Annual Minimum Data Set with an Assessment Reference date of 6/10/15 documented the resident was severely impaired in cognitive skills for daily decision making per the Staff Assessment for Mental Status and required extensive assistance with personal hygiene. a. A dental report dated 1/21/15 documented, Cleaned upper partial -very very dirty-covered in thick buildup [MEDICATION NAME] on lower teeth. b. A grievance report dated 1/21/15 documented, Resident went to dentist today. Upon arrival, dentures were noted to be unclean with food on them. The action taken documented, Denture/oral care in-service started on 1/21/15 for oral/denture care to be done every shift. c. A physician orders [REDACTED]. d. A grievance report, not dated, documented, (Name of daughter) the daughter of resident (Resident #6) reported to the interim DON (Director of Nursing) that when her mother went to the ER (emergency room ) following a fall the resident's toenails were excessively long. Her mother is a diabetic. She further states that other times when has had issue with the resident's teeth being unclean. The response documented, The DON had a lengthy conversation with the family member. (Treatment Nurse) the tx (treatment) nurse is to get the toenails trimmed immediately. I will speak to the housekeeping supervisor as well as the nursing staff in regards to the other issues. The form had the Administrator's signature at the bottom of the form with a date of 3/17/15 e. An in-service dated 3/20/15 documented the topics covered as Checking orders/24 hour chart checks, Responsible for admit, Bagging linens, peri-care -supplies on cart down hallway, nail care, handwashing, in-service book, charge nurse; CNA roles, meal service/meal monitoring, meals for employees, documentation and Incentive program. There was no documentation on this form that indicated the staff was in-serviced regarding oral/denture care. The in-service was signed as being conducted by the Administrator. f. Progress Notes dated 7/9/15 at 4:33 a.m., documented, Send to ER for eval (evaluation) due to swelling of nose, cheeks and upper lip. There was no other documentation in the nurses notes regarding this issue. g. A Incident report dated 7/9/15 at 4:44 a.m., documented the description as: CNA (Certified Nursing Assistant) brought this writer to rm (room) 105 to observe res (resident's) face. Noted her face seems swollen around mouth, nose seems swollen, also cheeks and under eyes. Small amt (amount) of old blood seen in mouth, dried around lips. Mouth care done but res is very tender in mouth, has trouble opening mouth and also very tender to touch on cheeks, nose and upper lip is also swollen. The notes section documented, Noted res had old blood in mouth and dried on lips. Mouth care done but res has difficulty opening mouth due to pain. On close exam found face to be swollen and very tender to touch around mouth, nose, both cheeks and under eyes. Res is able to answer yes and no questions but cannot elaborate as to anything that may have happened to her face. She can say 'yes' that it hurts, Given APAP ([MEDICATION NAME]) 650 mg (milligrams) crushed in applesauce, which she did get down with difficulty. h. The emergency room report dated 7/9/15 at 4:47 a.m., documented, Patient has a small amount of facial swelling noted to right side of her face over the maxillary sinus region. This area is tender to palpation. It is slightly [DIAGNOSES REDACTED]tous. The oral pharynx is this patient to have upper dentures which have not been removed for quite some time and are firmly in place. She has a fetid odor to her breath. There does not appear to be any intraoral trauma. The Radiology interpretation documented, CT (computerized tomography) of the facial bones reveal this patient to have some bony like destruction noted to the maxillary portion of her face on the right side which could be consistent with an [DIAGNOSES REDACTED]. This patient will be admitted to the hospital for IV (intravenous) antibiotics and further care. The ER notes documented, I spoke with the patient's daughter concerning the findings of the CT. The daughter did help keep the patient, while I removed the patient's dentures. There was a lot of foul-smelling odor to this and the patient's gum on the right maxillary side of her mouth is bleeding and broken down from infection. i. The ENT (Ears, Nose and Throat) specialist report dated 7/9/15 at 5:20 p.m., documented, CT showed some bony erosion of the maxilla on the right. Apparently ER had a hard time getting dentures out. Granulation tissue along the right Gingofabial groove along the right maxilla. The [DIAGNOSES REDACTED]. On 7/14/15 at 4:45 p.m., the ENT specialist stated that based on the history that he received her dentures had to have been there a long time. He further stated that he did not see her with her dentures, but was in the area that the dentures fit and it had to have been there a long time. j. The July 2015 Medication Administration Record [REDACTED]. This was documented, with nurses' initials, as being completed at 7:00 p.m. from 7/1 - 8/15. k. On 7/15/15 at 7:55 p.m., Licensed Practical Nurse (LPN) #1 was asked, Did you visually see the dentures in the cup when you initialed it being completed on 7/8/15? She replied, No, the CNA's told me that it was done. l. On 7/15/15 at 8:30 p.m., LPN #2 was asked, Did you visually see the dentures in the cup when you initialed it being completed on 7/3/15 and 7/6/15? She replied, No, I asked the CNA's and they told me they were. m. On 7/15/15 at 8:10 p.m., CNA #1 stated that she had worked for the facility for 7 months and that she floats. She stated that sometimes the resident would refuse to have her dentures removed but she did oral care on her. n. On 7/15/15 at 8:15 p.m., CNA #2 stated that she had worked at the facility since February 2015 and she did not know the resident even had dentures. o. On 7/15/15 at 8:25 p.m., CNA #3 stated that if the resident had her dentures in her mouth she removed them. She stated that she only works the hall where the resident resides two nights a week and that she did put the resident's dentures in a cup on those two nights. p. A form titled, Oral Care/Denture Care Completed was utilized by the CNA's to document the date and shift that they completed the care on the individuals who had dentures. There were forms documenting oral/denture care for January through May 2015. On 7/15/15 at 10:10 a.m., the Administrator stated that she started here in February 2015 and the form was already in place. She did not know why. She was asked to locate any documentation of this form being completed for this resident. As of 7/15/15 at 2:00 p.m., the Administrator did not provide any more forms that documented oral care for this resident. q. The plan of care initiated on 6/8/14 documented a problem of The resident has limited physical mobility r/t (related to) disease process ([MEDICAL CONDITION]) with interventions initiated on 7/13/15 of Clean teeth/partial dentures every morning, bedtime and PRN (as needed). Place dentures in cup with cleaner every bedtime. There was no documentation on the plan of care regarding denture care until 7/13/15. r. On 7/15/15 at 1:10 p.m., the Administrator stated that she was not here when the January 2015 grievance was filed and she did not know what the facility did. She stated she was here when the March 2015 grievance report was submitted and staff were in-serviced but did not know if she talked about oral care or not. She stated that she did not document it on the in-service sheet and she usually does. The Administrator was asked, What system did you put in place to prevent this re-occurring again? She stated, I didn't put any system in place. She stated that now she has in-serviced the staff regarding denture care with return demonstrations and that the CNA's were to report to the nurse if anyone refuses and that the LPN will visually check to make sure the dentures were in a cup at night.

Complaint # (AR 438) and # (AR 445) were substantiated (all or in part) in these findings. Based on observations, record review and interviews, the facility Administration and Nursing Administration failed to ensure there was a system in place to assure necessary care and services were consistently provided for oral and denture care to prevent infections of the oral cavity for 1 of 1 (Resident #6) case mix resident who required the use of dentures, was dependent on staff for oral care, and was cognitively impaired. This resulted in a pattern of harm for Resident #6 who was hospitalized with a [DIAGNOSES REDACTED]. This failed practice had the potential to cause more than minimal harm to 15 residents who required the use of dentures, were dependent for oral care, and cognitively impaired as per a list provided by the Medicare Manager on 7/15/15 at 12:45 p.m. The findings are: 1. The Job Description for the Administrator obtained on 7/15/15 at 12:45 p.m., documented, Purpose of your Job Position The primary purpose of your job position is to direct the day to day functions of the facility in accordance with current federal, state, and local standards, guidelines, and regulations that govern nursing facilities to assure that the highest degree of quality of care can be provided to our residents at all times . 2. The Job Description for the Director of Nurses obtained on 7/15/15 at 12:45 p.m., documented, Purpose of your Job Description The primary purpose of job position is to plan, develop, and direct the overall operation of our Nursing Service Department in accordance with current federal, state, and local standards, guidelines, and regulations, that govern our facility, and as may be directed by the Administrator and/or Company Consultant and the medical Director, to ensure that the highest degree of quality of care is maintained at all times . Standard Requirements . 17. Make daily rounds of the nursing service department to ensure that all nursing service personnel are performing their work assignments in accordance with acceptable nursing standards . 32. Schedule daily rounds to observe residents and to determine if nursing needs are being met in accordance with the resident request . 36. Ensure that residents who are unable to call for help are checked frequently. 37. Develop and participate in planning, conducting, and scheduling of timely in-service training classes that provide instructions on How to do the job, and ensure a well-educated nursing service department . 49. Develop a written plan of care, preliminary and comprehensive, for each resident that identified the problems/needs of the resident, indicates the care to be given, goals, to be accomplished, and which professional service is responsible for each element of care . 3. Resident #6 had [DIAGNOSES REDACTED]. The Annual Minimum Data Set with an Assessment Reference date of 6/10/15 documented the resident was severely impaired in cognitive skills for daily decision making per the Staff Assessment for Mental Status and required extensive assistance with personal hygiene. a. A dental report dated 1/21/15 documented, Cleaned upper partial -very very dirty-covered in thick buildup [MEDICATION NAME] on lower teeth. b. A grievance report dated 1/21/15 documented, Resident went to dentist today. Upon arrival, dentures were noted to be unclean with food on them. The action taken documented, Denture/oral care in-service started on 1/21/15 for oral/denture care to be done every shift. c. A physician orders [REDACTED]. d. A grievance report, not dated, documented, (Name of daughter) the daughter of resident (Resident #6) reported to the interim DON (Director of Nursing) that when her mother went to the ER (emergency room ) following a fall the resident's toenails were excessively long. Her mother is a diabetic. She further states that other times when has had issue with the resident's teeth being unclean. The response documented, The DON had a lengthy conversation with the family member. (Treatment Nurse) the tx (treatment) nurse is to get the toenails trimmed immediately. I will speak to the housekeeping supervisor as well as the nursing staff in regards to the other issues. The form had the Administrator's signature at the bottom of the form with a date of 3/17/15 e. An in-service dated 3/20/15 documented the topics covered as Checking orders/24 hour chart checks, Responsible for admit, Bagging linens, peri-care -supplies on cart down hallway, nail care, handwashing, in-service book, charge nurse; CNA roles, meal service/meal monitoring, meals for employees, documentation and Incentive program. There was no documentation on this form that indicated the staff was in-serviced regarding oral/denture care. The in-service was signed as being conducted by the Administrator. f. Progress Notes dated 7/9/15 at 4:33 a.m., documented, Send to ER for eval (evaluation) due to swelling of nose, cheeks and upper lip. There was no other documentation in the nurses notes regarding this issue. g. A Incident report dated 7/9/15 at 4:44 a.m., documented the description as: CNA (Certified Nursing Assistant) brought this writer to rm (room) 105 to observe res (resident's) face. Noted her face seems swollen around mouth, nose seems swollen, also cheeks and under eyes. Small amt (amount) of old blood seen in mouth, dried around lips. Mouth care done but res is very tender in mouth, has trouble opening mouth and also very tender to touch on cheeks, nose and upper lip is also swollen. The notes section documented, Noted res had old blood in mouth and dried on lips. Mouth care done but res has difficulty opening mouth due to pain. On close exam found face to be swollen and very tender to touch around mouth, nose, both cheeks and under eyes. Res is able to answer yes and no questions but cannot elaborate as to anything that may have happened to her face. She can say 'yes' that it hurts, Given APAP ([MEDICATION NAME]) 650 mg (milligrams) crushed in applesauce, which she did get down with difficulty. h. The emergency room report dated 7/9/15 at 4:47 a.m., documented, Patient has a small amount of facial swelling noted to right side of her face over the maxillary sinus region. This area is tender to palpation. It is slightly [DIAGNOSES REDACTED]tous. The oral pharynx is this patient to have upper dentures which have not been removed for quite some time and are firmly in place. She has a fetid odor to her breath. There does not appear to be any intraoral trauma. The Radiology interpretation documented, CT (computerized tomography) of the facial bones reveal this patient to have some bony like destruction noted to the maxillary portion of her face on the right side which could be consistent with an [DIAGNOSES REDACTED]. This patient will be admitted to the hospital for IV (intravenous) antibiotics and further care. The ER notes documented, I spoke with the patient's daughter concerning the findings of the CT. The daughter did help keep the patient, while I removed the patient's dentures. There was a lot of foul-smelling odor to this and the patient's gum on the right maxillary side of her mouth is bleeding and broken down from infection. i. The ENT (Ears, Nose and Throat) specialist report dated 7/9/15 at 5:20 p.m., documented, CT showed some bony erosion of the maxilla on the right. Apparently ER had a hard time getting dentures out. Granulation tissue along the right Gingofabial groove along the right maxilla. The [DIAGNOSES REDACTED]. On 7/14/15 at 4:45 p.m., the ENT specialist stated that based on the history that he received her dentures had to have been there a long time. He further stated that he did not see her with her dentures, but was in the area that the dentures fit and it had to have been there a long time. j. The July 2015 Medication Administration Record [REDACTED]. This was documented, with nurses' initials, as being completed at 7:00 p.m. from 7/1 - 8/15. k. On 7/15/15 at 7:55 p.m., Licensed Practical Nurse (LPN) #1 was asked, Did you visually see the dentures in the cup when you initialed it being completed on 7/8/15? She replied, No, the CNA's told me that it was done. l. On 7/15/15 at 8:30 p.m., LPN #2 was asked, Did you visually see the dentures in the cup when you initialed it being completed on 7/3/15 and 7/6/15? She replied, No, I asked the CNA's and they told me they were. m. On 7/15/15 at 8:10 p.m., CNA #1 stated that she had worked for the facility for 7 months and that she floats. She stated that sometimes the resident would refuse to have her dentures removed but she did oral care on her. n. On 7/15/15 at 8:15 p.m., CNA #2 stated that she had worked at the facility since February 2015 and she did not know the resident even had dentures. o. On 7/15/15 at 8:25 p.m., CNA #3 stated that if the resident had her dentures in her mouth she removed them. She stated that she only works the hall where the resident resides two nights a week and that she did put the resident's dentures in a cup on those two nights. p. A form titled, Oral Care/Denture Care Completed was utilized by the CNA's to document the date and shift that they completed the care on the individuals who had dentures. There were forms documenting oral/denture care for January through May 2015. On 7/15/15 at 10:10 a.m., the Administrator stated that she started here in February 2015 and the form was already in place. She did not know why. She was asked to locate any documentation of this form being completed for this resident. As of 7/15/15 at 2:00 p.m., the Administrator did not provide any more forms that documented oral care for this resident. q. The plan of care initiated on 6/8/14 documented a problem of The resident has limited physical mobility r/t (related to) disease process ([MEDICAL CONDITION]) with interventions initiated on 7/13/15 of Clean teeth/partial dentures every morning, bedtime and PRN (as needed). Place dentures in cup with cleaner every bedtime. There was no documentation on the plan of care regarding denture care until 7/13/15. r. On 7/15/15 at 1:10 p.m., the Administrator stated that she was not here when the January 2015 grievance was filed and she did not know what the facility did. She stated she was here when the March 2015 grievance report was submitted and staff were in-serviced but did not know if she talked about oral care or not. She stated that she did not document it on the in-service sheet and she usually does. The Administrator was asked, What system did you put in place to prevent this re-occurring again? She stated, I didn't put any system in place. She stated that now she has in-serviced the staff regarding denture care with return demonstrations and that the CNA's were to report to the nurse if anyone refuses and that the LPN will visually check to make sure the dentures were in a cup at night.

Complaint # (AR 438) and # (AR 445) were substantiated (all or in part) in these findings. Based on observations, record review and interviews, the facility failed to ensure the Quality Assurance and Assessment (QAA) committee met every 3 months, identified quality deficiencies and developed a plan of corrective action to address complaints regarding the staff's failures to provide oral and denture care to prevent development of an oral cavity infection for 1 of 1 (Resident #6) case mix resident who required the use of dentures, was dependent on staff for oral care, and was cognitively impaired. This resulted in a pattern of harm for Resident #6 who was hospitalized with a [DIAGNOSES REDACTED]. This failed practice had the potential to cause more than minimal harm to 15 residents who required the use of dentures, were dependent for oral care, and cognitively impaired as per a list provided by the Medicare Manager on 7/15/15 at 12:45 p.m. The findings are: 1. On 7/15/15 at 1:10 p.m., the Administrator was asked the following questions: a. How often does the QAA committee meet? She replied, Every Quarter. b. When was the last QAA meeting? She replied, Have not had one since February. We have a daily standup meeting and we go over the grievances. c. Did the QAA Committee develop and implement a system to prevent the continued harm for Resident #6? She replied, No, there was no system put in place. 2. Resident #6 had [DIAGNOSES REDACTED]. The Annual Minimum Data Set with an Assessment Reference date of 6/10/15 documented the resident was severely impaired in cognitive skills for daily decision making per the Staff Assessment for Mental Status and required extensive assistance with personal hygiene. a. A dental report dated 1/21/15 documented, Cleaned upper partial -very very dirty-covered in thick buildup [MEDICATION NAME] on lower teeth. b. A grievance report dated 1/21/15 documented, Resident went to dentist today. Upon arrival, dentures were noted to be unclean with food on them. The action taken documented, Denture/oral care in-service started on 1/21/15 for oral/denture care to be done every shift. c. A physician orders [REDACTED]. d. A grievance report, not dated, documented, (Name of daughter) the daughter of resident (Resident #6) reported to the interim DON (Director of Nursing) that when her mother went to the ER (emergency room ) following a fall the resident's toenails were excessively long. Her mother is a diabetic. She further states that other times when has had issue with the resident's teeth being unclean. The response documented, The DON had a lengthy conversation with the family member. (Treatment Nurse) the tx (treatment) nurse is to get the toenails trimmed immediately. I will speak to the housekeeping supervisor as well as the nursing staff in regards to the other issues. The form had the Administrator's signature at the bottom of the form with a date of 3/17/15 e. An in-service dated 3/20/15 documented the topics covered as Checking orders/24 hour chart checks, Responsible for admit, Bagging linens, peri-care -supplies on cart down hallway, nail care, handwashing, in-service book, charge nurse; CNA roles, meal service/meal monitoring, meals for employees, documentation and Incentive program. There was no documentation on this form that indicated the staff was in-serviced regarding oral/denture care. The in-service was signed as being conducted by the Administrator. f. Progress Notes dated 7/9/15 at 4:33 a.m., documented, Send to ER for eval (evaluation) due to swelling of nose, cheeks and upper lip. There was no other documentation in the nurses notes regarding this issue. g. A Incident report dated 7/9/15 at 4:44 a.m., documented the description as: CNA (Certified Nursing Assistant) brought this writer to rm (room) 105 to observe res (resident's) face. Noted her face seems swollen around mouth, nose seems swollen, also cheeks and under eyes. Small amt (amount) of old blood seen in mouth, dried around lips. Mouth care done but res is very tender in mouth, has trouble opening mouth and also very tender to touch on cheeks, nose and upper lip is also swollen. The notes section documented, Noted res had old blood in mouth and dried on lips. Mouth care done but res has difficulty opening mouth due to pain. On close exam found face to be swollen and very tender to touch around mouth, nose, both cheeks and under eyes. Res is able to answer yes and no questions but cannot elaborate as to anything that may have happened to her face. She can say 'yes' that it hurts, Given APAP ([MEDICATION NAME]) 650 mg (milligrams) crushed in applesauce, which she did get down with difficulty. h. The emergency room report dated 7/9/15 at 4:47 a.m., documented, Patient has a small amount of facial swelling noted to right side of her face over the maxillary sinus region. This area is tender to palpation. It is slightly [DIAGNOSES REDACTED]tous. The oral pharynx is this patient to have upper dentures which have not been removed for quite some time and are firmly in place. She has a fetid odor to her breath. There does not appear to be any intraoral trauma. The Radiology interpretation documented, CT (computerized tomography) of the facial bones reveal this patient to have some bony like destruction noted to the maxillary portion of her face on the right side which could be consistent with an [DIAGNOSES REDACTED]. This patient will be admitted to the hospital for IV (intravenous) antibiotics and further care. The ER notes documented, I spoke with the patient's daughter concerning the findings of the CT. The daughter did help keep the patient, while I removed the patient's dentures. There was a lot of foul-smelling odor to this and the patient's gum on the right maxillary side of her mouth is bleeding and broken down from infection. i. The ENT (Ears, Nose and Throat) specialist report dated 7/9/15 at 5:20 p.m., documented, CT showed some bony erosion of the maxilla on the right. Apparently ER had a hard time getting dentures out. Granulation tissue along the right Gingofabial groove along the right maxilla. The [DIAGNOSES REDACTED]. On 7/14/15 at 4:45 p.m., the ENT specialist stated that based on the history that he received her dentures had to have been there a long time. He further stated that he did not see her with her dentures, but was in the area that the dentures fit and it had to have been there a long time. j. The July 2015 Medication Administration Record [REDACTED]. This was documented, with nurses' initials, as being completed at 7:00 p.m. from 7/1 - 8/15. k. On 7/15/15 at 7:55 p.m., Licensed Practical Nurse (LPN) #1 was asked, Did you visually see the dentures in the cup when you initialed it being completed on 7/8/15? She replied, No, the CNA's told me that it was done. l. On 7/15/15 at 8:30 p.m., LPN #2 was asked, Did you visually see the dentures in the cup when you initialed it being completed on 7/3/15 and 7/6/15? She replied, No, I asked the CNA's and they told me they were. m. On 7/15/15 at 8:10 p.m., CNA #1 stated that she had worked for the facility for 7 months and that she floats. She stated that sometimes the resident would refuse to have her dentures removed but she did oral care on her. n. On 7/15/15 at 8:15 p.m., CNA #2 stated that she had worked at the facility since February 2015 and she did not know the resident even had dentures. o. On 7/15/15 at 8:25 p.m., CNA #3 stated that if the resident had her dentures in her mouth she removed them. She stated that she only works the hall where the resident resides two nights a week and that she did put the resident's dentures in a cup on those two nights. p. A form titled, Oral Care/Denture Care Completed was utilized by the CNA's to document the date and shift that they completed the care on the individuals who had dentures. There were forms documenting oral/denture care for January through May 2015. On 7/15/15 at 10:10 a.m., the Administrator stated that she started here in February 2015 and the form was already in place. She did not know why. She was asked to locate any documentation of this form being completed for this resident. As of 7/15/15 at 2:00 p.m., the Administrator did not provide any more forms that documented oral care for this resident. q. The plan of care initiated on 6/8/14 documented a problem of The resident has limited physical mobility r/t (related to) disease process ([MEDICAL CONDITION]) with interventions initiated on 7/13/15 of Clean teeth/partial dentures every morning, bedtime and PRN (as needed). Place dentures in cup with cleaner every bedtime. There was no documentation on the plan of care regarding denture care until 7/13/15. r. On 7/15/15 at 1:10 p.m., the Administrator stated that she was not here when the January 2015 grievance was filed and she did not know what the facility did. She stated she was here when the March 2015 grievance report was submitted and staff were in-serviced but did not know if she talked about oral care or not. She stated that she did not document it on the in-service sheet and she usually does. The Administrator was asked, What system did you put in place to prevent this re-occurring again? She stated, I didn't put any system in place. She stated that now she has in-serviced the staff regarding denture care with return demonstrations and that the CNA's were to report to the nurse if anyone refuses and that the LPN will visually check to make sure the dentures were in a cup at night.

Complaint # was substantiated, all or in part, with these findings. Based on record review and interview, the facility failed to ensure Resident #7 was provided the necessary care and services to attain her highest practicable physical well-being in accordance with the comprehensive assessment and plan of care. The facility failed to conduct an assessment to include vital signs, lung sounds and bowel sounds to identify if there was a need to notify the physician for further interventions during a change in condition that required treatment; failed to ensure that Cardiopulmonary Resuscitation (CPR) included usage of a back board to ensure effective chest compressions; failed to ensure licensed staff was knowledgeable in the operation of the suction machine to aide in clearing the airway if needed for 1 of 1 (Resident #7) case mix resident who complained of nausea and who later required cardiopulmonary resuscitation. The failed practice resulted in Immediate Jeopardy, which likely caused or could have caused serious harm, injury or death to Resident #7, who was found unresponsive and without a pulse 1 hour after being medicated with a suppository for nausea and was a full code, and had the potential to cause more than minimal harm for 19 residents who had a Full Code status as documented on a list provided by the Minimum Data Set Coordinator on [DATE] at 9:10 a.m. The facility was informed of the Immediate Jeopardy on [DATE] at 2:25 p.m. The findings are: 1. Resident #7 had [DIAGNOSES REDACTED]. The Minimum Data Set with an assessment reference date of [DATE] documented the resident scored 15 (,[DATE] indicates cognitively intact) on a brief interview for mental status, was totally dependent on two persons for transfer and toilet use, one person physical assist for locomotion, personal hygiene and bathing and was frequently incontinent of bowel and bladder. a. An Advance Directive in the Event of Cardiopulmonary Resuscitation form dated [DATE] was documented and signed by (Resident #7) on [DATE]. b. A Physicians order for a Full Code and signed by the Primary Care Physician was dated [DATE]. c. A Nurse's Progress Note dated [DATE] at 5:25 a.m. and signed by Licensed Practical Nurse (LPN) #2 documented "CNA (Certified Nurse Assistant) came to this nurse stating that res (resident) is complaining of nausea. Went to res room to assess res, pale and complaining that she was nauseated. Gave [MEDICATION NAME] HCL ([MEDICATION NAME]) Suppository 25 mg (milligram) at approximately 5:35 a.m. with no difficulty." The Nurses ' Progress note did not document any vital signs or assessment of bowel sounds. On [DATE] at 9:45 a.m., the Director of Nursing stated, "(Resident #7's) last vital signs were taken on [DATE] at 4:51 p.m. On [DATE] at 5:25 a.m. (LPN #1) administered [MEDICATION NAME] and at 5:31 a.m., checked her blood sugar which was 288. That is the only assessment that she did." d. A Nurse's Progress Note dated [DATE] at 6:25 a.m. and signed by LPN #2 documented, "Went into res room. Observed res laying in bed dusky and non-responsive, skin was cold and clammy to the touch, eyes open and fixed, no respirations, no pulse noted. This nurse began CPR (cardiopulmonary resuscitation) immediately and yelled for help. (LPN #3) came in with crash cart to assist with CPR. (CNA #9) called 911 at 6:32 a.m. CPR remained in progress without pulse or respirations. (Fire Department) arrived at 6:37 a.m. and took over CPR. (Local Hospital Emergency Physician #1) called code at 6:57 a.m. EMT's (Emergency Medical Technician's) stopped CPR. Coroner pronounced death at 7:18 a.m..." e. On [DATE] at 11:35 p.m., LPN #2 stated, "About three weeks ago around 5:30 a.m., the resident called me to the room by telling (CNA #9) that she was nauseated. I went to the room, assessed her. She was pale and complained of nausea and asked for something for nausea. I gave her a [MEDICATION NAME] suppository. (CNA #9) checked on her frequently. About 6:30 a.m., I went to her room. She had no pulse and her pupils were fixed. I started CPR and yelled for help. (LPN #3) and (CNA #9) came to assist. (LPN #3) brought the crash cart with her. She used an ambu bag and then (Resident #7) started vomiting green emesis. We tried to use the suction machine but it was not working properly. We swept the mouth with a sheet. (CNA #9) called 911. We continued CPR until the Fire Department and ambulance arrived. The paramedic suctioned her. She expired at approximately 6:50 a.m. Me and (LPN #3) reported the failure of the suction machine. I have not personally checked the crash cart since that time. I do know that the Director of Nursing checked the suction." LPN #2 and surveyor went to the crash cart. LPN #2 plugged in the suction, applied a suction cath and the suction worked to a pressure of 25 mm Hg (millimeters of mercury). f. On [DATE] at 12:20 p.m., LPN #3 stated via phone "I heard (LPN #1) yell. I went down to (Resident #7's) room. I ran back and got the crash cart. (LPN #1) was doing chest compressions. I got the ambu. (Resident #7) vomited and it was like a slow erupting volcano. I tried to get the suction to seal. It never would suction. (LPN #2) tried. We both tried. It was a small suction. It would not suction the vomit. We wiped her mouth to remove the vomitus. The Fire Department arrived. They continued CPR and took her to the floor. We did not use the backboard. It was on the cart. It didn't cross my mind to use the board. This was my second code. I told the DON (Director of Nursing) that I could not get the suction to work. I have not had an inservice relative to the suction machine. Also, the tubing and all components were in packets. The canister was put together. Within a couple of days, I was told the suction machine worked just fine and it was prepped and ready to go by the DON." g. The Fire Department's narrative dated [DATE] at 6:33 a.m. documented, "Engine #1 was dispatched for a code blue at (Facility). Engine 1 arrived to find staff nurses performing CPR on a female pt (patient) lying in her bed. Engine 1 crew placed the pt on a backboard and moved her to the floor to continue CPR. (Fireman #1) took over compressions and (Fireman #2) suctioned the pt using the manual suction device in order to ventilate the pt via bag valve mask until (Emergency Medical Services) arrived and then we used their electrical suction machine. AED (Automated External Defibrillator) analyzed the pt again and advised 'No Shock. Continue CPR.' (Fireman #3) took over BVM (bag valve mask). (Emergency Medical Services) disconnected our pads and attached their monitor which advised asystole. We continued CPR while (Medic) intubated the pt. (Emergency Medical Services) then administered cardio drugs. After several additional rounds of CPR, (Emergency Medical Services) contacted (local hospital) and (Physician #1) advised stop CPR and all resuscitative efforts at 6:57 a.m. Engine 1 requested a PD (Police Department) officer on scene and Deputy Coroner was notified. PD and Coroner arrived and conducted their investigation. Coroner advised that we could place the pt back in the bed as the pt was being released to the funeral home. Engine 1 moved the pt back to the bed and removed our backboard. Engine 1 crew and (Emergency Medical Services) returned to service." h. The Emergency Medical Services note her pulseless and apneic so they started chest compressions and called 911. FD (Fire Department) rescue reports that they placed pt onto LSB (long spine board) and moved her from the bed to the floor and continued CPR. During BVM ventilations pt began to vomit large amounts of emesis. FD (Fire Department) also reports that they placed their AED on pt and had 'no shock advised' throughout their efforts. (Emergency Medical Services) to find pt in floor on LSB with CPR being performed by FD rescue. Pt's airway was suctioned and then the pt was intubated and BVM ventilations continued. Strong resistance felt during ventilations but placement of ET (endotracheal (tube)) was confirmed throughout by EtCO2 (End-Tidal Carbon [MEDICATION NAME]) readings. IV (Intravenous) attempted but unsuccessful so 1 dose of epi ([MEDICATION NAME]) and 1 dose of [MEDICATION NAME] was introduced down ET tube. Pt's rhythm on monitor changed from asystole to PEA (pulseless electrical activity) with epi admin (administration) but no pulse was present. At this point CPR had been ongoing for 30 minutes, so physician consult with ER MD (emergency room Medical Doctor) for orders to cease CPR efforts or transport. CPR stopped at 6:57 a.m. per (Physician #1)." i. On [DATE] at 12:15 p.m., the Director of Nursing was asked to tell the surveyors about the incidents occurring during (Resident #7's) code. The Director of Nursing stated, "I did not know about any incident. I knew there was a code. (LPN #2) asked me if I would look at the suction machine as it wasn't working well. I checked the suction and it was working. The only thing I could think of was that the canister lid may not have been snapped shut to give it suction. I have not given inservice regarding the suction equipment to the staff. I did not get back with (LPN #2)." j. On [DATE] at 12:55 p.m., LPN #7 was asked to turn on the suction machine on the crash cart and to first tell the surveyor where the on/off switch was located. LPN #7 stated, "I do not know where the on/off switch is. I have not had an inservice." k. On [DATE] at 1:00 p.m., LPN #4 was asked to turn on the suction machine on the crash cart. LPN #4 stated, "I have been here two weeks. No one has showed me the suction machine on the crash cart. I do not know where the on/off switch is. I do not know how to adjust the mm Hg pressure." l. On [DATE] at 1:05 p.m., LPN #5 was asked to turn on the suction machine on the crash cart and to first tell the surveyor where the on/off switch was located. LPN #5 stated, "I have not been inserviced on the suction machine or the crash cart at this facility. I do not know without investigating where the on/off switch is located." m. On [DATE] at 1:40 p.m., the Director of Nursing stated, "I was not aware that the two LPNs did not use a backboard. I was not aware that the Fire Department placed the resident on the floor for a solid surface. There is a board on the crash cart. I have not inserviced the staff on the use of the crash cart." The backboard and the suction machine were located on the crash cart. 2. On [DATE] at 4:25 p.m., the immediate jeopardy was removed and the scope and severity reduced to "G" after the facility began implementation of the following plan of removal : a. There are 19 residents who had signed a request for a Full Code and had physician authorization for same at risk for same failed practice. b. On [DATE] at 2:35 p.m., DON immediately began in-servicing all current licensed staff members on duty regarding company Policy and Procedure of CPR and use of equipment to include suction machine and backboard and what to do if equipment is not in working condition with return demonstration. All staff will be in-serviced prior to starting work. The in-service will be documented to include topics and signature of attendance. Newly hired licensed nurses will be trained on company policy and procedure of CPR and use of suction machine and backboard prior to working the floor. c. On [DATE] at 2:38 p.m., the Administrator called and ordered a back-up suction for crash cart from (Medical Supply Company). If machine is a different model, licensed nurses will be in-serviced on proper operation of machine. d. On [DATE] at 3:22 p.m., a checklist for crash cart was completed and Director of Operation will in-service DON and Administrator immediately. Contents will be checked daily by the Director of Nursing/designee and turned in to the Administrator at the end of each week. Any negative findings will be corrected immediately. Equipment failure, the Maintenance Supervisor will be notified immediately and repairs made. Monitoring sheets will be reported to the Administrator. Any negative findings will be addressed immediately. All findings will be reported to the QA & A (Quality Assessment and Assurance) meeting monthly."