Every finding on record at Lake Forest Senior Living at Hot Springs Village

Number of residents sampled: Number of residents cited: Based on record review, interview and facility policy review, it was determined the facility failed to ensure written notification was provided to the resident and/or the resident's representative of transfer or discharge to the hospital for two (Resident #45 and Resident #7) of two residents reviewed for transfer or discharge to the hospital. The findings include: Resident #45 Review of Resident #45's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/08/2025, indicated Resident #45 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. Resident #45's MDS also indicated the resident had diagnoses which included heart disease and acute respiratory failure with decreased oxygen to tissues and organs. During an interview on 09/05/2025 at 10:00 AM, this surveyor requested the Administrator (AD) provide the documentation that was provided to Resident #45 and/or the resident representative at the time of transfer. The AD provided a document titled View Progress Note that indicated on 07/16/2025 at 5:15 PM Nursing Progress Note indicates that Resident follow up chest x-ray sent to Dr. [named], he gave order to send resident to ER for worsening pulmonary edema. The resident's wife was present in the room and was notified. Resident requested to go to [NAMED] hospital. EMS arrived at 5:20 PM and resident left via stretcher. The document was a copy of the electronic records progress note and did not contain a complete notice of transfer and bed hold. Resident #7 Review of Resident #7's Quarterly MDS with an ARD of 06/13/2025, indicated Resident #7 had a Brief Interview for Mental Status (BIMS) score of 10, which indicated the resident had moderate cognitive impairment. Resident #7's MDS also indicated the resident had diagnoses which included end stage kidney disease, respiratory failure, and condition of brain dysfunction. Review of a Discharge summary dated [DATE], indicated Resident #7 was admitted to the hospital on [DATE] with diagnoses which included acute respiratory failure with decreased oxygen to tissues and organs secondary to health care associated lung infection and severe bloodstream infection. Review of a Discharge summary dated [DATE] indicated Resident #7 was admitted to the hospital on [DATE] for acute brain dysfunction. On 09/04/2025 2:00PM, this surveyor reviewed Resident #7's Medical Record and did not see a notice of bed hold or notice of transfer to the hospital for 05/24/2025 or 06/26/2025. On 09/04/2025 2:35 PM, the AD was asked for documentation of the notice of bed hold and notice of transfer that was given to the resident and/or the resident representative when the resident transferred to the hospital on [DATE] and 06/26/2025. During an interview on 09/04/2025 3:03 PM, the AD provided three documents titled Other Progress Note with effective dates of 05/19/2025, 06/26/2025 and 06/27/2025 and indicated these were the only documents the facility had for notification of bed hold and transfer for these two hospitalizations on Resident #7. Review of a document titled Other Progress Note dated 5/19/2025 7:14 AM, indicated the Power of Attorney (POA) for Resident #7 was contacted regarding whether they wanted to hold the bed for the resident since the resident was in the hospital and the POA indicated they would have to speak with other family members before making the decision and would get back with facility staff later in the day. Review of a document titled Other Progress Note dated 06/26/2025 3:33 PM, indicated Social Services attempted to contact Resident #7's family member to ask about bed hold but was unable to reach them and unable to leave a message. Review of a document titled Other Progress Note dated 6/27/25 11:44 AM, indicated Social Services spoke with the resident's family member and they did say they wanted to hold the resident's bed. During an interview on 09/05/2025 11:35 AM, the Director of Nursing (DON) was asked who was responsible for sending the notice of transfer and bed hold the resident and/or the resident's representative. The DON indicated that the nurse on duty was the one responsible for sending out the notice of transfer and bed hold. The DON was asked if the notice of transfer and bed hold was completed for Resident #45 when he was transferred to the emergency room on [DATE]. She indicated that it was not done. The facility could not provide evidence that Resident #45 and the resident's representative received complete information for the hospitalization on 07/16/2025. During an interview on 09/04/2025 3:17 PM, the Administrator indicated the nursing department was responsible for giving the notice of bed hold and transfer to the resident and/or the resident representative when a resident goes to the hospital. The Administrator indicated that social services would follow up as she did on those two hospitalizations with Resident #7. The Administrator indicated that they had identified a problem with notice of bed hold and transfers being sent out and that she would check with the DON to identify when they did the performance improvement plan and in-serviced staff. On 09/05/2025 8:35 AM, the DON provided in-service documentation dated 07/11/23 that indicated all residents and/or family are to be asked if they want a bed hold. The form should be completed to indicate yes or no if they want a bed hold. Also, a transfer form should be filled out and given to the resident/family at the time of transfer. A form titled Bed-Hold and Return Agreement and Release of Bed Space was attached. In addition, the DON provided a form titled Quality Assurance Performance Improvement (QAPI) Works Sheet dated 08/19/25 that indicated issues identified were bed holds and transfer forms. The work sheet indicated forms to be combined to make one and staff would need to be in-serviced on the new form. There was a form attached titled Notice of Transfer and Bed-Hold. The form did not include a statement of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request. During an interview on 09/05/2025 9:03 AM, Licensed Practical Nurse (LPN ) #2 indicated when a resident goes to the hospital she filled out a hospital hold form that the resident or family must sign, but she does not give any other paperwork at the time of transfer or discharge to the hospital, resident or family. During an interview on 09/05/2025 9:27 AM, the Admissions Coordinator/Social indicated that when a resident goes to the hospital the nurse was to give the resident a notice of bed hold, but she was not aware of the notice of transfer being given to the resident or their representative. During an interview on 09/05/2025 10:00 AM, the DON indicated that she was still in the process of revising the notice of bed hold and transfer or discharge to the hospital and that she had done a verbal in-service with staff but had not put this in-service in writing. The DON indicated the notice of transfer or discharge should include the location the resident transferred to, the reason for the transfer or discharge and the price of the bed hold. The DON did not indicate that the notice would contain information regarding the appeal process if the resident did not agree with the transfer. The DON was asked for a policy on bed hold and transfer or discharge. During an interview on 09/05/2025 at 12:17 PM, the Administrator indicated that the form attached to the QAPI plan dated 8/19/25 was from their corporate office and she believed the DON was making the changes that were needed to the form, and she would have to confirm with the DON that the changes had been made. The administrator confirmed that the notice of transfer should include where the resident discharged or transferred to, the reason for the transfer and the appeal process. A review of a policy titled Transfer or Discharge Notice (revised March 2021) indicated that the resident and/or their representative would be notified in writing, and in a language and format they understand at least within 30 days or as soon as practicable but before the transfer or discharge if an immediate transfer or discharge was required by the residents urgent medical needs. The notice includes: a. The specific reason for the transfer or discharge. b. The effective date of transfer or discharge. c. The location to which the resident is being transferred or discharged to. d. An explanation of the residents' rights to appeal the transfer or discharge to the state, including: 1. The name, address, email and telephone number to the entity which receives appeal hearing requests. 2. Information on how to obtain, complete and submit an appeal request; and 3. How to get assistance completing the appeal process. A review of a policy titled, Bed Holds and Returns (revised March 2022) indicated, all residents/representatives are provided written information regarding the facilities bed-hold policy which address holding or reserving a resident's bed during periods of absence such as hospitalization at the time of the transfer or within 24 hours if the transfer was an emergency.

Number of residents sampled:3Number of residents cited:2Based on observations, interviews, record review, and facility policy review, it was determined that the facility did not ensure Enhance Barrier Precautions (EBP) were implemented; and that staff donned proper Personal Protective Equipment (PPE) when care was provided for 2 (Resident #3, Resident # 52) of 3 residents, who were reviewed for PEG tube care and IV medication administration. Based on record review, observation, interview, and facility policy review, it was determined that the facility did not ensure Enhance Barrier Precautions (EBP) were implemented; and that staff donned proper Personal Protective Equipment (PPE) when care was provided for two (Resident #3, Resident # 52) of three residents, who were reviewed for Percutaneous Endoscopic Gastrostomy (PEG) tube care and Intravenous (IV) medication administration. The findings include: Resident #3 Review of a Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/18/2025, indicated Resident # 3 had a Brief Interview for Mental Status (BIMS) score of 00, which indicated the resident had severe cognitive impairment. The MDS also indicated that Resident # 3 had diagnoses which included blocked blood flow to the brain (Stroke); memory, thinking and behavior problems; loss of feeling to one side of the body and surgical opening to the stomach to provide nutrition via feeding tube. Review of Resident # 3's Care Plan report with a completion date of 08/18/25 indicated the resident required EBP related to the presence of a PEG tube. Review of Physicians Order dated 08/04/2025 indicated Resident # 3 required EBP related to Gastrostomy Tube (GT) placement. During an observation on 09/04/2025 12:08 PM, this surveyor observed Licensed Practical Nurse (LPN) # 1 perform PEG placement check and tube flush on Resident # 3. LPN # 1 entered Resident #3's room with gloves on and PEG tube flush supplies in hand, with no gown on. LPN # 1 brushed against resident # 3's bed and Resident # 3's body while performing PEG tube placement check and PEG tube flush. During an interview on 09/04/2025 12:30 PM, LPN # 1 stated she was not aware of any EBP to for PEG tube care. This surveyor noted signage on the door indicating the resident was on EBP. LPN # 1 stated the purpose of EBP was to prevent infections. During an interview on 09/05/2025 10:35 AM, the Infection Preventionist (IP) stated gloves and gowns were to be worn for PEG tube care including PEG tube flushes with the purpose being to prevent infections. During an interview on 09/05/2025 10:50AM, the Director of Nursing (DON) stated a gown, and gloves are to be worn when providing care to residents with a PEG tube. The DON stated the purpose was to prevent the transmission of bacteria to residents with open areas such as PEG tube and that all staff have been in serviced on proper PPE. Resident #52 Review of an admission MDS with an Assessment Reference Date (ARD) of 09/04/2025 for Resident #52 indicated it was unavailable due to it being in progress. Review of an admission Record indicated the facility admitted Resident #52 on 08/29/2025 with diagnoses which included infection and inflammatory reaction due to an internal artificial left knee, urinary tract infection, and diabetes mellitus. Review of a Care Plan with an initiation date of 09/04/2025 indicated Resident #52 was on EBP related to a Peripherally Inserted Central Catheter (PICC) for administration of antibiotics and staff were to provide care according to EBP guidelines. Review of an Order Summary report dated 09/04/2025 indicated Resident #52 was to receive IV antibiotics every 12 hours for urinary tract infection until 09/22/2025. The Order Summary also indicated Resident #52 was on EBP related to PICC placement. During an observation on 09/04/2025 8:25 AM, LPN #2 prepared an antibiotic to administer intravenously through a PICC line in Residents #52's left arm. LPN #2 washed her hands and put on gloves. LPN #2 did not put on a gown. This surveyor observed the door to Resident #52's room and there was not a sign indicating the resident was on EBP. LPN#2 entered Resident #52's room and explained to the resident what she was about to do. LPN #2 took off the cap to the IV catheter and cleaned the hub with an alcohol preparation pad. LPN #2 checked for patency of the IV line, flushed the line with 10 milliliters of normal saline and connected the tubing to the IV infusion pump setting the IV to infuse over 30minutes. LPN #2 removed her gloves and washed her hands. LPN #2 exited the resident's room after ensuring the resident had no requests. During an interview on 09/04/2025 8:35 AM, LPN #2 indicated Resident #52 was on EBP because of the PICC line and there had been a sign on the door yesterday indicating the resident was on EBP. When this surveyor asked LPN #2 what PPE should be worn when providing care for the resident's IV catheter. She stated that the resident had a urinary infection and when providing care that involved the urinary tract, she would wear a gown and gloves but for the PICC line she would wear only gloves. LPN #2 indicated that EBP were used to prevent the spread of infection to herself, and other residents. During an interview on 09/05/2025 10:35AM, the IP indicated staff are made aware that residents are on EBP by a sign that was placed on the door. The IP indicated Resident #52 was on EBP because the resident had a PICC and that during direct care to the PICC, a gown and gloves should be worn to help reduce the risk of spreading infection to the resident. During an interview on 09/05/2025 10:45AM, the Director of Nursing (DON) indicated that Resident #52 was on EBP because the Resident had a PICC and when the line was accessed to administer antibiotics, staff should wear a gown and gloves. The DON stated when Resident #52 was admitted a sign stating they were on EBP had been placed on the resident's door, but they had to replace it yesterday because it was no longer on the door. The DON indicated a PICC was an open access and EBP are used to prevent any possible blood splashes getting on staff during the procedure and to prevent the spread of infection. The DON was asked for any in-services or policies on EBP. A review of an in-service dated 07/10/2025, titled Enhanced Barrier Precautions the who, what and why indicated providers and staff must wear gloves and gowns for the following high contact resident care activities that include direct care or use of central line, urinary catheter, tube feeding or tracheostomy. A review of a policy titled Enhanced Barrier Precautions indicated EBP are recommended by the Centers of Disease Control (CDC) to prevent the spread of multi-drug-resistant organisms (MDROs) to residents. EBP indicated the use of gown and gloves during high contact resident care such as direct care or use of a central line or feeding tube. .

Based on observation, interview, record review and facility policy review, the facility failed to follow residents request to initiate resuscitative measures for one (Resident #1) of five residents who had a full code status. It was determined the facility's non-compliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) was related to State Operations Manual, Appendix PP, 483.24 (Quality of Life) at a scope and severity of J. The IJ began on [DATE] at approximately 7:40 PM when Resident #1 became unresponsive in - the resident's room. No action to perform cardiopulmonary resuscitation (CPR) was taken by facility staff. Emergency Medical Services (EMS) arrived at the facility and performed CPR. Resident #1 was transported to the hospital and was pronounced expired. The Administrator was notified of the IJ on [DATE] at 1:55 PM. A Removal Plan was accepted by the State Agency on [DATE]. The findings are: Review of the Medical Diagnosis portion of Resident #1's electronic health record revealed diagnoses of coronary artery disease, heart failure, chronic obstructive pulmonary disease, hypertension, and acute respiratory failure. The Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 14, indicating the resident was cognitively intact, and received supplemental oxygen. Review of Resident #1's Order Summary Report revealed an order for supplemental oxygen at two liters per minute, as needed for shortness of breath, that the resident used a ventilator at bedtime, and noted the resident wished to be resuscitated per their advanced directive. Review of Resident #1's Progress Notes for [DATE] at 10:09 PM revealed the resident had 2 episodes of unresponsiveness, a ventilator mask was applied, emergency medical services were called, and that Resident #1 became cyanotic as Emergency Service Personnel entered their room. On [DATE] at 3:00 PM, during an interview Certified Nursing Assistance (CNA) #1 stated on [DATE] she responded to CNA #2's call for help. She was unsure of the time. When she arrived at Resident #1's room, she saw Resident #1 sitting in a wheelchair slumped over unresponsive. After she entered the room Resident #1 became responsive and was talking to Licensed Practical Nurse (LPN) #2. CNA #1 reported a short time later, CNA #2 again called for nursing staff to come to Resident #1's room, Resident #1 had become unresponsive again. CNA #1 stated LPN #1 confirmed with LPN #2 that Resident #1 was a full code. CNA #1 reported she tried to obtain vital signs on Resident #1 but was unable to find any. She and CNA #2 requested to place Resident #1 on the floor to begin CPR. CNA #1 stated that LPN #2 denied the request to move the resident to the floor. When asked if the nurses had tried to assist the resident to the floor to begin CPR, she stated no they did not, they both (the nurses) have back problems. CNA #1 confirmed Resident #1 remained in wheelchair. On [DATE] at 3:20 PM, LPN #1, who was on duty the evening of [DATE], was interviewed and asked to explain the events of that evening pertaining to Resident #1. She responded, He was not my patient. She then said CNA #2 had called down the hall that she needed assistance right away and that resident #1 was going out. She stated LPN #2, CNA #1, and herself all went to Resident #1's room immediately. After going into room and assessing the resident, she retrieved the crash cart and brought it to Resident #1's room. When asked if staff had attempted to assist Resident #1 to the floor to start CPR, she confirmed they did not, stating, He was a large man, (clinical record documented weight at 195 pounds) and that they were unable to lift him. She stated the ambulance service initiated CPR when they arrived. On [DATE] at 11:00AM, via phone interview was conducted with LPN #2, who was Resident #1's nurse on the evening of [DATE]. She stated CNA #2 called for assistance to Resident #1's room, and all nursing personnel had responded. She stated Resident #1 was slumped over in a wheelchair in the bathroom in the resident's room, snore breathing and unresponsive. She related when resident was wheeled into the center of the room, Resident #1 became responsive. She stated Resident #1 had oxygen on via nasal cannula at 2 liters and that she replaced it with resident's tabletop positive pressure ventilation mask and that resident's saturation of peripheral oxygen (SPO2) was in the 90's according to the ventilation machine. LPN #2 stated that CNA #2 was behind the resident's wheelchair holding his head upright and the ventilation mask sealed. She reported LPN #1 brought the crash cart to the room. LPN #2 then related she had already called EMS and went to get contact information to contact the resident's family and when she got back to resident's room, Resident #1 had become unresponsive again and was snore breathing. LPN #2 then stated that the ambulance service arrived immediately. Resident #1 continued to be unresponsive and the ambulance crew immediately transferred resident from the wheelchair to the ambulance gurney and began resuscitation measures. LPN #2 was asked if the staff initiated any resuscitative measures and responded no, that resident was still responsive prior to the ambulance service arrival. LPN #2 confirmed she was CPR certified. When asked if she had contacted the doctor concerning Resident #1's change of condition she replied she had contacted the Director of Nurses on call but did not contact the doctor until notified by emergency room of resident expiring. Review of Resident #1's clinical record failed to reveal vital signs for the evening of [DATE]. On [DATE] at 12:00 PM the Director of Nursing (DON) was asked if she could locate the vital signs in Resident #1's medical record for the evening of [DATE] and she was unable to. The DON was then asked if she was present on the evening of [DATE]. She stated she was but was not DON at that time. She stated she was in facility when she heard CNA #2 call for assistance of nursing personnel, she responded as well. She was unsure of the time, but stated, It was late. She confirmed Resident #1 had become more responsive and stable, with staff talking to them, so she left the room. She is unsure about the events of the second occurrence. When asked about staff training for code status, she confirmed staff had CPR training, but being new to the position of DON, is unsure about further training. On [DATE] at 3:13 PM a phone interview was conducted with CNA#2. When asked what took place on the evening of [DATE] pertaining to Resident #1, she stated between 7:00 and 7:15 PM she assisted Resident #1 to the bathroom, with a rolling walker. As Resident #1 was brushing their teeth, the resident stated he was lightheaded. CNA #2 stated Resident #1 became cyanotic and fell back against her. She reported she called for help with no response. She said she grabbed the rolling walker and was able to assist the resident to sit. She then exited the bathroom to find the nurse. CNA #2 stated that she was unable to locate LPN #2 and after relating the urgency, LPN #1 came to Resident #1's room. Then LPN #2 and CNA #1 arrived. CNA #2 reported the first episode lasted approximately 7 or 8 minutes, then the resident became responsive. CNA #2 stated at approximately 7:,d+[DATE]:30 PM Resident #1 became unresponsive again and it was ,d+[DATE] minutes before the ambulance service was called. She stated she was behind wheelchair holding Resident #1's head up and ventilation mask in place. She continued, CNA #1 was getting Resident #1's vital signs but could not get a blood pressure or pulse. She reported the ambulance service arrived and began resuscitative measures on the resident. On [DATE] at 10:50 AM a phone interview was conducted with Paramedic #1 Who confirmed they had responded to the event on [DATE] related to Resident #1. He stated when the ambulance service arrived there were 3 staff members in Resident #1's room. The resident was sitting in a wheelchair with what looked like a bi-level positive airway pressure (Bi-pap) mask on, was cyanotic, and in respiratory arrest. He went on to say the staff was not attempting any recitative measures. Paramedic #1 related CPR should have already been initiated. He stated Resident #1 was transferred to the gurney, CPR was initiated and they began ventilating with an artificial manual breathing unit (AMBU) bag. Paramedic #1 stated that the nursing home staff exited resident's room as soon as the ambulance service arrived. Review of LPN #2's employee record revealed documentation of CPR certification. A copy of the facility policy and procedure for, Emergency Procedure - Cardiopulmonary Resuscitation noted, immediately initiating CPR with Basic Life Support (BLS) increases the chance of surviving a sudden cardiac arrest, a licensed staff member trained in CPR should initiate CPR if a person is found unresponsive with abnormal breathing and continue with CPR/BLS until emergency medical personnel arrive. Removal Plan: 1. The facility will initiate education training of all staff on code blue. 2. The facility will initiate education training of all nurses on physician notification and CPR. 3. The facility will have a code blue drill on every shift. Onsite Verification: The IJ was removed on [DATE] at 5:30 AM, after the surveyor preformed an onsite verification that the Removal Plan had been implemented. Onsite verification of the Removal Plan began [DATE] at 10:00 AM, with verification of implementation A total of 5 staff interviews were conducted with staff for all shifts to verify training had been completed. The staff interview included certified nursing assistants, Licensed Practical Nurses, housekeeping, and maintenance. The staff interviewed verified they had been trained on: Code Blue response and participated in Code Blue drills. Licensed staff verified they had been trained on Physician notification, change of condition, and Cardiopulmonary Resuscitation and had participated in Code Blue Drills. A review of in-service sheets provided indicated 24 of 25 staff members had been provided training. In addition, 20 staff members were trained on use of an Automated external defibrillator (AED) on [DATE].

Based on observation, record reviews and interviews, the facility failed to ensure serving items were properly handled, hand sanitation was utilized, the kitchen was free from buildup of unknown substances that had the potential to cross-contaminate food items to be served, equipment was in safe and useable state, open food items were properly closed or sealed and had an open date, food items were not expired. The findings are as follows: On [DATE] at 10:35 AM, the following observations were made during the initial kitchen tour: The right side of the floor water drain grate was broken in 2 pieces. The larger piece inside the floor drain grate were covered in a brownish unknown substance with paint missing. The left side of the floor drain grate had paint missing and was covered in a black and brownish unknown substance. The floor under the ice machine had a grimy, sticky looking black and blackish-brown unknown substance. The cleaning closet contained boxes directly on the floor. The dry goods storage room had unknown stains and spots of black, brown, and various specks of debris, paper, and plastic; one 8 ounce bottle of water and one 6 ounce can of lime soda was on the floor; a 3-tier rolling cart had brownish-orange spills with a blue cloth with purplish colored stains. The walk-in freezer and refrigerator doors and walls on either side were covered in a blackish-brown unknown substance. The floor crevasse along the walls had a thick greyish-black substance built up with various white and brown unknown particles. A ventilation cover screwed into a wood like frame had a buildup of white, brown and/or grey fuzzy unknown substance. A three-tiered cart in the main kitchen area held 1 box of hot breakfast cereal and spaghetti noodles in the original package that was sealed shut with clear wrap. The three-tiered cart had a grimy buildup of a black unknown substance. The Dietary Manager confirmed the cart needed to be cleaned and could have bacteria and cause cross contamination. The sandwich refrigerator cart had a white plastic cutting board with numerous cut indentations and a yellowish-brown stain. When the Dietary Manager lifted the cutting board a pool of stagnant whitish liquid covered the surface directly under. The front panel had streaks of brown, white and grey with adhered pieces of white and brown unknown substances. The front right wheel had a buildup of an unknown whitish substance. The floor under the cart had a thick black, white, and grey built up. The Dietary Manager confirmed stagnate pooling water was a concern due to mildew, mold, and bacteria. The dishwasher room had 5 dish racks sitting directly on the floor. The floor under the dishwasher, sink compartment and countertop had a blackish build up between the tile grooves and floor drain gratings. The dishwasher front had white streaks running down the front. The top had a brownish unknown substance built up around the bottom groove of the detergent and rinse container. The temperature gauge side and cover of the dishwasher had a brown build up and white speckles of unknown substances that adhered to the dish washer outer surface. 2. On [DATE] at 7:18 AM, the following was observed in the kitchen area: The can opener blade had black, orange, and white unknown substances adhered to the blade. On [DATE] at 1:25 PM, the Dietary Manager confirmed the can opener needed to be cleaned and could cause cross-contamination or an allergic reaction. A preparation table held 2 desert bowls, 1 stack of Styrofoam plates, and 4 desert bowls that were not covered. One 32 ounce opened bottle of lemon juice was on the prep table. There was not an open date on the bottle and directions showed, refrigerate after opening. The Lead [NAME] confirmed the bowls and Styrofoam plates were not covered and the lemon juice did not have an open date, nor had it been placed in the refrigerator. The dishwasher room had 5 dish racks sitting directly on the floor. The floor under the dishwasher, sink compartment and countertop had a blackish build up between the tile grooves and floor drain gratings. The dishwasher front had white streaks running down the front. The top had a brownish unknown substance built up around the bottom groove of the detergent and rinse container. The temperature gauge side and cover of the dishwasher had a brown build up and white speckles of unknown substances that adhered to the dish washer outer surface. There was one spray bottle of a multi-surface cleaning substance in the serving area on the bottom shelf next to the bread. One bottle of multi-surface cleaning substance was in the kitchen on the bottom shelf of the prep table in front of a one gallon container of white distilled vinegar. The label showed, .All food contact surfaces must be thoroughly rinsed with potable water after use of this product.; Keep out of reach of children .Wash hands thoroughly after handling; .Read Safety Data Sheet before using this product . On [DATE] at 1:26 PM, the Dietary Manager confirmed the kitchen and equipment needed to be cleaned so cross-contamination does not occur. 3. On [DATE] at 7:47 AM, the Food Service Assistant placed his left thumb on the surface area of the plate then place food items on the plate. At 1:27 PM, the Dietary Manager confirmed nothing should meet the plate surface. 4. On [DATE] at 7:50 AM, the Food Service Assistant left the serving area, opened the door between the serving area and kitchen area with his right hand, then placed his right hand on the handle of the can opener. The Food Service Assistant then returned to the serving line and began to serve. The Lead [NAME] informed the Food Service Assistant that hand washing was required prior to serving when you leave the serving area. 5. On [DATE] at 10:05 AM, during observation of the spice cabinets, the following spices were open and did not have an open date: One 18 ounce container of ground cinnamon; One 16 ounce container of ground cloves; One 16 ounce container of ground all spice; One 16 ounce container of ground turmeric; One 8 ounce container of cinnamon sticks; Two 16 ounce containers of paprika; One 13 ounce container of Mediterranean style ground oregano; One 23 ounce container of Montreal chicken; One 16 ounce container of ground mustard; One 20 ounce container of lemon and pepper seasoning salt; One 29 ounce container of Montreal steak seasoning; One 11 ounce container of ground thyme; Two16 ounce containers of chili powder; One 18 ounce container of ground white pepper; One 6 ounce container of whole rosemary; One 14 ounce container of ground cumin; One 6 ounce container of rubbed sage; One 12 ounce container of poultry seasoning; One 26 ounce container of granulated garlic. The Lead Food Service Assistant confirmed there were no open dates on the containers. 6. On [DATE] at 10:15 AM, during observation of the spice cabinets the following items were expired: One 15-ounce container of dessert sauce mango flavor expired [DATE]; One 5-ounce container of dill week expired [DATE]; One 15-ounce container of dessert sauce kiwi lime expired on [DATE]. 7. On [DATE] at 8:45 AM, the following was observed in the walk-in refrigerator: The door did not seal properly. At 1:15 PM, the Dietary Manager confirmed the door did not properly seal. The following items failed to have an expiration date: 1 pan of sloppy joe meat; 1 pan or brown gravy; 2 pans of mashed potatoes; 1 pan of mandarin oranges; 1 pan of roasted potatoes; 1 pan meatballs and sauce. The Lead [NAME] confirmed the items did not have an expiration date. At 1:18 PM, the Dietary Manager confirmed there was not an expiration date and said an expiration date needs to be on the items to know when they are not safe to serve. 8. The following open items in the walk-in refrigerator did not have an opened date: One 12-pound container of potatoes salad; One 15-pound box of bacon; One box with 4 of 6 packages of 12-pound deli sliced turkey breast. One 15-pound box of bacon was not completely sealed. At 1:19 PM, the Dietary Manager confirmed the items needed an open date written on the containers or boxes. 9. On [DATE] at 9:20 AM, the following was observed in the dry good storage area: a. A container holding elbow noodles had a black and white unknown substance on the bottom of the container b. The opened food items did not have an open date. Food items removed from their transportation boxes did not have a received date nor an open date. c. One 6.75-pound can of pineapple slices with a dent by the top rim and a dent by the bottom rim; and another 6 pound can of pineapple slices with a dent on the bottom of the can. The Lead Food Service Assistant confirmed the dents and that the dents could lead to ruptures that could cause botulism. d. Six 40-ounce boxes of hashbrown potatoes were past the best by date of [DATE]. 10. On [DATE] at 4:45 PM the Administrator provided Policy for Food-Supply Storage which showed, .Plastic bins may be used if preferred but must be in good repair and washed routinely. Stock items are individually dated with delivery date if removed from the original container .Foods that have been opened or prepared are placed in an enclosed container, dated, labeled, and stored properly .Once meal service is over, cover, date, and label trays of individually portioned items such as desserts, salads, glasses of juice, milk, and supplements . Chemicals are not stored near food items . 11. On [DATE] at 4:45 PM the Administrator provided a policy for Cleaning Schedule which showed, .Check each equipment item in kitchen for cleanliness and that it is in good repair.7. Dry storage areas: a. Floors are to be swept and scrubbed regularly. b. Walls are to be spot cleaned on an as-needed basis and washed at a minimum annually . 10. Floor drains: a. Wear heavy-duty gloves. b. Clean with drain brush . 14. Walls and vents: a. Wipe up splashes as soon as possible with clean cloth and detergent. b. Schedule thorough cleaning about every six months or at a minimum, annually . 16. Refrigerator, freezer, and gaskets: a. Place on weekly cleaning schedule. b. Report concerning the DFN [Director of Food and Nutrition Services]. 17. Cabinets, drawers, and counter tops: a. Clean and sanitize between uses and at the end of the day. b. Empty and clean drawers weekly. 18. Carts: a. Clean and sanitize at the beginning of the a.m. shift and at least every four hours throughout the day. b. clean wheels weekly . 12. On [DATE] at 4:45 PM, the Administrator provided a policy titled, Chemical Use and Storage which shows, .5. Chemicals are stored away from the food supply in a separate room, on a shelf and off the floor .

Based on observations, interviews, record review, facility document review, and facility policy review, it was determined the facility failed to secure residents private health information on facility computers to prevent unauthorized sharing of electronic medical records (EMR), by leaving the EMR open in the hallway without staff present for 1 (Residents #5) of 16 sampled residents who were reviewed for protection on the electronic medical record. Findings include: A review of a facility policy titled, HIPAA (Health Insurance Portability and Accountability Act) Assigned Security Responsibilities- Enterprise, dated 04/11/2019, indicated, Confirming that Sanford's ePHI (electronic personal health information) receives reasonable and appropriate safeguards to protect its confidentiality, integrity, and availability. During an observation on 06/10/2024 at 04:21 PM, the Surveyor observed a facility laptop on the snack cart in the hallway with the facility laptop screen facing the hallway. Visible on the facility laptop screen was Resident #5's electronic health record. Available on the laptop screen for all non-staff members to see was the resident's name with supplement order details and scheduling details. Multiple guests and family members were noted in the hallway with the laptop screen visible. During an observation on 06/10/2024 at 4:25 PM, the Surveyor continued to observe the facility laptop on the snack cart in the hallway with the facility laptop screen facing the hallway. Visible on the facility laptop screen was Resident #5's electronic health record. Available on the laptop screen for all non-staff members to see was the resident's name with supplement order and scheduling details. Multiple guests and family members were noted in the hallway with the laptop screen visible. During an observation on 06/10/2024 at 4:48 PM, the Surveyor observed Licensed Practical Nurse (LPN) #1 return to the medication cart, then continue to work on computer screen before taking the medication cart down the hallway. During an interview on 06/12/2024 at 2:01 PM, LPN #2 was asked by the surveyor, What should be done to the facility laptops prior to leaving them unattended while in the hallway of the facility. LPN #2 stated, The screen should be locked within the electronic health record system prior to walking away in the hallway. LPN #2 confirmed this is performed to protect the privacy and confidentiality of each resident's electronic medical record. During an interview on 06/12/2024 at 03:07 PM, the Director of Nursing (DON) confirmed the facility laptop screen should be locked within the electronic medical record system prior to leaving the laptop unattended in the facility hallway. The DON also confirmed this process is in place to protect the confidentiality of each resident's electronic medical record in the facility.

Based on observations, interviews, and record review, the facility failed to ensure harmful chemicals, nail trimmers, and razors were stored securely to promote resident safety for 1 (Resident #135) of 1 sampled resident reviewed for accidents and hazards. Findings include: On 06/12/2024 at 4:59 PM, the Administrator stated the facility did not have a policy for chemical storage/hazards. A review of the Medical Diagnosis List, indicated the facility admitted Resident #135 with diagnoses that included unsteadiness on feet, difficulty in walking, not elsewhere classified, acute kidney failure, aftercare following joint replacement surgery. During an observation on 06/09/2024 at 10:40 AM, a large grey top Germicidal disposable wipe container noted in Resident #135's room on the over the bed table. During an observation on 06/09/2024 at 10:52 AM, the Surveyor observed the Bath room on the 300 Hall was fully unlocked with no lock present and the door opened for the Surveyor. Upon entering the room, the Surveyor observed a plastic storage cabinet in the room with a combination lock through a hole on the upper right door but not latched or through both doors. The bottom doors were fully unlocked with no lock present. The cabinet doors were opened for observation. The Surveyor identified: A. (2) large spray bottles of a multi surface disinfectant cleaner with a chemical label in place was over 50% full. B. (1) 32 ounce (oz) spray bottle of a disinfectant. C. (1) disposable razor D. (1) small set of nail trimmers During an observation on 06/09/2024 at 01:10 PM, a container hand sanitizing wipes were noted in the resident common/activity area across from the nurse's station sitting on the bookshelf at waist high. During an observation on 06/09/2024 at 1:13 PM, a large grey top germicidal disposable wipe container was noted in Resident #135's room on the bedside dresser. During an observation on 06/09/2024 at 1:59 PM, the Surveyor observed the Bath room on the 300 Hall was unlocked with no lock present and the door opened for the Surveyor. Upon entering the room, the Surveyor observed a plastic storage cabinet in the room with a combination lock through a hole on the upper right door but not latched or through both doors. The bottom doors were fully unlocked with no lock present. The cabinet doors were opened for observation. The Surveyor identified: A. (2) large spray bottles of a multi surface disinfectant cleaner with a chemical label in place was over 50% full. B. (1) 32 oz spray bottle of a disinfectant. C. (1) disposable razor. D. (1) small set of nail trimmers. During an observation on 06/09/2024 at 2:01 PM, the Surveyor observed the bathing/spa room on the 100 Hall. The door was closed but opened with a light touch by the Surveyor. The sign on the door read, Please keep door closed at all times this was in all caps and red letters. There was a keypad lock in place, but the door was not secured shut. Upon entering the room, the Surveyor observed a low wall mounted cabinet. This cabinet did not have locks in place. The cabinet doors were opened for observation. The Surveyor identified the following: A. (1) small set of nail trimmers. B. (1) 8 oz spray bottle of wound cleanser. C. (1) large spray bottle of an all-purpose cleaner. D. (1) large spray bottle with a chemical label in place of a multi surface disinfectant cleaner, which was full. During an observation on 06/10/2024 at 9:06 AM, a large grey top germicidal disposable wipe container was noted in Resident #135's room on the bedside dresser. During an observation on 06/10/2024 at 5:22 PM, a large grey top germicidal disposable wipe container was noted in Resident #135's room on the bedside dresser. During an interview on 06/12/2024 at 2:08 PM, Licensed Practical Nurse (LPN) #2 confirmed chemicals should be stored in storage rooms, in medication/treatment carts, or anywhere secure that residents cannot get to them. LPN #2 stated they are to be secure, because a resident could use a germicidal wipe to wipe their face or perineal area and all chemicals are potentially dangerous. LPN #2 confirmed razors and nail trimmers are stored in the facility storage room to keep them out of reach of residents. LPN #2 added that with nail trimmers and razors the residents could cut themselves which could be even worse if they were on a blood thinner. During a concurrent observation and interview on 06/12/2024 at 2:53 PM, the Director of Nursing (DON) stated chemicals are always stored in locked areas, and this does not include shower/bathing areas. The DON confirmed nail trimmers and razors should be stored locked up to prevent a resident from cutting themselves especially if they are on anticoagulants. The DON observed at this time with the Surveyor the Bath room on the 300 Hall was unlocked with an unlocked cabinet containing chemicals, razor, and a nail trimmer. A review of a facility safety data sheet titled, [Germicidal Disposable Wipes], dated 10/12/2022, indicated, Use as a disinfectant on hard, non-porous surfaces. For professional and hospital use. Description of first aid measures: inhalation- not a normal route of exposure. If symptoms develop move victim to fresh air. Get medical attention if symptoms develop. Eye contact- rinse thoroughly with water. Get medical attention if irritation develops or persists. Skin contact- no first aid should be required. Wash skin with water. Get medical attention if irritation develops or persists. Ingestion- ingestion is unlikely for solid products. No first aid is required for small amounts transferred from hands to mouth. A review of a facility safety data sheet for the [All Purpose Cleaner] dated 10/19/2015, indicated, All-purpose cleaner. Reserved for industrial and professional use. Hazardous statements: causes eye irritation. Wash skin thoroughly after handling. A review of a facility safety data sheet for the [Multi Surface Disinfectant Cleaner] dated 08/18/2022, indicated, Disinfectant. Reserved for industrial and professional use. Hazardous statements: Causes severe skin burns and eye damage. Harmful if inhaled. Precautionary statement: Avoid breathing mist or vapors. Wash skin thoroughly after handling. Use only outdoors or in a well-ventilated area. Wear protective gloves/protective clothing/eye protection/face protection. If swallowed: rinse mouth. Do not induce vomiting. If on skin or hair take off immediately all contaminated clothing. Rinse skin with water/shower. If inhaled, remove person to fresh air and keep comfortable for breathing. Immediately call poison center/doctor. If in eyes rinse cautiously with water for several minutes. Remove contact lenses, if present and easy to do. Continue rinsing. Storage: store locked up. A review of a facility safety data sheet for the [Disinfectant] dated 03/26/2014, indicated, Disinfectant. Reserved for industrial and professional use. Hazardous statements: causes serious eye damage. Wear eye protection/face protection. Warning! Do not use together with other products. May release dangerous gases (chlorine). If in eyes: rinse cautiously with water for several minutes. Remove contact lenses, if present and easy to do. Continue rinsing. Immediately call a poison center or doctor/physician A review of a facility safety data sheet for the [Hand Sanitizing Wipes] dated 08/09/2018, indicated, Antiseptic. Precautionary Statements: keep away from heat, hot surfaces, sparks, open flames or other ignition sources, no smoking. Use explosion proof, electrical, ventilating, or lighting equipment. Wash thoroughly after handling. Wear eye protection. In case of fire: use water fog, alcohol-resistant foam, carbon dioxide and dry chemicals to extinguish.

Based on observations, interviews, and record review, the facility failed to perform proper hand hygiene during resident care for 1 (Resident #23) of 1 sampled resident reviewed for tube feeding. Findings include: 1. A review of a facility policy titled, Hand Hygiene- Enterprise dated 03/29/2022, indicated, Hand Hygiene: a general term that applies to either handwashing or applying hand sanitizer. Handwashing includes washing hands with soap and water. Hand sanitizer involves using a waterless antiseptic agent. All employees are responsible for maintaining adequate hand hygiene by adhering to specific infection control practices. All employees in patient care areas (unless otherwise noted in their policy) will adhere to the 4 moments of hand hygiene and 2 zones of hand hygiene. 1. Entering room. 2. Before clean task. 3. After bodily fluid/glove removal. 4. Exiting room. 5. Zones: patient zone and health-care zone. Gloves are a protective barrier for the HCW (Healthcare Worker) according to standard precautions. 1. Gloves are never to be reused or sanitized. 2. Hand hygiene should be performed after glove removal. A review of the Order Summary Report indicated the facility admitted Resident #23 with diagnoses that included hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, dysphagia following cerebral infarction, and encounter for attention to other artificial openings of digestive tract. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/13/2024, revealed Resident #23 had a Staff Assessment of Mental Status (SAMS) score of 3 which indicated the resident had severe cognitive impairment and had a feeding tube while a resident. A review of Resident #23's Care Plan revised on 02/27/2024, revealed the resident required tube feedings. Interventions included the resident was to receive a nutritional supplement 5 times a day (every 4 hours from 6:00 AM to 10:00 PM daily) and the head of the bed was to be elevated 45 degrees during and 30 minutes after each tube feeding bolus. A review of the Order Summary Report, revealed Resident #23 had a Physician's Order dated 11/20/2023 for a nutritional supplement bolus five times a day with 100 cc (cubic centimeters) of water before and after each bolus. During an observation on 06/11/2024 at 2:00 PM, Licensed Practical Nurse (LPN) #2 checked the residual of the PEG (percutaneous endoscopic gastrostomy) tube using a large syringe. LPN #2 removed her gloves to retie the resident's gown and did not perform hand hygiene and applied a new pair of clean gloves and finished the task. During an interview on 06/11/2024 at 2:26 PM, LPN #2 confirmed contaminated gloves were removed to retie the isolation gown and hand hygiene was never performed before applying a clean pair of gloves. LPN #2 said hand hygiene should be performed when applying a new pair of gloves and removing a used pair to prevent cross contamination to the new pair of gloves. During an interview on 06/12/2024 at 2:49 PM, the Director of Nursing (DON) confirmed hand hygiene should be performed following each glove removal and/or before applying a clean pair of gloves to prevent the transmission of bacteria.

Based on observations, interviews, and record review, the facility failed to implement and carry out physician's orders for wound care and to identify new skin changes for 1 (Resident #18) of 1 resident reviewed for skin conditions. Findings include: A review of a facility policy titled, Skin Tear Treatment and Prevention, dated 05/21/2024, indicated, .To identify and treat skin tears as soon as possible. To promote early wound healing. To prevent further destruction of skin or infection . Skin Tear Treatment Skin tears should be treated before 12 hours have elapsed from the time of a tear so wound healing can begin as soon as possible.Check area of skin tear at least daily. Documentation may be captured in [Facility Computer Software] on the skin observation . A review of a facility policy titled, Physician/Practitioner Orders- Rehab/Skilled, dated 04/01/2024, indicated, .Note: The option for the physician/practitioner to select the agent of the prescriber is contained within the standing orders . Wounds: Orders must be obtained for wound care including product to be used, when to be change and when to reassess. A licensed nurse must provide wound care . A review of Resident #18's Medical Diagnosis form indicated the facility admitted Resident #18 with diagnoses that included: lack of coordination, difficulty in walking, unsteadiness on feet, abnormal posture, and malaise (a general feeling of discomfort, illness, or lack of well-being). The Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/27/2024, revealed Resident #18 had a Staff Assessment of Mental Status (SAMS) score of 3, which indicated the resident had severe cognitive impairment. This MDS showed no skin issues. A review of Resident #18's Care Plan revealed the resident had the potential for pressure ulcer development related to altered mental status, immobility, and incontinence. Interventions included educating the resident/family as to causes of skin breakdown including transfer/positioning requirements; importance of taking care during ambulating/mobility, good nutrition and frequent repositioning, initiated on 06/03/2024; and to notify the nurse immediately of any new areas of skin breakdown: redness, blisters, bruises, discoloration, etc. noted during bath or daily care, initiated 06/03/2024. A review of the Order Summary Report, revealed Resident #18 had a physician's order with an order date of 05/21/2024 which stated may use standing orders including agent of the prescriber. A review of the Treatment Record, revealed Resident #18 had not had any wound care orders appear on the treatment record for the month of June 2024, nor any documentation of any completed wound care that has been performed. A review of an Activity of Daily living task Skin Check, revealed Resident #18 had no data found for the past 30 days on the Skin Check task in the resident's electronic health record. During an observation on 06/09/2024 at 10:47 AM, the Surveyor noted a skin toned dressing in place to the right elbow with black substance underneath but visible from the external surface. During an observation on 06/11/2024 at 9:01 AM, the Surveyor noted 2 white border dressings on the right arm near the elbow, each dressing was dated 06/09/2024. The Surveyor also noted a skin tone colored dressing to the left elbow dated 06/01/2024. A review of the Nursing Admit Re-Admit Data Collection ([NAME]) form dated 05/21/2024, revealed Resident #18 had no skin issues at the time of the form completion. A review of Wound Data Collection form, revealed Resident #18 had an identified wound to the left elbow which documented a wound wash and bordered foam dressing was applied, this form was completed on 06/01/2024 at 11:49 AM. A review of Wound RN [Registered Nurse] assessment dated [DATE], revealed Resident #18 had a left elbow skin tear identified and this was an initial assessment by the RN. The RN also documented the physician was notified regarding wound status, modifications to treatment plan received, and the care plan was updated. During an interview on 06/12/2024 at 2:16 PM, Licensed Practical Nurse (LPN) #2 stated that once a skin change is identified the treatment nurse and wound nurse practitioner are notified and they will note the skin issue as well. The treatment nurse practitioner comes every Friday. LPN #2 reported nurses in the facility cannot put a dressing on any open wound without a physician's order. During a concurrent observation and interview on 06/12/2024 at 2:34 PM, LPN #4 stated the nursing staff perform weekly skin assessments and if changes are identified the treatment nurse practitioner is notified. Typically, the initial order is to cover with a border dressing, and it will be assessed in person on Friday by the treatment nurse practitioner. LPN #4 stated none of their residents had any skin conditions that required a dressing. LPN #4 accompanied the Surveyor to Resident #18's room and confirmed the Surveyor's observations of the dressings and confirmed the Surveyor's observed dates. LPN #4 stated the dressings were not observed due to not pulling back the covers to view the resident's arms. The Surveyor accompanied LPN #4 to the nurse's station. After reviewing Resident #18's electronic medical record, LPN #4 confirmed there were no orders for skin care dressings and the last skin assessment was completed on 06/01/2024 which was the RN assessment and wound data collection forms completed. During an interview on 06/12/2024 at 3:35 PM, the Director of Nursing (DON) was asked about the dressings in place to Resident 18's arms. The DON stated the Certified Nursing Assistant (CNA) should notify the nurses of skin changes during baths or the nurses should identify during the weekly skin assessment. The DON did confirm there were facility standing orders, which were requested by the Surveyor at this time. The DON confirmed there was no physician's orders for wound care in the resident's chart and that there was only the Nursing Admit Re-Admit Data Collection form, wound RN assessment form, and wound data collection form completed. The DON also confirmed there should have been a nursing skin assessment on 05/28/2024, 06/04/2024, and 06/11/2024. The DON stated the charted treatment on 06/01/2024 was completed without a physician's order and no follow up had been completed. The DON also confirmed the other skin conditions on the right arm had not been identified or any orders were put in place. A review of the Standing Orders, revealed the facility had a standing order for wound care: skin tear- unable to approximate edges. The order read: skin tear: cleanse all skin tears with sterile saline wound solution. If unable to approximate edges: apply skin barrier wipe to peri-wound and allow to dry. Apply hydrogel dressing to area and secure with bandage roll. Change every 3 days or PRN [as needed] if leakage or soiling.

Based on observation, interview, and record review, the facility failed to ensure dressings were replaced for 1 (Resident #13) of 3 (Residents #13, 15, 17) sampled residents who had a Physician's order for wound care. The findings are: On 07/03/23 at 02:45 PM observed a dressing dated 07/01 on Resident #13 left wrist. On 07/05/23 at 09:17 AM observed a dressing dated 07/01 on Resident #13 left wrist. On 07/05/23 at 02:30 PM observed a dressing dated 07/01 on Resident #13 left wrist. An incident report for Resident #13 dated 06/19/23 at 07:14 AM noted, the resident slid down in her geriatric chair and two Certified Nursing Assistants (CNA) reclined the chair and pulled the resident up in the chair. The resident's left hand was caught under the arm rest and caused a skin tear to the back of left hand. A Physician's order for Resident #13 dated 06/19/23 at 05:00 PM noted a wound care order for the left wrist, to be changed every three days, and as needed. The Treatment Administration Record (TAR) for Resident #13 revealed wound care was provided on 7/1/23 but did not document wound care on 07/04/23. On 07/05/23 at 03:46 PM, the Surveyor asked Licensed Practical Nurse, (LPN) #1 to identify the date written on the dressing for Resident #13. She stated, 07/01. The Surveyor asked LPN #1 to identify what the wound care order for the resident documented. She stated, it says change it every 3 days. It should have been changed yesterday. The Surveyor asked LPN #1 to identify if a refusal had been documented for the wound care. She stated, No, it's not charted. On 07/06/23 at 10:50 AM the Director of Nurses (DON) reviewed the TAR and confirmed the dressing change was not documented and confirmed there was no documentation of the resident refusing, and confirmed the dressing change should have been done. On 07/06/23 at 1:08 PM the Administrator provided a policy titled, Wound Dressing Change- R/S LTC, Therapy and Rehab, last revised on 11/2/22. It documented, Purpose: To promote wound healing, to help wound remain free of infection, check Physician's order; review previous assessment and notes, identify time, date, and initials on dressing chart dressing change and wound observations

Based on observation, interview, and record review the facility failed to ensure an oxygen mask was covered and dated for 1(Resident #5) of 4 (Resident #5, #14, #15, and #17) sampled residents that has an order for a nebulizer, and the facility failed to ensure a sign was posted indicating that oxygen was in use for 1 (Resident #182) of 4 (Resident #5, #14, #15, and #17) sampled residents that had an order for oxygen. The findings are: 1. Resident #5 had a diagnosis of unspecified asthma, uncomplicated. A Minimum Data Set (MDS) with an assessment reference date of 5/17/23 indicated Resident #5 had a Brief Interview for Mental Status (BIMS) Score of 6, which indicated the resident had severe cognitive impairment. A. A review of the physician orders with a start date of 1/05/23 documented, .DuoNeb Solution 0.5-2.5 (3) MG [milligrams]/3ML [milliliters] (Ipratropium-Albuterol) 1 vial inhale orally via [by] nebulizer three times a day for SOB [shortness of breath]/pneumonia . B. On 7/03/23 at 11:37 AM a nebulizer oxygen mask was laying on the bedside table. There was not a date on the nebulizer, and it was not covered. C. On 7/05/23 at 09:55 AM a nebulizer oxygen mask was laying on the bedside table. There was not a date on the nebulizer, and it was not covered. D. On 7/05/23 at 9:56 AM Licensed Practical Nurse (LPN) #2 was giving Resident #5 her morning medications. The surveyor asked LPN #2, Does Resident #5 use her nebulizer oxygen mask? She stated, Yes she uses it at night. The Surveyor asked, Do you know why it is on the table uncovered, and not dated? She stated, No I do not. E. On 7/06/23 at 1:10 PM the surveyor asked the Director of Nurse (DON), where should the nebulizer mask be stored? She stated, They should be stored in a bag, a zip lock, or something to be covered. The Surveyor asked, When should the tubing and the humidifier be dated? She stated, When they put it on them. F. A review of a facility policy titled, .Oxygen Administration . documented, .When oxygen is not in use, store cannula, face mask, or face tent and tubing in zip lock bag/plastic bag secured to oxygen cylinder or concentrator. 2. Resident #182 had diagnoses of Chronic respiratory failure with hypoxia and Chronic obstructive pulmonary disease. Resident #182 had a Physician's Order that documented, oxygen at 3 liters via nasal cannula. A. On 07/03/23 at 10:07 AM observed Resident #182 lying in bed. The resident was receiving supplemental oxygen from a nasal cannula attached to an oxygen concentrator at bedside. There was no signage observed in the doorway of the resident's room to alert staff and visitors that oxygen was in use. B. On 07/03/23 at 03:17 PM observed Resident #182 lying in bed receiving oxygen. There was no signage observed in the doorway of the resident's room to alert staff and visitors that oxygen was in use. C. On 07/04/23 at 08:30 AM observed Resident #182 lying in bed receiving oxygen. There was no signage observed in the doorway of the resident's room to alert staff and visitors that oxygen was in use. d. On 07/05/23 at 2:17 PM the Surveyor asked LPN #3 if Resident #182 was receiving supplemental oxygen. LPN #3 stated, Yes. The Surveyor asked if there was anything missing from the doorway of the resident's room. She stated, Oh, yes. It got put on the wrong room and retrieved an oxygen alert sign from another doorway and placed it on the doorway of Resident #182's room. The Surveyor asked LPN #3 why posting the alert was important. She stated, It would let people know not to smoke in the room and prevent fires. e. On 07/06/23 at 01:02 PM the Administrator provided a policy titled, Oxygen Administration, Safety, Mask Types- R/S, LTC, Therapy & Rehab. The policy documented under the heading of Equipment, Signage for door-oxygen precaution/in use if appropriate.

FACILITY Kitchen Based on observation and interview, the facility failed to store food items in a manner that would prevent contamination. This failed practice had the potential to affect all 29 residents residing in the facility as documented by a list provided by the Administrator on 07/07/23 at 09:16 AM. The findings are: On 07/03/23 at 10:46 AM observed the kitchen's walk-in refrigerator with Dietary Employee #1 (DE#1). Observed a metal tray containing peaches partially covered with plastic wrap. The tray was resting on the middle shelf allowing liquid to drip from the top shelf into the tray containing food intended to be served to the residents. Observed an open plastic bag sitting on the top shelf of the rack containing two pieces of ham. The Surveyor asked DE#1 if there was an issue with how these items were stored. DE #1 stated, Yeah they should be sealed. On 07/06/23 at 09:07 AM the Dietary Manager (DM) accompanied the Surveyor to the refrigerator. Observed an open plastic bag full of chocolate chips resting on the top shelf. The DM confirmed the bag should be closed and further stated, Things could get in there, it could get contaminated. On 07/06/23 at 01:08 PM the Administrator provided a policy titled, General Sanitation-Food and Nutrition. The policy documented, .Policy .The location stores, prepares, distributes, and serves food under sanitary conditions at all times .

Based on interview and record review, the facility failed to ensure that baths were provided for 1 (Resident #184) of 7 (Residents #5, 9, 10, 17, 182, 184, 187) sampled residents that relied on the facility for bathing assistance. The findings are: On 07/03/23 at 10:51 AM observed Resident #184 lying in bed. The Surveyor asked if the facility was providing hygiene care to meet her needs. The resident stated, Mostly, it's been a really long time since I've had a bath. The Surveyor asked Resident #184 if she could remember when her last bath was. She stated, I don't know .at least a week. The Surveyor asked if anyone had offered a bath during that time. She stated, No. Review of the Care Plan for Resident #184 initiated on 06/23/23 documented, The resident has an ADL [Activities of Daily Life] self-care performance deficit: Bathing: Resident requires shower chair, shower gurney, with 1-2 staff assist . A review of the task sheet dated 7/5/23 with a lookback period of 14 days revealed Resident #184 was provided a bed bath on 06/27/23. On 6/30/23 and 7/4/23 Did not occur was documented. On 07/06/23 at 11:33 AM the Surveyor asked the Director of Nursing (DON) if the facility had documentation showing the reason Resident #184 did not receive a bath on 6/30/23 and 7/4/23. She stated, We don't have a separate binder. If the resident refused, it should have been documented in the resident chart. Review of policy titled, Activities of Daily Living, last revised on 11/29/22 revealed, ADLs are those necessary tasks conducted in the normal course of a resident's daily life. Included in these are the following: Bathing: Preparation for and the activity of washing and drying the body as well as transferring into and out of a tub or shower

Based on record review and interview the facility failed to ensure a resident did not leave the building unattended for 1 (Resident # 15) of 2 (Resident #14, and Resident #15) sampled residents that were at risk for elopement. The findings are: An incident report dated [DATE] at 2:30 PM specified, Resident #15 was found outside the building by the dietary manager. [She was] walking around with assist of wheelchair .Resident unable to give description .Dietary Manager and other staff member assisted resident as she was wheeled back into the building. Resident was given a cool drink of water for comfort . No injuries observed at the time of the incident . A review of Resident #15 medical records indicated he had diagnoses of Alzheimer's Disease with Late Onset, Dementia and Confusion. The Physician Order Summary revised [DATE] indicated, Resident may wear Wander Guard bracelet to alert staff to movement in facility Check Wander Guard bracelet every shift to ensure it is functioning and not expired. Use the Wander Guard Universal Tester in the long-term care cart; every shift for functionality of wander guard (point tester at the bracelet and push button; light will turn green if functioning) The Quarterly Minimum Date Set with an Assessment Reference Date (ARD) of [DATE] revealed a Staff Assessment for Mental Status that indicated Resident #15 had short- and long-term memory problems, and her decision making was severely impaired. Resident #15 required supervision with locomotion on and off the unit. A review of Resident #15 Care Plan dated [DATE] revealed the resident had impaired cognitive function, impaired thought processes, potential for elopement, wandering in wheelchair and on foot, and poor safety awareness at exit doors. A review of Resident #15 Elopement Risk assessment dated [DATE] indicated that she was a risk for elopement. On [DATE] at 11:32 AM Resident #15 was in her room sitting in a wheelchair. She had a wander guard on her left wrist. Resident #15 was not able to answer questions. On [DATE] at 1:02 PM the surveyor asked the Director of Nurses (DON), How did Resident #15 get out of the building by herself? She stated, Assumption, I didn't see her no one saw her. We assume it was a door that did not latch. The Surveyor asked, how does the facility ensure that residents don't exit the building without staff assistance? She stated, They have wonder guards if their safety is a concern. On [DATE] at 2:27 PM the surveyor asked Licensed Practical Nurse (LPN) #1, Has Resident #15 had an elopement? She stated, She has, I had just got here on the day it occurred. The Surveyor asked, When did the elopement happen? She stated, Few days ago. The Surveyor asked, What were the circumstances around the elopement? She stated, I was made aware she had made it through a set of doors and out the other doors. On [DATE] at 2:32 PM the surveyor asked the Dietary Manager, Has Resident #15 had an elopement? She stated, Yes. The Surveyor asked, When did the elopement happen? She stated, Friday I don't remember the day. Dietary employee #1 and I were outside. I was out back by the door. I went to throw something in the golf cart, and I looked up and saw somebody. I looked and saw Resident #15 pushing her wheelchair. I asked her to walk with me up to the back kitchen door. When I made it to the kitchen hollered for my cook, and he went for a nurse. When Licensed Practical Nurse (LPN) #1 came, we all got her back in. On [DATE] at 9:59 AM the surveyor asked the administrator, Has Resident #15 had an elopement? She stated, Yes. The Surveyor asked, When did the elopement happen? She stated, I think it was the on Friday [DATE]rd. The Surveyor asked, What were the circumstances around the incident? She stated, I was informed that the resident was outside with the dietary manager. I went outside and saw the Activities Director and CNA #1 bringing the resident back in. The Surveyor asked, Do you know how she got out of the building?' She stated, I can only make an assumption of how she got out the building? She stated, We think the emergency exit door on the end of 200 hall was cracked, and she got out that way because maintenance had to go and install another door arm so it could close tightly. The Surveyor asked, What could have happened if the kitchen staff had not noticed Resident #15? She stated, She could've been out there a longer period of time. She could have gotten lost. She could have been injured in some way.

Based on observation, record review and interview, the facility failed to ensure residents seated at the same table were served their meals at the same time to allow the residents to eat together and staff sat at eye level when assisting with eating to promote dignity for 1 (Resident #3) who required assistant with eating. This failed practice had the potential to affect 13 residents who received a meal tray in the dining room as documented on the Seating Chart for the Healthcare Dining Room. The findings are: 1. On 05/02/22 at 12:14 PM, the first lunch tray was served in the Main Dining Room to Resident #3. There was one other resident sitting at the table but was not served their meal until other residents at other tables were served. The second tray from the kitchen was served to a resident at another table and not to the resident seated at the table with Resident #3. The third tray was served to a resident at a third table. The fourth tray was served to a resident at another table. The fifth tray was served to the resident who shared the table with Resident #3. 2. On 05/02/22 at 12:30 PM, the Acting Director of Nursing (DON) approached Resident #3 and began to assist her with the meal, but she did not sit at eye level with the resident. She stood up and offered Resident #3 bites of food. After a period, the Dietary Manager took a stool to the table and provided the DON with a seat. 3. On 05/04/22 at 12:10 PM, the Dietary Manager was asked, Should the residents be served one table at a time in sequence? She answered, Yes. She was asked, Could it be considered a dignity issue if the residents are served out of sequence? She answered, Yes. She was asked, What position should the staff be in when they assist a resident with a meal? She answered, They should be sitting at eye level and conversing. She was asked, Could it be a dignity issue if a staff member stands over a resident to assist them with a meal? She answered, It would be to me. 4. On 05/04/22 at 12:40 PM, the MDS (Minimum Data Set) RN on duty was asked, Should the residents be served one table at a time in sequence? She answered, Yes. She was asked, Could it be considered a dignity issue if the residents are served out of sequence? She answered, Yes. She was asked, What position should the staff be in when they assist a resident with a meal? She answered, They should be sitting at eye level. She was asked, Could it be a dignity issue if a staff member stands over a resident to assist them with a meal? She answered, Yes. 5. A Policy titled Dignity in Dining, which was provided by the Administrator on 05/04/22 at 12:40 PM documented, .To provide dining in a manner that enhances resident dignity . Treat each resident like an individual and focus on making the dining experience as individualized as possible . Serving all residents at the table at the same time so residents can eat together except by resident choice .

Based on record review and interview, the facility failed to develop and implement a comprehensive person-centered care plan that included measurable objectives and timeframes to meet residents' needs and includes resident goals, desired outcomes, and preferences for 2 (Resident #24 and 8) of 13 (Resident #16, 24, 75, 6, 1, 23, 7, 21, 26, 77, 12, 9, 8) sampled residents whose care plans were reviewed. The findings are: 1. Resident #8 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/14/22 documented the resident scored 4 (0-7 indicates severe impairment) on the Brief Interview for Mental Status (BIMS), received 7 days of Antianxiety Medications and 7 days of Antidepressant Medications during the look back period. a. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . c. As of 5/4/2022, the resident's Care Plan did not document the use of Antidepressant Medications. d. A Policy titled, Care Plan which was provided by the Administrator on 05/04/22 at 12:40 PM documented, This plan of care will be modified to reflect the care currently required/provided for the resident . The interdisciplinary team will review care plans at least quarterly. Care plans also will be reviewed, evaluated and updated when there is a significant change in the resident's condition . e. On 05/04/22 at 01:00 PM, the MDS (Minimum Data Set) Coordinator asked, Should the use of antidepressants be documented on the care plan? She answered, Yes. She was asked, What could happen if the care plans are not accurate or reviewed and revised? She answered, The staff won't know how to care for the resident accurately. 2. Resident #24 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/07/22 documented a score of 13 (13-15 indicates cognitively intact) on the Brief Interview for Mental Status. He received 7 days of injections, and 7 days of Insulin during the look back period. a. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . b. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . c. As of 5/4/2022, there was no documentation on the resident ' s care plan for the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] 3. A Policy titled, Care Plan which was provided by the Administrator on 05/04/22 at 12:40 PM documented, .Each resident will have an individualized, person centered, comprehensive plan of care that will include measurable goals and timetables directed toward achieving and maintaining optimal medical, nursing, physical, functional, spiritual, emotional, psychosocial, and educational needs . The care plan will emphasize the care and development of the whole person ensuring that the resident will receive appropriate care and services . 4. On 05/04/22 at 01:00 PM, the MDS (Minimum Data Set) Coordinator was asked, Should the use of insulin be documented on the care plan? She answered, Yes. Absolutely. She was asked, What could happen if the care plans are not reviewed and revised? She answered, The staff won't know how to care for the resident accurately.

Based on record review and interview, the facility failed to review and revise the Care Plan to meet the needs of the residents who had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The findings are: Resident #12 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/23/22 documented the resident scored 1 (0-7 indicates severe impairment) on the Brief Interview for Mental Status (BIMS), required limited assistance of one person with transferring, toileting and ambulating in room. a. An Incident Progress Note dated 7/19/21 at 11:14 AM documented, Note Text: MDS [Minimum Data Set] nurse found resident on floor in closet. Appears resident was ambulating unassisted which resident has been observed doing on multiple occasions over the past few days . An Incident Progress Note dated 7/28/21 at 12:03 PM documented, Note Text: Resident was witnessed sliding out of her w/c [wheelchair] onto the floor by housekeeper . An Incident Progress Note dated 4/13/22 at 12:30 AM documented, Note Text: Staff heard crying from resident's room and upon entering, found her on the floor between her wheelchair and nightstand lying on her right side . An Incident Progress Note dated 4/24/22 at 10:00 PM documented, Note Text: resident found lying on the floor in her room in front of the bathroom door lying on her right side. Resident said she was going to the bathroom, and she started to wobble then fell down . b. As of 5/2/22, there was no documentation on the Care Plan of revision for any of the falls/incidents. c. On 5/2/22 at 1:05 PM, the resident was in her room without assistance and having complications with moving her wheelchair out of doorway of restroom. Certified Nursing Assistant (CNA) notified of resident being up in her room. CNA #1 came to assist resident and stated, She is not to be up in her room alone she is a fall risk. d. On 5/5/22 at 9:10 AM, Registered Nurse (RN) #1 was asked, How often are care plans to be revised regarding a resident ' s fall? She stated, I am as needed here and have not worked here in 6 months, but I would think they needed to be updated at least every 3 months or so. e. On 5/5/22 at 10:10 AM, the Administrator was asked, How often should a care plan be revised/updated when a resident has a fall? She stated, Oh, we generally revise them with each fall. We do the falls and incident meeting after we have our morning meeting with the teams and do them then.

Based on observation, record review and interview, the facility failed to ensure the baseline care plan included the use of oxygen and [CONDITION(S)] (Continuous Positive Airway Pressure) to provide staff with necessary care and treatment meet professional standards of care for 1 (Resident #77) of 13 (Resident #16, 24, 75, 6, 1, 23, 7, 21, 26, 77, 12, 9, 8) residents whose care plans were reviewed. The findings are: Resident #77 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) 05/02/22 was still in process. a. A Physician's Order dated 04/06/22 documented, Oxygen via nasal cannula 1-4 liters per minute as needed for Dyspnea, [CONDITION(S)] (O2 saturation less than 88%) or Acute [CONDITION(S)]. Call provider/practitioner with Nursing Report. every 8 hours as needed for Dyspnea, [CONDITION(S)], Acute [CONDITION(S)] . There was no Physician's Order for the [CONDITION(S)]. b. On 05/02/22 at 12:00 PM, Resident #77 was not in the room. A [CONDITION(S)] [Continuous Positive Airway Pressure] machine was on the nightstand with the mask lying in a wash basin. c. On 05/03/22 at 09:16 AM, a [CONDITION(S)] mask was lying in the wash basin. d. On 05/03/22 at 01:31 PM, Resident #77 was lying in bed with the [CONDITION(S)] mask on. e. On 05/04/22 at 09:20 AM, Resident #77 was not in bed. The [CONDITION(S)] mask was lying on the nightstand. f. As of 5/4/2022, there was no documentation for the use of oxygen and a [CONDITION(S)] on the Baseline Care Plan. g. On 05/04/22 at 09:30 AM, Licensed Practical Nurse (LPN #1) was asked, what is her [CONDITION(S)] order? She answered, I don't see an order. She was asked, should she have an order for [MEDICAL RECORD OR PHYSICIAN ORDER] ? She answered, Yes. She was asked, Is the use of oxygen and a [CONDITION(S)] documented on her care plan? She answered, It's not on there. She was asked, Should the use of oxygen and [CONDITION(S)] be on the care plan? She answered, Yes if that is part of her care. h. A Policy titled, Care Plan which was provided by the Administrator on 05/04/22 at 12:40 PM documented, . Baseline Care Plan - includes instructions needed to provide effective and person-centered care of the resident what meet professional standards of quality care . A baseline care plan will be developed upon admission according to federal and state regulations . i. On 05/04/22 at 01:00 PM, the MDS [Minimum Data Set] Coordinator was asked, Should oxygen be on the care plan? She answered, Absolutely. She was asked, should the use of a [CONDITION(S)] be on the care plan? She answered, Yes. She was asked, What could happen if oxygen or [CONDITION(S)] are not on the care plan? She answered, It could be devastating. The patients need it. She was asked, When should a baseline care plan be completed? She answered, Within 48 hours. We have to know how to care for the residents. She was asked, What could happen if the care plans are not accurate or reviewed and revised? She answered, The staff won't know how to care for the resident accurately.

Based on observation, record review, and interview, the facility failed to ensure a portable oxygen cylinder was stored safely when not in use to prevent a potential accident for 1 (Resident #77) of 6 (Resident #77, 16, 6, 23, 7, 8) sampled residents who used oxygen. The findings are: Resident #77 had diagnoses of Fractured Right and Left Pubis, Fracture T 11-12 Vertebrae, and [CONDITION(S)]. The Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) 05/02/22 was still in process. a. A Physician's Order dated 04/06/22 documented, Oxygen via nasal cannula 1-4 liters per minute as needed for Dyspnea, [CONDITION(S)] (O2 saturation less than 88%) or Acute [CONDITION(S)]. Call provider/practitioner with nursing report every 8 hours as needed for Dyspnea, [CONDITION(S)], Acute [CONDITION(S)] . b. On 05/02/22 at 12:00 PM, Resident #77 was not in the room. A small portable oxygen cylinder was sitting unsecured on the floor beside the closet. c. On 05/03/22 at 09:16 AM, a small portable oxygen cylinder was sitting unsecured on the floor beside the closet d. On 05/04/22 at 09:20 AM, Resident #77 was not in bed. The small portable oxygen cylinder was sitting unsecured on the floor beside the closet. e. A Policy titled, Oxygen Administration, Safety . which was provided by the Administrator on 05/04/22 at 10:28 AM documented, . To . store oxygen in a safe manner . oxygen cylinder chained on a stand . All oxygen cylinders should be chained in place, racked, or stored in stable carts at all times . f. On 05/04/22 at 09:30 AM, Licensed Practical Nurse (LPN #1) was asked, What is the appropriate way to store a portable oxygen cylinder? She answered, Out of the room in a locked area. But she wouldn't let me take that from her room. She was afraid it would get lost. g. On 05/04/22 at 01:00 PM, the MDS (Minimum Data Set) Coordinator was asked, How should portable oxygen cylinders be stored? She answered, Not on the floor. They should be on a stand of a rolling cart. Always secured. She was asked, What could happen if a portable oxygen cylinder is not stored correctly? She answered, It could blow up.

Based on observation, record review, and interview, the facility failed to ensure there was physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] #77) sampled resident who used a [CONDITION(S)] machine. The findings are: Resident #77 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) 05/02/22 was still in process. a. A Physician's Order dated 04/06/22 documented, Oxygen via nasal cannula 1-4 liters per minute as needed for Dyspnea, [CONDITION(S)] (O2 saturation less than 88%) or Acute [CONDITION(S)]. Call provider/practitioner with nursing report every 8 hours as needed for Dyspnea, [CONDITION(S)], Acute [CONDITION(S)] . There was no Physician's Order for the [CONDITION(S)]. b. On 05/02/22 at 12:00 PM, Resident #77 was not in the room. A [CONDITION(S)] machine was on the nightstand with the mask lying in a wash basin. c. On 05/03/22 at 09:16 AM, the [CONDITION(S)] mask was lying in the wash basin. d. On 05/03/22 at 01:31 PM, Resident #77 was lying in bed with the [CONDITION(S)] mask on. e. On 05/04/22 at 09:20 AM, Resident #77 was not in bed. The [CONDITION(S)] mask was lying on the nightstand. f. On 05/04/22 at 09:30 AM, Licensed Practical Nurse (LPN #1) was asked, What is her [CONDITION(S)] order? She answered, I don't see an order. She was asked, Should she have an order for [MEDICAL RECORD OR PHYSICIAN ORDER] ? She answered, Yes. g. On 05/04/22 at 01:00 PM, the MDS (Minimum Data Set) Coordinator was asked, How should a [CONDITION(S)] mask be stored when not in use? She answered, In a case or a plastic bag. She was asked, Should there be a physician's order for the use of [MEDICAL RECORD OR PHYSICIAN ORDER] ? She answered, Absolutely. h. A Policy titled Non-Invasive Respiratory Support which was provided by the Administrator on 05/04/22 at 10:28 AM documented, . Provider orders must be obtained stipulating when the device can be removed and how it is to be used while the resident is performing activities of daily living . Cleaning . The Machine . Refer to the user manual .

Based on observation, record review, and interview, the facility failed to ensure expired milk was discarded to prevent the potential for food borne illness for residents who received milk with meals from the kitchen. These failed practices had the potential to affect 23 residents who received meals from the kitchen, as documented on the Diet List provided by the Administrator on [DATE]. The findings are: On [DATE] at 11:00 AM , there was a one-gallon jug containing milk in the small refrigerator located in the hydration area of the kitchen. The gallon jug was approximately half full of milk. The jug had an opened date of [DATE] written on it and the use by date/ expiration date of [DATE] stamped near the written date. a. On [DATE] at 10:15 AM., The Dietary Manager was asked, What could the potential outcome have been if the residents were served outdated/expired milk? The Dietary Manager stated, Expired milk can cause the residents to become sick. b. A Policy titled, Food Supply/Storage which was provided by the Administrator on [DATE] at 10:28 AM documented, . Use by/Use of Freeze By (expiration date) . these products should be consumed on or before the date listed on the package due to the product's perishable nature and the product should be disposed of . dates are checked on a regular basis . foods/fluids that have expired or are otherwise unsafe for use are to be discarded .

Complaint # (AR 310) was substantiated, all or in part, with these findings: Based on interview and record review, the facility failed to ensure physician orders [REDACTED].#1) of 2 (Residents #1 and #2) sampled residents who had physician's orders [REDACTED]. This failed practice resulted in past noncompliance at the level of actual harm to Resident #1 who received insulin when it was not required based on sliding scale blood sugar levels resulting in hospitalization to regulate the resident's blood sugar level, and had the potential to cause more than minimal harm to 2 residents who had physician's orders [REDACTED]. The findings are: Resident #1 had [DIAGNOSES REDACTED]. a. A physician's orders [REDACTED]. The physician's orders [REDACTED]. of insulin; for a blood glucose level of 351-399, the resident was to receive 8 units of insulin; and for a blood glucose level of 400 or greater, the resident was to receive 10 units of insulin, and call the Practitioner. The scheduled administration times documented on the Medication Administration Record (MAR) dated February 2020 were 7:00 a.m., 11:00 a.m., and 4:00 p.m. b. The MAR dated February 2020 documented on 2/29/2020 at 7:00 a.m., Licensed Practical Nurse (LPN) #1 performed the resident's capillary blood glucose test. The capillary blood glucose level result was documented to be 191. According to the physician's orders [REDACTED].#1 did not require any insulin administration for a capillary blood glucose level result less than 200. The Medication Administration Record documented LPN #1 administered 100 units of [MEDICATION NAME] R insulin to the resident. c. An Office of Long Term Care (OLTC) Incident and Accident Report, Division of Medical Services (DMS) form 7734 dated 2/29/2020 at 10:00 a.m. documented, .Date of Discovery . 2/29/2020 at 10:00 a.m.The Director of Nursing (DON) reported that the Charge Nurse mistakenly administered 100 units of [MEDICATION NAME] R to (Resident #1) . APRN (Advanced Practice Registered Nurse) notified with new order obtained for following Glucogon 1 SQ (subcutaneously) . FSBS (Finger Stick Blood Sugar) monitoring; and a STAT (immediate) BMP (Basic Metabolic Panel) . Resident's condition initially stabilize, but then declined with resident becoming hypoglycemic . APRN then gave an order for [REDACTED]. Notifications were made to the Administrator and family . Charge Nurse involved in the incident suspended pending investigation . Nursing in-service on Medication Rights and an investigation was implemented . d. A Nurses Note dated 2/29/2020 at 11:19 a.m. documented, Unresponsiveness .Blood Glucose 82 . e. A Nurses Note dated 2/29/2020 at 12:12 p.m. documented, .Change in Condition . Unresponsive . The resident's capillary blood glucose result was 42. The Nurse Practitioner was notified, and Emergency Medical Services (EMS) was called. f. A Nurses Note dated 2/29/2020 at 12:30 p.m. documented, .EMS (Emergency Medical Services) administered [MEDICATION NAME] (D10) in the right antecubital after several attempts to start IVs (Intravenous site). Blood glucose level was 82 after administration of D10. At 12:52 pm the blood glucose level was 156 and Resident #1 was having facial drooping, 's/s of stroke'. The resident was transferred to the hospital, family was notified. g. The Hospital Transfer Forms, Hospital records during course of stay, and Hospital Discharge Records dated 2/29/2020 through 3/1/2020 documented Resident #1 was seen in the emergency room and continued to have an IV of [MEDICATION NAME] 10 running. According to the ER note, the resident's blood sugar result on 2/29/2020 at 1:38 p.m. upon arrival to the ER was 43, and at 2:11 p.m. the resident's blood sugar result was 144. The resident was admitted to the Intensive Care Unit (ICU) for hourly glucose checks, frequent neurological checks, and continuation of the IV fluids. According to the hospital records, Resident #1 was back to baseline with blood sugars and mental status and was discharged back to the facility. The hospital [DIAGNOSES REDACTED]. h. On 4/2/2020 at 10:35 a.m., LPN #2 was asked, Are there any special things that you do when you administer insulin? LPN #2 stated, Yes. For example, I would go in and check the resident's blood sugar, then come back and check to verify on the computer the doctor's orders. Then I would have another nurse look at the blood sugar reading, look at the doctor's orders, then look at the insulin I had drawn up before I gave it. She was asked, Is this the facility's policy or just the way you do it? She stated, This is the way we do it here now. i. On 4/2/2020 at 10:43 a.m., LPN #3 was asked, Are there any special things that you do when you administer insulin? She stated, Yes. We had an in-service on having two nurses check to verify insulin before it is given. j. A facility policy titled Medication Administration provided by the Administrator on 4/1/2020 at 9:26 a.m., documented, .Dosage of high-risk medications (e.g. Liquid narcotics, Insulin) should be double checked by another nurse prior to administration . k. This was a significant medication error due to the classification of the medication, anti-diabetic / insulin. l. The facility initiated corrective action immediately after discovering the significant medication error on 2/29/2020 by implementing the following: 1.) An Office of Long Term Care (OLTC) Incident and Accident Report, Division of Medical Services (DMS) form 7734 dated 2/29/2020 at 10:00 a.m. documented, .Date of Discovery . 2/29/2020 at 10:00 a.m.The Director of Nursing (DON) reported that the Charge Nurse mistakenly administered 100 units of [MEDICATION NAME] R to (Resident's name) . APRN (Advanced Practice Registered Nurse) notified with new order obtained for following Glucogon 1 SQ (subcutaneously) . FSBS (Finger Stick Blood Sugar) monitoring; and a STAT (immediate) BMP (Basic Metabolic Panel) . Resident ' s condition initially stabilize, but then declined with resident becoming hypoglycemic . APRN then gave an order for [REDACTED]. Notifications were made to the Administrator and family . Charge Nurse involved in the incident suspended pending investigation . Nursing in-service on Medication Rights and an investigation was implemented 2.) On 2/29/2020, the facility initiated in-service education for licensed nurses for Medication Administration. 3.) On 2/29/2020, the facility initiated the Medication Administration Clinical Skills-Check-Off of licensed nurses. 4.) On 2/29/2020, the facility implemented a policy of dosages of high-risk medications (such as insulin) to be checked with another nurse prior to administration.

Complaint # (AR 929) was substantiated, all or in part, with these findings: Based on record review and interview, the facility failed to ensure adequate supervision was provided to prevent elopement, as evidenced by failure to ensure staff closely monitored residents at risk for elopement and performed daily monitoring checks of the wander alert bracelets and failure to ensure the wander alert bracelets were properly applied, as per manufacturer's instructions to prevent failure of the bracelets to transmit a signal to the receiver when a resident approached an exit door for 1 (Resident #1) of 3 (Residents #1, #2, and #3) case mix residents who exhibited exit-seeking behaviors, were at an increased risk of elopement, and had physician's orders [REDACTED]. These failed practices resulted in Immediate Jeopardy, which caused or could have caused serious harm, injury or death to Resident #1, who exhibited frequent exit-seeking behaviors, had an improperly applied wander alert bracelet, and left the facility unnoticed by staff, and had the potential to cause more than minimal harm to 2 other residents who were at risk for elopement, and had physician's orders [REDACTED]. The findings are: 1. Resident #1 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set with an Assessment Reference Date of 2/28/19 documented the resident scored 13 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status; exhibited verbal behavioral symptoms directed toward others on 1 to 3 of the last 7 days; required supervision of one person for locomotion on and off unit, used a wheelchair and a walker for mobility, and had a wander / elopement alarm used daily. a. A Nursing Note dated 7/6/17 documented, .Summary of discussion / notification and any education provided . We talked about what happened with (Resident #1) on 7/4/17. I told (Responsible Party / Power of Attorney's (POA) Name) that we cannot restrain (Resident #1) in order to prevent him from leaving the building, and that right now he can be redirected from wanting to leave. We talked about a wanderguard. (POA) agreed to a wanderguard and stated that (Resident #1) will refuse to wear it, cut it off, or think he is a prisoner. I agreed with her. We decided that the wanderguard can be placed in his personal bag that is attached to the back of his wheelchair. We also discussed that if (Resident #1) continues to want to leave and is trying to constantly elope, that they will need to find alternative placement for him at a secured facility. (POA) stated that she understood . Was consent needed? If so, document risk / benefits and decision . Family gave approval for the wander guard . b. A Nursing Note dated 7/13/17 documented, .Note Text . Mood and Behavior Meeting was held on 7/11/17. This reporting period, the resident had one incident of exit seeking, threatening that he would leave and that 'he wanted to go home.' Resident now has a wanderguard inside of the bag that is attached to the back of his wheelchair. His Care Plan was also updated to address the use of a wanderguard. We will continue to monitor for further behaviors . c. A Nursing Note dated 12/1/17 documented, .Resident had four documented incidents of being upset and trying to leave the building. The resident refuses to wear a wanderguard on his wrist, but there is one attached to his wheelchair, and also one in the bag that is on the back of his wheelchair . d. A physician's orders [REDACTED].Active Orders as of . 5/10/19 .wanderguard placed due to confusion .Communication Method . Verbal . Order Status . Active . Order Date . 7/6/17 .Check wanderguard every night shift for proper functioning. Every night shift to prevent leaving building unaccompanied related to [MEDICAL CONDITION] . Communication Method . Phone . Order Status . Active . Order Date . 5/8/19 .Start Date . 5/8/19 . e. The Care Plan with a revised date of 9/24/18 documented, .Focus . (Resident #1) has a(n) impaired cognitive function or impaired thought processes R/T (related to) [MEDICAL CONDITION] / Dementia confusion / needing reorientation . Date initiated .12/22/14 . Revision on . 3/6/18 . Goal . Resident will be safe in their own environment as evidenced by not eloping . Date initiated .7/6/17 .revision on . 7/6/17 .Target Date . 6/8/19 .Interventions . Cue, reorient and supervise as needed . Date initiated . 12/22/14 . Personal Alarm . wanderguard used to alert staff to resident's movement and to assist staff in monitoring movement. Resident refuses to wear the wanderguard; thus, it is placed on his wheelchair on the right side and / or in his wheelchair bag . Date initiated . 7/6/17 . Revision on . 5/7/19 . (Resident #1) has a behavior symptom R/T (related to) Depression / Anxiety /[MEDICAL CONDITION]. being rude toward staff, cursing at people, wanting to argue with people, refusing assistance with some ADLs (Activities of Daily Living), i.e. (such as) . transfers and toileting, exit seeking and making sexual comments toward staff . Date initiated . 8/26/14 . Revision on . 9/24/18 . Goal . Resident will have fewer episodes of being rude toward staff, cursing, arguing, refusing assistance with some ADLs, exit seeking, making sexual comments toward staff . Date Initiated . 8/26/14 . Revision on . 9/24/18 . Interventions . Intervene as necessary to protect the rights and safety of others . Divert attention. Remove from situation and take to alternate location as needed . Date initiated . 12/2/14 . f. An Office of Long Term Care (OLTC) Incident and Accident Report (I&A) dated 5/6/19 documented, .Date and Time of Discovery . 5/6/19 at 4:25 p.m . Type of incident . Elopement . Summary of Incident . On 5/6/19 at 4:25 p.m., (Physical Therapy Employee #1), Physical Therapy Assistant, saw the resident in the parking lot, next to the sidewalk, sitting in his wheelchair which was stuck in the parking lot drain. The resident was approximately 80 feet from the front door of the Administrative offices. Review of surveillance video showed that Resident exited the front door at 4:22 p.m. (Physical Therapy Employee #1) and another person helped get the resident's wheelchair out of the drain. The resident was trying to resist (Physical Therapy Employee #1) pushing him back into the building, so (Physical Therapy Employee #1) tipped the resident's wheelchair back in order to get the resident back in the building. Once inside the facility, (Physical Therapy Employee #1) informed two nursing staff of the incident . Steps taken to prevent continued abuse or neglect during the investigation . Upon the resident and (Physical Therapy Employee #1) entering the facility, (RN #1) was informed of the incident. She proceeded to assess the resident to determine if there were any injuries, and none were noted. Resident had a wanderguard on the left side of his wheelchair (he refuses to wear it on his wrist). The wanderguard was checked on the Therapy (Department) door and it was working. Maintenance will be conducting further tests on the doors that are equipped with a wanderguard system to ensure that the doors are properly functioning. In addition, the resident's wanderguard will be tested on the front door by the Administrative offices . g. The Elopement Checklist Worksheet dated 5/7/19 documented, .1. Was the resident assessed during the pre-admission process to determine if there is a risk for elopement? . Yes . 2. At the time of admission, was the risk for elopement addressed on the initial / temporary Care Plan? . No . 3. Have previous elopement attempts been documented by center staff? .Yes . 4. Was the risk for elopement addressed on the Comprehensive Care Plan? .Yes . 5. After elopement, was resident's Care Plan updated for appropriate interventions? . Yes . 6. Were individualized interventions from the Care Plan implemented? . Yes . 7. Was there adequate supervision? . Yes .8. Is an individual resident safety alarm, i.e., wander alert bracelet, used? . Yes . 9. If resident has an individual safety alarm, was it in working order? . No . 10. Was the exit door alarm activated when the resident eloped? . No . 11. If the exit door did not have an alarm, is the door within the sight of a staff member at all times? . N/A (Not Applicable) .12. Is the exit door alarm in working order? Yes . h. The Service Call Report dated 5/8/19 documented, .Issues with wanderguard on Main Entry Door . Adjusted the sensitivity a little, but the biggest problem was they had the bracelet on the very bottom of the wheelchair. (Maintenance Supervisor) and I tested it multiple times with a new bracelet and also with the wheelchair with the sensor higher on the wheelchair. Door locking properly . i. The Treatment Administration Record dated (MONTH) 2019 documented, .Check wanderguard every night shift for proper functioning. Every night shift to prevent (Resident) leaving building unaccompanied related to [MEDICAL CONDITION] .Start Date . 5/8/19 (at) 2300 (11:00 p.m.) . The wanderguard bracelet was checked on 5/8/19, as indicated with a check mark. j. The Departure Alert System manufacturer's instructions provided by the Maintenance Supervisor on 5/9/19 at 11:51 p.m. documented, .All staff members involved in the care of wanderers should read and understand all of the information contained within this manual, particularly the warnings and cautions. In addition, staff should develop and carry out a 'Wanderer Management Protocol ' that outlines correct procedures and assigns staff responsibilities .Warning .Read and follow these instructions carefully before using your system, failure to do so could cause an unauthorized departure resulting in injury or death . Equipment must be operated by trained personnel only who are thoroughly familiar with the procedures outlined in this User Manual. Train and test new staff members before they begin their duties .Test the (Brand Name) ID system regularly. Test each monitoring system weekly with all surrounding power devices turned on. Record the results. Test bracelets daily as detailed in the bracelet instructions and the (Brand Name) ID Universal Tester Manual. Record the results in each resident's records. The components inside the bracelet .were carefully tested prior to sealing the case and after final assembly. However, it is important after activation to test every bracelet before putting it into use and daily thereafter . (Brand Name) ID system signaling device bracelets are designed to be worn only on the resident's dominant wrist. Before considering any alternative placement, you must call (Name Brand) Customer Service . Do not place the bracelet on or next to metal, such as wheelchair frames, jewelry, watches etc. (et cetera), or allow it to come in contact with a door or associated hardware such as crash-bars, push-bars, etc. Metal could interfere with the signal sent from the bracelet to the door antennas and result in an unauthorized departure .Bracelet Placement . (Brand Name) bracelets (Model 3600 series) should be placed on the resident's dominant wrist. The metal in a wheelchair frame (or any other metal items) may interfere with the bracelet's signal to the door modules. Before proceeding with alternate placement, you must contact Technical Service for further instructions. Your bracelet placement protocol needs to define the standard placement for bracelets and any special procedures required before using an alternate placement. Call Technical Service at (phone number) before using any alternate placement . Wrist Placement . (Name Brand) specifies dominant wrist placement for several reasons . 1. Bracelets placed on the wrist are more readily visible, so staff can check routinely to verify placement. If transmitters are attached to clothing, they can be easily forgotten or lost. When clothing is removed, the resident is no longer being monitored and the bracelet can be lost in the laundry. When transmitters are placed on the ankle, the transmitter cannot be visibly checked because they are hidden beneath trousers or stockings, and as a result, a lost bracelet could go undetected. Also, by placing the bracelet on the ankle, socks and stockings are difficult to wear comfortably. Additionally, the ankles of many elderly people may swell for a variety of reasons such that the bracelet placed on the ankle could cause discomfort or even problems with circulation. 2. Placing the bracelet on the dominant wrist can make it more difficult to remove by the resident. Keep in mind that metal may interfere with the signal, so keep the bracelet away from metal jewelry such as bracelets, watches, or snaps on cuffs. Do not place the bracelet directly on the metal on a wheelchair .Wheelchair Placement . Facilities often ask about attaching the bracelet to a wheelchair. If attempts to use wrist placement have failed, mount the bracelet away from the metal frame of a wheelchair at a height of approximately 3' (feet) from the floor (in the center of the back of the wheelchair). Use only plastic clips or plastic (non-metallic) tape to attach the bracelet. DO NOT use a metal safety pin to attach the bracelet. Call Technical Service at (phone number) before putting the bracelet on a wheelchair . Staff Training . Each staff member should . View the (Name Brand) orientation video . Experience the system in operation . Each staff member should pass through a monitored doorway holding an activated bracelet .Understand the (Name Brand) ID System commands . Staff must know .3. How to properly attach wristbands to residents . 6. How to test door monitors and bracelets and to record testing results . Always Remember To .4. Test each bracelet upon activation and daily thereafter and record the results in the resident's records . k. On 5/9/19 at 2:53 p.m., the Administrator was asked, Do you know if there are any other residents who have a Wanderguard placed somewhere other than wrist or ankle? She stated, No. There are only 3 residents in total who have wanderguards, and the other 2 have them on their wrists. She was asked, Do you know when the resident began to refuse the wanderguard to be placed on his person? She stated, No. I am not sure when it happened. She was asked, On 5/6/19 when he exited through the front door, did the alarm sound? She stated, No, and the door didn't lock. She was asked, What interventions were in place at that time? She stated, We have an alert system, and that is the main way we monitor those who are at risk (for elopement). She was asked, Do you know the reason the system failed? She stated, I thought it was because the band was on the left side of the wheelchair, so when this happened, I told them to put it on the right side. She was asked, Where on the wheelchair was the band? She stated, It was on the frame below the armrest on the left. She was asked, Do you know when the band was attached to the wheelchair frame? She stated, No, but those nurses who would have been here and doing that are no longer here. She was asked, Are staff members provided an in-service or any training on the alarm system? She stated, Well, they are shown the doors that have the monitors on them. She was asked, Who does the training? She stated, (Maintenance Supervisor) I would think would be doing that, but I have only been here a year and I don't know of any training class really. Maybe he just tells them a few things about it. She was asked, Who is responsible for placing the bracelets? She stated, The nurses. She was asked, Who does the weekly monitoring? She stated, Maintenance. She was asked, Who does the daily monitoring of the bracelets? She stated, The nurses, and they put it on the Treatment Record. She was asked, When does the task to check the bracelets get added to the Treatment Record? She stated, When it is ordered. She was asked, When did it get added to (Resident #1's) Treatment Record? She stated, You are not going to like it, but during us looking into this incident, we found out that it had not been added at all, and so it wasn't being checked. She was asked, Can you confirm with documentation or a statement that daily checks have been conducted since the placement of the bracelet (2017)? She stated, I will need to find out because I think Restorative does that. She was asked, What was done after he eloped to prevent recurrence? She stated, We notified Maintenance, and he called the company, and the guy came and looked at everything. She was asked, What was his determination as to why the system failed. She stated, It was because it (bracelet) was on the wheelchair frame, and too low, and now it is mounted correctly on the handle. She was asked, What else was done? She stated, I began to roll out to the Department Heads on 5/7/19 the Elopement policy. She was asked, Does the policy include the specifics about alternate placement? She stated, No. She was asked, When did you begin in-servicing the direct-care staff? She stated, That would have been on 5/9/19, I believe. The DON (Director of Nursing) did that. She was asked, Did that in-service address the alternate placement of the bracelet? She stated, It was the same as what I had done with policy. She was asked, Have you incorporated the alternate placement of the bracelet into the training? She stated, We started that today. She was asked, Did you start the placement training before the initiation of this survey? She stated, No. We just were doing the policy at first. l. The facility policy titled Wander Alert Bracelets / Elopement provided by the Director of Nursing on 5/9/19 documented, .6. Wander alert bracelets are to be checked daily by rehab (Rehabilitation) or nursing to determine if they are in working order . m. On 5/9/19 at 3:06 p.m., the Maintenance Supervisor was asked, Where was the bracelet located when it failed? He stated, It was on the lower right-hand side (of the resident's wheelchair) .probably 4 to 6 inches from the floor. He was asked, Who does the testing on the system? He stated, We (Maintenance) document once a week on the actual doors. He was asked, When did you become aware of the failure? He stated, I believe it was the next day. He was asked, What did you do? He stated, I went and got his wheelchair when he was out of it, and I called the technician out here. I didn't even pay attention to placement, but when he came out here, he said that the bracelet was mounted too low, and once they moved it to higher area, it worked. He was asked, What model do you have here? He stated, Model series. n. On 5/9/19 at 3:56 p.m., the Administrator was asked, Can you provide documentation or a statement confirming that (Brand Name) Technical Support was contacted prior to the alternate placement of the Wanderguard? She stated, Well, I wouldn't know who would have done that, but whoever it was, isn't here anymore. She was asked, Can you tell me where the bracelet was on the wheelchair? She stated, It was down by, or below, the armrests (of the resident's wheelchair), and we moved it to the handles on the back of the wheelchair. She was asked, Was it attached directly on the frame of the wheelchair? She stated, Yes. o. On 5/9/19 at 4:14 p.m., the Director of Nursing (DON) was asked, Following the elopement on 5/6/19, what was done to prevent recurrence? She stated, He was placed on one-on-one for a while. She was asked, Do you have documentation of the one-on-one activities? She stated, I am not sure, but pretty sure she didn't document it. At 5:00 p.m., the DON provided the sign-in sheet with one-on-one written in next to one of the staff member's name. p. On 5/10/19 at 11:09 a.m., the Maintenance Supervisor was asked, What type of system is used here? He stated, I am going to have to ask (Name of Manufacturer) to give me the exact number based on our model. At 10:13 a.m., he stated, The people at (Name of Manufacturer) told me that the system is 'E' and we don't have mixed receivers. He was asked, We are going to need to have your documentation that you complete when you do your weekly checks. He stated, I gave it to (Administrator). He was asked, Since the representative came out and checked the system, can you determine the exact reason why the system failed? He stated, It was the bracelet being too low from what I can tell. After reading the manual, it was just them not doing enough. He was asked, Who? He stated, The nurses. They did not call the number and read the instructions. q. The Immediate Jeopardy was removed and the scope / severity reduced to D on 5/10/19 at 11:25 a.m., when the facility implemented the following Plan of Removal: 1. On 5/6/19, after (Resident #1) was brought back into the facility through the therapy / rehab (Rehabilitation) door. The Wandeguard did work / sound as he was brought back into the facility. (Resident #1) was placed on one-on-one immediately to ensure he did not go out without staff accompaniment throughout the remainder of the evening and the night. An incident report was completed and all notifications were made to the physician, Administrator, Director of Nursing Services, and (the resident's) family; 2. On 5/7/19, a reportable was sent to The Office of Long Term Care of the unusual occurrence of an attempted elopement; 3. On 5/7/19, the Administrator / designee started in-services for all Department Heads and all nursing staff, including CNAs (Certified Nursing Assistants), on the policy and procedures on elopement; 4. On 5/7/19, the Environmental Director called the service technician for the Wanderguard system to come in and check the system; 5. On 5/8/19, (Resident #1) and the other 2 residents wearing the Wanderguard bracelets were checked by a nurse to ensure placement. The MDS (Minimum Data Set) nurse reviewed the medical records of (Resident #1) and the other 2 residents to ensure the Wanderguard bracelets were being checked for placement daily. Negative findings were corrected immediately; 6. On 5/8/19, the service technician for the Wanderguard system came here to ensure the system was properly working and proper placement of the bracelet; 7. On 5/9/19, the Administrator / designee started in-services for all licensed nurses on the manufacturer's guidelines (instructions) for alternate placement of a Wanderguard bracelet when it cannot be place on the resident's arm. This in-service was focused on licensed nurses since they are responsible for placement; 8. Beginning 5/10/19, the Administrator / designee started in-services for all other nursing staff, to include CNAs on the manufacturer's guidelines for alternate placement of a Wanderguard bracelet when it cannot be placed on the resident's arm; 9. To ensure the failed practice does not recur, on 5/9/19, the Administrator added orientation with a live demonstration and in-service for all staff by the Environmental Services Director of the Wanderguard system on how it functions, including manufacturer's guidelines for alternate placement of a Wanderguard bracelet, and (facility) Elopement policy and procedures; 10. Beginning 5/9/19, the DNS (Director of Nursing Services) / designee will observe the resident's Wanderguard bracelet placement to ensure the facility is following manufacturer guidelines, and will review their medical records to ensure physician's orders [REDACTED]. Monitoring will be 3 times a week for 4 weeks. Any negative findings will be corrected immediately. If no negative findings, monitoring will continue 2 times a week for 4 weeks. Any negative findings will be corrected immediately. Then if no negative findings are observed, monitoring will continue 1 time a week until sustained and substantial compliance is achieved. Results of the monitoring will be presented to the QA (Quality Assurance) Committee monthly for any recommendation .

Based on record review and interview, the facility failed to ensure an allegation of staff to resident physical abuse was promptly reported to the Administrator/Designee; the allegation was thoroughly investigated and residents were protected from the potential of further abuse during the investigation; the local law enforcement agency was notified at the time of the allegation; and the allegation was reported to the Office of Long Term Care (OLTC) by 11:00 a.m. the next business day for 1 of 1 (Resident #9) case mix resident who made an allegation of abuse. These failed practices resulted in Immediate Jeopardy which caused or could have caused serious harm, injury or death to Resident #9, who alleged a rib fracture due to rough handling during bed mobility assistance by Certified Nursing Assistant (CNA) #4, and had the potential to affect 28 residents who required assistance with bed mobility, according to a list provided by the Administrator on 3/26/13. The facility was notified of the Immediate Jeopardy on 3/14/13 at 6:45 p.m. The findings are: 1. Resident #9 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set with an Assessment Reference Date of 1/29/13 documented the resident scored 10 (8-12 indicates moderate cognitive impairment) on the Brief Interview for Mental Status, required extensive physical assistance of one person with bed mobility, was 64-inches tall, weighed 130 pounds and had experienced no pain in the last five days. The resident's Comprehensive Care Plan dated 1/31/13 documented, "Alteration in mobility r/t (related to) muscle deconditioning... Bed mobility: Assist of 1 to turn side to side, move up in bed, move legs in / out of bed..." a. The resident's Daily Skilled Note forms dated 12/1/12 through 12/14/12 contained entries for each day that documented the resident had no complaints of pain. The Interdisciplinary Progress Notes contained a nurse's note entry dated 12/15/12 that documented the resident had no complaints of pain or discomfort. b. The Interdisciplinary Progress Notes contained a nurse's note entry dated 12/19/12 at 8:00 p.m. that documented, "Residents wife reported to this nurse that resident was experiencing pain to (right) lower ribs. Wife stated '(Resident #9) said the CNA (Certified Nursing Assistant) (CNA #4) has been too rough and I think he has a cracked rib' ...Resident also exhibited labored breathing ...R (respirations) 22 ...T (temperature) 100.5 Ax (axillary) ...APN (Advanced Practice Nurse) notified of change. Received new orders for CXR (chest x-ray) & rib x-ray..." c. The Interdisciplinary Progress Notes contained a nurse's note entry dated 12/19/12 at 8:30 p.m. that documented,"(Director of Nursing (DON)) notified by letter of complaint about CNA." d. A Request for X-ray form dated 12/19/12 documented, "...Date for X-ray to be performed... Today... If ordering between 10 (p.m.) and 7 (a.m.), do you want someone to come do the x-ray now or in the morning after 7 (a.m.)? ...Now ...Type of X-ray requested: Chest, (right) lower rib cage... Reason for X-Ray... pain shortness of breath..." Handwriting on the bottom of the form documented, "Faxed 2135 (9:35 p.m.) 12/19/12" e. A Final Radiology Report with an examination time of 12/19/2012 (at) 11:48 p.m. documented, "Date of Dictation: (12/20/12)... Date of Exam: (12/19/12) ...Findings: ...Irregularity in the anterior portion of the RIGHT 11th rib and 9th rib. The age of this finding is indeterminate and this may be acute and / or chronic ...Impression: 1. Possible RIGHT rib fractures as noted. The age of this finding is indeterminate and this may be acute and / or chronic..." f. The Interdisciplinary Progress Notes contained a nurse's note entry dated 12/20/12 at 10:00 a.m. that documented, "...APN called (and) asked that the DON (Director of Nursing) or ADON (Assistant Director of Nursing) be notified for rib fractures of unknown cause..." g. The Interdisciplinary Progress Notes contained a nurse's note entry dated 12/20/12 at 4:15 p.m. that was signed by the DON and documented, "Wife (and) resident interviewed at this time (with) Social Worker... present. It was agreed that resident had had a fall on 11/22, 23 (and) 24, 2012 and may have hurt himself then. The resident guided this writer (DON) through the event (with) the CNA. The resident then realized the CNA couldn't have physically caused him harm during the reenactment due to the layout of the bed. The resident decided he rolled over onto his own elbow enough to put pressure on 'a sore spot' ...Both wife and resident were relieved to know he had not been hurt by the CNA and probably hurt himself more than he thought in his falls in Nov (November)..." h. A Suggestion or Concern form dated 12/20/12 and signed by the DON documented, "...Report of Concern: 12:20 p.m. Received note from (LPN #2) dated 12/19/12 stating the resident believed his ribs were cracked due to rough care of CNA (CNA #4) ...16:15 (4:15 p.m.) investigation Social worker (name of Social Worker) and writer visited (with) resident & his wife ...The resident was asked to review the rough treatment resulting in cracked ribs ...The resident & wife agreed he could not have put an elbow in him (right ribs) during the turn to his right side ...Note: I was not called about this situation. LPN gave me a handwritten note recharted info that was found in a stack of papers later the next morning (12/20/12). (signed by DON) ...Resolution: Resident stated he did not want (CNA #4) to care for him. CNA (CNA #4) is not scheduled to work 12/20/12 so not suspended ...Follow up Comments ...The resident continues to not want (CNA #4) to care for him." i. The Interdisciplinary Progress Notes contained a nurse's note entry dated 12/24/12 at 10:30 a.m. that documented, "... Police Dept. Department) here to speak (with) resident regarding a report filed 'last week' by residents daughter...." j. The DMS (Division of Medical Services)-7734 OLTC (Office of Long Term Care) Incident and Accident Report (I&A) dated 12/24/12 documented, "Date and Time Submitted (if known): 12/24/12 (at) 1:00 p.m. ...Date & Time of Discovery: 12/20/12 (at) 12:20 p.m. Date of I&A: 12/19/12 Time: 8:00 p.m. ...Notifications: ...Law Enforcement ... No ...Summary of Incident ...On 12/20/12 at 12:20 p.m. (Director of Nursing (DON)) received written notification that wife reported resident experiencing right, lower rib pain and complained about C.N.A. (Certified Nursing Assistant) (CNA #4) being too rough with resident. On 12/20/12 at 4:20 p.m., D.O.N. and Director of Social Services met with the resident and his spouse in resident's room. D.O.N. reenacted how the CNA turned the resident (based on the resident's explanation of incident). Resident reported that the alleged incident occurred when the CNA was turning him in order to change his brief. After reenactment of alleged incident, resident and his spouse agreed that the resident's own elbow caused pressure on a sore spot and that it was not the CNA directly causing the source of the pain. In addition, resident and spouse also agreed that resident may have hurt himself during previous falls on 11/22/12, 11/23/12 and 11/24/12... Steps taken to prevent continued abuse or neglect during the investigation ... CNA (CNA #4) has not been providing care to the Resident." k. An Incident Details form signed by LPN #2 on 12/25/12 documented, "...Date Incident Reported: 12/19/12... Time Reported: ...2000 (8:00 p.m.) Alleged Nature of Incident: ...Staff-To-Resident Incident ...Comments: Residents wife reported to this nurse that CNA (CNA #4) had been too rough & that wife and resident both thought his (right) lower ribs may be fractured Part of Body Allegedly injured... Ribs (right) ...What immediate interventions have been put in place to prevent this incident from happening again? ...CNA not to care for resident ...Signature of Person Completing... (LPN #2) Date: 12/25/12 ...Notification: Administrator Notified (Yes) ...12/24/12 at 12:00 p.m. ...Does this incident require notification to a State / Agency? (Yes) ...Arkansas OLTC ...Date 12/24/12 Time 1300 (1:00 p.m.)..." l. The DMS-762 Facility Investigation Report for Resident Abuse, Neglect, Misappropriation of Property, & Exploitation of Residents in Long-Term Care Facilities documented, "...Date Incident Reported to OLTC: 12/24/12 Time: 1:00 p.m. ...Date and Time of Discovery: 12/19/12 Time: 8:00 p.m. ...Section III-Findings and Actions Taken Please include Resident's current medical condition Resident's current medical condition is stable. Vital signs: B/P (Blood Pressure) 114/54; P(pulse) 78; R (respirations) 20; Temp (Temperature) 96.8. He is alert and oriented to place, person and event and can self-propel his own wheelchair. Findings: Resident is not always oriented to time and on occasion, he is confused. At times, he can be over-demanding. Resident is hearing impaired and needs to wear hearing aides in order to hear. Administrator Signature: (DON) Date: 12/31/12... Section IV- Notification Status Administrator / Written Designee Must be Notified! Name of Administrator (Administrator Name) Date 12/20/12 Time 12:20 p.m. ...Law Enforcement Must be Notified for Abuse and Neglect ...Date 12/24/12 Time 10:30 a.m." 1) An OLTC witness statement signed by LPN #3, who worked the 3:00 p.m. to 11:00 p.m. shift, was dated 12/24/12 at 3:23 p.m. and documented, "...(LPN #2) came to me & wanted to know what to do about (Resident #9)'s wife report about her husband. I told her to call (DON) and fill out report on it." 2) An OLTC witness statement signed by the Director for Social Services was dated 12/24/12 at 4:25 p.m. and documented, "...I met with resident's roommate... I asked him if he remembers the resident getting hurt and (roommate) said 'No.' I also asked (roommate) if he ever had problems with the CNA (CNA #4) and resident said 'No'." 3) An OLTC witness statement signed by CNA #4 was dated 12/27/12 at 11:33 a.m. and documented, "...1. I did not hit him in any way ...3. I thought there were not any problems between us & he has thanked me many times when changing him." 4) An OLTC witness statement dated 12/28/12 at 11:15 a.m. and signed by the spouse of Resident #9 documented, "Met with resident and spouse (The DON and Social Services) ...spouse stated 'The CNA is rough with (Resident #9). The times that he fell he did not complain about side pain." 5) An OLTC witness statement signed by the DON was dated 12/28/12 at 4:15 p.m. and documented, "...On 12/20/12 I found a nurses note regarding (Resident #9) in my correspondence at 12:20 p.m. ...I then asked (Resident #9) what happened & he said that the aide hurt his rib when turning him ...(Resident #9) then told me how to turn him to show us how it happened ...Recognizing the aide has a protuberant stomach (Resident #9) realized the aide could not have gotten his elbow past his stomach & into his side..." 6) An OLTC witness statement signed by LPN #2 (no longer employed at the facility), who worked the 7:00 a.m. to 3:00 p.m. to 11:00 p.m. shift and the 3:00 p.m. to 11:00 p.m. shift, was dated 12/28/12 at 3:15 p.m. and documented, "...Residents wife reported to this nurse on 12/19/12 (3:00 p.m. to 11:00 p.m.) shift that resident was experiencing pain to lower (right) ribs. Wife then told me that the CNA (CNA #4) was too rough & she thought resident had a cracked rib. Resident also thought he had a cracked rib ...I then ask(ed) the senior nurse (LPN) on staff... what else should be done. I told her (LPN) I kinda felt like I should be doing something more. She told me there was a report paper to be filled out for the DON to make her aware of the situation & she looked for the form but could not find any. She then told me to just write the DON a letter explaining the situation. I wrote a letter to the DON restating what the resident's chart says. The residents wife was present & aware of the new orders for x-ray and that I had to report what she told me." m. On 3/14/13 from 4:35 p.m. to 4:55 p.m., 7 alert and oriented residents were interviewed individually and asked if they knew CNA #4 and if the CNA had been rough or abusive during care. Two of the 7 residents stated the CNA was rough during care. m. On 3/14/13 at 4:40 p.m., the DON was interviewed regarding the 12/19/12 incident. She stated, "He (Resident #9) thought he (CNA #4) was rough with him and we re-enacted it out with him. The Social Services, his wife, he and I all met in his room and after the re-enactment he realized that the CNA could not have hurt him but that in turning over onto his side his own elbow was under him and could've caused the soreness." She was asked, "When the LPN received this report from the resident's wife, what should she have done?" She stated, "She should've called me." The DON was asked, "What did you do to protect him from the CNA?" She stated, "He (CNA #4) couldn't go back in his (Resident #9) room." She was asked, "What about the other residents in the facility? What was done to protect them?" She stated, "I'll have to look in the file. The Social Services talked to them. It should be in the file." She looked at the file, locating one statement from the resident's roommate. She was asked, "Did you talk to other employees that work with this CNA?" She stated "Yes, we did. They said they don't have any problems with him." As of 3/14/13 at 6:25 p.m., the DON or Administrator did not provide further witness statements other than those listed above in order to indicate that a thorough investigation had been completed. n. On 3/15/13 at 9:56 a.m., the Social Services Director was asked, "When was an investigation started for this (12/19/12) incident?" She looked at the calendar and looked at the file and stated, "I'd say 12/24/12." She further stated, "When the ADON (Assistant Director of Nursing) came in, we reviewed it." She was asked, "What prompted an investigation on 12/24/12?" She stated, "The police showed up at the facility. The daughter had called the police and made an allegation. I had been worried about it and then the police came so I called and told them (Administration) that we needed to report this." She was asked if she interviewed all of the cognitively aware residents. She stated, "Everyone I talked to (interview form) is in the folder." She was asked, "When the nurse got this report from the resident's wife what should she have done?" She stated, "Called the DON immediately?" The Social Services Director was asked, "What should have been done with the CNA?" She stated, "Should've been suspended." She was asked, "And this is to do what?" She stated, "To protect all of our residents." o. On 3/15/13 at 10:15 a.m., the resident's wife was asked, "Do you feel he (CNA #4) was rough with him (Resident #9)?" She stated, "He almost had to be. It hadn't happened before or since." She further stated, "She (DON) told me he (CNA #4) wouldn't be back in the room." She was asked if her husband had any pain in his ribs since his falls in November (2012). She stated, "No." She was asked had he ever experienced problems with pain in his ribs or had other issues with his ribs in the past. She stated "No." p. The employee's time sheet was reviewed and CNA #4 worked 12/17/12, 12/18/12 and 12/19/12. The Shift Detail Report dated 12/12/12 through 3/13/13 documented CNA #4 continued to work in the facility, and last worked 3/13/13. 2. The Immediate Jeopardy was removed on 3/14/13 and the scope and severity reduced to an "H" when the facility implemented the following plan of removal: Upon discovery, effective 5:10 p.m. March 14, 2013 the Administrator instructed Director of Nursing Services to contact C.N.A. and suspend pending investigation. Administrator instructed DNS to prepare policy and procedure to be in-serviced effective immediately on all nursing staff pertaining to abuse and neglect including immediate reporting and protection of residents, safe resident handling, and resident rights. Administrator instructed DNS to conduct in-services effective immediately with all staff through staff acknowledgement on in-service record. No nursing staff will be allowed to work until they have been in-serviced on the above mentioned items. Administrator and Nurse Consultant conducted chart audits March 14, 2013 to determine any other residents who had the potential for abuse and neglect, improper resident handling, and violation of resident rights. Effective March 14, 2013 at 6:00 p.m., the Administrator instructed the Director of Nursing Services to interview residents & existing staff regarding the conduct of C.N.A. in question. Administrator, Director of Nursing Services, Director of Social Services, Nurse Consultant, and other interdisciplinary team members will meet daily Monday thru Friday at 8:45 a.m. to discuss any clinical condition changes for residents. Included in discussion will be Physician Notification, state mandated reportable information, resident change of condition, review and intervention established based upon Incident and Accident reporting, dietary and therapy information. Negative findings will be corrected immediately by the Director of Nursing Services, Director of Social Services, Director of Rehabilitation, Nurse Consultant and Dietary Services Manager. Additionally, Weekend Supervisor will be responsible for reviewing I&A reports and taking appropriate measures to ensure residents are protected.

Based on record review and interview, the facility failed to ensure their abuse policy and procedures were implemented as evidenced by the facility's failures to ensure an allegation of staff to resident physical abuse was promptly reported to the Administrator/Designee; the allegation was thoroughly investigated and residents were protected from the potential of further abuse during the investigation; the local law enforcement agency was notified at the time of the allegation; and the allegation was reported to the Office of Long Term Care (OLTC) by 11:00 a.m. the next business day for 1 of 1 (Resident #9) case mix resident who made an allegation of abuse. These failed practices resulted in Immediate Jeopardy which caused or could have caused serious harm, injury or death to Resident #9, who alleged a rib fracture due to rough handling during bed mobility assistance by Certified Nursing Assistant (CNA) #4, and had the potential to affect 28 residents who required assistance with bed mobility, according to a list provided by the Administrator on 3/26/13. The facility was notified of the Immediate Jeopardy on 3/14/13 at 6:45 p.m. The findings are: 1. The facility's Abuse and Neglect procedure was received from the Administrator on 3/11/13 at 1:10 p.m. and documented, "Purpose... To ensure that residents are not subjected to abuse by anyone, including, but not limited to, center staff... To ensure that all identified incidents of alleged or suspected abuse / neglect are promptly investigated to determine probable cause of unknown origin injuries... To identify and remedy any abuse situations. To prevent future injuries... To identify events, such as suspicious bruising of residents, occurrences, patterns and trends that may constitute abuse and to determine the direction of the investigation... Responsible Staff... All staff. Procedure... If a staff member receives an allegation of abuse... the staff member will immediately report this to a supervisor... The charge nurse or licensed nurse will be notified immediately, assess the situation to determine if any emergency treatment or action is required... If this is an injury of unknown origin, he or she also will attempt to determine the cause of the injury. The charge nurse also will ensure that any potential for further abuse is eliminated by taking one of the following actions... If this is an allegation of staff to resident abuse, the staff person will be removed from providing direct care to all residents. Additionally, the staff person will (be) placed on suspension pending the results of the internal investigation... When no determination of the cause of injury can be made OR when abuse or neglect is alleged or suspected, appropriate correction action will be taken... Notification Procedures: ...Notify the center administrator immediately of any incidents of resident abuse... alleged or suspected abuse and injury of unknown origin... In case of absence of the administrator, follow the chain of command for notification (DNS (Director of Nursing Services), SW (Social Worker), etc)... If it is suspected that a crime has been committed against a resident, then a report will be made to the survey and certification agency and law enforcement. If the events that cause the suspicion: results in serious bodily injury, the individual will report the suspicion, and... do not result in serious bodily injury, the individual will report the suspicion no later than 24 hours after forming the suspicion... Immediately call the critical incident notification (CIN) hotline when there is an allegation of ...physical abuse... The investigation team (social worker, the administrator and the director of nursing services) will review all Incident Report... that involve residents including those that indicate an injury of unknown origin, abuse... no later than the next working day following the incident... The investigation may include interviewing staff, residents or other witnesses to the incident. Interview all involved (staff, resident and family) individually... If possible, get signed and dated statements from any witnesses... The social worker or designated staff will report the results of all investigations to the state survey and certification agency and other officials within five (5) working days of the incident, unless otherwise specified by state law, whichever is stricter... Next Business Day Reporting of Incidents... The following events shall be reported to the Office of Long Term Care by facsimile transmission... no later than 11:00 a.m. on the next business day following discovery by the facility... Any alleged, suspected or witnessed occurrences of abuse or neglect to residents... Other Reporting Requirements... The facility's administrator is also required to make any other reports of incidents, accidents, suspected abuse... as required by state and federal laws and regulations... The facility must ensure that all alleged or suspected incidents involving resident abuse... are thoroughly investigate. The facility's investigation must be in conformance with the process and documentation requirements specified on the form designated by the Office of Long Term Care, Form DMS 762, and must prevent further potential incidents while the investigation is in progress..." 2. Resident #9 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set with an Assessment Reference Date of 1/29/13 documented the resident scored 10 (8-12 indicates moderate cognitive impairment) on the Brief Interview for Mental Status, required extensive physical assistance of one person with bed mobility, was 64-inches tall, weighed 130 pounds and had experienced no pain in the last five days. The resident's Comprehensive Care Plan dated 1/31/13 documented, "Alteration in mobility r/t (related to) muscle deconditioning... Bed mobility: Assist of 1 to turn side to side, move up in bed, move legs in / out of bed..." a. The resident's Daily Skilled Note forms dated 12/1/12 through 12/14/12 contained entries for each day that documented the resident had no complaints of pain. The Interdisciplinary Progress Notes contained a nurse's note entry dated 12/15/12 that documented the resident had no complaints of pain or discomfort. b. The Interdisciplinary Progress Notes contained a nurse's note entry dated 12/19/12 at 8:00 p.m. that documented, "Residents wife reported to this nurse that resident was experiencing pain to (right) lower ribs. Wife stated '(Resident #9) said the CNA (Certified Nursing Assistant) (CNA #4) has been too rough and I think he has a cracked rib' ...Resident also exhibited labored breathing ...R (respirations) 22 ...T (temperature) 100.5 Ax (axillary) ...APN (Advanced Practice Nurse) notified of change. Received new orders for CXR (chest x-ray) & rib x-ray..." c. The Interdisciplinary Progress Notes contained a nurse's note entry dated 12/19/12 at 8:30 p.m. that documented,"(Director of Nursing (DON)) notified by letter of complaint about CNA." d. A Request for X-ray form dated 12/19/12 documented, "...Date for X-ray to be performed... Today... If ordering between 10 (p.m.) and 7 (a.m.), do you want someone to come do the x-ray now or in the morning after 7 (a.m.)? ...Now ...Type of X-ray requested: Chest, (right) lower rib cage... Reason for X-Ray... pain shortness of breath..." Handwriting on the bottom of the form documented, "Faxed 2135 (9:35 p.m.) 12/19/12" e. A Final Radiology Report with an examination time of 12/19/2012 (at) 11:48 p.m. documented, "Date of Dictation: (12/20/12)... Date of Exam: (12/19/12) ...Findings: ...Irregularity in the anterior portion of the RIGHT 11th rib and 9th rib. The age of this finding is indeterminate and this may be acute and / or chronic ...Impression: 1. Possible RIGHT rib fractures as noted. The age of this finding is indeterminate and this may be acute and / or chronic..." f. The Interdisciplinary Progress Notes contained a nurse's note entry dated 12/20/12 at 10:00 a.m. that documented, "...APN called (and) asked that the DON (Director of Nursing) or ADON (Assistant Director of Nursing) be notified for rib fractures of unknown cause..." g. The Interdisciplinary Progress Notes contained a nurse's note entry dated 12/20/12 at 4:15 p.m. that was signed by the DON and documented, "Wife (and) resident interviewed at this time (with) Social Worker... present. It was agreed that resident had had a fall on 11/22, 23 (and) 24, 2012 and may have hurt himself then. The resident guided this writer (DON) through the event (with) the CNA. The resident then realized the CNA couldn't have physically caused him harm during the reenactment due to the layout of the bed. The resident decided he rolled over onto his own elbow enough to put pressure on 'a sore spot' ...Both wife and resident were relieved to know he had not been hurt by the CNA and probably hurt himself more than he thought in his falls in Nov (November)..." h. A Suggestion or Concern form dated 12/20/12 and signed by the DON documented, "...Report of Concern: 12:20 p.m. Received note from (LPN #2) dated 12/19/12 stating the resident believed his ribs were cracked due to rough care of CNA (CNA #4) ...16:15 (4:15 p.m.) investigation Social worker (name of Social Worker) and writer visited (with) resident & his wife ...The resident was asked to review the rough treatment resulting in cracked ribs ...The resident & wife agreed he could not have put an elbow in him (right ribs) during the turn to his right side ...Note: I was not called about this situation. LPN gave me a handwritten note recharted info that was found in a stack of papers later the next morning (12/20/12). (signed by DON) ...Resolution: Resident stated he did not want (CNA #4) to care for him. CNA (CNA #4) is not scheduled to work 12/20/12 so not suspended ...Follow up Comments ...The resident continues to not want (CNA #4) to care for him." i. The Interdisciplinary Progress Notes contained a nurse's note entry dated 12/24/12 at 10:30 a.m. that documented, "... Police Dept. Department) here to speak (with) resident regarding a report filed 'last week' by residents daughter...." j. The DMS (Division of Medical Services)-7734 OLTC (Office of Long Term Care) Incident and Accident Report (I&A) dated 12/24/12 documented, "Date and Time Submitted (if known): 12/24/12 (at) 1:00 p.m. ...Date & Time of Discovery: 12/20/12 (at) 12:20 p.m. Date of I&A: 12/19/12 Time: 8:00 p.m. ...Notifications: ...Law Enforcement ... No ...Summary of Incident ...On 12/20/12 at 12:20 p.m. (Director of Nursing (DON)) received written notification that wife reported resident experiencing right, lower rib pain and complained about C.N.A. (Certified Nursing Assistant) (CNA #4) being too rough with resident. On 12/20/12 at 4:20 p.m., D.O.N. and Director of Social Services met with the resident and his spouse in resident's room. D.O.N. reenacted how the CNA turned the resident (based on the resident's explanation of incident). Resident reported that the alleged incident occurred when the CNA was turning him in order to change his brief. After reenactment of alleged incident, resident and his spouse agreed that the resident's own elbow caused pressure on a sore spot and that it was not the CNA directly causing the source of the pain. In addition, resident and spouse also agreed that resident may have hurt himself during previous falls on 11/22/12, 11/23/12 and 11/24/12... Steps taken to prevent continued abuse or neglect during the investigation ... CNA (CNA #4) has not been providing care to the Resident." k. An Incident Details form signed by LPN #2 on 12/25/12 documented, "...Date Incident Reported: 12/19/12... Time Reported: ...2000 (8:00 p.m.) Alleged Nature of Incident: ...Staff-To-Resident Incident ...Comments: Residents wife reported to this nurse that CNA (CNA #4) had been too rough & that wife and resident both thought his (right) lower ribs may be fractured Part of Body Allegedly injured... Ribs (right) ...What immediate interventions have been put in place to prevent this incident from happening again? ...CNA not to care for resident ...Signature of Person Completing... (LPN #2) Date: 12/25/12 ...Notification: Administrator Notified (Yes) ...12/24/12 at 12:00 p.m. ...Does this incident require notification to a State / Agency? (Yes) ...Arkansas OLTC ...Date 12/24/12 Time 1300 (1:00 p.m.)..." l. The DMS-762 Facility Investigation Report for Resident Abuse, Neglect, Misappropriation of Property, & Exploitation of Residents in Long-Term Care Facilities documented, "...Date Incident Reported to OLTC: 12/24/12 Time: 1:00 p.m. ...Date and Time of Discovery: 12/19/12 Time: 8:00 p.m. ...Section III-Findings and Actions Taken Please include Resident's current medical condition Resident's current medical condition is stable. Vital signs: B/P (Blood Pressure) 114/54; P(pulse) 78; R (respirations) 20; Temp (Temperature) 96.8. He is alert and oriented to place, person and event and can self-propel his own wheelchair. Findings: Resident is not always oriented to time and on occasion, he is confused. At times, he can be over-demanding. Resident is hearing impaired and needs to wear hearing aides in order to hear. Administrator Signature: (DON) Date: 12/31/12... Section IV- Notification Status Administrator / Written Designee Must be Notified! Name of Administrator (Administrator Name) Date 12/20/12 Time 12:20 p.m. ...Law Enforcement Must be Notified for Abuse and Neglect ...Date 12/24/12 Time 10:30 a.m." 1) An OLTC witness statement signed by LPN #3, who worked the 3:00 p.m. to 11:00 p.m. shift, was dated 12/24/12 at 3:23 p.m. and documented, "...(LPN #2) came to me & wanted to know what to do about (Resident #9)'s wife report about her husband. I told her to call (DON) and fill out report on it." 2) An OLTC witness statement signed by the Director for Social Services was dated 12/24/12 at 4:25 p.m. and documented, "...I met with resident's roommate... I asked him if he remembers the resident getting hurt and (roommate) said 'No.' I also asked (roommate) if he ever had problems with the CNA (CNA #4) and resident said 'No'." 3) An OLTC witness statement signed by CNA #4 was dated 12/27/12 at 11:33 a.m. and documented, "...1. I did not hit him in any way ...3. I thought there were not any problems between us & he has thanked me many times when changing him." 4) An OLTC witness statement dated 12/28/12 at 11:15 a.m. and signed by the spouse of Resident #9 documented, "Met with resident and spouse (The DON and Social Services) ...spouse stated 'The CNA is rough with (Resident #9). The times that he fell he did not complain about side pain." 5) An OLTC witness statement signed by the DON was dated 12/28/12 at 4:15 p.m. and documented, "...On 12/20/12 I found a nurses note regarding (Resident #9) in my correspondence at 12:20 p.m. ...I then asked (Resident #9) what happened & he said that the aide hurt his rib when turning him ...(Resident #9) then told me how to turn him to show us how it happened ...Recognizing the aide has a protuberant stomach (Resident #9) realized the aide could not have gotten his elbow past his stomach & into his side..." 6) An OLTC witness statement signed by LPN #2 (no longer employed at the facility), who worked the 7:00 a.m. to 3:00 p.m. to 11:00 p.m. shift and the 3:00 p.m. to 11:00 p.m. shift, was dated 12/28/12 at 3:15 p.m. and documented, "...Residents wife reported to this nurse on 12/19/12 (3:00 p.m. to 11:00 p.m.) shift that resident was experiencing pain to lower (right) ribs. Wife then told me that the CNA (CNA #4) was too rough & she thought resident had a cracked rib. Resident also thought he had a cracked rib ...I then ask(ed) the senior nurse (LPN) on staff... what else should be done. I told her (LPN) I kinda felt like I should be doing something more. She told me there was a report paper to be filled out for the DON to make her aware of the situation & she looked for the form but could not find any. She then told me to just write the DON a letter explaining the situation. I wrote a letter to the DON restating what the resident's chart says. The residents wife was present & aware of the new orders for x-ray and that I had to report what she told me." m. On 3/14/13 from 4:35 p.m. to 4:55 p.m., 7 alert and oriented residents were interviewed individually and asked if they knew CNA #4 and if the CNA had been rough or abusive during care. Two of the 7 residents stated the CNA was rough during care. m. On 3/14/13 at 4:40 p.m., the DON was interviewed regarding the 12/19/12 incident. She stated, "He (Resident #9) thought he (CNA #4) was rough with him and we re-enacted it out with him. The Social Services, his wife, he and I all met in his room and after the re-enactment he realized that the CNA could not have hurt him but that in turning over onto his side his own elbow was under him and could've caused the soreness." She was asked, "When the LPN received this report from the resident's wife, what should she have done?" She stated, "She should've called me." The DON was asked, "What did you do to protect him from the CNA?" She stated, "He (CNA #4) couldn't go back in his (Resident #9) room." She was asked, "What about the other residents in the facility? What was done to protect them?" She stated, "I'll have to look in the file. The Social Services talked to them. It should be in the file." She looked at the file, locating one statement from the resident's roommate. She was asked, "Did you talk to other employees that work with this CNA?" She stated "Yes, we did. They said they don't have any problems with him." As of 3/14/13 at 6:25 p.m., the DON or Administrator did not provide further witness statements other than those listed above in order to indicate that a thorough investigation had been completed. n. On 3/15/13 at 9:56 a.m., the Social Services Director was asked, "When was an investigation started for this (12/19/12) incident?" She looked at the calendar and looked at the file and stated, "I'd say 12/24/12." She further stated, "When the ADON (Assistant Director of Nursing) came in, we reviewed it." She was asked, "What prompted an investigation on 12/24/12?" She stated, "The police showed up at the facility. The daughter had called the police and made an allegation. I had been worried about it and then the police came so I called and told them (Administration) that we needed to report this." She was asked if she interviewed all of the cognitively aware residents. She stated, "Everyone I talked to (interview form) is in the folder." She was asked, "When the nurse got this report from the resident's wife what should she have done?" She stated, "Called the DON immediately?" The Social Services Director was asked, "What should have been done with the CNA?" She stated, "Should've been suspended." She was asked, "And this is to do what?" She stated, "To protect all of our residents." o. On 3/15/13 at 10:15 a.m., the resident's wife was asked, "Do you feel he (CNA #4) was rough with him (Resident #9)?" She stated, "He almost had to be. It hadn't happened before or since." She further stated, "She (DON) told me he (CNA #4) wouldn't be back in the room." She was asked if her husband had any pain in his ribs since his falls in November (2012). She stated, "No." She was asked had he ever experienced problems with pain in his ribs or had other issues with his ribs in the past. She stated "No." p. The employee's time sheet was reviewed and CNA #4 worked 12/17/12, 12/18/12 and 12/19/12. The Shift Detail Report dated 12/12/12 through 3/13/13 documented CNA #4 continued to work in the facility, and last worked 3/13/13. 3. The Immediate Jeopardy was removed on 3/14/13 and the scope and severity reduced to an "H" when the facility implemented the following plan of removal: Upon discovery, effective 5:10 p.m. March 14, 2013 the Administrator instructed Director of Nursing Services to contact C.N.A. and suspend pending investigation. Administrator instructed DNS to prepare policy and procedure to be in-serviced effective immediately on all nursing staff pertaining to abuse and neglect including immediate reporting and protection of residents, safe resident handling, and resident rights. Administrator instructed DNS to conduct in-services effective immediately with all staff through staff acknowledgement on in-service record. No nursing staff will be allowed to work until they have been in-serviced on the above mentioned items. Administrator and Nurse Consultant conducted chart audits March 14, 2013 to determine any other residents who had the potential for abuse and neglect, improper resident handling, and violation of resident rights. Effective March 14, 2013 at 6:00 p.m., the Administrator instructed the Director of Nursing Services to interview residents & existing staff regarding the conduct of C.N.A. in question. Administrator, Director of Nursing Services, Director of Social Services, Nurse Consultant, and other interdisciplinary team members will meet daily Monday thru Friday at 8:45 a.m. to discuss any clinical condition changes for residents. Included in discussion will be Physician Notification, state mandated reportable information, resident change of condition, review and intervention established based upon Incident and Accident reporting, dietary and therapy information. Negative findings will be corrected immediately by the Director of Nursing Services, Director of Social Services, Director of Rehabilitation, Nurse Consultant and Dietary Services Manager. Additionally, Weekend Supervisor will be responsible for reviewing I&A reports and taking appropriate measures to ensure residents are protected.

Based on record review and interview, the facility Nursing Administration failed to ensure residents were free of abuse as evidenced by the failures to ensure an allegation of staff to resident physical abuse was promptly reported to the Administrator/Designee; the allegation was thoroughly investigated and residents were protected from the potential of further abuse during the investigation; the local law enforcement agency was notified at the time of the allegation; and the allegation was reported to the Office of Long Term Care (OLTC) by 11:00 a.m. the next business day for 1 of 1 (Resident #9) case mix resident who made an allegation of abuse. These failed practices resulted in Immediate Jeopardy which caused or could have caused serious harm, injury or death to Resident #9, who alleged a rib fracture due to rough handling during bed mobility assistance by Certified Nursing Assistant (CNA) #4, and had the potential to affect 28 residents who required assistance with bed mobility, according to a list provided by the Administrator on 3/26/13. The facility was notified of the Immediate Jeopardy on 3/14/13 at 6:45 p.m. The findings are: 1. The Job Description titled Director of Nursing Services was provided by the Director of Nursing on 3/15/13 at 11:50 a.m. and documented, "...Reports to Administrator... Provides care to assigned residents in a caring, safe and efficient manner; is responsible to perform the following according to... standards, procedures and individualized resident care plan: ...ensures quality performance and conformance with regulation and laws... Accepts accountability for activities under direct control... Exercises sound judgment and decision-making... Assures residents are free of neglect or abuse. Immediately reports any concerns related to ...resident abuse... Reports / assures appropriate action on any physical or emotional problems / concerns from observation or residents' report..." 2. Resident #9 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set with an Assessment Reference Date of 1/29/13 documented the resident scored 10 (8-12 indicates moderate cognitive impairment) on the Brief Interview for Mental Status, required extensive physical assistance of one person with bed mobility, was 64-inches tall, weighed 130 pounds and had experienced no pain in the last five days. The resident's Comprehensive Care Plan dated 1/31/13 documented, "Alteration in mobility r/t (related to) muscle deconditioning... Bed mobility: Assist of 1 to turn side to side, move up in bed, move legs in / out of bed..." a. The resident's Daily Skilled Note forms dated 12/1/12 through 12/14/12 contained entries for each day that documented the resident had no complaints of pain. The Interdisciplinary Progress Notes contained a nurse's note entry dated 12/15/12 that documented the resident had no complaints of pain or discomfort. b. The Interdisciplinary Progress Notes contained a nurse's note entry dated 12/19/12 at 8:00 p.m. that documented, "Residents wife reported to this nurse that resident was experiencing pain to (right) lower ribs. Wife stated '(Resident #9) said the CNA (Certified Nursing Assistant) (CNA #4) has been too rough and I think he has a cracked rib' ...Resident also exhibited labored breathing ...R (respirations) 22 ...T (temperature) 100.5 Ax (axillary) ...APN (Advanced Practice Nurse) notified of change. Received new orders for CXR (chest x-ray) & rib x-ray..." c. The Interdisciplinary Progress Notes contained a nurse's note entry dated 12/19/12 at 8:30 p.m. that documented,"(Director of Nursing (DON)) notified by letter of complaint about CNA." d. A Request for X-ray form dated 12/19/12 documented, "...Date for X-ray to be performed... Today... If ordering between 10 (p.m.) and 7 (a.m.), do you want someone to come do the x-ray now or in the morning after 7 (a.m.)? ...Now ...Type of X-ray requested: Chest, (right) lower rib cage... Reason for X-Ray... pain shortness of breath..." Handwriting on the bottom of the form documented, "Faxed 2135 (9:35 p.m.) 12/19/12" e. A Final Radiology Report with an examination time of 12/19/2012 (at) 11:48 p.m. documented, "Date of Dictation: (12/20/12)... Date of Exam: (12/19/12) ...Findings: ...Irregularity in the anterior portion of the RIGHT 11th rib and 9th rib. The age of this finding is indeterminate and this may be acute and / or chronic ...Impression: 1. Possible RIGHT rib fractures as noted. The age of this finding is indeterminate and this may be acute and / or chronic..." f. The Interdisciplinary Progress Notes contained a nurse's note entry dated 12/20/12 at 10:00 a.m. that documented, "...APN called (and) asked that the DON (Director of Nursing) or ADON (Assistant Director of Nursing) be notified for rib fractures of unknown cause..." g. The Interdisciplinary Progress Notes contained a nurse's note entry dated 12/20/12 at 4:15 p.m. that was signed by the DON and documented, "Wife (and) resident interviewed at this time (with) Social Worker... present. It was agreed that resident had had a fall on 11/22, 23 (and) 24, 2012 and may have hurt himself then. The resident guided this writer (DON) through the event (with) the CNA. The resident then realized the CNA couldn't have physically caused him harm during the reenactment due to the layout of the bed. The resident decided he rolled over onto his own elbow enough to put pressure on 'a sore spot' ...Both wife and resident were relieved to know he had not been hurt by the CNA and probably hurt himself more than he thought in his falls in Nov (November)..." h. A Suggestion or Concern form dated 12/20/12 and signed by the DON documented, "...Report of Concern: 12:20 p.m. Received note from (LPN #2) dated 12/19/12 stating the resident believed his ribs were cracked due to rough care of CNA (CNA #4) ...16:15 (4:15 p.m.) investigation Social worker (name of Social Worker) and writer visited (with) resident & his wife ...The resident was asked to review the rough treatment resulting in cracked ribs ...The resident & wife agreed he could not have put an elbow in him (right ribs) during the turn to his right side ...Note: I was not called about this situation. LPN gave me a handwritten note recharted info that was found in a stack of papers later the next morning (12/20/12). (signed by DON) ...Resolution: Resident stated he did not want (CNA #4) to care for him. CNA (CNA #4) is not scheduled to work 12/20/12 so not suspended ...Follow up Comments ...The resident continues to not want (CNA #4) to care for him." i. The Interdisciplinary Progress Notes contained a nurse's note entry dated 12/24/12 at 10:30 a.m. that documented, "... Police Dept. Department) here to speak (with) resident regarding a report filed 'last week' by residents daughter...." j. The DMS (Division of Medical Services)-7734 OLTC (Office of Long Term Care) Incident and Accident Report (I&A) dated 12/24/12 documented, "Date and Time Submitted (if known): 12/24/12 (at) 1:00 p.m. ...Date & Time of Discovery: 12/20/12 (at) 12:20 p.m. Date of I&A: 12/19/12 Time: 8:00 p.m. ...Notifications: ...Law Enforcement ... No ...Summary of Incident ...On 12/20/12 at 12:20 p.m. (Director of Nursing (DON)) received written notification that wife reported resident experiencing right, lower rib pain and complained about C.N.A. (Certified Nursing Assistant) (CNA #4) being too rough with resident. On 12/20/12 at 4:20 p.m., D.O.N. and Director of Social Services met with the resident and his spouse in resident's room. D.O.N. reenacted how the CNA turned the resident (based on the resident's explanation of incident). Resident reported that the alleged incident occurred when the CNA was turning him in order to change his brief. After reenactment of alleged incident, resident and his spouse agreed that the resident's own elbow caused pressure on a sore spot and that it was not the CNA directly causing the source of the pain. In addition, resident and spouse also agreed that resident may have hurt himself during previous falls on 11/22/12, 11/23/12 and 11/24/12... Steps taken to prevent continued abuse or neglect during the investigation ... CNA (CNA #4) has not been providing care to the Resident." k. An Incident Details form signed by LPN #2 on 12/25/12 documented, "...Date Incident Reported: 12/19/12... Time Reported: ...2000 (8:00 p.m.) Alleged Nature of Incident: ...Staff-To-Resident Incident ...Comments: Residents wife reported to this nurse that CNA (CNA #4) had been too rough & that wife and resident both thought his (right) lower ribs may be fractured Part of Body Allegedly injured... Ribs (right) ...What immediate interventions have been put in place to prevent this incident from happening again? ...CNA not to care for resident ...Signature of Person Completing... (LPN #2) Date: 12/25/12 ...Notification: Administrator Notified (Yes) ...12/24/12 at 12:00 p.m. ...Does this incident require notification to a State / Agency? (Yes) ...Arkansas OLTC ...Date 12/24/12 Time 1300 (1:00 p.m.)..." l. The DMS-762 Facility Investigation Report for Resident Abuse, Neglect, Misappropriation of Property, & Exploitation of Residents in Long-Term Care Facilities documented, "...Date Incident Reported to OLTC: 12/24/12 Time: 1:00 p.m. ...Date and Time of Discovery: 12/19/12 Time: 8:00 p.m. ...Section III-Findings and Actions Taken Please include Resident's current medical condition Resident's current medical condition is stable. Vital signs: B/P (Blood Pressure) 114/54; P(pulse) 78; R (respirations) 20; Temp (Temperature) 96.8. He is alert and oriented to place, person and event and can self-propel his own wheelchair. Findings: Resident is not always oriented to time and on occasion, he is confused. At times, he can be over-demanding. Resident is hearing impaired and needs to wear hearing aides in order to hear. Administrator Signature: (DON) Date: 12/31/12... Section IV- Notification Status Administrator / Written Designee Must be Notified! Name of Administrator (Administrator Name) Date 12/20/12 Time 12:20 p.m. ...Law Enforcement Must be Notified for Abuse and Neglect ...Date 12/24/12 Time 10:30 a.m." 1) An OLTC witness statement signed by LPN #3, who worked the 3:00 p.m. to 11:00 p.m. shift, was dated 12/24/12 at 3:23 p.m. and documented, "...(LPN #2) came to me & wanted to know what to do about (Resident #9)'s wife report about her husband. I told her to call (DON) and fill out report on it." 2) An OLTC witness statement signed by the Director for Social Services was dated 12/24/12 at 4:25 p.m. and documented, "...I met with resident's roommate... I asked him if he remembers the resident getting hurt and (roommate) said 'No.' I also asked (roommate) if he ever had problems with the CNA (CNA #4) and resident said 'No'." 3) An OLTC witness statement signed by CNA #4 was dated 12/27/12 at 11:33 a.m. and documented, "...1. I did not hit him in any way ...3. I thought there were not any problems between us & he has thanked me many times when changing him." 4) An OLTC witness statement dated 12/28/12 at 11:15 a.m. and signed by the spouse of Resident #9 documented, "Met with resident and spouse (The DON and Social Services) ...spouse stated 'The CNA is rough with (Resident #9). The times that he fell he did not complain about side pain." 5) An OLTC witness statement signed by the DON was dated 12/28/12 at 4:15 p.m. and documented, "...On 12/20/12 I found a nurses note regarding (Resident #9) in my correspondence at 12:20 p.m. ...I then asked (Resident #9) what happened & he said that the aide hurt his rib when turning him ...(Resident #9) then told me how to turn him to show us how it happened ...Recognizing the aide has a protuberant stomach (Resident #9) realized the aide could not have gotten his elbow past his stomach & into his side..." 6) An OLTC witness statement signed by LPN #2 (no longer employed at the facility), who worked the 7:00 a.m. to 3:00 p.m. to 11:00 p.m. shift and the 3:00 p.m. to 11:00 p.m. shift, was dated 12/28/12 at 3:15 p.m. and documented, "...Residents wife reported to this nurse on 12/19/12 (3:00 p.m. to 11:00 p.m.) shift that resident was experiencing pain to lower (right) ribs. Wife then told me that the CNA (CNA #4) was too rough & she thought resident had a cracked rib. Resident also thought he had a cracked rib ...I then ask(ed) the senior nurse (LPN) on staff... what else should be done. I told her (LPN) I kinda felt like I should be doing something more. She told me there was a report paper to be filled out for the DON to make her aware of the situation & she looked for the form but could not find any. She then told me to just write the DON a letter explaining the situation. I wrote a letter to the DON restating what the resident's chart says. The residents wife was present & aware of the new orders for x-ray and that I had to report what she told me." m. On 3/14/13 from 4:35 p.m. to 4:55 p.m., 7 alert and oriented residents were interviewed individually and asked if they knew CNA #4 and if the CNA had been rough or abusive during care. Two of the 7 residents stated the CNA was rough during care. n. On 3/14/13 at 4:40 p.m., the DON was interviewed regarding the 12/19/12 incident. She stated, "He (Resident #9) thought he (CNA #4) was rough with him and we re-enacted it out with him. The Social Services, his wife, he and I all met in his room and after the re-enactment he realized that the CNA could not have hurt him but that in turning over onto his side his own elbow was under him and could've caused the soreness." She was asked, "When the LPN received this report from the resident's wife, what should she have done?" She stated, "She should've called me." The DON was asked, "What did you do to protect him from the CNA?" She stated, "He (CNA #4) couldn't go back in his (Resident #9) room." She was asked, "What about the other residents in the facility? What was done to protect them?" She stated, "I'll have to look in the file. The Social Services talked to them. It should be in the file." She looked at the file, locating one statement from the resident's roommate. She was asked, "Did you talk to other employees that work with this CNA?" She stated "Yes, we did. They said they don't have any problems with him." As of 3/14/13 at 6:25 p.m., the DON or Administrator did not provide further witness statements other than those listed above in order to indicate that a thorough investigation had been completed. o. On 3/15/13 at 9:56 a.m., the Social Services Director was asked, "When was an investigation started for this (12/19/12) incident?" She looked at the calendar and looked at the file and stated, "I'd say 12/24/12." She further stated, "When the ADON (Assistant Director of Nursing) came in, we reviewed it." She was asked, "What prompted an investigation on 12/24/12?" She stated, "The police showed up at the facility. The daughter had called the police and made an allegation. I had been worried about it and then the police came so I called and told them (Administration) that we needed to report this." She was asked if she interviewed all of the cognitively aware residents. She stated, "Everyone I talked to (interview form) is in the folder." She was asked, "When the nurse got this report from the resident's wife what should she have done?" She stated, "Called the DON immediately?" The Social Services Director was asked, "What should have been done with the CNA?" She stated, "Should've been suspended." She was asked, "And this is to do what?" She stated, "To protect all of our residents." p. On 3/15/13 at 10:15 a.m., the resident's wife was asked, "Do you feel he (CNA #4) was rough with him (Resident #9)?" She stated, "He almost had to be. It hadn't happened before or since." She further stated, "She (DON) told me he (CNA #4) wouldn't be back in the room." She was asked if her husband had any pain in his ribs since his falls in November (2012). She stated, "No." She was asked had he ever experienced problems with pain in his ribs or had other issues with his ribs in the past. She stated "No." q. The employee's time sheet was reviewed and CNA #4 worked 12/17/12, 12/18/12 and 12/19/12. The Shift Detail Report dated 12/12/12 through 3/13/13 documented CNA #4 continued to work in the facility, and last worked 3/13/13. 3. The Immediate Jeopardy was removed on 3/14/13 and the scope and severity reduced to an "H" when the facility implemented the following plan of removal: Upon discovery, effective 5:10 p.m. March 14, 2013 the Administrator instructed Director of Nursing Services to contact C.N.A. and suspend pending investigation. Administrator instructed DNS to prepare policy and procedure to be in-serviced effective immediately on all nursing staff pertaining to abuse and neglect including immediate reporting and protection of residents, safe resident handling, and resident rights. Administrator instructed DNS to conduct in-services effective immediately with all staff through staff acknowledgement on in-service record. No nursing staff will be allowed to work until they have been in-serviced on the above mentioned items. Administrator and Nurse Consultant conducted chart audits March 14, 2013 to determine any other residents who had the potential for abuse and neglect, improper resident handling, and violation of resident rights. Effective March 14, 2013 at 6:00 p.m., the Administrator instructed the Director of Nursing Services to interview residents & existing staff regarding the conduct of C.N.A. in question. Administrator, Director of Nursing Services, Director of Social Services, Nurse Consultant, and other interdisciplinary team members will meet daily Monday thru Friday at 8:45 a.m. to discuss any clinical condition changes for residents. Included in discussion will be Physician Notification, state mandated reportable information, resident change of condition, review and intervention established based upon Incident and Accident reporting, dietary and therapy information. Negative findings will be corrected immediately by the Director of Nursing Services, Director of Social Services, Director of Rehabilitation, Nurse Consultant and Dietary Services Manager. Additionally, Weekend Supervisor will be responsible for reviewing I&A reports and taking appropriate measures to ensure residents are protected.