Every finding on record at Gassville Therapy and Living

Based on observation and interviews, the facility failed to promote a healthy, comfortable environment by allowing residents to dispose of their waste appropriately, preventing contamination of their environment, in five (Rooms 106, 401, 402, 403, and 411) resident rooms. The findings are: 1. On 11/18/2024 at 11:45 AM, as environmental rounds were made in the facility, the following were observed: a. Upon entering room [ROOM NUMBER], toward the right of the room, past the bathroom, the wall trim and door trim before entering the bathroom, had discolored darkish black gouges, deep scratches, and cuts in the sheetrock and wood. b. Upon entering room [ROOM NUMBER], toward the right side of the room, a red isolation bag was observed stacked up against the bathroom sink against another unemptied trash can was obstructing the wall sink and an additional overflowing carboard box container was present. In addition, on 11/19/24, during environmental rounds at 1:00 PM, the trash receptacles remained unemptied. c. During a tour of the closed unit, on 11/18/2024 at 12:34 PM, standing in front of room [ROOM NUMBER], on the immediate left, the bathroom toilet floor had ground-in brownish/blackish debris and clear stains, in front of the toilet. d. Upon entering room [ROOM NUMBER], to the immediate right, the bathroom toilet floor had ground-in brownish/blackish debris and clear stains, in front of the toilet. e. While standing at the entrance of the room, toward the left on the right side of the wall sink, the wall trim next to the bathroom door, had darkish black discolored gouges, with deep scratches and cuts, in room [ROOM NUMBER]. Upon entering the bathroom door, immediately to the right, the toilet had a dark black colored stain around the edge of the toilet bowl. In front of the toilet bowl, the surveyor observed brownish/blackish debris and clear stains on the floor. In addition, the trash can on the right side of the bathroom sink and the trash can by the recliner on the right side of the room had not been emptied. Further investigation on 11/19/24, during environmental rounds at 1:00 PM, revealed the bathroom had not been cleaned or the trash cans emptied. 2. On 11/18/2024 at 12:30 PM, during an interview with Maintenance, in response to the question who is responsible for repair of trim, and wood gouges, and repairing sheetrock, Maintenance indicated that the repairs are made by request and written on a tablet at the nurse ' s station. There were no requested repairs for cuts, gouges, or scratches on the wall trim. 3. During environmental rounds with the Administrator on 11/19/2024 at 1:15 PM, in response to the question, were you are aware of the gouges, cuts, scratches on the wall, trim, toilet bowl rim stains, brownish/blackish debris and clear stains on the floor in front of the toilets, unemptied trash cans and boxes, the Administrator indicated that he had not been aware of the gouges, cuts, scratches on the wall trim. The Administrator stated that the hard water contributed to the toilet stains, and that Maintenance had been replacing some of the toilets but had not replaced the floors under the toilets. In addition, the facility would work toward trash removal from the rooms, including hazardous waste.

Based on observations, interviews, and record review, it was determined that the facility failed to ensure dignity while resident (#3) removed dental appliances (dentures), leaving them on the bedside table in between dining, with white cake-like reside adhered to dentures without an assessable denture cup or oral care. This failed practice had the potential to affect all residents who are dependent on dental appliances while maintaining dignity, self-esteem, and self-worth and maintaining proper cleaning between meals and at night. Findings include: Review of Resident #3 ' s Admission Record revealed diagnoses of coronary obstruction pulmonary disease, congestion heart failure, muscle wasting and atrophy, abnormality of gait and mobility, non-pressure ulcer of left lower leg, and peripheral vascular disease. The Minimum Data Set (MDS)-Version 3.0, dated 09/23/2024, under section titled Cognitive Patterns listed a Brief Interview for Mental Status (BIMS) with a summary score of fourteen (14), a score of 13 to 15 indicating the resident is cognitively intact. In addition, the resident requires setup or clean-up assistance for oral hygiene. On 11/18/2024 at 11:15 AM, Resident #3 left room in a manual wheelchair to attend a facility activity in the dining room. The wheeled flat surface bedside table had upper and lower unsecured dentures lying on top of the table. A white colored residue was caked between the upper part of the front teeth of the top denture and the lower part of the back teeth on the lower denture. On 11/18/2024 at 12:15 PM, Resident #3 returned to room, sat in recliner, and placed dentures in mouth after picking them up from the top of the bedside table to eat lunch. On 11/18/2024 at 2:53 PM, during an interview with Resident #3, when asked if the facility assisted the resident with denture care in between meals or at night and provide a denture cup, Resident #3 responded No, I never ask them for assistance. Look, I have a denture cup on the sink, but I cannot reach it. When asked if the facility provided a soft toothbrush or set-up assistance for oral care, the resident responded, no. During an interview conference, on 11/19/2024 at 1:20 PM, in response to the question are you aware that Resident #3 had dried cake-liked white residue on upper and lower dentures on the bedside table, and unable to access a toothbrush or denture cup? The Administrator indicated that the facility would ensure that the resident was offered denture care. The Director of Nursing (DON) stated that the facility would provide a bedside table with a drawer mount to provide additional space for oral hygiene supplies.

Based on observation, interview, and record review the facility failed to have a securement device in place for a catheter for 2 out of 2 sampled residents. A review of the Order Summary reveals that Resident #9 has these diagnoses hemiplegia and hemiparesis from a stroke, acute kidney disease, benign prostatic hyperplasia with urinary tract infection symptoms. Further review of foley catheter orders reveals no order for a securement device. A review of the Order Summary revealed an active order from 06/07/2024 that states Cleanse open tear to base of right side of penis with wound cleanser, or ns and pat dry. Leave open to air. every shift for wound care. A review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/03/2024 reveals that Resident #9 scored a 2 (severe cognitive impairment) on the Brief Interview for Mental Status (BIMS). A review of the Care Plan reveals that foley catheter interventions are in place but none for a securement device in place, it states Goal: will be free/remain from catheter-related trauma through review date. On 07/08/2024 at 1:40 PM Observed Resident #9 up in geri-chair with no securement device in place for catheter. On 07/09/2024 at 9:00 AM Observed Resident #9 up in ger-chair with no securement device in place for catheter. On 07/09/2024 at 9:36 AM During an interview Certified Nursing Assistant (CNA) #3 confirmed no securement device in place after giving Resident #9 a complete bed bath. Then stated that without it the catheter could pull and rip. On 07/09/2024 at 9:45 Am During an interview Registered Nurse (RN) #4 stated that the resident has a current peri-wound and was not sure what caused, has not put on a securement device as it could of caused the skin breakdown. RN #4 then stated that there were no orders or documentation on the securement device for Resident #9 or that it could have caused Resident #9's current skin breakdown. A review of the Order Summary reveals that Resident #25 had diagnoses of acute kidney failure and congestive heart failure (CHF). Further review of foley catheter orders reveals no order for a securement device. A review of the Quarterly MDS with an ARD of 06/24/2024 reveals that Resident #25 scored a 12 (moderate cognitive impairment) on the Brief Interview for Mental Status (BIMS). A review of the Care Plan reveals that foley catheter interventions are in place but none for a securement device in place, it states Goal: will be free/remain from catheter-related trauma through review date. On 07/08/2024 at 12:45 PM Observed Resident #25 sitting on the side of the bed, with no securement device in place for catheter. Resident #25 confirmed no securement device in place. Resident #25 stated that it sometimes does pull and hurt, that if a securement device existed 0they would like one as it could help out. On 07/09/2024 at 9:15 AM Observed Resident #25 in bed, no securement device in place for catheter. On 07/09/2024 at 9:45 AM RN #4 confirmed no securement device in place for catheter on Resident #25. Then stated it could get pulled out without a device. RN #4 stated that there were no orders or documentation on the securement device for Resident #25 including refusals of such care. On 07/10/2024 at 3:50 PM During an interview with the Director of Nursing stated that securement devices should be used if the resident wants them to keep the catheter from pulling out. A review of the facility policy Catheter Care, Urinary states 2. Ensure that the catheter remains secured with a leg band to reduce friction and movement at the insertion site. (Note: Catheter tubing should be strapped to the resident's inner thigh.)

Based on observations, record review, and interview, the facility left an extra treatment cart unlocked and the whirlpool next to the secure unit was left unlocked with the key inside the doorknob exposing residents to chemical hazards. The finding are: 1. On 07/08/2024 at 9:40 PM, the surveyor observed a key left in the doorknob of a shower room next to the secure unit. Upon entry the top of the tub had a bottle of lotion, a can of shaving cream, a bottle of body wash, a pink bar of soap, and a half full container of gel. Next to the tub is a bag of dirty linen tied off with dirty gloves resting on top of it. To the right is a small three tiered metal rack with two hair dryers plugged in, and one curling iron unplugged. Next to the metal rack is a three-tiered black plastic shelf the top shelf contains spray deodorant, roll-on deodorant, body wash and shampoo 16 ounces, lotion, a pump bottle of body wash, a medicine cup containing white cream, and a container of cleaning clothes with the lid left opened. Across from the shelves is a shower stall, that was wet from the last bath with a white residue splatter on the floor, the shower chair was dripping water, in the back left corner a pink bath loofah lies in a puddle with the pump part of a container, the handrail has containers of shampoo, a white container missing the pump bottle part, shaving cream, and a clear container only filled a 1/4 of the way with a purple substance. The handrail along the back wall has a small container of shampoo and a clear bottle nearly empty with a blue substance in it. The containers on both rails were dripping water. On 07/08/2024 a 9:45 AM, on the wooden cabinet above the metal shelf and the plastic shelf states CNAS (Certified Nursing Assistants) It is your responsibility to clean shower and shower room after each use. On 07/08/2024 at 9:47 AM, during an interview Licensed Practical Nurse (LPN)#1 confirmed the shower room should be locked and all the products left out should be put away into locked cabinets. LPN #1 stated the shower should have been cleaned immediately after the shower, to spray it down and clean it. Then stated a resident could get into the room and have access to chemicals they should not have access to, and it, some of which could be poisonous if ingested or allergic to some of the products. LPN #1 stated that that the medicine cup may contain zinc but they were unsure as it was not labeled or dated. On 07/08/2024 at 9:50 AM, during an interview CNA #2 stated they had just recently given a bath in the tub and it should not have been left unlocked because residents have access to things they need to and could ingest chemicals. CNA #2 stated the shower room should be cleaned immediately after by spraying it down and cleaning it. On 07/10/2024 at 3:50 PM, during an interview the Director of Nursing (DON) stated the shower room should not be left unlocked, and it is to prevent residents from getting access to things they should not have access to. A review of the material safety data sheet for [brand] gel revealed, Eye contact: in the case of contact with eyes, rinse immediately with plenty of water for 15 minutes and seek medical attention. Skin Contact: If a person feels unwell or symptoms of skin irritation appear, consult a physician. Ingestion: If ingested, seek medical attention immediately and show the label. A review of the policy of the Hazard Communication Program states that b. Hazards are properly labeled and recognized; b. List of hazardous chemicals in the workplace. 2. On 07/08/2024 at 9:15 PM, the Surveyor observed the treatment cart unlocked at the end of the 200 Hallway outside of room [ROOM NUMBER]. On 07/08/2024 at 9:21 PM, the Surveyor interviewed LPN #1 and asked, What type of cart is this? She stated, It's the extra treatment cart. When asked, Is it unlocked? She stated, Yes. When asked, Should it be kept locked? She stated, Yes, ma'am it should be. When asked, Why should it be kept locked when unattended? She stated, To prevent the residents from getting into it. When asked, How long has it been unlocked? She stated, I don't know. The surveyor requested LPN #01 to open the treatment cart. Inside the treatment cart the Surveyor observed: a. three packages of five count Monoject 29-gauge one half inch insulin needles b. zinc oxide cream in two medicine cups labeled zinc c. gas relief pills mint flavor d. Triamcinolone Acetonide Cream 0.1% e. Arginaid powder packets approximately 08 f. bottle of wound cleanser spray g. Ostomy supplies h. COVID-19 Ag Card box with tests i. Dorzolamide Hydrochloride and Timolol Maleate Ophthalmic Solution 60 single use containers X 2 boxes j. Exuderm Hydrocolloid Wound Dressing k. Calcium Alginate Dressings l. Diclofenac Sodium (tube) m. Ketoconazole 2% Shampoo n. Vitamin D-3 2000 IU o. Vitamin E, vitamin B-12 500 mcg p. Nystatin 100,000 units q. Hydrogen peroxide topical solution 3% H2O2 r. Suppositories for hemorrhoids (box of 12) s. Hemorrhoidal cream t. Voltaren Gel 1% (2 tubes) u. (Named trpopical analgesic v. Clindamycin w. Estradiol Vaginal Cream 0.01% x. Ketoconazole Cream 2% y. Stoma adhesive z. Acetaminophen 325 mg aa. Chloraseptic sore throat spray bb. Niacin 500 mg cc. Alpha Lipoic Acid 200 mg The facility provided a Material Safety Data Sheet for 9 (Named) gas relief tables with a prepared date of April 18, 2002, that revealed, Section 4 First Aid Measures Ingestion: In case of accidental overdose/ over-ingestion, seek medical attention or contact a poison control center immediately. The facility provided a Material Safety Data Sheet for Clindamycin Palmitate Hydrochloride for Oral Solution with a revision date of July 27, 2010, that documented, 4. First Aid Measures: Eye Contact: Flush with water while holding eyelids open for at least 15 minutes. Seek medical attention immediately. Skin Contact: Remove contaminated clothing. Flush area with large amounts of water. Use soap. Seek medical attention. Ingestion: Never give anything by mouth to an unconscious person. Wash out mouth with water. Do not induce vomiting unless directed by medical personnel. Seek medical attention immediately. Inhalation: Remove to fresh air and keep patient at rest. Seek medical attention immediately. The facility provided a Safety Data Set for Diclofenac sodium with a revision date of July 13, 2011, that revealed, 2. Hazard(s) identification: Hazard Statements: Toxic if swallowed. 3. Composition/ Information on Ingredients: Eye Contact: Rinse immediately with plenty of water, also under the eyelids, for at least 15 minutes. Get medical attention. Skin Contact: Wash off immediately with plenty of water for at least 15 minutes. Get medical attention. Ingestion: Do not induce vomiting. Call a physician or poison control center immediately. The facility provided an Actavis Safety Data Sheet for Estradiol Cream with an effective date of December 18, 2013, that revealed, 4. First-Aid Measures: Skin Exposure: Basic hygiene should prevent any problems. If the product contaminates the skin, and adverse effect occurs, begin decontamination with running water. Minimum flushing is for 20 minutes. Do not interrupt flushing. Remove exposed or contaminated clothing taking care not to contaminate eyes. Seek medical attention if adverse effect occurs after flushing. Eye Exposure: If this product enters the eyes, open victim's eyes while under gently running water. Use sufficient force to open eyelids. Have the victim roll eyes. Minimum flushing is for 20 minutes. Do not interrupt flushing. Seek medical attention after flushing if adverse effect occurs. Ingestion Exposure: If this product is swallowed, call physician or poison control center for most current information. 16. Other Information: ANSI Labeling (Based on 129.1, Provided to Summarize Occupational Exposure Hazards): Warning! May be harmful if swallowed. The facility provided a Material Safety Data Sheet for (Named topical analgesic cream) with 4% Lidocaine with a revision date of August 14, 2014, that documented, IV. First Aid Measures: Ingestion: In case of overdose or child ingestion, vomiting. Seek immediate medical attention or contact poison control center. VII. Handling and Storage: Keep out of reach of children. The facility provided a US- OSHA Safety Data Sheet for (Named Acetaminophen) Regular Strength Tablets with a revision date of November 12, 2014, that revealed, 2. Hazards Identification: Other Information: When used as directed, side effects associated to acetaminophen are rare. If ingested in large doses, long term chronic use or with alcohol, acetaminophen may cause liver damage, acute renal failure and jaundice. 4. First Aid Measures: Eye contact: In case of eye contact, immediately flush eyes with fresh water for at least 15 minutes while holding the eyelids open. Remove contact lenses if worn. Get medical attention if irritation persists. Ingestion: If symptomatic, seek medical advice. If ingestion of a large amount does occur, call a poison control center immediately. The facility provided a Safety Data Sheet for Hydrogen Peroxide 3% with a revision date of December 16, 2014, that revealed, Section 2: Hazards identification: Hazards statements: Harmful if swallowed; Causes severe skin burns and eye damage; Harmful if inhaled. Precautionary statements: Keep out of reach of children; Read label before use. Avoid release to the environment; Wear protective gloves/ protective clothing; eye protection/ face protection. Store locked up. Section 4: First aid measures: After skin contact: flush with water for 15 minutes. Get medical assistance if irritation develops. Wash affected area with soap and water. Rinse thoroughly. Seek medical attention if irritation, discomfort or vomiting persists. After eye contact: Immediately flush eyes with water for at least 15 minutes. Immediately get medical assistance. Protect unexposed eye. Rinse/ flush exposed eye(s) gently using water for 15-20 minutes. The facility provided a Safety Data Sheet for Niacinamide with a revision date of June 03, 2015, that revealed, Section 2. Hazards Identification: Hazard and precautionary statements: Hazard Statement(s): H303 May be harmful if swallowed. P280 Wear protective gloves/ eye protection/ face protection. P312 Call a poison center or doctor/ physician if you feel unwell. P405 Store locked up. Potential Health Effects: Ingestion: May be harmful if swallowed. Section 4. First Aid Measures: In case of eye contact: Rinse thoroughly with plenty of water for at least 15 minutes and consult a physician. Section 8. Exposure Controls/ Personal Protection: Hand protection: Handle with gloves. Gloves must be inspected prior to use. Use proper glove removal technique (without touching glove's outer surface) to avoid skin contact with this product. Section 11. Toxicological Information: Potential Health Effects: Inhalation: May be harmful if inhaled. Causes respiratory tract irritation. Ingestion: May be harmful if swallowed. Skin: May be harmful if absorbed through skin. Causes skin irritation. The facility provided a Safety Data Sheet for Alpha Lipoic Acid with a revision date of October 5, 2015, that revealed, Section 2. Hazards Identification: Hazards statements H302: Harmful if swallowed. Precautionary statements: P301+P312+P330: If swallowed, call a poison control center or doctor/ physician if you feel unwell. Rinse mouth. Section 4. First Aid Measures: Skin contact: Wash off with soap and plenty of water. Consult a physician. The facility provided Safety Data Sheet for Dorzolamide Hydrochloride-Timolol Maleate Ophthalmic Solution with a revision date of May 29, 2015, that revealed, 4. First Aid Measures: Ingestion: If swallowed, seek medical advice immediately and show the container or label. Eye contact: Remove source of exposure. Flush with copious amounts of water for at least 15 minutes. If irritation persists or signs of toxicity occur, seek medical attention. Skin Contact: Remove from source of exposure. Remove and isolate contaminated clothing and shoes. Flush with copious amounts of water for at least 20 minutes. Use soap. If irritation persists or signs of toxicity occur, seek medical attention. The facility provided a Safety Data Sheet for Zinc Oxide Ointment 20% with an Effective Date of May 30, 2015, that revealed, Emergency Overview Health Hazards: May be harmful if swallowed. 4 First-Aid Measures: Eye Exposure: If this product contaminates the eyes, rinse eyes under gently running water. Use sufficient force to open eyelids and then roll eyes while flushing. Minimum flushing is for 20 minutes. The contaminated individual must seek medical attention if any adverse effect continues after rinsing. Ingestion: If this product is swallowed, Call physician or poison control center for most current information. 7. Handling and Use: Precautions for safe handling: All employees who handle this product should be thoroughly trained to handle it safely. The facility provided a Safety Data Sheet for (Named Hemorrhoid medication) Suppositories with a revision date of August 29, 2015, that documented, 4. First Aid Measures: Eye contact: Flush with water while holding eyelids open for at least 15 minutes. Seek medical attention immediately. Ingestion: Never give anything by mouth to an unconscious person. Wash out mouth with water. Do not induce vomiting unless directed by medical personnel. Seek medical attention immediately. Inhalation: Remove to fresh air and keep patient at rest. Seek medical attention immediately. 11. Toxicological Information: Short Term: Active ingredients may be harmful if swallowed. The facility provided a Safety Data Sheet for Dermal Wound Cleanser with a revision date of November 11, 2015, that documented, Section 4: First-Aid Measures: Eyes: Immediately flush eyes with plenty of water for at least 15 minutes. The facility provided a Safety Data Sheet for [named brand of diclofenac cream] Gel 2% with an issue date of August 31, 2016, that revealed, Section 4: First aid measures: General information: In the case of accident or if you feel unwell, seek medical advice immediately. Eye contact: Rinse thoroughly with plenty of water for at least 15 minutes and consult a physician. Ingestion: If swallowed, rinse mouth with water (only if the person is conscious). If ingestion of a large amount does occur, call a poison control center immediately. Do not induce vomiting without advice from poison control center. Section 11: Toxicological information: 11.1. Information on toxicological effects: Acute toxicity: Health injuries are not known or expected under normal use. Harmful if swallowed. The facility provided a Safety Data Sheet for Cyanocobalamin, USP Grade (Vitamin B12) with a revision date of June 08, 2019, that revealed, 4. First Aid Measures: Eye Contact: Rinse immediately with plenty of water, also under the eyelids, for at least 15 minutes. Get medical attention. Skin Contact: Wash off immediately with soap and plenty of water while removing all contaminated clothes and shoes. Obtain medical attention. Inhalation: Remove from exposure, lie down. Move to fresh air. If not breathing, give artificial respiration. Obtain medical attention. Ingestion: Clean mouth with water. Get medical attention. 7. Handling and Storage: Handling Storage: Avoid contact with skin and eye. Do not breathe dust. The facility provided a Safety Data Sheet for Ketoconazole with revision date of December 24, 2021, that revealed, 2. Hazard(s) identification: Label Elements: Hazard Statements: Toxic if swallowed. Precautionary Statements Prevention: Do not handle until all safety precautions have been read and understood. Use personal protective equipment as required. Ingestion: If swallowed: Immediately call a poison center or doctor/ physician. 4. First-aid measures: Skin contact: Wash off immediately with plenty of water for at least 15 minutes. Immediate medical attention is required. Inhalation: Remove to fresh air. If not breathing, give artificial respiration. Do not use mouth-to-mouth method if victim ingested or inhaled the substance; give artificial respiration with the aid of a pocket mask equipped with a one-way valve or other proper respiratory medical device. Immediate medical attention is required. Ingestion: Do not induce vomiting. Call a physician or poison control center immediately. 7. Handling and storage: Storage: Keep containers closed in a dry, cool and well-ventilated place. Keep refrigerated. The facility provided a Safety Data Sheet for L+ Arginine with a revision date of December 24, 2021, that revealed, 3. Composition/ Information on Ingredients: Eye Contact: Rinse immediately with plenty of water, also under the eyelids, for at least 15 minutes. Get medical attention. Skin Contact: Wash off immediately with plenty of water for at least 15 minutes. Get medical attention if symptoms occur. Inhalation: Remove to fresh air. Get medical attention if symptoms occur. If not breathing, give artificial respiration. Ingestion: Do not induce vomiting. Get medical attention if symptoms occur. 7. Handling and storage: Handling: Wear personal protective equipment/ face protection. Ensure adequate ventilation. Avoid dust formation. Avoid contact with skin, eyes or clothing. Avoid ingestion and inhalation. The facility provided a Safety Data Sheet for Nystatin with a revision date of December 24, 2021, that revealed, 4. First-aid measures: Eye contact: Rinse immediately with plenty of water, also under the eyelids, for at least 15 minutes. Get medical attention. Skin contact: Wash off immediately with plenty of water for at least 15 minutes. Get medical attention immediately if symptoms occur. Inhalation: Remove to fresh air. Get medical attention immediately if symptoms occur. Ingestion: Clean mouth with water and drink afterwards plenty of water. Get medical attention if symptoms occur. 7. Handling and storage: Handling: Wear personal protective equipment/ face protection. Ensure adequate ventilation. Avoid contact with skin, eyes or clothing. Avoid ingestion and inhalation. Avoid dust formation. The facility provided a Safety Data Sheet for Vitamin E (D-a-Tocopherol) with a revision date of December 26, 2021, that revealed, 2. Hazard(s) identification: Hazards not otherwise classified (HNOC): Other hazards: May cause skin, eye, and respiratory tract irritation. May be harmful by ingestion, or skin absorption. 3. Composition/ Information on Ingredients: Eye contact: Rinse immediately with plenty of water, also under the eyelids, for at least 15 minutes. Get medical attention. Skin Contact: Wash off immediately with plenty of water for at least 15 minutes. Get medical attention. Inhalation: Remove to fresh air. Get medical attention immediately if symptoms occur. If not breathing, give artificial respiration. Ingestion: Do not induce vomiting. Get medical attention. The facility provided a Safety Data Sheet for Vitamin D3 with a revision date of March 29, 2024, that revealed, 2. Hazard(s) identification: Fatal if swallowed, in contact with skin or if inhaled. Precautionary Statements: Inhalation: If inhaled: Removed victim to fresh air and keep at rest in a position comfortable for breathing immediately call a poison center or doctor/ physician. Skin: Immediately call a poison center or doctor/ physician. Ingestion: If swallowed: immediately call a poison center or doctor/ physician. Rinse mouth. Storage: Store locked up. The facility provided a Safety Data Sheet for Triamcinolone acetonide with a revision date of March 30, 2024, that revealed, 2. Hazard(s) Identification: Hazard Statements: Harmful if swallowed. Precautionary Statements: Ingestion: If swallowed call a poison center or doctor/ physician if you feel unwell. Storage: Store locked up. 4. First-aid measures: Eye Contact: Rinse immediately with plenty of water, also under the eyelids, for at least 15 minutes. Get medical attention. Skin Contact: Wash off immediately with plenty of water for at least 15 minutes. If skin irritation persists, call a physician. 7. Handling and storage: Storage: Keep refrigerated. The facility provided a Material Safety Data Sheet for Ketoconazole Cream 2% that revealed, 7. Handling and Storage Handling: Avoid contact with eyes, skin or clothing. Use only with appropriate personal protective equipment, safe work practices, and good hygiene practices. 8. Exposure Control/ Personal Protection: Eye/ Skin Protection: Avoid contact with eyes and skin. Wear eye protection and appropriate gloves while handling. The facility provided an in-service titled Attention: All Nurses dated 03/11/24 that revealed, Inservice overview: All med carts are to remain locked when you walk away from it. On 07/10/24 at 10:12 AM, the Surveyor interviewed the DON and asked, Should the treatment carts be kept lock at all times when unattended? She stated, Yes. When asked, Why should it be kept locked when unattended? She stated, So the residents don't get in it and get something out that shouldn't have. A facility policy titled Storage and Medications with a revision date on April 2007 revealed, Policy Statement The facility shall store all drugs and biologicals in a safe, secure, and orderly manner. Policy Interpretation and Implementation 2. The nursing staff shall be responsible for maintaining storage AND preparation areas in a clean, safe, and sanitary manner. 7. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes.) containing drugs and biologicals shall be locked when not in use, and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others. 49689

Based on observation, interview, and record review the facility failed to revise the care plan to have a securement device intervention in place for a catheter for 2 (Resident #9, #25) out of 2 sampled residents and failed to ensure interventions were in place for a contracture for 1 (Resident #42) out of 1 sampled resident. The findings are: 1. A review of the Order Summary revealed Resident #9 had diagnoses of hemiplegia and hemiparesis from a stroke, acute kidney disease, and benign prostatic hyperplasia with urinary tract infection symptoms. Further review of indwelling catheter orders revealed no order for a securement device. A review of the Order Summary revealed an active order from 06/07/2024 that states Cleanse open tear to base of right side of penis with wound cleanser or [normal saline] and pat dry. Leave open to air. every shift for wound care. A review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/03/2024 revealed that Resident #9 scored a 2 (severe cognitive impairment) on the Brief Interview for Mental Status (BIMS). A review of the Care Plan revealed that indwelling catheter interventions are in place but none for a securement device, it stated Goal: will be free/remain from catheter-related trauma through review date. On 07/08/2024 at 1:40 PM, the surveyor observed Resident #9 up in chair with no securement device in place for catheter. On 07/09/2024 at 9:00 AM, the surveyor observed Resident #9 up in chair with no securement device in place for catheter. On 07/09/2024 at 9:36 AM, during an interview Certified Nursing Assistant (CNA) #3 confirmed no securement device was in place after giving Resident #9 a complete bed bath, then stated without it the catheter could pull and rip. On 07/09/2024 at 9:45 AM, during an interview Registered Nurse (RN) #4 stated the resident had a current perineal wound and was not sure what caused it, and that they have not put on a securement device as it could of caused the skin breakdown. RN #4 then stated there were no orders or documentation concerning the securement device for Resident #9 or it could have caused Resident #9's current skin breakdown. 2. A review of the Order Summary revealed Resident #25 had diagnoses of acute kidney failure and congestive heart failure (CHF). Further review of indwelling catheter orders revealed no order for a securement device. A review of the Quarterly MDS with an ARD of 06/24/2024 revealed that Resident #25 scored a 12 (moderate cognitive impairment) on the BIMS. A review of the Care Plan revealed indwelling catheter interventions are in place but none for a securement device, it states Goal: will be free/remain from catheter-related trauma through review date. On 07/08/2024 at 12:45 PM, the surveyor observed Resident #25 sitting on the side of the bed, with no securement device in place for catheter. Resident #25 confirmed no securement device in place. Resident #25 stated that it sometimes does pull and hurt, that if a securement device existed, they would like one as it could help out. On 07/09/2024 at 9:15 AM, the surveyor observed Resident #25 in bed, no securement device was in place for catheter. On 07/09/2024 at 9:45 AM, RN #4 confirmed no securement device was in place for catheter of Resident #25, then stated it could get pulled out without a securement device. RN #4 stated that there were no orders or documentation on the securement device for Resident #25 including refusals of such care. On 07/10/2024 at 3:50 PM, during an interview the Director of Nursing stated that securement devices should be used if the Resident wants them to keep the catheter from pulling out. A review of the facility policy Catheter Care, Urinary states 2. Ensure that the catheter remains secured with a leg band to reduce friction and movement at the insertion site. (Note: Catheter tubing should be strapped to the Resident's inner thigh.) 3. A review of Order Summary reveals that Resident #42 had a diagnosis of hemiplegia and hemiparesis from a stroke affecting the left side. A review of Admission MDS with an ARD of 06/09/2024 revealed that Resident #42 scored a13 (cognitively intact) on the BIMS. Review of section GG revealed that Resident #42 had limited mobility on one side for lower and upper extremity. A review of the Care Plan for Resident #42 revealed, Goal: Resident #42 will remain free of complications related to immobility, including contractures, thrombus formation, skin-breakdown, fall related injury. On 07/08/2024 at 1:54 PM, the surveyor observed Resident #42 sitting in wheelchair, left hand dropped down in between legs with no interventions in place for contracture. Resident #42 stated it is painful, and that they do range of motion when possible. Resident #42 showed the surveyor the hand was truly contracted and stated that no interventions have been in place since admission in June. On 07/09/2024 at 12:00 PM, the surveyor observed Resident #42 sitting in wheelchair, left hand dropped down in between legs with no intervention in place for contracture. Resident #42 was repeatedly lifting their left arm and moving it to a more comfortable location, before it fell again in between their legs. On 07/10/2024 at 10:00 AM, the surveyor observed Resident #42 in bed with no interventions in place for the left-hand contracture. On 07/10/2024 at 3:10 PM, during an interview CNA #6 stated no interventions for Resident #42 ' s left hand contracture has been in place since admission. CNA #6 stated that they have requested a sling to the nurse and therapy as they have noticed that Resident #42's left arm is constantly dropped into their lap. CNA #6 stated different interventions could be in place to help with Resident #42's contracture including hand rolls, wash clothes, and a sling to prevent dropping. CNA stated that it is important to have interventions in place to prevent the contracture worsening and that they have been concerned about their left arm with how it drops for as long as the Resident had been here. On 07/10/2024 at 3:20 PM, during an interview the MDS Coordinator confirmed the Resident did not have interventions for a contracture. The MDS Coordinator stated it is important to have interventions for a contracture to keep fingernails from digging into the palms and to prevent worsening. The MDS Coordinator stated it is important to revise the care plans so we can provide the best care possible. On 07/10/2024 at 3:50 PM, during an interview the Director of Nursing (DON) stated there have been no interventions in place since admission to facility. The DON stated several interventions could be implemented to prevent worsening of contractures. The DON stated it is important to have interventions to prevent it from worsening or even have the nails dig into the skin causing wounds or infection. The DON stated it is important to revise the care plan so just in case they refuse it we can chart it. A review of the policy Resident Mobility and Range of Motion revealed, l. Residents will not experience an avoidable reduction in range of motion (ROM). 2- Residents with limited range of motion will receive treatment and services to increase and/or prevent a further decrease in ROM. 3. Residents with limited mobility will receive appropriate services, equipment and assistance to maintain or improve mobility unless reduction in mobility is unavoidable .The care plan will include specific interventions, exercises and therapies to maintain. prevent avoidable decline in and/or improve mobility and range of motion. A review of the policy Care Plans, Comprehensive Person Centered revealed, 13. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' condition change

Based on observation, record review, and interview the facility failed to ensure items were dated and labeled in the walk-in refrigerator, expired items were discarded, and cross contamination of food occurred during lunch service. The findings are: On [DATE] at 11:28 AM, the following items were observed in the facility kitchen: 1. a pint of lime juice, expired [DATE], confirmed by the Dietary Manager. 2. half a bag of purple cabbage, expired on [DATE], confirmed by the Dietary Manager. 3. full bag of green leaf romaine lettuce full bag with no date, confirmed by the Dietary Manager. On [DATE] at 12:56 PM, the surveyor observed during lunch service the pureed vegetable scoop, and the pureed bean scoop were placed in the puree sausage steam table bin. The Dietary [NAME] took the original scoop for the sausage around the steam table bin rattling the other scoops, before plating it for the puree tray. On [DATE] at 1:06 PM, the surveyor observed during lunch service, Dietary [NAME] #5 plated the red beans and rice and sausage in a scoop plate, scooped zucchini and squash in a separate bowl. Added the bowl into the scoop plate, where Dietary [NAME] #5 fingers touched the food that is on the plate. The Dietary Manager was standing next to Surveyor and stated they saw it occur and it is cross contamination. On [DATE] at 8:30 AM, during an interview the Dietary [NAME] #5 confirmed scoops should not go in other steam table bins, and fingers should not touch food as it is cross contamination. A review of the facility policy Food Service and Storage revealed 7. Dry foods that are stored in bins will be removed from original packaging, labeled and dated ('use by' date). Such foods will be rotated using a first in - first out system, e. Other opened containers must be dated and sealed or covered during storage.

Based on observations, record review and interview the facility failed to ensure that pureed food was processed to the correct consistency to meet the needs one (Resident #9) of one sampled resident. The findings are: A review of the Order Summary revealed Resident #9 had a diagnosis hemiplegia and hemiparesis from a stroke. A review of the Order Summary revealed Resident #9 had an active order as of 06/24/2024 for consistent carbohydrate, pureed texture diet, honey consistency, for nutrition. A review of the Care Plan for Resident #9 revealed Focus: Resident# 9 has an Activity of Daily Living (ADL) self-care performance deficit r/t right side hemiplegia and hemiparesis; Intervention: Eating .The resident is dependent x1 staff for meal consumption. On 07/09/2024 at 11:34 AM, Dietary [NAME] #5 added 2 scoops of polish sausage to the food processor. The Dietary [NAME] then added 2 ounces of gravy and ran the food processor. Surveyor observed the texture was gritty with small sausage pieces in the puree. Dietary [NAME] stated that it was of a pudding like consistency. On 07/09/2024 at 11:40 AM, Dietary [NAME] #5 added 2 scoops of zucchini and squash to the food processor, which was then ran. Surveyor observed that the vegetables were smooth in consistency but runny and did not hold form. The Dietary [NAME] stated that it is soupy and a little runny but it will be in a bowl. On 07/09/2024 at 11:45 AM, Dietary [NAME] #5 added 2 scoops of red beans and rice to the food processor with 2 two-ounce ladles of gravy, which was then ran. The surveyor observed that the red beans and rice were gritty with pieces of beans still in the mixture. The Dietary [NAME] stated that it is pudding like in consistency. On 07/09/2024 at 12:30 PM, the surveyor observed Resident #9 being assisted by a Certified Nursing Assistant (CNA). Surveyor observed the zucchini and squash did not hold form and was soupy. The red beans and rice had pieces of beans throughout it, and the sausage had pieces throughout it as well. On 07/10/2024 at 3:00 PM, during an interview the Dietary Manager described the puree for lunch yesterday as the vegetable was soupy, the rest of it looks like gritty paste, then stated pureed foods are supposed to be pudding-like in consistency to prevent aspiration. A review of the facility recipe Slice Smoked Sausage Puree stated that The desired thickness should be mashed potato or pudding. There should be no large lumps or particles. A review of the facility recipe Red Beans and Rice Puree states that the The desired thickness should be mashed potato or pudding texture. There should be no lumps or particles. A review of the facility recipe Soft Cooked Vegetable Puree states that the The desired thickness should be mashed potato or pudding.

Based on observation, record review, and interview the facility failed to ensure residents who required assistance with activities of daily living were regularly provided with the necessary assistance to maintain good hygiene and grooming for one (Resident #1) of one sampled Resident. The findings are A review of the Order Summary reveals Resident #1 had diagnoses of dementia, recurrent depressive disorder, and osteoarthritis. A review of the Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/18/2024 revealed that Resident #1 scored an 8 (moderate cognitive impairment) on the Brief Interview for Mental Status (BIMS). According to Section GG Resident #1 is coded as Dependent for Shower/Bathe Self. A review of the Care Plan for Resident #1 revealed Focus: has an ADL self-care performance deficit r/t (related to) functional limitation. Interventions/Tasks: BATHING/SHOWERING: The resident is dependent with showering at least twice weekly and as necessary. On 07/08/2024 at 12:30 PM, Resident #1 stated they have not been shaved for over a week, then stated it is embarrassing and would like to be shaved. The surveyor observed two-inch facial hair spanning across the resident's chin. On 07/09/2024 at 8:15 AM, the surveyor observed Resident #1 had not been shaved. On 07/10/2024 at 9:00 AM, the surveyor observed Resident #1 had not been shaved. On 07/10/2024 at 3:15 PM, during an interview Certified Nursing Assistant (CNA) #6 stated the Resident has stubble on their chin. CNA #6 stated residents are to be shaved on shower days, and their shower day is usually on Monday. CNA #6 stated that facial hair can cause irritation, cause confidence issues, and cause embarrassment. On 07/10/2024 at 3:35 PM, during an interview the MDS Coordinator stated the Resident ' s chin was hairy and the facial hair as long. The MDS Coordinator stated residents should be shaved on shower days. Resident #1 rubbed their chin with their right hand and stated that they would like to be shaved and that it's been bothering [the Resident] to not have this done. The MDS Coordinator stated that not shaving facial hair could be seen as a dignity issue. The MDS Coordinator stated bath days were on Monday and Thursday. On 07/10/2024 at 3:50 PM, during an interview the Director of Nursing (DON) stated residents are to be shaved on shower days and anytime in between when it is needed. The DON then stated that this is a dignity issue. On 07/10/2024 at 2:00 PM, the surveyor received bath sheets for the last three months for Resident #1 stopping at 6/27/2024. On 07/11/2024 at 8:30 AM, during an interview the DON stated the July bath sheets may still be in the box, as she has not checked it in over a week. The DON brought one CNA Inspection Report for 07/03/2024 that stated yes for female facial hair being removed. The DON stated this was the only one they could find in the box. A review of the policy Activities of Daily Living (ADLS), Supporting revealed residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene. 2. Appropriate care and services will be provided residents who are unable ADLS independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: a. Hygiene (bathing, dressing, grooming and oral care);

Based on record review and interview, the facility failed to ensure residents with concerns and complaints regarding call light answering times in the facility were able to have their grievances thoroughly investigated as part of the process of resident rights for 1 (Resident #15) of 01 sampled residents. The findings are: 1. Review of the Order Summary Report indicated Resident #15 had diagnoses of muscular dystrophy and benign prostatic hyperplasia. a. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/01/2024 indicated a score of 15 (indicates cognitively intact) on the Brief Interview for Mental Status (BIMS). b. On 07/08/2024 at 2:08 PM, the Surveyor interviewed Resident #15 and asked, Do staff answer your call light timely? Resident #15 stated, This girl, her boyfriend is the nurse, an LPN, he lets her get away with things. She wants someone else to come take care of the residents, and she even says no, and he allows her to get away with that. The day of the incident he came in and I told him my bed is wet and I'm wet and need changed. He told me he would let one of the girls know. It was time to pass trays, so I had to wait 45 minutes. I hit my call light again and he came, and I told him this was becoming abuse now. He went and got linens and after they passed trays they showed up. They started to do the bed; the girl that is his girlfriend got a little cranky. They asked me what pillow goes under my legs and I said the one that says My Pillow and they said none of them say My Pillow. I talked to another CNA, and she looked and said look it says My Pillow all over it. The girlfriend bailed and left out and let the other girl do the job. They let me stay in (urine) for over 45 minutes. It happened on June 25th. The nurse consultant took notes and said she would let the guy who is running the place know, but he nor the DON came to talk to me. I talked to the guy today and he told me the problem was resolved. I asked how it is resolved when no one came to talk to me to see what happened. I asked her to help me up the other day and she didn ' t, she went over to where her boyfriend was, and another girl helped me out. c. Review of Resident Council Minutes with a meeting date of 05/28/2024 revealed a new business of call lights not being answered and being ignored with 5 of 6 resident council members in agreement. d. Review of Location Event Report dated 06/25/2024 revealed Resident #15 call light times as: 4:46 PM through 5:05 PM Response Time 18 minutes 6:09 PM through 6:19 PM Response Time 09 minutes 6:22 PM through 6:23 PM Response Time 01 minute 6:23 PM through 6:28 PM Response Time 15 minutes 6:56 PM through 7:07 PM Response Time 11 minutes d. Review of a Grievance Log dated July 2024 revealed Resident #15 filed a grievance on 07/02/2024 regarding the call light with a resolution date noted as 07/03/2024. Nature/description of resolution was noted as performing a call light audit and counseling staff. e. Review of a Grievance Form with a date of 07/02/2024 revealed Resident #15 expressed the grievance and form was completed by a third party. The issue was involving patient care/treatment and documented, Resident #15 stated I put on my call light because I needed to use the urinal. Resident #15 stated the call light was on for 45 minutes. Also stated when [Named CNA] answered the call light she said she can't put up with this and walked off. Also stated that CNA staff placed [Resident #15 ' s] pillow that goes under [Resident ' s] legs was placed under [Resident ' s] arms instead. f. Review of three OLTC (Office of Long Term Care) Witness Statement Forms showed they were filled out by the same CNA and were not dated. OLTC witness form #1 documented, Time: 6:00 PM Job Title CNA. (Named room number) had stated to the nurse [resident] urinated the bed and needed to be changed and I went in to resident room and told him me and the other CNAs working on the hall was in the middle of passing supper trays and assisting other residents with feeding that I will go get a CNA to come back with me to get [resident] cleaned up and bed changed. The resident yelled at me that I had to do it right away and continuously pushed [resident] call light yelling out. I went to get another CNA and we cleaned and changed [resident ' s] bed. i. OLTC witness form #2 documented, Explained to [resident] one CNA was in the middle of assisting another resident and the other CNA was assisting a nurse with a resident, that when one of them was done, we would help get [resident] to bed. [Resident] started yelling and going back to [resident ' s] room that I refused to help [resident] and [resident] was going to call and turn me in and I better watch it. The other two CNAs came back on the hall and assisted the resident to bed. ii. OLTC witness form #3 documented, Time 7:30 PM Job title CNA. After assisting (named room) to bed and gave [resident] urinal the only thing left was to cover resident up and I was feeling sick and felt over-heated and asked the other CNA if she was okay if I stepped out of the room and she said yes, and I said I had gotten too hot and stepped out. The resident said I refused to continue to help and left CNA and that [he/she] was going to talk with someone about me in the morning. g. Review of (Named Facility) Daily Census for 200 hallway dated 07/09/2024 provided by the Nurse Consultant revealed 6 residents with a BIMS of 12 or higher that were interviewable and 15 residents that were non-interviewable. h. On 07/10/2024 at 10:08 AM, the Surveyor interviewed the Social Activity Director and asked, Did you conduct the grievance investigation for Resident #15 about the call light not being answered? She stated, Yes. When asked, Which cognitive residents on the 200 hallway were interviewed over Resident #15's complaint about the call light not being answered? She stated, None. When asked, Should residents who are cognitively intact been interviewed about call light response time? She stated, Yes, ma'am. When asked, Why should other cognitively intact residents on the hall be interviewed? She stated, To see if others had issues. When asked, How many staff members were interviewed about Resident #15's complaint about the call light not being answered? She stated, The witness statement was only through [Certified Nurse Aide (CNA) name] the CNA, and she was counseled verbally. There was a nurse involved but no statement was taken from him. When asked, Did you interview the other CNA involved? She stated, No. When asked, Should the other staff members involved be interviewed? She stated, Yes. When asked, Why should they have been interviewed? She stated, To get all sides of what happened. When asked, How many non-cognitively intact residents family members were interviewed about their call lights being answered timely? She stated, None. When asked, Was this a thorough investigation? She stated No. i. On 07/10/24 at 10:10 AM, the Surveyor interviewed the Director of Nursing (DON) and asked, Which cognitive residents on the 200 hallway were interviewed over Resident #15's complaint about the call light not being answered? She stated, I didn't interview any of them, I don't know if the Social Director did. When asked, Should residents who are cognitively intact been interviewed about call light response time? She stated, Yes. When asked, Why should cognitively intact residents be interviewed? She stated, Because they could have the same problem. When asked, How many staff members were interviewed about Resident #15's complaint about the call light not being answered? She stated, The witness statements are from one staff member. When asked, Was a nurse also involved in the situation that led to the grievance to be filed? She stated, Yes. When asked, Was that nurse interviewed? She stated, No. When asked, Was the other CNA involved in the situation interviewed? She stated, No. When asked, Should the other CNA have been interviewed also? She stated, Yes. When asked, Why should the other two staff members be interviewed? She stated, So you don't get just one version of what went on. When asked, How many non-cognitively intact residents family members were interviewed about their call lights being answered timely? She stated, None that I see. When asked, Was this a thorough investigation? She stated, No. When asked, Did you follow up with resident #15? She stated, I think the Social Director spoke to him, I didn't. j. On 07/10/2024 at 3:57 PM, the Surveyor interviewed the Administrator and asked, Which cognitive residents on the 200 hallway were interviewed over Resident #15's complaint about the call light not being answered? He stated, I'm not sure. None are listed. When asked, Should residents who are cognitively intact been interviewed about call light response time? He stated, Yes. When asked, How many staff members were interviewed about Resident #15's complaint about the call light not being answered? He stated, Looks like just one that the Resident #15 identified. When asked, Was a nurse also involved in the situation that led to the grievance to be filed? He stated, I'm not sure. When asked, Was there a nurse interviewed? He stated, Not that I'm aware. When asked, How many non-cognitively intact residents family members were interviewed about their call lights being answered timely? He stated, None that I'm aware of. When asked, Was this a thorough investigation? He stated, This was investigated. When asked, Did you follow up with Resident #15? He stated, I talked to Resident #15. (Resident) had no complaints when I talked to (Resident) on 6/25. Social Director would've followed up. I just talked to (Resident) in the hallway. k. Facility provided a policy titled, Grievances/ Complaints, Recording and Investigating with a revision date of April 2017 documented, Policy Statement: All grievances and complaints filed with the facility will be investigated and corrective actions will be taken to resolve the grievance(s). Policy Interpretation and Implementation: 2. Upon receiving a grievance and complaint report, the Grievance Officer will begin an investigation into the allegations. 4. The investigation and report will include, as applicable: g. Accounts of any other individuals involved.

Based on observation and interview, the facility failed to ensure that hands were washed between clean and dirty tasks to minimize the risk of cross contamination and foods were dated when received or opened to assure first in first out usage to prevent potential for food borne illness. The failed practices had the potential to affect 42 residents who received meals from the kitchen (total census: 43) as documented on a list provided by the Dietary Supervisor on 1/25/24 at 2:16 pm. The findings are: On 1/25/24 at 11:18 am, the following items were observed in the dry storage area without a received on date: 1. 2 bags of 32 ounces toasted oats cereal bags. 2. 1 large box with bags of penne rigate pasta. On 1/25/24 at 11:37 am, the following items were observed in the walk-in refrigerator without a received on date: 1. 1 large box of multiple blocks of margarine 2. 1 5-pound bag of mozzarella shredded cheese. On 1/25/24 at 11:41 am, the following items were found with no open date: 1. 1 plastic tub of individual sugar packets. 2. 1 plastic tub of individual sweet n low packets. On 1/25/24 at 12:29 pm, the cook was observed while serving the lunch meal doing the following actions without washing her hands: 1. Observed the cook picking up multiple plates and placing her thumb on the top of the plate. 2. Observed the cook placing both hands on her hips then return to the utensils and continue serving lunch. 3. Observed the cook place left hand in her pants pocket then return to the utensils and continue serving lunch. On 1/25/24 at 1:47 pm, the cook confirmed during an interview that she placed her thumbs on the plates while serving lunch. The cook confirmed she failed to wash her hands after placing her hands on her hips and in her pockets while serving lunch. The cook confirmed she had been educated on proper handwashing techniques and she failed to do so. The cook confirmed failing to wash her hands can contaminate the food, plates, and residents. The cook confirmed she has been educated on dating food that comes into the kitchen when it is received and when it is opened. On 1/25/24 at 1:53 pm, the Dietary Manager confirmed during an interview there were food products in the dry storage area, kitchen and refrigerator that were not dated when received and when opened. The Dietary Manager confirmed food should be dated when received and when opened. The Dietary Manager confirmed the cook placed her thumbs on the plates during the lunch meal service. The Dietary Manager confirmed the cook placed her hands on her hips and in her pocket during meal service and continued to serve lunch without washing hands. The Dietary Manager confirmed that not washing hands can cause germs to get to the residents, on the plates, and the food. The Dietary Manager confirmed hands should be washed when moving from one task to another and when you touch your clothes and hairnets. On 1/25/24 at 1:45 pm, the facility provided a policy titled, Food Receiving and Storage. The policy documented, Policy Statement: Food shall be received and stored in a manner that complies with safe food handling practices .7. Dry food that are stored in bin will be remove from original packaging, labeled and dated (use by date). Such foods will be rotated using a first in -first out system. 8. All food stored in the refrigerator or freezer will be covered, labeled and dated (use by date) .e. Other opened containers must be dated and sealed or covered during storage . On 1/25/24 at 1:45 pm, the facility provided a policy titled, Preventing Foodborne Illness-Employee Hygiene and Sanitary Practices. The policy documented, Policy Statement: Food and nutrition services employees will follow appropriate hygiene and sanitary procedures to prevent the spread of foodborne illness. Policy Interpretation and Implementation 1. All employees who handle, prepare or serve food will be trained in the practices of safe food handling and preventing foodborne illness. Employees will demonstrate knowledge and competency in these practices prior to working with food or serving food to residents .6. Employees must wash their hands: .d. Before coming in contact with any food surface .f. After handling soiled equipment or utensil; g. During food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing task; and/or h. After engaging in other activities that contaminate hands .9. Food service employees will be trained in the proper use of utensils such as tongs, gloves, deli paper and spatulas as tools to prevent foodborne illness .

Based on record review and interview, the facility failed to ensure the plan of care was revised to reflect the current needs of new fall interventions for 2 (Resident #3 and #4) of 4 sample mix residents. Review of Resident #3's Care plan dated 11/06/2023 documented, .High risk for falls (related to) r/t (Cardiovascular Accident) CVA with L non-dominant side hemiplegia, falls prior to admission for no apparent acute injury, determine and address causative factors of the fall; Make sure non-slip socks are on correctly; PT consult for strength and mobility. On 11/16/2023 it notes anticipate and meet the residents needs, be sure residents call light is within reach and encourage the resident to use for assistance as needed. The resident needs prompt response for all requests; Ensure that the resident is wearing appropriate footwear, either non-skid socks or non-skid soled shoes when ambulating or mobilizing in w/c (wheelchair); PT evaluate and treat as ordered or PRN. Review of Resident #3's Incident and Accident Report on 12/08/2023 at 12:15 PM, noted two falls on 11/06/2023; two falls 11/07/2023; one fall on 11/09/2023; one fall on 11/13/2023; and one fall on 11/14/2023. Review of Resident #4's Care plan dated 12/07/2023 documented, . bed to be in lowest position except during cares and transfers; PT consult for strength and mobility . Review of Resident #4's Incident and Accident Report on 12/08/2023 at 12:36 PM, noted falls on 11/25/2023 and on 12/04/2023. Facility Falls- Clinical Protocol provided by the Nursing Consultant on 12/07/2023 at 03:35 PM, documented, .Treatment/ Management 1. Based on the preceding assessment, the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address the risks of clinically significant consequences of falling. 2. If underlying causes cannot be readily identified or corrected, staff will try various relevant interventions, based on assessment of the nature or category of falling, until falling reduces or stops or until a reason is identified for its continuation (for example, if the individual continues to try to get up and walk without waiting for assistance) . Monitoring and Follow-Up . 2. The staff and physician will monitor and document the individual's response to interventions intended to reduce falling or the consequences of falling . 3. If interventions have been successful in fall prevention, the staff will continue with current approaches and will discuss periodically with the physician whether these measures are still needed . 4. If the individual continues to fall, the staff and physician will re-evaluate the situation and reconsider possible reasons for the resident falling (instead of, or in addition to those that have already been identified) and also reconsider the current interventions . During an interview on 12/07/2023 at 3:26 PM, Nursing Consultant confirmed that Resident #3 and Resident #4's care plan did not include interventions for each fall. During an interview on 12/07/2023 at 3:58 PM, Director of Nursing confirmed that Resident #3 and Resident #4's care plan did not include interventions for each fall. Facility Falls and Fall Risk, Managing provided by the Nursing Consultant on 12/07/2023 at 03:35 PM, documented, . Resident-Centered Approaches to Managing Falls and Fall Risk 1. The staff, with input of the attending physician, will implement a resident- centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls . 5. If falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant. 6. If underlying causes cannot be readily identified or corrected, staff will try various interventions, based on assessment of the nature or category of falling, until falling is reduced or stopped, or until the reason for the continuation of the falling is identified as unavoidable. 7. In conjunction with the attending physician, staff will identify and implement relevant interventions . Monitoring Subsequent Falls and Fall Risk 1. The staff will monitor and document each resident's response to interventions intended to reduce falling or the risks of falling. 2. If interventions have been successful in preventing falling, staff will continue the interventions or reconsider whether these measures are still needed if a problem that required the intervention (e.g., dizziness or weakness) has resolved. 3. If the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions. As needed, the attending physician will help the staff reconsider possible causes that may not previously have been identified .

Based on record review and interview, the facility failed to ensure resident assessments were completed for 3 (Resident #1, #3, and #4) sample mix residents. The findings are: Review of Resident #1's care plan dated 10/30/2023 showed Resident has been educated on sterile trach care procedure but chooses not to use sterile gloves with her independent trach care. Review of Resident #1's facility assessments on 12/06/2023 at 1:14 PM, do not note the resident was assessed to provide her own tracheostomy care. During interview on 12/06/2023 at 1:17 PM, the Director of Nursing confirmed Resident #1 provided her own tracheostomy care but was not assessed. Review of Resident #3's Incident and Accident Report on 12/08/2023 at 12:15 PM, noted falls on 11/06/2023; 11/07/2023; 11/09/2023; 11/13/2023; and 11/14/2023. Resident #3 has fall assessments dated 11/13/2023 and 11/14/2023. Review of Resident #4's Incident and Accident Report on 12/08/2023 at 12:36 PM, noted falls on 11/25/2023 and on 12/04/2023. Resident #4 has a fall assessment dated [DATE]. During an interview on 12/07/2023 at 12:41 PM, the Director of Nursing confirmed that Resident's #3 and #04 did not have fall assessments completed after each fall. During an interview on 12/07/2023 at 3:26 PM, the Nursing Consultant confirmed that Resident's #03 and #4 did not have fall assessments completed after each fall. Facility Fall Risk Assessment policy provided by the Nursing Consultant on 12/07/2023 at 03:42 PM, documented, . The nursing staff, in conjunction with the attending physician, consultant pharmacist, therapy staff, and others, will seek to identify and document resident risk factors for falls and establish a resident-centered falls prevention plan based on relevant assessment information 6. Assessment data shall be used to identify underlying medical conditions that may increase the risk of injury from falls .

Based on observation, interview, and record review, the facility failed to ensure the food items in the refrigerators were properly sealed, labeled or dated, and were disposed of in a timely manner to prevent food borne illnesses; and failed to ensure staff wore hair nets/beard restraints while serving to prevent the potential contamination of food. These failed practices had the potential to affect 41 residents who received meals from the kitchen as documented on the Diet Order Tally Report provided by the Dietary Manager on 06/13/23 at 3:40 p.m. The findings are: a. On 06/12/23 at 3:48 p.m., the Surveyor made initial rounds in the facility kitchen with the Dietary Manager (DM). The refrigerator contained two metal pans covered with aluminum foil that were not labeled and dated. The Surveyor asked, What is in the pans? The DM replied, It's cake for dessert. The Surveyor asked, Should the pans be labeled with the contents and dated? The DM replied, Yes, they should have stuck a label and date on it. b. On 06/12/23 at 3:52 p.m., an open, half-full, one gallon plastic container of lemon juice was on the top shelf of the refrigerator and was not labeled with an open date. c. On 06/12/23 at 3:55 p.m., a plastic pan containing 3-120 cc (cubic centimeters) glasses of red liquid was on the shelf in the refrigerator. The glasses were not labeled and dated. d. On 06/12/23 at 3:56 p.m., a half of head of purple cabbage wrapped in plastic wrap with a date of 5/23 was on the shelf in the refrigerator. e. On 06/12/23 at 3:57 p.m., the Surveyor asked the DM, Should items be labeled and dated? The DM replied, It should be. f. On 06/12/23 at 5:45 p.m. and 5:56 PM, Dietary Employee (DE) #2 was in the kitchen window preparing meal trays with sideburns and a 6-inch beard that was not contained. g. On 06/12/23 at 5:57 p.m., the Surveyor asked the DM, Are staff supposed to have hair/beards covered when preparing food? The DM replied, Yes. The Surveyor asked, Why are staff hair/beards supposed to be covered when preparing food? The DM replied, So hair doesn't fall into the food, I told DE #2 to get a beard cover on earlier today. h. On 06/12/23 at 6:01 p.m., the Surveyor asked DE #2, Are you supposed to have beard net/cover on while preparing food? DE #2 replied, Tonight I'm cutting my beard off, they are uncomfortable. The Surveyor asked, Why are staff supposed to wear beard/hair nets while preparing food? DE #2 replied, In case beard hair falls into the food. i. On 06/13/23 at 1:46 p.m., the Surveyor asked the Registered Dietician (RD), Why should food be labeled and dated in the kitchen? The RD replied, So we know how long it's good for. The Surveyor asked, How long is fresh cabbage good for? The RD replied, 3 days. The Surveyor asked, Who is responsible for ensuring food is labeled and dated in the kitchen? The RD replied, All kitchen staff. The Surveyor asked, Why should hair/beards be covered while serving/preparing meals or working with food in the kitchen? The RD replied, So we do not get hair in the food. j. On 06/13/23 at 3:43 p.m., the Surveyor asked the Administrator, Why should food be labeled and dated in the kitchen? The Administrator replied, So you know when it's received and when to discard it. The Surveyor asked, Who is responsible for ensuring food is labeled and dated in the kitchen? The Administrator replied, Dietary. The Surveyor asked, Why should hair/beards be covered while serving/preparing meals or working with food in the kitchen? The Administrator replied, Sanitary. The Surveyor asked, What are your expectations from your staff regarding following the facilities policies and procedures and the Centers for Medicare and Medicaid Services (CMS) guidelines? The Administrator replied, I want them to follow State and Federal guidelines and facility policies. k. The facility policy titled, Food Receiving and Storage, provided by the Administrator on 06/13/23 at 11:22 a.m. documented, .foods shall be received and stored in a manner that complied with safe food handling practices .all foods stored in the refrigerator or freezer will be covered, labeled and dated . l. The facility policy titled, Food Preparation and Service, provided by the Administrator on 06/13/23 at 11:22 a.m. documented, .food and nutrition services employees shall prepare and serve food in a manner that complies with safe food handling practices .food preparation staff will adhere to proper hygiene and sanitary practices to prevent the spread of food-borne illness .food and nutrition services staff shall wear hair restraints (hair net, beard restraint) etc [et cetera]. so that hair does not contact food .

Based on observation, record review, and interview, the facility failed to provide appropriate care to include obtaining a physician treatment order and dating a wound dressing for 1 (Resident #3) of 4 (#1, #2, #3, #4) sampled residents. The findings are: 1. Resident #3 had diagnoses of Kidney Disease and a fracture of First Lumbar Vertebra. The Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/21/23 documented the resident scored 15 (13-15 indicates cognitively intact) on the Brief Interview for Mental Status (BIMS), required extensive assist of 2 persons for dressing and bed mobility and had no skin conditions. a. The Care Plan with a revision date of 06/02/23 documented, .resident has actual impairment to skin integrity .keep skin clean and dry .treatments as ordered . b. The Nursing Skin Audit dated 06/12/23 at 14:04 [2:04 p.m.] documented, .ruptured blister to upper left thigh .treatment in place .no other skin issues noted . c. On 06/12/23 at 4:13 p.m., Resident #3 was lying in his bed with a visitor [family member] at his bedside. A 2 inch by 2-inch white bordered foam dressing was on Resident #3's left forearm. There was no date on the dressing. The Surveyor asked Resident #3 and the visitor what happened to his arm. Resident #3's visitor [family member] stated, It happened this morning, here in the room, while they were getting Resident #3 dressed. The Surveyor asked, Who put the bandage on Resident #3? Resident #3's visitor [family member] stated, It was the Certified Nursing Assistant (CNA) that rides in the van. d. On 06/13/23 at 10:46 a.m., Resident #3 was lying in his bed with visitor [family member] at his bedside. A 2 inch by 2-inch white bordered foam dressing was on his left forearm, with no date on the dressing. There was no treatment ordered documentation for skin issues to his left forearm. e. On 06/13/23 at 10:50 a.m., the Surveyor asked Licensed Practical Nurse (LPN) #1, What happened to Resident #3 left forearm? LPN #1 replied, I do not know. The Surveyor asked, What type of wound is under the bandage? LPN #1 replied, I don't know. The Surveyor asked, Is there an order for wound treatment? LPN #1 replied, Not that I'm seeing. The Surveyor asked, What do you do if a resident receives a skin tear? LPN #1 replied, Assess, the floor nurse initiates treatment if the treatment nurse is not here and notify the Physician. The Surveyor asked, Who is responsible for ensuring an order is obtained and the Physician is notified? LPN #1 replied, The floor nurse notifies, it's a team effort. f. On 06/13/23 at 11:08 a.m., the Surveyor asked Registered Nurse (RN) #1, What happened to Resident #3's left forearm? RN #1 replied, I haven't seen that, and I didn't do that. The Surveyor asked, What type of wound is under the bandage? RN #1 replied, I don't know. The Surveyor asked, Is there an order for wound treatment? RN #1 replied, No there is not. The Surveyor asked, What do you do if a resident receives a skin tear? RN #1 replied, Do an Incident and Accident (I and A), write a treatment order, and figure out how they got it and notify the family and doctor. g. On 06/13/23 at 2:14 p.m., the Surveyor asked Certified Nursing Assistant (CNA) #3, What happened to Resident #3's left forearm? CNA #3 replied, Me and Maintenance #1 took Resident #3 to an appointment on 06/12/23. He was already dressed, and the bandage was on. I asked Resident #3's visitor [family member] about the skin tear, and the visitor [family member] said it happened on the bed rail. The Surveyor asked, What time did you leave the facility on 06/12/23? CNA #3 replied, At 10:25 a.m. h. On 06/13/23 at 3:04 p.m., the Surveyor asked the Director of Nursing (DON), What happened to Resident #3's left forearm? The DON replied, I overheard something about a skin tear. The Surveyor asked, What do you do if a resident receives a skin tear? The DON replied, The nurse should do an I and A, provide treatment, and notify family and the Physician. The Surveyor asked, Who is responsible for wound care, monitoring and assessing residents' wounds/skin? The DON replied, The treatment nurse, if the treatment nurse is not here, then it's the assigned nurse. i. On 06/13/23 at 3:54 p.m., the Surveyor asked the Administrator, What happened to Resident #3's left forearm? The Administrator replied, I do not know. The Surveyor asked, What is the facilities policy for skin tears? The Administrator replied, I and A, treatment, and notification. The Surveyor asked, Who is responsible for ensuring an order is obtained and the Physician is notified? The Administrator replied, The DON or designee. The Surveyor asked, What are your expectations from your staff regarding following the facilities policies and procedures and the Centers for Medicare and Medicaid Services (CMS) guidelines? The Administrator replied, I want them to follow State and Federal guidelines and facility policies.

Based on observations, interview, and record review, the facility failed to ensure the residents who required assistance to eat, were assisted in a manner to maintain dignity and respect for 1 (Resident #4) of 4 (#1, #2, #3, #4) sampled residents. This failed practice had the potential to affect 3 (Resident #1, #2, and #4) of 4 (#1, #2, #3, #4) sampled residents who require assistance to eat according to a list provided by the Director of Nursing (DON) on 06/13/23 at 4:08 p.m. The findings are: 1. Resident #4 had a diagnosis of Dementia. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/26/23 documented the resident scored 2 (0-7 indicate severe impairment) on the Brief Interview for Mental Status (BIMS); required 1 person to physically assist with eating. a. The Physician Order with a start date of 05/13/20 documented, .resident to be up in wheelchair and in dining room at assist table for all meals due to decreased meal consumption three times a day . b. The Care Plan with a revision date of 05/20/21 documented, .resident has an ADL [activity of daily living] self-care performance deficit .resident requires limited assistance by x [times] 1 staff to eat . c. On 06/12/23 at 6:42 p.m., Resident #4 was sitting in a specialized wheelchair in the hallway of 200 Hall with 2 other residents. All three residents had their meal trays. There were no staff assisting her with her meal. d. On 06/12/23 at 6:49 p.m., the Surveyor asked Certified Nursing Assistant (CNA) #1, Why don't the residents go to the Dining Room to eat? CNA #1 replied, Because we don't have enough staff to assist with meals. e. On 06/12/23 at 6:52 p.m., the Surveyor asked CNA #2, Why don't the residents go to the Dining Room to eat? CNA #2 replied, They have more staff on days. f. On 06/12/23 at 6:57 p.m., the Director of Nurses, (DON) was standing next to Resident #4 giving her two bites of food from her plate. The DON continued to stand next to her, administering 1 bite of vegetables, 1 bite of noodles, then another bite of noodles. g. On 06/12/23 at 6:59 p.m., the Surveyor asked the DON, Do you normally stand over the residents when assisting them with eating? The DON replied, No I usually don't, I didn't have a chair. The Surveyor asked, Why should we sit at eye level when assisting residents with eating? The DON replied, So it's not intimidating. The Surveyor asked, Are residents provided with dignity when we stand over them while assisting them with eating? The DON replied, No. h. On 06/13/23 at 2:14 p.m., the Surveyor asked CNA #3, Why are staff encouraged to sit at eye level when assisting residents with meals? CNA #3 replied, So they are not towering over them. The Surveyor asked, What resident right is violated when standing over a resident while assisting them with meals? CNA #3 replied, Dignity. i. On 06/13/23 at 3:43 p.m., the Surveyor asked the Administrator, Why are staff encouraged to sit at eye level when assisting them with eating? The Administrator replied, It's a dignity issue. The Surveyor asked, What are your expectations from your staff regarding following the facilities policies and procedures and the Centers for Medicare and Medicaid Services (CMS) guidelines? The Administrator replied, I want them to follow State and Federal guidelines and facility policies. j. The facility policy titled, Resident Rights, provided by the Administrator on 06/13/23 at 1:34 p.m. documented, .employees shall treat all residents with kindness, respect, and dignity .federal and state laws guarantee certain basic rights to all residents of this facility .these rights include the resident's right to .a dignified existence .be treated with respect, kindness, and dignity .

Based on observation, interview, and record review, the facility failed to ensure food items stored in the refrigerators, freezers, and dry storage area were covered, sealed, and dated when received and opened; expired or spoiled food items were discarded promptly, and the facility kitchen was deep cleaned on a regular basis to prevent the potential of food borne illness for residents who received meals from 1 of 1 kitchen. The failed practice had the potential to affect 46 residents who received meals from the kitchen (total census: 46), as documented on the diet list provided by the Administrator on [DATE] at 8:00 AM. The findings are: 1. On [DATE] at 10:39 AM, a black residue was covering 75% of the top of a greyish white two shelf cart with a clean drying rack sitting on top filled with 6 clean cups. The Surveyor asked the Dietary Manager (DM) to describe the residue. The DM stated, I am not sure, and scraped at the residue with his fingernail. The DM stated, There is definitely something on there and it needs to be cleaned. 2. On [DATE] at 10:40 AM, the bread rack in the hallway to the Dry Storage Room contained 6 bags of hotdog buns dated, Best by [DATE], and 7 bags of hamburger buns dated, Best by [DATE]. The DM stated the food delivery company had been delivering bread products that were already past their best by date at delivery and he was sending back 4 boxes (stacked next to bread rack), but the bags on the rack were being used. 3. On [DATE] at 10:42 AM, the Dry Storage Room shelves contained a ,d+[DATE] full large round plastic container of solidified baking powder dated, best by [DATE] , no other date marked, and a box of brown rice wrapped in clear plastic not dated. The Surveyor asked the DM if the baking powder should be used. The DM stated, I don't know how long that is good for. The Surveyor asked if he could find a date on the rice. The DM stated, That should have a date. I will toss it. 4. On [DATE] at 11:00 AM, the standing stainless refrigerator contained a plastic bag of leftover Swiss steak dated [DATE]. The Surveyor asked how long leftovers were good for. The DM stated, Leftovers are only good for 3 days. I will toss that too. On the middle shelf there was a small individual serving bowl of unrecognizable food. The Surveyor asked the DM to describe what was in the bowl and when it was made. The DM stated, I am unsure what it is. Honestly, I don't know. I'll toss it. On a shelf next to the refrigerator there was a large opened white ,d+[DATE] full plastic tub of peanut butter with loose plastic wrap sitting on the top. The DM stated, I will toss that. We have plenty of peanut butter. 5. On [DATE] at 11:04 AM, the walk-in refrigerator contained an opened plastic container of chicken base half full, not dated. The Surveyor asked the DM if he could find a date. The DM stated, No, I can't see one. The Surveyor asked if all foods stored should have a received and opened date. The DM stated, I believe so. Are you saying they should have them? Two bags of shredded lettuce with a use by date of [DATE] contained a brown liquid pooled at bottom of the bags. The DM stated, Those should have been thrown out already. A small individual serving bowl with a lid and no date was on a shelf and the contents in the bowl had a white fuzzy substance on it. The Surveyor asked what it was and when it was made. The DM stated, They look like they were pickles. I don't know how long they have been in here. It needs to be tossed. 6. On [DATE] at 11:10 AM, the walk-in freezer contained an opened box with an unsealed bag of riblets with white crystals and discolored spots. The DM stated, I can't tell if it's freezer burn or not. There was also an opened box with an unsealed bag of fish fillets dated [DATE] and an opened box with an unsealed bag of vegetable mix dated [DATE]. 7. On [DATE] at 11:14 AM, the Surveyor asked the DM the last time the fryer was cleaned. The DM stated, I am not sure. We are three staff short and have been doing the best we can. The Surveyor asked the DM to describe the substance on the fryer. The DM stated, I don't know. It looks like really old grease build up. The Surveyor asked when the last time the stove top was cleaned. The DM stated, We are trying. I guess we haven't gotten to that either. I see all the food on it. The oven had a thick black residue around 3 sides of the door and on the oven floor. The Surveyor asked when the last time the oven was cleaned. The DM took his finger and scraped the matter along the oven door and stated, This really needs to be deep cleaned. This is more grease and dirt build up. It just needs to be deep cleaned. The Surveyor asked how often the kitchen was cleaned. The DM stated, We are doing the daily cleaning every day. The Surveyor asked the DM to describe the brown substance on the floor tiles of the kitchen. The DM stated, They might not have gotten to mop the floor yesterday. It looks like build up. The Surveyor asked about the ,d+[DATE] inch thick build up, with a white plastic spoon stuck in it, on the floor behind a corner shelving unit and the standing stainless refrigerator. The DM stated, Dirt and grease, I guess. We are trying to clean as much as we can. The Surveyor asked how often the kitchen was deep cleaned. The DM stated, It should be done more than it is. Right now, we are so short and working a lot. We are trying. 8. The facility policy titled, Food Receiving and Storage, provided by the Administrator on [DATE] at 8:00 AM documented, .Foods shall be received and stored in a manner that complies with safe food handling practices. Policy Interpretation and Implementation 1. Food Services, or other designated staff, will maintain clean food storage areas at all times . 8. All foods stored in the refrigerator or freezer will be covered, labeled, and dated (use by date) . e. opened containers must be dated and sealed or covered during storage . 9. The facility policy titled, Sanitation, provided by the Administrator on [DATE] at 9:01 AM documented, .The food service area shall be maintained in a clean and sanitary manner . Policy Interpretation and Implementation 1. All kitchens, kitchen areas, and dining areas shall be kept clean, free from litter and rubbish . 2. All utensils, counters, shelves and equipment shall be kept clean . 16. Kitchen and dining room surfaces not in contact with food shall be cleaned on a regular schedule and frequently enough to prevent accumulation of grime .

Based on observation, interview, and record review, the facility failed to ensure staff washed and/or sanitized their hands during meal service on the Special Care Neighborhood , Secure Unit to prevent cross-contamination and failed to ensure resident's clean personal laundry was covered during transport to prevent contamination. The failed practices had the potential to affect 16 residents who resided on the Secure Unit as documented on a list by hall provided by the Administrator on 04/17/23 and 46 residents whose laundry was done by the facility as documented on the list provided by the Administrator on 04/21/23 at 8:51 AM. The findings are: 1. On 04/17/23 at 1:14 PM, Certified Nursing Assistant (CNA) #1 delivered a meal tray to the Dining Room on the Secure Unit. CNA #1 unlocked Resident #30 ' s wheelchair brakes, repositioned the wheelchair, opened the air conditioner lid and touched the air conditioner controls and closed the air conditioner cover. Without washing or sanitizing her hands, CNA #1 proceeded to grab the edge of Resident #30 ' s plate and unwrap and handle the silverware. CNA #1 cut up Resident #30 ' s food, removed the lids off the bowls, put a lid on the beverage, and unwrapped and touched Resident #30 ' s straw without washing or sanitizing her hands. a. On 04/17/23 at 2:50 PM, the Surveyor asked CNA #1 what should occur after touching a resident's wheelchair and the air conditioner while serving a resident their food. CNA #1 stated, Oh no. I should have washed and sanitized. I know better. The Surveyor asked what could happen when hands are not washed or sanitized before touching a resident's plate, silverware, lids, and straw. CNA #1 stated, Cross contamination. b. On 04/19/23 at 3:36 PM, the Surveyor asked the Infection Control & Preventionist (ICP) when hand washing, or sanitization was performed during meal service. The ICP stated, Before and after, and sanitize between trays, and between feeding residents. The Surveyor asked if hands needed to be washed or sanitized after touching a resident's wheelchair or the air conditioner unit during meal service. The ICP stated, Yes. The Surveyor asked what could happen if handwashing was not performed. The ICP stated, Cross contamination. c. On 04/21/23 at 11:26 AM, the Surveyor asked the Director of Nursing (DON) when staff needed to wash or sanitize their hands during meal service. The DON stated, They need to sanitize any time they touch like this (The DON touched her hair, her pocket, her face, and then her shoulder). Anytime they come into contact with anything other than the clean [food] tray, and also in between residents. d. The facility policy titled, Handwashing/Hand Hygiene, provided by the Administrator on 04/21/23 at 9:01 AM documented, Policy Statement This facility considers hand hygiene the primary means to prevent the spread of infections . 2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors . o. Before and after eating or handling food . p. Before and after assisting a resident with meals . 2. On 04/19/23 at 9:48 AM, during a laundry tour with the Laundry Supervisor and Laundry Employee #1, the Laundry Supervisor stated, When we return the laundry, if there is no COVID in the building we do not cover the carts. We used to have to keep them covered all the time because of COVID, but we don't anymore. Laundry Employee #1 stated, It is easier not having to cover it. I do cover the linens though. The Surveyor asked the Laundry Supervisor what could happen to clean laundry if it was not covered. The Laundry Supervisor stated, It could get COVID, or if we had a flu outbreak that could get on the clothes. The Surveyor asked the Laundry Supervisor what else could happen to clean clothes if they were transported uncovered. Laundry Employee #1 stated, They could get germs or get dirty. The Laundry Supervisor stated, They would not be clean anymore. We will start covering them. a. On 04/19/23 at 3:36 PM, the Surveyor asked the ICP if clean laundry needed to be covered when being delivered to the resident's rooms. The ICP stated, Uh, Yes. The Surveyor asked if she was aware that laundry was being delivered uncovered due to no COVID or Influenza in the building. The ICP stated, No, I was not aware. We will have to educate them on that. b. On 04/21/23 at 11:26 AM, the Surveyor asked the DON how laundry should be returned to the resident's rooms from the Laundry Room. The DON stated, Covered and then placed in their closets. The Surveyor asked what could happen to the clean clothing if not covered. The DON stated, It could become dirty. The Surveyor asked if clean laundry needed to be covered all the time or only when there was an infection in the building. The DON stated, All the time. I think all the time we have at least one infection in the building. c. The facility policy titled, Laundry and Bedding, Soiled, provided by the Administrator on 04/20/23 at 8:00 AM documented, . Policy Interpretation and Implementation . Transport . 5. Clean linens are protected from dust and soiling during transport and storage to ensure cleanliness .

Based on observation, record review, and interview, the facility failed to provide adequate direct care staff coverage to properly supervise and provide care for residents to prevent accidents, injury, decline, and promote general health and quality of life for 3 (Residents #19, #28 and #44) of 23 (Residents #3, #6, #10, #11, #16, #18, #19, #21, #22, #23, #27, #28, #29, #30, #31, #35, #36, #38, #39, #42, #44, #45 and #49) sampled residents. This failed practice had potential to affect 46 residents as documented on the Resident Census and Conditions of Residents provided by the Administrator on 04/17/23 at 1:29 PM. The findings are: 1. Resident #19 had diagnosis of Muscular Dystrophy, Unspecified and Type 2 Diabetes Mellitus without Complications. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/03/23 documented the resident scored 15 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status (BIMS) and required total physical assistance of two plus persons for transfer and bathing, extensive physical assistance of two plus persons for bed mobility, dressing, toilet use and personal hygiene and was always continent of bladder and bowel. a. On 04/20/23 at 3:28 PM, Resident #19 was lying in bed watching television. He stated I wanted you to come in here so I could voice a concern. We don't have enough staff to take care of all the residents. I know that [Administrator] says we do, but I can recall several times during the night there was only one Certified Nursing Assistant [CNA] and 1 nurse on the floor. They have one CNA in the Unit, but one CNA isn't enough to work the other floors [Floors100 and 200] by themselves. I'm a two person assist with lift, and they always tell me that they have to go get someone to help and then be gone for 30 minutes or longer. I know they are very busy and work hard, but I'm concerned about the residents that can't speak up for themselves. There are always staff calling in and no one is called to replace them. Of course, this week while the Surveyors are here, they have called in extra staff. I promise you; it isn't like that. My roommate over there, they get him up in the morning and take him to the Dining Room, then leave him out in the hall until later in the afternoon. Then they bring him and put him in bed. They come in and feed him supper then are gone. The Surveyor asked, How often are you or your roommate checked on during the night and turned or repositioned? He stated, Are you kidding? To my knowledge, no one checks on us during the night unless I push my call light. I don't see any staff until the next morning. 2. Resident #28 had diagnoses of Alzheimer's Disease, Unspecified, Benign Paroxysmal Vertigo and Repeated Falls. The Annual MDS with an ARD of 02/03/23 documented the resident scored 3 (0-7 indicates moderately cognitively impaired) on a BIMS and required limited physical assistance of one person for dressing, toilet use and personal hygiene, was independent for bed mobility and transfer, required physical help of two plus persons in part of bathing, and was frequently incontinent of bladder and always incontinent of bowel. a. The Progress Notes in the Electronic Medical Records (EMR) documented, .2/4/2023 .Resident was found lying on the floor in another resident's room . Assessed for injuries, noting 3 inch incision on back of head .; 2/26/2023 .CNA [Certified Nursing Assistant] notified nurse and weekend supervisor that resident had fell . noted injury (laceration) to right ear, right forehead, and left forehead .; 3/1/2023 . Resident was discovered on the floor in another Resident's room, across the hall from own room . with back of head covered in blood . and 3/9/2023 .Resident was discovered by staff lying on floor, on his side, in dining room next to a table . No visible injuries noted All incidences were unwitnessed by staff. b. On 04/20/23 at 10:16 AM, the Surveyor asked the Administrator to provide the Incident and Accident [I&A] Reports for Resident #28 for last 60 days. The Administrator stated, No. That's a QA [Quality Assurance] thing, and other facilities ruin that. [Corporation] says no way, I&As are a QA thing. It's a QA thing and you have no right to that. c. On 04/20/23 at 10:39 AM, the Surveyor asked the Administrator to provide the investigations and interventions for Resident #28's unwitnessed falls for the last 60 days. At 10:43 AM, the Administrator stated, If the DON [Director of Nursing] investigation is part of the QA then I am not giving it unless Corporate says. d. On 04/20/23 at 11:12 AM, the Administrator provided I&A reports for two unwitnessed falls on 03/09/23, one unwitnessed fall on 03/01/23, and one unwitnessed fall on 02/26/23. The reports did not contain documentation of any staff interviews of where staff were and what staff were doing when the incidents occurred, of Resident #28 wandering into other residents ' rooms and the Dining Room and of falling and being injured, nor were any staffing interventions documented. e. On 04/20/23 at 11:32 AM, the Surveyor asked the DON how unwitnessed falls on the Unit were investigated. She stated, They are all [facility] wide, looked at the same way. We look at the documentation of whomever wrote about the fall. We try to get together in standup meetings or earlier. We as a team will discuss what we got there and come up with our interventions. If the nurse has put a feasible intervention, we may put in additional ones if we feel it is needed for long term intervention. That is our standard process. The Surveyor asked if staff should be interviewed. She stated, Well of course they should. It may or may not be something they can give any information about. We have a questionnaire standard for everybody on the Unit or not on the Unit. f. On 04/20/23 at 2:30 PM, the Administrator provided the time sheets for staff on shift during the fall incidents for Resident #28. At 6:30 AM, the time of the incident on 02/04/23, the report documented 3 nursing staff were in the building: 1 Registered Nurse (RN) and 2 CNAs. At 7:00 AM, the time of the incident on 02/26/23, the report documented 4 nursing staff were in the building: 1 RN, 1 Licensed Practical Nurse (LPN), and 2 CNAs. At 2:00 AM, the time of the incident on 03/01/23, the report documented 3 nursing staff were in the building: 1 RN and 2 CNAs. At 6:00 AM, the time of the incident on 03/09/23, the report documented 3 nursing staff were in the building: 1 RN and 2 CNAs. 3. Resident #44 had diagnoses of Quadriplegia, Unspecified, Quadriplegia, C1-C4 (Cervical 1 through C4) Incomplete, and Functional Quadriplegia. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/24/23 documented the resident scored 15 (13-15 indicates cognitively intact) on a BIMS and required total physical assistance of two plus persons for transfer and bathing, extensive physical assistance of two plus persons for bed mobility, dressing and toilet use, extensive physical assistance of one person for eating and personal hygiene, had suprapubic catheter and was always incontinent of bowel. a. On 04/17/23 at 11:02 AM, Resident #44 was sitting in bed. He stated, There is never enough help around here. At meal times, they put a bib on me, then are always too busy to take it off. They set me in my chair then leave me there for hours. They say they have to go get help then they can't find anyone to help them. I feel like staff doesn't take me serious when I have a concern about my health. I know I complain a lot but my God, this is a terrible place to be. 4. On 04/21/23 at 11:29 AM, the Surveyor asked the DON, Do you think the facility has enough staff to competently care for the residents? She stated, We could always use more, but yes, I think we have adequate staff to do what we need to do. 5. The Facility Assessment Tool dated 06/04/22, provided by the Assistant Director of Nursing (ADON) on 04/18/23 at 11:29 AM documented, .The facility supports a culture of person centered care with respect to personal preferences .Then we try to provide each resident with what they need to support their individual . preferences . Staffing . After completion of the facility assessment, the facility is confident that staffing needs are currently adequate . 6. The facility policy titled, Safety and Supervision of Residents, provided by the Administrator on 04/20/23 at 8:00 AM documented, Policy Statement .Resident safety and supervision and assistance to prevent accidents are facility-wide priorities . Individualized, Resident-Centered Approach to Safety . 3. The care team shall target interventions to reduce individual risks related to hazards . including adequate supervision . 7. The facility policy titled, Behavioral Assessment, Intervention and Monitoring, provided by the Administrator on 04/21/23 at 7:50 AM documented, .Management .7. Interventions will be individualized and part of an overall care environment that supports physical, functional, and psychosocial needs and strives to understand, prevent or to relieve the resident's distress or loss of abilities . 11. The Director of Nursing, or designee, will evaluate whether the staffing needs have changed based on acuity of the residents and their plans of care .

Based on interview, and record review, the facility failed to ensure Care Plans were developed for appropriate respiratory therapy interventions for 1 (Resident #27) sampled resident who resided in the facility's Special Care Neighborhood with Physician Orders for oxygen therapy; for heel protector usage for the prevention of pressure sores for 1 (Resident #44) sampled resident with Physician Orders for heel protectors; and appropriate wandering interventions for 1 (Resident #45) sampled resident who wandered. The failed practice had the potential to affect 46 residents residing in the facility who required Care Plans as documented on the Census and Conditions of Residents provided by the Administrator on 04/17/23 at 1:29 PM. The findings are: 1. Resident #27 had diagnoses of Alzheimer's Disease, Unspecified, Traumatic Subdural Hemorrhage without Loss of Consciousness, Subsequent Encounter and Unspecified Atrial Fibrillation. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/02/23 documented the resident was severely impaired in cognitive skills for daily decision making per a Staff Assessment for Mental Status (SAMS) and received oxygen therapy. a. A Physicians Order dated 12/28/21 documented, O2 [oxygen] @ [at] 2 LPM [liters per minute] via NC [nasal cannula] continuous for Shortness of Breath, may remove when toileting, every shift. b. On 04/18/23 at 1:40 PM, the Surveyor asked Certified Nursing Assistant (CNA) #1 how Resident #27 ' s oxygen was kept non-contaminated. CNA #1 stated, She takes it off to go to the bathroom because it does not reach. I can't go by what she says though, so it's only when we see it. The Surveyor asked why Resident #27 cannot tell staff when it was on the floor. CNA #1 stated, Because sometimes she is going back in time. c. On 04/18/23 at 2:45 PM, the Surveyor asked Licensed Practical Nurse (LPN) #1 if Resident #27 was able to inform staff when the cannula was contaminated. LPN #1 stated, Umm, I would say no. She takes it off and on about 20 times a day. The tubing is too short to reach her bathroom. The Surveyor asked if Resident #27 was care planned for that. LPN #1 stated, I'm not sure. I would have to check. d. On 04/18/23 at 2:55 PM, the Surveyor asked the Director of Nursing (DON) if it was safe and sanitary for Resident #27 to be care planned to remove her oxygen and use the restroom due to the tubing not reaching. The DON shook her head No and stated, This sounds like a teaching moment for my staff. [Resident #27] should have new tubing ordered if does not reach. The concentrator cord and the tubing are both long. e. On 04/20/23 at 3:19 PM, the Surveyor asked the MDS Coordinator what was available to the CNAs and nurses for Resident #27 to ensure her oxygen supplies remained as uncontaminated as possible. The MDS Coordinator stated, I just updated that to be individualized and specific for [Resident #27] this morning. f. The facility policy titled, Departmental (Respiratory Therapy) - Prevention of Infection, provided by the Administrator on 04/21/23 at 9:01 AM documented, . Preparation 1. Review the resident's care plan to assess for any special circumstances or precautions related to the resident . 2. Resident #44 had diagnosis Quadriplegia, Unspecified, Quadriplegia, C1-C4 Incomplete and Functional Quadriplegia. The Quarterly MDS with an ARD of 01/24/23 documented the resident scored 15 (13-15 indicates cognitively intact) on a Brief Mental for Status (BIMS) and required total physical assistance of two plus persons for transfer, extensive physical assistance of two plus persons for bed mobility and had range of motion impairments to both the upper and lower extremities. a. A Physician Order dated 04/01/23 documented, [Company Brand] (Green) Boots on BLE [Bilateral Lower Extremities] at all times when in bed. every shift for prevention. b. The Care Plan did not address the use of [Company Brand] (Green) Boots on BLE at all times when in bed, every shift for prevention as identified in the Physician Order dated 04/01/23. c. On 04/17/23 at 11:02 AM, Resident #44 was seated in his bed. The Surveyor asked, Do you have any limitations in your hands and what is staff doing to help with your limited range of motion [ROM]? He stated My hands are getting worse, my fingers are curling up, and I try to stretch them out. I bought those gloves over there on the bed, but they won't put them on me. I've bought boots to wear on my feet to prevent foot drop, they are over there on the bed. A pair of black gloves with wires sticking out of them, a pair of black plastic and cloth boots and a pair of green boots [heel protectors] were lying on the other bed in the room. 3. Resident #45 had diagnoses of Unspecified Dementia, Unspecified Severity with other Behavioral Disturbance, Manic Episode without Psychotic Symptoms, Unspecified, Unspecified Psychosis not due to a Substance or Known Physiological Condition, Anxiety Disorder, Unspecified, Bipolar Disorder, Current Episode Depressed. The Admission MDS with an ARD of 01/16/23 documented the resident scored 8 (8-12 indicates moderately cognitively impaired) on a BIMS and wanders and intrudes on the privacy or activities of others. a. The Care Plan with revision date of 01/19/23 documented, is an elopement risk/wanderer related to: exit seeking . Distract [Resident #45] from wandering by offering pleasant diversions, structured activities, food, conversation, television, book . The Care Plan does not address entering rooms and lying on another resident ' s bed. b. On 04/18/23 at 1:40 PM, the Surveyor asked CNA #1 what staff has been told or trained to do when Resident #45 lays in another resident's bed. CNA#1 stated, I try to get her to sit up. She can go visit them [Resident #18] and [Resident #22] but we cannot stop her from laying down. The Surveyor asked what she does when Resident #45 lies in another resident's bed. CNA #1 stated, I will change the sheets when she chooses to get off the bed. The Surveyor asked if Resident #45, being in Resident #18 ' s bed, prevents her from lying down and how do staff know if she wishes to lie down. CNA #1 stated, I guess she could tell us. She hasn't told me that in a long time. I wish she would tell us because she needs to rest, and we can tell she is tired sometimes. I guess I don't really know if she would lay down if [Resident #45] was not in the bed. The Surveyor asked what negative outcome could occur for allowing a resident to lay in another resident's bed. CNA #1 stated, Oh, I have no concerns. They are just friends. [Resident #45] and [Resident #18] have clicked. The Surveyor asked if there was a concern due to their cognitive impairment. CNA #1 stated, No, should there? c. On 04/18/23 at 2:55 PM, the Surveyor asked the DON what staff have been trained to do if they find a resident in another resident's bed. The DON stated, Redirect, redirect, redirect. Then if you still do not know, they confer with coworkers. It takes a village. The Surveyor asked if Resident #45 was care planned for interventions to assist with this behavior. The DON stated, No, but she will be. 4. On 04/20/23 at 3:08 PM, the Surveyor asked the MDS Coordinator if she created and updated Care Plans. The MDS Coordinator stated, Yes, it is a joint effort. The Surveyor asked how often she updated the resident's' Care Plans. The MDS Coordinator stated, I update it every 3 months with the quarterly MDS and also as needed. The Nursing department lets me know the interventions. Each department is responsible for their portion. The Surveyor asked, What could occur if a Care Plan care area or intervention was not in place. The MDS Coordinator stated, If an intervention was not in place anything could happen. If there was not a fall intervention, then the resident could get hurt. We use the orders, Care Plan and [Resident Care Information] and try to keep all three updated. We try to make sure the three match. 5. On 04/20/23 at 3:25 PM, the Surveyor asked the MDS Coordinator how staff know interventions are in place to handle mental health behaviors. The MDS Coordinator stated, The CNAs have access to [Resident Care Information] for that information. The Surveyor asked how specific the interventions for each resident are. The MDS Coordinator stated, They should be pretty specific. The Surveyor asked what was in Resident #45 ' s [Resident Care Information] for the CNAs to access for mental health behaviors such as lying on other residents' beds. The MDS Coordinator stated, I was just told about that this morning. The MDS Coordinator pulled up the [Resident Care Information] and it was blank. The MDS Coordinator stated, There is nothing in there. I will get that updated. 6. On 04/20/23 at 3:08 PM, the Surveyor asked the MDS Coordinator if she created and updated Care Plans. The MDS Coordinator stated, Yes, it is a joint effort. The Surveyor asked how often she updated the resident's' Care Plans. The MDS Coordinator stated, I update it every 3 months with the quarterly MDS and also as needed. The Nursing department lets me know the interventions. Each department is responsible for their portion. The Surveyor asked, What could occur if a Care Plan care area or intervention was not in place. The MDS Coordinator stated, If an intervention was not in place anything could happen. If there was not a fall intervention, then the resident could get hurt. We use the orders, Care Plan and [Resident Care Information] and try to keep all three updated. We try to make sure the three match. 7. The facility policy titled, Using the Care Plan, provided by the Administrator on 04/21/23 at 7:50 AM documented, .The care plan shall be used in developing the resident's daily care routines and will be available to staff personnel who have responsibility for providing care or services to the resident . 2. The Nurse Supervisor uses the care plan to complete the CNAs daily/weekly work assignment sheets and/or flow sheets .

Based on observation, record review, and interview, the facility failed to ensure residents had the right to make treatment decisions and physician and therapy evaluations were provided for 1 (Resident #44) of 2 (Residents #19 and #44) sampled residents who were cognitively intact and capable of making health care decisions to prevent a decline in their health. This failed practice had the potential to affect 7 residents who had a Brief Interview for Mental Status (BIMS) cognitive score of 13 and higher as documented on a list provided by the Administrator on 04/21/23 at 7:50 am. The findings are: 1. Resident #44 had diagnoses of Quadriplegia, Unspecified, Quadriplegia, C1-C4 (Cervical 1 through C4) Incomplete, and Functional Quadriplegia. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/24/23 documented the resident scored 15 (13-15 indicates cognitively intact) on a BIMS and required total physical assistance of 2 two plus persons for transfer and bathing, extensive physical assistance of two plus persons for bed mobility, dressing and toilet use, extensive physical assistance of one person for eating and personal hygiene, had suprapubic catheter and was always incontinent of bowel. a. A Care Plan with a revision date of 08/01/22 documented, [Resident #44] has an ADL [activities of daily living] self-care performance deficit r/t [related to] spinal cord injury . Confabulates stories .Is on the internet and orders different braces and hand stimulators to try that are not approved of by therapy or MD [Medical Doctor], but he states that it is his right to try what he wants to . PT/OT [Physical Therapy/Occasional Therapy] evaluation and treatment as per MD orders . b. A Care Plan with revision date of 08/26/22 documented [Resident #44] has an alteration in musculoskeletal status r/t spinal injury . Ordered and received [Tradename] rehabilitation robot glove for both hands from internet. He does not have a doctor's order for them, but stated he wants to use them per his rights . [Resident #44] ordered and received foot brace for his feet r/t stating he didn't want his feet to contracture down while he is in bed. He does not have a doctor's order for it, but stated he still wants to wear it per his rights . c. A Physician Order dated 04/01/23 documented, [Tradename] (Green) Boots on BLE [bilateral lower extremities] at all times when in bed. Every shift for prevention . d. On 04/17/23 at 11:02 AM, Resident #44 was sitting in his bed. The Surveyor asked, Do you have any limitations in your hands, if so, what is staff doing to help with your limited range of motion [ROM]? He stated My hands are getting worse, my fingers are curling up, and I try to stretch them out. I bought those gloves over there on the bed, but they won't put them on me. I've bought boots to wear on my feet to prevent foot drop, they are over there on the bed. Lying on the other bed in the room were a pair of black gloves with wires attached to a battery pack, a pair of black plastic and cloth boots and a pair of green boots (heel protectors). e. On 04/20/23 at 3:28 PM, the Surveyor asked Occupational Therapy Assistant (OTA) #1 if a resident bought Robot gloves to prevent hand contractures or boots to help prevent foot drop, would PT or OT evaluate them to see if the equipment could be used. She stated, Well, I would call my boss and see if they could be evaluated. We would have to get a Physicians Order, then run the resident's insurance to see if they qualify. The Surveyor asked if therapy had been asked to evaluate Resident #44. She stated, Not that I am aware of. f. On 04/21/23 at 11:30 AM, the Surveyor asked the Director of Nursing (DON) if she was familiar with Resident #44. She stated, Yes. The Surveyor asked if she was aware of the gloves, he had purchased himself to prevent further decline in his hands. She stated, No, I didn ' t know that he had ordered any gloves. I guess I ' ll have to go look at them. The Surveyor asked if she was aware of the boots, he purchased to prevent foot drop. She stated, I know that he has heel protectors that he wears but I ' m assuming those aren ' t the ones. The Surveyor asked if the doctor was ever asked for an order for PT/OT to assess the devices the resident's use. She stated, No, because I wasn ' t aware that he had them. The Surveyor asked if the resident had the right to have PT/OT to evaluate for use of the devices. She stated, Of course. g. A facility policy titled, Resident Rights, provided by the Administrator on 04/20/23 at 8:00 AM documented, .Policy Interpretation and Implementation 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: .g. exercise his or her rights as a resident of the facility . h. be supported by the facility in exercising his or her rights . p. be informed of, and participate in, his or her care planning and treatment .

Complaint # (AR 550) was substantiated, all or in part, with these findings: Based on observation, record review, and interview, the facility failed to ensure alternatives were attempted prior to using side rails, and the resident was assessed for possible entrapment risk prior to utilization of bed rails to prevent potential injury or entrapment for 1 (Resident #1) of 3 (Residents #1, #5 and #7) case mix residents who had bed rails in use. This failed practice resulted in Past Non-compliance at the level of Immediate Jeopardy, which caused or could have caused serious harm, injury, or death for Resident #1 who was entrapped in the bed rail, and expired from asphyxia, and had the potential to cause more than minimal harm to 6 residents who used side rails, according to a list provided by the Administrator on [DATE] at 4:03 p.m. The Administrator was informed of the Past Immediate Jeopardy situation on [DATE] at 1:06 p.m. The findings are: 1. Resident #1 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set with an Assessment Reference Date of [DATE] documented the resident was severely impaired in cognitive skills for daily decision making per a Staff Assessment for Mental Status; required extensive two-plus person assistance for bed mobility, transfer, toilet use, and personal hygiene; was totally dependent on one person assistance for bathing; was always incontinent of bowel and of bladder; and had no falls since prior assessment. The MDS contained no documentation related to the use of side rails. a. A physician's orders [REDACTED]. b. A Care Plan dated [DATE] documented, . Resident is high risk of falls . Be sure the residents call light is within reach and encourage the resident to use it for assistance as needed . The resident needs prompt response to all requests for assistance . Follow facility fall protocol . c. A document titled Nursing Admit / Readmit Assessment and Care Plan dated [DATE] documented, .Side Rails .Side rails are not indicated at this time . Morse Fall Scale . Morse Fall Score: 60 . At high risk for falling . d. A Care Plan dated [DATE] documented, .Resident has an ADL (activities of daily living) self-care performance deficit r/t (related to) impaired mobility, cognitive impairments . ,[DATE] side rail up (times) 2 at HOB (head of bead) as enabler to assist resident with bed mobility and repositioning . Transfer: The resident requires extensive assist of 2 staff and requires stand-up lift at times for transfers . e. An MDS Kardex Report dated [DATE] documented, . Bed Mobility . Extensive assistance . One-person physical assist . Transfer . Extensive assistance . One-person physical assist . Locomotion on Unit . Limited assistance . One-person physical assist . Locomotion off Unit . Limited assistance . One-person physical assist . Dressing . Extensive assistance . Two plus persons physical assist . Eating . Extensive assistance . One-person physical assist . Toilet Use . Extensive assistance . Two plus persons physical assist . Personal Hygiene . Extensive assistance . Two plus persons physical assist . Bathing . Total dependence . One-person physical assist . ,[DATE] rails for getting up . Use stand-up lift when needed for transfers . Falls XXX,[DATE] rail for position / rising . f. A physician's orders [REDACTED]. COVID Isolation every shift . g. A Social / Activities Social Note dated [DATE] at 12:29 p.m. documented, .Note Text . Spoke with (Resident #1's son) to inform him that (Resident #1) test result came back Positive for COVID-19 though she is asymptomatic . h. A document titled Nursing Morse Fall Scale and Care Plan dated [DATE] documented, .Category . High Risk for Falling . Score: 75 . i. An Incident and Accident Report dated [DATE] at 16:17 (4:17 p.m. documented, .CNA (Certified Nursing Assistant) notified nurse that pt. (patient) was on floor and nurse needed to come immediately. Nurse found pt. in a very awkward position. She had her upper body / torso half hanging out of bed, while her lower half / bottom were still in bed but somewhat crooked. Her body weight from torso was situated on upper right crest of her head. Resident has a low bed for this purpose and bed was in lowest position . Resident is non-communicative for anything more than to nod head yes. She was unable to give a description . Nurse and CNA both lifted pt. back into bed and re-situated. Physical exam (examination) completed with no concerns. Area on head where pt. was resting in floor is pink but does not appear to be broken skin or any raised area. Physician notified. Family notified. Nurse Manger notified. Fall mat has been placed at bedside for future injury prevention . j. A Nursing Incident and Accident Note dated [DATE] at 19:19 (7:19 p.m.) documented, .Physician Contact . Incident Description: CNA notified nurse that pt. was on floor and nurse needed to come immediately. Nurse found pt. in a very awkward position. She had her upper body / torso half hanging out of bed, while her lower half / bottom were still in bed but somewhat crooked. Her body weight from torso was situated on upper right crest of her head. Immediate Intervention: Nurse and CNA both lifted pt. back into bed and re-situated. Physical exam completed with no concerns. Area on head where pt. was resting in floor is pink but does not appear to be broken skin or any raised area . k. A document titled Nursing Every Shift Skilled Charting dated [DATE] documented, .1b. Alert: Yes . 2. Orientation . 2.d. Situation . No . 5. Lying to sitting on side of bed . Dependent . Sit to stand . Dependent . l. A Nursing General Note dated [DATE] at 01:30 (1:30 a.m.) documented, .Late Entry . Note Text . Resident was found unresponsive at approximately 01:30. After assessing resident, I was unable to auscultate heart sounds or find a palpable pulse. I notified facility Administrator, MD (Medical Doctor), and the Coroner. The Coroner arrived at approximately 02:20 (2:20 a.m.) and pronounced resident deceased . (Funeral Home) was notified per family request and body was released at approximately 05:00 (5:00 a.m.) . m. A Nursing Incident and Accident Note dated [DATE] at 01:30 (1:30 a.m.) documented, .Late Entry . Incident Description . Bed was in the lowest position, fall mat was on the other side of her, call light was in reach . n. A Nursing Incident and Accident Note dated [DATE] at 01:30 documented, .Late Entry . Incident Description . At approximately 130 am (1:30 a.m.) while walking the hall I discovered resident bottom half out of bed, top half face down against the positional bar . Immediate Intervention . Immediately assessed, no vitals (vital signs) were present, no heart sounds or lung sounds or pulse. Then I called (Administrator) . The Coroner was notified. He arrived and pronounced at 220 am (2:20 a.m.) . o. The Office of Long Term Care Division of Medical Services (DMS) form 7734 dated [DATE] at 5:50 a.m. documented, .On [DATE] at 1:00 a.m. (RN (Registered Nurse) #1) and (CNA #1) checked on resident, (Resident #1), performed peri-care and repositioned her. Her call light was within reach, and she was comfortable. Then on [DATE] at 01:15 (1:15 a.m.), (RN #1), walked in resident's room to check on (Resident #1) and found that (Resident #1) had rolled off the bed. (Resident #1's) head and neck resting on the positioning bar and mattress with the rest of her body on the floor. The bed is a low bed and was in the lowest position. (Resident #1) had stripped off her gown and her brief (incontinent brief) which was clean and dry. (RN #1) checked (Resident #1) for vital signs and found none. (Resident #1) has a DNR (Do Not Resuscitate) order. (Resident #1) had a [DIAGNOSES REDACTED]. (RN #1) immediately called (Medical Director). The Coroner was called. 911 was called, and the dispatcher stated that she would also call the Coroner. The Administrator, DON (Director of Nursing), and family were also notified of the death . p. A Nursing Incident and Accident Follow Up Note dated [DATE] at 18:16 (6:16 p.m.) documented, .Date and I&A (Incident and Accident) Description . On [DATE] at 1617 (4:17 p.m.), CNA notified nurse that pt. (patient) was on the floor and nurse needed to come immediately. Nurse found pt. in a very awkward position. She had her upper body / torso half hanging off of the bed, while her lower half / bottom were still in bed but somewhat crooked. Resident is nonverbal and unable to tell staff what happened. Resident was noted to have had an incontinent episode. Resident was in a low HTTA with no injury noted. Neuros (neurological) and ROM (range of motion) wnl (within normal limits) for resident. MD (Medical Doctor) and family notified. Long Term Intervention . Incontinence check with toileting offered every 2 hrs (hours). Added to the Care Plan . Yes . Ensure MD and Family Notification . Yes . q. A Nursing Incident and Accident Follow Up Note dated [DATE] at 17:49 (5:49 p.m.) documented, .Date and I&A Description . Approximately 1230 am (12:30 a.m.) I changed the patient I made sure the bed was in the lowest position. I noticed she was a little pale, so I assessed her breathing and pulse and they were within normal range. Approximately 1 am (1:00 a.m.) I walked by and observed her in bed resting. Approximately 115 (1:15 a.m.) I was walking up the hall to check on another patient. I observed her in bed. When finished with the other patient, I walked back down the hall. When I noticed she was not in bed, I stepped in and turned on the light. This was approximately 130am (1:30 a.m.). I discovered her laying with her bottom half in the floor and her top half resting against the positional bar. Long Term Intervention . Immediately assessed . No vitals (vital signs) were present, no heart sounds or lung sounds or pulse. Then I called (Administrator), notified doctor and called family. The Coroner was notified. He arrived and pronounced at 220 am (2:20 a.m.) . r. An Arkansas Department of Health Vital Records Certificate of Death dated [DATE] documented, .Cause of Death . Traumatic Asphyxia . Manner of Death . Accident . Describe How Injury Occurred . Subject (Resident) became wedged between mattress and bed rail . s. On [DATE] at 10:05 a.m., the Administrator was asked about the incident. The Administrator stated, The resident's bed had been moved from the COVID Hall. The Surveyor accompanied the Administrator and the Nurse Consultant to room [ROOM NUMBER]. The Administrator stated, We had her bed cleaned and moved to this room. It is set up just like it was that night. The sheets were not messed up, they were flat just like this. The Administrator was asked, Can you tell me about what occurred and where it occurred? The Administrator stated, Originally, the resident was in (Room) 108B on the COVID Hall by the window, facing left, and the left side of her head was on the bed, not on the pillow. I was called at 1:31 a.m. (RN #1), the nurse, called and stated, '(Administrator), (Resident #1) is dead and (CNA #1) and I can't pick her up. The Administrator was asked, Was she a DNR (Do Not Resuscitate)? The Administrator stated, Yes. Comfort care. The Administrator was asked, What did you do when you arrived at the facility? The Administrator stated, I screened in, I walked in, and I walked around the head of the bed and looked at her and her position. Her clothes were off. Her brief (incontinent brief) was around the right thigh and connected there. It was still clean and dry and a blue gown. The Administrator was asked, Was it a night gown? The Administrator stated, Hospital gown was on the floor under her upper body. Her right ear and neck were against the bar and her head was on the mattress. Her head was not wedged. Her torso was prone, and her right foot was against the air conditioner. The Administrator was asked, Where was the bed? The Administrator stated, The bed was at an angle and the wheels were not locked. The top of the mattress was twelve inches from the floor. The Administrator and Nurse Consultant explained and demonstrated the position of the resident's body and head and stated the resident's foot was against the air conditioner. The bed had ,[DATE] bed rails on the upper half of the bed. (The Surveyor took a photograph of bed with side rails was taken at this time.) t. On [DATE] at 1:32 a.m., RN #1 was asked, Did the resident require assistance with transferring? RN 1 stated, She was a Hoyer lift and required two persons to get up. RN #1 was asked, Did the resident have a history of falls? RN #1 stated, Yes. RN 1 was asked, When was the last fall? RN #1 stated, I believe it was three days before on the Day Shift 97:00 a.m. to 3:00 p.m.). RN #1 was asked, Who was the nurse during that incident? RN #1 stated, (Name). RN #1 was asked, What interventions were put in place at that time? RN #1 stated, Frequent rounding. RN #1 was asked, Was she able to use her call light? RN #1 stated, I am not for sure. RN #1 was asked, Were bed rails used for this resident? RN #1 stated, All she had was a positional hand bar. It was on both sides of the bed. Both were in the up position. RN #1 was asked, Were they able to be placed in the down position? RN #1 stated, I am not sure. RN #1 was asked, What are the resident's risk factors for having an accident safe side rail use? RN 1 stated, During the changing, I have seen her grab the positional bar to help pull herself. RN #1 was asked, Did she use the rail to get up and down in bed? RN 1 stated, No, she did not have the coordination to get up in and out of the bed. RN #1 was asked, How often was the resident's use of the bar assessed and where is it documented? RN #1 stated, I do not know. I think PT (Physical Therapy) has their own documentation. RN #1 was asked, How do you know what interventions or assistance is needed to prevent falls? RN #1 stated, I don't know. RN #1 was asked, What was the resident trying to do when she fell on the 12th ([DATE])? RN #1 stated, I was not aware of her fall on the 12th until after this incident. RN #1 was asked, How many falls have there been on the night shift? RN #1 stated, I think just her two. Her one on Day Shift with (LPN #4) and then the night of the incident. RN #1 was asked, What did you watch for with this resident? RN #1 stated, Nothing in particular. I had her the week before and she did not get up on my shift. On rounds, I would change her and sometimes she would have her leg over the side of the bed. RN #1 was asked, How did you identify that the interventions were suitable for this resident? RN #1 stated, The low bed and the fall mat were adequate for her. I can't think of anything else that would have been done. u. On [DATE] at 1:54 a.m., Certified Nursing Assistant (CNA) #1 was asked, Were bed rails used for this resident? CNA #1 stated, Yes. I don't really know why the positional bar was on there. I think it was a reminder so she didn't roll off or she could grab them when we changed her. She still had her strength. CNA #1 was asked, Were they able to be placed in the down position? CNA #1 stated, You could put them down. CNA #1 was asked, Was there a bed alarm in use? CNA #1 stated, No. CNA #1 was asked, Are there any bed alarms in the facility? CNA #1 stated, No, not that I am aware of. CNA #1 was asked, What are the resident's risk factors for having an accident safe side rail use? CNA #1 stated, I don't know that. She was a fall risk. That was the only thing I know. CNA #1 was asked, Did she use the rail to get up and down in bed? CNA #1 stated, Yes. I have seen her grab them, but with her mental I don't know if she could actually do it. I know she could grip and pull, but whether she knew what she was actually doing, I can't say. CNA #1 was asked, How often was resident's use of the bar assessed and where is it documented? CNA #1 stated, No, I don't know. CNA #1 was asked, How did you identify that the interventions were suitable for this resident? CNA #1 stated, We did tell them about the bed not locking. CNA #1 was asked, Who did you tell? CNA #1 stated, We had to call and tell the nurse to put it on (Maintenance Director's) list. We both called on that. I don't remember who I talked to. RN #1 in background stated, I complained loudly, and I don't remember who I spoke with. CNA #1 was asked, What did you watch for with this resident? CNA #1 stated, When she moved or when sometimes she would get fidgety, and that would be a sign that perhaps she could get up. If they are moving, I go in and make sure they are not getting up. Like I said we were always up and down the hall and we have one resident that is a 'hollerer', and we always are going down the hall. We have several that are fall risks. CNA #1 was asked, How do you know what interventions or assistance is needed to prevent falls? CNA #1 stated, Normally they write out an in-service paper and we read and sign it, or they tell us, and we sign it. CNA 1 was asked, How often do you have those? CNA #1 stated, It was not too long ago, right before they took them (bed rails) all off. CNA #1 was asked, Do you know why they removed them? CNA #1 stated, We were told State said they could not use them anymore. v. On [DATE] at 2:42 p.m., the Maintenance Director was asked, Have you worked on the bed since the incident? The Maintenance Director stated, No. We just took it from her room down to the room it's currently in so you guys could investigate. The Maintenance Director was asked, Have you been asked to remove side rails since the incident? The Maintenance Director stated, We started removing side rails a few months ago. It's been a slow process until recently. Of course, now we have accelerated. If a resident needs it for mobility, a consent form has to be filled out. The Maintenance Director was asked, Have you found any loose side rails? The Maintenance Director stated, Every now and again. They usually will write them down. The Maintenance Director was asked, Have you been told to go around and check the beds since the incident? The Maintenance Director stated, I do a quarterly bed audit. As I go in rooms, I check them. I don't spend a lot of time going room-to-room. Since the incident I'm doing a Daily Audit. I am checking zip ties on the ones that have those. I'm also checking for gaps. The Maintenance Director was asked, What is the gap allowance for side rails? The Maintenance Director stated, Our gap allowance is one inch or less. I think it was 2016 when the Director of Operations sent the FDA (Food and Drug Administration) information to us and I had to go around and measure every one of them in the facility to see what the gap was. The Maintenance Director was asked, But has that bed been here that long? The Maintenance Director stated, No. But I visually inspect them. The Maintenance Director was asked, Visually inspect? Does that mean you don't measure? The Maintenance Director stated, I don't usually get my tape measure and measure it but I'm a life-long carpenter so I can pretty much tell. The Maintenance Director was asked, Can I get a copy of the Manufacturer's Guidelines on those? The Maintenance Director stated, We have printed them off recently, but it actually has nothing on there about the rails. Just the bed. If you have the proper size mattress on the bed, you'll have about an inch by each side rail. I have noticed with my dealings with the beds that's mostly been what we have had. The Maintenance Director was asked, How often do you go around and check the beds and rails? The Maintenance Director stated, I do a Quarterly Audit. w. On [DATE] at 4:32 p.m., Licensed Practical Nurse (LPN) #6, who routinely provided care of Resident #1, was asked, Have you ever known her to try and get out of the bed or find her half-way in or out of the bed? LPN #6 stated, You would go in and find her sideways. And she was quiet. LPN #6 was asked, Could she crawl out of bed? LPN #6 stated, Oh yeah. That was one of the reasons for the low bed. LPN #6 was asked, Did (Resident #1) use the rail to assist herself with turning side-to-side? LPN #6 stated, I don't know. because I usually would find her already in the position. And I would find her sometimes with her legs off the bed, but her upper part on the bed. LPN #6 was asked, How often would you say that would happen? LPN #6 stated, Maybe once every 2 weeks. LPN #6 was asked, How long did she have that bed? LPN #6 stated, When she was on B Hall, she had a different bed than when she was moved to the COVID Unit. On B Hall she actually had half side rails. I feel like those rails were a little more space defining for her. But when they moved her, they took her and her chair over to that hall. x. On [DATE] at 7:15 p.m., RN #1 accompanied the Surveyors to room [ROOM NUMBER], where Resident #1's bed was located. Resident #1's bed was moved to room [ROOM NUMBER], according to the Administrator on [DATE] at 10:05 a.m., and the Maintenance Director on [DATE] at 2:42 p.m. and set up to reenact the room. RN #1 repositioned the bed, so the head of the bed was against the wall. RN #1 was asked, Are doors open? RN #1 stated, Doors all stay open. The cots are not rolling like it did. (Location of bed when resident was repositioned and changed.) RN #1 attempted to lock the wheels of the bed and the wheels locked. RN #1 stated, This bed did not lock. This is not right. RN #1 then placed the bed off-angle. RN #1 was asked, Where were blankets? RN #1 stated, I don't remember. RN #1 was asked, Where was (Resident 1) and what did you do? RN #1 stated, I came down the hall, looked in, and saw the bed was askew and I didn't see her legs. I said, '(Resident #1) what did you do?' and I turned on the light. RN #1 was asked, Were the transfer bars up or down? RN #1 stated, Up. RN #1 was asked, Where was the call light? RN #1 stated, On the bed, here like this. (She placed the call light on the bed, not tied to the bedrail.) RN #1 was asked to demonstrate how the resident's body was located. RN #1 demonstrated by placing the right side of her neck on the bar, head on the bed, and right foot on the air conditioner. y. On [DATE] at 7:26 p.m., CNA #1 was asked, Did she (the resident) have a history of trying to get out of the bed? CNA 1 stated, Yes. She was a fall risk. CNA #1 accompanied the Surveyors to room [ROOM NUMBER] and was asked to demonstrate the locking of the bed wheels. The bed wheels locked, CNA 1 stated, They would not lock. We tried several times and it would not lock. I always make sure my beds are locked. z. On [DATE] at 9:42 a.m., Licensed Practical Nurse (LPN) #3 was asked, Do you think an assessment should have been done to see if that bed and side rail was appropriate for her? LPN #3 stated, Of course. aa. On [DATE] at 11:40 a.m., the Director of Nursing (DON) was asked, Do we have all of the Side Rail Assessments on (Resident #1)? The DON stated, They should all be under the Assessment Tab in (the Electronic Medical Record System). I don't know where any others might be. The DON was asked, I know when (Resident #1) moved to the COVID Hall, she was put in a different bed with a different side rail. Was an assessment completed to see if that bed / rail was appropriate for her? The DON stated, I'm not sure. I would have to look in her chart. The DON was asked, Should an assessment be done if a resident starts using a different type of side rail? The DON stated, Yes. The DON was asked, Who would be responsible for doing that assessment? The DON stated, The nurse on the floor. The DON was asked, (Resident #1) had a history of [REDACTED]. With that being a safety issue, especially if rails are used, has she been assessed for the appropriateness of the rails? The DON stated, I'm not sure. I would have to look. The DON was asked, Was she reassessed for appropriateness after the [DATE] incident when she was found half-way out of the bed? The DON stated, I'm not sure. I would have to look. The DON was asked, Do you know anything about the brakes on the bed not working? The DON stated, I myself did not, but (Maintenance Supervisor) and his Consultant went around and did safety checks. bb. On [DATE] at 12:46 p.m., LPN #4 was asked, Are you the nurse when (Resident #1) was found halfway out of the bed on [DATE]? LPN #4 stated, I believe so. I remember the incident. LPN #4 was asked, Do you remember if the assist rail was up or down? LPN #4 stated, I'm sorry. I don't recall that. Is it on my I/A (Incident and Accident) form? (LPN #4 looked at the I/A.) LPN #4 stated, I didn't note it, but that doesn't mean it wasn't there. LPN #4 was asked, Did she have a history of trying to get out of bed? LPN #4 stated, That day, on the 12th ([DATE]) was the first time I remember seeing her in a position that would make me think she was trying to get out of bed. LPN #4 was asked, Do you know if you had ever assessed her for the appropriateness of those side rails on her bed? LPN #4 stated, We do our Annual Care Plans and there is a Section that asks about the appropriateness of side rails. Has anyone ever specifically told me to do that? I can't say they have. LPN #4 was asked, Did she use the rails that were on her bed? LPN 4 stated, Yes, she could use it to grab hold of during a transfer. I don't know if she could have positioned herself in bed using it. cc. On [DATE] at 4:33 p.m., RN #2 was asked, (Resident #1) tested positive for COVID-19 on [DATE]. Where was she moved to? RN #2 stated, room [ROOM NUMBER]. RN #2 was asked, Where did she move from? RN #2 stated, B Hall. RN #2 was asked, What did you receive in Report about the resident? RN #2 stated, She tested COVID Positive and was asymptomatic. RN #2 was asked, Did she try to get out of the bed? RN #2 stated, I have never, ever seen her try to get out of the bed or her chair. She would sit up in the chair, but never try to get out of it. RN #2 was asked, Did she have a history of falls? RN #2 stated, Not to my knowledge. RN #2 was asked, Was she assessed for bed rails? RN #2 stated, I don't remember who did what. I don't know who did the assessment. I am sure one was done. RN #2 was asked, Do you believe the bed rail benefited her at all being on the bed? RN #2 stated, Maybe to hang onto while we were changing her, but I don't know about benefit. RN #2 was asked, Do you think the bed rail was detrimental? RN #2 stated, Yes. They could be very much so. RN #2 was asked, How would they be detrimental? RN #2 stated, Falling out, breaking an arm or leg, getting hung up in them. I never thought about that before (Resident #1). Bolster mattresses really help, as do fall mats. RN #2 was asked, Did she have a fall mat? RN #2 stated, I believe she did. RN #2 was asked, Did you get any Report on [DATE], or after her fall, to increase checks on her? RN #2 stated, I do not remember. RN #2 was asked, Did the bed lock or move? RN #2 stated, I don't think so. I did not see it happen. dd. On [DATE] at 3:44 p.m., the Administrator was asked, Is the issue a high risk, high volume, or problem-prone issue that the committee should know about? The Administrator stated, We are monitoring daily, and we had worked on that before you got here, and we are checking to make sure the zip ties on the hospital beds are intact, the ones (rails) we cannot remove. The Administrator was asked, Has corrective action been taken? The Administrator stated, Yes. Quarterly side rail assessments must be completed. ee. A document titled Bed Safety Inspection provided by the Maintenance Supervisor on [DATE] at 3:00 p.m. documented, . [DATE] . Bed in hall on 200 Hall had rail mounted over a bolt. Bed had been moved out of a resident room and was not in use . [DATE] to date some side rails have been removed, some left for safety, others left as grab bars at resident request . [DATE] Continue to remove side rails as possible . ff. On [DATE] at 6:00 p.m., the bed rails throughout the facility were checked and zip ties were found to be in place, securing rails to the bed frame and not allowing for rails to move for the beds in which where removal of rails was not possible. Rails that remained in place were checked for gaps between the mattress and rail. gg. On [DATE], a bed lock check was conducted on beds with the Maintenance Supervisor with the following results: 1.) The bed in room [ROOM NUMBER]A continued to roll even when the brakes were locked. The room was empty. There was no resident assigned to this bed. 2.) The bed in room [ROOM NUMBER]B continued to roll when the bed was locked. This bed was occupied by Resident #8. 3.) The bed in room [ROOM NUMBER]B continued to roll when the bed was locked / brakes applied. There was no resident assigned to this bed. 4.) The bed in room [ROOM NUMBER]A continued to roll when the bed was locked / brakes applied. There was no resident assigned to this bed. 5.) The bed in room [ROOM NUMBER]A continued to roll when the bed was locked / brakes applied. This bed was occupied by Resident #9. 6.) The bed in room [ROOM NUMBER]A continued to roll when the bed was locked / brakes were applied. This bed was occupied by Resident #10. hh. A facility policy titled Proper Use of Side Rails provided by the Nurse Consultant on [DATE] at 3:33 p.m. documented, . 3. An assessment will be made to determine the resident's symptoms, risk of entrapment, and reason for using side rails. When used for mobility or transfer, an assessment will include a review of the resident's . a. Bed mobility . b. Ability to change positions, transfer to and from bed or chair, and to stand and toilet . c. Risk of entrapment from the use of side rails . 6. Less restrictive interventions that will be incorporated in care planning include . c. and surrounding the bed with a soft mat . d. Equipping the resident with a device that monitors attempts to arise . 7. Documentation will indicate if less restrictive approaches are not successful prior to considering the use of side rails . 9. Signed consent forms do not relieve the facility from meeting the requirements for restrain use including proper assessment and Care Planning . 11. The resident will be checked periodically for safety relative to side rail use . ii. A facility policy titled Room Change / Roommate Assignment provided by the Administrator on [DATE] at 4:15 p.m. documented, . 10. Room change from a Secure Dementia Care Neighborhood . An example would be a resident whose skilled medical needs exceed that which can be provided on the Secure Neighborhood . jj. A document titled (Facility Name) Timeline: (Resident #1) documented the following corrective measures were conducted by the facility prior to the survey entrance date: 1.) . New bedrail assessments were completed for all beds. Residents not needing bedrail assistance had bedrails removed on this date. New assessments were placed in the Care Plan for both those requiring siderails and those not requiring siderails . 2.) .By close of business on [DATE], the facility has accomplished the following . Identified the facility has 31 hospital grade beds that had bedrails . Identified 6 hospital beds that had those residents assessed and side rails removed . 21 hospital beds had those residents assessed and siderails zip-tied in a lowered position . 4 residents refused siderail removal. Those residents were assessed for siderail appropriat (TRUNCATED)

Complaint # (AR 550) was substantiated, all or in part, with these findings; Based on observation, record review, and interview, the facility failed to provide supervision to prevent accidents / injuries for 1 (Resident #1) of 3 (Residents #1, #5 and #7) case mix residents who used side rails. The facility failed to identify side rails as a hazard for this resident and failed to reassess the resident, identify entrapment zones, and implement interventions when Resident #1 was found hanging off the bed with her upper body hanging out of the bed and the lower body remaining in the bed to prevent the potential for fall-related or entrapment injuries. These failed practices resulted in Past Noncompliance at the level of Immediate Jeopardy, which caused, or could have caused, serious harm, injury or death for Resident #1 who was entrapped in the bed rail, and expired from asphyxia, and had the potential to cause more than minimal harm to 6 residents who used side rails, according to a list provided by the Administrator on [DATE] at 4:03 p.m. The Administrator was informed of the Past Immediate Jeopardy situation on [DATE] at 1:06 p.m. The findings are: 1. Resident #1 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date of [DATE] documented the resident was severely impaired in cognitive skills for daily decision making per a Staff Assessment for Mental Status; required extensive two-plus person assistance for bed mobility, transfer, toilet use, and personal hygiene; was always incontinent of bowel and of bladder; and had no falls since prior assessment. The MDS contained no documentation related to the use of side rails. a. A physician's orders [REDACTED]. b. A Care Plan dated [DATE] documented, . Resident is high risk of falls . Be sure the residents call light is within reach and encourage the resident to use it for assistance as needed . The resident needs prompt response to all requests for assistance . Follow facility fall protocol . c. A document titled Nursing Admit / Readmit Assessment and Care Plan dated [DATE] documented, .Side Rails .Side rails are not indicated at this time . Morse Fall Scale . Morse Fall Score: 60 . At high risk for falling . d. A Care Plan dated [DATE] documented, .Resident has an ADL (activities of daily living) self-care performance deficit r/t (related to) impaired mobility, cognitive impairments . ,[DATE] side rail up (times) 2 at HOB (head of bead) as enabler to assist resident with bed mobility and repositioning . Transfer: The resident requires extensive assist of 2 staff and requires stand-up lift at times for transfers . e. An MDS Kardex Report dated [DATE] documented, . Bed Mobility . Extensive assistance . One-person physical assist . Transfer . Extensive assistance . One-person physical assist . Locomotion on Unit . Limited assistance . One-person physical assist . Locomotion off Unit . Limited assistance . One-person physical assist . Dressing . Extensive assistance . Two plus persons physical assist . Eating . Extensive assistance . One-person physical assist . Toilet Use . Extensive assistance . Two plus persons physical assist . Personal Hygiene . Extensive assistance . Two plus persons physical assist . Bathing . Total dependence . One-person physical assist . ,[DATE] rails for getting up . Use stand-up lift when needed for transfers . Falls XXX,[DATE] rail for position / rising . f. A physician's orders [REDACTED]. COVID Isolation every shift . g. A Social / Activities Social Note dated [DATE] at 12:29 p.m. documented, .Note Text . Spoke with (Resident #1's son) to inform him that (Resident #1's) test result came back positive for COVID-19 though she is asymptomatic . h. A document titled Nursing Morse Fall Scale and Care Plan dated [DATE] documented, .Category . High Risk for Falling . Score: 75 . i. An Incident and Accident Report dated [DATE] at 16:17 (4:17 p.m. documented, .CNA (Certified Nursing Assistant) notified nurse that pt. (patient) was on floor and nurse needed to come immediately. Nurse found pt. in a very awkward position. She had her upper body / torso half hanging out of bed, while her lower half / bottom were still in bed but somewhat crooked. Her body weight from torso was situated on upper right crest of her head. Resident has a low bed for this purpose and bed was in lowest position . Resident is non-communicative for anything more than to nod head yes. She was unable to give a description . Nurse and CNA both lifted pt. back into bed and re-situated. Physical exam (examination) completed with no concerns. Area on head where pt. was resting in floor is pink but does not appear to be broken skin or any raised area. Physician notified. Family notified. Nurse Manger notified. Fall mat has been placed at bedside for future injury prevention . The photographs taken by the Coroner on [DATE] showed no fall mat next to the resident's bed. j. A Nursing Incident and Accident Note dated [DATE] at 19:19 (7:19 p.m.) documented, .Physician Contact . Incident Description: CNA (Certified Nursing Assistant) notified nurse that pt. (patient) was on floor and nurse needed to come immediately. Nurse found pt. in a very awkward position. She had her upper body / torso half hanging out of bed, while her lower half / bottom were still in bed but somewhat crooked. Her body weight from torso was situated on upper right crest of her head. Immediate Intervention: Nurse and CNA both lifted pt. back into bed and re-situated. Physical exam completed with no concerns. Area on head where pt. was resting in floor is pink but does not appear to be broken skin or any raised area . k. A document titled Nursing Every Shift Skilled Charting dated [DATE] documented, .1b. Alert: Yes . 2. Orientation . 2.d. Situation . No . 5. Lying to sitting on side of bed . Dependent . Sit to stand . Dependent . l. A Nursing General Note dated [DATE] at 1:30 a.m. documented, .Late Entry . Note Text . Resident was found unresponsive at approximately 01:30. After assessing resident, I was unable to auscultate heart sounds or find a palpable pulse. I notified facility Administrator, MD (Medical Doctor), and the Coroner. The Coroner arrived at approximately 02:20 (2:20 a.m.) and pronounced resident deceased . (Funeral Home) was notified per family request and body was released at approximately 05:00 (5:00 a.m.) . m. A Nursing Incident and Accident Note dated [DATE] at 1:30 a.m. documented, .Late Entry . Incident Description . Bed was in the lowest position, fall mat was on the other side of her, call light was in reach . n. A Nursing Incident and Accident Note dated [DATE] at 1:30 a.m. documented, .Late Entry . Incident Description . At approximately 130 am (1:30 a.m.) while walking the hall I discovered resident bottom half out of bed, top half face down against the positional bar . Immediate Intervention . Immediately assessed, no vitals (vital signs) were present, no heart sounds or lung sounds or pulse. Then I called (Administrator) . The Coroner was notified. He arrived and pronounced at 220 am (2:20 a.m.) . o. The Office of Long Term Care Division of Medical Services (DMS) form 7734 dated [DATE] at 5:50 a.m. documented, .On [DATE] at 1:00 a.m. (RN (Registered Nurse) #1) and (CNA #1) checked on resident, (Resident #1), performed peri-care and repositioned her. Her call light was within reach, and she was comfortable. Then on [DATE] at 01:15 (1:15 a.m.), (RN #1), walked in resident's room to check on (Resident #1) and found that (Resident #1) had rolled off the bed. (Resident #1's) head and neck resting on the positioning bar and mattress with the rest of her body on the floor. The bed is a low bed and was in the lowest position. (Resident #1) had stripped off her gown and her brief (incontinent brief) which was clean and dry. (RN #1) checked (Resident #1) for vital signs and found none. (Resident #1) has a DNR (Do Not Resuscitate) order. (Resident #1) had a [DIAGNOSES REDACTED]. (RN #1) immediately called (Medical Director). The Coroner was called. 911 was called, and the dispatcher stated that she would also call the Coroner. The Administrator, DON (Director of Nursing), and family were also notified of the death . p. A Nursing Incident and Accident Follow Up Note dated [DATE] at 18:16 (6:16 p.m.) documented, .Date and I&A (Incident and Accident) Description . On [DATE] at 1617 (4:17 p.m.), CNA notified nurse that pt. (patient) was on the floor and nurse needed to come immediately. Nurse found pt. in a very awkward position. She had her upper body / torso half hanging off of the bed, while her lower half / bottom were still in bed but somewhat crooked. Resident is nonverbal and unable to tell staff what happened. Resident was noted to have had an incontinent episode. Resident was in a low HTTA with no injury noted. Neuros (neurological) and ROM (range of motion) wnl (within normal limits) for resident. MD (Medical Doctor) and family notified. Long Term Intervention . Incontinence check with toileting offered every 2 hrs (hours). Added to the Care Plan . Yes . Ensure MD and Family Notification . Yes . q. A Nursing Incident and Accident Follow Up Note dated [DATE] at 5:49 p.m. documented, .Date and I&A Description . Approximately 1230 am (12:30 a.m.) I changed the patient I made sure the bed was in the lowest position. I noticed she was a little pale, so I assessed her breathing and pulse and they were within normal range. Approximately 1 am (1:00 a.m.) I walked by and observed her in bed resting. Approximately 115 (1:15 a.m.) I was walking up the hall to check on another patient. I observed her in bed. When finished with the other patient, I walked back down the hall. When I noticed she was not in bed, I stepped in and turned on the light. This was approximately 130am (1:30 a.m.). I discovered her laying with her bottom half in the floor and her top half resting against the positional bar. Long Term Intervention . Immediately assessed . No vitals (vital signs) were present, no heart sounds or lung sounds or pulse. Then I called (Administrator), notified doctor and called family. The Coroner was notified. He arrived and pronounced at 220 am (2:20 a.m.) . r. An Arkansas Department of Health Vital Records Certificate of Death dated [DATE] documented, .Cause of Death .Traumatic Asphyxia . Manner of Death . Accident . Describe How Injury Occurred . Subject became wedged between mattress and bed rail . s. On [DATE] at 10:05 a.m., the Administrator was asked, Can you tell me about what occurred and where it occurred? The Administrator stated, Originally the resident was in (Room) 108B on the COVID Hall by the window, facing left, and the left side of her head was on the bed, not on the pillow. I was called at 1:31 a.m. (RN #1), the nurse called and stated, '(Administrator), (Resident #1) is dead and (CNA #1) and I can't pick her up . The Administrator was asked, What did you do when you arrived at the facility? The Administrator stated, . Her right ear and neck were against the bar and her head was on the mattress. Her head was not wedged. Her torso was prone, and her right foot was against the air conditioner . The bed had ,[DATE] bed rails on the upper half of the bed. (The Surveyor took a photograph of the bed with side rails at this time.) t. On [DATE] at 1:32 a.m., RN #1 was asked, Did the resident require assistance transferring? RN #1 stated, She was a Hoyer lift and required two persons to get up. RN #1 was asked, Did the resident have a history of falls? RN #1 stated, Yes. RN #1 was asked, When was last fall? RN #1 stated, I believe it was three days before on the Day Shift (7:00 a.m. to 3:00 p.m.). RN #1 was asked, What interventions were put in place at that time? RN #1 stated, Frequent rounding. RN #1 was asked, Was she able to use her call light? RN #1 stated, I am not sure. RN #1 was asked, Was there a fall mat? RN #1 stated, There was a fall mat. RN #1 was asked, What side of the bed was the fall mat on? RN #1 stated, Not by the air conditioner, it was on the opposite side of what she fell . RN #1 was asked, Were bed rails used for this resident? RN #1 stated, All she had was positional hand bar. It was on both sides of the bed. Both were in the up position. RN #1 was asked, Were they able to be placed in the down position? RN #1 stated, I am not sure. RN #1 was asked, What are the resident's risk factors for having an accident safe side rail use? RN #1 stated, During the changing I have seen her grab the positional bar to help pull herself. RN #1 was asked, Did she use the rail to get up and down in bed? RN #1 stated, No, she did not have the coordination to get up in and out of the bed. RN #1 was asked, How often was resident use of the bar assessed and where is it documented? RN #1 stated, I do not know. I think PT (Physical Therapy) has their own documentation. RN #1 was asked, How do you know what interventions or assistance is needed to prevent falls? RN #1 stated, I don't know. RN #1 was asked, What was the resident trying to do when she fell on the 12th? RN #1 stated, I was not aware of her fall on the 12th until after this incident. RN #1 was asked, How many falls have there been on the night shift? RN #1 stated, I think just her two. Her one on Day Shift with (LPN #4) and then the night of the incident. RN #1 was asked, What did you watch for with this resident? RN #1 stated, Nothing in particular. I had her the week before and she did not get up on my shift. On rounds I would change her and sometimes she would have her leg over the side of the bed. RN #1 was asked, How did you identify that the interventions were suitable for this resident? RN #1 stated, The low bed and the fall mat were adequate for her. I can't think of anything else that would have been done. RN #1 was asked, Was there a bed alarm in use? RN #1 stated, There was not a bed alarm. It would have been nice. RN #1 was asked, How do you know what interventions or assistance is needed to prevent falls? RN #1 stated, I don't know. u. On [DATE] at 1:54 a.m., Certified Nursing Assistant (CNA) #1 was asked, Were bed rails used for this resident? CNA #1 stated, Yes. I don't really know why the positional bar was on there. I think it was a reminder so she didn't roll off or she could grab them when we changed her. She still had her strength. CNA #1 was asked, Were they able to be placed in the down position? CNA #1 stated, stated, You could put them down. CNA #1 was asked, Was there a bed alarm in use? CNA #1 stated, No. CNA #1 was asked, Are there any bed alarms in the facility? CNA #1 stated, No, not that I am aware of. CNA #1 was asked, What are the resident's risk factors for having an accident safe side rail use? CNA #1 stated, I don't know that. She was a fall risk. That was the only thing I know. CNA #1 was asked, Did she use the rail to get up and down in bed? CNA #1 stated, Yes. I have seen her grab them, but with her mental, I don't know if she could actually do it. I know she could grip and pull, but whether she knew what she was actually doing I can't say. CNA #1 was asked, How did you identify that the interventions were suitable for this resident? CNA #1 stated, We did tell them about the bed not locking. CNA #1 was asked, Who did you tell? CNA #1 stated, We had to call and tell the nurse to put it on (Maintenance Director's) list. We both called on that. I don't remember who I talked to. Registered Nurse (RN) #1 stated, I complained loudly, and I don't remember who I spoke with. CNA #1 was asked, What did you watch for with this resident? CNA #1 stated, When she moved, or when sometimes she would get fidgety, and that would be a sign that perhaps she could get up. We were always up and down the hall. CNA #1 was asked, How do you know what interventions or assistance is needed to prevent falls? CNA #1 stated, Normally they write out an in-service paper and we read and sign it, or they tell us, and we sign it. CNA #1 was asked, How often do you have those. CNA #1 stated, It was not too long ago, right before they took them (side rails) all off. CNA #1 was asked, Do you know why they removed them? CNA #1 stated, We were told state said they could not use them anymore. v. On [DATE] at 2:42 p.m., the Maintenance Director was asked, Have you been asked to remove side rails since the incident? The Maintenance Director stated, We started removing side rails a few months ago. It's been a slow process until recently. Of course, now we have accelerated. If a resident needs it for mobility, a consent form has to be filled out. The Maintenance Director was asked, Have you found any loose side rails? The Maintenance Director stated, Every now and again. They usually will write them down. The Maintenance Director was asked, Have you been told to go around and check the beds since the incident? The Maintenance Director stated, I do a quarterly Bed Audit. As I go in rooms, I check them. I don't spend a lot of time going room-to-room. Since the incident I'm doing a Daily Audit. I am checking zip ties on the ones that have those. I'm also checking for gaps. The Maintenance Director was asked, What is the gap allowance for side rails? The Maintenance Director stated, Our gap allowance is 1 inch or less. I think it was 2016 when the Director of Operations sent the FDA (Food and Drug Administration) information to us and I had to go around and measure every one of them in the facility to see what the gap was. The Maintenance Director was asked, But has that bed been here that long? The Maintenance Director stated, No. But I visually inspect them. The Maintenance Director was asked, Visually inspect. Does that mean you don't measure? The Maintenance Director stated, I don't usually get my tape measure and measure it, but I'm a life-long carpenter so I can pretty much tell. The Maintenance Director was asked, Can I get a copy of the Manufacturer's Guidelines on those? The Maintenance Director stated, We have printed them off recently, but it actually has nothing on there about the rails. Just the bed. If you have the proper size mattress on the bed, you'll have about an inch by each side rail. I have noticed with my dealings with the beds that's mostly been what we have had. The Maintenance Director was asked, How often do you go around and check the beds and rails? The Maintenance Director stated, I do a Quarterly Audit. w. On [DATE] at 4:32 p.m., (Licensed Practical Nurse) LPN #6, who routinely provided care of Resident #1, was asked, Have you ever known her to try and get out of the bed or found her half-way in or out of the bed? LPN #6 stated, You would go in and find her sideways. And she was quiet. LPN #6 was asked, Could she crawl out of bed? LPN #6 stated, Oh, yes. That was one of the reasons for the low bed. LPN #6 was asked, Did (Resident #1) use the rail to assist herself with turning side to side? LPN #6 stated, I don't know because I usually would find her already in the position. And I would find her sometimes with her legs off the bed but her upper part on the bed. LPN #6 was asked, How often would you say that would happen? LPN #6 stated, Maybe once every 2 weeks. LPN #6 was asked, How long did she have that bed? LPN #6 stated, When she was on B Hall, she had a different bed than when she was moved to the COVID Unit. On B Hall, she actually had half side rails. I feel like those rails were a little more space defining for her. But when they moved her, they took her and her chair over to that hall. x. On [DATE] at 7:15 p.m., Registered Nurse (RN) #1 accompanied the Surveyors to room [ROOM NUMBER], where Resident #1's bed was located. Resident #1's bed was moved to room [ROOM NUMBER], according to the Administrator, on [DATE] at 10:05 a.m. and the Maintenance Director on [DATE] at 2:42 p.m. and set up to reenact the room. RN #1 repositioned the bed, so the head of the bed was against the wall. RN #1 was asked, Are doors open? RN #1 stated, Doors all stay open. The cot's not rolling like it did. (Location of bed was situated to be as it was when the resident was repositioned and changed.) RN #1 attempted to lock the wheels of the bed and the wheels locked. RN #1 stated, This bed did not lock. This is not right. RN #1 was asked, Were the transfer bars up or down? RN #1 stated, Up. RN #1 was asked, Where was the call light? RN #1 stated, On the bed here like this. (She placed the call light on the bed, not tied to the bed rail.) RN #1 was asked to demonstrate how the resident's body was located. RN #1 demonstrated by placing the right side of her neck on the bar, head on bed, and right foot on air conditioner. y. On [DATE] at 7:26 p.m., CNA #1 was asked, Did she have a history of trying to get out of the bed? CNA #1 stated, Yes. She was a fall risk. CNA #1 accompanied the Surveyors to room [ROOM NUMBER] and was asked to demonstrate the locking of the bed wheels. The wheels on the bed locked. CNA #1 stated, They would not lock (at the time of the incident). We tried several times and it would not lock. I always make sure my beds are locked. z. On [DATE] at 9:42 a.m., LPN #3 was asked, Do you think an assessment should have been done to see if that bed and side rail was appropriate for her? LPN #3 stated, Of course. aa. On [DATE] at 11:40 a.m., the Director of Nursing (DON) was asked, Do we have all of the Side Rail Assessments for (Resident #1)? The DON stated, They should all be under the Assessment Tab in (Electronic Clinical Record System). I don't know where any others might be. The DON was asked, I know when (Resident #1) moved to the COVID Hall, she was put in a different bed with a different side rail. Was an Assessment completed to see if that bed / rail was appropriate for her? The DON stated, I'm not sure. I would have to look in her chart. The DON was asked, Should an assessment be done if a resident starts using a different type of side rail? The DON stated, Yes. The DON was asked, Who would be responsible for doing that assessment? The DON stated, The nurse on the floor. The DON was asked, (Resident #1) had a history of [REDACTED]. With that being a safety issue, especially if rails are used, had she been assessed for the appropriateness of the rails? The DON stated, I'm not sure. I would have to look. The DON was asked, Was she reassessed for appropriateness after the [DATE] incident when she was found half-way out of the bed? The DON stated, I'm not sure. I would have to look. The DON was asked, Do you know anything about the brakes not working? The DON stated, I myself did not, but (Maintenance Supervisor) and his Consultant went around and did safety checks. bb. On [DATE] at 12:46 p.m., LPN #4 was asked, Are you the nurse when (Resident #1) was found halfway out of the bed on [DATE]? LPN #4 stated, I believe so. I remember the incident. LPN #4 was asked, Do you remember if the assist rail was up or down? LPN #4 stated, I'm sorry. I don't recall that. Is it on my I/A (Incident and Accident) form? (LPN #4 looked at the I/A form) LPN #4 stated, I didn't note it, but that doesn't mean it wasn't there. LPN #4 was asked, Did she have a history of trying to get out of bed? LPN #4 stated, That day, on the 12th, was the first time I remember seeing her in a position that would make me think she was trying to get out of bed. LPN #4 was asked, Do you know if you had ever assessed her for the appropriateness of those side rails on her bed? LPN #4 stated, We do our Annual Care Plans and there is a section that asks about the appropriateness of side rails. Has anyone ever specifically told me to do that? I can't say they have. LPN #4 was asked, Did she use the rails that were on her bed? LPN #4 stated, Yes. She could use it to grab hold of during a transfer. I don't know if she could have positioned herself in bed using it. cc. On [DATE] at 4:33 p.m., RN #2 was asked, (Resident 1) tested Positive for COVID-19 on [DATE]. Where was she moved to? RN #2 stated, room [ROOM NUMBER]. RN #2 was asked, Where did she move from? RN #2 stated, B Hall. RN #2 was asked, What did you receive in Report about the resident? RN #2 stated, She tested COVID Positive and was asymptomatic. RN #2 was asked, Did she try to get out of the bed? RN #2 stated, I have never, ever seen her try to get out of the bed or her chair. She would sit up in the chair, but never try to get out of it. RN #2 was asked, Did she have a history of falls? RN #2 stated, Not to my knowledge. RN #2 was asked, Was she assessed for bed rails? RN #2 stated, I don't remember who did what. I don't know who did the assessment. I am sure one was done. RN #2 was asked, Do you believe the bed rail benefited her at all being on the bed? RN #2 stated, Maybe to hang onto while we were changing her, but I don't know about benefit. RN #2 was asked, Do you think the bed rail was detrimental? RN #2 stated, Yes. They could be very much so. RN #2 was asked, How would they be detrimental? RN #2 stated, Falling out, breaking an arm or leg, getting hung up in them. I never thought about that before (Resident #1). Bolster mattresses really help, as do fall mats. RN #2 was asked, Did she have a fall mat? RN #2 stated, I believe she did. RN #2 was asked, Did you get any Report on [DATE] or after her fall to increase checks on her? RN #2 stated, I do not remember. RN #2 was asked, Did the bed lock or move? RN #2 stated, I don't think so. I did not see it happen. dd. On [DATE], a lock check was conducted on beds with the Maintenance Supervisor with the following results: 1.) The bed in room [ROOM NUMBER]A continued to roll even when brakes locked. This room was empty. There was no resident assigned to this bed. 2.) The bed in room [ROOM NUMBER]B still rolled when the bed was locked. This bed was occupied by Resident #8. 3.) The bed in room [ROOM NUMBER]B continued to roll even when the brakes were applied. There was no resident assigned to this bed. 4.) The bed in room [ROOM NUMBER]A continued to roll even after the brakes were applied. There was no resident assigned to this bed. 5.) The bed in room [ROOM NUMBER]A continued to roll even after the brakes were applied. This bed was occupied by Resident #9. 6.) The bed in room [ROOM NUMBER]A continued to roll after the brakes were locked. This bed was occupied by Resident #10. ee. A facility policy titled Proper Use of Side Rails provided by the Nurse Consultant on [DATE] at 3:33 p.m. documented, . 3. An assessment will be made to determine the resident's symptoms, risk of entrapment, and reason for using side rails. When used for mobility or transfer, an assessment will include a review of the resident's . a. Bed mobility . b. Ability to change positions, transfer to and from bed or chair, and to stand and toilet . c. Risk of entrapment from the use of side rails . 6. Less restrictive interventions that will be incorporated in Care Planning include . c. and surrounding the bed with a soft mat . d. Equipping the resident with a device that monitors attempts to arise . 7. Documentation will indicate if less restrictive approaches are not successful, prior to considering the use of side rails . 9. Signed consent forms do not relieve the facility from meeting the requirements for restrain use including proper assessment and care planning . 11. The resident will be checked periodically for safety relative to side rail use . ff. A document titled (Facility) Timeline: (Resident #1) documented the following corrective measures conducted by the facility prior to the survey entrance date: 1.) . New bedrail assessments were completed for all beds. Residents not needing bedrail assistance had bedrails removed on this date. New assessments were placed in the Care Plan for both those requiring siderails and those not requiring siderails . 2.) .By close of business on [DATE], the facility has accomplished the following . Identified the facility has 31 hospital grade beds that had bedrails . Identified 6 hospital beds that had those residents assessed and side rails removed . 21 hospital beds had those residents assessed and siderails zip-tied in a lowered position . 4 residents refused siderail removal. Those residents were assessed for siderail appropriateness. A BIMS (Brief Interview for Mental Status) was completed to determine capacity to request siderails. Consent and understanding of risk / benefit was signed by each resident . 3.) .Care Plans were reviewed and updated to correct siderail action / use . A siderail audit tool was created to have the Maint Sup (Maintenance Supervisor) or designee perform daily rounds to assure the zip-tied siderails remain in tied status . 4.) .In-services began with clinical teams on [DATE] regarding siderail use . A Statement provided by the Nurse Consultant on [DATE] at 3:28 p.m. documented, .On [DATE] during in-service regarding bed safety, proper use of side rails, and incident and accidents . In-service when discussing side rails and proper use also included proper assessment and consent for the use of side rails. This was conducted by myself (Nurse Consultant) Clinical Nursing Consultant . 5.) .Action plans were created for I&As (Incident and Accidents) . Action Plans were created for siderail use / appropriateness .

Based on observation, record review and interview, the facility failed to ensure an effective system was in place to ensure the accurate administration of medications, as evidenced by failure to ensure physician orders [REDACTED].#18) of 15 (Residents #1-#13, #16 and #17) case mix residents who received medications from a licensed nurse with a history of making frequent medication errors (Licensed Practical Nurse (LPN) #1). The facility also failed to ensure physician orders [REDACTED].#1, #2, #16 and #17) of 15 (Residents #1-#13, and #16 and #17) case mix residents who received medications from Licensed Practical Nurses (LPN's #1, #2, #3, #4, #5, and #6) and currently reside in the facility. The failed practices resulted in past immediate jeopardy, which caused or likely caused the death of Resident #18, who received doses of MS Contin (an extended release version of Morphine Sulfate) and Percocet intended for another resident and subsequently expired in the hospital of respiratory failure secondary to narcotic overdose. The failed practice also had the potential to cause more than minimal harm to 84 residents who received medications, as documented on a list provided by the Administrator on 3/16/17 at 6:35 p.m. The facility removed the Immediate Jeopardy and corrected the underlying failed practices on 7/23/16 1/12/17 prior to the survey entrance date. The facility was notified of the Past Immediate Jeopardy on 3/16/17 at 5:35 p.m. The findings are: 1. Resident #18 had [DIAGNOSES REDACTED]. An Annual Minimum Data Set (MDS) with an assessment reference date (ARD) of 1/8/17 documented the resident scored 15 (13 - 15 indicates cognitively intact) on a Brief Interview for Mental Status (BIMS), required extensive assistance of one person for transfer, dressing, personal hygiene, bathing, was non-ambulatory, and had impaired range-of-motion of the upper and lower extremities on one side. a. An Incident and (&) Accident Next Day Reporting Form, Division of Medical Services (DMS) form 7734 dated as submitted to the Office of Long Term Care (OLTC) on 1/17/17 documented, Date of I&A: 1/11/17, Time: 22:30 (10:30 p.m.) . Summary of Incident . On 1/11/2017 at 22:30 p.m. (LPN #1) was passing medications and had completed an accucheck (blood glucose test) of (Resident #18). (LPN #1) then prepared the appropriate dose of sliding scale insulin and lantus and laid them down on her med (medication) cart because someone spoke to her. She needed to go down the hall so she placed both syringes in the top drawer of the med cart. When she returned to the med cart she pulled a different resident's oral medication out and then had to go to the bathroom - she placed the oral meds in the drawer beside the insulin syringes. When she returned to the med cart she gathered the oral meds along with the syringes and proceeded to administer the correct insulin but the wrong oral meds to (Resident #18). She had given (Resident #18) Morphine Sulfate ER (extended release) 60 mg (milligrams) and 2 Percocet 10/325 mg . b. The Facility Investigation Report for Resident Abuse, Neglect, Misappropriation of Property & Exploitation of Residents in Long Term Care Facilities, DMS Form 762 dated as submitted to OLTC on 1/17/17 documented the same description of the 1/11/17 medication incident and, .She (LPN #1) did not compare the MAR (Medication Administration Record) to the oral medications a second time prior to administering them and also did not label the cup of meds before locking them up in the top drawer of the med cart . c. Nurse's Notes dated 1/11/17 at 10:30 p.m., electronically signed by Licensed Practical Nurse (LPN) #1 documented, Incident Description: 1/11/17 @ (at) 2230 (10:30 p.m.) - I inadvertently gave this resident another resident's oral medication. Immediate Intervention: As soon as I realized my error, I contacted the resident's physician and received new orders: 1) Give 0.4 ml (milliliters) Narcan IM (intramuscular) immediately, 2) Send resident to (hospital) ER (emergency room ) for eval (evaluation) and treatment as indicated . 1.) The Emergency Department Note dated 1/11/17 at 11:56 p.m. documented, Additional Information: Chief complaint from Nursing Triage Note: Nursing Chief Complaint 01/11/17 23:48 (11:48 p.m.) Nursing Chief Complaint per snf (skilled nursing facility) pt (patient) was given wrong medications. Pt given narcan 0.4 mg IM per snf and tow (two) additional doses per ems (emergency medical service). Pt denies pain at this time. History of Present Illness: The patient presents with accidental overdose. The substance ingested was narcotics. The onset was late evening. Amount ingested: 2 (two) 10 mg Percocet, one 60 mg MS (Morphine Sulfate) Contin extended release . Along with 400 mg of Neurontin which is her own p.m. medication. The location where the incident occurred was at a nursing home . Therapy today: emergency medical services and multiple doses of Narcan. Associated symptoms: altered mental status which is now improved. Additional history: at this point patient is alert and able to provide good history . 2.) The hospital Drug Screen report dated 1/12/17 at 1:15 a.m. documented the resident's urine specimen was positive for benzodiazepines, opiates and oxycodone. 3.) The hospital History and Physical dated 1/12/17 documented, Date of Admission: 1/12/17; Anticipated Length of Stay: 1-2 days; Chief Complaint: med (medication) overdose; History of Present Illness: 65 y/o (year old) female brought in due to incidental drug overdose. Apparently given the wrong meds at the nursing home. Was given a total of 20 mg of Percocet x (times) 60 mg of MS Contin. She was given Narcan prior to arrival. Was still sedated but doing better. Currently she seems wide awake. She is asking for Benadryl for itching which she says is a side effect of the pain meds. She has no other complaints . Re-examination/Re-evaluation: Time: 01/12/17 01:23 (1:30 a.m.). Notes: mildly sleepy, has not required Narcan again while in the emergency department, but is going to the ICU (Intensive Care Unit) for careful monitoring should her status decline. Impression and Plan: Diagnosis: [REDACTED]. 4.) The hospital Progress Note dated 1/12/17 at 14:40 p.m. documented, Subjective/History of Present Illness: The patient was reevaluated several times over the course of the day. I was called to see her around 10 AM when she was extremely obtunded. She is also nauseated and diaphoretic. She improved with antiemetics by then became extremely drowsy again. She was transferred to a room closer to the nurses station and started on continuous tidal CO2 (carbon dioxide) monitoring. Her CO2 levels remained stable but she became completely unresponsive even to sternal rub and early this afternoon required another dose of Narcan. Just a few minutes ago she was sitting up and eating food in looking considerably better . Assessment/Plan: 1. Accidental drug overdose . with MS Contin and relapse of narcotic overdose symptoms requiring multiple doses of Narcan. She is doing better and as time goes on this affect should ultimately wear off . 5.) The hospital Progress Note dated 1/14/17 at 12:03 a.m. documented, Called by RN (Registered Nurse) stating pt (patient) went asystole on telemetry. I came up to evaluate her. She had no respirations and no heart sounds on auscultation. She had no pulse either. She was pronounced dead. Time of death is 2314 (11:14 p.m.). Of note the nurse had just seen her 20 minutes prior and had given her a bath. She was sleepy but arousable at the time, per report. On telemetry she had a brief wide complex arrhythmia and then went asystole. She was DNR (Do Not Resuscitate) so CPR (Cardiopulmonary Resuscitation) was not performed. 6.) The hospital Discharge Summary dated 1/14/17 at 8:38 p.m. documented, Course of Treatment: The patient looked pretty good after her initial assessment and treatment with Narcan but after several minutes her narcotic overdose symptoms with lethargy and slow respirations recurred. She also received her Lantus insulin and then developed some [DIAGNOSES REDACTED] as she was unable to eat. She ended up receiving multiple doses of Narcan over the course of the day and was started on a drip of D5 (Dextrose 5 percent) to combat the [DIAGNOSES REDACTED]. The next day she developed profound respiratory failure. X-rays really didn't look that bad but clinically it sounded like the volume that was given her because of low blood pressure and low blood sugar cause volume overload. She also had developed acute kidney injury with decreased urine output. She was aggressively diuresed and seemed to be doing better by the evening of the 13th but later that evening her symptoms relapsed and she essentially stopped breathing and died . No resuscitative efforts were performed in accordance with her advance directives. The patient's cause of death is respiratory failure secondary to accidental narcotic overdose. d. The January 2017 Medication Administration Record (MAR) for Resident #18 documented on the evening / night shift of 1/11/17, prior to receiving the other resident's MS Contin and Percocet in error from LPN #1, the resident had already received her own scheduled medications of Ultram 50 mg (as per a physician order [REDACTED]. e. On 3/16/17 at 4:18 p.m., the personnel file of LPN #1, who administered MS Contin and Percocet in error to Resident #18 on 1/11/17, was reviewed, with the following findings: 1.) For a medication error involving Resident #1: An Employee Memorandum dated 10/19/15 documented, Employee Name: (LPN #1) . Date of occurrence: 10/8/15 - 10/17/15. Failed to compare med card to MAR resulting in wrong dose of Neurontin being given. Failure to observe 6 med admin (administration) rights during routine med pass. Action taken: Counsel. Comment/Explanation: 1 on 1 counsel of the possible indications r/t (related to) failure to comply with 6 rights of med admit. The form was signed / acknowledged by LPN #1 on 10/19/15. The attached Medication Error Report, signed by LPN #1 and the Director of Nursing (DON) on 10/18/15, documented, Patient: (Resident #1's name). Medication given: Gabapentin (Neurontin). Dosage given: 800 mg . What was physician's orders [REDACTED]. Reason for making error: card wasn't being double checked with order in MAR. Could the error have endangered the life or welfare of the patient? Yes . could increase impaired renal function . What precautions can you take to prevent a similar error? Always observe the 6 rights of medication administration . There was no documentation of a plan to monitor LPN #1 during medication passes to minimize the potential for further medication errors. 2.) For a medication error involving a non-case mix resident: An Employee Memorandum dated 10/30/15 documented, Employee Name: (LPN #1) . Date of occurrence: 10/25/15-10/26/15. Write up. On 10/25/15 administered a PRN (as needed) narcotic to a resident from another resident's narcotic card. On 10/26/15 'misread' eMAR (electronic medication administration record) + (and) administered a B12 injection to a resident who had already received their scheduled dose during day shift that a.m. (morning) . Specific violation: Violation of policy - both show a failure to observe the 6 rights of medication administration . Action taken: Disciplinary Warning . Nurse must always observe these rights with each resident + each med for safest outcome: RIGHT: person, drug, dose, time, route, documentation . An attached Medication Error Report dated 10/26/15 documented, Patient (non-case mix resident's name). Date of error: 10/23/15. Time of error: 10:00 p.m. Medication given: Cyanocobalamin (Vitamin B12) sol (solution) 1000 mcg/ml (micrograms per milliliter). What was physician's orders [REDACTED].? No. Resident showed no s/s (signs / symptoms) of adverse effects . What precautions can you take to prevent a similar error? Re-educated on the eMAR system. There was no documentation of a plan to monitor LPN #1 during medication passes to minimize the potential for further medication errors. 3.) For a medication error involving a non-case mix resident: An Employee Memorandum dated 12/17/15 documented, Employee Name: (LPN #1). Date of occurrence: 12/16/15. Write up. Was 'unable to find' new card of hydrocodone dose (which was found present in cart lock box) so she gave a dose out of the resident's recently changed lower dose card . failure to obtain an MD (Medical Doctor) one time order for lower dose upon possible unavailability of new dose of hydrocodone . Action taken: Counsel. Proper steps for PRN med admin - if current dose not avail (available), must contact MD for temp (temporary) order for what is on hand in ER (emergency) box, contact pharmacy + take steps to get new med in . There was no documentation of a plan to monitor LPN #1 during medication passes to minimize the potential for further medication errors. 4.) For a medication error involving Resident #2: An Employee Memorandum dated 1/12/16 documented, Employee Name: (LPN #1). Date of occurrence: 1/6/16. Write up. Failed to check scheduled insulin against eMAR resulting in resident receiving 18 u (units) of Humalog instead of Lantus. Failure to perform rights of medication administration. Action Taken: Counsel. Disciplinary Warning. With any medication must observe / perform the rights of administration to prevent possible injury to residents . An attached Medication Error Report dated 1/6/16 documented, Patient: (Resident #2's name) . Medication given: 18 units Humalog. What was physician's orders [REDACTED]. Reason for making error: I picked up wrong insulin pen, the Humalog pen instead of the Lantus pen . Could the error have endangered the life or welfare of the patient? The insulin was fast acting and could have dropped resident's BS (blood sugar) below 100 and caused [DIAGNOSES REDACTED] . What precautions can you take to prevent a similar error? I will double or triple check the label with eMAR to make sure the insulin pen is the correct drug. Yellow sticker added to all fast acting insulin . There was no documentation of a plan to monitor LPN #1 during medication passes to minimize the potential for further medication errors. 5.) For a medication error involving Resident #17: An Employee Memorandum dated 6/22/16 documented, Employee Name: (LPN #1). Date of occurrence: 5/9-6/11, 5/17-5-18, 6/2-6/5, 6/9-6/11, 6/15-6/17, 6/20 (2016) . documenting on eMAR as giving Aricept 10 mg (at) 8 p.m. during the month of May + June 2016. When the last pharmacy fill for med is documented as 3/31/16 for #30 pills. No medication card is located in the cart. Failure to perform proper match back (with) meds / MAR resulting in missing medication . Action Taken: Disciplinary Warning . There was no documentation of a plan to monitor LPN #1 during medication passes to minimize the potential for further medication errors. 6.) For a medication error involving Resident #16: An Employee Memorandum dated 7/26/16 documented, Employee Name: (LPN #1). Date of occurrence: 7/25/16. Write up, counsel (with) education. Mistakenly administered Ultram 50 mg instead of Ativan 0.5 mg to a resident for anxiety as she 'grabbed the wrong card' . failure to provide + follow the 6 rights of medication administration by not having the right medication or dose . 1) Read order on MAR, 2) pull narc (narcotic) card for resident/med + compare to MAR, 3) Pop out dose, 4) Open green narc book + sign dose out on appropriate page + check card against page . An attached Medication Error Report dated 7/25/16 documented, Patient: (Resident #16's name) . Medication given: Tramadol (Ultram) 50 mg . What was physician's orders [REDACTED]. How was the error discovered? During med count (with) 2nd (second) shift nurse . What precautions can you take to prevent a similar error? Double check name on card and nurse given education on successful med pass technique . There was no documentation of a plan to monitor LPN #1 during medication passes to minimize the potential for further medication errors. 2. Resident #17 had a [DIAGNOSES REDACTED]. An annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) 1/22/17 documented the resident scored 0 (0-7 indicates severely impaired) on the Brief Interview for Mental Status (BIMS) and did not exhibit any behaviors. a. A physician's orders [REDACTED]. b. The May and June 2016 MARs documented by nurses' initials that Aricept 10 mg was administered by Licensed Practical Nurse (LPN) #1, #2, #3, #4, #5, and #6 daily from 5/1/16 thru 6/20/16. The MAR also documented an End Date of 6/22/16. c. Employee Memorandum forms dated 6/22/16 for LPN's #2, #3, #4 and #6 documented, .Documenting on eMAR as giving Aricept 10 mg at 8 p.m. during the month of May + June 2016 when the last pharmacy fill for med is documented as 3/31/16 for #30 pills. No medication card is located in the cart . Disciplinary Warning. Nurse failure to match medication cards with the MAR to ensure appropriate meds given at the appropriate times . (Also refer to paragraph 1. e. 5.) above regarding the Employee Memorandum for LPN #1 for this medication error.) There was no documentation of a plan to monitor medication passes with these nurses. 3. Resident #16 had [DIAGNOSES REDACTED]. An Annual MDS with an ARD of 1/19/17 documented the resident was moderately impaired in cognitive skills for daily decision making per a Staff Assessment for Mental Status and had verbal behavioral symptoms directed at staff occurring 4 to 6 days but less than daily. a. A physician's orders [REDACTED]. b. A Medication Error Report for LPN #1 dated 7/25/16 documented, Resident: (Resident #16); Date of Error: 7/25/16; Medication Given: Tramadol 50 mg; Dosage Given: 50 mg; Rte. (Route) of Admin. (Administration): PO (by mouth); What was physician's orders [REDACTED]. What precautions can you take to prevent a similar error? Double check name on card and number on card to drug book. Nurse given education on successful med pass technique. (Refer to paragraph 1. e. 6.) above for the Employee Memorandum for this error.) 4. On 3/16/17 at 3:33 p.m., the Administrator was asked about the employee memorandum dated 6/22/16 for LPN #1 related to Resident #17's Aricept being signed off by nurses on the MAR when the medication was not available in the medication cart from May through June (6/20/16). The Administrator stated, That's why all the nurses were written up, because they documented they gave it, and it was not in the cart. The Administrator was asked, Did you put any monitoring in place to ensure it did not happen again? The Administrator stated, .my DON (Director of Nursing) at the time did random med pass audits on every shift with every nurse. The Administrator was asked for documentation related to the random medication pass audits at this time. At 4:32 p.m., the Administrator stated, I spoke with our old DON. She said she did 1 on 1 counseling with these nurses, but she didn't start med pass audits until the incident with (LPN #1) after the significant med error with (Resident #18) on January 11th (the error that resulted in Resident #18's hospitalization and subsequent death). One on one counseling forms were done for all the nurses except (LPN #5), and she's been gone for months. The Administrator was asked, Of the LPN's listed, who still works here? She stated, (LPN #6) does not work here, the rest do, (LPN #2, #3, and #4). The Administrator was asked, What halls do these nurses work on? She stated, They work on all of them. On 3/16/17 at 5:20 p.m., the Administrator provided documentation of a medication pass audit dated 7/23/16 conducted with Registered Nurse (RN) #1 and a medication pass audit dated 10/29/16 conducted with LPN #2. There was no other documentation of medication pass monitoring that was conducted prior to 1/11/17 when Resident #18 received the overdose of narcotic medications and subsequently died . 5. The facility removed the Immediate Jeopardy, corrected the failed practice and reduced the scope / severity to G on 1/12/17 as evidenced by the following: a. A Termination of Employment form dated 1/17/17 documented LPN #1's employment was terminated for, .violation of med pass procedure resulting in med error and resident to (hospital). The form documented LPN #1's last day worked was 1/12/17. b. An Inservice Education Report dated 1/14/17 documented twelve facility LPN's and one facility RN were retrained on the 6 Rights of Medication Administration, to include the right drug, dose, route, time, patient and documentation, as well as checking the drug card to the MAR when the card is removed from the medication cart, checking the drug card against the MAR again when preparing the medications for administration, matching the prepared medications to the MAR and double checking the patient's identity prior to administration. c. A Pharmacy Inservice sheet dated 1/19/17 documented retraining on medication pass was provided to ten LPN's and one RN on that date by the facility's Consultant Pharmacist. d. Medication Administration Observation sheets dated 1/15/17 through 1/21/17 documented licensed nurses were observed during medication passes, with zero medication errors identified. e. The Findings and Actions Taken section of the DMS-762 form submitted to the facility on [DATE] documented, . On 1/14/17 facility DON came in at approximately 7:00 a.m. and in-serviced all of the charge LPN's on duty on facility's policy and procedure of medication pass. At approximately 8:00 a.m., facility nurse consultant immediately began to do med pass audits with all of the nurses on duty . Facility DON, nurse consultant and weekend supervisor RN will continue to preform (perform) ongoing med pass audits as well as re-in-servicing all of the nurses on facility's policy and procedure on med pass . f. On 3/13/17 and 3/14/17 during the survey, the RN surveyor observed medication passes with a total of 5 licensed nurses who were working the 3:00 p.m. to 11:00 p.m. shift, the 7:00 a.m. to 3:00 p.m. shift and the 7:00 a.m. to 7:00 p.m. shift. Upon reviewing all physician orders [REDACTED].

Based on record review and interview, the facility failed to ensure physician orders [REDACTED].#18) of 15 (Residents #1-#13, #16 and #17) case mix residents who received medications from a licensed nurse with a history of making frequent medication errors (Licensed Practical Nurse (LPN) #1). The facility also failed to ensure physician orders [REDACTED].#1, #2, #16 and #17) of 15 (Residents #1-#13, and #16 and #17) case mix residents who received medications from Licensed Practical Nurses (LPN's #1, #2, #3, #4, #5, and #6) and currently reside in the facility. The failed practices resulted in past immediate jeopardy, which caused or likely caused the death of Resident #18, who received doses of [MEDICATION NAME](an extended release version of [MEDICATION NAME]) and [MEDICATION NAME] intended for another resident and subsequently expired in the hospital of [MEDICAL CONDITION] secondary to narcotic overdose. The failed practice also had the potential to cause more than minimal harm to 84 residents who received medications, as documented on a list provided by the Administrator on [DATE] at 6:35 p.m. The facility removed the Immediate Jeopardy and corrected the underlying failed practices on [DATE] prior to the survey entrance date. The facility was notified of the Past Immediate Jeopardy on [DATE] at 5:35 p.m. The findings are: 1. Resident #18 had [DIAGNOSES REDACTED]. An Annual Minimum Data Set (MDS) with an assessment reference date (ARD) of [DATE] documented the resident scored 15 (13 - 15 indicates cognitively intact) on a Brief Interview for Mental Status (BIMS), required extensive assistance of one person for transfer, dressing, personal hygiene, bathing, was non-ambulatory, and had impaired range-of-motion of the upper and lower extremities on one side. a. An Incident and (&) Accident Next Day Reporting Form, Division of Medical Services (DMS) form 7734 dated as submitted to the Office of Long Term Care (OLTC) on [DATE] documented, Date of I&A: [DATE], Time: 22:30 (10:30 p.m.) . Summary of Incident . On [DATE] at 22:30 p.m. (LPN #1) was passing medications and had completed an accucheck (blood glucose test) of (Resident #18). (LPN #1) then prepared the appropriate dose of sliding scale insulin and [MEDICATION NAME] and laid them down on her med (medication) cart because someone spoke to her. She needed to go down the hall so she placed both syringes in the top drawer of the med cart. When she returned to the med cart she pulled a different resident's oral medication out and then had to go to the bathroom - she placed the oral meds in the drawer beside the insulin syringes. When she returned to the med cart she gathered the oral meds along with the syringes and proceeded to administer the correct insulin but the wrong oral meds to (Resident #18). She had given (Resident #18) [MEDICATION NAME] ER (extended release) 60 mg (milligrams) and 2 [MEDICATION NAME] ,[DATE] mg . b. The Facility Investigation Report for Resident Abuse, Neglect, Misappropriation of Property & Exploitation of Residents in Long Term Care Facilities, DMS Form 762 dated as submitted to OLTC on [DATE] documented the same description of the [DATE] medication incident and, .She (LPN #1) did not compare the MAR (Medication Administration Record) to the oral medications a second time prior to administering them and also did not label the cup of meds before locking them up in the top drawer of the med cart . c. Nurse's Notes dated [DATE] at 10:30 p.m., electronically signed by Licensed Practical Nurse (LPN) #1 documented, Incident Description: [DATE] @ (at) 2230 (10:30 p.m.) - I inadvertently gave this resident another resident's oral medication. Immediate Intervention: As soon as I realized my error, I contacted the resident's physician and received new orders: 1) Give 0.4 ml (milliliters) [MEDICATION NAME] IM (intramuscular) immediately, 2) Send resident to (hospital) ER (emergency room ) for eval (evaluation) and treatment as indicated. 1.) The Emergency Department Note dated [DATE] at 11:56 p.m. documented, Additional Information: Chief complaint from Nursing Triage Note: Nursing Chief Complaint [DATE] 23:48 (11:48 p.m.) Nursing Chief Complaint per snf (skilled nursing facility) pt (patient) was given wrong medications. Pt given [MEDICATION NAME] 0.4 mg IM per snf and tow (two) additional doses per ems (emergency medical service). Pt denies pain at this time. History of Present Illness: The patient presents with accidental overdose. The substance ingested was narcotics. The onset was late evening. Amount ingested: 2 (two) 10 mg [MEDICATION NAME], one 60 mg MS ([MEDICATION NAME])[MEDICATION NAME] release . Along with 400 mg of [MEDICATION NAME] which is her own p.m. medication. The location where the incident occurred was at a nursing home . Therapy today: emergency medical services and multiple doses of [MEDICATION NAME]. Associated symptoms: altered mental status which is now improved. Additional history: at this point patient is alert and able to provide good history . 2.) The hospital Drug Screen report dated [DATE] at 1:15 a.m. documented the resident's urine specimen was positive for benzodiazepines, opiates and [MEDICATION NAME]. 3.) The hospital History and Physical dated [DATE] documented, Date of Admission: [DATE]; Anticipated Length of Stay: ,[DATE] days; Chief Complaint: med (medication) overdose; History of Present Illness: 65 y/o (year old) female brought in due to incidental drug overdose. Apparently given the wrong meds at the nursing home. Was given a total of 20 mg of [MEDICATION NAME] x (times) 60 mg of MS Contin. She was given [MEDICATION NAME] prior to arrival. Was still sedated but doing better. Currently she seems wide awake. She is asking for [MEDICATION NAME] for itching which she says is a side effect of the pain meds. She has no other complaints . Re-examination/Re-evaluation: Time: [DATE] 01:23 (1:30 a.m.). Notes: mildly sleepy, has not required [MEDICATION NAME] again while in the emergency department, but is going to the ICU (Intensive Care Unit) for careful monitoring should her status decline. Impression and Plan: Diagnosis: [REDACTED]. 4.) The hospital Progress Note dated [DATE] at 14:40 p.m. documented, Subjective/History of Present Illness: The patient was reevaluated several times over the course of the day. I was called to see her around 10 AM when she was extremely obtunded. She is also nauseated and diaphoretic. She improved with antiemetics by then became extremely drowsy again. She was transferred to a room closer to the nurses station and started on continuous tidal CO2 (carbon [MEDICATION NAME]) monitoring. Her CO2 levels remained stable but she became completely unresponsive even to sternal rub and early this afternoon required another dose of [MEDICATION NAME]. Just a few minutes ago she was sitting up and eating food in looking considerably better . Assessment/Plan: 1. Accidental drug overdose . with [MEDICATION NAME] relapse of narcotic overdose symptoms requiring multiple doses of [MEDICATION NAME]. She is doing better and as time goes on this affect should ultimately wear off . 5.) The hospital Progress Note dated [DATE] at 12:03 a.m. documented, Called by RN (Registered Nurse) stating pt (patient) went asystole on telemetry. I came up to evaluate her. She had no respirations and no heart sounds on auscultation. She had no pulse either. She was pronounced dead. Time of death is 2314 (11:14 p.m.). Of note the nurse had just seen her 20 minutes prior and had given her a bath. She was sleepy but arousable at the time, per report. On telemetry she had a brief wide complex arrhythmia and then went asystole. She was DNR (Do Not Resuscitate) so CPR (Cardiopulmonary Resuscitation) was not performed. 6.) The hospital Discharge Summary dated [DATE] at 8:38 p.m. documented, Course of Treatment: The patient looked pretty good after her initial assessment and treatment with [MEDICATION NAME] but after several minutes her narcotic overdose symptoms with lethargy and slow respirations recurred. She also received her [MEDICATION NAME] and then developed some [DIAGNOSES REDACTED] as she was unable to eat. She ended up receiving multiple doses of [MEDICATION NAME] over the course of the day and was started on a drip of D5 ([MEDICATION NAME] 5 percent) to combat the [DIAGNOSES REDACTED]. The next day she developed profound [MEDICAL CONDITION]. X-rays really didn't look that bad but clinically it sounded like the volume that was given her because of low blood pressure and low blood sugar cause volume overload. She also had developed acute kidney injury with decreased urine output. She was aggressively [MEDICATION NAME] and seemed to be doing better by the evening of the 13th but later that evening her symptoms relapsed and she essentially stopped breathing and died . No resuscitative efforts were performed in accordance with her advance directives. The patient's cause of death is [MEDICAL CONDITION] secondary to accidental narcotic overdose. d. The (MONTH) (YEAR) Medication Administration Record (MAR) for Resident #18 documented on the evening / night shift of [DATE], prior to receiving the other resident's [MEDICATION NAME] in error from LPN #1, the resident had already received her own scheduled medications of [MEDICATION NAME] 50 mg (as per a physician order [REDACTED]. e. On [DATE] at 4:18 p.m., the personnel file of LPN #1, who administered [MEDICATION NAME] in error to Resident #18 on [DATE], was reviewed, with the following findings: 1.) For a medication error involving Resident #1: An Employee Memorandum dated [DATE] documented, Employee Name: (LPN #1) . Date of occurrence: [DATE] - [DATE]. Failed to compare med card to MAR resulting in wrong dose of [MEDICATION NAME] being given. Failure to observe 6 med admin (administration) rights during routine med pass. Action taken: Counsel. Comment/Explanation: 1 on 1 counsel of the possible indications r/t (related to) failure to comply with 6 rights of med admit. The form was signed / acknowledged by LPN #1 on [DATE]. The attached Medication Error Report, signed by LPN #1 and the Director of Nursing (DON) on [DATE], documented, Patient: (Resident #1's name). Medication given: [MEDICATION NAME] ([MEDICATION NAME]). Dosage given: 800 mg . What was physician's orders [REDACTED]. Reason for making error: card wasn't being double checked with order in MAR. Could the error have endangered the life or welfare of the patient? Yes . could increase impaired renal function . What precautions can you take to prevent a similar error? Always observe the 6 rights of medication administration . There was no documentation of a plan to monitor LPN #1 during medication passes to minimize the potential for further medication errors. 2.) For a medication error involving a non-case mix resident: An Employee Memorandum dated [DATE] documented, Employee Name: (LPN #1) . Date of occurrence: [DATE]-[DATE]. Write up. On [DATE] administered a PRN (as needed) narcotic to a resident from another resident's narcotic card. On [DATE] 'misread' eMAR (electronic medication administration record) + (and) administered a B12 injection to a resident who had already received their scheduled dose during day shift that a.m. (morning) . Specific violation: Violation of policy - both show a failure to observe the 6 rights of medication administration . Action taken: Disciplinary Warning . Nurse must always observe these rights with each resident + each med for safest outcome: RIGHT: person, drug, dose, time, route, documentation . An attached Medication Error Report dated [DATE] documented, Patient (non-case mix resident's name). Date of error: [DATE]. Time of error: 10:00 p.m. Medication given: [MEDICATION NAME] (Vitamin B12) sol (solution) 1000 mcg/ml (micrograms per milliliter). What was physician's orders [REDACTED].? No. Resident showed no s/s (signs / symptoms) of adverse effects . What precautions can you take to prevent a similar error? Re-educated on the eMAR system. There was no documentation of a plan to monitor LPN #1 during medication passes to minimize the potential for further medication errors. 3.) For a medication error involving a non-case mix resident: An Employee Memorandum dated [DATE] documented, Employee Name: (LPN #1). Date of occurrence: [DATE]. Write up. Was 'unable to find' new card of [MEDICATION NAME] dose (which was found present in cart lock box) so she gave a dose out of the resident's recently changed lower dose card . failure to obtain an MD (Medical Doctor) one time order for lower dose upon possible unavailability of new dose of [MEDICATION NAME] . Action taken: Counsel. Proper steps for PRN med admin - if current dose not avail (available), must contact MD for temp (temporary) order for what is on hand in ER (emergency) box, contact pharmacy + take steps to get new med in . There was no documentation of a plan to monitor LPN #1 during medication passes to minimize the potential for further medication errors. 4.) For a medication error involving Resident #2: An Employee Memorandum dated [DATE] documented, Employee Name: (LPN #1). Date of occurrence: [DATE]. Write up. Failed to check scheduled insulin against eMAR resulting in resident receiving 18 u (units) of Humalog instead of [MEDICATION NAME]. Failure to perform rights of medication administration. Action Taken: Counsel. Disciplinary Warning. With any medication must observe / perform the rights of administration to prevent possible injury to residents . An attached Medication Error Report dated [DATE] documented, Patient: (Resident #2's name) . Medication given: 18 units Humalog. What was physician's orders [REDACTED]. Reason for making error: I picked up wrong insulin pen, the Humalog pen instead of the [MEDICATION NAME] pen . Could the error have endangered the life or welfare of the patient? The insulin was fast acting and could have dropped resident's BS (blood sugar) below 100 and caused [DIAGNOSES REDACTED] . What precautions can you take to prevent a similar error? I will double or triple check the label with eMAR to make sure the insulin pen is the correct drug. Yellow sticker added to all fast acting insulin . There was no documentation of a plan to monitor LPN #1 during medication passes to minimize the potential for further medication errors. 5.) For a medication error involving Resident #17: An Employee Memorandum dated [DATE] documented, Employee Name: (LPN #1). Date of occurrence: ,[DATE]-,[DATE], ,[DATE]-,[DATE], ,[DATE]-,[DATE], ,[DATE]-,[DATE], ,[DATE]-,[DATE], ,[DATE] (2016) . documenting on eMAR as giving [MEDICATION NAME] 10 mg (at) 8 p.m. during the month of (MONTH) + (MONTH) (YEAR). When the last pharmacy fill for med is documented as [DATE] for #30 pills. No medication card is located in the cart. Failure to perform proper match back (with) meds / MAR resulting in missing medication . Action Taken: Disciplinary Warning . There was no documentation of a plan to monitor LPN #1 during medication passes to minimize the potential for further medication errors. 6.) For a medication error involving Resident #16: An Employee Memorandum dated [DATE] documented, Employee Name: (LPN #1). Date of occurrence: [DATE]. Write up, counsel (with) education. Mistakenly administered [MEDICATION NAME] 50 mg instead of [MEDICATION NAME] 0.5 mg to a resident for anxiety as she 'grabbed the wrong card' . failure to provide + follow the 6 rights of medication administration by not having the right medication or dose . 1) Read order on MAR, 2) pull narc (narcotic) card for resident/med + compare to MAR, 3) Pop out dose, 4) Open green narc book + sign dose out on appropriate page + check card against page . An attached Medication Error Report dated [DATE] documented, Patient: (Resident #16's name) . Medication given: [MEDICATION NAME] ([MEDICATION NAME]) 50 mg . What was physician's orders [REDACTED]. How was the error discovered? During med count (with) 2nd (second) shift nurse . What precautions can you take to prevent a similar error? Double check name on card and nurse given education on successful med pass technique . There was no documentation of a plan to monitor LPN #1 during medication passes to minimize the potential for further medication errors. 2. Resident #17 had a [DIAGNOSES REDACTED]. An annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) [DATE] documented the resident scored 0 (,[DATE] indicates severely impaired) on the Brief Interview for Mental Status (BIMS) and did not exhibit any behaviors. a. A physician's orders [REDACTED]. b. The (MONTH) and (MONTH) (YEAR) MARs documented by nurses' initials that [MEDICATION NAME] 10 mg was administered by Licensed Practical Nurse (LPN) #1, #2, #3, #4, #5, and #6 daily from [DATE] thru [DATE]. The MAR also documented an End Date of [DATE]. c. Employee Memorandum forms dated [DATE] for LPN's #2, #3, #4 and #6 documented, .Documenting on eMAR as giving [MEDICATION NAME] 10 mg at 8 p.m. during the month of (MONTH) + (MONTH) (YEAR) when the last pharmacy fill for med is documented as [DATE] for #30 pills. No medication card is located in the cart . Disciplinary Warning. Nurse failure to match medication cards with the MAR to ensure appropriate meds given at the appropriate times . (Also refer to paragraph 1. e. 5.) above regarding the Employee Memorandum for LPN #1 for this medication error.) There was no documentation of a plan to monitor medication passes with these nurses. 3. Resident #16 had [DIAGNOSES REDACTED]. An Annual MDS with an ARD of [DATE] documented the resident was moderately impaired in cognitive skills for daily decision making per a Staff Assessment for Mental Status and had verbal behavioral symptoms directed at staff occurring 4 to 6 days but less than daily. a. A physician's orders [REDACTED]. b. A Medication Error Report for LPN #1 dated [DATE] documented, Resident: (Resident #16); Date of Error: [DATE]; Medication Given: [MEDICATION NAME] 50 mg; Dosage Given: 50 mg; Rte. (Route) of Admin. (Administration): PO (by mouth); What was physician's orders [REDACTED]. What precautions can you take to prevent a similar error? Double check name on card and number on card to drug book. Nurse given education on successful med pass technique. (Refer to paragraph 1. e. 6.) above for the Employee Memorandum for this error.) 4. On [DATE] at 3:33 p.m., the Administrator was asked about the employee memorandum dated [DATE] for LPN #1 related to Resident #17's [MEDICATION NAME] being signed off by nurses on the MAR when the medication was not available in the medication cart from (MONTH) through (MONTH) ([DATE]). The Administrator stated, That's why all the nurses were written up, because they documented they gave it, and it was not in the cart. The Administrator was asked, Did you put any monitoring in place to ensure it did not happen again? The Administrator stated, .my DON (Director of Nursing) at the time did random med pass audits on every shift with every nurse. The Administrator was asked for documentation related to the random medication pass audits at this time. At 4:32 p.m., the Administrator stated, I spoke with our old DON. She said she did 1 on 1 counseling with these nurses, but she didn't start med pass audits until the incident with (LPN #1) after the significant med error with (Resident #18) on (MONTH) 11th. One on one counseling forms were done for all the nurses except (LPN #5), and she's been gone for months. The Administrator was asked, Of the LPN's listed, who still works here? She stated, (LPN #6) does not work here, the rest do, (LPN #2, #3, and #4). The Administrator was asked, What halls do these nurses work on? She stated, They work on all of them. On [DATE] at 5:20 p.m., the Administrator provided documentation of a medication pass audit dated [DATE] conducted with Registered Nurse (RN) #1 and a medication pass audit dated [DATE] conducted with LPN #2. There was no other documentation of medication pass monitoring that was conducted prior to [DATE] when Resident #18 received the overdose of narcotic medications and subsequently died . 5. The facility removed the Immediate Jeopardy, corrected the failed practice and reduced the scope / severity to a G on [DATE] as evidenced by the following: a. A Termination of Employment form dated [DATE] documented LPN #1's employment was terminated for, .violation of med pass procedure resulting in med error and resident to (hospital). The form documented LPN #1's last day worked was [DATE]. b. An Inservice Education Report dated [DATE] documented twelve facility LPN's and one facility RN were retrained on the 6 Rights of Medication Administration, to include the right drug, dose, route, time, patient and documentation, as well as checking the drug card to the MAR when the card is removed from the medication cart, checking the drug card against the MAR again when preparing the medications for administration, matching the prepared medications to the MAR and double checking the patient's identity prior to administration. c. A Pharmacy Inservice sheet dated [DATE] documented retraining on medication pass was provided to ten LPN's and one RN on that date by the facility's Consultant Pharmacist. d. Medication Administration Observation sheets dated [DATE] through [DATE] documented licensed nurses were observed during medication passes, with zero medication errors identified. e. The Findings and Actions Taken section of the DMS-762 form submitted to the facility on [DATE] documented, . On [DATE] facility DON came in at approximately 7:00 a.m. and in-serviced all of the charge LPN's on duty on facility's policy and procedure of medication pass. At approximately 8:00 a.m., facility nurse consultant immediately began to do med pass audits with all of the nurses on duty . Facility DON, nurse consultant and weekend supervisor RN will continue to preform (perform) ongoing med pass audits as well as re-in-servicing all of the nurses on facility's policy and procedure on med pass . f. On [DATE] and [DATE] during the survey, the RN surveyor observed medication passes with a total of 5 licensed nurses who were working the 3:00 p.m. to 11:00 p.m. shift, the 7:00 a.m. to 3:00 p.m. shift and the 7:00 a.m. to 7:00 p.m. shift. Upon reviewing all physician orders [REDACTED].

Based on record review and interview, the facility failed to ensure their policies and procedures for abuse / neglect prohibition were implemented, as evidenced by failure to ensure a thorough investigation was conducted to rule out possible abuse or neglect after a resident made an allegation of maltreatment against a facility employee, failure to ensure residents were protected from further potential abuse or neglect while an investigation was ongoing and failure to ensure the allegation was reported to the Office of Long Term Care (OLTC) and other agencies in accordance with State law for 1 (Resident #10) of 8 (Residents #1, #3, #5, #6, #8, #10, #12, and #16) case mix residents who required extensive assistance of two persons for transfers. This failed practice resulted in Immediate Jeopardy, which caused or could have caused serious harm, injury or death to Resident #10, who reported an allegation of staff-to-resident maltreatment to the Director of Nursing, and had the potential to cause more than minimal harm to 30 residents who required extensive assistance of two persons for transfer, as documented on a list provided by the Administrator on 3/16/17 at 6:35 p.m. The facility was notified of the Immediate Jeopardy condition on 3/14/17 at 2:45 p.m. The findings are: 1. The facility's Abuse Investigation Protocol, received from the Administer on 3/15/17 at 1:33 p.m., documented, Policy Statement: All reports of resident abuse, neglect . are promptly and thoroughly investigated by facility management. Policy Interpretation and Implementation: 1. Should an incident of resident abuse, neglect . be reported, the administrator, or his/her designee, will appoint an individual to investigate the incident. 2. The individual conducting the investigation will, as a minimum: . f. Interview any witnesses to the incident; . k. Interview the resident's family members and visitors who have had contact with the resident during the 24 hour period prior to the time of the incident; l. Interview the accused individual(s) or accused employee(s). (Note: If the accused individual is an employee, review the personnel file to determine if a background check was completed and if appropriate educational/orientation programs were attended.); m. Interview other residents to whom the accused employee provides care or services to determine if they have complaints about the employee; n. Interview other employees to determine if they have ever witnessed other incidents of mistreatment involving the accused employee; and o. Review all events preceding the alleged incident . 5. Witness reports will be in writing. Witnesses will be required to sign and date such reports . 7. Employees of this facility who have been accused of resident abuse will be suspended from duty until the administrator has reviewed the results of the investigation; . 11. Should there be an allegation of abuse or suspicion of a crime against a resident; the administrator or designee will make an initial report to the local police department and the state licensing agency within 24 hours as required by law. A final report with findings of the investigation will be made to the state agency within five (5) business days . Reporting Abuse: Policy Statement: 3. When an alleged or suspected case of abuse, neglect . is reported, the facility administrator, or his/her designee, will notify the following persons or agencies of such incident: a. The State licensing/certification agency responsible for surveying/licensing the facility; b. The resident's representative (sponsor) of record; c. Law enforcement officials; d. The resident's attending physician . 5. Such reports should be made without fear of retaliation from the facility or staff . Protection of Residents During Abuse Investigation. Policy Statement; Our facility will protect residents from harm during investigation of abuse allegations. Policy Interpretation and Implementation: 1. During abuse investigations, residents will be protected from harm by the following measures: a. Employees accused of participating in the alleged abuse will be suspended until the findings of the investigation have been reviewed by the administrator . d. Allegations involving residents will require assessment and appropriate interventions to protect the victim and other residents. Interventions may include temporary one-on-one supervision, transfer to another level of care or discharge to a family member/responsible party . 2. Resident #10 had [DIAGNOSES REDACTED]. An Admission Minimum Data Set with an Assessment Reference Date of 2/24/17 documented the resident scored 15 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status, required extensive assistance of two plus persons for transfers, was non-ambulatory, was not steady and only able to stabilize with staff assistance with moving from seated to standing position and surface to surface transfers, had functional limitation in range of motion of the upper and lower extremity on one side, had no physical, verbal or other behavioral symptoms and did not reject care. a. The Care Plan dated as initiated on 11/8/16 documented, The resident has an ADL (activities of daily living) self-care performance deficit r/t (related to) [MEDICAL CONDITION] with right sided weakness . Interventions / Tasks . Transfer: The resident requires extensive assist (assistance) by 2 staff to move between surfaces q (every) transfer and as necessary . High risk for falls r/t gait / balance problems, paralysis, 12/25/16 fall during spouse assist self-transfer, 2/11/17 fall resident lowered to floor during transfer, no injuries . Low bed to be used at all times . Spouse and resident educated to allow facility staff to perform all transfers . b. An Incident Report dated 3/4/17 documented, Shower aide noticed bruising to left outer calf while giving her a shower. No further apparent injuries noted. Resident denies pain or discomfort at this time . Resident stated that while she was being transferred, a couple days ago to bed, her leg bumped against side rail of the bed. She states that she would have reported it immediately if she thought it was on purpose. Educated / demonstrated proper technique to a CNA while transferring resident. Padded protruding parts of side rail in upright position . Resident noted to have a bruising to left outer calf. No further apparent injuries noted at this time . Her left outer calf bumped against the tubular ends of side rail that protrude when rail is in upright position . c. On 3/14/17 at 9:00 a.m., a group interview was conducted with cognitively alert residents. The residents were asked if any of them were aware of any instances in which a resident was abused or neglected, and Resident #10 stated, A CNA (Certified Nurse Assistant) was rough with me about two weeks ago. She was moved to another hall. She also talked down to me. I don't want to say her name right now. d. On 3/14/17 at 10:30 a.m., the resident was in her room. She was asked about the incident she had referred to during the group interview. The resident stated she was being transferred from the wheelchair to the bed with the assistance of two CNAs. During the transfer, her, .left lower leg was pushed against a black knob on the side rail of the bed. I told the CNAs, 'I can't turn good.' The resident was asked who the CNA was and stated, (First name of CNA #1) something, I can't remember last name . The resident stated she told the CNAs to stop because it was hurting, but the CNAs continued with the transfer. The resident stated she saw the bruising the next day and reported it to the DON and that the DON said, I'll take care of it. The resident stated the next day, the DON told her the CNA was no longer allowed in the resident's room. The resident also stated that on a previous occasion (could not recall date), the same CNA had answered her call light and asked, What do you want? The resident stated she told the CNA she needed to go to the bathroom, and that the CNA responded, Get up and go yourself. You can do it. The resident stated she replied, If I could do it myself, I wouldn't have asked you. She stated the CNA then took her to the bathroom without incident. The resident's husband, who was present at the time of this interview, stated his wife (resident), .may have misconstrued the CNA's statement as insulting and it could have really been meant as encouraging, such as, 'Come on, let's go'. The resident stated, (CNA #1) is a good CNA, but I felt she talked down to me. When asked why she did not report the incidents with CNA #1 to someone immediately, the resident stated, I do not need any repercussions about this. e. On 3/16/17 at 9:45 a.m., the resident was asked, After that incident, would it have made you uneasy to have (CNA #1) assist you? The resident stated, Yes, because I would never want her to transfer me again. I just don't trust her. I wouldn't want her to take me to the bathroom again either, as I don't balance too well. The resident was asked if CNA #1 ever came back in her room after the transfer incident and stated, No, never. They told me she would not come back. She is usually a good CNA, but she has an attitude problem or something. If she's going to hurt people, she doesn't need to be around them. The resident was asked if there was a reason she didn't report that CNA #1 was rough with her right away and she stated, I just felt like I didn't want to get anyone into trouble, that's the only reason, and sometimes it hard to get someone right away. The resident was asked, In a previous conversation, you were worried about repercussions; what repercussions were you worried about? She stated, Some of the CNAs won't even look at me; some are now scared to take care of me, as they think I'm a snitch. I didn't do anything wrong. I didn't do anything to deserve this. The Administrator came and talked to me after you did the other day. She was upset about all this and said she had been blind-sided by this and said she did not know about this happening. f. On 3/14/17 at 11:04 a.m., the DON was asked, Do you have a CNA, (CNA #1) who works here? He stated, Yes, I know what you are talking about. The DON was asked, So you know about the incident? The DON stated, When she transferred her out or in bed. She has a low bed with 1/2 side rails, which the rails flip up and there are two bars that stick out on the bottom, they have caps, but her leg was pushed up against that. We have since padded them, and all of them in the building. The DON was asked, Did you speak with (Resident #10) about what happened? He stated, I did, (Resident #10) and her caretaker. The DON was asked, What did she tell you? The DON stated, She thought that (CNA #1), when she transferred her, had been rough with her, and (CNA #1) talks really loud. I don't know if she thought (CNA #1) raised her voice to her or . The DON was asked, Did you ask how she was rough? He stated, She just said that when she transferred her, she pushed that leg up against that rail when they were transferring her. The DON was asked, Did she say anything else? The DON stated, No, that's it. She told me it hurt, which is why she brought the incident up to me. The DON was asked, Was an investigation done related to the complaint that the CNA was rough? He stated, We talked to (Resident #10) about it. Brought (CNA #1) into the office to get her side of it. The DON was asked, Did you talk to any other residents on the hall to see if they had any problems with (CNA #1)? The DON stated, No, I did not, but I haven't had any other complaints about her. The DON was asked, How is (Resident #10) transferred? The DON stated, She is weight bearing and has paralysis on one side. The DON was asked, Does she transfer with one or two people? He stated, She's extensive (assistance) with two (staff). The DON was asked, Do you have any documentation related to speaking with (Resident #10) or (CNA #1)? He stated, No, I just spoke to both of them. The DON was asked, What did (CNA #1) say? He stated, (CNA #1) said that she (resident) did say it hurt being pressed against the bar and that she (CNA) did not continue pushing after she said it hurt. The DON was asked, Is (CNA #1) still working? The DON stated, Yes, she is the restorative nursing aide. The DON was asked, After (Resident #10) said the CNA had been rough with her, you didn't do any other investigation besides talk with (CNA #1) and (Resident #10)? He stated, That is correct. The DON was asked, Did (Resident #10) tell you about the incident that day? The DON stated, I think it was, I believe. The DON was asked, What did you do with the CNA? He stated, I took her off that hall and told her not to go in (Resident #10's) room. That if (Resident #10) needed something, tell her she would get her some help. The DON was asked, The CNA was moved to another hall in the building? He stated, Yes. The DON was asked, Did you do any monitoring of (CNA #1) to monitor how she transferred people, if she was being rough? He stated, No. Just the normal day-to-day supervision. The DON was asked, Looking back, do you think an investigation should have been conducted after the resident said the aide was rough with her? He stated, Yes, we should have done some paperwork on it. The DON was asked, Was there any other complaints by (Resident #10)? The DON stated, She said that she (CNA #1) was loud and she raised her voice to her. The DON was asked, Did you ask her what she said to her? He stated, No, I didn't. The DON was asked, Did you talk to the other CNA that was in the room with them? He stated, No. The DON was asked, Do you think you should have asked what the CNA said that made the resident feel she (CNA #1) was talking down to her or rough to her? He stated, In retrospect, yes. The DON was asked, Is she (CNA #1) working today? The DON stated, I believe so. g. On 3/14/17 at 4:50 p.m., the Daily Staffing Logs were reviewed. The logs documented CNA #1 worked in the facility on 3/6/17, 3/7/17, 3/8/17, 3/9/17, 3/10/17, 3/11/17, and 3/12/17, a total of 7 occasions after the alleged incident on 3/4/17, with no additional training, monitoring, or direct supervision. 2. The Immediate Jeopardy was removed and the scope/severity reduced to a E on 3/14/17 at 5:00 p.m. when the facility implemented the following Plan of Removal: a. On notification (3/14/17) of deficient practice DON, Weekend Supervisor, and (CNA #1) were suspended immediately pending the outcome of the investigation. b. Body Audits will be completed on residents that require extensive assist with transfers and that could not be interviewed by 3/15/17. c. Witness statements were obtained on 3/14/17 by the SSD (Social Services Director) from all alert and oriented residents with no negative findings noted. d. Witness statements were obtained by ADON (Assistant Director of Nursing) from facility staff regarding any abuse and neglect in the facility with no negative findings. e. ADON on 3/14/17 initiated an Abuse and Neglect In-service with facility staff that are here currently and a Department head/designee will be assigned to In-service on 3:00 p.m. - 11:00 p.m. shift and 11:00 p.m. -7:00 a.m. shift until all staff have been in-serviced. f. The Administrator completed the 7734 (OLTC Incident and Accident Next Day Reporting form) on 3/14/17 and is in the process of completing 762 (Facility Investigation Report for Resident Abuse, Neglect, Misappropriation of Property and Exploitation of Residents in Long Term Care Facilities). g. The Administrator will monitor abuse and neglect daily during daily Stand-up meetings, risk management, and QAA (Quality Assurance and Assessment) monthly until compliance is achieved.

Based on record review and interview, the facility failed to ensure a thorough investigation was conducted to rule out possible abuse or neglect after a resident made an allegation of maltreatment against a facility employee, failed to ensure residents were protected from further potential abuse or neglect while an investigation was ongoing and failed to ensure the allegation was reported to the Office of Long Term Care (OLTC) and other agencies in accordance with State law for 1 (Resident #10) of 8 (Residents #1, #3, #5, #6, #8, #10, #12, and #16) case mix residents who required extensive assistance of two persons for transfers. This failed practice resulted in Immediate Jeopardy, which caused or could have caused serious harm, injury or death to Resident #10, who reported an allegation of staff-to-resident maltreatment to the Director of Nursing, and had the potential to cause more than minimal harm to 30 residents who required extensive assistance of two persons for transfer, as documented on a list provided by the Administrator on 3/16/17 at 6:35 p.m. The facility was notified of the Immediate Jeopardy condition on 3/14/17 at 2:45 p.m. The findings are: 1. Resident #10 had [DIAGNOSES REDACTED]. An Admission Minimum Data Set with an Assessment Reference Date of 2/24/17 documented the resident scored 15 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status, required extensive assistance of two plus persons for transfers, was non-ambulatory, was not steady and only able to stabilize with staff assistance with moving from seated to standing position and surface to surface transfers, had functional limitation in range of motion of the upper and lower extremity on one side, had no physical, verbal or other behavioral symptoms and did not reject care. a. The Care Plan dated as initiated on 11/8/16 documented, The resident has an ADL (activities of daily living) self-care performance deficit r/t (related to) [MEDICAL CONDITION] with right sided weakness . Interventions / Tasks . Transfer: The resident requires extensive assist (assistance) by 2 staff to move between surfaces q (every) transfer and as necessary . High risk for falls r/t gait / balance problems, paralysis, 12/25/16 fall during spouse assist self transfer, 2/11/17 fall resident lowered to floor during transfer, no injuries . Low bed to be used at all times . Spouse and resident educated to allow facility staff to perform all transfers . b. An Incident Report dated 3/4/17 documented, Shower aide noticed bruising to left outer calf while giving her a shower. No further apparent injuries noted. Resident denies pain or discomfort at this time . Resident stated that while she was being transferred, a couple days ago to bed, her leg bumped against side rail of the bed. She states that she would have reported it immediately if she thought it was on purpose. Educated / demonstrated proper technique to a CNA while transferring resident. Padded protruding parts of side rail in upright position . Resident noted to have a bruising to left outer calf. No further apparent injuries noted at this time . Her left outer calf bumped against the tubular ends of side rail that protrude when rail is in upright position . c. On 3/14/17 at 9:00 a.m., a group interview was conducted with cognitively alert residents. The residents were asked if any of them were aware of any instances in which a resident was abused or neglected, and Resident #10 stated, A CNA (Certified Nurse Assistant) was rough with me about two weeks ago. She was moved to another hall. She also talked down to me. I don't want to say her name right now. d. On 3/14/17 at 10:30 a.m., the resident was in her room. She was asked about the incident she had referred to during the group interview. The resident stated she was being transferred from the wheelchair to the bed with the assistance of two CNAs. During the transfer, her, .left lower leg was pushed against a black knob on the side rail of the bed. I told the CNAs, 'I can't turn good.' The resident was asked who the CNA was and stated, (First name of CNA #1) something, I can't remember last name . The resident stated she told the CNAs to stop because it was hurting, but the CNAs continued with the transfer. The resident stated she saw the bruising the next day and reported it to the DON and that the DON said, I'll take care of it. The resident stated the next day, the DON told her the CNA was no longer allowed in the resident's room. The resident also stated that on a previous occasion (could not recall date), the same CNA had answered her call light and asked, What do you want? The resident stated she told the CNA she needed to go to the bathroom, and that the CNA responded, Get up and go yourself. You can do it. The resident stated she replied, If I could do it myself, I wouldn't have asked you. She stated the CNA then took her to the bathroom without incident. The resident's husband, who was present at the time of this interview, stated his wife (resident), .may have misconstrued the CNA's statement as insulting and it could have really been meant as encouraging, such as, 'Come on, let's go'. The resident stated, (CNA #1) is a good CNA, but I felt she talked down to me. When asked why she did not report the incidents with CNA #1 to someone immediately, the resident stated, I do not need any repercussions about this. e. On 3/16/17 at 9:45 a.m., the resident was asked, After that incident, would it have made you uneasy to have (CNA #1) assist you? The resident stated, Yes, because I would never want her to transfer me again. I just don't trust her. I wouldn't want her to take me to the bathroom again either, as I don't balance too well. The resident was asked if CNA #1 ever came back in her room after the transfer incident and stated, No, never. They told me she would not come back. She is usually a good CNA, but she has an attitude problem or something. If she's going to hurt people, she doesn't need to be around them. The resident was asked if there was a reason she didn't report that CNA #1 was rough with her right away and she stated, I just felt like I didn't want to get anyone into trouble, that's the only reason, and sometimes it hard to get someone right away. The resident was asked, In a previous conversation, you were worried about repercussions; what repercussions were you worried about? She stated, Some of the CNAs won't even look at me; some are now scared to take care of me, as they think I'm a snitch. I didn't do anything wrong. I didn't do anything to deserve this. The Administrator came and talked to me after you did the other day. She was upset about all this and said she had been blind-sided by this and said she did not know about this happening. f. On 3/14/17 at 11:04 a.m., the DON was asked, Do you have a CNA, (CNA #1) who works here? He stated, Yes, I know what you are talking about. The DON was asked, So you know about the incident? The DON stated, When she transferred her out or in bed. She has a low bed with 1/2 side rails, which the rails flip up and there are two bars that stick out on the bottom, they have caps, but her leg was pushed up against that. We have since padded them, and all of them in the building. The DON was asked, Did you speak with (Resident #10) about what happened? He stated, I did, (Resident #10) and her caretaker. The DON was asked, What did she tell you? The DON stated, She thought that (CNA #1), when she transferred her, had been rough with her, and (CNA #1) talks really loud. I don't know if she thought (CNA #1) raised her voice to her or . The DON was asked, Did you ask how she was rough? He stated, She just said that when she transferred her, she pushed that leg up against that rail when they were transferring her. The DON was asked, Did she say anything else? The DON stated, No, that's it. She told me it hurt, which is why she brought the incident up to me. The DON was asked, Was an investigation done related to the complaint that the CNA was rough? He stated, We talked to (Resident #10) about it. Brought (CNA #1) into the office to get her side of it. The DON was asked, Did you talk to any other residents on the hall to see if they had any problems with (CNA #1)? The DON stated, No, I did not, but I haven't had any other complaints about her. The DON was asked, How is (Resident #10) transferred? The DON stated, She is weight bearing and has paralysis on one side. The DON was asked, Does she transfer with one or two people? He stated, She's extensive (assistance) with two (staff). The DON was asked, Do you have any documentation related to speaking with (Resident #10) or (CNA #1)? He stated, No, I just spoke to both of them. The DON was asked, What did (CNA #1) say? He stated, (CNA #1) said that she (resident) did say it hurt being pressed against the bar and that she (CNA) did not continue pushing after she said it hurt. The DON was asked, Is (CNA #1) still working? The DON stated, Yes, she is the restorative nursing aide. The DON was asked, After (Resident #10) said the CNA had been rough with her, you didn't do any other investigation besides talk with (CNA #1) and (Resident #10)? He stated, That is correct. The DON was asked, Did (Resident #10) tell you about the incident that day? The DON stated, I think it was, I believe. The DON was asked, What did you do with the CNA? He stated, I took her off that hall and told her not to go in (Resident #10's) room. That if (Resident #10) needed something, tell her she would get her some help. The DON was asked, The CNA was moved to another hall in the building? He stated, Yes. The DON was asked, Did you do any monitoring of (CNA #1) to monitor how she transferred people, if she was being rough? He stated, No. Just the normal day-to-day supervision. The DON was asked, Looking back, do you think an investigation should have been conducted after the resident said the aide was rough with her? He stated, Yes, we should have done some paperwork on it. The DON was asked, Was there any other complaints by (Resident #10)? The DON stated, She said that she (CNA #1) was loud and she raised her voice to her. The DON was asked, Did you ask her what she said to her? He stated, No, I didn't. The DON was asked, Did you talk to the other CNA that was in the room with them? He stated, No. The DON was asked, Do you think you should have asked what the CNA said that made the resident feel she (CNA #1) was talking down to her or rough to her? He stated, In retrospect, yes. The DON was asked, Is she (CNA #1) working today? The DON stated, I believe so. g. On 3/14/17 at 4:50 p.m., the Daily Staffing Logs were reviewed. The logs documented CNA #1 worked in the facility on 3/6/17, 3/7/17, 3/8/17, 3/9/17, 3/10/17, 3/11/17, and 3/12/17, a total of 7 occasions after the alleged incident on 3/4/17, with no additional training, monitoring, or direct supervision. 2. The Immediate Jeopardy was removed and the scope/severity reduced to an E on 3/14/17 at 5:00 p.m. when the facility implemented the following Plan of Removal: a. On notification (3/14/17) of deficient practice DON, Weekend Supervisor, and (CNA #1) were suspended immediately pending the outcome of the investigation. b. Body Audits will be completed on residents that require extensive assist with transfers and that could not be interviewed by 3/15/17. c. Witness statements were obtained on 3/14/17 by the SSD (Social Services Director) from all alert and oriented residents with no negative findings noted. d. Witness statements were obtained by ADON (Assistant Director of Nursing) from facility staff regarding any abuse and neglect in the facility with no negative findings. e. ADON on 3/14/17 initiated an Abuse and Neglect In-service with facility staff that are here currently and a Department head/designee will be assigned to In-service on 3:00 p.m. - 11:00 p.m. shift and 11:00 p.m. -7:00 a.m. shift until all staff have been in-serviced. f. The Administrator completed the 7734 (OLTC Incident and Accident Next Day Reporting form) on 3/14/17 and is in the process of completing 762 (Facility Investigation Report for Resident Abuse, Neglect, Misappropriation of Property and Exploitation of Residents in Long Term Care Facilities). g. The Administrator will monitor abuse and neglect daily during daily Stand-up meetings, risk management, and QAA (Quality Assurance and Assessment) monthly until compliance is achieved.

Based on record review and interview, the facility failed to ensure the facility's nursing administration recognized resident allegations that were suspicious of abuse and immediately implemented the facility's policies and procedures to address the allegations, as evidenced by failure to ensure a thorough investigation was conducted to rule out possible abuse or neglect after a resident made an allegation of maltreatment against a facility employee, failure to ensure residents were protected from further potential abuse or neglect while an investigation was ongoing and failure to ensure the allegation was reported to the Office of Long Term Care (OLTC) and other agencies in accordance with State law for 1 (Resident #10) of 8 (#1, #3, #5, #6, #8, #10, #12, and #16) case mix residents who required extensive assistance of two persons for transfers. This failed practice resulted in Immediate Jeopardy, which caused or could have caused serious harm, injury or death to Resident #10, who reported an allegation of staff-to-resident maltreatment to the Director of Nursing, and had the potential to cause more than minimal harm to 30 residents who required extensive assistance of two persons for transfer, as documented on a list provided by the Administrator on 3/16/17 at 6:35 p.m. The facility was notified of the Immediate Jeopardy condition on 3/14/17 at 2:45 p.m. The findings are: 1. The Job Description for the Director of Nursing Services, received from the Administrator on 3/15/17 at 11:32 a.m., documented, Purpose of Your Job Position: The primary purpose of your job position is to plan, organize, develop, and direct the overall operation of our Nursing Department in accordance with current federal, state and local standards, guidelines, and regulations that govern our facility, and as may be required by the Administrator and Medical Director, to ensure that the highest degree of quality care is maintained at all times . Duties and Responsibilities: . Patient Rights Functions: . Monitor nursing care to ensure that all patients are treated fairly, and with kindness, dignity, and respect . Review complaints and grievances made by the patient and make a written/oral report to the Director indicating what action(s) were taken to resolve the complaint or grievance. Follow facility's established procedures. Report and investigate all allegations of patient abuse and/or misappropriation of property. 2. Resident #10 had [DIAGNOSES REDACTED]. An Admission Minimum Data Set with an Assessment Reference Date of 2/24/17 documented the resident scored 15 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status, required extensive assistance of two plus persons for transfers, was non-ambulatory, was not steady and only able to stabilize with staff assistance with moving from seated to standing position and surface to surface transfers, had functional limitation in range of motion of the upper and lower extremity on one side, had no physical, verbal or other behavioral symptoms and did not reject care. a. The Care Plan dated as initiated on 11/8/16 documented, The resident has an ADL (activities of daily living) self-care performance deficit r/t (related to) [MEDICAL CONDITION] with right sided weakness . Interventions / Tasks . Transfer: The resident requires extensive assist (assistance) by 2 staff to move between surfaces q (every) transfer and as necessary . High risk for falls r/t gait / balance problems, paralysis, 12/25/16 fall during spouse assist self transfer, 2/11/17 fall resident lowered to floor during transfer, no injuries . Low bed to be used at all times . Spouse and resident educated to allow facility staff to perform all transfers . b. An Incident Report dated 3/4/17 documented, Shower aide noticed bruising to left outer calf while giving her a shower. No further apparent injuries noted. Resident denies pain or discomfort at this time . Resident stated that while she was being transferred, a couple days ago to bed, her leg bumped against side rail of the bed. She states that she would have reported it immediately if she thought it was on purpose. Educated / demonstrated proper technique to a CNA while transferring resident. Padded protruding parts of side rail in upright position . Resident noted to have a bruising to left outer calf. No further apparent injuries noted at this time . Her left outer calf bumped against the tubular ends of side rail that protrude when rail is in upright position . c. On 3/14/17 at 9:00 a.m., a group interview was conducted with cognitively alert residents. The residents were asked if any of them were aware of any instances in which a resident was abused or neglected, and Resident #10 stated, A CNA (Certified Nurse Assistant) was rough with me about two weeks ago. She was moved to another hall. She also talked down to me. I don't want to say her name right now. d. On 3/14/17 at 10:30 a.m., the resident was in her room. She was asked about the incident she had referred to during the group interview. The resident stated she was being transferred from the wheelchair to the bed with the assistance of two CNAs. During the transfer, her, .left lower leg was pushed against a black knob on the side rail of the bed. I told the CNAs, 'I can't turn good.' The resident's husband, who was present in the room during the interview, stated, I was not here, but she doesn't balance good and I think they were holding her up and not worried about her leg. The resident was asked who the CNA was and stated, (First name of CNA #1) something, I can't remember last name . The resident stated she told the CNAs to stop because it was hurting, but the CNAs continued with the transfer. The resident stated she saw the bruising the next day and reported it to the DON and that the DON said, I'll take care of it. The resident stated the next day, the DON told her the CNA was no longer allowed in the resident's room. The resident also stated that on a previous occasion (could not recall date), the same CNA had answered her call light and asked, What do you want? The resident stated she told the CNA she needed to go to the bathroom, and that the CNA responded, Get up and go yourself. You can do it. The resident stated she replied, If I could do it myself, I wouldn't have asked you. She stated the CNA then took her to the bathroom without incident. The resident's husband, who was present at the time of this interview, stated his wife (resident), .may have misconstrued the CNA's statement as insulting and it could have really been meant as encouraging, such as, 'Come on, let's go'. The resident stated, (CNA #1) is a good CNA, but I felt she talked down to me. When asked why she did not report the incidents with CNA #1 to someone immediately, the resident stated, I do not need any repercussions about this. e. On 3/16/17 at 9:45 a.m., the resident was asked, After that incident, would it have made you uneasy to have (CNA #1) assist you? The resident stated, Yes, because I would never want her to transfer me again. I just don't trust her. I wouldn't want her to take me to the bathroom again either, as I don't balance too well. The resident was asked if CNA #1 ever came back in her room after the transfer incident and stated, No, never. They told me she would not come back. She is usually a good CNA, but she has an attitude problem or something. If she's going to hurt people, she doesn't need to be around them. The resident was asked if there was a reason she didn't report that CNA #1 was rough with her right away and she stated, I just felt like I didn't want to get anyone into trouble, that's the only reason, and sometimes it hard to get someone right away. The resident was asked, In a previous conversation, you were worried about repercussions; what repercussions were you worried about? She stated, Some of the CNAs won't even look at me; some are now scared to take care of me, as they think I'm a snitch. I didn't do anything wrong. I didn't do anything to deserve this. The Administrator came and talked to me after you did the other day. She was upset about all this and said she had been blind-sided by this and said she did not know about this happening. f. On 3/14/17 at 11:04 a.m., the DON was asked, Do you have a CNA, (CNA #1) who works here? He stated, Yes, I know what you are talking about. The DON was asked, So you know about the incident? The DON stated, When she transferred her out or in bed. She has a low bed with 1/2 side rails, which the rails flip up and there are two bars that stick out on the bottom, they have caps, but her leg was pushed up against that. We have since padded them, and all of them in the building. The DON was asked, Did you speak with (Resident #10) about what happened? He stated, I did, (Resident #10) and her caretaker. The DON was asked, What did she tell you? The DON stated, She thought that (CNA #1), when she transferred her, had been rough with her, and (CNA #1) talks really loud. I don't know if she thought (CNA #1) raised her voice to her or . The DON was asked, Did you ask how she was rough? He stated, She just said that when she transferred her, she pushed that leg up against that rail when they were transferring her. The DON was asked, Did she say anything else? The DON stated, No, that's it. She told me it hurt, which is why she brought the incident up to me. The DON was asked, Was an investigation done related to the complaint that the CNA was rough? He stated, We talked to (Resident #10) about it. Brought (CNA #1) into the office to get her side of it. The DON was asked, Did you talk to any other residents on the hall to see if they had any problems with (CNA #1)? The DON stated, No, I did not, but I haven't had any other complaints about her. The DON was asked, How is (Resident #10) transferred? The DON stated, She is weight bearing and has paralysis on one side. The DON was asked, Does she transfer with one or two people? He stated, She's extensive (assistance) with two (staff). The DON was asked, Do you have any documentation related to speaking with (Resident #10) or (CNA #1)? He stated, No, I just spoke to both of them. The DON was asked, What did (CNA #1) say? He stated, (CNA #1) said that she (resident) did say it hurt being pressed against the bar and that she (CNA) did not continue pushing after she said it hurt. The DON was asked, Is (CNA #1) still working? The DON stated, Yes, she is the restorative nursing aide. The DON was asked, After (Resident #10) said the CNA had been rough with her, you didn't do any other investigation besides talk with (CNA #1) and (Resident #10)? He stated, That is correct. The DON was asked, Did (Resident #10) tell you about the incident that day? The DON stated, I think it was, I believe. The DON was asked, What did you do with the CNA? He stated, I took her off that hall and told her not to go in (Resident #10's) room. That if (Resident #10) needed something, tell her she would get her some help. The DON was asked, The CNA was moved to another hall in the building? He stated, Yes. The DON was asked, Did you do any monitoring of (CNA #1) to monitor how she transferred people, if she was being rough? He stated, No. Just the normal day-to-day supervision. The DON was asked, Looking back, do you think an investigation should have been conducted after the resident said the aide was rough with her? He stated, Yes, we should have done some paperwork on it. The DON was asked, Was there any other complaints by (Resident #10)? The DON stated, She said that she (CNA #1) was loud and she raised her voice to her. The DON was asked, Did you ask her what she said to her? He stated, No, I didn't. The DON was asked, Did you talk to the other CNA that was in the room with them? He stated, No. The DON was asked, Do you think you should have asked what the CNA said that made the resident feel she (CNA #1) was talking down to her or rough to her? He stated, In retrospect, yes. The DON was asked, Is she (CNA #1) working today? The DON stated, I believe so. g. On 3/14/17 at 4:50 p.m., the Daily Staffing Logs were reviewed. The logs documented CNA #1 worked in the facility on 3/6/17, 3/7/17, 3/8/17, 3/9/17, 3/10/17, 3/11/17, and 3/12/17, a total of 7 occasions after the alleged incident on 3/4/17, with no additional training, monitoring, or direct supervision. 2. The Immediate Jeopardy was removed and the scope/severity reduced to an E on 3/14/17 at 5:00 p.m. when the facility implemented the following Plan of Removal: a. On notification (3/14/17) of deficient practice DON, Weekend Supervisor, and (CNA #1) were suspended immediately pending the outcome of the investigation. b. Body Audits will be completed on residents that require extensive assist with transfers and that could not be interviewed by 3/15/17. c. Witness statements were obtained on 3/14/17 by the SSD (Social Services Director) from all alert and oriented residents with no negative findings noted. d. Witness statements were obtained by ADON (Assistant Director of Nursing) from facility staff regarding any abuse and neglect in the facility with no negative findings. e. ADON on 3/14/17 initiated an Abuse and Neglect In-service with facility staff that are here currently and a Department head/designee will be assigned to In-service on 3:00 p.m. - 11:00 p.m. shift and 11:00 p.m. -7:00 a.m. shift until all staff have been in-serviced. f. The Administrator completed the 7734 (OLTC Incident and Accident Next Day Reporting form) on 3/14/17 and is in the process of completing 762 (Facility Investigation Report for Resident Abuse, Neglect, Misappropriation of Property and Exploitation of Residents in Long Term Care Facilities). g. The Administrator will monitor abuse and neglect daily during daily Stand-up meetings, risk management, and QAA (Quality Assurance and Assessment) monthly until compliance is achieved.