Every finding on record at The Springs of Barrow

Based on observations, interviews, record review, and facility policy review, the facility failed to ensure a comprehensive Care Plan was developed and implemented to include oxygen therapy interventions for one (Resident #67) of three residents reviewed for Respiratory Care. The findings include: During observations on 03/02/2026 at 11:05 AM, on 03/04/2026 at 2:17 PM, and on 03/04/2026 at 2:34 PM, Resident #67 was observed to be receiving oxygen therapy at 4 liters per minute via nasal cannula, via oxygen concentrator. The observation on 03/04/2026 at 2:34 PM included Licensed Practical Nurse (LPN) #1 at Resident #67's bedside. A review of Resident #67's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/25/2026, revealed a Brief Interview of Mental Status score of 10, which indicated the resident had moderate cognitive impairment. Resident #67's MDS also revealed the resident had diagnoses which included pneumonia, chronic respiratory failure with hypoxia and hypercapnia, asthma, chronic obstructive pulmonary disease, and chronic lung disease. Resident #67's MDS did not include oxygen therapy. A review of Resident #67's 5-day MDS with an ARDS of 02/07/2026, revealed the resident was admitted , and had continued while a resident, to receive oxygen therapy. A review of Resident #67's Care Plan revealed no interventions regarding oxygen therapy. During an interview on 03/04/2026 at 2:34 PM, while at Resident #67's bedside, LPN #1 confirmed the oxygen therapy was in place at 4 liters per minute via nasal cannula. LPN #1 could not locate care plan interventions regarding oxygen therapy for Resident #67 and indicated there did need to be care plan interventions for any resident that received oxygen therapy. During an interview on 03/05/2026 at 12:18 PM, the MDS Coordinator stated they were responsible for creating and modifying care plans, and that any resident on oxygen therapy should have interventions listed for oxygen therapy. The MDS Coordinator also indicated Resident #67 was admitted to the facility on [DATE], went to the hospital on [DATE], returned on 02/05/2026, and there were no interventions for oxygen therapy on the care plan from admission through 03/03/2026. The MDS Coordinator also indicated that the reason it was important to have interventions in the Care Plan for oxygen therapy with Resident #67, was so that they could be discussed during care planning meetings with the family and Resident #67's care could be accurately relayed to any party involved. During an interview on 03/05/2026 at 10:52 AM, the Advanced Practice Registered Nurse (APRN) indicated that Resident #67 was admitted to the facility on oxygen. The APRN also stated Resident #67 informed the facility they had been on oxygen for 10 years. During an interview on 03/05/2026 at 11:05 AM, the Director of Nursing indicated that it was important for the Care Plan to have oxygen therapy interventions in place for Resident #67, so staff could be aware of Resident #67's needs, to ensure proper care was provided. During an interview on 03/05/2026 at 12:56 PM, the Administrator indicated that interventions for oxygen therapy for Resident #67 should have been in place in the Care Plan, for transparency between all departments. A review of a policy titled Care Plans, Comprehensive Person-Centered, with a revision date of March 2022, indicated a comprehensive, person-centered care plan is developed within seven days of the completion of the required MDS assessment and no more than 21 days after admission. The policy also indicated the comprehensive, person-centered Care Plan describes the services that are to be furnished to attain or maintain the resident's highest practicable physical well-being. In addition, the Care Plan interventions are chosen after data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making.

Based on observations, interviews, record review, and facility policy review, the facility failed to ensure physician's orders for oxygen therapy were in place before administering supplemental oxygen for one (Resident #67) of three residents reviewed. The findings include: During observations on 03/02/2026 at 11:05 AM, on 03/04/2026 at 2:17 PM, and on 03/04/2026 at 2:34 PM, Resident #67 was observed to be receiving oxygen therapy at 4 liters per minute via nasal cannula via oxygen concentrator. The observation on 03/04/2026 at 2:34 PM included Licensed Practical Nurse (LPN) #1 at Resident #67's bedside. A review of Resident #67's admission Record revealed Resident #67 was admitted on [DATE] with a primary diagnosis of Chronic Obstructive Pulmonary Disease (COPD). A review of Resident #67's admission Minimum Data Set (MDS) with an Assessment Reference Date of 01/25/2026, revealed a Brief Interview of Mental Status score of 10, which indicated the resident had moderate cognitive impairment. Resident #67's MDS also revealed the resident had diagnoses, which included pneumonia, chronic respiratory failure with hypoxia and hypercapnia, asthma, COPD, and chronic lung disease. Lastly, Resident #67's MDS did not indicate the resident was receiving oxygen therapy. A review of Resident #67's Provider notes, dated 03/03/2026 stated Co-morbidity: COPD, Risk of complication: HIGH Monitor Pulse Ox before and after therapy, breathing treatments and oxygen as needed to augment therapy outcomes. Due to poor endurance, patient at high risk for poor progression in therapy. A review of Resident #67's Order Summary revealed there were no physician's orders regarding oxygen therapy. A review of Resident #67's Provider Notes, with a service date of 03/03/2026, revealed Resident #67 was admitted to the hospital for acute on chronic hypoxic respiratory failure, sepsis secondary to influenza A, community-acquired bacterial pneumonia and COPD exacerbation. The Provider Notes also revealed Resident #67 had an oxygen saturation level of 94% on oxygen at 5 liters. During an interview on 03/04/2026 at 2:34 PM, while at Resident #67's bedside, LPN #1, responsible for Resident #67's care, confirmed the oxygen therapy was in use, with oxygen being administered at 4 liters per nasal cannula. LPN #1 could not locate a physician's order in the Electronic Health Record (EHR) regarding oxygen therapy for Resident #67 and confirmed there did need to be an order in place for the oxygen therapy Resident #67 was receiving. During an interview on 03/05/2026 at 10:52 AM, the Advanced Practice Registered Nurse (APRN) indicated that there should have been a physician's order for Resident #67 for oxygen therapy, so the staff knew how many liters should be delivered to Resident #67, and so the resident did not get over-oxygenated, due to their COPD. The APRN also indicated that Resident #67 informed the staff upon admission that Resident #67 had been receiving oxygen therapy for 10 years. During an interview on 03/05/2026 at 12:18 PM, the MDS Coordinator indicated the resident was admitted to the facility on [DATE], went to the hospital on [DATE], and returned to the facility on [DATE], and no physician's order was placed for oxygen therapy from admission through 03/03/2026. During an interview on 03/05/2026 on 11:05 AM, the Director of Nursing (DON) indicated that any resident receiving oxygen therapy should have a physician's order in place, so staff were aware of what a resident needed. During an interview on 03/05/2026 at 12:56 PM, the Administrator indicated Resident #67 had oxygen therapy since admission and that physician's orders for oxygen therapy should have been in place for Resident #67, to provide transparency between all departments. A review of a facility policy titled Oxygen Administration, last revised October 2010, indicated Verify that there is a physician's order for this procedure.

Based on observations, interviews, and facility policy review, the facility failed to ensure a trash can was cleansed and had a liner inside and the inside of a resident's toilet bowl was clean for 1 (Resident #4) of 3 whose rooms were reviewed for cleanliness; failed to ensure walls and baseboards were cleansed in the hallways of the facility; failed to ensure cigarette butts were removed from the grounds of a smoking area and shower rooms were maintained in a clean and sanitary condition for 3 of 4 showers in the facility. The findings are: On 01/06/2024, initial rounds were conducted at the facility and the following observations were made: 1. At the end of hall 100, the base boards and lower walls to the right of the doorway upon entrance had brown stains and a brown unknown substance on the floor. 2. Resident #4's trash can had no liner and there were gloves, debris and stains in the bottom of the trash can. There was a brown ring inside the toilet bowl in the Resident #4's bathroom. 3. On hall 400, between rooms [ROOM NUMBERS], there was a How to view resident care plan in [program name] sign on the wall with brown stains on and around the sign. 4. The baseboards between rooms [ROOM NUMBERS] had brown stains on it. 5. The female shower room, for halls 100 and 200, had black stains on the grout between the tiles on the floor, and the lower walls of two shower stalls and a trash can with no liner half full of a discolored liquid with dark sediment in the bottom. 6. The male shower room, for halls 100 and 200, had black stains on the grout lines between the tiles on the floor, and walls of the two shower stalls. One shower stall had a pair of black boots with debris on them and a dustpan with brown, black and white stains on it on the floor of the shower stall. On 01/07/2025 at 12:05 PM, the smoking area for the secured unit was observed and there were several used cigarette butts and ashes on the concrete slab. On 01/07/2025 at 1:00 PM, the toilet bowl in Resident #4's bathroom continued to have a brown ring inside and toilet paper. On 01/08/2025 at 1:47 PM, the trash can in Resident #4's room did not have a liner and there was a brown stain and debris in the bottom of the trash can. Certified Nursing Assistant (CNA) #4 placed a clean trash liner in the trash can without cleaning the inside first. He was interviewed and stated housekeeping was responsible for cleaning the inside of the trash can. On 01/08/2025 at 2:52 PM, the Laundry/Housekeeping Supervisor (LHS) was interviewed and stated he was responsible for cleaning the shower rooms every day. He stated he used a disinfectant [brand name]. He stated Maintenance swept the [cigarette] butts early each morning and before he (Maintenance) left for the day. He stated housekeeping cleaned the walls and railings in the hallways every other day. He stated housekeeping was responsible for cleaning the resident's rooms, including the floor, toilet, sink, trash can and putting a liner in the resident's trash can every day. On 01/08/2025 at 3:04 PM, LHS was asked to remove the liner from Resident #4's trash can and describe what he observed. He stated there was old trash and dirt on the bottom of the trash can and there were brown and black discolorations inside the trash can. On 01/08/2025 at 3:06 PM, LHS entered the men's shower room on the locked unit and described the smell upon entrance as old water. He described the color between the tiles on the floor as black. He stated there was dirt on the lower tiles of the shower wall and described the color as black. On 01/08/2025 at 3:11 PM, LHS opened the janitor's closet leading to Hall 100 and there was a cleaning system set up on the wall with a brand name one step disinfectant solution inside. LHS stated a bottle could be placed under the spout of the cleaning system and filled with the cleaning solution. He stated the cleaning solution was diluted and ready to use and required a 3-second sit, which he explained as once the solution was sprayed on something, it would sit for 3 seconds before being removed. He stated the disinfectant was supposed to work on mold and mildew. On 01/08/2025 at 4:04 PM, the Maintenance Director (MD) was interviewed, and stated staff were expected to pick up after themselves in the smoking area and staff with the residents in the smoking were expected to pick up after the residents. He stated the responsibility of removing cigarette butts from the grounds was a shared duty, which he did rounds once a day, but he did not indicate who else shared the responsibility. He stated cigarette butts should be removed from the grounds because it gave a bad appearance. A Daily cleaning procedures (DCP) policy, not dated, provided by the Administrator on 01/08/2025, was reviewed and indicated the waste basket should be disinfected and a can liner inserted. The restroom required supplies such as toilet paper, paper towels and soap be restocked, trash emptied, toilet area disinfected. The policy did not specify cleaning of the walls or baseboards in the hallways outside resident rooms. The [name brand] One-Step Disinfectant manufacture's guidelines, not dated and provided by the Administrator on 01/08/2025, was reviewed and indicated this product is a concentrated hospital use disinfectant cleaner which it's uses include inhibiting the growth of mold and mildew and odors when used as directed. The directions indicated the original container label should be referred to for use directions. For Fungi, the contact time indicated 3 minutes, but did not specify mold or mildew contact time.

Based on interview, record review and facility policy review, the facility failed to ensure a resident's emergency contact was notified of a change in a resident's plan of care for 1 (Resident #5) of 1 sampled resident reviewed for plan of care changes. The findings are: On 01/07/2024, Resident #5's emergency contact was exiting the resident's room. This surveyor asked her about the resident's care at the facility and she stated she had called the facility earlier and was told there was a fall mat in place. She asked this surveyor to look in the room and see if a fall mat was in place. This surveyor entered the resident's room and there was no fall mat in place. Resident #5's Medical Diagnosis Screen was reviewed and indicated the resident had a fracture of the neck of the right femur (a break in the thigh bone) and a brain condition with causes the progressive decline in memory, thinking, learning and organizing skills (Alzheimer's disease). A quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/05/2025 was reviewed and indicated Resident #5 had a Staff Assessment for Mental Status (SAMS) score of 3, which indicated severe cognitive impairment. A Plan of Care, dated 11/04/2024, was reviewed and indicated Resident #5 had an actual fall with an intervention for staff to check range of motion and scheduled pain medication. An established patient visit note, dated 12/20/2024 at 23:59 (11:59 PM), was reviewed and indicated Resident #5 was seen due to readmission. The fall risk section of the note indicated a plan of treatment which included implementation of safety measures with a low bed and a floor mat. A Nursing Incident and Accident follow up note, dated 12/31/2024 at 11:51 AM, was reviewed and indicated a fall mat was initially placed as an intervention to prevent injury, but after therapy evaluation the mat was removed. Resident #5's Progress Notes were reviewed from 12/30/2024 through 01/07/2025, and there was no documentation which revealed Resident #5's emergency contact, or any other person was notified of a decision to remove the resident's fall mat. On 01/08/2025 at 3:43 PM, the Director of Nursing (DON) was interviewed and stated after Resident #5 returned to the facility the immediate intervention was to put a fall mat bedside the resident's bed. She stated the facility held weekly interdisciplinary team (IDT) fall meetings and per her note dated 12/31/2024, the fall mat was not appropriate because Resident #5 was mobile and there was a concern the resident would trip over the fall mat. She stated the emergency contact should have been notified of the change by someone from the interdisciplinary team. A Change in a resident's condition or status policy, dated as revised February 2021, was reviewed and indicated the facility promptly notifies the resident, attending physician and the resident representative of changes in the resident's medical/mental condition and/or status such as changes in level of care and resident rights.

Based on interviews, record review, and facility document review, it was determined the facility failed to provide needed care or services resulting in an actual decline in one resident's physical well-being (Resident #1) of 3 sampled residents reviewed for Quality of Care. Findings include: Review of an admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/14/2024, revealed Resident #1 had Brief Interview for Mental Status (BIMS) score of 13 which indicated the resident was cognitively intact. Other diagnoses on the MDS included hypertension (high blood pressure), end-stage renal disease (kidney disease) and hemiplegia (not being able to move one side of the body). Resident #1 ' s medical record was reviewed for accuracy of medications. 1)A review of Resident #1's hospital and facility records revealed the following. a. 11/04/2024 - The Discharge (DC) Summary from the hospital stay ending on 11/04/2024, for admission to the Nursing facility has this medication listed - [Name brand angiotensin-converting enzyme inhibitor] 40 milligrams (mg) tab take one tablet by mouth every day for high blood pressure. [Name brand angiotensin-converting enzyme inhibitor] was one medication in a list of medications recommended for Resident #1 to continue by the discharging hospital. b. 11/08/2024 - The DC Summary from a hospital procedure, admitted [DATE], and discharge date [DATE], had a note Medication(s) stopped/held - [Name brand angiotensin-converting enzyme inhibitor] (this medicine is to be resumed upon discharge). c. 11/12/2024 - The Medication Reconciliation Report from a procedure performed on 11/12/2024, has listed [name brand angiotensin-converting enzyme inhibitor] 40mg tab - take one tablet by mouth every day for high blood pressure. d. A review of the November 2024 Administration Record, and the December 2024 Administration Record, demonstrated that Resident #1 did not receive [name brand angiotensin-converting enzyme inhibitor] from 11/04/2024 (admission to facility) through 12/23/2024, when Resident #1 was being admitted to the hospital for a hypertensive (high blood pressure) emergency. e. A review of the [name brand angiotensin-converting enzyme inhibitor] order report demonstrated Resident #1 did not have [name brand angiotensin-converting enzyme inhibitor] ordered from the time of admission to the facility (11/4/2024) until 12/23/2024, when Resident #1 was being admitted to the hospital for hypertensive (high blood pressure) emergency. f. A review of the hospital History and Physical (H&P) from 12/24/2024, revealed the following information from the hospital provider. Within the Assessment and Plan of Care, it states the resident told the provider that they used to take [name brand angiotensin-converting enzyme inhibitor] but had not gotten any at the nursing home. Also, it stated Resident #1 would be started on [name brand angiotensin-converting enzyme inhibitor] moving forward. The first issue on the H&P problem list was hypertensive emergency, requiring an Intensive Care Unit (ICU) admission. 2)On 01/07/2025 at 2:16 PM, the Admission Nurse and LPN #1 were interviewed regarding the process for 1) determining what medications residents are to receive and 2) determining who reviews for medication accuracy. Both nurses responded the process for residents coming to a facility was as follows. a. Facility receives the Discharge (DC) medication list b. Nurse managers put the medication list into the queue which is the electronic platform where orders wait to be reviewed by the floor nurse c. Floor nurse double checks and confirms each medication is in the queue. d. Admission nurse does the match back process to confirm the correct medications are on the Medication Administration Record (MAR). This process is where the discharge medications/orders are resubmitted by the Admission Nurse to ensure it matches the original order. The Admission Nurse also stated this process provided a third set of eyes on the orders. Both nurses stated that they started the last step because a medication got missed about a month ago. 3) On 01/08/2025 at 10:15 AM, the Admission Nurse and LPN #1 were interviewed regarding the process for orders and document review after someone has gone to the hospital/doctor appointment/dental visit, etc. The Admission Nurse stated that it was their responsibility (Admission Nurse) to review the documents and then follow up with any orders. 4) On 01/08/2025 at 1:50 PM, an interview with the Director of Nursing (DON) was conducted, included, but not limited to, acquiring orders for a new resident and verification of the orders. a. What is the process regarding orders for a new resident? The Discharge (DC) orders come with the resident, and one nurse puts admission orders in. The orders are reviewed with the provider within 24 hours. The floor nurse reviews, and another nurse reviews for a double check. The admissions nurse receives the admission orders and checks the orders again, against the paperwork provided. b. What is the process regarding documents and/or orders for a resident that has gone to the hospital, doctor appointment, dental appointment, etc.? If someone goes to an appointment, the transport personnel give the papers to a nurse or department head for processing. c. Who communicates with the provider if there is an order that is recommended for the resident? Prior to December 2024, the Medical Director would be contacted by the nurse or Department Heads. A Nurse Practitioner (NP) was hired in the early part of December. Since the early part of December 2024, the NP is notified by the nurse and/or department heads. With the addition of the NP, Clinical meetings are now conducted daily, and any new orders can be reviewed at that time for accuracy/resolution. 5) On 01/08/2025 at 2:20PM, the Administrator provided a procedure document titled Reconciliation of Medications on Admission. The body of the document listed the steps in the procedure, which include: 1) Listing all medications from the discharge summary and 2) Reviewing the list carefully to determine if there are discrepancies/conflicts. 6) On 01/08/2025 at 3:15 PM, the DON was interviewed again and stated there was not an additional policy to address orders/medication orders when a resident returns to the facility. The DON was asked why it is important for Medication Reconciliation be completed accurately. The DON answered for the health and safety of the resident and that incorrect medications and/or missing medications are not good.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure enhanced barrier precautions (EBP) were consistently implemented during resident care activities for 1 (Resident #4) of 1 sampled resident reviewed for enhanced barrier precautions. The findings are: On 01/07/2024 at 12:15 PM, Certified Nursing Assistant (CNA) #2 and CNA #3 were in Resident #4's room to provide incontinence care. Both CNAs put on gloves prior to the start of the high-contact care activity but did not put on a gown. There was a sign on the wall outside the Resident #4's room under the resident's name which was reviewed and indicated the resident was on EBP and staff must wear gloves and a gown for high-contact resident care activities and changing briefs was included on the list. Resident #4 was incontinent of bowel and CNA #2 and CNA #3 completed this high contact care activity and only used gloves. Both CNAs were interviewed and asked if the resident was on EBP. CNA #3 stated she was sure Resident #4 was, and CNA #2 indicated he did not know. CNA #3 confirmed neither she nor CNA #2 wore a gown while providing incontinent care to Resident #4. Resident #4's Medical Diagnosis Screen was reviewed and indicated a diagnosis of gastrostomy status (a surgical opening into the stomach for nutritional support). A review of Resident #4's Order Summary Report indicated the resident received continuous enteral (a form of nutrition delivered into the digestive system as a liquid) feeding and was on EBP related to a percutaneous endoscopic gastrostomy (PEG) tube. A review of Resident #4's Plan of Care dated 11/27/2024, indicated Resident #4 had a self-care performance deficit in activities of daily living (ADL) and required total assistance with bathing/showers, extensive to total assistance of one staff member with toilet use and was at risk for skin breakdown due to incontinence of bowel and bladder. An Enhanced Barrier Precautions policy, copyright 2024, The Compliance Store, LLC (limited liability company), was reviewed and indicated EBP referred to an infection control intervention to reduce transmission of multidrug-resistant organisms in which employees use gown and gloves during high contact resident care activities. The policy indicated an order for EBP would be obtained for residents with wounds and/or medical devices such as a feeding tube.

Based on observation, interview, and faculty policy review, the facility failed to ensure dietary staff washed their hands and changed gloves when contaminated; the ice machine was maintained in a clean and sanitary condition; opened food items in the refrigerator and freezer were sealed or covered to maintain freshness and prevent potential cross-contamination; expired dressing products were promptly removed/discarded on or before the expiration or use by date to prevent the growth of bacteria; cold beverages were held at 41 degrees Fahrenheit to maintain the quality of food items and beverages. The findings are: 1. On [DATE] at 9:28 AM, Dietary Aide (DA) #1 picked up his phone and placed it in his pocket, contaminating his hands. Without washing his hands, DA #1 picked up clean plates from the dish racks and placed them on the plate warmer to be used in portioning food items for lunch. 2. On [DATE] at 9:53 AM, the ice machine in the kitchen had a wet, pink, and slimy residue on the panel. It was pointed out to the Dietary District Manager and asked if the residue build up could be wiped off. She used tissue paper and wiped it off. The pink slimy residue easily transferred to the tissue. DA #1 was asked who used the ice from the ice machine and how often they cleaned it. DA #1 stated, CNAs (Certified Nursing Assistants) use it to fill beverages served to the residents at mealtimes and they use it for the water pitchers in the residents' rooms. I don't know how they clean it. On [DATE] at 10:09 AM, Dietary [NAME] (DC) #2 was asked how often they cleaned the ice machine. DC #2 stated, Once a every week. 3. On [DATE] 10:09 AM, DA #1 turned on the hand washing sink, washed his hands, turned off the hand washing faucet with his bare hands, contaminating his hands, and then used his contaminated hands to pick up clean plates and place them on the plate warmer to be used in portioning food items to be served to the residents for supper. 4. On [DATE] at 10:15 AM, an opened box of sausage was on a shelf in the refrigerator. The box was not covered or sealed. 5. On [DATE] at 10:18 AM, the following observations were made on a shelf in the freezer: a. An opened box of steak fritters. The box was not covered or sealed. b. An opened box of corndogs. The box was not covered or sealed. 6. On [DATE] at 10:45 AM, the following observations were on a shelf in the - Medication Room between the 100 Hall and the 200 Hall: a. Two bags of potato chips with an expiration date of [DATE]. b. An opened bottle of tea. The manufacturer specification on the bottle indicated to keep refrigerated. 7. On [DATE] at 11:09 AM, DA #1 removed a carton of milk from the refrigerator and gave it to a staff member, contaminating his hands. Without washing his hands, DA #1 then picked up utensils from the area and wrapped them in napkins for the supper meal. DA #1 was asked what he should have done after touching dirty objects and before handling clean equipment? DA #1 stated, I should have washed my hands. 8. On [DATE] at 11:54 AM, DA #1 walked into the kitchen and placed a bag that contained packages of cream cheese on the counter. Without washing his hands, DA #1 picked up clean eating utensils by the tip of the utensils and wrapped them in individual napkins for the residents to use at their noon meal. Dietary Aide DA #1 stated he should have washed his hands. 9. On [DATE] at 1:00 PM, Dietary [NAME] (DC) #2 wore gloves when he opened two bags of shredded cabbage and emptied them into a pan. Then, using his gloved hands, he smoothed the shredded cabbage, shredded carrots and shredded red cabbage evenly in the pan. DC #2 poured dressing over the slaw, mixed it with a spoon, covered the pan with saran wrap and placed it on a shelf in the walk-in refrigerator to be served to the residents at their supper meal. DC #2 was asked what she should have done after touching dirty objects and before handling food items. DC #2 stated she should have washed her hands. 10. On [DATE] at 8:05 AM, the Dietary Manager was asked to check the temperature of the leftover cartons of strawberry shake and cartons of apple juice that she was about to put in the refrigerator. DC #2 did and stated the apple juice was 51 degrees, and the strawberry shake was 50 degrees. They are supposed to be 41 degrees. The manufacturers specification on the cartons of strawberry indicated, store frozen, thaw under refrigerator. After thawing keep refrigerated and use within 14 days. 11. A review of a facility policy titled, QRT (Quick Reference Tool) Hand Washing, initiated on [DATE] indicated, wash your hands as often as possible. Before starting to work with food utensils or equipment, and as often as needed during food preparation and when changing tasks.

Based on observation, interview, and facility policy review, the facility failed to ensure the storage closet and the janitor's closet near the dining area, and the water heater closet off the 100 Hall were locked to ensure residents did not have access to equipment that could result in accidents or injuries. Findings include: 1. A review of a policy titled, Maintenance Service, dated December 2009, revealed maintenance was responsible for the safe maintenance of the facility and keeping it free of hazards. 2. On 09/09/2024 at 09:48 AM, the Surveyor opened a set of white double doors revealing the heating and cooling equipment. 3. On 09/09/2024 at 09:49 AM, the Storage Closet was opened revealing a large metal cabinet with coiling wires hanging down on the right-hand side, and on the left side was a bucket with 4 inches of gray fluid resting under a humidifier. 4. On 09/09/2024 at 09:51 AM, the Surveyor observed a slightly opened door marked, water heater, located off the 100 Hall, the doors were opened revealing the hot water system. 5. During an interview with the Maintenance Supervisor on 09/09/2024 at 02:15 PM, the Maintenance Supervisor stated the batteries in the keypad locks were dead, and the doors should require a key to be unlocked. He confirmed residents should not have access to the hot water heaters, electrical, and equipment, because they could get hurt.

Based on observations, record review, and interviews, the facility failed to provide a safe, clean, comfortable, and homelike environment for 5 (Residents #2, #13, #14, #33, and #65) of 5 sampled residents residing on the 300 Hall. The findings are: 1. On 9/09/24 at 10:40 AM, the Surveyor observed: a) Resident #2's bathroom floor was dirty and sticky, causing the surveyor's shoes to stick to the floor. b) The bathroom door had several brown smears on the inside and outside of the door. c) Resident #2's feeding pole had a brownish-white hard-dried substance dried to the pole, the pole's electrical cord, and the base of pole. d) Several areas of the resident's wardrobe had the finish missing and the rough particle board was exposed. e) The over the bed table had a large chunk out of the top right corner, leaving rough particle board exposed. 2. On 9/9/24 at 1:00 PM, the Surveyor observed: a) Resident #2's bathroom floor was dirty and sticky; causing the surveyor's shoes to stick to the floor. b) Resident #2's bathroom door was sticky to touch and had several brown smears on the door. c) Resident #2's bathroom floor had black, yellow, and orange stains on the floor under the sink and around the toilet. d) Resident #2's feeding pole had a thick dried brownish-white substance on the pole, the pole's electrical cord, and on the base of the pole. e) The two wardrobes in Resident #2's room had several areas of rough particle board exposed. f) The over the bed table in Resident #2's room, had a large chunk of finish missing from the top right corner, leaving rough particle board exposed and a sharp plastic corner sticking up where the top finish had broken off. 3. On 9/10/24 at 2:00 PM, the Surveyor observed: a) Resident #2's bathroom door had several brown smears on the door, above and below the door handle. The surveyor's shoes were sticking to the floor. b) Resident #2's bathroom floor had black, yellow, and orange stains on the floor under the sink and around the commode. c) Resident #2's feeding pole had a brownish-white substance dried to the pole, the pole's electrical cord, and the base of the pole. d) The two wardrobes in the room had several areas of rough particle board exposed. e) The over the bed table had a large chunk of finish missing from the top right corner, leaving rough particle board exposed and a sharp plastic corner sticking up where the top finish had broken off. 4. On 9/11/24 at 12:07 PM, the Surveyor observed: a) A large brown stain on the privacy curtain. b) Resident #2's feeding pole had a brownish-white substance dried to the pole, the pole's electrical cord, and the base of the pole. c) The two wardrobes, in the room, had several areas of rough pressed board exposed. d) The over the bed table had a large chunk of finish missing from the top right corner, leaving rough particle board exposed and a sharp plastic corner sticking up where the top finish had broken off. e) Resident #2's bathroom floor had black, yellow, and orange stains on the floor under the sink and around the toilet. The surveyor's shoes were sticking to the floor. 5. On 9/09/24 at 11:12 AM, the Surveyor observed: a) Resident #13's bathroom had a foul musty odor, and the floors were dirty with a black substance. b) The trim atop the wainscoting (wood paneling) was missing along the wall where the headboards of the beds were positioned, leaving a rough edge exposed. 6. On 9/09/24 at 1:42 PM, the Surveyor observed: a) Resident #13's bedroom had a strong, nauseating odor in the room. b) The trim atop the wainscoting was missing along the wall where the headboards of the beds were located, leaving a rough edge exposed. c) The bedroom floors were dirty with a black substance around the baseboards. 7. On 9/10/24 at 1:02 PM, the Surveyor observed: a) Resident #13's bathroom had a large area of black substance on the center of the floor. b) Resident #13's room had a musty odor. c) The trim atop the wainscoting was missing along the wall where the headboards of the beds were positioned, leaving a rough edge exposed. d) The bedroom floors were dirty with a black substance around the baseboards in the room. 8. On 9/11/24 at 12:17 PM, the Surveyor observed: a) Resident #13's room had a strong urine odor in the room. b) The bedroom floors were dirty with a black substance around the baseboards in the room. c) Resident #13's bathroom had a large area of black substance on the center of the floor. 9. On 9/11/2024 at 3:30 PM, while making rounds with the Administrator the Surveyor observed the Administrator attempt to open the Resident #13's bathroom door. The door stuck and the Administrator had to jerk the door open. The Administrator said the door would need to be sanded down at the top. 10. On 9/09/24 at 10:50 AM, the Surveyor observed: a) Resident #14's bathroom door was difficult to open. The roommate yelled out that the door sticks and is hard to open sometimes, just pull it hard. 11. On 9/09/24 at 10:59 AM, the Surveyor observed: a) Resident #14's bedroom had a strong odor of feces in the room. b) Resident #14's footboard had a large hole in the fiberglass facing covering the outside of the footboard. The Surveyor could put her open hand over the hole, and it did not cover the hole. c) Resident #14's bathroom had a toilet plunger sitting inside a clear plastic bag. The contents inside the bag were visible. The handle of the plunger and the suction cup had a dark brown clumpy substance on them. The plunger was sitting to the left side of the toilet under the toilet tissue roll and a clear plastic bag with a urinal inside was hanging from the handrail. 12. On 9/09/24 at 1:01 PM, the Surveyor observed: a) Resident #14's bedroom had a strong odor of feces in the room. b) Resident #14's footboard had a large hole in the fiberglass facing covering the outside of the footboard. The Surveyor could put her open hand over the hole, and it did not cover the hole. c) Resident #14's bathroom had a toilet plunger sitting inside a clear plastic bag. The contents of the bag were visible. The handle of the plunger and the suction cup had a dark brown clumpy substance on them. The plunger was sitting to the left side of the toilet under the toilet tissue roll and a clear plastic bag with a urinal inside was hanging from the handrail. 13. On 9/10/24 at 1:17 PM, the Surveyor observed: a) Resident #14's room had a strong odor of feces in the room. Resident #14's footboard had a large hole in the fiberglass facing covering the outside of the footboard. The Surveyor could put her open hand over the hole, and it did not cover the hole. b) Resident #14's bathroom had a toilet plunger sitting inside a clear plastic bag. The handle of the plunger and the suction cup had a dark brown clumpy substance on them. The plunger was sitting to the left side of the toilet under the toilet tissue roll. 14. On 9/09/24 at 9:52 AM, the Surveyor observed: a) Resident #33's privacy curtain had dark brown smears over the lower portion of the curtain. b) The privacy curtain had a dark lumpy brown particle near the bottom of the curtain. c) Resident #33's floor, near the dresser, had a dark brown spot on the floor tiles. d) Resident #33's bathroom had paint and dry wall peeling from the wall on the right side of the commode and behind the commode, causing the baseboard to peel away from the wall. The baseboard had a buildup of a yellow substance along the top of the baseboard. e) Resident #33's bathroom floor had dark orange spots on the floor tiles. f) The Surveyor observed a gap between the base of the commode and the tiles around the base of the commode on the right side, exposing the concrete slab. This allowed for urine to pool and get under the tile. g) The seams of 12 tiles in the bathroom around the commode and out into the bathroom floor were outlined with dark brown lines. h) Resident #33's wardrobe had the finish peeling off, leaving the particle board exposed. The particle board had several areas chipped off and the drawers were not working properly. 15. On 09/10/24 at 9:33 AM, the Surveyor observed: a) Resident #33's privacy curtain had dark brown smears over the lower portion of the curtain. b) The curtain had a dark lumpy brown particle near the bottom of the curtain. c) The floor in Resident #33's room near the dresser had a dark brown spot on the floor. d) Resident #33's bathroom had paint and dry wall peeling from the wall on the right side of the commode and behind the commode, causing the baseboard to peel away from the wall. The baseboard had a buildup of a yellow substance along the top of the baseboard. e) The floor in the bathroom had dark orange spots on the floor tiles. f) The Surveyor observed a gap between the base of the commode and the tiles around the base of the commode on the right side exposing the concrete slab. This allowed for urine to pool and get under the tile. g) The seams of 12 tiles in the bathroom around the commode and out into the bathroom were outlined with dark brown lines. h) Resident #33's wardrobe had the finish peeling off, leaving the particle board exposed and chipped off, the drawers were not working properly. 16. On 9/11/24 at 12:23 PM, the Surveyor observed: a) Resident #33's privacy curtain had dark brown smears over the lower portion of the curtain. b) The privacy curtain had a dark lumpy brown particle near the bottom of the curtain. c) Resident #33's floor, near the dresser, had a dark brown spot on the floor tiles. d) Resident #33's bathroom had paint and dry wall peeling from the wall on the right side of the commode and behind the commode, causing the baseboard to peel away from the wall. The baseboard had a buildup of a yellow substance along the top of the baseboard. e) The floor in Resident #33's the bathroom had dark orange spots on the floor tiles. f) The Surveyor observed a gap between the base of the commode and the tiles around the base of the commode on the right side exposing the concrete slab. This allowed for urine to pool and get under the tile. g) The seams of 12 tiles in the bathroom floor, around the commode and out into the floor were outlined with dark brown lines. h) Resident #33's wardrobe had the finish peeling off, leaving the particle board exposed and chipped off, the drawers are not working properly. 17. On 9/9/24 at 11:05 AM, the Surveyor observed Resident #65's bedroom had a strong urine odor in the room. 18. On 9/9/24 at 1:38 PM, the Surveyor observed Resident #65's bedroom had a strong odor of urine in the room. 19. On 9/10/24 at 12:55 PM, the Surveyor observed: a) Resident #65's bedroom had a black buildup along the edge of baseboards on the floor around the bedroom and bathroom. b) The commode in Resident #65's bathroom had a yellowish/orange substance on the base of toilet and the floor around toilet. c) Seven floor tiles under the sink and around the base of the commode had black stains on them. 20. On 9/11/24 at 12:12 PM, the Surveyor observed: a) Resident #65's bedroom had a black buildup on the floor along the edge of baseboards around the bedroom and the bathroom. b) The commode in Resident #65's bathroom had a yellowish/orange substance on the base of the toilet and the floor around the toilet. c) Seven floor tiles under the sink and around the base of the commode had black stains on them. d) The two wardrobes in the room had broken door hinges. e) The drawers on Resident #65's nightstand were broken and hanging crossways of the nightstand. 21. On 9/11/2024 at 2:15 PM, the Surveyor conducted an interview with Certified Nurse Aide (CNA) #5 the CNA confirmed the substance on Resident #2's feeding pole, the electrical wire and the base of the pole, was dried milk and said the nurses were responsible for cleaning the tube feeding poles. CNA #5 had concerns of a resident getting scratched on the rough boards of the over-the-bed table. 22. On 9/11/2024 at 2:30 PM, CNA #6 said the drawers were not in working order on the wardrobe due to being warped from water and the said it looks like it is coming apart. CNA #6 said Resident #33 ' s privacy curtain had food, toothpaste and as she pointed to a brown particle on the curtain, she said I don't know what that is. CNA #6 said the room smelled like urine, mildew, and the wall behind the toilet looked like mildew and the floor is sticky 23. On 9/11/2023 at 2:40 PM, Licensed Practical Nurse (LPN) #7 said Resident #2 ' s room smelled musty and had a smell of urine. LPN #7 said the rough wood on the over-the-bed table could cause a cut to a resident and it could contain bacteria. 24. On 9/11/2024 at 3:00 PM, Housekeeping Supervisor (HKS) #9 said the floors are sticky because someone is using something they should not be using in their mop water. HKS #9 looked in the Resident #14 ' s bathroom and said he did not know why that dirty plunger had been left in the bathroom but that he would get it. HKS #9 said the odor in Resident #14's room smelled like urine and boo-boo. 25. On 9/11/2024 at 3:33 PM, the Administrator and the Surveyor were walking down the hallway and observed the plunger in the clear plastic bag with dark brown clumps and yellowish liquid on the handle and on the suction cup of the plunger sitting in Resident #14's bedroom beside the wardrobe. The Administrator informed the Surveyor he knew he needed to replace some wardrobes but wasn't sure exactly when they would be replaced. The Administrator identified the orange spots on the floors to be rust. 26. On 9/11/2024 at 3:38 PM, the Assistant Director of Nursing (ADON) gave the Survey Team a Floors policy. The policy was dated 2001 Med-Pass with a revised date of December 2009. The Policy Statement indicates the floors should be maintained in a clean, safe, and sanitary manner. Item 1. Indicates all floors shall be mopped/cleaned/vacuumed daily in accordance with our established procedures.

Based on observation, record review, interview, and facility policy review, the facility failed to ensure clear, legible medication labels were on narcotics to prevent medication errors, and misappropriation of resident medications in the 100 Hall/200 Hall Medication Room. Findings include: 1. A review of a policy titled, Storage of Medications, revised November 2020, revealed nursing staff are responsible for the medication storage area. Medications are stored separately from food and are labeled accordingly. 2. On 09/10/24 at 01:00 PM, Licensed Practical Nurse (LPN) #3 opened the refrigerated narcotic box and verified there were four bottles of anti-anxiety medication belonging to Resident #61 and three belonging to three non-sampled residents, and one unidentified bottle of medication in a plastic bag marked 102, with a completely faded out label and a red C. LPN #3 confirmed that she was not sure of the process, but the unidentified medication should be given to the Director of Nursing (DON), because it could disappear, and nobody would know where it was. 3. On 09/10/2024 at 01:30 PM, Registered Nurse (RN) #4 located narcotic page 102, and verified the unidentified bottle of medication was an anti-anxiety medication belonging to a non-sampled resident. 4. On 09/10/24 at 01:35 PM, RN #4 stated another nurse was asked to contact the pharmacy for a new label about 2 weeks ago. The pharmacy verified they had not sent out a replacement label. RN #4 confirmed that when a label is faded nursing is supposed to have the pharmacy print a label, because there was a risk the faded label could have resulted in someone getting the wrong mediation. 5. During an interview with the Assistant Director of Nursing (ADON) on 09/11/24 at 02:15 PM, the ADON stated that if a medication label is worn and cannot be read, staff are expected to notify the DON or the ADON, and to call the pharmacy to request a new label, because someone could be given the wrong medication, or the medication could be taken.

Based on observation, record review and interview the facility failed to demonstrate competent direct care staffing to provide nursing and related services, to assure resident safety and to maintain the highest practicable physical, mental, and psychosocial well-being for 20 (#16, #27, #31, #32, #33, #39, #45, #49, #53, #57, #59, #62, #63, #64, #65, #69, #72, #71, #73, #182) sampled residents. This had the potential to affect all residents listed on the Resident Matrix provided by the administrator on 10/30/23 at 09:35 am. The findings are: 47912 A. On 10/31/23 at 09:40 AM Surveyor observed Certified Nursing Assistant (CNA) #1 cleaning liquid that had spilled onto the floor, cleaning bedside table, then handling lifesavers and chapstick, and emptying trash in room [ROOM NUMBER] with the same pair of gloves. The sheets were changed for Resident #57 wearing the same set of gloves. There were 2 baby dolls sitting on the windowsill and CNA #1 knocked the dolls onto the floor while she was closing the blinds. She picked them up and placed them in a chair and placed the chair on Bed A's side of the room. At 09:42 AM CNA #4 entered room [ROOM NUMBER] pushing Resident #57 on a shower gurney and asked CNA #1 to assist with transferring from gurney to chair using mechanical lift. CNA #1 assisted with the transfer without removing dirty gloves or sanitizing. CNA #4 moved the chair with the dolls, and they fell on to the floor as she was making room to remove the shower gurney and place the lift and wheelchair into position. She picked them up and placed them back into the chair after accidentally kicking one. After completing the transfer using hoyer the mechanical lift, CNA #4 removed gloves, and sanitized hands prior to leaving resident room. Neither CNA #1 nor CNA #2 wiped the dolls or cleaned them after picking them off of the floor. The Surveyor asked CNA #1 if she changed gloves between resident care. CNA #1 answered, No this is only my 4th day here. I just started last week. The Surveyor asked CNA #1 what could happen if gloves were not changed and hands were not sanitized between residents. The CNA #1 answered, Infection Control and walked out of the room. The Surveyor remained in the room. Resident #57 told the Surveyor that she had soiled her brief. The Surveyor pushed the call light. At 0:950 AM CNA #1 returned to the room and attempted to change Resident #57's soiled brief by herself. She raised the bed into the highest position, left Resident #57 lying on her side, and left the room at 0953 AM. At 09:56 AM CNA #1 reentered the room with CNA #2. CNA #1 left the room again to gather lift supplies. CNA #2 lowered the bed stating I'm going to let you down. You are scaring me being high up like this CNA #2 left the room to get plastic bags for trash and soiled brief. CNA #2 re-entered Resident #57's room at 10:00 AM with supplies for incontinent care and plastic bags. Resident #57 asked to have her teeth brushed. CNA #2 answered, I'm waiting on her to get back so we can change you and transfer you into your wheelchair, then we'll get your teeth brushed and wipe that face. 10:02 AM, CNA #1 returned with CNA #3. CNA #1 and #2 donned gloves and changed Resident #57's soiled brief. CNA #1 threw the wet brief onto the bed and picked it up after CNA #2 told her to put it in the plastic bag. At 10:13 AM, CNA #1 and #2 and #3 attempted to lift Resident #57 out of bed to transfer to chair using mechanical lift. The battery was dead, and the lift would not work. CNA #1 stated, Oh my God, I grabbed the wrong one. At 10:15 AM CNA #3 left the room to get a different battery to replace the one on the lift. CNA #3 returned and replaced the battery. The lift still did not work. CNA #3 left again to find another lift. At 10:19 AM CNA #3 returned with a different lift that worked and Resident #57 was transferred to chair. CNA #3 and CNA #2 operated the lift while CNA #1 stood behind resident's wheelchair. At 10:28 AM Resident #57 had to be re-lifted and repositioned in chair. Resident #57 stated she was uncomfortable, getting tired, and wanted to brush her teeth. CNA #1 left the room at 10:37 AM to gather supplies to brush teeth as there were no toothbrushes or cups in room. CNA #2 left room to get nail care clippers. CNA #3 gathered oral care items and placed them on bedside table. CNA #3 sent CNA #2 out of the room to get another cup for resident to spit in as she had only brought on. CNA #3 removed gloves and sanitized hands and prompted CNA #1 to put water into one of the cups so resident could brush her teeth. At 10:40 AM Surveyor left room. B. On 11/02/23 at 07:28 AM the Surveyor observed the LPN #2 walk away from the medication cart in hall 200, leaving it unlocked, from 7:28 AM - 7:35 AM for a total of 7 minutes. The Surveyor stayed beside the cart and asked LPN #2 upon returning what could happen if medication cart was left unattended in the hallway. LPN #2 answered, It won't lock. The lock has been messed up on this cart. I've told them to fix it multiple times. LPN #2 pushed the lock in. The surveyor pulled on the drawer, and it was locked. The Surveyor asked the LPN if she was able to get back into the cart to finish the medication pass. LPN #2 unlocked the drawer and stated, I thought I had pushed it in all the way, but I guess I didn't. The lock is working, I guess they fixed it. On 11/02/23 at 07:53 AM the Surveyor asked the Director of Nursing (DON) what could happen if the medication cart was left unattended and unlocked. The DON answered, It's a safety thing, any resident or anybody else could get into it. On 11/02/23 at 12:32 PM the Administrator provided documentation entitled, Administering Medications which documented, .19. During administration of medications, the medication cart is kept closed and locked when out of sight of the medication nurse or aide .The cart must be clearly visible to the personnel administering medications, and all outward sides must be inaccessible to residents or others passing by . C. On 11/01/23 LPN#3 informed surveyors Resident #60 was pre-medicated for wound care. At 09:44 AM the Surveyor accompanied LPN #3 and CNA #3 to observe wound care for Resident #60 stage 2 pressure ulcer on coccyx. There were no paper towels in the restroom for staff to wash hands. LPN #3 sent CNA #3 to get paper towels from another resident room. The Surveyor observed as LPN #3 prepared wound care supplies on bedside table transferring supplies from wound supply cart. LPN #3 was wearing 2 bracelets that were uncovered by the glove she was wearing. One bracelet had multiple charms dangling which came into contact with wound care supplies in wound care supply drawer, bedside table, and multiple contaminated areas throughout the process. Resident #60 had a wet brief that was touching wound care areas throughout the procedure. LPN #3 ran out of gloves and had to send CNA #3 to get another box during the procedure. Resident #60 was rolled onto his left side facing the wall and CNA #3 during the wound care procedure. LPN #3 removed the bandage with gloved hands and there was a copious amount of serous purulent drainage. The Surveyor asked LPN #3 the size and depth of the wound. LPN #3 took a sterile Q tip and inserted it onto the wound and answered, 0.3. LPN #3 did not measure the length or width of the stage 2 pressure ulcer. The Surveyor asked if the wound had gotten better or worse since being in the facility. LPN #3 and CNA #3 answered, he came back from the hospital, and it was worse. That's why I got the orders changed. He is non-compliant with turning. LPN #2 stated to Resident #60, You didn't turn every 2 hours like I told you to, and it has gotten worse. Resident #60 stated, Oh, Oh God, Oh. The Surveyor asked LPN #3 how often the wound was measured. The LPN #3 answered, I'm going to halt the wound care procedure because he's in pain and I've been told to stop if residents say they are in pain. The Surveyor asked the LPN #3 if the resident should be asked if he wanted to halt the procedure, and what her next step would be. She stated, I'm going to put the dressing on and halt the procedure. The LPN #3 asked Resident #60 if he wanted her to continue and put the meta honey onto the wound. Resident #60 stated, Go ahead and finish. The Surveyor asked how the wound would heal if the meta honey was not placed on the wound. LPN #3 asked the Surveyor, How am I supposed to apply the meta honey without hurting him by poking into the wound with the Qtip. The Surveyor asked LPN #3 what she thought would be best to do. LPN #3 answered, I'll just pour it on and proceeded to pour a scant amount of the meta honey onto part of the wound. The bandage was placed over part of the wound and dated with initials. The adhesive was sticking to part of the excoriated skin, and Resident #60 had a small Bowel Movement (BM) visible. The Surveyor asked the LPN #3 and the CNA #3 if they had noticed the BM prior to adhering the bandage. CNA #3 answered, Yes I see it. We will clean it The Surveyor asked the LPN #3 and CNA #3 what could have been done differently during the procedure. The LPN #3 stated, I would not wear my bracelet during wound care The CNA #3 answered, I would make sure we had all the supplies in the room, and that I would have made sure the wet brief didn't touch the parts that we had cleaned. The Surveyor asked why those things were issues. The LPN #3 answered, Infection Control. 48483 Resident #63's diagnosis showed osteomyelitis of the vertebra to the lumbar region with a start date of 10/24/23. Resident #63's physician's order summary dated 11/2/23 showed, flush peripherally inserted central catheter [PICC] line before and after each medication administration using SASH [Saline-Administration-Saline-Heparin] method (10cc NS, Aspirate for blood, 10cc NS, 10cc Heparin). every 1 hour as needed for PICC Flush-Medication Administration Flush PICC line before and after each medication administration using SASH method (10cc NS, Aspirate for blood, 10cc NS, 10cc Heparin). Start Date: 10/24/2023. On 11/01/23 at 01:36 PM, the Surveyor observed the DON administer Intravenous [IV] Vancomycin 1.25 grams [G]/250 milliliters [mL] to Resident #63 via PICC line. The DON performed hand hygiene then removed the green cap from the port and cleansed it with an alcohol wipe, allowed it to dry, then attached a 10mL syringe of normal saline [NS] to the port, opened the clamp and then flushed with 5mL of NS, aspirated for blood return then continued to flush with the remaining 5mL of NS. The DON then removed the syringe and cleansed the port with an alcohol pad, allowed it to dry. The primed line of vancomycin was then attached to the port and the pump was programmed at 125mL/hour [hr] at 2 hours to infuse 250mL. Hand hygiene was performed. Upon completion, the DON stated, we use the SASH method. The surveyor asked the DON, what is the SASH method? The DON stated, we clean the port with an alcohol swab then let it dry, attach the NS and open the clamp, then push 10mL of NS, clean the port with an alcohol swab, let it dry, then push 10mL of heparin, clean the port and let it dry, then we attach the line for administration or place a green cap and close the clamp. On 11/01/23 at 03:41 PM, the Surveyor observed the DON perform hand hygiene then remove the line from the port, cleanse the port with an alcohol wipe, allowed it to dry. The DON then attached a 10mL syringe of NS to the port and flushed, the syringe was then removed and cleansed with an alcohol wipe, allowed to dry. The DON then attached a 5mL syringe of heparin and flushed with a push/stop method, the syringe was removed then the port cleansed with an alcohol swab and allowed to dry. A 2nd 5mL syringe of heparin was then attached and the line was flushed with a push/stop method, the clamp was closed, the syringe was removed, and the port cleansed with an alcohol pad, allowed to dry. A green cap was then placed on the port. Hand hygiene was performed. The DON followed the facility policy but failed to follow the Physician's Order. A Policy titled Flushing Peripheral and Central Vascular Access (ALLCARE Pharmacy and Procedures Manual) provided by the Administrator on 11/2/23 at 2:43 PM showed, .All vascular access devices used for intermittent medication administration will be flushed using the S-A-S-H or S-A-S technique . A Policy titled Intravenous Therapy [Date Implemented: 6/23 (Copyright 2022 The Compliance Store, LLC)] provided by the DON on 11/2/23 at 11:17 AM showed, .IV Push: Review and verify practitioner's order for infusion solution or medication, dose, frequency, and route of administration . On 11/03/23 at 12:44 pm the DON was asked: How do you determine the competency needed to meet each resident's needs each day and during emergencies? The DON stated, I want to watch someone before I just let them go do something, I want to know without a doubt they know what they are doing. The Surveyor asked: How often is this reassessed? The DON stated, I'm on the halls all the time, watching and making sure staff is doing what they need to do. I'm there to help them if they need it. The surveyor asked: How do you assure that staff are appropriately assigned to meet the needs of residents and are implementing care-planned approaches for each resident on each shift and unit? The DON stated, We have meetings every day, I round on everything. I walk around this building; I don't know how many times a day. The surveyor asked: Do you use temporary/contract staff? The DON stated, We do have some agency. The surveyor asked: How do you ensure these staff are competent and have the knowledge and skills to care for residents? The DON stated, The same way I do my permanent staff, by observing them before they actually do a skill, I want to make sure they know how to do something before doing it. The surveyor asked: What type of education or training is provided upon hire? The DON stated, We go over skills in orientation, I want to know that they know how to do everything. The surveyor asked: How often does CNAs and nurses receive training/education to get their skills updated, and what areas are covered? The DON stated, I do in-services all the time, covering everything. Nursing skills or any skills needed to do their job. The facility Assessment Tool provided by the administrator on 10/30/23 at 11:00 am documented.Purpose The purpose of the assessment is to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies .Overview of the Assessment Tool .3. Facility resources needed to provide competent care for residents, including staff, staffing plan, staff training/education and competencies, education and training .Staff training/education and competencies .All employees complete training and competencies on the following upon hire (* and completed annually) .Clinical Services: .infection control .hand hygiene .All nurses .Annual in-service training for nurses is designed to ensure continue competencies .medication administration .wound care, oxygen use, IVs .Nurse aides are required to complete . At a minimum, the following competencies are evaluated for topic selection .nail and hair care .using mechanic lifts, hand washing and infection control (hand hygiene .

Based on observation, record review and interview, the facility failed to ensure meals were served in a method that maintained the appearance that were acceptable to the residents to improve palatability and encourage good nutritional intake during 1 of 1 meal observed. This failed practice had the potential to affect 79 residents who receive meal trays from 1 of 1 kitchen, their rooms on the as documented on a list provided by the Dietary Supervisor #1 on 010/31/2023 at 02:05 PM. The findings are: 1. On 10/30/23 at 11:14 AM, The Surveyor asked Resident #52 how is the food, and how does it taste. She stated, The food is no good. I ask for different things to eat and I don't like it either. We have the same thing every day. It's not like I made it at home, and I just don't like the food. 2. On 10/30/23 at 11:20 AM, the Surveyor asked Resident #74 how is the food and how does it taste. He stated, I don't like the food. They feed us dog food here. 3. On 10/31/2023 at 01:44 PM, the Surveyor asked Certified Nursing Assistant #4 who was assisting residents with their noon meal in the dining room, to describe the appearance of food items served to the residents on mechanical soft diets and residents on regular diets. She stated, Stuffing was like clay, ground pork chops were dry, will need gravy and apple crisp was hard to cut. 4. On 10/31/23 at 01:46 PM, the Surveyor asked Certified Nursing Assistant #1 who was assisting residents with their noon meal in the dining room, to describe the appearance of food items served to the residents on mechanical soft diets and residents on regular diets. She stated, Pork chops were a little dry. Stuffing was dry, it looks like it was left in the oven a little longer. 5. On 10/31/23 at 01:47 PM, a test tray consisting of regular pork chop, brussels sprouts, cut green beans, ground pork chops and stuffing were obtained by the Dietary Supervisor. The Surveyor asked the Dietary Supervisor about the appearance of the food items. He tested them and stated, Brussels sprouts were mushy, stuffing was gummy and ground pork chops were dry. The Registered Dietitian tested the food items and stated, Stuffing was gummy, brussels sprouts was kind of mushy, ground regular pork chops were dry, and could need gravy.

Based on observation and interview the facility failed to ensure a suprapubic urinary catheter bag did not come into contact with the floor for 1 sampled resident (Resident #60) on hall 100 and failed to ensure proper wound care was performed for 1 sampled resident (Resident #60) to prevent potential cross contamination and infection. This failed practice had the potential to effect 2 residents (Resident #60) and 1 non sampled resident on hall 100 with urinary catheters based on a list of residents on hall 100 with foley catheters and 1 sampled resident with wounds provided by the facility Chief Executive Officer (CEO). The findings are: On 10/31/23 at 04:18 PM, the Surveyor observed R#60 lying in bed awake. The suprapubic catheter bag was touching the floor and was hooked to the bed rail between the wall and the bed. The bed was in the lowest position. On 11/01/23 at 09:42 AM, the Surveyor observed Resident #60's suprapubic foley catheter bag resting directly on the floor between the wall and the bed. The bag was not hooked to the bed rail. On 11/03/23 at 09:32 AM Resident #60 was lying in bed asleep. The Surveyor observed Resident #60's foley catheter bag resting on the floor. The bag was hooked to the bed rail facing the room, and the bed was in the lowest position. On 11/03/23 at 10:10 AM, The Surveyor accompanied the Director of Nursing (DON) to Resident #60 room and asked who is responsible for making sure catheter bags and tubing do not come in contact with the floor. The DON repositioned the bag and answered, It's not supposed to be on the floor. Everyone that comes in here is responsible for making sure it's not. The Surveyor asked the DON what could happen if catheter bags were left lying on the floor, or tubing comes into contact with the floor. The DON answered, It can be an infection issue The Surveyor asked the DON how often catheter bags are checked and how to prevent this from happening in the future. The DON answered, Check multiple times a day. I come in several times a day myself. More need to be done to educate staff. On 11/2/23 at 2:45 PM the Administrator provided documentation entitled, Infection Prevention and Control Program which documented, .This facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections a per accepted national standards and guidelines . and .2. All staff are responsible for following all policies and procedures related to the program . On 11/01/23, Licensed Practical Nurse (LPN) #3 informed the surveyors Resident #60 was pre-medicated for wound care. At 09:44 AM, the Surveyor accompanied LPN #3 and Certified Nursing Assistant (CNA) #3 to observe wound care for Resident #60's stage 2 pressure ulcer on the coccyx. There were no paper towels in the restroom for staff to wash their hands. LPN #3 sent CNA #3 to get paper towels from another resident room. The Surveyor observed as LPN #3 prepared wound care supplies on the bedside table transferring supplies from wound supply cart. LPN #3 was wearing 2 bracelets that were uncovered by the glove she was wearing. One bracelet had multiple charms dangling which came into contact with wound care supplies in wound care supply drawer, bedside table, and multiple contaminated areas throughout the process. Resident #60 had a wet brief that was touching wound care areas throughout the procedure. LPN #3 ran out of gloves and had to send Licensed Practical Nurse Licensed Practical Nurse to get another box during the procedure. R#60 was rolled onto his left side facing the wall and CNA #3 during the wound care procedure. LPN#3 removed the bandage with gloved hands and there was a copious amount of serous purulent drainage. The Surveyor asked LPN #3 the size and depth of the wound. LPN #3 took a sterile q tip and inserted it onto the wound and answered, 0.3 LPN #3 did not measure the length or width of the stage 2 pressure ulcer. The Surveyor asked if the wound had gotten better or worse since being in the facility. LPN #3 and CNA #3 answered, he came back from the hospital, and it was worse. That's why I got the orders changed. He is non-compliant with turning LPN #2 stated to Resident #60, You didn't turn every two hours like I told you to, and it has gotten worse. Resident #60 stated, Oh, Oh God, Oh. The Surveyor asked LPN #3 how often the wound was measured. LPN #3 answered, I'm going to halt the wound care procedure because he's in pain and I've been told to stop if residents say they are in pain. The Surveyor asked LPN #3 if the resident should be asked if he wanted to halt the procedure, and what her next step would be. She stated, I'm going to put the dressing on and halt the procedure. LPN #3 asked Resident #60 if he wanted her to continue and put the meta honey onto the wound. Resident #60 stated, Go ahead and finish. The Surveyor asked how the wound would heal if the meta honey was not placed on the wound. LPN #3 asked the Surveyor, How am I supposed to apply the meta honey without hurting him by poking it into the wound with the q-tip The Surveyor asked LPN #3 what she thought would be the best to do. LPN #3 answered, I'll just pour it on., and proceeded to pour a scant amount of the meta honey onto part of the wound. The bandage was placed over part of the wound and dated with initials. The adhesive was sticking to part of the excoriated skin, and Resident #60 had a small BM (bowel movement) visible. The Surveyor asked LPN #3 and CNA #3 if they had noticed the BM prior to adhering the bandage. CNA #3 answered, Yes I see it. We will clean it. The Surveyor asked e LPN #3 and CNA #3 what could have been done differently during the procedure. LPN#3 stated, I would not wear my bracelet during wound care. CNA #3 answered, I would make sure we had all the supplies in the room, and I would have made sure the wet brief didn't touch the parts that we had cleaned. The Surveyor asked why those things were issues. LPN #3 answered, Infection Control.

Based on observation, record review and interview, the facility failed to ensure meals were. prepared and served in accordance with the planned written menu were consistently utilized for preparation of altered consistency diets to meet the nutritional needs of the residents for 1 of 1 meal observed. These failed practices had the potential to affect 20 residents who received mechanical soft diets and 5 residents who received pureed diets from the kitchen according to a list provided by the Dietary Supervisor on 10/31/2023 at 02:05 PM. The findings are: 1. The 2023 menu for noon meal specified for the residents on mechanical soft diets to receive ground baked chicken pasta and for the residents on pureed diets to receive a #6 dip (2/3 cup) of pureed baked chicken pasta and pureed buttered dinner roll each. 2. On 10/30/23 at 10:10 AM Dietary Employee (DE) #1 used a 10 scoop to place 5 servings of chicken spaghetti into a blender and puree. At 10:12 AM DE #1 poured the pureed spaghetti into a pan. She covered the pan with foil and placed it in the oven to be served to the residents who required pureed diets, instead of a #6 dip as specified on the menu. At 12:41 PM Dietary Employee (DE) #1 used a #10 scoop (3/8 cup) to serve a single portion of pureed baked chicken pasta to 4 residents on pureed diets, instead of a #6 dip (2/3 cup) At 12:59 PM The surveyor asked the Dietary Employee (DE) #1 what scoop size you used to scoop baked chicken spaghetti into a blender. How many servings did you prepare? DE #1 stated, I used #10 scoop, and I did 5 servings. She again was asked what scoop size you served pureed baked chicken spaghetti with and how many servings you gave to each resident who required pureed diets. DE #1 stated, I used #10 scoop and gave one serving each. 3. On 10/30/23 at 12:16 PM Dietary Employee (DE) #1 Served regular baked chicken cubes pasta to the residents on mechanical soft diets, instead of ground baked chicken pasta. At 12:59 The surveyor asked DE #1 the reason residents on mechanical soft diets were served baked chicken cubes pasta. She stated, I thought they will have the same chicken as the ones on regular diets. c. On 10/30/23 at 12:51 PM The kitchen ran out of pureed bread. d. On 10/30/23 at 12:56 PM a resident was sitting in a blue Geri chair at the feed table in the dining room being assisted by Certified Nursing Assistant #1. The Tray card read: Regular Pureed Enhanced diet with Mildly Thick (2) Nectar-Like. Magic Cup L/D, House Shake TID. The resident was served 1/2 cup of pureed baked chicken spaghetti, 1/2 cup of pureed cut green beans, 1/2 cup of banana bread 1/2 cup of fortified mashed potatoes, a carton of thick and easy, a carton of cranberry Juice, a carton vanilla mighty shake. There was no substitute served to the resident in place of the pureed bread.

Based on Observation, Interview and Record Review, the facility failed to ensure that oxygen was administered at the rate ordered, equipment was assessed and maintained to prevent respiratory complications and infections by not securing humidifier bottle with tubing to concentrator, positioning nasal cannula correctly, and changing contaminated tubing, for 1 sampled resident (R#16). This failed practice had the potential to affect 3 residents on hall 100 who were receiving oxygen therapy per physician orders. The findings are: Resident #16 had a diagnosis of Chronic Obstructive Pulmonary Disease (COPD), unspecified. A Quarterly Minimum Data Set (MDS) documented a Brief Mental Status Score of 8 (8-12 moderate cognitive impairment) requiring assistance with 1-person physical support for bed mobility, transfer, and toileting. Section O under special procedures and treatments documented, Yes for oxygen therapy. a. A Physicians order dated 9/21/23 documented Oxygen 2L [liters] via NC [nasal cannula] PRN [as needed] for SOB [shortness of breath] as needed for Shortness of Breath b. A Care Plan dated 5/5/21 documented, .I have altered respiratory status/difficulty breathing r/t COPD . and .Change, date and initial oxygen tubing/bottle and place in a re-sealable storage bag every Sunday night shift . and Oxygen Settings: O2 @ [at] 2L via NC PRN . c. On 11/01/23 at 09:38 AM, the Surveyor observed Resident #16 Lying in bed asleep leaning to the right side of the bed. The nasal canula (n/c) prongs were under the chin and resting on the neck. The flow meter on the concentrator was set at 1.5 Liters/Minute. The Humidifier bottle was not dated and dangling from the concentrator by clear tubing. The top of the tubing that the humidifier bottle was dangling from had a bend in the tubing restricting the air flow through the tubing into the bottle of water. The humidifier bottle was suspended in the air and approximately 3 inches from the floor. The tubing attached to the humidifier bottle to the resident was lying on the floor. d. On 11/01/23 at 02:57 PM, Resident #16 was lying in bed asleep leaning to right side of bed. The Surveyor observed the nasal cannula prongs remained under the chin and resting on neck. The flow meter was set at 1.5 Liters. The humidifier bottle was not dated and dangled from the clear tubing attached to the concentrator. The top of the tubing, from which the humidifier bottle was dangling, had a bend restricting the air flow through the tubing into the bottle of water. The tubing attached to the humidifier bottle to the resident was lying on the floor. e. On 11/01/23 at 04:17 PM, two Surveyors walked into room [ROOM NUMBER]. Resident #16 was lying in bed asleep leaning to the right side of bed. The nasal cannula prongs remained under chin and resting on the neck. The flow meter was set at 1.5 Liters. The humidifier bottle remained undated and dangling in the air by the clear tubing from concentrator, with the bend at the top of the clear tubing. The tubing attached to the humidifier bottle to the resident was lying on the floor. f. On 11/01/23 at 04:18 PM, the Surveyor asked Licensed Practical Nurse (LPN #1) if the humidifier bottle should be dangling from the concentrator like that. LPN#1 answered, No as she picked up the humidifier bottle and secured it to the concentrator. The Surveyor asked what could happen if the tubing was left kinked like that. LPN #1 answered, Water could get in the cannula or it could get clamped off. It should have been holstered. g. On 11/01/23 at 04:19 PM, the Surveyor accompanied the Assistant Director of Nursing (ADON) into Resident #16's room and asked how often oxygen administration is checked for Resident #16. The ADON answered, We have to watch it frequently The Surveyor asked the ADON what could happen if the tubing stayed kinked and the humidifier bottle was left dangling from the concentrator. The ADON answered, If it was kinked badly, she's not getting as much air, but it looks like she's still getting air because the water is still bubbling. h. On 11/01/23 at 04:28 AM, the Director of Nursing (DON) informed the Surveyors in the conference room that Resident #16's oxygen saturation was 98% and her Pulse Rate was 72. i. On 11/02/23 06:45 AM, the Surveyor observed the DON walk into Resident #16 's room and reholstered the humidifier bottle that was dangling in the air approximately 3 inches from the floor with the tubing kinked at the top where it was attached to the concentrator. Resident #16 was asleep in bed receiving oxygen via nasal cannula. j. On 11/03/23 at 10:10 AM, the Surveyor asked the DON when oxygen tubing was found on the floor, what should be done and why. The DON answered, Get new tubing. If it been on the floor, there are germs on the floor from the bottom of your shoes. The Surveyor asked why that was an issue. The DON answered, Infection Control. k. On 11/02/23 at 2:46 PM, the Administrator provided documentation entitled, Oxygen Administration which documented, .Oxygen is administered under orders of a physician . and Staff shall monitor for complications associated with the use of oxygen and take precautions to prevent them . and Change oxygen tubing and mask/cannula weekly and as needed if it becomes soiled or contaminated . Change humidifier bottle when empty or at a minimum once a week .

Based on Observation and Interview the facility failed to ensure that call lights were within reach for 1 sampled resident (R#16). This failed practice had the potential to affect 80 residents based on a resident matrix provided by the Administrator on 10/30/23 at 10:39 AM. The findings are: a. On 10/30/23 at 01:41 PM, the Surveyor observed the call light lying on the floor next to Resident #16s bed, out of her reach. The Surveyor asked Resident #16 if she could find her call light. Resident #16 answered, No, where is it? b. On 10/30/23 at 02:28 PM, the Surveyor observed the call light lying on floor in the same spot next to Resident #16's bed, out of her reach. Resident #16 was lying awake in bed. c. On 10/30/23 at 03:32 PM, the Surveyor observed the call light lying on floor in the same position, next to Resident #16's bed out of her reach. Resident #16 was lying in bed asleep. d. On 10/30/23 at 03:58 PM, Resident #16 was lying awake in bed watching TV. The Surveyor observed the call light remained on the floor in the same position, out of Resident #16's reach. The Surveyor asked Certified Nurse Assistant (CNA) #5 if Resident #16 was cognitive enough to use her call light. She answered, Yes. and picked the call light from the floor and handed it to Resident #16. e. On 11/1/23 at 10:47 AM, the Surveyor asked the Social Worker if it was important for a resident to be able to reach her call light. The Social Worker answered, Yes Ma'am, absolutely. The Surveyor asked the Social Worker what could happen if call lights were left out of reach. The Social Worker answered, If assistance was needed, she wouldn't be able to contact staff. f. On 11/3/23 at 10:10 AM, the Surveyor asked the Director of Nursing who was responsible for making sure call lights were within residents reach and how often they should be checked. The DON answered, Everybody and anybody that walks into the room. They should be checked several times a day every time anyone enters a room it should be done.

Based on observation, interview and record review the facility failed to provide nail care for 1 sampled resident (#57) dependent upon staff for nail care to prevent infection, injury and promote good hygiene. This failed practice had the potential to affect 5 case mix residents (R#32, R#49, R#57, R#60 and R#72) on hall 100 dependent upon staff for nail care based on a list provided by the Administrator on 11/2/23 at 2:46 PM. The findings are: Resident #57 had a diagnosis of HEMIPLEGIA AND HEMIPARESIS FOLLOWING CEREBRAL INFARCTION AFFECTING RIGHT DOMINANT SIDE. A Quarterly Minimum Data Set (MDS) with an assessment review date (ARD) of 8/1/23 documented a Brief Interview for Mental Status Score of (BIMS) of 12 (8-12 moderate cognitive impairment) requiring extensive assistance with 1 person support for personal hygiene and total dependence for transfers with 2-person support. a. A Care Plan with an initiation date of 4/20/23 documented, .I have an ADL [Activities of Daily Living] self-care performance deficit r/t (related to) Hemiparesis following Cerebral Infarction . and .I will be clean and well-groomed daily throughout review date . b. On 10/30/23 at 11:05 AM, the Surveyor observed Resident #57's fingernails were approximately 1/4 - 1/2 inches long past tips of fingers on both hands with light brown substance visible underneath nails. The Surveyor asked Resident #57 if she liked her nails the way they were. Resident #57 answered, I would like to have them trimmed and am hoping they will do it tomorrow since that's bath day. c. On 10/31/23 at 09:40 AM, Resident #57 had returned from shower and was lying in bed. Fingernails and toenails remained 1/4 - 1/2 inches long. The Surveyor asked Resident #57 if she would allow staff to trim her fingernails and toenails. Resident #57 answered, Yes, I would like to have them cut, and I need to brush my teeth. d. On 10/31/23 at 10:02 AM, the Surveyor asked CNA #3 who was responsible for doing Resident #57 nail care. CNA #3 answered, Treatment or shower team. The Surveyor asked how often resident nail care is done. CNA #3 answered, When necessary, like now. The Surveyor asked CNA #3 to observe Resident #57 toenails and to see if they needed to be trimmed. CNA #3 answered, Yes, they need to be trimmed. Sometimes they refuse. CNA #3 asked Resident #57 Do you want your nails done and trimmed? Resident #57 answered, Yes. The Surveyor asked CNA #3 what could happen if nail care is not provided to residents on a regular basis. CNA#3 answered, She could cut herself and hurt her toes getting caught up in the sheets. The Surveyor asked CNA#3 to observe Resident # 57's fingernails. CNA #3 answered, Yeah, she refuses those. e. On 11/01/23 at 09:33 AM, Resident #57 was lying in bed awake. The Surveyor asked Resident #57 if her nail care had been done. Resident #57 answered, My fingernails got done, but my toenails were not done. I guess they ran out of time. The Surveyor observed nails on both hands. Right hand was holding a carrot, but the nails were clean and trimmed. Left hand nails were clean and trimmed. The Surveyor observed Resident #57's toenails and they remained approximately 1/4-inch past tips of toes on both great toes. There were jagged edges and some sharp corners observed on toenails, both feet. f. On 11/3/23 at 10:10 AM The Surveyor asked the DON who is responsible for nail care, why it's important and what can happen if it isn't done on a regular basis. The DON answered, The (Certified Nurse Assistants) CNA's usually get it done on bath days unless it's a Diabetic. Then the Nurses do them to keep them from getting ingrown toenails or scratching themselves. If they scratch themselves, it could become an infection control issue. g. On 11/02/23 at 02:46 PM, the Administrator provided documentation entitled, Policy Nail Care which documented, .3. Routine cleaning and inspection of nails will be provided during [Activities of Daily Living] ADL care on an ongoing basis. 4. Routine nail care, to include trimming, and filing, will be provided on a regular schedule (such as weekly on Wednesday 3-11 shift). 6.Nails should be kept smooth to avoid skin injury .

Based on record review and interview the facility failed to follow the Advanced Directive and obtain physician orders regarding cardiopulmonary resuscitation (CPR) for 1 (Resident #2) of 3 (Resident #1, #2, and #3) sampled residents which resulted in a hospital admission. The findings included: 1. Review of Order Summary Report dated [DATE], showed Resident #2 was admitted to the facility on [DATE] with the following diagnoses Functional Quadriplegia, Hydrocephalus, Tracheostomy and Encephalopathy Unspecified. 2. Review of the facility's Consent for Treatment and Authorization for Care dated [DATE] and completed the day before Resident #2 was admitted showed the responsible party signed the following: a. Yes, to the Acknowledgement of Advance Directive Discussion. b. Yes, I have executed an Advance Directive. I do not want CPR. 3. Review of Resident #2's Hospital Visit Summary/Patient Care Order Sheet dated [DATE] through [DATE] showed resuscitation status as of [DATE] as DNR (do not resuscitate), no intubation, and no Advanced Cardiovascular Life Support (ACLS). 4. Review of facility's Progress Notes dated [DATE] at 6:03 PM showed CNA [Certified Nurse Assistant] reported to this nurse resident was on the floor. Upon entering the room found resident on floor unresponsive. Alerted administrator and DON [Director of Nursing]. Resident was transported to [named hospital] via stretcher and emergency personnel. Responsible party was notified. 5. Review of Witness Statements (DMS-762) dated [DATE] showed the following: a. Licensed Practical Nurse (LPN) #1stated .this nurse notice resident on the floor. This nurse, alone with 3 other nurses and 2 CNAs .transferred resident to bed.The Infection Preventionist Nurse started to suction resident. Resident became unresponsive. CPR was initiated immediately and continued until EMS [emergency medical services] arrived and took over. b. LPN #2 stated Nurse was called to assist with getting resident off the floor.We proceeded to do CPR until EMS came . 6. Review of a Cardiology consult dated [DATE] showed Resident #2 was admitted from an outside hospital with respiratory arrest from a suspected mucus plugging. 7. Review of facility's policy titled Advance Directives provided by the Administrator on [DATE] at 9:13 AM, showed the following: a. Policy Statement: Advance directives will be respected in accordance with state law and facility policy. b. Policy interpretation and implantation: Number 20: The director of nursing services or designee will notify the attending physician of advance directive so that appropriate orders can be documented in the resident 's medical record and plan of care. 8. During record review of Resident #2's Order Summary Report, showed code status as DNR with an active date of [DATE] with no physician orders regarding CPR noted prior to this date or the incident date of [DATE]. 9. During an interview with the Administrator on [DATE] at 9:02 AM he stated they initiated CPR on the resident because they did not have a DNR order from the physician. The incident occurred 7 days after the family member imitated the facility advance directive. The Surveyor asked were the facility staff aware of the family's wishes and hospital documentation reflecting a note to withhold CPR? He stated the physician did not see the resident in time to provide a DNR order.

Based on observation, interview and record review, the facility failed to provide necessary services to maintain grooming, and personal hygiene for 2 (Residents #3 and #4) of 5 sampled residents. The findings are: Resident #3 had a diagnosis of kidney failure and respiratory failure. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/24/2023 documented the resident scored 13 (13-15 cognitively intact) on the Brief Interview for Mental Status (BIMS), was dependent on staff for bathing. A care plan with a revision date of 2/27/2023 documented .I have an activity of daily living self-care (ADL) performance deficit .The resident requires extensive assistance of staff for bathing, nail care, and personal hygiene. On 6/27/2023 at 2:22 p.m., The Surveyor asked Resident #3 how often do you receive showers/baths? Resident #3 replied, one time a week. A task ADL bathing document dated 5/30/2023 through 6/26/2023 documented on 6/24/2023 not applicable for bathing. There was no documentation why the resident did not receive a bath/shower. Resident #4 had a diagnosis of pressure ulcer to sacral and colostomy. The Quarterly MDS with an ARD of 3/15/2023 documented the resident scored 15 on the BIMS and required supervision of one staff for bathing. A care plan with a revision date of 2/6/2023 documented .I have an ADL self-care performance deficit .Resident requires supervision / set up with bathing . A task ADL bathing document dated 5/31/2023 through 6/26/2023 revealed Resident #4 did not get a bath/shower on. 6/7/2023, 6/12/23, 6/14/23. There was no bathing documented between 6/21/21 and 6/26/23. On 6/27/2023 at 2:35 p.m., the Surveyor asked Certified Nursing Assistant (CNA) #2, when are residents showered/bathed? CNA #2 replied, even rooms gets baths/showers on Monday, Wednesday, and Fridays, (M, W, F) and odd rooms get baths/showers on Tuesday, Thursday, and Saturdays, (T, TH, Sat.) on days and evening shifts, but most are done on day shift. The Surveyor asked CNA #2, who is responsible for ensuring residents get baths/showers? CNA #2 replied, we have shower aides, if no shower aides, we do our own showers. The Surveyor asked, where is this charted? CNA #2 replied, we chart in PCC (point click care). On 6/28/2023 at 9:55 a.m., the Surveyor asked the Director of Nursing (DON), how often are the residents showered? The DON replied, scheduled three times a week on day shift. The Surveyor asked, do you have a shower team? The DON replied, yes, sometimes; and if not, the CNAs are responsible for showers. On 6/28/2023 at 11:37 a.m., the Surveyor asked the DON, how do the CNA's know which residents are scheduled for showers on that day? The DON replied, it triggers in the Point of Care, on the CNA side of the electronic medical record. There should be an alert to notify that the resident is scheduled for a shower, and they know that even rooms are M, W, F, and odd rooms are T, TH, Sat. On 6/28/2023 at 11:45 a.m., the Surveyor asked CNA #1 how often are residents showered? CNA #1 replied, even rooms are M, W, F, and odd rooms are T, TH, Sat. The Surveyor asked, who is responsible for ensuring residents are getting showers? CNA #1 replied, we are responsible, on the shower day, it will pop up on the computer and tells us who gets a shower. The Surveyor asked, where are showers documented? CNA #1 replied, in the Point of Care in the computer. The Surveyor asked, who is responsible for documenting residents showers after they are done? CNA #1 replied, we document after we do them. The Surveyor asked, what does not applicable mean? CNA #1 replied, they didn't get it. On 6/28/2023 at 12:07 p.m., the Surveyor asked the Staffing Coordinator (SC), how often are residents showered? The SC replied, three times a week and as needed. The Surveyor asked, who is responsible for ensuring residents are getting showers? The SC replied, I'm first in line, all showers are done on day shift. The Surveyor asked, how do the CNAs know who is to be showered? The SC replied, it triggers in the Kiosk and that's part of their daily charting. The Surveyor asked, where are showers documented? The SC replied, CNA's document in the Point of Care in the computer. The Surveyor asked, who is responsible for documenting residents showers after they are done? The SC replied, whoever does them. On 6/28/2023 at 12:57 p.m., the Surveyor asked the Administrator, what are your expectations from your staff regarding following the facilities policies and procedures and the Centers for Medicare and Medicaid Centers (CMS) guidelines? The Administrator replied, that they follow it to the letter. A policy provided by the DON on 6/28/2023 at 10:57 a.m. documented .Bath, Shower/Tub .the purpose of this procedure are to promote cleanliness, provide comfort to the resident and to observe the condition of the resident's skin .stay with the resident throughout the bath .Documentation .the date and time the shower/tub bath was performed .if the resident refused the shower/tub bath, the reason(s) why and the intervention taken . Reporting .notify the supervisor if the resident refuses the shower/tub bath .report other information in accordance with facility policy and professional standards of practice .

Based on observation, record review, and interview, the facility failed to ensure the resident's Physician and Personal Representative were notified of change in resident condition for 4 (Resident #25, #26, #34 and #223) of 4 sampled residents, who tested positive for COVID-19 on 04/07/23. This failed practice had the potential to affect 72 residents who reside in the facility according to the Resident Census and Conditions of Residents, provided by the Administrator on 04/10/23. The findings are: On 04/10/23 at 10:40 am., The Assistant Administrator provided the Surveyors a list 4 residents names and the dates they tested positive for COVID-19. 1.Resident #25 had diagnoses of Alzheimer's Disease, Chronic Obstructive Pulmonary Disease, and Contact with Exposure to Other Viral Communicable Diseases. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/24/23 documented a Staff Assessment for Mental Status (SAMS) of 3 (indicates severely impaired in cognitive skills for daily decision-making). a. Resident #25 tested positive for COVID-19 on 04/07/23 according to a list provided by the Assistant Administrator on 04/10/23 at 10:40am. b. The Record Review completed on 04/12/23 showed no notification to Resident #25's Representative regarding the change in his Health Status. The Late Entry Note created by Infection Preventionist/Licensed Practical Nurse (IP/LPN) #1 on 04/11/23 at 3:23pm [15:23] with an effective date of 04/07/23 at 3:20pm [15:20] documented, Tried to make contact with family about the resident testing positive for COVID-19. Left message. 2. Resident #26 had diagnoses of Multiple Sclerosis, COVID-19, and Cerebral Infarction. The Significant Change/Medicare 5-Day MDS with an ARD of 03/06/23 documented a Brief Interview for Mental Status (BIMS) of 10 (08-12 indicates moderately impaired). a. Resident #26 was tested positive for COVID-19 on 04/07/23 according to a list provided by the Assistant Administrator on 04/10/23 at 10:40am. b. The Record Review completed on 04/12/23 showed no notification to Resident #26's Representative regarding the change in his Health Status. The Late Entry Note created by IP/LPN #1 on 04/11/23 at 3:27pm, [15:27] with an effective date of 04/07/23 at 3:25pm [15:25] documented, Called and left message for the resident's Social Worker regarding the resident testing positive for COVID-19. 3. Resident #34 had diagnoses of Dysphagia, Oropharyngeal Phase, Essential (Primary) Hypertension. The Quarterly MDS with an ARD of 02/10/23 documented a BIMS of 13 (13-15 indicates cognitively intact). a. Resident #34 tested positive for COVID-19 on 04/07/23 according to a list provided by the Assistant Administrator on 04/10/23 at 10:40am. b. The Record Review completed on 04/12/23 showed no notification to Resident #34's Representative regarding the change in his Health Status. The Late Entry Note created by IP/LPN #1 on 04/11/23 at 3:24pm [15:24] effective date for 04/07/23 at 3:23pm [15:23] stated Called and left message about resident being positive for COVID-19. 4.Resident #223 had diagnoses of Unspecified Dementia with other Behavioral Disturbance, Hypertension and COVID-19. The Admission MDS with an ARD of 04/11/23 documented the resident scored 2 (indicates Moderately Impaired) SAMS; needs limited assist of one person for toileting, extensive assist of one person for personal hygiene, and supervision with ambulation. a. On 04/11/23 at 11:20 am., a review of Resident #223's Electronic Health Record (EHR), Physician Order dated 04/07/23 stated, .Droplet Isolation due to COVID-19 every shift for 11 Days . Care Plan documents Focus . Isolation Precautions: Droplet Isolations r/t [related to] COVID-19 Date Initiated: 04/07/23 . b. On 04/11/23 at 2:45pm., the Surveyor was provided Resident #223's COVID-19 Rapid testing form dated 04/07/23 which documented positive results. c. On 04/11/23 at 3:00 pm., the Surveyor was unable to locate the Progress Note in the EHR on 04/07/23 documenting communication of Resident #223's change in condition COVID-19 positive relayed to her Physician, her Representative or her family. d. On 04/12/23 at 10:05 am., the Surveyor requested a copy of the Progress Note for 04/07/23 that documented communication to Resident #223's Physician and Representative/Family regarding her testing positive for COVID-19 from Assistant Director of Nursing (ADON). e. On 04/12/23 at 11:24 am., the Surveyor was provided a copy of the Progress Note/General Note for Resident #223 that documented Late entry created date 04/12/23 at 11:14:02, effective date 04/07/23 at 11:11:00 by Infection IP/LPN #1 [nurses name] stating .Attempted to call [named family member], in regard to the resident being positive. Left message to call back facility . f. On 04/12/23 at 12:00 pm., the Surveyor reviewed Resident #223's EHR and noted a Progress Note/General Note that documented the Late Entry created date 04/12/23 at 11:18:44, effective date 04/11/23 14:15:00 by IP/LPN #1 [nurses name] stating, .Attempted to reach residents daughter on the phone to confirm COVID-19 positive notification. Left message to call back facility . g. On 04/12/23 at 3:30 pm., the Surveyor asked the DON, Should the resident's Physician be notified when one of his residents test positive for COVID-19? She replied, yes. The Surveyor asked, Should the communication with the Physician and the resident's family be documented in the resident's EHR? She replied, Yes. The Surveyor asked, Is there documentation in Resident #223's EHR stating the Physician was notified of the resident testing positive for COVID-19 on 04/07/23? She replied, No, we do have orders for the isolation though. The Surveyor asked, Why should the communication between the resident's Physician and the family be documented in the resident's EHR? She replied, So we know what is going on with the resident and who did the contacting and who was contacted. 5. On 04/12/23 at 3:00 pm., the Surveyor asked the Director of Nursing (DON), Who is responsible for notifying a residents family of the resident testing positive for COVID-19? She replied, The nurses, whoever does the test. The Surveyor asked, Should the family of a resident that has tested positive for COVID-19 be notified by the facility? She replied, Yes. The Surveyor asked, Why should family be notified of the resident testing positive for COVID-19? She replied, They have a right to know of a change in condition of the resident. The Surveyor asked, Is a resident testing positive for COVID-19 considered a change in condition? She replied, Yes, it is. 6. On 04/12/23 at 3:15 pm., the Surveyor asked IP/LPN #1 Who is responsible for notifying family of a resident having a COVID-19 positive test? She replied, Ultimately it is me, I am the one that notifies the family members of the residents test results. The Surveyor asked, What about on the weekends? She replied, It is still me; the nurse would let me know and I would be the one to tell the families. The Surveyor asked, Should the family of a resident that has tested positive for COVID-19 be notified by the facility? She replied, Yes. The Surveyor asked, What could a family member not being notified of a positive COVID-19 test result cause? She replied, The family will be upset, and they expect us to take care of their family members and they should be notified of changes. The Surveyor asked, Is resident testing positive for COVID-19 considered a change in the resident's condition that the family should be notified of? She replied, Yes, it is we should notify the family anytime the resident falls, or has new orders, change in medications, testing, behaviors, if the go or come back from the hospital. 7. The facility policy titled, Change in a Resident's Condition or Status, provided by the DON documented, 1. the nurse will notify the resident's attending Physician or Physician on call when there has been a(an): d. Significant change in the resident's physical/emotional/mental condition . and .4. Nurse will notify the resident's representative when: there is a significant change in the resident's physical, mental or psychosocial status . 46319

Based on observation, record review, and interview, the facility failed to ensure the cooking range in 1 of 1 kitchen was kept in safe operating condition to prevent injury to staff and residents. This failed practice resulted in Immediate Jeopardy, which caused or was likely to cause serious harm, injury or death for all 58 residents, as documented on the Resident Census and Conditions of Residents form provided by the Administrator on 02/01/2021 at 11:24 A.M., as well as staff and visitors. The Administrator was informed of the Immediate Jeopardy condition on 02/09/2021 at 1:40 P.M. The findings are: 1. On 02/02/2021 at 10:54 A.M., Dietary Employee #1 took a paper towel and twisted it, she then walked over to the gas stove and turned the knob for the right front burner. The burner did not light completely, but a small flame could be seen at the outlet. Dietary Employee #1 then stuck the paper towel into the flame and moved the now lit paper towel over the other two burners to the left, a flame then appeared over those burners. Dietary Employee #1 was asked what she was doing. She stated, This is how I have to light the stove because it doesn't work right. a. On 02/02/2021 at 11:02 A.M., Dietary Employee #3 stated, Yeah the stove doesn't work so we have to light it ourselves. The two bottom ovens don't work neither. Dietary Employee #3 was asked if the Administrator was aware that the stove did not function correctly. She stated Yes, I've told her because I am afraid that that flame may burst into (Dietary Employee #1) face one day. She said we can't replace it yet and have to make do with what we have. b. On 02/03/2021 at 12:38 P.M., Dietary Employee #1 was asked, How long has the stove not worked? She stated, For three years basically. Dietary Employee #1 was asked if the Administrator was aware that it was not working. She stated, Yeah, they know that. (Dietary Employee #3) told them again when she first started. The ovens to it don't work neither. c. On 02/03/2021 at 12:42 P.M., Dietary Employee #3 was asked when she notified the Administrator the stove did not work properly. She stated, When I first started I did a walk-through of the kitchen and I told her about the stove not working and the ovens not working and all she said then was that we don't have to use those ovens just use the conventional ovens. But I told her then and the RD (Registered Dietician) told her too. d. On 02/03/2021 at 12:48 P.M., the Registered Dietician (RD) was called and asked if she was aware that the stove did not work properly. She stated, I put a note in on January 13th that the range needed to be replaced. e. On 02/03/2021 at 01:02 P.M., the Director of Nursing (DON) was asked if she was aware that the range on the stove did not work properly, she stated, I found out when (Dietary Employee #3) reported it to me about 3 weeks ago. DON was asked what she did after she reported it to you, she stated I made sure the admin (administrator) was also aware and talked to the RD who also said it wasn't working and needed to be replaced. f. On 02/03/2021 at 1:13 P.M., the Administrator was asked if she was aware that the stove did not work properly, she stated, I was just made aware of it this morning. I told the maintenance man to work on it and clean each individual outlet on each of the eyes because the pots might have boiled over and got into the eyes. The Dietary Manager didn't let me know until this morning otherwise I'd have it fixed. g. A January 2020 RD note titled, RD Report 1/14/21 provided by the Administrator on 02/04/2021 at 11:58 A.M. documented . The range needs to be calibrated or replaced to properly prepare food . h. On 02/09/2021 at 12:10 P.M., entered the kitchen for tour. Dietary Employee #3 was asked to turn the burners on the range on. All burners came on when turned to the on position except for the middle back burner. Dietary Employee #3 was asked, Why doesn't that middle burner not work? She stated, He came in and switched one out this morning. She was asked, Did the burners just start working this morning? She stated, They started working before the state left out of here. The Maintenance man has been in here every day working on them. She was asked, Do the ovens on the range work? She stated, They do not work, they do not use them, we use the convection oven. i. On 02/09/2021 at 12:15 P.M., Dietary Employee #4 was asked, When did the burners start working again? She stated, I ' m not sure. j. On 02/09/2021 at 12:30 P.M., Dietary Employee #1 was asked, How long has it been since the oven was used? She stated, It has been over 2 years. She was asked, When did the burners start working correctly so that you did not have to light them with a paper towel? She stated, Today. She was asked, Do you use the ovens on the range? She stated, No, they won ' t stay lit. Dietary Employee #1 and #3 were asked, Does everyone who works in the kitchen know to not use the ovens on the range? They both stated, Yes. k. On 02/09/2021 at 12:35 P.M., the Maintenance man was asked, When did you fix the range so that the burners would lite correctly? He stated, On Tuesday 2/2/21 and again this morning 2/9/21. He was asked, What did you do on 2/2/21? He stated, I took all the burners out and cleaned them. He was asked, What did you do today? He stated, I took everything apart this morning and cleaned it. I took the lines and all and blew them out. He was asked, Did the work you did on 2/2/21 fix the range? He stated, It helped, but it didn ' t fix it. 2. The Immediate Jeopardy was removed, and the scope/severity reduced to F on 02/09/2021 at 3:47 p.m., when the facility implemented the following Plan of Removal: a. On 2/2/21 Maintenance Director evaluated all 6 burners to the stove top. He identified 3 burners that were clogged and would not automatically light. He took burners apart and unclogged identified burners. All 6 burners were in safe working order and would automatically light on Wednesday 2/3/21. On 2/9/21, Maintenance Director, was notified by dietary staff that 2 burners would not light. Maintenance director blew out all gas lines to the burners and purchased a part to repair the back, middle burner to ensure lines were clear and evaluated stove to ensure burners were working properly, as verified by the administrator. b. No other issues with the stove burners were found by Administrator on 2/9/21. c. The Dietary Staff will be in-serviced starting 2/9/21 to notify Dietary Manager immediately for any maintenance repairs needed with kitchen equipment. d. The Administrator/Designee will monitor the stove burners 5 times weekly for 4 weeks, then 2 times weekly for 4 weeks or until verified by OLTC (Office of Long Term Care). e. The QAA committee will review any negative findings forwarded by the Administrator/Designee monthly to determine the need for any further repairs or education.

Based on observations, record review, and interviews the facility failed to ensure adequate supervision was provided to prevent elopement for 1 (Resident #1) of 3 (Resident #'s 1, 2, 3) sampled residents at risk for elopement. The failed practice resulted in past immediate jeopardy that caused or was likely to cause serious harm, injury or death for Resident #1 who eloped from the facility and was not found until 2 days later after being notified by a local shelter. This failed practice had the potential to affect 29 residents at risk for elopement provided by the Administrator on 10/22/20 at 2:35 PM. The Administrator was informed of the past immediate jeopardy on 10/22/20 at 4:56 PM. The findings are: Resident #1 had [DIAGNOSES REDACTED]. a. An elopement risk assessment completed on 9/25/20 and another on 9/28/20 documented the resident had had no history of wandering and had not wandered. His readmission assessment for elopement risk documented that he had a history of [REDACTED]. b. An OLTC (Office of Long Term Care) Incident and Accident Report documented, .Date and time of Discovery: 10/16/20 645 (6:45 a.m.) . Summary of Incident . At 0645am the administrator was notified that resident (Resident #1) could not be found In the facility after a room search . STEPS TAKEN TO PREVENT CONTINUED ABUSE OR NEGLECT DURING THE INVESTIGATION . Police immediately notified and missing resident report made by the administrator, Resident's sister notified and Physician, A search of the facility grounds and surrounding area started by staff and (police). The facility immediately checked all other residents and all others were accounted for. Nursing staff in service started on visual checks of all residents every two hours and on Abuse and neglect by the DON (Direector of Nursing) . c. Nurses Notes documented the residents where about were unknown from 10/16/20 at 9:30 PM until 10/18/20 at 12:30 PM when a local shelter notified the Administrator that he was at their facility. The Administrator took the resident to the hospital for an assessment for injuries or health issues relating to his incident and he was readmitted to the facility on [DATE]. d. On 10/22/20 at 9:30 AM, the Administrator stated, They (the staff she had interviewed during the time the resident eloped) had stated they had not checked on the resident because he didn't like them in his room, but we did not know that to have care planned it. She stated that the Licensed Practical Nurse (LPN) had been suspended pending investigation. She then stated that all the windows had screws in them where they cannot be opened all the way. When we investigated how he managed to get out, we discovered the windows had clips to release the window for cleaning and caused it to jam. She stated they had a hard time getting it raised. She stated the screws had bent enough he was able to raise it. e. On 10/22/20 at 11:17 AM, LPN #2 was asked if he had worked on 10/16/20 with Resident #1 and he stated he had from 7AM to 7 PM. The LPN was asked about the resident's demeanor and he stated, He wasn't any different from normal. He gets frustrated when you cannot understand him. Nothing beyond baseline. He was asked how often staff rounded on residents and he stated, Supposed to make rounds typically every 2 hours. They (Certified Nursing Assistant (CNA) are on the hall all the time. f. On 10/22/20 at 12:41 PM, LPN#1 stated that she did work with Resident #1. She stated, When I first got there he had been upset and acting out because he didn't want to be there. Around 8 PM one of the residents was wandering and he had gone to (Resident 1) room. Resident 1 was fussing and carrying on so one of the CNAs took him out a little early to smoke to try to calm him down. When he got back, he told the aids not to come into his room. About 9:30 PM I checked on him and he said he was okay and didn't need anything. I checked to see if he had call light, and he did. There was staff a short distance from his room with a resident. She stated that she had asked the CNAs if they had completed their rounds and if everyone was okay and they said yes, they had made rounds. She said she expected that they had made rounds with oncoming shift. When she went into his room around 6 AM, the door was hard to open, and she had pushed it opened to find a folded wheelchair behind the door. He was not in the room, she had glanced at the window and it did not look like it had been tampered with, but it was dark and hard to tell. She then inquired if the CNAs had seen him, thinking he might have changed rooms in the night, but they had not seen him. They had started a search. She looked in his closet for him, and discovered his clothes were gone. She then contacted the Nurse Supervisor and the Administrator. When she looked out the window again, she could see the screen, but when she tried to get the window up, she couldn't get it up. She was asked if he had ever said he was leaving or getting out, and she said 'No. When she asked the CNAs when they last saw him, they told her that the resident didn't want to be disturbed and they had not disturbed him. She stated if she had known that she would have checked in on him. She stated, A lot of mornings he would have the wheelchair behind door. She was asked if she checked heads in the bed when doing the midnight census, and she said, I check by the head. She was asked if she checked him at midnight and she stated, I did not check him at midnight. g. On 10/22/20 at 3 PM, the maintenance man stated that when they investigated, they saw that the screws backed out enough that he could raise it up. He figured he pushed up sharply until it bent. He stated, All windows have screws on each side to prevent the window from raising but in the secure unit, I have put a wooden strip and screwed it in the track so that want happen anymore, plus (Resident 1) was placed in a room where the window opens to the courtyard. h. On 10/22/20 at 3:12 PM, CNA #1 was asked how often the residents were checked on and she stated, Every 2 hours. She was then asked what about (Resident 1) and she stated, He has requested not to be disturbed, he'll say 'Get out'. She works 11:00 p.m. to 7:00 a.m. and 7:00 a.m. to 3:00 p.m. shift. i. On 10/22/20 at 3:38 PM, CNA #2 was the CNA that took Resident #1 out to smoke early on 10/16/20. He stated he had worked 3:00 - 11:00 p.m. shift that night. He stated, I saw him at 8:30 PM and that was the last time I saw him. He stated he was not assigned to him that night; he had just taken him out to smoke. j. The plan of removal was completed on 10/17/2020 prior to the survey entrance. The facility performed a head count of the residents on the secured unit immediately and found all other residents were accounted for. Upon arrival the administrator went to the resident's room and found that the screw was in place for air flow only restriction to ensure no resident exiting from the window on the secure unit and found that the window clip went past the screw allowing the window to raise. The corporate maintenance director was notified per administrator to come and assess the windows on the unit to formulate a plan over the current air flow only opening, to ensure no other incidents could occur and arrived at 10:15 am. All resident had an elopement risk assessment completed by nursing on 10/17/2020 by 8:30 PM to identify others at risk for elopement and care plans updated and verified by the Administrator at 8:45 PM. All residents identified at risk for elopement had the risk added to their closet care plan on The elopement risk book was reviewed and updated by nursing on 10/17/20 at 6 PM and verified by the administrator at 6:30 PM. On 10/17/20 staff in-service started on resident elopements and statement obtained on the incident. The Risk Management team reviewed the resident's chart on 10/17/20 and found no active exit seeking activity. The facility will monitor resident closet care plans and elopement risk books to ensure they are in place and updated 3 times a week for 2 weeks then 1 time weekly for 8 weeks. The facility will monitor resident closet care plans and elopement risk books to ensure they are in place and updated 3 times a week for 2 weeks then 1 time weekly for 8 weeks. The facility will monitor resident elopement risk assessments and care plans updates are completed on admission, readmission and quarterly 3 times a week for 2 weeks then weekly for 8 weeks. The facility will monitor all windows on the secured unit for safety and security weekly for 8 weeks.

Based on observation, record review, and interview, the facility failed to ensure close supervision and monitoring were implemented and continued after a resident verbalized [MEDICAL CONDITION], and exhibited the intent to harm himself or commit suicide; failed to thoroughly assess the residents' environment to identify and address items that could be used by the resident to attempt suicide; and failed to ensure all staff involved with the resident's care were aware of the resident's self-harm / suicidal behavior for 1 (Resident #4) of 1 sampled resident who attempted to take his own life. This failed practice resulted in an Immediate Jeopardy, which caused or could have caused serious harm, injury, or death to Resident #4, who verbalized [MEDICAL CONDITION], and subsequently utilized a plastic bag placed over his head to attempt suicide. This failed practice had the potential to affect 1 resident who had verbalized suicidal ideation in the past 30 days, as documented on a list provided by the Administrator on 8/4/2020. The Administrator was informed of the Immediate Jeopardy condition on 8/4/2020 at 2:45 p.m. The findings are: 1. Resident #4 was admitted [DATE] from Acute Care with [DIAGNOSES REDACTED]. A Discharge Return Anticipated Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/15/2020 documented the resident scored 13 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status; Mood Severity Score 8 (5-9 indicates mild depression); feeling bad about yourself . yes . 7 to 11 days; poor appetite . yes . 7 to 11 days . and thoughts you would be better off dead or hurting yourself . yes . 2 to 6 days. a. A Nursing General Note dated 5/15/2020 at 10:31 a.m. documented, .Resident is exhibiting [MEDICAL CONDITION]. Resident asked this nurse if this nurse could 'just shoot him in the head and end it all'. Resident states that he does not want to live anymore. DON (Director of Nursing) and Social Worker notified . b. A Nursing General Note dated 5/15/2020 at 10:45 a.m. documented, .(Doctor) was notified of resident's behaviors. MD (Medical Doctor) recommended that resident be transferred out for further psych (psychiatric) evaluation. DON (Director of Nursing), Administrator, and Social Worker all notified of MD's recommendation . c. A Social Note dated 5/15/2020 at 11:29 a.m. documented, .This resident was admitted here to this facility on 5/14/2020 from (Hospital) here in (city) to Medicare. The facility van drivers went and picked him up around 1:00 pm. He completed his own admission paperwork. He will be a DNR (Do Not Resuscitate), the facility will be doing his laundry, and he plans to leave this facility after therapy with a place to stay. During the time that this resident was doing his admission paperwork with Social and made the statement that he was suicidal recently and told his friend that if he had a gun that he would shoot himself. Social then asked him if he still felt that way and he said that he was just depressed because he wanted legs to walk and that he was hoping that therapy could help him walk again . d. A Discharge Summary Note dated 5/15/2020 at 1:30 p.m. documented, .Resident was transferred to (Facility) via (Transportation van). Resident took all belongings and wheelchair during transfer. No signs of distress noted. Denies any pain at this time . e. A Social Note dated 5/20/2020 at 12:36 p.m. documented, .Social had to make a referral for this resident to be sent out to (Hospital Behavior Unit) on 5/15/2020 due to him telling his nurse that if he had a gun, he would shoot himself. (Doctor) gave the order for this resident to be sent to a psych (psychiatric) facility and (Facility) Psych Unit accepted him, and the facility van drivers took this resident over there via facility van to (Facility) and he was assessed and placed . f. A Nursing Admission Summary dated 5/21/2020 at 2:40 p.m. documented, .Resident returned to facility via facility transportation van at 1:42 p.m. (Doctor) notified of return and no new orders. Family also notified. Will continue to monitor . g. A physician's orders [REDACTED].[MEDICATION NAME] Oxalate Tablet 20 mg (milligrams) Give 20 mg by mouth one time a day related to Major [MEDICAL CONDITION], Recurrent Severe Without Psychotic Features . for 90 days . Start date 5/21/2020 . End date 8/20/2020 . h. The Care Plan with a revised date of 6/1/2020 documented, .(Resident #4) uses antidepressant medication [MEDICATION NAME] Oxalate Tablet 20 mg (milligrams) r/t (related to) Major [MEDICAL CONDITION], Recurrent and Severe Without Psychotic Features, [MEDICAL CONDITION] . Goal . (Resident #4) will be free from discomfort or adverse reactions related to antidepressant therapy . Interventions . Administer antidepressant medications as ordered by physician . Observe / document side effects and effectiveness Q (every) shift . Oxalate Tablet 20 mg (milligrams) . Black Box Warning . Suicidality and antidepressant drugs Antidepressants increased the risk compared with placebo of suicidal thinking and behavior (suicidality) in children, adolescents, and young adults in short-term studies of Major [MEDICAL CONDITION] and other psychiatric disorders. Anyone considering the use of [MEDICATION NAME] or any other antidepressant in a child, adolescent, or young adult must balance this risk with the clinical need . Depression and certain other psychiatric disorders are themselves associated with increases in the risk of suicide. Appropriately monitor patients of all ages who are started on antidepressant therapy and closely observe for clinical worsening, suicidality, or unusual changes in behavior . Problem . (Resident #4) has or is at risk for a psychosocial well-being problem R/T (related to) admission to facility / Depressions . Goal . (Resident #4) will demonstrate adjustment to nursing home placement this review period . Interventions . Allow the resident time to answer questions and to verbalize feelings, perceptions, and fears as needed . Arrange Care Plan meeting to facilitate communication between resident / family / caregivers as needed . Referral to PT (Physical Therapy) / OT (Occupational Therapy) to screen for possible need for intervention to allow for great mobility . As of 8/3/2020 at 2:50 p.m., the Care Plan contained no documentation related to the resident's verbalized expression of suicidal ideation. i. A Nursing General Note dated 6/29/2020 at 4:19 p.m. documented, .Another resident reported seeing resident with plastic bag over head and told this nurse. I paged to have Social Services meet me in resident's room. This nurse and Social went to check on resident and observed him lying prone in bed stuffing plastic bag under the padding of wc (wheelchair). When asking him, 'what was the matter' he stated, 'I'm just tired. I'm constipated. I'm hurting and nothing seems to help. I'm just miserable.' I reconciled all treatment options in place for resident to date .I told patient that his best option at this point would be going to the hospital and allowing them to perform more tests to see what's the cause of his discomfort. He states that the pain is in his groin, and his nubs (amputations). Social reiterated the need for hospitalization . Pt (patient) agreed. Received order from (Advanced Practice Registered Nurse (APRN)). Resident left via (Ambulance) at 4:20 p.m. to go to (Hospital) . j. A Nursing General Note dated 6/30/2020 at 2:18 a.m. documented, .Res (Resident) returned via hospital ambulance at 2:00 a.m. Res (Resident) with no c/o (complaints of) or s/s (signs / symptoms) of pain or discomfort noted. VS (vital signs) wnl (within normal limits). Will con (continue) to monitor . The Hospital Transfer form documented the reason for the resident's transfer to the hospital was Constipation. k. The Care Plan dated 7/31/2020 documented, .(Resident #4) has a behavior problem of making false allegations . Goal . (Resident #4) will have no evidence of behavior problems by review date . Interventions . Listen to his concerns when voiced . When interacting with him, have 2 staff members present . The Care Plan contained no documentation related to [MEDICAL CONDITION]. l. On 8/4/2020 at 9:34 a.m., Licensed Practical Nurse (LPN) #3 was asked, On 6/29/2020, do you remember the time the resident made the allegation of [MEDICAL CONDITION]? She stated, It was about 9:30 a.m. and I called the DON (Director of Nursing) and the Doctor. She was asked, What was done to protect (Resident #4) from 9:30 a.m. until 1:30 p.m. when he left? She stated, We had a CNA (Certified Nursing Assistant) watch him at all times. She was asked, Who was the CNA? She stated, I don't remember. She was asked, Do you recall what was in place when he returned from the geri-psych center on 5/21/2020? She stated, I don't think anything other than checking him regularly every hour. She was asked, Is there anything documented about monitoring him anywhere? She stated, Not that I'm aware of. m. On 8/4/2020 at 10:10 a.m., LPN #5 was asked, What was the resident's name that told you (Resident #4) had a plastic bag on his head? She stated, It was (Name). She routinely checks on others. She was asked, Do you know where the plastic bag came from? She stated, No, I don't. She was asked, What kind of a plastic bag was it? She stated, Like a trash bag liner. She was asked, What was done to protect (Resident #4) until he left for (Hospital)? She stated, One-on-one. She was asked, Is that documented anywhere? She stated, I'm not sure. n. On 8/4/2020 at 10:40 a.m., LPN #4 was asked, What was done to monitor (Resident #4) after he returned from the hospital after placing a plastic bag over his head? She stated, We checked him during every 2-hour bed checks. She was asked, Is that documented anywhere? She stated, No ma'am, it's not documented. o. On 8/4/2020 at 10:50 a.m., the Administrator was asked, When were you made aware of (Resident #4) placing a plastic bag over his head? The Administrator stated, I believe that it was as he was going out the door to (Hospital). They made sure he was safe and secured. She was asked, What does the facility document one-on-one monitoring on? She stated, We have a one-on-one form the DON gets. She was asked, What was done to protect (Resident #4) on 5/21/2020 when he returned from geri-psych? She stated, We reviewed the medical record. She was asked, What was done to protect (Resident #4) on 6/29/2020? She stated, One-on-one. She was asked, And when he re-admitted on [DATE]? She stated, We followed what the hospital identified. p. On 8/4/2020 at 11:18 a.m., (Non-sampled Resident) was asked, What prompted you to check on other residents? The resident stated, Somebody needs to . The resident was asked, Do you remember finding (Resident #4) with a bag on his head? The resident stated, I sure do. I was down there and knew he was very depressed over the loss of his legs. The resident was asked, Who did you report it to? The resident stated, Somebody at the front desk. They went right down. q. On 8/4/2020 at 11:30 a.m., the former Director of Nursing (DON) was notified via telephone, and asked, Can you recall when (Resident #4) asked a nurse if they could just shoot him in the head and end it all? She stated, Oh yes, I do. She was asked, Can you tell me what was done to protect (Resident #4) until he was sent out? She stated, He was put on one-on-one. She was asked, Is that documented anywhere? She stated, Oh, my. I don't remember. I think it was. It's somewhere on that desk. The Lead Certified Nursing Assistant (CNA) is the one that did the one-on-one. r. On 8/4/2020 at 11:35 a.m., the DON was asked if she could search for any one-on-one logs / documentation? She stated, I'll do my best. At 4:45 she stated, I haven't found anything. s. On 8/4/2020 at 11:50 a.m., Certified Nursing Assistant (CNA) #2, Lead Certified Nursing Assistant, was asked, Do you remember providing one-on-one for (Resident #4) on 5/21/2020? She stated, I don't remember anything. I have no memory of that. t. On 8/4/2020 at 2:45 p.m., the Social Worker was asked to clarify the Social Note dated 5/15/2020 which documented, .This resident was admitted here to this facility on 5/14/2020. He completed his own admission paperwork. During the time that this resident was doing his admission paperwork with Social and made the statement that he was suicidal recently and told his friend that if he had a gun that he would shoot himself. She stated, He was talking about his past life! The Social Worker was asked, Was the facility aware of his [MEDICAL CONDITION]? She stated, We discussed his suicidal tendencies in the Morning Meeting. She was asked, Was a plan developed on how to monitor him? She stated, Obviously not. u. The facility policy titled Depression Clinical Protocol provided by the Administrator on 8/6/2020 at 9:16 a.m. documented, .The staff will screen residents / patients for depression, using appropriate screening tools, on admission and subsequently, if suggested by changes in mood, function, or behavior. Staff will evaluate residents / patients (especially, those with a high-risk history) for possible evidence of a mood disorder. Examples of risk factors for depression include current use of a medication associated with a high risk of depression, history of attempted suicide. The staff will provide pertinent individualized non-pharmacologic interventions for the individual with depression. The staff and physician will monitor the resident's response to treatment for [REDACTED]. v. The facility policy titled Behavioral Assessment, Intervention, and Monitoring provided by the Administrator on 8/6/2020 at 9:29 a.m. documented, .As part of the initial assessment, the nursing staff and Attending Physician will identify individuals with a history of impaired cognition, altered behavior, or mental illness (e.g. (such as), [MEDICAL CONDITION] Disorder or [MEDICAL CONDITION]). The nursing staff will identify, document, and inform the physician about specific details in an individual's mental status, behavior, including onset, duration, intensity, and frequency of behavioral symptoms. The Interdisciplinary Team will evaluate behavioral symptoms in resident to determine the degree of severity, distress and potential safety risk to the resident, and develop a Plan of Care accordingly. Safety strategies will be implemented immediately if necessary, to protect the resident from harm. The Care Plan will incorporate findings from the comprehensive assessment and be consistent with current standards of practice. Interventions and approaches will be based on a detailed assessment of physical, psychological, and behavioral symptoms and their underlying causes. The Care Plan will include, at a minimum: a description of the behavioral symptoms, targeted and individualized interventions for the behavioral and / or psychosocial symptoms. If the resident is being treated for [REDACTED]. Interventions will be adjusted based on the impact on behavior and other symptoms, including any adverse consequences related to treatment . w. On 8/6/2020 at 12:30 p.m., Registered Nurse (RN) #1 was asked, Have you ever seen or reviewed the Behavioral Assessment, Interventions, and Monitoring policy and procedure? She stated, No, never. She was asked, Have you ever seen or reviewed the Depression Clinical Protocol? She stated, No, never. She was asked, What is the purpose of the Care Plan? She stated, To show us how to take care of them (residents). She was asked, Did (Resident #4's) Care Plan identify what to do if he expressed suicidal thoughts? She stated, No, it did not. We do our best until we know better. She was provided the P&P of the Clinical Protocol to review. After reviewing the policy, she stated, That's good stuff there. She was asked, Do you think a Comprehensive Care Plan could have been developed if you had these in the beginning of his admission? She stated, Yes, I think so. I'm going to ask for them right now. 2. The Immediate Jeopardy was removed, and the scope and severity decreased to E on 8/4/2020 at 7:40 p.m. when the facility initiated the following plan of removal: a.For Affected resident . 1.) .On 8/4/2020, Social Director completed a new PHQ9 to determine resident's current needs . 2.On 8/4/2020, the Director of Nursing updated the resident's Care Plan to reflect his history of [MEDICAL CONDITION] and suicidal attempts .

Based on record review and interview, the facility failed to ensure the facility abuse prohibition policies and procedures were implemented, as evidenced by failure to ensure an alleged incident that was suspicious for potential staff-to-resident abuse, including an alleged verbal threat to beat up a resident, was immediately and thoroughly investigated, failure to ensure immediate protective measures to prevent further potential abuse were implemented and maintained until a thorough investigation could be completed, and failure to ensure the alleged incident and verbal threat were immediately reported to the Office of Long Term Care (OLTC) to enable the state agency to provide the necessary oversight of the facility's efforts to investigate and protect residents from potential harm for 1 (Resident #6) of 1 case mix resident who had aggressive behaviors. The failed practices resulted in Immediate Jeopardy, which caused or could have caused serious harm, injury or death to Resident #6, and had the potential to cause more than minimal harm to 5 residents who had aggressive behaviors, according to a list provided by the Administrator on 12/11/18. The Administrator was informed of the Immediate Jeopardy situation on 12/11/18 at 2:08 PM. The findings are: 1. The facility's policy and procedure titled, Abuse Investigation and Reporting, provided by the Director of Nursing (DON) on 11/29/18 at 12:38 p.m. documented, .All reports of resident abuse, neglect, exploitation, misappropriation of resident property, or mistreatment and/or injuries of unknown source (abuse) shall be promptly be promptly reported to local, state, and federal agencies (as thoroughly investigated by facility management). Findings of abuse investigations will also be reported .If an incident or suspected incident of resident abuse, mistreatment, neglect or injury or unknown source is reported, the Administrator will assign the investigation to an appropriate individual . Reporting: All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source, and misappropriation of property will be reported by the facility administrator, or his/ her designee, to the following agencies: a. The state licensing/ certification agency responsible for surveying/ licensing the facility; b. The local/ State Ombudsman; c. The Resident's Representative (Sponsor) of Record; d. Adult protective Services (Where state law provides jurisdiction in long-term care); e. Law enforcement officials; f. The resident's Attending Physician; g. The facility Medical Director. 2. An alleged violation of abuse, neglect, exploitation, or mistreatment, including injuries of an unknown source and misappropriation of property will be reported immediately, but no later than: a. Two (2) hours if the alleged violation involves abuse OR has resulted in serious bodily injury; or b. Twenty-four (24) hours if he alleged violation does not involve abuse AND has not resulted in serious bodily injury . The Administrator . will provide the appropriate agencies or individuals listed above with a written report of the findings of the investigation within five (5) working days of the occurrence of the incident. If the investigation reveals findings of abuse, such findings will be reported to the State Abuse Registry . If the investigation reveals that the allegation(s) of abuse are founded, the employee(s) will be terminated . Appropriate professional and licensing boards will be notified when an employee is found to have committed abuse . 2. Resident #6 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Admission Minimum Data Set (MDS) with an assessment reference date of 10/09/18 documented the resident scored 5 (0-7 indicates severely impaired) on a Brief Interview for Mental Status (BIMS), required supervision with bed mobility, transfers, locomotion on and off the unit, and bed mobility, and had disorganized thinking present that fluctuated, but no other behavioral symptoms. a. The Care Plan dated 10/1/18 documented, (Resident #6) is an elopement risk/wanderer . Distract resident from wandering by offering pleasant diversion . The resident is grieving r/t (related to) death of loved one . Assist the resident to identify, access and use support systems . The resident has or is at risk for a psychosocial well-being problem: unsettled relationships, language/cultural barrier, obsession with physical problems and/or bodily functions . Allow the resident time to answer questions and to verbalize feelings perceptions and fear, (frequently) . b. On 11/26/18 at 4:17 PM, the MDS Coordinator informed the surveyor that she had something to tell her. She stated, I gathered all the witness statements and gave them to the Administrator. Me and (Licensed Practical Nurse (LPN) #1) tried to call the Administrator. I removed the CNA (Certified Nursing Assistant #2) off the hall to get her away from the resident. The nurse went up front and got the CNA to restrain her (Resident #6). The nurse no longer works here anymore. The CNA covered the cameras with a trash bag. She was mad, because the resident had threw (sic) a Bible at her. She told another staff she was going to beat her up, and the nurse was going to give her a shot. She was asked, Did you talk to any residents? She stated, No, I passed my pills and turned everything over to the Administrator. I only talked to the Administrator. I talked to the DON (Director of Nursing) today and told her that CNA was here. She (DON) called the staffing office and said she (CNA #2) could not work the 400 Hall (where Resident #6 resided). c. On 11/26/18 at 4:42 PM, the DON was asked, Can you tell me about the garbage bags over the cameras? She stated, On 11/05/18, the nurse wanted the cameras covered for dignity. She was asked, Do you think the cameras should have been covered? She stated, No. She was asked, When the Administrative staff is notified of an incident, who is responsible for the safety of the residents? She stated, We all are, me and the Administrator. d. On 11/26/18 at 5:00 PM, Resident #6 was asked, How long have you lived here? She stated, I don't know. She was asked, Has anyone ever hit you? She stated, No. She was asked, Are you afraid of any staff? She stated, No. 1.) On 12/11/18 at 12:16 PM Certified Nursing Assistant (CNA) #6 was asked, Does (Resident#6) have any memory issues that you know of? She stated, She's forgetful . 2.) On 12/11/18 at 12:18 PM, Licensed Practical Nurse (LPN) #5 was asked, Does (Resident#6) have any memory issues that you know of? She stated, Sometimes she's kind of forgetful, short term, and long term; impaired decision making sometimes. 3.) On 12/11/18 at 12:21 PM, CNA #7 was asked, Does (Resident#6) have any memory issues that you know of? She stated, Yes, well she don't remember what she did the day before. You have to repeat yourself and go back; she's forgetful. 4.) On 12/11/18 at 12:23 PM, CNA #8 was asked, Does (Resident#6) have any memory issues that you know of? She stated, No more than when she tries to get out the door. She thinks she be at work and be trying to get out. e. An Office of Long Term Care (OLTC) Incident and Accident Report (I&A), Division of Medical Services (DMS) form 7734, dated as submitted to OTLC on 11/26/18 at 5:00 PM (21 days after the alleged incidents took place and after OLTC's onsite investigation was initiated) documented, Summary of Incident . On 11/05/2018 on the night shift, (Resident #6) was up most of the night exit seeking and combative with care. Per the nurse's notes, 'alert and verbal, resident was on the door all night, trying to elope verbally redirected with no help. Refuses po (by mouth) meds. Resident also refuses PRN [MEDICATION NAME] as ordered, was raising her voice on the staff, hit one of the staff members when we block the door so that R (resident) cannot leave. DON called. Return call awaiting. (CNA #2) states that nurse (LPN#2) had her to place a trash bag over the camera but refused to help restrain the resident and the LPN then (went) to another hall for help. Then (LPN #6) went to 400 hall where (Resident #6) is and (told) (LPN #2) that she could not hold down a resident against her will to give her a shot. Steps taken to prevent continued abuse or neglect during the investigation . (LPN #2) was terminated on 11/05/18. (CNA #2) was suspended pending investigation. Little Rock Police was called to report incident, Family and MD (Medical Doctor) called to report incident. Abuse in-service started for all staff. Social Worker will interview residents under the care of the LPN and CNA. The resident interviews were documented on an attached Witness Statement form and indicated 4 residents were asked, Has any of the staff treated you wrong? All 4 residents stated, No. No other questioning of residents was documented. On 11/26/18 at 5:03 PM, the Administrator was asked, Do you remember any incidents of staff reporting that a CNA covered the cameras to beat up (Resident #6) or to hold her down for an injection? She stated, I have statements that it never occurred. She was asked, Was it reported to the Office of Long Term Care? She stated, No, because it never occurred. They did state that the nurse asked the CNA to put bags over the camera, because she was going to hold the resident down. The Administrator showed the surveyor the Witness Statements she had in her desk drawer related to this incident. 1.) A Witness Statement form dated 11/05/18 and signed by CNA #2 documented, I was closing the door after the nurse went out and I was turning around, and (Resident #6) hit me with her book. I went back on the hall to finish working and reported the incident to the nurse when she came back to hall. The nurse on duty asked me to cover the camera in the hall with plastic bag and I did so. I did not tell any resident or staff in building that I would harm a resident. The nurse on duty asked me to help hold a resident to give her a shot, I refused because I didn't want to restrain the resident. She told me she would get it done and to put the plastic over the camera, I did so. She went to the front of building to get two male CNAs to help, who were told to go back to their hall. The nurse told me I could uncover it, and she didn't give the resident the shot. 2.) A Witness Statement form dated 11/5/18 and signed by LPN #1 documented, I was called to my office to speak with (CNA #4) who told me that (CNA #2) on the 400 hall had covered the camera on the 400 hall with a trash bag and stated that she (CNA #2) was going to beat the resident because she hit her with a Bible. I went to the 400 Hall to get (CNA #2) and told her I need to talk with her. She refused and walked out. She returned about 10 minutes later. I started to explain to (CNA #2), I am not accusing you of anything, but when someone makes an allegation, we have to do an investigation. (CNA #2) became defensive and said, 'I did what my nurse told me to.' I started to ask for a statement, then the CNA walked out again. 3.) A Witness Statement form dated 11/5/18 and signed by CNA #1 documented, To whom it may concern, the 400 hall nurse ask me, the 300 hall CNA, would I come help her hold a pt (patient) down. One hold the legs, someone else hold the arms. I, the CNA, ask for what. Nurse states so that she going to give a pt a shot to help calm her down. I, the CNA, asked the nurse can that be done against her will. I, the CNA, told 400 hall nurse, I can't do that, that's against the pt will, so I didn't. 4.) A Witness Statement form dated 11/5/18 and signed by CNA #5 documented, I was talking to (CNA #4) when (LPN #2) came and told me and (CNA #3) to come hold (Resident #6) down to get a shot but when we got back there, (CNA #3) notices the camera was covered and told me. Then my 200 hall nurse came and got us. 5.) A Witness Statement form dated 11/5/18 and signed by LPN #3 documented, (LPN #1) called (CNA #2), the night shift CNA on the 400 hall into my office and explained to her that she was sending her home pending an investigation about (Resident #6) d/t (due to) CNA covering the camera with a trash bag. The CNA stated to (LPN #1) that she was 'doing what her nurse told her to do'. 6.) A Witness Statement form dated 11/5/18 and signed by CNA #3 documented, I was approached by (LPN #2), the 400 hall nurse, to accompany her with (CNA #5) to her hall. I was not aware of the intention of this unscheduled excursion but, my place was to help a nurse in need. Upon arriving on the scene of the incident at hand, I noticed (Resident #6) was beating at the locked door, trying to escape. I noticed two things that made me question the situation I was put in. First, I noticed a trash bag over the camera at the entrance of 400 hall. Second, (LPN #2) was preparing an injection for the irate resident . I was not asked to restrain the resident, but I feel (LPN #2) may have intended for me to do so, I did not. It was then that another nurse entered the scene and scolded (LPN #2) that we, (CNA #5) and I, could not, by law, restrain the resident . 7.) A Grievance form dated 11/05/18 by CNA #4 documented, Me (CNA #4) was on the halls when (Resident #6) was banging on the door and was mad because she wanted to go home .400 hall nurse came to (CNA #5) and (CNA #3) asking them to hold (Resident #6) down and (CNA #2) had the camera covered .I wouldn't hold (Resident #6) down after her asking me 3 or 4 times to hold her .I overheard (CNA #2) tell (CNA #3) say she covered the camera to beat (Resident #6's) but (butt) because she hit her with the Bible. f. On 12/11/18, the surveyor reviewed the following records to attempt to determine whether Resident #6 received an injection on the night of 11/4/18 / morning of 11/5/18: 1.) The Medication Review Report dated 11/2/18 documented orders for, [MEDICATION NAME] solution 2 mg/ml (milligrams per milliliter) inject 0.5 ml intramuscularly every 6 hours as needed for Anxiety for 14 days . The report also documented the resident was receiving scheduled antipsychotic medication and an as-needed sedative: [MEDICATION NAME] tablet 25 mg give 25 mg by mouth two times a day at noon and bedtime . [MEDICATION NAME] 50 mg give 50 mg by mouth at bedtime . [MEDICATION NAME] HCL ([MEDICATION NAME]) tablet 50 mg give 50 mg by mouth as needed for [MEDICAL CONDITION] prn (as needed). 2.) A Progress Note dated 11/05/18 at 2:22 AM and signed by LPN #2 documented, Alert, and verbal, resident was on the door all night, trying to elope. Verbally re-directed with no help. Refuses PO (by mouth) meds (medications). Resident also refuses PRN (as needed) [MEDICATION NAME] as ordered, was raising her voice to the staff. Hit one of the staff members when we block the door so that R (Resident) cannot leave. DON called. Return call awaiting. 3.) A Progress Note dated 11/05/18 at 4:59 AM and signed by LPN #2 documented, Continue fighting on the door wanted to go home. Continue to refuse PRN meds when offered. 4.) The (MONTH) (YEAR) Medication Administration Record [REDACTED]. The narcotic sign-out sheet did document that on 11/05/18 at 1:55 AM, LPN #2 signed out a dose of the [MEDICATION NAME], but wasted the medication. The time the medication was wasted was not documented on the narcotic sign-out sheet. g. On 11/29/18 at 12:20 PM, the DON was asked, When should an allegation of abuse be reported to OLTC (Office of Long Term Care)? She stated, Hour with injury, and two hours without. h. On 11/29/18 at 1:10 PM, the Administrator was asked, When should an allegation of abuse be reported to OLTC? She stated, Within two hours for 7734 (OLTC Incident and Accident Report form); police called before that. i. A Termination of Employment form dated 11/29/18 documented CNA #2's name and, .Violation of policies and procedures . tampering with camera / surveillance .Beginning 11/26/18 . The form was signed by the DON and the Administrator. This was a period of 24 days after the alleged incident took place. j. On 12/11/18 at 10:09 AM, CNA #2's (MONTH) (YEAR) schedule and time card reports were provided by the facility's Staffing Coordinator and were reviewed with the following findings: The schedule documented that CNA #2 was scheduled to work the night of 11/4/18 on the 400 Hall. She was again scheduled to work the night of 11/5/18 on the 400 Hall, and did work that shift, according to the time card report. CNA #2 was scheduled off 11/6/18 and 11/7/18. On 11/08/18, CNA #2 worked on the 400 hall, where Resident #6 resided. On 11/09/18, CNA #2 worked on the 200 hall. On 11/10/18, she worked on the 300 hall. On 11/11/18, she worked on the 400 hall, where Resident #6 resided. CNA #2 was scheduled off 11/12/18 and 11/13/18, then returned to work on the 400 Hall on 11/14/18. She was scheduled to work 11/15/18 on the 200 hall, but did not clock in or out on that date. On 11/16/18 and 11/17/18, she worked on the 400 hall, where Resident #6 resided. She was off 11/18/18 and 11/19/18, then worked 11/20/18 and 11/21/18 on the 400 hall where Resident #6 resided. She was scheduled to work 11/22/18 and 11/23/18, but did not clock in or out on either date, per the time card report. According to the Termination of Employment form dated 11/29/18, CNA #2 was terminated on 11/26/18. k. On 12/11/18 at 10:30 AM the Staffing Coordinator was asked, Did (CNA #2) work 11/15/18? She stated, I'm going to say she was not here. She didn't work that day. She didn't have her flu shot so I had to take her off the schedule. She returned on 11/16/18. She was asked, Did she work 11/23/18 and 11/24/18? She stated, She was already terminated. The last text message I had with her was on 11/19/18. Then the next text message was 11/26/18. I don't have anything saying she called in. I'm really not sure. I don't know if it's just a day she didn't come to work. She was asked, What was her regular hall? She stated, 400 hall, between 400 and 200. She was asked, After 11/05/18, were you ever told not to schedule (CNA #2) on the 400 hall or any other hall? She stated, No. She was asked, When did you first hear of the incident involving (Resident #6)? She stated, She (CNA #2) called me at 3:00 AM or 4:00 AM that morning and told me she was being sent home. The nurse told her to cover up the camera, so she could give an injection, and she did what the nurse told her to do. The nurse wanted her to hold the patient down and she refused because she didn't feel comfortable holding her down. l. On 12/11/18 at 10:58 AM, CNA #3 was interviewed via telephone. (He is no longer employed with the facility.) He was asked, Can you tell me about the incident that happened on 11/05/18? He stated, One of the nurses from the 400 hall - I forgot her name - she asked me and another aide from 100 (Hall) to help her. When I got to 400 hall, there was a CNA (stated CNA #2's name) holding her face. I looked up and saw the trash bag over the camera. I asked them, 'should the bag be over the camera?' He was asked, Did you ever hear (CNA #2) say she was going to beat up the resident? He stated, No, I never heard her say that. Maybe it was the nurse who wanted to cover up something, because she was trying to give the resident a shot. He was asked, Do you remember an in-service right after the incident? He stated, I was no longer working at the facility. m. On 12/11/18, the surveyor attempted to conduct telephone interviews with other staff members who worked the night of 11/4/18 to the morning of 11/5/18. At 11:08 AM, CNA #4 was called, and there was no answer. At 11:30 AM, CNA #2 was called, and there was no answer. At 3:43 PM, LPN #2 was called, and there was no answer - the call went directly to voice mail. n. On 12/11/18 at 11:45 AM, LPN #3 was interviewed via telephone. (She is no longer employed with the facility). She was asked, Can you tell me about the incident on 11/05/18? She stated, I got to work at 4:30 that morning. We were short, and they needed someone to pass pills. I was informed by a nurse named (LPN #4's name) that a CNA had covered the camera. (CNA #3) told me that (CNA #2) had covered the camera, and she was going to beat up the resident. I had everybody fill out witness statements. I put the witness statements in the hands of the Administrator and told her what I had done. I'm not sure of the exact time I gave them to her. It was around 7:00 AM or so, on the morning of 11/05/18. She was asked, Did you hear about the incident after that? She stated, Not that I know of, was anything done. She was asked, Did (CNA #2) return to work right after the incident? She stated, I was on vacation for a while and I noticed she was at work when I returned. I called staffing and told her she was back on the hall, and she called the DON. The Administrator took my holiday pay, because I told you about what happened, and yelled at me. She didn't like what I had done, as far as the investigation. She was asked, Was the Administrator aware that (CNA #2) said she was going to beat up the resident? She stated, Yes, I took the treatment nurse with me. I told her everything that was going on. I took the treatment nurse with me, because the Administrator has the tendency to forget things. She was asked, Did the resident receive the injection? She stated, I was told the resident didn't receive the injection. The nurse who worked back there, that was her last night. It was all hearsay. I wasn't there - I just gathered witness statements when I was informed of what was going on. She was asked, What day did you see (CNA #2) back at work? She stated, I can't remember if it was the day you came on 11/26 or the week before. o. On 12/11/18 at 12:49 PM, the Administrator was asked, When did (LPN #1) first report to you that one of the CNAs covered the camera with a trash bag and stated she was going to beat up a resident? She stated, The morning of the 5th, approximately between 8AM and 9AM, about covering up the camera. I wasn't aware that she (CNA #2) said she was going to beat up a resident until this morning. She was asked, Did you read the witness statements on 11/05/18? She stated, I guess I didn't read them good enough. She was asked, Who did you get this information from? She stated, I really can't recall. I remember having a discussion with the DON. She was asked, Who gave you the witness statements? She stated, The DON. She was asked, Did she collect those witness statements? She stated, Yes. She was asked, How were the residents protected if you just found out today that a CNA stated she was going to beat up a resident? She stated, I made sure the LPN was gone. I ensured CNA was suspended. She was asked, When was (CNA #2) suspended? She stated, I reviewed the time sheet this morning. I was unaware that she was working. I was under the impression she was off on suspension. Upon reviewing CNA #2's personnel file, there was no suspension paperwork available for review. The Administrator was asked, Can you tell me where the suspension paperwork is kept? She stated, I've only been here since 10/01/18, and I don't know if a form was filled out. She was asked, Why was (CNA #2) terminated on 11/26/18? She stated, Because of the trash bag. She was asked, Did (LPN #1) inform you of anything concerning the incident that happened on 11/05/18? She stated, Not to my recollection. p. On 12/11/18 at 3:07 PM, the Administrator was asked body audits were completed on Resident #6 and other residents after the allegations were made (and as per the DMS-7734 dated 11/26/18) to determine if there were any injuries. The Administrator stated, All the residents get body audits weekly. q. The immediate Jeopardy was removed, and the scope and severity lowered to E on 12/11/18 when the facility implemented the following Plan of Removal: Corrective Actions: A DMS-7734 for (Resident #6) was completed and reported to OLTC, Little Rock Police department, resident's son and MD (Medical Doctor) on 12/11/18 at 2 p.m. The employee involved (CNA #2) was terminated on 11/26/18. Other residents: On 11/27/18 the social director interviewed all other cognitive residents on the locked unit and no other issues were reported. On 12/11/18 the social director started interviewing all other cognitive residents in the general part of the building concerning abuse and no other issues have been found. On 12/11/18 statements will be obtained from staff members concerning any abuse in the building. Body audits on all residents were completed between 11/2 and 12/1/2018 and no bruising or injuries were found by the LPN. Systemic changes: On 12/11/18 all nursing staff was in serviced on reporting any Abuse immediately by the DON. On 12/11/18 the Nurse Consultant in serviced the Administrator on Abuse and neglect and the reporting requirements. Monitoring: The Administrator/designee will monitor the computerized 24-hour report documentation to ensure proper treatment of [REDACTED].

Based on record review and interview, the facility failed to ensure an alleged incident that was suspicious for potential staff-to-resident abuse, including an alleged verbal threat to beat up a resident, was immediately and thoroughly investigated, failed to ensure immediate protective measures to prevent further potential abuse were implemented and maintained until a thorough investigation could be completed, and failed to ensure the alleged incident and verbal threat were immediately reported to the Office of Long Term Care (OLTC) to enable the state agency to provide the necessary oversight of the facility's efforts to investigate and protect residents from potential harm for 1 (Resident #6) of 1 case mix resident who had aggressive behaviors. The failed practices resulted in Immediate Jeopardy, which caused or could have caused serious harm, injury or death to Resident #6, and had the potential to cause more than minimal harm to 5 residents who had aggressive behaviors, according to a list provided by the Administrator on 12/11/18. The Administrator was informed of the Immediate Jeopardy situation on 12/11/18 at 2:08 PM. The findings are: Resident #6 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Admission Minimum Data Set (MDS) with an assessment reference date of 10/09/18 documented the resident scored 5 (0-7 indicates severely impaired) on a Brief Interview for Mental Status (BIMS), required supervision with bed mobility, transfers, locomotion on and off the unit, and bed mobility, and had disorganized thinking present that fluctuated, but no other behavioral symptoms. a. The Care Plan dated 10/1/18 documented, (Resident #6) is an elopement risk/wanderer . Distract resident from wandering by offering pleasant diversion . The resident is grieving r/t (related to) death of loved one . Assist the resident to identify, access and use support systems . The resident has or is at risk for a psychosocial well-being problem: unsettled relationships, language/cultural barrier, obsession with physical problems and/or bodily functions . Allow the resident time to answer questions and to verbalize feelings perceptions and fear, (frequently) . b. On 11/26/18 at 4:17 PM, the MDS Coordinator informed the surveyor that she had something to tell her. She stated, I gathered all the witness statements and gave them to the Administrator. Me and (Licensed Practical Nurse (LPN) #1) tried to call the Administrator. I removed the CNA (Certified Nursing Assistant #2) off the hall to get her away from the resident. The nurse went up front and got the CNA to restrain her (Resident #6). The nurse no longer works here anymore. The CNA covered the cameras with a trash bag. She was mad, because the resident had threw (sic) a Bible at her. She told another staff she was going to beat her up, and the nurse was going to give her a shot. She was asked, Did you talk to any residents? She stated, No, I passed my pills and turned everything over to the Administrator. I only talked to the Administrator. I talked to the DON (Director of Nursing) today and told her that CNA was here. She (DON) called the staffing office and said she (CNA #2) could not work the 400 Hall (where Resident #6 resided). c. On 11/26/18 at 4:42 PM, the DON was asked, Can you tell me about the garbage bags over the cameras? She stated, On 11/05/18, the nurse wanted the cameras covered for dignity. She was asked, Do you think the cameras should have been covered? She stated, No. She was asked, When the Administrative staff is notified of an incident, who is responsible for the safety of the residents? She stated, We all are, me and the Administrator. d. On 11/26/18 at 5:00 PM, Resident #6 was asked, How long have you lived here? She stated, I don't know. She was asked, Has anyone ever hit you? She stated, No. She was asked, Are you afraid of any staff? She stated, No. 1.) On 12/11/18 at 12:16 PM Certified Nursing Assistant (CNA) #6 was asked, Does (Resident#6) have any memory issues that you know of? She stated, She's forgetful . 2.) On 12/11/18 at 12:18 PM, Licensed Practical Nurse (LPN) #5 was asked, Does (Resident#6) have any memory issues that you know of? She stated, Sometimes she's kind of forgetful, short term, and long term; impaired decision making sometimes. 3.) On 12/11/18 at 12:21 PM, CNA #7 was asked, Does (Resident#6) have any memory issues that you know of? She stated, Yes, well she don't remember what she did the day before. You have to repeat yourself and go back; she's forgetful. 4.) On 12/11/18 at 12:23 PM, CNA #8 was asked, Does (Resident#6) have any memory issues that you know of? She stated, No more than when she tries to get out the door. She thinks she be at work and be trying to get out. e. An Office of Long Term Care (OLTC) Incident and Accident Report (I&A), Division of Medical Services (DMS) form 7734, dated as submitted to OTLC on 11/26/18 at 5:00 PM (21 days after the alleged incidents took place and after OLTC's onsite investigation was initiated) documented, Summary of Incident . On 11/05/2018 on the night shift, (Resident #6) was up most of the night exit seeking and combative with care. Per the nurse's notes, 'alert and verbal, resident was on the door all night, trying to elope verbally redirected with no help. Refuses po (by mouth) meds. Resident also refuses PRN [MEDICATION NAME] as ordered, was raising her voice on the staff, hit one of the staff members when we block the door so that R (resident) cannot leave. DON called. Return call awaiting. (CNA #2) states that nurse (LPN#2) had her to place a trash bag over the camera but refused to help restrain the resident and the LPN then (went) to another hall for help. Then (LPN #6) went to 400 hall where (Resident #6) is and (told) (LPN #2) that she could not hold down a resident against her will to give her a shot. Steps taken to prevent continued abuse or neglect during the investigation . (LPN #2) was terminated on 11/05/18. (CNA #2) was suspended pending investigation. Little Rock Police was called to report incident, Family and MD (Medical Doctor) called to report incident. Abuse in-service started for all staff. Social Worker will interview residents under the care of the LPN and CNA. The resident interviews were documented on an attached Witness Statement form and indicated 4 residents were asked, Has any of the staff treated you wrong? All 4 residents stated, No. No other questioning of residents was documented. On 11/26/18 at 5:03 PM, the Administrator was asked, Do you remember any incidents of staff reporting that a CNA covered the cameras to beat up (Resident #6) or to hold her down for an injection? She stated, I have statements that it never occurred. She was asked, Was it reported to the Office of Long Term Care? She stated, No, because it never occurred. They did state that the nurse asked the CNA to put bags over the camera, because she was going to hold the resident down. The Administrator showed the surveyor the Witness Statements she had in her desk drawer related to this incident. 1.) A Witness Statement form dated 11/05/18 and signed by CNA #2 documented, I was closing the door after the nurse went out and I was turning around, and (Resident #6) hit me with her book. I went back on the hall to finish working and reported the incident to the nurse when she came back to hall. The nurse on duty asked me to cover the camera in the hall with plastic bag and I did so. I did not tell any resident or staff in building that I would harm a resident. The nurse on duty asked me to help hold a resident to give her a shot, I refused because I didn't want to restrain the resident. She told me she would get it done and to put the plastic over the camera, I did so. She went to the front of building to get two male CNAs to help, who were told to go back to their hall. The nurse told me I could uncover it, and she didn't give the resident the shot. 2.) A Witness Statement form dated 11/5/18 and signed by LPN #1 documented, I was called to my office to speak with (CNA #4) who told me that (CNA #2) on the 400 hall had covered the camera on the 400 hall with a trash bag and stated that she (CNA #2) was going to beat the resident because she hit her with a Bible. I went to the 400 Hall to get (CNA #2) and told her I need to talk with her. She refused and walked out. She returned about 10 minutes later. I started to explain to (CNA #2), I am not accusing you of anything, but when someone makes an allegation, we have to do an investigation. (CNA #2) became defensive and said, 'I did what my nurse told me to.' I started to ask for a statement, then the CNA walked out again. 3.) A Witness Statement form dated 11/5/18 and signed by CNA #1 documented, To whom it may concern, the 400 hall nurse ask me, the 300 hall CNA, would I come help her hold a pt (patient) down. One hold the legs, someone else hold the arms. I, the CNA, ask for what. Nurse states so that she going to give a pt a shot to help calm her down. I, the CNA, asked the nurse can that be done against her will. I, the CNA, told 400 hall nurse, I can't do that, that's against the pt will, so I didn't. 4.) A Witness Statement form dated 11/5/18 and signed by CNA #5 documented, I was talking to (CNA #4) when (LPN #2) came and told me and (CNA #3) to come hold (Resident #6) down to get a shot but when we got back there, (CNA #3) notices the camera was covered and told me. Then my 200 hall nurse came and got us. 5.) A Witness Statement form dated 11/5/18 and signed by LPN #3 documented, (LPN #1) called (CNA #2), the night shift CNA on the 400 hall into my office and explained to her that she was sending her home pending an investigation about (Resident #6) d/t (due to) CNA covering the camera with a trash bag. The CNA stated to (LPN #1) that she was 'doing what her nurse told her to do'. 6.) A Witness Statement form dated 11/5/18 and signed by CNA #3 documented, I was approached by (LPN #2), the 400 hall nurse, to accompany her with (CNA #5) to her hall. I was not aware of the intention of this unscheduled excursion but, my place was to help a nurse in need. Upon arriving on the scene of the incident at hand, I noticed (Resident #6) was beating at the locked door, trying to escape. I noticed two things that made me question the situation I was put in. First, I noticed a trash bag over the camera at the entrance of 400 hall. Second, (LPN #2) was preparing an injection for the irate resident . I was not asked to restrain the resident, but I feel (LPN #2) may have intended for me to do so, I did not. It was then that another nurse entered the scene and scolded (LPN #2) that we, (CNA #5) and I, could not, by law, restrain the resident . 7.) A grievance form dated 11/05/18 by CNA #4 documented, Me (CNA #4) was on the halls when (Resident #6) was banging on the door and was mad because she wanted to go home .400 hall nurse came to (CNA #5) and (CNA #3) asking them to hold (Resident #6) down and (CNA #2) had the camera covered .I wouldn't hold (Resident #6) down after her asking me 3 or 4 times to hold her .I overheard (CNA #2) tell (CNA #3) say she covered the camera to beat (Resident #6's) but (butt) because she hit her with the Bible. f. On 12/11/18, the surveyor reviewed the following records to attempt to determine whether Resident #6 received an injection on the night of 11/4/18 / morning of 11/5/18: 1.) The Medication Review Report dated 11/2/18 documented orders for, [MEDICATION NAME] solution 2 mg/ml (milligrams per milliliter) inject 0.5 ml intramuscularly every 6 hours as needed for Anxiety for 14 days . The report also documented the resident was receiving scheduled antipsychotic medication and an as-needed sedative: [MEDICATION NAME] tablet 25 mg give 25 mg by mouth two times a day at noon and bedtime . [MEDICATION NAME] 50 mg give 50 mg by mouth at bedtime . [MEDICATION NAME] HCL ([MEDICATION NAME]) tablet 50 mg give 50 mg by mouth as needed for [MEDICAL CONDITION] prn (as needed). 2.) A Progress Note dated 11/05/18 at 2:22 AM and signed by LPN #2 documented, Alert, and verbal, resident was on the door all night, trying to elope. Verbally re-directed with no help. Refuses PO (by mouth) meds (medications). Resident also refuses PRN (as needed) [MEDICATION NAME] as ordered, was raising her voice to the staff. Hit one of the staff members when we block the door so that R (Resident) cannot leave. DON called. Return call awaiting. 3.) A Progress Note dated 11/05/18 at 4:59 AM and signed by LPN #2 documented, Continue fighting on the door wanted to go home. Continue to refuse PRN meds when offered. 4.) The (MONTH) (YEAR) Medication Administration Record [REDACTED]. The narcotic sign-out sheet did document that on 11/05/18 at 1:55 AM, LPN #2 signed out a dose of the [MEDICATION NAME], but wasted the medication. The time the medication was wasted was not documented on the narcotic sign-out sheet. g. On 11/29/18 at 12:20 PM, the DON was asked, When should an allegation of abuse be reported to OLTC (Office of Long Term Care)? She stated, Hour with injury, and two hours without. h. On 11/29/18 at 1:10 PM, the Administrator was asked, When should an allegation of abuse be reported to OLTC? She stated, Within two hours for 7734 (OLTC Incident and Accident Report form); police called before that. i. A Termination of Employment form dated 11/29/18 documented CNA #2's name and, .Violation of policies and procedures . tampering with camera / surveillance .Beginning 11/26/18 . The form was signed by the DON and the Administrator. This was a period of 24 days after the alleged incident took place. j. On 12/11/18 at 10:09 AM, CNA #2's (MONTH) (YEAR) schedule and time card reports were provided by the facility's Staffing Coordinator and were reviewed with the following findings: The schedule documented that CNA #2 was scheduled to work the night of 11/4/18 on the 400 Hall. She was again scheduled to work the night of 11/5/18 on the 400 Hall, and did work that shift, according to the time card report. CNA #2 was scheduled off 11/6/18 and 11/7/18. On 11/08/18, CNA #2 worked on the 400 hall, where Resident #6 resided. On 11/09/18, CNA #2 worked on the 200 hall. On 11/10/18, she worked on the 300 hall. On 11/11/18, she worked on the 400 hall, where Resident #6 resided. CNA #2 was scheduled off 11/12/18 and 11/13/18, then returned to work on the 400 Hall on 11/14/18. She was scheduled to work 11/15/18 on the 200 hall, but did not clock in or out on that date. On 11/16/18 and 11/17/18, she worked on the 400 hall, where Resident #6 resided. She was off 11/18/18 and 11/19/18, then worked 11/20/18 and 11/21/18 on the 400 hall where Resident #6 resided. She was scheduled to work 11/22/18 and 11/23/18, but did not clock in or out on either date, per the time card report. According to the Termination of Employment form dated 11/29/18, CNA #2 was terminated on 11/26/18. k. On 12/11/18 at 10:30 AM the Staffing Coordinator was asked, Did (CNA #2) work 11/15/18? She stated, I'm going to say she was not here. She didn't work that day. She didn't have her flu shot so I had to take her off the schedule. She returned on 11/16/18. She was asked, Did she work 11/23/18 and 11/24/18? She stated, She was already terminated. The last text message I had with her was on 11/19/18. Then the next text message was 11/26/18. I don't have anything saying she called in. I'm really not sure. I don't know if it's just a day she didn't come to work. She was asked, What was her regular hall? She stated, 400 hall, between 400 and 200. She was asked, After 11/05/18, were you ever told not to schedule (CNA #2) on the 400 hall or any other hall? She stated, No. She was asked, When did you first hear of the incident involving (Resident #6)? She stated, She (CNA #2) called me at 3:00 AM or 4:00 AM that morning and told me she was being sent home. The nurse told her to cover up the camera, so she could give an injection, and she did what the nurse told her to do. The nurse wanted her to hold the patient down and she refused because she didn't feel comfortable holding her down. l. On 12/11/18 at 10:58 AM, CNA #3 was interviewed via telephone. (He is no longer employed with the facility.) He was asked, Can you tell me about the incident that happened on 11/05/18? He stated, One of the nurses from the 400 hall - I forgot her name - she asked me and another aide from 100 (Hall) to help her. When I got to 400 hall, there was a CNA (stated CNA #2's name) holding her face. I looked up and saw the trash bag over the camera. I asked them, 'should the bag be over the camera?' He was asked, Did you ever hear (CNA #2) say she was going to beat up the resident? He stated, No, I never heard her say that. Maybe it was the nurse who wanted to cover up something, because she was trying to give the resident a shot. He was asked, Do you remember an in-service right after the incident? He stated, I was no longer working at the facility. m. On 12/11/18, the surveyor attempted to conduct telephone interviews with other staff members who worked the night of 11/4/18 to the morning of 11/5/18. At 11:08 AM, CNA #4 was called, and there was no answer. At 11:30 AM, CNA #2 was called, and there was no answer. At 3:43 PM, LPN #2 was called, and there was no answer - the call went directly to voice mail. n. On 12/11/18 at 11:45 AM, LPN #3 was interviewed via telephone. (She is no longer employed with the facility). She was asked, Can you tell me about the incident on 11/05/18? She stated, I got to work at 4:30 that morning. We were short, and they needed someone to pass pills. I was informed by a nurse named (LPN #4's name) that a CNA had covered the camera. (CNA #3) told me that (CNA #2) had covered the camera, and she was going to beat up the resident. I had everybody fill out witness statements. I put the witness statements in the hands of the Administrator and told her what I had done. I'm not sure of the exact time I gave them to her. It was around 7:00 AM or so, on the morning of 11/05/18. She was asked, Did you hear about the incident after that? She stated, Not that I know of, was anything done. She was asked, Did (CNA #2) return to work right after the incident? She stated, I was on vacation for a while and I noticed she was at work when I returned. I called staffing and told her she was back on the hall, and she called the DON. The Administrator took my holiday pay, because I told you about what happened, and yelled at me. She didn't like what I had done, as far as the investigation. She was asked, Was the Administrator aware that (CNA #2) said she was going to beat up the resident? She stated, Yes, I took the treatment nurse with me. I told her everything that was going on. I took the treatment nurse with me, because the Administrator has the tendency to forget things. She was asked, Did the resident receive the injection? She stated, I was told the resident didn't receive the injection. The nurse who worked back there, that was her last night. It was all hearsay. I wasn't there - I just gathered witness statements when I was informed of what was going on. She was asked, What day did you see (CNA #2) back at work? She stated, I can't remember if it was the day you came on 11/26 or the week before. o. On 12/11/18 at 12:49 PM, the Administrator was asked, When did (LPN #1) first report to you that one of the CNAs covered the camera with a trash bag and stated she was going to beat up a resident? She stated, The morning of the 5th, approximately between 8AM and 9AM, about covering up the camera. I wasn't aware that she (CNA #2) said she was going to beat up a resident until this morning. She was asked, Did you read the witness statements on 11/05/18? She stated, I guess I didn't read them good enough. She was asked, Who did you get this information from? She stated, I really can't recall. I remember having a discussion with the DON. She was asked, Who gave you the witness statements? She stated, The DON. She was asked, Did she collect those witness statements? She stated, Yes. She was asked, How were the residents protected if you just found out today that a CNA stated she was going to beat up a resident? She stated, I made sure the LPN was gone. I ensured CNA was suspended. She was asked, When was (CNA #2) suspended? She stated, I reviewed the time sheet this morning. I was unaware that she was working. I was under the impression she was off on suspension. Upon reviewing CNA #2's personnel file, there was no suspension paperwork available for review. The Administrator was asked, Can you tell me where the suspension paperwork is kept? She stated, I've only been here since 10/01/18, and I don't know if a form was filled out. She was asked, Why was (CNA #2) terminated on 11/26/18? She stated, Because of the trash bag. She was asked, Did (LPN #1) inform you of anything concerning the incident that happened on 11/05/18? She stated, Not to my recollection. p. On 12/11/18 at 3:07 PM, the Administrator was asked if they did body audits on Resident #6 and other residents after the allegations were made to determine if there were any injuries. The Administrator stated, All the residents get body audits weekly. q. The Immediate Jeopardy was removed, and the scope and severity lowered to E on 12/11/18 when the facility implemented the following Plan of Removal: Corrective Actions: A DMS-7734 for (Resident #6) was completed and reported to OLTC, Little Rock Police department, resident's son and MD (Medical Doctor) on 12/11/18 at 2 p.m. The employee involved (CNA #2) was terminated on 11/26/18. Other residents: On 11/27/18 the social director interviewed all other cognitive residents on the locked unit and no other issues were reported. On 12/11/18 the social director started interviewing all other cognitive residents in the general part of the building concerning abuse and no other issues have been found. On 12/11/18 statements will be obtained from staff members concerning any abuse in the building. Body audits on all residents were completed between 11/2 and 12/1/2018 and no bruising or injuries were found by the LPN. Systemic changes: On 12/11/18 all nursing staff was in serviced on reporting any Abuse immediately by the DON. On 12/11/18 the Nurse Consultant in serviced the Administrator on Abuse and neglect and the reporting requirements. Monitoring: The Administrator/designee will monitor the computerized 24-hour report documentation to ensure proper treatment of [REDACTED].

Complaint # (AR 335) was substantiated (all or in part) with these findings. Based on record review and interview, the facility's administration and nursing administration failed to ensure a training / competency plan was in place to ensure all staff who transported residents in the facility van were trained and demonstrated competency before allowing them to transport residents. The facility failed to ensure a resident in a wheelchair was properly secured prior to transport in the facility van to prevent potential serious injury and failed to ensure the resident received attention by a physician or qualified nursing staff after an incident on the facility van, to prevent exacerbation of any injuries that may have resulted from the incident for 1 (Resident #1) of 2 (Residents #1 and #5) case mix residents who required a wheelchair for transport in the facility van. The failed practices resulted in past noncompliance at the level of Immediate Jeopardy, which caused or could have caused serious harm, injury or death to Resident #1, who was not properly secured in the van and fell / tipped over during transport, and had the potential to cause more than minimal harm to 22 residents who required the use of a wheelchair during transport on the facility van, according to a list provided by the Administrator on 5/02/18. The Administrator was informed of the past Immediate Jeopardy on 5/02/18 at 5:00 p.m. The findings are: 1. The Administrator Job Description, provided by the Administrator on 5/02/18, documented, .The purpose of this position is to establish and maintain systems that are effective and efficient to operate the facility in a manner to safely meet residents' needs in compliance with federal, state and local requirements . Authority is delegated to the individual in this position to: Develop, maintain and implement operational policies and procedures to meet resident's needs in compliance with federal, state and local requirements. Determine the personnel requirements of the facility and hire or arrange for sufficient staff to implement the facility policies and procedures. Develop a monitoring system to assure compliance with federal, state, and local requirements . 2. The facility's Director of Nursing Job Description, provided by the Administrator on 5/02/18, documented, The purpose of this position is to provide nursing management, set resident care standards for all direct care providers and provide complete supervision and management for the nursing department . Set resident care standards in accordance with accepted current standards of care to provide high quality care to residents. Develop and implement policies and procedures for nursing care of residents. Supervise and manage all aspects of the nursing department .Identify safety hazards and initiate corrective action . Assume responsibility for nursing service compliance with federal, state and local regulations .Be responsible for safety of residents under his/her supervision. Observe all facility safety policies and procedures . Assume accountability for all data contained in the employees' handbook. 3. Resident #1 had [DIAGNOSES REDACTED]. The Minimum Data Set with an assessment reference date of 3/2/18 documented the resident scored 12 (8-12 indicates moderately impaired) on a brief interview for mental status, was totally dependent on 2 plus persons for bed mobility and transfer, and required a wheelchair for mobility. a. The Plan of Care with a review date of 3/20/18 documented, Resident has a (an) ADL (activities of daily living) self-care deficit r/t (related to) he is dependent on staff for ADLs. He is a quadriplegic. He is assisted with 2 staff and mechanical lift for transfers . Resident has a risk for abnormal bleeding or hemorrhage because of anticoagulant use .Resident is at risk for pain r/t spinal cord injury and gout .(handwritten) 4/12/18 At risk for fall .need for 2 person assist r/t spinal cord injury .4/20 reeducate van staff to safety protocol with van usage . b. A Nurses Note dated 4/12/18 at 1910 (7:10 p.m.) documented, Received report from van driver that during transport, while going down slope shoulder strap loosened and resident proceeded to lean forward, stopped the van and assisted resident to floor. Small abrasion noted above Rt. (right) eye. Resident is alert & (and) oriented x (times) 3. Denies HA (headache), pupils reactive EOM (extra ocular movements) intact. Family, sister, and son (Name) notified of event. Insist that resident go to ER (emergency room ) for eval (evaluation). Spoke with .APN (Advanced Practice Nurse) and received order to sent (send) to ER, (Emergency Transport Provider) notified & (and) here to transport . c. The Emergency Department (ED) Triage Note dated 4/12/18 at 7:54 p.m. documented, .Pt (patient) arrived via (Emergency Transport Provider) from nursing home after a fall 6 hours ago .The incident occurred 6 to 12 hours ago . Fall occurred: while sitting in wheelchair. The point of impact was the head. The pain is present in the head. Pertinent negatives include no nausea, no vomiting and no loss of consciousness . CT (computed tomography) Head WO (without) Contrast .No acute intracranial findings. d. An Incident and Accident Report dated 4/16/18 at 12:15 p.m. documented, On 4/12/18 at approximately 1750 (5:50 p.m.) the van driver reported that he took (Resident #1) to a doctor's appointment which was scheduled for 1400 (2:00 p.m.). The van driver reported at approximately 1345 (1:45 p.m.), while in route to the appointment, (Resident #1) began to lean forward because the shoulder strap to the seat belt did not lock securely. The van driver stopped the van and eased (Resident #1) to the floor. The van driver stated that (Resident #1) did not hit anything. (Transportation Aid #1) assisted (Resident #1) back to his wheelchair, and proceeded to take him to his doctor's appointment. The van driver did not call the facility to alert anyone that the incident occurred until later that evening. The van driver initially reported that the wheelchair tilted forward, but later clarified that the wheel remained in place . On 4/16/2018, a witness statement was discovered under the director of nursing's door written by the alleged van driver. The statement stated that he was in a hurry and forgot to strap the bottom half of the seatbelt around the resident's waist prior to leaving for the appointment. He applied the brakes and (Resident #1) began to lean and slide forward slowly .On 4/16/2018, the van driver was asked to demonstrate (with staff sitting in the same wheelchair) how he placed the resident on the van lift, lifted the person onto the van, secured the chair wheel lock in place, and applied the shoulder straps. The van driver did not place the shoulder strap properly and did not secure the belt across the waist. The person could easily lean forward based on how the straps were placed. However, the wheel remained locked in place. When (Transportation Aid #1) was questioned about the incident, he stated he saw the resident slowly leaning forward in his rearview mirror. He immediately stopped the van and realized the lap belt was not hooked up. He stated that he did completely secure the resident using seat belts properly prior to taking resident on his appointment . An Office of Long Term Care (OLTC) Witness Statement dated 4/12/18 at 1:45 a.m. and signed by Transportation Aid #1 documented, My fault, I forgot to put belt around his waist. I hit the brakes. He starting (started) to slide out the chair. Then I relizes (realized) I was missing the other belt. He slide (slid) forward went down slow not hard. I help (helped) him back in the chair. I was moving to (too) fast, in a hurry and forgot . e. On 5/02/18 at 9:00 a.m., the resident was asked about the van incident that occurred on 4/12/18 and stated, I was going to a doctor's appointment. My chair wasn't working, and they got me another chair. When I got on the van, he (Transport Aide #1) pulled me up, he put the straps on the tires . the wheelchair rolled. He put the strap across the chest part. We left out of the parking lot. When we got close to the hill, I slid to one side of the chair. He pulled over and pulled me back in the chair. When he started going down the hill, the chair started moving and flipped over. I hit my mouth and the right side of my face, above my eye. He straightened me back up. He leaned me back this time. I went to the doctor's office. I had a little headache. Then they called my family and they told them to take me to the hospital. The resident was asked, Did the driver ask if you were hurt? He stated, He didn't think I was hurt. The resident was asked, Did the staff call anyone after the fall? He stated, No, he told the nurse when we got back. I'm having problems with my back. I have muscle spasms every day, on the left side. f. On 5/02/18 at 10:09 a.m., Van Driver #1 was asked, Can you tell me what happened on 4/12/18 when (Resident #1) fell out the wheelchair in the van? He stated, I loaded him up and I didn't put one strap around him good enough. The waist strap didn't click good (well). I was really moving too fast that day. I was working the floor that day. The shoulder strap still had him when he fell . When I looked out the rear view mirror I could see the strap easing him down real slow. I looked at him and I saw that he was okay. I picked him up and put him back in the chair. The driver was asked, How did you strap him back in the chair? He stated, I put him back in there correctly. The driver was asked, Did you see any open areas anywhere on his body? He stated, No, because he went down slowly, and it wasn't a boom or anything like that. The driver was asked, When did you report the incident? He stated, When I came back in the building. The driver was asked, What time was it when you reported it? and stated, Maybe about 3:30 p.m. The driver was asked, How do you know what time the incident happened? and stated, His appointment was at 2 (2:00 p.m.), so it had to be about 1:45 p.m. The driver was asked, Can you tell me why you didn't report it immediately? He stated, I saw that he was okay. We were in the middle of traffic. I just put him in his chair and took him to his appointment. I told them what happened when I got back. I told (Licensed Practical Nurse (LPN) #1) about the incident. g. On 5/02/18 at 11:38 a.m., LPN #1 was asked, What time was the incident on 4/12/18 reported to you? and stated, Between 5 and 6 (5:00 and 6:00 p.m.), when he came back. The driver reported it. The LPN was asked, Did you assess the resident after you found out he had a fall? and stated, Yes, he had an abrasion to his eyelid. The LPN was asked, Did you start the I&A (Incident and Accident) Report? and stated, I reported it to (Director of Nursing (DON) #2), and she took over and started the I&A Report. She called the family and everybody. He didn't want to go to the ER (emergency room ), and the DON insisted that he go. I called the son, and the son insisted that he go to the ER. The LPN was asked, What did the van driver tell you happened? and stated, When he was going downhill, the wheelchair tilted over. He repositioned the chair. h. On 5/02/18 at 4:15 p.m., the Administrator was asked, How long had (Transportation Aide #1) been driving the van? and stated, He came over here in (MONTH) (2017). He was driving the van at one of our sister facilities. The Administrator was asked, Did he have any training on the van when he started working here? She stated, No, he immediately started driving. The Administrator was asked, Do you think (Transportation Aide #1) should've been trained on the van when he was transferred to this facility? and stated, Yes ma'am. The Administrator was asked, Who does the training for the placement and securing of the residents in the van? and stated, We send them to (offsite training provider) for the training. The Administrator was asked how often staff were retrained or checked off and stated, Every 6 months. The Administrator was asked, When (Transportation Aide #1) started working here, do you know the last time he had been retrained? She stated, No I don't. The Administrator was asked, How often do you monitor or spot check to see if they're securing residents properly? and stated, Every day. The Administrator was asked, Before the incident, how often did you do it? and stated, Before the incident, I had not done it. The Administrator was asked, Who does the monitoring for the safety of residents on the van? and stated, I do. i. The facility removed the Immediate Jeopardy and corrected the failed practices on 4/16/18 prior to the survey, as evidenced by the following: 1.) The Incident and Accident Report dated 4/16/18 at 12:15 p.m. documented, .The van driver was in-serviced on how to properly secure a wheelchair in the van with return demonstration . On 4/12/18 the alleged van driver was taken off the van and instructed get checked off and will remain off the van until the investigation is complete .The facility van was taken out of service until inspected by the maintenance supervisor. The maintenance supervisor inspected the van for any problems with the seat belt straps and floor locks with no negative findings .All van w/c (wheelchair) seat belts were rechecked by the nursing consultant with no negative findings. 2.) An in-service sheet dated 4/12/18 at 1830 (6:30 p.m.) documented, (Transportation Aid #1) was in-serviced with return demonstration on how to properly secure a resident in seat belt and wheelchair locks to ensure safe patient transports via facility van. The in-service was conducted by Certified Nurse Assistant (CNA) #1. 3.) The facility's written corrective action plan dated 4/16/18 documented the following: i.) By 4/16/16 the DON/ Designee ensured all transportation staff have completed van safety training at (offsite training provider) and are certified to utilize equipment properly. Person responsible - DON/Designee. Target date of completion - 4/16/18. ii.) The DON/ Designee will ensure all transportation staff have completed van/transport education, checkoffs, and return demonstration prior to driving/riding on van. Person responsible - DON/Designee. Target date of completion - Ongoing. iii.) By 4/16/18 the DON/ Designee educated all transport aides on facility policy and procedure regarding incident reporting and equipment malfunction reporting. Person responsible - DON/Designee. Target date of completion - 4/16/18. iv.) By 4/16/18 the Administrator/Designee verified all transportation staff, maintenance, DON/ADON and Administrator have been certified and educated on proper van maintenance, equipment procedures, and return demonstration of proper use and technique prior to allowing staff to use facility van per policy. Documentation of training and certifications will be kept up to date in employee files, as well as a transportation binder kept in Administrator's office. Person responsible - Administrator/Designee. Target date of completion - 4/16/18. v.) By 4/16/18 the Administrator/Designee reported any negative findings immediately and followed facility protocol on reporting requirements to OLTC and all other agencies according to state and local law. Person responsible - Administrator/Designee. Target date of completion - 4/16/18. vi.) By 4/16/18 the Administrator ensured staff does not transport residents alone without assistance to provide for optimal resident safety. Person responsible - Administrator/Designee. Target date of completion - 4/16/18 vii.) Beginning 4/16/18 the Administrator/Designee monitor transportation staff member properly securing residents in van prior to transportation 5x/week x2 weeks (5 times per week for 2 weeks), then 3x/week x2 weeks (3 times per week for 2 weeks), then 1x/week x1 month (1 time per week for one month). Person responsible - Administrator/Designee. Target date of completion - 4/16/18 . 4.) On 5/1/18 at 10:00 a.m., Certified Nurse Assistant (CNA) #1 and 2 demonstrated securing a non- case mix female resident into the facility van. The resident was in a wheel chair. The CNA secured the resident, checked the restraints and verified the belts and wheel chair was secured. CNA #2 stated she would be driving the van, and CNA #1 would be riding with them. 5.) On 5/02/18 at 3:42 p.m., the Administrator provided a copy of documentation related to Transportation Aide #1's suspension. The form documented the employee was suspended on 4/16/18, pending the outcome of the facility's investigation and returned to work on 4/21/18. The form documented the Administrator in-serviced Transportation Aide #1 on 4/20/18 on: 1. Being reassigned to perform direct care. Will be assigned a hall and report to charge nurse. 2. Will be monitored by Adm/Designee (Administrator/Designee) three times weekly to ensure residents are properly cared for with no negative outcome. 3. Instructed to follow residents' plan of care, if you have questions please ask. 4. Employee returning to work on 4/21/18 and will be retrained/orientation.

Complaint # (AR 335) was substantiated (all or in part) with these findings. Based on record review and interview, the facility failed to ensure a resident in a wheelchair was properly secured prior to transport in the facility van to prevent potential serious injury and failed to ensure the resident received attention by a physician or qualified nursing staff after an incident on the facility van, to prevent exacerbation of any injuries that may have resulted from the incident for 1 (Resident #1) of 2 (Residents #1 and #5) case mix residents who required a wheelchair for transport in the facility van. The failed practices resulted in past noncompliance at the level of Immediate Jeopardy, which caused or could have caused serious harm, injury or death to Resident #1, who was not properly secured in the van and fell / tipped over during transport, and had the potential to cause more than minimal harm to 22 residents who required the use of a wheelchair during transport on the facility van, according to a list provided by the Administrator on 5/02/18. The Administrator was informed of the past Immediate Jeopardy on 5/02/18 at 5:00 p.m. The findings are: Resident #1 had [DIAGNOSES REDACTED]. The Minimum Data Set with an assessment reference date of 3/2/18 documented the resident scored 12 (8-12 indicates moderately impaired) on a brief interview for mental status, was totally dependent on 2 plus persons for bed mobility and transfer, and required a wheelchair for mobility. a. The Plan of Care with a review date of 3/20/18 documented, Resident has a (an) ADL (activities of daily living) self-care deficit r/t (related to) he is dependent on staff for ADLs. He is a quadriplegic. He is assisted with 2 staff and mechanical lift for transfers . Resident has a risk for abnormal bleeding or hemorrhage because of anticoagulant use .Resident is at risk for pain r/t spinal cord injury and gout .(handwritten) 4/12/18 At risk for fall .need for 2 person assist r/t spinal cord injury .4/20 reeducate van staff to safety protocol with van usage . b. A Nurses Note dated 4/12/18 at 1910 (7:10 p.m.) documented, Received report from van driver that during transport, while going down slope shoulder strap loosened and resident proceeded to lean forward, stopped the van and assisted resident to floor. Small abrasion noted above Rt. (right) eye. Resident is alert & (and) oriented x (times) 3. Denies HA (headache), pupils reactive EOM (extra ocular movements) intact. Family, sister, and son (Name) notified of event. Insist that resident go to ER (emergency room ) for eval (evaluation). Spoke with .APN (Advanced Practice Nurse) and received order to sent (send) to ER, (Emergency Transport Provider) notified & (and) here to transport . c. The Emergency Department (ED) Triage Note dated 4/12/18 at 7:54 p.m. documented, .Pt (patient) arrived via (Emergency Transport Provider) from nursing home after a fall 6 hours ago .The incident occurred 6 to 12 hours ago . Fall occurred: while sitting in wheelchair. The point of impact was the head. The pain is present in the head. Pertinent negatives include no nausea, no vomiting and no loss of consciousness .CT (computed tomography) Head WO (without) Contrast .No acute intracranial findings. d. An Incident and Accident Report dated 4/16/18 at 12:15 p.m. documented, On 4/12/18 at approximately 1750 (5:50 p.m.) the van driver reported that he took (Resident #1) to a doctor's appointment which was scheduled for 1400 (2:00 p.m.). The van driver reported at approximately 1345 (1:45 p.m.), while in route to the appointment, (Resident #1) began to lean forward because the shoulder strap to the seat belt did not lock securely. The van driver stopped the van and eased (Resident #1) to the floor. The van driver stated that (Resident #1) did not hit anything. (Transportation Aid #1) assisted (Resident #1) back to his wheelchair, and proceeded to take him to his doctor's appointment. The van driver did not call the facility to alert anyone that the incident occurred until later that evening. The van driver initially reported that the wheelchair tilted forward, but later clarified that the wheel remained in place . On 4/16/2018, a witness statement was discovered under the director of nursing's door written by the alleged van driver. The statement stated that he was in a hurry and forgot to strap the bottom half of the seatbelt around the resident's waist prior to leaving for the appointment. He applied the brakes and (Resident #1) began to lean and slide forward slowly .On 4/16/2018, the van driver was asked to demonstrate (with staff sitting in the same wheelchair) how he placed the resident on the van lift, lifted the person onto the van, secured the chair wheel lock in place, and applied the shoulder straps. The van driver did not place the shoulder strap properly and did not secure the belt across the waist. The person could easily lean forward based on how the straps were placed. However, the wheel remained locked in place. When (Transportation Aid #1) was questioned about the incident, he stated he saw the resident slowly leaning forward in his rearview mirror. He immediately stopped the van and realized the lap belt was not hooked up. He stated that he did completely secure the resident using seat belts properly prior to taking resident on his appointment . An Office of Long Term Care (OLTC) Witness Statement dated 4/12/18 at 1:45 a.m. and signed by Transportation Aid #1 documented, My fault, I forgot to put belt around his waist. I hit the brakes. He starting (started) to slide out the chair. Then I relizes (realized) I was missing the other belt. He slide (slid) forward went down slow not hard. I help (helped) him back in the chair. I was moving to (too) fast, in a hurry and forgot . e. On 5/02/18 at 9:00 a.m., the resident was asked about the van incident that occurred on 4/12/18 and stated, I was going to a doctor's appointment. My chair wasn't working, and they got me another chair. When I got on the van, he (Transport Aide #1) pulled me up, he put the straps on the tires . the wheelchair rolled. He put the strap across the chest part. We left out of the parking lot. When we got close to the hill, I slid to one side of the chair. He pulled over and pulled me back in the chair. When he started going down the hill, the chair started moving and flipped over. I hit my mouth and the right side of my face, above my eye. He straightened me back up. He leaned me back this time. I went to the doctor's office. I had a little headache. Then they called my family and they told them to take me to the hospital. The resident was asked, Did the driver ask if you were hurt? He stated, He didn't think I was hurt. The resident was asked, Did the staff call anyone after the fall? He stated, No, he told the nurse when we got back. I'm having problems with my back. I have muscle spasms every day, on the left side. f. On 5/02/18 at 10:09 a.m., Van Driver #1 was asked, Can you tell me what happened on 4/12/18 when (Resident #1) fell out the wheelchair in the van? He stated, I loaded him up and I didn't put one strap around him good enough. The waist strap didn't click good (well). I was really moving too fast that day. I was working the floor that day. The shoulder strap still had him when he fell . When I looked out the rear view mirror I could see the strap easing him down real slow. I looked at him and I saw that he was okay. I picked him up and put him back in the chair. The driver was asked, How did you strap him back in the chair? He stated, I put him back in there correctly. The driver was asked, Did you see any open areas anywhere on his body? He stated, No, because he went down slowly, and it wasn't a boom or anything like that. The driver was asked, When did you report the incident? He stated, When I came back in the building. The driver was asked, What time was it when you reported it? and stated, Maybe about 3:30 p.m. The driver was asked, How do you know what time the incident happened? and stated, His appointment was at 2 (2:00 p.m.), so it had to be about 1:45 p.m. The driver was asked, Can you tell me why you didn't report it immediately? He stated, I saw that he was okay. We were in the middle of traffic. I just put him in his chair and took him to his appointment. I told them what happened when I got back. I told (Licensed Practical Nurse (LPN) #1) about the incident. g. On 5/02/18 at 11:38 a.m., LPN #1 was asked, What time was the incident on 4/12/18 reported to you? and stated, Between 5 and 6 (5:00 and 6:00 p.m.), when he came back. The driver reported it. The LPN was asked, Did you assess the resident after you found out he had a fall? and stated, Yes, he had an abrasion to his eyelid. The LPN was asked, Did you start the I&A (Incident and Accident) Report? and stated, I reported it to (Director of Nursing (DON) #2), and she took over and started the I&A Report. She called the family and everybody. He didn't want to go to the ER (emergency room ), and the DON insisted that he go. I called the son, and the son insisted that he go to the ER. The LPN was asked, What did the van driver tell you happened? and stated, When he was going downhill, the wheelchair tilted over. He repositioned the chair. h. On 5/02/18 at 4:15 p.m., the Administrator was asked, How long had (Transportation Aide #1) been driving the van? and stated, He came over here in (MONTH) (2017). He was driving the van at one of our sister facilities. The Administrator was asked, Did he have any training on the van when he started working here? She stated, No, he immediately started driving. The Administrator was asked, Do you think (Transportation Aide #1) should've been trained on the van when he was transferred to this facility? and stated, Yes ma'am. The Administrator was asked, Who does the training for the placement and securing of the residents in the van? and stated, We send them to (offsite training provider) for the training. The Administrator was asked how often staff were retrained or checked off and stated, Every 6 months. The Administrator was asked, When (Transportation Aide #1) started working here, do you know the last time he had been retrained? She stated, No I don't. The Administrator was asked, How often do you monitor or spot check to see if they're securing residents properly? and stated, Every day. The Administrator was asked, Before the incident, how often did you do it? and stated, Before the incident, I had not done it. The Administrator was asked, Who does the monitoring for the safety of residents on the van? and stated, I do. i. The facility removed the Immediate Jeopardy and corrected the failed practices on 4/16/18 prior to the survey, as evidenced by the following: 1.) The Incident and Accident Report dated 4/16/18 at 12:15 p.m. documented, .The van driver was in-serviced on how to properly secure a wheelchair in the van with return demonstration . On 4/12/18 the alleged van driver was taken off the van and instructed get checked off and will remain off the van until the investigation is complete .The facility van was taken out of service until inspected by the maintenance supervisor. The maintenance supervisor inspected the van for any problems with the seat belt straps and floor locks with no negative findings .All van w/c (wheelchair) seat belts were rechecked by the nursing consultant with no negative findings. 2.) An in-service sheet dated 4/12/18 at 1830 (6:30 p.m.) documented, (Transportation Aid #1) was in-serviced with return demonstration on how to properly secure a resident in seat belt and wheelchair locks to ensure safe patient transports via facility van. The in-service was conducted by Certified Nurse Assistant (CNA) #1. 3.) The facility's written corrective action plan dated 4/16/18 documented the following: i.) By 4/16/16 the DON/ Designee ensured all transportation staff have completed van safety training at (offsite training provider) and are certified to utilize equipment properly. Person responsible - DON/Designee. Target date of completion - 4/16/18. ii.) The DON/ Designee will ensure all transportation staff have completed van/transport education, checkoffs, and return demonstration prior to driving/riding on van. Person responsible - DON/Designee. Target date of completion - Ongoing. iii.) By 4/16/18 the DON/ Designee educated all transport aides on facility policy and procedure regarding incident reporting and equipment malfunction reporting. Person responsible - DON/Designee. Target date of completion - 4/16/18. iv.) By 4/16/18 the Administrator/Designee verified all transportation staff, maintenance, DON/ADON and Administrator have been certified and educated on proper van maintenance, equipment procedures, and return demonstration of proper use and technique prior to allowing staff to use facility van per policy. Documentation of training and certifications will be kept up to date in employee files, as well as a transportation binder kept in Administrator's office. Person responsible - Administrator/Designee. Target date of completion - 4/16/18. v.) By 4/16/18 the Administrator/Designee reported any negative findings immediately and followed facility protocol on reporting requirements to OLTC and all other agencies according to state and local law. Person responsible - Administrator/Designee. Target date of completion - 4/16/18. vi.) By 4/16/18 the Administrator ensured staff does not transport residents alone without assistance to provide for optimal resident safety. Person responsible - Administrator/Designee. Target date of completion - 4/16/18 vii.) Beginning 4/16/18 the Administrator/Designee monitor transportation staff member properly securing residents in van prior to transportation 5x/week x2 weeks (5 times per week for 2 weeks), then 3x/week x2 weeks (3 times per week for 2 weeks), then 1x/week x1 month (1 time per week for one month). Person responsible - Administrator/Designee. Target date of completion - 4/16/18 . 4.) On 5/1/18 at 10:00 a.m., Certified Nurse Assistant (CNA) #1 and 2 demonstrated securing a non- case mix female resident into the facility van. The resident was in a wheel chair. The CNA secured the resident, checked the restraints and verified the belts and wheel chair was secured. CNA #2 stated she would be driving the van, and CNA #1 would be riding with them. 5.) On 5/02/18 at 3:42 p.m., the Administrator provided a copy of documentation related to Transportation Aide #1's suspension. The form documented the employee was suspended on 4/16/18, pending the outcome of the facility's investigation and returned to work on 4/21/18. The form documented the Administrator in-serviced Transportation Aide #1 on 4/20/18 on: 1. Being reassigned to perform direct care. Will be assigned a hall and report to charge nurse. 2. Will be monitored by Adm/Designee (Administrator/Designee) three times weekly to ensure residents are properly cared for with no negative outcome. 3. Instructed to follow residents' plan of care, if you have questions please ask. 4. Employee returning to work on 4/21/18 and will be retrained/orientation.

Complaint # (AR 548) was substantiated (all or in part) with these findings: Based on record review and interview, the facility failed to ensure necessary care and services were provided to attain or maintain the highest practical physical well-being for Resident #1, as evidenced by failure to ensure respiratory assessments, including oxygen saturation levels, were consistently conducted before and after tracheal suctioning and failure to ensure proper tracheal suctioning was conducted to manage copious secretions to maintain a patent airway and prevent potential complications for 1 (Resident #1) of 1 case mix resident who had a [MEDICAL CONDITION] (trach). The failed practices resulted in immediate jeopardy, which caused or could have caused serious harm, injury or death to Resident #1, who was transported to the hospital related to shortness of breath and copious secretions. The failed practices had the potential to affect only this resident (the only resident in the facility who had a [MEDICAL CONDITION]), as documented on a list provided by the Nurse Consultant on 10/29/16 at 4:00 p.m. The facility was informed of the immediate jeopardy condition on 10/21/16 at 6:30 p.m. The findings are: Resident #1 was admitted to the facility 8/5/16 and had [DIAGNOSES REDACTED]. The Admission Minimum Data Set with an Assessment Reference Date of 8/19/16 documented the resident was severely impaired in cognitive skills for daily decision making per a Staff Assessment for Mental Status, was totally dependent on staff for activities of daily living, and received [MEDICAL CONDITION] care. a. Physician's admission orders [REDACTED]. This order was also on the current October 2016 Physicians Orders sheet. b. A Nurses Note dated 8/5/16 at 1:00 p.m. documented, Arrive to facility (at) 1300 (1:00 p.m.) resp (respirations) even unlabored. Come via EMT (Emergency Medical Technician) X (times) 2. Resident has copious drainage clear from trach. (No) s/s (signs or symptoms) of distress noted O2 (oxygen) intact [MEDICAL CONDITION]. Cont (Continuous) tube feeding (No) n/v (nausea/vomiting) noted. Non verbal of needs. NPO (Nothing by mouth) . Total Care.[MEDICAL CONDITION] X5 . c. The Plan of Care dated 8/23/16 documented, Resident has potential for difficulty breathing related to chronic condition: Tracheotomy . Administer / monitor effectiveness of treatments. Oxygen Nebulizer treatments. Suction [MEDICAL CONDITION] care. Elevate HOB (head of bed) at least 45 degrees . Pulse ox (oximeter) every shift and PRN (as needed) .[MEDICAL CONDITION] every shift and PRN (as needed). Suction per MD (Medical Doctor) order . Assess lung sounds every shift and PRN and report to MD (Medical Doctor) any abnormal findings. d. Nurses Notes and Medication Administration Record [REDACTED]. e. A Nurses Note dated 8/26/16 at 8:00 a.m. documented, HOB elevated 30 degrees for aspiration precaution .Respiration even and unlabored. O2 at 2 LPM (liters per minute) via trach. SpO2 93%.3:30 p.m. Excessive secretions noted, suction [MEDICAL CONDITION] provided at this time. (Physician) notified. Order received and noted. Chest X ray related to excessive secretions [MEDICAL CONDITION]. There was no documentation the resident's lung sounds were assessed at this time. A Nurses Note dated 8/26/16 documented, [MEDICATION NAME] received at this time and started . f. A chest x-ray (CXR) result dated 8/26/16 documented, Patient has increased mucous secretions, congested chest . Findings suggestive of left basilar pneumonia. g. Nurses Notes and MAR indicated [REDACTED]. h. A Nurse's Note dated 9/21/16 documented, Called (hospital) to admit resident. Resident coughing up brown secretions with excessive secretions from trach. Seemed in respiratory distress. Doctor notified and was unable to reach . There was no documentation the resident's oxygen saturation or lung sounds were assessed at this time. i. A Hospital History and Physical dated 9/21/16 documented, .Per EMS (Emergency Medical Services) through nursing staff, patient had shortness of breath at nursing home . Exam: Lots of tracheal secretion . + (lung sounds positive for) rales . Assessment: Increased tracheal secretions; Acute [MEDICAL CONDITION] . Plan: Deep Tracheal suction . j. A Hospital [MEDICAL CONDITION] Consultation dated 9/21/16 documented, The patient is an [AGE] year-old patient who presents with a history of being noticed by nursing staff at the nursing home to having increased shortness of breath. Chest x-ray revealed no active infiltrate; however, the patient is coughing up green sputum . Assessment: Acute [MEDICAL CONDITION]; Acute tracheitis . k. A Nurse's Note dated 9/29/16 at 10:30 p.m. documented, (Emergency Medical Services) returns resident to (facility) . Rhonchi bilateral upper and lower lobes . Will continue to monitor. l. Nurses Notes and MAR indicated [REDACTED]. m. A Nurse's Note dated 10/17/16 not timed and written by Licensed Practical Nurse (LPN) #1 documented, This nurse suctioned resident (at family member's request) due to constant large amounts of heavy, thick secretions. After suctioning (which resident tolerated) equipment put away, this nurse continued to clean resident's fingernails. Resident vomited moderate amount of dark yellow/orange liquid. This nurse began to clean resident up, check for any signs of distress, daughter states 'last time she vomited she had pneumonia. Will you get one of the others so they can see it too.' Reported to ADON (Assistant Director of Nursing), called APN (Advanced Practice Nurse) . informed of resident's status. Order given for AP (anterior posterior) and lateral CXR (Chest X Ray). As this nurse hung up with APN, was informed by ADON that family requested she be sent out to ER (emergency room ). This nurse called APN back, informed that family wanted resident sent to ER. (EMS) notified of transport at 1:30 p.m . n. A Nurse's Note dated 10/17/16 at 10:30 p.m. documented, Returned from (hospital) . No congestion sound to lungs. Reported by (EMS) that resident required deep suctioning by them prior to arrival . o. On 10/20/16 at 4:35 p.m., the resident was in bed with copious amount of grayish white colored secretions coming from [MEDICAL CONDITION] mouth. LPN #2 was preparing to suction the resident. The LPN was asked if the resident's secretions are always that copious and stated, Yes. She really needs to be 1:1 (one staff to one resident). The LPN donned sterile gloves and advanced the suction catheter until the resident coughed, then properly applied intermittent suctioning as she withdrew the suction catheter. She did not check the resident's oxygen saturation or listen to the resident's breath sounds before or after the suctioning. p. On 10/21/16 at 10:22 a.m., the Registered Nurse (RN) Consultant was asked about the resident's condition on 10/17/16 and stated, All I was doing was preparing for our annual. I went into her room to see what equipment was there. She was up in the geri-chair, and the daughter was frantic and anxious. I explained I was there to check the equipment. I was doing the audit, and she was elaborating on how her mother was coughing, and she did cough some while I was in there . she asked if her mother could be sent out. I told (ADON) and asked if resident could be sent out. The charge nurse was on the phone with (APN). (Charge nurse) was aware of the situation per (ADON). It sounded like they had it under control. I told (ADON) to let (APN) know that family requested for resident to be sent out. In a little while, I was walking down the hall and (ADON) gave me the phone. (APN) wanted to know who had given the family the option of the resident being sent out. I told (APN) the resident and family had the right to request for her to be sent out. Then I went back to my office. When the ambulance came, (APN) came at the same time. (ADON) came to get me and said she didn't want (APN) to be yelling at her again. I went down the hall and heard (APN) talking loudly to the daughter. She was telling the daughter how she works at (hospital) ER and if they sent her over there she would be sent right back . She told the daughter she had given the order for her to be sent out today, but she knew they would just suction and send her back . The resident left. (APN) stopped me to tell me our nurses did not know how to deep suction people . I told her we have to follow our policy. Our policy is specific about suctioning and it is not the same as what she perceives as deep suctioning . (APN) asked me if I knew how much it costs to send this resident to the ER. I said no, but they had the right to request to go to the ER . I also ensured (APN) we would get suction training for our staff . We had contacted (equipment company) [MEDICAL CONDITION]. I don't know what training the staff already had, but if (APN) had concerns, we needed to address it . q. On 10/21/16 at 11:17 a.m., the Director of Nursing (DON) was asked about the resident being sent to the hospital on [DATE] and if she assessed her prior to going and stated, I looked at her, but there were enough nurses in there that I didn't. I stepped in because the Charge Nurse told me she was going to have to send her out. She said the daughter was concerned and wanted her to go to the hospital. I said that's fine, but to call the APN and let her know . They had it under control, so I stepped out to make more rounds. (APN) came over to the facility to try and change things. She kept trying to educate the daughter and make her feel comfortable enough to leave her here. The daughter still wanted her evaluated . (APN) said (ADON) had been trained in another facility to do deep suctioning. We don't do deep suctioning here. The DON was asked what would happen if the resident needed deep suctioning and staff had not been trained to do it and stated, That's a good question. I would have to get with the Nurse Consultant and see what we need to do. The DON was asked if it had been mentioned that the facility staff had not been suctioning the resident appropriately and stated, (APN) had said the ER doctor said to her if we could deep suction, she wouldn't have had to come to the ER. r. On 10/21/16 at 11:55 a.m., the ADON was asked about how Resident #1 was suctioned and stated, .Staff is instructed to go to the 4 or 5 on the suction catheter (markings on the suction catheter are in centimeters. 5 centimeters equals 1.96 inches). Staff is instructed not to deep suction and going past the 5 is deep suctioning. The ADON was asked what would happen if the resident needed to be deep suctioned and stated, I was told the only nurses that work over there are the nurses [MEDICAL CONDITION] experience . s. On 10/21/16 at 2:40 p.m., RN #1 was asked about suctioning the resident and stated, I'm taking care of (Resident #1) today, but I have not received instruction [MEDICAL CONDITION] and suctioning from the facility. Just from my nursing training. If I had to suction her today I would . insert tubing 1 to 1 and 1/2 inches, pull back slowly while suctioning, clear the tubing with sterile water, wait a minute or so, wait to see if clear. I was told not to do it more than 2 times . In this facility, we don't do deep suctioning. Deep is 3 and 1/2 to 4 inches. No one told me that, but I overheard the Nurse Consultant talk about it. RN #1 was asked what she would do if the resident'[MEDICAL CONDITION] occluded with a mucus plug and stated, If I am unable to remove the mucus plug because of not being able to deep suction, I would call the doctor. t. On 10/21/16 at 2:41 p.m., LPN #1 was asked how the resident was suctioned and stated, .I was informed we do not deep suction. I was informed that day (10/17/16). Nothing had been told to me prior to this date of how far to suction. She's only my [MEDICAL CONDITION], but I had been doing it the way I was taught before - to go down until you meet resistance with my finger off the suction and apply suction intermittently while twisting the tube and coming back up . u. On 10/21/16 at 3:10 p.m., the facility provided an in-service dated 10/10/16 that documented, .Trach management - care and suctioning . According to the sign in sheet, some of the nurses had not been inserviced, including two LPNs who were scheduled to provide care to the resident over the weekend of 10/22/16 and 10/23/16. v. On 10/21/16 at 4:35 p.m., the Medical Director was asked via telephone if it was necessary to know how to deep suction a resident who had a [MEDICAL CONDITION] and stated, It would be good to be trained in it; not that it's always required, but I would say in an emergency situation, it would be good to be trained. The Medical Director was asked about what one of the nurses had stated that she would contact the physician if the resident'[MEDICAL CONDITION] occluded with a mucus plug and stated, It makes sense to call the doctor, but in an urgent situation you may not have time. The Medical Director was asked if failure to suction properly could potentially lead to pneumonia and stated, The bigger danger is trying to suction and not know what you're doing. I can't say it would cause pneumonia, but it certainly would increase the risk. w. On 10/21/16 at 4:48 p.m., LPN #3 was asked if she had been trained at the facility on how to suction a [MEDICAL CONDITION] and stated, .To be honest, no one here has trained me or had me do a return demonstration. When (Resident #1) first came here, I told my ADON and DON that she was a different patient, critical patient, just because of her excessive secretions. You have to be very patient to take care of her because you are in there for a long time. The LPN was asked if she deep suctioned the resident and stated, No. Deep is bad. There's no need to ever do deep suctioning. x. On 10/21/16 at 5:00 p.m., the APN was asked about what happened with the resident on 10/17/16 and stated, She was not in distress, but if they suctioned her properly, they wouldn't have to send her out. She has reoccurring pneumonia. If they're able to suction her correctly and sit her up in a chair, her secretions would decrease. I talked to them about deep suctioning and was told they don't do that. The APN was asked if she felt that not suctioning properly could lead to pneumonia and stated, Most definitely. That's evidence-based. The APN was asked if it would be a serious problem if the resident developed a mucus plug and staff could not perform deep suctioning and stated, Oh yeah. We have discussed that. They're supposed to get someone out this week I think to in-service. I don't think she's ever had a plug that I know of. y. On 10/21/16 at 5:27 p.m., RN #1, who was assigned to the resident on the 7 a.m.-7 p.m. shift (Day/Evening Shift) on 10/21/16, was asked if she knew how to suction Resident #1 and stated, I guess they go over the suctioning policy with normal staff that are going to work the floor, but it wasn't gone over with me. The RN was asked if she had had any training at the facility on [MEDICAL CONDITION] care and stated, No. I haven't suctioned her today. (ADON) and (LPN #3) have done it for me. z. On 10/21/16 at 6:40 p.m., the ADON stated she had begun in-servicing staff on suctioning and stated she's instructing staff to start with checking the resident's pulse ox (oxygen saturation), lung sounds, then oxygenate, advance the catheter until resistance is met, pull back with intermittent suctioning while swirling the catheter back out, rinse the catheter with sterile saline, reapply oxygen, recheck lung sounds, and then ask for a return demonstration. aa. The facility's Policy and Procedure for [MEDICAL CONDITION] Suctioning documented, .Maintain sterile technique and a patent airway . Hyperventilate (and oxygenate if possible) . Warn patient then insert catheter approximately 4-6 inches into inner cannula or until resistance is met or cough reflex is stimulated. Place thumb over suction port and apply suction (intermittently and rapidly) . bb. The immediate jeopardy was removed and the scope and severity reduced to E on 10/21/16 at 7:55 p.m. when the facility implemented the following Plan of Removal: 1.) On October 21, 2016 at 6:40 p.m., the DON on notification of findings immediately assessed Resident #1's lung sounds, assessed pulse ox saturation, and documented these findings in resident's medical record. DON notified the resident family and physician of assessment findings. 2.) On October 21, 2016 via resident list, identified one resident, Resident #1, with the potential to be affected. 3.) On October 21, 2016 at 6:40 p.m., ADON, on notification of findings began with in-service to all nurses on duty on proper suctioning with return demonstration and will continue training with all nurses prior to their working the floor. Completion date 10/24/2016. 4.) On October 21, 2016 at 6:40 p.m., DON on notification of findings began in-service to all nurses on duty on assessment of lung sounds and assessment of pulse ox saturation every shift and PRN with documentation. In-service will continue with nurses prior to their working the floor. Completion date 10/24/16. 5.) On October 24 2016 at 2:00 p.m., respiratory therapist will train all nurses including Director of Nursing on proper suctioning with return demonstrations to reinforce training already provided. On October 24, 2016, respiratory therapist will train all nurse including Director of Nursing on lung sound assessment and pulse ox saturation assessment and correct documentation. Completion date 10/24/2016. 6.) DON/Designee will observe staff perform suctioning, lung sound assessment, pulse ox saturation assessment and documentation of 1 resident daily x (times) 7 days, 3 times weekly x 4, then weekly till compliance is achieved making corrections as needed. DON will report all negative findings to Administrator. 7.) Administrator will monitor via monitoring log all new hired nurses records prior to working the floor to ensure they have been trained on proper suctioning with return demonstration, lung sound and pulse ox saturation assessment every shift and PRN and correct documentation of assessments, making corrections as needed. 8.) Administrator and DON will present all findings to QA (Quality Assessment / Assurance) committee for further recommendations.

Complaint # (AR 548) was substantiated, all or in part, with these findings: Based on record review and interview, the facility Nursing Administration failed to ensure deficient practices related to [MEDICAL CONDITION] management were identified and addressed, as evidenced by failure to ensure respiratory assessments, including oxygen saturation levels, were consistently conducted before and after tracheal suctioning and failure to ensure proper tracheal suctioning was conducted to manage copious secretions to maintain a patent airway and prevent potential complications for 1 (Resident #1) of 1 case mix resident who had a [MEDICAL CONDITION] (trach). The failed practices resulted in immediate jeopardy, which caused or could have caused serious harm, injury or death to Resident #1, who was transported to the hospital related to shortness of breath and copious secretions. The failed practices had the potential to affect only this resident (the only resident in the facility who had a [MEDICAL CONDITION]), as documented on a list provided by the Nurse Consultant on 10/29/16 at 4:00 p.m. The facility was informed of the immediate jeopardy condition on 10/21/16 at 6:30 p.m. The findings are: 1. The facility's Director of Nursing Service Job Description and Performance Standards, provided by the Registered Nurse Consultant on 10/24/16, documented, The purpose of this position is to provide nursing management, set resident care standards for all direct care providers and provide complete supervision and management for the nursing department . Authority is delegated to the individual in this position to: assess resident needs; set resident care standards in accordance with accepted current standards of care to provide high quality care to residents; develop and implement policies and procedures for nursing care of residents; supervise and manage all aspects of the nursing department . 2. Resident #1 was admitted to the facility 8/5/16 and had [DIAGNOSES REDACTED]. The Admission Minimum Data Set with an Assessment Reference Date of 8/19/16 documented the resident was severely impaired in cognitive skills for daily decision making per a Staff Assessment for Mental Status, was totally dependent on staff for activities of daily living, and received [MEDICAL CONDITION] care. a. Physician's admission orders [REDACTED]. This order was also on the current October 2016 Physicians Orders sheet. b. A Nurses Note dated 8/5/16 at 1:00 p.m. documented, Arrive to facility (at) 1300 (1:00 p.m.) resp (respirations) even unlabored. Come via EMT (Emergency Medical Technician) X (times) 2. Resident has copious drainage clear from trach. (No) s/s (signs or symptoms) of distress noted O2 (oxygen) intact [MEDICAL CONDITION]. Cont (Continuous) tube feeding (No) n/v (nausea/vomiting) noted. Non verbal of needs. NPO (Nothing by mouth) . Total Care.[MEDICAL CONDITION] X5 . c. The Plan of Care dated 8/23/16 documented, Resident has potential for difficulty breathing related to chronic condition: Tracheotomy . Administer / monitor effectiveness of treatments. Oxygen Nebulizer treatments. Suction [MEDICAL CONDITION] care. Elevate HOB (head of bed) at least 45 degrees . Pulse ox (oximeter) every shift and PRN (as needed) .[MEDICAL CONDITION] every shift and PRN (as needed). Suction per MD (Medical Doctor) order . Assess lung sounds every shift and PRN and report to MD (Medical Doctor) any abnormal findings. d. Nurses Notes and Medication Administration Record [REDACTED]. e. A Nurses Note dated 8/26/16 at 8:00 a.m. documented, HOB elevated 30 degrees for aspiration precaution .Respiration even and unlabored. O2 at 2 LPM (liters per minute) via trach. SpO2 93%.3:30 p.m. Excessive secretions noted, suction [MEDICAL CONDITION] provided at this time. (Physician) notified. Order received and noted. Chest X ray related to excessive secretions [MEDICAL CONDITION]. There was no documentation the resident's lung sounds were assessed at this time. A Nurses Note dated 8/26/16 documented, [MEDICATION NAME] received at this time and started . f. A chest x-ray (CXR) result dated 8/26/16 documented, Patient has increased mucous secretions, congested chest . Findings suggestive of left basilar pneumonia. g. Nurses Notes and MAR indicated [REDACTED]. h. A Nurse's Note dated 9/21/16 documented, Called (hospital) to admit resident. Resident coughing up brown secretions with excessive secretions from trach. Seemed in respiratory distress. Doctor notified and was unable to reach . There was no documentation the resident's oxygen saturation or lung sounds were assessed at this time. i. A Hospital History and Physical dated 9/21/16 documented, .Per EMS (Emergency Medical Services) through nursing staff, patient had shortness of breath at nursing home . Exam: Lots of tracheal secretion . + (lung sounds positive for) rales . Assessment: Increased tracheal secretions; Acute [MEDICAL CONDITION] . Plan: Deep Tracheal suction . j. A Hospital [MEDICAL CONDITION] Consultation dated 9/21/16 documented, The patient is an [AGE] year-old patient who presents with a history of being noticed by nursing staff at the nursing home to having increased shortness of breath. Chest x-ray revealed no active infiltrate; however, the patient is coughing up green sputum . Assessment: Acute [MEDICAL CONDITION]; Acute tracheitis . k. A Nurse's Note dated 9/29/16 at 10:30 p.m. documented, (Emergency Medical Services) returns resident to (facility) . Rhonchi bilateral upper and lower lobes . Will continue to monitor. l. Nurses Notes and MAR indicated [REDACTED]. m. A Nurse's Note dated 10/17/16 not timed and written by Licensed Practical Nurse (LPN) #1 documented, This nurse suctioned resident (at family member's request) due to constant large amounts of heavy, thick secretions. After suctioning (which resident tolerated) equipment put away, this nurse continued to clean resident's fingernails. Resident vomited moderate amount of dark yellow/orange liquid. This nurse began to clean resident up, check for any signs of distress, daughter states 'last time she vomited she had pneumonia. Will you get one of the others so they can see it too.' Reported to ADON (Assistant Director of Nursing), called APN (Advanced Practice Nurse) . informed of resident's status. Order given for AP (anterior posterior) and lateral CXR (Chest X Ray). As this nurse hung up with APN, was informed by ADON that family requested she be sent out to ER (emergency room ). This nurse called APN back, informed that family wanted resident sent to ER. (EMS) notified of transport at 1:30 p.m . n. A Nurse's Note dated 10/17/16 at 10:30 p.m. documented, Returned from (hospital) . No congestion sound to lungs. Reported by (EMS) that resident required deep suctioning by them prior to arrival . o. On 10/20/16 at 4:35 p.m., the resident was in bed with copious amount of grayish white colored secretions coming from [MEDICAL CONDITION] mouth. LPN #2 was preparing to suction the resident. The LPN was asked if the resident's secretions are always that copious and stated, Yes. She really needs to be 1:1 (one staff to one resident). The LPN donned sterile gloves and advanced the suction catheter until the resident coughed, then properly applied intermittent suctioning as she withdrew the suction catheter. She did not check the resident's oxygen saturation or listen to the resident's breath sounds before or after the suctioning. p. On 10/21/16 at 10:22 a.m., the Registered Nurse (RN) Consultant was asked about the resident's condition on 10/17/16 and stated, All I was doing was preparing for our annual. I went into her room to see what equipment was there. She was up in the geri-chair, and the daughter was frantic and anxious. I explained I was there to check the equipment. I was doing the audit, and she was elaborating on how her mother was coughing, and she did cough some while I was in there . she asked if her mother could be sent out. I told (ADON) and asked if resident could be sent out. The charge nurse was on the phone with (APN). (Charge nurse) was aware of the situation per (ADON). It sounded like they had it under control. I told (ADON) to let (APN) know that family requested for resident to be sent out. In a little while, I was walking down the hall and (ADON) gave me the phone. (APN) wanted to know who had given the family the option of the resident being sent out. I told (APN) the resident and family had the right to request for her to be sent out. Then I went back to my office. When the ambulance came, (APN) came at the same time. (ADON) came to get me and said she didn't want (APN) to be yelling at her again. I went down the hall and heard (APN) talking loudly to the daughter. She was telling the daughter how she works at (hospital) ER and if they sent her over there she would be sent right back . She told the daughter she had given the order for her to be sent out today, but she knew they would just suction and send her back . The resident left. (APN) stopped me to tell me our nurses did not know how to deep suction people . I told her we have to follow our policy. Our policy is specific about suctioning and it is not the same as what she perceives as deep suctioning . (APN) asked me if I knew how much it costs to send this resident to the ER. I said no, but they had the right to request to go to the ER . I also ensured (APN) we would get suction training for our staff . We had contacted (equipment company) [MEDICAL CONDITION]. I don't know what training the staff already had, but if (APN) had concerns, we needed to address it . q. On 10/21/16 at 11:17 a.m., the Director of Nursing (DON) was asked about the resident being sent to the hospital on [DATE] and if she assessed her prior to going and stated, I looked at her, but there were enough nurses in there that I didn't. I stepped in because the Charge Nurse told me she was going to have to send her out. She said the daughter was concerned and wanted her to go to the hospital. I said that's fine, but to call the APN and let her know . They had it under control, so I stepped out to make more rounds. (APN) came over to the facility to try and change things. She kept trying to educate the daughter and make her feel comfortable enough to leave her here. The daughter still wanted her evaluated . (APN) said (ADON) had been trained in another facility to do deep suctioning. We don't do deep suctioning here. The DON was asked what would happen if the resident needed deep suctioning and staff had not been trained to do it and stated, That's a good question. I would have to get with the Nurse Consultant and see what we need to do. The DON was asked if it had been mentioned that the facility staff had not been suctioning the resident appropriately and stated, (APN) had said the ER doctor said to her if we could deep suction, she wouldn't have had to come to the ER. r. On 10/21/16 at 11:55 a.m., the ADON was asked about how Resident #1 was suctioned and stated, .Staff is instructed to go to the 4 or 5 on the suction catheter (markings on the suction catheter are in centimeters. 5 centimeters equals 1.96 inches). Staff is instructed not to deep suction and going past the 5 is deep suctioning. The ADON was asked what would happen if the resident needed to be deep suctioned and stated, I was told the only nurses that work over there are the nurses [MEDICAL CONDITION] experience . s. On 10/21/16 at 2:40 p.m., RN #1 was asked about suctioning the resident and stated, I'm taking care of (Resident #1) today, but I have not received instruction [MEDICAL CONDITION] and suctioning from the facility. Just from my nursing training. If I had to suction her today I would . insert tubing 1 to 1 and 1/2 inches, pull back slowly while suctioning, clear the tubing with sterile water, wait a minute or so, wait to see if clear. I was told not to do it more than 2 times . In this facility, we don't do deep suctioning. Deep is 3 and 1/2 to 4 inches. No one told me that, but I overheard the Nurse Consultant talk about it. RN #1 was asked what she would do if the resident'[MEDICAL CONDITION] occluded with a mucus plug and stated, If I am unable to remove the mucus plug because of not being able to deep suction, I would call the doctor. t. On 10/21/16 at 2:41 p.m., LPN #1 was asked how the resident was suctioned and stated, .I was informed we do not deep suction. I was informed that day (10/17/16). Nothing had been told to me prior to this date of how far to suction. She's only my [MEDICAL CONDITION], but I had been doing it the way I was taught before - to go down until you meet resistance with my finger off the suction and apply suction intermittently while twisting the tube and coming back up . u. On 10/21/16 at 3:10 p.m., the facility provided an in-service dated 10/10/16 that documented, .Trach management - care and suctioning . According to the sign in sheet, some of the nurses had not been inserviced, including two LPNs who were scheduled to provide care to the resident over the weekend of 10/22/16 and 10/23/16. v. On 10/21/16 at 4:35 p.m., the Medical Director was asked via telephone if it was necessary to know how to deep suction a resident who had a [MEDICAL CONDITION] and stated, It would be good to be trained in it; not that it's always required, but I would say in an emergency situation, it would be good to be trained. The Medical Director was asked about what one of the nurses had stated that she would contact the physician if the resident'[MEDICAL CONDITION] occluded with a mucus plug and stated, It makes sense to call the doctor, but in an urgent situation you may not have time. The Medical Director was asked if failure to suction properly could potentially lead to pneumonia and stated, The bigger danger is trying to suction and not know what you're doing. I can't say it would cause pneumonia, but it certainly would increase the risk. w. On 10/21/16 at 4:48 p.m., LPN #3 was asked if she had been trained at the facility on how to suction a [MEDICAL CONDITION] and stated, .To be honest, no one here has trained me or had me do a return demonstration. When (Resident #1) first came here, I told my ADON and DON that she was a different patient, critical patient, just because of her excessive secretions. You have to be very patient to take care of her because you are in there for a long time. The LPN was asked if she deep suctioned the resident and stated, No. Deep is bad. There's no need to ever do deep suctioning. x. On 10/21/16 at 5:00 p.m., the APN was asked about what happened with the resident on 10/17/16 and stated, She was not in distress, but if they suctioned her properly, they wouldn't have to send her out. She has reoccurring pneumonia. If they're able to suction her correctly and sit her up in a chair, her secretions would decrease. I talked to them about deep suctioning and was told they don't do that. The APN was asked if she felt that not suctioning properly could lead to pneumonia and stated, Most definitely. That's evidence-based. The APN was asked if it would be a serious problem if the resident developed a mucus plug and staff could not perform deep suctioning and stated, Oh yeah. We have discussed that. They're supposed to get someone out this week I think to in-service. I don't think she's ever had a plug that I know of. y. On 10/21/16 at 5:27 p.m., RN #1, who was assigned to the resident on the 7 a.m.-7 p.m. shift (Day/Evening Shift) on 10/21/16, was asked if she knew how to suction Resident #1 and stated, I guess they go over the suctioning policy with normal staff that are going to work the floor, but it wasn't gone over with me. The RN was asked if she had had any training at the facility on [MEDICAL CONDITION] care and stated, No. I haven't suctioned her today. (ADON) and (LPN #3) have done it for me. z. On 10/21/16 at 6:40 p.m., the ADON stated she had begun in-servicing staff on suctioning and stated she's instructing staff to start with checking the resident's pulse ox (oxygen saturation), lung sounds, then oxygenate, advance the catheter until resistance is met, pull back with intermittent suctioning while swirling the catheter back out, rinse the catheter with sterile saline, reapply oxygen, recheck lung sounds, and then ask for a return demonstration. aa. The facility's Policy and Procedure for [MEDICAL CONDITION] Suctioning documented, .Maintain sterile technique and a patent airway . Hyperventilate (and oxygenate if possible) . Warn patient then insert catheter approximately 4-6 inches into inner cannula or until resistance is met or cough reflex is stimulated. Place thumb over suction port and apply suction (intermittently and rapidly) . bb. The immediate jeopardy was removed and the scope and severity reduced to E on 10/21/16 at 7:55 p.m. when the facility implemented the following Plan of Removal: 1.) On October 21, 2016 at 6:40 p.m., the DON on notification of findings immediately assessed Resident #1's lung sounds, assessed pulse ox saturation, and documented these findings in resident's medical record. DON notified the resident family and physician of assessment findings. 2.) On October 21, 2016 via resident list, identified one resident, Resident #1, with the potential to be affected. 3.) On October 21, 2016 at 6:40 p.m., ADON, on notification of findings began with in-service to all nurses on duty on proper suctioning with return demonstration and will continue training with all nurses prior to their working the floor. Completion date 10/24/2016. 4.) On October 21, 2016 at 6:40 p.m., DON on notification of findings began in-service to all nurses on duty on assessment of lung sounds and assessment of pulse ox saturation every shift and PRN with documentation. In-service will continue with nurses prior to their working the floor. Completion date 10/24/16. 5.) On October 24 2016 at 2:00 p.m., respiratory therapist will train all nurses including Director of Nursing on proper suctioning with return demonstrations to reinforce training already provided. On October 24, 2016, respiratory therapist will train all nurse including Director of Nursing on lung sound assessment and pulse ox saturation assessment and correct documentation. Completion date 10/24/2016. 6.) DON/Designee will observe staff perform suctioning, lung sound assessment, pulse ox saturation assessment and documentation of 1 resident daily x (times) 7 days, 3 times weekly x 4, then weekly till compliance is achieved making corrections as needed. DON will report all negative findings to Administrator. 7.) Administrator will monitor via monitoring log all new hired nurses records prior to working the floor to ensure they have been trained on proper suctioning with return demonstration, lung sound and pulse ox saturation assessment every shift and PRN and correct documentation of assessments, making corrections as needed. 8.) Administrator and DON will present all findings to QA (Quality Assessment / Assurance) committee for further recommendations.

Complaint # (AR 548) was substantiated, all or in part, with these findings: Based on observation, record review and interview, the facility failed to ensure that Resident #1, who had a [MEDICAL CONDITION], received proper treatment and care to prevent potential complications. The facility failed to ensure licensed nurses were capable of properly providing tracheal suctioning to manage copious secretions in order to maintain a patent airway and prevent potential complications for 1 (Resident #1) of 1 case mix resident who had a [MEDICAL CONDITION] (trach). The failed practice resulted in Immediate Jeopardy, which caused or could have caused serious harm, injury, or death to Resident #1, who was transported to the hospital emergency room due to shortness of breath and copious secretions that were not removed with the facility's nursing staff's attempt at shallow tracheal suctioning. The failed practice had the potential to affect only this resident (the only resident in the facility with a [MEDICAL CONDITION]), as documented on a list provided by the Nurse Consultant on 10/20/16 at 4:00 p.m. The facility was informed of the Immediate Jeopardy condition on 10/21/16 at 6:30 p.m. The findings are: Resident #1 was admitted to the facility 8/5/16 and had [DIAGNOSES REDACTED]. The Admission Minimum Data Set with an Assessment Reference Date of 8/19/16 documented the resident was severely impaired in cognitive skills for daily decision making per a Staff Assessment for Mental Status, was totally dependent on staff for activities of daily living, and received [MEDICAL CONDITION] care. a. Physician's admission orders [REDACTED]. This order was also on the current October 2016 Physicians Orders sheet. b. A Nurses Note dated 8/5/16 at 1:00 p.m. documented, Arrive to facility (at) 1300 (1:00 p.m.) resp (respirations) even unlabored. Come via EMT (Emergency Medical Technician) X (times) 2. Resident has copious drainage clear from trach. (No) s/s (signs or symptoms) of distress noted O2 (oxygen) intact [MEDICAL CONDITION]. Cont (Continuous) tube feeding (No) n/v (nausea/vomiting) noted. Non verbal of needs. NPO (Nothing by mouth) . Total Care.[MEDICAL CONDITION] X5 . c. The Plan of Care dated 8/23/16 documented, Resident has potential for difficulty breathing related to chronic condition: Tracheotomy . Administer / monitor effectiveness of treatments. Oxygen Nebulizer treatments. Suction [MEDICAL CONDITION] care. Elevate HOB (head of bed) at least 45 degrees . Pulse ox (oximeter) every shift and PRN (as needed) .[MEDICAL CONDITION] every shift and PRN (as needed). Suction per MD (Medical Doctor) order . Assess lung sounds every shift and PRN and report to MD (Medical Doctor) any abnormal findings. d. A Nurses Note dated 8/26/16 at 8:00 a.m. documented, HOB elevated 30 degrees for aspiration precaution .Respiration even and unlabored. O2 at 2 LPM (liters per minute) via trach. SpO2 93%.3:30 p.m. Excessive secretions noted, suction [MEDICAL CONDITION] provided at this time. (Physician) notified. Order received and noted. Chest X ray related to excessive secretions [MEDICAL CONDITION]. A Nurses Note dated 8/26/16 documented, [MEDICATION NAME] received at this time and started . e. A chest x-ray (CXR) result dated 8/26/16 documented, Patient has increased mucous secretions, congested chest . Findings suggestive of left basilar pneumonia. f. A Nurse's Note dated 9/21/16 documented, Called (hospital) to admit resident. Resident coughing up brown secretions with excessive secretions from trach. Seemed in respiratory distress. Doctor notified and was unable to reach . g. A Hospital History and Physical dated 9/21/16 documented, .Per EMS (Emergency Medical Services) through nursing staff, patient had shortness of breath at nursing home . Exam: Lots of tracheal secretion . + (lung sounds positive for) rales . Assessment: Increased tracheal secretions; Acute [MEDICAL CONDITION] . Plan: Deep Tracheal suction . h. A Hospital [MEDICAL CONDITION] Consultation dated 9/21/16 documented, The patient is an [AGE] year-old patient who presents with a history of being noticed by nursing staff at the nursing home to having increased shortness of breath. Chest x-ray revealed no active infiltrate; however, the patient is coughing up green sputum . Assessment: Acute [MEDICAL CONDITION]; Acute tracheitis . i. A Nurse's Note dated 9/29/16 at 10:30 p.m. documented, (Emergency Medical Services) returns resident to (facility) . Rhonchi bilateral upper and lower lobes . Will continue to monitor. j. A Nurse's Note dated 10/17/16 not timed and written by Licensed Practical Nurse (LPN) #1 documented, This nurse suctioned resident (at family member's request) due to constant large amounts of heavy, thick secretions. After suctioning (which resident tolerated) equipment put away, this nurse continued to clean resident's fingernails. Resident vomited moderate amount of dark yellow/orange liquid. This nurse began to clean resident up, check for any signs of distress, daughter states 'last time she vomited she had pneumonia. Will you get one of the others so they can see it too.' Reported to ADON (Assistant Director of Nursing), called APN (Advanced Practice Nurse) . informed of resident's status. Order given for AP (anterior posterior) and lateral CXR (Chest X Ray). As this nurse hung up with APN, was informed by ADON that family requested she be sent out to ER (emergency room ). This nurse called APN back, informed that family wanted resident sent to ER. (EMS) notified of transport at 1:30 p.m . k. A Nurse's Note dated 10/17/16 at 10:30 p.m. documented, Returned from (hospital) . No congestion sound to lungs. Reported by (EMS) that resident required deep suctioning by them prior to arrival . l. On 10/20/16 at 4:35 p.m., the resident was in bed with copious amount of grayish white colored secretions coming from [MEDICAL CONDITION] mouth. LPN #2 was preparing to suction the resident. The LPN was asked if the resident's secretions are always that copious and stated, Yes. She really needs to be 1:1 (one staff to one resident). The LPN donned sterile gloves and advanced the suction catheter until the resident coughed, then properly applied intermittent suctioning as she withdrew the suction catheter. m. On 10/21/16 at 10:22 a.m., the Registered Nurse (RN) Consultant was asked about the resident's condition on 10/17/16 and stated, All I was doing was preparing for our annual. I went into her room to see what equipment was there. She was up in the geri-chair, and the daughter was frantic and anxious. I explained I was there to check the equipment. I was doing the audit, and she was elaborating on how her mother was coughing, and she did cough some while I was in there . she asked if her mother could be sent out. I told (ADON) and asked if resident could be sent out. The charge nurse was on the phone with (APN). (Charge nurse) was aware of the situation per (ADON). It sounded like they had it under control. I told (ADON) to let (APN) know that family requested for resident to be sent out. In a little while, I was walking down the hall and (ADON) gave me the phone. (APN) wanted to know who had given the family the option of the resident being sent out. I told (APN) the resident and family had the right to request for her to be sent out. Then I went back to my office. When the ambulance came, (APN) came at the same time. (ADON) came to get me and said she didn't want (APN) to be yelling at her again. I went down the hall and heard (APN) talking loudly to the daughter. She was telling the daughter how she works at (hospital) ER and if they sent her over there she would be sent right back . She told the daughter she had given the order for her to be sent out today, but she knew they would just suction and send her back . The resident left. (APN) stopped me to tell me our nurses did not know how to deep suction people . I told her we have to follow our policy. Our policy is specific about suctioning and it is not the same as what she perceives as deep suctioning . (APN) asked me if I knew how much it costs to send this resident to the ER. I said no, but they had the right to request to go to the ER . I also ensured (APN) we would get suction training for our staff . We had contacted (equipment company) [MEDICAL CONDITION]. I don't know what training the staff already had, but if (APN) had concerns, we needed to address it . n. On 10/21/16 at 11:17 a.m., the Director of Nursing (DON) was asked about the resident being sent to the hospital on [DATE] and if she assessed her prior to going and stated, I looked at her, but there were enough nurses in there that I didn't. I stepped in because the Charge Nurse told me she was going to have to send her out. She said the daughter was concerned and wanted her to go to the hospital. I said that's fine, but to call the APN and let her know . They had it under control, so I stepped out to make more rounds. (APN) came over to the facility to try and change things. She kept trying to educate the daughter and make her feel comfortable enough to leave her here. The daughter still wanted her evaluated . (APN) said (ADON) had been trained in another facility to do deep suctioning. We don't do deep suctioning here. The DON was asked what would happen if the resident needed deep suctioning and staff had not been trained to do it and stated, That's a good question. I would have to get with the Nurse Consultant and see what we need to do. The DON was asked if it had been mentioned that the facility staff had not been suctioning the resident appropriately and stated, (APN) had said the ER doctor said to her if we could deep suction, she wouldn't have had to come to the ER. o. On 10/21/16 at 11:55 a.m., the ADON was asked about how Resident #1 was suctioned and stated, .Staff is instructed to go to the 4 or 5 on the suction catheter (markings on the suction catheter are in centimeters. 5 centimeters equals 1.96 inches). Staff is instructed not to deep suction and going past the 5 is deep suctioning. The ADON was asked what would happen if the resident needed to be deep suctioned and stated, I was told the only nurses that work over there are the nurses [MEDICAL CONDITION] experience . p. On 10/21/16 at 2:40 p.m., RN #1 was asked about suctioning the resident and stated, I'm taking care of (Resident #1) today, but I have not received instruction [MEDICAL CONDITION] and suctioning from the facility. Just from my nursing training. If I had to suction her today I would . insert tubing 1 to 1 and 1/2 inches, pull back slowly while suctioning, clear the tubing with sterile water, wait a minute or so, wait to see if clear. I was told not to do it more than 2 times . In this facility, we don't do deep suctioning. Deep is 3 and 1/2 to 4 inches. No one told me that, but I overheard the Nurse Consultant talk about it. RN #1 was asked what she would do if the resident'[MEDICAL CONDITION] occluded with a mucus plug and stated, If I am unable to remove the mucus plug because of not being able to deep suction, I would call the doctor. q. On 10/21/16 at 2:41 p.m., LPN #1 was asked how the resident was suctioned and stated, .I was informed we do not deep suction. I was informed that day (10/17/16). Nothing had been told to me prior to this date of how far to suction. She's only my [MEDICAL CONDITION], but I had been doing it the way I was taught before - to go down until you meet resistance with my finger off the suction and apply suction intermittently while twisting the tube and coming back up . r. On 10/21/16 at 3:10 p.m., the facility provided an in-service dated 10/10/16 that documented, .Trach management - care and suctioning . According to the sign in sheet, some of the nurses had not been inserviced, including two LPNs who were scheduled to provide care to the resident over the weekend of 10/22/16 and 10/23/16. s. On 10/21/16 at 4:35 p.m., the Medical Director was asked via telephone if it was necessary to know how to deep suction a resident who had a [MEDICAL CONDITION] and stated, It would be good to be trained in it; not that it's always required, but I would say in an emergency situation, it would be good to be trained. The Medical Director was asked about what one of the nurses had stated that she would contact the physician if the resident'[MEDICAL CONDITION] occluded with a mucus plug and stated, It makes sense to call the doctor, but in an urgent situation you may not have time. The Medical Director was asked if failure to suction properly could potentially lead to pneumonia and stated, The bigger danger is trying to suction and not know what you're doing. I can't say it would cause pneumonia, but it certainly would increase the risk. t. On 10/21/16 at 4:48 p.m., LPN #3 was asked if she had been trained at the facility on how to suction a [MEDICAL CONDITION] and stated, .To be honest, no one here has trained me or had me do a return demonstration. When (Resident #1) first came here, I told my ADON and DON that she was a different patient, critical patient, just because of her excessive secretions. You have to be very patient to take care of her because you are in there for a long time. The LPN was asked if she deep suctioned the resident and stated, No. Deep is bad. There's no need to ever do deep suctioning. u. On 10/21/16 at 5:00 p.m., the APN was asked about what happened with the resident on 10/17/16 and stated, She was not in distress, but if they suctioned her properly, they wouldn't have to send her out. She has reoccurring pneumonia. If they're able to suction her correctly and sit her up in a chair, her secretions would decrease. I talked to them about deep suctioning and was told they don't do that. The APN was asked if she felt that not suctioning properly could lead to pneumonia and stated, Most definitely. That's evidence-based. The APN was asked if it would be a serious problem if the resident developed a mucus plug and staff could not perform deep suctioning and stated, Oh yeah. We have discussed that. They're supposed to get someone out this week I think to in-service. I don't think she's ever had a plug that I know of. v. On 10/21/16 at 5:27 p.m., RN #1, who was assigned to the resident on the 7 a.m.-7 p.m. shift (Day/Evening Shift) on 10/21/16, was asked if she knew how to suction Resident #1 and stated, I guess they go over the suctioning policy with normal staff that are going to work the floor, but it wasn't gone over with me. The RN was asked if she had had any training at the facility on [MEDICAL CONDITION] care and stated, No. I haven't suctioned her today. (ADON) and (LPN #3) have done it for me. w. On 10/21/16 at 6:40 p.m., the ADON stated she had begun in-servicing staff on suctioning and stated she's instructing staff to start with checking the resident's pulse ox (oxygen saturation), lung sounds, then oxygenate, advance the catheter until resistance is met, pull back with intermittent suctioning while swirling the catheter back out, rinse the catheter with sterile saline, reapply oxygen, recheck lung sounds, and then ask for a return demonstration. x. The facility's Policy and Procedure for [MEDICAL CONDITION] Suctioning documented, .Maintain sterile technique and a patent airway . Hyperventilate (and oxygenate if possible) . Warn patient then insert catheter approximately 4-6 inches into inner cannula or until resistance is met or cough reflex is stimulated. Place thumb over suction port and apply suction (intermittently and rapidly) . y. The immediate jeopardy was removed and the scope and severity reduced to E on 10/21/16 at 7:55 p.m. when the facility implemented the following Plan of Removal: 1.) On October 21, 2016 at 6:40 p.m., the DON on notification of findings immediately assessed Resident #1's lung sounds, assessed pulse ox saturation, and documented these findings in resident's medical record. DON notified the resident family and physician of assessment findings. 2.) On October 21, 2016 via resident list, identified one resident, Resident #1, with the potential to be affected. 3.) On October 21, 2016 at 6:40 p.m., ADON, on notification of findings began with in-service to all nurses on duty on proper suctioning with return demonstration and will continue training with all nurses prior to their working the floor. Completion date 10/24/2016. 4.) On October 21, 2016 at 6:40 p.m., DON on notification of findings began in-service to all nurses on duty on assessment of lung sounds and assessment of pulse ox saturation every shift and PRN with documentation. In-service will continue with nurses prior to their working the floor. Completion date 10/24/16. 5.) On October 24 2016 at 2:00 p.m., respiratory therapist will train all nurses including Director of Nursing on proper suctioning with return demonstrations to reinforce training already provided. On October 24, 2016, respiratory therapist will train all nurse including Director of Nursing on lung sound assessment and pulse ox saturation assessment and correct documentation. Completion date 10/24/2016. 6.) DON/Designee will observe staff perform suctioning, lung sound assessment, pulse ox saturation assessment and documentation of 1 resident daily x (times) 7 days, 3 times weekly x 4, then weekly till compliance is achieved making corrections as needed. DON will report all negative findings to Administrator. 7.) Administrator will monitor via monitoring log all new hired nurses records prior to working the floor to ensure they have been trained on proper suctioning with return demonstration, lung sound and pulse ox saturation assessment every shift and PRN and correct documentation of assessments, making corrections as needed. 8.) Administrator and DON will present all findings to QA (Quality Assessment / Assurance) committee for further recommendations.

Complaint # (AR 972), substantiated, all or in part, in these findings. Based on observation, record review, and interview, the facility failed to ensure staff were trained to assess, measure, and describe the size and location of pressure ulcers, and document the information on a regular basis to provide pertinent information to the physician to implement the necessary care and services for 5 of 5 (Resident #1, #2, #4, #6 and #7) case mix residents who had pressure ulcers. The facility failed to ensure the physician was notified when new pressure ulcers were identified to obtain appropriate treatment to promote healing and prevent further decline for 2 (Resident #2 and #7) of 5 (Resident #1, #2, #4, #6 and #7) case mix residents who had pressure ulcers. The facility failed to ensure physician orders for pressure ulcer treatments were transferred to the current treatment record to assure treatments were conducted as ordered for 1 (Resident #7) of 5 (Resident #1, #2, #4, #6 and #7) case mix residents who had pressure ulcers. The facility failed to ensure recommendations for change in treatment by the Registered Nurse (RN) Wound Consultant were not implemented without permission of the wound clinic physician, wound clinic appointments were not missed to assure physician evaluation and treatment orders for pressure ulcers, and wound treatment supplies were available to promote healing of pressure ulcers for 1 (Resident 6) of 5 (Resident #1, #2, #4, #6 and #7) case mix residents who had pressure ulcers. These failed practices resulted in actual harm to Resident #2 who had 3 Stage II pressure ulcers and the physician was not immediately notified so appropriate treatment could be initiated, and Resident #6 who had an unstageable pressure ulcer and the physician was not notified of treatment order recommendations by the RN Would Consultant, a wound clinic appointment was missed, and the wound was identified as deteriorating. These failed practices also had the potential to affect 8 residents who had pressure ulcers as documented on a list received form the Nurse Consultant 2/19/16. The findings are: 1. The facility's guidelines titled Care and Prevention of Pressure Ulcer and Skin Conditions received at 10:20 a.m. on 2/11/16 from the Registered Nurse Consultant documented, Basic Responsibility: Licensed Nurse . Purpose To prevent and treat further breakdown of pressure sores. To promote healing of pressure sores that is present. To identify and treat other skin conditions.Procedure for Weekly Ulcer Monitoring Venous Stasis Ulcers, Diabetic Ulcers, Pressure Ulcers, and Arterial Ulcers When assessing the ulcer itself, it is important to differentiate the type of ulcer (pressure related versus non-pressure related) because interventions may vary. 1. Measure all ulcers weekly, stating location, stage, size, and exudate if present. 2. Utilize Pressure Ulcer Monitoring Record for . Pressure Ulcers . 3. Measure and document wound's width and length in centimeters using linear clock method (head=12 o'clock, feet=6 o'clock, etc) 4. Measure and document wound's depth in centimeters using cotton tipped applicator and measuring the deepest area of the wound bed. 5. Observe and document drainage, odor, and color of wound bed and granulation. 6. If undermining or tunneling exists, use cotton tipped applicator to determine the location and extent. Document the location using the linear clock method, document the extent in centimeters. 7. Observe response to treatment. If response to treatment is poor, consider changing to alternative treatment. 8. Assess for signs and symptoms of infection, purulent exudates, peri-wound warmth, swelling, duration or [DIAGNOSES REDACTED], increasing pain or tenderness around the site or delayed wound healing. Notify physician to determine need for culture and/or treatment. 9. Notify physician, family, and dietary of any new wound. 10. Whether pain is present and is adequately controlled. Procedure for weekly skin audits 1. Conduct body audits on all residents weekly. 2. Utilize Weekly Skin Audit Record weekly for all skin conditions. 3. In addition to the Weekly Skin Audit Record, the Weekly Ulcer Monitoring Record is also utilized for .Pressure Ulcers . 4. Examine general condition of skin and check appropriate box on form. 5. If any specific conditions exist, note on the form the specific site on the body diagram using the body legend. Treatment: treatment of [REDACTED]. The nurse is responsible for carrying out the treatment as ordered by the attending physician and for implementing measures to prevent pressure ulcers.General Resident Care Plan Documentation Guidelines Problem: Identify the appropriate problem under which to list the pressure/non-pressure ulcer care as an approach. Identify and treat the underlying cause of the pressure ulcer/non-pressure ulcer. Identify potential risk factors utilizing the Braden scale and cause(s) individually that increase the potential for the resident to develop pressure ulcers and what extent the factors can be modified, stabilized, removed if possible. Example: At risk for developing pressure sores due to being constantly moist, immobility, and poor nutrition. Goal List Measurable goal(s) to be accomplished.Approaches List responsible discipline for each approach. List instructions unique to this resident. List necessary monitoring and observation of the underlying condition. List treatment as ordered if necessary. List pressure-reducing devices. List frequency of positioning. Develop and implement preventative interventions, i.e. frequent incontinent care, more frequent turning and positioning and assessing for nutritional needs . 2. Resident #2 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/1/16 documented the resident scored 2 (0-7 indicates severely impaired) on the Brief Interview for Mental Status (BIMS), was totally dependent on 2 persons for bed mobility and transfers, totally dependent on 1 person for personal hygiene, was incontinent of bowel and bladder, at risk for pressure ulcers, and had no pressure ulcers. a. The Resident Plan of Care last reviewed on 1/4/16 documented a problem of being at risk for skin breakdown with approaches of Report changes in skin status . to physician . Complete weekly skin check. Complete Braden Scale Risk Assessment quarterly & (and) prn (as needed)and Skin Risk Analysis the 1st time the Braden Scale less than 18. b. On 2/9/16 at 3:25 p.m., Certified Nursing Assistant (CNA) #1 and #2 were providing incontinent care. The resident had a [MEDICATION NAME] (Duoderm) located on the left ischial area. The Duoderm was discolored and the date was not readable. There was an area on the left mid portion of the resident's back that was discolored and covered an area approximately 10 cm x 8 cm with an open area that was pinkish in color that measured approximately 0.5 cm x 0.5 cm. CNA #1 stated that the resident had a rash to her back and the nurses put a cream on it. As of 2/9/16 there was no physician order for [REDACTED]. c. On 2/9/16 at 4:33 p.m., the Body Assessments dated 12/8/15 through 2/9/16 documented, No skin issues. d. As of 2/10/16, there was no documentation of any skin concerns in the Nurses Notes. The latest Telephone Order dated 12/8/15 documented, D'C (Discontinue) Tx (Treatment) to left inner thigh area has resolved. There were no other physician orders or skin assessments in the clinical record since 12/8/15. e. On 2/10/16 at 4:12 p.m., the Director of Nursing (DON) conducted a body audit. The resident had a Duoderm dressing to the left ischial area. The DON was asked if the Duoderm could be removed. The DON removed the Duoderm and there was a pinkish area approximately 3 cm x 2 cm that was irregularly shaped with an open area through the center of the pinkish area that was open. There was an area on the left mid buttocks that was open with a reddish wound bed. There was an open area to the left side of the back that was darkish in appearance with an open area to the top portion of the area, the wound bed was pinkish in color. The DON was asked what she thought the areas were. The DON stated, All 3 areas are Stage II Pressure Ulcers. The DON was asked where was the location of the Duoderm and the DON stated it was on the lower buttocks in the crease. The DON was asked if this was the ischial area. The DON stated, Yes. The DON was asked if this was the inner thigh area. The DON stated, No. The DON and this Surveyor reviewed the resident's clinical record. The DON was asked if there was an order for [REDACTED]. The DON stated, No. The resident's clinical records were reviewed and the last treatment order was dated 12/8/15 and it documented, D'C Tx to left inner thigh area has resolved. The DON was asked if there was a Treatment Administration Record (TAR) for this resident. The DON checked the Treatment Book. The DON stated, No. The DON was shown the Body Audit for 2/9/16 that documented, No skin issues. The DON was asked if the Body Audit addressed the resident's skin issues and was the Body Assessment documented on 2/9/16 accurate. The DON stated, No. The DON was asked if there were any other documentation regarding wound measurement. f. On 2/11/15 at 8:45 a.m., the DON was asked for the measurement and orders for Resident #2's pressure ulcers. The DON stated that she had gotten the measurements this morning and was about to call the physician. The DON was asked if the measurements had not been obtained until this morning. The DON stated, Yes, I did them this morning. The DON was asked, The physician has not been notified regarding the 3 stage II pressure ulcers? The DON stated, No. The DON was asked when a resident has new open areas when should the assessment, measurement, and the physician be notified. The DON stated, Immediately. g. On 2/11/16 at 9:10 a.m., the DON was asked for the measurements, assessments, documentation, and physician orders for the pressure ulcers for this resident. h. On 2/11/16 at 10:30 a.m., Licensed Practical Nurse (LPN) #1 stated that he had done the treatment to the areas this morning, when the orders were received from the DON. The LPN was documenting the measurements on the Body/Skin Assessment sheet. i. On 2/11/16 at 2:40 p.m., the Administrator provided the Body/Skin Assessment sheet dated for 2/11/16. The sheet documented, lower back area noted open (with) (no) drainage noted; 0.5 cm (centimeter) x (by) 0.5 cm., 2 open areas open about 0.8 cm x 1.2 cm, 2.0 cm x 1.0 cm outer left gluteal fold. No drainage noted The sheet was signed by LPN #1. There was no description of the wounds. As of 2/11/15 at 3:50 p.m., there was no documentation in the clinical record of any physician orders for treatment of [REDACTED]. 3. Resident #6 had [DIAGNOSES REDACTED]. The Quarterly MDS with an ARD of 12/7/15 documented the resident scored 7 (0-7 indicates severely impaired) on the BIMS and had Stage 1 or higher pressure ulcers. a. The Resident Plan of Care dated 12/2/15 documented, Pressure Ulcers Resident has pressure ulcer . Pressure ulcer will exhibit signs of healing evidenced by decrease in size, improved appearance, .Approaches Report changes in skin status ( .non-healing, .) to physician . Monitor effectiveness of/response to treatment(s) as ordered. (see physicians orders) . Complete Weekly Skin Check . b. A wound physician progress notes [REDACTED].New right hip eschar reported over previous surgical incision, most consistent with pressure wound . Wound #3 Right Hip is a Necrotic Tissue (unstageable) Pressure Ulcer and has received a status of Not Healed. Initial wound encounter measurements are 3.5 cm length (by) 3 cm width . Diagnosis . Pressure ulcer of right hip, unstageable . c. A wound care center Physician Orders Details dated 1/26/16 documented, .Wound Orders . Change dressing(s) every: - only if becomes soiled or dislodges, if this happens remove down to hydroactive b (green dressing) and reinforce . Wound #2 Right Hip Other Orders Wound Cleansing (and) Dressings Cleanses wound with Normal Saline. Zinc Ointment to protect surrounding skin. Cover wound and secure dressing in place-hydroactive b Additional Orders Other Orders Follow-Up Appointments Return Appointment in 1 week.-February 2, 2016 (at) 9am . d. The Body/Skin Assessment form documented, Date 1/29/16 Tx (treatment) cont (continues) to (right) great toe (and) (right) heel (and) (right) hip . Date 2/12/16 Large mass noted on (left) side of abd. (abdomen) to ER (emergency room ) for evaluation Tx cont to . (right) hip . There was no documentation in the clinical record of any completed weekly skin assessments between 1/29/16 and 2/12/16, a 2 week period. e. A wound care center Multi Wound Chart Details dated 2/2/16 documented, .Wound Assessments . Wound Location . Right Hip . Wound Status Not Healed Measurements L (length) (by) W (width) (by) D (depth) (cm) 2.3 (by) 2.2 (by) 0 . Physician Orders Details . Wound #2 Right Hip Other Orders Wound Cleansing (and) Dressings Cleanse wound with Normal Saline. Zinc Ointment to protect surrounding skin Cover wound and secure dressing in place-hydroactive b Additional Orders Other Orders Follow-up Appointments Return Appointment in 1 week. February 9, 2016 (at) 8:30 a.m . f. Physician's Telephone Orders dated 2/12/16 signed by Wound Consultant RN, not signed by a physician, documented, (1) D/C (discontinue) previous wound care orders to (right) hip (2) Cleanse (right) hip wound (with) cleanser of choice, dry. Apply [MEDICATION NAME] to wound. Cover (with) a bordered foam drsg (dressing). Change daily . g. A wound care center form titled Multi Wound Chart Details dated 2/16/16 by the wound physician documented, .Right Hip .Measurements L (by) W (by) D (cm) .3.4 (by) 2.4 (by) 0.2 . Wound Progress: .Deteriorating . The record review indicated that the wound to the hip had increased in size. There was no wound care center form available for review dated 2/9/16. A wound care center form dated 2/16/16 titled Physician Orders Details documented .Wound Orders Wound #1 Right Heel Other Orders Wound Cleansing (and) Dressings Cleanse wound with Normal Saline. Zinc Ointment to protect surrounding skin. Moisturizing lotion to surrounding skin Venelex Cover wound and secure dressing in place-hydroactive b, abd pad, cast padding, kerlix, and tape Change dressing(s) every: only if becomes soiled or dislodges, if this happens remove down to hydroactive b (green dressing) and reinforce with abd (abdominal), pad, cast padding, rolled gauze and tape. Wound #2 Right Hip Other Orders Wound Cleansing (and) Dressings Cleanse wound with Normal Saline. Zinc Ointment to protect surrounding skin Cover wound and secure dressing in place-hydroactive b . h. A Treatment Record documented, D/C previous orders to (right) hip. Cleanse (right) hip wound (with) cleanser of choice dry. Apply [MEDICATION NAME] to wound. Cover (with) a bordered foam dressing (change every) day . D/C previous orders to (right) heel Cleanse (right) heel wound (with) 2% acetic acid moisturized 4 (by) 4 gauze pads (by) 10 and 15 min prior to each drsg (change) The date for 2/18/16 was initialed by LPN #1. i. On 2/19/16 at 3:15 p.m., the DON observed the resident's wound sites with this Surveyor. The border dressing on the right hip was dated 2/18 and the kerlix dressing to the right foot was dated 2/18. The DON was asked what the dressings were dated and the DON stated, 2/18. The DON was asked who the initials were on the dressings and the DON stated, That's (LPN #1) On 2/19/16 at 4:25 p.m., the DON was asked when the resident had the last wound physician visit and the DON stated, 2/16/2016. The DON was asked if the wound care center physician had given orders for wound care on that date and the DON stated, Yes. The DON was asked what the orders were for 2/16/16 and the DON stated, Right heel cleanse wound with Normal Saline (NS), zinc ointment surrounding skin, Moisturizing lotion to surrounding skin Venelex Cover wound and secure dressing in place-hydroactive b, abd pad, case padding, kerlix, tape Change dressings only if becomes soiled and dislodges, if this happens remove down to hydroactive b green dressing and reinforce with abd pad, cast padding rolled gauze Right hip cleanse wound with NS zinc ointment to surrounding skin cover and secure dressing in place hydroactive b. The DON was asked if the hydroactive b was to be removed and the DON stated, Change only if soiled or dislodged outer dressing The DON was asked if the dressing order was because the wound center did the dressing changes and the DON stated, Yes. The DON was asked what the most recent orders were dated and the DON stated, 2/16/2016. The DON was asked if the wound center clinic applied the dressings and the DON stated, Yes we're only to do it if becomes soiled or dislodged. The DON was asked if the (facility) nurses had changed the dressings and the DON referred to the Treatment Record. The DON stated, I see one on the 16th and one on the 18th. The DON was then asked when the most recent physician's order was received was that the order to follow for dressings and the DON stated, Yes. The DON was asked if the date the order was faxed and received was 2/17/16 and the DON stated, Yes. j. On 2/22/16 at 10:53 a.m., LPN #1 was asked when the RN Wound Consultant saw the resident on 2/12/16 and wrote orders on the physicians telephone orders form, if either the attending physician or the wound physician were notified of the nurse's recommendation. The LPN was asked to show this Surveyor where the physician was notified and the LPN referred to the resident's record and stated, I don't remember. The record review and nurses notes did not document that either physician was notified of the recommendation for the daily dressing changes. The LPN was asked about the dressings to the right hip and right foot that were dated 2/18/16 and the LPN stated, The resident had a shower. The LPN was asked why the dressing treatment for [REDACTED].I just used what was available. We didn't have the supplies here. k. On 2/22/16 at 11:50 a.m., the DON was asked if wound treatment supplies were not available what was to be done and the DON stated, We'll have to call the doctor. Main thing is to get the supplies in the building but we'll have to call the doctor and see what to do. The DON was asked if nursing staff made her aware that supplies for dressing changes for wound clinic center physician orders were not available and the DON stated, No I was not. n. On 2/22/16 at 1:45 p.m., there was no wound care center note dated 2/9/16 provided by the DON and the DON was asked if the resident had gone to the scheduled appointment that day. The DON stated, No the van was in a wreck and not in use. The DON reviewed the weekly skin audits with this Surveyor and was asked if there were assessments of the wounds between clinic visits when the resident had not gone to the 2/9/16 appointment and the DON stated, No. 4. Resident #1 had [DIAGNOSES REDACTED]. The Quarterly MDS with an ARD of 1/22/16 documented the resident scored 11 (8-12 indicates moderately impaired) on the BIMS, totally dependent on 2 persons for bed mobility and transfers, required extensive assistance of 1 person for personal hygiene, was always incontinent of bowel and bladder, at risk for developing pressure ulcers, and had no pressure ulcers. a. The Resident Plan of Care dated for 10/28/15 documented a problem of pressures ulcers. The last documented pressure ulcer treatment was dated 7/28/15. b. The Braden Scale for Predicting Pressure Ulcers dated 10/27/15 documented a total score of 13, a total score of 13-14 indicates moderate risk. c. A Telephone Order dated 1/21/16 documented, Cleanse open area to coccyx (with) NS (normal saline)/WC (wound cleanser) or soap and water apply Zinc Oxide q shift until resolved then D/C. d. The Body/Skin Assessment Sheet dated 2/1/16 documented, (No) skin issues. The Body Audit dated 2/8/16 documented, (No) skin issues. Open area to buttocks healed. As of 2/11/16 there was no documentation in Nurses Notes related to the pressure ulcer to the coccyx area. e. On 2/11/16 at 11:a.m., LPN #2 was asked if Resident #1 had a pressure ulcer. The LPN stated, Yes, to her coccyx. The LPN was asked if she had measured the area. The LPN stated, No. The LPN was asked if there was an assessment documented for the pressure ulcer to the coccyx. The LPN stated. No. The LPN was asked if a pressure ulcer should be assessed, measured, and documented. The LPN stated, Yes. The LPN was asked what was the importance for the pressure ulcer to be measured. The LPN stated, To see if it was healing or the treatment needed to be changed. The LPN was asked if the resident's pressure ulcer had healed. The LPN stated, Yes, but we are still using the Zinc Oxide on it, it's pink and healed. The LPN was asked when did the pressure ulcer healed. The LPN stated, I don't know. The LPN was asked when a new area on the resident's skin is found what should you do. The LPN stated, Notify the physician, initiate treatment, and update the Body/Audit sheet. 5. Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Admission MDS with an ARD of 1/26/16 documented the resident scored 15 (14-15 indicates cognitively intact) on the BIMS, required total assistance of 2 persons for bed mobility and transfers, and 1 person for personal hygiene, was incontinent of bowel and bladder, at risk for developing pressure ulcers, and had no pressure ulcers. a. The admission orders [REDACTED] Clean L great toe (with) NS apply [MEDICATION NAME], dry drsg (dressing) qd (daily) (and) PRN. Ulcer. b. The Resident-Data Collection, (Admission) was dated 1/16/16 at 6:00 p.m. documented, Skin Condition. Using the diagrams provided indicate all body marks such as old/recent scares (surgical and other), bruises, discolorations, abrasions, pressure ulcers or questionable markings. Indicate size, depth (in-cms), color and drainage. Comments: .Diabetic Ulcer to L (left) great toe, Open area to Coccyx, open area to left groin area. Special Treatments & Procedures: See Physician order for [REDACTED]. There was no documentation of measurements or assessment of the wounds for the open area to the coccyx or left groin or the diabetic ulcer on the left great toe. c. The Braden Scale-For Predicting Pressure Sore Risk dated 1/16/16 documented, A total score of 17. A total score of 15-18 indicates mild risk. d. The Nurses Notes dated 1/16/16 at 6:00 p.m. documented, Body Audit revealed, old surgical scar to midline chest, open area to left groin and open area to coccyx, Diabetic Ulcer to left great toe, bilateral foot extremity dry. Pedal pulses present. There was no documentation of measurements or assessments of the open areas to the coccyx area, groin area, or the left inner great toe. e. The Resident Plan of Care reviewed on 1/27/16 did not document the skin condition of the open area to the coccyx, left groin, or the left great toe. f. Nurses Notes from 1/16/16 through 2/19/16 did not document concerns with the open area to the coccyx or the left groin. There was one entry dated 1/17/16 that documented, Black eschar noted to left great toe. No drainage noted at this time. There were no measurements documented. g. On 2/19/16 at 4:00 p.m., the 100 Hall Body Audit Book was reviewed and there were no Body Audits forms completed for this resident. h. The January 2016 Treatment Administration Record (TAR) documented, Clean Rt great toe (with) NS. Apply [MEDICATION NAME] (with) NS and dry drsg. Qday & prn. Dx (diagnosis): ulcer. Clean coccyx/groin area (with) NS, apply [MEDICATION NAME] qd & prn (open areas). The TAR documented the treatments, by nurses initials, were performed as ordered by the physician from 1/16/16-1/31/16. i. As of 2/19/16 there was no February 2016 Treatment Administration Records for this resident. j. On 2/19/16 at 5:05 p.m., this Surveyor had the Director of Nurses perform a body audit. The body audit revealed the area to the coccyx and left groin were healed. There was no dressing on the left great toe nail. The inner side of the great toe nail, along the edge of the toenail from the top of the nail extending along the side of the toenail to the mid area on the base of the toenail, had a thick reddish brown crusty substance. There was no black eschar noted. There was a new pressure ulcer on the mid left buttocks that measured 1 cm x 0.5 cm. The resident had noted bright red vaginal bleeding. k. On 2/19/16 at 5:25 p.m., the Director of Nurses (DON) stated that she had checked the February 2016 Treatment Administration Book and there was no TAR for this resident. The DON was asked, Were there any body audits for this resident since admission on 1/16/16? The DON stated there were no body audits completed for this resident. The DON was asked, There was no documentation of treatments for this resident in February 2016 or body audits for this resident? The DON stated, That's correct. The DON was asked if there was documentation of when the open areas to the coccyx and left groin had healed. The DON stated, No. l. On 2/22/16 at 10:12 a.m., there was no documentation in the clinical record of Physician Orders for the Stage II pressure ulcer to the resident's left buttocks. The DON was asked if there was an order obtained for the Stage II pressure ulcer to the resident's left mid buttocks. The DON checked her documentation on the body audit that was performed on 2/19/16 at 5:08 p.m. and stated, I sure missed that. I will call the doctor right now and take care of it. This resulted in a delay in notifying the physician and obtaining treatment for [REDACTED]. m. On 2/22/16 at 11:19 a.m., LPN #1 was asked about the end of the month chart reviews to ensure that all orders were transcribed to the following months Mediation Administration Record (MAR) and the TAR. The LPN stated, The Medical Record person was on maternity leave for 3 months and they didn't have anyone in that position. They put a lady in that spot and she was training, she really didn't know how to do medical records. The LPN was asked, Since the Medical Records person was out and a new person had started were the charts checked at the end of the month? The LPN stated, I don't think so. On 2/22/15 at 11:52 a.m., the DON was asked who checked the clinical records at the end of the month to ensure all orders were transcribed to the MAR and TAR. The DON stated that the Medical Records person did that. The DON was asked if there was someone in that position at the beginning of February 2016. The DON stated, Yes, (Medical Records Person). n. On 2/22/16 at 11:58 a.m., the MDS Coordinator was asked if she was also the Medical Records Person. The MDS Coordinator stated, I was covering for Medical Records, that had someone in that position but when she started on January 27, 2016 she was to putting in the Physician Orders in the computer. The MDS Coordinator was asked how she handled the end of the month for the MAR's and TAR's. The MDS Coordinator stated that she printed the orders off on Friday and left a note on the MAR's and TAR's for the Nurses to check and make any correction and then change them and put them in the computer. The MDS Coordinator was asked if they had spoken to the Nurses of what they were supposed to do. The MDS Coordinator stated, No, I just left the note on the MAR's and TAR's. The MDS Coordinator was asked if she was aware that a TAR had gotten missed. The MDS Coordinator stated, No, I was not aware of that. 6. Resident #4 had [DIAGNOSES REDACTED]. The Quarterly MDS with an ARD of 12/18/15 documented the resident scored 0 (0-7 indicates severely impaired) on the BIMS, was at risk for pressure sores, did not have any pressure sores and required pressure relieving devices for chair and bed. a. The Resident Plan of Care dated 9/16/15 documented, Pressure Ulcers . Goal Resident will not develop any new areas of skin breakdown . Approaches Report changes in skin status (i.e. (for example): s/s (signs and symptoms) infection, non healing, new areas) to physician. There was no other documentation on the care plan that addressed specific methods for prevention, assessment, and/or treatment. b. Nurses Notes dated 1/17/16 at 7:00 p.m. documented, Opened area noted to left coccyx about 0.1 x (by) 0.2 cm (Physician) notified N.O. (new order) received to apply Duoderm and change (every) 3 days until resolved . c. The Body/Skin Assessment form dated 1/17/16 documented, Opened area noted to (left) coccyx area. Tx (treatment) in progress. d. The Body/Skin Assessment form dated 1/26/16 documented, (no) new skin breakdown noted. There was no documentation that indicated the wound size or description. e. Hospice Nursing Clinical Notes written by Hospice Registered Nurse (RN) #1 dated 1/29/16 documented, .Wound #1 Location Coccyx Type Ulcer and Stage St (stage) II L (length) 1 W (width) 1 D (depth) 0.1 Wound Red . Left buttocks and coccyx area with stage (2) . f. Hospice Nursing Clinical Notes written by Hospice RN #1 dated 2/4/16 documented .Wound Location lt (left) buttocks, coccyx Type ulcer L 1 W 1 D 0.1 . On 2/11/16 at 12:18 p.m., Hospice RN #1 was asked if the pressure ulcer wound to the buttock/coccyx had been assessed and measured on 2/4/16 and the Hospice RN stated, I did do it . The Hospice RN was asked if the measurements that were documented were in centimeters and the Hospice RN stated, Yes. The Hospice RN was asked if the length was 1 cm, the width was 1 cm and the depth was 0.1 cm and the Hospice RN stated Yes. to each of these questions. g. A physician progress notes [REDACTED].Pt (patient) with sacral and left buttock wounds, staged as Stage 2 . Integumentary Wound #1 Sacral is a Stage 2 Pressure Ulcer and has received a status of Not Healed. Initial wound encounter measurements are 0.7 cm length x 0.3 cm width x 0.1 cm depth, . Wound #2 Left Buttock is a Stage 2 Pressure Ulcer and has received a status of Not Healed. Initial wound encounter measurements are 0.7 cm length x 0.4 cm width x 0.1 cm depth . A physician progress notes [REDACTED].Wound #1 Sacral is a Stage 2 Pressure Ulcer and has received a status of Not Healed. Subsequent wound encounter measurements are 0.8 cm length x 0.3 cm width x 0.1 cm depth . h. Nursing Notes dated 2/4/16 at 2:00 p.m. documented, Open area noted to inner side of Rt (right) elbow tx (treatment) order in place to clean (with) N/S (normal saline), apply protective dressing qd (every day) until resolved . The Body/Skin Assessment form dated 2/4/16 documented, New area noted to Rt inner elbow (with) tx now in place. There was no documentation that indicated the wound assessment, wound description, and wound size. i

Complaint # (AR 408) was substantiated (all or in part) with these findings. Based on observation, record review and interview, the facility failed to consistently assess, monitor and document the condition of pressure ulcers for 2 (Residents #1 and #3) of 4 (Residents #1, #2, #3 and #5) case mix residents who had pressure ulcers. The facility failed to relieve pressure to an existing pressure ulcer and failed to obtain a new treatment order when the wound did not improve for 1 (Resident #3) of 4 (Residents #1, #2, #3 and #5) case mix residents who had pressure ulcers. The facility failed to notify the physician of signs of wound infection for 1 (Resident #1) of 4 (Residents #1, #2, #3 and #5) case mix residents who had pressure ulcers. These failures resulted in immediate jeopardy which caused or could have caused serious harm, injury or death to Residents #1 who had pressure ulcers that subsequently led to the resident being hospitalized and expiring due wound [MEDICAL CONDITION] and to #3 who had a recurrent pressure sore that deteriorated from stage II to unstageable. These failures had the potential to cause more than minimal harm for 5 residents who had pressure ulcers according to a list provided by the Administrator on [DATE] at 1:32 p.m. The facility was informed of the immediate jeopardy on [DATE] at 11:00 a.m. The findings are: 1. The facility's 'Pressure Ulcer Protocol' provided by the Administrator on [DATE] documented, .Assess the resident. Wounds should be assessed upon admission and weekly thereafter. Monitor resident daily for signs/symptoms of infection (periwound, [DIAGNOSES REDACTED], induration, malodorous drainage, increase in non-viable tissue, and/or fever or increased WBC count). Pressure redistribution - Float heels from the bed surface to provide pressure relief. Standard foam elbow/heel protectors do not provide sufficient pressure reduction. 2. Resident #1 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The 5 Day Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] documented the resident was moderately impaired in cognitive skills for daily decision making per a Staff Assessment for Mental Status; was totally dependent on 1 staff for bed mobility, dressing, eating, personal hygiene, toileting and bathing; required 2 staff for transfers; had a feeding tube for nutrition; was always incontinent of bowel and bladder and was at risk for developing pressure ulcers. a. The Plan of Care dated [DATE] documented, .Problem: Resident has a need for use of a feeding tube due to dysphagia related [MEDICAL CONDITION]: Dietician to monitor adequacy of tube feeding formula and free-water flushes at least quarterly, also PRN (as needed) with any change of status .Problem: Resident is at risk for skin breakdown and/or alterations in skin integrity related to incontinence, impaired mobility and dependency on ADL care .Approach: .Report changes in skin status (i.e.: s/s infection, non-healing, new areas) to physician. b. A Physician order [REDACTED]. May be off one hour per day for ADL care. c. A Nurse's Note dated [DATE] (,[DATE] shift) and signed by LPN #3 documented, .Clean coccyx with wound cleanser, pat dry. Apply Duoderm every 3 days until resolved (shearing). d. A Nurse's Note dated [DATE] (,[DATE] shift) and signed by LPN #3 documented, Resident has a DTI (deep tissue injury).noted to coccyx area. Area is discolored, dark purple 10 x 8 x (centimeters) US (unstageable). e. A Nurse's Note dated [DATE] at 7:05 a.m. documented, Called to resident room by CNA (Certified Nursing Assistant), found resident unresponsive, clammy and cool to touch.B/P (blood pressure) ,[DATE], BS (blood sugar) 426. 7:15 a.m. resident taken to (hospital) ER (emergency room ). f. A Hospital History and Physical dated [DATE] (not timed) documented, .In ER pt (patient) was noted to be [MEDICAL CONDITION] tachypnea with leukocytosis and admitted to ICU for [REDACTED]. g. A Nurse's Note dated [DATE] at 7:50 p.m. documented, Readmit to (facility).Resident has a sacral decubitus with [MEDICATION NAME] dressing present, and left plantar with black eschar area present. There was no documented assessment for the areas. The Physician Readmission orders [REDACTED]. h. A Dietary Progress Note dated [DATE] and signed by the Registered Dietician documented, Weight ,[DATE] 170.6, ,[DATE] 167, ,[DATE] 172.6. Resident was on TF (tube feeding) of [MEDICATION NAME] 1.5 at 60 ml/hr cont. 2070 Kcal, 80 gm (gram) Pro (protein). She was hospitalized and returned on TF of [MEDICATION NAME] 1.5 at 40 ml/hr. This regimen supplies 1380 Kcal, 59 gm Pro. Estimated needs for healing of her two unstageable wounds ~ 2352 Kcal, 109 gm Pro. Current TF may not be meeting needs for wound healing. Rec (recommend) increasing TF per tolerance to goal rate of 68 ml/hr x 23 hours. If she is unable to tolerate this increase, please call me for additional recommendations. The [DATE] Weight Tracking form documented the resident's weight as 171.2 pounds. i. A Physician order [REDACTED]. On [DATE] at 9:52 a.m., the Registered Dietician (RD) was asked about her Dietary Progress Note dated [DATE] and if she remembered getting a call from the facility telling her that the resident could not tolerate a higher tube feeding rate. She stated, No. On [DATE] at 2:05 p.m., the APN was asked if she remembered why the resident's tube feeding was increased by only 5 ml/hr on [DATE] instead of following the RD recommendations from [DATE]. She stated, What may have happened is the nurse called him (physician) ,[DATE] about the RD recommendation, and he is a stickler about gradually increasing tube feeding, and then she went back to the hospital. And when a resident comes back from the hospital, we don't go back and look at the RD recommendation. We would approve what the readmit order is. That is more than likely the scenario. As of [DATE] at 1:30 p.m., there was no documentation provided to verify the facility had contacted the RD with concerns about the resident's inability to tolerate a higher tube feeding rate. j. A Nurse's Note dated [DATE] at 10:45 a.m. documented, CBC (complete blood count) results received. White blood cell 21.0. APN (Advanced Practice Nurse) for (physician) notified. Order received and noted to send patient to (hospital) ER for further evaluation related to elevated WBC (white blood count). A Hospital History and Physical dated [DATE] documented, .Present for abnormal lab with WBC of 30,000. ED (emergency department) workup indicated possible [MEDICAL CONDITION] and UTI (urinary tract infection) and is to be admitted to ICU. k. A Nurse's Note dated [DATE] at 1:30 p.m. documented, Resident readmitted . Multiple wounds noted to both lower extremities. Sacral wound also noted.4:00 p.m. Glucerna 1.5 cal infusing at 45 ml/hr. l. A Nurse's Note dated [DATE] at 2:30 p.m. and signed by LPN #3 documented, Resident readmitted to facility [DATE]. Upon readmission, resident has multiple wounds and multiple fluid filled blisters. Wound to sacral area is 13 x 13 x US (unstageable). Wound bed is necrotic, moderate brown drainage noted, wound edges are intact. Wound to right buttocks is 14 x 8 x US, wound bed is necrotic with some pink tissue noted, small amount of drainage noted. Wound to left heel 4 x 2 x US, half of wound is necrotic and half is red pink tissue noted .Wound to left plantar foot is 4 x 2 x US, wound bed is eschar, hard to touch, wound edges are dry and intact, peri wound is dark purple and fluid filled . right plantar foot has a fluid filled dark purple blister 8 x 5 x US. Right great toe is dark purple, no open areas. Right heel 3 x 1 x US . right lateral leg has an open blister 4 x 1 x 0.2 . left leg fluid filled blister closed 6 x 1.5 x US . On [DATE] at 3:46 p.m., the Treatment Nurse was asked to provide any additional wound assessments conducted on Resident #1 after the [DATE] nurse's notes and prior to the [DATE] wound clinic assessment. As of [DATE] at 1:30 p.m., the Treatment Nurse was unable to provide any additional wound assessments until the resident went to the wound clinic on [DATE]. n. A Nurse's Note dated [DATE] at 11:00 a.m. documented, Resident left the facility at 9:00 a.m. via facility van for wound clinic appointment. No signs and symptoms of distress noted at this time. Wound Clinic notes dated [DATE] at 10:17 a.m. documented, (Wound #1) Right lat (lateral)- 6 x 1XXX,[DATE].4 x 0.3 eschar; (#2) Right ankle - 1.6 x 1 x eschar; (#3) Right ant (anterior)- 0.7 x 0.3 x eschar; (#4) Right medial lower leg - 0.5 x 1; (#5) Right great toe - 7.2 x 1.5 x eschar; (#6) Right plantar - 4 x 7.4; (#7) Left lateral - 4.5 x blister; (#8) Left heel - 4.3 x 4 x eschar. Wound care orders dated [DATE] at 12:48 p.m. documented, Please keep dressing clean, dry and intact. Please change dressing's daily, zinc to periwound, santyl to wound bed ( .only to eschar), [MEDICATION NAME], secure with webril, kerlix, tape to lower ext (extremities), secure buttocks wounds with abd (abdominal) pads and tape. Please rotate patient every hour, keep heels off loaded at all times, please call with any questions are concerns. o. A Dietary Progress Note dated [DATE] and signed by the Registered Dietician documented, Weight 162. Resident down 10 pounds x 2 months. She is currently NPO (nothing by mouth) and gets TF of Glucerna 1.5 at 45 ml/hr cont (continuous) (23 hrs (hours)). This supplies ~ 1553 Kcal, 85 gm Pro. Resident's estimated needs for wound healing ~ ,[DATE] Kcal, 110 gm Pro. Due to her continued weight loss and slow healing wounds, rec try 2 Cal HN (high nutrition) at 57 ml/hr continuous. A Physician order [REDACTED]. On [DATE] at 9:52 a.m., the Registered Dietician (RD) was asked about her Dietary Progress Note dated [DATE] and if she remembered getting a call from the facility telling her that the resident could not tolerate a higher tube feeding rate. She stated, No. As of [DATE] at 1:30 p.m., there was no documentation provided to verify the facility had contacted the RD with concerns about the resident's inability to tolerate a higher tube feeding rate. p. A Nurse's Note dated [DATE] at 9:30 a.m. documented, Resident left facility at 9:30 a.m. for wound clinic appointment. No signs and symptoms of distress upon leaving the facility. Wound clinic notes dated [DATE] at 10:49 a.m. documented assessments and measurements with care provided and/or required on 15 wounds. The notes did not document any signs or symptoms of infection. q. Wound clinic notes dated [DATE] at 12:05 p.m. documented assessments and measurements with care provided and/or required for 15 resident wounds. The notes did not document any signs or symptoms of infection. r. A Nurse's Note dated [DATE] at 7:30 p.m. and signed by LPN #1 documented, Resident moaning out loud, found resident perspiring profusely, front of resident clothing, arms and chest wet, noted resident's back and lower extremities dry. Resident repositioned to right side. BS (blood sugar) 119 at this time. A Nurse's Note dated [DATE] at 6:00 p.m. and signed by LPN #1 documented, No apparent problems noted. Dressing to buttock area dry and in place. Noted odor from wounds. Skin warm and dry to touch. Totally dependent on all needs. Foley patent with yellow clear urine draining. V/S (vital signs) ,[DATE], 100, 18. There was no documentation the physician was notified of the wound odor. A Nurse's Note dated [DATE] at 9:30 a.m. and signed by LPN #1 documented, Lying quietly, skin warm and dry to touch. V/S (blank). Dressing intact to buttocks area. Foul odor from wounds noted. Foley patent with yellow urine draining with sediment. There was no documentation the physician was notified of the wound odor. On [DATE] at 2:56 p.m., Licensed Practical Nurse (LPN) #1 was asked about the Nurse's Notes she wrote on [DATE], [DATE] and [DATE] addressing the resident's status; change in condition and wound odor. When asked if she had notified the physician of the resident's change in condition, especially the wound odor. She stated, I don't think so. I don't want to tell you something I can't remember. s. The [DATE] Treatment Administration Record (TAR) documented, Clean left lower extremity with wound cleanser, apply zinc to periwound, santyl to wound bed (only to eschar), [MEDICATION NAME], Kerlix and tape every day. Clean right lower extremity with wound cleanser; apply zinc to periwound and santyl to wound bed (only to eschar), [MEDICATION NAME], kerlix and tape every day. Clean buttocks with wound cleanser, zinc to periwound, santyl to wound bed (only to eschar), cover with ABD pads and secure with tape every day. The TAR documentation indicated the resident was not provided wound care as ordered on ,[DATE] (Sunday), ,[DATE] (Saturday), ,[DATE] (Sunday), ,[DATE] (Saturday), and ,[DATE] (Sunday). On [DATE] at 3:46 p.m., LPN #3 (facility treatment nurse) was asked why there were blanks on the resident's [DATE] TAR, specifically on the weekends. She stated, Because the treatments weren't done. She was asked if she specifically remembered coming in on Mondays and Resident #1's treatments had not been done. She stated, Yes. t. A Nurse's Note dated [DATE] at 8:00 a.m. documented, Received lab report of WBC of 29.4. Notified (APN). New order given, send to ER. A Hospital ED Note dated [DATE] documented, .Wounds uncovered and assessed by MD. Unstageable wounds noted to bilat (bilateral) LE (lower extremities) and buttocks. Draining noted and foul odor present. Physical Exam: .Multiple decubiti of the lower extremities and buttocks/sacral area. Assessment/Plan: .Pt with multiple severe decubiti, she is septic and she also has UTI. A Hospital Progress Note dated [DATE] documented, Consult received, pt with multiple severe decubiti, gangrene of limbs. Has PEG (percutaneous endoscopic gastrostomy tube). Pt has massive wounds to hips and connecting to sacrum with black eschar. Some small areas open with foul drainage. Bilat LE with multiple arterial wounds and gangrenous and to heels and plantar foot. A Hospital Discharge Summary dated [DATE] documented, Discharge Diagnosis: [REDACTED]. u. On [DATE] at 10:36 a.m., the resident's daughter was asked when the resident expired. She stated her mother was discharged from the hospital on [DATE] to Hospice and died a couple of hours later on [DATE] due to wound [MEDICAL CONDITION]. 3. Resident #3 had [DIAGNOSES REDACTED]. The Quarterly MDS with an ARD of [DATE] documented the resident scored 9 (,[DATE] indicates moderately impaired) on a Brief Interview for Mental Status; required 2 staff physical assistance with bed mobility, transfers and toileting, 1 person assistance with set up for eating, bathing and dressing, had impairment in range of motion (ROM) 1 side upper and lower extremities; was always incontinent of bowel and bladder; and was at risk for developing pressure ulcers, had stage I and Stage III pressure ulcers, had 1 [MEDICAL CONDITION], and used pressure relieving devices and received application of dressings to feet. a. The Care plan dated [DATE] documented, . Problem [DATE] - (Resident #3) has wounds and is at risk for pressure ulcers r/t (related to) incontinence, immobility, late effects of [MEDICAL CONDITION], and needing total care with ADLs and transfers. Approaches: Report changes in skin status (ie: s/s infection, non-healing, to physician primary risk factors prevention treatment. Float heels when in bed. b. A wound clinic report dated [DATE] documented, There is complete [MEDICATION NAME] of the right lateral ankle ulcer. There is a small area of ecchymosis present. No maceration. Ulcer: is closed . c. The facility's Weekly Skin Report dated [DATE] documented, .right ankle, Stage II, size 2 x 2 x 0.2 cm (centimeter) . sera-sanguineous drainage . d. A physician's orders [REDACTED]. (treatment) to right ankle and start clean with wc (wound cleanser), pat dry, apply calcium alginate cover with dry dressing every other day until resolved. As of [DATE] at 2:15 p.m., the treatment regimen for the resident's right ankle had not been changed according to the treatment nurse. e. The facility's Weekly Skin Report dated [DATE] documented, .Right ankle; Stage III, size 2 x 2 x 0.2 cm with sera-sanguineous drainage . f. On [DATE] at 2:55 p.m., Resident #3 was lying in bed on his back. The resident's right ankle was resting directly on the mattress and his heel was not off-loaded. At 4:36 p.m., Resident #3 was in bed lying on his back his right ankle was resting directly on the mattress and his heel was not off-loaded. g. On [DATE] at 10:10 a.m., Resident #3 was in bed. The treatment nurse peeled back the resident's dressing to his right lateral ankle. The area was unstageable due to a small section of black eschar in the wound bed. The area measured 4 x 2.5 x UTD (unable to determined). There was moderate amount of brownish colored drainage noted, no odor. Periwound was pink. The ankle has a foam boot, but when resident's foot is on the bed, the ankle is not offloaded. The treatment nurse was asked if the area was worse this week than last. She stated, Yes. h. On [DATE] at 12:38 p.m., the Director of Nursing provided the following documentation, [DATE] - Treatment nurse brought resident to therapy room to consult with PTA/COTA (Physical Therapy Assistant/Certified Occupational Therapy Assistant) pressure relief for resident's right ankle.PTA also checked resident's room for off-loading bolster to be used when resident is in bed to float feet and consulted with hall nurse regarding proper placement of bolster . 4. The immediate jeopardy was removed on [DATE] at 1:40 p.m. and the scope and severity lowered to an H when the facility initiated the following plan of removal: a. All LPNs and RNs were in-serviced beginning on [DATE] by the Corporate Nurse and the Director of Nursing/Designee addressing completing ordered treatments, completing body audits, weekly documentation of wounds. b. All LPNs and RNs in-serviced by Corporate Nurse/Director of Nursing/Designee beginning [DATE] on notification of the resident physician on any change of condition to ensure that the physician is aware of all changes in the resident. c. All residents found to be at risk of skin breakdown, as determined by an MDS review, were assessed beginning [DATE] and completed on [DATE]. Assessments were completed by the Charge Nurses after being in-serviced by the Corporate Nurse and the Director of Nursing on [DATE]. All skin areas were properly documented on a body audit form. These forms were reviewed by the Director of Nursing/Designee to ensure that all concerns were addressed, properly documented, and that the physician was notified to ensure that orders for treatment were in place. d. The Treatment Nurse was individually in-serviced on [DATE] by the Corporate Nurse and the Director of Nursing/designee to ensure that she is following the Treatment Plan for those residents with pressure ulcers, that weekly documentation is to be completed, that the physician is notified of any change of condition or and lack of response by a wound to the current treatment. The treatment nurse will complete a weekly skin report of all pressure ulcers. A copy of this weekly report will be provided to the Administrator and Director of Nursing for follow-up. e. Director of Nursing/RN designee will observe all pressure ulcers at least one time weekly to ensure that the documentation is accurate and that the current treatment is effective, or if there is a need for a change in treatment. f. A specific Nurse has been assigned to the weekend Treatment Nurse position. The nurse will be in-serviced prior to [DATE] to ensure that he/she is aware of the requirement of accurate documentation, following the current plan of treatment, preventative nursing interventions, and notification of the physician of any change of condition. g. All CNAs in-serviced [DATE] by the ADON/Designee on preventative measures to avoid skin breakdown, offloading of pressure points to reduce risk of breakdown. h. DON/Designee will monitor residents requiring offloading twice daily for 2 weeks to ensure that proper offloading is being done beginning [DATE]. i. DON/CDM/Designee in-serviced by the corporate nurse on [DATE] regarding completing RD dietary recommendations within 48 hours of receiving the recommendation. The CDM will address all issues not requiring a physician's orders [REDACTED]. A copy of the completed dietary recommendation form will be provided to the Administrator and Corporate Nurse within 48 hours of receiving. j. All in-services will be continued until all off duty employees have been in-serviced prior to returning to the floor to provide resident care.

A. Based on observation, interview and record review, the facility failed to ensure that Resident #2 received adequate supervision and devices to minimize the potential for injury from side rails. The facility failed to ensure alternatives to side rails were attempted prior to the implementation to side rails, to ensure residents were re-assessed for the risk of injury for climbing over side rails, and failed to plan and implement interventions to minimize the risk of injury from climbing over side rails for 1 (Residents #2) of 2 (Residents #1, #2) case mix residents who were assessed to climb over the side rails and had either four half side rails fully elevated or full side rails on the bed. The failed practices resulted in Immediate Jeopardy which caused or could have caused serious harm, injury, or death to Resident #2, who had multiple documented falls from climbing over the bed rails and had the potential to cause more than minimal harm for 9 residents who had full side rails in use according to a list provided by the Director of Nursing on 1/26/15. The facility was informed of the Immediate Jeopardy on 1/25/15 at 6:50 p.m. The findings are: 1. The facility's policy and procedure titled 'Proper Use of Side Rails' provided by the DON on 1/26/15 at 11:25 a.m. documented, "Purpose: To ensure the safe use of side rails as resident mobility aids and to prohibit the use of side rails as restraints unless necessary to treat a resident's medical symptoms. Procedure: 1. Side rails are considered a restraint when they are used to limit the resident's freedom of movement (prevent resident from leaving his/her bed). ...4. An assessment will be made to determine the resident's symptoms or reasons for using side rails. When used for mobility or transfer, an assessment will include a review of the resident's: a. Bed Mobility and b. (Resident's) Ability to transfer between positions, to and from bed or chair and to stand and toilet. ...8. Documentation will indicate if less restrictive approaches are not successful and orders to apply and monitor the use of side rails for a specific time frame will be obtained. 9. The use of side rail will be evaluated in terms of risks and benefits for each individual resident. ...11. The resident will be checked frequently for safety. ...15. Designated facility staff will use judgment in assessing the resident's risk for injury due to neurological disorders ...16. For residents who have been restrained by side rails, the process to reduce the use of side rails as restraints will be systematic and gradual (e.g. lessening the time the bed rail is used while increasing visual and verbal reminders to use the call light, using 1/2 rails, etc.). " 2. Resident #2 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/16/14 documented the resident was moderately impaired in cognitive skills for daily decision making per a Staff Assessment of Mental Status (SAMS); was totally dependent on 2 staff for transfers, dressing, eating, toilet use, hygiene and bathing; rarely understood others; and had functional limitation in range of motion in one lower extremity. a. The Side Rail Evaluation Form dated 6/10/14 documented, "... 4. Is the resident able to get in/out of bed? Yes. 5. Is the resident able to get out of bed safely? No. 6. Does the resident have a history of falls? Yes. 7. Is the resident having problems with balance or poor trunk control? (If yes, explain). Yes: Weakness. 8. Does the resident use the side rails for positioning or support? No. 9. Does the side rail help the resident rise from a supine position to a sitting/standing position? No. ...11. Is there a possibility the resident will climb over the side rails? Yes. 12. Is there evidence (reason to believe) the resident has (or may have) a desire or reason to get out of bed. (If yes, explain). Yes: Confusion. ... 14. Is there a risk to the resident if side rails are used? (If yes, explain). No. 15. Do the side rail alternatives/interventions create more risks than side rail use? (If yes, explain). No ..." The back of the Side Rail Evaluation form dated 6/12/14 documented a list of interventions. None of the interventions were marked. The Summary of Findings documented, "R (Resident) will have all 4 side rails for ((a restraint) was marked through) an enabler to decrease falls..." b. A Fall Risk Evaluation dated 6/12/14 documented a total score of 20. The legend on the form documented, "Total score of 10 or above represents HIGH RISK (sic)." Fall risk assessments were documented on 6/30/14, 7/17/14, and 9/4/14, with a total score of 20 documented on each assessment. There was no Fall Risk Assessment documented in the clinical record after 9/4/14. c. The Side Rail Evaluation Form dated 6/16/14 documented the following, "... 4. Is the resident able to get in/out of bed? Yes. 5. Is the resident able to get out of bed safely? No. 6. Does the resident have a history of falls? Yes. 7. Is the resident having problems with balance or poor trunk control? (If yes, explain). Yes: Weakness. 8. Does the resident use the side rails for positioning or support? No. 9. Does the side rail help the resident rise from a supine position to a sitting/standing position? No. ... 11. Is there a possibility the resident will climb over the side rails? Yes. 12. Is there evidence (reason to believe) the resident has (or may have) a desire or reason to get out of bed. (If yes, explain). Yes: Confusion. ... 14. Is there a risk to the resident if side rails are used? (If yes, explain). No. 15. Do the side rail alternatives/interventions create more risks than side rail use? (If yes, explain). No." d. Nurse's Note dated 9/4/14 at 5:30 p.m. documented, "R (Resident) was found (at) approximately 5:15 p.m. on the floor mat beside his bed in an upright position. His arms (and) hands were still holding on to the side rails. His bed was in the lowest position (and) side rails were up. His daughter was the first one to witness him on the floor. She called for someone to come in the room. ... When I got into the room he was still in an upright position holding on to the side rails on his knees. He stated that he was trying to go to football practice. ... No bruises or marks on his body anywhere. He denies any pain. ... Will continue to monitor, call light within reach." The Post Fall & Incident/Accident Follow Up form documented, "Date of incident: 9/4/14. Date of Investigation: 9/8/14. Multiple Falls: Has the resident fallen before? Yes. ... Summary of event: R (Resident) was found by his daughter sitting on his floor mat holding onto the bed. R stated he was going to 'suit up for football practice'. No injuries noted. Interdisciplinary Team Follow Up and Interventions: All safety precautions in place (floor mat, safety side rails) ...Frequent rounds on this R due to (increased) # (number) of falls." e. Nurse's Note dated 9/12/14 (no time given) documented, "Resident was observed alongside bed on the floor mat (with) bed in lowest position. (No) abnormalities noted. (No) c/o (complaints of) pain or discomfort ...Will continue to monitor and note any change of condition." The Incident/Accident Report dated 9/12/14 at 11:15 a.m. documented, "... Were bed rails present? yes. If Yes: (position) Up..." The Post Fall Incident/Accident Follow Up dated 9/12/14 documented, " ... Summary of the Event: R was found on his floor mat sitting on his bottom. Bed in lowest position (with) padded side rails intact. (No) pain or injuries noted. Interdisciplinary Team Follow Up and Interventions: All safety/fall precautions in place. Padded SR (side rails) up and in proper place. Non-slip socks to be worn at all times. Incontinent care at least q (every) 2 hrs (hours) and PRN (as needed)." f. Nurse's Note dated 9/12/14 at 7:00 p.m. documented, "R has tried to get up out of bed again, told R to stay in bed, R states that he needs to go talk to the Government about his job. ..Will continue to monitor." g. Nurse's Note dated 9/13/14 at 6:00 a.m. documented, "R in bed. SR (up) x 2 (padded) (with) fall mat on both sides of bed. R is alert (with) confusion per usual LOC (Level of Consciousness)..." h. The Side Rail Evaluation Form dated 9/15/2014 documented the following, "... 4. Is the resident able to get in/out of bed? Yes. 5. Is the resident able to get out of bed safely? No. 6. Does the resident have a history of falls? Yes. 7. Is the resident having problems with balance or poor trunk control? (If yes, explain). Yes: Weakness. 8. Does the resident use the side rails for positioning or support? No. 9. Does the side rail help the resident rise from a supine position to a sitting/standing position? No. ... 11. Is there a possibility the resident will climb over the side rails? Yes. 12. Is there evidence (reason to believe) the resident has (or may have) a desire or reason to get out of bed. (If yes, explain). Yes: Confusion. ... 14. Is there a risk to the resident if side rails are used? (If yes, explain). No. 15. Do the side rail alternatives/interventions create more risks than side rail use? (If yes, explain). No." There were no alternatives to side rails documented, and no interventions documented to minimize the risk of injury to the resident from climbing over the side rails. There was no Side Rail Evaluation documentation in the resident's clinical record after 9/15/14. i. Nurse's Note dated 10/6/14 at 4:00 p.m. documented, "R constantly tries to get (up) out of bed. R roommate notified staff when R tries to get (up) by turning on the call light ...Will continue to monitor." There was no documentation of any alternatives to the side rails, and no interventions documented to minimize the risk of injury to the resident from climbing over the side rails. j. The Plan of Care updated on 12/16/14 documented, "... Problem: ADL (Activities of Daily Living). Resident will need care of his ADL care needs ...Approaches: ...Side rail(s) as an enabler 1/4 rails for mobility. ..Provide adaptive/safety equipment ...Padded Side Rail(s) r/t (related to) seizure precautions. ... Problem: Resident is at risk for falls r/t dementia, use of psychotropic (medications), use of LAL (Low Air Loss) Mattress ...Approaches: Use fall risk screen to identify risk factors ...Padded side rails r/t low air loss mattress not being winged ...Resident unable to transfer alone." There was no documentation in the plan of care that the resident had climbed over the side rails twice before, and no interventions documented to minimize the potential for injury related to climbing over the side rails. k. Nurse's Note dated 1/24/15 at 5:05 p.m. documented, "Resident was found on the floor in R's (Resident's) room (with) R (Right) inner elbow between bed rail. R was verbally combative ...Didn't want staff to get him up off floor. Head to (toe) assessment. Found skin tear to R (right) inner area of forearm (with) bleeding noted. Area cleansed (and) dried. Sterile drsg (dressing) applied. ... Report given to on coming nurses. Will con't (continue) to monitor." The resident climbed out of bed and caught the right arm in the side rail sustaining a skin tear. There were no interventions documented and/ or implemented at that time to minimize the risk of injury from climbing over the side rails. 1) On 1/25/14 at 7:18 p.m., LPN #6 was asked, "Do you take care of (Resident #2)?" LPN #6 stated, "Yes." LPN #6 was asked, "Does he ever try to get out of bed?" LPN #6 stated, "Yes. I was working last night. The day shift nurse asked me to assist him back in bed." LPN #6 was asked, "Was he caught in the side rail?" LPN #6 stated, "Yes. His right arm was bleeding and (he) had a skin tear. He was on his bottom." The LPN was asked to show where the resident was on a rough drawing of the resident's bed. The LPN indicated that the resident was on the floor on the side of the bed away from the door at the center of the bed, with the right arm caught under the side rail at the head of the bed. LPN #6 was asked, "What did you do?" LPN #6 stated, "Put him back to bed and notified his nurse." LPN#6 was asked, "Did you put his side rails up?" LPN#6 stated, "They were already up." 2) On 1/25/14 at 7:40 p.m., the DON provided a copy of an untimed Incident/Accident Report dated 1/24/15 that documented, "... Were bed rails ordered? Blank. Were bed rails present? Yes. If Yes: (position) Up. Was height of bed adjustable? Yes. If Yes: Blank. ... Describe exactly what happened; why it happened; what the causes were. If an injury, state part of body injured ...Resident was found on floor @ BS (bedside) by staff (with) R (right) arm caught between bed rail." There were no documented interventions to prevent injury from climbing over the bedrails. The DON was asked, "Do you see any interventions to prevent injury from climbing over the bedrails?" The DON stated, "I don't see any." l. On 1/25/15 at 1:55 p.m., the resident was in the bed with four half side rails elevated with full length side rail pads stretched between the two side rails on each side of the bed. The resident asked if the surveyor could get him out of the bed and help him to his closet to get a phone number to call a tow truck and get him out of here. Licensed Practical Nurse (LPN) #5 stated the resident had fallen on 1/24/15. m. On 1/25/15 at 5:20 p.m., the resident was in the bed with four half side rails elevated with full side rail pads stretched between the two half side rails on each side of the bed. The resident had a dressing to the right arm, and multiple bruises to the right arm and to both hands. The resident was confused and yelled out repeatedly, "What's your name". There were no staff with the resident. The head of the resident's bed was elevated approximately 45 degrees and the full length side rail pad was buckled on each side where the bed was angled, exposing the side rail. The bed was at a regular height. The resident was slumped down in the bed and leaning against the right side rail. At 5:31 p.m., Certified Nursing Assistant (CNA) #4 went into the resident's room, straightened the resident in the bed, and then left the room. n. On 1/25/15 at 6:05 p.m., the Director of Nursing (DON) was asked, "Where is the consent for the side rails?" The DON stated, "We don't need consent. They are an enabler." The surveyor read the Side Rail Evaluation form to the DON and asked, "The resident doesn't use it for positioning or support, and doesn't use them to help rise from a supine position, so how can they be an enabler?" The DON stated, "They help prevent falls." The surveyor showed the DON the Nurse's Note from 1/24/15 and asked, "The resident fell after crawling over the rails last night. His right arm was caught under the rail and the resident had a skin tear. The side rail assessment documented the resident was assessed to climb over the rails, and there was evidence to believe he would try to get out of bed because of confusion. Are the 4 side rails appropriate?" The DON stated, "No. I was told they are not a restraint but an enabler." The DON was asked, "When the resident crawled over the rails last night, they put him back to bed and kept the 4 side rails up. The rails have been observed to be elevated since we entered the building (1:50 p.m. on 1/25/15) keeping the resident at risk of serious injury. Was there anything done to prevent the resident from being injured?" The DON stated, "I don't know." o. Staff interviews were conducted regarding Resident #2 ' s attempts to get out of bed: 1) On 1/25/14 at 7:15 p.m., CNA #5 was asked, "Do you ever take care of (Resident #2)?" CNA #5 stated, "Yes." CNA #5 was asked, "Does he try to get out of bed sometimes?" CNA #5 stated, "Yes." CNA #5 was asked, "What do you do about it?" CNA #5 stated, "Assist him back to bed and make sure the side rails are up." 2) On 1/25/14 at 7:25 p.m., CNA #7 was asked, "Do you take care of (Resident #2)?" CNA #7 stated, "Yes." CNA #7 was asked, "Does he try to get out of bed?" CNA #7 stated, "Yes." CNA #7 was asked, "What do you do?" CNA #7 stated, "We talk with him, and keep the side rails up." CNA #7 was asked, "Does he try to climb over the rails?" CNA#7 stated, "Yes, all the time." 3) On 1/26/15 at 11:30 a.m., the resident was in the bed with safety rails on the top half of the bed only. LPN #2 and CNA #8 provided care for the resident. The resident's left upper arm had multiple dark bruises. LPN #2 was asked, "What are those from?" LPN #2 stated, "From thrashing around in bed." At 11:38 a.m., CNA #8 was asked, "Does the resident try to climb over the side rails?" CNA #8 stated, "Yes, all the time." The resident's roommate, Non-Case Mix Resident #1 was asked "Does he (Resident #2) ever try to climb over the side rails?" Non-Case Mix Resident #1 stated, "Yes. All the time." CNA #8 stated, "He (Non-Case Mix Resident #1) is always calling us to let us know that he's (Resident #2) climbing out." p. On 1/26/15 at 8:20 a.m., the DON was asked, "Were you ever able to find where any interventions were put in place to minimize the risk of injury from climbing over the side rails?" The DON stated, "No." q. On 1/26/15 at 8:50 a.m., the DON provided a Post Fall & Incident/Accident Follow Up form dated 1/25/14 that documented, "Description of Incident: Resident climbed out of bed - 4 side rails where (sic) up. Received skin tear to right forearm ...Interdisciplinary Team Follow Up and Interventions: Upon notification by survey team that resident had four side rails up on his bed; the two bottom rails were removed. In-service began 1/25/15 to all staff that no resident has four side rails or full side rails prior to an (sic) side rail assessment is done and the DON or Administrator is notified." r. The Immediate Jeopardy was removed on 1/26/15 at 10:00 a.m. and the scope/severity reduced to " E ", when the facility initiated the following Plan of Removal: 1) On 01/25/15, immediately upon notification, Administrator and maintenance man removed the lower 2 side rails from effected resident's bed. 2) On 01/25/15, Administrator designee assessed all residents and identified 8 other residents with the potential to be affected by practice, and the maintenance man immediately removed the lower side rails or changed out bed for another without lower rails or full rails. 3) On 01/25/15, DON immediately initiated an in-service for all staff prior to working on the floor to ensure no resident is placed in a bed with 4 rails or full rails and that no rails to be applied to a bed without DON authorization as 4 rails could cause entrapment and potentially death. 4) Administrator designee will audit all resident rooms daily x 5 then 3 times weekly x 4 weeks, then monthly until compliance is achieved to ensure no resident is placed in a bed with 4 rails or full rails. Any negative findings will be corrected immediately. Administrator will report findings to QAPI (Quality Assurance and Performance Improvement) committee monthly for further recommendations and necessary corrective action." B. Based on observation, record review, and interview, the facility failed to ensure staff provided needed support when transferring non-weight bearing residents from one surface to another in order to minimize discomfort and prevent potential injury for 1 (Resident # 14) of 10 (Residents #1, #2 and #5 through #13) case mix residents who were non weight bearing during transfers. This failed practice had the potential to cause more than minimal harm to 37 residents who were non weight bearing during transfers according to a list provided by the Director of Nursing (DON) on 1/28/15. The findings are: Resident #14 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/8/14 documented the resident was moderately impaired in cognitive skills for daily decision making per a Staff Assessment of Mental Status (SAMS); required extensive assistance of 1 person (s) with transfers; and had one fall with no injury since the prior assessment. a. The Plan of Care updated on 12/8/14 documented, "Problem: ADL (Activities of Daily Living): Resident has ADL Self-Care deficit. Transfer: Extensive assist one person ...Approaches: Report changes in ADL self-performance to nurse ...NSG (Nursing) staff to provide all ADL care to ensure daily needs are met..." b. The Guidelines for Daily Care plan from the closet in the resident's room documented, "Transfer/Locomotion: Propels Self. Wheelchair" There was no documentation on the plan on how much assistance the resident required for surface to surface transfers. c. On 1/26/15 at 2:25 p.m., the resident was in a wheelchair in the room by his bed. CNA #1 and CNA #2 stated, "We're going to transfer him back to bed." CNA #2 left the room and returned with a gait belt. The gait belt was placed around the resident's upper abdomen. The CNAs held to the back of the gait belt and lifted up. The resident's feet were crossed and tilted to the side, with the sides of the feet against the floor. No weight was borne by the resident. CNA #1 and #2 held to the back of the resident's pants loop and pulled the resident's bottom up to prevent the resident from going down to the floor. The pants wedged up into the buttocks and perineal area, with the weight borne by the gait belt around the upper abdomen and the buttock/perineal area. The CNAs were asked, "Did he put any weight on his legs at all?" Both CNAs stated, "No, not at all." d. On 1/28/15 at 8:50 a.m., CNA #1 was asked, "When you transferred the resident to the bed, you used a gait belt. He didn't put weight on his feet and you held to the back of his pants to keep him from going down. How are you supposed to transfer residents who cannot bear weight?" CNA #1 stated, "With a mechanical lift." e. The facility's policy titled 'Transfer Activities (2 Person Assist)' provided by the DON on 1/29/15 documented, "... Procedure: ... 3. Any resident unable to bear their weight on their feet/legs will be transferred using a mechanical lift. . ."

Complaint # (AR 844) was substantiated (all or in part) in this finding. Based on observation, record review and interview, the facility failed to ensure enteral feedings met the nutritional needs of 2 (Resident #1and #5) of 3 (Resident #1, #5 and #12) case mix residents who received tube feedings. The facility failed to ensure that interventions (health shakes, fortified foods, and feeding assistance) to address a significant weight loss were consistently implemented for 1 (Resident #2) of 3 (Residents #2, #5 and #7) case mix residents who had a significant weight loss. The facility failed to ensure staff provided needed assistance with meals in order to ensure adequate nutritional intake to prevent continued weight loss was provided for 1 (Resident #7) of 3 (Residents #2, #5 and #7) case mix residents who had a significant weight loss. The failed practices resulted in a pattern of actual harm to Resident #5, who lost 22.6 (11.69%) pounds in 4 weeks between December 2014 and January 2015 and to Resident #2, who lost 12.5 pounds (8.9%) in 1 month between December 2014 and January 2015. The failed practices also had the potential to cause more than minimal harm to 8 residents in the facility who received enteral feedings and 6 residents who had a significant weight loss according to the lists provided by the Administrator on 1/29/15. The findings are: 1. Resident #5 had [DIAGNOSES REDACTED]. The Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/25/14 documented the resident was severely impaired in cognitive skills for daily decision making per a Staff Assessment of Mental Status (SAMS); was totally dependent on staff for eating; received more than 51% of calories per tube feeding and more than 501 cc (cubic centimeters) of fluid per tube feeding; and had a significant weight loss. a. The Physician's Admission Order dated 11/24/14 documented, "Diet Order: NPO (nothing by mouth): [MEDICATION NAME] 1.5 @ (at) 45 ml/ hr (milliliters per hour)." b. The Nutritional Progress Notes dated 11/26/14 documented, " ... Receiving NPO (with) TF (tube feeding) [MEDICATION NAME] 1.5 @ (at) 45 ml (milliliters)/hr (hour) x 23 (hours) ...Estimated needs (approximately) 2023-2427 kcal (kilocalories) ...TF + (and) Prostat provide (approximately) 1681 kcal ...Rec (recommend) (increase) TF per tolerance to 63 ml x 23 hrs..." The prescribed tube feeding nourishment provided approximately 342 to 746 calories less than the resident's body needed. c. The Nutritional Progress Notes dated 12/22/14 documented, "Weight 180.6 - This is (down) 22 # (pounds) (11%) x 1 mo (month). Res (resident) was re-weighed today. Res was on a Puree Diet (with) HTL (honey thick liquids), was hospitalized (with) [MEDICAL CONDITION] +(and) is now NPO (Nothing by Mouth). He gets TF of [MEDICATION NAME] 1.5 @ 45 ml/hr x 23 hrs ...This regimen supplies (approximately) 1553 kcal. ... Estimated needs (approximately) 2052-2463 kcal... Rec (recommend) (increase) TF gradually per tolerance to 62 ml/hr continuous..." The prescribed feeding of 45 ml/hr of [MEDICATION NAME] 1.5 provided approximately 499 to 910 calories less (daily) than the resident's body needed. d. The Medication Administration Record [REDACTED]@ (at) 45 ml (milliliters)/hr (hour) continuous in auto pump." e. The weight list provided by the Director of Nursing on 1/26/14 documented the following weights: December 2014: 188.00 (pounds) January 2015: 193.2 (pounds). The weekly weights provided by the Director of Nursing (DON) on 1/27/15 documented the following weights; January 2015: Week 1: 181.0 lbs (pounds) Week 2: 183.4 lbs Week 3: 179.4 lbs Week 4: 170.6 lbs From the weight list January 2015 weight of 193.2 to the Week 4 weight in January 2015, the resident lost 22.6 pounds (11.69 %). The Resident lost 12.7 pounds (6.97%) in the 2 weeks between week 2 and week 4 of January 2015. This represents a significant weight loss. f. On 1/25/15 at 2:28 p.m., and 5:17 p.m., the resident's feeding pump was infusing [MEDICATION NAME] 1.5 at 45 ml per hour. g. On 1/26/15 at 8:05 a.m., 11:29 a.m., 12:50 p.m., the resident's feeding pump was infusing [MEDICATION NAME] 1.5 at 45 ml per hour. h. On 1/27/15 at 9:30 a.m., Advanced Practice Nurse (APN) #1 was asked, "Is there a reason (Resident #5)'s tube feeding has not been increased per the registered dietician's recommendation?" APN #1 stated, "No. I was not aware of that recommendation." On 1/27/15 at 1:45 p.m., the DON was asked, "How are recommendations made by the registered dietician communicated and acted on?" The DON stated, "I had an LPN (Licensed Practical Nurse) who was responsible for the weights and weight loss." The DON was asked, "Is there any reason (Resident #5) tube feeding was not increased per the registered dietician's recommendations?" The DON stated, "I don't know." i. On 1/27/15 at 2:00 p.m., the Registered Dietician (RD) #1 was asked, "Did you leave recommendations when you visited on 12/19/14?" RD #1 stated, "Yes." RD #1 was asked, "Do you remember who you gave them to?" RD #1 stated, "The Director of Nursing". j. On 1/27/15 at 2:15 p.m., LPN #1 was asked, "Are you involved in weight loss monitoring?" LPN #1 stated, "I've been working with Dietary and Restorative. We've been having weekly weight meetings." LPN #1 was asked, "When the registered dietician makes a recommendation on a progress note, what happens?" LPN#1 stated, "When they make a recommendation, we make a list. I make myself a 'to do' list then send orders to the MD (physician)." LPN #1 was asked, "Are there any notes from the meeting?" LPN #1 stated, "I have notes in my office." LPN #1 was asked, "How does information get spread to the persons responsible when a recommendation is made by the registered dietician?" LPN #1 stated, "I have a list the RD leaves me. I go down the list and check off when I send out an order or referral." A copy of the list was requested. At 3:20 p.m., LPN #1 provided a redacted copy of a Dietary Quality Assurance report dated 12/19/14 that documented, "... Current Diet Order: [MEDICATION NAME] 1.5 45/hr x 23. ... Rec (recommended) Change: (Increase) TF (Tube Feeding). ...Response: Blank." The report documented a recommendation for an increase in the tube feeding. There was no documented response or documented reason the tube feeding was not increased. k. On 1/28/15 at 9:50 a.m., the DON was asked, "Was the physician notified of the RD recommendations (November and again in December) to increase the tube feeding on Resident #5?" The DON stated, "No." 2. Resident #2 had [DIAGNOSES REDACTED]. The Quarterly MDS with an ARD of 12/16/14 documented the resident was moderately impaired in cognitive skills for daily decision making per a Staff Assessment of Mental Status (SAMS); was totally dependent on staff for eating; and had a significant weight loss. a. The Physician's Admitting History and Physical dated 10/31/14 documented, "... Assessment & Plan: ... 2. Poor Appetite - [MEDICATION NAME], Health shakes tid (three times a day) with meals, snacks between meals. ... 13. Dysphagia - Mechanical Soft diet with extra portions, and nectar thickened liquids." b. The December 2014 physician's orders [REDACTED]. Supplement: 12/19/2013: Prostat 2100 (9:00 p.m.). Magic Cup at 2100. 7/31/2014: Snacks Between Meals. 12/19/2013. Weekly Weight..." There was no signed physician's orders [REDACTED]. c. The Plan of Care updated on 12/16/14 documented on the front page that the resident weighed 137.8 pounds in December 2014 and was 73 inches (6 feet 1 inches) tall. The third page of the Plan of Care documented, "ADL (Activities of Daily Living): Resident will need care of his ADL care needs... Brought to restorative DR (dining room) for all his meals. Set up tray and liquids for resident and cue to keep on task. Feed on days resident unable to feed self... Problem: Behavior: Resident with resistance with eating at meals at times and ADL care. Approaches: ... Anticipate care needs and provide them before the resident becomes overly stressed. ... Problem: Resident at risk for weight loss r/t (related to) end stage [MEDICAL CONDITION], Terminal Illness, Dementia. Leaves 25% or more of food uneaten at most meals. Approaches: Weigh and monitor results. Monitor and report to the physician: Signs/symptoms of malnutrition, Significant weight loss, Chewing/swallowing problems. Administer nutritional support as ordered (see current physician orders/MAR (Medication Administration Record). Provide Diet as ordered (see current physician orders). ... Health Shakes with meals. Extra Portions on all trays." d. The Dietary Progress Notes signed by the Registered Dietician dated 12/22/14 documented, "Weight 137.8 # (pounds) ... Res (resident) is now on Hospice care ...He gets a mech (mechanical) soft diet (with) NAS, [MEDICATION NAME], Promod, Zinc Sulfate, Fer Sulf ([MEDICATION NAME]), Juven, Prostat. ... Res states he wants more shakes. ... Consider more shakes (per request)." e. The Monthly Weights documented by Restorative Nursing Assistant (RNA) #1 on 1/5/15 documented the resident weighed 125.4 pounds. This represents a 12.4 pound (8.9%) weight loss in one month. This is a significant weight loss. There were no weekly weights documented by the RNA for January 2015. There was no documentation in the nurse's notes the physician was notified of the resident's significant weight loss identified by the facility on 1/5/15. On 1/27/15 at 1:45 p.m., the DON was asked, "Was he (the physician) notified of the significant weight loss (for Resident #5) before now?" The DON stated, "I don't know." LPN #1 was asked, "Did you notify the MD of the weight loss on Resident #5?" LPN #1 stated, "I did not. My last documentation showed a gain for him." LPN #1 was asked, "Do you have the weekly weight notes?" LPN #1 stated, "No. We have the list of recommendations by the RD on her last visit." A Telephone Order signed by the Nurse Consultant (Registered Nurse (RN) #1 documented, " 1/23/15: D/C (Discontinue) snack between meals. D/C extra portions. Add fortified foods." f. On 1/25/15 at 5:20 p.m., the resident was served a tuna salad sandwich, 1/2 cup macaroni salad, 1 scoop fortified potatoes, 1/2 cup very small canned pear, less than 1/2 bowl of vegetable soup with crackers, 4 ounces of nectar thick water, 8 ounces of nectar thick milk. His tray was placed on the over bed table in his room. There was no health shake served to the resident. The resident was lying in the bed with four half side rails elevated. The head of the bed was elevated 45 degrees. The resident was confused and had his fingers in the soup bowl yelling, "What's your name." The resident was not feeding himself, and no staff members were in the room to give the resident assistance. At 5:30 p.m., the resident was in the bed with the meal tray on the over bed table, and his fingers in the soup. The resident was not feeding himself, and no assistance was given to the resident to eat. At 5:31 p.m., the resident was in the bed slumped against the side rail. The meal tray was on his over bed table with the nectar thick milk spilled over the bottom of the meal tray. The resident was not feeding himself. Certified Nursing Assistant (CNA) #4 entered the resident's room and straightened the resident in the bed. CNA #4 stated, "She just brought this tray in and left it?" CNA #4 was asked, "Who is 'she'?" CNA #4 stated, "I don't know who. Whoever brought the resident's tray in." CNA #4 then put the meal tray on the over bed table in front of the resident. The head of the resident's bed was at 45 degrees. The resident was restless. CNA #4 then left the resident's room and began to pass meal trays to other residents. No assistance was given to the resident, and the resident was not feeding himself. At 5:45 p.m., 5:50 p.m., and 5:55 p.m., the resident was observed in the room with the tray on the over bed table, the milk spilled over the bottom of the tray. The resident was not feeding himself, and no assistance was given to the resident to eat. g. On 1/25/15 at 6:05 p.m., the Director of Nursing (DON) was asked, "Is the resident able to feed himself?" The DON stated, "No." The DON was informed that the resident was observed since 5:20 p.m. with no assistance given to eat. At 6:07 p.m., the DON sent CNA #5 into the resident's room to assist the resident to eat. The resident was not provided any replacement for the nectar thick milk that was spilled on the bottom of the tray. h. On 1/26/15 at 12:15 p.m., the resident was in a Geri-chair in the restorative dining room. The resident was served spaghetti, garlic bread, salad dressing, pineapple chunks, two 4 ounce containers of nectar thick water, and one 8 ounce glass of nectar thick punch. There was no fortified food on the tray, and the resident was not served a health shake. The resident was trying to feed himself, but fumbled with the utensils. At 12:25 p.m., CNA #1 came up to the resident and began to assist the resident by feeding him the food from the tray. CNA #1 was asked, "What is the fortified food for today?" CNA #1 stated, "I don't know." i. The resident's meal card for the lunch meal on 1/26/15 documented, "Meal Note: Nectar water, nectar juice, fortified food. Special Notes: Red napkin, fortified food. ..." On 1/26/15 at 12:35 p.m., the resident was assisted to eat by Licensed Practical Nurse (LPN) #2 in the restorative dining room. LPN #2 was asked, "Do you see any fortified food on his plate?" LPN #2 stated, "No." LPN #2 was asked, "Was the resident served a health shake?" LPN #2 stated, "No." At 12:55 p.m., LPN #2 stated, "I went and got him some fortified potatoes." The resident was not served any health shake. 3. Resident #1 had [DIAGNOSES REDACTED]. The Quarterly MDS with an ARD of 12/24/14 documented the resident was moderately impaired in cognitive skills for daily decision making per a Staff Assessment of Mental Status (SAMS); was totally dependent on two staff members for all activities of daily living; and received greater than 50% of daily nutrition and 501cc/day or more of fluids through gastrostomy. a. The plan of care updated 12/23/2014 documented, " ...Problem: ...Feeding tube related to: Dysphasia ...Approaches: tube feeding formula and flushes as ordered, NPO peg tube continuously per orders, provide/monitor intake of tube feeds..." b. The January 2015 Physician order [REDACTED].@ 45 ML/HR every shift. Monitor resident every shift for tolerance of enteral feedings." c. Dietary progress notes dated 11/26/14 documented, " ...Staff report that the resident's family wants resident to try pureed food. Recommend refer to ST (speech therapy) to eval (evaluate) for possible oral feedings." The note was signed by the Registered Dietician. Dietary progress notes dated 12/19/14 documented " ...wt 188#, LPN reports that tube feeding was decreased from 60 (ml/hr) back down to 45 ml/hr due to intolerance... old rate provided 2070 Kcal (calories per kilogram), 88 gm (gram) protein.... current rate provides approximately 1553 Kcal, 66 gm protein...estimated needs approximately 2136 Kcal, 85 gm protein. Weight loss may be expected with decreased tube feed rate.... Recommend consider increasing tube feed rate gradually to original rate per tolerance. Consider ST eval at family request." The note was signed by the Registered Dietician. d. The weight record provided by the facility documented the following weights for the resident: October 2014 - 195 pounds (lbs) November 2014 - 190 lbs December 2014 - 188 lbs January 2015 - 184 lbs e. On 1/27/15 at 1:05p.m., Registered Nurse #1 stated the procedure for follow up on dietary recommendations was, "Nurse contacts the doctor to notify of recommendation see if he agrees with the order. The recommendation would only not be followed if the doctor did not agree to it. The risk of too few calories daily include organ failure, weight loss, and confusion." On 1/27/15 at 1:30 p.m., the Director of Nursing stated the procedure for follow up on dietary recommendations was, "Whoever is in charge of follow thru is to call the doctor and get the order and notify Dietary Department. The only reason to not follow the recommendation would be if the Doctor said it was contraindicated. The risk of receiving less calories than daily need include weight loss and wounds." f. On 1/28/15 at 10:35a.m., when asked why the physician had not been notified of the dietary recommendations for Resident #1. The DON stated, "The doctor was not contacted about these recommendations because we were not aware they were made. We dropped the ball." 4. Resident #7 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/28/14 documented the resident was moderately impaired in cognitive skills for daily decision making per a staff interview of mental status; was at risk of malnutrition; required oversight, encouragement and/or cueing and set up help for eating; and had no weight loss. a. The Resident Plan of Care updated 10/28/14 documented, " ...Problem: resident is at ADL (Activities of daily Living) self-care deficit R/T (related to) needing assistance with ADLS ....Eating-Set up. ...Problem Date 4/28/14...Problem: resident is at nutritional risk r/t not eating her trays ...Approaches: Weigh and monitor results. Monitor and report to the physician. Signs/symptoms of malnutrition significant weight loss ...administer nutritional support as ordered; provide diet as ordered." b. On 1/25/15 at 5:23 p.m., the resident dinner tray was served and set-up in her room. She was served macaroni salad, vegetable soup, crackers, tuna salad sandwich, ? cup pears, mashed potatoes and milk. At 5:33 p.m., the resident had her eyes closed. The resident had taken 2 bites from her tuna sandwich. The remainder of the tray was untouched. At 5:44 p.m., the resident remained in bed, her eyes were closed and the remaining food on her tray had not been touched. At 5:51 p.m., Certified Nursing Assistant (CNA) #2 entered the resident's room. The CNA stated to the resident, "Need to eat another bite; its yum, yum." The CNA then exited the room. At 5:59 p.m., the resident had her eyes closed. The remaining food on her tray had not been touched. The resident was not assisted to eat. At 6:10 p.m., the Director of Nursing (DON) was notified of the lack of assistance provided to the resident with her supper meal. c. On 1/27/15 at 8:10 a.m., the resident was observed in bed with her eyes closed. Her breakfast tray was on her over bed table next to the bed. The resident was served ground sausage, biscuit, gravy, super cereal, scrambled eggs and a carton of milk. The resident was not served coffee or other beverage with her meal. The super cereal had the lid intact and the milk carton was unopened. None of the food had been disturbed. A teaspoon was in the serving of eggs, but none of the eggs had been consumed. d. On 1/27/15 at 9:53 a.m., CNA #1 and CNA #3 were asked, "Who fed (Resident #7) this morning?" CNA #1 stated, "It wasn't me." CNA #3 stated, "It wasn't me." CNA #1 stated to CNA #3, "You took the tray in to her." CNA #3 stated, "Well, I tried to give her a bite of egg, but she wouldn't take it." CNA #3 was asked, "Did you offer her any milk?" CNA #3 stated, "I tried to, but she wouldn't take it." CNA #3 was asked, "You opened the carton and offered it to her?" CNA #3 stated, "Yes." CNA #3 was asked, "Why was the milk carton unopened?" CNA #3 stated, "She likes to drink coffee." CNA #3 was asked, "Why was there no coffee on the tray?" CNA #3 stated, "We had to rush to get another resident ready for an appointment." e. On 1/28/15 at 10:30 a.m., CNA #3 was asked, "What do you do if a resident will not eat for you?" CNA #3 stated, "I stop. I don't force them to eat." CNA #3 was asked, "Do you tell anybody?" CNA #3 stated, "No. I write it down on the sheet (ADL sheet)." CNA #3 was asked, "Do you ever try to get another CNA to feed the resident?" CNA #3 stated, "No." The January 2015 (ADL Sheet) documented the resident was in the hospital from the 11:00 p.m. to 7:00 a.m. shift on 1/10/15 and returned sometime on 1/16/15. The ADL sheet is difficult to decipher. The form documented: Breakfast Intake 0800 (almost next row) % (percentage); Lunch Intake 1200 (almost next row) %; Dinner Intake 1700 (next row) %. There are only 5 rows with 6 items to initial or fill in so it cannot always be determined which meal is being documented. The form does not specify whether % is amount of food consumed or fluid intake. The ADL sheet documented: 1/1/15 " r " at 0800, 120 at %; " r " at 1200 and 50%; and at 1700 120 %. Breakfast, Lunch, and Supper intakes were blank on 1/2/15 and 1/3/15. 1/4/15 at 0800 10 %; at 1200 " r " 120%; and at 1700 120 %. 1/5/15 the column for the meals document " r " 120, " r " , and " m " ...the form is blank for meals on 1/16/15 and 1/17/15 ...1/18/15 and 1/21/15 document " r " for all meals and %. 1/23/15 is blank and 1/24/25 documents " 0 " for all meals and %. 1/26/15 is blank for all meals and %. f. On 1/27/15 at 11:22 a.m., the Director of Nursing (DON) provided a copy of the resident's monthly 'Weight Tracking' record which documented the following which represented a 5% weight loss times 2 months: 1) November 2014 - Wt= 140.8 pounds (lbs) 2) December 2014-Wt=139.2 lbs 3) January 2015 -Wt=(Week 4 Note: Week 1-3 129.8 lbs) 133.8 lbs. 5. Staff interviews regarding the communication of Registered Dietician (RD) recommendations: a. On 1/27/15 at 1:45 p.m., the DON was asked, "How are recommendations made by the Registered Dietician communicated and acted on?" The DON stated, "I had an LPN (LPN #1) who was responsible for the weights and weight loss." b. On 1/27/15 at 2:00 p.m., during a telephone interview, Registered Dietician (RD) #1 was asked, "How are RD recommendations communicated at this facility?" RD #1 stated, "I leave a list of recommendations with the Director of Nursing and Dietary Manager." c. On 1/27/15 at 2:15 p.m., LPN #1 was asked, "Are you involved with weight loss monitoring?" LPN #1 stated, "I've been working with Dietary and Restorative. We've been having weekly weight meetings." LPN #1 was asked, "When the RD makes a recommendation on the progress note, what happens?" LPN #1 stated, "When they make a recommendation, we make a list. I make myself a 'to do' list such as send orders to the MD." LPN #1 was asked, "Are there any notes from the meetings?" LPN #1 stated, "I have the notes in my office." The Surveyor requested a copy of the weight meeting notes. LPN #1 was asked, "How does the information get spread to the persons responsible when a recommendation is made by the RD?" LPN #1 stated, "I have a list the RD leaves me. I go down the list and check off when I send out an order or referral." LPN #1 was asked, "May we have a copy of that list?" LPN #1 stated, "Yes." d. On 1/27/15 at 1:45 p.m., the Dietary Manager was asked, "How are you involved with following the RD recommendations?" The Dietary Manager stated, "I get a copy of the recommendation. If it's a food preference recommendation, I talk with the resident." The Dietary Manager was asked, "What if it's a tube feeding recommendation?" The Dietary Manager stated, "The Director of Nursing handles that." The DON and LPN #1 were asked, "Has anyone notified the MD of the significant weight loss on Resident #2?" Both stated, "No." The DON was asked, "Who is responsible for monitoring weights?" The DON stated, "We are working on a system for the future that all weights are done on the same day each week and reported to the Dietary Manager, who puts them into the computer, and then gives them to (LPN #1). We plan to have a meeting to discuss risk management and to include weights on Thursdays." The Dietary Manager was asked, "One of the concerns about weight loss involves Resident #2. He never got health shakes. Why?" The Dietary Manager stated, "I thought they were d/c'd (discontinued)." The dietary manager was shown the telephone order dated 1/23/15 that discontinued the between meal feedings, not the health shakes. The Dietary Manager then stated, "I was told not to give him any." The Dietary Manager was asked, "By whom?" The Dietary Manager stated, "I prefer not to say." e. On 1/28/15 at 9:30 a.m., LPN #1 provided a copy of the Dietary Quality Assurance Report for December 19, 2014 containing the list of recommendations made by the Registered Dietician on that date. The report documented that Resident #2 was recommended Prostat, Snacks Between Meals, (a redacted entry), and Health shakes TID. Resident #5 was recommended to increase the tube feeding.

A. Complaint # was substantiated (all or in part) in these findings: Based on observation, record review and interview, the facility failed to ensure direct care staff were supervised and trained on the use of a new shower bed prior to its use for resident showers and failed to ensure the shower bed was operated only when 2 staff were in attendance to prevent accident/injury for 1 (Resident #24) of 9 (Residents #12, #14, #15, #17, #21, #22, #24, #25 and #28) case mix residents who required extensive assistance with bathing. This failed practice resulted in actual harm to Resident #24, who fell off the shower bed and sustained a laceration to the forehead that required sutures, extensive bruising and neck, arm and bilateral knee pain. The failed practice also had the potential to cause more than minimal harm to 44 residents who required extensive assistance with bathing, according to a list provided by the Director of Nursing (DON) on 3/12/14 at 2:37 p.m. The findings are: Resident #24 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/4/14 documented the resident scored 15 (13-15 indicates cognitively intact) on the Brief Interview for Mental Status (BIMS), required total assistance of two-plus people for transfers, required physical help of one person in part of bathing, had limitation in range of motion one upper and one lower extremity, was 5 foot and 6 inches tall, weighed 250 pounds and received anticoagulant medication daily. a. The resident's Plan of Care dated 1/4/14 documented, "Resident has ADL (activity of daily living) self-care deficit... Shower 3 (times) week bed bath other days... Hoyer lift (times) 2 assistance..." b. An Incident / Accident Report dated 2/28/14 documented, "Called to shower room at 10:10 a.m. Resident was observed on the shower room floor. Resident complained of left arm pain, pain level 8/10. Bleeding noted to forehead... Steps taken to prevent recurrence: Inservice staff regarding the use of the shower bed, two person assist during shower with shower bed." 1) A Nurse's Note dated 2/28/14 documented, "Called to shower room at 10:10 a.m. Resident was observed on the shower room floor. On assessment, resident complained of left arm pain. On the scale 0-10, pain level 8/10. Bleeding noted to forehead. APN (Advanced Practice Nurse)...notified. Order received and noted. Send resident to (hospital) for further evaluation..." 2) A hospital emergency room (ER) note dated 2/28/14 documented, "PT (patient) presents to ER via EMS (Emergency Medical Services) from (nursing home) after rolling off a bath table approximately 4 feet, landing face first. Pt has laceration above left eye to forehead, bleeding controlled. Complaining of neck, left shoulder, and bilateral knee pain. Swelling to left eye..." 3) A hospital History and Physical dated 2/28/14 documented, "Pt has significant facial swelling, bruising, and a 3 cm (centimeter) laceration present with moderate bleeding... The point of impact was the head... Patient was prepped and draped in the usual sterile fashion... Number of sutures: 7 ... Facial laceration. Facial contusion." c. A Nurse's Note dated 2/28/14 at 5:30 p.m. documented, "Resident arrived back by ambulance, alert, awake, able to make needs known. Left eye swollen with discoloration to left side of face, stitches to mid upper forehead... discoloration to right elbow area, slight discoloration to left knee..." d. A Nurse's Note dated 2/28/14 at 5:40 p.m. documented, "Resident complained of pain... 1 tab Percocet per MD (Medical Doctor) order for pain." e. A Nurse's Note dated 3/1/14 at 9:00 a.m. documented, "...Complained of neck pain... Per resident request (times) 1 Percocet 5/325 mg (milligram) PO (by mouth) given. Stitches intact to forehead. Discoloration noted to forehead and left side of face..." f. A Nurse's Note dated 3/4/14 at 5:20 p.m. documented, "Resident complained of pain all over. Gave pain medication per orders. Resident reports pain 10/10..." g. A Nurse's Note dated 3/6/14 at 8:00 a.m. documented, "Resident complains of pain (headache). Resident reports her pain level of 10/10..." h. A Nurse's Note dated 3/10/14 at 2:30 a.m. documented, "Complained of pain at 8:30 p.m. to forehead and arm. Asked for and received Endocet 5/325 mg 1 PO..." i. The resident's February 2014 Medication Administration Record (MAR) documented that, prior to the incident on 2/28/14, the resident had received pain medication on only 1 occasion during the month of February 2014. j. On 3/10/14 at 12:39 p.m., the resident was in an electric wheelchair in her room. There was a large dark purple area to the resident's left jaw / neck area, along with swelling. A dark purple area was observed underneath the left eye and stitches were observed to a laceration to the forehead. There was a large dark purple area to the right medial elbow, medial forearm and upper medial arm. The entire right dorsal hand, with the exception of the fingers, was also purple, blue and red in color. The resident was asked if she was in any pain. She stated, "It's all very tender." She was asked what happened to cause her injuries. She stated, "I fell off a shower bed onto a concrete floor, face down. (Certified Nursing Assistant (CNA) #12) told me to roll over... and I was already on the edge. But she said to roll over, that she wouldn't let me fall." k. On 3/10/14 at 1:30 p.m., CNA #12 was asked about the incident that occurred on 2/28/14. She stated, "We had three CNAs on that hall that day. Normally we have four. That day, I couldn't get (any) help. I asked another CNA, the ADON (Assistant Director of Nursing) and another nurse to help me. No one did. The Activity Director helped me put (Resident #24) on the shower bed with the lift. The bed was a new shower bed and I didn't really know how it worked. The rails had these pins on the end. Maintenance kind of showed me how it worked when she was already on the bed. He showed me how to raise the head of the bed." She was asked how the resident fell off of the bed. She stated, "I had the rails up, but I don't know if the pins weren't in all the way or what, and (Resident #24) can swing over to her good side and that's what happened. And that pad on the new bed is slick when it gets wet." She was asked where she was when Maintenance showed her how the bed worked. She stated, "I already had her in the shower room." She was asked how many people were normally in the shower room when Resident #24 received a shower. She stated, "Normally two." She was asked what the facility had done to prevent something like this from happening again. She stated, "They did an inservice on the bed; make sure there are two people in there to help if we use the shower bed." l. On 3/10/14 at 2:25 p.m., the Administrator was asked about the incident that occurred on 2/28/14. She stated, "When the incident happened, I was here in my office and heard her scream. By that time, (CNA #12) was hysterical, so I took her outside. I sent her home because she was so upset, then I in-serviced staff to make sure there were always two people to help in the shower room, especially if a shower bed is being used." She was asked if she was aware that staff allegedly refused to help CNA #12 with Resident #24. She stated, "She did tell me that she had asked for help. One of the young ladies that refused to help her was sent home that day, but because of another incident." The Administrator was asked if CNA #12 was in-serviced on how to use the new shower bed prior to it being put on the floor. She stated, "I don't think so. I wasn't even aware the new bed was in use. But I was told it was the same type of bed that was already in use." She was asked who would be responsible for in-servicing staff on using new equipment prior to it being put on the floor. She stated, "Maintenance got the equipment, so I guess all of us. Honestly I'm not sure." The Administrator was asked what actually caused the incident. She stated, "(CNA #12) said that one of the pins wasn't in good and when she went to push it in further, the resident rolled over and out of the bed." The Administrator provided a DMS-7734 titled OLTC (Office of Long Term Care) Incident and Accident Report dated 2/28/14 that documented, "Date and Time submitted: 3/4/14 - 10:30 a.m. Nurse was called to shower room and she observed the resident on the floor with bleeding noted from the forehead and the resident complaining of left arm pain. Steps taken to prevent continued abuse or neglect during the investigation: Resident was sent out to the ER. The CNA was interviewed and the CNA stated... the resident was on the shower bed when she was finishing up her shower and started drying the resident off, the CNA noticed that the pin on the rail of shower bed wasn't all the way in so she reached over to put the pin in when the resident rolled over and fell on the floor. The CNA was suspended pending the outcome of the investigation. Staff will be inserviced on abuse, neglect... family, physician and authorities were notified. Facility will continue to monitor and assist residents for their safety and well being." Attached to the DMS-7734 were witness statements from CNA #12, LPN #4 and the Activity Director. The Administrator was asked if staff was in-serviced on helping their coworkers, and to not use new equipment until instructed on how to use it. She stated, "An in-service was done on checking equipment to make sure it is properly functioning before using it and the nurses and CNAs were all in-serviced on helping out their coworkers." m. On 3/10/14 at 2:40 p.m., the ADON was asked about the incident on 2/28/14 and whether or not CNA #12 had asked her for assistance that morning. She stated, "I was on the north side of the building doing orders. Before we went into our morning meeting, (CNA #12) asked me to help her with another resident, but not (Resident #24). I've told the CNAs to be sure and ask me for help if they need it. I helped her when she asked, but she did not ask me for help with (Resident #24)." She was asked how many people were supposed to be in the shower room to assist residents. She stated, "I think it's a facility policy that two people are in the shower room for residents who are on a shower bed." She was asked if that was something new since the incident with Resident #24. She stated, "No. That's always been in place." She was asked if she knew how the incident occurred. She stated, "(Resident #24) told me that (CNA #12) told her to turn over and she said 'I can't because I'll fall out'. But (CNA #12) told her to turn over again and she fell out." She was asked if she knew anything about staff refusing to help CNA #12. She stated, "I heard that a CNA did, but she has since been terminated." n. On 3/10/14 at 3:00 p.m., the Maintenance Director was asked about the new shower bed and the incident on 2/28/14. He stated, "I put the thing together, put the pins in it and put it in here. That day, the 28th (2/28/14), I came in the shower room to fix the shower head. It was messed up. And (CNA #12) was in here with (Resident #24). When I came in here, both side rails were up and pinned correctly. (CNA #12) was by the wall and said 'How do you let these rails down?'. I showed her how to pull the pins to let it down. So she did that. She let that rail closest to the wall down. I left out of the shower room and that's the way they were. One up and one down. Probably 10 minutes didn't go by before the incident happened. When I came back in here, right after the incident, both rails were down. I think she let them down to dry her and she told her to roll and when the resident rolled she went out. That's the only way it could've happened." He was asked if he checked the bed after the incident to ensure there was not an equipment failure. He stated, "I did. There was nothing wrong with the bed." He was asked if staff had been in-serviced on the new shower bed. He stated, "There was no in-service prior to it being used, but it used pins just like the old one." At this time, the old shower bed was observed, along with the new one. The beds did use the same kind of locking pins, however, the pins had to be inserted into a different place on the bed. o. On 3/11/14 at 10:44 a.m., the DON was asked if CNA #12, or any CNA, was in-serviced on how to use the new shower bed before it was put on the floor for use. She stated, "I didn't realize the new shower bed was already in use, because it was either that day or the day before that I saw maintenance putting it together, and State was in the building at that time for our annual, so I was kind of busy." She was asked if two staff people were supposed to be in the shower room for assisting residents when they were on a shower bed. She stated, "It depends on the individual person. I did look at her closet care plan that day and it said 'assist' with ADLs, but it didn't say 1 or 2. After the incident I wrote 2-person assist on there." She was asked, "Based on (Resident #24's) condition, were two people needed in the shower room for assistance that day?" She stated, "Based on her and her size, yes." p. On 3/11/14 at 12:55 p.m., LPN #4, who was on duty on 2/28/14, was asked about the incident. She stated, "I was sitting at the Nurse's Station charting and I heard a loud yell. I jumped and then (CNA #12) came out of the shower room and said 'She fell off the bed.' I went in and (Resident #24) was lying on her stomach and her head was up against the wall. There was blood." She was asked if she remembered if the side rails of the shower bed were up or down. She stated, "The rail was down on the side that she fell ." LPN #4 was asked how many staff were normally used to assist Resident #24 in the shower room. She stated, "If they're a two person assist, then there should be two in the shower room, and if someone is on a shower bed then they would probably be a two-person assist." She was asked if Resident #24 would need two people for assistance in the shower room. She stated, "Yes." She was asked if CNA #12 asked her for help with Resident #24. She stated, "No." LPN #4 was asked if staff had been in-serviced on using the new shower bed prior to the incident. She stated, "I don't know." She was asked what interventions had been implemented to prevent recurrences since the incident. She stated, "We've had in-services on making sure two people are in the shower room and proper use of the shower bed." q. On 3/11/14 at 1:14 p.m., LPN #5, who was Resident #24's nurse on 2/28/14, was asked about the incident. She stated, "I was at the Nurse's Station. I heard '(Resident #24) is in the floor.' I went into the shower room and she was lying on her stomach on the floor, bleeding. I put a towel and pressure on her forehead." She was asked if she remembered anything about the shower bed at that time. She stated, "I didn't even look at the shower bed. My focus was on the resident. I asked her what happened and she said 'I fell . I'm hurting'." LPN #5 was asked if CNA #12 had asked her for help with Resident #24. She stated, "No, and I always tell them to ask me. I have helped her before. No one asked me." She was asked if there were normally two people in the shower room to assist with Resident #24. She stated, "She always had two people." She was asked if staff was in-serviced on using the new shower bed before it was put on the floor. She stated, "I don't remember that. I don't know exactly when the bed was put together." She was asked if an in-service was conducted on not using new equipment until staff had been trained on it. She stated, "I don't remember that either." r. On 3/12/14 at 12:45 p.m., the facility's scheduler was asked about the staffing on 2/28/14 on 200-Hall. He stated, "There (were) only three CNAs on the hall that day, but the team leader and I helped (CNA #12) with other residents earlier that day. The facility was fully staffed on 2/28/14." s. On 3/12/14 at 1:00 p.m., the facility provided a copy of the Bath / Shower Policy and Procedure. It did not address how to safely provide care to a resident on a shower bed. B. Complaint # was substantiated (all or in part) in these findings: Based on observation, record review and interview, the facility failed to ensure: supervision was provided to decrease wandering and intrusive behaviors for 1 of 1 (Resident #1) case mix resident who wandered; 3 of 3 mechanical lifts were inspected and maintained in good working order to prevent potential injuries from unsafe transfers as evidenced by failure to ensure safety clips were in place prior to transfer to reduce the potential for injury for 2 (Residents #2 and #4) of 9 (Residents #2, #3, #4, #6, #10, #12, #13, #14, and #15) case mix residents who required the use of a mechanical lift for surface to surface transfers; only metal smoking containers were utilized and smoking areas were free of trash and paper to reduce the potential for fire in 1 of 1 resident smoking area; and metal door coverings were free of sharp edges in 1 (300 Hall) of 4 shower rooms, to reduce the potential for skin tears or other injuries. These failed practices had to potential to affect 2 residents who exhibited signs of wandering, according to the Director of Nursing (DON) on 3/12/14 at 2:37 p.m., 23 residents who lived on the 300-Hall adjacent to the smoking area, according to initial rounds on 2/24/14; 13 residents who used the 300 Hall Men's shower room, according to a list received from the Administrator on 3/6/14 and 36 residents who required use of the mechanical lift for transfers, according to a list provided by the Director of Nursing on 3/1/14. The findings are: 1. Resident #1 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 1/21/14 documented the resident had a severely impaired cognitive status per staff assessment of mental status, continuously was inattentive and had disorganized thinking, had trouble concentrating nearly every day, was fidgety or restless nearly every day, was short-tempered and easily annoy nearly every day, wandered daily, was totally dependent on the physical assistance of one person for dressing, toilet use, personal hygiene and bathing and ambulated independently. a. The resident's Care Plan dated 1/21/14 documented, "...(Resident) experiencing extreme behaviors (running up and down halls, entering other (resident's) rooms, climbing on tables, etc.) ...Wandering ...Address wandering behavior by walking with resident, redirect from inappropriate areas; engage in diversional activity." As of 3/11/14, there was no documentation to indicate specifically what the planned diversional activities were. b. The Social Progress Notes dated 1/21/14 documented, "...she has been having some behavior problems; she will walk briskly thru the facility then start running, through the hall and she has been wandering in and out of resident rooms. She was exit seeking but has ceased. She will jump on the couch in the main lobby and, will jump back down and walk away. She has been observed lying on the couch then roll to the floor, she was recently sent to geri psych (Geriatric Psychiatric) she was not admitted because of insurance issue, she was 1 on 1 but she has been calmer and no longer requires that." c. A "Report of Concern" dated 3/9/14 documented, "Resident involved: (Resident #9)... Concern: Mom is already confused she don't need other residents entering her room confusing her more. (Resident #1) entered room and tried to get in her bed with her. Please keep (Resident #1) out of her room. She got in the empty bed and was found there. Mom got out of her bed (alone) to help (Resident #1) and could have fallen. Mom was found standing beside her bed next to the window. She said she was going to give her a pair of shoes... Result of Investigation: Staff will cont (continue) to redirect the resident when she is on the hall. Will put a stop sign across resident's door frame, when available." d. The Nurse's Notes dated 2/3/14 at 11:30 a.m. documented, "Resident exhibits disruptive behaviors ... wandering aimlessly in and out of other resident's rooms requiring frequent redirecting and coaching. Going around / through stop sign barriers posted on other resident's door running up and down hall. Standing over other residents etc. was treated for [REDACTED]. New orders were noted. No improvement in behavior..." e. The Nurse's Notes dated 2/3/14 at 12:15 p.m. documented, "Met with resident's son, discussed resident's behaviors, med. (medication) change and possibility of referring to a unit for behaviors. Son states that he would rather resident stay at (nursing home), but understood transfer if / when necessary..." f. The Nurse's Notes dated 2/5/14 at 10:50 a.m. documented, "...she will have to transfer to another facility for her safety due to her upsetting the other residents by going in their rooms and taking their personal items." g. The Nurse's Notes dated 2/22/14 at 5:00 a.m. documented, "In another resident's room in empty bed asleep, was able to redirect after few minutes had passed. At 7:15 a.m., attempted to snatch linen out of CNAs (Certified Nursing Assistant) hand and proceeded to yell at CNA and stated 'I'm going to spit on you because I don't like you' she turned and started running / fast walking to dining room." h. The Nurse's Notes dated 3/9/14 at 4:30 p.m. documented, "Resident had been noted to wander around the facility and running she's been entering other resident's rooms. She has hard time sitting still in one place. She enters a room and gets in an empty bed. When redirected to her room, or around at common area, she sits for less than a minute then takes off running. Staff has been reminded to keep an eye and redirect her..." i. On 3/12/14 at 8:59 a.m., Registered Nurse (RN) #1 was asked, What are the diversional activities per Care Plan for the resident's behaviors of wandering? She stated, "We have tried to keep her busy by getting her to fold towels. We even tried bringing her to therapy, restorative has attempted to put her on the bicycle." She was asked, Has the facility had an interdisciplinary team Care Plan meeting regarding (Resident #1)'s wandering in and out of other resident's rooms? RN #1 stated, "We have no formal Care Plan meeting." The RN added that the resident could easily get out of the facility if the opportunity presented itself. j. On 3/12/14 at 10:50 a.m., Resident #26 was asked if Resident #1 ever entered her room. She stated, "Yes, she enters my room. She has taken a pair of my shoes and my long sleeved shirt. I've reported it." She stated, "It has been a while since last time she came into my room... maybe a couple of weeks ago." Resident #26 was asked, "How does it make you feel when (Resident #1) enters your room?" She stated, "It scared me. I don't like that. I don't know what she is going to do. She likes lying down in the extra bed. She goes into other rooms..." k. On 3/12/14 at 11:10 a.m., LPN #2 was asked if she had any residents on 300 and 400 halls who had complained of Resident #1 going in and out of their rooms. She stated, "Yes. (Resident #23) and (Resident #28)." l. On 3/12/14 at 11:12 a.m., Resident #28 was asked if Resident #1 had ever entered his room. Resident #28 stated, "Yes, she will just lay in the extra bed in my room, but it don't bother me." m. On 3/12/14 at 1:40 p.m., LPN #3 was asked if he knew of any residents who have complained about Resident #1 wandering into their room? LPN #3 stated, "Yes, (Resident #27). He has complained. She (Resident #1) has gone into his room and laid down in the extra bed. He can become very aggressive. He gets upset when she goes into his room. He has never done anything to her, but he has told her and gestured to her, "Get out! Get out!" 2. The Invacare Reliant Mechanical Lift Operation Manual was provided by the Administrator on 2/27/13 and documented, "...(page 9) Be sure to check the sling attachments each time the sling is removed and replaced, to ensure that it is properly attached before the patient is removed from a stationary object (bed, chair or commode).... (page 40) Maintenance Safety Inspection Checklist... (page 41) Institutional Inspection / Adjust Monthly... The Swivel Bar: check the bolt / hooks for wear or damage... Check sling hooks for wear or deflection... (page 42) Slings and Hardware... Check All Sling Attachments each time it is used to ensure proper connection and patient safety..." 3. The facility's "Transfer Activity (Mechanical Lift) Policy and Procedure", provided by the Administrator on 3/1/14 documented, "...Attach the lift sling to the lift using the hook guards (hook latch)-ensure the sling is in the hook guards completely and correctly..." 4. Resident # 2 had [DIAGNOSES REDACTED]. The 5 Day Medicare MDS with an ARD of 1/13/14 documented the resident was moderately impaired in cognitive skills for daily decision making per a Staff Assessment for Mental Status (SAMS), required extensive physical assistance of one person for transfers and the limited physical assistance of one person for bed mobility. a. The Resident's Plan of Care was last updated 10/30/13 and did not document a method of transfer, as of 2/26/14. b. On 2/25/14 at 10:25 a.m., Certified Nursing Assistant (CNA) #1 and CNA #3 placed a mechanical lift sling under the resident while the resident was lying in bed. CNA #1 and CNA #3 attached the four sling straps onto the balance bar of the Reliant 450 mechanical lift. The resident was transferred with the resident's head elevated at an approximate 45-degree angle; the bottom of the sling was supported during the transfer by the CNAs and the resident was transferred into a wheelchair. c. On 2/25/14 at 10:40 a.m., the Reliant 450 mechanical lift was inspected and the middle anterior hook latch was missing. CNA #3 was asked what was wrong with the mechanical lift that was used to transfer the resident. CNA #3 stated, "The silver latch on the right side is missing." CNA #3 was then asked, "Why is the latch important?" CNA #3 stated, "It is a safety feature. She was secure. There was another aide (during the transfer). She (resident) was positioned securely in the sling. At the time of the transfer, I didn't notice the missing clip." d. On 2/27/14 at 6:20 p.m., the Director of Nursing (DON) was asked if the Certified Nursing Assistant (CNA) staff should be aware of safety features on mechanical lifts. The DON stated, "Yes." The DON was asked how staff knew what features ensured safety on a mechanical lift. The DON stated, "During initial orientation they round with therapy..." The DON was asked how CNAs were trained on the lift's safety features. The DON stated, "By PT (physical therapy)" The DON was asked if the mechanical lift should be used if the hook latches were absent from the lift bars. She stated, "No." The DON was asked what was the purpose of the hook latches on the lift. The DON stated, "It keeps the sling from slipping off." On 2/27/14 at 6:25 p.m., the Director of Nursing (DON) was asked if the CNAs should have used the mechanical lift to transfer the resident with one of the hook latches missing. The DON stated, "No, for safety reasons." 5. Resident #4 had [DIAGNOSES REDACTED]. a. The Resident Comprehensive Care Plan dated 12/19/14 documented, "Resident has ADL (activities of daily living) self-care deficit... Needs assistance with... Transfer... Provide adaptive / safety equipment (Hoyer lift for transfers)..." b. On 2/25/14 at 11:00 a.m., CNA #4 and CNA#8 took the Reliant 450 mechanical lift into the resident's room. The mechanical lift had been observed in the hallway with 3 of 6 safety clips missing. The CNAs placed the lift over the resident's bed and began to fasten the lift sling to the mechanical lift. The Surveyor asked both CNAs if there were any problems with the mechanical lift. The CNAs looked at the lift for a few moments. Then CNA #8 stated, "I don't know." The CNA then stated, "The clips are missing." The CNAs were asked, "What is the importance of the safety clips (hook latches)?" CNA #4 stated, "I don't know; I just started." CNA #8 was asked, "When did you start?" The CNA stated, "November 2013 and we were told the safety clips were for safety, to prevent the straps from slipping." CNA #4 stated, "I didn't know they (hook latches) did that." The DON was called to the resident's room. The DON was asked to look at and identify any problems with the mechanical lift. The DON looked at the lift and did not answer. CNA #8 then told the DON what was wrong with the mechanical lift. The DON stated they (facility) would check all the lifts. 6. On 2/25/14 at 11:25 a.m., the facility had 3 Invacare Reliant Mechanical Lifts. There was another Invacare Reliant Mechanical Lift on the 300 hall that had 2 hook latches missing (one in the center and 1 on the end) and there was one Reliant Mechanical Lift on the 100 hall that had 1 hook latch missing in the center. 7. On 2/25/14 at 11:40 a.m., the Maintenance man was asked, "How many mechanical lifts does the facility have?" He stated, "Four, one sit to stand lift and three Invacare Reliant 450 mechanical lifts. When asked how staff was supposed to report needed equipment repairs he stated, "On the maintenance log at each station." He was then asked if he was aware of any problems with the mechanical lifts and stated, "No." a. The facility's Maintenance Log provided by Maintenance on 2/25/14 documented the three Invacare Lifts were inspected on 1/13/14 and had been documented as, "OK" by Maintenance. b. On 2/25/14 at 12:00 p.m., copies of all maintenance requests within the past 6 months were reviewed by the survey team. There was no documentation regarding missing clips on any of the three Invacare Reliant 450 mechanical lifts. 8. On 3/1/14 at 1:45 p.m., the ground was covered with wood chips, which were littered with numerous cigarette butts. In a small plastic waste basket on the patio/courtyard area, there were numerous cigarette butts mixed with paper trash. On 3/1/14 at 4:00 p.m., the Administrator was asked if cigarette butts should be in a metal container and stated, "Yes." The Administrator was then asked if the ground should be littered with cigarette butts and stated, "No." 9. On 3/1/14 at 2:28 p.m., during the environmental tour, the entrance door to the 300 Hall men's shower room had a metal panel on the inside lower third of the entrance door that was approximately 3 to 4 feet wide by 2 feet long. The metal panel had a sharp and jagged edge that was detached from the door frame. In the center of the metal panel there was an exposed metal screw that protruded outward approximately 1 and 1/2 inches.

Based on observation, record review and interview, the facility failed to ensure planned interventions were consistently implemented to prevent further skin tears for 1 of 1 (Resident #13) case mix resident care planned for Geri-Sleeves and a personal alarm was operational to decrease the potential for fall related injuries for 1 (Resident #1) of 3 (Residents #1, #6 and #16) case mix residents who had wheelchair alarms. This failed practice had the potential to affect 1 resident with Geri-Sleeves and 16 residents who used chair alarms, according to a list provided by the Nurse Consultant on 5/23/14. The findings are: 1. Resident #13 had a [DIAGNOSES REDACTED]. a. The resident's Plan of Care developed 1/20/14 and updated 4/8/14 documented, "...4/15/14 ...Resident observed on floor, rolled out of bed onto floor (sustained skin tear to left forearm) ...Long Geri sleeves to both arms." b. On 5/21/14 at 8:42 a.m. and 9:15 a.m., the resident was in bed and had no Geri-sleeves on either arm. c. On 5/21/14 at 10:00 a.m., the Hospice aid applied the Geri-sleeves. d. On 5/21/14 at 9:20 p.m., the resident was in bed and had no Geri-sleeves on either arm. e. On 5/22/14 at 8:20 a.m., the resident was in bed and had no Geri-sleeves on either arm. 2. Resident #1 had [DIAGNOSES REDACTED]. The Quarterly MDS with an ARD of 3/7/14 documented the resident was moderately impaired in cognitive skills for daily decision making per a staff assessment for mental status, was totally dependent on the physical assistance of two-plus people for transfers, did not walk, had limitation in range of motion of one lower extremity and one upper extremity and had experienced one fall without injury since admission or prior assessment. a. On 5/21/14 at 8:43 a.m., the resident was in a wheelchair in the hallway with an alarm box on the back of the wheelchair. Licensed Practical Nurse (LPN) #5 was asked, "Is the resident's wheelchair alarm working?" She stated, "Yes, I put the batteries in the box this morning ...I'm going to transfer her to see if it works." b. On 5/21/14 at 9:20 a.m., Certified Nursing Assistant (CNA) #3 and CNA #4 stood the resident in a stand-up lift in the resident's room; the alarm with the wheelchair sensor pad did not sound. CNA #3 stated, "Her alarm is not working. We will take her to therapy." c. On 5/21/14 at 9:30 a.m., CNA #3 stated, "I noticed this morning when I changed her (Resident #1) the alarm did not go off." CNA #3 was asked, "How often do you check the wheelchair alarms." She stated, "Every shift. I told the nurse (LPN #5); she said she put batteries in the alarm box." d. On 5/21/14 at 9:35 a.m., LPN #5 pushed the resident in her wheelchair to the Physical Therapy room. The Physical Therapist checked the alarm and stated "See it's the pad that's not alarming..." e. On 5/21/14 at 2:45 p.m. LPN #5 was asked, "When are you supposed to check the resident's wheelchair alarm?" She stated, "You're supposed to check it every shift." LPN #5 was asked, "When did you check (Resident #5)'s wheelchair alarm?" She stated, "I checked it when you (surveyor) said something about the alarm."

Complaint # was substantiated, all or in part, with these findings. Based on record review and interview, the facility failed to ensure the facility's Abuse Policy and Procedure was operationalized as evidenced by the facility's failure to ensure that witnessed mental/verbal abuse and inappropriate language between CNA #1 (Certified Nursing Assistant #1) and 1 Resident #7) of 1 case mix resident (Resident #7), as well as, witnessed unsafe driving by the transport driver (CNA #1) for 2 (Residents #7 and #8) of 2 case mix residents (Residents #7 and #8) was immediately reported to the Administrator to assure residents were protected from further abuse. This failed practice resulted in Immediate Jeopardy which caused or was likely to cause serious injury, harm or death for Residents #7 and #8 who were passengers on the van on 9/26/12; Residents #6, #7 and #9 who were passengers on the van on 9/28/12; and had the potential to affect 8 residents transported in the facility van per day, according to a list provided by the Administrator on 11/8/12 at 9:55 a.m. The Immediate Jeopardy was removed and reduced to an "H" level deficiency on 9/28/12 at approximately 1:40 p.m., when the van driver was suspended with the suspension remaining in effect until employment was terminated on 10/5/12. The findings are: 1. The facility's policy and procedure titled "Abuse Policy", provided by the Administrator on 11/8/12, documented, " ...Reporting/Response a. All allegations of abuse, neglect, misappropriation of resident property or exploitation shall be reported to the Administrator and/or designee who shall initiate an investigation ... e. All reports will be made in a manner consistent with the mandated reporting requirements in effect at the time of the incident." 2. The Witness Statement dated 9/28/12 and signed by CNA #2 documented, "On Wednesday, September 26, 2012, I went with (Resident #8) to an appointment at her ENT (Ear, Nose and Throat) doctor. (CNA #1) was our van driver. When (CNA #1) picked (Resident #8) and me up at the ENT office, (Resident #7) was already loaded in the front seat. (Resident #7) was upset because (CNA #1) had forgotten her walker at the last appointment and they had to backtrack to pick it up. (Resident #7) and (CNA #1) were already yelling at each other when they picked me and (Resident #8) up. The argument escalated with both people yelling, cussing and threatening each other. At one point (Resident #7) took off her seat belt and told (CNA #1) that she was going to jump out of the van on the freeway. (CNA #1) sped up and told (Resident #7) that she could go ahead and jump, that she'd just run over her. Meanwhile, (CNA #1) had turned up the radio very loud so she couldn't hear the residents. I was busy checking on (Resident #8), who was in a wheelchair in the back, and calming (Resident #7) down to keep her from opening her door and arguing with (CNA #1). Both (Resident #7) and (CNA #1) used profanity at each other and made threatening remarks like: (Resident #7)--'I'll make sure you don't work anymore'. (CNA #1)--'Go ahead and jump, I'll just run over you'. All passengers were in danger as the speed of the van exceedingly increased past speed limits and we radically changed lanes. When we arrived at (facility), I took (Resident #7) to her nurse and then to the dining room and I left (Resident #8) in (CNA #1's) care." a. Resident #7 had [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/1/12 documented the resident scored 14 (13-15 indicates cognitively intact) on the Brief Interview for Mental Status (BIMS), did not exhibit physical, verbal, or other behavioral symptoms directed toward others or rejection of care, was dependent on the assistance of one person for activities of daily living and required [MEDICAL TREATMENT]. On 11/7/12 at 9:00 a.m., the surveyor asked the resident if she knew (CNA#1). The resident stated, "Yes. She doesn't work here anymore. I heard she got fired. I sure hope it isn't because of me. We worked it out. We don't have any problems between us." The surveyor asked the resident what happened and she stated, "(CNA #1) left my walker at the doctor's office. She wanted to go back and get it and I told her I would just get it on my next appointment. It had my name on it. (CNA #1) said she would go back and get it because I would need it. She was right. She went back on overtime. She didn't get paid for going back to get it." The surveyor asked the resident if (CNA #1) threatened to run over her. The resident stated, "Well, not that I know of." Resident #7 denied trying or stating she tried to get out of the van and stated, "Who told you that?" b. Resident #8 had [DIAGNOSES REDACTED]. The quarterly MDS with an ARD of 9/4/12 documented the resident scored 14 on the BIMS and exhibited no behaviors. 1) A statement related to the van incident on 9/26/12, dated 10/2/12 and signed by the Administrator, documented, "I asked (Resident #8) to tell me about the trip she made to an appointment on Wednesday, 9/26/12 in the facility van. (Resident #8) said she went to see her ear doctor. I asked (Resident #8) if she went by herself with the van driver (CNA #1). (Resident #8) stated, 'No, that (CNA #2) went with her.' She stated that she was sitting in the back of the van in her wheelchair and (CNA #2) was seated in the seat in front of her. I asked (Resident #8) if anyone else was in the van other than her, (CNA #2) and (CNA #1). (Resident #8) stated, 'Yes, that woman that always sits by the door, south side entrance, the one with the walker (Resident #7).' I asked (Resident #8) if the van driver and (Resident #7) said anything to each other. (Resident #8) stated that, 'Yes, they started shouting at each other.' I asked (Resident #8) if she could tell me what they were saying. (Resident #8) said no, that the van driver turned the radio up loud that she couldn't hear them. She stated that after awhile, the driver turned the radio back down. I asked (Resident #8) if the driver drove safely. (Resident #8) stated, 'I guess it was okay, we got there and back just fine'." 2) On 11/7/12 at 10:40 a.m., the surveyor asked the resident about the 9/26/12 van drive to her physician's appointment. Resident #8 stated, "There was another resident on the van. They, the resident and van driver (CNA #1), were arguing. Then the van driver was driving real fast, especially around curves. I was hanging on as I didn't want to turn over (in the wheelchair). She was driving a lot faster than the other van drivers drive. I told (Administrator) all about it. It was a spooky ride. I had been to the wound clinic. (CNA #2) was on the van with me." c. On 11/7/12 at 9:40 a.m., the surveyor asked CNA #1 about the van ride on 9/26/12. CNA #1 stated, "On 9/26/12 (Resident #7) said she was going to jump out of the van. I do not know why she was going to jump. There was no cussing or any argument. She just decided to jump out. I kept trying to talk to her so she would not jump. I did not report her behavior when I returned to the facility. I don't remember if I did. I was not driving reckless or fast." 3. The Facility Investigation Report for Resident Abuse, Neglect, Misappropriation of Property and Exploitation of Residents in Long-Term Care Facilities (DMS (Division of Medical Services) -762) dated 9/28/12 documented, "Facility employee, (Certified Nursing Assistant (CNA) #2), reported to facility Administrator that facility employee, (CNA #1), van driver, shouted at (Resident #7) while transporting (Resident #7) to an outside the facility medical appointment. (CNA #2) reported that (CNA #1) and (Resident #7) got into an argument and began shouting at each other using coarse/cursing language. (CNA #2) was a passenger in the van." a. A Witness Statement dated 9/28/12 and signed by CNA #1 documented, "I asked (Resident #7) to be quiet cause I was trying to drive and when she wouldn't, I turned up the music and then I turned it down when she stopped talking. I was doing 65 mph (miles per hour) when I was transporting (Resident #6) to the doctor's office." On 11/7/12 at 9:10 a.m., the surveyor asked CNA #1 about the van ride on 9/28/12. CNA #1 stated, "I was not arguing with (Resident #7) on 9/28/12. I did not tell her to shut up. I did turn the music up and then I turned it down and then apologized to (Resident #7) for turning it up. I did not break the speed limit. I did not pass in an intersection." b. Resident #7 had [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/1/12 documented the resident scored 14 (13-15 indicates cognitively intact) on the Brief Interview for Mental Status (BIMS), did not exhibit physical, verbal, or other behavioral symptoms directed toward others or rejection of care, was dependent on the assistance of one person for activities of daily living and required [MEDICAL TREATMENT]. A statement dated 10/2/12 and signed by the Administrator regarding the van incident on 9/28/12 documented, "I asked (Resident #7) if her rides in the facility van to her [MEDICAL TREATMENT] appointments were okay. (Resident #7) stated, 'It's okay now.' I asked (Resident #7) if there had been any problems recently. (Resident #7) stated it's okay now, everything is alright between us. I asked (Resident #7) to tell me what had happened, why was it okay now, did something happen on one of your trips. (Resident #7) stated, 'it's okay now, I don't need to tell you anything.' I asked (Resident #7) to please tell me if something happened. (Resident #7) stated, 'I don't have anything to tell you, everything is alright'." 4. The Facility Investigation Report for Resident Abuse, Neglect, Misappropriation of Property and Exploitation of Residents in Long-Term Care Facilities (DMS-762) dated 9/28/12 documented, "This facility reported an alleged act of verbal abuse against a facility resident on 9/28/12. Upon review of statements from witnesses and interviews of residents, concerning this matter, it was discovered that in addition to this incident and indirectly related to the incident, an alleged act of emotional/mental abuse might have occurred to (Resident #6). (Resident #6) was a passenger in the facility van on 9/28/12 being transported back to this facility from a medical appointment. It was reported that the driver of the van could have been driving erratically and/or speeding. The report states that (Resident #6) could have been distressed from the manner in which the employee (CNA #1) was driving the van." a. On 11/7/12 at 9:40 a.m., the surveyor asked CNA #1 about the van transport on 9/28/12. CNA #1 stated, "(Resident #6) was not crying or hollering (on 9/28/12 transport). (Resident #6's) daughter said (Resident #6) threw up in the doctor's office. I was terminated. I do not know the reason why I got fired. I was suspended on 9/28/12. I was fired 10/5/12 in person by the Administrator." b. Resident #6 had a [DIAGNOSES REDACTED]. 1) A memorandum dated 10/3/12 and signed by (Resident #6's) daughter documented, "On Friday, September 28, 2012, my mom (Resident #6) had a dentist appointment in (City) at (Dentist Office). Her appointment was scheduled at 8:30 a.m. She did not leave the facility until after 8:30 a.m. I followed (or attempted to follow) the van to her appointment. We left the facility and turned left on John Barrow toward I (Interstate)-630. I reached I-630 E (East) before the van and I was traveling at 55 mph in the right lane. I could see the van in my rear view mirror. As soon as the van reached I-630 E, the driver immediately changed to the far left lane and passed me at a high rate of speed. I was shocked to see the van moving so fast. I didn't want to call the driver on the phone and distract her so I thought if I caught up with her, she might decide to slow down. That did not happen because I was not able to catch her since she was moving so fast. I drove as fast as 70 and 75 and I was still not able to catch the van. She changed lanes several times but stayed in the far left lane most of the time. I was able to see the van at a far distance but was not able to catch the van without driving reckless myself. I was afraid for my mom. I drove between 70-75 mph until right before the exit to merge onto I-30 E toward North Little Rock. When I approached the exit to merge onto I-30E, I realized that I would not be able to catch her or slow her down. I only was able to see her at a distance in hopes I would get there before my mom was taken off the van. I only was able to get close enough to see the van entering the ramp to get on I-30. When I got on I-30, I could see the van at a far distant in the far left lane. Again, I was traveling 70-80 mph and was not able to catch the van on I-30E. I could see the van at a distance when it exited off of I-30 toward (Mall). When I exited off on the McCain Blvd exit and as I was going around the curve, I could see the van going in the wrong direction....When I located the van, it was traveling in the right direction so I turned around again. The van passed the dentist office numerous times before arriving at the right location. We were called back shortly after we arrived. Before they could start the impressions, my mom vomited as we went down the hall. She vomited all over her clothes, wheelchair cushion and floor. She could not get her words out. She just mumbled until I figured out she was trying to show me she had also vomited on her shoes. They were afraid she would have a difficult time with her impressions because of the vomiting incident. They did not give her any type of medication since no extractions were necessary. When we arrived back to the facility, the driver told me that my mom screamed all the way back and said she wanted to get off the bus. After we arrived back to her room, I was still concerned about her because she was not acting like her normal self. The nurse came and talked to her. Her speak was no longer slurred. (CNA #3) asked her where she had been and about her trip. She told (C NA #3) that she had been 'to hell and back'." On 11/7/12 at 9:50 a.m., the surveyor asked the resident's daughter about her statement and she stated, "Everything I wrote on 10/3/12 related to the 9/28/12 incident is true and factual to my knowledge." 2) A statement from an interview with the resident, dated 10/5/12 and signed by the Administrator, documented, "I asked (Resident #6) if she took a trip to a doctor appointment in the facility van last week on Friday. (Resident #6) stated, I reckon so, if you say I did. I asked (Resident #6) if the ride was okay. (Resident #6) stated, yes, it was okay. I asked (Resident #6) if anything happened to her during the ride in the van. (Resident #6) stated, no, everything was just fine." On 11/6/12 at 12:47 a.m., the surveyor asked the resident about the 9/28/12 van transport. Resident #6 stated, "I don't remember right now." 5. The Facility Investigation Report for Resident Abuse, Neglect, Misappropriation of Property and Exploitation of Residents in Long-Term Care Facilities (DMS-762) dated 9/28/12 documented, "This facility reported an alleged act of verbal abuse against a facility resident on 9/28/12. Upon review of statements from witnesses and interviews of residents, concerning this matter, it was discovered that in addition to this incident and indirectly related to the incident, an alleged act of emotional/mental abuse might have occurred to (Resident #9). (Resident #9) was a passenger in the facility van on 9/28/12 being transported back to this facility from a medical appointment. It was reported that the driver of the van could have been driving erratically and/or speeding. The report states that (Resident #9) could have been distressed from the manner in which the employee was driving the van." a. Resident #9 had [DIAGNOSES REDACTED]. lower extremity that interfered with daily functions or placed the resident at risk of injury and used a wheelchair for mobility. 1) A statement from an interview with (Resident #9), dated 10/5/12 and signed by the Administrator, documented, "I asked (Resident #9) if he recalled making a trip in the facility van on 9/28/12. (Resident #9) stated, yes, that he had gone to the wound doctor. I asked if anyone went with him to his appointment. He stated, no, just me and the driver. I asked (Resident #9) if the same person/driver picked him up after his appointment. He said, yes. I asked (Resident #9) if anyone else was with him. He stated, yes, that the woman that does the nails, (CNA #2) met him at his appointment and was with him. He stated that another patient was picked up too (Resident #6). I asked (Resident #9) how was the trip back to the facility. (Resident #9) stated that the van driver, (CNA #1) seemed to be in a hurry. He stated that he and (Resident #6) were swaying side to side when the driver would turn or change lanes, she seemed to be going a little too fast. I asked (Resident #9) if he felt in danger because of the way the driver was driving. (Resident #9) stated, no, she was just going a little too fast. I asked (Resident #9) if he could tell if (Resident #6) was upset. (Resident #9) stated yes, she started to cry a little bit." 2) On 11/7/12 at 1:30 p.m., the surveyor asked the resident if (CNA #1) drove too fast or recklessly on 9/28/12 on the way to his appointment. The resident stated, "No, we were alone on our way to my appointment." The surveyor asked about his ride back and if (CNA #1) drove too fast and if she was whipping in and out of traffic. Resident #9 stated, "Yes, she was driving too fast and she was whipping in and out of traffic. We got back safe but, if we would have had a wreck none of us could have helped each other. I was just holding on for dear life. (Resident #6) was scared to death. I told her to just hold on, we would be back soon. I was holding on (the resident demonstrated how he was swaying from side to side in his wheelchair)." b. A Witness Statement dated 9/28/12 and signed by (CNA #2) documented, "On Friday, September 28th, 2012, (Facility Employee #1) asked me to ride with (CNA #1), the van driver, to (Hospital) to assist (Resident #9) at his appointment. (Resident #9) had already been dropped off at (Hospital) and was in with his doctor when I arrived.....We called (CNA #1) to pick us up. We waited 30-35 minutes. When (CNA #1) arrived, she was able to reposition (Resident #9) and make him more comfortable. On the way to the above appointment, (Resident #7) was in the van front seat being taken to her appointment. She and (CNA #1), once again, began arguing again about how (CNA #1) was driving. (CNA #1) told (Resident #7) to 'shut up' and 'not start with her today'. Again the argument escalated and the speed of the van increased and the music volume went up. Then I was dropped off at (Hospital). When (CNA #1) picked me and (Resident #9) up, she was aggravated, running behind and short of patience. After we loaded (Resident #9) and buckled (Resident #6) in her chair in the back of the big box truck, we left (Hospital). We sped out of the parking lot and came to an intersection behind a car. (CNA #1) blew her horn at the car several times and when the car didn't move, she passed it on the left in a busy intersection. We drove home well beyond the posted speed limit, changing lanes radically with the music turned up so loud nothing else could be heard. (Resident #6) was using both hands to hang on to a bar in the back of the van and she was trembling and crying. (Resident #9) told her to hold on and not to cry and I tried to comfort her as we sped down the freeway. When we arrived at (Facility), (CNA #1) began unloading (Resident #9), (Resident #6) and (Resident #6's) daughter pulled up, got out of her car and said that she had tried to follow the van and was going 73 miles an hour but couldn't catch up to us. She was concerned about her mother, who was visibly shaken. The posted speed limit is 55 mph. I told (Resident #6's) daughter that I would report the incident and then I took (Resident #9) to his nurse for pain medication because his hip hurt and the bumpy ride aggravated his condition." 1) On 11/6/12 at 2:31 p.m., CNA #2 reviewed her witness statement of 9/28/12 and stated, "That is what happened. I do not have anything further to add. In my opinion, both (Resident #6) and (Resident #7) were abused by (CNA #1). (Resident #7) was talked to with curse words and yelling. (Resident #6), (Resident #7) and (Resident #9) were driven at a high rate of speed and was reckless. I was given an in-service on abuse reporting by the Administrator." 2) On 11/7/12 at 8:45 a.m., the surveyor asked CNA #2 to clarify words and driving attributes of CNA #1. CNA #2 stated, "(CNA #1) used words like 'don't start that (expletive)' with (Resident #7), 'today is not your day', used words like (expletive), (expletive) and (expletive). She used the F word at other drivers on the road like 'Get the F out of the way'. We were flying past people but, I did not see the speedometer. (Resident #6) was crying and upset. (Resident #7) told (CNA #1) repetitively to slow down and was arguing with (CNA #1). I was scared. We were weaving in and out of traffic. She was rattled and screaming profanity at other cars and arguing and cursing at (Resident #7). I tried to calm the situation down because (Resident #7) unbuckled her seat belt and tried to open the door. I grabbed the door and kept it shut and buckled (Resident #7) back in her seat belt. I did not report the 9/26/12 incident until 9/28/12 when the second incident occurred. I watched the video regarding abuse/neglect after I reported on 9/28/12. I did not report the 9/26/12 incident because (CNA #1) had always interacted really well with the residents on the floor. She was a new driver and (Resident #7) was pushing her buttons."

Complaint # is substantiated, all or in part, with these findings. Based on record review and interview, the facility failed to ensure that witnessed mental/verbal abuse and inappropriate language between CNA #1 (Certified Nursing Assistant #1) and 1 Resident #7) of 1 case mix resident (Resident #7), as well as, witnessed unsafe driving by the transport driver (CNA #1) for 2 (Residents #7 and #8) of 2 case mix residents (Residents #7 and #8) was immediately reported to the Administrator to assure residents were protected from further abuse. This failed practice resulted in Immediate Jeopardy which caused or was likely to cause serious injury, harm or death for Residents #7 and #8 who were passengers on the van on 9/26/12; Residents #6, #7 and #9 who were passengers on the van on 9/28/12; and had the potential to affect 8 residents transported in the facility van per day, according to a list provided by the Administrator on 11/8/12 at 9:55 a.m. The Immediate Jeopardy was removed and reduced to an "H" level deficiency on 9/28/12 at approximately 1:40 p.m. when the van driver was suspended with the suspension remaining in effect until employment was terminated on 10/5/12. The findings are: 1. The Witness Statement dated 9/28/12 and signed by CNA #2 documented, "On Wednesday, September 26, 2012, I went with (Resident #8) to an appointment at her ENT (Ear, Nose and Throat) doctor. (CNA #1) was our van driver. When (CNA #1) picked (Resident #8) and me up at the ENT office, (Resident #7) was already loaded in the front seat. (Resident #7) was upset because (CNA #1) had forgotten her walker at the last appointment and they had to backtrack to pick it up. (Resident #7) and (CNA #1) were already yelling at each other when they picked me and (Resident #8) up. The argument escalated with both people yelling, cussing and threatening each other. At one point (Resident #7) took off her seat belt and told (CNA #1) that she was going to jump out of the van on the freeway. (CNA #1) sped up and told (Resident #7) that she could go ahead and jump, that she'd just run over her. Meanwhile, (CNA #1) had turned up the radio very loud so she couldn't hear the residents. I was busy checking on (Resident #8), who was in a wheelchair in the back, and calming (Resident #7) down to keep her from opening her door and arguing with (CNA #1). Both (Resident #7) and (CNA #1) used profanity at each other and made threatening remarks like: (Resident #7)--'I'll make sure you don't work anymore'. (CNA #1)--'Go ahead and jump, I'll just run over you'. All passengers were in danger as the speed of the van exceedingly increased past speed limits and we radically changed lanes. When we arrived at (facility), I took (Resident #7) to her nurse and then to the dining room and I left (Resident #8) in (CNA #1's) care." a. Resident #7 had [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/1/12 documented the resident scored 14 (13-15 indicates cognitively intact) on the Brief Interview for Mental Status (BIMS), did not exhibit physical, verbal, or other behavioral symptoms directed toward others or rejection of care, was dependent on the assistance of one person for activities of daily living and required [MEDICAL TREATMENT]. On 11/7/12 at 9:00 a.m., the surveyor asked the resident if she knew (CNA#1). The resident stated, "Yes. She doesn't work here anymore. I heard she got fired. I sure hope it isn't because of me. We worked it out. We don't have any problems between us." The surveyor asked the resident what happened and she stated, "(CNA #1) left my walker at the doctor's office. She wanted to go back and get it and I told her I would just get it on my next appointment. It had my name on it. (CNA #1) said she would go back and get it because I would need it. She was right. She went back on overtime. She didn't get paid for going back to get it." The surveyor asked the resident if (CNA #1) threatened to run over her. The resident stated, "Well, not that I know of." Resident #7 denied trying or stating she tried to get out of the van and stated, "Who told you that?" b. Resident #8 had [DIAGNOSES REDACTED]. The quarterly MDS with an ARD of 9/4/12 documented the resident scored 14 on the BIMS and exhibited no behaviors. 1) A statement related to the van incident on 9/26/12, dated 10/2/12 and signed by the Administrator, documented, "I asked (Resident #8) to tell me about the trip she made to an appointment on Wednesday, 9/26/12 in the facility van. (Resident #8) said she went to see her ear doctor. I asked (Resident #8) if she went by herself with the van driver (CNA #1). (Resident #8) stated, 'No, that (CNA #2) went with her.' She stated that she was sitting in the back of the van in her wheelchair and (CNA #2) was seated in the seat in front of her. I asked (Resident #8) if anyone else was in the van other than her, (CNA #2) and (CNA #1). (Resident #8) stated, 'Yes, that woman that always sits by the door, south side entrance, the one with the walker (Resident #7).' I asked (Resident #8) if the van driver and (Resident #7) said anything to each other. (Resident #8) stated that, 'Yes, they started shouting at each other.' I asked (Resident #8) if she could tell me what they were saying. (Resident #8) said no, that the van driver turned the radio up loud that she couldn't hear them. She stated that after awhile, the driver turned the radio back down. I asked (Resident #8) if the driver drove safely. (Resident #8) stated, 'I guess it was okay, we got there and back just fine'." 2) On 11/7/12 at 10:40 a.m., the surveyor asked the resident about the 9/26/12 van drive to her physician's appointment. Resident #8 stated, "There was another resident on the van. They, the resident and van driver (CNA #1), were arguing. Then the van driver was driving real fast, especially around curves. I was hanging on as I didn't want to turn over (in the wheelchair). She was driving a lot faster than the other van drivers drive. I told (Administrator) all about it. It was a spooky ride. I had been to the wound clinic. (CNA #2) was on the van with me." c. On 11/7/12 at 9:40 a.m., the surveyor asked CNA #1 about the van ride on 9/26/12. CNA #1 stated, "On 9/26/12 (Resident #7) said she was going to jump out of the van. I do not know why she was going to jump. There was no cussing or any argument. She just decided to jump out. I kept trying to talk to her so she would not jump. I did not report her behavior when I returned to the facility. I don't remember if I did. I was not driving reckless or fast." 2. The Facility Investigation Report for Resident Abuse, Neglect, Misappropriation of Property and Exploitation of Residents in Long-Term Care Facilities (DMS (Division of Medical Services) -762) dated 9/28/12 documented, "Facility employee, (Certified Nursing Assistant (CNA) #2), reported to facility Administrator that facility employee, (CNA #1), van driver, shouted at (Resident #7) while transporting (Resident #7) to an outside the facility medical appointment. (CNA #2) reported that (CNA #1) and (Resident #7) got into an argument and began shouting at each other using coarse/cursing language. (CNA #2) was a passenger in the van." a. A Witness Statement dated 9/28/12 and signed by CNA #1 documented, "I asked (Resident #7) to be quiet cause I was trying to drive and when she wouldn't, I turned up the music and then I turned it down when she stopped talking. I was doing 65 mph (miles per hour) when I was transporting (Resident #6) to the doctor's office." On 11/7/12 at 9:10 a.m., the surveyor asked CNA #1 about the van ride on 9/28/12. CNA #1 stated, "I was not arguing with (Resident #7) on 9/28/12. I did not tell her to shut up. I did turn the music up and then I turned it down and then apologized to (Resident #7) for turning it up. I did not break the speed limit. I did not pass in an intersection." b. Resident #7 had [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/1/12 documented the resident scored 14 (13-15 indicates cognitively intact) on the Brief Interview for Mental Status (BIMS), did not exhibit physical, verbal, or other behavioral symptoms directed toward others or rejection of care, was dependent on the assistance of one person for activities of daily living and required [MEDICAL TREATMENT]. A statement dated 10/2/12 and signed by the Administrator regarding the van incident on 9/28/12 documented, "I asked (Resident #7) if her rides in the facility van to her [MEDICAL TREATMENT] appointments were okay. (Resident #7) stated, 'It's okay now.' I asked (Resident #7) if there had been any problems recently. (Resident #7) stated it's okay now, everything is alright between us. I asked (Resident #7) to tell me what had happened, why was it okay now, did something happen on one of your trips. (Resident #7) stated, 'it's okay now, I don't need to tell you anything.' I asked (Resident #7) to please tell me if something happened. (Resident #7) stated, 'I don't have anything to tell you, everything is alright'." 3. The Facility Investigation Report for Resident Abuse, Neglect, Misappropriation of Property and Exploitation of Residents in Long-Term Care Facilities (DMS-762) dated 9/28/12 documented, "This facility reported an alleged act of verbal abuse against a facility resident on 9/28/12. Upon review of statements from witnesses and interviews of residents, concerning this matter, it was discovered that in addition to this incident and indirectly related to the incident, an alleged act of emotional/mental abuse might have occurred to (Resident #6). (Resident #6) was a passenger in the facility van on 9/28/12 being transported back to this facility from a medical appointment. It was reported that the driver of the van could have been driving erratically and/or speeding. The report states that (Resident #6) could have been distressed from the manner in which the employee (CNA #1) was driving the van." a. On 11/7/12 at 9:40 a.m., the surveyor asked CNA #1 about the van transport on 9/28/12. CNA #1 stated, "(Resident #6) was not crying or hollering (on 9/28/12 transport). (Resident #6's) daughter said (Resident #6) threw up in the doctor's office. I was terminated. I do not know the reason why I got fired. I was suspended on 9/28/12. I was fired 10/5/12 in person by the Administrator." b. Resident #6 had a [DIAGNOSES REDACTED]. 1) A memorandum dated 10/3/12 and signed by (Resident #6's) daughter documented, "On Friday, September 28, 2012, my mom (Resident #6) had a dentist appointment in (City) at (Dentist Office). Her appointment was scheduled at 8:30 a.m. She did not leave the facility until after 8:30 a.m. I followed (or attempted to follow) the van to her appointment. We left the facility and turned left on John Barrow toward I (Interstate)-630. I reached I-630 E (East) before the van and I was traveling at 55 mph in the right lane. I could see the van in my rear view mirror. As soon as the van reached I-630 E, the driver immediately changed to the far left lane and passed me at a high rate of speed. I was shocked to see the van moving so fast. I didn't want to call the driver on the phone and distract her so I thought if I caught up with her, she might decide to slow down. That did not happen because I was not able to catch her since she was moving so fast. I drove as fast as 70 and 75 and I was still not able to catch the van. She changed lanes several times but stayed in the far left lane most of the time. I was able to see the van at a far distance but was not able to catch the van without driving reckless myself. I was afraid for my mom. I drove between 70-75 mph until right before the exit to merge onto I-30 E toward North Little Rock. When I approached the exit to merge onto I-30E, I realized that I would not be able to catch her or slow her down. I only was able to see her at a distance in hopes I would get there before my mom was taken off the van. I only was able to get close enough to see the van entering the ramp to get on I-30. When I got on I-30, I could see the van at a far distant in the far left lane. Again, I was traveling 70-80 mph and was not able to catch the van on I-30E. I could see the van at a distance when it exited off of I-30 toward (Mall). When I exited off on the McCain Blvd exit and as I was going around the curve, I could see the van going in the wrong direction....When I located the van, it was traveling in the right direction so I turned around again. The van passed the dentist office numerous times before arriving at the right location. We were called back shortly after we arrived. Before they could start the impressions, my mom vomited as we went down the hall. She vomited all over her clothes, wheelchair cushion and floor. She could not get her words out. She just mumbled until I figured out she was trying to show me she had also vomited on her shoes. They were afraid she would have a difficult time with her impressions because of the vomiting incident. They did not give her any type of medication since no extractions were necessary. When we arrived back to the facility, the driver told me that my mom screamed all the way back and said she wanted to get off the bus. After we arrived back to her room, I was still concerned about her because she was not acting like her normal self. The nurse came and talked to her. Her speak was no longer slurred. (CNA #3) asked her where she had been and about her trip. She told (C NA #3) that she had been 'to hell and back'." On 11/7/12 at 9:50 a.m., the surveyor asked the resident's daughter about her statement and she stated, "Everything I wrote on 10/3/12 related to the 9/28/12 incident is true and factual to my knowledge." 2) A statement from an interview with the resident, dated 10/5/12 and signed by the Administrator, documented, "I asked (Resident #6) if she took a trip to a doctor appointment in the facility van last week on Friday. (Resident #6) stated, I reckon so, if you say I did. I asked (Resident #6) if the ride was okay. (Resident #6) stated, yes, it was okay. I asked (Resident #6) if anything happened to her during the ride in the van. (Resident #6) stated, no, everything was just fine." On 11/6/12 at 12:47 a.m., the surveyor asked the resident about the 9/28/12 van transport. Resident #6 stated, "I don't remember right now." 4. The Facility Investigation Report for Resident Abuse, Neglect, Misappropriation of Property and Exploitation of Residents in Long-Term Care Facilities (DMS-762) dated 9/28/12 documented, "This facility reported an alleged act of verbal abuse against a facility resident on 9/28/12. Upon review of statements from witnesses and interviews of residents, concerning this matter, it was discovered that in addition to this incident and indirectly related to the incident, an alleged act of emotional/mental abuse might have occurred to (Resident #9). (Resident #9) was a passenger in the facility van on 9/28/12 being transported back to this facility from a medical appointment. It was reported that the driver of the van could have been driving erratically and/or speeding. The report states that (Resident #9) could have been distressed from the manner in which the employee was driving the van." a. Resident #9 had [DIAGNOSES REDACTED]. lower extremity that interfered with daily functions or placed the resident at risk of injury and used a wheelchair for mobility. 1) A statement from an interview with (Resident #9), dated 10/5/12 and signed by the Administrator, documented, "I asked (Resident #9) if he recalled making a trip in the facility van on 9/28/12. (Resident #9) stated, yes, that he had gone to the wound doctor. I asked if anyone went with him to his appointment. He stated, no, just me and the driver. I asked (Resident #9) if the same person/driver picked him up after his appointment. He said, yes. I asked (Resident #9) if anyone else was with him. He stated, yes, that the woman that does the nails, (CNA #2) met him at his appointment and was with him. He stated that another patient was picked up too (Resident #6). I asked (Resident #9) how was the trip back to the facility. (Resident #9) stated that the van driver, (CNA #1) seemed to be in a hurry. He stated that he and (Resident #6) were swaying side to side when the driver would turn or change lanes, she seemed to be going a little too fast. I asked (Resident #9) if he felt in danger because of the way the driver was driving. (Resident #9) stated, no, she was just going a little too fast. I asked (Resident #9) if he could tell if (Resident #6) was upset. (Resident #9) stated yes, she started to cry a little bit." 2) On 11/7/12 at 1:30 p.m., the surveyor asked the resident if (CNA #1) drove too fast or recklessly on 9/28/12 on the way to his appointment. The resident stated, "No, we were alone on our way to my appointment." The surveyor asked about his ride back and if (CNA #1) drove too fast and if she was whipping in and out of traffic. Resident #9 stated, "Yes, she was driving too fast and she was whipping in and out of traffic. We got back safe but, if we would have had a wreck none of us could have helped each other. I was just holding on for dear life. (Resident #6) was scared to death. I told her to just hold on, we would be back soon. I was holding on (the resident demonstrated how he was swaying from side to side in his wheelchair)." b. A Witness Statement dated 9/28/12 and signed by (CNA #2) documented, "On Friday, September 28th, 2012, (Facility Employee #1) asked me to ride with (CNA #1), the van driver, to (Hospital) to assist (Resident #9) at his appointment. (Resident #9) had already been dropped off at (Hospital) and was in with his doctor when I arrived.....We called (CNA #1) to pick us up. We waited 30-35 minutes. When (CNA #1) arrived, she was able to reposition (Resident #9) and make him more comfortable. On the way to the above appointment, (Resident #7) was in the van front seat being taken to her appointment. She and (CNA #1), once again, began arguing again about how (CNA #1) was driving. (CNA #1) told (Resident #7) to 'shut up' and 'not start with her today'. Again the argument escalated and the speed of the van increased and the music volume went up. Then I was dropped off at (Hospital). When (CNA #1) picked me and (Resident #9) up, she was aggravated, running behind and short of patience. After we loaded (Resident #9) and buckled (Resident #6) in her chair in the back of the big box truck, we left (Hospital). We sped out of the parking lot and came to an intersection behind a car. (CNA #1) blew her horn at the car several times and when the car didn't move, she passed it on the left in a busy intersection. We drove home well beyond the posted speed limit, changing lanes radically with the music turned up so loud nothing else could be heard. (Resident #6) was using both hands to hang on to a bar in the back of the van and she was trembling and crying. (Resident #9) told her to hold on and not to cry and I tried to comfort her as we sped down the freeway. When we arrived at (Facility), (CNA #1) began unloading (Resident #9), (Resident #6) and (Resident #6's) daughter pulled up, got out of her car and said that she had tried to follow the van and was going 73 miles an hour but couldn't catch up to us. She was concerned about her mother, who was visibly shaken. The posted speed limit is 55 mph. I told (Resident #6's) daughter that I would report the incident and then I took (Resident #9) to his nurse for pain medication because his hip hurt and the bumpy ride aggravated his condition." 1) On 11/6/12 at 2:31 p.m., CNA #2 reviewed her witness statement of 9/28/12 and stated, "That is what happened. I do not have anything further to add. In my opinion, both (Resident #6) and (Resident #7) were abused by (CNA #1). (Resident #7) was talked to with curse words and yelling. (Resident #6), (Resident #7) and (Resident #9) were driven at a high rate of speed and was reckless. I was given an in-service on abuse reporting by the Administrator." 2) On 11/7/12 at 8:45 a.m., the surveyor asked CNA #2 to clarify words and driving attributes of CNA #1. CNA #2 stated, "(CNA #1) used words like 'don't start that (expletive)' with (Resident #7), 'today is not your day', used words like (expletive), (expletive) and (expletive). She used the F word at other drivers on the road like 'Get the F out of the way'. We were flying past people but, I did not see the speedometer. (Resident #6) was crying and upset. (Resident #7) told (CNA #1) repetitively to slow down and was arguing with (CNA #1). I was scared. We were weaving in and out of traffic. She was rattled and screaming profanity at other cars and arguing and cursing at (Resident #7). I tried to calm the situation down because (Resident #7) unbuckled her seat belt and tried to open the door. I grabbed the door and kept it shut and buckled (Resident #7) back in her seat belt. I did not report the 9/26/12 incident until 9/28/12 when the second incident occurred. I watched the video regarding abuse/neglect after I reported on 9/28/12. I did not report the 9/26/12 incident because (CNA #1) had always interacted really well with the residents on the floor. She was a new driver and (Resident #7) was pushing her buttons."

Complaint # was substantiated, all or in part, with these findings. Based on record review and interview, the facility failed to ensure that 4 case mix residents were transported safely in the facility van and were not subjected to mental/verbal abuse and inappropriate language for 4 (Residents #6 - #9) of 4 case mix residents who were transported in the facility van on 9/26/12 and 9/28/12. This failed practice resulted in Immediate Jeopardy which caused or was likely to cause serious injury, harm or death for Residents #7 and #8 who were passengers on the van on 9/26/12; Residents #6, #7 and #9 who were passengers on the van on 9/28/12; and had the potential to affect 8 residents transported in the facility van per day, according to a list provided by the Administrator on 11/8/12 at 9:55 a.m. The Immediate Jeopardy was removed and reduced to an "H" level deficiency on 9/28/12 at approximately 1:40 p.m. when the van driver was suspended with the suspension remaining in effect until employment was terminated on 10/5/12. The findings are: 1. The Witness Statement dated 9/28/12 and signed by CNA #2 documented, "On Wednesday, September 26, 2012, I went with (Resident #8) to an appointment at her ENT (Ear, Nose and Throat) doctor. (CNA #1) was our van driver. When (CNA #1) picked (Resident #8) and me up at the ENT office, (Resident #7) was already loaded in the front seat. (Resident #7) was upset because (CNA #1) had forgotten her walker at the last appointment and they had to backtrack to pick it up. (Resident #7) and (CNA #1) were already yelling at each other when they picked me and (Resident #8) up. The argument escalated with both people yelling, cussing and threatening each other. At one point (Resident #7) took off her seat belt and told (CNA #1) that she was going to jump out of the van on the freeway. (CNA #1) sped up and told (Resident #7) that she could go ahead and jump, that she'd just run over her. Meanwhile, (CNA #1) had turned up the radio very loud so she couldn't hear the residents. I was busy checking on (Resident #8), who was in a wheelchair in the back, and calming (Resident #7) down to keep her from opening her door and arguing with (CNA #1). Both (Resident #7) and (CNA #1) used profanity at each other and made threatening remarks like: (Resident #7)--'I'll make sure you don't work anymore'. (CNA #1)--'Go ahead and jump, I'll just run over you'. All passengers were in danger as the speed of the van exceedingly increased past speed limits and we radically changed lanes. When we arrived at (facility), I took (Resident #7) to her nurse and then to the dining room and I left (Resident #8) in (CNA #1's) care." a. Resident #7 had [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/1/12 documented the resident scored 14 (13-15 indicates cognitively intact) on the Brief Interview for Mental Status (BIMS), did not exhibit physical, verbal, or other behavioral symptoms directed toward others or rejection of care, was dependent on the assistance of one person for activities of daily living and required [MEDICAL TREATMENT]. On 11/7/12 at 9:00 a.m., the surveyor asked the resident if she knew (CNA#1). The resident stated, "Yes. She doesn't work here anymore. I heard she got fired. I sure hope it isn't because of me. We worked it out. We don't have any problems between us." The surveyor asked the resident what happened and she stated, "(CNA #1) left my walker at the doctor's office. She wanted to go back and get it and I told her I would just get it on my next appointment. It had my name on it. (CNA #1) said she would go back and get it because I would need it. She was right. She went back on overtime. She didn't get paid for going back to get it." The surveyor asked the resident if (CNA #1) threatened to run over her. The resident stated, "Well, not that I know of." Resident #7 denied trying or stating she tried to get out of the van and stated, "Who told you that?" b. Resident #8 had [DIAGNOSES REDACTED]. The quarterly MDS with an ARD of 9/4/12 documented the resident scored 14 on the BIMS and exhibited no behaviors. 1) A statement related to the van incident on 9/26/12, dated 10/2/12 and signed by the Administrator, documented, "I asked (Resident #8) to tell me about the trip she made to an appointment on Wednesday, 9/26/12 in the facility van. (Resident #8) said she went to see her ear doctor. I asked (Resident #8) if she went by herself with the van driver (CNA #1). (Resident #8) stated, 'No, that (CNA #2) went with her.' She stated that she was sitting in the back of the van in her wheelchair and (CNA #2) was seated in the seat in front of her. I asked (Resident #8) if anyone else was in the van other than her, (CNA #2) and (CNA #1). (Resident #8) stated, 'Yes, that woman that always sits by the door, south side entrance, the one with the walker (Resident #7).' I asked (Resident #8) if the van driver and (Resident #7) said anything to each other. (Resident #8) stated that, 'Yes, they started shouting at each other.' I asked (Resident #8) if she could tell me what they were saying. (Resident #8) said no, that the van driver turned the radio up loud that she couldn't hear them. She stated that after awhile, the driver turned the radio back down. I asked (Resident #8) if the driver drove safely. (Resident #8) stated, 'I guess it was okay, we got there and back just fine'." 2) On 11/7/12 at 10:40 a.m., the surveyor asked the resident about the 9/26/12 van drive to her physician's appointment. Resident #8 stated, "There was another resident on the van. They, the resident and van driver (CNA #1), were arguing. Then the van driver was driving real fast, especially around curves. I was hanging on as I didn't want to turn over (in the wheelchair). She was driving a lot faster than the other van drivers drive. I told (Administrator) all about it. It was a spooky ride. I had been to the wound clinic. (CNA #2) was on the van with me." c. On 11/7/12 at 9:40 a.m., the surveyor asked CNA #1 about the van ride on 9/26/12. CNA #1 stated, "On 9/26/12 (Resident #7) said she was going to jump out of the van. I do not know why she was going to jump. There was no cussing or any argument. She just decided to jump out. I kept trying to talk to her so she would not jump. I did not report her behavior when I returned to the facility. I don't remember if I did. I was not driving reckless or fast." 2. The Facility Investigation Report for Resident Abuse, Neglect, Misappropriation of Property and Exploitation of Residents in Long-Term Care Facilities (DMS (Division of Medical Services) -762) dated 9/28/12 documented, "Facility employee, (Certified Nursing Assistant (CNA) #2), reported to facility Administrator that facility employee, (CNA #1), van driver, shouted at (Resident #7) while transporting (Resident #7) to an outside the facility medical appointment. (CNA #2) reported that (CNA #1) and (Resident #7) got into an argument and began shouting at each other using coarse/cursing language. (CNA #2) was a passenger in the van." a. A Witness Statement dated 9/28/12 and signed by CNA #1 documented, "I asked (Resident #7) to be quiet cause I was trying to drive and when she wouldn't, I turned up the music and then I turned it down when she stopped talking. I was doing 65 mph (miles per hour) when I was transporting (Resident #6) to the doctor's office." On 11/7/12 at 9:10 a.m., the surveyor asked CNA #1 about the van ride on 9/28/12. CNA #1 stated, "I was not arguing with (Resident #7) on 9/28/12. I did not tell her to shut up. I did turn the music up and then I turned it down and then apologized to (Resident #7) for turning it up. I did not break the speed limit. I did not pass in an intersection." b. Resident #7 had [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/1/12 documented the resident scored 14 (13-15 indicates cognitively intact) on the Brief Interview for Mental Status (BIMS), did not exhibit physical, verbal, or other behavioral symptoms directed toward others or rejection of care, was dependent on the assistance of one person for activities of daily living and required [MEDICAL TREATMENT]. A statement dated 10/2/12 and signed by the Administrator regarding the van incident on 9/28/12 documented, "I asked (Resident #7) if her rides in the facility van to her [MEDICAL TREATMENT] appointments were okay. (Resident #7) stated, 'It's okay now.' I asked (Resident #7) if there had been any problems recently. (Resident #7) stated it's okay now, everything is alright between us. I asked (Resident #7) to tell me what had happened, why was it okay now, did something happen on one of your trips. (Resident #7) stated, 'it's okay now, I don't need to tell you anything.' I asked (Resident #7) to please tell me if something happened. (Resident #7) stated, 'I don't have anything to tell you, everything is alright'." 3. The Facility Investigation Report for Resident Abuse, Neglect, Misappropriation of Property and Exploitation of Residents in Long-Term Care Facilities (DMS-762) dated 9/28/12 documented, "This facility reported an alleged act of verbal abuse against a facility resident on 9/28/12. Upon review of statements from witnesses and interviews of residents, concerning this matter, it was discovered that in addition to this incident and indirectly related to the incident, an alleged act of emotional/mental abuse might have occurred to (Resident #6). (Resident #6) was a passenger in the facility van on 9/28/12 being transported back to this facility from a medical appointment. It was reported that the driver of the van could have been driving erratically and/or speeding. The report states that (Resident #6) could have been distressed from the manner in which the employee (CNA #1) was driving the van." a. On 11/7/12 at 9:40 a.m., the surveyor asked CNA #1 about the van transport on 9/28/12. CNA #1 stated, "(Resident #6) was not crying or hollering (on 9/28/12 transport). (Resident #6's) daughter said (Resident #6) threw up in the doctor's office. I was terminated. I do not know the reason why I got fired. I was suspended on 9/28/12. I was fired 10/5/12 in person by the Administrator." b. Resident #6 had a [DIAGNOSES REDACTED]. 1) A memorandum dated 10/3/12 and signed by (Resident #6's) daughter documented, "On Friday, September 28, 2012, my mom (Resident #6) had a dentist appointment in (City) at (Dentist Office). Her appointment was scheduled at 8:30 a.m. She did not leave the facility until after 8:30 a.m. I followed (or attempted to follow) the van to her appointment. We left the facility and turned left on John Barrow toward I (Interstate)-630. I reached I-630 E (East) before the van and I was traveling at 55 mph in the right lane. I could see the van in my rear view mirror. As soon as the van reached I-630 E, the driver immediately changed to the far left lane and passed me at a high rate of speed. I was shocked to see the van moving so fast. I didn't want to call the driver on the phone and distract her so I thought if I caught up with her, she might decide to slow down. That did not happen because I was not able to catch her since she was moving so fast. I drove as fast as 70 and 75 and I was still not able to catch the van. She changed lanes several times but stayed in the far left lane most of the time. I was able to see the van at a far distance but was not able to catch the van without driving reckless myself. I was afraid for my mom. I drove between 70-75 mph until right before the exit to merge onto I-30 E toward North Little Rock. When I approached the exit to merge onto I-30E, I realized that I would not be able to catch her or slow her down. I only was able to see her at a distance in hopes I would get there before my mom was taken off the van. I only was able to get close enough to see the van entering the ramp to get on I-30. When I got on I-30, I could see the van at a far distant in the far left lane. Again, I was traveling 70-80 mph and was not able to catch the van on I-30E. I could see the van at a distance when it exited off of I-30 toward (Mall). When I exited off on the McCain Blvd exit and as I was going around the curve, I could see the van going in the wrong direction....When I located the van, it was traveling in the right direction so I turned around again. The van passed the dentist office numerous times before arriving at the right location. We were called back shortly after we arrived. Before they could start the impressions, my mom vomited as we went down the hall. She vomited all over her clothes, wheelchair cushion and floor. She could not get her words out. She just mumbled until I figured out she was trying to show me she had also vomited on her shoes. They were afraid she would have a difficult time with her impressions because of the vomiting incident. They did not give her any type of medication since no extractions were necessary. When we arrived back to the facility, the driver told me that my mom screamed all the way back and said she wanted to get off the bus. After we arrived back to her room, I was still concerned about her because she was not acting like her normal self. The nurse came and talked to her. Her speak was no longer slurred. (CNA #3) asked her where she had been and about her trip. She told (C NA #3) that she had been 'to hell and back'." On 11/7/12 at 9:50 a.m., the surveyor asked the resident's daughter about her statement and she stated, "Everything I wrote on 10/3/12 related to the 9/28/12 incident is true and factual to my knowledge." 2) A statement from an interview with the resident, dated 10/5/12 and signed by the Administrator, documented, "I asked (Resident #6) if she took a trip to a doctor appointment in the facility van last week on Friday. (Resident #6) stated, I reckon so, if you say I did. I asked (Resident #6) if the ride was okay. (Resident #6) stated, yes, it was okay. I asked (Resident #6) if anything happened to her during the ride in the van. (Resident #6) stated, no, everything was just fine." On 11/6/12 at 12:47 a.m., the surveyor asked the resident about the 9/28/12 van transport. Resident #6 stated, "I don't remember right now." 4. The Facility Investigation Report for Resident Abuse, Neglect, Misappropriation of Property and Exploitation of Residents in Long-Term Care Facilities (DMS-762) dated 9/28/12 documented, "This facility reported an alleged act of verbal abuse against a facility resident on 9/28/12. Upon review of statements from witnesses and interviews of residents, concerning this matter, it was discovered that in addition to this incident and indirectly related to the incident, an alleged act of emotional/mental abuse might have occurred to (Resident #9). (Resident #9) was a passenger in the facility van on 9/28/12 being transported back to this facility from a medical appointment. It was reported that the driver of the van could have been driving erratically and/or speeding. The report states that (Resident #9) could have been distressed from the manner in which the employee was driving the van." a. Resident #9 had [DIAGNOSES REDACTED]. lower extremity that interfered with daily functions or placed the resident at risk of injury and used a wheelchair for mobility. 1) A statement from an interview with (Resident #9), dated 10/5/12 and signed by the Administrator, documented, "I asked (Resident #9) if he recalled making a trip in the facility van on 9/28/12. (Resident #9) stated, yes, that he had gone to the wound doctor. I asked if anyone went with him to his appointment. He stated, no, just me and the driver. I asked (Resident #9) if the same person/driver picked him up after his appointment. He said, yes. I asked (Resident #9) if anyone else was with him. He stated, yes, that the woman that does the nails, (CNA #2) met him at his appointment and was with him. He stated that another patient was picked up too (Resident #6). I asked (Resident #9) how was the trip back to the facility. (Resident #9) stated that the van driver, (CNA #1) seemed to be in a hurry. He stated that he and (Resident #6) were swaying side to side when the driver would turn or change lanes, she seemed to be going a little too fast. I asked (Resident #9) if he felt in danger because of the way the driver was driving. (Resident #9) stated, no, she was just going a little too fast. I asked (Resident #9) if he could tell if (Resident #6) was upset. (Resident #9) stated yes, she started to cry a little bit." 2) On 11/7/12 at 1:30 p.m., the surveyor asked the resident if (CNA #1) drove too fast or recklessly on 9/28/12 on the way to his appointment. The resident stated, "No, we were alone on our way to my appointment." The surveyor asked about his ride back and if (CNA #1) drove too fast and if she was whipping in and out of traffic. Resident #9 stated, "Yes, she was driving too fast and she was whipping in and out of traffic. We got back safe but, if we would have had a wreck none of us could have helped each other. I was just holding on for dear life. (Resident #6) was scared to death. I told her to just hold on, we would be back soon. I was holding on (the resident demonstrated how he was swaying from side to side in his wheelchair)." b. A Witness Statement dated 9/28/12 and signed by (CNA #2) documented, "On Friday, September 28th, 2012, (Facility Employee #1) asked me to ride with (CNA #1), the van driver, to (Hospital) to assist (Resident #9) at his appointment. (Resident #9) had already been dropped off at (Hospital) and was in with his doctor when I arrived.....We called (CNA #1) to pick us up. We waited 30-35 minutes. When (CNA #1) arrived, she was able to reposition (Resident #9) and make him more comfortable. On the way to the above appointment, (Resident #7) was in the van front seat being taken to her appointment. She and (CNA #1), once again, began arguing again about how (CNA #1) was driving. (CNA #1) told (Resident #7) to 'shut up' and 'not start with her today'. Again the argument escalated and the speed of the van increased and the music volume went up. Then I was dropped off at (Hospital). When (CNA #1) picked me and (Resident #9) up, she was aggravated, running behind and short of patience. After we loaded (Resident #9) and buckled (Resident #6) in her chair in the back of the big box truck, we left (Hospital). We sped out of the parking lot and came to an intersection behind a car. (CNA #1) blew her horn at the car several times and when the car didn't move, she passed it on the left in a busy intersection. We drove home well beyond the posted speed limit, changing lanes radically with the music turned up so loud nothing else could be heard. (Resident #6) was using both hands to hang on to a bar in the back of the van and she was trembling and crying. (Resident #9) told her to hold on and not to cry and I tried to comfort her as we sped down the freeway. When we arrived at (Facility), (CNA #1) began unloading (Resident #9), (Resident #6) and (Resident #6's) daughter pulled up, got out of her car and said that she had tried to follow the van and was going 73 miles an hour but couldn't catch up to us. She was concerned about her mother, who was visibly shaken. The posted speed limit is 55 mph. I told (Resident #6's) daughter that I would report the incident and then I took (Resident #9) to his nurse for pain medication because his hip hurt and the bumpy ride aggravated his condition." 1) On 11/6/12 at 2:31 p.m., CNA #2 reviewed her witness statement of 9/28/12 and stated, "That is what happened. I do not have anything further to add. In my opinion, both (Resident #6) and (Resident #7) were abused by (CNA #1). (Resident #7) was talked to with curse words and yelling. (Resident #6), (Resident #7) and (Resident #9) were driven at a high rate of speed and was reckless. I was given an in-service on abuse reporting by the Administrator." 2) On 11/7/12 at 8:45 a.m., the surveyor asked CNA #2 to clarify words and driving attributes of CNA #1. CNA #2 stated, "(CNA #1) used words like 'don't start that (expletive)' with (Resident #7), 'today is not your day', used words like (expletive), (expletive) and (expletive). She used the F word at other drivers on the road like 'Get the F out of the way'. We were flying past people but, I did not see the speedometer. (Resident #6) was crying and upset. (Resident #7) told (CNA #1) repetitively to slow down and was arguing with (CNA #1). I was scared. We were weaving in and out of traffic. She was rattled and screaming profanity at other cars and arguing and cursing at (Resident #7). I tried to calm the situation down because (Resident #7) unbuckled her seat belt and tried to open the door. I grabbed the door and kept it shut and buckled (Resident #7) back in her seat belt. I did not report the 9/26/12 incident until 9/28/12 when the second incident occurred. I watched the video regarding abuse/neglect after I reported on 9/28/12. I did not report the 9/26/12 incident because (CNA #1) had always interacted really well with the residents on the floor. She was a new driver and (Resident #7) was pushing her buttons."

Based on observation, record review, and interview, the facility failed to ensure Resident #8 was free of verbal and mental abuse from a family member. The facility failed to ensure interventions were developed and implemented to prevent verbal and mental abuse for 1 of 1 (Resident #8) case mix resident whose family member threatened the resident did not get out of bed everyday. This failed practice resulted in a pattern of actual harm to Resident #8, who suffered mental anguish and the potential to affect only this one resident who suffered verbal and mental abuse according to a list provided by the Administrator on 11/16/11. The findings are: Resident #8 had [DIAGNOSES REDACTED]. The Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/6/11 documented the resident scored 12 (8-12 indicates moderately impaired) on the Brief Interview for Mental Status (BIMS), had a Total Severity Score of 12 (10-14 indicates moderate depression) on the Resident Mood Interview which included symptoms of feeling bad about herself or that she was a failure or had let herself or her family down 2-6 days over the last 2 weeks, and had open [MEDICAL CONDITION] other than ulcers, rashes, cuts (e.g. cancer lesion). A copy of the computerized signage, which was taped to the resident's closet door, was obtained on 11/3/11 at 2:05 p.m. and documented, "Resident to be up for all 3 meals, resident is to be bathed 3 times a week, resident is not to receive extra snacks unless it's from her refrigerator only, resident is to be turned every 2 hours while in bed, resident is to be changed every two hours, resident may wear briefs while up in wheelchairs only, resident teeth are to be soaked nightly, if resident refuses, the family is to be notified. No exceptions..." The document had a computerized signature "j (resident's daughter)." a. The Nurses Notes dated 10/5/11 at 3:10 p.m. documented, "Alert X (times) 3. Able to make needs known. Staff provide extensive assist (with) ADLs (Activities of Daily Living). Resident un-cooperative (with) staff at times regarding getting OOB (out of bed) to w/c (wheelchair). States she hurts or does not feel like getting up. Resident offered pain med (medication) prior to getting up today but declined stating she didn't feel like it. Resident encouraged to participate in ADLs. In bed at this time with call light in reach. Did get up for shower today..." b. The Nurses Notes dated 10/13/11 at 2:00 p.m. and signed by Licensed Practical Nurse (LPN) #1 documented, "Resident got up for breakfast @ (at) 0730 (7:30 a.m.) (with) encouragement. Refused to get up @ lunch. Daughter called @1150 (11:50 a.m.) to inform that resident declined to get up. Daughter called resident and resident stated she would get up. Resident stated that her daughter was acting crazy and that if she didn't get up that she would come up to facility and scrub her hard and she didn't want to experience that kind of treatment. I informed social worker of comments made by resident." At 11:00 p.m. the Nurses Notes documented, "... Daughter phoned @ 1730 (5:30 p.m.) (with) c/o (complaints of) resident laying in bed... (Assistant Director of Nursing (ADON)) notified. Will continue to monitor." On 11/3/11 at 2:45 p.m., LPN #1 stated, (Resident #8) doesn't like to get up that much, but will get up around 10:30 a.m. and stay up 4 hours. We were told if she says no, we are to call the daughter. The LPN was asked to clarify the nurses notes documented on 10/13/11. The LPN stated, "I noticed the resident was upset and I asked why won't you get up for us but you will for your daughter. She stated, 'You just don't understand. She will come in and be real rough with me, she'll scrub real hard.' I didn't ask any questions." The LPN was asked if she thought this was abuse. LPN #1 stated, "Yes, I would consider it abuse. Yes, I do think (Resident #8) is scared of her daughter. I have seen her in tears." The LPN was asked if she had reported this to anyone. She stated she had only reported it to the Social Worker. The LPN also stated, "The family friend got upset with me when I told her that I am the resident's advocate and I will not get her up unless she wants up. I've reported it the social worker on two occasions." c. A physician order [REDACTED]. On 11/4/11 at 1:30 p.m., the Licensed Social Worker (LSW) was asked if she had knowledge of the physician order [REDACTED]. The LSW stated, "Yes, her nurse told me about it." When asked if the appointment had been made she stated, "No, when the nurse told me about the physicians order for a dermatology follow-up I told the resident's daughter about it. The resident's daughter said her mother didn't need to go to the Dermatologist, so I never did make her an appointment." When asked if she had notified the nurse, the Director of Nursing (DON), the Administrator or the physician about the daughter's refusal she stated, "No, I never did report what the daughter had said, and I never reported to anyone that a dermatology appointment was not being made." d. Social Service Progress dated 10/31/11 documented, "...daughter told her mother that if she doesn't start taking showers and getting up that she will make her a DNR (Do Not Resuscitate). Resident was very upset regarding the way her daughter talked to her." The progress notes dated 11/1/11 documented, "Licensed Social Worker (LSW) talked to resident's daughter and told her that LSW was monitoring her mom to make sure she gets up 3 x a day ...Resident stated, "She was tired of her daughter dogging her and talking the way she does." The progress notes dated 11/2/11 documented, "LSW visited with resident and resident's daughter in the dining room, resident's daughter got on to her mom for having a diet Dr. Pepper and graham crackers. The resident was upset". On 11/3/11 at 3:10 p.m., the LSW was asked to verify the copied Social Service progress notes. The LSW stated, "Yes, these are my notes." When asked if she reported the daughter's behavior toward the resident she stated, "No, I didn't report it because her daughter is caring, even though she does make her mother cry. She just wants her mother to do better... I don't think it is abuse if it gets the resident up and taking care of herself... the resident told us she would comply that is why I didn't write it or report it... but now that I think about it, I guess it is abuse." e. On 11/1/11 at 2:13 p.m., Resident #8 was in the bed. The resident told the surveyor she would like to stay in the bed for about 3 days to let the wounds on her legs heal. The resident stated, "When they get me up, the lift pad scratches them." The resident was asked if she had spoken with the nurse about this and she stated, "No." Certified Nurse Assistant (CNA) #1, who was in the room was asked to have a nurse come to talk to the resident about staying in the bed. f. On 11/2/11 at 8:55 a.m., the resident was in the wheelchair in her room. The resident stated that she had never spoken to the nurse about staying in the bed for a few days. She stated, "The nurse said my legs were better." At 10:10 a.m., CNA #2 and #3 were transferring the resident to the bed from the wheelchair using a mechanical lift. The resident stated, "It hurts" and facial grimacing was noted. The resident was asked what hurts and the resident stated, "My legs, those sores on my legs." The lift sling was directly against the open wounds on the resident's posterior upper thighs. There were approximately 10 open wounds on the left thigh and 12 open wounds on the right thigh, all moist and of varying sizes. The resident requested to stay in bed until lunch. Blisters were noted under breast, left and right arms. The resident stated, "I am supposed to go to the Dermatologist." At 4:35 p.m., the resident was in a wheelchair in the dining room with the lift sling positioned underneath her buttocks with direct skin contact to the wounds on the posterior bilateral thighs. At 5:55 p.m., CNA #4 and #5 were preparing to transfer the resident to the bed from the wheelchair using a mechanical lift. The Director of Nursing (DON) was present in the room. The resident stated, "This pain is worse than a tooth ache." When asked what pain, the resident stated, "Sitting on these sores, it's horrible. Especially my left leg, it's horrible, it's really paining me." The DON asked the resident about the pain level. The resident stated, "7 to 8". The resident requested to stay in bed for 2-3 days so the thighs could heal some. The resident was crying and stating, "It hurts" during the transfer. The lift sling was directly pressing against the open areas on the posterior thighs during the transfer. g. On 11/2/11 at 6:05 p.m., the DON stated, "...Her family wants her up, but I think she should be in the bed and turned every 2 hours..." h. On 11/3/11 at 9:00 a.m., the resident was in the bed and the DON came into the room. The resident stated, "Look at my neck and face. It's much worse than yesterday. Please, you've got to do something to help me." The resident's neck area was red and moist with small fluid filled vesicles noted on the right side of the face and the neck folds. At 9:24 a.m. the DON stated, "I called the doctor and we are sending her to (Hospital) for evaluation..." i. On 11/3/11 at 11:00 a.m., the Wound Nurse, Registered Nurse (RN) #2 reviewed the resident's record and stated, "It started out as a gross [MEDICAL CONDITION] of posterior thighs... My first note dated 8/26/11, I thought (Resident #8) needed to go to the hospital... (Resident #8) came back with open superficial blisters... The family insisted (Resident #8) get up 3 times a day. I felt some of the sores were linear from the sling and (Resident #8) being scooted and the use of the Hoyer Lift. We brought in Physical Therapy and changed the size of the sling harness. I continued to talk with family to let them know I was concerned. I never saw them lift (Resident #8) without the burn dressing being in place. I thought (Resident #8) should not be getting up. I am not sure if I documented that or not... Staff said they had to get (Resident #8) up because of the family... (Resident #8) would cry constantly because she was afraid of her daughter... (Resident #8's) daughter is mean to her, talks to her terribly. (Resident #8) says 'I have to do what she says'. (Resident #8's) expression was teary when she said this." The surveyor asked RN #2 if she had reported this to anyone. RN #2 stated, "No, I didn't talk to anyone because I'm not here all the time... There was Physical Therapy, CNAs, and other people in the room. I didn't think about it being abuse. I was so focused on the wounds... I believe with her daughter insisting she get up, things got worse, her sores couldn't heal... (Resident #8) was always upset when I talked with her because she didn't want to get up because of the sores." j. On 11/3/11 at 2:15 p.m. CNA #2 stated, "We do only what we are told, we have been told (Resident #8) has to be gotten up 3 times a day for meals. It's mainly her family wanting her up. The resident says it hurts her bottom when she's up. It should be up to the resident what they do." The CNA was asked if the resident seemed afraid of her daughter. The CNA stated, "Maybe a little."

Based on observation, record review, and interview, the facility failed to ensure observations of a family member threatening a resident was immediately reported to the Administrator so the incidents could be thoroughly investigated, interventions were developed and implement to ensure protection from the potential for further abuse and the incidents reported to the Office of Long Term Care (OLTC) and other agencies in accordance with state law for 1 of 1 (Resident #8) case mix resident who suffered verbal and mental abuse from a family member and had the potential to affect only this one resident who suffered verbal and mental abuse according to a list provided by the Administrator on 11/16/11. The findings are: Resident #8 had [DIAGNOSES REDACTED]. The Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/6/11 documented the resident scored 12 (8-12 indicates moderately impaired) on the Brief Interview for Mental Status (BIMS), had a Total Severity Score of 12 (10-14 indicates moderate depression) on the Resident Mood Interview which included symptoms of feeling bad about herself or that she was a failure or had let herself or her family down 2-6 days over the last 2 weeks, and had open [MEDICAL CONDITION] other than ulcers, rashes, cuts (e.g. cancer lesion). A copy of the computerized signage, which was taped to the resident's closet door, was obtained on 11/3/11 at 2:05 p.m. and documented, "Resident to be up for all 3 meals, resident is to be bathed 3 times a week, resident is not to receive extra snacks unless it's from her refrigerator only, resident is to be turned every 2 hours while in bed, resident is to be changed every two hours, resident may wear briefs while up in wheelchairs only, resident teeth are to be soaked nightly, if resident refuses, the family is to be notified. No exceptions..." The document had a computerized signature "j (resident's daughter)." a. The Nurses Notes dated 10/5/11 at 3:10 p.m. documented, "Alert X (times) 3. Able to make needs known. Staff provide extensive assist (with) ADLs (Activities of Daily Living). Resident un-cooperative (with) staff at times regarding getting OOB (out of bed) to w/c (wheelchair). States she hurts or does not feel like getting up. Resident offered pain med (medication) prior to getting up today but declined stating she didn't feel like it. Resident encouraged to participate in ADLs. In bed at this time with call light in reach. Did get up for shower today..." b. The Nurses Notes dated 10/13/11 at 2:00 p.m. and signed by Licensed Practical Nurse (LPN) #1 documented, "Resident got up for breakfast @ (at) 0730 (7:30 a.m.) (with) encouragement. Refused to get up @ lunch. Daughter called @1150 (11:50 a.m.) to inform that resident declined to get up. Daughter called resident and resident stated she would get up. Resident stated that her daughter was acting crazy and that if she didn't get up that she would come up to facility and scrub her hard and she didn't want to experience that kind of treatment. I informed social worker of comments made by resident." At 11:00 p.m. the Nurses Notes documented, "... Daughter phoned @ 1730 (5:30 p.m.) (with) c/o (complaints of) resident laying in bed... (Assistant Director of Nursing (ADON)) notified. Will continue to monitor." On 11/3/11 at 2:45 p.m., LPN #1 stated, (Resident #8) doesn't like to get up that much, but will get up around 10:30 a.m. and stay up 4 hours. We were told if she says no, we are to call the daughter. The LPN was asked to clarify the nurses notes documented on 10/13/11. The LPN stated, "I noticed the resident was upset and I asked why won't you get up for us but you will for your daughter. She stated, 'You just don't understand. She will come in and be real rough with me, she'll scrub real hard.' I didn't ask any questions." The LPN was asked if she thought this was abuse. LPN #1 stated, "Yes, I would consider it abuse. Yes, I do think (Resident #8) is scared of her daughter. I have seen her in tears." The LPN was asked if she had reported this to anyone. She stated she had only reported it to the Social Worker. The LPN also stated, "The family friend got upset with me when I told her that I am the resident's advocate and I will not get her up unless she wants up. I've reported it the social worker on two occasions." c. A physician order [REDACTED]. On 11/4/11 at 1:30 p.m., the Licensed Social Worker (LSW) was asked if she had knowledge of the physician order [REDACTED]. The LSW stated, "Yes, her nurse told me about it." When asked if the appointment had been made she stated, "No, when the nurse told me about the physicians order for a dermatology follow-up I told the resident's daughter about it. The resident's daughter said her mother didn't need to go to the Dermatologist, so I never did make her an appointment." When asked if she had notified the nurse, the Director of Nursing (DON), the Administrator or the physician about the daughter's refusal she stated, "No, I never did report what the daughter had said, and I never reported to anyone that a dermatology appointment was not being made." d. Social Service Progress dated 10/31/11 documented, "...daughter told her mother that if she doesn't start taking showers and getting up that she will make her a DNR (Do Not Resuscitate). Resident was very upset regarding the way her daughter talked to her." The progress notes dated 11/1/11 documented, "Licensed Social Worker (LSW) talked to resident's daughter and told her that LSW was monitoring her mom to make sure she gets up 3 x a day ...Resident stated, "She was tired of her daughter dogging her and talking the way she does." The progress notes dated 11/2/11 documented, "LSW visited with resident and resident's daughter in the dining room, resident's daughter got on to her mom for having a diet Dr. Pepper and graham crackers. The resident was upset". On 11/3/11 at 3:10 p.m., the LSW was asked to verify the copied Social Service progress notes. The LSW stated, "Yes, these are my notes." When asked if she reported the daughter's behavior toward the resident she stated, "No, I didn't report it because her daughter is caring, even though she does make her mother cry. She just wants her mother to do better... I don't think it is abuse if it gets the resident up and taking care of herself... the resident told us she would comply that is why I didn't write it or report it... but now that I think about it, I guess it is abuse." e. On 11/1/11 at 2:13 p.m., Resident #8 was in the bed. The resident told the surveyor she would like to stay in the bed for about 3 days to let the wounds on her legs heal. The resident stated, "When they get me up, the lift pad scratches them." The resident was asked if she had spoken with the nurse about this and she stated, "No." Certified Nurse Assistant (CNA) #1, who was in the room was asked to have a nurse come to talk to the resident about staying in the bed. f. On 11/2/11 at 8:55 a.m., the resident was in the wheelchair in her room. The resident stated that she had never spoken to the nurse about staying in the bed for a few days. She stated, "The nurse said my legs were better." At 10:10 a.m., CNA #2 and #3 were transferring the resident to the bed from the wheelchair using a mechanical lift. The resident stated, "It hurts" and facial grimacing was noted. The resident was asked what hurts and the resident stated, "My legs, those sores on my legs." The lift sling was directly against the open wounds on the resident's posterior upper thighs. There were approximately 10 open wounds on the left thigh and 12 open wounds on the right thigh, all moist and of varying sizes. The resident requested to stay in bed until lunch. Blisters were noted under breast, left and right arms. The resident stated, "I am supposed to go to the Dermatologist." At 4:35 p.m., the resident was in a wheelchair in the dining room with the lift sling positioned underneath her buttocks with direct skin contact to the wounds on the posterior bilateral thighs. At 5:55 p.m., CNA #4 and #5 were preparing to transfer the resident to the bed from the wheelchair using a mechanical lift. The Director of Nursing (DON) was present in the room. The resident stated, "This pain is worse than a tooth ache." When asked what pain, the resident stated, "Sitting on these sores, it's horrible. Especially my left leg, it's horrible, it's really paining me." The DON asked the resident about the pain level. The resident stated, "7 to 8". The resident requested to stay in bed for 2-3 days so the thighs could heal some. The resident was crying and stating, "It hurts" during the transfer. The lift sling was directly pressing against the open areas on the posterior thighs during the transfer. g. On 11/2/11 at 6:05 p.m., the DON stated, "...Her family wants her up, but I think she should be in the bed and turned every 2 hours..." h. On 11/3/11 at 9:00 a.m., the resident was in the bed and the DON came into the room. The resident stated, "Look at my neck and face. It's much worse than yesterday. Please, you've got to do something to help me." The resident's neck area was red and moist with small fluid filled vesicles noted on the right side of the face and the neck folds. At 9:24 a.m. the DON stated, "I called the doctor and we are sending her to (Hospital) for evaluation..." i. On 11/3/11 at 11:00 a.m., the Wound Nurse, Registered Nurse (RN) #2 reviewed the resident's record and stated, "It started out as a gross [MEDICAL CONDITION] of posterior thighs... My first note dated 8/26/11, I thought (Resident #8) needed to go to the hospital... (Resident #8) came back with open superficial blisters... The family insisted (Resident #8) get up 3 times a day. I felt some of the sores were linear from the sling and (Resident #8) being scooted and the use of the Hoyer Lift. We brought in Physical Therapy and changed the size of the sling harness. I continued to talk with family to let them know I was concerned. I never saw them lift (Resident #8) without the burn dressing being in place. I thought (Resident #8) should not be getting up. I am not sure if I documented that or not... Staff said they had to get (Resident #8) up because of the family... (Resident #8) would cry constantly because she was afraid of her daughter... (Resident #8's) daughter is mean to her, talks to her terribly. (Resident #8) says 'I have to do what she says'. (Resident #8's) expression was teary when she said this." The surveyor asked RN #2 if she had reported this to anyone. RN #2 stated, "No, I didn't talk to anyone because I'm not here all the time... There was Physical Therapy, CNAs, and other people in the room. I didn't think about it being abuse. I was so focused on the wounds... I believe with her daughter insisting she get up, things got worse, her sores couldn't heal... (Resident #8) was always upset when I talked with her because she didn't want to get up because of the sores." j. On 11/3/11 at 2:15 p.m. CNA #2 stated, "We do only what we are told, we have been told (Resident #8) has to be gotten up 3 times a day for meals. It's mainly her family wanting her up. The resident says it hurts her bottom when she's up. It should be up to the resident what they do." The CNA was asked if the resident seemed afraid of her daughter. The CNA stated, "Maybe a little."

Based on observation, record review, and interview, the facility failed to ensure their abuse prohibition policy and procedure was implemented as evidenced by the staffs' failure to immediately report to the Administrator suspicions of abusive behaviors toward a resident by a family member so the incidents could be thoroughly investigated, interventions developed and implemented to ensure protection from the potential for further abuse and the incidents reported to the Office of Long Term Care (OLTC) and other agencies in accordance with state law for 1 of 1 (Resident #8) case mix resident who suffered verbal and mental abuse from a family member and had the potential to affect only this one resident who suffered verbal and mental abuse according to a list provided by the Administrator on 11/16/11. The findings are: 1. A copy of the facility Abuse Policy, provided by the Administrator on 11/3/11 at 10:41 a.m., documented, "Basic Responsibility: All Employees. Purpose: Provide an environment that is free from abuse, neglect, exploitation and misappropriation of resident property. Procedures: ... 2. Training:... Employees will be trained in the following areas:... c. Reporting of suspected abuse, neglect, mistreatment of [REDACTED]...5. Investigation:... suspected incidents of abuse, neglect, exploitation... mistreatment shall be reported and investigated... d) any visitor involved in the alleged abuse should be required to leave the facility pending the outcome of the investigation... h) the DON (Director of Nursing), Administrator (or designee) shall... interview the resident, question staff and residents to determine if anyone has intimate knowledge of the incident... 6. Protection:... the resident involved shall be assessed for injury, assured of protection from further harm, and monitored closely with both medical and social interventions as indicated. 7. Reporting /Response: a) all allegations of abuse, neglect... shall be reported to the Administrator and/or designees who shall initiate an investigation... b) ... promptly notify the following: state licensing/certification agency, the resident's attending physician, the resident's representative... e) with all reports made in a manner consistent with the mandated reporting requirements in effect at the time of the incident." 2. Resident #8 had [DIAGNOSES REDACTED]. The Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/6/11 documented the resident scored 12 (8-12 indicates moderately impaired) on the Brief Interview for Mental Status (BIMS), had a Total Severity Score of 12 (10-14 indicates moderate depression) on the Resident Mood Interview which included symptoms of feeling bad about herself or that she was a failure or had let herself or her family down 2-6 days over the last 2 weeks, and had open [MEDICAL CONDITION] other than ulcers, rashes, cuts (e.g. cancer lesion). A copy of the computerized signage, which was taped to the resident's closet door, was obtained on 11/3/11 at 2:05 p.m. and documented, "Resident to be up for all 3 meals, resident is to be bathed 3 times a week, resident is not to receive extra snacks unless it's from her refrigerator only, resident is to be turned every 2 hours while in bed, resident is to be changed every two hours, resident may wear briefs while up in wheelchairs only, resident teeth are to be soaked nightly, if resident refuses, the family is to be notified. No exceptions..." The document had a computerized signature "j (resident's daughter)." a. The Nurses Notes dated 10/5/11 at 3:10 p.m. documented, "Alert X (times) 3. Able to make needs known. Staff provide extensive assist (with) ADLs (Activities of Daily Living). Resident un-cooperative (with) staff at times regarding getting OOB (out of bed) to w/c (wheelchair). States she hurts or does not feel like getting up. Resident offered pain med (medication) prior to getting up today but declined stating she didn't feel like it. Resident encouraged to participate in ADLs. In bed at this time with call light in reach. Did get up for shower today..." b. The Nurses Notes dated 10/13/11 at 2:00 p.m. and signed by Licensed Practical Nurse (LPN) #1 documented, "Resident got up for breakfast @ (at) 0730 (7:30 a.m.) (with) encouragement. Refused to get up @ lunch. Daughter called @1150 (11:50 a.m.) to inform that resident declined to get up. Daughter called resident and resident stated she would get up. Resident stated that her daughter was acting crazy and that if she didn't get up that she would come up to facility and scrub her hard and she didn't want to experience that kind of treatment. I informed social worker of comments made by resident." At 11:00 p.m. the Nurses Notes documented, "... Daughter phoned @ 1730 (5:30 p.m.) (with) c/o (complaints of) resident laying in bed... (Assistant Director of Nursing (ADON)) notified. Will continue to monitor." On 11/3/11 at 2:45 p.m., LPN #1 stated, (Resident #8) doesn't like to get up that much, but will get up around 10:30 a.m. and stay up 4 hours. We were told if she says no, we are to call the daughter. The LPN was asked to clarify the nurses notes documented on 10/13/11. The LPN stated, "I noticed the resident was upset and I asked why won't you get up for us but you will for your daughter. She stated, 'You just don't understand. She will come in and be real rough with me, she'll scrub real hard.' I didn't ask any questions." The LPN was asked if she thought this was abuse. LPN #1 stated, "Yes, I would consider it abuse. Yes, I do think (Resident #8) is scared of her daughter. I have seen her in tears." The LPN was asked if she had reported this to anyone. She stated she had only reported it to the Social Worker. The LPN also stated, "The family friend got upset with me when I told her that I am the resident's advocate and I will not get her up unless she wants up. I've reported it the social worker on two occasions." c. A physician order [REDACTED]. On 11/4/11 at 1:30 p.m., the Licensed Social Worker (LSW) was asked if she had knowledge of the physician order [REDACTED]. The LSW stated, "Yes, her nurse told me about it." When asked if the appointment had been made she stated, "No, when the nurse told me about the physicians order for a dermatology follow-up I told the resident's daughter about it. The resident's daughter said her mother didn't need to go to the Dermatologist, so I never did make her an appointment." When asked if she had notified the nurse, the Director of Nursing (DON), the Administrator or the physician about the daughter's refusal she stated, "No, I never did report what the daughter had said, and I never reported to anyone that a dermatology appointment was not being made." d. Social Service Progress dated 10/31/11 documented, "...daughter told her mother that if she doesn't start taking showers and getting up that she will make her a DNR (Do Not Resuscitate). Resident was very upset regarding the way her daughter talked to her." The progress notes dated 11/1/11 documented, "Licensed Social Worker (LSW) talked to resident's daughter and told her that LSW was monitoring her mom to make sure she gets up 3 x a day ...Resident stated, "She was tired of her daughter dogging her and talking the way she does." The progress notes dated 11/2/11 documented, "LSW visited with resident and resident's daughter in the dining room, resident's daughter got on to her mom for having a diet Dr. Pepper and graham crackers. The resident was upset". On 11/3/11 at 3:10 p.m., the LSW was asked to verify the copied Social Service progress notes. The LSW stated, "Yes, these are my notes." When asked if she reported the daughter's behavior toward the resident she stated, "No, I didn't report it because her daughter is caring, even though she does make her mother cry. She just wants her mother to do better... I don't think it is abuse if it gets the resident up and taking care of herself... the resident told us she would comply that is why I didn't write it or report it... but now that I think about it, I guess it is abuse." e. On 11/1/11 at 2:13 p.m., Resident #8 was in the bed. The resident told the surveyor she would like to stay in the bed for about 3 days to let the wounds on her legs heal. The resident stated, "When they get me up, the lift pad scratches them." The resident was asked if she had spoken with the nurse about this and she stated, "No." Certified Nurse Assistant (CNA) #1, who was in the room was asked to have a nurse come to talk to the resident about staying in the bed. f. On 11/2/11 at 8:55 a.m., the resident was in the wheelchair in her room. The resident stated that she had never spoken to the nurse about staying in the bed for a few days. She stated, "The nurse said my legs were better." At 10:10 a.m., CNA #2 and #3 were transferring the resident to the bed from the wheelchair using a mechanical lift. The resident stated, "It hurts" and facial grimacing was noted. The resident was asked what hurts and the resident stated, "My legs, those sores on my legs." The lift sling was directly against the open wounds on the resident's posterior upper thighs. There were approximately 10 open wounds on the left thigh and 12 open wounds on the right thigh, all moist and of varying sizes. The resident requested to stay in bed until lunch. Blisters were noted under breast, left and right arms. The resident stated, "I am supposed to go to the Dermatologist." At 4:35 p.m., the resident was in a wheelchair in the dining room with the lift sling positioned underneath her buttocks with direct skin contact to the wounds on the posterior bilateral thighs. At 5:55 p.m., CNA #4 and #5 were preparing to transfer the resident to the bed from the wheelchair using a mechanical lift. The Director of Nursing (DON) was present in the room. The resident stated, "This pain is worse than a tooth ache." When asked what pain, the resident stated, "Sitting on these sores, it's horrible. Especially my left leg, it's horrible, it's really paining me." The DON asked the resident about the pain level. The resident stated, "7 to 8". The resident requested to stay in bed for 2-3 days so the thighs could heal some. The resident was crying and stating, "It hurts" during the transfer. The lift sling was directly pressing against the open areas on the posterior thighs during the transfer. g. On 11/2/11 at 6:05 p.m., the DON stated, "...Her family wants her up, but I think she should be in the bed and turned every 2 hours..." h. On 11/3/11 at 9:00 a.m., the resident was in the bed and the DON came into the room. The resident stated, "Look at my neck and face. It's much worse than yesterday. Please, you've got to do something to help me." The resident's neck area was red and moist with small fluid filled vesicles noted on the right side of the face and the neck folds. At 9:24 a.m. the DON stated, "I called the doctor and we are sending her to (Hospital) for evaluation..." i. On 11/3/11 at 11:00 a.m., the Wound Nurse, Registered Nurse (RN) #2 reviewed the resident's record and stated, "It started out as a gross [MEDICAL CONDITION] of posterior thighs... My first note dated 8/26/11, I thought (Resident #8) needed to go to the hospital... (Resident #8) came back with open superficial blisters... The family insisted (Resident #8) get up 3 times a day. I felt some of the sores were linear from the sling and (Resident #8) being scooted and the use of the Hoyer Lift. We brought in Physical Therapy and changed the size of the sling harness. I continued to talk with family to let them know I was concerned. I never saw them lift (Resident #8) without the burn dressing being in place. I thought (Resident #8) should not be getting up. I am not sure if I documented that or not... Staff said they had to get (Resident #8) up because of the family... (Resident #8) would cry constantly because she was afraid of her daughter... (Resident #8's) daughter is mean to her, talks to her terribly. (Resident #8) says 'I have to do what she says'. (Resident #8's) expression was teary when she said this." The surveyor asked RN #2 if she had reported this to anyone. RN #2 stated, "No, I didn't talk to anyone because I'm not here all the time... There was Physical Therapy, CNAs, and other people in the room. I didn't think about it being abuse. I was so focused on the wounds... I believe with her daughter insisting she get up, things got worse, her sores couldn't heal... (Resident #8) was always upset when I talked with her because she didn't want to get up because of the sores." j. On 11/3/11 at 2:15 p.m. CNA #2 stated, "We do only what we are told, we have been told (Resident #8) has to be gotten up 3 times a day for meals. It's mainly her family wanting her up. The resident says it hurts her bottom when she's up. It should be up to the resident what they do." The CNA was asked if the resident seemed afraid of her daughter. The CNA stated, "Maybe a little."

Based on observation, record review, and interview the facility failed to ensure the provision of the necessary care and services for Resident #8 to maintain the highest practicable, mental and physical well-being, in accordance with the comprehensive assessment and plan of care. The facility failed to ensure the physician's requests for dermatology consult to evaluate continued complaints of a rash, blisters and sores were acted upon; to ensure the lift sling did not directly press against open [MEDICAL CONDITION]; interventions were developed and implemented to relieve pain and promote optimal wound healing for 1 of 1 (Resident #8) case mix resident who had a deterioration of skin condition and increased pain upon transfer/sitting. This failed practice resulted in a pattern of actual harm to Resident #8 who experienced increased pain and deterioration in skin condition and had the potential to affect only this one resident who experienced increased pain and deterioration in skin condition according to a list provided by the Administrator on 11/16/11. The findings are: Resident #8 had [DIAGNOSES REDACTED]. The Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/6/11 documented the resident scored 12 (8-12 indicates moderately impaired) on the Brief Interview for Mental Status (BIMS), had a Total Severity Score of 12 (10-14 indicates moderate depression) on the Resident Mood Interview which included symptoms of feeling bad about herself or that she was a failure or had let herself or her family down 2-6 days over the last 2 weeks, was dependent for transfers and had open [MEDICAL CONDITION] other than ulcers, rashes, cuts (e.g. cancer lesion). A copy of the computerized signage, which was taped to the resident's closet door, was obtained on 11/3/11 at 2:05 p.m. and documented, "Resident to be up for all 3 meals, resident is to be bathed 3 times a week, resident is not to receive extra snacks unless it's from her refrigerator only, resident is to be turned every 2 hours while in bed, resident is to be changed every two hours, resident may wear briefs while up in wheelchairs only, resident teeth are to be soaked nightly, if resident refuses, the family is to be notified. No exceptions..." The document had a computerized signature "j (resident's daughter)." a. Resident admitted to facility 3/16/11 Skin and Body assessment sheet documented: "Skin in excellent condition no bruises or abrasions". b. Nurses notes dated 7/8/11 documented, "C/O (complains of) itching around neck and mouth. Rash noted on (right) side of neck and around mouth..." Nurses notes dated 7/14/11 documented, "...Resident remains on antibiotic for rash... Performed skin assessment... resident noted to have a small opened area on left lower hip and a small raised bump on her tailbone..." Nurses notes dated 7/15/11 documented, "c/o skin irritation. Skin on forehead and jaw on right side with dry flaky patches. Skin reddened around gray dead skin patches. Resident irritated that no treatment has been implemented..." Nurses notes dated 7/18/11 documented, "Finished antibiotics... resident concerned about cream for legs... c/o facial rash... area between butt checks looks irritated... moist with slight odor. Pigmentation discolored with pinkish areas. Still concerned about facial rash..." Nurses notes dated 7/22/11 documented, "...restarted on [MEDICATION NAME] antibiotics today... rash present..." c. A physician order [REDACTED]." As of 11/4/11, there was no documentation in the clinical record related to dermatologist appointment requested on 7/22/11. d. The Nurses Notes dated 10/5/11 at 3:10 p.m. documented, "Alert X (times) 3. Able to make needs known. Staff provide extensive assist (with) ADLs (Activities of Daily Living). Resident un-cooperative (with) staff at times regarding getting OOB (out of bed) to w/c (wheelchair). States she hurts or does not feel like getting up. Resident offered pain med (medication) prior to getting up today but declined stating she didn't feel like it. Resident encouraged to participate in ADLs. In bed at this time with call light in reach. Did get up for shower today..." The Nurses Notes dated 10/13/11 at 2:00 p.m. documented, "Resident got up for breakfast @ (at) 0730 (7:30 a.m.) (with) encouragement. Refused to get up @ lunch. Daughter called @1150 (11:50 a.m.) to inform that resident declined to get up. Daughter called resident and resident stated she would get up. Resident stated that her daughter was acting crazy and that if she didn't get up that she would come up to facility and scrub her hard and she didn't want to experience that kind of treatment. I informed social worker of comments made by resident." The notes were signed by Licensed Practical Nurse (LPN) #1. At 11:00 p.m. the Nurses Notes documented, "... Daughter phoned @ 1730 (5:30 p.m.) (with) c/o (complaints of) resident laying in bed... (Assistant Director of Nursing (ADON)) notified. Will continue to monitor." On 11/3/11 at 2:45 p.m., LPN #1 stated, (Resident #8) doesn't like to get up that much, but will get up around 10:30 a.m. and stay up 4 hours. We were told if she says no, we are to call the daughter. The LPN was asked to clarify the nurses notes documented on 10/13/11. The LPN stated, "I noticed the resident was upset and I asked why won't you get up for us but you will for your daughter. She stated, 'You just don't understand. She will come in and be real rough with me, she'll scrub real hard.' I didn't ask any questions." The LPN was asked if she thought this was abuse. LPN #1 stated, "Yes, I would consider it abuse. Yes, I do think (Resident #8) is scared of her daughter. I have seen her in tears." The LPN was asked if she had reported this to anyone. She stated she had only reported it to the Social Worker. The LPN also stated, "The family friend got upset with me when I told her that I am the resident's advocate and I will not get her up unless she wants up. I've reported it the social worker on two occasions." e. physician progress notes [REDACTED]...1. rash-[MEDICAL CONDITION]?... 2. wound bilateral buttocks 3. blistering to BLE (bilateral lower extremities)... pt. (patient) to be sent to the ED (emergency department) for evaluation of rash, blisters and sores..." f. A physician order [REDACTED]. As of 11/4/11, there was no documentation in the clinical record related to dermatologist appointment requested on 10/25/11. On 11/4/11 at 1:30 p.m., the LSW was asked if she had knowledge of the physician order [REDACTED]. The LSW stated, "Yes, her nurse told me about it." When asked if the appointment had been made she stated, "No, when the nurse told me about the physicians order for a dermatology follow-up I told the resident's daughter about it. The resident's daughter said her mother didn't need to go to the Dermatologist, so I never did make her an appointment." When asked if she had notified the nurse, the DON, the Administrator or the physician about the daughter's refusal she stated, "No, I never did report what the daughter had said, and I never reported to anyone that a dermatology appointment was not being made." g. Social Service Progress dated 10/31/11 documented, "...daughter told her mother that if she doesn't start taking showers and getting up that she will make her a DNR (Do Not Resuscitate). Resident was very upset regarding the way her daughter talked to her." The progress notes dated 11/1/11 documented, "Licensed Social Worker (LSW) talked to resident's daughter and told her that LSW was monitoring her mom to make sure she gets up 3 x a day ...Resident stated, "She was tired of her daughter dogging her and talking the way she does." The progress notes dated 11/2/11 documented, "LSW visited with resident and resident's daughter in the dining room, resident's daughter got on to her mom for having a diet Dr. Pepper and graham crackers. The resident was upset". h. On 11/1/11 at 2:13 p.m., Resident #8 was in the bed. The resident told the surveyor she would like to stay in the bed for about 3 days to let the wounds on her legs heal. The resident stated, "When they get me up, the lift pad scratches them." The resident was asked if she had spoken with the nurse about this and she stated, "No." Certified Nurse Assistant (CNA) #1, who was in the room was asked to have a nurse come to talk to the resident about staying in the bed. i. On 11/2/11 at 8:55 a.m., the resident was in the wheelchair in her room. The resident stated that she had never spoken to the nurse about staying in the bed for a few days. She stated, "The nurse said my legs were better." At 10:10 a.m., CNA #2 and #3 were transferring the resident to the bed from the wheelchair using a mechanical lift. The resident stated, "It hurts" and facial grimacing was noted. The resident was asked what hurts and the resident stated, "My legs, those sores on my legs." The lift sling was directly against the open wounds on the resident's posterior upper thighs. There were approximately 10 open wounds on the left thigh and 12 open wounds on the right thigh, all moist and of varying sizes. The resident requested to stay in bed until lunch. Blisters were noted under breast, left and right arms. The resident stated, "I am supposed to go to the Dermatologist." At 4:35 p.m., the resident was in a wheelchair in the dining room with the lift sling positioned underneath her buttocks with direct skin contact to the wounds on the posterior bilateral thighs. At 5:55 p.m., CNA #4 and #5 were preparing to transfer the resident to the bed from the wheelchair using a mechanical lift. The Director of Nursing (DON) was present in the room. The resident stated, "This pain is worse than a tooth ache." When asked what pain, the resident stated, "Sitting on these sores, it's horrible. Especially my left leg, it's horrible, it's really paining me." The DON asked the resident about the pain level. The resident stated, "7 to 8". The resident requested to stay in bed for 2-3 days so the thighs could heal some. The resident was crying and stating, "It hurts" during the transfer. The lift sling was directly pressing against the open areas on the posterior thighs during the transfer. j. On 11/2/11 at 6:05 p.m., the DON stated, "The sling is not supposed to be up on those open areas. There should be a pad or barrier between her and the lift sling. Her family wants her up, but I think she should be in the bed and turned every 2 hours. I agree the sling should not be touching those opened areas at all." k. On 11/3/11 at 9:00 a.m., the resident was in the bed and the DON came into the room. The resident stated, "Look at my neck and face. It's much worse than yesterday. Please, you've got to do something to help me." The resident's neck area was red and moist with small fluid filled vesicles noted on the right side of the face and the neck folds. At 9:24 a.m. the DON stated, "I called the doctor and we are sending her to (Hospital) for evaluation... About the problem with the lift yesterday on this patient. Physical Therapy in-serviced the 3-11 (3:00 p.m. - 11:00 p.m.) shift and the rest of the shifts will be in-serviced about making sure a pad is used between residents and the sling and we will monitor that from now on." l. On 11/3/11 at 11:00 a.m., the Wound Nurse, Registered Nurse (RN) #2 reviewed the resident's record and stated, "It started out as a gross [MEDICAL CONDITION] of posterior thighs... My first note dated 8/26/11, I thought (Resident #8) needed to go to the hospital... (Resident #8) came back with open superficial blisters... The family insisted (Resident #8) get up 3 times a day. I felt some of the sores were linear from the sling and (Resident #8) being scooted and the use of the Hoyer Lift. We brought in Physical Therapy and changed the size of the sling harness. I continued to talk with family to let them know I was concerned. I never saw them lift (Resident #8) without the burn dressing being in place. I thought (Resident #8) should not be getting up. I am not sure if I documented that or not... Staff said they had to get (Resident #8) up because of the family... I believe with her daughter insisting she get up, things got worse, her sores couldn't heal... (Resident #8) was always upset when I talked with her because she didn't want to get up because of the sores." The RN was asked if she felt it was appropriate for the lift sling to be touching the open wounds. The RN stated, "No, no, no, they should at least use chucks, the slings are rough in texture." m. On 11/3/11 at 2:15 p.m. CNA #2 stated, "We do only what we are told, we have been told (Resident #8) has to be gotten up 3 times a day for meals. It's mainly her family wanting her up. The resident says it hurts her bottom when she's up. It should be up to the resident what they do."

Based on record review and interview, the facility failed to ensure allegations of abuse were immediately reported to the Administrator/Designee, the allegations of abuse were thoroughly investigated, residents were protected from the potential for further abuse and the allegations of abuse were reported to local law enforcement and the Office of Long Term Care in accordance with state law for 5 of 5 (Residents #4, #5, #8, #9 and #10) case mix residents who had allegations of abuse reported. The failed practice resulted in Immediate Jeopardy that likely caused or could have caused serious harm for Residents #5 and #10 who made allegations of staff to resident psychological abuse by Certified Nursing Assistant (CNA) #3, and for Resident #8, #4, and #9 who were the subjects of an allegation of staff to resident abuse by CNA #2. The failed practice was likely to cause more than minimal harm for 95 residents who were at risk for abuse, according to the Roster Sample Matrix received from the Administrator on 6/2/11 at 5:20 a.m. The facility was informed of the Immediate Jeopardy condition on 6/3/11 at 12:12 p.m. The findings are: 1. Resident #10 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 3/30/11 documented the resident scored 13 (13-15 cognitively intact) in the brief interview for mental status (BIMS) and over the last 2 weeks felt down, depressed or hopeless for 2 to 6 days. a. A Report of Concern dated 3/22/11 (no time noted) documented, "Name of person expressing Concern: (Resident #10)... Concern: "CNA on 3-11 (3:00 p.m. to 11:00 p.m. shift) red from Louisiana is sprinkling Voodoo dust in my rm (room)... Signature: Registered Nurse (RN) #1... Results of Investigation: "CNA (CNA #3) will not work with this resident. (CNA #3) did admit discussing this 'Voodoo' joking with the resident. She was instructed and given boundaries of the role of the CNA interaction with residents. Directed to not to enter the resident rm." 1) On 6/2/11 at 9:45 a.m., the resident, with the Director of Nursing (DON) present, was interviewed and stated, "This girl (CNA #3) was from Louisiana. She was throwing Voodoo dust. She had a little bottle of dust in her pocket. She threw some Voodoo dust in my eyes. I was asleep. When I woke up my eyes were burning. It felt like sand. She told me she had put Voodoo dust in our eyes - me and my roommate. She talked real foolish, like she was bragging about it. I felt like she was trying to hurt me. I wouldn't eat food from her." The resident was asked if he believed in Voodoo. He stated, "I have seen people being 'fixed'. I believe once it gets in you it can hurt you. She said her family was Cherokee. Cherokee women do that Voodoo stuff. To me she acted like a devil. I don't want her handling my food or anything. I don't trust her. I feel that she's the devil. Any time a person does what she does and brags about it, she's a devil. I don't want her around me. I don't trust her. My roommate doesn't trust her either. She doesn't come around anymore. The stuff in the bottle looks like brown dust. She showed it to us. She said she was going to blind me. I told my sister; my sister called up here. The Voodoo lady got mad. I think (RN #1) talked to me. She told me the Voodoo lady wouldn't be back in my room. She didn't ask me any questions about the Voodoo dust. (CNA #3) is the Voodoo lady. She keeps that bottle on her. If she brought me food I would probably eat it because I would be hungry - if it was from the kitchen." 2) On 6/2/11 at 10:03 a.m., RN #1 was interviewed and stated, "(Resident #10)'s sister called and asked me about that 'crazy woman'. It was on the weekend. I went through the process to then turn it over to our Social Services and the Administrator. I turned the concern into the front office - to (Assistant Administrator #1) and (Administrator). I don't handle the concerns. I was not aware that he was afraid of the lady." 3) On 6/2/11 at 10:07 a.m., Assistant Administrator #1 was interviewed relative to the "Report of Concern" dated 3/22/11 and stated, "Yes, I have seen the report. I just log them (Report of Concern) in and file them." 4) On 6/2/11 at 10:10 a.m., the Administrator read the "Report of Concern" relative to the incident of 3/22/11, as requested by the surveyor. The Administrator stated, "First, I think (Resident #10) needs a psych (psychiatric) eval (evaluation). I need to look to see about his mental status. I would be removing the CNA from that area. It would be an allegation of abuse." When asked if she was aware of the culture that believes in Voodoo, the Administrator stated, "Yes, there are some in Louisiana." The Administrator stated, "Someone should have done more of an investigation than we did. Anytime a resident would call a person a devil that would be a real concern." 5) On 6/2/11 at 10:15 a.m., the DON was asked what her impression was of the resident's feelings toward CNA #3. The DON stated, "He's scared, frightened. He called her a devil." 6) On 6/2/11 at 10:20 a.m., CNA #3 stated, "I'm from Lake Charles, Louisiana. My grandfather was full blown Cherokee." The CNA was asked, "Do you ever carry anything to work with you with anything in it?" CNA #3 stated, "No." The CNA was asked if she had ever sprinkled any Voodoo dust on any person. The CNA stated, "No." When asked if she believed in Voodoo, CNA #3 stated, "No." She was asked if she had ever sprinkled any dust. The CNA stated, "No. (RN #1) called me in. (Resident #10) asked me if I was from Louisiana. I don't practice Voodoo. I don't believe in Voodoo. I'm a Catholic. I still work with (Resident #10). I bathe him and set up his tray. If I'm assigned to him. (RN #1) told me not to go in his room. She did not say 'ever'. You can call him in and ask him. He's asked me to set up his tray, open his cartons and change him." CNA #3 was asked why someone would think she had sprinkled Voodoo dust on them and told them they were going to go blind. The CNA stated, "I don't know. I haven't did anything to him. He always wants to be first. He gets mad if he's not first. He got mad at (another employee) and said (the other employee) had put a foot in his back. There's several CNAs here that aren't to go in his room." CNA #3 was asked who had released her to go back into the resident's room. The CNA stated, "Whoever assigned me to him. (RN #1) said to stay out of his room at that time. I don't believe in Voodoo. I don't know anyone that believes in Voodoo. There could be some people in this nursing home that believe in Voodoo. I don't know, that doesn't come up in my conversation." When asked if she carried Voodoo dust with her to work, CNA #3 stated, "All I carry to work is my keys and my pen." 7) On 6/3/11 at 10:35 a.m., CNA #5 stated, "A while back, probably in March 2011), (Resident #10) said this girl keeps putting dust in my cup. He didn't say who. He wasn't upset about it. Like, he wanted me to get him a clean cup. Like, last month he said that girl (CNA #3) keeps putting Voodoo dust in his cup. I asked if he told the nurse. He said yes. I asked (Licensed Practical Nurse (LPN) #3) and she said she knew about it. She told me (CNA #3) could not go into his room, that I had to take care of him. (CNA #3) told me she could not go in his room; I didn't ask why. That was probably one and one-half months ago, the end of April (2011)." When asked if the resident was upset, CNA #5 stated, "He was very upset, more of the Voodoo. He was worried about what if something she would do. He was worried and concerned about her and how she was acting." 8) On 6/3/11 at 10:58 a.m., LPN #3 stated, "(Resident #10) said it started as a joke. It was something about fairy dust that she was joking about sprinkling in his eyes. After that they said he was scared of it. He said he was afraid of her to work with him. The Aides said that he had said this. He never complained to me personally... I never reported it due to I thought it had been taken care of." 9) On 6/3/11 at 3:00 p.m., CNA #6 stated, "I heard from (Resident #10), not sure of the dates. In April (2011) I think. It was about Voodoo dust or Angel Dust on him. He said (CNA #3) did it." 10) On 6/3/11 at 11:50 a.m., the resident was asked how many times CNA #3 had used the Voodoo dust on him or threatened to use it. The resident stated, "About five times." b. An OLTC (Office of Long Term Care) Incident and Accident Report (I & (and) A) documented, "Date and Time Submitted (if known: 06/02/2011 (at) 11:00 a.m. Date & Time of Discovery: 6/2/11 (at) 10:30 a.m. ...Date of I&A: 3/22/11 Time: 3-11 shift... Name of Resident: (Resident #10)... Status of Alleged Perpetrator: Facility Employee... Type of Incident: Abuse... Emotional/Mental... Summary of Incident... On 3/22/11, (Resident #10) reported to (RN #1) that a 3-11 CNA, was sprinkling 'voodoo dust' in his room. (Resident #10) described the CNA as 'red' (skin color) and being from Louisiana. (RN #1) determined that the CNA was (CNA #3). (RN #1) completed a report of concern (grievance) form and addressed the concern with (CNA #3). (CNA #3) admitted to having a conversation jokingly with (Resident #10) about ''voodoo dust'. (RN #1) instructed (CNA #3) on (boundaries), the role of the C.N.A. and appropriate interaction with residents. (CNA #3) was instructed to not work with resident and not to enter his room unless during an emergency situation and no other staff is available. On today 6/2/11, the facility Administrator (name of Administrator) was informed by OLTC survey team that this incident is reportable and a 7734 and 762 need to be completed." 1) An OLTC Witness Statement Form documented, "Date 6/2/11 Time 11:20 a.m. Witness Full Name (CNA #3) ...Shift 3-11 p.m. ...State in your own words what you witnessed (be very descriptive and sign below): 'I don't know the exact date when I started working with (Resident #10) (and) (Resident #5) on 400 hall but the first day I started working with (Resident #10) he asked me was I mixed and I told him no. (Resident #10) asked me where was I from and I told him Louisiana. (Resident #10) asked me did I have Indian in me and I told him my great grandfather was Cherokee Indian. (Resident #10) asked me did I believe in voodoo and I told him no that you had to be a weak person to believe in voodoo. Then one day (RN #1) called me in the office and asked me was I from Louisiana and I told her yes and she asked me did I know voodoo and I told her no and she asked me did I sprinkle voodoo dust on (Resident #10) and I told her no. She asked me have I ever came to (Resident #10) about voodoo and I told (RN #1) that (Resident #10) would tease me about knowing voodoo and I told him I didn't believe in voodoo. (RN #1) told me (Resident #10) called his sister and told her that I sprinkled voodoo dust in his eyes and he was afraid I was putting something in his food. I told (RN #1) that (Resident #10) was always talking about voodoo when I walked in the room. (RN #1) told me not to go back in his room. They moved me to the back of 400 hall. Since March (Resident #10) has asked me to do several things for him. To open milk cartons on his tray, give something to drink and even change him. I have never refused to do anything for (Resident #10) or had any other conversation with (Resident #10). I wasn't told to stay out of (Resident #10's) room forever or I wouldn't have been assigned to his room in as recently as yesterday (6/1/11). (Resident #10) asked me to help out of the dining room. If (Resident #10) is so afraid of me, why do he still ask me to do thing for him if thinks I know voodoo. (Resident #10) didn't start saying these things about me until I told him if I was with another resident he would have to wait. (Resident #10) is very demanding and you can't do what him or his roommate (Resident #5) wants right then they get angry. (Resident #10) want you to drop whatever you're doing when he puts on his light and if you don't he tries to get you fired. He has told other employees, he was going to get me fired. I'm not the only employee (Resident #10) has done this to." 2) An OLTC Witness Statement Form documented, "Date 6/2/11 Time (blank) Witness Full Name (LPN #3)... Shift 7/3 (7:00 a.m. to 3:00 p.m.) ...State in your own words what you witnessed (be very descriptive and sign below): (Resident #10) used to joke around (with) (CNA #3) because she is from New Orleans. He would say 'She may sprinkle fairy dust in my eyes'. He would be laughing and joking about it. He never complained about the care he received from her as an aide. He never voiced any concerns to me about being afraid of her." c. On 6/7/11/ at 9:45 a.m., the Administrator stated, "I had no knowledge of the 3/22/11 Report of Concern until the surveyor questioned me regarding it." The Administrator was asked if she had looked at the "Report of Concern Log" since 3/22/11. The Administrator stated, "I had not looked at it from 3/22/11, not for March." The Administrator was asked if she would consider the "Report of Concern" dated 3/22/11 as a true concern. The Administrator stated, "I think this Report of Concern should have been investigated and reported to the OLTC." The Administrator was asked if Resident #10 was protected. The Administrator stated, "No, he was not." 2. Resident #5 had [DIAGNOSES REDACTED]. The Quarterly MDS with an ARD of 4/1/11 documented the resident scored 14 (13-15 cognitively intact) per BIMS. a. On 6/2/2011 at 11:00 a.m., the Administrator submitted an OLTC (Office of Long Term Care) Incident and Accident Report that documented, "Date and Time Submitted (if known): 06/03/2011 10:30 a.m. ...Date & Time of Discovery: (blank)... Date of I & A: unknown. Time: 3-11 shift... Name of Resident: (Resident #5)... Status of Alleged Perpetrator: Facility Employee... Type of Incident: ...Abuse: ...Emotional/Mental ...Summary of Incident ...Today 6/3/11 at approximately 9:25 a.m. during an OLTC survey, it was brought to the facility's attention that (Resident #5) had been threatened with 'voodoo'. The facility is currently conducting an investigation into a similar allegation made by (Resident #5's) roommate against (CNA #3). (Resident #5) was immediately interviewed by (Administrative Assistant). (Resident #5) was asked the following questions: Are you aware of any staff treating residents in an inappropriate manner? (Resident #5) responded 'No, not other than this incident'. Are you aware of any residents being abused, neglected or mistreated by any staff, visitor or other resident? (Resident #5) responded 'No, not other than this incident.' Are you aware of any resident including yourself being mistreated or threatened by (CNA #3)? '(Resident #5) responded 'Yes, (CNA #3) saw me in the dining room and stated 'If (Resident #10) doesn't watch out I'm going to voodoo him and I just wanted you to know what was on my mind.' When did this happen? (Resident #5) responded 'Happened a week or so ago'. Did you hear (CNA #3) threaten (Resident #10) by saying she would sprinkle Voodoo dust in the room? (Resident #5) responded 'No, but I did hear (CNA #3) and (Resident #10) talking in the room and (CNA #3) said if (Resident #10) wasn't careful she would put voodoo dust in his eyes.' Did (CNA #3) threaten you by saying she would sprinkle Voodoo dust in the room? (Resident #5) responded 'No, she told me that I needed to be careful because when she came to voodoo (Resident #10) she would get me too.' (Resident #5) ended our interview by stating 'I hope (CNA #3) doesn't come back to work here because I'm afraid I won't wake up from my sleep because of her voodoo. I believe voodoo is real and she is capable. I don't play when it comes to voodoo'." b. On 6/3/11 at 8:40 a.m., the resident was asked if a staff member had ever talked to him about voodoo. The resident stated, "Yes, I don't know her name, but she told us she had some voodoo dust to sprinkle on us to make us go to sleep and not wake up." He stated that he did not want her taking care of him again. The resident also stated, "I'm scared of anyone who talks about voodoo." c. On 6/3/11 at 11:30 a.m., the resident was asked how many times (CNA #3) had sprinkled or threatened to sprinkle voodoo dust on him. The resident stated, "To him, just that one time. She threw dust on my roommate more than that, but just told me she was going to do it." 3. A Report of Concern documented, "name of person expressing concern: (CNA #1) Date: 5/16/11... Resident Involved: (Resident #4, Resident #8, Resident #9)... Concern: Went into room to change R (resident) on round. I (CNA #1) observed (CNA #2) saying 'Boo' to wake up (Resident #4). Also observed (CNA #2) getting frustrated and rough handling pts (patients) and calling pts names... Results of investigation: (blank)." a. On 6/2/11 at 6:20 a.m., the Administrator was interviewed about the Report of Concern turned in by CNA #1. The Administrator stated, "They (CNA #1 and CNA #2) went to school together." The Administrator was asked if in the report CNA #1 had made an allegation of abuse by (CNA #2). The Administrator stated, "There was no abuse. We did an internal investigation." The Administrator was asked if saying 'Boo' to wake a resident was all right. The Administrator stated, "No, that is not all right." b. On 6/2/11 at 6:08 a.m., the DON was asked if it was reported to her that a CNA was making residents cry. The DON stated, "I was called to the Administrator's office. (CNA #1) was there. She filled out a Report of Concern. We called (CNA #2) in. CNA #1 told of allegations that (CNA #2) had woke up a resident with 'Boo', and was rough while turning a resident." When asked if she considered these allegations as abusive, the DON stated, "Yes, suspected abuse. That warrants investigation. I obtained witness statements from people working and from (CNA #1). We took (CNA #2) off for 2 or 3 days while it was investigated. I did not file a report with State on an allegation of abuse. When we finished the investigation it was found unsubstantiated. We brought (CNA #2) back to day shift. She was in orientation." 1) An OLTC Witness Statement Form dated 5/17/11 at 2:57 p.m. documented, "...Witness Full Name (CNA #2) ...Shift 11p - 7a (11:00 p.m. to 7:00 a.m.)... State in your own words what you witnessed (be very descriptive) and sign below: I have never been rough with a resident. There have been times when I have not been able to change a resident and have went and got help. When I went into (Resident #4)'s room, I did frighten her by saying 'boo' but I did apologize to her. I never called (Resident #9) a 'meanie' to her face and make her cry." 2) An OLTC Witness Statement Form dated 5/18/11 at 8:25 a.m. documented, "...Witness Full Name (LPN #2)... Shift: 11p - 7a... State in your own words what you witnessed (be very descriptive) and sign below: On May 14th, 2011 (at) approx (approximately) 8:00-8:30 p.m., I was called to a R (resident) room by (CNA #1) in regards to (CNA #2) saying 'boo' to a R and frightening the R. Told (CNA #1) to fill out a Report of Concern and make sure she round with (CNA #2) from rm (room) to rm to observe any other abusive behavior. I did assess R (at) approx 8:45 to ask if she was ok. R was fine just c/o (complained of) being cold. (No) further reports of abuse reported this shift." 3) On 6/2/11 at 7:15 a.m., a typed statement dated 5/18/11 at 4:00 p.m. was received from the DON. The statement was signed by the DON and documented: "I was notified on May 17th, 2011 by (CNA #1) that she suspected (CNA #2) of abuse of residents. (CNA #2) was called to the facility where she completed her statement. Notified (CNA #2) at that time she will be placed on suspension until completion of our internal investigation. I received a statement from (CNA #1). Statements were also received from 2 LPN (Licensed Practical Nurses) nurses and 1 RN (Registered Nurse) nurse that were present at the time of the incident. Upon completion of my internal investigation, the suspected abuse has been found unsubstantiated. Interview of residents that are oriented on halls 300 and 400 stated they feel safe and no one is rough with their care. Upon complete assessment of the residents in question. I found no bruising, residents stated they felt safe and verbalized no rough handling. (CNA #2) will be allowed to return to work. She will be placed on probation and retraining. Her training will consist of 30 days on day shift with a preceptor. Will retrain (CNA #2) on the appropriate manner to speak to residents, families and co-workers." c. On 6/2/11 at 5:20 a.m., CNA #1 stated, "I've reported on pink sheets. No one ever does anything with it. I've reported to (RN #1), pink slip slipped under her door. I noticed a fell ow CNA (CNA #2) being abusive, made a resident cry, called a patient a 'Meanie' on first shift. Woke a patient up by saying 'Boo'." d. On 6/3/11 at 11:20 a.m., the Administrator was asked if after receiving the Report of Concern dated 5/16/11, the family, police or physician were notified. The Administrator stated, "No." The Administrator was asked what the responsibility of the Administrator was in such matters. The Administrator stated, "An internal investigation and report to the state. It should have been reported the day of the reporting. There was no thorough investigation." On 6/7/11 at 9:45 a.m., the Administrator was interviewed regarding the Report of Concern dated 5/16/11, specific to CNA #2 and the care of Residents #4, #8 and #9. The Administrator was asked what she had done when the Report of Concern came to her attention, relative to investigation, protection and reporting. The Administrator stated, "The Report of Concern, I gave it to the DON. I told her to call in the staff for interviews, that I felt we had issues on the night shift. We received the concern on the 17th. (CNA #2) wasn't scheduled to work again until 5/20/11. On 5/20/11 we had (CNA #2) come in to work on the day shift for additional training. It was alleged abuse on 5/17/11 when I got the report. With an allegation of abuse the observer should have reported to me or the DON immediately." The Administrator read the Report of Concern again and then stated, "I wish I had a good answer. (CNA #2) was new, had never worked in Long Term Care; I thought it was an issue between the two staff members (CNA #1 and CNA #2). If I had it to do again, I would have followed the Abuse Procedure." e. Resident #4 had [DIAGNOSES REDACTED]. The Minimum Data Set with an ARD of 2/8/11 documented the resident scored 3 (0-7 severe impairment) per BIMS. 1) On 6/3/11 at 11:12 a.m., the DON was asked if any other documentation was available relative to the concern dated 5/16/11, involving Resident #4, other than the Report of Concern sheet. The DON stated, "No more documentation other than the concern sheet and my typed statement dated 5/18/11." The DON was asked, in regard to her 5/18/11 typed statement, if the police were notified. The DON stated, "No." The DON was asked if the family or the physician was notified. The DON stated, "I cannot answer. To my understanding the Administrator was going to do the notifications. There is no documentation of interviews with residents. There is no documentation of the body audit I did on the resident. The resident disagreed with anyone handling roughly or speaking harshly." 2) On 6/6/11 at 1:45 p.m., CNA #1 stated, "I did fill out a Report of Concern on 5/16/11 ...The staff member I reported was (CNA #2). (Resident #4) was sleeping. (CNA #2) walked over to the bed and loudly said, 'Boo'. The resident woke up and said, 'Oh that scared me'. (CNA #2) said, 'I'm sorry'. I said, 'You cannot say that (Boo).' We left the room. I informed (LPN #2) about the incident. (LPN #2) told (CNA #2) she was not allowed to say that." 3) On 6/6/11 at 3:55 p.m., LPN #2 stated, "It was on the weekend. Saturday. I was working the 100 hall on the back end. (CNA #1) stepped out of (Resident #4)'s room. She said (CNA #2) had bowed down and said 'Boo' to (Resident #4)." 4) On 6/6/11 at 2:07 p.m., CNA #2 stated, "I was reported for going into (Resident #4)'s room and saying 'Boo'. I admit that was wrong. I was just being playful with her. I think that was abusive. I know not to do that anymore." 5) From 6/2/11 through 6/7/11, the resident did not, or could not, answer any questions posed by the surveyor regarding abuse. f. Resident #8 had [DIAGNOSES REDACTED]. The MDS with an ARD of 2/17/11 documented the resident scored 3 (0-7 severe impairment) per BIMS. 1) An OLTC Witness Statement Form dated 5/18/11 at 7:50 a.m., documented, "...Witness Full Name (LPN #1)... Shift: 11 - 7... (CNA #1) notified me that (CNA #2) was observed speaking to (Resident #8) in a rough manner. I walked down to (Resident #8)'s room and asked her how she was doing and she looked at me and said 'I am doing ok'. I told her to let me know if she needed anything and she stated 'No, I am okay'." 2) On 6/3/11 at 11:12 a.m., the DON was ask if any other documentation was available relative to the concern dated 5/16/11 involving Resident #8, other than the Report of Concern sheet. The DON stated, "No more documentation other than the concern sheet and my typed statement dated 5/18/11." The DON was asked if the police were notified. The DON stated, "No." The DON was asked if the family or the physician was notified. The DON stated, "I cannot answer. To my understanding, the Administrator was going to do the notifications. There is no documentation of interviews with residents. There is no documentation of the body audit I did on the resident. The resident disagreed with anyone handling roughly or speaking harshly." 3) On 6/6/11 at 1:25 p.m., LPN #1 stated, "(CNA #1) came to me and reported about (Resident #8). She had (CNA #2) working with her in orientation. While in the room of (Resident #8), (CNA #2) spoke to (Resident #8) in a very harsh tone and it was so bad that (Resident #8) had started to cry. I went to (Resident #8)'s room and she was lying in the bed with her back towards me. I called her name, she looked over at me and I asked if she was okay. I asked how was she. She said, 'I'm doing okay'. She looked like she had a small tear in her left eye but said she was 'okay'. I did not ask her if she had been verbally abused by anyone or if anyone had spoken to her rudely." 4) On 6/6/11 at 1:45 p.m., CNA #1 stated, "I did fill out a Report of Concern on 5/16/11. ...The staff member I reported was (CNA #2). While changing (Resident #8), (CNA #2) pushed so hard she made (Resident #8) cry. I had been asked by (LPN #2) to watch how (CNA #2) turned and changed people so we could know what was wrong and how we could retrain her. I was at the foot of the bed on the same side watching her technique. (CNA #2) was changing (Resident #8)'s brief and turned her forcibly over and made her cry. (Resident #8) said 'Ouch'. I made (CNA #2) stop. I completed the task then went and informed (LPN #1). (LPN #1) came and assessed the resident." 5) On 6/6/11 at 2:07 p.m., CNA #2 stated, "I went to turn (Resident #8). I said, Can you turn over so I can wipe? I tried to push to turn her. She said, 'Ouch'. I must have put too much muscle into it - she said 'Ouch'. It wasn't intentional to hurt her. I didn't push her into to rail. The resident said 'Ouch'. I said, I apologize." 6) On 6/6/11 at 3:10 p.m., Resident #8 stated, "One aide on nights was too fast and too hard and hurt me and I cried when she turned me. It was carelessness." On 6/6/11 at 3:45 p.m., the resident repeated her statement in the presence of the Administrator and Director of Nursing. g. Resident #9 had [DIAGNOSES REDACTED]. The Admission MDS with an ARD of 3/30/11 documented the resident was severely impaired in cognitive skills for daily decision making per staff assessment for mental status. 1) On 6/3/11 at 11:12 a.m., the DON was asked if any other documentation was available relative to the concern dated 5/16/11 involving Resident #9, other than the Report of Concern sheet. The DON stated, "No more documentation other than the concern sheet and my typed statement dated 5/18/11." The DON was asked if the police were notified. The DON stated, "No." The DON was asked if the family or the physician was notified. The DON stated, "I cannot answer. To my understanding the Administrator was going to do the notifications. There is no documentation of interviews with residents. There is no documentation of the body audit I did on the resident. The resident disagreed with anyone handling roughly or speaking harshly." 2) On 6/6/11 at 1:25 p.m., LPN #1 was interviewed and stated, "I don't remember (CNA #1) reporting anything about (Resident #9) to me." 3) On 6/6/11 at 1:45 p.m., CNA #1 "I did fill out a 'Report of Concern' on 5/16/11. ...The staff member I reported was (CNA #2). We went to check (Resident #9). (CNA #2) told (Resident #9) that she was a 'meanie'. (Resident #9) doesn't speak very often, just facial expressions. She had a frown on her face. I reported the incident to (LPN #1)." 4) On 6/6/11 at 2:07 p.m., CNA #2 stated, "I never called any resident a 'meanie'. I've never heard anyone called a 'meanie' and I've never called anyone by that name. That is just a lie - I didn't do that." 5) From 6/2/11 through 6/7/11, Resident #9 could not answer any questions posed by the surveyor regarding abuse, or any other questions, as she did not verbalize. 4. The Immediate Jeopardy was removed and the scope/severity reduced to "H" on 6/3/11 at 3:13 p.m. when the facility implemented the following Plan of Removal: "Administrator and Director of Nursing (DON) will be in-serviced on Abuse and Neglect on June 3rd, 2011 at 1305 by (Corporate Representative). When allegation of abuse and neglect is received, the Administrator will be notified immediately. The DON or designee will immediately open an investigation. The staff member(s) involved will be removed from the facility to protect the resident. The allegation will be immediately reported to the Office of Long Term Care by the Administrator by 11:00 a.m. the next day. All negative findings will be reported to the Office of Long Term Care immediately. Reports of Concern will be reviewed daily by Quality Management Team (QMT) Department Heads during morning Quality Assurance (QA) meeting. Reports of Concern received on weekends will be reported to the DON/designee immediately and the Administrator will be notified. Abuse allegations will be monitored by the Administrator and the DON daily and reviewed by the Quality Assurance Committee monthly. All staff will be in-serviced regarding reporting of any abuse and neglect and the facility's policy and procedures pertaining to abuse and neglect on June 3rd, 2011 by midnight. The Administrator/DON or designee will in-service all employees and no employee will be allowed to work until this in-service requirement is met. All residents will be informed of the abuse and neglect policy and procedures by Social Services on June 3rd, 2011 by midnight. Documentation will be obtained by Social Services on June 3rd, 2011. All residents upon admission will be informed of the Abuse and Neglect policy and procedures by the admission coordinator. Human Resources will ensure that all new employees attend a mandatory abuse and neglect training prior to initiation of services. Annual training will be provided. Training in-service will be given with each allegation of abuse and neglect. To document understanding of abuse/neglect; 5 staff members weekly will be required to successfully complete competency testing with a s

Based on record review and interview, the Facility Administration failed to ensure the facility was administered in a manner that enabled it to use its resources effectively and efficiently to ensure that allegations of abuse were immediately reported to the Administrator/Designee, were thoroughly investigated, residents were protected from potential further abuse, and the allegations were reported to local law enforcement and the Office of Long Term Care in accordance with state law for 5 of 5 (Residents #4, #5, #8, #10 and #9) case mix residents who had allegations of abuse reported. The failed practice resulted in Immediate Jeopardy that likely caused or could have caused serious harm for Residents #5 and #10 who made allegations of staff to resident psychological abuse by Certified Nursing Assistant (CNA) #3, and for Resident #8, #4, and #9 who were the subjects of an allegation of staff to resident abuse by CNA #2. The failed practice was likely to cause more than minimal harm for 95 residents who were at risk for abuse, according to the Roster Sample Matrix received from the Administrator on 6/2/11 at 5:20 a.m. The facility was informed of the Immediate Jeopardy condition on 6/3/11 at 12:12 p.m. The findings are: 1. The Administrator's Job Description documented , "The Administrator is a qualified person appointed by the board of directors to administer, direct and coordinate all the activities of the facility... Responsibilities: Plans overall development and administration of the facility as set forth in the Conditions of Participation and/or applicable state regulations under the direction of the board of directors and the advisory board... Ensures continuous compliance with all applicable federal and state regulations and facility policy... Handles resident complaints not resolved at DCS (direct care services) level..." The facility's Report of Concern (Grievance) policy documented, "...The Charge Nurse will review the completed report and address any items that can be immediately corrected. Charge Nurse will document on form any actions taken. The report will then be given to the Administrator for review and follow-up. The Administrator will assign someone in management to investigate and suggest interventions to resolve and prevent issue. This person will document all findings and suggestions on the report. Administrator will approve interventions and those will be followed through with by investigator and applicable staff members..." 2. Resident #10 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 3/30/11 documented the resident scored 13 (13-15 cognitively intact) in the brief interview for mental status (BIMS) and over the last 2 weeks felt down, depressed or hopeless for 2 to 6 days. a. A Report of Concern dated 3/22/11 (no time noted) documented, "Name of person expressing Concern: (Resident #10)... Concern: "CNA on 3-11 (3:00 p.m. to 11:00 p.m. shift) red from Louisiana is sprinkling Voodoo dust in my rm (room)... Signature: Registered Nurse (RN) #1... Results of Investigation: "CNA (CNA #3) will not work with this resident. (CNA #3) did admit discussing this 'Voodoo' joking with the resident. She was instructed and given boundaries of the role of the CNA interaction with residents. Directed to not to enter the resident rm." 1) On 6/2/11 at 9:45 a.m., the resident, with the Director of Nursing (DON) present, was interviewed and stated, "This girl (CNA #3) was from Louisiana. She was throwing Voodoo dust. She had a little bottle of dust in her pocket. She threw some Voodoo dust in my eyes. I was asleep. When I woke up my eyes were burning. It felt like sand. She told me she had put Voodoo dust in our eyes - me and my roommate. She talked real foolish, like she was bragging about it. I felt like she was trying to hurt me. I wouldn't eat food from her." The resident was asked if he believed in Voodoo. He stated, "I have seen people being 'fixed'. I believe once it gets in you it can hurt you. She said her family was Cherokee. Cherokee women do that Voodoo stuff. To me she acted like a devil. I don't want her handling my food or anything. I don't trust her. I feel that she's the devil. Any time a person does what she does and brags about it, she's a devil. I don't want her around me. I don't trust her. My roommate doesn't trust her either. She doesn't come around anymore. The stuff in the bottle looks like brown dust. She showed it to us. She said she was going to blind me. I told my sister; my sister called up here. The Voodoo lady got mad. I think (RN #1) talked to me. She told me the Voodoo lady wouldn't be back in my room. She didn't ask me any questions about the Voodoo dust. (CNA #3) is the Voodoo lady. She keeps that bottle on her. If she brought me food I would probably eat it because I would be hungry - if it was from the kitchen." 2) On 6/2/11 at 10:03 a.m., RN #1 was interviewed and stated, "(Resident #10)'s sister called and asked me about that 'crazy woman'. It was on the weekend. I went through the process to then turn it over to our Social Services and the Administrator. I turned the concern into the front office - to (Assistant Administrator #1) and (Administrator). I don't handle the concerns. I was not aware that he was afraid of the lady." 3) On 6/2/11 at 10:07 a.m., Assistant Administrator #1 was interviewed relative to the "Report of Concern" dated 3/22/11 and stated, "Yes, I have seen the report. I just log them (Report of Concern) in and file them." 4) On 6/2/11 at 10:10 a.m., the Administrator read the "Report of Concern" relative to the incident of 3/22/11, as requested by the surveyor. The Administrator stated, "First, I think (Resident #10) needs a psych (psychiatric) eval (evaluation). I need to look to see about his mental status. I would be removing the CNA from that area. It would be an allegation of abuse." When asked if she was aware of the culture that believes in Voodoo, the Administrator stated, "Yes, there are some in Louisiana." The Administrator stated, "Someone should have done more of an investigation than we did. Anytime a resident would call a person a devil that would be a real concern." 5) On 6/2/11 at 10:15 a.m., the DON was asked what her impression was of the resident's feelings toward CNA #3. The DON stated, "He's scared, frightened. He called her a devil." 6) On 6/2/11 at 10:20 a.m., CNA #3 stated, "I'm from Lake Charles, Louisiana. My grandfather was full blown Cherokee." The CNA was asked, "Do you ever carry anything to work with you with anything in it?" CNA #3 stated, "No." The CNA was asked if she had ever sprinkled any Voodoo dust on any person. The CNA stated, "No." When asked if she believed in Voodoo, CNA #3 stated, "No." She was asked if she had ever sprinkled any dust. The CNA stated, "No. (RN #1) called me in. (Resident #10) asked me if I was from Louisiana. I don't practice Voodoo. I don't believe in Voodoo. I'm a Catholic. I still work with (Resident #10). I bathe him and set up his tray. If I'm assigned to him. (RN #1) told me not to go in his room. She did not say 'ever'. You can call him in and ask him. He's asked me to set up his tray, open his cartons and change him." CNA #3 was asked why someone would think she had sprinkled Voodoo dust on them and told them they were going to go blind. The CNA stated, "I don't know. I haven't did anything to him. He always wants to be first. He gets mad if he's not first. He got mad at (another employee) and said (the other employee) had put a foot in his back. There's several CNAs here that aren't to go in his room." CNA #3 was asked who had released her to go back into the resident's room. The CNA stated, "Whoever assigned me to him. (RN #1) said to stay out of his room at that time. I don't believe in Voodoo. I don't know anyone that believes in Voodoo. There could be some people in this nursing home that believe in Voodoo. I don't know, that doesn't come up in my conversation." When asked if she carried Voodoo dust with her to work, CNA #3 stated, "All I carry to work is my keys and my pen." 7) On 6/3/11 at 10:35 a.m., CNA #5 stated, "A while back, probably in March 2011), (Resident #10) said this girl keeps putting dust in my cup. He didn't say who. He wasn't upset about it. Like, he wanted me to get him a clean cup. Like, last month he said that girl (CNA #3) keeps putting Voodoo dust in his cup. I asked if he told the nurse. He said yes. I asked (Licensed Practical Nurse (LPN) #3) and she said she knew about it. She told me (CNA #3) could not go into his room, that I had to take care of him. (CNA #3) told me she could not go in his room; I didn't ask why. That was probably one and one-half months ago, the end of April (2011)." When asked if the resident was upset, CNA #5 stated, "He was very upset, more of the Voodoo. He was worried about what if something she would do. He was worried and concerned about her and how she was acting." 8) On 6/3/11 at 10:58 a.m., LPN #3 stated, "(Resident #10) said it started as a joke. It was something about fairy dust that she was joking about sprinkling in his eyes. After that they said he was scared of it. He said he was afraid of her to work with him. The Aides said that he had said this. He never complained to me personally... I never reported it due to I thought it had been taken care of." 9) On 6/3/11 at 3:00 p.m., CNA #6 stated, "I heard from (Resident #10), not sure of the dates. In April (2011) I think. It was about Voodoo dust or Angel Dust on him. He said (CNA #3) did it." 10) On 6/3/11 at 11:50 a.m., the resident was asked how many times CNA #3 had used the Voodoo dust on him or threatened to use it. The resident stated, "About five times." b. An OLTC (Office of Long Term Care) Incident and Accident Report (I & (and) A) documented, "Date and Time Submitted (if known: 06/02/2011 (at) 11:00 a.m. Date & Time of Discovery: 6/2/11 (at) 10:30 a.m. ...Date of I&A: 3/22/11 Time: 3-11 shift... Name of Resident: (Resident #10)... Status of Alleged Perpetrator: Facility Employee... Type of Incident: Abuse... Emotional/Mental... Summary of Incident... On 3/22/11, (Resident #10) reported to (RN #1) that a 3-11 CNA, was sprinkling 'voodoo dust' in his room. (Resident #10) described the CNA as 'red' (skin color) and being from Louisiana. (RN #1) determined that the CNA was (CNA #3). (RN #1) completed a report of concern (grievance) form and addressed the concern with (CNA #3). (CNA #3) admitted to having a conversation jokingly with (Resident #10) about ''voodoo dust'. (RN #1) instructed (CNA #3) on (boundaries), the role of the C.N.A. and appropriate interaction with residents. (CNA #3) was instructed to not work with resident and not to enter his room unless during an emergency situation and no other staff is available. On today 6/2/11, the facility Administrator (name of Administrator) was informed by OLTC survey team that this incident is reportable and a 7734 and 762 need to be completed." 1) An OLTC Witness Statement Form documented, "Date 6/2/11 Time 11:20 a.m. Witness Full Name (CNA #3) ...Shift 3-11 p.m. ...State in your own words what you witnessed (be very descriptive and sign below): 'I don't know the exact date when I started working with (Resident #10) (and) (Resident #5) on 400 hall but the first day I started working with (Resident #10) he asked me was I mixed and I told him no. (Resident #10) asked me where was I from and I told him Louisiana. (Resident #10) asked me did I have Indian in me and I told him my great grandfather was Cherokee Indian. (Resident #10) asked me did I believe in voodoo and I told him no that you had to be a weak person to believe in voodoo. Then one day (RN #1) called me in the office and asked me was I from Louisiana and I told her yes and she asked me did I know voodoo and I told her no and she asked me did I sprinkle voodoo dust on (Resident #10) and I told her no. She asked me have I ever came to (Resident #10) about voodoo and I told (RN #1) that (Resident #10) would tease me about knowing voodoo and I told him I didn't believe in voodoo. (RN #1) told me (Resident #10) called his sister and told her that I sprinkled voodoo dust in his eyes and he was afraid I was putting something in his food. I told (RN #1) that (Resident #10) was always talking about voodoo when I walked in the room. (RN #1) told me not to go back in his room. They moved me to the back of 400 hall. Since March (Resident #10) has asked me to do several things for him. To open milk cartons on his tray, give something to drink and even change him. I have never refused to do anything for (Resident #10) or had any other conversation with (Resident #10). I wasn't told to stay out of (Resident #10's) room forever or I wouldn't have been assigned to his room in as recently as yesterday (6/1/11). (Resident #10) asked me to help out of the dining room. If (Resident #10) is so afraid of me, why do he still ask me to do thing for him if thinks I know voodoo. (Resident #10) didn't start saying these things about me until I told him if I was with another resident he would have to wait. (Resident #10) is very demanding and you can't do what him or his roommate (Resident #5) wants right then they get angry. (Resident #10) want you to drop whatever you're doing when he puts on his light and if you don't he tries to get you fired. He has told other employees, he was going to get me fired. I'm not the only employee (Resident #10) has done this to." 2) An OLTC Witness Statement Form documented, "Date 6/2/11 Time (blank) Witness Full Name (LPN #3)... Shift 7/3 (7:00 a.m. to 3:00 p.m.) ...State in your own words what you witnessed (be very descriptive and sign below): (Resident #10) used to joke around (with) (CNA #3) because she is from New Orleans. He would say 'She may sprinkle fairy dust in my eyes'. He would be laughing and joking about it. He never complained about the care he received from her as an aide. He never voiced any concerns to me about being afraid of her." c. On 6/7/11/ at 9:45 a.m., the Administrator stated, "I had no knowledge of the 3/22/11 Report of Concern until the surveyor questioned me regarding it." The Administrator was asked if she had looked at the "Report of Concern Log" since 3/22/11. The Administrator stated, "I had not looked at it from 3/22/11, not for March." The Administrator was asked if she would consider the "Report of Concern" dated 3/22/11 as a true concern. The Administrator stated, "I think this Report of Concern should have been investigated and reported to the OLTC." The Administrator was asked if Resident #10 was protected. The Administrator stated, "No, he was not." 3. Resident #5 had [DIAGNOSES REDACTED]. The Quarterly MDS with an ARD of 4/1/11 documented the resident scored 14 (13-15 cognitively intact) per BIMS. a. On 6/2/2011 at 11:00 a.m., the Administrator submitted an OLTC (Office of Long Term Care) Incident and Accident Report that documented, "Date and Time Submitted (if known): 06/03/2011 10:30 a.m. ...Date & Time of Discovery: (blank)... Date of I & A: unknown. Time: 3-11 shift... Name of Resident: (Resident #5)... Status of Alleged Perpetrator: Facility Employee... Type of Incident: ...Abuse: ...Emotional/Mental ...Summary of Incident ...Today 6/3/11 at approximately 9:25 a.m. during an OLTC survey, it was brought to the facility's attention that (Resident #5) had been threatened with 'voodoo'. The facility is currently conducting an investigation into a similar allegation made by (Resident #5's) roommate against (CNA #3). (Resident #5) was immediately interviewed by (Administrative Assistant). (Resident #5) was asked the following questions: Are you aware of any staff treating residents in an inappropriate manner? (Resident #5) responded 'No, not other than this incident'. Are you aware of any residents being abused, neglected or mistreated by any staff, visitor or other resident? (Resident #5) responded 'No, not other than this incident.' Are you aware of any resident including yourself being mistreated or threatened by (CNA #3)? '(Resident #5) responded 'Yes, (CNA #3) saw me in the dining room and stated 'If (Resident #10) doesn't watch out I'm going to voodoo him and I just wanted you to know what was on my mind.' When did this happen? (Resident #5) responded 'Happened a week or so ago'. Did you hear (CNA #3) threaten (Resident #10) by saying she would sprinkle Voodoo dust in the room? (Resident #5) responded 'No, but I did hear (CNA #3) and (Resident #10) talking in the room and (CNA #3) said if (Resident #10) wasn't careful she would put voodoo dust in his eyes.' Did (CNA #3) threaten you by saying she would sprinkle Voodoo dust in the room? (Resident #5) responded 'No, she told me that I needed to be careful because when she came to voodoo (Resident #10) she would get me too.' (Resident #5) ended our interview by stating 'I hope (CNA #3) doesn't come back to work here because I'm afraid I won't wake up from my sleep because of her voodoo. I believe voodoo is real and she is capable. I don't play when it comes to voodoo'." b. On 6/3/11 at 8:40 a.m., the resident was asked if a staff member had ever talked to him about voodoo. The resident stated, "Yes, I don't know her name, but she told us she had some voodoo dust to sprinkle on us to make us go to sleep and not wake up." He stated that he did not want her taking care of him again. The resident also stated, "I'm scared of anyone who talks about voodoo." c. On 6/3/11 at 11:30 a.m., the resident was asked how many times (CNA #3) had sprinkled or threatened to sprinkle voodoo dust on him. The resident stated, "To him, just that one time. She threw dust on my roommate more than that, but just told me she was going to do it." 4. A Report of Concern documented, "name of person expressing concern: (CNA #1) Date: 5/16/11... Resident Involved: (Resident #4, Resident #8, Resident #9)... Concern: Went into room to change R (resident) on round. I (CNA #1) observed (CNA #2) saying 'Boo' to wake up (Resident #4). Also observed (CNA #2) getting frustrated and rough handling pts (patients) and calling pts names... Results of investigation: (blank)." a. On 6/2/11 at 6:20 a.m., the Administrator was interviewed about the Report of Concern turned in by CNA #1. The Administrator stated, "They (CNA #1 and CNA #2) went to school together." The Administrator was asked if in the report CNA #1 had made an allegation of abuse by (CNA #2). The Administrator stated, "There was no abuse. We did an internal investigation." The Administrator was asked if saying 'Boo' to wake a resident was all right. The Administrator stated, "No, that is not all right." b. On 6/2/11 at 6:08 a.m., the DON was asked if it was reported to her that a CNA was making residents cry. The DON stated, "I was called to the Administrator's office. (CNA #1) was there. She filled out a Report of Concern. We called (CNA #2) in. CNA #1 told of allegations that (CNA #2) had woke up a resident with 'Boo', and was rough while turning a resident." When asked if she considered these allegations as abusive, the DON stated, "Yes, suspected abuse. That warrants investigation. I obtained witness statements from people working and from (CNA #1). We took (CNA #2) off for 2 or 3 days while it was investigated. I did not file a report with State on an allegation of abuse. When we finished the investigation it was found unsubstantiated. We brought (CNA #2) back to day shift. She was in orientation." 1) An OLTC Witness Statement Form dated 5/17/11 at 2:57 p.m. documented, "...Witness Full Name (CNA #2) ...Shift 11p - 7a (11:00 p.m. to 7:00 a.m.)... State in your own words what you witnessed (be very descriptive) and sign below: I have never been rough with a resident. There have been times when I have not been able to change a resident and have went and got help. When I went into (Resident #4)'s room, I did frighten her by saying 'boo' but I did apologize to her. I never called (Resident #9) a 'meanie' to her face and make her cry." 2) An OLTC Witness Statement Form dated 5/18/11 at 8:25 a.m. documented, "...Witness Full Name (LPN #2)... Shift: 11p - 7a... State in your own words what you witnessed (be very descriptive) and sign below: On May 14th, 2011 (at) approx (approximately) 8:00-8:30 p.m., I was called to a R (resident) room by (CNA #1) in regards to (CNA #2) saying 'boo' to a R and frightening the R. Told (CNA #1) to fill out a Report of Concern and make sure she round with (CNA #2) from rm (room) to rm to observe any other abusive behavior. I did assess R (at) approx 8:45 to ask if she was ok. R was fine just c/o (complained of) being cold. (No) further reports of abuse reported this shift." 3) On 6/2/11 at 7:15 a.m., a typed statement dated 5/18/11 at 4:00 p.m. was received from the DON. The statement was signed by the DON and documented: "I was notified on May 17th, 2011 by (CNA #1) that she suspected (CNA #2) of abuse of residents. (CNA #2) was called to the facility where she completed her statement. Notified (CNA #2) at that time she will be placed on suspension until completion of our internal investigation. I received a statement from (CNA #1). Statements were also received from 2 LPN (Licensed Practical Nurses) nurses and 1 RN (Registered Nurse) nurse that were present at the time of the incident. Upon completion of my internal investigation, the suspected abuse has been found unsubstantiated. Interview of residents that are oriented on halls 300 and 400 stated they feel safe and no one is rough with their care. Upon complete assessment of the residents in question. I found no bruising, residents stated they felt safe and verbalized no rough handling. (CNA #2) will be allowed to return to work. She will be placed on probation and retraining. Her training will consist of 30 days on day shift with a preceptor. Will retrain (CNA #2) on the appropriate manner to speak to residents, families and co-workers." c. On 6/2/11 at 5:20 a.m., CNA #1 stated, "I've reported on pink sheets. No one ever does anything with it. I've reported to (RN #1), pink slip slipped under her door. I noticed a fell ow CNA (CNA #2) being abusive, made a resident cry, called a patient a 'Meanie' on first shift. Woke a patient up by saying 'Boo'." d. On 6/3/11 at 11:20 a.m., the Administrator was asked if after receiving the Report of Concern dated 5/16/11, the family, police or physician were notified. The Administrator stated, "No." The Administrator was asked what the responsibility of the Administrator was in such matters. The Administrator stated, "An internal investigation and report to the state. It should have been reported the day of the reporting. There was no thorough investigation." On 6/7/11 at 9:45 a.m., the Administrator was interviewed regarding the Report of Concern dated 5/16/11, specific to CNA #2 and the care of Residents #4, #8 and #9. The Administrator was asked what she had done when the Report of Concern came to her attention, relative to investigation, protection and reporting. The Administrator stated, "The Report of Concern, I gave it to the DON. I told her to call in the staff for interviews, that I felt we had issues on the night shift. We received the concern on the 17th. (CNA #2) wasn't scheduled to work again until 5/20/11. On 5/20/11 we had (CNA #2) come in to work on the day shift for additional training. It was alleged abuse on 5/17/11 when I got the report. With an allegation of abuse the observer should have reported to me or the DON immediately." The Administrator read the Report of Concern again and then stated, "I wish I had a good answer. (CNA #2) was new, had never worked in Long Term Care; I thought it was an issue between the two staff members (CNA #1 and CNA #2). If I had it to do again, I would have followed the Abuse Procedure." e. Resident #4 had [DIAGNOSES REDACTED]. The Minimum Data Set with an ARD of 2/8/11 documented the resident scored 3 (0-7 severe impairment) per BIMS. 1) On 6/3/11 at 11:12 a.m., the DON was asked if any other documentation was available relative to the concern dated 5/16/11, involving Resident #4, other than the Report of Concern sheet. The DON stated, "No more documentation other than the concern sheet and my typed statement dated 5/18/11." The DON was asked, in regard to her 5/18/11 typed statement, if the police were notified. The DON stated, "No." The DON was asked if the family or the physician was notified. The DON stated, "I cannot answer. To my understanding the Administrator was going to do the notifications. There is no documentation of interviews with residents. There is no documentation of the body audit I did on the resident. The resident disagreed with anyone handling roughly or speaking harshly." 2) On 6/6/11 at 1:45 p.m., CNA #1 stated, "I did fill out a Report of Concern on 5/16/11 ...The staff member I reported was (CNA #2). (Resident #4) was sleeping. (CNA #2) walked over to the bed and loudly said, 'Boo'. The resident woke up and said, 'Oh that scared me'. (CNA #2) said, 'I'm sorry'. I said, 'You cannot say that (Boo).' We left the room. I informed (LPN #2) about the incident. (LPN #2) told (CNA #2) she was not allowed to say that." 3) On 6/6/11 at 3:55 p.m., LPN #2 stated, "It was on the weekend. Saturday. I was working the 100 hall on the back end. (CNA #1) stepped out of (Resident #4)'s room. She said (CNA #2) had bowed down and said 'Boo' to (Resident #4)." 4) On 6/6/11 at 2:07 p.m., CNA #2 stated, "I was reported for going into (Resident #4)'s room and saying 'Boo'. I admit that was wrong. I was just being playful with her. I think that was abusive. I know not to do that anymore." 5) From 6/2/11 through 6/7/11, the resident did not, or could not, answer any questions posed by the surveyor regarding abuse. f. Resident #8 had [DIAGNOSES REDACTED]. The MDS with an ARD of 2/17/11 documented the resident scored 3 (0-7 severe impairment) per BIMS. 1) An OLTC Witness Statement Form dated 5/18/11 at 7:50 a.m., documented, "...Witness Full Name (LPN #1)... Shift: 11 - 7... (CNA #1) notified me that (CNA #2) was observed speaking to (Resident #8) in a rough manner. I walked down to (Resident #8)'s room and asked her how she was doing and she looked at me and said 'I am doing ok'. I told her to let me know if she needed anything and she stated 'No, I am okay'." 2) On 6/3/11 at 11:12 a.m., the DON was ask if any other documentation was available relative to the concern dated 5/16/11 involving Resident #8, other than the Report of Concern sheet. The DON stated, "No more documentation other than the concern sheet and my typed statement dated 5/18/11." The DON was asked if the police were notified. The DON stated, "No." The DON was asked if the family or the physician was notified. The DON stated, "I cannot answer. To my understanding, the Administrator was going to do the notifications. There is no documentation of interviews with residents. There is no documentation of the body audit I did on the resident. The resident disagreed with anyone handling roughly or speaking harshly." 3) On 6/6/11 at 1:25 p.m., LPN #1 stated, "(CNA #1) came to me and reported about (Resident #8). She had (CNA #2) working with her in orientation. While in the room of (Resident #8), (CNA #2) spoke to (Resident #8) in a very harsh tone and it was so bad that (Resident #8) had started to cry. I went to (Resident #8)'s room and she was lying in the bed with her back towards me. I called her name, she looked over at me and I asked if she was okay. I asked how was she. She said, 'I'm doing okay'. She looked like she had a small tear in her left eye but said she was 'okay'. I did not ask her if she had been verbally abused by anyone or if anyone had spoken to her rudely." 4) On 6/6/11 at 1:45 p.m., CNA #1 stated, "I did fill out a Report of Concern on 5/16/11. ...The staff member I reported was (CNA #2). While changing (Resident #8), (CNA #2) pushed so hard she made (Resident #8) cry. I had been asked by (LPN #2) to watch how (CNA #2) turned and changed people so we could know what was wrong and how we could retrain her. I was at the foot of the bed on the same side watching her technique. (CNA #2) was changing (Resident #8)'s brief and turned her forcibly over and made her cry. (Resident #8) said 'Ouch'. I made (CNA #2) stop. I completed the task then went and informed (LPN #1). (LPN #1) came and assessed the resident." 5) On 6/6/11 at 2:07 p.m., CNA #2 stated, "I went to turn (Resident #8). I said, Can you turn over so I can wipe? I tried to push to turn her. She said, 'Ouch'. I must have put too much muscle into it - she said 'Ouch'. It wasn't intentional to hurt her. I didn't push her into to rail. The resident said 'Ouch'. I said, I apologize." 6) On 6/6/11 at 3:10 p.m., Resident #8 stated, "One aide on nights was too fast and too hard and hurt me and I cried when she turned me. It was carelessness." On 6/6/11 at 3:45 p.m., the resident repeated her statement in the presence of the Administrator and Director of Nursing. g. Resident #9 had [DIAGNOSES REDACTED]. The Admission MDS with an ARD of 3/30/11 documented the resident was severely impaired in cognitive skills for daily decision making per staff assessment for mental status. 1) On 6/3/11 at 11:12 a.m., the DON was asked if any other documentation was available relative to the concern dated 5/16/11 involving Resident #9, other than the Report of Concern sheet. The DON stated, "No more documentation other than the concern sheet and my typed statement dated 5/18/11." The DON was asked if the police were notified. The DON stated, "No." The DON was asked if the family or the physician was notified. The DON stated, "I cannot answer. To my understanding the Administrator was going to do the notifications. There is no documentation of interviews with residents. There is no documentation of the body audit I did on the resident. The resident disagreed with anyone handling roughly or speaking harshly." 2) On 6/6/11 at 1:25 p.m., LPN #1 was interviewed and stated, "I don't remember (CNA #1) reporting anything about (Resident #9) to me." 3) On 6/6/11 at 1:45 p.m., CNA #1 "I did fill out a 'Report of Concern' on 5/16/11. ...The staff member I reported was (CNA #2). We went to check (Resident #9). (CNA #2) told (Resident #9) that she was a 'meanie'. (Resident #9) doesn't speak very often, just facial expressions. She had a frown on her face. I reported the incident to (LPN #1)." 4) On 6/6/11 at 2:07 p.m., CNA #2 stated, "I never called any resident a 'meanie'. I've never heard anyone called a 'meanie' and I've never called anyone by that name. That is just a lie - I didn't do that." 5) From 6/2/11 through 6/7/11, Resident #9 could not answer any questions posed by the surveyor regarding abuse, or any other questions, as she did not verbalize. 5. The Immediate Jeopardy was removed and the scope/severity reduced to "H" on 6/3/11 at 3:13 p.m. when the facility implemented the following Plan of Removal: "Administrator and Director of Nursing (DON) will be in-serviced on Abuse and Neglect on June 3rd, 2011 at 1305 by (Corporate Representative). When allegation of abuse and neglect is received, the Administrator will be notified immediately. The DON or designee will immediately open an investigation. The staff member(s) involved will be removed from the facility to protect the resident. The allegation will be immediately reported to the Office of Long Term Care by the Administrator by 11:00 a.m. the next day. All negative findings will be reported to the Office of Long Term Care immediately. Reports of Concern will be reviewed daily by Quality Manag

Based on record review and interview, the facility failed implement their abuse prohibition policy and procedures as evidenced by the facility's failures to ensure allegations of abuse were immediately reported to the Administrator/Designee, the allegations of abuse were thoroughly investigated, residents were protected from the potential for further abuse and the allegations of abuse were reported to local law enforcement and the Office of Long Term Care in accordance with state law for 5 of 5 (Residents #4, #5, #8, #9 and #10) case mix residents who had allegations of abuse reported. The failed practice resulted in Immediate Jeopardy that likely caused or could have caused serious harm for Residents #5 and #10 who made allegations of staff to resident psychological abuse by Certified Nursing Assistant (CNA) #3, and for Resident #8, #4, and #9 who were the subjects of an allegation of staff to resident abuse by CNA #2. The failed practice was likely to cause more than minimal harm for 95 residents who were at risk for abuse, according to the Roster Sample Matrix received from the Administrator on 6/2/11 at 5:20 a.m. The facility was informed of the Immediate Jeopardy condition on 6/3/11 at 12:12 p.m. The findings are: 1. The facility's Abuse Policy dated 4/1/10 documented, "Purpose - Provide an environment that is free from abuse, neglect, exploitation and misappropriation of resident property. Procedure... 5. Investigation... Reported and/or suspected incidents of abuse, neglect, exploitation or misappropriation of property shall result in the completion of the following forms and procedures: a. The person making the allegation will be asked to give as much information regarding the incident as possible. b. The reporter will be assured that no retribution shall occur as a result of their reporting. c. The person taking the report shall assess the resident to assure they are in no immediate danger of further possible abuse, neglect and/or mistreatment. d. Any visitor or staff member involved in the alleged abuse should be required to leave the facility pending the outcome of the investigation... g. The person taking the allegation shall complete an Incident and Accident form and Administration a DMS (Division of Medical Services) -7734. The Medical Director, D.O.N. (Director of Nursing), Administrator, Police and resident's family are immediately notified. Witness statements are obtained and should include a detailed description of the incident, the time, date and a signature. h. The DON/Administrator (or designee) shall: i. Interview the person filing any allegation. ii. Interview the resident if possible and as appropriate. iii. Question staff and residents to determine if anyone has intimate knowledge of the incident. iv. The identified (alleged) abuser will be advised of the allegation and will be provided an opportunity to submit a written statement in response. v. The alleged abuser will be suspended until the investigation is complete or until it is determined that the person poses no risk to any resident or staff. vi. Disciplinary action up to and including possible termination will be determined based on the information obtained during the investigation. vii. A file of all information gathered will be maintained for review by OLTC (Office of Long Term Care) during their investigation. 6. Protection - Any time a report of possible abuse, neglect or exploitation is made against an employee, the person in charge will suspend that employee without pay until the D.O.N./Administrator can conduct and complete an investigation. The resident involved shall be assessed for injury, assured of protections from further harm and monitored closely with both medical and social interventions as indicated. 7. Reporting/Response - a. All allegations of abuse, neglect, misappropriation of resident property or exploitation shall be reported to the Administrator and/or designee who shall initiate an investigation. b. Should an allegation/suspected violation or substantiated incident of abuse, neglect, exploitation or misappropriation of resident's property be reported, the facility Administrator or designee will promptly notify the following: i. The state licensing/certification agency ii. The resident's attending physician iii. The resident's representative c. Law enforcement officials will be notified as required by regulation. d. At the time of the incident, all policies and procedures regarding the incident shall be reviewed to ensure compliance. Recommendations for changes in operating policies should be noted on the written report. e. All reports will be made in a manner consistent with the mandated reporting requirements in effect at the time of the incident." 2. Resident #10 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 3/30/11 documented the resident scored 13 (13-15 cognitively intact) in the brief interview for mental status (BIMS) and over the last 2 weeks felt down, depressed or hopeless for 2 to 6 days. a. A Report of Concern dated 3/22/11 (no time noted) documented, "Name of person expressing Concern: (Resident #10)... Concern: "CNA on 3-11 (3:00 p.m. to 11:00 p.m. shift) red from Louisiana is sprinkling Voodoo dust in my rm (room)... Signature: Registered Nurse (RN) #1... Results of Investigation: "CNA (CNA #3) will not work with this resident. (CNA #3) did admit discussing this 'Voodoo' joking with the resident. She was instructed and given boundaries of the role of the CNA interaction with residents. Directed to not to enter the resident rm." 1) On 6/2/11 at 9:45 a.m., the resident, with the Director of Nursing (DON) present, was interviewed and stated, "This girl (CNA #3) was from Louisiana. She was throwing Voodoo dust. She had a little bottle of dust in her pocket. She threw some Voodoo dust in my eyes. I was asleep. When I woke up my eyes were burning. It felt like sand. She told me she had put Voodoo dust in our eyes - me and my roommate. She talked real foolish, like she was bragging about it. I felt like she was trying to hurt me. I wouldn't eat food from her." The resident was asked if he believed in Voodoo. He stated, "I have seen people being 'fixed'. I believe once it gets in you it can hurt you. She said her family was Cherokee. Cherokee women do that Voodoo stuff. To me she acted like a devil. I don't want her handling my food or anything. I don't trust her. I feel that she's the devil. Any time a person does what she does and brags about it, she's a devil. I don't want her around me. I don't trust her. My roommate doesn't trust her either. She doesn't come around anymore. The stuff in the bottle looks like brown dust. She showed it to us. She said she was going to blind me. I told my sister; my sister called up here. The Voodoo lady got mad. I think (RN #1) talked to me. She told me the Voodoo lady wouldn't be back in my room. She didn't ask me any questions about the Voodoo dust. (CNA #3) is the Voodoo lady. She keeps that bottle on her. If she brought me food I would probably eat it because I would be hungry - if it was from the kitchen." 2) On 6/2/11 at 10:03 a.m., RN #1 was interviewed and stated, "(Resident #10)'s sister called and asked me about that 'crazy woman'. It was on the weekend. I went through the process to then turn it over to our Social Services and the Administrator. I turned the concern into the front office - to (Assistant Administrator #1) and (Administrator). I don't handle the concerns. I was not aware that he was afraid of the lady." 3) On 6/2/11 at 10:07 a.m., Assistant Administrator #1 was interviewed relative to the "Report of Concern" dated 3/22/11 and stated, "Yes, I have seen the report. I just log them (Report of Concern) in and file them." 4) On 6/2/11 at 10:10 a.m., the Administrator read the "Report of Concern" relative to the incident of 3/22/11, as requested by the surveyor. The Administrator stated, "First, I think (Resident #10) needs a psych (psychiatric) eval (evaluation). I need to look to see about his mental status. I would be removing the CNA from that area. It would be an allegation of abuse." When asked if she was aware of the culture that believes in Voodoo, the Administrator stated, "Yes, there are some in Louisiana." The Administrator stated, "Someone should have done more of an investigation than we did. Anytime a resident would call a person a devil that would be a real concern." 5) On 6/2/11 at 10:15 a.m., the DON was asked what her impression was of the resident's feelings toward CNA #3. The DON stated, "He's scared, frightened. He called her a devil." 6) On 6/2/11 at 10:20 a.m., CNA #3 stated, "I'm from Lake Charles, Louisiana. My grandfather was full blown Cherokee." The CNA was asked, "Do you ever carry anything to work with you with anything in it?" CNA #3 stated, "No." The CNA was asked if she had ever sprinkled any Voodoo dust on any person. The CNA stated, "No." When asked if she believed in Voodoo, CNA #3 stated, "No." She was asked if she had ever sprinkled any dust. The CNA stated, "No. (RN #1) called me in. (Resident #10) asked me if I was from Louisiana. I don't practice Voodoo. I don't believe in Voodoo. I'm a Catholic. I still work with (Resident #10). I bathe him and set up his tray. If I'm assigned to him. (RN #1) told me not to go in his room. She did not say 'ever'. You can call him in and ask him. He's asked me to set up his tray, open his cartons and change him." CNA #3 was asked why someone would think she had sprinkled Voodoo dust on them and told them they were going to go blind. The CNA stated, "I don't know. I haven't did anything to him. He always wants to be first. He gets mad if he's not first. He got mad at (another employee) and said (the other employee) had put a foot in his back. There's several CNAs here that aren't to go in his room." CNA #3 was asked who had released her to go back into the resident's room. The CNA stated, "Whoever assigned me to him. (RN #1) said to stay out of his room at that time. I don't believe in Voodoo. I don't know anyone that believes in Voodoo. There could be some people in this nursing home that believe in Voodoo. I don't know, that doesn't come up in my conversation." When asked if she carried Voodoo dust with her to work, CNA #3 stated, "All I carry to work is my keys and my pen." 7) On 6/3/11 at 10:35 a.m., CNA #5 stated, "A while back, probably in March 2011), (Resident #10) said this girl keeps putting dust in my cup. He didn't say who. He wasn't upset about it. Like, he wanted me to get him a clean cup. Like, last month he said that girl (CNA #3) keeps putting Voodoo dust in his cup. I asked if he told the nurse. He said yes. I asked (Licensed Practical Nurse (LPN) #3) and she said she knew about it. She told me (CNA #3) could not go into his room, that I had to take care of him. (CNA #3) told me she could not go in his room; I didn't ask why. That was probably one and one-half months ago, the end of April (2011)." When asked if the resident was upset, CNA #5 stated, "He was very upset, more of the Voodoo. He was worried about what if something she would do. He was worried and concerned about her and how she was acting." 8) On 6/3/11 at 10:58 a.m., LPN #3 stated, "(Resident #10) said it started as a joke. It was something about fairy dust that she was joking about sprinkling in his eyes. After that they said he was scared of it. He said he was afraid of her to work with him. The Aides said that he had said this. He never complained to me personally... I never reported it due to I thought it had been taken care of." 9) On 6/3/11 at 3:00 p.m., CNA #6 stated, "I heard from (Resident #10), not sure of the dates. In April (2011) I think. It was about Voodoo dust or Angel Dust on him. He said (CNA #3) did it." 10) On 6/3/11 at 11:50 a.m., the resident was asked how many times CNA #3 had used the Voodoo dust on him or threatened to use it. The resident stated, "About five times." b. An OLTC (Office of Long Term Care) Incident and Accident Report (I & (and) A) documented, "Date and Time Submitted (if known: 06/02/2011 (at) 11:00 a.m. Date & Time of Discovery: 6/2/11 (at) 10:30 a.m. ...Date of I&A: 3/22/11 Time: 3-11 shift... Name of Resident: (Resident #10)... Status of Alleged Perpetrator: Facility Employee... Type of Incident: Abuse... Emotional/Mental... Summary of Incident... On 3/22/11, (Resident #10) reported to (RN #1) that a 3-11 CNA, was sprinkling 'voodoo dust' in his room. (Resident #10) described the CNA as 'red' (skin color) and being from Louisiana. (RN #1) determined that the CNA was (CNA #3). (RN #1) completed a report of concern (grievance) form and addressed the concern with (CNA #3). (CNA #3) admitted to having a conversation jokingly with (Resident #10) about ''voodoo dust'. (RN #1) instructed (CNA #3) on (boundaries), the role of the C.N.A. and appropriate interaction with residents. (CNA #3) was instructed to not work with resident and not to enter his room unless during an emergency situation and no other staff is available. On today 6/2/11, the facility Administrator (name of Administrator) was informed by OLTC survey team that this incident is reportable and a 7734 and 762 need to be completed." 1) An OLTC Witness Statement Form documented, "Date 6/2/11 Time 11:20 a.m. Witness Full Name (CNA #3) ...Shift 3-11 p.m. ...State in your own words what you witnessed (be very descriptive and sign below): 'I don't know the exact date when I started working with (Resident #10) (and) (Resident #5) on 400 hall but the first day I started working with (Resident #10) he asked me was I mixed and I told him no. (Resident #10) asked me where was I from and I told him Louisiana. (Resident #10) asked me did I have Indian in me and I told him my great grandfather was Cherokee Indian. (Resident #10) asked me did I believe in voodoo and I told him no that you had to be a weak person to believe in voodoo. Then one day (RN #1) called me in the office and asked me was I from Louisiana and I told her yes and she asked me did I know voodoo and I told her no and she asked me did I sprinkle voodoo dust on (Resident #10) and I told her no. She asked me have I ever came to (Resident #10) about voodoo and I told (RN #1) that (Resident #10) would tease me about knowing voodoo and I told him I didn't believe in voodoo. (RN #1) told me (Resident #10) called his sister and told her that I sprinkled voodoo dust in his eyes and he was afraid I was putting something in his food. I told (RN #1) that (Resident #10) was always talking about voodoo when I walked in the room. (RN #1) told me not to go back in his room. They moved me to the back of 400 hall. Since March (Resident #10) has asked me to do several things for him. To open milk cartons on his tray, give something to drink and even change him. I have never refused to do anything for (Resident #10) or had any other conversation with (Resident #10). I wasn't told to stay out of (Resident #10's) room forever or I wouldn't have been assigned to his room in as recently as yesterday (6/1/11). (Resident #10) asked me to help out of the dining room. If (Resident #10) is so afraid of me, why do he still ask me to do thing for him if thinks I know voodoo. (Resident #10) didn't start saying these things about me until I told him if I was with another resident he would have to wait. (Resident #10) is very demanding and you can't do what him or his roommate (Resident #5) wants right then they get angry. (Resident #10) want you to drop whatever you're doing when he puts on his light and if you don't he tries to get you fired. He has told other employees, he was going to get me fired. I'm not the only employee (Resident #10) has done this to." 2) An OLTC Witness Statement Form documented, "Date 6/2/11 Time (blank) Witness Full Name (LPN #3)... Shift 7/3 (7:00 a.m. to 3:00 p.m.) ...State in your own words what you witnessed (be very descriptive and sign below): (Resident #10) used to joke around (with) (CNA #3) because she is from New Orleans. He would say 'She may sprinkle fairy dust in my eyes'. He would be laughing and joking about it. He never complained about the care he received from her as an aide. He never voiced any concerns to me about being afraid of her." c. On 6/7/11/ at 9:45 a.m., the Administrator stated, "I had no knowledge of the 3/22/11 Report of Concern until the surveyor questioned me regarding it." The Administrator was asked if she had looked at the "Report of Concern Log" since 3/22/11. The Administrator stated, "I had not looked at it from 3/22/11, not for March." The Administrator was asked if she would consider the "Report of Concern" dated 3/22/11 as a true concern. The Administrator stated, "I think this Report of Concern should have been investigated and reported to the OLTC." The Administrator was asked if Resident #10 was protected. The Administrator stated, "No, he was not." 3. Resident #5 had [DIAGNOSES REDACTED]. The Quarterly MDS with an ARD of 4/1/11 documented the resident scored 14 (13-15 cognitively intact) per BIMS. a. On 6/2/2011 at 11:00 a.m., the Administrator submitted an OLTC (Office of Long Term Care) Incident and Accident Report that documented, "Date and Time Submitted (if known): 06/03/2011 10:30 a.m. ...Date & Time of Discovery: (blank)... Date of I & A: unknown. Time: 3-11 shift... Name of Resident: (Resident #5)... Status of Alleged Perpetrator: Facility Employee... Type of Incident: ...Abuse: ...Emotional/Mental ...Summary of Incident ...Today 6/3/11 at approximately 9:25 a.m. during an OLTC survey, it was brought to the facility's attention that (Resident #5) had been threatened with 'voodoo'. The facility is currently conducting an investigation into a similar allegation made by (Resident #5's) roommate against (CNA #3). (Resident #5) was immediately interviewed by (Administrative Assistant). (Resident #5) was asked the following questions: Are you aware of any staff treating residents in an inappropriate manner? (Resident #5) responded 'No, not other than this incident'. Are you aware of any residents being abused, neglected or mistreated by any staff, visitor or other resident? (Resident #5) responded 'No, not other than this incident.' Are you aware of any resident including yourself being mistreated or threatened by (CNA #3)? '(Resident #5) responded 'Yes, (CNA #3) saw me in the dining room and stated 'If (Resident #10) doesn't watch out I'm going to voodoo him and I just wanted you to know what was on my mind.' When did this happen? (Resident #5) responded 'Happened a week or so ago'. Did you hear (CNA #3) threaten (Resident #10) by saying she would sprinkle Voodoo dust in the room? (Resident #5) responded 'No, but I did hear (CNA #3) and (Resident #10) talking in the room and (CNA #3) said if (Resident #10) wasn't careful she would put voodoo dust in his eyes.' Did (CNA #3) threaten you by saying she would sprinkle Voodoo dust in the room? (Resident #5) responded 'No, she told me that I needed to be careful because when she came to voodoo (Resident #10) she would get me too.' (Resident #5) ended our interview by stating 'I hope (CNA #3) doesn't come back to work here because I'm afraid I won't wake up from my sleep because of her voodoo. I believe voodoo is real and she is capable. I don't play when it comes to voodoo'." b. On 6/3/11 at 8:40 a.m., the resident was asked if a staff member had ever talked to him about voodoo. The resident stated, "Yes, I don't know her name, but she told us she had some voodoo dust to sprinkle on us to make us go to sleep and not wake up." He stated that he did not want her taking care of him again. The resident also stated, "I'm scared of anyone who talks about voodoo." c. On 6/3/11 at 11:30 a.m., the resident was asked how many times (CNA #3) had sprinkled or threatened to sprinkle voodoo dust on him. The resident stated, "To him, just that one time. She threw dust on my roommate more than that, but just told me she was going to do it." 4. A Report of Concern documented, "name of person expressing concern: (CNA #1) Date: 5/16/11... Resident Involved: (Resident #4, Resident #8, Resident #9)... Concern: Went into room to change R (resident) on round. I (CNA #1) observed (CNA #2) saying 'Boo' to wake up (Resident #4). Also observed (CNA #2) getting frustrated and rough handling pts (patients) and calling pts names... Results of investigation: (blank)." a. On 6/2/11 at 6:20 a.m., the Administrator was interviewed about the Report of Concern turned in by CNA #1. The Administrator stated, "They (CNA #1 and CNA #2) went to school together." The Administrator was asked if in the report CNA #1 had made an allegation of abuse by (CNA #2). The Administrator stated, "There was no abuse. We did an internal investigation." The Administrator was asked if saying 'Boo' to wake a resident was all right. The Administrator stated, "No, that is not all right." b. On 6/2/11 at 6:08 a.m., the DON was asked if it was reported to her that a CNA was making residents cry. The DON stated, "I was called to the Administrator's office. (CNA #1) was there. She filled out a Report of Concern. We called (CNA #2) in. CNA #1 told of allegations that (CNA #2) had woke up a resident with 'Boo', and was rough while turning a resident." When asked if she considered these allegations as abusive, the DON stated, "Yes, suspected abuse. That warrants investigation. I obtained witness statements from people working and from (CNA #1). We took (CNA #2) off for 2 or 3 days while it was investigated. I did not file a report with State on an allegation of abuse. When we finished the investigation it was found unsubstantiated. We brought (CNA #2) back to day shift. She was in orientation." 1) An OLTC Witness Statement Form dated 5/17/11 at 2:57 p.m. documented, "...Witness Full Name (CNA #2) ...Shift 11p - 7a (11:00 p.m. to 7:00 a.m.)... State in your own words what you witnessed (be very descriptive) and sign below: I have never been rough with a resident. There have been times when I have not been able to change a resident and have went and got help. When I went into (Resident #4)'s room, I did frighten her by saying 'boo' but I did apologize to her. I never called (Resident #9) a 'meanie' to her face and make her cry." 2) An OLTC Witness Statement Form dated 5/18/11 at 8:25 a.m. documented, "...Witness Full Name (LPN #2)... Shift: 11p - 7a... State in your own words what you witnessed (be very descriptive) and sign below: On May 14th, 2011 (at) approx (approximately) 8:00-8:30 p.m., I was called to a R (resident) room by (CNA #1) in regards to (CNA #2) saying 'boo' to a R and frightening the R. Told (CNA #1) to fill out a Report of Concern and make sure she round with (CNA #2) from rm (room) to rm to observe any other abusive behavior. I did assess R (at) approx 8:45 to ask if she was ok. R was fine just c/o (complained of) being cold. (No) further reports of abuse reported this shift." 3) On 6/2/11 at 7:15 a.m., a typed statement dated 5/18/11 at 4:00 p.m. was received from the DON. The statement was signed by the DON and documented: "I was notified on May 17th, 2011 by (CNA #1) that she suspected (CNA #2) of abuse of residents. (CNA #2) was called to the facility where she completed her statement. Notified (CNA #2) at that time she will be placed on suspension until completion of our internal investigation. I received a statement from (CNA #1). Statements were also received from 2 LPN (Licensed Practical Nurses) nurses and 1 RN (Registered Nurse) nurse that were present at the time of the incident. Upon completion of my internal investigation, the suspected abuse has been found unsubstantiated. Interview of residents that are oriented on halls 300 and 400 stated they feel safe and no one is rough with their care. Upon complete assessment of the residents in question. I found no bruising, residents stated they felt safe and verbalized no rough handling. (CNA #2) will be allowed to return to work. She will be placed on probation and retraining. Her training will consist of 30 days on day shift with a preceptor. Will retrain (CNA #2) on the appropriate manner to speak to residents, families and co-workers." c. On 6/2/11 at 5:20 a.m., CNA #1 stated, "I've reported on pink sheets. No one ever does anything with it. I've reported to (RN #1), pink slip slipped under her door. I noticed a fell ow CNA (CNA #2) being abusive, made a resident cry, called a patient a 'Meanie' on first shift. Woke a patient up by saying 'Boo'." d. On 6/3/11 at 11:20 a.m., the Administrator was asked if after receiving the Report of Concern dated 5/16/11, the family, police or physician were notified. The Administrator stated, "No." The Administrator was asked what the responsibility of the Administrator was in such matters. The Administrator stated, "An internal investigation and report to the state. It should have been reported the day of the reporting. There was no thorough investigation." On 6/7/11 at 9:45 a.m., the Administrator was interviewed regarding the Report of Concern dated 5/16/11, specific to CNA #2 and the care of Residents #4, #8 and #9. The Administrator was asked what she had done when the Report of Concern came to her attention, relative to investigation, protection and reporting. The Administrator stated, "The Report of Concern, I gave it to the DON. I told her to call in the staff for interviews, that I felt we had issues on the night shift. We received the concern on the 17th. (CNA #2) wasn't scheduled to work again until 5/20/11. On 5/20/11 we had (CNA #2) come in to work on the day shift for additional training. It was alleged abuse on 5/17/11 when I got the report. With an allegation of abuse the observer should have reported to me or the DON immediately." The Administrator read the Report of Concern again and then stated, "I wish I had a good answer. (CNA #2) was new, had never worked in Long Term Care; I thought it was an issue between the two staff members (CNA #1 and CNA #2). If I had it to do again, I would have followed the Abuse Procedure." e. Resident #4 had [DIAGNOSES REDACTED]. The Minimum Data Set with an ARD of 2/8/11 documented the resident scored 3 (0-7 severe impairment) per BIMS. 1) On 6/3/11 at 11:12 a.m., the DON was asked if any other documentation was available relative to the concern dated 5/16/11, involving Resident #4, other than the Report of Concern sheet. The DON stated, "No more documentation other than the concern sheet and my typed statement dated 5/18/11." The DON was asked, in regard to her 5/18/11 typed statement, if the police were notified. The DON stated, "No." The DON was asked if the family or the physician was notified. The DON stated, "I cannot answer. To my understanding the Administrator was going to do the notifications. There is no documentation of interviews with residents. There is no documentation of the body audit I did on the resident. The resident disagreed with anyone handling roughly or speaking harshly." 2) On 6/6/11 at 1:45 p.m., CNA #1 stated, "I did fill out a Report of Concern on 5/16/11 ...The staff member I reported was (CNA #2). (Resident #4) was sleeping. (CNA #2) walked over to the bed and loudly said, 'Boo'. The resident woke up and said, 'Oh that scared me'. (CNA #2) said, 'I'm sorry'. I said, 'You cannot say that (Boo).' We left the room. I informed (LPN #2) about the incident. (LPN #2) told (CNA #2) she was not allowed to say that." 3) On 6/6/11 at 3:55 p.m., LPN #2 stated, "It was on the weekend. Saturday. I was working the 100 hall on the back end. (CNA #1) stepped out of (Resident #4)'s room. She said (CNA #2) had bowed down and said 'Boo' to (Resident #4)." 4) On 6/6/11 at 2:07 p.m., CNA #2 stated, "I was reported for going into (Resident #4)'s room and saying 'Boo'. I admit that was wrong. I was just being playful with her. I think that was abusive. I know not to do that anymore." 5) From 6/2/11 through 6/7/11, the resident did not, or could not, answer any questions posed by the surveyor regarding abuse. f. Resident #8 had [DIAGNOSES REDACTED]. The MDS with an ARD of 2/17/11 documented the resident scored 3 (0-7 severe impairment) per BIMS. 1) An OLTC Witness Statement Form dated 5/18/11 at 7:50 a.m., documented, "...Witness Full Name (LPN #1)... Shift: 11 - 7... (CNA #1) notified me that (CNA #2) was observed speaking to (Resident #8) in a rough manner. I walked down to (Resident #8)'s room and asked her how she was doing and she looked at me and said 'I am doing ok'. I told her to let me know if she needed anything and she stated 'No, I am okay'." 2) On 6/3/11 at 11:12 a.m., the DON was ask if any other documentation was available relative to the concern dated 5/16/11 involving Resident #8, other than the Report of Concern sheet. The DON stated, "No more documentation other than the concern sheet and my typed statement dated 5/18/11." The DON was asked if the police were notified. The DON stated, "No." The DON was asked if the family or the physician was notified. The DON stated, "I cannot answer. To my understanding, the Administrator was going to do the notifications. There is no documentation of interviews with residents. There is no documentation of the body audit I did on the resident. The resident disagreed with anyone handling roughly or speaking harshly." 3) On 6/6/11 at 1:25 p.m., LPN #1 stated, "(CNA #1) came to me and reported about (Resident #8). She had (CNA #2) working with her in orientation. While in the room of (Resident #8), (CNA #2) spoke to (Resident #8) in a very harsh tone and it was so bad that (Resident #8) had started to cry. I went to (Resident #8)'s room and she was lying in the bed with her back towards me. I called her name, she looked over at me and I asked if she was okay. I asked how was she. She said, 'I'm doing okay'. She looked like she had a small tear in her left eye but said she was 'okay'. I did not ask her if she had been verbally abused by anyone or if anyone had spoken to her rudely." 4) On 6/6/11 at 1:45 p.m., CNA #1 stated, "I did fill out a Report of Concern on 5/16/11. ...The staff member I reported was (CNA #2). While changing (Resident #8), (CNA #2) pushed so hard she made (Resident #8) cry. I had been asked by (LPN #2) to watch how (CNA #2) turned and changed people so we could know what was wrong and how we could retrain her. I was at the foot of the bed on the same side watching her technique. (CNA #2) was changing (Resident #8)'s brief and turned her forcibly over and made her cry. (Resident #8) said 'Ouch'. I made (CNA #2) stop. I completed the task then went and informed (LPN #1). (LPN #1) came and assessed the resident." 5) On 6/6/11 at 2:07 p.m., CNA #2 stated, "I went to turn (Resident #8). I said, Can you turn over so I can wipe? I tried to push to turn her. She said, 'Ouch'. I must have put too much muscle into it - she said 'Ouch'. It wasn't intentional to hurt her. I didn't push her into to rail. The resident said 'Ouch'. I said, I apologize." 6) On 6/6/11 at 3:10 p.m., Resident #8 stated, "One aide on nights was too fast and too hard and hurt me and I cried when she turned me. It was carelessness." On 6/6/11 at 3:45 p.m., the resident repeated her statement in the presence of the Administrator and Director of Nursing. g. Resident #9 had [DIAGNOSES REDACTED]. The Admission MDS with an ARD of 3/30/11 documented the resident was severely impaired in cognitive skills for daily decision making per staff assessment for mental status. 1) On 6/3/11 at 11:12 a.m., the DON was asked if any other documentation was available relative to the concern dated 5/16/11 involving Resident #9, other than the Repo

Based on observation, record review, and interview the facility failed to ensure reassessments were conducted to determine sufficient daily fluid intake after a weight gain for 1 (Resident #3) and accurate calculations were conducted to determine daily fluid intake for 1 (Resident #5) of 6 (Residents #1, 3, 4, 5, 6, and 7) case mix residents who had feeding tubes. This failed practice had the potential to affect 18 residents who had feeding tubes as documented on a list provided by the Administrator on 2/4/11 at 10:20 a.m. The findings are: 1. Resident #3 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set with an Assessment Reference Date of 12/10/10 documented the resident was severely impaired in cognitive skills for daily decision making, required total assistance for eating, received 51% or more of total calories through a feeding tube, and 501 cc (cubic centimeters)/day or more fluid intake per day through a feeding tube. a. A physician order [REDACTED].[REDACTED].) b. The Nutritional Assessment of Tube Fed Resident dated 4/21/10 documented the resident's weight as 162 pounds (lbs). Further documentation was: "... Estimated Fluid Needs: 73.6 wt/kg (weight in kilograms) times 25-30 fluid factor = 1840-2208 cc's fluid ...Current order: Glucerna 1.2 C (calorie) 60 cc/hr, flush (with) 110 cc Q (every) 4 hrs (hours) and 50/60 cc (before) and (after) meds... Assessment/recommendations: ...(The resident) has exp (experienced) 12 lbs or 7% weight gain times 6 months. Cont (continued) weight gain not desirable... Suggest (decrease) feeding to 55 cc/hr... Will monitor..." c. A physician order [REDACTED].@ (at) 55 cc/hr per G (gastrostomy) tube continuous. May be off for ADLs (Activities of Daily Living) first date: 8/10/09." (For a total of 1320 cc/24 hours multiplied by 0.80 to equal 1056 cc of free water.) d. The Care Plan with an update date of 12/7/10 documented: "...Problem: Feeding NG ([MEDICAL CONDITION])/G ([MEDICAL CONDITION])-Tube ...Obtain order/tube feeding care, started 3/15/10, ...Assess tolerance of tube feeding ...Monitor weight gain or loss..." e. A physician order [REDACTED]." (660 cc/day) f. The weight sheet documented the resident's weight on 1/5/11 as 201 pounds (lbs), which equaled 91.36 kg (kilograms), for a minimum daily fluid requirement of 2,730 cc/day. With the free water from the tube feeding and the flushes, the total hydration the resident was receiving was 2196 cc/day, a fluid deficit of 534 cc/day. g. On 1/31/11 at 3:26 p.m. the resident was in bed with the tube feeding of Glucerna 1.2 cal (calorie) flowing at 55 cc/hr via pump. h. On 2/3/11 at 11:35 a.m. the Registered Dietician (RD) was asked if there was additional notes/assessments other than what was in the resident's record. The RD stated, "No". After reviewing the resident's record, the RD stated, "There is no reassessment since I did one in April (2010) when I was the Consultant." She was not aware of the resident's weight gain. The RD was asked how often a resident with a tube feeding should be assessed. The RD stated, "Quarterly, if the condition changes, weight gain, weight loss, or abnormal labs." She stated she would reassess the resident today. 2. Resident #5 had [DIAGNOSES REDACTED]. a. A telephone order dated 1/6/11 documented, "Increase H2O (water) 150cc Q (every) 4 hours." b. A telephone order dated 1/12/11 documented, "Diabetisource AC @ (at) 50cc (cubic centimeter)/hr(hour) continuous." c. A telephone order dated 1/13/11 documented, "...2. Decrease tube feeding to 40cc." d. A telephone order dated 1/25/11 and not yet signed by the physician documented, "(increase) tube feeding to 45cc/hr." e. The weight sheet documented the resident's weight on 1/4/11 was 149 pounds for a minimum fluid requirement of 2031 cc/day. f. The RD documented on 1/12/11, "Suggest change to Diabetisource at 50cc/hr to provide 1440 kcal and 72 gm pro (protein). Free H2O =960cc plus flush of 1860cc H2O...." g. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]@ 45cc/hr Enteral Tube continuous and the MAR indicated [REDACTED]." at 6:00 a.m., 10:00 a.m., 4:00 p.m., 6:00 p.m. and 8:00 p.m. There were only 5 allotted spaces for initials instead of the six flushes that should have been documented if water flushes were administered every 4 hours. h. According to CMS guidelines for calculating fluid intake, the resident should receive 2031 cc/day (67.7 kilograms x 30 cc = 2031 cc per day). According to the facility's documentation, the resident received 1614 cc/day, resulting in a 418cc/day deficit.

Based on observation, record review, and interview, the facility failed to ensure reassessments were conducted to determine sufficient daily fluid intake; a system for provision and monitoring of sufficient daily fluid intake was planned and implemented; and new interventions to ensure adequate fluids to prevent dehydration and UTIs were planned and implemented for 1 of 1 (Resident #5) case mix residents who had a history of [REDACTED].#5, who had repeated incidents of clinical signs Dehydration between 8/16/10 and 12/7/10 that required hospitalization s for treatment and had the potential to cause more than minimal harm for 67 residents who were at risk for Dehydration as documented by the facility's Registered Dietitian (RD) on 12/28/10. The findings are: 1. Centers for Medicare and Medicaid (CMS) interpretive guidelines at F327 documented: a. "Sufficient fluid means the amount of fluid needed to prevent dehydration (output of fluids far exceeds fluid intake) and maintain health. The amount needed is specific for each resident, and fluctuates as the resident's condition fluctuates," b. "A general guideline for determining baseline daily fluids needs is to multiply the resident's body weight in kg (kilograms) times 30 cc (cubic centimeters) (2.2 lbs = 1 kg), except for residents with renal or cardiac distress," c. Clinical signs of possible insufficient fluid intake (e.g., dry skin and mucous membranes, fever), abnormal laboratory values (e.g., elevated hemoglobin and hematocrit, potassium, chloride, sodium, transferrin, blood urea nitrogen (BUN), or urine specific gravity.) 2. The Stedman's Medical Dictionary, 26th Edition, Copyright 1995, documented definitions of exudate/drainage as follows: a. On page 1602, Serosanguineous: "Denoting an exudate or a discharge composed of or containing serum and also blood." On page 1603, Serum: "The fluid portion of the blood." b. On page 1603, Serous: "Relating to, containing, or producing serum or a substance having a watery consistency." 3. Resident #5 had [DIAGNOSES REDACTED]. The Significant Change of Status Minimum Data Set with an Assessment Reference Date of 6/9/10 documented the resident was severely impaired in cognitive skills for daily decision making, required total assistance for eating, had 4 stage III and 1 stage IV pressure ulcers, received 20-50% of calories and 1,001 - 1500 cubic centimeters (cc) fluids per day through a feeding tube, had an indwelling catheter, had no incidents of dehydration, "output exceeds input," or insufficient fluid in last 3 days and Intake and Output (I&O) was documented. a. The Resident Assessment Protocol for Dehydration/Fluid Maintenance dated 6/15/10, documented, "poor intake . . . feeding tube is in use . . . no apparent decrease in intake . . . no apparent increase in fluid loss," and, "is at risk for inadequate fluid intake." b. Monthly Assignment Sheets (MASs) were printed each month and on readmission to the facility, and had spaces for documentation by licensed and certified nursing staff (CNA's) on a daily basis for each shift. The MASs documented nursing problems with planned interventions and on the backs of the pages had Nurses' Notes sections. Weekly Assignment Sheets (WASs) forms were used by certified nursing staff for documentation on a daily basis for each shift and included meal consumption, "Report significant changes to nurse," in the sections for breakfast, lunch, dinner, snacks, and nutritional supplements, and, "Fluids - Monitor intake . . . Document Fluid Intake . . . Report significant changes to nurse." c. Weight sheets documented the resident's weight on 8/11/10 as 155 pounds (lbs.) which equaled 70.45 kg, for a minimal daily fluid requirement of 2,113 cc/day. d. Nurses' MASs dated 7/21/10 through 8/16/10, documented, "Assess skin color/temperature/hydration - check for: cyanosis/skin cool, dry," which were initialed as "done," twice per day. The same MASs documented the resident received [MEDICATION NAME] 1.5 one can bolus twice per day (bid) for 389 cc fluid from tube feeding. Dietary Assessment Notes dated 7/1/10, documented physicians orders to flush 250 cc water 4 times per day (1000 cc), give 50-60 cc water before and after medications 4 times per day (400 cc), and Juven in 8 ounces water twice per day (480 cc), for a total of 2,269 cc provided through the resident's feeding tube daily prior to 8/16/10. The Dietary Notes documented the resident received a pureed diet at meals during the day. e. Wound Clinic Notes dated 7/6/10 documented the resident had pressure ulcers at the sacrum and right hip with moderate amounts serous exudates. Wound Clinic Notes dated 8/3/10 documented the wound drainage at the sacrum as moderate amount serosanguineous and at the right hip, moderate amounts serous. There was no documentation in the Nurses Notes, Dietary Notes, physician progress notes [REDACTED]. f. Nurse's Notes dated 8/16/10 at 1:00 p.m., documented, "(resident) had very little output . . . noticed foley output was very little, milky brown urine in bag (abnormal color, consistency are indicators of infection)." The Notes documented the resident's physician was contacted and stated he would see the resident in the facility that day. Nurses' Notes dated 8/16/10 at 6:30 p.m. documented the resident's physician had not been to the facility and was paged. Notes dated 8/16/10 at 7:40 p.m. (a total of 6 hours and 40 minutes since signs of infection noted) documented the physician was paged again, and gave orders to send the resident to a hospital for evaluation. There was no documentation in the above Notes of provision of additional fluids in the presence of signs of a urinary tract infection [MEDICAL CONDITION]. g. A Hospital History and Physical (H&P) dated 8/17/10 documented an Impression of UTI, Urinary Obstruction, and Acute [MEDICAL CONDITION] secondary to Obstruction. Hospital Laboratory Reports dated 8/16/10 at 10:45 p.m. documented clinical signs of insufficient fluid intake as follows: Elevated BUN of 111 mg/dL (normal = 6-20) and Creatinine of 6.7 mg/dL (normal = 0.7-1.2). Laboratory reports dated 8/25/10 documented the resident's BUN was 11 and Creatinine 0.7, both within normal limits. The Hospital Consult Report dated 8/17/10 at 12:00 a.m., documented the resident presented without urine in the catheter drainage bag and, "does not have a prior history of renal dysfunction." The Hospital Discharge Summary dated 8/25/10, documented the resident's hospital course included intravenous (IV) antibiotics, IV hydration and consultation with a physician for the resident's renal status. h. Nurses' and CNA's MASs documented the resident was readmitted to the facility on [DATE]. Weight records documented the resident's readmission weight as 152 lbs. = 69 kg = 2070 cc fluid/day minimum fluid needs. The September 2010 MAR indicated [REDACTED]. water twice per day, water flushes and [MEDICATION NAME] 1.5 bolus one can twice per day, as previously ordered, for a total of 2,269 cc fluid per day through the resident's feeding tube. Dietary Progress Notes dated 9/1/10, documented, "Diet and (tube feeding) adequate to meet (estimated) needs. Will continue current (plan of care) and monitor (weights), (oral) intake . . . " i. The Care Plan dated 8/25/10 and Nurses' MASs dated 8/25/10 through 9/24/10 documented a problem for catheter use with a new intervention, "Maintain adequate Fluid Intake. Encourage (resident) to drink: 1-2 pitchers water daily" with initials that it was done twice per day. There was no documentation on Medication Administration Records (MARs) or Nurses' Notes of whether the resident consumed that amount of water by mouth each day. The Care Plan dated 8/25/10 and CNA's MASs dated 8/25/10 through 9/24/10, documented a new intervention, "Encourage (resident) to drink at least 1000 cc fluid daily." The CNA's MASs had 90 opportunities for documentation with 60 "blank," spaces for that period of time (30 days). j. WASs dated 9/1/10 through 9/24/10, documented meal consumption between 50-100% for breakfasts and lunches, did not document consumption percentages for dinners and there were no fluid intake amounts documented in the sections for, "Fluids - monitor intake." k. Wound Clinic records dated 9/23/10 documented the resident's wound at the right hip had moderate serosanguineous drainage. l. The September 2010 MAR indicated [REDACTED]. Nurses Notes and MASs did not document "abnormals," for urine assessments or decrease in fluid intake between 9/1/10 and 9/22/10. MAR's dated September 2010 documented urine output on 9/23/10 (7:00 a.m. - 3:00 p.m. - 450 cc) and (3:00 p.m. - 11:00 p.m. - 100 cc). m. Nurses Notes dated 9/23/10 at 6:30 p.m., documented, "observed purulent blood tinged urine in foley bag. Output was 100 cc at (5:00 p.m.) Notified (physician), new order for UA C&S (Urinary Analysis with Culture and Sensitivity) in (morning). Monitor urine output, reported (change) in condition to oncoming nurse (at 7:00 p.m.)." Nurses Notes dated 9/23/10 at 11:00 p.m. documented the resident, "has only 100 cc output observed in (catheter) bag (at) this time. UA collected. Called (physician) to notify of urine output, awaiting call back." Nurses Notes dated 9/24/10 at 5:00 a.m., documented the physician was paged to notify him the resident, "has no urine output (at) this time . . . awaiting call back." Notes dated 9/24/10 at 7:00 a.m. documented, "reported off to oncoming nurse (resident) had no urine output on 11-7 (11:00 p.m. - 7:00 a.m.) but (physician) had been paged . . . awaiting call back." A period of 8 hours had passed since the decreased urine output had been observed and the physician paged without a response. Nurses Notes dated 9/24/10 at 10:00 a.m., documented the physician had ordered catheter irrigation as needed and if no results, to call back. There was no documentation of the irrigation results, or lack thereof. Notes dated 9/24/10 at 12:30 p.m. documented the resident was sent to a local hospital, "for no urinary output," with a temperature of 102.9 degrees Farenheit (F), "vomiting, (and) diaphoresis." There was no documentation in those Notes of additional fluids provided to the resident between 9/23/10 at 11:00 p.m. and 9/24/10 at 12:30 p.m., a period of 13.5 hours. n. A Hospital H&P dated 9/24/10 documented the resident was evaluated for mental status change with no urine output for 12 hours, the catheter could not be flushed and the Impression was, "Sepsis, Urinary Tract Infection, Dehydration . . ." Emergency Physician Record dated 9/24/10 at 1:45 p.m. documented the resident received, "IV rehydration," of Normal Saline at 125 cc/hour. Hospital Lab Reports dated 9/24/10 at 1:54 p.m., documented an elevated BUN of 65 mg/dL and Creatinine of 3.6 mg/dL. The Hospital Discharge Summary dated 9/30/10 documented the resident was transferred back to the nursing facility. o. Nurses' and CNA's MASs and WASs dated 9/30/10 through 11/2/10 and 11/19/10 through 12/6/10, did not document new interventions for provision and monitoring of sufficient fluid to prevent Dehydration for this resident. A Hospital Discharge Summary dated 11/18/10 documented the resident was hospitalized between 11/2/10 and 11/18/10 for treatment of [REDACTED]. = 61.81 kg = 1854 cc minimum fluid required per day. The November 2010 MAR indicated [REDACTED]. water, as previously ordered, for a total of 2,987 cc water daily through the feeding tube. Nurses' and CNA's MASs dated between 11/19/10 and 12/6/10 documented initials next to the same interventions for encouragement of 1-2 pitchers water and 1,000 cc fluid per day that were originally planned on 8/25/10. p. Wound Clinic records dated 11/30/10 documented the resident had wounds at the sacrum that had moderate serosanguineous drainage and right hip with "heavy," serosanguineous drainage, which indicated an increase in amount of exudate from that wound. q. WASs dated 12/4/10 documented the resident consumed between 25-50% of 3 meals and 25%-50% of supplements. There was no documentation on WASs of fluid intake amounts between 11/19/10 and 11/27/10 or 12/1/10 through 12/6/10. r. WASs dated 12/5/10 and 12/6/10, documented the resident refused breakfasts, lunches, and supplements. There was no documentation in the sections for dinners and fluid intakes for those dates. There was no documentation on the backs of those WASs or in Nurses' Notes that nurses had been informed of the resident's refusal of oral food/fluids. On 12/29/10 at 11:00 a.m., December 2010 nursing schedules documented CNA #4 and RCNA #1 were on duty 12/5/10 and 12/6/10 and assigned to the resident's hall. They both denied they had documented the refusal of meals for the resident on those dates. Dietary Progress Notes dated 12/6/10 documented the resident's weight as 136 lbs., daily fluid needs (based on 30 cc/kg) of 1,854 cc/day, provision of 2,632 cc fluids through the resident's feeding tube per day and, "fed by staff in his room. Intake fair. (Tube feeding) adequate to meet (estimated) needs . . ." s. Nurses MASs dated between 11/18/10 and 12/7/10 had a total of 10 pages with Notes sections on the back of each page. Those Notes sections were blank except for the back of page 2; Nurses Notes dated 12/7/10 at 11:10 a.m., documented the resident was lying in bed with eyes half open, had decreased level of consciousness, minimal response to stimuli, "sunken eyes, dry mucous membranes," and "green purulent fluid draining from buttocks (sacral) wound. Notified (physician)." Notes dated 12/7/10 at 11:20 a.m. documented the resident's suprapubic catheter was leaking urine at the insertion site and Notes at 11:24 a.m. documented the resident was sent to a local hospital. t. A Hospital H&P dated 12/7/10 documented the resident had evidence of, "severe urinary tract infection and severe dehydration," with a plan to treat with broad-spectrum antibiotic and IV hydration. Hospital Lab Reports dated 12/7/10 at 2:37 p.m., documented elevated levels of Sodium at 152 mg/dL (normal =70-105), Chloride at 119 mMole/Liter (normal = 98-109), and BUN at 60 mg/dL. u. Nurses Notes dated 12/20/10 at 2:45 p.m., documented the resident was readmitted to the nursing facility and Weight Records dated 12/24/10 documented the resident's readmission weight at 137 lbs. A Wound/Skin Report dated 12/27/10 documented both wounds at the sacrum and right hip continued to have, "large," serous drainage. As of 12/27/10 at 4:15 p.m., Nurses' and CNA's MASs documented initials next to the same interventions dated 8/25/10 for provision of increased fluids and did not document new interventions to provide and monitor daily fluid intake for this resident. v. On 12/27/10 at 2:35 p.m., the resident was in bed, had clear tea-colored urine draining to a catheter bag, [MEDICATION NAME] 1.5 was infusing at 60 cc/hour per enteral pump, and had a sippy-cup of water at the bedside. w. On 12/28/10 at 9:19 a.m., the resident's physician was interviewed via phone. The physician was asked if the resident had a history of [REDACTED]." The physician stated the resident's suprapubic catheter (placed due to abnormal [MEDICAL CONDITION] tract) placed him at high risk for UTI's [MEDICAL CONDITION]. The physician was asked if there were any restrictions which would limit increases of fluid per day for the resident, and he stated, "No." The physician was asked how he expected the resident to be assessed for sufficient daily fluid needs and he stated, "Dietary (RD) every time needed, go by her assessments." The physician was asked how the resident's fluid intake should be monitored and he stated, "By nursing." The physician was asked if the facility had approached him at any time since 8/25/10 for assistance in determination of sufficient daily fluid needs for this resident, and he stated, "No, not asked," and, "I have not suggested it to them." On 12/29/10 at 7:55 a.m., the DON was asked who was responsible for monitoring of meal and fluid consumption (documented on WASs) and she stated, "Nurses are to monitor." The DON was asked if a resident refused to eat, what should the CNA staff do, and she stated, "they should come and tell nurse." x. On 12/29/10, CNA #4 and Restorative CNA (RCNA) #1, who both worked with this resident, were asked what they were supposed to do if consumption amounts changed for a resident, and what it meant to them when they initialed the WASs for encouragement to drink 1,000 cc daily. At 10:25 a.m., CNA #4 stated if consumption were not the same as usual, "I go tell nurse right after that meal that they are not eating as much." CNA #4 stated, "I encourage them to drink as much as they can so they won't get a UTI or dehydrated," but she did not state she had been instructed to document fluid intake on the WASs. At 10:33 a.m., RCNA #1 stated, "To me it means when I give care, offer something to drink." RCNA #1 also denied instructions to document fluid intake amounts on the WASs. y. On 12/29/10 at 10:40 a.m., LPN #4 was asked how she knew if a resident was not eating or drinking as well as usual and she stated, "the CNAs are to make us aware of that, we also ask CNAs and monitor dining rooms." When asked about the MASs interventions to increase fluids, LPN #4 stated, "I monitor their output and encourage them to drink. The only person that does monitor that (intake), is hydration cart people." On 12/28/10 at 1:13 p.m., the facility's RD was asked about the use of a hydration cart in the facility and she stated the facility did not have a "hydration cart." The facility had a list of residents with risk for or actual weight loss and extra food/supplements were offered to those residents between meals. The RD stated this resident was not on that list. On 12/28/10 at 12:45 p.m., the DON was asked what the facility's system of monitoring sufficient daily fluid intake was for residents at risk or with a history of Dehydration. She stated the nurses documented tube feedings, flushes, and urine outputs on MAR's. The DON was asked to provide evidence of how the facility monitored this resident's hydration status and the facility's policy and procedure for maintenance of hydration and their system for monitoring for sufficient daily fluids for residents in the facility. As of 12/29/10, the DON had not provided the above requested information. z. As of 12/29/10 at 10:50 a.m., the Care Plan did not document new interventions for provision and monitoring of daily fluid intake for this resident.

Based on observation, record review and interview, the facility failed to ensure planned interventions to increase daily fluid intake were implemented to prevent/lessen severity of Urinary Tract Infections (UTI's) and that routine licensed nursing assessments of urine color, consistency and presence or lack thereof of signs of infection were documented for 1 (Resident #5) of 2 (Residents #5 and #6) case mix residents who had a history of [REDACTED]. This failed practice resulted in a pattern of harm for Resident #5 who required multiple hospitalization s for treatment of [REDACTED]. The findings are: Resident #5 had was admitted on [DATE] and had [DIAGNOSES REDACTED]. The Significant Change of Status Minimum Data Set with an Assessment Reference Date of 6/9/10 documented the resident was severely impaired in cognitive skills for daily decision making, required total assistance for eating, had 4 stage III and 1 stage IV pressure ulcers, received 20-50% of calories and 1,001 - 1500 cubic centimeters (cc) fluids per day through a feeding tube, had an indwelling catheter, Intake and Output (I&O) was documented and did not have a UTI in the last 30 days. a. The Resident Assessment Protocol for Dehydration/Fluid Maintenance dated 6/15/10, documented, "poor intake . . . feeding tube is in use . . . no apparent decrease in intake . . . no apparent increase in fluid loss," and, "is at risk for inadequate fluid intake." b. Monthly Assignment Sheets (MASs) were printed each month and on readmission to the facility, and had spaces for documentation by licensed and certified nursing staff (CNAs) on a daily basis for each shift. The MASs documented nursing problems with planned interventions and on the backs of the pages had Notes sections. On 12/29/10 at 10:40 a.m., Licensed Practical Nurse (LPN) #4 was asked what she had been instructed to document on a routine basis about the resident's urine and how often to do that documentation. LPN #4 stated, "Only thing we are told to document is abnormality, leaking, different color, pain, discomfort with irrigation. If everything is normal, we don't document." c. Nurses' MASs dated 6/23/10 through 7/5/10 documented, "Assess urine color, clarity, amount - complaints of burning, pain / increase in temperature." The Nurses' MASs had initials that indicated those assessments were done twice per day (nurses had worked 12-hour shifts). There was no documentation in Nurses' Notes of the resident's "normal," urine appearance, consistency. Nurses Notes dated 7/2/10, 7/3/10, and 7/4/10 documented the resident's catheter was "patent." Weekly Assignment Sheets (WASs) were printed for certified nursing staff documentation on a daily basis for each shift and included "Fluids - Monitor intake . . . Document Fluid Intake: Report significant changes to nurse." d. A Hospital History and Physical (H&P) dated 7/6/10, documented the resident had a fever of 101 degrees Farenheit (F) and, "abnormal pus in his urine . . . Patient is admitted for broad-spectrum antibiotic coverage." A Hospital Discharge Summary dated 7/20/10 documented the resident was readmitted to the nursing facility. e. Nurses' MASs dated 7/21/10 through 8/16/10, documented, "Assess skin color/temperature/hydration - check for: cyanosis/skin cool, dry," and "Monitor for s/s (signs/symptoms) UTI - Assess urine color, clarity, amount - complaints of burning, pain,/increase in temperature," which were initialed as "done," twice per day. The same MASs documented the resident received [MEDICATION NAME] 1.5 one can [MEDICATION NAME] twice per day (bid), Dietary Assessment Notes dated 7/1/10 documented physicians orders to flush 250 cc water 4 times per day, give 50-60 cc (cubic centimeters) water before and after medications 4 times per day (400 cc), [MEDICATION NAME] in 8 ounces water twice per day (480 cc), for a total of 2,269 cc provided through the resident's feeding tube daily prior to 8/16/10. The Dietary Notes documented the resident received a pureed diet at meals during the day. f. Wound Clinic Notes dated 7/6/10 documented the resident had pressure ulcers at the sacrum and right hip with moderate amounts serous exudates. Wound Clinic Notes dated 8/3/10 documented the wound drainage at the sacrum as moderate amounts serosanguineous and at the right hip, moderate amounts serous. There was no documentation in Nurses Notes, Dietary Notes, physician progress notes [REDACTED]. g. Nurse's Notes dated 8/16/10 at 1:00 p.m., documented, "(resident) had very little output . . . noticed foley output was very little, milky brown urine in bag (abnormal color, consistency are indicators of infection)." The Notes documented the resident's physician was contacted and stated he would see the resident in the facility that day. Nurses' Notes dated 8/16/10 at 6:30 p.m. documented the resident's physician had not been to the facility and was paged. Notes dated 8/16/10 at 7:40 p.m. (a total of 6 hours and 40 minutes since signs of infection noted) documented the physician was paged again, and gave orders to send the resident to a hospital for evaluation. There was no documentation in the above Notes of further assessment of the resident's urine or the provision of additional fluids in the presence of signs of a urinary tract infection [MEDICAL CONDITION]. h. A Hospital History and Physical (H&P) dated 8/17/10 documented the resident had poor urine output over the past 24 hours, had evidence of urinary obstruction, and had drained copious amounts of pus in the blood-tinged urine. The H&P documented an Impression of UTI, Urinary Obstruction, Acute [MEDICAL CONDITION] secondary to Obstruction. An emergency room Nursing Record (page 3) dated 8/16/10 at 8:43 p.m. documented, "with [MEDICAL CONDITION] (times) 2 days, foley in place, cloudy yellow/brown pus-looking 30 cc urine in bag. (Abdomen) distended, painful with palpation," at 10:35 p.m. documented the Foley catheter was replaced, at 10:45 p.m. documented Foley clogged with pus and irrigated and on 8/17/10 at 12:45 a.m., "emptied Foley 1400 (cc) urine out, slight hematuria with pus (and) chunks." Hospital Laboratory Reports dated 8/16/10 at 10:45 p.m. documented clinical signs of insufficient fluid intake with an elevated BUN of 111 mg/dL (normal = 6-20) and Creatinine of 6.7 mg/dL (normal = 0.7-1.2). A Laboratory report dated 8/16/10 at 10:45 p.m. for Urinary Analysis with Culture and Sensitivity (UA with C&S) documented the resident's urine, "very cloudy," Protein 100 mg (milligrams)/dL (normal = negative), Blood 250/ul (normal = negative), Leuk Est 500/ul (normal = negative), WBC, "TNTC (too numerous to count)," and an inability to count presence of RBC's (red blood cells) and bacteria due to obscured fields with WBC's. The Consult Report dated 8/17/10 at 12:00 a.m., documented the resident presented without urine in the catheter drainage bag and, "does not have a prior history of renal dysfunction." The Hospital Discharge Summary dated 8/25/10, documented the resident's hospital course included intravenous (IV) antibiotics, IV hydration and the consultation with a physician for the resident's renal status. i. Nurses' and CNA's MASs documented the resident was readmitted to the facility on [DATE]. The September 2010 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. j. The Care Plan dated 8/25/10 and Nurses' MASs dated 8/25/10 through 9/24/10 documented a problem for catheter use with a new intervention, "Maintain adequate Fluid Intake. Encourage (resident) to drink: 1-2 pitchers water daily" with initials that it was done twice per day. There was no documentation on the Medication Administration Records (MAR) or Nurses' Notes of whether the resident consumed that amount of water by mouth each day. The Care Plan dated 8/25/10 and CNA's MASs dated 8/25/10 through 9/24/10, documented a new intervention, "Encourage (resident) to drink at least 1000 cc fluid daily." The CNA's MASs had 90 opportunities for documentation with 60 "blank," spaces for that period of time (30 days). k. Nurses' Notes dated 8/25/10, 8/27/10 X 3 notes, 8/28/10 X 2 notes, and 8/29/10 x 2 notes did not document an assessment of the resident's urine or patency of the resident's catheter. Nurses' MASs dated 8/25/10 through 9/5/10 documented initials in the section for "Monitor for s/s UTI." l. Nurses' Notes dated 9/6/10 at "7a-7p (7:00 a.m. - 7:00 p.m.)," documented, "family came (and) reported that (resident) did not have urine in foley tubing. Assessed foley (and) obtained order to irrigate foley. STAT (immediate) UA (with) C&S . . . After irrigation reddish/brown urine in color (and) odor (with) pus." A UA with C&S report dated 9/6/10 at 4:00 p.m., documented urine as red, cloudy, large amount occult blood, protein greater than 300 mg/dL, large amount Leuk Est, 50-75 RBCs (normal = none seen), 50-75 WBC's (normal = 0-5) and Bacteria 3+ (normal = negative). Nurses Notes dated 9/6/10 at 10:55 p.m. documented new orders for [MEDICATION NAME] (an antibiotic) 250 mg one tablet per feeding tube times 7 days for UTI. Nurses Notes dated 9/7/10 x 3, 9/8/10, 9/9/10 x 2 did not document assessments of the resident's urine or attempts to increase fluid intake. Nurses Notes dated 9/10/10 at "7a-7p" documented new orders to discontinue the [MEDICATION NAME] and start Keflex 500 mg 4 times per day for UTI (in response to C&S result dated 9/9/10 of greater than 100,000 Proteus mirabilis that was resistant to [MEDICATION NAME]). Nurses Notes dated 9/11/10, 9/12/10 X 2, 9/13/10 and 9/14/10 did not document assessments of the resident's urine or fluid intake. m. WASs dated 9/1/10 through 9/24/10 did not document fluid intake amounts documented in the sections for, "Fluids - monitor intake." n. Wound Clinic records dated 9/23/10 documented the resident's wound at the right hip had moderate serosanguineous drainage. o. The September 2010 MAR indicated [REDACTED]. Nurses Notes and MASs did not document "abnormals," for urine assessments, decreases in fluid intake between 9/1/10 and 9/22/10, or assessments of the resident's urine in the presence of marked decrease in urine output. p. Nurses Notes dated 9/23/10 at 6:30 p.m., documented, "observed purulent blood tinged urine in foley bag. Output was 100 cc at (5:00 p.m.) Notified (physician), new order for UA C&S (Urinary Analysis with Culture and Sensitivity) in (morning). Monitor urine output, reported (change) in condition to oncoming nurse (at 7:00 p.m.)." Nurses Notes dated 9/23/10 at 11:00 p.m. documented the resident, "has only 100 cc output observed in (catheter) bag (at) this time. UA collected. Called (physician) to notify of urine output, awaiting call back." Nurses Notes dated 9/24/10 at 5:00 a.m., documented the physician was paged to notify him the resident, "has no urine output (at) this time . . . awaiting call back." Notes dated 9/24/10 at 7:00 a.m. documented, "reported off to oncoming nurse (resident) had no urine output on 11-7 (11:00 p.m. - 7:00 a.m.) but (physician) had been paged . . . awaiting call back." A period of 8 hours had passed since the decreased urine output was observed and the physician paged. Nurses Notes dated 9/24/10 at 10:00 a.m., documented the physician had ordered catheter irrigation as needed and if no results, to call back. There was no documentation of the irrigation results, or lack thereof. Notes dated 9/24/10 at 12:30 p.m. documented the resident was sent to a local hospital, "for no urinary output," with a temperature of 102.9 degrees F, "vomiting, (and) diaphoresis." There was no documentation in those Notes of the resident's urine, patency of the catheter, or of additional fluids provided to the resident between 9/23/10 at 11:00 p.m. and 9/24/10 at 12:30 p.m., a period of 13.5 hours. q. A Hospital H&P dated 9/24/10 documented the resident was evaluated for mental status change with no urine output for 12 hours, the catheter could not be flushed and the Impression was, "Sepsis, Urinary Tract Infection, Dehydration . . ." Emergency Physician Record dated 9/24/10 at 1:45 p.m. documented the resident received, "IV rehydration," of Normal Saline at 125 cc/hour, and the resident's penis had, "yellow pus-like d/c (discharge) at opening." The emergency room Nursing Record dated 9/24/10 at 4:00 p.m. documented the resident was administered [MEDICATION NAME] 500 mg IV. Hospital Lab Reports dated 9/24/10 at 1:54 p.m., documented an elevated BUN of 65 mg/dL and Creatinine of 3.6 mg/dL. A hospital UA report dated 9/24/10 at 2:08 p.m. documented the resident's urine was brown, very cloudy, had an elevated pH of 9 (normal = 5.0-9.0), 500 mg/dL protein, 250/ul blood, and 500/ul Leuk Est. A hospital Physician's Progress Note dated 9/27/10 documented the surgical placement of a Suprapubic catheter due to "hypospadia (with) purulent discharge." A hospital Discharge Summary documented the resident was treated with IV antibiotics and readmitted to the facility on [DATE]. r. Nurses' and CNA's MASs and WASs dated 9/30/10 through 11/2/10 and 11/19/10 through 12/6/10, did not document new interventions for documentation of routine assessments of the resident's urine or provision and monitoring of sufficient fluid for this resident. A Hospital Discharge Summary dated 11/18/10 documented the resident was hospitalized between 11/2/10 and 11/18/10 for treatment of [REDACTED]. water, as previously ordered, for a total of 2,987 cc water daily through the feeding tube. s. WASs dated 11/28/10, 11/29/10, and 11/30/10 had documentation of fluid intakes, in the sections for fluid intake amounts, for amounts between 400 cc and 550 cc. There was no documentation on WASs of fluid intake amounts between 11/19/10 and 11/27/10 or 12/1/10 through 12/6/10. Nurses' and CNA's MASs dated between 11/19/10 and 12/6/10 documented initials next to the same interventions for encouragement of 1-2 pitchers water and 1,000 cc fluid per day that were originally planned on 8/25/10. t. Wound Clinic records dated 11/30/10 documented the resident had wounds at the sacrum that had moderate serosanguineous drainage and right hip with "heavy," serosanguineous drainage, which indicated an increase in amount of exudate, or body fluids, from that wound. u. Dietary Progress Notes dated 12/6/10 documented the resident's weight as 136 lbs., daily fluid needs (based on 30 cc / kg) of 1,854 cc/day and provision of 2,632 cc fluids through the resident's feeding tube per day, (tube feeding) adequate to meet (estimated) needs . . ." There was no documentation in those Notes of discussion of estimated fluid loss through wound drainage. v. WASs dated 12/5/10 and 12/6/10 documented the resident refused breakfasts, lunches, and supplements. There was no documentation in the sections for dinners and fluid intakes for those dates. There was no documentation on the backs of those WASs or in Nurses' Notes that nurses had been informed of the resident's refusal of oral food/fluids, attempted to provide increased fluids to the resident or assessed the resident's urine. The Nurses MASs dated 11/7/10 through 12/7/10 had a total of 10 pages with Notes sections on the back of each page. Those Notes sections were blank except for the back of page 2; Nurses Notes dated 12/7/10 at 11:10 a.m., documented the resident was lying in bed with eyes half open, had decreased level of consciousness, minimal response to stimuli, "sunken eyes, dry mucous membranes," and "green purulent fluid draining from buttocks (sacral) wound. Notified (physician)." Notes dated 12/7/10 at 11:20 a.m. documented the resident's suprapubic catheter was leaking urine at the insertion site and Nurses Notes at 11:24 a.m. documented the resident was sent to a local hospital. w. A Hospital H&P dated 12/7/10 documented the resident had evidence of, "urinary tract infection and severe dehydration," with a plan to treat with a broad-spectrum antibiotic and IV hydration. Hospital Lab Reports dated 12/7/10 at 2:37 p.m., documented clinical signs of Dehydration with elevated levels of Sodium at 152 mg/dL (normal = 70-105), Chloride at 119 mMole/Liter (normal = 98-109), and BUN at 60 mg/dL. A hospital laboratory report for UA with C&S dated 12/7/10 at 12:52 p.m. documented the resident's urine was yellow, very cloudy, had 100mg/dL protein, 150/ul blood, 500/ul Leuk Est, 5-10 WBC's, 3-5 RBC's, 2+ mixed bacteria and sediment. The hospital C&S dated 12/7/10 documented Proteus mirabilis identified in the resident's urine. A Hospital Physician's Progress Note dated 12/7/10 documented the resident's suprapubic catheter was changed due to leaking. x. Nurses Notes dated 12/20/10 at 2:45 p.m., documented the resident was readmitted to the nursing facility and Weight Records dated 12/24/10 documented the resident's readmission weight at 137 lbs. A Wound/Skin Report dated 12/27/10 documented both wounds at the sacrum and right hip continued to have, "large," serous drainage. As of 12/27/10 at 4:15 p.m., Nurses' and CNA's MASs documented initials next to the same interventions dated 8/25/10 for provision of increased fluids and assessments of the resident's urine and did not document new interventions to monitor daily fluid intake or document routine assessments of the resident's catheter. The Care Plan documented a problem for catheter use with an intervention dated 12/21/10 for irrigation of the suprapubic catheter with 0.25% Acetic Acid Solution daily. y. On 12/27/10 at 2:35 p.m., the resident was in bed, had clear tea-colored urine draining to a catheter bag. z. On 12/28/10 at 9:19 a.m., the resident's physician was interviewed via phone. The physician was asked if the resident had a history of [REDACTED]." The physician stated the resident had an indwelling catheter on admission to the facility due to an abnormal [MEDICAL CONDITION] Tract. The physician stated the resident's suprapubic catheter placed him at high risk for UTIs [MEDICAL CONDITION]. The physician was asked if there were any restrictions which would limit increases of fluid per day for the resident, and he stated, "No." The physician was asked how he expected the resident to be assessed for sufficient daily fluid needs and he stated, "Dietary (RD) every time needed, go by her assessments." The physician was asked how the resident's fluid intake should be monitored and he stated, "By nursing." The physician was asked if the facility had approached him at any time since 8/25/10 for assistance in determination of sufficient daily fluid needs for this resident, and he stated, "No, not asked," and, "I have not suggested it to them." On 12/28/10 at 12:45 p.m., the DON was asked where nursing assessments of the resident's urine were located. The DON stated it was not documented on their MAS or Nurses Notes forms and that nurses, "chart by exception."