Every finding on record at The Lakes at Maumelle Health and Rehabilitation

Based on observations, interviews, record review, and facility policy review, the facility failed to ensure residents were free from neglect for one (Resident #42) of three residents reviewed. The findings include: A review Resident #42's quarterly Minimum Data Set (MDS), with an Assessment Reference Date of 06/26/2025, revealed the facility admitted Resident #42 on 09/22/2022. Resident #42 had a Brief Interview for Mental Status score of 15, which indicated the resident was cognitively intact. The MDS also revealed, Resident #42 used a manual wheelchair for mobility. A review of Resident #42's Medical Diagnoses report revealed diagnoses that included a long-lasting open sore that developed due to poor circulation in the veins of left lower extremity, swelling, paralysis and weakness following a stroke which affected the left side, muscle wasting and atrophy, unsteadiness on feet, stage 3 chronic kidney disease, venous insufficiency, depression, anxiety, and high blood pressure. A review of Resident #42's Active Orders revealed active orders to assess the left lower extremity dressing for intactness every morning and at bedtime, assess for pain every shift related to venous ulcer lower extremity, elevate left leg during morning and night medication pass for one hour two times a day, and provide wound care as ordered. A review of Resident #42's Care Plan revealed the resident had a chronic venous hypertensive ulcer to the left leg. Resident #42's Care Plan interventions dated 09/28/2023, included to evaluate the wound, document the progression of wound healing and notify the physician as indicated. Resident #42's Care Plan, revised on 12/12/2024, indicated the resident had actual impairment to skin integrity of the left lower leg related to a venous wound. The resident's Care Plan interventions included treatments as ordered, monitor and document location, size, and treatment of skin injury. Interventions dated 07/10/2025, revealed compression dressing as ordered by doctor for drainage/edema control, change dressing and compression wrap every Wednesday and Friday and as needed, treatment per orders, observe dressing daily for cleanliness, drainage and compression, check toes daily for circulation, document abnormalities and report to MD [Medical Doctor]. A review of Resident #42's MAR/TAR (Medication Administration Record/Treatment Administration Record) from January 2025 through September 2025 revealed 14 of 33 missed scheduled wound care/dressing changes in the facility. A review of Resident #42's Wound Clinic Visit Reports revealed on 12/05/2024, the resident was admitted to the wound care clinic with a bacterial infection of a chronic venous ulcer on the left leg. Wound care was provided and dressing changes were ordered to be completed at the wound care clinic. The wound care clinic provider cared for Resident #42 from 12/05/2024 to 09/19/2025 (present). Wound care was provided in wound care clinic and varied from weekly, twice weekly and three times weekly. Weekly Discharge Instructions Details sent from wound clinic to facility via Resident #42's transportation revealed detailed instructions for the facility including wound care orders, appointments to make, appointments to attend, supplies to order and bring to the wound clinic and when to return to clinic for next wound care appointments. A review of Resident #42's 03/19/2025 Wound Care Clinic Visit notes revealed, The resident reported extreme left lower leg pain today. Patient's left lower leg wound has regressed due to poor drainage control as [pronoun] has not had a wrap change in nine days, since last seen in clinic A review of Resident #42's Wound Care Clinic Visit notes dated 01/31/2025, 02/07/2025, 02/11/2025, 02/24/2025, 03/12/2025, 03/24/2025, 07/07/2025, 07/11/2025, 07/21/2025, 08/18/2025, revealed the resident returned for follow up care with wet bandages, unchanged bandages, inconsistent rewraps, and no primary dressing. A review of Resident #42's Wound Care Clinic Visit notes dated 08/20/2025 indicated, [Resident #42's] wounds are extremely wet, and peri wound was macerated, and wound was nearly circumferential today. The Wound Care Clinic Visit notes dated 08/20/2025 also indicated, patient is extremely distraught today as [the resident] noticed a maggot in wound. On 09/16/2025 at 9:30 AM, during a phone interview, the wound care clinic doctor indicated the resident was seen in the office on 09/15/2025. They reported the wound clinic was currently providing wound care three times a week and the plan, at this point, was to continue providing wound care three times a week, which was not something the wound clinic generally does. The wound care clinic doctor stated it was necessary because the nursing home was not providing wound care. They reported the resident was clean and appropriate for appointments, but the resident was very distraught when we found the maggot and the condition of the wound. On 09/18/2025 at 3:30 PM, during an interview Social Services indicated that if a resident had wound care orders and the wound care was not provided it would absolutely be considered neglect. On 9/19/2025 at 8:55 AM, during an interview, Advance Practice Registered Nurse (APRN) stated she was aware of Resident #42, and the resident was alert and oriented. She reported the resident had a chronic wound to their left lower extremity. She reported the facility provided wound care in the past because the resident anticipated pain from debridement. The APRN reported that the resident went to the wound clinic three times a week for wound care now. On 09/19/2025 at 11:29 AM, during an interview, the DON indicated her role in wound care for the facility was to make sure wounds got healed. The DON indicated on 08/18/2025, a phone call was received which indicated Resident #42's wound care was not being provided. The DON reported she gave a verbal warning to Licensed Practical Nurse (LPN) #5, who was the treatment nurse, on 08/19/2025 after an investigation revealed wound care dates were missing. The DON indicated she would go with LPN #5 on Fridays to evaluate wound care. She reported on Friday, 09/12/2025 she discussed the treatments with LPN #5 in her office. On 09/19/2025 at 12:54 PM, during an interview, the Administrator reported he had not received any information nor complaints of wound care not being provided for a resident. He reported the facility did have a treatment nurse but if the treatment nurse did not provide wound care the floor nurses were able to complete that care. He indicated if a resident had wound care orders and the wound care was not done it would be considered neglect. He reported it was important for a resident to receive wound care as ordered so they will heal. On 09/19/2025 at 5:15 PM, during an interview, the DON verified that she first knew about Resident #42 not receiving wound care dressing changes on 08/18/2025. The DON reported she spoke with LPN #5 on 08/19/2025 and gave a verbal warning. The DON added LPN #5 did not disagree that the wound care was not completed. She reported on 09/09/2025 she in serviced LPN #5, gave a written warning to LPN #5 and instructed LPN #5 you will report to me once a week on all the treatments in the facility with pictures and measurements. The DON reported she met with LPN #5 on 09/12/2025 and discussed the treatments with LPN #5 in the DON's office. She reported LPN #5 was placed on medical leave 09/18/2025. The DON indicated it was undetermined if LPN #5 would continue employment when returning from medical leave. The DON indicated when a resident had ordered wound care and did not receive that wound care it can be seen as neglect. On 09/19/2025 the DON provided a Performance Plan for LPN #5 dated 09/09/2025. The plan was signed on 09/09/2025 by LPN #5, the DON and Administrator. A review of a facility document titled admission Documents included [State]Patient Rights section, dated 05/2017, which indicated the residents have the right to be adequately informed of their health, medical conditions, treatments, refuse medication or treatment and be notified of the consequences of refusals. Residents have the right to 8. Receive adequate and appropriate health care, protective and support services with recognized practice standards. A review of a facility policy titled Abuse Prevention dated 2001, revised 04/2021, indicated Residents have the right to be free from abuse, neglect. The policy interpretation indicated residents will be protected from abuse, neglect by facility staff and any other individual. A review of a facility titled Inservice Education Report dated 05/02/2025 stated g. neglect is defined as failure to provide goods and services necessary to avoid physical harm, mental anguish, mental illness or the deterioration of a resident's physical or mental condition A review of a facility document titled Wound Care indicated the purpose of wound care is to promote healing of wounds. The wound care includes verify physician's orders, assemble the supplies that are needed, utilize personal protective equipment (PPE), wash hands thoroughly, clean wound, apply treatments as indicated, dress wound, and document findings.

Based on record review, interview, and facility policy review, the facility failed to ensure a Physician's Order for the administration of oxygen was received for one (Resident #50) of two residents reviewed for oxygen administration. The findings include: A review of Resident #50's admission Record from the Electronic Health Record (EHR) revealed the resident was admitted to the facility on [DATE], with diagnoses which included chronic obstructive pulmonary disease (COPD) and congestive heart failure. A review of Resident #50's Physician's Orders from the resident's EHR revealed there was no order for the administration of oxygen. A review of the admission Minimum Data Set (MDS) with an Assessment Reference Date of 02/14/2025, revealed Resident #50 had a Brief Interview for Mental Status score of 15, which indicated the resident was cognitively intact. The MDS also indicated that Resident #50 received oxygen therapy while a resident at the facility. A review of Resident #50's Care Plan Report, initiated on 02/07/2025, did not reveal a focus area of oxygen usage or interventions for oxygen usage. A review of Resident #50's electronic Medication Administration Record (eMAR)for February 2025, did not reveal an order for oxygen administration. A review of Resident #50's Progress Notes revealed the following: -On 02/08/2025 at 5:20 PM, the resident arrived to the facility at approximately 2:30 PM, using oxygen by way of a nasal cannula at 4 liters. -On 02/13/2025 at 5:40 AM, oxygen was in use by way of nasal cannula with no shortness of breath. -On 02/19/2025 at 5:39 PM, pulse oximetry 96% at 5:19 AM, and oxygen via nasal cannula was in use. -On 02/22/2025 at 11:37AM, oxygen saturation at 96% on 4 liters of oxygen per minute by way of nasal cannula. During an interview with the Director of Nursing (DON) on 09/19/2025 at 5:49 PM, she stated the nurses knew how much oxygen to administer to a resident by [looking at] the Medication Administration Record (MAR). The DON also stated the resident should have an order [from the medical provider] for oxygen to be administered, unless it was a situation where the resident was short of breath, but the nurses should call the doctor [for an order for this]. A review of an Oxygen Administration policy, revised October 2010, revealed the purpose for the policy was to provide guidance for safe oxygen administration and that in preparation for oxygen administration, the Physician's Order should be verified.

Based on observation, record review, and interview it was determined that the facility failed to ensure dishes were properly sanitized. The findings are: 1. On 6/03/2024 at 11:06 AM the surveyor asked Dietary Consultant if she could check the temperature of the dishwasher. The dishwasher was currently in a rinse cycle. Dietary Consultant placed the thermometer in bowl of hot water inside dishwasher. The temperature reached 130. Dietary Consultant then ran the rinse cycle a little longer and then rechecked the water. The thermometer then reached the temperature of 140. The Dietary Manager stated, sometimes the dishwasher may need to run a few cycles before the temperature climbs. The surveyor then showed the Dietary Consultant the binders where temperatures should be documented. The book had not yet been documented for the month of June. The Dietary Consultant stated that the kitchen staff most likely have the temperatures written down on paper that had not yet been added to the binder. a. On 6/04/2024 at 7:47 AM, Surveyor spoke with Dietary Manager (DM) regarding temperatures from the day before not reaching 180 during rinse cycle. The surveyor asked DM to run a rinse cycle so it could be checked. DM tried 8 times, in various places to get the temperature of rinse water. The highest temperature recorded is 150 degrees. DM stated that there is a feature on the dishwasher that can be initiated when temperatures aren't high enough so a chemical can be added. DM stated that he would do that until somebody could check the dishwasher. b. On 6/04/24 at 1:48 PM Surveyor went back into kitchen to have DM check a chemical test strip from the dishwasher. DM informed surveyor that he purchased a new thermometer and had checked the temperature of the dishwasher, and it was rinsing hot enough. DM placed the thermometer on tray and ran through dishwasher. Thermometer showed a temperature of 182.3. c. On 6/05/2024 at 8:30 AM, the Dietary Manager provided the training materials that kitchen staff are in-service on titled Employee Food Safety: Maintaining and Cleaning Equipment. d. On 6/05/2024 at 8:55 AM, the Administrator provided in-services for dietary and kitchen staff regarding sanitation and hazards.

Based on observation, record review, and interview the facility failed to ensure residents that require fall mats at the bedside have them placed in a manor to prevent injury in event of a fall for 1 (Resident #26) of 1 sample mix residents; to ensure fall mats at the bedside were properly maintained for 1 (Resident #43) of 1 sample mix residents; to ensure housekeeping carts and janitors closet was kept secure. The findings are: On 06/02/24 at 2:52 PM, the Surveyor observed Resident #43 lying in bed, lunch tray with 25% eaten on over the bed table sitting on fall mat that has tears and edges are peeling up. Progress note dated 04/12/2024 noted Nursing Incident and Accident Report showed the following: Description: Was found on the floor of bedroom lying on left side. Aide found resident on the floor. Immediate Intervention: Check head to make sure resident didn't hit it. Complained of pain in the left arm and left hip, no bruising on the hip, but was discoloration on the left forearm. Progress note dated 4/16/2024 at 03:01 noted Nursing-Hot Rack Charting: Neuro checks completed. No delayed injury noted. No distress or discomfort noted. Care plan with a date of 04/16/2024 revealed Resident #43 has had an actual fall with minor injury 04/12/24 that was unwitnessed. Interventions were bed maintenance repair, continue interventions on the at-risk plan . On 06/02/224 at 2:52 PM, the Surveyor interviewed Certified Nurse Aide (CNA) #06 and asked, Describe Resident #6's fall mat? She stated, Its ripped and sides are coming up. When asked, Is the fall mat in proper working order? She stated, No, it makes it more of a fall risk. On 06/02/24 at 3:05 PM, the Surveyor interviewed the Director of Nursing (DON) and asked, Can you describe the fall mat? She stated, Its torn and the edges are coming up. When asked, Is the fall mat in proper working order? She stated, Nope. It increases the fall risk. On 06/03/24 at 9:54 AM, the Surveyor observed same fall mat on Resident #43's floor as on 06/01/2024 that was discussed with the CNA and DON. On 06/03/24 at 02:42 PM, the Surveyor interviewed the DON and asked, When should Resident #43's fall mat been replaced? She stated, When we found it. When asked, Why should it have been replaced when you found it? She stated, Because of safety. Resident #26 had a diagnosis of fall on same level from slipping, tripping, and stumbling with subsequent striking against other objects and displaced intertrochanteric fracture of right femur. Annual Minimum Data Set with the Assessment Reference Date of 04/17/24 that documented that Resident #26 scored 04 (0-7 indication severe cognitive impairment) on the Brief Interview of Mental Status. A Care Plan for Resident #26, revision date 03/25/22, documented that Resident #26 was at risk for falls related to (r/t) poor balance, weakness, Cerebrovascular accident (CVA), Hypertension (HTN), Diabetes Mellitus (DM), and Seizures. On 06/02/24 at 10:34 AM, the Surveyor observed Resident #26 lying in bed the fall mat was placed under the bed. On 06/02/24 at 1:35 PM, the Surveyor observed Resident #26 lying in bed and the fall mat was placed under the bed. On 06/03/24 at 9:00 AM, the Surveyor observed Resident #26 lying in bed fall mat was next to bed. The Surveyor observed that the fall mat was slanted causing a gap between the fall mat and the head of the bed. On 06/03/24 at 3:20 PM, the Surveyor observed Resident #26 lying at the edge of the bed fall mat was partially next to bed. The Surveyor observed the fall mat slanted causing a gap between the fall mat and the head of the bed. On 06/03/24 at 3:25 PM, the Surveyor asked CNA #2 was the fall mat in place as an intervention for falls? CNA #2 voiced the fat was an intervention for falls. The Surveyor asked CNA #2 was it placed in the correct manner? CNA #2 stated no. On 06/03/24 at 3:32 PM, the Surveyor asked Licensed Practical Nurse (LPN) #9 was the fall mat an intervention used to protect Resident #26 in an event of a fall. LPN #9 voiced that Resident #26 had several falls after admission and the fall mat was put in place as an intervention. LPN #9 voiced that the fall mat would not be effective under the bed or partially away from the bed. On 06/05/24 at 9:34 AM, the Surveyor asked the DON what is the proper way to place a fall mat? the DON voiced the fall mat should be parallel to the Resident's bed. The Surveyor asked the DON if the fall mat is not properly place what could be a potential negative outcome? The DON verbalized that the fall mat would not catch the Resident and it was useless. On 06/02/24 at 10:41 AM, the Surveyor observed a door to a closet titled Janitor, with a lock pad on the exterior of the door, unlocked. The Surveyor opened the door and observed several cleaning chemicals stored in the closet. On 06/02/24 at 10:58 AM, the Surveyor observed a housekeeping cart unattended in the hallway with the door slightly ajar. The Surveyor opened the door on the housekeeping cart and noted chemicals stored inside. a. cart in the hallway of 200 hall labeled 200 & 400 hall? Housekeeping staff #10 voiced that it was her cart. The Surveyor asked Housekeeping Staff #10 was it locked? Housekeeping Staff #10 voiced the lock is broken on the cart therefore it cannot be locked. The Surveyor asked Housekeeping Staff #10 how long had the lock been broken? The Housekeeping Staff #10 voiced the lock had been broken about a month. The Surveyor asked Housekeeping Staff #10 what could be a negative outcome of the chemicals being unlocked and unattended? Housekeeping Staff #10 voiced a resident could get into the chemicals. On 06/05/24 at 9:30 AM, the Surveyor asked the Housekeeping Supervisor what intervention did you put into place after you became aware that the lock was broken on the housekeeping cart? The Housekeeping Supervisor voiced that he educated staff on putting the cart up when not in use but was unable to provide documentation of any in-services on that matter.

Based on record review and interview, the facility failed to ensure the comprehensive care plan was individualized to addressed appropriate care and services for use of fall mats for 2 (Resident #26, and #43) of 2 sampled residents. The findings are: 1. Resident #26 had a diagnosis of fall from slipping, tripping, and stumbling with subsequent striking against other objects and displaced intertrochanteric fracture of right femur. a. Annual Minimum Data Set with the Assessment Reference Date of 04/17/24 that documented that Resident #26 scored 04 (0-7 indication severe cognitive impairment) on the Brief Interview of Mental Status and b. A Care Plan for Resident #26, revision date 03/25/22, documented that Resident #26 was at risk for falls related to (r/t) poor balance, weakness, Cerebrovascular accident (CVA), Hypertension (HTN), Diabetes Mellitus (DM), and Seizures. The Care Plan for Resident #26 did not note that a fall mat was put into place as an intervention. c. On 06/02/24 at 10:34 AM, the Surveyor observed Resident #26 lying in bed and the fall mat was placed under the bed. On 06/02/24 at 1:35 PM, the Surveyor observed Resident #26 lying in bed and the fall mat was placed under the bed. On 06/03/24 at 9:00 AM, the Surveyor observed Resident #26 lying in bed fall mat was next to bed. The Surveyor observed that the fall mat was slanted causing a gap between the fall mat and the head of the bed. On 06/03/24 at 3:20 PM, the Surveyor observed Resident #26 lying at the edge of the bed fall mat next to bed. The Surveyor observed that the fall mat was slanted causing a gap between the fall mat and the head of the bed. d. On 06/03/24 at 3:34 PM, the Surveyor asked the LPN #9 is the fall mat noted on Resident #26 Care Plan? LPN #9 voiced after reviewing the care plan it is not documented on Resident #26 Care Plan, but the fall mat was in place as an intervention for risk. e. On 06/05/24 at 9:34 AM, The Surveyor asked the Director of Nursing (DON) should an intervention that was place for fall prevention such as a fall mat be noted on the Resident's Care Plan? DON voiced that it should be documented on the care plan. 2. On 06/02/24 at 2:52 PM, the Surveyor observed Resident #43 lying in bed, with the over the bed table sitting on fall mat that has tears and edges peeling up. The surveyor interviewed Certified Nurse Aide (CNA) #6 and asked, Describe Resident ' s fall mat? She stated, Its ripped and sides are coming up. When asked, Is the fall mat in proper working order? She stated, No, it makes it more of a fall risk. a. On 06/02/24 at 3:05 PM, the Surveyor interviewed the DON and asked, Can you describe Resident ' s fall mat for me? She stated, Its torn and the edges are coming up. When asked, Is the fall mat in proper working order? She stated, Nope. It increases the fall risk. b. On 06/03/24 at 9:54 AM, the Surveyor observed the same fall mat on Resident #43's floor as on 06/01/2024 that was discussed with the CNA and DON. c. On 06/03/24 at 12:21 PM, Resident #43 has a diagnosis of Metabolic Encephalopathy, and Overactive Bladder. d. Progress note dated 04/12/2024 at 12:59 noted Nursing (Nsg) Incident and Accident (I&A) Incident Description: Was found on the floor of bedroom. was lying on left side. Aide found resident on the floor. Pick up and put back in bed. Immediate Intervention: Check head to make sure resident didn't hit it. complained of pain in the left arm and left hip. looked and no bruising on the hip. But was discoloration on the left forearm. e. Progress note dated 4/16/2024 at 3:01 noted Nsg-Hot Rack Charting: Neuro checks completed. No delayed injury noted. Resident in bed resting with no c/o. No distress or discomfort noted. Call light (C/L) and water (H20) in reach and bed in low position. f. Care plan with a date of 04/16/2024 revealed The resident has had an actual fall with minor injury 04/12/24- unwitnessed fall 04/12/24- Unwitnessed fall with minor injury- bed maintenance repair. Continue interventions on the at-risk plan . g. 06/03/24 03:30 PM A review Resident #43's care plan does not document fall mat in room. h. On 06/04/24 at 10:19 AM, the Surveyor interviewed the Minimum Data Set (MDS) Coordinator and asked, Is Resident #43 care planned for a fall mat? She stated, Not on this care plan. Last fall on [Resident #43] was 4/12 and it's a bed maintenance repair. When asked, If a resident has a fall mat on their floor due to fall should the fall mat be listed on their care plan as an intervention? The MDS Coordinator stated, Yes, ma'am. When asked, Why? The MDS Coordinator stated, So that the staff know to put it in place for a safety measure. The facility provided a policy titled,Care Plans, Comprehensive Person-Centered with a revision date of December 2016 that documented, Policy Statement A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident ' s physical, psychosocial and functional needs is developed and implemented for each resident. Policy Interpretation and Implementation 2. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment.

Based on observation, interview, and record review, it was determined the facility failed to ensure residents rooms are sanitary, clean, and homelike for Resident #4 and the heating and air conditioning unit was maintained and in good repair for Resident #6. The findings are: On 6/02/2024 at 11:38 AM, during initial rounds, surveyor observed Resident #4's room to have an unpleasant odor, the floor was sticky, there was a brown liquid substance on the floor near the left side of the foot of Resident's bed. The puddle of brown liquid substance had napkins laying on top of it. There was a bag of chips laying under the Resident ' s bed, and the over the bed table had spills and trash on top. The room had a clutter of personal belongings throughout the room. On 6/03/2024 at 7:45 AM, while making rounds in facility, there was a puddle of clear liquid substance in the middle of 100 hallway. There was a caution wet floor sign sitting over the wet substance. There is a strong smell of urine/odor on 400 Hall. Surveyor asked Social Services Director (SSD) to look at the puddle of liquid in the hallway. Surveyor asked SSD what the substance is. SSD said that it looks like water but doesn't know why it was left there. The Director of Nursing (DON) and the housekeeper looked at the liquid in the hallway and the housekeeper grabbed supplies to dry up the spill. On 6/04/2024 at 7:42 AM, when entering dining room to observe breakfast, there was one table to the right of the dining room with a stack of trays and plates on it with leftover food trays. One of the foods left on the tray appeared to be carrots. There were cups with liquids left in them. One of the cups had a white liquid in it and a dead fly floating on top. There were residents sitting at the other tables around the table with the food plates and trays stacked on it. Staff were passing out beverages to the residents. On 6/04/2024 at 7:45 AM, Surveyor and the DON walked into the kitchen to speak to Dietary Manager (DM) regarding dishes stacked on the table in the dining room. Surveyor asked DM what were the trays of food from stacked on the table. DM stated they were most likely leftovers from dinner the night before that came from residents on the hallway. Surveyor asked DM why they weren't washed the previous day. DM said they were probably late getting them back to the kitchen and all the kitchen staff had gone home for the day. Resident #4 has a medical diagnosis of: Encephalopathy, muscle wasting & atrophy, pulmonary edema, anxiety disorder, restlessness, Type II Diabetes with Hyperglycemia, Parkinsonism, and edema. A Quarterly Minimum Data Set (MDS) with an Assessment Reference Date [ARD] of 4/12/2024 shows resident to have a score of 15 on the Brief Interview for Mental Status (BIMS), cognitive assessment summary. On 6/05/2024 at 9:40 AM, surveyor asked Housekeeping Supervisor (HS) how often are resident's rooms cleaned? HS stated they are cleaned daily. Surveyor asked HS if he ever checks behind his staff. HS said he spot checks down all hallways. The surveyor asked HS if there were ever any noticeable odors. HS stated there are sometimes in resident's rooms, and he feels like it's contained to their personal belongings, and they are not allowed to do anything with those. The surveyor asked HS what his procedure is that his staff are educated on when a spill is found. HS stated if there are meal trays on the hallway, a wet floor sign is placed over the spill. Once meals are finished, the housekeeper will clean the area with the spill. On 6/05/2024 at 8:55 AM, a policy on accidents and hazards and resident's rights was provided to surveyors by the Administrator. Also provided were in-services on Room Maintenance, Sanitation, and Resident's Rights. 06/02/24 12:09 PM, the Surveyor interviewed Resident #6 and Resident stated, My heat and air don't work right. If they turn it on it only goes on high and it freezes me. Surveyor observed heating and air conditioning unit missing a knob. 06/02/24 12:13 PM, the Surveyor interviewed Certified Nurse Aide (CNA) #07 and asked, How would you adjust Resident #6 ' s heat and air unit from hot to cold? She stated, It had a little thing on it. Here I can switch it and use the other one (pulled off knob to other side). When asked, Should it have a knob on each side? She stated, Ya it should. When asked, Why should it have a knob on each side? She stated, To adjust the temperature from hot to cold. On 06/02/24 at 12:25 PM, the Surveyor interviewed the DON and asked, How you would adjust hot too cold on Resident #6 ' s heat and air unit? The DON confirmed since there were no knobs on the unit she would use pliers. When asked, Should it have a knob? She stated, Yes. When asked, Why should it have both knobs? She stated, So they can control their own temperature. On 06/04/24 at 11:05 AM, the Surveyor observed Resident #6's heat and air conditioning unit still missing a temperature adjustment knob. On 06/04/24 at 12:14 PM, the Surveyor interviewed the Maintenance Director in Resident #6's room and asked, How would Resident #6 adjust the heat and air conditioning unit from hot to cold? He stated, It's actually missing a knob. If someone would've told me, I would have replaced it. When asked, How do staff notify you when equipment needs fixed? He stated, They either text message me or write it in the maintenance log. When asked, Should the unit have two knobs? He stated, Yes. When asked, Why should the unit have two knobs? He stated, So Resident #6 can turn her air hot or cold. Surveyor obtained a copy of the maintenance records that do not document staff reported the missing heating and air conditioning knob to the Maintenance Director.

Based on observations, interviews, and facility policy reviews the facility failed to store drugs and biologicals in accordance with professional principles and the facility's policy. This failed practice had the potential to affect every Resident residing in the building. The findings include: 1. On 06/03/24 at 7:38 AM, the Surveyor observed the Licensed Practical Nurse (LPN) #8 walk to the dining room, with a medication cup in hand, leaving the medication cart unlocked. a. On 06/03/24 8:31 AM, the Surveyor observed an unattended unlocked medication cart in the hallway up against the wall not in front of a doorway. The Surveyor could hear talking in the room across the hall encouraging a Resident to take medication. The Surveyor walked up the hall father to see in the room and observed LPN #9 at the head of bed with her back to the door. b. On 06/03/24 at 8:35 AM, LPN #9 confirmed she was the nurse who left the medication cart unlocked and the medication cart was not viewable from position in the room. c. On 06/05/24 at 9:34 AM, the Director of Nursing (DON) voiced the cart should be unlocked when unattended because anyone can get anything. d. On 06/05/24 at 10:32 AM, a policy was provided titled Storage of medications that documented 7. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes.) containing drugs and biologicals shall be locked when not in use, and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to other.

Based on the observations, interviews, and facility policy review the facility failed to ensure 1 sampled (Resident #20) did not self-administer medication prior to an assessment conducted by the interdisciplinary team to determined it clinically appropriate and safe for the Resident to do so. The findings include: Resident #20 had a diagnosis of dysphagia, acute kidney failure, and chronic pulmonary edema. Resident #20 had an order for sore throat oral liquid (Acetaminophen) give 1 spray by mouth every 2 hours as needed for pain - moderate related to COVID-19 throat pain. Quarterly Minimum Data Set with an Assessment Reference Date of 04/09/24 that documented that Resident #20 was unable to complete the Brief Interview of Mental Status and had long term memory problems. A Care Plan for Resident #20 did not document that Resident self-administers medications. On 06/03/24 at 8:45 AM, the Surveyor noted sore throat spray was on Resident #20 ' s bedside table. On 06/03/24 at 8:56 AM, the Surveyor asked the Director of Nursing (DON) are there any residents in the facility that self-administers medications? The DON voiced that the facility did not have any residents in the facility that self-administers medications. On 06/03/24 8:75 AM, the Surveyor asked the DON should there be medications on the Resident's bed side table? The DON voiced that there should not be medication on the bedside table. 06/05/24 at 9:34 AM, the Surveyor asked the DON what could be a potential negative outcome from the Resident self-administering medications unknowingly? The DON voiced the Resident could overdose, the medication could interfere with other medication the Resident is prescribed, or another Resident could get the medication. On 06/05/24 at 10:32 AM, the Surveyor was provided a policy titled Self-Administration of Medications that documented Residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so.

Based on observation and interview, it was determined that the facility failed to ensure kitchen equipment was in safe, working condition. The findings are: 1. On 6/02/24 at 11:07 AM, the surveyor entered the facility kitchen. Upon entry, the surveyor found water in a puddle between the dishwasher and sinks. 2. On 6/04/24 at 7:42 AM, the surveyor entered the kitchen to find a large puddle of water in the floor between the steam table and refrigerators. The surveyor showed Director of Nurse's (DON) and Dietary Manager (DM) the dishwasher had water coming from it and going all over the floor and running down the table beside the dishwasher. a. On 6/04/2024 at 7:50 AM, the surveyor asked DM how long dishwasher had been leaking water on the floor. DM said he did not know but not for that long. b. On 6/04/2024 at 7:51 AM, the surveyor asked DM if he had reported the dishwasher to anybody. DM said he had not, but he would let somebody know. c. On 6/04/2024 at 7:52 AM, the surveyor noticed a long strip of white trim that runs between the dishwasher and the wall with a black substance. The surveyor asked DM what the black colored substance was on a strip of wood between the stainless-steel table and the wall. DM said he wasn't sure if it was mildew or mold. d. On 6/05/2024 at 8:30 AM, the Dietary Manager provided the training materials that kitchen staff are in-serviced on titled Employee Food Safety: Maintaining and Cleaning Equipment. e. On 6/05/2024 at 8:55 AM, the Administrator provided in-services for dietary and kitchen staff regarding sanitation and hazards.

Based on observation, record review, interview, and facility policy review it was determined the facility failed to ensure staff washed/cleaned hands after changing gloves during incontinent and wound care for 1 (Resident #32) of 1 sampled resident reviewed for pressure ulcers; to ensure wound care supplies were cleaned or replaced when contaminated to reduce the risk infection for Resident # 32. The findings are: 1. Resident # 32 with diagnoses of: Complete traumatic amputation at level between right hip and knee, gastrointestinal hemorrhage, pulmonary embolism, esophagitis, muscle wasting, pressure ulcer of sacral region, stage 2, pressure ulcer, unspecified site stage 2, schizophrenia. a. A physicians order dated 6/3/24 documented, . Order Summary: Treatment: Pressure Ulcer to Right superior dorsal thigh area, (W #3). Clean with wound cleanser, pat dry, apply Silvadene, cover with foam dressing. Change daily and as needed every day shift for Wound care. skin integrity. Replace dressing and notify Treatment nurse. and as needed for Ineffective or soiled dressing. Change and notify treatment nurse. Physicians order dated 6/3/24- documented .Treatment left posterior trochanter area for skin integrity and protection. Change M, W, F [Monday, Wednesday, Friday] and as needed. Cleanse with wound cleaner, pat dry and apply Foam dressing Treatment: Stage 2 Pressure Ulcer to coccyx area (W #1). Clean with wound cleanser, pat dry, apply Silvadene cream, cover with foam dressing. Change daily and as needed b. Care Plan Entry Date Initiated: 05/30/2024 showed, Focus . The resident has multiple pressure ulcers to dorsal buttocks and thigh region along with areas of fragile skin related to pressure and compromised skin integrity. Goal .The residents will Pressure ulcer will show signs of healing and remain free from infection by/through review date. Date Initiated: 06/03/2024 Created byLicensed Practical Nurse, (LPN) Target Date: 08/28/2024 The resident will have intact skin, free of redness, blisters, or comorbidities. Interventions . Monitor dressing (specify frequency) to ensure it is intact and adhering. Report lose dressing to Treatment nurse. c. On 06/3/2024 at 11:08 AM, during wound care/pressure ulcer care the surveyor observed Licensed Practical Nurse (LPN) #1 perform care to Resident #32. The surveyor observed enhanced precautions signs and Personal Protection Equipment (PPE) cart outside Resident #32 ' s door. d. On 6/3/2024 at 11:08 AM LPN #1 prepared wound care supplies. Applied gloves without washing hands and placed a red bag on top of 4x4's. Resident is on enhanced barrier precautions. LPN#1 donned gown, donned gloves, and did not wash/cleanse hands prior to donning PPE equipment. Entered Resident ' s room changed resident brief, did not remove gloves, touched dresser drawer, bathroom door, exited Resident ' s room searching for new brief without removing gloves or cleansing hands. e. On 06/03/2024 at 11:12 AM, LPN # 1 returned to Resident ' s room with new brief. Put on clean gloves without cleansing hands, removed old dressing from right thigh pressure ulcer, removed gloves, donned new gloves, cleaned wound with cleanser, applied a gel to hip to right wound, removed gloves, donned clean gloves, and applied foam dressing to wound on right hip. Removed gloves and disposed of them in red bag. f. On 06/03/24 at 11:20 AM, LPN #1, donned clean gloves removed and dressing from coccyx area. Changed gloves, scratched head, picked up a 4x4 to clean coccyx area with wound cleanser applied, applied gel to coccyx wound, changed gloves, applied foam dressing to coccyx. g. On 06/03/24 at 11:30 AM, LPN #1 changed gloves, removed dressing from left hip, applied new foam dressing to wound. LPN #1 went to Resident ' s dresser removed shorts and placed them on the Resident, then removed gloves and exited room. h. On 6/3/2024 at 11:33 AM, Surveyor conducted an interview with LPN # 1, the surveyor stated you scratched your head and touched your scrubs while providing wound care, what did you potentially do? LPN #1 stated, cross contaminated. The surveyor asked: You changed your gloves 12 times, what should you have done between each glove change? LPN #1 stated, Washed my hands or used hand sanitizer. The Surveyor asked LPN #1, You opened the red bag, placed on tray on top of 4x4's on dressing change tray, what did you potentially do? LPN #1 stated, cross contamination. The surveyor asked LPN #1 After removing Resident's soiled brief you went Resident ' s dresser and bathroom with gloves on, what did you potentially do?' LPN #1 stated, cross contamination. Surveyor asked LPN #, The foam dressing in package laid it on top of your cart, opened it, labeled dressing, then placed package on top of 4x4 gauze pads, what potentially did you do? LPN #1 stated, cross contamination. i. The facility provided a policy titled Infection Control Guidelines for All Nursing Procedures that documented Purpose: To provide guidelines for general infection control while caring for resident. General Guidelines 3. Employees must wash their hands for ten (10) to fifteen (15) seconds using antimicrobial or nonantimicrobial soap and water under the following conditions: a. Before and after direct contact with residents; .d. After removing gloves . e. After handling items potentially contaminated with blood, body fluids or secretions .

50580 Based on observation, interview, and record review, it was determined that the facility failed to provide palatable food to Residents. The findings are: Resident #4 has a medical diagnosis of: Encephalopathy, muscle wasting & atrophy, pulmonary edema, anxiety disorder, restlessness, Type II Diabetes with Hyperglycemia, Parkinsonism, and edema. A Quarterly Minimum Data Set (MDS) with an Assessment Reference Date [ARD] of 4/12/2024 shows Resident to have a score of 15 on the Brief Interview for Mental Status (BIMS), cognitive assessment summary. On 6/03/24 at 9:00 AM, Surveyor asked Resident #4 if pleased with the food received at this facility. Resident told surveyor that the food doesn't taste very good most of the time. On 6/03/2024 at 1:02 PM, the surveyor checked the Resident's meal card and there was an order for sweet and low. The Resident told the surveyor there was none on the tray. The surveyor observed there to be no sweet and low on resident's meal tray to go in resident's beverage. On 6/04/2024 at 8:57 AM, the surveyor observed the Resident's breakfast meal being set up for resident in the room. The tray consisted of sausage, scrambled eggs, waffles, and cream of wheat. Resident had sweet and low (which is ordered) on tray. There was no butter for the waffles or cream of wheat. Surveyor asked Director of Nursing (DON) for butter for the waffles and hot cereal. On 6/04/2024 at 1:42 PM, the surveyor asked Dietary Manager (DM) who is responsible for getting meal trays ready that go to the hallway. DM stated the Dietary Aides. Surveyor asked DM if hall trays get the usual condiments with their meals. DM stated, absolutely. Surveyor informed DM that on two separate occasions, resident received a tray without the ordered sweet and low artificial sweetener and butter for breakfast that included waffles and cream of wheat. Based on record review, Resident #4's last dietary assessment was on 7/05/2022. On 06/02/24 at 11:51 AM, the surveyor interviewed Resident #41 and the resident stated Food is not too good. Served black beans 3 days in a row. Family brings in food or I wound starve to death. On 06/02/24 at 11:57 AM, the Surveyor interviewed Resident #6 who confirmed meals are not palatable or seasoned. Review of Resident #6's Order Summary Report revealed the resident is ordered a regular diet, regular texture, regular consistency. Review of Resident #6's Care Plan dated 11/19/2021 revealed the resident feeds self with tray set up. Review of Resident #6's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/10/2024 did not reveal any swallowing disorder but did reveal the resident is edentulous. 06/02/24 1:35 PM, the Surveyor received test tray from the facility kitchen. The meal consisted of pork roast, mashed potatoes with gravy, green beans, dinner roll and vanilla ice cream. Ice cream was melted, pork was slightly over cooked, dry, and chewy, green beans and mashed potatoes were bland with no seasoning. On 06/05/24 at 10:17 AM, the Surveyor interviewed the Dietary Manager and asked, Should resident ' s meals be palatable? He stated, Yes. When asked, Why should meals be palatable? He stated, Because no one wants to eat anything not palatable. We want it to taste good. When asked, Should meat be overcooked, dry and chewy? He stated, No. It doesn't taste good. When it's chewy the older residents can't eat it and you cook out too much of the nutrients.

Based on record review and interview, the facility failed to complete an accurate Minimum Data Set (MDS) for 01 (Resident #40) of 1 sample mix residents. The findings are: Resident #40's Quarterly MDS with an Assessment Reference Date (ARD) of 02/29/2024 documented the Resident as taking an anticoagulant, however there is no physician order on the order recap report dating back to 02/28/2024 noting the resident taking an anticoagulant. On 06/04/24 at 10:23 AM, the Surveyor interviewed the MDS Coordinator and asked, Does resident #40's MDS with an ARD of 02/29/2024 indicate the Resident is taking an anticoagulant? MDS Coordinator stated, It's saying yes. When asked, Can you tell me when resident #40 was ordered an anticoagulant? She stated, On [Resident #40] current orders it doesn't say [Resident #40] takes one let me look on [Resident #40's] other. I'm not seeing where [Resident #40] had an anticoagulant. When asked, Is Resident #40's MDS coded correctly? She stated, No ma'am it's not and we will be doing a modification on that.

Based on observations, interviews, and facility policy reviews the facility failed to protect the Patient Health Information (PHI) of 1 (Resident #2) sampled resident. This failed practice had the potential to affect all residents residing in the facility. The findings include: 1. On 06/03/2024 at 7:38 AM, the Surveyor observed Licensed Practical Nurse (LPN) #8 walk to the dining leaving the computer screen on the laptop mounted to a medication cart unlocked displaying Resident #2's personal and medical information. The following was observed: a. Facility name b. Resident's name c. Status d. Location e. Gender f. Date of birth g. Age h. Physician i. Allergies j. Code status k. Ordered medications 2. On 06/03/2024 at 7:40 AM, the Director of Nursing (DON) observed the Surveyor standing at the medication cart taking notes and pictures and instructed LPN #8 to leave the facility. The Surveyor was unable to conduct an interview with LPN #8 due to LPN #8 no longer being in the building. 3. On 06/05/2024 at 9:34 AM, the Director of Nursing (DON) confirmed the computer screen should be locked or closed to protect Resident #2's privacy. The DON voiced that it was a Health Insurance Portability and Accountability Act (HIPAA) issue if the computer screen was unattended and unlocked with a resident's personal and medical information displayed. 4. On 06/05/2024 at 10:32 AM, the Surveyor was provided with a policy titled Protected Health Information (PHI), Management and Protection of that documented It is the responsibility of all personnel who have access to the resident and facility information to ensure that such information is managed and protected to prevent unauthorized release or disclosure.

Based on interview and record review, the facility failed to ensure staff members (Floor Nurse, Certified Nursing Assistant and Human Resource Director) reported an allegation of physical abuse immediately to the Administrator for 1 (Resident #1) of 4 (Residents #1, #2, #3 and #4) case mix residents. The finding include: Resident #1 was admitted to the facility on [DATE] with a diagnosis of Cerebral Infarction due to Thrombosis of unspecified cerebral artery. The Quarterly Minimum Data Set (MDS) dated [DATE] assessed the resident's Brief Interview for Mental Status (BIMS) was a 12. A score of 8 to 12 indicates Resident #1 was moderately cognitively impaired and required cueing to answer questions. The Care Plan dated 8/01/23 documented Resident #1 had an ADL (activities of daily living) self-care performance deficit related to hemiplegia and hemiparesis affecting the right dominant side. Intervention: When bathing/showering avoid scrubbing and pat dry sensitive skin. A Nurses Note dated 10/27/23 at 12:01 PM documented, Note Detail: Seems different than usual. Resident stated that someone was trying to rape her; staff was only giving shower and peri care. Will continue to monitor . A Nurses Note dated 11/01/23 at 3:33 PM documented the facility sent Resident #1 to the hospital for rape kit and exam due to the resident's allegation that she was raped. The Adult Protective Service Report dated 11/01/23 documented the hospital reported the victim was being touched inappropriately when being bathed by an employee. On 11/29/23 at 10:07 AM, during an interview with Nurse #1 she stated that Resident #1 was not acting normal. They had even drug tested her which came back clear. Then Certified Nursing Assistant (C.N.A) #1 said that Resident #1 said she had raped her. Human Resources was talking with C.N.A. #1 and Nurse #1 had overheard the conversation. I did not tell anyone, I just documented it in the notes. I got busy and forgot about it until I was asked about it later. On 11/29/23 at 10:21 A.M., during an interview with C.N.A. #1 stated the resident was already up and maybe she gave her a shower, she does not remember. She did not know anything about the allegation until another C.N.A. told her that the resident said she had been mean or ugly to her. On 11/29/23 at 10:45 A.M., during an interview with the Human Resource (H.R.) Director, she stated that Resident #1 rolled up to the nurse's station after receiving a shower. Nurse #1 and the C.N.A #1 and herself were at the nursing station. She said the resident was calm acting and stated that they were rough with her. As she (Resident #1) was trying to explain it all, after a little bit, then she said the rape word. I told Nurse #1 to document it. I tried to get the resident to explain what happened and she could not get the words out. The H.R. Director was asked who completes orientation for new hires on abuse. She said she does. The H.R. Director was asked who was supposed to report abuse allegations. She said, The nurse does. The Surveyor asked whose responsibility it was to report allegations. She said Everyone. She said it was her responsibility to call and report it. I didn't do it. It just came out of the blue. I thought she got the wrong word. I thought she was confusing it with the word rough. On 11/29/23 at 11:58 AM, during an interview with the Administrator, she was asked what the time frame for reporting abuse was. She said she had twenty-four hours to report to the state. The Surveyor asked what the time frame for reporting physical abuse was. She said 2 hours and they have inserviced the staff on timely reporting. On 11/29/2023 at 12:05 PM, the Administrator provided the facility Abuse Investigation and Reporting policy which documented, Policy Statement: All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source (abuse) shall be promptly reported to local, state, and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. Findings of abuse investigations will also be reported . Reporting 1. All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of an unknown source and misappropriation of property will be reported by the facility Administrator, or his/her designee, to the following persons or agencies: a. The State licensing/certification agency responsible for surveying/licensing the facility; b. The local state Ombudsman; c. The Resident's Representative (Sponsor) of Record; d. Adult Protective Services (where state law provides jurisdiction in long-term care); e. Law enforcement officials: f. The resident's Attending Physician; and g. The facility Medical Director. 2. An alleged violation of abuse, neglect, exploitation, or mistreatment (including injuries of unknown source and misappropriation of resident property) will be reported immediately, but not later than: a. Two (2) hours if the alleged violation involves abuse OR has resulted in serious bodily injury; or b. Twenty-four (24) hours if the alleged violation does not involve abuse AND has not resulted in serious bodily injury .

Based on observation, record review and interview, the facility failed to ensure that a humidification bottle was present to humidify oxygen for 1 (Resident #1) of 1 sampled resident who received oxygen. The findings are: 1. Resident #1 was admitted on [DATE] with a diagnosis of Shortness of Breath. a. The Care Plan dated 07/26/2023 documented, .OXYGEN SETTINGS: O2 [oxygen] via nasal prongs @ [at] 2-4LM [2 to 4 liters per minute]. Humidified . b. The Physician Orders dated October 2023 documented, .OXYGEN as needed for SHORTNESS OF BREATH 2 LITERS/MIN [minute] PER NASAL CANNULA PRN [as needed] .Change and date o2 tubing and water bottle q [every] week every night shift every Sun [Sunday] .OXYGEN as needed for SHORTNESS OF BREATH 2 LITERS/MIN PER NASAL CANNULA PRN AND every shift for Shortness of Breath . Change and date o2 tubing and water bottle q week . c. During observation on 11/07/2023 at 02:14 PM, the Surveyor observed Resident #1 lying in bed on her left side with two liters of oxygen per nasal cannula. The Surveyor did not observe humidification attached to the oxygen concentrator. d. During observation on 11/08/2023 at 11:00 AM, the Surveyor observed Resident #1 lying in bed on her back with two liters of oxygen per nasal cannula. The Surveyor did not observe humidification attached to the oxygen concentrator. e. During an interview on 11/08/2023 at 11:36 AM, the Surveyor directed Licensed Practical Nurse (LPN) #1 to Resident #1's room and asked, Does the resident have humidification attached to her oxygen concentrator? She stated, She doesn't have humidification right now, but she is also only receiving two liters. When asked, Does she have an order for humidification? She stated, I believe so. When asked, If she has an order for humidification should it be provided? She stated, Yes, if that is what the physician wants, we follow the orders. f. During an interview on 11/08/2023 at 11:41 AM, the Surveyor directed the Director of Nursing (DON) to Resident #1's room and asked, Does the resident have humidification attached to her oxygen concentrator? She stated, No, it's not on her concentrator. When asked, Does she have an order for humidification? She stated, I'm not sure, but if it's ordered it should be on there. g. The facility Oxygen Administration Policy documented, .Review the physician's orders . Equipment and Supplies . Humidifier bottle . Steps in the Procedure .10. Check the mask, tank, humidifying jar, etc., to be sure they are in good working order and are securely fastened. Be sure there is water in the humidifying jar and that the water level is high enough that the water bubbles as oxygen flows through . 12. Periodically re-check water level in humidifying jar .

FACILITY Kitchen Based on observation, interview, and record review, the facility failed to ensure food items stored in the refrigerators, freezers, and dry storage were sealed or closed, and labeled and dated when received and opened; expired or spoiled items were discarded promptly, and facility dietary staff washed their hands before serving food and picked up plates during service without touching the food surface area to prevent the potential of food borne illness for residents who received meals from 1 of 1 kitchen. The failed practices had the potential to affect 49 residents who received meals from the kitchen (total census: 50), as documented on the diet list provided by the Administrator on [DATE] at 08:05 AM. The findings are: 1. On [DATE] at 11:00 AM, observed a paper liquid egg carton dated [DATE] with the spout open on a shelf in refrigerator #1. Cook #1 stated, Oh that's just from breakfast. I forgot to close it. a. On [DATE] at 11:04 AM, Cook #1 was asked to describe the cardboard box of bell peppers and the plastic open bin of non-dated cabbage on the bottom shelf in refrigerator #2. Cook #1 stated, Oh, that should be dated. They are in fair shape, not bad just really brown outer leaves. The bell peppers don't look so good, but they're still fair. b. On [DATE] at 11:07 AM, observed one open package of ham which was labeled as received ,d+[DATE] and opened ,d+[DATE], in a non-sealed zippered storage bag. The Surveyor asked Cook #1 to locate dates on four packages of turkey slices on a shelf in refrigerator #3 and asked to describe the open package of ham. Cook#1 stated, The package must have opened. Cook#1 proceeded to zip closed the bag. The turkey was just pulled. I just haven't dated it yet. The Surveyor asked Cook#1 what date needed to be on the turkey. Cook #1 stated, the date was on the box. It's in the dumpster. I'll remember the date. c. On [DATE] at 11:10 AM, the surveyor asked Cook#1 to locate the dates on two large plastic bags of tater tots, a plastic bag with two pie crusts, a chocolate bar, and three chocolate cream pies in metal pans with plastic lids. Cook #1 stated, Nope, no dates. The [named chocolate bar] is activities, not the kitchens. He proceeded to write today's date on the two bags of tater tots and stated, Maybe they just faded and laughed. d. On [DATE] at 11:21 AM, in the dry storage room, observed a cardboard box dated [DATE] of yellow onions covered in black areas filled with black and whiteish grey fuzzy matter. Cook #1 stated, We could just cut off the outside. e. On [DATE] at 11:26 AM, the Surveyor observed remnants of black fuzzy matter floating down from two vents over an oven with uncovered trays of dinner rolls sitting on the top. When asked if the trays of food on top were exposed to the matter coming out of the vents, Cook #1 stated, Well yeah, they will be covered. I just haven't done it yet. 2. On [DATE] at 07:40 AM, Cook #2 washed hands, then moved a cart next to the steam table, then picked up three drying racks of bowls and placed them on the cart, then uncovered ,d+[DATE] of the foil and paper cover from the biscuits and bread in the steam table, folded the foil and paper over, and grabbed a stack of three plates with her thumb on the top plate, past the edge, down onto the food area of the plate and began handling tongs and scoops and served breakfast. Cook #2 continued through the meal service to handle plates with her thumb touching the food surface. a. On [DATE] at 07:58 AM, The Surveyor asked Cook #2 if she washed her hands at the appropriate times during the set up and meal service during the breakfast service. Cook #2 answered that she guessed she had not. The Surveyor asked Cook #2 if she had handled the cart and the three plastic drying racks of bowls after washing hands and before beginning service. Cook #2 stated, Yes and I forgot to wash my hands before I started. The Surveyor asked Cook #2 how plates were to be handled. Cook#2 stated, Did I touch more than the edge? I should only touch the edge and bottom. 3. On [DATE] at 8:38 AM, the Dietary Consultant stated, The bell peppers and cabbage needed to be thrown out. The Surveyor noted the yellow onions were gone. 4. The facility policy titled Food Receiving and Storage provided by the Administrator on [DATE] at 04:17 PM documented .8. All foods stored in the refrigerator or freezer will be covered, labeled, and dated (use by date) .e. Opened containers must be dated and sealed or covered during storage . 5. The facility policy titled Storage of Frozen and Refrigerated Foods provided by the Administrator on [DATE] at 04:17 PM documented .16. Label and date food items when removing them from the freezer to thaw . 6. The facility policy titled Employee Cleanliness and Handwashing Technique provided by the Administrator on [DATE] at 04:17 PM documented .Dietary employees will .practice good hygiene .Dietary department employees are required to wash their hands on the occasions listed below . j. any other time deemed necessary .

Based on observation, interview, and record review the facility failed to provide bathing assistance for 3 (Residents #1, #13, #107) of 16 (Residents #1, #13, #15, #17, #19, #21, #26, #37, #38, #40, #49, #101, #103, #105, #107, and #157) sampled residents who required staff assistance with bathing. The findings are: 1. Resident #107 admitted on [DATE] and discharged on [DATE]. She had diagnoses of unspecified fracture of right femur, subsequent encounter for closed fracture with routine healing. The 5-Day Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/1/23 documented the resident scored 15 (cognitively intact) on a Brief Interview for Mental Status (BIMS), required limited assistance with personal hygiene, extensive assistance for bed mobility, transfers, dressing, and toileting and bathing was documented as did not occur. a. The Baseline Care Plan initiated on 5/26/23 documented, .The resident has an ADL (Activities of Daily Life) self-care performance deficit r/t [related to] ORIF [open reduction internal fixation] right femur .Bathing/Showering: The resident requires maximum assistance by 1 staff with bathing/showering 2X/week and as necessary . b. Review of the Progress notes revealed no documentation of a bath, sponge bath, or shower being offered, given, or refused. c. Review of the ADL Bathing document noted bathing scheduled for Monday, Thursday and as needed, the type of bathing was noted as, Not Applicable. There was no documentation that bathing was done. d. On 6/29/23 at 10:10 AM an interview with Certified Nursing Assistance (CNA) #5, revealed he usually works on the 11 PM-7AM shift and sometimes stays over to help at the end of his shift. He reported that showers are usually scheduled on the day shift, 7 AM-3 PM. The Surveyor asked CNA #5 if Resident #107 reported to him any complaints regarding her care or need for a bath or shower. He replied, No, she didn't. We don't usually do showers on 11 to 7 shift. The nurses usually put the shower schedule in for day shift. e. On 6/29/23 at 10:15 AM an interview with the Director of Nurses (DON), who stated, When a resident is admitted , there is a prn [as needed] task that automatically triggers in the computer. At that time the resident would need to ask, or staff can identify the need. Then when we have stand up meeting, we discuss new admissions, and the bath/shower task is scheduled according to what hall a resident is residing. She was on 100 Hall so she would have been Monday/Thursday. We would not have discussed her until Monday morning and the first scheduled bath or shower would have triggered on Thursday. The Surveyor asked, So a week could go by without the system indicating a resident is due for a bath? She stated, Yes, it could. She [Resident #107] discharged on Wednesday of the following week. 2. On 06/25/23 at 10:15 PM Resident #1 said, I have not had a bath in 2 weeks. The roommate stated, I can confirm it, because I have been here. a. Review of Resident #1 bath sheet revealed bath days were scheduled for Monday and Thursday, on the dayshift and as needed. The document revealed the resident refused a bath on 6/15/23, 6/19/23 not applicable was documented and on 6/26/23 shower was documented. 3. On 06/28/23 at 3:03 PM The Surveyor asked CNA #1 how often the residents are given baths. The CNA #1 said, most residents are scheduled for two times weekly and as needed. The Surveyor asked do the residents get their baths two times per week. CNA #1 stated, yes, as far as I know. The Surveyor asked if two weeks is too long for a resident to wait between their baths. CNA #1 stated, yes. CNA #1 said, it could make a resident feel that she is not worthy, plus she could be stinking and self-conscious. 4. On 06/28/23 at 3:11 PM The Surveyor asked Licensed Practical Nurse (LPN) #2 how often are residents given a bath. LPN #2 said, I believe it is twice a week. The Surveyor asked, do you know if the residents get their baths this often. The LPN #2 said, I think so. The Surveyor asked if waiting two weeks between baths is too long. The LPN #2 said, that is too long, I would not like that. 5. On 06/28/23 at 3:17 PM The Surveyor asked the DON how often residents are given a shower/bath. The DON stated, should be twice a week or more if needed. The Surveyor asked the DON, if residents are receiving baths this often. The DON responded, Yes, they are. The Surveyor asked if waiting two weeks between baths is an issue. The DON said, Yes, it would bother me. 6. On 06/29/23 at 8:00 AM a document titled, Activities of Daily Living, last revised March 2018 provided by the Nurse Consultant documented, .Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident in accordance with the plan of care, including appropriate support and assistance with: a. Hygiene (bathing, dressing, grooming, and oral care.) . 46723

Based on Observation and Interview, the facility failed to ensure the residents environment was free of potential accident/hazards for 27 residents who are ambulatory and who reside in the facility according to a list provided by the Nurse Consultant on 6/29/23 at 9:03 AM. The Findings are: 1.On 6/25/23 at 11:56 AM, a red topped container of Germicidal Disposable Cloth wipes was sitting on a crash cart uncovered against the wall outside an office in the common area. Observed residents sitting and ambulating by it throughout the survey. 2. On 6/27/23 at 09:30 AM the Surveyor observed a red topped container of Germicidal Disposable Cloth wipes in the 200 -shower room. The door was unlocked and standing wide open with residents outside the door. There was no staff nearby for during an observation of 17 minutes. 3.On 6/27/23 at 10:00 AM, a red topped container of Germicidal Disposable Cloth wipes was sitting on a crash cart uncovered, against the wall, in the common area at the nurse's desk. Observed residents sitting and ambulating by it throughout the survey. 4.On 6/27/23 at 9:40 AM the Surveyor observed a red topped container of Germicidal Disposable Cloth wipes were sitting on a box at the nurse's station unattended with no staff nearby. There were residents at the nurse's station. 5. On 6/27/23 at 10:00 AM The Surveyor observed a gray topped container of Disposable Cloth wipes was sitting on the treatment cart on 100 hall, unattended by staff. There were residents nearby approximately 3 feet from the container. 6. On 6/27/23 at 10:27 AM the Surveyor observed Germicidal Disposable Cloth wipes sitting on a medication cart at the nurses' station unattended with no staff nearby. There were residents sitting next to the desk approximately 1 foot from the wipes. 7. On 6/27/23 at 2:52 PM, observed a container of Germicidal Disposable Cloth wipes was sitting on the top of the nurse's station unattended by staff. There were residents sitting next to the desk about a foot away. 8. On 6/28/23 at 7:45 AM observed a red topped container of Germicidal Disposable Cloth wipes sitting on the 100-medication cart at the nurse's station, unattended. There were residents ambulating by the cart. 9. On 6/28/23 at 9:17 AM a red topped container of Germicidal Disposable Cloth wipes was sitting on a crash cart uncovered against the wall. Residents sat and ambulated by it throughout the survey. 10. On 6/29/23 at 7:40 AM a red topped container of Germicidal Disposable Cloth wipes was sitting on a crash cart uncovered, against the wall, in the common area at the nurse's desk. Residents sat and ambulated by it throughout the survey. 11. On 6/27/23 at 9:48 AM, Certified Nurse Assistant (CNA) # 3 walked into the shower room then walked away and left the door open. The Surveyor asked, what could happen if the container of Germicidal Disposable Cloth wipes were left out unattended? She stated, A resident could get into it. The Surveyor asked, if a resident did get into the container what could happen? She stated, Well you need to wear gloves because it can cause a chemical burn. It is poisonous. 12. On 6/27/23 at 9:46 AM the Surveyor asked CNA # 4 what could happen if a container of Germicidal Disposable Cloth wipes was left out and not locked up? She stated, Residents might get into them, and they have alcohol and poison in them. They can burn them and cause a sore. It could cause them more harm than good. 13. On 6/29/62 at 10:55 AM, The Surveyor asked the Director of Nurses, (DON), how do you monitor Germicidal Disposable Cloth wipes so that residents couldn't accidently get into them? She stated, They should have been locked away. The Surveyor asked, what could happen if a resident did get into a container? She stated, They could wipe their face, put them in their mouth or wipe their bottom with them then poison control would have to be called. 14. On the label of Germicidal Disposable Cloth wipes it documented, .When using this product, use disposable protective gloves, masks, and eye coverings .Precautionary Statements: Hazards to Humans Caution: Causes Moderate eye irritation. Call Poison control center or doctor for advice. Physical or chemical Hazards: Combustible . Keep Out Of Reach of Children Caution, Precautionary statements hazards to Humans . 15. On 6/29/23 at 8:00 AM the Administrator provided a policy, Storage Areas, Environmental Services which noted, Cleaning supplies, etc. shall be stored in areas separate from food storage rooms and shall be stored as instructed on the labels of such products.

Based on observation, record review and interview, the facility failed to ensure oxygen was administered per physicians' orders for 1 (Resident #259) of 5 (Resident # 1, #17, #19, #49, & #259) sampled residents who had a physician's order for oxygen on a list provided by the Administrator on 6/29/23 at 8:00AM. The findings are: 1. Review of Resident #259 physician's orders with an order date of 6/2/2023 noted an order for 4 liters of oxygen as needed for shortness of breath. 2. Review of Resident #259 Care Plan, last revised on 6/15/23 noted the resident had altered cardiovascular status due to high blood pressure, with an intervention to use oxygen at 4 liters per minute. 3. On 06/25/23 at 11:37 AM during initial rounds, resident #259 was lying in bed with Oxygen on at 3 Liters Per Minute by nasal cannula. 4.On 06/25/23 at 3:37 PM observed Resident #259 lying in the bed with oxygen at 3 Liters Per Minute by nasal cannula. 5. On 06/25/23 3:46 PM observed Resident #259 lying in bed with oxygen at 3 Liters Per Minute by nasal cannula. 7. On 6/29/23 at 8:39 AM the Surveyor asked Licensed Practical Nurse (LPN) #1 if a resident who had orders for oxygen at 4 liters per minute should be set on 3 LPM. She stated no. The Surveyor asked, what could happen if the physicians order is not followed for the correct amount of oxygen? She stated, It's not following physicians orders. 8. On 6/29/23 at 10:44 AM the Surveyor asked the Director of Nurses (DON) how she expected the nurses to monitor residents who have orders for oxygen. She stated, it should be checked once a shift by the nurses. The Surveyor asked why it was important to follow Physicians orders she stated, because they can become hypoxic and confused. 9. A policy was provided by the Administrator on 6/29/23 at 8:00AM titled Oxygen Administration which noted the Purpose: .is to provide guideline for safe oxygen administration . On Page 2 under Steps in the Procedure, . #8 .adjust .the proper flow of oxygen is being administered .

Based on observation, interview, and record review, the facility failed to ensure resident food preferences were communicated to reflect preferences and dislikes for 1 (Resident #21) of 11 (Residents # 1, 15, 17, 19, 21, 33, 34, 40, 46, 49, and 259) sampled residents who were able to voice food preferences per list provided by the Registered Nurse (RN) Consultant on 06/29/23 at 09:03 AM. The findings are: 1. Resident #21 admitted on [DATE] with diagnoses of age-related osteoporosis, abnormal weight loss, and iron deficiency anemia. a. On 06/25/23 at 11:40 AM, Resident #21 stated she does not like scrambled eggs and was served them every morning. The Surveyor asked if she requested eggs in another form from staff. Resident #21 stated, I asked them for fried or boiled eggs, and they said they don't do that. Only scrambled. Resident #21 family, who was visiting, stated she had informed a nurse that her mother did not like scrambled eggs, and asked if they would they provide another form, so she would eat since she is picky. b. Physician's order for Resident #21 dated 06/19/23 noted an order for a Very High Calorie supplement three times a day. c. Review of the electronic weight summary for Resident #21 noted on 05/18/2023, the resident weighed 120.8 pounds and on 06/15/2023, the resident weighed 108.4 pounds which was a -10.26 % (percent) loss. 2. On 06/25/23 the Surveyor asked Certified Nursing Assistant (CNA) #1 what the process was if a resident or family informed staff they did not want a food item served any longer. She stated, We are supposed to tell the charge nurse or the kitchen so they can make the change. 3. On 06/27/23 at 07:47 AM, observed Resident #21 tray card during breakfast meal service which failed to have any preferences or dislikes noted. 4. On 6/27/23 at 08:12 AM, observed Resident #21 sitting in the dining room. All the food on her breakfast plate, except the scrambled eggs were eaten. 5. On 6/27/23 at 08:21 AM, the Surveyor asked Resident #21 what eggs were served this morning. Resident #21 stated, Scrambled. The nurse told me she couldn't get me other eggs. I really want boiled eggs. I was hungry so I ate all the other food. At least I get these chocolate shakes. 6. On 06/27/23 at 12:04 PM, the Surveyor asked the Dietary Manager (DM) the process for determining residents' food preferences. The DM stated, If it's a change I'm told and, I can correct it within a few hours. I meet with new residents within 24 hours. The Consultant stated, I believe our policy says he has 3 days. The DM stated, I am unsure the process of how the staff are supposed to tell [me]. I don't know if it's a set way. The Surveyor asked the DM if a resident has been at the facility for two months and voiced a dislike for a food to CNAs, should it already be documented on the resident's tray card. The DM stated, Yes, if I have been told, I would have changed it already. 7. On 06/27/23 at 03:52 PM, the Surveyor asked CNA #2 what the process was if a resident or family informed staff they did not want a food item served to them any longer. CNA #2 stated, I respect their choice and inform the nurse for the hall so she can notify the kitchen staff, so it is not put on their tray. 8. On 06/28/23 at 12:45 PM, the Surveyor asked the Director of Nursing (DON) the process for a CNA or nurse, who was informed by a resident, family member, or representative that a resident did not wish for an item to be served to the resident. The DON stated, We should get with the Dietician or Dietary staff. The CNAs should tell the nurse. The nurse should be filling out a dietary slip. The preference should be put on a slip immediately. 9. The facility policy titled Resident Food Preferences provided by the Administrator on 6/29/23 at 08:05 AM documented .3. The Food Service Supervisor will document the resident's food and eating preferences in the care plan .8. If the resident refuses or is unhappy with their diet, the staff will create a care plan that the resident is satisfied with .

Based on record review, and interview, the facility failed to ensure proper infection prevention and control practices to prevent the development and transmission of Covid-19 and other communicable diseases and infections were implemented by not quarantining newly admitted residents in separate rooms for 2 (Residents #4 and #5) of 3 (Residents #3, #4 and #5) sampled residents admitted from community/hospital within the last 14 days, had an unknown COVID-19 status upon admission and were unvaccinated. This failed practice resulted in Immediate Jeopardy which caused or was likely to cause serious harm or death to 2 (Residents #4 and #5) sampled residents who were in the same room and Resident #4 testing positive for COVID 19 after admission. The IJ was removed when the facility moved Resident #4 to a private room on June 16, 2021 prior to the survey, but current failed practices still remained. The Administrator was informed of the Immediate Jeopardy removed on 6/17/2021 at 3:00 p.m. The findings are: 1. Resident #4 was admitted to the facility, Resident room [ROOM NUMBER]-A, from an acute-care medical facility on 6/7/21 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . At the time of admission to the facility, the resident's COVID-19 status was unknown, and the resident had not been vaccinated with the COVID-19 vaccine. a. The June 2021 Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Order Date: 06/07/2021 . b. Resident #4's Electronic Medical Record documented refusal of COVID-19 vaccine 1st dose on 06/07/2021. 2. Resident #5 was admitted to the facility, Resident room [ROOM NUMBER]-B, from an acute-care medical facility on 6/9/21 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . At the time of admission to the facility, the resident's COVID-19 status was unknown, and the resident had not been vaccinated with the COVID-19 vaccine. a. The June 2021 Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Order Date: 06/09/2021 . b. As of 6/18/21 Resident #4's Electronic Medical Record documented the date of COVID vaccine TBD [to be determined]. 3. The Daily Census dated 6/9/2021 documented the facility had 52 in-house residents, which was 74.3% of total occupancy. 4. On 6/17/2021 at 12:30 P.M., the Assistant Director of Nursing (ADON) and the facility's Infection Preventionist was asked, What is the facility's policy regarding admitting residents from the hospital with unknown COVID-19 status? She stated, We follow the guidelines that says we can put like residents in the same room. She was asked, The facility's policy is to place 2 newly admitted and unvaccinated residents in the same room? She stated, I will check to make sure but those 2 residents [Resident #4 and Resident #5] have the same status. She was asked, What status would that be? She stated, Unknown status and since they were both unknown, then they are the same and can be in the same room. She was asked, How many days were [Resident #4 and Resident #5] in the same room? She stated, From June 9th until June 16th [2021]. She was asked, Why was [Resident #5] moved out of room [ROOM NUMBER] that was shared with [Resident #4]? She stated, She tested positive for COVID. She was asked, When was the positive reported to you? She stated, The lab reported it to us on June 16, and that is why we moved her. 5. On 6/17/21 at 1:05 P.M., the ADON was asked, On 6/9/21, when Resident #5 was admitted and placed in the same room with Resident #4, would there have been any reason that the 2 residents could not have had separate rooms? She stated, Long-term residents don't want to move and some of the short-term residents were told that they could have a private room. She was asked, On 6/9/21, was the facility's census at 100% of occupancy? She stated, No, our census has been running around 49-55. 6. On 6/17/21 at 2:30 P.M., the Administrator was asked, If a resident is admitted to the facility with unknown COVID status, what is the facility's policy regarding where they are placed and with whom they are placed? She stated, If they come in with unknown status, they are placed in a room by themselves. She was asked, But in this case, that did not happen? She stated, What do you mean in this case? She was advised, I mean [R Resident #4 and R Resident #5] were placed in a room together. She stated, Oh, well if they have the same status then they can go in a room together. She was asked, Is that the facility's policy? She stated, Let me go ask the Consultant. 7. A Coronavirus Disease (COVID-19) - Identification and Management of Ill Residents policy and procedure provided by the Administrator on 6/17/2021 at 1:30 P.M., documented, .Resident Placement and Cohorting . 2. Residents with suspected COVID-19 are placed in a private room . Procedures for Accepting Admissions from Hospitals . 1. The decision to admit new residents to the facility is based on the ability to provide care and to keep current residents safe. Factors that are considered when presented with a potential hospital admission include physical space to provide appropriate distancing, staffing levels, and availability of personal protective equipment. 4. For any resident admitted from the hospital with unknown status: a. Place in a single room or observation area; . d. Place on contact and droplet precautions . until testing for COVID-19 is complete and results are known . 8. An Isolation - Categories of Transmission-Based Precautions policy and procedure provided by the Administrator on 6/17/2021 at 1:30 P.M. documented, . Contact Precautions: 1. Contact Precautions may be implemented for residents Known or suspected to be infected with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident-care items in the resident's environment. 3. The individual on contact precautions will be placed in a private room if possible. Droplet Precautions: 1. Droplet precautions may be implemented for an individual documented or suspected to be infected with microorganisms transmitted by droplets . 2. Residents on droplet precautions will be placed in a private room if possible. 9. The Centers for Disease Control's (CDC) toolkit Create a Plan for Managing New Admissions and Readmissions; New Admission and Residents who Leave the Facility documented, . In general, all other new admission and readmissions should be placed in a 14-day quarantine, even if they have a negative test upon admission . Residents in quarantine should be placed in a single-person room. 10. The Arkansas Department of Health's Revised Visitation, Screening, and Staffing Guidance for Long-term Care Facilities, dated December 23, 2020, documented, . General Quarantine and Isolation Guidance for Staff and Residents . Residents should be quarantined utilizing transmission-based precautions for 10 days following a known or potential COVID-19 exposure, including on admission .

A. Complaint # (AR 539) was substantiated (all or in part) in these findings. Based on observation, record review, and interview, the facility failed to ensure the transport van's wheelchair restraints were securely and properly applied which resulted in a resident tipping over backward and hitting her head, and failed to ensure an additional resident who witnessed the incident was interviewed in an effort to identify causative factors to facilitate the ability to develop interventions to prevent recurrence for 1 (Resident #1) of 2 (Residents #1 and 2) case mix residents who were transported via the facility van. This failed practice resulted in Immediate Jeopardy, which caused or could have caused serious harm, injury or death to Resident #1, who sustained a head injury after her wheelchair tipped over backwards during a van transport, and had the potential to cause more than minimal harm to 12 residents who were transported in the facility van from 10/12/16 through 10/27/16, as documented on a list provided by the Administrator via fax on 10/31/16. The Administrator was informed of the Immediate Jeopardy condition on 10/27/16 at 1:00 p.m. The findings are: 1. The Q-Straint Wheelchair Passenger Safety Solutions User Instructions, provided by the Administrator on 10/26/16 at 2:30 p.m., documented, .A. SECURE WHEELCHAIR - 1. Place wheelchair facing forward in securement area; apply wheel locks or turn power off. 2. Attach tie-downs into floor anchorages and ensure they are locked in. 3. Attach the four tie-down hooks to solid frame members or weldments, near seat level. Ensure tie-downs are fixed at approximately 45 degrees, and are within angles shown in figure 2. Do not attach hooks to wheels, plastic, or removable parts of wheelchair. 4. Ensure all tie-downs are locked and properly tensioned. If necessary, rock wheelchair back and forth or manually tension retractor knobs (if present) to take up additional webbing slack . 2. Attach Shoulder Belt - Extend shoulder belt over passenger's shoulder and across upper torso and fasten pin connector onto lap belt. 3.Ensure belts are adjusted as firmly as possible, but consistent with user comfort. Warning . Lap and shoulder belt should not be held away from passenger's body by wheelchair components or parts such as the wheelchair's wheels, armrests, panels or frame . 2. Resident #1 had [DIAGNOSES REDACTED]. The Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/21/16 documented the resident scored 12 (7-12 indicates moderately impaired) on the Brief Interview for Mental Status (BIMS), required extensive assistance of 2 staff for bed mobility and transfers, was not steady and only able to stabilize with staff assistance for moving from seated to standing position and surface-to-surface transfers, had functional limitation in range of motion on one side of upper and lower extremities and used a walker and wheelchair for mobility. a. The Care Plan dated as revised 9/27/16 documented, .Focus She requires limited to extensive assistance with ADLs (activities of daily living) putting her at risk for decline and fluctuation. She has a dx (diagnosis) of ESRD with dialysis, anxiety, depression and HTN (hypertension) along with recent fx (fracture) which may affect ability to complete ADLs as well. Date Initiated: 9/15/16 . Revision on: 9/27/16 . b. The facility's appointment book for transporting residents via the facility van documented the resident had an appointment at a local physician's office for a follow-up visit on 10/12/16 at 10:30 a.m. c. The Facility Investigation Report for Resident Abuse, Neglect, Misappropriation of Property, and Exploitation of Residents in Long term Care Facilities, Division of Medical Services (DMS) form 762 documented, Date and Time of Incident: 10/12/16 Time: 9:30 a.m . Complete Description of Incident . On 10/12/16 at approximately 9:30 a.m., the Administrator (name) was notified by (Director of Nursing (DON)) of an incident during the transport of (Resident #1). Van had come to a full stop while at a red light. Upon proceeding through green light, (Resident #1's) chair (wheelchair) fell backwards with (Resident #1). Transport Aide (Certified Nursing Assistant (CNA) #1) immediately pulled over, called 911 for assistance, had contacted (DON). (Resident #1) was immediately comforted to prevent mental anguish while waiting for assistance. Facility LPNs (Licensed Practical Nurse #1 and Assistant Director of Nursing (ADON)) arrived to scene to assess resident. (Resident #1) transported via ambulance to local hospital for additional assessment. d. An emergency room physician note dated 10/12/16 at 10:17 a.m. documented, PT (patient) bib (brought in by) (emergency medical service ambulance) for head injury after fall. PT was in wheelchair in nursing home van, van shook and PT went backwards in wheelchair hitting head. Pt denies LOC (loss of conciseness). Denies pain at this time. States she's on 'whatever blood thinner they use in dialysis.' Pt does dialysis TU (Tuesday) TH (Thursday) SAT (Saturday). Hematoma and tenderness with palpation noted on left temporal and occipital region. PT states tailbone pain from previous FX . Chief Complaint - Fall and Head Injury . Assessment/Plan . Left posterolateral hematoma on her scalp . patient . having back pain at the moment, given Tramadol to take home for pain. Cold compress was suggested for further healing of scalp hematoma . e. On 10/26/16 at 1:30 p.m., CNA # 1 was asked to provide details of the incident that occurred on 10/12/16. He stated, She has dialysis on Tuesday, Thursday and Saturday at (name of dialysis center) on (street). When I loaded her up, all the straps were tightened down tightly, they were secure, I jiggled her wheelchair to ensure they were secure. I got to the red light at the (gas station) and had to stop. Everything was fine. When I took off, I heard a loud pop, then heard her and wheelchair fall backwards as I looked in the rearview mirror. I immediately pulled over and my mind kicked in to firefighter mode. I opened the door and assessed her. She was talking to me and joking. I called the facility and was instructed to call 911. She had a small laceration to the top of her head at the crown approximately 1 to 1 1/2 inches, it was very small. My number shows up as Emergency Personal - I am a firefighter - and the fire truck then the ambulance was here within 2 to 3 minutes. Before they got here, 2 nurses from the facility arrived and had taken the resident's vital signs and assessed her. The (county law enforcement) department showed up also. The EMTs (Emergency Medical Technicians) loaded her in the ambulance and took her to the ER (emergency room ). I drove the van back to the facility and parked it. The Maintenance man inspected the van. I was called to the Administrator's office, then myself, (maintenance man) and the Administrator did a return demonstration on securing the wheelchair. She tried to turn the wheelchair over and couldn't. They suspended me that day. The facility took the van to (adaptive equipment specialist company). CNA #1 was asked, How are the wheelchairs to be secured in the van? He stated, There are 4 straps, 2 on the front wheels and same on the back. You put those on the actual frame of the wheelchair and tighten them down, then you take the seat belt through the arms of the wheelchair. I use 2 fingers to adjust the tightness, then the shoulder brace strap goes across the chest. He was asked if the resident was in the wheelchair when it turned over and he stated, She was out of the wheelchair. The wheelchair was still strapped but the belt on the front left was loose. The CNA was asked, When did you come back to work? He stated, The next day. The CNA was asked, Did you receive any training? He stated, They inserviced me and the other driver again and we watched a video. They also inserviced other CNAs, in case they had to transport. The CNA was asked, Did they do anything with the van? He stated it was taken to a local van company on 10/13/16 and They upgraded it with a fire extinguisher and the lift was upgraded. It was all new inside. On 10/27/16 at 1:31 p.m., CNA #1 was asked, Did you set the wheelchair up? He stated, When she was on the ground I had to. He was asked, Was the resident out of the wheelchair when you went to the back of the van to assess her? He stated, Yes, I had to undo it to get her free from the wheelchair. f. On 10/26/16 at 1:58 p.m., the Maintenance staff was asked to explain in detail what he did when the van returned to the facility. He stated, I assessed the buckles, pulled on them to check to see if they were locking correctly. We had (CNA #1) do a return demonstration on how the wheelchair was secured with the Administrator in the chair. I went over with (CNA #1) a check-off to ensure he was doing it correctly and it was okay. We took the van to (adaptive equipment specialist company) on 10/13/16 and told them what had happened. They inspected the van. The Maintenance staff was asked, How often do you do a maintenance check on the van? He stated, I check the straps quarterly. The driver is to check the van every morning to make sure everything is okay before they leave. We take the van to (adaptive equipment specialist company) every 6 months and have them look at everything. On 10/27/16 at 12:57 p.m., the maintenance staff was asked, Have you done any monitoring of (CNA #1) securing the residents prior to transport? He stated, I wouldn't know what day, if I did, but I don't remember doing any though. g. On 10/26/17 at 3:50 p.m., Resident #2, who scored 15 (13-15 indicates cognitively intact) on a BIMS per the MDS dated [DATE], was asked, Have you ever had an issue with the facility not securing your wheelchair or with a wheelchair turning over during a transport? She stated, No, but another resident did, (Resident #1). I was in the van with her the day she turned over. Resident #2 was asked, Was the resident's wheelchair secured? She stated, I don't know. (CNA #1) put her in first, so I can't say. 1.) On 10/27/16 at 8:21 a.m., Resident #2 was asked, When (Resident #1's) wheelchair flipped over, did you see any straps attached to the wheelchair at the front? She stated, No, there were no straps on the front of the wheelchair. 2.) On 10/27/16 at 10:30 a.m., Resident #2 was asked, Where were you sitting in the van, and where was (Resident #1)? She stated, (Resident #1) was in front. I was slightly behind her on the opposite side. I was secured in. She was on the left side at the front, and I was on the right side slightly behind her. She was asked, Did you hear a loud pop? She stated, I did not hear a loud pop, and I did not see any straps on the front of the wheelchair when it flipped over. She was still strapped in the wheelchair and (CNA #1) released her from the wheelchair because she was complaining of being uncomfortable, and he sat the wheelchair up. The back straps were still in place. Then (CNA #1) took me out of the van. h. On 10/27/16 at 8:35 a.m., the adaptive equipment specialist company representative was asked, Did you do the inspection on the van on 10/13/16? He stated, Yes. He was asked, Were all straps in good repair and working order? He stated, There were no discrepancies in any of the straps. He was asked, If a wheelchair is properly secured per instructions is there anyway a wheelchair could flip backwards? He stated, Without seeing what actually happened, I can't say (what caused) this instance, but if it is secured per the instructions, there is no way a wheelchair could flip backwards or frontwards. i. On 10/27/16 at 8:45 a.m., CNA #1 was loading Resident #1 onto the transport van with the surveyor observing the procedure. CNA #1 pulled the shoulder harness under the right side armrest of the resident's wheelchair, then pulled it through the left side, under the armrest, but had secured the strap over the top and around the wheelchair wheel on the left side, then secured the end of the belt/buckle to a floor anchor. As the CNA was exiting the van through the right side door, the surveyor stopped the CNA and asked if the seat belt was secured correctly around the resident and the wheelchair. The CNA returned to the van and stated, No, that is not supposed to be over the wheel . I didn't notice that. The CNA unbuckled the strap and properly positioned it between the wheelchair frame and the inside of the left wheel. j. On 10/27/16 at 9:05 a.m., the ADON was asked, Was the wheelchair still turned over when you arrived at the scene (on 10/12/16)? She stated, No, it was sitting up and the back straps were still secured. I didn't look at the front straps. She was asked, Where was (Resident #2)? She stated, She was still in her wheelchair. She was asked, Where was (Resident #1)? She stated, She was still on the van floor but her wheelchair was sitting up. (Emergency service personnel) physically moved her to the stretcher and transported her to the hospital. The ADON was asked, Where was the other nurse that came with you? She stated, She was supporting (Resident #1's) back while I was getting the vital signs. The ADON was asked, What did (CNA #1) tell you about the incident? She stated, He said, 'I don't know what happened. I put the straps on there'. k. On 10/27/16 at 10:00 a.m., the Administrator was asked, Did you obtain a witness statement from (Resident #2)? She stated, No ma'am. She was asked, Why didn't you interview or speak with her about the incident? She stated, I didn't, not intentionally. The Administrator was asked, What was the facility's policy for transportation of residents? Does only the driver go on transports, or is there another staff member riding along? She stated, There was no policy until after this incident, and then we implemented where a CNA goes on the transport (in addition to the driver). The Administrator was asked, Did anyone ever go along on a transport? She stated, On occasion, someone might have. It was based on a resident's needs that we sent someone else. On 10/27/16 at 12:55 p.m., the Administrator was asked, Since the last inservice on 10/12/16, have you monitored (CNA #1) on securing residents prior to transport? She stated, Not as far as me going out there and watching, no. I can check with maintenance and see if he has. l. On 10/27/16 at 1:24 p.m., LPN #1 was asked, When you arrived, where was (Resident #1)? She stated, She was lying in the back of the van with her head facing the back of the van and the wheelchair was in front of her, upright. She was asked, Were the straps attached? She stated, I did not pay any attention to the straps. (Resident #1) was upset, and I was trying to calm her down. LPN #1 was asked, When you say upset, what was she doing? She stated, She was crying and complaining of her head and back hurting. The LPN was asked, What did the resident tell you about the incident? She stated, She said, 'we were at the light' and she remembered flipping backwards. 3. On 10/27/16 at 2:10 p.m., the Immediate Jeopardy was removed and the scope and severity was reduced to G, when the facility implemented the following Plan of Removal a. All van transports were suspended until retraining of facility van drivers could be completed. 1) Maintenance manager retrained a different van driver with return demonstration 2) Van driver was accompanied by the maintenance manager for the rest of the day to ensure all residents were secured in the van restraining system correctly. 3) The van driver failing to properly secure resident in the van while being observed was removed from driving the van on 10/27/16 at 1:23 p.m. b. All staff members who will be driving the facility van will have a valid drivers license and approved driving record. 1) Human Resources will obtain a copy of staff members drivers license. 2) A check of the employees driving record will be logged by human resources. c. All staff members who will be driving the facility van or assisting during transport will be trained per manufacturers guidelines, operator training video, and facility checklist. 1) Maintenance/Designee will ensure that all staff members who will be transporting or assisting with transports are trained. Staff member will demonstrate competency of education. This will be completed initially, then 3 times weekly for four weeks, 1 time weekly for four weeks and monthly for 3 months and then bi-annually and PRN (as needed) for continued demonstration of competence. 2) All staff members who will participate in transportation will watch the training video initially and then bi-annually for continuing education. 3) Training will focus on addressing direction of resident (outward facing) when loading and unloading in order to provide visual confirmation that lift is in place. d. The facility will maintain employee competency check offs for van drivers and assistants. Facility will maintain all check offs and training that has been completed. e. The facility will maintain a current list of employees who have been trained to drive the facility van and to assist with transportations. 1) The maintenance/designee will give all competency check offs and employee training to human resources as proof of training and competence. 2) Human resources will keep a current list of all trained transport aides and assistants. 3) Human resources will provide the Director of Nursing and Assistant Director of Nursing with a current list of trained staff members 4) The Director of Nursing and/or Assistant Director of Nursing will only assign those staff members who have been trained and demonstrated competency per the facility process. f. Pre-transport inspection 1) The transportation aide will perform a Pre-transport documented inspection daily, per facility checklist, prior to first transport x (times) 14 days 2) After 14 days daily check off transport aide will perform a pre transport visual inspection daily. 3) The inspection check list will be signed after completions of inspection daily and given to the administrator to maintain for record of inspection x 14 days. g. Maintenance Inspection of facility van 1) Maintenance will perform a quarterly inspection of the facility van for safety and proper functioning of all equipment and PRN. 2) Maintenance will keep record of the inspections and any negative findings will be reported to the administrator and addressed before van is placed back in use. h. Incidents/Accidents 1) All incidents/accidents will immediately be reported to the Administrator and Director of Nursing. 2) Incidents/Accidents will be investigated and a incident report completed and a red Alert will be sent to the risk management team. i. All staff members who will be participating in transports will be trained per manufacturer's guidelines on safety restraint system. Staff members will be checked off and provide a return demonstration on securing and unsecuring a resident. B. Based on observation, record review and interview, the facility failed to ensure new interventions were developed and implemented to prevent further potential falls or injuries for 1 (Resident #5) and failed to ensure planned fall prevention interventions were promptly and/or consistently implemented for 2 (Residents #4 and #5) of 4 (Resident #1, 3-5) case mix residents who were at risk for falls. The facility also failed to ensure the correct size mechanical lift sling was utilized during transfers to prevent potential accidents for 1 (Resident #5) of 2 (Residents #2 and #5) case mix residents who required the use of a Hoyer lift for transfer. The failed practices had the potential to affect 46 residents who were at risk for falls, and 9 residents who required the use of a Hoyer Lift for transfers, as documented on the lists provided by the Administrator on 10/31/16. The findings are: 1. Resident #5 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set with an assessment reference date of 8/19/16 documented the resident was severely impaired in cognitive skills per a Staff Assessment for Mental Status, required extensive assistance of 2-plus staff for bed mobility, transfers, and dressing; was not steady, only able to stabilize with staff assistance for moving from seated to standing position and surface-to-surface transfers; had no functional limitations in range of motion to the upper or lower extremities; used a wheelchair for mobility; and had 1 fall with no injury and 2 or more falls with minor injuries. a. A facility Progress Note dated 7/9/16 at 1:24 p.m. documented, Type: Nsg (nursing) - I&A (Incident and Accident) Note Text: .CNA (Certified Nursing Assistant) brought resident to the Nurse d/t (due to) skin tear received during transfer from bed to wheelchair. Resident was being assisted during transfer and bumped right top side hand against w/c (wheelchair) armrest causing small tear measuring 4.0 x (by) 1.0 x .01 cm (centimeter) with minimal amount of bleeding present. Immediate Intervention: cleaned with wound cleanser, applied mepore. Re-educated staff on being aware of the placement of all resident's extremities during transfers. 1.) Nurses Notes on 7/10/16 at 4:54 p.m. documented, .Long Term Intervention - In Service staff on proper transfers . 2.) On 10/27/16 at 4:00 p.m., the DON was asked to provide documentation regarding staff being re-educated / in-serviced on transfers after the above incident. On 10/28/16 at 8:30 a.m., the DON provided in-service documentation on proper transfers, that was dated 7/25/16, 15 days after the transfer incident. b. An I&A dated 7/12/16 at 7:05 p.m. documented, .Incident Description Nursing Description: Resident was found in floor by bed. He had tried to get out of bed without assistance . 1.) A facility Progress Note dated 7/12/16 at 7:08 p.m. documented, Type: Nsg (nursing) - I&A Note Text: . Incident Description: Resident found in floor by bed. Bruising noted to right elbow. Neuro checks started. No other apparent injures noted. Will continue to monitor . 2.) A facility Progress Note dated 7/12/16 at 7:16 p.m. documented, Type: Nsg (nursing) - I&A Follow-up Notes Text: Date and I&A Description: 7/12/15 1908 (7:08 p.m.) Skin tear noted after transfer. Long Term Intervention: Inservice staff with return demonstration on proper transfer techniques. Added to the Care plan: 7/12/16. 3.) On 10/27/16 at 4:08 p.m., the DON was asked if the skin tear had been the result of a fall by the resident or from an improper transfer and stated, I don't know, I was not here then. The DON was asked what new intervention had been put in place by the facility following this incident and she stated, No intervention was put into place. 4) As of 10/28/16 at 8:30 a.m., there was no documentation provided by the facility that staff were in-serviced or re-educated regarding proper transfers following the 7/12/16 skin tear from a fall or improper transfer. c. An I&A dated 7/25/16 at 6:35 a.m. documented, This nurse was called to nurses station via CNA. When this nurse came to nurses station resident was noted to be on the floor, laying on back with legs/arms straight out in front of him. Resident's wheelchair was tipped over and laying on its side. Resident is without s/s (signs/symptoms) or c/o (complaint of) pain nor discomfort . Description: Resident was assessed for injury. Resident is noted to have a skin tear 1 x 0.5 to right lower side of forearm. Resident also noted to have skin tear to lower right leg along with a scratch to right knee cap. Resident has full passive ROM (range of motion) to BLE (bilateral lower extremity) and BUE (bilateral upper extremity) without s/s of discomfort/pain noted. Resident then was assisted back into wheelchair via 2 person assist with gait belt. Skin tears cleaned with wound cleaner and Mepilex applied. 1) A facility Progress Note dated 7/26/16 at 6:51 p.m. documented, Type: Nsg (nursing)-I&A Follow-up Date and I&A Description: Unwitnessed fall without injury noted. Resident unable to recall event. Long Term Intervention: Hourly rounding X 3 days by Nursing. 2) On 10/17/16 at 4:08 p.m., the DON was asked where the 1 hour monitoring checks for 3 days would be documented. She stated the 3 days of monitoring by nurses should have been documented on the Medication Administration Record (MAR). She pulled up the July 2016 MAR for Resident #5 on the computer and stated it had not been documented on the MAR. She then stated it may have been documented on the Treatment Administration Record (TAR). She looked at the July 2016 TAR and stated nursing had no documentation of monitoring the resident on the TAR either. She called Treatment Nurse #1 into her office and asked her where the CNAs/Nurses would have documented the hourly checks. Treatment Nurse #1 stated they were done on paper, were kept at the nurses' station and when completed, would have been picked up by herself and she would have slid them under the DON's door. As of 10/28/16 at 8:30 a.m., the facility had no documentation the 1 hour checks over a 3 day time frame were completed. d. The care plan, printed on 10/26/16, documented, The resident is at risk for falls r/t (related to) poor balance . Interventions/Tasks . 8/4/16 Fall, minor injury, changed pad on w/c alarm . 1.) The resident's closet care plan, printed 10/14/16, documented, Accidents-Fall Risk . Assistive Devices . Chair alarm . 2.) On 12/2716 at 12:50 p.m., the resident was seated in the Assist Dining Room in a high back wheelchair and there was no chair alarm in place. CNA #1 was asked if Resident #5 had a chair alarm in place and stated, Not on his chair, but has one on his bed. CNA #2 stated, He doesn't have one on the chair, but has one on his bed. 3.) On 12/27/16 at 12:55 p.m., the ADON was asked to look under the covers on Resident #5's bed to see if there was a bed alarm on the resident's bed. She stated, There is not one on. The ADON was asked to look at the resident's wheelchair for a chair alarm. The ADON accompanied this Surveyor to the Assist Dining Room where the resident was sitting in a wheelchair. She stated there was no alarm in the resident's wheelchair. The ADON went back into the resident's room and looked in the drawer on the bedside table, looked under the bed, beside the bed and stated, There is no alarm here. (Resident #5) doesn't get out of bed anymore, so now we have the alarm in his chair. They transfer it back and forth from bed to chair. Let me go find another alarm and get it on his chair. e. On 10/27/16 at 12:00 p.m., the closet care plan, with a printed date of 10/14/16, documented, .Mechanical lift with 2 person assist transfer - Red Lift Pad. 1.) On 10/27/16 at 12:50 a.m., the resident was in the Assist Dining Room sitting in a highback wheelchair and was being assisted with eating by Certified Nursing Assistant (CNA) #1. There was a blue lift sling with white/blue tabs positioned underneath the resident. 2.) On 10/27/16 at 1:16 p.m., the resident was in his wheelchair by the nurses station and there was a blue mesh lift bad with white/blue tabs positioned underneath him. 3.) On 10/27/16 at 1:20 p.m., CNA #2 took the resident to his room to be transferred to the bed. CNA #2 was asked what colors of lift pad the facility used and she stated, Red, blue, brown - the whole list pad is blue, but the straps you pull the residents back with are colored, red, blue, brown. At 1:30 p.m., CNA #3 and CNA #4 used the Hoyer lift and transferred the resident from the wheelchair to the bed using a blue-tabbed lift pad. The CNAs were asked how they knew what size sling they were using. CNA #1, who was the training CNA and present in the room, stated, I believe it is large, or maybe medium. CNA #3 and 4 were asked how they knew which lift pad was to be used on the resident and they both stated the closet care plan identified the color of the sling pad. The Closet Care Plan, printed on 10/27/16 documented, Mechanical lift with 2-person assist, but did not document the color of sling size to use. 2. Resident #4 had [DIAGNOSES REDACTED]. The MDS dated [DATE] documented the resident scored 6 (0-7 indicates severely impaired) on the BIMS; required extensive staff assistance of 1-2 staff for bed mobility, transfers, and toileting,; not steady and only able to stabilize with staff assistance when moving from seated to standing position, walking, turning around, moving on and off toilet, and surface-to-surface transfers; had no functional limitations in range of motion of upper or lower extremities; used walker and wheelchair as mobility devices; and has had no falls. a. An I&A dated 10/5/16 at 11:15 p.m. documented, .Nursing Description: Writer was called into patient room at 23:15 (11:15 p.m.). Upon arrival into patient room, resident observed in a sitting position on the floor by her bed side towards the foot of her bed leaning against her W/C. Arm and legs stretched out. Resident stated, 'I fell out of bed.' Immediate Action Taken Description: Head to toe assessment. Denies pain at this time. No injury observed during assessment. No swelling/hematoma noted to head/scalp . Assisted back to w/c and brought to Nurses station and neurochecks initiated. b. A facility Progress Note dated 10/6/16 at 7:51 a.m. documented, Type: Nsg (nursing)-I&A Note Note Text: . Immediate Intervention: . Family notified as well. According to resident's daughter resident was probably trying to go to the bathroom. Will in-service staff to take resident to bathroom every 2 hours. DON notified and said she will follow-up with that intervention. c. A facility Progress Note dated 10/6/16 at 3:46 p.m. documented, Type: Nsg (nursing)-I&A Follow-up Note text: Date and I&A Description: 10/5/16 2315 (11:15 p.m.) Resident found floor . Resident states she was attempting to get OOB (out of bed) d/t brief wet and attempted to toilet self. Long Term Intervention: every 2 hour monitoring by nursing staff for toileting and ambulation . d. On 10/27/16 at 4:08 p.m., the DON was asked to provide the facility in-servicing report regarding the intervention for the fall on 10/5/16 and documentation of staff offering to take resident to bathroom for toileting. e. On 10/28/16 at 8:30 p.m., she stated she could not find any of this information.

Based on record review and interview, the facility failed to ensure the physician was promptly consulted regarding an elevated temperature for 1 (Resident #1) of 2 (Residents #1 and #3) case mix residents who had elevated temperatures and had physician orders [REDACTED].#1, who was hospitalized for [REDACTED]. The findings are: 1. Resident #1 had a [DIAGNOSES REDACTED]. The significant change Minimum Data Set with an assessment reference date of 12/13/10 documented a Brief Interview for Mental Status score of 0 (0 - 7 indicates severely impaired). a. The December 2010 Physician order [REDACTED]." b. The Nurse's Notes dated 12/1/10 at 10:25 p.m. and written by Licensed Practical Nurse (LPN) #1 documented, "Notified by CNA (Certified Nursing Assistant) that (resident's) temp (temperature) was 102(degrees Fahrenheit). (Administered) Tylenol 500 mg (milligrams) 1 PO (by mouth) at 10:30 p.m. Will continue to monitor..." There was no documentation the physician was consulted regarding the elevated temperature and no documentation of a physician order [REDACTED]. On 12/28/10 at 4:30 p.m. LPN #1 was asked, "Do you notify the physician for the temperatures of 102?" LPN #1 stated, "I guess I didn't that night". LPN #1 was asked, "Was there any reason why you didn't notify the physician?" LPN #1 stated, "Not that I can think of." c. The Nurse's Notes dated 12/2/10 at 2:20 p.m. and written by LPN #2 documented, "...(Resident) temp today was 102.1. Tylenol 500 mg given PO at 2:25 p.m. due to (increase) in temp. Will continue to monitor..." There was no documentation the physician was consulted. On 12/28/10 at 2:25 p.m., LPN #2 was asked, "Do you notify the physician for a temperature of 102.1?" LPN # 2 stated, "Normally I don't if there's a prn order." LPN #2 was asked, "How long do you wait before you notify the physician of an increased temperature of 102 that is more than a one-time elevation?" LPN #2 stated, "At the end of 2 days or maybe 1 day. If a resident had a temp and didn't have an order for [REDACTED].#2 was asked "Did you think about calling the physician for the temperature elevation of 102.1?" LPN #2 stated, "No, it went down from the night before". d. The Nurse's Notes dated 12/2/10 on the 3:00 p.m. to 11:00 p.m. shift and written by LPN #1 documented, "...VS (Vital Signs)... 101.7 (temperature)... Tylenol (administered) as ordered. Will continue to monitor." There was no documentation the physician was consulted. On 12/28/10 at 4:30 p.m. LPN #1 was asked, "On 12/2/10, when was the resident's temperature taken?" LPN #1 stated "Later in the shift". LPN #1 was asked, "Why didn't you notify the physician?" LPN #1 stated, "There was no reason why I didn't". LPN #1 was asked if the facility had a policy and procedure regarding physician notification for elevated temperatures. LPN #1 stated, "If we do, I'm not aware of it." e. The Nurse's Notes dated 12/3/10 on the 11:00 p.m. to 7:00 a.m. shift documented, "(Resident) (continues) to have (elevated) temp of 101.5 (at) 2:00 a.m... on call (physician) notified. New orders to transfer (resident) to (hospital) (emergency room )..." This was a period of approximately 28 hours after the elevated temperature was first identified. f. The hospital emergency room History and Physical dated 12/3/10 documented, "Chief Complaint... fever... [DIAGNOSES REDACTED]." g. The hospital Progress Record dated 12/8/10 documented, "1) UTI 2) Bacteremia (E-Coli) (Escherichia coli) 3) Fever/(elevated) WBC (white blood cells)... Continue [MEDICATION NAME] 12/10/10 transfer to NH (Nursing Home) tomorrow..." The resident was hospitalized for [REDACTED]. h. On 12/28/10 at 4:25 p.m., the DON was asked for a policy on physician notification. The DON stated, "We don't have a policy on physician notification". i. On 12/28/10 at 4:45 p.m., the DON was asked to review the Nurse's Notes for Resident #1 from 12/1/10 through 12/3/10. The DON was asked, "On 12/1/10 at 10:25 p.m., should the LPN have notified the physician?" The DON stated, "If Tylenol was already ordered, I'd give it and watch the temp." The DON was asked, "On 12/2/10 at 2:25 p.m. when the resident's temperature was 102.1, should the LPN have notified the physician?" The DON stated, "Yes, it should have been addressed then." The DON was asked, "On 12/2/10 on the 3 to 11 shift when the resident's temperature was 101.7, should the LPN have notified the physician?" The DON stated, "Yes".