Every finding on record at Rector Nursing and Rehab

Based on observation, interview, and record review, it was determined the facility failed to ensure transport staff correctly secured a resident in a wheelchair according to the manufacturer's instructions and was properly trained with return demonstration on the use of the van's safety restraints prior to securing and transporting 1 (Resident #1) resident in a wheelchair to prevent serious injury for 1 resident who was transported on the facility van. The lack of effective training for the transport driver resulted in Resident #1 falling backward in a wheelchair during transport and being positioned in the wheelchair in a manner that had the likelihood to affect Resident #1's ability to breathe. It was determined the facility's non-compliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) was related to the State Operations Manual, Appendix PP, S483.25 (Quality of Care) at a scope and severity of J. The IJ began on [DATE] at 1:30 PM when Certified Nurse Aide (CNA) #1 put Resident #1 on the facility transport van to take to a doctor appointment approximately 40 miles away without proper training. The Administrator and the Registered Nurse Consultant (RNC) were notified of the Past Non-Compliance (PNC) Immediate Jeopardy (IJ) on [DATE] at 3:51 PM. A corrected IJ Template was requested by the NC and resubmitted at 5:51 PM. The facility was found to be in Compliance on [DATE] at 3:00 PM when the facility's Plan of Correction (POC) was confirmed complete by the State Survey Agency. The findings include: A review of an Admission Record indicated the facility admitted Resident #1 with diagnoses of type 2 diabetes mellitus (a condition where the pancreas doesn't make enough insulin), congestive heart failure (a chronic condition in which the heart doesn't pump blood as well as it should), atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow), chronic obstructive pulmonary disease (COPD-a lung disease that blocks airflow and makes it difficult to breathe) and chronic kidney disease (a progressive loss of kidney function). The Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] indicated Resident #1 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact, and had functional impairment of lower extremities requiring the use of a walker for short distance and a wheelchair for long distance mobility. Review of Resident #1's Care Plan, initiated [DATE], revealed the resident's code status was Do Not Resuscitate (DNR). Review of Resident #1's Care Plan, initiated [DATE], revealed the resident had emphysema/COPD related to smoking in the past, interventions included monitor for difficulty breathing (dyspnea) on exertion and to remind the resident not to push beyond endurance. Review of Resident #1's Care Plan, initiated [DATE], revealed the resident had limited physical mobility related to legs giving way, and was able to ambulate for short distances or propel by wheelchair by self. Review of Resident #1's Care Plan, initiated [DATE], revealed the resident had oxygen therapy related to a respiratory illness, interventions included oxygen via nasal cannula (nasal prongs) at 2 l/min (liters per minute) as needed (PRN). A review of a Incident Narrative # PFD2500497 from (911 provider) revealed the call was received on [DATE] at 2:18:04 PM, where Certified Nurse Aide (CNA) #1 reported she was on the side of the road across from (business name). Resident #1's wheelchair had slipped backwards, and the resident wasn't breathing. CNA #1 said she couldn't get the wheelchair out from underneath the resident. She hit a bump, and the wheelchair flipped backwards. The resident had too many clothes on, and she couldn't tell if Resident #1's chest was going up and down, but there was no way she could do Cardiopulmonary Resuscitation (CPR) but could see Resident #1's eyes twitching. At 2:22 PM (city name) Fire Department (PFD) arrived on scene and at 2:24 PM CPR was initiated. The dispatch call disconnected at 2:31 PM. A review of a Incident Narrative #,d+[DATE] from PFD dated [DATE] at 2:19 PM revealed PFD was dispatched to a call where the patient had fallen and was no longer responsive. PFD arrived on scene at a transit van parked on the side of the highway. PFD was approached by the driver of the van who alerted PFD the patient was not breathing and was inside at the back of the van. When PFD entered the van, the patient was in a wheelchair which had fallen backwards, pinning the patient between the wheelchair and the wheelchair lift on their back. PFD then sat the wheelchair in the upright position while checking for responsiveness of the patient. When the wheelchair was sitting upright PFD observed that the patient was unresponsive and not breathing. PFD then moved the patient from the chair and onto the floor of the van and began CPR. PFD continued rotations of CPR while also giving breaths through a BVM (Bag-Valve-Mask). When EMS (Emergency Medical Service) arrived, PFD and EMS removed the patient from the van onto the stretcher and continued CPR. EMS and PFD loaded the patient into the ambulance for further treatment. PFD entered the ambulance to help with continuing CPR and other treatment. When EMS was ready to transport, firefighter (PFD #7)) drove the ambulance while firefighter (PFD #4) followed in Unit L-1. When all units arrived on scene at (named hospital), PFD assisted with unloading the patient from the ambulance and taking them into the hospital. PFD continued CPR until EMS and hospital staff advised PFD they were no longer needed. PFD cleared the scene and returned to service. A review of a Incident Statement from (city name) Police Department (PPD) revealed at approximately 2:19 PM on February 10, 2025, Lieutenant PPD #5 responded to an unconscious person, later identified as (Resident #1), at the intersection of (street name) and (street name). Once on scene, PPD #5 contacted Certified Nurse Aide (CNA) #1, who said she worked for a nursing home in (city named) where Resident #1 stays. CNA #1 stated she was transporting the resident to (city approximately 40 miles from the nursing home) for a doctor ' s appointment. CNA #1 stated she looked back and the resident had fallen back in the wheelchair and was stuck. CNA #1 stated she then pulled over and realized that she couldn ' t pick resident up and called emergency services. At the time of speaking with CNA #1, the resident was in the ambulance receiving CPR. PPD #5 escorted the ambulance to (hospital name). A review of a Incident Statement from PPD revealed that on [DATE] Lieutenant PPD #6 was dispatched to the area of (address given) in reference to a person unconscious. Upon arrival, the unconscious person later identified as Resident #1 was in the back of an EMS ambulance being given CPR. A (facility name) van was on scene. PPD #6 advised driver CNA #1 go to the PPD and speak with detectives, and provided CNA #1 with directions on how to get to the PD. Upon arrival to (hospital named), Fire and EMS staff stated when they arrived on scene, Resident #1 had been folded inside the van and ramp. Fire and EMS staff stated when they arrived Resident #1 was unresponsive, and they began CPR shortly after arrival. While at the ER (emergency room ), Resident #1 coded (When a patient is described as having coded, this generally refers to cardiac arrest) and nursing staff were able to resuscitate the resident to allow the family to arrive and tell the ER staff that Resident #1 had a DNR (Do Not Resuscitate). Shortly after Resident #1 coded and was brought back, a Detective from the Criminal Division arrived on scene. A review of a Criminal Investigation Note Case Note - 25-F-123 dated [DATE] at 2:44 PM, revealed PPD Officers contacted a Detective from Criminal Division regarding a (named facility) patient, later known as Resident #1, that was being transported to a doctor's appointment in (named a city approximately 40 miles from the facility). Officers explained that during the transport, Resident #1 had fallen over and was unconscious. Officers stated that EMS was on scene and currently providing lifesaving aid. Officers stated that they will be escorting an ambulance through town going to (named hospital) for additional medical services. The driver of van, (CNA #1), was interviewed at the police department, located at (address). The interview was conducted by Detective (name). CNA #1 stated she works at (named facility). She was taking Resident #1 to a scheduled doctor's appointment. CNA #1 said she had been an employee with the nursing home for about six years and was familiar with the resident. CNA #1 said she loaded Resident #1 in the van around l:30 pm. CNA #1 said it took about 10 minutes to get resident in the van and strapped down inside the van. CNA #1 said they left the nursing home in (named city of facility) around l:40 pm. CNA #1 said they were talking and at some point, Resident #1 stopped talking. CNA #1 said that when she came up to the (name of High School), she noticed that Resident #1 had fallen backwards. CNA #1 said the resident never said anything about any of the buckles or straps coming loose during transport. CNA #1 said when she realized Resident #1 had fallen, she immediately pulled over and attempted to pick resident up. CNA #1 said she was not able to get resident up and called 911. CNA #1 said that she doesn't know what happened or how Resident #1 fell . CNA #1 said she doesn't know if she may have hit a bump just right or what. CNA #1 said that Resident #1 was talking and told her I can't breathe and then suddenly passed out. When she couldn ' t get the resident up, she called for help. CNA #1 said EMS arrived and immediately began performing CPR. CNA #1 said she has transported patients on several occasions and nothing like this has ever happened. Following the interview, photographs were taken of the transport van along with a demonstration from CNA #1 explaining how the straps were used during the transport. After strapping the wheelchair down, it was apparent that the wheelchair was still able to be pushed backwards. The video from (intersection identified) was reviewed and downloaded into the case file. After reviewing all evidence in this case, probable cause for an arrest was not established and no criminal charges will be filed. A review of a Progress Note Type: Nursing Incident & Accident (I & A) dated [DATE] at 7:33 PM revealed the Administrator received a call from the transport CNA #1 that resident had tilted back in the wheelchair. CNA #1 reported she heard Resident #1 say I flipped so she pulled over and went back to the resident to assist with no luck sitting resident back upright, so CNA #1 then called for an ambulance. A review of a facility incident report dated [DATE] at 2:15 PM indicated the Administrator received a phone notification from the van driver (CNA #1) approximately 2:30 PM that she had to pull over and call 911 for a resident in transport who tilted backward in a wheelchair. The Findings and Actions Taken: During transport the resident tilted back in a chair and notified the driver (CNA #1). Van driver (CNA #1) immediately pulled over to a safe place and climbed to the back of van to assist. When the van driver (CNA #1) found she could not assist Resident #1 back to upright position, she called 911 at approximately 2:17 pm. Resident #1 stated they could not breathe and then went unconscious. First on scene was the fire department at which time they entered the van and were able to assist Resident #1 to the floor on the van and initiate CPR. EMS arrived shortly after and was able to take resident through the back of van on stretcher and into ambulance to be transported to (named hospital) for treatment. The report indicated CNA #1 performed a demonstration of securing the wheelchair for the officer, and the straps securing the wheelchair were loose and allowed the wheelchair to be moved backwards without force. It was noted CNA #1 did not tighten the strap using a black knob designed to be used to remove slack from the securement straps. It was indicated this failure to properly tighten the straps allowed Resident #1's wheelchair to move to the tilted position. A review of a Coroner Report Investigation Summary dated [DATE] at 11:39 pm indicated Resident #1 was brought in from (named nursing home). According to (named hospital) clinical notes, Resident #1 arrived by EMS due to patient collapsing. The decedent was examined. There appeared to be a contusion on the upper part of the chest, but no other apparent trauma. The suspected cause of death was indicated to be cardiac. A review of Witness Statement with a date of [DATE] revealed Certified Nurse Aide (CNA) #1 loaded Resident #1 in the facility van to transport to doctor appointment. She had never taken this resident in the van, so it took her about 10 minutes to strap all 4 straps and hook the seat belt. She started with the back strap and tightened it and proceeded to the rest of the straps. After strapping them down, she pushed the button to make sure the straps were fastened. CNA #1 then went behind the wheelchair and shook it from side to side to make sure it was secure. She proceeded to get in and drive the van. CNA #1 and Resident #1 were talking during the transport and the next thing she knew she heard Resident #1 say they had flipped. CNA #1 said the resident was actually tilted back with Resident #1's head against the lift gate. Resident #1's feet were off the floor and all the straps were still fastened. She was trying to get the resident and chair up but was unable to, so she called 911 at 2:17 pm. CNA #1 said 911 wanted her to start CPR but she was unable to with the position the resident was in and being by herself. When the PFD arrived, CNA #1 got out of the van and opened the back doors to let the lift gate down. PFD got Resident #1 to the floor and the wheelchair out of the van by unstrapping the rest of the straps. On [DATE] at 1:30 PM, Transport CNA #2 and Transport CNA #3 demonstrated loading, unloading, and securing of a resident in a wheelchair. During the demonstration, it was determined when the wheelchair wheels were locked, the 4 tie-down straps were attached to the wheelchair (2 on the front and 2 on the back) and the tension of the straps manually tightened by a black tension retractor knob, no movement of the wheelchair would occur. On [DATE] at 08:30 AM, the Administrator and Maintenance Director demonstrated the black tension retractor knob on the floor anchors had dual action with two steps to be completed. First, push the button to remove the slack in the tie-down straps then turn the black tension retractor knob to remove all the slack. A review of the manufacture User Instructions QRT-1 Series Q ' Straint indicated to secure a wheelchair: 1. Place w/c facing forward in securement area; apply wheel locks or turn power off. 2. Attach tie-down into floor anchorages (fig 1) and ensure they are locked in. 3. Attach the four tie-down hooks to solid frame members or weldments, near seat level. Ensure tie-downs are fixed at approximately 45 degrees and are within angles shown in (Fig 2). Do not attach to wheels, plastic or removable parts of wheelchair. 4. Ensure all tie-downs are locked and properly tensioned. If necessary, rock wheelchair back and forth or manually tension retractor knobs (if present) to take up additional webbing slack. To secure a passenger, the lab belts and shoulder blet were secured and adjusted as firmly as possible, but consistent with user comfort. A review of manufacture Sure-Lok Installation/Operation Instructions for L Track Applications of Retraktors with S-hooks indicated to 1) center wheelchair in a forward-facing position between the front and rear retractors. Push the rear retractor release lever and pull out the webbing. Release the lever and place the S-hook securely around the structural member of the chair. Pull on the S-hook to ensure full engagement around the structural member. Push the release lever until the loose webbing is retrieved into the retractor. Repeat procedure with the other rear retractor. 2) Push the front retractor release lever and pull out the webbing. Release the lever and place the S-hook securely around the structural member of the chair. Pull on the S-hook to ensure full engagement around the structural member. Push the release lever until the loose webbing is retrieved into the retractor. Repeat procedure with the other front retractor and 3) Tension the retractors by turning the tensioning handles until the straps are tight. During a telephone interview on [DATE] at 3:06 PM, Certified Nurse Aide (CNA) #1 said she pushed Resident #1 to the van and put wheelchair on the lift then lifted to go inside van. CNA #1 said she started with the back two straps, used the hook to attach to the wheelchair, then proceeded to the front two straps at the front of the chair. She pushed the button on the straps to make sure it was tight, then put the shoulder seat belt and the belt across Resident #1's stomach. CNA #1 said she then shook the wheelchair left to right to make sure it was secure. After Resident #1 was secure, she noted that it was 1:40 PM when they actually left the facility. CNA #1 said she was driving along and occasionally looking in the rearview mirror at Resident #1 while they were talking. When she got close to (name of school), Resident #1 quit talking so she looked back at the resident. Resident #1 said I fell back. CNA #1 said she pulled over and went through the van to the resident. Resident #1 told CNA #1, I'm having trouble breathing. She said she couldn't lift the wheelchair back up, Resident #1 was too heavy for her to lift. CNA #1 said she immediately called 911 for help. The 911 dispatch advised her to do CPR, but she said she couldn't, due to the position Resident #1 was in. The (city name) Fire Department (PFD) showed up and got Resident #1 out of the wheelchair and on the floor on the van and then started CPR. EMS showed up and took over CPR until they could transfer Resident #1 to the hospital. When EMS got there, CNA #1 called the Administrator and told her what happened. CNA #1 said police wanted her to tell them what happened, so she gave a witness statement before driving back to the facility. CNA #1 said she was not the regular driver; she was doing it as a favor because regular transport CNA #2 had a doctor appointment and CNA #3 had a family emergency. She confirmed she worked at the facility for almost 6 years and had taken residents to appointments a couple of times, but the residents she had transported could walk on the van and seatbelt themselves in. She had never taken a resident that required securing of a wheelchair. CNA #1 confirmed she had never been trained to transport a resident in a wheelchair; she was shown once how to do it, but she never had signed off on a check list or been formally trained. A review of Van Transport Log dated [DATE] - [DATE] was reviewed. CNA #1 was recorded on 2 different occasions; [DATE] driving the van to take blood to the hospital and on [DATE] taking Resident #1 to doctor appointment. During an interview on [DATE] at 1:40 PM, the surveyor requested training verification of CNA #1 for van transport and usage of floor anchors. The Administrator was unable to provide any training on transporting for CNA #1. During an interview on [DATE] at 2:00 PM, Certified Nurse Aid (CNA)/Transport #3 said that she had worked at facility as a transporter off and on for about 9 years. She had received training on the job before the incident on [DATE] and after the incident, she had watched videos with return demonstration check off with CNA/transport #2 and the Maintenance Director. She said she thought the Administrator was responsible for ensuring the transporters had completed the training and was getting training every 6 months. During an interview of [DATE] at 3:30 PM, CNA/Transport #2 said she had worked at facility for 2 years. She had on the job training before the incident on [DATE] and training through Mobility works, with a check-off demonstration of their knowledge. CNA/Transport #2 said after the incident they watched 2 online videos and then did the teach back demonstration. She said that she and the Maintenance Director complete the training with Mobility Works, then come back and train CNA/Transport #3 every 6 months. During an interview on [DATE] at 3:49 PM, the Administrator confirmed that she will ensure training/re-training is received for all transport staff every six months. In addition, CNA/Tranasport #2 will retain records to show the training and demonstration/teach back forms. Review of a facility policy titled, Motor Vehicles revised [DATE] indicated 3. If driving the facility van, the employee must be trained on proper procedure and van usage. Prior to the surveyor entering the facility, the following corrective actions were performed by the facility and verified to be completed: 1. All staff members who will be driving the facility van will have a valid driver's license and an approved driving record - Human Resources will obtain a copy of staff members' driver's license. Completed [DATE] 2. All staff members who will be driving the facility van will have a valid driver's license and an approved driving record - A check of the employees' driving record will be logged by human resources. Completed [DATE] 3. All staff members who will be driving the facility van or assisting during transport will be trained per manufactures guidelines/operator training videos and facility checklist. This will include instructions on lift operation and use of a sure-lock restraint system - Maintenance / Designee will ensure that all staff members who will be transporting or assisting with transport are trained. Staff members will demonstrate competency of education with the return demonstration prior to driving/transporting. This will be completed initially and then biannually & PRN for continued demonstration of competency. Started [DATE] and completed [DATE] 4. All staff members who will be driving the facility van or assisting during transport will be trained per manufactures guidelines/operator training videos and facility checklist. This will include instructions on lift operation and use of a sure-lock restraint system - All staff members who participate in transportation will watch the training videos initially prior to driving/transport and then bi-annually for continuing education. Started [DATE] and completed [DATE] 5. All staff members who will be driving the facility van or assisting during transport will be trained per manufactures guidelines/operator training videos and facility checklist. This will include instructions on lift operation and use of a sure-lock restraint system - Training will focus on ensuring sure-lock restraint system is used properly. Started [DATE] and completed [DATE] 6. The facility will maintain employee competency check offs for van drivers. The facility will maintain a current list of employees who have been trained to drive the facility van and to assist with transportation. Completed [DATE] 7. The facility will maintain a current list of employees who have been trained to drive the facility van and to assist with transportation - The maintenance/designee will give all competency check offs and employee training to human resources as Proof of training and competence. Completed [DATE] 8. The facility will maintain a current list of employees who have been trained to drive the facility van and to assist with transportation - Human resources will keep a current list of all trained transport aides and assistants. Completed [DATE] 9. The facility will maintain a current list of employees who have been trained to drive the facility van and to assist with transportation - Human resources will provide the Director of Nursing and Assistant Director of Nursing with a current list of trained staff members. Completed [DATE] 10. The facility will maintain a current list of employees who have been trained to drive the facility van and to assist with transportation - The Director of Nursing and/or Assistant Director of Nursing will only assign those staff members who have been trained and demonstrate competence with the facility process to participate in transportation. Completed [DATE] 11. Pre-transport inspection - The transportation aide will perform a pre-transport documented inspection confirmed daily, prior to transport, per facility checklist, prior to first transport. Completed [DATE] current and ongoing per van schedule. 12. Pre-transport inspection - The inspection check list will be signed after completion of the inspection daily and given to the administrator to maintain. Completed [DATE] 13. Maintenance inspection of facility van - Maintenance will perform an inspection of the facility van for safety and proper functioning of all equipment weekly and PRN. Completed [DATE] and ongoing weekly. 14. Maintenance inspection of facility van - Maintenance will keep records of the inspections, and any negative findings will be reported to the administrator and addressed before the van is placed back in use. Completed [DATE] and up to date. 15. Incidents/Accidents - All incidents/accidents will immediately be reported to the Administrator and Director of Nursing. Completed [DATE] 16. Incidents/Accidents will be investigated, and an incident report completed. A Red Alert will be sent to the risk management team. Completed [DATE] 17. Monitoring - Every transport from the facility will be monitored by a second trained staff member for accuracy weekly for 4 weeks. Completed upon return from (van company name) clearance inspection with no negative findings. 18. Monitoring - A second trained individual will monitor weekly for 2 weeks. 19. Monitoring - The above plan will be presented to the QAA committee monthly, and any negative finding. 20. Follow up - Any transport driver found that not following the appropriate transport policies will be immediately taken off transportation duty and disciplined up to and including termination. Completed [DATE] 21. Suspension of Van - Van was taken out of commission until it could be checked by (van company name) and cleared for use. Completed [DATE] 22. Employee Suspension - Employee involved in incident was suspended pending investigation. Completed [DATE] 23. Van inspection by life Safety Consultant - Life Safety inspected van and reviewed/observed required trainings per facility protocol with facility trainer. Completed [DATE] 24. Life Safety checked off for [NAME] - Life Safety completed all required checkoffs with van drivers on proper positioning when strapping down wheelchair to ensure safety, with return demonstration. Completed [DATE] 25. New tools to be initiated - Visual cues to be placed on transport w/c (in red) and any personal w/c used for transport, to indicate placement for hooks on the straps. Completed [DATE] 26. New tools to be initiated - Visual step by step instructions be placed on back of headrest of bench seat for transport driver. Completed [DATE]

Based on observation, record review, and interview, the facility failed to ensure all residents who were seated at the same table were fed at the same time to promote resident dignity for 3 (Residents #7, #14, and #27) of 3 sampled residents. The findings are: 1. A review of the Order Summary revealed Resident #7 had diagnoses of Alzheimer disease, and cognitive communication deficit. A review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/03/2024 revealed Resident #7 scored a 3 (severe cognitive impairment) on a Brief Interview for Mental Status (BIMS). A review of the Care Plan revealed Resident #7 was able to feed self after set up. 2. A review of the Order Summary revealed Resident #14 had diagnoses of stroke, aphasia, and hemiplegia and hemiparesis affecting the right dominant side. A review of the Quarterly MDS with an ARD of 05/20/2024 revealed Resident #14 scored a 7 (severe cognitive impairment) on a BIMS. A review of the Care Plan revealed Resident #14 required extensive assistance of one person and can hold and eat fingers foods. 3. A review of the Order Summary revealed Resident #27 had diagnoses of dementia, cognitive communication deficit, and dysphagia. A review of the Quarterly MDS with an ARD of 05/23/2024 revealed Resident #27 had a Staff Assessment for Mental Status (SAMS) performed which revealed the resident's cognitive skills for daily decision making were severely impaired. A review of the Care Plan revealed Resident #27 was able to hold finger foods and needed assistance with the rest of meal. On 06/11/2024 at 12:20 PM, the Surveyor observed the residents were seated around the assist table. A staff member was assisting Resident #14 at the end of the table, to the left was Resident #7 and to the right was Resident #27. The Surveyor observed Resident #7 and Resident #27 kept looking over at Resident #14's lunch tray. The Surveyor observed Resident #14 was being assisted with chocolate ice cream and chocolate milk. On 06/11/2024 at 12:25 PM, during an interview, Certified Nursing Assistant (CNA) #1 stated that this is where the residents usually sits at, and now that I think about it, they should be seated at a different table. CNA #1 then stated that if these residents are hungry, they are watching this resident eat and they do not have any. CNA #1 stated that I would feel terrible absolutely terrible. On 06/12/2024 at 11:24 AM, during an interview with the Administrator, she stated that the whole table is to be served on a normal day to day basis. Yesterday, Resident #14 had an appointment and had to be fed early. The Administrator then stated that this could be a dignity issue when eating in front of another resident. A review of the policy Dignity stated, Policy Statement: Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem .

Based on observation, record review and interview, the facility failed to ensure interventions were utilized to prevent worsening of contractures in 1 of 1 sampled resident (Resident #14). The findings are: a. A review of the Order Summary revealed Resident #14 had diagnoses of stroke, aphasia (a language disorder that affects how you communicate), and hemiplegia and hemiparesis (complete paralysis and partial muscle weakness) affecting the right dominant side. b. A review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date of 05/20/2024 revealed Resident #14 scored a 7 (severe cognitive impairment) on the Brief Interview of Mental Status (BIMS). A review of Section GG reveals Resident #14 has limited range of motion impairment on one side for upper and lower extremity. c. A review of Resident #14's Care Plan revealed: Focus: The resident has an ADL [activities of daily living] self-care performance deficit R/T [related to] muscle weakness, abnormal gait, vision and CVA [Cerebral Vascular Accident (stroke)] . Goal: The resident will maintain current level of function in in ADLs through the review date . Intervention: NURSING hand rolls in bilateral hands. d. A review of Resident #14's Care Plan revealed: Focus: Weakness and Right-Hand Contracture, Goal: to muscle weakness, Interventions: resident to have hand splint on while up. e. On 06/10/2024 at 11:30 AM, the Surveyor observed Resident #14 to be up in the dayroom next to the nurse's station. The right hand was contracted into a closed fist with no interventions in place. f. On 06/10/2024 at 1:30 PM, the Surveyor observed Resident #14 to have no interventions in the right hand. The right hand was still closed like a fist. g. On 06/11/2024 at 12:20 PM, the Surveyor observed Resident #14 eating lunch in the dining room. No interventions were in the right hand. The right hand was still closed like a fist. h. On 06/12/2024 at 9:30 AM, the Surveyor observed Resident #14 being pushed to their room, no interventions were in the resident's right hand. The right hand was still closed like a fist. i. On 06/12/2024 at 9:40 AM, during an interview Certified Nursing Assistant #1 (CNA) stated that she is familiar with Resident #14's care, usually I float the building. CNA #1 then stated Resident #14 had interventions, but they are lost and have not been able to find them to use as normal. CNA #1 stated she did not know how long the interventions had been lost. CNA #1 stated they usually use a hand roll, but they could have used wash clothes as well. CNA #1 stated the contracture could worsen, if not cleansed properly and could become red and irritated. j. On 06/12/2024 at 11:04 AM, during an interview Certified Occupational Therapist Assistant (COTA) #3 stated the restorative aide left recently, and I was not informed about the missing hand roll. Then stated they had got that at another facility for the resident as it pumps up to slowly expand the contracture, as the resident's contracture was so difficult to start with. k. On 06/12/2024 at 2:05 PM, during an interview Licensed Practical Nurse (LPN) #2 stated the resident was supposed to have a hand roll in place for the contracted hand. LPN #2 then stated without an intervention the contracture will not correct itself, and it will not have the inability to stretch, not allowing staff to perform nail care. Then LPN #2 stated this can cause redness, wounds, and infections if it was not properly cleansed or taken care of. l. A review of the policy Restorative Nursing Services stated, .5. Restorative goals may include but are not limited to supporting and assisting the resident in: a. Adjusting or adapting to changing abilities; b. developing, maintaining, or strengthening his/her physiological and psychological resources .

Based on observation, interview, and policy review, the facility failed to ensure controlled medications were stored in a locked and permanently affixed box in the medication refrigerator. The findings are: 1. On 6/12/2024 at 9:30 AM, during observation of the medication storage room, the Director of Nurses (DON) was showing locked boxes of controlled medications in a mini fridge inside of Medication Storage room [ROOM NUMBER]. There was a larger black box, which had a lock on it and was affixed to a refrigerator shelf. There was a smaller black box, which was also locked, but the DON was able to pick it up off the shelf. The DON said, I don't think I have a key to this one. The DON and the Surveyor stepped outside of the storage room, while the DON went and got the key to unlock the small black box. The DON returned with the key and unlocked the smaller black box. It contained liquid Ativan (Lorazepam). The DON said, I believe that should be affixed to the refrigerator shelf. a. On 06/12/2024 at 3:04 PM, a policy on Medication Labeling and Storage was provided by Administrator. b. The policy stated under Medication Storage, article #7, Controlled substances (listed as Schedule II-V of the Comprehensive Drug Abuse Prevention and Control Act of 1976) and other drugs subject to abuse are separately locked in permanently affixed compartments, except when using single unit package drug distribution systems in which the quantity stored is minimal and missing dose can be readily detected. c. On 06/13/2024 at 9:25 AM, the Surveyor asked the Administrator where controlled medications are to be stored. The Administrator said, In a locked box affixed to something permanent.

Based on observation and interview, the facility failed to ensure that dietary staff washed their hands before handling clean equipment or food items to prevent potential food borne illness for the residents who received meals from 1 of 1 kitchen. This failed practice had the potential to affect 36 residents who received meals from the kitchen (total census: 37) according to the list provided by the Dietary Supervisor dated 04/13/23. The findings are: a. On 04/10/23 at 10:36 AM., Dietary Employee (DE) #1 pushed a cart with an iced tea container on it towards the tea maker. She removed the iced tea container from the cart and placed it on the tea maker. Without washing her hands, she picked up the bowls from the clean dish rack and placed them on a shelf with her fingers inside of them. b. On 04/10/23 at 11:28 AM., DE #1 pushed a cart towards the steam table. Without washing her hands, she picked up the bowls to be used in portioning the dessert to the residents for lunch. She placed them on the trays with her fingers inside of them. c. On 04/10/23 at 11:54 AM., DE #2 emptied a bag of cake mix into a bowl. She threw the empty bag in the trash can and pushed it down with her bare hands. She picked up a pan and placed it on the counter with her fingers inside of it. When she was ready to pour the cake batter into the pan, the Surveyor stopped her and asked, What should you have done after touching dirty objects and before handling clean equipment? She stated, I should have washed my hands. d. On 04/10/23 at 12:03 PM., DE #3 turned on the food preparation sink faucet, contaminating her hands. She picked up glasses by their rims and filled each glass with water and placed them on the trays to be served to the residents for lunch. She did not wash her hands before touching the glasses. At 3:56 PM, the Surveyor asked, What should you have done after touching dirty objects and before handling clean equipment? She stated, I should have washed my hands. e. On 04/10/23 at 12:25 PM., DE #1 was on the line assisting with lunch. She picked up the condiments, a milk carton and the supplements and placed them on trays. Without washing her hands, she picked up beverage glasses by their rims and placed them on the meal trays to be served to the residents for lunch. The Surveyor asked, What should you have done after touching dirty objects and before handling clean equipment? She stated, Washed my hands. f. The facility policy titled, Preventing Foodborne Illnesses-Employee Hygiene and Sanitary Practices, provided by the Dietary Supervisor on 04/13/23 at 9:00 AM documented, Employees must wash their hands after engaging in other activities that contaminate the hands.

Based on observation, record review, and interview, the facility failed to ensure showers were regularly provided to maintain good hygiene for 2 (Resident #17 and #18) of 16 (#1, #2, #3, #8, #15, #17, #18, #19, #20, #21, # 22, #23, #26, # 27, #31, #34) sampled residents who required some assistance from staff for showers. This failed practice had the potential to affect 37 residents who required some assistance with bathing/showers according to a list provided by the Administrator on 04/14/23. The findings are: 1. Resident #17 had diagnoses of Unspecified Fracture of Shaft of Right Ulna, Subsequent Encounter for Closed Fracture with Routine Healing, Pain in the Right Wrist, Need for Assistance with Personal Care and Other Abnormalities of Gait and Mobility. An Admission Medicare 5-day Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/24/23 documented a Brief Interview of Mental Status (BIMS) score of 14, (a score of 13-15 indicates cognitively intact). She required extensive assistance of two persons for toilet use and personal hygiene, extensive assistance of one person for bed mobility, toilet use and dressing, physical assistance of one person for bathing, supervision after setting up for eating, and was occasionally incontinent of bladder and always continent of bowel. a. The Care Plan with a revision date of 04/10/23 documented, The resident has an ADL [Activities of Daily Living] self-care performance deficit r/t [related to] recent fx [fracture] of ulna .Need for Assist with Personal Care .The resident requires (extensive assistance) by (1) staff with showering [2-3 X weekly] and as necessary . b. On 04/10/23 at 11:30 am., Resident #17 was lying in her bed resting. The Surveyor asked if she had any concerns with her care and she stated, I've only had 2 showers since I've been here, and I had to ask for both of them. The Surveyor asked if she had ever complained to anyone. She stated, No, they will probably say I refuse. I do refuse Physical Therapy sometimes because I'm tired or hurting and want to go back to my room. c. On 04/13/23 at 10:38 am., Resident #17 was lying in her bed, resting with her eyes closed. She had on the same shirt that she had worn the day before. d. On 04/14/23 at 9:00 am., Resident #17 was lying in her bed. The Surveyor asked if she had received her showers this week. She stated, Yes, I've gotten 2 this week. I was told that I was supposed to get another one today and I asked if I could get it tomorrow instead. The Surveyor asked if she was told she can get her shower tomorrow instead of today. She stated, I was told that I need to get one today. I asked her why I have to get one today, when I begged for a shower before. 2. Resident #18 had diagnoses of Hemiplegia and Hemiparesis following Nontraumatic Intracerebral Hemorrhage affecting Left Non-Dominant side, Atherosclerotic Heart Disease of Native Coronary Artery without Angina Pectoris and Type 2 Diabetes Mellitus with Hyperglycemia. An Admission Medicare 5-day MDS with an ARD of (03/15/23) documented a BIMS score of 14, (a score of 13-15 indicates cognitively intact). He required Extensive assistance of one person for bed mobility, transfer, dressing, toilet use and personal hygiene, physical assistance of one for bathing, supervision after setting up for eating, and was always continent of bladder and bowel. a. On 04/10/23 at 11:30 am., Resident #18 was seated in his wheelchair out in the 300 Hall. The Surveyor asked if he had any concerns about his care. He stated I've been here about 2 months and have only had 3 showers. My shower days are Tuesday, Thursday and Saturdays. b. On 04/12/23 at 8:30 am., Resident #18 was seated in his wheelchair at the 300 Hall door preparing to go outside and smoke. He had on different clothes than the previous 2 days. The Surveyor asked if he had received a shower on his scheduled day [Tuesday]. He stated, No, I was supposed to get one yesterday, but I didn't. c. On 04/12/23 at 11:00 am., the Surveyor asked the Nursing Consultant for Resident #17's Bathing Task Sheet. At 03:49 pm, the Administrator brought Witness Statements from 2 Certified Nursing Assistants (CNAs) #3 and #2, and 2 Registered Nursing Assistants (RNAs) #1 and #2 that documented, Resident #17 gets regular showers when she chooses. There was a problem with the [Facility Computer Software] and they didn't get charted. The Administrator stated, When I realized that we didn't have any bathing tasks documented, I went and asked the CNAs how showers were documented. They stated, there wasn't any way to document them. I had them write up a witness form stating that residents received showers. That part of the [Facility Computer Software] has now been fixed so they can document in it. d. On 04/14/23 at 8:51 am., Resident #18 was seated in his wheelchair beside the door in the 300 Hall. He had on different clothes than yesterday. The Surveyor asked if he received a shower yesterday. He stated, Yes, I got one after my 2:30 smoke break. I was told that my name is on the list for Tuesday, Thursday and Saturday and that I will be getting showers now on those days. The Surveyor asked if he ever refused a shower/bath. He stated, Never. 3. On 04/14/23 at 9:20 am., the Surveyor asked CNA #4, Who is responsible for giving resident showers? She stated, The CNAs are. The Surveyor asked, After resident receives a shower, is it documented anywhere? She stated, Yes, we have shower sheets we document on and put it in [Facility Computer Software]. The Surveyor asked, How long have you been documenting on showers sheets and in the [Facility Computer Software]? She stated, We just started in [Facility Computer Software] but we have had the shower sheets for a while. The Surveyor asked if Residents #17 or #18 ever refuse showers. She stated, Resident #17 will refuse but will usually give in and Resident #18 has refused before. 4. On 04/14/23 at 9:25 am., the Surveyor asked RNA #2 if she was familiar with Residents #17 and #18. She stated, Yes. The Surveyor asked, Who is responsible for giving showers to residents? She stated, The girls working the floor that day. The Surveyor asked if the showers were documented anywhere. She stated, We were documenting them in [Facility Computer Software], but it was messed up for a couple of months and we couldn't use it. The Surveyor asked if it was written down on paper or in a book. She stated, No, they would tell one of the nurses, and the nurse would document it. 5. On 04/14/23 at 9:33 am., the Surveyor asked Licensed Practical Nurse (LPN) #3 if she was familiar with Residents #17 and #18. She stated, Yes. The Surveyor asked if they ever refused showers. She stated, Resident #17 does but I'm not aware of Resident #18 ever refusing. 6. On 04/14/23 at 9:58 am., the Surveyor asked the Director of Nursing (DON), Who is responsible for giving the residents showers? She stated, The CNAs. The Surveyor asked, Where are the showers documented? The DON stated, In the [Facility Computer Software] and I have implemented this week a shower sheet, a body audit sort of, that has date, shower/bed bath given or refused. They take it to the nurse and the nurse will then attempt to get resident to take shower. If still refuses, they document it in the [Facility Computer Software]. 7. The facility policy titled Bath, Shower/Tub and Procedure, provided by the DON on 04/14/23 at 10:25 am documented, Purpose .The purposes of this procedure are to promote cleanliness .to observe the condition of the resident's skin .Documentation 1. The date and time the shower/tub bath was performed .5. If the resident refused .

Based on record review and interview, the facility failed to ensure protocol was followed for a telephone ordered antibiotic for 1 (Resident #18) of 8 (Resident #18, #14, #7, #10, #33, #4, #13 and #37) sampled residents who had orders for antibiotic therapy. This failed practice had the potential to affect 14 residents under this physicians' care, according to the list provided by the Assistant Director of Nursing (ADON) on 9/17/20. The findings are: 1. A telephone order dated 7/16/20 documented, (Resident #18) . Ordered by: (Medical Doctor #1) . Medication:[MEDICATION NAME] 500MG (milligram) . Order Type: Antibiotic Orders . a. The July 2020 Medication Administration Record [REDACTED]. b. The Antibiotic and Infection Monitoring Log for July 2020 was received from the ADON on 9/17/20 at 3:25 p.m. The log documented on 7/12/20, Resident #18 was [MEDICATION NAME] mg (milligram) for an UTI from Medical Doctor #1. c. On 9/17/20 at 8:28 a.m., the ADON was asked, When does (MD #1) see his residents? She stated, He only comes once a month to see his residents. She was asked, Does anyone else see his residents. She stated No. She was asked, If he prescribed an antibiotic over the phone, when does he see / assess the resident? She stated, When he makes his monthly visit. d. On 9/17/20 at 2:41 p.m., a copy of the Antibiotic Stewardship was received from the ADON and documented, Antibiotics will be prescribed and administered to residents under the guidance of the facility's Antibiotic Stewardship Program .The purpose of our Antibiotic Stewardship Program is to monitor the use of antibiotics in our residents . When antibiotics are prescribed over the phone, the primary care practitioner will assess the resident within 72 hours of the telephone order . e. On 9/18/20 a copy of the Physician's Visits was received from the ADON and documented that MD #1 visited Resident #18 on 6/19/20 and 8/28/20.

Based on record review and interview, the facility failed to ensure the Minimum Data Set (MDS) assessment was properly coded to reflect the presence of a Serious Mental Disorder for 2 (Residents #9 and #20) of 2 sampled residents who required Level II evaluations per the Medicaid Preadmission Screening and Resident Review (PASRR) process. The failed practice had the potential to affect 4 residents who required PASRR II evaluations according to a list provided by the Administrator on 09/17/2020 at 1:50 PM. The findings are: 1. Resident #20 was admitted [DATE] and had [DIAGNOSES REDACTED]. The Annual MDS with an Assessment Reference Date (ARD) of 07/01/2020 documented, .Is the resident currently considered by the state level II PASRR process to have serious mental illness .the item was coded 0 (no). Also documented the resident had a Psychiatric/Mood disorder. a. A physician's orders [REDACTED].[MEDICATION NAME] .related to [MEDICAL CONDITION] II Disorder; [MEDICAL CONDITION] . b. The Comprehensive Care Plan dated 07/23/2020 documented, .The resident uses [MEDICAL CONDITION] medications antipsychotic, antianxiety and antidepressant r/t (related to) Disease process of [MEDICAL CONDITIONS] and depression . c. On 09/16/2020 at 2:01 PM, the MDS Coordinator was asked, Should you have coded item A1500 on the Annual MDS as no? She stated, Yes, that's the way I've always done it. She was asked, Is the resident considered to have serious mental illness per the level II screening? She stated, .He was a level II, but he went down to a level I . She was asked, Did you mark the MDS indicating the resident has [MEDICAL CONDITION] Disorder and [MEDICAL CONDITION]? She stated, Yes . I marked it the way I was trained to mark it. d. On 09/16/2020 at 2:25 PM, a form titled CMS's RAI (Centers for Medicare and Medicaid Resident Assessment Instrument) Version 3.0 Manual .provided by the MDS Coordinator documented, .Page A-23 .A1500: Preadmission Screening and Resident Review (PASRR) .Code 1, yes: if PASRR Level II screening determined that the resident has a serious mental illness .and continue to A1510, Level II Preadmission Screening and Resident Review (PASRR) Conditions. e. On 09/17/2020 at 11:12 AM, a (Mental Health) Associates letter provided by the Administrator documented, .Recently an evaluation was completed of your physical and mental condition in compliance with Federal Law regarding nursing facility admission .As a result of your evaluation it has been determined that: You Do require specialized services for your mental illness (MI) . f. On 09/17/2020 at 10:24 AM, the Administrator and Nurse Consultant were asked, Should item A1500 on the Annual MDS dated [DATE] be coded yes? They both stated, Yes. 2. Resident #9 had [DIAGNOSES REDACTED]. The Significant Change MDS with ARD of 05/15/2020 documented, .Is the resident currently considered by the state level II PASRR process to have serious mental illness .the item was coded 0, (no) . Resident had an active [DIAGNOSES REDACTED].boxes beside [MEDICAL CONDITION] and [MEDICAL CONDITION] were marked. a. A physician's orders [REDACTED].[MEDICATION NAME] . related to Paranoid [MEDICAL CONDITION] . b. The Comprehensive Care Plan dated 08/25/2020 documented, .The resident exhibits behavioral indicators of sexual inappropriate behaviors, threatening staff .r/t (related to) Dx (Diagnosis) of .unspecified [MEDICAL CONDITION] and paranoid [MEDICAL CONDITION] . c. On 09/17/2020 at 10:55 AM, a (Mental Health) Associates letter dated 8/18/2016 provided by the Administrator documented, .Client has mental illness with severe dementia .box beside this statement was marked with an X. d. On 09/17/2020 at 10:24 AM, the Administrator and Nurse Consultant were asked, Should item A1500 on the Annual MDS dated [DATE] be coded yes? They both stated, Yes.

Based on observation, record review and interview, the facility failed to ensure appropriate infection prevention and control practices were implemented during oxygen administration to prevent potential contamination for 1 (Resident #20) of 1 sampled resident who was receiving oxygen therapy. The failed practice had the potential to affect 14 residents who had physician's orders [REDACTED]. The findings are: Resident #20 had [DIAGNOSES REDACTED]. a. The physician's orders [REDACTED].@ (at) 2L (Liters) via NC (Nasal Cannula) as needed . b. The September 2020 Comprehensive Care Plan documented, .The resident has altered respiratory status/difficulty breathing r/t (related to) [MEDICAL CONDITION] .Interventions: OXYGEN SETTINGS: O2 via (nasal prongs) @ (2-3) L . c. On 09/14/2020 at 12:39 PM, Resident #20 was sitting in a chair in his room without O2 on. The nasal prongs of the O2 tubing was in the floor. The switch on the concentrator was in the on position. Certified Nursing Assistant (CNA) #1 was informed that Resident #20's tubing was on the floor. She stated, .he takes if off all the time. d. On 09/14/2020 at 12:52 PM, the Director of Nursing (DON) entered the room and picked oxygen tubing up from the floor and applied the nasal cannula to the resident. She did not change the tubing. e. On 09/14/2020 at 03:11 PM, the DON was asked, When you picked the oxygen tubing off the floor for Resident #20 what did you do with it? She stated, I know, I should have got a new one.

Based on observation, interview and record review, the facility failed to ensure staff avoided handling residents' drinking glasses by their rims and food items stored in the kitchen and unit refrigerators and dry storage area were labeled and dated to prevent potential food borne illness for residents who received meals from 1 of 1 kitchen. This failed practice had the potential to affect 51 residents who received meals from the kitchen (total census: 54), as documented on the Resident Listing Report provided by the Administrator on 4/30/19. The findings are: 1.On 4/29/19, during the initial kitchen tour, the following observations were made: a. At 11:37 a.m., in the dry storage room, there was an opened 32-ounce (oz) bag of light brown sugar with no opened date. b. From 12:10 p.m. to 1:01 p.m., Dietary Employee #1 was on the serving line for the lunch meal service, placing napkin-wrapped silverware, condiments (salt/pepper/sugar packets and butter), desserts and beverages on residents' trays and not wearing gloves. Using her right hand, she picked up the drinking glasses, touching the rim of each glass as she placed residents' beverages on the meal trays. 2. On 4/29/19 at 2:29 p.m., on the 100 Hall Secure Unit dining area, in a locked cabinet to the right of the sink, there was a bag of popcorn with no label or date. 3. On 4/29/19 at 2:33 p.m., the refrigerator in the medication room behind the nurses' station contained the following items: a. Three 4.4-fluid ounce containers of Blue Raspberry-Lemon Flavored 100% juice from concentrate - not dated. b. Two brown boxes, 1 containing 4 vanilla ice cream sandwiches and another containing 9 vanilla ice cream sandwiches had no dates documented on the boxes. 4. On 4/30/19 at 8:30 a.m., Dietary Employee #1 was asked, Should the rims of residents' drinking glasses be touched when serving drinks? She stated, No. 5. On 4/30/19 at 8:50 a.m., the Administrator was asked, should food items contain the opened date and be labeled? She stated, Yes.

Based on observation, record review and interview, the facility failed to ensure a staff member knocked and awaited permission to enter before entering a resident's room and alerted the resident to his presence prior to initiating care, to promote dignity and convey respect for 1 (Resident #100) of 18 (Residents #10, #20, #18, #3, #179, #45, #39, #100, #43, #200, #42, #11, #28, #35, #7, #44, #36, and #22) sampled residents who received care from Certified Nursing Assistant (CNA) #3. The failed practices had the potential to affect 21 residents who received care from CNA #3, as documented on a list provided by the Administrator on 7/27/18. The findings are: Resident #100 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Minimum Data Set with an Assessment Reference Date of 7/17/18 documented the resident scored 7 (0-7 indicates severely impaired) on a Brief Interview for Mental Status and required extensive assistance of 2 people with activities of daily living. a. On 7/17/18 at 9:15 a.m., the resident was lying in bed on his right side. His head was covered with the sheet. Certified Nursing Assistant (CNA) #3 entered the room without knocking and, without alerting the resident to his presence, lifted the top sheet from the resident's legs without telling the resident. The resident was startled and jerked the sheet back. b. On 7/17/18 at 9:17 a.m., the resident was asked, Does it bother you when staff come into your room without knocking and identifying themselves? He stated, Yes it does. He was asked, How did you feel when the CNA lifted the bottom of the sheet? He stated, It scared me. c. On 7/19/18 at 9:00 a.m., the Director of Nursing was asked Do you expect your staff to knock before entering a room and to tell the resident what they are going to do prior to doing it? She stated, Yes.

Based on observation, record review and interview, the facility failed to ensure the labia and urinary meatus were thoroughly cleansed of stool during incontinent care to prevent potential urinary tract infection for 1 (Resident 14) of 4 (Residents #10, #14, #40 and #46) female case mix residents who were dependent for incontinent care. This failed practice had the potential to affect 10 female residents who were dependent for incontinent care, according to a list provided by the Director of Nursing (DON) on 7/19/18 at 9:35 a.m. The findings are: Resident #14 had a [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set with an Assessment Reference Date of 5/17/18 documented the resident was severely impaired in cognitive skills for daily decision-making per a staff assessment for mental status, was totally dependent on 2 staff members for toileting and was incontinent of bowel and bladder. a. The Plan of Care dated 5/18/18 documented Resident has bowel and bladder incontinence r/t (related to) immobility and loss of habit and inability to retrain Secondary to her Dementia . Check resident every two hours and assist with toileting as needed and incontinent care to be provided after each incontinent episode. b. On 7/18/18 at 9:28 a.m., Certified Nursing Assistants (CNA)s #1 and #2 provided incontinent care for the resident, who had been incontinent of bowel and bladder. CNA #1 cleansed across the lower abdomen, down each side of the groin and wiped one time down the labia. CNA #1 did not spread the labia to cleanse around the urinary meatus. The resident was then turned to her right side, and CNA #2 cleansed the stool from the anus and inner buttocks and placed a clean brief under the resident. They turned the resident to her back. They were asked if they were finished with incontinent care and they both stated Yes. They were then asked to separate the labia and wipe from front to back. CNA #1 spread the labia and wiped; the wipe became soiled with feces. The CNA then used two additional wipes to completely cleanse the area. c. On 7/19/18 at 9:00 a.m., the Director of Nursing was asked Do you expect your staff, when providing incontinent care for a resident who had a bowel movement, to spread the labia and wipe the urinary meatus? She replied Yes. She was asked, Why is that so important? She stated, It prevents Urinary Tract Infections. d. The facility's policy and procedure for Perineal Care, provided by the DON on 7/19/18 at 11:20 a.m., documented, .Wash perineal area from front to back. Spread the labia and wash area downward.

Based on observation, record review and interview, the facility failed to ensure an unclear oxygen order that documented the oxygen therapy was to be both continuous and as needed (PRN) was clarified and failed to ensure the oxygen was promptly applied after the resident returned from [MEDICAL TREATMENT] to prevent [MEDICAL CONDITION] for 1 (Resident #100) of 1 case mix resident who had physician orders [REDACTED]. Resident #100 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Minimum Data Set with an Assessment Reference Date of 7/17/18 documented the resident scored 7 (0-7 indicates severely impaired) on a Brief Interview for Mental Status, required extensive assistance with activities of daily living and required oxygen therapy in the past 7 days. a. A physician's orders [REDACTED]. b. The Plan of Care dated 7/19/18 documented, Resident wears oxygen for shortness of breath . O2 (oxygen) sat (saturation) to be checked every 4 hours and resident to wear oxygen continuous at 3L PRN. (MONTH) remove for showers and transfers. c. On 7/18/18 at 3:45 p.m., the resident was lying in bed. He did not have his oxygen on. He was asked, Do you feel like you need it? He stated, I don't know, but I'm supposed to have it on. The resident did not appear to be in respiratory distress. At 3:50 p.m., the Administrator checked the resident's oxygen saturation level with a pulse oximeter. It was 86%. She applied his oxygen at 2 liters per minute, then went and checked his orders and stated the order was for 3 liters per minute. At 3:55 p.m., the Administrator rechecked the resident's oxygen saturation, and it was 95%. The resident stated he got back from [MEDICAL TREATMENT] around 2:30 p.m., and staff did not put his oxygen back on him when they put him into bed. At 3:57 p.m., the Administrator was asked, Does someone tell the Nurse when he comes back? She replied, They should. d. On 7/18/18 at 4:00 p.m., Licensed Practical Nurse (LPN) #1, the Charge Nurse for this resident's hall, was asked, Did anyone tell you that he was back from [MEDICAL TREATMENT]? She stated No, this is the first I have heard about it. e. A Nursing Incident and Accident (I and A) Note dated 7/18/18 at 8:14 p.m. documented, Resident returned from [MEDICAL TREATMENT] and was SOB and when O2 sat was checked by Administrator, it was 86% on room air. O2 was applied and res (resident)'s O2 sat steadily increased to 96%. Res states that he does not wear his oxygen all the time, but the order was unclear and said 'continuous and prn'. The order was clarified, and res is stable. Immediate Intervention: Applied O2 and got O2 sat up from 86% to 96%. f. On 7/19/18 at 8:40 a.m., the Director of Nursing stated they called the physician to clarify the oxygen order, and the physician changed the order to 'as needed'. She stated the family told her he used oxygen at home and that she would contact the physician again for an order for [REDACTED].>

Based on observation, record review and interview, the facility failed to ensure staff washed their hands and changed gloves when soiled during incontinent care and failed to ensure the pillow cases on a pressure relief cushion were changed after being on the floor to prevent cross-contamination and potential infection for 1 (Resident #14) of 14 (Residents #10, #14, #40, #46, #202, #2, #30, #26, #45, #39, #100, #43, #42 and #11) case mix residents who were dependent for incontinent care. The failed practices had the potential to affect 18 residents who were dependent for incontinent care and 4 residents who used pressure relief cushions in bed, as documented on lists provided by the Administrator on 7/27/18. The findings are: Resident #14 had a [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set with an Assessment Reference Date of 5/17/18 documented the resident was severely impaired in cognitive skills for daily decision-making skills, per a staff assessment for mental status, was totally dependent on 2 staff members for toileting and was incontinent of bowel and bladder. a. The Plan of Care dated 5/18/18 documented, Resident has bowel and bladder incontinence r/t (related to) immobility and loss of habit and inability to retrain Secondary to her Dementia . Check resident every two hours and assist with toileting as needed and incontinent care to be provided after each incontinent episode. b. On 7/18/18 at 9:28 a.m., Certified Nursing Assistants (CNAs) #1 and #2 provided incontinent care for the resident, who had been incontinent of bowel and bladder. CNA #1 washed her hands and put on a pair of gloves. CNA #2 did not wash her hands, but did put on a pair of gloves. CNA #1 took 1 disposable wipe out of the package and cleansed across the lower abdomen, reached back into the package and got another wipe and cleansed the right groin area. She reached back into the package for another wipe and cleansed the left groin. She reached back into the package, still wearing the same gloves, removed another wipe and used it to cleanse the outer labia. The resident was then turned to her right side, and CNA #2 removed a clean wipe and cleansed the anal area and right inner buttock, reached back into the package for another wipe, cleansed the left inner buttock, then without changing gloves or washing her hands, placed a clean brief under the resident. At 9:35 a.m., the heel off-loading cushion fell off the bed onto the floor, contaminating the pillow cases. At 9:45 a.m., CNA #2 picked up the cushion, straightened the pillow cases on the cushion and placed the cushion under the resident's calves. She did not put clean pillow cases on the cushion. c. On 7/19/18 at 9:50 a.m., the Director of Nursing (DON) was asked, Do you expect your staff to get (incontinent) wipes out of the package after contaminating their gloves? She stated, Our policy, and I prefer, them to lay out the clean wipes. d. The Perineal Care Skills Check sheet, provided by the DON on 7/19/18 at 11:18 a.m., documented, Change gloves between cleansing the front and back.

Complaint # (AR 867) was substantiated, all or in part, with these findings: Based on record review and interview, the facility failed to ensure adequate supervision was provided to prevent elopement for 1 (Resident #1) of 3 (Residents #1, #2 and #6) case mix residents who were at risk for elopement, as evidenced by failure to develop and implement interventions and staff training to ensure cognitively impaired residents who resided on the secure wing due to risk for elopement were closely monitored and their whereabouts accounted for when the facility fire alarm sounded and the exit doors automatically unlocked. The failed practice resulted in past non-compliance at the level of Immediate Jeopardy, which caused or could have caused serious harm, injury or death for Resident #1, who eloped from the facility and was missing for approximately 1.5 hours while the fire alarm was sounding, fell into a ditch, sustaining multiple injuries and became hypothermic due to exposure, and had the potential to cause more than minimal harm to 16 residents who were at risk for elopement, as documented on a list provided by the Administrator on 12/28/17 at 3:05 p.m. The Administrator was informed of the past Immediate Jeopardy situation on 12/28/17 at 2:45 p.m. The findings are: 1. Resident #1 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Admission Minimum Data Set with an Assessment Reference Date of 10/19/17 documented the resident scored 6 (0-7 indicates severely impaired) on the Brief Interview for Mental Status, was ambulatory and had no wandering behavior. a. The Nursing Elopement Risk with Care Plan form dated 10/15/17 documented, .Has history of wandering . Wandered when she was at home . The resident is an elopement risk/wanderer related to dementia. The resident's safety will be maintained through the review date. The resident will not leave facility unattended through the review date . The Care Plan did not address the need to monitor the resident's whereabouts at any particular frequency. b. A Nurse's Note dated 11/8/17 at 2:04 p.m. documented, Res (resident) has been wandering all night and not sleeping. Very confused about different things. Will talk with SSD (Social Service Director) and family about possible neighborhood (secure unit) placement. c. A Nursing Elopement Risk with Care Plan form dated 11/11/17 documented, .The resident is an elopement risk/wanderer related to dementia. The resident's safety will be maintained through the review date. The resident will not leave facility unattended through the review date . The Care Plan did not address the need to monitor the resident's whereabouts at any particular frequency. d. An Incident/Accident (I/A) Report dated 12/23/17 at 6:40 a.m. documented, NA (Nurse's Aide) instructed the nurse that (Resident #1) could not be located in the secured neighborhood unit. Nurse immediately went to secured unit and could not locate inside, then went out back door of unit and she could hear (Resident #1) calling out 'help'. She immediately ran out of unit to front entrance of building where she exited and observed staff member and (Resident #1) in small ditch beside far right driveway of facility where she ran to evaluate resident's condition. Ambulance notified immediately. Res taken inside to warm up and evaluate condition. Long Term Intervention: When fire alarm sounds, staff are to post at exit doors to make sure residents do not go outside until system is back in place. Staff inserviced . No V/S (vital signs) taken. Ambulance notified. e. A Nurse's Note dated 12/23/17 at 9:18 a.m. and written signed by Licensed Practical Nurse (LPN) #1 documented, CNA (Certified Nursing Assistant) instructed the nurse that (Resident #1) could not be located in the secured neighborhood unit. I immediately went to secured unit and could not locate inside. Then went out back door of unit to front entrance of building where I exited and observed staff member and (Resident #1) in small ditch beside far right driveway of facility, to where I ran to evaluate resident's condition . Ambulance transported to (hospital) for eval/tx (evaluation and treatment) per MD (Medical Doctor) . f. The Facility Investigation Report for Resident Abuse, Neglect, Misappropriation of Property and Exploitation of Residents in Long-Term Care Facilities, Division of Medical Services (DMS) form 762 dated 12/23/17 documented, On 12/23/17 at 6:58 a.m . notified me that resident (Resident #1) had eloped from the facility and was found in a ditch in the front of the facility around 6:45 a.m. Body audit was completed upon finding resident once resident was brought into the facility, small bruise to right forehead noted. Resident sent to (hospital) by ambulance for precautionary reasons. X-rays were completed at the hospital and were negative . On 12/23/17 the fire alarm sounded at 4:29 a.m. (LPN #1) notified (Maintenance). (Maintenance) came to the facility at 5:10 a.m. to check the system and place back in working order. The system was placed back in order between 5:30 a.m. - 5:45 a.m. During this time, resident (Resident #1) eloped from the building and was found in a ditch out in front of the building around 6:40 a.m. This was due to the fire alarm system being triggered because the pressure switch on the air compressor failed and would not let air compressor work. This caused the automatic locks on the doors to release . Resident has returned to the facility and is doing fine at this time . The staff did a search of the building to see if there was a fire. (LPN #1) notified (Maintenance). (Maintenance) came to the facility to assess the reason the alarm sounded . (Maintenance) clocked out at 5:51 a.m . Resident was identified by (CNA #1) at 6:40 a.m. lying in a ditch outside of the facility on the north side driveway of the building, her walker was located nearby. (CNA #1) called into the facility with her cell phone . (Resident #1) was brought back inside to her room, dry clothes were put on her and blankets to help warm her up . Immediate assessment of the environment revealed the following: resident was sitting in ditch with her walker next to her. There was no standing water in the ditch, it was raining and the outside temperature was 38 degrees. Resident was wearing blue pants, red shirt and black shoes, and had her coat on her walker . (CNA #2) was checking rooms after the alarms sounded. (CNA #2) states that as she was checking rooms, resident came out into the hallway and asked for her glasses. (CNA #2) stated she told resident that she would get her glasses for her shortly, when she finished checking everything. (CNA #2) finished checking rooms and then gave (Resident #1) her glasses. This was after 5:00 a.m . (CNA #2) states she started making rounds a little after 6:00 a.m. and when she went into resident's room around 6:30 a.m., (Resident #1) was not there . g. The hospital Physician Clinical Report dated 12/23/17 at 7:50 a.m. documented, .Was found outside in a ditch, estimated time in 40 degree temperature, rain was 1 1/2 to 2 hours according to nurses at nursing home . Temp (temperature) 89.6 F (Fahrenheit) . Clinical Impression: Moderate hypothermia secondary to exposure. h. The hospital Clinical Report dated 12/23/17 documented, Triage time: 0750 (7:50 a.m.), 12/23/2017 . Found lying outside in a ditch beside the NH (nursing home) . Physical Assessment: 15 x (by) 25 cm (centimeter) circumferential bruising to right lower leg; hematoma noted below knee cap; 2 x 2 cm circular shape bruising to right inner thigh, 6 cm linear abrasion to left inner knee area, 4 cm light purple bruising to left shin distal to knee cap, 2 cm x 2.5 cm light purple bruising to left medial shin, 3 x 1 cm light purple to lateral left lower leg, 3 x 3 cm dark purple bruising with deformity noted to right forearm and wrist, 1 x 1.5 cm dark purple irregular shaped bruising to right forearm above deformity, 2 x 1.5 cm dark purple bruising to right middle finger, 4 x 4 dark purple circular bruising to right upper arm, 4 x 7.5 cm dark purple bruising to left dorsal hand, 1 x 1 cm bruising to left snuff box region. 4 x 2.5 cm bruising left shoulder, 1 x 1 cm dark purple bruising to right side of forehead, 1.5 x 1.5 cm dark purple bruising to left elbow and right elbow, 4 x 3.5 cm dark purple bruising to left inner forearm, 2 x 1 cm bruising to left flank area, 4 x 4 cm bruising to left calf . Patient noted to be shivering. Skin cool to touch. Peripheral cyanosis . 16 Fr (French) temperature sensing Foley catheter placed . 9:02 a.m. (1 hour and 12 minutes after triage) . Temp: 92.8 F . i. On 12/28/17 at 11:26 a.m., LPN #1 was asked about the 12/23/17 incident involving Resident #1 and stated, I was her nurse that morning. I heard the fire alarm, so I went to the fire panel, and it said it was the sprinkler system. I notified the staff that it was the sprinkler system, so I silenced the alarm. I called (Maintenance) to let him know and I went to the front to turn the main water valve off and I waited up there for (Maintenance) to make sure I did it right. I told (CNA #1 and #2) to stay on their halls. After (Maintenance) got done, I went back to get my meds (medications) ready and then (CNA #2) told me she couldn't find (Resident #1). We started a perimeter search. I went out the back door and around the fence line. I heard a faint 'help' and I knew it was her. She was asked how the resident got outside and stated, When the fire alarms go off, all the doors unlock. She had to have come through the main part of the building and out either the main dining room door or the front door. I was up front waiting for (Maintenance) and I would have heard her if she had gone out the front door. LPN #1 was asked how the resident could have exited the unit without staff seeing her and stated, That is a busy time of the morning. It was time for residents to be getting up, so it's busy. LPN #1 was asked when the resident was last seen that morning before she eloped and stated, Around 5:00 a.m. and she was found at 6:30 to 6:40 a.m. LPN #1 was asked if she was aware the resident was at risk for elopement before this incident and stated, Yes ma'am. She has dementia. j. On 12/28/17 at 12:10 p.m., CNA #3 was asked what happened the morning of 12/23/17 with Resident #1 and stated, It was around 4:00 a.m., and the fire alarm went off. The nurse went up there to check on what was going on and then she called (Maintenance). After that, we started making rounds and (CNA #2) asked us if we had seen (Resident #1) and we said 'no'. She freaked and went and told (LPN #1). We started looking everywhere, and then I saw (CNA #1) outside. She had found her in a ditch. I ran and got her wheelchair and we got her back inside. We got her wet clothes off and put her under some warm blankets. CNA #3 was asked if she was working on the secure unit that morning and stated, No. (CNA #2) was on the neighborhood. The CNA was asked how the resident got out of the building and stated, The only door I could think of was that one in the dining room. She was in the ditch, so based on where that door is, it makes sense. The CNA was asked if she was aware Resident #1 was at risk for elopement before the 12/23/17 incident and stated, No. I mean, she wanders, but it's just to ask questions about stuff, like is it time to get up. The CNA was asked if she had been in-serviced on anything since the incident and stated, Yes. Like if the fire alarm goes off, one person should watch the hall until everyone has been accounted for . k. On 12/28/17 at 1:24 p.m., CNA #1 was asked what happened the morning of 12/23/17 and stated, The fire alarms went off. Then around 5 (5:00 a.m.), there was me and one other girl and we were starting to get people up. (CNA #2) came up and asked if I had seen (Resident #1). I said 'no' so I went and told (LPN #1) what was going on and she went back to search. I went outside and didn't see anything, but I heard her. I took off to see if I could find her. I found her sitting in the wet grass at the edge of the ditch. I asked her if she was hurt and she said 'no, but I'm numb.' We brought her in and stripped her and tried to get her warm. The nurse came in and could not get a temp on her, so we sent her out. The CNA was asked who was working that morning and stated, Me, (CNA #3) and (CNA #2) were the CNAs that night. (CNA #2) was assigned to the unit. The CNA was asked if she was aware, prior to this incident, that when the fire alarms are activated, all the doors unlock. She stated, I thought when the fire alarm goes off, it unlocks just the interior doors, but it deactivates every door. The CNA was asked what time she found the resident and stated, I got on my cell phone at exactly 6:40 a.m. to call inside the building to get help. CNA #1 was asked if she knew Resident #1 was at risk for elopement prior to this incident and stated, No, I didn't. She wanders, but she had never tried to get off the hall before. l. On 12/28/17 at 3:15 p.m., CNA #4 was asked if she worked the secure unit at times and stated, Yes. CNA #4 was asked if she was aware Resident #1 was at risk for elopement prior to the incident on 12/23/17 and stated, I did not know that before this happened. CNA #4 was asked if she knew, prior to this incident, that the fire alarm would deactivate the door locks. She stated, No, I did not. I thought during a fire alarm, all the doors locked. I was trying to figure out how she got out. m. On 12/28/17 at 3:20 p.m., CNA #5 was asked about the incident on 12/23/17 with the resident and stated, I work day shift, and I always get here early. I got here that morning at 6:10 a.m. (CNA #1) said she couldn't find (Resident #1) so we started looking. Then, they said the fire alarms had gone off and I said, 'when did that happen, because y'all know the doors don't lock if the fire alarms go off'. Then (CNA #1) came running through and said she was in the ditch. Everyone should know the doors unlock when the fire alarm sounds, so they should make sure their residents are okay. And everyone knew she was an elopement risk. n. On 12/28/17 at 3:45 p.m., CNA #6 was asked if he was aware the doors would unlock if the fire alarm was activated and stated, I didn't know that until we were in-serviced after (Resident #1) got out. o. On 12/28/17 at 5:17 p.m., the Director of Nursing (DON) was asked about the 12/23/17 incident and stated, I was notified by the Administrator that (Resident #1) got out and we needed to come to the nursing home. The resident was sent out due to her temp being low. We did elopement risk assessments on everybody in the building, in-serviced staff . I was heartbroken. I'm just thankful she is alive and well. The DON was asked if staff are taught that the doors unlock when the fire alarm sounds and that they need to watch their residents and stated, I asked (Administrator) if that information is included in the fire training and she said 'no'. That is being changed. p. As of 12/28/17 at 5:18 p.m., CNA #2 could not be reached for comment. q. The weather history website, Weather Underground, at www.wunderground.com/history documented the weather on the morning of 12/23/17 during the approximately 1.5-hour period when the resident was missing, in the town where the facility is located, as follows: 1.) At 5:02 a.m., the temperature was 41 degrees Fahrenheit (F.), the wind chill was 31.6 degrees F., and there were North winds with a speed of 20.7 miles per hour (mph). 2.) At 5:19 a.m., the temperature was 41 degrees F., the wind chill was 30.9 degrees F., and there were North winds with a speed of 24.2 mph. 3.) At 5:53 a.m., the temperature remained 41 degrees F., the wind chill was 31.9 degrees F., and North wind speeds were 19.6 mph, with gust speeds of up to 27.6 mph. 4.) At 6:50 a.m. (approximately 10 minutes after the time the resident was located outside in a ditch), the temperature was 41 degrees F., the wind chill was 31.6 degrees F., North by Northwest wind speeds were 20.7 mph and it was raining. r. The facility removed the immediate jeopardy and corrected the failed practices on 12/23/17, prior to the survey, as evidenced by the following: 1.) The facility's written corrective action plan dated 12/23/17 documented the following corrective actions: QAA (Quality Assessment and Assurance) Plan 12/23/17 . In-service to all staff started. When fire alarms sound, one staff member is to be at each exit until the system is placed back in order . On day shift, department heads will be stationed at front exit, dietary staff at dining room exit, laundry/housekeeping at 300 hall exit, and neighborhood staff at their exit. On 3-11 and 11-7, charge nurse will assign staff to stay at nurse's station to monitor all exits from the nurse's station. Staff will check the alarm, and complete a head count of all residents to ensure that all residents are in the facility. Updated elopement risk assessments were completed for all residents on 12/23/17. Care plans were audited to ensure all appropriate interventions to minimize the potential for elopement were in place. Any assessments or care plan clarifications were implemented at this time. Ongoing monitoring to ensure compliance with elopement safety will be initiated as follows: Administrator/designee will sound door alarms unannounced a minimum of 2 times weekly x (times) 4 weeks on varying shifts to ensure compliance with response and address any retraining needs immediately. All residents who are potentially at risk for harm because of wandering (elopement) will be assessed at the time of admission, readmission or with a change of condition and reassessed at least quarterly thereafter. Residents identified to be at risk will have an information sheet with current photograph placed in the Wandering/Elopement Information Book at the Nurse's station. Staff will be in-serviced to remain familiar with the residents identified to be at risk and their information sheets. Staff will also be in-serviced on reporting practices in the event that any resident is suspected of being missing . Information sheets are to be reviewed and updated at the time of the MDS assessments (admission, readmission, or change of condition, and at least quarterly for elopement potential) . 2.) On 12/28/17, the Resident Council Minutes, Grievance Logs and I/A information dated from October 2017 through December 2017 was reviewed, and there was no documentation of any further elopement incidents. 3.) On 12/28/17 at approximately 11:00 a.m., the facility was observed activating the fire alarm to monitor staff response. Staff manned each exit door as trained, and no problems were observed. 4.) On 12/28/17 at 11:26 a.m., LPN #1 was asked about her knowledge of any interventions the facility had implemented since Resident #1's elopement on 12/23/17 and stated, We have an action plan where we man each door to make sure we are at constant watch of every exit. And a frequent roll call. We have a book of residents who are at risk for elopement.

Based on observation, record review and interview, the facility failed to ensure a urinary catheter drainage bag was kept off of the floor to prevent cross-contamination and potential infection for 1 (Resident #5) of 1 case mix resident who had an indwelling urinary catheter. The failed practice had the potential to affect 2 residents who had an indwelling urinary catheter, according to the Resident Census and Conditions of Residents form dated 2/28/17. The findings are: Resident #5 had [DIAGNOSES REDACTED]. The Annual Minimum Data Set with an Assessment Reference Date of 2/20/17 documented the resident scored 13 (13 - 15 indicates cognitively intact) on the Brief Interview for Mental Status (BIMS), required extensive assistance of one person with bathing, dressing and toileting and had an indwelling urinary catheter. a. The February 2017 Physician order [REDACTED]. b. On 2/27/17 at 7:43 p.m., during initial rounds, the resident #5 was sitting in the bedside chair in her room. The urinary catheter bag was lying on the floor beside the chair, and did not have a privacy bag or any other barrier between the bag and the floor. c. On 2/28/17 at 9:10 a.m. and 10:54 a.m., the resident was sitting in a recliner in her room. The resident's urinary catheter bag was hanging on the side of the recliner; however, the bottom of the bag was in contact with the floor. There was no privacy bag or other barrier between the bag and the floor. d. On 2/28/17 at 11:55 a.m., Certified Nursing Assistant (CNA) #1 was asked, Should the resident's catheter bag be on the floor or touching the floor? The CNA stated, No it should not. e. On 3/2/17 at 2:10 p.m., the Director of Nursing (DON) was asked, Should a catheter bag be on the floor? She stated, No.

Based on observation, record review and interview, the facility failed to ensure dietary recommendations were promptly acted upon to address nutritional deficits and decrease the potential for further weight loss for 1 of 1 (Resident #2) case mix resident who had Registered Dietician (RD) recommendations in the past 2 months. This failed practice had the potential to affect 2 residents who had RD recommendations in the last 2 months, according to a list provided by Administrator on 4/22/16 at 8:10 a.m. The findings are: Resident #2 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set with an Assessment Reference Date of 4/08/16 documented the resident was severely impaired in cognitive skills for daily decision making per a Staff Assessment of Mental Status and required extensive assistance for eating, has a feeding tube, received 51% of total calories via tube feeding and over 501cc (cubic centimeter) of fluid in the last 7 days and had a 5% weight loss in the last 6 months. a. The Care Plan dated 2/03/16 documented, The resident requires tube feeding r/t (related to) weight loss. The Registered Dietician (RD) to evaluate quarterly and prn (as needed). Monitor caloric intake, estimate needs. Make recommendations for changes to tube feeding as needed. b. The Diet RD onsite Visit and Recommendation form dated 4/15/16 documented, Monthly weight declined 10.9% over the past 6 months and continues monthly decline . Recommend: Continue to offer pureed diet with enhanced foods for current intake of 0-25%. Give bolus feedings to meet primary weight maintenance need of 1700 calories per day. Please bolus 5 cans per day of [MEDICATION NAME] 1.5 to maintain weight. Flush with 150 cc of water before and after each feeding for hydration. Observe weights for stabilization. Current weekly weight is 174.2 # (pounds). c. As of 4/20/16 at 2:40 p.m., there was no documentation in the clinical record to indicate the Physician or Advanced Practice Nurse (APN) had been consulted regarding the RD recommendations or that the recommendations had been acted upon. At this time, when asked if the Physician or APN had been notified of the RD's 4/15/16 recommendations, the Director of Nursing (DON) stated she sent a text to the APN on 4/18/16 and had received no response as of this date. d. On 4/21/16 at 1:25 p.m., the DON was asked if, in her opinion, there was a delay in acting upon the RD recommendations. She stated, We try to turn it around in 72 hours, but cannot always get it done.

Based on record review and interview, the facility failed to ensure physician-ordered laboratory services were provided promptly to assist the physician with making treatment decisions for 1 of 1 (Resident #8) case mix resident who had a physician order [REDACTED]. The findings are: Resident #8 had [DIAGNOSES REDACTED]. a. A physician's orders [REDACTED]. A physician's orders [REDACTED]. Give 1 tablet by mouth one time a day for [MEDICAL CONDITION]. b. On 4/20/16 at 8:45 a.m., the Director of Nursing (DON) was asked for documentation of the results of the potassium level ordered by the physician on 4/9/16, to be obtained on 4/16/16. c. On 4/20/16 at 10:20 a.m., the DON provided a typed and signed note in response to the request for the potassium level. The note documented, Potassium order for 4/16/16. I reviewed the labs, did not find a potassium result for 4/16/16. Called (laboratory provider): They have no correspondence as to where it was ordered to be drawn. Progress Notes reviewed for the date, states only to change [MEDICATION NAME] dose. There is no progress note for the lab to be drawn. The MD (Medical Doctor) was called and stated that he did not remember if he ordered the lab or not and gave new order to draw potassium level tomorrow in the a.m. (morning). d. On 4/20/16 at 10:55 a.m., the DON was asked how the facility informed the lab service when a physician ordered a lab test. The DON stated that the nurse that received the order either called or faxed the lab provider and that a requisition form was put in a notebook. The DON stated that the requisition for the potassium level was in the notebook. The DON also stated The progress notes were reviewed every day, Monday through Friday, at stand up meetings, to double check for physician orders [REDACTED].

Based on observation and interview, the facility failed to ensure food was served at temperatures that were acceptable to the residents, to enhance palatability and encourage good nutritional intake for residents who ate meals in 1 (100 Hall dining room) of 2 dining rooms. The failed practice had the potential to affect 7 residents who ate in the 100 Hall (Unit) dining room, according to a list provided by the Food Service Supervisor (FSS) on 6/10/15. The findings are: 1. On 6/9/15 at 9:45 a.m., a group interview was conducted with 4 alert and oriented residents. One of four residents complained that the facility food was sometimes late. Another of the four residents stated that if the food was not on time it would be cold. None of the other resident agreed or disagreed. 2. On 6/9/15 at 12:41 p.m., a cart that contained 7 trays was delivered to the 100 Hall unit dining room. At 12:47 p.m., the door to the cart was left open while the meal trays were being passed to the residents by staff. At 12:54 p.m., immediately after the last resident was served, the temperatures of the food items on a tray used as a test tray were checked and read by Dietary Employee #1 as follows: a. Pureed smothered pork chops - 111 degrees Fahrenheit. b. Pureed broccoli - 105 degrees Fahrenheit. c. Fortified potatoes - 110 degrees Fahrenheit. d. Regular Broccoli - 99 degrees Fahrenheit. e. Regular smothered pork chops - 95 degrees Fahrenheit. 3. On 6/9/15 at 5:26 p.m., a cart that contained 7 supper trays was delivered to the 100 Hall unit dining room. At 5:33 p.m., immediately after the last resident was served, the temperatures of the food items on a tray used as test tray were tested and read by Dietary Employee #1. The temperature was of the pureed tuna casserole was 110 degrees Fahrenheit. 4. On 6/9/15 at 5:33 p.m., Licensed Practical Nurse (LPN) #1 was asked, Why do you leave the food cart open when passing out trays? The LPN stated, Normally when they come, we open the cart and we serve one tray per person. We keep it open. That's how they've always done it. 5. On 6/9/15 at 5:39 p.m., Certified Nursing Assistant (CNA) #1 was asked, Why do you leave the food cart open when passing out the meal trays? The CNA stated, I guess it was easier for me to pass trays.

Based on observation and interview, the facility failed to ensure adequate amounts of potable drinking water were available in the facility to meet the needs of the residents in the event of a loss of normal water supply. The failed practice had the potential to affect all 46 residents who resided in the facility, according to the Resident Census and Conditions of Residents form dated 4/14/14 at 4:15 p.m. The findings are: 1. On 4/14/14 at 4:30 p.m., the Dietary Manager was asked where the emergency water supply was stored. She took the surveyor to an outside storage building. The Dietary Manager (DM) was asked how much water was available and stated, "There are three 5-gallon bottles." The DM was asked if there was any more water stored and stated, "I'll have to find out." 2. On 4/14/14 at 4:35 p.m., the Administrator was asked where the emergency water was stored. The Administrator stated, "There is some stored in the activity storage room and in the storage shed." 3. On 4/14/14 at 4:35 p.m., the Dietary Manager was accompanied by surveyor to the activity storage room where there were gallon sized bottles of water stored. The DM was asked how much water was there, and stated, "18 gallons." Added to the 15 gallons stored in the storage building, the facility had a total of 33 gallons of water on hand, with a census of 46 residents. 4. On 4/14/14 at 4:42 p.m., the Administrator was asked again where emergency water was stored and the Administrator stated, "In the storage shed and activity storage. We also have... gallons in the water heater and ice machine." The Administrator was informed that there were 33 gallons of potable water available in the facility and stated, "It's not a matter of getting it; it's a matter of storing it. We will have it tomorrow."

Complaint # was substantiated, all or in part, with these findings. Based on record review and interview, the facility failed to ensure incidents of verbal, mental and physical abuse witnessed by staff were immediately reported to the Administrator/designee, promptly and thoroughly investigated and residents were protected from potential further abuse during the investigations for 4 (Residents #1 - #4) of 4 (Residents #1 - #4) case mix residents for whom verbal abuse was witnessed and not immediately reported by staff. This failed practice resulted in Immediate Jeopardy, which caused or could have caused serious harm, injury, impairment or death for Residents #1 through #4, and was likely to cause more than minimal harm for 44 cognitively impaired residents, as documented on a list provided by the the Director of Nursing (DON) on 5/31/12 at 2:30 p.m. The facility removed the Immediate Jeopardy prior to the survey however, did not fully correct the underlying failed practices. On 5/31/12 at 2:20 p.m., the Administrator was informed of the Immediate Jeopardy removed. The findings are: 1. The Division of Medical Services (DMS) 762 Witness Statement Form, dated 4/29/12 at 5:00 p.m. and signed by Licensed Practical Nurse (LPN) #1, documented, "Tonight while in the dining room (CNA #1) yelled out '(expletive)' really loud with family members and residents present. I walked him to the time clock and asked him to leave. After that it was brought to my attention that he has had several CNAs witness him being rude or mean to a resident. I notified the (DON) and she came up to the facility to investigate this further." The "Termination of Employment" form dated 4/29/12 documented (CNA #1) was terminated for "Violation of company rules" and "Explanation Employee was walked to the door on 4/29 due to using profanity after numerous write ups and verbal warnings. After employee left fell ow employees wrote witness statements concerning (CNA #1's) behavior towards the residents. State of AR (Arkansas) & (and) local Police Department was notified ... Performance Rude ". 2. Resident #3 had [DIAGNOSES REDACTED]. The annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/09/12 documented the resident scored 6 (0-7 indicates severely impaired) on the Brief Interview for Mental Status (BIMS), required the extensive physical assistance of two plus persons for ambulation, transfers, toileting and personal hygiene. a. A Witness Statement Form, dated 4/29/12 at 5:40 p.m. and signed by CNA #2 documented, "The first night I worked with (CNA #1) he was very rude to most residents. (CNA #1) told (Resident #3) to put his damn foot in his pants and (Resident #3) cursed at him back then (CNA #1) said 'if your gonna curse me I don't have to do anything for you, I can leave you right here on the toilet'. Tonight in the dining room he (CNA #1) cursed really loudly and family members were in there." A DMS-762 dated 4/30/12 documented, "Date & Time of Incident Unknown ... Date & Time of Discovery 4/30/12 ... Date Incident Reported/Faxed to OLTC 4/30/12 1:31 p.m. ...Description of Incident On 04/29/12 the Director of Nursing was notified that (CNA #1) had been suspended due to cursing in dining room in front of residents. (DON) came to facility to investigate problem, while investigating was told by the Charge Nurses that she needed to talk with the other CNAs because something was wrong and the Charge Nurses felt that the CNAs would tell her what the problem was. While talking with CNAs it was reported that (CNA #1) had been assisting (Resident #3) one night and had told (Resident #3) to put his damn foot in his pants. When (Resident #3) cursed back, (CNA #1) said, 'if you're gonna curse me I don't have to do anything for you. I can leave you right here on the toilet'." b. On 5/30/12 at 2:12 p.m., CNA #2 stated, "The statement he (CNA #1) made to (Resident #3) was in mid April. When I heard him tell (Resident #3) he would leave him on the toilet, I didn't tell anyone. I knew I was supposed to. I didn't tell because I was new and I wanted everyone to like me." 3. Resident #4 had [DIAGNOSES REDACTED]. The quarterly MDS with an ARD of 3/10/12 documented the resident was moderately impaired in cognitively skills for daily decision-making per a staff assessment of mental status and required the extensive physical assistance of two persons for toilet use. a. The DMS- 762 Witness Statement Form, dated 4/29/12 at 5:20 p.m. and signed by CNA #3, documented, "Saw (CNA #1) being rough with (Resident #4) while we were trying to get him up out of bed just because (Resident #4) was trying to hit him. He (CNA #1) is always cussing around the residents." The DMS-762 dated 4/30/12 documented, "Date & Time of Incident Unknown ... Type of Incident emotional/mental ...Complete Description of the Incident On 4/29/12 (DON) was notified that (CNA #1) had been suspended due to cursing in dining room in front of residents. (DON) came to facility to investigate problem, while investigating was told by the Charge Nurses that she needed to talk with the other CNAs because something was wrong and the Charge Nurses felt that the CNAs would tell her what the problem was. While talking with CNAs it was reported that (CNA #1) had been witnessed being rough with (Resident #4) during care. This was described as (Resident #4) is combative during transfers and (CNA #1) was rough holding his arms down. No bruises or skin tears have been noted. (CNA #1) was notified several times to come to facility to write out statement refused stated he was too busy. (CNA #1) did contact (DON) on 4/30/12 and told her that all accusations were false but did not write out statement. (CNA #1) was suspended pending investigation. Family was notified. Police were notified. In-service was held with staff about abuse, neglect and reporting. Doctor was notified. Statements from alert, oriented residents revealed no problems were noted with (CNA #1). (Resident #4) continues to be alert and disoriented. (Resident #4) has no bruises or skin tears noted. Accusations against (CNA #1) are founded. (CNA #1) has been terminated due to failure to follow policy and procedure." b. On 5/30/12 at 1:25 p.m., CNA #3 stated, "I'm a new CNA. The 16th of April, I believe, is when I started this job. On 4/29/12, I wrote a statement relative to (CNA #1) and abusiveness toward residents. He grabbed (Resident #4) arms real hard and shoved them down roughly. I only saw him do that once. It was around the middle of April. I don't know the exact date. Every night that I worked around (CNA #1) he said the words, '(expletive), (expletive) and (expletive),' mainly at least once every shift. '(expletive)' was the word he used the most. He only worked weekends. He used these words when I worked with him. Before 4/29/12 I heard him curse and saw him be rough with (Resident #4). I did not report any of his actions or cursing. I should have though. I know that now. When I was hired as a CNA, I was told about abuse. I did not follow the Abuse Policy. Since 4/29/12, I went to an in-service on abuse on 5/7/12. I worked between 4/29/12 and 5/7/12." 4. Resident #1 had [DIAGNOSES REDACTED]. The quarterly MDS with an ARD of 3/13/12 documented the resident scored 5 (0-5 indicates severely impaired) on the BIMS and was totally dependent on the extensive physical assistance of 2 persons for transfers, dressing, toilet use and bathing. a. A DMS-762 Witness Statement Form dated, 4/29/12 at 5:40 p.m. and signed by CNA #2, documented, "(CNA #1) is also mean to (Resident #1), pulls on her ears (and) says annoying things to her to get her riled up." The DMS-762 dated 4/30/12 documented, "Date and Time of the Incident Unknown Type of Incident emotional/mental Complete Description of the Incident On 4/29/12 (DON) was notified that (CNA #1) had been suspended due to cursing in dining room in front of residents. (DON) came to facility to investigate problem, while investigating was told by the Charge Nurses that she needed to talk with the other CNAs because something was wrong and the Charge Nurses felt that the CNAs would tell her what the problem was. While talking with CNAs it was reported that (CNA #1) had been witnessed tugging on (Resident #1's) ears and saying things to her to annoy her. He had walked into room and pulled covers off her without telling her he was in the room to make her scream. (CNA #1) was notified several times to come to facility to write out statement refused stated he was too busy. (CNA #1) did contact (Director of Nursing) on 4/30/12 and told her that all accusations were false but did not write out statement. (CNA #1) was suspended pending investigation. Family was notified. Police were notified. In-service was held with staff about abuse, neglect and reporting. Doctor was notified. Statements from alert, oriented residents revealed no problems were noted with (CNA #1). (Resident #1) continues to be alert and disoriented. She has no signs or symptoms of injury noted. When CNAs were asked to explain what they meant about pulling on her ears, they stated he had tugged on ear lobe but not hard. Accusations against (CNA #1) were founded. (CNA #1) has been terminated due to failure to follow policy and procedure." The DMS-762 Witness Statement Form, dated 4/30/12 at 1:25 p.m. and signed by CNA #4, documented, "I saw (CNA #1) purposely yank the covers off of (Resident #1) knowing that she cannot see and that she gets cold easily and yank on her ears to make her scream and then laugh because it was fun." b. On 5/30/12 at 2:12 p.m., CNA #2 stated, "(CNA #1) would yank on (Resident #1's) ears. He would tickle her belly and her sides and say 'you like that, don't you.' It would get her riled up. I did not report this. That was in mid April also. I didn't report it. I was new but, I knew better. I attended the in-service on 5/7/12. I worked between 4/29/12 and 5/7/12 my normal schedule." c. On 5/30/12 at 3:05 p.m., CNA #4 stated, "I saw (CNA #1) yank the covers off of (Resident #1) about the first of April when I first started, the first time I ever worked with him. The same day, I saw him yank on her hears. She screamed, 'Oh Jesus, Oh Jesus'. She screams 'Oh Jesus' when she's scared. I didn't tell anyone about it when it happened." 5. Resident #2 had [DIAGNOSES REDACTED]. The quarterly MDS with an ARD of 2/14/12 documented the resident scored 5 (0-7 indicates severely impaired) on the BIMS and was totally dependent on the extensive physical assistance of two persons for transfers, dressing, toilet use and bathing. a. The DMS-762 Witness Statement Form, dated 4/29/12 at 5:55 p.m. and signed by CNA #5, documented, "On 4/28/12 in (Resident #2's) room I was getting her v/s (vital signs). (CNA #1) came in and told her he was going to see her 'hoo-hoo' when he put her to bed. He laughed and said he was kidding, she laughed then he left the room". The DMS-762 dated 4/30/12 documented, "Date and Time of Incident Unknown Type of Incident emotional/mental Complete Description of the Incident On 4/29/12 (DON) was notified that (CNA #1) had been suspended due to cursing in dining room in front of residents. (Director of Nursing) came to facility to investigate problem, while investigating was told by the Charge Nurses that she needed to talk with the other CNAs because something was wrong and the Charge Nurses felt that the CNAs would tell her what the problem was. While talking with CNAs it was reported that (CNA #1) had came into (Resident #2's) room and said to her that he was going to see her 'hoo-hoo' when he put her to bed. That one time he had yanked her out of w/c (wheelchair) and then when pulling her pants down while she was trying to hold them up so he could not see her he said, 'Oh Lena, I've seen your (slang for vagina) before it will be o.k. (CNA #1) was notified several times to come to facility to write out statement refused stated he was too busy. (CNA #1) did contact (DON) on 4/30/12 and told her that all accusations were false but did not write out statement. (CNA #1) was suspended pending investigation. Family was notified. Police were notified. In-service was held with staff about abuse, neglect and reporting. Doctor was notified. Statements from alert, oriented residents revealed no problems were noted with (CNA #1)." The DMS -762 Witness Statement Form, dated 4/30/12 at 1:25 p.m. and signed by CNA #4, documented, "I was in the room helping with (Resident #2) whom doesn't like men to get her undressed in the first place (CNA #1) yank her out of her chair without a gait belt then when pulling her pants down while she was trying to hold them up so he couldn't see her privates he said 'Oh Lena, I've seen your (slang for vagina) before. It will be ok.'" b. On 5/30/12 at 1:47 p.m., CNA #5 stated, "I wrote a statement on 4/29/12 about (CNA #1) cursing and what he said to (Resident #2) on 4/28/12. He (CNA #1) said curse words in the hall ever since I started working in March. He said he had been written up for cursing before but he continued to curse. In March is when I first started and heard him curse then and he continued to curse. I did not report it. I thought the nurses knew about it. The words he used were '(expletive), (expletive), (expletive)' and the 'F' word. On 4/28/12, he told (Resident #2) he would be the one putting her to bed and he would see her 'hoohoo'. I didn't report it that minute - I should have. I don't know why I didn't. I had an in-service on abuse on 45/7/12. I worked between the dates of 4/29/12 and 5/7/12." c. On 5/30/12 at 3:05 p.m., CNA #4 stated, "Probably mid April (CNA #1) yanked (Resident #2) out of her chair by her pants. She's supposed to be a two person lift with a gait belt. He pulled her pants down - she was trying to hold them up because she doesn't like men undressing her. He said. 'Oh Lena, I've seen your (slang for vagina) before. It will be OK.' I didn't report it to my charge nurse. I told another CNA but, I should have reported to my charge nurse. From 4/29/12 through 5/7/12 I did not receive an in-service. I worked my regular schedule between 4/29 and 5/7/12. I did receive a verbal counseling. I watched a short film on it when I first started." 6. The Immediate Jeopardy was removed and reduced to "H" when the facility presented documentation of a mandatory, house wide in-service dated 5/7/12 attended by 63 employees of all disciplines on the Abuse Policy and Procedure. The in-service documented, "Policy: It is the policy to ensure that a system is in place to prevent and detect resident abuse, neglect or the misappropriation of resident property. To that end, the following seven criteria will be utilized in the abuse prevention system: 1. Screening of potential employees, 2. Training of all employees regarding abuse or alleged abuse, 3. Prevention of abuse, 4. Identification of abuse or neglect of residents and the identification of events or occurrence which could lead to abuse or neglect of the resident, 5. Investigation protocols, 6. Protection of residents from abuse or neglect during an investigation and 7. Reporting/Response protocols ... Procedure ... 5. Any staff member that is a witness to or has knowledge of abuse, neglect or misappropriation of property will immediately report the incident to their direct supervisor...The charge nurse will notify the Director of Nursing, Administrator, the resident's physician and the resident's family or legal representative...6. Upon notification of abuse, neglect or misappropriation of resident property or upon notification of an allegation of abuse, neglect or misappropriation of resident property, the affected resident will be removed from the immediate area of the incident or alleged incident. If the allegation pertains to an employee or employees, that employee or those employees shall be suspended from duty, pending the outcome of the investigation....Proper intervention will be made to prevent further occurrences."

Complaint # was substantiated, all or in part, with these findings. Based on record review and interview, the facility failed to ensure the facility's Resident Abuse and Neglect Policy was implemented, as evidenced by failure to ensure incidents of verbal, mental and physical abuse witnessed by staff were immediately reported to the Administrator/designee, promptly and thoroughly investigated and residents were protected from potential further abuse during the investigations for 4 (Residents #1 - #4) of 4 (Residents #1 - #4) case mix residents for whom verbal abuse was witnessed and not immediately reported by staff. This failed practice resulted in Immediate Jeopardy, which caused or could have caused serious harm, injury, impairment or death for Resident #s 1, 2, 3, and #4, and was likely to cause more than minimal harm for 44 cognitively impaired residents, as documented on a list provided by the the Director of Nursing (DON) on 5/31/12 at 2:30 p.m. The facility removed the Immediate Jeopardy prior to the survey however, the underlying deficient practices were not fully corrected at the time of the survey. On 5/31/12 at 2:20 p.m., the Administrator was informed of the Immediate Jeopardy removed. The findings are: 1. The facility's policy and procedure titled "Abuse Policy and Procedure", provided by the DON on 5/30/12, documented, "Policy: It is the policy to ensure that a system is in place to prevent and detect resident abuse, neglect or the misappropriation of resident property. To that end, the following seven criteria will be utilized in the abuse prevention system: 1. Screening of potential employees, 2. Training of all employees regarding abuse or alleged abuse, 3. Prevention of abuse, 4. Identification of abuse or neglect of residents and the identification of events or occurrence which could lead to abuse or neglect of the resident, 5. Investigation protocols, 6. Protection of residents from abuse or neglect during an investigation and 7. Reporting/Response protocols." The procedure section documented the intent of each criteria including, " ...5. Any staff member that is a witness to or has knowledge of abuse, neglect or misappropriation of property will immediately report the incident to their direct supervisor...The charge nurse will notify the Director of Nursing, Administrator, the resident's physician and the resident's family or legal representative ...6. Upon notification of abuse, neglect or misappropriation of resident property or upon notification of an allegation of abuse, neglect or misappropriation of resident property, the affected resident will be removed from the immediate area of the incident or alleged incident. If the allegation pertains to an employee or employees, that employee or those employees shall be suspended from duty, pending the outcome of the investigation....Proper intervention will be made to prevent further occurrences." 2. The Division of Medical Services (DMS) 762 Witness Statement Form, dated 4/29/12 at 5:00 p.m. and signed by Licensed Practical Nurse (LPN) #1, documented, "Tonight while in the dining room (CNA #1) yelled out '(expletive)' really loud with family members and residents present. I walked him to the time clock and asked him to leave. After that it was brought to my attention that he has had several CNAs witness him being rude or mean to a resident. I notified the (DON) and she came up to the facility to investigate this further." The "Termination of Employment" form dated 4/29/12 documented (CNA #1) was terminated for "Violation of company rules" and "Explanation Employee was walked to the door on 4/29 due to using profanity after numerous write ups and verbal warnings. After employee left fell ow employees wrote witness statements concerning (CNA #1's) behavior towards the residents. State of AR (Arkansas) & (and) local Police Department was notified ... Performance Rude. " 3. Resident #3 had [DIAGNOSES REDACTED]. The annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/09/12 documented the resident scored 6 (0-7 indicates severely impaired) on the Brief Interview for Mental Status (BIMS), required the extensive physical assistance of two plus persons for ambulation, transfers, toileting and personal hygiene. a. A Witness Statement Form, dated 4/29/12 at 5:40 p.m. and signed by CNA #2 documented, "The first night I worked with (CNA #1) he was very rude to most residents. (CNA #1) told (Resident #3) to put his damn foot in his pants and (Resident #3) cursed at him back then (CNA #1) said 'if your gonna curse me I don't have to do anything for you, I can leave you right here on the toilet'. Tonight in the dining room he (CNA #1) cursed really loudly and family members were in there." A DMS-762 dated 4/30/12 documented, "Date & Time of Incident Unknown ... Date & Time of Discovery 4/30/12 ... Date Incident Reported/Faxed to OLTC 4/30/12 1:31 p.m. ...Description of Incident On 04/29/12 the Director of Nursing was notified that (CNA #1) had been suspended due to cursing in dining room in front of residents. (DON) came to facility to investigate problem, while investigating was told by the Charge Nurses that she needed to talk with the other CNAs because something was wrong and the Charge Nurses felt that the CNAs would tell her what the problem was. While talking with CNAs it was reported that (CNA #1) had been assisting (Resident #3) one night and had told (Resident #3) to put his damn foot in his pants. When (Resident #3) cursed back, (CNA #1) said, 'if you're gonna curse me I don't have to do anything for you. I can leave you right here on the toilet'." b. On 5/30/12 at 2:12 p.m., CNA #2 stated, "The statement he (CNA #1) made to (Resident #3) was in mid April. When I heard him tell (Resident #3) he would leave him on the toilet, I didn't tell anyone. I knew I was supposed to. I didn't tell because I was new and I wanted everyone to like me." 4. Resident #4 had [DIAGNOSES REDACTED]. The quarterly MDS with an ARD of 3/10/12 documented the resident was moderately impaired in cognitively skills for daily decision-making per a staff assessment of mental status and required the extensive physical assistance of two persons for toilet use. a. The DMS- 762 Witness Statement Form, dated 4/29/12 at 5:20 p.m. and signed by CNA #3, documented, "Saw (CNA #1) being rough with (Resident #4) while we were trying to get him up out of bed just because (Resident #4) was trying to hit him. He (CNA #1) is always cussing around the residents." The DMS-762 dated 4/30/12 documented, "Date & Time of Incident Unknown ... Type of Incident emotional/mental ...Complete Description of the Incident On 4/29/12 (DON) was notified that (CNA #1) had been suspended due to cursing in dining room in front of residents. (DON) came to facility to investigate problem, while investigating was told by the Charge Nurses that she needed to talk with the other CNAs because something was wrong and the Charge Nurses felt that the CNAs would tell her what the problem was. While talking with CNAs it was reported that (CNA #1) had been witnessed being rough with (Resident #4) during care. This was described as (Resident #4) is combative during transfers and (CNA #1) was rough holding his arms down. No bruises or skin tears have been noted. (CNA #1) was notified several times to come to facility to write out statement refused stated he was too busy. (CNA #1) did contact (DON) on 4/30/12 and told her that all accusations were false but did not write out statement. (CNA #1) was suspended pending investigation. Family was notified. Police were notified. In-service was held with staff about abuse, neglect and reporting. Doctor was notified. Statements from alert, oriented residents revealed no problems were noted with (CNA #1). (Resident #4) continues to be alert and disoriented. (Resident #4) has no bruises or skin tears noted. Accusations against (CNA #1) are founded. (CNA #1) has been terminated due to failure to follow policy and procedure." b. On 5/30/12 at 1:25 p.m., CNA #3 stated, "I'm a new CNA. The 16th of April, I believe, is when I started this job. On 4/29/12, I wrote a statement relative to (CNA #1) and abusiveness toward residents. He grabbed (Resident #4) arms real hard and shoved them down roughly. I only saw him do that once. It was around the middle of April. I don't know the exact date. Every night that I worked around (CNA #1) he said the words, '(expletive), (expletive) and (expletive),' mainly at least once every shift. '(expletive)' was the word he used the most. He only worked weekends. He used these words when I worked with him. Before 4/29/12 I heard him curse and saw him be rough with (Resident #4). I did not report any of his actions or cursing. I should have though. I know that now. When I was hired as a CNA, I was told about abuse. I did not follow the Abuse Policy. Since 4/29/12, I went to an in-service on abuse on 5/7/12. I worked between 4/29/12 and 5/7/12." 5. Resident #1 had [DIAGNOSES REDACTED]. The quarterly MDS with an ARD of 3/13/12 documented the resident scored 5 (0-5 indicates severely impaired) on the BIMS and was totally dependent on the extensive physical assistance of 2 persons for transfers, dressing, toilet use and bathing. a. A DMS-762 Witness Statement Form dated, 4/29/12 at 5:40 p.m. and signed by CNA #2, documented, "(CNA #1) is also mean to (Resident #1), pulls on her ears (and) says annoying things to her to get her riled up." The DMS-762 dated 4/30/12 documented, "Date and Time of the Incident Unknown Type of Incident emotional/mental Complete Description of the Incident On 4/29/12 (DON) was notified that (CNA #1) had been suspended due to cursing in dining room in front of residents. (DON) came to facility to investigate problem, while investigating was told by the Charge Nurses that she needed to talk with the other CNAs because something was wrong and the Charge Nurses felt that the CNAs would tell her what the problem was. While talking with CNAs it was reported that (CNA #1) had been witnessed tugging on (Resident #1's) ears and saying things to her to annoy her. He had walked into room and pulled covers off her without telling her he was in the room to make her scream. (CNA #1) was notified several times to come to facility to write out statement refused stated he was too busy. (CNA #1) did contact (Director of Nursing) on 4/30/12 and told her that all accusations were false but did not write out statement. (CNA #1) was suspended pending investigation. Family was notified. Police were notified. In-service was held with staff about abuse, neglect and reporting. Doctor was notified. Statements from alert, oriented residents revealed no problems were noted with (CNA #1). (Resident #1) continues to be alert and disoriented. She has no signs or symptoms of injury noted. When CNAs were asked to explain what they meant about pulling on her ears, they stated he had tugged on ear lobe but not hard. Accusations against (CNA #1) were founded. (CNA #1) has been terminated due to failure to follow policy and procedure." The DMS-762 Witness Statement Form, dated 4/30/12 at 1:25 p.m. and signed by CNA #4, documented, "I saw (CNA #1) purposely yank the covers off of (Resident #1) knowing that she cannot see and that she gets cold easily and yank on her ears to make her scream and then laugh because it was fun." b. On 5/30/12 at 2:12 p.m., CNA #2 stated, "(CNA #1) would yank on (Resident #1's) ears. He would tickle her belly and her sides and say 'you like that, don't you.' It would get her riled up. I did not report this. That was in mid April also. I didn't report it. I was new but, I knew better. I attended the in-service on 5/7/12. I worked between 4/29/12 and 5/7/12 my normal schedule." c. On 5/30/12 at 3:05 p.m., CNA #4 stated, "I saw (CNA #1) yank the covers off of (Resident #1) about the first of April when I first started, the first time I ever worked with him. The same day, I saw him yank on her ears. She screamed, 'Oh Jesus, Oh Jesus'. She screams 'Oh Jesus' when she's scared. I didn't tell anyone about it when it happened." 6. Resident #2 had [DIAGNOSES REDACTED]. The quarterly MDS with an ARD of 2/14/12 documented the resident scored 5 (0-7 indicates severely impaired) on the BIMS and was totally dependent on the extensive physical assistance of two persons for transfers, dressing, toilet use and bathing. a. The DMS-762 Witness Statement Form, dated 4/29/12 at 5:55 p.m. and signed by CNA #5, documented, "On 4/28/12 in (Resident #2's) room I was getting her v/s (vital signs). (CNA #1) came in and told her he was going to see her 'hoo-hoo' when he put her to bed. He laughed and said he was kidding, she laughed then he left the room." The DMS-762 dated 4/30/12 documented, "Date and Time of Incident Unknown Type of Incident emotional/mental Complete Description of the Incident On 4/29/12 (DON) was notified that (CNA #1) had been suspended due to cursing in dining room in front of residents. (Director of Nursing) came to facility to investigate problem, while investigating was told by the Charge Nurses that she needed to talk with the other CNAs because something was wrong and the Charge Nurses felt that the CNAs would tell her what the problem was. While talking with CNAs it was reported that (CNA #1) had came into (Resident #2's) room and said to her that he was going to see her 'hoo-hoo' when he put her to bed. That one time he had yanked her out of w/c (wheelchair) and then when pulling her pants down while she was trying to hold them up so he could not see her he said, 'Oh (name), I've seen your (slang for vagina) before it will be o.k. (CNA #1) was notified several times to come to facility to write out statement refused stated he was too busy. (CNA #1) did contact (DON) on 4/30/12 and told her that all accusations were false but did not write out statement. (CNA #1) was suspended pending investigation. Family was notified. Police were notified. In-service was held with staff about abuse, neglect and reporting. Doctor was notified. Statements from alert, oriented residents revealed no problems were noted with (CNA #1)." The DMS -762 Witness Statement Form, dated 4/30/12 at 1:25 p.m. and signed by CNA #4, documented, "I was in the room helping with (Resident #2) whom doesn't like men to get her undressed in the first place (CNA #1) yank her out of her chair without a gait belt then when pulling her pants down while she was trying to hold them up so he couldn't see her privates he said 'Oh Lena, I've seen your (slang for vagina) before. It will be ok.'" b. On 5/30/12 at 1:47 p.m., CNA #5 stated, "I wrote a statement on 4/29/12 about (CNA #1) cursing and what he said to (Resident #2) on 4/28/12. He (CNA #1) said curse words in the hall ever since I started working in March. He said he had been written up for cursing before but he continued to curse. In March is when I first started and heard him curse then and he continued to curse. I did not report it. I thought the nurses knew about it. The words he used were '(expletive), (expletive), (expletive)' and the 'F' word. On 4/28/12, he told (Resident #2) he would be the one putting her to bed and he would see her 'hoohoo'. I didn't report it that minute - I should have. I don't know why I didn't. I had an in-service on abuse on 5/7/12. I worked between the dates of 4/29/12 and 5/7/12." c. On 5/30/12 at 3:05 p.m., CNA #4 stated, "Probably mid April (CNA #1) yanked (Resident #2) out of her chair by her pants. She's supposed to be a two person lift with a gait belt. He pulled her pants down - she was trying to hold them up because she doesn't like men undressing her. He said. 'Oh (name), I've seen your (slang for vagina) before. It will be OK.' I didn't report it to my charge nurse. I told another CNA but, I should have reported to my charge nurse. From 4/29/12 through 5/7/12, I did not receive an in-service. I worked my regular schedule between 4/29 and 5/7/12. I did receive a verbal counseling. I watched a short film on it when I first started." 7. The Immediate Jeopardy was removed and reduced to "H" when the facility implemented the following corrective actions: a. The CNA was suspended on 4/29/12 and later terminated without a return to work. b. The Director of Nursing initiated the investigation into the allegations on 4/29/12. The allegations were reported to OLTC, the police, the physician and the family members. c. The facility conducted a mandatory, house wide in-service dated 5/7/12 attended by 63 employees of all disciplines on the Abuse Policy and Procedure. The in-service documented, "Policy: It is the policy to ensure that a system is in place to prevent and detect resident abuse, neglect or the misappropriation of resident property. To that end, the following seven criteria will be utilized in the abuse prevention system: 1. Screening of potential employees, 2. Training of all employees regarding abuse or alleged abuse, 3. Prevention of abuse, 4. Identification of abuse or neglect of residents and the identification of events or occurrence which could lead to abuse or neglect of the resident, 5. Investigation protocols, 6. Protection of residents from abuse or neglect during an investigation and 7. Reporting/Response protocols ... Procedure ... 5. Any staff member that is a witness to or has knowledge of abuse, neglect or misappropriation of property will immediately report the incident to their direct supervisor...The charge nurse will notify the Director of Nursing, Administrator, the resident's physician and the resident's family or legal representative...6. Upon notification of abuse, neglect or misappropriation of resident property or upon notification of an allegation of abuse, neglect or misappropriation of resident property, the affected resident will be removed from the immediate area of the incident or alleged incident. If the allegation pertains to an employee or employees, that employee or those employees shall be suspended from duty, pending the outcome of the investigation....Proper intervention will be made to prevent further occurrences."(Verified per facility documentation and staff interviews)