Every finding on record at The Green House Cottages of Homewood

Based on observation, record review, interview, and facility policy review, it was determined the facility failed to follow Enhanced Barrier Precautions (EBP) during intravenous catheter care for 1 (Resident #33) of 1 sampled resident reviewed for intravenous (IV) catheter care, IV antibiotic administration, and EBP. The findings are: Resident #33 had diagnoses of kidney abscess, diabetes mellitus (DM), cerebral palsy, hemiplegia, and neurogenic bladder. The significant change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/21/2025 indicated the resident scored 15 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status (BIMS), had an IV access, and took an antibiotic. Review of the care plan revealed Resident # 33 was on Isolation Precautions: Enhanced Barrier Precautions. Enhanced Barrier Precaution signage and personal protective equipment (PPE) was observed at the entry of Resident #33 ' s room. On 02/24/2025 at 3:30 PM, this surveyor observed Licensed Practical Nurse (LPN) #1 access an IV catheter to Resident #33 ' s left arm for IV antibiotic therapy. LPN # 1 entered the room with gloves already on, IV medication in hand, and did not don a PPE gown. This surveyor observed LPN # 1 initiate Resident #33 ' s IV medication through the IV catheter in the resident ' s left arm. No hand hygiene was performed between glove changes and a gown was worn while providing direct care to the resident. On 02/24/2025 at 3:40 pm, during an interview, this surveyor asked LPN #1 what she should have done differently while providing care to Resident #33. LPN #1 stated she should have performed hand hygiene and worn a gown due to Resident #33 being on Enhanced Barrier Precautions (EBP). This surveyor asked LPN #1 what the reason for hand hygiene and EBP was. LPN #1 stated the purpose was to prevent infection. On 02/26/2025 at 9:45 AM, this surveyor received a Hand Washing Policy and Enhanced Barrier Policy from The Infection Preventionist. On 02/26/2025 at 3:50 PM, this surveyor interviewed the Assistant Director of Nursing (ADON). The ADON was asked what process staff were expected to use during IV access and antibiotic administration and providing care for residents on EBP. The ADON stated staff should wash their hands and don gloves prior to care and staff should follow Enhanced Barrier Precautions prior to resident care. A review of a policy titled, Hand Hygiene, revealed hand hygiene should be performed before applying and after removing gloves. A review of a policy titled, Implementation of Personal Protective equipment (PPE) Use in nursing homes to prevent spread of Methicillin Resistant Drug Organism (MDRO) read, .Enhanced Barrier Precautions. Enhanced Barrier Precautions (EBP) are indicted for residents that have wounds and/or indwelling medical devices Personal Protective Equipment (PPE) (Gloves and Gowns) are to be utilized for these residents during high-contact resident care activities such as indwelling medical device.

Surveyor: Cahoone, [NAME] Based on observation, and interview, three employees who did not perform hand hygiene before serving food in the kitchen in Cottages 7 and 8, this had the potential to affect 22 residents who receive meals, and 1 employee who did not perform hand hygiene going from raw meat to serving bread in Cottage 3. This had the potential to affect 10 residents who receive a tray from the kitchen, and open food in freezers in Cottages 4 and 5 that was not dated. This had the potential to affect 21 residents who receive food in Cottages 4 and 5. The findings are: 1. Cottage 7: a. On 1/30/24 at 12:03 pm, observed Certified Nursing Assistant (CNA) #1 leave Cottage 7 and go to Cottage 6 to get a puree machine and return and start serving food to residents without performing hand hygiene. b. On 1/30/24 at 12:09 pm, CNA #1 pulled down her top in the back with both ungloved hands, then began to serve food again without performing hand hygiene. c. On 1/30/24 at 12:16 pm, CNA 2 took a food tray into a resident's room then returned to pick up another tray to take to another resident's room without performing hand hygiene. d. On 1/30/24 at 12:29 pm, the Surveyor asked CNA #1 when you touch your uniform what should be done before serving food. CNA #1 said wash my hands. The Surveyor asked what should be done if you go from one cottage to another and then start to serve food. CNA #1 said wash my hands. e. On 1/30/24 at 12:31 pm, the Surveyor asked CNA #2 when you assist a resident what should you do before assisting another resident. CNA #2 said wash my hands. The Surveyor asked what should be done after taking a food tray to a resident's room before taking another tray to another resident's room. CNA #2 said wash my hands. 2. Cottage 3: a. On 1/31/24 at 7:40 am, without changing gloves or washing his hands, CNA #3 pulled frozen meat (round brown patties) from the freezer, took them out of the bag, placed them in a frying pan, then opened the bread bag and pulled slices of bread out of the bag, placing them in an egg mixture. b. On 1/31/24 at 7:45 am, the Surveyor asked CNA #3 why it is important to wash your hands after touching dirty items and before touching clean items. CNA #3 said you wash hands for infection control, so people don't get sick. 3. Cottage 8: a. On 1/31/24 at 12:15 pm, CNA #4 in Cottage 8, take a tray to Resident room [ROOM NUMBER] and come and get another tray and serve to a resident in room [ROOM NUMBER] without performing hand hygiene. b. On 1/31/24 at 12:21 pm, the Surveyor asked CNA #4 what you should do before serving a meal. CNA #4 said we wash our hands before we start serving trays. The Surveyor asked what should you do in between serving resident trays in their rooms? CNA #4 said wash my hands. 49071 4. Cottage 5: a. On 01/31/24 at 07:21 AM, in the freezer there was an opened container of strawberry ice cream, and goat cheese bites that did not have an open date. Dietary Employee (DE) #1 was asked the procedure for storing food in the freezer after it is opened. DE #1 said they date the food, because after it is opened, it's only good for so many days then it should be thrown out. 5. Cottage 4: a. On 01/31/24 at 07:30 AM, in the freezer there was an opened gallon bucket of vanilla ice cream without an open date. The Surveyor asked DE #2 what the procedure was for returning opened containers to the freezer. DE #2 said I think we should have put an open date on it so we would know when it would need to be thrown out, should have been dated when it was opened. 6. On 01/31/24 at 09:30 AM, the Surveyor asked the Director of Nursing (DON) if a cook leaves a cottage to help the kitchen in another cottage and returns to the original cottage what do you expect the cook to do before preparing food. The DON said they need to wash their hands. The Surveyor asked what procedure she expected staff to follow, after opening frozen food and returning it to the freezer. The DON said it should be closed, sealed, and dated before returning to the freezer or refrigerator. The Surveyor asked if she expects staff to follow this procedure for dating opened foods. The DON said, Absolutely, I do. 7. On 01/31/2024 at 10:05 AM, the Dietician said they do not have a policy on food storage, and provided a policy titled, Handwashing and Glove Usage in Food Service which documented, .Objectives: 1. Understand the importance of handwashing in prevention of illness 2. Identify when hands need to be washed 3. Correctly demonstrate the correct handwashing procedure. 4. Identify the correct usage of single use gloves in food service .When Food Handlers must wash their hands: Before starting work . Before and after handling raw meat, poultry and seafood .After leaving and returning to the kitchen/prep area, after touching anything else such as dirty equipment, work surface or cloths .How to use Single-Use Gloves Single-use gloves can help keep food safe by creating a barrier between hands and food, They should be used when handling ready-to eat foods .When to change gloves (ready to eat foods should not be handled with bare hands) .Before beginning a different task, After an interruption, such as taking a phone call, after handling raw meat, seafood or poultry and before handling ready-to eat food. 8. On 01/31/2024 at 11:30 AM, the DON provided an in-service dated 01/07/2023 titled, Cook Tasks documenting, .6. Make sure food and drinks are labeled. 7. Discard out of date items .

Based on observation, record review and interview the facility failed to ensure a resident had physicians order for oxygen for 1 (Resident #41) of 3 (Residents #41, #10 and #39) Residents who received oxygen as documented on a list provided by the Director of Nursing (DON) on 02/01/24 at 9:05 AM. The findings are: Resident #41 diagnosis of hemiplegia and hemiparesis, non-Hodgkin lymphoma, and peripheral vascular disease. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/01/23 documented a Brief Interview for Mental Status (BIMS) score of 14 (13-15 indicates cognitively intact) and did not receive oxygen therapy. a. A Care Plan with a revision date of 01/08/24 documented, 01/07/2024 Oxygen as ordered/needed for SOB [shortness of breath]. b. Resident #41's Physician Orders, active as of 01/31/24, did not address oxygen therapy. c. On 01/29/24 at 12:21 PM, Resident #41 was receiving oxygen at 2.5 to 3 liters via nasal cannula. The Surveyor asked Resident #41 how much oxygen he was wearing. Resident #41 stated, I am not sure how much oxygen I am on. The Surveyor asked why he wore oxygen. Resident #41 said he was not sure. d. On 1/31/24 at 1:20 PM, Resident #41 was observed wearing oxygen between 3 - 4 liters nasal cannula. e. On 1/31/24 at 1:29 PM, the Surveyor asked Licensed Practical Nurse (LPN) to look up how many liters of oxygen Resident #41 should be on. After looking in the facility's computer program, LPN #1 verified there was no order for oxygen. f. On 1/31/24 at 2:00 PM, the Surveyor asked the Director of Nursing (DON) to explain the process she would expect a nurse to take when applying oxygen. She said the nurse needs to assess the resident and check for orders. The Surveyor asked why you would need an order. The DON said to modify the change in condition. The Surveyor asked if oxygen was a medication. The DON said yes.

Based on observation, interview and record review, the facility failed to ensure licensed staff had been trained properly to take care of a resident with an enteral feeding tube. The findings are: 1. On 1/31/24 at 1:50 PM, Licensed Practical Nurse (LPN) #1 administered medication through a enteral feeding tube. The nurse failed to check for placement before administering the medication and hydration. The Surveyor asked LPN #1 what process she uses to check placement. LPN #1 stopped administering the flush and said, We do that by pulling back on the syringe. I should have done that. The Surveyor asked what the reason was for checking placement before flushing the enteral feeding tube. LPN #1 said she was not sure what the reason would be, and she cannot remember what the case would be. The Surveyor asked if she ever used a stethoscope to check placement. LPN #1 said, No, we just check by pulling back for residual. The Surveyor asked if she has ever had a enteral feeding tube in-service. She said, No, I never had a tube feeding in-service before. 2. On 1/31/24 at 2:34 PM, the Surveyor asked the Director of Nursing (DON), why do you check for placement on an enteral feeding tube before administering medications or feedings. The DON said to ensure proper placement. The Surveyor asked should all nurses be trained on checking placement before taking care of a resident with a feeding tube. The DON said yes, our nurses are checked off on skills before taking care of the residents. 3. On 1/31/24 at 2:40 PM, after reviewing LPN #1's competency file, the Surveyor was made aware by Human Resources (HR), that LPN #1 had not completed her checkoff skills list for this year. The Competency Assessment Enteral Feedings - Safety Precautions competency checkoff skills list for LPN #1 provided by the DON on 1/31/24 at 2:20 PM was blank except for LPN #1's signature and a date of 3/28/23. 4. On 1/31/24 at 2:20 PM, the Competency Assessment for Enteral Feedings from the DON on page 3 documented, .Preventing Aspiration 1. Check enteral tube placement prior to each feeding and administration of medication .

Based on observation and interview the facility failed to ensure a therapeutic diet was prescribed by the attending physician for 1 (Resident #283) for a pureed diet. The findings are: 1. On 1/30/24 at 11:56 am, Resident #283 received a regular texture diet tray for lunch in the Dining Room. Resident #283 took 2 bites of turkey and dressing before the cook realized Resident #283 had the wrong meal tray. The Cook immediately had Certified Nursing Assistant (CNA) #2 remove the tray and later Resident #283 received a puree diet meal tray. 2. On 1/31/24 at 11:16 am, the Surveyor asked CNA #5, how do you know what the proper therapeutic diet is to serve each resident? CNA #5 said the resident diets are in a binder, and I write them down so I can make sure they get the correct tray. 3. On 1/31/24 at 11:19 am, the Surveyor CNA #6 how do you know the correct therapeutic diet for each of the residents. CNA #6 said they have the diets for each resident listed in a binder and I write them down on a piece of paper and I look at it before serving the resident a tray. 4. On 1/31/24 at 1:42pm, the Surveyor asked the Director of Nursing (DON), how does your staff know the correct therapeutic diet to serve to the residents? The DON said the staff has a binder in each cottage with the resident's therapeutic diets listed in it. The Surveyor asked what could happen if a resident received the wrong therapeutic diet. The DON said potential aspiration.

Based on record review and interview, the facility failed to ensure the Quality Assurance and Performance Improvement Program (QAPI) Committee developed and implemented appropriate plans of action to prevent repeated deficiencies with revision of Care Plans and ADLs regarding grooming. The failed practice had the potential to affect all 82 residents who resided in the facility as documented on the Daily Census provided by the Administrator on 01/29/24 at 10:30 AM. The findings are: 1. A Recertification Survey was conducted on 12/1/2022 at the facility. During this survey, the team identified concerns with revisions of resident care plans, and ADLs regarding grooming. A review of the facility's Plan of Correction, with a completion date of 1/11/2023, indicated the MDS Coordinator/Designee would monitor: 1. Revision of Care Plans to ensure deficient practice does not recur: On 12-1-22, the Administrator in-serviced MDS Coordinators regarding revision to Care Plan should be completed within 14 days after determining the change in condition. 2. Monitoring: MDS Coordinators/Designee will monitor by review/observation to ensure revision to Care Plan is completed within 14 days after determining the change in condition, for any resident with a change in condition, for 4 wks [weeks] or until compliance is achieved. Any negative findings will be corrected immediately and Administrator/Designee notified. 3. QA [Quality Assurance]: Administrator/Designee will present all findings to the monthly QA committee for further review and recommendation. 2. A Recertification Survey was conducted on 12/1/2022 at the facility. During this survey, the team identified concerns with grooming, regarding facial hair. To ensure deficient practice does not reoccur: On 12-1-22, the DON/Designee in-serviced direct care staff on ensuring dependent residents receive needed ADL care. Monitoring: Primary care nurse/designee will monitor by observation to ensure dependent residents receive needed ADL care for 4 wks or until compliance is achieved. Any negative findings will be corrected immediately, and Administrator/Designee notified. QA: Administrator/Designee will present all findings to the monthly QA committee for further review and recommendation. 3. A Recertification Survey was conducted on 2/1/2024. During the survey the team identified concerns with revision of care plans and ADLs regarding facial hair. Cross Reference F657, and F677. On 2/1/2024 at 11:10 AM, the Surveyor asked the Administrator, How does the QAA Committee know when an issue arises in any department? She answered, By observation, management by walking around, using the concern form/grievance form, I&As [Incident and Accident]. There are multiple ways, but these are ones off the top of my head. Talking to people, reviewing minutes of resident council, looking for trends etcetera. Burnt cookies we would QAPI that and determine the cause. The Surveyor asked, How does the QAA Committee know when a deviation from performance or a negative trend is occurring? She answered, Observations, looking at PCC [Facility Computer Software], looking at the QMs [Quality Measures], weekly weights, daily weights, diets, weight gain, ask family that brings [cheese snack] with help. Falls, poor safety awareness. The Surveyor asked, How does the QAA Committee decide which issues to work on? She answered, Hierarchy to what is most critical to their welfare. Eating, like, if someone will not stop eating snacks from family. Pay attention to what is going on. Daily nursing notes. Communication, family council - during COVID we couldn't have it, but we are glad we have it back. The Surveyor asked, How long will the QAA Committee monitor an issue that has been corrected? She answered, Until resolved. It could be ongoing for a year if we see something that is reoccurring. Like Medicare days, everybody thinks they get 100 days. We must explain how the program works to families. The Surveyor asked, Is the QAA Committee aware of repeated survey deficiencies? She answered, They will be. We do go over those and say let ' s not repeat this because that is the worst thing we can do. The Surveyor asked, If aware, did the Committee implement corrective action? She answered, 2567, yes.

Based on observation, record review and interview, the facility failed to ensure fingernail care and shaving was regularly provided for 4 (Residents #32, #51, #57 and #60) of 4 sampled residents who required staff assistance with personal hygiene. The findings are: 1. On 1/29/2024 at 9:08 AM, Resident #32's fingernails nails were uncut and jagged the resident was unshaved. Resident #32 stated he likes to be shaved. a. On 01/30/24 at 9:08 AM, Resident #32 remained unshaved. Resident #32 stated he likes to be shaved and asked for a shave. b. Resident #32's Care Plan with a revision date of 01/16/24 documented, .ADLs fluctuate a bit d/t [due to] COPD [chronic obstructive pulmonary disease] and dialysis. Personal Hygiene: Combing hair, shaving, washing/drying face, and hands: Resident #32 requires Set up or clean up Assistance . c. Resident #32's Personal Hygiene Sheet documented, .PERSONAL HYGEINE: The ability to maintain personal hygiene, including combing hair, shaving, applying makeup, washing/drying face and hands (excludes baths, showers and oral hygiene) . Resident #32 received Personal Hygiene daily from 01/01/24 to 01/29/24. d. Resident #32's Nail Care Task sheet noted Resident #32 had received nail care weekly on Fridays from 01/05/24 to 01/26/24, with no refusals noted. 2. On 01/29/24 at 01:05 PM, Resident #51 was observed to have facial chin hair and dirty jagged fingernails. a. On 01/30/24 at 08:50 AM, Resident #51 continued to have dirty fingernails and chin hair. b. Resident #51's Care Plan with an initiated and revision date of 12/26/23 documented, .[Resident #51's] usual performance .varies with ADLs due to Cognitive Impairment . Personal Hygiene: Combing hair, makeup, washing/drying face, and hands: Weight bearing with assistance of 1 staff . Shower/bathe self: Dependent (1-2 staff)(Helper does all of effort. Resident does none of the effort to complete or the assistance of 2 or more helpers is required . c. Resident #51's Personal Hygiene Task sheet for 01/01/24 to 01/30/24 documented, .PERSONAL HYGEINE: The ability to maintain personal hygiene, including combing hair, shaving, applying makeup, washing/drying face and hands (excludes baths, showers and oral hygiene). Resident #51 received Personal Hygiene daily from 01/01/24 to 01/30/24, with no refusals noted. d. Resident #51's Nail Care Task sheet noted Resident #51 had received nail care weekly on Mondays from 01/01/24 to 01/29/24, with no refusals noted. 3. On 01/29/24 at 1:44 PM, observed Resident #57 with dirty and jagged fingernails. a. On 01/30/24 at 08:56 AM, observed Resident #57 with dirty and jagged fingernails. b. Resident #57's Care Plan with an initiated and revision date of 11/30/23 documented, .usual performance is weight bearing with ADLs due to wheelchair bound; Personal Hygiene: Combing hair, shaving, makeup, washing/drying face and hands: Weight bearing assistance of 1 staff . Shower/bathe self: Weight bearing with assistance of 1 staff . c. Resident #57's Personal Hygiene Task sheet documented, .PERSONAL HYGEINE: The ability to maintain personal hygeine, including combing hair, shaving, applying makeup, washing/drying face and hands (excludes baths, showers and oral hygeine). Resident #51 received Personal Hygiene daily from 01/01/24 to 01/30/24, with no refusals were noted. d. Resident #57's Nail Care Task sheet noted Resident #57 received fingernail care weekly on Sundays from 01/07/24 to 01/28/24, with no refusals noted. 4. On 1/29/24 at 1:30 PM Resident #60 had some chin hair. a. On 1/30/24 at 8:58 AM Resident #60 had chin hair. b. On 01/30/24 at 08:28 PM, Resident #60's Care Plan with an initiated and revision date of 12/20/23 documented, .usual performance with ADLs varies day to day due to Cognitive Impairment; Personal Hygiene: Set up or clean up Assistance. (Helper sets up or cleans up: resident completed task. Helper assists only prior to activity or following activity) Combing hair, shaving, makeup, washing/drying face, and hands . Shower/bathe self: Touching Assistance (helper provides touching/steadying and or contact guard assistance as resident completes activity) Assistance may be provided throughout the activity or as needed) . c. Resident #60's Personal Hygiene Task sheet documented, .PERSONAL HYGEINE: The ability to maintain personal hygeine, including combing hair, shaving, applying makeup, washing/drying face and hands (excludes baths, showers and oral hygeine) . Resident #60 received Personal Hygiene daily from 01/01/24 to 01/30/24, with no refusals were noted. d. Resident #60's Nail Care Task sheet noted Resident #60 received fingernail care weekly on Tuesdays from 01/02/24 to 01/30/24, with no refusals noted. 5. On 1/31/2024 at 1:10 PM, the Surveyor asked Certified Nursing Assistant (CNA) #6, how often residents were shaved and who was responsible for shaving the residents. CNA #6 said at every shower residents were to be shaved. The person giving the shower is to shave the resident. The Surveyor asked why should male and female residents be free from facial hair? CNA #6 said, so food doesn't get in there. 6. On 1/31/2024 at 1:20 PM, the Surveyor asked CNA #7 how often residents were shaved and who was responsible for shaving the residents. CNA #7 said residents should be shaved at showers if they want to be shaved. The CNA or beautician will do the shaving. The Surveyor asked why should male and female residents be free from facial hair? CNA #7 said, so residents look good, and it doesn't itch or bother them. The Surveyor asked how often does Resident #32 shave? CNA #7 said on Wednesdays the beautician will shave Resident #32 if he will let her. Resident #32's family member has set it up to where the beautician is the person to shave him. The Surveyor asked how much assistance does Resident #32 need with shaving. CNA #7 said Resident #32 has it done for him. 7. On 1/31/2024 at 3:35 PM, the Surveyor asked the Director of Nursing (DON) how often residents were shaved and who was responsible for shaving the residents. The DON said that shaving is based on the residents' preference. If they want to be shaved, they get a shave if the resident refuses a shave it is documented. If a resident requests a certain hair style, then it is care planned. CNAs or nurses are responsible for shaving residents. The Surveyor asked why should both male and female residents be free from facial hair? The DON said for dignity. 8. On 1/31/24 at 01:38 PM, the Nurse Consultant said the facility did not have an ADL policy.

Based on observation and interview, the facility failed to ensure residents were fed in a manner at meal service to promote dignity for 2 (Residents #283 and #71) of 1 sampled resident. The findings are: a. On 1/30/24 at 11:52 AM, the first tray was taken to a resident at dining room table. b. On 01/30/24 at 12:07 PM, the Surveyor observed Resident #283 sitting at the dining table without her tray, everyone else was eating at the table. c. On 1/30/24 at 12:16 PM, the Surveyor observed Resident #283 still had no tray and was asking Certified Nursing Assistant (CNA) #2 where is my food, I want to eat too. d. On 1/30/24 at 12:22 PM, Resident #283 received a pureed tray 30 minutes after the other residents had received their trays. e. On 1/31/24 at 11:16 AM, the Surveyor asked CNA #5 why residents who eat at the dining table should be served in sequential order. CNA #5 replied for their dignity. f. On 1/31/24 at 11:19 AM, the Surveyor asked CNA #6 why residents who eat at the dining table should be served in sequential order. CNA #6 replied so food doesn't get cold, and they should be served in a timely manner. g. On 1/31/24 at 1:41 PM, the Surveyor asked the Director of Nursing (DON) why residents should be served in sequential order when eating at the dining room table. The DON replied for their dignity. The Surveyor asked if it was proper for a resident to sit and watch the other residents at the table eat and the resident not have a tray. The DON replied no it is not. 2. Resident #71 had diagnoses of Alzheimer's Disease, Dementia, Disorientation, and Mild Protein-Caloric Malnutrition. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/29/23 documented the resident scored 3 (0-7 indicates severe cognitive impairment) on a Brief Interview for Mental Status (BIMS), required supervision or touching assistance with eating, and had a weight loss of 5% or more in the last month or 10% or more in the last 6 month and was not on a prescribe weight lost regimen. a. On 01/31/2024 at 07:10 AM, observed Resident #71 sitting at the dining table with an untouched breakfast plate in front of her. Resident #71 was slowly propelling herself from the table. b. On 01/31/2024 at 07:27 AM, observed an untouched breakfast plate resting on the table. Resident #71 was propelling herself slowly around in a circle. c. On 01/31/2024 at 07:44 AM, observed an untouched breakfast plate on the table. Resident #71 had propelled herself to the outside of her room door. d. On 01/31/2024 at 07:45 AM, the Surveyor asked CNA #8 who does the untouched breakfast plate on the table belong to? CNA #8 replied oh that's Resident #71's plate. e. On 01/31/2024 at 07:54 AM, Surveyor observed Certified Nursing Assistant (CNA) #8 push Resident #71 to the table, sat down next to her, and gave her a bite of unheated sausage. f. On 01/31/2024 at 07:55 AM, the Surveyor requested and observed CNA #9 check the temperature of the food on the breakfast plate. CNA #9 checked the temperature of the sausage and stated that the temperature was 76 degrees. g. On 01/31/2024 at 08:00 AM, observed CNA #8 place the breakfast plate in the microwave and reheat the food. CNA #8 then sat next to Resident #71, and assisted Resident #71 with the meal. The Surveyor asked CNA #8 if Resident #71 required assistance with meal service? CNA #8 stated, Off and on. The Surveyor asked how much time staff generally allows to pass after a meal has been placed before the resident before someone offers assistance to the resident. CNA #? stated I don't know. h. On 01/31/24 at 11:45 AM, the Surveyor asked CNA #10 if you are scheduled to work in a house that you are not usually assigned to work, how would you know if a resident required assistance with meal service? CNA #10 stated, The kiosk. The Surveyor asked if you observed a resident not eating their meal and propelling in circles near the table what would you do? CNA #10 stated, Push them back to the table and make sure no one else eats their food because the residents in the house have dementia. The Surveyor stated if I tell you there was a resident in this house that had a plate on the table for almost an hour before staff offered assistance what would you say? CNA #10 replied I had no idea; someone should have assisted her. i. On 01/31/24 at 02:00 PM, the Surveyor asked the Director of Nursing (DON) how are staff informed what level of assistance a resident requires for meal service? The DON stated, The kiosk. The Surveyor asked how much assistance does Resident #71 require? The DON looked it up and stated, She is set-up and cutting of food. The Surveyor asked what was Resident #71's care planned for in reference to meal service? The DON voiced that Resident #71 received high calorie meals. The Surveyor asked has Resident #71 lost weight? The DON looked at the board and stated, No, she has not triggered as of 1/10 [January 10, 2024]. She has not lost weight more that 5% for 30 days or 10% for 6 month. The Surveyor asked the DON to pull up the weight for Resident #71 and asked now that you have Resident #71's weight in front of you has Resident #71 lost any weight? The DON stated, You would show me a weight after the tenth, see I didn't lie I said as of the tenth she has not. The Surveyor asked has the resident lost weight? The DON stated, Yes. j. On 01/31/24 at 02:26 PM, the DON provided the Surveyor with an in-service training guide titled, Resident's Rights and Dignity which defined Dignity as, The quality or state of being worthy of respect, esteem, nobility, and honor .

Based on interview and record review, the facility failed to implement a procedure to monitor declines in activities of daily living (ADL) of residents to ensure accuracy of resident assessments. This failed process had the potential to affect all 82 residents living in the facility as documented on the Daily Census provided by the Administrator on 01/29/24 at 10:30 AM. The findings are: a. On 01/31/2024 at 12:35 PM, the Surveyor asked Minimum Data Set (MDS) Nurse #1 and MDS Nurse #2 with the recent changes in section GG of the MDS, what process has been implemented to monitor ADL decline in residents. MDS Nurse #1 said they have not implemented a system but, she has been discussing this with physical therapy and was thinking about continuing to fill out the old GG form. b. On 01/31/2024 at 12:40 PM, MDS Nurse #1 provided a blank form titled, Section GG: Three Day Performance Data Collection Tool. The Surveyor asked what tools were available to the MDS nurses to guide them through the MDS process. MDS Nurse #1 said they use the Resident Assessment Instrument (RAI) manual. c. On 01/31/2024 at 12:45 PM, MDS Nurse #2 said that residents were discussed in the stand-up meetings as well. d. On 01/31/2024 at 01:30 PM, the Director of Nursing (DON) was asked what staff code to the MDS. The DON said the MDS nurses, dietician, and the physical therapist document on the MDS. The Surveyor asked why it was important to implement, and document appropriately to the MDS. The DON said everything in resident care was built around the MDS. The MDS flows to the care plan. The Surveyor asked for an MDS policy. e. On 01/31/2024 at 03:30 PM, the Nurse Consultant and DON said they do not have an MDS policy.

Based on record review and interview, the facility failed to ensure a comprehensive care plan was developed to address the necessary monitoring and precautions related to shaving for 1 (Resident #32) of 1 sampled resident. The findings are: 1. On 1/30/2024 at 9:41 AM, Resident #32's Care Plan with a revision date of 01/16/2024 documented, .ADLs fluctuate a bit d/t [due to] COPD [Chronic Obstructive Pulmonary Disease] & dialysis . Personal Hygiene: Combing hair, shaving, washing/drying face, and hands: Resident #32 requires Set up or clean up Assistance . a. On 1/31/2024 at 1:20 PM, the Surveyor asked Certified Nursing Assistant (CNA) #7, how often were residents shaved and who was responsible for shaving? CNA #7 said residents should shave with showers if they want to be shaved. The CNA or beautician will do the shaving. The Surveyor asked why should male and female residents be free from facial hair? CNA #7 said, so residents look good, and it doesn't itch or bother them. The Surveyor asked how often does Resident #32 shave? CNA #7 said that on Wednesdays the beautician will shave Resident #32 if he will let her. Resident #32's (family member) has set it up to where the beautician is the person to shave him. The Surveyor asked how much assistance Resident #32 needs with shaving. CNA #7 said Resident #32 has it done for him. b. On 1/31/2024 at 3:35 PM, the Surveyor asked the Director of Nursing (DON) how often residents were shaved and who was responsible for shaving the residents. The DON said shaving is based on the residents' preference. If they want to be shaved, they get a shave. If the resident refuses a shave it is documented. If a resident requests a certain hair style, then it is care planned. CNAs or Nurses are responsible for shaving residents. The Surveyor asked why should both male and female residents be free from facial hair? The DON said for dignity. c. On 1/31/2024 at 3:25 PM, the Administrator informed the Surveyor they do not have a Care Plan policy.

Based on observation, interview, and record review, the facility failed to ensure the care plan was revised to reflect the resident's ability to self-administer oxygen therapy for 1 (Resident #41) of 1 sampled resident. The findings are: 1. Resident #41 with a diagnosis of hemiplegia and hemiparesis, non-[NAME] lymphoma, and peripheral vascular disease. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/08/2023 documented a Brief Interview for Mental Status (BIMS) score of 14 (13-15 indicates cognitively intact) required extensive assistance for bed mobility, dressing, personal hygiene and toileting, was totally dependent for transfers, and supervision for eating. The MDS did not reflect the resident was on oxygen. a. A Care Plan with a revision date of 01/08/2023 documented, .has altered respiratory status/difficulty breathing r/t [related to] congestion, cough, COPD [chronic obstructive pulmonary disease], and allergies, oxygen as ordered/needed for SOB [shortness of breath] . b. On 01/30/24 at 11:44 AM, Resident #41 was resting in bed with oxygen set on 2.5 to 3.00 liters. When the Surveyor asked Resident #41 when he wears the oxygen, Resident #41 said he wears it when the nurses tell him to. c. On 01/31/24 at 12:12 PM, during record review there was no physician's order for oxygen; the oxygen use was not documented on the MDS; the oxygen use is documented in the care plan. The Medication Administration Record documented the oxygen order had been discontinued on 1/10/24. d. On 01/31/24 at 12:43 PM, MDS Nurse #2 said she puts revisions to the MDS within 2 days of when she gets the physician's orders. MDS #1 said they use the Resident Assessment Instrument (RAI) manual, and their consultant guides them, and we also discuss it in the morning meetings. e. On 01/31/2024 at 1:29 PM, the Surveyor asked Licensed Practical Nurse (LPN) #1 what could happen if a resident was using oxygen, and it was not ordered. LPN #1 said having too much oxygen could cause them to get poison. f. On 01/31/2024 at 2:00 PM, the Surveyor asked the Director of Nursing (DON) to explain what negative outcome could occur if a resident was receiving oxygen without an order. The DON said someone with COPD could reduce the drive to breath on their own. They could become dependent on it. We would need to know if they were using a petroleum-based medication. The Surveyor asked, What process would you expect your staff to do before using oxygen? The DON said the staff should assess the resident and check for an order. The DON was asked, Why is the order important? She stated they would have a change in condition, and we would need to modify. It is considered a medication. g. On 01/31/2024 8:45 AM, the DON was asked, Do you expect your staff to revise the care plan when there is a change of condition order? The DON said she expects the CNA to report changes to the nurse and the nurse to report to the MDS and they will make the changes. The DON was asked, Why is this important? The DON said, so we can meet their needs in a timely manner and in taking care of the residents. The DON was asked what does the RAI manual say on ways to revise the care plan? The DON said that is not my area of specialty, we depend heavily on the MDS staff.

Based on observation, interview, and record review, the facility failed to ensure that record of receipt of stock Ativan oral concentration was accurately documented in sufficient detail to ensure accurate administration to residents. This failed practice had the potential to affect 1 (Cottage #4) of 8. The findings are: a. On 01/30/24 at 12:09 PM, the Surveyor accompanied Licensed Practical Nurse (LPN) #1 to check the narcotic refrigerator in Cottage 4. LPN #1 unlocked the medication refrigerator and unlocked the narcotic box located on the inner door of the refrigerator. LPN #1 handed a small, plastic box that she identified as the EKIT (Emergency Medication Kit) to the Surveyor. The Surveyor observed 5 Lorazepam 1mg (milligram)/0.5ml (milliliter) syringes, and a paper inside that did not have the syringe count written on it. There was a note that said vials are on backorder. The Surveyor asked how they count the narcotics. LPN #1 said that the count is in the narcotic book. Page 125 in the narcotic book documented Ativan 2mg/ml, and shows they have 2 0.5ml on hand. LPN #1 verified there was not a stock page for the 1mg/0.5ml syringes. LPN #1 said, We should have made a whole new page for it. It was confusing and she would have to call the pharmacist. The Surveyor asked why staff would be expected to write a new stock page for the medications they have on hand. LPN #1 told the Surveyor that there is Definitely, a potential for a med (medication) error because the concentration is written out wrong. b. On 01/30/2024 at 02:00 PM, the Surveyor requested a medication storage policy, and the Nurse Consultant provided a policy titled, Disposal of Medication and Medication Related Supplies, which documented, .Policy: Medications included in the Drug Enforcement Administration (DEA) classification as controlled substances are subject to special handling, storage, disposal. and recordkeeping in the facility in accordance with federal and state laws and regulations. c. On 01/31/2024 at 09:35 AM, the Surveyor asked the Director of Nursing (DON) if they had Ativan 1mg/0.5ml Syringes on hand, is it okay for staff to document the syringes in the narcotic book under Ativan 2 mg/1 ml? The DON said there would be a concern for a medication error. The Consultant pointed out that they are the same concentration. d. On 01/31/24 10:00 AM, the DON and Nurse Consultant said that the concentration for Lorazepam 1mg/0.5ml, and 2mg/1ml are the same and they do not have a problem with the way it is documented in the narcotic book. They told the Surveyor they discussed this with the Pharmacist Consultant, and he agrees with them. e. On 01/31/24 at 10:39 AM, the DON said that it just dawned on her what the Surveyor was saying, and she provided a Pharmacy Care EKIT charge slip to show how Lorazepam is documented on the charge slip. The DON stated, The concentration is the same. The DON said that she went to Cottage 4 and clarified the dosage on the narcotic page and would do the same in Cottage 1.

Based on observations, interviews, and record reviews, the facility failed to ensure 1 (Resident 71) received a meal that was palatable, attractive, and at an appetizing temperature as determined by the type of food to ensure resident's satisfaction, while minimizing the risk for scalding and burns. The findings are: 1. Resident #71 had diagnoses of Alzheimer's Disease, Dementia, Disorientation, and Mild Protein-Caloric Malnutrition. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/29/23 documented Resident #71 scored 03 (0-7 indicates severe cognitive impairment) on a Brief Interview for Mental Status (BIMS) and had had a weight loss of 5% or more in the last month or 10% or more in the last 6 month and was not on a prescribe weight lost regimen. a. On 01/31/24 at 07:10 AM, Resident #71 was sitting at the dining table with an untouched breakfast plate in front of her. Resident #71 was slowly propelling herself from the table. b. On 01/31/24 at 07:27 AM, an untouched breakfast plate was on the table. Resident #71 was propelling herself slowly around in a circle. c. On 01/31/24 at 07:44 AM, an untouched breakfast plate was on the table. Resident #71 had propelled herself to the outside of her room door. d. On 01/31/24 at 07:45 AM, the Surveyor asked Certified Nursing Assistant (CNA) #8 who does the untouched breakfast plate on the table belong to? CNA #8 replied oh that's Resident #71's plate. e. On 01/31/24 at 07:54 AM, CNA #8 pushed Resident #71 to the table, sat down next to her, and gave her a bite of unheated sausage. f. On 01/31/24 at 07:55 AM, the Surveyor requested and observed CNA #8 check the temperature of the food on Resident #71's breakfast plate. CNA #8 temped the sausage and stated that the temperature was 76 degrees. g. On 01/31/23 at 08:00 AM, CNA #8 placed the breakfast plate in microwave, reheated, sat next to Resident 71, and assisted Resident #71 with meal service. h. On 01/31/24 at 02:00 PM, the Surveyor asked the Director of Nursing (DON) how are staff informed what level of assistance a resident requires for meal service? The DON stated, The kiosk. The Surveyor asked how much assistance does Resident #71 require? The DON stated, Can I look it up? The Surveyor stated, Of course. The DON stated, She is set-up and cutting of food. The Surveyor asked what was Resident #71 care planned for in reference to meal service? The DON voiced that Resident #71 received high calorie meals. i. On 01/31/24 at 02:26 PM, the DON voiced that the facility does not have a policy on the temperature in which meals should be served, that the facility follows the regulations. The Surveyor requested the portion of the regulation that the facility follows. j. On 01/31/24 at 02:45 PM, the Dietician provided the portion of the regulations that the facility follows in reference to serving temperature that states, F804 .Is food served at preferable temperature for the Resident (hot food are served hot and cold foods are served cold and in accordance with resident preferences) .

Based on record review and interview, the facility failed to obtain a declination form for the COVID-19 Vaccine with Education for 1 (Resident #30) of 3 sampled residents. The findings are: a. On 01/29/2024 at 11:30 AM, The Administrator provided the admission packet, the Consent for Vaccinations documented, .Consent for Vaccinations . I have read, or had explained to me, the vaccine information statements and understand that there is a risk of having an allergic reaction to the vaccine/s . b. Resident #30's medical record stated the resident refused the COVID-19 vaccine. c. On 1/30/2024 at 2:30 PM, the Surveyor asked the Assistant Director of Nursing (ADON) to show the consent to the Surveyor. He looked for it in his computer but could not find it and asked for time to find the declination. The ADON provided a copy of Resident #30's updated immunization documentation from his personal computer. d) On 1/31/2024 at 2:00 PM, the Surveyor asked the Director of Nursing (DON), the ADON, and the Nurse Consultant if they had located the COVID-19 Refusal/Declination form for Resident #30 they all concluded they could not locate the form. e) On 2/1/2023 8:45 AM, the Surveyor asked the DON and ADON why is it important to offer the COVID-19 vaccine and education. The DON said it is important to prevent the spread of COVID-19. The ADON said because of the risk, COVID wiped out several people, the benefits, and immunized against it.

Based on observation, interview, and record review, the facility failed to ensure that stock medications for the EKIT (Emergency Medication Kit) were documented and labeled with the correct concentration to prevent the potential for medication errors. This failed practice had the potential to affect 1 (Cottage #4) of 8 cottages. The findings are: a. On 01/30/24 at 12:09 PM, the Surveyor accompanied Licensed Practical Nurse (LPN) #1 to the laundry room to check the narcotic refrigerator in Cottage 4. LPN #1 unlocked the medication refrigerator located in the laundry room, and unlocked the narcotic box located on the inner door or the refrigerator. LPN #1 handed a small, plastic box that she identified as the EKIT to the Surveyor. The Surveyor observed 5 Lorazepam 1mg (milligram)/0.5 ml (milliliter) syringes, and a paper inside that did not have the syringe count written on it. There was a note that says vials are on backorder. The Surveyor asked how they count the narcotics. LPN #1 said that the count is in the narcotic book. Page 125 in the narcotic book documented Ativan 2mg/ml, and shows they have 2.5ml on hand. LPN #1 verified there was not a stock page for the 1mg/0.5ml syringes. LPN #1 said, We should have made a whole new page for it. LPN #1 said it was confusing and she would have to call the pharmacist. The Surveyor asked if there were any reasons that stock narcotics should be documented correctly by concentration in the narcotic book. LPN #1 told the Surveyor that there is a potential for a medication error because it is documented wrong. b. On 01/30/2024 at 02:00 PM, the Nurse Consultant provided a policy titled, Disposal of Medication and Medication Related Supplies with a revised date of 01/18 documented, .Policy: Medications included in the Drug Enforcement Administration (DEA) classification as controlled substances are subject to special handling, storage, disposal. and recordkeeping in the facility in accordance with federal and state laws and regulations. c. The Medication Storage in the Facility policy with a revised date of 01/18 documented, .G. Current controlled substance accountability records are kept in the MAR, or designated book. Completed accountability records are submitted to the director of nursing and kept on file at the facility for 5 years or as required by applicable law or regulation . d. On 01/31/2024 at 09:35 AM, the Surveyor asked the DON if they had Ativan 1 mg/0.5 mg syringes on hand, is it okay for staff to document the syringes in the narcotic book under Ativan 2 mg/1 ml. The DON said there would be a concern for a medication error. The Consultant pointed out that they are the same concentration.

Based on observation, record review, and interview, the facility failed to ensure resident wishes/documentation for Cardiopulmonary Resuscitation/Advanced Directives were accurate and up to date for 2 (Resident #13 and #50) of 8 ( R #13, R #23, R #50, R#57, R #66, R #71, R #76, R #80)(make sure all the residents are included that are named there were only 6) sample residents whose Advance Directives/Code Status forms were reviewed. This failed practice had the potential to affect all 78 residents in the facility as documented on the Resident Census and Conditions of Residents provided by the Administrator on [DATE]. The findings are: 1. Resident #13 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] documented a score of 11 (,d+[DATE] Indicates Cognitively Intact) on the Brief Interview for Mental Status (BIMS), the resident required extensive assist of 1 person with transferring, toileting, bed mobility, and locomotion. a. On [DATE] at 02:00 PM, review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Do Not Resuscitate (DNR) - Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] unless comfort needs cannot be met in house . b. On [DATE] at 02:15 PM, review of the Care Plan initiated [DATE] and revised on [DATE] showed, I have requested that no Cardiopulmonary Resuscitation (CPR) measures be performed. My code status is DNR (Do Not Resuscitate). DNR (POLST?) on file: Do NOT send to hospital unless comfort needs cannot be met in house . c. On [DATE] at 02:30 PM, review of the Residents Resuscitation Designation signed by the resident on [DATE] showed, .I want Cardiopulmonary Resuscitation in addition to all other applicable medical interventions to be provided in the event I have a cardiac or respiratory arrest . 2. Resident #50 was admitted on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly MDS with an ARD of [DATE] documents a score of 15 (,d+[DATE] Indicates Cognitively Intact) on the BIMS, the resident required supervision of 1 person with transferring, toileting, and locomotion. a. On [DATE] at 03:00 PM, review of a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .If found without a pulse, Do max of 2 chest compressions, then stop, do nothing else. Per resident's specific request. Do not send to hospital . b. On [DATE] at 03:15 PM, review of the Care Plan initiated on [DATE] showed, I have requested that CPR measures be performed. I am a Full Code-Advance Directives- see chart for full details. [DATE] Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . per resident's specific request. Do not send to hospital . c. On [DATE] at 03:30 PM, review of the Residents Resuscitation Designation signed form dated [DATE] showed, I want cardiopulmonary resuscitation in addition to all other applicable medical interventions to be provided in the event I have a cardiac or respiratory arrest . d. On [DATE] at 08:20 AM, the Surveyor asked The Director of Nursing (DON), When should advance directives/Code status information be completed on a resident? The DON stated, On admission we do those, but if they change and we get the POLST? form signed, we update the Care Plan and the order overrides, we have always done it that way. The Surveyor asked, If the resident signs the CPR form on admission and then changes their mind shouldn't another CPR form be re-signed with the new decision of the resident to show their wishes regarding end-of-life decision? She stated, We use the POLST? for that we always have. e. On [DATE] at 09:00 AM, the Surveyor requested a CPR policy status form from the DON. She stated, I don't know if we have one, we just respect the residents wishes per the POLST? or the form they signed and the Physicians Order. f. On [DATE] 09:25 AM, the DON provided a typed statement that stated, .We have no policy on how staff knows resident's choices regarding CPR status .

Based on observation, record review and interview the facility failed to ensure that necessary services were provided to promote function and prevent the decline in Range of Motion (ROM) for 1 (R #55) of 5 sampled residents (R# 4, R #10, R #21, R #44 and R #55) residents with a right-hand/wrist contracture, (and how many residents were likely to be affected?) Findings follow: Resident #55 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of his quarterly MDS [Minimum Data Set] with ARD [Assessment Reference Date] of 11/04/22, documented resident had a BIMS [Brief Interview of Mental Status] of 4 (0 to 7 Suggests Severe Impairment), required extensive two-person assist with bed mobility, transfer, bathing, toileting, and dressing and one-person extensive assist with locomotion on and off unit, and personal hygiene. a. On 11/28/22 at 11:49 AM, R #55 was in a wheelchair in the dining room with his right upper extremity lying in the wheelchair seat beside him. Resident #55 had a contracture of the right hand and wrist. Resident #55 did not wear a brace or splint. There was no foot brace or wheelchair pedal. b. On 11/28/22 at 3:20 PM, the Surveyor asked LPN #1, What can you tell me about R #55 and his right upper extremity and right lower extremity contracture/weakness? LPN #1 replied Are you talking about the pedal? He won't keep it on, he prefers to put right leg over left and scoots like that. The Surveyor then asked LPN #1 What about a splint for his right wrist and hand? The LPN responded, He won't keep that on either. c. On 11/30/22 at 1:45 PM, Review of the Care Plan documented, .OT [Occupational Therapy] to evaluate and treat as indicated for contracture management to right hand . Date initiated 02/25/21. New pedal provided by therapy department that has a strap to help keep foot in place on pedal. Date Initiated: 02/25/21.

Based on observation, record review, and interview, the facility failed to ensure infection control measures were consistently implemented to reduce the potential for the spread of disease and infection, this failed practice had the potential to affect all 78 residents who reside in the facility according to the Resident Census and Condition provided by the Administrator on 11/28/22. Noncompliance is evidenced by: 1. On 11/29/22 at 9:57 AM, Certified Nursing Assistant (CNA) # 1 donned a N95 mask outside of an isolation room which contained a COVID-19 positive resident. The CNA failed to secure the bottom strap of the N95, left it lose under her chin. She proceeded into the resident's room. a. On 11/29/22 at 9:59 AM, CNA #1 exited the isolation room, the Surveyor asked her if she knew the proper way to don a N95 mask and if she had been in-serviced on use and if she had applied the N95 masked correctly. The CNA responded Yes, I have been in-serviced on wearing and use. The Surveyor asked CNA #1 if she applied the mask properly. The CNA #1 stated No, I should have both straps on my head. 2. On 11/29/22 at 10:00 AM, there were 18 open paper bags that contained used N95 masks (masks are being reused) on the handrails outside of 4 isolation rooms of COVID-19 positive residents. a. On 11/29/22 at 2:46 PM, the Surveyor interviewed the Infection Preventionist (IP) who had [named] Certification, certification in respiratory education, and fit testing of N95 masks. He confirmed that CNA #1 had been in-serviced on proper use of N95 masks (which included storage of used masks; when not in use N95 masks should be placed in clean paper bag that is folded, closed, and stored at room temperature.) The Surveyor requested the policy for the re-use of N95 masks and he stated the facility did not have a written policy but followed the Respiratory Protection Program. b. On 11/30/22 at 8:36 AM, review of the information provided by the IP for mask use in-service to staff showed the IP was certified in Particulate Respiratory use and fit testing in May 2022, this was part of the Respiratory Protection Program. 3. On 11/30/22 at 1:22 PM, review of COVID-19 Guidance showed, . Healthcare Professional (HCP) who enter the room of a resident with suspected or confirmed Severe Acute Respiratory Syndrome [CONDITION(S)]-Co V-2 infection should adhere to standard precautions and use a National Institute for Occupational Safety and Health (NIOSH)-approved particulate respirator with N95 filter or higher, gown, gloves, and eye protection . 4. On 11/30/22 at 1:32 PM, review of the Infection Control Program showed, . PREVENTION OF INFECTION .Staff and patient education is done to focus on risk of infection and practices to decrease risk. Personnel in performing procedures and in disinfection of equipment follow policies, procedures, and aseptic practices .

Based on observation, record review and interview, the facility failed to review and revise the Care Plan to meet the needs for 1 (Resident #50) of 1 Resident sampled whose Care Plans were reviewed. The findings are: 1. Resident #50 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/26/22 documented the resident scored 15 (13-15 Cognitively intact) on the Brief Interview Mental Status (BIMS) and required supervision with all locomotion, toileting and transferring. a. On 11/29/22 at 11:00 am, a review the Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Document findings and notify Medical Doctor (M.D). of occurrence . b. On 11/29/22 at 12:00 pm, a review the Care Plan with an initiated date of 09/30/20 documented under Problem, .Hemodialysis at [named clinic] Mon [Monday] and Fri [Friday] Has a [MEDICATION(S)] port . c. On 11/29/22 at 12:00 pm, a review an entry in the chart with an initiated date of 6/30/21 documented under approaches and task, .Monitor [CONDITION(S)] shunt to (L) forearm Q [every] shift for thrill and bruit. Document findings and notify MD of occurrence . d. On 11/30/22 at 08:00 am, the Surveyor asked Registered Nurse (RN) #1, Does Resident #50 have a [MEDICATION(S)] catheter for his [CONDITION(S)] or a Shunt in his left arm? The RN Stated, He has a Shunt in his left arm. The Surveyor asked, Does he have the catheter and the Shunt? She stated, No he only has the Shunt and has had it for a while. e. On 11/30/22 at 02:30 pm, the Surveyor asked the MDS Coordinator to look at the Care Plan for Resident #50. The MDS Coordinator went into the EHR and pulled up the Care Plan. The Surveyor asked her to look at the Care Plan, specifically the [CONDITION(S)] area. She pulled up the record. The Surveyor asked, Does the Care Plan document resident had a [MEDICATION(S)] port for [CONDITION(S)] or a Shunt? RN #1 stated, It has the [MEDICATION(S)] on it and also has under task resident has a shunt in his left arm. The Surveyor asked, Does the resident have a [MEDICATION(S)] port or a shunt or both? She stated, He has the shunt in his left arm. The Surveyor asked, Should the Care Plan reflect that resident #50 has the shunt only? She stated, It probably should have been changed and taken off. f. On 11/30/22 at 02:45 PM, The Surveyor asked the Director of Nursing (DON), Should the Care Plan reflect Resident #50 having a [MEDICATION(S)] port or a Shunt in his left arm? She stated, It should have been updated when the [MEDICATION(S)] was removed. The Surveyor asked, Who is responsible for revising the Care Plan and updating them? She stated, Oh that is me, I am the only one that can close the Care Plan after a revision, I make them let me look at them before they are closed after changes to them. g. On 12/01/22 at 8:30 AM, The Surveyor asked the DON, Do you have a policy on Care Plans and revision? The DON stated, I will look for one for you. h. On 12/01/22 at 09:25 AM, The Surveyor received a typed statement stating, We have no policy on Care Plan revision. i. A 12/01/22 review of the Resident Assessment Information (RAI) guidelines showed, .revision to Care Plan should be completed within 14 days after determining the change in condition .

Based on observation, record review, and interview, the facility failed to ensure a female resident's facial hair was trimmed or shaved to promote good personal hygiene and grooming for 1 (Residents #7) of 3 (Resident #4, R #7, and R #55) sampled residents that reside in Cottage #5, who were dependent on staff for personal hygiene. The findings are: 1.Resident #7 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Quarterly MDS [Minimum Data Set] with ARDS [Assessment Reference Date] of 09/23/2022 documented a SAMS [Staff Assessment of Mental Status] of severely impaired. No rejection of care or other behavior problems were documented. Resident #7 required two Person extensive assistance with Bed Mobility, Transfer, and Toileting and required one-person extensive assistance with locomotion on and off unit, dressing and hygiene and one-person partial assistance with bathing. a. On 11/28/22 at 11:28 AM, Resident #7 was sitting in a recliner in her room. She had thick white facial hair approximately a quarter inch long above and below her mouth, surrounding her lips, and on her chin. b. On 11/29/22 at 03:20 PM, Resident #7 was in her room in a recliner resting with her eyes closed. She had thick white hair on her face and chin. c. On 11/29/22 at 03:22 PM, The Surveyor asked Licensed Practical Nurse LPN #1 Do the female residents get their facial hair removed? Are they shaved, waxed, or plucked? LPN #1 responded Resident #7? She needs that trimmed, doesn't she? I was noticing that.

Based on record review and interview, the facility failed to ensure their neglect policies and procedures were fully implemented after receiving an allegation of neglect against a facility Certified Nursing Assistant (CNA), by failing to ensure their planned protective measures were carried out to prevent further potential neglect for 1 (Resident #5) of 5 (Residents #1, #2, #4, #5 and #10) case mix residents who required extensive assistance or were totally dependent on staff for activities of daily living (ADLs). The facility also failed to thoroughly review all witness statements during their investigation for Resident #5, which resulted in failure to investigate 3 additional allegations of possible neglect for other residents. The failed practice resulted in immediate jeopardy, which caused, or could have caused, serious harm, injury or death to Resident #5, and had the potential to cause more than minimal harm to 82 residents who required extensive assistance or were totally dependent on staff for ADLs, as documented on the Resident Census and Conditions of Residents form received from the Administrator on 11/14/16. The Administrator was informed of the Immediate Jeopardy situation on 11/18/16 at 3:20 p.m. The findings are: 1. The facility's policy and procedure titled, Abuse and Neglect Policy and Procedures . Investigation and Reporting, received from the Administrator on 11/18/16 at 10:00 a.m., documented, .It is a policy of this facility to ensure that a system is in place to prevent and detect mistreatment, neglect, and abuse of residents and the misappropriation of resident property. This policy also states that ALL alleged violations involving mistreatment, neglect, abuse, injuries of unknown source and misappropriation of resident property are reported to the Facility Compliance Officer and Administrator . An internal investigation will be initiated immediately in every case of alleged resident neglect, abuse, mistreatment, misappropriation of property and/or resident injury from unknown cause . An Incident/Accident Report form will be completed immediately after an incident occurs or is found to have occurred. The report form will be given to the Administrator, Director of Nurses, and Facility Compliance Officer immediately for review and follow-up investigation .The Administrator or Facility Compliance Officer will conduct an immediate investigation of all alleged, suspicious, or actual incidents of abuse, including injuries of unknown origin; neglect; or misappropriation of property. The investigation should determine whether an incident has occurred, to what extent the resident was mistreated, by whom, and the measures needed to protect residents from further incidents .All alleged or suspected incidents must also be reported according to state and federal law .The facility will undertake other Protective and Preventive measures as follows: .staff and residents will be supervised in an effort to identify inappropriate behaviors that could signal possible signs of abuse, employee burnout, or unreasonable stress . This facility does not tolerate any form of resident mistreatment. It requires all employees to report suspicions and allegations of mistreatment as soon as they become known . Neglect . is a failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. Neglect occurs on an individual basis when a resident does not receive care in one or more areas . Verbal Abuse . Any use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance, regardless of their age, ability to comprehend, or disability . Abuse . Willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm or pain or mental anguish, or deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being . 2. Resident #5 had [DIAGNOSES REDACTED]. The Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/9/16 documented the resident was severely impaired in cognitive skills for daily decision making per a Staff Assessment for Mental Status, had no ability to speak, was sometimes able to make self understood to make concrete requests, was rarely able to understand others, had highly impaired vision, was totally dependent on two-plus persons for bed mobility, transfer, dressing, bathing and toilet use, totally dependent on one person for eating and personal hygiene, had functional limitation of range of motion in all extremities, had an indwelling catheter, had a [MEDICAL CONDITION], received as-needed pain medication, had a percutaneous endoscopic gastrostomy tube, used bed rails daily, and received antibiotic medication on 7 of the past 7 days. a. Physician order [REDACTED].Oxygen at 2 LPM (liters per minute) via nasal cannula as needed for shortness of breath . Cath (urinary catheter) care Q (every) shift and PRN (as needed) . A physician's orders [REDACTED].Monitor for signs and symptoms of aspiration such as increased temp (temperature), difficulty breathing and gurgling after meals . b. The Care Plan dated as reviewed / revised 11/16/16 documented, .(Resident #5) is at risk for alteration in toileting .Bowel - Assist as needed with toileting and record (each shift) .Turning and repositioning while in bed or chair .(Resident #5) has shortness of breath upon exertion/activity .Obtain and record (Resident #5's) oxygen saturation levels as ordered and prn .Assess (Resident #5's) respiratory status as needed .Administer (Resident #5's) oxygen therapy as ordered .Updrafts as directed .(Resident #5) is at risk for skin issues. Has hx (history) of ulcers that has been debrided. Has a F/C (Foley Catheter) and a [MEDICAL CONDITION] .Turn and reposition Q2 (every 2) hours and prn (as needed) .Provide [MEDICAL CONDITION] and foley catheter care as ordered .(Resident #5) has [MEDICAL CONDITION] d/t (due to) MVA (motor vehicle accident) . cognition is severely impaired. Does not talk, he will blink 1x (one time) for no or 2x (two times) for yes at times. Is sometimes understood and rarely understands others .Staff will anticipate and meet (Resident #5's) wants and needs through this quarter .Due to [MEDICAL CONDITION] may need to remind him of things frequently .(Resident #5) has urine retention . is at risk for fluid retention and side effects/complications of F/C . also has [MEDICAL CONDITION] .Catheter care and output Q (every) shift with leg band in place .[MEDICAL CONDITION] care/burp as needed .(Resident #5) has dx of [MEDICAL CONDITIONS], muscle spasms . he does not walk and is paralyzed from neck down . is (dependent) on staff for ADLs (activities of daily living) . Is blind in (right) eye, wears glasses with patch over (right) lens .Staff will anticipate and meet (Resident #5's) needs through this quarter . Staff to provide personal care (wash face/hands, comb hair, shaved, brush teeth/oral care, etc. (et cetera)) . c. A Facility Investigation Report for Resident Abuse, Neglect, Misappropriation of Property & Exploitation of Residents in Long Term Care Facilities, Division of Medical Services (DMS) form 762 documented, .Date and Time Submitted to OLTC (Office of Long Term Care) (if known): 10/3/16 at 11:00 a.m.Date and Time of Discovery: 9/30/16 at 1:00 p.m.Status of Alleged Perpetrator: Facility Employee . Summary of Incident . On 9/30/16 at approximately 1:00 p.m., the Mom of (Resident #5) made known to Assistant Director of Nursing (ADON), her concerns over care provided to her son by (CNA #4) . Steps Taken to Prevent Continued Abuse or Neglect . Accused CNA .was immediately pulled off her assigned duties . ADON .immediately ensured staff provided adequate care for resident (Resident #5) . determined there was no negative outcome such as skin breakdown as result of care provided . ADON . gave immediate attention to (Resident #5's) mom and allowed her time to explain what her concerns were and statement obtained. (ADON) then brought in accused CNA, (CNA #4), for her to be made aware of the concerns .Obtained witness statement from accused CNA .and she was then placed on administrative leave pending the outcome of investigation . d. A handwritten OLTC Witness Statement Form dated 10/3/16 at 4:10 p.m. documented, .Relation to Resident (if any) . Mother . Upon arriving to (Resident #5's) room, I observed him in distress. His head was hyperextended back with his O2 (oxygen) down around his neck not in place in his mouth. When he heard my voice, tears ran down his cheeks. He was moaning. His eyes were matted up, so he couldn't open them. His nose was impacted with hard dry buggers (sic). His tongue was stuck to the roof of his mouth, because there was a very large amount of dried sputum stuck to his tongue, roof of mouth and lips. Upon pulling down his sheet, I saw that there was no leg band and the cath (catheter) had pulled his penis very tight. The cath tubing was stuck at side of bed between mattress and side rail. He was lying on his back with a pillow that was flat under each leg. His heels were pressed into the mattress and purple. His brief on left leg side had large amount of discharge that had a very strong foul odor. At the O2 water (humidification) bottle, the tubing was bent and pinched off so no O2 was flowing. He was wet with sweat. He was very upset. I feel (Resident #5) was abused and neglected. There was also an indentation on upper left leg where cath tubing had been across his upper leg. It was red and purple in color. e. A handwritten OLTC Witness Statement Form dated 10/3/16 documented, .Incident Date 9/30/16 . early afternoon .Came to visit (Resident #5) with his Mom and uncle. Noticed (Resident #5) was in distress upon entering room. His mother (mother's name) . immediately knew something was off. After closely checking him, she realized he was having a hard time breathing; crusty nasal discharge with each breath, nose was full. His mouth was also full. She had to use 7-10 swabs to clear his mouth of 'gunky,' solidified residue. (Resident #5) had tears. Then noticed his diaper was dirty with penal (penile) discharge that had been there so long it had started to harden. It was already hardened on fold of his diaper. He was terrible soiled. There was no leg band on his catheter. There was an indention on his leg where it had been unfortunately .it had been pulling on his penis. He was in pain. In addition to this, his oxygen was around his face but kinked at the humidifier. No oxygen was flowing. He was struggling to breathe. (Resident #5's) Mom called for DON (Director of Nursing) to come to his room via phone. She, the acting Director, was appalled by his physical condition. She called the attending CNA into (Resident #5's) room to question her. She admitted she had not been in there since a little after 6:00 a.m. (Resident #5) had clearly been neglected, and by neglect-abused by not caring for him. Not only was he not cared for properly, timely or at all during this time, it crossed the line to abuse. (Resident #5) and his family rely on his aides to keep him alive. This was a very scary, unbelievable and unacceptable situation. The Director sent aide home immediately. f. A handwritten OLTC Witness Statement Form dated 10/3/16 documented, .Date of Incident 9/30/16 early afternoon .Relation to Resident (if any) .Uncle .Upon entering (Resident #5's) (room) for a visit, immediately noticed he was red-faced and warm. With (Resident #5) when he is bothered, hurting, or upset, you can tell from little signs like those. The clipboard (turn log) showed he had been turned every 2 hours or so, but he didn't appear to have been. When his mother .went to straighten his bedding, we could smell fecal discharge odor, and then we saw that his left side diaper material, what appeared to be discharge had been rolled and squeezed up between his leg and crotch (illegible), his urine catheter was not strapped or taped down and was pulling down on his penis hard enough and had been that way long enough that it left an indentation across his left quad/upper leg .(Resident #5's) face was also a mess with snot and nasal material crusted on his nose and mouth area. He was breathing through his nose .buggers (sic) were being blown out into his mouth and (Resident #5) some would then be breathed back into his nose. His O2 and vacuum tubing (humidification) were also ineffective and not working at this point as well . They immediately called for the nursing supervisor to get these things corrected . g. A handwritten OLTC Witness Statement Form dated 9/30/16 and signed by the ADON, documented, .Have you ever known a staff member to intentionally to not give care to a resident? .Yes .I was called into resident's room by mother of resident. She had cleaned his mouth and nose and had 7-8 swabs on table that were covered in dry pieces she cleaned out from both areas. His brief had a stain of ? (possible / unknown) stool from his [MEDICAL CONDITION] which had a bad odor. I called (CNA #4) into the room, and after (Resident #5's) mother got finished telling her what all wasn't done, sent her home. Two other CNAs cleaned him and positioned him properly and (Resident #5's) Mom was pleased. (CNA #4) had not turned or fluffed and puffed him at all. (DON) and (Administrator) were notified. (CNA #4) was removed from the schedule for now . h. A typewritten statement dated 11/18/16, signed by CNA #4 and attached to the facility's investigation documented, .This information is true and correct . I, (CNA #4), was the primary CNA on Blackberry Blvd (Boulevard) (Hall B) 9/30/16. It was a very fast morning and I fell behind quickly after breakfast. I did (Resident #5's) turns every 2 hours. I changed his brief and began freshening him up for activities outside. I was then needed elsewhere to address an immediate need and did not start oral or nasal care on (Resident #5). This was about 8:30 a.m. After tending to transfers, appointments and showers, another turn was due. I rushed through (Resident #5's) turn and did not complete peri (perineal) care. After answering several call lights and tending to other residents, I soon became distracted and forgot about (Resident #5's) care and went to my first break - my lunch break. When I came back it was 11:05 (a.m.) and I had to begin getting resident showers, rounds and get ups for lunch. After getting a resident back from the showers and ready for lunch, it was 12:15 (p.m.) and I rushed to the dining room so I could feed our assist residents, forgetting (Resident #5's) turn due at that time. At the end of the meal I was approached by (ADON) and brought into (Resident #5's) room with his mother where she voiced her concerns on her son. I explained that I agreed with her, he shouldn't have been left like this and that I was terribly sorry and would try better. I was then sent home . i. Page 4 of the DMS form 762 titled, Section III - Findings and Actions Taken, documented, .Accused (CNA #4) was immediately pulled off her assigned duties .ADON .immediately ensured staff provided adequate care for resident (Resident #5) . determined there was no negative outcome such as skin breakdown as a result of care provided .On 10/5/16, Administrator and DON met with approximately 15 of (CNA #4's) co-workers. The staff that (CNA #4) works with directly, were all in agreeance that she did no action with intent to cause harm. Her co-workers were willing to assist (CNA #4) with her plan of action for performance improvement. A few CNAs offered their training 1:1 (one-on-one) to help mentor her and help her develop a routine where time management and resident care were proficient .On 10/5/16, Administrator and DON met with (CNA #4) regarding her actions and her Performance Improvement Plan (PIP). (CNA #4's) personal PIP will include Duties and Improvements Required, Expected Outcomes/Measurement, Support and Dependencies, Review Dates, and identified 'met/not met/partially met'. During her period of the PIP (CNA #4) will be monitored to assess if appropriate improvement is being made. If the expected outcomes are not achieved / improvements attained, more formal action may be initiated under the relevant procedure .Investigation concluded. Based (on) interviews/statements, it is determined that no form of abuse has occurred. (CNA #4) will be brought back to assigned direct care duties under her Performance Improvement Plan and those improvements will be required, monitored/measured, and addressed in appropriate manner . This document was signed by the Administrator on 10/6/16. j. The Performance Improvement Action Form dated 10/5/16 documented, .Date of Recent Incident: 9/30/2016 .Summary of Incident: A total dependent resident was found having had no extensive total personal care when family arrived. Concern was brought before ADON by family member. CNA responsible was sent home and put on administrative leave, pending investigation .Action to be Taken to Improve Employee's Performance (Education, Verbal Counseling, Warning, Suspension, Termination of employment): .Employee put on administrative leave, verbal counseling given on 10/5/16 by: Administrator and DON, education by nsg (nursing) staff .Performance Improvement Action to be Taken in the Event of a Subsequent Performance Incident (Verbal Counseling, Warning, Suspension, Termination of Employment): .Administrative leave and verbal counseling were given to employee, pending investigation. CNA has plan of correction involving: notes and reminders, asking available nursing staff for help, when needed . The form was signed by the DON and CNA #4 on 10/5/16. k. A Payroll Change Form dated 10/6/16 documented CNA #4 terminated her employment on 10/6/16 due to, I just can't do this job . This form was signed by the Administrator on 10/11/16. l. A Termination of Employment/Leave of Absence Form documented, .Employee Name: .(CNA #4) .Voluntary Termination: .Yes .Walked off job . During shift said she couldn't do this job and quit .Last date worked: 10-6-16 . This form was signed by the DON on 10/6/16 and by the Administrator on 10/11/16. m. A New Hire Check List Form dated 11/11/16 documented CNA #4 was rehired by the facility. n. On 11/18/16 at 9:27 a.m., the DON was asked, Can you tell me what happened on 9/30/16 with (Resident #5)? She stated, (Assistant Director of Nursing) was handling it. The DON left the room to get her calendar and returned at 9:30 a.m. and stated, I was off that day (9/30/16), so to give you first-hand information, I am not going to have that. She was asked, When was this incident reported to you, and who reported it to you? She stated, It would have been the day they sent her home, the 30th (9/30/16) and they called me and told me they were sending her home and why. She was asked, Who did you report it to? She stated, (Administrator). She was asked, When did you report to her? She stated, I am sure that day. She was asked, So you called her on the phone? She stated, To the best of my recollection, I called her because that is what we do. Actually, (Administrator) was here that day and she would have known before I did. She was asked, You don't recall speaking to the Administrator about this incident? She stated, Not really. She was asked, Do you get reports of neglect very often? She stated, No. The DON left to get her October calendar and returned at 9:35 a.m. and stated, I came back to work on the 3rd (10/3/16) and, yes, I did call (Administrator) on 9/30/16. At this time, the DON referenced the I&A and stated, (CNA #4) stated it was an immediate need. She was asked, Did (CNA #4) report to you that she knew she needed to finish his care, such as pericare and oral care, but she only turned him, and neglected to complete the other care? The DON began to read from the I&A and stated, .rushed through the turn and did not complete pericare . She stated, I think what she was telling me is that after it was all said and done, and she was looking back on her shift, she was able to identify what she had missed, and what she could do differently. She was asked, How did you classify the incident at the time it was reported to you? She stated, It was an allegation of abuse, neglect. I don't believe for a second that she ever said that she was going to leave him there and whatever will be will be. I think it was a matter of poor prioritizing and poor planning. But to say that (CNA #4) intentionally neglected (Resident #5), no way. The DON was asked, What was the outcome of the facility's investigation? She stated, It pretty much centered around (CNA #4) letting us know that she didn't meet the needs of the resident that day. She was asked, Had there been any complaints prior to this incident? She stated, Not that I can recall. I think there are some significant personal issues between (CNA #4) and some of the other staff. They made it clear that whether they liked her or not, she took care of residents when she was here. Then she worked primarily on day shift. Now she works primarily night shift. Actually, I would have to look at her schedule to see when she has worked, because she just came back and I mean she just came back. She was asked, When did she come back, what date? She stated, I'd have to look at her hire date. The DON left to get (CNA #4)'s file. The DON returned at 9:45 a.m. and stated, She was hired back on 11/11/16. She was asked, Who designed the PIP (Personal Improvement Plan)? She stated, (CNA #4) and I. She was asked, So she has completed the PIP? She stated, No, she has not completed it because she quit the next day. She was asked, She called you and quit on Saturday? She stated, No, I was not here, but I don't know exactly when it was that she quit. The DON left and returned at 10:01 a.m. with the PIP and stated, We did this together. We did the PIP on 10/5/16. She was on suspension till 10/5/16. I brought her in to do the PIP. This is the initiation paperwork. We would have had a log to monitor that, but she quit. She was asked, Did you find out what day she quit? She stated, It would have been the 6th. She was asked, Had she accepted her assignment? She stated, Yes. I think it was during her lunch break that she left. She was asked, But she came to you and told you she was leaving and not coming back? She stated, Yes. She was asked, What reason did she give? She stated, Just that she could not handle this. She was asked, Then she reapplied for a position here? She stated, Yes. She had let us know that she was interested in a job as CNA. We called OLTC and they assured us that she was eligible for rehire. We asked the staff and they all were accepting of her coming back. She was asked, The PIP? What happened to that plan? She stated, My intention was to start it back. Monday is when I would have started the PIP back? She was asked, Monday? What date? She stated, The 14th (11/14/16). She was asked, So what happened? She stated, You all came in and I had to start getting stuff for you all. Monday is when I would have picked back up on the PIP and the log and everything. She was asked, What has the staff reported to you about them taking her 'under their wing'? She stated, I have not addressed it with the staff here yet because I have been focused on the survey. The DON was asked, Have there been any other complaints? She stated, No. She was asked, Who is responsible for checking references when somebody applies for a job? She stated, (Business Office Clerk) and I do those. She was asked, Did (CNA #4's) references get checked? She stated, There were no references to check other than us. She was asked, This is the only job she has had? She stated, That is what she told me. She was asked, What was the outcome of the investigation? She stated, The outcome was determined that no form of abuse had taken place. She was asked, What other staff were assigned to care for (Resident #5) on 9/30/16? She stated, I don't know. She was asked, How many CNAs are usually on B hall? She stated, Two or according to the acuity of the patients. Typically we would have 1 or 2 there (B hall). She was asked, How many people does it take to turn him (Resident #5)? She stated, Normally 2 (staff members) would turn him. She was asked, What happened in the facility that justified pulling (CNA #4) out of (Resident #5's) room? She stated, I don't know what happened. She was asked, You didn't ask her? She stated, I don't recall. The DON was asked, Has (CNA #4) resolved the issue of poor time management? She stated, And that would have been stuff I would dug into on the 14th (11/14/14) but my focus shifted. She was asked, Did (Resident #5) go 'out to activities' as (CNA #4) stated in her statement? She stated, I don't know. She was asked, You did not ask her? She stated, No. She was asked, What was your staffing situation on 9/30/16? She stated, I wouldn't know. The DON was asked to, Please provide all supporting documentation to include the Personal Improvement Plan, the one-one-one training, any and all in-services with sign-in sheets, and monitoring of her improvement. o. On 11/18/16 at 11:37 a.m., the Administrator was asked, Can you tell me what happened on 9/30/16 with (Resident #5)? She stated, I was notified at home on my land line by either (ADON), (DON), or (LPN #1). I was told the situation. I made sure they sent her home. I called the police department and they (staff) called the doctor, and the mother was here when it happened. She was asked, How did you classify the incident at the time it was reported to you? She stated, To me, it was that she got overwhelmed and fell behind. She was asked, What did you report it as? She stated, We never mark those. She was asked, Who conducted the investigation? She stated, I wrote out the I&A. She was asked, Did you speak with (CNA #4)? She stated, No. She was asked, Who took her statement? She stated, (ADON) and (DON). She was asked, What was the outcome of the investigation? She stated, We talked with our CNAs and they will help her understand she can ask for help, and they all agreed it was worth a 2nd chance. When she was brought back, she decided it wasn't for her and she needed some time off. She was asked, So she quit? She stated, Yes. She was asked, The plan was to initiate the PIP? She stated, Yes. We did initiate it. She was asked, Who has been monitoring the PIP? She stated, The DON. (CNA #4) had called the OLTC and was told that she could come back. I also called OLTC. It would have been right before she came for orientation, and I also was told, 'If that's what you want to do, then bring her back. The decision is still out, but if you get a letter that says anything negative or unfavorable, tell her to fight it.' . She was asked, Does (CNA #4) still have time-management issues? She stated, I have not heard anything. She was asked, Has anyone been monitoring her? She stated, That would be the (DON); you would have to ask her. She was asked, Has (CNA #4) been given any additional training, other than the standard new-hire training? She stated, We didn't have any indication that she needed it. To me, she is very competent. She got too busy and didn't ask for help. It was not willful. That particular day, she didn't do it. She knows how to do her job; she just didn't do it that day. p. On 11/18/16 at 12:25 p.m., CNA #4 was asked, Can you tell me what happened on 9/30/16 with (Resident #5)? She stated, When I came in, I was assigned to Blackberry, where most of the residents are 2-person assist, and I was the single CNA on the hall. We had a float. There were 3 floats and they go between 2 halls. She was asked, Does (Resident #5) require 2 staff members to turn? She stated, Yes. When I came in at 6 a.m., he was due to turn. I was asked to get him up for activities outside. A little after 8 a.m., I changed him, but did not do oral care, wash his face, or look at his nose. At around 9:30-10 a.m., I realized I would not have time to get the resident up. I informed the Activity Director. I grabbed another aide and we turned him and moved back onto the floor. His last turn was at 10:30 a.m. with another aide because I had another resident up on side of bed waiting to be transferred. She was asked, At 10:30 a.m., you knew he still needed care. What care did you still need to complete at that time? She stated, Oral care, washing face and nose. She was asked, Did you notice a smell at that time? She stated, No. She was asked, Who came and got you from the room? She stated, I heard (LPN #1) walking down the hall and I could hear a resident yelling out. I knew then I was going to be very busy. I initially left the care of (Resident #5) at 8 a.m. that morning because I had done the pericare and needed help to turn him. She was asked, There was not an emergent situation? She stated, No. We had dentist appointments and I had other residents. We had to get residents to showers, meals, and physical therapy. She was asked, Was the facility short-staffed that day? She stated, No. Three-fourths of the residents require 2-person assist. I missed the resident's 12:00 p.m. I was across the hall and went on to meal. I got distracted and forgot. I knew he still had other care that needed to be tended to and took care of the other residents because we had a dentist here. I was feeding residents in the dining room when the ADON asked me to come with her and she brought me into (Resident #5's) room. She was asked, What did you see when you got to the room, (Resident#5's)? She stated, The resident's mom was standing at the bedside with 2 other family members. There were napkins and several swabs that had some gunk on them and she asked me, 'Why was my son left like this? Look what I just cleaned out of his nose and mouth.' I told her 'I understand and I am very sorry'. There was also discharge from his cath (catheter) on the brief. I had intended to do the care. The ADON advised me to go home. I wrote out a statement that night on my computer and sent it by email . She was asked, What days have you worked since rehire? She stated, November 12th, 13th, 14th, 16th, 17th. She was asked, So you have been working weekends at night and weekdays at night? She stated, Yes. She was asked, What shift have you worked since rehire (11/11/16)? She stated, Six p.m. to 6 a.m. She was asked, What about the PIP? What was done about that? She stated, It just said that I was going to manage time better. She was asked, Do you know who is monitoring your progress? She stated, I believe the nurses and CNAs are. She was asked, Why do you think the nurses and CNAs are monitoring the PIP? She stated, Because that's just who have been here. I was keeping a notebook for myself. She was asked, So you haven't had any guidance or monitoring by the facility since you came back? She stated, No, not really. I had just decided on my own that I was going to continue it. She was asked, You haven't had to sign anything like some kind of monitoring of performance? She stated, No. q. On 11/18/16 at 1:25 p.m., the DON was asked which residents CNA #4 had taken care of since her rehire on 11/11/16. The DON stated that she would need to get that information. At 2:05 p.m., the DON stated, Have you seen (CNA #4's) notebook? The DON was informed that the notebook had been reviewed, but the survey team still needed CNA #4's assignments to be confirmed by the facility. The DON stated, I am just going to have to see who she charted on. The DON was asked about assignment sheets or anything like that so we can know who she is re

Based on record review and interview, the facility failed to ensure planned protective measures were carried out after receiving an allegation of neglect against a facility Certified Nursing Assistant (CNA), to prevent further potential neglect for 1 (Resident #5) of 5 (Residents #1, #2, #4, #5 and #10) case mix residents who required extensive assistance or were totally dependent on staff for activities of daily living (ADLs). The failed practice resulted in immediate jeopardy, which caused, or could have caused, serious harm, injury or death to Resident #5. The Administrator was informed of the Immediate Jeopardy situation on 11/18/16 at 3:20 p.m. The facility also failed to thoroughly review all witness statements during their investigation for Resident #5, which resulted in failure to investigate an allegation of possible verbal abuse for 1 (Resident #10) of 5 (Residents #1, #2, #4, #5 and #10) case mix residents who required extensive assistance or were totally dependent on staff for activities of daily living (ADLs). The failed practices had the potential to cause more than minimal harm to 82 residents who required extensive assistance or were totally dependent on staff for ADLs, as documented on the Resident Census and Conditions of residents form received from the Administrator on 11/14/16. The findings are: 1. Resident #5 had [DIAGNOSES REDACTED]. The Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/9/16 documented the resident was severely impaired in cognitive skills for daily decision making per a Staff Assessment for Mental Status; had no ability to speak, was sometimes able to make self understood to make concrete requests, was rarely able to understand others, had highly impaired vision, was totally dependent on two-plus persons for bed mobility, transfer, dressing, bathing and toilet use, totally dependent on one person for eating and personal hygiene, had functional limitation of range of motion in all extremities, had an indwelling catheter, had a [MEDICAL CONDITION], received as-needed pain medication, had a percutaneous endoscopic gastrostomy tube, used bed rails daily, and received antibiotic medication on 7 of the past 7 days. a. Physician order [REDACTED].Oxygen at 2 LPM (liters per minute) via nasal cannula as needed for shortness of breath . Cath (urinary catheter) care Q (every) shift and PRN (as needed) . A physician's orders [REDACTED].Monitor for signs and symptoms of aspiration such as increased temp (temperature), difficulty breathing and gurgling after meals . b. The Care Plan dated as reviewed / revised 11/16/16 documented, .(Resident #5) is at risk for alteration in toileting .Bowel - Assist as needed with toileting and record (each shift) .Turning and repositioning while in bed or chair .(Resident #5) has shortness of breath upon exertion / activity .Obtain and record (Resident #5's) oxygen saturation levels as ordered and prn . Assess (Resident #5's) respiratory status as needed .Administer (Resident #5's) oxygen therapy as ordered .Updrafts as directed .(Resident #5) is at risk for skin issues. Has hx (history) of ulcers that has been debrided. Has a F/C (Foley Catheter) and a [MEDICAL CONDITION] .Turn and reposition Q2 (every 2) hours and prn (as needed) .Provide [MEDICAL CONDITION] and foley catheter care as ordered .(Resident #5) has [MEDICAL CONDITION] d/t (due to) MVA (motor vehicle accident) . cognition is severely impaired. Does not talk, he will blink 1x (one time) for no or 2x (two times) for yes at times. Is sometimes understood and rarely understands others .Staff will anticipate and meet (Resident #5's) wants and needs through this quarter .Due to [MEDICAL CONDITION] may need to remind him of things frequently .(Resident #5) has urine retention . is at risk for fluid retention and side effects/complications of F/C . also has [MEDICAL CONDITION] .Catheter care and output Q (every) shift with leg band in place .[MEDICAL CONDITION] care/burp as needed .(Resident #5) has dx of [MEDICAL CONDITIONS], muscle spasms . he does not walk and is paralyzed from neck down . is (dependent) on staff for ADLs (activities of daily living) . Is blind in (right) eye, wears glasses with patch over (right) lens .Staff will anticipate and meet (Resident #5's) needs through this quarter . Staff to provide personal care (wash face/hands, comb hair, shaved, brush teeth/oral care, etc. (et cetera)) . c. A Facility Investigation Report for Resident Abuse, Neglect, Misappropriation of Property & Exploitation of Residents in Long Term Care Facilities, Division of Medical Services (DMS) form 762 documented, .Date and Time Submitted to OLTC (Office of Long Term Care) (if known): 10/3/16 at 11:00 a.m.Date and Time of Discovery: 9/30/16 at 1:00 p.m.Status of Alleged Perpetrator: Facility Employee . Summary of Incident . On 9/30/16 at approximately 1:00 p.m., the Mom of (Resident #5) made known to Assistant Director of Nursing (ADON), her concerns over care provided to her son by (CNA #4) . Steps Taken to Prevent Continued Abuse or Neglect . Accused CNA .was immediately pulled off her assigned duties . ADON .immediately ensured staff provided adequate care for resident (Resident #5) . determined there was no negative outcome such as skin breakdown as result of care provided . ADON . gave immediate attention to (Resident #5's) mom and allowed her time to explain what her concerns were and statement obtained. (ADON) then brought in accused CNA, (CNA #4), for her to be made aware of the concerns .Obtained witness statement from accused CNA .and she was then placed on administrative leave pending the outcome of investigation . d. A handwritten OLTC Witness Statement Form dated 10/3/16 at 4:10 p.m. documented, .Relation to Resident (if any) . Mother . Upon arriving to (Resident #5's) room, I observed him in distress. His head was hyperextended back with his O2 (oxygen) down around his neck not in place in his mouth. When he heard my voice, tears ran down his cheeks. He was moaning. His eyes were matted up, so he couldn't open them. His nose was impacted with hard dry buggers (sic). His tongue was stuck to the roof of his mouth, because there was a very large amount of dried sputum stuck to his tongue, roof of mouth and lips. Upon pulling down his sheet, I saw that there was no leg band and the cath (catheter) had pulled his penis very tight. The cath tubing was stuck at side of bed between mattress and side rail. He was lying on his back with a pillow that was flat under each leg. His heels were pressed into the mattress and purple. His brief on left leg side had large amount of discharge that had a very strong foul odor. At the O2 water (humidification) bottle, the tubing was bent and pinched off so no O2 was flowing. He was wet with sweat. He was very upset. I feel (Resident #5) was abused and neglected. There was also an indentation on upper left leg where cath tubing had been across his upper leg. It was red and purple in color. e. A handwritten OLTC Witness Statement Form dated 10/3/16 documented, .Incident Date 9/30/16 . early afternoon .Came to visit (Resident #5) with his Mom and uncle. Noticed (Resident #5) was in distress upon entering room. His mother (mother's name) . immediately knew something was off. After closely checking him, she realized he was having a hard time breathing; crusty nasal discharge with each breath, nose was full. His mouth was also full. She had to use 7-10 swabs to clear his mouth of 'gunky,' solidified residue. (Resident #5) had tears. Then noticed his diaper was dirty with penal (penile) discharge that had been there so long it had started to harden. It was already hardened on fold of his diaper. He was terrible soiled. There was no leg band on his catheter. There was an indention on his leg where it had been unfortunately .it had been pulling on his penis. He was in pain. In addition to this, his oxygen was around his face but kinked at the humidifier. No oxygen was flowing. He was struggling to breathe. (Resident #5's) Mom called for DON (Director of Nursing) to come to his room via phone. She, the acting Director, was appalled by his physical condition. She called the attending CNA into (Resident #5's) room to question her. She admitted she had not been in there since a little after 6:00 a.m. (Resident #5) had clearly been neglected, and by neglect-abused by not caring for him. Not only was he not cared for properly, timely or at all during this time, it crossed the line to abuse. (Resident #5) and his family rely on his aides to keep him alive. This was a very scary, unbelievable and unacceptable situation. The Director sent aide home immediately. f. A handwritten OLTC Witness Statement Form dated 10/3/16 documented, .Date of Incident 9/30/16 early afternoon .Relation to Resident (if any) .Uncle .Upon entering (Resident #5's) (room) for a visit, immediately noticed he was red-faced and warm. With (Resident #5) when he is bothered, hurting, or upset, you can tell from little signs like those. The clipboard (turn log) showed he had been turned every 2 hours or so, but he didn't appear to have been. When his mother .went to straighten his bedding, we could smell fecal discharge odor, and then we saw that his left side diaper material, what appeared to be discharge had been rolled and squeezed up between his leg and crotch (illegible), his urine catheter was not strapped or taped down and was pulling down on his penis hard enough and had been that way long enough that it left an indentation across his left quad/upper leg .(Resident #5's) face was also a mess with snot and nasal material crusted on his nose and mouth area. He was breathing through his nose .buggers (sic) were being blown out into his mouth and (Resident #5) some would then be breathed back into his nose. His O2 and vacuum tubing (humidification) were also ineffective and not working at this point as well . They immediately called for the nursing supervisor to get these things corrected . g. A handwritten OLTC Witness Statement Form dated 9/30/16 and signed by the ADON, documented, .Have you ever known a staff member to intentionally to not give care to a resident? .Yes .I was called into resident's room by mother of resident. She had cleaned his mouth and nose and had 7-8 swabs on table that were covered in dry pieces she cleaned out from both areas. His brief had a stain of ? (possible / unknown) stool from his [MEDICAL CONDITION] which had a bad odor. I called (CNA #4) into the room, and after (Resident #5's) mother got finished telling her what all wasn't done, sent her home. Two other CNAs cleaned him and positioned him properly and (Resident #5's) Mom was pleased. (CNA #4) had not turned or fluffed and puffed him at all. (DON) and (Administrator) were notified. (CNA #4) was removed from the schedule for now . h. A typewritten statement dated 11/18/16, signed by CNA #4 and attached to the facility's investigation documented, .This information is true and correct . I, (CNA #4), was the primary CNA on Blackberry Blvd (Boulevard) (Hall B) 9/30/16. It was a very fast morning and I fell behind quickly after breakfast. I did (Resident #5's) turns every 2 hours. I changed his brief and began freshening him up for activities outside. I was then needed elsewhere to address an immediate need and did not start oral or nasal care on (Resident #5). This was about 8:30 a.m. After tending to transfers, appointments and showers, another turn was due. I rushed through (Resident #5's) turn and did not complete peri (perineal) care. After answering several call lights and tending to other residents, I soon became distracted and forgot about (Resident #5's) care and went to my first break - my lunch break. When I came back it was 11:05 (a.m.) and I had to begin getting resident showers, rounds and get ups for lunch. After getting a resident back from the showers and ready for lunch, it was 12:15 (p.m.) and I rushed to the dining room so I could feed our assist residents, forgetting (Resident #5's) turn due at that time. At the end of the meal I was approached by (ADON) and brought into (Resident #5's) room with his mother where she voiced her concerns on her son. I explained that I agreed with her, he shouldn't have been left like this and that I was terribly sorry and would try better. I was then sent home . i. Page 4 of the DMS form 762 titled, Section III - Findings and Actions Taken, documented, .Accused (CNA #4) was immediately pulled off her assigned duties .ADON .immediately ensured staff provided adequate care for resident (Resident #5) . determined there was no negative outcome such as skin breakdown as a result of care provided .On 10/5/16, Administrator and DON met with approximately 15 of (CNA #4's) co-workers. The staff that (CNA #4) works with directly, were all in agreeance that she did no action with intent to cause harm. Her co-workers were willing to assist (CNA #4) with her plan of action for performance improvement. A few CNAs offered their training 1:1 (one-on-one) to help mentor her and help her develop a routine where time management and resident care were proficient .On 10/5/16, Administrator and DON met with (CNA #4) regarding her actions and her Performance Improvement Plan (PIP). (CNA #4's) personal PIP will include Duties and Improvements Required, Expected Outcomes/Measurement, Support and Dependencies, Review Dates, and identified 'met/not met/partially met'. During her period of the PIP (CNA #4) will be monitored to assess if appropriate improvement is being made. If the expected outcomes are not achieved / improvements attained, more formal action may be initiated under the relevant procedure .Investigation concluded. Based (on) interviews/statements, it is determined that no form of abuse has occurred. (CNA #4) will be brought back to assigned direct care duties under her Performance Improvement Plan and those improvements will be required, monitored/measured, and addressed in appropriate manner . This document was signed by the Administrator on 10/6/16. j. The Performance Improvement Action Form dated 10/5/16 documented, .Date of Recent Incident: 9/30/2016 .Summary of Incident: A total dependent resident was found having had no extensive total personal care when family arrived. Concern was brought before ADON by family member. CNA responsible was sent home and put on administrative leave, pending investigation .Action to be Taken to Improve Employee's Performance (Education, Verbal Counseling, Warning, Suspension, Termination of employment): .Employee put on administrative leave, verbal counseling given on 10/5/16 by: Administrator and DON, education by nsg (nursing) staff .Performance Improvement Action to be Taken in the Event of a Subsequent Performance Incident (Verbal Counseling, Warning, Suspension, Termination of Employment): . Administrative leave and verbal counseling were given to employee, pending investigation. CNA has plan of correction involving: notes and reminders, asking available nursing staff for help, when needed . The form was signed by the DON and CNA #4 on 10/5/16. k. A Payroll Change Form dated 10/6/16 documented CNA #4 terminated her employment on 10/6/16 due to, I just can't do this job . This form was signed by the Administrator on 10/11/16. l. A Termination of Employment/Leave of Absence Form documented, .Employee Name: .(CNA #4) .Voluntary Termination: .Yes .Walked off job . During shift said she couldn't do this job and quit .Last date worked: 10-6-16 . This form was signed by the DON on 10/6/16 and by the Administrator on 10/11/16. m. A New Hire Check List Form dated 11/11/16 documented CNA #4 was rehired by the facility. n. On 11/18/16 at 9:27 a.m., the DON was asked, Can you tell me what happened on 9/30/16 with (Resident #5)? She stated, (Assistant Director of Nursing) was handling it. The DON left the room to get her calendar and returned at 9:30 a.m. and stated, I was off that day (9/30/16), so to give you first-hand information, I am not going to have that. She was asked, When was this incident reported to you, and who reported it to you? She stated, It would have been the day they sent her home, the 30th (9/30/16) and they called me and told me they were sending her home and why. She was asked, Who did you report it to? She stated, (Administrator). She was asked, When did you report to her? She stated, I am sure that day. She was asked, So you called her on the phone? She stated, To the best of my recollection, I called her because that is what we do. Actually, (Administrator) was here that day and she would have known before I did. She was asked, You don't recall speaking to the Administrator about this incident? She stated, Not really. She was asked, Do you get reports of neglect very often? She stated, No. The DON left to get her October calendar and returned at 9:35 a.m. and stated, I came back to work on the 3rd (10/3/16) and, yes, I did call (Administrator) on 9/30/16. At this time, the DON referenced the I&A and stated, (CNA #4) stated it was an immediate need. She was asked, Did (CNA #4) report to you that she knew she needed to finish his care, such as pericare and oral care, but she only turned him and neglected to complete the other care? The DON began to read from the I&A and stated, .rushed through the turn and did not complete pericare . She stated, I think what she was telling me is that after it was all said and done, and she was looking back on her shift, she was able to identify what she had missed, and what she could do differently. She was asked, How did you classify the incident at the time it was reported to you? She stated, It was an allegation of abuse, neglect. I don't believe for a second that she ever said that she was going to leave him there and whatever will be will be. I think it was a matter of poor prioritizing and poor planning. But to say that (CNA #4) intentionally neglected (Resident #5), no way. The DON was asked, What was the outcome of the facility's investigation? She stated, It pretty much centered around (CNA #4) letting us know that she didn't meet the needs of the resident that day. She was asked, Had there been any complaints prior to this incident? She stated, Not that I can recall. I think there are some significant personal issues between (CNA #4) and some of the other staff. They made it clear that whether they liked her or not, she took care of residents when she was here. Then she worked primarily on day shift. Now she works primarily night shift. Actually, I would have to look at her schedule to see when she has worked, because she just came back and I mean she just came back. She was asked, When did she come back, what date? She stated, I'd have to look at her hire date. The DON left to get (CNA #4)'s file. The DON returned at 9:45 a.m. and stated, She was hired back on 11/11/16. She was asked, Who designed the PIP (Personal Improvement Plan)? She stated, (CNA #4) and I. She was asked, So she has completed the PIP? She stated, No, she has not completed it because she quit the next day. She was asked, She called you and quit on Saturday? She stated, No, I was not here, but I don't know exactly when it was that she quit. The DON left and returned at 10:01 a.m. with the PIP and stated, We did this together. We did the PIP on 10/5/16. She was on suspension till 10/5/16. I brought her in to do the PIP. This is the initiation paperwork. We would have had a log to monitor that, but she quit. She was asked, Did you find out what day she quit? She stated, It would have been the 6th. She was asked, Had she accepted her assignment? She stated, Yes. I think it was during her lunch break that she left. She was asked, But she came to you and told you she was leaving and not coming back? She stated, Yes. She was asked, What reason did she give? She stated, Just that she could not handle this. She was asked, Then she reapplied for a position here? She stated, Yes. She had let us know that she was interested in a job as CNA. We called OLTC and they assured us that she was eligible for rehire. We asked the staff and they all were accepting of her coming back. She was asked, The PIP? What happened to that plan? She stated, My intention was to start it back. Monday is when I would have started the PIP back? She was asked, Monday? What date? She stated, The 14th (11/14/16). She was asked, So what happened? She stated, You all came in and I had to start getting stuff for you all. Monday is when I would have picked back up on the PIP and the log and everything. She was asked, What has the staff reported to you about them taking her 'under their wing'? She stated, I have not addressed it with the staff here yet because I have been focused on the survey. The DON was asked, Have there been any other complaints? She stated, No. She was asked, Who is responsible for checking references when somebody applies for a job? She stated, (Business Office Clerk) and I do those. She was asked, Did (CNA #4's) references get checked? She stated, There were no references to check other than us. She was asked, This is the only job she has had? She stated, That is what she told me. She was asked, What was the outcome of the investigation? She stated, The outcome was determined that no form of abuse had taken place. She was asked, What other staff were assigned to care for (Resident #5) on 9/30/16? She stated, I don't know. She was asked, How many CNAs are usually on B hall? She stated, Two or according to the acuity of the patients. Typically we would have 1 or 2 there (B hall). She was asked, How many people does it take to turn him (Resident #5)? She stated, Normally 2 (staff members) would turn him. She was asked, What happened in the facility that justified pulling (CNA #4) out of (Resident #5's) room? She stated, I don't know what happened. She was asked, You didn't ask her? She stated, I don't recall. The DON was asked, Has (CNA #4) resolved the issue of poor time management? She stated, And that would have been stuff I would dug into on the 14th (11/14/14) but my focus shifted. She was asked, Did (Resident #5) go 'out to activities' as (CNA #4) stated in her statement? She stated, I don't know. She was asked, You did not ask her? She stated, No. She was asked, What was your staffing situation on 9/30/16? She stated, I wouldn't know. The DON was asked to, Please provide all supporting documentation to include the Personal Improvement Plan, the one-one-one training, any and all in-services with sign-in sheets, and monitoring of her improvement. o. On 11/18/16 at 11:37 a.m., the Administrator was asked, Can you tell me what happened on 9/30/16 with (Resident #5)? She stated, I was notified at home on my land line by either (ADON), (DON), or (LPN #1). I was told the situation. I made sure they sent her home. I called the police department and they (staff) called the doctor, and the mother was here when it happened. She was asked, How did you classify the incident at the time it was reported to you? She stated, To me, it was that she got overwhelmed and fell behind. She was asked, What did you report it as? She stated, We never mark those. She was asked, Who conducted the investigation? She stated, I wrote out the I&A. She was asked, Did you speak with (CNA #4)? She stated, No. She was asked, Who took her statement? She stated, (ADON) and (DON). She was asked, What was the outcome of the investigation? She stated, We talked with our CNAs and they will help her understand she can ask for help, and they all agreed it was worth a 2nd chance. When she was brought back, she decided it wasn't for her and she needed some time off. She was asked, So she quit? She stated, Yes. She was asked, The plan was to initiate the PIP? She stated, Yes. We did initiate it. She was asked, Who has been monitoring the PIP? She stated, The DON. (CNA #4) had called the OLTC and was told that she could come back. I also called OLTC. It would have been right before she came for orientation, and I also was told, 'If that's what you want to do, then bring her back. The decision is still out, but if you get a letter that says anything negative or unfavorable, tell her to fight it.' . She was asked, Does (CNA #4) still have time-management issues? She stated, I have not heard anything. She was asked, Has anyone been monitoring her? She stated, That would be the (DON); you would have to ask her. She was asked, Has (CNA #4) been given any additional training, other than the standard new-hire training? She stated, We didn't have any indication that she needed it. To me, she is very competent. She got too busy and didn't ask for help. It was not willful. That particular day, she didn't do it. She knows how to do her job; she just didn't do it that day. p. On 11/18/16 at 12:25 p.m., CNA #4 was asked, Can you tell me what happened on 9/30/16 with (Resident #5)? She stated, When I came in, I was assigned to Blackberry, where most of the residents are 2-person assist, and I was the single CNA on the hall. We had a float. There were 3 floats and they go between 2 halls. She was asked, Does (Resident #5) require 2 staff members to turn? She stated, Yes. When I came in at 6 a.m., he was due to turn. I was asked to get him up for activities outside. A little after 8 a.m., I changed him, but did not do oral care, wash his face, or look at his nose. At around 9:30-10 a.m., I realized I would not have time to get the resident up. I informed the Activity Director. I grabbed another aide and we turned him and moved back onto the floor. His last turn was at 10:30 a.m. with another aide because I had another resident up on side of bed waiting to be transferred. She was asked, At 10:30 a.m., you knew he still needed care. What care did you still need to complete at that time? She stated, Oral care, washing face and nose. She was asked, Did you notice a smell at that time? She stated, No. She was asked, Who came and got you from the room? She stated, I heard (LPN #1) walking down the hall and I could hear a resident yelling out. I knew then I was going to be very busy. I initially left the care of (Resident #5) at 8 a.m. that morning because I had done the pericare and needed help to turn him. She was asked, There was not an emergent situation? She stated, No. We had dentist appointments and I had other residents. We had to get residents to showers, meals, and physical therapy. She was asked, Was the facility short-staffed that day? She stated, No. Three-fourths of the residents require 2-person assist. I missed the resident's 12:00 p.m. I was across the hall and went on to meal. I got distracted and forgot. I knew he still had other care that needed to be tended to and took care of the other residents because we had a dentist here. I was feeding residents in the dining room when the ADON asked me to come with her and she brought me into (Resident #5's) room. She was asked, What did you see when you got to the room, (Resident#5's)? She stated, The resident's mom was standing at the bedside with 2 other family members. There were napkins and several swabs that had some gunk on them and she asked me, 'Why was my son left like this? Look what I just cleaned out of his nose and mouth.' I told her 'I understand and I am very sorry'. There was also discharge from his cath (catheter) on the brief. I had intended to do the care. The ADON advised me to go home. I wrote out a statement that night on my computer and sent it by email . She was asked, What days have you worked since rehire? She stated, November 12th, 13th, 14th, 16th, 17th. She was asked, So you have been working weekends at night and weekdays at night? She stated, Yes. She was asked, What shift have you worked since rehire (11/11/16)? She stated, Six p.m. to 6 a.m. She was asked, What about the PIP? What was done about that? She stated, It just said that I was going to manage time better. She was asked, Do you know who is monitoring your progress? She stated, I believe the nurses and CNAs are. She was asked, Why do you think the nurses and CNAs are monitoring the PIP? She stated, Because that's just who have been here. I was keeping a notebook for myself. She was asked, So you haven't had any guidance or monitoring by the facility since you came back? She stated, No, not really. I had just decided on my own that I was going to continue it. She was asked, You haven't had to sign anything like some kind of monitoring of performance? She stated, No. q. On 11/18/16 at 1:25 p.m., the DON was asked which residents CNA #4 had taken care of since her rehire on 11/11/16. The DON stated that she would need to get that information. At 2:05 p.m., the DON stated, Have you seen (CNA #4's) notebook? The DON was informed that the notebook had been reviewed, but the survey team still needed CNA #4's assignments to be confirmed by the facility. The DON stated, I am just going to have to see who she charted on. The DON was asked about assignment sheets or anything like that so we can know who she is responsible for. The DON stated, They do assignment sheets, but we don't keep them. r. At 3:40 p.m., the DON entered the room with stacks of ADL (Activities of Daily Living) charting and stated, It is what it is. This is charting (CNA #4) has done since she came back. There are residents in this that she may have not necessarily taken care of, but just charted on for somebody else. The DON was asked if she would feel comfortable, then, saying that (CNA #4) may have taken care of, and had access to, every resident in the facility. The DON stated, Yes, unfortunately, this is affecting every one of them. s. The ADL charting that was received from the DON on 11/18/16 at 3:40 p.m., indicated that CNA #4 charted care for (Resident #5) on the following dates: 11/12/16, 11/13/16, 11/15/16, and 11/17/16. When the DON was asked to confirm this information, she stated, If she charted on him, then she must have taken care of him. 2. Resident #10 had [DIAGNOSES REDACTED]. A Quarterly MDS with an ARD of 10/01/16 documented the resident scored 10 (8-12 indicates moderately cognitively impaired) on a Brief Interview for Mental Status (BIMS), usually made self understood and usually understood others, had moderately impaired vision, required extensive two person assistance for bed mobility, bathing, dressing, toilet use and personal hygiene, was totally dependent on two-plus persons for transfer, received oxygen therapy and was frequently incontinent of bowel and bladder. a. The Care Plan, updated on 10/18/16, documented, .Care Tasks .Bowel - Assist as needed with toileting and record (each shift) .Bladder - Assist resident as needed and record each shift .(Resident) does not walk .is dependent on staff for transfer and bathing .extensive assist with all other ADLs .bathe / shower two times per week and prn .assist with transfers for safety due to vision .turn and reposition every 2 hours and PRN (as needed) .will be pushed to destinations per staff as needed .has ½ lap tray/arm rest to relieve pressure from (right) shoulder (due to) history of fracture . b. The facility's documentation of their investigation into allegations of neglect involving Resident #5 contained a handwritten paragraph on a plain, white sheet of paper. The statement was not signed, dated or timed. It documented, .Me and (CNA #4) were on (Resident #10's) room transfer from shower chair to bed. (Resident #10) kept complaining for the way (CNA #4) was being towards her. (CNA #4) stated, 'The more fits you have, the more I will have to go talk to (LPN #1), and you'l

Based on record review and interview, the facility failed to ensure a resident who was allegedly found by his mother in respiratory distress and pain related to a lack of care by a Certified Nursing Assistant (CNA) was promptly and thoroughly assessed after a licensed nurse was made aware of his condition, as evidenced by failure to check lung sounds, vital signs and oxygen saturation after the oxygen tubing was found kinked and resident's airway was found to be partially occluded with dried secretions, in order to rule out the possible need for emergency medical care, and failure to ensure the resident was assessed for pain or possible bladder / urethral trauma related to his urinary catheter being found unsecured and tautly pulled against the urethral meatus for 1 (Resident #5) of 5 (Residents #1, #2, #4, #5 and #10) case mix residents who required extensive assistance or were totally dependent on staff for activities of daily living (ADLs). These failed practices resulted in immediate jeopardy, which caused, or could have caused, serious harm, injury or death to Resident #5, and had the potential to cause more than minimal harm to 82 residents who required extensive assistance or were totally dependent on staff for ADLs, as documented on the Resident Census and Conditions of Residents form received from the Administrator on 11/14/16 The Administrator was informed of the Immediate Jeopardy condition on 11/18/16 at 3:20 p.m. The findings are: 1. The facility's Abuse and Neglect Policy and Procedures, provided by the Administrator on 11/18/16 at 10:00 a.m., documented, .The DON (Director of Nursing) / Facility Compliance Officer (licensed staff) is responsible for assessing residents who are the victims of alleged, suspected, or actual mistreatment . The resident will be re-assessed as frequently as required by the circumstances. If physical abuse is alleged or suspected, vital signs will be taken and a skin audit will be completed by a licensed nurse every 8 hours for a period of 48 hours following the incident and will be documented in the medical record. Residents will be referred for further medical treatment as circumstances indicate. The resident's medical record will contain documentation of objective clinical findings . 2. Resident #5 had [DIAGNOSES REDACTED]. The Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/9/16 documented the resident was severely impaired in cognitive skills for daily decision making per a Staff Assessment for Mental Status, had no ability to speak, was sometimes able to make self understood to make concrete requests, was rarely able to understand others, had highly impaired vision, was totally dependent on two-plus persons for bed mobility, transfer, dressing, bathing and toilet use, totally dependent on one person for eating and personal hygiene, had functional limitation of range of motion in all extremities, had an indwelling catheter, had a [MEDICAL CONDITION], received as-needed pain medication, had a percutaneous endoscopic gastrostomy tube, used bed rails daily, and received antibiotic medication on 7 of the past 7 days. a. Physician order [REDACTED].Oxygen at 2 LPM (liters per minute) via nasal cannula as needed for shortness of breath . Cath (urinary catheter) care Q (every) shift and PRN (as needed) . A physician's orders [REDACTED].Monitor for signs and symptoms of aspiration such as increased temp (temperature), difficulty breathing and gurgling after meals . b. The Care Plan dated as reviewed / revised 11/16/16 documented, .(Resident #5) is at risk for alteration in toileting .Bowel - Assist as needed with toileting and record (each shift) .Turning and repositioning while in bed or chair .(Resident #5) has shortness of breath upon exertion/activity .Obtain and record (Resident #5's) oxygen saturation levels as ordered and prn .Assess (Resident #5's) respiratory status as needed .Administer (Resident #5's) oxygen therapy as ordered .Updrafts as directed .(Resident #5) is at risk for skin issues. Has hx (history) of ulcers that has been debrided. Has a F/C (Foley Catheter) and a [MEDICAL CONDITION] .Turn and reposition Q2 (every 2) hours and prn (as needed) .Provide [MEDICAL CONDITION] and foley catheter care as ordered .(Resident #5) has [MEDICAL CONDITION] d/t (due to) MVA (motor vehicle accident) . cognition is severely impaired. Does not talk, he will blink 1x (one time) for no or 2x (two times) for yes at times. Is sometimes understood and rarely understands others .Staff will anticipate and meet (Resident #5's) wants and needs through this quarter .Due to [MEDICAL CONDITION] may need to remind him of things frequently .(Resident #5) has urine retention . is at risk for fluid retention and side effects/complications of F/C . also has [MEDICAL CONDITION] .Catheter care and output Q (every) shift with leg band in place .[MEDICAL CONDITION] care/burp as needed .(Resident #5) has dx of [MEDICAL CONDITIONS], muscle spasms . he does not walk and is paralyzed from neck down . is (dependent) on staff for ADLs (activities of daily living) . Is blind in (right) eye, wears glasses with patch over (right) lens .Staff will anticipate and meet (Resident #5's) needs through this quarter . Staff to provide personal care (wash face/hands, comb hair, shaved, brush teeth/oral care, etc. (et cetera)) . c. A Facility Investigation Report for Resident Abuse, Neglect, Misappropriation of Property & Exploitation of Residents in Long Term Care Facilities, Division of Medical Services (DMS) form 762 documented, .Date and Time Submitted to OLTC (Office of Long Term Care) (if known): 10/3/16 at 11:00 a.m.Date and Time of Discovery: 9/30/16 at 1:00 p.m.Status of Alleged Perpetrator: Facility Employee . Summary of Incident . On 9/30/16 at approximately 1:00 p.m., the Mom of (Resident #5) made known to Assistant Director of Nursing (ADON), her concerns over care provided to her son by (CNA #4) . Steps Taken to Prevent Continued Abuse or Neglect . Accused CNA .was immediately pulled off her assigned duties . ADON .immediately ensured staff provided adequate care for resident (Resident #5) . determined there was no negative outcome such as skin breakdown as result of care provided . ADON . gave immediate attention to (Resident #5's) mom and allowed her time to explain what her concerns were and statement obtained. (ADON) then brought in accused CNA, (CNA #4), for her to be made aware of the concerns .Obtained witness statement from accused CNA .and she was then placed on administrative leave pending the outcome of investigation . d. A handwritten OLTC Witness Statement Form dated 10/3/16 at 4:10 p.m. documented, .Relation to Resident (if any) . Mother . Upon arriving to (Resident #5's) room, I observed him in distress. His head was hyperextended back with his O2 (oxygen) down around his neck not in place in his mouth. When he heard my voice, tears ran down his cheeks. He was moaning. His eyes were matted up, so he couldn't open them. His nose was impacted with hard dry buggers (sic). His tongue was stuck to the roof of his mouth, because there was a very large amount of dried sputum stuck to his tongue, roof of mouth and lips. Upon pulling down his sheet, I saw that there was no leg band and the cath (catheter) had pulled his penis very tight. The cath tubing was stuck at side of bed between mattress and side rail. He was lying on his back with a pillow that was flat under each leg. His heels were pressed into the mattress and purple. His brief on left leg side had large amount of discharge that had a very strong foul odor. At the O2 water (humidification) bottle, the tubing was bent and pinched off so no O2 was flowing. He was wet with sweat. He was very upset. I feel (Resident #5) was abused and neglected. There was also an indentation on upper left leg where cath tubing had been across his upper leg. It was red and purple in color. e. A handwritten OLTC Witness Statement Form dated 10/3/16 documented, .Incident Date 9/30/16 . early afternoon .Came to visit (Resident #5) with his Mom and uncle. Noticed (Resident #5) was in distress upon entering room. His mother (mother's name) . immediately knew something was off. After closely checking him, she realized he was having a hard time breathing; crusty nasal discharge with each breath, nose was full. His mouth was also full. She had to use 7-10 swabs to clear his mouth of 'gunky,' solidified residue. (Resident #5) had tears. Then noticed his diaper was dirty with penal (penile) discharge that had been there so long it had started to harden. It was already hardened on fold of his diaper. He was terrible soiled. There was no leg band on his catheter. There was an indention on his leg where it had been unfortunately .it had been pulling on his penis. He was in pain. In addition to this, his oxygen was around his face but kinked at the humidifier. No oxygen was flowing. He was struggling to breathe. (Resident #5's) Mom called for DON (Director of Nursing) to come to his room via phone. She, the acting Director, was appalled by his physical condition. She called the attending CNA into (Resident #5's) room to question her. She admitted she had not been in there since a little after 6:00 a.m. (Resident #5) had clearly been neglected, and by neglect-abused by not caring for him. Not only was he not cared for properly, timely or at all during this time, it crossed the line to abuse. (Resident #5) and his family rely on his aides to keep him alive. This was a very scary, unbelievable and unacceptable situation. The Director sent aide home immediately. f. A handwritten OLTC Witness Statement Form dated 10/3/16 documented, .Date of Incident 9/30/16 early afternoon .Relation to Resident (if any) .Uncle .Upon entering (Resident #5's) (room) for a visit, immediately noticed he was red-faced and warm. With (Resident #5) when he is bothered, hurting, or upset, you can tell from little signs like those. The clipboard (turn log) showed he had been turned every 2 hours or so, but he didn't appear to have been. When his mother .went to straighten his bedding, we could smell fecal discharge odor, and then we saw that his left side diaper material, what appeared to be discharge had been rolled and squeezed up between his leg and crotch (illegible), his urine catheter was not strapped or taped down and was pulling down on his penis hard enough and had been that way long enough that it left an indentation across his left quad/upper leg .(Resident #5's) face was also a mess with snot and nasal material crusted on his nose and mouth area. He was breathing through his nose .buggers (sic) were being blown out into his mouth and (Resident #5) some would then be breathed back into his nose. His O2 and vacuum tubing (humidification) were also ineffective and not working at this point as well . They immediately called for the nursing supervisor to get these things corrected . g. A handwritten OLTC Witness Statement Form dated 9/30/16 and signed by the ADON documented, .Have you ever known a staff member to intentionally to not give care to a resident? .Yes .I was called into resident's room by mother of resident. She had cleaned his mouth and nose and had 7-8 swabs on table that were covered in dry pieces she cleaned out from both areas. His brief had a stain of ? (possible / unknown) stool from his [MEDICAL CONDITION] which had a bad odor. I called (CNA #4) into the room, and after (Resident #5's) mother got finished telling her what all wasn't done, sent her home. Two other CNAs cleaned him and positioned him properly and (Resident #5's) Mom was pleased. (CNA #4) had not turned or fluffed and puffed him at all. (DON) and (Administrator) were notified. (CNA #4) was removed from the schedule for now . There was no documentation to indicate the ADON conducted an assessment of the resident's respiratory status, pain level, or urinary status at this time. h. A typewritten statement dated 11/18/16, signed by CNA #4 and attached to the facility's investigation documented, .This information is true and correct . I, (CNA #4), was the primary CNA on Blackberry Blvd (Boulevard) (Hall B) 9/30/16. It was a very fast morning and I fell behind quickly after breakfast. I did (Resident #5's) turns every 2 hours. I changed his brief and began freshening him up for activities outside. I was then needed elsewhere to address an immediate need and did not start oral or nasal care on (Resident #5). This was about 8:30 a.m. After tending to transfers, appointments and showers, another turn was due. I rushed through (Resident #5's) turn and did not complete peri (perineal) care. After answering several call lights and tending to other residents, I soon became distracted and forgot about (Resident #5's) care and went to my first break - my lunch break. When I came back it was 11:05 (a.m.) and I had to begin getting resident showers, rounds and get ups for lunch. After getting a resident back from the showers and ready for lunch, it was 12:15 (p.m.) and I rushed to the dining room so I could feed our assist residents, forgetting (Resident #5's) turn due at that time. At the end of the meal I was approached by (ADON) and brought into (Resident #5's) room with his mother where she voiced her concerns on her son. I explained that I agreed with her, he shouldn't have been left like this and that I was terribly sorry and would try better. I was then sent home . i. Page 4 of the DMS form 762 titled, Section III - Findings and Actions Taken, documented, .Accused (CNA #4) was immediately pulled off her assigned duties .ADON .immediately ensured staff provided adequate care for resident (Resident #5) . determined there was no negative outcome such as skin breakdown as a result of care provided . The documented corrective actions did not address an assessment of the resident's respiratory status, pain level or urinary status. This document was signed by Administrator on 10/6/16. j. The Vital Sign Form dated 9/30/16 documented the resident's vital signs were checked at 8:58 a.m. and 12:00 p.m., prior to the incident of alleged neglect. No further vital signs were documented on 9/30/16 until 8:45 p.m., approximately 7 hours after the incident occurred. k. As of 11/18/16, there was no documentation in the resident's clinical record to indicate a complete assessment was conducted of the resident's condition after the incident of alleged neglect on 9/30/16. l. On 11/18/16 at 12:04 p.m., LPN #1 was asked, Is there documentation of an assessment that was performed on 9/30/16, immediately following the report of the resident being in distress? LPN #1 stated, .I looked him over head to toe, listened to lungs, and administered a prn (as-needed) breathing treatment . A Witness Statement dated 11/18/16 and signed by LPN #1 documented, .Incident date: 9/30/16 . Around 1 p.m. Mother (of) resident had (told) ADON that her son was in need of oral care and brief changed . ADON assessed resident and found no signs of distress noted . Heart rate even and steady . had vital signs taken and within normal limits for resident . Mother was upset over oral care not being provided promptly and left room during care with ADON . O2 (oxygen) saturation was at 97% when taken by this nurse . This information was not documented anywhere in the clinical record or in the facility's documentation of their investigation until 11/18/16, when the LPN documented this Witness Statement. m. On 11/18/16 at 12:05 p.m., the ADON was asked, Is there documentation of an assessment that was performed 9/30/16 immediately following the report of the resident being in distress? The ADON stated, .I think LPN #1 did an assessment . No distress in any way . LPN #1's written statement documented the ADON assessed the resident, and during this interview with the ADON, she indicated that LPN #1 assessed the resident; however, no assessment of vital signs, lung sounds or oxygen saturation was documented in the clinical record until 8:45 p.m. on the evening of 9/30/16, a period of over 7 hours after the incident occurred. There was also no documentation that the resident was promptly assessed for pain or that his urine was checked for signs and symptoms of possible trauma to the bladder or urethral meatus, related to his catheter being found unsecured and pulled taut. n. On 11/18/16 at 5:00 p.m., the DON was asked, Is there documentation of an assessment that was performed on 9/30/16? The DON stated, No. I guess they did not document it, but I'm sure they did one. o. The Immediate Jeopardy was removed and the scope / severity reduced to E, on 11/18/16 at 5:55 p.m., when the facility implemented the following plan of removal: It is believed the facility has began (begun) to immediately remove the risk to individuals for potential for neglect/abuse by the particular involved CNA is not providing care at this time. She is on administrative leave. We have provided training to staff regarding abuse/neglect and intervention as well as reporting regulations per OLTC on dates September 30, 2016 for the 9-30-16 reportable, November 9-10, 2016 and November 18. 2016. Currently interviewing staff and alert and oriented residents regarding if they have witnessed any neglect or abuse in any way. Clarification on witness statements from (the) reportable 9-30-16 to ensure that the reported neglect was, in fact, referring to the accused CNA (CNA #4). This was completed on 11-18-16 at 5:30 p.m. All staff will be in-serviced prior to their next shift working at (facility name). In-service nurses will make assignments on each shift so that they and CNAs are fully aware of which CNAs are responsible for which residents. This will be completed by Wednesday 11-23-16. Assignment sheets to be turned into DON after each shift - DON or designee will monitor record of care assignments for 4 weeks to ensure CNA assignments are being made. Will continue this standard ongoing. In-service nurses on need for assessment and documentation of each resident involved in reportable of abuse / neglect, immediately upon discovery. In-service will be completed by Wednesday 11/23/16. Each resident, 78 (residents), will be assessed for any signs of abuse or neglect and addressed immediately. This will be completed by midnight on 11-18-16. The nurses on each hall will make rounds periodically on their shift - every 2 hrs (hours) to verify that dependent residents receive the required care and services per their care plan and that any negative findings will be corrected and addressed with the responsible staff member.