Every finding on record at Nightingale at Arkadelphia

Based on interview, record review, and policy review, the facility failed to ensure a refund was received by the resident or responsible party within 30 days from the date of discharge for 6 residents (Residents #277, #278, #279, #281, #282 and #284). The findings are: 1. The Surveyor reviewed the Discharge Minimum Data Set (MDS) of Resident #277, and it showed Resident #277 was discharged on [DATE]. Resident #277's balance as of 06/18/2024 was $8.00 as listed on the Trial Balance form. 2. The Surveyor reviewed the Discharge MDS of Resident #278 and it showed Resident #278 was discharged on [DATE]. Resident #278's balance as of 06/18/2024 was $520.00 as listed on the Trial Balance form. 3. The Surveyor reviewed the Discharge MDS of Resident #279 and it showed Resident #279 was discharged on [DATE]. Resident #279's balance as of 06/18/2024 was $598.37 as listed on the Trial Balance form. 4. The Surveyor reviewed the Discharge MDS of Resident #281 and it showed Resident #281 was discharged on [DATE]. Resident #281's balance as of 06/18/2024 was $100.21 as listed on the Trial Balance form. 5. The Surveyor reviewed the Discharge MDS of Resident #282 and it showed Resident #282 was discharged on [DATE]. Resident #282's balance as of 06/18/2024 was $0.22 as listed on the Trial Balance form. 6. The Surveyor reviewed the Discharge MDS of Resident #284 and it showed Resident #284 was discharged on [DATE]. Resident #284's balance as of 06/18/2024 was $63.08 as listed on the Trial Balance form. 7. The Surveyor reviewed the Discharge MDS of Resident #284 which revealed Resident #284 was discharged on [DATE]. a. On 06/19/2024 at 10:25 AM, a review of resident trust account balances on form titled Trial Balance revealed 6 Residents had balances that were at 30 days and over since the resident's discharged . b. On 06/20/2024 at 10:30 AM, the Surveyor interviewed the Business Office Manager (BOM) regarding the 6 accounts that had a balance and had been discharged over 30 days. The BOM was asked, can you explain why these accounts are still open? The BOM indicated she had asked her consultant, and I don't know. The BOM was asked when a resident is discharged from the facility how long does the facility have to return the money? The BOM indicated 30 days. c. On 06/20/2024 at 11:15 AM, during an interview with the Administrator about Resident Funds, the Administrator was asked when a resident discharges from the facility, how long does the facility have to return the resident's money. The Administrator indicated 30 days. d. An untitled Policy regarding Resident Accounts was provided by the Administrator on 06/20/2024 at 12:14 PM, the policy stated, .Conveyance of Funds upon death. Upon the death of a Resident/Elder, all money and valuables entrusted to the nursing facility will be surrendered in exchange for a signed receipt. The funds deposited with the nursing facility, and a final accounting of the Resident/Elder's funds, will be conveyed to the individual or probate jurisdiction administering the Resident/Elder's estate within 30 days.

Based on observation and interview, the facility failed to ensure 1 ice machine and 1 scoop holder were maintained in clean and sanitary condition to prevent contamination of airborne particles; foods stored in the dry storage area refrigerator and freezer were covered and sealed to minimize the potential for food borne illness for residents who received meals from 1 of 1 kitchen; expired food items were promptly removed from stock to prevent potential food borne illness for residents who received meal trays from 1 of 1 kitchen; foods were dated the day received to assure first in, first out usage to prevent potential for food bone illness; door frames and floor tiles were free of chips, stains and rust and were maintained in clean sanitary conditions, and dietary staff washed their hands before handling clean equipment or food items to prevent potential food borne illness for residents who received meals from 1 of 1 kitchen. These failed practices had the potential to affect 70 residents who received meals from the kitchen, (total census: 73), as documented on a list provided by the Dietary Supervisor on [DATE] at 9:01 AM. The findings are: 1. On [DATE] at 10:18 AM, an opened gallon of whole milk was on a shelf in the walk-in refrigerator. There was no opened or received date on the container. 2. On [DATE] at 10:19 AM, another opened gallon of whole milk was on a shelf in the walk-in refrigerator. There was no opened or received date on the container. 3. On [DATE] at 8:25 AM, the ice scoop holder on the wall by the ice machine had a buildup of pink residue at the bottom of it and the ice scoop was in direct contact with the buildup. The Surveyor asked the Dietary Supervisor to wipe the inside of the ice scoop holder. She did so and stated it was pink residue. The Surveyor asked how often they cleaned the scoop holder. She stated, We clean it every night. The Surveyor asked if it looked like it had been cleaned every night. She stated, No. 4. On [DATE] at 8:29 AM, the ice machine panel had an accumulation of wet rusty residue on it. The Surveyor asked the Dietary Supervisor to wipe the panel. The rust residue easily transferred to the tissue. She stated, That was rust on it. I have told the maintenance man to remove the screws. We wipe it off every day. The Surveyor asked, Who uses the ice from the ice machine? She stated, That's the ice the CNAs [Certified Nursing Assistants] use for the water pitchers in the residents' rooms and the residents' beverages at the mealtimes. 5. On [DATE] at 8:37 AM, the following observations were made in the Storage Room: a. Two 24 ounce bags of crispy fried onions were on a shelf with an expiration date of [DATE]. b. A closed box that contained 24 bags of crispy fried onions on a shelf with an expiration date of [DATE]. 6. On [DATE] at 8:41 AM, an opened box of dinner rolls was on a shelf in the freezer. The box was not covered or sealed, and the dinner rolls were discolored. The Surveyor asked the Dietary Supervisor to describe the appearance of the rolls in the box. She stated, They look like they have been unthawed and refrozen. 7. On [DATE] at 8:45 AM, an opened box of sausage was on a shelf in the refrigerator. The box was not covered or sealed. 8. On [DATE] at 8:50 AM, an opened bag of classic roast coffee was on the tray below the counter where the tea and coffee maker were kept. 9. On [DATE] at 8:52 AM, the door frames leading to the Kitchen, Janitor's Closet, Dish Washing Machine rooms, the Storage Room by the freezer, and the door frames where boxes of thickened beverages were stored were chipped exposing the metal. The Storage Room floor was chipped in 8 different areas exposing the concrete. The door leading to the outside from the Storage Room was rusty. 10. On [DATE] at 9:09 AM, the following observations were made in the refrigerator at the Nurse's Station on the East Hall: a. A cup of pudding on a shelf had no lid on it. b. A container with 8 pieces of fried chicken had a Sell by date of [DATE]. c. A bowl that contained casserole has no name and or date when it was received. 11. On [DATE] at 9:19 AM, the following observations were made in the freezer at the Nurse's Station on the [NAME] Hall: a. Two hot pockets with no received date on the packets. b. An opened bag of fully cooked sausage links was not sealed. 12. On [DATE] at 9:21 AM, the following observations were made in the refrigerator. a. An opened bottle of iced tea was on a shelf. There was no name and no opened or received dates on the bottle. b. An opened 32 ounce bottle of strawberry lemonade was on a shelf, the bottle had no name and no opened or receive dates on the bottle. c. A box of fried chicken breast was on a shelf. There was no name and no opened or received dates on the box. The Surveyor asked the Dietary Supervisor to describe the appearance of the chicken. She stated, They look old. d. An opened bag of plain potato chips was in a bowl on a rack on the counter at the Nurse's Station. The bag was not sealed. e. There were 5 opened bags of cereal in a bowl on the counter. The bags were not sealed. 13. On [DATE] at 9:40 AM, the following observations were made in the unit cabinet: a. An opened 4 pound bag of granulated sugar was not sealed. b. An opened 4 pound bag of granulated sugar was not sealed. c. An opened 32 pound bag of dark brown sugar was not sealed. d. An opened 16 ounce box of sugar with an expiration date of [DATE]. e. A bag of instant mashed potato flakes with an expiration date of [DATE]. f. An opened box of salt was not covered. g. An opened bag of spaghetti was not covered. h. An opened container of garlic powder with no opened or received date on the container. i. A container of mustard with no opened or received date on the container. j. A opened container of ground nutmeg with no opened or received date on the container. k. A container of poppy seed with no opened or received date on the container. l. Opened bottle of pure vanilla extract with no opened or received date on the bottle. m. An opened 2 pound box of spaghetti. The box documented, Best by [DATE]. n. An opened box of rock salt with no opened or received date on the box. 14. On [DATE] at 9:58 AM, a deep rubber basin that contained ice that slightly melting was below a cart between the door leading to the kitchen. There was an opened half gallon of cultured low-fat buttermilk sitting on it. At 10:14 AM, the milk was in the deep basin on a cart in the walk-in refrigerator. The Surveyor asked the Dietary Employee (DE) #2 to check the temperature of the milk. She did and stated, It is 50 degrees Fahrenheit. I will throw it away. At 11:17 AM, the Surveyor asked DE #3 if he checked the temperature of the milk before taking it to the refrigerator. He stated, No, I didn't because it was on ice. I drained the ice off before I took it to the refrigerator. 15. On [DATE] at 10:11 AM, DE #1 turned on the hand washing sink faucet and washed her hands. After washing her hands, she used her bare hands to turn off the faucet. Without washing her hands, she picked up clean plates and placed them on the plate warmer with her fingers inside the plates. The Surveyor asked what she should have done after touching dirty objects, before handling clean equipment. She stated, I should have washed my hands. 16. The facility policy titled, Handwashing and Glove Usage in Food Service, provided by the Dietary Supervisor on [DATE] at 9:01 AM documented, . When Food Handlers must wash their hands: Before starting work . After touching anything else such as dirty equipment, work surfaces or cloths . Proper hand washing Procedure: . Use paper towel to turn off faucet.

Based on observation, record review and interview, the facility failed to implement the plan of care for 1 (Resident #53) of 1 sampled resident who had a fall in the last 60 days. The findings are: 1. On 08/28/23 at 11:32 AM, observed Resident #53 was sitting in a Geri chair beside the bed. A pressure alarm (chair alarm) was on the recliner in the resident's room, not in use. There was not a helmet, fidget lap pad, or activity rack with movable balls in or around the resident's room during the observation. The resident had a low bed in the room. 2. On 08/29/23 at 8:14 AM, observed a chair alarm lying in the recliner seat in Resident #53's room. There was not an activity rack with movable balls in the room. Resident #53 was sitting in a Geri chair at the doorway in the Dining Room. The resident did not have a helmet, chair alarm, or fidget lap pad on or near the resident. 3. On 08/29/23 at 11:13 AM, Resident #53 was sitting in a Geri chair at the Nurse's Station. The resident did not have a helmet, chair alarm, or fidget lap pad on. Observed a chair alarm in the recliner in the resident's room. There was not an activity rack with movable balls in the room. 4. On 08/30/23 at 8:15 AM, Resident #53 was in a Geri chair eating breakfast. There was no helmet, activity rack or mattress in the floor with a fall mat on each side in the room. 5. A Care Plan with the revision date of 08/23/23 noted Resident #53 was a high risk for falls and was to have his mattress on the floor with fall mats on both sides, or a low bed; a fidget lap pad, activity rack with movable balls to provide activities while providing diversions and distractions to minimize the potential for falls; a helmet, and a pressure alarm when in the Geri chair to alert staff of attempts to get out of the chair. 6. On 08/29/23 at 11:28 AM, the Surveyor accompanied Certified Nursing Assistant (CNA) #1 to Resident #53's room. The Surveyor asked CNA #1 to locate in the room a helmet, an activity rack with balls, and a chair alarm. CNA #1 stated, It's not in here. CNA #1 went to where the resident was sitting and stated, It's not out here either. The Surveyor asked if she had seen any of the interventions mentioned. CNA #1 stated, No ma'am, the resident hasn't had any of those interventions. 7. On 08/29/23 at 11:30 AM, the Surveyor accompanied Licensed Practical Nurse (LPN) #1 to Resident #53's. The Surveyor asked LPN #1 to locate in the room a helmet, an activity rack with balls, or a chair alarm. LPN #1 located the chair alarm lying in the recliner and stated, I can't see any of the other stuff. LPN #1 went to the Dayroom and stated, I don't see any of those out here either. 8. On 08/29/23 at 12:22 PM, a family member was assisting Resident #53 to eat lunch. The family member asked, Where did this come from? (Pointing to a brown helmet lying on the bed.) I visit every day to feed him, and he has never had that. 9. On 08/31/23 at 9:38 AM, during an interview, the DON confirmed the interventions were put in place to prevent the incident from reoccurring. 10. A facility policy titled, Accident Hazards Prevention, provided by the Administrator on 08/31/23 at 10:53 AM documented, .It is important that all facility staff understand the facility's responsibility, as well as their own, to ensure the safest environment possible for residents . An effective way for the facility to avoid accidents is to develop a culture of safety and commit to implementing systems that address resident risk and environmental hazards to minimize the likelihood of accidents . The resident will be assessed upon admission and through the MDS [Minimum Data Set] process to individualize care plan interventions.

Based on observation, record review and interview, the facility failed to ensure nailcare was regularly provided for 2 (Residents #20 and #22) of 4 (Residents #20, #22, #53 and #57) sampled residents who required staff assistance with nail care on the 200 Hall. The findings are: 1. On 08/28/23 at 4:15 PM, Resident #20's fingernails were long with a dark brown substance under them. a. On 08/29/23 at 8:53 AM, Resident #20 was eating breakfast in the Dining Room. Resident #20's fingernails were long with a dark brown substance under them. The resident was eating and holding food with his fingers. b. On 08/30/23 at 8:50 AM, Resident #20 was lying in bed. Resident #20's had a dark brown substance under his fingernails, and his fingernails had an odor. c. A Care Plan with a revision date of 02/06/19 noted Resident #20 required extensive assistance - dependent on one staff person with bathing. d. A Care Plan with a revision date of 07/06/23 noted Resident #20 had potential/actual impairment to skin integrity and his fingernails were to be kept short. e. On 08/30/23 at 8:50 AM, the Surveyor asked Certified Nursing Assistant (CNA) #1 to look at Resident #20's fingernails. CNA #1 stated, They need cut and cleaned. The Surveyor asked who was responsible for providing nail care. CNA #1 stated, Nurses do for diabetics. f. On 08/30/23 at 8:52 AM, the Surveyor asked Registered Nurse (RN) #1 to describe Resident #20's fingernails. RN #1 stated, There is some dark brown substance under them. I will clean them now. 2. On 08/28/23 at 12:27 PM, Resident #22 was lying in the bed. Resident #22 had a dark brown dried substance under his fingernails. a. On 08/29/23 at 8:12 AM, Resident #22 had a dark brown dried substance under his fingernails. b. On 08/30/23 at 8:50AM, Resident #22 was lying in bed. Resident #22's fingernails had a dark brown substance under his fingernails. c. A Care Plan with a revision date of 02/10/20 noted Resident #22 required total assistance of one staff person with bathing and personal hygiene. d. On 08/30/23 at 8:53 AM, the Surveyor asked CNA #2 to describe Resident #22's fingernails. CNA #2 stated, They are long and have skin under them. He has a skin condition, and he scratches. The Surveyor asked how often nail care was provided. CNA #2 stated, Shower Day and in between. The Surveyor asked what the color under the fingernails was. CNA #2 stated, Dark brown. 3. On 08/31/23 at 9:38 AM, the Surveyor asked the Director of Nursing (DON) who was responsible for resident nail care. The DON stated, Diabetics are the nurses, CNAs do the others. The Surveyor asked how often she expected nail care to be provided. She stated, Shower days and as needed. 4. On 08/31/23 at 1:40 PM, the DON stated there was no policy for nail care. We go by the care plan.

Based on observation, interview, and record review, the facility failed to ensure call devices were available and within reach for 1 (Resident #27) of 14 (Residents #3, #7, #12, #14, #15, #20, #22, #27, #39, #44, #53, #57, #62 and #274) sampled residents residing on the East Hall. The findings are: 1. On 08/28/23 at 11:10 AM, Resident #27 was lying in bed. The call device was lying in the floor behind the bedside table four feet from the resident's bed. a. On 08/29/23 at 1:31 PM, Resident #27 was lying in bed. The call device had not been moved from its position on the floor behind the bedside table. b. On 08/30/23 at 3:14 PM, Resident #27 was lying in bed. The call device had not been moved from its position on the floor behind the bedside table. c. On 08/30/23 at 3:30 PM, the Surveyor asked Certified Nursing Assistant (CNA) #3 if Resident #27 had the call device within reach. CNA #3 stated, No, I'm not usually on this hall. I'll get it fixed. d. The Care Plan with an initiated date of 12/20/16 and the last revision made on 08/29/23 noted Resident #27 was at risk for falls and had had 7 falls in the past and had the potential for developing pressure ulcers. Resident #27's needs were to be anticipated and met by staff and two staff needed to change his position at least every 2 hours. A Care plan, last revised on 2/21/22 noted Resident #27 will remove bed linens and throw them on the floor, with an intervention to remake the bed. e. On 08/30/23 at 12:40 PM, the Administrator informed the Surveyor the facility did not have a policy on call devices and relied on the individual resident's care plan.

Based on observation and interview, the facility failed to repair water damage in the wall of 1 (Resident room [ROOM NUMBER]) of 1 room on the East Hall. The findings are: 1. On 08/28/23 at 11:06 AM, observed Resident room [ROOM NUMBER] a damaged section of wall behind the B bed. The section measured 5 inches in height and 24 inches in width. The molding at the foot of the wall below the damaged portions had brown stains. There were additional brown stains on the floor. When touched, the material in the damaged section of the wall crumbled easily. 2. On 08/29/23 at 12:59 PM, observed in Resident room [ROOM NUMBER] the damage to the wall remained unchanged. 3. On 08/30/23 at 8:54 AM, observed in Resident room [ROOM NUMBER] the damage to the wall remained unchanged. 4. On 08/31/23 at 9:10 AM, the Surveyor accompanied the Director of Operations to Resident room [ROOM NUMBER]. The Director of Operations observed the damaged section of the wall and stated it was likely water damage caused by a malfunctioning air conditioning unit. Observed in the shower room, next to Resident room [ROOM NUMBER] a damaged section of tiles in the shower stall on the opposite side of the wall from the damage in Resident room [ROOM NUMBER]. The Director of Operations stated they would ensure it was repaired. 5. On 08/31/23 at 11:25 AM, the Administrator provided a policy titled, Housekeeping and Maintenance . The policy documented, .Maintenance .The nursing facility provides maintenance services to assure maintenance of the physical plant.

Based on observation and interview, the facility failed to ensure cooked food was discarded within 3 days; food was sealed and dated; food was thawed at appropriate temperatures and the floors were cleaned in 1 of 1 kitchen. This failed practice had the potential to affect 68 residents according to a list provided by the Administrator on 07/11/23 at 2:59 PM. The findings are: 1. On 07/10/23 at 9:31 AM, the followings items were observed in the Kitchen with the Dietary Manager: a. In the refrigerator there was a pan of green beans dated 7/06/23 with a use by date of 7/09/23; a pan of green beans with corn dated 7/07/23 and a box of sausage uncovered without a date. b. In the sink were two large packs of ground beef thawing in hot water. c. On the floors were black spots, food crumbs, paper, dirt, and a cup. The Dietary Managers office floors were black and sticky. d. On the bottom rack of the steam table were food crumbs. 2. On 07/10/23 at 9:39 AM, the Surveyor asked the Dietary Manager, Who's responsible for cleaning and mopping the kitchen? She stated, Everybody. The Surveyor asked, When was the last time the floors were cleaned, and mopped? She stated, Supposed to be the night shift. The Surveyor asked, When was the last time your office was mopped? She stated, Last Thursday. The Surveyor asked, Do you think the floors are properly cleaned? She stated, No. 3. On 07/10/23 at 9:42 AM, the Surveyor asked the Dietary Manager, Can you tell me why the sausages are not sealed and dated? She looked in the refrigerator, then she stated, I'll make sure they do it. 4. On 07/11/23 at 2:07 PM, the Surveyor asked the Dietary Manager, How long should cooked food stay in the refrigerator before it is discarded? She stated, Three days. The Surveyor asked, How should you thaw ground beef? She stated, Under tap water. The Surveyor asked, Can you tell me why the ground beef was thawing in hot water yesterday? She stated, I know. I went back in there and corrected it. The Surveyor asked, Why is it important to not thaw food in hot water? She stated, To keep it from causing bacteria. The Surveyor asked, Can you tell me why the green beans dated 7/06/23 and documented to use by 7/09/23 were not discarded and still in the refrigerator yesterday. She stated, I was intending to throw it out, but hadn't gotten around to it. 5. On 07/11/23 at 2:15 PM, the Surveyor asked Kitchen Staff #1, How long should cooked food stay in the refrigerator before it is discarded? She stated, Three days. The Surveyor asked, How should you thaw ground beef? She stated, In the refrigerator. The Surveyor asked, Can you tell me why the ground beef was thawing in hot water yesterday? She stated, No, I didn't hear that. I didn't know they did that. The Surveyor asked, Why is it important to not thaw food in hot water? She stated, To keep it from spoiling. The Surveyor asked, Can you tell me why the green beans dated 7/06/23 and to use by 7/09/23 were not discarded and were still in the refrigerator yesterday? She stated, No, I had been the dishwasher, and didn't start cooking until yesterday. The Surveyor asked, How often is the kitchen cleaned, She stated, Everyday, supposed to be every shift. The Surveyor asked, Can you tell me why the floor was dirty, and had food crumbs on it yesterday? She stated, I don't know.

Based on interview and record review, the facility failed to protect 1 (Resident #1) of 3 (Residents #1, #2, and #3) sampled residents from verbal abuse. The findings are: 1. Resident #1 had diagnoses of Unspecified Dementia, Unspecified Severity, without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, and Anxiety. a. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/24/23 indicated the resident had severe cognitive impairment. b. A review of the Care Plan with a revision date of 08/12/22 indicated Resident #1 had fair to poor safety awareness and required supervision/prompts/cues. c. An Incident Report dated 06/30/23 documented, .Certified Nursing Assistant (CNA) #1 stated, I was in the resident's bathroom when I overheard [CNA #2] bring [Resident #1] in and ask her, 'Why you threw that damn cup.' I heard her hit her twice and Resident #1 screamed, 'Oww '. d. On 07/11/23 at 9:15 AM, the Surveyor asked Licensed Practical Nurse (LPN) #2, What should you do if you see or hear a staff cursing or hitting a resident? She stated, Intervene, and stop them. Tell the person to get away from the resident. e. On 07/11/23 at 9:20 AM, the Surveyor asked CNA #3, What should you do if you see or hear a staff cursing or hitting a resident? CNA #3 stated, I usually report it to the nurse. Make sure the CNA is out of there and comfort the resident. f. On 07/11/23 at 9:28 AM, during a phone interview with CNA #1, the Surveyor asked, Can you tell me what happened when you witnessed [Resident #1] being abused? She stated, I heard [CNA #2] ask [Resident #1], 'Why you throw that damn cup.' I came out of [Resident #1 ' s] bathroom, and I went told the Administrator what happened. The Surveyor asked, When you left the bathroom who was in the room with [Resident #1]? She stated, Only [Resident #1]. [CNA #2] had left out of the room. I don't know if she had gone back to the Dining Room. The Surveyor asked, Can you tell me why you didn't stay in the room with [Resident #1] and call for help after you witnessed her being abused? She stated, I was so nervous because I never seen it done to anyone before. I just knew to report it. g. On 07/11/23 at 9:38 AM, the Surveyor asked LPN #3, What should you do if you see or hear a staff cursing or hitting a resident? She stated, First thing I'm going to do is get the resident from the situation and then report it. h. On 07/11/23 at 11:30 AM, the Surveyor asked LPN #4, What should you do if you see or hear a staff cursing or hitting a resident? She stated, Immediately intervene. Stop it, then report it. i. On 07/11/23 at 1:10 PM, the Surveyor asked Registered Nurse (RN) #1, What should you do if you see or hear a staff cursing or hitting a resident? She stated, I can't leave the resident. I got to do my best to call for assistance. I'll remove the resident if I'm able. If not, I'll have to stay with the resident. j. On 07/11/23 at 1:42 PM, the Surveyor asked CNA #4, What should you do if you see or hear a staff cursing or hitting a resident? She stated, Immediately make sure the resident is OK, then report it. The Surveyor asked, Should you leave the resident? She stated, No, if they're in a wheelchair I'm going to take them to the Nurses Station. k. On 07/11/23 at 2:42 PM, the Surveyor asked the Administrator, What should you do if you see or hear a staff cursing or hitting a resident? She stated, You jump right in and protect them. m. On 07/11/23 at 3:23 PM, the Surveyor asked the Director of Nursing (DON), What should you do if you see or hear a staff cursing or hitting a resident? She stated, Intervene. I would stop it. n. A facility policy titled, Preventing Resident Abuse, received from the Administrator on 07/11/23 at 10:24 AM documented, Your responsibility: To protect all residents from any form of abuse . o. A facility policy titled, Mandatory Education 2021, received from the Administrator on 07/11/23 at 10:55 AM documented, If you suspect abuse, neglect or exploitation, you are required to STOP IT, and REPORT IT immediately! If you witness a resident being abused or neglected, you should intervene and stop it if at all possible . Protect Resident .

Based on observation, interview and record review, the facility failed to ensure a resident was monitored by a nurse when receiving a breathing treatment for 1 (Resident #3) of 2 (Residents #2 and #3) sampled residents who had an order for for breathing treatments. The findings are: 1. Resident #3 had a diagnosis of Chronic Systolic (Congestive) Heart Failure. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/03/23 indicated Resident #3 had severe cognitive impairment. a. A Care Plan with an initiated and revision date of 04/11/23 indicated the resident had altered respiratory status and or shortness of breath and was to receive nebulizer treatments and was to be monitored for effectiveness and side effects. b. A Physicians Order dated 05/03/23 indicated Resident #3 was to receive an Albuterol updraft four times a time for shortness of breath. c. On 07/10/23 at 9:56 AM, Resident #3 was in his room with a nebulizer mask on his face receiving a breathing treatment. The nurse wasn't in the room. d. On 07/10/23 at 9:57 AM, Registered Nurse (RN) #1 was in the hallway getting medications out of the medication cart. The Surveyor asked, Can you tell me why you're not in the room with [Resident #3] while he's receiving a breathing treatment? She stated, If I'm wrong for being here and not in the room, I guess I'm mistaken. e. On 07/11/23 at 9:15 AM, the Surveyor asked Licensed Practical Nurse (LPN) #2, Should you leave a resident unattended if you are giving them a breathing treatment? She stated, No. The Surveyor asked, Can you tell me why it's important to stay with them when they are receiving a breathing treatment? She stated, To make sure they are receiving it correctly. f. On 07/11/23 at 9:38 AM, the Surveyor asked LPN #3, Should you leave a resident unattended if you are giving them a breathing treatment? She stated, No. The Surveyor asked, Can you tell me why it's important to stay with them when they are receiving a breathing treatment? She stated, Because it's a medication, and you're not to leave them when they're receiving a medication. g. On 07/11/23 at 11:30 AM, the Surveyor asked LPN #4, Should you leave a resident unattended if you are giving them a breathing treatment? She stated, No. The Surveyor asked, Can you tell me why it's important to stay with them when they are receiving a breathing treatment? She stated, Because they could put it down and not complete it. We used to monitor their pulse. h. On 07/11/23 at 1:10 PM, the Surveyor asked RN #1, Should you leave a resident unattended if you are giving them a breathing treatment? She stated, No, unless it's in their Care Plan The Surveyor asked, Can you tell me why it's important to stay with them when they are receiving a breathing treatment? She stated, Because they may take it off, or not get all the prescribed medication. Just for their general safety. i. On 07/11/23 at 3:20 PM, the Administrator reported that there is not a policy for nebulizer treatments. j. On 07/11/23 at 3:23 PM, the Surveyor asked the Director of Nursing (DON), Should you leave a resident unattended if you are giving them a breathing treatment? She stated, Not unless they have an order to self-administer, and they are care planned for it. I did do an in-service with the nurses on it? k. A review of a form titled, Medication Pass In-Service, documented, .10.Please note the nurse must remain in the resident's room while medication are administered via nebulizer ( .albuterol updrafts) Setting up the medication and leaving he room will be considered a medication error unless the resident has an order to self-administer his mediations .

Based on observation and interview, the facility failed to ensure dietary staff washed their hands before handling clean equipment or food items, food items stored in the freezer were covered or sealed, leftover food items were used by its use-by date to maintain food quality and expired food items were promptly removed/discarded by the expiration or use by dates, six ceiling fans in the Main Dining Room were clean and free from dust, and staff members did not touch the food surfaces of plates with their fingers and thumbs during meal service to prevent the potential for contamination and food borne illness in 1 of 1 kitchen and dining room. These failed practices had the potential to affect 69 residents who received meals from the kitchen (total census: 69), as documented on a list provided by the Dietary Supervisor on [DATE] at 3:23 PM. The findings are: 1. On [DATE] at 9:48 AM., Dietary Employee #2 Picked a bag of bread from a rack and placed it on the counter. She opened the refrigerator, took out a container of pimento cheese, and place it on the counter. Without washing her hands, she untied the bread bag, removed sliced of bread from the bag, and placed them on a plate. She used a 4 0z [ounce] spoon to place a serving of pimento cheese on a slice of bread and top it with another slice of bread to be served to the resident who requested for pimento cheese sandwich. 2. On [DATE] at 9:49 AM., the right interior panel of the ice machine in the kitchen had an area of wet colored residue. Dietary Supervisor was asked to wipe the residue inside the ice machine. He did so, and the rust-colored substance easily transferred to the tissue. He was asked, How often do you clean the ice machine? She stated, Once a week. He was asked who used the ice from the machine? She stated, That's the ice the CNA's [Certified Nursing Assistants] use to fill the water pitchers in the residents' rooms. 3. On [DATE] at 9:51 AM., a zip lock bag that contained leftover scrambled eggs and left-over sausage was stored on a shelf in a refrigerator. Dietary Employee #2 was asked, What you do with leftover scrambled eggs and sausage? He stated, We use it tomorrow for pureed foods. 4. On [DATE] at 9:53 AM., an opened box of sausage on a shelf in the walk-in refrigerator was not covered or sealed. An opened box of cookie dough and a box of biscuit dough on a shelf in the walk-in freezer were not covered or sealed. 5. On [DATE] at 10:06 AM., an opened box of corn starch on a shelf in the storage room was not covered or sealed. 6. On [DATE] at 10:12 AM., Dietary Employee #1 was wearing gloves on her hands. She pushed a cart towards the counter. Without changing gloves and washing her hands, she began picking up bowls for the residents' dessert for lunch, with her gloved fingers touching the interior surfaces of the bowls. 7. On [DATE] at 10:30 AM., Dietary Employee #1 pushed a cart that contained a pan of mixed fruits towards the counter. Without washing her hands, she picked up a clean blade and attached it the base of the blender to be used in pureeing foods to be served to the residents on pureed diets. She was asked what should have done after touching dirty objects and before handling clean equipment? She stated, I should have washed my hands. 8. On [DATE] at 10:59 AM., Dietary Employee #3 turned on the faucet and washed her hands, after washing her hands, she turned off the faucet with her bare hands, contaminating her hands. Dietary Employee #3, dried her hands with tissue paper, moved to the clean side in dish washing area and without washing her hands picked up clean dishes from the dish rack and stacked them on a clean cart, touching the clean plates with her hands. 9. On [DATE] at 11:04 AM., Dietary Employee #3 turned on the faucet and washed her hands. After washing her hands, she turned off the sink faucet with her bare hands, contaminating her hands. She dried her hands with tissue paper, moved to the clean side in dish washing area and without washing her hands, she picked up clean dishes from the dish rack and stacked them on a clean cart, touching the clean plates with her hands. Dietary Employee immediately was asked, What should have done after touching dirty objects and before handling clean equipment? She stated, I should have washed my hands. 10. On [DATE] at 8:19 AM., the following observations were made in the freezer and or on top of the freezer on east nurses' station: a. A box of Blue Bell Ultimate Neapolitan Ice Cream was stored on a shelf in the refrigerator. There was no date when it was opened. The ice cream was frosted and discolored. Dietary Supervisor was asked to describe the appearance of the ice cream. He stated. It was frosted. It looked like it has been there forever. b. One box of vegetable fried rice was on top of the refrigerator. The vegetable fried rice had a use by date of [DATE]. There was no name on the box or date when it was received. c. An opened box of field day whole grain bran plus cereal on top of the refrigerator was not covered or sealed. 11. On [DATE] at 8:38 AM., the following observations were made in the freezer on West Nurses station a. A bag of Great Value White Sandwich was stored on a shelf in the freezer. The bag had a use by date of [DATE]. 12. On [DATE] at 8:43 AM., the following observations were made in the Unit refrigerator. a. A clear bag that contained slices of ham was stored on a shelf in the refrigerator. The bag had an expiration date of [DATE]. b. A clear bag that contained a slice of cheese was stored on a shelf in the refrigerator. The bag had an expiration date of [DATE]. The cheese was dried. 13. On [DATE] at 8:48 AM., the following observations were made in the cabinet in the unit kitchenette: a. An opened box of Pearl [NAME] Company Buttermilk complete mix was stored in the cabinet in the kitchenette. The box was not covered. b. An opened box of plain salt was stored in the cabinet. The box was not covered. c. An opened bags of Luzonians Tea were stored in the cabinet. The bags were not sealed. 14. The facility policy on hand washing provided by Dietary Supervisor on [DATE] at 3:23 PM under when to wash hands, documented. Food handlers must wash hands before preparing food or working with clean equipment and utensils. They must also wash their hands before putting on single use gloves. When touching anything else that may contaminate hands, such as dirty equipment, work surface or cloths. 15. On [DATE] at 12:14 PM., six ceiling fans over the tables in the Main Dining Room had an accumulation of dust on the blades. 16. On [DATE] at 12:48 PM., the Steam Table was set up in the Main Dining Room. During meal service in the Main Dining room, the staff members touched the food surface of every plate with their thumbs. 17. On [DATE] at 10:56 AM., six ceiling fans over the tables in the Main Dining Room had an accumulation of dust on the blades. 18. On [DATE] at 08:16 AM., six ceiling fans over the tables in the Main Dining Room had an accumulation of dust on the blades. 19. On [DATE] at 09:58 AM., the Housekeeping Supervisor was asked to provide the schedule for cleaning the ceiling fans in the Main Dining Room. He stated, We are supposed to clean them on Monday, Wednesday, and Friday, but they haven't been done in a long time because I haven't had the staff. He was asked, What could happen if the ceiling fans in the Main Dining Room have an accumulation of dust? He answered, It could fall in the food and contaminate it. 20. On [DATE] at 12:31 PM., the Dietary Manager was asked, What could happen if there was dust accumulation on the ceiling fans in the dining room? He answered, It could fall off and get in the food. He was asked, Should the staff touch the food surfaces of the plates during meal service? He answered, I'm going to say no. He was asked, What could happen if the staff touched the food surface of the plates during meal service? He answered, Cross contamination. 21. On [DATE] at 02:34 PM., the Director of Nursing (DON) was asked, What could happen if there was dust accumulation on the ceiling fans in the dining room? She answered, It could get in the food. She was asked, Should staff touch the food surface of a plate during meal service? She answered, If they wash their hands and not touch the food it should not be an issue.

Based on record review and interview, the facility failed to notify the resident representative in writing of the reason for discharge in language they understand and send a copy of the notice to the Ombudsman for 2 (Resident #22 and 68) of 3 (Resident #22, 76, 68) sampled residents who transferred to the hospital in the last 6 months. The findings are: 1. Resident #22 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/11/22 documented the resident scored 15 (13-15 indicates cognitively intact) on the Brief Interview for Mental Status (BIMS). a. A Progress Note dated 01/22/22 documented, . Noted to have labored breathing at 22. Lungs sound wet. Temp elevated at 100. Pulse ox 81. O2 2l/NC [liters per nasal cannula] applied. APN (Advance Practice Nurse) notified. Orders rec'd [received] to send to local hospital ER [emergency room ] for eval. [Evaluation] . Ambulance here to transport . b. A Discharge Return Anticipated MDS with an ARD of 01/22/22 documented discharge to acute hospital. c. On 05/17/22 02:26 PM., a Notice of Transfer/Discharge/Bed Hold form and Notification of the Ombudsman was requested from the Administrator for the hospital transfer on 01/22/22. She stated, I don't think anyone has been notifying the Ombudsman. d. On 05/17/22 at 03:15 PM., the Administrator stated, No one has notified the Ombudsman of any transfers since January [2022]. e. On 05/18/22 at 08:32 AM., the Administrator was asked to provide the Notice of Transfer/Discharge/Bed Hold form for the hospital transfer dated 1/22/22. f. On 05/18/22 at 09:46 AM., the Administrator stated, We do not have a Notice of Transfer/Discharge/Bed Hold form for her on that date. 2. Resident #68 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Significant Change in Status MDS with an ARD of 04/14/22 documented a score of 12 (8-12 indicates moderate impairment) on the Brief Interview for Mental Status (BIMS). a. An SBAR Communication Form (Situation, Background, Assessment, Recommendation) dated 01/17/22 documented, . altered mental status . weakness . b. A Progress Note dated 01/17/22 documented, . Spoke with ER. [emergency room ] Resident being admitted to hospital. Informed that resident also tested positive for COVID-19 . c. A Discharge Return Anticipated MDS with an ARD of 01/17/22 documented discharge to Acute Hospital. d. On 05/18/22 at 08:31 AM., the Administrator was asked to provide the Notice of Transfer/Discharge/Bed Hold form dated 01/7/22. She stated, We do not have one for 01/7/22. e. A Progress Note dated 04/1/22 documented, . doppler was preformed . verbally confirmed that resident had deep vein occlusion. resident was sent to [hospital] . f. A Discharge Return Anticipated MDS with an ARD of 04/1/22 documented discharge to Acute Hospital. g. A Notice of Transfer/Discharge/LOA with Bed Hold Policy form dated 04/1/22 documented, . discharged or Transferred for the following reason(s): a. The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility . There was no specific reason for transfer documented on the form. There was no documentation of notification of the Ombudsman. 3. A Policy titled, Admission, Transfer, & Discharge which was provided by the Administrator on 05/18/22 at 12:30 PM documented, . the nursing facility will notify the Resident/Elder and if known, a family member or legal representative . in a language and manner understood . shall be in writing and shall include the reason for discharge . The nursing facility shall send a copy of the notice to a representative of the Office of the State Long Term Care Ombudsman . 4. On 05/18/22 at 02:34 PM., the Director of Nursing was asked, Should a Notice of Transfer/Discharge/Bed Hold form be provided to the resident representative with reason for transfer in writing? She answered, Yes. She was asked, Should the Ombudsman be notified of all transfers? She answered, Yes we are supposed to send a report monthly.

Based on record review and interview, the facility failed to ensure the bed hold policy was provided to the resident or resident's representative at the time of transfer for 2 (Resident #22, 68) of 3 (Resident #22, 76, 68) sampled residents who transferred to the hospital in the last 6 months. The findings are: 1. Resident #22 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/11/22 documented the resident scored 15 (13-15 indicates cognitively intact) on the Brief Interview for Mental Status (BIMS). a. A Progress Note dated 01/22/22 documented, . Noted to have labored breathing at 22. Lungs sound wet. Temp elevated at 100. Pulse ox 81. O2 2l/NC [liters per nasal cannula] applied. APN (Advance Practice Nurse) notified. Orders rec'd [received] to send to local hospital ER [emergency room ] for eval. [Evaluation] . Ambulance here to transport . b. A Discharge Return Anticipated MDS with an ARD of 01/22/22 documented discharge to acute hospital. c. On 05/18/22 at 08:32 AM., the Administrator was asked to provide the Notice of Transfer/Discharge/Bed Hold form for the hospital transfer dated 1/22/22. d. On 05/18/22 at 09:46 AM., the Administrator stated, We do not have a Notice of Transfer/Discharge/Bed Hold form for her on that date. 2. Resident #68 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Significant Change in Status MDS with an ARD of 04/14/22 documented a score of 12 (8-12 indicates moderate impairment) on the Brief Interview for Mental Status (BIMS). a. An SBAR Communication Form (Situation, Background, Assessment, Recommendation) dated 01/17/22 documented, . altered mental status . weakness . b. A Progress Note dated 01/17/22 documented, . Spoke with ER. [emergency room ] Resident being admitted to hospital. Informed that resident also tested positive for COVID-19 . c. A Discharge Return Anticipated MDS with an ARD of 01/17/22 documented discharge to Acute Hospital. d. On 05/18/22 at 08:31 AM., the Administrator was asked to provide the Notice of Transfer/Discharge/Bed Hold form dated 01/7/22. She stated, We do not have one for 01/7/22. e. A Progress Note dated 04/1/22 documented, . doppler was preformed . verbally confirmed that resident had deep vein occlusion. resident was sent to [hospital] . f. A Discharge Return Anticipated MDS with an ARD of 04/1/22 documented discharge to Acute Hospital. g. A Notice of Transfer/Discharge/LOA with Bed Hold Policy form dated 04/1/22 documented, . discharged or Transferred for the following reason(s): a. The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility .

Based on observation, record review, and interview, the facility failed to ensure that a dental assessment was done to ensure a resident with a dental issue was seen promptly by a dentist for (Resident #64), of 7 sample Residents (#6 #10 #17 #21 #26 #58 #73), with dental concerns. The findings are: 1. Resident #64 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set [MDS] with an Assessment Reference Date [ARD] of 4/24/22 with a Staff Assessment Mental Status [SAMS] of 0 (indicated independent in cognition), required limited to extensive assistance with activities of daily living self-performance skills with one-person physical assistance. a. 05/17/22 09:23 AM., An interview was conducted with the Resident. When asked, do you have any broken or missing teeth? He nodded head and gestured with his hand, Yes, shows teeth, there are broken missing teeth top and bottom. When asked do they hurt? Resident nods head and stated, Yes. When asked if he had told someone about it? He nodded head yes. Licensed Practical Nurse [LPN] #3 was informed of the resident's teeth and that he said it hurt. She stated, I will tell the staff that does the appointments. b. On 05/19/22 at 11:12 AM., The staff that does the appointments was interviewed and asked, if she did the appointments? She stated, Yes. When asked, if this Resident had an appointment? She stated, No. c. On 05/19/22 at 11:45 AM., Licensed Practical Nurse [LPN] #2 was asked, if it had ever been reported to her that the resident needed to see a dentist for missing teeth and painful teeth? She stated, No, the only pain I know of is in his right upper leg, and we had that X-Rayed. When asked, did any staff report to you that he needed a dental appointment? She stated, No, but I am sure we can get him set up for one. d. The Facility's Dental Services Policy was given by the Director of Nursing [DON] on 5/20/22 at 9:45 AM. The policy documented, The facility shall, if necessary, assist residents in making appointments and in arranging for transportation to and from the dental services locations.

Based on observation, record review and interview, facility failed to ensure meals were prepared and served according to the panned written menu to ensure that nutritionally balance meals were provided for the residents for 1 of 1 meal observed. This failed practice had the potential to affect 40 residents who received regular diets, 20 residents who received mechanical soft diets 6 residents who received pureed 3 residents who received pleasure tray from the kitchen, according to the List provided by the Dietary Supervisor, dated 5/17/2022 (Total Census 69) The findings are: 1. On 5/16/2022, the facility's menu documented for the residents on regular diets, mechanical soft diets and on pureed diets to receive ½ cup of ziti and 6 oz [ounces] of meat sauce. 2. On 5/16/2022 at 1:05 PM., The following observations were made during noon meal service: a. The Dietary Employee #2 used #12 scooper which is equivalent to 2 ½ to 3 oz to serve a single portion of meat sauce to the residents on regular diets, residents on mechanical soft diets and residents on pureed diets, instead of 6 oz of meat sauce as specified on the menu for each resident to receive 6 oz of meat sauce. b. The residents on pureed diets were served mashed potatoes, instead of pureed ziti as specified on the menu. c. On 5/17/2022 at 1:15 PM., Dietary Employee #2 was asked the reason residents on pureed diets were served mashed potatoes, instead of pureed ziti. He stated, I forgot to do it. He was asked what size of scoop you used to serve meat sauce to the residents on regular diets, residents on mechanical soft diets and residents on pureed diets. He stated, I used the scoop that was in the pan. The green scooper (#12 Scoop).

Based on observation and interview, the facility failed to ensure pureed food items were blended to a smooth, lump free consistency to minimize the risk of choking or other complications for residents who required pureed diets for 1 of 1 meal observed, the failed practice had the potential to affect 6 residents who received pureed diets, as documented on the diet List provided by the Food Service Supervision 5/17/2022. 1. On 5/16/2022 at 11:32 AM., Dietary Employee #2 used 4 oz [ounce] spoon to place 10 servings of spaghetti sauce into blender and pureed. He poured the pureed into a pan. Covered with foil and places it in the oven. to be served to the residents on pureed diets for lunch. The mixture was gritty and not smooth. 2. On 5/16/2022 at 11:48 PM., Dietary Employee #2 used 4 Oz spoon to place 10 servings of vegetable blend into a blender and pureed. At 11:51 AM, he poured the pureed vegetable blend into a pan, covered with foil, and placed in the oven to be served the residents on pureed diets for lunch. The mixture was not smooth and there were pieces of vegetables visible in the mixture. 3. On 5/16/2022 at 11:59 AM., Dietary Employee #4 placed 12 servings of garlic bread into a blender, added water and pureed. At 12:03 PM, he added 1/8 s cup of thickener and pureed it. At 12:06 PM, he poured the pureed bread into a pan, and the consistency was lumpy and not smooth. 4. On 5/16/2022 at 1:06 PM., Certified Nursing Assistant (CNA) #1 who was assisting a resident in the dining room on 200 Hall was asked to describe the consistency of the pureed food items served to the residents on pureed diets. She stated, Pureed beef sauce was gritty and pureed vegetable has pieces of vegetables in it. 5. On 5/16/2022 at 1:15 PM., Dietary Employee #3 was asked to describe the consistency of the pureed food items served to the residents on pureed diets at the lunch meal. She stated, You can see pieces of vegetables in the mixture. There were pieces of meat in the mixture and pureed bread was lumpy.

Based on record review, and interview the facility failed to ensure that an Advance Directive Acknowledgement and/or Advance Directive was in place for 1 of 1 sample (Residents #67) who record was reviewed for an advanced directive. The findings are: Resident #67 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The significant Change Minimum Set with an Assessment Reference Date of 5/4/22 documented the resident scored 10 (8-12 indicates cognitively intact) on a Brief Interview Mental Status. a. On 05/17/22 at 12:17 PM., a record review was done and there was no advance directive in the medical record. b. On 05/17/22 at 3:15 PM., the Administrator was asked for the resident's advanced directive, and she stated, He does not have one.

Based on observation, record review, and interview, the facility failed to ensure there were no urine odors and the floor was clean to provide a sanitary and clean environment for 1 of 1 (Resident #10) who resided in Resident Room 249. The findings are: Resident #10 had diagnoses of Dementia with Behavioral Disturbance, [CONDITION(S)], Muscle Wasting/Atrophy, and General Muscle Wasting. The Quarterly Minimum Data Set with an Assessment Reference Date of 2/17/22 documented the resident scored 7 (0-7 indicates cognitively intact) on a Brief Interview Mental Status and required limited physical assistance of one-person for toilet use and personal hygiene and required one-person physical assistance with bathing. a. On 05/16/22 at 12:29 PM., the resident was self-propelling in wheelchair going to DR [Day Room], well groomed, alert, and not very conversational. There was a dark substance on the floor near to his bed. There was a urine odor at the door entrance and in the room. The roommate stated, He sits there and just pees [urinates] in his wheelchair. b. On 05/19/22 at 10:29 AM., the resident was out of room in the lobby. The resident's room smelled of urine and there was a black substance on the floor and a few spots of a brown substance on the floor on the resident's side of the room in front of the nightstand, and on the floor near the right side of the head of the bed. c. On 05/19/22, the Maintenance Employee accompanied the Surveyor to the room and was shown the area of black substance on the floor and the brown substances on the floor in front of the nightstand, and near the right side of the head of the bed on the floor. He also smelled the urine odor. He stated, I will pass this along to the Housekeeping Supervisor.

Based on observation, record review, and interview, the facility failed to ensure a Quarterly MDS Assessment was accurate for 1 of 1 sample Resident #10 who was coded for the use of a restraint. The findings are: Resident #10 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set with an Assessment Reference Date of 02/17/2022 documented the resident scored 7 (0-7 indicates severely impaired) on a Brief Interview Mental Status and used a trunk restraint less than daily. b. On 05/19/22 at 10:29 AM., the resident was in the lobby and no truck restraint was in use. c. On 05/19/22 at 11:07 AM., the resident was in church service in the DR [Day Room] at this time and the was no restraint in place. d. On 05/19/22 at 11:15 AM., Certified Nursing Assistant (CNA) #1 was asked, Does this resident have any restraints? She stated, No. She was asked, Does he use a trunk restraint? She stated, No. e. On 05/19/22 at 11:17 AM., Licensed Practical Nurse, [LPN] #1 was asked if the resident used a restraint and she stated, No. f. On 05/19/22 at 12:40 PM., the MDS Coordinator was asked regarding the resident being coded on the MDS for having a trunk restraint on MDS. She stated, He does not have a restraint. I saw that when you all asked for the Resident Census and Condition. I could not get it off, it must have been a miss click. She was asked, Do you go and assess the resident, or from documentation of the nurses? She stated, I go sometimes, and sometimes from the nurses' documentation, I know I should go and do an assessment.

Based on record review and interview, the facility failed to ensure the use of anticoagulants was documented on the care plan for 1 (Resident #44) of 3 (Resident #38, 34, 44) sampled residents who had a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Resident #44 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . a. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . b. As of 5/18/2022 there was no documentation on the care plan of the use of an anticoagulant. c. On 05/18/22 at 02:34 PM., the Director of Nursing (DON) was asked, Should the use of anticoagulants be documented on the care plan? She answered, Yes.

Based on observation, record review, and interview, the facility failed to ensure the Care Plan was revised to included Oral/Dental problems and that interventions for 1 of 1 (Resident #64) sample resident who had dental problems. The findings are: Resident #64 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set with an Assessment Reference Date of 4/24/22 documented the resident was independent in cognitive skills per a Staff Assessment Mental Status, required limited to extensive assistance with activities of daily living self-performance skills with one-person physical assistance. a. On 05/17/22 at 09:23 AM., The resident was asked, Do you have any broken or missing teeth? He nodded head yes and gestured with his hand, then shows his teeth. There were broken and missing teeth on the top and bottom. He was asked, Do they hurt? The resident stated, Yes. He was asked If he had told someone about it? He nodded head yes. Licensed Practical Nurse (LPN) #3 was informed of the resident's teeth and that he said it hurt. She stated, I will tell the staff that does the appointments. b. On 05/19/22 at 12:40 PM., the MDS/Care Plan Coordinator was asked if Dental should be included on the resident's care plan since he has a problem with his teeth? She stated, Yes, it should. I can add it now. She was asked, Do you go to the resident's room to assess them when you do their assessments? She stated, I do sometimes, but go from the nurse's documentation, I should go.

Based on observation, record review, and interview, the facility failed to ensure residents were secured in the van prior to moving the van and failed to ensure law enforcement and the facility were notified prior to leaving the area of the accident to ensure that the resident was properly assessed for injury for 1 (Resident #5) of 2 (Resident #1 and #5) sampled residents who were transported in the van from 7/20/2020 - 7/27/2020. This failed practice resulted in past non-compliance at the level of immediate jeopardy which caused or could have caused serious harm, injury or death to Resident #5, when the resident's wheelchair turned over when the van driver moved the van prior to securing the resident and then moving the resident back into the wheelchair and taking the resident back to the facility without notifying the facility immediately when the accident occurred. This failed practice had the potential to affect 7 residents who were transported in the facility van from 7/20/2020 to 7/27/2020 according to the list provided by the Administrator on 8/3/2020. The Administrator was notified of the past immediate jeopardy on 7/31/2020 at 2:15 p.m. The findings are: 1. Resident #5 had a [DIAGNOSES REDACTED]. The Annual Minimum Data Set (MDS) documented the resident was severely impaired in cognitive skills for daily decision maker per a Staff Assessment for Mental Status (SAMS); and required extensive assistance of 1 person for transfers, limited assistance with locomotion, wheelchair was normally used for mobility; and received [MEDICAL TREATMENT] services in the last 14 days. a. An In-service sheet dated 7/17/20 documented (Name of Company) In-Service Training Sign-In Sheet Presented by (name of company) Instructor: (name). Course: Correct lift Operation/Properly Securing Residents. Items covered: correct operation of the lift, correct procedure for loading/unloading resident on lift, manual operation of the lift, vehicle height and ensuring proper clearance for any type awning, covered driveway, parking garage, etc , properly securing oxygen tank in floor mounted oxygen tank holder. Van Driver #1 signed the in-service sheet. b. An Incident and Accident report dated 7/31/20 documented, Incident Location: Out of Facility/During Transport. Incident Description: Resident was being picked up from [MEDICAL TREATMENT]. While in the van going up the hill from [MEDICAL TREATMENT], resident flipped backwards causing resident to fall out of chair. Resident Description: I was in my wheelchair and the wheelchair flipped backwards and I fell out. Immediate Action Taken Description: Resident was re-secured in his wheelchair and van. He was brought back to the facility for evaluation by a nurse. Injury type: Abrasion Location back of head. Injury Type skin tear right forearm, left hand. Level of Pain: 2 Level of Consciousness: Alert Mobility: Wheelchair bound. Notes 7/27/20 Received new order from MD (Medical Doctor) to send to ER (emergency room ) for CT (Computerized Topography) of head/neck. In-serviced van driver one-on-one on securing resident properly and double checking that protocol was followed. 7/28/20 CT of head and neck were negative. This nurse checked resident this morning and no new findings noted at this time. Will continue to monitor. c. A DMS (Division of Medical Services) -762 documented Resident was being picked up from [MEDICAL TREATMENT] on 7/27/20 at approximately 3:30 PM. Van driver stated as she was going up the steep hill at [MEDICAL TREATMENT] the resident fell over backwards in his wheelchair. Van driver pulled over to check on resident. she noted a superficial skin tear to his arm. Van driver asked resident if he was ok and resident stated he was fine. Van driver assisted resident upright. secured his wheelchair and proceeded to the facility. Van driver took resident to his room then came and reported it to the DON and Administrator. Van driver stated it was her fault for not securing resident properly. Stated there was a long line of vehicles waiting to pick up other [MEDICAL TREATMENT] patients and she felt pressured to get out of their way. The van driver (#1) is back-up transportation and not our main van driver. she is our full time Activities Director. (Van Driver #1) was suspended pending investigation. reprimanded. brought back to facility as Activities Director only and is NOT to drive the van at any time. All other van drivers (full-time and back-up) were re-inserviced on the van. watched the Q-Straint video and made aware that any incident involving a commercial. passenger van must immediately call the police department and report. d. A physician's orders [REDACTED]. e. A physician's orders [REDACTED]. f. A physician's orders [REDACTED]. g. A physician's orders [REDACTED]. h. On 7/31/2020 at 10:25 a.m., the resident was being strapped in the facility van. There was a bandage on his left wrist dated 7/31/20, and 3 bandages on the right forearm with a date of 7/31/20. i. On 7/31/20 at 10:40 a.m., the Administrator was asked to state what exactly happened. She stated, the backup van driver who is actually the Activities Director was picking the resident up from [MEDICAL TREATMENT]. I guess there was a long line of vans, so she was in a hurry and did not secure the resident properly. There is a hill at [MEDICAL TREATMENT], so she said when she was going up the hill the resident fell back. She came here took him to his room and immediately told us what happened. She has been with us for years and this is her first incident, so we suspended her from driving the van at any time. She is only the activities director now. We had all the van drivers re-in serviced and had them watch a couple videos. The resident is okay. He has a couple of skin tears to his arms and a hematoma to the back of his head, we did a CT and neuro checks to be sure. Every time we ask the resident if he is okay or has any complaints, he says he is fine. We even went around and asked other residents if they had any issues with the van drivers and they all said No. j. On 7/31/20 at 10:59 a.m., Van Driver #1 was interviewed and asked what happened. She stated, Monday when I went to pick my residents up from [MEDICAL TREATMENT]. There is always a line of truck and cars and other vans. I went to pick up (Resident #5) and (another resident). I got (Resident #5) on first then (resident name). I started hooking (Resident #5) up and didn't finish buckling him up properly because (other resident) was fussing so I went and got (other resident) on and got her hooked up properly. Then I got out, let the lift down, let it back up and closed the doors. I proceeded to get out the way of the rest of the people. I proceeded to go up the hill from the [MEDICAL TREATMENT] covered portico, once I started to go up the hill (Resident #5's) chair tilted back and turned over. So, I pulled around to the front parking lot, parked the van, got out, let the lift down, got on and asked (Resident #5) if he was okay. He said yeah but he had these little skin tears on his left hand and right forearm and elbow from falling back. I proceeded to assist him in getting up after I got the wheelchair back straightened up. I then asked him again if he was okay and he stated yeah. Once I got him back in the wheelchair, I got him good and secured that time. I used some wipes to wipe the blood that was bleeding on his arms. I asked him again are you sure you're alright and he said yes. I came back to the facility assisted him and (other resident) off the van, came in and got their temps (temperatures). Another CNA (Certified Nursing Assistant) assisted (other resident) back to her room and I assisted (Resident #5) to the nurse on the east side. Once I got done talking to the nurse, I went immediately to (Administrator) office and (Director of Nurses) was in there and I told them exactly what had happened. Me and the DON went back down to see (Resident #5) and he was still at the nurse's station with the nurse receiving treatment. She was asked, Why did you not call the facility when it happened? She stated, I don't know, it scared me to death. I was just trying to get the resident back up into a comfortable position. I've been here since 2003 and this is the first time an accident like this has ever happened. She was asked, Why didn't you secure him? She stated, I got in such a hurry I guess, with all the traffic behind us. I guess I was nervous and got in a hurry and was just trying to get out of the people's way. She was asked, Have you been trained on how to properly secure residents? She stated, Yes. She was asked, Did you have any follow up training through the years? She stated, We had a training a week or 2 weeks before this happened. She was asked, During the training what did you do? She stated, The instructor that came he just redid the training that he already did. None of the wheelchairs are the same so you have to hook them up a certain way. She was asked, Did you have to do return demonstration during that training? She stated, No. He just showed us how to do it. 2. The facility removed the immediate jeopardy and corrected the failed practices on July 27 and 28, 2020 as evidenced by the following: a. On July 27, 2020 at 4:00 p.m., Van Driver #1 reported incident to Administrator and Director of Nursing (DON). The DON assessed resident. The Administrator inspected the van. The DON and Administrator were interviewed along with the van driver and the surveyor took a statement. The Administrator reprimanded and suspended the employee pending investigation. The DON called the Medical Director and received orders for CT of head (negative). A body audit, neuro checks, and I&A {Incident and Accident) was initiated. At 4:22 p.m. the Administrator notified the police department. At 4:25 the DON, Marketing Director, and Nurse Consultant interviewed the resident. At 4:30 p.m., the DON, Administrator, and Marketing Director spoke with the resident's sister. Cognitive residents with recent transfers were interviewed with statements being collected. In-services began to all authorized facility van drivers to include watching of Q straint DVD prior to driving the van stressing the importance of securing properly, checking and double checking prior to transportation. Also, reminded any/all commercial, passenger incidents must be reported to the police department immediately and not to move the resident or van. Notify Administrator/DON/Designee immediately. b. On July 28, 2020 at 5:40 a.m., the DON at facility to ensure in-servicing was done prior to driving the van. The Administrator reported to The Office of Long Term Care (OLTC) and the remaining interviews/statements from cognitive residents collected. c. A statement provided by the Administrator dated July 31, 2020 documented, . As the Administrator of (facility), I routinely inspect the facility van and also observe the van driver(s) loading, securing and unloading the residents on and off the van. My office is in close conjunction of the portico where the van drives up to load and unload residents. I frequently go out to open doors, greet residents or assist in any way, while I am assisting I observe for safety and compliance. Any issues are addressed and corrected immediately. signed by the Administrator. 3. A form titled Transportation Services documented, OLTC Reg. 323. If resident/elder do not meet the medical necessity for ambulance transportation and the resident/elder's family does not wish to transport them, the facility will provide reasonable transportation for the resident/elder to the hospital, medical clinics or dentists' offices. If resident/elder is wheelchair bound, the facility will lift them into the van with a wheelchair lift according to manufacturers' guidelines and will secure them in the van for safety with straps according to manufacturers' guidelines. All resident/elders must wear a seatbelt when in the facility van .

Complaint # (AR 711) was substantiated, all or in part, with these findings. Based on observation, record review and interview, the facility failed to ensure written abuse / neglect prohibition policies and procedures were implemented to ensure the provision of necessary supervision to prevent physical harm for Resident #1. The facility failed to ensure a licensed nurse performing the duties of a van driver followed facility policy and State Law, with regard to restraining / securing a wheelchair-bound resident in the facility van for 1 (Resident #1) of 4 (Resident #1, 2, 6 and 7) case mix residents who required the use of a wheelchair when being transported in the facility van. This failed practice resulted in immediate jeopardy, which caused or could have caused serious harm, injury or death to Resident #1, who was not seat belted into her wheelchair during transport and sustained a left femur fracture and bilateral tibia / fibula fractures. The facility also failed to ensure possible neglect on the part of the van driver (Registered Nurse #1) was promptly reported to the Office of Long Term Care (OLTC) and the Arkansas State Board of Nursing in accordance with the facility's written policies and procedures and State Law. The failed practices had the potential to cause more than minimal harm to 56 residents who required a wheelchair when being transported via the facility van, as documented on a list provided by the Administrator on 1/20/17 at 1:00 p.m. The findings are: 1. The facility's policy and procedure titled, Abuse and Neglect Policy and Procedures - Investigation and Reporting, provided by the Administrator on 1/19/17 at 2:29 p.m., documented, Policy: It is a policy of this facility to ensure that a system is in place to prevent and detect . neglect . This policy also states that ALL alleged violations involving . neglect . are reported . The following criteria will be utilized in the abuse prevention system: .Reporting . All incidents alleged resident . neglect . must also be reported to the appropriate officials (such as city and/or county police) and to the OLTC (Office of Long Term Care) and the registry or licensing board. Reports are made according to State/Federal regulations . The following persons or entities may be notified by the Charge Nurse on duty at the time of the incident: .OLTC, State, county, or city police . Reports made according to current state and federal regulations. The facility will report incidents according to the time restrictions required by law . An Incident and Accident Report form will be completed by the Charge Nurse. The first report form (Division of Medical Services (DMS) form 7734) after completion will be submitted to the state survey agency the following business day after date of discovery. The Administrator and Facility Compliance Officer will complete an Investigation Report (DMS form 762) AND SUBMIT A COPY TO THE State Survey Agency within five (5) days of the incident's discovery, or as otherwise mandated by law . 2. The facility's policy titled, Vehicle and Safety Policy Statement and Commitment, provided by the Administrator on 1/19/17 at 2:29 p.m. documented, .All occupants of Company vehicles . must wear seat belts and/or restraints at all times. The Company adheres to all federal, state, and local laws governing vehicle operation . Safety Belts: The driver and all occupants are required to wear seat belts and shoulder harness in all Company-owned vehicles and non-owned vehicles operated on Company business. The driver is responsible to make sure that all passengers wear their safety belts . Loading and Unloading of Patients/Residents into vans - Safely securing residents in their seats and wheelchairs during transport will protect your residents and reduce distractions. This task is sometimes performed many times during the shift and each situation is different and should never be considered routine. More often than not, accidents are the result of not properly securing the resident and/or wheelchair. BE SURE TO USE ALL FOUR (4) TIE-DOWNS Appropriately! .Secure the resident with the wheelchair lap belt if applicable: .5. Driver Testing and Training: .In-service training will be conducted annually for existing drivers. At a minimum, this includes Defensive Driving, Driver Distraction Education and properly loading, securing and unloading residents . Responsibility: .seatbelts for patient/residents with and without wheelchairs . 3. Arkansas Code, Title 27 - Transportation, Subtitle 3 - Motor Vehicles And Their Equipment, Chapter 37 - Equipment Regulations, Subchapter 7 - Mandatory Seat Belt Use (§ 27-37-702) documented, .(c) . each driver or passenger who is seated in a wheelchair in a motor vehicle shall: (1) Wear a properly adjusted and fastened seat belt properly secured to the wheelchair; and (2) Have the wheelchair properly secured in the motor vehicle. 4. Resident #1 had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) with an assessment reference date (ARD) of 12/3/16 documented the resident scored 15 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status (BIMS), was totally dependent on 2 persons for bed mobility and transfers and had no functional limitations in range of motion. a. An Incident Report dated 12/24/16 at 11:11 a.m. documented, Incident Type: Fall w/inj (with injury) . Type of Injury: Laceration-deep; Location: Facility vehicle; Equipment: Wheelchair; Activity at time: Vehicle Passenger . Incident Level: .Event w (with) Mild Injury . Narrative of incident and description of injuries: Resident was lift transferred into her wheelchair. Her wheelchair was fastened to the van safety straps. When we got to 9th street and about to make the left turn down the slope, resident slid out of her wheelchair and landed on both of her knees. Left foot turned outwards and tender to touch. This nurse drove resident to (local hospital) ER (emergency room ) where she was admitted for treatment and eval. (evaluation) left foot by ankle noted with 2/1 inche laceration bruise noted to right knee bruise noted to left knee . b. A Departmental Note dated 12/24/16 at 2:36 p.m. documented, Resident was lift transferred into wheelchair to be transported home. Her wheelchair was fastened to the van safety straps. When we got to 9th street and was about to negotiate a left turn down the slope, resident slid out of wheelchair and landed on both of her knees. Left foot turned outwards and tender to touch. Laceration noted to left foot. Resident transported to (hospital) ER in facility van for treatment and evaluation . c. A Departmental Note dated 12/25/16 at 10:32 p.m. documented, Late Entry for 12/24/16. At approximately 11 a.m. resident was dressed and lift transferred into wheelchair to be transported home. This nurse and CNA (Certified Nursing Assistant) assisted resident into the van lift and into the van. Her wheelchair was fastened to the van safety straps and secured. When we got to 9th street and was about to negotiate a left turn down the slope, resident screamed, .I am falling. This nurse turned around and saw resident slide out of wheelchair and landed on the van floor on both of her knees with her legs underneath her. This nurse pulled over and put van in park. Her (resident's) right foot was lifted out. Left foot noted rotating outwards tender to touch and bleeding. Laceration noted to left foot. Wheelchair cushion adjusted behind resident's head for comfort while Resident stated to this nurse its ok (okay) let's just go to my house, my son in law will help you get me up. This nurse informed resident that it is very important for her to go to the hospital to have her checked out. Resident called someone on the phone and was explaining to them what had happened and then asked this nurse what hospital she was being transported to. This nurse responded, tell them to meet us at (local hospital) ER. Then this nurse placed call to (hospital) ER to give report x (times) 2 attempts. Resident transported to (hospital) ER in facility van for treatment and evaluation. When we arrived at the hospital, it took about 20-30 minutes to get adequate personnel to get resident off the floor (of van). When resident was transferred onto the stretcher Report given to ER nurse. This nurse returned to the facility where she obtained resident's daughter .phone number and notified her . d. The hospital emergency room record dated 12/24/16 documented, .admitted /Time 12/24/16 1158 (11:58 a.m.) . ED (Emergency Department) Triage Note . at 12/24/16 11:44 a.m.Patient was in a wheelchair in the back of a nursing home van. Driver reports that while maneuvering the van patient was thrown from her wheelchair landing in the floor of the van with both legs folded beneath her.Med flight notified of need for transfer.Chief Complaint Motor Vehicle Crash .Comments: Pt (Patient) morbidly obese. Pt's W/C (wheelchair) was secured but pt was not secured in her w/c. Pt has open wound on L (left) ankle . ED Provider Notes by . female presenting with trauma .Trauma Mechanism of injury: motor vehicle crash Injury location: Pelvis, leg and foot Leg injury location: L lower leg, R (right) lower leg, L upper leg and R upper leg. Foot injury location: L ankle . Motor vehicle crash: Patient position: Rear passenger's side . Collison type: Single vehicle pt was in NH (nursing home) van which suddenly came to a stop. Pt was jolted forward she was wedged between wheelchair and seat in front of her) . Review of Systems . Musculoskeletal . L leg open wound and bruising at knee .Wt. 372 lb (pounds) . Musculoskeletal: Left knee: She exhibits decreased range of motion, swelling and ecchymosis. Tenderness found. Left ankle: She exhibits decreased range of motion, swelling and ecchymosis.1. Laceration on top of ankle bleeding controlled. 2. Large hematoma forming at knee . [DIAGNOSES REDACTED]. Tibia/fibula fracture, left, open type 1 or II . Tibia/fibula fracture, right, open . Final [DIAGNOSES REDACTED]. Tibia/fibula fracture, left . Tibia/fibula, right . XR (X-ray) . Right Tibia/Fibula Radiographs . Findings: There are [MEDICATION NAME] oriented fractures through the proximal fibula and proximal tibia. Lateral displacement of the distal fracture fragment but no intra-articular extension. There is severe [MEDICAL CONDITION] of the right knee with [MEDICAL CONDITION] of the right ankle joint and midfoot osteopenia. Impression: 1. [MEDICATION NAME] mildly displaced fractures of the proximal tibia and fibula.XR Tibia Fibula Left .Findings: .There is a [MEDICATION NAME] oriented fracture through the distal femoral shaft with mild displacement.[MEDICATION NAME] fracture through the proximal tibia. The proximal fibula is poorly evaluated due to patient positioning.Impression: 1. [MEDICAL CONDITION] shaft of the femur. 2. [MEDICATION NAME] fracture through the proximal tibia. The proximal fibula is poorly evaluated.Left Femur Radiographs . Findings: .There is a fracture through the distal femoral metaphysis which is better appreciated on radiographs of the tibia and fibula. Left tibia fracture is also better appreciated on these exams.XR Femur .1. Fracture through the distal femur and proximal tibia, better appreciated on dedicate tibia/fibula radiographs . e. A Physician Consultation report dated 12/24/16 documented, .She is most definitely a very high risk patient for any type of general anesthesia given her vascular history, [MEDICAL CONDITION], sleep apnea, and [MEDICAL CONDITION] as well as her anticoagulation, but she understands that and understands that the surgery is essentially necessary for her to have any type of functional lift hereafter, and at the very least there needs to be stabilization of the fractures to prevent further complications, as they are open fractures. f. The Hospital Operative Report with a procedure date of 12/24/16 documented, Preoperative Diagnosis: [REDACTED]. 2. Comminuted intraarticular, bicondylar proximal tibia fracture. 3. Comminuted proximal fibular metaphyseal fracture. 4. Left ankle laceration measuring approximately 8 centimeters in length down to tendon and bone but not through bone. 5. Right comminuted intraarticular distal femur fracture. 6. Right comminuted intraarticular bicondylar proximal tibia fracture. 7. Right comminuted proximal fibular metaphyseal fracture. Postoperative Diagnosis: [REDACTED]. 2. Comminuted intraarticular, bicondylar proximal tibia fracture. 3. Comminuted proximal fibular metaphyseal fracture. 4. Left ankle laceration measuring approximately 8 centimeters in length down to tendon and bone but not through bone. 5. Right comminuted intraarticular distal femur fracture. 6. Right comminuted intraarticular bicondylar proximal tibia fracture. 7. Right comminuted proximal fibular metaphyseal fracture. PROCEDURE: 1. Percutaneous fixation with skeletal traction of left distal femur and proximal tibial intraarticular fractures with closed reduction of left proximal fibular fracture all encompassed with knee spanning [DEVICE] placement. 2. Debridement and primary closure of left ankle laceration. 3. Percutaneous fixation of right intraarticular comminuted distal femoral fracture and right proximal tibial intraarticular comminuted bicondylar fracture with knee spanning [DEVICE] placement.IMPLANTS: Zimmer [DEVICE] system with three pins in each proximal femur and two pins in each midshaft tibia as well as the diamond frame and crossbar spanning the knee . g. On 1/19/17 at 3:28 p.m., the Maintenance Supervisor was asked if he provided the training to transportation staff regarding application of the van restraints. He stated, Yes I do. The Maintenance Supervisor was asked how he trained the staff and stated, I show them how to do it and then we basically have a check-off list to make sure it's being done right. The Maintenance Supervisor was asked if there was a training video or instruction book that the surveyor could view that showed the correct way to secure someone. He stated, We did have a video in the past, but we passed that along to another facility .I think there's a YouTube video we used . I will find it on YouTube. The Maintenance Man searched on YouTube and showed the surveyor a video titled, Q'Straint QRT Training. The Maintenance Supervisor was asked if there was an incident involving Resident #1 and RN #1 on the facility van. He stated, Yes there was. The Maintenance Supervisor was asked what happened and stated, I'm not really sure what happened. I just heard she slid out of the chair. I know if she had been secured right, that wouldn't have happened . I think, as long as you have the shoulder and lap belt tight, there shouldn't be a problem. The Maintenance Supervisor was asked what, since the incident, had been done to ensure that this type of incident did not happen again and stated, I made sure I retrained all the people who drive the van. The Maintenance Supervisor was asked what was used during the training and stated, The checklist. The Maintenance Supervisor was asked, The same checklist as before the incident? He stated, Yes . they have to use that checklist every time someone is transported. The Maintenance Supervisor was asked if RN #1 had been trained on how to secure residents in the van before the incident and stated, I know she was trained, but I can't find the sheet that shows she was trained. h. On 1/20/17 at 9:30 a.m., the resident's daughter was asked about the incident on 12/24/16 and stated, This was terrible. Now, my mother is in excruciating pain because of this. The van driver was a nurse, not a CNA, a nurse. This happened, and then the van driver, who said she (RN #1) had never transported anyone before, decided to drive an additional 5 miles across town to the hospital instead of calling 911. All the time, she (Resident #1) was lying face down in the van. Me and my family had to actually help get her out of the van, and her legs broken up underneath her . It was awful. First, she (van driver) drives to a fire station and nobody was there, then drove 5 miles across town with my mother bleeding . i. On 1/20/17 at 10:05 a.m., RN #1 was asked what happened when she transported the resident on the facility van on 12/24/16. The RN stated, .I went and got the van and parked it out front. I hooked the wheelchair up; I put the 4 straps on the bottom (restraints to secure the wheelchair in place). When we got to 9th street, I had to make a left turn. All I heard was, '(RN #1, RN #1), I'm falling'. I looked around, and she was on her knees. I pulled over and went to her to ask her if she was okay. But, I could tell she wasn't. Her left foot was rotated outwards, so I knew it was broke. The wheelchair was strapped in place and it was putting a lot of pressure on her, so I unstrapped it, so I could use the cushion for a pillow for her. The RN was asked if the resident was placed on her back and stated, I laid her back on her back, but her left leg was underneath her and rotated out. I wasn't about to touch that leg. I left from there and took her to the ER (emergency room ). The RN was asked why she decided to drive to the ER, instead of calling an ambulance, if she felt there was significant injury. The RN stated, Even if I had called an ambulance, there was no way me and a couple of ambulance people could pick her up. When I got her to the ER, it took probably 20 to 30 minutes for them to get her out of the van. It took several people to get her out of the van. The RN was asked how the resident fell out of the wheelchair and whether the resident had on a seatbelt at the time of the incident. The RN stated, The wheelchair was secured, but no seatbelt. The RN was asked why no seatbelt was placed on the resident and stated, To be honest, I didn't know. I thought, as long as the wheelchair was secured, it was okay. The RN was asked if this was the first time she had transported a resident and stated, No. The RN was asked if she had used seatbelts with other residents she had previously transported. The RN stated, Honestly, no. The RN was asked if she had been trained on how to use the facility van and how to secure residents prior to transport. The RN stated, No. A van in-service sign-in sheet dated 7/14/15, which documented RN #1's signature, was shown to RN #1 at this time, and the RN was asked if she remembered the in-service. The RN stated, I don't remember that. No. But, I have been retrained since the incident. (Director of Nursing) trained me. j. On 1/20/17 at 12:00 p.m., the Administrator was asked when she first became aware of the incident involving Resident #1 on 12/24/16 and stated, It (12/24/16) was on a Saturday, so I was at home. (RN #1) called me and told me what happened. By that time, the resident was already at the hospital. She didn't know what the injuries were, so I told her to let me know when she found that out. I, of course, asked her how it happened. She told me the resident slid out of the wheelchair. I asked if she (resident) was buckled in with the seatbelt, and she (RN #1) said she didn't have it on her. Then (DON) called to tell me about it and she made the decision to come to the facility and retrain at that point . The Administrator was asked if RN #1 had been trained on proper transport procedures prior to the incident and stated, When we did the change-over (indicating the change of facility ownership), there was a lot of stuff going on. We narrowed it down from a huge list of van drivers to that smaller list (referring to a list of staff names provided by the DON on 1/20/17). The people on that list were in-serviced during the change-over. The Administrator was informed that RN #1 was not on the list of van drivers. RN#1 name was added to the list of current van drivers by the DON. The Administrator was then asked if RN #1 had been in-serviced and stated, (Maintenance Director) said he did it. k. On 1/20/17 at 12:35 p.m., the Director of Nursing (DON) was asked when she first became aware of the incident involving Resident #1 on 12/24/16. The DON stated, (RN #1) called me and told me there had been an incident in the van. I asked how the resident was. She said she had taken her to the hospital. I asked how it happened and then I asked if she had a seatbelt on her, and she (RN #1) said, 'no'. She (RN #1) explained that the resident lived on a dead end street and when she made a turn, she said the resident said, 'I'm sliding out of the chair.' By the time she got pulled over, she was out of the chair. I asked her if she called EMS (Emergency Medical Services). She said, 'no'. She said she got the resident as comfortable as possible and that, 'it would be faster to get her there myself'. She said they had to call extra EMS people to get her out of the van. I agreed she did the right thing by taking her on to the hospital. I immediately called (Administrator), and we decided that we needed to get the I & A (Incident and Accident Report) done, and I would come up and in-service on Sunday (12/25/16). I asked (RN #1) why she didn't use the seatbelt. She said, 'I just didn't'. The DON was shown an in-service dated 7/14/15 and was asked if this was the only documentation the facility had that indicated RN #1 was trained on use of the van restraints. The DON stated, Yes. l. The Facility Investigation Report for Resident Abuse, Neglect, Misappropriation of Property and Exploitation of Residents in Long-Term Care Facilities, Division of Medical Services (DMS) form 762 related to the 12/24/16 van incident involving Resident #1 documented, Date Incident Reported to OLTC: 1/20/17 Time: 10:15 a.m. Date and Time of Incident (if known): 12/24/16 11:11 a.m. Date and Time of Discovery: 12/24/16 Time: 11:11 a.m . On 12/24/16 (RN #1) was transporting (Resident #1) to her home via facility van. When slowing down to make a left-hand turn (Resident #1) yelled out (RN #1) 'I'm falling'. When (RN #1) turned, she saw (Resident #1) slide out of wheelchair onto van floor. Both of her legs underneath her. (RN #1) pulled the van over and put van in park then went to (Resident #1) to assess her. She noted her left foot was rotated outward and there was a laceration to left foot. She was able to lift her right foot out from under her. (RN #1) positioned wheelchair cushion behind (Resident #1) head for comfort then drove her to the local hospital emergency room where emergency room personnel and ambulance personnel lifted (Resident #1) out of facility van via stretcher. This form was signed and dated by the Administrator on 1/23/17. The incident was not reported to OLTC until 1/20/17, a total of 27 days after the incident occurred. m. On 1/27/17 at 1:40 p.m., the Administrator was asked why the 12/24/16 incident involving Resident #1 was not reported to OLTC until 1/20/17. The Administrator stated, Whenever (RN #1) called and told me about the incident, I immediately called (DON). Because we knew what happened. I'm an Administrator; I should have known. The Administrator was asked if the Arkansas State Board of Nursing was notified of RN #1's actions as well. The Administrator stated, They have now. I left a message last Friday (1/20/17), and they called me back this week. We'll send a formal report. 5. The Immediate Jeopardy was removed and the scope / severity reduced to G on 1/20/17 at 11:11 a.m., when the facility implemented the following Plan of Removal: 1. All van drivers listed below will be trained with return demonstration by the Director of Nurses and/or Designee beginning today at approximately 10:45 a.m. Training and skills check-off will continue until all van drivers have been trained and skills check-off documented. None of the listed van drivers will be allowed to transport any resident until training and skills check-off is complete. 2. The training and skills check-off will include the following outline: a. Viewing the Q'straint QRT training Video. b. Return demonstration according to the designated skills transport checklist: Fleet Wheelchair Safety and Check List. c. Follow up training will be done on an annual basis and as needed by Director of Nurses and/or Designee. d. Any new van drivers will follow the same protocol prior to transporting residents in facility van. 3. The list of current van drivers include: a. (Director of Nurses) b. (Unit Supervisor #1) c. (RN #1) d. (Maintenance Supervisor) e. (Licensed Practical Nurse (LPN) #2) f. (CNA #1) g. (Activities Director) 4. The Director of Nurses and/or Designee will monitor transports three times a week for four weeks, and PRN (as needed) thereafter.

Complaint # (AR 711) substantiated, all or in part, with these findings. Based on observation, record review and interview, the facility failed to ensure a licensed nurse (Registered Nurse #1), who was performing resident transportation duties in the facility van was supervised and verified to be competent to perform those duties and failed to ensure the RN applied a seat belt to a resident being transported, in accordance with facility policy and State Law, to minimize the potential for serious injuries in the event of a motor vehicle accident or other incident for 1 (Resident #1) of 4 (Residents #1, 2, 6 and 7) case mix residents who required a wheelchair during transport in the facility van. This failed practice resulted in immediate jeopardy, which caused or could have caused serious harm, injury or death to Resident #1, who was not seat belted into her wheelchair during transport, fell out of the wheelchair while the van was in motion, and sustained a left femur fracture and bilateral tibia / fibula fractures. The facility also failed to ensure adequate supervision was provided after the incident to ensure all transportation staff utilized the van restraint system in accordance with manufacturer's instructions, to prevent potential injury to 1 (Resident #2) of 4 (Residents #1, #2, #6 and #7) case mix residents who required a wheelchair during transport in the facility van. The failed practices had the potential to cause more than minimal harm to 56 residents who required a wheelchair when being transported via the facility van, as documented on a list provided by the Administrator on 1/20/17 at 1:00 p.m. The findings are: 1. The facility's policy titled, Vehicle and Safety Policy Statement and Commitment, provided by the Administrator on 1/19/17 at 2:29 p.m. documented, .All occupants of Company vehicles . must wear seat belts and/or restraints at all times. The Company adheres to all federal, state, and local laws governing vehicle operation . Safety Belts: The driver and all occupants are required to wear seat belts and shoulder harness in all Company-owned vehicles and non-owned vehicles operated on Company business. The driver is responsible to make sure that all passengers wear their safety belts . Loading and Unloading of Patients/Residents into vans - Safely securing residents in their seats and wheelchairs during transport will protect your residents and reduce distractions. This task is sometimes performed many times during the shift and each situation is different and should never be considered routine. More often than not, accidents are the result of not properly securing the resident and/or wheelchair. BE SURE TO USE ALL FOUR (4) TIE-DOWNS Appropriately! .Secure the resident with the wheelchair lap belt if applicable: .5. Driver Testing and Training: .In-service training will be conducted annually for existing drivers. At a minimum, this includes Defensive Driving, Driver Distraction Education and properly loading, securing and unloading residents . Responsibility: .seatbelts for patient/residents with and without wheelchairs . 2. Arkansas Code, Title 27 - Transportation, Subtitle 3 - Motor Vehicles And Their Equipment, Chapter 37 - Equipment Regulations, Subchapter 7 - Mandatory Seat Belt Use (§ 27-37-702) documented, .(c) . each driver or passenger who is seated in a wheelchair in a motor vehicle shall: (1) Wear a properly adjusted and fastened seat belt properly secured to the wheelchair; and (2) Have the wheelchair properly secured in the motor vehicle. 3. Resident #1 had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) with an assessment reference date (ARD) of 12/3/16 documented the resident scored 15 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status (BIMS), required total assistance of 2 persons for bed mobility and transfers and had no functional limitation in range of motion. a. An Incident Report dated 12/24/16 at 11:11 a.m. documented, Incident Type: Fall w/inj (with injury) . Type of Injury: Laceration-deep; Location: Facility vehicle; Equipment: Wheelchair; Activity at time: Vehicle Passenger . Incident Level: .Event w (with) Mild Injury . Narrative of incident and description of injuries: Resident was lift transferred into her wheelchair. Her wheelchair was fastened to the van safety straps. When we got to 9th street and about to make the left turn down the slope, resident slid out of her wheelchair and landed on both of her knees. Left foot turned outwards and tender to touch. This nurse drove resident to (local hospital) ER (emergency room ) where she was admitted for treatment and eval. (evaluation) left foot by ankle noted with 2/1inche laceration bruise noted to right knee bruise noted to left knee . b. A Departmental Note dated 12/24/16 at 2:36 p.m. documented, Resident was lift transferred into wheelchair to be transported home. Her wheelchair was fastened to the van safety straps. When we got to 9th street and was about to negotiate a left turn down the slope, resident slid out of wheelchair and landed on both of her knees. Left foot turned outwards and tender to touch. Laceration noted to left foot. Resident transported to (hospital) ER in facility van for treatment and evaluation . c. A Departmental Note dated 12/25/16 at 10:32 p.m. documented, Late Entry for 12/24/16. At approximately 11 a.m. resident was dressed and lift transferred into wheelchair to be transported home. This nurse and CNA (Certified Nursing Assistant) assisted resident into the van lift and into the van. Her wheelchair was fastened to the van safety straps and secured. When we got to 9th street and was about to negotiate a left turn down the slope, resident screamed, .I am falling. This nurse turned around and saw resident slide out of wheelchair and landed on the van floor on both of her knees with her legs underneath her. This nurse pulled over and put van in park. Her (resident's) right foot was lifted out. Left foot noted rotating outwards tender to touch and bleeding. Laceration noted to left foot. Wheelchair cushion adjusted behind resident's head for comfort while Resident stated to this nurse its ok (okay) let's just go to my house, my son in law will help you get me up. This nurse informed resident that it is very important for her to go to the hospital to have her checked out. Resident called someone on the phone and was explaining to them what had happened and then asked this nurse what hospital she was being transported to. This nurse responded, tell them to meet us at (local hospital) ER. Then this nurse placed call to (hospital) ER to give report x (times) 2 attempts. Resident transported to (hospital) ER in facility van for treatment and evaluation. When we arrived at the hospital, it took about 20-30 minutes to get adequate personnel to get resident off the floor (of van). When resident was transferred onto the stretcher Report given to ER nurse. This nurse returned to the facility where she obtained resident's daughter .phone number and notified her . d. The hospital emergency room record dated 12/24/16 documented, .admitted /Time 12/24/16 1158 (11:58 a.m.) . ED (Emergency Department) Triage Note . at 12/24/16 11:44 a.m.Patient was in a wheelchair in the back of a nursing home van. Driver reports that while maneuvering the van patient was thrown from her wheelchair landing in the floor of the van with both legs folded beneath her.Med flight notified of need for transfer.Chief Complaint Motor Vehicle Crash .Comments: Pt (Patient) morbidly obese. Pt's W/C (wheelchair) was secured but pt was not secured in her w/c. Pt has open wound on L (left) ankle . ED Provider Notes by . female presenting with trauma .Trauma Mechanism of injury: motor vehicle crash Injury location: Pelvis, leg and foot Leg injury location: L lower leg, R (right) lower leg, L upper leg and R upper leg. Foot injury location: L ankle . Motor vehicle crash: Patient position: Rear passenger's side . Collison type: Single vehicle pt was in NH (nursing home) van which suddenly came to a stop. Pt was jolted forward she was wedged between wheelchair and seat in front of her) . Review of Systems . Musculoskeletal . L leg open wound and bruising at knee .Wt. 372 lb (pounds) . Musculoskeletal: Left knee: She exhibits decreased range of motion, swelling and ecchymosis. Tenderness found. Left ankle: She exhibits decreased range of motion, swelling and ecchymosis.1. Laceration on top of ankle bleeding controlled. 2. Large hematoma forming at knee . [DIAGNOSES REDACTED]. Tibia/fibula fracture, left, open type 1 or II . Tibia/fibula fracture, right, open . Final [DIAGNOSES REDACTED]. Tibia/fibula fracture, left . Tibia/fibula, right . XR (X-ray) . Right Tibia/Fibula Radiographs . Findings: There are transversely oriented fractures through the proximal fibula and proximal tibia. Lateral displacement of the distal fracture fragment but no intra-articular extension. There is severe osteoarthritis of the right knee with osteoarthritis of the right ankle joint and midfoot osteopenia. Impression: 1. Transverse mildly displaced fractures of the proximal tibia and fibula.XR Tibia Fibula Left .Findings: .There is a transversely oriented fracture through the distal femoral shaft with mild displacement.Transverse fracture through the proximal tibia. The proximal fibula is poorly evaluated due to patient positioning.Impression: 1. Fracture of the distal shaft of the femur. 2. Transverse fracture through the proximal tibia. The proximal fibula is poorly evaluated.Left Femur Radiographs . Findings: .There is a fracture through the distal femoral metaphysis which is better appreciated on radiographs of the tibia and fibula. Left tibia fracture is also better appreciated on these exams.XR Femur .1. Fracture through the distal femur and proximal tibia, better appreciated on dedicate tibia/fibula radiographs . e. A Physician Consultation report dated 12/24/16 documented, .She is most definitely a very high risk patient for any type of general anesthesia given her vascular history, morbid obesity, sleep apnea, and chronic obstructive pulmonary disease as well as her anticoagulation, but she understands that and understands that the surgery is essentially necessary for her to have any type of functional lift hereafter, and at the very least there needs to be stabilization of the fractures to prevent further complications, as they are open fractures. f. The Hospital Operative Report with a procedure date of 12/24/16 documented, Preoperative Diagnosis: [REDACTED]. 2. Comminuted intraarticular, bicondylar proximal tibia fracture. 3. Comminuted proximal fibular metaphyseal fracture. 4. Left ankle laceration measuring approximately 8 centimeters in length down to tendon and bone but not through bone. 5. Right comminuted intraarticular distal femur fracture. 6. Right comminuted intraarticular bicondylar proximal tibia fracture. 7. Right comminuted proximal fibular metaphyseal fracture. Postoperative Diagnosis: [REDACTED]. 2. Comminuted intraarticular, bicondylar proximal tibia fracture. 3. Comminuted proximal fibular metaphyseal fracture. 4. Left ankle laceration measuring approximately 8 centimeters in length down to tendon and bone but not through bone. 5. Right comminuted intraarticular distal femur fracture. 6. Right comminuted intraarticular bicondylar proximal tibia fracture. 7. Right comminuted proximal fibular metaphyseal fracture. PROCEDURE: 1. Percutaneous fixation with skeletal traction of left distal femur and proximal tibial intraarticular fractures with closed reduction of left proximal fibular fracture all encompassed with knee spanning [DEVICE] placement. 2. Debridement and primary closure of left ankle laceration. 3. Percutaneous fixation of right intraarticular comminuted distal femoral fracture and right proximal tibial intraarticular comminuted bicondylar fracture with knee spanning [DEVICE] placement.IMPLANTS: Zimmer [DEVICE] system with three pins in each proximal femur and two pins in each midshaft tibia as well as the diamond frame and crossbar spanning the knee . g. On 1/19/17 at 3:28 p.m., the Maintenance Supervisor was asked if he provided the training to transportation staff regarding application of the van restraints. He stated, Yes I do. The Maintenance Supervisor was asked how he trained the staff and stated, I show them how to do it and then we basically have a check-off list to make sure it's being done right. The Maintenance Supervisor was asked if there was a training video or instruction book that the surveyor could view that showed the correct way to secure someone. He stated, We did have a video in the past, but we passed that along to another facility .I think there's a YouTube video we used . I will find it on YouTube. The Maintenance Man searched on YouTube and showed the surveyor a video titled, Q'Straint QRT Training. The Maintenance Supervisor was asked if there was an incident involving Resident #1 and RN #1 on the facility van. He stated, Yes there was. The Maintenance Supervisor was asked what happened and stated, I'm not really sure what happened. I just heard she slid out of the chair. I know if she had been secured right, that wouldn't have happened . I think, as long as you have the shoulder and lap belt tight, there shouldn't be a problem. The Maintenance Supervisor was asked what, since the incident, had been done to ensure that this type of incident did not happen again and stated, I made sure I retrained all the people who drive the van. The Maintenance Supervisor was asked what was used during the training and stated, The checklist. The Maintenance Supervisor was asked, The same checklist as before the incident? He stated, Yes . they have to use that checklist every time someone is transported. The Maintenance Supervisor was asked if RN #1 had been trained on how to secure residents in the van before the incident and stated, I know she was trained, but I can't find the sheet that shows she was trained. h. On 1/20/17 at 9:30 a.m., the residents daughter was asked about the incident on 12/24/16 and stated, This was terrible. Now, my mother is in excruciating pain because of this. The van driver was a nurse, not a CNA, a nurse. This happened, and then the van driver, who said she (RN #1) had never transported anyone before, decided to drive an additional 5 miles across town to the hospital instead of calling 911. All the time, she (Resident #1) was lying face down in the van. Me and my family had to actually help get her out of the van, and her legs broken up underneath her . It was awful. First, she (van driver) drives to a fire station and nobody was there, then drove 5 miles across town with my mother bleeding . i. On 1/20/17 at 10:05 a.m., RN #1 was asked what had happened to the resident on 12/24/16 and stated, I knew (Resident #1) was going to the house to spend time with family that Saturday. I went and got the van and parked it out front. I hooked the wheelchair up, I put the 4 straps on the bottom. When we got to 9th street I had to make a left turn. All I heard was (RN #1, RN#1) I'm falling. I looked around and she was on her knees. I pulled over and went to her to ask her if she was ok. But I could tell she wasn't Her left foot was rotated outwards so I knew it was broke. The wheelchair was strapped in place and it was putting a lot of pressure on her so I unstrapped it so I could use the cushion for a pillow for her. The RN was asked if the resident had been laid on her back and the RN stated, I laid her back on her back but her left leg was underneath her and rotated out. I wasn't about to touch that leg. I left from there and took her to the ER. The RN was asked why she had decided to drive to the ER instead of calling an ambulance if it was known that there was significant injury and stated, Even if I had called an ambulance, there was no way me and a couple of ambulance people could pick her up. When I got her to the ER, it took probably 20-30 minutes for them to get her out of the van. It took several people to get her out of the van. The RN was asked how the resident had fallen out of the wheelchair and if the resident had on a seatbelt. The RN stated, The wheelchair was secured, but no seatbelt. The RN was then asked why the seatbelt had not been put on the resident and the RN stated, To be honest, I didn't know. I thought as long as the wheelchair was secured it was okay. The RN was asked if this had been the first transport done and stated, No. The RN was asked if she had used seatbelts with residents previously transported and the RN stated, Honestly, no. The RN was asked if she had been trained on how to use the facility van and secure residents in it and the RN stated, No. A van in-service sheet dated 7/14/15 (refer to paragraph 'l' below), which documented RN #1's signature as an attendee, was shown to the RN at this time. The RN was asked if she remembered the in-service. The RN stated, I don't remember that. No. But, I have been retrained since the incident. (Director of Nursing) trained me. j. On 1/20/17 at 12:00 p.m., the Administrator was asked when she first became aware of the incident involving Resident #1 on 12/24/16 and stated, It (12/24/16) was on a Saturday, so I was at home. (RN #1) called me and told me what happened. By that time, the resident was already at the hospital. She didn't know what the injuries were, so I told her to let me know when she found that out. I, of course, asked her how it happened. She told me the resident slid out of the wheelchair. I asked if she (resident) was buckled in with the seatbelt, and she (RN #1) said she didn't have it on her. Then (DON) called to tell me about it and she made the decision to come to the facility and retrain at that point . The Administrator was asked if RN #1 had been trained on proper transport procedures prior to the incident and stated, When we did the change-over (indicating the change of facility ownership), there was a lot of stuff going on. We narrowed it down from a huge list of van drivers to that smaller list (referring to a list of staff names provided by the DON on 1/20/17). The people on that list were in-serviced during the change-over. The Administrator was informed that RN #1 was not on the list of van drivers. The Administrator was then asked if RN #1 had been in-serviced and stated, (Maintenance Director) said he did it. k. On 1/20/17 at 12:35 p.m., the Director of Nursing (DON) was asked when she first became aware of the incident involving Resident #1 on 12/24/16. The DON stated, (RN #1) called me and told me there had been an incident in the van. I asked how the resident was. She said she had taken her to the hospital. I asked how it happened and then I asked if she had a seatbelt on her, and she (RN #1) said, 'no'. She (RN #1) explained that the resident lived on a dead end street and when she made a turn, she said the resident said, 'I'm sliding out of the chair.' By the time she got pulled over, she was out of the chair. I asked her if she called EMS (Emergency Medical Services). She said, 'no'. She said she got the resident as comfortable as possible and that, 'it would be faster to get her there myself'. She said they had to call extra EMS people to get her out of the van. I agreed she did the right thing by taking her on to the hospital. I immediately called (Administrator), and we decided that we needed to get the I & A (Incident and Accident Report) done, and I would come up and in-service on Sunday (12/25/16). I asked (RN #1) why she didn't use the seatbelt. She said, 'I just didn't'. l. On 1/20/17 at 9:00 a.m., the director of Nursing (DON) provided the following information: i.) A Staff In-service Education sheet dated 7/14/15, which documented, .Attention All Staff That Drive the Van! When you get into the facility van . to transport them . you must fill out these two sheets of paper kept on the van . Transportation: Automobile/Van Safety Program .Securement Steps .7. Apply lap/seat belt around resident with lap belt buckle on hip opposite shoulder strap to be used. Ensure belt is across lap and under w/chair (wheelchair) armrest to fit snugly.Final Check . 5. Lap belt/seat is on and secure. 6. Shoulder strap is on (and) secured to the lap belt/seat belt . Registered Nurse #1's name was documented as one of the attendees of this in-service. There was no documentation provided by the facility to indicate RN #1 had received any further training on the use of the van's restraint system prior to the incident on 12/24/16, which was a period of 17 months after the in-service training was provided. On 1/20/17 at 12:35 p.m., the Director of Nursing (DON) was asked if the July 2015 in-service was the only documentation the facility had that indicated RN #1 was trained on use of the van restraints. The DON stated, Yes. ii.) A list of current van drivers who had been trained on van use, which documented that Registered Nurse #1 was added to the list on 1/20/17 and was not included on the facility's list of drivers until 1/20/17. 4. Resident #2 had [DIAGNOSES REDACTED]. The MDS with an ARD of 1/16/17 documented the resident scored 12 (8-12 indicates moderately impaired) on a BIMS, required extensive assistance for transfer, limited assistance with walking, was not steady with balance, had functional limitation in range of motion in one upper extremity and had fracture due to a pre-admission fall. a. On 1/19/17 at 3:19 p.m., Resident #2 was seated in a wheelchair in the facility van and Certified Nursing Assistant (CNA) #1 was securing the resident inside the van. The wheelchair was secured to the van floor with belts and the Q-Straint ratcheting system. The CNA placed the shoulder/lap seatbelt combo on the resident. The lap part of the belt was placed on the outside of the frame of the wheelchair, around the outside of the armrest. The surveyor asked the CNA how she was trained to secure the resident and stated, It would make more sense to me to put the lap belt under the armrests, next to the resident, but I was told to do it this way. The lap/shoulder belt was connected on the outside of the wheelchair armrest instead of on the inside of the wheelchair frame, which prevented the belt from being snugly secured around the resident's waist / pelvic area. The surveyor took a photograph of how the lap / shoulder belt was applied to the resident at this time. b. On 1/19/17 at 7:00 p.m., the surveyor viewed the online training video referenced by the Maintenance Director. The video demonstrated that the lap portion of the seatbelt should be snug against the resident's pelvic area, with the strap going down beside the resident, between the side panel and the seat of the wheelchair (not around the outside of the armrest). The video narrator stated, The lap belt should pass through the gap between the side panel and the seat. Never put the belt over the armrests. c. On 1/20/17 at 12:35 p.m., the Director of Nursing (DON) was shown the photograph of the lap / shoulder belt application to Resident #2. The DON was asked if RN #1 and the other van drivers had been taught to apply the belt around the metal frame of the wheelchair, around the outside of the armrest, as shown in the photograph. The DON stated, Yes, because that's what the checklist says and that's how I was shown. The DON was asked if, based on the Q'straint QRT training video, staff been applying the seatbelt incorrectly. The DON stated, I personally didn't know that video existed until yesterday, but now everybody will be watching it. 5.The Immediate Jeopardy was removed and the scope / severity reduced to G on 1/20/17 at 11:11 a.m., when the facility implemented the following Plan of Removal: 1. All van drivers listed below will be trained with return demonstration by the Director of Nurses and/or Designee beginning today at approximately 10:45 a.m. Training and skills check-off will continue until all van drivers have been trained and skills check-off documented. None of the listed van drivers will be allowed to transport any resident until training and skills check-off is complete. 2. The training and skills check-off will include the following outline: a. Viewing the Q'straint QRT training Video. b. Return demonstration according to the designated skills transport checklist: Fleet Wheelchair Safety and Check List. c. Follow up training will be done on an annual basis and as needed by Director of Nurses and/or Designee. d. Any new van drivers will follow the same protocol prior to transporting residents in facility van. 3. The list of current van drivers include: a. (Director of Nurses) b. (Unit Supervisor #1) c. (RN #1) d. (Maintenance Supervisor) e. (Licensed Practical Nurse (LPN) #2) f. (CNA #1) g. (Activities Director) 4. The Director of Nurses and/or Designee will monitor transports three times a week for four weeks, and PRN (as needed) thereafter.

Complaint # was substantiated (all or in part) with these finding: Based on record review and interview, the facility failed to provide sufficient fluid intake to maintain proper hydration and health for Resident #1 who had abnormal lab values and an elevated body temperature. The facility failed to consistently assess, monitor and document the hydration status for 1 (Resident #1) of 5 (Residents #1 through #5) case mix residents who were at risk for dehydration. The failed practice resulted in a pattern of actual harm for Resident #1, who was hospitalized with Diabetic Ketoacidosis, Dehydration and [MEDICAL CONDITION] and had the potential to cause more than minimal harm for 21 residents who were at risk for dehydration according to a list provided by the Administrator on 2/13/14. The findings are: 1. The facility's Policy and Procedure on Administration of Enteral feeding dated 4/24/06 received from Registered Nurse (RN) #1, Director of Clinical Education on 2/12/14 documented, "Objective: To provide nutritional formula via a gastric tube by bolus/gravity drip...Document the amount of formula administered, the amount of water flushes administered...the amount of free water administered and any exceptions noted..." The facility's Change of Condition Guidelines for Fever dated 4/24/06 received from the Administrator on 2/12/14 documented, "...Physical Assessment - Dry mucous membranes, Poor skin turgor... Nursing considerations: Increase fluid intake to prevent dehydration." The facility's Change of Condition Guidelines for Fluid Maintenance Status dated 4/24/06 received from the Administrator on 2/12/14 documented, "...Physical Assessment: Dry mucous membranes, Poor skin turgor... Nursing Considerations: When correcting fluid volume deficits watch for hypovolemia (poor skin turgor, dryness of mucous membranes, [MEDICAL CONDITIONS]" 2. Resident #1 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set with an Assessment Reference Date of 1/17/14 documented the resident scored 0 (0-7 indicates severely impaired) on the Brief Interview for Mental Status, received nutrition via a feeding tube and was totally dependent on staff for eating. The resident ' s care plan documented, "Problem Onset: 5/21/13 - I may be at risk for dehydration ... (Approaches) Assess my hydration status daily or as ordered. Obtain my I & O (intake and output) to assess fluid balance. Monitor my electrolytes. Monitor for changes in my symptoms that may indicate worsening of my condition and notify the physician." Lab results dated 11/7/13 documented, "Sodium (Na) - 145 (132-146), Potassium (K) - 4.2 (3.5-5.5), Chloride (Cl) - 101 (99-109), BUN (Blood Urea Nitrogen)- 39 (9-23), Creatinine (Cr)- 0.70 (0.5-1.1), Hemoglobin (Hgb)- 15 (12-16), Hematocrit (Hct)- 43.2 (37.0-47.0), Red blood cells (RBC)- 4.79 (4.2-5.4), Glucose 141 (74-106)." The January and February 2014 Physician order [REDACTED]. Check and clear pump after each shift. Record water intake per [DEVICE] in mls each shift. Include water used for med pass, irrigation, flushes, free water, etc. Flush [DEVICE] (Gastrostomy-tube) with 100 cc (cubic centimeters) free water Q (every) 6HR. Flush [DEVICE] with 30 cc water before and after medications." The January and February 2014 Physician order [REDACTED].) ... " a. The Nurses Notes from 1/9/14 thru 1/11/14 documented elevated body temperature: 1) 1/9/14 at 2:59 a.m., "VS (vital signs) 162/74, 72, 22, 99.5... Resident temp (temperature) re-checked approximately one hour later and ax temp was 98.4..." There was no documentation of hydration assessment. 2) 1/10/14 at 4:23 a.m., "VS 150/74, 99.0 ax (axillary), 74, 20. 0130 (1:30 a.m.) Tylenol 325 mg (milligrams) tab (tablet) x 2 to equal 650 mg (milligrams) via GT (gastrostomy tube) for elevated temp. This nurse will cont (continue) to observe and monitor..." There was no documentation of hydration assessment. 3) 1/11/14 at 10:39 a.m., "BP (blood pressure) 136/80, pulse 72, resp (respirations) 18, temp 99.1..." There was no documentation of hydration assessment. 4) 1/11/14 at 11:06 p.m., "At 1530 (3:30 p.m.) I went into res (resident) room and noticed that the res appears clammy, non responsive to touch or sound, res is very limp, face appears puffy and shiny, not at all like at noon. Mouth appeared dry... BP (Blood Pressure) 210/104, pulse 88, res 16 shallow, temp 100.8, BS (blood sugar) 407. Gave [MEDICATION NAME] 0.1 mg... Called APN (Advanced Practice Nurse) and gave report that res (resident) was not WNL (within normal limits) and res had a big change. APN ordered BMP (Basic Metabolic Panel) and CBC (Complete Blood Count) stat and UA (urinalysis) with C and S (culture and sensitivity) stat and chest X-ray stat... Lab was faxed and received at 1830 (6:30 p.m.), faxed to APN. She ordered [MEDICATION NAME] At 8:10 p.m., I rechecked VS. BP 120/80, temp 99.1. I gave Tylenol PRN (as needed)... BS 429... APN called back... ordered Regular insulin 10 U (units), to up the Gtube water flushes to 150 cc QID (four times daily) every 6 hours, redraw BMP (Basic Metabolic Profile) and CBC (Complete Blood Count) on Monday (1/13/14) by facility stat... VS q4 x 48 hrs (hours) notify APN of temp greater than 101, pulse greater than 100 and BP of less than 90/60... Resident is resting at this time, non clammy and appears to be better. Gave full report to oncoming nurse of all new orders. Will cont to observe." Lab Results dated 1/11/14 documented, "Sodium - 158 (136-146), Potassium - 4.4 (3.5-5.5), Chloride - 113 (98-107), BUN - 55 (7-18), Creatinine - 0.76 (0.5-1.20), Hemoglobin - 15.0 (12-16), Hematocrit - 47.3 (36-48), Red blood cells - 5.04 (4.1-5.0), Glucose - 506 (65-105)." A Physician order [REDACTED]. " [DATE] In-Service R/T (related to) Family Complaint of Care for Resident (Resident #1) " documented, " ...All water flushes by GT (gastrostomy tube) should be verified by two licensed nurses. Water amounts are to be recorded on the MAR (Medication Administration Record) at the end of each shift ... " b. Nurses Notes dated 1/12/14 at 10:39 a.m. documented, "VS 130/96, 99.5 ax, 80, 20. Tylenol 325 mg tab x 2... Accucheck 375..." There was no documentation of hydration assessment. c. A Nursing Facility Progress Note written by the APN dated 1/13/14 documented, "...Fever over the weekend, labs obtained, new orders given...UTI - continue [MEDICATION NAME] 1 gram IM (intramuscular) QD (every day) x 4 more days, [MEDICAL CONDITION] - increase flushes to 250 ml (milliliter) Q6H, DM - Increase [MEDICATION NAME] to 25 units QHS (every night at bedtime)...Increase Glucerna 1.5 to 55 ml per hour...BMP on 1/14/14 on 3/11 shift...Spoke to daughter concerning labwork and disease process. Explained to daughter about her having some [MEDICAL CONDITIONS](Hypertension), DM. Daughter voiced concern regarding care including hydration, feeding... I told her I understood and was concerned and would address her concerns. We spoke about her plan of care regarding increased flushes, IV (Intravenous) hydration or sending to hospital. Daughter did not want her sent to the hospital... She wanted a dual pump for feeds and hydration. Facility was not able to obtain one today. Called (dietician). New order received...My recommendation was to increase flushes, redraw labs in 24 hours, if not any better send to ER (emergency room )...Also told daughter I did not know how she would respond to increased flushes secondary to comorbidities. She understood but wanted to continue with plan of care." 1) A Nurse's Note dated 1/13/14 at 7:14 p.m. documented, "New orders. [MEDICATION NAME] 1 gram QD x 4 days = total of 7 days. BMP stat 1/14/14..." 2) Lab results dated 1/13/14 documented, "Sodium - 156 (136-146), Potassium - 4.3 (3.5-5.5), Chloride - 113(98-107), BUN - 61 (7-18), Creatinine - 0.58 (0.5-1.20), Glucose - 335 (65-105)." 3) A Physician order [REDACTED]. d. A Nurse's Note dated 1/14/14 at 5:07 a.m. documented, "Received resting quietly in bed...Skin warm and dry to touch, resp (respirations) even and nonlabored with no cough noted. VS 98.2, 20, 76, 160/80, 02 sat 95% at 2400 (12:00 a.m.)... Visual checks every 30 minutes..." Lab results dated 1/14/14 documented, "Sodium - 147 (136-146), Potassium - 4.7 (3.5-5.5), Chloride - 105 (98-107), BUN - 47 (7-18), Creatinine - 0.46 (0.50-1.20), Glucose - 432 (65-105)." e. A Nurse's Note dated 1/16/14 documented, "APN called... draw BMP..." 1) Lab results dated 1/16/14 documented, "Sodium - 142 (136-146), Potassium - 4.1 (3.5-5.5), Chloride - 101 (98-107), BUN - 38 (7-18), Creatinine 0.55 (0.5-1.2), Glucose - 305 (65-105)." 2) A Nursing Comprehensive Admission and Quarterly Eval (Evaluation) form dated 1/17/14 documented the resident had no [MEDICAL CONDITION], no cough, had a regular respiratory rhythm with clear breath sounds. The form also documented the resident's skin had good turgor. 3) Lab results dated 1/21/14 documented, "Sodium - 138 (136-146), Potassium - 4.6 (3.5-5.5), Chloride - 96 (98-107), BUN - 53 (7-18)) Creatinine - 0.6 (0.5-1.2), Glucose - 291 (65-105)." f. A Nurse's Note dated 1/22/14 at 6:53 p.m. documented, "VS 142/76, HR (heart rate) 74, resp 18, T (temperature) 98.2 SPO2 (oxygen saturation) 98% RA (room air)... Resp even and nonlabored, abdomen soft and nontender with + BS (bowel sounds) x 4 quads... Skin warm and dry to touch with normal turgor noted. APN here to see, reviewed labs and ordered labs - BMP on 1/26/14..." g. A Registered Dietician (RD) Note dated 1/23/14 at 10:01 a.m. documented, "...Labs 1/21/14: glucose 291, BUN 53, Cr .6, sodium 138, K+ 4.6, Ca 9.1... On 1/14/14 sodium was 147 and RD consulted via phone to increase flushes...resident has hx of [MEDICAL CONDITION], DM, dementia...resident receiving nutrition via PEG (Percutaneous Endoscopic Gastrostomy) and nurse reporting to RD that resident very 'full', so much that it has been difficult for nursing to administer feedings and flushes...resident receives Glucerna 1.5 at 55 cc x 23 H with 30 cc H2O ac/pc (before and after) meds, 100 cc H2O Q6H, 250 cc H2O Q6H which provides: 1897.5 kcals, 104.4 g protein, 960 cc free water (total with flushes 2540 cc H2O)... Estimated energy needs... 1725-2070 kcals, 69-83 g protein, 1725-2070 cc fluid... RD to recommend: decrease bolus flush to 180 cc H2O Q4H (1080 cc for total H2O via PEG 2220), which is higher than estimated needs yet resident has hx of increased Na+. RD to continue to decrease H2O to acceptable range as resident has hx of [MEDICAL CONDITION] as well...RD to continue to f/u (follow up) prn." The January 2014 MAR documented the resident had been receiving 250 cc per 6 hours with 30 cc H2O ac/pc meds and not the 100 cc every 6 hours. 1) A Nurse's Note dated 1/24/14 at 3:05 p.m. documented, "Spoke with (daughter) about new orders per RD/APN to decrease flushes to 180 ml H2O Q4H. Discussed recent lab values from 1/13/14-1/21/14. Resident's sodium has continued to decrease from 1/13/14 and BUN values have fluctuated from 38-61. Spoke with (daughter) about resident's dx of [MEDICAL CONDITION] and (daughter) stated she was unaware of such dx. Informed (daughter) (lab company) would be drawing lab values of BMP and TSH ([MEDICAL CONDITION] Stimulating Harmone) on 1/26/14..." A Physician order [REDACTED]. 2) Lab results dated 1/26/14 documented, "Sodium - 142 (132-146), Potassium - 5.1 (3.5-5.5), Chloride - 104 (99-109), BUN - 43 (9-23), Creatinine - 0.80 (0.5-1.1), Glucose - 410 (74-106)." h. A Nurse's Note dated 1/28/14 at 10:24 a.m. documented, "BP 146/82, pulse 82, resp 16, temp 97.4... Resp even and unlabored, abd (abdomen) soft and non tender, BS (positive)...skin w/d (warm/dry) to touch, color wnl..." There was no documentation of hydration assessment. i. A Nurse's Note dated 1/30/14 at 2:05 p.m. documented, "...skin warm and dry with normal turgor noted. Resp even and nonlabored..." There was no documentation of hydration assessment. j. The Nurses Notes from 2/1/14 - 2/2/14 documented: 1) 2/1/14 at 8:33 a.m., "V/S 164/80, 84, 22, 99.6. Received resident in bed... resp even and unlabored with no s/s of pain or discomfort noted at this time. Skin warm and dry to touch... temp rechecked at 0620 (6:20 a.m.), 98.4 and BP 138/72. Information passed on to incoming nurse..." 2) 2/1/14 at 7:29 p.m., "Went into res room at 7 pm... there was a lot of feeding on the covers. I checked and [DEVICE] was out... called APN, ordered to send to (hospital) for replacement..." 3) 2/2/14 at 1:00 a.m., " Received resident from (hospital) via ambulance at 2350 (11:50 p.m.) ...Unable to restart tube feedings due to no placement confirmation from hospital .... " 4) 2/2/14 at 3:25 a.m., "...orders received to continue resident's feedings..." Based on the 2/1/14 and 2/2/14 Nurses Notes, the resident went without nutrition/hydration for 8 hours and 25 minutes due to the need to replace the gastrostomy tube and there were no documented assessments of the resident for signs/symptoms of dehydration. k. A Chest X-ray result dated 2/4/14 documented, "...Right upper and left lower lobe parenchymal density most consistent with airspace consolidation from pneumonia." A Physician order [REDACTED]. l. A Nurse's Note dated 2/5/14 at 10:23 p.m. documented, "7:05 a.m.- Called to room by CNA (Certified Nurse Assistant) pointing to [DEVICE] that was out. Resident was on shower gurney with dressing still intact with bulb deflated and lying on abdomen... 7:15 a.m. Called APN back and she decided to just send resident to (hospital) for [DEVICE] replacement... 7:35 a.m.- spoke to (family) and informed of findings... she questioned this nurse why is her [DEVICE] coming out so frequently. I explained that they just sometimes do this. She informed me that she just had it replaced this past Saturday... 9:25 a.m.- Called (ambulance company) to inform of transfer. 10:00 a.m.- APN here to assess. 10:10 a.m.- Ambulance...here to transport... 1:40 p.m.- Arrived back to facility via ambulance...feeding restarted..." A Nurse's Note dated 2/6/14 at 10:56 a.m. documented, "BP 166/88, pulse 101, resp 20, temp 101.5, eyes glossy, face puffy, lung sounds crackly, res does not appear how she does normally. In report RN stated that 6 am BS said HI and gave 16 U (units) Reg (Regular) R and that she was sent out yesterday for [DEVICE] replacement, and 8am (8:00 a.m.) nurse stated that it still stated HI. I rechecked again at 9:30 and it stated HI. (Physician) in facility and gave order to give 30 U of Reg R and up [MEDICATION NAME] to 30 U in HS (bedtime). When I told him about her condition and that she had CBC, Chest X-ray, he looked at it and stated to send her to (hospital)..." Based on the documentation found in the clinical record, the resident went without nutrition/hydration for 6 hours and 35 minutes due to the need to replace the gastrostomy tube and there were no documented assessments of the resident for signs/symptoms of dehydration. m. The January 2014 Medication Administration Record (MAR) documented, "Record total tube feedings in mls each shift. Check and clear pump after each shift." This section on the MAR was blank for the 7/3 shift on 1/5/14, 1/24/14 and 1/27/14. This section for the 3/11 shift was blank on 1/5/14, 1/6/14, 1/10/14, 1/17/14, 1/19/14, 1/23/14, 1/24/14, 1/27/14 and 1/30/14. The section for the 11/7 shift was blank on 1/11/14, 1/23/14, 1/28/14 and 1/31/14. The form also documented, "Record water intake per [DEVICE] in mls each shift. Include water used for med (medication) pass, irrigation, flushes, free water, etc." The section on the MAR was blank for the 7/3 shift on 1/5/14 and 1/24/14. The section for the 3/11 shift was blank on 1/10/14, 1/19/14, 1/24/14 and 1/31/14. The section for the 11/7 shift was blank on 1/30/14 and 1/31/14. The February 2014 MAR (2/1/14 -2/5/14) documented, "Record total tube feedings in mls each shift. Check and clear pump after each shift." The section on the MAR was blank for the 7/3 shift on 2/2/14. The section was blank for the 3/11 shift on 2/1/14, 2/2/14, 2/3/14 and 2/4/14. The section for the 11/7 shift was blank on 2/4/14. The MAR also documented, "Record water intake per [DEVICE] in mls each shift. Include water used for med pass, irrigation, flushes, free water, etc." This section on the MAR was blank for the 3/11 shift on 2/1/14, 2/2/14, 2/3/14 and 2/4/14. This section for the 11/7 shift was blank on 2/1/14 and 2/5/14. As of 2/11/14 at 5:00 p. m., there was no documentation on the January and February 2014 (2/1/14 -2/5/14) MARs to indicate fluid intake was consistently documented to accurately assess the resident ' s hydration status. n. The hospital Emergency Department notes dated 2/6/14 documented, "Pt sent from local nursing home with reports of high BS (blood sugar) today... Pt had feeding tube replaced yesterday and was started on [MEDICATION NAME] for pneumonia yesterday... BP 122/65, Pulse 112, Temp 97 F Axillary, Resp 30... SpO2 85%... [MEDICAL CONDITION]/chest: Breath sounds normal. Tachypnea noted. She has no wheezes. She has no rales... Sodium - 168 (136-146), Chloride - 122 (98-107), BUN - 102 (7-18), Creatinine - 1.56 (0.50-1.20), Glucose - 1123 (65-105)... Diabetic Ketoacidosis, Dehydration, [MEDICAL CONDITION] Admit to ICU (Intensive Care Unit)." On 2/12/14 at 10:56 a.m., the APN was asked about the dehydration [DIAGNOSES REDACTED]. I think the high blood sugar was due to infection, although she was always high anyway. She had pneumonia right around there." o. Staff members were interviewed regarding the lack of assessment/monitoring for signs/symptoms of dehydration: 1) On 2/13/14 at 11:10 a.m., the Administrator was asked if the facility had identified and intervened regarding the lack of assessing and monitoring of hydration status for (Resident #1) between 1/11/14 and 2/6/14. She stated, "We haven't done anything in writing." 2) On 2/13/14 at 11:45 a.m., Licensed Practical Nurse (LPN) #1, who provided care to (Resident #1), was asked where it would be documented if she performed a hydration assessment on the resident. She stated, "It should be in the Nurse's Notes." LPN #1 was asked if she had skips on the MARs for (Resident #1) and why she would not complete the section for water intake. She stated, "I don't know, because I know if you don't document you didn't do it. I don't know why. It might've been a bad day. I know what it looks like." 3) On 2/13/14 at 11:50 a.m., Registered Nurse (RN) #1 provided an inservice that documented, "2/12/14 - Dehydration Assessment. Residents who get their feedings and hydration from [DEVICE] must be assessed each shift for dehydration... Assess for dry lips, mouth chapped, blood pressure decreased, rapid pulse, nausea/vomiting, cold sweat, thirst, poor skin turgor, dry mucosa, lethargy, small or low urine output." 4) On 2/13/14 at 12:44 p.m., LPN #2, who provided care to (Resident #1) was asked where it would be documented if he performed a hydration assessment on the resident. He stated, "It would be in the Nurse's Notes." He was asked why he didn't do hydration assessments on the resident when she had a history of [REDACTED]. He stated, "I used to do skin turgor a lot, but the only time I documented it is if there was something wrong. But I've started back doing it." LPN #2 was asked about there being skips on the MARs where the resident's water intake would be documented. He stated, "I had some skips on the MARs. They had me come in and sign the MAR because I knew I had given them." He was asked why he would not initial the MAR if he had actually completed the order on it. He stated, "There's not really a reason." He was asked if he was inserviced yesterday (2/12/14) on anything. He stated, "Yes ma'am. Hydration assessment documentation." 5) On 2/13/14 at 3:10 p.m., LPN #3, who provided care to Resident #1, was asked during a telephone interview where it would be documented if she performed a hydration assessment on the resident. She stated, "In the Nurse's Notes." She was asked if she ever performed hydration assessments on (Resident #1) since she had a history of [REDACTED]. She stated, "I know her pretty good. When she is sick, she'll get puffy and her facial expression is totally different." The LPN was asked about the lack of documented assessments and skips on MARs where fluid intake should have been documented and how the resident's intake and status could be monitored if it's not documented. She stated, "It would be difficult. How else would you know if she's getting enough?" 6) On 2/13/14 at 3:45 p.m., the DON was asked about the lack of documented hydration assessments and fluid intake for (Resident #1). She stated, "We learn in school if it's not documented it's not done. I expect a nurse to look at the resident and do an assessment. I expect them to chart on every Medicare resident and tube fed resident every shift and I would expect them to be able to tell me about that resident." She was asked how she would know that the nurses are assessing a resident's hydration status if they don't document it. She stated, "You don't."