Every finding on record at The Blossoms at White River Rehab & Nursing Center

Based on record review, document review, interviews, and facility policy review, the facility failed to report an incident of resident-to-resident abuse. Specifically, the facility investigated but did not report to the state survey agency (SSA) within 2 hours, a resident-to-resident altercation in which Resident #63 stabbed Resident #68 with an ink pen in the chest. The findings include: Resident #63 Review of an admission Record indicated the facility admitted Resident #63 on 05/04/2023 with diagnoses that included dementia, with other behavioral disturbance; unspecified psychosis; personal history of traumatic brain injury; personal history of other mental and behavioral disorders; schizoaffective disorder. The discharge return anticipated Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/06/2025, revealed Resident # 63 had a Staff Assessment for Mental Status (SAMS) score of 1, which indicated the resident required modified independence for daily decision making, with some difficult making decisions in new situations only. Review of Resident #63's Care Plan Report initiated on 10/13/2023 revealed the resident had irrational thoughts and behaviors that drive resident into aggressive thoughts and behaviors towards others. Interventions included intervening as necessary to protect the rights of others, remove [Resident #63] from situation and take to alternate location as needed; encourage the resident to express feelings appropriately. Review of Resident #63's Progress Note completed on 09/06/2025 at 9:36 AM, indicated that Resident #68 wandered into Resident #63's room and laid down in Resident #63's bed. Resident #63 took an ink pen and punctured Resident #68 on chest. Both residents separated immediately [by staff]. Director of Nursing (DON) and administrator aware. MD notified and ordered to send Resident #63 to emergency room for evaluation and treatment related to aggressive behaviors. A review of Resident #63 Behavioral hospital discharge papers revealed that Resident #63's reason for admission was that Resident #63 was mad due to another resident coming into [their] room and repeatedly messing with Resident #63 's stuff and getting on [their] bed. Resident #63 took a pen and stabbed Resident #68 in the chest. Per hospital course Resident #63 revealed to the behavior hospital provider not feeling bad or have guilt about stabbing Resident #68. Resident #68 Review of the admission Record indicated the facility admitted Resident #68 on 08/23/2024 with diagnoses that included unspecified psychosis; autistic disorder; dementia with other behavioral disturbance. Review of the annual MDS, with an ARD of 08/29/2025, revealed Resident # 68 had a Brief Interview for Mental Status (BIMS) score of 08, which indicated Resident #68 had moderate cognitive impairment. Review of Resident #68's Progress Notes completed on 09/06/2025 at 10:48 AM, indicated that Residet #68 wandered into Resident #63's room, laid on Resident #63's bed. Resident #63 took an ink pen and punctured Resident #68 on chest. Both residents separated [by staff]. Resident #68 received a new order to clean skin with wound cleanser and apply band-aid. During an interview on 06/15/2026 at 11:25 AM, Resident #63 revealed that Resident #68 came into [their] room messing with stuff and Resident #63 stabbed Resident #68 with a pen around the neck area. During an interview on 06/18/2026 at 8:51 AM, LPN #3 stated that a CNA reported that Resident #63 stabbed Resident #68 with an ink pen after Resident #68 came into Resident #63's room. Residents were then separated [by staff]. LPN #3 indicated Resident #68 had a mark on their chest and the area was cleaned and bandaged after calling the Medical Doctor (MD). Resident #63 was sent to the behavioral hospital due to aggression per MD order. LPN#3 stated the area on Resident #68's chest looked like something had gone in but was not bleeding. LPN #3 stated that she did talk with Resident #63 who stated the stabbing with a pen was done because Resident #68 came into [their] room. During an interview on 06/18/2026 at 1:19 PM CNA #4 stated that she was coming out of another resident's room after completing care and heard Resident #63 say get out of my room. CNA #4 then heard Resident #68 say ouch. CNA #4 immediately went to Resident #63's room, where she saw Resident #68 coming out of the room and Resident #63 in the room holding an ink pen in hand. CNA #4 then immediately reported the incident to the nurse on duty. During an interview on 06/18/2026 at 2:11 PM, the Director of Nursing (DON) revealed that he received a call regarding an incident with Resident #63 and Resident #68. The DON stated when he saw Resident #68 after notification of the incident there was a red mark on Resident #68's chest but there was no open area. The DON revealed that he did ask Resident #63 about the incident and Resident #63 reported not liking Resident #68 coming into [their] room. The DON stated Resident #63 reported not having stabbed Resident #68. Resident #63 indicated to the DON that they had been walking, tripped and fell forward toward Resident #68 with the ink pen in hand. The DON revealed a reportable did not need to be completed due to the incident being unintentional and was just a behavior. During an interview on 06/17/2026 at 1:48 PM, the Administrator stated she requested witness statements from the DON and treatment nurse and completed one herself. No other witness statements had been made. The Administrator indicated the incident happened on a Saturday and she had witness statements completed on that Monday after the treatment nurse looked at the resident. Review of a facility policy titled, Report of Reasonable Suspicion of a Crime, with a review date of 01/2024, indicated, The Administrator, Director of Nursing, or any other designated individual will report (within the required time frames) any reasonable suspicion of a crime against a resident to the state Survey Agency and local law enforcement agency. Employees will be protected against retaliation for reporting any reasonable suspicion of a crime against a resident. Review of the facility's policy titled Abuse, Neglect and Exploitation, with a review date of 07/2023, indicated The facility will report all alleged violations involving mistreatment, neglect or abuse to the Office of Long-Term Care, Family, Police and MD. Suspicion or allegations of abuse shall be reported immediately, but not later than 2 hours after forming the suspicion.

Based on interviews, record review, facility document review, facility policy review, it was determined that the facility failed to correctly code a Minimum Data Set (MDS) for one (Resident #39) of one resident reviewed for Accuracy of Assessments. The findings include: Review of the admission Record indicated the facility admitted Resident #39 on 11/03/2016 with diagnoses that included dementia, severity with other behavioral disturbance; mild neurocognitive disorder due to known physiological condition with behavioral disturbance. Review of a quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/15/2026, revealed Resident #39 had a Staff Interview for Mental Status (SAMS) which indicated the resident was severely impaired for daily decision making. The MDS also indicated Resident #39 took antipsychotic medications. Anticonvulsant medications were not marked on the MDS as being taken by Resident #39. Review of Resident's #39's Order Summary, revealed the resident had an active order for an anticonvulsant (medications that treat seizures) that was given for dementia and an antipsychotic that (medications to treat psychosis) was discontinued on 04/02/2026. During an interview on 06/18/2026 at 12:25 PM, the MDS Coordinator stated that she uses RAI manual to code the MDS. The MDS Coordinator stated that she will google the classification of a medication for coding High Risk Drug Class Use and Indication. The MDS Coordinator stated that she just overlooked the antipsychotic being discontinued and the anticonvulsant being taken. A review of a facility policy titled, RAI Version 3.0 Manual, dated 10/01/2025, indicated, Code all high-risk drug class medications according to their pharmacological classification, not how they are being used. Check if an antipsychotic medication was taken by the resident at any time during the 7-day look back period. Check if an anticonvulsant medication was taken by the resident any time during the 7-day look back period. Assessors should consult the manufacturer's package insert, which may contain the medication's pharmacological classification. They can also work with the resident's pharmacist to confirm the medication classification(s) for a resident's medication (s).

Based on observations, interviews, record review, facility document review, and facility policy review, it was determined that the facility failed to develop and implement a person-centered care plan that included measurable objectives and timeframes to meet the needs for one (Resident #8) of six residents reviewed. Specifically, the facility failed to implement/develop a care plan for Resident #8 concerning the diagnosis and medical interventions needed for diabetes mellitus. The findings include: Review of the Resident #8's admission Record indicated the facility admitted Resident #8 on an initial admit date of 12/05/2025 with diagnoses that included type 2 diabetes mellitus, acute kidney failure, altered mental status, and hyperglycemia. Review of a quarterly Minimum Data Set (MDS), with an Assessment Reference Date of 03/17/2026, revealed Resident #8 had a Brief Interview for Mental Status (BIMS) score of 0 which indicated the resident had severe cognitive impairment. The MDS indicated Resident #8's active diagnosis included high blood pressure, renal failure, diabetes mellitus and dementia. The MDS also indicated Resident #8 received insulin injections seven out of seven days for the look back period of the MDS. The MDS indicated Resident #8 took medications such as hypoglycemics that were considered to be a high-risk drug class. Review of Resident #8's Medication Administration Record, (MAR) for December of 2025, revealed Resident #8 received 10 mg of a hypoglycemic medication at 8 AM, 1000mg of a hypoglycemic medication at 8 AM, 500 mg of a hypoglycemic medication at 6 PM, and 10 units of insulin at bedtime. Resident #8 also received blood glucose monitoring checks at 6 AM, 11 AM, 4 PM and 8 PM. Resident #8's glucose level ranged from 85 to 408. Resident #8 received 28 doses of as needed insulin from 12/06/2025 until 12/18/2025. Review of a document titled Lab dated 12/10/2025 indicated Resident #8's glucose was 152, with the normal range being 74-109. Resident #8's Hemoglobin A1C was 8.2 with a normal reference range of 4.4 to 6.1. Review of document titled Lab dated 03/16/2026 indicated Resident #8's glucose was 71, which was within normal range. Resident #8's Hemoglobin A1C was 6.5, with a normal reference of 4.4 to 6.1. Review of Resident #8's Care Plan initiated on 04/17/2025, revealed no mention of Resident #8's active diagnosis of diabetes mellitus nor interventions for diabetes mellitus were indicated in Resident #8s care plan. During an interview on 06/18/2026 at 12:24 PM, with the Minimum Data Set (MDS) Nurse indicated she updated care plans quarterly and reviewed quarterly and annually. She indicated she knows what needs to be added to the care plan through doctor orders, medical diagnoses, hospital records, admission records. She indicated Resident #8 did not have a diagnosis of diabetes on the first admission date in April of 2025, but when Resident #8 returned to the facility on [DATE] there was a diagnosis of diabetes mellitus. The MDS nurse stated, Diabetes should be included in their care plan. It shows you their plan of care. It's what we go by to take care of them. During an interview on 06/18/2026 at 2:00 PM the Director of Nursing (DON) stated, Care plans should be looked at daily. They tell us how to care for our residents. They are specific to each resident. During an interview on 06/18/2026 at 3:50 PM, the Administrator indicated Resident #8 returned to the facility on [DATE] with the diagnosis of diabetes and it should have been entered on the care plan. The Administrator stated, You would put new diagnoses like diabetes on the care plan, so the other staff know what to do. A review of the document titled, RAI Chapter 4 Care Area Assessment (CAA) Process and Care Planning dated October 2025, stated, The completed MDS must be analyzed and combined with other relevant information to develop an individualized care plan. And the comprehensive care plan is an interdisciplinary communication tool. It must include measurable objectives and time frames and must describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. The care plan must be reviewed and revised periodically, and the services provided or arranged must be consistent with each resident's written plan of care. And The overall care plan should be oriented towards: Applying current standards of practice in the care planning process and evaluating treatment of measurable objectives, timetables and outcomes of care.

Based on observation, record review, and interview, the facility failed to monitor and supervise a severely cognitively impaired resident to prevent elopement, and failed to ensure staff responded promptly to an exit door alarm and thoroughly check the area outside the building after a door alarm sounded for 1 (Resident #1) of 3 sampled residents (Residents #1, #4, and #5) who were at risk for elopement. Consequently, Resident #1 eloped from the facility without staff knowledge, traveled across rough ground, and was found by law enforcement in a dehydrated state. It was determined the facility's past non-compliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) was related to the State Operations Manual, Appendix PP, S483.25 (Quality of Care) at a scope and severity of J. The IJ began on 06/15/2025 at approximately 4:15 PM. The facility did not have camera surveillance, but staff suspect Resident #1 who resided on the secured 300 Hall followed a visitor to the secured 400 Hall, before exiting the facility via the North exit door. Resident #1 held down the door handle until it opened and went outside to a fenced-in area and removed two wood pickets from a fence. Resident #1 walked approximately 30 yards behind the facility to a tree line, then down approximately 100 yards of plowed field, then approximately 30 yards of waist high grass to a cemetery, which was where Resident #1 was found at 8:00 PM by an officer from the local police department. The resident had exited the facility without staff knowledge. The Administrator and the Registered Nurse Consultant (RNC) were notified of the Past Non-Compliance (PNC) IJ on 06/25/2025 at 11:24 AM. The facility was found to have returned to compliance on 06/16/2025 when the facility's corrective actions were completed. The findings include: A review of the admission Record indicated the facility admitted Resident #1 on 04/07/2025 with diagnoses which included intracranial injury, dementia, and type 2 diabetes.The admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/21/2025, revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 04 which indicated the resident had severe cognitive impairment. Resident #1 was independent with sitting, standing, walking, transfers, and repositioning in bed, and was receiving antipsychotic, antianxiety, antidepressant, hypnotic, antiplatelet and hypoglycemic medications. A review of Admission/readmission Nursing Evaluation dated 04/07/2025 in Section III: Elopement Risk Evaluation revealed a score of 10 indicating Resident #1 was high risk for elopement although there was no documented history of elopement episodes for the past three months before admission to the facility. A review of Resident #1's Care Plan initiated 04/07/2025 revealed the resident required placement on a secured unit related to behaviors affecting self or others and risk for elopement. Interventions included: assist the resident to develop methods of coping and interacting, and distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television or books. 06/16/2025 holidays could be possible trigger for elopement attempts, 06/16/2025 Resident #1 was placed on one to one. A review of a late entry Behavior Note written 04/13/2025 at 5:57 AM revealed at approximately 6:40 PM one of the Certified Nursing Assistants (CNA) was getting ready to take the smoking residents out when Resident #1 pressed down the handle of the door until it opened and then ran out and proceeded to try and climb a fence. Resident #1 was redirected and taken back in the building. A review of an Incident Report from the local police department revealed a narrative provided by a law enforcement officer (LEO), dated 06/16/25 at 12:16 AM. The narrative revealed that on Sunday, June 15, 2025, at approximately 5:55 PM, the LEO reported for start of his shift. Dispatch advised that there was a resident who walked out of [facility was named]. Multiple agencies such as the local fire department, state police, the sheriff department, a neighboring city ' s police department, and the state department of corrections began assisting in the search for the resident. The resident was located in a cemetery located approximately 1,500 feet from the facility at 8:02 PM. Resident #1 was returned to the facility, treated by Emergency Medical Services (EMS) and later transported to a local hospital for further treatment. The LEO and a detective walked to the rear of the facility where staff believed the resident walked out of. Once opening the door leading outside, an audible alarm sounded off, notifying that the door had been opened. He observed two pieces of the wooded fence to be higher than the rest of the fence, it was advised that the employees believed the resident had removed those two pieces of the fence to leave the area and walk off the property. When the detective attempted to secure the door leading outside, the door had trouble latching and locking therefore making it easy to open. It was also advised that earlier in the day the alarm from the door sounded and that an employee walked outside but did not further inspect the reason for the alarm sounding. It was advised that [Resident #1] was last seen at approximately 4:09 PM. The facility did not contact the police department until approximately 5:50 PM. The facility was not equipped with surveillance cameras and therefore it was only assumed how the resident walked out of the property. An Adult Protective Services report was completed. Further review of the Incident Report revealed an additional narrative from a second LEO dated 06/16/25 at 2:45 PM. This narrative revealed that on June 15, 2025, the police department was contacted by the facility regarding a missing resident. The missing resident was last seen at approximately 4:09 PM by nursing staff and was said to have exited one of the back doors of the facility. Resident #1 was located approximately 8:05 PM at a cemetery approximately 1,500 feet from the facility. Resident #1 was transported back to the facility after being examined by EMS. At approximately 8:23 PM, the resident was transported to the emergency room of the local hospital by EMS. An Adult Protective Services report has been completed. A review of a Facility Incident Report dated 06/15/2025 indicated Resident #1 was admitted to the secured unit of the facility on 04/07/2025. Resident #1 was independently ambulatory with no use of assistive devices. Resident #1's BIMS per the MDS was a 4 (which indicated severe cognitive impairment). The resident was noted per hospital note dated 04/06/2025 to have thought blocking, which involved an abrupt stop in the middle of a thought, making it difficult to continue. This thought blocking could make an accurate assessment of BIMS difficult. It was noted Resident #1 often turned away and disassociated from staff and declined to answer simple questions. The Findings and Actions Taken section revealed on 06/15/2025 the door alarm was noted to be going off. Staff checked the door. CNA #1 then went to Licensed Practical Nurse (LPN) #2 and got the door code, checked the door again and shut off the alarm. Staff completed a head count in the dining room and noted that Resident #1 was absent. The staff immediately began searching the facility interior and exterior for the resident. The DON (Director of Nursing) was notified at 5:40 PM. The Administrator was notified of the missing resident at 5:42 PM. Police were notified at 5:44 PM. Family was notified at 5:58 PM. The physician was notified at 6:00 PM. Resident #1 was located at a cemetery and returned to the facility at 8:03 PM. The temperature was 91 degrees Fahrenheit. A review of ER (emergency room) Record, dated 06/15/2025 at 8:28 PM, revealed EMS transported Resident #1 to hospital following an elopement from the nursing home that lasted approximately four hours and ended with the resident being found in a nearby cemetery. The resident was wet and sweating profusely when found. Resident #1 ' s body temperature was found to be 99.8 degrees Fahrenheit. The ER Record revealed Resident #1 presented to the ER with, and was treated for, dehydration. A review of a Witness Statement dated 06/15/2025 by LPN #2 revealed that she and Resident #1 were sitting on 400 hall. She offered to call Resident #1's dad. The LPN then called Resident #1's family member. LPN #2 was called to a different area in the facility to assist with another resident, so she took Resident #1 back to the 300 hall where they resided and left the resident in the dining room eating a honeybun. CNA #1 asked LPN #2 for the North end door code on 400 hall. She was later asked if she had seen Resident #1 and she told the CNA the Resident was in the dining room. LPN #2 was told that staff could not find Resident #1 after a head count. The staff on 300 and 400 halls then searched all the rooms and outside but could not find Resident #1. The DON was notified. LPN #2 said that she had not noticed any behaviors after Resident #1 spoke with family members on the phone. A review of a Witness Statement dated 06/15/2025 at 9:31 PM by CNA #1 revealed that she was assisting a resident in their room when she heard the alarm go off around 4:30 PM. She looked out of the resident's door but did not see anyone. CNA #1 stepped off the hall to ask the nurse for the code to the door. She looked again but did not see anyone, so she put in the code to silence the alarm. She did not know Resident #1 was missing until 5:00 PM when supper trays were passed, and the resident could not be found. CNA #1 said that she had seen Resident #1 earlier in the day talking on the phone but had not noticed any behaviors from the resident. A review of a Witness Statement dated 06/15/2025 by the Maintenance Director (MD) revealed that he evaluated all doors in the facility to ensure they worked properly. He repaired the North 400-hall courtyard fence that had been removed, and all courtyard fences were assessed for security with no negative findings. During an interview and observation on 06/24/2025 at 08:38 AM, the MD went to the secure unit with this surveyor. The secured units were shaped like a T, the 300 hall was vertical, and 400 hall was horizonal with two exit doors on both ends. There was a locked door between the 300 & 400 Halls. The MD held down the North (right side) door handle for 15 seconds and the door opened. An alarm sounded during the 15 seconds, then stopped when the door opened, then after five seconds, started alarming again. Outside the door was a wood picket fenced in area with a locked wood gate. The MD showed surveyor the two boards that was assumed Resident #1 removed to get out. The wood picket fence had three wood 2 x 4s on the opposite side for reinforcement and nails in each picket. After the elopement, the MD enforced the pickets with two additional wood 2 x 4s and wood screws in the top and bottom of every picket on the fence sections. The MD also placed a shrill alarm system on the top of both 400 hall exit that required a key to be turned off and the nurses were the ones to carry the key. The MD said that he monitored the outside gate every day and provided documentation for March, April, May, and through June 23. After the elopement on June 15, 2025, he initiated Door Monitoring ensuring the doors, keypad, mag locks, closers and alarms were properly functioning for the front lobby, 100 Hall, 200 Hall, the smoke area, service hall entrance and exit, 300 Hall entrance, 400 Hall entrance, 400 north exit and 400 south exit. The MD provided documentation showing this was monitored daily starting 06/15/25 and continued through 06/23/25 (current date). During a phone interview on 06/24/2025 at 9:00 AM, CNA #1 revealed at approximately 4:30 PM she heard the door alarm on the 400 hall going off, but she was assisting a resident in their room. She poked her head out of the room to see if anyone was at the door, but did not see anyone, so she finished with the resident. The alarm on the door continued to sound every few seconds. CNA #1 had not been working at the facility long, so she did not know the door code. She went to the 300 Hall to ask a nurse for the code. She came back to the 400 Hall, went to the door, opened it and looked outside but still did not see anyone outside. A little later after 5:00 PM, CNA #1 was asked if she knew where Resident #1 was, and was told that the resident was not found while passing supper trays at 5:00 PM. During a phone interview on 06/24/2025 at 10:37 AM, LPN #2 revealed she had been with Resident #1 previously on the 400 hall while passing medications. She said the resident kept saying Dad, Dad. She asked the resident if they wanted to call their dad. Resident #1 said yes, so a call was made, and after hanging up, Resident #1 said another family member's name. She asked if the resident wanted to call the second family member. LPN #2 called this person as well. LPN #2 reported working the 300 & 400 halls but was called to the front to get medication for another resident going on leave of absence with family, so she took Resident #1 back to 300 hall, gave the resident a honeybun and glass of water in the dining room, and asked the resident to sit and finish the honeybun until she got back. LPN #2 reported Resident #1 was standing in the dining room when she left. CNA #1 later came and asked for the code to the North door on 400 hall, which she provided. CNA #1 approached to ask if LPN #2 knew where Resident #1 was. LPN #1 said she last saw the resident in the 300-dining room eating a honeybun. CNA #1 told her that the resident was missing, and they started looking in all rooms on the 300 & 400 halls but couldn't find the resident. CNA #1 reminded her about the alarm going off. They went to the door and looked outside. At that time, they noticed some boards on the fence were missing. The DON was notified and an immediate search for the resident began. During an interview on 06/24/2025 at 11:30 AM, CNA #5 revealed that she occasionally worked in the 300 and 400 halls and was familiar with Resident #1. She said that the resident hadn't been here long but shortly after being admitted had tried to jump the fence outside. CNA #5 said she wasn't surprised that Resident #1 had eloped. Resident #1 had exit seeking behaviors and she had observed a bag packed and the resident waiting at one of the doors. CNA #5 reported thinking the facility was short-staffed, especially on weekends. During an interview on 06/26/2025 at 08:35 AM, the MDS Coordinator revealed that she was familiar with Resident #1. She said that the resident did not have exit seeking behaviors upon admission, but she was the one that completed the care plan and there were concerns for elopement in the hospital paperwork. She came in the night of the elopement so the LPN that had been working could go home. The MDS Coordinator had noticed that Resident #1 stood at the door more now, after the elopement, but was usually easy to redirect. During a phone interview on 06/26/2025 at 08:50 AM, the Medical Director revealed that he had been the Medical Director since September 2023. The facility notified him when a resident eloped, and he would give orders to send to the ER for evaluation and treatment. The Medical Director said he was familiar with Resident #1, and did not know if he had exit seeking behaviors but the resident had mentioned not wanting to be in a nursing home. During an interview on 06/26/2025 at 09:24 AM, CNA #6 revealed that she was familiar with Resident #1. She said the resident had been observed going to the doors before the elopement and was observed the day after the elopement beating on the door. CNA #6 said the resident was placed on one-on-one monitoring after the elopement, the codes on the doors were changed, they had to sign residents in and out whenever they went out to smoke or anytime they were taken off the secured units. She said that she was concerned that a resident getting out of the facility could be picked up by someone, bit by something out in the field, or just get hurt. During an interview on 06/26/2025 at 09:30 AM, CNA #7 revealed that she had observed Resident #1 pulling on the doors, before and after the elopement. CNA #7 said that she had worked 11:00 AM to 2:00 PM that day, so the elopement occurred after she left for the day. During an interview on 06/26/2025 at 10:15 AM, Medication Administration Certified (MAC) #8 revealed she was familiar with Resident #1. She said that she had observed Resident #1 standing at the door and pushing on it before the elopement occurred. During an interview on 06/26/2025 at 10:30 AM the DON stated Resident #1 did not have exit seeking behaviors before or after the elopement. The DON said that the facility process during an elopement is to search every room in the facility, then outside, to notify him (DON), the Administrator, the police department, and search until the resident is found. The physician is then called for an order to send to the ER for evaluation and treatment.During an interview on 06/26/2025 at 10:36 AM, the Administrator stated Resident #1 did not have exit seeking behaviors before the elopement. The facility had sent the resident to the ER for evaluation, then upon return monitored the resident one-on-one. Signage was posted on doors between 300 and 400 halls to remind families not to let anyone out. Maintenance had also reinforced fences on the outside on the secured units and installed another type of alarm on the doors that had to be turned off with a key. Also, the staff working on the secured units were to sign in/out all residents leaving the secured units. Review of a facility policy titled, Accidents and Hazards Policy with a revised date of 05/20/2022 revealed, the facility strives to ensure the resident environment remains as free of accident hazards as is possible and each resident receives adequate supervision and assistance devices to prevent accidents. Following the incident and prior to the survey entrance date, the facility identified and addressed the issue with the following corrective actions: 1. Resident #1 was sent to the emergency room at a local hospital and treated for dehydration. Upon return from the hospital, the resident was placed on one-on-one monitoring. Correction completed 06/14/2025. 2. Resident #1's elopement risk assessment was updated, care plan updated to 1:1. Increased monitoring for 24 hours after family visits or calls for exit seeking behaviors and emotional distress. Correction completed 06/15/2025 3. Witness statements were collected from all staff and cognitive residents. Correction completed 06/15/2025. 4. Elopement Binder updated with Resident #1's new assessment. Correction completed 06/15/2025. 5. All residents verified for current elopement risk assessment. Updated care plans to reflect elopement interventions. Correction completed 06/15/2025. 6. Maintenance ensured all doors were secure, door alarms were functioning properly, and repaired the North 400 hall courtyard fence and areas were secure. Additional alarms with key turn offs were installed on 400 hall North and South doors. Correction completed 06/15/2025. 7. Signs were placed on doors reminding visitors to not allow residents to exit. Correction completed 06/15/2025. 8. Staff were in serviced on elopement policy and steps in the event of an elopement. Correction completed 06/16/2025. 9. Administrator/designee completed elopement drills on all three shifts with no negative findings. Correction completed 06/16/2025. 10. Door monitoring for front lobby, 100 hall, 200 hall, smoke area, service hall entrance, service hall exit, 300 unit entrance, 400 unit entrance, 400 north exit and 400 south exit. Correction completed 06/16/2025. 11. Sign in, sign out log by staff, for all secure unit resident when leaving the unit to smoke, attend activities, etc. Initiated 06/16/2025 and will be ongoing. Onsite verification of the corrective actions was completed on 06/26/2025 at 1:30 PM. A total of 15 staff interviews were conducted with staff from all shifts to verify training had been completed. The staff interviewed included 7 Certified Nursing Assistants (CNA), 1 Medicine Administration Certified (MAC), 2 Licensed Practical Nurses (LPN), The MDS Coordinator, Maintenance Director, Director of Nurses, Administrator and the Medical Director. The staff interviewed verified they had been trained on the elopement policy and steps in the event of an elopement. Elopement drills performed on 06/16/2025 on all 3 shifts with total of 29 staff members participated.

Based on observation, record review, and interview, the facility failed to ensure that items were dated properly, items were sealed/closed properly, and cross contamination in the kitchen did not occur during meal service in one of one kitchen observed. The findings include: A review of the facility policy and procedure Avoiding Cross Contamination indicated that store food at least six inches above the floor. A review of the facility policy Labeling and Date Marking Policy indicated, Labeling and dating food products helps you identify what they are, when they were prepared, and how long they can be safely stored. This way, you can ensure that you use the first-in, first-out (FIFO) method, which means that you use the oldest products first and the newest ones last. Labeling and dating also helps you avoid cross-contamination, which occurs when harmful bacteria or allergens are transferred from one food to another. A review of the facility policy FIFO (First in, first out) Facts indicates FIFO stock rotation helps prevent unnecessary food waste' Store items in order of their use-by dates, with the earliest dates in front. That way, the first item you grab will be the one that needs to be used the soonest. FIFO is a great system for foods in dry storage as well as in the refrigerator; Food-to-food cross-contamination occurs when contaminated food comes into contact with uncontaminated food and taints it. This can happen in two ways: one food directly touches another, or one food touches a surface which then touches another food' Where bacteria are allowed to spread, illness is sure to follow. A review of the Cleaning Schedule indicated daily drip pans should be done with the stove top/grill cleaning daily, the oven and fryer should be cleaned weekly, or as needed, per Dietary Manager. In the walk-in refrigerator: During an observation on [DATE] at 6:15 PM, this surveyor observed a one-gallon plastic food storage bag of chicken salad with no date. Dietary [NAME] (DC #3) confirmed that it did not have a date. During an observation on [DATE] at 6:20 PM, this surveyor observed one opened plastic container of eight cherry tomatoes wrinkled and discolored with no date. The Dietary Manager (DM) stated the tomatoes were not fresh, they were wrinkled, and no date was written on the container. During an observation on [DATE] at 6:21 PM, this surveyor observed one bag of liquid eggs, with no date. The DM confirmed there was no date on the liquid eggs. During an observation on [DATE] at 6:22 PM, this surveyor observed one box of bacon, on the second shelf next to containers of produce. The DM confirmed the bacon was raw and should have been stored on the bottom shelf to prevent cross contamination. During an observation on [DATE] at 6:24 PM, this surveyor observed one box of green bell peppers with no date. The green bell peppers were discolored, wrinkled and two of the bell peppers had whitish gray matter on the outside. DC #3 stated there were 22 green bell peppers total, and they were wrinkled. The DM stated the green bell peppers were not dated, and they were not fresh. The DM stated the bell peppers need thrown out. During an observation on [DATE] at 6:26 PM, this surveyor observed a one-gallon plastic food storage bag, with a tube of ground beef halfway out of it, not sealed. The bottom half of the ground beef was covered in aluminum foil, with the edges separating from the tube. The DM stated the plastic storage bag was not sealed, which exposed the meat to the air, and the aluminum foil was coming off the tube at the end. The DM stated that it could have been cross contaminated. In the dry storage: During an observation on [DATE] at 6:36 PM, this surveyor observed a one-gallon plastic food storage bag of spaghetti noodles, not sealed. The DM confirmed the bag was not sealed. There was about two pounds of spaghetti noodles in the large plastic storage bag. During an observation on [DATE] at 6:38 PM, this surveyor observed one container of fish shaped crackers, left open on the top shelf. The DM confirmed the container was not closed properly, and it was roughly ,d+[DATE] full. During an observation on [DATE] at 6:42 PM, this surveyor observed one bag of light brown sugar, sitting on the floor next to the canned goods rack, the bag was open. The DM stated the bag should not have been on the floor and the bag should have been put in a container and sealed. In the main kitchen: During an observation on [DATE] at 12:10 PM, this surveyor observed DC #3 temping food for the lunch service. DC #3 used a paper towel to clean the probe of the thermometer while temping foods on the steam table line that included marinated chicken thighs, mashed potatoes, carrots, fortified mashed potatoes, mechanical chicken, pureed carrots, and pureed chicken. When DC #3 was getting temperatures for the mashed potatoes, fortified mashed potatoes, and mechanical chicken, the body of the thermometer touched the food. DC #3 stated, it was being cleaned with a regular piece of paper towel. DC #3 stated there was nothing else to use to wipe the probe off. During an observation of the lunch service on [DATE] at 12:20 PM, DA#1 stated, We have alcohol wipes in the top drawer of the plastic bin by the door. We have been out of those and that may be why [DC #3] did not look for them in there. The Dietary Consultant removed alcohol wipes to use to sanitize the probe of the thermometer. During an interview on [DATE] at 1:12 PM, DC #3 stated the process for cleaning the thermometer was to use alcohol in between foods. DC #3 stated this process kept the germs away, to prevent sickness. DC #3 stated on Tuesday, during the lunch service they used a paper towel only. During an interview on [DATE] at 1:17 PM, the DM stated the process was first in, first out and as soon as items were received, they should be dated. When items were opened, they should be dated. The DM stated, dating items lets you know when an item is expired or shelf-life date. You do not want to use expired food or not fresh food. The DM stated the process for sealing items in the kitchen was, for example, if it's a block of cheese, wrap it up, make sure it is airtight and put it in a [Brand Name] bag to prevent contamination. The DM stated items needed to be sealed, to prevent pests, rodents, and prevent contamination and dated to prevent using unsafe food. The DM stated the process for sanitizing the thermometer was to use some type of solution to sanitize such as alcohol wipes or sanitizing solution. The DM stated, I always tell staff to go to the sanitation sink, if you cannot find alcohol wipes. The DM indicated, sanitizing the thermometer prevents cross contamination. The DM stated bell peppers and tomatoes that had a slimy residue or were withered were supposed to be discarded, because they could cause sickness.

Based on observation, record review, interview, and facility policy review, it was determined that the facility failed to perform proper hand hygiene, put on proper Personal Protective Equipment (PPE), and follow standard infection control procedures for two (Resident #5, Resident #33) of five residents reviewed for isolation precautions. The findings are: 1. A review of the Admission Record noted Resident #5 was admitted to the facility on [DATE] with diagnoses which included cerebral infarction. a. A review of the Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/12/2025, revealed Resident #5 was unable to complete a Brief Interview for Mental Status (BIMS). Resident #5 had active diagnoses, which included: aphasia, which meant the resident was unable to speak. Section GG indicated Resident #5 was dependent on staff for all care and was transferred via a lift device, such as a sit to stand lift. Resident #5 used a wheelchair for mobility. b. A review of the Physician Order Summary revealed Resident #5 was on Enhanced Barrier Precautions (EBP), due to a PEG (Percutaneous Endoscopic Gastrostomy) tube. c. During an observation on 04/29/2025 at 2:00 PM, a sign was posted on the door to Resident #5 ' s room indicating the resident was on EBP. PPE was observed in a container near the door of the room. d. During an observation on 04/29/2025 3:00 PM, CNA #5 and CNA #6 performed a transfer and incontinent care for Resident #5, who was on EBP due to having a PEG tube. CNA #5 and CNA# 6 wore gloves, but failed to wear gowns, during the transfer and care. Both CNA #5 and CNA #6 completed incontinent care for Resident #5. Neither CNA were observed to change their gloves or perform hand hygiene anytime during or between transferring and providing incontinent care for Resident #5. Resident #5 had both a bowel and a bladder incontinent episode. CNA #5 began cleaning the resident and reached into the wipe container with soiled hands multiple times during the task, which contaminated the wipe container for future use. The wipe container was three quarters full. e. During an interview on 04/29/2025 at 3:20 PM, CNA #5 confirmed Resident #5 was on EBP. CNA #5 confirmed she should have worn a gown and gloves while providing care, but she only wore gloves. CNA #5 also confirmed EBP was used to protect vulnerable residents from infection, and that she contaminated the wipe container by retrieving wipes, with a soiled hand, multiple times during the care. f. During an interview on 04/29/2025 at 3:20 PM, CNA #6 confirmed Resident #5 was on EBP. CNA #6 confirmed she should have worn a gown and gloves while providing care, but she only wore gloves. She also confirmed EBP was used to protect residents from infection, and she should have assisted CNA #5 by handing her clean wipes, as needed, or prepared them for her to prevent contamination to the wipe container. d. During an interview on 04/30/2025 at 9:05 AM, the Director of Nursing (DON) confirmed it was important to wear appropriate PPE when providing care for residents on EBP, to help protect the residents. The DON also confirmed the staff were trained to work as a team when providing care and should not have retrieved wipes with soiled hands and doing this contaminated the package of wipes. e. During an interview on 05/01/2025 at 9:00 AM, the Infection preventionist (IP)confirmed EBP was in place to protect residents that may be more vulnerable than others and failing to put on the appropriate PPE could put residents at risk. She stated the CNAs were trained to follow the Centers for Medicare and Medicaid (CMS) guidelines such as: EBP and to put on a gown and gloves, while performing direct care for residents on EBP. 2. A review of the Admission Record noted Resident #33 was admitted to the facility on [DATE] with diagnoses which included diabetes mellitus (DM). a. The Quarterly MDS with an ARD of 04/11/2025 revealed, Resident #33 was unable to complete a BIMS. Section GG indicated Resident #33 was dependent on staff for transfers. b. During an observation of medication administration on 04/30/2025 at 8:03 AM, Licensed Practical Nurse (LPN) #7 failed to perform hand hygiene between each resident, including before administering medications to Resident #33. LPN #7 touched multiple pills while placing them in the plastic medication cup and touched multiple drinking straws as they were placed into the water provided to the residents. c. During an interview on 04/30/2025 at 8:10 AM, LPN #7 confirmed she failed to perform hand hygiene between each resident, while she administered medications. LPN #7 stated she should have washed her hands to help prevent the spread of germs to each resident. d. During an interview on 04/30/2025 at 9:05 AM, the DON confirmed it was important to perform hand hygiene between each resident when administering medications, to help prevent the spread of germs. e. During an interview on 05/01/2025 at 9:00 AM, the IP stated hand hygiene was important to prevent the spread of infections to the residents. 3. A review of the Enhanced Barrier Precautions policy, last reviewed 04/24/2025, noted, The EBP requires gowns and gloves during high-contact resident care activities. It also indicated, For residents for whom EBP are indicated, EBP is employed when performing the following high contact resident care activities: Dressing, Bathing/Showering, Transferring, Providing Hygiene, Changing Linens, Changing Briefs or Assisting with Toileting, Device Care or use, Wound Care. 4. A review of the Competency Based Skills Check-Off list, which is completed upon hire, for training nurses noted the nurses demonstrate universal precautions which during an interview, the DON confirmed this included proper use of appropriate PPE, knowledge of infection control systems, and no cross contamination during medication pass . 5. A review of the Competency Based Skills Check-Off list for the Certified Nursing Assistants (CNA)s also noted, demonstrates universal precautions, knowledge of infection control systems, and knowledge of different isolation policies . 6. A review of the Infection Prevention & Control Program policy noted under Section 7: Prevention of Infection, Sub Section 3 stated: educating staff and ensuring that they adhere to proper techniques and procedures.

Based on interviews, record review, facility policy review, and facility staff certifications, it was determined that the facility failed to ensure staff met Cardiopulmonary Resuscitation (CPR) certification requirements before providing CPR to residents in need, affecting1 (Resident #1) of 1 resident reviewed for resident/patient/client neglect. The findings include: Resident #1 had medical diagnoses that included type 2 diabetes, end stage renal disease, heart failure, chronic embolism, and thrombosis of unspecified deep veins of unspecified lower extremities. A review of Resident #1 ' s progress notes on [DATE] at 5:00 AM revealed LPN#1 was called to the resident ' s room by Certified Nursing Assistant (CNA) #2. Resident #1 was found to have no pulse. A code was called, and CPR was initiated and performed by LPN #1. Ambulance was called. A review of a facility policy titled, Cardiopulmonary Resuscitation Policy, effective [DATE] and revised [DATE] indicated staff were to, Obtain and/or maintain American Heart Association certification in Basic Life Support BLS/Cardiopulmonary Resuscitation (CPR) for key clinical staff members who will direct resuscitative efforts, including non-licensed personnel. CPR Certification - Licensed nurses should maintain current CPR certification for Healthcare Providers. A review of Licensed Practical Nurse (LPN) #1 CPR certification document indicated, LPN #1 had CPR certification from [DATE] to when it lapsed on [DATE]. LPN #1 did not renew their CPR certification before providing CPR to Resident #1 on [DATE]. During an interview with LPN #1 on [DATE] at 10:15 AM, she stated I did CPR on [Resident #1] until the ambulance arrived. I even rode in the ambulance with [Resident #1] and went to the hospital with them. During an interview with CNA #2 on [DATE] at 11:23 AM, CNA #2 stated LPN #1, and another LPN performed CPR on Resident #1 the morning of [DATE]. During an interview with the Administrator on [DATE] at 12:49 PM, the Administrator stated incorrect techniques may be done if someone is not certified in CPR. During an interview with LPN #1 on [DATE] at 12:59 PM, LPN #1 stated CPR certification was needed to ensure being up to date on new policies or procedures. You need to be CPR certified so you can be educated on performing CPR correctly and be certified to do it.

Based on observation, interview, and record review, the facility failed to ensure spices stored in the cabinet or on a shelf in the storage room were dated for first-in-first out spice rotation; and dietary staff washed their hands before handling clean equipment or food items to prevent the potential for cross contamination for residents who received meals from 1 of 1 kitchen. These failed practices had the potential to affect 50 residents who received meals from 1 of 1 kitchen (Total Census:53). The findings are: 1. On 03/06/2024 at 08:06 AM, the following observations were made in the kitchen: a. A pan of green beans is noted sitting on the stove top uncovered. The green beans were never covered while the initial tour was conducted, exposing it to possible cross-commination. b. The floors were dirty with food crumbs. The bottom shelf of the table which housed the rice, sugar, and flour containers was stained. The containers had dry, brown, spilled substances running down them on the outside. 2. On 03/06/2024 at 08:13 AM, Dietary Employee (DE) #1 had a tissue in his/her hand, they threw it in the trash can, opened a bag of coffee, removed a prefilled coffee filter, and put it in the coffee maker to be brewed and served to the residents for lunch meal. 3. On 03/06/2024 at 08:14 AM, the hand washing sink was clogged and slow draining. The sink filled to the point of overflowing when more than one person washed their hands. The Dietary Supervisor stated the Maintenance Man had worked on it on Monday and it is still draining slow. The Dietary Supervisor stated this problem had been occurring for about a month. 4. On 03/06/2024 at 08:15 AM, DE #1 turned off the hand washing sink with his/her bare hand, contaminating his/her hands. Without washing his/her hands, DE #1 removed gloves from the glove box and put them on. DE #1 then picked up glasses by the rims and placed them on the trays to be used in serving beverages to the residents for lunch. 5. On 03/06/2024 at 08:18 AM, the floor underneath the counter where the cereal bags were kept was dirty with spilled cereal and other food particles. 6. On 03/06/2024 at 08:21 AM, the spice. rack above the food preparation counter beside the stove contained spice bottles with build-up of black stains on the tops and sides of the containers. a. The following items were on the spice rack and did not have opened dates on them: 1) Thyme. 2) Dillweed. 3) Light Chili Powder. 4) Spanish Paprika. 5) A gallon size container of vanilla. 6)Apple cider vinegar. b. The following spices did not have an open or received date: 1) Ground Cayenne pepper. 2) ground coriander. 3) Ground cumin, 4) whole rosemary leaves 5) oregano. 6) Italian seasoning. 7) Nutmeg, 8) Ginger, 9) Paprika. 10) Cinnamon. 11) [NAME] leaves. 12) Sugar. 13) (Mixed seasoning). 14) French fry seasoning. 15) Cinnamon seasoning. c. The following spices did not have any dates: 1) Basil. 2) Salt. 3) Pepper. 4) Red pepper. 5) Parsley flakes. 6)A loaf of bread sitting on top of the toaster did not have an opening date. 8. On 03/06/2024 at 08:38 AM, the cabinet below the deep fryer had 4 pallets which were covered with dust/grease/lint. The shelf inside of the deep fryer was covered in food particles and a layer of yellow grease in the fryer was covered with a film of crumbs. The Surveyor asked the Dietary Supervisor, How often do you clean the deep fryer and pallets? She stated, It is cleaned every week and they had used it on Tuesday to fry something. The Dietary Supervisor said he/she did not clean the pallets of the fryer because he/she was scared he/she would get burned. The Dietary Supervisor said that the area had not been cleaned for about one month. 9. On 03/06/2024 at 09:22 AM, in the storage room the following observations were made: 1) An opened container of Mediterranean style ground oregano without an open date. 2) An opened bottle of cayenne pepper without an open date. 3) A bottle of chili powder no dates on it. 10. A facility policy titled, Hand Washing documented, When to wash hands: a. When entering the kitchen at the start of a shift . f. After handling soiled equipment or utensils. g. During food preparation, as often as necessary to remove soil or contamination and to prevent cross contamination when changing tasks . 49596

Based on observation, interview, and record review, the facility failed to ensure trays were passed table by table to 3 residents (Resident #11, #35, and #47) out of 18 residents who receive trays in the secured unit dining room. The findings are as follows: 1. Resident #11 had diagnoses of Dementia and Schizophrenia. The Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/08/23 documented a Brief Interview for Mental Status (BIMS) of 6 (0-7 indicates severe impairment). Resident #11 is independent for meals. a. On 03/04/2024 at 12:35 PM, Surveyor observed Resident #10, and Resident #38 received lunch trays. Resident #11, seated at the same table, did not receive a tray. Resident #11 was observed looking around as Certified Nursing Assistants (CNAs) passed trays before asking about Resident #11's tray after five minutes of waiting. Resident #11 received a tray at 12:48 PM, by which time Resident #10 had finished eating, while Resident #38 was halfway done with lunch service. 2. Resident #35 had diagnoses of Transient cerebral ischemic attack, Dementia, and Expressive language disorder. The Quarterly MDS with an ARD of 01/12/2024 documented a Staff Assessment of Mental Status (SAMS) that indicated long-term memory and short-term memory problems. Resident #35 is dependent on help with meals. a. On 03/04/2024 at 12:43 PM, CNAs began passing trays to the assisted dining table. Resident #35 was seated at the table. Resident #35 received a tray at 12:55 PM. CNA #2 sat down to feed Resident #35 at 12:57 PM. 3. Resident #47 had diagnoses of Dementia and Paranoid personality disorder. The Quarterly MDS with an ARD of 01/17/2024 the resident received a score of 3(severe impairment) on the BIMS. Resident is independent for meals. a. On 03/04/2024 at 12:37 PM, Resident #54 and Resident #8 received a lunch tray. Resident #47, seated at the same table, did not receive a tray. Resident #47 received a tray at 12:54 PM, by which time both Resident #54 and Resident #8 had finished with lunch service. b. On 03/04/2024 at 12:58 PM, the Surveyor asked CNA #1 how should trays be passed in the dining room? CNA # 1 responded, Table by table, and I realized that as I was walking down the hall. The Surveyor asked why is that an issue, and how would the residents feel having to wait for a tray? CNA # 1 responded, That they should not have to wait that they should get their trays together and that I would feel like crap having to wait for food. c. On 03/04/2024 at 01:30 PM, the Surveyor asked CNA #2 how trays should be passed in the dining room. CNA #2 said, Should be done table by table. Surveyor asked CNA #2, Why is that any issue and how would a resident feel having to wait for a tray? CNA #2 responded, They are watching others eat and they probably feel left out or irritated. d. On 03/04/2024 at 01:36 PM, the Surveyor asked the Director of Nursing (DON) how trays should be passed in the dining room. The DON said they should be passed table by table. The Surveyor asked why is this an issue, and how would a resident feel waiting for a tray? The DON said that the temperature of the tray would be cooled, and it is a dignity issue. They would probably not feel so good. e. On 03/05/2024 at 03:30 PM, the Administrator said the facility did not have a dignity policy.

Based on observation, interview, and record review, the facility failed to maintain a safe and homelike manner for 13 (Rooms 401, 402, 403, 404, 405, 406, 407, 408, 409, 411, 412, 414, 415) resident rooms, the dining area, and the activity area. The findings are: On 03/06/2024 at 10:22 AM, the following observations were made in the Secure Unit: a. room [ROOM NUMBER]: Above the sink is a ceiling tile that is bowed with the vent placed in the middle. The Surveyor asked the Maintenance Supervisor what could happen to a resident while using the sink. The Maintenance Supervisor said that it could fall. b. room [ROOM NUMBER]: Above the toilet in the bathroom the vent is separating from the ceiling tile. c. room [ROOM NUMBER]: In the corner by the closet, the baseboard has come off the wall exposing sheet rock. The paint is chipped off and part of the area has been re-plastered. The Maintenance Supervisor said approximately 4 inches of it has been re-plastered. The baseboard on the side next to the bathroom door is coming off the wall. d. room [ROOM NUMBER]: Above the closet, a tile is observed to be bowing. In the bathroom the vent is separating from the tile above the sink. Behind the toilet the paint is bubbling along the length of the wall from the toilet to the sink. The Surveyor asked the Maintenance Supervisor to describe the paint behind the toilet to the sink. The Maintenance Supervisor said it's bubbling like there is water behind the paint and it's approximately 4 feet in length. e. room [ROOM NUMBER]: Under the air conditioning unit by the bed, a board is observed to be on the floor and underneath the unit the surveyor observed light coming in. The Surveyor asked the Maintenance Supervisor what the issue is with the air conditioning unit in the current condition. The Maintenance Supervisor said that something could get in from the outside. The Surveyor asked the Maintenance Supervisor to check the toilet in the bathroom. The Surveyor observed the toilet moved back and forth left to right at a 35-degree angle. The Surveyor asked how this could be an issue for the residents. The Maintenance Supervisor said that it definitely needs to be tightened and the residents could fall. f. room [ROOM NUMBER]: A broken outlet is observed to next to bed A, below a vent area next to the bathroom door frame the baseboard is coming up in the middle, there is missing tile between the bathroom and bedroom floor, the toilet shifts left to right at a 20-degree angle, and there is bubbling paint behind the toilet. g. room [ROOM NUMBER]: A discolored blue mattress with various colors including brown, gray, and pink, that is not made up with linen is observed on side bed A. h. room [ROOM NUMBER]: A corner by the closet is observed with no baseboard, and the paint is chipped exposing sheet rock. Behind the toilet is an area with scrapped paint, bubbling paint is observed behind the toilet and underneath the sink. The Surveyor asked the Maintenance Supervisor to describe the paint behind the toilet and the sink. The Maintenance Supervisor said that the paint is bubbling like water damage, and it is approximately three feet in length. i. room [ROOM NUMBER]: The toilet shifts left to right at a 45-degree angle. j. room [ROOM NUMBER]: The corner of the closet the baseboard is broken down with chipped paint exposing sheet rock. A small piece of baseboard is observed to be laying on the floor. k. Activity Area-Discolored tiles are observed throughout the length of the room. A vent in the right corner of the room is observed to be bowing. Two tiles have two grooves each in the tile. The closet has three drawers with no handles, the left door is ajar and coming loose from the hinges hanging at a 20-degree angle. l. Dining Room Area: The baseboard along the back of the room is coming loose from the wall. m. On 03/04/2024 at 1:45 PM, the Surveyor asked Certified Nursing Assistant (CNA) #3 to describe what they see on the stripped mattress on side A in room [ROOM NUMBER]. CNA #3 said that there was brown dried stuff on the mattress that had been there a while and it looked like feces. n. On 03/05/2024 at 11:15 AM, the Surveyor asked CNA #1 to describe the area under the air conditioning unit in room [ROOM NUMBER]. CNA #1 said that the board is laying in the floor, which could be hazardous to the resident, there could be sharp edges that could harm the resident, and something could come in from the outside. o. On 03/05/2024 at 03:30 PM, the Administrator stated that they do not have a maintenance policy.

Based on observation, interview, and record review, the facility failed to ensure residents who required assistance with foot care were regularly provided with the necessary assistance to maintain good hygiene and grooming, as evidenced by failure to ensure toenails were kept clean and trimmed for 1 (Resident #47) sampled resident out of 18 residents who require assistance with daily living on the Secure Unit. 1. Resident #47 had diagnoses of Dementia and Paranoid personality disorder. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/17/24 the resident received a score of 3 (0-7 indicates severe impairment) on the Brief Interview for Mental Status (BIMS). Per care plan with a targeted completion date of 04/17/24 Resident requires assistance with ADL [activities of daily living] functions, Grooming: Someone must assist the resident to groom self. a. On 03/04/2024 at 10:40 AM, Resident #47's left shoe had the top ripped off. The Surveyor asked Resident #47 what happened to their shoe. Resident #47 said that they had ripped it off because his/her toes were hurting. b. On 03/04/2024 at 3:30 PM, the Surveyor asked Certified Nursing Assistant (CNA) #4 to describe Resident #47's toenails. CNA #4 said they were long, and that the resident needs to see a podiatrist. Resident #47 said that their left big toe is really bothering them. The Surveyor asked when he/she noticed the resident's shoe being ripped off and what should the intervention have been. CNA #4 said that he/she was unsure and that he/she should have got the resident a bigger pair of shoes and looked at his/her feet. The Surveyor asked what could happen to the resident. CNA #4 said that it could cause an infection. Both feet had a foul-smelling odor, the skin was flaky, and there was pitting edema around the ankles. On the left foot Resident #47's left great toenail was greenish yellow, the nail was built up with growth two inches off the nail bed, was curved around the toe, thick, and the bed was calloused and cracked. The other nails on the left foot were 11/2 inches in length, the toenails were curved into the nail beds, the nails were jagged, and the nail beds were calloused and cracked. The right great toe was curved at a 45 degree angle, the nail itself was greenish yellow, with the toenail built up with growth an inch off the nail bed, the edges were curved into the nail bed, and the nail bed was calloused and cracked. The other nails on the right foot are 11/2 inches in length, were jagged and pointed at the ends, and the nail beds were cracked and calloused. c. On 03/05/2024 at 12:00 PM, the Surveyor asked CNA #1 how long the top of Resident #47's shoe had been ripped off. CNA #1 said that it was early in February when they had noticed his/her shoe had been ripped off at the top by the resident. d. On 03/05/2024 at 12:15 PM, the Surveyor asked Licensed Practical Nurse (LPN) #1 to describe Resident #47's toenail. LPN #1 said that that the resident needs a podiatry appointment, and they most definitely need trimmed. The Surveyor asked what could happen to the resident with their toes being like that. LPN #1 said that it could indicate circulation or heart problems. LPN #1 then explained to Resident #47 that they were calling the Registered Nurse to come look at his/her feet and make an appointment. e. On 03/05/24 at 2:30 PM Nurse Consultant stated they did not have a policy for activities of daily living (ADL).

Based on observation, interview, and record review, the facility failed to ensure a resident was protected from hazards by having a vent area in the room with exposed wiring and by having no light in the bathroom for 1 (Resident #38) of 17 mobile residents on the Secure Unit. The findings are: 1. Resident #38 had medical diagnoses of Unspecified dementia and Altered mental status. According to the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) 01/02/24 the Staff Assessment for Mental Status (SAMS) documented Resident #38 had short-term and long-term memory loss. a. The Care Plan with a target completion date of 3/28/24 documented, Resident #38 had impaired cognitive function/dementia or impaired thought processes. b. On 03/04/2024 at 11:05 AM, in Resident #38's Room a metal vent area was left open and exposed. The inside of the area contained a light socket without a bulb and wiring was exposed, dirt and debris were noted on the bottom of the vent area. In the bathroom, the light was not functional. Above the mirror on the right hand wall in the bathroom was a white rectangular box with an area for two light bulbs. The left socket had a non-working light bulb, and the right socket did not contain a light bulb. There was no cover for the light bulbs. c. On 03/04/2024 at 02:00 PM, Resident #38 was sitting in their room and the vent area or lighting in the bathroom had not been fixed. d. On 03/04/2024 at 01:45 PM, the Surveyor asked Certified Nursing Assistant (CNA) #3 to describe the vent area in Resident #38's room. CNA #3 said that it is a light socket with exposed wiring that is within the reach of the resident. The Surveyor asked what the issue could be with that being opened to the resident. CNA #3 said that it could be hazardous to the resident. The Surveyor asked CNA #3 to turn on the light switch in the bathroom. CNA #3 went to turn it on, and the light did not come on. The Surveyor asked how this could be an issue for the resident. CNA #3 said the resident takes his/her self to the bathroom and if they close the bathroom door they cannot see, which could cause an accident. e. On 03/04/2024 at 03:45 PM, the Surveyor asked the Maintenance Supervisor how issues were reported. The Maintenance Supervisor said through a log that is kept at the front Nurse's Station. The Surveyor asked the Maintenance Supervisor to describe the vent area. The Maintenance Supervisor said that it could be a problem with the light socket and the exposed wiring. The Surveyor asked the Maintenance Supervisor to turn on the light in the bathroom. The Maintenance Supervisor then said this could be an issue cause the resident would not be able to see, and may trip, slip, or get hurt. The Surveyor asked if the Maintenance Supervisor was aware of these issues. The Maintenance Supervisor said no. not. f. On 03/05/2024 at 03:30 PM, the Administrator stated that they do not have a maintenance policy.

Based on observation, interview, and record review, the facility failed to ensure residents who required assistance with activities of daily living were regularly provided with the necessary assistance to maintain good hygiene and grooming, as evidenced by failure to ensure fingernails were kept clean and trimmed for 1 resident (Resident #47) out of 18 residents who require assistance with daily living on the secure unit. The findings are: 1. Resident #47 had diagnoses of Dementia and Paranoid personality disorder. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/17/24 the resident received a score of 3 (0-7 indicates severe impairment) on the Brief Interview for Mental Status (BIMS). Per care plan with a targeted completion date of 04/17/24 Resident requires assistance with ADL [activities of daily living] functions, Grooming: Someone must assist the resident to groom self. a. On 03/04/2024 at 10:40 AM, the Surveyor observed that Resident #47's fingernail on the right index finger was chipped off and comes to a point, the rest of the nails were jagged and split, with the nails measuring 11/2 inches in length. Surveyor observed that Resident #47's middle fingernail on the left hand was chipped off and coming to a point, the rest of the nails on the left hand are jagged and split, the nails were 11/2 inches in length. The Surveyor asked the resident if they would like to have their nails trimmed. Resident #47 stated, Yes, I would like them to be trimmed, some of them drag when I am using my hands. b. On 03/04/2024 at 1:00 PM, the Surveyor observed Resident #47 eating lunch in the dining room. Resident #47's nails had not been trimmed. c. On 03/04/2024 at 3:15 PM, the Surveyor asked Certified Nursing Assistant (CNA) #4 to describe Resident #47's fingernails. CNA #4 said that they are long, jagged, split, and need trimmed. The Surveyor asked what could happen to the resident with nails like this. CNA #4 said that it could cause an infection. d. On 03/06/2024 at 9:20 AM, the Surveyor asked the Administrator when nail care should be performed. The Administrator said that they do it weekly in the facility. The Surveyor asked what could happen to a resident if nails are left long. The Administrator said that it could cause infections, and possible skin tears if they scratch themselves. e. On 03/05/2024 at 2:30 PM, the Nurse Consultant stated they did not have a policy for activities of daily living (ADL).

Based on observation, interview and record review, the facility failed to ensure a positioning device was utilized to decrease the potential for further decline in range of motion (ROM) for 1 (Resident #13) out of 3 residents who are dependent for positioning on the secured unit. The findings are as follows: 1. Resident #13 had diagnoses of Muscle weakness, generalized, Unspecified abnormalities of gait and mobility, and Alzheimer's Disease. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/29/23 documented the resident received a score of 00 (0-7 indicates severely cognitively impaired) on a Brief Interview for Mental Status (BIMS). a. The Care Plan with a target completion date of 4/16/2024 documented, Requires assistance with Activities of Daily Living (ADL) function .Mobility: Occasional physical assistance required. b. On 03/04/2024 at 10:40 AM, Resident #13 was in the activity area of the Secure Unit leaning on his/her left side with their arm resting on the top of the wheel of the wheelchair. c. On 03/05/2024 at 12:20 PM, Resident #13 was leaning on his/her left side with their arm resting on the top of the wheel of wheelchair. When Resident #13 moved the left arm, the Surveyor observed a 2 centimeter (cm) by 3 cm bright red blood spot on Resident #13's elbow. d. On 03/05/2024 at 01:45 PM, the Surveyor asked Certified Nursing Assistant (CNA #2) if Resident #13 should have been repositioned. CNA #2 said they should have been. The Surveyor asked how long has this issue been occurring. CNA #2 said they were unsure, but the resident had been leaning this morning. The Surveyor asked what interventions should have been utilized. CNA #2 said that they dropped the resident's chair recently. e. On 03/05/2024 at 01:50 PM, the Surveyor asked the Director of Nursing (DON) if Resident #13 leans in his/her wheelchair. The DON said sometimes. The Surveyor asked if they should have been repositioned. The DON said maybe, I will ask therapy for a better chair. f. On 03/05/2024 at 03:30 PM, a policy titled Mobility and Range of Motion provided by the Administrator documented, b. Current mobility status (per current MDS assessment tool), including his or her ability to: *Change body positions . 5. The care plan will include specific interventions, exercises, and therapies to maintain, prevent avoidable decline in and/or improve mobility and range of motion.

Based on observation and interview, the facility failed to clean and eliminate black substances, properly store shower linen, and clean the air vents from several areas in the facility's kitchen and shower rooms. This failed practice has the potential to affect the health of the residents and employees. The findings include: A. On 09/21/2023 at 8:09 AM during observation, the shower room on Hall 200 had a bed pan, mouth basin, and commode urine hat on the floor. The shower gurney's top side middle area of the pad had cracks on both sides. B. During interview on 09/21/2023 at 8:09 AM, the Business Office Manger confirmed the findings in A and said the shower room is used for storage. C. The following observations were made of Hall 300 on 09/21/2023 at 8:14 AM. 1. A used brief was on the floor. 2. The following observations were made in the shower room. a. A chair wedge was halfway covered with a plastic bag and leaned up against the wall on the floor. b. The clean towels were folded and stacked on the bare floor, and washcloths on the windowsill. c. A pair of gloves on the windowsill. d. The shower chair had several wet towels on the seat. e. The tiles had a black substance around the walls and stained grout between some of the tiles. f. A shampoo bottle was on its side in the floor. D. The following observations were made of Hall 400 shower room [ROOM NUMBER]/21/2023 at 8:18 AM. 1. The tiled wall had a black substance and stained grout between some of the tiles. 2. The air vent was covered with a brown fuzzy substance. 3. The whirlpool had clean folded towels on the seat which was covered with a white substance. 4. An open package of wipes was in the tub. The tub had a sticky substance with black specks next to the open package of wipes. 5. An air vent in the hall had a brown and black fuzzy substance hanging off the vent. E. The following observations were made in the shower room of Hall 100 on 09/21/2023 at 8:27 AM. 1. A black substance was on the floor next to the walls around the room. 2. The air vent was covered with a brown fuzzy substance and hanging down from the vent. 3. The ice cart had a dark substance on the shelves. F. During observation on 09/21/2023 8:35 AM, the conference room wall had a black substance on the wall approx. 2 feet long and 5 inch wide running above the base board. G. During observation on 09/21/2023 8:54 AM of Hall 400, the chemical room walls had large areas of a black substance covering the walls. H. The following observations were made in the kitchen on 09/21/2023 at 9:10 AM. 1. A dark black substance was on the floor and wall by the juice machine. 2. The divided compartment sink had a buildup of a black substance on the pipes, wall, and floor. 3. The tan colored four drawer hard plastic container had a thick brown and black substance on the front and side.

Based on observation and interview, the facility failed to ensure the kitchen and dry storage for residents who received meals from 1 of 1 kitchen; failed to ensure a freezer air vent was functioning properly to prevent ice buildup; failed to ensure frozen food items were kept frozen, expired food items were promptly removed/ discarded by the expiration or use by dates, and foods were dated when received to assure first in first out usage to prevent potential for food borne illness; failed to ensure leftover food items were maintained to promote food quality; failed to ensure Dietary staff washed their hands before handling clean equipment or food items to prevent the potential for cross contamination, and 2 of 2 ice machines were maintained in a clean and sanitary condition. These failed practices had the potential to affect 35 residents who received meals from the kitchen (total census: 36), as documented on a list provided by Dietary Supervisor on [DATE] at 11:49 AM the findings are: 1. On [DATE] at 10:42 AM, the following were in the walk-in freezer. a. The 2 fan blades on the air unit had icicles hanging down from them. There was an accumulation of icicles that hung down from the back side of the air unit condenser. There was an accumulation of ice buildup from the floor to the wall, there was ice chips on the floor. The shelves with boxes of food items had icicles on them. There was an accumulation of ice droplets on the ceiling. On [DATE] at 10:44 AM The Surveyor asked the Maintenance Employee to measure the ice buildup in the walk-in freezer. He did and stated, The ice buildup from the floor to the wall measured 44 inches and the ice on the floor measured 57 inches. The Surveyor asked, What the cause of ice buildup in the freezer was? He stated, The wedge? refrigeration from [named city] stated, The freezer box is drawing moisture from the outside. b. 1 open box of biscuits. The box was not covered or sealed. c. 1 open box of cinnamon rolls. The box was not covered or sealed. There was no opened date on the box or the bag. d. 1 open box of sopapillas. The box was not covered or sealed. e. A bag of pecan pie. There was no received date on the box. f. 4 bags of [named] vegetables. There was no received date on the bags. 2. On [DATE] at 10:44 AM, the following were on a cart close to the walk-in freezer: a. A box that contained 5 bags of 8 count hot dog buns. The manufacturer's instructions on the box documented, keep frozen. b. I box of 8 count hamburger buns. The manufacturer's instruction on the box documented, keep frozen. The Surveyor asked the Dietary Supervisor when the bread was received? She stated, It came in on [DATE]. 3. On [DATE] at 11:07 AM, a box of French toast sticks with a received date of [DATE] was stored in the walk-in refrigerator. The manufacturer's instruction on the box documented, keep frozen. 4. On [DATE] at 11:11 AM, Dietary Employee (DE) #2 opened a can of pineapple tidbits and without washing her hands, she attached a clean blade to the base of the blender to be used to puree food items to be served to the residents for lunch. 5. On [DATE] at 11:19 AM, DE #3 was wearing gloves on her hands. She unwrapped pans of graham cracker pie shells and placed them in a pan which contaminated the gloves. She mixed the crumbs and melted butter to be used in banana split for supper. 6. On [DATE] at 11:25 AM, Dietary Employee #4 was wearing gloves on her hands. She opened the walk-in refrigerator and took out a zip lock bag that contained ham, a zip lock bag that contained slices of cheese and placed them on the counter. She picked up a bag of bread from the counter and untied it. She removed 2 slices of bread from the bag and placed them on the counter. She removed a slice of ham and a slice of cheese and placed them on top of the bread. She picked up the other slice of bread and placed it on the bread to be served to the resident who requested a ham and cheese sandwich. The Surveyor immediately asked, What should you have done after touching dirty objects and before handling clean equipment? She stated, Removed gloves and washed my hands. I will throw the sandwich away and prepare another one. She threw the ham and cheese sandwich away. 7. On [DATE] at 11:35 AM, The ice machine in the kitchen had an accumulation of wet, brown residue on the metal sections where the ice formed before it dropped in the ice collector. The Surveyor asked the Dietary Supervisor to wipe the residue off of the metal sections. The Surveyor asked, How often do you clean the ice machine and who uses the ice from the ice machine? She wiped the residue with a tissue, and the brown colored residue easily transferred to the tissue. The Surveyor asked the Dietary Supervisor to describe the residue within the ice machine. She stated, There was brown slimy type. The Surveyor asked, How often do you clean the ice machine and who uses ice from the machine? She stated, They are supposed to clean it 2 times a week. The Surveyor asked, Does it look like it has been cleaned? She stated, NO. 8. On [DATE] at 11:46 AM, the following were in the walk-in refrigerator: a. 3 containers of [named] potato salad with an expiration date of [DATE].) b. 1 opened/unsealed bag of bacon bits. c. A pan of leftover pureed eggs, a pan of leftover scrambled eggs, a pan of leftover pureed sausage and a pan of ground sausage. The Surveyor asked the Dietary Supervisor was asked What do you use those for? She stated, We used them the following morning for breakfast. d. Three 1-gallon containers of (Brand) Eggnog with an expiration date of [DATE]. 9. On [DATE] at 12:23 PM, the ice machine panel in the room opposite the nurse's station on 200 Hall had brown residue in it. The Surveyor asked the Dietary Supervisor to wipe the residue off the panel of the ice machine. She did with a tissue, and the brown colored residue easily transformed to the tissue. The Surveyor asked, How often do you clean the ice machine and who uses the ice from the ice machine? The Surveyor asked the Dietary Supervisor to describe the contents within the ice machine. She stated, It looks like brown coffee rust color. I don't know who cleans it. The Certified Nursing Assistants (CNA)s use it for the water pitchers in the residents' rooms. 10. On [DATE] at 12:30 PM, the following were in the refrigerator in the Nourishment Room on the 400 Hall: a. One bottle of [named] horseradish sauce had an expiration date of [DATE]. There was no date when it was opened or received and there was no name on it. b. One open bottle of [named] fruit punch with no date that indicated when it was opened or received. c. One open carton of nectar mildly thick consistency lemon flavor water with an expiration date of [DATE]. The carton was sticky to touch. d. A bag of [named] Philly cheesesteaks with no name on it and no received date. e. 2 bottles of [named] fruit juice with no name and no received date. f. 1 open box of [named] original mashed potatoes with not name and no opened or received date. g. 7 cartons of whole milk with an expiration date of [DATE]. h. 1 carton of chocolate milk with an expiration date of [DATE]. i. 1 bottle of [named] Italian creamy dressing and a bottle of soy sauce with no name on them and no received date. j. 4 of 4 cartons of nutrition juice with no received date. k. 1 open container of Doritos [named] Jalapeno dip with no name and no date when opened and/or received. The box has an expiration date of [DATE]. 11. The following were on top of the freezer in a room at the nurses' station on the (400) Hall: a. An opened box of honey nut [named] cereal cheerios with an expiration date of [DATE]. b. A box of buttery smooth crackers with no name or received date on the box. c. A 12 count box of [named] sugar cones. The box of sugar cones had an expiration date of [DATE]. d. A bottle of [named] cooking spray. The cooking spray bottle had an expiration date of [DATE]. e. An opened box of frosted flakes [named] cereal with no opened date. f. An opened bag of wavy ripple chips with an expiration date of [DATE]. g. An 11-count box of instant grits with an expiration date of [DATE]. 12. On [DATE] at 4:42 PM, Dietary Employee #3 turned on the 3-compartment sink faucet and washed a blender blade. After sanitizing the blade, she turned off the faucet. Without washing her hands, she picked up the blade and attached it to the base of the blender to puree food items to be served to the residents. The Surveyor immediately asked, What should you have done after touching dirty objects and before handling clean equipment? She stated, I should have washed my hands. 13. The facility Hand Washing policy provided by the Dietary Supervisor on [DATE] at 11:57 PM Documented, After engaging in other activities that contaminates the hands. 14. The facility policy on Leftover Storage provided by the Consultant on [DATE] at 3:12 PM documented, Leftovers cannot be used as alternates unless requested by residents. Not to be served as pureed foods.

Based on observation, record review, and interview, the facility failed to ensure the Minimum Data Set (MDS) assessment was accurate and complete to facilitate the ability to plan and provide necessary care and services for 3 (Residents #7, #20, #26) of 6 (Residents #7, #13, #20, #26, #35, #37) sample case mix residents who had Physician Orders for Antiplatelet medications and 1 (Resident #3) who had a discontinued order for an Anticoagulant medication selected for MDS accuracy review. The findings are: 1. Resident #3 was admitted to the facility on [DATE] with Diagnoses of Atrial Fibrillation and Cerebral Infarction. A Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/04/22 documented the resident was severely impaired in cognitive skills for daily decision making on a Staff Assessment for Mental Status (SAMS); question N0410E documented, Medication received, Days: Anticoagulant: 7 a. On 12/13/22 at 3:52 PM, a review of Resident #3's Physician Orders documented .Order date 02/13/16 Eliquis Tablet 5 MG [milligrams] (Apixaban) Give 1 tablet by mouth two times a day related to UNSPECIFIED ATRIAL FIBRILLATION Discontinued 12/26/20 . b. On 12/13/22 at 3:52 PM, a review of Resident #3's Care Plan with a completed date of 11/04/22 did not address the resident's use of Eliquis. c. On 12/14/22 at 11:41 AM, the Surveyor asked Licensed Practical Nurse (LPN) #1 to look at Resident #3 's Quarterly MDS with an ARD of 11/4/22 Section N 0410 E and tell the Surveyor what medication was coded as the Anticoagulant received over the last 7 days of the look back period. LPN #1 said, I guess I just brought it forward. The Surveyor asked LPN #1 to verify when the Anticoagulant was discontinued and LPN #1 said, it was discontinued on 12/26/20. 2. Resident #7 was admitted to the facility on [DATE] with Diagnoses of Cerebrovascular Disease and Heart Failure. A Quarterly MDS with an ARD of 10/16/22 documented the resident scored 15 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status (BIMS); question N0410E documents, Medication received, Days: Anticoagulant: 7 a. On 12/13/22 at 3:55 PM, a review of Resident #7's Physician Orders documented . Aspirin EC [Enteric-Coated] Tablet Delayed Release 81 MG [milligrams] (Aspirin) Give 1 tablet by mouth one time a day related to HEART FAILURE, UNSPECIFIED Do not crush Active 07/13/2022 . b. On 12/13/22 at 3:55 PM, a review of Resident #3's Care Plan with a completed date of 10/16/22 did not address the resident's use of Aspirin. c. On 12/14/22 at 11:40 AM, the Surveyor asked LPN #1 to look at Resident #7's Quarterly MDS with an ARD of 10/16/22 Section N 0410 E and tell the Surveyor what medication was coded as the Anticoagulant received over the last 7 days of the look back period. LPN #1 said, I guess it was the Aspirin. 3. Resident #20 was admitted to the facility on [DATE] with Diagnoses of Peripheral Vascular Disease and Cerebrovascular Disease. A quarterly MDS with ARD of 11/12/22 documented the resident was modified independence in cognitive skills for daily decision making on a SAMS; question N0410E documents, Medication received, Days: Anticoagulant: 7 a. On 12/13/22 at 3:52 PM, a review of Resident #20's Physician Orders documented .Plavix Tablet 75 MG (Clopidogrel Bisulfate) Give 75 MG by mouth one time a day for blood thinner related to CEREBROVASCULAR DISEASE, UNSPECIFIED Active 03/09/2017 . b. On 12/13/22 at 3:55 PM, a review of Resident #20's Care Plan with a completed date of 11/12/22 did not address the resident's use of Clopidogrel. c. On 12/14/22 at 11:38 AM, The Surveyor asked (LPN #1) and the Director of Nursing (DON) to look at Resident #20's Quarterly MDS with an ARD 11/12/22 Section N 0410 E and tell the Surveyor what medication was coded as the Anticoagulant received over the last 7 days of the look back period. LPN #1 said, it was the Plavix [Clopidogrel]. 4. Resident #26 was admitted to the facility on [DATE] with Diagnoses of Congestive Heart Failure and Atherosclerotic Heart Disease. An Admission MDS with an ARD of 10/25/22 documented the resident scored 5 (0-7 indicates severe impairment) on a BIMS question N0410E documents, Medication received, Days: Anticoagulant: 7 a. On 12/13/22 at 3:52 PM, a review of Resident #26's Physician Orders documented . Aspirin 81 Tablet Delayed Release (Aspirin) Give 81 MG by mouth in the morning for Congestive Heart Failure (CHF) related to ATHEROSCLEROTIC HEART DISEASE OF NATIVE CORONARY ARTERY WITHOUT ANGINA PECTORIS Active 10/12/2022 . b. On 12/13/22 at 3:55 PM, a review of Resident #26's Care Plan with a start date of 11/2/22 did not address the resident's use of Aspirin. c. On 12/14/22 at 11:40 AM, The Surveyor asked LPN #1 to look at Resident #26 's Admission MDS with an ARD of 10/25/22 Section N 0410 E and tell the Surveyor what medication was coded as the Anticoagulant received over the last 7 days of the look back period. LPN #1 said, I guess it was the Aspirin. 5. The Resident Assessment Instrument manual documents, N0410E, Anticoagulant (e.g., Warfarin, Heparin, or Low-Molecular Weight Heparin): .Do not code antiplatelet medications such as aspirin/extended release, Dipyridamole, or Clopidogrel here .

Based on interview and record review, the facility failed to ensure Care Plan meetings were held regularly for 1 (Resident #35) of 1 sample selected resident and their family and failed to ensure the Care Plan was updated to include Hospice services for 1 (Resident #13) of 1 sampled resident who began Hospice services during their stay. The findings are: 1. Resident #35 was admitted to the facility with diagnoses of Chronic Embolism and Thrombosis of Unspecified Vein and Chronic Atrial Fibrillation. The Quarterly Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 10/3/22 documented the resident scored 4 (indicated impaired cognition) on the Brief Interview for Mental Status (BIMS) and required supervision with bed mobility, transfer, eating, toilet use, and required limited assistance with dressing and personal hygiene. The resident was always continent of bladder and occasionally incontinent of bowel. a. On 12/13/22 at 11:03 AM, R #35's family provided a complaint to the Surveyor that alleged the resident had not had any Care Plan Meetings this year. b. On 12/13/22 at 08:50 PM, a review of the electronic records for notes or documentation of a Care Plan Meeting held for R #35 showed none. c. On 12/14/22 at 08:22 AM, the Surveyor asked the Administrator for documentation of Care Plan Meetings for R #35. The Administrator stated she would have [named] MDS Coordinator locate those. d. On 12/14/22 at 10:02 AM, the Surveyor asked the MDS Coordinator and Interim Director of Nursing (DON) if they had located documentation of Care Plan Meetings for R #35. The Interim DON stated, Due to lack of staffing and staff wear multiple hats, Care Plan Meetings went to the wayside. We only found documentation for 2020 and 2021. The Surveyor asked, So, there is no documentation of any in 2022 for R #35? The Interim DON stated, No record of any this year. e. On 12/14/22 at 01:45 PM, the Surveyor asked the Administrator, how often should Care Plan Meetings be held? The Administrator stated, Quarterly. f. On 12/14/22 at 04:01 PM, the Administrator provided the facility's Care Conference policy which documented .Care Planning Team shall be composed of .the following members .resident; family member or responsible party . 2. Resident # 13 admitted to facility on 10/24/22 with diagnoses of Unspecified Dementia, Unspecified Severity with Agitation and Chronic Systolic (Congestive) Heart Failure. The Modification Significant Change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/25/22 documented the Staff Assessment for Mental Status (SAMS) showed the resident was severely impaired and required limited assistance with eating, extensive assistance with bed mobility, dressing, toilet use, personal hygiene, and total dependent with transfer. a. On 12/13/22 at 03:54 PM, [named] Hospice contract dated and signed 11/28/18 and reviewed without revision 11/14/19, 11/18/20, 11/16/21 showed Hospice not documented on R #13's CP [care plan], with name of Hospice agency, Agency phone number, or facility's interventions. b. On 12/14/22 at 09:40 AM, the Administrator provided the [named] Hospice Care contract which documented services began on 10/25/22. c. On 12/14/22 at 04:01 PM, the Surveyor asked the Administrator, how often should care plans be updated? The Administrator stated, any time the resident has a new diagnosis, or change in care needed that deviate from what is on the current care plan. The Surveyor asked, when should the update be done by? The Administrator stated, Within 48 hours. The Surveyor asked, How long after a Significant Change MDS is completed should the care plan be updated? The Administrator stated, Within 48 hours. The Interim Director of Nursing (DON) stated, 14 days. The Surveyor asked the Administrator or Interim DON to pull up R #13's Care plan and locate the Hospice documentation. The Administrator stated, She does not have a Care Plan Template for Hospice in [named] electronic records. It has never been triggered. The Surveyor asked, when should have her care plan have been updated since she began Hospice services on 10/25/22 and her MDS Significant Change was completed on 10/25/22? The Interim DON stated, Ultimately by 11/7/22. 46032

Based on observation and interview, the facility failed to ensure food was prepared by methods that maintained the appearance and encourage good nutritional intake for the residents who received pureed diets from 1 of 1 kitchen for 2 of 2 meals observed The failed practice had the potential to affect 7 residents who required pureed diets, 22 residents who received regular diets and 8 residents who received mechanical soft diets according to lists provided by the Dietary Supervisor on 12/13/2022. At 11:49 AM. The findings are: 1. On 12/12/22 at 12:08 PM, the following were on the steam table: a. The edges of the ham slices were burnt. The Surveyor asked Dietary Employee (DE) #1, to describe the appearance of the ham. She stated, the top layers were dried, and the edges were a little burnt. b. The pureed turnip greens were dry. The Surveyor asked DE #1 to describe the appearance of the pureed turnip greens. She stated, It was a little dry. c. The ground ham was burnt. The Surveyor asked DE #1 to describe the appearance of the ground ham. She stated, It was burnt. d. A pan of fortified oatmeal was thick and dry. DE #1 stated, It was a little dried. 2. A pan of pureed cornbread was on ice, and it was thick. DE #1 stated, It was thick. 3. The following were observed during breakfast: a. On 12/13/22 at 7:24 AM, the pureed hash browns were thick. b. On 12/13/22 at 7:35 AM, the Surveyor asked DE #1 to describe the appearance of the pureed hash browns served to the residents on pureed diets. She stated, Pureed hash brown was too thick. c. On 12/13/22 at 10:49 AM, the Surveyor asked the Dietary Supervisor to describe the appearance of the pureed hash browns served to the residents. She stated, Pureed hash brown was too thick. I did not add enough milk.

Based on observation, record review, and interview, the facility failed to ensure pureed food items were blended to a smooth, lump-free consistency to minimize the risk of choking or other complications for residents who required pureed diets for 2 of 2 meals observed. This failed practice had the potential to affect 2 residents who received pureed diets, as documented on a list provided by the Dietary Supervisor on 12/13/22. The findings are: 1. On 12/12/22 at 12:08 PM, the following were on the steam table: a. A pan of pureed white beans, the consistency was runny and not formed. b. A pan of pureed ham, the consistency was gritty and not smooth. 2. On 12/12/22 at 12:55 PM, the Surveyor asked Dietary Employee (DE) #1 to describe the consistency of the pureed food items prepared and served to the residents. She stated, pureed white beans were too runny. Pureed ham is too runny, was not smooth. It is just like mechanical soft meat. 3. On 12/13/22 at 10:49 AM, the Surveyor asked the Dietary Supervisor to describe the consistency of the pureed food items prepared and served to the residents. She stated, Pureed ham was a little watery and did not have smooth texture. The Pureed white beans were too runny. 4. On 12/13/22 at 7:24 AM, the following pureed food items were served to the residents for breakfast: a. the pureed hash browns were thick, b. the pureed sausage was gritty and not smooth, c. the pureed bread was runny. 5. On 12/13/22 at 7:35 AM, the Surveyor asked DE #1 to describe the pureed food items served to the residents on pureed diets for breakfast. She stated, Pureed sausage was gritty, pureed bread was running and pureed hash brown was too thick. 6. On 12/13/22 at 10:49 AM, the Surveyor asked the Dietary Supervisor to describe the appearance of pureed hash brown served to the residents on pureed diets for breakfast. She stated, Pureed hash brown was too thick. I did not add enough milk.

Complaint # (AR 818) was substantiated, all or in part, with these findings. Based on observation, record review and interview, the facility failed to ensure the van lift was utilized in accordance with the manufacturer's instructions, as evidenced by failure to ensure the van lift was in the elevated (van floor level) position prior to offloading a resident in a wheelchair which resulted in a fall with injury for 1 (Resident #1) of 3 (Residents #1, #4, and #5) case mix residents who required a wheelchair during transport in the facility van. This failed practice resulted in Immediate Jeopardy, which caused or could have caused serious harm, injury, or death to Resident #1, who was offloaded while facing the front of the van and while the van lift was incorrectly positioned, which caused the resident to fall backward out of the van and sustain a scalp laceration requiring sutures and a concussion. The failed practice also had the potential to cause more than minimal harm to 9 residents who required the van lift for loading onto, and offloading from, the facility van, according to a list provided by the Director of Nursing (DON) on 4/4/19. The facility removed the immediate jeopardy by initiating corrective actions prior to the survey; however, there were current underlying failed practices at the time of the survey. The Administrator was notified of the (removed) Immediate Jeopardy condition on 4/4/19 at 4:50 p.m. The findings are: 1. Resident #1 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set with an Assessment Reference Date of 1/1/19 documented the resident scored 14 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status; required extensive 2 plus person assistance with bed mobility, transfers and toilet use; was not steady, only able to stabilize with human assistance with moving from seated to standing position, and moving on and off toilet; had shortness of breath with exertion; received oxygen therapy; and required a wheelchair for mobility. a. The facility Skills Checklist Form for Transporting Residents in the facility van dated 3/25/19, and for CNA #1, documented, .Date 3/25/19 . Evaluator Name . (Maintenance Supervisor) .e. Exit Vehicle . Fasten Occupant restraint belt . Place wheelchair in center of platform, facing outward if possible . Lock Wheelchair Brakes . Press and hold down button to lower platform to ground level . Release wheelchair brakes and exit . f. Stow lift . Press and hold 'Stow' button to fold platform which will stop automatically when completely folded . Turn pendant switch off . Close doors . The Checklist Form was initialed by CNA #1 and the Maintenance Supervisor as being completed on 3/25/19. The checklist did not include a reference to correctly positioning the van lift prior to offloading a resident. b. An Office of Long Term Care (OLTC) Incident and Accident Next Day Reporting Form, Division of Medical Services (DMS) form 7734, dated 4/2/19 at 1:30 p.m. documented, .Date of I & A (Incident and Accident) . 4/2/2019 . Time . 1:30 p.m.Name of Resident . (Resident #1) . Summary of Incident . (Resident #1) was injured in a fall after returning from a Doctor's appointment. Her wheelchair tipped over while on the lift and she struck the back of her head. An ambulance was called, and she was transported to (Hospital) in (Nearby Town) . Steps Taken to Prevent Continued Abuse or Neglect During the Investigation . Administrator, (Local) Police, Family, and physician notified. (Certified Nursing Assistant (CNA) #1) immediately removed from building and placed on Administrative Leave pending outcome of investigation . All transports are cancelled until transport drivers have been reeducated on resident transport procedures . Witness Statements initiated . Abuse Prevention Program In-service initiated . 1.) An OLTC Witness Statement Form dated 4/2/19 documented, .Witness Full Name . (Certified Nursing Assistant #1) . I brought (Resident #1) from her appointment. I got out of the van went to the other side, got inside the van to unstrap her and to unhook her. I then got out the van and went around to the back of the van, then proceeded to let lift out. I got back into the van and pushed her onto the lift. I locked her wheelchair and placed the belt around her wheelchair. I got back out of the van to let the lift down. Everything was fine, then all of a sudden, she fell back. I tried to stop her from falling, but it was too late . 2.) An OLTC Witness Statement Form dated 4/2/19 documented, .Witness Full Name . (Resident's Family Member) . My dad (and) I were in the dining area and my dad asked what was outside the front doors. I looked and said it was the van used to transport residents with the back doors open. I looked away and then back at the van, and witnessed a person in a wheelchair fall out of the van backwards, landing on the lift below, which appeared to be all the way on the ground. I saw the person's head hit the lift . 3.) An OLTC Witness Statement Form dated 4/2/19 documented, .Witness Full Name: (Resident #3) written by the Admission Coordinator . the van pulled up, driver got out walked to the back and let the lift to the ground, with nobody on the lift. Then, she walked to the side door and climbed into the van, and unbuckled the resident. Then, the resident fell out of the back of the van. (Resident #3) states the lift was already on the ground. Then, the van driver immediately ran inside and asked for help . 4.) An OLTC Witness Statement Form dated 4/2/19 documented, .Witness Full Name . (Occupational Therapist Aide) . Therapist was walking to vehicle, when noted pt (patient) behind van in w/c (wheelchair) tipped backwards on the ground. Pt was alert, and nursing staff coming out the door to pt. Pt stated she hit her head. Emergency staff was called. Pt.'s w/c (wheelchair) was still strapped in the van lift . 5.) An OLTC Witness Statement Form dated 4/4/19 documented, .Witness Full Name . (Maintenance Supervisor) .The lift was working properly. The arm on the right side was slightly bent to where the door on that side wouldn't close properly. We had lift repairman in (local town) fix or reposition arm . 6.) An OLTC Witness Statement Form dated 4/4/19 documented, .Witness Full Name . (Director of Nursing) . CNA (Certified Nursing Assistant) transport driver (CNA #1) transport driver, was orientated (times) 1 week by (CNA #2) for transport positioning . c. The Hospital Radiology Report dated 4/2/19 documented, .CT (computerized tomography) Head without Contrast Enhancement . [AGE] year-old female with history of fall, injury, pain. Patient fell backward in the nursing home when in wheelchair, hit back of head. Complains of headache . Impression . No acute intracranial abnormality is seen . CT Scan Cervical Spine without contrast enhancement . Impression . No acute fracture seen . CT scan [MEDICATION NAME] spine . Impression . There is seen a questionable mild compression of the superior endplate of T4 ([MEDICATION NAME] vertebra #4), which when compared to the CT chest of (MONTH) 25, (YEAR), is essentially unchanged. Findings are very equivocal. MRI (magnetic resonance imaging) T ([MEDICATION NAME]) spine is recommended . Discharge Instructions . Wound Care . Wound care indicated for wound debridement and cleansing . Wound care indicated for preparing wound for repair . Wound care indicated to promote healing . Wound site . Back of head . Cause of wound . Fall . Wound cleansed with . Wound Cleanser .Wound repaired with sutures . using 1 pack of suture . Diagnosis . Acute, scalp laceration, due to chair level fall . initial visit . Concussion without loss of consciousness . Discharge, Disposition . Nursing Home . 14:58 (2:58 p.m.) . 4/2/2019 . d. On 4/4/19 at 12:53 p.m., Resident #1 was asked to describe the events leading up to her fall from the van. Resident #1 stated, I was just coming back from the pain clinic. I got an injection in my hip. We were pulling up here and we stopped. Best I can remember, it was a lady driver. She was pushing me backwards to get in the ramp. Next thing I know I was on the concrete after flying through the air. I never lost consciousness. I hit my head and still have a bump and stitches or staples. I know you get on the ramp when you get on and get off the van with you on it. They have to back you up. I was on the ramp as far as I know. All I can tell you is what I think happened. It felt like I was flying through the air, then I hit my head on the concrete. My whole body hit the concrete, and I was still in my wheelchair. The Lord was with me. I have been on the van several times and have had no problems. She wasn't new; I don't think. She didn't do anything wrong. It wasn't anybody's fault. e. On 4/4/19 at 1:44 p.m., CNA #1 was asked (via telephone) about the events leading up to Resident #1's fall from the facility van. CNA #1 stated, We pulled up out front of the building. I walked around to the double doors and climbed in and unstrapped the straps; four straps and the seat belt. You hook them across her. I went around to the back of the van. I opened the back of the van and let the lift out. I deployed the lift where you unfold it from the back. I climbed back in through the double doors and pushed her on the ramp lift and locked her wheelchair. The safety strap was in place. I climbed back out and went to the back of the van. The lift was not on the ground. We are not supposed to be on the lift when lowering them down. The straps are connected to the two bars. I was standing on the ground and started to lower the resident when she was in the lift. The lift was all the way to the ground and she fell backwards in her wheelchair. She fell after I had lowered the lift to the ground. It was all of a sudden. Somehow her wheelchair just tipped over. f. On 4/4/18 at 2:18 p.m., Resident #3 was asked to describe what he witnessed when Resident #1 was transported by the facility van driver. Resident #3 stated, I was sitting in the right spot. I wanted to see who she had in there. The van was out in front of the building. She walked to the back of the van and opened the back doors and put the lift on the ground. I thought she might put some boxes or packages on the lift. She was in there a few minutes, and that's when I saw the woman fall out of the van with the lift on the ground. She had to undo everything off of her. The next thing I know, she fell backwards out of the truck. I know (Resident Family Member) . (resident's) dad is over there on 300 Hall and saw it happen. I don't know how much more he saw. I saw her open the back doors and she lowered that lift all the way to the ground. The transport person was still in the van when the lady rolled out. I heard her say she didn't know what happened. I think the girl thought the lift was still up. The lift is always up. It's folded up in the van. The lady fell down in the lift. I know the transport driver got in the building real quick. I would know her if I saw her. g. On 4/4/19 at 3:17 p.m., Resident #3's family member was interviewed via telephone, and was asked to describe what he witnessed. He stated, I was sitting in the day area. It was around the end of the lunch hour. I couldn't see if the lift was on the ground. It looked like it was on the ground at that time. I witnessed this person fall out of the van. I ran up front to get someone to help. I was inside the building. I did not see the transport driver initially. I saw her later. I did not see her initially when I saw the resident fall. I didn't see her out there initially. I cannot say she was back there behind the van for sure, but I did not see her. It happened so fast. It was an awkward fall. I saw her hitting the straps on the lift. Resident #1's family member was asked how the resident fell out of the van and stated, She rolled out backwards and landed on the lift upside down. The wheels of her wheelchair were pointing to the back of the van. It happened so quickly. The transport driver came in and said she needed help. The lady was lying on the lift itself. I saw the van with the back doors open. I saw the person look like she had a fall and I got people to assist. I looked out and saw the person flopped over the lift. She had apparently fallen, or fell out the back of the van. The lift looked like it was on the ground. h. On 4/4/19 at 2:00 p.m., CNA #2 was asked how long she trained CNA #1 on the transport van and using the lift on the back of the van. CNA #2 stated, I trained her for 1 week, and then she did it for about a week on her own. CNA #2 was asked who trained her on the transport van and how to transfer residents on and off the van using the lift on the back of the van. CNA #2 stated, The Maintenance Supervisor trained me. CNA #2 was asked to describe the steps required to safely offload a resident from the facility van, using the lift. CNA #2 stated, I put the emergency brake on, or I deploy the emergency brake before I get out of the van. I get out and open the back doors of the van. I then go in the side doors and unbuckle the resident. I go back to the back of the van and let the lift go back out. I push them (resident) out of the van and make sure the wheels are locked on the wheelchair. Then you can let them down with the lift. You push a button and the lift will unfold. You have a safety belt that you fasten. You don't stay on the lift, but you are outside of the van. You can't do it from inside the van. You push from inside the van out onto the lift. Make sure the wheels are locked and the safety belt is fastened. You back out and lower the lift to the ground. i. On 4/4/19 at 3:43 p.m., the Maintenance Supervisor was asked to describe the steps required to safely offload a resident, using the lift on the back of the facility van. The Maintenance Supervisor stated, It would be safer to ride up and down on the lift with the resident on the lift. It does not specify in the manual. That is my preference. You cannot do that with a bariatric resident. You have to stay clear of the lift by the back of the van. You have to set the emergency brake and go around to the back and open the doors. You get the hand control and put the lift down. You put the lift back up level with the van. Level with the back of the van. The only way it will do this is with the van doors open. At that point, the lift is level with the van doors. You go to the side doors and unstrap the wheelchair. You push them back on the lift and lock the brakes on the wheelchair. It is a tight squeeze to get through there and get them turned around in the wheelchair. You roll them back into the lift and lock the wheelchair brakes. You ride down the lift with them. The belt, the lift won't operate unless the safety harness is connected. The safety harness is automatically connected. You can't fold back the lift unless the safety harness is connected. It folds out level to the back of the van doors. If they can ride down with the residents, that is what I tell them. j. On 4/4/19 at 1:10 p.m., Resident #1's wheelchair was observed by the surveyor, with the DON present. The wheelchair sat low to the ground and was wider in the seat area than a typical wheelchair. The wheelchair brakes worked when tested . There was a portable oxygen tank connected to the back of the wheelchair. The surveyor and the Director of Nursing sat in the resident's wheelchair. The wheelchair was not top heavy, and did not tip backwards or feel unstable when leaning back in the wheelchair. k. The manufacturer's instructions for the van lift, provided by the Administrator on 4/4/19, documented, .Refer to Figure 2-2.It is never safe for a wheelchair occupant to exit a vehicle facing inboard. It is not safe to rely on threshold warning device (audible or other) to confirm that it is safe to exit vehicle while facing inboard. Exiting the vehicle while facing outboard allows for visual confirmation that the lift platform has been raised in the event that the threshold warning device is inoperative or unheard and prevents the occupant from exiting the vehicle backwards when the platform is still on the ground . 2. The facility removed the Immediate Jeopardy and reduced the scope / severity G on 4/2/19, prior to the survey, as evidenced by the following corrective actions: a. The facility's written corrective action plan documented, 1). Resident (Resident #1's Name) was immediately assessed on site by RN (Registered Nurse) on 4/2/19 and sent to Emergency department for treatment and returned to facility. 2). All 8 residents with the potential to be affected by transport CNA during transports were assessed for injuries and interviewed immediately by DON / designee with no negative findings noted on 4/2/19. 3). No transports occurred until transportation aide was re-trained with returned demonstration by DON / designee. 4). All transportation aides will be re-trained by DON / designee on safely transporting residents with return demonstration before performing any transports; to be completed by 4/4/19. 5). DON / designee will monitor and document 3 residents being unloaded in the facility van 5 times weekly for 8 weeks, or until substantial compliance is achieved to ensure proper safety techniques are used. 6). Monitoring of safe transports by DON / designee through review of weekly progress notes and I/As (Incident and Accident Reports). 7). Update training to include correct position of van lift when off-loading resident. b. The facility provided the following evidence of the above corrective actions: 1). The Weekly Transport Schedule dated 4/1/19 through 4/5/19 documented the following entries: 4/2: .Transports suspended. 4/3: No Transports. 4/4: Transports resumed (after) check off on rental van (1 resident transported on this date). 4/5: No Transports 2.) An In-Service Training Report dated 4/2/19 documented, Van Transports . All facility transports are rescheduled until further notice . 3.) A letter dated 4/3/19 and signed by the RN Nurse Consultant documented, To ensure the safety of our residents and add an extra layer of training for transport staff, certification by independent specialist (name) from (company) has been set up for Thursday, (MONTH) 11th . No transports will occur in the facility's van until the certification training specific to our van has taken place. The rented van, which has no mechanical or hydraulic lift, will be in use until all van drivers are deemed certified by (name). 4.) Monitoring sheets dated 4/4/19 through 4/8/19 documented all transports conducted during that time frame were monitored, with no negative findings. c. The facility's van remained out for repairs at the time of the survey.

Complaint # (AR 092) was substantiated, all or in part, with these findings: Based on record review and interview, the facility failed to ensure an incident of possible neglect was reported to the Administrator within 2 hours of discovery, which resulted in a delay in initiating an investigation and protective measures to prevent further potential neglect for 1 (Resident #3) of 1 case mix resident who reported that her wheelchair tipped over backward in the facility van during transport. The failed practice resulted in immediate jeopardy, which could have caused serious harm, injury or death to Resident #3, and had the potential to cause more than minimal harm to 15 residents who were transported via wheelchairs in the facility van, as documented on a list provided by the Clinical Consultant on 9/26/18 at 1:05 p.m. The Administrator, Clinical Consultant, Admission Coordinator and Acting Director of Nursing (DON) were informed of the Immediate Jeopardy on 9/25/18 at 3:20 p.m. The findings are: 1. Resident #3 had [DIAGNOSES REDACTED]. A Quarterly Minimum Data Set with an Assessment Reference Date of 7/19/18 documented the resident scored 14 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status, required limited one person assistance for transfer, bed mobility, toilet use, and personal hygiene, required limited one person assistance to walk in room, required supervision and one person assistance to walk in corridor, and used no mobility devices. a. An Office of Long Term Care (OLTC) Incident and Accident Report (I&A), Division of Medical Services (DMS) form 7734, dated 9/7/18 documented, .Date and Time Submitted (if known) . 9/7/2018 . 4:30 p.m. Date and Time of Discovery . 9/7/18 . 4:20 p.m. Name of Resident . (Resident #3) . Type of Incident: .Neglect . Summary of Incident . I was notified by our main transport driver (Certified Nursing Assistant (CNA) #2) that (Resident #3) told him that when she was on the (facility) van coming from the hospital, the CNA (CNA #1) didn't strap her wheelchair in. When the driver hit the gas, the chair (wheelchair) flipped over in the van, but the resident said she was not hurt in this incident. This incident happened on 9/3/2018 and was reported to us on 9/7/2018 by the resident . Steps Taken to Prevent Continued Abuse or Neglect During the Investigation: 1. We suspended (CNA #1) pending the investigation of this incident. 2. Contacted Police Department for a report. 3. We contacted PCP (primary care physician) as well as had our nursing staff to conduct a full body audit to ensure no injuries. 4. Contacted the family to inform them of this incident. 5. Advised maintenance supervisor to inspect the van for safety pf all harnesses and locking systems. 6. Initiated an in-service with staff concerning transport and appointed one designated driver during investigation. b. A Facility Investigation Report for Resident Abuse, Neglect, Misappropriation of Property and Exploitation of Residents in Long Term Care Facilities, DMS form 762, dated 9/7/18 documented, .Complete description of Incident . I was notified by our main transport driver that (Resident #3) told him that when she was on the (facility) van coming back from the hospital, the CNA (Certified Nursing Assistant) (CNA #1) didn't strap her wheelchair in. When the driver hit the gas, the chair flipped over in the van, but the resident claimed she was not hurt in this incident. This incident happened on 9/2/2018 and reported to us on 9/7/2018 by the resident . Section III . Findings and Actions Taken . The facility immediately began an investigation gathering statements and interviewing the resident and staff members. (Local) Police Department and family member was informed of the incident as well. Resident's daughter is responsible party . The Administrator called (CNA #1) to inform her that she was suspended pending an investigation and scheduled a meeting with the Administrator and the Acting Director of Nursing. The police department sent an officer on 9/7/2018 to file a report on the incident in question . We then contacted the PCP (name) to inform him of the incident, as well as had the Nursing Dept (department) conduct a full body audit to ensure no visible injuries were present . The resident's daughter was contacted to inform her of the incident and she thanked us for letting her know, and that we were investigating the incident. The Administrator instructed the Maintenance Supervisor to inspect the van for safety of all harnesses and locking systems. The facility immediately initiated an in-service with the staff concerning transport and appointed one designated driver during the investigation . Acting Director of Nursing had a meeting with (CNA #1) and during this meeting, employee stated that the wheelchair flipped back when the van was moving. Employee had been properly trained and checked off on the van on 1/23/2018 . Facility is unsure of the substantiation or unsubstantiation of the allegation of neglect . The facility's documented investigation had one witness statement attached, from CNA #2. There was no documented interview with Resident #3 or any other resident who received wheelchair transport in the van, and no documented interview with CNA #1. An Employee Warning Notice dated 9/10/18 documented, .Employee Information Employee Name . (CNA #1) . Date . 9/10/18 . Type of Warning . First Warning . Type of Offense . Violation of Company Policies . Description of Infraction . Resident had an incident while being transported from hospital to facility; no harm was done, but was not reported. Expected Action . Employee must report all incidents that happen (with) residents immediately . Consequences of Further Infractions . Termination . Employee to do statement on occurrence . The notice was signed by CNA #1, the Acting DON and previous Administrator on 9/10/18. c. On 9/24/18 at 2:13 p.m., CNA #1 was interviewed via telephone and was asked to describe the incident involving Resident #3 during transportation from the hospital. She stated, I picked her (Resident #3) up from the hospital. She was in a wheelchair. When I got her in the back of the van, the floor has hooks on the bottom. There are 4 areas to hook the wheelchair to. All 4 areas were hooked. I had to re-adjust the wheelchair, because she is so tall. I had to secure the oxygen tank, and that's what fell , not the wheelchair. While I was adjusting the wheelchair to get it secured, I did have to tip the wheelchair back some to make sure all 4 areas were secured. She was asked if the van was moving when the oxygen tank fell . She stated, The van was in motion when the oxygen tank fell . I had put an extra seat belt around the tank. I didn't have a wheelchair with the oxygen tank sling to secure the tank. After it fell , I retightened the seat belt around the tank. The wheelchair never fell , tipped or anything during transport. CNA #1 was asked if she was asked for a witness statement regarding this incident and stated, No. I got wrote (sic) up though. d. On 9/24/18 at 2:24 p.m., the Acting DON was asked if a witness statement was obtained from CNA #1 regarding the incident with Resident #3. She stated, No. I'm not sure why we didn't obtain a witness statement from (CNA #1). I talked to her and wrote her up. I wrote her up for not reporting it to the Charge Nurse. (CNA #1) reported to me that she had put the resident into the van. She told me the oxygen tank fell and scared the resident. She said she had not left the parking lot of the hospital when the oxygen tank fell . She did state the resident did not tip or fall. The Acting DON was asked if any other residents were interviewed. She stated, No, not that I'm aware of. She was asked if any in-services had been conducted due to this incident, regarding supervision / accident prevention, reporting, investigating, and / or protection. She stated, I didn't do any in-services regarding that. e. On 9/24/18 at 2:43 p.m., the Admission's Coordinator was asked about the incident involving Resident #3. He stated, The resident reported to (CNA #2), the main transport person, that when she was being brought back from the hospital, the van hit a bump or something, and the wheelchair flipped back. f. On 9/24/18 at 2:49 p.m., the Administrator was asked if anyone had interviewed Resident #3 regarding this incident. He stated, I did on the 7th (9/7/18). He was asked if he had documented the interview and stated, No, I didn't, but I can. He was asked if any other residents or staff were interviewed and stated, No, not to my knowledge. g. On 9/25/18 at 9:38 a.m., the Admission's Coordinator was asked what investigation the facility conducted after the incident with Resident #3. He stated, (CNA #2) is the only one at this time doing transportation. He was asked if there had been any in-services regarding supervision / accidents, investigating, reporting and / or protection. He stated, We did an in-service about the van. The In-service Training Report dated 9/7/18 documented, .Topic . Abuse Prevention Program . Contents or summary of training session . At this time no one is to drive the van except (CNA #2) . There were signatures attached to this report. There were 62 signatures on the in-service training report, including Certified Nursing Assistant #1. h. On 9/25/18 at 9:45 a.m., Resident #3 was in her room, sitting in a wheelchair. She was asked if she remembered the incident. She stated she did. She was asked to explain what happened. She stated, She (the CNA) put me in the back of the van and did not chain me down. She had picked me up at the hospital, and before she brought me back, they had ordered fish from somewhere here in town, and she was going to pick it up before she brought me back. She hit a bump and my wheelchair flipped over backwards. She stopped and climbed through the seats and chained me down, then went and got the fish, and then brought me back. I didn't want to tell anyone here when it happened, because I didn't want to get her in trouble. I did tell the nurse and finally (CNA #2), because I felt like it was the thing to do. Resident #3 denied any incidents with transportation before or after this incident. i. On 9/25/18 at 10:58 a.m., the Acting DON was asked again asked whether any other residents were interviewed related to van transports and stated, There were no residents interviewed . j. On 9/25/18 at 11:02 a.m., CNA #1 was interviewed via telephone and was asked if, after the incident with Resident #3, she had gone and picked up food before bringing the resident back to the facility. She stated, I went to the hospital and back to the facility. I did not pick up food with (Resident #3). I got her back with the oxygen tank. She was asked what she did after the oxygen tank fell and stated, When I stopped the van, I got out and went through the side door. I did not climb between the seats. She was asked, after this incident, if she had transported residents. She stated, After the incident with (Resident #3), I transported people 4 or 5 times after that. I don't remember who the residents were. One day last week, I went and got someone, but I don't remember who that was. k. On 9/25/18 at 1:05 p.m., CNA #2 was asked what Resident #3 had reported to him regarding an incident with the van. He stated, (Resident #3) reported the van incident to me on 9/6/18. When I got her back from her appointment, all the administration was gone, so I reported it to them the next morning, on the 7th (9/7/18). I didn't have the number to the Administrator. He had just started that day, and we didn't have a DON. (Resident #3) told me when she was picked up from the hospital - (CNA #1) was the one that picked her up that day - that (CNA #1) did not strap her wheelchair in properly and when she hit a bump it flipped over backwards. He was asked if he knew what day that was. He stated he had checked the Nurses Notes, and it was documented the resident returned to the facility on [DATE]. He stated, She said she didn't get hurt, and she didn't hit her head on anything . she told me after they left the hospital and the wheelchair had flipped, they went and picked up supper before coming back to the facility. The next morning, I went to (Admission's Coordinator) and told him what (Resident #3) had told me. He was asked if the resident had told him anything about the oxygen tank falling. He stated, (Resident #3) never mentioned anything about an oxygen tank falling. He was asked if the facility kept a schedule of the resident transports. He stated he kept a schedule. On 9/25/18 at 1:49 p.m., CNA #2 provided the transportation schedule. This schedule documented only his name, and he stated, This is only for the ones that I transport. If someone else transports, the nurse is supposed to document who takes them and brings them back. If I don't take them, I don't know who took them. After the incident, I was told no one else was supposed to transport except for me until they were re-trained. I was the only one doing transports for about 4 days. The next Thursday (9/13/18) after the incident was reported, the Administrator told me that (CNA #1) was good to go. She had been checked off on 9/13/18. l. On 9/25/18 at 2:03 p.m., Licensed Practical Nurse (LPN) #1 was asked about the incident involving Resident #3 and the transportation van. She stated, (Resident #3) told me on the evening that (CNA #1) brought her back from the hospital in the van, that (CNA #1) 'didn't fasten my wheelchair down and when she took off my wheelchair went backwards.' I asked her if she hit her head, and she said 'no'. The only bruises she had was from IV (intravenous) sites in the hospital and lab draws. I went to (CNA #1), and she said, 'I forgot to lock the wheelchair, and when I took off it rolled backwards.' She said she stopped and fastened it in. The LPN was asked if she reported this to anyone and stated, I did not report to anyone that night; then when (Resident #3) told (CNA #2) and he told the prior Administrator, she asked me what happened, and I told her just what I told you. She had me to make a note of it, and I documented it for the 7th (9/7/18), when she told me I needed to document about what was reported to me. That's not the date she returned from the hospital. According to the resident's clinical record, Nurses Notes, the resident was readmitted to the facility from the hospital on [DATE]; the clinical record contained no further documentation of any transports in the van after that date. m. On 9/26/18 at 10:08 a.m., the Administrator was asked if any staff had been re-trained or if check-offs had been done after the reported incident with Resident #3. He stated, Nobody after the incident was retrained or re-checked off on transportation. He was asked for a policy on the transportation van and a job description for the transportation van drivers. n. On 9/26/18 at 10:39 a.m., the Administrator stated, We don't have a policy on the transportation van. At 1:13 p.m., the Clinical Consultant stated, We can't find a job description for the transportation van drivers. o. The Immediate Jeopardy was removed, and the scope / severity reduced to D, on 9/26/18 at 1:09 p.m., when the facility implemented the following Plan of Removal: 1). Resident (Resident #3) was immediately assessed by RN (Registered Nurse) on 9/25/18 with no negative findings. 2). All 5 residents transported by (CNA #1) will be assessed for injuries by DON / designee and any negative findings addressed immediately by 9/26/18. 3). The 15 residents with the potential to be affected during transports will be assessed for injuries by DON / designee and any negative findings addressed immediately by 9/27/18. 4). No transports will occur until transportation aides are retrained with return demonstration by DON / designee. 5). All transportation aides will be re-trained by DON / designee on safely transporting residents with return demonstration before performing any transports, to be completed by 9/26/18. 6). All staff will be re-trained by Administrator / designee on the reporting policies and procedures pertaining to abuse, neglect, and misappropriation upon return to work, to be completed by 9/30/18. 7). DON / designee will monitor and document 3 residents being loaded in the facility van 5 times weekly for 8 weeks, or until substantial compliance is achieved, to ensure proper safety techniques are used. 8). Administrator / designee will interview and document 5 staff members on abuse, neglect and misappropriation reporting policies 5 times weekly for eight weeks, or until substantial compliance is achieved, to ensure resident safety.

Complaint # (AR 092) was substantiated, all or in part, with these findings: Based on record review and interview, the facility failed to ensure an incident of possible neglect was thoroughly investigated and protective measures immediately implemented to prevent further potential neglect for 1 (Resident #3) of 1 case mix resident who reported that her wheelchair tipped over backward in the facility van during transport. The failed practice resulted in immediate jeopardy, which could have caused serious harm, injury or death to Resident #3, and had the potential to cause more than minimal harm to 15 residents who were transported via wheelchairs in the facility van, as documented on a list provided by the Clinical Consultant on 9/26/18 at 1:05 p.m. The Administrator, Clinical Consultant, Admission Coordinator and Acting Director of Nursing (DON) were informed of the Immediate Jeopardy on 9/25/18 at 3:20 p.m. The findings are: 1. Resident #3 had [DIAGNOSES REDACTED]. A Quarterly Minimum Data Set with an Assessment Reference Date of 7/19/18 documented the resident scored 14 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status, required limited one person assistance for transfer, bed mobility, toilet use, and personal hygiene, required limited one person assistance to walk in room, required supervision and one person assistance to walk in corridor, and used no mobility devices. a. An Office of Long Term Care (OLTC) Incident and Accident Report (I&A), Division of Medical Services (DMS) form 7734, dated 9/7/18 documented, .Date and Time Submitted (if known) . 9/7/2018 . 4:30 p.m. Date and Time of Discovery . 9/7/18 . 4:20 p.m. Name of Resident . (Resident #3) . Type of Incident: .Neglect . Summary of Incident . I was notified by our main transport driver (Certified Nursing Assistant (CNA) #2) that (Resident #3) told him that when she was on the (facility) van coming from the hospital, the CNA (CNA #1) didn't strap her wheelchair in. When the driver hit the gas, the chair (wheelchair) flipped over in the van, but the resident said she was not hurt in this incident. This incident happened on 9/3/2018 and was reported to us on 9/7/2018 by the resident . Steps Taken to Prevent Continued Abuse or Neglect During the Investigation: 1. We suspended (CNA #1) pending the investigation of this incident. 2. Contacted Police Department for a report. 3. We contacted PCP (primary care physician) as well as had our nursing staff to conduct a full body audit to ensure no injuries. 4. Contacted the family to inform them of this incident. 5. Advised maintenance supervisor to inspect the van for safety pf all harnesses and locking systems. 6. Initiated an in-service with staff concerning transport and appointed one designated driver during investigation. b. A Facility Investigation Report for Resident Abuse, Neglect, Misappropriation of Property and Exploitation of Residents in Long Term Care Facilities, DMS form 762, dated 9/7/18 documented, .Complete description of Incident . I was notified by our main transport driver that (Resident #3) told him that when she was on the (facility) van coming back from the hospital, the CNA (Certified Nursing Assistant) (CNA #1) didn't strap her wheelchair in. When the driver hit the gas, the chair flipped over in the van, but the resident claimed she was not hurt in this incident. This incident happened on 9/2/2018 and reported to us on 9/7/2018 by the resident . Section III . Findings and Actions Taken . The facility immediately began an investigation gathering statements and interviewing the resident and staff members. (Local) Police Department and family member was informed of the incident as well. Resident's daughter is responsible party . The Administrator called (CNA #1) to inform her that she was suspended pending an investigation and scheduled a meeting with the Administrator and the Acting Director of Nursing. The police department sent an officer on 9/7/2018 to file a report on the incident in question . We then contacted the PCP (name) to inform him of the incident, as well as had the Nursing Dept (department) conduct a full body audit to ensure no visible injuries were present . The resident's daughter was contacted to inform her of the incident and she thanked us for letting her know, and that we were investigating the incident. The Administrator instructed the Maintenance Supervisor to inspect the van for safety of all harnesses and locking systems. The facility immediately initiated an in-service with the staff concerning transport and appointed one designated driver during the investigation . Acting Director of Nursing had a meeting with (CNA #1) and during this meeting, employee stated that the wheelchair flipped back when the van was moving. Employee had been properly trained and checked off on the van on 1/23/2018 . Facility is unsure of the substantiation or unsubstantiation of the allegation of neglect . The facility's documented investigation had one witness statement attached, from CNA #2. There was no documented interview with Resident #3 or any other resident who received wheelchair transport in the van, and no documented interview with CNA #1. An Employee Warning Notice dated 9/10/18 documented, .Employee Information Employee Name . (CNA #1) . Date . 9/10/18 . Type of Warning . First Warning . Type of Offense . Violation of Company Policies . Description of Infraction . Resident had an incident while being transported from hospital to facility; no harm was done, but was not reported. Expected Action . Employee must report all incidents that happen (with) residents immediately . Consequences of Further Infractions . Termination . Employee to do statement on occurrence . The notice was signed by CNA #1, the Acting DON and previous Administrator on 9/10/18. c. On 9/24/18 at 2:13 p.m., CNA #1 was interviewed via telephone and was asked to describe the incident involving Resident #3 during transportation from the hospital. She stated, I picked her (Resident #3) up from the hospital. She was in a wheelchair. When I got her in the back of the van, the floor has hooks on the bottom. There are 4 areas to hook the wheelchair to. All 4 areas were hooked. I had to re-adjust the wheelchair, because she is so tall. I had to secure the oxygen tank, and that's what fell , not the wheelchair. While I was adjusting the wheelchair to get it secured, I did have to tip the wheelchair back some to make sure all 4 areas were secured. She was asked if the van was moving when the oxygen tank fell . She stated, The van was in motion when the oxygen tank fell . I had put an extra seat belt around the tank. I didn't have a wheelchair with the oxygen tank sling to secure the tank. After it fell , I retightened the seat belt around the tank. The wheelchair never fell , tipped or anything during transport. CNA #1 was asked if she was asked for a witness statement regarding this incident and stated, No. I got wrote (sic) up though. d. On 9/24/18 at 2:24 p.m., the Acting DON was asked if a witness statement was obtained from CNA #1 regarding the incident with Resident #3. She stated, No. I'm not sure why we didn't obtain a witness statement from (CNA #1). I talked to her and wrote her up. I wrote her up for not reporting it to the Charge Nurse. (CNA #1) reported to me that she had put the resident into the van. She told me the oxygen tank fell and scared the resident. She said she had not left the parking lot of the hospital when the oxygen tank fell . She did state the resident did not tip or fall. The Acting DON was asked if any other residents were interviewed. She stated, No, not that I'm aware of. She was asked if any in-services had been conducted due to this incident, regarding supervision / accident prevention, reporting, investigating, and / or protection. She stated, I didn't do any in-services regarding that. e. On 9/24/18 at 2:43 p.m., the Admission's Coordinator was asked about the incident involving Resident #3. He stated, The resident reported to (CNA #2), the main transport person, that when she was being brought back from the hospital, the van hit a bump or something, and the wheelchair flipped back. f. On 9/24/18 at 2:49 p.m., the Administrator was asked if anyone had interviewed Resident #3 regarding this incident. He stated, I did on the 7th (9/7/18). He was asked if he had documented the interview and stated, No, I didn't, but I can. He was asked if any other residents or staff were interviewed and stated, No, not to my knowledge. g. On 9/25/18 at 9:38 a.m., the Admission's Coordinator was asked what investigation the facility conducted after the incident with Resident #3. He stated, (CNA #2) is the only one at this time doing transportation. He was asked if there had been any in-services regarding supervision / accidents, investigating, reporting and / or protection. He stated, We did an in-service about the van. The In-service Training Report dated 9/7/18 documented, .Topic . Abuse Prevention Program . Contents or summary of training session . At this time no one is to drive the van except (CNA #2) . There were signatures attached to this report. There were 62 signatures on the in-service training report, including Certified Nursing Assistant #1. h. On 9/25/18 at 9:45 a.m., Resident #3 was in her room, sitting in a wheelchair. She was asked if she remembered the incident. She stated she did. She was asked to explain what happened. She stated, She (the CNA) put me in the back of the van and did not chain me down. She had picked me up at the hospital, and before she brought me back, they had ordered fish from somewhere here in town, and she was going to pick it up before she brought me back. She hit a bump and my wheelchair flipped over backwards. She stopped and climbed through the seats and chained me down, then went and got the fish, and then brought me back. I didn't want to tell anyone here when it happened, because I didn't want to get her in trouble. I did tell the nurse and finally (CNA #2), because I felt like it was the thing to do. Resident #3 denied any incidents with transportation before or after this incident. i. On 9/25/18 at 10:58 a.m., the Acting DON was asked again asked whether any other residents were interviewed related to van transports and stated, There were no residents interviewed . j. On 9/25/18 at 11:02 a.m., CNA #1 was interviewed via telephone and was asked if, after the incident with Resident #3, she had gone and picked up food before bringing the resident back to the facility. She stated, I went to the hospital and back to the facility. I did not pick up food with (Resident #3). I got her back with the oxygen tank. She was asked what she did after the oxygen tank fell and stated, When I stopped the van, I got out and went through the side door. I did not climb between the seats. She was asked, after this incident, if she had transported residents. She stated, After the incident with (Resident #3), I transported people 4 or 5 times after that. I don't remember who the residents were. One day last week, I went and got someone, but I don't remember who that was. k. On 9/25/18 at 1:05 p.m., CNA #2 was asked what Resident #3 had reported to him regarding an incident with the van. He stated, (Resident #3) reported the van incident to me on 9/6/18. When I got her back from her appointment, all the administration was gone, so I reported it to them the next morning, on the 7th (9/7/18). I didn't have the number to the Administrator. He had just started that day, and we didn't have a DON. (Resident #3) told me when she was picked up from the hospital - (CNA #1) was the one that picked her up that day - that (CNA #1) did not strap her wheelchair in properly and when she hit a bump it flipped over backwards. He was asked if he knew what day that was. He stated he had checked the Nurses Notes, and it was documented the resident returned to the facility on [DATE]. He stated, She said she didn't get hurt, and she didn't hit her head on anything . she told me after they left the hospital and the wheelchair had flipped, they went and picked up supper before coming back to the facility. The next morning, I went to (Admission's Coordinator) and told him what (Resident #3) had told me. He was asked if the resident had told him anything about the oxygen tank falling. He stated, (Resident #3) never mentioned anything about an oxygen tank falling. He was asked if the facility kept a schedule of the resident transports. He stated he kept a schedule. On 9/25/18 at 1:49 p.m., CNA #2 provided the transportation schedule. This schedule documented only his name, and he stated, This is only for the ones that I transport. If someone else transports, the nurse is supposed to document who takes them and brings them back. If I don't take them, I don't know who took them. After the incident, I was told no one else was supposed to transport except for me until they were re-trained. I was the only one doing transports for about 4 days. The next Thursday (9/13/18) after the incident was reported, the Administrator told me that (CNA #1) was good to go. She had been checked off on 9/13/18. l. On 9/25/18 at 2:03 p.m., Licensed Practical Nurse (LPN) #1 was asked about the incident involving Resident #3 and the transportation van. She stated, (Resident #3) told me on the evening that (CNA #1) brought her back from the hospital in the van, that (CNA #1) 'didn't fasten my wheelchair down and when she took off my wheelchair went backwards.' I asked her if she hit her head, and she said 'no'. The only bruises she had was from IV (intravenous) sites in the hospital and lab draws. I went to (CNA #1), and she said, 'I forgot to lock the wheelchair, and when I took off it rolled backwards.' She said she stopped and fastened it in. The LPN was asked if she reported this to anyone and stated, I did not report to anyone that night; then when (Resident #3) told (CNA #2) and he told the prior Administrator, she asked me what happened, and I told her just what I told you. She had me to make a note of it, and I documented it for the 7th (9/7/18), when she told me I needed to document about what was reported to me. That's not the date she returned from the hospital. According to the resident's clinical record, Nurses Notes, the resident was readmitted to the facility from the hospital on [DATE]; the clinical record contained no further documentation of any transports in the van after that date. m. On 9/26/18 at 10:08 a.m., the Administrator was asked if any staff had been re-trained or if check-offs had been done after the reported incident with Resident #3. He stated, Nobody after the incident was retrained or re-checked off on transportation. He was asked for a policy on the transportation van and a job description for the transportation van drivers. n. On 9/26/18 at 10:39 a.m., the Administrator stated, We don't have a policy on the transportation van. At 1:13 p.m., the Clinical Consultant stated, We can't find a job description for the transportation van drivers. o. The Immediate Jeopardy was removed, and the scope / severity reduced to D, on 9/26/18 at 1:09 p.m., when the facility implemented the following Plan of Removal: 1). Resident (Resident #3) was immediately assessed by RN (Registered Nurse) on 9/25/18 with no negative findings. 2). All 5 residents transported by (CNA #1) will be assessed for injuries by DON / designee and any negative findings addressed immediately by 9/26/18. 3). The 15 residents with the potential to be affected during transports will be assessed for injuries by DON / designee and any negative findings addressed immediately by 9/27/18. 4). No transports will occur until transportation aides are retrained with return demonstration by DON / designee. 5). All transportation aides will be re-trained by DON / designee on safely transporting residents with return demonstration before performing any transports, to be completed by 9/26/18. 6). All staff will be re-trained by Administrator / designee on the reporting policies and procedures pertaining to abuse, neglect, and misappropriation upon return to work, to be completed by 9/30/18. 7). DON / designee will monitor and document 3 residents being loaded in the facility van 5 times weekly for 8 weeks, or until substantial compliance is achieved, to ensure proper safety techniques are used. 8). Administrator / designee will interview and document 5 staff members on abuse, neglect and misappropriation reporting policies 5 times weekly for eight weeks, or until substantial compliance is achieved, to ensure resident safety.

Complaint # (AR 092) was substantiated, all or in part, with these findings: Based on record review and interview, the facility failed to ensure a resident's wheelchair was properly secured prior to being transported in the facility van, to prevent the wheelchair from rolling or tipping over during transport for 1 (Resident #3) of 3 (Residents #3, #4 and #5) case mix residents who were transported in a wheelchair via the facility van. The failed practice resulted in immediate jeopardy, which could have caused serious harm, injury or death to Resident #3, and had the potential to cause more than minimal harm to 15 residents who were transported via wheelchairs in the facility van, as documented on a list provided by the Clinical Consultant on 9/26/18 at 1:05 p.m. The Administrator, Clinical Consultant, Admission Coordinator and Acting Director of Nursing (DON) were informed of the Immediate Jeopardy on 9/25/18 at 3:20 p.m. The findings are: 1. Resident #3 had [DIAGNOSES REDACTED]. A Quarterly Minimum Data Set with an Assessment Reference Date of 7/19/18 documented the resident scored 14 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status, required limited one person assistance for transfer, bed mobility, toilet use, and personal hygiene, required limited one person assistance to walk in room, required supervision and one person assistance to walk in corridor, and used no mobility devices. a. An Office of Long Term Care (OLTC) Incident and Accident Report (I&A), Division of Medical Services (DMS) form 7734, dated 9/7/18 documented, .Date and Time Submitted (if known) . 9/7/2018 . 4:30 p.m. Date and Time of Discovery . 9/7/18 . 4:20 p.m. Name of Resident . (Resident #3) . Type of Incident: .Neglect . Summary of Incident . I was notified by our main transport driver (Certified Nursing Assistant (CNA) #2) that (Resident #3) told him that when she was on the (facility) van coming from the hospital, the CNA (CNA #1) didn't strap her wheelchair in. When the driver hit the gas, the chair (wheelchair) flipped over in the van, but the resident said she was not hurt in this incident. This incident happened on 9/3/2018 and was reported to us on 9/7/2018 by the resident . Steps Taken to Prevent Continued Abuse or Neglect During the Investigation: 1. We suspended (CNA #1) pending the investigation of this incident. 2. Contacted Police Department for a report. 3. We contacted PCP (primary care physician) as well as had our nursing staff to conduct a full body audit to ensure no injuries. 4. Contacted the family to inform them of this incident. 5. Advised maintenance supervisor to inspect the van for safety pf all harnesses and locking systems. 6. Initiated an in-service with staff concerning transport and appointed one designated driver during investigation. b. A Facility Investigation Report for Resident Abuse, Neglect, Misappropriation of Property and Exploitation of Residents in Long Term Care Facilities, DMS form 762, dated 9/7/18 documented, .Complete description of Incident . I was notified by our main transport driver that (Resident #3) told him that when she was on the (facility) van coming back from the hospital, the CNA (Certified Nursing Assistant) (CNA #1) didn't strap her wheelchair in. When the driver hit the gas, the chair flipped over in the van, but the resident claimed she was not hurt in this incident. This incident happened on 9/2/2018 and reported to us on 9/7/2018 by the resident . Section III . Findings and Actions Taken . The facility immediately began an investigation gathering statements and interviewing the resident and staff members. (Local) Police Department and family member was informed of the incident as well. Resident's daughter is responsible party . The Administrator called (CNA #1) to inform her that she was suspended pending an investigation and scheduled a meeting with the Administrator and the Acting Director of Nursing. The police department sent an officer on 9/7/2018 to file a report on the incident in question . We then contacted the PCP (name) to inform him of the incident, as well as had the Nursing Dept (department) conduct a full body audit to ensure no visible injuries were present . The resident's daughter was contacted to inform her of the incident and she thanked us for letting her know, and that we were investigating the incident. The Administrator instructed the Maintenance Supervisor to inspect the van for safety of all harnesses and locking systems. The facility immediately initiated an in-service with the staff concerning transport and appointed one designated driver during the investigation . Acting Director of Nursing had a meeting with (CNA #1) and during this meeting, employee stated that the wheelchair flipped back when the van was moving. Employee had been properly trained and checked off on the van on 1/23/2018 . Facility is unsure of the substantiation or unsubstantiation of the allegation of neglect . The facility's documented investigation had one witness statement attached, from CNA #2. There was no documented interview with Resident #3 or any other resident who received wheelchair transport in the van, and no documented interview with CNA #1. An Employee Warning Notice dated 9/10/18 documented, .Employee Information Employee Name . (CNA #1) . Date . 9/10/18 . Type of Warning . First Warning . Type of Offense . Violation of Company Policies . Description of Infraction . Resident had an incident while being transported from hospital to facility; no harm was done, but was not reported. Expected Action . Employee must report all incidents that happen (with) residents immediately . Consequences of Further Infractions . Termination . Employee to do statement on occurrence . The notice was signed by CNA #1, the Acting DON and previous Administrator on 9/10/18. c. On 9/24/18 at 2:13 p.m., CNA #1 was interviewed via telephone and was asked to describe the incident involving Resident #3 during transportation from the hospital. She stated, I picked her (Resident #3) up from the hospital. She was in a wheelchair. When I got her in the back of the van, the floor has hooks on the bottom. There are 4 areas to hook the wheelchair to. All 4 areas were hooked. I had to re-adjust the wheelchair, because she is so tall. I had to secure the oxygen tank, and that's what fell , not the wheelchair. While I was adjusting the wheelchair to get it secured, I did have to tip the wheelchair back some to make sure all 4 areas were secured. She was asked if the van was moving when the oxygen tank fell . She stated, The van was in motion when the oxygen tank fell . I had put an extra seat belt around the tank. I didn't have a wheelchair with the oxygen tank sling to secure the tank. After it fell , I retightened the seat belt around the tank. The wheelchair never fell , tipped or anything during transport. CNA #1 was asked if she was asked for a witness statement regarding this incident and stated, No. I got wrote (sic) up though. d. On 9/24/18 at 2:24 p.m., the Acting DON was asked if a witness statement was obtained from CNA #1 regarding the incident with Resident #3. She stated, No. I'm not sure why we didn't obtain a witness statement from (CNA #1). I talked to her and wrote her up. I wrote her up for not reporting it to the Charge Nurse. (CNA #1) reported to me that she had put the resident into the van. She told me the oxygen tank fell and scared the resident. She said she had not left the parking lot of the hospital when the oxygen tank fell . She did state the resident did not tip or fall. The Acting DON was asked if any other residents were interviewed. She stated, No, not that I'm aware of. She was asked if any in-services had been conducted due to this incident, regarding supervision / accident prevention, reporting, investigating, and / or protection. She stated, I didn't do any in-services regarding that. e. On 9/24/18 at 2:43 p.m., the Admission's Coordinator was asked about the incident involving Resident #3. He stated, The resident reported to (CNA #2), the main transport person, that when she was being brought back from the hospital, the van hit a bump or something, and the wheelchair flipped back. f. On 9/24/18 at 2:49 p.m., the Administrator was asked if anyone had interviewed Resident #3 regarding this incident. He stated, I did on the 7th (9/7/18). He was asked if he had documented the interview and stated, No, I didn't, but I can. He was asked if any other residents or staff were interviewed and stated, No, not to my knowledge. g. On 9/25/18 at 9:38 a.m., the Admission's Coordinator was asked what investigation the facility conducted after the incident with Resident #3. He stated, (CNA #2) is the only one at this time doing transportation. He was asked if there had been any in-services regarding supervision / accidents, investigating, reporting and / or protection. He stated, We did an in-service about the van. The In-service Training Report dated 9/7/18 documented, .Topic . Abuse Prevention Program . Contents or summary of training session . At this time no one is to drive the van except (CNA #2) . There were signatures attached to this report. There were 62 signatures on the in-service training report, including Certified Nursing Assistant #1. h. On 9/25/18 at 9:45 a.m., Resident #3 was in her room, sitting in a wheelchair. She was asked if she remembered the incident. She stated she did. She was asked to explain what happened. She stated, She (the CNA) put me in the back of the van and did not chain me down. She had picked me up at the hospital, and before she brought me back, they had ordered fish from somewhere here in town, and she was going to pick it up before she brought me back. She hit a bump and my wheelchair flipped over backwards. She stopped and climbed through the seats and chained me down, then went and got the fish, and then brought me back. I didn't want to tell anyone here when it happened, because I didn't want to get her in trouble. I did tell the nurse and finally (CNA #2), because I felt like it was the thing to do. Resident #3 denied any incidents with transportation before or after this incident. i. On 9/25/18 at 11:02 a.m., CNA #1 was interviewed via telephone and was asked if, after the incident with Resident #3, she had gone and picked up food before bringing the resident back to the facility. She stated, I went to the hospital and back to the facility. I did not pick up food with (Resident #3). I got her back with the oxygen tank. She was asked what she did after the oxygen tank fell and stated, When I stopped the van, I got out and went through the side door. I did not climb between the seats. She was asked, after this incident, if she had transported residents. She stated, After the incident with (Resident #3), I transported people 4 or 5 times after that. I don't remember who the residents were. One day last week, I went and got someone, but I don't remember who that was. j. On 9/25/18 at 1:05 p.m., CNA #2 was asked what Resident #3 had reported to him regarding an incident with the van. He stated, (Resident #3) reported the van incident to me on 9/6/18. When I got her back from her appointment, all the administration was gone, so I reported it to them the next morning, on the 7th (9/7/18). I didn't have the number to the Administrator. He had just started that day, and we didn't have a DON. (Resident #3) told me when she was picked up from the hospital - (CNA #1) was the one that picked her up that day - that (CNA #1) did not strap her wheelchair in properly and when she hit a bump it flipped over backwards. He was asked if he knew what day that was. He stated he had checked the Nurses Notes, and it was documented the resident returned to the facility on [DATE]. He stated, She said she didn't get hurt, and she didn't hit her head on anything . she told me after they left the hospital and the wheelchair had flipped, they went and picked up supper before coming back to the facility. The next morning, I went to (Admission's Coordinator) and told him what (Resident #3) had told me. He was asked if the resident had told him anything about the oxygen tank falling. He stated, (Resident #3) never mentioned anything about an oxygen tank falling. He was asked if the facility kept a schedule of the resident transports. He stated he kept a schedule. On 9/25/18 at 1:49 p.m., CNA #2 provided the transportation schedule. This schedule documented only his name, and he stated, This is only for the ones that I transport. If someone else transports, the nurse is supposed to document who takes them and brings them back. If I don't take them, I don't know who took them. After the incident, I was told no one else was supposed to transport except for me until they were re-trained. I was the only one doing transports for about 4 days. The next Thursday (9/13/18) after the incident was reported, the Administrator told me that (CNA #1) was good to go. She had been checked off on 9/13/18. k. On 9/25/18 at 2:03 p.m., Licensed Practical Nurse (LPN) #1 was asked about the incident involving Resident #3 and the transportation van. She stated, (Resident #3) told me on the evening that (CNA #1) brought her back from the hospital in the van, that (CNA #1) 'didn't fasten my wheelchair down and when she took off my wheelchair went backwards.' I asked her if she hit her head, and she said 'no'. The only bruises she had was from IV (intravenous) sites in the hospital and lab draws. I went to (CNA #1), and she said, 'I forgot to lock the wheelchair, and when I took off it rolled backwards.' She said she stopped and fastened it in. The LPN was asked if she reported this to anyone and stated, I did not report to anyone that night; then when (Resident #3) told (CNA #2) and he told the prior Administrator, she asked me what happened, and I told her just what I told you. She had me to make a note of it, and I documented it for the 7th (9/7/18), when she told me I needed to document about what was reported to me. That's not the date she returned from the hospital. According to the resident's clinical record, Nurses Notes, the resident was readmitted to the facility from the hospital on [DATE]; the clinical record contained no further documentation of any transports in the van after that date. l. On 9/26/18 at 10:08 a.m., the Administrator was asked if any staff had been re-trained or if check-offs had been done after the reported incident with Resident #3. He stated, Nobody after the incident was retrained or re-checked off on transportation. He was asked for a policy on the transportation van and a job description for the transportation van drivers. m. On 9/26/18 at 10:39 a.m., the Administrator stated, We don't have a policy on the transportation van. At 1:13 p.m., the Clinical Consultant stated, We can't find a job description for the transportation van drivers. n. The Immediate Jeopardy was removed, and the scope / severity reduced to D, on 9/26/18 at 1:09 p.m., when the facility implemented the following Plan of Removal: 1). Resident (Resident #3) was immediately assessed by RN (Registered Nurse) on 9/25/18 with no negative findings. 2). All 5 residents transported by (CNA #1) will be assessed for injuries by DON / designee and any negative findings addressed immediately by 9/26/18. 3). The 15 residents with the potential to be affected during transports will be assessed for injuries by DON / designee and any negative findings addressed immediately by 9/27/18. 4). No transports will occur until transportation aides are retrained with return demonstration by DON / designee. 5). All transportation aides will be re-trained by DON / designee on safely transporting residents with return demonstration before performing any transports, to be completed by 9/26/18. 6). All staff will be re-trained by Administrator / designee on the reporting policies and procedures pertaining to abuse, neglect, and misappropriation upon return to work, to be completed by 9/30/18. 7). DON / designee will monitor and document 3 residents being loaded in the facility van 5 times weekly for 8 weeks, or until substantial compliance is achieved, to ensure proper safety techniques are used. 8). Administrator / designee will interview and document 5 staff members on abuse, neglect and misappropriation reporting policies 5 times weekly for eight weeks, or until substantial compliance is achieved, to ensure resident safety.

Complaints # (AR 252) and # (AR 253) were substantiated, all or part, in these findings. Based on record review and interview, the facility failed to ensure a nutritional assessment was conducted by the Registered Dietician (RD) to determine the necessary calorie, protein, and fluid intake to stabilize or prevent continued weight loss or nutritional complications, failed to ensure the physician followed up on a request to review the resident's medication regimen to determine if adjustments were necessary to restore the resident's appetite, and failed to follow-up with the physician when he did not respond to their concerns about a significant weight loss for 1 (Resident #1) of 3 (Residents #1, #5 and #6) case mix residents who had experienced a significant weight loss in the past 6 months. This failed practice resulted in actual harm to Resident #1 who had significant weight loss and had the potential cause more than minimal harm 18 residents who had experienced a significant weight loss in the last 6 months, according to a list provided by the Registered Nurse Consultant on 7/18/17 at 11:45 a.m. The findings are: Resident #1 was admitted to the facility 3/9/17 and had [DIAGNOSES REDACTED]. The Admission Minimum Data Set with an Assessment Reference Date of 3/16/17 documented the resident scored an 11 (8-13 indicates moderately impaired) on the Brief Interview for Mental Status, required limited assistance with eating, had no swallowing problems, and did not have a weight loss. a. A Physician order [REDACTED]. [MEDICATION NAME] tablet 5 mg give 1 tablet by mouth at bedtime for dementia . b. The Weights and Vital Summary record documented the following weights: 3/9/17 - 167.6 (pounds); 3/14/17 - 166; 3/21/17 - 168.7; 3/28/17 - 163.4; 4/3/17 - 161; 4/19/17 - 150 The resident was sent to a behavioral unit on 4/9/17 and returned to the facility on [DATE]. From 4/19/17 to 7/4/17, the resident lost 21.6 pounds (14.4%), including the 11 pounds lost during his behavioral unit stay. The weekly weights were not continued after the resident's readmission. Physician orders [REDACTED]. c. The Care Plan dated 4/5/17 documented in the Focus section, The resident has unplanned/unexpected weight loss relate to acute illness. The Intervention section documented, Add supercereal, date initiated 4/5/17 . Weigh weekly, date initiated 4/5/17 . If weight decline persists, contact physician and dietician immediately, date initiated 4/5/17 . Add Thrive ice cream at lunch, date initiated 4/21/17 . d. The Weights and Vital Summary record documented the resident's weight on 5/3/17 was 144.8 pounds. e. A Registered Dietician (RD) Note dated 5/3/17 documented, Referred to RD due to new admission with weight loss. Weight is 144.8 down from 161, that's a 10.1% weight loss if the admission weight is correct. Diet is Regular with thrive at all meals and super cereal at breakfast. He has a poor appetite, taking 0-25% of most meals. Meds include [MEDICATION NAME] and [MEDICATION NAME] that both can have side effect of anorexia and weight loss. Please ask MD to review medications. Recommend adding 2 calorie supplement 60 ml (milliliters) bid (twice daily) with medications for increase kcals (kilocalories). f. Care Plan revisions dated 5/3/17 documented, .Add 60 cc (cubic centimeters) med pass bid (twice daily), date initiated 5/3/17 . MD (Medical Doctor) to review meds (medications), date initiated 5/3/17 . nosy cup, date initiated 5/3/17 . g. A Nurse's Note text dated 5/4/17 at 10:59 a.m. and sent from the Director of Nursing (DON) to the physician documented, The dietician was here yesterday and asked if you could do a medication review because he has an order for [REDACTED]. The dietician also recommended a 2 calorie supplement - 60 ml bid, and to add a nosey cup because the resident hangs his head down. Are you ok with these recommendations? The Physician's response to this text was, Yes. There was no documentation of any follow up to the request for a medication review. h. A Nurse's Note dated 5/16/17 at 9:18 a.m. documented, Stage 2 pressure ulcer found to right buttock. Res (resident) has been a weight loss. Res has had a recent decline. Res no longer walks. Res sits in dino chair and has to be propelled by staff. Appetite is poor. Res will drink 2-3 8 oz (ounce) cups of house supplements each meal. Vit (Vitamin) C also started QD (daily). Son notified and agrees with current POC (plan of care). A Nurses's Notes dated 7/6/17 documented an unstable pressure ulcer on the right ankle. i. A physician progress notes [REDACTED].#1) has been known to me and under my care at (nursing home) for only a short time. He suffers from Dementia, from generalized weakness, and anxiety among multiple other chronic ailments. He is seen in routine follow up today at (nursing home). He seems to be stable at this time and the nursing staff report no problems. He is eating fairly well and nutritional status is stable at this time. Skin condition is good. Vital signs are stable. The mucous membranes are moist, the throat is clear . Will continue to follow (Resident #1) with his present medical regimen since he does appear to be stable. The physician did not address the weight loss and pressure ulcer, nor did he document a review of the resident's medications, as recommended by the RD on 5/3/17. j. A Dietary Note dated 6/2/17 at 12:38 p.m. documented, Resident's diet was changed to mechanical soft. k. The Weights and Vital Summary record documented the resident's weight on 6/3/17 was 145.1 pounds. l. A Nurse's Note text dated 6/3/17 at 8:03 a.m. to the physician documented, Res started on multivitamin to assist with wound healing. Wound is slowly improving. Appetite has been very poor. Res has only been drinking house shakes. Res already on prostat. The physician's response dated 6/4/17 at 3:47 p.m. documented, Thx (Thanks). m. A Care Plan revision dated 6/6/17 documented, .Kennedy cup, date initiated 6/6/17 . n. The Weights and Vital Summary record documented the resident's weight on 7/4/17 was 128.4 pounds. o. A Registered Dietician Note dated 7/5/17 at 3:16 p.m. documented, Referred to RD due to weight loss. Weight is 128.4 down from 145, that's an 11.5% weight loss in 30 days. Diet is regular with Thrive at all meals and supercereal at breakfast. He also receives extra eggs at breakfast and 2 calorie supplement 60 ml BID with medications for increase kcals. Staff reports that he likes sweets. Will add syrup to his tray to enhance his meals. Will follow as necessary. p. A Care Plan revision dated 7/5/17 documented, .Add syrup to meals, date initiated 7/5/17 . q. A Nurse's Note dated 7/10/17 at 2:38 p.m. documented, Granddaughter here to see resident. Wanting him shipped to (town) due to decline in overall condition. (Physician) okayed for resident to be sent to (hospital) for evaluation . r. On 7/13/17 at 9:05 a.m., the DON was asked if there was a dietary assessment that documented the resident's nutritional and hydration needs. She stated, I can't find one. What is in the Progress Notes is all we have. s. On 7/13/17 at 1:30 p.m., the Dietary Manager (DM) was asked if there was a dietary assessment that documented the resident's nutritional and hydration needs and she stated, Not that I know of. t. On 7/13/17 at 4:15 p.m., the DON provided documentation of meal intake for Resident #1 for the month of April, May, June, and July 2017. The July 2017 Intake sheet documented the resident consumed 0-25% of his meals from the evening meal on 7/7/17 to the noon meal on 7/10/17, a total of 9 consecutive meals. u. On 7/14/17 at 9:06 a.m., the Restorative Certified Nursing Assistant (CNA) was asked how often residents who had sustained a weight loss were weighed. She stated, We weigh them weekly. She was asked why the weekly weights stopped for Resident #1. She stated, The weekly weights should not have stopped. These computers will sometimes kick the weights out, and then they're gone. v. On 7/14/17 at 9:45 a.m., the RD was asked, At what point is a nutritional assessment, one that shows caloric and fluid needs, done on a resident? She stated, Usually whenever they tell me there's a problem, or for a tube feeder, a weight loss, [MEDICAL TREATMENT]. She was asked if an assessment that included this resident's needs was done and she stated, Sometimes if they call me, we'll talk about the issue on the phone and I'll make some notes. The problem with the situation is they are electronic and my notes don't always get to the chart. There's no form to fill out. I just do a narrative note. As of 7/17/17 at 12:00 p.m., there was no documentation in the resident's record to indicate a nutritional assessment that included calorie, protein and hydration needs was completed. w. On 7/17/17 at 1:55 p.m., the Speech Therapist was asked about the resident's weight loss and she stated, He had dementia . He had quit chewing. His dementia was bad enough to where he could not open his mouth on command . He wouldn't open his mouth for me to see if there was something wrong in there . I would even put food to his lips and he would clamp down . x. On 7/17/17 at 4:00 p.m., the resident's Physician was asked what he remembered about the resident. He stated, He was not very verbal, and he lost some weight. He was asked about the text that was sent to him by the DON on 5/4/17 in reference to the RD wanting him to review the resident's medications since the resident was on [MEDICATION NAME] and [MEDICATION NAME]. He was asked if he reviewed the medications. He stated, No I didn't. Wasn't the [MEDICATION NAME] PRN (as needed)? He was told that the resident received it every night at bedtime and he stated, I didn't realize that. I don't like that drug. He was asked if he was aware of how much weight the resident had lost and he stated, Yeah he lost like 16 pounds I think, by the time he left here. It was explained to the physician that the resident had lost over 20 pounds by the time he had written his Progress Note on 5/28/17 and had lost approximately 40 pounds since admission (3/9/17) to the time he left the faciity on [DATE]. He stated, Really? I didn't realize he had lost that much weight. y. As of 7/17/17 at 4:30 p.m., a weight loss protocol had been requested several times the DON, but one was not provided.

Complaints # (AR 252) and # (AR 253) were substantiated, all or in part, in these findings. Based on record review and interview, the facility failed to ensure an assessment for fluid requirements and monitoring of fluid intake was conducted to prevent potential dehydration for 3 (Residents #1, #2 and #4) of 4 (Residents #1, #2, #4 and #5) case mix residents who were at risk for dehydration. This failed practice resulted in a pattern of harm for Resident #1, who was not assessed and monitored for dehydration after having a change of condition, which resulted hospitalization for severe dehydration, and had the potential to cause more than minimal harm for 27 residents who were at risk for dehydration, according to a list provided by the Director of Nursing (DON) on 7/18/17. The findings are: 1. Resident #1 was admitted to the facility 3/9/17 and had [DIAGNOSES REDACTED]. The Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/16/17 documented the resident scored 11 (8-12 indicates moderately impaired) on the Brief Interview for Mental Status (BIMS), required limited assistance from one person for eating, and had no swallowing disorder. The Care Area Assessment Summary (CAAS) dated 3/16/17 did not trigger for the area of Dehydration/Fluid Maintenance. a. The Care Plan dated 3/10/17 did not address dehydration as a potential problem. b. The Weights and Vital Summary record the resident lost a total of 21.6 pounds from 4/19/17 to 7/4/17. A Nurse's Note dated 5/16/17 at 9:18 a.m. documented, Stage 2 pressure ulcer found to right buttock. Res (resident) has been a weight loss. Res has had a recent decline. Res no longer walks. Res sits in dino chair and has to be propelled by staff. Appetite is poor. Res will drink 2-3 8 oz (ounce) cups of house supplements each meal. Vit (Vitamin) C also started QD (daily). Son notified and agrees with current POC (plan of care). A Nurses's Notes dated 7/6/17 documented an unstable pressure ulcer on the right ankle. c. A Progress Note dated 7/10/17 at 2:38 p.m. documented, Granddaughter here to see resident. Wanting him shipped to (city) due to decline in overall condition. (Physician) okayed for resident to be sent to (hospital) for evaluation . d. The Hospital emergency room record dated 7/10/17 documented, .Triage - Mon (Monday) July 10, 2017 1500 (3:00 p.m.) . Family states patient not eating or drinking and poor appetite for over a month . BP (blood pressure) 77/58, Pulse 98, Resp (Respirations) 12, Temp (Temperature) 97.7 oral, O2 sat (saturation) 94 on r/a (room air) . Currently symptoms are severe . PHYSICAL EXAM - patient afebrile, patient appears non toxic, emaciated . mouth exam included findings of mucous membranes dry . Hematocrit 51.1 (37.2-44.4) . Sodium 174 (137-145) . Chloride 129 (98-107) . BUN 169 (7-25) . Creatinine 4.71 (0.60-1.30) . Severe dementia with acute [MEDICAL CONDITIONS] . Diagnosis: [REDACTED]. Additional - Dehydration, Dementia, Hyperosmolality and [MEDICAL CONDITION] . (hospital) notified for room request for transfer . patient accepted to room ICU (Intensive Care Unit) . e. A Hospitalist Service History and Physical Note dated 7/10/17 documented, .now is transferred to ICU due to altered mental status, severe dehydration, ARF and [MEDICAL CONDITION]. He by their history, has not been eating well . Last weight recorded here was 190 in Feb (February) of this year. Today his weight is 112! . f. On 7/13/17 at 9:05 a.m., the DON was asked if the facility documented fluid intake for residents. She stated, No. Just meal percentages. She was asked if there was no documentation of how much fluid a resident consumes, how does the facility monitor to ensure residents get an adequate amount based on their assessed needs. She stated, Honestly, I can't answer that. She was asked if there was a dietary assessment that documented the resident's nutritional and hydration needs. She stated, I can't find one. What is in the Progress Notes is all we have. g. On 7/13/17 at 1:30 p.m., the Dietary Manager (DM) was asked if there was a dietary assessment that documented the resident's nutritional and hydration needs and she stated, Not that I know of. h. On 7/13/17 at 4:15 p.m., the DON provided documentation of meal intake for Resident #1 for the month of April, May, June and July 2017. The June 2017 Intake sheet documented the resident consumed 0-25% of his meals 18 out of 29 evening meals offered, and 0 - 25% of his meals 5 of 29 breakfast meals offered and 25-50% of his meals 15 out of 29 breakfast meals offered. From 6/26/17 through 6/30/17 the resident consumed 0-25% of 9 of 15 meals offered. The July 2017 Intake sheet documented the resident consumed 0-25% of his meals from the evening meal on 7/7/17 to the noon meal on 7/10/17, a total of 9 consecutive meals. The meal consumption record did not specify fluid intake. i. As of 7/14/17 at 9:00 a.m., there were no documented hydration assessments since the MDS with ARD of 6/16/17. j. On 7/14/17 at 9:06 a.m., Certified Nursing Assistant (CNA) #1 was asked how she monitored a resident's fluids to ensure they get enough and she stated, We don't monitor the fluids. We used to, but when this new computer system started, it took that out. k. On 7/14/17 at 9:45 a.m., the Registered Dietician (RD) was asked, At what point is a nutritional assessment, one that shows . caloric and fluid needs, done on a resident. She stated, Usually whenever they tell me there's a problem, or for a tube feeder, a weight loss, [MEDICAL TREATMENT]. She was asked if an assessment that included this resident's needs was done and she stated, Sometimes if they call me, we'll talk about the issue on the phone and I'll make some notes. The problem with the situation is they are electronic and my notes don't always get to the chart. There's no form to fill out. I just do a narrative note. As of 7/17/17 at 12:00 p.m., there was no documentation in the resident's clinical record to indicate a nutritional assessment that included hydration needs was completed. l. On 7/14/17 at 10:15 a.m., Registered Nurse (RN) #1, a weekend supervisor, was asked how the facility monitored fluid intake for residents. She stated, It's up to the CNAs to notify the nurses if a resident isn't drinking. I know that residents are offered hydration. Staff is constantly asking residents if they want something to drink. She was asked if the facility documented the fluid intake. She stated, No. She was asked if the facility doesn't document fluid intake, how does staff know if a resident gets as much fluid as they need to stay hydrated and she stated, I can't answer that. m. On 7/14/17 at 12:16 p.m., the MDS Coordinator was asked if something doesn't trigger on the CAAS, at what point is it decided that something needs to be placed on a resident's plan of care. She stated, We have our morning meetings, we talk about changes of condition and if it needs to be care planned. She was asked about Resident #1 and the fact that when he was admitted , he was walking and talking, however, he declined and lost weight and developed a pressure ulcer. She was asked why he was not reassessed and determined to be at risk for dehydration after his change of condition. She state, To be honest, I don't think hydration risk ever came up. She was asked if the facility had a way to determine who was at risk for dehydration and she stated, There's not a system that I'm aware of to determine who needs to be care planned for dehydration. n. On 7/17/17 at 2:39 p.m., CNA #2, who provided care to the resident the day before he was sent to the hospital, was asked about his condition when she last saw him. She stated, He was acting like he just didn't feel well. He wouldn't eat or drink. He declined. He would drink like three shakes at a time, but he even quit that. She was asked if she had any way of finding out how much fluid the resident needed and she stated, No. She was asked if the staff documented the amount of fluid a resident drank. She stated, No, we didn't document how much fluid a resident took in. o. On 7/17/17 at 2:48 p.m., Licensed Practical Nurse (LPN) #1, who provided care to the resident on 7/10/17, was asked about his condition that day. She stated, I called his son and told him about how he was and he said 'I will be there.' He was up that morning but I told them to put him to bed because he didn't look right. She was asked why there was no hydration assessment documented since his intake had greatly decreased. She stated, We supposed to do hydration assessments. I just knew he looked bad that day. She was asked if there was anything that told her how much fluid the resident was supposed to get. She stated, No. She was asked if the facility monitored and documented fluid intake for residents. She stated, No. p. As of 7/17/17 at 3:00 p.m., a hydration policy had been requested from the DON numerous times but one was not provided. 2. Resident #2 was admitted to the facility 11/10/16 and had [DIAGNOSES REDACTED]. The Quarterly MDS with an ARD of 5/20/17 documented the resident scored 14 (13-15 indicates cognitively intact) on the BIMS, required supervision with eating, and received a diuretic 7 of the last 7 days. a. A Physician order [REDACTED]. b. The Care Plan dated 2/7/17 did not address dehydration as a potential problem, even though the resident received [MEDICATION NAME] (a diuretic) every day. c. As of 7/14/17 at 9:00 a.m., there were no documented hydration assessments provided by the DON since the MDS dated [DATE]. There was no documentation to indicate the resident's fluid intake had been monitored. 3. Resident #4 was admitted to the facility 2/17/09 and had [DIAGNOSES REDACTED]. The Quarterly MDS with an ARD of 5/20/17 documented the resident was moderately impaired in cognitive skills for daily decision making per a Staff Assessment for Mental Status, and required extensive assistance from staff for eating. a. The Care Plan dated 2/7/17 did not address dehydration as a potential problem, even though the resident had [DIAGNOSES REDACTED]. b. As of 7/14/17 at 9:00 a.m., there were no documented hydration assessments provided by the DON since the MDS dated [DATE]. There was no documentation to indicate the resident's fluid intake had been monitored.

Complaints # (AR 252) and # (AR 253) were substantiated. Based on record review and interview, the facility failed to ensure Physician #1 monitored the medical care provided and addressed changes in medical status to determine if changes in treatment or care were necessary to prevent medical complications [REDACTED].#1) of 6 (Residents #1 through #6) case mix residents who utilized this Physician. This failed practice resulted in actual harm to Resident #1 who was not evaluated for a severe weight loss and dehydration after having a change of condition, which resulted hospitalization for severe dehydration, and had the potential to cause more than minimal harm for 63 residents who utilized Physician #1, according to a list provided by the Director of Nursing (DON) on 7/18/17 at 12:20 p.m. The findings are: Resident #1 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Admission Minimum Data Set with an Assessment Reference Date of 3/16/17 documented the resident scored an 11 (8-12 indicates moderately impaired) on the Brief Interview for Mental Status (BIMS), required limited assistance from one person for eating, had no swallowing disorder, and did not have a weight loss. a. A Physician order [REDACTED]. [MEDICATION NAME] tablet 5 mg give 1 tablet by mouth at bedtime for dementia . b. The Care Plan dated 3/10/17 did not address dehydration as a potential problem. The Care Plan dated 4/5/17 documented in the Focus section, The resident has unplanned/unexpected weight loss relate to acute illness. The Intervention section documented, Add supercereal, dated initiated 4/5/17 . Weigh weekly, date initiated 4/5/17 . If weight decline persists, contact physician and dietician immediately, date initiated 4/5/17 . Add Thrive ice cream at lunch, date initiated 4/21/17 . Add 60 cc (cubic centimeters) med pass bid (twice daily), date initiated 5/3/17 . MD to review meds, date initiated 5/3/17 . nosy cup, date initiated 5/3/17 . Kennedy cup, date initiated 6/6/17 . Add syrup to meals, date initiated 7/5/17 . c. The Weight and Vitals Summary, the resident lost a total of 21.6 pounds from 4/19/17 to 7/4/17, developed a Stage 2 pressure ulcer to the right buttock on 5/16/17, and an unstageable area to the right ankle on 7/6/17. d. The Weight and Vitals Summary documented the following weights: 3/9/17 - 167.6; 3/14/17 - 166; 3/21/17 - 168.7; 3/28/17 - 163.4; 4/3/17 - 161; 4/19/17 - 150; 5/3/17 - 144.8; 6/3/17 - 145.1; 7/4/17 - 128.4. The resident was sent to a behavioral unit on 4/9/17 and returned to the facility on [DATE]. From 4/19/17 to 7/4/17, the resident lost 21.6 pounds (14.4%). e. A Nurses Notes dated 4/18/17 at 1:50 p.m. documented the resident returned to the facility from the behavioral unit on 4/18/17 with an order to increase the dose of [MEDICATION NAME] from 5 mg at bedtime to 10 mg at bedtime. f. An Registered Dietician (RD) Note dated 5/3/17 documented, Referred to RD due to new admission with weight loss. Weight is 144.8 down from 161, that's a 10.1% weight loss if the admission weight is correct. Diet is Regular with thrive at all meals and super cereal at breakfast. He has a poor appetite, taking 0-25% of most meals. Meds (medications) include [MEDICATION NAME] and [MEDICATION NAME] that both can have side effect of anorexia and weight loss. Please ask MD(Medical Doctor) to review medications. Recommend adding 2 calorie supplement 60 ml (milliliters) bid with medications for increase kcals (kilocalories). g. A Nurse's Note text dated 5/4/17 at 10:59 a.m. and written by the DON documented, The dietician was here yesterday and asked if you could do a medication review because he has order for [MEDICATION NAME] and [MEDICATION NAME] and these medications will cause a poor appetite. The resident is a weight loss, he is 16.2 pound weight loss for the month. The dietician also recommended a 2 calorie supplement - 60 ml bid, and to add a nosey cup because the resident hangs his head down. Are you ok with these recommendations? The Physician's response to this text was, Yes. h. A Nurse's Note dated 5/16/17 at 9:18 a.m. documented, Stage 2 pressure ulcer found to right buttock. Res has been a weight loss. Res has had a recent decline. Res no longer walks. Res sits in dino chair and has to be propelled by staff. Appetite is poor. Res will drink 2-3 8 oz (ounce) cups of house supplements each meal. Vit (Vitamin) C also started QD (daily). Son notified and agrees with current POC (plan of care). i. A physician progress notes [REDACTED].#1) has been known to me and under my care at (nursing home) for only a short time. He suffers from Dementia, from generalized weakness, and anxiety among multiple other chronic ailments. He is seen in routine follow up today at (nursing home). He seems to be stable at this time and the nursing staff report no problems. He is eating fairly well and nutritional status is stable at this time. Skin condition is good. Vital signs are stable. The mucous membranes are moist, the throat is clear . Will continue to follow (Resident #1) with his present medical regimen since he does appear to be stable. j. A Nurse's Note text to the physician dated 6/3/17 at 8:03 a.m. documented, Res (Resident) started on multivitamin to assist with wound healing. Wound is slowly improving. Appetite has been very poor. Res has only been drinking house shakes. Res already on prostat. The physician's response dated 6/4/17 at 3:47 p.m. documented, Thx (Thanks). k. A Progress Note dated 7/10/17 at 2:38 p.m. documented, Granddaughter here to see resident. Wanting him shipped to (city) due to decline in overall condition. (Physician) okayed for resident to be sent to (hospital) for evaluation . l. A Hospitalist Service History and Physical Note dated 7/10/17 documented, .now is transferred to ICU (Intensive Care Unit) due to altered mental status, severe dehydration, ARF (acute [MEDICAL CONDITION]) and [MEDICAL CONDITION]. He by their history, has not been eating well . Last weight recorded here was 190 (pounds) in Feb (February) of this year. Today his weight is 112! . m. On 7/17/17 at 4:00 p.m., the resident's Physician was asked what he remembered about the resident. He stated, He was not very verbal, and he lost some weight. He was asked about the text that was sent to him by the DON on 5/4/17 in reference to the RD wanting him to review the resident's medications since the resident was on [MEDICATION NAME] and [MEDICATION NAME]. He was asked if he reviewed the medications. He stated, No I didn't. Wasn't the [MEDICATION NAME] PRN (as needed)? He was told that the resident received it every night at bedtime and he stated, I didn't realize that. I don't like that drug. He was asked if he was aware of how much weight the resident had lost and he stated, Yeah he lost like 16 pounds I think, by the time he left here. It was explained to the physician that the resident had lost over 20 pounds by the time he had written his Progress Note on 5/28/17 and had lost approximately 40 pounds since admission (3/9/17) to the time he left the faciity on [DATE]. He stated, Really? I didn't realize he had lost that much weight. He was asked about the facility not monitoring fluid intake and he stated, Well they really need to monitor these fluids and how much residents take in.

Complaint# 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 during an emergency situation, by failing to ensure nursing staff provided cardiopulmonary resuscitation (CPR) when a resident presented without vital signs for 1 (Resident #1) of 3 (Residents #1, #3 and #4) 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 #1, who expired on [DATE] after being found without vital signs, and had the potential to cause more than minimal harm to 35 residents whose clinical records indicated a full code status, according to a list provided by the Director of Nursing (DON) on [DATE] at 9:15 a.m. The Administrator was notified of the past immediate jeopardy situation on [DATE] at 4:40 p.m. The findings are: Resident #1 had [DIAGNOSES REDACTED]. An Admission Minimum Data Set with an Assessment Reference Date of [DATE] documented the resident was moderately impaired in cognitive skills for daily decision-making per a staff assessment for mental status, required extensive assistance of two-plus persons for transfer, extensive assistance of one person for bed mobility, received oxygen therapy and had a change in physician orders [REDACTED]. a. A physician's orders [REDACTED]. [REDACTED].Admission [DATE] . Neither of the admission / re-admission physician orders [REDACTED]. b. The section titled Advanced Directive on the April and [DATE] Medication Administration Records (MARs) was blank. c. A Care Plan dated [DATE] documented in the Focus section, .The resident has altered cardiovascular status (related to) [MEDICAL CONDITION] . The resident has altered respiratory status / difficulty breathing (related to) [MEDICAL CONDITION] . There was no documentation on the Care Plan regarding code status or advanced directives. d. An Admission Record copied from the Electronic Medical Record on [DATE] at 11:30 a.m. documented, .Resident Information . Code Status (left blank) . page 2 . Advanced Directive: (left blank) . On [DATE] at 3:00 p.m., the DON was asked what was (Resident #1's) code status. She stated, She had no code status, but an absence of a code status would make a resident a full code. e. A Nursing Progress Note dated [DATE] at 6:25 a.m. documented, .Health Status Note . 4:30 a.m. This nurse went into resident's room to check on her and she appeared to not be breathing. Listened and felt for pulse, none detectable. No vital signs detected . 4:36 a.m. called 911 . 4:40 a.m. (physician) notified by phone . 4:45 a.m. (emergency medical services) and police here, and made decision to not send to hospital . 4:48 a.m. family notified by phone . 4:50 a.m. called and left message informing DON . 4:55 a.m. Coroner here to pronounce . 4:58 a.m. Funeral home notified . 5:45 a.m. Family members arrived . 6:15 a.m. Funeral Home arrived to facility . 6:25 a.m. Funeral Home taking expired resident from building . There was no documentation that CPR was provided to the resident. f. A Fire Department Pre-Hospital Care Report dated [DATE] documented, .Dispatched 4:34 a.m. Enroute 4:36 a.m. Scene Arrival 4:41 a.m . On arrival patient covered in bed no CPR pulseless, Apneic last known well 2+ hours ago per nursing staff Asystolic leads II, I, III advised dispatch to call Coroner. Patient cold to touch. Cardiac, Respiratory history . Destination (Dead on Arrival) no transport . g. On [DATE] at 1:30 p.m. Certified Nursing Assistant (CNA) #1 was asked to describe the events that occurred on the night of [DATE] with Resident #1. She stated, The nurse called me down to the room at around 4:00 a.m. or a little before. When she called me down to the room, (Licensed Practical Nurse (LPN) #1) was stating she was thinking the resident was deceased so she just made her calls. (LPN #1) had staff with her, I guess . brought the crash cart. The Nurse checked vital signs. She was trying to figure out if the resident expired. She was saying, 'I need to remember what I need to do' . The CNA was asked if she saw anyone place oxygen or use an ambu bag on the resident. She stated, No I didn't see that. She was asked how long she was in the room with the nurse. She stated, About 10 minutes. h. On [DATE] at 1:40 p.m., CNA #2 was asked about the incidents that occurred on the night of [DATE] with Resident #1. She stated, At 4:00 a.m., I was on 300 Hall and I heard someone call for help and I came and they found (Resident #1) was without a pulse and non-responsive. They were trying to look on the resident's face sheet to determine if the resident was a full code or not. The nurse was at the nurse's desk. The Nurse had the record for the resident pulled up on the computer screen. The other nurse, (LPN #2), was two minutes behind me. I told them to do what they needed to. I would finish looking for resident's (code) status. They could go down and do what they needed, 'cause even I know if in doubt, you just do CPR . I looked in the computer. I could not find anywhere in her chart to determine if the resident was a DNR (Do Not Resuscitate) or Full Code . (LPN #2) came to the Nurse's Station, and I told her I could not find it, and she stated, 'just keep looking' and said the ambulance would be here shortly. i. On [DATE] at 1:48 p.m., CNA #3 was asked about the incidents that occurred on the night of [DATE] with Resident #1. She stated, At about 3:30 or 3:45 a.m., the nurse hollered at us and we went down to the resident's room. We had to get the crash cart. Don't remember who grabbed it . (LPN #2) was on the phone calling 911 . CNA #3 was asked if the nurses performed chest compressions or used an ambu bag. She stated, No . not sure about breathing for the resident. She was in the process of setting up supplies on the crash cart. CNA #3 was asked about the resident's body temperature and she stated, Arms were cold, but her trunk or torso was still warm to touch. j. On [DATE] at 2:48 p.m., LPN #1 was asked about the night of [DATE] with Resident #1. She stated, I went in at 4:30 a.m. to find resident not breathing . no breath sounds . LPN #1 was asked to describe her steps after finding the Resident. She stated, .Went into room talking to her . she did not respond. She was very still . mouth open, not responding. I ran to the desk . called . spoke to the CNA and asked her to send the other nurse . grabbed a stethoscope, listened to her . didn't hear anything . ran back down, grabbed the crash cart. Never had this happen, but was shocked . in over my head . pulled cover off. I was going to grab a back board but didn't find one, but the other nurse called 911. When I got back from looking for a back board the ambulance was arriving. LPN #1 was asked if she used anything from the crash cart. She stated, No . didn't remove anything from the crash cart. LPN #1 was asked if she initiated CPR. She stated, No ma'am. LPN #1 was asked if she was aware of the resident's code status. She stated, No . I didn't have any idea. When I tried to pull up her name on the computer, it wasn't on her face sheet. I assumed she was a full code. LPN #1 was asked if she was CPR certified. She stated, It (CPR certification) expired last Summer. LPN #1 was asked if she had been reprimanded because of the incident. She stated, I got suspended for 3 days and had a mandatory CPR class to attend, yes. k. On [DATE] at 4:00 p.m., the DON was asked if there was any documentation to indicate the resident's code status. She stated, There's not one, and when there's nothing designated, they (residents) are a full code. l. On [DATE] at 7:52 a.m., LPN #2 was asked about the night of [DATE] with Resident #1. She stated, At 4:30 a.m.I was told by my CNA that I was needed at front station . (LPN #1) told me she couldn't find the code status on the resident. I told (LPN #1) to go on down to the room with the crash cart and I would try to find the code status . I tried to look it up. I couldn't find it . I started calling 911. After I called 911, five or six minutes later, the city brought out an officer . I walked him down . As I entered the room, she (LPN #1) was not doing CPR . I told the nurse before she took the crash cart to the room that if we can't find the code status, let's go ahead and start CPR. LPN #2 was asked what she did when she saw the LPN had not started CPR. She stated, My mind went blank, because by that time, 6 minutes had passed. I had always been taught that if 6 to 7 minutes went by, it was futile. LPN #2 was asked if she thought to start CPR. She stated, No I didn't initiate. I just looked. I thought CPR should've already been started . after the fact, I did talk to the nurse, LPN #1. She stated she just froze and learned a lesson on it. m. On [DATE] at 9:00 a.m., the Administrator was asked how the facility determined whether a resident had an Advanced Directive. She stated, Before the admission person was part time, they would do the paperwork with families . The code status was sent to the physician office. Sometimes it would be days before we would get those back . Now the admission person is doing all the admissions. A copy of code status goes to the DON, Administrator, and the admission nurse, and then she is driving it to the Physician's office to get them signed that day. The Administrator was asked what training staff received regarding full code status and initiating CPR. She stated, Before, the charge nurses were just going over the initial admission packet. The nurses were trained on the computer skills through the orientation process .Now when we hire nurses, the ADON and DON will talk to the new hires, show them the crash cart, instruct them on CPR, Code Status . this is done every 3 months. n. The immediate jeopardy was removed and the scope / severity reduced to D on [DATE] at 8:30 a.m., as evidenced by the following: 1.) On [DATE] at 1:45 p.m., the Administrator stated, I launched my own investigation and QAd (Quality Assessment / Assurance) it to ensure it would not happen again. The Administrator's investigation report documented, On [DATE] at approximately 4:30 a.m. (Resident #1) was found without a pulse and not breathing by (LPN #1). LPN ran to her cart, got her stethoscope and listened for heart sounds. None were heard. Resident's face and arms were cool to touch. (LPN #1) then ran .called another nurse grabbed a crash cart and went back to the room. 911 was called. (Ambulance) arrived. Electrocardiogram showed no activity . (LPN #1) was put on suspension pending the investigation . witness statements from all working staff ,[DATE] (10:00 p.m. to 6:00 a.m.) shift of [DATE] . CPR training and education for all nurses will be conducted . All code status will be double checked to make sure they are in the computer . CPR training completed [DATE] . QA code / code status [DATE] . All code status' in computer and correct . (LPN #1) may return back after CPR training . [DATE] . 2.) A form titled QA form dated [DATE] documented, .Identified problem . Code / Code Status . goal . all licensed nurses to be CPR certified . all resident code status identified . Nurses to identify . Protocol for withholding CPR . Actions to Achieve Goal . 1) Mandatory CPR class [DATE] . 2) Audit of resident chart . 3) Provide protocol . Person assigned . 1) DON . 2) Social Services Director / Medical Records . 3) DON by inservice . Outcome . All licensed nurses have provided a valid CPR card or attended class . Charts audited . Inservice attendance by [DATE] by licensed nurses . continued actions . 24 hour chart audit after admissions (next business day) . each new hire of licensed staff will provide proof of CPR upon hire . CPR classes will be held every 6 months to ensure license remain valid . 3.) On [DATE], the Administrator also provided documentation of the following corrective actions and ongoing monitoring to prevent reoccurrence: .(LPN #1) was suspended pending investigation . (LPN #1) was suspended until she was able to complete a CPR class . QA was initiated related to CPR Certification of licensed staff and code status identification . Between [DATE] at 8:30 a.m. and [DATE] at noon, all licensed staff, to include 19 employees, were contacted per phone or in person by the DON and educated on identification of code status, CPR initiation related to code status, and alternatives to using a back board during CPR. All named staff were required to provide current CPR certification or attend CPR class on [DATE]. Staff were notified that they would be suspended from resident care if proof was not received or class was not attended (a list of nurses' names was provided, which documented 11 nurses with CPR certification prior to [DATE]) . A written in-service was initiated for all licensed staff with 100% completion rate provided within 24 hours. The written inservice included: Four ways to identify code status in the electronic chart, the ACT 718 of 2009 Protocol for Withholding CPR, What to do if Code status is unidentified, and contacting of the ambulance service directly as well as dialing 911. The education provided also included tips for documentation and mandatory CPR certification for each licensed individual . On [DATE] the admission process to (facility) was changed and a system was implemented for obtaining Advanced Directive/Code status . On [DATE] resident's charts were audited for code status by Social Director. Any unidentified code statuses were addressed with resident and / or family immediately. By [DATE], all residents had a code status scanned into electronic record and physician orders [REDACTED]. On [DATE], 24 hour resident chart audits to be completed by medical records were initiated. These audits are to be completed and licensed staff educated by medical records no later than the next business day . On [DATE] CPR certification notebook initiated by Business Office Manager and is to be maintained by DON. All Licensed staff will be required to be CPR certified upon hiring . CPR class will be held at facility every 6 months and as needed to ensure all staff remain CPR certified . 4.) On [DATE] at 8:13 a.m., six of six Licensed Nurses who were interviewed by the surveyors were able to correctly report where to find a resident's code status in the clinical record / computer and when to initiate CPR.