Every finding on record at The Springs Jonesboro

Based on record review, interview, and facility policy review, it was determined that the facility failed to ensure alleged or suspected sexual abuse was reported to the State Agency within two hours for one (Resident #1) of one resident reviewed. The findings include: Resident #1 A review of Resident #1's admission Record indicated the facility re-admitted the resident on 05/26/2021, with diagnoses which included Parkinson's disease with dyskinesia (involuntary uncontrolled muscle movements), dementia, generalized anxiety disorder, and major depressive disorder. A review of Resident #1's annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/24/2025, revealed a Staff Assessment for Mental Status (SAMS) score of 03, which indicated the resident was severely impaired for their daily decision making and never/rarely made decisions. A review of Resident #1's Care Plan, revised 02/21/2025, revealed the resident appeared to have impaired cognitive function related to dementia, traumatic brain injury, and cognitive communication deficit. Interventions included to cue, reorient, and supervise as needed, anticipate and meet needs, and observe for physical or nonverbal indicators of discomfort or distress and follow-up as needed (revised 04/19/2021). Resident #2 A review of Resident #2's admission Record indicated the facility readmitted the resident on 09/18/2025, with diagnoses which included dementia anxiety disorder, irritability and anger, and unspecified psychosis not due to a substance or known physiological condition (clinical diagnosis for psychotic symptoms [like hallucinations or delusions] that do not fit a specific disorder, with no clear link to drugs or underlying medical issues). A review of Resident #2's annual MDS with an ARD of 10/30/2025, revealed a Brief Interview for Mental Status (BIMS) score of 01, which indicated the resident had severe cognitive impairment. A review of Resident #2's Care Plan, revised 01/05/2026 following the incident with Resident #1, to indicate the resident had a history of being physically and sexually aggressive towards females related to anger, dementia, history of harm to others, and poor impulse control. Interventions included when the resident becomes agitated: Attempt to intervene before agitation escalates; Guide away from source of distress; Engage calmly in conversation; If response is aggressive, staff to walk calmly away, and approach later. A review of an OLTC (Office of Long-Term Care) Incident and Accident Report (I&A) revealed the date and time of the I&A was 01/01/2026 at 12:05 PM. The discovery date and time for the I&A was 01/01/2026 at 12:05 PM. The submission date and time was 01/01/2026 at 3:52 PM. The I&A Report contained a description of the incident, [CNA #1] entered [Resident #2's] room and observed [Resident #1] standing in [the room]. Both residents were fully clothed at the time. [CNA #2] walked [Resident #1] to [Resident #1's] room, [perineal care] was performed, and blood was noted in resident's brief. CNA notified charge nurse. Charge nurse and nurse manager assessed resident. Redness noted to vaginal area .At this time charge nurse and nurse manager assessed [Resident #2] and scant amount of dried blood was noted to first and second digits of left hand. During an interview at 01/12/2026 at 1:05 PM, Certified Nurse's Assistant (CNA) #1 revealed Resident #1 was found in Resident #2's room between the times of 10:30 AM and 10:40 AM on 01/01/2026. CNA #1 explained that CNA #2 reported seeing blood in Resident #1's brief at approximately 11:00 AM, at which time CNA #1 went to get Licensed Practical Nurse (LPN) #5. During an interview on 01/12/2026 at 1:16 PM, CNA #2 revealed on 01/01/2026 at 11:00 AM, she took Resident #1 to their room to change them and noticed blood in the resident's brief. CNA #2 reported that the blood looked fresh, and went to get LPN #5. During an interview at 01/12/2026 at 3:14 PM, LPN #5 reported around 11:00 AM on 01/01/2026, she was walking down the hall, and CNA #2 informed them during Resident #1's perineal care, the CNA saw a small amount of blood in the resident's brief. LPN #5 stated, I saw a small amount of blood in the brief. She reported she proceeded to contact the Director of Admissions and Marketing, who was the charge nurse at the time, at around 11:30 AM on 01/01/2026. During an interview on 01/13/2026 at 10:39 AM, the Director of admission and Marketing revealed that on 01/01/2026 at 11:30 AM, LPN #5 notified them of their finding of blood in Resident #1's brief. The Director of admission and Marketing explained that she went to assess Resident #1, and then afterwards at around 12:00 PM on 01/01/2026, reported the situation to the Director of Nursing (DON) and the Administrator. During an interview on 01/13/2026 at 10:10 AM, the DON revealed that on 01/01/2026 at approximately 12:00 PM, the incident was reported to administration. She explained that she was at home, and the Administrator called around noon and informed the DON that there had been an incident between Resident #1 and Resident #2. She explained that she arrived at the facility on 01/01/2026 around 1:00 PM. She then explained that the Director of Admissions and Marketing and LPN #5 assessed Resident #1. The DON stated that CNA #2 was the one who reported the incident to LPN #5. During an interview on 01/13/2026 at 11:45 AM, the Administrator revealed that she was notified of the incident on 01/01/2026 around 12:00 PM. She explained that she notified the DON and was headed toward the facility. She explained that the facility started staff interviews and then began talking to the Director of Admissions and Marketing and LPN #5. She confirmed that the Director of Admissions and Marketing and LPN #5 did the body audit for Resident #1. The Administrator revealed that she and the DON reviewed the investigation. She explained the DON and the Director and admission and Marketing did body audits on all the women on the secured neighborhood. She explained that a sister facility was contacted and accepted transfer of Resident #2 to that facility. She then explained the facility did a one-to-one observation for Resident #2 until they were transported to the sister facility. The Administrator stated, I done my report and notified both family, police, doctor, in-services on abuse and neglect, staff interviews, and body audits. The Administrator explained that she had two hours to notify the OLTC regarding allegations or suspicions of abuse. She confirmed that it was sent to OLTC close to four hours following the discovery around 1550 [3:50 PM] and that she was notified at 12:00 PM. She explained that it was a delicate situation, and she wanted to make sure she asked all the questions she needed to and had all the facts needed to report on it. A review of a facility policy titled, Abuse Investigation Protocol, revised 11/28/2017, indicated The facility will ensure that all allegations of abuse, neglect, exploitation, mistreatment, including injuries of unknown origin and misappropriation or suspicion of a crime against a resident are reported immediately; the administrator or designee will make an initial report to the local police department as applicable and to the state licensing agency not more than 2 hours after the allegation is made if the events that caused the allegation involve abuse or result in serious bodily injury.

Based on record review, interview, and facility policy review, the facility failed to ensure that one (Resident #2) of one resident reviewed received supervision to prevent avoidable accidents or elopement. The findings include: Review of an admission Record revealed the facility admitted Resident #2 on 06/28/2024. Review of Resident #2's Medical Diagnosis report revealed the resident had diagnoses which included a progressive brain disease that affects the frontal and temporal lobes leading to changes in behavior, personality and language abilities, paranoid schizophrenia, dementia psychosis, depression, convulsions, and nicotine dependence. Review of a quarterly Minimum Data Set with an Assessment Reference Date of 08/27/2025, revealed Resident #2 had a Brief Interview for Mental Status score of 14, which indicated the resident had no cognitive impairment. Review of a Care Plan revealed interventions for facility staff to educate Resident #2 to let staff know when they would like to sit outside and take walks in the courtyard area. The Care Plan also revealed Resident #2 had fair to poor safety awareness, required supervision, and was an elopement risk due to cognitive deficit. Review of a facility In-service Education Report, completed on 05/22/2025, indicated rounds must be completed on every resident every two hours. During an interview on 09/29/2025 at 11:51 AM, Resident #2 revealed knowing the code to the door that went outside to the smoking area. Resident #2 reported going to a grocery store approximately 2.5 miles from the facility and back. Resident #2 then reported while walking back someone had picked them up at the gas station and brought them back to the facility. Resident #2 also reported that a key was stored in a box on the fence and was used to unlock the gate to get off the facility property and that it was still dark outside when they left the facility. During an interview with CNA #1 and CNA #2 on 09/30/2025 at 3:27 PM, Certified Nursing Assistant (CNA) #1 reported that rounds were made on residents once the CNAs came into work, at breakfast, and every two hours while on shift. CNA #2 revealed that it was not unusual for Resident #2 not to be in their room due to either being outside, or in another resident's room. CNA #2 then stated that at 7:30 AM on 09/24/2025, Resident #2's breakfast tray was put down on the bedside table in their room due to Resident #2 not being in the room. CNA #1 reported that staff was told by the CNA supervisor at approximately 8:20 AM that Resident #2 was not in the building, outside or on property. CNA #1 revealed that staff did not know Resident #2 was not in the building or on the property. CNA #2 reported the last time Resident #2 was seen had been around 5:00 AM, in the resident's room. During an interview on 09/30/2025 at 4:10 PM, Receptionist #3 stated Resident #2 was spotted between 8:20 AM to 8:30 AM down the road from the facility at a gas station parking lot approximately 1000 yards away. Receptionist #3 revealed Resident #2 had on a shirt that was recognized as one that was worn frequently. Receptionist #3 revealed she had rolled the car window down and called Resident #2's name. Resident #2 got into Receptionist #3's car, the administrator was called and informed Resident #2 had been found away from the facility property and was being brought back to the facility. During review of Facility Routine Resident Checks policy revised July 2013 revealed that nursing staff make routine resident check to ensure the safety and well-being of residents. Routine resident checks involve entering the resident's room and/or identifying the resident.

Based on observation, interview, and menu review, the facility failed to ensure meals were prepared and served according to the planned written menu to meet the nutritional needs of the residents for two of two meals observed. The findings include: 1. A review of the 06/09/2025 noon meal menu, indicated the residents on pureed diets were to receive 1/2 cup of pureed scalloped potatoes, 3/8 cup of vegetables, and 3/8 cup of pureed cornbread. During an observation in the kitchen on 06/09/25 at 12:46 PM, Dietary Aide (DA) #2 used a #12 scoop, which was equal to 1/3 cup, to serve a single portion of pureed vegetable blend, instead of a #10 which was equal to 3/8 cup. DA #2 also used the #12 scoop for a single portion of pureed scalloped potatoes, instead of a #8 scoop which was equal to 1/2 cup. Pureed breadcrumbs were served instead of pureed cornbread as specified on the menu. During an interview on 06/10/25 at 12:04 PM, Dietary diet, (DC) #1 was asked the reason cornbread was not served to the residents on a puree diet. DC #1 stated the staff always used breadcrumbs instead of cornbread and she forgot to do cornbread. During an interview on 06/10/25 at 12:05 PM, DA #2 was asked what scoop sizes she had used when serving pureed scalloped potatoes, pureed vegetables and how many servings she gave to each resident on pureed diets. DA #2 stated she used the green scoop #12, equal to 1/3 cup, and gave a serving each. 2. A review of the 06/10/2025 breakfast meal menu indicated the residents on pureed diets were to receive 1/2 cup of pureed hash browns. During an observation on 08/10/25 at 7:48 AM, DC #1 used a #12 scoop which was equal to 1/3 cup, to serve a single portion of pureed hash browns to the residents who received pureed diets for breakfast, instead of 1/2 cup, a #8 scoop or 4-ounce ladle spoon of pureed hash browns as specified on the menu. During an interview on 06/10/25 at 9:28 AM, DC #1 was asked what size of scoop she had used to serve pureed hash browns and how many servings she gave to each resident on pureed diets. DC #1 stated she used the green scoop #12, equal to 1/3 cup, and gave a serving each.

Based on observation, record review, interview, and facility policy review, the facility failed to ensure food stored in the refrigerator, freezer, and dry storage area were covered; refrigerated food was kept refrigerated; expired food items were promptly removed and discarded on or before the expiration or use by date; dietary staff washed their hands between dirty and clean tasks and before handling clean equipment; food items were free of discoloration; ice machine and ice scoop were maintained in a sanitary condition, and manufactures instructions were followed for 2 of 2 meals observed. The findings include: 1. During an observation and interview in the facility kitchen on 06/09/25 at 10:34 AM, the Dietary Manager (DM) the following observations were made in the refrigerator: a. An opened packet of butter was stored on a shelf. The packet was not sealed, exposing it to cross contamination. During an interview, the DM stated it should have been sealed. b. An opened plastic storage bag contained slices of cheese and other cheese that were stuck together. During an interview, the DM stated that the bag of cheese should have been sealed, and the other slices of cheese should not have been put in the bag after they were melted. c. A container of chicken salad was on a shelf in the kitchen. The container had an expiration date of 06/03/2025. d. Two containers of tuna salad were stored on a shelf. The containers had expiration dates of 05/25/2025. 2. On 06/09/25 at 10:40AM, the following observations were made on a shelf above the food preparation counter: a. An opened box of salt was stored on a shelf above the food preparation counter. The box was not covered, exposing it to air and contaminants. b. An opened plastic storage bag of peppered biscuit gravy was stored on a shelf. The bag was not sealed, exposing it to air and contaminants. c. An opened bag of brown gravy was on the shelf. The bag was not sealed, exposing it to air and contaminants. d. There was an opened bag of hamburger buns on the shelf. The bag was not sealed, exposing it to air and contaminants. e. An opened box of baking soda was on the shelf. The box was not covered, exposing it to air and contaminants. f. An opened bag of breadcrumbs was on the shelf. The bag was not sealed, exposing it to air and contaminants. On 06/09/25 at 10:46 AM, during an interview, the DM stated once bags and boxes of food were opened, they were supposed to be sealed to prevent something from crawling in. 3. On 06/09/25 at 11:00 AM, the following observations were made in the storage room: a. An opened container of oatmeal. The container was not covered, exposing it to moisture from the air. b. An unopened box on a shelf that contained six bags of hot dog buns with 12 buns in each bag. All 72 buns had a sage color on them. On 06/09/25 at 11:03 AM, the DM described the appearance of what was observed on the hot dog buns. The DM stated, We just received it on 06/02/2025 and they have mold on them. c. An unopened box of cereal on a shelf had an expiration date of 05/11/25. d. Five 46-fluid ounce unopened boxes of nectar fruit punch were on a shelf with expiration dates of 06/04/2025. e. A wheeled container of powdered sugar was stored under the rack in the storage room. The container was not covered. f. An open bag of corn meal was stored on a shelf. The bag was not sealed. g. An opened gallon of spaghetti sauce was on a shelf. The manufacturer specification on the bottle indicated to refrigerate after opening. h. An opened gallon of burrito sauce was on a shelf. The manufacturer specification on the bottle indicated to refrigerate after opening. i. An opened bag of corn starch was on a shelf. The bag was not sealed. 4. On 06/09/25 at 11:22 AM, during the concurrent interview and observation, the following observations were made in the walk-in freezer. The freezer temperature was -2 degrees Fahrenheit. a. An opened box of garlic was on a shelf. The box was not covered or sealed. b. An opened box of biscuits was on a shelf. The box was not covered or sealed. c. An opened box of okra was on a shelf. The box was not covered or sealed. d. An opened box of pizza was on a shelf. The box was not covered or sealed. e. An opened box of chicken burritos with cheese was on a shelf. The box was not covered or sealed. On 06/09/25 at 11:23 AM, during an interview, the DM stated leaving food not covered or sealed would cause freezer frost bite. 5. On 06/09/25 at 11:37 AM, the ice scoop holder on the wall opposite the ice machine had water standing with black residue floating on it and the ice scoop was resting on it. The DM was asked if she could describe what was observed inside the scoop holder and she stated it had about 1/4 cup of water with black dirt floating on it and it was dirty. When asked how often she cleaned the scoop holder, she stated every week. 6. On 06/09/25 at 11:38 AM, the ice machine panel in a room leading to the kitchen had wet, black residue on it. This surveyor asked the DM to wipe the panel inside of the ice machine. She used tissue to wipe the panel inside of the ice machine which had a black, brown, and gray residue on it that easily transferred from the ice machine onto the tissue. The DM was asked to describe the residue found inside the ice machine that was shown on the tissue, who used the ice machine, and how often she cleaned it. The DM stated, It's mold and has black, brown, and gray dirt. It is supposed to be cleaned every three days, but it doesn't look like it has been cleaned. The Certified Nursing Assistants used the ice to fill beverages served to the residents for mealtimes. That was also the ice Certified Nursing Assistants used to fill the water pitchers for the residents' rooms. 7. On 06/09/25 at 11:49 AM, Dietary [NAME] (DC) #1 turned on the food preparation sink faucet and rinsed a spatula. After rinsing the spatula, she turned off the faucet with her bare hand, contaminating her hand. Without washing her hands, she picked up a clean blade and attached it to the base of the blender to be used in pureeing food items for the residents on pureed diets for lunch. When DC #1 was ready to place vegetable blend into the blender to puree, she immediately was asked what she should have done after touching dirty objects and before handling clean equipment. DC #1 stated she should have washed her hands. 8. On 06/09/25 at 12:48 PM, Dietary Aide (DA) #3, who was assisting with lunch meal, opened the refrigerator door, took out cartons of milk, and placed them in a container of ice on top of the utility food cart. During the meal service and preparation of trays, DA #3 picked up the cartons of milk. Without washing her hands, she picked up glasses with beverages in them by the rims and placed them on the trays to be served to the residents during the lunch meal. DA #3 was asked what she should have done after touching dirty objects before handling clean equipment. DA #3 stated she should have washed her hands. 9. A review of the facility policy titled, Hand Washing, indicated employees should wash their hands before the beginning of shift, and any other time deemed necessary. 10. A review of the facility policy titled, Personal Hygiene, indicated hands should always be washed before beginning work. 11. A review of the facility policy titled, Sanitation of Ice Machine, indicated ice machine should be sanitized twice a month, and ice scoop should be sanitized daily.

Based on observations, interviews, record review, facility document review, facility policy review, it was determined that the facility failed to ensure fingernail care was provided for 1 (Resident #7) of 1 resident reviewed for Activities of Daily Living (ADLs). The findings include: A review of facility policy titled, Fingernails/Toenails, Care of, revised in February 2023, indicated The purposes of this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infections. Nail care includes daily cleaning and regular trimming. A review of the Medical Diagnosis, indicated Resident #7 had a diagnosis of dementia. The quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/31/2024, revealed Resident #7 had a Staff Interview for Mental Status (SAMS) score of 3 which indicated the resident had severe cognitive impairment. A review of Resident #7's Care Plan, updated on 07/22/2024, revealed the resident had an ADL self-care performance deficit related to confusion and impaired balance. Interventions included: the resident has a contracture of the left hand, provide skin care as needed to keep clean and prevent skin breakdown and nail care, check nail length and trim and clean as necessary. A review of Resident #7's Closet Care Plan, dated 07/19/2024, indicated that Resident #7 had contracture of the left hand and skin care was to be provided as needed to keep clean and prevent skin breakdown. A review of an activity of daily living task Nail Care, revealed Resident #7 had nail care provided on 11/03/2024, 11/10/2024, 11/17/2024, and 11/24/2024. No refusals were documented. During an observation on 11/26/2024 at 8:44 AM, Resident #7's left hand appeared to be contracted as the resident could not open the hand. The ring finger fingernail on the left hand was 1/4 inches long or longer. Resident #7, then held up the right hand and stated, Just look at this black stuff. Around each fingernail cuticle and underneath each fingernail was a dark brownish substance, and the hand had a pungent odor. During an interview on 11/26/2024 at 8:50 AM, Certified Nursing Assistant (CNA) #5 confirmed the fingernail on the left hand of Resident #7 was too long and needed to be trimmed. CNA #5 stated Resident #7's right hand should have been cleaned prior serving the breakfast tray. During an interview on 11/26/2024 at 8:59 AM, the Director of Nursing (DON) confirmed the fingernail on Resident #7's left hand needed to be trimmed. The DON confirmed that Resident #7's right hand was dirty and that it would be taken care of.

Based on observations, interviews, record review, facility document review, and facility policy review, it was determined the facility failed to identify, and ensure preventative measures were put into place to prevent worsening of contractures for 1 (Resident #7) of 1 resident reviewed for contracture management/prevention. Findings include: A review of a facility policy titled, Resident Mobility and Range of Motion, revised in July 2024, indicated residents with limited mobility will receive appropriate services, equipment and assistance to maintain or improve mobility unless reduction in mobility is unavoidable. A review of the Medical Diagnosis, indicated the Resident #7 has a diagnosis of unspecified dementia. No diagnosis was noted for contracture to the left hand. The quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/31/2024, revealed Resident #7 had functional limitation in range of motion to the upper extremity on one side. A review of Resident #7's Care Plan, updated on 07/22/2024, revealed self the resident had an ADL self-care performance deficit related to confusion and impaired balance. Interventions included: the resident has a contracture of the left hand, provide skin care as needed to keep clean and prevent skin breakdown and nail care, check nail length and trim and clean as necessary. A review of Resident #7's Closet Care Plan dated 07/19/2024 indicated that Resident #7 had contracture of the left hand and skin care was to be provided as needed to keep clean and prevent skin breakdown. A review of the Clinical Admission for Resident #7 had no documentation of contracture upon admission to the facility. During an observation on 11/26/2024 at 8:44 AM, Resident #7's left hand appeared to be contracted as the resident could not open the hand. No device, hand roll or splint was observed in the room or with Resident #7. During an interview on 11/26/2024 at 8:50 AM, the Certified Nursing Assistant (CNA) #5, confirmed that Resident #7's left hand appeared to be contracted and was uncertain if there were any devices that were to be used. During an interview on 11/26/2024 at 8:59 AM, the Director of Nursing (DON) was asked if Resident #7 had a hand roll, splint or other device for the left-hand contracture. The DON responded, I will have to look, I am not sure about the contracture.

Based on observation, interview, and record review the facility failed to properly transfer 1 (Resident #6) of 1 (Resident #6) sampled residents to prevent the potential for injury. The findings are: The quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/12/2024, revealed Resident #6 had a Brief Interview for Mental Status (BIMS) score of 01, which indicated the resident cognitive status was severely impaired. The MDS indicated that Resident #6 was dependent on staff for transfers. A review of Resident #6's care plan revised on 03/04/2024 revealed the resident required substantial assistance by one staff with transfers. A care plan revision on 02/26/2024 indicated that resident #6 does not ambulate. On 11/25/2024 at 3:33 PM Resident #6 was in a shower chair in her room. Certified Nurse Aide (CNA) #1, and CNA #2 transferred Resident #6 from a shower chair to her bed. CNA #1 had her arm under Resident#6's right arm, and CNA #2 had her arm under Resident#6's left arm. During an interview on 11/25/2024 at 3:42 PM CNA #1 indicated that Resident #6 required 2 people for transfers using a gait belt. She indicated that she transferred Resident #6 without a gait belt because there was not a gait belt in the room. During an interview on 11/25/2024 at 3:52 PM CNA #2 indicated that Resident #6 required 2 people for transfers using a gait belt. She indicated that she transferred Resident #6 without a gait belt because there was not a gait belt in the room. She indicated that she should have gone to therapy to get a gait belt before transferring Resident #6. During an interview on 11/26/2024 at 9:50 AM, the Director of Rehab indicated that Resident #6 is a one person assist with a gait belt. During an interview on 11/26/24 at 3:23 PM the Director of Nurse (DON) indicated that Resident #6 is a two-person assist with transfers. During an interview on 11/26/24 at 3:29 PM the Director of Nurse (DON) indicated that Resident #6 is a 1 person assist with transfers. She indicated that the staff could transfer Resident #6 with a gait belt, or using the bear hug technique. Review of a facility policy titled, Safe Lifting and Movement of Residents, revised July 2024, indicated, In order to protect the safety and well-being of staff and residents, and to promote care, this facility uses appropriate techniques and devices to lift and move residents. Manual lifting of residents shall be eliminated when feasible(done). Safe lifting and movement of residents is part of an overall facility employee health and safety program which provides training on safety, and proper use of equipment.

Based on observation, interview, record review and policy review, the facility failed to ensure hands were washed between clean and dirty tasks; hair covering was worn at all times; and meals were served, and food was stored in a manner as to prevent cross contamination for the 113 residents who received their meals from one of one kitchen. The findings are: On 07/22/2024 at 10:18 AM, upon attempting to determine the internal temperature of the two-door refrigerator the Dietary Manager (DM) reported there was no thermometer located inside the machine. The shelves inside the two door refrigerator were observed to have areas of rust. On 07/22/2024 at 10:20 AM, upon entering the walk-in refrigerator the plastic sheeting covering of the door was observed to have a red substance which was spilled and had congealed and stuck to the plastic. The walk-in freezer was observed to have a red liquid substance which had spilled on the floor and left to freeze. Two steam table pans (2 inches deep) of gelatin were observed to be located on the middle shelf of the walk-in freezer. The plastic wrap had been removed from the corner of the pan exposing the mixture to air and contaminants. On 07/22/2024 at 10:21 AM, three large garbage cans were observed in front of the door to the walk-in freezer. One of the cans had no lid. The lids on top of the other two cans were ajar. On 07/22/2024 at 10:23 AM, a large plastic tub (18 gallon) labeled flour was observed to contain a foam cup which was laying on top of the flour. The large plastic tub labeled cornmeal had a foam cup laying on top of the cornmeal. The lid of the container of cornmeal had not been properly sealed leaving the contents open to air and contaminants. The large plastic container labeled thickener was observed to have a piece of blue plastic protruding from the dry ingredient. The Dietary Manager observed that the container was missing a closure which was the blue plastic piece which was half submerged into the thickener. The absence of the closure prevented the container from maintaining a proper seal, leaving the contents open to air and contaminants. On 07/22/2024 at 11:36 AM, a 21 ounce container of garlic powder was observed on a shelf above the counter in the kitchen. The lid of the container was open exposing the contents to air and contaminants. On 07/22/2024 at 11:40 AM, three large trays of dinner rolls were removed from the oven. The trays were placed on a rack to cool and were left uncovered. On 07/22/2024 at 11:45 AM, the Dietary Manager was observed with the bottom half of her hair uncovered. The hairnet was observed to cover the large top knot of hair, however leaving the bottom half of the head exposed. On 07/22/2024 at 11:47 AM, Dietary Aide #4 was observed carrying clean pitchers to the shelf for storage. Dietary Aide #4 placed her fingers inside the containers. Dietary Aide #4 was then observed to raise her shirt exposing her midriff to pull up her pants. She then lowered her shirt and wiped her hands down the front of her shirt to smooth. Dietary Aide #4 continued to the clean dish area of the dish-room and retrieved more clean dishes. Hands were not washed after touching her person or clothing and prior to touching the clean dishes. Dietary Aide #4 was observed multiple times bringing her shirt up to wipe her face. On 07/22/2024 at 11:49 AM, Dietary Aide #3 was observed to carry multiple large plastic containers to the sink to make powdered drinks. Fingers were placed inside the containers. On 07/22/2024 at 12:15 PM, Dietary Aide #2 was observed to enter the kitchen and proceed to the office prior to putting on a hair covering. A sign located at the entrance to the kitchen instructs employees to apply hair covering prior to entering the kitchen. On 07/22/2024 at 12:17 PM, Dietary Aide #3 was observed to dry his hands on his pants, adjust his face covering, and obtain a cart. Hands were not washed prior to continuing with meal service or providing coffee to a resident through the window. On 07/22/2024 at 12:20 PM, Dietary Aide #1 was observed to place her thumb on each plate prior to filling the plate for the noon meal. Dietary Aide #1 was observed to have fingernails which extend approximately one inch over the end of the finger and into the plate. On 07/22/2024 at 12:24 PM, Dietary Aide #4 was observed to place contaminated hands into each insulated dome prior when placing the dome over the plate of food. On 07/22/2024 at12:35 PM, a meal cart was observed to leave the kitchen to be delivered to the unit. The Dietary Consultant was asked if it was customary for the temperature to be taken of the food prior to serving the meal. The Dietary Consultant described that she did not take the temperature and that the new Dietary Manager forgot to do it. On 07/24/2024 at 7:35 AM, Dietary Aide #1 was observed to place her hand on her hip contaminating her hand just prior to picking up a plate. Dietary Aide #1's thumb went into each plate as it was picked up and placed on the tray. The hand to hip motion was observed between the placement of every plate served on the 300 Hall. On 07/24/2024 at 7:38 AM, Dietary Aide #1 was observed to drop an insulated base into the steam table pan containing French toast. The base encountered three slices of toast. The base was removed, and the French toast was served to the residents. On 07/24/2024 at 7:40 AM, the Dietary Manager was observed to place her fingers inside the insulated dome each time just prior to placing the dome over the hot food. On 07/24/2024 at 1:43 PM, review of a policy provided by the Administrator titled, Preventing Foodborne Illness - Food Handling revealed, the policy statement reflected food will be stored, prepared, handled and served so that the risk of foodborne illness is minimized. Review of a second policy titled, Preventing Foodborne Illness - Employee Hygiene and Sanitary Practices, addressed the prevention of food borne illness through employee hygiene and sanitary procedures. Employees must wash hands before coming into contact with any food surfaces; when changing tasks or after engaging in other activities that contaminate the hands; fingernails shall be kept clean and trimmed; hair nets or caps and/or beard restraints must be worn to keep hair from contacting exposed food. On 07/25/2024 at 8:25 AM, the Dietary Consultant reported that dietary employees should be washing their hands, every two seconds. He continued to identify after you touch your person, move from one task to the next, move from one area to the next. Concerning hair coverings, he reported that a hair covering should be applied before entering the kitchen. The nails of a dietary employee should not extend over the end of the finger. Fingers should not extend into the inside of containers, or the surface of plates or inside the domes which cover the plates. Dry ingredients should be stored in air-tight containers and should not have scoops or other items left inside.

Based on observation, interview and record review, the facility failed to ensure dietary employees maintained proper facial hair covering, dishes were processed in a manner that prevents cross contamination, and employees washed their hands before handling clean equipment or food items to prevent potential food borne illness for residents who received meals from 1 of 1 kitchen. The failed practices had the ability to affect 99 residents who received meals from 1 of 1 kitchen according to a list obtained from the Administrator on 06/22/23 at 9:22 AM. The findings are: 1. On 06/19/23 at 11:00 AM, Dietary Employee (DE) #1 was observed in the kitchen with his facial hair uncovered. 2. On 06/19/23 at 11:02 AM, in the kitchen there was a large trash can with trash protruding from the top with no lid. 3. On 06/19/23 at 11:05 AM, 2 large pans of cornbread were sitting on top of the oven uncovered. 4. On 06/19/23 at 11:11 AM, a personal drink belonging to a dietary employee was sitting in front of the microwave in the kitchen work area. 5. On 06/19/23 at 11:34 AM, DE #2 was observed moving a tray of cornbread from the oven to the worktable for slicing, holding the tray against her clothing/person. She then removed a second tray from the oven and brought it to the work area holding the tray against her person allowing her clothing to brush the top of the bread. 6. On 06/19/23 at 11:52 AM, DE #3 carried a large clean tray from the dish room pressed against her person allowing her clothing to brush the inside of the tray contaminating the tray during transport. DE #3 then returned a clean cutting board to the work area. During transport, the cutting board was pressed against the DE #3's t-shirt which was wet from the cast off while washing dishes. 7. On 06/19/23 at 12:12 PM, DE #3 removed her cell phone from the pocket of her pants with her gloved hands, contaminating her gloves. With contaminated gloves DE #3 continued to prepare food for lunch. 8. On 06/19/23 at 12:19 PM, DE #1 was preparing to serve the lunch meal. Upon reaching for a base for the plate he dislodged 11 insulated plate bases which fell on to the large steam table pan filled with sliced ham for lunch. Multiple slices of ham were contaminated and were served to the residents. 9. On 06/20/23 at 11:15 AM, DE #1 was in the kitchen with his facial hair uncovered. 10. On 06/20/23 at 11:43 AM, DE #4 donned a pair of clear gloves. With gloved hands she obtained a double bag of rolls and used her gloved hands to tear the plastic bag revealing the rolls. With contaminated gloves DE #4 proceeded to remove the rolls from the packaging, break them apart and place in a steam table pan. 11. On 06/22/23 at 8:10 AM, the Surveyor asked the Dietary Manager when a covering for facial hair was to be worn when in the kitchen. She stated, All the time. The Surveyor asked if it was important to prevent cross contamination of dishes and utensils. She stated, Yes. The Surveyor asked to discuss ways in which cross contamination could be minimized. She stated, They should remember to wash their hands, not stop between the dish room and where the item is stored and remember to store the item correctly. Wearing an apron helps, I have ordered aprons I think two times, but I was turned down because of the funds. The Surveyor asked when it is important to wash hands. She stated, Between clean and dirty tasks, when coming into the kitchen, after the restroom. 12. A facility policy titled, Preventing Foodborne Illness - Employee Hygiene and Sanitary Practices, provided by the Administrator on 06/22/23 at 8:35 AM documented, Policy Statement Food and nutrition services employees will follow appropriate hygiene and sanitary procedures to prevent the spread of food borne illness . 6. Employees must wash their hands: .f. after handling soiled equipment or utensils; g. during food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks; and/or . h. after engaging in other activities that contaminate the hands .

Based on observation and interview, the facility failed to ensure the clothes dryers remained free of excess lint to decrease the potential for fire and loss of personal property. The failed practice had the ability to affect all 101 residents who resided in the facility according to the Census and Conditions of Residents provided by the Administrator on 06/19/23 at 12:40 PM. The findings are: 1. On 06/21/23 at 8:15 AM, the Surveyor asked the Laundry Manager to open the bottom panel of the dryer which houses the lint trap. The lint screen was covered in a layer of lint thick enough to separate from the screen and hang down toward the bottom of the dryer. Above the screen was a bundle of lint 2 to 3 inches thick. The bottom of the dryer was covered in lint particles including a sheet of lint and debris. 2. On 06/21/23 at 8:20 AM, the Surveyor asked the Laundry Manager how often the lint was removed from the dryer. She stated, This is just from 2 hours of running this morning. We empty it after a certain number of loads depending on what we are drying, and we follow the manufacturer's guidelines. The Laundry Manager provided a schedule where the laundry employees are to initial and document the time when the lint filter is cleaned. The schedule started on 06/19/23 and contained only 2 entries on 06/20/23. The Laundry Manager stated, Oh those were just written on the wrong day, those were for today. According to the schedule the lint was removed at 6:30 AM. 3. A policy titled, [Brand]/Tumble Dryer Maintenance, provided by the Administrator on 06/22/23 at 8:35 documented, .Maintenance .Daily .3. Clean lint from lint compartment and screen to maintain proper airflow and avoid overheating . 4. On 6/22/23 at 9:50 AM, the Surveyor asked the Administrator how often the lint screen should be cleaned. He stated, Let me check my policy.

Based on observation, interview and record review, the facility failed to ensure the medication carts were locked when out of the nurse's sight, medication was not left on top of the medication carts when out of the line of the nurse's sight for 1 of 1 medication cart and failed to ensure over the counter (OTC) medications were dated when opened. The findings are: 1. On 06/20/23 at 8:18 AM, Registered Nurse (RN) #1 left the medication cart unlocked when she went into a residents' room to administer medication. 2. On 06/20/23 at 8:23 AM, RN #1 administered insulin to a resident and left the bottle of insulin on top of the medication cart unattended and out of the line of sight of RN #1. 3. On 06/20/23 at 8:57 AM, RN #1 opened a new bottle of Zinc, an OTC medication, and did not document the date opened on the medication bottle before she put it back into the drawer on the medication cart. 4. On 06/21/23 at 2:06 PM, the Surveyor asked Licensed Practical Nurse (LPN #1) when you leave your cart to take medicine into the resident's room, what should you do. LPN #1 stated, Make sure you lock your cart and that your screen is blank. The Surveyor asked if you are preparing meds (medications) on top of your med cart, what would you do with the meds you have used. LPN #1 stated, Make sure the meds are back in their drawers and locked. The Surveyor asked if you open a new bottle of medication, what should you do with the new bottle. LPN #1 stated, It should be dated the day the new bottle is opened. 5. On 06/21/23 at 2:10 PM, the Surveyor asked LPN #2 when you leave your cart to take medicine into the resident's room, what should you do. LPN #2 stated, The cart is locked, and the screen should be blank. The Surveyor asked if you have prepared your meds on top of your med cart, what should happen before you take the meds to the resident. LPN #2 Unused meds need to be returned to the cart. The Surveyor asked if you open a new bottle of meds what are you supposed to do. LPN #2 said, The bottle is dated the date you opened it. 6. On 06/21/23 at 2:18 PM, the Surveyor asked the Director of Nursing (DON) if you are preparing meds for a resident what should you do before you take the meds to the residents. The DON stated, Clear the meds off the top of the carts and lock them. The Surveyor asked if you are taking the meds to the resident what should be done. The DON stated, Lock the cart and make sure the computer screen is blank. The Surveyor asked if you get a new bottle of meds what do you do when the new bottle is opened. The DON said, Make sure the expiration date is current. 7. The facility policy titled, Storage of Medications, documented, .The facility stores all drugs and biologicals in a safe, secure, and orderly manner . 6. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biologicals are locked when not in use. Unlocked medication carts are not left unattended .

Based on observation, interview and record review, the facility failed to ensure pureed food items were blended to a smooth, lump free consistency to minimize the risk of choking or other complications for residents who required pureed diets for 1 of 1 meal observed. The failed practice had the potential to affect 5 residents who received a pureed diet as documented on a list provided by the Administrator on 06/22/23 at 9:22 AM. The findings are: 1. On 06/19/23 at 12:35 PM, a resident who received a pureed tray was being fed their lunch meal. The pureed ham was observed to have a [NAME] appearance. When the spoon was placed into the ham mixture the particles remained and did not appear smooth. The pureed cabbage was observed to have liquid pooling around the bottom of the mixture. The bread mixture maintained its shape and when the utensil was inserted a piece came away whole, having reformed into a solid mixture. 2. On 06/19/23 at 12:40 PM, the Administrator instructed the Certified Nursing Assistant (CNA) to stop feeding the ham mixture to the residents. The Administrator then instructed the Dietary Manager to prepare more ham and to process the ham until smooth. 3. On 06/22/23 at 8:20 AM, the Surveyor asked the Dietary Manager to describe the desired consistency of pureed food. She stated, Pudding. The Surveyor asked why it is important that food is served at the correct consistency. She stated, So it won't be running all over the plate, so they can swallow it correctly. 4. A facility policy titled, Therapeutic Diets, provided by the Administrator on 06/22/23 at 8:35 AM documented, .4. A 'therapeutic diet' is considered a diet ordered by a physician, practitioner or dietitian as part of treatment for a disease or clinical condition, to modify specific nutrients in the diet, or to alter the texture of a diet, for example: .d. altered consistency diet .

Based on observation and interview, the facility failed to ensure linen was processed in a manner to limit the possibility of cross contamination. The failed practice had the ability to affect all residents who resided in the facility and utilize linen processed by 1 of 1 laundry according to a list provided by the Administrator on 06/22/23 at 9:22 AM. The findings are: 1. On 06/21/23 at 8:20 AM, Laundry Employee (LE) #1 was standing next to a folding table in the clean side of the laundry facility folding clean blankets and towels. LE #1 was holding the blanket against her person allowing the blanket to come in contact with her clothing. LE #1 placed the blanket under her [NAME] and used her [NAME] to hold the blanket against her chest as the blanket was folded. The Surveyor asked LE #1 if she should allow the clean laundry to touch her clothing as she was folding it. She stated, I don't know. 2. On 06/21/23 at 8:18 AM, the Housekeeping Manager and LE #1 were asked to identify what, if anything, clean laundry was ok to touch when folding. They both identified the floor as the only thing that should be avoided when processing clean laundry. 3. On 06/22/23 at 9:14 AM, the Surveyor asked the Administrator what clean laundry should not come into contact with to prevent cross contamination. The Administrator stated, The floor and your clothing.

Based on observation, interview and record review, the facility failed to ensure respiratory care was provided in accordance with Physician Orders to prevent respiratory distress or infection for 1 (Resident #102) of 5 (Residents #9, #13, #100, #102 and #310) sampled residents who received oxygen therapy according to a list provided by the Administrator on 06/22/23 at 9:22 AM. The findings are: Resident #102 had diagnoses of Tracheostomy Status, Acute Respiratory Failure with Hypoxia and Quadriplegia Unspecified. a. A Physicians Order dated 06/18/23 documented, Oxygen 10L [liters] via trach [tracheostomy] . b. A Progress Note dated 06/18/23 at 3:40 PM documented the resident returned to the facility from [Hospital] with new diagnoses including UTI [Urinary Tract Infection], Sepsis, and Pneumonia, and on oxygen at 10L. c. The Readmission assessment dated [DATE] noted Resident #102 uses 10 L of oxygen. d. On 06/19/23 at 11:06 AM, 06/20/23 at 1:58 PM, 06/21/23 at 8:12 AM, 06/21/23 at 1:22 PM and 06/22/23 at 7:50 AM, observed Resident #102's oxygen flow meter rate was set at 9 liters. e. On 06/22/23 at 7:50 AM, the Surveyor asked Licensed Practical Nurse (LPN) #3 if you read a Physicians Order that documented, Oxygen at 10 liters, what should the oxygen be set at and why. LPN #3 stated it should be set at 10 so the resident gets the proper care and the right amount of medication. The Surveyor asked LPN #3 to read Resident #102's oxygen flow rate meter. She stated, It is set at 9. The Surveyor asked if there is a specific person responsible for oxygen administration. LPN #3 stated they (the nurses) are responsible for all care. f. On 06/22/23 at 8:35 AM, the Surveyor asked the Administrator why it is important to follow Physician Orders. The Administrator stated, Because we have to practice by Physician Orders, so if you are not following Physician Orders, you're not being compliant. g. A facility policy titled, Oxygen Management, last updated 06/23 documented, .Procedure/Protocol: .4. Connect the nasal cannula to the bubble humidifier and turn flow meter to the appropriate flow as ordered by the physician .

Based on observation and interview, the facility failed to ensure the air conditioning (AC) unit was in proper working order to prevent water from leaking and leaving a puddle of water which has a potential to cause serious injury in Resident room [ROOM NUMBER]. The findings are: 1. On 06/19/23 at 7:47 AM, 10:59 AM and at 1:24 PM, in Resident room [ROOM NUMBER], there was water on floor on the left side of the bed by the AC unit. 2. On 06/20/23 at 9:16 AM, in Resident room [ROOM NUMBER], there was a water puddle on the floor by the left side of the bed by the AC unit. The water puddle was larger than it was on 06/19/23 at 1:24 PM. 3. On 06/20/23 at 1:13 PM, in Resident room [ROOM NUMBER], there was a water puddle on the left side of the bed by the AC unit. The water puddle was smaller than it was on 06/19/23 at 9:16 AM. 4. On 06/20/23 at 1:15 PM, the Surveyor asked Certified Nursing Assistant (CNA) #1, Have you seen the puddle of fluid on the floor, in front of the AC unit? CNA #1 stated, No, I will go get a towel to clean it up. The Surveyor asked, Have you ever noticed fluid in front of the AC unit? CNA #1 stated, No. 5. On 06/20/23 at 1:24 PM, the Surveyor asked Housekeeper #1 if she had seen the puddle in front of the AC unit in room [ROOM NUMBER] this AM while she was cleaning. Housekeeper #1 stated, Yes, I cleaned it up. The Surveyor asked if this was the first time she had noticed a puddle of fluid in front of the AC unit. Housekeeper #1 stated, The AC unit sweats, making the puddle of water. 6. On 06/20/23 at 2:25 PM, the Surveyor asked the Maintenance Supervisor if he was aware of a leak from the AC unit in room [ROOM NUMBER] that had caused water to puddle for two days. The Maintenance Supervisor said, No. What is happening, is the water is puddling in the bottom pan and it does not drain. So, it spills over onto the floor. I can drill a couple holes in the back, and it will drain outside.

Based on observation, record review and interview, the facility failed to ensure nutritional interventions recommended by the Registered Dietitian [RD] were implemented in order to minimize further weight loss and maintain nutritional status to the extent possible for 1 (Resident #33) of 6 (Residents #41, #33, #4, #78, #70 and #54) sampled residents who had experienced a weight loss. This failed practice resulted in actual harm for Resident #33 who experienced a severe, unplanned, 32.6 pound (22.12 percent) weight loss in a 2-month period. The findings are: Resident #33 was admitted on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Minimum Data Set with an Assessment Reference Date of 12/03/21 documented the resident scored 10 (8 -12 indicates moderately cognitively impaired) and required extensive physical assistance of two plus persons with bed mobility, toilet use and personal hygiene, was independent with set up only for eating, had no weight gain or weight loss of 5% (percent) or more in the last month or gain of 10% or more in last 6 months and was not on an Altered or Therapeutic Diet. a. The Care Plan with a revision date of 12/01/21 documented, .Resident has potential for nutritional deficits . Provide diet as ordered . b. The Weight Summary in the Electronic Medical Record (EMR) from 11/29/21 to 02/04/22 documented the following weights for Resident #33: 11/29/2021 - 147.4 Lbs (pounds) 12/08/2021 - 147.4 Lbs 01/13/2022 - 128.4 Lbs (12/821 to 1/13/22 12.89% weight loss) 01/26/2022 - 122.4 Lbs (12/8/22 to 1/26/22 16.96% weight loss) 02/04/2022 - 120.8 Lbs (12/8 - 2/4 there was a 18.05% weight loss) On 02/16/2022 at 10:29 AM, Resident #33 was weighed per surveyor's request. Resident #33's weight was 114.8 Lbs. From 12/08/2021 to 02/16/2022 (2 months and 8 days), Resident #33 had a 22.12% weight loss. c. The IDT [Interdisciplinary Team] Weekly Weight Note dated 01/14/2022 in the EMR documented, .significant weight loss over 30 days, CW [current weight] 128.4 BMI [body mass index] 20.7. On regular diet average cons [consumed] 47% receives liquid protein supplement and MVI [multivitamin]. Increased needs secondary to wound healing RD [Registered Dietician] to review next week. Will cont [continue] to follow. d. A Medical Visit Note by the Primary Care Physician (PCP) in the EMR documented, .Encounter Date: Jan [January] 19 2022 10:06AM . [Resident #33] was seen ., examined, and her chart reviewed. She has been doing very well. She is eating well . 4. I will see patient again for recheck in approximately one month; sooner, if there are any new developments or needs . e. The Diet-RD Recommendations Note dated 01/20/2022 at 4:33 PM in the EMR documented, .Resident reviewed due to skin issues and weight. Resident is on a regular diet.Current wt [weight] 128.4 lb 1/13/22, down 19 lb in 1 mo [month] (12.89%), down 19 lb since admit [admission] (12.89%). Significant wt loss x [times] 1 mo, admit. Goals 1) Maintain wt 2) No significant wt changes 3) PO [taken by mouth] intake 50-75% or greater 4) Improved skin integrity. Receives protein supplement, MVI to assist with healing. Rec [recommend] 1) Consider starting vit C and [MEDICATION(S)] 1 pkt [packet] mixed with at least 4-6 oz [ounces] fluid BID [Twice a Day] 2) Consider starting MedPass 90 ml [milliliters] TID [Three times a day]. f. The IDT-Weekly Weight Note on 01/21/22 at 8:42 AM documented, .IDT following resident for weight loss. Refused weights this week x3, no weight to compare to last week. RD recommendations received. Will f/u [follow-up] PCP [Primary Care Physician], weigh next week. g. The Medical Visit Note by the APRN (Advanced Practice Registered Nurse) in the EMR documented, .Encounter Date: [DATE] 8:25AM . Nursing staff notifies me that she has tested positive for COVID-19. She is currently asymptomatic . Staff to continue to monitor the resident and notify me of any new concerns . There was no documentation concerning the resident's weight loss. h. The February 2022 Physicians Orders documented, .REGULAR diet REGULAR texture, REGULAR Consistency Order Date 11/26/21 .Multivitamin Tablet (Multiple Vitamin) Give 1 tablet by mouth one time a day for wound healing 1/17/22 .Protein Liquid Give 30 ml [milliliters] by mouth one time a day for wound healing Order Date 01/17/22 . i. On 2/14/22 at 11:54 AM, Resident #33 was resting in bed, when asked about her food and her diet, she stated, I have lost weight, not hungry and it turns my stomach, at times I can eat. j. On 2/14/22 at 2:04 PM, Resident #33 received her meal in bed. She received regular diet of lettuce, tomato, salad dressing, fried okra, sweet potato, breaded pork chop, dessert and 8 ounces of tea. k. On 2/15/22 at 9:04 AM, Resident #33 was served breakfast in bed of eggs, bacon, and toast with margarine / jam with 6 ounces of orange juice. l. On 2/16/22 @ 11:15 AM, the Director of Nursing (DON) was asked, What interventions were implemented for the resident's weight loss? She replied, On 1/17, MV [Multivitamin] and Protein supplement. She was asked, On 1/20 the RD recommended Arginate and Medpass, when did the APN address her recommendations? The DON replied, She did not, until 2/12/22 when I addressed them with her. The APN is here daily and knows she needs to address the RD assessments and Recommendations. Since the resident has GERD and is on [MEDICATION(S)], the APN does not want the resident to have Arginate or Medpass d/t [due to] it would interfere with the medication. She ordered vit [vitamin] c to be started on 2/12 and CMP [Comprehensive Metabolic Panel] to be completed this week. I talked to the resident yesterday, to get her likes, and she will receive magic cup and ice cream with her meals. The DON was asked, Who is responsible to ensure the APN addresses the RD recommendations? She replied, I am. m. The facility policy titled, Weighing the Resident, provided by the Administrator on 02/17/22 at 8:11 AM documented, .It is the policy of this facility to maintain accurate information about weight gain or loss.Any unplanned weight loss/gain is to be reported to the physician, family/responsible party, dietitian, nursing supervisor, and address weekly at the At Risk Meeting, Re-weigh of resident is required with fluctuation from previous weight, with Licensed Nurse observation/validation: a. 5% loss or gain in one month b. 7.5% loss or gain in 3 months c. 10% loss or gain in six months .

Based on observation and interview, the facility failed to ensure dietary staff washed their hands before handling clean equipment or food items to prevent potential food borne illness for residents who received meals from 1 of 1 kitchen, failed to ensure an ice scoop holder and ice machine were maintained in clean and sanitary condition to prevent contamination of airborne particles, failed to ensure food items stored in the refrigerator or freezer were covered or sealed and labeled; hot foods were maintained at or above 135 degrees Fahrenheit on the steam table while awaiting service to prevent potential food borne illness for residents who received meals from 1 of 1 kitchens and failed to ensure proper hand hygiene was used while serving food to prevent the potential for food borne illness during meal service on the 300 Hall Secure Unit, 100 Hall and 400 Hall. These failed practices had the potential to affect all 103 residents who received meals from the kitchen (total census:103) as documented on a list provided by Dietary Supervisor on 02/15/22. The findings are: 1.On 2/14/22 at 11:06 AM, the scoop holder on the wall by the ice machine had water standing in it. There was a black residue at the bottom of it. The ice scoop was stored in the scoop holder and was in direct contact with the residue. The Dietary Supervisor was asked how much water was in the scoop holder. She poured it in a cup and stated, It was 6 oz. The Dietary Supervisor was asked to describe the contents within the ice scoop holder. She stated, It's a black dirt, nasty. He was asked, How often do you clean the scoop holder? She stated, We wipe it off every day. She was asked, Does it look like it has been cleaned? She stated, It does not look like it has been cleaned every shift. 2. On 2/14/22 at 11:28 AM, an open box of bacon was on a shelf in the freezer. The box was not covered or sealed. 3. On 2/14/22 at 11:29 AM, the following observations were made in the kitchen: a. An open box of dough was on a shelf in the freezer. The box was not covered or sealed. b. An open box of strapped pork patties was on a shelf in the freezer. The box was not covered or sealed. c. An open box of fish patties was on a shelf in the freezer. The box was not covered or sealed. d. An open box of corn dogs was on a shelf in the freezer. The box was not covered or sealed. e. An open box of cinnamon rolls was on a shelf in the freezer. The box was not covered or sealed. f. An open box of beef patties was on a shelf in the freezer. The box was not covered or sealed. g. An open box of okra was on a shelf in the freezer. The box was not covered or sealed. 4. On 2/14/22 at 11:40 AM, Dietary Employee (DE) #1 washed his hands in the hand washing sink. He used his bare hands to turn off the faucet contaminating his hands. He then, picked up a clean blade and attached it to the base of the blender to be used in pureeing foods to be served to the residents who required pureed foods for lunch. DE #1 immediately was asked, What should you have done after touching dirty objects before handling clean equipment? He stated, I should have washed my hands. 5. On 2/14/22 at 12:25 PM, an open box of vanilla wafers was on a shelf in the storage room. The box was not covered or sealed. 6. On 2/14/ at 12:26 PM, an open bag of cereal was on a shelf in the storage room. The bag was not sealed. 7. On 2/14/22 at 12:37 PM, the temperature of the food items when checked and read on the steam table by DE #1 were as follows: a. Mashed Potatoes (on the counter) - 118 degrees Fahrenheit. b. Yams - 123 degrees Fahrenheit c. Peas - 117 degrees Fahrenheit. 8. On 02/14/22 at 1:06 PM, during lunch meal service on the 300 Hall Secure Unit, staff put on gloves and removed trays from the insulated cart and took the trays to each resident. Staff opened plastic packages of plastic silverware and used the silverware to cut meat and cut baked sweet potatoes and opened packets of salad dressing and squeezed onto the salads. After setting up each tray, the staff returned to the cart and wearing the same gloves and without performing hand hygiene, retrieved another tray from the cart. Without performing hand hygiene and while wearing the same gloves, Certified Nursing Assistant (CNA) #3 removed a pitcher of red punch from the top of the cart and poured a cup of punch for each resident. Without performing hand hygiene and while wearing the same gloves, she removed a tray from the cart and placed the tray in front of a resident. She opened a package of plastic utensils and removed the utensils from the package. Wearing the same gloves, she tore open a package of salad dressing and squeezed the dressing onto the resident's salad. She returned to the cart and retrieved another tray. Wearing the same gloves and without performing hand hygiene, she took the tray and placed it in front of another resident and set up the tray. When meal service was completed, the staff removed their gloves and washed their hands in the sink. 9. On 02/14/22 at 1:41 PM, staff were serving lunch trays to the residents on the 100 Hall and the 400 Hall. Staff were not wearing or changing gloves and was not sanitizing their hands between each resident. Hand sanitizer was available on both hallways. 10. On 02/15/22 at 9:30 AM, staff were serving breakfast trays to the residents on the 100 Hall and the 400 Hall. Staff were not wearing or changing gloves and was not sanitizing their hands between each resident. Hand sanitizer was available on both hallways. 11. On 02/17/22 at 2:06 PM, CNA #2 was asked, When should hands be sanitized when meal trays are being passed to the residents on the halls? She stated, In between each resident being served. 12. On 02/17/22 at 2:13 PM, the Director of Nursing (DON) was asked, When should hands be sanitized when meal trays are being passed to the residents on the halls? She stated, In between every resident. 13. The facility policy titled, Infection Control and Prevention Plan for COVID-19, provided by the Administrator on 2/17/22 at 1:15 PM documented, .Communal Dining: Hand hygiene (alcohol based hand sanitizer or hand washing station) must be available in the dining area for use by residents and facility staff . 14. The facility policy titled Snacks (Between Meal and Bedtime), Serving, provided by the Administrator on 2/17/22 at 1:23 PM documented, .Infection Control Protocol and Safety .wash your hands .before the procedure . upon completion of your task or procedure .

Based on observation and interview, the facility failed to ensure trash was properly contained within 2 of 2 dumpsters to minimize the presence of foul odors and decrease the potential for pest infestation. The findings are: 1. On 2/14/22 at 11:02 AM, the lids to 2 dumpsters behind the facility were not closed. Both dumpsters were overflowing with trash. overflowing. There were loose gloves, paper plates, forks, straws, spoons, milk cartons, diapers, gowns, cola cans, and a loose mixture of food items on the ground in front of the dumpsters. There was an accumulation of trash between the dumpsters. 2. On 2/15/2022 at 7:57 AM, there were loose papers, forks, shoe covers, gowns, milk cartons and loose bags of trash on the ground beside the two dumpers. One dumpster was empty and and one was full. 3. On 2/15/2022 at 11:01 AM, the Maintenance Supervisor was asked to describe the area around the dumpsters. He stated, There is trash everywhere on the ground. Waste Management comes every other day. They come Monday, Wednesday and Friday.

Based on observation, record review and interview, the facility failed to ensure assistance with eating was promptly provided and the staff sat at eye level when assisting with eating to enhance the quality of life for 1 (Resident #75) of 2 (Residents #75 and #78) sampled residents who required assistance with meals. This failed practice had the potential to affect 7 residents who were dependent on staff for feeding according to a list provided by the Nurse Consultant on 2/17/22 at 2:03 PM. The findings are: 1. Resident #75 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set with an Assessment Reference Date of 01/21/22 documented the resident scored 6 (0-7 indicates severely cognitively impaired) on a Brief Interview of Mental Status and required extensive physical assistance of one person with eating, was on a mechanically altered diet and had a weight loss of 5% or more in the last month or loss of 10% or more in last 6 months and was not on a physician-prescribed weight-loss regimen. a. The Plan of Care with a revision date of 09/02/21 documented, .The resident has an ADL [activities of daily living] self-care performance deficit . requires set up assist [assistance] with meals/eating . b. On 02/14/22 at 1:41 PM, Resident #75 was lying in bed. Certified Nursing Assistant (CNA) #6 came into the room and placed Resident #75's lunch from the food warmer cart on her bedside table. Resident #75 asked Certified Nursing Assistant (CNA) #6 to help feed her. CNA #6 told the resident that she had to finish serving the meals to the other residents and she would come back and help her eat. CNA #6 left the room and continued passing trays. Resident #75's meal consisted of pureed green beans, chicken, creamed potatoes, oranges, salad, and pudding. Resident #75 was trying to feed herself lying down in her bed while continuing to yell out for someone to please come and help feed her. c. On 02/14/22 at 2:15 PM, Resident #75 was lying in bed asking for assistance to be fed. Registered Nurse (RN) #3 was walking down the 400 hall and was asked, Does [Resident #75] need assist to feed? She stated, I am not sure, let me look at her and see. RN #3 went into Resident #75's and looked her meal and stated, Yes, she does need assistance with feeding but I will need to get someone to help me pull her up in bed so we can get her fed. RN #3 was informed Resident #75's lunch tray had been setting on her bedside table since 1:41 PM, and it was now 2:21 PM. RN #3 was asked, Should a resident have to wait over for over 40 minutes for someone to help feed her? She stated, No, I am going to get someone to help me pull her up in bed, straighten her up and I will feed her myself. d. On 02/14/22 at 02:30 PM, Certified Nursing Assistant (CNA) #6 was standing up feeding Resident #75 with the door opened. The resident was not offered a fresh warm meal and CNA #6 did not offer to warm the food up that had been sitting on the resident's bedside table for over 40 minutes. e. On 02/16/22 at 2:42 PM, the Director of Nursing (DON) was asked, How are meals to be served to residents eating in their rooms? She stated, The independent residents that can feed themselves should be served first and after those trays are passed, then the residents that are needing assistance with feeding from staff are served last and the person feeding them should be eye level to the resident while feeding them. The DON was asked, Should a meal be place on the bedside table of a resident that needs assistance with feeding and sit on the bedside table for over 40 minutes before someone comes to help her eat? She stated, No ma'am. The DON was asked, What should have been done with the meal that had sat on the bedside table of the resident for over 40 minutes? She stated, Well, they should have gone to the kitchen and got a fresh tray if it [the tray] had been sitting that long and they could have offered to warm the meal up before feeding her, but I would say it would have been better if staff had just went to the kitchen and had dietary make her a fresh tray.

Based on observation, record review and interview, the facility failed to ensure fingernails were regularly trimmed and cleaned to promote good personal hygiene and grooming for 2 (Residents #11 and #29), failed to ensure facial hair was removed for 5 (Residents #11, #78, #52, #50 and #29) and failed to ensure baths or showers were regularly provided for 2 (Residents #50 and #78) of 19 (Residents #3, #85, #245, #15, #33, #36, #29, #50, #65, #54, #55, #78, #11, #17, #12, #42, #75, #91 and #52) sampled residents who were dependent for nail care, required assistance with shaving and with bathing. The findings are: 1. Resident #11 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/10/21 documented the resident scored 0 (0-7 indicates severely cognitively impaired) on a Brief Interview for Mental Status (BIMS) and required limited physical assistance of one person with personal hygiene and bathing. a. The Care Plan with a revision date of 01/14/22 documented, .The resident has an ADL [activities of daily living] self-care deficit r/t [related to] [CONDITION(S)] and muscle weakness . Bathing and Hygiene: The resident requires extensive assistance (1) staff with bathing/showering. Personal Hygiene: The resident requires extensive assistance with personal hygiene . The Care Plan did not specifically address nail care or the shaving of facial hair. b. On 02/14/22 at 11:53 a.m., Resident #11 was in his room with no clothes on, attempting to put on a pair of denim jeans, his facial hair was ¼ inch long. c. On 02/15/22 at 10:20 AM, Resident #11 was lying in bed. His facial hair was ¼ inch long and his fingernails were 1/8 inch long from the tip of some of his fingers, uneven, and jagged with a dark substance under them. d. On 02/16/22 at 02:28 PM, Resident #11 was lying in bed. His facial hair was ¼ inch long. He was asked, Are you growing a beard? He answered, No, I am not growing a beard. e. The POC [Plan of Care] Response History for ADL - Personal Hygiene from 02/03/22 to 02/16/22 in the Electronic Medical Record (EMR) did not document Resident #11 had refused personal hygiene. 2. Resident #52 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission MDS with an ARD of 11/18/21 documented the resident scored 3 (0-7 indicates severely cognitively impaired) on BIMS and required limited physical assistance of one person with personal hygiene and bathing. a. The Care Plan with a revision date of 01/27/22 documented, . The resident has an ADL self-care deficit r/t . Bathing: is totally dependent on staff for bathing. Requires extensive assistance of (1) staff . Personal Hygiene: .requires the assistance of one (1) staff with personal hygiene . The Care Plan did not specifically address nail care or the shaving of facial hair. b. On 02/14/22 at 12:12 PM, Resident #52 was sitting in the Dining Room with his wife. He was wearing red sweatshirt and sweatpants. His facial hair was ¼ inch long. c. On 02/15/22 at 7:49 AM, Resident #52 was in the Dining Room wearing a red sweatshirt, black pants, and shoes. His facial hair was ¼ inch long. d. On 02/16/22 at 2:18 PM, Resident #52 was in the Dining Room wearing a red sweatshirt, black pants, and shoes. His facial hair was ¼ inch long. He was asked, Do you like your beard? He answered, No. I don't want a beard. e. The POC Response History for ADL - Personal Hygiene from 02/03/22 to 02/16/22 in the EMR, did not document Resident #52 refused personal hygiene on 02/16/22. 3. On 02/17/22 at 10:15, CNA #5 was asked, Who is responsible for shaving the men? He answered, We do it on their shower days. He was asked, Who is responsible for nail care? He answered, If they are diabetic, the nurse does it. If they are not diabetic, we do nails on Sunday. He was asked, Does [Resident #11] look like he needs a shave? He answered, Yes. We have only single blade razors, and they pull the hair and hurt the men. We used to have an electric razor that worked better but it is missing. He was asked, Does [Resident #52] look like he needs a shave? He answered, Yes. They all need a shave. We are just trying to keep them clean. The Administration is aware that we need different razors. 4. Resident #78 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly MDS with an ARD of 12/20/21 documented the resident was severely impaired in cognitive skills for daily decision making on the Staff Assessment for Mental Status (SAMS) and required extensive physical assistance of one person with personal hygiene and was totally dependent of one person with bathing. a. The Care Plan with a revision date of 02/03/22 documented, The resident has an ADL self-care deficit r/t . Bathing: The resident is totally dependent on staff for bathing. Requires assistance of (1) staff . Nail Care: Check nail length and trim and clean as necessary .Personal Hygiene/oral care: The resident is totally dependent staff x [times] 1 for personal hygiene and oral care . The Care Plan did not specifically address shaving of facial hair. b. On 02/14/22 at 11:50 AM, Resident #78 was lying in bed. He had approximately 3 millimeter long facial hair on his chin. His hair was matted and stuck to his head. c. On 02/15/22 at 7:55 AM, Resident #78 was lying in bed. His hair was matted and stuck to his head. He had approximately 3 millimeter long facial hair on his chin d. On 02/16/22 at 2:21 PM, Resident #78 was lying in bed. His hair was matted and stuck to his head. He had approximately 3 millimeter long facial hair on his chin. e. The POC Response History for ADL - Personal Hygiene from 02/03/22 to 02/16/22 in the EMR, did not document Resident #78 had refused personal hygiene. 5. Resident #29 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Quarterly MDS with an ARD of 12/02/21 documented the resident scored 6 (0-7 indicates severely cognitively impaired) on a BIMS and required extensive physical assistance of one person with bathing and personal hygiene. a. The Care Plan with a revision date of 01/20/22 documented, .The resident has an ADL self-care performance deficit r/t [CONDITION(S)] . Bathing: dependent assist [assistance] X 1 .Personal Hygiene/oral care: extensive assist X 1 . The Care Plan did not specifically address nail care or the shaving of facial hair. b. On 2/14/22 at 1:47 PM, Resident #29 was lying in bed and had chin hair approximately ½ inch long. He stated he likes his face to be shaved. His fingernails, on both hands, were 1/8 inch long from his fingertips, uneven and jagged, and had a brown substance under the nail tip. He stated he does not recall the last time staff did them. c. The POC Response History for Nail Care from 01/17/22 to 02/15/22 in the EMR documented Resident #29 received nail care on 1/23/22, 1/30/22 and 2/13/22. d. The ADL - Bathing Task Sheet from 01/17/22 to 02/15/22 provided by the Director of Nursing (DON) on 02/15/22 at 3:45 PM documented, .ADL - Bathing 2-10 Monday, Wednesday, Friday. The last date and time documented was on 2/9/22 (Wednesday) at 17:37 (5:37 PM) sponge bath. 6. On 02/14/22 at 3:19 PM, CNA #3 was asked, How often do the residents receive their showers? She replied, Three times a week. CNA #3 was asked, Who gives them their showers? CNA #3 replied, The shower team usually does them but if they don't the day shift CNAs does them. CNA #3 was asked, When are the residents shaved, men and women? She replied, On their showers days and as needed. She was asked, Who does the nail care on the residents? CNA #3 replied, The CNAs and if they're a diabetic the nurses. CNA #3 was asked, When is the nail care performed? She stated, Every day, we can clean the diabetics nails, but we cannot trim them. 7. On 02/14/22 at 3:29 PM, Licensed Practical Nurse (LPN) #4 was asked, How often do the residents receive showers / bed baths? She replied, Three times a week, the shower team does the showers. LPN #4 was asked, When are the residents shaven, men and women? She replied, On their shower days, and prn [as needed]. LPN #4 was asked, Who does nail care on the residents? LPN #4 replied, The CNAs, if diabetic the nurses. LPN #4 was asked, When is the nail care completed? She replied, On their shower days and prn. LPN #4 accompanied the surveyor to the Resident #29's room and was asked, When was the last time the resident was shaved? She replied, 'I do not know, it's been a while. LPN #4 was asked, What is that brown substance under his nail tips. She replied, I have no idea. LPN #4 was asked, Does his fingernails need to be, clean, trimmed and filed? She replied, Yes. 8. Resident #50 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly MDS with an ARD of 12/28/22 documented the resident scored 10 (8-12 indicates moderately cognitively impaired) on a BIMS and required extensive physical assistance of two plus persons with bathing and extensive physical assistance of one person with personal hygiene. a. The Care Plan with a revision date of 02/02/22 documented, .Resident requires assistance with ADL functions r/t diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . HYGIENE/PERSONAL CARE: requires ext [extensive] assist [assistance] X 1 for all hygiene and personal care needs . The Care Plan did not specifically address shaving of facial hair. b. On 02/14/22 at 2:33 PM, Resident #50 was lying in bed, she had facial hair approximately ½ inch long on her chin. She stated she has not been shaved in a long time and wants it gone. The CNAs tell me when we can get around to it, they will shave me. She stated she receives one bath every two to three weeks and has refused showers since it's too hard on her but prefers a bed bath and the CNAs know this. I don't ever refuse a bed bath. c. The ADL - Bathing Task Sheet from 01/17/22 to 02/15/22 provided by the DON on 02/15/22 at 3:45 PM documented, Bathing 2-10 Tuesday, Thursday, Saturday. Resident #50 Resident Refused on 2/5/22 (Saturday), was Resident Not Available on 2/8/22 (Tuesday) and Not Applicable was marked on 2/10/22 (Thursday). d. On 02/14/22 at 3:33 PM, LPN #4 accompanied the surveyor to Resident #50's room, and was asked, When was the last time the resident had a shower / bed bath? LPN #4 replied, I do not know. LPN #4 was asked, What is on her chin? She replied, Facial hair. LPN #4 was asked, When was the last time she was shaven? She replied, I have no idea? LPN #4 was asked, Does her facial hair need to be shaved? She replied, Yes. 9. On 02/14/22 at 3:38 PM, the DON was asked, How often do the residents receive showers? She replied, Three times a week. The DON was asked, When are the residents shaven? She replied, Everyday if needed and on shower days. She was asked, Who performs nail care on the residents? She replied, The CNAs, if diabetic the Treatment Nurse. The DON was asked, When is nail performed on the residents? She replied, Twice a week and prn. She was asked, Who is responsible to ensure showers, the residents are shaven and nail care is completed as needed? She replied, The nurses. The DON was asked, What does Not Applicable mean on the task sheet? She replied, It's not applicable at that time. 10. On 02/17/22 at 12:35 PM, the DON was asked, Who is responsible for shaving the men? She answered, The CNA on the hall or if we have a shower team, they do it. She was asked, Who is responsible for providing nail care? She answered, The CNA on the hall or the shower team. She was asked, could there be a negative outcome if a resident isn't shaved? She answered, Hair harbors bacteria, or it could be a dignity issue. 11. The facility policy titled, Personal Needs, provided by the Administrator on 2/17/22 at 8:11 AM documented, The facility strives to promote a healthy environment by meeting the personal care needs of the residents . Personal care and support include but is not limited to . nail care . shave .

F689 Based on record review and interview, the facility failed to that the residents environment was free from accidents/hazards and failed to ensure that residents were provided with adequate supervision to prevent accidents/injuries, as evidenced by failure to ensure the housekeeping carts were locked/secured while on the dementia unit that housed chemicals, as evidence by a resident getting a bottle of Pine-Sol off the cart. This failed practice resulted in a current non-compliance at the level of immediate jeopardy, which caused or could have cause serious harm, injury, or death for Resident #1. This failed practice had the potential to affect 28 residents who resident on 300 hall, which had a Brief Interview Mental Status (BIMS) score of 12 or lower, as documented on listed provided by the administrator on 9/20/21 at 4:10pm. The administrator was notified of the immediate jeopardy condition on 9/20/21 at 3:47pm. The findings are: 1. Resident #1 was admitted to the facility on [DATE] with the diagnoses of [CONDITION(S)], Autistic Disorder, Unspecified [CONDITION(S)] not due to substance or known physiological condition, and Unspecified Intellectual Disabilities. The Quarterly Minimum Data Set (MDS) with the Assessment Reference Date (ARD) of 7/1/21 documented no BIMS score; the MDS did documented a Staff Assessment for Mental Status (SAMS) score of 3 (indicates severely impaired). The resident is totally dependent on 2 or more staff members for bed mobility, transfers, dressing, eating, toilet use, personal hygiene, and bathing. a. The update care plan with a revision date of 7/2/2021 documented, .Resident appears to have impaired cognitive function r/t [related to] Rarely/Never Understood/Understands, [CONDITION(S)], Autism, Intellectual Disabilities . and .Resident has fair to poor safety awareness and requires supervision / prompts / cues . b. On 9/18/21 at 3:10pm a progress note documented, .Description of incident: I was notified by a janitor that one of our residents had or may had drunk some pine-sol cleaner. I immediately notify my weekend supervisor and went to see resident. Resident was laying in bed with covers over his head. Resident had no smell of pine-sol on him. Resident was alert x 1 to his baseline. Floor was dry. Lights were on. Immediate intervention: I took an Initial set of VS and then call poison control. We discuss the type of pine-sol that may have been used and since it was 8% containing pine oil and not the 20% percent they felt like monitor for 24 hours would be safe. They told me to look out for symptoms like nausea, coughing, fever, emesis, like flu like symptoms to consider that poisoning and resident would need to go to ER. I call [NAME] Clinic and spoke to the APRN on call and told them what poison control told me. She agreed with the plan and ordered a cbc and cmp for Monday to make sure resident was ok. I talked to resident's case manager, she wants a copy of the incident report and was concerned about resident's health. She stated that we could call anytime if anything changes in his status. An in-service was made and we started having employees sign it about having cleaning supplies locked up on cleaning carts . c. On 9/18/21 a facility Incident and Accident (I and A) form was filled and documented was .Description of incident: I was notified by a janitor that one of our residents had or may had drunk some pine-sol cleaner. I immediately notify my weekend supervisor and went to see resident. Resident was lying in bed with covers over his head. Resident had no smell of pine-sol on him. Resident was alert x 1 to his baseline. Floor was dry. Lights were on. Resident was unable to give description . d. On 9/20/21 the administrator provided in-services x2 dated 9/18/21 related to all chemicals must be kept in locked compartment of cart, especially on the secured it. Housekeeper #1 signed both in-services. e. On 9/20/21 at 12:55pm the administrator provided the Material Safety Data Sheet (MSDS) for the Pine-Sol and documented, .Ingestion: call poison control center or doctor for treatment advice . f. On 9/20/21 at 1:26pm interviewed License Practical Nurse (LPN) #1 and asked, On 9/18/21, can you tell about the incident that happened with Resident #1? And he stated, A housekeeper came to me and stated, I think that (resident #1) may or may not have drank some Pine-Sol. I went back there to the unit and assessed the resident, took his vital signs, then reported it to the weekend supervisor. I then called poison control and talked to them, The housekeeper told me that it didn't look like any was missing out of the bottle but the housekeeper did witness the resident holding the bottle of pine-sol in his hand. When I spoke with poison control, they told what to look for and what to watch for. I call the [NAME] Clinic for the on-call Advance Practicing Registered Nurse (APRN) and notified her of what is going on. She said to follow what poison control says and then she ordered some labs. I also notified the Adult Protective Services (APS) case worked because the resident is under APS guardianship. I continued to monitor the resident through-out the shift. He was asked, Was the resident sent to the hospital? and he replied, No, I was following what the poison control said. If he consumed any of the Pine-Sol, it was the 8% not the 20% bottle. When I was on the phone with poison control, we discussed the pine-sol and its percentage of ingredients. Poison control did call back 4 or 5 hours to check up on the resident and the resident was doing ok so the poison control dropped it since the resident was ok. He was asked, Did you physically witness the resident with the bottle of Pine-Sol in his hands? and he replied, No. I smelled his breath and his hand. Neither one of them smelled of Pine-Sol. He was asked, Did the resident ever have any signs of consuming the Pine-Sol? and she replied, No. I believe he didn't drink it. g. On 9/20/21 at 1:40pm interview Certified Nurse's Aide (CNA) #1 and asked, On 9/18/21, do you remember what happened with resident #1? and she replied, We were cleaning up after lunch, and another CNA put the resident to bed. I was in the kitchen tidying up. The housekeeper [housekeeper #1] was at her at cart, getting ready to clean and then I heard the housekeeper say, I think that the resident drank the Pine-Sol. So, I turned around and there was the resident by the cart. She was asked, Do you think that the resident consumed the Pine-Sol? and she replied, No, I do not because I smelled his breath and I could not smell the pine-sol and I smelled his and I could not smell it on his hands. She was asked, Did you see the resident with the bottle of Pine-Sol in his hands? and she replied, No I did not. She was asked, Did the resident have any signs or symptoms that indicated that he drank Pine-Sol? and she replied, No. He was being himself after that. They were monitoring him closely and they even called Poison Control. h. On 9/20/21 at 1:56pm interviewed Housekeeper #1 and asked, Can you tell what happened with the resident and the Pine-Sol? and she replied, I was in the dining room on the secure unit, mopping the floor and there was some residents in there and the cart is always with me. I turned around and I saw the resident with the bottle of Pine-Sol in his hand, turned up like he was trying to drink it. She was asked, Was you cart locked? and she replied, No. She was asked, What type of lid did the bottle of Pine-Sol have? and she replied, It was a flip top lid. She was asked, was the flip top open or closed? and she replied, Closed. She was asked, Did you see the resident drink the Pine-Sol? and she replied, I don't know for sure if he drank it but I felt like I needed to report it. She was asked, Who did you report it to? and she replied, The nurse. She was asked, Could you tell if there was any liquid missing after the resident had the pine-sol in hand? and she replied, I think maybe a little bit. I it looked like a little bit may have been gone. She was asked, Was any liquid on the resident's face or clothes? and she replied, No not that I know of. I do know they smell his breath, and they said there was no scent of pine-sol on his breath. She was asked, What happened after you reported it to the nurse? and she replied, The nurse came back here and checked on the resident and then called Poison Control. i. On 9/20/21 at 2:25pm the administrator was asked, Did you watch the cameras to see what happened? ands he replied, Yes, but the cart was at angle and you could not the resident at the cart. j. On 9/20/21 at 2:40pm the surveyor observed housekeeper #1 on the secured unit cleaning tables in the dining room, cognitively impaired residents were sitting in the dining room and cognitively impaired residents were wandering up and down the halls; the cart was approximately 6 feet away from and the cart appeared to be unlocked. Housekeeper #1 stated Oh I forgot it to lock it. The housekeeper was asked, Can you tell what is in the cart? and she replied, Bathroom cleaner, hand sanitizer, window cleaner, and disinfectant. The surveyor observed a container of disinfectant wipes on the cart. k. On 9/20/21 at 3:15pm the maintenance director stated, The cart was locked but you still open it. And he was asked, Could a resident open the cart and get something out it? and replied, Yes. The maintenance director stated, I changed out all the locks on the carts, where they now locked. l. On 9/20/21 at 3:30pm the administrator provided a documented titled Housekeeping Equipment Supplied Care, Use, and Maintenance Policy and documented, .To provide care, use of maintenance of housekeeping equipment/supplies in a safe way consistent with industry standards . m. On 9/20/21 at 3:30pm the administrator provided a document titled Housekeeping Guidelines, and documented .Do not leave chemicals on cart unattended and must be locked at all times . n. On 9/20/21 at 3:47pm the administrator was notified of the current immediate jeopardy and deficient practice. 2. The Immediate Jeopardy was removed, on 9/20/21 at 4:46pm, when the facility implemented the following Plan of Removal: a. On 9/20/21 the maintenance supervisor and the administrator verified that all carts had appropriate locking devices in place and all pine-sol was removed. b. On 9/20/21 upon notification of deficient practice the maintenance supervisor replaced all existing locks on all housekeeping carts. c. On 9/20/21 housekeeper #1 was terminated immediately upon notification. d. On 9/20/21 upon notification of deficient practice the administrator/designee started in-servicing all current staff on ensuring all housekeeping carts are locked. e. Maintenance Supervisor/Designee will monitor housekeeping carts 7 days a week x4 weeks or until overall compliance is achieved and documented on the monitoring form provided by the administrator f. Maintenance Supervisor/Designee will present all findings to the monthly QA committee x1 quarter for further review and recommendations.

Based on observation, record review, and interview, the facility failed to ensure the urinary catheter tubing was secured to prevent potential trauma to the urinary meatus and a torn catheter bag was replaced for 1 (Residents #48) of 6 (Residents #4, #8, #48, #58, #66 and #71) sampled residents with indwelling catheters. This failed practice resulted in actual harm to Resident #48 who had no device in place to prevent the indwelling catheter from pulling on the meatus resulting in pain and an reddened and opened area to the meatus and had the potential to affect 7 residents who had indwelling urinary catheters, according to a list provided by the Director of Nursing (DON) on 11/19/2020. The findings are: Resident #48 had [DIAGNOSES REDACTED]. The Annual Minimum Data Set with an Assessment Reference date of 10/26/2020 documented the resident scored 15 (12-15 indicates cognitively intact) on a Brief Interview for Mental status and required extensive assistance with toilet use, limited assistance with personal hygiene and physical help in part of bathing. a. The November 2020 Physician order [REDACTED].>Foley catheter 18 FRENCH WITH 10CC (cubic centimeters) Bulb Due To ([MEDICAL CONDITION]). Change PRN (as needed) Removal/Occlusion. Verify every shift placement of Foley Catheter privacy bag, every shift for Foley Cath, Verify every shift placement of Foley Catheter privacy bag. Foley catheter care every shift and prn with soap and water or wipe. Order Date 03/19/2020. b. The Care Plan dated 10/26/2020 documented, Resident has a Foley Catheter related to [MEDICAL CONDITION] Date Initiated: 12/15/2017 GOALS: Resident will be/remain free from catheter-related trauma through review date. INTERVENTIONS: Check tubing for kinks each shift. Monitor/document for pain/discomfort due to catheter. Monitor/record/report to MD for signs and symptoms UTI: pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, Urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating. Date Initiated: 03/12/2019. c. On 11/15/2020 at 11:57 A.M., Resident #48 was sitting in a chair in his room. He complained of pain when he walked due to the leg bag hanging and tugging on his catheter tubing. The resident showed the surveyor how he had secured his leg bag to his left thigh. The leg bag was tied around his thigh with the leg band, the bag was discolored and dirty and the opening for the leg strap at the bottom of the bag was torn out. Resident #48 stated, I've asked for a stat-lock & leg band for the last week because my leg bag is tore up and the leg bands won't stay on it, I've tried to tie the bag up with the straps that hold the bag on my leg. You can tell I have had this bag for a long time because it is so dirty and filthy. I had a stat-lock when I came over from the 400 hall. The glue came off it and it would not stick to my leg anymore. Resident #48 was asked, When did you start hurting down there? He stated, I have been hurting for a while, but when the stat-lock came off it hurt a lot worse, especially when I stand up. He was asked, Did you tell anyone that you were hurting? He stated, Yes, I did. I heard the (nurse) in the hallway yesterday. I told him, but he didn't do anything. I told another nurse, but I can't remember her name. They change nurses a lot. I have told several nurses and aides. He was asked, What did the nurses do? He stated, They didn't do anything. He was asked, Did any of the nurses come in and look at your catheter site or check your stat-lock? He stated, I have shown it to them on several occasions, but they still haven't done anything to it. They talked like they were going to get me a stat-lock, but no one has got me one yet. The aides do come in sometimes and empty my bag and help me with my bath, but they just wouldn't get me a new bag. d. On 11/15/2020 at 1:34 P.M., the DON was asked, Can you come in and look at the condition of the (Resident #48's) Foley catheter leg bag? She came into the room and asked Resident #48 if he would pull his pants down and lie down so she could observe his Foley catheter bag. The resident showed the DON his Foley bag and how he had it secured it to his leg. The DON was asked, Do you think this resident needs a new catheter leg bag? She stated, Yes he does. She was asked, Should he have a stat-lock to secure the tubing? She stated, Yes he should have one. Resident #48 told the DON, It hurts me down there when I stand up because there is nothing to break the pull when I walk. He then told her, I have had this bag for way over a month, it's dirty and torn up and I need a new one. The DON was asked, How do the staff ensure (Resident #48) has a stat-lock to secure his Foley tubing? She stated, Each shift should be checking for placement and making sure the stat-lock is in place and there are no problems with the catheter. e. On 11/15/2020 at 2:43 P.M., Certified Nursing Assistant (CNA) #4 was asked, Has (Resident #48) asked you for a stat-lock? She stated, No he hasn't asked me for one and I've been off for two days. She was asked, Should a resident with a Foley catheter have a stat-lock? She stated, Yes, they should. She was asked, What do you do if a resident needs a stat-lock? She stated, I would let the nurse know. f. On 11/15/2020 at 2:55 P.M., Licensed Practical Nurse (LPN #5) received the stat-lock and the new drainage leg bag from the DON. LPN #5 entered the resident's room and explained to him that she was going to change his bag out and place a stat-lock on his leg to secure his catheter tubing. Resident #48 said, Thank you. LPN #5 looked at the meatus and the meatus was irritated and reddened with a small 2 mm (millimeter) open area. LPN #5 was asked, How often is (Resident #48's) catheter changed? She stated, Once a month. She was asked, Who is responsible for emptying (Resident #48's) bag and changing the leg bags out? She stated, The CNAs are supposed to empty the bag at the end of each shift. She was asked, Has (Resident #48) complained to you about pain with his catheter? She stated, No he hasn't. g. On 11/15/2020 at 3:15 P.M., LPN #2 was asked, Did (Resident #48) inform you yesterday that he needed a stat-lock and a new leg bag? He stated, He did tell me that there was something wrong with his bag because it was leaking. He was asked, What did you do? He stated, I was orientating a nurse to the 200 unit yesterday, so I asked her to look at it. I'm not sure if she looked at it but he said he needed a stat-lock, so I tried to get one from the other side and they didn't have one and we never got one before I left. He was asked, Did you let the oncoming shift know about it? He stated, No I didn't and I'm not sure if the other nurse did either. He was asked, Should (Resident #48's) have a stat-lock on his catheter tubing? He stated, Yes, he should have a stat-lock and a leg band. He was asked, Did (Resident #48's) complain of pain at his catheter site yesterday? He stated, He complained of back pain and I gave him a [MEDICATION NAME], then later on he did complain of some pain when he was talking about his stat-lock, but he complains about back pain and bladder pain often. h. On 11/15/2020 at 3:37 P.M., CNA # 3 was asked, Did (Resident #48's) have a stat lock? CNA #3 stated, I think so. Yesterday he said something was wrong with his bag because it was leaking, I told (LPN #2). CNA # 3 was asked, Did he complain about his catheter yesterday? She stated, I was training yesterday, the resident complained about the band and stat-lock. We didn't have a stat-lock at that time. (LPN#2) tried to get one but couldn't find one. She was asked, Have you emptied his catheter bag recently? She stated, He opens his bag up sometimes and his bag will be empty, and it drains all over the place so I would clean him up and then clamp the bag. i. On 11/15/2020 at 3:49 P.M., LPN #3 stated, I was orienting with (Nurse) on 200 yesterday. She said (Resident #48) complained about a strap for the catheter. He didn't ask me to check it, he called up front and didn't get an answer I don't know if he got one. j. A Female and Male Catherization Policy provided by the Administrator on 11/15/2020 at 2:46 P.M. documented, . Indwelling Catheters: PROTOCHOL: Catheters will not be used unless the resident/patient's clinical condition demonstrates that catheterization is necessary, and a physician's orders [REDACTED]. Indwelling Catheter. # 2 Connect catheter to drainage bag. Hang below level of bladder. Check drainage tubing to assure it does not loop below the top of the drainage bag. Secure catheter to the leg strap or secure device as required .

Complaint # (AR 531) was substantiated, all or in part, in these findings. Based on record review and interview, the facility failed to ensure an assessment was completed immediately upon discovery of swelling and bruising of the arm and a change in mental status (inability to remember or describe an event that caused injury in a resident who was normally able to do so) and failed to ensure the physician was immediately notified of the change of condition to prevent a delay in providing medical treatment for 1 (Resident #1) of 4 (Residents #1, #3, #4 and #7) case mix residents who had a change in condition in the past 30 days. This failed practice resulted in immediate jeopardy, which caused or could have caused serious harm, injury or death for Resident #1, who, upon assessment by the Advanced Practice Nurse (APN) approximately 9 hours later, was discovered to have bruising and swelling to the right arm with a weak radial pulse, severe bruising to the torso and back and was diagnosed with [REDACTED]. The facility was notified of the Immediate Jeopardy on 10/12/16 at 4:27 p.m. This failed practice had the potential to affect 21 residents who had a change in condition in the past 30 days, according to a list received from the Director of Nurses (DON) on 10/12/16. The findings are: 1. The facility's Policy and Procedure for Change in Condition, received from the DON on 10/12/16, documented, Policy: It is the policy of this facility to monitor residents for changes in their condition, to respond appropriately to those changes and to notify the Physician and responsible party/family member of changes . Procedure . 2. In the event of a non-life threatening but significant change in the resident's condition, the facility will notify the Physician, according to American Medical Directors Association (AMDA) guidelines unless otherwise directed by the Physician . 2. Resident #1 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set with Assessment Reference Date of 8/5/16 documented the resident scored 14 (13-15 indicates cognitively intact) on the Brief Interview for Mental Status; had no behaviors; required limited assistance of 1 person for bed mobility, transfers, walking in room and corridor; and personal hygiene, was not steady and only able to stabilize with staff assistance when moving from seated to standing position and surface to surface transfers; had no functional limitation in range of motion of the upper or lower extremities; used a wheelchair for mobility; was frequently incontinent of bladder and always incontinent of bowel, and had no falls. a. The Care Plan, not dated, documented, Problem Onset: 7/14/2014 Res (Resident) has hx (history) of falls. He is non-ambulatory but does transfer himself. He takes Antipsychotic/Antidepressant medication. At risk for . falls Approaches Res reminded to call for assist as needed/call light in reach. Staff to notify Nurse if Res. becomes unsteady with transfers. b. A Fall Risk Evaluation dated 9/1/16 documented, . History of Falls - Post Admission . Yes . Balance . Balance: walking (with assistive device if used) . Activity did not occur . Balance; turning around while walking . Activity did not occur . Balance moving on and off toilet . Not steady, but able to stabilize without human assistance . Summary . Fall Risk Score A score above 10 indicates Resident is at risk for Falls . Grand Total: 4 . c. Nurses Notes dated 10/6/16 at 9:47 a.m. documented, Noted 3+ (plus) [MEDICAL CONDITION] in right hand & (and) lower arm. Resident is taking [MEDICATION NAME] c/o (complains of) discomfort in right shoulder & (and) arm at times. Referred to APRN (Advanced Practice Registered Nurse). d. Nurses Notes dated 10/6/16 at 2:16 p.m. documented, Refer to earlier note regarding [MEDICAL CONDITION] noted this morning in R (right) hand & arm & subsequent referral to APRN. APRN saw Resident at aprox (approximately) 1340 (1:40 p.m.) & got R to remove shirt for eval (evaluation) & noted that resident had bruising to RUE (right upper extremity), R (right) back & sternum. Also noted fingerprint bruising to R back. Resident does not remember any fall or other incident to have caused this. Order received to transfer Resident to (Hospital name) ER (emergency room ) for eval &TX (treatment) & Doppler US (ultrasound) of R arm. (Family member) notified via voicemail . Resident transported via stretcher with (ambulance service) 1 & 2 assistance to (Hospital name) ER. e. The Hospital emergency room Physician Documentation report dated 10/6/16 at 3:18 p.m. documented, Description/onset of Symptoms: Pt (patient) transported from home (nursing home) via (ambulance service) for evaluation of abnormal bruising and right arm swelling. Pt denies falling and NH (Nursing Home) denies injury to EMS (Emergency Medical Services). Pt has dementia. Has bruising to the right chest and upper abdomen. Also has pain and swelling to right upper extremity as well . f. The x-ray report dated 10/6/16 documented, Conclusion: Possible impaction [MEDICAL CONDITION] distal humerus involving the capitellum. CT (computerized tomography) may be helpful. The CT Scan done on 10/6/16 documented, Impression, Anterior Shoulder dislocation that may be subacute to chronic. Large Hill-Sachs lesion with a large amount of osseous remodeling involving the humeral head and glenoid fossa. Age indeterminate fracture in the base of the acromium. Chronic-appearing coracoid process fracture. g. Primary Care Physician notes dated 10/6/16 documented, Chief complaint-Bruising HPI (History Physical Information) . Pt . who is a NH resident at (Facility Name). He has alcoholic dementia and cannot give any history. No known falls. Pt was sent to ER by NH (nursing home) staff for bruising. X-rays of RUE (right upper extremity) show possible distal humeral fracture . Physical Exam . Integumentary: No rash, other-reddish/purple bruising to right anterior chest at clavicular area, dark purple/blu (blue) bruising at chest with triangular shape at xiphoid process area following in the area below his breast and spreading to both sides. purple/blue bruising under right arm on trunk and axilla, purple bruising small circular spots on right mid back in the shape of fingers. Large purple bruising on right lower trunk on the side spreading to the right lateral hip. Face is normal, no bruising . Comment: Bruising is worrisome for possible abuse. Night Nurse and Charge Nurse had the same assessment and already contacted APS (Adult Protective Services) prior to my arrival. I had then contact (Police Department) as well. h. The Hospital Consultation dated 10/6/16 documented, (Resident #1) .was brought to the emergency room for bruising and right arm swelling. The patient has dementia and is unable to provide any history. He denies falling, but again does not answer other questions appropriately. We consulted for evaluation of possible right distal humerus fracture. The patient denies any pain. There is significant swelling to the right upper extremity, but no tenderness . Assessment Right upper extremity [MEDICAL CONDITION] with bruising. Review of x-rays. Humeral head changes appear to be chronic likely secondary to alcoholic vascular necrosis. The elbow shows what appears to be chronic changes to the capitellum. Plan: Treat conservative flow from our standpoint. No need for surgical interventions . i. On 10/12/16 at 11:40 a.m., Licensed Practical Nurse (LPN) #3 stated she worked the 10:00 p.m. - 6:00 a.m. shift. The LPN stated she had been employed by the facility for approximately 2 years. The LPN was asked how much help Resident #1 required. The LPN stated, He can transfer himself to the bed and bathroom. He calls if he needs help. The LPN was asked about the resident's mental status and the LPN stated, He is able to tell you what was going on. The LPN was asked if she worked the night of 10/5/16. The LPN stated, Yes. The LPN was asked what happened that evening with Resident #1. The LPN stated, He was up several times during the night; at one time, I helped him get money out of his pocket. He went to the snack machine. The LPN was asked if the resident's hand was swollen at that time. The LPN stated, I didn't notice at that time. The LPN stated, I noticed his hand was swollen between 3:30 and 4:00 a.m. The resident complained of pain in his right arm. I gave him Tylenol and noticed that his hand was swollen. The LPN was asked if she assessed the resident at that time, due to the pain in the right arm and swelling of the right hand. The LPN stated, No, I passed it on to the day nurse, and she was going to put him on the list for the APRN to check. The LPN was asked, If the resident had a change of condition, should you have assessed the resident? The LPN stated, Yes, but I assumed he slept on it. The LPN was asked if the resident had ever had a swollen hand before. The LPN stated, I can't remember. The LPN was asked, Could the resident tell you what happened? The LPN stated, He usually could tell you what's going on. The LPN was asked if the resident was able to tell her about his swollen hand. The LPN stated, No. The LPN was asked if the resident should have been assessed at 4:00 a.m. when you found the right hand was swollen. The LPN stated, I should have; I didn't. The LPN was asked, Did you check with the staff to see if the resident had fallen? The LPN stated, If something had happened, they would have let me know. j. On 10/12/16 at 9:42 a.m., Certified Nursing Assistant (CNA) #1 stated she had been employed by the facility for approximately 3 years and worked the 6:00 a.m. - 2:00 p.m. shift and would occasionally work over on the 2:00 p.m. - 10:00 p.m. shift. The CNA was asked if she had taken care of Resident #1. The CNA stated, Yes. The CNA was asked how much help Resident #1 required. The CNA stated, Minimum assistance in the morning. He was usually already dressed and up in the wheelchair or occasionally lying across the bed. He liked to be independent. He only needed supervision with care. He appreciated help. He would transfer to bed and to the toilet himself. The CNA was asked, What do you recall regarding the day of 10/6/16? The CNA stated, The resident was already up in the chair, already dressed, sweat shirt. I let him know what time it was. He said 'ok' and 'going to dining room for breakfast'. Later, he had pushed the call light to ask for help. I went in and he had already put his arm in the sweater. The CNA was asked if she had gotten the resident dressed. The CNA stated, Not really; he had already put his arms in the sweater so I pulled it down in the back. I noticed that his hand and wrist were swollen. I asked him what happened. He said he didn't know. I asked him to make a fist and he did and I touched his hand and it was tight. I reported to the nurse (LPN #4). The CNA was asked if it was normal for the resident to be unable to explain or remember what happened. The CNA stated, .he could usually tell us what happened. The CNA was asked if she saw any other bruising at that time. The CNA stated, Just the discoloration of the hand and arm that I reported to the nurse. k. On 10/12/16 at 10:05 a.m., LPN #1 stated she had worked at the facility for approximately 13 months. The LPN stated she worked the 6:00 a.m. - 2:00 p.m. shift. The LPN was asked if she took care of Resident #1. The LPN stated, Yes. The LPN was asked how much care Resident #1 required. The LPN stated, He required more supervision due to he was prone to falling out of bed. The LPN was asked if she had worked 10/5/16 and 10/6/16 and the LPN stated, Yes. The LPN was asked what happen that day, 10/6/16, with Resident #1 and the LPN stated, That morning (10/6/16) I noticed his hand was swollen. I noticed it about 5:30 a.m., before I even clocked in. I don't know what time I charted it. I asked the resident, but he said he didn't know how it happened. I asked if it hurt and I was going to have APRN check him. The LPN was asked if she assessed the resident. The LPN stated, No. At that time, he wasn't his usual self. I asked him at that time if anything else was swollen. I only looked at his hand and lower arm. The LPN was asked if he had refused to let her assess/check him. The LPN stated, I just pulled his shirt sleeve up and looked at his lower arm and he stated, 'I'm fine darling. I'm going to get a cup of coffee.' He was in a great mood; he said nothing was wrong. He was in the mood that he didn't want to be bothered. The LPN was asked if she had asked the resident if she could check his arm. The LPN stated, No. The LPN was asked, During the day, did you go back and check the resident and try to assess him later in the day? The LPN stated, No. The LPN was asked if the resident could usually remember and explain what was going on with him. The LPN stated, Yes. The LPN was asked, The resident had a change of condition, with the swelling of the right hand and the change in his ability to tell you what happened, but you did not assess the resident? The LPN stated, No. The LPN was asked, When does the APRN make rounds? The LPN stated around 1 or 1:30 p.m. The LPN was asked, When did the APRN make rounds on 10/6/16? The LPN stated, It was around 1:30 (p.m.); the next shift had already gotten here. (LPN #2) and the APRN were in the room, and they called me to come in the room. When he took his shirt off, I was absolutely stunned. He had a hematoma under the right arm (the LPN pointed to her axillary area), bruises on his right side around to the back, the chest area, and sternum. The APRN was requesting a doppler of the arm, and I left and proceeded to get paperwork in order. The LPN was asked if she had reported to the DON that the resident's right hand and arm was swollen and was unable to tell what happened to him. The LPN stated. No. The LPN was asked, If a resident has a change in condition, such as a swollen hand and arm, and is unable to recall what happened, should you have reported this to the DON? The LPN stated, I normally would, but I didn't. The LPN was asked if she had called the APRN or the Physician regarding the resident's swollen hand and arm and the resident's inability to recall what happened. The LPN stated, No, I put him on the list to be seen by the APRN. The LPN was asked, Should you have called the Physician or APRN? The LPN stated, Yes. l. On 10/12/16 10:56 a.m., LPN #2 stated she had been employed by the facility for 8 years and worked the 2:00 p.m. - 10:00 p.m. shift. The LPN was asked if she had cared for Resident #1. The LPN stated, Yes. The LPN was asked if the resident was able to remember and explain what was happening to him. The LPN stated, Yes. He could usually transfer himself; if he needed help, he would yell out for help. He didn't use the call light. The LPN also stated that on 10/6/16, she was clocking in, and the APRN was in the resident's room. The LPN stated, .that some point in the morning, the resident had swelling of the hand and his arm was hurting. The APRN removed his shirt and saw the bruising. I called the Day Nurse. The LPN was asked if the resident was able to tell what happened. The LPN stated, The resident was unable to give an explanation. The resident stated he hadn't fallen, but didn't know what happened. There were bruises on his chest and a triangle shaped area on the chest area. We couldn't see anything that could have caused a shaped area like that. The LPN was asked if the resident could dress himself. The LPN stated, Yes, at times he needed help pulling up his pants or pulling down his shirt. m. On 10/12/16 at 3:41 p.m., a phone interview was conducted with CNA #2. CNA #2 stated that she had been working at the facility for approximately 7 years on the 10:00 p.m. - 6:00 a.m. The CNA stated she had worked the night of 10/5/16 and took care of Resident #1. The CNA stated, (Resident #1) had been up most of the night and had been up and down going to the snack machine. He had drunk 2 sodas. I asked him if he needed anything and he said no. The CNA was asked if the resident could usually tell what was going on. The CNA stated, Yes. The CNA was asked if she had observed any problems with Resident #1. The CNA stated, No. The CNA was asked if she had noticed that Resident #1's hand was swollen. The CNA stated, I didn't notice. The CNA was asked if Resident #1 had fallen during the evening. The CNA stated, No. n. On 10/6/16 at 1:01 p.m., the APRN stated that she had worked at the facility for approximately 2 years. The APRN stated that she made rounds and, They (staff) put the residents on the list for me to see. The APRN was asked what time she usually made rounds. The APRN stated, Around 1:00 p.m. The APRN was asked when she was made aware of Resident #1's swollen hand. The APRN stated, When I made rounds that afternoon. The APRN was asked, When the nurses noticed the resident's hand was swollen and he was unable to tell what happened, what should they have done? The APRN stated, They should have looked at him more thoroughly. In my opinion, he should have been more thoroughly assessed. When I turned his hand over, it was swollen and the palm was purple; the hand was so swollen that I could barely get a pulse. I was concerned with a blood clot. When I took the shirt off, I saw all the bruises across his chest and back, and the hematoma on the underside of the right arm. When they said the CNA had gotten him dressed, I assumed they would have seen the bruising. The APRN was informed that the CNA stated she only pulled the sweater down. The APRN stated, When I got here, he wasn't himself. He couldn't tell me what happened. He has a history of low sodium and when he got to the hospital his sodium was 112, which could account for this. o. On 10/12/16 at 12:12 p.m., the was asked if the resident could usually tell you what was going on. The DON stated, Yes. The DON was asked, If a resident has a change of condition, hand swollen and unable to tell what happened should the nurse go and look at the resident to see what was going on and notify the physician? The DON stated, Yes, they should go down and assess the resident and notify the physician and the family. The DON stated she was called to the resident's room at approximately 1:45 p.m. and, .the APRN was there and she showed me the bruising and the hematoma. A period of 9 hours and approximately 40 minutes elapsed between when the swollen upper extremity was identified and when the resident was assessed. 3. The Immediate Jeopardy was removed and the scope and severity reduced to D on 10/12/16 at 6:06 p.m. when the facility implemented the following plan of removal: a. In-service initiated with all Nursing Staff per ADON (Assistant Director of Nursing) on Policy and Procedure for change in condition notification. Nursing staff instructed to notify Physician immediately when a change of condition is noted. All Nursing Staff not currently at the facility that are either on their off day, vacation or leave will receive this in-service prior to working their next shift per DON or designee. All new hires will be given this in-service per DON or designee during new hire orientation. b. Nurses in-serviced to always document changes of condition on the 24 hour report log. Nursing management staff will monitor 24 hour report log and incident and accident reports Monday through Friday during daily start up to verify all changes of condition have been followed-up on properly and that MD was notified immediately. Weekend Supervisor will monitor the above items each Saturday and Sunday. This monitoring will continue daily. This monitoring will be performed daily x (times) 2 weeks and then 3 times per week x 2 weeks.

A. Based on observation, record review and interview, the facility failed to ensure dishware, utensils, drinking glasses and pots / pans were sanitized before reusing and failed to ensure sanitizer levels in the low-temperature dish machine were routinely monitored to prevent potential food borne illness for the residents who received meals from 1 of 1 kitchen. This failed practice resulted in immediate jeopardy, which caused or could have caused serious harm, injury or death for 127 residents who received meals from the kitchen, according to the Diet Roster provided by the Dietary Manager on 6/13/16 at 2:40 p.m. (Total census: 128). The Administrator was notified of the immediate jeopardy condition on 6/13/16 at 5:32 p.m. The findings are: On 6/13/16 at 4:05 p.m., Dietary Employee #1 went into the dishwashing area of the kitchen and, after spraying 4 pitchers, 6 drinking glasses and 4 coffee cups with water, placed them in the dishwashing machine tray and put them through the dishwasher. The water temperature gauge on the dishwashing machine registered 136 degrees Fahrenheit (F.) for the wash cycle and the rinse cycle. Dietary Employee #1 was asked at this time, to test the dish machine for chemical sanitation. Dietary Employee #1 obtained a test strip and dipped it into the rinse water. The test strip did not change color to indicate the presence of sanitizer. The Dietary Manager (DM) got a new bottle of test strips and re-tested the water. The new test strip did not change color to indicate the presence of sanitizer. The surveyor observed the tubing running from the liquid sanitizer bottle to the machine, and there was no visible liquid sanitizer moving through the tube. The Dietary Manager stated, You are right; there is no sanitizer going through the line. At this time, the Temperature Record posted in a plastic sleeve on the wall in the dishwashing room was reviewed. The log documented morning and evening temperature results for the dish machine, but no sanitizer levels were documented. The temperature ranges for the wash cycle ranged from 124 to 184 degrees F. and rinse cycle temperatures ranged from 124 to 157 degrees F. b. On 6/13/16 at 4:10 p.m., Dietary Employee #1 was asked what the temperatures should be for the dish machine. He stated, Not sure. I just write it down on the log. He was asked if he used the test strips to check the sanitizer levels. He stated, No. c. On 6/13/16 at 4:15 p.m., the Dietary Manager was asked how often the sanitizer on the dish machine was checked. She stated, Should be checked before washing the dishes. The DM was asked where the results were documented. She stated, They document the temperature checks, because we don't have a form for the sanitizer checks. d. On 6/13/16 at 5:05 p.m., the employees on the evening meal serving line used the dishes that had not been sanitized to prepare all of the residents' meals, including plates, glasses, silverware, serving utensils, meals trays and plate covers. e. On 6/14/16 at 8:15 a.m., Dietary Employees #2, #3 and #4 were asked if, prior to today, they had been trained on using test strips to check the sanitizer levels in the dish machine. All 3 employees stated, No. Dietary Employee #4 stated, I had no test strips to test with. I only check the temperatures and write them down and had no training to use test strips. f. On 6/14/16 at 8:35 a.m., the Administrator was asked about the lack of sanitizer in the dish machine. The Administrator stated, We switched the dishwasher from chlorine to sanitizer on 4/12/16 and we dropped the temperature down at that time. We are now doing low temps (temperatures) with sanitizer and they (dietary staff) should be doing the test strip checks and keeping a log of the results. g. On 6/16/16 at 10:07 a.m., the Dietary Manager was asked if all dietary employees washed dishes using the dishwashing machine. She stated, Yes. h. The Immediate Jeopardy was removed on 6/13/16 at 7:05 p.m., and the scope and severity was lowered to F after the facility initiated the following Plan of Removal: 1.) (On 6/13/16), (Dish Machine Service Company #1) here at facility and made adjustments on sanitizer in dish washer at 5:42 PM which corrected the issue. Sanitation strip retested and read 100 ppm, (parts per million). 2.) In-service with kitchen staff initiated at 5:40 PM per administrator that sanitizer strips must be checked 3 times daily prior to washing dishes after each meal and a demonstration was completed showing staff how to properly perform test. Results of checks will be documented on log that will be kept on dish machine in kitchen. Dietary Manager or administrator will continue in-servicing dietary staff until all has been instructed. 3.) Dietary manager/designee will monitor log at least 5 times weekly to ensure the checks are being done and are within normal range. CEO will monitor that this is being done at least weekly. If sanitizer is not reading at an appropriate level, staff will notify maintenance supervisor and administrator immediately. (Dish Machine Service Company #1) or appropriate service company will be called for service if needed. Facility will use Styrofoam/paper/plastic plates, cups and utensils for next meal or until problem resolved. 4.) Nursing staff is checking residents for signs and symptoms of food-borne illnesses, with all residents to be assessed by the end of the day today (6/13/16). B. Based on observation and interview, the facility failed to ensure the refrigerator in the kitchen was free of dietary staff members' personal beverages; food in the refrigerator was tightly sealed and dated as to when it was initially opened; dietary staff replaced a soiled apron before serving food and covered facial hair while working in the kitchen; and fish filets were thawed in the refrigerator or under running water to prevent potential food borne illness for residents who received meals from 1 of 1 kitchen. The failed practices had the potential to affect 127 residents who received meals from the kitchen, according to the Diet Roster provided by the Dietary Manager on 6/13/16 at 2:40 p.m. (Total census: 128). The findings are: 1. On 6/13/16 at 12:30 p.m., during the initial observation of the kitchen, the following observations were made: a. A previously opened 10-ounce bottle of Starbucks Frappuccino which was half full was stored in refrigerator #1. The Dietary Manager stated, That belongs to the staff and they are not supposed to put it in this refrigerator. b. A package of turkey breast slices, with 6 slices remaining, was stored in an unsealed and undated bag in refrigerator #1. The Dietary Manager stated, They (the staff) are supposed to place those in baggies and put the date it was opened on the baggies. 2. On 6/13/16 at 4:05 p.m., Dietary Employee #1 went into the dishwashing area of the kitchen and, after putting on a plastic apron he began spraying dirty dishes and placing them in the dishwasher. His plastic apron became soiled while spraying the dirty dishes. He went directly from the dishwasher room to the sink and washed his hands, then went to the serving line and began preparing meals for the residents' evening meal, without removing the soiled apron. On 6/16/16 at 10:07 a.m., the Dietary Manager stated, They should remove the dirty apron when leaving the dishwasher room. 3. On 6/13/16 at 4:05 p.m., while preparing and serving the evening meal, and 6/14/16 at 11:00 a.m., while preparing and serving the lunch meal, Dietary Employee #5 was not wearing a beard cover and had approximately ½-inch of hair growth on his chin. 4. On 6/14/16 at 10:30 a.m., there was a large container of fish filets sitting on the kitchen counter. At 12:45 p.m., the container of fish remained on the kitchen counter. The Dietary Manager was asked why the container was sitting on the counter and stated, I took the fish out of the freezer this morning about 9:00 a.m. and placed them in the container to thaw. The Dietary Manager was asked if that was the proper way to thaw frozen fish and stated, I planned on putting cold water over the fish, but I have been busy and not got to it yet.

A. Based on observation, record review and interview, the facility failed to ensure that thorough investigations were conducted to determine causal factors and interventions were planned, implemented and monitored consistently in attempts to prevent falls for 1 (Resident #4) of 8 (Residents #1, #2, #4, #6, #8, #9, #10 and #12) case mix residents who were at risk for falls. The failed practice likely resulted in a pattern of actual harm for Resident #4 who after multiple falls without implementation of new interventions, suffered a fracture of the right femur that required surgical repair. The failed practice had the potential to cause more than minimal harm for 72 residents who were at risk for falls according to a list provided by the Director of Nursing (DON) on 6/15/12 and 19 residents who used alarms according to a list provided by the DON on 6/27/12. The facility also failed to ensure a resident was not transferred using the axillae for 1 (Resident #7) of 4 (Resident #s 4,6,7 and 8) case mix residents who required the assistance of 2 staff member for transfers. The failed practice had the potential to cause more than minimal harm for 9 residents that required the assistance of 2 staff members for safe transfers according to a list provided by the Director of Nursing on 6/15/12. The findings are: 1. The facility's policy and procedure, "Falls and Fall Risk, Managing" documented: a. "Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling." b. "If falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant." c. "Staff will identify and implement relevant interventions to try to minimize serious consequences of falling." d. "The staff will monitor and document each resident's response to interventions intended to reduce falling or the risks of falling." e. "If the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions." 2. Resident #4 was admitted on [DATE] and had [DIAGNOSES REDACTED]. The Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/5/11 documented the resident scored 9 (8-12 indicates moderately impaired) on the Brief Interview for Mental Status (BIMS), required supervision for transfers and all locomotion, used a walker, was not steady but did not require human assistance to stabilize for balance, had no functional limitations in range of motion, was always continent and had a history of [REDACTED]. The Care Area assessment dated [DATE] documented the resident walked with a rolling walker with "slightly unsteady gait. (Requires) supervision for transfer for safety reasons . . . At risk for falls." a. The Admission Care Plan (not dated) documented a problem for ADL (activities of daily living) Care with an approach, "Assist resident with transfers as needed," and a problem for Assessments with an approach, "Fall risk assessment." A Fall Risk assessment dated [DATE] documented the resident had a score of 1. The form documented a score of 10 or above represented High Risk. b. An Incident/Accident (I&A's)Reports, Nurses Notes (NN's) and the resident's Care Plan documented falls for the resident as follows: 1) 10/10/11 at 1:00 a.m. - "(resident) said thought it was time to get up . . . tried to stand up, began to slide and landed down on her bottom." The I&A documented no injuries and the resident' Care Plan documented a revision for non-skid strips on the floor by bed and in front of toilet. I&A and the resident's Care Plan documented other falls with new interventions planned and implemented for 10/24/11 (Physical Therapy (PT) screening; The PT Initial Plan of Care dated 11/2/11 documented therapy services began on 11/2/11 and resident was disharged on 12/30/11), 10/28/11 (educated to use a rolling walker with seat) and 11/2/11 (planned use of non-skid socks or shoes at all times, in bed and wheelchair). No injuries resulted from those falls. 2) 11/4/11 at 2:30 p.m. - "Called to room per CNA (Certified Nursing Assistant). (Resident) lying in floor in supine position . . . (complained of) pain (right) wrist." Nurses Notes dated 11/4/11 at 9:40 p.m. documented receipt of mobile x-ray report done at 2:35 p.m. that day. The X-ray report dated 11/4/11 documented an impression, "Acute intra-articular fracture of right distal radius with mild displacement and chip fracture of distal ulna." Reports of Consultation dated 11/7/11, 11/15/11 and 1/5/12 documented orthopaedic consult visits. No surgery was required and the reports documented the presence of a cast that was worn for approximately 6 weeks. The resident's Care Plan documented a revision dated 11/4/11 for use of a bed alarm. 3) I&A and the resident's Care Plan documented other falls without injury and new interventions planned and implemented on 11/7/11 (chair alarm in wheelchair) and 11/13/11 (non-skid material in wheelchair seat). c. The Significant Change in Status MDS with an ARD of 11/8/11 documented the resident scored 3 (0-7 indicates severely impaired) on the BIMS, required extensive assistance with one person for transfers, had total dependence with one person for locomotion on and off the unit, was only able to stabilize with human assistance for all balance tests, had functional limitation on one side of upper extremity, used a wheelchair for mobility device and was frequently incontinent of urine. d. The Care Plan documented a revision dated 11/26/11 documented, "Staff to assist resident to bed after meals if she appears tired." e. I&A Reports, Nurses Notes and the resident's Care Plan documented falls for the resident as follows: 1) 12/8/11 at 2:30 p.m., "(resident) laying on floor by bathroom. Self transferred (and) fell . Pump knot to back of head. Spoke (with) son, he states, 'Don't send her to the ER (emergency room ), she's fine. Neuro (neurological) checks (within normal limits)." A Post-Fall 72-Hour Monitoring Report dated 12/8/11 through 12/10/11 documented neuro checks without evidence of injury to the resident. 2) 12/27/11 at 12:45 p.m. - "(resident) sitting on bottom in bathroom floor." No injuries were identified. The Investigation Follow-up documented, "Staff to assist to Bathroom (every) 2 hours (and as needed)." That intervention met previously planned assistance to bathroom and was not a new intervention. There was no documentation of assessments to determine frequency of voiding to assist in planning how often the resident should be assisted to bathroom. 3) 1/14/11 at 3:28 p.m. - "lying in floor in (Main Dining Room)." No injuries were noted. The resident's Care Plan documented a revision dated 1/14/12 for Restorative services 3 times per week times 3 weeks. The January 2012 Restorative sheets dated for January 2012 documented the resident received range of motion to both lower extremities, 20 repetitions and Gait activities with a rolling walker for approximately 200 feet 3 times per week through 1/27/12. I&A and the resident's Care Plan documented the resident had other falls with planned interventions on 1/23/12 at 4:35 a.m. (increase restorative services to 5 times per week) and 1/23/12 at 3:00 p.m. (use of an anti-thrust cushion in wheelchair). No injuries were identified for those falls. The Nurse's Notes, I&A Investigation Follow-up Reports and the resident's Care Plan did not document investigation for causal factors or planning of new interventions to prevent further falls for this resident after the falls on 12/8/11 and 12/27/11. f. An I&A Report dated 1/27/12 at 3:45 p.m. documented, "(resident) laying floor on (right) side, (wheelchair) behind her. Chair alarm sounding in front of door to room. Knot noted to (right) side of head, edema to (right) wrist (and right) leg deformity (with) severe pain to upper leg." Nurses Note dated 1/27/12 at 3:45 p.m. documented, "(resident) unable to move leg (and) cries out (with) movement." The same entry documented the resident was transferred to a local emergency room for evaluation. The Investigation Follow-up dated 1/27/12 documented a plan for use of an alarming seat belt when in a wheelchair upon the resident's return. g. A Hospital emergency room records dated 1/27/12 at 4:21 p.m., documented an imaging services report for a CAT (computerized axial tomography) Scan of the brain with conclusion of, "no acute intracranial process," and report for Pelvis, "Osteoporosis. Previous bilateral joint arthroplasties. Acute fracture through the diaphysis of the proximal femoral shaft on the right side." A hospital Discharge Summary dated 1/28/12 documented the resident was transferred to a hospital out-of-state for further treatment. A hospital Report of Operation dated 1/28/12 documented the resident had an Open Reduction, internal fixation for the right periprosthetic femur fracture. h. Nurse's Notes dated 2/2/12 at 10:05 p.m., documented the resident's readmission to the nursing facility, "(two) assist transfers to (wheelchair) (with) seatbelt (with) alarm, bed alarm on. Needs assistance with meals . . . (non-weight bearing) to (right) leg." i. The February 2012 Physician Order's sheet documented orders dated 2/3/12 for PT to treat 5 times per week for 4 weeks for, "therapeutic exercises (and) activities (and) progressive gait training." j. The Quarterly MDS with an ARD of 2/9/12 documented the resident was severely impaired in cognitive skills for daily decision making per a Staff Assessment of Mental Status, had total dependence with two-person assist for transfers, range of motion limitations on one side of upper and lower extremities, used a wheelchair, had 2 or more falls since the prior assessment without injuries, one fall since prior assessment with major injury and had ongoing Physical and Occupational therapies. k. A Fall Risk assessment dated [DATE] documented a score of 14, indication a high risk for falls. l. Nurse's Notes dated 3/28/12 at 1:30 p.m. documented improvement in the resident's mobility, "PT - Gait 150 feet (times) 1 (assist) (with rolling walker), unsteady at times, uneven steps." Nurse's Notes dated 3/28/12 at "6-2 (6:00 a.m. - 2:00 p.m. shift)" documented, "requires extensive assist for bed mobility, transfers." m. The I&A's and Nurses Notes and/or the resident's Care Plan documented falls for the resident as follows: 1) 4/6/12 at 6:30 p.m. - "found resident near bed on knees, stated she was trying to get in bed." The Investigation Follow-Up dated 4/6/12 documented in the section for "recommendations / new interventions," "Assist resident to bed after meals if she wishes to lie down." There were no injuries identified at the time of this fall. 2) 4/30/12 at 6:20 p.m. - "Alarm sounding, entered room, (resident) sitting in floor beside bed. (Resident) states, 'I was going to bed' . . . (no) injury noted." The Post-Incident Actions form dated 4/30/12 documented, "staff to observe seatbelt to make sure it is intact and assist resident with transfers." That intervention represented a standard of practice when the seatbelt alarm was placed for the resident and not a new intervention to prevent falls. Nurse's Notes, I&A Investigation Follow-up Reports and the resident's Care Plan did not document investigation for causal factors or planning of new interventions to prevent further falls for this resident after the falls documented above. n. The Quarterly MDS with an ARD of 5/7/12 documented the resident was severely impaired in cognitive skills for daily decision making per Staff Assessment of Mental Status, required extensive assistance with two persons for transfers and locomotion on unit and had ongoing physical and occupational therapies. o. I&A's, Nurses Notes and/or the resident's Care Plan documented falls for the resident as follows: 1) 5/12/12 at 6:10 p.m. - "Resident sitting on floor in front of wheelchair beside bed. Chair alarm (not) sounding, (not) on. (Resident) states, 'put me to bed." The Post-Incident Actions form documented, "Staff to observe placement and ensure (wheelchair) alarm is on and functioning." This intervention did not represent a new intervention for this resident. 2) 6/3/12 at 6:15 p.m. - "(resident) laying on (right) side on floor next to bed. (Wheelchair) at side, alarm sounding, (resident) states, 'I tried to get in bed (and) fell ,' no injury noted." The Post-Incident Actions form documented, "non-skid in (wheelchair) seat." This intervention did not represent a new intervention for this resident. 3) 6/4/12 at 12:50 p.m. - "(resident) was attempting to get in bed on her own and fell in floor, landing on her (right) side, none apparent (injuries)." The Post-Incident Actions form documented, "when resident leaves the dining room (assisted dining room), staff to assist and notify charge nurse or staff on the floor that resident is done eating so that resident can be assisted to bed if she wishes to lie down." This intervention did not represent a new intervention for this resident. The Nurse's Notes and I&A Investigation Reports and the resident's Care Plan did not document investigation for causal factors (such as resident's continued demonstration of ability to self-release seatbelt with alarm) with appropriately planned interventions to prevent falls for the incidents on 5/12/12, 6/3/12 and 6/4/12. As of 6/27/12 at 10:45 a.m., the resident's Care Plan did not document interventions to check on the resident more frequently than every 2 hours. p. An I&A dated 6/18/12 at 3:00 p.m. documented, "chair alarm sounding, entered room, (resident) laying on bathroom floor . . . (complained) (right) hip pain . . send to (emergency room )." A Nurse's Notes dated 6/18/12 at 7:00 p.m. documented the resident's return to the facility without new physician's orders [REDACTED]. q. A Physician order [REDACTED]." r. On 6/11/12 at 4:06 p.m., the resident was in a wheelchair in the Main dining room with a seatbelt alarm in place. The light on the alarm box was not on, which signified the alarm was not functioning at that time. On 6/12/12 at 8:56 a.m., the seatbelt alarm box had a blinking green light visible on the box, which signified appropriate functioning. s. On 6/13/12 at 9:01 a.m., the resident's seatbelt alarm was sounding. The resident was standing up next to the bed. Certified Nursing Assistant (CNA's) #4 and #7 entered the room and assisted the resident to bed. The resident's bed alarm was activated and in the "on" position when the CNA's left the room. The resident's wheelchair had a wedge cushion with Dyson non-skid material under it. t. On 6/26/12 at 4:32 p.m., the resident was in her room in a wheelchair with a lab buddy in place. On 6/26/12 at 5:07 p.m., the resident was up in wheelchair in the assisted dining room with staff present. On 6/26/12 at 5:52 p.m., the resident was in a low mechanical bed with a pressure bed alarm in place and in the "on" position. Two 1/4 unpadded side rails were in place bilaterally at the mattresses midpoint section. u. On 6/27/12 at 1:40 p.m., CNA #8, who worked frequently with the resident, was asked how often she had been instructed to check on the resident. CNA #8 stated, "every 2 hours to release restraint, every 1 hour to make sure she's not slumped down." On 6/27/12 at 1:43 p.m., CNA #9 was asked the same question as above and she stated, "every 2 hours, and put back to bed after meals." CNA #9 was asked if putting the resident to bed after meals was something new they were doing and she stated, "no, it's always been that way." v. On 6/27/12 at 1:48 p.m., Licensed Practical Nurse (LPN) #4 was asked how often nursing staff were to check on the resident and she stated, "every 2 hours, but I check her every 30 minutes because she can turn her (bed) alarm off." LPN #4 also stated all alarms used for residents in the facility were checked for placement and functioning every shift by nurses and documented on Medication Administration Records (MAR's). The MAR's dated for December 2011 and January through June 2012 MAR documented every shift checks for both bed, chair and seatbelt alarms for this resident. w. On 6/27/12 at 5:15 p.m., the Director of Nursing and the Assistant Director of Nursing were asked to provide evidence that the facility had investigated all fall incidents without documentation of investigation for causal factors, assessments for resident's frequency in voiding and any planned increases in frequency of checks to provide adequate supervision to prevent falls for this resident. On 6/28/12 at 9:55 a.m., the DON provided initial documentation dated 6/27/12 for voiding assessments for the resident and stated no documentation of planned increases in frequency of checks or investigations for causal factors for falls on 12/8/11, 12/27/11, 4/6/12, 4/30/12, 5/12/12, 6/3/12 and 6/4/12 could be located. 3. Resident #7 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set with Assessment Reference Date of 4/11/12 documented the resident was moderately impaired in cognitive skills for daily decision making per a staff assessment of mental status, required total assistance for all activities of daily living, and required the assist of 2 persons to transfer. a. The Care Plan updated 6/9/12 did not address transfers. The facility policy for transfers was obtained from the DON on 6/15/12 and did not address the transfer of residents with bilateral amputation. b. On 6/12/12 at 12:45 p.m., LPN #1 and CNA #1 were in the resident's room to transfer the resident from an electric wheelchair back to the bed. A gait belt was placed around the resident's torso. The LPN on one side and the CNA on the other lifted the resident with all the resident ' s weight on the axilla area. The gait belt was around the resident but not utilized. LPN #1 was asked if physical therapy (PT) had been contacted for a recommendation on the transfer of this resident. The LPN stated she didn't think so. c. On 6/15/12 at 11:15 a.m., PT Personnel #1 was asked if they had been consulted concerning how to appropriately transfer (Resident #7). PT Personnel #1 stated that staff had been trained on the transfer of this resident but that they would reinforce that training. B. Based on record review and interview, the facility failed to ensure interventions were developed and implemented to promptly identify onset of aggressive behaviors and to protect residents from injuries for 1 (Resident #6) of 1case mix residents who exhibited aggressive behavioral symptoms toward staff and other residents. This failed practice had the potential to affect 17 residents who resided on Hall One as identified by the list of residents titled Jonesboro Healthcare Center dated 6/14/12 received from the Director of Nursing on 6/15/12. The findings are: 1. Resident #6 had [DIAGNOSES REDACTED]. The Admission Minimum Data Set (MDS) with an assessment reference date of 2/17/12 documented the resident scored 3 (0-7 indicates severely impaired) on the Brief Interview for Mental Status, had no behavioral symptoms directed toward others, had an active [DIAGNOSES REDACTED]. a. The Care Area Assessment Summary signed as complete by the RN Assessment Coordinator 2/22/12 documented Behavioral symptoms were triggered. The Care Area Triggers (CAT) Worksheet Area: Behavioral Symptoms documented the following: 1) Long -standing mental health problems associated with the behavioral disturbances, such as schizophrenia, bipolar disorder, depression, anxiety, post-traumatic stress disorder 2) Delirium 3) The actions and responses of family members and caregivers can aggravate or even cause behavioral outburst 4) Residents displays behavior symptoms that impacts self or others 5) Resident is immediate threat to self and others The area documented, "A care plan will be developed for this care area." b. The Care Plan dated 2/17/12 did not address behaviors that impacted self or others or the fact that the further assessment (CAA) documented the resident was an immediate threat to self and others. c. Nurses Notes were reviewed from 2/13/12 (admission) to 4/8/12 and there was no documentation of any behavioral problems. d. Nurses Notes from 4/9/12 documented decline in cognitive status with onset of aggressive behaviors: 1) Nurses Notes dated 4/9/12 at 3:45 p.m. documented, " Resident seem to be confused stating someone broke in and taking some things .... " The notes documented call to physician with new orders (lab work including Urinalysis with culture and sensitivity). Nurses Notes dated 4/11/12 no time noted documented receipt of new physician orders [REDACTED]. Nurses Notes dated 4/13/12 (no time) documented physician telephone order received for antibiotic. Nurses Notes dated 4/13/12 at 4 p.m. documented, " Unable to find resident. Room to Room check done. Resident noted sitting in Room (number), in the bathroom sitting in bathtube (bathtub) states ' I was just sitting here ' ... " 2) Nurses Note dated 4/14/12 documented, "LE (late entry) 7:20 (did not designate a.m. or p.m.) 4/13/12. This Nurse was sitting in her car on lunch break. I observed a CNA (Certified Nurse Assistant) attempting to come out of exit door. This resident rolled up to door and stuck his foot in door to prevent CNA from closing the door. This nurse started toward exit door resident grabbed the rope that CNA had her name tag attached to and started pulling it. CNA unable to get loose from resident. This Nurse told resident to let go of her after 3 times he let go. This Nurse instructed resident to back up from door he complied. This LPN went and got Station I (One) Nurse and she came and talked to resident and assisted him away from area." A Nurses Note dated 4/14/12 at 2:45 p.m. documented, "This Nurse was page to room 16, because of a incident between two resident. On enter room resident in the 1st (first) bed noted to have blood spots on his clothes and resident in 2nd (second) bed noted to have blood on his hand and a scratched on his neck on (left) side. Stated (Resident #6) struck me with something 2-3 (times) ..." A Nurses Note dated 4/14/12 at 2:55 p.m., asked this resident why he had stabbed his room mate. He stated, 'He was going to shoot me (with) a rifle.' Residents room mate is legally blind (and) was lying in his bed. Call placed to (Physician). Received (telephone order) to send resident to (behavioral health facility)." The (Hospital) Inpatient Admission Information Form dated 4/14/12 at 2:55 p.m. documented "1. What is the current acute criteria for the admission? ...Homicidal, stabbed roommate in (left) side of neck (with) pen. .... Any psych (psychiatric) [DIAGNOSES REDACTED]. ...2. Do they have a history of similar behaviors? Checked N/A (not applicable)/unknown." e. A Nurses Note dated 4/18/12 at 12:00 p.m., documented, "Res (Resident) returned to facility per our facility van (and) our staff ..." f. A Nurses Notes dated 4/19/12 at 8:40 a.m. documented, "Charge Nurse came to this LPN (Licensed Practical Nurse) in (regard) to(resident) refused to take meds for her, threw across room. Knowing that (resident) has good repore (rapport) (with) this LPN I attempted, (resident) grabbed this LPN by throat, got loose, grabbed scrub top, breast, arms , hands took to (two) CNAs to get him off of this LPN (and) apparently close to the same to his (continue) primary nurse. (Physician) notified ... " The Notes documented the resident was transferred back to the (behavioral health facility). g. Nurses Notes dated 4/27/12 at 11:30 a. m. documented the resident returned to the facility. h. Nurses Notes from 4/27/12 to 6/15/12 did not document aggressive behaviors. i. On 6/12/12 at 8:45 a.m., the resident was up in a wheel chair in the doorway of his room. He stated he was a church man, didn ' t smoke, drink, or cuss. He was observed at 3:20 p.m. self propelling his wheelchair down the hallway. j. The care plan last dated as reviewed on 5/31/12 did not address interventions to ensure aggressive behaviors were promptly identified and responded to in order to reduce the risk of resident injury. 1) On 6/15/12 at 12:50 p.m., the Treatment Nurse, Licensed Practical Nurse (LPN) #2, was asked, "What are you doing now to monitor (Resident #6's) behaviors." LPN #2 stated, "He's not had any. I document his behaviors if I have any. The Psychiatrist will be here Monday at 5:30 p.m. and he will see him first. When I document, I put it in the Nurses Notes." LPN #2 was asked if this resident was care planned for these behaviors. LPN #2 stated, "I'd have to go look." 2) At 1:00 p.m., the Director of Nursing (DON) was asked what was being done to monitor the resident's behaviors. The DON stated, "Staff watch daily and document in his chart. They call (Name of behavioral health facility) if there is anything unusual, then they call me." ... The DON was asked if the resident was care planned for behaviors. The DON stated, "No, but he will be in about 5 minutes." 3) At 1:10 p.m., LPN #3 was asked what she was doing to monitor the resident's behavior. LPN #3 stated, "Staff monitors throughout the day. Usually, he hangs out by his room and he stays close to me when I'm here. I chart anything we see that's unusual. We call (name of behavioral health facility) if we see anything." LPN #3 was asked if the resident was care planned for behaviors. LPN #3 stated, "I just watch and monitor. He hollers for me within 30 minutes of my getting here. I give his psych (psychotropic) meds (medications) as ordered. He never gives us a problem about taking his meds."