Every finding on record at Ozark Nursing and Rehab

Based on observation, interview, and record review, the facility failed to ensure clean linens and clothing were handled and transported in a manner to prevent contamination by failing to maintain covers on laundry carts during delivery to resident care areas. This deficient practice occurred during three separate observations and had the potential to affect all residents residing in facility.Based on observation, interview, and facility policy review, the facility failed to ensure clean linens and clothing were handled and transported in covered carts during delivery to resident care areas to prevent contamination or spread of infection during three of three observations, which had the potential to affect all residents residing in the facility. The findings include: On 02/19/2026 at 8:15 AM, this Surveyor observed Laundry Tech (LT) #1 pushing a laundry cart down the 400 Hall without a cover over the clean clothing. On 02/19/2026 at 8:22 AM, this Surveyor observed LT #1 pushing a laundry cart down the 100 Hall without a cover over the clean clothing. On 02/19/2026 at 8:34 AM, this Surveyor observed LT #1 deliver a laundry cart to a room near the common area with clean linens inside; the linens were not covered. During an interview on 02/19/2026 at 9:54 AM, LT #1 stated the linen covering was removed from clean laundry upon entering the building. LT #1 expressed uncertainty regarding the procedure, stating the policy changed frequently. During an interview on 02/20/2026 at 9:20 AM, LT #2 confirmed being unaware until the current week that clean linens required a covering during transport. LT #2 indicated no knowledge of any type of periodic in-service training with laundry staff. During an interview on 02/19/2026 at 12:30 PM, the Infection Preventionist (IP) stated that quarterly infection control in-service training was provided to all staff, and the housekeeping supervisor oversaw laundry operations. During an interview on 02/19/2026 at 1:42 PM, the Housekeeping Supervisor (HS) confirmed that laundry should be kept covered during transport to all areas unless removing garments and linens from the cart. During an interview on 02/20/2026 at 10:13 AM, the Director of Nursing (DON) acknowledged familiarity with the laundry operations and the prevention of contamination but could not recall ever seeing linens being transported in the hallways uncovered. Review of a facility in-service document titled Infection Control dated 10/2025, revealed the infection control program will properly store, handle and transport linens to minimize contamination. Review of an undated facility policy titled Infection Prevention & Control Program, revealed Laundry and direct care staff shall handle, store, process, and transport linens to prevent spread of infection. This policy also revealed Clean linen shall be delivered to resident care units on covered linen carts with covers down. Review of Standards of Practice indicated under the section Linens in the Code of Federal Regulations 483.80(e) Personnel must handle, store, process, and transport linens so as to prevent the spread of infection.

Based on observations, interviews, and facility policy review, it was determined the facility failed to ensure kitchen equipment used during meal preparation and service was kept clean and uncontaminated to prevent the spread of illness with the potential to effect 76 residents served from the 1 of 1 kitchen reviewed for food preparation and service. Findings include: A review of the facility's undated policy titled Handwashing and glove usage in food service, indicated Food handlers must wash hands after touching dirty equipment and work surfaces. During an observation on 08/11/2024 at 12:30 PM, [NAME] #2 touched the green pea ladle scoop to the ladle handles of the cauliflower and pureed green peas resting in the two right adjacent containers of the stem table while plating resident food. The green pea ladle was then placed back in the container of green peas and continued to be used for plating of resident food without being washed and sanitized. During an interview on 08/11/2024 at 1:00 PM, Registered Dietician (RD) #1 agreed the ladle for the green peas was considered dirty after contact with the ladle handles of the other vegetables and once placed into the food it was contaminated. During an observation on 08/13/24 at 11:00 AM, [NAME] #3 removed the bowl scrapper attachment of the food processor with the left hand and placed it on the countertop, added pork chops to the bowl for processing, then replaced the bowl scrapper with the left hand in the bowl of food without being washed and sanitized. During an interview on 08/13/24 at 11:15 AM, [NAME] #3 was initially unable to recall the incorrect handling of the bowl scrapper attachment, but acknowledged a tray was added as a barrier to the counter surface and tongs were utilized for handling of the scrapper attachment. During an interview on 08/14/24 at 2:45, the Administrator stated no written policy for washing and sanitizing food preparation equipment, utensils, or surfaces was currently in place, but provided new re-education in-service statement dated 08/13/24 conducted by RD #1 and Dietary Manager #4. Inservice for procedure stated Make sure service end does not touch handles of another scoop or other surface. Any item that will be touching food cannot be placed on a dirty surface

Based on observation and interview, the facility failed to ensure kitchen food items stored in the dry storage area, were covered, and sealed; the dish washing machine room ' s air vents were cleaned to provide a sanitary environment for clean dishes, 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. The failed practices had the potential to affect 79 residents who received meals from the kitchen (total census: 80), as documented on a list provided by the Dietary Supervisor on 06/22/23 at 1:37 PM. The findings are: 1. On 06/19/23 at 11:15 AM, on a rack in the Storage Room there were two cans of pasta sauce that had dents at their rims. The Surveyor asked the Intern Dietary Supervisor what the outcome of a dent to the rim of a can could be. She stated, Botulism. 2. On 06/19/23 at 11:26 AM, the following opened containers of spices were on a shelf in the Storage Room. a. A container of oregano. b. A container of onion powder. c. A container of white pepper. d. The Surveyor asked the Intern Dietary Supervisor if those containers should be left open. She stated, Yeah I thought they were closed, and began closing them. 3. On 06/19/23 at 11:28 AM, an opened bag of hot dog buns was on the bread rack in the storage room. The top was loosely twisted and not secured. 4. On 06/21/23 at 8:43 AM, the temperature in the walk-in refrigerator was 41 degrees Fahrenheit and Freezer temperature was 8 degrees Fahrenheit. 5. On 06/21/23 at 8:58 AM, the temperature in the milk refrigerator was 38 degrees Fahrenheit. 6. On 06/21/23 at 8:59 AM, Dietary Employee (DE) #1 was wearing gloves on her hands. She turned on the food preparation sink faucet and rinsed cabbage heads and placed them on the cutting board. She then turned off the faucet contaminating her gloves. Without changing gloves and washing her hands, she sliced the cabbage heads and placed them into three pans to be cooked and served to the residents for lunch. 7. On 06/21/23 at 9:01 AM, three air vents in the dish washing machine room had rust build up on them. Two of the 3 air vents had dirty lint hanging down from them. There was dirty black residue stuck in the slats of the air vents. 8. On 06/21/23 at 9:17 AM, DE #1 removed pans that contained polish sausage from the stove and placed them on the counter. She removed gloves from the glove box and placed them on her hands, contaminating the gloves. Without changing gloves and washing her hands, she placed 24 servings of polish sausage into a blender, ground and poured into a pan. She covered the pan with foil and placed it in the warmer to be served to the residents who received mechanical soft diets. 9. On 06/21/23 at 9:19 AM, DE #2 moved a floor fan into the dish washing machine room. Without washing her hands, she picked up clean plates from the clean side of the dish machine and placed them in the warmer to be used in portioning foods to be served to the residents for lunch. 10. On 06/21/23 at 9:23 AM, DE #1 lifted the trash can lid and threw away an emptied water gallon container into the trash. She immediately went into the freezer, picked up a box of bread sticks and placed it on the counter. She removed a zip lock bag that contained bread sticks from the Storage Room and placed it in a warmer. At 9:24 AM, she removed a container of meat sauce and emptied it into a pan. She covered the pan with foil and placed it in the oven. At 9:25 AM, when she was about to place polish sausages into a blender to puree. The Surveyor immediately stopped her and asked her what she should have done after touching dirty objects and before handing food and or clean equipment. She stated, I should have washed my hands. 11. On 06/21/23 at 9:30 AM, DE #1 was wearing gloves on her hands. She picked up a pan that contained cornbread and placed it on the counter. Without changing gloves and washing her hands, she used her contaminated gloved hand to place slices of corn bread in individual bags to be served to the residents for lunch. 12. On 06/21/23 at 9:40 AM, DE #2 used a scraper and scraped off excess water on the clean side of the dish washing machine counter and used scissors to cut open a bag of napkins. Without washing her hands, she removed napkins from the bag for residents to use in wiping their mouth when eating their lunch meal. At 10:02 AM, DE #2 still had not washed her hands. She picked clean plates and placed them in the plate warmer with her fingers inside the plates. At 10:06 AM, DE #3 picked up a clean blade and attached it to the base of the blender, to be used in pureeing food items to be served to the residents on pureed diets. The Surveyor immediately stopped DE #2 and asked her what she should have done after touching dirty objects and before handling clean equipment. She stated, I should have washed my hands. 13. On 06/21/23 at 9:59 AM, DE #1 had gloves on her hands. She picked up a pan of corn bread and placed it on the counter. She used her contaminated gloved hands to remove 14 slices of corn bread from the pan and placed the corn bread into a blender to be pureed and served to the residents on pureed diets. 14. On 06/21/23 at 10:29 AM, DE #1 was wearing gloves on her hands as she removed a log of butter from the walk-in refrigerator. She used a knife to slice a portion of it and used her contaminated gloved hand to place it in a pan on the stove to be used in preparing mashed potatoes to be served to the residents for lunch. 15. On 06/21/23 at 10:53 AM, DE #3 opened a can of sliced apples. Without washing her hands, she removed gloves from the glove box and placed them on her hands, contaminating the gloves. She attached a clean blade to the base of the blender. She used a 6-ounce spoon to place sliced apples into a blender, added brown sugar, cinnamon and juice from the apple slices and pureed them. She used a #8 scoop to place portions the pureed apple mixture into 10 bowls. 16. On 06/21/23 at 11:12 AM, DE #3 removed two cans of tomato soup from the Storage Room and placed them on the counter. She picked up clean bowls from a tray on a rack in the clean area of the dish washing machine and placed them on the counter with her fingers inside the bowls. She opened the cans of tomato soup and poured them into individual bowls. She then placed them in a warmer to be served to the residents who requested tomato soup with their meal. 17. On 06/21/23 at 11:20 AM, DE #1 turned on the food preparation sink faucet and obtained water in a pitcher and poured it inside the pans on the steam table. Without washing her hands, she picked up a clean blade and attached it to the base of the blender to be used in pureeing food items to be served to the residents on pureed diets. 18. The facility policy titled, Handwashing and Glove Usage in Food Service, provided by the Dietary Supervisor on 06/22/23 at 1:37 PM documented, .When Food Handlers must wash their hands: Before starting work . After leaving and returning to the kitchen/prep area After touching anything else such as dirty equipment, work surfaces or cloths .

Based on observation, record review, and interview, the facility failed to ensure a resident's urinary catheter drainage bag was kept in a privacy bag from view of other residents/visitors to promote dignity for 1 (Resident #39) of 1 sampled resident who had an indwelling catheter. This failed practice had the potential to affect 5 residents who had catheters according to a list provided by the Director of Nursing (DON) on 06/21/23 at 8:33 AM. The findings are: 1. Resident #39 had diagnoses of obstructive uropathy. The Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/08/23 documented the resident scored 6 (0-7 indicates severely cognitively impaired) on a Brief Interview for Mental Status (BIMS) and had an indwelling catheter. a. On 06/19/23 at 11:14 AM, Resident #39 was sitting up in a recliner in his room. There was a urinary catheter drainage bag sitting in a plastic wash basin on the floor next to the resident's recliner. There was no privacy bag covering the drainage bag. b. On 06/20/23 at 8:55 AM, Resident #39 was sitting up in a recliner with his eyes closed. His urinary catheter drainage bag was folded over itself and sitting directly on the floor to the left side of his recliner. There was no privacy bag covering the drainage bag. c. On 06/21/23 at 9:06 AM, Resident #39 was sitting on a bedside commode in his room. Resident #39's family member was sitting in a recliner. His urinary catheter drainage bag was hanging on the bottom rung of his walker not in a privacy bag. d. On 06/22/23 at 9:32 AM, Resident #39 was sitting up in a recliner. His catheter drainage bag was folded over itself sitting in a wash basin on the floor not in a privacy bag. e. On 06/23/23 at 7:30 AM, the Surveyor asked the DON if urinary catheter drainage bags should have privacy bags covering them. The DON answered, If you are talking about [Resident #39] then no, because there's no place to hang it on his recliner and he's not out and about from his room. It's not required in the regulations. The Surveyor clarified by asking the DON if catheter drainage bags should be covered for residents in general. The DON answered, Not as long as they are in their rooms. If they are out and about, then yes, they should have a privacy bag. It's in the thing because we don't want it on the floor. f. On 06/23/23 at 9:00 AM, the Surveyor asked Certified Nursing Assistant (CNA) #3 if urinary catheter drainage bags should have privacy bags covering them. CNA #3 answered, Yes, especially if they are in front of other people that can see it. The Surveyor asked why Resident #39's catheter drainage bag was in the plastic wash basin on the floor. CNA #3 answered, We'd rather it be in that then on the floor because we don't want it to get contaminated. g. On 06/21/23 at 8:28 AM, the DON stated, There is no policy for quality of life or dignity as it's not required. h. A review of the Catheter Care and UTI inservice speaker notes from 9/2022 provided by the MDS Coordinator on 6/22/23 at 10:14 AM revealed the staff are to use a bag cover to protect the resident's dignity.

Based on observation, interview, and record review, the facility failed to follow a Physicians Order for placement of compression stockings for 1 (Resident #61) of 10 (Residents #15, #19, #20, #26, #27, #43, #46, #61, #62 and #63) sampled residents who had Physician Orders for compressions stockings. The findings are: 1. Resident #61 had diagnoses of Essential (Primary) Hypertension, Other Specified Symptoms and Signs Involving the Circulatory and Respiratory Systems and Chronic Kidney Disease, Unspecified. a. A Physicians Order dated 06/01/23 documented, Compression Stockings in place to BLE [bilateral lower extremities] during daytime; remove at HS [hour of sleep] . b. The June 2023 Medication Administration Record (MAR) documented, Compression stockings in place to BLE during daytime; remove at HS . and documented they had been applied at 6:00 AM and removed at 8:00 PM on 06/20/23 and applied at 6:00 AM on 06/21/23. c. On 06/20/23 at 12:07 PM, Resident #61 was sitting up in a chair in her room. Resident #61's ankles and feet were swollen to an extent that made it difficult to identify the transition between calf, ankle, and foot. No compression stockings were in place on the resident's legs. d. On 06/21/23 at 8:12 AM, Resident #61 was sitting on the side of her bed, both legs were swollen. No compression stockings were in place on the resident's legs. e. On 06/21/23 at 9:46 AM, observed Resident #61 being pushed down the hallway in a wheelchair to the Dining Hall. No compression stockings were in place on the resident's legs. f. On 06/21/23 at 10:17 AM, the Surveyor asked the Infection Preventionist to navigate to Resident #61's MAR and identify if it documented compression stockings were placed on the resident that morning. He stated, Shows they were. I know [Resident #61] doesn't like anything on but briefs. g. On 06/21/23 at 10:30 AM, the Surveyor asked the Infection Preventionist to accompany the Surveyor to the Dining Hall to see Resident #61. The Surveyor asked if the compression stockings were in place as documented on the MAR. He stated, No they're not on there. h. On 06/21/23 at 10:35 AM, the Surveyor asked Medication Tech #1 if they had documented that compression stockings had been placed on Resident #61. She stated, I don't remember seeing that, can I go put them on her now. The Infection Preventionist asked Medication Tech #1, You came in at 5 [AM]? Medication Tech #1 stated, Yes. The Infection Preventionist stated, You marked them put on at 6 [AM].

Based on observation, interview, and record review, the facility failed to ensure suprapubic/indwelling catheters were free of sediment to prevent possible infection for 1 (Resident #39) of 1 sampled resident. This failed practice had the potential to affect 5 residents according to a list provided by the Director of Nursing (DON) on 06/21/23 at 8:33 AM. The findings are: 1. Resident #39 had diagnoses of Urinary Tract Infection, Site not Specified and Benign Prostatic Hyperplasia with Lower Urinary Tract Symptoms. The Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/08/23 documented the resident scored 6 (0-7 indicates severely cognitively impaired) on a Brief Interview for Mental Status (BIMS) and had an indwelling catheter. a. A Care Plan with an initiated date of 04/04/23 documented, [Resident #39] has a foley catheter r/t [related to] obstructive uropathy . Position catheter bag and tubing below the level of bladder, secure catheter tubing to leg with applicable device . b. On 06/19/23 at 11:14 AM, Resident #39 was sitting up in a recliner in his room. The drainage bag was sitting in a plastic wash basin on the floor next to the resident's recliner. There was a dried substance on the bottom and on one side of the basin and was in contact with the catheter bag. The top of the drainage bag was folded down and over the drainage tube, restricting the flow of urine into the drainage bag. There was a tan colored residue noted on the inside of the clear catheter tubing running from Resident #39 to the catheter drainage bag. c. On 06/20/23 at 8:53 AM, Resident #39 was sitting in a recliner in his room. The catheter drainage bag was folded over and sitting on the floor next to the recliner. A wash basin was sitting beside the bag on the floor next to the resident's recliner. There was a tan colored residue noted on the inside of the clear catheter tubing running from Resident #39 to the catheter drainage bag. d. On 06/22/23 at 8:50 AM, the Surveyor asked Licensed Practical Nurse (LPN) #2 who was responsible for catheter care inservices. She answered, The CNA Supervisor takes them monthly and they are checked off. The Surveyor asked if nurses get inserviced on catheter care. She answered, No. The Surveyor asked who was responsible for changing or irrigating foley catheters. She answered, Nurses change foley catheters weekly as it pops up on the MAR [Medication Administration Record] for being changed out. We have a RN [Registered Nurse] that is assigned to do that during the day now. The Surveyor asked, How do you make sure the Care Plan for [Resident #39] is followed and interventions are implemented. LPN #2 answered, We follow up and I check him a lot as far as his urine. Ask aides a lot. You just can't assume. The Surveyor asked if she knew how often his drainage bag was supposed to be changed. She answered, Weekly, the bag is changed as it was on the MAR. I'm assuming it's still that way. e. On 06/22/23 at 10:55 AM, the Surveyor accompanied DON to Resident #39's room where he was sitting up in recliner. His foley catheter was not in dignity bag and was sitting in a wash basin on the floor. The drainage bag was dated 5/21. The Surveyor asked the DON what the date was on the catheter drainage bag. The DON answered, 5/21, but it's supposed to be changed every 4-8 weeks. They changed it from weekly to monthly so yesterday would have been the 4 week mark. f. A policy and procedure titled, Management of the Patient with an Indwelling (Self-Retaining) Catheter and Closed Drainage System from [Manual of Nursing Practice] 10th edition provided by the DON on 06/21/23 at 4:30 PM documented, .keep the drainage bag off the floor .urine should not be allowed to collect in the tubing because a free flow of urine must be maintained to prevent infection . g. An Inservice titled, Catheter Care and Urinary Tract Infections Lesson Plan and Speakers Notes, provided by the MDS Coordinator on 06/22/23 at 10:14 AM documented, .Secure Catheter tubing to upper leg to prevent catheter from being pulled out. Keep the bag below the level of the resident's bladder at all times. Use a catheter bag cover to protect the resident's dignity .

Based on observation, record review, and interview, the facility failed to ensure fortified food was prepared and served according to the planned written menu to meet the nutritional needs of the residents for 1 of 1 meal observed. This failed practice had the potential to affect 14 residents who received fortified foods from 1 of 1 kitchen according to a list provided by the Interim Dietary Supervisor on 06/22/23 at 1:37 PM. The findings are: 1. On 06/22/23 at 1:37 PM, the menu for breakfast documented the residents who received a Super Calorie diet were to receive 1 cup of Super Cereal. 2. On 06/22/23 at 7:50 AM, a pan of Super Cereal was on the steam table with a 4-ounce spoon inside the pan. At 7:55 AM, the Surveyor asked Dietary Employee (DE) #1, How did you prepare the super calorie cereal? She stated, I used oatmeal, 1/2 cup of heavy cream and 1/2 cup of brown sugar. The Surveyor asked what size of spoon she used to serve and how many servings were given to each resident. She stated, I used a 4- ounce spoon and I gave one serving each. The Surveyor asked if she looked at the recipe. She stated, No, I did it the way I was taught by the previous Manager. 3. The facility recipe for Super Cereal provided by the Interim Dietary Supervisor on 06/22/23 at 8:05 AM documented for 15 servings to use: 23/4 cup plus 2 tablespoon of water, 21/2 cup of nonfat dry milk, 1 cup plus 1 tablespoons of evaporated milk. 1. Mix water, nonfat dry milk, and evaporated milk. Bring it to boil. 2. Pour in 13/4 cup plus 2 tablespoon dry oatmeal and cook until done (Approximately 5 minutes). 3. Add 1 pound plus 1 ounce of margarine bulk, 111/2 ounce of light brown sugar, 11/4 cup plus 3 tablespoon of granulated sugar, add 21/4 cup additional evaporated milk. Stir until creamy. Portion size one cup.

Based on observation and interview, the facility failed to ensure pureed food items were blended to a smooth, lump-free consistency to minimize the risk of choking or other complications for residents who required pureed diets for 2 of 2 meals observed. This failed practice had the potential to affect 8 residents who received pureed diets as documented on a list provided by the Interim Dietary Supervisor on 06/22/23 at 1:37 PM. The findings are: 1. On 06/21/23 at 9:26 AM, Dietary Employee (DE) #1 placed 8 servings of polish sausage into a blender, added broth and pureed. She poured the pureed polish sausage into a pan, covered the pan with foil, and placed it in the oven. The consistency of the pureed polish sausage was gritty and not smooth. 2. On 06/21/23 at 9:59 AM, DE #1 had gloves on her hands. She picked up a pan of corn bread and placed it on the counter. She used her contaminated gloved hands, removed 14 slices of corn bread from the pan, and placed the corn bread into a blender to be pureed and serve to the residents on pureed diets. The consistency of the pureed cornbread was thick with lumps in it and not smooth. 3. On 06/21/23 at 10:58 AM, DE #1 prepared mashed potatoes with 1/4 cup of melted butter, salt, and potatoes. She placed the pan in the warmer. The consistency was thin. 4. On 06/21/23 at 11:24 AM, DE #1 used a 4-ounce spoon to place 11 servings of cabbage into a blender and pureed. She poured the pureed cabbage into a pan and placed it on the steam table. The consistency was not formed and was not smooth. It had little pieces of cabbage in it. 5. On 06/21/23 at 1:25 PM, the Surveyor asked the Interim Dietary Supervisor to describe the consistency of the pureed food items served to the residents for lunch. She stated, Pureed polish sausage was dry and chunky. Pureed cabbage was not smooth enough. Needs to be pureed a little longer and the mashed potatoes were thin. Pureed cornbread was thick with little lumps. 6. On 06/22/23 at 7:50 AM, a pan of sausage was on the steam table. The consistency was gritty and not smooth. A pan of pureed bread was on the steam table. The consistency was lumpy, thick, and not smooth. 7. On 06/22/23 at 7:55 AM, the Surveyor asked DE #1 to describe the consistency of the pureed food items served to the residents for breakfast. She stated, Pureed sausage was gritty. It's hard to get it smooth. Pureed bread with milk was thick with a little lump in it. Our blending machine is not working well.

Based on observation, interview, and record review, the facility failed to maintain accurate documentation in the health records regarding placement of compression stockings for 1 (Resident #61) of 10 (Residents #15, #19, #20, #26, #27, #43, #46, #61, #62 and #63) sampled residents who had a Physicians Order for compression stockings and replacement of foley catheter collection bags for 1 (Resident #39) of 1 sampled resident who had an indwelling catheter. The findings are: 1. Resident #61 had diagnoses of Essential (Primary) Hypertension, Other Specified Symptoms and Signs Involving the Circulatory and Respiratory Systems and Chronic Kidney Disease, Unspecified. a. A Physicians Order dated 06/01/23 documented, Compression Stockings in place to BLE [bilateral lower extremities] during daytime; remove at HS [hour of sleep] . b. The June 2023 Medication Administration Record (MAR) documented, Compression stockings in place to BLE during daytime; remove at HS . The MAR revealed staff documented they had been applied the compression stockings at 6:00 AM and removed at 8:00 PM on 06/20/23 and applied at 6:00 AM on 06/21/23. c. On 06/20/23 at 12:07 PM, Resident #61 was sitting up in a chair in her room. No compression stockings were in place on the resident's legs. d. On 06/21/23 at 8:12 AM, Resident #61 was sitting on the side of her bed. No compression stockings were in place on the resident's legs. e. On 06/21/23 at 9:46 AM, Resident #61 being pushed down the hallway in a wheelchair to the Dining Hall. No compression stockings were in place on the resident's legs. f. On 06/21/23 at 10:17 AM, the Surveyor asked the Infection Preventionist (IP) to navigate to Resident #61's MAR and identify if it documented compression stockings were placed on the resident that morning. He stated, Shows they were. I know [Resident #61] doesn't like anything on but briefs. g. On 06/21/23 at 10:30 AM, the Surveyor asked the Infection Preventionist to accompany the Surveyor to the Dining Hall to see Resident #61. The Surveyor asked if the compression stockings were in place as documented on the MAR. He stated, No they're not on there. h. On 06/21/23 at 10:35 AM, the Surveyor asked Medication Tech #1 if they had documented that compression stockings had been placed on Resident #61. She stated, I don't remember seeing that. Can I go put them on her now? The Infection Preventionist asked Medication Tech #1, You came in at 5 [AM]? She stated, Yes. The Infection Preventionist stated, You marked them put on at 6 [AM]. 47912 2. Resident #39 had diagnoses of Urinary Tract Infection, Site not Specified and Benign Prostatic Hyperplasia with Lower Urinary Tract Symptoms. a. A Care Plan with an initiated date of 04/04/23 documented, [Resident #39] has a foley catheter r/t [related to] obstructive uropathy . Position catheter bag and tubing below the level of bladder, secure catheter tubing to leg with applicable device . b. A Physicians Order dated 05/23/23 documented, Foley Cath [Catheter]: Replace Drain Bag once a month every day shift every 4 weeks on Tue [Tuesday] . c. On 06/22/23 at 9:32 AM, Resident #39's was sitting up in a recliner. His catheter drainage bag was sitting in a wash basin on the floor. The date on drainage bag was 5/21. d. On 06/22/23 at 9:35 AM, on review of the May 2023 MAR, staff documented the foley catheter drainage bag was replaced on Tuesday 05/02/23, 05/09/23 and 05/16/23. There was no documentation on 05/23/23 or 05/30/23. The June 2023 MAR documented the foley catheter drainage bag was replaced on Tuesday 06/06/23. e. On 06/22/23 at 10:55 AM, the Surveyor accompanied the Director of Nursing (DON) to Resident #39 ' s room where he was sitting up in a recliner. The catheter drainage bag was not in dignity bag and was sitting in a wash basin on the floor dated 5/21. The Surveyor asked the DON what the date was on the catheter drainage bag. The DON answered, 5/21, but it's supposed to be changed every 4-8 weeks. They changed it from weekly to monthly so yesterday would have been the 4 week mark. The DON reviewed the MAR for May and June. There was no documentation on the MAR for 5/21/23, noting the catheter drainage bag had not been changed. The last drainage bag change documented was dated 06/06/23. The DON phoned the staff who documented the catheter was changed on 06/06/23, who stated, I can't remember what day I changed the bag, but I remember doing it. It was before [Named staff] had access to the computer. She had been predating the bags and I guess she grabbed the wrong bag. The DON stated to the Surveyor, We will be doing something about this.

Based on observation, record review and interview, the facility failed to ensure an indwelling urinary catheter bag was maintained in a manner to prevent contamination for 1 (Resident #39) of 1 resident sampled for catheters. The findings are: 1. On 06/19/23 at 11:14 AM, Resident #39 was sitting in a recliner in his room. There was a urinary catheter drainage bag in a plastic wash basin on the floor next to the resident's recliner. The top of the drainage bag was folded down and over the drainage tube, restricting the flow of urine into the drainage bag. There was a dried substance on the bottom and one side of the basin which was in contact with the catheter bag. 2. On 06/20/23 at 8:55 AM, Resident #39 was sitting in a recliner with his eyes closed. The urinary catheter drainage bag was folded over itself and sitting directly on the floor to the left side of the recliner. The tubing was stretched over the end of the elevated footrest on the recliner and stretched back to the base of the chair. A plastic wash basin was on the floor next to the recliner. 3.On 06/22/23 at 9:32 AM, Resident #39 was sitting in a recliner. The urinary catheter drainage bag was folded over itself sitting on the floor. Review of Resident #39 care plan, last revised on 04/05/23 revealed a care plan for urinary catheter related to obstructive uropathy. Interventions include, position catheter bag and tubing below the level of the bladder, secure catheter tubing to leg with applicable device. Review of the Medication Administration Record (MAR) revealed Resident #39 was treated for a urinary tract infection with Bactrim DS, an antibiotic, on 04/28/23 through 05/02/23 then with Levaquin, an antibiotic on 05/02/23 through 05/8/23. 4. On 06/23/23 at 9:00 AM, an interview with Certified Nursing Assistant (CNA) #3 who stated the urinary drainage bag was in the wash basin on the floor because, We'd rather it be in that then on the floor because we don't want it to get contaminated. 5. On 06/23/23 at 7:30 AM an interview with the Director of Nurses, (DON), who stated Resident #39 does not have a privacy bag because there is no place to hang it on the recliner. She further stated the drainage bag was in the wash basin because, we don't want it on the floor. 6. A review of [NAME] 10th Edition procedure guidelines, provided by the facility on 06/21/23 at 4:30 PM in response to a request for a policy related to catheter care revealed the urine should not be allowed to collect in the tubing because a free flow of urine must be maintained to prevent infection. Keep the bag off the floor to prevent bacterial contamination.

Based on observation, interview, and record review, the facility failed to provide nail care for 1 (Resident #35) of 1 sampled resident who was dependent on staff for assistance with Activities of Daily Living (ADL). The findings are: 1. Resident #35 had diagnoses of Weakness and Need for Assistance with Personal Care. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/18/23 documented the resident required extensive physical assistance of one person with personal hygiene and physical help with bathing. a. A Care Plan with an initiated date of 05/17/23 documented [Resident #35] has an ADL self-care performance deficit r/t [related to] debility . Personal Hygiene: [Resident #35] requires extensive assistance x [times] 1 staff with personal hygiene . b. On 06/19/23 at 11:10 AM, Resident #35 was sitting up in a wheelchair. Her fingernails were approximately 1/4 inch past her fingertips on both hands. The Surveyor asked Resident #35 if she liked them that way. Resident # 35 replied, No, but I can't cut them myself. c. On 06/21/23 at 9:31 AM, Resident #35's fingernails remained approximately 1/4 inch past her fingertips on both hands. Her thumbnails were approximately 1/2 inch in length past her fingertips. A light brown substance was underneath the nailbeds on both hands, and a medium brown substance was under both thumbnails. d. On 06/21/23 at 2:26 PM, the Surveyor accompanied Certified Nursing Assistant (CNA) #1 into Resident #35's room and asked her to describe Resident #35's fingernails. CNA #1 replied, They are not sharp, but they could be cleaned out underneath and be better. They could definitely be trimmed. They need to be filed. e. On 06/21/23 at 2:47 PM, the Surveyor asked the Director of Nursing (DON) who was responsible for resident nail care. She replied, We have a Registered Nurse (RN) responsible for that. She checks nails and oxygen. The Surveyor asked how often the RN was in the facility, and how often she checked nails. The DON replied, She is here Monday through Thursday. I usually get a sheet from her every week, but I haven't gotten one yet this week. She is supposed to check them every day. The Surveyor asked why nail care was important. The DON replied, It's nasty, hygiene, or they could scratch themselves. The Surveyor asked what could potentially happen if nail care doesn't get done. She replied, The worst is they can scratch themselves. f. On 06/21/23 at 2:34 PM, the ADON informed the Survey Team that there is no facility policy or procedure for nailcare.

Based on observation, interview, and record review, the facility failed to adequately maintain the cleanliness of an oxygen concentrator for 1 (Resident #45) of 5 (Residents #34, #45, #51, #55 and #58) sampled residents who received supplemental oxygen in the facility per a list provided by the Minimum Data Set (MDS) Coordinator on 06/23/23 at 11:41 AM. The findings are: Resident #45 had a diagnosis of Chronic Obstructive Pulmonary Disease (COPD) with Acute Exacerbation. a. A Physicians Order dated 03/18/23 documented, .Oxygen at 2-4 LPM [liters per minute] via nasal cannula, may remove for ADLS [activities of daily living] . b. On 06/21/23 at 9:40 AM, Resident #45 was lying in bed with oxygen in place via nasal cannula. The Surveyor observed an abundance of particles and debris gathered on the concentrator, primarily on the concave edge under the flow rate meter. c. On 06/21/23 at 3:34 PM, Resident #45 was lying in bed with oxygen in place via nasal cannula. The Surveyor observed that the particles below the flow rate meter were 1/4 inch deep and was a mixture of hair, smokeless tobacco, unidentified food, and dust. The Surveyor observed smokeless tobacco resting on the resident's nightstand. d. On 06/22/23 at 7:03 AM, the Surveyor accompanied Certified Nursing Assistant (CNA) #4 into Resident #45's room. Resident #45 was lying in bed receiving oxygen via nasal cannula. A 1/4 inch mixture of hair, tobacco, unidentified food, and dust remained on the concentrator below the flow meter. The smokeless tobacco remained on the nightstand. e. On 06/23/23 at 7:33 AM, the Surveyor accompanied the Director of Nursing (DON) to Resident #45's room. The Surveyor asked the DON to look at the oxygen concentrator below the flow meter and describe what she saw. She stated, It looks like dust. The Surveyor asked if it looked like anything else was there. The DON took a tissue and wiped the concentrator a few times with the tissue and stated, It hasn't been there long because it isn't stuck to it and brushes off easily. Should it be there? No. f. The facility policy titled, Respiratory Care 42 C.F.R. 483.25 (i), provided by the Nurse Consultant on 06/23/23 at 9:55 AM documented, Policy. The facility will ensure residents that need respiratory care, including tracheostomy care and suctioning, will be provided consistent with professional standards of care .

Based on observation, interview, and record review, the facility failed to ensure resident rooms were free of damage for 2 (rooms [ROOM NUMBERS]) rooms on the 200 Hall. The findings are: 1. On 06/19/23 at 2:10 PM, in Resident room [ROOM NUMBER], the Surveyor observed the paint was scraped off the wall on the right side of the window beside the recliner. There were scratches in the veneer wall guard pieces attached below where the paint was scraped off the wall. The Resident ' s family member was in the room and expressed she was unhappy with the condition of the resident's room. She asked the Surveyor, Can you stay long enough to get these walls painted? 2. On 06/21/23 at 11:14 AM, in Resident room [ROOM NUMBER] the paint on the wall and veneer wall guard remained damaged. The area measured 11 inches by 10 inches. 3. On 06/21/23 at 11:31 AM, the Surveyor accompanied Licensed Practical Nurse (LPN) #3 to room [ROOM NUMBER]. The Surveyor asked if maintenance was aware of the peeling paint and scratches on the veneer wall panel. LPN #3 stated, The scratches on the wall guard were here before I got here. I didn't know about the paint peeling and the scratches on the wall. The Surveyor asked if they kept a log or had work orders for room [ROOM NUMBER]. LPN #3 stated, No, but I will get this fixed. 4. On 06/20/23 at 9:55 AM, in Resident room [ROOM NUMBER], the Surveyor observed paint peeling off the wall behind the Resident ' s recliner and next to a wall outlet. The damaged area behind the resident's recliner measured 6 feet in length by 11 inches in width. 5. On 06/21/23 at 10:11 AM, Resident room [ROOM NUMBER] remained in ill repair with paint peeling and gouges on the wall behind the recliner. 6. On 06/21/23 at 2:00 PM, the Surveyor asked the Administrator who was responsible for building maintenance. She stated, We have our department meetings and do rounds in the morning. It's a big, old building. Staff comes to us and reports issues they see, and we try to get those fixed immediately. There's only one maintenance guy, and he's good but it's a big place. We've told staff to let us know if they see anything that needs to be fixed. The Surveyor asked if the facility had a policy or procedure for building maintenance. She stated, No.

Based on record review and interview, the facility failed to ensure medications were accurately coded on the Minimum Data Set (MDS) for 1 (Resident #34) of 1 sampled resident. The findings are: 1. Resident #34 had a diagnosis of Chronic Venous Hypertension (Idiopathic) without Complications of Bilateral Lower Extremity. The Quarterly MDS with Assessment Reference Date (ARD) of 05/09/23 documented Resident #34 received an anticoagulant for 7 days of the 7 day look back period. a. The May 2023 and the June 2023 Medication Administration Records (MAR) did not contain anticoagulant medication. b. On 06/21/23 at 2:13 PM, the Surveyor asked the MDS Coordinator, Was [Resident #34] coded for receiving 7 days of an Anticoagulant on the MDS with ARD of 05/09/23? She said, Yes. The Surveyor asked, Is it documented on the Medication Administration Record (MAR) and the Physicians Orders for an anticoagulant? The MDS Coordinator said, She doesn't have an order and it's not on the MAR. Its coded wrong. The Surveyor asked, Should the anticoagulant have been coded? She said, No. c. On 06/23/23 at 9:17 AM, the Surveyor asked the Director of Nursing (DON), If a resident is not receiving an anticoagulant, should it be coded on the MDS that the resident is receiving it? She said, No. The Surveyor asked if she expected her nurses to accurately assess and document information onto the MDS. She stated, Yes. d. On 06/21/23 at 12:34 PM, the Surveyor asked the MDS Coordinator for a policy and procedure on MDSs. The MDS Coordinator stated, I'll try to find you one. e. On 06/22/23 at 3:10 PM, the Surveyor asked the MDS Coordinator if she had located a policy and procedure on accurately coding assessments. She stated, We don't have one. We go by the Resident Assessment Instrument manual.

Based on observation, record review and interview, the facility failed to ensure humidification bottles were changed weekly for 1 (Resident [R] #13) sampled resident, oxygen tubing was dated for 5 (Residents #04, #13, #26, #38, and #45) sampled residents, and storage bags were available and changed weekly for 3 (Rs #13, #26, and #38) of 10 (Rs #42, #26, #45, #65, #75, #04, #49, #38, #13, and #79) sampled residents who required oxygen use. The findings are: 1. Resident #26 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/07/2022 documented the resident was severely impaired in cognitive skills for daily decision making per the Staff Assessment for Mental Status (SAMS) and had no documented oxygen use. a. The Care Plan documented, .has diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Date Initiated: 06/17/2020 . Give oxygen therapy as ordered by the physician. May provide longer oxygen tubing if short tubing unavailable or at resident's request . b. The Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] @ [at] 2 l/m [liters per minute] via n/c [nasal cannula] prn [as needed], may titrate up to 4 l/m prn to maintain spo2 [oxygen saturation] above 92% as needed for SOB [shortness of breath] Start Date 08/23/2021 . oxygen tubing and humidifier bottle to be changed every week every night-shift every Mon [Monday] . c. On 3/21/22 at 12:32 PM, the resident was lying in the bed on his back at a 30-degree angle with his eyes closed. The resident was receiving oxygen at 2.5-3.0 liters per minute via nasal cannula. Humidification was present and dated 03/17/2022. There was no storage bag present, and the tubing was not dated. d. On 03/24/22 at 03:21 PM, Licensed Practical Nurse (LPN) #2 was at the bedside and was asked, Should the resident have a storage bag for their oxygen tubing? She stated, Yes. When asked, Why? She stated, It's for infection purposes and needs changed weekly. When asked, Should oxygen tubing be dated? She stated, Yes. When asked, Why? She stated, So, we know it's been changed weekly. 2. Resident #45 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Medicare 5-Day MDS with an ARD of 02/04/2022 documented a score of 14 (13-15 indicates cognitively intact) on the Brief Interview for Mental Status (BIMS) and had oxygen in use while a resident. a. The Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] @ [at] 2 l/m [liters per minute] via n/c [nasal cannula] prn [as needed], may titrate up to 4 l/m prn to maintain spo2 [oxygen saturation] above 92% as needed for SOB Start Date 02/02/2022 oxygen tubing and humidifier bottle to be changed every week every night shift every Mon Start Date 02/07/2022 . b. The Care Plan documented, . has altered respiratory status/Difficulty Breathing r/t [CONDITION(S)]/asthma. Date Initiated: 03/11/2022 Provide oxygen as ordered. May provide longer oxygen tubing if short tubing unavailable or at resident's request. Date Initiated: 03/17/2022 c. On 03/21/22 at 12:11 PM, the resident was sitting on the side of his bed watching television. The resident was receiving oxygen at 2.0-2.5 LPM via nasal cannula. The oxygen tubing was not dated. d. On 03/24/2022 at 03:22 PM, LPN #2 at the bedside and asked, Should oxygen tubing be dated? She stated, Yes. When asked, Why? She stated, So, we know it's been changed weekly. 3. Resident #4 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly MDS with an ARD of 11/30/2021 documented the resident scored 07 (0-7 indicates severely impaired) on the Brief Interview for Mental Status (BIMS) and received oxygen while a resident. a. The physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . May increase up to 4 l/m PRN (TO MAINTAIN SPO2 ABOVE 94%) as needed for shortness of breath Start Date 10/11/2020 . Check Oxygen Humidifier Bottle to ensure it is filled with Distilled Water every day shift every Wed, Fri, Sun [Wednesday, Friday, Sunday] Start Date 07/04/2019 Oxygen tubing and humidifier to be changed weekly every night shift every Mon for O2 . b. The Care Plan documented, .Oxygen Therapy as needed for shortness of breath . 9/22/21: She pulls her oxygen off herself then her SPO2 drops. She will not leave it on at times . OXYGEN SETTINGS: Per MD orders. May provide longer oxygen tubing if short tubing unavailable or at resident's request . c. On 03/21/22 at 12:15 PM, the resident was lying in bed on her back at a 30-degree angle. The resident was receiving oxygen at 2.0-2.5 LPM via nasal cannula. The oxygen tubing was not dated. d. On 03/24/2022 at 03:23 PM, LPN #2 was at the bedside and was asked, Should oxygen tubing be dated? She stated, Yes. When asked, Why? She stated, So, we know it's been changed weekly. 4. Resident #38 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly MDS with an ARD of 01/24/2022 documented the resident scored 06 (0-7 indicates severely impaired) on the BIMS and received oxygen while a resident. a. The Care Plan documented, . [Resident #38] has asthma r/t [related to] [CONDITION(S)] and receives oxygen therapy. [Resident #38] will remove her tubing from oxygen concentrator at times. She will throw the tubing in the floor at times. Date Initiated: 09/25/2018 Give nebulizer treatments and oxygen therapy as ordered . b. The physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . May increase up to 4 l/m PRN to maintain SPO2 above 92% as needed for SOB Start Date 06/25/2019 oxygen tubing and humidifier bottle to be changed every week every night shift every Mon Start Date 10/19/2020 . c. On 03/21/22 at 12:54 PM, the resident was sitting in her wheelchair in her room eating lunch. The resident was receiving oxygen at 2 LPM via nasal cannula. The nasal cannula was not dated and there was no storage bag n the room. 5. Resident #13 had diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . a. The Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . b. The March 2022 Medication Administration and Treatment Administration records had no documentation of oxygen tubing, storage bags, or humidity bottle changed. c. On 03/21/22 at 11:49 AM, the resident was not in her room. The humidity bottle and bag for storage of oxygen tubing was dated 2/23/22. d. On 03/21/22 at 1:15 pm, Resident #13 was sitting in a wheelchair in the hallway with a large roll of oxygen tubing in her lap. e. On 03/22/22 at 08:21 am, Resident #13 was lying in bed and receiving with oxygen at 2 L per NC. There was no date on the oxygen tubing. f. On 03/24/22 at 2:42 pm, LPN #1 was asked how often the oxygen tubing, humidity bottles and storage bags should be changed and why. LPN #1 stated weekly, and it is for infection control purposes. g. On 03/24/22 at 3:07 pm, the Assistant Director of Nursing (ADON) was asked how often the oxygen tubing, humidity bottles and storage bags should be changed and why. The ADON stated, Once a week and as needed. Just to prevent bacteria growth and to keep it clean. h. On 3/24/22 at 3:15 pm, LPN #1, and the ADON were asked, Is it acceptable for the tubing, storage bag, and humidity bottle not to be dated, dated with a date over a week old, or not in a bag when not in use? They all stated, No.

Based on record review and interview, the facility failed to ensure the comprehensive Minimum Data Set (MDS) assessments were completed by the 14th day after admission to identify the residents' care needs and preferences and facilitate development of a comprehensive plan of care for 2 (Residents #281 and #04) of 2 residents whose MDS were reviewed. 1. Resident #281 was admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/14/2022 documented Export Ready and has not been transmitted. b. On 3/24/22 at 2:33 pm, the MDS Coordinator was asked, Can you tell me what is wrong the MDS with an ARD of 03/14/2022? She stated, Hers is late. When asked, When does the RAI [Resident Assessment Instrument] identify the Admission MDS needs to be completed? She stated, In 14 days. 2. Resident #4 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly MDS with an ARD of 03/02/2022 documented Export Ready and has not been transmitted. c. On 3/24/22 at 2:33 pm, the MDS Coordinator was asked, Can you tell me what is wrong the MDS with an ARD of 03/02/2022? She stated, It's late. When asked, When does the RAI identify the MDS needs to be completed? She stated, In 14 days.

Based on observation, record review and interview, the facility failed to ensure contaminated biohazards were disposed of properly for 1 (Resident #1) who was on isolation related to MRSA ([CONDITION(S)] Resistant Staphylococcus Aureus) in a draining wound for 1 of 1 (Resident #1) sampled residents. This failed practice had the potential to affect 1 resident who was on isolation per a list provided by the Administrator on 9/16/21. The findings are: Resident #1 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set with an Assessment Reference Date of 06/11/21 documented the resident scored 15 (13-15 indicates cognitively intact) per had a Brief Interview for Mental Status and had one Stage 1 pressure ulcer. a. A Lab Report with a collection date of 07/19/21, received date of 07/19/21 and a report date of 07/23/21 documented, . Culture Wound Left Groin . Organism 3 [CONDITION(S)] Staph [Staphylococcus] Aureus. b. The Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Ordered on 07/24/21 and 08/05/21. c. A Skin/Wound Note dated 09/15/21 at 3:15 P.M. documented, Open abscess area to L [left] buttock/groin measures 0.7cm [centimeter] X [by] 1cm X 3cm. Heavy amount of purulent drainage noted. d. On 09/15/21 at 8:47 A.M., Resident #1's bathroom had 2 biohazard boxes with red bags inside each box. The second box (the one furthest from the bathroom door) had discarded blue isolation gowns stacked over the top of the box and one dicarded blue isolation gown was on the floor in front of the box. e. On 09/15/21 at 8:55 A.M., the Director of Nursing (DON) was asked to come to Resident #1's bathroom. f. On 09/15/21 at 8:57 A.M., the DON was asked, Who is responsible for ensuring that the biohazards are secured and disposed of as they should be? She stated, [Infection Preventionist] is responsible, along with staff and housekeeping. I know that this can't happen. g. On 09/15/21 at 8:59 A.M., Housekeeper #1 was asked, When do you check the biohazards in [Resident #1's] room? She stated, I check when I go in his room, usually in the afternoon. I thought I was supposed to change when it was full. I haven't had an isolation in a long time. h. On 09/15/21 at 9:03 A.M., the DON was asked, Who is responsible for checking the biohazards after the housekeepers leave? She stated, After the housekeepers leave the CNA's [Certified Nurses Assistants] are supposed to get the nurses and let them know, that's what I would think. They may actually would close it up. The CNA's don't have a key to biohazard so they would have to get with the nurse. i. On 09/16/21 at 8:34 A.M., CNA #1 was asked, Have you found the biohazard containers with the soiled PPE [Personal Protective Equipment] not in the bins and/or on the floor? CNA #1 stated, Yes ma'am, I have. I have gone to housekeeping 2 or 3 times in [Resident #1's] room. I would tell them, and they would go in and clean it. They have been doing a better job. Haven't had to tell them about it since last week. j. On 09/16/21 at 9:13 A.M., CNA #2 was asked, Have you found the biohazard containers with the soiled PPE not in the bins and/or on the floor? CNA #2 stated, Yes, I have gone into [Resident #1's] bathroom and found the biohazard overflowing with the used PPE. I never found anything on the floor, just overflowing out of the box. I went and asked housekeeping to change it out and they did. k. A Medical Waste, Handling of Policy and Procedure provided by the DON on 09/16/21 at 1:20 P.M. documented, . 4. Disposable items, which are contaminated with excretions or secretions from residents believed to be infectious, must be placed in red plastic bags and sealed, and either decontaminated with bleach (1:10 or 1:100 dilution), incinerated, or stored until removal from the premises.

Based on observation and interview, the facility failed to ensure expired foods items were promptly removed/discarded on or before the expiration or use by dates to prevent potential food borne illness and failed to ensure Dietary staff washed their hands before handling 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 64 residents who received meals from the kitchen, as documented on the list provided by the Dietary Manager on [DATE]. The findings are: 1. On [DATE] at 11:34 AM, that were chicken breast in stand-up freezer to be dated [DATE], chicken was freezer burned. The Dietary Manager stated, Oh goodness that looks freezer burned that should not be in there. The Dietary Manager discarded the chicken. 2. On [DATE] at 11:43 AM, there were 3 - 12 count packages of hamburger buns expired. The expiration date was [DATE]. 3. On [DATE] at 12:06 PM, Dietary Employee #2 covered the plates with plastic covers. Dietary Employee #2 placed a scoop of mechanical soft hamburger meat on a bun then pick up the top of the hamburger bun and place on the meat with her unwashed hands. Dietary Employee #2 touched other items and did not wash her hands prior to handling food. 4. On [DATE] at 09:26 AM, Dietary Employee #2 was asked if she could identify any issues while preparing the lunch trays yesterday. Dietary Employee #2 stated, Yes. I grabbed the bun with my hands. I realized it and knew I should not have done that. 5. On [DATE] at 09:28 AM, the Dietary Manager was asked to identify any failed practice observed during meal service. She stated, One of the employees touched the hamburger bun with her hands after touching other surfaces. I told them after I saw that to use the tongs. 6. On [DATE] at 09:30 AM, the Dietary Manager was asked when the bread should be used or discarded of. She stated, It should be used by the expiration date. The bread man comes on Monday and we rotate the stock. I try to look at it at least weekly, but I must have missed those that were expired. 7. On [DATE] at 09:32 AM, the Dietary Manager was asked when the chicken should be discarded of. The Dietary Manager stated, It should not in the freezer if it is freezer burned.

Based on observation, record review and interview, the facility failed to ensure oxygen was administered at the flow rate ordered by the physician to reduce the potential for complications for 1 (Resident (R) #35) of 13 ( #37, #27, #38, #20, #5, #47, #31, #35, #11, #59, #60, #15, and #22) sampled residents who had physician orders [REDACTED]. The facility also failed to ensure nebulizer (up draft) and tubing was properly stored when not in use to prevent potential contamination that could result in respiratory infection for 2 (Resident #22 and #38 ) of 2 ( #28, #38) sampled residents with orders for breathing treatments. The facility also failed to ensure oxygen tubing was properly stored to prevent potential contamination that could result in in respiratory infection for 2 (Resident #31 and 59 ) of 13 ( #37,#27, #38, #20, #5, #47, #31, #35, #11, #59, #60, #15,and #22) sampled residents with orders for Oxygen. The facility failed to ensure that tubing was changed for 1(Resident #27) of 13 (Resident #37,#27, #38, #20, #5, #47, #31, #35, #11, #59, #60, #15,and #22) sampled residents who had orders for oxygen. These failed practices had the potential to affect 24 resident who had physician orders [REDACTED]. The findings are: 1. Resident #35 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set with an Assessment Reference Date (ARD) of 10/8/20 documented 9 (8-12 indicates moderately impaired) on a Brief Interview of Mental Status (BIMS); and required extensive assist of two persons for activities of daily living (ADL's). a. A physician order [REDACTED]. b. The Plan of Care dated 10/8/20 documented, . Oxygen as ordered c. On 12/14/20 at 11:26 AM, Resident #35 was sitting up beside bed in recliner. The oxygen concentrator was set at 1 and half liters per minute and the resident was receiving oxygen via nasal cannula. d. On 12/14/20 at 02:20 PM, Resident #35 was sitting in the recliner with the oxygen at 1.5 l/m via n/c. e. On 12/15/20 at 8:30 AM, Resident #35 was sitting in the recliner with Oxygen at 1.5 l/m via n/c. f. On 12/17/20 11:25 AM, the resident was in bed with 02 @ 1.5 l/m via n/c Licensed Practical Nurse #4 was asked, Can you tell me what the concentrator is set on? She stated, Well from standing here it looks like 2 liters Can you look at the concentrator eye level and tell me what it says. She stated, It is actually set at 1 and a half 2. Resident #22 had [DIAGNOSES REDACTED]. The Minimum Data Set with an Assessment Reference Date of 9/26/20 documented the resident scored 14 (13 - 15 indicates cognitively intact) on a Brief Interview of Mental Status (BIMS); and required limited assist for activities of daily living (ADL's). a. A physician ordered dated 06/15/20 documented, [MEDICATION NAME] Nebulization Solution (2.5 MG/3ML) 0.083% (percent) 3 ml (milliliter) inhale orally via (by way of) nebulizer every 6 hours as needed for Shortness of Breath/ (SOB) Wheezing AND 3 ml inhale orally via nebulizer four times a day. b. The Care Plan dated 3/30/20 documented, . medication as ordered .monitor for signs and symptoms of respiratory distress . c. On 12/14/20 at 11:23 AM, the resident's nebulizer was sticking in a drawer with the tube sitting on the resident's electric razor in the drawer. A photograph of the nebulizer was taken at this time. d. On 12/15/20 at 08:42 AM, the resident's nebulizer machine was sitting on the bedside table with tubing and an updraft pipe. The updraft pipe was stuck in the drawer open to air. e. On 12/17/20 at 08:13 AM, Licensed Practical Nurse (LPN) #3 was asked, Should a resident's nebulizer be stuck in the drawer open to air? She stated, No. It should be cleaned and in a bag. LPN #3 was asked, Does the chamber have solution in it? She stated, Yes. I am throwing the whole thing away. f. On 12/17/20 at 09:38 AM, the Director of Nursing (DON) was asked, What is the facilities policy for storing nebulizer and updraft tubing? She stated, I heard about the residents incident, the updraft tubing should be stored in a bag between uses. The tubing should be cleaned and stored after each use. The tubing should be changed weekly. g. A policy titled Cleaning Updraft Equiupment documented, when not in use items to be placed in ziploc bag at the bedside . 3. Resident #38 had [DIAGNOSES REDACTED]. The Significant Change Minimum (MDS) data set [DATE] documented the resident scored 5 (0-7 indicates cognitively impaired) on a Brief Interview of Mental Status; and required minimal assist with activities of daily living. a. The Plan of Care with a revision date of 7/27/20 documented, . give medication as ordered . b. A physician ordered dated 03/18/20 documented, [MEDICATION NAME]-[MEDICATION NAME] Solution 0.5-2.5 (3) MG/3ML 1 vial inhale orally every 6 hours. c. On 12/15/20 at 11:20 AM, the Nebulizer with tubing and a updraft pipe was sitting in a recliner in the resident's room uncovered and open to air. d. On 12/15/20 at 2:23 PM, the Nebulizer with tubing and a pipe was sitting in the recliner at the left side of the resident's bed. e. On 12/17/20 at 08:37 AM, the nebulizer with updraft tubing and a nebulizer tube was sitting in a chair in the resident's room beside the bed. 4. Resident #27 had [DIAGNOSES REDACTED]. a. On 12/14/2020 at 12:40 PM, the oxygen tubing was dated 11/30/20. b. A physician order [REDACTED]. c. On 12/17/20 at 08:30 AM, the Director of Nursing (DON) was asked to review the picture taken Monday December 14, 2020 of the resident's oxygen tubing. The DON looked at the photo and stated, It is dated 11/30/20, that is out of compliance. They are supposed to be changed every Monday. d. An Oxygen Administration Policy dated 05/31/2012 did not identify how often the tubing and humidifier bottle should be changed. 5. Resident #59 had [DIAGNOSES REDACTED]. a. The Care Plan with an initiation date of 05/14/20 documented, Give nebulizer treatments and oxygen therapy as ordered. b. A physician order [REDACTED]. May increase up to 4 l/m PRN to maintain SPO2 oxygen saturation) above 92% as needed for SOB. c. A physician order [REDACTED]. d. On 12/15/20 at 02:21 PM, CNA #1 entered Resident #59's room. CNA #1 noticed the resident did not have on her oxygen. CNA #1 stated, Sometimes the resident takes off her oxygen. CNA #1 picked up the oxygen tubing at the concentrator and followed the oxygen tubing until he found the nasal canula behind the bedside stand. CNA #1 pulled the oxygen tubing from behind the bedside nightstand and applied it to the resident's nose. e. On 12/16/20 at 10:18 AM, LPN #1 was asked if a resident removed their oxygen and lays it in the floor or on the nightstand when should the tubing be replaced. LPN #1 stated, If it is in the floor it should be replaced, if it is laid on the table it should be in a bag but for sure replaced if it is in the floor. LPN #1 was asked what the CNA's are supposed to do if they find a resident has removed their oxygen. LPN stated, They are supposed to get the nurse. They are not supposed to touch it at all. f. On 12/16/20 at 10:24 AM, CNA #2 was asked what a CNA should do if they find a resident has taken off their oxygen and the tubing is laying behind the furniture. CNA #2 stated, I go get the nurse. g. On 12/16/20 at 10:27 AM, CNA #1 was asked while in the resident's room could he identify anything that should have been done differently. CNA #1 stated, I did, I shouldn't have messed with the oxygen. I should have got the nurse in case the tubing needed changed. h. On 12/16/20 at 10:35 AM, the Director of Nursing (DON) was asked if the tubing was found behind the bedside nightstand should the oxygen tubing be replaced. The DON stated, Yes. Since you wouldn't know if it had fell in the floor or not then it should have been replaced. i. On 12/17/20 at 08:37 AM, the Administrator was asked if they had a policy on storage of oxygen. The administrator stated, I have looked, and we do not have one the mentions those items. 6. Resident #31 had a [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/1/20 documented the resident was severely impaired in cognitive skills for daily decision making per a Staff Assessment (SAMS); and was totally dependent on two plus persons with bed mobility, transfers, toilet use, and personal hygiene; and required Oxygen therapy. a. The Care Plan with a revised date of 5/9/19 documented . (Resident #31) has altered respiratory status/Difficulty Breathing r/t (related to) Acute AND Chronic [MEDICAL CONDITION] . Provide oxygen as ordered . b. A physician order [REDACTED].@(at) 2 L/M (liters per minute) VIA N/C (nasal cannula) PRN (as needed), May Titrate up to 4 L/M PRN to maintain SPO2 above 92% as needed for SOB (Shortness of Breath) c. On 12/14/20 at 11:20 AM, the resident's oxygen was not in use at the time. The oxygen cannula was wrapped around the humidifier and not contain in a protective bag. The humidifier was dated 12/14/20. A photograph of the oxygen cannula and the humidifier was taken at this time. d. On 12/17/20 at 2:05 PM, The Director of Nursing (DON) was asked, How should oxygen tubing that is not in use be stored. She stated, In a plastic baggie.

Based on observation, record review, and interview the facility failed to ensure an assessment was completed and physicians order were available for self-administration of medications for 1 (Resident (R) #22) of 7 (Residents #22, #26, #27, #31,#38, #59 and #60 ) sample residents who had physician's orders [REDACTED]. The findings are: 1. Resident #22 had a [DIAGNOSES REDACTED]. The Minimum Data Set with an Assessment Reference Date of 9/26/20 documented the resident scored 14 (13-15 indicates cognitively intact) on a Brief Interview of Mental Status (BIMS); and required limited assist for activities of daily living (ADL's). a. A Physician order [REDACTED]. b. A Physician order [REDACTED]. c. The Plan of Care dated 03/20/20 documented . give inhalers as ordered . d. On 12/14/20 at 11:23 AM, Resident #22 had 2 inhalers ([MEDICATION NAME] Aerosol, [MEDICATION NAME]) on the bedside table. Resident #22 was asked, Do the nurses always leave them with you? He stated, Sometimes. e. On 12/14/20 at 11:48 AM, Licensed Practical Nurse (LPN) #2 was asked, Can Resident #22 administer his own inhalers? She stated, I haven't been on this hall in 6 months but I'm going to say, No. LPN #2 was asked, Should they (inhalers) be in his room on the overbed table? She stated, No. f. On 12/17/20 at 08:37 AM, the MDS Coordinator was asked, Does Resident #22 have a self-administration assessment? She stated, No. Resident (#22) does not have a self-administration assessment and he is not care planned for it. g. On 12/17/20 at 09:38 AM, the Director of Nursing (DON) was asked, Should inhalers be left at resident's bedside? She stated, I heard about this and no.

Complaint # (AR 751) and Complaint # (AR 754) were substantiated, all or in part, with these findings: Based on record review and interview, the facility failed to ensure Positive, Symptomatic staff were not placed on the COVID-19 Unit to work per their Temporary and Limited Waiver for Critical Staffing requirements; failed to ensure symptomatic staff identified by the Screening Form were sent home to Quarantine; and also failed to ensure staff who resided with another Positive, Symptomatic staff member were placed on Quarantine per the Centers for Medicare and Medicaid Services (CMS) and the Centers for Disease Prevention and Control (CDC) guidance. These failed practices resulted in Immediate Jeopardy, which caused, or could have caused, serious harm, injury, or death to 77 residents who resided in the facility and who were not currently Positive for COVID-19, according to the list provided by the Administrator on 10/20/2020 at 10:02 a.m. The Administrator was informed of the Immediate Jeopardy condition on 10/20/2020 at 2:15 p.m. The findings are: 1. A document titled Arkansas Department of Health's Residential Congregate Setting Reporting Form completed for Certified Nursing Assistant (CNA) #3 on 10/12/2020 and provided by the Assistant Director of Nursing (ADON) on 10/19/2020 at 2:45 p.m. documented, . (Staff) Name (Last, First) . (Certified Nursing Assistant (CNA) #3) date of Birth . (Date) . Positive Swab Collection Date . 10/12/2020 . Positive Swab Result Date . 10/12/2020 . What was the type of testing . [MEDICATION NAME] . Is the Case Symptomatic for COVID-19 . Yes . When Did The Case Become Symptomatic for COVID-19 . 10/10/2020 . Symptoms . Congestion / Runny Nose, Sore Throat and Other . Loss of Taste and Smell . a. A document titled COVID-19 Screening Checklist for Staff and Health Care Providers completed for CNA #3 on 10/12/2020 and provided by the ADON on 10/19/2020 at 3:30 p.m. documented, .As areas of the country lift visitors restrictions, it is important to continue to screen anyone who enters the facility. Early identification of symptoms and possible exposure reduces the likelihood of spreading [MEDICAL CONDITION]. ALL staff, including Health Care Providers (Agency Staff, Regional or Corporate Staff, Health Care Workers, such as Hospice, EMS (Emergency Medical Services), [MEDICAL TREATMENT] Technicians that provide care to residents) entering the building must be asked the following questions . 1. Has this individual washed their hands or used alcohol-based hand rub (ABHR) on entry . Yes (checked) .2. Ask the individual if they have any of the following respiratory symptoms . None . (were checked) . If NO to all, proceed to step 3. Check Temperature and document results . 97.3 . If NO proceed to step 4. Ask if they have worked in facilities or locations with recognized COVID-19 cases . If NO, proceed to step 5 . Allow entry to building and remind the individual to . Wash their hands or use ABHR throughout their time in the building . Not shake hands with, touch, or hug individuals during their visit . Name . (CNA #3) .Date . 10/12/2020 . b. On 10/19/2020 at 3:32 p.m., CNA #3 was notified via telephone and was asked, When did you first start to experience signs and symptoms of COVID-19? She stated, I called in on 10/10/2020 and 10/11/2020. On Saturday (10/10/2020), I wasn't the best. I was up all night with Shortness of Breath. On Sunday (10/11/2020), I was going to come into work but had to rush my brother to the hospital. I still didn't feel well Sunday. I had Shortness of Breath. I thought it might be sinus. (ADON) did ask me to come to the nursing home at 7:00 a.m. on Sunday but I was at the hospital with my brother. I did come to work on 10/12/2020. I was having symptoms when I came in Monday (10/12/2020). I couldn't taste or smell, had congestion, and a runny nose. As I worked, I had Shortness of Breath. I went and found (ADON) and told her I couldn't taste or smell, and she Rapid tested me, and I was Positive. She was asked, What hall did you work on? She stated, I think I worked the 300 Hall. The 300 Hall is the COVID Hall. c. On 10/20/20 at 4:38 p.m., Screener #1 was asked when she started doing the Staff Screening. She stated, I was working in the kitchen, but since about 3 weeks ago I started being Screener. She was asked, Did you work on 10/12/2020. She stated, I did work on 10/12/2020. She was asked if she had been trained to fill out the COVID-19 Screening Form. She stated, I have been trained to do the COVID Screening. I don't really remember when I was trained. (ADON) trained me as a Screener. She was asked if she remembered if she had asked (CNA #3) the questions from the screening form on 10/12/2020. She stated, I don't remember not asking (CNA #3) the screening questions. 2. A document titled Arkansas Department of Health's Residential Congregate Setting Reporting Form dated 10/13/2020 for CNA #1 and provided by the Assistant Director of Nursing (ADON) on 10/19/2020 at 3:30 p.m. documented, .Staff . Name (Last, First) . (CNA #1) .Date of Birth . (Date) Positive Swab Collection Date . 10/13/2020 . Positive Swab Result Date . 10/16/2020 . What was the type of testing . PCR . Is the Case Symptomatic for COVID-19 . Yes . When Did the Case Become Symptomatic for COVID-19 . 10/15/2020 . Symptoms . Congestion / Runny Nose . a. A document titled COVID-19 Screening Checklist for Staff and Health Care Providers dated 10/14/2020 for CNA #1 and provided by the ADON on 10/19/2020 at 3:30 p.m. documented, .As areas of the country lift visitors restrictions, it is important to continue to screen anyone who enters the facility. Early identification of symptoms and possible exposure reduces the likelihood of spreading [MEDICAL CONDITION]. ALL staff, including Health Care Providers (Agency Staff, Regional or Corporate Staff, Health Care Workers such as Hospice, EMS (Emergency Medical Services), [MEDICAL TREATMENT] Technicians that provide care to residents) entering the building must be asked the following questions . 1. Has this individual washed their hands or used alcohol-based hand rub (ABHR) on entry . Yes . 2. Ask the individual if they have any of the following respiratory symptoms . None . If NO to all, proceed to step 3 . Check Temperature and document results . 96.3 . If NO proceed to step 4 . Ask if they have worked in facilities or locations with recognized COVID-19 cases . If NO, proceed to step 5. Allow entry to building and remind the individual to . Wash their hands or use ABHR throughout their time in the building . Not shake hands with, touch, or hug individuals during their visit . Name . (CNA #1) .Date . 10/14/2020 . b. A document titled COVID-19 Screening Checklist for Staff and Health Care Providers for CNA #1 dated 10/15/2020 and provided by the ADON on 10/19/2020 at 1:30 p.m. documented, .As areas of the country lift visitors restrictions, it is important to continue to screen anyone who enters the facility. Early identification of symptoms and possible exposure reduces the likelihood of spreading [MEDICAL CONDITION]. ALL staff, including Health Care Providers (Agency Staff, Regional or Corporate Staff, Health Care Workers such as Hospice, EMS (Emergency Medical Services), [MEDICAL TREATMENT] Technicians that provide care to residents) entering the building must be asked the following questions . 1. Has this individual washed their hands or used alcohol-based hand rub (ABHR) on entry . Yes . 2. Ask the individual if they have any of the following respiratory symptoms . None . If NO to all, proceed to Step 3 . Check Temperature and document results . 97.1 . If NO proceed to Step 4 . Ask if they have worked in facilities or locations with recognized COVID-19 cases . If NO, proceed to Step 5 . Allow entry to building and remind the individual to . Wash their hands or use ABHR throughout their time in the building . Not shake hands with, touch, or hug individuals during their visit . Name . (CNA #1) .Date .10/15/2020 . c. On 10/20/2020 at 8:45 a.m., CNA #1 was notified via telephone and was asked if she reported her symptoms on 10/15/2020. She stated, I had sniffles on the 15th (10/15/2020) that afternoon. I didn't think anything about it since I have allergies. It's common for me to have sniffles because of allergies and sinus problems. After I got home on the 15th, I just started feeling worse, had chills, could just feel heat around my neck and head. She was asked if she had let them know she had symptoms prior to coming to work. She stated, No. They notified my mother-in-law who I live with and work with. They told her to tell me not to come to work on the 16th (10/16/2020) because my test was Positive. The DON (Director of Nursing) then told my mother-in-law to tell me to come in the back and work the COVID Hall. I was texting my mother-in-law and said, 'what if I have symptoms', and by that time she was here to get me. I was congested and couldn't breathe while I was working. She was asked who screened her on the morning of the 16th. She stated, I just came in the back and started to work. I was not screened on that morning. She was asked when she is screened, if she was asked the questions on the Screening Sheet. She stated, Normally I come in and clock in. They ask us if we have a cough or anything and to check the boxes and they take our temperature. Once I got to work (Licensed Practical Nurse (LPN) #1), the nurse, was asking some of us how we were feeling. I told her I didn't feel good. I was congested and having trouble breathing, and I had no taste or smell. She was telling us 'I'm so sorry y'all. I don't know why y'all are here.' (CNA #2) and I were working together because we were Positive. She had told me during our shift that she didn't know why we were working since we were sick. (CNA #2) was really congested and having trouble breathing but she had not lost her taste or smell yet. I don't know if (CNA #2) had told (DON) or (ADON), but I didn't. They already knew I was sick. She was asked if she had been placed on Quarantine since she had symptoms and was Positive. She stated, No, not until I had my mother-in-law text (ADON) yesterday evening to see what I was supposed to do since no one let me know anything and I still have symptoms. (ADON) said to just go ahead and stay off until I didn't have symptoms. She didn't give me a time frame. What I thought was funny about this was our in-services instructed that if we had symptoms, we were to stay at home, and the last in-service was Friday (10/16/2020). She was asked if she was aware of other staff working with symptoms. She stated, No, not that I'm aware of. d. On 10/20/2020 at 9:30 a.m., the Transport Driver was asked if she had been notified by the facility of (CNA #1) being COVID Positive. She stated, On Friday morning the 16th (ADON) text me at 6:53 a.m. (The Transport Driver looked at her phone and found the text) and said (CNA #1) was positive. I text her back and said, 'We don't come to work?' (ADON) text back and said you can but not her. She lives with me. She was asked if the ADON knew that (CNA #1) lived with her. She stated, Yes. I text back and said we were just walking out the door. We ride together. (ADON) asked if I was symptomatic and I told her I have my normal sinus stuff I usually have. She asked if (CNA #1) had symptoms and I text her (The Surveyor viewed this text) at 6:55 a.m. and told her last night she couldn't taste or smell anything and she sounds really congested. She was asked if she or her son who also works at the facility were told to Quarantine. She stated, No. After I got through texting (ADON) I went ahead and came to work and (CNA #1) stayed home. When I got here, (DON) said, 'You can go get her. She can work the COVID Hall.' I told (DON) she has lost her taste and smell and she sounds really congested. (DON) said to go get her to work the COVID Unit. She said tell her to go around and enter 300 Hall. I was assuming they were doing screening back there since she told her to go back that way. She was asked if she had asked the DON or anyone else if she and her son should be Quarantined. She stated, No, (DON) just gets so (at that time the Transport Driver threw her arms up in the air and started swinging them back and forth). Back in June my husband was Positive, and we were told by (DON) and (ADON) that we had to Quarantine because he was Positive. He was tested because he had symptoms on 6/12/2020. He got his results on 6/16/2020. I was in (DON's) office when he called and said they had just called him with the Positive results. I told (DON) at that time and she tested me and sent me home. My son was not working here at that time. I don't think (CNA #1) was here that day. I think it was the next day that they tested her, and she was Negative, but she was told to Quarantine. We both Quarantined for 2 weeks. I thought it was not right if they did that in June but had her work with symptoms when she tested Positive. e. On 10/20/2020 at 10:02 a.m., the ADON / Infection Control Preventionist (ICP) was asked if she had told the Transport Driver and her son to Quarantine since (CNA #1) tested Positive and since the Transport Driver and son live with (CNA #1). She stated, No, I didn't. I didn't think about it but they both should have been sent home for 14 days. f. On 10/20/2020 at 1:41 p.m., Licensed Practical Nurse (LPN) #1 was asked how they screen the staff working on the COVID Hall. She stated, We got screening forms today that we have in the front entrance. Originally everyone was going in the front door to get screened then walking around to enter. Then they changed that to everyone that was Positive had to just come and enter on COVID Hall. She was asked how they were screening prior to receiving their screening forms. She stated, We were getting temperatures and pulse ox's (oxygen saturation testing). We got some typed up forms last week and on that it has place for temperature, pulse ox, and signs and symptoms. She was asked if there had been Positive staff working on the COVID Hall with symptoms. She stated, I had been off prior to the 16th of October, and when I came back, they were saying there were people who were Positive working. (CNA #1) had told me she was feeling really tired. When she told me that, that's when I said I couldn't believe anyone testing Positive is even here. I know (CNA #2) said she didn't have fever, but she was feeling really tired and worn down. She was asked if those were symptoms of COVID. She stated, Yes. She was asked if she had sent them home. She stated, No, I didn't. I didn't feel I had the authority. She was asked if she let the DON and / or the ADON know about the Positive staff with symptoms and working. She stated, No, I didn't. I knew they knew they both had symptoms because they had told the CNA Supervisor their symptoms and they were still to come in. They were just saying they didn't understand why they were being made to work with being Positive and having symptoms. 3. A document titled COVID-19 Screening Checklist for Staff and Health Care Providers for CNA #2 dated 10/11/2020 and provided by the ADON on 10/19/2020 documented, .As areas of the country lift visitors restrictions, it is important to continue to screen anyone who enters the facility. Early identification of symptoms and possible exposure reduces the likelihood of spreading [MEDICAL CONDITION]. ALL staff, including Health Care Providers (Agency Staff, Regional or Corporate Staff, Health Care Workers such as Hospice, EMS (Emergency Medical Services), [MEDICAL TREATMENT] Technicians that provide care to residents) entering the building must be asked the following questions . 1. Has this individual washed their hands or used alcohol-based hand rub (ABHR) on entry . Yes . 2. Ask the individual if they have any of the following respiratory symptoms . None . If NO to all, proceed to Step 3 . Check Temperature and document results . 96.9 . If NO proceed to Step 4 . Ask if they have worked in facilities or locations with recognized COVID-19 cases . If NO, proceed to Step 5 . Allow entry to building and remind the individual to . Wash their hands or use ABHR throughout their time in the building . Not shake hands with, touch, or hug individuals during their visit . Name . (CNA #2) .Date .10/11/2020 . a. A document titled Arkansas Department of Health's Residential Congregate Setting Reporting Form for CNA #2 dated 10/14/2020 and provided by the Assistant Director of Nursing (ADON) on 10/19/2020 at 3:30 p.m. documented, .Staff Checked . Name (Last, First) . (CNA #2) . Date of Birth . (Date) . Positive Swab Collection Date . 10/14/2020 . Positive Swab Result Date . 10/16/2020 . What was the Type of Testing . [MEDICATION NAME] . Is the Case Symptomatic for COVID-19 . Yes . When did the Case Become Symptomatic for COVID-19 . 10/14/2020 . Symptoms . Congestion / Runny Nose and Muscle Aches . Handwritten documentation on the form and signed by the ADON documented, .She worked 200 Hall on 13th (with) no symptoms. (CNA #2) came in for her shift but came to me first, stated she started having symptoms this AM (morning). I tested her. She had not entered (the facility). Sent home with direction on what to do for self, home Quarantine. (CNA #2) came back to work on COVID Hall 17th (with) no symptoms per (CNA #2) . c. On 10/20/2020 at 10:10 a.m., the CNA Supervisor was asked if (CNA #2) had worked on the 16th of October (10/16/2020). He stated, She wasn't here at 7:00 a.m., but I'm pretty sure she was here. Someone must have called her in. The day before she came up here to get a Quick Test. She called me on her way home and told me she felt like she had a fever. She wasn't sure if it was the PPE (personal protective equipment) gowns. I'm pretty sure it was Thursday, 10/15/2020, she sent me a picture of her thermometer and it was 99.8. She sent another text and said it's even higher now (expletive). (The Surveyor viewed the text.) The next text was the CNA Supervisor sending a text to CNA #2 on 10/16/20 at 7:06 a.m. which documented, (DON) wants to know if you feel well enough to work. We are short. He stated, I did tell (DON) about the text from (CNA #2) of her temp (temperature) and also that she had called me about having body aches after her temp went up. (CNA #2) said after her temp crossed the 100 mark, she had very painful like muscle aches. I did tell (DON) about that. He was asked if CNA #2 had told him she didn't have symptoms on the 16th. He stated, No. The only thing she ever told me was she was feeling some better on the 16th. The only interaction I had with her was through the window on the door of the COVID Hall. d. On 10/20/2020 at 4:48 p.m., CNA #2 notified via telephone and was asked if she had tested Positive for COVID. She stated, I did test Positive for COVID on 10/14/2020. On the 13th, I called (CNA Supervisor) after I got off work and told him I don't know if I'm tired from a 12-Hour shift and sinuses just bothering me. I told him I felt like I might have fever. When I got home it (temperature) was 98.9. He told me not to come in at 3:00 a.m. the next morning and to wait until 7:00 a.m. and talk to (ADON). So, that's what I did. She Rapid tested me and sent me home. She was asked what symptoms she was having. She stated, I was having like sinus issues. She was asked if, on the 16th, if she had made comments to (CNA #1) about them having to work sick. She stated, The only thing I said is that these people who have been off 10 to 12 days should be here working. She was asked if she had worked with symptoms. She stated, I guess I worked with symptoms. I had congestion and I was tired. She was asked the last time she had symptoms. She stated, The last day with any symptoms was the 16th. 4. A document titled COVID-19 Screening Checklist for Staff and Health Care Providers for the DON dated 10/13/2020 and provided by the ADON on 10/20/2020 at 3:50 p.m. documented, .As areas of the country lift visitors restrictions, it is important to continue to screen anyone who enters the facility. Early identification of symptoms and possible exposure reduces the likelihood of spreading [MEDICAL CONDITION]. ALL staff, including Health Care Providers (Agency Staff, Regional or Corporate Staff, Health Care Workers such as Hospice, EMS (Emergency Medical Services), [MEDICAL TREATMENT] Technicians that provide care to residents) entering the building must be asked the following questions . 1. Has this individual washed their hands or used alcohol-based hand rub (ABHR) on entry . Yes . 2. Ask the individual if they have any of the following respiratory symptoms . Cough . If YES to any, ask if they have alternative [DIAGNOSES REDACTED]. (There was no documentation of any cause) .If NO to all, proceed to Step 3 . Check Temperature and document results . 95.7 . If NO proceed to Step 4 . Ask if they have worked in facilities or locations with recognized COVID-19 cases . If NO, proceed to Step 5 . Allow entry to building and remind the individual to . Wash their hands or use ABHR throughout their time in the building . Not shake hands with, touch, or hug individuals during their visit . Name . (DON) Date .10/13/2020 . a. A document titled COVID-19 Screening Checklist for Staff and Health Care Providers for the DON dated 10/14/2020 and provided by the ADON on 10/20/2020 at 3:50 p.m. documented, .As areas of the country lift visitors restrictions, it is important to continue to screen anyone who enters the facility. Early identification of symptoms and possible exposure reduces the likelihood of spreading [MEDICAL CONDITION]. ALL staff, including Health Care Providers (Agency Staff, Regional or Corporate Staff, Health Care Workers such as Hospice, EMS (Emergency Medical Services), [MEDICAL TREATMENT] Technicians that provide care to residents) entering the building must be asked the following questions . 1. Has this individual washed their hands or used alcohol-based hand rub (ABHR) on entry . Yes . 2. Ask the individual if they have any of the following respiratory symptoms . Cough . If YES to any, ask if they have alternative [DIAGNOSES REDACTED]. (There was no documentation of any cause.) If NO to all, proceed to Step 3 . Check Temperature and document results . 96.8 . If NO proceed to step 4 . Ask if they have worked in facilities or locations with recognized COVID-19 cases . If NO, proceed to Step 5 . Allow entry to building and remind the individual to . Wash their hands or use ABHR throughout their time in the building . Not shake hands with, touch, or hug individuals during their visit . Name . (DON) .Date . 10/14/2020 . b. A document titled COVID-19 Screening Checklist for Staff and Health Care Providers for the DON dated 10/15/2020 and provided by the ADON on 10/20/2020 at 3:50 p.m. documented, .As areas of the country lift visitors restrictions, it is important to continue to screen anyone who enters the facility. Early identification of symptoms and possible exposure reduces the likelihood of spreading [MEDICAL CONDITION]. ALL staff, including Health Care Providers (Agency Staff, Regional or Corporate Staff, Health Care Workers such as Hospice, EMS (Emergency Medical Services), [MEDICAL TREATMENT] Technicians that provide care to residents) entering the building must be asked the following questions 1. Has this individual washed their hands or used alcohol-based hand rub (ABHR) on entry . Yes . 2. Ask the individual if they have any of the following respiratory symptoms . Cough . If YES to any, ask if they have alternative [DIAGNOSES REDACTED]. (There was no documentation of any cause.) If NO to all, proceed to Step 3 . Check Temperature and document results . 97.1 . If NO proceed to Step 4 . Ask if they have worked in facilities or locations with recognized COVID-19 cases . If NO, proceed to Step 5 . Allow entry to building and remind the individual to . Wash their hands or use ABHR throughout their time in the building . Not shake hands with, touch, or hug individuals during their visit . Name . (DON) .Date . 10/15/2020 . c. A document titled Arkansas Department of Health's Residential Congregate Setting Reporting Form for the DON dated 10/16/2020 and provided by the Assistant Director of Nursing (ADON) on 10/19/2020 at 3:30 p.m. documented, .Staff checked . Name (Last, First) . (DON) .Date of Birth . (Date) . Positive Swab Collection Date . 10/16/2020 . Positive Swab Result Date . 10/16/2020 . What was the type of testing . [MEDICATION NAME] . Is the case symptomatic for COVID-19 . Yes . When did the case become symptomatic for COVID-19 . 10/15/2020 . Symptoms . Congestion / Runny Nose . Other . SOB (shortness of breath) (with) exertion . d. On 10/20/2020 at 11:27 a.m., the DON was notified via telephone and was asked if she was aware of staff working with Positive COVID results and symptoms. She stated, No, that's why I haven't come back because I'm still coughing. I thought you had to be asymptomatic. She was asked if she had told the Transport Driver to go get (CNA #1) and bring her to work after she had tested Positive and had symptoms. She stated, I had told (Transport Driver) to go get her if she's not having any symptoms. (Transport Driver) told me she didn't have any symptoms and (ADON) knew I sent her after (CNA #1) and no one told me she had symptoms. She was asked if the Transport Driver and her son were told to Quarantine since they all live in the same house and (CNA #1) was Positive. She stated, I don't have a clue why they weren't Quarantined. I didn't tell them to Quarantine, but they should have been. She was asked if she had told the CNA Supervisor to have (CNA #2) to come in on the 16th of October after she had tested Positive on the 14th and was experiencing symptoms. She stated, I did have (CNA Supervisor) get ahold of her to see if she was having symptoms. If he told me she was having symptoms, I don't recall that. I know you have to be fever free for 24 hours, 24 to 72 hours, and that's with no symptoms. She was asked when the first time she was symptomatic. She stated, I can't remember the dates. The night of the 13th when we were sitting up rooms, I was doing the cleaning. On the 14th when I came in, I had a tickle in my throat and thought it was just from the cleaning. I did a Rapid Test on myself the 14th and it was Negative. She was asked if she was supposed to test herself. She stated, Probably not, but I did. The DON was reminded the cleaning was done on the 12th. She stated, So I tested myself on the 13th and it was Negative. She was asked if anyone was supposed to work with symptoms even with no temperature. She stated, I'm confused because I thought you had to have 2 or more of the symptoms. She was asked if the ADON had told her she had never seen her so short of breath. She stated, She did tell me she thought I was really short of breath and I think this was the 15th. I had been doing a lot of walking. I probably shouldn't have stayed there. 5. A document titled Temporary and Limited Waiver for Critical Staffing dated 10/15/2020 and provided by the Administrator on 10/19/2020 at 1:45 p.m. documented, .Re: Temporary and Limited Waiver for Critical Staffing . Dear, (Administrator) (Facility Name) may allow its Healthcare Workers who test Positive for COVID-19 and are asymptomatic to return to work in certain limited circumstances described below for the duration of the Public Health Emergency declared by the Governor. Pursuant to section 213 of the Arkansas Nursing Home Rules, the Office of Long Term (OLTC) has determined that the health and welfare of the community requires this facility's services. OLTC consulted with the Arkansas Department of Health (ADH) in evaluating this waiver and the safety and well-being of all residents. This letter constitutes a temporary and limited waiver by the OLTC of the following rules in order to allow (Facility) to have adequate staff to ensure the health and safety to all residents. The waiver is limited to the express terms of waiver. These rules remain in effect for all other circumstances not covered by this waiver. Healthcare workers authorized to work under this waiver are subject to the following limitations . COVID-19 Positive workers must immediately be excluded from work if the COVID-19 Positive worker becomes symptomatic, including without limitation by developing a temperature above 100.4 degree Fahrenheit, a cough, shortness of breath, or any other COVID-19 symptom by the Centers for Disease Control or ADH . 6. A facility in-service titled COVID-19 Guidance for Self-Home Quarantine provided by the ADON on 10/21/2020 at 11:10 a.m. documented, .COVID-19 Update In-service . COVID-19 Guidance for Self-Home Quarantine . We want to keep you informed regarding the Novel Coronavirus and inform you how to self-home quarantine. If you have had close contact with a person who tested positive for COVID-19, your medical provider will recommend that you home quarantine. You must remain home for 14 days after you had last contact with that the person who tested Positive or left that country to prevent the spread of [MEDICAL CONDITION] . 7. The Immediate Jeopardy was removed, and the scope and severity reduced to F on 10/21/2020 at 11:05 a.m. when the facility implemented the following Plan of Removal: a.Facility failed to ensure that Confirmed Positive staff with symptoms did not work the COVID-19 Unit. On 10/20/2020 at 2:50 p.m. the Administrator verified that there were not any positive symptomatic staff working the COVID Unit. Also verified that (CNA #2) currently working the COVID Unit was asymptomatic today . b.Nurse will monitor Positive staff for signs and symptoms three times per shift. Nurse to notify Administrator / Designee of Negative findings. Monitoring will be 7 times a week for 3 weeks, 5 times a week for 3 weeks, 3 times a week for 2 weeks, and then weekly until substantial compliance is achieved . c.Facility failed to ensure that staff exhibiting signs and symptoms of COVID were tested and immediately sent home to Quarantine . On 10/20/2020 at 3:00 p.m. the Administrator verified that no staff working who had been screened this morning had any signs or symptoms of COVID-19. The Administrator also verified that no staff had been exhibiting signs and symptoms throughout their shift . d. Administrator / Designee will monitor Screening Sheet daily for any signs and symptoms of staff. Screener will notify Administrator / Designee immediately with any Positive symptoms. Monitoring will be 7 times a week for 3 weeks, 5 times a week for 3 weeks, 3 times a week for 2 weeks, and then weekly until substantial compliance is achieved . e.Facility failed to ensure to ensure staff exposed to Confirmed Positive staff who lived together and rode to work together were not sent home to Quarantine and not allowed to ride together to work per the Temporary and Limited Waiver for Critical Staffing approved on 10/15/2020. On 10/20/2020 at 11:00 a.m., Administrator sent the Transport Driver, who was exposed, home to Quarantine for 14 days due to exposure. Also informed the Screener who is the spouse of (CNA #1) to Quarantine for 14 days due to exposure . f.Question added to Screener form . 'Do you live with anyone that test Positive . or, .Do you commute to work with anyone that has tested Positive?' Administrator / Designee will monitor Screening Sheet daily for any signs and symptoms of staff. Screener will notify Administrator / Designee immediately with any Positive symptoms. Monitoring will be 7 times a week for 3 weeks, 5 times a week for 3 weeks, 3 times a week for 2 weeks, and then weekly until substantial compliance is achieved . g.Facility failed to screen Confirme (TRUNCATED)

Based on observation, record review and interview, the facility failed to ensure the physician was immediately consulted regarding failure to heal and subsequent deterioration of a pressure ulcer to allow for prompt changes in treatment to promote healing and decrease the potential for further skin breakdown for 1 (Resident #11) of 3 (Residents #8, #11 and #14) case mix residents who had a pressure ulcer. The facility's failure to immediately consult with the physician regarding deterioration of a pressure ulcer resulted in a pattern of harm for Resident #11 whose pressure ulcer failed to heal and was found to have deteriorated and had the potential to cause more than minimal harm for 8 residents who had pressure ulcers, according to a list provided by the Assistant Director of Nursing (ADON) on 6/11/15. The findings are: 1. Resident #11 had [DIAGNOSES REDACTED]. The Significant Change Minimum Data Set with an assessment reference date of 3/12/15 documented the resident was moderately impaired in cognitive skills for daily decision making per staff assessment for mental status; was totally dependent on the physical assistance of two-plus people for bed mobility, transfers and toilet use; was totally dependent on the physical assistance of one person for locomotion, dressing, personal hygiene and bathing; did not walk, had limitation in range of motion of both upper and both lower extremities; and was at risk for the development of pressure ulcers and had no pressure ulcers. a. The wound assessment form dated 4/4/15 and signed by Licensed Practical Nurse (LPN) #1 documented, .Date Wound ID'd (identified) 4/4/15. Etiology. Pressure. Location. (Left) outer calf. Measurements (cm (centimeter)) (Length)1.5 cm (by) (Width) 1.8 (cm) (by) (Depth) (less than) 0.3 cm. [MEDICATION NAME] / Collagen. Daily. Dressing Change Protocol: (clean) (with) soap / H2O (water) / dry. Apply silvergel, collagen, cover (with) adhesive foam dressing. A Telephone Physician order [REDACTED]. Re-eval (reevaluate). b. The wound assessment form dated 4/13/15 and signed by LPN #2 documented, .Date Wound ID'd 4/4/15. Etiology. Pressure. Location. (Left) outer calf. Measurements (cm) (Length)1.3 cm (by) (Width) 1.3 (cm) (by) (Depth) (less than) 0.2 cm. Silvergel. Daily. Dressing Change Protocol: clean (with) soap / H2O. Pat dry. Apply silvergel, collagen, cover (with) adhesive foam dressing. c. The wound assessment form dated 4/30/15 and signed by LPN #6 documented, .Date Wound ID'd 4/4/15. Etiology. Pressure. Location. Re-eval of (Left) outer calf. Measurements (cm) (Length) 0.5 cm (by) (Width) 1 (cm) (by) (Depth) (less than) 0.2 cm. Silvergel, collagen. Daily. Dressing Change Protocol: clean (with) soap (and) H2O. pat dry, apply thin layer of silvergel, collagen (and) cover (with) brd (border) foam (dressing) q (every) day. Re-eval (in) 14 days d. The wound assessment form dated 5/11/15 and signed by LPN #2 documented, .Date Wound ID'd 4/30/15. Etiology. Pressure. Location. (Left) outer calf. Measurements (cm) (Length) 0.6 cm (by) (Width) 0.6 (cm) (by) (Depth) (less than) 0.2 cm. Dressing Change Protocol: clean (with) soap / H2O, pat dry, apply thin layer silvergel, collagen, cover (with) border foam dressing qd e. The wound assessment form dated 5/25/15 and signed by LPN #2 documented, .Date Wound ID'd (blank). Etiology. Pressure. Location. (Left) outer calf. Measurements (cm) (Length) 1 cm (by) (Width) 1 (cm) (by) (Depth) (less than) 0.2 cm. Dressing Change Protocol: clean (with) soap / H2O, pat dry. apply silvergel collagen and bordered foam qd f. The wound assessment form dated 6/1/15 and signed by LPN #2 documented, .Date Wound ID'd (blank). Etiology. Pressure. Location. (Left) outer calf. Measurements (cm) (Length) 1.5 cm (by) (Width) 0.8 (cm) (by) (Depth) (less than) 0.3 cm. Exudate. Amount: Scant / Min. Consistency: Sanguineous / bleeding. Wound Bed. Tissue Type / Color (and) percent. Granulation: (percent blank). Red, Friable (fragile / bleeds) and / or Duskey. Wound Edges / Periwound. Wound Edges / Margins. Irregular wound edges. Peri wound Tissues. Intact / Uninvolved tissues. Dressing Change Protocol: clean (with) soap / H2O, pat dry. apply silvergel, collagen (and) cover (with) bordered foam dressing qd g. The Nurse's Notes entry dated 6/2/15 at 11:19 a.m. documented, New Order. Change Tx (treatment) to (left) lower calf to: clean (with) soap / H2O, pat dry. Apply collagen and border foam dressing. Apply tubi-grip from foot to above knee qd on 11-7. There was no further documentation in the nurse's notes regarding the resident's calf wound through 6/10/15 at 6:45 a.m. 1) The June 2015 physician's orders [REDACTED]. Pat dry. apply collagen and border foam dressing. apply tubi-grip from foot to above knee qd on 11-7. 2) The June 2015 Treatment Record documented, 5-2-15 (6/2/15) Tx to (left) outer calf: Clean (with) soap / H2O. Pat dry apply collagen and border foam dressing. Apply tubi-grip from foot to above knee qd 11-7 In the spaces provided on the Treatment Record, nurse' initials documented the treatment was provided on the 11:00 p.m. to 7:00 a.m. shift from 6/3/15 through 6/9/15. h. As of 6/9/15, in the Physicians Progress Notes from 3/28/15 to the current date, there was no documentation of a pressure area to the resident's left lower outer calf. i. On 6/10/15 at 9:30 a.m., the resident was lying in bed. With the Director of Nursing (DON) present, LPN #1 removed the dressing from the resident's left lateral calf and measured the pressure ulcer as 2.4 cm long by 4.2 cm wide by 0.7 cm deep. The pressure ulcer was round, covered with slough / eschar from 6 to 12 o'clock. There was an open tunnel area at 3 o'clock. The DON told LPN #1, Go call the doctor and get new orders to the left calf cause it looks infected. j. The physician's orders [REDACTED]. There appears to be some necrotic tissue and some depth to the wound. She is a quadriplegic but is not diabetic. pressure ulcer to (left) posterior lower leg: off loading refer to wound clinic for evaluation and treatment. k. On 6/11/15 at 9:55 a.m., LPN #1 was asked, When did you notify the physician that the pressure area to the left lower outer calf had worsened? She stated, Yesterday (6/10/15). 2. A document titled Checking for Skin Problems was provided by the DON on 6/10/15 at 11:37 a.m. and documented, .If there is no noted improvement in skin problems within 7-14 days the physician will be notified. If (there) is a noted worsening of the skin problem, the physician is to be notified immediately.

Based on observation, record review and interview, the facility failed to ensure the physician was immediately consulted regarding failure of a pressure ulcer to heal and the subsequent deterioration of the pressure ulcer to allow for prompt changes in treatment and failed to ensure pressure relief was consistently provided to promote healing and prevent further skin breakdown for 1 (Resident #11) of 3 (Residents #8, #11 and #14) case mix residents who had a pressure ulcer. The facility's failure to immediately consult with the physician regarding deterioration of a pressure ulcer and failure to provide pressure relief resulted in a pattern of harm for Resident #11 whose pressure ulcer failed to heal and was found to have deteriorated and had the potential to cause more than minimal harm to 8 residents who had pressure ulcers, according to a list provided by the Assistant Director of Nursing (ADON) on 6/11/15. The findings are: 1. Resident #11 had [DIAGNOSES REDACTED]. The Significant Change Minimum Data Set with an assessment reference date of 3/12/15 documented the resident was moderately impaired in cognitive skills for daily decision making per staff assessment for mental status; was totally dependent on the physical assistance of two-plus people for bed mobility, transfers and toilet use; was totally dependent on the physical assistance of one person for locomotion, dressing, personal hygiene and bathing; did not walk, had limitation in range of motion of both upper and both lower extremities; and was at risk for the development of pressure ulcers and had no pressure ulcers. a. The Care Plan dated 3/19/15 documented, .Resident is at risk for develop a pressure ulcer .Report changes in skin status to physician .Provide pressure relieving or reduction device. b. The wound assessment form dated 4/4/15 and signed by Licensed Practical Nurse (LPN) #1 documented, .Date Wound ID'd (identified) 4/4/15. Etiology. Pressure. Location. (Left) outer calf. Measurements (cm (centimeter)) (Length)1.5 cm (by) (Width) 1.8 (cm) (by) (Depth) (less than) 0.3 cm. [MEDICATION NAME] / Collagen. Daily. Dressing Change Protocol: (clean) (with) soap / H2O (water) / dry. Apply silvergel, collagen, cover (with) adhesive foam dressing. A Telephone Physician order [REDACTED]. Re-eval (reevaluate). c. The wound assessment form dated 4/13/15 and signed by LPN #2 documented, .Date Wound ID'd 4/4/15. Etiology. Pressure. Location. (Left) outer calf. Measurements (cm) (Length)1.3 cm (by) (Width) 1.3 (cm) (by) (Depth) (less than) 0.2 cm. Silvergel. Daily. Dressing Change Protocol: clean (with) soap / H2O. Pat dry. Apply silvergel, collagen, cover (with) adhesive foam dressing. d. The wound assessment form dated 4/30/15 and signed by LPN #6 documented, .Date Wound ID'd 4/4/15. Etiology. Pressure. Location. Re-eval of (Left) outer calf. Measurements (cm) (Length) 0.5 cm (by) (Width) 1 (cm) (by) (Depth) (less than) 0.2 cm. Silvergel, collagen. Daily. Dressing Change Protocol: clean (with) soap (and) H2O. pat dry, apply thin layer of silvergel, collagen (and) cover (with) brd (border) foam (dressing) q (every) day. Re-eval (in) 14 days e. The wound assessment form dated 5/11/15 and signed by LPN #2 documented, .Date Wound ID'd 4/30/15. Etiology. Pressure. Location. (Left) outer calf. Measurements (cm) (Length) 0.6 cm (by) (Width) 0.6 (cm) (by) (Depth) (less than) 0.2 cm. Dressing Change Protocol: clean (with) soap / H2O, pat dry, apply thin layer silvergel, collagen, cover (with) border foam dressing qd f. The wound assessment form dated 5/25/15 and signed by LPN #2 documented, .Date Wound ID'd (blank). Etiology. Pressure. Location. (Left) outer calf. Measurements (cm) (Length) 1 cm (by) (Width) 1 (cm) (by) (Depth) (less than) 0.2 cm. Dressing Change Protocol: clean (with) soap / H2O, pat dry. apply silvergel collagen and bordered foam qd g. The wound assessment form dated 6/1/15 and signed by LPN #2 documented, .Date Wound ID'd (blank). Etiology. Pressure. Location. (Left) outer calf. Measurements (cm) (Length) 1.5 cm (by) (Width) 0.8 (cm) (by) (Depth) (less than) 0.3 cm. Exudate. Amount: Scant / Min. Consistency: Sanguineous / bleeding. Wound Bed. Tissue Type / Color (and) percent. Granulation: (percent blank). Red, Friable (fragile / bleeds) and / or Duskey. Wound Edges / Periwound. Wound Edges / Margins. Irregular wound edges. Peri wound Tissues. Intact / Uninvolved tissues. Dressing Change Protocol: clean (with) soap / H2O, pat dry. apply silvergel, collagen (and) cover (with) bordered foam dressing qd h. The Nurse's Notes entry dated 6/2/15 at 11:19 a.m. documented, New Order. Change Tx (treatment) to (left) lower calf to: clean (with) soap / H2O, pat dry. Apply collagen and border foam dressing. Apply tubi-grip from foot to above knee qd on 11-7. There was no further documentation in the nurse's notes regarding the resident's calf wound through 6/10/15 at 6:45 a.m. 1) The June 2015 physician's orders [REDACTED]. Pat dry. apply collagen and border foam dressing. apply tubi-grip from foot to above knee qd on 11-7. 2) The June 2015 Treatment Record documented, 5-2-15 (6/2/15) Tx to (left) outer calf: Clean (with) soap / H2O. Pat dry apply collagen and border foam dressing. Apply tubi-grip from foot to above knee qd 11-7 In the spaces provided on the Treatment Record, nurse' initials documented the treatment was provided on the 11:00 p.m. to 7:00 a.m. shift from 6/3/15 through 6/9/15. i. As of 6/9/15, in the Physicians Progress Notes from 3/28/15 to the current date, there was no documentation of a pressure area to the resident's left lower outer calf. j. On 6/9/15 at 9:12 a.m., the resident was lying in bed with a pillow under her left and right calves. The outer left calf was directly on the pillow. k. On 6/10/15 at 9:30 a.m., the resident was lying in bed with a pillow underneath her bilateral calves. With the Director of Nursing (DON) and Assistant Director (ADON) present, LPN #1 removed the dressing from the resident's left lateral calf, provided wound care and measured the pressure ulcer as 2.4 cm long by 4.2 cm wide by 0.7 cm deep. The pressure ulcer was round, covered with slough / eschar from 6 to 12 o'clock. There was an open tunnel area at 3 o'clock. When asked what the condition of the resident's left lower outer leg was, the DON and ADON stated it looked like a pressure ulcer with tunneling. The DON was asked how the pressure sore got on the resident's left lower outer calf. She stated, Because her legs (lie) on that pillow and it caused pressure. I've seen that before. The left lower calf remained lying on the pillow, causing pressure. The DON told LPN #1, Go call the doctor and get new orders to the left calf cause it looks infected. l. On 6/10/15 at 2:40 p.m., the DON was asked, Should there be a pillow under her left calf if it is what is causing the pressure? She stated, Yes ,it should. They just didn't have it placed correctly. m. The physician's orders [REDACTED]. There appears to be some necrotic tissue and some depth to the wound. She is a quadriplegic but is not diabetic. pressure ulcer to (left) posterior lower leg: off loading refer to wound clinic for evaluation and treatment. n. On 6/11/15 from 9:55 a.m. to 10:15 a.m., the following interviews were conducted: 1) At 9:55 a.m., LPN #1 was asked when the facility started using the pillow under the resident's legs. She stated, They have been doing that since I was hired here in August. The LPN was asked, When did you notify the physician that the pressure area to the left lower outer calf had worsened? She stated, Yesterday (6/10/15). 2) At 10:05 a.m., CNA #5 was asked when the facility started using the pillow under the resident's legs. She stated, About three months ago. 3) At 10:08 a.m., CNA #3 was asked when the facility started using the pillow under the resident's legs. She stated, About two or three months ago. 4) At 10:11 a.m., the DON was asked when the facility started using the pillows under the resident's legs. She stated, They put the pillow under her legs everyday to try to keep her heels off floated. We've used the pillow for months and months. 2. A document titled Checking for Skin Problems was provided by the DON on 6/10/15 at 11:37 a.m. and documented, .If there is no noted improvement in skin problems within 7-14 days the physician will be notified. If (there) is a noted worsening of the skin problem, the physician is to be notified immediately.

Based on observation, interview and record review, the facility failed to ensure nutritional interventions to prevent further weight loss were consistently implemented for 2 (Residents #5 and #8) of 4 (Residents #5, #15, #18, and #19) case mix resident who had a severe weight loss. The facility failed to promptly develop and implement interventions to address continued weight loss and to accurately calculate and document meal consumption to minimize the potential for further weight loss for 1 (Resident #5) of 4 (Residents #5, #15, #18, and #19) case mix resident who had a severe weight loss. These failed practices resulted in a pattern of actual harm for Resident #5 who experienced a severe weight loss and had the potential to cause more than minimal harm for 20 residents who had actual weight loss, according to a list provided by the Administrator on 6/10/15. The findings are: 1. The facility's policy titled Responsibility for Obtaining and Recording Weights and Vital Signs was provided by the Director of Nursing (DON) on 6/10/15 at 4:55 p.m. and documented, .Weights are to be obtained monthly on all residents unless otherwise specified by the attending physician. LPN (Licensed Practical Nurse) will notify the attending physician of significant weight losses or gains. Also Dietary Manager will be notified of significant weight losses or gains for dietary interventions or suggestions. Dietary Manager will be notified if physician orders [REDACTED]. Responsible family members are to be notified of significant weight losses or gain (5% or more in last 30 days) and they are to be notified of interventions the physician and staff are taking. Any new orders or steps taken regarding weight losses or gains are to be recorded in the nurses notes. All of these areas must be addressed in the care plan and are to be done by the LPN or nurse receiving the orders. Significant changes will be discussed by department heads in weekly weight meetings and a list given to the LPNs to notify doctor's and families. Care plan it and chart in nurses notes and implement new orders. 2. Resident #5 had [DIAGNOSES REDACTED]. The Annual Minimum Data Set (MDS) with an assessment reference date (ARD) of 5/21/15 documented the resident scored 10 (8-12 indicates moderate cognitive impairment) on the brief interview for mental status (BIMS); required supervision with setup help for eating; had limitation in range of motion of both upper extremities; and had experienced weight loss and was not on a physician-prescribed weight loss regimen. a. The June 2014 physician's orders [REDACTED]. b. The Resident Plan of Care dated 5/28/15 documented, Resident is at nutrition risk, she is above her ibw (ideal body weight). Currently in the past months has gradually lost weight, but that has stabilized now. Will monitor likes and dislikes. Weigh and monitor results. Monitor and report to the Physician: Sign / symptoms of malnutrition, Significant weight loss and / or gain. Chewing / swallowing problems. Administer nutritional support as ordered. Provide diet as ordered. Provide / monitor intake of diet / fluids. Offer substitutes if 50% or less consumed. Provide dining room / meal accommodations. Allow adequate time to eat. Provide a quiet, calm setting. Report to nurse any s/s (signs and symptoms) chewing / swallowing or other problems consuming meals: Choking, Coughing during eating or drinking. Refuses meal (and / or) substitute. Nose dripping or eyes tearing while eating. Pocketing of food. Eats less than 50% of meal. Excessive drooling. c. The Annual Weight Report for 3/1/14 through 4/10/15 was provided by the Administrator on 6/8/15 and the Monthly Weights list dated 6/9/15 was provided by Administrator on 6/10/15 and documented the following monthly weights for the resident: 1) 12/9/14 - 192.1 pounds (Annual Weight Report) 2) 1/13/15 - 186.5 pounds (Annual Weight Report) 3) 2/3/15 - 183.8 pounds (Annual Weight Report) 4) 3/3/15 - 181.8 pounds (Annual Weight Report) 5) 4/6/15 - 176.8 pounds (Annual Weight Report) 6) May 2015 - 174.9 pounds (Monthly Weights list) 7) June 2015 - 170.5 pounds (Monthly Weights list) The resident experienced an 11.3 pound weight loss in the 3 months since March 2015 (6.2%) and a 21.6 pound weight loss in the 6 months since December 2014 (11.2 %). d. The Dietary Charting Summary dated 12/18/14 documented, .Weight: 192.1 (pounds). Resident is a regular solid texture diet - receives HS (hour of sleep) snack will continue to monitor. The December 2014 food intake record documented the resident refused all breakfast meals (0% consumption), consumed 59% of her lunches and 69% of her evening meals. The resident had average meal consumption for December 2014 of 43%. The form further documented the resident consumed an average of 97% of her 7:00 p.m. HS snack for December 2014. e. The Dietary Charting Summary dated 1/14/15 documented, .Weight: 192 (pounds). receives a snack at HS will continue to monitor. The January 2015 food intake record documented the resident refused all breakfast meals (0% consumption), consumed 70% of her lunches and 81% of her evening meals. The resident had average meal consumption for January 2015 of 50%. There were no percentages of consumption charted for the resident's 7:00 p.m. HS snack. f. The physician's orders [REDACTED]. The February 2015 food intake record documented the resident refused all breakfast meals (0% consumption), consumed 54% of her lunches and 65% of her evening meals. The resident had average meal consumption for February 2015 of 40%. The form further documented the resident consumed an average of 98% of her 7:00 p.m. HS snack for February 2015. g. The Dietary Charting Summary dated 3/11/15 documented, .Weight: 181.8. no diet changes noted will continue to monitor. The physician's orders [REDACTED]. The March 2015 food intake record documented the resident refused all breakfast meals (0% consumption), consumed 59% of her lunches and 68% of her evening meals. The resident had average meal consumption for March 2015 of 44%. The form further documented the resident consumed an average of 45% of her 7:00 p.m. HS snack for March 2015. h. The Dietary Charting Summary dated 4/7/15 documented, .Weight: 182. no diet changes noted will continue to monitor. The Dietary Progress Notes entry dated 4/9/15 documented, RD (Registered Dietician) note: Wt (weight) loss of 5 (pounds) over past month to current wt of 176.8 (pounds). 43% average PO intake (times) 2 days on Regular diet. Refuses breakfast most days. No new labs. Recommend adding snacks between meals BID (twice a day). The June 2014 physician's orders [REDACTED].04/13/2015. Healthshake 4 oz. (ounce) PO (by mouth) BID (twice a day). The April 2015 food intake record documented the resident refused all breakfast meals (0% consumption), consumed 51% of her lunches and 60% of her evening meals. The resident had average meal consumption for April 2015 of 37%. The form further documented the resident consumed 0% of her 7:00 p.m. HS snack. There was no documentation on the form that the resident was offered or consumed Health Shakes during April 2015. i. The Dietary Charting Summary dated 5/28/15 documented, .Weight: 172.2 5/18/15. (Resident #5) reports eating well for (lunch and dinner), but has never been a (breakfast) eater. She states snacks have not been offered lately; requests Health Shake at (10:00 a.m. and 3:00 p.m.) cont (continue) but wants PB (peanut butter) (and) crackers at HS. Adjust snacks per request. Discuss snacks (with) nursing to make sure they are being offered. On 6/10/15 at 9:40 a.m., the Dietary Manager was asked if she was aware that the resident was losing weight. She stated, Yes and you will see it in my note on 5/28/15 our recommendation. I am not aware of what they were doing before I started working here. She was asked if she has any other notes. She stated, Don't have any other notes. The physician's orders [REDACTED]. doing well / no issues. Meds (medications) / labs (laboratory test results) / vitals reviewed. continue current plan. There was no documentation regarding weight losses. The May 2015 food intake record documented the resident refused all breakfast meals (0% consumption), consumed 61% of her lunches and 61% of her evening meals. The resident had average meal consumption for May 2015 of 40%. The form further documented, for May 2015, the resident consumed 35% of an 8:00 a.m. Health Shake, 16% of her 7:00 p.m. HS snack and 35% of an 8:00 p.m. Health Shake. j. The June 2015 food intake record (from 6/1/15 through 6/10/15) documented the resident refused all breakfast meals (0% consumption), consumed 49% of her lunches and 55% of her evening meals. Through 6/10/15, the resident had an average meal consumption for June 2015 of 34%. The form further documented, for June 2015, the resident consumed 20% of an 8:00 a.m. Health Shake and 0% of an 8:00 p.m. Health Shake. There was no documentation on the form that the resident had been offered, or had consumed, her 7:00 p.m. HS snack. k. On 6/9/15 at 12:30 p.m., during the lunch meal, the resident was served roast turkey, mashed potatoes, seasoned carrots, dinner roll, margarine, angel food cake and two 120 cubic centimeter (cc) glasses of tea. She ate 25 % of her lunch meal, consuming 2 bites of roast turkey, 3 bites of mashed potatoes, 2 bites of carrots, 1/2 angel food cake and 1/2 glass of tea. There was no attempt made by staff to encourage resident to eat her lunch meal. There were no substitutes offered to the resident, in place of food items not eaten. 1) As of 6/11/15 at 11:05 a.m., the June 2015 food intake record documented the resident consumed 80% of her lunch meal on 6/9/15. 2) On 6/11/15 at 12:10 p.m., Certified Nursing Assistant (CNA) #2 was asked, Did you record the resident's meal percentage of 80%. He stated, I didn't put it on the meal ticket; I just chart it in the book. I asked another CNA what she ate. I didn't see personally what she consumed; I just charted it. l. On 6/9/15 at 5:55 p.m., during the supper meal, the resident was served crunchy fish, macaroni and cheese, green beans, bread, margarine, brownie and two 120 cc glasses of tea in her room. She ate 5 % of her meal, consuming all the brownie, a bite of crunchy fish and a bite of macaroni and cheese. There was no attempt made by staff to encourage resident to eat her lunch meal. There were no substitutes offered to the resident, in place of food items not eaten. As of 6/11/15 at 11:05 a.m., the June 2015 food intake record documented the resident consumed 40% of her supper meal on 6/9/15. m. On 6/10/15 at 12:23 p.m., during the lunch meal, the resident was served mixed vegetables, mashed potatoes, steak fingers, a slice of white bread, a cookie, fortified chocolate pudding and margarine with two 120 cc glasses of tea, in her room. She ate a bite of steak finger and 2 bites of mashed potatoes. She stated, I'll eat the chocolate pudding. There was no attempt made by staff to encouraged resident to eat her lunch meal. There were no substitutes offered to the resident, in place of food items not eaten. As of 6/11/15 at 11:05 a.m., the June 2015 food intake record documented the resident consumed 25% of her lunch meal on 6/10/15. n. On 6/10/15 at 2:45 p.m., the DON and Administrator approached the surveyor and stated, She (Resident #5) is on weekly weights and she told a nurse that she wanted to lose weight and it was addressed in our weekly weight meeting on 5/13/15, but I'm not sure if it is documented in the Nurse's notes. At 2:50 p.m., the Administrator provided documentation of an interview conducted with resident by the Assistant Director of Nursing (ADON) that documented, .she was happy with her weight loss. 1) On 6/10/15 at 3:15 p.m., during a phone interview, the RD was asked if she was aware that the resident wanted to lose weight. She stated, I knew nothing of (Resident #5) wanting to lose. I never asked her, but had no knowledge; no one told me that she wanted to lose weight. 2) On 6/10/15 at 3:55 p.m., the DON was asked how information concerning resident weights or requests was passed on to the RD or Certified Dietary Manager (CDM). She stated, Make copies of monthly weights and give to CDM and RD when she comes. She was asked why the resident request to lose weight was not passed on from the 5/13/15 weekly weight meeting to the RD and CDM, the request Care Planned and the Physician informed. She stated, I didn't care plan it because she didn't report it to me and I didn't check chart or Nurse's notes to see if that LPN had care planned or documented that. 3) On 6/10/15 at 4:00 p.m., the Administrator was asked how information concerning resident weights or requests were passed on to the RD or Certified Dietary Manager. He stated, The nurse needs to write a slip and turn it into the CDM. He was asked why the resident request to lose weight was not passed on from the 5/13/15 weekly weight meeting to the RD and CDM, care planned, and the physician informed. He stated, I can't answer that; I don't know why it wasn't. 3. Resident #8 had [DIAGNOSES REDACTED]. The Annual MDS with an ARD of 1/8/15 documented the resident scored 4 (0-7 indicates severe cognitive impairment) on the BIMS, was totally dependent on the physical assistance of one person for eating; had limitation in range of motion of both upper extremities; weighed 84 pounds, had experienced a weight loss, was not on a physician-prescribed weight-loss regimen, received a therapeutic diet, was at risk for the development of pressure ulcers; and had one Stage II pressure ulcer. a. The Resident Plan of Care dated 4/16/15 documented, Problem Date: 12/31/2010. Resident is at nutrition risk. Weigh and monitor results. Monitor and report to the physician: Significant weight loss Chewing / swallowing problems. Administer nutritional support as ordered. Provide diet as ordered. Provide / monitor intake of diet / fluids. Provide dining room / meal accommodations. Allow adequate time to eat. Provide a quiet, calm setting. Report to nurse an s/s (signs and symptoms) chewing / swallowing or other problems consuming meals: Choking Coughing during eating or drinking Refuses meal (and / or) substitute Eats less than 50% of meal. Resident is at risk for skin breakdown and / or developing pressure ulcers due to she is dependent upon care givers. Provide diet as ordered and monitor nutritional status and dietary needs; consult dietitian PRN (as needed). b. The Annual Weight Report for 3/1/14 through 4/10/15 was provided by the Administrator on 6/8/15 and the Monthly Weights list dated 6/9/15 was provided by Administrator on 6/10/15 and documented the following monthly weights for the resident: 1) 3/3/15 - 77.0 pounds (Annual Weight Report) 2) 4/6/15 - 71.4 pounds (Annual Weight Report) 3) May 2015 - 68.8 pounds (Monthly Weights list) 4) June 2015 - 65.2 pounds (Monthly Weights list) The resident experienced a 2.8 pound weight loss in 1 month (5.2%) and an 11.8 pound weight loss in the 3 months since March 2015 (15.3%). c. The Dietary Progress Notes entry dated 3/17/15 documented, RD note: Wt gain of 8 (pounds) (times) 1 month to current wt of 77 lbs. Fair PO intake NAS, puree diet. Interventions include: [MEDICATION NAME] (multivitamin), fortified foods, pudding TID (three times a day), ensure 4 oz (with) meals. The June 2015 physician's orders [REDACTED].03/10/2015 Ensure snack pudding. d. The Dietary Progress Notes entry dated 4/9/15 documented, RD note: Wt loss of 5.6 (pounds) over past month to current wt of 71.4 (pounds). 52% average PO intake (times) 3 days on NAS, puree diet. Dietary interventions include: pudding TID, healthshake (with) protein powder TID, ensure BID, fortified foods at all meals. Staff reports resident does not like the ensure pudding at snack times, but likes thrive ice cream. Recommend changing ensure pudding TID to thrive TID. e. The Dietary Progress Notes entry dated 5/8/15 documented, RD note: Wt loss of 2.6 (pounds) over past month to current wt of 68.8 (pounds) 46% average PO intake (times) 3 days on NAS, puree diet. Dietary interventions include: orange juice (times) 2 at all meals, thrive TID, ensure pudding TID, healthshake TID, ensure BID and fortified foods at all meals. Family declines TF (tube feeding). Staff reports resident dislikes sweets; likes orange juice and thrive. Recommend (discontinuing) ensure, ensure pudding and healthshakes r/t not consuming and adding buttermilk to all meals. The June 2015 physician's orders [REDACTED].05/11/2015 Diet. Regular NAS (no added salt) pureed. Add fortified foods; 4 oz (ounce) ensure (and) 8 oz buttermilk to all meals. f. The Dietary Progress Notes entry dated 6/9/15 documented, RD note: Wt loss of 3.2 (pounds) over past month to current wt of 65.2 lbs. 44% average PO intake (times) 3 days on regular diet. Diet advanced 6/4/15. Also, peanut butter sandwiches TID between meals added 6/4/15. Also, receives orange juice (times) 2 at meals, health shakes TID, fortified foods at meals, thrive TID. Will follow to allow time for current interventions to take affect. A Physician's telephone order dated 6/4/15 at 12:10 a.m. documented, Resume regular diet with peanut butter sandwich. g. On 6/9/15 at 12:30 p.m., the resident was up in a wheelchair in the main dining room where she received her noon meal tray. She was served roast turkey, mashed potatoes, seasoned carrots, a dinner roll, margarine, angel food cake with strawberries and whipped topping, fortified peanut butter pudding, two 120 cc glasses of orange juice and 240 cc of coffee. There was no buttermilk or peanut butter sandwich on her tray. h. On 6/9/15 at approximately 6:00 p.m., the resident was served a dinner tray in her room. She was served fish, macaroni and cheese, green beans, bread, chocolate pudding fortified and 240 cc of orange juice. No buttermilk or peanut butter sandwich was served to the resident. i. On 6/10/15 at 10:00 a.m., a snack of chocolate Thrive was brought to the resident's room No other food was brought to her at that time. j. On 6/10/15 at 1:00 p.m., the resident was served chicken and dumplings, lettuce and tomato salad, fortified chocolate pudding and 240 cc of orange juice. No buttermilk or peanut butter sandwich was served to the resident. k. On 6/11/15 at 1:00 p.m., the resident was served cornbread, ham, cabbage, fortified peanut butter pudding, potato soup, fruit salad, 240 cc of coffee, 240 cc of orange juice. No butter milk or peanut butter sandwich was served to the resident. l. On 6/11/15 at 3:00 p.m., the Dietary Manager was asked, When did you receive the order for buttermilk at meals for (Resident #8)? She stated, It was added 5/11/15 and on 5/14/15 taken off relating to patient refused. The Dietary Manager was asked who told her to take the buttermilk off. She replied, A CNA because resident didn't like it. The Dietary Manager was asked if a CNA had authority to discontinue a physician's orders [REDACTED]. She was asked, Do you, as a dietary manager, have the authority to discontinue a physician's orders [REDACTED]. The Dietary Manager was asked when the resident received her peanut butter sandwiches. She replied, At 10:00 a.m., 2:00 p.m. and at HS. The Dietary Manager was asked, Do you send them out, because I have not seen any sandwiches delivered to her? She stated, Yes, the chocolate thrive goes out at the same time.

Based on observation, record review and interview, the facility failed to ensure fall interventions to prevent further falls and decrease the potential for injury were promptly developed, communicated to staff, consistently implemented, and re-evaluated to determine effectiveness for 3 (Residents #6, #9 and #13) of 4 (Residents #6, #9, #11 and #13) case mix residents at high risks for falls. This failed facility practice resulted in Immediate Jeopardy, which caused or could have caused serious harm, injury, impairment or death to Resident #6, who experienced multiple falls and suffered a fractured hip and rib as a result of falls and had the potential to affect 37 residents assessed as being at high risk for falls, according to a list provided by the Director of Nursing (DON) on 2/21/13. The Administrator was informed of the Immediate Jeopardy on 2/22/13 at 3:50 pm. The facility further failed to ensure a non-weight bearing resident was not transferred by gait belt to decrease the potential for injury for 1 (Resident #13) of 17 (Residents #1, #3, #4, #5, #7, #8, #9, #10, #11, #12, #13, #16, #18, #19 , #27, #28, #30) case mix residents who required staff assistance for transfers. This failed practice had the potential to cause more than minimal harm to 66 residents who required staff assistance for transfers, according to a list provided by the Administrator on 2/22/13. The findings are: 1. Resident #6 had [DIAGNOSES REDACTED]. The Significant Change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/2/13 documented the resident scored 6 (0-7 indicates severe cognitive impairment) on the Brief Interview for Mental Status (BIMS); did not walk, was unsteady and only able to stabilize with staff assistance when moving from a seated to standing position and for surface-to-surface transfers; was totally dependent on the physical assistance of 2-plus people for transfers; and had two or more falls since admission or prior assessment. a. An Incident Report documented, "...8/18/12 at (12:15 a.m.) Exact Location of Incident: Resident's Room... Resident getting up without assistance causing him to fall to floor, small abrasion noted to right side back... Additional Comments: Encourage use of call light, check on q (every) hour." b. An Incident Report documented, "...9/26/12 at 8:45 a.m. Exact Location of Incident: Resident Room... Res (resident) found in floor by roommate's trash can. No visible injuries noted... Additional Comments: Enc (encourage) res to call for help to empty trash." c. An Incident Report documented, "...10/18/12 at 0730 (7:30 a.m.) Exact Location of Incident: Room beside closet Res noted standing beside closet and lost balance and slid between wall and w/c (wheelchair) to floor along wall... No visible injury noted. Additional Comments: Staff to monitor res for wants and needs." d. An Incident Report documented, "...10/26/13 at 0200 (2:00 a.m.) Exact Location of Incident: Resident's Room... Resident getting up without assist, lost his balance causing him to fall. .5 x (by) .5 x .1 (centimeter) abrasion to (right) knee. Twisted ankle, ROM (range of motion) WNL (within normal limits)... Additional Comments: Check more often, encourage use of CL (call light)." The intervention documented on the incident report was not specific as to the frequency the resident would be checked. e. An Incident Report documented, "...11/4/12 at 0110 (1:10 a.m.) Exact Location of Incident: Resident's Rm (room)... Resident up to BR (bathroom) without assist, had only socks on, slid to floor. No visible (injuries) noted... Additional Comments: Enc (encourage) use of CL, check on more often." There were no new interventions to prevent further falls documented on the Incident Report and there was no documented frequency the resident would be checked. f. An Incident Report documented, "...11/5/12 at 0655 (6:55 a.m.) Exact Location of Incident: Resident's room... Resident attempting to transfer himself from bed to WC (wheelchair), slipped, fell causing ST (skin tear) to L (left) forearm... Additional Comments: Encourage use of CL, monitor more closely." There were no new interventions to prevent further falls documented on the Incident Report and there was no documented frequency the resident would be checked. g. An Incident Report documented, "...12/14/12 at 2121 (9:21 p.m.)... Resident stood up with walker with house shoes on, lost his balance and fell to floor causing .5 x .5 abrasion. Res. unable to bear weight on (right) leg... Statement of Physician: Send to (hospital) for tx (treatment) and eval (evalution). Additional Comments: Res sent via (Nursing Home) transport." There were no new interventions to prevent further falls documented on the Incident Report. 1) The X-Ray Preliminary Report dated 12/14/12 at 23:08 (11:08 p.m.) documented, "...There is a fracture of the right greater trochanter. Comminuted. Minimal displacement..." 2) The CT (computed tomography) scan of the right hip dated 12/14/12 at 2327 (11:27 p.m.) documented, "...Reason for Exam: Fall... Impression: 1. Comminuted mildly displaced greater trochanter fracture proximal right femur..." h. An Incident Report documented, "...12/18/12 at 2400 (12:00 a.m.)... Res found in floor beside bed lying on (right) side. C/O (complained of) (right) hip pain. Res not moved by staff. Res states he was transferring self to bed without assistance. EMS (emergency medical service) notified. Res transferred to (emergency room ) via EMS... Additional Comments: Pressure alarms to W/C (wheelchair) and bed." 1) The X-ray Report of the right ribs dated 12/18/12 at 0200 (2:00 a.m.) documented, "...Impression: 1. Right pneumothorax of approximately 15% 2. Probable nondisplaced fracture of the right seventh rib laterally..." 2) The X-ray Report of the chest dated 12/19/12 at 1026 (10:26 a.m.) documented, "...Impression: Enlarging (now perhaps 20%) right apical pneumothorax..." i. An Incident Report documented, "...12/23/12 at 0120 (1:20 a.m.)... Res stood up in front of nurses' station and immediately fell on to (right) side, landed on prev. (previous) hip fx, (fracture). Notified M.D. (medical doctor). NNO (no new orders). Notified wife, requested that he be sent to ER." There were no new interventions to prevent further falls documented on the Incident Report. 1) The X-Ray Report of the chest dated 12/23/12 at 0245 (2:45 a.m.) documented, "...Impression: 1. No acute abnormality... 2. No right pneumothorax identified at this time..." 2) The X-Ray Report of the Pelvis dated 12/23/12 at 0245 documented, "...Impression: Separation of the fragments at the right proximal femoral fracture..." j. An Incident Report documented, "...2/11/13 at 1715 (5:15 p.m.)... Resident found on floor in bathroom with walker. He stated he 'slipped and fell '. Resident had socks on. Did not wait for help from nursing staff... Additional Comments: Non-skid strips in bathroom and at doorway." k. An Incident Report documented, "...2/16/13 at 7:45 a.m. ...Res attempt to get into bed without assist and fell to floor. No injury noted... Additional Comments: Staff to assist Res with transfers." l. On 2/22/13 at 9:32 a.m., the resident was lying in the bed. There was no pressure alarm in the resident's electric wheelchair seat. Certified Nursing Assistant (CNA) #5 was asked, "Does he have a pressure alarm in his chair?" CNA #5 stated, "Yes, he is supposed to." The CNA was asked, "Is there one on his chair now?" The CNA answered, "No, it may be in the bed with him... He is supposed to have one in bed too." At 9:37 a.m., Licensed Practical Nurse (LPN) #4 was asked to look at the pressure alarm in the bed. The LPN stated, "It's on the bed but it's not hooked up. He doesn't even have an order for [REDACTED]. Now I can put it in his chair." At 11:55 a.m., LPN #5 was asked, "Have you ever seen (Resident #6) remove his alarm?" LPN #5 answered, "All the time. Sometimes he comes out in the hall and he has it unplugged so it doesn't go off." m. On 2/22/13 at 12:45 p.m., the Director of Nursing (DON) was asked, "Was (Resident #6) a high risk for falls before he came in?" The DON stated, "Yes." The DON was asked, "Do you review the Incident Reports?" The DON stated, "The ADON (Assistant Director of Nursing) does. The DON was asked, "On several of the Incident Reports, the intervention was, 'Encourage the resident to use call light. Check on him frequently.' His BIMS is 6. Is that an appropriate intervention?" The DON stated, "No." The DON was asked, "There was no intervention to keep him from falling. Should there have been an intervention put in place?" The DON stated, "Yes there should have. Checking him over and over was not going to do any good." The DON was asked, "He fell on [DATE] and the intervention was 'Encourage use of call light. Monitor more closely.' Was there any other intervention put in place?" The DON stated, "The chart doesn't say there was." The DON was asked, "When he fell on [DATE] he broke his hip. Do you think if an intervention had been put in place in November (2012) he might not have fallen again?" The DON stated, "Yes, if they had put something like an alarm or something." The DON was asked, "Was an intervention put in place on 12/14/12?" No, it doesn't appear that the nurses did an intervention." The DON was asked, "Tell me about when he fell on [DATE]?" The DON stated, "The nurse's note says he fell while transferring self from wheelchair to bed without assistance from staff. If he had had an intervention in place it would have decreased the possibility greatly of another fall." The DON was asked, "The intervention documented on the Incident Report for the fall on 12/18/12 was 'Pressure alarms to wheelchair and bed' but your physician's orders [REDACTED]. How will your nurses know it should be on the bed?" The DON stated, "No it doesn't say bed. It should be in the order so it will print out on the MAR (Medication Administration Record)... They need a clarify order for the bed alarm and the chair alarm." n. On 2/22/13 at 2:05 p.m., the DON was asked, "After (Resident #6)'s fall on 12/23/12 there was separation of the fractured hip bone. Is that when he had to have hip surgery." The DON stated, "Yes, he had surgery on 12/24/12 to repair the hip." The DON was asked, "Was any other intervention put into place regarding that fall?" The DON stated, "No." 2. Resident #9 had [DIAGNOSES REDACTED]. The Quarterly MDS with an ARD of 12/26/12 documented the resident was severely impaired for cognitive skills for daily decision making per staff assessment for mental status; required extensive assistance of one person for transfers; was unsteady and only able to stabilize with staff assistance when moving from a seated to standing position and for surface-to-surface transfers; and had two or more falls since admission or prior assessment. a. The Resident Plan of Care dated 1/3/13 documented, "Problem Date: 9/21/12... At risk for fall related injury... Provide environmental adaptations: Call light within reach. Adequate glare free lighting. Area free of clutter. Provide / monitor use of adaptive devices: Wheelchair lock brakes on bed, chair, etc. before transferring. When rising from a lying position, sit on side of bed for a few minutes before transferring / standing... Problem Date: 9/21/12... Resident requires physical restraint (to) protect him / her from harm. Restraint Type: trunk restraint... Restrain per physicians order... Provide safe environment, call light (and) personal items within reach, bed in low position..." b. An Incident Report dated 10/13/12 (untimed) documented, "...Exact location of Incident: Residents Day Room... Description of Incident by Person Involved: Resident getting (up) (without) assist removed lap Buddy. fell to floor... Describe exactly what happened: Why it happened: What causes were. If an injury, stated part of body injured. If property or equipment damaged, describe damage: Resident getting up (without) assist removed lap buddy fell to floor... Was it necessary to notify Physician? Yes... Time of notification 0600 (6:00 a.m.)." There was no new intervention to prevent further falls documented on the report. c. An Incident Report dated 10/15/12 at 1:30 p.m. documented, "...Exact location of Incident: Hallway... Describe exactly what happened: Why it happened: What causes were. If an injury, state part of body injured. If property or equipment damaged, describe damage: Resident took off lap buddy was found in floor in hallway. No injuries noted. MD (medical doctor) notified... Statement of physician: Monitor (times) 72 (hours) for further injuries... Additional Comments: Monitor frequently (and) placed on b&b (bowel and bladder) program." d. An Incident Report dated 10/22/12 at 12:20 p.m. documented, "...Exact location of Incident: 200/ 300 dining room... Description of Incident by Person Involved: Res unable to verbalize what happened... Describe exactly what happened: Why it happened: What causes were. If an injury, state part of body injured. If property or equipment damaged, describe damage: Res. (resident) removed lap buddy and tried to ambulate, res. too unsteady on feet and fell on buttocks in floor. (No) injuries noted." There was no new intervention to prevent further falls documented on the report. e. An Incident Report dated 11/28/12 at 1:10 p.m. documented, "...Exact location of Incident: 2-3 D. R. (dining room)... Description of Incident by Person Involved: Res. Removed lap buddy, began to slide. Slid out of w/c onto floor. (No) redness. (No) swelling. c/o (complained of) 'a little' pain to (left) hip. ROM (range of motion) within normal limits... Describe exactly what happened: Why it happened: What causes were. If an injury, state part of body injured. If property or equipment damaged, describe damage: Pull string alarm didn't go off until res. Was already sliding according to CNA (Certified Nursing Assistant)... Additional Comments: ...2. Shorten pull string alarm string. 3. Monitor for injuries. f. An Incident Report dated 12/2/12 at 5:00 a.m. documented, "...Exact location of Incident: Residents Room... Description of Incident by Person Involved: Trying to get (up) (without) assist. Lost his balance (and) fell on mat... Describe exactly what happened: Why it happened: What causes were. If an injury, state part of body injured. If property or equipment damaged, describe damage: Resident trying to get up (without) assist fell on mat hit (right) ankle small scratch noted... Additional comments: check more often. Make sure alarms in place q (every) shift." g. An incident Report dated 12/25/12 at 3:05 p.m. documented, "...Exact location of Incident: 300 hall / Dayroom... Description of Incident by Person Involved: unclear speech... Describe exactly what happened: Why it happened: What causes were. If an injury, state part of body injured. If property or equipment damaged, describe damage: Removed lap buddy attempted to stand while holding onto w/c. Slid to the floor, (no) redness, bruising or injury noted. (no) c/o pain voiced when asked. Just wanted lap buddy off... Additional Comments: Offer resident snack when he seems agitated - this usually calms him down some." h. An Incident Report dated 1/9/13 at 6:30 p.m. documented, "...Exact location of Incident: Dayroom... Describe exactly what happened: Why it happened: What causes were. If an injury, state part of body injured. If property or equipment damaged, describe damage: Resident removed lap buddy and fell to the floor. Abrasion... Additional Comments: Shorten string on pull string monitor. 7 cm (by) 1 cm red area to back. (No) broken skin." i. An Incident Report dated 2/1/13 at 7:55 p.m. documented, "...Exact location of Incident: 300 Hall... Describe exactly what happened: Why it happened: What causes were. If an injury, state part of body injured. If property or equipment damaged, describe damage: Resident came into hallway holding string pull alarm. Resident fell while walking. Skin tear noted to (left) upper elbow area (with) bruising noted." There was no new fall prevention intervention documented. j. On 2/21/13 at 6:25 p.m., the DON and the ADON were asked, "What the new interventions were for each fall?" The DON stated "We should've tried a positioning device and a different alarm for his chair instead of the clip since he could get that one off." 3. Resident #13 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/29/12 documented the resident was severely impaired in cognitive skills for daily decision making per a staff assessment of mental status; required extensive physical assistance of one person for transfers; and did not walk, required extensive physical assistance of one person for locomotion on the unit, was totally dependent on the physical assistance of one person for locomotion off the unit and was unsteady and only able to stabilize with staff assistance during surface-to-surface transfer. a. An untimed Incident Report dated 6/28/12 documented, "...Time of Incident: 10:00 a.m. ...Exact Location of Incident: 500 dayroom ...Description of Incident by Person Involved: Res unable to voice what happened... Describe exactly what happened: Why it happened: What causes were. If an injury, state part of body injured. If property or equipment damaged, describe damage: Res safety belt was not securely latched. She reached for something in the floor and fell out of w/c. (No) injuries noted... Additional comments: Make sure safety belt is applied correctly." b. An untimed Incident Report dated 9/25/12 documented, "...Resident (up) in w/c in room. Res (resident) fell out of w/c onto floor on to (right) side. Pressure alarm sounded. Res had C/L (call light) in place. Shoes bilat (bilateral) feet in place. Res c/o (right) hip (and) (right) shoulder pain. Bruise to top of hand (and) abrasion to (right) knee... Was person involved seen by a physician? ER (emergency room ) yes..." There was no new fall prevention intervention documented. c. The Fall Risk assessment dated [DATE] documented, "...Total Score - Total score of 10 or above represent high risk ...(total score) 18." d. The Resident Plan of Care dated 12/6/12 documented, "...Resident has ADL (Activities of Daily Living) Self-Care Deficit as evidenced by: Needs assistance with... Transfer... At risk for fall related injury due to she is unaware of personal safety, attempts to get up by self... Provide environmental adaptations..." The Plan of Care contained no documentation of what method of transfer the resident required. e. On 2/19/13 at 3:17 p.m., Certified Nursing Assistant (CNA) #3 and CNA #4 used a gait belt to transfer the resident from a wheelchair to a low bed. During the transfer, the resident's knees were bent beyond a 90 degree angle, the right foot was tangled in the wheelchair foot positioner and the resident was on the toes of her left foot. The resident did not bear any weight on her feet during the transfer. f. On 2/21/13 at 6:20 p.m., the DON and ADON were asked, "How do you determine when a resident needs to move from a gait belt transfer to a mechanical lift?" The DON stated, "When they can't touch the floor or bear weight, then they need to go to the mechanical lift." The DON and ADON were asked if there was a new intervention developed after the resident's fall on 9/25/12. The ADON stated, "I'd have to look at that and get back with you." As of 2/22/13, there was no new information provided. 4. The Immediate Jeopardy was removed and the scope/severity reduced to "H" on 2/22/13 at 4:35 p.m. when the facility implemented the following Plan of Removal: Immediate Intervention 2/22/13 Family staying the night with resident (Resident #6). 2/23/13 7:00 a.m. - Staff checking (and) documenting on resident every 15 min (minutes) for 24 hrs (hours). Beginning 2/24/13 7:00 a.m. - Staff will check (and) document on resident every 30 minutes for 30 days. After 30 days resident will be re-evaluated by DON and determine if further interventions are necessary. 2/22/13 Staff inserviced by DON on above high fall risk resident on new interventions to ensure resident safety. A log will be kept documenting that the resident is being checked on by the above methods. Resident will be checked by ensuring safe environment. DONs or charge RN (Registered Nurse) will check log daily to verify documentation and correct any negative findings immediately. DONs will forward at least monthly to QA (Quality Assurance) Committee to revise policy (and) procedures and schedule additional monitoring or interventions as necessary. When checking on resident, staff will ensure that current interventions are in place. 2/22/13 - Other high fall risk residents identified by I&A (incident and accident) log obtained by ADON. Starting 2/23/13 a new fall risk assessment will be done by nursing staff on all residents in facility. Any resident scoring 10 or above on assessment will be evaluated for interventions and implemented immediately. DONs will report to QA Committee at least monthly to revise policy (and) procedures and schedule additional monitoring or interventions as necessary."

Based on observation, interview and record review, the Nursing Administration failed to ensure fall interventions to prevent further falls and decrease the potential for injury were promptly developed, communicated to staff, consistently implemented, and re-evaluated to determine effectiveness for 3 (Residents #6, #9 and #13) of 4 (Residents #6, #9, #11 and #13) case mix residents at high risks for falls. This failed facility practice resulted in Immediate Jeopardy, which caused or could have caused serious harm, injury, impairment or death to Resident #6, who experienced multiple falls and suffered a [MEDICAL CONDITION] and rib as a result of falls and had the potential to affect 37 residents assessed as being at high risk for falls, according to a list provided by the Director of Nursing (DON) on 2/21/13. The Administrator was informed of the Immediate Jeopardy on 2/22/13 at 3:50 pm. The findings are: 1. The Job Description for the Director of Nursing was received from the Administrator on 2/22/13 at 4:35 p.m. and documented, "...Responsible for: Development and maintenance of nursing service objectives, that will (ensure) patients of supportive, therapeutic and rehabilitative nursing care. Her major functions are planning, organizing, directing and coordinating, nursing policy and procedure manuals... Coordination of nursing services with other patients services. Reviews nursing requirements of each patient admitted and assists attending physician in planning patient's care. Establishes and evaluates both qualitative and quantitative standards of care to patients within the framework of acceptable nursing practice." 2. Resident #6 had [DIAGNOSES REDACTED]. The Significant Change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/2/13 documented the resident scored 6 (0-7 indicates severe cognitive impairment) on the Brief Interview for Mental Status (BIMS); did not walk, was unsteady and only able to stabilize with staff assistance when moving from a seated to standing position and for surface-to-surface transfers; was totally dependent on the physical assistance of 2-plus people for transfers; and had two or more falls since admission or prior assessment. a. An Incident Report documented, "...8/18/12 at (12:15 a.m.) Exact Location of Incident: Resident's Room... Resident getting up without assistance causing him to fall to floor, small abrasion noted to right side back... Additional Comments: Encourage use of call light, check on q (every) hour." b. An Incident Report documented, "...9/26/12 at 8:45 a.m. Exact Location of Incident: Resident Room... Res (resident) found in floor by roommate's trash can. No visible injuries noted... Additional Comments: Enc (encourage) res to call for help to empty trash." c. An Incident Report documented, "...10/18/12 at 0730 (7:30 a.m.) Exact Location of Incident: Room beside closet Res noted standing beside closet and lost balance and slid between wall and w/c (wheelchair) to floor along wall... No visible injury noted. Additional Comments: Staff to monitor res for wants and needs." d. An Incident Report documented, "...10/26/13 at 0200 (2:00 a.m.) Exact Location of Incident: Resident's Room... Resident getting up without assist, lost his balance causing him to fall. .5 x (by) .5 x .1 (centimeter) abrasion to (right) knee. Twisted ankle, ROM (range of motion) WNL (within normal limits)... Additional Comments: Check more often, encourage use of CL (call light)." The intervention documented on the incident report was not specific as to the frequency the resident would be checked. e. An Incident Report documented, "...11/4/12 at 0110 (1:10 a.m.) Exact Location of Incident: Resident's Rm (room)... Resident up to BR (bathroom) without assist, had only socks on, slid to floor. No visible (injuries) noted... Additional Comments: Enc (encourage) use of CL, check on more often." There were no new interventions to prevent further falls documented on the Incident Report and there was no documented frequency the resident would be checked. f. An Incident Report documented, "...11/5/12 at 0655 (6:55 a.m.) Exact Location of Incident: Resident's room... Resident attempting to transfer himself from bed to WC (wheelchair), slipped, fell causing ST (skin tear) to L (left) forearm... Additional Comments: Encourage use of CL, monitor more closely." There were no new interventions to prevent further falls documented on the Incident Report and there was no documented frequency the resident would be checked. g. An Incident Report documented, "...12/14/12 at 2121 (9:21 p.m.)... Resident stood up with walker with house shoes on, lost his balance and fell to floor causing .5 x .5 abrasion. Res. unable to bear weight on (right) leg... Statement of Physician: Send to (hospital) for tx (treatment) and eval (evalution). Additional Comments: Res sent via (Nursing Home) transport." There were no new interventions to prevent further falls documented on the Incident Report. 1) The X-Ray Preliminary Report dated 12/14/12 at 23:08 (11:08 p.m.) documented, "...There is a [MEDICAL CONDITION] greater trochanter. Comminuted. Minimal displacement..." 2) The CT (computed tomography) scan of the right hip dated 12/14/12 at 2327 (11:27 p.m.) documented, "...Reason for Exam: Fall... Impression: 1. Comminuted mildly displaced greater trochanter fracture proximal right femur..." h. An Incident Report documented, "...12/18/12 at 2400 (12:00 a.m.)... Res found in floor beside bed lying on (right) side. C/O (complained of) (right) hip pain. Res not moved by staff. Res states he was transferring self to bed without assistance. EMS (emergency medical service) notified. Res transferred to (emergency room ) via EMS... Additional Comments: Pressure alarms to W/C (wheelchair) and bed." 1) The X-ray Report of the right ribs dated 12/18/12 at 0200 (2:00 a.m.) documented, "...Impression: 1. Right pneumothorax of approximately 15% 2. Probable nondisplaced [MEDICAL CONDITION] seventh rib laterally..." 2) The X-ray Report of the chest dated 12/19/12 at 1026 (10:26 a.m.) documented, "...Impression: Enlarging (now perhaps 20%) right apical pneumothorax..." i. An Incident Report documented, "...12/23/12 at 0120 (1:20 a.m.)... Res stood up in front of nurses' station and immediately fell on to (right) side, landed on prev. (previous) hip fx, (fracture). Notified M.D. (medical doctor). NNO (no new orders). Notified wife, requested that he be sent to ER." There were no new interventions to prevent further falls documented on the Incident Report. 1) The X-Ray Report of the chest dated 12/23/12 at 0245 (2:45 a.m.) documented, "...Impression: 1. No acute abnormality... 2. No right pneumothorax identified at this time..." 2) The X-Ray Report of the Pelvis dated 12/23/12 at 0245 documented, "...Impression: Separation of the fragments at the right proximal femoral fracture..." j. An Incident Report documented, "...2/11/13 at 1715 (5:15 p.m.)... Resident found on floor in bathroom with walker. He stated he 'slipped and fell '. Resident had socks on. Did not wait for help from nursing staff... Additional Comments: Non-skid strips in bathroom and at doorway." k. An Incident Report documented, "...2/16/13 at 7:45 a.m. ...Res attempt to get into bed without assist and fell to floor. No injury noted... Additional Comments: Staff to assist Res with transfers." l. On 2/22/13 at 9:32 a.m., the resident was lying in the bed. There was no pressure alarm in the resident's electric wheelchair seat. Certified Nursing Assistant (CNA) #5 was asked, "Does he have a pressure alarm in his chair?" CNA #5 stated, "Yes, he is supposed to." The CNA was asked, "Is there one on his chair now?" The CNA answered, "No, it may be in the bed with him... He is supposed to have one in bed too." At 9:37 a.m., Licensed Practical Nurse (LPN) #4 was asked to look at the pressure alarm in the bed. The LPN stated, "It's on the bed but it's not hooked up. He doesn't even have an order for [REDACTED]." At 11:55 a.m., LPN #5 was asked, "Have you ever seen (Resident #6) remove his alarm?" LPN #5 answered, "All the time. Sometimes he comes out in the hall and he has it unplugged so it doesn't go off." m. On 2/22/13 at 12:45 p.m., the Director of Nursing (DON) was asked, "Was (Resident #6) a high risk for falls before he came in?" The DON stated, "Yes." The DON was asked, "Do you review the Incident Reports?" The DON stated, "The ADON (Assistant Director of Nursing) does. The DON was asked, "On several of the Incident Reports, the intervention was, 'Encourage the resident to use call light. Check on him frequently.' His BIMS is 6. Is that an appropriate intervention?" The DON stated, "No." The DON was asked, "There was no intervention to keep him from falling. Should there have been an intervention put in place?" The DON stated, "Yes there should have. Checking him over and over was not going to do any good." The DON was asked, "He fell on [DATE] and the intervention was 'Encourage use of call light. Monitor more closely.' Was there any other intervention put in place?" The DON stated, "The chart doesn't say there was." The DON was asked, "When he fell on [DATE] he broke his hip. Do you think if an intervention had been put in place in November (2012) he might not have fallen again?" The DON stated, "Yes, if they had put something like an alarm or something." The DON was asked, "Was an intervention put in place on 12/14/12?" No, it doesn't appear that the nurses did an intervention." The DON was asked, "Tell me about when he fell on [DATE]?" The DON stated, "The nurse's note says he fell while transferring self from wheelchair to bed without assistance from staff. If he had had an intervention in place it would have decreased the possibility greatly of another fall." The DON was asked, "The intervention documented on the Incident Report for the fall on 12/18/12 was 'Pressure alarms to wheelchair and bed' but your physician's orders [REDACTED]. How will your nurses know it should be on the bed?" The DON stated, "No it doesn't say bed. It should be in the order so it will print out on the MAR (Medication Administration Record)... They need a clarify order for the bed alarm and the chair alarm." n. On 2/22/13 at 2:05 p.m., the DON was asked, "After (Resident #6)'s fall on 12/23/12 there was separation of the [MEDICAL CONDITION] bone. Is that when he had to have hip surgery." The DON stated, "Yes, he had surgery on 12/24/12 to repair the hip." The DON was asked, "Was any other intervention put into place regarding that fall?" The DON stated, "No." 3. Resident #9 had [DIAGNOSES REDACTED]. The Quarterly MDS with an ARD of 12/26/12 documented the resident was severely impaired for cognitive skills for daily decision making per staff assessment for mental status; required extensive assistance of one person for transfers; was unsteady and only able to stabilize with staff assistance when moving from a seated to standing position and for surface-to-surface transfers; and had two or more falls since admission or prior assessment. a. The Resident Plan of Care dated 1/3/13 documented, "Problem Date: 9/21/12... At risk for fall related injury... Provide environmental adaptations: Call light within reach. Adequate glare free lighting. Area free of clutter. Provide / monitor use of adaptive devices: Wheelchair lock brakes on bed, chair, etc. before transferring. When rising from a lying position, sit on side of bed for a few minutes before transferring / standing... Problem Date: 9/21/12... Resident requires physical restraint (to) protect him / her from harm. Restraint Type: trunk restraint... Restrain per physicians order... Provide safe environment, call light (and) personal items within reach, bed in low position..." b. An Incident Report dated 10/13/12 (untimed) documented, "...Exact location of Incident: Residents Day Room... Description of Incident by Person Involved: Resident getting (up) (without) assist removed lap Buddy. fell to floor... Describe exactly what happened: Why it happened: What causes were. If an injury, stated part of body injured. If property or equipment damaged, describe damage: Resident getting up (without) assist removed lap buddy fell to floor... Was it necessary to notify Physician? Yes... Time of notification 0600 (6:00 a.m.)." There was no new intervention to prevent further falls documented on the report. c. An Incident Report dated 10/15/12 at 1:30 p.m. documented, "...Exact location of Incident: Hallway... Describe exactly what happened: Why it happened: What causes were. If an injury, state part of body injured. If property or equipment damaged, describe damage: Resident took off lap buddy was found in floor in hallway. No injuries noted. MD (medical doctor) notified... Statement of physician: Monitor (times) 72 (hours) for further injuries... Additional Comments: Monitor frequently (and) placed on b&b (bowel and bladder) program." d. An Incident Report dated 10/22/12 at 12:20 p.m. documented, "...Exact location of Incident: 200/ 300 dining room... Description of Incident by Person Involved: Res unable to verbalize what happened... Describe exactly what happened: Why it happened: What causes were. If an injury, state part of body injured. If property or equipment damaged, describe damage: Res. (resident) removed lap buddy and tried to ambulate, res. too unsteady on feet and fell on buttocks in floor. (No) injuries noted." There was no new intervention to prevent further falls documented on the report. e. An Incident Report dated 11/28/12 at 1:10 p.m. documented, "...Exact location of Incident: 2-3 D. R. (dining room)... Description of Incident by Person Involved: Res. Removed lap buddy, began to slide. Slid out of w/c onto floor. (No) redness. (No) swelling. c/o (complained of) 'a little' pain to (left) hip. ROM (range of motion) within normal limits... Describe exactly what happened: Why it happened: What causes were. If an injury, state part of body injured. If property or equipment damaged, describe damage: Pull string alarm didn't go off until res. Was already sliding according to CNA (Certified Nursing Assistant)... Additional Comments: ...2. Shorten pull string alarm string. 3. Monitor for injuries. f. An Incident Report dated 12/2/12 at 5:00 a.m. documented, "...Exact location of Incident: Residents Room... Description of Incident by Person Involved: Trying to get (up) (without) assist. Lost his balance (and) fell on mat... Describe exactly what happened: Why it happened: What causes were. If an injury, state part of body injured. If property or equipment damaged, describe damage: Resident trying to get up (without) assist fell on mat hit (right) ankle small scratch noted... Additional comments: check more often. Make sure alarms in place q (every) shift." g. An incident Report dated 12/25/12 at 3:05 p.m. documented, "...Exact location of Incident: 300 hall / Dayroom... Description of Incident by Person Involved: unclear speech... Describe exactly what happened: Why it happened: What causes were. If an injury, state part of body injured. If property or equipment damaged, describe damage: Removed lap buddy attempted to stand while holding onto w/c. Slid to the floor, (no) redness, bruising or injury noted. (no) c/o pain voiced when asked. Just wanted lap buddy off... Additional Comments: Offer resident snack when he seems agitated - this usually calms him down some." h. An Incident Report dated 1/9/13 at 6:30 p.m. documented, "...Exact location of Incident: Dayroom... Describe exactly what happened: Why it happened: What causes were. If an injury, state part of body injured. If property or equipment damaged, describe damage: Resident removed lap buddy and fell to the floor. Abrasion... Additional Comments: Shorten string on pull string monitor. 7 cm (by) 1 cm red area to back. (No) broken skin." i. An Incident Report dated 2/1/13 at 7:55 p.m. documented, "...Exact location of Incident: 300 Hall... Describe exactly what happened: Why it happened: What causes were. If an injury, state part of body injured. If property or equipment damaged, describe damage: Resident came into hallway holding string pull alarm. Resident fell while walking. Skin tear noted to (left) upper elbow area (with) bruising noted." There was no new fall prevention intervention documented. j. On 2/21/13 at 6:25 p.m., the DON and the ADON were asked, "What the new interventions were for each fall?" The DON stated "We should've tried a positioning device and a different alarm for his chair instead of the clip since he could get that one off." 4. Resident #13 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/29/12 documented the resident was severely impaired in cognitive skills for daily decision making per a staff assessment of mental status; required extensive physical assistance of one person for transfers; and did not walk, required extensive physical assistance of one person for locomotion on the unit, was totally dependent on the physical assistance of one person for locomotion off the unit and was unsteady and only able to stabilize with staff assistance during surface-to-surface transfer. a. An untimed Incident Report dated 6/28/12 documented, "...Time of Incident: 10:00 a.m. ...Exact Location of Incident: 500 dayroom ...Description of Incident by Person Involved: Res unable to voice what happened... Describe exactly what happened: Why it happened: What causes were. If an injury, state part of body injured. If property or equipment damaged, describe damage: Res safety belt was not securely latched. She reached for something in the floor and fell out of w/c. (No) injuries noted... Additional comments: Make sure safety belt is applied correctly." b. An untimed Incident Report dated 9/25/12 documented, "...Resident (up) in w/c in room. Res (resident) fell out of w/c onto floor on to (right) side. Pressure alarm sounded. Res had C/L (call light) in place. Shoes bilat (bilateral) feet in place. Res c/o (right) hip (and) (right) shoulder pain. Bruise to top of hand (and) abrasion to (right) knee... Was person involved seen by a physician? ER (emergency room ) yes..." There was no new fall prevention intervention documented. c. The Fall Risk assessment dated [DATE] documented, "...Total Score - Total score of 10 or above represent high risk ...(total score) 18." d. The Resident Plan of Care dated 12/6/12 documented, "...Resident has ADL (Activities of Daily Living) Self-Care Deficit as evidenced by: Needs assistance with... Transfer... At risk for fall related injury due to she is unaware of personal safety, attempts to get up by self... Provide environmental adaptations..." e. On 2/21/13 at 6:20 p.m., the DON and ADON were asked if there was a new intervention developed after the resident's fall on 9/25/12. The ADON stated, "I'd have to look at that and get back with you." As of 2/22/13, there was no new information provided. 5. The Immediate Jeopardy was removed and the scope/severity reduced to "H" on 2/22/13 at 4:35 p.m. when the facility implemented the following Plan of Removal: Immediate Intervention 2/22/13 Family staying the night with resident (Resident #6). 2/23/13 7:00 a.m. - Staff checking (and) documenting on resident every 15 min (minutes) for 24 hrs (hours). Beginning 2/24/13 7:00 a.m. - Staff will check (and) document on resident every 30 minutes for 30 days. After 30 days resident will be re-evaluated by DON and determine if further interventions are necessary. 2/22/13 Staff inserviced by DON on above high fall risk resident on new interventions to ensure resident safety. A log will be kept documenting that the resident is being checked on by the above methods. Resident will be checked by ensuring safe environment. DONs or charge RN (Registered Nurse) will check log daily to verify documentation and correct any negative findings immediately. DONs will forward at least monthly to QA (Quality Assurance) Committee to revise policy (and) procedures and schedule additional monitoring or interventions as necessary. When checking on resident, staff will ensure that current interventions are in place. 2/22/13 - Other high fall risk residents identified by I&A (incident and accident) log obtained by ADON. Starting 2/23/13 a new fall risk assessment will be done by nursing staff on all residents in facility. Any resident scoring 10 or above on assessment will be evaluated for interventions and implemented immediately. DONs will report to QA Committee at least monthly to revise policy (and) procedures and schedule additional monitoring or interventions as necessary."

Complaint # substantiated (all or in part) with these findings: Based on observation, record review, and interview, the facility failed to ensure necessary and services were provided to ensure Resident #6 attained or maintained the highest practicable physical well-being, in accordance with the plan of care and physician's orders [REDACTED].#6) case mix resident who had antibiotic inhalation nebulizer treatments ordered. The facility failed to ensure significant changes in the resident's condition were immediately assessed and the physician consulted following an elevation of temperature and decreased urinary output for 1 (Resident #6) of 9 (Residents #1, 2, 6, 7, and 9) case mix residents who required increased monitoring for an unstable condition. These failed practices resulted in a pattern of actual harm to Resident #6 who had not received antibiotic inhalation medication as ordered, experienced an elevated temperature, delay in assessment and notification to the physician that resulted in a readmission hospitalization with treatment that included antibiotic inhalation treatments and measures to stabilize the resident. These failed practices had the potential to cause more than minimal harm for all 15 residents who required increased monitoring for an unstable condition according to a list received from the Director of Nursing (DON) on 8/16/12. The findings are: 1. The facility's policy titled, "Updated Policy & Procedure on Antibiotics November 11, 2010" received on 8/1/12 documented, "...Other Pertinent Documentation:.. Note: Physician must be notified when a medication is not given for several doses/days... Document in the above medical record... Intake and Output Records: a. Must be consistent and accurate. b. Both must be recorded when a resident has a catheter... tube feeding... Example: suspected dehydration, elevated temperature..." The facility's policy titled, "Change In Condition of Resident" received on 8/2/12 documented, "Anytime a resident's condition worsens physically..., the attending physician will be notified... Take V/S (vital signs) B/P (blood pressure), P (pulse), R (respirations), T (temperature)... and call Dr (doctor)... Follow Dr orders... Start certain meds (medications)..." 2. Resident #6 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set with an Assessment Reference Date of 2/24/12 did not document the completion of a Brief Interview for Mental Status or Staff Assessment for Mental Status, the resident was totally dependent on staff for activities of daily living, had an indwelling catheter, active [DIAGNOSES REDACTED]. a. The Resident Plan of Care dated 5/31/12 documented, "Breathing Difficulty Resident has potential for difficulty breathing related to chronic condition:... pneumonia... Monitor for changes in/development of signs & (and) symptoms of breathing difficulty and report... Fever... Administer/monitor effectiveness of treatments (see current physicians orders)... Administer/monitor effectiveness of drugs affecting respiratory status (see current physician's orders [REDACTED]. skin/poor skin turgor Dark urine... Sunken eyes Fever... INFECTION Resident has potential to develop infection related to medical condition, hx (history) of pneumonia, ...Resident will have no signs or symptoms of active infection. Administer medications as ordered (see current MAR & Physician orders) ...Report to physician worsening signs and symptoms of infection or lack of improvement from treatment... Administer medications as ordered (see current MAR & Physician orders)..." b. A hospital Discharge Summary for admitted [DATE] thru 7/3/12 documented, "Discharge Diagnoses... Pseudomonas pneumonia... he was still on abx (antibiotics) with aerosolized TOBI which was recommended to continue every alternate week for next six weeks. ...MEDICATIONS Discharge medications and new prescriptions: Discharge Medication List as of 7/4/12... START taking these medications [MEDICATION NAME] (TOBI) 300 mg (milligrams)/5 mL (milliliters) Inhalation Nebu (nebulizer) Take 5 mL by inhalation every 12 hours for 7 days. Continue 7 days every alternate week for total of 6 weeks per recommendation... Other instructions: ... has been instructed to seek urgent medical care or call PCP (primary care physician) if patient has ANY health care concerns or questions such as fever greater than 101, ...or any other concerns." A sputum culture report dated 6/7/12 documented, "Final Report: Heavy Growth Pseudomonas aeruginosa Multi Drug resistant organism... Culture & Susceptibility [MEDICATION NAME] 2 S (sensitive) ..." c. Physician's Telephone orders dated 7/3/12 documented, "Re-admit to (facility) (with) following orders:... [MEDICATION NAME] 300 mg/5 ml Inhalation nebu take 5 ml by inhalation (every) 12 (hours) X 7 d (days) to start (after) received from pharmacy per t.o. (telephone order) (Physician #1)..." A prescription dated 7/3/12 documented, "[MEDICATION NAME] (TOBI) 300 mg/5 ml: Inhalation Nebu Sig: Take 5 mL by inhalation every 12 hours for 7 days Comment: Continue 7 days every alternate week for total of 6 weeks per recommendation (Physician #2)..." d. A hospital After Visit Summary form in the resident's nursing home clinical record dated 7/3/12 documented, "...Discharge Instructions Current Discharge Medication List START taking these medications [MEDICATION NAME] (TOBI) 300 mg/5 ml Take 5 mL by inhalation every 12 hours for 7 days. Start date: 7/3/12 End date: 7/10/12... Discharge Instructions... SIGNS AND SYMPTOMS TO REPORT Contact your health care provider if you experience any of the following symptoms: increase in ...temperature greater than 101. ...If you experience any of the following symptoms contact your health care provider: increase in ...temperature greater than 101 degrees Fahrenheit..." e. A Nurse's Notes dated 7/3/12 at 5:45 p.m. documented, "Res. (resident) returned... Start following meds... [MEDICATION NAME] 300 mg/5 ml Inhalation nebulizer take 5 ml by inhalation (every) 12 (hours) X 7 (days) to start (after) received from pharmacy..." f. The July 2012 Medication Administration Record documented, "[MEDICATION NAME] 300 mg/5 ml give 5 ml by inhalation Q (every) 12 (hours) X (times) 7 d (days). Hold until received from pharmacy." The times for administration were 8:00 a.m. and 8:00 p.m. There were arrows drawn from the times through 7/3/12 and "Hold" was written down the MAR on 7/4/12. There was no documentation on the MAR that the [MEDICATION NAME] inhalation nebulizer medication was administered from 7/3/12 thru 7/17/12. There was no documentation in Nurses Notes dated from 7/3/12 thru 7/17/12 that the physician was notified that the [MEDICATION NAME] for inhalation nebulizer treatments was not available for administration to the resident. 1) On 8/1/12 at 2:58 p.m., Pharmacist #1 was contacted and asked if an order was received for [MEDICATION NAME] inhalation updraft treatment medication and was the medication filled. The Pharmacist stated, "No, we couldn't because we couldn't get it." The Pharmacist was asked what the status was of the order for the [MEDICATION NAME] inhalant. The Pharmacist stated, "It's on hold. I think we didn't fill it." The Pharmacist was asked if the medication was filled or would be filled. The Pharmacist stated, "No, it hasn't to the best of my knowledge unless [DIAGNOSES REDACTED]. It wasn't filled." The Pharmacist was asked if the physician was notified. The Pharmacist stated, "Don't recall. The facility was called and told the price of $5000.00 cost." 2) On 8/1/12 at 3:50 p.m. LPN #3 stated, "I helped the nurse that admitted him (Resident # 6). I called the pharmacy, he told me that it would be $5,000.00 to fill it because he needed a prior authorization done. I called the doctor and he told me to, "Start after the medication is available." 3) On 8/1/12 at 2:05 p.m. LPN # 1 stated, "I worked with him (Resident #6) a couple of days after he was admitted . LPN #1 was asked if Resident #6 had an order for [REDACTED]. He didn't receive it from the pharmacy. There was a notation on the medication record." LPN # 1 was asked who had ordered the updrafts to be held. LPN #1 stated, "Whoever got him on admit." Between 7/3/12 and re-admit to the hospital (7/17/12) Resident #6 didn't receive the [MEDICATION NAME] Updrafts. LPN #1 was asked if she had asked anyone about the resident not getting the updraft as ordered and LPN #1 stated, "No, I didn't." LPN #1 was asked what was she supposed to do if a medication was not available for administration. LPN #1 stated, "Call the pharmacy and see why it ([MEDICATION NAME] updraft solution) was not received. Call MD (medical doctor) and try to get something different." LPN #1 was asked who was responsible for a medication being available. LPN #1 stated, "The DON (Director of Nurses) or ADON (Assistant Director of Nurses). I would have called by the time I worked down there again. He (Resident # 6) would have completed it (the [MEDICATION NAME] updrafts)." 4) On 8/1/12 at 2:30 p.m. LPN #2 when referred to the resident's MAR and stated, "No, we haven't had the [MEDICATION NAME] updrafts. I was thinking that it was d/c (discontinued). It has been on hold on the MAR for 7/4/12, 7/5/12, 7/9/12, 7/13/12, 7/16/12 and 7/17/12. It ([MEDICATION NAME] updrafts) wasn't available. No, I didn't tell anyone (it wasn't available)." LPN #2 was asked if a medication was not available what was she supposed to do. LPN #2 stated, "If it is on hold, try to figure out why the medication was on hold. I did ask someone that worked down there and they said that we didn't have it and didn't know if we were going to get it." LPN #2 was asked what was she supposed to do if a medication is not given. LPN #2 stated, "Circle the MAR and write on the back of the MAR why it wasn't given. Surveyor asked LPN #2 if she was supposed to contact the doctor. LPN #2 stated, "Yes." 5) On 8/1/12 at 3:30 p.m. Registered Nurse (RN) #1 stated, "The bottom line (is), couldn't get the medication ([MEDICATION NAME] updraft solution from the pharmacy) and the resident didn't get it." g. Nurses Notes dated 7/13/12 at 1:15 a.m. documented, "T -100.1 Ax (axillary)...1:45 a.m. APAP ([MEDICATION NAME]) 325 mg (tabs 2) via peg given D/T (due to) (elevated) temp 100.1 ...3:10 a.m. temp 101.6 ax will cont. (continue) to monitor...6:00 a.m. (elevated) temp 101.8 ax APAP 325 mg (2 tabs) given via peg ..." There was no documentation in the nurses notes that the physician was notified of the elevated temperature unrelieved by medication. h. Nurses Notes dated 7/14/12 at 12:30 p.m. documented a temperature of "100.3... (tabs 2) apap 325 mg given via peg tube..." There was no documentation in the nurses notes that the physician was notified of the elevated temperature." i. Nurses Notes dated 7/15/12 at 12:50 a.m. documented, "Temp 99.5 -that's down from 100.2 ...Suctioned lg (large) amt (amount) of thick mucous from trach..." There was no documentation in the nurses notes that the physician was notified of the elevated temperature and the large amount of thick mucous suctioned from the [MEDICAL CONDITION]. Nurses Notes dated 7/15/12 at 10:00 a.m. documented, "100.3" for the resident's temperature. There was no documentation in the clinical record of an assessment of the resident that included complete vital signs or that the physician was notified of the elevated temperature. j. Nurses Notes dated 7/16/12 at 10:00 a.m. documented, "(Physician #1) here to (change) [DEVICE], (changed) using sterile technique..." There was no documentation in the clinical record that the physician was informed of the resident's elevated temperature or that a large amount of thick mucous was suctioned from the [MEDICAL CONDITION] on 7/15/12. k. Nurses Notes dated 7/17/12 at 1:20 a.m. documented, "T-100.2...APAP (tabs 2) via peg d/t (elevated) temp. ...5:00 a.m. T-101.2 APAP (tabs 2) via peg." There was no documentation in the nurses notes of an assessment of the resident that included complete vital signs, lung sounds, and assessment of hydration status or that the physician was notified that the resident had an elevated temperature. Nurses notes dated 7/17/12 at 11:30 a.m., documented, "LPN (Licensed Practical Nurse) called to room by mom d/t res (resident) breathing funny unable to obtain Sp02 (oxygen saturation rate) UDN (updraft nebulizer) tx admin..." There was no documentation in the nurses notes of an assessment that included complete vital signs and that the physician was notified that the resident had not received the [MEDICATION NAME] inhalation treatments as ordered. l. The July Monthly Intake/Output record for July 2012 did not document any output on 7/6/12 on the 11:00 p.m. - 7:00 a.m. shift; no intake/output on 7/10/12; no intake/output on 7/15/12 on the 11:00 p.m. - 7:00 a.m. shift and 7/16/12 on the 11:00 p.m. - 7:00 a.m. shift, and no output on 7/16/12 on the 7:00 a.m. - 3:00 p.m. shift. The output for the 7/16/12 3:00 p.m. - 11:00 p.m. shift documented 50 cc (cubic centimeters) and 11:00 p.m. - 7:00 a.m. shift documented 150 cc. There was no documentation in the nurses notes or physician's telephone orders that the physician was notified of the decreased urinary output. m. An emergency room Record Physical Exam dated 7/17/12 at 12:05 p.m. documented, "ED (Emergency Department) Medication Administration... 7/17/12 4:00 p.m. sodium chloride 0.9% [MEDICATION NAME] solution 1,000 mL IV (intravenous) [MEDICATION NAME] 7/17/12 4:59 p.m. sodium chloride 0.9% [MEDICATION NAME] solution 500 mL IV [MEDICATION NAME] [DIAGNOSES REDACTED]. ...Pulmonary/Chest: He is in respiratory distress... He has rales... Diagnostics Lab: WBC (white blood count) value 30.8 Range 5.0-14.0... Foley patent from (long term care facility) and draining amber urine. ...Basic Metabolic Panel (Final result) 7/17/12 Na (sodium) 156 K (potassium) 6.4 Cl (chloride) 121... BUN (blood urea nitrogen) (greater than) 112 Creat (creatinine) 5.26 ...Imaging Results XR Chest... Impression: 1. Infiltrate at the right lung base compatible with pneumonia..." Emergency Department notes after the resident was transferred from the local hospital to an area hospital dated 7/17/12 at 6:38 p.m. documented, "...Lungs with rhonchi and coarse crackles bilat. ...Foley cath patent with dark yellow urine... Wife reports pt (patient) has had temp for past two weeks..." Physician notes documented, "Fluid [MEDICATION NAME] ordered for persistent [MEDICAL CONDITION]" n. A History and Physical dated 7/18/12 at 7:02 a.m. documented, "Chief Complaint: Pneumonia and dehydration. History: ...for the past 2 weeks, according to the family, he has been having fever off and on. ...Vital Signs: His vitals on arrival to the (Hospital #2) ER (emergency room ): His blood pressure was 78/30, pulse was 148, temperature was 101.8,... Respiratory: He is on a ventilator. There is crackles and wheezes heard... Skin: Hot and dry. ...Assessment: [MEDICAL CONDITION], pneumonia..." A physician progress notes [REDACTED]. "...For the 13 days he was at (facility) since being discharged from (Hospital #2), he did not receive any of the aerosolized TOBI ordered at discharge. Apparently their Pharmacy could not supply the TOBI Critically Ill, Unresponsive... On [MEDICATION NAME] & dobutamine. ...Physical Exam: General: critically ill ...Pulmonary: Coarse rales bilaterally ...Labs: Results for orders placed during the hospital encounter of 7/17/12 ...Basic Metabolic Panel ...Sodium Value 161 (Range 136-145) Potassium 5.8 (Range 3.5-5.1) Chloride 128 (Range 98-107) BUN 129 (Range 6-20) Creatinine 5.0 (Range 0.6-1.3) ...MRSA ([MEDICAL CONDITION] resistant staph aureus) rapid screen positive... CBC with differential WBC 32.5 (range 4.1-10.5)... Sputum Cultures from 7/3/12: Heavy Growth Pseudomonas aeruginosa... Multidrug resistant. Chest XR: 1. Infiltrate at the right lung base compatible with pneumonia. ...Principal Problem: Shock, septic: Continue vasopressors... RLL (right lower lobe) pneumonia: Last sputum cultures showed MDRO (multidrug resistant organism) Pseudomonas,... add aerosolized TOBI, Change [MEDICATION NAME] to [MEDICATION NAME] Consult Infectious Diseases... Acute on [MEDICAL CONDITION], stage 3: Secondary to dehydration. Dehydration: IV hydration with 0.45% saline. [MEDICAL CONDITION](hypertension): Hold all antihypertensives due to shock. [MEDICAL CONDITION]: Due to dehydration [MEDICAL CONDITION]: due to dehydration... (Resident #6) ...was recently discharged to (nursing home) where he was supposed to have alternating weeks treatment with [MEDICATION NAME]. He was admitted through the ER yesterday with acute resp (respiratory) failure, acute [MEDICAL CONDITION] and septic shock. ...His heart rate is in the 150's. ...Fever 102... Chest: diffusely coarse bs (breath sounds) Heart: tachy... 1. Septic shock: will wean dobutamine to off and use [MEDICATION NAME] and [MEDICATION NAME] if needed. ...I have ordered him a one liter fluid [MEDICATION NAME]. ...Will hydrate... 2. Acute [MEDICAL CONDITION]: I suspect secondary to prerenal causes. Continue fluids and hydrate...4. MDR pseudomonas: I suspect this is the source of [MEDICAL CONDITION]. ...Review of Systems ...Constitutional: Positive for fever and diaphoresis. Respiratory: Positive for cough, sputum production... [DIAGNOSES REDACTED]. [MEDICAL CONDITION] thick secretions present... [MEDICAL CONDITION]/Chest: He is in respiratory distress. He has wheezes. ... [MEDICAL CONDITION]-from [MEDICAL CONDITION] source... Clinical Impression: Dehydration, Acute [MEDICAL CONDITION], RLL pneumonia..." o. On 8/1/12 at 2:05 p.m. LPN #1 was asked if Resident #6 ran any temperature she worked with him. LPN #1 stated, "He did on 7/11/12 it was 100 degrees axillary... he had received Tylenol. I waited, re-checked the temp but I didn't"t document it (that the resident did not have a temperature)" LPN #1 was asked if she notified the MD of the elevated temperature. LPN #1 stated, "He usually ran between 99-100 degrees axillary. If he ran 101 degrees axillary I would first use the prn (as needed) orders, then notify the physician if it didn't go down." LPN #1 was asked if a resident had a temperature does he loose fluids and what was the parameter for temperature elevation. LPN #1 stated, "Yes (to loosing fluids), Tylenol (administration), push fluids, use wet wash cloth, take vital signs and notify the MD. The resident was not on any antibiotic therapy on re-admitted ." LPN #1 was asked what was to be done if a resident had a change of condition? LPN # 1 stated, "Get vital signs and notify the MD." p. On 8/1/12 at 6:20 p.m., RN #1 was asked what the 11:00 p.m.-7:00 a.m. shift nurse told her. RN #1 stated, "I worked 7/13/12. I was told (Resident #6) at 6:00 a.m. had a temp of 101.8 axillary. I thought the Tylenol had brought the temperature down. I didn't question it. I see that it (temperature) went a little bit up on 3-11 (3:00 p.m. - 11:00 p.m.) shift later." RN #1 was asked "When a resident with multiple problems has just been admitted to the facility after 2 months hospitalization , has a temperature elevation, was not on antibiotic coverage, has decreased urinary output should the resident receive closer monitoring, assessment and the physician to notified of symptoms?" RN #1 stated, "Of course, yes." RN #1 was asked if she had contacted the Medical Director regarding the medication not being given. RN #1 stated, "No." q. On 8/1/12 at 3:03 p.m., the DON was asked what the nurses should have done regarding holding the [MEDICATION NAME] Updrafts. The DON stated, "They should have called the doctor and let him know that the meds couldn't be given. I think by Friday they (nurses) should have notified the doctor."

Complaint # was substantiated (all or in part) with these findings: Based on observation, record review and interview, the facility failed to ensure medically-related social services were provided to Resident #3 to ensure he attained or maintained the highest practicable mental and psychosocial well-being. The facility failed to ensure the relocation within the facility of 1 case mix resident (Resident #4) who subjected a second case mix Resident (Resident #3) to verbal abuse for an extended period of time. The failed practice caused a pattern of actual harm for Resident #3, who experienced increased agitation and received antipsychotic drug therapy, and had the potential to cause more than minimal harm to 27 residents who had behaviors as listed by the Administrator on 11/13/12. The findings are: 1. The facility's Policy and Procedure on Behavior Management provided by the Director of Nursing (DON) on 1/12/12 documented, " ...If roommates have a conflict the aggressor should be moved to a different room. This has to be cleared through the Administrator and DON, and all responsible parties are notified. As with any room change these residents should be charted on for 72 hrs or until behaviors are subdued." 2. Resident #3 had [DIAGNOSES REDACTED]. No identified mood indicators were documented. a. A Care Plan dated 1/12/12 documented, "Problem Date: 6/30/2011 Resident has ... Psychosocial Well-being problem ...Approaches ...Give positive reinforcement as initiative/involvement improves/attempts to solve conflicts ..." b. The January 2012 physician's orders [REDACTED]." c. On 1/12/11 at 8:28 a.m., LPN #3 was asked if she had worked the evening shift on 1/4/11 at which time the resident received Haldol 5 mg intramuscular (IM). She said she did work that shift prior. LPN #3 was asked, "How was the 2 residents ' behavior at the time of shift-change when you left at 11:00 p.m.?" The LPN said, "They were ok, no problems, they were both in bed asleep when I left at 11:00 p.m ... I'd guess that someone went into the room, and turned on the light, which makes the roommate (Resident #4) very upset, and the roommate probably began cussing (Resident #3)." LPN #3 was asked, "Have you let the Administrator know of the conflicts between the residents, concerning the roommate (Resident #4) cussing (Resident #3)?" LPN #3 said, "Yes, and I let them know how the roommate gets about the light being turned on." When asked who the aggressor was between the roommates LPN #3 stated, "(Resident #4) is the aggressor." d. A Incident Report (I&A) dated 1/4/12 at 12:15 a.m. and signed by LPN #5 documented, "Resident needed to use restroom, didn't make it, went in the floor, slipped and fell ...Resident fell twice in (one) night, no injury fall (second) time, Resident just set down to the floor ..." No time was documented for the second fall on this Incident Report. 1) A nurses' notes dated 1/4/12 with no time and signed by LPN #5, documented, "Resident (up) to use the restroom, didn't make it, used in the floor, slipped and fell . S/T (skin tear) to (left) forearm (no) c/o (complains of) pain voiced. Fall packet filled out, family notified. 2) A nurses' note with no date or time and signed by LPN #5 documented, "L.E.(late entry), S/T to (left) forearm clean (with) soap and H2O (water), apply OpSite (dressing) and Betadine (every) day." 3) A telephone order dated 1/4/12 documented, "Haldol 5 mg IM d/t (due to) agitation (every) 4 hrs prn." A nurses' note with no date or time and signed by LPN #5 documented, "Late Entry T.O. (telephone order) Haldol 5 mg IM (every) 4 hrs d/t agitation (Physician)." 4) On 1/11/12 at 9:15 p.m., in a telephone interview LPN #5 was asked, "Why Haldol 5 mg IM was administered to the resident?" LPN #5 stated, "The resident wouldn't stay in the bed, he kept getting out of bed, he seemed weak, about to fall when he'd get out of bed and the CNAs (Certified Nurse Aide) told me they were trying to get him to stay in bed and he was becoming aggressive with them, trying to get him to stay in bed." LPN #5 stated, "They (CNAs) kept asking him to stay in bed, but the roommate was egging him on by calling him stupid, crazy, and retarded." LPN #5 was asked, "How was his behavior when your shift began?" And she stated, "When I came on at 11 p.m., he was up, wouldn't stay in bed, and I gave him a Serax 10 mg about 1 a.m. or maybe 12:30 a.m., I don't remember the time." LPN #5 was asked, "When did the resident have his first fall that shift?" She stated, "It was just before the Serax was given, I do not remember, but he got skin tears and a bruise when he fell on his way to the bathroom, and the 2nd fall, he fell out of bed, best I remember." LPN #5 stated, "He still wouldn't stay in bed, so I called the doctor, not sure what time, but I think it was about 4:30a.m., and that's when I gave him the Haldol shot." LPN #5 was asked if the resident had hit anyone. She replied, "He did not hit, he just wouldn't stay in bed." LPN #5 was asked, "What did you do about the roommate name-calling the resident and egging him on frequently?" The LPN stated, "I have told the DON and left the administrator a note about a month ago, that the roommate was calling him names and they moved the roommate, but because he said he wanted to go back, they moved him right back in there. LPN #5 was asked, "Did you notify the Administrator and the DON of this occurrence?" The LPN stated, "I did not." e. On 1/12/12 at 3:20 p.m., the DON was asked for documentation of when the facility made room changes due to conflicts between the roommates (Resident #3 and #4). The DON presented a nurses' note dated 11/8/11 that documented, "11p.m. Res. (Resident #4) noted yelling at roommate, 'You SOB (expletive), you're a bastard, freak, you need to die you retard.' Resident moved to room 406 B for tonight, administration to be notified of behaviors in a.m." The DON was asked, "When were you made aware of this room change and the resident's behaviors?" She said, "The Administrator nor I were notified of it until now, just finding out now, right now, because I was finding those dates for you." The DON was asked, "How long was (Resident #4) in that room (Room number on different hall)?" She stated, "Oh he was moved back to the other room (with Resident #3) by the time we (pointing to the ADON) got here the next morning. We didn't know the incident or the behaviors ever happened." f. A nurses' note dated 1/4/12 for the 7-3 shift documented, "Resident up in wc (wheelchair), extremely drowsy d/t (due to) Haldol IM, constant supervision is required this shift, ST to L FA (forearm) noted- OpSite removed by the resident." g. A Social Summary dated 1/9/12 documented, " ...(Resident) is friendly and cooperative with his caregivers most of the time ...(Resident) has psychosocial well-being problems." The Social Summary did not document any issues between this resident and the roommate. On 1/13/12 at 2:43 p.m., the Social Service Director (SSD) was asked what information she was made aware of concerning the on-going conflict between (Residents #3 & #4)? She said, "Just that they got into an argument." The SSD was asked, "What did you do about the argument?" She said, "I'm just told what's going on, I do a report." The SSD was again asked for information on the argument, she looked in the left-hand drawer of the desk and said, "I didn't do anything on that." The SSD was asked, "What interventions she developed when she was told of them getting into arguments?" She said, "Looks like I didn't do anything on that." After she looked in the computer she said, "I don't know why I didn't, but I didn't do anything." h. On 1/11/12 at 2:10 p.m., the Assistant Director of Nursing (ADON) was asked how staff document resident to resident conflicts, and is it done on I&A reports. The ADON stated, "Sometimes they do, but it depends on what the issue is." The ADON also stated, "If it is roommate issues, we look at separating the residents, maybe changing rooms." No I&A report documented the resident to resident conflicts on 11/8/11 or 1/4/12. i. On 1/12/11 at 2:24 p.m., the DON was asked, "Have you been informed of (Resident #4) calling (Resident #3) names such as: stupid, crazy, and retarded. The DON stated, "(LPN #3) told me over a month ago. I knew (Resident #4) was being ornery with (Resident #3) at times, but I don't remember being told of that recently." The DON stated, "We'll move (Resident #4) out now, and to another room." j. On 1/12/12 at 2:41 p.m., the Administrator was asked about the two male residents' conflicts. The Administrator said, "I remember them going at it from time to time." The Administrator was asked, "When were you made aware of it?" He stated, "I don't remember." The Administrator was asked, "Why wasn't (Resident #4) moved to another room?" The Administrator said, "Because I don't have an empty room to move him, it's the same now as it was then, I don't have anywhere to move him." The resident was moved to a room on the 500 hall that evening (1/12/12). k. As of 1/12/12, the resident's care plan dated 1/12/12 was reviewed, and there was no documentation of the 11/8/11 or 1/4/12 resident to resident behaviors or incidents. 3. Resident #4 had a [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an Assessment Reference date of 11/24/11 documented the resident scored 6 (0-7 indicates severe impairment) on the Brief Interview for Mental Status (BIMS), and required minimal assistance with ADLs and no mood indicators or behaviors were identified. a. The Care Plan dated 12/1/11 did not document any behaviors. b. A Nurses' note dated 11/8/11 documented, "11p.m. Res.(resident) noted yelling at roommate (Resident #3) ,'You SOB,' 'You're a bastard, freak.' 'You need to die you retard.' Resident moved to room 406 B for tonight, administration to be notified of behaviors in a.m." c. A Nurses' note dated 12/27/11 and signed by LPN #5 documented, "Resident having words (with) roommate (Resident #3), call him stupid, crazy, and saying anything to upset his roommate. Resident was asked to stop calling names, he said he would do or say whatever he wanted to. Roommate was very upset and agitated. d. The January 2012 "LPN Flow Sheet" for Behavior documented with all initialed boxes that the resident was calm with no behaviors. e. The January 2012 MAR did not document the resident received any PRN medications for treatment of [REDACTED]. f. On 1/9/12 at 5:28 p.m., LPN #6 reported on initial rounds that the resident has behaviors of making up stuff, and cussing his roommate.