Every finding on record at The Blossoms at van Buren Rehab and Nursing Center

Based on observation, record review, interview, and facility policy review, the facility failed to ensure hand hygiene was performed while assisting with wound care, to prevent the risk for infection for one (Resident #71) of three sampled residents observed for wound care. The facility also failed to ensure Enhanced Barrier Precautions (EBP) were followed during flushing of a feeding tube, for one of one observation for one (Resident #4) of one sampled resident observed for feeding tube care, to prevent infections and cross contamination. The findings include: 1. A review of Diagnosis Report for Resident #71 revealed diagnoses which included frostbite with necrosis, gangrene, and vascular disease. a. A review of Resident #71 ' s Medicare-5 Day Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/04/2025, suggested a Brief Interview for Mental Status (BIMS) score of 15, which indicated no cognitive impairment. Section M0300, of the MDS, revealed Resident #71 had four Stage IV pressure ulcers and had one Stage IV pressure ulcer on admission. b. During an observation on 04/29/2025 at 3:24 PM, Certified Nursing Assistant (CNA) #7 was observed handling trash, then without performing hand hygiene, donned gloves in the hallway and entering Resident #71's room to assist with wound care. CNA #7 put on a gown, then removed Resident #71's dirty gown, walked over to the right side of the bed and assisted Resident #71 in turning onto their right side, then pulled up the left buttocks to expose a large, open wound in the gluteal cleft to the nurse. CNA #7 removed their gloves and donned clean gloves after the dressing change, without using hand gel or hand washing. When asked, CNA #7 stated the process for assisting with wound care was to wash hands, puts on gloves and follow the direction of the nurse performing wound care. CNA #7 confirmed he did not perform hand hygiene before/or upon entering the room, after assisting with wound care, or use alcohol gel, when making a glove change because the alcohol gel pump on the wall was not working. c. During an interview on 04/30/2025 at 9:22 AM, the Director of Nursing (DON) stated staff should use hand gel or wash their hands before gloving up and change their gloves, as needed, and use hand gel in between glove changes, so that good infection control practices were maintained. The DON said she also expected staff to follow EBP during wound care. d. During an interview on 05/01/2025 at 1:02 PM, the Administrator said CNAs should perform hand hygiene before putting on gloves to assist with wound care, and when changing gloves, CNAs should perform hand hygiene by washing or using alcohol gel in between. Hand hygiene should also be performed after taking out trash, before gloving up to assist with wound care. 2. A review of Medical Diagnoses revealed Resident #4 had diagnoses which included malnutrition, dysphagia (difficulty swallowing), and gastrostomy status (tube). a. A review of an MDS with an ARD of 02/04/2025 for Resident #4 revealed a Staff Assessment for Mental Status (SAMS) score of 3, which indicated severe cognitive impairment. Section V0200 Care Area #13 revealed the resident had a feeding tube. b. A review of Physician Orders 06/04/2024, revealed Resident #4 received a flush feeding with 35 cubic centimeters (cc) of water, before and after medication administration. c. A review of an In-service Education Report on EBP conducted on 08/20/2024, included a policy titled Enhanced Barrier Precautions, revised 03/21/2024, revealed identified residents on EBP will have appropriate signage, and required PPE Residents with indwelling medical devices such as feeding tubes require EBP. d. During an observation on 04/28/2025 at 9:21 AM, Licensed Practical Nurse (LPN) #1 was observed using a stethoscope to check Resident #4 for placement of a gastrostomy tube. LPN #1 flushed the tube with 35 (milliliters) mL of water. LPN #1 was not wearing a gown when the gastrostomy tube was flushed. e. During an interview on 04/28/2025 at 9:28 AM, LPN #1 said she was supposed to be wearing a gown when flushing Resident #4 ' s gastrostomy tube for EBP. This surveyor observed EBP signage on Resident #4 ' s outer door indicating staff were to wear gown and gloves during device care or use: feeding tubes. 3. During an interview on 05/01/2025 at 11:55 AM, the Director of Nursing (DON) stated EBP should be used on a resident who had a gastrostomy tube, by donning a gown and gloves. PPE was located in the residents ' rooms. The DON stated if EBP was not used, it could cause the spread of germs. 4. During an interview on 05/01/2025 at 12:47 PM, the Administrator said his expectations for staff regarding EBP was that staff would follow the policy. 5. During an interview on 04/30/2025 at 12:52pm, LPN # 8 said EBP signage was outside the doors of residents with PEG tubes, IV ' s, and catheters. LPN #8 said PPE should be worn with any personal care, to prevent passing of germs. 6. A review of an in-service titled, Infection Control, dated 10/29/2024, revealed topics covered included personal protective equipment (PPE) donning and removal, hand washing, hand cleanser, and hand hygiene. The in-service also revealed that EBP required gowns and gloves to be worn by staff during high-contact resident care activities. 7. A review of a policy titled Wound and Pressure Ulcer Management Policy, revised 11/01/2022, did not address hand hygiene during wound care. 8. A review of policy titled Infection Prevention and Control Programs, revised 11/02/2022, revealed the facility followed the guidance of the Center for Disease Control (CDC), implemented isolation precautions when appropriate, educating staff on proper procedures, and instituted measures to prevent infections. 52432

Based on observation, record review, interview, and facility policy review, the facility failed to ensure medications were not stored unlocked at the residents ' bedside, and failed to ensure medication treatment carts were locked to three (Resident #37, Resident #71, Resident #72) of 11 sampled residents, to prevent accidents and injuries. The findings include: 1. A review of a policy titled Medication Administration, revised 11/25/2022, revealed the Director of Nursing (DON) directs and supervises staff that administer medications, and they were to be done in a safe, timely manner. Medication carts were to be closed and locked, when out of sight of the medication nurse. Topical medications were to be documented on the Treatment Administration Record (TAR), when used. Medications shall be administered in a safe and timely manner, and as prescribed. Item 1. Only persons licensed or permitted by this state to prepare, administrate and document the administration of medications may do so. Item 21. Topical medications used in treatments must be recorded on the resident's treatment record (TAR). Item 24. Residents may self-administer their own medications only if the Attending Physician, in conjunction with the Interdisciplinary Care Planning Team, has determined that they have the decision-making capacity to do so safely. 2. A review of a policy titled Label/Store Drugs and Biologicals, revised 12/26/22, revealed nursing staff was responsible for making sure drugs were stored in a safe, and secure manner. Medication carts, used to transport medications, should be locked when not in use, and medications should not be stored in a resident ' s room, unless they were approved for self-administration. 3. A review of Medical Diagnoses revealed Resident #37 had diagnoses which included schizophrenia, stage III kidney disease, and osteomyelitis. a. A review of the Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/17/2025 indicated Resident #37 had a Brief Interview for Mental Status (BIMs) of 15, which indicated no cognitive impairment. Section M0300, of the MDS, indicated Resident #37 had one unstageable pressure ulcer, due to moisture associated skin damage. Section M1200, of the MDS, suggested the resident required pressure reducing devices and had application of ointments/medications, other than to the feet. b. A review of Physicians Order, for Resident #37 dated 03/13/2025, revealed anti-fungal powder was to be used, twice a day, topically to affected areas. c. A review of Care Plan for Resident #37, dated 03/19/2025, revealed altered skin integrity including a stage three ulcer to the right second toe. Interventions included: provide medication as indicated, check skin daily basis, and report issues to the charge nurse and physician, as needed. d. On 04/28/2025 at 8:32 AM, this surveyor observed Resident #37 to have antifungal powder and hydrophilic wound dressing cream at the bedside. Resident #37 said it was the resident ' s medication e. During a concurrent observation and interview on 04/28/2025 at 11:57 AM, the antifungal powder and hydrophilic wound dressing cream remained at Resident #37's bedside. Licensed Practical Nurse (LPN) #1 said that the medication should be left in the cart and offered to the resident, but not left in the room, because another resident could wander in and eat it or use it inappropriately. 4. On 04/28/2025 at 8:11 AM, a medication treatment cart was observed unlocked sitting between the 200-300 hall, with residents observed ambulating and in wheelchairs going up and down the hallway. LPN #2 was asked who was responsible for the treatment cart. LPN #2 said weekend nursing, that used the cart, left the treatment cart unlocked. LPN #2 read off the following medications found in the unlocked treatment cart: a. Silver Sulfadiazine cream b. Wound gel; x3 tubes c. Anti-microbial ointment; x2 tubes d. Collagenase ointment e. Butt paste d. Debriding paste; x2 tubes e. Hydrophilic Wound Dressing cream; x3 tubes f. Alcohol prep; 1 box g. A bottle of antibacterial/antimicrobial skin cleanser g. Peroxide 3% h. Sani-cloth i. Skin protectant j. Lanolin Moisture shield; x2 k. Anti-Fungal cream; 2% Miconazole Nitrate l. Honey with Anti-Bacterial properties; x3 tube m. Zinc Oxide ointment 20% n. Anti-Fungal spray 2% o. Open box with six (6) steel safety scalps p. Arthritis gel; 10% Trolamine Salicylate q. Tincture of Benzine a. During the observation mentioned above, LPN #2 revealed the facility process was to lock the medication carts when unattended and said residents should not have access to any of these medications, because residents could take and eat something they should not have. 5. On 04/28/2025 9:08 AM, Resident #72 was observed sitting in a bedside chair reading and antifungal spray was observed resting on the over the bed table. a. During an interview on 04/28/2025 at 11:57 AM, LPN #1 was asked what the process was for keeping medications at the bedside. The question was not answered. This surveyor observed LPN #1 go to Resident #72's room and pick up the antifungal spray. Resident #72 told LPN #1 it was not theirs, and the resident did not know how the medication got in the resident ' s room. LPN #1 confirmed she did not know medication was at the bedside of Resident #37 or Resident #72. LPN #1 said someone with dementia or someone who wanders could eat it or misuse it. 6. A review of the Physician's Order, dated 04/29/2025, for Resident #71 did not reveal an order for [Name Brand Wound/Burn Gel]. a. A review of the resident's 5-Day MDS with an ARD of 04/04/2025, for Resident #71 identified in Section M item H: Applications of ointments/medications other than to feet was checked. b. A review of the resident's Care Plan identified Resident #71 to have little or no activity related to Physical Limitations; the resident has an alteration in skin integrity and is at risk for additional and/or worsening of skin integrity issues related to gangrene left and right hand, left and right foot, stage 4 on coccyx, venous ulcer left and right lateral shin, and right ankle. With an intervention to administer wound care (treatments) per Medical Doctor orders. c. During an interview on 04/30/2025 at 8:25 AM, Resident #71 told this surveyor they were using a tube of ointment with [Name Brand Wound/Burn Gel], for itching. d. During an interview on 04/30/2025 at 8:50 AM, the Medical Director (MD) said a resident should not apply any type of medication to themselves, without a physician ' s order to do so, because the ointment could be harmful to the resident. e. During a concurrent interview on 05/01/2025 at 8:37 AM, the MD said he should have been aware of any medication left at the resident's bedside, and he must approve it, because they may take something that could harm them. 7. During an interview on 05/01/2025 at 11:55 AM, the Administrator said medications could not be left at the bedside, because the resident had to be assessed for self-administration of medications and the medications should have been stored and locked in a secure area. 8. During an interview on 04/30/2025 at 9:30 AM, the Director of Nursing (DON) was asked what the process was for medications being left at the bedside. The DON stated medications should not be left at the bedside, because another resident might come in and take the medication, which could cause harm to the resident. The DON stated they [the facility] did not have a self-administration policy, and no residents had been approved for self-administration rights. 49596

Based on record review, interview, and Resident Assessment Instrument (RAI) manual review, the facility failed to ensure a discharge was coded to the Minimum Data Set (MDS) in a timely manner for one (Resident #65) of one sampled resident reviewed for accuracy of assessments to accurately capture a residents health status at the time of discharge. The findings include: Review of Medical Diagnosis revealed Resident #65 had diagnoses that included vertebra and humerus fracture and malnutrition. Review of Progress Note dated 12/02/2024 at 3:10 PM, revealed Resident #65 was transported from the facility to [Local Hospital] via ambulance. Review of the Discharge MDS, with an Assessment Reference Date (ARD) of 12/02/2024, revealed a Staff Assessment for Mental Status (SAMS) of short-term memory problems, and moderate cognitive skills for daily living. Section A2000 indicated a discharge date of [DATE] to a short-term general hospital. Section Z revealed completion date: signed 04/30/2025 and RN Assessment Coordinator signed assessment as complete: 04/30/2025. During an interview on 04/30/2025 at 3:35 PM, the MDS Nurse indicated Resident #65's discharge had not been coded to the MDS, and after confirming with the Regional MDS consultant, it was revealed the facility had 14 days to report discharges on the MDS, and it should have been done after Resident #65 was discharged . The Regional MDS Consultant revealed they had no way to track and see that the discharge was not reported and confirmed the discharge assessment was not completed and submitted in the allowed 14 days. During an interview on 04/30/2025 at 3:41 PM, the MDS Trainer confirmed Resident #65's discharge was not reported within the allowed time. The MDS Trainer said, discharges are usually triggered in the MDS scheduled tab, and we discuss discharges during stand-up meetings held daily. The Regional MDS Consultant said, someone erased the tab. This surveyor asked for a copy of discharge instructions from the RAI manual. A review of the documents from the RAI (Omnibus Budget Reconciliation Act) OBRA, on 04/30/2025 at 4:46 PM, revealed discharge assessments were required within fourteen (14) days. Discharge under the RAI manual, refers to the date a resident was discharged .

Based on interview and record review, the facility failed to ensure that the State Designated Agency was notified that one (Resident #6) of two residents, reviewed for Preadmission Screening and Resident Review (PASARR), had been admitted to the facility. The findings are: A review of Resident #6's Diagnosis Record revealed a diagnosis of schizoaffective disorder, bipolar type, with an onset date of 04/12/2025. There was no PASSAR noted in the electronic record. During a phone interview on 04/30/2025 at 9:59 AM, an employee at the State Designated Agency indicated Resident #6 had a level II PASARR in 2022. She indicated that Resident #6 had a review at a local facility in 09/2024. The State Designated Agency indicated the review was still open, because they had never been notified that Resident #6 had been admitted into any facility. The State Designated Agency indicated, Resident #6's new diagnosis of schizoaffective disorder, bipolar type that was diagnosed on [DATE], would not make the Preadmission Screening and Resident Review (PASARR) less or more since [pronoun] had already been diagnosed with bipolar, unless the resident had suicidal behavior. During an interview on 05/01/2025 at 11:00 AM, the Administrator indicated the State Designated Agency should have be notified when a resident entered the facility. During an interview on 05/01/2025 at 11:10 AM, the Director of Nursing (DON) indicated the MDS nurse was responsible for notifying the State Designated Agency when a resident had been admitted to the facility. During an interview on 05/01/2025 at 2:29 PM, the Marketing Director indicated she had been in her position for four months, and that she did not inform the State Designated Agency of Resident #6 ' s admission to the facility. During an interview on 05/01/2025 at 2:37 PM, the Marketing Director indicated she had just found out that she was responsible for contacting the State Designated Agency when a resident was admitted to the facility. She indicated, she was not aware that she was supposed to contact the State Designated Agency. During an interview on 05/01/2025 at 3:21 PM, the Administrator indicated the facility did not have a policy on PASARR's.

Based on observations, interviews, and record review, the facility failed to ensure medications were not left in resident rooms unattended for 2 (Resident #3 and Resident #6) of 2 residents and failed to ensure medication was not left on the floor of a resident's room for 1 (Resident #2) of 1 resident family interviewed for unattended medications. Findings include: 1. A review of the Admission Record, indicated the facility admitted Resident #3 with diagnoses that included malignant neoplasm of the tongue, bipolar disorder, and schizophrenia. The quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/27/2024 revealed Resident #3 had a Brief Interview for Mental Status (BIMS) score of 9 which indicated the resident required moderate cognitive impairment. Resident #3 required supervision to moderate assistance with activities of daily living. A review of Resident #3's Care Plan, initiated on 10/13/2023, revealed the resident had a history of malignant neoplasm of the tongue, was dependent on staff for activities related to cognition deficit, had short- and long-term memory deficits with impaired decision-making skills, was at risk for further cognitive decline, had poor safety awareness, and pain related to neoplasm of the tongue. Interventions included: to administer medications as ordered, activities compatible with mental capabilities, and maintaining physical environment to help ensure safety. A review of the Order Summary, revealed Resident #3 had a physician's order for a medicated mouth rinse 5 milliliters (ml) by mouth for mouth pain with instructions to swish, gargle and spit, 2 times daily as needed. A review of the Medication Administration Record for June 2024, revealed Resident #3 had medicated mouth rinse administered on 06/29/2024 at 10:40 AM. A review of the July 2024 Medication Administration Record revealed Resident #3 had not received the medicated mouth rinse. A review of the Standard Assessments revealed Resident #3 did not have an assessment for self-administration of medication. During an observation on 07/01/2024 at 12:00 PM, a 30 milliliter (ml) medication cup with graduated markings was located on the bedside table. The cup contained an opaque pink liquid filled to the top graduated mark, indicating 30 ml of fluid, 6 times the dose ordered. During a concurrent observation and interview on 07/01/2024 at 3:07 PM, a 30 ml medication cup with graduated markings, containing an opaque pink liquid, filled to the top graduated mark, was located on the bedside table. Resident #3 stated the medication was for mouth cancer and was provided by a nurse to use when it was needed. During an observation on 07/02/2024 at 8:10 AM, a 30 ml medication cup was located on the bedside table. The medication cup contained 20 ml of an opaque pink liquid. During a concurrent observation and interview on 07/02/2024 at 10:34 AM, Resident #3 placed the opaque pink liquid, from the medication cup, into the resident's mouth and spit the liquid back into the medication cup. Resident #3 stated the nurse leaves the medication in the room so it can be used when needed. Resident #3 indicated the resident just puts some of the fluid in their mouth and swishes it around and puts it back in the cup. Resident #3 could not recall when the medication was placed in the room. During a concurrent observation and interview on 07/02/2024 at 10:36 AM, Certified Nursing Assistant (CNA) #2 stated they did not know what the medication cup contained. During an interview on 07/02/2024 at 10:41 AM, Licensed Practical Nurse (LPN) #1 stated the fluid in the medication cup was Resident #3's swish and spit medication for mouth cancer, and it should be given by a nurse and not left in resident's room. Resident #3 does not have an order to self-administer medication. If a resident can self-administer medication they would have a physician's order, only if their BIMS score was competent, and if they were able to take the medication. A review of Staffing Sheets revealed LPN #3 was working Saturday 06/29/2024 day shift and was assigned to Resident #2's hall. On 07/02/2024 at 2:27 PM, LPN #3 was interviewed by telephone. LPN #3 stated she was familiar with Resident #3 and on 06/29/2024 did administer medications to Resident #3 twice during the shift. LPN #3 stated the swish and spit was administered to the resident after other medications, due to Resident #3 should not drink after administration. The medication was not left at the bedside and should not be left at the bedside because Resident #3 did not have an order to self-administer medications and LPN #3 was not aware of an assessment for self-administration being done. 2. A review of the Admission Record, indicated the facility admitted Resident #6 with diagnoses that included metabolic encephalopathy, transient ischemic attack (TIA), and dementia. The quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/28/2024 revealed Resident #6 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated the resident was cognitively intact. Resident #6 required a wheelchair for mobility and was dependent upon staff for activities of daily living. A review of Resident #6's Care Plan initiated on 02/01/2024 revealed the resident had a history of TIA and was at risk for complications, short- and long-term memory deficits with impaired decision making with diagnosis of dementia. Interventions included administering medications as ordered. A review of the Order Summary, revealed Resident #6 did not have an order to self-administer mediations, did not have an order for triple antibiotic ointment and did not have an order for a medicated gel shampoo. A review of the June 2024 Medication Administration Record, revealed Resident #6 did not have orders to receive triple antibiotic ointment or medicated gel shampoo. A review of the June 2024 Treatment Administration Record, revealed Resident #6 did not have orders for triple antibiotic ointment or medicated gel shampoo. A review of the July 2024 Medication Administration Record, revealed Resident #6 did not have orders for triple antibiotic ointment or medicated gel shampoo. A review of the July 2024 Treatment Administration Record, revealed Resident #6 did not have orders for triple antibiotic ointment or medicated gel shampoo. A review of the Standard Assessments revealed Resident #3 did not have an assessment for self-administration of medication. During an observation on 07/01/2024 at 1:20 PM, a tube of triple antibiotic ointment and a bottle of medicated gel shampoo, was in a gray bath basin, located on the bedside table in reach of Resident #6. During an observation on 07/01/2024 at 3:20 PM, a tube of triple antibiotic ointment and a bottle of medicated gel shampoo was located on the bedside table in reach of Resident #6. During an observation on 07/02/2024 at 8:17 AM, a tube of triple antibiotic ointment and a bottle of medicated gel shampoo was located on the bedside table in reach of Resident #6. During a concurrent observation and interview on 07/02/2024 at 10:48 AM, Licensed Practical Nurse (LPN) #1 identified the shampoo as a medicated gel shampoo containing coal tar, and the tube as triple antibiotic ointment. LPN #1 stated there was no order for this resident to receive the shampoo or triple antibiotic ointment. LPN #1 stated only nurses should have access to the shampoo and triple antibiotic ointment and should not be left in a resident's room because anyone would have access to it and cause injury. The label instructed to ask a doctor before use, use as directed by a doctor, and warnings instructed the product was for external use only. During a concurrent observation and interview on 07/02/2024 at 10:58 AM, medicated gel shampoo was located on a shelf in the supply room. Medical Records stated they did the order of supplies and did order the shampoo. Medical Records stated supplies are kept locked in the supply room to keep residents out of the supply room, so they do not access and get sick or injured, to keep them safe. 3. A review of the Admission Record, indicated the facility admitted Resident #2 with diagnoses that included Cerebral Infarction and Convulsions. The admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/29/2024 revealed Resident #2 had a Brief Interview for Mental Status (BIMS) score of 6 which indicated the resident had severe cognitive impairment. Care Area Assessment indicated cognitive loss. A review of Resident #2's Care Plan, initiated on 05/06/2024, revealed the resident had short- and long-term memory deficits with impaired decision making and was at risk for further cognitive declines and impaired decision making and memory loss. Interventions included administering medication as ordered. During an interview on 07/01/2024 at 12:57 PM, Resident #2's responsible party stated a cup of pills was left on the bedside table within reach of Resident #2. It had another resident's name on it. Resident #2 did not have a roommate at that time, was not aware of a resident with that name and the nurse said there was no one on the hall with that name. The nurse removed the cup of pills from the room. Resident representative stated on Saturday morning there was a pill laying on the floor, under the overbed table, next to the bed. The nurse was notified and came in and removed the medication. Resident representative stated they were unsure whose medication it was. Review of staffing sheets revealed Licensed Practical Nurse (LPN) #3 was working Saturday 06/29/2024, day shift, and was assigned to Resident #2's hall. During an interview on 07/02/2024 at 12:11 PM, the Director of Nursing (DON) stated medications should not be left at the bedside to be self-administered. Medications and supplies are locked so residents cannot access for safety and if left at bedside anyone could access. The resident with dementia could consume the medication and it could cause harm. On 07/02/2024 at 2:27 PM, LPN #3 was interviewed by telephone. LPN #3 stated she was familiar with Resident #2 and their representative, and on 06/29/2024, Resident #2's representative called LPN #3 to Resident #2's room regarding a pill that was found on the floor. LPN #3 stated the pill looked like it had been in someone's mouth, and she had taken the pill and disposed of it. LPN #3 stated they had not passed medication at that time, so she was not able to determine what it was or whose medication it was. LPN #3 was not aware of any cup of pills. A review of a facility policy titled, Medication Administration, with an effected date 04/2021, and a revised date of 11/25/2022, indicated, .1. Only persons licensed or permitted by this state . administer . medication may do so . 3. Medications must be administered in accordance with orders . 24. Residents may self-administer their own medications only if the Attending Physician, in conjunction with the Interdisciplinary Care Planning Team, has determined that they have the decision-making capacity to do so safely . A review of a facility policy titled, Label/Store Drugs & Biologicals, with an effective date of 04/2021, and a reviewed date of 12/26/2022, indicated, The nursing staff shall be responsible for maintaining medication storage AND preparation . Compartments (including, but not limited to, drawers, cabinets, rooms .) containing drugs . shall be locked when not in use . items shall not be left unattended if open or otherwise potentially available to others . Medication will not be stored in a resident room unless the resident has been approved for self-administration of medication .

Based on observation, interview, and record review, the facility failed to ensure the head of the bed was elevated appropriately to decrease the potential of aspiration for 1 (Resident #53) of 1 sampled resident who required a Percutaneous Endoscopic Gastrostomy (PEG) tube (a tube passed into the stomach through the abdominal wall, most commonly to provide a means of feeding when oral intake is not adequate). The findings are: Resident #53 had diagnoses of Dysphagia following cerebral infarction, Gastrostomy malfunction, and Gastrostomy. The Order Summary with an order date of 11/09/2023, showed the resident's diet was nothing by mouth; Enteral Feeding Order (Nutritional Supplement) at 60 milliliter per hour with a 30 milliliter water flush every hour. No order was found for positioning the head of the bed. The Care Plan with an initiated date of 12/11/2023, showed the resident required tube feedings for nutrition and hydration. The resident needs the head of bed (HOB) elevated 45 degrees during tube feedings. On 02/12/24 at 11:18 AM, Resident #53 was lying in bed and the head of the bed was not elevated to 30 degrees. On 02/13/24 at 2:44 PM, Resident #53 was lying in bed and the head of the bed was not elevated to 30 degrees. On 02/14/24 at 2:55 PM, Resident #53 was lying in bed and the head of the bed was not elevated to 30 degrees. On 2/14/24 at 3:00 PM, the Maintenance Director verified that Resident #53's head of the bed was elevated to 24 degrees. On 2/14/24 at 3:04 PM, the Surveyor asked Licensed Practical Nurse (LPN) #6, if the head of the bed was elevated to 30 degrees. LPN #6 stated the head of the bed was not at 30 degrees. On 02/15/24 at 03:54 PM, the Director of Nursing (DON) confirmed that the head of the bed was not at 30 degrees. A document provided by Nurse Consultant #2 on 2/15/24 at 4:01 PM labeled, Policies and Procedures Enteral Feedings effective date 4/2021 with a review date 11/25/22 showed, .Always elevate the head of the bed (HOB) at least 30 degrees to 45 degrees during tube feeding .

Based on observation, and interview, the facility failed to ensure the call light was within reach for 2 (Residents #11, and #128) of 15 (Residents #1, #10, #11, #16, #20, #23, #26, #29, Resident #31, #42, #53, #65, #278, #428, and #429) sampled residents. The findings are: 1. Resident #128 had diagnoses of Need for assistance with personal care, Unspecified lack of coordination, Unspecified abnormalities of gait and mobility, Muscle weakness (generalized), Spinal stenosis, cervical region, and Dehydration. A Care Plan initiated on 2/12/24 documented, .Access ability to use call light and bed controls on regular basis . Ensure that the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance . Need a safe environment with . a working and reachable call light . Ensure call light within easy reach . On 02/13/24 at 08:24 AM, Resident #128 was in bed. His call light was on the floor and not within reach. On 02/13/24 at 09:40 AM, Resident #128 was in bed. His call light was on the floor and not within reach. On 02/13/24 at 10:15 AM, Resident #128 was in bed. His call light was on the floor and not within reach. On 02/13/24 at 01:35 PM, Resident #128 was in bed. His call light was on the floor and not within reach. On 02/13/24 at 01:48 PM, the Director of Nursing (DON) was asked, Can you tell me where [Resident #128's] call light is located? She stated, It's on the floor. On 02/13/24 at 02:08 PM, the Surveyor asked Certified Nursing Assistant (CNA) #1, How often have you checked on [Resident #128] since your shift started this morning? She stated, Less than every couple of hours. She was asked, Can you tell me why his call light has been on the floor, in the same spot all day? She stated, I probably didn't notice it when I went in there. 49866 2. Resident #11 had diagnoses of glaucoma, spastic hemiplegia (affecting left nondominant side), history of falling and Alzheimer's disease. The Significant Change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/25/24 showed the Staff Assessment for Mental Status (SAMS) noted memory problems. The Care Plan with an initiated date of 07/27/17 showed, .Be sure call light is within reach and encourage to use it for assistance as needed. Provide prompt response to all requests for assistance . On 02/12/24 at 01:38 PM, Resident #11 was in bed and the call light was lying in the floor out of reach. On 02/12/24 at 02:41 PM, Resident #11 was lying in the bed with the call light in the floor out of reach. On 02/12/24 at 03:26 PM, Resident #11 was lying in the bed with the call light in the floor out of reach. On 02/12/24 at 3:28 PM, the Surveyor asked CNA #4, how is a resident to call if they need help? CNA #4 said with a call light. The Surveyor asked, can you show me where a call light is supposed to be located to the resident? CNA #4 said it is usually clipped to a side rail. The Surveyor asked, can you show me where Resident #11's call light is located? CNA #4 stated, Yes, it's on the floor. On 02/12/24 at 3:38 PM, the Surveyor asked Licensed Practical Nurse (LPN) #5, how is a resident to call if they need help? LPN #5 stated, The call light. The Surveyor asked, where is a call light supposed to be located to the resident? LPN # 5 stated, Within reach. The Surveyor asked, can you tell me where this resident's call light is located? LPN #5 stated, On the floor. On 02/15/24 at 03:42 PM, the Director of Nursing (DON) confirmed Resident #11's call light was on the floor.

Based on observation, interview and record review, the facility failed to ensure 1 (Resident #278) of 1 sampled resident was taken to a scheduled appointment. The findings are: 1. On 2/12/24 at 1:13 pm, Resident #278 informed the Surveyor that an orthopedic follow up appointment was missed earlier that day. Resident #278 said the facility had rescheduled it for Wednesday 2/14/24 at 8:00 am. 2. On 2/13/24 at 09:12 am, the Surveyor asked the Social Worker, who was responsible for getting residents to their scheduled appointments? The Social Worker confirmed the van driver was. The Van Driver schedules all of the appointments. 3. On 2/13/24 at 9:21 am, the Surveyor asked the Van Driver, who was responsible for resident appointments? The Van Driver confirmed I am. The Surveyor asked, do you schedule all the appointments? The Van Driver confirmed, yes, I do. The Surveyor asked, can you explain why Resident #278 missed her follow up orthopedic appointment? The Van Driver confirmed, the appointment wasn't given to me until mid-morning on Monday after (Resident #278) had already missed it. The (family member) had given the time to a nurse this weekend, and I didn't know about it until she had already missed the appointment. I have already rescheduled it for 2/14/24 at 08:00am. 4. On 2/14/24 at 8:15 am, Resident #278 and a family member said that the facility had failed to take her to the follow up orthopedic appointment. Resident #278 was very upset. The Surveyor went and got the Nurse Consultant. Resident #278 informed the Nurse Consultant that the facility had failed to take her to an appointment on 2/12/24, and today, 2/14/24. The Nurse Consultant apologized and assured Resident #278 would be taken on 2/15/24 at 8:00 am to her appointment. 5. On 2/14/24 at 08:15 am, Resident #278 said that her appointment had been missed again. The Surveyor asked the Nurse Consultant, who was responsible for making sure residents get to their appointment? The Nurse Consultant confirmed the van driver was. The Surveyor asked, why did this resident miss her appointment again? The Nurse Consultant confirmed, I don't know but I will find out and I will reschedule your appointment and make sure you get to it. 6. On 2/15/24 at 1:47 pm, the Nurse Consultant provided a copy of the Admission Agreement which documented, .Ancillary Supplies and Services. Resident may utilize a variety of ancillary supplies and services during his or her stay in the facility. Ancillary supplies and services are supplies and services indirectly related to Resident's stay in the facility and include, but are not limited to, prescription drugs, certain medical supplies, intravenous therapy, radiology, laboratory, certain support services, certain medical equipment and transportation .

Based on observation and interview, the facility failed to ensure that the 2023 survey results were located in the State Inspection Book made accessible to residents and family members. The findings are: On 2/14/24 at 10:35 AM, the Resident Council was asked if they were familiar with the State Inspections Book and where it was located in the facility if they wanted to read it. All 3 Residents (Resident #2, #48, and #60) that were in the meeting stated that they were not aware of the State Inspections Book, or where it was located. On 2/14/24 at 11:10 AM, a binder titled, State survey book, was located on the bottom shelf of a table by the entrance door. The 2023 survey results were not in the binder. On 2/14/24 at 11:15 AM, the Administrator was asked where the 2023 survey results were located. The Administrator looked in the state survey binder then stated, They were in here when I started last year in December. I remember because they got 16 tags. On 2/1/24 at 1:47 PM, a policy titled, Resident Rights, was received from Nurse Consultant #2. It documented, .Federal and state laws guarantee certain basic rights to all residents of this facility. The rights include the resident's right to .examine survey results .

Based on observations and interviews the facility failed to provide a safe, clean, comfortable, and homelike environment for Rooms #103B and #108, and the floor in front of the 300 hall shower. This failed practice had the potential to affect 2 out of 31 residents that reside on 100 hall and 15 residents that reside on 300 hall and walk past the shower room. The findings are: 1. On 2/12/24 at 11:56 AM, food particles and a white pill were on the floor behind bed 103B. On 2/12/24 at 1:13 PM, brown spots were on the wall in room [ROOM NUMBER]. On 2/12/24 at 2:35 PM, food particles and a white pill were on the floor behind bed 103B. On 2/12/24 at 2:41 PM, brown spots were on the wall in room [ROOM NUMBER]. On 2/14/24 at 3:25 PM, brown spots were on the wall in room [ROOM NUMBER], and trash was on the floor. On 2/14/24 at 3:44 PM, the Housekeeping Supervisor (HS) was asked to identify the substance on the wall in room [ROOM NUMBER]. The HS looked at the wall, and stated, [The resident in room [ROOM NUMBER]] dips and can't see that good. They are supposed to wash it off every day. I'll make sure they get it tomorrow. On 2/13/24 at 3:22 PM, Housekeeper #1 (HK #1) was asked, Have you cleaned room [ROOM NUMBER] today? HK #1 stated, Yes I've already cleaned it. HK #1 was asked to look on the side of the bed that's close to the window and describe what was seen. HK #1 looked beside the bed, then stated, To be honest I didn't clean over there by the bed. On 2/13/24 at 3:43 PM, food particles and a white pill were on the floor behind bed 103B. On 2/13/24 at 3:47 PM, brown spots were on the wall in room [ROOM NUMBER]. 2. On 02/13/24 at 09:44 AM, a 3 [inch] wide, 2' [feet] long strip of vinyl flooring was absent in front of the shower room on Hall 300. To the left of the absent vinyl strip was a 2' x 3 wide strip that moved upon touching, on the right side of absent strip there was a strip that moved upon touching. There was water coming from the shower room leading into the linen closet 2 feet away from each other on the same side of the hall. On 02/15/24 at 03:17 PM, the Maintenance Director was asked, How do you know when something in the facility needs to be fixed? The Maintenance Director said, There is a log at the nurse's station that has stuff in it that needs to be fixed. The Maintenance Director was taken to the Hall 200 bathroom, shown the white bucket behind the sink and the blanket around the sink, and asked, Is this sink leaking? The Maintenance Director said, Not that I'm aware of. I don't know why this stuff is here. I've been working on the bathroom on the other side. The Maintenance Director bent down and checked the faucet and said, It is not leaking. The Maintenance Director was taken to the 300 Hall shower room and shown the floor tile that was missing. The Maintenance Director was asked, Is there a maintenance request to fix this? The Maintenance Director said, I didn't know this was like that, but I'm going to fix right away. 37634

Based on observation, record review, and interview, the facility failed to ensure bathing services were regularly provided to maintain good hygiene for 4 (Residents #28, #69, #128, and #331) sampled residents who were dependent on staff for bathing/showers, and nail care was provided for 1 (Resident #20), and oral care was provided for 1 (Resident #28) to promote good personal hygiene and grooming. The findings are: 1. An Entry Minimum Data Set (MDS) noted Resident #128 was admitted on [DATE]. On 2/12/24 at 1:23 PM, Resident #128's fingernails were long and jagged. There was a black substance under the nails. The Surveyor asked when was the last time the staff had trimmed and cleaned the fingernails. Resident #128 stated, They haven't been cleaned since I've been here. I've been here almost a week. The Surveyor asked, When was the last time you had a shower? Resident #128 stated, I haven't had one since I've been here. On 2/12/24 at 2:55 PM, Resident #128's fingernails were long and jagged. There was a black substance under the nails. On 2/13/24 at 1:48 PM, the Director of Nursing (DON) was asked, Can you tell me how [Resident #128's] nails look to you? The DON stated, They look rough. They definitely need to be done. I'll get someone to do them. On 2/13/24 at 2:00 PM, the DON was asked, What days does [Resident #128] get showered? The DON stated, I think it's twice a week. I can't find a bath sheet, but I'll get someone to give him a bath. 43262 2. Resident #331 had diagnoses of Respiratory failure, unspecified with hypoxia, Unspecified asthma, uncomplicated, and Cryptogenic organizing pneumonia. A Quarterly MDS with an ARD of 08/28/23 documented Resident #331 had a BIMS of 15 (13-15 indicates cognitively intact) and required supervision and setup with bathing. a. An email from Resident #331 documented, Most days the staffing is so horrible that I had to call an ombudsman to get a shower more than once a week. Once she intervened it got better for two weeks then right back to one shower a week most because of usually having only one CNA [Certified Nursing Assistant] on the floor for 28 residents. I was told by someone in social services that I refused my showers a lot which is not true but I found out from the CNA's that on days they can't give showers to chart pt [patient] refused . b. On 02/13/24 at 10:00 AM, Resident #331 was notified by phone, who verified the complaint of not getting showers. c. A review of the Grievances dated October 2023 documented, On 10/23/23, Resident #331 complained about showers and that the CNAs were told to write refused on resident's shower sheet. Resolution documented 5 nurses with witness statements answering: Have you ever told staff member to document a shower as refused even when a resident didn't refuse? On 10/18/23, 10/23/23 and 10/30/23, 11/14/23 and 01/18/24 there were 5 other complaints from different residents that had not received showers. d. A Care Plan documented [Resident #331] needs assist of staff for basic needs including: Dressing, incontinent care, bathing, grooming, personal hygiene, locomotion, etc . Bathing/showering: Provide shower/bath following facility policies. If shower/bath cannot be tolerated offer bed bath as alternative. Resident requires Extensive assist 2 staff for bathing . e. Shower sheets provided on 02/14/24 at 03:46 PM by Nurse Consultant documented Resident #331 for Tuesday 08/01/23, 2:00 PM to 10:00 PM shift, shower and shave; Tuesday 08/15/23, 2:00 PM to 10:00 PM shift, blank shower sheet; Tuesday 08/22/23 2:00 PM to 10:00 PM shift shower, nails trimmed and shave; Saturday 08/26/23, 2:00 PM to 10:00 PM shift shower, Friday 09/01/23, 2-10 shift shower, Tuesday 09/19/23, 2:00 PM to 10:00 PM shift shower, Tuesday 10/03/23, 2:00 PM to 10:00 PM shift shower, Saturday 10/07/23, 2:00 PM to 10:00 PM shift shower, Tuesday 10/10/23, 2:00 PM to 10:00 PM shift shower, Friday 10/13/23, 2:00 PM to 10:00 PM shift shower. The month of August 2023 had 4 documented showers. The month of September had 2 documented showers. The month of October had 4 documented showers. f. On 02/15/24 at 10:30 AM, the Surveyor asked CNA #2, Who is responsible for giving resident showers? CNA #2 stated, The aides. The Surveyor asked, How is it decided which resident gets a shower on a certain day? CNA #2 stated, I think that is discussed upon admission. The resident is asked their preference, either shower or bed bath, and on which days they prefer. The Surveyor asked, Can a resident ask for a shower on a day other than their scheduled day? CNA #2 stated, Yes. The Surveyor asked, Are the residents getting showers as scheduled and where are they documented? CNA #2 said as far as I know. We have a shower team that does first and second shift showers. The Surveyor asked, Where would a refusal be documented? In [Facility Computer Software]. The Surveyor asked, Have you ever been told to document a resident refused a shower when there wasn't enough time to give showers? No. g. On 02/15/24 at 11:08 AM, the Surveyor asked Licensed Practical Nurse (LPN) #1, Who is responsible for giving resident showers? LPN #1 stated, The CNAs. The Surveyor asked, How do the CNAs know which residents get a shower on which day? LPN #1 stated, We have a communication book at the nurse's station that has resident preferences, new skin issues, any information that we want nurses and CNAs to know. The Surveyor asked, Can a resident ask for a shower on a day other than their scheduled day? LPN #1 stated, Yes. The Surveyor asked, If a resident refuses a shower, what does the CNAs do? LPN #1 stated, They fill out a refusal sheet then let me know. I will go in and talk to the resident about getting a shower/bath. It may have just been too early or maybe they weren't feeling well, for them to refuse. We will ask again later in the day to see if they changed their minds. h. On 02/15/24 at 11:24 AM, the Surveyor asked the DON, How often do residents receive showers/bath? The DON stated, Most residents are put on the schedule for three times a week. We have a couple of gentlemen that believe three times a week is excessive. Actually, upon admission, we try to fill out their preferences, bath or shower, and how many times a week they want. The Surveyor asked, Who is responsible for giving the resident showers? The DON stated, We have a bath team. Since I started (12/04/23) it has taken up a while to get that team settled because we have so much agency. The Surveyor asked, Are the residents getting showers as scheduled and where are they documented? The DON stated, As far as I know they are, we try to get showers done as soon as notified. Documented in the tasks, shower sheets. The Surveyor asked, To your knowledge, have any residents complained to you about them not receiving showers/bath as scheduled? The DON stated, Yes, I would say that it a common complaint. We are trying to rectify that, and we are doing what we can to make it better. We try to fix complaints as fast as possible. The Surveyor asked, To your knowledge, have the CNAs been advised to document a resident refused a shower/bath when there wasn't enough time to give showers? The DON stated, No. They have been told to notify the nurse of the refusal and it will go in the shift report for the next shift. The Surveyor asked, Do you feel the facility is short-staffed? The DON stated, Yes, that's why I'm using agency. What is the facility doing about the shortage? The DON stated, Using twenty to twenty five percent, if they would not be no call, no show. The DON said midnight is hard to cover when you get call ins. I try my best to get it covered. i. On 02/15/24 at 02:19 PM, the Nurse Consultant said there was not a facility policy on ADLs (Activities of Daily Living). 47661 3. Resident #69 was admitted to the facility on [DATE]. An Admissions MDS with an ARD of 01/25/2024 documented in Section GG, subsection E. Shower/bathe self: The ability to bathe self, including washing, rinsing, and drying self (excludes washing of back and hair). Does not include transferring in/out of tub/shower an assessment of Dependent. On 02/13/2024 at 01:45 PM, during an interview with Resident #69's family member, the family member reported visiting Resident #69 on the Thursday (01/18/2024) following the resident's admission on 01/12/2024. The family member reported Resident #69 was lying in feces and the sheets on the resident's bed had urine rings surrounding the body. The family member reported the resident's bedding did not appear to have been changed. On 02/15/2024 at 08:50 AM, the DON provided a document titled, Task: Shower/Bathe Tues [Tuesday]-Thurs [Thursday]-Sat [Saturday] for Resident #69. It documented dates and times that bathing assistance was provided or refused. The first two entries were: 01/17/2024 at 09:47 [AM] - Not Applicable and 01/23/2024 at 01:59 [PM]- Substantial/maximal assistance [bathing] The DON was asked what Not Applicable implied. The DON stated they were unaware of what the entry meant. The Surveyor asked the DON to provide additional information related to bathing assistance being offered to Resident #69 between the date of admission, 01/12/2024, and the first documented bath, 01/23/2024. On 02/15/2024 at 09:20 AM, the DON provided a document titled, Shower Sheet . dated 01/15/2024. It documented a skin assessment but did not include any information regarding bathing assistance being offered or refused. 48483 4. Resident #28 diagnosis showed muscular dystrophy. The Annual MDS with an ARD of 12/11/23 showed a BIMS of 15 (13-15 indicates cognitively intact) and was dependent for all activities of daily living. 2. The Care Plan with an initiated date of 06/08/21 showed the resident was totally dependent on staff to anticipate and meet all basic needs including dressing, incontinent care, bathing, grooming, and personal hygiene. The resident is dependent on 1 to 2 staff for personal hygiene and oral care. Provide a sponge bath daily and as needed when a full bath or shower cannot be tolerated. c. On 02/13/24 at 08:53 AM, Resident #28's toenails were 3/4 inch long with some jagged edges. d. On 02/13/24 at 03:11 PM, Resident #28's toenails were 3/4 inch long with some jagged edges. e. On 02/14/24 at 02:57 PM, Resident #28's toenails were 3/4 inch long with some jagged edges. f. On 02/13/24 at 08:53 AM, Resident #28 stated, I refuse some baths and showers, but can go a while without getting one. I don't remember the last time I received a shower and oral care is non-existent. I need my teeth brushed. I have an electric toothbrush, but I rarely get my teeth brushed. g. On 02/14/24 at 02:32 PM, the Surveyor asked CNA #5, What shift do you work? CNA #5 stated, Second. The Surveyor asked, Does Resident #28 receive a shower or a bed bath regularly? CNA #5 stated, Not that I know of. The Surveyor asked, Has the resident ever refused a shower or bath? CNA #5 stated, I don't know if they refuse them. h. On 2/14/24 at 4:09 PM, the DON provided a shower sheet dated 1/16/24 through 2/13/24 that showed Resident #28 had not refused a shower for the past month. It showed 7 baths completed and 9 days marked not applicable. i. On 02/14/24 at 04:11 PM, the Surveyor asked the DON, what does not applicable mean on the shower sheets? The DON stated, I don't know what not applicable means. j. On 02/15/24 at 10:10 AM, the Surveyor asked CNA #6 to describe Resident #28's toenails. CNA #6 stated, They are overgrown and need to be clipped. The Surveyor asked, Can you tell me what they look like? CNA #6 stated, They are about one half inch on the right foot and the left foot is at least an inch. They are a little yellow. The Surveyor asked, Who is responsible for nail care and oral care? CNA #6 stated, The assigned CNA, and the nails are usually cut on shower days. The Surveyor asked, Does the resident refuse showers? CNA #6 stated, They are a second shift shower. The Surveyor asked, How often is oral care provided? CNA #6 stated, Daily and as needed. The Surveyor asked, Has the resident ever refused oral care? CNA #6 stated, They have never refused oral care when I offer. k. On 02/15/24 at 10:15 AM, the Surveyor asked Resident #28, Would you like your teeth brushed? Resident #28 stated Yes, I would like them brushed today. l. On 02/15/24 at 10:17 AM, the Surveyor asked CNA #7, Are you caring for Resident #28 today? CNA #7 stated, Yes. The Surveyor asked, Does Resident #28 ever refuse showers or oral care? CNA #7 said, the resident is a second shift shower and usually tells me when they want oral care. The Surveyor asked, Do you offer oral care? CNA #7 stated, Yes, they usually refuse it. m. On 02/15/24 at 11:50 AM, the Surveyor asked LPN #3, Does Resident #28 refuse showers or oral care? LPN #3 stated, Not that I know of. They are an evening shift shower. The Surveyor asked, Who is responsible for clipping toenails? LPN #3 stated, The aids can clip them. The Surveyor asked, Can you describe the resident's toenails? LPN #3 stated, They are very long and need to be trimmed. They have rough edges. n. On 12/25/23 at 12:11 PM, the DON confirmed Resident #28's toenails were long and jagged. 49071 5. On 2/12/24 at 11:24 AM, Resident #20's toenails were 1/2 long and jagged. Both feet had dry flaking with peeling skin with cracks on the bottom of both feet. a. On 2/12/24 at 11:24 AM, Resident #20 said they had been asking to have toenails trimmed and feet groomed since being admitted to the facility. b. On 2/13/24 at 0:823 AM, observed Resident #20's feet, both feet had nails clipped and bottom of feet had been scraped and lotion applied. Resident #20 said someone came in late in the evening to do feet. Resident #20 stated, I have been asking since admission, but it took you coming in here to get it done. c. On 2/15/24 at 2:49 PM, the Surveyor asked CNA #3, How often is toenail care provided. CNA #3 confirmed, 3 to 4 times a week or if they want it done more frequently. The Surveyor asked, Who performs nailcare on residents. CNA #3 confirmed, the CNAs do, unless they are diabetic then we get the nurse to do them. The Surveyor asked, Should toenails be 1/2 inch longer than the toe and jagged. CNA #3 confirmed, no they shouldn't. d. On 2/15/24 at 2:53 PM, the Surveyor asked LPN #3, how often is nailcare/toenail care performed. LPN #3 confirmed, on shower days. The Surveyor asked, Who is responsible for making sure nailcare is done. LPN #3 confirmed, if they are not diabetic the CNA does them, if they are diabetic the nurses do the nailcare. The Surveyor asked, Should toenails be 1/2 inch long past the toe and jagged. LPN #3 confirmed, no they shouldn't.

Based on interview and record review the facility failed to complete the required quarterly assessments for 2 (Residents # 6, and #278) of 2 sampled residents. The findings are: 1. Resident #6 had diagnoses of Heart failure, Gout; unspecified, and Vascular dementia. A Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/22/2024 documented a Brief Interview for Mental Status [BIMS] of 11 (8-12 indicates moderate cognitive impairment), weight 209, weight loss: No/Unknown. a. On 02/12/24 at 01:54 PM, Resident #6 reported not caring for the food, it was often cold when served and alternatives were not offered. Resident #6 confirmed that an alternate meal is never offered. b. A Physician's Order for Resident #6 documented .No Added Salt diet, Regular texture, Thin Liquids consistency . c. A care plan for Resident #6 documented .Has a diagnosis of gout and is medicated and is at risk for the problems relate to this .Avoid food high in purine, such as: red meats, gravy, broth, poultry, shellfish, sardines, legumes, etc . d. An assessment dated [DATE] documented, .[Quarterly] review; CBW [current body weight] 210.2 # [pounds], [body mass index] 37.2 is above normal range. Diet order: No Added Salt diet, Regular texture, Thin Liquids consistency; no changes in diet recommended . f. On 2/15/2024 at 9:20 AM, the Dietary Manager [DM] was asked, How often do you do dietary assessments/evaluations? The DM answered, Upon admission. The DM was asked, Where are the updated evaluations kept/documented? The DM answered, They could be found in the User Defined Assessment [UDA] section on [Facility Computer Software]. The DM was asked, How often are these assessments supposed to be made. The DM said, She has 24 hours to fill out pink slips that have likes, dislikes, and food allergies. The DM also stated that the Registered Dietician does admission and UDA's. The DM was asked, How often after the initial assessment are they updated? The DM said, Quarterly. g. On 2/15/2024 at 9:22 AM, the DM was asked if dietary sheets for 2 residents could be provided. As of 2/15/2024 at 5:00 PM, the dietary sheets for the selected residents had not been provided. 2. On 2/13/24 at 2:17 PM, smoking and self- medication administration assessments had not been completed for Resident (R) #278. a. On 2/12/24 at 1:13 PM, R#278 had an inhaler at bedside. b. On 2/13/24 at 2:51 PM, R#278 had an inhaler at bedside. c. On 2/14/24 at 11:07 AM, R#278 had an inhaler at bedside. d. On 2/12/24 at 2:07 PM, R#278 was outside smoking. e. On 2/14/24 at 3:08 PM, R#278 was outside in front of the facility smoking. f. On 2/13/24 at 3:37 PM, no self- medication assessment or smoking assessment had been completed for R #278. g. On 02/12/24 at 2:17 PM, R#278 reported smoking 2-3 cigarettes a day. h. On 2/15/24 at 10:23 AM, the Director of Nurses (DON) was asked, Who is responsible for making sure that resident quarterly assessments are completed? The DON stated, Myself, as well I have unit managers on all the halls to assure these get completed. The DON was asked, Why is it important to make sure these assessments are completed? The DON stated, So we can stay current on our resident's condition. i. On 2/15/24 at 10:18 AM, the Administrator reported the facility did not have a policy for assessments. 49981

Based on observation, interview, and record review, the facility failed to ensure the water temperature was maintained at a safe level to prevent burns on the 200 Hall, and failed to ensure medications were not left at bedside for 1 (Resident #278) of 1 sampled resident. The findings are: 1. On 02/12/2024 at 01:13 PM, a resident reported that the water was scalding hot on the unit on which the resident resided, the 200 Hall. The Surveyor turned the hot water on in the resident's bathroom and was only able to tolerate touching the water momentarily. On 02/13/2024 at 01:16 PM, the Surveyor requested the Maintenance Supervisor test the water temperature on the 200 Hall using the facility's test equipment. The Maintenance Supervisor reported the water temperature was 125 degrees Fahrenheit. The Surveyor asked the Maintenance Supervisor which water heaters were supplying hot water to the 200 Hall and was shown a Maintenance Room at the end of the hallway containing two water heaters. The Surveyor asked if the restrooms that were open to the residents on the 200 Unit received water from the same heaters. The Maintenance Supervisor confirmed that they did. On 02/15/2024 at 02:45 PM, the Assistant Director of Nursing (ADON) confirmed that the water temperature of 125 degrees recorded on the 200 Hall was capable of causing burns and should be lowered. On 02/15/2024 at 02:55 PM, the Administrator confirmed that water temperatures should be maintained below 120 degrees to prevent burns. On 02/16/2024 at 08:15 AM, Nurse Consultant #2 reported the facility did not have a policy that documented guidelines for maintaining safe water temperatures. 49071 2. On 02/12/2024 at 1:13 PM, Resident #278's inhaler was at the bedside. On 02/13/2024 at 9:32 AM, Resident #278's inhaler was at the bedside. On 02/14/2024 at 11:07 AM, Resident #278's inhaler was at the bedside. On 02/13/2024 at 3:37 PM, Resident #278's medical record did not contain a self-administration medication assessment. On 02/15/2024 at 10:58 AM, the Surveyor asked the Director of Nursing (DON), how do you determine if a resident can self-administer their medication? The DON confirmed, by their Brief Interview for Mental Status (BIMS), if it is high they can self-administer their medication, but the nurse should always be in control of the medication. The Surveyor asked should medication be left at a resident's bedside. The DON confirmed, no, never. On 02/15/2024 at 11:04 AM, the Surveyor asked Licensed Practical Nurse (LPN) #4, how do you determine if a resident can self-administer their own medication. LPN #4 confirmed, by their Brief Interview of Mental Status (BIMS) score (a test used regularly to measure and track a resident's cognitive decline or improvements in a long-term care facility), if it is high and they are cognitive they can self-administer their own medication. The Surveyor asked if medication should be left at the resident's bedside. LPN #4 confirmed, no, never. On 02/15/2024 at 11:00 AM, Nurse Consultant provided a policy titled, Self-Administration of Medications, which documented, .9. Staff shall identify and give to the charge nurse any medications found at the bedside that are not authorized for self-administration, for return to the family or responsible party .

Based on observation, interview, and record review, the facility failed to ensure an indwelling urinary catheter drainage bag was concealed in a privacy bag when visible to promote dignity and privacy for 1 (Resident #31) of 3 (Residents #1, #31, and #428) sampled residents who had an indwelling urinary catheter. The findings are: Resident #31's diagnoses showed neuromuscular dysfunction of bladder and vascular dementia. The Medicare 5-day Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/27/24 showed a Brief Interview for Mental Status (BIMS) of 04 (0-7 suggests severe cognitive impairment) and had an indwelling catheter. The care plan showed position the catheter bag and tubing below the level of the bladder and away from entrance room door. Place in privacy bag when up in wheelchair or geriatric chair. The Physician's Order Summary showed, active 7/14/23, Resident #31 was to have an indwelling urinary catheter for neuromuscular dysfunction of bladder. On 02/12/24 at 01:34 PM, observed Resident #31's indwelling urinary catheter drainage bag with no cover and facing the door. On 02/12/24 at 02:41 PM, observed Resident #31's indwelling urinary catheter drainage bag with no cover and facing the door. On 02/12/24 at 03:25 PM, observed Resident #31's indwelling urinary catheter drainage bag with no cover and facing the door. On 02/13/24 at 03:11 PM, observed Resident #31's indwelling urinary catheter drainage bag with no cover and facing the door. On 02/12/24 at 03:30 PM, the Surveyor asked Certified Nursing Assistant (CNA) #4, should an indwelling catheter collection bag be exposed? CNA #4 stated, No. The Surveyor asked, should there be a cover on the bag when facing the door? CNA #4 stated, Yes. The Surveyor asked, is this catheter bag covered? CNA #4 stated, No. On 2/12/24 at 03:38 PM, the Surveyor asked Licensed Practical Nurse (LPN) #5, should an indwelling catheter bag be covered? LPN #5 stated, Yes. The Surveyor asked, is Resident #31's collection bag covered? LPN #5 stated, No, it is not. On 02/15/24 at 03:57 PM, the DON confirmed there was no dignity cover on Resident #31's urinary catheter bag. A document titled, Policies and Procedures-Dignity with an effective date 4/2021 and a revised date 3/10/22, provided by Nurse Consultant #1 on 2/16/24 at 10:30 am, showed, .Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect, and individuality . 9. Demeaning practices and standards of care that compromise dignity are prohibited. Staff shall promote dignity and assist residents as needed by: a. Helping the resident to keep urinary catheter bags covered; .

Based on observation, record review, and interview, the facility failed to ensure oxygen was administered as ordered by the physician for 1 (Resident #428) of 10 sampled residents who had a physician's orders for oxygen; the facility failed to ensure a (portable ventilator) filter and tubing was changed weekly and dated for 1 (Resident #23) of 1 sampled resident who required the use of a (portable ventilator); the facility failed to ensure a tracheostomy collar was changed for 1 (Resident #26) of 1 sampled resident who required the use of a ventilator. The findings are: Resident # 23 diagnoses included Muscular dystrophy. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/11/23 showed a Brief Interview for Mental Status (BIMS) of 15 (13-15 indicates cognitively intact). The MDS indicated the resident is dependent for all activities of daily living. The Physician's Order with an active date of 10/16/22, documented .change filter to the [portable ventilator] on day shift every Saturday; Clean the [portable ventilator], change the filter and tubing, date everything on day shift every Saturday . The care plan did not address the changing of the (portable ventilator) tubing or filter. On 02/13/24 at 08:53 AM, Resident #23's (portable ventilator) filter was dated 12/30/24 with no date on the tubing. On 02/13/24 at 03:13 PM, Resident #23's (portable ventilator) tubing had no date, and the filter was dated 12/30. On 02/14/24 at 09:19 AM, Resident #23's (portable ventilator) tubing had no date, and the filter was dated 12/30. On 02/15/24 at 11:50 AM, Licensed Practical Nurse (LPN) #3 was asked, Can you tell me what the date is on Resident #23 tubing and the [portable ventilator] filter? LPN #3 stated, The filter is dated 12/30. I don't see a date on the tubing. The Surveyor asked, Do you know who orders the supplies? LPN #3 stated, We do, but I don't know who the person is in charge of that right now. It has changed over the last few months of people doing the ordering. The Surveyor asked LPN #3, What is the order for changing the tubing and filter? LPN #3 stated, Change the filter and tubing every day shift every Saturday. On 02/15/24 at 12:06 PM, the Director of Nursing (DON) was asked, Who is in charge of ordering [portable ventilator] supplies? The DON stated, The nurses let us know when they need to be ordered. The Surveyor asked, What is on the date on Resident #23's [portable ventilator] filter and tubing? The DON stated, There is no date on the tubing and the filter is dated 12/30. The DON confirmed the orders were to change the tubing and filter every Saturday on dayshift. On 02/15/24 at 03:47 PM, Nurse Consultant #2 confirmed there was not a (portable ventilator) policy and were unable to provide a copy of the manufacturer's manual. Resident #26 had a diagnosis of Personal history of malignant neoplasm of larynx. A Modification MDS with an ARD of 1/18/24 documented that Resident #26 is rarely/never understood. A Physician ' s order dated 1/24/24 documented, .CHANGE OXYGEN TUBING WEEKLY TIME AND DATE EVERYTHING . A care plan dated 11/07/23 documented, .Change oxygen tubing weekly time and date everything . On 02/14/24 at 09:46 AM, the date on Resident #26's tracheostomy mask was 12/27/23. LPN #3 was asked, What date is on the mask? LPN #3 stated, 12/27/23. The Surveyor asked, How often should the trach mask be changed? LPN #3 stated, I'm not 100% sure on that, but I'll go get another mask. Nurse Consultant #3 provided a form titled, Oxygen Administration-Resident. It documented, .Oxygen tubing will be changed weekly, and labeled with date it was changed . 49981 3. Resident #428 had diagnoses of Acute and chronic respiratory failure with hypoxia and Chronic obstructive pulmonary disorder (COPD). A Quarterly MDS with an ARD of 02/12/2024 documented a BIMS of 15 (13-15 indicates cognitively intact), .Section O - Special Treatments, Procedures and Programs . C1. Oxygen therapy .A On Admission Yes .C2. Continuous. On Admission Yes . a. On 2/12/2024 at 11:20 AM, Resident #428 was receiving oxygen via nasal cannula. The resident was asked, Do you wear oxygen at all times? The resident stated, Yes. b. On 02/12/24 at 11:20 AM, an empty O2 humidifier was attached to Resident #428's oxygen machine. c. On 2/12/2024 at 12:01 PM, Resident #428 was overheard telling staff that the oxygen humidifier was supposed to have water and it was empty. d. A Physicians Order dated 2/6/2024 documented, .Change nasal cannula, humidifier, updraft tubing weekly. Date everything. every night shift every [Wednesday] . e. The care plan documented, .OXYGEN SETTINGS: [Oxygen] via [nasal cannula] at 4 [liters per minute as needed] .Resident at risk for respiratory problems, including: Shortness of breath, coughing, wheezing, respiratory distress, respiratory infections, etc. related to COPD .Administer oxygen per physician's orders . f. On 2/14/2024 at 9:19am, LPN #1 was asked, Who monitors resident's oxygen? LPN #1 stated, The nurse's do. LPN #1 was asked, Is it necessary for 02 humidifiers to have water in them? LPN #1 answered, Yes. LPN #1 was asked, Should 02 humidifiers have water in them at all times? LPN #1 stated, Yes. LPN #1 was asked, Are there any possibilities of negative outcomes resulting from an oxygen humidifier that did not have any water? LPN #1 stated, This will dry out a resident, cause nose bleeds, and can decrease blood oxygen levels. g. On 2/14/2024 at 3:32pm, the DON was asked, Who monitors resident's oxygen? The DON stated, On Wednesday's, the nurses who are assigned to the hall in which the oxygen is located, will change out tubing, add water, etc. according to physician's orders for the oxygen. The DON was asked, Is it necessary for 02 humidifiers to have water in them. The DON replied, If the physician's order calls for a resident to have a humidifier, then yes, they should have water. The DON was asked, Is it necessary for 02 humidifiers to have water in them at all times? The DON replied, Yes. The DON was asked, Is there a potential for any negative outcomes if the resident receiving oxygen from a nasal cannula with no water in the humidifier. The DON stated, Yes, there is a potential for negative outcome if the humidifier runs out of water. The humidifier is ordered by the doctor to keep the resident's secretions from solidifying, which can cause pneumonia and other potentially negative outcomes. h. A Policy titled, Oxygen Administration - Resident, provided by the Nurse Consultant on 2/14/2024 at 3:49pm, documented, .Equipment and Supplies . 3. Humidifier bottle if needed . 37634

Based on interview and record review, the facility failed to ensure there was Registered Nurse (RN) coverage for at least 8 consecutive hours per day, 7 days a week. The findings are: 1. Review of staffing for 8 consecutive hour work shifts showed the following: a. On 01/14/24 and 01/20/24, there was no documentation that an RN was on duty. b. On 01/21/24, there was no documentation that an RN was on duty. c. On 02/16/24 at 11:16 am, the Director of Nursing (DON) was asked, have you had any RN shortages where there is not an RN here? The DON said, no, a weekend supervisor has been hired and I have been working weekends.

Based on observation, interview, and record review, the facility failed to ensure monthly medication regimen reviews (MRR) were performed for 2 (Residents #10 and #28) of 5 (Residents #10, #26, #28, #65, and #128) sampled residents who were selected for unnecessary medication review. The findings are: 1. Resident (R) #10 was admitted to the facility on [DATE]. The Surveyor was unable to locate MRRs for R #10 in the resident's electronic health record. On 02/14/2024 at 02:00 PM, Nurse Consultant #1 provided documentation related to MRR's for R #10. R #10 did not have an MRR performed for the months of October, November, and December. Nurse Consultant #1 reported that R #1 had been hospitalized on two occasions, preventing an MRR from being performed. On 02/15/2024 at 02:45 PM, the Assistant Director of Nursing (ADON) confirmed an MRR should be performed monthly for each resident to improve resident outcomes. On 02/15/2024 at 02:55 PM, the Administrator confirmed MRR's were to be performed on a monthly basis. On 02/16/2024 at 08:15 AM, Nurse Consultant #2 reported the facility did not have a policy on medication regimen reviews. 48483 2. Resident # 28 diagnoses showed Generalized anxiety disorder; Chronic pain; Contracture of left and right hip; Hereditary and idiopathic neuropathy; and Depressive episodes. The Minimum Data Set (MDS) with an Assessment Referent Date (ARD) of 12/25/23 showed a Brief Interview for Mental Status (BIMS) of 15 (13-15 indicates cognitively intact). The resident takes an antianxiety, antidepressant, anticoagulant, diuretic, opioid, and an antiplatelet medication. The Physician's Order Summary showed, active 11/1/22, Hydroxyzine hydrochloride tablet 10 milligrams (mg). Give 1 tablet by mouth two times a day. Active 5/28/21, Eliquis Tablet 2.5 mg (Apixaban). Give 1 tablet by mouth two times a day. Active, 3/31/23, Oxycodone-Acetaminophen Tablet 10-325 mg. Give 1 tablet by mouth every 4 hours as needed. Active, 1/10/24, Amitriptyline hydrochloride tablet 10 mg. Give 1 tablet by mouth at bedtime. Active, 5/27/21, Trazodone hydrochloride tablet 50 mg. Give 1 tablet by mouth at bedtime. Active, 7/31/23, Lasix Oral Tablet 40 mg (Furosemide). Give 0.5 mg tablet by mouth as needed for shortness of breath. Active 7/30/23, Lasix Oral Tablet 40 mg (Furosemide). Give 1 tablet by mouth one time a day every Monday, Wednesday, Friday, and Sunday. The Care Plan showed to administer anti-anxiety medications as ordered by the physician. Monitor the pharmacist's drug regime review for identification of potential drug interactions or problems. Monitor for side effects for anti-anxiety medication, anti-coagulant drug therapy, opioid medication, antidepressant medication, and diuretic medication. On 02/14/2024 at 09:26 AM, the Surveyor requested the MRRs (Medication Regimen Review) and GDRs (Gradual Dose Reduction) for Resident #28 for the past year. On 02/14/2024 at 2:21 PM, the Surveyor reviewed MRRs & GDRs provided by Nurse Consultant #1. They showed GDRs for 7/23 Hydroxyzine 10mg two times a day since 11/22 for anxiety with no physician's recommendation or signature; 9/23 Trazadone 50mg every night since 5/21 with no physician's recommendation or signature; 11/23 Hydroxyzine 10mg twice a day since 11/22 for anxiety with no physician's recommendation or signature. No GRR or MRR's provided for February 2023 through June 2023 or for December 2023. On 02/15/2024 at 09:13 AM, the Surveyor asked Nurse Consultant #1, are these all the MRRs and GDRs for this resident? Nurse Consultant #1 confirmed there were no more MRRs or GDRs for Resident #28. On 02/15/2024 at 03:05 PM, the Surveyor asked the Director of Nursing (DON), how does the facility ensure MRRs and GDRs are completed? The DON stated, We have a meeting with the department heads or the unit supervisors. The Surveyor asked, who is responsible for ensuring they are completed? The DON stated, I am.

Based on record review and interview, the facility failed to ensure the Quality Assurance and Performance Improvement program (QAPI) Committee developed and implemented appropriate plans of action to prevent repeated deficiencies for (561) Self Determination (677) failed to ensure bathing services, nail care and oral care were provided for residents dependent on staff, (684) Quality of Care (695) Physician Order (PO) was followed for Use of Oxygen (O2), (727) failed to ensure a Registered Nurse (RN), worked 8 consecutive hours a day seven days a week, (847) Arbitration Agreement was explained to resident/representative. These failed practices had the potential to affect 79 residents. The findings are: 1. A Recertification survey was conducted on 02/16/24 at the facility. During this survey, F561 was cited for failure to ensure a resident got to a scheduled appointment. A review of the facility' s Plan of Correction, with a correction date of 01/27/23 indicated: a. Based on interview and record review 1/23/2023 to 1/25/2023, the facility failed to ensure residents had the right to receive visitors of their choice in their home to come indoor for visits for resident #36. On 1/27/2023, Administrator and Social Services spoke with resident #36 to inform her that the visitors that were former employees were allowed to come in and visit her. b. Step #2 Identification of others with the potential of being affected: This failed practice had the potential to affect 1 resident who desired to have visitors come indoors as observed on 1/24/2023 by the Administrator. Administrator had been told by prior Management that these visitors were causing chaos in the facility and were not allowed in. All residents will be allowed visitors as long as they aren't a danger to our residents. c. Step #3 To ensure deficient practice does not recur: All staff will be in serviced by Administrator/Designee on resident's visitation policy, specifically for resident #36 by 2/15/2023. d. Step #4 Monitoring: Administrator/designee, in order to protect resident rights will allow visitors requested by the residents as long as they are not a harm to the resident or other residents in the facility. e. Step #5 QA: Administrator/Designee will present all findings to the monthly QA committee for further review and recommendations. 2. A Recertification survey was conducted on 02/16/24 at the facility. During this survey, F677 was cited for the facility failure to ensure bathing services and nail care were regularly provided for resident's dependent on staff for bathing/showers and nail care. A review of the facility's Plan of Correction, with a correction date of 01/27/23 indicated: a. Step #1 Corrective Action: Based on observation, record review and interview, the facility failed to ensure fingernails were cleaned and trimmed 1/23/2023 on resident #219. LPN cleaned and trimmed the resident ' s nails on 1/24/2023. b. Step #2 Identification of others with the potential of being affected: Based on failed practice, Nurse management/designee assessed resident's dependent on nail care by 1/27/2023. Any negative findings were corrected immediately. c. Step #3 To ensure deficient practice does not recur: Nurse Management/designee by 2/6/2023 in serviced all nursing staff to ensure all residents nails are cleaned and trimmed at least weekly. d. Step #4 Monitoring: Nurse Management/Designee will monitor 3 residents on each hall 3 times weekly for 6 weeks or until compliance is achieved to ensure nail care is being provided. e. Step #5 QA: Nurse Management/designee will present all findings to the monthly QA committee for further review and recommendations. 3. A Recertification survey was conducted on 02/16/24 at the facility. During this survey, F684 was cited for the facility failure to ensure quarterly assessment were performed for 2 residents. A review of the facility' s Plan of Correction, with a correction date of 01/27/23 indicated: a. Step #1 Corrective Action: Based on interview and record review, the facility failed to ensure residents received all of their physician ordered medications in a timely manner after admission for resident #67. Resident #67 no longer resides in the facility. On 1/25/2023, Nurse management verified that resident #67 discharged home and no longer resides in the facility. b. Step #2 Identification of others with the potential of being affected: Nurse management/designee identified on 1/27/2023, all residents who had potential to be affected and reviewed to ensure all physician ordered medications were received by resident in a timely manner after admission. Any negative findings were addressed immediately. c. Step #3 To ensure deficient practice does not recur: Nurse Management/designee by 2/6/2023, in serviced all licensed nurses on ensure that residents receive their physician ordered medications in a timely manner and nurses not documenting supplement not available or awaiting arrival from supplier. d. Step #4 Monitoring: Nurse management/designee will monitor 5 residents physician orders weekly X 6 weeks to ensure medications are being received in a timely manner. Any negative findings will be corrected immediately. e. Step #5 QA: Nurse Management/Designee will present all findings to the monthly QA committee for further review and recommendations. 4. A Recertification survey was conducted on 02/16/24 at the facility. During this survey, F695 was cited for the facility failure to follow physician order with Oxygen [O2] administration. A review of the facility's Plan of Correction, with a correction date of 01/27/23 indicated: a. Step #1 Corrective Action: Based on observation, record review, and interview, the facility failed to provide specialized care needs for the provision of respiratory care by administering oxygen at the prescribed rate for 3 residents and failed to date the tubing and humidifier bottle for 1 resident. Nurse management assessed residents #16, #45 and #219 to ensure they are receiving oxygen at the correct rate on 1/25/2023. Nurse management observed resident #55 to ensure oxygen tubing and humidifier bottle were dated per professional standard. b. Step #2 Identification of others with the potential of being affected: Failed practice had potential to affect 14 residents as identified by Nurse management/designee on 1/25/23. On 1/25/2023, residents were assessed to ensure oxygen was administered at prescribed rate and oxygen tubing and humidifier bottles were dated. Any negative findings were corrected immediately. c. Step #3 To ensure deficient practice does not recur: Nurse Management/Designee in serviced by 2/7/2023 all licensed nurses to check flow rates of oxygen and to ensure all humidifier bottles and tubing is dated. d. Step #4 Monitoring: Nurse Management/designee will monitor oxygen flow rate to match physician orders and check to ensure tubing and humidifier bottles are dated on 3 residents weekly X 6 weeks or until compliance is achieved. Any negative findings will be corrected immediately. e. Step #5 QA: Nurse Management/designee will present all findings to the monthly QA committee for further review and recommendations. 5. A Recertification survey was conducted on 02/16/24 at the facility. During this survey, F727 was cited for the facility failure to ensure a Registered Nurse (RN), worked 8 consecutive hours a day, seven days a week. A review of the facility's Plan of Correction, with a correction date of 02/26/23 indicated: a. Step #1 Corrective Action: Based on interview and record review, the facility failed to ensure there was RN coverage for at least 8 consecutive hours a day, 7 days a week. Weekend RNs had clocked out after 7.75 [hours] or weren ' t there consecutively for 8 hours. RN worked then left and then returned. b. Step #2 Identification of others with the potential of being affected: Facility has now hired DON as of 2/7/2023. DON will clock in/out daily to ensure that all days worked are accounted for. Administrator/designee used census to identify all 58 residents having the potential to be affected. c. Step #3 To ensure deficient practice does not recur: Administrator/designee in serviced by 2/7/2023, DON and all RN s that will be working weekly and/or weekends that they must be in facility for a consecutive 8 hours, 7 days per week to be in compliance with RN coverage guideline. d. Step #4 Monitoring: Administrator/designee will monitor RN time sheets daily X 6 weeks or until compliance is achieved. e. Step #5 QA: Administer/designee will present all findings to the monthly QA committee for further review and recommendations. 6. A Recertification survey was conducted on 02/16/24 at the facility. During this survey, F847 was cited for the facility failed to ensure the Arbitration agreement was explained in a manner the resident/representative could understand. A review of the facility' s Plan of Correction, with a correction date 02/26/23 a. Step #1 Corrective Action: Based on record review and interviews from 1/23 to 1/26, the facility failed to ensure the Binding Arbitration Agreement stated the resident and/or resident's representative were not required to sign the agreement, allowed the resident and/or representative to communicate with OLTC Ombudsman and was not required as part of admission process for 3 residents who were contacted. b. Step #2 Identification of others with the potential of being affected: Failed practice had potential to affect 39 residents who signed Binding arbitration agreements as identified by Administrator/designee on 1/27/2023. Steps have been taken to add the missing language into the facility s arbitration agreement pursuant to federal regulations by Administrator by 2/8/2023. c. Step #3 To ensure deficient practice does not recur: On 1/27/2023, Administrator in serviced the clinical liaison, social services/hr and BOM on ensuring that residents and their representatives understand the arbitration agreement and that all areas covered in the regulation must be present in the arbitration agreement before it is signed. d. Step #4 Monitoring: Administrator/designee will monitor weekly for 6 weeks or until compliance is achieved all signed arbitration agreements. Any negative findings will be corrected immediately. e. Step #5 QA: Administrator/Designee will present all findings to the monthly QA committee for further review and recommendations. 7. On 02/16/24 at 11:16 am the Administrator was interviewed: a. When a deviation from expected performance or a negative trend occurs how does the QAA committee know? We go over what's gone wrong, we write a PIP, and if something isn't working, we have to come up with something different. b. Is there a mechanism for staff to report quality concerns to the QAA committee? Yes, we have stand up meetings every morning and have a look back. Any problems that come up between now and the next meeting is addressed. c. How the facility decides which issues to work on? If you have problems, you work on them all. Review of PIPS, adjustment with tasks. Complete audit. d. How the facility know that corrective action has been implemented, is effective, and improvement is occurring? Because you will not have recurring issues with the problem if it is working. e. Policy titled, QAPI Improvement Activities, provided by the Administrator on 02/12/24 at 11:15 am documented Purpose The facility will take actions aimed at performance improvement and, after implementing those actions, measure its success, and track performance to ensure that improvements are realized and sustained .a. Develop and implement appropriate plans of action to correct identified quality deficiencies .

Based on observation, interview, and record review the facility failed to ensure that staff washed their hands in between residents when administering medication for 1 (Resident #53) sampled resident, failed to ensure an uncapped feeding tip was not connected to the percutaneous enteral gastrostomy (PEG) for 1 (Resident #53) sampled resident, and failed to ensure that dirty linen did not touch employee clothing. The findings are: 1. On 2/14/24 at 08:02 AM, Licensed Practical Nurse (LPN #3), went into Resident (R) #22's room to obtain vitals then returned to the medication cart without sanitizing hands before preparing medications for R #53. 2. On 2/14/24 at 08:28 AM, LPN#3 administered medication to R #53 then removed the tube feeding line hanging from the pole which was uncapped and connected to the PEG. 3. On 2/14/24 at 08:45 AM, LPN#3 was asked, What should you do after coming out of one resident room before going into another resident room to give medications? LPN#3 stated, Wash my hands. LPN #3 was asked, What should be on the end of a tube feeding line to protect the tip from being contaminated. LPN#3 stated, A cap. LPN #3 was asked, Should an uncapped tube feeding be connected to a PEG tube? LPN #3 stated, No it should not. LPN #3 was asked, What negative outcome could happen from connecting uncapped tubing? LPN #3 stated, They could get an infection. 4. On 2/15/24 at 4:07 PM, the Nurse Consultant provided a policy titled, Hand Hygiene, which documented, . 2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors .3. Hand hygiene products and supplies (sinks, soap, towels, alcohol-based hand rub, etc.) shall be readily accessible and convenient for staff use to encourage compliance with hand hygiene policies . 5. On 2/14/24 at 7:58 AM, Certified Nurse Aide (CNA) #1 was observed coming out of room [ROOM NUMBER] carrying linen in a white plastic bag. Half of the linen was in the bag, and the other half was sticking out of the bag touching (the CNA ' S) clothes. CNA #1 was asked, Should the linen touch your clothes during transport? CNA #1 stated, It shouldn't be, but that's the size of bags we got. On 2/15/24 at 3:46 PM, Nurse Consultant #2 provided a form titled, Infection Control. It documented, .Place and transport contaminated laundry in bags or containers in accordance with established polices . 37634

Based on observation and interview, the facility failed to ensure a safe environment on the 100 Hall. This potential failed practice had the potential to affect 7 (Residents # 6, #8, 17, #51, #55, 72, and #284) sampled residents who could independently locomote. The findings are: On 02/13/24 at 02:18 PM, the 100 Hall shower room door was left half-way open with a black mesh basket hanging on the inside of the door and keys left in the doorknob for 5 minutes with staff walking around the open door and not shutting it. On 02/13/24 at 02:23 PM, the black mesh bag contained the following items four 4-ounce bottles of aftershave with aloe vera, one 4-ounce bottle of baby oil, three 1.5-ounce bottles of anti-perspirant, two 4-ounce bottles of moisturizing lotion, and 3 disposable razors. All bottles showed caution external use only, avoid contact with eyes, keep out of reach of children. The anti-perspirant label documented instructions to contact poison control if accidentally swallowed. On 02/13/24 at 02:31 PM, Certified Nursing Assistant (CNA) #5 was asked, Should the shower door be left open with the keys in the door? CNA #5 stated, It should not. CNA #5 was asked, What is stored in the door? CNA #5 stated, Lotion, razors, shaving cream, baby oil, after shave, and anti-perspirant. On 02/13/24 at 02:33 PM, Licensed Practical Nurse (LPN) #3 was asked, Should the shower door be left open with keys in the door? LPN #3 stated, No, it shouldn't be. CNA #3 was asked, Was the shower door open with the keys in the door? LPN #3 stated, Yes, it was. On 02/15/24 02:39 PM, the Director of Nursing (DON) confirmed the shower door on 100 Hall was left open and unattended with the keys left in the doorknob. A document provided by Nurse Consultant #1 on 2/16/24 at 1:11 PM titled, Accidents and Hazards Policy with an effective date of 8/2021 and a revised date of 5/20/2022 documented, .the facility strives to ensure the resident environment remains as free of accident hazards as is possible .

Based on record review and interview, the facility failed to ensure adequate supervision and monitoring was provided to prevent elopement for 1 (Resident #1) of 3 (#1, #2 and #3) case mix residents who were at risk for elopement, as evidenced by a failure to develop and implement interventions and staff training to ensure that cognitively impaired residents who resided in the facility were closely monitored and their whereabouts accounted for when a facility door alarm sounded. This failed practice resulted in Non-Compliance at the level of Immediate Jeopardy, which caused injury and harm for Resident #1, who eloped from the facility, was missing for approximately 4 hours, fell into a ditch, sustained multiple injuries, and became Hypothermic due to exposure. This failed practice had the potential to cause more than minimal harm to 22 residents who were at risk for elopement, as documented on a list provided by the Administrator on 05/01/23 at 10:36 AM. The Director of Nursing (DON) and Consultant #2 were informed of the Immediate Jeopardy situation on 05/02/23 at 11:25 AM. The findings are: 1. Resident #1 was admitted to the facility on [DATE] and had diagnoses of Vascular Dementia, Major Depressive Disorder, and Anxiety Disorder. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date of 04/10/23 documented the resident scored 1 (0-7 indicates severely impaired) on the Brief Interview for Mental Status (BIMS), was ambulatory, wandering behavior occurred daily, and did not have a wander alarm. 2. The Wandering Risk Scale dated 10/21/22 documented, Score: 13 .Category: High Risk to Wander .Is ambulatory . Has history of wandering (past hospitalization or history from resident/family) .Has wandered in the past month .Medical diagnosis of dementia/cognitive impairment .resident exit seeking during admission assessment . 3. The Admission Summary Note Text dated 10/21/22 at 14:45 [2:45] PM documented, .Exit seeking, [named ankle guard] placed to left wrist per safety protocol . 4. The Care Plan with an initiated date of 10/24/22 documented, Focus: Wanders associated with judgment or reasoning deficit and is at risk for elopement due to this as well as the potential for falls and nutritional deficits 10/21/22, 10/22/22, 10/23/22, 11/02/22, 11/08/22, and 12/26/22, Goal: to receive no injury due to wandering this review period Date Initiated: 10/24/22, Will have fewer episodes of attempting to leave facility without staff/family member this review period Date Initiated: 10/24/22, Will wander less frequently this review period Date Initiated: 10/24/22. Intervention: [named ankle guard] to remain in place Date Initiated: 10/24/22. The Care Plan did not address the need to monitor the resident's whereabouts at any particular frequency. 5. The Administration Note dated 12/26/22 at 12:15 PM documented, .History of exit seeking .Wandering noted this shift, attempted to exit front door x2 . 6. The Entry Note Text dated 03/29/23 at 17:15 [5:15] PM documented, .Wandering behaviors continue . 7. A Witness Statement from Certified Nursing Assistant (CNA) #2 dated 04/28/23 at 2:45 AM documented, Resident #1 was toileted at 2 AM. At 2:20 AM, the West 2 door alarm was triggered via notification on the pager when she eloped. 8. The [named city] Police Report with a Dispatch date/time 04/28/23 at 3:31 AM documented, .I was told .that if you push on the side door long enough the door opens. I then went to observe the door that I was told would open and I was able to push the door causing it to open ., officers .Departed date/time 04/28/23 at 5:27 AM ., a missing persons report would be opened, and when an officer was dispatched that Resident #1 was found .[Housekeeping Supervisor] said she first laid eyes on [Resident #1] at 6:18 AM . 9. A Witness Statement from the Housekeeping Supervisor dated 04/28/23 at 5:41 AM documented, Resident #1 was found at 6:14 AM at the corner of [named] streets near [named] hospital. 10. The emergency room Report dated 04/28/23 at 7:41 AM, provided by the Administrator on 05/01/23 documented, Resident #1 arrived at 6:36 AM, via ambulance and Resident #1 sustained Hypothermia and a Closed displaced fracture of the first cervical vertebra .Resident #1 was then transferred to [named] Hospital. 11. The Hospital Report dated 04/29/23 at 9:44 AM, provided by the Administrator on 05/01/23 documented, .transferred from Hospital .Neurosurgery was consulted for the type II Odontoid Fracture .wearing the cervical collar . 12. On 05/01/23 at 1:03 PM, the Surveyors accompanied the MDS Coordinator and Registered Nurse (RN) Consultant #1 to where Resident #1 was located 4 hours after she had eloped. The MDS Coordinator stated, The West Door alarm is what was sounding. No one saw her come out. He pressed the West 2 Door bar until the alarm began beeping. The alarm was barely audible to the Surveyors standing 2-3 feet from the door. The MDS Coordinator stated the sound for the [named ankle guards] were a bit louder. He walked out the door across the facility parking lot, through a break in the fence, down the pathway near the apartment complex residential smoking area, across a road near ER [emergency room ] entrance, through the ER parking lot, through the hospital back parking lot, through the parking lot behind a vision clinic, across the parking lot near the helicopter pad, down [named] street, across [named] street near a blind curve to a small hill, and down the hill which led to a cement water drainage ditch. The MDS Coordinator pointed to a location in the ditch where Resident #1 was found. He stated the Smearing on the ground was more visible before the rain the other day .where she] had scooted from where she landed. Utilizing her fitness watch, RN Consultant #1 calculated the distance from the West 2 door to the location of the water drainage ditch where Resident #1 was found to be 0.2 miles. 13. On 05/01/23 at 1:43 PM, the Surveyor asked Licensed Practical Nurse (LPN) #2, What do you do if a resident is missing or has eloped? LPN #2 replied, If you hear the alarm on the door, you go check it, look outside and around the door. If you don't find them, we do head counts. The Surveyor asked, Who do you notify if a resident is missing? LPN #2 replied, The DON and the Administrator. The Surveyor asked, When do you notify the DON and the Administrator? LPN #2 replied, Immediately. The Surveyor asked, Who notifies the DON and the Administrator? LPN #2 replied, The nurse on the floor. The Surveyor asked, When is the Office of Long-Term Care (OLTC) notified if a resident elopes from the facility? LPN #2 replied, I don't know. The Surveyor asked, When was the last time you were trained and in-serviced on elopement/missing residents and reporting of resident's elopement? LPN #2 replied, on Friday 04/28/23. The Surveyor asked, Were you here when Resident #1 eloped on 04/28/23? Tell me about what happened. LPN #2 replied, I got here at 5:45 AM and they [staff] were still looking for Resident #1 [her]. They found her across from the hospital .I got a call from, the Housekeeping (HK) Supervisor, that Resident #1 had been found. I got a blanket and ran it to HK Supervisor and Resident #1. There were 2 nurses and 3 other staff members with Resident #1. The Surveyor asked LPN #2, What was Resident #1's condition? LPN #2 replied, Resident #1 was sitting on the ground hunched over. The Surveyor asked, Was it cold outside? LPN #2 replied, Yes, it was pretty cold out there. The Surveyor asked, Then what did you do? LPN #2 replied, I left and came back to the building to do count. 14. On 05/01/23 at 1:54 PM, the Surveyor asked Certified Nursing Assistant (CNA) #3, What do you do if a resident is missing or has eloped? CNA #3 replied, Check doors outside, notify the police, and check the facility. The Surveyor asked, Who do you notify if a resident is missing? CNA #3 replied, The Charge Nurse, the DON, the Administrator, everyone. The Surveyor asked, When do you notify the DON and the Administrator? CNA #3 replied, Immediately, especially if you can't find them. The Surveyor asked, When is the OLTC notified if a resident elopes from the facility? CNA #3 replied, Not sure, I assume immediately. The Surveyor asked, When was the last time you were trained and in-serviced on elopement/missing residents and reporting of resident's elopement? The CNA #3 replied, On Friday, 04/28/23. The Surveyor asked, Were you here when Resident #1 eloped on 04/28/23? Tell me about what happened. CNA #3 replied, No, I worked day shift. The Surveyor asked Did Resident #1 wander daily/or exit seek? The CNA #3 replied, Yes, in the facility. 15. On 05/01/23 at 2:04 PM, the Surveyor asked Laundry Assistant #1, What do you do if a resident is missing or has eloped? Laundry Assistant #1 replied, Check with the nurse, follow instructions, and search for the resident. The Surveyor asked, Who do you notify if a resident is missing? Laundry Assistant #1 replied, Stop the resident and call the nurse. The Surveyor asked, When do you notify the DON and the Administrator? The Laundry Assistant #1 replied, First or immediately. The Surveyor asked When is the OLTC notified if a resident elopes from the facility? Laundry Assistant #1 replied, I don't know. The Surveyor asked, When was the last time you were trained and in-serviced on elopement/missing residents and reporting of resident's elopement? Laundry Assistant #1 replied, In April 2023. The Surveyor asked, Were you here when Resident #1 eloped on 04/28/23? Tell me about what happened. Laundry Assistant #1 replied, No. The Surveyor asked, Do you have Silver Alert drills? Laundry Assistant #1 replied, No, not in the last little bit. The Surveyor asked, Did Resident #1 ever get out before 04/28/23? Laundry Assistant #1 replied, not that I know of. 16. On 05/01/23 at 2:14 PM, the Surveyor asked the Dietary Manager (DM), What do you do if a resident is missing or has eloped? The DM replied, Dietary goes outside and search the back area. The Surveyor asked, Who do you notify if a resident is missing? The DM replied, The nurse, the DON, and the Administrator. The Surveyor asked, When do you notify the DON and the Administrator? The DM replied, After we have looked at the book, (the elopement book, residents with wander guards), and look for the resident, if we can't find them, then we notify the DON and the Administrator. The Surveyor asked When is the OLTC notified if a resident elopes from the facility? The DM replied, Within 24 hours. The Surveyor asked, When was the last time you were trained and in-serviced on elopement/missing residents and reporting of resident's elopement? The DM replied, I left before the in-services were started on Friday 04/28/23. The Surveyor asked, Were you here when Resident #1 eloped on 04/28/23? Tell me about what happened. The DM replied, No. The Surveyor asked, Did Resident #1 wander daily/exit seek? The DM replied, Yes, and wandered and had a [named ankle guard]. The Surveyor asked, Do you have Silver Alert drills? The DM replied, I'm not sure. The Surveyor asked, Did Resident #1 ever get out before 04/28/23? The DM replied, No, only Friday 04/28/23. 17. On 05/01/23 at 2:26 PM, CNA #2 stated, I was doing my rounds and we went to look at the door and we find out that Resident #1 was not in the facility. We looked all through the facility and didn't find her. And then we checked the doors. The back door is an emergency door and it opens pretty easily. The Surveyor asked when was the last time she saw Resident #1? CNA #2 stated, Around 2 AM I helped her to the bathroom. I try to get her back to her room, but she didn't want to go. She normally stays in the nurses' station or wanders around. The Surveyor asked what CNA #2 to describe the process for when a resident is noted to be missing. CNA #2 stated, We log it in elopement book, we count everybody. We open every door and check. The nurse calls the police. There was four of us. Three of us stayed inside with the residents and one went outside. The Surveyor asked who was notified when someone had eloped. CNA #2 stated, This is the first time that this has happened to me. I didn't tell anyone. The nurse called the DON and police. I don't know who to call. When it happens, I don't do that. The nurse does. I was hoping she was inside somewhere in one of the recliners. 18. On 05/01/23 at 2:28 PM, the Administrator provided a document titled, Door Alarm and Battery Checks, which documented, .04/19/23 All Good 04/28/23 Good 04/29/23 Good. The Administrator stated the facility did not have a set frequency for the alarms to be checked. 19. On 05/01/23 at 3:32 PM, the Surveyor asked LPN #1 when she was notified of Resident #1's elopement. LPN #1 stated, We were just going about our night and the alarm went off on the pager for the West 2 door and RN #1 didn't know the alarm code or how to turn it off and the door was open. I did a quick sweep of the outside. We did a sweep of the inside. The Surveyor asked who she was supposed to notify. LPN #1 stated, I called the police after I called the DON. I called within the hour. It was about 40 min [minutes]. I know I should have called sooner but I hadn't realized how much time had passed. We started at one end and went through every area. 20. On 05/01/23 at 3:46 PM, the Surveyor asked the Housekeeping (HK) Supervisor, via a telephone interview, What do you do if a resident is missing or has eloped? The HK Supervisor replied, Staff are notified, and we search. If you find the resident, then you notify them. I was on my way to work, and staff texted me and said Resident #1 was missing. The Surveyor asked, Who do you notify if a resident is missing? The HK Supervisor replied, the DON and Administrator, and the police. The Surveyor asked Who notifies the DON, the Administrator, and the police? The HK Supervisor replied, The nurses. The Surveyor asked, When do you notify the DON and the Administrator? The HK Supervisor replied, Immediately. The Surveyor asked, When is the OLTC notified if a resident elopes from the facility? The HK Supervisor replied, I'm not sure. The Surveyor asked, When was the last time you were trained and in-serviced on elopement/missing residents and reporting of resident's elopement? The HK Supervisor replied, On Friday 04/28/23. The Surveyor asked, Were you here when Resident #1 eloped on 04/28/23? Tell me about what happened. The HK Supervisor replied, I was on my way to work when I got the text that Resident #1 was missing for 2 hours. I clocked in, it was true, (Resident #1 was missing), I went out back and I got in my car and drove around the hospital and the clinic, as I go around the curve around the hospital, I saw her sitting on the ground, in the drainage ditch. The Surveyor asked What was the temperature outside? The HK Supervisor replied, It was cool. The Surveyor asked Then what did you do? The HK Supervisor replied, I got out of my car, I saw Resident #1 had blood on her face. The Surveyor asked, Did she complain of any pain? The HK Supervisor replied, No. The Surveyor asked, Then what did you do? The HK Supervisor replied, I called LPN #2, and told her to bring a blanket and the DON was right next to her. The DON notified Emergency Medical Services (EMS) and the police at that time, I stayed with Resident #1 until EMS got there. The Surveyor asked Who took the Resident #1 to the ER [emergency room ] and which one? The HK Supervisor replied, EMS took her to ER [named hospital emergency room ], up the hill and through the parking lot. 21. On 05/01/23 at 6:23 PM, the Surveyor asked LPN #1 if she could hear the alarms on the doors or the pager. LPN #1 stated, The front door is loud. West 2 door is a light beep. It is hard to hear. I haven't heard that one [door by therapy room]. The pager is just what you set it to, and it rings like someone that has pressed a call light. You have to really pay attention to it, or you wouldn't know it was an emergency. The Surveyor asked if she was informed of any new tasks, process, or monitoring the doors that were put in place since Resident 1's elopement. LPN #1 stated, No, I have not been told to check it more or anything like that. 22. On 05/01/23 at 6:27 PM, the Surveyor asked RN #1 if she could hear the door alarms. RN #1 stated, The one by the front door is very loud. The one on the West you cannot hear it at all. The pager is pretty annoying, but I could not hear it from down the hall. I have never heard that one [door near therapy] go off. The Surveyor asked if she was informed of any new tasks, process, or monitoring the doors that were put in place since Resident #1's elopement. RN #1 stated, I was not told that we needed to do anything different. 23. On 05/01/23 at 6:35 PM, the Surveyor asked CNA #1 when she was notified that Resident #1 had eloped. CNA #1 stated, I was on a hall by myself and helping residents and a nurse come down and told me and asked if I saw her and I said no. We just kept looking. I've been there [AGE] years. I did not hear the door alarm. I was on the East Hall, so I [NAME] couldn't hear the alarm .There were 4 of us .I looked out the front door, but LPN #1 went around the building several times and then got in her car and drove around. If I am down in the front, I can hear the alarm and I can hear it because it shows up on the pager. The Surveyor asked if she could hear the pager and the door alarms. CNA #1 stated, Yeah, we can turn the pager up and down. On the East Hall, it depends what room you are in and how much noise they are making. The Surveyor asked who was to be notified. CNA #1 stated, First, they call the DON and then the Police Dept [department]. The Surveyor asked if they notify anyone else and who was responsible for the notifications. CNA #1 stated, I don't know. LPN #1 did all the notifying. We need a lot more help up there. There just isn't enough of us. 24. On 05/02/23 at 8:39 AM, the Surveyor asked the DON, What do you do if a resident is missing/elopes? The DON replied, Call the police and start looking. The Surveyor asked, Who do you notify if a resident is missing? The DON replied, Somebody notifies me and the Administrator, we call the police. The Surveyor asked, When are the DON and Administrator notified? The DON replied, Immediately upon discovering if a resident is missing. The Surveyor asked, When is the OLTC notified? The DON replied, I try with in the two hours, this one did not get done in the two hours because we were looking for Resident #1. The Surveyor asked, When was the last time the facility was trained and in-serviced on elopement/missing residents, and reporting of resident's elopement? The DON replied, On the date of 04/28/23. The Surveyor asked, Did the facility lose sight of Resident #1 when she eloped on 04/28/23? The DON replied, Yes they did. The Surveyor asked, How long was Resident #1 out of the sight? The DON replied, I was notified at 3:30 AM, and LPN #1 told me the door had went off at 2:45 AM. The Surveyor asked, Did Resident #1 wander daily/exit seek? The DON replied, I've never seen Resident #1 exit seek, she wandered in the facility or followed us. The Surveyor asked, Do you or the facility have Silver Alert drills? The DON replied, We had not had any. The Surveyor asked, Did Resident #1 ever get out before 04/28/23? The DON replied, Not that I'm aware of, that door [West 2] is not loud. The Surveyor asked, Why/when are [named ankle guards] placed on the Care Plan? The DON replied, To prevent these things form happening, they should be on the Care Plan when they admit. The Surveyor asked When staff check the exit doors, and the [named ankle guards], what are they checking for? The DON replied, To make sure they are going off, making sure they are audible, and to make sure they are functioning. The Surveyor asked When Resident #1 eloped, what system for monitoring the doors were put in place to ensure residents didn't elope? The DON replied, [named Security Service Company] was here the next day, and the regional maintenance staff was notified, not sure what else mechanically was installed. I had not been checking the [named ankle guards] before this. The Surveyor asked, How are staff notified when the doors alarm, especially at night? The DON replied, They have a pager they carry, and it will alarm and say like which door. The Surveyor asked, When was the family supposed to be notified of Resident #1's elopement? The DON replied, Immediately. The Surveyor asked, When the pager went off, did it notify staff the [named ankle guard] alarm went off the night of 04/28/23? The DON replied, They said it did. LPN #1 told me she heard the door alarm go off and CNA #2 said West 2 door, they said they didn't hear the [named ankle guard] alarm go off, and none of them heard the [named ankle guard] alarm go off. The Surveyor asked, Who carries the pagers? The DON replied, The CNA's have the pagers, they hand them off every shift, they should be kept on their person, it's the wireless call light system. The nurses don't have to carry them. The Surveyor asked, Is there a difference between door alarms and call light notification on the pagers? The DON replied, No. The Surveyor asked Did you put/assign anyone to monitor the doors hourly or every five minutes, etc [et cetera] .after Resident #1 eloped? The DON replied, I did not. The Surveyor asked the DON, Were you here when Resident #1 eloped on 04/28/23? Tell me about what happened. The DON replied, I got the phone call at 3:30 AM that Resident #1 was missing. I called the Administrator. I told the staff (at the facility) to call the police, they hadn't called the police prior to that. The Surveyor asked, Didn't staff contact the police prior to that? The DON replied, No they had not. The DON stated, I got here (the facility) at 4 AM, I also told them to start a head count. The Surveyor asked the DON, did they staff know what to do? The DON replied, Well they were looking for Resident #1. The Surveyor asked the DON, then what happened? The DON replied, I got here and started a physical search myself, then met up with the [named Police Officer], then went outside and did the same thing. The Surveyor asked, When did you call the family? The DON replied, At 5:26 AM, that was my fault, I was concentrated on looking for the resident. The Surveyor asked Who found the resident? The DON replied, The HK Supervisor. The Surveyor asked, When did they find Resident #1? The DON replied, Around 6 AM. The Surveyor asked Where was she found? The DON replied, At the bottom of the hill, in a ditch, down the slope, across from the hospital. Staff took blankets and stayed with her until EMS got there. The Surveyor asked, What was the temperature and the weather like? The DON replied, It was 52 degrees, morning coolness. The Surveyor asked, What did Resident #1 look like, what was her condition when found? The DON replied, Non-verbal, there was blood on the right corner of the mouth. She was hunched over and holding her right arm. The Surveyor asked, How far/what was the distance from the door to where Resident #1 was found? The DON replied, We guessed around 1000 feet. The Surveyor asked to describe the terrain. The DON stated, There were tree roots, hills, rocks, unlevel terrain, buildings, roads. The Surveyor asked, What injuries did Resident #1 sustain after elopement? The DON replied, A cervical spine fracture at the C1-C2 and a broken nose, the report said the hospital recommended surgery, but the family said no. The Surveyor asked, Did Resident #1 have hypothermia? The DON replied, I think the body temperature was 92 degrees, so yeah. 25. On 05/02/23 at 9:35 AM, the Surveyor asked the Administrator, What do you do if a resident is missing/elopes? The Administrator replied, Begin searching, call the police, call department heads, call the family, and call the doctor. The Surveyor asked, When do you notify the DON and the Administrator? The Administrator replied, Immediately upon seeing something is not right. The Surveyor asked, When is the OLTC notified if a resident elopes from the facility? The Administrator replied, Within two hours need to notify, it was later because we were searching for Resident #1. The Surveyor asked, When staff check the exit doors and wander guards, what are they checking for? The Administrator replied, To make sure alarms sound off, the locks are working properly, and the doors open correctly. The Surveyor asked, When Resident #1 eloped, what system for monitoring the doors were put in place to ensure residents didn't elope? The Administrator replied, We had someone monitoring those doors from the time of elopement, [named Home Security Company] was called, no one came in, they didn't show up till yesterday. The Surveyor asked, Were you here when Resident #1 eloped on 04/28/23? Tell me about what happened. The Administrator replied, I got the call and came in. The Surveyor asked, When did you get the call? The Administrator replied, On 04/28/23 at 3:46 AM, I drove up here and started making phone calls. The Surveyor asked, Who notified you? The Administrator replied, The DON, she was headed there, and she said it was West 2 door, but she said she was told it was West 1 door. The Surveyor asked, When was the family notified? The Administrator replied, Around 5:26 AM. The Surveyor asked, When was the Physician notified? The Administrator replied, Around the same time the family was notified. The Surveyor asked, Who found Resident #1? The Administrator replied, The HK Supervisor, she was out driving around and called and said she found her. The Surveyor asked, Where was she found? The Administrator replied, Across from the hospital in a drainage ditch, Resident #1 had a blanket around her, the temp was 52 degrees. The Surveyor asked, Did she complain of pain? The Administrator replied, She did not have or complain of pain until they went to put her in the ambulance. The Surveyor asked, What did Resident #1 look like/what was her condition when found? The Administrator replied, She had some blood on the face. The Surveyor asked, Where did Resident #1 go after being found? The Administrator replied, EMS took her to [named Hospital ER] then was transferred to [named] hospital. The Surveyor asked What was the hospital diagnosis? The Administrator replied, A hairline fracture in the neck, a possible broken nose, and her body core temperature was low. 26. On 05/01/23 at 2:03 PM and again on 05/02/23 at 9:35 AM, the Surveyor asked the Administrator to provide documentation of door monitoring prior to and since the 04/28/23 elopement. The Administrator failed to provide documentation of consistent/constant monitoring of the doors until [named Home Security Company] could fix the volume of the alarms. 27. Two documents titled, Door Checks, provided by the Administrator on 05/02/23 at 10:12 AM and 10:17 AM documented, Alarm checks on 6 occurrences on 04/28/23 and 1 occurrence on 04/30/23 and 1 check on 04/28 and 1 on 04/29 both indicated Good. 28. On 05/02/23 at 11:19 AM, the DON documented the location of the West 2 door and the location the resident was found on a printed map of the area. The facility's Plan of Removal was accepted by the State Agency on 05/02/23 at 12:58 PM. 1. The resident affected has been discharged home on hospice. On 05/02/23 administrator supervised the in-service of staff on duty immediately to ensure that staff kept pager alarms on their person at all times to reduce delay in response time. On 05/02/23 Administrator supervised the immediate placement of staff on door watch at West 2 door to ensure monitoring of doors at all times, On 05/02/23, Administrator supervised the contacting of alarm vendor to see when annunciator repair will be done to ensure alarm is loudly audible. 2. 2 residents had the potential to be affected that have impaired cognition and history of wandering. On 05/02/23 Administrator visually assessed all doors with elopement alarm to ensure the alarms are loudly audible, including 2 West, with no further negative findings Administrator will validate the installation and annunciator is loudly audible after repair is completed. Administrator will supervise the temporary placement of red alarms that are loudly audible until speakers can be added to elopement alarm system. 3. Administrator will supervise the in-service of clinical staff before tour of duty on ensuring that staff keep pager alarms on their person at all times. Administrator will supervise the education of maintenance supervisor on ensuring elopement alarms of loudly audible Administrator will in-service department heads on ensuring door monitoring when the elopement alarm is not loudly audible. 4. Administrator/designee using a monitoring log will round on each shift to ensure that staff keep pager alarms on their person at all times to reduce delay in response time daily x5 then 1 shift 3 x week x 8 weeks or until compliance is achieved making corrections as necessary and reporting negative findings to the administrator. Administrator/designee using a monitoring log will round each shift to visually assess the placement of staff on door watch at West 2 to ensure monitoring of doors at all times daily x5 days then 3 x week x 8 weeks or until compliance is achieved, making corrections as necessary, and reporting negative findings to the administrator. Administrator/designee using a monitoring log will visually/auditorily assess the elopement alarms to ensure they are loudly audible to ensure residents with impaired cognition and history of wandering are properly supervised to prevent elopement harm daily x 5 then 3 x week x 8 weeks or until compliance is achieved making corrections as necessary and reporting negative findings to the administrator. 5. Administrator/designee will report negative findings to the QAPI committee monthly for review and recommendations

Based on record review and interview, the facility failed to ensure allegations of possible staff-to-resident abuse and neglect that were documented in the facility's grievance log were identified as possible abuse and neglect and were reported immediately to the Administrator / Designee, which resulted failure to conduct thorough investigations, failure to implement appropriate measures to protect all residents from further potential abuse or neglect, and failure to report the allegations to local law enforcement and the Office of Long Term Care (OLTC) for 12 (Residents #12, #18, #19, #20, #21, #22, #23, #24, #25, #26, #27 and #28) of 12 case mix residents whose allegations of possible staff-to-resident abuse or neglect were documented on Grievance / Complaint Reports. The failed practice also resulted in failure to promptly identify a pattern of repeated allegations against a specific Certified Nursing Assistant (CNA #8) and take appropriate corrective measures to prevent further potential abuse or neglect by that CNA for 6 (Residents #12, #18, #19, #20, #24 and #27) of the 12 case mix residents whose allegations of possible staff-to-resident abuse or neglect were documented on Grievance / Complaint Reports (see identifiers above). The failed practices resulted in immediate jeopardy, which caused or could have caused serious harm, injury, or death to Residents #12, #18, #19, #20, #21, #22, #23, #24, #25, #26, #27 and #28, and had the potential to cause more than minimal harm to all 98 residents who resided in the facility, as documented on the Roster Matrix provided by the Administrator on 11/28/16. The Administrator was notified of the Immediate Jeopardy on 11/30/16 at 12:05 p.m. The findings are: 1. On 11/30/16 at 8:00 a.m., the facility's grievance logs dated June 2016 through November 2016 were reviewed. Twelve of the grievances, that were reviewed at this time, documented possible allegations of staff-to-resident abuse or neglect. None of the 12 allegations included evidence to indicate they were reported to the Administrator, investigated or that appropriate protective measures were implemented to minimize the potential for further abuse / neglect. The allegations involved the following residents and, for the first 6 residents below (Residents #27, #19, #24, #18, #20 and #12), named CNA #8 as the accused party, either on the grievance form itself or on the attached documentation: a. Resident #27 had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) with an assessment reference date (ARD) of 8/11/16 documented the resident scored 10 (8-12 indicates moderately impaired) on a Brief Interview for Mental Status (BIMS), required extensive assistance of 2-plus people for bed mobility, transfer and toilet use; limited assistance of 1 person for personal hygiene and was frequently incontinent of bladder. 1.) The Plan of Care dated as initiated on 8/12/16 documented, .Needs assist of staff for basic needs including: dressing, incontinent care, bathing, grooming, personal hygiene . Interventions / Tasks: .assist of 1 to 2 staff for personal hygiene . needs assist of 2 staff for toilet use. Incontinent of bowel and bladder with change and skin care PRN (as needed) . 2.) A Grievance Report dated 8/26/16 at 9:00 a.m. documented, (Resident #27) stated that a nurse's aide had become upset with her for having an accident (incontinence) the night before. She stated that the aide cussed at her and told her she should have been able to hold her bladder. She said the nurse's aide said 'I'm not your maid'. (Resident #27) stated she felt upset about the experience and that she was 'still a person'. She felt apologetic about having the accident . The Department Response dated 8/27/16 at 8:00 a.m. documented, The CNA (Certified Nursing Assistant) wrote a response, attached, however to satisfy this grievance, the CNA is not allowed to care for this resident . The grievance report did not identify which CNA was accused by the resident; however, the attached witness statement was signed by CNA #8. 3.) The written attachment dated 8/27/16 and signed by CNA #8 documented, I went into (Resident #27's) room to help (another CNA) with a complete bed change and asked resident if she was ok because I know she go to the BSC (bedside commode). She said she just waited to (sic) long to turn on call light. I told her it was ok and we will get her fixed up . Employee who followed up: (Director of Nursing (DON)) . 4.) There was no documentation the resident's allegation was reported to the Administrator, and no documentation that an investigation was conducted. The only witness statements were the resident's documented grievance and CNA #8's statement, which conflicted with the resident's description of the events. There was no documentation the other CNA who was present in the resident's room at the time of the alleged event was interviewed or that any further effort was made to determine what happened. There was no documentation of protective measures that were implemented, other than informing the CNA that she was no longer allowed to care for this resident. b. Resident #19 had [DIAGNOSES REDACTED]. The MDS with an ARD of 9/16/16 documented the resident scored 15 (13-15 indicates cognitively intact) on a BIMS, had no behavioral symptoms, required supervision of 1 person for bed mobility, transfer and walking in room; required supervision and set-up help only for walking in corridor; required limited assistance of 1 person for dressing and personal hygiene; and required extensive assistance of 1 person for toilet use. 1.) A Plan of Care dated as initiated on 9/22/16 documented, Focus: Needs assist of staff for basic needs including: dressing, incontinent care, bathing, grooming, personal hygiene, locomotion . Interventions / Tasks . Dressing: Position so that dressing can occur while in a secure (balanced) position . Toilet Use: needs assist of 1 staff for toilet use . The Plan of Care did not address the resident's [MEDICAL CONDITION]. 2.) A Grievance Report dated 9/29/16 documented, Pt (patient) stated that on night shift, she walked to desk at nurses station and asked for assistance in emptying her [MEDICAL CONDITION] bag. Pt stated (CNA #8) replied by saying that she did not need to be asking for any help to empty her bag and that she needed to be doing that by herself. Pt stated that she got very upset by being spoken to that way and she was so upset she was unable to sleep the rest of the night. The Department Response dated 9/29/16 documented, Staff inservice on ADLs (Activities of Daily Living) of the rehab resident. This CNA moved to different hall. The Department Response was signed by the ADON and dated 9/29/16. 3.) There was no documentation that the resident's grievance was identified as a possible allegation of neglect due to the CNA's alleged refusal to provide the necessary care to the resident's [MEDICAL CONDITION], and no documentation the allegation was reported to the Administrator or investigated. The only documented protective measure was to move CNA #8 to a different hall. c. Resident #24 had [DIAGNOSES REDACTED]. The Admission MDS with an ARDS of 9/18/16 documented the resident scored 15 (13-15 indicates cognitively intact) on a BIMS, required extensive assistance of 2-plus people for bed mobility, transfer and toilet use and was frequently incontinent of bowel and bladder. 1.) The Plan of Care dated as initiated 9/22/16 documented, Focus . Needs assist of staff for basic needs including: dressing, incontinent care, bathing, grooming, personal hygiene, locomotion . Interventions / Tasks: .Needs assist of 2 staff for toilet use. Incontinent of bowel and bladder with change and skin care PRN . 2.) A Grievance Report dated 9/29/16 documented, (Resident #24) reported that she pushed her call light sometime between 10 pm - 6 am shift. She asked to use the bathroom. The aide asked her if she could get up and walk. She replied, 'You know I can't walk'. The aide said, 'Well you can't go to the bathroom then'. The aide walked out and shut the door resulting in the resident being incontinent. The Department Response dated 9/29/16 documented, Spoke with 10/6 (CNA #8) coaching done on how we respond to resident request. (CNA #8) stated she did not say this to the resident as she was assisting another resident up to the BSC (bedside commode). (CNA #8) will be moved to a different hall. The Department Response was signed by the ADON and dated 9/29/16. There was no documentation to indicate the CNA's alleged refusal to provide necessary care and assistance to the resident was identified as possible neglect and reported to the Administrator. There was no documentation an investigation was conducted or that any protective measures were implemented, other than moving the CNA to another hall. d. Resident #18 had [DIAGNOSES REDACTED]. The MDS with an ARD of 11/14/16 documented the resident scored 13 (13-15 indicates cognitively intact) on a BIMS, exhibited behavioral symptoms not directed toward others (such as hitting or scratching self, pacing, rummaging, disrobing, screaming) on 1 to 3 of the past 7 days, required extensive assistance of 2-plus people for bed mobility and transfers and experienced a fall in the last 2 to 6 months. 1.) The Plan of Care dated as initiated 11/16/16 documented, Needs assist of staff for basic needs including: dressing, incontinent care, bathing, grooming, personal hygiene, locomotion . Interventions / Tasks: .requires assist by 2 staff to turn and reposition in bed at least every 2 hours and as necessary . requires extensive 2 person assist to move between surfaces . Focus: Has had behavioral problems, agitation and hallucinations . Interventions / Tasks: Approach calmly and give empathy, support and [MEDICATION NAME] while talking with warmly and positively. Assess and anticipate needs . Intervene before agitation escalates . Focus: Potential to fall associated with psychoactive drug therapy, mobility issues and history of falls . Interventions / Tasks: .Be sure call light is within reach and encourage to use it for assistance as needed. Provide prompt response to all requests for assistance . 2.) A Grievance Report dated 11/15/16 documented, Patient stated that specific CNA was 'hateful and mean' and stated she laughed at everyone and thought everything was funny and he didn't want her back in his room. Patient stated she allowed his bed alarm to go off for an hour and left him unable to sleep. Patient stated it was the 'colored' CNA. The Department Response dated 11/17/16 documented, Spoke to (CNA #8) who was on West 2 on 11/14/16 10/6 (10:00 p.m. to 6:00 a.m.) shift. She wrote a statement. (CNA #8) was informed that she is not allowed to enter (Resident #18's) room at any time or for any reason. (CNA #8) received a written warning. The Department Response was signed by the ADON. There was no documentation the resident's allegation regarding the CNA's behavior and failure to respond to the bed alarm was identified as a possible allegation of neglect, no documentation the allegations were reported to the Administrator or investigated, and no documentation of any protective measures that were implemented other than instructing the CNA not to enter the resident's room. e. Resident #20 had [DIAGNOSES REDACTED]. The MDS with an ARD of 10/26/16 documented the resident scored 15 (13-15 indicates cognitively intact) on the BIMS. A Grievance Report dated 11/17/16 documented, Person filing grievance: (Resident #20) . (CNA #8) made the statement 'I'm going to take your clothes and throwing them away.' (Resident #20) was very upset by this. He was just asking 'I want my clothes to go to laundry and that's it'. The Departmental Response dated 11/17/16 documented, (CNA #8) received final written warning regarding rudeness to residents. (CNA #8) is not allowed back in (Resident #20's) room. The Department Response was signed by the ADON. An additional handwritten note dated 11/18/16 in the Department Response section of the form documented, Update: Spoke w/ (with) (Resident #20) concerning incident with CNA, he said she has not been back in his room . There was no documentation the resident's allegation was reported to the Administrator or that any further investigation was done. There was no documentation of any protective measures that were implemented, other than instructing the CNA to stay out of the resident's room. f. Resident #12 had [DIAGNOSES REDACTED]. A quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 11/18/16 documented the resident scored 6 (0-7 indicates severely impaired) on a brief interview for mental status (BIMS) and required limited assistance of 1 person for transfer. 1.) A Grievance Report dated 11/21/16 documented, Pt's (Patient's) husband and pt (patient) states (Resident #12) is scared to transfer / stand due to evening shift staff being abrasive and too rough. Pt and husband stated a CNA staff member was performing hoyer lift transfer when the (husband) stated he heard (resident) scream and heard the black CNA tell (resident) to shut up, that she didn't do anything to hurt her + to stop screaming. (Husband) also reports same CNA being very rough and abrasive with him. The Department Response dated 11/24/16 at 7:30 a.m. documented, CNAs have been in-serviced on proper lift techniques, and how to coach resident during the lift. CNA states she did not tell (resident) to shut up. I will be making rounds to observe during lifts. The Department Response was signed by the ADON. The grievance form did not document the identity of the accused CNA; however, the resident's husband identified the CNA as CNA #8, in the following interview. On 11/29/16 4:17p.m., the resident's husband was asked about the grievance dated 11/21/16 and stated, .Negro gal using the hoist for (Resident #12) yelled, 'Oh hush up (Resident #12), I didn't hurt you'. The resident's spouse, who is also Resident #12's roommate, stated, (CNA #8) is just rough; just jerked my dependable (incontinent brief). Kind of hurt my testicles; she worked last night. g. Resident #26 had [DIAGNOSES REDACTED]. An Admission MDS with an ARD of 8/5/16 documented the resident scored 15 (13-15 indicates cognitively intact) on a BIMS, required extensive assistance of 2-plus people for bed mobility, transfer and toilet use; extensive assistance of 1 person for personal hygiene and locomotion on and off the unit; was not steady - only able to stabilize with staff assistance when moving from a seated to standing position, surface-to-surface transfers and moving on and off the toilet; had an indwelling urinary catheter; was frequently incontinent of bowel; and received oxygen therapy and Continuous Positive Airway Pressure ([MEDICAL CONDITION]) while a resident. 1.) The Plan of Care dated as initiated on 8/10/16 documented, Needs assist of staff for basic needs including: dressing, incontinent care, bathing, grooming, personal hygiene, locomotion . Interventions / Tasks: assist of 1 to 2 staff for personal hygiene . requires assist by 2 staff to turn and reposition in bed at least every 2 hours . needs assist of 2 staff for toilet use. Incontinent of bowel and bladder with change and skin care PRN . Requires extensive two person assist to move between surfaces . Potential to fall associated with psychoactive drug therapy and mobility issues . Interventions / Tasks . Assist as needed with transfers and ambulation . Be sure call light is within reach and encourage to use it for assistance as needed. Provide prompt response to all requests for assistance . 2.) A Grievance Report dated 8/30/16 documented, .(Resident #26) . notified me that she was very upset about last night. I asked her what happened, she stated that she had pushed her call light several times last night they came in and turned it off. At one point she asked for mouth dry they look for it and told her that they didn't know what she was talking about. She said she spelled it out for them. They left the room. She asked several times to go to bathroom, they turned light off and left. At one point she tried to get on bedside commode by herself. She removed [MEDICAL CONDITION], put on N/C (nasal cannula) and then they came in to put her on pot. They put her back in bed put [MEDICAL CONDITION] back on and left N/C on. She was so upset she wanted to go home. The Department Response dated 9/2/16 documented, Staff will be in serviced on answering call lights in a timely manner, as well as toileting schedule. Nursing to manage oxygen equipment . Employee who followed up: (Assistant Director of Nursing (ADON)). The department response was signed by the ADON and dated 9/2/16. 3.) There was no documentation the resident's allegation of possible neglect was reported immediately to the Administrator; no evidence that an investigation was conducted; and no documentation any protective measures were implemented to prevent further potential neglect. The documentation did not identify which staff were responsible for providing care to the resident on the night shift for 8/29/16 and there was no documentation those staff members, their charge nurse, other staff or other residents were interviewed to determine what happened and whether any other residents may have been affected. h. Resident #28 had [DIAGNOSES REDACTED].#4 (C4). The MDS with an ARD of 9/20/16 BIMS documented the resident scored 15 (13-15 indicates cognitively intact) on the BIMS, required extensive assistance of 2-plus people for bed mobility and transfer, frequently experienced pain in the past 5 days, with the worst pain being rated by the resident as 10 on a scale of 0 to 10, with 0 indicating no pain and 10 indicating the worst pain imaginable. 1.) An Order Review History Report dated 10/2/16 through 10/31/16 documented physician orders [REDACTED].>A physician order [REDACTED]. Give 1 capsule by mouth three times a day related to Pain, Unspecified. A physician order [REDACTED]. Give 1 tablet by mouth every 4 hours as needed for breakthrough pain related to Central Cord Syndrome . A physician order [REDACTED]. Give 1 tablet by mouth every 6 hours as needed for breakthrough pain related to Pain, Unspecified . 2.) The Plan of Care dated as initiated on 9/22/16 documented, .Focus: Has episodes of muscle spasm and is medicated as ordered . Interventions / Tasks: Medicate as ordered and notify physician if ineffective . Observe for signs and symptoms of pain, discomfort . Focus: At risk for pain related to [DIAGNOSES REDACTED]. Interventions / Tasks: Anticipate the need for pain relief and respond immediately to any complaint of pain . 3.) A Grievance Report dated 9/28/16, and reported by the resident's wife, documented, Before leaving around 14:20 (2:20 p.m.), (Resident 28) had asked for pain medication. I had left; when I returned at 18:42 (6:42 p.m.), (Resident #28) had yet to receive any medication. We pushed the button a CNA has come in several times and has told (Licensed Practical Nurse (LPN) #5) about (Resident #28) needing medication. We've sat here, ate dinner and she (LPN #5) still had not come. I, (wife), went looking for (LPN #5) she was from what I had seen 'visiting' a room for 36 minutes . Department Response: Update on pg (page) 2 . The second page of the Grievance Report dated 9/27/16 and completed by CNA #13 documented, .(Resident #28) asked for pain pill for several hours before the nurse (LPN #5) gave him one. (Three other staff members) and I asked her to give him one, and her response was just a minute. When I asked again she told me he had already had one earlier. I told her he had a (sic) order for 2 different kinds and she told me it would be a minute. Resident was in bed holding his head complaining of bad pain . The Department Response dated 9/30/16 documented, Nurse was placed on 6 month probation. An additional handwritten note dated 10/1/16 at the bottom of the form documented, Update: checked in with (Resident #28) to see if he was getting pain meds (medications) on time and he said everything is going good. 4.) There was no documentation the resident's allegation of possible neglect was reported immediately to the Administrator or that an investigation was conducted. There was no documentation of witness statements from LPN #5, CNA #13 or the other 3 staff members that were mentioned on page 2 of the grievance and no documentation of any effort to determine. i. Resident #23 had [DIAGNOSES REDACTED]. The MDS with an ARD of 9/2/16 documented the resident scored 7 (0-7 indicates severely impaired) on a BIMS, had no hallucinations or signs / symptoms of [MEDICAL CONDITION], required extensive assistance of 2-plus people for bed mobility and transfer. 1.) The Plan of Care dated as initiated 9/6/16 documented, Focus: Needs assist of staff for basic needs, including dressing, incontinent care, bathing, grooming, personal hygiene . Interventions / Tasks: Bed mobility: requires assist by 2 staff to turn and reposition in bed at least every 2 hours and as necessary 2.) A Grievance Report dated 9/28/16 and completed by the Social Director documented, Daughter (name) came to my office and reported that (Resident #23) had complained to her about a white male night shift CNA had been hateful to him and shined a light in his eyes. He also states that the bed monitor was shocking him and sending fire volts through his skin. The Department Response dated 9/29/16 documented, After speaking to (daughter) we feel (Resident #23) is confused due to UTI (Urinary Tract Infection) and that the grievance is unfounded. The form was signed by the ADON and dated 9/29/16. There was no documentation to indicate an investigation was conducted to support the conclusion that the resident's allegation was unfounded. j. Resident # 25 had [DIAGNOSES REDACTED]. The MDS with an ARD of 8/2/16 BIMS documented the resident scored 13 (13-15 indicates cognitively intact) on a BIMS and required extensive assistance of 2-plus people for bed mobility and transfer. 1.) The Plan of Care dated as initiated 8/13/15 documented, Focus: Needs assist of staff for basic needs including: dressing, incontinent care, bathing, grooming, personal hygiene, locomotion . Interventions / Tasks: .requires assist of 2 staff to move between surfaces with lift (revision on: 7/22/16) . Encourage to use bell to call for assistance (revision on: 8/13/15) . 2.) A Grievance Report dated 10/20/16 documented, Nurse went to give resident her meds. She asked for a nerve pill, then said she wanted the pill cause (CNA #12) was being very rude and hateful to her. She asked him to stop or she would report him to (Physician). He said 'go ahead I have nothing to do with him and they won't do anything to me'. He keep being hateful + (and) rude. She finally asked him to leave and don ' t want him back in her room. She very upset + crying. The Department Response dated 10/21/16 documented, (CNA #12) stated resident requested many times to go back to bed, resident is a lift and the lift was being used. Resident was laughing when she stated she would report this to (physician). So (CNA #12) laughed and said ok - go ahead, resident was put back to bed. Today 10/21/16 resident apologized to (CNA #12) for her behavior yesterday and everything was ok. (CNA #12) will not go into (Resident #25's) room alone. The Department Response was signed by the ADON and dated 10/21/16. There was no documentation the resident's allegation against CNA #12 was reported to the Administrator or that any investigation was conducted, other than speaking with CNA #12 about his version of the incident. k. Resident #22 had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) with an assessment reference date (ARD) of 7/04/16 documented the resident scored 15 (13-15 indicates cognitively intact) on the brief interview for mental status (BIMS), had no behavioral symptoms, required extensive assistance of 1 person for bed mobility, extensive assistance of 2 people for transfer and functional limitation of range of motion in one lower extremity. 1.) The Plan of Care dated as initiated 7/7/16 documented, Focus: At risk for pain related to history of femur fracture, generalized discomfort . Interventions / Tasks: Comfort measures: reposition, pillows . Focus: Needs assist of staff for basic needs . Interventions / Tasks: requires assist by 2 staff to turn and reposition in bed . requires extensive 2 person assist to move between surfaces . 2.) A Grievance Report dated 6/28/16 documented, Patient felt like Physical Therapist was not listening to her request. After standing, patient asked for assistance with lifting of leg back into bed and therapist responded with 'after that?' Patient stated he aggressively transferred her leg into bed and walked out. The Department Response dated 6/28/16 documented, Addressed Physical Therapist about the patient's concerns and the DOR's (Director of Rehab) concerns about the handling of this situation. He understood and explained he was trying to motivate patient to do for herself. She will be treated by a different therapist from here on out. The Department Response was signed by the DOR and dated 6/28/16. l. Resident #21 had [DIAGNOSES REDACTED]. The MDS with an ARDS of 10/05/16 documented the resident scored 15 (13-15 indicates cognitively intact) on a BIMS, had no behavioral symptoms, required limited assistance of 1 person for bed mobility and limited assistance of 2-plus people for transfers and toilet use. 1.) The Plan of Care dated as initiated 10/7/16 documented, Focus: Needs assist of staff for basic needs including: dressing, incontinent care, bathing, grooming, personal hygiene, locomotion . Interventions / Tasks: requires assist by 1 staff to turn and reposition in bed . needs assist of 2 staff for toilet use. Incontinent of bladder occasionally . requires limited one person assist to move between surfaces . Potential to fall associated with psychoactive drug therapy and mobility issues . Interventions / Tasks: .Assist as needed with transfers and ambulation . Be sure call light is within reach and encourage to use it for assistance as needed. Provide prompt response to all requests for assistance . 2.) A Grievance Report dated 11/17/16 documented, (CNA #11) has displayed rude behavior towards resident, leaving resident in uncomfortable positions, (bedside commode, unable to reach call light) several different times. Rude comments made to resident by this CNA. Resident would not state the comments that were made but stated that they made her very uncomfortable and displeased. Resident does not want this aide back in her room. The Department Response dated 10/21/16 documented, (CNA #11) stated that she has never been rude or made rude comments to any of her residents. Stated she would never do such things & (and) understands that she is not allowed back in (Resident #21's) room going forward. The Department Response was co-signed by the ADON and another unidentified male staff member. An additional handwritten entry dated 10/24/16 in the Department Response section of the form documented, checked back in to make sure everything was ok with (Resident #21) and she says that she is. There was no documentation the resident's allegations were reported to the Administrator or investigated, and no documentation that any protective measures were implemented other than instructing the CNA not to enter the resident's room. 2. On 11/30/16 8:27 a.m., the Director of Nursing (DON) was asked how grievances were handled by the facility and stated they were given to the Social Services Director, who then forwarded them to the responsible department to address. The DON stated she was unware of pattern with CNA #8, who was named in multiple allegations in the grievance documentation. Upon reviewing the above 12 grievances, the DON stated, I have concerns about these. The DON was asked about the ADON signing off on several of the department responses and stated, I don't know . I don't have an answer. The DON was asked what should be done with allegations of abuse and stated, I'm sorry; I never saw these and they should be checked into. 3. On 11/30/16 at 8:48 a.m., the ADON was asked how grievances were handled by the facility and stated, They go to the Social Director; she gives them to the department to address. Then we address / fill them out and give them back to her. Allegations of abuse, we report to our supervisor, mine is the DON. The ADON was asked to review the above 12 grievances and after doing so, she was asked, Do you agree with the response to the grievances? The ADON shrugged her shoulders and stated, Yes. The ADON acknowledged she had signed off on most of the grievances that were shown to her. The ADON was asked if she had reported any of the allegations to the DON and stated, No. After reviewing the grievances, the ADON also stated, What's an allegation of abuse? The ADON was asked if she had reported any of the above allegations to the DON and stated, No. 4. On 11/30/16 at 9:03 a.m., the Administrator was asked about how grievances were handled at the facility and stated, Department heads get the grievance . I don't usually see them. After reviewing the above grievances, the Administrator was asked what should be done with the allegations of abuse and stated, Probably report, in-services, more investigation with resident/staff . We have a lot of work to do. 5. The immediate jeopardy was removed, and the scope and severity was reduced to E on 11/30/16 at 2:28 p.m., when the facility implemented the following plan of removal: a. On 11/30/16 at 2:15 p.m., immediately upon notification by surveyors, administrator initiated an audit of all grievances filed in the past 6 months, to ensure any further allegations of abuse/neglect were identified. All grievances that are possible allegations of abuse or neglect will have investigation initiated immediately by Administrator, and will be reported to OLTC (Office of Long Term Care) and local law enforcement in accordance with State Law. b. (CNA #8) terminated 11/30/16 by the DON. Any other staff members identified as possible perpetrators will be suspended immediately, until investigations are completed. c. Re-education provided to all department by consulting team on grievance process and procedure on 11/30/16. d. All new grievances will be reviewed in morning QA (Quality Assurance) meetin

Based on record review and interview, the facility failed to ensure its abuse prohibition policies and procedures were implemented, as evidenced by failure to ensure allegations of possible staff-to-resident abuse and neglect that were documented in the facility's grievance log were identified as possible abuse and neglect and were reported immediately to the Administrator / Designee, which resulted in failure to conduct thorough investigations, failure to implement appropriate measures to protect all residents from further potential abuse or neglect, and failure to report the allegations to local law enforcement and the Office of Long Term Care (OLTC) for 12 (Residents #12, #18, #19, #20, #21, #22, #23, #24, #25, #26, #27 and #28) of 12 case mix residents whose allegations of possible staff-to-resident abuse or neglect were documented on Grievance / Complaint Reports. The failure to identify the allegations of abuse / neglect also resulted in failure to promptly identify a pattern of repeated allegations against a specific Certified Nursing Assistant (CNA #8) and take appropriate corrective measures to prevent further potential abuse or neglect by that CNA for 6 (Residents #12, #18, #19, #20, #24 and #27) of the 12 case mix residents whose allegations of possible staff-to-resident abuse or neglect were documented on Grievance / Complaint Reports (see identifiers above). The failed practices resulted in immediate jeopardy, which caused or could have caused serious harm, injury, or death to Residents #12, #18, #19, #20, #21, #22, #23, #24, #25, #26, #27 and #28, and had the potential to cause more than minimal harm to all 98 residents who resided in the facility, as documented on the Roster Matrix provided by the Administrator on 11/28/16. The Administrator was notified of the Immediate Jeopardy on 11/30/16 at 12:05 p.m. The findings are: 1. On 11/30/16 at 8:00 a.m., the facility's grievance logs dated June 2016 through November 2016 were reviewed. Twelve of the grievances, that were reviewed at this time, documented possible allegations of staff-to-resident abuse or neglect. None of the 12 allegations included evidence to indicate they were reported to the Administrator, investigated or that appropriate protective measures were implemented to minimize the potential for further abuse / neglect. The allegations involved the following residents and, for the first 6 residents below (Residents #27, #19, #24, #18, #20 and #12), named CNA #8 as the accused party, either on the grievance form itself or on the attached documentation: a. Resident #27 had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) with an assessment reference date (ARD) of 8/11/16 documented the resident scored 10 (8-12 indicates moderately impaired) on a Brief Interview for Mental Status (BIMS), required extensive assistance of 2-plus people for bed mobility, transfer and toilet use; limited assistance of 1 person for personal hygiene and was frequently incontinent of bladder. 1.) The Plan of Care dated as initiated on 8/12/16 documented, .Needs assist of staff for basic needs including: dressing, incontinent care, bathing, grooming, personal hygiene . Interventions / Tasks: .assist of 1 to 2 staff for personal hygiene . needs assist of 2 staff for toilet use. Incontinent of bowel and bladder with change and skin care PRN (as needed) . 2.) A Grievance Report dated 8/26/16 at 9:00 a.m. documented, (Resident #27) stated that a nurse's aide had become upset with her for having an accident (incontinence) the night before. She stated that the aide cussed at her and told her she should have been able to hold her bladder. She said the nurse's aide said 'I'm not your maid'. (Resident #27) stated she felt upset about the experience and that she was 'still a person'. She felt apologetic about having the accident . The Department Response dated 8/27/16 at 8:00 a.m. documented, The CNA (Certified Nursing Assistant) wrote a response, attached, however to satisfy this grievance, the CNA is not allowed to care for this resident . The grievance report did not identify which CNA was accused by the resident; however, the attached witness statement was signed by CNA #8. 3.) The written attachment dated 8/27/16 and signed by CNA #8 documented, I went into (Resident #27's) room to help (another CNA) with a complete bed change and asked resident if she was ok because I know she go to the BSC (bedside commode). She said she just waited to (sic) long to turn on call light. I told her it was ok and we will get her fixed up . Employee who followed up: (Director of Nursing (DON)) . 4.) There was no documentation the resident's allegation was reported to the Administrator, and no documentation that an investigation was conducted. The only witness statements were the resident's documented grievance and CNA #8's statement, which conflicted with the resident's description of the events. There was no documentation the other CNA who was present in the resident's room at the time of the alleged event was interviewed or that any further effort was made to determine what happened. There was no documentation of protective measures that were implemented, other than informing the CNA that she was no longer allowed to care for this resident. b. Resident #19 had [DIAGNOSES REDACTED]. The MDS with an ARD of 9/16/16 documented the resident scored 15 (13-15 indicates cognitively intact) on a BIMS, had no behavioral symptoms, required supervision of 1 person for bed mobility, transfer and walking in room; required supervision and set-up help only for walking in corridor; required limited assistance of 1 person for dressing and personal hygiene; and required extensive assistance of 1 person for toilet use. 1.) A Plan of Care dated as initiated on 9/22/16 documented, Focus: Needs assist of staff for basic needs including: dressing, incontinent care, bathing, grooming, personal hygiene, locomotion . Interventions / Tasks . Dressing: Position so that dressing can occur while in a secure (balanced) position . Toilet Use: needs assist of 1 staff for toilet use . The Plan of Care did not address the resident's [MEDICAL CONDITION]. 2.) A Grievance Report dated 9/29/16 documented, Pt (patient) stated that on night shift, she walked to desk at nurses station and asked for assistance in emptying her [MEDICAL CONDITION] bag. Pt stated (CNA #8) replied by saying that she did not need to be asking for any help to empty her bag and that she needed to be doing that by herself. Pt stated that she got very upset by being spoken to that way and she was so upset she was unable to sleep the rest of the night. The Department Response dated 9/29/16 documented, Staff inservice on ADLs (Activities of Daily Living) of the rehab resident. This CNA moved to different hall. The Department Response was signed by the ADON and dated 9/29/16. 3.) There was no documentation that the resident's grievance was identified as a possible allegation of neglect due to the CNA's alleged refusal to provide the necessary care to the resident's [MEDICAL CONDITION], and no documentation the allegation was reported to the Administrator or investigated. The only documented protective measure was to move CNA #8 to a different hall. c. Resident #24 had [DIAGNOSES REDACTED]. The Admission MDS with an ARDS of 9/18/16 documented the resident scored 15 (13-15 indicates cognitively intact) on a BIMS, required extensive assistance of 2-plus people for bed mobility, transfer and toilet use and was frequently incontinent of bowel and bladder. 1.) The Plan of Care dated as initiated 9/22/16 documented, Focus . Needs assist of staff for basic needs including: dressing, incontinent care, bathing, grooming, personal hygiene, locomotion . Interventions / Tasks: .Needs assist of 2 staff for toilet use. Incontinent of bowel and bladder with change and skin care PRN . 2.) A Grievance Report dated 9/29/16 documented, (Resident #24) reported that she pushed her call light sometime between 10 pm - 6 am shift. She asked to use the bathroom. The aide asked her if she could get up and walk. She replied, 'You know I can't walk'. The aide said, 'Well you can't go to the bathroom then'. The aide walked out and shut the door resulting in the resident being incontinent. The Department Response dated 9/29/16 documented, Spoke with 10/6 (CNA #8) coaching done on how we respond to resident request. (CNA #8) stated she did not say this to the resident as she was assisting another resident up to the BSC (bedside commode). (CNA #8) will be moved to a different hall. The Department Response was signed by the ADON and dated 9/29/16. There was no documentation to indicate the CNA's alleged refusal to provide necessary care and assistance to the resident was identified as possible neglect and reported to the Administrator. There was no documentation an investigation was conducted or that any protective measures were implemented, other than moving the CNA to another hall. d. Resident #18 had [DIAGNOSES REDACTED]. The MDS with an ARD of 11/14/16 documented the resident scored 13 (13-15 indicates cognitively intact) on a BIMS, exhibited behavioral symptoms not directed toward others (such as hitting or scratching self, pacing, rummaging, disrobing, screaming) on 1 to 3 of the past 7 days, required extensive assistance of 2-plus people for bed mobility and transfers and experienced a fall in the last 2 to 6 months. 1.) The Plan of Care dated as initiated 11/16/16 documented, Needs assist of staff for basic needs including: dressing, incontinent care, bathing, grooming, personal hygiene, locomotion . Interventions / Tasks: .requires assist by 2 staff to turn and reposition in bed at least every 2 hours and as necessary . requires extensive 2 person assist to move between surfaces . Focus: Has had behavioral problems, agitation and hallucinations . Interventions / Tasks: Approach calmly and give empathy, support and [MEDICATION NAME] while talking with warmly and positively. Assess and anticipate needs . Intervene before agitation escalates . Focus: Potential to fall associated with psychoactive drug therapy, mobility issues and history of falls . Interventions / Tasks: .Be sure call light is within reach and encourage to use it for assistance as needed. Provide prompt response to all requests for assistance . 2.) A Grievance Report dated 11/15/16 documented, Patient stated that specific CNA was 'hateful and mean' and stated she laughed at everyone and thought everything was funny and he didn't want her back in his room. Patient stated she allowed his bed alarm to go off for an hour and left him unable to sleep. Patient stated it was the 'colored' CNA. The Department Response dated 11/17/16 documented, Spoke to (CNA #8) who was on West 2 on 11/14/16 10/6 (10:00 p.m. to 6:00 a.m.) shift. She wrote a statement. (CNA #8) was informed that she is not allowed to enter (Resident #18's) room at any time or for any reason. (CNA #8) received a written warning. The Department Response was signed by the ADON. There was no documentation the resident's allegation regarding the CNA's behavior and failure to respond to the bed alarm was identified as a possible allegation of neglect, no documentation the allegations were reported to the Administrator or investigated, and no documentation of any protective measures that were implemented other than instructing the CNA not to enter the resident's room. e. Resident #20 had [DIAGNOSES REDACTED]. The MDS with an ARD of 10/26/16 documented the resident scored 15 (13-15 indicates cognitively intact) on the BIMS. A Grievance Report dated 11/17/16 documented, Person filing grievance: (Resident #20) . (CNA #8) made the statement 'I'm going to take your clothes and throwing them away.' (Resident #20) was very upset by this. He was just asking 'I want my clothes to go to laundry and that's it'. The Departmental Response dated 11/17/16 documented, (CNA #8) received final written warning regarding rudeness to residents. (CNA #8) is not allowed back in (Resident #20's) room. The Department Response was signed by the ADON. An additional handwritten note dated 11/18/16 in the Department Response section of the form documented, Update: Spoke w/ (with) (Resident #20) concerning incident with CNA, he said she has not been back in his room . There was no documentation the resident's allegation was reported to the Administrator or that any further investigation was done. There was no documentation of any protective measures that were implemented, other than instructing the CNA to stay out of the resident's room. f. Resident #12 had [DIAGNOSES REDACTED]. A quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 11/18/16 documented the resident scored 6 (0-7 indicates severely impaired) on a brief interview for mental status (BIMS) and required limited assistance of 1 person for transfer. 1.) A Grievance Report dated 11/21/16 documented, Pt's (Patient's) husband and pt (patient) states (Resident #12) is scared to transfer / stand due to evening shift staff being abrasive and too rough. Pt and husband stated a CNA staff member was performing hoyer lift transfer when the (husband) stated he heard (resident) scream and heard the black CNA tell (resident) to shut up, that she didn't do anything to hurt her + to stop screaming. (Husband) also reports same CNA being very rough and abrasive with him. The Department Response dated 11/24/16 at 7:30 a.m. documented, CNAs have been in-serviced on proper lift techniques, and how to coach resident during the lift. CNA states she did not tell (resident) to shut up. I will be making rounds to observe during lifts. The Department Response was signed by the ADON. The grievance form did not document the identity of the accused CNA; however, the resident's husband identified the CNA as CNA #8, in the following interview. On 11/29/16 4:17p.m., the resident's husband was asked about the grievance dated 11/21/16 and stated, .Negro gal using the hoist for (Resident #12) yelled, 'Oh hush up (Resident #12), I didn't hurt you'. The resident's spouse, who is also Resident #12's roommate, stated, (CNA #8) is just rough; just jerked my dependable (incontinent brief). Kind of hurt my testicles; she worked last night. g. Resident #26 had [DIAGNOSES REDACTED]. An Admission MDS with an ARD of 8/5/16 documented the resident scored 15 (13-15 indicates cognitively intact) on a BIMS, required extensive assistance of 2-plus people for bed mobility, transfer and toilet use; extensive assistance of 1 person for personal hygiene and locomotion on and off the unit; was not steady - only able to stabilize with staff assistance when moving from a seated to standing position, surface-to-surface transfers and moving on and off the toilet; had an indwelling urinary catheter; was frequently incontinent of bowel; and received oxygen therapy and Continuous Positive Airway Pressure ([MEDICAL CONDITION]) while a resident. 1.) The Plan of Care dated as initiated on 8/10/16 documented, Needs assist of staff for basic needs including: dressing, incontinent care, bathing, grooming, personal hygiene, locomotion . Interventions / Tasks: assist of 1 to 2 staff for personal hygiene . requires assist by 2 staff to turn and reposition in bed at least every 2 hours . needs assist of 2 staff for toilet use. Incontinent of bowel and bladder with change and skin care PRN . Requires extensive two person assist to move between surfaces . Potential to fall associated with psychoactive drug therapy and mobility issues . Interventions / Tasks . Assist as needed with transfers and ambulation . Be sure call light is within reach and encourage to use it for assistance as needed. Provide prompt response to all requests for assistance . 2.) A Grievance Report dated 8/30/16 documented, .(Resident #26) . notified me that she was very upset about last night. I asked her what happened, she stated that she had pushed her call light several times last night they came in and turned it off. At one point she asked for mouth dry they look for it and told her that they didn't know what she was talking about. She said she spelled it out for them. They left the room. She asked several times to go to bathroom, they turned light off and left. At one point she tried to get on bedside commode by herself. She removed [MEDICAL CONDITION], put on N/C (nasal cannula) and then they came in to put her on pot. They put her back in bed put [MEDICAL CONDITION] back on and left N/C on. She was so upset she wanted to go home. The Department Response dated 9/2/16 documented, Staff will be in serviced on answering call lights in a timely manner, as well as toileting schedule. Nursing to manage oxygen equipment . Employee who followed up: (Assistant Director of Nursing (ADON)). The department response was signed by the ADON and dated 9/2/16. 3.) There was no documentation the resident's allegation of possible neglect was reported immediately to the Administrator; no evidence that an investigation was conducted; and no documentation any protective measures were implemented to prevent further potential neglect. The documentation did not identify which staff were responsible for providing care to the resident on the night shift for 8/29/16 and there was no documentation those staff members, their charge nurse, other staff or other residents were interviewed to determine what happened and whether any other residents may have been affected. h. Resident #28 had [DIAGNOSES REDACTED].#4 (C4). The MDS with an ARD of 9/20/16 BIMS documented the resident scored 15 (13-15 indicates cognitively intact) on the BIMS, required extensive assistance of 2-plus people for bed mobility and transfer, frequently experienced pain in the past 5 days, with the worst pain being rated by the resident as 10 on a scale of 0 to 10, with 0 indicating no pain and 10 indicating the worst pain imaginable. 1.) An Order Review History Report dated 10/2/16 through 10/31/16 documented physician orders [REDACTED].>A physician order [REDACTED]. Give 1 capsule by mouth three times a day related to Pain, Unspecified. A physician order [REDACTED]. Give 1 tablet by mouth every 4 hours as needed for breakthrough pain related to Central Cord Syndrome . A physician order [REDACTED]. Give 1 tablet by mouth every 6 hours as needed for breakthrough pain related to Pain, Unspecified . 2.) The Plan of Care dated as initiated on 9/22/16 documented, .Focus: Has episodes of muscle spasm and is medicated as ordered . Interventions / Tasks: Medicate as ordered and notify physician if ineffective . Observe for signs and symptoms of pain, discomfort . Focus: At risk for pain related to [DIAGNOSES REDACTED]. Interventions / Tasks: Anticipate the need for pain relief and respond immediately to any complaint of pain . 3.) A Grievance Report dated 9/28/16, and reported by the resident's wife, documented, Before leaving around 14:20 (2:20 p.m.), (Resident 28) had asked for pain medication. I had left; when I returned at 18:42 (6:42 p.m.), (Resident #28) had yet to receive any medication. We pushed the button a CNA has come in several times and has told (Licensed Practical Nurse (LPN) #5) about (Resident #28) needing medication. We've sat here, ate dinner and she (LPN #5) still had not come. I, (wife), went looking for (LPN #5) she was from what I had seen 'visiting' a room for 36 minutes . Department Response: Update on pg (page) 2 . The second page of the Grievance Report dated 9/27/16 and completed by CNA #13 documented, .(Resident #28) asked for pain pill for several hours before the nurse (LPN #5) gave him one. (Three other staff members) and I asked her to give him one, and her response was just a minute. When I asked again she told me he had already had one earlier. I told her he had a (sic) order for 2 different kinds and she told me it would be a minute. Resident was in bed holding his head complaining of bad pain . The Department Response dated 9/30/16 documented, Nurse was placed on 6 month probation. An additional handwritten note dated 10/1/16 at the bottom of the form documented, Update: checked in with (Resident #28) to see if he was getting pain meds (medications) on time and he said everything is going good. 4.) There was no documentation the resident's allegation of possible neglect was reported immediately to the Administrator or that an investigation was conducted. There was no documentation of witness statements from LPN #5, CNA #13 or the other 3 staff members that were mentioned on page 2 of the grievance and no documentation of any effort to determine. i. Resident #23 had [DIAGNOSES REDACTED]. The MDS with an ARD of 9/2/16 documented the resident scored 7 (0-7 indicates severely impaired) on a BIMS, had no hallucinations or signs / symptoms of [MEDICAL CONDITION], required extensive assistance of 2-plus people for bed mobility and transfer. 1.) The Plan of Care dated as initiated 9/6/16 documented, Focus: Needs assist of staff for basic needs, including dressing, incontinent care, bathing, grooming, personal hygiene . Interventions / Tasks: Bed mobility: requires assist by 2 staff to turn and reposition in bed at least every 2 hours and as necessary 2.) A Grievance Report dated 9/28/16 and completed by the Social Director documented, Daughter (name) came to my office and reported that (Resident #23) had complained to her about a white male night shift CNA had been hateful to him and shined a light in his eyes. He also states that the bed monitor was shocking him and sending fire volts through his skin. The Department Response dated 9/29/16 documented, After speaking to (daughter) we feel (Resident #23) is confused due to UTI (Urinary Tract Infection) and that the grievance is unfounded. The form was signed by the ADON and dated 9/29/16. There was no documentation to indicate an investigation was conducted to support the conclusion that the resident's allegation was unfounded. j. Resident # 25 had [DIAGNOSES REDACTED]. The MDS with an ARD of 8/2/16 BIMS documented the resident scored 13 (13-15 indicates cognitively intact) on a BIMS and required extensive assistance of 2-plus people for bed mobility and transfer. 1.) The Plan of Care dated as initiated 8/13/15 documented, Focus: Needs assist of staff for basic needs including: dressing, incontinent care, bathing, grooming, personal hygiene, locomotion . Interventions / Tasks: .requires assist of 2 staff to move between surfaces with lift (revision on: 7/22/16) . Encourage to use bell to call for assistance (revision on: 8/13/15) . 2.) A Grievance Report dated 10/20/16 documented, Nurse went to give resident her meds. She asked for a nerve pill, then said she wanted the pill cause (CNA #12) was being very rude and hateful to her. She asked him to stop or she would report him to (Physician). He said 'go ahead I have nothing to do with him and they won't do anything to me'. He keep being hateful + (and) rude. She finally asked him to leave and don ' t want him back in her room. She very upset + crying. The Department Response dated 10/21/16 documented, (CNA #12) stated resident requested many times to go back to bed, resident is a lift and the lift was being used. Resident was laughing when she stated she would report this to (physician). So (CNA #12) laughed and said ok - go ahead, resident was put back to bed. Today 10/21/16 resident apologized to (CNA #12) for her behavior yesterday and everything was ok. (CNA #12) will not go into (Resident #25's) room alone. The Department Response was signed by the ADON and dated 10/21/16. There was no documentation the resident's allegation against CNA #12 was reported to the Administrator or that any investigation was conducted, other than speaking with CNA #12 about his version of the incident. k. Resident #22 had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) with an assessment reference date (ARD) of 7/04/16 documented the resident scored 15 (13-15 indicates cognitively intact) on the brief interview for mental status (BIMS), had no behavioral symptoms, required extensive assistance of 1 person for bed mobility, extensive assistance of 2 people for transfer and functional limitation of range of motion in one lower extremity. 1.) The Plan of Care dated as initiated 7/7/16 documented, Focus: At risk for pain related to history of femur fracture, generalized discomfort . Interventions / Tasks: Comfort measures: reposition, pillows . Focus: Needs assist of staff for basic needs . Interventions / Tasks: requires assist by 2 staff to turn and reposition in bed . requires extensive 2 person assist to move between surfaces . 2.) A Grievance Report dated 6/28/16 documented, Patient felt like Physical Therapist was not listening to her request. After standing, patient asked for assistance with lifting of leg back into bed and therapist responded with 'after that?' Patient stated he aggressively transferred her leg into bed and walked out. The Department Response dated 6/28/16 documented, Addressed Physical Therapist about the patient's concerns and the DOR's (Director of Rehab) concerns about the handling of this situation. He understood and explained he was trying to motivate patient to do for herself. She will be treated by a different therapist from here on out. The Department Response was signed by the DOR and dated 6/28/16. l. Resident #21 had [DIAGNOSES REDACTED]. The MDS with an ARDS of 10/05/16 documented the resident scored 15 (13-15 indicates cognitively intact) on a BIMS, had no behavioral symptoms, required limited assistance of 1 person for bed mobility and limited assistance of 2-plus people for transfers and toilet use. 1.) The Plan of Care dated as initiated 10/7/16 documented, Focus: Needs assist of staff for basic needs including: dressing, incontinent care, bathing, grooming, personal hygiene, locomotion . Interventions / Tasks: requires assist by 1 staff to turn and reposition in bed . needs assist of 2 staff for toilet use. Incontinent of bladder occasionally . requires limited one person assist to move between surfaces . Potential to fall associated with psychoactive drug therapy and mobility issues . Interventions / Tasks: .Assist as needed with transfers and ambulation . Be sure call light is within reach and encourage to use it for assistance as needed. Provide prompt response to all requests for assistance . 2.) A Grievance Report dated 11/17/16 documented, (CNA #11) has displayed rude behavior towards resident, leaving resident in uncomfortable positions, (bedside commode, unable to reach call light) several different times. Rude comments made to resident by this CNA. Resident would not state the comments that were made but stated that they made her very uncomfortable and displeased. Resident does not want this aide back in her room. The Department Response dated 10/21/16 documented, (CNA #11) stated that she has never been rude or made rude comments to any of her residents. Stated she would never do such things & (and) understands that she is not allowed back in (Resident #21's) room going forward. The Department Response was co-signed by the ADON and another unidentified male staff member. An additional handwritten entry dated 10/24/16 in the Department Response section of the form documented, checked back in to make sure everything was ok with (Resident #21) and she says that she is. There was no documentation the resident's allegations were reported to the Administrator or investigated, and no documentation that any protective measures were implemented other than instructing the CNA not to enter the resident's room. 2. On 11/30/16 8:27 a.m., the Director of Nursing (DON) was asked how grievances were handled by the facility and stated they were given to the Social Services Director, who then forwarded them to the responsible department to address. The DON stated she was unware of pattern with CNA #8, who was named in multiple allegations in the grievance documentation. Upon reviewing the above 12 grievances, the DON stated, I have concerns about these. The DON was asked about the ADON signing off on several of the department responses and stated, I don't know . I don't have an answer. The DON was asked what should be done with allegations of abuse and stated, I'm sorry; I never saw these and they should be checked into. 3. On 11/30/16 at 8:48 a.m., the ADON was asked how grievances were handled by the facility and stated, They go to the Social Director; she gives them to the department to address. Then we address / fill them out and give them back to her. Allegations of abuse, we report to our supervisor, mine is the DON. The ADON was asked to review the above 12 grievances and after doing so, she was asked, Do you agree with the response to the grievances? The ADON shrugged her shoulders and stated, Yes. The ADON acknowledged she had signed off on most of the grievances that were shown to her. The ADON was asked if she had reported any of the allegations to the DON and stated, No. After reviewing the grievances, the ADON also stated, What's an allegation of abuse? The ADON was asked if she had reported any of the above allegations to the DON and stated, No. 4. On 11/30/16 at 9:03 a.m., the Administrator was asked about how grievances were handled at the facility and stated, Department heads get the grievance . I don't usually see them. After reviewing the above grievances, the Administrator was asked what should be done with the allegations of abuse and stated, Probably report, in-services, more investigation with resident/staff . We have a lot of work to do. 5. The facility's Abuse Prevention Policy, provided by the Administrator on 11/28/16 at 4:00 p.m., documented, .The facility does and will continue to ensure that all alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown sources and misappropriation of resident property are reported immediately to administrator of the facility and to other officials in accordance with State Law though established procedures . Definitions: Abuse: The willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm or pain or mental anguish, or deprivation by an individual , including a caretaker or goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being . Neglect: Failure to provide goods and services necessary to avoid physical harm, mental anguish,

Complaint # (AR 605) was substantiated (all or in part) with these findings. Based on record review and interview, the facility failed to ensure necessary care and services were provided to address an emergency situation, by failing to ensure nursing staff provided cardiopulmonary resuscitation (CPR) when a resident who had requested full code status presented without vital signs for 1 (Resident #13) of 6 (Residents #3, #4, #5, #9, #13 and #15) case mix residents whose clinical records documented a full code status. The failed practice resulted in past immediate jeopardy, which caused or could have caused serious harm, injury or death for Resident #13, who had a documented full code status and expired when CPR was withheld, and had the potential to cause more than minimal harm to 35 residents whose clinical records indicated a full code status prior to [DATE], according to a list provided by the Director of Nursing (DON) on [DATE] at 10:20 a.m. The Administrator was notified of the past immediate jeopardy situation on [DATE] at 12:05 p.m. The findings are: Resident #13 had [DIAGNOSES REDACTED]. The Minimum Data Set with an Assessment Reference Date of [DATE] documented the resident scored 15 (,[DATE] indicates cognitively intact) on a brief interview for mental status, required extensive assistance of two-plus persons for transfers and bed mobility, had dyspnea with exertion, when sitting at rest and when lying flat, received oxygen therapy, suctioning and [MEDICAL CONDITION] care and had been discharged from a hospital on [DATE] to the facility on 1 occasion in the past 14 days with a hospital discharge [DIAGNOSES REDACTED]. a. physician progress notes [REDACTED]. b. An Admission Record dated and signed by the resident on [DATE] and copied from the Electronic Medical Record documented, Pre-Hospital Consent . I, (Resident #13), request that CPR be administered to myself, and at request, that he / she be stated as a Full code. The Advance Directive Acknowledgment dated [DATE] and signed [DATE] by (Resident #13) documented, (Resident #13) . I HAVE NOT executed an Advance Directive . The Declaration of Living Will listed no life sustaining treatments that were to be withheld or withdrawn. c. A physician's orders [REDACTED]. d. The [DATE] Medication Administration Record [REDACTED]. e. The Care Plan dated [DATE] documented, 1) At risk for respiratory problems, including shortness of breath, respiratory distress . [MEDICAL CONDITION] (date initiated [DATE]) . Will maintain respiratory status without decline. Interventions . Oxygen as ordered. Monitor for signs and symptoms of respiratory distress, 2). Problem: [MEDICAL CONDITION]: Oxygen settings: oxygen at 5 to 10 l/m (liters per minute) via [MEDICAL CONDITION] collar every shift. There was no documentation on the Care Plan regarding code status or advanced directives. f. A Progress Note dated [DATE] at 4:17 a.m. and signed by Licensed Practical Nurse (LPN) #1 documented, .Health Status Note . Summoned to room per CNA (Certified Nurse Assistant) 0400 (4:00 a.m.), resident without vs (vital signs). Resident had been talking at 0340 (3:40 a.m.). Called the coroner, husband, notified DON (Director of Nursing), (physician), Administrator . Awaiting return call from husband. There was no indication that CPR was initiated for the resident. A Health Status Note dated [DATE] at 11:04 a.m. documented, .release body to mortician at 0745 (7:45 a.m.). (Local Funeral Home). g. The Office of Long Term Care (OLTC) Incident and Accident Report (I&A), Division of Medical Services (DMS) form 7734, dated [DATE] documented, Summary of Incident . Resident was alert and oriented at approximately 3:40 a.m., while staff was doing rounds. At approximately 4:00 a.m., Hall Nurse (LPN #1) was summoned by CNA to (Residents #13's) room. She was then found without vital signs. Hall nurse (LPN #1) failed to initiate compression though resident was a full code. Family and physician of resident notified, policy, administrator and director of nursing was also notified. The Facility Investigation Report for Resident Abuse, Neglect, Misappropriation of Property & (and) Exploitation of Residents in Long Term Care Facilities, DMS form 762, Section II Complete Description of Incident dated [DATE] documented, At approximately 4:00 a.m. on Tuesday, [DATE], (Resident #13) on our short term Rehab Hall was found in bed unresponsive and without vital signs by (Certified Nursing Assistant (CNA) #9). (CNA #9) then ran to notify her colleague (CNA #10) and nurse (Licensed Practical Nurse (LPN) #1). (LPN #1) then went to (Resident #13's) room, checked for pulse and after not finding one, pronounced her dead. (LPN #1) failed to administer CPR though the resident was a full code. (LPN #1) then proceeded to notify coroner. The Police, Administrator, DON, and Family were notified. h. The Witness Statement dated [DATE] and signed by CNA #9, documented, I came back from lunch at 3:53 (a.m.) and found resident not breathing. I ran out of the room to ask for help from (CNA #10) and (other staff member). (CNA #10) came in to room running from the nurse station. He checked pulse and her breathing. He then ran out of the room and told (LPN #1) 'Code Blue'. She walk from nurse's station into the room, checked her pulse and said she has passed . On [DATE] at 3:48 p.m., CNA #9 was asked to describe the events of [DATE] and stated, (Resident #13) was having increased problems with her breathing that night. I told the nurse she was having more difficulty with her breathing - she told us to help her get to bed . I found (Resident #13) not breathing / unresponsive after lunch. The last time I saw her before finding her unresponsive, her oxygen saturation was low, about 70% to 80%, and the nurse had set her up with a breathing treatment. She had the mask for the treatment on. When I found her not breathing, I called (CNA #10) for help. The CNA was asked if, when she prepared the resident's body for the funeral home, there was any discoloration / lividity to dependent parts of the resident's body. She denied observing any lividity or discoloration when preparing the body for the funeral home. i. On [DATE] at 4:02 p.m., CNA #10 was asked to describe the events that occurred on the night of [DATE] with Resident #13. He stated, (CNA #9) called for me . I came into the room to help (CNA #9). (Resident #13) was not responding . she didn't have any pulse. She was limp, her arms and neck were very pale and cold. Her arms were easily movable. I quickly got the nurse. She checked (Resident #13's) radial pulse. She didn't use a stethoscope or check any other pulse or do anything else or demonstrate any sense of urgency. (LPN #1) said, 'I guess I need to call the coroner'. j. On [DATE] at 9:20 a.m., the DON was asked for documentation of any pulse oximetry results obtained on this resident on [DATE] and stated she was unable to find any documentation of the pulse oximetry results or updraft treatments provided for the resident on that date. A Nurse's Note dated [DATE] at 3:23 p.m. was the last documented assessment of oxygen saturation in the clinical record, with a result of 95% documented. k. A Witness Statement dated [DATE] and signed by the DON documented, I was notified of death through PCC (Patient Care Conference) Conversation. I asked nurse, (LPN #1) why CPR was not initiated, her response was that she thought she didn't have to. I explained that resident was a full code status. She replied, 'Oh'. She was then terminated from employment. I witness her to have no expression at all. l. A Termination form dated [DATE] for LPN #1 documented, Detailed reasoning for termination: Failure to follow protocol in notifying DON, Administrator(s) by telephone about a major event (death) and failure to provide compression to a full code patient. m. On [DATE] at 6:15 a.m., LPN #4 was asked about Resident #13's condition on the morning of [DATE] and stated that LPN #1 never asked for her assistance in evaluating or assessing Resident #13 on that date. n. On [DATE] at 1:31 p.m., the DON stated she had been unaware, prior to [DATE], of whose responsibility it was to verify CPR certification of the facility nurses upon hire by the facility. The DON further stated, This was clarified after this incident and the front office staff are checking every nurse, and they can't work until we have a copy of their current CPR certification. The DON provided copies of CPR certification for 3 nurses who worked the night shift on [DATE] through [DATE]. LPN #1's CPR card documented her CPR certification expired [DATE]; however, there were 2 CPR-certified nurses available in the facility at the time of Resident #13's death. LPN #1 failed to obtain assistance from either of the 2 available LPNs. o. On [DATE] at 10:06 a.m., the DON was asked what in-service / training regarding CPR / code policy and procedure was provided to staff prior to the resident's death on [DATE]. The DON stated, Prior to this incident, we had no policy or check off sheets on CPR / code status. p. The facility removed the Immediate Jeopardy, corrected the failed practices and reduced the scope and severity to G on [DATE], as evidenced by the following: 1.) The Findings and Actions Taken portion of the DMS-762 documented: .All nurses were in-serviced on when to administer CPR. A new color coded door tag policy was implemented to identify residents code status by the font color of their door label. An emergency crash cart was ordered. All nurses are now CPR certified. Nurse involved was terminated. Notified state board of nursing. Employee was terminated on the basis of violation of company policies for failure to provide CPR to a resident whose code status is Full Code. All nurses were in-serviced on our policy as it relates to code status. CPR training class has been scheduled for all nurses. 2.) A Nursing In-service Agenda dated [DATE] documented a CPR training was provided by the facility's Nurse Consultant as follows: CPR - a. Required. b. CPR class tomorrow at 9 a.m. If you don't have it you are required to come to it! c. CPR by CMS (Centers for Medicare and Medicaid Services) guidelines. 3.) The facility's new door sign protocol implemented on [DATE] documented, Door Signs: a. Full code status / DNR . Blue Name - Full Code . Red Name - DNR . 4.) A Quality Assurance (QA) Form provided by the DON on [DATE] documented CPR class was provided to 2 facility nurses and 8 facility CNAs on [DATE] and, .All residents' doors now have names color coded to correct status of code - Blue letters - Full code, Red letters - DNR; Audit of all code status completed on [DATE], All nurses and some night shift CNAs will be trained on CPR by [DATE]. Abuse policy and signatures completed [DATE]. 5.) On [DATE] at 10:20 a.m., the Administrator stated, The QA we did found all residents on [DATE] after the incident found the code status were correctly listed as DNR or full code on their charts before [DATE]. No discrepancies in code status documentation were identified by the surveyors during the survey. 6.) On [DATE] at 10:30 a.m., the facility's Medical Director stated he was notified of the [DATE] full code incident involving Resident #13 and was aware of the corrective action plan to avoid future occurrences. 7.) The facility's new Cardiopulmonary Resuscitation policy, provided by the Assistant Director of Nursing (ADON) on [DATE], documented: Policy: It is the policy of this facility that licensed nurses have and maintain current CPR certification. 8.) A total of 8 CNAs, including 2 newly hired staff, and 6 LPNs were interviewed by the survey team during the survey regarding the facility's color-coding system on resident room doors. All staff who were questioned were able to correctly identify which residents were full code status versus DNR status, and all stated they had recently been in-serviced on this system.

Based on observation, record review and interview, the facility failed to ensure residents were assessed upon admission and reassessed periodically thereafter for the ability to handle hot liquids without supervision/assistance and to determine if assistive devices were needed to minimize the potential for injury from hot liquids for 2 (Residents #3 and #14) of 11 (Resident #2, 3, 4, 5, 7, 9, 10, 14, 17, 18, and 23) case mix residents who experienced burns from hot liquids. The failed practice resulted in Immediate Jeopardy which caused or could have caused serious harm, injury, or death to Resident #3, who received a second degree burn to the right thigh on 3/20/14 after spilling hot coffee on her lap; Resident #14, who received a first degree burn to the chest on 3/1/14 after spilling hot coffee on her chest; and had the potential to affect 68 residents who were identified to be at risk for injury from hot liquids according to the Director of Nursing (DON) on 5/2/14. The facility removed the immediate jeopardy prior to the initiation of the survey, however, the facility failed to correct all the underlying deficient practices. The Administrator was informed of the Immediate Jeopardy removed on 4/30/14 at 2:00 p.m. The findings are: 1. On 4/29/14 at 4:40 p.m., the Director of Nursing (DON) was asked what their policy was for assessing residents for hot liquids. She stated, "We do not do hot liquid assessments on any resident unless there has been a spillage. We do not have a written policy. I called our consultant and she said ... we do not do an assessment unless there is a problem." 2. Resident #3 had [DIAGNOSES REDACTED]. The Significant Change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/15/14 documented the resident scored 3 (0-7 indicates severely impaired cognitive skills) on the Brief Interview for Mental Status (BIMS), was totally dependent on staff for bed mobility, personal hygiene and bathing, was frequently incontinent of bowel and bladder, required one person physical assist for eating and had a second or third degree burn. a. The Nurses Note dated 3/20/14 documented, "4:45 (pm) CNA (Certified Nursing Assistant) reports resident was in dining room. She heard resident scream. When she went into dining room resident said she spilled coffee. Legs red bil (bilateral) upper bilateral thighs. ... (Physician) notified & (and) new order received & noted to apply Silvadene Oint (ointment) to coffee burn q (every) shift x (times) 7 days. ... . 7:30 (p.m.) Checked burn area & (and) noted several blisters ou (both) (left upper) thigh & (right upper) thigh..." 1) The Incident and Accident report dated 3/20/14 documented, "CNA reported she heard resident yell & went to dining room & resident said she spilled coffee on her. Legs red bilateral thighs. ... Intervention. If she request coffee make sure it's in a cup (with) lid..." 2) The Coffee Temperature Log dated 3/20/14 documented the coffee temperature for the dinner meal was 165 degrees. b. The Nurses Note dated 3/24/14 documented, "9:35 (am) Blisters to inner (right) thigh measures 11 cm (centimeters) x 5 cm open. Lt (left) measures 6 cm x 5 cm open. Closed blister to rt (right) upper thigh. Resident states pain when measuring. New orders received to start ABT (antibiotic) Bactrim DS (one) po (by mouth) BID (twice a day) x 10 days. Consult wound clinic..." The wound clinic Physician Procedure Note dated 3/24/14 documented, "1. (left) thigh - (second degree) burn. ... 2. (right) thigh - (second degree) burn..." c. There was no hot liquids safety assessment performed on the resident prior to the accident on 3/20/14. The Hot Liquids Safety form dated 3/21/14 documented, "Cognition: BIMS Score (if interviewable) < 8 ... : 3 Mood: Varies over course of day/easily agitated: 0 Behaviors: Frequent impulsive acts/short tempered: 0 Tremors: Observed tremors in upper ext. (extremities): 0 Contractures: Contractures in fingers/hands/wrists/elbows/shoulders: 0 Strength: Weakness/paresis in upper ext.: 0 Mobility: Loss of mobility/reduced mobility in upper extremities: 0 Total # (number) of check marks: 1 TWO OR MORE CHECK MARKS INDICATE THE RESIDENT IS AT RISK FOR INJURIES FROM SPILLS OF HOT LIQUIDS.(sic) Interventions: 3/20/14: Coffee cup (with) lid." 1) On 4/29/14 at 4:20 p.m., the DON was asked if there was a hot liquid assessment completed on Resident #3 prior to her receiving the burn on 3/20/14. She stated, "No." 2) On 4/29/14 at 4:30 p.m., the Administrator was asked if there was a hot liquid assessment completed on Resident #3 prior to her getting burned on 3/20/14. She stated, "No. There was no reason to. She had not had any problems prior to then." d. The Resident Care Plan updated 4/16/14 documented, "...Problem/Need ... Totally dependent on staff to anticipate and meet all basic needs ... Will be totally assisted with dining..." There was no documentation on the care for intervention(s) to minimize the risk of injury from hot liquids. e. On 4/30/14 at 10:00 a.m., Licensed Practical Nurse (LPN) #6 and CNA #7 entered the resident's room. The resident was in the bed with covers over her body up to the chest. LPN #6 explained to the resident that she was going to change the dressing. LPN #6 placed a barrier on the overbed table (paper towels) and placed a plastic cup containing 4x4's wet with wound cleanser, a 30 cc (cubic centimeters) plastic medication cup containing Silvasorb gel, and two telfa pads (sterile wrapped) and two border dressings (sterile wrapped) on the paper towel barrier. LPN #6 pulled back the covers and the resident's right thigh contained a long linear burn along the fold to the upper right thigh with an area in the center that contained dark tissue. Two smaller linear wounds were semi-perpendicular to the main wound on the right upper thigh. There were no wounds seen on the left thigh. On 4/30/14 at 10:07 a.m., the Assistant Director of Nursing (ADON) measured the wounds to the resident's right thigh. The main wound was measured at 14 cm (centimeters) long with a section of dark tissue in the center that measured 4 cm long by 0.9 cm wide. The two semi-perpendicular wounds measured 1.6 cm long by 0.3 cm wide for the section above the main wound, and 1.1 cm long by 0.3 cm wide for the section below the main wound. LPN #6 performed wound care to the resident. f. On 4/30/14 at 3:00 p.m., the DON provided documentation of inservices provided to staff as follows: The DON provided a copy of an inservice that documented, "Inservice Topic: Prevention of Burns. Date: 3/25/14. Instructor: (DON). Summary: (Resident #3). 1) Hot liquids in cup (with) lid every time. 2) Put shirt protector on and one in lap for protection there. 3) Cool down her hot liquids." The inservice was conducted 4 days following the accident and 2nd degree burn on Resident #3 on 3/20/14. The Inservice was signed by 20 employees. g. On 4/30/14 at 10:02 a.m., CNA #7 was asked, "How do you know if a resident is at risk for hot liquids injury?" CNA #7 stated, "We put lids on everybody's cup." CNA #7 was asked, "What did you do before (the resident's injury)?" CNA #7 stated, "We poured coffee in the cup and gave it to the resident." CNA #7 was asked, "Did you put anything in it? Ice?" CNA #7 stated, "No." 3. Resident #14 had [DIAGNOSES REDACTED]. The Quarterly MDS with an ARD of 4/17/14 documented the resident scored 3 (0-7 indicates severely impaired) on the BIMS, had highly impaired vision and did not wear glasses, was totally dependent on two or more staff for bed mobility, required limited assistance of one person for eating, had other skin problems: burns (second or third degree), and received antipsychotic medication on 4 days and antianxiety medication 7 days in the past 7 days. a. The March 2014 Medication Administration Record (MAR) documented the resident received Norco 10-325 QID (four times a day) by mouth at 6:00 a.m., 10:00 a.m., 2:00 p.m., and 6:00 p.m. daily. The start date for this medication was documented as 10/23/13. The March 2014 MAR documented the resident received Seroquel 50 mg (milligrams) every evening at 7:00 p.m. until 3/18/14 when the dose was reduced to 25 mg every evening. The start date for this drug was documented as 1/31/14. The March 2014 MAR documented the resident received Lorazepam 1 mg every evening. The start date for this drug was documented as 1/15/13. b. The Incident and Accident Report dated 3/1/14 at 12:20 p.m. documented, "... Describe exactly what was observed ... : 12:20 p.m.. Res (resident) was hollering 'help me.' CNA (checked) on res. Res spilt (sic) coffee on self. Res has reddened area between breast. Res voiced discomfort. Physician notified. New order received: Apply TAO (Triple Antibiotic Ointment) to reddened area between breasts BID (twice a day) X (times) 7 days then re-eval (re-evaluate). Family notified. Res voiced relief after tx (treatment). ... Type of Intervention to prevent further injury: Lap and Shirt protector. Spill proof lid." The Coffee Temperature Log dated 3/1/14 documented the coffee temperature for the lunch meal was 169 degrees. c. The Hot Liquids Safety Evaluation dated 3/1/14 documented, "Cognition: BIMS Score (if interviewable) < 8 ... : 3 Mood: Varies over course of day/easily agitated: Checked Behaviors: Frequent impulsive acts/short tempered: Blank Tremors: Observed tremors in upper ext. (extremities): Blank Contractures: Contractures in fingers/hands/wrists/elbows/shoulders: blank Strength: Weakness/paresis in upper ext.: Blank Mobility: Loss of mobility/reduced mobility in upper extremities: Blank Total # (number) of check marks: 1 TWO OR MORE CHECK MARKS INDICATE THE RESIDENT IS AT RISK FOR INJURIES FROM SPILLS OF HOT LIQUIDS.(sic) Interventions: Resident to wear clothing protector/lap protector: 3/1/14." As of 4/30/14, there was no documentation of a hot liquid evaluation in the clinical record prior to the resident spilling coffee on herself causing burns to the breast area. d. The Incident and Accident Report dated 3/27/14 at 7:00 a.m.. documented, "... Describe exactly what was observed ... : Resident was yelling for help, aide checked on her and informed me resident had spilled coffee on her chest. Chest red, laid cold cloth over chest. Resident stated, 'It didn't hurt'. Monitored chest area, one hour later area not red. (No) signs of injury, resident denied pain. Spoke (with) aide that served her tray, resident was wearing clothes protector. Dr. (doctor) notified. Family notified. Type of intervention initiated to prevent further injury: Resident is to have lid on coffee cup. Clothing Protector. Coffee cup (with) lid." The Coffee Temperature Log dated 3/27/14 documented the coffee temperature for the breakfast meal was 171 degrees. e. The Hot Liquids Safety Evaluation dated 3/27/14 documented, "Cognition: BIMS Score (if interviewable) < 8 ... : 3 Mood: Varies over course of day/easily agitated: Checked Behaviors: Frequent impulsive acts/short tempered: Blank Tremors: Observed tremors in upper ext. (extremities): Blank Contractures: Contractures in fingers/hands/wrists/elbows/shoulders: blank Strength: Weakness/paresis in upper ext.: Blank Mobility: Loss of mobility/reduced mobility in upper extremities: Blank Total # (number) of check marks: 1 TWO OR MORE CHECK MARKS INDICATE THE RESIDENT IS AT RISK FOR INJURIES FROM SPILLS OF HOT LIQUIDS.(sic) Interventions: Coffee cup (with) lid: 3/27/14." On 4/30/14 at 12:23 p.m., the Director of Nursing (DON) was asked, "Do you perform the hot liquid assessment?" The DON stated, "Yes." The DON was asked, "How do you perform a hot liquids risk assessment?" The DON looked at a blank evaluation form and stated, "I fill this out according to my assessment." The DON was asked, "If a resident has a BIMS score of less than 8, that equals 1 check?" The DON stated, "Yes." The DON was asked, "If a resident has a change in mood, that equals one check?" The DON stated, "Yes." The DON was asked, "If a resident has behaviors, that equals one check?" The DON stated, "Yes." The DON was asked, "Resident #14 was assessed on 3/1/14 and had a check under 'BIMS score less than 8' and a check under mood changes. However, under the total number of checks a '1' was documented?" The DON stated, "That was a mistake. There should be a '2' there." At 3:00 p.m., the DON provided documentation of inservices provided to staff as follows: The DON provided a copy of an inservice provided to all nursing staff dated 3/10/14 that documented, "Inservice Topic: Restorative Nursing, Prevention of Accidents. Spillage of hot liquids." This inservice was conducted 9 days after the initial burn on Resident #14 on 3/1/14. f. On 4/30/14 at 11:55 a.m., the Assistant Activity Director brought a cup of coffee to the resident in the bed. The Assistant Activity Director added cold water to the cup of coffee and put a lid on the cup. The resident was sitting upright in the bed with the overbed table in front of her. Clothing protectors were on her chest and lap. 4. On 5/1/14 from 2:00 p.m. to 4:00 p.m., the Administrator provided copies of Hot Liquid Safety Evaluations performed on all residents in the facility on 5/1/14. There were 68 residents identified to be at risk of injury from hot liquids. 5. The facility removed the Immediate Jeopardy on 4/7/14 prior to surveyor entrance and reduced the scope/severity to "H" by implementing the following corrective actions: a. On 5/1/14 at 11:50 a.m., the Administrator provided a QA (Quality Assurance) Form dated 4/3/14 documented, "Problem: Spillage of hot liquids. Solution: 1) Inservice of nursing staff by Director of Nursing. 2) Reduce temperature of coffee from kitchen to 160 (degrees). 3) Monitor coffee temperature by Dietary Department. 4) Nursing monitor meal service 3 x (times)/week for lids on cups, cooling down coffee, etc. by DON. " On 4/30/14 at 3:00 p.m., the DON provided a copy of an inservice to all nursing staff that documented, "Inservice Date: 4/7/2014. Inservice Topic: Survey preparedness. Prevention of spillage of hot liquids, med (medication) pass, med rooms." b. On 5/1/14 at 2:50 p.m., the Dietary Manager provided a copy of an inservice dated 4/7/14 that documented, "...Lids must be sent for all hot beverages. ..." c. An Inservice Sheet dated 4/16/14 documented, "Topic: Hot liquid precautions. Instructor: (DON). Summary: Temperature of coffee coming from kitchen is 160. Serve hot liquids with lids on cup. Let dietary manager and nurse managers of residents non compliant with lids.(sic) Make sure hot coffee is cooled by adding ice. Residents to wear clothing protector/lap protector. Residents are to be assisted with all hot liquids. Read policy and procedures on classifications of burns." The inservice was signed by 25 employees. d. The March 2014 Coffee Temperature Log documented the coffee temperatures were above 155 degrees for 75 of the 93 meals served (80.6% of meals served); above 170 degrees for 24 of the 93 meals served (26%) and above 180 degrees for 14 of the 93 meals served (15%). The April 2014 Coffee Temperature Log documented that the coffee temperature was served above 155 degrees for 84 of the 87 meals documented (95%). 6. Facility's implementation of corrective actions in removing the immediate jeopardy verified as follows: a. On 5/1/14 at 1:37 p.m., the Dietary Manager provided the April 2014 coffee temperature log. The Dietary Manager was asked, "Are the temps from the (nursing) unit or the kitchen?" The Dietary Manager stated, "They are the temps from the kitchen." The Dietary Manager was asked, "Before it is put into carafes?" The Dietary Manager stated, "Yes." The Dietary Manager was asked, "Did you ever check the temps out on the unit before it was served to the residents?" The Dietary Manager stated, "No." The Dietary Manager was asked, "Were you involved in any of the plans after the resident was burned by spilled coffee?" The Dietary Manager stated, "Yes." The Dietary Manager was asked, "What was your involvement?" The Dietary Manager stated, "To provide the plastic lids for the cups." The Dietary Manager was asked, "When did you start that?" The Dietary Manager stated, "I don't know, I'll have to look." The Dietary Manager was asked to provide temperature monitoring for March 2014, and a copy of documentation of when the lids were provided with all cups of hot liquid. On 5/2/14 at 9:00 a.m., the Dietary Manager was asked, "After reviewing the coffee temps served in March, 75 of the 93 meals served documented a temperature of more than 155 degrees. What did the facility do to mitigate the temperature of the coffee?" The Dietary Manager stated, "We contacted the company (distributor of the coffee maker) to service the coffee maker and adjust the temperature." The Dietary Manager was asked, "When did you do this?" The Dietary Manager stated, "I don't remember." The Dietary Manager was asked, "Do you have any documentation for this?" The Dietary Manager stated, "I'm getting it." The Survey Team requested a copy of the documentation of the service visit. The Dietary Manager was asked, "Were the temperatures of the coffee in carafes sent to the units monitored?" The Dietary Manager stated, "No." On 5/2/14 at 11:10 a.m., the Administrator provided a copy of an e-mail from the coffee machine distributor dated 5/2/14 at 10:12 a.m. that documented, "...I confirmed your original call on 4/17/14 which stated the machine was not heating. My tech called you and found out that the actual issue was the machine was over heating at 192 degrees. There was some confusion on our end due to the fact that 192 degrees is the normal range. Our standard temp for brewing coffee is 190 to 200 degrees, however we understand that you are trying to eliminate risk by brewing at lower temps. I apologize for the confusion which resulted in us not responding and closing the call based on our belief that the machine was functioning properly. My service tech will be on his way to drop the brew temperature for you shortly. ... He should arrive before 12:00 p.m. today." There was no action to adjust the temperature of the coffee at the kitchen before 5/2/14. b. On 4/30/14 at 10:20 a.m., the ADON was asked, "How do you know which residents are at risk for hot liquids injury?" The ADON stated, "The ones with a disease process, such as Alzheimer's Dementia." The ADON was asked, "What interventions were put into place after Resident #3 was burned?" The ADON stated, "Plastic white lids go on the cups, like at Starbucks. We make sure the temp of the coffee that goes to the units is less than the dining room." The ADON was asked, "Do you do temp checks?" The ADON stated, "The kitchen does, I don't." The ADON was asked, "Do you use molded plastic mugs with screw on lids for residents that remove the lids?" The ADON stated, "I haven't seen them used." c. On 4/30/14 at 12:23 p.m., the Director of Nursing (DON) was asked, The DON was asked, "What investigation did you do after the burns on the residents? Were the temps (of the coffee) checked?" The DON stated, "The dietary department checked the temps. We inserviced the staff (on hot liquids)." d. On 4/30/14 at 1:45 p.m. to 1:55 p.m., 2 LPN's (LPN #6 and 7) and 12 CNA's (CNA #1, 4, 7 - 17) were interviewed to determine if they had been inserviced on hot liquids safety and what interventions were implemented to reduce the risk of hot liquids injury. All staff interviewed stated they were given an inservice on hot liquids safety and that all hot liquids were served in cups with a lid and that the temperature of the hot liquid is reduced with cool water before giving to residents.

Based on record review and interview, the facility failed to provide necessary care and services to ensure that Resident #3 maintained the highest practicable physical well being. The facility failed to ensure a thorough assessment of the cause of continued pain and bruising after a fall and to immediately consult with the physician in order to ensure prompt treatment and to decrease/alleviate the pain for 1 (Resident #3) of 4 (Residents #1, #3, #4 and #8) case mix residents who had a significant change in condition. This failed practice resulted in a pattern of harm for Resident #3 who experienced increased pain after a fall and had a femoral fracture that was not identified until 11 days later and had the potential to cause more than minimal harm to 17 residents who had a significant change of condition per a list provided by the Administrator on 6/6/13 at 11:58 a.m. The findings are: 1. A Policy and Procedure provided by the Administrator on 6/6/13 at 11:58 am documented, "... Subject: Change In Condition ... Policy: Resident change in condition will be assessed promptly and follow-up interventions will occur as indicated and in a timely manner. Procedure: 1. Resident change in condition will be reported immediately to the licensed charge nurse by the staff person who first notices the change. 2. The licensed charge nurse will assess the resident and make note of signs and symptoms, including physical and/or mental changes in condition. 3. The resident's primary care physician or designated alternate will be notified immediately of any change in the resident's physical or mental status. The resident's designated medical contact will also be notified. ...4. Notification of the physician and/or responsible parties will be documented in the clinical record as well as on the 24-hour report form. Status changes which are not significant enough to be reported must be documented in the clinical record. 5. Significant change in condition may require a comprehensive resident reassessment with associated documentation. "Significant Change" is defined as a major improvement or decline in the resident's condition affected by the change. Acute conditions such as a ... or broken hip ... can trigger a reassessment. 6. The Director of Nursing (or a designee) will assist in determining significant change of condition for purposes of reassessment when questions arise. Nursing staff that are in doubt about this should automatically refer to the Director of Nurses (or a designee) for assistance in a determination. ... Essential Points: ... There are many signs and symptoms of a change of condition. It is the responsibility of the licensed charge nurse to monitor resident for these. ..." 2. Resident #3 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/1/13 documented the resident scored 3 (0-7 indicates severe impairment) on the Brief Interview for Mental Status Score; required extensive assistance with bed mobility, total assistance for transfer, was not on any scheduled or PRN (as needed) pain medication and had no falls since admit/reentry/prior assessment. a. A Nurses Note dated 2/22/13 documented: 1) At 3:45 p.m., "I heard somebody screaming for help in the back hall et (and) ran to check resident in Rm (Room) #118 lying on the floor (with) her socks on, a fair amount of blood dripping on her head. 2 lacerations noted on the (left) side of the head (with) bruise. ... ER (emergency room ) notified et gave the report. (Doctor) notified. Order received et noted. Send resident to (Hospital) ER for tr (treatment) et eval (evaluation)." 2) At 3:56 p.m., "Resident left (with) 2 staff via (by way of) w/c (wheelchair) to (Hospital) ER." 3) At 6:00 p.m., "ER nurse called, resident ready to go back to Nursing home..." 4) At 6:15 p.m., "Discharge order from ER 1. Transfer pt (patient) to Crawford Health and Rehab, 2. Dx (Diagnosis): [MEDICAL CONDITION], hematoma, 3. Remove pressure dressing in 24 (hours) ... 6. [MEDICATION NAME] 5/325 mg (one) po (every) 6 (hours) PRN for pain (72 hours only). ... ER nurse gave resident [MEDICATION NAME] 5/325 mg (one) tab (tablet) @ (at) 5:45 pm. c/o (complained of) (lower) (left) breast pain." 5) At 6:30 p.m., "Resident c/o (left) (lower) breast pain if she moved her (left) hand. Will Monitor closely..." There was no documentation in the nurses notes of an assessment of the cause of the pain. b. Nurses Notes from 2/23/13 through 3/3/13 documented the following complaints of pain after the 2/22/13 fall: 1) A Nurses Note dated 2/23/13 at 12:00 a.m. documented, "... c/o (left) side pain. [MEDICATION NAME] 5/325 mg (one) po given for c/o (left) side pain..." There was no documentation in the nurses notes of an assessment of the cause of the pain. 2) A Nurses Note dated 2/24/13 at 5:42 a.m. documented, "[MEDICATION NAME] 5/325 mg (one) po given for c/o (left) side pain..." There was no documentation in the nurses notes of an assessment of the cause of the pain. 3) A Nurses Note dated 2/25/13 at 11:30 p.m. documented, "[MEDICATION NAME] 5-325 mg (one) po given for c/o (left) side pain." There was no documentation in the nurses notes of an assessment of the cause of the pain. 4) A Nurses Note dated 2/26/13 at 10:15 a.m. documented, "(Resident) c/o (left) hip pain when raising HOB (head of bed). (no) further c/o when transferring and bearing wt. (weight). Bruising noted to hip area consistent (with) fall on 2/22. Will monitor." There was no documentation in the nurses notes of an assessment of the cause of the pain or that the physician was consulted regarding the continued complaints of pain and the bruising to the left hip. 5) A Nurses Note dated 2/27/13 at 12:19 a.m. documented, "[MEDICATION NAME] 5/325 mg (one) po given for c/o (left) side pain. 1:19 am Fair relief. " There was no documentation in the nurses notes of an assessment of the cause of the pain or that the physician was consulted regarding the continued complaints of pain. 6) A Nurses Note dated 2/28/13 at 9:48 a.m. documented, "[MEDICATION NAME] 5/325 mg (one) po given for c/o left leg pain." There was no documentation in the nurses notes of an assessment of the cause of the pain or that the physician was consulted regarding the continued complaints of pain. 7) A Nurses Note dated 2/28/13 at 10:30 a.m. documented, "... little effect noted from pain med (medication). Will continue to monitor." There was no documentation in the nurses notes of an assessment of the cause of the pain or that the physician was consulted regarding the continued complaints of pain. 8) A Nurses Note dated 2/28/13 at 5:33 p.m. documented, "Resident hollering/screaming for pain on her leg, gave [MEDICATION NAME] 5/325 mg (one) tab po..." There was no documentation in the nurses notes of an assessment of the cause of the pain. 9) A Nurses Note dated 3/1/13 at 5:38 a.m. documented, "[MEDICATION NAME] 5/325 mg (one) po given for c/o (left) side pain. 6:30 am fair results." There was no documentation in the nurses notes of an assessment of the cause of the pain or that the physician was consulted regarding the continued complaints of pain. 10) A Nurses Note dated 3/2/13 at 4:30 a.m. documented, "Resident complain of leg pain & (and) pain in her ribs left side, area bruised ..." There was no documentation on the March 2013 MTAR that the resident was given any pain medication on this date and time. There was no documentation in the nurses notes of an assessment of the cause of the pain or that the physician was consulted regarding the continued complaints of pain and the bruising to the left side. 11) A Nurses Note dated 3/3/13 at 1:54 a.m. documented, "[MEDICATION NAME] 5/325 mg (one) po given for c/o (left) leg pain." There was no documentation in the nurses notes of an assessment of the cause of the pain or that the physician was consulted regarding the continued complaints of pain. 12) A Nurses Note dated 3/3/13 at 5 p.m. documented, "... I'm not feeling well and ... I don't think I will get well. at 5:34 pm gave routine medications and [MEDICATION NAME] 5/325 mg (one) tab PRN c/o general pain..." There was no documentation in the nurses notes of an assessment of the cause of the pain. 13) A Nurses Note dated 3/4/13 at 4:03 a.m. documented, "Late entry (documented after 3/4/13 3:00 p.m. notes) [MEDICATION NAME] 5/325 mg (one) po for c/o pain all over." There was no documentation in the nurses notes of an assessment of the cause of the pain or that the physician was consulted regarding the continued complaints of pain. 14) A Nurses Note dated 3/4/13 at 9:29 a.m. documented, "[MEDICATION NAME] 5/325 mg (one) po as needed given for c/o left leg pain. Sitting up in w/c..." There was no documentation in the nurses notes of an assessment of the cause of the pain or that the physician was consulted regarding the continued complaints of pain. c. A Nurses Note dated 3/4/13 at 3:00 p.m. documented, "Order received (and) noted 1. [MEDICATION NAME] 5/325 mg (one) tab po (every) 6 hours. Dx: pain management, 2. X-Ray ribs, (left) hip ... 5:00 pm resident refused dinner, tried to feed resident but she don't want anybody to be close to her stated, 'I'm in pain, it hurts so bad' holding (left) ribs and (left) leg hurts to touch, gave routine [MEDICATION NAME] 5/325 mg (one) tab po @ 6 pm. able to drink milk a little bit @ a time then wants cold water,. Resident calling her family if she is in pain. ..." There was no documentation in the nurses notes of an assessment of the cause of the pain. 1) A Nurses Note dated 3/5/13 at 8:30 a.m. documented, "Onsite Imaging Solutions here for x-ray of left ribs et left hip. 2) An Onsite Imaging Solutions Report dated 3/5/13 at 7:21 a.m. documented, "...Findings: There is an acute fracture at the femoral neck with approximately 40 percent displacement. This displacement results in varus deformity..." 3) 9:45 am Received x-ray report (with) acute fracture at left femoral neck ... New order rec'd (received) et noted to send to (Hospital) ER for eval (evaluation) et tr..." 4) A Nurses Note dated 3/6/13 at 9:00 a.m. documented, "New order rec'd et noted to admit to (Hospital) as of 3/5/13..." d. On 6/4/13 at 10:45 a.m., the Director of Nursing (DON) was interviewed regarding the resident's fall on 2/22/13. She was asked if the physician was notified due to the resident's increased need for pain medication after the fall. The DON stated, "I thought she had x-rays at the hospital." The DON was informed by the surveyor that the resident received a CT (computerized tomography) on 2/22/13. The DON then stated, "I thought they had called the doctor about her pain." After reviewing the resident's record the DON stated, "I can't see where the doctor was called." She was then asked when the facility had requested x-ray results from the hospital and identified that what was done was a CT of the head. The DON stated, "On the (March) 5th, when she had continued to complain and then we knew she hadn't had an x-ray." e. On 6/4/13 at 11:10 a.m., Licensed Practical Nurse (LPN) #1 was interviewed by phone and she was asked if Resident #3 had experienced an increase in pain after her fall on 2/22/13. The LPN stated, "I do know that she would complain of arm pain. It's hard to say since I don't have the chart in front of me. I would have to read and look back. Possibly wasn't reported to the doctor since she had already been to the hospital." f. On 6/4/13 at 11:17 a.m., the DON came to the surveyor and stated, "When she was sent to the emergency roiagnom on ,[DATE] the Administrator went and told them she was complaining of hip pain. We thought they did an x-ray. She continued to have complaints of pain. We requested the x-rays on March the 5th. That's when we saw she only had the CT of the head. We should have reviewed those results sooner than that." g. On 6/4/13 at 11:35 a.m., LPN #2 was interviewed regarding Resident #3's fall on 2/22/13. The LPN stated, "Her need for the pain medication increased after the fall. I didn't call the doctor about her increase in the pain and taking the pain med more often. I went through her chart, I remember, at least one time and I didn't see anything. I just assumed the report hadn't come back yet. Sometimes it takes a while, at least a couple of days I think. Now as I think about it somebody should have called for the results. I thought they did x-ray of her hip when she was over there. That was too long for her to complain of pain." h. On 6/4/13 at 2:29 p.m., LPN #3 was asked if she remembered the resident's fall on 2/22/13. She stated, "Yes, I found her." When she was asked if she had reviewed the report from the hospital she stated, "I really don't remember, I know she had a scan. (Doctor) had asked for the scan one time but it wasn't on the chart. We are suppose to get the results so we can get them to the doctor." The LPN was asked if the resident had required more pain medication after this fall and she stated, "She did require the pain medication more often after the fall. I really don't remember if I called the Doctor. I did not call the hospital and ask for any report results." i. On 6/5/13 at 1:41 p.m., LPN #1 came to this Surveyor and stated, "I've had a chance to look at the chart and maybe can explain something." The LPN and this Surveyor went to the nurses station and the LPN stated, "She was getting pain medication before the fall." When the LPN was asked if the resident's need for pain medication had increased after the fall she stated, "Well yes, but she had fallen and most people hurt after a fall." When the LPN was asked if she had notified the physician of the resident's increased need for pain medication she did not answer. The LPN was then asked if she had called the hospital to obtain results of any tests done on 2/22/13 she stated, "No, I knew they did a CT because we have the results on the chart." She was then asked when the facility obtained the result, she stated, "I just knew we had a report." The resident's chart was obtained and turned to the CT results. The LPN was asked when the results were obtained. After looking and seeing that the results were faxed to the facility on [DATE] the LPN stated, "I see what you're seeing now." j. On 6/4/13 at 2:10 p.m., the Administrator was asked if she remembered the fall Resident #3 had experienced on 2/22/13 and that she required more pain medication. The Administrator stated, "I assumed she was taking more pain medication because she had a laceration to her head and she was just sore from the fall. I didn't read the nurses notes but I will from now on."

A. Based on observation, record review, and interview, the facility failed to identity and implement appropriate measures to minimize the spread of Clostridium Difficile (C-Diff) infections: The facility failed to promptly consult with the physician regarding incontinent episodes of slimy foul smelling diarrhea within 7 days of admission to nursing home from hospital for 1 of 1 case-mix resident (Resident #22) who wandered in and out of other residents ' rooms and experienced incontinent episodes of diarrhea. The facility failed to ensure staff implemented isolation precautions to decrease the potential for the spread of Clostridium Difficile and that staff and visitors were informed of isolation precautions required for 1 (Residents #3) of 3 (Resident #s 3, 22 and 23) who resided on the 100 Hall unit and were diagnosed with [REDACTED]. The facility failed to ensure a disinfectant that was effective against[DIAGNOSES REDACTED] was utilized for laundry to prevent the potential spread of[DIAGNOSES REDACTED]. The facility further failed to ensure isolation linens were washed with a disinfectant that killed the bacteria that cause[DIAGNOSES REDACTED] to prevent the possible spread of infection to all residents who resided in the facility. Three case-mix residents (Resident #s 3, 22 and 23) were [DIAGNOSES REDACTED]. The facility failed to ensure a disinfectant cleaner that killed[DIAGNOSES REDACTED] spores was used to clean contaminated equipment and the immediate environment to prevent the spread of[DIAGNOSES REDACTED] infection to other residents who resided on the closed unit and potential spread to all 104 residents who resided at the facility. The facility failed to ensure residents without[DIAGNOSES REDACTED] were not cohorted with residents who had active[DIAGNOSES REDACTED] for 1 of 1 (Resident # 4) case mix resident who did not have a [DIAGNOSES REDACTED]. The facility also failed to ensure the infection control log recorded, tracked and trended all communicable diseases, not just antibiotic use; recorded if cultures were done; what organism was cultured; if isolation was implemented and when; if the communicable disease was nosocomial or community acquired; if a recapture was done, and the date the communicable disease was resolved for and reviewed in order to identify patterns of infection and intervene to correct any problems with infection control techniques. These failed practices resulted in Immediate Jeopardy which caused or could have caused serious harm, injury or death to Resident(s) # 22, 23, and 3 who contracted or repeatedly contracted Clostridium Difficile infections and had the potential to cause more than minimal harm for 1 resident in the facility who was cohorted with a resident who had active[DIAGNOSES REDACTED] and for all 104 residents in the facility who used facility linens as documented by the Administrator on 4/12/12 at 4:30 p.m. The facility was notified of the Immediate Jeopardy condition on 4/12/12 at 4:30 p.m. The findings are: 1. The facility policy titled "Isolation Precautions - All departments" documented, "Policy Statement: Any resident suspected or diagnosed as having a communicable disease shall be placed in the appropriate type of isolation as delineated in these policies and procedures. ... If the disease of infection, according to CDC Guidelines, requires isolation or precautions, the resident will be isolated only to the degree necessary to isolate the infecting organism. ... Categories of Isolation Precautions: ... c. Contact Isolation ... Supervision Policy. The Infection Control Coordinator or designee shall be responsible for organizing and directing the implementation of the Infection Control Procedures when isolation becomes necessary. The charge nurse of each unit shall be responsible for carrying out all functions of the isolation precautions as directed by the Infection Control Coordinator and the policies and procedures of this facility. This includes supervision of personnel and assurance that all personnel and visitors follow established isolation precautions as well as any special instructions that become necessary. Isolation Procedure. ... 3. The isolation room is easily identified with an appropriate isolation sign which is posted outside the door by the Infection Control Coordinator or the Nurse Supervisor. Placement in Isolation Procedure: 1. If there is a reason to believe (based upon Guidelines for Determining an Infection) that a resident has a communicable disease, the attending physician or alternate shall be notified immediately of such condition and permission requested to initiate the appropriate isolation precautions. ... 5. All residents placed in isolation, for suspected or confirmed infections, shall have isolation precautions implemented in accordance with procedures established in the CDC Guidelines for Isolation Precautions in Hospitals. ... Posting of Isolation Signs. 1. When isolation of a resident is ordered, the appropriate isolation signs shall be posted outside the entrance to the resident ' s room by the Infection Control Coordinator or the Director of Nurses. ... Equipment and Supplies. ... 4. The Infection Control Coordinator or designee will review specific procedures with the charge nurse and assigned nursing assistant(s). ... Record Keeping Requirements. 1. A record shall be maintained of all communicable disease found within this facility. ... Appendix A. ... Gastroenteritis ... Infection/Condition: [DIAGNOSES REDACTED]icile; Type: C (Contact); Duration: (Duration of Illness); Precautions: Discontinue antibiotics if appropriate. Do not share electronic thermometers; ensure consistent environmental cleaning and disinfection. Hypochlorite solutions may be required for cleaning if transmission continues. Handwashing with soap and water preferred because of the absence of sporicidal activity of alcohol in waterless antiseptic hand rubs. ...". 2. The CDC Frequently Asked Questions about Clostridium difficile for Healthcare Providers documented: (found at http://www.cdc.gov/HAI/organisms/cdiff/Cdiff_faqs_HCP.html#a6>) "...How is Clostridium difficile transmitted? Clostridium difficile is shed in feces. Any surface, device, or material (e.g., commodes, bathing tubs, and electronic rectal thermometers) that becomes contaminated with feces may serve as a reservoir for the Clostridium difficile spores. Clostridium difficile spores are transferred to patients mainly via the hands of healthcare personnel who have touched a contaminated surface or item...How can Clostridium difficile infection be prevented in hospitals and other healthcare settings? ...Use Contact Precautions: for patients with known or suspected Clostridium difficile infection: Place these patients in private rooms. If private rooms are not available, these patients can be placed in rooms (cohorted) with other patients with Clostridium difficile infection. Use gloves when entering patients' rooms and during patient care. Perform Hand Hygiene after removing gloves. Because alcohol does not kill Clostridium difficile spores, use of soap and water is more efficacious than alcohol-based hand rubs. However, early experimental data suggest that, even using soap and water, the removal of [DIAGNOSES REDACTED]icile spores is more challenging than the removal or inactivation of other common pathogens. Preventing contamination of the hands via glove use remains the cornerstone for preventing Clostridium difficile transmission via the hands of healthcare workers; any theoretical benefit from instituting soap and water must be balanced against the potential for decreased compliance resulting from a more complex hand hygiene message. If your institution experiences an outbreak, consider using only soap and water for hand hygiene when caring for patients with Clostridium difficile infection. Use gowns when entering patients' rooms and during patient care. Dedicate or perform cleaning of any shared medical equipment. Continue these precautions until diarrhea ceases. Because Clostridium difficile-infected patients continue to shed organism for a number of days following cessation of diarrhea, some institutions routinely continue isolation for either several days beyond symptom resolution or until discharge, depending upon the type of setting and average length of stay. Implement an environmental cleaning and disinfection strategy: Ensure adequate cleaning and disinfection of environmental surfaces and reusable devices, especially items likely to be contaminated with feces and surfaces that are touched frequently. Consider using an Environmental Protection Agency (EPA) -registered disinfectant with a sporicidal claim for environmental surface disinfection after cleaning in accordance with label instructions; generic sources of hypochlorite (e.g., household chlorine bleach) also may be appropriately diluted and used. (Note: Standard EPA-registered hospital disinfectants are not effective against Clostridium difficile spores .) Hypochlorite-based disinfectants may be most effective in preventing Clostridium difficile transmission in units with high endemic rates of Clostridium difficile infection. Follow the manufacturer's instructions for disinfection of endoscopes and other devices. Recommended infection control practices in long term care and home health settings are similar to those practices taken in traditional health-care settings. 3. Resident # 22 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. A facility Detailed Admission/Discharge Report received from the Administrator on 4/9/12 documented the resident was admitted to West I to a semi private room. Nurses Notes dated 12/28/11 at 4:25 p.m. documented, "... transferred from ... hospital ..." a. Nurses Notes from 12/29/11 to 1/8/12 documented resident wandering hallways, entering other resident rooms and incontinent episodes of diarrhea: 1) Nurses Notes dated 12/29/11 for the 11:00 p.m. to 7:00 a.m. shift documented, "Resident was (up) ambulating and wandering into hallway early in the evening, also noted to be across the (bathroom) into other resident room - confused and lost ... easily redirected to his bed (times) 3 tonight ..." Nurses Notes dated 12/29/11 for the 3:00 p.m. to 11:00 p.m. shift documented, "Resident ambulating per self. Wandering down halls. Caught resident in two other residents' room ... " 2) Nurses Notes dated 12/30/11 for the 11:00 p.m. to 7:00 a.m. shift documented, "Resident alert and confused. He walked into another resident's room ... He continues to wander up and down the halls going into other resident's room ..." 3) Nurses Notes dated 1/2/12 for the 11:00 p.m. to 7:00 a.m. shift documented, "... Then he was (up) wandering - noted to have diarrhea in pants ... He was (up) wandering when wet (with) urine, also was (up) wandering across hallway about 6:30 a.m., noted to have diarrhea in his pants again ..." Nurses Notes dated 1/2/12 for the 3:00 p.m. to 11:00 p.m. shift documented, "Resident wandering this shift ... Found in one resident's bathroom (with) her water pitcher. Found in another resident's recliner. Also heading to hopper room, toward West II and Central (at) different (times) ..." 4) Nurses Notes dated 1/3/12 for the 11:00 p.m. to 7:00 a.m. shift, written by Licensed Practical Nurse (LPN) # 4, documented, "Resident (up) wandering this shift. Resident had foul smelling slimy (bowel movement). Will monitor." (On 4/18/12 at 11:10 a.m., LPN # 4 was asked "Did you notify the physician of (Resident # 22's) foul smelling, slimy bowel movement?" LPN # 4 stated, "I can't remember if I wrote it on the communication sheet or not." LPN # 4 was asked "Did you call the physician since the stool you described is indicative of[DIAGNOSES REDACTED]?" LPN # 4 stated, "No." LPN # 4 was asked, "Did you know a foul smelling slimy stool can be a sign of[DIAGNOSES REDACTED]?" LPN # 4 stated, "No.") Nurses Notes dated 1/3/12 at 2:05 p.m. documented, "Room transfer to East hall ..." 5) Nurses Notes dated 1/5/12 for the 11:00 p.m. to 7:00 a.m. shift documented, "Up several times during night. Going into others room (and) (up) (and) (down) hallway for awhile ..." 6) Nurses Notes dated 1/6/12 for the 3:00 p.m. to 11:00 p.m. shift documented, "... (Bowel movement) has a foul odor/strong odor ..." 7) Nurses Notes dated 1/8/12 for the 7:00 a.m. to 3:00 p.m. shift documented, "(Temperature) 100.1. (Family member) (complained) (Resident) feeling warm to touch. Temp (checked) - febrile. Stool formed (and) liquefied (with) foul odor. New orders 1) Lab - check for[DIAGNOSES REDACTED] (Clostridium difficile) ..." A laboratory report dated 1/8/12 documented, "Collected: 1/8/12, Reported: 1/10/12 ...[DIAGNOSES REDACTED]icile by lamp ... Positive ... Reference Range: Negative." b. Nurses Notes dated 1/10/12 at 7:30 a.m. documented, "New orders received and noted to start [MEDICATION NAME] ... for[DIAGNOSES REDACTED]. Recheck stool for[DIAGNOSES REDACTED] on (January) 23. Contact Isolation until[DIAGNOSES REDACTED] (negative)." The resident's room was not changed. The resident remained in a private room that had no bathroom and no sink. The "Care Plan" dated 1/10/12 and reviewed on 4/4/12 documented, "Problem/Need: Resident has[DIAGNOSES REDACTED] ... Approaches: Staff to keep resident in contact isolation to prevent spread of germs ... Disinfect all equipment before it leaves the resident's room. Place in private room ..." c. A physician progress notes [REDACTED]. ..." d. A laboratory report dated 1/24/12 documented, "Collected: 1/24/12, Reported: 1/26/12 ...[DIAGNOSES REDACTED]icile by lamp ... Positive ... Reference Range: Negative." A physician progress notes [REDACTED]. The following week, stool specimen was submitted to re-check on[DIAGNOSES REDACTED], and it still reported at positive ..." e. A laboratory report dated 1/30/12 documented, "Collected: 1/30/12, Reported: 1/31/12 ...[DIAGNOSES REDACTED]icile by lamp ... Positive ... Reference Range: Negative." A physician progress notes [REDACTED]. stay in his room for purposes of isolation, although staff tries to guide him in that direction." f. A laboratory report dated 2/21/12 documented, "Collected: 2/21/12, Reported: 2/22/12 ...[DIAGNOSES REDACTED]icile by lamp ... Positive ... Reference Range: Negative." A physician progress notes [REDACTED]. ... More than a week after treatment ended, we have collected a specimen, and it is still showing positive for[DIAGNOSES REDACTED] ..." A physician progress notes [REDACTED].# 22) is often up wandering the hall day and night ... continues on his month-long third treatment for [REDACTED]. g. A laboratory report dated 3/28/12 documented, "Collected: 3/28/12, Reported: 4/2/12 ...[DIAGNOSES REDACTED]icile by lamp ... Negative ... Reference Range: Negative." h. On 4/9/12 at 3:28 p.m., during initial rounds with LPN # 4, a 3 inch wide and 11 inch long orange colored "Contact Isolation" sign was noted on the upper right hand side of the door frame. LPN # 4 stated the resident "was recently over[DIAGNOSES REDACTED]." There were no isolation supplies outside or inside the room. 4. Resident # 23 was admitted on [DATE] with a [DIAGNOSES REDACTED]. a. Nurses Notes dated 2/14/12 for the 3:00 p.m. to 11:00 p.m. shift documented, "... (At) 7:30 p.m. ... CNA notified this nurse that resident (bowel movement) watery, yellow in color (and) slimy ... (At) 8:20 p.m. (doctor) notified. Order received ... check for[DIAGNOSES REDACTED] ... (Temperature) 100.3 ..." b. Nurses Notes dated 2/15/12 for the 7:00 a.m. to 3:00 p.m. shift documented, "... (Bowel movement) noted yellowish in color (and) slimy ..." Nurses Notes dated 2/15/12 for the 3:00 p.m. to 11:00 p.m. shift documented, "... (Bowel movement) still slimy (and) yellowish in color ... " c. Nurses Notes dated 2/16/12 for the 7:00 a.m. to 3:00 p.m. shift documented, "... (Bowel movement) noted yellowish in color (and) slimy ... " d. Nurses Notes dated 2/17/12 at 2:01 a.m. documented, "... lab called (with) positive results for[DIAGNOSES REDACTED]. Physician paged ... Isolation precautions set up." The laboratory report documented, "Collected: 2/14/12, Reported: 2/17/12 ...[DIAGNOSES REDACTED]icile by lamp ... Positive ... Reference Range: Negative." The physician progress notes [REDACTED]. Exam now confirms it. I am going to start ... dual antibiotic therapy ... " e. The physician progress notes [REDACTED].# 23) was found to have[DIAGNOSES REDACTED] enteritis, but was losing weight even before then. She had finished out her course of treatment for [REDACTED]." f. The laboratory report documented, "Collected: 3/1/12, Reported: 3/2/12 ...[DIAGNOSES REDACTED]icile by lamp ... Negative ... Reference Range: Negative". Nurses Notes dated 3/2/12 at 2:30 p.m. documented, "Results from stool sample negative for[DIAGNOSES REDACTED], resident no longer on contact isolation due to negative results, will monitor." g. Nurses Notes dated 3/5/12 for the 3:00 p.m. to 11:00 p.m. shift documented, "3:00 p.m. Order received ... Re-check for[DIAGNOSES REDACTED] ... 6:00 p.m. Resident (bowel movement) looks like a mild diarrhea (and) slimy ...". h. Nurses Notes dated 3/6/12 for the 3:00 p.m. to 11:00 p.m. shift documented, "... (Bowel movement) (times) 3, still slimy (with) strong odor ... " i. Nurses Notes dated 3/8/12 for the 3:00 p.m. to 11:00 p.m. shift documented, "3:00 p.m. Received report from (lab) that resident is positive for[DIAGNOSES REDACTED]. (Doctor) notified (at) 4:00 p.m. Order received (and) noted. 2nd treatment for [REDACTED]. One month of [MEDICATION NAME] ... One month of [MEDICATION NAME] ... " The laboratory report documented, "Collected: 3/5/12, Reported: 3/8/12 ...[DIAGNOSES REDACTED]icile by lamp ... Positive ... Reference Range: Negative." j. Nurses Notes dated 4/2/12 for the 7:00 a.m. to 3:00 p.m. shift documented, "Ate 60% for breakfast ...11:45 a.m. Resident ... unresponsive ... unable to palpate heart rate ... 11:47 a.m. New order to notify coroner ... " The Arkansas Department of Health Certificate of Death documented, "... date of death : April 2, 2012; Time of Death: 11:45 a.m. ...Cause of Death ... Immediate Cause ... a. Ventricular fibrillation (unwitnessed sudden cardiac death) b. atherosclerotic heart disease ... other significant conditions contributing to death but not resulting in the underlying cause ... Clostridium difficile enteritis ..." 5. Resident # 3 had a [DIAGNOSES REDACTED]. a. Nurses Notes dated 3/2/12 at 3:30 p.m. documented, "Resident's stool - thick jelly texture. Notified physician, stool -[DIAGNOSES REDACTED]. Contact isolation due to possible[DIAGNOSES REDACTED] ..." c. Nurses Notes dated 3/6/12 for the 3:00 p.m. to 11:00 p.m. shift documented, "4:20 p.m. (lab) called. Resident was positive for[DIAGNOSES REDACTED]. (At) 4:25 p.m. (doctor) notified. Order received ... [MEDICATION NAME] ... [MEDICATION NAME] ... Re-check stool for[DIAGNOSES REDACTED] on 3/19/12. Contact isolation ..." A laboratory report dated 3/3/12 documented, "Collected: 3/3/12, Reported: 3/6/12 ...[DIAGNOSES REDACTED]icile by lamp ... Positive ... Reference Range: Negative." d. A laboratory report dated 3/19/12 documented, "Collected: 3/19/12, Reported: 3/20/12 ...[DIAGNOSES REDACTED]icile by lamp ... Positive ... Reference Range: Negative." A physicians order dated 3/20/12 documented, "1. [MEDICATION NAME] 500 (milligrams) ... (three times a day) (times) one month ... 2. [MEDICATION NAME] 125 (milligrams)...every 6 (hours) (times) one month. 3. Then repeat[DIAGNOSES REDACTED] 4/21/12." e. Nurses Notes dated 3/21/12 at 5:24 p.m. documented, "Administered antibiotic to resident after eating 20% of dinner, resident began gagging (and) acted as if she would vomit. Resident appetite has depleted, resident lost several pounds over last couple of months. Notified physician of residents deteriorating condition, new orders received ... (discontinue) HCTZ, [MEDICATION NAME], reduce [MEDICATION NAME] to 50 (milligrams) once daily ..." f. Nurses Notes dated 3/22/12 for the 7:00 a.m. to 3:00 p.m. shift documented, "New order ... (discontinue) [MEDICATION NAME]. Change [MEDICATION NAME] give 500 (milligrams) (20 milligrams) (three times a day) (times) 10 days ..." g. Nurses Notes dated 3/23/12 at 6:15 p.m. documented, "Difficulty swallowing food at dinner. Tolerated yogurt and softened foods well ..." Nurses Notes dated 3/23/12 at 6:30 p.m. documented, "New order ... Trial puree diet (times) 3 days due to difficulty swallowing." h. Nurses Notes dated 3/25/12 for the 7:00 a.m. to 3:00 p.m. shift documented, "Spoonfed 15% refusing to eat meals. New order ... Med pass 2.0 give 60 (milliliters) ... (three times a day) ..." i. Nurses Notes dated 3/26/12 for the 7:00 p.m. to 3:00 p.m. shift documented, "Resident continues to decline. (Physician) notified (and) here to see resident. New orders ... direct admit to (hospital) due to[DIAGNOSES REDACTED] enteritis, dehydration ..." 1) The (hospital) History and Physical dated 3/26/12 documented, "Date of Admission: 3/26/12. Chief Complaint: Dehydration and [DIAGNOSES REDACTED] enteritis. History of Present Illness: This [AGE] year-old nursing home resident ... has had [DIAGNOSES REDACTED] enteritis treated since mid February. She is on her second round of antibiotics, taking [MEDICATION NAME] 3 times a day. I had to stop [MEDICATION NAME] because of decreasing intake, which I figured was from impaired taste or taste aversion side effect form it. However, her intake has not picked up since we stopped that a week to 10 days ago, and she is becoming clinically dehydrated. The diarrhea has slowed down but not stopped. ... Impression: 1. Dehydration due to diminished intake and increased fluid loss of [DIAGNOSES REDACTED]icile enteritis. 2. Advanced dementia. 3. Clostridium difficile, on second round of treatment. ... Plan: IV (intravenous) fluids, continue oral [MEDICATION NAME] ..." 2) The (hospital) Discharge Summary dated3/30/12 documented, "... Date of Discharge: 3/30/12. Final Diagnoses: [REDACTED]. 2. Anorexia, due to # 1. 3. Dehydration, multifactorial. 4. Acute renal insufficiency. 5. Advanced Alzheimer's disease. 6. Urinary infections, Escheria coli. ... Summary: This [AGE] year-old nursing home resident ... has been treated for [REDACTED]. I had stopped almost all of her medications except for the [MEDICATION NAME] oral solution 500 (milligrams) (three times a day). Even though she was not a candidate for very aggressive intervention or resuscitation, family was interested in giving her a chance and reversing her dehydration. Her admission electrolytes showed BUN (Blood Urea Nitrogen) 96, Creatinine 2.8. Wit IV hydration, the BUN and Creatinine came down every day to level off at about 24/1.4 ...". j. The "Care Plan" dated 4/6/12 documented, "Problem/Need: (Resident # 3) has had a change in cognition and health ... she was recently hospitalized with dehydration and[DIAGNOSES REDACTED] ..." This was the only documentation related to[DIAGNOSES REDACTED] on the Care Plan. k. On 4/9/12 at 3:05 p.m. during initial rounds, LPN # 4 stated Resident # 3 was "in contact isolation for[DIAGNOSES REDACTED]." There was no isolation sign on the door. LPN # 4 stated (Resident # 3) was "sick times 2 weeks, just back from hospital." There were 2 plastic trash cans, approximately 3 feet tall and 1 foot wide, with lids inside the resident's room. The trash cans had removable lids and were lined with a red bio-hazardous liner. The lid on the trash can labeled "linen" was partially opened with a gap of approximately 2 inches. There were 2 small trash cans, approximately 1 foot high, 1 foot long and 8 inches wide, in the room with bio-hazardous liners. These trash cans had no lids. A pair of used gloves was hanging over the rim of the trash can on the room-mate ' s (Resident # 4) side of the room. Resident # 4 (Resident #3 ' s room-mate) had a [DIAGNOSES REDACTED]. The Quarterly MDS with an ARD of 2/8/12 documented the resident scored a 3 (0 - 7 indicates severe impairment) on the Brief Interview for Mental Status, was dependent on staff for toilet use, was frequently incontinent of urine, and was always incontinent of bowel. (On 4/9/12 at 3:05 p.m. during initial rounds, Licensed Practical Nurse (LPN) # 4 stated, "(Resident #4) Not in isolation, just in room.") At 6:45 p.m., there was no isolation sign or sign with instructions to check at nurse's station prior to entering for staff and/or visitors. The lid to the isolation linen container was not fully closed. A gap of approximately 1 inch was present. The small trash can on Resident # 4's side of the room still had a pair of used gloves hanging over the rim of the trash can. l. On 4/10/12 at 7:22 a.m., Certified Nurse Assistant (CNA) # 5 was present in the resident's room taking vital signs with a portable cuff. CNA # 5 wore no gown or gloves. CNA # 5 wrote the vital signs on a clipboard which was sitting on the foot of the resident's bed. CNA # 5 placed the portable cuff in the right hand pocket of her uniform top. CNA # 5 then took the clip board and put it on the left hand corner of the medication cart that was outside the resident's room. CNA # 5 reentered the room and began to feed the resident breakfast after using alcohol gel on her hands. CNA # 5 still wore no gown or gloves. There was a 3 by 11 inch contact isolation sign on the upper right hand corner of the doorway frame. The lid on the large isolation container was not fully closed. A gap of approximately 1 inch was noted. The two small trash cans had bio-hazardous liners inside. A used pair of gloves was hanging over the rim of the small trash can on the room-mates side of the room. Resident # 3 told CNA # 5 she was done with breakfast. CNA # 5 put the lid on the plate and moved the resident ' s over-bed table. CNA # 5's gait belt was around her waist. When CNA # 5 moved the over-bed table, the end of the gait bed brushed across the resident's bed. CNA # 5 used alcohol gel on her hands, picked up the tray and went to the dining room. CNA # 5 placed the tray on the cart then went to the nurses ' station at 7:42 a.m. m. A laboratory report with a report date of 4/10/12 documented, "Collected: 4/6/12, Reported: 4/10/12 ...[DIAGNOSES REDACTED]icile by lamp ... Negative ... Reference Range: Negative" On 4/10/12 at 8:55 a.m., the isolation sign, both large isolation containers, and the supplies outside the resident's room were no longer present. n. On 4/11/12 at 9:22 a.m., CNA # 5 was asked, "Was (Resident # 3) in isolation?" CNA # 5 stated "Yes, she was. They took her out yesterday morning." CNA # 5 was asked, "What was (Resident # 3) in isolation for?" CNA # 5 stated, "C diff." CNA # 5 was asked, "For[DIAGNOSES REDACTED] infections what do you do for isolation?" CNA # 5 stated, "We put a gown on and gloves and they have their own isolation barrels in the room." CNA # 5 was asked, "Why do you put a gown and gloves on for[DIAGNOSES REDACTED]?" CNA # 5 stated, "You can only get it from contact with feces and you wear a gown and gloves because you don't want it on your hands when you do incontinent care." CNA # 5 was asked, "What do you know about[DIAGNOSES REDACTED]?" CNA # 5 stated, "It's a colon infection and you get it from feces." CNA # 5 was asked, "Why no gown or gloves when you were feeding (Resident # 3) breakfast yesterday?" CNA # 5 stated, "We were told we only had to wear gowns and gloves when in contact with BM (bowel movement)." CNA # 5 was asked, "Did you know you only used alcohol gel on your hands when leaving the room yesterday?" CNA # 5 stated, "No I didn't realize it. I know I should have washed." CNA # 5 was asked, "The blood pressure cuff you used with vital signs, was that cuff used for all the residents on the unit?" CNA # 5 stated, "Yes." CNA # 5 was asked, "Did you clean the cuff off after taking it from the resident's room?" CNA # 5 stated, "No." CNA # 5 was asked, "What do you use to disinfect shower chairs?" CNA # 5 stated, "A spray bottle." CNA # 5 was asked, "Can you get a bottle of it for me?" CNA # 5 brought this surveyor a bottle of 20 Neutral Disinfectant Cleaner. CNA # 5 was asked, "Do you use anything different to clean the shower chairs for residents with[DIAGNOSES REDACTED]?" CNA # 5 stated, "No." On 4/11/12 at 10:47 a.m., CNA # 4 was asked, "If a resident had[DIAGNOSES REDACTED] what do you use to disinfect the shower chair with?" CNA # 4 stated, "The same stuff I just used on the shower chair." CNA # 4 used 20 Neutral Disinfectant Cleaner. CNA # 4 was asked, "Was (Resident # 3) in isolation?" CNA # 4 stated, "Yes." CNA # 4 was asked, "What for?" CNA # 4 stated, "C diff." CNA # 4 was asked, "What are you supposed to do for[DIAGNOSES REDACTED]?" CNA # 4 stated, "Wear gown, mask, gloves." On 4/11/12 at 11:35 a.m., LPN # 2 was asked, "Was (Resident # 3) in isolation?" LPN # 2 stated, "Yes, she was." LPN # 2 was asked, "What for ?" LPN #2 stated, "[DIAGNOSES REDACTED]. " LPN # 2 was asked, "What precautions are needed when going into the room of a resident in isolation for[DIAGNOSES REDACTED]?" LPN # 2 stated, "If going into to do incontinent care, they need to gown and glove up." On 4/11/12 at 12:35 p.m., CNA # 3 was asked, "Was (Resident # 3) in isolation?" CNA # 3 stated, "Yes, she's cleared of[DIAGNOSES REDACTED]." CNA # 3 was asked, "What precautions do you do for[DIAGNOSES REDACTED]?" CNA # 3 stated, "Wear gowns and gloves any time we are going to touch her." CNA # 3 was asked, "Were you aware alcohol gel doesn't kill[DIAGNOSES REDACTED]?" CNA # 3 stated, "No, we've been told we can't use the bathrooms in resident's rooms to wash our hands so we use alcohol gel. " CNA #3 was asked, "Do you have isolation containers in resident's rooms with foot pedal controls for the lids?" C

Based on observation, record review, and interview, Nursing Administration failed to identity and implement appropriate measures to minimize the spread of [MEDICAL CONDITIONS] infections as evidenced by the following failed practices: Failure to ensure prompt consultation with the physician regarding incontinent episodes of slimy foul smelling diarrhea within 7 days of admission to nursing home from hospital for 1 of 1 case-mix resident (Resident #22) who wandered in and out of other residents ' rooms and experienced incontinent episodes of diarrhea. Failure to ensure staff implemented isolation precautions to decrease the potential for the spread of [MEDICAL CONDITION] and that staff and visitors were informed of isolation precautions required for 1 (Residents #3) of 3 (Resident #s 3, 22 and 23) who resided on the 100 Hall unit and were diagnosed with [REDACTED]. Failure to ensure a disinfectant that was effective against[DIAGNOSES REDACTED] was utilized for laundry to prevent the potential spread of [MEDICAL CONDITION]. The facility further failed to ensure isolation linens were washed with a disinfectant that killed the bacteria that cause[DIAGNOSES REDACTED] to prevent the possible spread of infection to all residents who resided in the facility. Three case-mix residents (Resident #s 3, 22 and 23) were [DIAGNOSES REDACTED]. Failure to ensure a disinfectant cleaner that killed[DIAGNOSES REDACTED] spores was used to clean contaminated equipment and the immediate environment to prevent the spread of [MEDICAL CONDITION] infection to other residents who resided on the closed unit and potential spread to all 104 residents who resided at the facility. Failure to ensure residents without[DIAGNOSES REDACTED] were not cohorted with residents who had active[DIAGNOSES REDACTED] for 1 of 1 (Resident # 4) case mix resident who did not have [DIAGNOSES REDACTED]. Failure to ensure the infection control log recorded, tracked and trended all communicable diseases, not just antibiotic use; recorded if cultures were done; what organism was cultured; if isolation was implemented and when; if the communicable disease was nosocomial or community acquired; if a recapture was done, and the date the communicable disease was resolved for and reviewed in order to identify patterns of infection and intervene to correct any problems with infection control techniques. These failed practices resulted in Immediate Jeopardy which caused or could have caused serious harm, injury or death to Resident(s) # 22, 23, and 3 who contracted or repeatedly contracted [MEDICAL CONDITION] infections and had the potential to cause more than minimal harm for 1 resident in the facility who was cohorted with a resident who had active[DIAGNOSES REDACTED] and for all 104 residents in the facility who used facility linens as documented by the Administrator on 4/12/12 at 4:30 p.m. The facility was notified of the Immediate Jeopardy condition on 4/12/12 at 4:30 p.m. The findings are: 1. The Assistant Director of Nursing Services job description documented, "... Major Duties and Responsibilities: Administrative Functions: Assist the Director of Nursing Services in the planning, developing, organizing, implement(ation), evaluation, and directing the day-to-day functions of the Nursing Services Department, in accordance with current rules, regulations, and guidelines that govern the long-term care facility ... Safety and Sanitation: ... Assist the Infection Control Committee in the development, implementation, and revision of written aseptic and isolation techniques. Participate in the development, implementation, and maintenance of the infection control program for monitoring communicable and/or infectious diseases among the residents and personnel. Ensure that nursing service personnel follow established infection control procedures when isolation precautions become necessary...." 2. The Director of Nursing Services job description documented, "... Major Duties and Responsibilities: Administrative Functions: Plan, develop, organize, implement, and evaluate, and direct the Nursing Services Department, as well as its programs and activities, in accordance with current rules, regulations, and guidelines that govern the long-term care facility ... Safety and Sanitation: ... Assist the Infection Control Committee in the development, implementation, and revising of written aseptic and isolation techniques. Develop, implement and maintain a program for monitoring communicable and/or infectious diseases among the residents and personnel. Ensure that nursing service personnel follow established infection control procedures when isolation precautions become necessary. ...". 3. The facility policy titled "Isolation Precautions - All departments" documented, "Policy Statement: Any resident suspected or diagnosed as having a communicable disease shall be placed in the appropriate type of isolation as delineated in these policies and procedures. ... If the disease of infection, according to CDC Guidelines, requires isolation or precautions, the resident will be isolated only to the degree necessary to isolate the infecting organism. ... Categories of Isolation Precautions: ... c. Contact Isolation ... Supervision Policy. The Infection Control Coordinator or designee shall be responsible for organizing and directing the implementation of the Infection Control Procedures when isolation becomes necessary. The charge nurse of each unit shall be responsible for carrying out all functions of the isolation precautions as directed by the Infection Control Coordinator and the policies and procedures of this facility. This includes supervision of personnel and assurance that all personnel and visitors follow established isolation precautions as well as any special instructions that become necessary. Isolation Procedure. ... 3. The isolation room is easily identified with an appropriate isolation sign which is posted outside the door by the Infection Control Coordinator or the Nurse Supervisor. Placement in Isolation Procedure: 1. If there is a reason to believe (based upon Guidelines for Determining an Infection) that a resident has a communicable disease, the attending physician or alternate shall be notified immediately of such condition and permission requested to initiate the appropriate isolation precautions. ... 5. All residents placed in isolation, for suspected or confirmed infections, shall have isolation precautions implemented in accordance with procedures established in the CDC Guidelines for Isolation Precautions in Hospitals. ... Posting of Isolation Signs. 1. When isolation of a resident is ordered, the appropriate isolation signs shall be posted outside the entrance to the resident ' s room by the Infection Control Coordinator or the Director of Nurses. ... Equipment and Supplies. ... 4. The Infection Control Coordinator or designee will review specific procedures with the charge nurse and assigned nursing assistant(s). ... Record Keeping Requirements. 1. A record shall be maintained of all communicable disease found within this facility. ... Appendix A. ... Gastroenteritis ... Infection/Condition: [DIAGNOSES REDACTED]icile; Type: C (Contact); Duration: (Duration of Illness); Precautions: Discontinue antibiotics if appropriate. Do not share electronic thermometers; ensure consistent environmental cleaning and disinfection. Hypochlorite solutions may be required for cleaning if transmission continues. Handwashing with soap and water preferred because of the absence of sporicidal activity of alcohol in waterless antiseptic hand rubs. ...". 4. The CDC Frequently Asked Questions about [MEDICAL CONDITION] for Healthcare Providers documented: (found at http://www.cdc.gov/HAI/organisms/cdiff/Cdiff_faqs_HCP.html#a6>) "...How is [MEDICAL CONDITION] transmitted? [MEDICAL CONDITION] is shed in feces. Any surface, device, or material (e.g., commodes, bathing tubs, and electronic rectal thermometers) that becomes contaminated with feces may serve as a reservoir for the [MEDICAL CONDITION] spores. [MEDICAL CONDITION] spores are transferred to patients mainly via the hands of healthcare personnel who have touched a contaminated surface or item...How can [MEDICAL CONDITION] infection be prevented in hospitals and other healthcare settings? ...Use Contact Precautions: for patients with known or suspected [MEDICAL CONDITION] infection: Place these patients in private rooms. If private rooms are not available, these patients can be placed in rooms (cohorted) with other patients with [MEDICAL CONDITION] infection. Use gloves when entering patients' rooms and during patient care. Perform Hand Hygiene after removing gloves. Because alcohol does not kill [MEDICAL CONDITION] spores, use of soap and water is more efficacious than alcohol-based hand rubs. However, early experimental data suggest that, even using soap and water, the removal of [DIAGNOSES REDACTED]icile spores is more challenging than the removal or inactivation of other common pathogens. Preventing contamination of the hands via glove use remains the cornerstone for preventing [MEDICAL CONDITION] transmission via the hands of healthcare workers; any theoretical benefit from instituting soap and water must be balanced against the potential for decreased compliance resulting from a more complex hand hygiene message. If your institution experiences an outbreak, consider using only soap and water for hand hygiene when caring for patients with [MEDICAL CONDITION] infection. Use gowns when entering patients' rooms and during patient care. Dedicate or perform cleaning of any shared medical equipment. Continue these precautions until diarrhea ceases. Because [MEDICAL CONDITION]-infected patients continue to shed organism for a number of days following cessation of diarrhea, some institutions routinely continue isolation for either several days beyond symptom resolution or until discharge, depending upon the type of setting and average length of stay. Implement an environmental cleaning and disinfection strategy: Ensure adequate cleaning and disinfection of environmental surfaces and reusable devices, especially items likely to be contaminated with feces and surfaces that are touched frequently. Consider using an Environmental Protection Agency (EPA) -registered disinfectant with a sporicidal claim for environmental surface disinfection after cleaning in accordance with label instructions; generic sources of hypochlorite (e.g., household chlorine bleach) also may be appropriately diluted and used. (Note: Standard EPA-registered hospital disinfectants are not effective against [MEDICAL CONDITION] spores .) Hypochlorite-based disinfectants may be most effective in preventing [MEDICAL CONDITION] transmission in units with high endemic rates of [MEDICAL CONDITION] infection. Follow the manufacturer's instructions for disinfection of endoscopes and other devices. Recommended infection control practices in long term care and home health settings are similar to those practices taken in traditional health-care settings. 5. Resident # 22 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The facility ' s Detailed Admission/Discharge Report received from the Administrator on 4/9/12 documented the resident was admitted to West I to a semi private room. Nurses Notes dated 12/28/11 at 4:25 p.m. documented, "... transferred from ... hospital ..." a. Nurses Notes from 12/29/11 to 1/8/12 documented resident wandering hallways, entering other resident rooms and incontinent episodes of diarrhea: 1) Nurses Notes dated 12/29/11 for the 11:00 p.m. to 7:00 a.m. shift documented, "Resident was (up) ambulating and wandering into hallway early in the evening, also noted to be across the (bathroom) into other resident room - confused and lost ... easily redirected to his bed (times) 3 tonight ..." Nurses Notes dated 12/29/11 for the 3:00 p.m. to 11:00 p.m. shift documented, "Resident ambulating per self. Wandering down halls. Caught resident in two other residents' room ... " 2) Nurses Notes dated 12/30/11 for the 11:00 p.m. to 7:00 a.m. shift documented, "Resident alert and confused. He walked into another resident's room ... He continues to wander up and down the halls going into other resident's room ..." 3) Nurses Notes dated 1/2/12 for the 11:00 p.m. to 7:00 a.m. shift documented, "... Then he was (up) wandering - noted to have diarrhea in pants ... He was (up) wandering when wet (with) urine, also was (up) wandering across hallway about 6:30 a.m., noted to have diarrhea in his pants again ..." Nurses Notes dated 1/2/12 for the 3:00 p.m. to 11:00 p.m. shift documented, "Resident wandering this shift ... Found in one resident's bathroom (with) her water pitcher. Found in another resident's recliner. Also heading to hopper room, toward West II and Central (at) different (times) ..." 4) Nurses Notes dated 1/3/12 for the 11:00 p.m. to 7:00 a.m. shift, written by Licensed Practical Nurse (LPN) # 4, documented, "Resident (up) wandering this shift. Resident had foul smelling slimy (bowel movement). Will monitor." (On 4/18/12 at 11:10 a.m., LPN # 4 was asked "Did you notify the physician of (Resident # 22's) foul smelling, slimy bowel movement?" LPN # 4 stated, "I can't remember if I wrote it on the communication sheet or not." LPN # 4 was asked "Did you call the physician since the stool you described is indicative of[DIAGNOSES REDACTED]?" LPN # 4 stated, "No." LPN # 4 was asked, "Did you know a foul smelling slimy stool can be a sign of[DIAGNOSES REDACTED]?" LPN # 4 stated, "No.") Nurses Notes dated 1/3/12 at 2:05 p.m. documented, "Room transfer to East hall ..." 5) Nurses Notes dated 1/5/12 for the 11:00 p.m. to 7:00 a.m. shift documented, "Up several times during night. Going into others room (and) (up) (and) (down) hallway for awhile ..." 6) Nurses Notes dated 1/6/12 for the 3:00 p.m. to 11:00 p.m. shift documented, "... (Bowel movement) has a foul odor/strong odor ..." 7) Nurses Notes dated 1/8/12 for the 7:00 a.m. to 3:00 p.m. shift documented, "(Temperature) 100.1. (Family member) (complained) (Resident) feeling warm to touch. Temp (checked) - febrile. Stool formed (and) liquefied (with) foul odor. New orders 1) Lab - check for [MEDICAL CONDITIONS] ..." A laboratory report dated 1/8/12 documented, "Collected: 1/8/12, Reported: 1/10/12 ...[DIAGNOSES REDACTED]icile by lamp ... Positive ... Reference Range: Negative." b. Nurses Notes dated 1/10/12 at 7:30 a.m. documented, "New orders received and noted to start [MEDICATION NAME] ... for [MEDICAL CONDITION]. Recheck stool for [MEDICAL CONDITION] on (January) 23. Contact Isolation until [MEDICAL CONDITION] (negative)." The resident's room was not changed. The resident remained in a private room that had no bathroom and no sink. The "Care Plan" dated 1/10/12 and reviewed on 4/4/12 documented, "Problem/Need: Resident has [MEDICAL CONDITION] ... Approaches: Staff to keep resident in contact isolation to prevent spread of germs ... Disinfect all equipment before it leaves the resident's room. Place in private room ..." c. A physician progress notes [REDACTED]. ..." d. A laboratory report dated 1/24/12 documented, "Collected: 1/24/12, Reported: 1/26/12 ...[DIAGNOSES REDACTED]icile by lamp ... Positive ... Reference Range: Negative." A physician progress notes [REDACTED]. The following week, stool specimen was submitted to re-check on [MEDICAL CONDITION], and it still reported at positive ..." e. A laboratory report dated 1/30/12 documented, "Collected: 1/30/12, Reported: 1/31/12 ...[DIAGNOSES REDACTED]icile by lamp ... Positive ... Reference Range: Negative." A physician progress notes [REDACTED]. stay in his room for purposes of isolation, although staff tries to guide him in that direction." f. A laboratory report dated 2/21/12 documented, "Collected: 2/21/12, Reported: 2/22/12 ...[DIAGNOSES REDACTED]icile by lamp ... Positive ... Reference Range: Negative." A physician progress notes [REDACTED]. ... More than a week after treatment ended, we have collected a specimen, and it is still showing positive for [MEDICAL CONDITION] ..." A physician progress notes [REDACTED].# 22) is often up wandering the hall day and night ... continues on his month-long third treatment for [REDACTED]. g. A laboratory report dated 3/28/12 documented, "Collected: 3/28/12, Reported: 4/2/12 ...[DIAGNOSES REDACTED]icile by lamp ... Negative ... Reference Range: Negative." h. On 4/9/12 at 3:28 p.m., during initial rounds with LPN # 4, a 3 inch wide and 11 inch long orange colored "Contact Isolation" sign was noted on the upper right hand side of the door frame. LPN # 4 stated the resident "was recently over [MEDICAL CONDITION]." There were no isolation supplies outside or inside the room. 6. Resident # 23 was admitted on [DATE] with a [DIAGNOSES REDACTED]. a. Nurses Notes dated 2/14/12 for the 3:00 p.m. to 11:00 p.m. shift documented, "... (At) 7:30 p.m. ... CNA notified this nurse that resident (bowel movement) watery, yellow in color (and) slimy ... (At) 8:20 p.m. (doctor) notified. Order received ... check for [MEDICAL CONDITION] ... (Temperature) 100.3 ..." b. Nurses Notes dated 2/15/12 for the 7:00 a.m. to 3:00 p.m. shift documented, "... (Bowel movement) noted yellowish in color (and) slimy ..." Nurses Notes dated 2/15/12 for the 3:00 p.m. to 11:00 p.m. shift documented, "... (Bowel movement) still slimy (and) yellowish in color ... " c. Nurses Notes dated 2/16/12 for the 7:00 a.m. to 3:00 p.m. shift documented, "... (Bowel movement) noted yellowish in color (and) slimy ... " d. Nurses Notes dated 2/17/12 at 2:01 a.m. documented, "... lab called (with) positive results for [MEDICAL CONDITION]. Physician paged ... Isolation precautions set up." The laboratory report documented, "Collected: 2/14/12, Reported: 2/17/12 ...[DIAGNOSES REDACTED]icile by lamp ... Positive ... Reference Range: Negative." The physician progress notes [REDACTED]. Exam now confirms it. I am going to start ... dual antibiotic therapy ... " e. The physician progress notes [REDACTED].# 23) was found to have [MEDICAL CONDITION] enteritis, but was losing weight even before then. She had finished out her course of treatment for [REDACTED]." f. The laboratory report documented, "Collected: 3/1/12, Reported: 3/2/12 ...[DIAGNOSES REDACTED]icile by lamp ... Negative ... Reference Range: Negative". Nurses Notes dated 3/2/12 at 2:30 p.m. documented, "Results from stool sample negative for [MEDICAL CONDITION], resident no longer on contact isolation due to negative results, will monitor." g. Nurses Notes dated 3/5/12 for the 3:00 p.m. to 11:00 p.m. shift documented, "3:00 p.m. Order received ... Re-check for [MEDICAL CONDITION] ... 6:00 p.m. Resident (bowel movement) looks like a mild diarrhea (and) slimy ...". h. Nurses Notes dated 3/6/12 for the 3:00 p.m. to 11:00 p.m. shift documented, "... (Bowel movement) (times) 3, still slimy (with) strong odor ... " i. Nurses Notes dated 3/8/12 for the 3:00 p.m. to 11:00 p.m. shift documented, "3:00 p.m. Received report from (lab) that resident is positive for [MEDICAL CONDITION]. (Doctor) notified (at) 4:00 p.m. Order received (and) noted. 2nd treatment for [REDACTED]. One month of [MEDICATION NAME] ... One month of [MEDICATION NAME] ... " The laboratory report documented, "Collected: 3/5/12, Reported: 3/8/12 ...[DIAGNOSES REDACTED]icile by lamp ... Positive ... Reference Range: Negative." j. Nurses Notes dated 4/2/12 for the 7:00 a.m. to 3:00 p.m. shift documented, "Ate 60% for breakfast ...11:45 a.m. Resident ... unresponsive ... unable to palpate heart rate ... 11:47 a.m. New order to notify coroner ... " The Arkansas Department of Health Certificate of Death documented, "... date of death : April 2, 2012; Time of Death: 11:45 a.m. ...Cause of Death ... Immediate Cause ... a. Ventricular fibrillation (unwitnessed sudden cardiac death) b. [MEDICAL CONDITIONS] ... other significant conditions contributing to death but not resulting in the underlying cause ... [MEDICAL CONDITION] enteritis ..." 7. Resident # 3 had a [DIAGNOSES REDACTED]. a. Nurses Notes dated 3/2/12 at 3:30 p.m. documented, "Resident's stool - thick jelly texture. Notified physician, stool - [MEDICAL CONDITION]. Contact isolation due to possible [MEDICAL CONDITION] ..." c. Nurses Notes dated 3/6/12 for the 3:00 p.m. to 11:00 p.m. shift documented, "4:20 p.m. (lab) called. Resident was positive for [MEDICAL CONDITION]. (At) 4:25 p.m. (doctor) notified. Order received ... [MEDICATION NAME] ... [MEDICATION NAME] ... Re-check stool for [MEDICAL CONDITION] on 3/19/12. Contact isolation ..." A laboratory report dated 3/3/12 documented, "Collected: 3/3/12, Reported: 3/6/12 ...[DIAGNOSES REDACTED]icile by lamp ... Positive ... Reference Range: Negative." d. A laboratory report dated 3/19/12 documented, "Collected: 3/19/12, Reported: 3/20/12 ...[DIAGNOSES REDACTED]icile by lamp ... Positive ... Reference Range: Negative." A physicians order dated 3/20/12 documented, "1. [MEDICATION NAME] 500 (milligrams) ... (three times a day) (times) one month ... 2. [MEDICATION NAME] 125 (milligrams)...every 6 (hours) (times) one month. 3. Then repeat [MEDICAL CONDITION] 4/21/12." e. Nurses Notes dated 3/21/12 at 5:24 p.m. documented, "Administered antibiotic to resident after eating 20% of dinner, resident began gagging (and) acted as if she would vomit. Resident appetite has depleted, resident lost several pounds over last couple of months. Notified physician of residents deteriorating condition, new orders received ... (discontinue) HCTZ, [MEDICATION NAME], reduce [MEDICATION NAME] to 50 (milligrams) once daily ..." f. Nurses Notes dated 3/22/12 for the 7:00 a.m. to 3:00 p.m. shift documented, "New order ... (discontinue) [MEDICATION NAME]. Change [MEDICATION NAME] give 500 (milligrams) (20 milligrams) (three times a day) (times) 10 days ..." g. Nurses Notes dated 3/23/12 at 6:15 p.m. documented, "Difficulty swallowing food at dinner. Tolerated yogurt and softened foods well ..." Nurses Notes dated 3/23/12 at 6:30 p.m. documented, "New order ... Trial puree diet (times) 3 days due to difficulty swallowing." h. Nurses Notes dated 3/25/12 for the 7:00 a.m. to 3:00 p.m. shift documented, "Spoonfed 15% refusing to eat meals. New order ... Med pass 2.0 give 60 (milliliters) ... (three times a day) ..." i. Nurses Notes dated 3/26/12 for the 7:00 p.m. to 3:00 p.m. shift documented, "Resident continues to decline. (Physician) notified (and) here to see resident. New orders ... direct admit to (hospital) due to [MEDICAL CONDITION] enteritis, dehydration ..." 1) The (hospital) History and Physical dated 3/26/12 documented, "Date of Admission: 3/26/12. Chief Complaint: Dehydration and [DIAGNOSES REDACTED] enteritis. History of Present Illness: This [AGE] year-old nursing home resident ... has had [DIAGNOSES REDACTED] enteritis treated since mid February. She is on her second round of antibiotics, taking [MEDICATION NAME] 3 times a day. I had to stop [MEDICATION NAME] because of decreasing intake, which I figured was from impaired taste or taste aversion side effect form it. However, her intake has not picked up since we stopped that a week to 10 days ago, and she is becoming clinically dehydrated. The diarrhea has slowed down but not stopped. ... Impression: 1. Dehydration due to diminished intake and increased fluid loss of [DIAGNOSES REDACTED]icile enteritis. 2. Advanced dementia. 3. [MEDICAL CONDITION], on second round of treatment. ... Plan: IV (intravenous) fluids, continue oral [MEDICATION NAME] ..." 2) The (hospital) Discharge Summary dated 3/30/12 documented, "... Date of Discharge: 3/30/12. Final Diagnoses: [REDACTED]. 2. Anorexia, due to # 1. 3. Dehydration, multifactorial. 4. Acute [MEDICAL CONDITION]. 5. Advanced [MEDICAL CONDITION]. 6. Urinary infections, Escheria coli. ... Summary: This [AGE] year-old nursing home resident ... has been treated for [REDACTED]. I had stopped almost all of her medications except for the [MEDICATION NAME] oral solution 500 (milligrams) (three times a day). Even though she was not a candidate for very aggressive intervention or resuscitation, family was interested in giving her a chance and reversing her dehydration. Her admission electrolytes showed BUN (Blood Urea Nitrogen) 96, Creatinine 2.8. Wit IV hydration, the BUN and Creatinine came down every day to level off at about 24/1.4 ..." j. The "Care Plan" dated 4/6/12 documented, "Problem/Need: (Resident # 3) has had a change in cognition and health ... she was recently hospitalized with dehydration and [MEDICAL CONDITION] ..." This was the only documentation related to [MEDICAL CONDITION] on the Care Plan. k. On 4/9/12 at 3:05 p.m. during initial rounds, LPN # 4 stated Resident # 3 was "in contact isolation for [MEDICAL CONDITION]." There was no isolation sign on the door. LPN # 4 stated (Resident # 3) was "sick times 2 weeks, just back from hospital." There were 2 plastic trash cans, approximately 3 feet tall and 1 foot wide, with lids inside the resident's room. The trash cans had removable lids and were lined with a red bio-hazardous liner. The lid on the trash can labeled "linen" was partially opened with a gap of approximately 2 inches. There were 2 small trash cans, approximately 1 foot high, 1 foot long and 8 inches wide, in the room with bio-hazardous liners. These trash cans had no lids. A pair of used gloves was hanging over the rim of the trash can on the room-mate ' s (Resident # 4) side of the room. Resident # 4 (Resident #3 ' s room-mate) had a [DIAGNOSES REDACTED]. The Quarterly MDS with an ARD of 2/8/12 documented the resident scored a 3 (0 - 7 indicates severe impairment) on the Brief Interview for Mental Status, was dependent on staff for toilet use, was frequently incontinent of urine, and was always incontinent of bowel. (On 4/9/12 at 3:05 p.m. during initial rounds, Licensed Practical Nurse (LPN) # 4 stated, "(Resident #4) Not in isolation, just in room.") At 6:45 p.m., there was no isolation sign or sign with instructions to check at nurse's station prior to entering for staff and/or visitors. The lid to the isolation linen container was not fully closed. A gap of approximately 1 inch was present. The small trash can on Resident # 4's side of the room still had a pair of used gloves hanging over the rim of the trash can. l. On 4/10/12 at 7:22 a.m., Certified Nurse Assistant (CNA) # 5 was present in the resident's room taking vital signs with a portable cuff. CNA # 5 wore no gown or gloves. CNA # 5 wrote the vital signs on a clipboard which was sitting on the foot of the resident's bed. CNA # 5 placed the portable cuff in the right hand pocket of her uniform top. CNA # 5 then took the clip board and put it on the left hand corner of the medication cart that was outside the resident's room. CNA # 5 reentered the room and began to feed the resident breakfast after using alcohol gel on her hands. CNA # 5 still wore no gown or gloves. There was a 3 by 11 inch contact isolation sign on the upper right hand corner of the doorway frame. The lid on the large isolation container was not fully closed. A gap of approximately 1 inch was noted. The two small trash cans had bio-hazardous liners inside. A used pair of gloves was hanging over the rim of the small trash can on the room-mates side of the room. Resident # 3 told CNA # 5 she was done with breakfast. CNA # 5 put the lid on the plate and moved the resident ' s over-bed table. CNA # 5's gait belt was around her waist. When CNA # 5 moved the over-bed table, the end of the gait bed brushed across the resident's bed. CNA # 5 used alcohol gel on her hands, picked up the tray and went to the dining room. CNA # 5 placed the tray on the cart then went to the nurses ' station at 7:42 a.m. m. A laboratory report with a report date of 4/10/12 documented, "Collected: 4/6/12, Reported: 4/10/12 ...[DIAGNOSES REDACTED]icile by lamp ... Negative ... Reference Range: Negative" On 4/10/12 at 8:55 a.m., the isolation sign, both large isolation containers, and the supplies outside the resident's room were no longer present. n. On 4/11/12 at 9:22 a.m., CNA # 5 was asked, "Was (Resident # 3) in isolation?" CNA # 5 stated "Yes, she was. They took her out yesterday morning." CNA # 5 was asked, "What was (Resident # 3) in isolation for?" CNA # 5 stated, "C diff." CNA # 5 was asked, "For[DIAGNOSES REDACTED] infections what do you do for isolation?" CNA # 5 stated, "We put a gown on and gloves and they have their own isolation barrels in the room." CNA # 5 was asked, "Why do you put a gown and gloves on for[DIAGNOSES REDACTED]?" CNA # 5 stated, "You can only get it from contact with feces and you wear a gown and gloves because you don't want it on your hands when you do incontinent care." CNA # 5 was asked, "What do you know about[DIAGNOSES REDACTED]?" CNA # 5 stated, "It's a colon infection and you get it from feces." CNA # 5 was asked, "Why no gown or gloves when you were feeding (Resident # 3) breakfast yesterday?" CNA # 5 stated, "We were told we only had to wear gowns and gloves when in contact with BM (bowel movement)." CNA # 5 was asked, "Did you know you only used alcohol gel on your hands when leaving the room yesterday?" CNA # 5 stated, "No I didn't realize it. I know I should have washed." CNA # 5 was asked, "The blood pressure cuff you used with vital signs, was that cuff used for all the residents on the unit?" CNA # 5 stated, "Yes." CNA # 5 was asked, "Did you clean the cuff off after taking it from the resident's room?" CNA # 5 stated, "No." CNA # 5 was asked, "What do you use to disinfect shower chai