Every finding on record at The Springs of Park Ave

Based on observation, interview, record review, and facility policy review, it was determined the facility did not ensure incontinence care was provided in a manner that was timely and promoted cleanliness, good hygiene, and/or prevented infection for two (Resident #27 and Resident #54) of two sampled residents. The findings include: Resident #27 During an observation on 08/03/2025 at 11:59 AM, this surveyor observed Certified Nursing Assistant (CNA) #1 provide incontinence care to Resident #27. CNA #1 had the resident roll to their left side. This surveyor noted Resident #27's incontinence brief was saturated with urine, there were two wet incontinence pads, and the resident's fitted sheet was wet. CNA #1 wiped the resident's buttocks towards their genitals. The direction in which CNA #1 cleaned the resident's genital area could introduce bacteria into the body and cause an infection. This surveyor noted when Resident #27 was rolled to the right side, their gown was wet from just below the waist to above the left knee. CNA #1 did not clean Resident #27's left side, which also appeared to have been in contact with the wet linens. During an observation on 08/05/2025 at 9:25 AM, this surveyor observed CNA #3 provide incontinence care to Resident #27. Resident #27 was rolled to their left side, and this surveyor noted the resident's gown, incontinence pad, and fitted sheet were wet. CNA #3 did not clean the resident's genital area thoroughly to promote cleanliness and prevent infection. A review of Resident #27's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/26/2025, revealed a Brief Interview of Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. Resident #27's MDS also revealed the resident was always incontinent of bowel and bladder. A review Resident #27's Care Plan Report, with a revision date of 05/22/2025, revealed the resident was at risk for impaired skin integrity related to decreased mobility. Resident #27's Care Plan Report included an intervention to provide incontinent care and perineal care as needed. During an interview on 08/03/2025 at 11:45 AM, Resident #27 was very upset and stated the weekend staff was horrible. Resident #27 stated they had been incontinent and were waiting for someone to provide care, due to their inability to ambulate. The resident's call light was on at the time. Resident #27 stated that a male CNA had responded to their call light earlier, but he made the resident nervous, with all that jumping around. I guess he is nervous because you all are here. Resident #27 stated they asked for a different CNA. When this surveyor asked why the resident had two incontinence pads under them, Resident #27 stated staff do not change the resident in time. This surveyor asked the resident when the last time they received care was, and Resident #27 stated 6:00 am. During an interview on 08/03/2025 at 2:48 PM, CNA #1 confirmed Resident #27's incontinence pads, bed sheets, and gown were wet with urine. CNA #1 described the incontinence brief as very wet and stated that was the first time she had provided care to Resident #27. CNA #1 stated there were two aides working the hall, with herself included. CNA #1 stated she wiped towards the resident's genital area while wiping the resident's buttocks. CNA #1 confirmed she did not clean Resident #27's left side, which possibly left the resident in a cold and germy condition. During an interview on 08/03/2025 at 3:04 PM, CNA #2 stated he was the second aide on the hall, and he had not provided any care to Resident #27 on this day. During an interview on 08/05/2025 at 9:44 AM, CNA #3 confirmed the resident's incontinence pad, gown, fitted sheet, and flat sheet were wet. CNA #3 described the incontinence brief as pretty wet. CNA #3 confirmed that she did not clean the resident's genital area thoroughly. Resident #54 During an observation on 08/03/2025 at 2:35 PM, this surveyor observed CNA #1 completing incontinence care with Resident #54. This surveyor noted the room smelled of urine and there were two wet incontinence pads and wet bed linens on the floor. A review of Resident #54's admission MDS with an ARD of 05/06/2025, revealed a BIMS score of 13, which indicated the resident was cognitively intact. Resident #54's MDS also revealed the resident was always incontinent of bowel and bladder. A review of Resident #54's Care Plan Report, with a revision date of 05/04/2025, revealed the resident was at risk for impaired skin integrity. Resident #54's Care Plan Report included an intervention to provide incontinence care and perineal care as needed. The Care Plan Report also revealed Resident #54 had an activities of daily living self-care performance deficit related to limited mobility. During an interview on 08/03/2025 at 2:36 PM, CNA #1 confirmed the two incontinence pads and Resident #54's bed linens were wet. CNA #1 also stated she did not have the time to get a bag. During an interview on 08/06/2025 at 8:15 AM, the Director of Nursing (DON) stated staff were instructed to place one incontinence pad under the resident. The DON stated placing two incontinence pads under a resident could lead to maceration and/or skin breakdown. The DON stated if she noted two incontinence pads, the resident's fitted sheet, and gown were wet, then the aides were not doing rounds in a timely manner. The DON also stated that when staff provided incontinence care to a resident, they should wipe away from the genitals. The DON explained wherever the resident's wet gown touched should be cleaned, to prevent skin break down and avoid a dignity issue. During an interview on 08/06/2025 at 9:35 AM, the Administrator stated that staff should wipe away from the genital area and ensure the resident's genitals were cleaned thoroughly. A review of an untitled in-service dated, 08/03/2025 noted, Do not double brief residents if a resident is a heavy wetter the increase rounds or assist them up to toilet. Extra layers lead to skin maceration and breakdown of tissue. A review of the policy titled Perineal Care, revised February 2018 noted, the purpose of this procedure is to provide cleanliness and comfort to the resident, to prevent infection and skin irritation. A review of the policy tilted Activities of Daily Living (ADLs), Supporting, revised March 2018, Resident who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene.

Based on observation, interview, and facility document review, the facility failed to ensure meals were prepared and served according to the planned written menu to meet the nutritional needs of the residents for one of one meal observed. The findings include: During an observation on 08/03/2025 at 12:43 PM, this surveyor observed Dietary [NAME] (DC) #7 use a #20 scoop, which was equal to 1.5 ounces, to serve a single portion of ground roast turkey to the residents who received mechanical soft diets instead of 3 ounces, per the menu. During an observation and interview on 08/03/2025 at 12:48 PM, this surveyor observed DC #7 using a #12 scoop, which was equal to 1/3 cup, to serve a single portion of pureed baked sweet potato, instead of 1/2 cup per the menu. DC #7 also used the #12 scoop (1/3 cup) to serve a single portion of pureed cut green beans, instead of a 3/8 cup per the menu. This surveyor also observed DC #7 use a #16 scoop, which was equal to 1/4 cup, to serve a single portion of pureed ham, instead of a 1/3 cup as per the menu. In addition, this surveyor observed there were no pureed dinner rolls, or any pureed peach cobbler prepared at the noon meal for the residents on pureed diets. During an interview on 08/03/25 at 1:22 PM, DC 7 stated that he did look at the menu before serving the lunch meal but forgot to make sure the right scoops were used. A review of the noon meal menu on 08/03/2025 indicated that residents on pureed diets were to receive a 1/3 cup of pureed dinner roll and a 3/8 cup of pureed peach cobbler each. During an interview on 08/03/2025 1:29 PM, this surveyor asked DC #4 why there were no rolls or dessert served to the residents on pureed diets, per the menu, and DC #4 stated she was in a rush and forgot to puree the dinner roll and dessert.

Based on observation, interview, and facility policy review, the facility failed to ensure that food items stored in the freezer were covered or sealed, that dietary staff washed their hands between handling dirty and clean equipment, and hot food items were maintained at the required temperatures for one of one meal observed. The findings include: During a concurrent observation and interview on 08/03/2025 at 10:29 AM, this surveyor observed an open box of fish on a shelf in the freezer. The box was not covered or sealed, which exposed it to freezer burn and cross contamination. Dietary [NAME] (DC) #4 stated leaving the box open would cause the food to have freezer burn or could cause potential cross contamination. During a concurrent observation and interview on 08/03/2025 at 11:08 AM, DC #4 pushed the blender motor to the edge of the counter, contaminating her hands. Without washing her hands, she used her bare hand to pick up a clean blade and attached it to the base of the blender to puree food items for the residents who received pureed diets. This surveyor asked DC #4 what she should have done after touching dirty objects and before handling clean equipment. DC #4 confirmed she should have washed her hands. During a concurrent observation and interview on 08/23/2025 at 11:20 AM, Dietary Aide (DA) #5 wiped off the dish washer temperature gauge with his bare hand, which contaminated his hands. Without washing his hands, DA #5 picked up a clean blade and attached it to the base of the blender to puree food items to be served to the residents who received pureed diets. DA #5 confirmed he should have washed his hands. During an observation on 08/03/2025 at 11:23 AM, DA #6 turned on the hand washing sink and washed his hands. Afterwards, he used a tissue to turn off the faucet and then used the same tissue to dry his hands, thereby contaminating them. Without rewashing his hands, DA #6 picked up bowls, with his fingers inside the bowls, and placed them on the resident's meal trays. DA #6 confirmed he should have rewashed his hands. During a concurrent observation and interview on 08/03/2025 at 11:50 AM, this surveyor observed DA #6 turn on the hand washing sink and wash his hands. After washing and drying his hands, he used his bare hand to lift the lid of the trash can and throw the tissue away, which contaminated his hand. Without rewashing his hands, he picked up a glass by the rim and poured a beverage to serve to a resident. The Dietary Manager and DA #6 confirmed that hands should have been washed after touching the trash can. During a concurrent observation and interview on 08/03/2025 at 12:27 PM, the temperatures of the food items on the kitchen steam table, which were checked and read by DC #7, resulted as: a. Regular roast turkey 125 degrees Fahrenheit, instead of 135 degrees Fahrenheit or above per the regulation. b. Pureed roast turkey 118.5 degrees Fahrenheit, instead of 135 degrees Fahrenheit or above per the regulation. DC #7 verified the above food items were not reheated before being served to the residents and stated he should have reheated them. A review of a facility policy titled Quick Resource Tool Safe Storage of Food indicated, all foods will be stored wrapped or in covered containers and arranged in a manner to prevent cross contamination. A review of a facility policy titled Food and Nutrition Services Quick Resource Tool: QRT Hand Washing indicated, It's important to wash your hands before starting to work with food, utensils, or equipment and as often as needed during food preparation and when changing tasks.

Based on observation, record review, interview, and facility policy review, the facility failed to ensure that staff followed Enhanced Barrier Precautions (EBP) by wearing required Personal Protection Equipment (PPE), and staff failed to change their gloves during perineal care for a resident on EBP before touching resident ' s lift pad, clean brief, clothing, and linens to prevent cross contamination and the risk for infection for 1 of 1 sampled (Resident #6) resident. Findings include: 1. A review of Medical Diagnoses, revealed Resident #6 had diagnoses of chronic obstructive pulmonary disease, kidney disease, bipolar, and heart failure. 2. The quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/30/2024, indicated a Brief Interview for Mental Status score of 11 (8-12 suggest moderate cognitive impairment). Section H0300 and H0400 indicated Resident #6 was incontinent of bowel and bladder. 3. On 12/30/2024 at 11:20 AM, the surveyor observed an Enhanced Barrier Precaution (EBP) sign outside Resident #6's door, and Certified Nursing Assistant (CNA) #1 and CNA #2 were observed providing perineal care for Resident #6 without wearing protective gowns. CNA #2 used both gloved hands to roll up and remove a soiled brief with the assistance of CNA #1, place a lift pad under Resident #6, and straighten Resident #6's clothing, and surrounding linens without removing the soiled gloves or performing hand hygiene. 4. On 12/30/2024 at 11:32 AM, during an interview CNA #1 and CNA #2 were asked why Resident #6 was on EBP. CNA #1 revealed Resident #6 had a wound on the coccyx that was found a few weeks ago. When asked how staff were made aware of residents who had been placed on EBP, CNA #1 stated that nursing would communicate that to them. EBP signage was pointed out and the surveyor asked if that was a form of communication used by the facility. CNA #2 confirmed that signage could communicate precautions. The CNAs spoke to each other and agreed that PPE was in a closet across from the nurse's station. When asked the rationale for wearing PPE while providing care to residents on EBP, CNA #2 revealed if staff caught something from the resident it could be passed on to other residents. 5. On 12/31/2024 at 5:30 AM, a record review of Skin and Wound Evaluation, dated 12/30/2024, revealed Resident #6 had a stage II pressure wound that was new on the coccyx. (Stage 2 pressure injuries are open wounds. The skin breaks open, wears away, or forms an ulcer, which is usually tender and painful. The wound expands into deeper layers of the skin. It can look like a scrape (abrasion), blister, or a shallow crater in the skin.) Resident #6 was to be repositioned every two hours, and time in a specialty chair limited to 2 hours. 6. During an interview on 12/31/2024 at 10:55 AM, the Director of Nursing (DON) confirmed EBP signs should be on the outside of the resident's door, and staff should wear gowns and gloves when providing personal care. The DON confirmed staff would be expected to perform hand hygiene or change gloves when going from dirty to clean sites because it is an infection control risk. 7. A policy titled perineal care, revised, February 2018, which revealed its purpose was to prevent infections and skin conditions, but did not address hand hygiene when going from a dirty to clean body site. 8. A policy titled Hand Hygiene, revised August 2019, revealed staff should be regularly in-serviced on the importance of hand hygiene, and hand hygiene should be performed when moving from a contaminated body site to a clean body site. 9. A policy provided, titled Enhanced Barrier Precautions, copyright 2024, revealing EBP are designed to reduce transmission of multi-drug-resistant organisms that target staff ' s gloves during resident contact. All staff is to be trained on EBP annually, an order should be placed by the physician, gowns and gloves should be immediately available or outside a resident's room and should be worn by staff during times of high contact including during toileting and changing briefs. 10. On 12/31/2024 at 12:51 PM, the Administrator provided in-services titled: a. Peri Care, dated 01/12/2024, which revealed staff are to make sure they are wearing clean gloves. b. Enhanced Barrier Precautions, dated 03/28/2024, and beginning on 04/01/2024, signature sheet was provided showing signage and policy, and education on multi- resistant organisms were addressed. c. Hand Hygiene, dated 08/12/2024, revealed washing hands prevents the spread of infection, and an in-service was received titled Infection Control, dated 09/06/2024, signature sheet was received, which revealed Center for Disease Control (CDC) Guidelines, OSHA, PPE Donning and Doffing, and Handwashing was addressed. d. Peri Care, dated 10/28/2024, revealed staff are to wash hands before perineal care and donning gloves and change towel between wipes.

Based on observation, interview, and record review the facility failed to report to the state survey agency when a resident, that was care planned not to leave the facility without supervision, left the facility without staff knowledge for 1 (Resident #8) of 1 sampled resident identified as an elopement risk. 1. The quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/05/2024 indicated Resident #8 had a diagnosis of non-Alzheimer's dementia, coronary artery disease, malnutrition and scored 12 (8-12 indicates moderate impairment) on the Brief Interview for Mental Status (BIMS). a. Resident #8 ' s Care Plan with an initiation date of 05/30/2024, indicated, Focus; Risk for elopement/wandering identified, Goal: The resident will not leave the facility unattended b. An Elopement assessment dated [DATE], for Resident #8 indicated, 6. Resistant to nursing home placement a) Yes 7. Expresses desire to go home a) Yes 8. Exit Seeking a) Yes 9. Evidence Sundowning behavior [increase in behaviors at the close of day] a) Yes; scored 9 [7-14 indicates moderate risk]; Conclusion: was at risk for exit seeking and wander guard was applied c. A form titled OLTC (Office of Long-Term Care) Witness Statement Form dated 10/20/2024 and signed by the Director of Nursing (DON), indicated, a wander guard was put on Resident #8 as a precaution due to Resident #8 thinking it was funny and stating next time would not tell staff when leaving. d. A form titled In-service Attendance Sheet with staff signatures attached, dated 10/20/24, with the DON listed as the signature of the presenter, indicated Topic: Wandering and Elopement; Reporting any equipment that is not functioning properly; Procedure on any alarming door. e. Resident #8 ' sCare Plan with an initiation date of 10/21/24, indicated, Focus: The resident is an elopement risk r/t [related to] history of attempts to leave the facility unattended; Goal: The resident will not leave the facility unattended through the review period; Target date 02/13/2025 f. On 10/24/24 at 11:46, a Behavior Note indicated when the nurse was passing medications Resident #8 laughed and said that they knew how to get the code to the door, and that when they left, they would leave a note by the door. The nurse documented that she notified the DON (Director of Nursing) and was instructed to place the resident on 15-minute checks. g. On 10/30/2024 at 12:20 PM, the policy titled, Abuse, Exploitation or Misappropriation - Reporting and Investigating (revision date April 2021) indicated all reports of resident abuse (including juries of unknown origin) neglect, exploitation or theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) .2. Neglect is defined as failure to provide goods or services necessary to avoid physical harm, mental anguish or mental illness . h. On 12/30/24 at 3:30 PM, Resident #8 was asked if they had ever left the facility without staff knowing. Resident #8 stated about a month ago they did leave to go and see their girlfriend and forgot to sign out. The resident stated it happened on a Sunday, they left about 2:30 PM and were gone for about four hours. i. On 12/30/2024 at 4:10PM, during an interview, Certified Nursing Assistant (CNA) #3 stated Resident #8 left the faciity on her weekend off without staff knowledge and a wander guard was immediately put on the resident. j. On 12/30/24 at 4:15 PM, during an interview, the Activity Director (AD) stated she was aware Resident #8 left the facility without supervision because the facility did Senior Alert Drills after it happened. Resident #8 had a wander guard put on and was placed on 15-minute checks. The AD stated she believed the resident was able to leave because they watched someone enter the code or heard visitors saying the code out loud to other visitors. The AD stated the door codes had to be changed all the time. The AD also stated they talked with the resident and the resident now knows to sign in and out and tell the nurse when leaving the facility. k. On 12/30/24 at 4:50 PM, the Director of Nursing (DON) was asked if Resident #8 was considered an elopement risk. She stated that Resident #8 was their own person and could come and go whenever the resident wanted to, but needed to sign out and let staff know. When asked if Resident #8 ever left without letting staff know, the DON said she was notified (possibly in October) by facility staff Resident #8 left and forgot to sign out. The DON stated when she discovered the resident was missing, she went looking for them. When she got to the facility, the resident was already back and when she asked Resident #8 where they had gone, the resident stated they had gone to see their girlfriend. The DON stated she reviewed with the resident the process for notifying staff and signing out when leaving the facility several times when the resident returned to the facility. The DON stated she thought Resident #8 got the code to the door that allowed the resident to leave by watching family members or staff enter the code. When asked why a wander guard was put on Resident #8 after the elopement assessment was done following the incident, the DON stated, it could have been done as a precaution. The DON was asked if the facility had a policy on elopement and she stated there was a binder at each nurse ' s desk and at the front of the building with a list of residents that were at risk for elopement. The DON was asked for a copy of the list of residents at risk for elopement and a copy of the policy and she stated she would get them for the surveyor. l. On 12/31/24 at 8:50 AM, the Administrator was asked if Resident #8 was considered an elopement risk and she stated, no. The Administrator was asked if Resident #8 had ever left the facility without staff knowledge. The Administrator stated, yes, she received a call from the facility the evening it happened telling her the resident had left without signing out. The Administrator stated she called the facility to get the address of the resident ' s girlfriend, who had just recently moved out of the facilities, since she thought that was most likely where Resident #8 had gone. By the time she got to the facility Resident #8 was already back. The Administrator stated she went over signing the sign in book and location of the book with Resident #8 after the resident returned to the facility. When asked if anything else was done after Resident #8 left the facility without notifying staff, the Administrator stated they did an elopement action plan. She stated Resident #8 knew the code to the door and that was how the resident was able to get out. She stated we checked to be sure doors were functioning correctly and changed the door codes. Resident #8 acted like it was all a joke and made the comment I will leave and just leave a note at the door, so the DON put a wander guard on as a precaution. The Administrator was asked if she completed a Facility Reportable Incident to submit to the state. she stated, no, because Resident #8 did not sign out but was not lost and was capable of taking care of their self. They had never been exit seeking and were just worried about their girlfriend. The Administrator stated, Resident #8 was smart, walked around a lot and probably saw someone enter the door code, or maybe heard someone, like visitors say it. We have to change the code frequently. The Administrator was asked if she had a copy of the elopement policy, and the list of residents that are at risk for elopement that the surveyor requested yesterday from the DON, and the surveyor was given a copy of both. The Administrator was asked for a copy of the Action Plan that was developed at the time Resident #8 left the building unsupervised, and the surveyor was given a copy. m. On 10/31/24 at 9:00 AM, the list provided by the Administrator titled Residents at Risk for Elopement included Resident #8's name. n. On 10/31/24 at 9:05 AM, the policy titled Wandering and Elopement (revised March 2019) provided by the Administrator indicated, Policy heading; the facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents; Policy Interpretation and Implementation:1. If identified as at risk for wandering, elopement, or other safety issues, the resident's care plan will include strategies and interventions to maintain the resident's safety;4. When the resident returns to the facility, the director of nursing or change nurse will e. Complete and file an incident report, and f. document relevant information in the resident's medical record. o. On 12/31/2024 at 3:35 PM, during an interview the DON stated an incident report was not done when Resident #8 left the facility without staff knowledge because they just did not consider it an elopement and they told the nurse she did not need to do an incident report and that was most likely why a note was not written. When asked if they treated Resident #8 leaving the facility without notifying staff as an elopement, the DON stated in the beginning we did, but once we determined the resident was their own responsible party, we determined it was not an elopement. The DON was asked, why if it was determined it was not an elopement was an Elopement Action Plan put in place after the incident happened and she stated the plan was a preventative measure. When asked how long the resident was missing from the facility, the DON stated she believed the resident was missing from the facility for an hour, possibly less than an hour p. On 12/31/24 at 3:45 PM, the Administrator was informed the Surveyor had reviewed the policy she had provided on elopement and asked why an incident report was not done when Resident #8 left the facility without staff knowing. The Administrator stated Resident #8 knew what they were doing when they left, they just did not sign out. The Administrator was asked if the nurse should have written a note in the record documenting that the resident had left without staff knowing and she stated, the DON did get with the nurse and told the nurse she should have documented something. The Administrator was asked what time she become aware that the resident was not at the facility, and she stated she thought it was about 8 or 9 PM. The Administrator was asked if she thought she should have reported the incident to the state since staff were not aware of where the resident was for an unknown period of time, and she stated she did not think that was something that needed to be reported to the state.

Through observation, record review, and interviews, the facility failed to ensure open food packages were properly closed, ensure walls and floors were in sanitary condition, canned goods were dent free, dietary staff washed their hands between dirty and clean tasks, chemicals were kept away from serving items, food on the steam table was properly covered, and proper serving sizes were provided. The findings are as follows: 1) On 05/05/24 at 10:45 AM, two trash cans were not covered by the hand washing sink and the reach in refrigerator in the main kitchen prep area. The Registered Dietician stated trash cans should not be opened if not being used to prevent cross-contamination. 2) On 05/05/24 at 10:46 AM, a coffee filter containing coffee and one pitcher container were uncovered and sat next to the hand washing sink. The Dietary Supervisor confirmed the coffee in the coffee filter and pitcher not being covered could cause cross-contamination because something could land on them. 3) On 05/05/24 at 10:47 AM a plate warmer contained plates with serving side face up and uncovered. The Dietary Supervisor confirmed something could land on the plates that were not covered. 4) On 05/05/24 at 10:48 AM, a cart stored food warmer covers where the inside was not covered. The Dietary Supervisor confirmed something could land on the food domes that are not covered. 5) On 05/05/24 at 10:49 AM, in the dry goods storage room one 111 ounces can (name) pinto beans that had a dent on the top seal. The Registered Dietician confirmed the dent could cause a broken seal or the contents to be bad. 6) On 05/05/24 at 10:50 AM, in the dishwasher room a metal shelving unit contained clean dishes, cups, bowls, and dishes serving side up and 2 - 1 quart spray bottles of Mold & Mildew Stain remover on the third shelf were hanging by the trigger. The label on the spray bottles contained the warning, Keep out of reach of children and pets and Harmful if Swallowed. For emergency medical assistance, call your local poison control center. Each bottle was half full. The Registered Dietician confirmed that chemicals are to be stored in a separate area because the chemicals could make someone sick. 7) On 05/05/24 at 10:51 AM, a water bottle belonging to staff was stored on clean silverware shelving unit in the dishwasher room. The Registered Dietitian confirmed that personal bottles and foods are not to be near anything and to be kept in a specific area. 8) On 05/05/24 at 10:52 AM, greyish brown stagnant water was pooled under the dishwasher and the 3 compartment sinks. The Registered Dietitian confirmed this could cause cross-contamination, make people sick because clean dishes are stored and dried there, and could cause someone to fall. 9) On 05/05/24 at 10:56 AM, a chest freezer held 4 pitchers that did not have the open top covered and 4 pitcher lids inside facing up not covered. The Registered Dietitian confirmed the pitchers uncovered could cause cross-contamination. 10) On 05/05/24 at 10:57 AM, 1 spray bottle of glass and hard surface cleaner had the spray nozzle touching napkins on a shelf next to the chest freezer that held the 4 pitchers. The label of the spray bottle documented, DO NOT DRINK; WARNING! Causes skin and eye irritation. Harmful if swallowed or in contact with skin. The Registered Dietitian confirmed that chemicals are to be stored in a separate area, and the chemical touching the napkin or food could cause someone to get sick. 11) On 05/05/24 at 11:00 AM, 2 plastic storage containers in the main kitchen area holding various serving scoops were not covered. 12) On 05/07/24 at 6:39 AM, 1 pitcher of orange juice and 2 pitchers of iced tea were on the counter by the handwashing sink not covered. 13) On 05/07/24 at 6:40 AM, the light switch and plug outlet on the located on the right-side wall above the ice machine had a brown fuzzy substance on the top, the light switch cover left an opening on the upper right corner. The Dietary Supervisor confirmed that the fuzzy substance felt like wall insulation and could be a concern because there is a possibility the stuff could get into the ice that is used for residents' consumption. On 05/07/24 at 9:09 AM the Registered Dietitian confirmed the light switch near the ice machine had a hole in the facing and the stuff on top could cause cross contamination. 14) On 05/07/24 at 6:41 AM, the hall door that led to an outside alcove had black and brown smudges. The alcove contained 7 milk crates, 1- 30-gallon trash can, 1 ice chest, 1 water cooler, 1 chair, 3 bun racks 3 metal serving pans and 1 cart with wheels, 2 mops, 1 mop bucket and various unknown items in a pile. At 8:47 AM, the Maintenance Director confirmed the outside alcove was a safety issue that could possibly draw bugs and pest that like to live in trash. At 9:11 AM, the Registered Dietitian confirmed the stuff probably needed to be picked up, the concern would be bugs could come through the door. 15) On 05/07/24 at 6:43 AM, the wall on the right in the walkway from the main kitchen to the dishwasher room contained 2 dustpans with various particles and substances adhered to the dustpan, 4 different brooms that contained various brown and black fuzzy items on the bristles, and 1 squeegee. At 8:48 AM, the Registered Dietitian confirmed the brooms, dustpans, and squeegee on the wall are a cross-contamination concern with the clean dishes being transported from the dishwasher room to the kitchen area. 16) On 05/07/24 at 6:50 AM, the shelving unit against the back wall in the dishwasher room on the bottom shelf a container with pitcher lids was uncovered and the second shelf held 2 dessert bowls with serving side up and uncovered. At 8:48 AM, the Dietary Supervisor confirmed the serving items not covered is a concern due to stuff getting on them. 17) On 05/07/24 at 6:51 AM, the corner shelving unit bottom shelf held 9 desert bowls and 5 regular bowls serving side up uncovered. 18) On 05/07/24 at 6:59 AM, the freezer by the 3 compartments sink in the food prep area contained the following open food items that were not properly closed: 1- 10-pound box of breakfast turkey skinless link sausages the following open items that were not and 1 - 10-pound box of 4-ounce 80/20 individual pure ground beef patties 19) On 05/07/24 at 8:04 AM, a serving cart used to store clean serving trays had black smudges with unknown substance particles with yellowish and brown sludge built up on bottom tier and around the bolts. On 05/07/24, the Registered Dietitian confirmed the cart was dirty and needed to be cleaned. 20) On 05/07/24 at 8:16 AM, a kitchen puree prep table had a container of thickener lying on top. The lid has black smudges and white granules substance with scoop with brown substance adhered laying on top of the container lid. The Dietary Supervisor confirmed the lid had powder on top of it. 21) On 05/07/24 at 8:20 AM, the spice shelf above the microwave contained 1 - 7-ounce container of thyme leaves not properly sealed. The Dietary Supervisor confirmed the lid was not properly closed. 22) On 05/07/24 at 8:27 AM, a plug outlet over the clean dish dry counter contained a brownish grimy substance. The Dietary Supervisor confirmed the clean serving items drying under the outlet did have some debris that could get onto the clean serving items. 23) On 05/07/24 at 8:30 AM, ceiling tiling in various areas or the kitchen had yellow - brownish stains; the Chef confirmed the ceiling tiles were old. On 05/07/24 at 9:12 AM, the Registered Dietitian confirmed the tiles need replaced. 24) On 05/07/24 at 12:27 AM, food placed on the steam table at 11:45 AM remained uncovered for 32 minutes. The Registered Dietitian confirmed the food should have been covered. 25) On 05/07/24 at 12:46 PM, Dietary Aide #2 failed to provide a full serving scoop of turkey pot pie for a resident that received a room tray. The Registered Dietitian confirmed the serving scoop should be full. 26) On 05/07/24 at 12:53 PM, Dietary Aide #2 accepted scissors from staff that were in the dining room, then proceeded to serve food without washing hands. The Registered Dietitian confirmed Dietary Aide #2 should have washed her hands between touching the scissors and serving food. 27) On 05/07/24 at 1:10 PM, Dietary Aide #3 had prepared a mechanical soft cheeseburger. After the hamburger was at the mechanical soft stage, Dietary Aide #3 threw away a hamburger bun in paper then returned to the food prep area and ripped a piece of wrapping paper from the roll, placed the paper on the counter. The Registered Dietitian confirmed that Dietary Aide #3 should have washed hands before returning to the food prep area. 28) On 05/07/24 at 3:10 PM, the Administrator provided the Hand Washing Policy which documented, Standard: Do not block the area around hand washing sinks or stack items, such as soiled utensils, in them. Do not use hand washing sinks for any other purpose .Guidelines: Wash your hands as often as possible. It is important to wash your hands: Before starting to work with food utensils, or equipment Before putting on gloves; After handling soiled utensils and equipment AS often as needed during food preparation and when changing tasks . 29) On 05/07/24 at 3:10 PM, the Administrator provided a document titled, Cleaning and Sanitizing and Proper Hair Restraints which documented, Standard: Non-food contact surfaces are cleaned per individual facility cleaning schedule to maintain optimal cleanliness of kitchen equipment .Guidelines: Non-food contact surfaces are washed with soapy water per frequency identified on the facility cleaning schedule - or as visually necessary. These are then wiped down with sanitizer solution . 30) On 05/07/24 at 3:10 PM, the Administrator provided the Material Safety Data Sheet for Glass and Hard Surface Cleaner that documented, Hazards Identification .Harmful if swallowed; Harmful in contact with skin; Causes skin irritation; Causes eye irritation . First Aid Measures Ingestion: If swallowed, call a poison center if you feel unwell. Rinse mouth. Skin contact: If on skin, wash with plenty of water. If skin irritation occurs, get medical advice. Take off contaminated clothing and wash it before reuse. Eye Contact: If in eyes, rinse cautiously with water for several minutes .If eye irritation persists, get medical advice.

Based on observation, record review and interview, the facility failed to ensure the medication error rate was less than 5%. An observation of a medication pass performed on 08/16/23 at 7:53 AM resulted in the identification of 3 errors in 25 opportunities, resulting in a medication error rate of 12.00 %. The findings are: 1. Resident #176 had a physician's order for Aspirin Oral Capsule 81 MG (milligram) Give 1 tablet by mouth one time a day for blood thinner. a. On 05/06/24 at 08:10 AM, Licensed Practical Nurse (LPN) #3 gave Aspirin enteric coated 81 MG (Enteric-coated aspirin is designed to resist dissolving and being absorbed in the stomach. the purpose of taking low-dose aspirin is to help prevent the development of harmful artery-blocking blood clots. However, with enteric-coated aspirin, research indicates that bloodstream absorption may be delayed and reduced, compared to regular aspirin absorption). 2. Resident #176 had a physician's order for B Complex-C Oral Tablet (B Complex w/ C) Give 1 tablet by mouth one-time a day for supplement (Vitamin B with vitamin C added). a. On 05/06/24 at 8:10 AM, Licensed Practical Nurse (LPN) #3 gave B complex with vitamin B. 3. Resident #176 had a Physicians order for Multivitamin Oral Tablet (Multiple Vitamin) Give 1 tablet by mouth one time a day for supplement. a. On 05/06/24 at 8:10 AM, LPN #3 gave Multi-Vitamin with Minerals 1 tablet. 4. On 05/07/24 at 9:10 AM, LPN #3 was asked to look at all medications she gave Resident #176 on 05/06/24 at 8:10 AM. LPN #3 got all the medications out of the cart and placed them on the top. The Surveyor asked LPN #3 if she was certain that these medications were the same medications that she gave. LPN #3 checked again and stated yes. The Surveyor asked LPN #3 to read the order for the aspirin on the medication administration record (MAR) and compare it to what she gave. LPN #3 stated, I shouldn't have given enteric coated because it says plain aspirin. The Surveyor asked LPN #3 to repeat this process with the bottles of B Complex and Multi vitamin with Minerals. LPN #3 read the Medication record for the B complex and stated, Oh it says with vitamin C; I gave with vitamin B. LPN #3 stated, The order for multivitamin was plain and I gave the multivitamin with minerals. On 05/08/24 at 10:30 AM, the Director of Nurses (DON) was asked if nurses were expected to follow the physicians orders while administering medications. The DON stated, Yes. The DON was asked what could happen when a nurse does not follow physician orders. The DON stated, Medication Errors. The DON was asked to explain how she expected the nurses to do the medication pass accurately. The DON stated, Have everything ready and in date then use the 5 (Five) rights and compare the MAR and meds. On 05/07/24 at 3:32 PM, the Administrator provided a form titled Administering Medications which documented, Medications administered .as prescribed . Medications are administered in accordance with prescribed orders .The Individual administering the medication checks the label THREE (3) times to verify the .right medication, right dosage .As required or indicated for a medication, the individual administering the medication records in the residents medical record: b the dosage .

46868 Based on observation, record review, interview, it was determined that the facility failed to store controlled medications in a permanently affixed container, and to ensure medications were not left at the bedside. Findings include: 1. On [DATE] at 01:30 PM, the surveyor asked Licensed Practical Nurse (LPN) #1 what the procedure was to dispose of medications if a resident discharges or passes away in the facility. She stated the take the narcotics and the narcotic book to the Director of Nursing's (DON) office, count the medications, and then sign them over for her to send them out of facility. a. On [DATE] at 01:50 PM, LPN #2 was asked what the procedure was to dispose of medications if a resident discharges or passes away in the facility. She stated they take the narcotics and the narcotic book to the DON's office, count, and sign them over for her to send them out of facility. A b. On [DATE] at 01:50 PM, the surveyor observed the container used to store controlled medications in the medication room on Hall C was not permanently affixed inside the refrigerator. LPN #2 was asked to open the container, but reported she did not have a key to open box. c. On [DATE] at 02:25 PM, the DON reported the Maintenance Director was coming to unlock the container used to store controlled medications because no one has a key. The surveyor asked if the Maintenance Director had a key to this container. The DON stated, No, he will have to break the lock as I didn't think we were using this anymore. There is nothing in there no there shouldn't be maybe it's just an expired wrapper I already sent back we are not supposed to use this at this time because it's not fixed to the refrigerator. d. On [DATE] at 03:05 PM, the Maintenance Director and DON remove the lock from the container. Inside was Ativan 2 MG/ML, expiration [DATE], belonging to a non-sample resident. 2. Per a quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE], Resident #16 scored 10 (,d+[DATE] indicates moderately impaired) on the Brief Interview for Mental Status (BIMS). a. On [DATE] at 11:59 AM, in the room of Resident #16 an inhaler was lying on the bed side table, and a nebulizer was present with clear liquid in the chamber. The door was open and the medication was visible from the doorway. b. On [DATE] at 12:59 AM, LPN #4 was asked to accompany the Surveyor to Resident #16's room. The Surveyor asked if any resident on the hall was assessed for self-administration of medications. LPN#4 stated, No. LPN #4 was asked if there should be any medications left at bedside. LPN #4 stated, No, it can cause respiratory failure. LPN #4 picked up the Inhaler from the bedside table and stated, Yes that's her inhaler, I must have left it here, but I gave her medication this morning in the dining room. LPN #4 picked up the chamber of the Updraft. LPN #4 stated, That's her updraft medication; they gave that at 6 this morning. c. On [DATE] at 10:20 AM, the Director of Nurses (DON) was asked if the facility had anyone who is assessed for self-administration of medications. The DON stated, No. The DON was asked to explain what she expected the nurses to do with medications received. The Don stated, Stay with them till all meds are taken. The DON was asked if the medication should ever be left at bedside. The DON stated, No; someone one else could go in and take them and have a bad reaction, hurt themselves or others. d. On [DATE] at 3:32 PM, the Administrator provided a Policy titled, Storage of Medications which documented, The facility stores all drugs and biologicals in a safe, secure, and orderly manner .Drugs and biologicals used in the facility are stored in locked compartments .

Based on record review and interview, the facility failed to ensure an advanced directive was readily accessible in the electronic health record for 1 (Resident #24) of 1 sampled resident whose electronic health record (EHR) was reviewed for an advanced directive. The findings are: 1. Resident #24 had diagnoses of dementia and type 2 diabetes mellitus as documented on an order summary. a. A quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] documented a Brief Interview of Mental Status (BIMS) score of 03 (,d+[DATE] indicates severely impaired) b. A Care Plan dated [DATE] documented the residents did not want cardiopulmonary resuscitation (CPR) and to follow the do not resuscitate (DNR) instructions as detailed inside the Advance Directive and/or Living Will. c. On [DATE] at 11:03 AM, Resident #24's electronic health record (EHR) was reviewed and a resuscitation designation order dated [DATE] documented the resident had an advance directive but this surveyor did not locate it in the EHR. d. On [DATE] at 12:33 PM, the Administrator brought a copy of an advanced directive acknowledgement form dated [DATE] and stated, Some of the older ones were in the Social Services Office and I didn't know that they weren't scanning them in. The form documented, .I have been informed of my rights to formulate Advanced Directives .I Have not executed an Advance Directive . She also provided a copy of a General Durable Power of Attorney of [Resident #24] that she stated was also in the Social Services Office in a binder and was dated [DATE]. It documented on page 15 and 16, .Section 4.01 Power to Provide for My Support .My agent may do anything reasonably necessary to maintain my customary standard of living, including .Make all necessary arrangements, contractual or otherwise, for my care at any hospital, hospice, nursing home .should I desire it . e. On [DATE] at 04:43 PM, Licensed Practical Nurse (LPN) #4 was asked how she knew if a resident had or did not have an Advanced Directive in place and she confirmed that she looked at their chart.

Based on observation, record review, and interview, the facility failed to ensure a baseline care was completed within 48 hours of a residents admission to address activities of daily living, to promote continuity of care and communication among nursing home staff for 1 (Resident #123) of 1 sampled resident whose electronic health record (EHR) was reviewed for a 48 hour baseline care plan. The findings are: 1. Resident #123 had diagnoses of full incontinence of feces (unable to control bowel movements) and adult failure to thrive, as documented on an Order Summary. a. An entry Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/03/2024 documented Resident #123's most recent admission/entry or reentry to the facility was 05/03/2024. b. A care plan dated 05/05/2024 did not address Resident #123's activities of daily living (ADLs) for bathing, personal hygiene, oral hygiene, mobility, dressing, grooming or toileting for bowel incontinence. c. An admission assessment dated [DATE] on pages 20 through 38 contained questions for the Care Plan and all the sections were left blank. d. On 05/05/2024 at 11:47 AM, Resident #123 was lying in bed in a gown with the head of bed up about 30 degrees. Resident #123 asked this surveyor for something for Resident #123's lips which were visibly dry and cracked. e. On 05/07/2024 at 08:36 AM, Resident #123 was lying in bed in a gown, awake, with the head of bed up about 30 degrees. Resident #123's lips were visibly dry and cracked. f. On 05/08/2024 at 04:43 PM, Licensed Practical Nurse (LPN) #4 was interviewed and confirmed that the nurses do admit residents but did not do the 48 hour baseline care plan. She added they only answer questions such as how the residents transfer, their diet, can they ambulate independently, do they have any broken teeth, things like that. She confirmed there is a template in the residents' EHR and an admission assessment is filled out. She was asked if answering those questions triggered a care plan for the residents and she stated, As far as I know it doesn't. g. On 05/09/2024 at 05:20 PM, the Director of Nursing was interviewed and confirmed the nurses were able to do a baseline care plan on the admission assessment.

Based on record review and interview, the facility failed to ensure care plans were reviewed and revised at least annually, or when the residents care needs changed, as evidenced by failure to revise the plan of care to address the use of insulin, a high risk medication, to ensure staff were made aware of the necessary care, assessments and services required for insulin for 1 (Resident #39) of 1 sampled residents who were reviewed for care plan revisions for insulin. The findings are: 1. Resident #39 had a diagnosis of type 2 diabetes mellitus with hyperglycemia as documented on the medical diagnosis section of the electronic health record (EHR). a. An order summary documented a physician's order for insulin glargine .Inject 30 unit subcutaneously two times a day for diabetes which was ordered 03/26/2024. b. An annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/18/2024 documented Resident #39 had a Brief Interview for Mental Status (BIMS) score of received 7 (0-7 indicates severe cognitive impairment) and received insulin injections during the last 7 days or since admission/entry or reentry if less than 7 days. c. A care plan dated 02/08/2024 documented Resident #39 had diabetes mellitus and to observe the resident for side effects and effectiveness. The care plan did not list any signs/symptoms or side effects to monitor Resident #39 for regarding insulin use, which is a high risk medication. d. On 05/08/2024 at 04:18 PM, the MDS Coordinator was interviewed and she confirmed that she was familiar with the Resident Assessment Instrument (RAI) manual. She was asked to look at Resident #39's annual MDS regarding insulin injections and she confirmed it documented insulin injections were administered for 7 days in the look back period. She confirmed that insulin should be added to the resident's care plan. When she was asked why this was not added to Resident #39's care plan after the annual MDS dated [DATE] reflected the use of insulin injections, she looked at the resident's care plan in the EHR and stated, I'm not seeing it on there. It was an oversight. She confirmed that insulin should be added to the care plan so the nursing staff could see what [Resident #39] took for diabetes. When she was asked if there were any other reasons, she added, For complications.

Based on observation, interview, and record review, the facility failed to ensure enteral feeding and flush bags were properly labeled with the necessary information to promote continuity of care and decrease the potential for complications for 1 (Resident #123) of 1 sampled resident who had a percutaneous endoscopic gastrostomy (PEG) tube (tube that goes through the skin into the stomach). The findings are: 1. Resident #123 had a diagnosis of gastrostomy status as documented on an order summary. a. An order summary documented a physician's order of, .[named a 2.0 Cal/ml formula] continuous feed- 80 cc/hr (cubic centimeters per hour). b. An electronic Medication Administration Record (eMAR) documented, .[named a 2.0 Cal/ml formula] continuous feed- 80 cc/hr with flush 100 cc/2 hr (2 hours) every shift -Start Date 05/03/2024 2300 (11:00 PM) . There were initials in the boxes on 05/03/24 for night, 05/04/24-05/06/24 had initials in boxes for day, evening, and night and 05/07/24 initials in the box for day. That order was stopped on 05/05/24 at 9:47 AM and a new order to decrease the feeding rate to 50 cc/hr start 05/07/24 at 3:00 PM and there were initials in the evening box for this date. c. A care plan dated 05/05/24 documented the resident required tube feeding related to dysphagia (difficulty swallowing) and was dependent with tube feeding and water flushes and to see the MD (Medical Doctor) orders for the current feeding orders. d. On 05/05/24 at 11:47 AM, Resident #123 was lying in bed and an empty enteral feeding bag with a small amount of tan colored liquid in the tubing was hanging and was not connected to the resident and was not labeled. A flush bag with clear liquid had the following written on it in black H20 [water]100 cc/24 hrs). The feeding pump was off. e. On 05/06/24 at 08:21 AM, Resident #123 was lying in bed with the head of bed (HOB) elevated 30 degrees. The enteral feeding bag was labeled but the flush bag had about 950 ml of clear liquid in it and it was not labeled. f. On 05/07/24 at 08:36 AM , Resident #123 was lying in bed with the HOB elevated 30 degrees. The feeding bag was labeled and there was a flush bag with clear liquid inside hanging but not labeled. g. On 05/08/24 at 04:43 PM, Licensed Practical Nurse (LPN) was interviewed and confirmed that she was familiar with performing enteral feedings to residents. She confirmed that the date, milliliters per hour, name, room number should be on the enteral feeding bag and the water bag should have the flush amount, date, name, room number and time started. She stated they should be labeled in case someone comes in and doesn't know what to set it at and to make sure it's being ran correctly. h. An Enteral Nutrition policy provided by the Administrator on 05/07/24 documented, .The recommendation to initiate the use of enteral nutrition is based on the results of the comprehensive nutritional assessment, and is consistent with current standards of practice, the resident's advance directives, treatment goals and facility policies .

37925 Based on observation, interview, and record review, the facility failed to ensure a linen cart was covered while on a resident hall, failed to ensure hand hygiene was performed and proper protective equipment (PPE) was used when caring for 1 (Resident #44) of 1 sampled resident with Clostridium Difficile (C-Diff) and failed to ensure Enhanced Barrier Precautions were consistently implemented for 1 (Resident #39) of 1 sampled resident who was reviewed for EBP. The findings are: 1. On 05/05/24 at 10:35 AM, the clean linen cart was uncovered and unsupervised by staff. a) 05/07/24 at 11:19 AM, Laundry Personnel #1 confirmed clean laundry is to be distributed through the facility by placing the clean linen on the linen cart. Linen that hangs is placed on the metal rack in front of the wall with a sign that says Hall B. A brown cover is then placed on the linen cart then it goes out. The cover is only removed to take items from the cart that need to be taken to residents' room. 2. Resident #44 was n transmission based precaution for C-diff. a. On 05/05/24 at 12:59 PM, a 3 drawer cart was outside Resident #44's room. A sign titled, Contact Isolation Precautions, was affixed to the door of the room and documented, Please see nurse before entering room. Remove all PPE Before leaving the room. There were no masks in the cart and none on the hall. b. On 05/05/24 at 11:10 AM, Certified Nursing Assistant (CNA) #1 entered Resident #44's room with a gown and mask. Inside the door on a wall was a dispenser for gloves. CNA #1 did not wash her hands before she went to the room and got the breakfast tray and moved the items on the over bed table. CNA #1 then removed her gloves and gown and exited the room. CNA #1 did not remove her mask or wash her hands. c. On 05/05/24 at 11:16, CNA #1 was asked what she should do prior to entering a room with under contact isolation precautions. CNA #1 stated, Sanitize my hands. CNA #1 was asked if she washed her hands and stated, No I sanitized. CNA #1 was asked if hand sanitizer was enough to clean C-diff from her hands. CNA #1 stated, Yes. CNA #1 wore the same mask in and out of all rooms on the hall. d. On 05/06/22 at 1:33 PM, CNA #3 entered Resident #4's room with a gown on then put on her gloves. Her hands were not washed. Upon coming out of the room CNA #3 removed her gloves and gown. The Surveyor asked CNA #3 to explain what staff should do prior to entering an isolation room with the diagnosis of C-Diff. CNA#2 stated, Put on gloves, gown, and shoe covers. Maybe a mask; I'm not sure. CNA#3 was asked what should be done after giving care to a resident on C-Diff. CNA #3 stated, Remove my PPE. e. On 05/06/24 at 1:40 PM, Licensed Practical Nurse (LPN) # 1 was asked, What should you do prior to entering a residents room who is diagnosed with C-Diff? LPN #1 stated, Gloves, gown and shoe covers. LPN #1 was asked what should be done after caring for a resident and exiting the room. LPN #1 stated, Remove all PPE. f. On 05/07/24 at 2:11 PM, CNA #2 was asked to explain what is done prior to entering a residents room with C-Diff, while providing care, then when exiting the room. CNA #2 stated, I put on gloves, gown and shoe covers and I keep my mask on at all times; I never take it off. I sanitize while in the room and when I leave the room I remove my gown, and gloves. I leave my mask on. CNA #3 was asked to explain when hands are to be washed. CNA stated, I sanitize while in the room then wash my hands after I leave the room. 3. Resident #39 had diagnoses of type 2 diabetes mellitus with hyperglycemia and protein-calorie malnutrition as documented on an order summary. a. A physician's order dated 04/01/24 documented Resident #39 was on enhanced barrier precautions for chronic wounds. b. An annual Minimum Data Set (MDS) with as Assessment Reference Date (ARD) of 04/18/24 documented Resident #39 had a Brief Interview for Mental Status (BIMS) score of 13 (13-15 indicates cognitively intact) and had an unhealed pressure ulcer / injury. c. A Care Plan dated 02/08/24 documented Resident #39 was on enhanced barrier precautions related to a wound and staff were to put on a gown and gloves during high-contact resident care activities. d. An in-service on Enhanced Barrier Precautions dated 04/01/24 and provided by the Director of Nursing (DON) on 05/07/24 documented, .Wear gloves and a gown for the following High-Contact Resident Care Activities .Changing briefs or assisting with toileting . e. On 05/05/24 at 12:27 PM, this surveyor approached Resident #39's door and there was an enhanced barrier precaution sign on the door. CNA #4 was in Resident #39's room and took a pair of gloves to the bathroom where the resident was sitting on the toilet. This surveyor asked CNA #4 what she was about to do and she stated, I'm about to get [Resident #39] cleaned up and she walked in the resident's bathroom not wearing an isolation gown. This surveyor remained in the room and waited until CNA #4 was done in the bathroom. At 12:36 PM, CNA #4 opened the door and propelled Resident #39 out of the bathroom by wheelchair (w/c) to the side of the bed. CNA #4 had gloves on but no gown. CNA #4 attempted to close the blinds with the gloves on but was unsuccessful. CNA #4 then assisted Resident #39 to bed. This surveyor stepped in the bathroom and there was a brown substance on the outer part of the toilet bowl. Resident #39 stated, I got a sick stomach. CNA #4 removed her gloves and without sanitizing hands, pushed a bedside table near the resident. She touched the w/c handles and pushed the w/c away from Resident #39's bed. At 12:40 PM, CNA #4 put on a pair of clean gloves and did not sanitize her hands. She went in the bathroom and removed paper towels from the dispenser and began cleaning a brown substance from the outer toilet bowl with no gown on. At 2:38 PM CNA #4 confirmed that she was familiar with Resident #39's care. She was asked if knew if Resident #39 was on Enhanced Barrier Precautions and she replied, I don't at this moment. CNA #4 was asked if she knew what Enhanced Barrier Precautions were for and she stated, Well, I'm assuming it's something to help them not fall or it could be something for acid reflux. After surveyor asked if she again knew what EBP was for, CNA #4 said that she thought it could have been something to do with safety. CNA #4 was asked if she had any in-services on Enhanced Barrier Precautions and she stated she was not recalling it at that time. This surveyor asked the CNA to walked to Resident #39's door and asked her if she was familiar with the enhanced barrier precautions signage on the door and she did not answer. She was asked, Were you aware that there was a sign there? and she stated, Yes, I was aware that's there. She was asked what she was supposed to put on before caring for the resident and she stated, Gloves. When she was asked if there was anything else, she looked at the enhanced barrier precautions signage on Resident #39's door and stated, I see the gown, yeah. She confirmed that she was not wearing a gown when she went into Resident #39's bathroom. She confirmed that she was supposed to wash her hands when she changed gloves. She admitted the reason for washing her hands was to keep the germs away. f. On 05/05/24 at 2:47 PM, this surveyor and CNA #4 entered Resident #39's room and CNA #4 was asked to show the surveyor any gowns in the room or bathroom. She checked Resident #39's closets, drawers and bathroom and she stated, There are no gowns anywhere in here. g. On 05/07/24 at 12:24 PM, the Infection Preventionist was asked to state what her understanding of enhanced barrier precautions was and she stated, The way I understand it, for anybody that comes in with an open wound that has drainage and that's not healing, feeding tubes, catheters and any type of device that would not normally be there . anything that has an open area that they could transmit to us or us to them we are putting up an enhanced barrier precautions [sign] . She was asked where the PPE was located and she stated it was in the supply closets or on the carts on the halls. She was asked, On whose carts? She stated, Their linen carts. She was asked, Is the new staff being trained on enhanced barrier precautions? She stated, They get orientation. We're still working on it. She was asked, Is enhanced barrier precautions a part of their [new employees] training? She stated, Honestly, I couldn't tell you right now if it is. This surveyor then stated, To be clear, you are saying that the new employees are being trained in orientation on EBP? She stated, Well I'll have to say not at this time but we're working on getting something together because it's so new.

Based on observation, record review, and interview, the facility failed to ensure the laptop with the Medication Administration Record (MAR) was closed or covered when out of the Nurse's line of vision to maintain resident privacy of personal health information. This failed practice had the potential to affect 27 residents who resided on the A Hall as documented on a list provided by the Administrator on 05/10/23 at 11:30 AM. The findings are: 1. On 05/10/23 at 7:15 AM, during observation of the 8:00 am medication pass, Registered Nurse (RN) #1 prepared medications for Resident #168. After preparing the medications RN #1 sanitized her hands and donned gloves. Without locking the Medication Cart or closing the laptop with the MAR on the screen, RN #1 left the medication cart at the Nurses' Station and walked with Resident #168 ' s medications down the hall, around a corner and disappearing down a short hallway leaving the Medication Cart unattended and out of her field of vision. 2. On 05/10/23 at 7:33 AM, RN #1 returned to the Medication Cart to retrieve another cup of water. She locked the Medication Cart and closed the laptop and stated, I forgot to lock my cart. 3. On 05/10/23 at 8:10 AM, the Surveyor asked RN #1, What should you do when you leave your cart unattended? She answered, I close the laptop and lock the cart. I knew that. The Surveyor asked, What could happen if you don't close the laptop or lock the cart? She answered, Someone could get in it. 4. On 05/10/23 at 1:00 PM, the Surveyor asked the Director of Nursing (DON), What should the Nurse do to the Medication Cart when it is out of their line of sight? She answered, Lock it. The Surveyor asked, What should the Nurse do with the MAR when it is out of their line of sight? She answered, Cover it. The Surveyor asked, What could happen if the Medication Cart was left unlocked and unattended? She answered, Someone could get in an accident. The Surveyor asked, What could happen if the MAR was left unattended and open? She answered, It could be a violation of privacy with the resident information. 5. A facility policy titled, Confidentiality of Information and Personal Privacy, provided by the Administrator on 05/10/23 at 12:00 PM documented, .Our facility will protect and safeguard resident confidentiality and personal privacy . 1. The facility will safeguard the personal privacy and confidentiality of all resident personal and medical records .

Based on observation, record review, and interview, the facility failed to ensure the Medication Cart was locked when out of the Nurse's line of vision to prevent potential accident hazards. This failed practice had the potential to affect 21 residents on the A Hall who were independent or supervised with locomotion, as documented on a list provided by the Administrator on 10/11/23 at 8:29 AM. The findings are: 1. On 05/10/23 at 7:15 AM, during observation of the 8:00 am medication pass, Registered Nurse (RN) #1 prepared medications for Resident #168. After preparing the medications RN #1 sanitized her hands and donned gloves. Without locking the medication cart or closing the laptop with the Medication Administration Record (MAR) on the screen, RN #1 left the Medication Cart at the Nurses' Station and walked with Resident #168's medications down the hall, around a corner and disappearing down a short hallway leaving the Medication Cart out of her field of vision. 2. On 05/10/23 at 7:33 AM, RN #1 returned to the Medication Cart to retrieve another cup of water. She locked the Medication Cart and closed the laptop and stated, I forgot to lock my cart. 3. On 05/10/23 at 8:10 AM, the Surveyor asked RN #1, What should you do when you leave your cart unattended? She answered, I close the laptop and lock the cart. I knew that. The Surveyor asked, What could happen if you don't close the laptop or lock the cart? She answered, Someone could get in it. 4. On 05/10/23 at 1:00 PM, the Surveyor asked the Director of Nursing (DON), What should the Nurse do to the medication cart when it is out of their line of sight? She answered, Lock it. The Surveyor asked, What should the Nurse do with the MAR when it is out of their line of sight? She answered, Cover it. The Surveyor asked, What could happen if the medication cart was left unlocked and unattended? She answered, Someone could get in an accident. The Surveyor asked, What could happen if the MAR was left unattended and open? She answered, It could be a violation of privacy with the resident information. 5. A facility policy titled, Administering Medications, provided by the Administrator on 05/10/23 at 11:30 AM documented, . Policy Interpretation and Implementation . 19. During administration of medications, the medication cart is kept closed and locked when out of sight of the medication nurse or aide . The cart must be clearly visible to the personnel administering medications .

Based on observation, record review, and interview, the facility failed to ensure an indwelling catheter tubing was secured with a stabilization device to prevent potential pulling of the catheter, pain, and injury for 1 (Resident #168) of 3 (Residents #9, #42 and #168) sampled residents who had an indwelling catheter as documented on a list provided by the Administrator on 05/10/23 at 12:43 PM. The findings are: 1. Resident #168 was admitted on [DATE] with a diagnosis of Chronic Kidney Disease, Other Disorders of the Male Genital Organs and Hematuria. The Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/10/23 was In Progress. a. A Physician's Order dated 05/07/23 documented, Foley Catheter 16 FR [French] with 30 CC [cubic centimeters] balloon record output every shift for follow up with urologist on 05/09/2023 . b. A Care Plan with initiation date of 5/8/23 documented, I have an indwelling Foley catheter . Catheter: The resident has 16 French 30cc bulb Foley catheter. Position catheter bag and tubing below the level of the bladder, secure catheter tubing to leg with applicable device . c. On 05/08/23 at 12:07 PM, Resident #168 was lying in bed, uncovered. The resident had an indwelling catheter with a privacy flap covering the drainage bag. There was no stabilization device in use to secure the catheter tubing. d. On 05/10/23 at 7:15 AM, during observation of the 8:00 AM Medication Pass with Registered Nurse (RN) #1, the Nurse applied Nystatin powder to Resident #168's groin area. The indwelling catheter tubing was observed with no stabilization device in use. The Surveyor asked Resident #168, Has anyone tried to give you a leg band or a Stat Lock to hold your catheter tubing in place? Resident #168 answered, No. e. On 05/10/23 at 7:15 AM, the Surveyor asked RN #1, Should this resident have a stabilization device in use? RN #1 answered, Yes. The Surveyor asked, What could happen if a resident with a catheter does not have a stabilization device? RN #1 answered, The catheter could get pulled out with the balloon inflated and cause trauma. f. On 05/10/23 at 1:00 PM, the Surveyor asked the Director of Nursing (DON), Should all residents with an indwelling catheter have a stabilization device? She answered, Yes. The Surveyor asked, Why do they need them? She answered, To keep them in place and not get pulled. g. A facility policy titled, Foley Catheter Insertion, Male Resident, provided by the Administrator on 05/10/23 at 8:00 AM documented, . Steps in the Procedure .25.Tape the catheter to top of thigh or lower abdomen . h. A facility policy titled Catheter Care, Urinary, provided by the Administrator on 05/11/23 at 9:27 AM documented, .Changing Catheters .2. Ensure the catheter remains secured with a leg strap to reduce friction and movement at the insertion site. (Note: Catheter tubing should be strapped to the resident's inner thigh.) .Steps in the Procedure .18. Secure catheter utilizing a leg band .

Surveyor: Rather, [NAME] Based on observation, record review, and interview, the facility failed to provide the necessary respiratory care and services in accordance with professional standards of practice for 2 (Residents #16 and #35) of 3 (Residents #12, #16 and #35) sampled residents who had a Physician's Order for a CPAP (Continuous Positive Airway Pressure) Machine, and for 3 (Residents #16, #35 and #50) of 6 (Residents #16, #30, #35, #50, #167 and #168) sampled residents who had a Physician's Order for Oxygen as documented on lists provided by the Administrator on 05/11/23 at 10:50 AM, and the facility failed to ensure emergency tracheostomy supplies were readily available in the resident's room for 1 (Resident #167) of 2 (Residents #39 and #167) sampled residents who had a tracheostomy as documented on a list provided by the Administrator on 05/10/23 at 12:00 PM. The findings are: 45065 1. Resident #16 had diagnoses of Chronic Obstructive Pulmonary Disease (COPD) with (Acute) Exacerbation and Acute and Chronic Respiratory Failure with Hypercapnia. The Medicare 5-Day Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/13/23 documented the resident scored 7 (0-7 indicates severely cognitively impaired) on a Brief Interview for Mental Status (BIMS) and received oxygen therapy. a. A Physicians order dated 04/14/23 documented, .Trilogy while asleep: maintain sat [saturation] at 88-92% every shift for sleep . b. The Care Plan with an initiated date of 04/17/23 documented, I have altered respiratory status/difficulty breathing r/t [related to] COPD and respiratory failure . OXYGEN SETTINGS: O2 [oxygen] via NC [nasal cannula] @ [at] 1 LPM [liters per minute] PRN [as needed] . Trilogy to be worn while asleep. May self remove for ADL's [activities of daily living] . c. A Physicians Order dated 04/18/23 documented, .O2 [oxygen] AT 3 LITER VIA nc every 8 hours as needed . d. On 05/08/23 at 12:45 PM, in Resident #16's room the Surveyor observed an oxygen nasal cannula tubing on the floor by the head of the bed. A CPAP/Trilogy machine was sitting on the bedside table with the mask and tubing attached to the CPAP machine. The mask and tubing were draped over the machine, not contained in a storage bag. e. On 05/08/23 at 1:53 PM, Resident #16 was sitting up in a manual wheelchair and had just pushed the call light. Oxygen tubing was attached to an oxygen concentrator. The concentrator was set at 3 liters per minute and the nasal canula tubing was lying on the floor. A CPAP-Trilogy tubing and mask was lying draped over the machine on the bedside table, not contained in a bag. f. On 05/09/23 at 2:02 PM, the Surveyor asked Licensed Practical Nurse (LPN) #4, Who is responsible for setting up and providing the oxygen to the residents when you get the order? LPN #4 replied, Whoever gets the order, the nurses. The Surveyor asked, Does that include the Oxygen in use sign for the doorway being applied? LPN #4 stated, Yes that is part of it. The Surveyor asked, Who is responsible for the storage of the CPAP/Trilogy mask, the Nasal Cannula, or the face mask for the residents that have Oxygen when the Oxygen is not is use? She stated, The nurses are, they are to be bagged in a bag when they are not in use by the resident. g. On 05/09/23 at 2:32 PM, the Surveyor asked the Director of Nursing (DON), Who is responsible for setting up and providing the oxygen to the residents when you get the order? She stated, That would be the nurses. The Surveyor asked, Who is responsible for the storage of the CPAP/Trilogy mask, the Nasal Cannula, or the face mask for the residents that have orders for Oxygen, when the Oxygen is not in use by the resident? She stated, It should be in a bag. Anytime it is not in use it should be in a bag. 46724 2. Resident #35 had a diagnosis of COPD. The Quarterly MDS with an ARD of 02/02/23 documented the resident scored 11 (8-12 indicates moderately cognitively impaired) on a BIMS and received oxygen therapy. a. Physicians Order dated 01/30/23 documented, Change oxygen tubing q [every] week on Sunday night every night shift . Oxygen 2 LPM VIA NC every 8 hours as needed for Shortness of Breath QD [every day] . b. A Physicians Order dated 04/26/23 documented, Clean CPAP machine and hose with warm soapy water and hang to dry daily. every shift for Sleep Apnea . c. A Care Plan with a revision date of 08/30/22 and an Intervention revision date of 05/08/23 documented, .I have been known to refuse my cpap use at night even though I have been educated the risk vs [verses] benefits. I will remove my Oxygen prior to me going outside to smoke . Oxygen @ [at] 2 LPM VIA NC PRN change tubing weekly date tubing and keep in plastic bag when not in use . d. On 05/08/23 at 12:00 PM, Resident #35 was sitting up in a wheelchair in his room with a nasal cannula connected to an oxygen concentrator with the oxygen set at 3.5 liters per minute. The oxygen tubing was not dated. An oxygen tank secured to the wheelchair at the bedside registered empty with oxygen tubing connected and not dated or bagged. e. On 05/08/23 at 3:36 PM, Resident #35 ambulated to the doorway of his room and requested the oxygen tank on the back of his wheelchair be changed for when he wants to go out. f. On 05/09/23 at 8:02 AM, Resident #35 was lying in bed. The top drawer of his bedside table was open and a CPAP mask was connected to tubing connected to the CPAP machine. The CPAP mask was lying unbagged in the bedside table drawer. The oxygen tubing connected to the oxygen cylinder on the back of the wheelchair and to the oxygen concentrator was not dated. g. On 05/09/23 at 11:35 AM, Resident #35 had the concentrator in use and oxygen was running at 4 liters per millimeter. The tubing connected to the oxygen cylinder and to the oxygen concentrator were not dated. The tubing connected to the oxygen cylinder was not bagged. The CPAP mask was in the top drawer of the bedside table, unbagged. 3. Resident #50 had a diagnosis of Respiratory Failure with Hypoxia. The Quarterly MDS with an ARD of 02/23/23 documented the resident scored 15 (13-15 indicates cognitively intact) on a BIMS and required oxygen therapy and had shortness of breath (SOB) upon exertion and while lying flat. a. A Physicians Order dated 10/16/22 documented, Change oxygen tubing q week every night shift every Sun [Sunday] . b. A Physicians Orders dated 10/17/22 documented. Oxygen 3 LPM VIA NC PRN SOB every shift . c. A Care Plan with a revision date of 12/01/22 documented, .I have oxygen therapy r/t Respiratory failure with hypoxia. I will sometimes take off my nasal cannula . OXYGEN SETTINGS: O2 via nasal cannula @ (3) LPM prn. Change tubing weekly, date tubing and bag when not in use . d. On 05/08/23 at 11:54 AM, Resident #50's nasal cannula and tubing were draped across the oxygen concentrator, out of reach of Resident #50. A storage bag dated 2/27 was attached to the concentrator, the tubing was not dated and was not bagged. The Surveyor asked Resident #50 if she needed her oxygen. Resident #50 stated, I must of left it off after I got my shower this morning. e. On 05/09/23 at 8:56 AM, Resident #50 was asleep in bed with oxygen on at 2 liters per nasal cannula. The oxygen tubing was not dated. f. On 05/10/23 at 8:31 AM, the oxygen on at 2 liters per minute via NC, the tubing was not dated. g. On 05/10/23 at 3:17 PM, the Surveyor asked the Assistant Director of Nursing (ADON), How should oxygen masks/cannulas and CPAP masks be stored? The ADON responded, The CPAP masks should be stored in a dated bag. Sometimes residents take them out of the bag. Oxygen masks and NC should be stored in a dated bag. The tubing should be dated. Again, sometimes the residents will wrap the tubing up and put it across the machine. The Surveyor asked, How does a nurse know what setting the oxygen should be on? The ADON responded, The Physician ' s Orders. The Surveyor asked, How often is oxygen equipment changed and who is responsible? The ADON responded, The tubing, masks/nasal cannulas and humidifier bottles are changed out on night shift [11:00 PM to 7:00 AM] ever Sunday. h. On 05/10/23 at 3:30 PM, the Surveyor asked Licensed Practical Nurse (LPN) #2, How do you know how many liters oxygen is supposed to be on for residents who receive oxygen? LPN #2 stated, By the Physician's Orders. LPN #2 accompanied the Surveyor to Resident #35's room. The Surveyor asked, Can you tell me what the flow rate is for his oxygen? LPN #2 looked at the oxygen concentrator and the oxygen cylinder on the back of the wheelchair and stated, They are supposed to be set at 2 liters, but both are set at 4 liters. LPN #2 accompanied the Surveyor to Resident #50's room. The Surveyor asked what setting Resident #50's oxygen was set at. LPN #2 looked at the oxygen concentrator and stated, It should be set at 3 liters, but it is on 3.5 liters, and she can't get to it to change the settings. i. The facility's policy titled, Oxygen Administration, provided by the Administrator on 05/10/23 at 12:02 PM documented, .Purpose The purpose of this procedure is to provide guidelines for safe oxygen administration . The policy did not address storage of oxygen and CPAP equipment. j. On 5/11/23 at 10:15 AM, the Surveyor asked the Administrator if they had another policy on storage. The Administrator stated, No, that's all we have. 4. Resident #167 had diagnoses of Chronic Respiratory Failure and Tracheostomy Status. The Admission MDS with an ARD of 04/25/23 documented the resident scored 15 (13-15 indicates cognitively intact) on a BIMS and required oxygen therapy and tracheostomy care while not a resident and while a resident. a. A Physician's Order dated 04/21/23 documented, Trach [Tracheostomy] care every shift - Resident Self Administration care every shift . b. A Care Plan with a revision date of 04/24/23 documented, I have a tracheostomy . Ensure that trach ties/fasenting [fastening] device are secure . OXYGEN SETTINGS: O2 via trach at 6LPM PRN . c. On 05/09/23 at 11:56 AM, Resident #167 was lying in bed. The resident had a tracheostomy. There was no AMBU (Artificial Manual Breathing Unit) bag or emergency tracheostomy care equipment in the room. d. On 05/09/23 at 4:04 PM, Resident #167 was lying in bed. There was no AMBU bag or emergency tracheostomy equipment in the room. e. On 05/09/23 at 11:56 AM, the Surveyor asked Resident #167, Do you have an AMBU bag, emergency equipment or any extra cannulas in the room? She answered, No. f. On 05/10/23 at 8:00 AM, Resident #167 was lying in bed awake. There was no AMBU bag or emergency tracheostomy equipment in the room. g. On 05/10/23 at 1:00 PM, the Surveyor asked the Director of Nursing (DON), Should residents with a tracheostomy have emergency tracheostomy equipment in their rooms, such as extra cannulas and an AMBU bag? She answered, Yes. The Surveyor asked, What could happen if they do not have emergency equipment in their room? She answered, In case of respiratory distress. h. A facility policy titled, Tracheostomy Care, provided by the Administrator on 05/10/23 at 8:00 AM documented, .Purpose The purpose of this procedure is to guide tracheostomy care and the cleaning of reusable tracheostomy cannulas . General Guidelines . 6. A replacement tracheostomy tube must be available at the bedside at all times. 7. A suction machine, supply of suction catheters, exam and sterile gloves, and flush solutions, must be available at the bedside at all times .

Based on observation, record review, and interview, the facility failed to ensure an indwelling catheter drainage bag was not on the floor to prevent the risk of infection for 1 (Resident #42) of 3 (Residents #9, #42 and #168) sampled residents who had a Physicians Order for an indwelling catheter as documented on a list provided by the Administrator on 05/10/23 at 12:43 PM. The findings are: 1. Resident #42 had diagnoses of Benign Prostatic Hyperplasia with Lower Urinary Tract Symptoms and Other Obstructive and Reflux Uropathy. The resident required extensive assistance from two people for toilet use. The resident had an indwelling catheter during the lookback period. a. A Physicians Order dated 06/29/22 documented, Suprapubic Catheter 16 FR [French] with 30 CC [cubic centimeters] balloon record output every shift . b. A Care Plan with a revision date of 02/20/23 documented, I have a Suprapubic Catheter r/t [related to] Neurogenic bladder . CATHETER: .Position catheter bag and tubing below the level of the bladder, secure catheter tubing to leg with applicable device. c. A Physicians Order dated 05/08/23 documented, Keflex Oral Capsule 500 MG [milligrams] (Cephalexin) Give 1 capsule by mouth three times a day for UTI [urinary tract infection] . d. A Care Plan with an initiated date of 05/08/23 documented, I have a Urinary Tract Infection and am receiving antibiotic therapy . e. On 05/09/23 at 8:24 AM, Resident #42 was lying on a low bed A catheter drainage bag with a privacy covering was lying on the floor under the bed. f. On 05/09/23 at 4:00 PM, Resident #42 was lying on a low bed. A catheter drainage bag with a privacy covering was lying on the floor under the bed. The Surveyor asked Certified Nursing Assistant (CNA) #1, Is [Resident #42's] catheter drainage bag on the floor? She answered, Yes but it's hanging from the bed. It's got to be hooked to the bed. g. On 05/09/23 at 4:02 PM, the Surveyor asked Licensed Practical Nurse (LPN) #3, Is [Resident #42's] catheter drainage bag on the floor? She answered, Yes. It's hooked to the bed. He has to be in a low bed, but the bag is touching the floor. The Surveyor asked, What could happen if a catheter drainage bag touches the floor? She answered, Anything. It could get squished, torn, contaminated, infection. The Surveyor asked, Is the resident currently on an antibiotic for a UTI? She answered, Yes. h. On 05/10/23 at 8:27 AM, Resident #42 was lying on a low bed A catheter drainage bag with a privacy covering was lying on the floor under the bed. i. On 05/10/23 at 10:26 AM, Resident #42 was lying on a low bed. A catheter drainage bag with a privacy covering was lying on the floor under the bed. j. On 05/10/23 at 1:00 PM, the Surveyor asked the Director of Nursing (DON), Where should the catheter drainage bag be kept? She answered, Below the level of the privates but not on the floor. The Surveyor asked, What could happen if the catheter drainage bag is on the floor? She answered, Possible risk for infection. k. A facility policy titled, Suprapubic Catheter Care, provided by the Administrator on 05/10/23 at 8:00 AM documented, The purpose of this procedure is to prevent . infection of the resident's urinary tract . l. A facility policy titled, Catheter Care, Urinary, provided by the Administrator on 05/11/23 at 9:27 AM documented, The purpose of this procedure is to prevent catheter-associated urinary tract infection . Infection Control . Maintain clean technique when handling or manipulating the catheter, tubing, or drainage bag . b. Be sure the catheter tubing and drainage bag are kept off the floor .

Based on record review, and interview, the facility failed to ensure a Preadmission Screening and Resident Review (PASARR) was completed prior to admission to ensure the resident received the needed care and services in the most integrated setting appropriate to their needs for 1 (Resident #13) of 1 sampled resident who required a PASARR. This failed practice had the potential to affect 6 residents as documented on a list provided by the Administrator on 05/09/23 at 3:50 PM. The findings are: 1. Resident #13 was admitted to the facility on [DATE] with diagnoses of Other Specified Depressive Episodes, Posttraumatic Stress Disorder Unspecified and Multiple Sclerosis. The Medicare 5-Day Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/06/23 documented the resident scored 14 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status (BIMS) and received antipsychotic and antidepressant medications 7 of the last 7 days. a. On 05/09/23 at 10:49 AM, the Surveyor reviewed Resident #13's Electronic Health Record (EHR) for a Level I PASARR Screening. The Surveyor was unable to locate the information in the EHR. The Surveyor requested a copy of the PASARR Screening from the Administrator. b. A PASARR /Level II Screening from (State Designated Professional Associates) dated 05/09/23 provided by the Administrator on 05/10/23 at 7:40 AM documented, .Special Instructions: The above-named client will require a PASRR/Level II screening to be completed at your nursing facility per the Office of Long Term Care [OLTC]. An assessor from [State Designated Professional Associates] will contact your facility to make arrangements for this appointment . c. On 05/10/2023 at 8:00 AM, the Administrator stated, Resident was to just come in on the waiver part, stay less than 30 days and has now stayed over that number of days and we had requested it, and we even followed up on it. [State Designated Professional Associates] had stated they were short staffed and was trying to get it to us. We had a Mock Survey and found that this resident did not have a PASARR, and I did a facility action plan on it on 05/05/23 and we were following up on it Monday, that was on 05/08/23, and we called them yesterday again when you asked for it and got it faxed to us. d. On 05/10/23 at 11:00 AM, a phone interview was conducted with a [State Designated Professional Associates] Employee regarding Resident #13, who stated, The facility contacted us yesterday 05/09/23 and we sent the Level I PASARR to the nursing facility and the resident has been scheduled for the PASARR II evaluation. The Surveyor asked, Did the nursing facility contact [State Designated Professional Associates] during the month of April, after the resident was in the nursing facility over the 30 days she had originally planned on being at the facility? [State Designated Professional Associates] Employee stated, No we don't have anything showing they had contacted us till yesterday, 05/09/23. e. On 05/10/23 at 2:13 PM, the Surveyor asked the MDS Coordinator, Do you know when [Resident #13's] information was sent to [State Designated Professional Associates] for the Level I screening after she had stayed over the 30 days? She replied, Resident came in as skilled and was going to be short term, but due to her burns and other complications, ended up staying longer and is still here and I guess it just got missed. I do the 703's [Arkansas Department of Health and Human Services Evaluation of Medical Need Criteria] and I give a copy of it to the Business Office Manager [BOM] for her records and needs and then I give a copy to the Social Service Director (SSD) for it to be faxed to [State Designated Professional Associates] to get the PASARR back. The Surveyor asked, Can you tell me if the 703 you did got faxed in to [State Designated Professional Associates]? She stated, No, I don't know. That would be the SSD, they do that. f. On 05/10/23 at 2:26 PM, the Surveyor asked the BOM to show the Surveyor the 703's that had been completed on Resident #13 since she was admitted on [DATE]. The Surveyor reviewed three 703's, one dated 03/13/23, 04/25/23 and the last one dated 05/08/23. g. On 05/10/23 at 2:39 PM, the Surveyor asked the SSD, Can you tell me if either of the first two 703's completed on this resident, the first dated 03/13/23, and the second dated 04/25/23, was sent to [State Designated Professional Associates] for prescreening on [Resident #13] for the initial PASARR? The SSD replied, I don't know. I can look and see if there is anything showing that, they bring them to me, and I usually just fax them in to get the information returned. h. On 05/10/23 at 2:50 PM, the Administrator stated, We did not send either of the first two 703's to [State Designated Professional Associates]. We missed it. It just did not get done after her staying over the 30 days. i. A facility policy titled, Admission Criteria, provided by the Administrator on 05/09/23 at 3:50 PM documented, .Policy Interpretation and Implementation . 9. All new admissions and readmissions are screened for mental disorders (MD), intellectual disabilities (ID) or related disorders (RD) per the Medicaid Pre-Admission Screening and Resident Review (PASARR) process . If the level I screen indicates that the individual may meet the criteria for a MD, ID, or RD, he or she is referred to the state PASARR representative for the Level II (evaluation and determination) screening Process. (l) The admitting nurse notifies the social services department when a resident is identified as having a possible (or evident) MD, ID, or RD. (2) The social worker is responsible for making referrals to the appropriate state-designated authority .

Based on observation, record review, and interview, the facility failed to develop and implement a Comprehensive Care Plan that included a measurable focus, goals/outcomes, and interventions for 1 (Resident #47) of 8 (Residents #1, #3, #9, #47, #59, #62 and #168) sampled residents who had physician orders to receive an anticoagulant. The findings are: 1. Resident #47 had diagnoses of Pathological Fracture, Hip, Gastro-Esophageal Reflux Disease Without Esophagitis and Essential Hypertension. The Medicare 5-Day Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/21/23 documented the resident scored 7 (0-7 indicates severely cognitively impaired) on a Brief Interview for Mental Status (BIMS) and received an anticoagulant medication 4 of the last 7 days. a. A Physicians Order dated 04/18/23 documented, .Enoxaparin Sodium Injection Prefilled Syringe Kit 40 MG/0.4ML [40 milligrams per 0.4 milliliters] (Enoxaparin Sodium) Inject 1 application subcutaneously one time a day for blood thinner for 29 Days . b. The Care Plan with a revision date of 05/08/23 did not contain Focus, Goals, or Interventions for anticoagulant therapy. c. The April 2023 and May 2023 Medication Administration Records (MAR) documented Resident #47 started receiving daily Enoxaparin injections 04/19/23 at 8:00 AM on April 19th through April 30th, and May 1st through May 9th. d. On 05/10/23 at 10:00 AM, the Surveyor asked the Director of Nursing (DON), If a resident was admitted with orders to receive an anticoagulant medication, should the Care Plan reflect that with Focus, Goals and Interventions? She replied, Yes, they should. The Surveyor asked, If the Care Plan does not reflect that a resident is on anticoagulant therapy, what could happen? She replied, It does not show the residents care they need. e. A facility policy titled, Care Plans, Comprehensive Person-Centered, with a revised date of December 2016, provided by the DON on 05/10/23 at 12:30 PM stated, .8. The comprehensive, person-centered care plan will: .h. incorporate risk factors associated with identified problems . k. reflect treatment goals, timetables and objectives in measurable outcomes .

Complaint # (AR 183) was substantiated (all or in part) with these findings: Based on record review and interview, the facility failed to ensure a transfer was conducted with a mechanical lift and two-person assistance in accordance with the resident assessed, care planned needs, to prevent an accident with serious injury for 1 (Resident #1) of 2 (Residents #1 and #2) case mix residents who required mechanical lift transfers with 2-person assistance. This failed practice resulted in past non-compliance at the level of immediate jeopardy, which caused or could have caused serious harm, injury or death for Resident #1, who was manually transferred by one staff member and sustained a tibial fracture with massive blood loss. The failed practice also had the potential to cause more than minimal harm to 17 residents who required a lift for transfers, according to a list provided by the Director of Nursing (DON) on 10/31/18 at 1:50 p.m. The Administrator was informed of the past Immediate Jeopardy on 10/31/18 at 4:20 p.m. The findings are: Resident #1 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set with an Assessment Reference Date of 9/24/18 documented the resident scored 15 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status, required extensive assistance of two staff persons for transfers, was not steady for surface to surface transfer, only able to stabilize with staff assistance and had functional limitation in range of motion to the lower extremity on one side. a. A Care Plan dated 9/17/18 documented, .9/1718 I transfer with mechanical x 2 staff .I transfer with mechanical lift x (times) 2 staff . I4/17/18 I am at risk for fall r/t (related to) AKA (above the knee amputation) . c. A Kardex entry dated 9/17/18 documented, .I transfer with a mechanical lift x 2 staff . d. An Incident Report dated 10/14/18 at 7:00 p.m. documented, .Summoned to resident room by Certified Nurse Assistant (CNA). Resident on bed with horizontal laceration to LLE (left lower extremity) below knee. Profuse bleeding noted. Bed in low position . Resident description - 'broke my leg' . Assessed for injury. Pressure applied to site. EMS (Emergency Medical Services) notified. APN (Advanced Practice Nurse) notified. DON (Director of Nursing) and Responsible party notified . Injury Type - Laceration Left lower leg (front) .Notes - 10/16/18 - CNA was transferring resident to bed when resident's leg got caught under the bed. CNA was disciplined, and staff educated on transfers . A Nurse's Note dated 10/14/18 at 9:06 p.m. documented, .Summoned to resident room by CNA (Certified Nursing Assistant). Resident on bed with horizontal laceration to LLE below knee. Profuse bleeding noted. Bed in low position. Pressure applied to wound. EMS (Emergency Medical Services) notified. APN (Advanced Practice Nurse), CEO (Chief Executive Officer), Responsible Party notified. EMS arrived to facility. Transferred to stretcher x 2 EMS and 2 nurses. Assessed bed and wheelchair for sharp edges. No complaints of pain or discomfort at the time of transfer . 1.) An Emergency Department (ED) Progress Note dated 10/14/18 at 7:40 p.m. documented, .Patient is a nursing home resident who was sent for evaluation after she sustained a fall during transfer from her wheelchair to the bed. Patient is a previous right leg [MEDICAL CONDITION]. Today she fell on the left knee area and has a massive gaping laceration to the left knee. She has chronic [MEDICAL CONDITION] with extremity tight leg in this area . Patient has massive active bleeding from the wound . There is active bleeding, likely venous. This does not improve with direct pressure . significant blood loss from the wound . required emergent treatment to achieve hemostasis. Injection of the wound with [MEDICATION NAME] with [MEDICATION NAME]. Continued vascular bleeding. Temporarily required an upper leg tourniquet. [MEDICAL CONDITION] wound edges make it difficult for closure and somewhat increased tension on the sutures shows [MEDICAL CONDITION], significant with hemoglobin 7.7, likely related to acute blood loss . Tib - Fib (tibia-fibula) x-ray shows what appears to be avulsion type [MEDICAL CONDITION] tuberosity, underlying the area of laceration . 2.) A Nurses Note dated 10/14/18 at 10:19 p.m. documented, .Resident being admitted to CHI (Hospital). H&H (Hemoglobin and Hematocrit) 7 and 25, open fracture to Tibia. ER (emergency room ) RN (Registered Nurse) reports awaiting transfusion . 3.) An Office of Long Term Care (OLTC) Witness Statement form dated 10/14/18 and written signed by CNA #1 documented, .Doing our rounds me and (CNA #2) go into put . (Resident #1) to bed. While I was getting roommate ready, (CNA #2) went to put (Resident #1) to bed. (Resident #1) told her she was a two person and (CNA #2) told her you are underestimating me and pick up (Resident #1) and put her in bed. (Resident #1) screamed and said, 'you broke my leg'. I rush over to (Resident #1) bed and she was bleeding, so I rushed to get the nurse . 3.) An OLTC Witness Statement form dated 10/14/18 and signed by CNA #2 documented, .We were transferring (Resident #1); I had removed wheelchair leg rests and during transfer her leg slipped under the bed. When we got her legs on the bed, we seen blood and got the nurse . 4.) An OLTC Witness Statement form dated 10/15/18 and signed by the DON documented, . Spoke with (CNA #2) on the phone at 2 pm. (CNA #2) stated that she was unable to come to the facility to leave a witness statement or to discuss the events that happened. (CNA #2) stated that she had transferred the resident by herself and that resident's leg had gotten caught under the bed. Stated resident told her that her leg was broken and that she looked down and saw blood and called a nurse. (CNA #2) stated she was unsure of resident's transfer status but proceeded anyways. CNA verbally educated and terminated at this time. HR (Human Resources) present for length of phone call . e. On 10/31/18 at 9:03 a.m., Licensed Practical Nurse (LPN) #1 was asked about the incident with (Resident #1) and stated, I have known (Resident #1) for 6 years. I came to work for four hours to help pass medications on A and B Hall on the evening of the incident with (Resident #1). I came to work 3 p.m. to 7 p.m. I was assigned to (Resident #1) . I was walking down B Hall, when a CNA told me that (LPN #2), the nurse that was supposed to relieve me, was in (Resident #1's) room. I went into the room. The RN (Registered Nurse) Supervisor was in the room with the resident. The resident had a wound to her left leg . The Supervisor and (LPN #2) . started asking what had happened. They were both looking on the bed for any blood. I did not hear any conversation between the Supervisor and the CNA . The RN Supervisor told (LPN #2) there was an injury from the transfer. f. On 10/31/18 at 9:49 a.m., LPN #3 was asked about the incident with (Resident #1) and stated, I know (Resident #1) from the one night when the incident happened. I was working on the opposite hall. I received a phone call from the B Hall and CNA telling me that a resident had fallen and had possibly broken her leg. She told me that I and the RN supervisor was needed. We both took off running. The RN supervisor was with me helping because it was my 2nd shift being here for weekend option. We went into the resident's room. The resident's aide was standing by the wheelchair and the resident was in the bed. Someone was holding pressure on the resident's leg. The RN supervisor took over holding pressure. We saw blood on the towel covering the leg and blood on the bed. It did not look like a lot of blood, 60-70 milliliters. The RN supervisor asked what happened and the aide said that she must have cut her leg on the bed when she was transferring her . At that time, I bent over to look at the bed. I ran my hand across the bottom of it to check for any sharpened areas. Nothing sharp was found, no blood was found. The blood on the bed was pooling under the resident and was all around her leg. There was no blood on the bed frame or on the floor. There was no blood on the wheelchair. There was nothing sharp on the wheelchair. The wheelchair was right next to the bed. I told the RN supervisor that I could not find anything sharp. She then took the towel off of the resident's leg. The wound was on the left leg the bottom half across the shin of the leg going from one side to the other. The wound was very deep. It was obvious that the resident needed to be sent out. The RN supervisor put the towel back on it and reapplied pressure. This was between 7:00 p.m. and 8:00 p.m . I do not recall the resident saying anything. I have no knowledge as to how this happened. I remember seeing her CNA standing by the wheelchair; there was someone else holding pressure to the wound, but I don't know who it was. The CNA was in the room the whole time that I was in there. g. On 10/31/18 at 10:06 a.m., CNA #1 was asked about the incident with Resident #1 and stated, I am familiar with (Resident #1). I and (CNA #2) were doing rounds. (Resident #1) and her roommate were the last two to lay down for the evening. I was getting (Resident #1's) roommate ready for bed. (CNA #2) was getting Mrs. Covey (Resident #1) ready for bed. I heard them talking and (Resident #1) told (CNA #2) that she was a two-person lift. (CNA #2) told her, 'don't underestimate me'. (CNA #2) put resident's arms around her neck area. (Resident #1) placed her arms around (CNA #2's) neck, and then (CNA #2) transferred the resident to bed. During the transfer, Mrs. (Resident #1) said, 'you broke my leg'. I told (CNA #2) to wait for me to help with (Resident #1's) transfer, because the resident is a two-person lift transfer. (CNA #2) did not wait. (CNA #2) had her hands on the back of the resident's pants; she then pivot-turned her. (Resident #1) said, 'you broke my leg'. The wheelchair was at the side of the bed. (CNA #2) was still standing there. I could see blood coming out of the resident's pants onto the floor. (CNA #2) got the resident to the bed. Her leg was half way off the bed. I helped to get the resident onto the bed; I took her leg and placed it on the bed. I told (CNA #2) to go and get some help. I then went to get help. (CNA #2) was still walking in the hallway towards the phone. I passed her in the hallway. I then paged overhead and said, 'I need all nurses to (room number). When the nurse came, I saw the cut. After they took the resident out to the hospital, I had to clean up the blood from the floor. There was a lot of blood on the floor and all over the blanket. (CNA #2) returned to the room; she was told to go get some towels and Sani -wipes. I did not see what happened after the resident grabbed (CNA #2). I was helping her roommate. I and the nurses were trying to figure out what had happened. (CNA #2) did not say what happened; she appeared shocked. (Resident #1) is to be transferred by the (mechanical) lift with two people. Sometimes, resident does not want to use the lift. That day when I got her up, I used the lift . The lift was outside of the room for the transfer. The roommate did not need the lift. I never got to lay down the roommate. I have no idea how the cut happened. The resident was wearing long pants. The resident did not say anything. When I moved her leg, she did not say anything but then, when I left the room to get help she was saying 'it hurt, it hurt'. After I got help, I went back to the room. I was on the outside of the room. It was crowded in there. After the resident left to the hospital, I went into the room to clean up. (CNA #2) never returned back into the room; she was standing outside of the room. This happened about 6:45 - 6:50 p.m. After the resident was transferred, I got some help to lay the roommate down and then I wrote out a witness statement. (CNA #2) wrote a witness statement, and then I did not see her after that. (CNA #2) had worked with (Resident #1) before. I have never transferred the resident without the lift. I grab the nurse if the resident refuses the lift. I was trained on the lift when I was hired. I was observed doing a transfer. I have been retrained since the incident. I have been observed since the incident. I have not spoken to (CNA #2) since the incident. h. On 10/31/18 at 10:32 a.m., LPN #2 was asked about the incident with Resident #1 and stated, I am familiar with (Resident #1). I can only tell you, I walked into it. I was going to be working on B Hall that night. I had just come to work. One of the CNAs was looking for (LPN #1). I asked her what was wrong; she told me that something was wrong with (Resident #1). We all walked into the resident's room. Someone said, 'we need an ambulance'. I stepped out and called the ambulance. I went back into the room. The RN supervisor was holding pressure to resident's leg. (LPN #1) was holding ice to the resident's leg. The ambulance came shortly afterwards. (CNA #2) said, 'I was transferring her and she cut her leg on something'. After (CNA #2) told us this, we checked the bed; there was not anything sharp that I could feel. There was no blood on the floor or the resident's wheelchair. The resident said that she was hurt; she did not say what happened. I did not actually see the wound. The EMT lady did unwrap the wound, but I did not see it. I do not know what happened to cause the cut. After the resident was transferred to the hospital, the supervisor got statements from the CNAs. Transfer information for residents, to be honest I have not transferred a resident . i. On 10/31/18 at 10:49 p.m., the RN Supervisor was asked about the incident with Resident #1 and stated, I am familiar with (Resident #1). I was over on A hall when the incident happened, I had just gotten through checking orders. A CNA came over and told me that (Resident #1) had broken her leg. (LPN #3), another nurse, and I went to the resident's room. The resident's bed was in low position. There was a little blood on the resident's sheet. I lifted her pants leg and observed there to be a gash, bleeding profusely on the resident's left lower extremity below the knee. I grabbed a towel from the night stand and told (LPN #1) to go call the EMS. I told (LPN #3) to go print the paper work for the resident transfer. I asked (LPN #2) to look at the resident's bed to check for any sharp areas. I asked both of the CNAs in the room, (CNA #2) and (CNA #1), what had happened. (CNA #2) told me that the resident hit her leg on the bed when they were transferring the resident to bed. I asked if them if the resident had been transferred by two people. (CNA #2) told me 'yes' that two people had transferred the resident to bed. I then told both CNAs to leave the room and write statements. The ambulance arrived and transferred the resident to the hospital. After the resident was transferred to the hospital, all three nurses and myself checked the bed again to see if there were any sharp areas, none were found. After I left the room, (CNA #1), one of the CNAs came to me and asked me what she should write on her statement. I told her to write what had happened. The CNA said to me that she did not want to lie. (CNA #1) told me that she was with resident's roommate when she saw (CNA #2) transferring (Resident #1) to bed by herself. I tried to call the DON (Director of Nursing), but she did not answer her phone. I called the Administrator and, as I was talking to her, the DON returned my call. I was instructed to walk (CNA #2) out of the facility and to do an in-service with all other staff on transferring residents, per their care plan. Stated that (CNA #2) told me that the resident bumped her leg on the bed, she repeated that two people had transferred the resident to bed. Usually, (Resident #1) uses the lift for transfers; the resident does not like the lift. Therapy has been working with the resident on using the slide board for transfers. The wound to the resident's leg was higher than the height of the bed frame, the bed was in low position. (Resident #1) is not able to stand and pivot due to wounds on her heels, and some of her toes missing. I did wound care on (Resident #1) earlier that day. The resident had a wound to her heel and side of foot. I did not see any blood on the floor or on the wheelchair. When the EMS arrived, the wound was still bleeding. The resident said, 'she broke my leg, she broke my leg'. The resident did not complain of any pain, she was concerned about the laceration and bleeding. (LPN #1) wrapped the wound with gauze. An ice pack was applied over a towel covering the gauze bandage . j. On 10/31/18 at 1:28 p.m., CNA #3 was asked about the incident with (Resident #1) and stated, I am familiar with (Resident #1). I am assigned to B Hall where resident resides. I have no idea about what happened to (Resident #1) . I have been trained on how to use the lifts. I have been retrained on how to use the lift since the incident on 10/14/18. k. On 10/31/18 at 1:38 p.m., CNA #4 stated, .I have been trained on how to use the lifts. I have recently been retrained by the lead CNA and was observed using the lift. The retraining was done this month. I work A Hall all of the time. I have no knowledge of the incident with (Resident #1) . l. On 10/31/18 at 4:05 p.m., the DON was asked about the incident with Resident #1 and stated, .(CNA #2) had told the RN Supervisor that two CNAs had transferred the resident, but then (CNA #1), the other CNA in the room, said that (CNA #2) had transferred the resident by herself. I told the RN supervisor to get witness statements and to remove (CNA #2) from the building, to walk her out. The RN supervisor asked me if she should report the incident and I told her 'no', because we knew what had happened. The next day, I called (CNA #2) two times. (CNA #2) would not come to the facility. I asked (CNA #2) if she had transferred the resident by herself and she answered, 'yes'. I asked if she knew if she knew how (Resident #1) was to be transferred and she stated, 'using the lift' and that she knew this from the kiosk. I told (CNA #2) that she was terminated. (CNA #2) did ask how the resident was doing. The RN supervisor on the day of the incident was instructed to start in-servicing all staff on transfers per the care plan. We have, since then, put an action plan into place, which has included the MDS Coordinator checking all of the residents' transfer status and comparing this with the kiosk for accuracy, lift check offs on all staff with return demonstration, continued monitoring. I have not seen the resident since the incident; she remains in the hospital. I have tried to call the daughter, but she will not return my calls. m. On 10/31/18 at 4:19 p.m., the Administrator was asked about the incident with Resident #1 and stated, I was on vacation when the incident happened with (Resident #1). I received a call from the RN supervisor stating that there were two CNAs in the resident's room. One CNA was helping (Resident #1's) roommate and the other CNA was helping to get (Resident #1) ready for bed. Per the witness statement, (Resident #1) told (CNA #2) getting her ready for bed that she was a two person lift transfer. (CNA #2) told the resident, you underestimate me. (CNA #2) then picked the resident up physically and put her to bed. (Resident #1) told (CNA #2) that she had broken her leg. I told the RN supervisor to get statements and to send (CNA #2) home; the DON would terminate the next morning for not following the lift protocols. The RN supervisor asked me if she needed to report the incident and I replied, no, we know how the incident happened. I never spoke to (CNA #2) or to (CNA #1) the DON took care of that. The next day, I was still on vacation, but I did speak to the DON to make sure that the in-services and check offs with return demonstration were being done. I made sure that we obtained witness statements from alert residents and staff, that the Kardex was being audited for transfer. The DON and ADON had reassessed the bed of (Resident #1). (CNA #2) was terminated. n. The facility removed the immediate jeopardy and corrected the failed practices on 10/15/18 prior to the survey, as evidenced by the following (documentation related to the corrective action plan was provided by the Nurse Consultant on 10/31/18 at 9:34 p.m.): 1.) An Action Plan dated 10/15/18 documented, .Problem identified - Falls/use of lifts . Goals - Lifts to be used per assessments .Action Plan - Staff to be in-serviced on Kardex/where to find transfer status - 10/14/18 .All CNAs / Nurse checked off on proper lift transfers with return demonstration - 10/18/18 . Care Plans and Kardex audited for appropriate status on all residents - 10/16/18 . Random monitoring of staff lift transfers - ongoing . 2.) A Staff In-Service Sheet dated 10/14/18 documented, .staff must follow resident care plans on transfer status. If unsure of status check kiosk or ask nurse. All transfer status is on kiosk located under the kardex. Failure to transfer resident according to kardex care plan will result in termination of employment. If resident is not safe to transfer as written in care plan on kardex you must have nurse come and give instruction on how to safely transfer resident . 3.) A Staff In-Service Sheet dated 10/18/18 documented, .Lift transfer check off for the sit to stand for (MONTH) (YEAR) - with demonstration . Monitoring sheets documented return demonstrations of mechanical lift transfers were observed on 10/15, 10/16, 10/17, 10/18, 10/25, 10/26, 10/27 and 10/29/18. 4.) A Transfer Audit with Invacare Adjustable Base Lift was documented as completed from 10/16/18 through 10/30/18, for 34 residents. 5.) On 10/31/18 at 3:07 p.m., CNAs #4 and 5 were observed transferring another resident from the sample (Resident #2) from the bed to a wheelchair. The transfer was properly and safely completed without incident.

Complaint # (AR 381) was substantiated (all or in part) in these findings. Based on record review and interview, the facility failed to ensure staff immediately reported a suspicion / allegation of neglect to Administrator / Designee to ensure prompt investigation and to ensure residents were protected from the potential of further neglect as evidenced by staff failure to immediately report to the Administrator / Designee when Registered Nurse (RN) #1 refused to stay and assist with Cardiopulmonary Resuscitation (CPR) and Licensed Practical Nurse (LPN) #1 failed to immediately start CPR on a resident found without vital signs ([DATE]) for 1 (Resident #1) of 3 (Residents #1 through #3) case mix residents who had documentation of full code status within their resident clinical records. This failed practice resulted in a past Immediate Jeopardy which caused or could have caused death to Resident #1 who did not have cardiopulmonary resuscitation initiated when the resident's condition declined. This failed practice had the potential to cause more than minimal harm for 49 residents, who had documented full code status within their clinical records, according to a list provided by the Director of Nursing (DON) on [DATE]. On [DATE] at 11:39 a.m., the facility was informed of the past Immediate Jeopardy. The findings are: 1. Resident #1 had [DIAGNOSES REDACTED]. The Significant Change Minimum Data Set with an Assessment Reference Date of [DATE] documented the resident was totally dependent for all Activities of Daily Living. a. The Care Plan dated [DATE] documented, "I have requested that CPR measures ARE to be performed (Full code status). Staff will respect my wishes and rights in regards to my decision to have CPR performed. Communicate my choice to all appropriate staff members. Please continue to administer any ordered medications and treatments as per my physician's orders [REDACTED]. I need you to initiate CPR if you find me pulseless or breathless and continue CPR until Paramedics arrive to take over." Physicians' Orders dated [DATE] documented, "Full Code" b. Nurses' Notes dated [DATE] at 12:25 a.m. and signed by RN #1 documented, "At approx. (approximately) 11 p.m., CNA (Certified Nursing Assistant) called this nurse (RN #1) into room because resident needs to be suctioned. Breathing was labored. Suctioned thick mucus white / yellow approx 30 cc (cubic centimeters). B/P (blood pressure) ,[DATE], P. (pulse) 78, R. (respirations) 24, O 2 sat (oxygen saturation) ,[DATE]. Doctor notified. ,[DATE] (11:00 p.m. to 7:00 a.m. shift) nurse here." 1) On [DATE] at 12:45 p.m., RN #1 stated she was working the A hall ([DATE]) and the resident needed to be suctioned. She stated it was not uncommon for the resident to be suctioned. She stated the resident's oxygen saturation was 80% and she suctioned him. She stated she then called the doctor at approximately 11:15 p.m. (11:,[DATE]:30 p.m.) and that she had not had a return call. RN #1 was asked if she had checked the resident and she replied that she did not. She stated she made only one call to the doctor. 2) On [DATE] at 12:45 p.m., CNA #2 stated she worked the 3:00 p.m. to 11:00 p.m. shift ([DATE]). She was asked if she remembered the resident having something coming out of his mouth and she replied he had yellow sputum coming out of his mouth. She stated she changed the resident with another CNA. She stated she called the nurse (RN #1) to come check him. She stated RN #1 came in while the resident was being changed. She stated she remembered the nurse clearing his mouth, but did not remember if she suctioned the resident. CNA #2 was asked if RN #1 delayed coming when she called her and she replied, "No ma'am. When I called, she came." c. Nurses' Notes dated [DATE] at 1:28 a.m. and signed by LPN #1 documented, "After receiving report, delegated CNA (CNA#1) to check resident vital signs. Aide signaled this nurse (LPN #1) to resident's room. Assessed resident. No pulse found. Performed CPR with other nurse (LPN #2) while other nurse call ambulance." 1) On [DATE] at 4:30 p.m., CNA #1 stated she was running behind schedule the evening of the incident ([DATE]) and at approximately 12:00 a.m. or 12:30 a.m. she started doing vital signs ...She stated she went to the resident's room and tried to get vital signs on him. She stated she was not getting anything; no pulse. She stated she hollered for LPN #1 and she said to hold on and continued to talk to RN #1. She stated she went back in a few minutes to the nurses' station and said to LPN #1, "Look. I'm not getting nothing! No respirations, no pulse, nothing!" CNA #1 stated, "(LPN #1 and RN #1) were still talking. (LPN #1) came in the resident's room, looked at the resident and said, 'He's died '." CNA #1 stated LPN #1 touched the resident and checked for a pulse. She stated she could not remember if LPN #1 did vital signs or not, as that part was a little hazy. CNA #1 was asked if she was certain she had made it clear to LPN #1 there were no vital signs and she stated, "I actually told her, I'm not getting nothing." She stated LPN #1 stepped out of the room and called for LPN #2. CNA #1 was asked if she knew what role RN #1 played in the incident and she replied she knew she did come into the resident's room at some point, but she didn't remember when. She stated LPN #1 and RN #1 did not know what to do. 2) On [DATE] at 12:45 p.m., LPN #1 stated she arrived at the nursing home at 11:49 p.m. She stated she went to count out on the other hall and then went over to the A hall to count with RN #1. She stated that the narcotics were counted and then RN #1 gave the report. She stated RN #1 reported the resident was having respiratory distress earlier (in the shift) and that he required suctioning. She stated RN #1 said she had called the doctor, who had not returned the call at that time. She stated, "I asked (CNA #1) to go get vital signs on the resident. She stated it was not very long, a minute or two, and the CNA stuck her head out the door and told her (LPN #1) to come to the room. She stated when she arrived in the room, the resident's eyes were wide open, with no movement or reaction, no apical pulse, no rise and fall of the chest. She stated she said to CNA #1, "I think he deceased ," and asked the CNA to get RN #1, while she (LPN #1) finished assessing the resident. She stated the resident was so cool, he was cold. LPN #1 stated, "(RN #1) said she was going home and I asked her to stay to help her." She stated the CNA was not there and she went back to RN #1 to ask her to stay. The RN had left the facility. LPN #1 stated she saw LPN #2 and told him the resident did not have a pulse or respirations. She stated he initiated CPR and she went to call 911 and to get the crash cart. She stated she went to the resident's room and assisted with CPR. She stated they continued CPR for 8 to 10 minutes, before the paramedics arrived and called the resident's death. LPN #1 was asked what dependent lividity was. She replied, "That's not stiffness?" She was asked if she knew to check for dependent lividity and she said, "No." After it was explained to her that dependent lividity was "pooling of blood..." she stated she did not notice it if he had it. LPN #1 was questioned about the CNA's allegation that she had to tell her (LPN #1) more than once that the resident did not have vital signs before she (LPN #1) went to the room. LPN #1 denied the CNA told her more than once before she went into the room to check the resident. LPN #1 was asked what RN #1 said or did when she went to the resident's door and she replied that RN #1 said she was going home and that she did not want to get in involved in the situation. She stated RN #1 then turned around and went home. She stated, "I made it clear to her (RN #1) that I needed her to help me do CPR and she still turned around and went home." She stated RN #1 stayed outside the door, did not go into the room and did not assess the resident. LPN #1 was asked how much time had passed since the CNA had reported the resident had no vital signs and CPR was initiated and she replied, "3 to 5 minutes. It happened so fast. It didn't take too much time to assess him." She was asked how nurses identify code status prior to the incident. She stated, "Prior to the incident, I was not aware of what the dots meant. I knew they had the cards posted on the doors, but I didn't know what the dots meant. I do now." 3) On [DATE] at 12:45 p.m., RN #1 stated she and LPN #1 were counting narcotics when LPN #1 asked CNA #1 to get vital signs for the resident. She stated the CNA came out to LPN #1 and asked her to come to the resident's room. She stated LPN #1 called her to the room and said the resident's dead. She stated LPN #1 used either the word "stiff or hard." She stated LPN #1 wanted to do CPR and RN #1 stated, "I didn't see the need to do it. The man's already gone. He's passed." She stated she walked back to nurses' station to finish what she was doing. RN #1 stated she saw LPN #2 coming down the hall. She stated she believed LPN #1 knew the resident was dead and passed. She stated the signs were there that he did not need it (CPR). RN #1 was asked what were the signs that indicated there was no need to initiate CPR and she replied, "No respirations, no pulse. She (LPN #1) said he was cool. She used the word stiff or hard." RN #1 was asked if she assessed or touched the resident and she replied that she did not go over and look at him. She was asked when she would do CPR and she replied that if the signs were there, she would do it immediately. She stated, "He just had a list of signs. I read somewhere not to do CPR." RN #1 stated that LPN #1 had been in the room for a while with the resident and she was there when the CNA #1 called her into the (resident's) room. She stated it was 5 to 10 minutes she knew she was in the room with the resident. RN #1 was asked what dependent lividity was and she replied that she did not know. She stated she told LPN #1 at the resident's door that she was not going to do CPR. RN #1 stated she could not tell how long the resident had no vital signs or whether the resident had dependent lividly. She stated she did not go into the room to assess the resident to find out. RN #1 stated, "I know now I should have started CPR." She was asked when would CPR be done and she replied that if the resident was a full code, without pulse or respirations. RN #1 was reminded that the resident was a full code. She stated, "Yes, I know, but based on what the nurse (LPN #1) said, I did not." 4) On [DATE] at 1:20 p.m., LPN #2 stated LPN #1 had called and said she would be late. He stated she arrived at the nursing home at 11:45 p.m. He stated, "She asked me to come over to her hall, she said the resident didn't have a pulse." He stated he told her the resident is a full code and they needed to do CPR. He stated he started compressions (CPR). He stated there was no rigidity and he was able to move the resident's extremities easily. He stated the paramedics stopped the resuscitation, due to the rigidity of the resident's body and absent vital signs. LPN #2 was asked if he would have clocked out and left the facility and he replied, "I would've stuck around, just to see if they needed my help." d. On [DATE] at 10:00 a.m., the Assistant Director of Nursing stated LPN #1 had left a message that there had been a death. She stated, "The morning after we reviewed the nurses' notes and everything in general." She was asked if she knew there was a problem and she stated she did not even know that RN #1 was involved in it and did not remember her being in the facility. She stated LPN #1's message was very vague. On [DATE] at 9:56 a.m., LPN #1 was interviewed again. She was asked if she reported to the Director of Nursing that she felt that it was neglect on RN #1's part when she decided not to do CPR for the resident, who was a full code. She replied she reported it to the Assistant Director of Nursing when she called. She was asked if she reported it as neglect and she replied that she reported that RN #1 had refused to do CPR. e. The Facility Investigation Report DMS-762 documented date and time reported as [DATE] at 11:00 a.m. and date and time of discovery as [DATE] at 9:30 a.m. and designated the type of incident as "Neglect." The Section II-Complete Description of Incident documented, "Arkansas State Board of Nursing received an anonymous complaint that the nurse did not follow CPR procedure correctly." The Section III-Findings and Actions Taken documented, "...(RN #1's) statements and the nurses notes show that she had been with the resident at 11:00 p.m. and suctioned him, then showed vital signs were better. (RN #1) gave report to the oncoming nurse (LPN #1) at approximately 12:11 a.m. and during the report she told the oncoming nurse that this resident had to be suctioned at 11:00 p.m., so to please watch him closely to make sure he doesn't have any other change of condition. She told her that she had called the doctor, but no return call at that time... (LPN #1) oncoming nurse took the report close to end of (the) report she asked her CNA (CNA #1) to get this resident's vital signs. When (LPN #1) got close to the resident's room, the CNA told her she could not get any vital signs and thought the resident was dead. (LPN #1) assessed the resident and immediately and told (CNA #1) to have (RN #1) to come and help her. This is when (LPN #1) told (RN #1), 'he does not have a pulse and was expired.' This is when (RN #1) thought she was not needed anymore and went home. (RN #1) passed (LPN #2) in the hall on her way to clock out and this is when she heard (LPN #1) call for (LPN #2) for help. (LPN #2) responded immediately and he knew he (the resident) was a full code, because he had a conversation with (RN #1) earlier in the shift." 1) The Witness Statement dated [DATE] and signed by LPN #1 documented, "...During report (RN #1) stated that the resident was in respiratory distress and she had suctioned resident and notified M.D. (medical doctor) because she wanted to get permission to get resident sent out, but M.D. had not responded. I asked (CNA #1) to get resident vital signs. At approx. 12:30 a.m. (CNA #1) stood at resident doorway and asked I (LPN#1) to come to pt (patient) room. I immediately went to pt bedside and (CNA # 1) stated she couldn't get vital signs..." LPN #1 documented asking CNA #1 at approx. 12:32 a.m. and 12:35 a.m. to get RN #1. LPN #1 stated RN #1 came to the resident's door and was told that the resident had no pulse, no respirations and was cool to touch. LPN #1 stated RN #1 stated she was going home. LPN #1 stated she asked RN #1 to stay and assist and RN #1 refused and left the facility. 2) The Witness Statement dated [DATE] and signed by RN #1 documented she was called to the resident's room. She stated the resident's breathing was labored, with an oxygen saturation of 88%. She stated the resident needed to be suctioned. She stated that after suctioning, the resident's oxygen saturation was 90% and his respirations were even and unlabored. She stated she called the doctor, but had not received a return call. RN #1 stated that at approx. She stated that at 11:49 p.m., the ,[DATE] nurse arrived. The oncoming nurse (LPN #1) asked CNA #1 to get the resident's vital signs. The statement documented, "At approx. 12:30 a.m., ,[DATE] nurse (LPN #1) called this nurse to the resident's room stating the resident had no pulse or respirations, was cool to touch and 'hard'. This nurse did not do CPR because the resident had passed." 3) The Witness Statement (no date) and signed by LPN #2 documented, "Approximately 11:15 p.m., (RN #1) came over to C hall where I was and asked 'What do I do when a resident is in respiratory distress. I told her to give them oxygen and if that doesn't help ...to get them sent out to the hospital..." In his statement he noted that at approx. 12:15 a.m., he went to make copies and was called over by LPN #1. He stated LPN #1 said the resident had no pulse and that he has died . He stated that he asked if the resident was a full code and she replied that he was. He stated he told LPN #1 that CPR needed to be started and to have 911 called. He stated they performed CPR immediately and the resident's body was cold, but the extremities were easily moved and positioned to do CPR. He stated CPR continued until the paramedics arrived at approx. 12:50 a.m. 2. On [DATE] at 4:25 p.m., the Administrator was asked what the facility had done to prevent recurrence. She stated the facility was not informed there was an issue with the resident's death until [DATE] by the Arkansas State Board of Nursing. She stated: a. RN #1 and LPN #1 were suspended. b. LPN #1 had returned to work; however, she had to have Red Cross CPR training and provide a return demonstration. c. LPN #1 was given a written reprimand. d. Staff in-services regarding code status were completed, to include LPN #1 and RN #1. e. The concern was presented to the Quality Assessment and Assurance committee and an action plan was developed and implemented. f. RN #1 had not returned to work. Decision made to not allow RN #1 to return to work. 3. The Administrator was asked how the facility was monitoring to ensure this incident was not repeated. She stated the Director of Nursing checks all deaths to ensure everything was right at the time. Arrangements have been made with the ambulance service to notify the Administrator if there is an issue when they are called to the facility. The Director of Nursing has developed a plan to have the staff contact her or Assistant Director of Nursing in the event of a death. She or her assistant will go to the facility. All parties involved will write a statement regarding the occurrence. There has been no similar occurrences since the facility was informed. Two staff in-services on [DATE] and [DATE] were completed regarding the actions to be taken in the event of a death and the residents' code status. Staff was also in-serviced regarding the Unwitnessed Death law. There had been three previous in-services concerning the law on [DATE], [DATE] and [DATE].

Complaint # (AR 381) was substantiated (all or in part) in these findings. Based on record review and interview, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical well-being for Resident #1, in accordance with documented full code status within the resident's comprehensive assessment and physician plan of care. The facility failed to ensure nurses (Licensed Practical Nurse #1 and Registered Nurse #1) immediately provided cardio-pulmonary resuscitation (CPR) when a resident was found without vital signs for 1 (Resident #1) of 3 (Residents #1 through #3) case mix residents who had documentation of full code status within their clinical records. This failed practice resulted in a past Immediate Jeopardy which caused or could have caused death to Resident #1 who did not have cardiopulmonary resuscitation initiated when the resident's condition declined. This failed practice had the potential to cause more than minimal harm for 49 residents who had documented full code status within their clinical record, according to a list provided by the Director of Nursing (DON) on [DATE]. On [DATE] at 11:39 a.m., the facility was informed of the past Immediate Jeopardy. The findings are: 1. Resident #1 had [DIAGNOSES REDACTED]. The Significant Change Minimum Data Set with an Assessment Reference Date of [DATE] documented the resident was totally dependent for all Activities of Daily Living. a. The Care Plan dated [DATE] documented, "I have requested that CPR measures ARE to be performed (Full code status). Staff will respect my wishes and rights in regards to my decision to have CPR performed. Communicate my choice to all appropriate staff members. Please continue to administer any ordered medications and treatments as per my physician's orders [REDACTED]. I need you to initiate CPR if you find me pulseless or breathless and continue CPR until Paramedics arrive to take over." Physicians' Orders dated [DATE] documented, "Full Code" b. Nurses' Notes dated [DATE] at 12:25 a.m. and signed by RN #1 documented, "At approx. (approximately) 11 p.m., CNA (Certified Nursing Assistant) called this nurse (RN #1) into room because resident needs to be suctioned. Breathing was labored. Suctioned thick mucus white / yellow approx 30 cc (cubic centimeters). B/P (blood pressure) ,[DATE], P. (pulse) 78, R. (respirations) 24, O 2 sat (oxygen saturation) ,[DATE]. Doctor notified. ,[DATE] (11:00 p.m. to 7:00 a.m. shift) nurse here." 1) On [DATE] at 12:45 p.m., RN #1 stated she was working the A hall ([DATE]) and the resident needed to be suctioned. She stated it was not uncommon for the resident to be suctioned. She stated the resident's oxygen saturation was 80% and she suctioned him. She stated she then called the doctor at approximately 11:15 p.m. (11:,[DATE]:30 p.m.) and that she had not had a return call. RN #1 was asked if she had checked the resident and she replied that she did not. She stated she made only one call to the doctor. 2) On [DATE] at 12:45 p.m., CNA #2 stated she worked the 3:00 p.m. to 11:00 p.m. shift ([DATE]). She was asked if she remembered the resident having something coming out of his mouth and she replied he had yellow sputum coming out of his mouth. She stated she changed the resident with another CNA. She stated she called the nurse (RN #1) to come check him. She stated RN #1 came in while the resident was being changed. She stated she remembered the nurse clearing his mouth, but did not remember if she suctioned the resident. CNA #2 was asked if RN #1 delayed coming when she called her and she replied, "No ma'am. When I called, she came." c. Nurses' Notes dated [DATE] at 1:28 a.m. and signed by Licensed Practical Nurse (LPN) #1 documented, "After receiving report, delegated CNA (CNA#1) to check resident vital signs. Aide signaled this nurse (LPN #1) to resident's room. Assessed resident. No pulse found. Performed CPR with other nurse (LPN #2) while other nurse call ambulance." 1) On [DATE] at 4:30 p.m., CNA #1 stated she was running behind schedule the evening of the incident ([DATE]) and at approximately 12:00 a.m. or 12:30 a.m. she started doing vital signs ...She stated she went to the resident's room and tried to get vital signs on him. She stated she was not getting anything; no pulse. She stated she hollered for LPN #1 and she said to hold on and continued to talk to RN #1. She stated she went back in a few minutes to the nurses' station and said to LPN #1, "Look. I'm not getting nothing! No respirations, no pulse, nothing!" CNA #1 stated, "(LPN #1 and RN #1) were still talking. (LPN #1) came in the resident's room, looked at the resident and said, 'He's died '." CNA #1 stated LPN #1 touched the resident and checked for a pulse. She stated she could not remember if LPN #1 did vital signs or not, as that part was a little hazy. CNA #1 was asked if she was certain she had made it clear to LPN #1 there were no vital signs and she stated, "I actually told her, I'm not getting nothing." She stated LPN #1 stepped out of the room and called for LPN #2. CNA #1 was asked if she knew what role RN #1 played in the incident and she replied she knew she did come into the resident's room at some point, but she didn't remember when. She stated LPN #1 and RN #1 did not know what to do. 2) On [DATE] at 12:45 p.m., LPN #1 stated she arrived at the nursing home at 11:49 p.m. She stated she went to count out on the other hall and then went over to the A hall to count with RN #1. She stated that the narcotics were counted and then RN #1 gave the report. She stated RN #1 reported the resident was having respiratory distress earlier (in the shift) and that he required suctioning. She stated RN #1 said she had called the doctor, who had not returned the call at that time. She stated, "I asked (CNA #1) to go get vital signs on the resident. She stated it was not very long, a minute or two, and the CNA stuck her head out the door and told her (LPN #1) to come to the room. She stated when she arrived in the room, the resident's eyes were wide open, with no movement or reaction, no apical pulse, no rise and fall of the chest. She stated she said to CNA #1, "I think he deceased ," and asked the CNA to get RN #1, while she (LPN #1) finished assessing the resident. She stated the resident was so cool, he was cold. LPN #1 stated, "(RN #1) said she was going home and I asked her to stay to help her." She stated the CNA was not there and she went back to RN #1 to ask her to stay. The RN had left the facility. LPN #1 stated she saw LPN #2 and told him the resident did not have a pulse or respirations. She stated he initiated CPR and she went to call 911 and to get the crash cart. She stated she went to the resident's room and assisted with CPR. She stated they continued CPR for 8 to 10 minutes, before the paramedics arrived and called the resident's death. LPN #1 was asked what dependent lividity was. She replied, "That's not stiffness?" She was asked if she knew to check for dependent lividity and she said, "No." After it was explained to her that dependent lividity was "pooling of blood..." she stated she did not notice it if he had it. LPN #1 was questioned about the CNA's allegation that she had to tell her (LPN #1) more than once that the resident did not have vital signs before she (LPN #1) went to the room. LPN #1 denied the CNA told her more than once before she went into the room to check the resident. LPN #1 was asked what RN #1 said or did when she went to the resident's door and she replied that RN #1 said she was going home and that she did not want to get in involved in the situation. She stated RN #1 then turned around and went home. She stated, "I made it clear to her (RN #1) that I needed her to help me do CPR and she still turned around and went home." She stated RN #1 stayed outside the door, did not go into the room and did not assess the resident. LPN #1 was asked how much time had passed since the CNA had reported the resident had no vital signs and CPR was initiated and she replied, "3 to 5 minutes. It happened so fast. It didn't take too much time to assess him." She was asked how nurses identify code status prior to the incident. She stated, "Prior to the incident, I was not aware of what the dots meant. I knew they had the cards posted on the doors, but I didn't know what the dots meant. I do now." 3) On [DATE] at 12:45 p.m., RN #1 stated she and LPN #1 were counting narcotics when LPN #1 asked CNA #1 to get vital signs for the resident. She stated the CNA came out to LPN #1 and asked her to come to the resident's room. She stated LPN #1 called her to the room and said the resident's dead. She stated LPN #1 used either the word "stiff or hard." She stated LPN #1 wanted to do CPR and RN #1 stated, "I didn't see the need to do it. The man's already gone. He's passed." She stated she walked back to nurses' station to finish what she was doing. RN #1 stated she saw LPN #2 coming down the hall. She stated she believed LPN #1 knew the resident was dead and passed. She stated the signs were there that he did not need it (CPR). RN #1 was asked what were the signs that indicated there was no need to initiate CPR and she replied, "No respirations, no pulse. She (LPN #1) said he was cool. She used the word stiff or hard." RN #1 was asked if she assessed or touched the resident and she replied that she did not go over and look at him. She was asked when she would do CPR and she replied that if the signs were there, she would do it immediately. She stated, "He just had a list of signs. I read somewhere not to do CPR." RN #1 stated that LPN #1 had been in the room for a while with the resident and she was there when the CNA #1 called her into the (resident's) room. She stated it was 5 to 10 minutes she knew she was in the room with the resident. RN #1 was asked what dependent lividity was and she replied that she did not know. She stated she told LPN #1 at the resident's door that she was not going to do CPR. RN #1 stated she could not tell how long the resident had no vital signs or whether the resident had dependent lividly. She stated she did not go into the room to assess the resident to find out. RN #1 stated, "I know now I should have started CPR." She was asked when would CPR be done and she replied that if the resident was a full code, without pulse or respirations. RN #1 was reminded that the resident was a full code. She stated, "Yes, I know, but based on what the nurse (LPN #1) said, I did not." 4) On [DATE] at 1:20 p.m., LPN #2 stated LPN #1 had called and said she would be late. He stated she arrived at the nursing home at 11:45 p.m. He stated, "She asked me to come over to her hall, she said the resident didn't have a pulse." He stated he told her the resident is a full code and they needed to do CPR. He stated he started compressions (CPR). He stated there was no rigidity and he was able to move the resident's extremities easily. He stated the paramedics stopped the resuscitation, due to the rigidity of the resident's body and absent vital signs. LPN #2 was asked if he would have clocked out and left the facility and he replied, "I would've stuck around, just to see if they needed my help." d. On [DATE] at 10:00 a.m., the Assistant Director of Nursing stated LPN #1 had left a message that there had been a death. She stated, "The morning after we reviewed the nurses' notes and everything in general." She was asked if she knew there was a problem and she stated she did not even know that RN #1 was involved in it and did not remember her being in the facility. She stated LPN #1's message was very vague. On [DATE] at 9:56 a.m., LPN #1 was interviewed again. She was asked if she reported to the Director of Nursing that she felt that it was neglect on RN #1's part when she decided not to do CPR for the resident, who was a full code. She replied she reported it to the Assistant Director of Nursing when she called. She was asked if she reported it as neglect and she replied that she reported that RN #1 had refused to do CPR. e. The Facility Investigation Report DMS-762 documented date and time of The Facility Investigation Report DMS-762 documented date and time reported as [DATE] at 11:00 a.m. and date and time of discovery as [DATE] at 9:30 a.m. and designated the type of incident as "Neglect." The Section II-Complete Description of Incident documented, "Arkansas State Board of Nursing received an anonymous complaint that the nurse did not follow CPR procedure correctly." The Section III-Findings and Actions Taken documented, "...(RN #1's) statements and the nurses notes show that she had been with the resident at 11:00 p.m. and suctioned him, then showed vital signs were better. (RN #1) gave report to the oncoming nurse (LPN #1) at approximately 12:11 a.m. and during the report she told the oncoming nurse that this resident had to be suctioned at 11:00 p.m., so to please watch him closely to make sure he doesn't have any other change of condition. She told her that she had called the doctor, but no return call at that time... (LPN #1) oncoming nurse took the report close to end of (the) report she asked her CNA (CNA #1) to get this resident's vital signs. When (LPN #1) got close to the resident's room, the CNA told her she could not get any vital signs and thought the resident was dead. (LPN #1) assessed the resident and immediately and told (CNA #1) to have (RN #1) to come and help her. This is when (LPN #1) told (RN #1), 'he does not have a pulse and was expired.' This is when (RN #1) thought she was not needed anymore and went home. (RN #1) passed (LPN #2) in the hall on her way to clock out and this is when she heard (LPN #1) call for (LPN #2) for help. (LPN #2) responded immediately and he knew he (the resident) was a full code, because he had a conversation with (RN #1) earlier in the shift." 2. On [DATE] at 4:25 p.m., the Administrator was asked what the facility had done to prevent recurrence. She stated the facility was not informed there was an issue with the resident's death until [DATE] by the Arkansas State Board of Nursing. She stated: a. RN #1 and LPN #1 were suspended. b. LPN #1 had returned to work; however, she had to have Red Cross CPR training and provide a return demonstration. c. LPN #1 was given a written reprimand. d. Staff in-services regarding code status were completed, to include LPN #1 and RN #1. e. The concern was presented to the Quality Assessment and Assurance committee and an action plan was developed and implemented. f. RN #1 had not returned to work. Decision made to not allow RN #1 to return to work. 3. The Administrator was asked how the facility was monitoring to ensure this incident was not repeated. She stated the Director of Nursing checks all deaths to ensure everything was right at the time. Arrangements have been made with the ambulance service to notify the Administrator if there is an issue when they are called to the facility. The Director of Nursing has developed a plan to have the staff contact her or Assistant Director of Nursing in the event of a death. She or her assistant will go to the facility. All parties involved will write a statement regarding the occurrence. There has been no similar occurrences since the facility was informed. Two staff in-services on [DATE] and [DATE] were completed regarding the actions to be taken in the event of a death and the residents' code status. Staff was also in-serviced regarding the Unwitnessed Death law. There had been three previous in-services concerning the law on [DATE], [DATE] and [DATE].

Based on observation, record review and interview, the facility failed to ensure causative factors for falls were investigated; new interventions to prevent recurrence of falls were developed, implemented and evaluated for their effectiveness; planned interventions were consistently implemented; motion alarms were turned on and functioning; side-rails were not used unless risks were thoroughly assessed; and call lights were answered promptly to prevent recurrence of falls for 1 (Resident #1) of 13 (Residents #1, #3, #5, #6, #7, #8, #10, #14, #19, #20, #21, #22 and #26) case mix residents who were at risk for falls. The failed practice resulted in a pattern of actual harm for Resident #1 who sustained a fractured hip and had a potential to affect 70 residents who were at risk for falls as identified by the Administrator on 7/22/13. The facility failed to ensure the axilla was not used to lift and reposition a resident to prevent the potential for injury for 2 (Residents #7 and #11) case mix residents of 3 (Residents #5, #7 and #11) case mix who required repositioning while up in a wheel chair. The failed practice had the potential to affect 16 residents who required assistance with repositioning in a wheel chair as identified by the Administrator on 7/22/13. The facility also failed to ensure the plan of care was followed and a smokers apron was put in place when smoking for 1 (Residents #8) of 1 case mix resident who was care planned for the use of a smokers apron when smoking. The failed practice had the potential to affect 1 resident who was care planned for the use of a smokers apron when smoking as identified by the Administrator on 7/22/13. The facility also failed to ensure smoking containers were emptied at least daily to reduce the potential for fire; the smoking areas were free of trash and paper to reduce the potential for fire; linoleum tile was in good repair to reduce the risk of falls; and to ensure the dryers were not left running unsupervised in the event of a fire; and there was no lint build up in the base or lint filters of a dryer to reduce the potential of fire. The failed practices had the potential to affect 13 residents who used the B hall smoking area, 9 residents who used the B hall smoking area, 6 resident who used the bathrooms in C hall room 8 and 14, and 88 residents who resided at the facility as identified by the Administrator on 7/15/13. The findings are: 1. The Facility clinical Guideline: Falls Management received from the Administrator on 7/19/13 documented, "At risk resident are identified through a 'Fall alert' communication system to care givers. During orientation new associates are educated to the fall management system ....The interdisciplinary team evaluates the fall prevention plan of care of residents 'at risk' for falls. (e.g. Review methods: Grand Rounds, Daily Stand-Up or Team Conference). This evaluation may include a screening by rehabilitation services representative and pharmacy consultant for medications that could affect balance or gait....Appropriate intervention are implemented...The Interdisciplinary Team reviews the Change of Condition Report Post Fall/Trauma and make additional recommendations within 72 hours....The QA&A (Quality Assessment and Assurance) committee minutes reflect data analysis using the information driven by the Quality Control Event Reporting System to identify systemic trends and patterns related to resident falls and appropriate plans of action." 2. Resident #1 had [DIAGNOSES REDACTED]. The Minimum Data Set with Assessment Reference Date of 5/27/13 documented the resident had short term and long term memory problems, was moderately impaired for cognitive skills for daily decision making per a staff assessment for mental status; had behaviors that fluctuated, disorganized thinking, altered level of consciousness and acute onset of mental status changes; had behaviors regarding rejection of care towards others and wandering; required extensive assistance of 2 person for bed mobility, transfers and personal hygiene; walking did not occur; had no functional limitation in range of motion of the upper or lower extremities; had falls since admissions and was frequently incontinent of bowel and bladder. a. The Incident and Accident Reports and the Clinical Record were reviewed from 2/03/13 through 5/30/13 with the following findings regarding falls: 1) Resident Incident Report documented, " ...Fall ...Date/Time 2/03/13 01:36 p.m ...at 1336 nurse was into room by CNA (Certified Nursing Assistant), resident found on floor sitting down between w/c and bedside commode, states, 'I transferred myself from the pot.' Bed alarm found on bed, floor dry ...Immediate Post- Incident Action: Staff check q15min (minutes) to ensure safety and apply alarm after every transfer, respond to alarm promptly ...UA (urinalysis) ordered." 2) Resident Incident Report documented, " ...Fall ...Date/Time 2/13/13 10:11 a.m ...(at) 10:10 this nurse was in hallway and saw res fall to the floor on his buttocks in front of his recliner. When asked res what he was doing, he stated he had finished using his urinal and his 'left leg collapsed' reminded him that he is supposed to request assist. He had pressed the button on the alarm (and) turned it off ... Immediate Post- Incident Action: Informed CNAs to make sure to toilet resident q2hrs (hours) and prn (as needed) reminded res to use call light for assistance ...that alarm is for safety and he should not be turning it off ..." 3) Resident Incident Report documented, " ...Fall ...Date/Time 2/26/13 09:45 p.m...CNA informed me that he entered R(resident)/room and found him on the left side of his bed laying on the floor. Resident stated he was getting out of bed to walk and grabbed his bedside table and tumbled to the ground landing on his left side. CNA stated bed pad alarm had been turned off ... Immediate Post- Incident Action: Frequent alarm checks. Redirected R(resident) to use call light for assistance out of bed ... New Intervention: Staff to ensure residents alarm is out of reach as this resident frequently turns off alarms." A physician's orders [REDACTED]. 4) Resident Incident Report documented, " ...Fall ...Date/Time 3/14/13 at 12:30 a.m ... CNA heard alarm sound and found /R in the TV room in the floor on his back in front of the w/c... Immediate Post- Incident Action: Alarms in place in bed. W/c taken out of the room ...MD to review medications d/t insomnia ..." 5) Resident Incident Report documented, " ...Fall ...Date/Time 3/17/13 at 8:45 p.m. ...Resident climbed out of bed after turning off alarm, crawled to his chair ...stated he was looking the feces detector... Immediate Post- Incident Action: UA, Pad (fall mat) on floor by bed ..." A physician's orders [REDACTED]. Ensure alarm is in proper placement and working q shift." 6) Resident Incident Report documented, " ...Fall ...Date/Time 3/29/13 at 8:37 a.m ... Resident was sitting in his wheelchair in his room. CNA heard alarm sounding, immediately entered the room and resident was on the floor next to bedside table. Resident stated he was trying to stand up. ... Immediate Post- Incident Action: Keep resident in site (sight) of staff while up in wheelchair ...New interventions, Staff encouraged to have resident in visible sight when up in wheelchair for safety." 7) Resident Incident Report documented, " ...Fall ...Date/Time 4/20/13 at 8:03 p.m. ..Resident found in room on back on safety mat ...Alarm sounding ... Immediate Post- Incident Action: W/c placed outside room while resident in bed to ensure resident safety ..." 8) Resident Incident Report documented, " ...Fall ...Date/Time 5/1/13 at 12:11 a.m. ...Staff heard residents alarm and immediately responded to it, found resident in the floor. Resident climbed over siderails reaching for some cookies on bedside dresser. Resident bumped his head causing a ...skin tear on left side of forehead ... Immediate Post- Incident Action: moved dresser and add more floor mats ...staff to pull dresser closer so that resident can reach snacks ..." 9) Resident Incident Report documented, " ...Fall ...Date/Time 5/24/13 at 2:30 a.m ....Pressure alarm in place to bed and w/c working properly for residents safety. Fall mat in place for safety (at) approx (approximately) 0230 this nurse and CNA entered room to observe resident attempting to get up out of bed. Alarm was in place and on, resident was holding pressure to alarm to keep it from going off. He slid out of his bed and onto the blue safety mat ... Immediate Post- Incident Action: Monitor resident closely. Educated res to not hold pressure on the alarm ...and to use call light and ask for assistance ...Staff to make frequent safety checks on this resident." 10) Resident Incident Report documented, " ...Fall ...Date/Time 5/24/13 at 3:45 p.m. ...CNA notified Nurse that /R (Resident) was laying in the floor on his back... Bed in low position, safety mat in place next to bed. Pressure alarm in use. Call light in reach but not on. R stated, 'I want in my WC (wheelchair)' ... Immediate Post- Incident Action: Make sure alarms are turned on et (and) working properly reeducate /r to use call light before attempting to transfer self ...staff inserviced on ensuring residents sensor alarm is in place and working at the beginning of each shift." A Staff Inservice Education form dated 5/24/13 included the following instructions regarding the resident: "When taking care of (Resident #1) always check his sensor alarm at beginning of every shift as the battery dies really quickly and he is a fall risk. Batteries wil be at the Nurses Station." 11) Resident Incident Report documented, " ...Fall ...Date/Time 5/26/13 at 10:30 a.m ... While passing by resident's room this Nurse noted resident crawling out of bed onto floor mat., alarm and floor mat in place and in working order alarm sounding off upon resident getting out of bed ...New intervention: Staff encouraged resident to let them assist in getting out of bed into wheelchair when awake in bed." 12) Nurses Notes dated 5/28/13 documented, "Res (Resident) repeatedly trying to climb out of bed, redirected and encouraged to stay in bed and to get rest. Non compliant res continued to try to get out of bed. Kept getting on floor and crawling on safety mat. ..." There was no Incident Report documented for this date. A Nurses Notes dated 5/28/13 at 10:51 a.m. documented, "Resident moved back to the behavioral unit d/t increased confusion and resident wanting to move back. Nurses Notes dated 5/31/13 at 10:58 a.m. documented, "Res. continues to have cognitive decline and is now A&O (alert and oriented) x 1 (self) with confusion evident... Res is very demanding often times resulting in a fall or skin tear..." b. The Comprehensive Care Plan with a review date of 5/30/13 documented a problem dated 6/8/12 of risk for falls with approaches: "Encourage me to wear non skid footwear ...ensure my bed is in lowest position ... Staff to make frequent safety checks on this resident d/t (due to) non compliance with using call light Staff to check on resident q (every) 30 minutes for safety ...3/21/13 Motion alarm in place in room away from resident to aid staff in monitoring for res (resident) getting up without assistance. Res has hx (history) of turning off alarms ...3/29/13 Resident fell ...Resident to be in visible sight when up in w/c (wheelchair). Pressure alarm to bed (and) w/c, ensure placement (and) proper working order q shift ...4/20/13 Resident was found on the fall mat in his room trying to get to his w/c staff to keep resident wheelchair out of sight to provide rest periods ...5/1/13 fell on [DATE] d/t resident trying to reach over bedside rails to reach cookies on nightstand int (intervention): moved table closer to bed for easier access ...5/30/13 CPOC (continue plan of care) ..." c. The Incident and Accident Reports and the Clinical Record were reviewed from 6/01/13 through 7/10/13 with the following findings regarding falls: 1) Resident Incident Report documented, " ...Fall ...Date/Time 6/17/13 at 7:46 a.m ... Alarm sounding in resident's room. CNA entered and found resident in floor next to w/c and isolation barrels. Resident had been up in w/c eating breakfast in room. Resident stated that he was trying to get to the ceiling. Skin Tear ... Immediate Post- Incident Action: n/o (new order) for UA with C&S (culture and sensitivity) d/t confusion. " 2) Resident Incident Report documented, " ...Fall ...Date/Time 6/21/13 at 8:01 a.m ... Resident was sitting up in w/c in room eating breakfast. Alarm sounded CNA immediately entered room and found resident in floor in front of w/c. Resident stated that he was a rocket ship taking off into the sky. Immediate Post- Incident Action: Labs performed d/t confusion noted ..." A Nurses Notes dated 6/21/13 at 1:17 p.m. documented, "New Orders recd (received) and noted, 1/2 side rails x 1 ...BMP (Basic Metabolic Panel) stat d/t confusion." A physician's orders [REDACTED]." 3) Resident Incident Report documented, " ...Fall ...Date/Time 6/25/13 at 2:25 a.m ... on way back to hall other Nurse says she heard a thumb (thump) coming from res room and this Nurse and we both went to check on res, upon entering res on floor. when asked where he was trying to go res stated, "I need food ... Immediate Post- Incident Action: Res to be reffered (referred) to Therapy for possible diet upgrade ...New Intervention: Resident was given a snack and staff inserviced on offering resident snacks throughout the night." The resident's plan of care documented, "6/25/13 Resident was found on the floor (without) injury stated he 'needed food.' Staff inserviced to offer resident snacks throughout the night." 4) Resident Incident Report documented, " ...Fall ...Date/Time 7/1/13 at 2:55 a.m ... called out, 'Somebody come and help me please.' Upon entering res in floor, with arm still in bed lying on top of alarm in which is why alarm didn't sound to alarm staff that res was out of bed ...Residents motion alarm was not in place ... New intervention. Staff in-serviced on ensuring all belongings and alarms are moved when resident are transferred to a different room." The Fall Risk Evaluation dated 7/1/13 documented the resident scored 11 and that a score above 10 indicates resident is at risk for falls. A physician's orders [REDACTED]." Nurses Notes dated 7/8/13 at 11:20 a.m. documented, "N/O (new order) for side rails x2 for bed mobility ..." Nurses Notes dated 7/9/13 at 5:18 p.m. documented, "Clarification order: ? siderails x2 to aid in bed mobility." 5) Resident Incident Report documented, " ...Fall ...Date/Time 7/10/13 at 2:01 p.m .... Bruise was noted on inner right thigh. Resident stated that he was trying to get out of bed last night and attempted to climb over his left side rail. Stated he then fell into the floor landing on his right side. Resident then stated that his bed was like a rocket ship and it shot him up in the air. Received new order for right hip x-ray, results show right hip fracture ... New Intervention: Resident was ordered an x-ray and body pillows placed around resident while in bed ..." The plan of care for the resident documented, "7/10/13 Res fell with fracture when crawling over side rail. Body pillows placed while in bed." Nurses Notes dated 7/10/13 at 9:22 p.m. documented, "Received X-Ray results for right hip ...Results show acute appearing right hip fracture ...transported to (hospital) ..." Nurses Notes dated 7/12/13 documented the resident was readmitted to facility on at 3:10 p.m . d. On 7/15/13 at 2:24 p.m., the resident was lying in bed, the 1/2 side rails were up x 2 covered with styrofoam noodles with the bed positioned by the wall and ? side rails up. The pressure alarm was in the center of the bed and a mat on the floor beside the bed. The resident had the bed control in his left hand. e. On 7/16/13 at 8:33 a.m., the resident was lying in bed. The ? side rails were up x 2 with the bed positioned by the wall. The pressure alarm control was in the center of the side rails within the resident's reach. The bed control was in the resident's left hand. He was raising and lowering the head of the bed. The bed was not in the lowest positron. The call light was lying on the blue mat on the floor, and the light on the panel on the wall was red. An alarm was sounding at the nurses station, the light on the ceiling on the right side of the Nurses Station was on. The Resident was monitored, the call light was answered at 9:03 a.m. (30 minutes from the time surveyor first started monitoring) by Licensed Practical Nurse #2. The Surveyor and the LPN entered the resident room, the motion detector did not go off. The LPN stated, "I heard the call light, but didn't know where it was coming from." At 9:40 a.m., the resident was lying in bed, Certified Nursing Assistant (CNA) #5 and #6 entered the resident's room. The resident had the bed control in his left hand. The resident's bed was not in the lowest position. The CNA's completed care and left the resident's room. The resident's bed was not in the lowest position. At 9:52 a.m., the resident was lying in bed, CNA #5 was assisting the resident with his breakfast meal. Before the CNA left the resident room, the CNA handed the resident the bed control. The bed was not in the lowest position. The side rails were up x2 with the bed positioned by the wall. At 3:40 p.m., (Resident #22) was in the resident's room walking around. The motion detector did not sound. f. On 7/17/13 at 10:45 a.m., as the Treatment Nurse left the residents room the bed was not in the lowest position. The Treatment Nurse handed the resident the bed control. The Treatment Nurse did not turn the motion detector alarm on. At 11:30 a.m., LPN #2, was asked how often the alarms were to be checked. The LPN stated, "Every shift." The LPN was asked who was responsible for checking them. The LPN stated, "The LPNs and the CNAs." The LPN was asked when are the alarms checked? The LPN stated, "At the beginning of each shift and when the staff enters the resident's room." The LPN was asked about the side rails. The LPN stated, "We put pillows between the side rail and mattress." The LPN was asked if the resident had had a different mattress. The LPN stated, "No, he had this mattress before he moved to the secure unit." The Surveyor asked the LPN if she could check the resident's side rails. The Surveyor and the LPN entered the resident's room, the motion detector did not sound. The LPN checked the alarm and stated it was probably the batteries. The Surveyor told the LPN the Treatment Nurse did not turn the alarm on when she left the room at 10:45 a.m. The resident was lying on his back with the 1/2 side rails up covered in Styrofoam noodles, with the pressure alarm control in the center of the side rails, within the resident's reach. The control to the bed was in the resident's hands. The bed was not in the lowest position. The LPN was asked if the resident's bed was in the lowest potion. The LPN stated, "No." The LPN checked the resident's side rails, stated the side rails would give a little, but was not loose. The LPN checked the width between the mattress and the side rails and there was, approximately 8 inches and the mattress would give when pressure was applied. The LPN was asked if the resident could raise the bed. The LPN stated, "He likes to keep the controls in his hands." The LPN turned on the motion alarm when we left the resident's room. g. On 7/18/13 at 11:50 a.m., the Director of Nurses (DON) was asked if they had meetings to discuss resident falls and how often they met? The DON stated, "Yes, the Interdisciplinary Team (IDT) consists of me, the ADON (Assistant Director of Nurses), and the MDS (Minimum Data Set) Coordinator. We meet daily." The IDT, looks at residents' past interventions, changes in condition, lab, and environmental hazards in the resident's rooms." The DON was asked when interventions were put in place how they assessed them to determine if the interventions were effective or ineffective? The DON stated, "We monitor their falls, reports from staff." The DON was asked if ineffective what did they do. The DON stated, "We change the intervention." The DON was asked where would this be documented. The DON stated, "In the Nurses Notes." The DON was asked if a resident has cognitive impairment is asking the resident to use the call light an effective intervention. The DON stated, "No." Resident #1 falls history was reviewed with the DON. The DON was asked about the intervention on 5/24/12, "staff in-serviced to ensure resident's sensor alarms in place and working at the beginning of each shift" was also documented as an intervention on 2/26/13, was this a new intervention put in place. The DON stated, "No, the resident has had a cognitive decline so rapidly, the past 6 months he's declined so fast. He has End Stage Parkinson Disease each time it so difficult to put in new interventions, or to develop a new intervention." The DON was asked about the intervention on 5/26/13 "Staff to encourage the resident to let them assist in getting him out of bed into a wheelchair when awake" was this an appropriate intervention with the resident's cognitive status. The DON stated, "No." The DON was asked about the intervention for the fall on 6/17/13 for a UA. The UA report was shown to the DON, which reported it was normal. The DON was asked if the fall was re-assessed and a new intervention put in place. The DON stated, "No." The DON was asked about the intervention for the fall on 6/21/13 for lab, a BMP (Basic Metabolic Panel). The DON was shown the lab results which was normal for this resident. The DON was asked if the fall was re-assessed and a new intervention put in place. The DON stated, "No." The DON was asked about the Nurse Note dated for 7/6/13 that documented, "Noted to frequently let his legs slip between the mattress and side rail. Redirected and repositioned frequently, but will continue to be found in this same position. R is cognitively impaired and unable to use judgement r/t (related to) safety. Placed pillows in the space to reduce chance of injury." The DON stated, "This was regular pillows." The DON was asked if regular pillow put in place was an appropriate intervention. The DON stated, "They were there for padding." The DON was asked, "Wouldn't the regular pillows move." The DON stated, "I guess, they could, when he returned to the facility (7/12/13) we got the body pillows and put beside the resident." The DON was asked, in reviewing the resident's falls for the past 6 months, he has had multiple falls and there were incidents where he attempted to climb over the side rails did she feel the side rails were a problem. The DON stated, "We used the pillows." The DON was asked do you feel the pillows were an appropriate intervention. The DON stated, "When he returned we used the body pillows." The DON was asked if she had ever assessed the resident's side rails, the DON stated, "No." The DON was told that when the resident was monitored during the survey the motion alarm was not turned on, on 7/16/13 at 8:33 a.m. and the call light was on the fall mat in the floor. The call light was not answered until 9:03 a.m. for approximately 30 minutes. The DON was also told about an observation made during the survey when a wandering resident entered the residents room on 7/16/13 at 3:40 p.m., the motion detector did not sound and on 7/18/13 at 10:45 a.m., the Treatment Nurse left the resident room after treatment, and failed to turn the motion alarm back on, which was off for approximately 45 minutes. The DON stated, "The batteries were changed once." The Surveyor stated, "Yes, this was after the wandering resident had entered the resident's room on 7/16/13 at 3:45 p.m." The DON was asked how often were the alarms checked. The DON stated, "At the beginning of each shift." The DON was asked who is responsible for ensuring that the alarms were in place and functioning. The DON stated, "The Nurses and the CNAs (Certified Nursing Assistance)." The DON was asked in reviewing the resident's falls were there any new interventions put in place. The DON stated, "No." When the Resident returned from the hospital with a Fractured hip, that was not repaired due to not a surgical candidate, what interventions were put in place. The DON stated, "The body pillows were placed on the bed." h. On 7/18/13 at 12:50 a.m., the DON gave the Surveyor "PAR Notes." The DON stated, these were the notes that they used by the IDT to discuss the resident's falls." The PAR Notes documented: 1) 3/6/13, ...Resident taking batteries out of alarms and putting in top drawer moved to head of bed on trapeze bar so he can't reach will cont. (continue COPC (Comprehensive Plan of Care). 2) 5/29/13...2 falls in the last week (without) injury." There was no documentation of interventions put in place. 3) 6/26/13...3 falls within the last week, UA (Urinalysis) & BMP ordered (with) re new orders. Will cont. CPOC." i. On 7/19/13 at 2:50 p.m., the Nurse Consultant and the DON asked to speak to the surveyors. The Nurse Consultant stated that the DON was new to her position, was formerly the Minimum Data Set Coordinator, when she said that there had not been any new interventions in place, there were things done but not documented. The DON was asked, "What new interventions did you put in place that were not documented." The DON stated, "I can't remember." 3. Resident #7 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 6/10/13 documented the resident was severely impaired in cognitive skills for daily decision making per a Staff Assessment for Mental Status and required extensive staff assistance for transfer and balance. a. The Care Plan dated 4/3/13 documented, "...I have a dx (diagnosis) of Osteoporosis. ...Maxi (Maximum) lift times two staff for transfers to my wc. ..." b. On 7/17/13 at 10:55 a.m., the resident had slid down in the wheelchair he was in. Certified Nursing Assistant (CNA) #3 was on the resident's left side and Registered Nurse (RN) #2 was on the resident's right side. Each of the staff members placed their arms underneath the resident's axilla and lifted up underneath the arms to adjust the resident's position in the wheelchair. The resident grimaced and the RN asked the resident if she was hurting but the resident gave no response. c. On 7/17/13 at 12:15 p.m., CNA #3 was asked if a resident should be lifted under the arms to reposition the resident in a wheelchair and the CNA stated, "Yes and No. I'll explain it. Yes, because the lift may not specifically move the resident where you want them. No, cause it might hurt them, it might hurt them under their arms, it might break something or hurt them." 4. Resident #11 had [DIAGNOSES REDACTED]. The Quarterly MDS with an ARD of 6/24/13 documented the resident scored 2 (0-7 indicates severely impaired) on a Brief Interview for Mental Status (BIMS), required extensive assistance from staff for transfer, and was not steady for balance and only able to stabilize with staff assistance. a. The Care Plan dated 4/30/13 documented, "I am unable to reposition myself and need for you to ...reposition me (every) 2 hours and as needed..." b. On 7/17/13 at 11:14 a.m., CNA #3 and 4 transferred the resident to a wheelchair using a mechanical lift. After the transfer, CNA #3 stood on the resident's right side and CNA #4 stood on the left side, each placed an arm underneath one of the resident's axilla and lifted up on the resident to reposition the resident in the wheelchair. c. On 7/17/13 at 12:05 p.m., CNA #4 was asked if a resident should be repositioned by lifting underneath the arms and the CNA stated, "Not like with all the weight but we do it equally but I know you shouldn't." The CNA was asked what could occur if the resident is lifted underneath the arms. The CNA stated, "Dislocation." 5. Resident #8 had [DIAGNOSES REDACTED]. The 14 Day Medicare MDS with an ARD of 6/19/13 documented the resident scored 13 (13-15 indicates cognitively intact) on a BIMS. a. The Care Plan dated 6/24/13 documented, "I have chosen to continue to smoke and need you to monitor me for safety...I need you to supervise me, ...I need to wear a smoker's apron when I smoke due to safety concerns; please make sure and put it on me, then help me take it off after I smoke." b. On 7/16/13 at 4:15 p.m., the resident was seated on the patio area smoking and had no smoking apron to cover his clothing. c. On 7/17/13 at 9:25 a.m., the Director of Nursing (DON) was asked if the resident should wear a smoking apron if care planned to wear one and the DON stated, "Yes." 6. On 7/18/13 at 3:42 p.m., in the main courtyard between A Hall and B Hall across from the Physical Therapy department there was a large amount of cigarette butts that littered the concrete patio and the dry grassy areas. The Maintenance Services staff member was asked if the county was under a burn ban and the Maintenance Services stated, "Yes, Garland County." At 4:05 p.m., in the C Hall courtyard, there was a red metal cigarette can on the patio that contained a large amount of cigarette butts, a large amount of paper towels, a piece of paper, a paper cigarette box, a paper milk carton, and 2 plastic cups with 1 of the cups burnt on the end of the cup. At 4:08 p.m., there was a small black metal sided can with a plastic lid that contained a large amount of cigarette butts with a paper Marlboro brand cigarette box with the bottom of the box charred. At 4:10 p.m., in the secured C Hall unit courtyard, there were numerous cigarette butts that littered the dry grassy areas. The courtyard was enclosed with a wooden fence that surrounded the area. At 4:55 p.m., on the exterior area outside of the B Hall Exit Door the pavement and against the building was littered heavily with cigarette butts. At 5:25 p.m., the Housekeeping Supervisor (HSK) Supervisor was asked who was responsible for cleaning the smoking areas and the HSK Supervisor stated, "I'm not real sure I believe it's (Maintenance). We get out there every once in a while picking up when we can." The HSK was asked who emptied the cigarette cans and the HSK Supervisor stated, "On courtyard, my floor tech does. He empties the cans every day as much as needed. C Hall I believe that mainly nursing." At 5:30 p.m., Maintenance Services was asked who was responsible for cleaning the cigarette butts from the courtyard areas and the Maintenance Services stated, "I was under the assumption it was nurses on C Hall." Maintenance Services was asked if the bottom of the black can that contained cigarette butts was plastic and Maintenance Services stated, "Plastic bottom in the cigarette can." Maintenance Services was asked if there was paper in the cans with the cigarette butts and the Maintenance Services stated, "Yes." Maintenance Services was asked if paper and trash should be put in the cans with the cigarette butts and Maintenance Services stated, "No, there should not, they are suppose to be for cigarette butts. No trash." The facility's policy titled, "Smoking Policy" received on 7/19/13 documented, "...Safe, fire proof

Complaint # was substantiated (all or in part) with these findings. Based on observation, record review and interview, the facility failed to ensure allegations of sexual abuse were immediately reported to the Administrator, the allegations were promptly investigated and that interventions were immediately developed and implemented to protect residents from further potential abuse for 2 (Residents #3 and #4) of 2 case mix residents who alleged staff to resident abuse. These failed practices resulted in Immediate Jeopardy, which likely caused or could have caused serious harm, injury or death to Residents #3 and #4, who alleged staff to resident sexual abuse, and had the likelihood of causing more than minimal harm for 93 residents who were at risk of abuse from staff, as documented on a list provided by the Administrator on 5/5/11 at 4:10 p.m. The facility was informed of the Immediate Jeopardy condition on 5/10/11 at 3:20 p.m. The findings are: 1. Resident #4 had [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/11/11 documented the resident was severely impaired in cognitive skills for daily decision making. a. On 5/10/11 at 9:57 a.m., LPN #3 stated, "(On 5/2/11) (CNA #3) said (Resident #4) had told her that (CNA #4) had put his penis in her (Resident #4) mouth." The OLTC (Office of Long Term Care) Incident and Accident Report (I & A) documented, "Date and Time of Discovery: 5/2/11 3:30 p.m. ...Summary of Incident CNA (Certified Nursing Assistant) reported to DON (Director of Nursing) that on 4/28/11 this resident (Resident #4) pointed at a male (CNA #4) and said 'I don't like him he put his thing in my mouth.' Resident assessed at this time by DON for injury ...Steps taken to prevent continued abuse or neglect during the investigation ...Investigation initiated immediately upon discovery. Alleged employee suspended pending investigation immediately upon discovery. Police, family and physician notified. All cognitive residents and staff interviews initiated immediately, complete body audits performed on all residents. Staff inservice on abuse and neglect initiated." 1) On 5/6/11 at 9:30 a.m., the Administrator stated, "I brought (CNA #3 and LPN #1) in my office the next day (5/3/11). (CNA #3) said she wasn't specific about what the allegation (referencing 4/28/11) was; (Resident #4) was emotional. At first (CNA #1) said she told (LPN #1) (referencing allegation of sexual abuse reported by Resident #4 to CNA #3 on 4/28/11)." 2) An OLTC Witness Statement Form dated 5/3/11 at 2:13 p.m. documented, "Witness Full Name: (CNA #3)...On Thursday evening (4/28/11) (Resident #4) said that (CNA #4), she pointed at him and said he put his thing in her mouth. I went and told the nurse (Licensed Practical Nurse (LPN) #1) she was emotional and saying all kinds of stuff. I wasn't specific so (LPN #1) said she gets like that." On 5/10/11 at 9:04 a.m., CNA #3 stated, "(Resident #4) said (CNA #4) put his thing in her mouth. I went to (LPN #1) and said '(Resident #4) is being very emotional.' I should have told her everything right then and there." 3) An OLTC Witness Statement Form dated 5/3/11 at 4:25 p.m. documented, "Witness Full Name: (LPN #1) ...I do not recall (CNA #3) or anyone else telling me that (Resident #4) stated that (CNA #4) put his penis in her mouth." On 5/9/11 at 4:10 p.m., LPN #1 stated, "(CNA #3) came to me (on 4/28/11) and said (Resident #4) was having emotional problems. She didn't say anything else. She (Resident #4) has problems every day. The next day or after that they called me to the DON's office. (It had been reported) that one of the CNAs had stuck his penis in her (Resident #4) mouth. (CNA #3) came in about that time. I told her you did not tell me that. I would have remembered that. I was walking up and down and walked by (Resident #4) several times. She was no different and had no issues." 4) An OLTC Witness Statement Form dated 5/2/11 at 6:15 p.m. documented, "Witness Full Name: (DON) ...This nurse interviewed (Resident #4). Asked resident 'Has anyone ever been sexually inappropriate with you?' (Resident #4) responded, 'I ain't been in bed with no man. I ain't done nothing wrong.' I then asked her if anybody did anything inappropriate or wrong to her. She shook head back and forth in 'no' motion." b. The Division of Medical Services (DMS) 762 dated 5/9/11 (no time) documented, "Findings and Actions Taken: Investigation initiated immediately upon discovery. Police, family and physician notified. Alleged employee (CNA #4) was suspended immediately pending investigation. (CNA #3) suspended regarding late reporting of abuse allegation. Staff and cognitive residents interviewed. Body audit completed on all residents with no concerns. Staff inserviced on abuse and neglect. Resident assessed for injury without negative findings. Resident interviewed by DON. DON asked 'Has anyone ever been sexually inappropriate with you?'. Resident stated, 'I ain't been in bed with no man.' DON asked, 'Has anybody done anything inappropriate to you?' Resident shook her head back and forth in a 'no' motion. Based on staff and cognitive residents interviewed with no negative findings, no physical signs of injury from body audit, the facility is unable to substantiate abuse." c. On 5/9/11 at 1:40 p.m., Resident #4 was in the wheel chair in the hall with her feet propped up in a chair. Surveyor asked the resident if I could talk to her in a more private area. The resident stated, "You can talk to me here." Other residents were in the vicinity. The resident was asked how she liked living here. Resident #4 stated, "Fine." The surveyor asked how the staff treated her here. The resident stated, "Good." 2. Resident #3 had [DIAGNOSES REDACTED]. The quarterly MDS with an ARD of 3/19/11 documented the resident scored 1 on the Brief Interview for Mental Status (0-7 indicates severe impairment) and required limited physical assistance of 1 person for toilet use. a. The OLTC Incident and Accident Report (I & A), DMS-7734 documented: "... Date and Time of Discovery: 5/2/11, 3:30 p.m.... Date of I&A: 5/2/11. ... Name of Injured Resident: (Resident #3). Summary of Incident: CNA reported to DON and ADON (Assistant Director of Nursing) that when (CNA #4) walked in the dining room onto the hall this resident began crying and CNA (CNA #3) assisted to nurses station and asked her what was wrong, resident stated, 'He touched me and pulled it out and it was big, and I tried to leave and he wouldn't.' Resident transferred to (hospital) for evaluation. Rape Kit pending. Steps taken to prevent continued abuse or neglect during the investigation: Investigation initiated immediately upon notification. Employee suspended pending investigation. Police, family, and physician notified. All cognitive residents and staff interviews conducted on all residents. Staff inservice initiated on abuse and neglect." Body audits of the residents, interviews with the cognitively intact residents and the staff were included in the OLTC I&A Report. 1) The OLTC Witness Statement Form dated 5/2/11 at 3:30 p.m. documented, "Witness Full Name: (CNA #3). ... I saw (Resident #3) in the dining room. (CNA #4) came into the dining room and (Resident #3) started crying and was nervous. So I pulled (Resident #3) into the nurses' room and I asked (Resident #3) what happened. (Resident #3) said he touched her and pulled his thing out and it was big. (Resident #3) said she tried to leave and he wouldn't leave." On 5/10/11 at 9:04 a.m., CNA #3 (referring to 5/2/11) stated, "It was shift change. (Resident #3) was coming over to me and (CNA #4) was coming in. She was crying. She said, 'He touched me.' All she would say was he would not let me out. I asked her if 'he whipped it out.' She said, 'yes'." 2) On 5/10/11 at 9:57 a.m., LPN #3 stated, "(CNA #3) was in the nursing station (on 5/2/11) with (Resident #3). (Resident #3) was crying. (CNA #3) said that (CNA #4) had done some stuff to her (the resident) and did not want him taking care of her. That he was touching her in her places and (Resident #3) said he put his penis in her. (Resident #3) said it was big, it hurt and she did not like it at all." b. The Hospital ER (emergency room ) Record dated 5/2/11 documented, "... Final Diagnosis: [REDACTED]. The patient does have a history of dementia and [MEDICAL CONDITION]. She states that she was assaulted by a staff member at the nursing home. She says that he has done bad things to her. She says that he has hit her. She says that he picked her up and threw her. She also tells me that he did nasty things to her. She says that he raped her. The patient says that he has done these things to other girls. She says that this happened yesterday. ... Pelvic exam was done with two nurses' chaperoning ... The patient had some excoriation, but no signs of trauma. She had normal female external genitalia. On speculum exam, she did have a little white discharge, but otherwise unremarkable speculum exam. ... The patient is calm and cooperative, but she does get tearful when asked about what happened." c. The DMS-762, page 4 of 9, Section III - Findings and Actions Taken dated 5/9/11 documented, "... Action: Investigation initiated immediately upon discovery. Employee (CNA #4), immediately suspended pending investigation. Resident sent to (hospital) for examination. Rape kit performed and results sent to the ... Police Department per ER records. Staff and cognitive residents interviewed. Body audits completed on all residents. Resident returned to the facility. Emergency Department reports no trauma per ER exam. Based on body audits, staff and cognitive resident interviews with no negative findings, and ER exam, facility unable to substantiate abuse." 1) On 5/10/11 at 8:20 a.m., CNA #4 was asked if he exposed himself to either of these residents. He stated, "No, not in any way or form. Absolutely not." He also confirmed he was suspended on 5/2/11 and had not been back to work at the facility. 2) The Staff Inservice Education form dated 5/2/11 documented "Abuse must be reported immediately upon discovery to the DON and Administrator. When you report abuse and have not been asked for a witness statement within a hour of reporting, you must report to the next person in charge, DON, ADON (Assistant Director of Nursing) and Administrator. Abuse is very serious and if reporting is not done timely you could possibly be suspended for not reporting and/or jeopardizing the resident for further injury. CNAs (Certified Nursing Assistants) do not interview residents. When a resident reports to you, you immediately report this to charge nurse. ... Anytime any type of abuse or neglect is reported to you, you must immediately report it to your charge nurse. Anytime you witness or suspect abuse always; #1 remove the resident from harm, #2 report to charge nurse or supervisor, #3 if your charge nurse is the abuser report to any charge nurse in the building or call the RN (Registered Nurse) on call yourself. Types of abuse include but are not limited to physical, mental, verbal, neglect-not providing the care in which they are needed. Neglect includes not reporting that a resident is complaining of pain to charge nurse or MD (medical doctor). You are also in the wrong too if you do not report immediately." The Staff Inservice Education form documented that LPN #1and CNA #2 signed the attendance sheet for the "Abuse and Neglect" inservice on 5/2/11. 3) The Staff Inservice Education form dated 5/6/11 through 5/9/11 documented, "Housewide inservice on Abuse and Neglect. ... Anytime any type of abuse or neglect is reported to you, you must immediately report it to your charge nurse. Anytime you witness or suspect abuse always; #1 remove the resident from harm, #2 report to charge nurse or supervisor, #3 if your charge nurse is the abuser report to any charge nurse in the building or call the RN (Registered Nurse) on call yourself. Types of abuse include but are not limited to physical, mental, verbal, neglect-not providing the care in which they are needed..." The Staff Inservice Education form documented that LPN #1, CNA #1 and CNA #2 signed the attendance sheet for the "Abuse and Neglect" inservice on 5/6/11. d. On 5/9/11 at 1:25 p.m., Resident #3 was asked if a male had ever shown himself or exposed himself to her. The resident stated, "Yes." The surveyor asked her what happened. She stated, "They used to come at night and get on me." She was asked if it was someone that worked here. She stated, "I don't know." She was asked if she told someone about this. She stated, "Yes." The resident stated that she had not seen him when asked if he was still here. The resident was asked when this happened and she stated, "A while ago." e. On 5/9/11 at 4:10 p.m., LPN #1 stated, "I haven't told anyone this yet, but Saturday night (5/7/11) (CNA #1) got me and wanted me to hear what (Resident #3) was saying. (Resident #3) stated, 'I've never been felt like this before.' I explained that they are cleaning you like they always do." LPN #1 was asked, " In your opinion, what did you think (Resident #3) was saying?" LPN #1 stated, "That she (CNA #1) was feeling of her (Resident #3) inappropriately." On 5/10/11 at 2:26 p.m., LPN #1 stated, "(Resident #3) said, 'I've never been felt like this before.' I did not ask her what she meant. After talking to (Resident #3) my impression of what she was saying was that when they washed her down there, they touched her private parts different than they had before. (CNA #1) was washing her." f. On 5/10/11 at 2:21 p.m., CNA #1 stated, "On Saturday (5/7/11) night (Resident #3) had been incontinent. I put her on the commode. She had bowel movement on her buttocks. I attempted to wash her buttocks with periwash. She started crying and I stopped. I asked her what was wrong. She said, 'I've never been touched that way before.' I opened the door and called for (LPN #1). (LPN #1) and (CNA #2) came to the room. (Resident #3) continued to cry. (LPN #1) told (Resident #3) that she needed to be cleaned. (Resident #3) told (LPN #1)( that she had never been touched like that. (Resident #3) let me wash her up after (LPN #1) and I reassured her." g. On 5/10/11 at 2:37 p.m., CNA #2 stated, "(CNA #1) hollered for me and (LPN #1) to come to the room. (Resident #3) was crying and said she never felt like this before. She just kept saying she never felt like this before. I took from (Resident #3's) words that she was talking about the way she was being cleaned in her peri area. (LPN #1) asked (Resident #3) what she meant. (Resident #3) kept repeating that she never felt this way before. I think (CNA #1) called us to protect herself because of what (Resident #3) was saying." h. On 5/10/11 at 2:25 p.m., Resident #3 was asked by the surveyor in the presence of LPN #2 if she remembered Saturday (5/7/11) night when the two CNAs were caring for her and she told them 'I've never been felt like that before.' Resident #3 said, "Yes." Resident #3 was asked what she meant. Resident #3 stated, "They were going from one side to the other and it didn't feel right. Something that happened before. It scared me. It wasn't right. It didn't feel like it did before." Resident #3 paused for several seconds. She then repeated, "It wasn't right." Resident #3 became tearful. 3. The Immediate Jeopardy was removed and the scope/severity reduced to "H" on 5/10/11 at 6:40 p.m., when the facility implemented the following Plan of Removal: a. Transfer Resident #3 to St. Joseph's Geri-Psych Unit for evaluation. ADON has contacted St. Joseph's Geri-Psych Unit for evaluation of Resident #3 and has contacted physician and family and resident will be transferred to the Unit this evening, May 10, 2011. Resident will be reassessed prior to re-admission to this facility. b. LPN who failed to report allegation of abuse timely is to be terminated. LPN referred to is suspended currently and will be contacted on May 11, 2011 and employment terminated by Administrator. c. Regional Vice President/Quality Review Nurse/Administrator or designee will interview all cognitive residents in the facility by 10:00 p.m., May 10, 2011, asking "Have you ever been mistreated, has anyone been mean or rude or ignored a request or need that you may have had? Did you report it to a staff member of the facility and was it acted upon". Any new allegation of abuse will be immediately reported to the Administrator who will follow company policy and procedure regarding the investigation and reporting of abuse to protect, prevention of abuse, identify, report and investigate. d. Regional Vice President/Quality Review Nurse/Administrator or designee will interview all staff members, asking "Have you ever made an allegation of abuse and it was not acted upon by the facility?", by May 11, 2011. Any new allegation of abuse will be immediately reported to the Administrator who will follow company policy and procedure regarding the investigation and reporting of abuse. e. Regional Vice President/Quality Review Nurse/Administrator or designee will inservice staff on abuse and reporting abuse, ensuring that all staff members of Aegis Therapy, Health Services group (housekeeping), dietary and nursing staff are inserviced prior to the beginning of their shifts and all will be completed by 11:00 p.m., May 11, 2011. No staff member will be allowed to work until inserviced on abuse and reporting by the Human Resources Director of Office Manager/designee. f. All 5 recent [MEDICATION NAME] will be reviewed by Regional Vice President/Quality Review Nurse/Administrator for compliance with policy and procedure and State Regulations by 11:00 a.m., May 11, 2011. g. All interviews of residents will be reviewed by Regional Vice President/Quality Review Nurse/Administrator for compliance with policy and procedure and State Regulations by 10:00 p.m., May 10, 2011. h. All interviews of staff members will be reviewed by Regional Vice President/Quality Review Nurse/Administrator for compliance with policy and procedure and State Regulations by 10:00 p.m., May 10, 2011. i. In order to ensure that staff members have understanding of the abuse policy and reporting, two professional staff members and two non-professional staff members per shift per week will be randomly quizzed by Administrator/designee until compliance is achieved and then monthly thereafter. j. All future [MEDICATION NAME] will be forwarded by Administrator to Regional Vice President for review and approval prior to forwarding the OLTC 762 to the Office of Long Term Care according to the time frame requirements of the Office of Long Term Care. k. All negative findings will be corrected immediately.

Complaint # was substantiated (all or in part) with these findings. Based on record review and interview, the facility failed to ensure the Abuse Prohibition policy and procedures were consistently implemented to ensure allegations of sexual abuse were immediately reported to the Administrator/Designee, were promptly investigated, residents were immediately protected from potential further abuse and the allegation was reported to the local law enforcement and the Office of Long Term Care in accordance with state law at the time alleged for 2 (Residents #3 and #4) of 2 case mix residents who alleged staff to resident abuse. These failed practices resulted in Immediate Jeopardy, which likely caused or could have caused serious harm, injury or death to Residents #3 and #4, who alleged staff to resident sexual abuse, and had the likelihood of causing more than minimal harm for 93 residents who were at risk of abuse from staff, as documented on a list provided by the Administrator on 5/5/11 at 4:10 p.m. The facility was informed of the Immediate Jeopardy condition on 5/10/11 at 3:20 p.m. The findings are: 1. The facility's policy and procedure titled "Investigation and Reporting of Alleged Violations of Federal and State Laws Involving Mistreatment, Neglect, Abuse, Injuries of Unknown Source and Misappropriation of Resident's Property" , provided by the Administrator on 5/5/11, documented, "It is the policy of this facility to take appropriate steps to prevent the occurrence of abuse, neglect, injuries of unknown source and misappropriation of resident property (alleged violations), are reported immediately to the CEO (Chief Executive Officer) of the facility. Such violations will also be reported to state agencies in accordance with existing state law. The CEO or his/her designee will direct a thorough investigation of each alleged violation. The CEO or his/her designee is responsible to report the results of all investigations to the state agencies as required by state and federal law." 2. Resident #4 had [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/11/11 documented the resident was severely impaired in cognitive skills for daily decision making. a. On 5/10/11 at 9:57 a.m., LPN #3 stated, "(On 5/2/11) (CNA #3) said (Resident #4) had told her that (CNA #4) had put his penis in her (Resident #4) mouth." The OLTC (Office of Long Term Care) Incident and Accident Report (I & A) documented, "Date and Time of Discovery: 5/2/11 3:30 p.m. ...Summary of Incident CNA (Certified Nursing Assistant) reported to DON (Director of Nursing) that on 4/28/11 this resident (Resident #4) pointed at a male (CNA #4) and said 'I don't like him he put his thing in my mouth.' Resident assessed at this time by DON for injury ...Steps taken to prevent continued abuse or neglect during the investigation ...Investigation initiated immediately upon discovery. Alleged employee suspended pending investigation immediately upon discovery. Police, family and physician notified. All cognitive residents and staff interviews initiated immediately, complete body audits performed on all residents. Staff inservice on abuse and neglect initiated." 1) On 5/6/11 at 9:30 a.m., the Administrator stated, "I brought (CNA #3 and LPN #1) in my office the next day (5/3/11). (CNA #3) said she wasn't specific about what the allegation (referencing 4/28/11) was; (Resident #4) was emotional. At first (CNA #1) said she told (LPN #1) (referencing allegation of sexual abuse reported by Resident #4 to CNA #3 on 4/28/11)." 2) An OLTC Witness Statement Form dated 5/3/11 at 2:13 p.m. documented, "Witness Full Name: (CNA #3)...On Thursday evening (4/28/11) (Resident #4) said that (CNA #4), she pointed at him and said he put his thing in her mouth. I went and told the nurse (Licensed Practical Nurse (LPN) #1) she was emotional and saying all kinds of stuff. I wasn't specific so (LPN #1) said she gets like that." On 5/10/11 at 9:04 a.m., CNA #3 stated, "(Resident #4) said (CNA #4) put his thing in her mouth. I went to (LPN #1) and said '(Resident #4) is being very emotional.' I should have told her everything right then and there." 3) An OLTC Witness Statement Form dated 5/3/11 at 4:25 p.m. documented, "Witness Full Name: (LPN #1) ...I do not recall (CNA #3) or anyone else telling me that (Resident #4) stated that (CNA #4) put his penis in her mouth." On 5/9/11 at 4:10 p.m., LPN #1 stated, "(CNA #3) came to me (on 4/28/11) and said (Resident #4) was having emotional problems. She didn't say anything else. She (Resident #4) has problems every day. The next day or after that they called me to the DON's office. (It had been reported) that one of the CNAs had stuck his penis in her (Resident #4) mouth. (CNA #3) came in about that time. I told her you did not tell me that. I would have remembered that. I was walking up and down and walked by (Resident #4) several times. She was no different and had no issues." 4) An OLTC Witness Statement Form dated 5/2/11 at 6:15 p.m. documented, "Witness Full Name: (DON) ...This nurse interviewed (Resident #4). Asked resident 'Has anyone ever been sexually inappropriate with you?' (Resident #4) responded, 'I ain't been in bed with no man. I ain't done nothing wrong.' I then asked her if anybody did anything inappropriate or wrong to her. She shook head back and forth in 'no' motion." b. The Division of Medical Services (DMS) 762 dated 5/9/11 (no time) documented, "Findings and Actions Taken: Investigation initiated immediately upon discovery. Police, family and physician notified. Alleged employee (CNA #4) was suspended immediately pending investigation. (CNA #3) suspended regarding late reporting of abuse allegation. Staff and cognitive residents interviewed. Body audit completed on all residents with no concerns. Staff inserviced on abuse and neglect. Resident assessed for injury without negative findings. Resident interviewed by DON. DON asked 'Has anyone ever been sexually inappropriate with you?'. Resident stated, 'I ain't been in bed with no man.' DON asked, 'Has anybody done anything inappropriate to you?' Resident shook her head back and forth in a 'no' motion. Based on staff and cognitive residents interviewed with no negative findings, no physical signs of injury from body audit, the facility is unable to substantiate abuse." c. On 5/9/11 at 1:40 p.m., Resident #4 was in the wheel chair in the hall with her feet propped up in a chair. Surveyor asked the resident if could talk to her in a more private area. The resident stated, "You can talk to me here." Other residents were in the vicinity. The resident was asked how she liked living here. Resident #4 stated, "Fine." The surveyor asked how the staff treated her here. The resident stated, "Good." 3. Resident #3 had [DIAGNOSES REDACTED]. The quarterly MDS with an ARD of 3/19/11 documented the resident scored 1 on the Brief Interview for Mental Status (0-7 indicates severe impairment) and required limited physical assistance of 1 person for toilet use. a. The OLTC Incident and Accident Report (I & A), DMS-7734 documented: "... Date and Time of Discovery: 5/2/11, 3:30 p.m.... Date of I&A: 5/2/11. ... Name of Injured Resident: (Resident #3). Summary of Incident: CNA reported to DON and ADON (Assistant Director of Nursing) that when (CNA #4) walked in the dining room onto the hall this resident began crying and CNA (CNA #3) assisted to nurses station and asked her what was wrong, resident stated, 'He touched me and pulled it out and it was big, and I tried to leave and he wouldn't.' Resident transferred to (hospital) for evaluation. Rape Kit pending. Steps taken to prevent continued abuse or neglect during the investigation: Investigation initiated immediately upon notification. Employee suspended pending investigation. Police, family, and physician notified. All cognitive residents and staff interviews conducted on all residents. Staff inservice initiated on abuse and neglect." Body audits of the residents, interviews with the cognitively intact residents and the staff were included in the OLTC I&A Report. 1) The OLTC Witness Statement Form dated 5/2/11 at 3:30 p.m. documented, "Witness Full Name: (CNA #3). ... I saw (Resident #3) in the dining room. (CNA #4) came into the dining room and (Resident #3) started crying and was nervous. So I pulled (Resident #3) into the nurses' room and I asked (Resident #3) what happened. (Resident #3) said he touched her and pulled his thing out and it was big. (Resident #3) said she tried to leave and he wouldn't leave." On 5/10/11 at 9:04 a.m., CNA #3 (referring to 5/2/11) stated, "It was shift change. (Resident #3) was coming over to me and (CNA #4) was coming in. She was crying. She said, 'He touched me.' All she would say was he would not let me out. I asked her if 'he whipped it out.' She said, 'yes'." 2) On 5/10/11 at 9:57 a.m., LPN #3 stated, "(CNA #3) was in the nursing station (on 5/2/11) with (Resident #3). (Resident #3) was crying. (CNA #3) said that (CNA #4) had done some stuff to her (the resident) and did not want him taking care of her. That he was touching her in her places and (Resident #3) said he put his penis in her. (Resident #3) said it was big, it hurt and she did not like it at all." b. The Hospital ER (emergency room ) Record dated 5/2/11 documented, "... Final Diagnosis: [REDACTED]. The patient does have a history of dementia and [MEDICAL CONDITION]. She states that she was assaulted by a staff member at the nursing home. She says that he has done bad things to her. She says that he has hit her. She says that he picked her up and threw her. She also tells me that he did nasty things to her. She says that he raped her. The patient says that he has done these things to other girls. She says that this happened yesterday.... Pelvic exam was done with two nurses' chaperoning, ... The patient had some excoriation, but no signs of trauma. She had normal female external genitalia. On speculum exam, she did have a little white discharge, but otherwise unremarkable speculum exam... The patient is calm and cooperative, but she does get tearful when asked about what happened." c. The DMS-762, page 4 of 9, Section III - Findings and Actions Taken dated 5/9/11 documented, "... Action: Investigation initiated immediately upon discovery. Employee (CNA #4), immediately suspended pending investigation. Resident sent to (hospital) for examination. Rape kit performed and results sent to the ... Police Department per ER records. Staff and cognitive residents interviewed. Body audits completed on all residents. Resident returned to the facility. Emergency Department reports no trauma per ER exam. Based on body audits, staff and cognitive resident interviews with no negative findings, and ER exam, facility unable to substantiate abuse." 1) On 5/10/11 at 8:20 a.m., CNA #4 was asked if he exposed himself to either of these residents. He stated, "No, not in any way or form. Absolutely not." He also confirmed he was suspended on 5/2/11 and had not been back to work at the facility. 2) The Staff Inservice Education form dated 5/2/11 documented "Abuse must be reported immediately upon discovery to the DON and Administrator. When you report abuse and have not been asked for a witness statement within a hour of reporting, you must report to the next person in charge, DON, ADON (Assistant Director of Nursing) and Administrator. Abuse is very serious and if reporting is not done timely you could possibly be suspended for not reporting and/or jeopardizing the resident for further injury. CNAs (Certified Nursing Assistants) do not interview residents. When a resident reports to you, you immediately report this to charge nurse. ... Anytime any type of abuse or neglect is reported to you, you must immediately report it to your charge nurse. Anytime you witness or suspect abuse always; #1 remove the resident from harm, #2 report to charge nurse or supervisor, #3 if your charge nurse is the abuser report to any charge nurse in the building or call the RN (Registered Nurse) on call yourself. Types of abuse include but are not limited to physical, mental, verbal, neglect-not providing the care in which they are needed. Neglect includes not reporting that a resident is complaining of pain to charge nurse or MD (medical doctor). You are also in the wrong too if you do not report immediately." The Staff Inservice Education form documented that LPN #1and CNA #2 signed the attendance sheet for the "Abuse and Neglect" inservice on 5/2/11. 3) The Staff Inservice Education form dated 5/6/11 through 5/9/11 documented, "Housewide inservice on Abuse and Neglect. ... Anytime any type of abuse or neglect is reported to you, you must immediately report it to your charge nurse. Anytime you witness or suspect abuse always; #1 remove the resident from harm, #2 report to charge nurse or supervisor, #3 if your charge nurse is the abuser report to any charge nurse in the building or call the RN (Registered Nurse) on call yourself. Types of abuse include but are not limited to physical, mental, verbal, neglect-not providing the care in which they are needed..." The Staff Inservice Education form documented that LPN #1, CNA #1 and CNA #2 signed the attendance sheet for the "Abuse and Neglect" inservice on 5/6/11. d. On 5/9/11 at 1:25 p.m., Resident #3 was asked if a male had ever shown himself or exposed himself to her. The resident stated, "Yes." The surveyor asked her what happened. She stated, "They used to come at night and get on me." She was asked if it was someone that worked here. She stated, "I don't know." She was asked if she told someone about this. She stated, "Yes." The resident stated that she had not seen him when asked if he was still here. The resident was asked when this happened and she stated, "A while ago." e. On 5/9/11 at 4:10 p.m., LPN #1 stated, "I haven't told anyone this yet, but Saturday night (5/7/11) (CNA #1) got me and wanted me to hear what (Resident #3) was saying. (Resident #3) stated, 'I've never been felt like this before.' I explained that they are cleaning you like they always do." LPN #1 was asked, "In your opinion, what did you think (Resident #3) was saying?" LPN #1 stated, "That she (CNA #1) was feeling of her (Resident #3) inappropriately." On 5/10/11 at 2:26 p.m., LPN #1 stated, "(Resident #3) said, 'I've never been felt like this before.' I did not ask her what she meant. After talking to (Resident #3) my impression of what she was saying was that when they washed her down there, they touched her private parts different than they had before. (CNA #1) was washing her." f. On 5/10/11 at 2:21 p.m., CNA #1 stated, "On Saturday (5/7/11) night (Resident #3) had been incontinent. I put her on the commode. She had bowel movement on her buttocks. I attempted to wash her buttocks with periwash. She started crying and I stopped. I asked her what was wrong. She said, 'I've never been touched that way before.' I opened the door and called for (LPN #1). (LPN #1) and (CNA #2) came to the room. (Resident #3) continued to cry. (LPN #1) told (Resident #3) that she needed to be cleaned. (Resident #3) told (LPN #1)( that she had never been touched like that. (Resident #3) let me wash her up after (LPN #1) and I reassured her." g. On 5/10/11 at 2:37 p.m., CNA #2 stated, "(CNA #1) hollered for me and (LPN #1) to come to the room. (Resident #3) was crying and said she never felt like this before. She just kept saying she never felt like this before. I took from (Resident #3's) words that she was talking about the way she was being cleaned in her peri area. (LPN #1) asked (Resident #3) what she meant. (Resident #3) kept repeating that she never felt this way before. I think (CNA #1) called us to protect herself because of what (Resident #3) was saying." h. On 5/10/11 at 2:25 p.m., Resident #3 was asked by the surveyor in the presence of LPN #2 if she remembered Saturday (5/7/11) night when the two CNAs were caring for her and she told them 'I've never been felt like that before.' Resident #3 said, "Yes." Resident #3 was asked what she meant. Resident #3 stated, "They were going from one side to the other and it didn't feel right. Something that happened before. It scared me. It wasn't right. It didn't feel like it did before." Resident #3 paused for several seconds. She then repeated, "It wasn't right." Resident #3 became tearful. 4. The Immediate Jeopardy was removed and the scope/severity reduced to "H" on 5/10/11 at 6:40 p.m., when the facility implemented the following Plan of Removal: a. Transfer Resident #3 to (name of hospital) Geri-Psych Unit for evaluation. ADON has contacted St. Joseph's Geri-Psych Unit for evaluation of Resident #3 and has contacted physician and family and resident will be transferred to the Unit this evening, May 10, 2011. Resident will be reassessed prior to re-admission to this facility. b. LPN who failed to report allegation of abuse timely is to be terminated. LPN referred to is suspended currently and will be contacted on May 11, 2011 and employment terminated by Administrator. c. Regional Vice President/Quality Review Nurse/Administrator or designee will interview all cognitive residents in the facility by 10:00 p.m., May 10, 2011, asking "Have you ever been mistreated, has anyone been mean or rude or ignored a request or need that you may have had? Did you report it to a staff member of the facility and was it acted upon". Any new allegation of abuse will be immediately reported to the Administrator who will follow company policy and procedure regarding the investigation and reporting of abuse to protect, prevention of abuse, identify, report and investigate. d. Regional Vice President/Quality Review Nurse/Administrator or designee will interview all staff members, asking "Have you ever made an allegation of abuse and it was not acted upon by the facility?", by May 11, 2011. Any new allegation of abuse will be immediately reported to the Administrator who will follow company policy and procedure regarding the investigation and reporting of abuse. e. Regional Vice President/Quality Review Nurse/Administrator or designee will inservice staff on abuse and reporting abuse, ensuring that all staff members of Aegis Therapy, Health Services group (housekeeping), dietary and nursing staff are inserviced prior to the beginning of their shifts and all will be completed by 11:00 p.m., May 11, 2011. No staff member will be allowed to work until inserviced on abuse and reporting by the Human Resources Director of Office Manager/designee. f. All 5 recent [MEDICATION NAME] will be reviewed by Regional Vice President/Quality Review Nurse/Administrator for compliance with policy and procedure and State Regulations by 11:00 a.m., May 11, 2011. g. All interviews of residents will be reviewed by Regional Vice President/Quality Review Nurse/Administrator for compliance with policy and procedure and State Regulations by 10:00 p.m., May 10, 2011. h. All interviews of staff members will be reviewed by Regional Vice President/Quality Review Nurse/Administrator for compliance with policy and procedure and State Regulations by 10:00 p.m., May 10, 2011. i. In order to ensure that staff members have understanding of the abuse policy and reporting, two professional staff members and two non-professional staff members per shift per week will be randomly quizzed by Administrator/designee until compliance is achieved and then monthly thereafter. j. All future [MEDICATION NAME] will be forwarded by Administrator to Regional Vice President for review and approval prior to forwarding the OLTC 762 to the Office of Long Term Care according to the time frame requirements of the Office of Long Term Care. k. All negative findings will be corrected immediately.

Complaint # is substantiated, all or in part, with these findings. Based on record review and interview, the facility failed to ensure the management of resident pain as evidenced by the facility's failures to ensure complaints of pain were promptly communicated to licensed nursing staff and the licensed nursing staff thoroughly assessed residents for pain to assure prompt identification and assessment of pain so that interventions were developed and implemented to manage pain for 1 (Resident #5) of 1 case mix residents who had fallen the day before hospital discharge and who experienced pain after readmission to the facility. This failed practice resulted in a pattern of actual harm for Resident #5, who had documented pain during therapy and voiced complaints of pain to Certified Nursing Assistants for multiple days prior to hospitalization for a [MEDICAL CONDITION] femur and had the potential to cause more than minimal harm to 7 residents who were admitted from 12/1/10 through 1/5/11, as documented on the list provided by the Administrator on 1/18/11. The findings are: 1. The facility's policy and procedure titled, "Clinical Guide: Pain Management", provided by Employee #1 on 1/20/11, documented, ". . . Monitoring Compliance: The following elements demonstrate satisfactory compliance with the guide: Residents have been assessed for pain utilizing the pain scales referenced in the guide. Pain IPOC (Immediate Plan of Care) . . . is in place and reflects current plan management interventions. Documentation reflects ongoing monitoring of pain level and responses to interventions (pharmacological and non-pharmacological interventions). A comprehensive assessment is completed using the Pain COC (Change of Condition) report, when indicated. . ." 2. Resident #5 had [DIAGNOSES REDACTED]. a. A hospital Discharge Summary dated 12/1/10 documented, ". . . Hospital course: . . . Plan was made for discharge, but then he fell and complained of pain in his left femur. X-rays were negative. The following day, the pain had improved, but still having difficulty getting up. It was felt he needed to be transferred to the nursing home at this point. . ." b. The Nurse's Notes dated 12/1/10 at 10:04 p.m. documented, "Resident arrived at facility around 2:10 p.m. today via ambulance from hospital . . ." There was no documentation that the resident was assessed for pain. A Clinical Observation document dated 12/1/10 documented, ". . . Pain Symptoms: Frequency 1 (pain less than daily), Intensity 1 (mild pain). . ." An Immediate Plan of Care Pain and Pain Symptoms Risk form dated 11/10/10 was not completed. The form was not updated when the resident returned to the facility on [DATE]. c. The Nurse's Notes dated 12/2/10 at 7:39 a.m. did not document that the resident was assessed for pain or was having pain. The Nurse's Note dated 12/2/10 at 3:36 p.m. documented, ". . . No distress noted. . ." There was no documentation that the resident was assessed for pain. d. A Physical Therapy (PT) Plan of Treatment dated 12/2/10 documented, ". . . Medical History related to Diagnosis/Condition: . . . fall in hospital with increased c/o (complaint of) L (left) hip and knee pain x-rays reportedly negative. . . Precautions: Balance precautions. Low endurance - needs frequent rests. Recent fall with left leg pain. . . Underlying Impairments: . . . Neuro/Musculo/Skeletal, Pain with activity - 9 out of 10. . . Neuro/Musculo/Skelatal, Pain at rest - 2 out of 10. . . Neuro/Musculo/Skeletal, Pain Location 1 - Thigh - left anterior. . ." There was no documentation that the resident's complaint of pain was reported to nursing. An Occupational Plan of Treatment dated 12/2/10 documented, ". . . Pain reported LEs (lower extremities) during bed mobility but unable to localize. Patient with h/o (history of) pain Rt (right) LE as reported by family and considering h/o fx (fracture). Patient presents with increased alertness, communication and ability to follow commands since prior admit. Also, is more responsive to cueing." There was no documentation that the resident's complaint of pain was reported to nursing. A Speech Therapy (ST) Plan of Treatment dated 12/2/10 documented, ". . . ST attempted assess with ice chips; however, R (Resident) c/o pain and discomfort as ST raised HOB (head of bed), and he refused to sit fully upright with HOB at 90 degrees. ST only able to elevate head approx. (approximately) 60 degrees. Therefore assess with p.o. (by mouth) intake not attempted at time of eval. (evaluation) . . ." There was no documentation that the resident's complaint of pain was reported to nursing staff. e. The Nurse's Notes dated 12/3/10 at 1:31 a.m. did not document that the resident was assessed for pain. The Nurse's Notes dated 12/3/10 at 8:11 a.m. documented, "(Physician name) is here a.m., new orders, ok to change [MEDICATION NAME] feeding to [MEDICATION NAME] 1.2, order rec'd (received) and noted." There was no documentation that the physician was informed of the resident's complaints of pain or that the resident was assessed for pain. The Nurse's Notes dated 12/3/10 at 1:29 p.m. documented, ". . . Called MD (Medical Doctor). No new orders. . ." There was no documentation that the physician was notified of the resident's complaints of pain or that the resident was assessed for pain. The Nurse's Notes dated 12/3/10 at 1:34 p.m. documented, ". . . Received Therapy for strengthening exercises. Tolerated well. No complaints of pain or discomfort. . ." There was no documentation that the resident's complaints of pain noted by the rehabilitation therapists was reported to the licensed nursing staff for further evaluation and intervention. f. The Physical Therapy Monthly Service Minutes for December 2010 documented that the resident received PT for 45 minutes on 12/2/10, 35 minutes on 12/3/10, 38 minutes on 12/6/10 and 35 minutes on 12/7/10. g. The Nurse's Notes dated 12/5/10 at 11:54 a.m. documented, ". . . Received notification of a temp (temperature) = 99.1 AX (axillary). Called MD. Received new order for Tylenol 325 mg (milligrams) Q4 (every 4) hours PRN (as needed). . ." There was no documentation that the physician was informed of the resident's complaints of pain or that the resident was assessed for pain. The Nurse's Notes dated 12/5/10 at 2:57 p.m. documented, ". . . Contacted MD. Rcvd (received) new order for [MEDICATION NAME] S&S (swish and swallow) 5 cc (cubic centimeters) QID (four times a day) times 7 days. . ." There was no documentation that the physician was informed of the resident's complaints of pain or that a pain assessment was completed. The Nurse's Notes dated 12/5/10 at 9:30 p.m. did not document that the resident was assessed for pain. h. The Nurse's Notes dated 12/6/10 at 7:21 p.m. did not document that the resident was assessed for pain. i. A Physical Therapy Documentation Progress Note dated 12/7/10 documented, "Pt (patient) (with) various complaints of R (right) distal femur and left mid-thigh pain (with) PROM (Passive Range of Motion) of each hip and knee. At times pain appears to be a 9/10 (9 on a scale of 1 - 10) and later a 2-3/10 with same ROM (Range of Motion), pt. unable to give pain scale number and pain intensity determined by facial expressions, groans and verbal expressions. No increase in pain noted with mild compression through hip and knee joints and tapping on bone prominences. Discussed situation (with) RPC (Rehab Program Coordinator) and will discuss pt.'s (patient's) situation in morning meeting." There was no documentation that the resident's complaints of pain were reported to nursing. j. The Nurse's Notes dated 12/7/10 at 3:00 p.m. documented, "Resident complains of Rt leg pain post fall in hospital. X-ray ordered STAT (immediately) et (and) has been done at this time. X-ray to RT hip, femur et knee. . ." The Nurse's Note dated 12/7/10 at 9:55 p.m. documented, "Report back from (name of company) x-ray on the right hip and knee with no fx indicated but a complete femoral neck fx seen on the left hip. . ." k. A Radiology Report dated 12/7/10 documented, "Exam: Pelvis AP (Anterioposterior) only. Results: There is a complete [MEDICAL CONDITION] femoral neck with mild displacement. No dislocation is seen. Intact right hip arthroplasty is seen. The sacroiliac joints and hip joints are intact. [MEDICAL CONDITION] is present. Conclusion: Left [MEDICAL CONDITION] and right hip arthroplasty as described above. . . ." l. The Readmission/Return/Discharge Minimum Data Set (MDS) with an assessment reference date (ARD) of 12/7/10 documented the resident received 138 minutes of physical therapy in 4 days and that the MDS was not completed because the resident was transferred to the hospital on the ARD. Section J, the Pain Assessment Interview and Staff Assessment for pain, was not completed. On 1/20/11 at 8:25 a.m., LPN #3 was asked what the protocol was for the MDS process. The LPN stated that when a resident is admitted an entry record is completed and dates are set for the MDS. A quick assessment is done for ADL (activities of daily living) needs. The ARD is when the MDS, Care Plan and risk assessments are done. "The pain assessment interview is not done until the ARD." m. On 1/19/11 at 1:05 p.m., the December 2010 Physician order [REDACTED]. On 1/19/11 at 1:05 p.m., the December 2010 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. n. On 1/19/11 at 3:15 p.m., Therapist #1 was asked, "Did the resident have pain with therapy?" The therapist replied, "Yes, he had pain from the first day. We looked at x-ray reports and they were negative. I felt it was generalized pain." The therapist was asked, "Did you report the pain to the nurse?" The therapist replied, "Yes, I assumed they gave him something." On 1/20/11 at 8:39 a.m., Therapist #2 was asked, "Did the resident complain of pain?" The Therapist stated that when the initial evaluation was completed and the second time the resident was seen he complained of pain and said, "The pain was not any different from the time before (11/10/10) therapy. I don't remember if I reported it." o. On 1/19/11 at 2:06 p.m., Licensed Practical Nurse (LPN) #1 was asked, "Did the resident complain of pain?" The LPN replied, "No, the CNAs (Certified Nursing Assistants) did not report the resident having pain." The LPN was asked, "Did the resident show any signs or symptoms (s/s) of pain?" The LPN replied, "No." The LPN was asked, "Did Therapy report that the resident was having pain during sessions?" The LPN replied, "No, not to me." LPN #1 was asked, "How often do you assess the resident for pain?" The LPN replied, "I checked on the resident during the shift. He never complained of pain." On 1/20/11 at 8:49 a.m., LPN #2 was asked, "Did the resident complain of pain to you?" The LPN replied, "Did not complain of pain to me." The LPN was asked, "Did the CNA report that the resident was having pain?" The LPN stated, "They did not report the resident having pain." The LPN was asked, "Did Therapy report to you that the resident was having pain?" The LPN stated, "Therapy did not report to me the resident was having pain." p. On 1/19/11 at approximately 2:10 p.m., CNA #4 was asked, "Did the resident complain of pain to you?" The CNA replied, "Yes, pretty much from day he came in." The CNA was asked, "Did you report this pain to anyone?" The CNA answered, "Well, not sure, I would say yes. I figured since he had been in the hospital he ached." The CNA was asked, "Did the resident show any s/s of pain?" The CNA stated, "Yes, he would complain of pain mainly when we moved him." On 1/19/11 at 2:11 p.m., CNA #1 was asked, "Did the resident complain of pain to you?" CNA #1 stated, "Yes, I reported it to the nurse, I don't remember who." The CNA was asked, "Did the resident show s/s pain?" The CNA replied, "When we got him up." The CNA was asked, "Did you report this pain to anyone?" The CNA stated, "Yes, to the nurse." The CNA was asked, "Did therapy (staff) report that the resident had pain during sessions?" The CNA replied, "Not that I'm aware of." On 1/19/11 at 2:20 p.m., CNA #2 was asked, "Did the resident complain of pain to you?" The CNA replied, "Yes, (the resident) complained of pain all the time. We let the nurse know. Don't remember who it was." The CNA was asked, "Did the resident show any s/s of pain? " The CNA stated, "Yes, he complained all the time." The CNA was asked, "Did you report this pain to anyone?" The CNA replied, "Yes, the nurse. I don't remember who." The CNA was asked, "Did Therapy report that the resident had pain during sessions?" The CNA stated, "I don't remember him going to therapy". On 1/19/11 at 2:25 p.m., CNA #3 was asked, "Did the resident complain of pain to you?" The CNA replied, "Yes, from day one when admitted ." The CNA was asked, "Did the resident show any s/s of pain?" The CNA stated, "I never got him out of bed because of the pain." The CNA was asked, "Did you report this pain to anyone?" The CNA stated, "Told the nurse." The CNA was asked, "Did Therapy report that the resident had pain during sessions? " The CNA replied, "I don't remember him going to therapy. I think they worked with him in the room." q. On 1/19/11 at 2:15 p.m., Registered Nurse (RN) #1 was asked, "Did resident complain of pain to you?" The RN stated, "No, CNAs did not report the resident having pain." The RN was asked, "Did the resident show any s/s of pain?" The RN replied, "No". The RN was asked, "Did Therapy report that the resident had pain to anyone?" The RN stated, "Yes, the day he complained of pain and was sent to the hospital. I don't think he started therapy when he came in." The RN was asked, "How often do you assess residents for pain?" The RN replied, "When making rounds I ask residents if they are having pain." r. On 1/20/11 at 8:43 a.m., RN #2 was asked, "Did the resident complain of pain?" The RN replied, "I didn't really work the floor during that time, but no pain that I remember." The RN was asked, "Did staff report that the resident was having pain?" The RN stated, "No, the second time he came back, when therapy worked with him, he complained of pain." The RN was asked, "Was the physician notified?" The RN stated, "I didn't call, don't remember if anyone else called." The RN was asked, "How often do you assess residents for pain?" The RN replied, "At least every four hours. We document in the notes if a resident is having pain." The RN was asked, "Did the CNA report that the resident was having pain?" The RN replied, "Don't remember them reporting to me about pain." On 1/20/11 at 8:54 a.m., RN#3 was asked, "Did anyone report that the resident was having pain?" The RN stated, "No, it was never reported to me prior to the Medicare meeting that the resident was having pain." The RN was asked, "What is the facility protocol for pain assessments?" The RN replied, "At least once a shift. If there's no order for pain medication, call the physician for an order. Before treatments, assess pain level. On admit assess baseline level of pain. Pain is what the resident says it is."