Every finding on record at The Springs of Mt Vista

Based on observation, interview, and record review, the facility failed to ensure the laboratory waiver was renewed for 1 of 1 facility requiring a waiver to perform testing. Specifically, the facility Centers for Medical & Medicaid Services Clinical Laboratory Improvement Amendments (CLIA) Certificate of Waiver (COW) was expired. The findings are: Review of a Centers for Medicare and Medicaid Services (CMS) CLIA brochure titled, How to obtain a CLIA Certificate, revealed a COW is issued to perform waived tests, defined as a lab test with insignificant risk of erroneous results. Waived tests include SARS-COV-2 (COVID), Influenza A/B, gastric occult blood, and glucose monitoring devices. During an observation on [DATE] at 12:00 PM, Licensed Practical Nurse (LPN) #1 performed a blood glucose test on Resident #73 using a glucose monitoring device. During an observation of the medication room on [DATE] at 12:38 PM, a document titled, Centers for Medical & Medicaid Services Clinical Laboratory Improvement Amendments [CLIA] Certificate of Waiver, revealed the CLIA ID (Identification) Number was 04D0468396 with an expiration date of [DATE]. The Director of Nursing (DON) stated this is the updated one and pointed to a paper attached to the wall to the left of the CLIA certificate titled, CLIA Laboratory User Fees. A review of the CLIA Laboratory User Fees, with a billing date of [DATE], included a CLIA Fee Coupon at the bottom, indicating the CLIA ID Number was 04D0468396, a certificate period of [DATE] to [DATE]. A note, located above the CLIA Fee Coupon, instructed When renewing a certificate, if full payment is not received prior to the begin date of the above certificate period, your current certificate will expire, and you may not legally perform testing after this date. On [DATE] at 08:50 AM, the Administrator provided a copy of the CLIA Laboratory User Fee and email showing payment of $268.00 was made. The Administrator stated the renewed certificate will come by mail.

Based on observations, interviews, record review, facility document review, and facility policy review, it was determined the facility failed to maintain Legionella surveillance for 1 of 1 water management plan and maintain sanitary conditions for 1 of 1 resident unit refrigerator reviewed for infection control. Findings include: A review of the facility's undated policy but with a copyright date of 2022 titled Legionella Surveillance, indicated Legionella was a bacteria found in water that caused a serious type of pneumonia called Legionnaires' Disease. Legionella surveillance is one component of the facility's water management plan for reduction risk of bacteria in the facility's water system. Legionella grew best in water which is stagnated or did not have enough disinfectants and at 77-108 degrees Fahrenheit. Temperature control measures included hot water shall be stored at 140 degrees Fahrenheit and circulated at a minimum of 124 degrees Fahrenheit. A review of a facility policy titled, Legionella Water Management Program, revised in July of 2017, indicated a management program was to identify areas where Legionella bacteria can grow by first using a diagram of the facility's water system which mapped out where water was received, cold water distribution, heating, hot water distribution, and waste. Second, map identified areas which encourage growth and spread of Legionella and other waterborne bacteria like storage tanks, water heaters, filters, aerators, showerheads/hoses, humidifiers, hot tubs, fountains, and medical devices. Third, map identified situations such as presence of biofilm, sediment, water temperature fluctuations, water pressure changes, water stagnation, and inadequate disinfection. Lastly, a diagram of where control measures are applied and a system to monitor control limits and effectiveness. During an interview on 09/26/2024 at 11:00 AM, the Maintenance Supervisor (MS) stated he only monitors the hot water temperature of every hall and the hot water heaters were currently set at 110 degrees Fahrenheit which were completed weekly. The MS stated he had no knowledge of a diagram mapping the plumbing/water flow of the building and added several water lines that had been dug up and replaced prior to his employment. He indicated a main shut off valve was at the hub in the center of the building by the nurses' station and the gray water drained somewhere out by C-Hall. The MS stated he had no knowledge of identified areas of concern to be monitored like stagnated water. The MS stated the facility provided two days of training with the prior MS, then an unidentified regional employee later put the maintenance books in order. The MS stated the city had done water testing earlier this year but was unable to find the documentation they provided. During the Exit Conference Consultant #2 stated, if the MS would have come to the consultant the regional employee could have been contacted for a copy. A review of an untitled, undated floor plan sent to the survey team on 09/30/2024 post exit conference identified five hot water heater location, one boiler location and one in-flowing water line to the facility. No water flow through the facility was identified so no areas of stagnation could have been assessed. 51064 During a concurrent observation and interview on 09/25/2024 at 11:51 AM, the following items were located in a refrigerator on the F Hall: a can of soda, a lunch box, flavored gelatin cups, a bottle of water, a reusable thermos with an unidentified drink, a small bag of pizza bites, and a jar of pickles. When asked who used the refrigerator on the F Hall, Certified Nursing Assistant (CNA) #5 stated the staff and residents use the refrigerator. When asked how items were labeled for identification, CNA #5 stated the items were not labeled. During an interview on 09/25/2024 at 12:00 PM, the Assistant Director of Nursing (ADON) and Licensed Practical Nurse (LPN) #6 stated staff and residents both use the refrigerator on the F Hall. During an interview on 09/25/2024 at 12:30 PM, LPN #3 stated the residents and staff foods/beverages should not be stored in the same refrigerator due to the risk of contamination. During a concurrent observation and interview on 09/26/2024 at 8:12 AM, the following items were located in a refrigerator on the F Hall unit: two breast pumps with a substance in the bottom, a lunch bowl, a pack of hamburger buns, four bottles of water, a lunch box, flavored gelatin cups, fruit cups, two reusable thermoses with an unidentified drink, and two cans of soda. CNA #4 stated she was breastfeeding, and her pumps were kept in the refrigerator. During an interview on 09/26/2024 at 8:30 AM, LPN #3 stated the breast pumps with substance in the bottom should not be kept in the same refrigerator as resident foods/beverages due to the risk of contamination. During an interview on 09/26/2024 at 9:30 AM, the Activity Director stated she was responsible for cleaning the F Hall refrigerator. The Activity Director stated the residents and staff foods/beverages should not be kept in the same refrigerator due to the risk of contamination. The Activity Director stated breast pumps with a substance in the bottom should not be kept in a resident refrigerator due to the risk of contamination. During an interview on 09/26/2024 at 10:00 AM, the Assistant Director of Nursing (ADON) stated that staff and residents could use the same refrigerator. The ADON stated breast pumps containing a substance in the bottom should not be kept in the same refrigerator as resident foods/beverages due to risk of contamination. During an interview on 09/26/2024 at 10:30 AM, the Director of Nursing (DON) and Consultant #2 were asked for a policy and/or procedure outlining the storage of resident and staff foods/beverages. Consultant #2 stated that no current policy and/or procedure existed, that items stored together should be labeled. On 09/26/2024 at 11:00 AM, Consultant #2 provided an outline for storage of staff and resident foods/beverages. When asked if the policy outlining storage of staff and resident foods and beverages was in place before being brought to the Surveyor, Consultant #2 stated no, she identified the concerns, and a new refrigerator would be brought to the F Hall for staff to use and both staff and resident refrigerators would have a lock added for safety.

Based on observation, interview, record review, and policy review, the facility failed to provide a diet based on nutritional needs of 6 (Resident #4, #5, #8, #14, #27, and #47) of 37 residents reviewed for nutritional dietary needs and weight loss. Specifically, Residents #4, #5, #8, #14, #27, and #47 did not receive an enhanced/fortified diet as ordered. Findings include: A review of a facility policy titled, Food and Nutrition Services, dated 10/2017, indicated the facility provided each resident with a well-balanced diet to meet nutritional and special dietary needs based on a resident's nutritional need assessment. Meal trays were to be inspected to ensure the correct meal was provided to the resident. 1. A review of the Clinical Resident Profile, indicated the facility admitted Resident #14 on 03/06/2011 with diagnoses that included dementia. A review of Resident #14's care plan, revised on 05/14/2024, revealed the resident had a nutritional risk, required a physician ordered fortified, mechanically altered, puree textured diet. Interventions included offering supplements as ordered by physician, receiving fortified foods; ice cream at lunch, dinner, and at 10/2 (10 AM and 2 PM); receiving a house shake that contains ice cream, peanut butter, and milk with lunch and dinner; 2 ounces of peanut butter each meal; and sending the correct texture and consistency diet. The quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/21/2024, revealed Resident #14 had a Brief Interview for Mental Status (BIMS) score of 4 which indicated the resident had severe cognitive impairment. Resident #14 was independent with eating, had a 5% or more weight loss in the last month or 10% or more in the last 6 months, had a mechanically altered diet, and was not on hospice care. A review of the Dietary Quarterly assessment, dated 08/22/2024, revealed Resident #14 had a weight loss and was receiving fortified meal enhancements, a health shake, and peanut butter. A review of Medication Administration Record [MAR], with a start date of 08/23/2024, revealed Resident #14 was receiving an appetite stimulant daily, at bedtime. A review of Clinical Physician Orders, with a start date of 09/06/2024, revealed Resident #14 had a regular enhanced pureed diet. Additional directions revealed, ice cream at 10:00 AM and 2:00 PM and with lunch and dinner. A review of Progress Note with a sub type IDT - Weekly Weight Note, dated 09/13/2024, revealed a late entry Weight Warning of 133.2 pounds and indicated an 11.9% weight deficit in 180 days, and a 1.2-pound weight loss in one week. A review of the weekly weight loss meeting on 09/19/2024, revealed Resident #14 was receiving a regular enhanced diet with puree texture; peanut butter; a house shakes with peanut butter, ice cream and milk; and ice cream at 10:00 AM and 2:00 PM. A review of a facility document titled, [Facility Name] Newsletter, dated 09/23/2024, indicated lunch was a cheeseburger/hamburger, French fries, lettuce, tomato, onion, pickle, Hawaiian cake, and beverages. During an observation on 09/23/2024 at 12:47 PM, Resident #14's meal tray included chocolate milk, whole milk, two puree food items on a divided plate, covered with brown gravy, a green puree item. A clear condiment cup contained a creamy brown substance. A cup contained a puree food item, and a red mug contained an off-white beverage, a clear cup contained a clear beverage, a handled cup contained a dark beverage, and a cup contained a green ice product. A review of the document on Resident #14's meal tray revealed Resident #14's diet order was a pureed regular diet with enhanced foods and thin liquids. Notes: included chocolate milk and 2 ounces of peanut butter; Standing Orders that included a house shake with peanut butter and ice cream served in a red cup with shakes, whole milk, and one-half cup of vanilla ice cream. Fortified foods in red bowl. During an interview on 09/23/2024 at 12:52 PM, Licensed Practical Nurse (LPN) #8 identified the puree foods with gravy as hamburger and mashed potatoes, the green puree as green beans, the puree in the cup as cake, water in the clear cup, coffee in the handled cup, peanut butter in the clear condiment cup, and shake with peanut butter in the red mug. LPN #8 stated the shake contained milk and peanut butter. LPN #8 was asked if the resident should receive vanilla ice cream and LPN #8 stated, They ran out of ice cream, so they gave (resident pronoun) green sherbet. LPN #8 could not identify the enhanced food item. A review of the sherbet label revealed it was 4 ounces of Lime Fat Free Sherbet. During an interview on 09/23/2024 at 01:02 PM, the Dietary Manger (DM) stated Resident #14 was served a pureed burger with mayonnaise, ketchup, cheese, bread, mashed potatoes in place of fries, and green beans. The DM stated the shake did contain vanilla ice cream, that vanilla and chocolate ice cream were available, and could not state why Resident #14 did not receive vanilla ice cream on the meal tray. The DM stated the red mug containing the house shake is the fortified/enhanced food and takes the place of the red bowl. The DM stated all residents received a fortified/enhanced meal at lunch because the fat content in the hamburger made the meal enhanced. During an interview on 09/23/2024 at 01:21 PM, the Director of Nursing (DON) stated vanilla ice cream was obtained from the store and Resident #14 was provided with vanilla ice cream and should have received food per physician orders. 49866 2. A review of Resident #27's Order Summary Report, indicated the resident had medical diagnoses of moderate protein-calorie malnutrition, morbid (severe) obesity due to excess calories, unspecified dementia with other behavioral disturbance, and cancer of the cervix and uterus. A review of Resident #27's 5-day MDS with an ARD of 08/29/2024 indicated a weight loss of 5% or more in the last month or a loss of 10% or more in last 6 months. A review of Resident #27's Order Summary Report dated 09/16/2024 indicated Resident #27 was to receive a regular enhanced; regular texture and consistency diet with double portions of biscuit and gravy at breakfast; high calorie juice with meals; and a bowl of gravy with meals. On 09/25/2024 at 08:05 AM, Resident #27's diet card read: Enhanced diet with reg texture and thin fluids. Double portion biscuit and bowl of gravy at all meals. Resident #27 ate the bowl of oatmeal and the eggs. Observed bacon on the tray. No biscuits and gravy were on the tray. On 09/26/2024 at 2:30 PM, the Surveyor interviewed the Dietary Manager (DM) and she acknowledged that Resident #27 did not receive biscuits and gravy for breakfast. The DM stated that they normally have them, but did not have biscuits or gravy that morning, because she followed the menu. Also reported that the only thing they did for the enhanced diet was added more butter to the oatmeal. The Dietary Manager also stated she was unsure how to give the residents what they wanted and serve the menu that she is supposed to. 3. A review of Resident #8 Order Summary Report included medical diagnosis of severe protein-calorie malnutrition, muscle weakness, low potassium, heart failure, gastroesophageal reflux disease (GERD), and chronic obstructive pulmonary disease (COPD). A review of Resident #8's admission MDS with an ARD of 08/17/2024 documented a BIMS of 14 which indicated no cognitive impairment, and the resident had no swallowing disorders and was not on a physician prescribed weight loss regimen. A review of Resident #8's Order Summary Report, indicated Resident #8 was on a regular-enhanced food with regular texture, thin consistency diet. A review of Resident #8's care plan with a revision date of 09/26/2024 indicated Resident #8 had a potential for nutritional deficits related to COPD, heart failure with hypoxia and therapeutic diet, and was on a regular fortified diet with regular texture and thin fluids. Interventions included supplements/snacks as ordered; obtain food preferences, likes/dislikes; offer substitutes for foods not eaten; and provide diet as ordered, fortified foods. On 09/25/2024 at 12:44 PM, the Surveyor observed Resident #8's lunch tray. The tray included cubed chicken, broccoli and parsley noodles on a plate. No red bowl was located on the tray. During an interview with the Dietary Manager on 09/25/2024 at 01:15 PM, she confirmed no red bowl was on Resident #8's tray. She stated the noodles were cooked in a lot of butter. Enhanced/fortified is anything that is a food that has a fatty food added such butter, cheese, etcetera (etc.), and the parsley noodles had extra butter on top of what the recipe called for. The Dietary Manager stated she was uncertain whether the parsley noodles on the plate were enhanced or not. Then, she stated that everyone got fortified noodles today. On 09/26/2024 at 2:00 PM, the Dietary Manager disclosed that she has no menus for fortified diets and has only been adding butter, cheese, and things like that to certain items on the trays and serves them as fortified/enhanced diets. She also stated she has no idea what the calories are for what she adds. On 09/26/24 at 2:30 PM, after speaking to the Dietary Manager again, she stated that the parsley noodles had butter added to them more than the recipe called for and they make up what they feel would be a fortified/enhanced diet. 4. A review of Resident #47's Order Summary Report indicated medical diagnoses of dementia with anxiety, cirrhosis of the liver, lung cancer, pulmonary fibrosis, chronic kidney disease, stage 3, abnormal weight loss and gastro-esophageal reflux disease (GERD). A review of the annual MDS with an ARD of 09/17/24, indicated a BIMS score of 7 and required supervision or touching assistance with eating; did not have a swallowing disorder, and had lost 5% of weight or more in last month or 10% or more in last 6 months. A review Order Summary Report, indicated Resident #47 was on a regular-enhanced diet, regular texture, thin consistency. A review of the care plan with a revision date of 06/14/2024 indicated Resident #47 was to be served a regular enhanced diet with regular texture and thin liquids as ordered by the physician. On 09/25/2024 at 01:13 PM, observed Resident #47's lunch tray, there was no red bowl on the tray. Parsley noodles were on the plate with other lunch foods. On 09/25/2024 at 01:13 PM, during an interview the Dietary Manager stated the noodles were the enhanced/fortified food today. She stated that the noodles were not in a red bowl, but they should have been, the enhanced noodles had extra butter in them. She did not know if she got the enhanced/fortified. She asked the kitchen staff and stated that the noodles on the plate were fortified. When asked how the staff could know if the noodles were enhanced/fortified, she said that they just remembered. On 09/26/2024 at 2:00 PM, during an interview the Dietary Manager reported that they do not have enhanced/fortified menus and that they add butter, cheese, etc., to a food that they pick on the meal and use that as enhanced. No measuring or certain amount, just added by the cook. 50924 5. A review of the electronic health record indicated the facility admitted Resident #4 with diagnoses that included dementia, muscle weakness, and cerebral infarction. The quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/12/2024, revealed Resident #4 had a Brief Interview for Mental Status (BIMS) score of 0 which indicated Resident #4 had severe cognitive impairment. A review of Resident #4's Order Summary Report, revealed Resident #4 was ordered to receive enhanced/fortified foods with pureed texture, regular consistency, 2 shakes with meals, high calorie juice with meals, and ice cream with all meals. A review of the Dietary Quarterly report dated 07/14/2024 stated, Resident #4 was to receive fortified foods, house shakes, and high calorie juice. Resident #4 weight loss at the time was 4.87% over six months. A review of Resident #4's meal card, dated 09/25/2024, stated, house shake (add peanut butter, ice cream in red cup with shakes). Indicating the recipe for the blended shake should have contained more than one shake. During a concurrent observation and interview on 09/25/2024 at 1:03 PM, Resident #4 was served a tray of pureed chicken with gravy, pureed bread with gravy, pureed broccoli, 120 milliliters (ML) high calorie juice, pureed peach crisp, 120 ML chocolate ice cream, and a red mug filled with a blended shake. The Dietary Manager (DM) stated the shake was mixed with 1 container of ice cream, 1 carton of the prepackaged shake (house shake per facility), and 1 scoop of peanut butter. The scoop was described as a regular household flatware teaspoon and not a true measured scoop. The DM stated they did have access to the resident's electronic health record and orders. The DM denied knowledge that the meal card order was not clear and acknowledged the blended shake should have contained two cartons of the house shake. The DM stated the resident was not getting the correct supplements per ordered intake. 6. A review of the medical diagnosis in Resident #5's electronic health record indicated the facility admitted Resident #5 with diagnoses that included senile degeneration of the brain, and dementia. A review of Resident #5's Weight Summary, showed on 03/09/2024, an admission weight of 137.8 pounds (lbs.); on 06/07/2024, a weight of 116.2 lbs.; and on 09/05/2024, a weight of 111.4 lbs. Calculated weight loss showed 4.13% over three months and 19.16% significant weight loss over six months. A review of Resident #5's IDT [Interdisciplinary Team] Clinically Unavoidable Weight Loss, dated 04/19/2024, concluded Resident #5's weight loss was unavoidable with an explanation of resident has dementia and refuses care to allow staff to assist with eating. The admission MDS with an ARD of 03/13/2024, revealed Resident #5 had a BIMS score of 9 which indicated the resident had moderate cognitive impairment, required setup and clean-up assistance only for eating, and had no, or unknown weight loss noted. A review of Resident #5's, care plan, revised on 09/10/2024, revealed the resident had experienced a weight loss. Interventions included receiving adequate nutrition as a regular enhanced diet with mechanical soft texture and thin liquids. A review of Resident #5 ' s orders revealed Resident #5 had a regular enhanced diet with regular texture with thin liquids and high calorie juice ordered on 05/31/2024 and modified on 09/06/2024 to mechanical soft texture and added ice cream with lunch and dinner. During a phone interview on 09/25/2024 at 3:24 PM, the Registered Dietician (RD) stated she was not a full-time employee of the facility but rounded as a regional support for the company. The RD denied being present for the facility meetings for significant weight loss, and stated she only approved menus, and the recipes were the responsibility of the Dietary Manager. During an interview on 09/26/2024 at 2:00 PM, the Dietary Manager (DM) stated no fortified recipes existed in the facility. The DM stated they had been trained to add butter, milk, or cheese to a recipe to make it a fortified item. The DM denied any measurements of these items when they were added. The DM's exampled process was melted butter had been brushed on to the top of a pan of cooked cornbread on 09/24/2024 for lunch and the cornbread was now a fortified food item used to serve residents in need of a fortified food ordered for supplemental nutritional support. The DM was found to have no certification or specialized training in nutrition. 51064 During an observation on 09/24/2024 at 07:00 AM, Dietary [NAME] #7 used a #30 (1 ounce) black scoop for puree bread, a #20 (1.63 ounce) yellow scoop for puree egg, a #20 yellow scoop for puree sausage, a #16 (2 ounce) blue scoop for scrambled eggs, and a 120 (4 ounce) ladle for oatmeal. Review of the facility's Week 2 Menu stated measurements as follows: 1/4 cup egg. During an interview on 09/24/2024 at 09:00 AM, the Dietary Manager stated that scoop sizes were as follows: #20 yellow scoop equals 1.63 ounces; #16 blue scoop equals 2 ounces. The Dietary Manager stated that the scoop is filled all the way to the top. Following a measurement using the scoops used during the breakfast service, the Dietary Manager stated she was not aware the scoops used were not appropriate for the portions indicated on the facility provided menu. During an interview on 09/24/2024 at 09:00 AM, the Dietary Manager stated that the menus provided for the residents' breakfast service were not followed. The Dietary Manager stated that the facility always serves the same foods for breakfast: sausage, bacon, oatmeal, biscuits, gravy, and eggs. The Dietary Manager stated it was her decision to serve the same breakfast foods each day and to not follow the menus indicated for use during residents' meal services. During an interview on 09/24/2024 at 10:00 AM, the Dietary Manager stated enhanced/fortified foods were prepared by adding extra butter, cheese, and more milk to a selected item. The Dietary Manager stated foods where enhanced/fortified by increasing calories, she did not follow recipes for enhanced/fortified foods. During an interview on 09/25/2024 at 3:24 PM, the Registered Dietician stated that food menus and recipes were written by the food companies. Her job duty is to inspect and approve the menus. When asked how to measure the caloric intake of foods that were to be enhanced/fortified she stated you would measure the calories of the ingredients added to make the foods enhanced/fortified such as fortified milk. The Registered Dietician stated that substitutes or alternatives for foods offered to the residents should be nutritionally equivalent to what the food is replacing. The Registered Dietician stated she was not aware of a house shake prepared by the facility, or any recipe related to the house shake. Residents on enhanced/fortified diets are prescribed these diets as a method of gaining weight. It is important to follow dietary orders as these orders are put into place for a reason, such as to help a resident gain weight. Left over foods should not be used for puree as left over foods can lose nutritional value. Enhanced/fortified milk has added calories to make it enhanced/fortified, vitamins and minerals already in the milk do not make the milk enhanced/fortified. During a record review of the facility provided, Weekly Menus no recipes for enhanced/fortified foods were listed. During an interview on 09/26/2024 at 2:00 PM, the Dietary Manager stated that there were no recipes for enhanced/fortified foods. The Dietary Manager stated that she chooses an item off of the menu and makes that item enhanced/fortified by adding extra calories to it. The Dietary Manager stated she made enhanced/fortified cornbread on 09/24/2024 by adding butter to it. The Dietary Manager stated she did not measure the butter, it was melted and spread on top of the cornbread. The Dietary Manager stated she did not know how many calories she was adding to the foods she made enhanced/fortified. During an interview on 09/26/2024 at 4:47 PM, the Dietary Manager stated an enhanced/fortified recipe for oatmeal and an enhanced/fortified recipe for peanut butter drink were available from previous food service company. The Dietary Manager stated that dietary staff did not have access to recipes for enhanced/fortified oatmeal or peanut butter drink and no recipes were available to dietary staff when preparing enhanced/fortified foods. During an interview on 09/27/2024 at 3:43 PM, Consultant #2 asked the Surveyor if recipes for enhanced/fortified foods obtained from the current food service company would suffice for future use. The Surveyor stated that no recommendations could be made by the surveying team, Consultant #2 should consult with the Registered Dietician for recipe use. Consultant #2 stated that the recipes for enhanced/fortified foods were not available to dietary staff, but if approved by the Registered Dietician would be available for dietary staff for future use.

Based on observation, interview, record review, and policy review, the facility failed to ensure physician ordered foods were provided for 3 (Residents #4, #14, and #27) of 37 residents reviewed for dietary orders. Specifically, Resident #4 did not receive two house shakes, Resident #14 did not receive ice cream at lunch, and Resident #27 did not receive double portions of biscuits and gravy at breakfast, as ordered by a physician. Findings include: A review of a facility policy titled, Food and Nutrition Services, dated 10/2017, indicated the facility provided each resident with a well-balanced diet to meet nutritional and special dietary needs based on a resident's nutritional need assessment. Meal trays were to be inspected to ensure the correct meal was provided to the residents. 1. A review of the Clinical Resident Profile, indicated the facility admitted Resident #14 on 03/06/2011 with diagnoses that included dementia. A review of Resident #14's care plan, revised on 05/14/2024, revealed the resident had a nutritional risk, required a physician ordered fortified, mechanically altered, puree textured diet. Interventions included offering supplements as ordered by the physician, receiving fortified foods; ice cream at lunch, dinner, and 10:00 AM and 2:00 PM. The quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/21/2024, revealed Resident #14 had a Brief Interview for Mental Status (BIMS) score of 4 which indicated the resident had severe cognitive impairment, and was independent with eating, had a 5% or more weight loss in the last month or 10% or more in the last 6 months, required a mechanically altered diet, and was not on hospice care. A review of the Dietary Quarterly assessment, dated 08/22/2024, revealed Resident #14 had a weight loss and was receiving fortified meal enhancements, a health shake, and peanut butter. A review of the Medication Administration Record [MAR], with a start date of 08/23/2024, revealed Resident #14 was receiving an appetite stimulant daily, at bedtime. A review of the Clinical Physician Orders, with a start date of 09/06/2024, revealed Resident #14 had a regular enhanced pureed diet. Additional directions revealed ice cream at 10:00 AM & 2:00 PM and with lunch and dinner. A review of the Progress Note titled, IDT - Weekly Weight Note, dated 09/13/2024, revealed a late entry Weight Warning of 133.2 pounds and indicated an 11.9% weight deficit in 180 days, and a 1.2-pound weight loss in one week. During an observation on 09/23/2024 at 12:47 PM, Resident#14's meal tray food items included a cup that contained a green ice product. During an interview on 09/23/2024 at 12:52 PM, Licensed Practical Nurse (LPN) #8 identified the green ice product on Resident #14's meal tray as green sherbet. LPN #8 stated, They ran out of ice cream, so they gave (resident pronoun) green sherbet. A review of the sherbet label revealed it was 4 ounces of Lime Fat Free Sherbet. A review of Resident #14's meal tray document revealed Resident #14's diet order was a pureed regular diet with enhanced foods and thin liquids. Standing Orders included one-half (1/2) cup of vanilla ice cream. During an interview on 09/23/2024 at 01:02 PM, the Dietary Manger (DM) stated vanilla and chocolate ice cream were available and could not state why Resident #14 did not receive vanilla ice cream on the meal tray. During an interview on 09/23/2024 at 01:21 PM, the Director of Nursing (DON) stated vanilla ice cream was obtained from the store and Resident #14 was provided vanilla ice cream and should have received food per physician orders. 50924 2. A review of the electronic health record indicated the facility admitted Resident #4 with diagnoses that included dementia, muscle weakness, and cerebral infarction. Review of the quarterly MDS with an ARD of 07/12/2024, revealed Resident #4 had a BIMS score of 0 which indicated the resident had severe cognitive impairment. A review of Resident #4's, Order Summary Report, revealed Resident #4 was to receive enhanced/fortified foods with pureed texture, regular consistency, 2 shakes with meals, high calorie juice with meals, and ice cream with all meals. A review of the Dietary Quarterly report dated 07/14/2024 stated Resident #4 was to receive fortified foods, house shakes, and a high calorie juice. Resident #4 weight loss at the time was 4.87% over six months. A review of Resident #4's meal card, dated 09/25/2024, stated, house shake (add peanut butter, ice cream in red cup with shakes). Indicating the recipe for the blended shake should have contained more than one shake. During a concurrent observation and interview on 09/25/2024 at 1:03 PM, Resident #4 was served a tray of pureed chicken with gravy, pureed bread with gravy, pureed broccoli, 4 ounces of a high calorie juice, pureed peach crisp, 4 ounces chocolate ice cream, and a red mug filled with a blended shake. The Dietary Manager (DM) stated the shake was mixed with one container of ice cream, one carton of the house shake, and one scoop of peanut butter. The scoop was described as a regular household flatware teaspoon and not a true measured scoop. The DM stated they did have access to the residents' electronic health record and orders. The DM denied knowledge that the meal card order was not clear and acknowledged the blended shake should have contained two cartons of the house shake. The DM stated the resident was not getting the correct supplements per ordered intake. 51064 3. A review of Resident #27's Order Summary Report, indicated medical diagnoses of moderate protein-calorie malnutrition, morbid (severe) obesity due to excess calories unspecified dementia with other behavioral disturbance, and cancer of the cervix and uterus. A review of Resident #27's 5-day MDS with an ARD of 08/29/2024 indicated a weight loss of 5% or more in the last month or a loss of 10% or more in the past 6 months. A review of Resident #27's Order Summary Report dated 09/16/2024 indicated Resident #27 was to receive a regular enhanced; regular texture and consistency diet with double portions of biscuit and gravy at breakfast; high calorie juice with meals; and a bowl of gravy with meals. During a concurrent observation and interview on 09/24/2024 at 07:15 AM, Dietary [NAME] #7 placed three pieces of toast, one scoop of oatmeal, two pieces of sausage, and one scoop of egg on a plate to be served to a resident for breakfast service. Dietary [NAME] #7 stated that the resident was to receive double portions per order. During an interview on 09/24/2024 at 10:00 AM, the Dietary Manager stated that residents on double portion receive double of all foods served to the resident during that meal service, except for desserts. The Dietary Manager stated that she decided not to give extra desserts as she felt the calories in the food were sufficient. During an interview on 09/25/2024 at 3:24 PM, the Registered Dietician stated that residents who were to receive double portions, were to receive double portions of all foods being served to the residents during that meal service. The Registered Dietician stated that residents who receive double portions should receive double portions of dessert as well, in an attempt to increase the resident's calorie intake. The Registered Dietician stated it was important to follow the physicians' orders and give the resident the diet as specified in order to help the resident gain weight.

Based on observation, and interview, the facility failed to ensure staff properly washed hands with soap and water to prevent cross-contamination, and equipment was in good repair. The findings include: During an observation and interview on 09/23/2034 at 1:00 PM, Dietary Aid #9 pushed a rack of dirty dishes into the dish washing machine, closed the lid, and began the dish washing cycle. Without washing her hands, Dietary Aid #9 began pulling dishes from a clean dish rack to be used in the resident lunch service. Dietary Aid #9 was noted to have artificial nails in place. Dietary Aid #9 stated she should have washed hands between pushing dirty dishes into dish washing machine and before handling clean dishes to be used in resident meal service. The Dietary Manager stated artificial nails should not be worn by food preparation staff to decrease risk of contamination. During a concurrent observation and interview on 09/23/2024 at 1:53 PM, Dietary [NAME] #10 placed gloves on both hands, grabbed a pan from the bottom dish rack, and without removing the gloves or washing her hands she placed her hands into a bag of shredded cheese to be used in the residents' dinner service. Dietary [NAME] #10 stated her gloves should have been removed, her hands should have been washed, and new gloves should have been applied after grabbing a pan from the dish rack and before putting her hands into the bag of shredded cheese. During a concurrent observation and interview on 09/23/2024 at 2:14 PM, Dietary [NAME] #10 touched her clothing with gloves being used in dinner preparation. Without removing the gloves or washing her hands, Dietary [NAME] #10 placed her hands into bowl to prepare the residents' dinner. Dietary [NAME] #10 stated gloves should have been changed after touching clothing and before continuing to prepare the resident's dinner. During a concurrent observation and interview on 09/23/2024 at 2:30 PM, Dietary [NAME] #10 used her gloved hands to pick up a washcloth containing soap and water and wiped down the kitchen preparation counter. Without changing gloves or washing her hands, Dietary [NAME] #10 began placing pans on the kitchen preparation counter to be used for the dinner service. Dietary [NAME] #10 stated her gloves should have been changed and her hands should have been washed after wiping down the kitchen preparation counter and before continuing with resident's dinner service. During a concurrent observation and interview on 09/23/2024 at 4:17 PM, Dietary [NAME] #10 touched an electrical cord with her gloved hands. Without changing gloves or washing her hands, Dietary [NAME] #10 picked up a bowl of food to be used in resident's dinner service and placed food in a blender. Dietary [NAME] #10 stated her gloves should have been changed and her hands should have been washed after touching the electrical cord and before continuing with dinner service. During a concurrent observation and interview on 09/23/2024 at 4:17 PM, Dietary [NAME] #10 used a blender with several cracks in the side of the blender. Dietary [NAME] #10 stated the cracks in the plastic could contain possible contaminants and should not be used. During a concurrent observation and interview on 09/24/2024 at 4:30 AM, Dietary [NAME] #7 put gloves on to prepare a resident's breakfast then pulled up his pant leg. Without changing gloves or washing his hands, Dietary [NAME] #7 touched butter to be used in resident's breakfast. Dietary [NAME] #7 stated his hands should have been washed and his gloves changed after touching his pant leg and before continuing to prepare the resident's breakfast. Review of a facility policy titled, Hand Washing stated staff are to perform hand washing after touching parts of the human body, after handling soiled equipment or utensils, during food preparation, before donning gloves for working with food and after gloves are removed, and after engaging in other activities that contaminate the hands. Review of a facility policy titled, Quick Resource Tool: QRT Staff Attire stated fingernails will be kept clean, nail polish and/or acrylic nails are not permitted.

Based on interviews, record review, facility document review, and facility policy review, it was determined the facility failed to include a cognitively impaired resident's representative in the care plan meetings for 1 (Resident #5) of 28 residents reviewed for development of comprehensive care plans. Findings include: A review of a facility policy titled, Care Plans, Comprehensive Person-Centered, revised in March 2022 indicated that the interdisciplinary team (IDT) in conjunction with the resident or the resident's representative develops and implements the comprehensive care plan. As part of their resident's rights person-centered comprehensive care plans allow for resident or resident's representative participation in planning, resident goal and outcome setting, type, frequency, and duration of care, as well as request meetings, revision, and services. Notification of care plan meetings are provided in advance. Documentation in the resident's Electronic Health Record (EHR) should include steps taken to include the resident or resident's representative or an explanation of why it is not practicable for them to be included in the process. Comprehensive care plans are completed at admission, annually, and with a significant change in status. A review of the electronic health record (EHR) indicated the facility admitted Resident #5 with diagnoses that included senile degeneration of the brain, dementia, psychotic disturbances, and behavioral disturbances. Review of the admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/13/2024 revealed Resident #5 had a Brief Interview for Mental Status (BIMS) score of 9 which indicated the resident had moderate cognitive impairment. The quarterly MDS with an ARD of 06/13/2024 revealed Resident #5 had a BIMS score of 9 which indicated the resident had moderate cognitive impairment. The significant change MDS with an ARD of 08/20/2024 revealed Resident #5 had a BIMS score of 8 which indicated the resident had moderate cognitive impairment. A review of Resident #5's care plan, revised on 09/09/2024, revealed the resident and the family will receive the support needed to successfully transition into a long-term care. Interventions included emotional support, but no mention was made to include resident or resident's representative in the care planning process. Goal and interventions were initiated on 03/08/204 and revised on 08/09/2024, following the care plan meetings without the resident or the resident's representative. During an interview on 09/25/2024 at 09:31 AM, Resident #5 ' s Power of Attorney (POA) stated there is a lot of confusion about the long-term care process which included expectations of the family and the facility. The POA expressed lack of communication of medication changes, fall prevention, and notification process; failed attempts to reach the Social Services Director (SSD) on the phone, and the office door was never open and the POA had no knowledge of what a care plan meeting was and had never been to one. During an interview on 09/27/2024 at 1:12 PM, the Minimum Data Set Coordinator/Care Plan Coordinator (MDS/CP Coordinator) stated regarding the notification of the care plan meeting process is they first develop next month's care plan list which is then given to the Social Services Director (SSD) about a week before the beginning of the month. The SSD then sends out a letter to the residents or their representatives. The MDS/CP Coordinator stated the SSD does all communication with the residents and their representatives and denies any knowledge of any documentation process by the SSD. The MDS/CP Coordinator stated the care plan meeting concerns were documented on paper and signed by all attendees then handed over to the SSD. During an interview on 09/27/2024 at 2:35 PM, the SSD stated the process for the resident representative's notification of a care plan meeting was an initial phone call the month prior to the meeting to ensure availability. If the SSD was unable to reach the representative, a letter was mailed out with the information. The SSD stated the initial phone call to Resident #5's POA resulted in a voicemail, with no verbal contact ever made. The SSD stated she did not document the attempt in the resident's EHR because they often forgot to chart. The SSD denied ever mailing a care plan notification letter to Resident #5's POA because she forgot. The SSD stated the care plan meeting notes were not available in the EHR because they were on paper in the SSD's Office and Resident #5's POA had never been to a care plan meeting, and it had never been discussed with the POA by the SSD.

Based on interviews, record review, and facility policy review, it was determined the facility failed to ensure an accurate care plan for 1 (Resident #50) of 27 sampled residents who were reviewed for a comprehensive care plan. Findings include: A review of a facility policy titled, Care Plans, Comprehensive Person-Centered, dated 03/2022, indicated each resident would have a care plan developed and implemented to meet their needs, no more than 21 days after admission, and include identification of care needs and objectives to meet the resident's highest physical, mental and psychosocial well-being. The admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/16/2024, revealed Resident #50 had a Brief Interview for Mental Status (BIMS) score of 13 which indicated the resident was cognitively intact. Resident #50 did not exhibit mood disorders or behaviors; had active diagnoses that included mental health and stress disorders involving depression, mania, hallucinations, delusions, restlessness, and decision-making ability; and was receiving psychotropic medication. A review of the care plan with an admitted [DATE] and revision date of 08/18/2024, did not address Resident #50's diagnoses that included mental health and stress disorders involving depression, mania, hallucinations, delusions, restlessness, and decision-making ability. A review of the Order Summary Report, revealed Resident #50 was to be monitored for psychotropic drug side effects and was receiving psychotropic medications, with a start date of 08/12/2024. A review of Medication Administration Record [MAR], revealed Resident #50 had twice daily monitoring for antianxiety, antidepressant, and antipsychotic medications, with a start date of 08/12/2024. A review of Admission Assessment, with an effective date of 8/12/2024, revealed Resident #50 had admitting diagnoses that included anxiety, depression, bipolar disorder, and schizophrenia; and was receiving antianxiety medications. During an interview on 09/27/2024 at 1:16 PM, the MDS/CP Coordinator stated care plans were done as part of the Minimum Data Set (MDS) on admission. The MDS/CP Coordinator stated at the time of admission the nurse was responsible for ensuring the initial assessment was completed accurately. The MDS/CP Coordinator stated there was no policy or procedure for completing the care plan or MDS, and reviewed certain things, section by section of the MDS and used resources to prepare Resident #50's care plan, that included review of the assessment for identified issues, meeting with the resident, speaking with the nurses and certified nursing assistants (CNAs), reviewing daily reports, past and present diagnoses, and if something was new, the care plan was updated. The MDS/CP Coordinator stated it was important for Resident #50's care plan to be accurate and reflect their needs to receive the most beneficial help to remain healthy, comfortable, be able to return home, or remain in the facility. During an interview on 09/27/2024 at 1:50 PM, the Administrator stated the care plans and MDS were done in the first 24 hours. The nurse completed the assessment and the MDS Coordinator reviewed and completed the MDS, after reviewing the initial assessment following the policy and procedure. During an interview on 09/27/2024 at 1:58 PM, the Director of Nursing (DON) stated the nurse should complete the admission assessment completely and accurately based on what the medications and abilities were when the resident came through the door because it helps the CNAs in knowing how care is provided to the resident.

Based on observations, interviews, record review, it was determined the facility failed to ensure a Minimum Data Set (MDS) assessment was accurately completed for 1 (Resident #72) of 27 sampled residents who were reviewed for MDS assessment accuracy. Specifically, the facility failed to ensure information regarding a resident's diagnosis reflected the resident's current condition. Findings include: A review of the Clinical Resident Profile, indicated the facility admitted Resident #72 on 11/09/2023 with a diagnosis of pneumonia. A review of the quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/19/2024, revealed Resident #72 had a Brief Interview for Mental Status (BIMS) score of 7, which indicated Resident #72 had moderate cognitive impairment. Section I, subsection I2000, indicated an active diagnosis of pneumonia. A review of the Medical Diagnoses, revealed Resident #72 had a principal diagnosis of pneumonia, dated 10/31/2023. A review of a physician appointment dated 12/19/2023, indicated the reason for the visit was a nursing home follow-up and recent hospitalization for pneumonia and dementia care. A review of a physician appointment dated 07/08/2024, indicated the reason for the visit was a 6 week follow up nursing home visit for mental evaluation. A review of a physician appointment dated 09/04/2024, indicated the reason for the visit was a 6 week follow up nursing home visit for mental evaluation. A review of Resident #72's plan of care, with a target date of 11/06/2024, did not reveal a current focus, goal, or interventions for a respiratory infection. During an interview on 09/27/2024 at 1:33 PM, the MDS/Care Plan (CP) Coordinator stated MDS assessments are performed within 7 days, the look back period, of the ARD, and is responsible to accurately complete sections of the MDS, including Section I, to ensure residents are treated correctly. The MDS/CP Coordinator stated Resident #72's 08/19/2024 MDS assessment was completed in person in Resident #72's room, the day before. The MDS/CP Coordinator stated the last 7 days of orders were reviewed to determine the current diagnoses and changes were made at that time. The MDS/CP Coordinator stated Resident #72 was not receiving medication for pneumonia and did not have a current infection during the look back period, and the pneumonia diagnosis should have been resolved. The MDS/CP Coordinator stated there was no policy or procedure for completing a care plan or MDS and just reviewed certain things like activities and went section by section and looked up information needed and updated the care plan with new information. During an interview on 09/27/2024 at 1:55 PM, the Director of Nursing (DON) stated the nurses were responsible for assessments and the expectation is the assessment be completed in a timely manner, should be correct at the time it is done, at the time the nurse sees the resident. During an interview on 09/27/2024 at 1:50 PM, the Administrator stated the care plans and the MDS are completed in the first 24 hours. The nurse completes the assessment and the MDS Coordinator reviews and completes the MDS, after the review of the initial assessment, following the policy and procedure. During an interview on 09/27/2024 at 2:07 PM, Consultant #2 advised they do not have a policy and procedure for the MDS, the RAI Manual is used.

Based on observation, interview, and record review, the facility failed to ensure food stored in the facility's refrigerator, freezer, and dry storage were dated when received and/or opened, spices were discarded after a year, foods stored in opened boxes were in sealed bags, and perishable foods were accurately dated with the date prepared in 1 of 1 kitchen. The failed practice had the potential to affect 71 residents who received meals from the kitchen as documented on the Dietary Diet report provided by the Director of Nursing (DON) on 07/19/23 at 3:44 PM. The findings are: 1. On 07/17/23 at 11:24 AM, during the initial tour of the kitchen, the dry storage room, and the walk-in freezer the following observations were made: a. Kitchen: i) On the shelf under the coffee makers was a box of 4 lemonade packets with no received or use by dates. The Dietary Manager (DM) stated, No, I do not see any dates on those. and proceeded to ask Dietary Employee (DE) #1 to date them. b. Dry Storage Room: i) a plastic container of ground basil dated received on 3/17/21, and a plastic bottle of almond extract dated received on 3/22/18. The DM stated, Those are only good for 1 year. ii) A can of olives dated received 6/23/22. The DM stated they were good for a year or barely. Some items aren't even good a year in cans. iii) An opened bag of cake mix was in a thin plastic bag that was not sealed sitting in a broken plastic container. The District Manager stated, I did not seal that after I checked to see if it was opened this morning. iv) An opened bag of flour was in a plastic container with a cracked open top. The DM stated, The bag should be rolled down to seal it. c. In the walk-in freezer located outside. i) A zippered bag of peas dated 7/11 and a zippered bag of cauliflower dated 7/14. The Surveyor asked if the dates were received or opened dates. The DM stated, They are opened dates. I am not sure when they were received. ii) On the bottom shelf of the freezer was a box of 2 roasts sealed in plastic dated 1/12/23. The Surveyor asked if the facility had served a roast since 1/12/23. The DM stated, I don't think so, but those should have been used already. The District Dietary Manager stated, We just in-serviced on using oldest items first. iii) An opened box of tilapia fillets dated 7/5 were contained in an unsealed bag. The DM stated, That should be sealed better. d. On 07/17/23 at 12:08 PM, in the kitchen on the second shelf from the bottom of a stainless shelving rack between the entrance door and the steam table there was a blue plastic bowl of 11 pastries and 3 cookies not dated that had no best by dates. The DM stated, I guess we have no way to prove when those were received. DE #1 asked if they needed to be dated. The DM stated, I think they need to be. 2. On 07/19/23 at 7:05 AM, DE #2 took a stainless steel square container of peeled eggs and poured them into a zippered bag of hard boiled eggs dated 7/18. The Surveyor asked DE #2 the date of the new eggs and the date of the eggs in the bag and if she could tell the difference between them now. DE #2 stated, these were made today (holding up the empty stainless steel square container) and those are dated 7/18 (pointing to the zippered bag). I don't know which ones were made today now. The Surveyor asked what the outcome could be of combining items from different days in the same bag. DE #2 stated, I don't know which ones are from which days. The DM stated, They need to be dated correctly. 3. A facility policy titled, Food Storage, provided by the Administrator on 07/20/23 at 9:28 AM documented, .5. All foods will be stored wrapped or in covered containers, labeled and dated, and arranged in a manner to prevent cross contamination .10. All packaged and canned food items will be kept clean, dry, and properly sealed .11. Storage areas will be neat, arranged for easy identification, and date marked as appropriate .

Based on observation, interview, and record review, the facility failed to ensure No Smoking/Oxygen in Use signs were posted outside of the resident room for 3 (Resident #54, #62 and #167) sampled residents and the oxygen flow rate was administered per Physician Orders for 1 (Resident #54) sampled resident of 12 (Residents #17, #21, #33, #52, #54, #57, #58, #62, #116, #117, #120 and #167) who required oxygen therapy, and failed to ensure Bilevel Positive Airway Pressure (BiPap) masks and tubing were properly stored for 1 (Resident #167) of 1 sampled resident who required a BiPAP. The findings are: 1. On 07/17/23 at 10:52 AM, upon entering the facility, there was not a No smoking/oxygen in Use sign posted on the front door. 2. On 07/17/23 at 11:38 AM, Resident #54 was lying in bed with Oxygen (O2) on per Nasal Cannula at 3 liters per minute (LPM). A No Smoking/Oxygen in Use sign was not posted on the resident's door. a. On 07/18/23 at 8:42 AM, Resident #54 was lying in bed with oxygen at 3 LPM via nasal cannula (NC). No Smoking/Oxygen in Use sign was not posted on the resident's door. b. A Physicians Order dated 04/10/23 indicated Resident #54 was to receive O2 at 2 LPM via NC every night shift. c. A Care Plan with an initiated date of 05/15/23 indicated the resident was to receive O2 via NC at 2 LPM as needed. d. On 07/18/23 at 12:17 PM, the Surveyor asked Registered Nurse (RN) #2 if she could point out the No Smoking/Oxygen in Use sign and the importance of the sign when a resident received oxygen. RN #2 looked toward the doorway and stated, There isn't one. It's to remind us to go check on the resident and someone could go in the room that doesn't need to be near the oxygen. The Surveyor asked to visually observe the flow rate on Resident #54's concentrator. RN #2 stated, I don't think it's supposed to be on 3 and that's what it's on. I'll have to check the Physician Orders. RN #2 looked in the electronic record and stated, Nope it's supposed to be on 2. The Surveyor asked if it was ok for Resident #54 to be receiving the incorrect flow rate. She stated, Well no. The Surveyor asked what could happen by Resident #54 receiving the wrong flow rate. She stated, He could start retaining carbon dioxide and become confused, fall or have a mental change. 3. On 07/17/23 at 11:53 AM and 2:59 PM, Resident #62 was lying in bed with oxygen on by nasal cannula at 1 LPM. A No Smoking/Oxygen in Use sign was not posted on the resident's door. a. On 07/18/23 at 10:14 AM, Resident #62 was lying in bed with oxygen being administered by nasal cannula at 1 LPM. A No Smoking/Oxygen in Use sign was not posted on the resident's door. b. A Physicians Order dated 07/02/23 indicated Resident #62 was to receive O2 at 1 LPM via NC as needed for shortness of breath. c. A Care Plan with an initiated date of 07/18/23 indicated Resident #62 was to receive O2 at 1 LPM as needed. d. On 07/18/23 at 12:19 PM, the Surveyor asked RN #2 to go to Resident #62's room. The Surveyor asked if Resident #62 was being administered oxygen. She stated, Yes. The Surveyor asked RN #2 to verify where the No Smoking/Oxygen in Use sign was located. She stated there's not one. The Surveyor asked why there should be a warning sign on the door during oxygen administration. She stated, To remind us to go check it and someone could go in there that doesn't need to be near the oxygen. 4. On 07/17/23 at 10:35 AM, Resident #167 was lying in bed with oxygen running at 2 LPM via nasal cannula. A No Smoking/Oxygen in Use sign was not posted on the resident's door. A BiPAP mask and tubing were lying on the bedside table not in a bag. a. On 07/18/23 at 9:59 AM, Resident #167 was lying in bed with oxygen running at 2 LPM per nasal cannula. A No Smoking/Oxygen in Use sign was not posted on the resident's door. A BiPAP mask and tubing were lying on the bedside table not in a bag. The Surveyor asked Resident #167 if he used the BiPAP. He stated, Every night. The Surveyor asked if he puts the mask on and off himself. He stated, Oh no, the nurses do that for me. b. A Physicians Order dated 06/20/23 indicated Resident #167 received O2 at 2 to 4 LPM via NC as needed and may remove as desired. c. A Physicians Order dated 06/21/23 indicated the resident used a BiPAP at bedtime. d. A Care Plan with a revision date of 06/28/23 indicated Resident #167 was to receive O2 via NC at 2 to 4 LPM as needed. The Care Plan did not address the use and care of the BiPAP. e. On 07/18/23 at 12:10 PM, the Surveyor asked RN #1 if Resident #167 was actively receiving oxygen. She stated, Yes. The Surveyor asked if she could locate the No Smoking/Oxygen in Use sign on the door to Resident #167's room. She stated, There's not one and we need one of those. The Surveyor asked if it was necessary to have a No Smoking/Oxygen in Use sign on the door when a resident was receiving oxygen. She stated, Yes, so others are aware, and oxygen is flammable. The Surveyor asked RN #1 to observe the location of the BiPAP mask and tubing. She stated, It is laying directly on the table beside the bed. They should be bagged when not in use. The Surveyor asked RN #1 to explain why the mask and tubing should be bagged. She stated, So it doesn't fall in the floor and get contaminated with bacteria. 5. On 07/19/23 at 2:08 PM, the Surveyor asked the Director of Nursing (DON) to explain why a No Smoking/Oxygen in Use sign should be placed on the door of a resident who is being administered oxygen. She stated, For people who smoke because oxygen is flammable. The Surveyor asked if the No Smoking/Oxygen in Use sign should be placed on the door of a resident receiving oxygen. She stated, Yes. The Surveyor asked the DON to explain the process for storage of a BiPAP mask and tubing. She stated, It should be stored in a bag. The Surveyor asked why storage in a bag was necessary. She stated, To keep bacteria off of it. The Surveyor asked what the process for ensuring oxygen is being administered as ordered by Physician. She stated, Go by the Physicians Order, set the oxygen at that rate. The Surveyor asked the DON to explain what could happen by not following physicians prescribed orders. She stated, He will get an increase of carbon dioxide and that causes confusion. 6. A facility policy titled, Oxygen Administration, provided by the DON on 07/19/23 at 3:26 PM documented, Purpose: The purpose of this procedure is to provide guidelines for safe oxygen administration. Preparation 1. Verify that there is a physician's order for this procedure. Review the Physician's orders or facility protocol for oxygen administration. Equipment and Supplies The following equipment and supplies will be necessary when performing this procedure . 4. No Smoking/Oxygen in Use signs . 7. A facility policy titled, CPAP/BIPAP Support, provided the DON on 07/19/23 at 3:26 PM documented, .Equipment and Supplies 1. NO SMOKING sign for the resident's room . The policy did not address storage of the mask and tubing when not in use. 8. A facility policy titled, Oxygen Management, provided by the DON on 07/20/23 at 9:47 AM documented, .Equipment: #4 .Oxygen sign (If not on the entrance door to the facility) .#7 Store oxygen accessories such as tubing's in a designated container-like device .

Based on interview and record review, the facility failed to ensure resident funds were refunded promptly to the resident or resident's representative within 30 days after the resident's discharged and/or death for 9 (Residents #66, #67, #68, #69, #70, #71, #72, #73 and #115) of 9 sampled residents who had been discharged /expired and had a remaining balance in the resident trust fund account. This failed practice had the potential to affect 51 residents who had a personal trust account managed by the facility, according to the Trial Balance Report dated [DATE], provided by the Administrator on [DATE] at 1:24 PM. The findings are: 1. The facility Trial Balance Report documented 9 names of discharged or expired residents with balances remaining in their resident trust account. a. Resident #66 had a balance of $4.02 and a Death in Facility Minimum Data Set (MDS) dated [DATE]. b. Resident #67 had a balance of $814.34 and a discharged Return Anticipated MDS dated [DATE]. c. Resident #68 had a balance of $27.61 and a discharged Return Anticipated MDS dated [DATE]. d. Resident #69 had a balance of $240.00 and a Death in Facility MDS dated [DATE]. e. Resident #70 had a balance of $0.01 and a Death in Facility MDS dated [DATE]. f. Resident #71 had a balance of $407.00 and a Death in Facility MDS dated [DATE]. g. Resident #72 had a balance of $383.61 and a Discharge Return Anticipated MDS dated [DATE] and a Discharge Summary dated [DATE] documented, .Addendum: Resident expired . h. Resident #73 had a balance of $0.01 and a Death in Facility MDS dated [DATE]. i. Resident #115 had a balance of $49.32 and a Discharge Return Anticipated MDS dated [DATE]. 2. On [DATE] at 2:29 PM, the Surveyor asked the Business Office Manager [BOM] how long the facility had to return funds from resident trust accounts after the resident was discharged or expired. The BOM stated, I can find the answer because I am not sure. The BOM called the BOM Consultant who stated, You have 30 days. The Surveyor asked the BOM to verify the balances and if she knew of any circumstances the resident should not have received the funds. The BOM stated, All the discharge date s are right and the fact that they still have money is also right. The money should have gone to them or their family. I don't know of any circumstances. The Surveyor asked the BOM the reason the funds were not returned. The BOM stated, I was not aware that there was a 30-day window. If they have a beneficiary it goes to who is listed, if they did not fill a form out, then it goes back to the source either private pay or Social Security. 3. On [DATE] at 3:54 PM, the Surveyor asked the Administrator when funds are to be returned to discharged or expired residents. The Administrator stated, I did not know about the 30-day time frame until [BOM] told me. It has not come up in the 8 years I have been here. 4. The facility policy titled, Conveyance of Resident Funds, provided by the BOM on [DATE] at 10:08 AM documented, .Any funds on deposit with the facility are refunded to the resident, resident representative, or the resident's estate, upon discharge, eviction or death . 1. The resident's personal funds and a final accounting of funds are returned to the resident, the resident's representative or to the resident's estate (individual or probate jurisdiction per state law) within thirty (30) days from the date of the resident's discharge or eviction from the facility, or death .

Based on observation, interview, and record review, the facility failed to ensure tobacco products and ignition devices were secured for 1 (Resident #34) of 4 (Residents #17, #34, #48 and #117) sampled resident identified as a smoker in the facility per a list provided by the Administrator on 07/17/23 at 11:10 AM. The findings are: 1. On 07/17/23 at 1:44 PM, Resident #34 was sitting in the hallway outside his room in a wheelchair. A black lighter, and an open pack of cigarettes were resting in the chair next to the resident's right hip. a. On 07/18/23 at 3:49 PM, Resident #34 was seated in their wheelchair in their room. A black lighter, and a single cigarette were resting in the chair next to the resident's right hip. b. On 07/19/23 at 1:24 PM, Resident #34 was entering the dining hall in advance of the scheduled 1:30 PM smoke time. a black lighter, and an open pack of cigarettes were resting in the chair next to the resident's right hip. c. A facility policy regarding tobacco use with no title was provided by the Administrator on 07/19/23 at 1:37 PM documented, Policy: It is the policy of [Facility] to have all residents who wish to smoke at the facility to be properly supervised to ensure a safe environment for all residents, Procedure: 1. Any resident that wishes to smoke . will be required to keep their cigarettes, cigars, lighters, matches, electronic cigarettes and any other smoking items locked up . d. On 07/19/23 at 2:15 PM, the Surveyor asked the Director of Nursing (DON) if residents were permitted to have tobacco products and lighters inside the facility. The DON stated, No. Who does? The Surveyor informed the DON Resident #34 was seen with these items. The DON stated, I'll report this to the Administrator now. e. On 07/19/23 at 2:28 PM, the DON and Administrator approached the Surveyor to report they had retrieved the lighter and an empty cigarette pack from Resident #34's room. The Administrator stated, He's only been here for six weeks, and we've already talked about this with him. We'll just have to check him every morning from now on. 47661

Based on observation, interview, and record review, the facility failed to ensure staff documented dryer lint trap cleaning accurately to prevent the potential for fire in 1 of 1 facility. The findings are: 1. On 07/18/23 at 11:24 AM, the Surveyor asked Laundry Aide #1 and the Dietary Manager (DM) how often the lint traps were emptied. Laundry Aide #1 stated, Every hour. The Laundry Vent Trap Log documented signatures for every hour from 5:30 AM to 2:30 PM for 07/18/23. The Surveyor asked Laundry Aide #1 for the current time. Laundry Aide #1 stated, Almost 11:30. I did it until I leave today. The Surveyor asked what could happen if she signed the log ahead of time if someone else would know it needed to be performed. The Laundry Aide #1 stated, I'm sorry for doing that. a. On 07/18/23 at 11:37 AM, the District Manager stated, If we are going to do it, we must do it correctly. b. On 07/18/23 at 11:52 AM, the Surveyor asked the DM what outcomes could occur when the vent trap log was completed ahead of the process being performed and if the documentation should be accurate. The DM stated, If she was called away, then it could catch on fire. Yes ma'am, always it should be. c. On 07/18/23 at 11:56 AM, the Surveyor asked Laundry Aide #1 if the log should be completed as the process was performed or ahead of the process and if she was trained on compliance and ethics of accurate documentation. Laundry Aide #1 stated, I'm so sorry. I know I shouldn't have done that. I'm sure I have been. I have been here a long time. d. The facility in-service titled, Compliance and Ethics Inservice Training, dated 03/14/23 provided by the Administrator on 07/18/23 at 12:50 PM documented a discussion and handouts were provided and contained Laundry Aide #1 signature. e. On 07/20/23 at 2:56 PM, the Administrator stated the facility did not have a policy on laundry dryer lint trap cleaning, only dryer vent cleaning. The Administrator stated the Maintenance person and Dietary Manager both could not locate the manufacturer instructions for the dryers.

Based on interview and record review, the facility failed to employ a qualified Social Worker on a full-time basis as required by a facility licensed to provide care for more than 120 residents. The findings are: 1. Review of the Facility Assessment tool, dated 1/1/23 noted the facility is licensed to provide care for 154 residents. 2. On 07/19/2023 at 2:56 PM, the Surveyor asked the Social Services Director (SSD) to provide details regarding her level of education. She stated, I have a high school diploma and CNA [Certified Nursing Assistant] training. The Surveyor asked the SSD to verify that she did not possess a bachelor's degree. She confirmed that she did not. The Surveyor asked if the facility employed a qualified social worker with a minimum of a bachelor's degree in social work or a bachelor's degree in a human services field and at least one year of supervised social work experience. She confirmed they did not. The Surveyor asked if she was aware that having a qualified social worker employed on a full-time basis was a requirement for facilities licensed to provide care to 120 or more residents. She stated that she did not know. 3. On 07/19/23 at 3:04 PM, the Surveyor asked the Administrator how many residents the facility was licensed to provide care for. She stated, 154 residents. The Surveyor asked if the facility employed a qualified full-time Social Worker. She stated, No, we don't. I was under the impression that it was only necessary if we had over 120 residents in the facility. I went back and read the regulations this morning, and we are supposed to have one if we're licensed for more than 120.

Based on observation, interview, and record review, the facility failed to store medications in a secure manner. This failed practice had the potential to affect 4 residents who are independent in ambulation as stated on the Resident Census and Conditions of Residents, form CMS-672. The findings were: 1. On 07/20/23 at 11:04 AM, the Surveyor opened an unlocked door on the D Hall, labeled Medication Room. The Surveyor entered the room and discovered two large plastic tubs containing a variety of medications resting immediately inside the door. While the Surveyor was inside the doorway of the room the Director of Nursing (DON) passed by in the hallway and inquired if the Surveyor needed help locating anyone. The Surveyor stated that he was observing the contents of the unlocked room. The DON left the Surveyor inside the room and continued down the hall. 2. On 07/20/23 at 11:14 AM, Licensed Practical Nurse (LPN) #1 accompanied the Surveyor to the unlocked Medication Room. The Surveyor was again able to easily open the door to the room. The Surveyor asked LPN #1 to observe the medications inside the room and asked if the door should be unlocked. LPN #1 stated, No, it should be locked, and adjusted the doorknob so that it would lock. 3. On 07/20/2023 at 11:27 AM the DON confirmed medications were left on the medication room countertop, with the door unlocked. 4. On 07/20/23 at 3:20 PM, the Surveyor asked the DON if it was possible for a resident to open the door to the unlocked medication room. The DON stated, Yes, it should have been locked. The Surveyor asked what the outcome could have been if a resident had consumed some of the unsecured medication. The DON stated, They could get sick. 5. On 07/20/23 at 3:28 PM, the Surveyor asked the Administrator what the outcome could have been if a resident had entered the unlocked medication storage room and consumed medication that was not ordered for them. The Administrator stated, It could have made them very sick. 6. The facility policy titled, Storage of Medications, provided by LPN #1 on 07/20/23 at 4:45 PM documented, The facility stores all drugs and biologicals in a safe, secure, and orderly manner .1. Drugs and biologicals used in the facility are stored in locked compartments under proper temperatures, light, and humidity controls. Only persons authorized to prepare and administer medications have access to locked medications . 4. Discontinued outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed .

Based on observation, record review and interview, the facility failed to ensure necessary care and treatment were provided for management of a Peripherally Inserted Central Catheter (PICC) for 1 (Resident #57) of 1 sampled resident. The findings are: 1. On 7/17/23 at 12:33 PM, Resident #57 was lying in bed, observed a self-adhering dressing covering a clear self-adhering dressing on his right upper arm covering a PICC line insertion site with two lumens dangling. Resident #57 stated, I'm on some really strong antibiotics for the infection of my amputation. 2. On 07/20/23 at 1:15 PM, Resident #57 was lying in bed, a self-adhering dressing was halfway covering a clear self-adhering dressing over a PICC line insertion site. Resident #57 stated the nurse put that over my dressing to keep the IV from being pulled on. 3. A Physicians Order dated 07/13/23 indicated Resident #57 was to receive 1 gram of Merrem (an Antibiotic) Intravenous (IV) Solution one time a day for infection to stump for 14 days intravenously. The Physician Orders did not contain orders for monitoring for infection, dressing changes, or flushes. 4. A Care Plan with an initiated date of 07/14/23, last revised on 7/17/23, indicated Resident #57 was receiving antibiotics via IV access related to stump infection and was to have medications administered as ordered, the dressing changed as ordered, the IV port flushed as ordered and the site observed for infection and infiltration. 5. On 7/20/23 at 1:35 PM review of the July 2023 Medication Administration Record (MAR) documented Resident #57 was receiving the antibiotic since 07/13/23, but contained no information regarding flushes, monitoring for infection, or dressing changes had been done. 6. On 7/20/23 at 3:00 PM, the Surveyor asked Licensed Practical Nurse (LPN) #1 about orders for a dressing change to Resident #57's PICC line. She stated, I'm not sure. I haven't changed it. LPN #2 stated, We aren't to change the dressing, just reinforce it. The Dialysis gives the antibiotics and dressing changes, and we just reinforce it. We aren't giving him antibiotics here. LPN # 1 stated, Yes, they are giving the antibiotics through the PICC on the night shift. 7. On 07/20/23 at 3:30 PM, the Surveyor asked the Director of Nursing (DON) how often a dressing on a PICC line should be changed. She stated, Every seven days, The Surveyor asked if a Physicians Order was needed for dressing changes. She stated, Yes. The Surveyor asked if Resident #57 had a PICC line in place on admission. She stated, Yes. The Surveyor asked when he was admitted . The DON stated, 7/13/23. The Surveyor asked how she knew when it was changed and what should she do when a resident is admitted /readmitted with a dressing without a date on a dressing. She stated, I don't know when it was last changed, and I would call the Doctor for orders. 8. On 07/20/23 at 4:10 PM, LPN #2 stated, I talked to dialysis, and they are not giving his IV antibiotics or providing his dressing change. 9. A facility policy titled, Peripheral and Midline IV Dressing Changes, provided by the Treatment Nurse on 07/20/23 at 4:45 PM documented, .The purpose of this procedure is to prevent complications associated with intravenous therapy, including catheter-related infections associated with contaminated, loosened or soiled catheter site dressing changes.4. Change the dressing . a. at least every 7 days . c. immediately if the dressing or site appears compromised . 10. A facility policy titled, Admission Assessment and Follow Up: Role of the Nurse, provided by the Treatment Nurse on 7/20/23 at 4:45 PM documented, Purpose The purpose of this procedure is to gather information about the resident's physical, emotional, cognitive, and psychosocial condition upon admission for the purposes of managing the resident . Steps in the Procedure .12. Contact the Attending Physician to communicate and review the findings of the initial assessment and any other pertinent information and obtain admission orders that are based on these findings . Reporting 1. Notify the supervisor and the attending Physician of immediate needs that the resident may have .

Based on interview, and record review, the facility failed to develop and implement a comprehensive person-centered plan of care for 2 (Residents #117 and #167) of 2 sampled residents whose Care Plans were reviewed. The findings are: 1. Resident #117 had diagnoses of End Stage Renal Disease and Heart Failure, Unspecified. a. A Physicians Order dated 07/17/23 indicated the resident was to receive Furosemide 160 milligrams (mg) by mouth two times a day and to monitor Resident #117 every shift for decreased oral intake, acute confusion, delusions, agitation, aggression, lethargy, decreased sweating, tachycardia, hypotension, generalized weakness and/or sunken eyes due to the resident being on a diuretic. b. Resident #117 had a previous order for Furosemide 80 mg. to be given on Monday, Wednesday, and Friday with a start date of 6/28/23 and an end date of 7/11/23. c. Resident #117 had a previous order for Furosemide 80 mg to be given on Tuesday, Thursday, Saturday, and Sunday with a start date of 6/29/23 and an end dated of 7/11/23. d. Resident #117 had a previous order for Furosemide 80 mg two times a day with a start date of 7/12/23 and an end date of 7/17/23. e. The Care Plan did not address diuretic therapy. f. On 07/20/23 at 2:29 PM, the Surveyor asked the MDS Coordinator to check Resident #117's electronic record for the Care Plan to see if she could find where diuretics were ordered. She stated, It's not there. I missed it on the MDS therefore I missed it on the Care Plan. It should be there so they can observe and monitor for side effects and labs. 2. Resident #167 had diagnoses of Chronic Obstructive Pulmonary Disease (COPD) and Acute Respiratory Failure with Hypoxia. The MDS with an Assessment Reference Date (ARD) of 06/28/23 documented the resident required a Bilevel Positive Airway Pressure (BiPap)/Continuous Positive Airway Pressure (CPAP). a. A Physicians Order dated 06/21/23 indicated Resident #167 used a BiPAP at bedtime related to Chronic Obstructive Pulmonary Disease. b. The Care Plans for emphysema/COPD and altered respiratory status with a revision date of 07/13/23 did not address Resident #167's use of a BiPAP. c. On 07/18/23 at 12:26 PM, the Surveyor asked MDS Coordinator to check Resident #167's Care Plan and see if she could find the Bipap on it. She stated, It isn't. I'm not sure he has one. I haven't been able to verify to see if he had a BiPAP in place. The Surveyor asked where she got her information from to build the Care Plan. She stated, From the Doctors Orders and past records. 3. The facility policy titled, Care Plans, Comprehensive Person-Centered, provided by the DON on 07/19/23 at 3:26 PM documented, Policy Statement A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident. Policy Interpretation and Implementation . 46868

Based on observation and interview, the facility failed to ensure toilets were flushed, clean, and in proper working order; ceramic tiles were not missing; resident rooms were free of odors; flooring and walls were clean and good repair; bedpans were properly stored and clean; a toothbrush basin was clean; doors were in good repair; bathroom cabinets were in good repair; and resident rooms were free of flies to provide a clean, sanitary, and homelike environment. This failed practice had the potential to affect all 74 residents according to the Facility's Resident Matrix dated 7/7/2022. The findings are: 1. On 7/7/2022 the following observations were made on the Evergreen Expressway: a. At 1:37 p.m., in Resident Room 61, the bathroom toilet was stopped up and contents were close to the rim of the toilet bowl. The toilet was still running, and the room and bathroom smelled of urine and stool. There were 3 to 4 ceramic tiles used as the lower baseboard trim were missing in the bathroom. The linoleum floor tiling was worn and dusky. The wall adjacent to Bed B had several tears in the wall with exposed dry wall and missing paint. b. At 1:43 p.m., in Resident Room 62, the linoleum floor tiling was worn and dusky. The bathroom smelled of urine and stool. A bed pan was stuck in between the handicapped accessible bar in the bathroom. The bedpan was not covered and not sanitary. c. At 1:48 p.m., in Resident Room 58, the linoleum floor was worn and dusky. The bathroom smelled of urine and stool. There were 2 bed pans were stuck in between the handicapped accessible bar in the bathroom. The bedpans were not covered and not clean. A toothbrush basin was sitting on the sink counter. The basin was not clean and not labeled. d. At 1:51 p.m., in Resident Room 57, on the floor adjacent to Bed B were miscellaneous debris of unknown origins scattered in different locations. e. At 1:56 p.m., in Resident Room 56, the linoleum floor was worn and dusky. The door to the bathroom had multiple scrapes and tears in the wood. The door also had a hole approximately 3 inches by 3 inches in diameter. The wall adjacent to the head of Bed A had two to three holes in the dry wall. These holes had been repaired with a spackling compound but not sanded or repainted over. 2. On 7/7/2022 the following observations were made on Black Walnut Boulevard: a. At 2:03 p.m., in Resident Room 26, there were three flies on the blanket on the bed. The bathroom toilet was running and would not stop running even after several attempts by the Director of Nursing (DON) to shut it off. Maintenance was notified. b. At 2:07 p.m., in Resident Room 23, the wall adjacent to Bed A had several holes in the dry wall. These holes had been repaired with spackling compound but not sanded or repainted over. The door to the room was worn and tattered. The door had multiple scuffs and tears in the wood. c. At 2:10 p.m., in Resident Room 24, there were 3 flies were on Bed B. The linoleum floor was worn and dusky. The room had a musty, urine smell. d. On 7/7/2022 at 2:19 p.m., in Resident Room 21, the walls of the room had multiple dry wall repairs where the dry wall spackling compound was not sanded or repainted over. The bathroom walls were worn and tattered. The lower portion of the walls in the bathroom were pliable and would buckle when pushed on. The paint on the wall behind the toilet was blistering down the entire corner of the wall. The room and bathroom had a musty, urine smell. 3. On 7/8/2022 at 1:10 p.m., in Resident Room 46, the cabinet in the bathroom was missing all of the designated drawers. The lower portion of the cabinet was missing or had been broken off. The linoleum floor was worn and dusky. The room had a musty, urine smell. 4. On 7/8/2022 at 10:30 a.m., the DON stated, We are attempting to remodel some of these rooms when we get the opportunity. The bedpans that you saw were not being used by the residents. They just hadn't been removed. 5. On 7/8/2022 at 12:20 p.m., Certified Nursing Assistant (CNA #1) was asked, Was the residents in Room 58 asking for or using a bedpan? CNA #1 stated, I found out that [Resident in Bed B] did ask for a bedpan last week. She usually doesn't that I am aware of. I don't know about the others. CNA #1 was asked, Why were these bedpans just left in the room? CNA #1 stated, I cannot answer that. They should have been covered or thrown away.

Based on observation, record review and interview, the facility failed to ensure the kitchen equipment, refrigerators, and walls were clean; the kitchen ceiling was maintained in safe clean condition; fans in the food prep area were clean; staff wore facial hair coverings while preparing and or serving food; food items stored in the freezer, refrigerator and dry storage room were sealed and dated to maintain freshness and prevent and potential cross contamination; leftover food items were promptly used or discarded; and expired food items were removed / discarded on or before the expiration or use by dates to prevent potential food borne illness; for residents who received meals from 1 of 1 kitchen. These failed practices had the potential to affect 72 residents (total census 73) who received meals from the kitchen as documented on a list provided by the Administrator on [DATE] at 10:06 AM. The findings are: 1. On [DATE] at 10:45 AM, in the Dining Room there was a table with beverages on it and a coffee station. Three gallon-sized pitchers one with a red liquid (,d+[DATE] full), one with a brown liquid (,d+[DATE] full), and one with a clear liquid (,d+[DATE] full) with no date or description on the pitcher or lids. The coffee station had a white towel under it with brown liquid soaking into it. 2. On [DATE] at 10:48 AM, the Dietary Manager (DM) stated he is both DM and Cook since [DATE] due to not being able to hire a cook for the past 9 months. The step lever was not functioning on trash can inside the entry door to the kitchen. The DM stated, You have to lift the lid on that one. The high temp dish washing area had ceiling tile and metal trim falling above sink. The wall panels were falling inward in the dish washing area. The DM stated it had been this way awhile. There were 2 ceiling tiles with a brown discoloration above the clean dinnerware storage area. The DM stated the ceiling previously had a leak. The DM had no beard covering over his beard which was ,d+[DATE] to ,d+[DATE] inch long. 3. On [DATE] at 10:53 AM, the following observations were made in the indoor standing refrigerator: a. There were 2 packages of turkey bologna not dated. b. An opened container of strawberry jam approximately ,d+[DATE] full was not dated. c. Six small plastic cups of salsa were not labeled or dated. d. Three small plastic cups of sour cream were not labeled or dated. The DM stated they were leftovers, and he wasn't sure when they were served. e. Two square cubes of sliced cheese, the DM guessed 60 slices, were not labeled when they were opened and were in a plastic bag partially sealed with an office binder clip. f. Onion slices were in a ziplock bag and were not dated. The DM stated, Those should be dated. The DM was asked how long they had been in the refrigerator and DM stated, At longest, from last Thursday. The DM then stated, It's hit or miss when we have time to date them. g. An opened bag of salad was partially sealed by an office supply binder clip. h. An opened plastic bag with 3 hardboiled eggs was not dated. The DM was asked when they had been prepared. The DM stated, I'm not sure. The DM was asked, What should be on all items stored? DM stated, Should have an open date and/or use by date. i. A pitcher, ,d+[DATE] full of brown liquid did not have a label. The DM was asked what it was. The DM stated, It's tea. The DM was asked if pitchers needed to be labeled and he stated, They should be. j. An opened bag of sausage was partially sealed with an office binder clip. The DM was asked how many were in the bag. He stated, looks about 20 to 30. The DM then stated, [CONDITION(S)] is Monday, Wednesday, and Friday and they have to eat at 5:00 AM, so those are quick items for them. 4. On [DATE] at 11:06 AM, the following observations were made of the outdoor refrigerator: a. The refrigerator's door was open when this survey and the DM walked out the back door of the kitchen. The DM stated, must have not been shut. b. A metal food tray container with 3 Styrofoam cups of yellow-orange food not dated. The DM was asked what it was, and the DM stated, leftovers of vanilla pudding. c. A square plastic container of corn in a whitish-yellow liquid was dated ,d+[DATE](21). The DM was asked to describe the corn. The DM stated, Excess starch. This Surveyor smelled the corn and it smelled sour. The DM was asked to smell the corn and he stated he thought it smelled fine. d. Seven hot dogs in an orange liquid were in a plastic bag and were not dated. e. A package of bologna had an expiration date of [DATE]. f. Two gallons of mixed fruit were in a square plastic container with no date. The DM was asked when it was from. The DM stated Unknown. g. A silver square container with pureed food was not dated. The DM was asked when the food had been prepared, and stated, Leftovers from the mornings. h. A box of meatballs had a received date of [DATE] and an expired date of [DATE]. i. An opened package of bacon was not dated and was partially sealed with an office binder clip. The DM stated, I know these things should be labeled. 5. On [DATE] at 11:13 AM, the following observation were made in the outdoor freezer: a. Six packages of hotdog buns with a best by date of [DATE]. b. Five pie crusts in a plastic bag not dated. c. Two open containers of Blue Bunny ice cream not dated. d. A bag of breaded boneless chicken with translucent shiny particles on breading was partially sealed with an office binder clip. e. The DM stated he has no time to date and check foods . have not had a cook for 9 months. The freezer roof had a leak and a cone shaped ice formation approximately 10 inches tall was on the floor. The DM stated they had to put a tarp on the roof until it was fixed. 6. On [DATE] at 11:20 AM, the following observations were made in the Dry Storage room: a. The ceiling vent had a dark gray fuzzy build up that was hanging 2 to 3 inches from the air vent cover above the dry storage foods. The DM was asked to describe the ceiling vent. The DM stated, I'm not sure, dust maybe. b. Four spice bottles with the lids open. c. Four hamburger buns in a zip locked bag not labeled or dated. d. A box of Spanish Rice best buy [DATE]; 4 packages of tortillas best buy date [DATE]; 6 packages biscuit mix expiration date [DATE]. 7. On [DATE] at 11:26 AM, a black, sticky substance was dripping down the edge of the fry top to the stove top; a yellow orange splatter was dried on the side and the top of the stove. The back of the stove had a light gray fuzzy build up on the air vents, fan, and metal tubing. There were two ceiling panels hanging 1 to 2 inches down from the air vents with a gray and brown fuzzy substance on the edges at the back of the stove hood. The heater/air conditioner vent was covered in gray and black substance hanging off the edges and covered the slats that were separated from the seal and participles were floating out of vent. 8. On [DATE] at 11:28 AM, a metal pan with cooked french fries was sitting uncovered on a table next to the fryer. Above the table was a ceiling panel hanging loose with fuzzy grey film hanging off the edges. 9. On [DATE] at 11:29 AM, the Ice Machine in Dining Room had the Sanitize light on. 10. On [DATE] at 10:43 AM, a towel under the coffee station was completely brown with some dried and some wet brown liquid dripping off of the table. There were 3 gallon-sized pitchers with a red liquid (,d+[DATE] full), a brown liquid (,d+[DATE] full), and a clear liquid (,d+[DATE] full) with no date or description on the pitchers or lids. The Sanitize light was still on, on the ice machine in Dining Room. 11. On [DATE] at 10:48 AM, the indoor standing refrigerator had non-dated strawberry jam, one square cube of sliced cheese not labeled in a plastic bag partially sealed with a binder clip and an opened bag of salad partially sealed with a binder clip. 12. On [DATE] at 1:18 PM, the Maintenance Supervisor was asked if he was aware of the ceiling issues in the kitchen. The Maintenance Supervisor asked this surveyor to show him as he was not sure. Surveyor showed him the hanging metal and tiles above the dish washing area, that now had silver tape on metal bars. The Maintenance Supervisor stated he temporarily fixed that last night. Surveyor pointed out the wall paneling falling in, and The Maintenance Supervisor stated he has ordered glue to adhere panel to the wall because the drywall no longer holds screws well. He was asked about the brown areas on the ceiling over the clean dishware area and he stated, A pipe burst previously, and he needs to get the ceiling tiles put back in place. He was asked about the heater and air-conditioning vent with gaps and dirt and particles hanging down and coming out of vent. He stated the vent seems to be bent and needs to be put back into place to help keep out debris. He stated he would add that to his list. 13. On [DATE] at 1:27 PM, the Dining Room Beverage Station had three gallon-sized pitchers one with a red liquid (,d+[DATE] full), one with a brown liquid (,d+[DATE] full), and one with a clear liquid (,d+[DATE] full) with no date or description on the pitcher or lids. 14. On [DATE] at 2:00 PM, the Administrator was asked how staff know to inform Maintenance of repairs needed. The Administrator stated, They all know about the maintenance logbook at the nurses' station and are told when hired about it. The Administrator was asked if they had a policy for repairs and the Administrator stated they did not. The Administrator was asked if she was aware of the ceiling and wall issues in the kitchen. She stated, I was made aware of it yesterday morning when Maintenance was made aware of it. It must have happened over the weekend. The Administrator was informed that the DM had formed this surveyor that it had been like that for a while.

Based on observation, record review and interview, the facility failed to ensure the Care Plan was revised to address the care and monitoring of a central line in a resident on [CONDITION(S)] for 1 (Residents #19) of 1 sampled resident who received [CONDITION(S)] and failed to ensure the code status of a resident who was admitted to Hospice was updated to Do Not Resuscitate for 1 (Resident #58) of 1 sampled resident whose code status changed. This failed practice had the potential to affect all 73 residents who resided in the facility. The findings are: 1. Resident #19 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] documented the resident scored 13 (,d+[DATE] indicates cognitively intact) on a Brief Interview for Mental Status (BIMS) and received [CONDITION(S)] while a resident. a. The Physician's Order dated [DATE] documented, . [CONDITION(S)] at [Company] [CONDITION(S)] on M-W-F [Monday-Wednesday-Friday] . Order Date [DATE] . The Physician Orders did not address the central line. b. The Care Plan with a revision date of [DATE] documented, . I am at risk for complications as I receive [CONDITION(S)] on Monday, Wednesday, and Friday . My shunt site will be accessed by the [CONDITION(S)] center only or as ordered . The Care Plan does not address the resident's central line. c. The History of Accesses document provided by the DON on [DATE] at 9:52 AM documented, [Resident #19] . Patient Access . Effective Date [DATE] . Status: Primary .Location LIJ [left Internal Jugular] . d. On [DATE] at 11:37 AM, Resident #19 was asked when she went to [CONDITION(S)]. She stated, I go to [CONDITION(S)] Mondays, Wednesdays and Fridays. I just got back. She was asked where she gets her [CONDITION(S)]. She pulled down her shirt, a double lumen central line located on the left upper chest. The dressing dry was and intact and not dated. She stated, I used to get it in my arm, but they had to put this in and now I get it here . e. On [DATE] at 1:51 PM, Licensed Practical Nurse (LPN) #2 was asked, Where is [Resident #19] receiving her [CONDITION(S)]? She stated, Her upper chest, it was in her shunt in her arm .we check her bandage when she gets back and make sure she is not bleeding. She was asked, Who is changing the central line dressings? She stated, They take care of it at [CONDITION(S)]. f. On [DATE] at 2:49 PM, the Director of Nursing (DON) was asked, Where is [Resident #19] receiving her [CONDITION(S)]? She stated, It was in her arm, but they put in a port. She was asked, Should there be an order for [MEDICAL RECORD OR PHYSICIAN ORDER] ? She stated, Yes. The DON was asked, Should the central line interventions be addressed in the care plan? She looked at her computer screen and stated, Yes. The DON was asked, When was the central line inserted? The DON stated, I am not sure. 2. Resident #58 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly MDS with an ARD of [DATE] documented the resident scored 0 (,d+[DATE] indicates severely cognitively impaired on a BIMS and was on hospice and did not [CONDITION(S)]. required limited assist with one person for bathing, supervision with two persons assist for bed mobility, and transfer. a. The Care Plan with a revision date of [DATE] documented, I am a Full Code . I need you to initiate CPR [Cardiopulmonary Resuscitation] if you find me pulseless and breathless and continue CPR until Emergency personnel arrive to take over. b. The [DATE] Physician Orders documented, Admit to [name] Hospice . Order Date [DATE] . Do Not Resuscitate . Order Date [DATE] . c. On [DATE] at 2:34 PM, the MDS Coordinator was asked, What is [Resident #58's] code status? She looked in the physician's order in the electronic record and stated, On [DATE] they changed her to DNR [Do Not Resuscitate]. The MDS Coordinator was asked, What is [Resident #58's] code status on her Care Plan? She looked at Resident #58's care plan in the electronic record and stated, .You need to initiate CPR . That needs to come off of there . They should have updated it [care plan code status] when she went into Hospice . The MDS Coordinator was asked, Who is responsible for updating the code status on the resident's care plans? She stated, [Name] in Social Services .she is off due to . 3. The facility policy titled, Comprehensive Care Plans, provided by the Administrator on [DATE] at 10:05 AM documented, .It is utilized to plan for and manage resident care as evidenced by documentation from admission through discharge for each resident .1. The following health care professionals contribute to the interdisciplinary Care Plan by collaboration and direct documentation: Social Services Coordinator .

Complaint # (AR 305) was substantiated, all or in part, in these findings. Based on observation, record review, and interview, the facility failed to ensure a mechanical lift sling was correctly attached to the lift per manufacturer's instructions to prevent an accident with injury for 1 (Resident #3) of 3 (Residents #3, #4, and #5) case mix residents who required the use of a mechanical lift for all transfers. This failed practice resulted in past noncompliance at the level of Immediate Jeopardy, which caused or could have caused serious harm, injury or death for Resident #1, who was transferred via mechanical lift with the sling improperly attached, resulting in the resident falling and sustaining a laceration to her head, and had the potential to cause more than minimal harm to 25 residents who required transfers with a mechanical lift, as documented on a list provided by the Administrator on 12/13/18 at 3:15 p.m. The Administrator was informed of the past immediate jeopardy condition on 12/13/18 at 1:57 p.m. The findings are: 1. Resident #3 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set with an Assessment Reference Date of 11/22/18 documented the resident scored 10 (8-12 indicates moderately impaired) on a Brief Interview for Mental Status and required 2 person assistance with the mechanical lift for transfers. a. The Plan of Care documented, .I have an ADL (activities of daily living) self-care performance deficit r/t (related to) weakness, non-ambulatory . I require a green sling for the Hoyer lift . Transfer: I require a Hoyer lift x (times) 2 staff for transfers . Date Initiated: 04/18/2018 . b. The Visual/Bedside Kardex Report for Resident #3 documented, .Transferring - Green - Hoyer Lift x 2 staff . c. The Reliant Lift Sling Color Trim & (and) Weight Capacity documented, .Full Body Solid (Poly): Medium Purple 90-200 lbs. (pounds) Large Green 175-285 lbs. Xtra (Extra) Large Blue 265-500 lbs . This form was posted in the linen room where the transfer pads/slings were stored. d. The Facility Investigation Report for Resident Abuse, Neglect, Misappropriation of Property & (and) Exploitation of Residents in Long Term Care Facilities, Division of Medical Services (DMS) form 762 documented, .On 11/26/2018 at 5:00 am facility CNAs (Certified Nursing Assistants #1 and #2) were in the process of transferring (Resident #3) from her bed into her wheelchair; they had the appropriate sized Hoyer lift sling underneath (Resident #3); they proceeded to raise the lift when they noticed that one of the loops was not properly attached. (CNA #1) ran to try and attach it, but before she could reach it, (Resident #3) fell to the floor, hitting her head and left elbow. The 2 CNAs immediately called for the nurse and (Licensed Practical Nurse (LPN #1)) immediately came and assessed the situation and called for an ambulance . (CNA #1) and (CNA #2) were immediately suspended pending the outcome of this investigation. Facility administrator, family, physician and police were all notified. (Resident #3) returned from the (Hospital) emergency room a couple of hours later. The CT (Computed Tomography Scan) report from the hospital sates 'no CT evidence of acute intracranial abnormality or skull fracture'. She has a 3 cm (centimeter) laceration on her right posterior scalp. Upon return DON (Director of Nurses) completed a thorough body audit and found that (Resident #3) had her normal range of motion and had a headache that dulled with medication . On 11/28/18 during an interview with her nurse practitioner, (Resident #3) complained of left shoulder pain; an xray order was obtained and (mobile x-ray) came to facility and x rayed her left shoulder, humerus, forearm and hand. There were no negative findings . e. The hospital record Progress Notes dated 11/26/18 documented, .Patient's scalp wound is thoroughly washed out and closed with staples without difficulty . Primary Impression: Minor head injury . Exam: CT Head without Intravenous Contrast . 11/26/2018 6:22 AM . Impression: 1. No CT evidence of acute intracranial abnormality or skull fracture. 2. Large region of encephalomalacia re-identified throughout right cerebral hemisphere. This likely represents old infarct . f. The Radiology Results Report dated 11/28/18 documented, .Procedure: Shoulder 2V (views) . Left Shoulder . There is no evidence of acute fracture, dislocation or osseous lesion . Left Humerus . There is no evidence of acute fracture, dislocation or osseous lesion . Left Hand . There is no evidence of acute fracture, dislocation or osseous lesion . Left Forearm . There is no evidence of acute fracture, dislocation or osseous lesion . g. The manufacturer's instructions for the Invacare Reliant Mechanical Lift documented, .Section 8 page 28 . Transferring the Patient . Warning DO NOT move the patient if the sling is not properly connected to the hooks of the swivel bar. When the sling is a few inches off the stationary surface and before moving the patient, check to make sure that the sling is properly connected to the hooks of the swivel bar. If any attachments are NOT properly in place, lower the patient back onto the stationary surface and correct the problem - otherwise, injury or damage may occur . h. On 12/12/18 at 3:05 p.m., CNA #1 was asked if she had been trained on using the mechanical lifts prior to the accident on 11/26/18 and stated, Yes, we had a checklist we had to complete. I was checked off by the old Administrator. CNA #1 was asked to explain the events that took place prior to Resident #1's fall from the mechanical lift on 11/26/18. CNA #1 stated, It was around 5:00 a.m. We were getting her up and into her wheelchair. The transfer pad was in her wheelchair. We leave them in the rooms until they need to be changed out. I was on the right side of the bed and (CNA #2) was on the left side of her bed. I hooked up one side of her head and foot. We raised her up, but she would not clear her bed without dragging. I lowered the bed. We had a difficult time picking up her feet up. (CNA #2) was holding her legs and feet up. I noticed one of the straps was not attached. (CNA #2) quickly brought it to my attention, but (Resident #3) was already in the floor. Somehow one of the straps came undone. No straps broke, and the lift did have all the safety pins. It was on one of the sides that (CNA #2) had hooked up. The size of the slings is in our Kiosk kardex, I think it was green. I made sure my two were hooked up. I didn't see where (CNA #2) had hers hooked. (Resident #3) was completely level when we had her raised above the bed. We know to inspect the lifts before using. When we were raising her from the bed it showed no indication that not hooked up right. We backed up the mechanical lift and turned her body making sure her legs cleared from the bed. That is when (Resident #3) landed in the floor. She hit her head on the leg of the mechanical lift. She was sent out right away. CNA #1 was asked if she had any further training after the mechanical lift accident on 11/26/18? CNA #1 stated, Yes, with the (lift maintenance contractor) guy and with the ADON. The (lift maintenance contractor) guy said that the loop got right in the sweet spot. Where it would hold her up when level but slipped out when we were turning her. I did not personally witness, it showed no indication that it was not hooked up right. i. On 12/13/18 at 10:34 a.m., CNA #2 was asked if she had been trained on using the mechanical lifts prior to the accident on 11/26/18 and stated, Yes, when I was hired, I had to be checked off on how to use the mechanical lift. There was another incident and we had to be retrained on the mechanical lift. Before hooking the transfer pad, we check for rips or tears, if any fraying. CNA #2 was asked to explain the events that took place prior to the mechanical lift accident on 11/26/18 and CNA #2 stated, The transfer pad was already under her. We had gotten her ready, changed and everything. I was on the side of the bed closest to the window. On the head, we use the green strap and on the foot we use the purple strap. (CNA #1) was running the lift. We were raising her up slowly from her bed. We maxed out on the height, it will only go up so far. (Resident #1) was still on the bed. We lowered the bed, so we had clearance. We came around the foot of the bed and had issues where her feet would hit the bed. I noticed the strap was not secure. It was just dangling. I hollered at (CNA #1). I still had a hold of (Resident #3's) feet. She just dropped, none of the straps broke. She was suspended above the bed, earlier. CNA #2 was asked if she had any further training after the mechanical lift accident on 11/26/18 and CNA #2 stated, Wednesday, the mechanical lift guy came down and went through it over and over. He said it sat at the sweet spot until we started turning her. I have been retrained and in-services. Twice, the mechanical lift guy came back. We have been checked off six times. l. On 12/13/18 at 9:14 a.m., the DON was asked if there were any prior accidents involving the mechanical lift and transfers and the DON stated, I have been here for over a year and the only accident involving a mechanical lift was the one you investigated. The DON was asked what type of training the CNAs received when hired regarding mechanical lift transfers and the DON stated, The ADON checks them off. The mechanical lift transfer checklist on their new hire checklist. She goes through the return demonstration with them or she delegates certain nurses to do it. The Restorative Aides can do it, too. The DON was asked how many mechanical lifts were functional in the facility and the DON stated, We have 3-4 that are in working condition. The DON was asked if the aides were trained on how to inspect the transfer pads/slings and the DON stated, Absolutely, they are trained to look for rips and tears. That is part of their checklist, monitoring is ongoing. 2. The facility removed the immediate jeopardy and corrected the failed practice on 11/28/18, as evidenced by the following: a. The DMS form 762 documented, . 11/26/18 . Facility maintenance director inspected all 3 facility Hoyer lifts including clips and latches to ensure everything was working properly; there were no negative findings. Facility Housekeeping supervisor inspected all facility lift slings to ensure they were in good repair-there were no negative findings. Facility MDS RN (Registered Nurse) completed an audit on all residents requiring a Hoyer lift to ensure that the proper size sling was documented in their care plans and kardex's . Facility DON/designee began transfer audits on all nursing staff with return demonstration. On 11/28/18 facility's lift maintenance contractor conducted a full inspection of the Hoyer lift and sling that were used to transfer (Resident #3) (it has been locked up in a room since incident). He found that the lift and sling were in perfect working order and placed it back in use. On 11/28/18 the rep for (lift maintenance contractor) conducted a very thorough Hoyer lift in-service with all facility nurses and CNAs and demonstrated exactly how to place sling, checking the straps and latches, positioning of the Hoyer legs, etc (et cetera). Also on 11/28/18 the (lift maintenance contractor) conducted an interview with (CNA #1) and (CNA #2) and had them demonstrate what occurred with (Resident #3). He concluded that (CNA #2) did not have one of her loops hooked properly in the latch . Facility administrator and DON reviewed (CNA #2's) work history and found that she has had a very good work history as a CNA at facility since 09/07/16 . Since this incident she has demonstrated competency using the Hoyer lift during return demonstration with from (lift maintenance contractor) and ADON (Assistant Director of Nursing). We have written her up for this incident, she was suspended without any pay and will be placed on a 90-day probation. Upon (CNA #2's) return a charge nurse along with her CNA partner will observe the first 6 resident Hoyer lifts and then after that a charge LPN (Licensed Practical Nurse) will observe 2-3 Hoyer lifts per week for 4 weeks . b. On 12/13/18 the ADON provided a typed form that documented, On (MONTH) 28, (YEAR) a representative from (lift maintenance contractor) came to facility and performed in-service with staff on using the Hoyer lift. Since that date (CNA #2) was observed doing six Hoyer lift transfers on her first night back to work (November 29, (YEAR)) and is being monitored three times a week for four weeks. All CNAs and nurses have been monitored doing Hoyer lift transfers as of 11/26/2018. I will continue to monitor all new staff members upon hire and will continue to do random monitoring. c. The monitoring forms provided by the Registered Nurse (RN) Consultant on 12/13/18 documented, 11/29 . (CNA #2) returned to work DON/designee observed 6 lifts - 0 (zero) neg (negative) concerns, plus 3/(per) week afterwards . 3/week random monitoring of lift transfers to ensure proper techniques & (and) safe transfers - There have been 0 concerns noted .QA & A (Quality Assurance and Assessment) meeting (monthly) was completed, data reviewed with any new recommendations made. d. On 12/13/18 at 9:56 a.m., CNA #3 and #4 transferred Resident #3 from her wheelchair to her bed utilizing the mechanical lift without any concerns identified. e. Resident #5 had [DIAGNOSES REDACTED]. The Significant Change in Condition MDS with an ARD of 11/26/18 documented the resident scored 13 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status, required 2 person assistance for transfers and required a mechanical lift for transfers. On 12/13/18 at 11:48 a.m., CNAs #5 and #6 transferred Resident #5 from her bed to her wheelchair utilizing the mechanical lift without any concerns identified.

Complaint # (AR 311) was substantiated (all or in part) in these findings. Based on observation, record review, and interview, the facility failed to ensure a resident's wheelchair was correctly positioned in a forward-facing direction in the facility van, as per the van restraint manufacturer's instructions, to allow the van's wheelchair restraints to be securely and properly applied which resulted in an accident with injury during transport for 1 (Resident #1) of 5 (Residents #1 through 5) case mix residents who were transported via the facility van. This failed practice resulted in past noncompliance at the level of Immediate Jeopardy, which caused or could have caused serious harm, injury or death to Resident #1, whose wheelchair was incorrectly positioned, causing a wheelchair restraint failure resulting in the resident sliding out of the wheelchair during a transport, with the resident sustaining a left fibula fracture and left lateral malleolar fracture. The failed practice also had the potential to cause more than minimal harm to 14 residents who were transported in the facility van over the past 3 months, as documented on a list provided by the Administrator on 4/16/18. The Administrator was informed of the past Immediate Jeopardy situation on 4/17/18 at 1:38 p.m. The findings are: 1. The Q-Straint Installation Instructions 4-Point Wheelchair Securement Systems, provided by the Director of Nursing (DON) on 4/17/18 at 1:04 p.m., documented, Wheelchair Location Recommendations . IMPORTANT . The following are recommendations for the layout of designated Wheelchair Locations: TIEDOWNS SHOULD ONLY BE INSTALLED SO WHEELCHAIR PASSENGERS ARE FACING FORWARD. Note: Wheelchair passengers may face rearward when in compliance with ADA (Americans with Disabilities) . The instructions included an illustration that depicted 3 wheelchairs positioned in a forward-facing direction. 2. Resident #1 had [DIAGNOSES REDACTED]. The Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/26/18 documented the resident scored 15 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status (BIMS), required extensive assistance of 2 plus people for bed mobility, was totally dependent on 2 plus people for transfers, was not steady and only able to stabilize with staff assistance when moving from seated to standing position and surface-to-surface transfers, and used a wheelchair for mobility. a. The Care Plan revised on 3/7/18 documented, .I have an ADL (Activities of Daily Living) self-care performance deficit R/T (related to) dx (diagnosis) of [MEDICAL CONDITIONS] . I require a blue sling for the Hoyer lift, Locomotion: I am dependent x (times) 1 staff for locomotion by bariatric wheelchair. Please assist me to specific area when I am up in my wheelchair such as: activities, therapy, dining room and my room as needed. Transfer: I require a Hoyer lift x 2 staff for all transfers . b. The Facility Investigation Report for Resident Abuse, Neglect, Misappropriation of Property, and Exploitation of Residents in Long Term Care Facilities, Division of Medical Services (DMS) form 762 dated 4/12/18 documented, Date and Time of Incident: 04/12/18 Time: 8:45 a.m . Complete Description of Incident. On 04/12/18 at around 8:45 a.m., (Resident #1) slid out of her wheelchair while being transported in facility van, while van was descending a hill. This incident occurred at the end of the facility driveway. When Administrator arrived on the scene of the incident, I observed (Resident #1) on the floor of the van at a diagonal, in front of the lift, with bilateral legs under the van seat. (Resident #1) still had the lift sling under her and the wheelchair cushion underneath her buttocks. (Resident #1) was complaining of pain in her back and her left ankle. Administrator made the decision to call EMS (Emergency Medical Service) and have (Resident #1) transported to the local hospital for evaluation. When EMS arrived, they requested that the van be moved to level ground to be able to get resident safely out of van utilizing the van lift. EMS staff and facility nursing staff secured the resident while the van was moved to level ground, then EMS utilized mechanical lift sling and back board to move resident from inside the van, to the van lift, then onto the stretcher and into the ambulance safely. At the time of the incident, (Resident #1), 2 other residents, the van driver, and facility volunteer were present in the van. The facility Activities Director was following the facility van in her personal vehicle. Hospital evaluation determined that resident has sustained a left fibular fracture and left lateral malleolar fracture . Section III- Findings and Actions Taken . Investigation determined that (Resident #1) was placed in the facility van facing the side windows of the van, and van driver (Certified Nursing Assistant (CNA) #1) did attach all 4 points of retractable restraints to the wheelchair and the track, and she did attach the shoulder strap and lap belt. While van driver began turning left out of facility driveway, (Resident #1) began sliding out of her wheelchair with mechanical lift sling and wheelchair cushion. (Van Driver) immediately and safely stopped the van and attempted to reposition resident back onto wheelchair, with the assistance of facility volunteer and Activity Director. (Van Driver) then realized that the resident was not going to be able to be repositioned in her wheelchair, so they lowered resident to the floor as slowly as possible, utilizing mechanical lift sling and wheelchair cushion underneath resident's buttocks . c. The hospital Emergency Department Physician Report dated 4/12/18 at 10:17 a.m. documented, .General Chief Complaint: Multiple Trauma / Fall . Stated Complaint: Fall . Time Seen by MD (Medical Doctor): 9:16 (a.m.) Source: patient, EMS. History of Present Illness . Initial Comments: Patient is a [AGE] year-old morbidly obese white female with a past medical history pertinent for kidney failure on [MEDICAL TREATMENT], [MEDICAL CONDITION], who was in a wheelchair and a van. When the van went to stop at the stop sign, Patient slid out of her wheelchair and injured her left ankle and knee. She did not hit her head or lose consciousness. She denies any neck pain. She is having some mid lower back pain but no loss of bowel or bladder control or saddle paresthesia. Patent does not walk and uses a wheelchair and Hoyer Lift. Review of Systems: . Musculoskeletal: joint pain (left knee and ankle). Progress. Patient has a fibular head and lateral malleolar fracture. We'll place her in a short leg posterior splint, as she is not weight bearing anyway. X-RAY/CT (computerized tomography)/US (ultrasound) . X-RAYS ordered: Knee X-RAY results: fracture (fibular head, nondisplaced) X-RAY #2. X-RAYS Ordered: ankle, X-ray comments small fracture to distal fibula, lateral malleolus. Impression: Primary Impression: Fibula fracture. Additional Impression: Lateral malleolar fracture. Comments: Patient seen and examined. States she slid out of the chair and the van when it was coming to a stop at a stop sign. Patient states her leg got caught under another seat. Complains of pain everywhere but mostly in the lower leg and also the back. She is neurovascularly intact. She has a fibular head tenderness on the left as well as lateral malleolar tenderness. No gross deformity or laceration. Patient does have a nondisplaced fibular head and distal fibular fracture. Patient does not fit in the CT scanner to get a lumbar spine CT. I have fairly low suspicion given mechanism the patient has a burst fracture hernia retropulsion impeding the spinal cord return x-rays were ineffective due to habitus. Patient was advised to be transferred for further imaging but declines. I agree with above . d. An Office of Long Term Care (OLTC) Witness Statement Form dated 4/12/18 at 8:45 a.m. documented, Witness Full Name (CNA #1). I loaded everyone up into the Chevy van at 8:15 AM. I transferred (Resident #2) to a seat and buckled her up. Then, I loaded up (Resident #5) and moved her to the front to buckle up and strapped her in. Then, I loaded up (Resident #1), strapped her in and buckled her seat belt. I double check to make sure every strap and buckle was tight. We left, and I started driving down the hill, when I see (Resident #1's) chair go forward. I immediately stopped and went back there when I noticed the latch that holds the seat belt came undone and caused her to move forward. I quickly called for help then I unhooked everything so I could ease her to the floor so she didn't get hurt. At 4:20 p.m., CNA #1 was asked about the van accident involving Resident #1. CNA #1 stated, I was trained that way (to have wheelchair facing toward the lift side), and the CNA before me was trained that way, because that is how she trained me. The straps on the floor would give some. I would stop the van and readjust the floor straps . I told the maintenance man. (Resident #1) could not face forward in the van, because of her foot pedals. e. On 4/17/18 at 1:15 p.m., Volunteer # 1 was asked to describe the events on the facility van when Resident #1 was injured. Volunteer #1 stated, .She (Resident #1) came right up to the bench, close to (Resident #5); she came sliding out when we were trying to unhook the wheels. She was kind of lowered to the floor right up against the bench seat. She had slid into the legs of the bench seat with her shoulder strap still on. She was real close to (Resident #5); (Resident #2) was towards front right beside. She was all buckled up; the buckles gave, but she was still secured to the wheelchair. We turned left, and her wheelchair turned left. She actually never fell out of the wheelchair, not until we let her out . She said she didn't want it (strap) on the shoulder; it was directly over her shoulder . f. On 4/19/18 at 9:15 a.m., Resident #1 was asked, Have you ever had any problems in the van prior to the incident on 4/12/18? She stated, I'm used to the straps coming loose a lot, but they will usually catch you; they will give a little. She was asked, Which way is your wheelchair placed in the van for transport? She stated, For long trips, they place my chair facing the driver; for short trips, they place my chair facing the lift. She was asked, Are you aware of any problems with the vans? She stated, (CNA #2), the old driver, always complained about the straps coming undone. She would stop and re-secure them. She was asked, Had you ever been injured during a transport before? She stated, No incidents of me getting hurt. She was asked, Did (CNA #2) tell anyone about the straps coming undone all the time? She stated, I'm not sure if she told anyone or not. She was asked, How were you loaded into the van on the date of the incident? She stated, (CNA #1) pulled me in backwards, strapped me in and jiggled the straps to ensure they were secure, and they were. She was asked, Then what happened? She stated, We were doing down the hill and there is a slight turn at the bottom of the hill. When she made that slight turn, the wheelchair strap became loose - it didn't catch - and it slung me around and I slid out of the wheelchair. I tried to pull myself up, but I couldn't. Most of my weight was on my left leg. My left foot was turned out and my knee was turned in; the ball of my foot was on the wheelchair foot pedal. (CNA #1) was trying to pull me up; she had to undo the strap around my neck, and she still couldn't get me up. The Activity Director got into the van to see what was going on and tried to climb across (Resident #5) to help get me up, but she couldn't do much with (Resident #5) there. The wheelchair was still locked in behind me, they unlocked it and moved it out of the way . They must have undone them (straps); I was sitting on top of them. They laid me down real slowly on the floor. I still had the lift sling under me. (CNA #1) called for more help; they called the ambulance. They couldn't get me into the ambulance, because we were on the side of a hill, so they had them take me to where it was level down by the (restaurant), and they placed a board under me and slid me out onto the lift, then onto the stretcher and took me to the hospital. She was asked, Have you been transported in the van since this incident? She stated, No, I was supposed to go to [MEDICAL TREATMENT] yesterday (4/18/18), but I was wheezing, and they sent me to the emergency room ; I came back the same day. g. On 4/19/18 at 11:10 a.m. the Administrator was asked, Who does the training for the placement/securing of residents in the van? She stated, I just did everybody in (MONTH) (2018). (CNA #1) was done in (MONTH) (2018). An outside contractor comes in one time a year. This was done (MONTH) 1, (YEAR). She was asked, How often do you monitor or spot check to see if they are doing it correctly? She stated, I just randomly checked at different times. I hadn't documented this or had them sign anything. She was asked, Who does the monitoring? She stated, I do. She was asked, Did you do any monitoring prior to the incident? She stated, Random, just watch them. Every year, they sign a new van policy and had to do return demonstrations and watch a video. She was asked, Who trained (CNA #1) on securing residents for transport? She stated, (CNA #1) was instructed by (CNA #2), the previous van driver. She has only taken the resident to [MEDICAL TREATMENT], which is a short distance from here. She was asked, When did (CNA #1) become the main van driver? She stated, She was the prn (as needed) driver in (MONTH) (2018). When (CNA #2) was suspended on 3/16/18, then later terminated on 3/21/18, I had her (CNA #1) take over. She was asked, When (CNA #1) took over, did she receive any training from anyone other than (CNA #2)? She stated, I went over the stuff in the van, like the fire extinguisher and first aid kit, with her. I did not watch her secure a resident at that time. I had observed her in (MONTH) (2018) with return demonstration. She was asked, How often is the van inspected and serviced for the mechanisms and straps? She stated, In training, by the contractor. They are also supposed to be checking that; part of their training is to inspect equipment before securing someone in the van. I believe the fact that the resident was secured sideways instead of the proper way is what ultimately led to the strap coming unlatched. It is not meant to be that way. She was asked, What does the outside contractor do when he comes? She stated, He provides an in-service to the staff that are responsible for driving the van. h. On 4/19/18 at 12:10 p.m. the Administrator provided a In-Service Training Sign-In Sheet from the van mobility company that documented, Presented by: (van mobility company instructor) Course: Correct Lift Operation/Properly Securing Residents Items Covered: correct operation of the lift, correct procedure for loading/unloading resident on lift, correctly securing resident with proper tie down procedures, manual operation of the lift, vehicle height and ensuring proper clearance for any type awning, covered driveway, parking garage, etc. date: 3/1/18, Facility Name Mt. (Mount) Vista. Attendance Record Employee name (please print) (Van Driver #1), (Maintenance Director), (CNA #2). The Administrator stated, (CNA #1) was not at the (MONTH) (2018) training conducted by the contractor. She was out with a sick child in the hospital. i. The facility removed the immediate jeopardy and corrected the failed practice on 4/12/18, as evidenced by the following: On 4/19/18 at 11:10 a.m. the Administrator was asked What did the facility do immediately after the incident in the van on 4/12/18? She stated, I had Maintenance check all the mechanisms, and I checked them also. She provided a document signed by the Maintenance Director and dated 4/12/18. She was asked, Have you done any monitoring since the incident? She stated, Yes, I have a calendar that we are documenting on. After the incident, I set up where transports would be monitored 5 times a week for 4 weeks, then 3 times a week for 4 weeks and prn (as needed) thereafter. The Administrator provided a calendar sheet for (MONTH) (YEAR) that had documentation indicating monitoring was being performed as scheduled. The Administrator also provided documentation of the following investigative and corrective actions that were taken after the incident: i.) The facility initiated an investigation of the incident immediately on 4/12/18. Witness statements and follow up interviews were obtained from the van driver, the volunteer, the resident, the Activity Director and the other 2 residents that were in the van at the time of the incident. A re-creation of the incident was demonstrated by CNA #1 and observed by the Administrator, DON, and Assistant DON (ADON). The Maintenance Director inspected all retractors, tracks, lap belts, and shoulder belts and all were determined to be functioning properly. ii.) An In-Service sheet dated 4/12/18 documented all van drivers and potential van drivers were retrained on Van Safety, including, .All residents that are transported in the van are required to be restrained properly! All residents who are transported in the van are required to wear a seat belt at all times! If a resident refuses to wear their seatbelt or utilize the restraint properly they are NOT to be transported in the van, and the van should not even move until all restraints are properly secured! .When a resident is being transported in the van, they ALWAYS should be forward facing! The restraint system is equipped to secure and protect the resident in the forward-facing position. Any other position is unsafe and placing the resident at risk for harm. All J hooks, retractors, and the lap and shoulder belt must be properly applied and secured to ensure the safety of residents who use wheelchairs for transport . Q-Straint Education Video was also shown with In-Service. iii.) On 4/13/18 through 4/16/18, all van drivers were required to perform return demonstration of loading and securing residents for transport and completing a transport wheelchair safety checklist. iv.) On 4/13/18, the Administrator implemented the following monitoring plan: Administrator/Designee will check all residents who will be transported on the facility van to ensure: 1) Wheelchair is observed forward facing and all 4 J hooks and retractors are observed attached at the proper locations 2) Wheelchair is observed to have maximum tension on all retractors preventing any movement in wheelchair 3) Lap and shoulder belt are observed for proper placement and tightness to ensure resident safety. All negative findings will be documented on the attached page and corrected immediately. Administrator/Designee will monitor 5 x a week for 4 weeks then 3 x week for 4 weeks and prn thereafter.

Complaint # , (AR 720), and # (AR 768) were substantiated (all or in part) in these findings. A. Based on record review and interview, the facility Administration and Nursing Administration failed to ensure licensed nursing staff were knowledgeable regarding the criteria for meeting the needs of a resident who had shown a tendency for suicide or verbalized feelings of being better off dead for 1 of 1 (Resident #5) case mix resident who verbalized she was going to kill herself and 1 of 1 (Resident #7) case mix resident who voiced feeling of being better off dead. The failed practices resulted immediate jeopardy which caused or could have caused serious harm, injury or death for Resident #5, who attempted suicide, Resident #7 who verbalized feelings of being better off dead and had the potential to affect 2 residents who voiced an intent to kill themselves since 9/1/15 according to a list provided by the Minimum Data Set (MDS) Coordinator on 10/23/15 and 8 residents who voiced feeling of being better off dead since 8/1/15 according to a list provided by the Nurse Consultant dated 10/28/15. The facility was notified of the Immediate Jeopardy condition on 10/22/15 at 4:25 p.m. The findings are: 1. The Administrator Job Description and Performance Standards documented: . Authority is delegated to the individual in this position to: Develop, maintain and implement operational policies and procedures to meet residents' 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. The primary functions and responsibilities of this position are as follows: . 3. Establish systems to enforce the facility policies and procedures . 8. Supervise all department supervisors and administrative staff . 10. Assume responsibility with department supervisors to implement effective policies and assure adequate staffing to meet facility needs . The Director of Nursing Services Job Description and Performance Standards documented: . Authority is delegated to individual in this position to: Assess resident needs and interview, hire and terminate adequate nursing personnel . Supervise and manage all aspects of the nursing department. Assess, direct and supervise resident's care needs . The primary functions and responsibilities of this position are as follows: . 3. Direct, evaluate and supervise all resident care and initiate corrective action as necessary. 4. Assess resident care needs and assist in the development of individualized plans of resident care . Direct and supervise scheduling of employees within established guidelines for allocation of nursing service personnel on duty . 2. Resident #5 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/2/15 documented the resident scored 10 (8 - 12 indicates moderately impaired) on the Brief Interview for Mental Status;, had no signs or symptoms of [MEDICAL CONDITION]; had no thoughts of better off dead; and scored 2 (1 - 4 indicates minimal depression) on the Patient Health Questionnaire. a. The Care Plan dated 4/3/15 and updated on 9/8/15 documented, I have behaviors . 9/8/15 I have voiced [MEDICAL CONDITION] . Approaches: . 9/8/15 Notify MD/APN (Medical Doctor/Advanced Practice Nurse) of my [MEDICAL CONDITION] . b. The Departmental Notes dated 9/8/15 at 8:42 p.m. and signed by Licensed Practical Nurse (LPN #2) documented, Resident crying and verbally aggressive toward staff. This nurse sat and talked with resident for 20 (minutes) in order to get resident to take her medications that included (Klonopin(used to treat Panic Disorder). Resident stated to this nurse and other staff that she was 'going to hang herself because she could not get out of here'. Resident placed on 1 on 1 monitoring for suicidal ideation, and administrator notified. c. The Departmental Notes dated 9/9/15 at 1:25 p.m. and signed by the Social Services Director (SSD) documented, Earlier on this date, SSD spoke with the resident regarding her statement of wanting to hang herself made on 9/8/15. The resident stated she did say that to staff. SSD interviewed the resident to complete the Geriatric Depression Scale. The resident score was 9. Due to the client's answers and responses, the clients depression only appears to be situational and possibly attention seeking. Administrator and Nurse Practitioner were notified of the scores. Further analysis will take place. On 10/22/15 at 10:55 a.m., the SSD was asked, The 9/9/15 entry in the Departmental Notes, what had happened? The SSD stated, I was told about (LPN # 2's report) and was told to see her and I went to do the Geriatric Depression Scale. The SSD was asked, What did you tell the Nurse Practitioner? The SSD stated, Everything (Resident # 5) was saying - 'I'll do whatever it takes to get out of here, whether it's jump the fence or kill myself'. I did tell (APN # 1) I would feel more comfortable if we referred this over to (name of Behavioral Health). (APN # 1) said yes. The SSD was asked, Did (Name of Behavioral Health) come out? The SSD stated, Yes. I was in the room when she refused. The SSD was asked, Did you tell (APN # 1) that (Resident # 5) had refused admission to behavioral health? The SSD stated, No. d. A SOAP (Subjective, Objective, Assessment and Plan) note dated 9/9/15 and signed by Advanced Practice Nurse (APN) #1 documented, . Chief Complaint: Patient has told staff that she plans to kill herself, I have been asked to see her. I know her very well and I have taken care of her since she first admitted to LTC (Long Term Care). Today she is in her room with her son. She is defiant and irrational. She will not deny a desire to harm herself. She is fixated on 'leaving'. No specific reason. She is delusional - saying (she) has the ability to get on a plane or in a car and move to California, where her son says she lived [AGE] years ago. I can't redirect her. Her mood is labile. Active Diagnoses: [REDACTED]. Mood - her mood has always been labile, she is frequently anxious and gets only periodically, she is confused today which is worse than usual, she is wild and I am not able to redirect her, her son is not, she threatens to harm herself but does not have a plan in mind. Objective: . Mood - she is anxious, she is having delusional thoughts of driving to California, getting a job, she will not contract for safety with me or her son. Plan: Suicidal threat - she is more confused than usual today, more delusional than I am used to seeing her. I thought I would easily get her to contract for safety but I can't. Her son is here - we discussed the spot she has put herself in by telling staff that she would kill herself. Since she will not retract or clarify the statement then I think it's in her best interest to go to an (in-patient) psych unit. The son is in agreement. I spoke to the social worker and to the acting DON (Director of Nursing) and asked them to make the referral. I expect them to come out today. Case (discussed with) Dr. (name of resident's attending physician, who is also the facility's Medical Director ) and he agrees with plan. e. The (Name) Behavioral Health Pre-Admission Screening form documented Date: 9/10/15. Time: 7:30 a.m. Responsible Party/Relationship: Self . Presenting Symptoms: . (Suicidal Ideation) . Depressed . Behavior: . Verbally aggressive . Summary: (Patient) has a history of Depression and Anxiety. (Patient) currently has passive death wish but no plan to commit suicide. (Nursing facility) reports suicidal statements . Physician Recommendations (and) Family/Guardian Response: . MSW (Medical Social Worker) recommends admission to (name of behavioral health), Dr. (name) has accepted (patient) . No Admission Indicated due to: (Patient) accepted for admission to (name of behavioral health) however (patient) is refusing to come and has no designee or family that will be surrogate . As of 10/19/15 at 1:35 p.m., there was no departmental note found in the clinical record that documented any family member had been contacted or that the Nurse Practitioner of Physician had been notified of the resident's refusal to be admitted to behavioral health unit on 9/10/14. f. A SOAP note dated 9/11/15 and signed by APN #1 documented, . Chief Complaint: Nurses tell me patient is still here, she is not saying she is going to kill herself but she is distressed, moody, anxious and delusional. She has been combative and refusing basic care. The nurse has asked me to review her meds and see what I can do to help her psychological distress. I did review her meds after taking to 3 nurses about her recent and current behaviors. See chart for order change . 1) A physician order [REDACTED]. 2) The One on One Contact Forms documented resident observations were started on 9/8/15 at 8:30 p.m. and resident observations stopped on 9/10/15 at 6:45 a.m. The CNA assignment sheets dated from 9/8/15 through 9/12/15 were reviewed. There was no staff member who was documented as providing 1 on 1 monitoring during this time. The assignment sheets for 9/12/15 for the 3:00 p.m. to 11:00 p.m. shift were reviewed. CNA #s 5, 11, and 12 were assigned to Resident # 5's hall on 9/12/15 for the 3:00 p.m. to 11:00 p.m. shift. There was no indication that any of these CNAs provided 1 on 1 monitoring of the resident during this time frame. g. The Departmental Notes dated 9/13/15 at 1:46 a.m. documented, This nurse was called to resident's room at 1715 (5:15 p.m. 9/12/15) by CNA (Certified Nurse Assistant). Upon entering the room, this nurse observed resident to be non-responsive with a cloth tied around her neck. This nurse immediately had another nurse call 911. We removed the cloth from around resident's neck and sternal rubbed her for about 4 minutes before getting her eyes to fluttering. Resident also noted to have a pair of scissors which later this nurse found that another resident had given them to her and assisted her in cutting the cloth. Resident came around and was fighting with CNAs to get cloth back to put back around her neck. CNAs kept a tight grip on cloth until EMTs (Emergency Medical Technicians) arrived. Ambulance arrived at 1725 (5:25 p.m.) along with (name of town Police Department) to do formal evaluation and reports. EMTs helped to get resident away from the closet when resident became very combative and cursing them. EMTs and officers asked resident multiple times if she wanted to harm herself and resident stated yes, she wanted to kill herself. EMT asked resident how she planned on doing this and resident stated that she was going to choke herself. EMTs took resident to ER after thorough investigation and report was done with resident. After the resident left the facility, this nurse had all staff on 3:00 p.m. to 11:00 p.m. do a witness statement whether they had contact with resident or not. After talking with some of the CNAs, they reported that this resident had been seen talking with another resident (Resident # 12). This nurse approached resident and asked if this resident had said anything to her about trying to kill herself. Resident stated that she was very emotional talking about wanting to get out of here. Resident also reported that she was talking about how her kids left her here to die and she would rather be dead. Resident also stated that (Resident # 5) had repeatedly mentioned that her husband had killed himself years ago by shooting himself in the head. When (Resident # 5) asked resident to cut the cloth, resident asked (Resident # 5) 'What are you going to do, hang yourself?' Resident said that (Resident # 5) began to cry even more. Resident did admit to helping (Resident # 5) cut the cloth but she said she had no idea why she wanted this done . Around 8:30 p.m. one of the nurses from (Behavioral health/geri-psych) called reported that resident had been admitted . 1) The (name) EMS (Emergency Medical Services) Patient Encounter form dated 9/12/15 documented, . Date: 9/12/15 . Reason for Transfer or Dispatch Reason: Attempted hanging . Time: 6:00 p.m. (Blood pressure) 163/96, (pulse) 100, (respirations) 20 . Chief Complaint: (Attempted) hanging. Edge of sheet around door knob and around neck, pushing back with legs in wheelchair . staff stated may have been (unresponsive) (prior to arrival) of EMS. Awake (and) alert (and) able to answer questions . 2) The (hospital) Emergency Department Record dated 9/12/15 at 6:04 p.m. documented, . Arrival Date/Time: 9/12/15 6:04 p.m . Stated Complaint: Attempted hanging . Physical Assessment . Glasgow Coma Scale . Eye opening: Spontaneous . Motor: Obeys commands . Verbal: Oriented . Per (Nursing Home), per EMS (Emergency Medical Services) (patient) tied cord of sheet around door knob, around neck and initially was pale and unresponsive. On arrival of EMS (patient) awake and alert, (patient) stated 'I want out of there', referring to (nursing home) . Patient Discharge or Departure: discharge date : 9/12/15. Discharge time: 8:22 p.m. Discharge order: Transfer to psych . 9/12/15 6:04 p.m. 5:57 p.m. actual arrival of (patient) . with alleged hanging from sheet at (nursing home) Per (nursing home) on their arrival (patient) was pale and unresponsive but on arrival of EMS, (patient) alert and awake. No visible signs of strangulation noted. No redness or marks visible. (Respirations) even and unlabored. (Patient) admits of intentionally attempted to hang self due to fact that she does not like the (nursing home) and does not want to reside there . 3) The Diagnostic Imaging Report documented . Visit Date: 9/12/15 . Exam: Cervical spine . Order (diagnosis): tried to hang self . Impression: . without evidence of hangman's fracture . h. The Resident Incident Report dated 9/12/15 at 5:15 p.m. documented, . Associate Involved: (CNA # 4) . This nurse was called to resident's room . Narrative of Investigation: . Upon investigation it was determined resident had attempted to hang herself utilizing cut up sheets where she place around her neck and tied to her closet door knob, where she then propped her lower extremities off the floor. Staff was previously in room [ROOM NUMBER] - 10 minutes before setting up dinner tray where resident got up from bed to eat dinner without any difficulties or irrational statements leading up to incident. Staff found resident unresponsive, called 911 immediately and removed sheets to arouse after noting she was not responding. Stayed with resident until EMS arrived. Resident had days before been assessed by a house visit from the Behavioral Health unit . Resident was a candidate for inpatient care due to previous behaviors and statements, but refused to go to receive treatment. Currently admitted to Behavioral unit. 6. New Intervention: In-service staff on [MEDICAL CONDITION] pending in-service from behavioral health representative with nurses on suicidal threats and interventions . On 10/21/15 at 2:55 p.m., CNA # 4 was asked, Have you ever worked with (Resident # 5)? CNA # 4 stated, Yes, that day she hung herself (9/12/15). I'm the one who found her that night. She was okay when she got her dinner and I was on call lights and found her. CNA #4 was asked, About what time was that? CNA # 4 stated, About 5:15 p.m. to 5:30 p.m., I walked past her room and I saw her in the corner by her dresser. She was between the closet door and her dresser. She had one end of the sheet tied around the closet door handle and the other end wrapped around her neck a couple of times. She had her feet pushing against the door and she was leaning back in the wheelchair with her head back and she was holding onto the sheet around her neck. CNA #4 was asked, She had a grip on the sheet when you found her? CNA # 4 stated, Yes and she didn't want to let it go. CNA #4 was asked, She had her legs straight and was pushing back from the door when you found her? CNA # 4 stated, Yes. CNA #4 was asked, Was she responsive? CNA #4 stated, No, it took 4 to 5 minutes for her to answer us. CNA #4 was asked, Was she still breathing and still had a pulse? CNA #4 stated, Yes. CNA #4 was asked, The only thing she wasn't doing was responding? CNA #4 stated, Yes and then she opened her eyes and said 'Leave me alone, I'm dying'. i. The Verification of Investigation form signed by the Administrator documented, . Date/Time of Occurrence: 9/12/15 7:00 p.m. Provided detailed description of event/allegation: Resident found hanging from a cut bed sheet on closet. Assessment of Resident/Describe Injury: Resident was found unresponsive with cut cloth around her neck. Causal/Contributing Factor and Observations: Resident asked another resident to cut the bed sheet and had expressed the desire to harm herself to the resident. Resident had been upset that her family had not been visiting as often as she thought they should have. She does not like living in Arkansas and wishes she had never came. Specific Recommendations/Interventions Taken to Prevent Reoccurrence: One on one with resident on alerting staff if a resident makes statements of self-harm. Offer the resident the opportunity to locate another facility if she chooses. Was Abuse/Neglect Substantiated? No. Provide Summary of Investigative Findings: Resident had been assessed by (name) Behavioral health on the 9th for placement for increased symptoms of depression. Placement was offered to resident but resident denied wanting placement. On 9/12/15, resident requested another resident cut a bed sheet for her and expressed an idea of wanting to die. Resident did not alert staff to (Resident # 5's) statement. Resident was found at 7:00 p.m. with material around her throat. Staff removed her from immediate harm and she remained one on one until EMS took over care for the resident. She was then taken to (hospital name) under a suicide hold. j. On 10/21/15 at 10:00 a.m., APN # 1 was asked, Was (Resident # 5) treated by you? APN stated, Yes. APN # 1 presented progress noted dated 9/9/15 and 9/11/15. APN # 1 was asked, Did you recommend that the resident was safe to stop the 1 to 1 monitoring? APN # 1 stated, No one asked me that. When I was there on 9/9/15 her family was there but no staff was present. She kept repeating she was going to kill herself and I recommended a psych referral. I told (Acting DON) and (SSD) that she needed an in-patient psych referral and someone did come out and they saw her. I did not know she was still in the building on Friday (9/11/15) until a nurse casually asked me to review her meds. I reviewed her meds and I didn't ask about the psych referral on Friday. APN # 1 was asked, Did you know the resident was not one on one on Friday, 9/11/15? APN # 1 stated, You are they first person to even ask me about one on one monitoring. No I was only asked to look at her meds. I was told she would not consent to the psych admit but I'm not sure if she (LPN # 4) said that on Friday (9/11/15) or Monday (9/14/15) after all that happened. The son had already consented and the resident was delusional so I don't know why she wasn't sent to the psych unit. On Monday (9/14/15) I was told by the nurses she had asked for scissors all day Saturday (9/12/15) and even got a resident to cut her sheets. She carried out a plan to commit suicide over the course of a day and that's very high level functioning. k. The Quality Assessment and Assurance Committee form dated 9/29/15, received from the Administrator on 10/22/15 at 3:00 p.m., documented, Topic: Note: Resident attempted suicide. Process Owner: All Departments. Summary of Analysis should include trends and root cause analysis: Improve documentation using the behavior monitoring sheets contained in MARs (Medication Administration Records). Review medical record for indications missed to show staff how to identify possible harm to resident before (it) gets to that point. Speak with (name) Behavioral (Health) on inservice to be conducted to include a better understanding of warning signs of suicidal thoughts in the elderly. Inservice with staff on more effective documentation in respect to resident behaviors and changes in condition. l. CNA interviews were conducted regarding one to one monitoring of Resident #5 from 9/8/15 - 9/12/15: 1) On 10/21/15 at 3:30 p.m., CNA # 6 was asked, Has any resident stated to you they were going to kill themselves? CNA # 6 stated Yes, just one. CNA #6 was asked, Who? CNA # 6 stated, (Resident # 5). We were at the nurses station and she said she wanted to go to California with her brother or son and then she said I'll just kill myself. CNA # 6 was asked, What happened after that? CNA #6 stated, We had to go in there every 15 minutes and check on her. CNA # 6 was asked Were you doing 1 to 1 or every 15 minute checks? CNA #6 stated, Every 15 minute checks, not 1 to 1. CNA # 6 was asked, What day was that? CNA #6 reviewed the One on One Contact Forms for 9/8/15 through 9/10/15. CNA #6 stated, I don't recall when she said that but I did every 15 minute checks on 9/9/15 at 3:45 p.m., 4:00 p.m., 4:30 p.m., 4:45 p.m., 5:00 p.m. and 9:15 p.m. 2) On 10/21/15 at 3:50 p.m., CNA #7 was asked, Has any resident stated to you they were going to kill themselves? CNA #7 stated Yes. CNA #7 was asked, Who? CNA #7 stated, (Resident # 5). CNA # 7 was asked, When? CNA #7 stated, About 2 weeks before she tried to hang herself. CNA #7 was asked, What did she say? CNA # 7 stated, That she was tired of being here so she was just going to kill herself. CNA #7 was asked, What did you do? CNA #7 stated, I told the nurse, she said it numerous times. I know (LPN # 2) is usually the nurse. CNA #7 was asked, What did the nurse do? CNA # 7 stated, Started every 15 minute checks . CNA #7 was asked to review the One on One Contact Forms from 9/8/15 to 9/10/15. CNA #7 was asked, Can you put a check mark by when you did checks? CNA # 7 put 5 check marks on 9/8/15 at 9:30 p.m., 9:45 p.m., 10:30 p.m., 10:45 p.m. and 11:00 p.m. CNA #7 stated, It was me and (CNA # 13) who went and told (LPN # 2) about it, then she stopped saying it. 3) On 10/22/15 at 6:43 a.m., CNA # 13 was asked, Has any resident stated to you they were going to kill themselves? CNA #13 stated, Yes, (Resident # 5). CNA #13 was asked, How often did she say that? CNA #13 stated, Once and I reported it to my nurse. CNA #13 was asked, Which nurse? CNA #13 stated, (LPN # 2). CNA #13 was asked, What did (LPN # 2) have you do? CNA #13 stated, We started on 1 to 1 and when she went to bed we did every 15 minute checks. I made sure her door was open and curtains pulled back so I could see her. CNA #13 was asked, Was that on 9/8/15? CNA # 13 reviewed the on One Contact Forms from 9/8/15 to 9/10/15. CNA # 13 stated, Yes, (initials) on here is me. CNA #13 initials were documented on 9/8/15 at 9:00 p.m., 9:15 p.m., 10:00 p.m. and 10:15 p.m. m. On 10/22/15 at 10:35 a.m. LPN # 4 stated she had been the Acting Assistant Director of Nurses (ADON) since August 2015. LPN # 4 was asked What do you know about (Resident # 5's) threats to kill herself? LPN # 4 stated I knew she had threatened to kill herself. LPN # 4 was asked What did the facility do to protect the resident? LPN # 4 stated Put resident 1 to 1 and I know (SSD) talked with her and I know someone from the hospital came in to talk with her. LPN # 4 was asked, When did the 1 to 1 end? LPN # 4 stated, I don't know when or why it was stopped. The Acting DON, (SSD) and Administrator were dealing with that. LPN # 4 was asked, When did you tell (APN # 1) that (Resident # 5) would not go to in-patient psych? LPN # 4 stated, That was after she'd tried to hang herself. n. On 10/22/15 at 12:27 p.m., the Administrator was asked, Did you know about the 9/8/15 happening documented by (LPN # 2) when (Resident # 5) threatened to hang herself? The Administrator stated, No. He told me she was crying and upset but not that she wanted to hang herself. The Administrator was asked, What was staff doing, monitoring (Resident # 5) 1 to 1 or every 15 minute checks? The Administrator stated I thought it was 1 to 1. This surveyor informed the Administrator that the 3:00 p.m. to 11:00 p.m. staff had stated they were doing every 15 minutes checks. The Administrator was asked, Is every 15 minute checks okay for a resident threatening to hang herself? The Administrator stated, No. The Administrator was asked, On 9/9/15 what did you know about this situation? The Administrator stated, That was when I told (SSD) she needed to talk with (APN # 1) about behavioral health and possible admit to geri-psych. The Administrator was asked, Geri-psych came on 9/10/15? The Administrator stated, Yes. The Administrator was asked, Did you know they recommended in-patient admission? The Administrator stated, Yes and that she had refused placement. The Administrator was asked, Why was the monitoring of (Resident # 5) stopped? The Administrator stated, Because she refused to go and the nurses did not see the geri-psych notes. The Administrator was asked, Who made the decision to stop the monitoring? Were you involved? The Administrator stated, No, I was not. The Administrator was asked, Who made the decision? The Administrator stated, I don't know. The Administrator was asked, Did anyone call you before they stopped it? The Administrator stated No. The Administrator was asked, Were you in the building on 9/10/15 and 9/11/15? The Administrator stated, Yes. The Administrator was asked, Who was in charge of nursing? The Administrator stated, (Acting DON # 1). The Administrator was asked, Were you informed on 9/12/15 when the resident attempted to hang herself? The Administrator stated, Yes. The Administrator was asked, What's been done since this to prevent re-occurrence? The Administrator stated, We did an in-service on reporting increased symptoms of depression. We started a behavior monitoring sheet. We started that this month and who the nurse needed to report increased behaviors to. The Administrator was asked, Why do in-services on reporting increased behaviors when they did that? There was no response from the Administrator. This surveyor requested copies of the in-services. 1) On 10/22/15 at 1:55 p.m., Acting DON # 1 stated she was the DON from August through 10/14/15. Acting DON # 1 was asked, Did (Resident # 5) threaten to kill herself? Acting DON # 1 stated, Yes. Acting DON #1 was asked, What were you doing to monitor the resident for suicide attempts? Acting DON # 1 stated, It was supposed to be 1 to 1 monitoring but maybe the CNAs got confused and only did every 15 minute checks. Acting DON # 1 was asked, Who made the decision to stop the 1 to 1 or every 15 minute monitoring? Acting DON # 1 stated, I don't know. Acting DON # 1 was asked, Were you working 9/10/15 and 9/11/15? Acting DON # 1 stated, Yes. Acting DON # 1 was asked, Did anyone ask you if they could stop monitoring (Resident # 5)? Acting DON # 1 stated, No. Acting DON #1 was asked, Did you know the monitoring was stopped with (Resident # 5) prior to psych seeing the resident? Acting DON # 1 stated, No. Acting DON # 1 was asked, Who did the CNA assignments? Acting DON # 1 stated, The charge nurses or (LPN # 5). 2) On 10/22/15 at 2:20 p.m., LPN #5 was asked, Do you complete the 7:00 a.m. to 3:00 p.m. assignment sheets? LPN # 5 stated, If I have time, sometimes the nurses do it. There is no one assigned to fill it out. LPN # 5 was asked, Did you know about (Resident # 5) threatening to hang herself on 9/8/15? LPN #5 stated, Yes. I was working that night on C and D halls and (LPN # 2) told me what happened and I told him he better call (Administrator) and see what to do. I filled out the 9/10/15 3:00 p.m. to 11:00 p.m. assignment sheet and I didn't know she was 1 to 1 and I didn't make her 1 to 1 on the 11th and I did the 9/12/15 assignments and I didn't assign 1 to 1. When the resident refused to go to psych I was under the impression it was over and I was never told she was 1 to 1. If she had been 1 to 1 there would be 1:1 with a CNAs name. I know in stand up (Administrator) said the psych person came and she refused to go and made her own decision so we are covered. There was nothing said about 1 to 1. That was on 9/11/15. LPN # 5 was asked to review the One on One Contact Forms and the assignment sheets from 9/8/15 through 9/12/15 for indications of 1 to 1 monitoring. LPN # 5 stated, There was no one assigned to do 1 to 1 from 9/8/15 through 9/12/15 and her monitoring stopped on 9/10/15 at 6:45 a.m. o. On 10/23/15 at 5:15 p.m. the Administrator was asked, Who should have ensured the monitoring was 1 to 1 for (Resident # 5) and that it was in place and stayed in place? The Administrator stated, The DON at that time and I should have made sure she was doing that. The Administrator was asked, Do you have any documented in-services that were done since (Resident # 5) attempted to hang herself on notification or suicidal ideation, (et cetera) prior to 10/22/15?' The Administrator stated, No. 3. Resident # 7 had [DIAGNOSES REDACTED]. The Departmental Note dated 8/5/15 at 9:24 a.m. documented, New order received per (Advanced Practice Nurse (APN) # 1) to decrease [MEDICATION NAME] (anti-depressant) to 5 (milligrams) (per mouth) at bedtime . The Quarterly MDS with an ARD of 8/28/15 documented the resident scored 14 (13 - 15 indicates cognitively intact) on the Brief Interview for Mental Status, had thoughts of better off dead on 12 - 14 days (nearly every day), had a safety notification completed, and scored 12 (10 - 14 indicates moderate depression) on a Patient Health Questionnaire . The Signature of Person Completing the Assessment documented the Social Service Director (SSD) completed Section D Mood of the MDS on 8/28/15. a. On 10/22/15 at 10:55 a.m., the SSD was asked, For the MDS done 8/28/15, you completed the Mood Section? The SSD stated, Yes. The SSD was asked, Did the resident state he was having thoughts of being better off dead and he said this occurred almost daily? The SSD stated, Yes. The SSD was asked, Did you do a safety notification? The SSD stated, I told the hall (charge) nurse. I know now that I need to tell (Administrator) and (DON) and (APN # 1). I learned that yesterday (10/21/15). The SSD was asked, Did he verbalize any plan for suicide? The SSD stated, No he said he was jealous of his roommate and could not understand why his wife did not visit him. The SSD was asked, Did you go back and monitor (Resident # 7) after 8/28/15? The SSD stated Yes but I didn't document it. b. The Departmental Notes dated 8/28/15 at 3:32 p.m. and electronically signed by LPN # 1 contained no documentation to indicate the resident stated he would be better off dead. c. The Care Plan dated 8/2/13, reviewed on 9/1/15, documented, I am at risk for side effects from antidepressant/antianxiety medication use for a history of depression . Approaches: . Observe and record my target behaviors . There was no updated Plan of Care to address the reported thoughts of better dead that occurred nearly every day. d. As of 10/20/15 at 3:19 p.m., there was no documentation in the Departmental Notes dated 8/28/15 through 10/16/15 of the resident ' s mood, monitoring for further statements that the resident would be better off dead or assessment to determine if the resident had thoughts of suicide or a plan for suicide. e. On 10/21/15 at 11:35 a.m., Advanced Practice Nurse (APN) # 1 was asked, Were you told (Resident # 7) had expressed feelings of being better off dead on 8/28/15? APN # 1 stated, I don't think so I would have done an intervention for that. I was asked on 8/31/15 to clarify

Complaint # , (AR 720), was substantiated (all or in part) in these findings. Based on record review and interview, the facility failed to ensure the physician was immediately consulted regarding significant changes in mental or psychosocial status for 1 of 1 (Residents #5) case mix resident who voiced an intent to commit suicide and 1 of 1 (Resident # 7) case mix resident who voiced feelings of being better off dead. The facility failed to ensure the physician was immediately consulted regarding resident ' s refusal for treatment for 1 of 1 (Resident #5) case mix resident who had voiced an intent to kill self and refused admission to a behavioral unit. The failed practices resulted in immediate jeopardy which caused or could have caused serious harm, injury or death to Resident # 5, who had voiced her intent to hang herself and was found unresponsive following a hanging attempt after one on one monitoring was discontinued with her refusal to be admitted to a Behavioral Health Care Unit, Resident #7 who voiced feelings of being better off dead and had the potential to affect 2 residents in the facility who had stated an intent to kill themselves since 9/1/15 according to the listing received from the Minimum Data Set (MDS) Coordinator on 10/23/15, 3 residents with physician orders [REDACTED]. The facility was notified of the Immediate Jeopardy condition on 10/22/15 at 4:25 p.m. The findings are: 1. The facility's policy titled Change in a Resident's Condition or Status documented . 1. The Nurse Supervisor/Charge Nurse will notify the resident's Attending Physician or On-Call Physician when there has been: . d. A significant change in the resident's physical/emotional/mental condition; . f. Refusal of treatment . 2. A 'significant change' of condition is a decline or improvement in the resident's status that: a. Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions . c. Requires interdisciplinary review and/or revision to the care plan . 2. Resident #5 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/2/15 documented the resident scored 10 (8 - 12 indicates moderately impaired) on the Brief Interview for Mental Status;, had no signs or symptoms of [MEDICAL CONDITION]; had no thoughts of better off dead; and scored 2 (1 - 4 indicates minimal depression) on the Patient Health Questionnaire. a. The Care Plan dated 4/3/15 and updated on 9/8/15 documented, I have behaviors . 9/8/15 I have voiced [MEDICAL CONDITION] . Approaches: . 9/8/15 Notify MD/APN (Medical Doctor/Advanced Practice Nurse) of my [MEDICAL CONDITION] . b. The Departmental Notes dated 9/8/15 at 8:42 p.m. and signed by Licensed Practical Nurse (LPN #2) documented, Resident crying and verbally aggressive toward staff. This nurse sat and talked with resident for 20 (minutes) in order to get resident to take her medications that included (Klonopin) (used to treat Panic Disorder). Resident stated to this nurse and other staff that she was 'going to hang herself because she could not get out of here'. Resident placed on 1 on 1 monitoring for suicidal ideation, and administrator notified. 1) On 10/23/15 at 9:00 a.m., APN # 1 was asked, On 9/8/15 the 3:00 p.m. to 11:00 p.m. charge nurse documented that the Administrator was notified of (Resident # 5's) statement that she was going to hang herself. Were you notified? APN # 1 stated, No, and my husband is her doctor and was not notified either. The first I heard of it was when I walked in the building on 9/9/15 and I saw her and recommended an in-patient psych admit. 2) On 10/23/15 at 10:12 a.m., the residents attending physician was asked, Were you notified on 9/8/15 of (Resident # 5's) statement that she was going to hang herself? Resident # 5's attending physician stated, No. c. The Departmental Notes dated 9/9/15 at 1:25 p.m. and signed by the Social Services Director (SSD) documented, Earlier on this date, SSD spoke with the resident regarding her statement of wanting to hang herself made on 9/8/15. The resident stated she did say that to staff. SSD interviewed the resident to complete the Geriatric Depression Scale. The resident score was 9. Due to the client's answers and responses, the clients depression only appears to be situational and possibly attention seeking. Administrator and Nurse Practitioner were notified of the scores. Further analysis will take place. On 10/22/15 at 10:55 a.m., the SSD was asked, The 9/9/15 entry in the Departmental Notes, what had happened? The SSD stated, I was told about (LPN # 2's report) and was told to see her and I went to do the Geriatric Depression Scale. The SSD was asked, What did you tell the Nurse Practitioner? The SSD stated, Everything (Resident # 5) was saying - 'I'll do whatever it takes to get out of here, whether it's jump the fence or kill myself'. I did tell (APN # 1) I would feel more comfortable if we referred this over to (name of Behavioral Health). (APN # 1) said yes. The SSD was asked, Did (Name of Behavioral Health) come out? The SSD stated, Yes. I was in the room when she refused. The SSD was asked, Did you tell (APN # 1) that (Resident # 5) had refused admission to behavioral health? The SSD stated, No. d. A SOAP (Subjective, Objective, Assessment and Plan) note dated 9/9/15 and signed by Advanced Practice Nurse (APN) #1 documented, . Chief Complaint: Patient has told staff that she plans to kill herself, I have been asked to see her. I know her very well and I have taken care of her since she first admitted to LTC (Long Term Care). Today she is in her room with her son. She is defiant and irrational. She will not deny a desire to harm herself. She is fixated on 'leaving'. No specific reason. She is delusional - saying (she) has the ability to get on a plane or in a car and move to California, where her son says she lived [AGE] years ago. I can't redirect her. Her mood is labile. Active Diagnoses: [REDACTED]. Mood - her mood has always been labile, she is frequently anxious and gets only periodically, she is confused today which is worse than usual, she is wild and I am not able to redirect her, her son is not, she threatens to harm herself but does not have a plan in mind. Objective: . Mood - she is anxious, she is having delusional thoughts of driving to California, getting a job, she will not contract for safety with me or her son. Plan: Suicidal threat - she is more confused than usual today, more delusional than I am used to seeing her. I thought I would easily get her to contract for safety but I can't. Her son is here - we discussed the spot she has put herself in by telling staff that she would kill herself. Since she will not retract or clarify the statement then I think it's in her best interest to go to an (in-patient) psych unit. The son is in agreement. I spoke to the social worker and to the acting DON (Director of Nursing) and asked them to make the referral. I expect them to come out today. Case (discussed with) Dr. (name of resident's attending physician, who is also the facility's Medical Director) and he agrees with plan. e. The (Name) Behavioral Health Pre-Admission Screening form documented Date: 9/10/15. Time: 7:30 a.m. Responsible Party/Relationship: Self . Presenting Symptoms: . (Suicidal Ideation) . Depressed . Behavior: . Verbally aggressive . Summary: (Patient) has a history of Depression and Anxiety. (Patient) currently has passive death wish but no plan to commit suicide. (Nursing facility) reports suicidal statements . Physician Recommendations (and) Family/Guardian Response: . MSW (Medical Social Worker) recommends admission to (name of behavioral health), Dr. (name) has accepted (patient) . No Admission Indicated due to: (Patient) accepted for admission to (name of behavioral health) however (patient) is refusing to come and has no designee or family that will be surrogate . As of 10/19/15 at 1:35 p.m., there was no departmental note found in the clinical record that documented any family member had been contacted or that the Nurse Practitioner or Physician had been notified of the resident's refusal to be admitted to behavioral health unit on 9/10/14. The One on One Contact Forms documented residents observations were started on 9/8/15 at 8:30 p.m. and resident observations stopped on 9/10/15 at 6:45 a.m. f. A SOAP note dated 9/11/15 and signed by APN #1 documented, . Chief Complaint: Nurses tell me patient is still here, she is not saying she is going to kill herself but she is distressed, moody, anxious and delusional. She has been combative and refusing basic care. The nurse has asked me to review her meds and see what I can do to help her psychological distress. I did review her meds after taking to 3 nurses about her recent and current behaviors. See chart for order change . A physician order [REDACTED]. g. The Departmental Notes dated 9/13/15 at 1:46 a.m. documented, This nurse was called to resident's room at 1715 (5:15 p.m. 9/12/15) by CNA (Certified Nurse Assistant). Upon entering the room, this nurse observed resident to be non-responsive with a cloth tied around her neck. This nurse immediately had another nurse call 911. We removed the cloth from around resident's neck and sternal rubbed her for about 4 minutes before getting her eyes to fluttering. Resident also noted to have a pair of scissors which later this nurse found that another resident had given them to her and assisted her in cutting the cloth. Resident came around and was fighting with CNAs to get cloth back to put back around her neck. CNAs kept a tight grip on cloth until EMTs (Emergency Medical Technicians) arrived. Ambulance arrived at 1725 (5:25 p.m.) along with (name of town Police Department) to do formal evaluation and reports. EMTs helped to get resident away from the closet when resident became very combative and cursing them. EMTs and officers asked resident multiple times if she wanted to harm herself and resident stated yes, she wanted to kill herself. EMT asked resident how she planned on doing this and resident stated that she was going to choke herself. EMTs took resident to ER after thorough investigation and report was done with resident. After the resident left the facility, this nurse had all staff on 3:00 p.m. to 11:00 p.m. do a witness statement whether they had contact with resident or not. After talking with some of the CNAs, they reported that this resident had been seen talking with another resident (Resident # 12). This nurse approached resident and asked if this resident had said anything to her about trying to kill herself. Resident stated that she was very emotional talking about wanting to get out of here. Resident also reported that she was talking about how her kids left her here to die and she would rather be dead. Resident also stated that (Resident # 5) had repeatedly mentioned that her husband had killed himself years ago by shooting himself in the head. When (Resident # 5) asked resident to cut the cloth, resident asked (Resident # 5) 'What are you going to do, hang yourself?' Resident said that (Resident # 5) began to cry even more. Resident did admit to helping (Resident # 5) cut the cloth but she said she had no idea why she wanted this done . Around 8:30 p.m. one of the nurses from (Behavioral health/geri-psych) called reported that resident had been admitted . 1) The (name) EMS (Emergency Medical Services Patient Encounter form dated 9/12/15 documented, . Date: 9/12/15 . Reason for Transfer or Dispatch Reason: Attempted hanging . Time: 6:00 p.m. (Blood pressure) 163/96, (pulse) 100, (respirations) 20 . Chief Complaint: (Attempted) hanging. Edge of sheet around door knob and around neck, pushing back with legs in wheelchair . staff stated may have been (unresponsive) (prior to arrival) of EMS. Awake (and) alert (and) able to answer questions . 2) The Resident Incident Report dated 9/12/15 at 5:15 p.m. documented, . Associate Involved: (CNA # 4) . This nurse was called to resident's room . Narrative of Investigation: . Upon investigation it was determined resident had attempted to hang herself utilizing cut up sheets where she place around her neck and tied to her closet door knob, where she then propped her lower extremities off the floor. Staff was previously in room [ROOM NUMBER] - 10 minutes before setting up dinner tray where resident got up from bed to eat dinner without any difficulties or irrational statements leading up to incident. Staff found resident unresponsive, called 911 immediately and removed sheets to arouse after noting she was not responding. Stayed with resident until EMS arrived. Resident had days before been assessed by a house visit from the Behavioral Health unit . Resident was a candidate for inpatient care due to previous behaviors and statements, but refused to go to receive treatment. Currently admitted to Behavioral unit. 6. New Intervention: In-service staff on [MEDICAL CONDITION] pending in-service from behavioral health representative with nurses on suicidal threats and interventions . 3) The Verification of Investigation form signed by the Administrator documented, . Date/Time of Occurrence: 9/12/15 7:00 p.m. Provided detailed description of event/allegation: Resident found hanging from a cut bed sheet on closet. Assessment of Resident/Describe Injury: Resident was found unresponsive with cut cloth around her neck. Causal/Contributing Factor and Observations: Resident asked another resident to cut the bed sheet and had expressed the desire to harm herself to the resident. Resident had been upset that her family had not been visiting as often as she thought they should have. She does not like living in Arkansas and wishes she had never came. Specific Recommendations/Interventions Taken to Prevent Reoccurrence: One on one with resident on alerting staff if a resident makes statements of self-harm. Offer the resident the opportunity to locate another facility if she chooses. Was Abuse/Neglect Substantiated? No. Provide Summary of Investigative Findings: Resident had been assessed by (name) Behavioral health on the 9th for placement for increased symptoms of depression. Placement was offered to resident but resident denied wanting placement. On 9/12/15, resident requested another resident cut a bed sheet for her and expressed an idea of wanting to die. Resident did not alert staff to (Resident # 5's) statement. Resident was found at 7:00 p.m. with material around her throat. Staff removed her from immediate harm and she remained one on one until EMS took over care for the resident. She was then taken to (hospital name) under a suicide hold. h. On 10/21/15 at 10:00 a.m., APN # 1 was asked, Was (Resident # 5) treated by you? APN stated, Yes. APN # 1 presented progress noted dated 9/9/15 and 9/11/15. APN # 1 was asked, Did you recommend that the resident was safe to stop the 1 to 1 monitoring? APN # 1 stated, No one asked me that. When I was there on 9/9/15 her family was there but no staff was present. She kept repeating she was going to kill herself and I recommended a psych referral. I told (Acting DON) and (SSD) that she needed an in-patient psych referral and someone did come out and they saw her. I did not know she was still in the building on Friday (9/11/15) until a nurse casually asked me to review her meds. I reviewed her meds and I didn't ask about the psych referral on Friday. APN # 1 was asked, Did you know the resident was not one on one on Friday, 9/11/15? APN # 1 stated, You are they first person to even ask me about one on one monitoring. No I was only asked to look at her meds. I was told she would not consent to the psych admit but I'm not sure if she (LPN # 4) said that on Friday (9/11/15) or Monday (9/14/15) after all that happened. The son had already consented and the resident was delusional so I don't know why she wasn't sent to the psych unit. On Monday (9/14/15) I was told by the nurses she had asked for scissors all day Saturday (9/12/15) and even got a resident to cut her sheets. She carried out a plan to commit suicide over the course of a day and that's very high level functioning. i. The Quality Assessment and Assurance Committee form dated 9/29/15, received from the Administrator on 10/22/15 at 3:00 p.m., documented, Topic: Note: Resident attempted suicide. Process Owner: All Departments. Summary of Analysis should include trends and root cause analysis: Improve documentation using the behavior monitoring sheets contained in MARs (Medication Administration Records). Review medical record for indications missed to show staff how to identify possible harm to resident before (it) gets to that point. Speak with (name) Behavioral (Health) on inservice to be conducted to include a better understanding of warning signs of suicidal thoughts in the elderly. Inservice with staff on more effective documentation in respect to resident behaviors and changes in condition. j. On 10/20/15 at 9:20 a.m. the Administrator was asked for any [MEDICATION NAME] for Resident # 5. The Administrator stated, We did an internal investigation after she attempted to hang herself. We had behavioral health come out and see and they recommended admission. She refused. Her BIMS was 15 and she refused to go. She had the right to refuse. k. On 10/22/15 at 10:35 a.m., LPN # 4 stated she had been the Acting Assistant Director of Nurses (ADON) since August 2015. LPN # 4 was asked, What do you know about (Resident # 5's) threats to kill herself? LPN # 4 stated, I knew she had threatened to kill herself. LPN #4 was asked, When did you tell (APN # 1) that (Resident # 5) would not go to in-patient psych? LPN # 4 stated That was after she'd tried to hang herself. l. On 10/22/15 at 12:27 p.m., the Administrator was asked, Did you know about the 9/8/15 happening documented by (LPN # 2) when (Resident # 5) threatened to hang herself? The Administrator stated, No. He told me she was crying and upset but not that she wanted to hang herself. The Administrator was asked, On 9/9/15 what did you know about this situation? The Administrator stated, That was when I told (SSD) she needed to talk with (APN # 1) about behavioral health and possible admit to geri-psych. The Administrator was asked, Geri-psych came on 9/10/15? The Administrator stated Yes. The Administrator was asked, Did you know they recommended in-patient admission? The Administrator stated, Yes and that she had refused placement. The Administrator was asked, Were you informed on 9/12/15 when the resident attempted to hang herself? The Administrator stated, Yes. The Administrator was asked, What's been done since this to prevent re-occurrence? The Administrator stated, We did an in-service on reporting increased symptoms of depression. We started a behavior monitoring sheet. We started that this month and who the nurse needed to report increased behaviors to. The Administrator was asked, Why do in-services on reporting increased symptoms when they did that? There was no response from the Administrator. This surveyor requested copies of the in-services. The Administrator was asked, Were you notified on 9/8/15 as per the departmental notes? The Administrator stated, No. The Administrator was asked, Who else needed to be notified on 9/8/15? The Administrator stated The DON, the doctor and her family. The Administrator was asked Do you know if (APN # 1) or physician were asked before the 1 to 1/every 15 minutes checks were stopped or when the resident refused admit to geri-psych? The Administrator stated No. m. On 10/23/15 at 5:15 p.m., the Administrator was asked, Do you have any documented in-services that were done since (Resident # 5) attempted to hang herself on notification or suicidal ideation, etc. prior to 10/22/15? The Administrator stated, No. 2. Resident # 7 had [DIAGNOSES REDACTED]. The Quarterly MDS with an ARD of 8/28/15 documented the resident scored 14 (13 - 15 indicates cognitively intact) on the Brief Interview for Mental Status, had thoughts of better off dead on 12 - 14 days (nearly every day), had a safety notification completed, and scored 12 (10 - 14 indicates moderate depression) on a Patient Health Questionnaire . The Signature of Person Completing the Assessment documented the Social Service Director (SSD) completed Section D Mood of the MDS on 8/28/15. a. On 10/22/15 at 10:55 a.m., the SSD was asked, For the MDS done 8/28/15, you completed the Mood Section? The SSD stated, Yes. The SSD was asked, Did the resident state he was having thoughts of better off dead and he said this occurred almost daily? The SSD stated, Yes. The SSD was asked, Did you do a safety notification? The SSD stated, I told the hall (charge) nurse. I know now that I need to tell (Administrator) and (DON) and (APN # 1). I learned that yesterday (10/21/15). The SSD was asked, Did he verbalize any plan for suicide? The SSD stated, No he said he was jealous of his roommate and could not understand why his wife did not visit him. The SSD was asked, Did you go back and monitor (Resident # 7) after 8/28/15? The SSD stated Yes but I didn't document it. b. The Departmental Notes dated 8/28/15 at 3:32 p.m. and electronically signed by LPN # 1 contained no documentation to indicate the resident stated he would be better off dead. c. On 10/21/15 at 2:07 p.m., LPN # 1 was asked, Has any resident stated to you they were going to kill themselves? LPN # 1 stated No, but (Resident # 7) says 'Sometimes I feel like I'd be better off dead'. LPN # 1 was asked How long ago did he say that? LPN # 1 stated Several months ago. It was only once and I contacted Social and we monitored him for several days and he never said anything after that. LPN # 1 was asked, Did you tell the physician or the Advance Practice Nurse? LPN # 1 stated, No. d. On 10/21/15 at 11:35 a.m., APN # 1 was asked, Were you told (Resident # 7) had expressed feelings of being better off dead on 8/28/15? APN # 1 stated, I don't think so I would have done an intervention for that. I was asked on 8/31/15 to clarify his ICD 10 (International Statistical Classification of Diseases and Related Health Problems) [DIAGNOSES REDACTED]. I wasn't told anything about expression of better off dead. 4. The Immediate Jeopardy was removed and the scope/severity reduced to H on 10/22/15 at 5:00 p.m. when the facility implemented the following Plan of Removal: 1) Beginning on 10/22/15 at 5:00 p.m., residents in the facility were assessed for statements regarding being better off dead or statements of intent of self-harm by completing the PHQ 9 from MDS 3.0 section D for all residents who had not had the PHQ 9 completed since 10/19/15. There were 6 residents who answered yes to thoughts of being better off dead. There was one resident that stated yes to intent to commit self-harm. Seven residents were immediately placed on one-on-one monitoring and the physician was immediately notified. The one resident who answered yes to the question of intent to commit self-harm was transferred out to (name of hospital) behavioral health on 10/22/15 at approximately 8:00 p.m. 2) All nursing staff was in-serviced beginning on 10/22/15 at 10:00 p.m. and training will be ongoing to include new hires and staff returning from leave. Training will take place before staff works on the floor. Training will be done by CEO (Chief Executive Officer)/DON/Designee and in-service sign in sheets used. Training will include that all residents who answer yes to being better off dead (will) have further questioning to determine if they intend to commit self-harm. If the resident states they would be better off dead but have no ideation of self-harm, the nurse will provide notification to the physician of the resident's mood status. If the resident states they intend to commit self-harm then the resident will immediately be placed on one on one monitoring and physician will be immediately notified. Additionally, staff will notify the DON and CEO when the resident answers yes to better off dead or intent for self-harm. Licensed staff will document (every) shift regarding the resident's mood status. This training will be done by the CEO/DON/Designee. 3) On 10/22/15 at 10:00 a.m., a one on one in-service was completed with the Social Service Director by the MDS Consultant regarding the above. 4) The DON/Designee will ensure that one-on-one is initiated immediately following a resident's statement to commit self-harm and that physician is notified of the intent to harm self. The DON/Designee will assess nursing notes daily to ensure that one on one monitoring is continued, further notification is made to the physician prn (as needed), and that documentation is completed (every) shift for the resident's current mood status and any continued verbiage of intent of self-harm. Monitoring will be ongoing daily for thirty days. If any negative findings are identified, they will be reported immediately to the DON/Designee and/or CEO and corrective action will be taken. All documentation will be reviewed for completeness.

Complaint # , (AR 720), was substantiated (all or in part) in these findings. Based on record review and interview, the facility failed to ensure necessary care and services were provided Residents #5 and #7 to attain or maintain the highest practicable physical and mental well-being, in accordance with the plan of care and acceptable standards of practice. The facility failed to ensure the physician was immediately consulted regarding significant changes in mental or psychosocial status for 1 of 1 (Residents #5) case mix resident who voiced an intent to commit suicide and 1 of 1 (Resident # 7) case mix resident who voiced feelings of being better off dead. The facility failed to ensure the physician was immediately consulted regarding resident ' s refusal for treatment for 1 of 1 (Resident #5) case mix resident who had voiced an intent to kill self and refused admission to a behavioral unit. The facility failed to ensure ongoing one on one monitoring was provided after a verbal threat to commit suicide for 1 of 1 (Residents #5) case mix resident who threatened suicide. The failed practices resulted in immediate jeopardy which caused or could have caused serious harm, injury or death to Resident # 5, who had voiced her intent to hang herself and was found unresponsive following a hanging attempt after one on one monitoring was discontinued with her refusal to be admitted to a Behavioral Health Care Unit, Resident #7 who voiced feelings of being better off dead and had the potential to affect 2 residents in the facility who had stated an intent to kill themselves since 9/1/15 according to the listing received from the Minimum Data Set (MDS) Coordinator on 10/23/15, 3 residents with physician orders [REDACTED]. The facility was notified of the Immediate Jeopardy condition on 10/22/15 at 4:25 p.m. The findings are: 1. Resident #5 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/2/15 documented the resident scored 10 (8 - 12 indicates moderately impaired) on the Brief Interview for Mental Status;, had no signs or symptoms of [MEDICAL CONDITION]; had no thoughts of better off dead; and scored 2 (1 - 4 indicates minimal depression) on the Patient Health Questionnaire. a. The Care Plan dated 4/3/15 and updated on 9/8/15 documented, I have behaviors . 9/8/15 I have voiced [MEDICAL CONDITION] . Approaches: . 9/8/15 Notify MD/APN (Medical Doctor/Advanced Practice Nurse) of my [MEDICAL CONDITION] . b. The Departmental Notes dated 9/8/15 at 8:42 p.m. and signed by Licensed Practical Nurse (LPN #2) documented, Resident crying and verbally aggressive toward staff. This nurse sat and talked with resident for 20 (minutes) in order to get resident to take her medications that included (Klonopin(used to treat Panic Disorder). Resident stated to this nurse and other staff that she was 'going to hang herself because she could not get out of here'. Resident placed on 1 on 1 monitoring for suicidal ideation, and administrator notified. c. The Departmental Notes dated 9/9/15 at 1:25 p.m. and signed by the Social Services Director (SSD) documented, Earlier on this date, SSD spoke with the resident regarding her statement of wanting to hang herself made on 9/8/15. The resident stated she did say that to staff. SSD interviewed the resident to complete the Geriatric Depression Scale. The resident score was 9. Due to the client's answers and responses, the clients depression only appears to be situational and possibly attention seeking. Administrator and Nurse Practitioner were notified of the scores. Further analysis will take place. On 10/22/15 at 10:55 a.m., the SSD was asked, The 9/9/15 entry in the Departmental Notes, what had happened? The SSD stated, I was told about (LPN # 2's report) and was told to see her and I went to do the Geriatric Depression Scale. The SSD was asked, What did you tell the Nurse Practitioner? The SSD stated, Everything (Resident # 5) was saying - 'I'll do whatever it takes to get out of here, whether it's jump the fence or kill myself'. I did tell (APN # 1) I would feel more comfortable if we referred this over to (name of Behavioral Health). (APN # 1) said yes. The SSD was asked, Did (Name of Behavioral Health) come out? The SSD stated, Yes. I was in the room when she refused. The SSD was asked, Did you tell (APN # 1) that (Resident # 5) had refused admission to behavioral health? The SSD stated, No. d. A SOAP (Subjective, Objective, Assessment and Plan) note dated 9/9/15 and signed by Advanced Practice Nurse (APN) #1 documented, . Chief Complaint: Patient has told staff that she plans to kill herself, I have been asked to see her. I know her very well and I have taken care of her since she first admitted to LTC (Long Term Care). Today she is in her room with her son. She is defiant and irrational. She will not deny a desire to harm herself. She is fixated on 'leaving'. No specific reason. She is delusional - saying (she) has the ability to get on a plane or in a car and move to California, where her son says she lived [AGE] years ago. I can't redirect her. Her mood is labile. Active Diagnoses: [REDACTED]. Mood - her mood has always been labile, she is frequently anxious and gets only periodically, she is confused today which is worse than usual, she is wild and I am not able to redirect her, her son is not, she threatens to harm herself but does not have a plan in mind. Objective: . Mood - she is anxious, she is having delusional thoughts of driving to California, getting a job, she will not contract for safety with me or her son. Plan: Suicidal threat - she is more confused than usual today, more delusional than I am used to seeing her. I thought I would easily get her to contract for safety but I can't. Her son is here - we discussed the spot she has put herself in by telling staff that she would kill herself. Since she will not retract or clarify the statement then I think it's in her best interest to go to an (in-patient) psych unit. The son is in agreement. I spoke to the social worker and to the acting DON (Director of Nursing) and asked them to make the referral. I expect them to come out today. Case (discussed with) Dr. (name of resident's attending physician, who is also the facility's Medical Director ) and he agrees with plan. e. The (Name) Behavioral Health Pre-Admission Screening form documented Date: 9/10/15. Time: 7:30 a.m. Responsible Party/Relationship: Self . Presenting Symptoms: . (Suicidal Ideation) . Depressed . Behavior: . Verbally aggressive . Summary: (Patient) has a history of Depression and Anxiety. (Patient) currently has passive death wish but no plan to commit suicide. (Nursing facility) reports suicidal statements . Physician Recommendations (and) Family/Guardian Response: . MSW (Medical Social Worker) recommends admission to (name of behavioral health), Dr. (name) has accepted (patient) . No Admission Indicated due to: (Patient) accepted for admission to (name of behavioral health) however (patient) is refusing to come and has no designee or family that will be surrogate . As of 10/19/15 at 1:35 p.m., there was no departmental note found in the clinical record that documented any family member had been contacted or that the Nurse Practitioner of Physician had been notified of the resident's refusal to be admitted to behavioral health unit on 9/10/14. f. A SOAP note dated 9/11/15 and signed by APN #1 documented, . Chief Complaint: Nurses tell me patient is still here, she is not saying she is going to kill herself but she is distressed, moody, anxious and delusional. She has been combative and refusing basic care. The nurse has asked me to review her meds and see what I can do to help her psychological distress. I did review her meds after taking to 3 nurses about her recent and current behaviors. See chart for order change . 1) A physician order [REDACTED]. 2) The One on One Contact Forms documented resident observations were started on 9/8/15 at 8:30 p.m. and resident observations stopped on 9/10/15 at 6:45 a.m. The CNA assignment sheets dated from 9/8/15 through 9/12/15 were reviewed. There was no staff member who was documented as providing 1 on 1 monitoring during this time. The assignment sheets for 9/12/15 for the 3:00 p.m. to 11:00 p.m. shift were reviewed. CNA #s 5, 11, and 12 were assigned to Resident # 5's hall on 9/12/15 for the 3:00 p.m. to 11:00 p.m. shift. There was no indication that any of these CNAs provided 1 on 1 monitoring of the resident during this time frame. g. The Departmental Notes dated 9/13/15 at 1:46 a.m. documented, This nurse was called to resident's room at 1715 (5:15 p.m. 9/12/15) by CNA (Certified Nurse Assistant). Upon entering the room, this nurse observed resident to be non-responsive with a cloth tied around her neck. This nurse immediately had another nurse call 911. We removed the cloth from around resident's neck and sternal rubbed her for about 4 minutes before getting her eyes to fluttering. Resident also noted to have a pair of scissors which later this nurse found that another resident had given them to her and assisted her in cutting the cloth. Resident came around and was fighting with CNAs to get cloth back to put back around her neck. CNAs kept a tight grip on cloth until EMTs (Emergency Medical Technicians) arrived. Ambulance arrived at 1725 (5:25 p.m.) along with (name of town Police Department) to do formal evaluation and reports. EMTs helped to get resident away from the closet when resident became very combative and cursing them. EMTs and officers asked resident multiple times if she wanted to harm herself and resident stated yes, she wanted to kill herself. EMT asked resident how she planned on doing this and resident stated that she was going to choke herself. EMTs took resident to ER after thorough investigation and report was done with resident. After the resident left the facility, this nurse had all staff on 3:00 p.m. to 11:00 p.m. do a witness statement whether they had contact with resident or not. After talking with some of the CNAs, they reported that this resident had been seen talking with another resident (Resident # 12). This nurse approached resident and asked if this resident had said anything to her about trying to kill herself. Resident stated that she was very emotional talking about wanting to get out of here. Resident also reported that she was talking about how her kids left her here to die and she would rather be dead. Resident also stated that (Resident # 5) had repeatedly mentioned that her husband had killed himself years ago by shooting himself in the head. When (Resident # 5) asked resident to cut the cloth, resident asked (Resident # 5) 'What are you going to do, hang yourself?' Resident said that (Resident # 5) began to cry even more. Resident did admit to helping (Resident # 5) cut the cloth but she said she had no idea why she wanted this done . Around 8:30 p.m. one of the nurses from (Behavioral health/geri-psych) called reported that resident had been admitted . 1) The (name) EMS (Emergency Medical Services) Patient Encounter form dated 9/12/15 documented, . Date: 9/12/15 . Reason for Transfer or Dispatch Reason: Attempted hanging . Time: 6:00 p.m. (Blood pressure) 163/96, (pulse) 100, (respirations) 20 . Chief Complaint: (Attempted) hanging. Edge of sheet around door knob and around neck, pushing back with legs in wheelchair . staff stated may have been (unresponsive) (prior to arrival) of EMS. Awake (and) alert (and) able to answer questions . 2) The (hospital) Emergency Department Record dated 9/12/15 at 6:04 p.m. documented, . Arrival Date/Time: 9/12/15 6:04 p.m . Stated Complaint: Attempted hanging . Physical Assessment . Glasgow Coma Scale . Eye opening: Spontaneous . Motor: Obeys commands . Verbal: Oriented . Per (Nursing Home), per EMS (Emergency Medical Services) (patient) tied cord of sheet around door knob, around neck and initially was pale and unresponsive. On arrival of EMS (patient) awake and alert, (patient) stated 'I want out of there', referring to (nursing home) . Patient Discharge or Departure: discharge date : 9/12/15. Discharge time: 8:22 p.m. Discharge order: Transfer to psych . 9/12/15 6:04 p.m. 5:57 p.m. actual arrival of (patient) . with alleged hanging from sheet at (nursing home) Per (nursing home) on their arrival (patient) was pale and unresponsive but on arrival of EMS, (patient) alert and awake. No visible signs of strangulation noted. No redness or marks visible. (Respirations) even and unlabored. (Patient) admits of intentionally attempted to hang self due to fact that she does not like the (nursing home) and does not want to reside there . 3) The Diagnostic Imaging Report documented . Visit Date: 9/12/15 . Exam: Cervical spine . Order (diagnosis): tried to hang self . Impression: . without evidence of hangman's fracture . h. The Resident Incident Report dated 9/12/15 at 5:15 p.m. documented, . Associate Involved: (CNA # 4) . This nurse was called to resident's room . Narrative of Investigation: . Upon investigation it was determined resident had attempted to hang herself utilizing cut up sheets where she place around her neck and tied to her closet door knob, where she then propped her lower extremities off the floor. Staff was previously in room [ROOM NUMBER] - 10 minutes before setting up dinner tray where resident got up from bed to eat dinner without any difficulties or irrational statements leading up to incident. Staff found resident unresponsive, called 911 immediately and removed sheets to arouse after noting she was not responding. Stayed with resident until EMS arrived. Resident had days before been assessed by a house visit from the Behavioral Health unit . Resident was a candidate for inpatient care due to previous behaviors and statements, but refused to go to receive treatment. Currently admitted to Behavioral unit. 6. New Intervention: In-service staff on [MEDICAL CONDITION] pending in-service from behavioral health representative with nurses on suicidal threats and interventions . On 10/21/15 at 2:55 p.m., CNA # 4 was asked, Have you ever worked with (Resident # 5)? CNA # 4 stated, Yes, that day she hung herself (9/12/15). I'm the one who found her that night. She was okay when she got her dinner and I was on call lights and found her. CNA #4 was asked, About what time was that? CNA # 4 stated, About 5:15 p.m. to 5:30 p.m., I walked past her room and I saw her in the corner by her dresser. She was between the closet door and her dresser. She had one end of the sheet tied around the closet door handle and the other end wrapped around her neck a couple of times. She had her feet pushing against the door and she was leaning back in the wheelchair with her head back and she was holding onto the sheet around her neck. CNA #4 was asked, She had a grip on the sheet when you found her? CNA # 4 stated, Yes and she didn't want to let it go. CNA #4 was asked, She had her legs straight and was pushing back from the door when you found her? CNA # 4 stated, Yes. CNA #4 was asked, Was she responsive? CNA #4 stated, No, it took 4 to 5 minutes for her to answer us. CNA #4 was asked, Was she still breathing and still had a pulse? CNA #4 stated, Yes. CNA #4 was asked, The only thing she wasn't doing was responding? CNA #4 stated, Yes and then she opened her eyes and said 'Leave me alone, I'm dying'. i. The Verification of Investigation form signed by the Administrator documented, . Date/Time of Occurrence: 9/12/15 7:00 p.m. Provided detailed description of event/allegation: Resident found hanging from a cut bed sheet on closet. Assessment of Resident/Describe Injury: Resident was found unresponsive with cut cloth around her neck. Causal/Contributing Factor and Observations: Resident asked another resident to cut the bed sheet and had expressed the desire to harm herself to the resident. Resident had been upset that her family had not been visiting as often as she thought they should have. She does not like living in Arkansas and wishes she had never came. Specific Recommendations/Interventions Taken to Prevent Reoccurrence: One on one with resident on alerting staff if a resident makes statements of self-harm. Offer the resident the opportunity to locate another facility if she chooses. Was Abuse/Neglect Substantiated? No. Provide Summary of Investigative Findings: Resident had been assessed by (name) Behavioral health on the 9th for placement for increased symptoms of depression. Placement was offered to resident but resident denied wanting placement. On 9/12/15, resident requested another resident cut a bed sheet for her and expressed an idea of wanting to die. Resident did not alert staff to (Resident # 5's) statement. Resident was found at 7:00 p.m. with material around her throat. Staff removed her from immediate harm and she remained one on one until EMS took over care for the resident. She was then taken to (hospital name) under a suicide hold. j. On 10/21/15 at 10:00 a.m., APN # 1 was asked, Was (Resident # 5) treated by you? APN stated, Yes. APN # 1 presented progress noted dated 9/9/15 and 9/11/15. APN # 1 was asked, Did you recommend that the resident was safe to stop the 1 to 1 monitoring? APN # 1 stated, No one asked me that. When I was there on 9/9/15 her family was there but no staff was present. She kept repeating she was going to kill herself and I recommended a psych referral. I told (Acting DON) and (SSD) that she needed an in-patient psych referral and someone did come out and they saw her. I did not know she was still in the building on Friday (9/11/15) until a nurse casually asked me to review her meds. I reviewed her meds and I didn't ask about the psych referral on Friday. APN # 1 was asked, Did you know the resident was not one on one on Friday, 9/11/15? APN # 1 stated, You are they first person to even ask me about one on one monitoring. No I was only asked to look at her meds. I was told she would not consent to the psych admit but I'm not sure if she (LPN # 4) said that on Friday (9/11/15) or Monday (9/14/15) after all that happened. The son had already consented and the resident was delusional so I don't know why she wasn't sent to the psych unit. On Monday (9/14/15) I was told by the nurses she had asked for scissors all day Saturday (9/12/15) and even got a resident to cut her sheets. She carried out a plan to commit suicide over the course of a day and that's very high level functioning. k. The Quality Assessment and Assurance Committee form dated 9/29/15 documented, Topic: Note: Resident attempted suicide. Process Owner: All Departments. Summary of Analysis should include trends and root cause analysis: Improve documentation using the behavior monitoring sheets contained in MARs (Medication Administration Records). Review medical record for indications missed to show staff how to identify possible harm to resident before (it) gets to that point. Speak with (name) Behavioral (Health) on inservice to be conducted to include a better understanding of warning signs of suicidal thoughts in the elderly. Inservice with staff on more effective documentation in respect to resident behaviors and changes in condition. l. CNA interviews were conducted regarding one to one monitoring of Resident #5 from 9/8/15 - 9/12/15: 1) On 10/21/15 at 3:30 p.m., CNA # 6 was asked, Has any resident stated to you they were going to kill themselves? CNA # 6 stated Yes, just one. CNA #6 was asked, Who? CNA # 6 stated, (Resident # 5). We were at the nurses station and she said she wanted to go to California with her brother or son and then she said I'll just kill myself. CNA # 6 was asked, What happened after that? CNA #6 stated, We had to go in there every 15 minutes and check on her. CNA # 6 was asked Were you doing 1 to 1 or every 15 minute checks? CNA #6 stated, Every 15 minute checks, not 1 to 1. CNA # 6 was asked, What day was that? CNA #6 reviewed the One on One Contact Forms for 9/8/15 through 9/10/15. CNA #6 stated, I don't recall when she said that but I did every 15 minute checks on 9/9/15 at 3:45 p.m., 4:00 p.m., 4:30 p.m., 4:45 p.m., 5:00 p.m. and 9:15 p.m. 2) On 10/21/15 at 3:50 p.m., CNA #7 was asked, Has any resident stated to you they were going to kill themselves? CNA #7 stated Yes. CNA #7 was asked, Who? CNA #7 stated, (Resident # 5). CNA # 7 was asked, When? CNA #7 stated, About 2 weeks before she tried to hang herself. CNA #7 was asked, What did she say? CNA # 7 stated, That she was tired of being here so she was just going to kill herself. CNA #7 was asked, What did you do? CNA #7 stated, I told the nurse, she said it numerous times. I know (LPN # 2) is usually the nurse. CNA #7 was asked, What did the nurse do? CNA # 7 stated, Started every 15 minute checks . CNA #7 was asked to review the One on One Contact Forms from 9/8/15 to 9/10/15. CNA #7 was asked, Can you put a check mark by when you did checks? CNA # 7 put 5 check marks on 9/8/15 at 9:30 p.m., 9:45 p.m., 10:30 p.m., 10:45 p.m. and 11:00 p.m. CNA #7 stated, It was me and (CNA # 13) who went and told (LPN # 2) about it, then she stopped saying it. 3) On 10/22/15 at 6:43 a.m., CNA # 13 was asked, Has any resident stated to you they were going to kill themselves? CNA #13 stated, Yes, (Resident # 5). CNA #13 was asked, How often did she say that? CNA #13 stated, Once and I reported it to my nurse. CNA #13 was asked, Which nurse? CNA #13 stated, (LPN # 2). CNA #13 was asked, What did (LPN # 2) have you do? CNA #13 stated, We started on 1 to 1 and when she went to bed we did every 15 minute checks. I made sure her door was open and curtains pulled back so I could see her. CNA #13 was asked, Was that on 9/8/15? CNA # 13 reviewed the on One Contact Forms from 9/8/15 to 9/10/15. CNA # 13 stated, Yes, (initials) on here is me. CNA #13 initials were documented on 9/8/15 at 9:00 p.m., 9:15 p.m., 10:00 p.m. and 10:15 p.m. m. On 10/22/15 at 10:35 a.m. LPN # 4 stated she had been the Acting Assistant Director of Nurses (ADON) since August 2015. LPN # 4 was asked What do you know about (Resident # 5's) threats to kill herself? LPN # 4 stated I knew she had threatened to kill herself. LPN # 4 was asked What did the facility do to protect the resident? LPN # 4 stated Put resident 1 to 1 and I know (SSD) talked with her and I know someone from the hospital came in to talk with her. LPN # 4 was asked, When did the 1 to 1 end? LPN # 4 stated, I don't know when or why it was stopped. The Acting DON, (SSD) and Administrator were dealing with that. LPN # 4 was asked, When did you tell (APN # 1) that (Resident # 5) would not go to in-patient psych? LPN # 4 stated, That was after she'd tried to hang herself. n. On 10/22/15 at 12:27 p.m., the Administrator was asked, Did you know about the 9/8/15 happening documented by (LPN # 2) when (Resident # 5) threatened to hang herself? The Administrator stated, No. He told me she was crying and upset but not that she wanted to hang herself. The Administrator was asked, What was staff doing, monitoring (Resident # 5) 1 to 1 or every 15 minute checks? The Administrator stated I thought it was 1 to 1. This surveyor informed the Administrator that the 3:00 p.m. to 11:00 p.m. staff had stated they were doing every 15 minutes checks. The Administrator was asked, Is every 15 minute checks okay for a resident threatening to hang herself? The Administrator stated, No. The Administrator was asked, On 9/9/15 what did you know about this situation? The Administrator stated, That was when I told (SSD) she needed to talk with (APN # 1) about behavioral health and possible admit to geri-psych. The Administrator was asked, Geri-psych came on 9/10/15? The Administrator stated, Yes. The Administrator was asked, Did you know they recommended in-patient admission? The Administrator stated, Yes and that she had refused placement. The Administrator was asked, Why was the monitoring of (Resident # 5) stopped? The Administrator stated, Because she refused to go and the nurses did not see the geri-psych notes. The Administrator was asked, Who made the decision to stop the monitoring? Were you involved? The Administrator stated, No, I was not. The Administrator was asked, Who made the decision? The Administrator stated, I don't know. The Administrator was asked, Did anyone call you before they stopped it? The Administrator stated No. The Administrator was asked, Were you in the building on 9/10/15 and 9/11/15? The Administrator stated, Yes. The Administrator was asked, Who was in charge of nursing? The Administrator stated, (Acting DON # 1). The Administrator was asked, Were you informed on 9/12/15 when the resident attempted to hang herself? The Administrator stated, Yes. The Administrator was asked, What's been done since this to prevent re-occurrence? The Administrator stated, We did an in-service on reporting increased symptoms of depression. We started a behavior monitoring sheet. We started that this month and who the nurse needed to report increased behaviors to. The Administrator was asked, Why do in-services on reporting increased behaviors when they did that? There was no response from the Administrator. This surveyor requested copies of the in-services. 1) On 10/22/15 at 1:55 p.m., Acting DON # 1 stated she was the DON from August through 10/14/15. Acting DON # 1 was asked, Did (Resident # 5) threaten to kill herself? Acting DON # 1 stated, Yes. Acting DON #1 was asked, What were you doing to monitor the resident for suicide attempts? Acting DON # 1 stated, It was supposed to be 1 to 1 monitoring but maybe the CNAs got confused and only did every 15 minute checks. Acting DON # 1 was asked, Who made the decision to stop the 1 to 1 or every 15 minute monitoring? Acting DON # 1 stated, I don't know. Acting DON # 1 was asked, Were you working 9/10/15 and 9/11/15? Acting DON # 1 stated, Yes. Acting DON # 1 was asked, Did anyone ask you if they could stop monitoring (Resident # 5)? Acting DON # 1 stated, No. Acting DON #1 was asked, Did you know the monitoring was stopped with (Resident # 5) prior to psych seeing the resident? Acting DON # 1 stated, No. Acting DON # 1 was asked, Who did the CNA assignments? Acting DON # 1 stated, The charge nurses or (LPN # 5). 2) On 10/22/15 at 2:20 p.m., LPN #5 was asked, Do you complete the 7:00 a.m. to 3:00 p.m. assignment sheets? LPN # 5 stated, If I have time, sometimes the nurses do it. There is no one assigned to fill it out. LPN # 5 was asked, Did you know about (Resident # 5) threatening to hang herself on 9/8/15? LPN #5 stated, Yes. I was working that night on C and D halls and (LPN # 2) told me what happened and I told him he better call (Administrator) and see what to do. I filled out the 9/10/15 3:00 p.m. to 11:00 p.m. assignment sheet and I didn't know she was 1 to 1 and I didn't make her 1 to 1 on the 11th and I did the 9/12/15 assignments and I didn't assign 1 to 1. When the resident refused to go to psych I was under the impression it was over and I was never told she was 1 to 1. If she had been 1 to 1 there would be 1:1 with a CNAs name. I know in stand up (Administrator) said the psych person came and she refused to go and made her own decision so we are covered. There was nothing said about 1 to 1. That was on 9/11/15. LPN # 5 was asked to review the One on One Contact Forms and the assignment sheets from 9/8/15 through 9/12/15 for indications of 1 to 1 monitoring. LPN # 5 stated, There was no one assigned to do 1 to 1 from 9/8/15 through 9/12/15 and her monitoring stopped on 9/10/15 at 6:45 a.m. o. On 10/23/15 at 5:15 p.m. the Administrator was asked, Who should have ensured the monitoring was 1 to 1 for (Resident # 5) and that it was in place and stayed in place? The Administrator stated, The DON at that time and I should have made sure she was doing that. The Administrator was asked, Do you have any documented in-services that were done since (Resident # 5) attempted to hang herself on notification or suicidal ideation, (et cetera) prior to 10/22/15?' The Administrator stated, No. 2. Resident # 7 had [DIAGNOSES REDACTED]. The Departmental Note dated 8/5/15 at 9:24 a.m. documented, New order received per (Advanced Practice Nurse (APN) # 1) to decrease [MEDICATION NAME] (anti-depressant) to 5 (milligrams) (per mouth) at bedtime . The Quarterly MDS with an ARD of 8/28/15 documented the resident scored 14 (13 - 15 indicates cognitively intact) on the Brief Interview for Mental Status, had thoughts of better off dead on 12 - 14 days (nearly every day), had a safety notification completed, and scored 12 (10 - 14 indicates moderate depression) on a Patient Health Questionnaire . The Signature of Person Completing the Assessment documented the Social Service Director (SSD) completed Section D Mood of the MDS on 8/28/15. a. On 10/22/15 at 10:55 a.m., the SSD was asked, For the MDS done 8/28/15, you completed the Mood Section? The SSD stated, Yes. The SSD was asked, Did the resident state he was having thoughts of being better off dead and he said this occurred almost daily? The SSD stated, Yes. The SSD was asked, Did you do a safety notification? The SSD stated, I told the hall (charge) nurse. I know now that I need to tell (Administrator) and (DON) and (APN # 1). I learned that yesterday (10/21/15). The SSD was asked, Did he verbalize any plan for suicide? The SSD stated, No he said he was jealous of his roommate and could not understand why his wife did not visit him. The SSD was asked, Did you go back and monitor (Resident # 7) after 8/28/15? The SSD stated Yes but I didn't document it. b. The Departmental Notes dated 8/28/15 at 3:32 p.m. and electronically signed by LPN # 1 contained no documentation to indicate the resident stated he would be better off dead. c. The Care Plan dated 8/2/13, reviewed on 9/1/15, documented, I am at risk for side effects from antidepressant/antianxiety medication use for a history of depression . Approaches: . Observe and record my target behaviors . There was no updated Plan of Care to address the reported thoughts of better dead that occurred nearly every day. d. As of 10/20/15 at 3:19 p.m., there was no documentation in the Departmental Notes dated 8/28/15 through 10/16/15 of the resident ' s mood, monitoring for further statements that the resident would be better off dead or assessment to determine if the resident had thoughts of suicide or a plan for suicide. e. On 10/21/15 at 11:35 a.m., Advanced Practice Nurse (APN) # 1 was asked, Were you told (Resident # 7) had expressed feelings of being better off dead on 8/28/15? APN # 1 stated, I don't think so I would have done an intervention for that. I was asked on 8/31/15 to clarify his ICD 10 (International Statistical Classification of Diseases and Related Health Problems) [DIAGNOSES REDACTED]. I wasn't told anything about expression of better off dead. f. On 10/21/15 at 2:07 p.m., LPN # 1 was asked, Has any resident stated to you they were going to kill themselves? LPN # 1 stated, No, but (Resident # 7) says 'Sometimes I feel like I'd be better off dead'. LPN # 1 was asked, How long ago did he say that? LPN #1 stated, Several months ago. It was only once and I contacted Social and we monitored him for several days and he never said anything after that. LPN # 1 was asked, Where is it documented, the monitoring? LPN #1 stated, It's not. 3. The Immediate Jeopardy was removed and the scope/sev

Complaint # (AR 768) was substantiated (all or in part) in these findings. Based on record review, and interview, the facility failed to their Abuse Prohibition policy and procedure was implemented to ensure all allegations of staff to resident abuse were immediately reported to the Administrator/Designee, to ensure all allegations of abuse were investigated and that residents were protected from the potential of further abuse during the investigation for 2 of 2 (Residents # 6 and 8) case mix residents who were cognitively impaired and were subjects of staff to resident abuse allegations. The failed practices resulted in Immediate Jeopardy which caused or could have caused serious harm, injury or death to Resident # 6 who repeatedly told staff of an abuse allegation and a staff member allegation of a witnessed abuse of Resident # 8 and had the potential to affect 51 residents who were cognitively impaired according a list received from the Nurse Consultant on 10/28/15. The facility was notified of the Immediate Jeopardy condition on 10/22/15 at 4:25 p.m. The findings are: 1. The facility's policy titled Abuse Prohibition documented, . Policy: . The facility shall ensure that all alleged violations are reported immediately to the administrator or the administrative designee. The administrator designee shall ensure that the violations are investigated and reported to the appropriate regulatory agency in accordance with federal and state law. Procedure: . Training Employees: Prevention, Intervention and Detection. All new staff will receive training on the following information during general orientation and annually thereafter: . How to report suspected or witnessed abuse, neglect or misappropriation of resident property . Actions that must be taken if resident abuse or neglect is witnessed, for the protection and safety of the resident . Protection: In order to provide protection to the resident during an investigation the following will be done: The alleged abuser will be removed from the facility immediately, and not allowed in the facility, pending the outcome of the investigation . Reporting and Response to Alleged Incidents: . All alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source, and misappropriation of resident property shall be reported IMMEDIATELY after discovery to the Administrator or the DON (Director of Nursing) . If neither is in the facility when such incidents occur or are discovered after hours, the report will be given to the Charge Nurse or Supervisor in charge. The Charge Nurse or Supervisor must immediately contact the Administrator or the DON of the incident . 2. Resident # 6 had [DIAGNOSES REDACTED]. The Significant Change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/26/15 documented the resident scored 5 (0 - 7 indicates severe impairment) on the Brief Interview for Mental Status; had no inattention, disorganized thinking, altered level of consciousness or psychomotor [MEDICAL CONDITION]; and had no physical or verbal behaviors directed toward others. a. The Departmental Notes dated 8/17/15 at 11:33 a.m. and electronically signed by the Social Service Director (SSD) documented, The resident reported a male CNA (Certified Nurse Assistant) came into his room last night and punched him in the face. The resident could not remember what time this event occurred. The resident did not know the name of the staff member. The resident did not have any clear visible marks or bruises to his face the resident stated again he was punched in the face. The resident stated he did not know why the event occurred. The resident stated he was asleep when it happened. The resident then said this had happened 3 nights in a row. The resident stated he got mad in the dining room one day and punched the man in the face. The resident could not remember what the confrontation in the dining room occurred. The resident stated he was physically healthy and had no other aliments at this time. 1) On 10/22/15 at 10:55 a.m., the SSD was asked to review the departmental note for 8/17/15. The SSD was asked, On 8/17/15, what had happened? The SSD stated, Nursing staff told me a male CNA punched him (Resident #6) in the face and he was distraught. I was asked to go talk to him. The SSD was asked, What is that a complaint of? The SSD stated, A grievance. The SSD was asked, Are you sure? The SSD stated, It's an abuse allegation. The SSD was asked, What are you to do with an abuse allegation? The SSD stated, Now I know to write a grievance and do an investigation and report it. The SSD was asked, Now? The SSD stated, I was just told that today. The SSD was asked, Which nurse asked you to talk with him? The SSD stated, I don't recall. It could have been (Administrator), the Administrator or any nurse. The SSD was asked, Did the resident ever name a CNA? The SSD stated, No . 2) On 10/22/15 at 12:27 p.m., the Administrator was asked Did you know (Resident # 6) had reported he was punched in the face on 8/17/15? The Administrator stated, No. The Administrator was asked, Was this investigated? The Administrator stated, No, it was never reported on any I & A (incident and accident), grievance or witness statement. b. The Grievance Form dated 10/13/15 provided by the Administrator on 10/21/15 had a hand written statement attached to the Grievance Form dated 10/13/15 documented, (Resident # 6) states that when his tray was delivered this morning the man was rude and wouldn't get him his clothes. (Resident # 6) could not identify the staff member. Spoke (with) (Resident # 9) and she stated (Resident # 6) told her that during supper that night (can't recall night) the staff was mean. When asked if she knew what about she stated no. 10/13/15 (Resident # 6) approached me following lunch and asked if anyone had told me about the (expletive) hole from the weekend that wanted me to turn the TV down. I asked if he was talking about the person we discussed this morning. He asked me 'Did I talk to you this morning?' I explained yes we discussed the incident at breakfast. He stated he didn't know what I was talking about but the other (expletive) hole needs to be taken out back. Resident could not identify who he was talking about but thought his name could be Saru. No employee or resident in facility by that name. c. On 10/20/15 at 10:48 a.m., the resident propelled up to this surveyor in a wheelchair and stated he needed to complain. The resident was asked, What about? The resident stated, About an employee that works here, (Name # 1). He's the one that slaps me on the (expletive) and pokes me in the forehead with his finger and calls me a little girl. The resident was asked, When does he do this? The resident stated, At night. The resident was asked, Is (Name # 1) the only one you have problems with? The resident stated, It's either (Name # 1) or (Certified Nurses Assistant (CNA) # 14). I'm not sure of the name. The resident was asked, What time of night does he work, late night to mornings or supper to bed time? The resident stated, Supper to bed time. d. On 10/20/15 at 10:52 a.m. the Administrator was asked, Have you had any complaints from (Resident # 6) related to staff? The Administrator stated, He complained last Wednesday (10/14/15). He told his girlfriend (Resident # 9) and she told me and we interviewed him and his story kept changing as to time frames and what happened. We did a staff in-service on perception and attitude. This surveyor requested a witness statement form from the Administrator to document an allegation. e. On 10/20/15 at 4:05 p.m., CNA # 15 was asked, Do you have concerns that abuse or neglect is occurring in the facility? CNA #15 stated, More than I've ever heard of it. CNA #15 was asked, Is that because residents or staff are telling you? CNA #15 stated, Residents mostly. Here lately it's staff members who told me. CNA #15 was asked, Which residents and what have they said? CNA #15 stated, (Resident # 6). He complained that (CNA #14) yanked him off the toilet and slapped him on the butt. We told him lets go talk to (Acting DON # 1), she was the acting DON and he said he'd already told her. CNA #15 was asked, When was that? CNA #15 stated, Thursday (10/15/15) or Friday 10/16/15) last week. CNA #15 was asked, Have you told anyone other than the charge nurse about these concerns you told me about? CNA #15 stated, I sent (Administrator) a text message the next day and I asked her in person if she knew about the incident with (Resident # 6). CNA #15 was asked, Did you fill out a witness statement regarding this? CNA # 15 stated, No, but they asked me for one today but not in the last 7 days. f. On 10/20/15 at 4:42 p.m., CNA # 16 was asked, Do you have any concerns that abuse or neglect is occurring in the facility? CNA # 16 stated, Yes. CNA #16 was asked, What are these concerns? CNA # 16 stated, Last week (Resident # 6) told us that he put his light on during supper and the CNA answered it and the CNA was rough with him and jerked him off the toilet, didn't clean him and did not put a brief on him . We reported it, (CNA #15) and I and we told him to tell the nurse. CNA # 16 was asked, Which nurse did you tell? CNA #16 stated, Our Acting DON, (Acting DON # 1) . I don't recall what charge nurse we told. CNA #16 was asked, Did you fill out a witness statement? CNA #16 stated, No, we weren't asked to . We mentioned this to (Administrator) and she said she interviewed (Resident # 6) and he told her 3 different versions of the story but he repeated this verbalization to the Treatment Nurse (LPN # 7) and to (CNA # 15). g. On 10/22/15 at 10:04 a.m., CNA # 9 was asked, Do you work with (Resident # 6)? CNA # 9 stated, Yes. CNA # 9 was asked, Has he ever told you he's been yanked off the toilet and his butt slapped? CNA # 9 stated, Yes and he's also told me a certain CNA has left him in a poopy brief after sitting him on the toilet. CNA #9 was asked, When did he tell you this? CNA # 9 stated, 10/13/15. CNA #9 was asked, What did you do?' CNA # 9 stated, I told the nurse (LPN # 1). CNA #9 was asked, Did any one ask you to fill out a witness statement? CNA #9 stated, I'm pretty sure they did but I got bumped to D hall and forgot. CNA #9 was asked, Which CNA was he complaining about? CNA #9 stated, (CNA #14). h. On 10/22/15 at 12:27 p.m., the Administrator was asked, The grievance dated 10/13/15, what exactly did the girlfriend (Resident # 9) say? The Administrator stated, She said (Resident # 6) said a staff member had been mean to him. I was going up the hall and (LPN # 7) said (Resident # 6) had reported that a CNA had been rough with him and had not gotten his clothes when he asked for them. The Administrator was asked, Did you ask (LPN # 7) for a witness statement? The Administrator stated, No. The Administrator was asked, Did you interview (Resident # 6)? The Administrator stated, Yes and I asked him if anyone had hit him and what had happened and he replied he (CNA) was rude and would not get me my clothes. I asked who and he said (Name # 2), I don't know, a short guy. The Administrator was asked, (CNA # 9) did not report that (Resident # 6) stated he'd been yanked off the toilet and slapped? The Administrator stated, No and she admitted that to me this a.m. The Administrator was asked, Had you been told by any staff member or by (Acting DON # 1) of concerns from other CNAs related to (Resident # 6) being yanked off the toilet and slapped on the bottom? The Administrator stated, No. The Administrator was asked, Had you been texted on this regarding (Resident # 6) being slapped? The Administrator stated, No, that CNA, (CNA # 15) came to my office and asked if I knew about (Resident # 6). I said yes but she didn't say what and she turned around and left. The Administrator was asked, Did you call her back and ask what about (Resident # 6)? The Administrator stated, No. i. On 10/23/15 at 9:50 a.m., LPN # 7 was asked, Any concerns from (Resident # 6) regarding treatment from any one? LPN # 7 stated, Yes. LPN # 7 was asked, What did he say? LPN # 7 stated, That (CNA #14) was rough with him and wouldn't give him his clothes. Then he went down the hall and stopped at the next kiosk and stopped the CNA and said 'Did you hear about (CNA # 14) and the CNA said 'What about him?' and (Resident # 6) told the CNA he smacked me on the (expletive) and at that point I just put my stuff in the cart and went to (Administrator's) office and told her. LPN #7 was asked, You told her he said he's been smacked on the (expletive)? LPN # 7 stated, Yes. LPN # 7 was asked, When was that? LPN # 7 stated, One day last week. LPN # 7 was asked, Who was the CNA that (Resident # 6) was talking to? LPN # 7 stated, (CNA # 19), I think he had stayed over. LPN #7 was asked, Is (CNA # 19) here today? LPN #7 stated, Yes. LPN # 7 was asked, Could you go get him and come back with him? I need to try and get you two to pin down what day this happened on. LPN #7 left at 10:01 a.m. j. On 10/23/15 at 10:23 a.m., LPN #7 and CNA #19 brought in time records to compare what days they had worked together last week. LPN #7 stated, We don't have any idea what day. It was not on the 13th because I was off that day. I'm almost certain it was the 15th. We, (CNA #19), myself, and (CNA #14) were all here on that day, the 15th. LPN #7 and CNA #19 were asked, Did (Resident # 6) report this to you on a day that (CNA #14) worked a day shift? CNA # 19 stated, Yes, (Resident # 6) said he was rough with him and didn't wipe my (expletive) before he pulled my drawers up. LPN # 7 and CNA #19 were asked, Did (Resident # 6) say he'd been slapped? LPN # 7 stated, I thought he said (CNA # 14) had smacked him around. LPN #7 was asked, You told (Administrator) this? LPN # 7 stated, Yes. CNA # 19 stated, Since (LPN # 7) was going to tell (Administrator) I didn't report it. LPN #7 and CNA #19 were asked, Did either of you fill out a witness statement? LPN # 7 stated, Not then. We usually wait till we are asked and I wasn't asked for one until today. I'm certain I reported this to (Administrator) on 10/15/15. k. The employee time report provided by the Administrator on 10/23/15 at 9:12 a.m. documented CNA #14 worked on 10/13/15 from 2:49 p.m. to 11:11 p.m.; on 10/14/15 from 2:48 p.m. to 11:15 p.m.; on 10/15/15 from 6:53 a.m. to 11:00 p.m.; on 10/16/15 from 2:50 p.m. to 11:05 p.m.; and on 10/19/15 from 2:48 p.m. to 11:17 p.m. 2. Resident # 8 had [DIAGNOSES REDACTED]. The Quarterly MDS with an ARD of 8/7/15 documented the resident had severely impaired cognitive skills for daily decision making per a Staff Assessment of Mental Status (SAMS); had inattention, disorganized thinking, altered level of consciousness, and psychomotor [MEDICAL CONDITION] behaviors that were always present; and had no physical or verbal behaviors that were directed toward others. a. On 10/20/15 at 4:05 p.m., CNA # 15 was asked, Do you have concerns that abuse or neglect is occurring in the facility? CNA #15 stated, More than I've ever heard of it. CNA #15 was asked, Is that because residents or staff are telling you? CNA # 15 stated, Residents mostly. Here lately it's staff members who told me. I was told by (LPN # 6) and Housekeeper # 2 about an aide slapping a resident's hand . (Housekeeper # 2) told me about it . and I asked him if he filled out a witness statement and he said no, he was told to sign a paper saying he would report abuse to his supervisor. b. On 10/22/15 at 8:12 a.m. ,Housekeeper # 2 was asked, Have you ever seen any resident slapped by a staff member? Housekeeper #2 stated, Yes. Housekeeper # 2 was asked, Who was the resident? Housekeeper # 2 stated, (Resident # 8). Housekeeper #2 was asked, What happened? Housekeeper #2 stated, I was cleaning a room, coming out of the room when I turned around to go to my cart. (Resident # 8) was in her wheelchair in the hall at the linen cart and (Resident # 8) grabbed a CNA by her smock or shirt. I think it was (CNA #17). (Resident #8) had just reached up to get her snack, to get an oatmeal cake and the CNA took her hand and swatted the resident on the forearm. I told (LPN # 6) - she was right there passing meds. I asked (LPN # 6) did you see that and she said yes and I'm watching that. Housekeeper #2 was asked, That was all she said? Housekeeper #2 stated, Yes and from what I gather she went and told her supervisor but not while I seen it. Housekeeper #2 was asked, Did you tell anyone else? Housekeeper #2 stated, No, but I had to sign a paper that I had to tell my supervisor if it happened again. c. On 10/22/15 at 8:37 a.m. ,the Housekeeping Supervisor was asked, Have you ever seen any resident slapped by a staff member? The Housekeeping Supervisor stated, No. The Housekeeping Supervisor was asked, Have any of your staff reported that you? The Housekeeping Supervisor stated, No. I heard (Housekeeper #2) taking about it and I instructed him to let me know. The Housekeeping Supervisor was asked, When you heard him say that, who did you tell? The Housekeeping Supervisor stated, I told (LPN # 6). The Housekeeping Supervisor was asked, Did you ask (Housekeeper #2) to fill out a witness statement? The Housekeeping Supervisor stated, No, I failed to do that. Housekeeper #2 was asked, What did you understand (Housekeeper # 2) to say? The Housekeeping Supervisor stated, I understood him to say the CNA had slapped (Resident # 8's) hand. The Housekeeping Supervisor was asked, Is that abuse? The Housekeeping Supervisor stated, Yes and I'll go get a witness statement. The Housekeeping Supervisor was asked, What are you going to do after you get the witness statement? The Housekeeping Supervisor stated, Report it. The Housekeeping Supervisor was asked, How long ago did this happen? The Housekeeping Supervisor stated, Last week. The Housekeeping Supervisor was asked, Did you miss an important part of the incident? The Housekeeping Supervisor stated, Yes. I should have reported this last week. I'll go and take care of this right now. The Housekeeping Supervisor was asked to bring this surveyor a copy of Housekeeper # 2's witness statement and a copy of the disciplinary counseling done with Housekeeper #2. d. The Employee Warning Notice received from the Housekeeping Supervisor on 10/22/15 documented Employee Name: (Housekeeper # 2). Date of Incident: 10/12/15. Nature of Incident: Rule Violation. Description of Incident: On (page) 17 in your employee handbook it states if you see abuse or neglect or feel that you saw it you immediately come to you supervisor. If your supervisor is not available you report it to the ADON - Assistant Director of Nursing. Degree of Discipline: Document Counseling. Plan of Correction: If (Housekeeper # 2) feels he had witnessed abuse/neglect he will report directly to me or ADON. e. On 10/22/15 at 9:30 a.m., LPN # 6 was asked, Do you know anything about (Resident # 8) being slapped? LPN # 6 stated, I was there on the hall. I was 3 or 4 doors down from the resident and the housekeeper was only 1 door down from the resident. The resident and CNA were in the middle of the hall. The resident had gotten a snack from somewhere and had a handful of them. She was on a pureed diet and the aide was trying to get the snacks from her. The resident was getting combative when (CNA #18) was trying to get them and the resident slapped (CNA # 18) and you could hear a slap. I told (CNA #18) you need to just stop and let her be. That's when the housekeeper said 'Oh my god, did you just see that, she slapped her.' My initial thought was he's telling me that the resident slapped the CNA. I told (Housekeeper # 2) the resident is hitting her and she (CNA #18) is just trying to protect herself. LPN #6 was asked, Did you think he was alleging the CNA had slapped the resident? LPN # 6 stated, No. 3. The Immediate Jeopardy was removed and the scope/severity reduced to E on 10/22/15 at 5:00 p.m. when the facility implemented the following Plan of Removal: a. Beginning on 10/22/15 at 5:00 p.m., the facility identified 48 cognitively impaired residents at risk for abuse who scored below 13 on their BIMS from Section C of the MDS 3.0. b. Beginning at 5:00 p.m. on 10/22/15 body audits were initiated for these cognitively impaired residents with no significant findings. c. On 10/22/15 a one on one abuse training was conducted with the CEO (Chief Executive Officer/Administrator) by the RN (Registered Nurse) Regional MDS Consultant. Beginning on 10/22/15 a.m., all staff were in-serviced and training will be ongoing to include new hires and staff returning from leave. Training will take place before staff works on the floor. Training will be done by the CEO/DON/Designee and in-service sheets used. Training will include: a review of the abuse policy including identification of types of abuse, immediate resident protection to include the removal/suspension of the alleged perpetrator, reporting guidelines and investigation protocol. Training includes a verbal notification to the charge nurse of supervisor in charge, if the DON and/or CEO are not present in the facility. The charge nurse or supervisor will notify the CEO or DON immediately. The charge nurse or supervisor will remove the alleged abuser from the facility immediately and (the alleged abuser) will not be allowed in the facility pending the outcome of the investigation. d. The CEO/DON/designee will follow up on any verbal and written allegations of abuse and is to ensure the resident is protected, ensure the alleged perpetrator is suspended, and the investigative protocol is initiated and is completed per policy. Monitoring will be ongoing for 30 days to include evaluation of injuries of unknown origin for indications of potential abuse by the DON/designee; review of body audits for any indications of potential abuse by the treatment nurse or designee; random interviews will be conducted by CEO/DON/designee with 3 staff members per week covering all shifts to ensure staff knowledge of the abuse prohibition policy; and the CEO/DON /designee will conduct random interviews with 1 cognitively intact resident and 2 cognitively impaired residents regarding staff treatment toward them and other residents. Any negative findings will be reported immediately to the DON and CEO and corrective action taken.

Complaint # (AR 768) was substantiated (all or in part) in these findings. Based on record review and interview, the facility failed to ensure all allegations of abuse were immediately reported to the Administrator/Designee, to ensure all allegations of abuse were investigated and that residents were protected from the potential of further abuse during the investigation for 2 of 2 (Residents # 6 and 8) case mix residents who were cognitively impaired and were subjects of staff to resident abuse allegations. The failed practices resulted in Immediate Jeopardy which caused or could have caused serious harm, injury or death to Resident # 6 who repeatedly told staff of an abuse allegation and a staff member allegation of a witnessed abuse of Resident # 8 and had the potential to affect 51 residents who were cognitively impaired according a list received from the Nurse Consultant on 10/28/15. The facility was notified of the Immediate Jeopardy condition on 10/22/15 at 4:25 p.m. The findings are: 1. Resident # 6 had [DIAGNOSES REDACTED]. The Significant Change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/26/15 documented the resident scored 5 (0 - 7 indicates severe impairment) on the Brief Interview for Mental Status; had no inattention, disorganized thinking, altered level of consciousness or psychomotor [MEDICAL CONDITION]; and had no physical or verbal behaviors directed toward others. a. The Departmental Notes dated 8/17/15 at 11:33 a.m. and electronically signed by the Social Service Director (SSD) documented, The resident reported a male CNA (Certified Nurse Assistant) came into his room last night and punched him in the face. The resident could not remember what time this event occurred. The resident did not know the name of the staff member. The resident did not have any clear visible marks or bruises to his face the resident stated again he was punched in the face. The resident stated he did not know why the event occurred. The resident stated he was asleep when it happened. The resident then said this had happened 3 nights in a row. The resident stated he got mad in the dining room one day and punched the man in the face. The resident could not remember what the confrontation in the dining room occurred. The resident stated he was physically healthy and had no other aliments at this time. 1) On 10/22/15 at 10:55 a.m., the SSD was asked to review the departmental note for 8/17/15. The SSD was asked, On 8/17/15, what had happened? The SSD stated, Nursing staff told me a male CNA punched him (Resident #6) in the face and he was distraught. I was asked to go talk to him. The SSD was asked, What is that a complaint of? The SSD stated, A grievance. The SSD was asked, Are you sure? The SSD stated, It's an abuse allegation. The SSD was asked, What are you to do with an abuse allegation? The SSD stated, Now I know to write a grievance and do an investigation and report it. The SSD was asked, Now? The SSD stated, I was just told that today. The SSD was asked, Which nurse asked you to talk with him? The SSD stated, I don't recall. It could have been (Administrator), the Administrator or any nurse. The SSD was asked, Did the resident ever name a CNA? The SSD stated, No . 2) On 10/22/15 at 12:27 p.m., the Administrator was asked Did you know (Resident # 6) had reported he was punched in the face on 8/17/15? The Administrator stated, No. The Administrator was asked, Was this investigated? The Administrator stated, No, it was never reported on any I & A (incident and accident), grievance or witness statement. b. The Grievance Form dated 10/13/15 provided by the Administrator on 10/21/15 had a hand written statement attached to the Grievance Form dated 10/13/15 documented, (Resident # 6) states that when his tray was delivered this morning the man was rude and wouldn't get him his clothes. (Resident # 6) could not identify the staff member. Spoke (with) (Resident # 9) and she stated (Resident # 6) told her that during supper the other night (can't recall night) the staff was mean. When asked if she knew what about she stated no. 10/13/15 (Resident # 6) approached me following lunch and asked if anyone had told me about the (expletive) hole from the weekend that wanted me to turn the TV down. I asked if he was talking about the person we discussed this morning. He asked me 'Did I talk to you this morning?' I explained yes we discussed the incident at breakfast. He stated he didn't know what I was talking about but the other (expletive) hole needs to be taken out back. Resident could not identify who he was talking about but thought his name could be Saru. No employee or resident in facility by that name. c. On 10/20/15 at 10:48 a.m., the resident propelled up to this surveyor in a wheelchair and stated he needed to complain. The resident was asked, What about? The resident stated, About an employee that works here, (Name # 1). He's the one that slaps me on the (expletive) and pokes me in the forehead with his finger and calls me a little girl. The resident was asked, When does he do this? The resident stated, At night. The resident was asked, Is (Name # 1) the only one you have problems with? The resident stated, It's either (Name # 1) or (Certified Nurses Assistant (CNA) # 14). I'm not sure of the name. The resident was asked, What time of night does he work, late night to mornings or supper to bed time? The resident stated, Supper to bed time. d. On 10/20/15 at 10:52 a.m. the Administrator was asked, Have you had any complaints from (Resident # 6) related to staff? The Administrator stated, He complained last Wednesday (10/14/15). He told his girlfriend (Resident # 9) and she told me and we interviewed him and his story kept changing as to time frames and what happened. We did a staff in-service on perception and attitude. This surveyor requested a witness statement form from the Administrator to document an allegation. e. On 10/20/15 at 4:05 p.m., CNA # 15 was asked, Do you have concerns that abuse or neglect is occurring in the facility? CNA #15 stated, More than I've ever heard of it. CNA #15 was asked, Is that because residents or staff are telling you? CNA #15 stated, Residents mostly. Here lately it's staff members who told me. CNA #15 was asked, Which residents and what have they said? CNA #15 stated, (Resident # 6). He complained that (CNA #14) yanked him off the toilet and slapped him on the butt. We told him lets go talk to (Acting DON # 1), she was the acting DON and he said he'd already told her. CNA #15 was asked, When was that? CNA #15 stated, Thursday (10/15/15) or Friday 10/16/15) last week. CNA #15 was asked, Have you told anyone other than the charge nurse about these concerns you told me about? CNA #15 stated, I sent (Administrator) a text message the next day and I asked her in person if she knew about the incident with (Resident # 6). CNA #15 was asked, Did you fill out a witness statement regarding this? CNA # 15 stated, No, but they asked me for one today but not in the last 7 days. f. On 10/20/15 at 4:42 p.m., CNA # 16 was asked, Do you have any concerns that abuse or neglect is occurring in the facility? CNA # 16 stated, Yes. CNA #16 was asked, What are these concerns? CNA # 16 stated, Last week (Resident # 6) told us that he put his light on during supper and the CNA answered it and the CNA was rough with him and jerked him off the toilet, didn't clean him and did not put a brief on him . We reported it, (CNA #15) and I and we told him to tell the nurse. CNA # 16 was asked, Which nurse did you tell? CNA #16 stated, Our Acting DON, (Acting DON # 1) . I don't recall what charge nurse we told. CNA #16 was asked, Did you fill out a witness statement? CNA #16 stated, No, we weren't asked to . We mentioned this to (Administrator) and she said she interviewed (Resident # 6) and he told her 3 different versions of the story but he repeated this verbalization to the Treatment Nurse (LPN # 7) and to (CNA # 15). g. On 10/22/15 at 10:04 a.m., CNA # 9 was asked, Do you work with (Resident # 6)? CNA # 9 stated, Yes. CNA # 9 was asked, Has he ever told you he's been yanked off the toilet and his butt slapped? CNA # 9 stated, Yes and he's also told me a certain CNA has left him in a poopy brief after sitting him on the toilet. CNA #9 was asked, When did he tell you this? CNA # 9 stated, 10/13/15. CNA #9 was asked, What did you do?' CNA # 9 stated, I told the nurse (LPN # 1). CNA #9 was asked, Did any one ask you to fill out a witness statement? CNA #9 stated, I'm pretty sure they did but I got bumped to D hall and forgot. CNA #9 was asked, Which CNA was he complaining about? CNA #9 stated, (CNA #14). h. On 10/22/15 at 12:27 p.m., the Administrator was asked, The grievance dated 10/13/15, what exactly did the girlfriend (Resident # 9) say? The Administrator stated, She said (Resident # 6) said a staff member had been mean to him. I was going up the hall and (LPN # 7) said (Resident # 6) had reported that a CNA had been rough with him and had not gotten his clothes when he asked for them. The Administrator was asked, Did you ask (LPN # 7) for a witness statement? The Administrator stated, No. The Administrator was asked, Did you interview (Resident # 6)? The Administrator stated, Yes and I asked him if anyone had hit him and what had happened and he replied he (CNA) was rude and would not get me my clothes. I asked who and he said (Name # 2), I don't know, a short guy. The Administrator was asked, (CNA # 9) did not report that (Resident # 6) stated he'd been yanked off the toilet and slapped? The Administrator stated, No and she admitted that to me this a.m. The Administrator was asked, Had you been told by any staff member or by (Acting DON # 1) of concerns from other CNAs related to (Resident # 6) being yanked off the toilet and slapped on the bottom? The Administrator stated, No. The Administrator was asked, Had you been texted on this regarding (Resident # 6) being slapped? The Administrator stated, No, that CNA, (CNA # 15) came to my office and asked if I knew about (Resident # 6). I said yes but she didn't say what and she turned around and left. The Administrator was asked, Did you call her back and ask what about (Resident # 6)? The Administrator stated, No. i. On 10/23/15 at 9:50 a.m., LPN # 7 was asked, Any concerns from (Resident # 6) regarding treatment from any one? LPN # 7 stated, Yes. LPN # 7 was asked, What did he say? LPN # 7 stated, That (CNA #14) was rough with him and wouldn't give him his clothes. Then he went down the hall and stopped at the next kiosk and stopped the CNA and said 'Did you hear about (CNA # 14) and the CNA said 'What about him?' and (Resident # 6) told the CNA he smacked me on the (expletive) and at that point I just put my stuff in the cart and went to (Administrator's) office and told her. LPN #7 was asked, You told her he said he's been smacked on the (expletive)? LPN # 7 stated, Yes. LPN # 7 was asked, When was that? LPN # 7 stated, One day last week. LPN # 7 was asked, Who was the CNA that (Resident # 6) was talking to? LPN # 7 stated, (CNA # 19), I think he had stayed over. LPN #7 was asked, Is (CNA # 19) here today? LPN #7 stated, Yes. LPN # 7 was asked, Could you go get him and come back with him? I need to try and get you two to pin down what day this happened on. LPN #7 left at 10:01 a.m. j. On 10/23/15 at 10:23 a.m., LPN #7 and CNA #19 brought in time records to compare what days they had worked together last week. LPN #7 stated, We don't have any idea what day. It was not on the 13th because I was off that day. I'm almost certain it was the 15th. We, (CNA #19), myself, and (CNA #14) were all here on that day, the 15th. LPN #7 and CNA #19 were asked, Did (Resident # 6) report this to you on a day that (CNA #14) worked a day shift? CNA # 19 stated, Yes, (Resident # 6) said he was rough with him and didn't wipe my (expletive) before he pulled my drawers up. LPN # 7 and CNA #19 were asked, Did (Resident # 6) say he'd been slapped? LPN # 7 stated, I thought he said (CNA # 14) had smacked him around. LPN #7 was asked, You told (Administrator) this? LPN # 7 stated, Yes. CNA # 19 stated, Since (LPN # 7) was going to tell (Administrator) I didn't report it. LPN #7 and CNA #19 were asked, Did either of you fill out a witness statement? LPN # 7 stated, Not then. We usually wait till we are asked and I wasn't asked for one until today. I'm certain I reported this to (Administrator) on 10/15/15. k. The employee time report provided by the Administrator on 10/23/15 at 9:12 a.m. documented CNA #14 worked on 10/13/15 from 2:49 p.m. to 11:11 p.m.; on 10/14/15 from 2:48 p.m. to 11:15 p.m.; on 10/15/15 from 6:53 a.m. to 11:00 p.m.; on 10/16/15 from 2:50 p.m. to 11:05 p.m.; and on 10/19/15 from 2:48 p.m. to 11:17 p.m. 2. Resident # 8 had [DIAGNOSES REDACTED]. The Quarterly MDS with an ARD of 8/7/15 documented the resident had severely impaired cognitive skills for daily decision making per a Staff Assessment of Mental Status (SAMS); had inattention, disorganized thinking, altered level of consciousness, and psychomotor [MEDICAL CONDITION] behaviors that were always present; and had no physical or verbal behaviors that were directed toward others. a. On 10/20/15 at 4:05 p.m., CNA # 15 was asked, Do you have concerns that abuse or neglect is occurring in the facility? CNA #15 stated, More than I've ever heard of it. CNA #15 was asked, Is that because residents or staff are telling you? CNA # 15 stated, Residents mostly. Here lately it's staff members who told me. I was told by (LPN # 6) and Housekeeper # 2 about an aide slapping a resident's hand . (Housekeeper # 2) told me about it . and I asked him if he filled out a witness statement and he said no, he was told to sign a paper saying he would report abuse to his supervisor. b. On 10/22/15 at 8:12 a.m. ,Housekeeper # 2 was asked, Have you ever seen any resident slapped by a staff member? Housekeeper #2 stated, Yes. Housekeeper # 2 was asked, Who was the resident? Housekeeper # 2 stated, (Resident # 8). Housekeeper #2 was asked, What happened? Housekeeper #2 stated, I was cleaning a room, coming out of the room when I turned around to go to my cart. (Resident # 8) was in her wheelchair in the hall at the linen cart and (Resident # 8) grabbed a CNA by her smock or shirt. I think it was (CNA #17). (Resident #8) had just reached up to get her snack, to get an oatmeal cake and the CNA took her hand and swatted the resident on the forearm. I told (LPN # 6) - she was right there passing meds. I asked (LPN # 6) did you see that and she said yes and I'm watching that. Housekeeper #2 was asked, That was all she said? Housekeeper #2 stated, Yes and from what I gather she went and told her supervisor but not while I seen it. Housekeeper #2 was asked, Did you tell anyone else? Housekeeper #2 stated, No, but I had to sign a paper that I had to tell my supervisor if it happened again. c. On 10/22/15 at 8:37 a.m. ,the Housekeeping Supervisor was asked, Have you ever seen any resident slapped by a staff member? The Housekeeping Supervisor stated, No. The Housekeeping Supervisor was asked, Have any of your staff reported that you? The Housekeeping Supervisor stated, No. I heard (Housekeeper #2) taking about it and I instructed him to let me know. The Housekeeping Supervisor was asked, When you heard him say that, who did you tell? The Housekeeping Supervisor stated, I told (LPN # 6). The Housekeeping Supervisor was asked, Did you ask (Housekeeper #2) to fill out a witness statement? The Housekeeping Supervisor stated, No, I failed to do that. Housekeeper #2 was asked, What did you understand (Housekeeper # 2) to say? The Housekeeping Supervisor stated, I understood him to say the CNA had slapped (Resident # 8's) hand. The Housekeeping Supervisor was asked, Is that abuse? The Housekeeping Supervisor stated, Yes and I'll go get a witness statement. The Housekeeping Supervisor was asked, What are you going to do after you get the witness statement? The Housekeeping Supervisor stated, Report it. The Housekeeping Supervisor was asked, How long ago did this happen? The Housekeeping Supervisor stated, Last week. The Housekeeping Supervisor was asked, Did you miss an important part of the incident? The Housekeeping Supervisor stated, Yes. I should have reported this last week. I'll go and take care of this right now. The Housekeeping Supervisor was asked to bring this surveyor a copy of Housekeeper # 2's witness statement and a copy of the disciplinary counseling done with Housekeeper #2. d. The Employee Warning Notice received from the Housekeeping Supervisor on 10/22/15 documented Employee Name: (Housekeeper # 2). Date of Incident: 10/12/15. Nature of Incident: Rule Violation. Description of Incident: On (page) 17 in your employee handbook it states if you see abuse or neglect or feel that you saw it you immediately come to you supervisor. If your supervisor is not available you report it to the ADON - Assistant Director of Nursing. Degree of Discipline: Document Counseling. Plan of Correction: If (Housekeeper # 2) feels he had witnessed abuse/neglect he will report directly to me or ADON. e. On 10/22/15 at 9:30 a.m., LPN # 6 was asked, Do you know anything about (Resident # 8) being slapped? LPN # 6 stated, I was there on the hall. I was 3 or 4 doors down from the resident and the housekeeper was only 1 door down from the resident. The resident and CNA were in the middle of the hall. The resident had gotten a snack from somewhere and had a handful of them. She was on a pureed diet and the aide was trying to get the snacks from her. The resident was getting combative when (CNA #18) was trying to get them and the resident slapped (CNA # 18) and you could hear a slap. I told (CNA #18) you need to just stop and let her be. That's when the housekeeper said 'Oh my god, did you just see that, she slapped her.' My initial thought was he's telling me that the resident slapped the CNA. I told (Housekeeper # 2) the resident is hitting her and she (CNA #18) is just trying to protect herself. LPN #6 was asked, Did you think he was alleging the CNA had slapped the resident? LPN # 6 stated, No. 3. The Immediate Jeopardy was removed and the scope/severity reduced to E on 10/22/15 at 5:00 p.m. when the facility implemented the following Plan of Removal: a. Beginning on 10/22/15 at 5:00 p.m., the facility identified 48 cognitively impaired residents at risk for abuse who scored below 13 on their BIMS from Section C of the MDS 3.0. b. Beginning at 5:00 p.m. on 10/22/15 body audits were initiated for these cognitively impaired residents with no significant findings. c. On 10/22/15 a one on one abuse training was conducted with the CEO (Chief Executive Officer/Administrator) by the RN (Registered Nurse) Regional MDS Consultant. Beginning on 10/22/15 a.m., all staff were in-serviced and training will be ongoing to include new hires and staff returning from leave. Training will take place before staff works on the floor. Training will be done by the CEO/DON/Designee and in-service sheets used. Training will include: a review of the abuse policy including identification of types of abuse, immediate resident protection to include the removal/suspension of the alleged perpetrator, reporting guidelines and investigation protocol. Training includes a verbal notification to the charge nurse of supervisor in charge, if the DON and/or CEO are not present in the facility. The charge nurse or supervisor will notify the CEO or DON immediately. The charge nurse or supervisor will remove the alleged abuser from the facility immediately and (the alleged abuser) will not be allowed in the facility pending the outcome of the investigation. d. The CEO/DON/designee will follow up on any verbal and written allegations of abuse and is to ensure the resident is protected, ensure the alleged perpetrator is suspended, and the investigative protocol is initiated and is completed per policy. Monitoring will be ongoing for 30 days to include evaluation of injuries of unknown origin for indications of potential abuse by the DON/designee; review of body audits for any indications of potential abuse by the treatment nurse or designee; random interviews will be conducted by CEO/DON/designee with 3 staff members per week covering all shifts to ensure staff knowledge of the abuse prohibition policy; and the CEO/DON /designee will conduct random interviews with 1 cognitively intact resident and 2 cognitively impaired residents regarding staff treatment toward them and other residents. Any negative findings will be reported immediately to the DON and CEO and corrective action taken.

Complaint # (AR 347) was substantiated (all or in part) in these findings. Complaint # (AR 352) was substantiated (all or in part) in these findings. Based on observation, record review and interview, the facility failed to ensure staff were competent in transfer skills and the use of mechanical lifts; and knowledgeable in the amount of assistance needed to perform a resident transfer to decrease the risk of transfer related injuries for 1 (Resident #1) of 5 (Residents #1, #2, #3, #6 and #7) case mix residents who required a Hoyer lift for transfers. This failed practice resulted in Immediate Jeopardy which caused or could have caused serious harm, injury or death to Resident #1, who sustained a fractured femur after sliding out of a wheelchair during a staff assisted transfer and had the potential to affect 21 residents who required the use of a Hoyer lift for transfers, as documented on a list provided by the Director of Nursing (DON) on 7/22/14 at 9:40 a.m. The DON and Administrator were notified of the Immediate Jeopardy on 7/23/14 at 4:09 p.m. The facility also failed to ensure transfer needs were promptly assessed and the axillae and clothing were not used to facilitate transfers to decrease the potential for transfer related injuries for 1 of 1 (Resident #4) case mix resident who required assistance for transfers. This failed practice had the potential to affect 25 residents who required assistance for transfers, according to a list provided by the Medicare Manager on 7/24/14 at 5:35 p.m. The findings are: 1. Resident #1 had [DIAGNOSES REDACTED]. A Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/17/14 documented the resident scored 15 (13-15 indicates cognitively intact) on the Brief Interview for Mental Status (BIMS), was totally dependent on the physical assistance of two-plus people for bed mobility, transfers, dressing and bathing, was totally dependent on the physical assistance of one person for locomotion and personal hygiene, was non-ambulatory, was unsteady and only able to stabilize with staff assistance when moving from a seated to a standing position and during surface-to-surface transfers, had limitation in range of motion of one upper and one lower extremity and used a wheelchair for mobility. a. The resident's Care Plan dated 10/17/13, and reviewed by staff 4/20/14, documented, "Problem Onset: 10/17/13, I need extensive staff assist with my activities of daily living... I require the use of a mechanical lift and 2 staff for all transfers; please be safe and transfer me correctly." b. The Resident Incident Report dated 6/30/14 at 8:30 p.m. documented, "Incident Type: Fall (with) / inj (injury) - witnessed; Type of Injury: Fracture; Location: Resident room; Equipment: Lift; Incident Level: Lvl (level) 3 - Significant Injury / Event; Activity at time: Lifting resident. Narrative of Incident: This nurse heard resident call out, upon entering room resident was in floor with CNA standing beside her, cath bag was hanging from the lift. When asked what happened CNA told this nurse resident slid out of lift. This nurse checked resident and told her I needed to go get help to get her out of floor. This nurse returned to resident(')s room with help and we moved her from the floor to bed. Resident complained of right hip and knee pain. Immediate Action Taken: Vitals taken. Full body assessment completed. Immediate Post - Incident Action: Inservice with all staff about the importance of two people with all residents that are lifts. 24 Hour Follow-up, Resident Condition after 24 hours: hospitalized ; Mobility: Transfer - with assist; Mental: Alert oriented (times) 2; 24 Hour condition and injury appearance: Resident has fx (fracture) to right femur and to medial femoral condyle; Narrative of Investigation: Incident Investigation This investigation is based on the principles of Root Cause Analysis 1. Who: (Resident #1) 2. What: fall from w/c (wheelchair) 3. When: 6/30/14 at 2030 (8:30 p.m.) 4. Where: resident room 5. Why: Upon investigation it was determined that resident slid out of w/c onto floor. Aide was going to transfer resident with Hoyer lift and noticed that lift pad was not properly under resident. Aide unhooked lift pad to properly place under resident when resident began sliding out of w/c seat. Aide was unable to keep resident from sliding, resident slid into floor. 6. New Intervention: All CNAs and nurses inserviced about proper use of Hoyer lift. Physical therapy to assess resident for proper positioning in w/c upon return from hospital." A Nurse's Notes entry by Licensed Practical Nurse (LPN) #2 was dated 7/1/14 at 12:46 a.m. and documented, "This nurse heard resident call out, upon entering room resident was in floor with CNA (Certified Nursing Assistant) standing beside her, cath (catheter) bag was hanging from the lift. When asked what happened CNA told this nurse resident slid out of lift. This nurse checked resident and told her I needed to go get help to get her out of floor. This nurse returned to residents room with help and we moved her from the floor to bed. Resident complained of right hip and knee pain. Inservice with all staff about the importance of two people with all residents that are lifts. Vitals taken. Full body assessment completed. Physician notified with orders to ship to ER (emergency room ). Family notified. This nurse called ER for report, Resident right head of femur fractured and where femur fractured where femur meets the knee." c. The Hospital Diagnostic Imaging Report dated 6/30/14 documented, "Two-View Right Femur and Two-View Right Tibia and Fibula: Evaluation of this patient is limited by body habitus. The right hip is not able to be optimally visualized. If there is clinical suspicion for right hip fracture, I would recommend the obtaining of an AP (anterior / posterior) pelvis and two - view right hip radiographic evaluation and / or CT (Computerized Tomography) scan of the right hip. Note is made of fracture of the distal right femur. There is fracture involving the medial femoral condyle of the distal right femur. Further evaluation by CT scan can be provided at clinical discretion. No fracture of the right tibia and fibula is identified on limited radiograph evaluation. Radiographs centered over the right knee can be provided. Impression: 1. Limited evaluation due to body habitus and patient positioning in this patient with a femoral fracture. 2. Fracture of the distal right femur involving the medial condyle. 3. Limited evaluation of the right hip and right knee. Further evaluation of these joints can be provided utilizing additional radiographic examinations centered to each joint and / or CT scan." 1) The Hospital History and Physical dated 7/1/14 at 6:37 a.m. documented, "Imaging: This is a pleasant [AGE] year-old female who is bed bound from her multiple sclerosis and lives at the nursing home. She sustained at least a distal femur fracture after a fall. There is report of a hip fracture as well though that is born out on these x-ray reports that I am reading currently. Plan: 1. Distal femur fracture - We will see what (physician) says about (t)his today. Her non-weight bearing status already at the nursing home may influence his decision. There is report of a hip fracture as well though that was not obvious on the x-ray report and I do not know if (physician) disagrees with the x-ray report or not, I will talk to him as the day goes on." 2) The Hospital Consult report dated 7/1/14 documented, "Chief Complaint: Right femur fracture. History of Present Illness: (Resident #1) is a pleasant [AGE] year-old woman who is essentially wheelchair and bed bound secondary to longstanding multiple sclerosis. She is a resident at (name of nursing home) where yesterday she was being moved by a Hoyer lift when she slipped out of it and sustained injury to her right lower extremity. She was evaluated in the emergency room and found to have a distal femur fracture. She was placed in a posterior splint and was admitted for supportive care. Orthopedics is consulted for her femur fracture. Medical Diagnosis: [REDACTED]. Physical Examination: Examination is limited to the right lower extremity. She has a posterior splint on to approximately the distal third of the leg. She moves her digits freely. The splint is not removed. She has no palpable tenderness in the groin. However, we are unable to really do a log roll because she complains of knee pain. The calf is not examined. X-rays: X-rays taken in the emergency room show a medial condylar fracture of the right distal femur. The hip does not show any obvious fracture at this time. Assessment: Right distal femur fracture. Plan: X-rays were reviewed. The case was discussed with the attending physician... He feels this is an inoperative situation. We will leave her in a posterior splint and see if we can have a potentially better splint made, but this will be difficult with her body habitus. We will continue to follow her. This should take three to four months to heal." d. The Office of Long Term Care (OLTC) Incident and Accident Report (DMS (Division of Medical Services)-7734) documented, "Date and Time Submitted... 07/01/2014... 10:50 a.m. Date (and) Time of Discovery: 06/30/2014... 9:00 p.m. ...Date of I&A (Incident and Accident): 06/30/2014... Time: 8:30 (p.m.) ... Summary of Incident... C.N.A. (Certified Nursing Assistant) was preparing to transfer resident from wheel chair to bed with a lift, the pad was not positioned under her correctly, C.N.A. was adjusting the lift pad (harness) and resident slid from wheel chair to floor, resident was sent to ER (emergency room ) for eval (evaluation) and X Ray report reveals resident has Femoral Fracture and Fracture of right distal femur involving the medial condyle... Steps Taken to Prevent Continued Abuse or Neglect During the Investigation.... C.N.A. was immediately suspended pending investigation. Inservice and education for lifts / transfers started for all nursing employees. Inservice on Abuse / Neglect. Review of personnel file. Interview of employees and alert cognitive residents on this hall..." The Facility Investigation Report for Resident Abuse, Neglect, Misappropriation of Property, And Exploitation of Residents in Long-Term Care Facilities (DMS-762) documented: "...Date Incident Reported to OLTC: 07/01/2014... Time: 10:50 a.m. Date and Time of Incident (if known): 06/30/14... Time: 8:30 p.m. ...Date and Time of Discovery: 06/30/2014... Time 9:00 p.m. ...Physical Functional Level / Impairment - Resident requires staff assistance with transfers using a lift and movement to lower extremities, assistance with ADL's (Activities of Daily Living). Resident is able to use her upper extremities. Resident does have some lack of coordination... Mental Functional Level - Resident is alert to people, place and some things, she does become forgetful at times... Complete Description of Incident... C.N.A. was preparing to transfer resident from wheel chair to bed with a lift, the pad was not positioned under her correctly. C.N.A. was adjusting the lift page (harness) and resident slide from wheel chair to floor, resident was sent to ER for eval and X Ray report reveals resident has Femoral Fracture and Fracture of right distal femur involving the medical condyle... Findings and Actions Taken... The C.N.A. was immediately suspended pending investigation as nurse was under impression that resident fell from the lift. Inservice and education for lifts / transfers started for nursing employees and in service on Abuse / Neglect... During the investigation the Administrator interviewed the nurse as the nurses statement stated the resident fell from the sling, nurse assumed the resident fell from the lift. In the statement with the C.N.A. (CNA #3) stated that the resident started sliding out of the chair to the floor. Administrator notified (CNA #3) that I needed her to come to the facility to meet with me. During the interview (CNA #3) was asked if resident fell from lift, (CNA #3) stated 'no I was readjusting her lift pad under her leg and she started sliding I tried to stop her however I could only slow it down.' (CNA #3) was asked to accompany the Administrator to a room and demonstrate what happened and placement of equipment. In the demonstration the Administrator, ADON (Assistant Director of Nursing), Therapist were in room with (CNA #3), the placement of equipment (lift, W/C etc.) were identical to what the nurse described during a telephone call with the Administrator. It is apparent (CNA #3) was adjusting the lift pad and resident started sliding. Resident has no control over lower extremities and when she starts leaning back to(o) far she will start sliding on the seat, resident is not able to stop herself. During further interview with the Therapist the residents positioning with de weighting her right side to allow (CNA #3) to move the lift pad distally on the left side (initiated) a positive pelvic tilt allowing resident to slide out of her W/C to the floor. Resident was moved to the bed with the lift from the floor and sent to hospital for Eval. X ray report was reviewed and waiting to see surgeon, the resident has DX (diagnoses) Multiple Sclerosis, Osteoarthritis, Muscle Weakness and Anemia. Upon the conclusion of the facility investigation (CNA #3) will be reinstated to work as the incident was not neglect or abuse and unfounded the investigation. The C.N.A. will be checked off on competency with transfers and including the lift prior to being reinstated. The administrator met with the residents father to review the investigation and that she did not fall from the lift, explained to the father what actually occurred and how, at this time he stated I can see that 'the surgeon had met with us and discouraged the surgery due to her bone condition and explained to the family that (Resident #1)'s bones are weak and would not be able to hold onto the hardware for surgery and since she uses a lift for transfers and she was not able to bear weight it is his (recommendation) to use a splint as with the condition of her bones the surgery would be high risk when she is using a lift for transfers', she has one fracture of the distal right femur involving the medial condyle... (signature of Administrator)... 07/07/14..." 1) A statement dated 6/30/14 and signed by CNA #3 documented, "I (CNA #3) was lifting (Resident #1) from her chair to the bed in the lift and I noticed the harness was not on proper and when I was repositioning it and she started sliding out of the chair to the floor she did not hit anything. The nurse came in and then went to get help to lift her back in her wheelchair and then we got her in the bed. Took vitals on her..." A second statement dated 7/1/14 and signed by CNA #3 documented, "I (CNA #3) was transferring (Resident #1) from her wheelchair to the bed. I used the lift on her. I was in the process of lifting her when I noticed the harness was sliding up her left side and then I lowered the lift and unhooked it from the lift. Had her lean to the right side, was repositioning the harness and then she started sliding. I moved the lift so she would not hit it and her left foot pushed against it to stop her from sliding more. I had the catheter bag on the bottom of the lift so it would not get caught from her sliding. Then the nurse came in and the nurse came in and seen what happened. She went to get help to get her lifted back in the chair. Harness repositioned right then we lifted her into the bed and removed the harness from her in the bed. Then she was saying her right hip was hurting, nurse checked it then called to have her sent out to get X-ray." 2) An undated statement signed by LPN #2 documented, "On 6-30-14 around 8:30 p.m. I was on E-Hall doing med (medication) pass when I heard (Resident #1) scream as if she was in pain. I stopped what I was doing to go see what had happened. When I entered the room she was in the floor, cath (catheter) bag hanging from the lift and CNA (CNA #3) standing beside her. I asked what happened. (CNA #3) stated she slid out of sling. I asked (Resident #1) if she was (okay) and explained to her I had to go get help. I returned with other staff members and we picked her up out of the floor and got her into bed." On 7/22/14 at 4:10 p.m., Licensed Practical Nurse (LPN) #2 was asked, "Were you at the facility the night (Resident #1) fell being transferred on June 30th?" The LPN stated, "Yes." The LPN was asked, "Can you tell me what happened?" The LPN stated, "That evening I was in the hall and heard (Resident #1) let out a cry like she needed help, I went to the room and she was in the floor and the CNA was beside her, the lift was by the night stand, catheter bag was hanging from the lift and the chair was by the bathroom door. The resident was in the floor in front of the chair and I asked the CNA what happened. She said she slid out of the lift. I got down on the floor, calmed her down and explained to her ... could not get her out of the floor by ourselves so I was going to get help. So I went and got help and I believe there was six of us to get her up out of the floor. All of us physically picked her up, we didn't use the lift or anything we physically picked her up out of the floor and we put her to bed. (Name of Advanced Practice Nurse), the APN (Advanced Practice Nurse) told me to ship her. I called the ambulance and notified her family." The LPN was asked, "Was the lift pad under her?" The LPN stated, "Part of the pad was under her." e. On 7/22/14 at 4:23 p.m., CNA #3 was asked, "What lift were you using when (Resident #1) fell ?" The CNA stated, "The Hoyer lift." The CNA was asked, "Were you by yourself?" The CNA stated, "Yes." The CNA was asked, "Can you tell me what happened?" The CNA stated, "I was raising her up and noticed the sling was sliding on her left. The sling was bunched up under her leg and started sliding up." The CNA was asked, "When you were picking her up?" The CNA stated, "Yes, I lowered the lift and unhooked it. I was going to go get help and she started sliding out of the chair and she couldn't stop and just kept going." The CNA was asked, "Did you try to straighten the pad?" The CNA stated, "I was trying to pull it out just to straighten it up where it was bunched up." The CNA was asked, "When you were trying to straighten the pad out, was she in the chair?" The CNA stated, "Yes." The CNA was asked, "When you were trying to adjust the pad is that when she started sliding?" The CNA stated, "Yes." The CNA was asked, "Was she (resident) trying to stop herself?" The CNA stated, "No, once she started she couldn't stop." The CNA was asked, "Is it common practice to use the lift by yourself?" The CNA stated, "I usually do it, that was the only time I've transferred her by myself." The CNA was asked, "Was that the first time you used the lift with her?" The CNA stated, "Yes, usually there is someone else on the hall that transfers her." The CNA was asked, "So someone else usually works that hall?" The CNA stated, "Yes, I'm usually on the small halls that they don't have to be lifted, A, D and F is usually where I work." The CNA was asked, "Had you been trained to use the Hoyer lift?" The CNA stated, "Yes." The CNA was asked, "How were you trained?" The CNA stated, "We had an in-service and they gave me a book to read and we had to sign a paper saying that we read it." The CNA was asked, "Who trained you?" The CNA stated, "I believe it was (Assistant Director of Nursing) who trained me but it's been awhile and I'm not sure. But after this happened, I was properly trained on how to use the Hoyer. I was showed how to properly hook the padding to the lift." The CNA was asked, "Was that different than what you were showed before?" The CNA stated, "Yes, one was showing me to hook the straps on the outside of the legs, but then I was shown the proper way with the straps hooked inside the legs." The CNA was asked, "When you were transferring (Resident #1) were they hooked inside the legs or the outside of the legs?" The CNA stated, "The outside ..." The CNA was asked, "How did you get her back to bed?" The CNA stated, "It took 5 or 6 other people and we put her in the chair, then after we got her in the chair we hooked her back up and put her in her bed using the Hoyer lift. After we got her back in the bed that's when she said her right hip on the top was bothering her really bad and that's when they sent her out to get checked." The CNA was asked, "During the in-service about the Hoyer lift did they show you how to use the lift?" The CNA stated, "They talked about it." f. On 7/22/14 at 4:58 p.m., the Assistant Director of Nursing (ADON) was asked, "Have you ever trained anyone on how to use the Hoyer lift?" The ADON stated, "I personally did not, I think we did an in-service for the training, but I was not the one who did the in-service. I do know that part of their orientation is we give them the manual to read and they sign that they have read it." The ADON was asked, "Do you know when the in-service was done?" The ADON stated, "I believe it was before our annual survey in May (2014), because we started shifting over to the Hoyer before the survey, it was right around that mark and they did get an in-service on how to use the Hoyer. We did one the next working day that I was here." The ADON was asked, "Was that after (Resident #1) had fallen?" The ADON stated, "Yes." The ADON was asked, "Who did the in-service?" The ADON stated, "I believe it was the maintenance man and the Administrator." g. On 7/23/14 at 9:10 a.m., the resident was asked, "I understand you had an accident and slid out of a wheel chair?" The resident stated, "Yes, I did." The resident was asked, "Can you tell me what happened?" The resident stated, "Well I was coming back from the shower and they were going to put me to bed. I told the girl you need two people to put me in bed and she said I can do it myself. I always tell them I need two people, so she hooked up the sling and it wasn't right so then she tried to fix it and I slid out of my chair. I broke my leg and had to go to the hospital." The resident was asked, "Did you slide out of the shower chair or out of the wheel chair?" The resident stated, "I slid out of the wheelchair I think." The resident was asked, "Do you hurt?" The resident stated, "Sometimes, right now it's throbbing around my knee." The resident was asked, "Did they tell you it would heal?" The resident stated, "I have to drink a lot of milk so the calcium has to build-up around the bone. I used to walk a little, but they tell me I will probably never do that again. But, it's all right; I forgive them. I always tell them you need two people to put me to bed, transfer me." The resident was asked, "Did you tell the aide that before you got hurt?" The resident stated, "Yes, but they (CNA) just said it's okay I can do it myself. I just started screaming and yelling because I was hurting." h. The Summary of Report of Meeting dated 7/1/14 was received from the Administrator on 7/22/14 at 3:30 p.m. documented, "Subjects Covered: When transferring a resident who is an extensive two person assist. You must have two people present in the room. Also, if when you start to transfer resident and notice the lift sling is not properly placed. you must lower resident back onto bed / chair before attempting to reposition lift sling." There was no documentation of a demonstration of the use of the Hoyer lift or return demonstrations by staff. At that time, the Administrator was asked for documentation of check-off of staff competency for the use of the Hoyer lift. On 7/23/14 at 1:00 p.m., the Administrator and DON were interviewed. The Administrator was asked, "Have you found any documentation of the in-service provided in May 2014?" The Administrator stated, "I don't think we did one then." The DON stated, "Yes we did, it was where we gave them all a copy of the lift book and had them sign that they read them." i. On 7/24/14 at 11:34 a.m., the Administrator was asked, "Do you have a policy and procedure on Mechanical Lift Transfers?" The Administrator stated, "Just the book." The Administrator was asked if the facility had the User Manual. The Administrator stated, "Yes." The Invacare Reliant 450 RPL450-2, Reliant 600 RPL600-2, Electric Portable Patient Lift, User Manual was received from the DON on 7/22/14 at 2:00 p.m. and documented, "2 Safety, 2.2 Operating Information, General, Warning DO NOT attempt any transfer without approval of the patient's physician, nurse or medical assistant. Thoroughly read the instructions in this Owner's Manual, observe a trained team of experts perform the lifting procedure and then perform the entire lift procedure several times with proper supervision and a capable individual acting as a patient." j. A review of the employee files of CNA #3 and 5 other CNAs was conducted on 7/24/14 at 3:00 p.m. There was no documentation of yearly performance evaluations or competency evaluations for the use of the Hoyer lift dated before June 30, 2014, the date of the incident. As of 7/24/14 at 6:30 p.m., at the time of exit, the Administrator had not provided documentation of a return demonstration on the use of the Hoyer lift by facility staff dated before June 30, 2014, the date of the incident. k. The Immediate Jeopardy was removed and the scope and severity reduced to a "H" on 7/23/14 at 5:00 p.m. when the facility implemented the following Plan of Removal: DNS (Director of Nursing Services) / Designee immediately started conducting re education including a demonstration and return demonstration of the Invacare Hoyer Lifts to each nursing employee prior to the nursing employee using an Invacare Hoyer Lift. DNS / Designee will conduct re education, demonstration and employee will conduct a return demonstration for the on coming shift. No Nursing Employee will use a Hoyer lift until they have received the re education, demonstration and completed a proper return demonstration, training and demonstration will be documented. All New nursing employees will receive the education, demonstration and completed a return demonstration during general orientation. DNS / Designee will monitor 5 Hoyer Transfers weekly for eight weeks, then three Hoyer Transfers weekly for eight weeks, then 1 thereafter, monitoring will be documented. Any negative findings will immediately receive 1-1 retraining, Education, Demonstration with a return demonstration. Surveyor: Long, Brandi 2. Resident #4 had [DIAGNOSES REDACTED]. The Quarterly MDS with an ARD of 5/26/14 documented the resident was severely impaired in cognitive skills for daily decision making per staff assessment for mental status, required extensive physical assistance of two-plus people for transfers and toileting, had a feeding tube and had experienced one fall since admission. a. The resident's Care Plan updated 5/27/14 documented, "I am at risk for falls related to weakness and impaired balance... Transfers with extensive assistance of two staff members..." b. On 7/21/14 at 6:15 p.m., CNA #1 and CNA #2 entered the resident's room pushing the resident in her wheelchair. CNA #2 stated, "Can't put the gait belt around her because the PEG (percutaneous endogastrostomy) tube; don't know cause we've never toileted her before." CNA #1 positioned the resident's wheelchair close to the commode and each CNA reached under the resident's arm, took hold of her pants and stood the resident to transfer, while attempting to pull down her brief and pants. The resident only stood on her tip toes during the transfer. The resident was then transferred back to the wheelchair using her arms, with shoulders visibly raised and her feet not touching the floor. CNA #2 stated, "I have asked for a lift assessment because she needs more help now. It's in the works. I asked about 2 weeks ago. It is a really slow process I guess but she just keeps getting worse." The resident was wheeled to the bed and again lifted under her arms, with her pants visibly up on the left side of the buttocks and her brief on the right side of the bottom. The resident did not bear any weight and her shoulders were raised as she was laid in the bed. CNA #2 stated, "She is a total lift now and never even put her feet down. She needs a lift before someone gets hurt The lift mobility assessment dated [DATE] at 7:28 p.m. and signed as completed by LPN #1 documented resident as unable to stand and pivot, dependent, unable to bear 50% of her weight and unable to follow simple directions. Resident could tolerate being in semi-reclined position. Resident assessed for standard sling type with 2 staff required for lift transfers. c. The facility Transfer Activities Policy was provided by the Administrator on 7/22/14 at 3:05 p.m. and documented, "...transfer equipment to include a gait belt to be used in transfers. Procedure documented... Do not support the resident under the arms..."

Complaint # (AR 347) was substantiated (all or in part) in these findings. Complaint # (AR 352) was substantiated (all or in part) in these findings. Based on observation, record review and interview, facility Administration and Nursing Administration failed to ensure staff were competent in transfer skills and the use of mechanical lifts; and knowledgeable in the amount of assistance needed to perform a resident transfer to decrease the risk of transfer related injuries for 1 (Resident #1) of 5 (Resident #1, #2, #3, #6 and #7) case mix residents who required a Hoyer lift for transfers. This failed practice resulted in Immediate Jeopardy which caused or could have caused serious harm, injury or death to Resident #1, who sustained a fractured femur after sliding out of a wheelchair during a staff assisted transfer and had the potential to affect 21 residents who required the use of a Hoyer lift for transfers, as documented on a list provided by the Director of Nursing (DON) on 7/22/14 at 9:40 a.m. The DON and Administrator were notified of the Immediate Jeopardy on 7/23/14 at 4:09 p.m. The findings are: 1. The Job Description and Performance Standards received from the Administrator on 7/24/14 at 9:40 a.m. documented, "Position Title: Administrator; Purpose of this position: 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. The primary functions and responsibilities of this position are as follows... 8. Supervise all department supervisors and administrative staff. 9. Supervise the recruitment, employment, performance, evaluation, promotion and discharge of all staff. 26. Establish systems to ensure compliance with all federal, state and local requirements." 2. The Job Description and Performance Standards received from the Administrator on 7/24/14 at 9:40 a.m. documented, "Position Title: Director of Nursing Services; Delegation of Authority: Authority is delegated to the individual in this position to: ...Set resident care standards in accordance with accepted current standards of care to provide high quality care to residents... Supervise and manage all aspects of the nursing department. The primary functions and responsibilities of this position are as follows: ...3. Direct, Evaluate and supervise all resident care and initiate corrective action as necessary. 4. Assess resident care needs and assist in development of individualized plans of resident care ...9. Assume responsibility for analysis of incident and accident investigation reports to determine cause(s) and implement corrective action(s), when appropriate... 15. Identify safety hazards and initiate corrective action... 17. Direct and implement nursing service educational programs including, but not limited to, orientation and in-service for licensed and unlicensed personnel ...20. Assume responsibility for nursing service compliance with federal, state, and local regulations ...44. Be responsible for safety of residents under his / her supervision." 3. Resident #1 had [DIAGNOSES REDACTED]. A Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/17/14 documented the resident scored 15 (13-15 indicates cognitively intact) on the Brief Interview for Mental Status (BIMS), was totally dependent on the physical assistance of two-plus people for bed mobility, transfers, dressing and bathing, was totally dependent on the physical assistance of one person for locomotion and personal hygiene, was non-ambulatory, was unsteady and only able to stabilize with staff assistance when moving from a seated to a standing position and during surface-to-surface transfers, had limitation in range of motion of one upper and one lower extremity and used a wheelchair for mobility. a. The resident's Care Plan dated 10/17/13, and reviewed by staff 4/20/14, documented, "Problem Onset: 10/17/13, I need extensive staff assist with my activities of daily living... I require the use of a mechanical lift and 2 staff for all transfers; please be safe and transfer me correctly." b. The Resident Incident Report dated 6/30/14 at 8:30 p.m. documented, "Incident Type: Fall (with) / inj (injury) - witnessed; Type of Injury: Fracture; Location: Resident room; Equipment: Lift; Incident Level: Lvl (level) 3 - Significant Injury / Event; Activity at time: Lifting resident. Narrative of Incident: This nurse heard resident call out, upon entering room resident was in floor with CNA standing beside her, cath bag was hanging from the lift. When asked what happened CNA told this nurse resident slid out of lift. This nurse checked resident and told her I needed to go get help to get her out of floor. This nurse returned to resident(')s room with help and we moved her from the floor to bed. Resident complained of right hip and knee pain. Immediate Action Taken: Vitals taken. Full body assessment completed. Immediate Post - Incident Action: Inservice with all staff about the importance of two people with all residents that are lifts. 24 Hour Follow-up, Resident Condition after 24 hours: hospitalized ; Mobility: Transfer - with assist; Mental: Alert oriented (times) 2; 24 Hour condition and injury appearance: Resident has fx (fracture) to right femur and to medial femoral condyle; Narrative of Investigation: Incident Investigation This investigation is based on the principles of Root Cause Analysis 1. Who: (Resident #1) 2. What: fall from w/c (wheelchair) 3. When: 6/30/14 at 2030 (8:30 p.m.) 4. Where: resident room 5. Why: Upon investigation it was determined that resident slid out of w/c onto floor. Aide was going to transfer resident with Hoyer lift and noticed that lift pad was not properly under resident. Aide unhooked lift pad to properly place under resident when resident began sliding out of w/c seat. Aide was unable to keep resident from sliding, resident slid into floor. 6. New Intervention: All CNAs and nurses inserviced about proper use of Hoyer lift. Physical therapy to assess resident for proper positioning in w/c upon return from hospital." A Nurse's Notes entry by Licensed Practical Nurse (LPN) #2 was dated 7/1/14 at 12:46 a.m. and documented, "This nurse heard resident call out, upon entering room resident was in floor with CNA (Certified Nursing Assistant) standing beside her, cath (catheter) bag was hanging from the lift. When asked what happened CNA told this nurse resident slid out of lift. This nurse checked resident and told her I needed to go get help to get her out of floor. This nurse returned to residents room with help and we moved her from the floor to bed. Resident complained of right hip and knee pain. Inservice with all staff about the importance of two people with all residents that are lifts. Vitals taken. Full body assessment completed. Physician notified with orders to ship to ER (emergency room ). Family notified. This nurse called ER for report, Resident right head of femur fractured and where femur fractured where femur meets the knee." c. The Hospital Diagnostic Imaging Report dated 6/30/14 documented, "Two-View Right Femur and Two-View Right Tibia and Fibula: Evaluation of this patient is limited by body habitus. The right hip is not able to be optimally visualized. If there is clinical suspicion for right [MEDICAL CONDITION], I would recommend the obtaining of an AP (anterior / posterior) pelvis and two - view right hip radiographic evaluation and / or CT (Computerized Tomography) scan of the right hip. Note is made of [MEDICAL CONDITION] right femur. There is fracture involving the medial femoral condyle of the distal right femur. Further evaluation by CT scan can be provided at clinical discretion. No [MEDICAL CONDITION] tibia and fibula is identified on limited radiograph evaluation. Radiographs centered over the right knee can be provided. Impression: 1. Limited evaluation due to body habitus and patient positioning in this patient with a femoral fracture. 2. [MEDICAL CONDITION] right femur involving the medial condyle. 3. Limited evaluation of the right hip and right knee. Further evaluation of these joints can be provided utilizing additional radiographic examinations centered to each joint and / or CT scan." 1) The Hospital History and Physical dated 7/1/14 at 6:37 a.m. documented, "Imaging: This is a pleasant [AGE] year-old female who is bed bound from her [MEDICAL CONDITION] and lives at the nursing home. She sustained at least a distal femur fracture after a fall. There is report of a [MEDICAL CONDITION] as well though that is born out on these x-ray reports that I am reading currently. Plan: 1. Distal femur fracture - We will see what (physician) says about (t)his today. Her non-weight bearing status already at the nursing home may influence his decision. There is report of a [MEDICAL CONDITION] as well though that was not obvious on the x-ray report and I do not know if (physician) disagrees with the x-ray report or not, I will talk to him as the day goes on." 2) The Hospital Consult report dated 7/1/14 documented, "Chief Complaint: Right femur fracture. History of Present Illness: (Resident #1) is a pleasant [AGE] year-old woman who is essentially wheelchair and bed bound secondary to longstanding [MEDICAL CONDITION]. She is a resident at (name of nursing home) where yesterday she was being moved by a Hoyer lift when she slipped out of it and sustained injury to her right lower extremity. She was evaluated in the emergency room and found to have a distal femur fracture. She was placed in a posterior splint and was admitted for supportive care. Orthopedics is consulted for her femur fracture. Medical Diagnosis: [REDACTED]. Physical Examination: Examination is limited to the right lower extremity. She has a posterior splint on to approximately the distal third of the leg. She moves her digits freely. The splint is not removed. She has no palpable tenderness in the groin. However, we are unable to really do a log roll because she complains of knee pain. The calf is not examined. X-rays: X-rays taken in the emergency room show a medial condylar [MEDICAL CONDITION] distal femur. The hip does not show any obvious fracture at this time. Assessment: Right distal femur fracture. Plan: X-rays were reviewed. The case was discussed with the attending physician... He feels this is an inoperative situation. We will leave her in a posterior splint and see if we can have a potentially better splint made, but this will be difficult with her body habitus. We will continue to follow her. This should take three to four months to heal." d. The Office of Long Term Care (OLTC) Incident and Accident Report (DMS (Division of Medical Services)-7734) documented, "Date and Time Submitted... 07/01/2014... 10:50 a.m. Date (and) Time of Discovery: 06/30/2014... 9:00 p.m. ...Date of I&A (Incident and Accident): 06/30/2014... Time: 8:30 (p.m.) ... Summary of Incident... C.N.A. (Certified Nursing Assistant) was preparing to transfer resident from wheel chair to bed with a lift, the pad was not positioned under her correctly, C.N.A. was adjusting the lift pad (harness) and resident slid from wheel chair to floor, resident was sent to ER (emergency room ) for eval (evaluation) and X Ray report reveals resident has Femoral Fracture and Fracture of right distal femur involving the medial condyle... Steps Taken to Prevent Continued Abuse or Neglect During the Investigation.... C.N.A. was immediately suspended pending investigation. Inservice and education for lifts / transfers started for all nursing employees. Inservice on Abuse / Neglect. Review of personnel file. Interview of employees and alert cognitive residents on this hall..." The Facility Investigation Report for Resident Abuse, Neglect, Misappropriation of Property, And Exploitation of Residents in Long-Term Care Facilities (DMS-762) documented: "...Date Incident Reported to OLTC: 07/01/2014... Time: 10:50 a.m. Date and Time of Incident (if known): 06/30/14... Time: 8:30 p.m. ...Date and Time of Discovery: 06/30/2014... Time 9:00 p.m. ...Physical Functional Level / Impairment - Resident requires staff assistance with transfers using a lift and movement to lower extremities, assistance with ADL's (Activities of Daily Living). Resident is able to use her upper extremities. Resident does have some lack of coordination... Mental Functional Level - Resident is alert to people, place and some things, she does become forgetful at times... Complete Description of Incident... C.N.A. was preparing to transfer resident from wheel chair to bed with a lift, the pad was not positioned under her correctly. C.N.A. was adjusting the lift page (harness) and resident slide from wheel chair to floor, resident was sent to ER for eval and X Ray report reveals resident has Femoral Fracture and Fracture of right distal femur involving the medical condyle... Findings and Actions Taken... The C.N.A. was immediately suspended pending investigation as nurse was under impression that resident fell from the lift. Inservice and education for lifts / transfers started for nursing employees and in service on Abuse / Neglect... During the investigation the Administrator interviewed the nurse as the nurses statement stated the resident fell from the sling, nurse assumed the resident fell from the lift. In the statement with the C.N.A. (CNA #3) stated that the resident started sliding out of the chair to the floor. Administrator notified (CNA #3) that I needed her to come to the facility to meet with me. During the interview (CNA #3) was asked if resident fell from lift, (CNA #3) stated 'no I was readjusting her lift pad under her leg and she started sliding I tried to stop her however I could only slow it down.' (CNA #3) was asked to accompany the Administrator to a room and demonstrate what happened and placement of equipment. In the demonstration the Administrator, ADON (Assistant Director of Nursing), Therapist were in room with (CNA #3), the placement of equipment (lift, W/C etc.) were identical to what the nurse described during a telephone call with the Administrator. It is apparent (CNA #3) was adjusting the lift pad and resident started sliding. Resident has no control over lower extremities and when she starts leaning back to(o) far she will start sliding on the seat, resident is not able to stop herself. During further interview with the Therapist the residents positioning with de weighting her right side to allow (CNA #3) to move the lift pad distally on the left side (initiated) a positive pelvic tilt allowing resident to slide out of her W/C to the floor. Resident was moved to the bed with the lift from the floor and sent to hospital for Eval. X ray report was reviewed and waiting to see surgeon, the resident has DX (diagnoses) [MEDICAL CONDITIONS], Muscle Weakness and [MEDICAL CONDITION]. Upon the conclusion of the facility investigation (CNA #3) will be reinstated to work as the incident was not neglect or abuse and unfounded the investigation. The C.N.A. will be checked off on competency with transfers and including the lift prior to being reinstated. The administrator met with the residents father to review the investigation and that she did not fall from the lift, explained to the father what actually occurred and how, at this time he stated I can see that 'the surgeon had met with us and discouraged the surgery due to her bone condition and explained to the family that (Resident #1)'s bones are weak and would not be able to hold onto the hardware for surgery and since she uses a lift for transfers and she was not able to bear weight it is his (recommendation) to use a splint as with the condition of her bones the surgery would be high risk when she is using a lift for transfers', she has one [MEDICAL CONDITION] right femur involving the medial condyle... (signature of Administrator)... 07/07/14..." 1) A statement dated 6/30/14 and signed by CNA #3 documented, "I (CNA #3) was lifting (Resident #1) from her chair to the bed in the lift and I noticed the harness was not on proper and when I was repositioning it and she started sliding out of the chair to the floor she did not hit anything. The nurse came in and then went to get help to lift her back in her wheelchair and then we got her in the bed. Took vitals on her..." A second statement dated 7/1/14 and signed by CNA #3 documented, "I (CNA #3) was transferring (Resident #1) from her wheelchair to the bed. I used the lift on her. I was in the process of lifting her when I noticed the harness was sliding up her left side and then I lowered the lift and unhooked it from the lift. Had her lean to the right side, was repositioning the harness and then she started sliding. I moved the lift so she would not hit it and her left foot pushed against it to stop her from sliding more. I had the catheter bag on the bottom of the lift so it would not get caught from her sliding. Then the nurse came in and the nurse came in and seen what happened. She went to get help to get her lifted back in the chair. Harness repositioned right then we lifted her into the bed and removed the harness from her in the bed. Then she was saying her right hip was hurting, nurse checked it then called to have her sent out to get X-ray." 2) An undated statement signed by LPN #2 documented, "On 6-30-14 around 8:30 p.m. I was on E-Hall doing med (medication) pass when I heard (Resident #1) scream as if she was in pain. I stopped what I was doing to go see what had happened. When I entered the room she was in the floor, cath (catheter) bag hanging from the lift and CNA (CNA #3) standing beside her. I asked what happened. (CNA #3) stated she slid out of sling. I asked (Resident #1) if she was (okay) and explained to her I had to go get help. I returned with other staff members and we picked her up out of the floor and got her into bed." On 7/22/14 at 4:10 p.m., Licensed Practical Nurse (LPN) #2 was asked, "Were you at the facility the night (Resident #1) fell being transferred on June 30th?" The LPN stated, "Yes." The LPN was asked, "Can you tell me what happened?" The LPN stated, "That evening I was in the hall and heard (Resident #1) let out a cry like she needed help, I went to the room and she was in the floor and the CNA was beside her, the lift was by the night stand, catheter bag was hanging from the lift and the chair was by the bathroom door. The resident was in the floor in front of the chair and I asked the CNA what happened. She said she slid out of the lift. I got down on the floor, calmed her down and explained to her ... could not get her out of the floor by ourselves so I was going to get help. So I went and got help and I believe there was six of us to get her up out of the floor. All of us physically picked her up, we didn't use the lift or anything we physically picked her up out of the floor and we put her to bed. (Name of Advanced Practice Nurse), the APN (Advanced Practice Nurse) told me to ship her. I called the ambulance and notified her family." The LPN was asked, "Was the lift pad under her?" The LPN stated, "Part of the pad was under her." e. On 7/22/14 at 4:23 p.m., CNA #3 was asked, "What lift were you using when (Resident #1) fell ?" The CNA stated, "The Hoyer lift." The CNA was asked, "Were you by yourself?" The CNA stated, "Yes." The CNA was asked, "Can you tell me what happened?" The CNA stated, "I was raising her up and noticed the sling was sliding on her left. The sling was bunched up under her leg and started sliding up." The CNA was asked, "When you were picking her up?" The CNA stated, "Yes, I lowered the lift and unhooked it. I was going to go get help and she started sliding out of the chair and she couldn't stop and just kept going." The CNA was asked, "Did you try to straighten the pad?" The CNA stated, "I was trying to pull it out just to straighten it up where it was bunched up." The CNA was asked, "When you were trying to straighten the pad out, was she in the chair?" The CNA stated, "Yes." The CNA was asked, "When you were trying to adjust the pad is that when she started sliding?" The CNA stated, "Yes." The CNA was asked, "Was she (resident) trying to stop herself?" The CNA stated, "No, once she started she couldn't stop." The CNA was asked, "Is it common practice to use the lift by yourself?" The CNA stated, "I usually do it, that was the only time I've transferred her by myself." The CNA was asked, "Was that the first time you used the lift with her?" The CNA stated, "Yes, usually there is someone else on the hall that transfers her." The CNA was asked, "So someone else usually works that hall?" The CNA stated, "Yes, I'm usually on the small halls that they don't have to be lifted, A, D and F is usually where I work." The CNA was asked, "Had you been trained to use the Hoyer lift?" The CNA stated, "Yes." The CNA was asked, "How were you trained?" The CNA stated, "We had an in-service and they gave me a book to read and we had to sign a paper saying that we read it." The CNA was asked, "Who trained you?" The CNA stated, "I believe it was (Assistant Director of Nursing) who trained me but it's been awhile and I'm not sure. But after this happened, I was properly trained on how to use the Hoyer. I was showed how to properly hook the padding to the lift." The CNA was asked, "Was that different than what you were showed before?" The CNA stated, "Yes, one was showing me to hook the straps on the outside of the legs, but then I was shown the proper way with the straps hooked inside the legs." The CNA was asked, "When you were transferring (Resident #1) were they hooked inside the legs or the outside of the legs?" The CNA stated, "The outside ..." The CNA was asked, "How did you get her back to bed?" The CNA stated, "It took 5 or 6 other people and we put her in the chair, then after we got her in the chair we hooked her back up and put her in her bed using the Hoyer lift. After we got her back in the bed that's when she said her right hip on the top was bothering her really bad and that's when they sent her out to get checked." The CNA was asked, "During the in-service about the Hoyer lift did they show you how to use the lift?" The CNA stated, "They talked about it." f. On 7/22/14 at 4:58 p.m., the Assistant Director of Nursing (ADON) was asked, "Have you ever trained anyone on how to use the Hoyer lift?" The ADON stated, "I personally did not, I think we did an in-service for the training, but I was not the one who did the in-service. I do know that part of their orientation is we give them the manual to read and they sign that they have read it." The ADON was asked, "Do you know when the in-service was done?" The ADON stated, "I believe it was before our annual survey in May (2014), because we started shifting over to the Hoyer before the survey, it was right around that mark and they did get an in-service on how to use the Hoyer. We did one the next working day that I was here." The ADON was asked, "Was that after (Resident #1) had fallen?" The ADON stated, "Yes." The ADON was asked, "Who did the in-service?" The ADON stated, "I believe it was the maintenance man and the Administrator." g. On 7/23/14 at 9:10 a.m., the resident was asked, "I understand you had an accident and slid out of a wheel chair?" The resident stated, "Yes, I did." The resident was asked, "Can you tell me what happened?" The resident stated, "Well I was coming back from the shower and they were going to put me to bed. I told the girl you need two people to put me in bed and she said I can do it myself. I always tell them I need two people, so she hooked up the sling and it wasn't right so then she tried to fix it and I slid out of my chair. I broke my leg and had to go to the hospital." The resident was asked, "Did you slide out of the shower chair or out of the wheel chair?" The resident stated, "I slid out of the wheelchair I think." The resident was asked, "Do you hurt?" The resident stated, "Sometimes, right now it's throbbing around my knee." The resident was asked, "Did they tell you it would heal?" The resident stated, "I have to drink a lot of milk so the calcium has to build-up around the bone. I used to walk a little, but they tell me I will probably never do that again. But, it's all right; I forgive them. I always tell them you need two people to put me to bed, transfer me." The resident was asked, "Did you tell the aide that before you got hurt?" The resident stated, "Yes, but they (CNA) just said it's okay I can do it myself. I just started screaming and yelling because I was hurting." h. The Summary of Report of Meeting dated 7/1/14 was received from the Administrator on 7/22/14 at 3:30 p.m. documented, "Subjects Covered: When transferring a resident who is an extensive two person assist. You must have two people present in the room. Also, if when you start to transfer resident and notice the lift sling is not properly placed. you must lower resident back onto bed / chair before attempting to reposition lift sling." There was no documentation of a demonstration of the use of the Hoyer lift or return demonstrations by staff. At that time, the Administrator was asked for documentation of check-off of staff competency for the use of the Hoyer lift. On 7/23/14 at 1:00 p.m., the Administrator and DON were interviewed. The Administrator was asked, "Have you found any documentation of the in-service provided in May 2014?" The Administrator stated, "I don't think we did one then." The DON stated, "Yes we did, it was where we gave them all a copy of the lift book and had them sign that they read them." i. On 7/24/14 at 11:34 a.m., the Administrator was asked, "Do you have a policy and procedure on Mechanical Lift Transfers?" The Administrator stated, "Just the book." The Administrator was asked if the facility had the User Manual. The Administrator stated, "Yes." The Invacare Reliant 450 RPL450-2, Reliant 600 RPL600-2, Electric Portable Patient Lift, User Manual was received from the DON on 7/22/14 at 2:00 p.m. and documented, "2 Safety, 2.2 Operating Information, General, Warning DO NOT attempt any transfer without approval of the patient's physician, nurse or medical assistant. Thoroughly read the instructions in this Owner's Manual, observe a trained team of experts perform the lifting procedure and then perform the entire lift procedure several times with proper supervision and a capable individual acting as a patient." j. A review of the employee files of CNA #3 and 5 other CNAs was conducted on 7/24/14 at 3:00 p.m. There was no documentation of yearly performance evaluations or competency evaluations for the use of the Hoyer lift dated before June 30, 2014, the date of the incident. As of 7/24/14 at 6:30 p.m., at the time of exit, the Administrator had not provided documentation of a return demonstration on the use of the Hoyer lift by facility staff dated before June 30, 2014, the date of the incident. k. The Immediate Jeopardy was removed and the scope and severity reduced to a "H" on 7/23/14 at 5:00 p.m. when the facility implemented the following Plan of Removal: DNS (Director of Nursing Services) / Designee immediately started conducting re education including a demonstration and return demonstration of the Invacare Hoyer Lifts to each nursing employee prior to the nursing employee using an Invacare Hoyer Lift. DNS / Designee will conduct re education, demonstration and employee will conduct a return demonstration for the on coming shift. No Nursing Employee will use a Hoyer lift until they have received the re education, demonstration and completed a proper return demonstration, training and demonstration will be documented. All New nursing employees will receive the education, demonstration and completed a return demonstration during general orientation. DNS / Designee will monitor 5 Hoyer Transfers weekly for eight weeks, then three Hoyer Transfers weekly for eight weeks, then 1 thereafter, monitoring will be documented. Any negative findings will immediately receive 1-1 retraining, Education, Demonstration with a return demonstration.

Based on observation, record review and interview, the facility failed to ensure a planned fall prevention intervention for the use of a Bolster Mattress was promptly implemented to prevent further falls for 1 (Resident #11) of 3 (Residents #2, #9 and #11) case mix residents who had a history of [REDACTED]. This failed practice resulted in actual harm for Resident #1, who sustained a thoracic spine and rib fractures, and had the potential to cause more than minimal harm to 8 residents who were care planned for a bolster mattress, to reduce the risk of fall preventions according to a list provided by the Director of Nurses on 8/19/11 at 10:30 a.m. The findings are: Resident #11 had [DIAGNOSES REDACTED]. The Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/5/11 documented the resident scored 13 (13-15 indicates cognitively intact) per a Brief Interview for Mental Status, required limited assistance for bed mobility, transfer, and toilet use and had a fall in the last month prior to admission. a. An Incident Investigation form dated 8/12/11 at 8:15 a.m. documented, "...Was found on hands and knees next to bed with blood coming from nose... New Intervention: Upon return from hosp (hospital), will put bolster mattress on bed and apply PSA (pressure sensor alarm) to bed and chair..." At the bottom of the form was a handwritten note from the DON that documented, "X-Ray results showed fx (fractured) nasal bone and ligament injury in C (cervical)-spine Res (Resident) returned from hosp the same day she left on 8/12/11 - Did use PSA in bed/chair but then she fell the very next day and left facility again. Bolster mattress placed (after) 2nd (second) fall." b. The Care Plan updated on 8/12/11 documented, "PSA in bed/chair upon RTF (return to facility)." The entry, "bolster mattress in bed" was marked out. c. An Incident Investigation form dated 8/13/11 at 1:00 a.m. documented, "...Nurse called to room and resident was lying on floor face down... EMS (Emergency Medical Service) called... New Interventions: Resident sent to hosp, upon return she was placed 1 on 1 with staff and bolster mattress placed on bed..." At the bottom of the form was a handwritten note from the DON which documented, "Res obtained T (thoracic) 1, T10, T12 and rib fx's (fractures)." d. On 8/15/11 at2:05 p.m., during initial rounds the resident was in bed with her eye closed with a neck brace in place. The DON stated the resident was alert, confused, combative, has a history of falls and had a neck fracture. e. On 8/17/11 at 3:52 p.m., the DON was asked why the bolster mattress intervention was not implemented after the first fall on 8/12/11. The DON stated, "The reason I didn't put the mattress on the first day was because I thought she was being admitted to the hospital. She left the facility at 8:00 a.m. or 8:30 a.m. on 8/12/11 and returned that evening. I was already home and they called and told me she was back. I told them to put the pressure sensor alarm on. I didn't even think about the mattress... I thought she wasn't going to come back right then or I would have already had it set up." f. On 8/18/11 at 2:25 p.m., the DON stated, "I know the bolster mattress may not have kept her from falling, but it could have."