Every finding on record at St Johns Place of Arkansas, LLC

Based on interviews, record reviews, facility document review, facility policy review, it was determined that the facility failed to identify and act upon interruptions in monthly funds being deposited into a resident's trust fund after assuming responsibility to act as a fiduciary of the resident's funds for one (Resident #1) of three residents. The findings include: A review of Resident #1's quarterly Minimum Data Set (MDS) with an Assessment Reference Date of 04/08/2026 revealed Resident #1 had a Brief Interview for Mental Status (BIMS) of 5, indicating severe cognitive impairment. A review of Resident #1's Medical Diagnosis report revealed Resident #1 has diagnosis of type 2 diabetes mellitus, hypertension, major depressive disorder, anxiety, altered mental status, and dementia. A review of Resident #1's Care Plan revealed the resident resided in the facility's secure unit, was at risk for elopement/wandering, was disoriented to place, and had impaired safety awareness. Resident #1 had a communication problem related to dementia and disorientation. A review of Resident #1's admission Agreement revealed that on July 1, 2020, the resident's Power of Attorney (POA) assigned income to the facility as is necessary for payment of all charges incurred relating to Resident's care. The POA also elected, in writing, for the facility to manage Resident #1's personal funds and to receive funds on the resident's behalf for the facility to deposit into a Resident Trust Account. A review of Resident #1's Patient Trust Fund (PTF) account ledgers revealed the resident had been receiving a social security check and two pension checks, one in the amount of $115.08 and one in the amount of $60.15 for a total pension income of $175.23. -Beginning in December 2025, the pension checks were not received by the facility and were not deposited into the Resident #1's PTF account. -On 11/30/2025, Resident #1's PTF account had a balance of $963.96. -On 5/31/2026, the balance of Resident #1's PTF account had decreased to $138.78. A review of Resident #1's Correspondence Payment Summary revealed pension payments from November 16, 2021, January 1, 2022, November 1, 2022, Identified the amount of pension payment from the financial institution was $115.08 and $60.15 and that 1099's for years 2022, 2023, and 2024 were mailed to Resident #1 at the facility address. During an interview on 06/15/2026 at 2:17 PM, the Business Office Manager (BOM) stated that on May 27, 2026, the BOM noticed the resident's pension checks had not been deposited into Resident #1's PTF account since December 2025. The BOM stated the total amount that had not been deposited between December 2025, and May 2026 was $1,051.38. The BOM stated they did not notice anything when the checks stopped coming in December 2025 because the resident still had enough to pay the bills and had funds left in the account. -The BOM said Resident #1 received three checks each month, a social security check and two pension checks, which were paper checks that the facility had received on behalf of the resident. The BOM said the facility then deposited the paper checks into the PTF account each month. -The BOM stated Resident #1's total income was $1,947.23, out of which the resident paid their patient liability to the nursing home, paid $148.00 for their vision/dental insurance each month, and the resident was allowed to keep $40.00 each month. The BOM stated the facility had been paying the resident's dental/vision premium from the resident's PTF account, with a total of $888.00 had been paid over the 6-month period to the insurance company. -The BOM stated the amount of interest Resident #1 would have drawn each month was affected by the checks not being deposited and the depletion of the account balance each month because the interest was being paid on less money. -The BOM stated their responsibilities related to managing a residents' monies were to make sure the residents' room and board were paid, their insurance benefits were paid, and to make sure they get to keep their $40.00 for their personal needs. The BOM stated they did not manage Resident #1's money appropriately but tried to fix the oversight as soon as it was discovered. -The BOM stated they were responsible for managing the resident's accounts, which included reconciling the account each month. As a result, the BOM stated they should be aware of transactions going into and out of the residents' accounts. The BOM stated if the facility had received checks each month and then the checks just stopped coming, they should have contacted the POA and asked if they had received the checks. -The BOM stated the first time they contacted the POA about Resident #1's checks not arriving at the facility on May 27, 2026. The BOM stated they had left a voice mail for the POA, but the POA did not return their call and that is when the facility opened an investigation. The BOM stated the investigation revealed the checks had been mailed to the resident's former physical address, where one of the resident's POAs currently resides. The BOM stated this occurred when the financial institution that had managed the Pension Fund changed hands. During an interview on 06/16/2025 at 12:30 AM, the Administrator stated their process for when funds aren't received from a payor source would be to reach out and find out why the resident was not getting whatever payment they were supposed to be getting. The Administrator stated she was notified of the issue when the BOM was talking with the DHS Eligibility Specialist and the BOM stated the DHS Eligibility Specialist said the facility needed to do a report for misappropriation of property. The Administrator stated the facility should have identified the checks not being received and deposited between December of 2025 and May of 2026. The Administrator stated they should have identified it by looking at the residents' PTF and looking for money depletion. During a phone interview with DHS Eligibility Specialist on 06/16/2026 at 1:35 PM, the DHS Eligibility Specialist stated they noticed in May 2026 that the money had stopped being input into the resident's account in December 2025, so they called the nursing home and asked if the resident was still getting the income. The DHS Eligibility Specialist informed the BOM that the facility had to find out where the money was going. The DHS Eligibility Specialist stated the BOM told them the facility had contacted a family member and the retirement people to find out where the money was going. The DHS Eligibility Specialist said they were under the understanding from the BOM that the family was going to pay back the money. A payment was made on 06/08/2026 for the amount of $273.23, leaving $778.15 that was not returned. The DHS Eligibility specialist stated DHS had approved the Medicaid renewal application and counted the income back to the resident. During a follow-up interview on 06/16/2026 at 3:58 PM, the BOM reported they had informed one of Resident #1's POAs that the monies had to come back to the facility, and they were sending a bill to the other POA who resides at the address where the checks were mailed. The BOM stated the correct course of action would have been to identify the discrepancy, call the POA, and inquire about changes in the deposits. The BOM stated they first noticed Resident #1's monies were depleting in May, at which time a voicemail was left with one of the resident's POAs, informing them that the pension checks were not coming to the facility and the resident would not have enough money to pay the June bill if the checks did not come back to the facility. The DHS Eligibility Specialist called a few days later and asked if it had been noticed Resident #1's checks were not going into the resident's account. During an interview on 06/17/2025 at 10:31 AM, the Administrator stated the BOM and Administrator are responsible for ensuring an accurate management and accounting of residents' monies are being completed. The Administrator said the PTF accounts should be reviewed and balanced each month. The Administrator stated it is important to manage and account for a resident's monies going into and out of the PTF accounts to make sure the residents have funds. The Administrator stated when the facility accepts the responsibility of managing a resident's funds and a check that is scheduled to be received at the facility does not arrive the facility should reach out to the one who is supplying the check and figure out why it is not being delivered. The Administrator stated this should be done as soon as we are made aware of it. The Administrator stated the facility should have noticed the first month Resident #1's checks did not arrive at the facility. The Administrator stated they did not hold, safeguard, and manage the account for Resident #1's personal funds deposited with the facility properly. A review of a facility undated policy titled, Management of Resident and Elder Trust Accounts. Indicated, Quote Protection and management of Resident/Elder funds. If the Resident/Elder presents written authorization, the nursing facility shall hold, safeguard and manage, and account for the Resident/Elders personal funds deposited with the nursing facility. The nursing facility has established and maintains a system that assures a full, complete and separate accounting of funds entrusted to the nursing facility on the Resident/Elder's behalf. The accounting system is established according to generally accepted accounting principles .Ledger and bank accounts are reconciled monthly.

Based on observation, record review, interview, and facility policy review, the facility failed to ensure proper hand hygiene was consistently implemented during incontinence care for one (Resident #54) of one resident reviewed for bowel and bladder incontinence. The findings include: During an observation on 09/29/2025 at 1:12 PM, this surveyor observed Certified Nursing Assistant (CNA) #4 and CNA #5 assist Resident #54 from their wheelchair to their bed, using a mechanical lift, to provide incontinence care. Both CNAs put on gloves and a gown. CNA #4 then pulled an undetermined number of wet wipes from a package on the over-bed table and left them on top of the package. CNA #4 positioned the resident on their right side, removed their adult brief and began using the wipes to cleanse the resident's bottom. Resident #54's brief was wet and contained loose bowel movement that was malodorous. After CNA #4 had used all the loose wipes from on top of the package, without changing gloves or sanitizing her hands, she began pulling clean wet wipes directly from the package to continue cleaning feces off the resident's bottom. CNA #5 did not perform care, but she held the resident in position during incontinence care. After CNA #4 had completed cleaning the resident's bottom, without changing gloves or sanitizing her hands, she placed a clean brief under the resident's buttocks and continued removing wet wipes from the package to cleanse the resident's pubic area and groin. Again, without changing gloves or sanitizing her hands, CNA #4 fastened the resident's brief. After Resident #54's pants were put on, CNA #4 used the same gloves that were used to perform perineal care, to hook the lift pad to the mechanical lift, touching the metal parts of the lift. After Resident #54 was lifted off the bed, CNA #4, yet wearing the same gloves, guided the resident in the chair as the lift was lowered. After the resident was in their wheelchair, CNA #4 discarded the soiled pair of gloves in the resident's trash can in the room, then performed hand hygiene before exiting the resident's room. A review of Resident #54's quarterly Minimum Data Set (MDS) with an Assessment Reference Date of 09/18/2025, revealed a Brief Interview for Mental Status score of 07, which indicated the resident had severe cognitive impairment. Resident #54's MDS also revealed the resident required substantial/maximal assistance with toileting and personal hygiene, shower/bathe self and chair/bed-to-chair transfer. A review of Resident #54's Care Plan, reviewed 09/25/2025, revealed the resident required staff assistance with activities of daily living due to weakness and had leg contractures. Resident #54's Care Plan also revealed the resident required a mechanical lift with staff assist x2; and had some bladder incontinence related to overactive bladder, with an intervention that directed staff to clean the resident's perineal area with each incontinence episode. During an interview on 11/19/2025 at 1:55 PM, CNA #4 stated hands should be sanitized/washed before going into a resident's room and after leaving the resident's room. She stated, during incontinence care of a resident who had a bowel movement, she [usually] sanitizes her hands after entering the resident's room and put gloves on. She stated, during incontinence care of a resident; gloves should be changed before removing clean wipes from a package, after bowel has been cleansed from a resident, and then hands should be sanitized. CNA #4 revealed the reason gloves should be changed and hands should be sanitized was because bowel was present. She the stated she has had education/training on how to perform hand hygiene during incontinence care, but it had been a while, and she did not give the time frame. During an interview on 11/19/2025 at 2:17 PM, CNA #7 stated hands should be washed when you first walk in the door, sanitize [hands] and change your gloves before you start the actual care on a resident. She stated during incontinence care of a resident, you should change gloves before removing clean wipes from a package, unless you have an assistant helping you by pulling out your wipes for you because of cross contamination, and after you have cleansed bowel from the resident. CNA #7 then stated you should not use the same gloves used to cleanse bowel from a resident's skin, to put an adult brief on the resident because of cross contamination. During an interview on 11/19/2025 at 3:39 PM, the Director of Nursing (DON) stated hand hygiene was important to prevent the spread of germs and infection. She stated her expectation for staff and hand hygiene was they needed to keep their hands clean when dealing with bodily fluids, when going from dirty to clean staff needed to change their gloves, and they need to wash their hands after they removed their gloves. The DON later stated the facility did not have a policy on hand hygiene. A review of an undated Infection Prevention and Control Program policy, revealed for standard precautions, hand hygiene shall be performed in accordance with our [the facility's] hand hygiene guidance. A review of a Hand Hygiene document that was posted in the ladies restroom, located on the hallway to the left of the DON's office, revealed hand hygiene should be performed before having direct contact with patients; after contact with blood, body fluids or excretions; if hands will be moving from a contaminated -body site to a clean-body site during care; and after removing gloves.

Based on record review and interview, the facility failed to provide evidence that notice of transfers or discharges were sent to the state Ombudsman for residents transferred out of the facility to a local hospital for one (Resident #74) of two residents reviewed for hospitalization. The findings include: A review of Resident #74's admission Record revealed the facility initially admitted the resident on 01/01/2017, with diagnoses which included gastro-esophageal reflux disease without esophagitis and hyperlipidemia. A review of a Standard Forms Screen for Notice of Transfer/Discharge revealed a Notice of Transfer/Discharge form was completed for Resident #74 on 08/13/2025 and 09/16/2025. A review of the Emergency Transfers from Facility form revealed Resident #74 was transferred to the hospital on [DATE] and 09/16/2025. A review of a Notice of Transfer/Discharge/Leave of Absence with Bed Hold Policy form, dated 09/16/2025, indicated Resident #74 was transferred to [local hospital name] on 09/16/2025 for shortness of breath. The form did not indicate the Ombudsman was notified of this transfer. A review of Resident #74's Progress Notes for 08/16/2025 to 11/18/2025, did not reveal documentation of the notification of transfer/discharge forms being sent to the Ombudsman for the resident's transfers to the hospital on [DATE] or 09/16/2025. During an interview by another surveyor on 11/19/2025 at 11:10 AM, the Administrator acknowledged the Social Worker sent the transfer logs and transfer notices to the state Ombudsman. The Administrator added that he could not provide proof of the emails, because the Social Worker was out on leave. On 11/19/2025 at 11:25 AM, this surveyor attempted to reach the state Ombudsman by telephone, and the call was intercepted by voicemail. On 11/19/2025 at 11:27 AM, this surveyor attempted to reach the Program Coordinator for the state Ombudsman, and the call was intercepted by voicemail. During an interview on 11/19/2025 at 1:22 PM, the Administrator stated the Social Worker sent notifications [transfer/discharge] to the state Ombudsman around the first week of the month. He stated he did not know if the Social Worker was or was not sending the transfers and he would ask the Social Worker when she returned to work. The Administrator later stated the facility did not have a policy on Ombudsman notification. Following the survey exit, the State Agency contacted the Administrator on 12/04/2025, to provide an opportunity for the facility to supply the documentation requested during survey that was unavailable due to the facility Social Worker being on leave. The Administrator reported the Social Worker had returned from leave but was unable to produce evidence that the Ombudsman was contacted.

Based on record review, interview, and facility policy review, the facility failed to ensure required components were included in the facility assessment dated [DATE]. The findings include: A review of the Facility Assessment, with the date of assessment or update of 05/01/2025, revealed no governing body member was listed as being involved in the completion of the facility assessment and no staff retention information was documented in the facility assessment. During an interview on 11/19/2025 at 2:56 PM, the Administrator stated he completed the facility assessment. If he had any nursing questions, he involved the Director of Nursing (DON) and reviewed the facility assessment with the Medical Director for input. The Administrator reported there was not a member of the governing body that was actively involved in the formation of the facility assessment. He stated the Medical Director, the DON, and himself should be involved with the completion of the facility assessment, but that he was not 100 percent sure what the federal requirements were for the facility assessment. He stated the facility had not held any Quality Assurance and Assessment meetings since May 2025 to review the facility assessment, and that he did not know why the plan for staff retention was not put in the assessment. A review of a document, Attachment 1 Medicare and Medicaid Programs; Reform of Requirements for Long-Term Care Facilities Federal Register/Vol. [volume] 81, No. [number] 192/Tuesday, October 4, 2016/Rules and Regulations, which the Administrator provided when asked for a policy, did not indicate which members were included in the completion of the facility assessment and did not include the inclusion of a staff retention plan. Page 17 titled, Attachment 2 Sample Process for Conducting the Facility Assessment indicated the facility assessment leader reviewed the regulation for the facility assessment requirements and invited team members on the assessment team, including the Administrator, representative of the governing body, the Medical Director, and DON, and considered other persons to be on the team. Attachment 2 indicated the team leader and others assigned were to complete the assessment.

Based on observation, record review and interview, the facility failed to ensure foods stored in the freezer were covered and sealed to maintain freshness and decrease the potential for cross contamination who received meals from 1 of1 main kitchen; dietary staff washed their hands before handling clean equipment or food items to prevent potential food borne illness for residents who received meals from 1 of 1 kitchen; hot food items were not maintained at or above 135 degrees Fahrenheit on the steam table while awaiting service to prevent potential food borne illness for the residents who received meals from 1 of 1 kitchen. These failed practices had the potential to affect 67 residents who received meals from the Kitchen (Total Census: 69), according to the list provided by the Dietary Manager on 06/12/2024 at 9:40 AM. The findings are: 1 On 06/11/2024 at 9:24 AM, the following observations were made in the walk-in freezer: a. An opened box of corn dogs was on a shelf in the freezer. The box was not covered or sealed. b. An opened box of mixed vegetables was on a shelf in the freezer. The box was not covered or sealed. 2. On 06/11/2024 at 9:35 AM, Dietary Aide (DA) #1 picked up the water hose with her bare hand, used it to spray leftover food from inside of the dishes, contaminating her hands. She placed the dirty dishes in the dirty racks and pushed the racks into the dish washing machine to wash. After the dishes stopped washing, she moved to the clean side of the dishwasher area and picked up clean dishes and placed them on the clean utility cart to be used in serving the noon meal to the residents. The Surveyor asked her immediately, What should you have done after touching dirty objects and before handling clean equipment and food? She stated, I should have washed my hands. 3. On 06/11/2024 at 11:33 AM, Dietary [NAME] (DC) #2 turned on the hand washing sink faucet and washed her hands. DC #2 then turned off the faucet with her bare hands, contaminating them. Without washing her hands, DC #2 picked a clean blade and attached it to the base of the blender to be used in pureeing food items to be served to the residents on pureed diets. The Surveyor asked, What should you have done after touching dirty objects and before handling clean equipment and food? She stated, I should have washed my hands. 4. On 06/11/2024 at 11:43 AM, Dietary Aide (DA) #3 turned on the hand washing sink and washed her hands. She then used her bare hand to turn off the sink, contaminating her hands. Without washing her hands, DA #3 picked a clean blade and attached it to the base of the blender to be used in pureeing food items to be served to the residents on pureed diets. The Surveyor asked DA #3, What should you have done after touching dirty objects and before handling clean equipment and food? She stated, I should have washed my hands. 5. On 06/11/2024 at 12:01 PM, the temperature of the pureed bread with milk when checked and read on the table by the DA #2 was 100 degrees Fahrenheit. The pureed bread with milk was not reheated before being served to the residents. 6. The facility policy titled, Personal Hygiene, provided by the Dietary Manager on 06/12/2024 at 9:40 AM documented, .Wash hands carefully with soap and water whenever they become soiled, immediately before work in the morning . after handling raw unwashed food and dirty dishes; before touching food, clean dishes and silverware .

Based on record review and interview, the facility failed to ensure residents with a trust account had access to their personal funds after business hours and on weekends. This failed practice had the potential to affect 64 residents who had trust accounts managed by the facility; and failed to ensure resident trust account funds were reimbursed back to the resident/resident representative within 30 days of discharge this failed practice affected one resident. 1. On 06/12/2024 at 9:50 AM, the surveyor asked Resident #38 who handles their money. Resident #38 indicated the facility. The surveyor asked Resident #38 if the resident was able to get money on the weekends? Resident #38 stated No, the [Business Office Manager (BOM)] goes to the bank on Tuesday, so we have to request money on Monday. 2. On 06/12/2024 at 3:04 PM, the BOM was asked if petty cash was left with the charge nurse on the weekend? The BOM indicated no. The BOM indicated that they have never left money on the weekends for the residents. The BOM indicated that she goes around on Thursday and checks with the residents and sees if they need any money for the weekend she will go to the bank on Friday. 3. On 06/12/2024 at 3:04 PM, the BOM asked if the residents have access to their money on the weekends. The BOM stated No. 4. Resident A on the [Facility Name] Trust Current Account Balance passed away on 02/06/2024. Resident A had a balance of $515.77. 5. On 06/12/2024 at 3:04 PM, the BOM was asked when funds were supposed to be refunded or returned after someone discharges from the facility. The BOM indicated 30 days. 6. On 06/13/2024 at 11:13 AM, the Administrator was asked when funds were supposed to be refunded or returned after a resident discharged from the facility. The Administrator indicated 30 days. 7. On 06/12/2024 at 3:04 PM, the BOM was asked about Residents B, C, D and E on the [Facility Name] Trust Current Account Balance, have balances and in [Facility Computer Software] these residents show up under the New tab, they are not current residents. The BOM indicated that she has worked here four years and these residents (Resident's B, C, D and E) have not been residents here. BOM indicated all she could think of was that someone came up and put money in their account and they never came and admitted to the facility. 8. On 06/13/2024 at 11:13 AM, the Administrator was asked about Residents B, C, D and E on the [Facility Name] Trust Current Account Balance. The Administrator indicated that he did not know how these residents ended up in the New tab of [Facility Computer Software]. The Administrator was asked if any of these residents had resided in this facility. The Administrator indicated that he wasn't sure, but he was sure they hadn't in the last four years since he had been here.

Based on observation, interviews and facility policy review, the facility failed to ensure activities were provided to the Residents on the secured unit despite having an activities calendar in place designed for Residents with cognitive impairment. The findings include: On 06/10/2024 at 10:20 AM, the Surveyor observed Residents sitting in the common area with the television on, but the Residents did not appear to be watching the television. The Surveyor observed the Residents with their heads down, touching other Residents, picking at their clothing, and/or getting up and being told to sit down. On 06/10/2024 at 1:21 PM, the Surveyor observed several Residents sitting in the common area with the television on, but the Residents did not appear to be watching the television. On 06/12/2024 at 10:45 AM, the Surveyor observed Residents sitting in the common area with the television on, but the Residents did not appear to be watching the television. On 06/12/2024 at 1:53 PM, the Surveyor observed Residents sitting in the common area with the television on, but the Residents did not appear to be watching the television. The Surveyor observed Certified Nursing Assistant (CNA) #9 asked the Residents if they were ready for activities, then sat in a chair next to a desk in the common area. On 06/12/2024 at 2:30 PM, the Surveyor observed Residents sitting in the common area with the television on, but the Residents did not appear to be watching the television. The Surveyor observed CNA#9 sitting in a chair next to a desk in the common area. The Surveyor did not observe any ongoing activities. On 06/12/2024 at 2:40 PM, during an interview CNA #9 asked the Surveyor what was sit to stand when asked if sit to stand activity had been performed today. CNA #9 voiced that the Activity Director was responsible for doing activities with the Residents. On 06/12/2024 at 2:50 PM, during an interview the Activity Director voiced that the aides on the hall were responsible for doing activities with the Residents on the secured unit because the activities for the Residents on the secured unit was scheduled at the same time as the other Residents in the facility. The Activity Director voiced that there was an activity calendar posted on the secured unit with suggested time. On 06/13/2024 at 11:06 AM, during an interview the Director of Nursing (DON) voiced the Activity Director was responsible for doing activities with the Residents on the secured unit not the aide, because they have enough to do, and that watching television was not considered an activity if the Residents are not engaged or showing interest in watching the television. On 06/13/2024 at 11:07 AM, review of a policy provided to the Surveyor titled, Activity Programs stated, Activities. The nursing facility provides an ongoing program of Resident/Elder activities/meaningful engagement. Activities will be varied in nature and should be designed to meet the individual needs, interests, and limitations, of Residents/Elder's comprehensive assessment and in conjunction with the Residents/Elder's requests. This includes all Residents/Elders that are bedfast, ambulatory, and disabled. These activities should provide meaningful engagement, mental, social, and spiritual stimulation. The nursing facility will support the Residents/Elders with resources and supplies they need to participate in the program. Activity director/leader. The activity program is directed by a qualified individual who has completed a training course approved by the State. The activity director should be aware of the Residents/Elders' strengths, limitations, and develop activity plans on an individual and group basis .

Based observations, interviews, and facility policy review, the facility failed to ensure medication carts were locked and secure when untended and out of the line of sight of the nurse and controlled medications were stored in separately locked, permanently affixed compartment in the refrigerator to prevent misappropriation of medications. The findings include: 1. On 06/10/2024 at 12:30 PM, the Surveyor observed Registered Nurse (RN) #10 walk away from the unlocked medication cart and enter a Resident's room with her back turned to the hallway where the medication cart was placed. a. On 06/10/2024 at 12:33 PM, Registered Nurse #10 confirmed the medication cart was unlocked while unattended. b. On 06/13/2024 at 10:32 AM, the Director of Nursing (DON) voiced an unattended medication cart not within view of the nurse should be locked. The DON voiced that the Residents and staff can get medication out of the medication cart if the medication cart was left unlocked while unattended. 2. On 06/11/2024 at 2:40 PM, the Surveyor noted the locked medication box used to store refrigerated controlled medications was on a shelf in the refrigerator not permanently affixed. The Surveyor observed controlled medications inside the locked box for the Residents and the emergency kit. a. On 06/11/2024 at 2:45 PM, Licensed Practical Nurse (LPN) #11 confirmed the lock box used to store refrigerated controlled medications was not affixed and was able to be removed from the refrigerator by the Surveyor. b. On 06/13/2024 at 11:07 AM, the Surveyor was provided a policy titled Medication Storage in the Facility that documented, .Only licensed nurses, pharmacy personnel, and those lawfully authorized to administer medications (such as medications aides) permitted to access medications. Medication rooms, carts, and medication supplies are locked when not attended by persons with authorized access .

Based on observation, interviews and facility policy reviews, the facility failed to ensure 1 (Resident #44) sampled resident was not misdiagnosed with a psychological disorder and receive treatment with medication for a condition that was not present. The finding include: Resident #44 had a diagnosis of dementia and schizoaffective disorder depressive type. Resident #44 had a Physician's Order for Quetiapine Fumarate (an atypical antipsychotic used to treat schizophrenia, bipolar disorder, and depression) Oral Tablet 25 milligrams (MG) two times a day for dementia severe with mood disturbance and schizoaffective disorder depressive type. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/14/2024 documented Resident #44 scored 2 (0-7 indicates severe cognitive impairment) on a Brief Interview of Mental Status (BIMS) and had schizophrenia and non-Alzheimer ' s dementia. The Admission MDS with an ARD of 12/10/2020 documented Resident #44 did not have a diagnosis of schizophrenia. A Care Plan for Resident #44, revision date 03/19/2023, revealed Resident #44 used an antidepressant medication related to schizoaffective disorder depressive type and insomnia. On 06/12/2024 at 12:30 PM, during an interview the Director of Nursing (DON) voiced to the Surveyor that Resident #44 did not have a diagnosis schizoaffective. The DON voiced that she was informed by the current Advanced Practice Nurse (APN) that Resident #44's family member was upset and disagreed with the dose reduction with Resident #44's medication and that the previous APN entered the diagnosis of schizoaffective in to please the family member. The DON stated schizoaffective was not a true diagnosis and she was instructed by the current APN to remove the diagnosis. The Surveyor asked the DON if she was stating that Resident #44 was misdiagnosed . The DON stated, Yes. On 06/13/2024 at 10:35 AM, during an interview the DON voiced that a resident should not be diagnosed with a psychological disorder for the purpose of prescribing a medication, but she was not employed at the facility when this happened. On 06/13/2024 at 11:07 AM, the Surveyor was provided with a policy titled, Organizational Aspects that did not address the deficient practice.

Based on observation, interviews, and facility policy review, the facility failed to ensure a housekeeping cart used to store harmful chemicals was locked when not in use by staff. The findings include: On 06/10/2024 at 10:02 AM, the Surveyor observed an unattended housekeeping cart unlocked on the secured unit. On 06/10/2024 at 11:16 AM, the Surveyor observed a Resident standing at the housekeeping cart without staff in sight. On 06/10/2024 at 10:18 AM, Housekeeping Staff #9 voiced she had walked away to get something. Housekeeping Staff #9 confirmed the unattended housekeeping cart was not locked and that one of the Residents could get inside the housekeeping cart. On 06/13/2024 at 10:42 AM, Housekeeping Supervisor voiced that the housekeeping cart should be locked at all times, when not in use it is the facility policy and that cognitive impaired Residents could get in the cart and mistakenly ingest the chemicals stored inside, which was more likely to occur on the secured unit. On 06/13/2024 at 11:07 AM, review of a policy titled, Accident Hazards Prevention revealed, Resident Environment. The environment will be free from accidents hazards as is possible . An effective way for the facility to avoid accidents is to develop a culture of safety and commit to implementing systems that address resident risk and environmental hazards to minimize the likelihood of accidents. A facility with a commitment to safety: 1. Acknowledges the high-risk nature of its population and setting .Demonstrates a commitment to safety at all levels of the organization .

Based on observation, record review and interview, the facility failed to ensure fluids were maintained within reach to promote good hydration for 1 (Resident #1) of 1 sample mix resident. The findings are: Resident #1 was admitted on [DATE] and has a diagnosis of Urinary Tract Infection (UTI). The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/31/2024 revealed Resident #1 is a partial/ moderate assistance with documented Eating: The ability to use suitable utensils to bring food and/ or liquid to the mouth and swallow food and/ or liquid once the meal is placed before the resident- Partial/ moderate assistance. On 06/11/2024 at 9:03 AM, the Surveyor interviewed Resident #1 in the resident's room and asked, Do staff provide you with a water pitcher every day? Resident #1 stated, No, there ain't no drinks. The Surveyor did not observe a water pitcher in the resident's room, or fluids in the resident's mini refrigerator. On 06/11/2024 at 3:36 PM, the Surveyor observed Resident #1 lying in bed with eyes closed. No water pitcher was in the resident's room, and no fluids were in the mini refrigerator in the room. On 06/12/2024 at 9:26 AM, the Surveyor interviewed Certified Nurse Aide (CNA) #6 at the resident's room and asked, How do you ensure the resident is provided with adequate fluids? She stated, I give them water every time we go into the room, ask if they want a drink, or ice. When asked, Should fluids always be at the residents bedside? She stated, Yes. When asked, Can you tell me why Resident #1 didn't have a cup at her bedside? She stated, No. On 06/12/2024 at 9:32 AM, the Surveyor interviewed Licensed Practical Nurse (LPN) #7 and asked, How do you ensure the resident is provided with adequate fluids? She stated, I take them water. We do monthly labs .and if they are bad, we do fluids of normal saline. When asked, Should fluids always be at the resident's bedside? She stated, Yes, CNAs pass ice every two hours or as needed. If I'm passing meds [medications], if they need it, I'll get it. When asked, Can you tell me why Resident #1 has no cup at the bedside? She stated, No ma'am. The facility policy titled, Assisted Nutrition and Hydration with a Copyright date of 2023 documented, Policy Residents within the facility will maintain adequate parameters of nutritional ad hydration status, to the extent possible, to ensure each resident is able to maintain the highest practicable level of well-being. Guidelines 1. The facility will: a. Provide nutritional and hydration care and services to each resident, consistent with the resident's comprehensive assessment. 2. Based on the resident's comprehensive assessment, the facility will ensure each resident .Is offered sufficient fluid intake to maintain proper hydration and health .

Based on observations, interviews, and facility policy reviews, the facility failed to ensure 1 (Resident #44) sampled Resident was free from unnecessary psychotropic medication. The finding include: Resident #44 had a diagnosis of dementia and schizoaffective disorder, depressive type. Resident #44 had a Physician's Order for Quetiapine Fumarate (an atypical antipsychotic used to treat schizophrenia, bipolar disorder, and depression) Oral Tablet 25 milligrams (MG) two times a day for dementia severe with mood disturbance and schizoaffective disorder depressive type. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/14/2024 documented Resident #44 scored 2 (0-7 indicates severe cognitive impairment) on a Brief Interview of Mental Status (BIMS) and had schizophrenia and non-Alzheimer ' s dementia. The Admission MDS with an ARD of 12/10/2020 documented Resident #44 did not have a diagnosis of schizophrenia. A Care Plan for Resident #44, revision date 03/19/2023, revealed Resident #44 used an antidepressant medication related to schizoaffective disorder depressive type and insomnia. A Pharmacy Monthly Medication Review (MMR), with the effective date 05/17/2024, documented, please consider a gradual dose reduction or tapering the dose of this medication, Quetiapine Fumarate Oral Tablet 25 MG||1 tablet||by mouth|| two times a day, in an effort to determine optimal dose or if it may be unnecessary for this resident. The Attending Physician/Prescribing Practitioner documented continue current medication regimen with no changes. Clinical rationale provided documented that Resident #44 will need to continue current medication dosage of Seroquel due to Schizoaffective disorder (DO). [Resident] continues to have periodic behaviors. Due to fear of exacerbation/worsening, will need to continue with current medication dosage. On 06/12/2024 at 12:30 PM, during an interview the Director of Nursing (DON) voiced to the Surveyor that Resident #44 did not have a diagnosis schizoaffective. The DON voiced that she was informed by the current Advanced Practice Nurse (APN) that Resident #44's family member was upset and disagreed with the dose reduction with Resident #44's medication and that the previous APN entered the diagnosis of schizoaffective in to please the family member. The DON stated schizoaffective was not a true diagnosis and she was instructed by the current APN to remove the diagnosis. The Surveyor asked the DON if she was stating that Resident #44 was misdiagnosed ? The DON stated, Yes. On 06/13/2024 at 10:35 AM, the DON voiced that a Resident should not be prescribed an antipsychotic medication without a psychological disorder. On 06/13/2024 at 11:07 AM, the Surveyor was provided with a policy titled Organizational Aspects that did not address the deficient practice.

Based on observation, record review, and interview, the facility failed to ensure meals were prepared and served according to the planned written menu to meet the nutritional needs of the residents for 1 of 1 meal observed. This failed practice had the potential to affect 22 residents who received regular diets and 7 residents who received pureed diets as documented on a list provided by the Dietary Manager on 06/10/2024 at 9:40 AM. The findings are: 1. The menu for the breakfast meal documented the residents on regular diets were to receive 3/4 cup of hot cereal and residents on pureed diets were to receive #8 scoop (1/2 cup) of hot cereal. A. On 06/12/2024 at 7:19 AM, Dietary [NAME] (DC) #4 used a 2 ounce red spoon to serve a single portion of oatmeal to the residents on regular diets. The menu specified 3/4 cup of hot cereal for each resident on regular diets. B. On 06/12/2024 at 8:00 AM, the Surveyor asked DC #4, What scoop size did you use to serve regular oatmeal? She stated, I used the red spoon, two ounce spoon. The Surveyor asked, What size a blue spoon was? DC #2 stated, A two ounce spoon. The Surveyor asked how many servings were given to each resident on regular diets. DC #4 stated, I gave one serving each. c. On 06/12/2024 at 8:01 AM, the Surveyor asked DC #4, What scoop size did you use to serve the pureed oatmeal? She stated, I used the orange spoon. The Surveyor asked, What size is the orange spoon? DC #2 stated, A two ounce spoon. The Surveyor asked how many servings were given to each resident on regular diets. DC #4 stated, I gave one serving each.

Based on record review and interview, the facility failed to ensure home medication that was brought to the facility was safeguarded or returned for 1 (Resident #1) of 3 (Residents #1, #2 and #3) sampled residents who were admitted to the facility with home medications per list provided by the Director of Nursing (DON) on 8/2/2023. The findings are: On 8/2/23 at 10:59 AM an interview with Resident #1 family member who stated the resident did not get her home medications back upon discharge, and further stated the medications have now been destroyed. The family member stated they received a phone call from the facility around the week of 7/10 to notify them the medication was ready to be picked up. She stated she was waiting for a return call to notify her when she could pick up the medication, and she did not get a call. Review of Resident #1 Admission Evaluation revealed the resident was admitted to the facility on [DATE]. There was no mention the residents home medications were brought to the facility. On 8/2/23 at 10:00 am an interview with the Director of Nurses (DON) who stated Resident #1 was admitted with a large bag of medication bottles and it was in the facility during the resident's stay through discharge. She stated the discharge was sudden, and late at night. The DON stated, the facility failed to send the medications with the family on discharge which was at 10:00 PM on 7/6/23. The DON stated the medication was in the medication room, locked up securely and labeled with the resident's name on them. She stated the family was called and asked to pick up the medication, and she told the family member that if the medications were left here that they had the possibility of being destroyed per the facility policy. She stated the family was contacted again on 7/17/23, and further stated she was not sure if the medication was still in the facility, or if the family picked them up. On 8/2/2023 at 10:20 am an observation was made in the medication room to locate Resident #1 bag of home medications. The DON and Nurse Manager stated the medications were stored in the medication room. There were no home medications for Resident #1 in the medication room. The DON and Nurse Manager were unable to locate the bag of medications in the facility. On 8/2/23 at 10:50 am the DON stated, I am assuming the medications were destroyed when our pharmacist came on 7/21/23 for medication destruction. On 8/2/2023 at 12:15 pm during an interview with the Nurse manager, the surveyor asked for a list of medications Resident #1 brought in when admitted to the facility? She stated, we don't have the medications that Resident #1 brought into the facility listed anywhere. She stated the referral document from the hospital would have the home medications listed. She further stated they would have given the resident medications from the bottles on admission, because the resident admitted to the facility late in the evening. Review of the physician documentation from the discharging hospital, and included in the nursing home referral packet noted Resident #1 historical home medications were noted to include Gabapentin, Ferrous Sulfate, Pravastatin, Bumetanide, Albuterol Sulfate inhalation, Colchicine/Probenecid Potassium Chloride Terazosin Xarelto Olmesartan Hydralazine and Amlodipine On 8/2/2023 at 1:15pm the surveyor asked the DON, can you tell me exactly what happened to Resident #1's bag of home medications that was brought into the facility when she was admitted ? She stated, I am guessing I destroyed the medications on 7-21-23. I have started an in-service now to make sure we don't keep any home medications when the residents are admitted . Review of the admission agreement for the facility noted, personal property-the facility will not be liable for the loss, theft, or destruction of personal property of the resident except as delivered to the charge nurse or Administrator of the facility for safekeeping. The resident signed the document on June 15th, 2023. Reviewed policy titled Abuse, Neglect and Maltreatment which noted the facility will endeavor to protect Resident/Elders from maltreatment, which means adult abuse, exploitation, neglect, physical abuse, sexual abuse, neglect and the misappropriation of Resident/Elder property. Such maltreatment is strictly prohibited .

Based on observation and interview, the facility failed to ensure that the kitchen vents were cleaned to provide a sanitary environment for food preparation, the Dish Washing Room, kitchen walls, door frames and baseboards were free of rotten wood, the chipped walls were replaced, the food items stored in the refrigerator was covered or sealed to prevent potential food borne illness for the residents who received meal trays from I of I kitchen, and the ice machine and ice scoop holder were maintained in clean and sanitary conditions and dietary staff washed their hands before handling clean equipment or food items to prevent potential food borne illness for residents who received meals from 1 of 1 kitchen. These failed practices had the potential to affect 62 residents who received meals from the kitchen (total census: 64) as documented on a list provided by the Director of Nursing (DON) on 06/02/23 at 9:10 AM. The findings are: 1. On 06/02/23 at 9:05 AM, the following observations were made in the kitchen. a. Two air vents in the Dish Washing Room, three air vents above the Steam Table, and two air vents in the Storage Room had rusty brown dirt and lint particles stuck to their slats. b. The Dishwashing Room's door frame was loose from the wall, exposing the sheet rock. The bottom of the door frame was rotten. There was an accumulation of wet loose sheet rock on the floor, and a nail was protruding from the door frame. c. The wall between the stove and the Dish Washing Room was chipped, exposing the sheet rock. The board against the wall behind the oven was loose, and the wall paint was peeling, exposing the cement. d. On 06/01/23 at 9:20 AM, an open box of sausage was on the shelf in the refrigerator. e. On 06/01/23 at 9:33 AM, the interior surfaces of the Ice Machine had a wet black residue on it. The Surveyor asked the Dietary Supervisor to wipe off the black residue with a paper towel. The Dietary Employee Supervisor stated, It had black residue. The Surveyor asked, Who used the ice from the ice machine and how often do you clean it? The Dietary Supervisor stated, We use it to fill beverages served to the residents at meals. We clean it once. f. On 06/01/23 at 11:17 AM, Dietary Employee (DE) #1 removed the pans that contained meat loaf from the oven and placed them on the counter. Without washing her hands, she picked up a clean blade and attached it to the base of the blender to be used in pureeing the food items to be served to the residents who required the pureed diets for lunch. g. On 06/01/23 at 11:28 AM, DE #1 picked up a knife from the drawer to cut the meat loaf. Without washing her hands, she picked up a clean blade and attached it to the base of the blender to be used in pureeing food items for the residents who required the pureed or mechanical soft diets. h. On 06/01/23 at 11:44 AM, DE #2 removed a condiment container from the Storage Room and placed it on the counter. She removed a carton of chocolate milk from the milk refrigerator, opened it and placed it on the counter. Without washing her hands, she picked up a glass by the rim and poured the milk in it to be served to a resident for lunch. The Surveyor asked, What should you have done after touching dirty objects and before handling clean equipment? DE #2 stated, I should have washed my hands. i. On 06/01/23 at 11:59 AM, DE #1 lifted the trash can lid and threw away the alcohol pad, contaminating her hands. Without washing her hands, she picked up the plates to be used in portioning the food items and placed them on a shelf of the steam table with her fingers inside of them. When she was about to portion the food on the plates, the Surveyor immediately stopped her and asked, What should you do have done after touching dirty objects and before handling clean equipment? DE #1 stated, Washed my hands. j. On 06/01/23 at 12:08 PM, DE #1 was on the tray line serving lunch. She picked up the tray cards and placed them on the trays, contaminating her hands. Without washing her hands, she picked up the plates to be used in portioning food items to be served to the residents for lunch with her fingers touching the plates' interior surfaces.

Based on observation, record review, and interview, the facility failed to ensure that all essential areas of the building were in good repair. This failed practice had the potential to affect 61 residents who receive a meal tray from the kitchen, as documented on a list provided by the Assistant Director of Nursing (ADON) on 06/01/23 at 9:45 AM. The findings are: a. On 05/30/23 at 10:50 AM, during the brief tour of the Kitchen with the Dietary Manager, there was approximately 1/2 liter of standing water on the floor in the doorway of the Dry Storage Room. The Dietary Manager stated, I think that was caused by a leak in the Dish Machine. We try to keep it mopped up. b. On 05/31/23 at 9:06 AM, the Surveyor asked the Administrator to provide the Maintenance Logs. A review of the Maintenance Logs showed no documentation of leaking water in the kitchen or the leaking Dish Machine. The Surveyor asked, Has anyone made you aware of the leak in the kitchen? The Administrator answered, They told the Maintenance Supervisor about it this morning. c. On 05/31/23 at 9:57 AM, the Surveyor asked the Administrator, How long has the leak in the kitchen been going on? The Administrator answered, The Maintenance Supervisor is looking at it now. He thinks it may be caused by a drainpipe in the laundry. It happens every great once in a while. d. On 05/31/23 at 2:29 PM, the Surveyor took a tour of the Laundry Room with Housekeeping Staff #1. She stated, There are 2 men tearing out sheet rock between the 'dirty' side and the kitchen due to a leak. The two men were sitting in chairs in the Laundry Folding Room. There was missing sheet rock on the wall in the area of the Laundry Room that contained the washing machines. e. On 06/01/23 at 7:54 AM, during Breakfast service, the Surveyor asked the Dietary Manager, Did the leak in the Dry Storage Room get fixed? The Dietary Manager answered, They tore out part of the wall and they plan to come sometime over the weekend at night so they can move things around when no one is here. Approximately one liter of water was on the floor in the rear of the Dry Storage Room. The Sheet rock had been removed from the rear wall of the Dry Storage Room. f. On 06/01/23 at 9:45 AM, the Surveyor asked the Administrator to provide the building's Maintenance Policy. The Administrator stated, I will check but I don't think we have one. g. On 06/02/23 at 8:00 AM, the Surveyor asked the Dietary Manager, What could happen if water leaks into the Dry Storage Room? The Dietary Manager answered, If food is left open or on the floor it could get contaminated. Or it could cause mold. The Surveyor asked, What could happen if there was mold in the Dry Storage Room? The Dietary Manager answered, The workers or the residents could get sick. h. On 06/02/23 at 8:02 AM, the Surveyor asked the Maintenance Supervisor, How long have you been aware of the leak that is going in the Dry Storage Room? The Maintenance Supervisor answered, I was made aware of it this past week. We noticed it the most this week. We think it may be coming from the Dishwasher. i. On 06/02/23 at 8:03 AM, the Surveyor asked the Administrator, Did you ever find a Maintenance Policy? The Administrator answered, No we don't have one. The Surveyor asked, What could happen if there is a water leak that goes into the dry storage room? The Administrator answered, Most of it wouldn't be good. It could cause mold to grow. The Surveyor asked, What could happen if there was mold in the Dry Storage Room? The Administrator answered, That wouldn't be good.

Based on observations, record review, and interview, the facility failed to follow Physician's Orders by changing the respiratory equipment weekly for 2 (Residents #8 and #33) of 8 (#8, #9, #12, #24, #26, #33, #39 and #54) sample mix residents that were reviewed for Oxygen therapy. The findings are: 1. Resident #8 had diagnoses of Chronic Obstructive Pulmonary Disease (COPD), Unspecified and Unspecified Asthma, Uncomplicated. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/24/23 documented the resident scored a 12 (8-12 indicates Moderately Cognitively Impaired) on a Brief Interview of Mental Status (BIMS) and required Oxygen Therapy. a. The Physician Order dated 01/05/22 documented, Change oxygen tubing every week, every night shift every Sunday. b. The Care Plan with a revision date of 04/24/23 documented, Resident #8 has Oxygen therapy related to COPD and SOB [Shortness of breath]. Approaches: Change oxygen tubing, storage bag, and humidification bottle weekly and PRN [as needed]. Clean filter on concentrator weekly and PRN. c. On 05/30/23 at 10:57 AM, Resident #8's Oxygen was running at 2 liters per nasal cannula. The set-up bag's issue date was 05/21/23, which was over due to be changed out on 05/28/23. d. On 05/31/23 at 10:15 AM, the Surveyor showed the Director of Nursing (DON) that Resident #8s' Oxygen (O2) bag was dated for 05/21/23. The DON stated, I know that is a problem, she had started an in-service on changing out the O2 tubing yesterday. 2. Resident #33 had a diagnosis of COPD with Acute Exacerbation. The Quarterly MDS with an ARD of 05/28/23 documented the resident scored a 14 (13-15 Indicates Cognitively Intact) on a BIMS and required Oxygen Therapy. a. The Care Plan with an initiation date of 02/17/23 documented, Resident #33 has oxygen therapy. Approaches: if needed if concentrator present in room, date and change oxygen tubing, storage bag and humidification bottle weekly and PRN, Clean filter on concentrator weekly and PRN. b. The Physician Order with a start date of 05/06/23 documented, Change oxygen tubing every week, every night shift every Sunday. c. On 05/30/23 at 11:08 AM, Resident #33's oxygen was running at 3 liters per nasal cannula. The set-up bag issued date was 05/21/23, which was over due to be changed out on 05/28/23. d. On 05/31/23 at 10:15 AM, the Surveyor showed the DON that Resident #33's O2 bag was dated 05/21/23. The DON stated, I know that, and that she had started an in-service on changing out the O2 tubing yesterday. e. On 05/31/23 at 10:15 AM, the Surveyor asked the DON for a policy and procedure for changing the tubing and set-up equipment. The DON did not have a policy.

Based on observation, record review, and interview, the facility failed to ensure the fortified food was prepared and served according to the planned written Quantified recipe to meet the nutritional needs of the residents for 1 of 1 meal observed. This failed practice had the potential to affect 29 residents who received fortified foods from 1 of 1 kitchen according to a list provided by the Dietary Supervisor on 06/02/23. The findings are: 1. The facility's Quantified Recipe for 25 servings documented, 1. 3 quart plus 1/2 [half] cup of nonfat dry milk. 2. 2 1/4 [fourth] quarts of whole milk. 3. 3 quarts of oatmeal. 4. 2 1/4 cup of light brown sugar. 5. 2 1/4 cup of margarine bulk. Portion size 1/2 cup. a. On 06/02/23 at 7:19 AM, the Surveyor asked Dietary Employee (DE) #3, How do you prepare super cereal? DE #3 stated, I use 1/2 cup of brown sugar, 1/2 a stick of butter and pepper. The Surveyor asked, What size of spoon did you serve super cereal with and how many servings of super cereal did you give to the residents who received fortified foods? DE #3 stated, I used a 4-ounce spoon to serve a single portion and I gave one serving each. The menu specified 1 cup for each resident on fortified foods. 42017

Based on record review, observation, and interview, the facility failed to maintain acceptable parameters for nutritional status for 1 (Resident #43) of 11 (#2, #7, #9, #25, #32, #35, #38, #39, #43, #48 and #49) sampled residents who are at risk for weight loss. The findings are: 1. Resident #43 had a diagnosis of Alzheimer's Disease, Unspecified. The Minimum Data Set (MDS) with and Assessment Reference Date (ARD) of 05/28/23 documented the resident scored a 00 (0-7 indicates severely cognitively impaired) on a Brief Interview of Mental Status (BIMS). a. The Annual Dietary Evaluation for Resident #43 dated 05/18/23 documented no weight change. b The Physician Order with a start date of 05/19/23 documented, Super-calorie diet, regular texture, thin consistency. c. The Care Plan with a revision date of 05/31/23 documented, Resident #43 has potential for nutritional deficits, weight loss related to Alzheimer's Disease. Resident #43 also enjoys eating [named cakes] of all sorts. Approaches: 04/06/23 discontinue Supercal and double portions. 05/19/23 Supercal diet ordered. Staff to assist in the dining room. On 05/05/23 an appetite stimulant was ordered. Give supplements as ordered. Offer substitutes for food not eaten. Provide diet as ordered. RD to evaluate and make diet change recommendations PRN [as needed]. d. Resident #43's Weight Record documented on 04/04/23 that his weight was 166.8 lbs, [pounds]. On 05/21/23 his weight was 151.6 lbs, which was a 9.11% [percent] weight loss. e. On 05/31/23 at 12:25 PM, Resident #43 received the tray in his room. He was served beans and ham, greens, potatoes, corn bread, one pack of butter, tea, and cobbler. He ate the greens, the cobbler, the beans, and drank his tea. The packet of butter remained unopened. f. On 05/31/23 at 1:05 PM, the Surveyor asked Dietary Employee (DE) #1 What was the fortified food for the enhanced for lunch? DE #1 answered, It was the butter. The Surveyor asked if the butter had been added to the recipes or melted on the food. DE #1 answered, No. The enhancement was the butter was on the tray and the Certified Nursing Assistants were to put it on the cornbread. g. On 05/31/23 at 2:05 PM, the Surveyor reviewed the facility's menu. Margarine was listed on Wednesday's meals as a regular part of the meal. Resident #43 did not receive extra margarine with his meal or his Supercal diet as ordered. h. On 06/01/23 at 8:19 AM, the Surveyor asked DE #1, What was the super calorie food for breakfast? DE #1 stated, Cereal. The Surveyor showed DE #1 Resident #43's meal ticket and asked, What was Resident #43's Supercal food? DE #1 stated, Resident #43 doesn't like cereal or eggs, so he doesn't receive them. The Surveyor asked, What food was sent instead of super cereal and eggs? DE #1 stated, Nothing and then stated, the nurse will give him something later. DE #1 gave the Surveyor the menu for 05/31/23 and 06/01/23 with list of items of daily Supercal food. Resident #43 did not receive a substitution for his super cereal or eggs.

Based on observation and interview, the facility failed to ensure dietary staff washed their hands before handling clean equipment or food items; the ice machine was maintained in clean condition; and hot foods were maintained at or above 135 degrees Fahrenheit on the steam table while awaiting service, to prevent potential food borne illness for residents who received meals from 1 of 1 kitchen. These failed practices had the potential to affect 62 residents who received meals from the kitchen (total census: 63), as documented on a list provided by the Dietary Supervisor on 2/18/2022 at 7:58 AM. The findings are: 1. On 02/17/22 at 08:26 AM, the ice machine in a room on 400 Hall had wet pink residue on the interior panel. The Dietary Supervisor was asked to wipe the pink residue on the panel of the ice machine. She did so, and the pink residue easily transferred to a tissue. Dietary Supervisor was asked, How often do you clean the ice machine? She stated, Daily. Dietary Supervisor was asked, Who uses the ice from the ice machine? She stated, That's the ice the CNAs [Certified Nursing Assistants] use for the water pitchers in the residents' rooms, and we use it in the kitchen to fill beverages served to the residents at meals. 2. On 2/17/22 at 11:16 AM, Dietary Employee #1 was wearing gloves on her hands. She turned off the hand washing sink faucet. Without changing gloves and washing her hands, she picked up a clean blade and attached it to the base of the blender to be used in pureeing food items to be served to the residents on pureed diets. Dietary Employee #1 immediately was asked, what should you have done after touching dirty objects and after handling clean equipment? She stated, I should have washed my hands. 3. On 2/17/22 at 11:24 AM, Dietary Employee #1 turned on the hand washing sink faucet to rinse a spoon. Without changing gloves and washing her hands, she picked up a clean blade and attached it to the base of the blender to be used in pureeing food items to be served to the residents on pureed diets for lunch. 4. On 2/17/22 at 11:58 AM, the temperature of the food items were checked and read on the steamtable by Dietary Employee #1 as follows: a. Pureed roast beef: 128 degrees Fahrenheit. b. Pureed cream corn: 129 degrees Fahrenheit. c. Ground roast: 126 degrees Fahrenheit. 5. On 2/17/22 at 12:22 PM, Dietary Employee #1 was on the tray line serving the noon meal. She picked up tray cards and bags of chips and placed them on the trays. Without changing gloves and washing her hands, she picked up roast beef sandwiches and placed them on the plates to be served to the residents for lunch.

Based on observation, record review and interview, the facility failed to ensure residents' personal laundry was washed with detergent and the facility's soiled bed and bath linens that would be reused on multiple residents were washed with detergent, hot water and sanitizer, to remove dirt and microorganisms that could result in the spread of COVID-19 or other infectious illnesses to the residents who received laundry services and / or bed and bath linens from 1 of 1 laundry room; the facility also failed to ensure laundry employees were trained and had access to monitor the laundry supplies and change them out when empty to prevent inadequate cleaning of soiled laundry in 1 of 1 laundry room. The failed practices resulted in Immediate Jeopardy, which caused or could have caused serious harm, injury, or death to all 62 residents who received laundry from the laundry room, according to the Daily Census Report provided by the Administrator on 9/27/21 at 11:08 a.m. The Administrator was informed of the Immediate Jeopardy condition on 9/27/21 at 3:40 p.m. The facility also failed to ensure laundry staff rewashed clothing that had been in contact with the floor prior to placing it with clean clothing, to prevent potential cross-contamination in 1 of 1 laundry room. The findings are: 1. On 09/27/21, the surveyor reviewed the medical records of 5 residents on isolation precautions, as follows: a. Resident #11: A Nurse's Note dated 9/14/21 at 15:37 [3:37 pm] documented, .Resident c/o [complains of] runny nose, and just not feeling well at all. Also mentioned muscles hurting in neck .placed on isolation per precaution due to COVID like symptoms . b. Resident #12: A Nurse's Note dated 9/22/21 at 16:35 [4:35 pm] documented, .Resident placed on 14-day isolation due to s/s [signs / symptoms] of COVID (vomiting) . Droplet Precautions for COVID-19 . c. Resident #13: A Nurse's Note dated 9/27/21 at 13:16 [1:16 pm] documented, .Resident returned from hospital on 9/25/21. Placed on isolation . Droplet Precautions for COVID-19. d. Resident #14: A Nurse's Note dated 9/14/21 documented, .Resident placed on 14-day isolation yesterday due to reports of a cough . Droplet Precautions for COVID-19. e. Resident #15: A Nurse's Note dated 9/22/21 at 12:26 [12:26 pm] documented, .Resident placed on 14-day isolation related to abnormal lung sounds . Droplet Precautions for COVID-19. 2. On 09/27/21 at 11:50 a.m., the surveyor entered the laundry room. Laundry Worker #1 was attending to the laundry. There were 2 front-load washers. Both washers had a front window, and laundry was visible in both. The #1 washer was out of service, per Laundry Worker #1. The #2 washer was in use, washing multi-colored laundry. There was a timer on the front of the washer that read, 17. Laundry Worker #1 was asked, Why is the number 17 displayed on the washer? She stated, That's how much time remains for clothes washing. The water in the washer was clear and free of suds. The window of the front of the washers was cold to touch. There was a controller on top of the #2 washer that indicated the current wash type was, Personal #3. a. On 09/27/21 at 12:10 p.m., Laundry Worker #1 removed laundry from the #2 washer. One pair of beige panties fell on to the floor. She picked the panties up off the floor, placed them back in the basket of washed laundry and put the laundry in the dryer. She then placed a dirty load of white laundry (towels, pillowcases, sheets) in washer #2. She pressed the start button on the washer and 45 minutes appeared on the washer timer. She did not change the setting / wash type to whites on the controller to enable sanitizer / bleach and hot water to dispense into the soiled laundry. She was asked, Where are the chemicals used for washing laundry in the washing machine? While pointing to the back door in the laundry room, Laundry Worker #1 stated, The chemicals are locked up in the storage room, and I don't have a key to that room. She was asked, Who has the key to the storage room? Laundry Worker #1 stated, The Housekeeping Supervisor. She phoned the Housekeeping Supervisor at this time. b. On 09/27/21 at 12:20 p.m., the Housekeeping Supervisor entered the laundry room. She was asked, Where are the chemicals that run into the washing machine located? She stated, In the back storage room. She unlocked the storage room door. There was a clear 5-gallon container that documented, .Tri-Star Laundry Detergent Plus. The Housekeeping Supervisor was asked, How much detergent is in the container? She stated, Not any. I should get some on the truck today. I wasn't aware we were out of detergent until today. Yesterday, the other laundry lady went to the store and bought some detergent. The Housekeeping Supervisor picked up the clear container. There was no liquid visible in the container. She picked up the 5-gallon Tri-Star Laundry Detergent Plus container and stated, Actually, there's not anything in here. She was asked, How do the chemicals enter the machine? She stated, They run through the hoses coming from the buckets, and hoses are connected to the washing machine. As we exited the storage room, the Housekeeping Supervisor pointed to a green 1.99 gallon of Xtra liquid detergent and stated, That's what she bought at the store yesterday. She also stated, I addressed that with laundry employees this morning. She was asked, What did you address with the employee this morning? She stated, Running out of detergent. That's not the proper way we wash. We don't purchase laundry soap at the store and use it to wash with. She was asked, What is the proper way is to wash? She stated, You place the Xtra laundry soap on the clothes in the wash machine, before you close the door on washer. She was asked, Why do you place Xtra Laundry detergent in the washer before closing the door? She stated, The door locks once you close it and the wash cycle starts. She was asked, How long has the facility been out of the Tri-Star laundry detergent? She stated, Since yesterday. c. On 09/27/21 at 12:30 p.m., Laundry Worker #1 removed some laundry from the dryer. A white medium-sized towel fell on to the laundry room floor. She picked the towel up off the floor and placed it back into the dried clothing that she removed from the dryer. d. On 09/27/21 at 12:35 p.m., Laundry Worker #1 was asked to, Explain the laundry process for washing. She stated, The detergent and stuff come through the buckets, from there through the hoses attached to the washer. We don't have to physically put the laundry soap in the washer machine. She was asked, How many loads of laundry have you washed his morning? She stated, Around 4 or 5 loads. She was asked, Who picks up the laundry? She stated, I go around to all the halls and pick up the laundry. Like this morning when I got here, there were several bags of laundry on the halls. e. On 09/27/21 at 1:10 p.m., the Housekeeping Supervisor was asked, Who's responsible for ordering laundry detergent and when was the last time ordered? She stated, The Dietary Manager is responsible for ordering laundry detergent, the truck has not brought any laundry soap. f. On 9/27/21 at 1:35 p.m., Laundry Worker #1 was asked the following questions: 1.) What's the process for washing laundry? 2.) When are supplies checked and who's responsible for checking supplies? 3.) Were you aware that you ran out of laundry soap on Sunday 9/26/21? 4.) What detergent did you use on Sunday and Monday? 5.) Is there a special setting used for washing laundry? Are the settings preset? 6.) If you run out of laundry soap and have to purchase laundry soap from the store, tell me the process of how the laundry soap is added to washer and when it's added? Her responses were as follows: Laundry Worker #1 stated, I don't have a key to anything. I have to find someone to let me in the laundry room, and they keep the supplies locked up in the back-storage room .I've never been told how to check the laundry supplies or shown how to change supplies out. I was trained how to use setting #3 for personal laundry and setting #1 for whites. I wasn't aware that we were out of laundry soap. The Housekeeping Supervisor told me that we were out just a while ago. Nobody told me that. They don't let me know nothing . I didn't use any laundry soap [on Sunday and Monday]. They just let me come in here and start washing clothes without laundry soap. I worked yesterday 6 to 2 [6:00 a.m. to 2:00 p.m. shift]. I don't know if we were out of laundry soap or when it ran out. I've never been told I needed to check the supplies and I'm not provided a key. They don't communicate . When adding laundry soap, you should pour a cup into the washer, directly on the laundry, close the washer door and lock it. I don't know if we've ever run out of laundry soap because I don't have a key to unlock the door where it is stored. g. On 09/27/21 at 02:00 p.m., the Housekeeping Supervisor provided a pre-delivery invoice form from the facility's supplier. There was no laundry detergent listed on the invoice. On 09/30/21 at 10:52 a.m., the Administrator and Housekeeping Supervisor were asked, Where is the laundry detergent documented on the order invoice dated 9/27/21. The Administrator stated, The last Dietary Manager was responsible for ordering laundry supplies. She was not trained properly; it caused her not to know how to order right and check off stuff received from [supplier]. There was no laundry detergent on the invoice form. h. On 09/27/21 at 3:15 p.m., the Administrator was asked, Should laundry detergent be used to assure laundry is washed, clean and sanitized? He stated, Yes. i. On 09/27/21 at 3:30 p.m., Laundry Worker #2 was asked about the laundry and lack of soap. She stated, I came in at 2 p.m. Sunday, and nobody told me we were out of laundry soap. The container was empty when I got here. [Laundry Worker #1] didn't tell me we didn't have no detergent. I check it every evening when I come in at 2:00 p.m. I changed the [MEDICATION(S)] on Thursday. I didn't know which one was the laundry detergent. I saw a bottle of XTRA detergent. Somebody bought that Wednesday, because we had to go to an outside washateria [laundromat] because the washing machine was not working. She was asked, What did you use to wash the laundry with on Sunday? She stated, Nothing. She was asked. Why didn't you use the Xtra detergent? She stated, I didn't know we could use it. She was asked, How do you change the settings on the washing machine? She pointed to the controller. She was asked, What setting is the machine on now? She stated,3 for personal. She was asked, What other settings do you use? She stated, 1-for white clothes. j. A facility Laundry Services policy, received from the Director of Nursing on 9/29/21 at 10:40 a.m., documented, .Linens should be washed with a detergent .since this is an effective method for cleaning and killing most vegetative bacteria . k. On 09/29/21 at 1:29 p.m., Laundry Worker #1 was asked, Should detergent be used for washing, cleaning, and sanitizing laundry? She stated, Yes. She was also asked, When you drop washed laundry on the floor, what should you do with it? She stated, Re-wash it. l. On 09/30/21 at 10:09 a.m., the Housekeeping Supervisor was asked, Should laundry detergent be used to clean, wash, and sanitize laundry? She stated, Yes, ma'am. m. The immediate jeopardy was removed, and the scope / severity reduced to F on 09/27/21 at 4:52 p.m., when the facility implemented the following Plan of Removal: 1. All Laundry service will be shut down until [brand] Laundry Soap is obtained. 2. All laundry staff will be in serviced on using [brand] Laundry Detergent only and what to do when supplies run low. When supplies run low, the Housekeeping Supervisor needs to be notified immediately and laundry services shut down until more detergent is obtained. 3. All laundry in the building will be rewashed using [brand] detergent. 4. The Housekeeper Supervisor will conduct rounds two times per week times four weeks and then weekly to make sure [brand] detergent is available for use and the only detergent used. 5. These findings will be reported to [facility's] QA [Quality Assurance] committee.

Complaint # (AR 056) 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 by failure to ensure windows on the Secured Hall were secured for 1 (Resident #1) case mix resident who was at risk for elopement. This failed practice resulted in past non-compliance at the level of Immediate Jeopardy, which caused or could have caused serious harm, injury, or death to Resident #1, who had been assessed for being at risk for elopement, and eloped from the facility unnoticed by the staff, and was found approximately 15 minutes later at the convenience store across the road from the facility, and had the potential to cause more than minimal harm to 4 residents who were at risk for elopement, according to the list provided by the Administrator on 7/22/2020. The facility removed the Immediate Jeopardy and corrected the failed practice on 7/3/2020 prior to the survey. The Administrator was informed of the Past Immediate Jeopardy condition on 7/17/2020 at 3:04 p.m. The findings are: 1. Resident #1 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set with an Assessment Reference Date of 5/1/2020 documented the resident scored 5 (0-7 indicates severely impaired) on a Brief Interview for Mental Status (BIMS), exhibited wandering behavior one to three days out of the last 7 days; required supervision with transfer, walking in room and in corridor; and required a wander / elopement alarm daily. a. A physician's orders [REDACTED].Wander Guard bracelet in place to left ankle QS (every shift) every shift for Elopement Risk . b. A facility Incident and Accident form dated 2/24/2020 documented, .Elopement Date . 2/24/2020 (at) 17:50 (5:50 p.m.) . Resident . (Resident #1) . Incident Location . Outside . Incident Description . Another resident's son who was visiting told nurse at front desk that resident was outside of facility. Nurse (Nurse's first name) immediately headed out of front door to assist resident back into facility. Resident had made it across one side of two-lane highway and median to the other side of highway. (Nurse's first name) reached resident and was able to persuade resident to come back into facility. Resident and (Nurse first name) ambulated into front door of facility. Body audit performed and no apparent injury noted .No injuries observed at time of incident . Mobility . Ambulatory without assistance . Notes . 2/25/2020 Administrator came to facility to investigate. Statements were taken from staff who were aware of this incident. (LPN #3) stated she had seen resident in front lobby at 17:45 p.m. (5:45 p.m.) and several visitors had been in the facility this evening. She had gone to 300 Hall and then at 17:58 (5:58 p.m.) she saw (LPN #4) with resident . 2/25/2020 Care Planned elopement risk, Wander Guard in place . c. A Nursing Progress Note dated 2/24/2020 at 9:20 p.m. and signed by LPN #3 documented, .Incident Note . Nature / Description of Incident . Another resident's son who was visiting told Nurse (Nurse's first name) at front desk that resident was outside of facility. Nurse (Nurse's name) immediately headed out of front door to assist resident back into facility. Resident had made it across one side of two-lane highway and median to the other side of highway. Nurse (Nurse's first name) reached resident and was able to persuade resident to come back into facility. Resident and nurse ambulated into front door of facility. Body audit performed. No apparent injury noted. Description of Injuries . Body audit performed. Medical Professional Notified (Who / When) . (Physician) 2/24/2020 . Resident Representative Notified (Who / When) . (Resident spouse) 2/24/2020 . d. An Elopement Risk assessment dated [DATE] at 5:50 p.m. documented, .Score: 9.0 . Elopement Risk Assessment . b. Scoring: A score of less than 5 (equals) Low Risk for Elopement. Score of 5 or greater (equals) High Risk for Elopement . Checklist . 1. Cognition / Mental Status / Memory . b) Moderately impaired . 2. Dependent on staff for ADLs (activities of daily living) . b) 3. Ambulation . a) Able to ambulate independently . a) Yes . 4. Able to transfer independently . a) Yes . 5. History of wandering prior to nursing home placement . a) Yes . 6. Resistant to nursing home placement . a) Yes . 7. Expresses desire to go home . a) Yes . 8. Exit Seeking . a) Yes . The Elopement Risk Assessment score indicated the resident was at risk for elopement. e. An Elopement Risk assessment dated [DATE] at 3:50 p.m. documented, .Score: 12 .Elopement Risk Assessment . b. Scoring: A score of less than 5 (equals) Low Risk for Elopement . Score of 5 or greater (equals) High Risk for Elopement . Checklist . 1. Cognition / Mental Status / Memory . b) Moderately impaired . 2. Dependent on staff for ADLs (activities of daily living) . b) No 3. Ambulation . a) Able to ambulate independently . a) Yes . 4. Able to transfer independently . a) Yes . 5. History of wandering prior to nursing home placement . a) Yes . 6. Resistant to nursing home placement . a) Yes . 7. Expresses desire to go home . a) Yes . 8. Exit Seeking . a) Yes . Comments Wander Guard bracelet intact per MD (Medical Doctor) orders . The assessment score indicated the resident was at risk for elopement, and also indicated an increased score in the Elopement Risk Assessment from the assessment dated [DATE] due to the addition of medications. f. The Care Plan dated 7/3/2020 documented, .(Resident) is an elopement risk r/t (related to) hx (history) at home and Dx (diagnosis) (of) [MEDICAL CONDITION] . 7/3/2020 . Windows on the hall were secured so that they don't go up more than 6 (inches) Psych (Psychiatric) consult ordered . Resident eloped out of window in the Day Area on 7/3/ 0 . All windows were secured in Secured Unit . Distract (Resident) from wandering by offering pleasant diversions, structured activities, food, conversation, television, book. Resident prefers . color, draw, listening to music . (Doctorate of Nursing Dementia Consultant) contacted by nursing, medication review completed . Resident taken off a medication that doctor thought was making resident (sic) . Ordered labs (laboratory tests) and UA (urinalysis) . Resident placed on one-on-one until windows were secured on Secured Unit . Wander Alert . Wander Guard anklet . g. A Nursing Progress Note dated 7/3/2020 at 6:00 a.m. and signed by Licensed Practical Nurse (LPN) #1 documented, .This nurse was walking down hallway on 100 (Hall) when she heard a noise on 200 hallway. (Certified Nursing Assistant (CNA) #2) and (CNA #3) stated resident has started kicking on double door. Both CNAs stated they went around doors to enter hallway from another direction when they noticed resident was no longer at double doors. CNAs stated they both went to (the) resident room and resident was not in room so they proceeded to go through all rooms to look for resident, and that when they came and told this nurse, they searched all rooms and they could not locate resident. This nurse went to 200 Hall and helped both CNAs search all rooms, closets, and bathrooms for resident. When this nurse could not locate resident, this nurse began walking toward front door and noticed shades on the window in TV (Television) lobby was slightly pulled up. When this nurse approached the window, she noticed that window up and the screen pushed away from the window. This nurse immediately looked out window to pitch black darkness and could not see anything. So, she summoned CNA and herself to go outside with flashlights to look around back of facility where window is located. Resident was nowhere to be found. This nurse and CNA walked all around facility to search for resident. When this nurse came back in facility, the front door screener (Screener name) asked if we were looking for someone. When this nurse stated, 'Yes', he stated, 'I think I seen her at the (gas) station down the road' . h. A Nursing Progress Note dated 7/3/2020 at 7:21 a.m. and signed by LPN #1 documented, .Incident Note . Nature / Description of Incident . This nurse was walking down hallway on 100 (Hall) when she heard a noise on 200 Hallway. (CNA #2) and (CNA #3) stated, 'Resident has started kicking on double door.' Both CNAs stated they went around doors to enter hallway from another direction. When they noticed resident was no longer at double doors, CNAs stated they both went to resident room and resident was not in room so they proceeded to go through all rooms to look for resident; and that when they came and told this nurse they searched all rooms and they could not locate resident. This nurse began walking toward front door and noticed shades on the window in TV (Television) Lobby was slightly pulled up. When this nurse approached window, she noticed that window (was) up and the screen pushed away from the window. This nurse immediately looked out window to pitch black darkness and could not see anything. So, she summoned CNAs and herself to go outside with flashlights to look around back of facility where window is located. Resident was nowhere to be found. This nurse and CNAs walked all around facility to search for resident. When this nurse came back in facility, the front door screener (Screener name) asked if we were looking for someone. When this nurse stated, 'Yes', he stated, 'I think I seen her at the (gas) station down the road. Description of Injuries . No injuries noted at this time . Immediate Actions Taken . Supervised by staff one-on-one . Medical Professional Notified (Who / When) . (Advanced Practice Registered Nurse #1) APRN, (Director of Nursing), Resident Representative Notified (Who / When) . (Resident spouse) . i. A Nursing Progress Note dated 7/3/2020 at 7:27 a.m. and signed by LPN #1 documented, .This nurse contacted (Advanced Practice Registered Nurse (APRN) #1). Resident down hallway, agitated, kicking, grabbing, punching at staff. Stating she is getting the hell out of here. Staff try to redirect resident with no success. (APRN #1) ordered 2 mg (milligrams) [MEDICATION NAME] IM (intramuscular). Resident's husband was present at back door and is aware of (APRN #1) orders . j. A Nursing Progress Note dated 7/3/2020 at 10:56 a.m. and signed by the Director of Nursing (DON) documented, .06:45 (6:45 a.m.) Noted Resident sitting up in chair in hallway of 200 Hall. Calm at this time. CNA continues with 1:1 (one-on-one). 0700 (7:00 a.m.) b'fast (breakfast) served. Remains calm. 0830 (8:30 a.m.) called (Physician); notified of Resident leaving building this a.m.; that 1:1 is being continued at this time; and that we are awaiting results from COVID-19 testing done yesterday before BHU (Behavioral Health Unit) will accept her. 0920 (9:20 a.m.) phone call with (Doctor of Nursing Dementia Consultant), per (APRN #2), APN (Advanced Practice Nurse) with SAS (Behavioral Health Unit) re: (regarding) resident's behaviors and leaving building. Advised us to speak further with husband to find out if Resident ever was seen by psychiatrist prior to being diagnosed with [REDACTED]. That it appears that her behaviors have been ramping up in the last 2 weeks and this is possibly a form of [MEDICAL CONDITION] .0955 (9:55 a.m.) husband called while on conference call with (DNP (Doctor of Nursing Dementia Consultant), GNP (General Nurse Practitioner)). Advised that we are doing phone conference with (DNP, GNP) and resident was calm a little while ago, would call him back after conference. 1020 (10:20 a.m.) blood spec (specimen) obtained without incident from left a/c (antecubital) (times) 1 stick for CBC (complete blood count), CMP (comprehensive metabolic profile), TSH ([MEDICAL CONDITION] stimulating hormone) and urine obtained per voiding spec for UA. Spec's couriered to lab (laboratory) for stat (immediate) analysis at (Hospital #1). 1040 (10:40 a.m.) called and spoke to (resident's spouse). Res's (Resident's) husband and RP (responsible party) .Explained to him that we had spoken to (DNP-GNP) who is an expert on staff for Dementia residents having behavioral issues and that she has recommended stopping some of her med (medications), but that (Physician) would have to approve this and that we are getting labs (laboratory tests). Will call him back after labs back and Plan of Care discussed. Verbalizes understanding . 1120 (11:20 a.m.) Rec'd (received) results of lab . Spoke with (DNP-GNP) and rev'd (reviewed) labs and information gleaned from husband. States if (Physician) agrees, she will be glad to consult on Resident this weekend and provide orders to help manage her while here. 1210 (12:10 p.m.) attempted to reach (Physician) by phone. Left message. 1220 (12:20 p.m.) (Physician) returned call, notified of lab results, of (DNP-GNP) offer to consult and recommendations. New orders rec'd (received) and noted. Will discontinue the [MEDICATION NAME], Oxybutin, and Donepezil. (DNP-GNP) will be on call thru the weekend for further orders if needed . k. A report to the State Agency Office of Long Term Care (OLTC), Division of Medical Services (DMS) form 7734 received from the Administrator on 7/15/2020 documented, .OLTC Incident and Accident Report (I&A) . Date and Time Submitted (if known) . 7/3/2020 (at) 0800 (8:00 a.m.) Date and Time of Discovery . 07/03/2020 (at) 0545 (5:45 a.m.) . Staff Reporting I & A . (Administrator's Name) .Title . Administrator . Date of I & A . 07/03/2020 . Time . 0600 AM (6:00 a.m.) . Name of Resident . (Resident #1) .Summary of Incident . At approximately 5:45 a.m., Administrator was notified that resident (Resident #1) had eloped by opening a window and removing a screen. Charge Nurse (LPN #1), LPN reported to Administrator that the resident had crossed the road and was inside the convenience store there. Charge Nurse talked the resident into getting in her car and returned with her to the facility where she was placed under 1:1 (one-on-one) supervision. Resident was absent from facility approximately 15 minutes. Physician, Administrator, and family were notified. Steps Taken to Prevent Continued Abuse or Neglect During the Investigation . Resident was placed on 1:1 supervision until other interventions could be initiated. At the time of this report, (Resident #1) is residing in her room under supervision. All windows that the resident had access to in the facility were secured so that they cannot be raised more than 6 (inches) to prevent further incidents. Staff interviews and witness statements were begun. An in-service on facility policy/procedures for elopement was initiated for all staff. The investigation is continuing . l. An Office of Long Term Care (OLTC) Division of Medical Services (DMS) form 762 report form to the State Agency received from the Administrator on 7/15/2020 documented, .Complete Description of Incident . At approximately 5 a.m. (5:00 a.m.) Friday, July 3, 2020, LPN (LPN #1) was conducting her Medication Pass on 100 Hall when she heard a banging noise from 200 Hall. CNAs informed LPN that resident (Resident #1) was banging on the entry doors to 200 Hall. CNAs went around to the other end of the hall and entered, and (Resident #1) was no longer at the other end of the hall. Staff initiated a search on the hall for her, and when she could not be located, notified the LPN. LPN initiated a thorough room-to-room search and did not locate the resident. LPN then went to alert all staff of missing resident, and when she walked by the lounge area, she noticed the blinds on the window were slightly open LPN opened the shade to discover the window open about 12 to 15 inches and the screen pushed approximately halfway out. LPN directed CNAs (CNA #2) and (CNA #3) to do a ground search around the facility with a flashlight while she alerted other staff of the suspected elopement. LPN (LPN #1) then walked to the road to see if she could see the resident. She was unable to see the resident at that time. Upon her return to the building, COVID-19 screener (Screener #1) was coming in and he asked if they were 'looking for someone' and when LPN said, 'Yes', (Screener #1) said he had seen her 'going into (gas station)', a convenience store nearby. LPN contacted the Administrator with details and said she was 'on my way to (gas station)'. LPN immediately got in her car with CNA (CNA #2) and drove to the (gas station), approximately one-tenth (1/10) of a mile from the facility, where she observed (Resident #1) sitting in a chair inside the (Name) Restaurant which is inside the convenience store. LPN states that she calmly approached the resident, telling her they had come to take her home. Resident refused several times, stating she was 'not going back to that cage' and 'no way was she taking her back to that hell hole.' LPN says she then told the resident, 'let's go home so we could call (spouse) (resident's husband) and talk to him.' (Resident #1) then agreed to go with them. LPN says that resident stated that 'if I was lying, she was going to kick my (expletive).' LPN reassured the resident that they would call her husband. Upon return to the facility, (Resident #1) refused to get out of the car. LPN contacted the Administrator who gave permission to call (Resident #1) husband. The resident then went into the facility and down to the end of the hall where she could visit with her husband through the glass doors, as in-person visits are not allowed during the COVID-19 Public Health Emergency. While talking to her husband through the door, resident started banging on the door and yelling because her husband would not take her home. APN notified of incident and resident's subsequent actions. APN ordered 2mg (milligrams of) [MEDICATION NAME] injection. (Resident #1 spouse) was made aware of the order, and he left the facility grounds. He later told the Administrator, 'I hoped that if I left, she'd settle down after they gave her a shot.' The resident was placed on 1:1 (one-on-one) monitoring with staff until the windows could be secured. She remained on 1:1 monitoring until 2 p.m. (2:00 p.m.) A Nurses Note dated 7/3/2020 stated that at 0645 (6:45 a.m.), the resident was seated calmly in a chair in the hallway . Findings and Actions Taken . Family, Administrator, Physician all notified and aware. Administrator came to the facility and observed and was updated on the situation with (Resident #1). DON (Director of Nursing) (DON name), RN (Registered Nurse) and Nurse Consultant (APRN #2) began working on a Psychiatric Consult with (DNP-GNP), D.N.P., Director of the Centers on Aging at the (Hospital) to determine appropriate interventions. The consult was approved by the PCP (Primary Care Physician). After reviewing the case, (DNP-GNP) issued orders to discontinue three medications, [MEDICATION NAME], Oxybutin, and Doneprizil, as these can trigger agitation. Administrator secured all windows on 200 Hall so that they would not open more than 6 inches. This was completed at noon. Administrator observed resident to be asleep in her bed at this time.At this writing, there have been no further outbursts or attempts to elope from (Resident #1) and she remains under the care of (DNP-GNP). (Resident #1) sustained no injuries during her absence from the facility. An in-service on elopement policies and procedures was immediately initiated for all staff. No abuse or neglect is suspected in this incident, and the investigation is concluded. (Resident #1) is a [AGE] year old female who is ambulatory and functionally independent. She is only oriented to person and place. She has [DIAGNOSES REDACTED]. m. A Witness Statement form dated 7/3/2020 which was included with the State Agency Report dated 7/3/2020 and signed by LPN #1 documented, . Walking down 100 Hall passing my 5 am (5:00 a.m.) meds (medications), I heard a noise down on 200 Hall. CNAs, (CNA #2) and (CNA #3) approaching the door stated (Resident) was at the door kicking it when (CNAs) (CNA #2) (and) (CNA #3) noticed (resident) not to be on hall. They approached this nurse stating they had looked all over 200 Hall and could not locate (Resident), so this nurse went to 200 Hall (with) both CNAs to look in rooms. I myself could not locate (Resident). As this nurse was walking out of 200 Hall to alert other staff of missing (Resident), I noticed that the blinds on the window in TV (Television) Lobby on 200 Hall slightly open on Secure Unit. All doors locked, no alarms had gone off, so I pulled up the shade, and window was up, and screen was halfway out. This nurse then instructed CNAs (CNA #2) and (CNA #3) outside and do ground search around facility. This nurse then notified the other on-duty nurse, (LPN #2), and CNA that (resident) is not on 200 Hall and I proceeded to go outside. (LPN #2) and (CNA #4) continued to search in facility for (Resident) while CNAs (CNA #2) (and) (CNA #3) continued to look outside. This nurse then walked up to highway (with) flashlight to see if I could see (Resident). This nurse did not see (Resident), so as this nurse returned back into facility to make proper phone calls. (Screener) front door screener coming into facility asked if we were looking for someone and this nurse stated, 'Yes.' He then stated, 'I seen her going in (Name) gas station down the road. This nurse immediately drove down to (Name) gas station (with) CNAs (CNA #2), and this nurse pulled up and noticed (Resident) sitting in a chair inside the store. This nurse calmly approached res (Resident) and stated to (Resident) that we came to pick her up and take her back home. (Resident) refused several times, stating she was not going back to that cage no one was taking her back to that hell hole. This nurse then stated to res (Resident), 'Let's go home so we could call (Resident #1's husband) and talk to him.' (Resident) then agreed, and stated, 'If I was lying, she was going to kick my (expletive).' Reassured (Resident) we would call husband. (Resident) then got back to facility went down on 200 Hall and talk to husband and started banging on back door . n. A Witness Statement form dated 7/3/2020 included with the Report to the State Agency which was dated 7/3/2020 and signed by CNA #2 documented, .Around 5 (5:00 a.m.) something in the morning I heard (Resident) kicking on door 200 Hall. (CNA #3) and I walked around to another entry to keep resident from busting door. Upon entering, (Resident) was no longer at door. We proceeded to walk down to her room. She was not there. I opened the bathroom door; she was not there either. We then proceeded to go room-to-room on 200 Hall searching each bathroom and closet. She was not there so we went and got (LPN #1) and said we could not find resident. (LPN #1) came down. Then we all three searched every room and bathroom. (Resident) was not on hall. (LPN #1) noticed window was open in TV (Television) Room on 200 Hall. She instructed us to look around building. We proceeded to walk around the building with our phone flashlights on due to being dark outside. We walked around the perimeter on building with no sighting of (Resident) . o. A facility form titled Inservice Education Report dated 7/3/2020 and received from the Administrator on 7/15/20, documented, .Date . July 3, 2020 In-service Conducted by (Administrator's Name) . Elopement . Review and understand the attached Elopement Policy and Procedure. Familiarize yourself with all aspects and be able to explain it when asked. Know your role! Sign the In-service sign-in sheet attached. All staff must sign this in-service . The attached form documented, .Elopement . It is the intent of this facility to provide for the safety of all residents. This is the responsibility of the Registered Nurses, LPNs, CNAs, and Department Heads. Monitoring Compliance . The following elements are in place for the facility to demonstrate satisfactory compliance with the guide . Evaluate Risk of elopement at admission, readmission, and quarterly, a change of condition, and on occurrence, using the elopement assessment in (facility Medical Records Computer system). Resident identified as 'at risk' have a picture in the Elopement Book, Care Plan for elopement in place, and interventions are individualized. Staff able to verbalize knowledge of elopement procedure. Door alarms are checked weekly and documented. Resident wander guards are checked daily and documented. Elopement Review Report is completed at least quarterly by QA&A (Quality Assessment and Assurance) Committee . Definition . Elopement is defined as that situation where a resident with impaired decision-making ability, oblivious to his / her own safety and needs outside the confines of the facility has left the facility without the knowledge of staff. Elopement occurs when a resident leaves the premises or a safe area without authorization (i.e. (for example) an order for [REDACTED]. All new employees are in-serviced on elopement guidelines during orientation. All employees will be in-serviced on elopement procedures annually . A staffing sign-in sheet attached to the in-service included signatures of staff from all departments / areas who were in attendance. p. A facility procedure / protocol form attached to the in-service dated 7/3/2020 and received from the Administrator on 7/15/2020 documented, .Missing Resident Event . When a door alarm sounds, the source of the alarm must be identified immediately. Do not turn the alarm off until you have checked both the inside and outside areas . If the cause of the alarm cannot be identified, the facility elopement protocol must be initiated, and staff assume that a resident has eloped . When notified, Charge Nurses must immediately huddle at Nurse's Station and page for all staff to report to the Nurse's Station immediately. This will be called as a CODE SILVER on overhead paging system . The Charge Nurse will initiate a perimeter search and send 1 person immediately to Hwy 79 / 167 to search that area, working back to facility. He / she will send 2 people to the rear exit and instruct 1 to go right around building, and 1 to go left . Charge Nurse will initiate a head count of the facility to identify missing resident. A Daily Census Report can be printed from (Clinical Record Computer System) . Once missing resident has been identified, Charge Nurse will initiate a full search of the facility, including all rooms and common areas . If the resident cannot be located in the facility or on the grounds, the facility shall . A. Notify the resident's family or responsible party . B. Notify (local) Police Department (number) . C. Notify resident's attending physician . Maintain correct time specific documentation including date and time resident was last seen, all actions taken to find the resident, and all parties notified . Post Elopement Actions . Assess the resident and document findings . Notify MD (Medical Doctor) and family / responsible party of assessment and determine appropriate action as needed . Update resident Plan of Care to include visual checks, transfer to hospital, etc. (et cetera) . Complete I and A (Incident and Accident Report) . Monitoring . Elopement events will be reviewed, analyzed, summarized, and any significant trends will be reviewed by the facility QA & A (Quality Assessment and Assurance) Committee, to ensure the appropriate process improvement actions have been taken . q. An Elopement Risk assessment dated [DATE] at 8:24 a.m. documented, .Score . 12 . Elopement Risk Assessment . b. Scoring . A score of less than 5 (equals) Low Risk for Elopement . Score of 5 or greater (equals) High Risk for Elopement . Checklist . 1. Cognition / Mental Status / Memory . c) Severely Impaired . 2. Dependent on staff for ADLs (activities of daily living) . a) Yes . 3. Ambulation . a) Able to ambulate independently . a) Yes . 4. Able to transfer independently . a) Yes . 5. History of wandering prior to nursing home placement . a) Yes . 6. Resistant to nursing home placement . a) Yes . 7. Expresses desire to go home . a) Yes . 8. Exit Seeking . a) Yes . r. The Medication Administration Record [REDACTED].Wander Guard Bracelet In Place To Left Ankle QS (every shift) for Elopement Risk . Start Date .01/23/2020 . The MAR indicated [REDACTED]. s. On 7/15/2020 at 1:00 p.m., the 200 Hall door was locked and secured with a coded keypad. On 7/15/2020 at 3:00 p.m., the 2 doors on the odd numbered side of the hall each had a keypad below the door handle and the doors would not open. APRN #2 entered numbers into the keypad before the doors opened. t. On 7/15/2020 at 2:30 p.m., Resident #1 resided on the Secured Unit, 200 Hall. The resident opened the door to the room and a Wander Guard bracelet was visible on the resident's lower left ankle. u. On 7/15/2020 at 3:40 p.m., the Director of Nursing (DON) accompanied the Surveyor on the outside of the building's 200 Hall. At the end of the wing, there was a wooden fence that surrounded the outside yard area with a padlocked gate. The rooms on the even number side of the hall windows were checked for screws in the window frame that prevented the windows from being raised. The window in the lobby area of the 200 Hall had screws placed on each side of the upper window metal frame approximately 6 to 7 inches from the lower window. Each of the windows for the resident rooms on the even side of the building were then viewed and screws were intact in the upper window metal frame that were approximately 6 inches above the lower window for a total of 8 windows. The upper window for each unit was fixed and did not raise or lower. Screws were seen in the metal upper window frame to the room where Resident #1 resided. v. On 7/15/2020 at 5:50 p.m., the Administrator accompanied the surveyor to the outside of the facility to the enclosed fenced area of the 200 Hall on the odd numbered side of rooms. Each window had screws intact to the upper window metal frame approximately 6 inches above the lower window. The enclosed area had a high metal fence with a padlocked metal gate. w. On 7/15/2020 at 6:15 p.m., APRN #2 accompanied the surveyor to the window in the Day Room / Lobby Area and attempted to pull the window up. The window raised only approximately 6 to 7 inches and the APRN stated that the window would not raise higher due to screws. A random check of room [ROOM NUMBER] also had a window with screws intact in the metal frame that prohibited the APRN from being able to raise the window more than approximately 6 inches. At 6:55 p.m., the Main Front Door was locked with a key code required. x. On 7/17/2020 at 6:27 a.m., LPN #1 was asked what had occurred when the resident had eloped on 7/3/2020. LPN #1 stated, I was going down 100 Hall. I came to the desk to get some straws, and she (Resident #1) was kicking doors on the 200 Hall. CNAs said they went to see about her kicking. I guess they were looking for her. I locked Med (Medication) Cart, went to the 200 Hall, and the CNAs had looked for her. That's when I saw the window blind. It was not closed all the way. I moved the blind. The window was opened, and the screen was pushed out. (LPN #2) and (CNA #4) told them she was gone. Our phones were out, due to the storm, went to my car, got my cell phone to call the Administrator and DON, and as I was coming back in, the one who does the screening (COVID) was coming in to work and asked if we were looking for someone. He said he saw her going in the (gas station) convenience station down the road. I Called the Administrator and DON and we went and got her, me and (CNA #2). She was sitting in there in (restaurant part of gas station).

Based on observation, record review and interview, the facility failed to ensure nutritional interventions ordered by the physician or recommended by the Registered Dietitian were evaluated by the Interdisciplinary Team for effectiveness and promptly revised when ineffective; failed to ensure new interventions were promptly developed and initiated, and the RD was promptly consulted for further nutritional recommendations when the resident's weight continued to decline from month to month; and failed to ensure a physician-ordered supplement was consistently available in the facility for administration, in order to minimize further weight loss and maintain nutritional status to the extent possible for 1 (Resident #1) of 1 case mix resident who had experienced a severe weight loss. The failed practices resulted in a pattern of actual harm for Resident #1, who experienced a severe, unplanned, 29.4-pound (23%) weight loss in a 6-month period, and had the potential to cause more than minimal harm for 6 residents who had experienced significant weight losses, according to a list provided by the Administrator on 4/21/17 at 11:53 a.m. The findings are: Resident #1 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set with an Assessment Reference Date of 3/1/17 documented the resident had severely impaired cognitive skills for daily decision making per a Staff Assessment for Mental Status, had a weight loss of 5% or more in the last month or 10% or more in the last 6 months, required extensive assistance of one person for eating, had no swallowing problem, and received a therapeutic diet. a. Dietary Progress Notes dated 6/8/16 by the Dietary Manager documented, Resident admitted [DATE] to (room number). Diet is regular. Admission wt (weight) 142.6 (pounds), ht (height) 5'7 (5 feet, 7 inches). Dietary Progress Notes dated 6/20/16 by the Dietary Manager documented, Wt 144.8 (pounds), 2.2 (pound) wt gain since admission. Diet changed to regular mech (mechanical) soft due to resident not wearing her lower partial . Dietary Progress Notes dated 6/28/16 by the Dietary Manager documented, Wt 139.0 (pounds), 3.6 (pound) wt loss since admission. No changes in diet at this time. Resident eating all meals in her room (with) some assist from spouse . Dietary Progress Notes dated 6/29/16 by the Dietary Manager documented, Diet changed: diet has been changed back to regular diet. Healthshakes have been added to 10:00 a.m. & (and) 2:00 p.m. snack times due to wt loss. Dietary Progress Notes dated 7/6/16 by the Dietary Manager documented, Wt 135.4 (pounds) . Diet is regular. Resident had 7.2 (pound) wt loss since admission on 6/7/16. Resident receives Healthshakes (at) 10:00 a.m. (and) 2:00 p.m. snack time. Will continue current plan of care. According to the Weights and Vitals Summary printed from the facility's electronic documentation system, the resident had decreased from 142.6 pounds at admission to 135.4 pounds as of 7/1/16. This was a 5.04% weight loss in a one-month period. b. A physician's orders [REDACTED].[MEDICATION NAME] tablet 30 mg (milligrams) ([MEDICATION NAME]). Give 1 tablet by mouth in the evening related to other Depressive Episodes . (The National Institutes of Health / National Library of Medicine documents [MEDICATION NAME]'s range of clinically useful applications includes improved appetite and weight gain). c. Dietary Progress Notes dated 7/12/16 (11 days after the significant, 5.04% 1-month weight loss was initially documented) included the first documented evaluation by the Registered Dietitian (RD) as follows: Wt: 7/16 (July 2016) - 135.4 (pounds), (decreased) 7.2 (pounds) in 1 month . BMI (body mass index) 21.2, BEE (basal energy expenditure) . 1443 kcal (kilocalories), 62 g (grams) pro (protein) . Diet: Regular. Visited at noon as R was fed by her husband. He said she can chew OK (okay). She is very confused (and) distracted. Will ask to try super cereal (with) bkfst (breakfast). d. The Weights and Vitals Summary entry dated 8/1/16 documented the resident's weight on that date as 133 pounds. The resident had lost an additional 2.4 pounds in the 1-month period from 7/1/16 to 8/1/16. A Dietary Progress Note dated 8/8/16 by the RD (7 days after the additional 2.4-pound weight loss was identified) documented, Wt 8/16 (August 2016) - 133 (pounds). (Decreased) 2.4 (pounds) in 1 month, 9.6 (pounds) in 2 months. R was fed at noon by her husband. She appeared anxious. No further recommendations. e. A physician order [REDACTED]. f. The Weights and Vitals Summary entry dated 9/1/16 documented the resident's weight on that date as 125.6 pounds. The resident had lost an additional 7.4 pounds (5.56%) in the 1-month period from 8/1/16 to 9/1/16. The Nursing Notes dated 9/2/16 at 2:00 p.m. documented, (Physician) here for monthly rounds, aware of R (resident's) weight status. MD (Medical Doctor) examined R + (and) reviewed meds (medications) . A Dietary Progress Note dated 9/12/16 by the RD (11 days after the additional 7.4-pound weight loss was identified) documented, Wt 9/16 (September 2016) - 125.6 (pounds). (Decreased) 7.4 (pounds) in 1 month, (decreased) 17 (pounds) in 3 mo (months). Will ask to (change) diet to reg (regular), super cal (calorie). Per husband, R loves oatmeal. He asked to change sausage to bacon (and) send her double scr (scrambled) egg (with) bkfst and biscuit / gravy. He stated she eats best at breakfast. A physician order [REDACTED].Supercal diet, regular texture, thin consistency (liquids) . g. The Weights and Vitals Summary documented the following weights for October through December 2016: 10/1/16: 127.6 pounds (a 2-pound weight gain from the previous month). 11/1/16: 129.6 pounds (a 2-pound weight gain from the previous month). 12/1/6: 114 pounds (a 15.6-pound, 12.03% weight loss since the previous month). 1.) There were no Dietary Progress Notes documented by the Dietary Manager or Registered Dietitian until 12/9/16, a period of 8 days after the 15.6-pound weight loss was documented. The Dietary Progress Note dated 12/9/16 by the Dietary Manager documented, Wt 114.0 (pounds) . Diet is regular supercal . Resident had 15.6 (pound) wt loss (at) 1 month, monthly wt for November was 129.6. Resident receives fortified milk at 3 meals. Chocolate Ensure was added to lunch meal 12/8/16 (7 days after the 15.6 pound weight loss was identified), due to wt. loss. Nursing was notified of this resident's wt. loss . Resident had 11.6 (pound) wt loss (at) 3 months, 28.6 (pound) wt loss (at) 6 months . CNAs (Certified Nursing Assistants) on this hall state that this resident will sometimes eat better at a meal for them. Will continue to monitor wt. 2.) A Weight Change Notification Document dated 12/9/16 documented, .This Resident has experienced a 12.04% weight loss . Current Diet - Regular Supercal . Current Supplements - Supercal / 2 Cal / Ensure . We recommend / would like to try - Added to wkly (weekly) wts (weights) x (times) 4 wks (weeks) . 3.) A physician order [REDACTED]. Give 4 ounces PO (by mouth) BID (twice daily) with med (medication) pass . 4.) A Dietary Progress Note dated 12/12/16 by the RD (11 days after the 15.6-pound weight loss was identified) documented, Wt 12/16 (December 2016) 114 (pounds), (decreased) 15.6 pounds in 1 month, an unlikely 1 mo (month) loss. Will ask if wt was verified. R was eating at noon - fed by husband. He stated she is taking the choc (chocolate) Ensure well. Will ask to give 1 can all meals. There was no follow-up documentation by the RD to indicate whether the severe 1-month weight loss was actually verified at this time. h. The Weights and Vitals Summary documented the resident's weight on 1/1/17 was 108.4 pounds (a 5.6-pound, 4.9% weight loss since the previous month). 1.) A Dietary Progress Note dated 1/5/17 by the RD (4 days after the additional weight loss was identified) documented, Wt 1/17 (January 2017) - 114 (pounds), (decreased) 5.6 (pounds) in 1 month, (decreased) 27 (pounds) in 6 mo. She appeared very agitated this morning, roaming all over looking for (husband's name). Will ask if TF (tube feeding) has been declined as an option. There was no documentation of any new recommendations for nutritional enhancements / supplementation at this time. 2.) A Weight Change Notification Document dated 1/6/17 documented, .This resident has experienced a 15.05% weight loss . Current Diet - Regular Supercal . Current Supplements - Magic Cup - 2 Cal . Other - Tube feeding declination signed by family . We recommend / would like to try - currently on weekly weights . There was no documentation as to when the Magic Cup supplements were initiated, how often they were to be provided, and whether the resident was accepting them. i. A Tube Feeding Declination form dated 1/10/17 documented, I, (husband's name), as healthcare proxy for (Resident #1), request that tube feedings not be administered. (Physician) has explained the consequences of not administering tube feedings to insure proper nutrition and hydration. I understand that further complications could arise due to this decision, such as dehydration, weight loss and skin problems . The form was signed by the resident's husband and the physician on 1/10/17. After this date, there was no documentation in the resident's clinical record of any further new nutritional interventions that were attempted to address the resident's ongoing weight loss. j. A form titled, Identifying Clinically Unavoidable Weight Loss dated 1/12/17 documented, Any resident who has two or more of the conditions below should be evaluated by the IDT for clinically unavoidable weight loss . The conditions checked for this resident included Depression / MDD (Major [MEDICAL CONDITION]), [MEDICAL CONDITION], Dependent for Eating, and Dependent for ADLs (activities of daily living). The section of the form designated for documentation of nutritional interventions that applied to this resident included a pre-typed list of 17 possible interventions (such as finger foods, frequent small meals, assistive devices), with instructions to place a check mark in the boxes next to the interventions that applied to the resident. The only intervention checked was, Supplements. The section of the form designated for the IDT's findings was left blank. k. The Weights and Vitals Summary documented the resident's weight on 2/6/17 was 102.4 pounds (a 6-pound, 5.5% weight loss since the previous month). 1.) A Weight Change Notification Document dated 2/8/17 documented, .This resident has experienced a 5.54% weight loss . Current Diet - Regular Super Cal . Current Supplements - magic cup at 10:00 and 14:00 (2:00 p.m.) . We recommend/would like to try - add weekly weights x 4 weeks . There was no documentation of any new recommendations for nutritional enhancements / supplementation at this time. 2.) A Dietary Progress Note dated 2/12/17 by the RD (6 days after the additional 5.5% weight loss was identified) documented, Wt 2/17 (February 2017) - 102.4, (decreased) 6 (pounds) in 1 month, (decreased) 30.6 (pounds) in 6 mo. Diet: Reg, SuperCal. Receives 4 oz (ounces) 2 Cal BID (twice daily) (with) med pass. Family has declined TF as an option. Wt loss is likely to continue. There was no documentation of any new recommendations for nutritional enhancements / supplementation at this time. The RD's handwritten list of residents for the month of February 2017 was dated 2/12/17 and documented the names of 8 residents who were seen / evaluated by the RD on that date. Resident #1's name was on the list, with the following information written next to her name: (Husband) still no to TF, No to texture change, He wants 0 (nothing) added. There was no documentation the RD discussed any options, other than tube feeding and dietary texture changes, with the resident's husband at this time. l. A Care Plan dated as initiated on 2/15/17 documented, .(Resident) is at nutritional risk related to poor appetite / with recent unavoidable weight loss . is served a regular super cal diet. See Physicians orders . will receive supplements with meals, between meals for snacks and with med pass (see MAR (Medication Administration Record) . responsible party has declined feeding tube . Observe (resident) at meal times and report to Nurse / MD (Medical Doctor) any s/s (signs / symptoms) of chewing / swallowing / coughing / choking / nose dripping / eyes tearing while eating or pocketing foods, etc (et cetera) . Weigh (resident) and record Q (every) month and PRN (as needed). Notify MD promptly of (blank) . As of 4/20/17 at 8:10 a.m., no new interventions had been added to this Care Plan since 2/17/17, and the interventions that were included on the Care Plan were no different than those recommended or initiated prior to January 2017. m. The Weights and Vitals Summary documented the resident's weight on 3/8/17 was 101.6 pounds (an additional 0.8-pound weight loss since the previous month). 1.) A Weight Change Notification Document dated 3/13/17 documented, .This resident has experienced a 19.1% weight loss . Weight change has occurred over the past 6 months . Current Diet - Super Cal . Current Supplements - Magic cup . We recommend/would like to try - Continue monthly wts . The attached Order Summary Report dated 3/13/17 documented the resident remained on the Super Cal, regular texture diet and continued to receive 2 Cal supplements (4 ounces twice daily with med pass) and multivitamin (1 tablet once daily) as previously ordered. There were no new nutritional interventions recommended or ordered at this time. 2.) A Medical Nutrition Therapy Recommendation form dated 3/13/17 and signed by the Registered Dietitian documented the names of 20 facility residents who were seen / evaluated by the RD during the month of March 2017. Resident #1's name was not included on this list. n. The Weights and Vitals Summary documented the resident's weight on 4/5/17 was 98.2 pounds (an additional 3.4-pound, 3.34% weight loss since the previous month). Based on the documented 10/1/16 weight of 127.6 pounds, the resident had lost a total of 29.4 pounds (23.04%) in the last 6 months. Based on the 1/1/17 weight of 108.4 pounds, the resident had lost 10.2 pounds (9.4%) in the 3-month period from January to April 2017 (during which no new nutritional interventions were documented, other than the reference to Magic Cups on 1/6/17, which did not specify a frequency). Calculating the 142.6-pound admission weight, as compared with the current 98.2-pound weight in April 2017, the resident had lost a total of 44.4 pounds (31.13% of her total body weight) in the past 10 months. o. The February, March and April 2017 Task sheet for activities of daily living (ADLs) documented the resident's average meal consumption as follows: 1.) February 2017 - Average percentage of meals eaten - 35% 2.) March 2017 - Average percentage of meals eaten - 45% 3.) April 2017 - Average percentage of meals eaten - 36%. p. A Nourishment List provided by the Administrator on 4/17/17 at 3:00 p.m. documented the resident was to receive a Magic Cup supplement. The form did not indicate the frequency or specify a time to be served. q. On 4/17/17 at 4:44 p.m., the resident was sitting in a recliner in her room, with her husband visiting. Her husband stated he usually stays through supper time to feed his wife. r. On 4/17/17 at 6:11 p.m., the resident was served her supper tray, which consisted of a salmon croquette, creamy dill sauce, garden rice, green beans, one slice of bread, margarine, Mandarin oranges, one magic cup (orange flavored), 8 ounces of milk and 12 ounces of soda. There was no Ensure supplement served with the supper meal. s. On 4/18/17 at 12:39 p.m., the resident was served a lunch tray, which consisted of a bacon-wrapped pork filet, purple hull peas, squash casserole, cornbread, margarine, four-layer delight dessert, 8 ounces of milk and 8 ounces of soda. There was no Ensure supplement or magic cup served with the lunch meal. t. On 4/19/17 at 12:38 p.m., the resident was sitting in a wheelchair in her room with the overbed table in front of her. The resident's lunch tray consisted of chili with crushed crackers, creamed asparagus, baked potato with sour cream, 8 ounces of milk, 8 ounces of chocolate Ensure, a Magic Cup supplement and a slice of pound cake. The resident's husband was assisting the resident with the meal and stated the resident loved baked potatoes with sour cream. The resident took a bite, spit it out in her hand, and handed it to her husband. The resident refused the Ensure and the pound cake, turning her head away and stating, No. The husband then gave the resident a bite of the Magic Cup (frozen, ice cream-type supplement) and the resident accepted it. The husband mixed pound cake with Magic Cup and the resident accepted a bite. The resident's husband stated, She likes sweets. I brought her a donut this morning, and she ate it. The resident consumed a total of 25% of the meal. u. As of 4/19/17, the recommendation for chocolate Ensure with all meals, addressed in the Dietary Progress Note dated 12/12/16, was the most recent nutritional recommendation documented by the RD. v. On 4/19/17 at 1:17 p.m., the resident's husband was interviewed by the surveyor, regarding nutritional approaches for the resident. He stated his wife received Magic Cups with all 3 meals, and at 10:00 a.m. and 2:15 p.m. He also stated, The Nurse brings her 2 Cal 3 times a day - I put it in her super cereal in the morning - she likes it. She will take a bite or 2 bites of egg, then she tells you 'I am full' and will not eat any more. She will eat almost all of the oatmeal (super cereal); sometimes she will not, it depends . The Dietitian was here 3 weeks ago to ask what she will like to eat; she comes about once a month and, each time she comes, she will stop by and find out what she likes to eat . She loves cream potatoes, meat loaf, any soft steak, she doesn't like anything hard. They bring a menu every day for us to see what she will like. My daughter will also tell them what she will like to eat and they will bring it to her . w. On 4/19/17 at 3:35 p.m., the Director of Nursing (DON) was asked about the lack of new nutritional interventions since January 2017 and stated, I don't know why she (RD) didn't put another intervention in place for the January and February weight loss for (Resident #1); she was not on the list of residents that she saw in March. She was here on 3/13/17, but did not see the resident. x. On 4/19/17 at 3:35 p.m., the Dietary Manager was asked about the lack of new interventions since January 2017 and stated he did not know why the RD did not put any new interventions in place for the continued weight loss. y. On 4/19/17 at 3:48 p.m., the RD was asked about the lack of new interventions since January 2017 and stated, I think we kind of ran out of ideas; I did not know that she dropped in March when I was there. I had no other ideas. z. On 4/19/17 at 5:50 p.m., the Dietary Manager was asked about his qualifications. He stated he enrolled in Certified Dietary Manager (CDM) classes in April 2015, finished approximately 30% of the class, then quit due to, focusing on work. The Dietary Manager was asked, What is your responsibility regarding weight loss management? He stated, Get with the dietitian. We review weekly with Risk Management. aa. On 4/20/17 at 10:00 a.m., the resident's physician (facility Medical Director) was asked, Are you aware of the weight loss (Resident #1) has had over the last 6 months? The physician stated, Very acutely aware. (I was) contacted last Friday (4/14/17) . I don't know what else there is to do. I love these people. I went to high school with them. We've tried everything. The facility has kept me up to date on her continued weight loss. bb. A Physician's Progress Note dated 4/20/17 and signed by the Medical Director documented, I have talked to LTC (long-term care) about (Resident #1's) wt. loss. I have been aware of this for months and we have tried many types of dietary changes and measurements. Nothing has worked. I have talked at length with the family about what they want to do about this and they don't want any surgical interventions. Please note that these are friends of mine for [AGE] years and I will do anything that would be of any help. cc. Dietary Progress Notes provided by the Registered Nurse Consultant on 4/20/17 at 12:40 p.m. documented the following new entries dated 4/19/17 and 4/20/17: 1.) 4/19/17 (no time documented) . Will ask to visit (with) husband again about trying puree texture, which he has not wanted to do in the past . 2.) 4/19/17 (no time documented) . Current weight 98.4 (pounds) + 0.2 (pound) wt gain in 1 week. Diet is regular, supercal, resident receives super cereal at breakfast, fortified milk at 3 meals. Discussed with resident's spouse new food likes that this resident might eat. Spouse stated that she likes mashed potatoes, baked sweet potatoes, meat loaf, yogurt. Spouse stated resident used to drink chocolate Ensure at home, but didn't like it anymore. Dietary Staff sent mashed potatoes (non-fortified potatoes per surveyor observation) with dinner meal. Observed resident at dinner time. She ate 3-4 bites of mashed potatoes, 3-4 bites of mixed vegetables, 3-4 bites of Magic Cup. Resident drank 3-4 swallows of fortified milk and some of her chocolate Ensure, resident grimaced and said, 'no' after drinking the Ensure. RD recommends adding super cereal to all meals. Tray card updated. 3.) 4/19/17 (no time documented) . Resident's spouse agreed to diet change: meal changed to reg (regular) puree with supercal at all meals, super cereal at breakfast . 4.) 4/20/17 (no time documented) . Observed resident's breakfast tray. She drank approx. (approximately) 60 cc (cubic centimeters) of orange juice, a few sips of chocolate Ensure, a few sips of fortified milk, 3-4 bites of egg, approx. 10-15% of super cereal . dd. On 4/20/17 at 12:58 p.m., Licensed Practical Nurse (LPN) #1 was asked about the resident's 2 Cal supplements and stated, I get it from Dietary; I don't think I have any today. The LPN was asked if 2 Cal was available in the storage room and stated, No, there is not any. ee. On 4/20/17 at 1:00 p.m., LPN #3 was asked, Do you have any 2 Cal for your med pass? The LPN stated, No ma'am. The LPN was asked how long the facility had been out of 2 Cal and stated, I came back on Wednesday (4/19/17) and I did not have any to give. The LPN was asked if she had reported this to anyone and stated, Yes, I told the DON.

Complaint # was substantiated (all or in part) with these findings. Based on record review and interview, the facility failed to ensure an allegation of abuse was immediately reported to the Administrator, the allegation of abuse was thoroughly investigated, and interventions were promptly developed and implemented to protect residents from further potential abuse for 1 of 1 (Resident #9) case mix resident who had alleged staff to resident abuse. These failed practices resulted in Immediate Jeopardy, which caused or could have caused serious harm, injury or death to Resident #9 who had alleged abuse from staff and had the potential to affect 52 residents who were at risk of abuse from staff as documented on a list provided by the Administrator on 3/12/11. The facility was informed of the Immediate Jeopardy condition on 3/12/11 at 12:30 a.m. The findings are: 1. Resident #9 had [DIAGNOSES REDACTED]. The Arkansas Department of Health and Human Services Evaluation for Medical Need Criteria dated 2/24/11 documented the resident was alert and oriented to person and place. a. The Nurses Notes dated 3/5/11 4:30 a.m. documented, "A/O (alert and oriented) X (times) 3 R (resident) stayed in bed c (with) tube feeding @ (at) 35cc (cubic centimeters)/hr (per hour) G (gastrostomy) tube patent (and) intact (checked) for and confirmed... flushes per orders. R up in w/c (wheelchair) (at) this time watching T.V. (no) complaints will cont (continue) to monitor." b. The Nurse's Notes dated 3/5/11 documented, "Late entry 8:45 a.m. I/A (Incident and Accident report) written (resident) stated to RN (Registered Nurse) that a person dressed in blue came (at) 4:45 a.m. in the room and slapped her across the face because she asked to go to the bathroom. Then a little later (resident) stated to RN that it was a black female nurse dressed in blue came in and slapped her. (resident) stated that this happened yesterday also. Appropriate parties were contacted." c. An Incident/Accident Investigation Report dated 3/5/11 at 8:45 a.m. documented, "(Resident) stated to RN (Registered Nurse) that a person dressed in blue came at 4:45 a.m. into room and slapped her across the face because she asked to go the bathroom. Then a little later (resident) stated to RN that it was a black female nurse dressed in blue came in and slapped her. (resident) stated that this happened yesterday also. Appropriate parties were contacted. ...3/5/11 1:45 p.m., discharged home (with) family at shift change..." 1) An Office of Long Term Care (OLTC) Witness Statement form dated 3/5/11 at 10:53 p.m. and completed by Certified Nursing Assistant (CNA) #6 documented, "I was told that (resident) said the CNAs were hitting her. (CNA #5) and I sat with (resident) last night and when (Licensed Practical Nurse #2) came in she was saying something about someone hitting her. (LPN #2) said she already had those bruises." 2) An OLTC Witness Statement form dated 3/5/11 at 10:58 p.m. and completed by CNA #5 documented, "(Resident) had bruises already on her. (LPN #2) told (resident) that last night when she came in to see about her pump. (CNA #6) and I watched (resident) all night and there were no physical altercations." d. An Office of Long Term Care (OLTC) Incident and Accident Report Division of Medical Services (DMS) - 7734 form dated 3/7/11 at 8:00 a.m. documented, "(Resident's) husband brought her to the desk where she reported to the RN on duty that a person dressed in blue came into her room at 4:45 a.m. that morning and slapped her across the face because she ask to go to the bathroom, during the conversation the resident stated the person was a black female nurse, she later stated it had also happened the morning before. STEPS TAKEN TO PREVENT CONTINUED ABUSE OR NEGLECT DURING THE INVESTIGATION Her husband was here with her when she made the report so he was aware of allegation. Administrator, DON (Director of Nursing), Physician and police were all notified. RN in charge immediately began taking statements from staff and other residents, the schedule and sign in logs were checked to see who had worked at the indicated time. It was determined that there was no black nurse (the nurses wear blue) on duty on either of the times she indicated, we have no black nurses on that shift so she was again ask what color she was wearing and she was adamant about the uniform being blue. When ask if she could identify the female, she said no because they all looked the same to her. Section II Complete Description of Incident On March 5, ...at approximately 8:45 a.m. (Resident) was pushed to the nurse's station by her husband. (Resident) was calm ...(Resident) stated to the RN on duty that around 4:45 a.m. this morning (3/5/11) she was 'slapped in the face by a nurse' (resident) stated that she requested to go to the bathroom and the nurse told her 'nobody has to go to the bathroom this much' to which (resident) replied 'I don't have to answer to you, I only answer to God' (resident) states that the nurse slapped her across the face, indicating her right cheek with her hand. The resident was checked for redness, bruising or indication of trauma with none being present. The RN then ask (resident) if the person was wearing red or blue scrubs, (resident) stated she was wearing blue. At about 9:00 a.m. on this same date both (spouse) and (resident) were sitting in the front lobby (resident) again spoke of the event only now saying it happened yesterday. The RN on duty ask her to clarify when the alleged incident happened, (resident) stated 'both days.' (resident) continued to describe the event by saying 'it was a black lady that slapped me.' (resident) was then ask the resident what color the black lady was wearing to which she replied 'blue'." An OLTC Witness Statement form dated 3/8/11 10:00 p.m. - 6:00 a.m. shift and completed by LPN #2 documented, "(resident) was up in w/c at 2200 (10:00 p.m.) when this LPN came to work. (resident) refuse to go to bed she sat (at) nurse station when her CNA made rounds then she would go to sitting room where the large TV and watch TV for a while. (resident) refuse to be connected to feeding pump. She appeared in good spirits (no) problem noted (at) all this shift. No problems (with) the CNA that was one on one and very friendly and talkative (with) me the full 8 (hours). (resident) just wanted to be where the people was this night." e. On 3/11/11 at 10:50 p.m., (CNA #5 was asked if she had worked with Resident #9 and the CNA stated, "I sat with her last Friday night. I took her to the bathroom. We let her sit in a wheelchair in living room with the big TV. She watched TV. I asked her at 3:00 a.m. if she was ready to go to bed, but she changes her mind a lot. Put her in her bed. (LPN #2) came to check on the feeding pump." The CNA was asked if the resident was showered or bathed during the night shift and the CNA stated, "We don't do that at night." f. On 3/11/11 at 11:05 p.m., LPN #2 was asked if she was familiar with the resident and what occurred with the resident on the previous Thursday and Friday. The LPN stated, "Thursday, the 3rd, she was up all night in the big TV room with the aides, back to bed about 15 minutes, then she wanted to get back up. (CNA #7) sat with her all night. When (CNA #7) had to help make rounds, she (resident) sat with me. Friday about 9:30 p.m., she was asleep. The feeding tube was attached to the pump. About 1:30 a.m., me and (CNA #5 and CNA #6) got her up. I disconnected the pump, she was up in the wheelchair in a soft belt restraint and (resident) watched TV until 4 a.m. She started yelling that her tube was out and that she needed to go to the ER (emergency room ), that her Gastrostomy tube was out. She was hollering about her tube and I checked and (the tube was) not out. She (resident) pointed at (CNA #5) hurt her. I asked (CNA #5) and (CNA #5) stated that she didn't do anything. The resident said, 'I had a twin brother that was mean to me.' I jumped on her and said (resident) you know that girl did not hit or pinch you. (CNA #6) was in room. We put her back into bed and she slept until 7:00 a.m." The LPN was asked who was in the room with the resident that night and the LPN stated, "I think it was (CNA #5). I don't know. You'll have to ask them who was sitting with resident. I don't know who stayed at 6:15 a.m." LPN #2 was asked what the CNA reported about the resident and the LPN stated, "Just that she had slept." The LPN was asked who got the resident out of bed and the LPN stated, "I was in there. I disconnected her feeding tube and her pump and she was in the wheelchair with a soft belt restraint. She said she was needing to go to the emergency room . She was hollering about her tube and I checked and (the tube was) not out. She kept saying, 'you know I had a twin brother and she was pointing to her (CNA #5) and he mistreated me'." The LPN was asked who the resident pointed to and the LPN stated, "(CNA #5). She (resident) said no, I mean that one. I said (Resident) you know that girl didn't hit or pinch you." LPN #2 was then asked who had sat in the room with the resident and the LPN stated, "I don't remember. (CNA #6) was in room. We put her back into bed and she slept until 7:00 a.m. I think it was (CNA #5), I don't know. You'll have to ask them." The LPN was asked again who had sat with the resident and the LPN stated, "I don't know who stayed at 6:15 a.m." The LPN was asked if the resident had said anything else and the LPN stated, "She just said she had been hit." The LPN was asked what time the resident said this and the LPN stated, "Around 4:30 a.m." The LPN was asked if the resident was connected to the feeding pump and the LPN stated, "She didn't have that on. I disconnected it at 1:30 a.m. or 2..." The LPN then stated, "I've known her [AGE] years. (Resident) was just being (resident). I jumped on her for fussing at (CNA #5)." g. On 3/11/11 at 11:25 p.m., the Administrator was asked what the LPN should have done when the resident told her that a CNA slapped her and the Administrator stated, "She should have sent the aides home." h. On 3/12/11 at 12:00 midnight, CNA #6 was asked what hall he/she was scheduled to work and if she sat with or cared for the resident. The CNA stated, "I'm on 300 Hall permanently. I work 100 Hall whenever they are short. I only worked it that one night when they were short. Lately, I just worked with (resident) ...both of us were sitting in the room with her, (CNA #5) and me, yes. We had to keep her back in the bed because she kept trying to get up. We laid her down about 3 different times then she wanted to go to the bathroom. As soon as I got her, (LPN #3) told me to go down there. That is the only person. (LPN #2) came because (resident) was pulling on her stomach pump cord. We were lowering her down on the pot. (CNA #5) watched her and I went to get (LPN #2). I was gone not very long. (LPN #2) discontinued the pump 2 to 3 a.m. While she was up on the pot, she (resident) said something about somebody slapping her that night. (LPN #2) was disconnecting the pump and sometime before 4 we put her back to bed and she went to sleep." The CNA was asked if the resident had brusing to the face and the CNA stated, "I don't even remember." The CNA was asked if they had showered the resident and the CNA stated, "Never gave a shower, used wipes to clean, she used the bedside commode." i. On 3/12/11 at 12:20 a.m., CNA #5 was asked what occurred and the CNA stated, "Me and (CNA #6) sat with her, she was awake and watched TV in the living room area. She asked around 3:00 a.m. and then put to bed. Me and (CNA #6) put her to bed. (LPN #2) attended to her pump. It was connected (resident) pulled towards the bed with her with the line. (LPN #2) turned it off. She (resident) stayed awake a little bit longer and fell asleep. At 4:00 a.m., I started my rounds after she fell asleep. (CNA #6) stayed in room with resident. She came out at one point and helped me about 5:00 - I can't say. (CNA #6) went back in about 5:45 a.m. I didn't go back in." The CNA was asked if the resident had said anything about anyone hitting her and the CNA stated, "(LPN #2 stated) she (resident) said that she had been slapped. She didn't say who did it. (LPN #2) told her that we didn't slap her. (LPN #2) said she pointed at me. I didn't know that she pointed at me. (LPN #2) just told me a minute ago." The CNA was asked if the LPN had taken witness statements and the CNA stated, "No." On 3/12/11 at 12:25 a.m., CNA #5 was asked again if one on one care was provided for the resident and the CNA stated, "Me and (CNA #6) sat with her. She was awake and she watched TV in the living room, she was asked maybe around 3:00 a.m. about going to bed and she said no then she said yes and we put her to bed and (LPN #2) came in there." The CNA was asked what the nurse did and the CNA stated, "(LPN #2) attended to her pump." The CNA was asked what the nurse did to the pump and the CNA stated, "She turned it on or she turned it off. She (resident) pulled it towards the bed with the line. I think she turned it off and after (LPN #2) left we put the covers on her and she stayed awake a little bit longer and fell asleep. After she fell asleep it was time for me to do my rounds and (CNA #6) stayed in the room." CNA #5 was then asked if CNA #6 left the room to make rounds and when this took place. CNA #5 stated, "I can't say. About 5:00 (a.m.) (CNA #6) came out then (CNA #6) went back in, maybe about 5:00." The CNA was asked if the resident said anything to the nurse when LPN #2 came into the room. CNA #6 stated, "When (LPN #2) came in the room she (resident) said that she had been slapped." The CNA was asked if the resident named who had slapped her and the CNA stated, "No she didn't say who did it. (LPN #2) told her she knew we didn't slap her." The CNA was asked if it was heard who the resident said did this and the CNA stated, "I didn't know she pointed at me." The CNA was asked what was to be done when a resident alleged abuse and the CNA stated, "Report it." The CNA was then asked if the resident's allegation was reported and the CNA stated, "No." j. On 3/12/11 at 12:35 a.m., LPN #2 was asked who was to be notified if there was an allegation of abuse and the LPN stated, "Call the police. If I thought somebody had really been abused I'd call police, the doctor and DON (Director of Nursing) and Administrator. I hadn't determined it was abuse." The LPN was asked if the resident had informed her she had been slapped and the LPN stated, "Yes." The LPN was asked if she had received training or an in-service on abuse and the LPN stated, "Yes." The LPN was asked when she was in-serviced and the LPN stated, "Couple of months ago." The LPN was asked what is to be done if there is an allegation of abuse and the LPN stated, "If anybody has been abused then we are to talk to the aide then we call our Administrator or DON and they will tell us what to do." LPN #2 was asked why the resident's allegation was not reported and the LPN stated, "Probably didn't think about it. I don't know." The nurse was asked how long she had been a licensed nurse and the LPN stated, "[AGE] years." The nurse was asked if, as a licensed nurse in this state, she was aware she was mandated to report allegations or suspected abuse and the LPN stated, "That law just went in effect a few years ago." LPN #2 was asked where the resident's status and the allegations were documented and the LPN gave no response. k. On 3/12/11 at 12:45 a.m., the facility's Staffing Logs documented on the sign-in sheets that LPN #2, CNA #5 and CNA #6 worked in the facility after Resident #9's allegations on 3/5/11 and had direct resident care assignments throughout the facility on the night shift. LPN #2 documented a signature on the sign-in sheets dated 3/5/11, 3/7/11, 3/9/11, 3/10/11 and 3/11/11. The sign-in sheets documented that CNA #5 was working in the facility on 3/5/11, 3/6/11, 3/9/11, 3/10/11 and 3/11/11. The sign-in sheets documented CNA #6 was working in the facility on 3/5/11, 3/6/11, 3/9/11, 3/10/11 and 3/11/11. l. On 3/12/11 at 3:00 p.m., the DON was asked if licensed nurses are to report allegations of abuse and the DON stated, "Yes." The DON was asked to whom the licensed nurses are to report and the DON stated, "DON, Administrator." The DON was asked if the licensed nurse on duty was responsible to ensure residents were safe and protected and the DON stated, "Yes." The DON was asked if the licensed nurse should remove them from the care area when there were allegations of abuse by a CNA and the DON stated, "Yes." The DON was then asked if LPN #2 had reported allegations of abuse and the DON stated, "Not to myself." On 3/12/11 at 3:10 p.m., the Administrator was asked if licensed nursing staff were supposed to report allegations of abuse and the Administrator stated, "Yes and begin investigation." The Administrator was asked how soon this should begin and the Administrator stated, "Immediately, family, MD (medical doctor), Administrator, DON, police." The Administrator was asked what the licensed nurse was to do if the allegation of abuse involved a CNA and the Administrator stated, "Take CNA to a non-resident area, get statement, send them home pending investigation." 2. The Immediate Jeopardy was removed and the scope/severity reduced to a "E" on 3/12/11 at 1:50 a.m., when the facility implemented the following plan of removal: a. Upon knowledge of the allegation of abuse, the accused staff members and the nurse who failed to report were removed from all resident areas by the Administrator at 11:45 p.m. b. These staff members were placed in non-resident areas to complete their witness statements. Activity Director stayed with these employees until their witness statements and interviews with Office of Long Term Care were completed. Activity Director, Assistant Business Office Manager and Assistant Director of Nursing then stayed with these employees until they left the facility. c. The staff members accused of the alleged abuse have been suspended pending outcome of investigation and told not to return unless contacted by the Administrator. d. Police were notified and arrived at the facility at 12:03 a.m. at which time they took the accused staff 's statements and stated another officer will be back to continue the investigation. This officer remained at the facility until 12:25 a.m. e. All staff on duty at the time of discovery (except the 3 sent home on suspension) were inserviced by the Director of Nursing on the Facility Abuse Policy and reporting requirements (1:50 a.m.). f. All oncoming staff will be inserviced by DON/Designee on Facility Abuse Policy and Reporting requirements prior to being allowed to return to work. This will begin with shift change this morning and continue until all staff have completed training. Any staff member who is off on extended leave for any reason will also have to complete the inservice prior to returning to work. g. A list of all cognitive/interviewable residents will be obtained by MDS (Minimum Data Set) Coordinator by 9:00 a.m. on 3/12/11. Those residents determined to be interviewable will be interviewed by DON/Designee to discover if there are other nonreported allegations of abuse. Interviews of these residents will be completed by 11:30 a.m. on 3/12/11. In order to verify compliance, social will interview 2 residents from each hall weekly times 4 weeks. To verify compliance of non-interviewable residents, the interdisciplinary team will review I&As of those residents on a weekly basis to verify all potential allegations have been thoroughly investigated with proper notification when indicated and that all alledged perpetrators have been removed/suspended from facility".

Complaint # was substantiated (all or in part) with these findings. Based on record review and interview, the facility failed to ensure Abuse Prohibition Policies and Procedures were operationalized to ensure residents were free from abuse. The facility failed to ensure an allegation of abuse was immediately reported to the Administrator, the allegation of abuse was thoroughly investigated, and interventions were promptly developed and implemented to protect residents from further potential abuse for 1 of 1 (Resident #9) case mix resident who had alleged staff to resident abuse. These failed practices resulted in Immediate Jeopardy, which caused or could have caused serious harm, injury or death to Resident #9 who had alleged abuse from staff and had the potential to affect 52 residents who were at risk of abuse from staff as documented on a list provided by the Administrator on 3/12/11. The facility was informed of the Immediate Jeopardy condition on 3/12/11 at 12:30 a.m. The findings are: The facility's policy and procedure titled "Resident Abuse" provided by the Director of Nursing (DON) on 3/11/11 at 11:00 a.m., documented, "The facility must develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property. ...Policy This facility will endeavor to prevent mistreatment, neglect and abuse of residents and the misappropriation of resident property. Preventative steps taken by each facility include: ...III. Investigation/Reporting A. All incidents of alleged resident mistreatment, neglect, or abuse including injuries of unknown source and misappropriation of resident property MUST BE RESPORTED IMMEDIATELY TO THE ADMINISTRATOR by a facility staff member. All incidents of alleged violations must also be reported to the appropriate officials (such as city and/or county police) and to the OLTC (Office of Long Term Care) and the registry or licensing Board. Reports are made according to State/Federal regulations. B. An internal investigation will be initiated immediately in every case of alleged resident neglect, abuse, mistreatment, misappropriation of property and/or resident injury from unknown cause. C. An Incident/Accident Report form will be completed immediately after an incident occurs or is found to have occurred. D. The Incident/Accident Report will be given to the Administrator and a copy to the Director of Nursing immediately for review and follow-up investigation. E. The Administrator will thoroughly investigate each incident of alleged violation and or injury of unknown cause and will keep written documentation of that investigation and resulting determinations on file ... G. ALL alleged or suspected incidents must also be reported according to state and federal law. The following persons or entities may be notified by the Charge Nurse on duty at the time of the incident: a) Administrator b) OLTC c) State, county, or city police; d) Physician; e) Family members...Reports are made according to current state and federal regulations. The facility will report incidents according to the time restrictions required by law ... I. An Incident and Accident Report form will be completed by the Charge Nurse. ... IV. PROTECTING RESIDENTS FROM FURTHER INCIDENTS; AND PREVENTING FURTHER OCCURRENCES DURING INVESTIGATION A. In an effort to protect a resident who has alledgedly been abused, neglected, mistreated, or has had property misappropriated, the suspected employee(s) will be suspended immediately from employment (or re-assigned to non-resident care duties) until an investigation has determined that the employee is no longer a suspect. ...E. The Facility will undertake other Protective and Preventive measures as follow: ... A. This facility does not tolerate any form of resident mistreatment. It requires all employees to report suspicions and allegations of mistreatment as soon as they become known, and all residents, family members and staff may make reports without fear of retaliation from the facility. B. The person reporting an incident will be advised by the Facility Administrator to report any further incidents immediately so the proper authorities can be notified and proper action taken.... 3. Resident #9 had [DIAGNOSES REDACTED]. The Arkansas Department of Health and Human Services Evaluation for Medical Need Criteria dated 2/24/11 documented the resident was alert and oriented to person and place. a. The Nurses Notes dated 3/5/11 4:30 a.m. documented, "A/O (alert and oriented) X (times) 3 R (resident) stayed in bed c (with) tube feeding @ (at) 35cc (cubic centimeters)/hr (per hour) G (gastrostomy) tube patent (and) intact (checked) for and confirmed... flushes per orders. R up in w/c (wheelchair) (at) this time watching T.V. (no) complaints will cont (continue) to monitor." b. The Nurse's Notes dated 3/5/11 documented, "Late entry 8:45 a.m. I/A (Incident and Accident report) written (resident) stated to RN (Registered Nurse) that a person dressed in blue came (at) 4:45 a.m. in the room and slapped her across the face because she asked to go to the bathroom. Then a little later (resident) stated to RN that it was a black female nurse dressed in blue came in and slapped her. (resident) stated that this happened yesterday also. Appropriate parties were contacted." c. An Incident/Accident Investigation Report dated 3/5/11 at 8:45 a.m. documented, "(Resident) stated to RN (Registered Nurse) that a person dressed in blue came at 4:45 a.m. into room and slapped her across the face because she asked to go the bathroom. Then a little later (resident) stated to RN that it was a black female nurse dressed in blue came in and slapped her. (resident) stated that this happened yesterday also. Appropriate parties were contacted. ...3/5/11 1:45 p.m., discharged home (with) family at shift change..." 1) An Office of Long Term Care (OLTC) Witness Statement form dated 3/5/11 at 10:53 p.m. and completed by Certified Nursing Assistant (CNA) #6 documented, "I was told that (resident) said the CNAs were hitting her. (CNA #5) and I sat with (resident) last night and when (Licensed Practical Nurse #2) came in she was saying something about someone hitting her. (LPN #2) said she already had those bruises." 2) An OLTC Witness Statement form dated 3/5/11 at 10:58 p.m. and completed by CNA #5 documented, "(Resident) had bruises already on her. (LPN #2) told (resident) that last night when she came in to see about her pump. (CNA #6) and I watched (resident) all night and there were no physical altercations." d. An Office of Long Term Care (OLTC) Incident and Accident Report Division of Medical Services (DMS) - 7734 form dated 3/7/11 at 8:00 a.m. documented, "(Resident's) husband brought her to the desk where she reported to the RN on duty that a person dressed in blue came into her room at 4:45 a.m. that morning and slapped her across the face because she ask to go to the bathroom, during the conversation the resident stated the person was a black female nurse, she later stated it had also happened the morning before. STEPS TAKEN TO PREVENT CONTINUED ABUSE OR NEGLECT DURING THE INVESTIGATION Her husband was here with her when she made the report so he was aware of allegation. Administrator, DON (Director of Nursing), Physician and police were all notified. RN in charge immediately began taking statements from staff and other residents, the schedule and sign in logs were checked to see who had worked at the indicated time. It was determined that there was no black nurse (the nurses wear blue) on duty on either of the times she indicated, we have no black nurses on that shift so she was again ask what color she was wearing and she was adamant about the uniform being blue. When ask if she could identify the female, she said no because they all looked the same to her. Section II Complete Description of Incident On March 5, ...at approximately 8:45 a.m. (Resident) was pushed to the nurse's station by her husband. (Resident) was calm ...(Resident) stated to the RN on duty that around 4:45 a.m. this morning (3/5/11) she was 'slapped in the face by a nurse' (resident) stated that she requested to go to the bathroom and the nurse told her 'nobody has to go to the bathroom this much' to which (resident) replied 'I don't have to answer to you, I only answer to God' (resident) states that the nurse slapped her across the face, indicating her right cheek with her hand. The resident was checked for redness, bruising or indication of trauma with none being present. The RN then ask (resident) if the person was wearing red or blue scrubs, (resident) stated she was wearing blue. At about 9:00 a.m. on this same date both (spouse) and (resident) were sitting in the front lobby (resident) again spoke of the event only now saying it happened yesterday. The RN on duty ask her to clarify when the alleged incident happened, (resident) stated 'both days.' (resident) continued to describe the event by saying 'it was a black lady that slapped me.' (resident) was then ask the resident what color the black lady was wearing to which she replied 'blue'." An OLTC Witness Statement form dated 3/8/11 10:00 p.m. - 6:00 a.m. shift and completed by LPN #2 documented, "(resident) was up in w/c at 2200 (10:00 p.m.) when this LPN came to work. (resident) refuse to go to bed she sat (at) nurse station when her CNA made rounds then she would go to sitting room where the large TV and watch TV for a while. (resident) refuse to be connected to feeding pump. She appeared in good spirits (no) problem noted (at) all this shift. No problems (with) the CNA that was one on one and very friendly and talkative (with) me the full 8 (hours). (resident) just wanted to be where the people was this night." e. On 3/11/11 at 10:50 p.m., (CNA #5 was asked if she had worked with Resident #9 and the CNA stated, "I sat with her last Friday night. I took her to the bathroom. We let her sit in a wheelchair in living room with the big TV. She watched TV. I asked her at 3:00 a.m. if she was ready to go to bed, but she changes her mind a lot. Put her in her bed. (LPN #2) came to check on the feeding pump." The CNA was asked if the resident was showered or bathed during the night shift and the CNA stated, "We don't do that at night." f. On 3/11/11 at 11:05 p.m., LPN #2 was asked if she was familiar with the resident and what occurred with the resident on the previous Thursday and Friday. The LPN stated, "Thursday, the 3rd, she was up all night in the big TV room with the aides, back to bed about 15 minutes, then she wanted to get back up. (CNA #7) sat with her all night. When (CNA #7) had to help make rounds, she (resident) sat with me. Friday about 9:30 p.m., she was asleep. The feeding tube was attached to the pump. About 1:30 a.m., me and (CNA #5 and CNA #6) got her up. I disconnected the pump, she was up in the wheelchair in a soft belt restraint and (resident) watched TV until 4 a.m. She started yelling that her tube was out and that she needed to go to the ER (emergency room ), that her Gastrostomy tube was out. She was hollering about her tube and I checked and (the tube was) not out. She (resident) pointed at (CNA #5) hurt her. I asked (CNA #5) and (CNA #5) stated that she didn't do anything. The resident said, 'I had a twin brother that was mean to me.' I jumped on her and said (resident) you know that girl did not hit or pinch you. (CNA #6) was in room. We put her back into bed and she slept until 7:00 a.m." The LPN was asked who was in the room with the resident that night and the LPN stated, "I think it was (CNA #5). I don't know. You'll have to ask them who was sitting with resident. I don't know who stayed at 6:15 a.m." LPN #2 was asked what the CNA reported about the resident and the LPN stated, "Just that she had slept." The LPN was asked who got the resident out of bed and the LPN stated, "I was in there. I disconnected her feeding tube and her pump and she was in the wheelchair with a soft belt restraint. She said she was needing to go to the emergency room . She was hollering about her tube and I checked and (the tube was) not out. She kept saying, 'you know I had a twin brother and she was pointing to her (CNA #5) and he mistreated me'." The LPN was asked who the resident pointed to and the LPN stated, "(CNA #5). She (resident) said no, I mean that one. I said (Resident) you know that girl didn't hit or pinch you." LPN #2 was then asked who had sat in the room with the resident and the LPN stated, "I don't remember. (CNA #6) was in room. We put her back into bed and she slept until 7:00 a.m. I think it was (CNA #5), I don't know. You'll have to ask them." The LPN was asked again who had sat with the resident and the LPN stated, "I don't know who stayed at 6:15 a.m." The LPN was asked if the resident had said anything else and the LPN stated, "She just said she had been hit." The LPN was asked what time the resident said this and the LPN stated, "Around 4:30 a.m." The LPN was asked if the resident was connected to the feeding pump and the LPN stated, "She didn't have that on. I disconnected it at 1:30 a.m. or 2..." The LPN then stated, "I've known her [AGE] years. (Resident) was just being (resident). I jumped on her for fussing at (CNA #5)." g. On 3/11/11 at 11:25 p.m., the Administrator was asked what the LPN should have done when the resident told her that a CNA slapped her and the Administrator stated, "She should have sent the aides home." h. On 3/12/11 at 12:00 midnight, CNA #6 was asked what hall he/she was scheduled to work and if she sat with or cared for the resident. The CNA stated, "I'm on 300 Hall permanently. I work 100 Hall whenever they are short. I only worked it that one night when they were short. Lately, I just worked with (resident) ...both of us were sitting in the room with her, (CNA #5) and me, yes. We had to keep her back in the bed because she kept trying to get up. We laid her down about 3 different times then she wanted to go to the bathroom. As soon as I got her, (LPN #3) told me to go down there. That is the only person. (LPN #2) came because (resident) was pulling on her stomach pump cord. We were lowering her down on the pot. (CNA #5) watched her and I went to get (LPN #2). I was gone not very long. (LPN #2) discontinued the pump 2 to 3 a.m. While she was up on the pot, she (resident) said something about somebody slapping her that night. (LPN #2) was disconnecting the pump and sometime before 4 we put her back to bed and she went to sleep." The CNA was asked if the resident had brusing to the face and the CNA stated, "I don't even remember." The CNA was asked if they had showered the resident and the CNA stated, "Never gave a shower, used wipes to clean, she used the bedside commode." i. On 3/12/11 at 12:20 a.m., CNA #5 was asked what occurred and the CNA stated, "Me and (CNA #6) sat with her, she was awake and watched TV in the living room area. She asked around 3:00 a.m. and then put to bed. Me and (CNA #6) put her to bed. (LPN #2) attended to her pump. It was connected (resident) pulled towards the bed with her with the line. (LPN #2) turned it off. She (resident) stayed awake a little bit longer and fell asleep. At 4:00 a.m., I started my rounds after she fell asleep. (CNA #6) stayed in room with resident. She came out at one point and helped me about 5:00 - I can't say. (CNA #6) went back in about 5:45 a.m. I didn't go back in." The CNA was asked if the resident had said anything about anyone hitting her and the CNA stated, "(LPN #2 stated) she (resident) said that she had been slapped. She didn't say who did it. (LPN #2) told her that we didn't slap her. (LPN #2) said she pointed at me. I didn't know that she pointed at me. (LPN #2) just told me a minute ago." The CNA was asked if the LPN had taken witness statements and the CNA stated, "No." On 3/12/11 at 12:25 a.m., CNA #5 was asked again if one on one care was provided for the resident and the CNA stated, "Me and (CNA #6) sat with her. She was awake and she watched TV in the living room, she was asked maybe around 3:00 a.m. about going to bed and she said no then she said yes and we put her to bed and (LPN #2) came in there." The CNA was asked what the nurse did and the CNA stated, "(LPN #2) attended to her pump." The CNA was asked what the nurse did to the pump and the CNA stated, "She turned it on or she turned it off. She (resident) pulled it towards the bed with the line. I think she turned it off and after (LPN #2) left we put the covers on her and she stayed awake a little bit longer and fell asleep. After she fell asleep it was time for me to do my rounds and (CNA #6) stayed in the room." CNA #5 was then asked if CNA #6 left the room to make rounds and when this took place. CNA #5 stated, "I can't say. About 5:00 (a.m.) (CNA #6) came out then (CNA #6) went back in, maybe about 5:00." The CNA was asked if the resident said anything to the nurse when LPN #2 came into the room. CNA #6 stated, "When (LPN #2) came in the room she (resident) said that she had been slapped." The CNA was asked if the resident named who had slapped her and the CNA stated, "No she didn't say who did it. (LPN #2) told her she knew we didn't slap her." The CNA was asked if it was heard who the resident said did this and the CNA stated, "I didn't know she pointed at me." The CNA was asked what was to be done when a resident alleged abuse and the CNA stated, "Report it." The CNA was then asked if the resident's allegation was reported and the CNA stated, "No." j. On 3/12/11 at 12:35 a.m., LPN #2 was asked who was to be notified if there was an allegation of abuse and the LPN stated, "Call the police. If I thought somebody had really been abused I'd call police, the doctor and DON (Director of Nursing) and Administrator. I hadn't determined it was abuse." The LPN was asked if the resident had informed her she had been slapped and the LPN stated, "Yes." The LPN was asked if she had received training or an in-service on abuse and the LPN stated, "Yes." The LPN was asked when she was in-serviced and the LPN stated, "Couple of months ago." The LPN was asked what is to be done if there is an allegation of abuse and the LPN stated, "If anybody has been abused then we are to talk to the aide then we call our Administrator or DON and they will tell us what to do." LPN #2 was asked why the resident's allegation was not reported and the LPN stated, "Probably didn't think about it. I don't know." The nurse was asked how long she had been a licensed nurse and the LPN stated, "[AGE] years." The nurse was asked if, as a licensed nurse in this state, she was aware she was mandated to report allegations or suspected abuse and the LPN stated, "That law just went in effect a few years ago." LPN #2 was asked where the resident's status and the allegations were documented and the LPN gave no response. k. On 3/12/11 at 12:45 a.m., the facility's Staffing Logs documented on the sign-in sheets that LPN #2, CNA #5 and CNA #6 worked in the facility after Resident #9's allegations on 3/5/11 and had direct resident care assignments throughout the facility on the night shift. LPN #2 documented a signature on the sign-in sheets dated 3/5/11, 3/7/11, 3/9/11, 3/10/11 and 3/11/11. The sign-in sheets documented that CNA #5 was working in the facility on 3/5/11, 3/6/11, 3/9/11, 3/10/11 and 3/11/11. The sign-in sheets documented CNA #6 was working in the facility on 3/5/11, 3/6/11, 3/9/11, 3/10/11 and 3/11/11. l. On 3/12/11 at 3:00 p.m., the DON was asked if licensed nurses are to report allegations of abuse and the DON stated, "Yes." The DON was asked to whom the licensed nurses are to report and the DON stated, "DON, Administrator." The DON was asked if the licensed nurse on duty was responsible to ensure residents were safe and protected and the DON stated, "Yes." The DON was asked if the licensed nurse should remove them from the care area when there were allegations of abuse by a CNA and the DON stated, "Yes." The DON was then asked if LPN #2 had reported allegations of abuse and the DON stated, "Not to myself." On 3/12/11 at 3:10 p.m., the Administrator was asked if licensed nursing staff were supposed to report allegations of abuse and the Administrator stated, "Yes and begin investigation." The Administrator was asked how soon this should begin and the Administrator stated, "Immediately, family, MD (medical doctor), Administrator, DON, police." The Administrator was asked what the licensed nurse was to do if the allegation of abuse involved a CNA and the Administrator stated, "Take CNA to a non-resident area, get statement, send them home pending investigation." 2. The Immediate Jeopardy was removed and the scope/severity reduced to a "E" on 3/12/11 at 1:50 a.m., when the facility implemented the following plan of removal: a. Upon knowledge of the allegation of abuse, the accused staff members and the nurse who failed to report were removed from all resident areas by the Administrator at 11:45 p.m. b. These staff members were placed in non-resident areas to complete their witness statements. Activity Director stayed with these employees until their witness statements and interviews with Office of Long Term Care were completed. Activity Director, Assistant Business Office Manager and Assistant Director of Nursing then stayed with these employees until they left the facility. c. The staff members accused of the alleged abuse have been suspended pending outcome of investigation and told not to return unless contacted by the Administrator. d. Police were notified and arrived at the facility at 12:03 a.m. at which time they took the accused staff 's statements and stated another officer will be back to continue the investigation. This officer remained at the facility until 12:25 a.m. e. All staff on duty at the time of discovery (except the 3 sent home on suspension) were inserviced by the Director of Nursing on the Facility Abuse Policy and reporting requirements (1:50 a.m.). f. All oncoming staff will be inserviced by DON/Designee on Facility Abuse Policy and Reporting requirements prior to being allowed to return to work. This will begin with shift change this morning and continue until all staff have completed training. Any staff member who is off on extended leave for any reason will also have to complete the inservice prior to returning to work. g. A list of all cognitive/interviewable residents will be obtained by MDS (Minimum Data Set) Coordinator by 9:00 a.m. on 3/12/11. Those residents determined to be interviewable will be interviewed by DON/Designee to discover if there are other nonreported allegations of abuse. Interviews of these residents will be completed by 11:30 a.m. on 3/12/11. In order to verify compliance, social will interview 2 residents from each hall weekly times 4 weeks. To verify compliance of non-interviewable residents, the interdisciplinary team will review I&As of those residents on a weekly basis to verify all potential allegations have been thoroughly investigated with proper notification when indicated and that all alledged perpetrators have been removed/suspended from facility".

Complaint # is substantiated with these findings. Based on observations, record review and interview, the facility failed to ensure necessary care and services were provided to attain or maintain the highest practicable physical well-being for Resident #5 and #6. The facility failed to ensure an assessment of the resident's chewing and swallowing ability was conducted promptly upon receiving information that the resident had a history of [REDACTED].#5) who was on a mechanical soft diet and had a history of [REDACTED]. interventions following a swallow study for 1 (Resident #6) of 3 (Residents #1, #4 and #5) case mix residents who had histories of or were at risk for choking. The failed practices resulted in Immediate Jeopardy which caused or was likely to cause serious injury, harm, or death for Resident #5, who choked in the dining room on [DATE] and expired shortly later, and for Resident #6, who was assessed to be at risk for choking and had experienced a choking episode. The failed practices had the likelihood to cause more than minimal harm for 5 residents who were at risk for choking or had difficulty swallowing, according to a list provided by the Assistant Director of Nursing (ADON) on [DATE]. The Administrator was notified of the Immediate Jeopardy findings on [DATE] at 12:10 p.m. The findings are: 1. Resident #5 had a [DIAGNOSES REDACTED]. a. The Resident Diet Status Report dated [DATE], completed by the Certified Dietary Manager (CDM) when the resident was admitted , documented, "chopped consistency" and "Additional Comments - eats fast and large bites, will choke, has choked on meats before." On [DATE] at 8:35 a.m., the CDM stated that she documented this after being told (the information) by the resident's daughter. There was no physician's order in the resident's clinical record for a chopped diet. A physician's order dated [DATE] documented a regular diet. b. The Nurse's Notes dated [DATE] at 12:30 p.m. documented that the resident was "up in WC (wheelchair) in DR (dining room) eating lunch. R (resident) coughing, difficulty breathing. R taken to room, assisted to bed. R coughed up lg (large) piece of ham." c. On [DATE] at 4:29 p.m., the Administrator was asked for documentation of an initial or admission ([DATE]) assessment for the resident from the Registered Dietitian (RD) or an assessment after the resident coughed up the large piece of ham on [DATE]. The Administrator stated she had no documentation of an assessment by the RD for Resident #5. d. On [DATE] at 4:45 p.m., the surveyor and the CDM asked the speech therapist if she had documentation of a swallow study for the resident after he coughed up a large piece of ham on [DATE]. The speech therapist stated they had not received a physician's order for a swallow study. On [DATE] at 5:00 p.m., the Administrator stated, "...He (Resident #5) just fell through the cracks." e. A Telephone Order (T.O.) dated [DATE] (11 days later) documented, "T.O. 1. D/C (discontinue) current diet. 2. Change diet to reg (regular) mech (mechanical) soft." A physician's order dated [DATE] documented, "regular mechanical soft...changed [DATE]." f. The most recent Minimum Data Set (MDS), a quarterly assessment, was dated [DATE] and documented the resident was moderately impaired in cognitive skills for daily decision making, on a mechanically altered diet and required the extensive physical assistance of one person with eating. g. The Elite Medical Service (ambulance) report dated [DATE] documented, "Immed Res.(Immediate Response) to approx (approximate) location for 84 y/o (year old) who was post [MEDICATION NAME] maneuver from dinner @ (at) approx 1700 (5:00 p.m.) this evening. o/a (on arrival) [MEDICATION NAME] maneuver in progress. Pale cyanotic. Not moving any air in lungs, pupils dilated, en route to ER (emergency room ) look with laryngoscope revealed massive amts. (amounts) of partially digested food with multiple chards of taco shells and green peas removed from vocal cord region with McGill forceps. Intubated with 7.5 et (endo/tracheal) tube. Suctioned again partially digested material..." h. The (hospital) cardiopulmonary resuscitation record dated [DATE] documented, "Time CPR (cardiopulmonary resuscitation) started: 1745 (5:45 p.m.) End Time: 1804 (6:04 p.m.) admitting [DIAGNOSES REDACTED]." The (hospital) Emergency Physician's record dated [DATE] documented, "1750 (5:50 p.m.) Diagnosis: [REDACTED]." h. The menu for mechanical soft diets for [DATE] documented, "ground taco meat, green beans and Boston cream pie only." At the bottom of the menu "Taco Casserole" was handwritten for mechanical diets. The recipe for the Taco Casserole, provided by the CDM on [DATE] at 8:50 a.m., typed on a plain sheet of paper unlike other recipes in the Sysco Master Database recipe notebook, documented: "1oz (ounce) bag tortilla chips 1 52 oz can cream of chicken soup 1 12 oz can of diced pimento 2 Tablespoons beef broth mixed with 2 quarts water 5 lbs ground beef cooked and crumbled 2 cups shredded cheese Place chips in large bowl, crush into small pieces, place crumbled chips in large steam table pan, add soup, pimento, beef broth water, ground beef, mix well until all ingredients are blended. Cook ,[DATE] minutes. Serves 30 ,[DATE] cup servings" i. On [DATE] at 5:15 p.m., the Administrator stated that the menu dated [DATE] which documented ground taco meat, green beans and Boston cream pie was changed by the Sysco dietitians. However, the facility's consultant RD's signature was on the menu as approved. Taco casserole had been handwritten for the mechanical soft diet on the menu. 2. Resident #6 had [DIAGNOSES REDACTED]. a. The Weekly Nursing Summary dated [DATE] documented the resident's intake as 75% or more of his meal. The Summary did not document whether the resident was assisted with meals or not; location of meal service (in room or in dining room); and did not document the resident's diet. b. The Nurse's Notes dated [DATE] at 8:00 a.m., documented, "Resident started choking during breakfast while CNA (Certified Nursing Assistant) was feeding. Nursing staff was called to room. Performed [MEDICATION NAME] maneuver to resident. Procedure was successful. ....Family made aware. Talked to family about changing diet. Family agreed to regular mechanical soft meat only. N.O. (new order) received for change diet from regular to regular/mechanical soft meat only." The February 2010 Physician's Orders documented, "[DATE] Diet: Regular Mech Soft Meat Only." c. The Dietary Progress Notes did not document the resident was assessed by the facility's Registered Dietician after the choking incident on [DATE]. d. The Care Plan dated [DATE] documented, "...has difficulty chewing...provide dining room/meal accommodations. Assist with eating if needed. Allow adequate time to eat and provide a quiet, calm setting. Report to nurse any signs and symptoms chewing/swallowing or other problems consuming meals, choking or coughing during eating or drinking, refuses meal and or substitute pocketing of food, excessive drooling. Diet regular mech soft." e. The Weekly Nursing Summary dated [DATE] documented, "feeds self" and "eats in dining room" and that the resident received a "mech soft diet". f. The quarterly MDS with an assessment reference date of [DATE] documented a staff assessment of the resident's cognitive status as severely impaired, that the resident required the extensive assistance of one person with eating, had coughing or choking during meals or when swallowing medications and received a mechanically altered diet. g. The Speech/Language Pathology Evaluation dated [DATE] documented, "...Recommend resident be fed per caregivers when he is seated upright at a 90 degree angle. Bites of food should be ,[DATE] to ,[DATE] teaspoon and food should be cleared from his mouth prior to and (each) bite. Feeding should occur at a slow rate allowing him to alternate food with liquid." h. On [DATE] at 5:45 p.m., CNA #1 fed Resident #6 in his room. The meal consisted of a ground hamburger on a bun, tater tots, a brownie square, a 6 ounce glass of tomato juice, an 8 ounce glass of cranberry juice and an insulated water jug filled with ice and water. CNA #1 fed the resident multiple bites of food, without alternating liquid between bites, four times while feeding him his meal. 3. The Immediate Jeopardy was removed on [DATE] at 7:00 p.m., and the scope/severity reduced to "G", when the facility implemented the following plan of removal: "1) Identification of all Residents Affected A. A list of all residents with the following conditions obtained @ (at) 1:30 p.m. a.[MEDICAL CONDITION] b. [MEDICAL CONDITION]'s c. Parkinson d. [DIAGNOSES REDACTED]. All residents with these conditions will be evaluated by a Registered Nurse on [DATE] by 5:00 p.m. and a Speech Therapist within 24 hours for current medical status and diet orders reviewed for appropriateness based on the outcome of the assessment. B. All current residents with an incident of choking in the last 30 days will be re-assessed on [DATE] by 5:00 p.m. by a Registered Nurse and a Speech Therapist within 24 hours with recommendations implemented in a timely manner (within 24 hours following screening). C. All residents with a change of condition, potentially affecting their ability to swallow, within the past 30 days will be re-assessed [DATE] by 5:00 p.m. by a Registered Nurse and within 24 hours by a Speech Therapist for current medical status, with specific emphasis on signs and symptoms of swallowing difficulty or at potential risk for choking. Any identified as being at risk will be referred to their attending physician and the Speech Therapist will immediately make recommendations. One on one care will be provided these residents until the Speech Therapist has conducted a screening exam and made his/her recommendations. 2) Corrective Action A. Immediately ([DATE] @ 12:20 (p.m.)) begin to assess all current residents for swallowing difficulty or those potentially at risk for choking. These assessments will be conducted immediately by a Registered Nurse and by a Speech Therapist in a timely manner, but not greater than 24 hours. One on one care will be provided the resident until the Speech Therapist completes a screening exam and recommendations are documented. B. R. D. Consultant reported to the facility today at 4PM to assist in the assessment of "at risk" residents and coordinate, with the attending physician and/or Speech Therapist, any actions necessary to alleviate or reduce the risk of choking. C. All staff "on duty" and in-coming staff were in-serviced at 2:15 PM regarding signs and symptoms of choking and the actions to be taken should these signs and symptoms be observed. Third shift employees will be in-serviced at 9:45 PM tonight. The in-services will also include the necessity of reporting all changes in the resident's condition to the Charge Nurse, the DON (Director of Nursing) the attending physician and the family as appropriate. All other staff will be in-serviced upon reporting to work. D. A list of all resident's determined to be at risk, following completion of assessments, will be posted in the front of the CNA Communication Book, the ADL (activities of daily living) Book and the Meal Consumption Book. The list shall include the resident's name and any Speech Therapy recommendations. All staff will be in-serviced to refer to these lists daily for any changes in resident status. In-services will begin as soon as the assessments are complete and lists compiled. E. All Speech Therapy recommendations will be reviewed by the DON or designee and the facility Administrator. The DON or designee will review the communication tools (CNA Communication Book, ADL Book, and Meal Consumption Book) daily to assure compliance with the Speech Therapy recommendations. F. The Dietary Manager and/or Treatment Nurse on duty will review diet cards on any resident at risk for choking and compare the meal served to the physician's order. Any discrepancy will be resolved prior to the meal being served. The Treatment Nurse will observe all meals to ensure all recommendations are being followed at all times."

Complaint # is substantiated with these findings. Based on observations, record review and interview, Nursing Administration failed to ensure necessary care and services were provided to attain or maintain the highest practicable physical well-being for Resident #5 and #6. Nursing Administration failed to ensure an assessment of the resident's chewing and swallowing ability was conducted promptly upon receiving information that the resident had a history of [REDACTED].#5) who was on a mechanical soft diet and had a history of [REDACTED]. interventions following a swallow study for 1 (Resident #6) of 3 (Residents #1, #4 and #5) case mix residents who had histories of or were at risk for choking. The failed practices resulted in Immediate Jeopardy which caused or was likely to cause serious injury, harm, or death for Resident #5, who choked in the dining room on and expired shortly later, and for Resident #6, who was assessed to be at risk for choking and had experienced a choking episode. The failed practices had the likelihood to cause more than minimal harm for 5 residents who were at risk for choking or had difficulty swallowing, according to a list provided by the Assistant Director of Nursing (ADON) on [DATE]. The Administrator was notified of the Immediate Jeopardy findings on [DATE] at 12:10 p.m. The findings are: 1. The facility's "Job Description: Director of Nursing Service", provided by the Administrator on [DATE], documented: "1. Purpose of Your Job Position: The Primary purpose of your job position is to plan, organize, develop and direct the overall operation of our Nursing Services Department in accordance with current Federal, State, and local standards, guidelines and regulations that govern our facility, and as may be directed by the Administrator and Medical Director, to ensure that the highest degree of quality care is maintained at all times. 2. Delegation of Authority: As the Director of Nursing Services, you are delegated the administrative authority, responsibility, and accountability necessary for carrying out your assigned duties..." 3. Nursing Care Functions: ...Review nurses' notes to ensure that they are informative and descriptive of the nursing care being provided and that they reflect the resident's response to the care...Review and revise care plans and assessments as necessary..." 2. Resident #5 had a [DIAGNOSES REDACTED]. a. The Resident Diet Status Report dated [DATE], completed by the Certified Dietary Manager (CDM) when the resident was admitted , documented, "chopped consistency" and "Additional Comments - eats fast and large bites, will choke, has choked on meats before." On [DATE] at 8:35 a.m., the CDM stated that she documented this after being told (the information) by the resident's daughter. There was no physician's order in the resident's clinical record for a chopped diet. A physician's order dated [DATE] documented a regular diet. b. The Nurse's Notes dated [DATE] at 12:30 p.m. documented that the resident was "up in WC (wheelchair) in DR (dining room) eating lunch. R (resident) coughing, difficulty breathing. R taken to room, assisted to bed. R coughed up lg (large) piece of ham." c. On [DATE] at 4:29 p.m., the Administrator was asked for documentation of an initial or admission ([DATE]) assessment for the resident from the Registered Dietitian (RD) or an assessment after the resident coughed up the large piece of ham on [DATE]. The Administrator stated she had no documentation of an assessment by the RD for Resident #5. d. On [DATE] at 4:45 p.m., the surveyor and the CDM asked the speech therapist if she had documentation of a swallow study for the resident after he coughed up a large piece of ham on [DATE]. The speech therapist stated they had not received a physician's order for a swallow study. On [DATE] at 5:00 p.m., the Administrator stated, "...He (Resident #5) just fell through the cracks." e. A Telephone Order (T.O.) dated [DATE] (11 days later) documented, "T.O. 1. D/C (discontinue) current diet. 2. Change diet to reg (regular) mech (mechanical) soft." A physician's order dated [DATE] documented, "regular mechanical soft...changed [DATE]." f. The most recent Minimum Data Set (MDS), a quarterly assessment, was dated [DATE] and documented the resident was moderately impaired in cognitive skills for daily decision making, on a mechanically altered diet and required the extensive physical assistance of one person with eating. g. The Elite Medical Service (ambulance) report dated [DATE] documented, "Immed Res.(Immediate Response) to approx (approximate) location for 84 y/o (year old) who was post [MEDICATION NAME] maneuver from dinner @ (at) approx 1700 (5:00 p.m.) this evening. o/a (on arrival) [MEDICATION NAME] maneuver in progress. Pale cyanotic. Not moving any air in lungs, pupils dilated, en route to ER (emergency room ) look with laryngoscope revealed massive amts. (amounts) of partially digested food with multiple chards of taco shells and green peas removed from vocal cord region with McGill forceps. Intubated with 7.5 et (endo/tracheal) tube. Suctioned again partially digested material..." h. The (hospital) cardiopulmonary resuscitation record dated [DATE] documented, "Time CPR (cardiopulmonary resuscitation) started: 1745 (5:45 p.m.) End Time: 1804 (6:04 p.m.) admitting [DIAGNOSES REDACTED]." The (hospital) Emergency Physician's record dated [DATE] documented, "1750 (5:50 p.m.) Diagnosis: [REDACTED]." h. The menu for mechanical soft diets for [DATE] documented, "ground taco meat, green beans and Boston cream pie only." At the bottom of the menu "Taco Casserole" was handwritten for mechanical diets. The recipe for the Taco Casserole, provided by the CDM on [DATE] at 8:50 a.m., typed on a plain sheet of paper unlike other recipes in the Sysco Master Database recipe notebook, documented: "1oz (ounce) bag tortilla chips 1 52 oz can cream of chicken soup 1 12 oz can of diced pimento 2 Tablespoons beef broth mixed with 2 quarts water 5 lbs (pounds) ground beef cooked and crumbled 2 cups shredded cheese Place chips in large bowl, crush into small pieces, place crumbled chips in large steam table pan, add soup, pimento, beef broth water, ground beef, mix well until all ingredients are blended. Cook ,[DATE] minutes. Serves 30 ,[DATE] cup servings" i. On [DATE] at 5:15 p.m., the Administrator stated that the menu dated [DATE] which documented ground taco meat, green beans and Boston cream pie was changed by the Sysco dietitians. However, the facility's consultant RD's signature was on the menu as approved. Taco casserole had been handwritten for the mechanical soft diet on the menu. 2. Resident #6 had [DIAGNOSES REDACTED]. a. The Weekly Nursing Summary dated [DATE] documented the resident's intake as 75% or more of his meal. The Summary did not document if the resident was assisted with meals, the location of meal service (in room or in dining room) or the resident's diet. b. The Nurse's Notes dated [DATE] at 8:00 a.m., documented, "Resident started choking during breakfast while CNA (Certified Nursing Assistant) was feeding. Nursing staff was called to room. Performed [MEDICATION NAME] maneuver to resident. Procedure was successful. ....Family made aware. Talked to family about changing diet. Family agreed to regular mechanical soft meat only. N.O. (new order) received for change diet from regular to regular/mechanical soft meat only." The February 2010 Physician's Orders documented, "[DATE] Diet: Regular Mech Soft Meat Only." c. The Dietary Progress Notes did not document the resident was assessed by the facility's Registered Dietician after the choking incident on [DATE]. d. The Care Plan dated [DATE] documented, "...has difficulty chewing...provide dining room/meal accommodations. Assist with eating if needed. Allow adequate time to eat and provide a quiet, calm setting. Report to nurse any signs and symptoms chewing/swallowing or other problems consuming meals, choking or coughing during eating or drinking, refuses meal and or substitute pocketing of food, excessive drooling. Diet regular mech soft." e. The Weekly Nursing Summary dated [DATE] documented, "feeds self" and "eats in dining room" and that the resident received a "mech soft diet". f. The quarterly MDS with an assessment reference date of [DATE] documented a staff assessment of the resident's cognitive status as severely impaired, that the resident required the extensive assistance of one person with eating, had coughing or choking during meals or when swallowing medications and received a mechanically altered diet. g. The Speech/Language Pathology Evaluation dated [DATE] documented, "...Recommend resident be fed per caregivers when he is seated upright at a 90 degree angle. Bites of food should be ,[DATE] to ,[DATE] teaspoon and food should be cleared from his mouth prior to and (each) bite. Feeding should occur at a slow rate allowing him to alternate food with liquid." h. On [DATE] at 5:45 p.m., CNA #1 fed Resident #6 in his room. The meal consisted of a ground hamburger on a bun, tater tots, a brownie square, a 6 ounce glass of tomato juice, an 8 ounce glass of cranberry juice and an insulated water jug filled with ice and water. CNA #1 fed the resident multiple bites of food, without alternating liquids between bites, four times while feeding him his meal. 3. The Immediate Jeopardy was removed on [DATE] at 7:00p.m., and the scope/severity reduced to "G", when the facility implemented the following plan of removal: " 1) Identification of all Residents Affected A. A list of all residents with the following conditions obtained @ (at) 1:30 p.m. a.[MEDICAL CONDITION] b. [MEDICAL CONDITION]'s c. Parkinson d. [DIAGNOSES REDACTED]. All residents with these conditions will be evaluated by a Registered Nurse on [DATE] by 5:00 p.m. and a Speech Therapist within 24 hours for current medical status and diet orders reviewed for appropriateness based on the outcome of the assessment. B. All current residents with an incident of choking in the last 30 days will be re-assessed on [DATE] by 5:00 p.m. by a Registered Nurse and a Speech Therapist within 24 hours with recommendations implemented in a timely manner (within 24 hours following screening). C. All residents with a change of condition, potentially affecting their ability to swallow, within the past 30 days will be re-assessed [DATE] by 5:00 p.m. by a Registered Nurse and within 24 hours by a Speech Therapist for current medical status, with specific emphasis on signs and symptoms of swallowing difficulty or at potential risk for choking. Any identified as being at risk will be referred to their attending physician and the Speech Therapist will immediately make recommendations. One on one care will be provided these residents until the Speech Therapist has conducted a screening exam and made his/her recommendations. 2) Corrective Action A. Immediately ([DATE] @ 12:20 (p.m.)) begin to assess all current residents for swallowing difficulty or those potentially at risk for choking. These assessments will be conducted immediately by a Registered Nurse and by a Speech Therapist in a timely manner, but not greater than 24 hours. One on one care will be provided the resident until the Speech Therapist completes a screening exam and recommendations are documented. B. R. D. Consultant reported to the facility today at 4PM to assist in the assessment of "at risk" residents and coordinate, with the attending physician and/or Speech Therapist, any actions necessary to alleviate or reduce the risk of choking. C. All staff "on duty" and in-coming staff were in-serviced at 2:15 PM regarding signs and symptoms of choking and the actions to be taken should these signs and symptoms be observed. Third shift employees will be in-serviced at 9:45 PM tonight. The in-services will also include the necessity of reporting all changes in the resident's condition to the Charge Nurse, the DON (Director of Nursing) the attending physician and the family as appropriate. All other staff will be in-serviced upon reporting to work. D. A list of all resident's determined to be at risk, following completion of assessments, will be posted in the front of the CNA Communication Book, the ADL (activities of daily living) Book and the Meal Consumption Book. The list shall include the resident's name and any Speech Therapy recommendations. All staff will be in-serviced to refer to these lists daily for any changes in resident status. In-services will begin as soon as the assessments are complete and lists compiled. E. All Speech Therapy recommendations will be reviewed by the DON or designee and the facility Administrator. The DON or designee will review the communication tools (CNA Communication Book, ADL Book, and Meal Consumption Book) daily to assure compliance with the Speech Therapy recommendations. F. The Dietary Manager and/or Treatment Nurse on duty will review diet cards on any resident at risk for choking and compare the meal served to the physician's order. Any discrepancy will be resolved prior to the meal being served. The Treatment Nurse will observe all meals to ensure all recommendations are being followed at all times."