Every finding on record at The Springs of Pinnacle Mountain

Based on record review, interview, and facility policy review, the facility failed to ensure dietary orders were followed for one (Resident #1) of three residents.The findings include: A review of Resident #1's admission Record indicated the facility admitted the resident on 06/25/2025, with diagnoses which included a partial intestinal obstruction, a non-cancerous growth or tumor of the pancreas, abnormal heart rhythm, and swelling of both lower limbs. A review of Resident #1’s 5-day Minimum Data Set (MDS) with an Assessment Reference Date of 06/27/2025, revealed the resident had a Brief Interview for Mental Status score of 15, which indicated intact cognition. The remainder of the MDS, including functional abilities, health conditions, and medications, was not completed. A review of Resident #1’s Hospital Discharge records indicated the resident had the following procedures performed: on 06/03/2025 – Whipple Procedure (a complex abdominal surgery primarily used to treat tumors in the head of the pancreas) and a hernia repair. On 06/16/2025 – a medical procedure where a thin, flexible tube with a camera is used to examine the esophagus, stomach, and the first part of the small intestine (EGD). On 06/18/2025 -an EGD with placement of a percutaneous endoscopic gastrostomy (PEG) tube. The resident’s Hospital Discharge Record also indicated Resident #1 was not to perform any heavy lifting and was to have a clear liquid diet, with sips of liquids, and tube feedings of a prescribed formula at 20 milliliters (ml) per hour and to increase the rate by 10 ml every six to eight hours, until a rate of 61 ml per hour was reached. A review of Resident #1's Physician Orders indicated an order for a clear liquid diet and a nausea medication to be given as needed every eight hours, dated 06/25/2025. The resident’s Physician Orders revealed an enteral feed order to run at 20 ml an hour, via pump continuously with water flushes of 45 ml an hour, and to increase by 10 ml every 6 to 8 hours until a goal of 61 ml, if tolerated, dated 06/26/2025. Resident #1’s Physician Orders also indicated a chest x-ray for blood in sputum, dated 06/29/2025. During an observation on 07/03/2025 at 3:45 PM, this surveyor observed dietary communication slips, “Tray Card Slip” for Resident #1, which revealed a clear liquid diet for 06/25/2025, and a clear liquid diet/texture on 06/26/2025. A review of Resident #1's Care Plan initiated 06/27/2025, indicated the resident required extensive assistance with Activities of Daily Living, with an intervention that directed staff to encourage the resident to use their call light and request assistance. The resident’s Care Plan also instructed staff to serve the residents diet as ordered by the physician. Resident #1’s Care Plan did not address the resident’s PEG tube status or feeding. A review of Resident #1’s Advanced Practice Registered Nurse (APRN) Progress Notes dated 06/26/2025, indicated the resident had experienced delayed gastric emptying following their Whipple Procedure. The APRN assessment included 4+ edema to both lower extremities (A 4+ edema rating scale indicates a very deep indentation (8mm or greater) that takes 2-3 minutes to rebound after pressure is applied, according to a medical resource. This is considered the most severe grade of pitting edema), flank swelling, abdominal pain, nausea, and bloating. The APRN’s physical assessment indicated Resident #1 had clear lungs, even unlabored respirations, hyperactive bowel sounds, flank swelling, rounded abdomen, and pain of abdomen with palpitation. A review of Resident #1’s APRN Progress notes dated 06/27/2025, indicated the resident reported nausea, and the resident had accidentally been given a regular tray, with a cheeseburger and fries. Resident #1 had consumed a portion of it and appeared uncomfortable. The nausea was treated with anti-nausea medication and the resident was re-educated on following the clear liquid diet and tube feedings, as ordered. A review of Resident #1's Progress Notes dated 06/29/2025 at 6:43 AM, revealed Registered Nurse (RN) #3 indicated bloody vomitus was observed in a basin, in the resident’s room. The APRN was notified, and a chest x-ray was ordered. The chest x-ray results revealed lungs being clear with no acute cardiopulmonary concerns. A review of Resident #1’s Skilled Nursing Note, dated 06/29/2025 at 11:23 PM, revealed RN #3 indicated the resident was receiving nutrition via PEG tube on a feeding pump. Resident #1’s Skilled Nursing Note also revealed RN #3 documented that the resident had no pain, no respiratory issues, was not receiving oxygen, and had no swelling. A review of Resident #1’s Medication Administration Record (MAR) for June of 2025, indicated the resident’s tube feeding was ordered and started on 06/26/2025 at 1:10 PM. Resident #1’s MAR also revealed the resident’s anti-nausea medication was given twice during their stay: on 06/27/2025 at 12:58 PM, and again on 06/30/2025 at 3:24 AM. A review of Resident #1's Progress Notes dated 06/30/2025, indicated that RN #3 reported the resident was found unresponsive at 5:15 AM, cardiopulmonary resuscitation was initiated, and emergency medical services were called. The paramedics pronounced Resident #1’s time of death at 5:30 AM. During an interview on 07/03/2025 at 9:52 AM, Licensed Practical Nurse (LPN) #3 revealed nurses wrote the residents diets on a pink slip, that was then given to kitchen staff and managers. When asked if LPN #3 knew why Resident #1 received a cheeseburger and fries while being on a clear liquid diet, she stated, I believe they got that, but don't know why. During a telephone interview on 07/03/2025 at 9:54 AM, an RN who worked under the surgeon who performed the Whipple Procedure stated Resident #1 had called on 06/26/2025 at 12:45 PM, due to not having received their tube feeding since entering the facility on 06/25/2025. RN #4 stated, I called the facility at 1:06 PM, and spoke with the nurse and was told the facility had just received the order for the tube feeding. The RN could not remember the nurse she spoke with at the facility. The RN went on to say, It's my understanding they [the facility] had given the resident a regular tray with a cheeseburger, and they [the resident] were only supposed to be getting clear liquids and their tube feeding. During an interview on 07/03/2025 at 12:00 PM, the Treatment Nurse revealed she did not realize the meal Resident #1 received was not part of their diet, until she investigated it. The Treatment Nurse explained the process of ensuring residents received the correct diet order was whoever placed the trays on the meal cart were supposed to double check the diet orders to ensure they matched the food. The Certified Nursing Assistants (CNAs) then compared the diet orders with the food, before the meal was given to the resident. The Treatment Nurse stated, [Resident #1] had the meal in their room and part of [Resident #1’s] cheeseburger was missing when I noticed the food on tray off to the side. The resident complained of nausea, and I was going to see if we could get [Resident #1] something for nausea. The Nurse Practitioner told me the resident was on a clear liquid diet. The charge nurse and I confirmed the resident was eating a cheeseburger. During a telephone interview on 07/02/2025 at 3:21 PM, Resident #1's family member reported the resident called their surgeon's nurse on Friday 06/27/2025 and informed her of not being fed for two days. The family member stated the surgeon's nurse had called the facility concerning Resident #1 not being fed and that the facility had given Resident #1 a cheeseburger and fries that same day. The family member also reported Resident #1 had told the family, they had been vomiting since having received the regular tray for lunch. Per the family member, family had visited Resident #1 on Sunday 06/29/2025 and found the resident with dried blood on their face, in their nose, on their clothes, and on their bed linens. The staff had told the family the dried blood was due to oxygen the resident was receiving, which had dried out the nasal passages and caused the dried blood. The family member reported Resident #1 had bloody vomit in the trash can in their room. Resident #1 was not nauseated or vomiting during their visit, due to having received nausea medication. The family member reported the APRN informed the family that the resident had a bowel blockage. During a telephone interview on 07/03/2025 at 10:04 AM, RN #3 reported during the beginning of their shift on 06/29/2025, they had witnessed sputum mixed with blood in a bath basin in Resident #1’s room. When asked if RN #3 had completed a Change of Condition assessment, they reported they had not and instead notified the APRN and received an order for a chest x-ray. During an interview on 07/03/2025 at 10:56 AM, Certified Nursing Assistant (CNA) #6 reported that on Saturday 06/28/2025, they witnessed Resident #1 vomiting and described it as being dark green and did not observe anything bright red that looked like blood. CNA #6 went on to say the CNA from the previous shift had reported to them that Resident #1 had been vomiting all day, and it continued through CNA #6's shift. During an interview on 07/03/2025 at 11:42 AM, RN #7 confirmed giving Resident #1 anti-nausea medication due to the resident being nauseated. During an interview on 07/03/2025 at 12:40 PM, the ADON reported they were notified on 06/26/2025 that Resident #1 had received and eaten a regular tray. She explained that when the facility received the referral on the resident, the diet order was correct. When the resident was admitted , the pink slip was filled out and given to dietary to make the meal cards. The meal cards were then placed on the resident’s trays for mealtimes. The ADON revealed that an investigation was completed in which she checked the orders that stated, clear liquids, but dietary on their orders stated, regular but clear liquid only. The first line said regular. The ADON explained, We don't know how our orders got sent to their orders and read like that on their side. When asked if she had been aware of the resident having nausea and vomiting up blood, the ADON stated, No. I did not know that [Resident #1] was having nausea, vomiting, and bleeding for all of those days, until I came into work on Monday 06/30/2025 and [Resident #1] had passed. There was hearsay that the resident had blood in the vomit. During an interview on 07/03/25 at 1:58 PM, the APRN indicated they had not witnessed Resident #1 vomiting blood, but confirmed the resident had 4+ swelling to both lower extremities, and that the resident had informed her of having gained 40 pounds during their time in the hospital. The APRN stated she assumed it was improving, since the resident was taking a diuretic. The APRN went on to relate the call she received from RN #3 about having noticed a small amount of blood in Resident #1’s sputum and confirmed a chest x-ray had been ordered at that time. She stated the x-ray did not indicate Resident #1 had a respiratory issue. The APRN then reported she was not notified of Resident #1 vomiting blood, and that if she had, she would have given an order for them to be transferred to the hospital. After the results of the chest x-ray, the next time the APRN was notified of any condition change was 06/30/2025, when Resident #1 had expired. During an interview on 07/03/2025 at 3:04 PM, the DON confirmed they had been notified of Resident #1 having eaten a regular diet, when there was a mishap with the diet order. The DON reported that the APRN assessed the resident after they ate the cheeseburger and fries. The process of ensuring the residents received the correct diet order was by the referral that came with the hospital paperwork, and the facility either continued to follow the hospital paperwork, or the provider did a medication reconciliation. The DON explained there was a discrepancy between the two systems they had, one said, clear thin and the dietary systems said, Regular clear liquids only. The DON stated they would train staff on distribution of the wrong tray and provide ongoing training. In addition, the DON said he was planning on retraining staff on assessment and documentation. During an interview on 07/03/2025 at 3:25 PM, the Administrator explained the diet order was what was completed first, with a diet slip for the Electronic Medical Record System and was communicated to dietary. He explained that it was a mistake that happened. The Administrator revealed the dietary system showed Resident #1 on a regular diet and clear liquid stating, They should have seen the sheet with the order, prior to giving them out. During an interview on 07/03/2025 at 4:15 PM, the Dietary Manager (DM) confirmed Resident #1 was given food that was not part of their diet, one time on 06/26/2025. The DM explained that the cook read on the ticket that Resident #1 had a regular diet. She explained that a nurse informed the DM that the resident was eating a cheeseburger. The DM reported that whoever touched the ticket in the beginning placed the food on the plate. Then the dietary aides placed the drinks and ice cream on the trays, filled up the hall carts, and then placed the carts on the halls. The DM explained that the CNAs ensured the food dietary placed on the trays was correct and then took it to the resident. The DM reported that in-services were completed with most of her staff and CNAs to ensure to read each part of the ticket, so the incident would not happen again. During an interview on 07/03/2025 at 4:50 PM, the Dietary Manager (DM) stated, I'm not allowed to change the information in the system, but I compare the information to the information on [the electronic medical record system]. The DM verified that she thought the regular option on the system was in reference to the type of diet such as no added salt, or diabetic diet, and not the consistency of the meal. During an interview on 07/07/2025 at 6:09 PM, [NAME] #1 revealed that the tray goes from the cook to the dietary aides in the kitchen, and then to the CNAs. She reported that if the CNAs noticed something different, they were to let dietary know. [NAME] #1 reported that Resident #1’s diet information was written down and stated, I saw regular, and the aide did not see clear liquid after that and that is how it got done. A review of a facility policy titled, Change of residents condition, with a revision date of February 2025, indicated, The nurse will notify the residents attending physician when there has been .a significant change in the resident's condition, need to alter the resident's treatment .

Based on observation, record review, and interview, it was determined that the facility failed to consistently give prescription pain medication every four (4) hours, as scheduled, for one (1) (Resident #4) of five residents reviewed for medication review. The findings are: A review of an admission Record indicated Resident #4 was admitted to the facility with diagnoses that included: fracture to right ankle, chronic pain syndrome, anxiety disorder, bipolar disorder and borderline personality disorder. The quarterly Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 01/14/2025, revealed Resident #4 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact for their daily decision making. Review of Resident #4's Care Plan initiated 01/17/2025, revealed the resident was on pain medication therapy. Interventions included Warning: Addiction, abuse, and misuse, and to reduce the risk for respiratory depression, proper dosing and titration of [Name Brand Combination Opioid/Pain Medication], were essential. On 04/21/2025 at 3:30 PM, this surveyor observed Resident #4 seated at a table in the common area, with a small circulating fan blowing toward them. Resident # 4's hair was wet, and [Resident #4] was observed wiping sweat from their face. Resident #4 said, My hair is soaking wet from sweat, I am so hot, and I am hurting bad. I asked one of the nurses for my pain medication but was told that I didn't have any left. On 04/21/2025 at 3:45 PM, the Director of Nursing (DON), assisted by Licensed Practical Nurse (LPN) #,1 showed this surveyor the medication card from the locked narcotic box of the nurse's medication cart. There was not any medication left on the card. The Controlled Substance Log book (page 78) for Resident # 4's [Name Brand Opioid] documented the last pill given was on 04/20/2025 at 6:07 PM, leaving an ending count of 0. LPN #1 said the pharmacy said we will need a Prior Authorization (PA) to get more. On 04/21/2025 at 4:09 PM, (Pharmacy Name) was called. Pharmacist #7 was asked if Resident #4's [Name Brand Opioid] would need a PA. Pharmacist #7 said, I don't know, let me check . After verifying, Pharmacist #7 said yes, it needed a PA. The facility was responsible for getting one. A review of Resident #4's Order Summary for the month of 04/2025, revealed an order dated 03/31/2025 [Name Brand Combination Opioid/Pain Medication] Oral Tablet 7.5-325 milligram (mg) give one (1) tablet by mouth, four (4) times a day related to chronic pain syndrome. A review of a Medication Administration Record (MAR), for the month of April 2025, revealed the scheduled dose for 04/20/2025 at 5:00 PM, was checked as given. The scheduled dose for 04/20/2025 at 9:00 PM, was not checked as given, by the nurse on duty. A review of Resident #4 ' s Medication Administration Record for the month of April 2025, revealed: The scheduled dose for 04/21/2025 at 9:00 AM, was not checked as given, by the nurse on duty. The scheduled dose for 04/21/2025 at 1:00 PM, was not checked as given, by the nurse on duty. The scheduled dose for 04/21/2025 at 5:00 PM, was not checked as given, by the nurse on duty. The scheduled dose for 04/21/2025 at 9:00 PM, was checked as given, by the nurse on duty. A review of the Controlled Substance Log book (page 78) for Resident #4's [Name Brand Opioid], documented on 04/21/2025, a scheduled dose of medication was given at 9:00 PM, which was over twenty-four (24) hours since the last scheduled dose was given. During an interview on 04/22/2025 at 8:56 AM, LPN #3 said the nurses are responsible for notifying the doctor of new prescriptions. When I get to the blue section on the card, where there are 8 pills left, I will notify the doctor for refills, or if it's controlled, I will print off a prescription and send it to the doctor for signature. I don't know who is responsible for getting a PA for medication, I guess the doctor or pharmacy would be, I've never had to do that. During an interview on 04/22/2025 at 09:00 AM, LPN #1 said, the last time I gave Resident #4's pain medication, there were 12 pills left. I usually order them when pills are in the blue section. During an interview on 04/22/2025 at 9:21 AM, the Medical Director said, the pain management doctor, the Advance Practice Registered Nurse (APRN) or I are responsible for refilling medications. Typically, we get a call from one of the nurses. During an interview on 04/23/2025 at 9:49 AM, the DON said Resident #4's medication was ordered two (2) days prior to running out, by one of the night nurses. The medication needed a PA, which went through yesterday, and a new prescription was obtained at that time. The reason the facility did not take some medication from the emergency box was the box did not have the correct dosage in it. The Assistant Director of Nurses who was seated in the DON ' s office said, I believe Resident # 4 has a diagnosis of cirrhosis of the liver, and doubling up on the dosage would be giving too much (name brand acetaminophen). Review of a facility policy titled Administering Medications revised April 2019 indicated Medications are administered in accordance with prescriber orders, including any required time frame.

Based on observation, interview, record review, facility document and policy review, it was determined that the facility failed to report an abuse allegation to proper authorities for 1 (Resident #1) of 5 residents, reviewed for abuse and neglect. The findings include: A review of the facility's undated policy titled Abuse, Neglect, and Misappropriation, indicated facility must notify local law enforcement agencies. A review of the admission Record Face Sheet, indicated Resident #1 was admitted to the facility on [DATE], with diagnoses that included type II diabetes mellitus, cognitive communication deficit, schizophrenia, and bipolar disorder. The quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/01/2025, revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. On 04/21/2025 at 12:45PM, a review of the facility's internal investigation report, involving abuse allegations from Resident #1 against Medical Assistant - Certified (MA-C) #5, revealed the facility reported the incident to law enforcement and there were no negative findings. The investigation packet did not contain the police report, so a request was made to the local police records department for the incident report on 04/21/2025 at 1:09PM. On 04/21/2025 at 3:38PM, an employee with the local police record department responded with an email stating that no records were found on the resident named in the allegation. On 04/22/2025 at 8:00AM, a copy of the police report was requested from the Administrator. On 04/23/2025 at 9:01AM, the Administrator confirmed that there was not a police report filed with the investigation, and when the call was initially made to the police department to report the incident, a message was left with the incident information. The Administrator went home for the day and the police had not arrived prior to the Administrator ' s leaving. The internal investigation was completed, and a follow-up on the police report had not been conducted. On 04/23/2025 at 9:35AM, the Director of Nursing (DON) was asked if police were notified regarding the abuse allegations. The DON stated that the Administrator had indicated that the police had been contacted. The DON confirmed that follow-up was not thought of, to ensure the report had been given to police.

Based on observation, interview, and record review, it was determined the facility failed to ensure food preparations were separate from soiled areas of the kitchen, to ensure kitchen equipment was cleaned before storage, and that hand sanitation was performed during meal service. The findings are: On 9/25/2024 at 11:14 AM, while observing the [NAME] puree the lunch meal that consisted of chicken, broccoli, noodles, and garlic herb biscuits, the right side of a sink that was 10 inches away from food blender had several inches of brown liquid with chunks of what appeared to be noodles and broccoli floating in it. On 9/25/2024 at 11:28 AM, the [NAME] was observed draining noodles in a colander on the clean, left side of the sink prior to pureeing them. On 9/25/2024 at 11:59 AM, the [NAME] rinsed the colander out in the left side of the sink and hung it on a rack located directly above the sink, without washing and sanitizing it first. On 9/26/2024 at 8:17 AM, the surveyor asked the Dietary Manager (DM) if food preparation should be performed next to a dirty sink. The DM stated no, the facility has been having issues with the garbage disposal not working properly but maintenance made the repair yesterday evening, on 9/25/2024. The surveyor asked the DM why clean food prep area should not be next to a dirty sink and DM said it could cause cross contamination. On 9/26/2024 at 8:22 AM, during an interview the District Dietary Manager (DDM) confirmed seeing the [NAME] drain noodles in the clean (left) side of sink, rinse it out and hang it back up. On 9/26/2024 at 8:30 AM, spoke with [NAME] about pureeing foods next to dirty sink and the colander not being washed and sanitized after use. Asked [NAME] why the foods should not be prepared next to a dirty sink and why colander needed to be sanitized after use and before storage and [NAME] stated to keep from contaminating foods. On 9/26/2024 at 8:45 AM,, the policies and in-services were provided from the District Dietary Manager (DDM). The in-services were on kitchen cleaning and storing foods and food quality and puree. On 09/23/2024 at 1:13 PM, residents were observed being served lunch in the 300-hall dining room by the CNA. During the tray delivery and set up of the lunch tray, CNA #1, had long braids that were not tied back and kept touching the tables and chairs in the dining room while the trays were being served. The braids were touched with hands by CNA #1 to move them out of the way or head was flipped to the side to move the braids back. After serving the trays, CNA #1 sat down at a table and began to assist a resident with eating without sanitizing hands. CNA #1 touched clothing and the arms of the table, then would go back to feeding the resident without sanitizing hands. CNA #2 was observed picking up a resident's hamburger bun with un-sanitized bare hands, placed condiments and vegetables on the hamburger bun, put it back together and handed the hamburger to the resident to eat. During an interview on 09/23/2024 at 1:29 PM, CNA #1 confirmed that hands should have been sanitized before starting to serve the residents and hair should have been tied back to prevent it from touching the surrounding areas while lunch trays were being served and feeding the residents. CNA #1 also confirmed hands should have been sanitized after touching clothing or anything unclean. During an interview on 09/26/2024 at 10:07 AM . CNA #2 was asked how the hamburger should have been handled while preparing it for the resident to eat. CNA #2 confirmed eating utensils could have been used to keep the food from being touched and that hands should be sanitized after each tray was passed and before starting to assist residents to eat. A review of Handwashing/Hand Hygiene Policy indicated that the facility considers hand hygiene the primary means to prevent the spread of infections and that an alcohol-based hand rub should be used before and after handling food and before and after assisting a resident with meals.

Based on observation, record review, and interview, it was determined the facility failed to ensure reasonable accommodation of resident needs were provided for 2 (Residents #11,and #26) of 16 sampled residents. The findings are: Resident #11 had a score of 00 on the Brief Interview for Mental Status (BIMS) per a quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/22/2024. Additionally, Resident #11 was identified as being non-ambulatory, dependent on staff for all activities of daily living, and non-verbal. During an observation on 9/23/2024 at 10:20 AM, Resident #11 did not have a call light in reach. Resident was sitting in chair in front of tv and call light was on the floor behind resident's chair. During an observation on 9/25/2024 at 1:10 PM, Resident #11 and Resident #26, who were roommates, were in their room sitting in chairs with no call lights within the resident's reach. Both call lights were laying in the floor behind their chairs. On 9/25/2024 at 1:13 PM, Certified Nursing Assistant (CNA) #6 said staff should make sure residents have the call light within reach before leaving the room so residents can notify staff if they need assistance. On 9/26/2024 at 10:01 AM, the Medical Assistant-Certified (MA-C) #7 said staff should make sure the resident has the call light in reach because they may have an emergency or need something. On 9/26/2024 at 10:04 AM, Licensed Practical Nurse (LPN) #5 said staff should make sure a resident has the call light and bed remote within reach because a resident could experience choking or need assistance. On 9/26/2024 at 7:50 AM, the Administrator provided (Quality Assurance) QA meeting minutes which contained Call Light Monitoring Tool which was issued and signed by staff regarding call light placement and answering of call lights.

Based on interview and record review, it was determined the facility failed to formulate an advance directive, and document if formulation of an advanced directive was refused for 2 of 2 (Resident #13, and Resident #23) residents reviewed for advance directives. The findings are: A review of a facility policy titled, Advance Directives, revised December 2016, indicated the resident will be provided information concerning an advance directive upon admission. Information about whether the resident has executed an advance directive should be in medical records. The advance directives should be reviewed annually with the resident to ensure the directives are still the wishes of the resident. 1. A review of an Order Summary Report indicated Resident #13 had a diagnosis of Epilepsy. a. The quarterly Minimum Data (MDS) with an Assessment Reference Date (ARD) of 08/30/2024 revealed Resident #13 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. b. On 09/24/24 at 10:00 AM, an advance directive was not available for review in Resident #13 's clinical record. c. On 09/24/24 at 10:19 AM, the Assistant Director of Nurse (ADON) indicated she could not find the advance directive in the electronic clinical record for Resident #13. d. On 09/24/24 at 11:00 AM, during interview Resident #13 could not recall being asked to formulate an advance directive. e. On 09/25/24 at 2:45 PM, the ADON indicated that Resident #13 did not have an acknowledgement of an advance directive, or an advance directive in the medical records. She indicated that an advance directive should be completed upon admission. 2. A review of an Order Summary Report indicated Resident #23 had a diagnosis of Alzheimer's disease with late onset. a. The quarterly Minimum Data (MDS) with an Assessment Reference Date (ARD) of 09/24/2024 revealed Resident #13 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated the resident was moderate cognitive impairment. b. On 09/23/24 at 2:01 PM an advance directive was not available for review in Resident #23 's clinical record. c. On 09/24/24 at 2:20 PM, during interview Resident #23 could not recall being asked to formulate an advance directive. d. During an interview on 09/25/24 at 2:46 PM, the ADON indicated that Resident #23 did not have an acknowledgement of an advance directive, or an advance directive in the medical records. She indicated an advance directive should be completed upon admission. e. During an interview on 09/26/2024 at 11:22 AM, the Director of Nursing (DON) indicated that an advance directive should be formulated upon admission and documented if refused.

Based on observations, interviews, and facility policy review, the facility failed to keep resident's personal wheelchairs in good repair without holes, tears, and rips to prevent injuries for 3 (Residents #34, #43, and #45) reviewed for equipment safety. Findings include: A review of a facility policy titled, Maintenance Service, revised on 12/01/2009, indicated services would be provided to all areas of the building, grounds and equipment and maintenance personnel would follow safety regulations to ensure the safety and well-being of all concerned. During an observation on 09/23/2024 at 10:44 AM, the left arm rest on the wheelchair of Resident #43 was noted to be torn, the vinyl/leather turned up and the foam underneath showing. The right arm rest of the wheelchair had a tear/hole in the vinyl and was turned up around the edges. During an observation on 09/23/2024 10:45 AM, the back rest of the wheelchair along the edge, for Resident #45 was vinyl/leather was noted to be cracking and peeling, revealing the soft material underneath. During an observation on 09/25/24 at 9:42 AM, the right and left arm rest of Resident #34's wheelchair was noted to have the vinyl/leather torn and turned up. During a concurrent observation and interview on 09/25/2024 at 9:50 AM, (Certified Nursing Assistant) CNA #3 was shown Resident #34, #43 and #45's wheelchairs with the torn, raised areas and cracked and peeling vinyl/leather. CNA #3 confirmed the torn places could be a hazard and cause skin tears and would be difficult to clean those areas. CNA #3 was asked if the wheelchairs had been reported as needing repair, and CNA# 3 was unaware of any reporting of the wheelchairs. CNA #3 reported there was a maintenance book at the front desk of the facility to list any repairs that were needed and the wheelchairs would be added to the maintenance book. During a concurrent observation and interview on 09/25/2024 at 11:10 AM, the surveyor and Director of Nursing (DON) examined the wheelchairs of Resident #34, #43 and #45. The DON confirmed the torn vinyl/leather could lead to skin tears and would be difficult to clean. The DON was asked how maintenance would know what needed to be repaired, and stated the maintenance request book was located at the front nurse's station and the maintenance supervisor would then have the request in order to address the repairs that needed to be done. During an interview on 09/26/2024 at 9:55 AM, Maintenance confirmed that no one had reported any wheelchairs that needed to be repaired.

Based on observations, interviews, and record review, it was determined the facility failed to administer scheduled pain medication for 1 of 1 (Resident #19) reviewed for pain. The findings are: Review of a facility policy titled, Administering Medications, indicated medications are administered according with the prescriber orders. Medications are administered in accordance with prescriber's orders, and within the required time frame. Medication administration times are determined by resident need and benefit, and not for staff convenience. Medications are administered within one hour of their prescribed time. A review of an Order Summary Report indicated that Resident #19 had a diagnoses of low back pain, unspecified, and polyarthritis. Resident #19 had an order for Hydrocodone- Acetaminophen (Pain) 10-325 mg scheduled four times a day with a start date of 08/28/2024. The quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/14/2024, revealed Resident #19 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. The assessment indicated Resident #19 was on a scheduled pain medication regimen. Review of Resident #19's Care Plan revised on 06/21/2024, revealed the resident will have adequate relief of pain or ability to cope with incompletely relieved pain. Intervention included to administer scheduled pain medications as ordered. A review of Resident #19's demographic record indicated Resident #19 is scheduled to receive Hydrocodone at 9:00 AM, 1:00 PM, 5:00 PM, and at 9:00 PM. It indicated that she received Hydrocodone 10-325 mg on 09/23/2024 at 10:50 AM. On 09/23/2024 at 10:50 AM, during interview, Resident #19 indicated she's been waiting over an hour for her pain medicine. She indicated she asked the nurse for her medication, and she usually has the medication by this time. Resident #19 was observed clenching her face. On 9/23/24 at 10:52 AM, Registered Nurse #8 walked in Resident #19's room with a pill in a cup. When she walked out of the room Registered Nurse #8 confirmed it was a Hydrocodone in the cup. She indicated Resident #19's pain medication was administered late because she looked at it wrong. On 09/25/24 at 10:45 AM Resident #19 indicated she gets her pain meds on time mostly, but she does gets them late sometimes. During an interview on 09/26/2024 at 11:22 AM, the Director of Nursing (DON) indicated if a pain medication is scheduled at 9:00 AM it should be given on schedule at 9:00 AM. He indicated the medications can be given 1 hour before and 1 hour after the scheduled time. He indicated that pain medication should be given on time to regulate pain.

Based on observation and interview, the facility failed to ensure foods stored in the refrigerator, freezer and dry storage area were covered, sealed and dated to minimize the potential for food borne illness for residents who received meals from 1 of 1 kitchen; leftover food items were used in a manner to maintain food quality; expired food items were promptly removed from stock to prevent potential food borne illness; dietary staff washed their hands before handling clean equipment or food items to prevent potential food borne illness; 1 of 1 ice machine was maintained in clean condition; hot food items were at temperature that was acceptable to the residents to improve palatability; and floor and kitchen appliances and were maintained in clean sanitary conditions to prevent the potential food borne illnesses for residents who received meals from 1 of 1 kitchen.; These failed practices had the potential to affect 73 residents who received meals from the kitchen (Total Census: 76), as documented on a list provided by the Dietary District Manager on [DATE]. The findings are: 1. On[DATE] at 9:35 AM, an opened metal container of fruit punch was on a cart by the refrigerator. Dietary Employee (DE) #1 stated, I just made it. 2. On [DATE] at 10:07 AM, the panel of the ice machine in the kitchen had wet black residue on it. The Surveyor asked the Dietary District Manger to wipe the area. The wet black residue easily transferred to the tissue. She stated, It was black matter. The Surveyor asked the Dietary District Manager who uses the ice from the ice machine and how often do you clean it. She stated, That's the ice the CNAs [Certified Nursing Assistants] use for the water pitchers in the residents' rooms and we use it in the kitchen to fill beverages served to the residents' at mealtimes. The maintenance man cleans once a month. The kitchen staff is supposed to clean it daily. 3. On [DATE] at 10:09 AM, DE #1 unplugged a plate warmer and pushed it towards the clean side of the dish washing machine. Holding onto a box of gloves, he removed gloves from the box contaminating the gloves. Without changing gloves and washing his hands, he picked up plates and placed them on the plate warmer with his fingers inside the plates. At 12:15 PM, the Surveyor asked DE #1 what should you have done after touching dirty objects and before handing clean equipment. He stated, I should have washed my hands. 4. On [DATE] at 10:13 AM, the following observations were made on a shelf in the refrigerator: a. A carton of nectar thick milk with an expiration date of [DATE]. b. Two cartons of 2% milk with an expiration date of [DATE]. c. Six bowls of coleslaw dated [DATE]. The Dietary District Manger confirmed leftover food items could be kept up to 3 days. 5. On [DATE] at 10:17 AM, four pallets attached to the deep fryer were in the closed cabinet below the deep fryer. The pallets had grease built up on them. The floor between the deep fryer and the oven had an accumulation of grease on it. The body of the deep fryer and the oven had greasy food crumbs on them. 6. On [DATE] at 10:29 AM, the following observations were made on a shelf in the walk-in refrigerator: a. An opened ziplock bag of tarter tots. The bag was not sealed. b. An opened ziplock bag of ham. The bag was not sealed. c. An opened bag of cheese. The bag was not sealed. d. A box with 24 cartons of whole milk with an expiration date of [DATE]. e. A box with 24 cartons of 2% milk with an expiration date of [DATE]. f. An opened box of sausage links. The box was not covered or sealed. g. An opened box of bacon. The box was not covered or sealed. 7. On [DATE] at 10:31 AM, the following observations were made on a shelf in the walk-in freezer: a. An opened box of okra. The box was not covered and the bag inside the box was not sealed. b. An opened box of mixed vegetables. The box was not covered or sealed. c. An opened box of chicken thighs. The bag was not sealed. d. An opened box of beef patties. The box was not covered or sealed. e. An opened box of biscuits. The box was not covered or sealed. 8. On[DATE] at 10:37 AM, the following observations were made on a shelf in the dry storage room: a. An opened box of graham crackers. The box was not covered or sealed. b. A bag of refried beans with an expiration date of [DATE]. c. An opened bag of all-purpose flour. The bag was not sealed, exposing the flour to air. d. An opened bag of confectioner sugar. The bag was not sealed. e. An opened bag of regular sugar. The bag was not sealed. 9. On [DATE] at 11:19 AM, the following observations were made on a shelf in the refrigerator in the Unit ' s Medication Room: a. Two cartons of 2% milk with an expiration date of [DATE]. b. A container of leftover vegetable soup with no name on the container or date when received or opened. 10. On [DATE] at 11:26 AM, DE #1 pushed a cart with tray covers on it towards a rack. Without washing his hands, he picked up glasses by their rims and placed them on the trays to be used in serving beverages to the residents for lunch. 11. On [DATE] at 11:39 AM, DE #2 was wearing gloves on his hands. He opened the door to the dry storage room, he removed a bag of bread, united the bag, and placed it on the counter, contaminating his gloves. Without changing and washing his hands, he removed slices of bread from the bag and placed them on the cutting board. He sliced the bread and placed it into a pan to be served to the residents for lunch. 12. On [DATE] at 11:45 AM, observed 3 ziplock bags on a shelf in the refrigerator containing scrambled eggs, sausage, and bacon. The Surveyor asked DE #2 what was in the ziplock bags on the shelf. He stated, They are leftover scrambled eggs, sausage, and bacon from this morning. The Surveyor asked what they are used for. He stated, We use them for pureed diets the next morning. 13. On [DATE] at 12:07 PM, the temperature of the pureed noodles on the steam table when checked by DE #2 was 105 degrees Fahrenheit. The food item was not reheated before being served to the residents. 14. On [DATE] at 4:22 PM, DE #3 washed the blender bowl, blade and lid in the food preparation sink with soap and hot water and rinsed them off with hot water. She did not sanitize any of the equipment. When she was ready to use it to puree food items to be served to the residents for lunch. The Surveyor asked what she should do after rinsing washed equipment that encounters food. She stated, Sanitize them. 15. On [DATE] at 5:01 PM, DE #3 turned on the hand washing sink faucet and washed her hands. She then turned off the faucet contaminating her hands. She removed gloves from the box and placed them on her hands, contaminating the gloves. She united bags of hamburger buns, picked up tray cards and placed them on top of the shelf above the steam table and used a knife to cut open packages of cheese. She used the same gloved hands to remove buns from the bag, open the buns and placed them on the plates. She removed slices of cheese from the package with the same gloved hands and placed them on the buns to prepare cheeseburgers to be served to the residents for supper. The Surveyor asked DE #3 what should you have done after touching dirty objects and before handling equipment. She stated, Washed my hands. 16. The facility policy titled, Hand Washing, provided by the Dietary District Manager on [DATE] at 12:35 PM documented, .4. When to wash your hand. 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 . As often as needed during food preparation and when changing tasks.

Based on observation, record review, and interview, 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 2 of 2 meals observed. This failed practice had the potential to affect 4 residents who received pureed diets, 12 residents who received mechanical soft diets, and 57 residents who received regular diets from 1 of 1 kitchen according to a list provided by the Dietary District Manager on 10/03/23 at 12:04 PM. findings are: 1. The menu for the lunch meal on 10/02/23 documented all diets were to receive strawberry shortcake and residents on regular diets were to receive 3 ounces of herb roasted chicken and residents on pureed diets were to receive pureed dinner roll. 2. On 10/02/23 at 1:10 PM, the residents on regular diets were served one small herb roasted chicken thigh each. At 1:44 PM, the Surveyor asked the Dietary District Manger to weigh the same amount of baked chicken served to the residents for lunch. She did so and stated, It weighed 1.9 ounces, instead of 3 ounces as per the menu. 3. On 10/02/23 at 1:17 PM, all residents were served peach halves, instead of strawberry shortcake. 4. On 10/02/23 at 1:24 PM, residents on pureed diets were served pureed noodles, pureed chicken, and pureed brussels sprouts. There was no pureed bread served to the residents who required pureed diets. Pureed peaches were served, instead of strawberry shortcake. At 1:45 PM, the Surveyor asked Dietary Employee (DE) #2 the reason residents on pureed diets did not receive bread. He stated, I forgot it. 5. The menu for the supper meal documented the residents who received pureed diets were to receive a #6 dip (2/3 cup) of pureed Swiss cheeseburger/bun, a #12 dip (1/3 cup) pureed soft, cooked vegetable, a #12 dip (1/3 cup) of pureed green pea salad and all diets were to receive pudding parfait. a. On 10/02/23 at 5:10 PM, 5:31 PM, and 6:18 PM, DE #3 used a #16 scoop (1/4 cup) to serve a single portion of pureed hamburger patties, single portion of mashed potatoes and a single portion of carrots. b. Pureed hamburger buns were not served to the residents on pureed diets. Pureed peas were not served to 3 residents on pureed diets. The residents were served regular pudding, instead of pureed pudding parfait. c. On 10/02/23 at 6:29 PM, the Surveyor asked Dietary Employee (DE) #3 the reason the rest of the residents on pureed diets did not receive pureed pea salad. She stated, I forgot. The Surveyor asked the reason bread or buns were not served to the residents who required pureed diets. She stated, I forgot to do it.

Based on observation, and interview, the facility failed to ensure meals were served in a method that maintained the appearance, nutritive value, cold product, and hot food items at temperatures that were acceptable to the residents to improve palatability and encourage good nutritional intake during 1 of 1 meal observed. This failed practice had the potential to affect 24 residents who received meal trays in their rooms on the 100 Hall, 5 residents who received meal trays in their rooms on the 200 Hall, 20 residents who received meal trays on the 300 Hall, 23 residents who received meal trays on the 400 Hall, as documented on a list provided by the Administrator on 10/03/23 at 11:40 AM. The findings are: 1. On 10/02/23 at 11:22 AM, the Surveyor asked Resident #6 if the food being served was satisfactory. Resident #6 reported that the food was good but was sometimes cold. The Surveyor asked if food being served cold was a frequent occurrence. Resident #6 stated, Sometimes. 2. On 10/02/23 at 12:14 PM, the Surveyor asked Resident #73 if the food being served was satisfactory. Resident #73 stated the food was delivered to the room cold. The Surveyor asked if food being served cold was a frequent occurrence. Resident #73 confirmed that it occurred at almost every meal. 3. A facility recipe for pureed buttered egg noodles documented, For 5 servings use 1/2 cup of water, 1/2 teaspoon of chicken base, 2 1/2 cups of buttered eggs noodles and 2 tablespoons of melted margarine. If product needs thinning, gradually add an appropriate amount of liquid (not water) to achieve a smooth pudding or soft mashed potato consistency. a. On 10/02/23 at 11:56 AM, the Dietary Supervisor pureed noodles with 1/2 cup of water, she poured it into a pan and placed it on the steam table. b. On 10/02/23 at 1:10 PM, the noodles served to the residents were mushy and sticky. At 1:35 PM, the Surveyor asked the Dietary Supervisor and Dietary District Manager to describe the taste of pureed noodles and the appearance of noodles served to the residents on regular and mechanical soft diets. They both tasted pureed noodles and stated, It was bland, it does not have any seasoning to it. The Dietary Supervisor stated, Regular noodles looked gummy and stuck together. At 1:45 PM, The Surveyor asked Dietary Employee (DE) #2 about the appearance of the noodles and pureed food items served to the residents for lunch. DE #2 stated, Noodles were mushy, stuck together. I cooked it with too much water. 4. On 10/02/23 at 1:14 AM, an unheated food cart that contained 23 trays for lunch was delivered to the 400 Hall by DE #1. At 1:29 PM, immediately after the last resident was served in their room, the temperature of the food items on the tray used as test tray were taken and read by the District Dietary Manager with the following results: a. Baked chicken - 109 degrees Fahrenheit. b. Brussels sprouts - 102 degrees Fahrenheit. c. Noodles - 107 degrees Fahrenheit. 5. On 10/03/23 at 7:45 AM, an unheated food cart that contained 23 trays for breakfast was delivered to the 400 Hall by DE #4. At 7:54 PM, immediately after the last resident was served in their room, the temperature of the food items on the tray used as test tray were taken and read by the Dietary District Manager with the following results: a. Milk 51 - degrees Fahrenheit. b. Pureed sausage - 97 degrees Fahrenheit. c. Pureed eggs - 81 degrees. d. Scrambled eggs -100 degrees Fahrenheit. e. Sausage - 100 degrees Fahrenheit. f. Oatmeal - 114 degrees Fahrenheit.

Based on observation and interview, the facility failed to ensure pureed food items were blended to a smooth, lump free consistency to minimize the risk of choking or other complications for those residents who required pureed diets for 2 of 2 meals observed. The failed practice had the potential to affect 4 residents who received pureed diets as documented on a list provided by the Dietary District Manager on 10/03/23. The findings are: 1. On 10/02/23 at 12:07 PM, the following observations were made on the steam table: a. A pan of pureed brussels sprouts. The consistency of the pureed brussels sprouts was runny, not formed and was not smooth. There were pieces of brussels sprouts in the mixture. b. A pan pf pureed baked herb roasted chicken. The consistency was runny, not formed and not smooth. There were pieces of chicken visible in the mixture. At 1:35 PM, the Surveyor asked the Dietary Supervisor and the Dietary District Manger to describe the consistency of the pureed food items served to the residents on pureed diets. The Dietary Supervisor stated, Pureed brussels sprouts was too thin, has lumps and not smooth. Pureed chicken was thin and has pieces of chicken in it. The Dietary District Manger stated, Pureed brussels sprouts doesn't look like pureed. It is too thin, has lumps. It should have been a little thicker. Pureed baked chicken was too thin not the right consistency of pureed, it was not smooth and looks like oatmeal. c. On 10/02/23 at 1:45 PM, the Surveyor asked Dietary Employee (DE) #2 to describe the consistency of the pureed food items served to the residents for lunch. DE #2 stated, Pureed meat was thin, had pieces of chicken in it and was not smooth. I should have pureed it a little longer. Pureed Brussels sprouts had pieces of vegetables in it and was not smooth and was too thin. 2. On 10/02/23 at 4:20 PM, DE #3 used a 6 ounce spoon to place 3 servings of carrots into a blender and pureed. She poured the pureed carrots into a pan and placed it on the steam table. The consistency of the pureed carrots was not smooth. There were still pieces of carrots in the mixture. 3. On 10/02/23 at 4:25 PM, DE #3 placed 5 servings of beef patties into a blender, added broth and pureed. At 4:27 PM, she poured the pureed meat into a pan and placed it on the steam table. The consistency of the pureed meat was not smooth. Pieces of meat were still visible in the mixture. 4. On 10/02/23 at 4:30 PM, DE #3 used a 4 ounce spoon to place 6 servings of pea salad into a blender, added broth and pureed. At 4:32 PM, she poured the pureed green pea salad in a pan and placed it on ice. The consistency of the pureed pea salad was lumpy and not smooth. There were pieces of peas and cheese in the mixture. 5. On 10/02/23 at 6:30 PM, the Surveyor asked the Dietary District Manger to describe the consistency of the pureed food items served to the residents on pureed diets. She stated, They all have lumps.

Based on observation, interview, and record review, the facility failed to ensure call devices were in reach for 1 (Resident #65) of 6 (Residents #10, #21, #24, #49, #69 and #71) sampled residents who were bedbound as documented on a list provided by the Director of Nursing (DON) on 10/05/23 at 9:27 AM. The findings are: On 10/02/23 at 10:20 AM, Resident #65 was lying in bed with the call device lying on the floor by the head of the bed. The Surveyor asked if he was able to get out of bed unassisted. Resident #65 indicated that he could not. On 10/02/23 at 3:34 PM, Resident #65 was lying in bed. The call device was lying on the floor by the head of the bed. On 10/03/23 at 9:28 AM and 12:57 PM, Resident #65 was lying in bed. The call device was lying on the floor by the head of the bed. On 10/04/23 at 3:22 PM, Resident #65 was lying in bed. The call device was lying on the floor by the head of the bed. Resident #65 was unable to locate the call device. On 10/04/23 at 3:28 PM, CNA #3 picked the call device up from the floor and attached it to the bed near Resident #65, and confirmed the resident did not usually move the call light from where it was placed and confirmed the resident had fallen previously. On 10/04/23 at 3:38 PM, the DON confirmed Resident #65 should have the call device available. A Care Plan with a revision date of 08/22/23 noted Resident #65 was at risk for falls and was to be encouraged to use his call light or ask for assistance as needed. A facility policy titled, Answering the Call Light, with a revised date of March 2021, provided by the DON on 10/05/23 at 9:21 AM documented, Purpose The purpose of this procedure is to ensure timely responses to the resident's requests and needs. General Guidelines .4. When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident .

Based on observation, interview, and policy review, the facility failed to ensure access hatches located in resident rooms were secured in 1 (Resident room [ROOM NUMBER]) of 12 (Resident Rooms #301, #302, #303, #304, #305, #306, #308, #309, #310, #311, #312 and #314) Resident Rooms on the 300 Hall. The findings are: On 10/02/23 at 3:13 PM, 10/3/23 at 9:20 AM, and 10/4/23 at 3:31 PM observed in room [ROOM NUMBER] a gray access hatch that was partly opened above a resident bed. There was a white pipe with a valve surrounded by a fibrous yellow material behind the hatch. Two residents were in the room. During interview on 10/04/23 at 3:35 PM, the Maintenance Director confirmed the pipe and valve in room [ROOM NUMBER] was the insulated water shut-off for the sprinkler system. On 10/05/23 at 10:51 AM Nurse Consultant #2 provided a document titled, Preventative Maintenance Program. It documented, .The Maintenance Director shall assess all aspects of the physical plant to determine if Preventive Maintenance (PM) is required. Required PM may be determined from manufacturer's recommendations, maintenance requests, grand rounds, life safety requirements, or experience .

Based on interview and record review, the facility failed to notify a family member of a Care Plan meeting for one (Resident #1) of 18 (Residents #1, #6, #12, #21, #29, #32, #33, #40, #41, #44, #47, #51, #64, #66, #67, #69, #73 and #276) sampled residents. The findings are: Review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/28/23 documented the resident was severely cognitively impaired. Review of a Care Plan with a revision date of 04/24/21 noted Resident #1 was severely impaired in cognitive function related to diagnosis of Alzheimer's disease and needs assistance with all decision making. During an interview on 10/02/23 at 3:28 PM, Resident #1's family member stated, I have never come to a care plan meeting. I've never received any notification or been offered to come to a care plan meeting. During an interview on 10/04/23 at 9:15 AM, the Social Services Director said a letter is mailed out about a week and a half before the meeting and the family member is called to remind them. The Social Services Director said a template is used to generate the letters, and the letters are not saved and scanned to the system, but a progress note is entered in the resident ' s chart noting the family members were notified. During an interview on 10/04/23 at 9:23 AM, the MDS Coordinator said most families do not attend the care plan meeting, so a phone call is made, and the care plan is reviewed, and a progress note is made. The MDS Coordinator confirmed there was no progress note for Resident #1. On 10/04/23 at 10:07 AM, the MDS Coordinator provided a list of family members contacted for upcoming care plan meetings scheduled for notification on 08/23/23. This list did not include Resident #1. Review of the Progress Notes dated 04/01/23 through 10/04/23, there was no documentation regarding a care plan meeting. A facility policy titled, Care Planning-Interdisciplinary Team (Revised March 2022), provided by Nurse Consultant #2 documented, Policy Statement The interdisciplinary team is responsible for the development of resident care plans. Policy Interpretation and Implementation . 3. The IDT includes but is not limited to: .e. to the extent practicable, the resident and/or the resident's representative; .4. The resident, the resident's family and/or the resident's legal representative/ guardian or surrogate are encouraged to participate in the development of and revisions to the resident's care plan. 5. Care plan meetings are scheduled at the best time for the day for the resident and family when possible. If it is determined that participation of the resident or representative is not practicable for development of the care plan, an explanation is documented in the medical record .

Based on observation, record review, and interview, the facility failed to ensure residents were given physician prescribed medications within the timeframe they were ordered for 3 (Residents #1, #2, #3) of 3 (#1, #2, #3) sample mix residents. The finding are: 1. Resident #1 was admitted on [DATE] with a diagnoses of Type 2 Diabetes Mellitus, Idiopathic Peripheral Autonomic Neuropathy, Sleep Disorder, Long Term use of Insulin, Mood Disorder due to know Physiological Condition. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/17/23 documented a score of 15 (13-15 indicates cognitively intact) on the Brief Interview Mental Status (BIMS). 2. Resident #2 was admitted on [DATE] with diagnoses of Type 2 Diabetes Mellitus, Mild Protein Calorie Malnutrition, Hypertensive Heart and Chronic Kidney Disease with Heart Failure and with Stage 5 Chronic Kidney Disease, or End Stage Renal Disease, Gastro Esophageal Reflux Disease, Acute Kidney Failure, Abnormal Weight Loss, and Glaucoma. The Significant Change MDS with an ARD of 03/13/23 documented a score of 15 (13-15 indicates cognitively intact) on the BIMS. 3. Resident #3 was admitted on [DATE] with diagnoses of Type 2 Diabetes Mellitus, Atherosclerotic Heart Disease of Native Coronary Artery, and Hypertension. The Quarterly MDS with an ARD of 03/30/23 documented a score of 15 (13-15 indicates cognitively intact) on the BIMS. 4. On 05/20/23 at 9:26 PM, the Surveyor entered the facility, and immediately looked down each hallway to see if the nursing staff were passing 8:00 PM medications. The Surveyor observed a nurse on the 200 Hallway with her medication cart, looking up the residents on the computer and popping out medications from the residents' medication card. 5. On 05/20/23 at 9:30 PM, the Surveyor asked Licensed Practical Nurse #1 (LPN #1), What hallway do you usually work? LPN #1 stated, I'm agency, so I kind of float. The Surveyor asked, What time frame should 8:00 PM medications be given in? LPN #1 stated, I've got a two-hour window. An hour before and an hour after. The Surveyor asked, How often are medications passed outside of that time frame? LPN #1 stated, Maybe if something happens and you got an emergency or something or a new admit. The Surveyor asked, Should they be passed within the two-hour time fame? LPN #1 stated, Yes. The Surveyor asked, Have you or do you have any knowledge of a nurse passing 8:00 PM medications after 12:00 AM? LPN #1 stated, Not at midnight. The Surveyor asked, Should they be passed within the two-hour time frame? LPN #1 stated, No, it should be within that time. The Surveyor asked, Which residents that you are caring for are currently overdue for their 8:00 PM medications? LPN #1 stated, The ones in the pink (LPN showed the Surveyor her computer desktop with residents listed and ten (10) out of fifteen (15) residents were shown in the pink/overdue). The Surveyor asked, Why are they over the two-hour time frame? LPN #1 stated, I had some behaviors on the lock down unit. 6. On 05/20/23 at 9:36 PM, the Surveyor asked LPN #2, What hallway do you usually work? LPN #2 stated, I do one hundred (100) and some two hundred (200). The Surveyor asked, What time frame should 8:00 PM medications be given? LPN #2 stated, We've got a two-hour window. One hour before and one hour after. The Surveyor asked, How often are medications passed outside of that time frame? LPN #2 stated, It happens sometimes when you have to wait for medicine. The Surveyor asked, How often do you have to wait for medication to be delivered? LPN #2 stated, It doesn't happen often. The Surveyor asked, Have you or do you have any knowledge of a nurse passing 8:00 PM medications after 12:00 AM? LPN #2 stated, We use a lot of agencies. When we have an agency nurse they just aren't as familiar. We've had incidence lately where it has happened. 7. On 05/22/23 at 10:27 AM, the Surveyor asked Resident #1, How often do you receive your medication late on Saturday night? Resident #1 stated, Practically every Saturday. Usually, I get my 8:00 PM at 9:30 PM. I'm on Amitriptyline which keeps me up. I supposed to get it at 8:00 PM. A few Saturdays ago, it was after midnight. The Surveyor asked, Did you report it? Resident #1 stated, Yes, on one occasion when I had a Agency nurse. I called the Ombudsman the night I got it at around 12:20 AM. The Surveyor asked, Who was the nurse? Resident #1 stated, Not sure they [nurse] name, but she was through Agency. I talked to [name] Director of Nursing (DON) about it, but I still get them late. 8. On 05/22/23 at 10:35 AM, the Surveyor asked Resident #2, How often do you receive your medication late on Saturday night? Resident #2 stated, I believe the nurse brought me mine around 10:00 PM. That is commonplace. The Surveyor asked, Have you ever received your 8:00 PM medication at 12:00 AM? Resident #2 stated, No, they have never been that late. 9. On 05/22/23 at 10:56 AM, the Surveyor asked Resident #3, How often do you receive your medication late on Saturday night? Resident #3 stated, It's often late. I've had to be woken up several times for them to give it to me. The Surveyor asked, Have you ever received your 8:00 PM medication at 12:00 AM? Resident #3 stated, No, not that late but I believe it's been close. 10. On 05/22/23 at 12:58 PM, the DON provided the Surveyor with an In-Service Education Report dated 05/22/23 that documented, .Topic: Medication should sure be administered in a timely manner. Medication can be given one hour before or after scheduled time. Medication must be signed off on the MAR/TAR (Medication Administration Record/Treatment Administration Record) in a timely manner as well. Please sign all medication when administered to the patient. Failure to complete medication pass or sign off medication will result in disciplinary actions- up to possible termination . 11. On 05/22/23 at 12:58 PM, the DON provided the Surveyor with a Medication Administration Audit Report for Resident #1. The report showed the following medications were administered outside the 2-hour requirement for Resident #1 on 04/29/23: a. Acidophilus was scheduled for 8:00 PM and was documented as provided at 12:02 AM. b. Insulin Glargine Solution was scheduled for 8:00 PM and was documented as provided at 12:02 AM. c. Amitriptyline was scheduled for 8:00 PM and was documented as provided at 12:02 AM. d. Atorvastatin was scheduled for 8:00 PM and was documented as provided at 12:02 AM. e. Melatonin was scheduled for 8:00 PM and was documented as provided at 12:02 AM. f. Eliquis was scheduled for 8:00 PM and was documented as provided at 12:02 AM. g. Accucheck for blood glucose was scheduled for 8:00 PM and was documented as provided at 12:02 AM. h. Gabapentin was scheduled for 8:00 PM and was documented as provided at 12:02 AM. 12. On 05/22/23 at 12:59 PM, the Surveyor asked the Ombudsman, Did you report to anyone in the facility the concern that Resident #1 called you with on Saturday 04/29/23 about not receiving her 8:00 PM medication until after midnight? The Ombudsman stated, Yes. I talked to some nurses on Sunday when I went to the facility, and then I talked to the DON about it on Monday when I went back. She told me a nurse called in and they had to get an agency nurse and the nurse got there around eight (08). Resident text me at 11:15 PM on Saturday April 29th and said she still hadn't gotten her meds. I talked to the resident again just before 12 AM and she still hadn't gotten them. 13. On 05/22/23 at 1:30 PM, the Surveyor asked the DON, What time frame should residents receive their 8:00 PM medications? The DON stated, They have a two-hour window. One hour before and one hour after. The Surveyor asked, What residents have complained to you about receiving their medications outside of the two-hour window? She stated, I only had 1 resident [Resident #1] and I followed up with that nurse. The Surveyor asked, Did you speak with the Ombudsman on Monday May 1, 2023, about a resident contacting her on Saturday night April 29, 2023, about the resident not receiving 8:00 PM medications until after 12:00 AM? The DON stated, Yes, that is the weekend I'm referring to. 14. The facility policy titled, Administering Medications, was provided by the DON on 05/23/23 documented, . Medications are administered in a safe and timely manner, and as prescribed . 3. Staffing schedules are arranged to ensure that medications are administered without unnecessary interruptions . 4. Medications are administered in accordance with prescriber orders, including any required time frame . Medication administration times are determined by resident need and benefit, not staff convenience. Factors that are considered include: a. enhancing optimal therapeutic effect of the medication; b. preventing potential medication or food interventions; and c. honoring resident choices and preferences, consistent with his or her care plan . 7. Medications are administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders) . 22. The individual administering the medication initials the residents MAR on the appropriate line after giving each medication and before administering the next ones . 23. As required or indicated for a medication, the individual administering the medication records in the resident's medical record: a. the date and time the medication was administered; b. the dosage; c. the route of administration; d. the injection site (if applicable); e. any complaints or symptoms for which the drug was administered; f. any results achieved and when those results were observed; and g. the signature and title of the person administering the drug .

Based on record review, and interview, the facility failed to ensure the Ombudsman and residents with concerns and complaints regarding late medication administration in the facility were allowed to be voiced through grievances as part of the process of Resident Rights for 1 (Resident #1) of 3 (#1, #2, #3) sampled residents. This failed practice had the potential to affect 62 residents who resided in the facility, according to the Resident Census and Conditions of Residents form provided by the Director of Nursing (DON) on 05/22/23. The findings are: 1. Resident #1 was admitted on [DATE] with diagnoses of Type 2 Diabetes Mellitus, Idiopathic Peripheral Autonomic Neuropathy, Pure Hyperglyceridemia, Mixed Hyperlipidemia, Sleep Disorder, Long Term use of Insulin. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date of 03/17/23 documented a score of 15 (13-15 indicates cognitively intact) on the Brief Interview for Mental Status) BIMS. a. The Grievance log dated April 23 and May 23 did not document a grievance from Resident #1 or the Ombudsman. b. On 05/22/23 at 10:27 AM, the Surveyor asked Resident #1, How often do you receive your medication late on Saturday night? She stated, Practically every Saturday. Usually, I get my eight o'clock meds at nine-thirty. I'm on Amitriptyline which keeps me up. I'm supposed to get it at eight o'clock. A few Saturdays ago, it was after midnight. The Surveyor asked, Who was the nurse? Resident #1 stated, On one occasion when I had key shift nurse. I called the Ombudsman that night I got it around twelve twenty in the morning. Not sure of the nurses' name but she was through shift key. I talked to the DON about it, but I still get them late. The Surveyor asked, Did you file a grievance? Resident #1 stated, The DON did it for me. The Surveyor asked, Was it in April or May? Resident #1 stated, It was the end of the month so April. c. On 05/22/23 at 12:59 PM, the Surveyor asked the Ombudsman, Did you report to anyone in the facility the concern that Resident #1 called you with on Saturday 04/29/23 about not receiving her 8:00 PM medication until after midnight? The Ombudsman stated, Yes. I talked to some nurses on Sunday when I went to the facility, and then I talked to the DON about it on Monday when I went back. She told me a nurse called in and they had to get an agency nurse and the nurse got there around 8. Resident text me at 11:15 PM on Saturday April 29th and said she still hadn't gotten her meds. I talked to the resident again just before 12 AM and she still hadn't gotten them. d. On 05/22/23 at 1:30 PM, the Surveyor asked the DON, What residents have complained to you about receiving their medications outside of the two-hour window? The DON stated, I only had 1 resident [Resident #1] and I followed up with that nurse. The Surveyor asked, Did you write a grievance? The DON stated, I did not write a grievance on that, I should have. The Surveyor asked, Did you speak with the Ombudsman on Monday May 1, 2023, about a resident contacting her on Saturday night April 29, 2023, about the resident not receiving 8:00 PM medications until after 12:00 AM? The DON stated, Yes, that is the weekend I'm referring to. The Surveyor asked, Did you file a grievance? The DON stated, No, I just spoke with the nurse about it. I didn't do a grievance though. The Surveyor asked, Why? The DON stated, Because it was the weekend and Social Services was off that weekend. I should have done it Monday. e. On 05/23/23 at 11:36 AM, the Surveyor asked the Administrator, If the resident or Ombudsman complain should a grievance be filed? The Administrator stated, Yes. We look at every grievance and resolution and file it. I take a look at it and decide if it is resolved or not and talk with the resident directly. The Surveyor asked, If a resident makes a complaint on the weekend should the grievance still be filed even if social services is off for the weekend? The Administrator stated, Every grievance is to be filed regardless of what day or time it. f. The facility policy titled, Grievance/Complaints Filing, provided by the DON on 05/23/23 documented, .Policy Statement .Residents and their representatives have the right to file grievances, either orally or in writing, to the facility staff or to the agency designated to hear grievances (e.g., the State Ombudsman). The administrator and staff will make prompt efforts to resolve grievances to the satisfaction of the resident and/or representative .Policy Interpretation and Implementation . 1. Any resident, family member, or appointed resident representative may file a grievance or complaint concerning care, treatment, behavior of other residents, staff members, theft of property, or any other concerns regarding his or her stay at the facility. Grievances also may be voiced or filed regarding care that has not been furnished. 2. Residents, family and resident representatives have the right to voice or file grievances without discrimination or reprisal in any form, and without fear of discrimination or reprisal. 3. All grievances, complaints or recommendations stemming from resident or family groups concerning issues of resident care in the facility will be considered. Actions on such issues will be responded to in writing, including a rationale for the response 5. Grievances and/or complaints may be submitted orally or in writing and may be filed anonymously .8. Upon receipt of a grievance and/or complaint, the grievance officer will review and investigate the allegations and submit a written report of such findings to the administrator within five (5) working days of receiving the grievance and/or complaint . 10. The grievance officer, administrator and staff will take immediate action to prevent further potential violations of resident rights while the alleged violation is being investigated . 11. The administrator will review the findings with grievance officer to determine what corrective actions, if any, need to be taken . 12. The resident, or person filing the grievance and/or complaint on behalf of the resident, will be informed (verbally and in writing) of the findings of the investigation and the actions that will be taken to correct any identified problems . 14. The results of all grievances files, investigated and reported will be maintained on file for a minimum of three years form the issuance of the grievance decision .

Based on observation and interview, the facility failed to ensure food was labeled and dated; failed to ensure food was covered while sitting out in the open; failed to ensure kitchen confined hair in a hair net/cap to prevent potential food-borne illness and possible cross contamination and infections. This had the potential to affect 79 residents who received meals from the kitchen according to a list provided by the Administrator on 2/3/23 at 9:55 a.m. The findings are: a. On 2/2/23 at 4:01 p.m., Dietary Employee #2 prepared food in the kitchen with 6 inches of hair hanging down and exposed, on the left side and right side of the face and not confined in a hair net or cap. Dietary Employee #3 was in the kitchen with the crown of head to the base of the neck, approximately eight inches, of hair exposed and not confined to a hair net or cap. b. On 2/2/23 at 4:05 p.m. a metal pan that contained hot dogs was on the steam table and not covered. Three metal pans that contained puree food was on the steam table and not covered. Dietary Employee #2 moved around the food and in the kitchen with approximately six inches of hair on the left side and the right side of face, exposed and not contained in a hair net or cap. c. On 2/2/23 at 4:07 p.m., the Surveyor asked Dietary Employee #2, what is in the metal pans on the steam table? Dietary Employee #2 stated, puree beef stew, bread, and vegetables. Dietary Employee #2 moved throughout the kitchen with approximately six inches of hair exposed on the left side and right side of face and not confined in a hair net or cap. d. On 2/2/23 at 4:12 p.m., Dietary Employee #2 was in the kitchen, walking from the sink to a counter next to the refrigerator, approximately 20 feet, with six inches of hair exposed and hanging down on the left side and right side of the face, not confined to a hair net or cap. e. On 2/2/23 at 4:19 p.m., a metal pan that contained hot dogs, puree vegetables, puree beef stew, and puree bread was on the steam table not covered and exposed food to the open air. Dietary Employee #3 maneuvered around the kitchen with the crown of head to the base of the neck, approximately eight inches of hair exposed and not confined to a hair net or cap. f. On 2/2/23 at 4:23 p.m., a metal pan that contained 29 baked cookies was on top of a grey plastic bin uncovered and exposed food to the open air. g. On 2/2/23 at 4:24 p.m., eleven bowels of fruit were in the refrigerator not labeled or dated. The Surveyor asked Dietary Employee #1, should those be labeled and dated? Dietary Employee #1 stated, it should be, it should have been discarded. h. On 2/2/23 at 4:28 p.m., Dietary Employee #2 exited the dry storage area in the kitchen with approximately six inches of hair exposed and hanging on the left side and right side of face. and not confined to a hair net or cap. i. On 2/2/23 at 4:29 p.m., a metal pan with baked cookies was on top of a grey plastic bin uncovered and exposed food to the open air. j. On 2/2/23 at 4:30 p.m., a clear plastic bag that contained seven slices of bread was on the counter with no label and not dated. k. On 2/2/23 at 4:35 p.m., a metal pan that contained hot dogs, a metal pan that contained pureed vegetables, a metal pan that contained pureed bread, and a metal pan that containedpureed beef stew were on the steam table not covered and exposed to the open air. l. On 2/2/23 at 4:38 p.m., Dietary Employee #4 placed tator tots in a metal pan and placed on the steam table. Dietary #4 did not cover the tator tots and left them exposed to the open air. m. On 2/2/23 at 4:46 p.m., Dietary Employee #2 walked around the kitchen with six inches of hair exposed and hanging down on the left side and right side of the face. Dietary #2's hair was not cofined in a hair net or cap. n. On 2/2/23 at 4:48 p.m., Dietary Employee #2 checked the temperature of the food on the steam table. Dietary #2's hair was exposed and hanging down approximately six inches on the left side and right side of the face. Dietary Employee #2's hair was not confined in a hair net or cap. o. On 2/2/23 at 5:03 p.m., three bowels of pureed cookies were on a plastic tray on the counter not covered and exposed to the open air. p. On 2/2/23 at 5:10 p.m., Dietary Employee #2 and Dietary Employee #3 were on either side of the steam table around the uncovered food. Dietary Employee #2 had six inches of hair exposed and hanging down on the left side and right side of the face. Dietary Employee #3 had the crown of head to the base of the neck, approximately eight inches, of hair exposed and not confined to a hair net or cap. q. On 2/2/23 at 5:12 p.m., Dietary Employee #2 dished out food onto a plate with six inches of hair exposed and hanging down on the left side and right side of the face. Dietary Employee #2 hair was not confined in a hair net or cap. Dietary Employee #2 placed the plate of food on top of the steam table, Dietary Employee #3 took the plate of food and placed on a room tray. Dietary Employee #3 had the crown of head to the base of the neck, approximately eight inches, of hair exposed and was not confined to a hair net or cap. r. On 2/3/23 at 1:48 p.m., the Surveyor asked the Director of Nursing (DON), why should food be labeled and dated when stored? The DON stated, so they don't spoil. The Surveyor asked the DON, why should staff hair be covered with a hair net and confined when working in the kitchen? The DON stated, so it doesn't fall in the food. The Surveyor asked the DON, what are your expectations from your staff regarding following the facilities policy and procedures and the Centers for Medicare and Medicaid Services (CMS) guidelines? The DON stated, I expect them to follow them. s. On 2/3/23 at 2:32 p.m., the Surveyor asked Dietary Employee #1, why should food be labeled and dated when stored? Dietary Employee #1 stated, to prevent the service of food that could harm a resident by allergy and dated to prevent bacterial growth and ensure we're serving fresh food at all times. The Surveyor asked Dietary Employee #1, why should staff hair be covered with a hair net and confined when working in the kitchen? Dietary Employee #1 stated, to prevent physical contamination of the food. The Surveyor asked Dietary Employee #1, what are your expectations from your staff regarding following the facilities policy and procedures and the CMS guidelines? Dietary Employee #1 stated, compliance. t. On 2/3/23 at 2:49 p.m., the Surveyor asked the Administrator, why should food be labeled and dated when stored? The Administrator stated, for safety. The Surveyor asked the Administrator, why should staff hair be covered with a hair net and confined when working in the kitchen? The Administrator stated, so non-food related items can fall into it. The Surveyor asked the Administrator, what are your expectations from your staff regarding following the facilities policy and procedures and the CMS guidelines? The Administrator stated, they should be followed. u. A policy provided by Dietary Employee #1 documented, .Food and Nutrition Services .Staff Attire .all employees wear approved attire for the performance of their duties .all staff members will have their hair off the shoulders .confined in a hair net or cap . v. A policy provided by Dietary Employee #1 documented, .Safe Food Handling .all foods are prepared in accordance with the Food and Drug Administration (FDA) Food Code .dining services staff will be responsible for food preparation procedures that avoid contamination by potentially harmful physical, biological, and chemical contamination .all foods will be stored wrapped or in covered containers, labeled and dated .

Based on record review and interview, the facility failed to ensure prompt efforts were made to resolve a grievance regarding dietary requests and missing items, to promote resident rights for 1 (Resident #1) of 6 (Resident #1, R #2, R #3, R #4, R, #5, and R #6) sample mix residents. This failed practice had the potential to affect 80 residents who reside in the facility, as documented on the Roster Matrix provided by the Administrator on 1/31/23. The findings are: 1.Resident #1 had a diagnosis of Diabetes Mellitus. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/22/22 documented the resident scored 15 (13-15 indicated cognitively intact) on the Brief Interview for Mental Status (BIMS), required extensive assist for bed mobility, dressing, and personal hygiene, required set up help for eating. a. A Physician Order with a start date of 11/4/21 documented .regular .enhanced foods, regular texture, regular consistency . b. A Physician Order with a start date of 8/18/22 documented .provide a snack of his choosing after supper/at bedtime .one time a day related to mild protein calorie malnutrition . c. A Care Plan with an initiated date of 8/27/21 documented .the resident has diabetes mellitus .offer substitutes for food not eaten . d. On 1/31/2023 at 11:05 a.m., the Administrator provided a copy of the Grievance Log dated November 2022 with no resolution for R #1 grievance filed on 11/21/22. e. On 2/1/2023 at 7:30 a.m. a review of R #1's Inventory Personal Effects sheet dated 6/8/22 with no personal effects listed. f. On 2/1/2023 at 8:40 a.m., the grievances were requested from the Administrator via [by way of] email. The Administrator replied to the email .as soon as my Social Services Director makes it in, I will get those to you . g. On 2/1/2023 at 10:00 a.m., the grievances were received from the Administrator via email and reviewed. R #1 filed a grievance on 11/21/22 with the following concerns and no resolution: i. Resident #1 wanted 2 eggs and 10 pieces of bacon every morning. ii.Resident #1 wanted a peanut butter and jelly sandwich for late night snack every day between 6-9 pm. iii. Resident #1 was missing two pair of sweatpants and 3 or 4 sweatshirts. h. On 2/3/23 at 9:53 a.m., the Surveyor asked House Keeping Supervisor (HKS) #1, what do you do for resident's missing/lost clothes? HKS #1 stated, we'll look for them and return. The Surveyor asked HKS #1, how have the issues with R #1 missing clothes/items been resolved? HKS #1 stated, R #1 has one thing missing, a pair of denim jeans .I have to go to each room and look, if we can't find them, we will replace them, but we usually have thirty days. i. On 2/3/23 at 10:58 a.m., the Surveyor asked R #1, has the facility found your clothes? R #1 stated, most of them, a pair of jeans are still gone. The Surveyor asked R #1, you filed a grievance in November of 2022 with no resolution, how did that make you feel? R #1 stated, disrespected. j. On 2/3/23 at 1:43 p.m., the Surveyor asked the Director of Nursing (DON), what is a grievance? The DON stated, when someone has a concern that they want addressed? The Surveyor asked the DON, who can file a grievance? The DON stated, anybody. The Surveyor asked the DON, who is responsible for grievances? The DON stated, anyone can write one, but usually social or the administrator. The Surveyor asked the DON, what is the time frame for addressing grievances? The DON stated, I'm not positive. The Surveyor asked the DON, why was R #1 grievance dated 11/21/2022 for missing items and food preferences not addressed? The DON stated, I'm not aware of it. The Surveyor asked the DON, what are your expectations from your staff regarding following the facilities policy and procedures and the Centers for Medicare and Medicaid Services (CMS) guidelines? The DON stated, I expect them to follow them. k. On 2/3/23 at 2:12 p.m., the Surveyor asked the Social Worker (SW), what is a grievance. The SW stated, a complaint or concern. The Surveyor asked the SW, who can file a grievance. The SW stated, anybody. The Surveyor asked the SW, who is responsible for grievances? The SW stated, me and the Administrator. The Surveyor asked the SW, what is the time frame for addressing grievances? The SW stated, five days. The Surveyor asked the SW, why was R #1 grievance dated 11/21/22 for missing items and food preferences not addressed? The SW stated, I don't know. The Surveyor asked the SW, should it have already been completed? The SW stated, yes, I just got my book caught up, it's an ongoing concern with this R #1 (man). The Surveyor asked the SW, when did you complete this? The SW stated, just now. The Surveyor asked the SW, did you complete this after the surveyor entered the facility? The SW did not answer the question. l. On 2/3/23 at 2:59 p.m., the Surveyor asked the Administrator, what is a grievance? The Administrator stated, an issue a resident has with some performance of the facility. The Surveyor asked the Administrator, who can file a grievance? The Administrator stated, anyone. The Surveyor asked the Administrator, who is responsible for grievances? The Administrator stated, the social worker and falls to me. The Surveyor asked the Administrator, what is the time frame for addressing grievances? The Administrator stated, shoot for ten days. The Surveyor asked the Administrator, why was R #1 grievance dated 11/21/2022 for missing items and food preferences not addressed? The Administrator stated, I don't know why R #1 wasn't resolved. The Surveyor asked the Administrator, what are your expectations from your staff regarding following the facilities policy and procedures and the CMS guidelines? The Administrator stated, they should be followed. m. A policy provided by the Administrator on 2/3/23 at 9:55 a.m. documented .Grievances/Complaints Filing .Residents .have the right to file grievances, either orally or in writing, to the facility staff or to the agency designated to hear grievances .the administrator and staff will make prompt efforts to resolve grievances to the satisfaction of the resident and/or representative .any resident, family member, or appointed resident representative may file a grievance or complaint concerning care, treatment, behavior of other residents, staff members, theft of property, or any other concerns regarding his or her stay at the facility .grievances also may be voiced or filed regarding care that has not been furnished .all grievances, complaints or recommendations stemming from resident or family groups concerning issues of resident care in the facility will be considered .actions on such issues will be responded to in writing , including a rationale for the response .upon receipt of a grievance and/or complaint, the grievance officer will review and investigate the allegations and submit a written report of such findings to the administrator within five (5) working days of receiving the grievance and/or complaint .the grievance officer will coordinate actions with the appropriate state and federal agencies, depending on the nature of the allegations .all alleged violations of neglect, abuse and/or misappropriation of property will be reported and investigated under guidelines for reporting abuse, neglect and misappropriation of property, as per state law .the grievance officer, administrator and staff will take immediate action to prevent further potential violations of resident rights while the alleged violation is being investigated .the administrator will review the findings with grievance officer to determine what corrective actions, if any, need to be taken .the resident, or person filing the grievance and/or complaint on behalf of the resident, will be informed (verbally and in writing) of the findings of the investigation and the actions that will be taken to correct any identified problems .a written summary of the investigation will also be provided to the resident and a copy will be filed in the business office . n. A policy provided by the Administrator on 2/3/23 at 9:55 a.m. documented .Resident Rights .employees shall treat all residents with kindness, respect, and dignity .federal and state laws guarantee certain basic rights to all residents of this facility .these rights include the resident's right to .voice grievances to the facility, or other agency that hears grievances, without discrimination or reprisal and without fear of discrimination or reprisal .have the facility respond to his or her grievances .

Based on observation, interview, and record review, the facility failed to ensure residents received physician ordered skin treatments to promote healing and to prevent possible infection for 1 (Resident #1) of 6 (Resident #1, R #2, R #3, R #4, R, #5, and R #6) sample mix residents. The findings are: Resident #1 had diagnoses of Xerosis Cutis and Pruritus. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/22/2022 documented the resident scored 15 (13-15 cognitively intact) on the Brief Interview for Mental Status (BIMS), required extensive assist for bed mobility, dressing, and personal hygiene, and required set up help for eating. 1. A Physician Order with a start date of 6/29/2022 documented .Clobetasol Propionate Cream 0.05 % [percent] apply to affected areas topically every day and night shift related to pruritus . a. On 2/1/2023 at 8:34 a.m., review of R #1 December 2022 Medication Administration Record (MAR) revealed Clobetasol Propionate Cream 0.05% was not administered on the 7/P-7/A shift on the night of 12/14/2022. b. On 2/1/2023 at 9:16 a.m., review of R #1 January MAR revealed Clobetasol Propionate Cream 0.05% was not administered on the 7/A-7/P shift on 1/20/2023; and was not administered on the 7/P-7/A shift on the night of 1/31/2023. 2. A Physician Order with a start date of 10/28/2022 documented . [named] Lotion 0.5-0.5 % (Camphor-Menthol) apply to affected areas topically every day and night shift for itching . a. On 2/1/2023 at 8:34 a.m., review of R #1 December 2022 Treatment Administration Record (TAR) revealed [named] Lotion treatment was not administered on the 7/A-7P shift on days: 12/3, 12/4, 12/6, 12/7, 12/10, 12/12, 12/14, 12/19, 12/20, 12/21, 12/22, 12/23, 12/26, 12/27, 12/28, 12/30, and 12/31/2022; and was not administered on the 7/P-7/A shift on the nights of 12/15, 12/18, and 12/24/2022. b. On 2/1/2023 at 9:16 a.m., review of R #1 January 2023 TAR revealed [named] Lotion treatment was not administered on the 7/A-7/P shift on days: 1/2, 1/4, 1/5, 1/6, 1/9, 1/10, 1/11, 1/12, 1/13, 1/14, 1/15, 1/17, 1/18, 1/19, 1/20, 1/22, 1/23, and 1/24/2023; and was not administered on the 7/P-7/A shift on the nights of 1/22, 1/23, and 1/24/2023. 3. On 2/3/2023 at 10:44 a.m., R #1 was in the room in bed scratching his right forearm with his left hand. R #1's right forearm had white, dried skin. The Surveyor asked R #1, do you get your lotion treatments twice a day? R #1 stated, it's a hit or miss situation, I get it sometimes and sometimes I don't. 4. On 2/3/2023 at 11:15 a.m., the Surveyor asked Licensed Practical Nurse (LPN) #1, where are skin treatments documented? LPN #1 stated, on the TAR. The Surveyor asked LPN #1, can you tell me why R #1 [named] lotion was not administered on the days with no documentation on the TAR. LPN #1 stated, I do not know. 5. On 2/3/2023 at 1:48 p.m., the Surveyor asked the Director of Nursing (DON), who is responsible for ensuring resident's medications and skin ointments are administered? The DON stated, the nurses. The Surveyor asked the DON, what are your expectations from your staff regarding following the facility policy and procedures and the Centers for Medicare and Medicaid Services (CMS) guidelines. The DON stated, I expect them to follow them. 6. On 2/3/2023 at 2:59 p.m., the Surveyor asked the Administrator, who is responsible for ensuring resident's medications and skin ointments are administered? The Administrator stated, the treatment nurse. The Surveyor asked the Administrator, what are your expectations from your staff regarding following the facility policy and procedures and the CMS guidelines? The Administrator stated, they should be followed. 7. A policy provided by the Administrator on 2/3/2023 at 9:55 a.m. documented .Administering Medication .medications are administered in a safe and timely manner, and as prescribed .medications are administered in accordance with prescriber orders, including any required time frame .topical medications used in treatments are recorded on the resident's treatment record (TAR) .

Based on observation, record review and interview, the facility failed to provide adequate supervision to prevent potential accidents and/or elopement during Fire Watch periods as evidenced by fire doors propped open, the front entry door open, supply room storage room door propped open, magnetic lock to the secured unit not functioning, magnetic lock to the exit doors not functioning; and failure to ensure written policy and procedures were followed during Fire Watch periods due to sprinkler system/fire alarm systems not in working condition to prevent potential injuries to residents; and the facility failed to ensure that staff members performing fire watch were trained on fire watch procedures and what to do in the event of a fire to prevent potential injuries to residents, and the facility failed to ensure all staff members were trained on what to do in the event of a fire to prevent potential injuries to residents. The failed practice resulted in Immediate Jeopardy, which caused or could have caused serious harm and/or injury to affect all 80 residents who resided in the facility, as documented on the Midnight Census Report provided by the Administrator on 1/10/23 at 9:15 a.m. The facility Administrator was notified of the Immediate Jeopardy on 1/10/23 at 12:00 p.m. The findings are: 1. On 1/10/23 at 8:00 a.m., the Surveyor entered facility through the front entrance. The front door was standing open. There were no staff members present. A sign on the door documented, Please pull door closed. 2. On 1/10/23 at 8:05 a.m., the fire doors on the 100 Hall were propped open with folded cardboard, preventing closure. The fire doors on the 200 Hall were propped open with a chair on the right-side door and a Personal Protective Equipment (PPE) cart on the left side door preventing closure. 3. On 1/10/23 at 8:15 a.m., the Surveyor entered the double doors of the 300 Hall secured Dementia unit without entering a code on the code pad. After rounding on the hall, the Surveyor asked Certified Nursing Assistant (CNA) #2 for the code to exit the hall. She stated, You can just push the door. 4. On 1/10/23 at 8:27 a.m., the fire doors on the 400 Hall were propped open with folded cardboard preventing closure. The door of a storage room containing personal care items was propped open with a metal weight. 5. On 1/10/23 at 8:30 a.m., the Administrator stated, We are going through a renovation and then right before Christmas we had some pipes burst and flood the building. We never ran out of water. The pipes that burst were to the sprinkler system. The Surveyor asked, are the sprinklers working now? He answered, no we are doing fire watches. The Surveyor asked the Administrator to provide documentation of the fire watches. 6. On 1/10/23 at 9:15 a.m., the Surveyor asked the Administrator, have you notified Office of Long-Term Care (OLTC) of the issues with the sprinklers? He answered, No. From what I understand, we only have to notify the office for loss of water that affects the residents. The Surveyor asked, would this be considered an unusual occurrence? He answered, it is unusual. The Surveyor asked, what is the procedure for fire watches? He answered, we have a designated staff member who is assigned every shift who does not have any other duties assigned. They make rounds every 15 minutes and fill in the log. The Surveyor asked, who is assigned today? He answered, Hospitality Assistant #1. The Surveyor asked, why are all the fire doors propped open? He answered, because the alarm system is deactivated while the sprinklers are turned off. They kept notifying the fire department. The Surveyor asked, how is your dementia unit monitored to prevent elopement? He answered, the staff member who is assigned fire watches also watches the door to the unit. And the staff is also diligent. The Surveyor asked, is there a log for that door? He answered, It's all part of the fire watch. 7. On 1/10/23 at 9:40 a.m., The Facility Emergency Preparedness program which was provided by the Administrator on 1/10/23 at 9:15 a.m. showed, the Loss of Utilities Action Plan, In the event of extended interruptions, contact the local fire department as per the fire watch procedures. The Fire Watch policy documented, If the fire alarm system or sprinkler system goes out of service, a fire watch will be conducted immediately following the procedures below . In the event the fire alarm system goes out of service for more than 4 hours in a 24-hour period, call the authorities having jurisdiction . State Department of Health . Local Fire Department . State Fire Marshall Office . A fire watch is a temporary measure . by one or more trained individuals for controlling and identifying fire hazards, detecting early signs of unwanted fires, . and notifying the fire department . Staff will be designated for the sole purpose of fire watch (this is the only dedicated job they can have during this time) to physically inspect and complete 15 minute rounds and record findings .Every 15 minutes someone must physically inspect all spaces . including opening all locked and secured rooms . If the fire alarm system is not operating/sounding, then the code phrase 'Code F' will be communicated through the facility among staff, residents, and visitors . Upon initiation of a fire watch, this facility will adhere to a strict no smoking policy on or around the own properties - including outdoors, parking lot, or any other area on the owned property . 8. On 1/10/23 at 9:50 a.m., an observation of the fire alarm panel read, Silenced. The Surveyor asked Hospitality Assistant #1, have you been trained on fire watch? She answered, not really. I was told to go around every 15 minutes to look for fire and mark it on this sheet. The Surveyor asked, do you have any other duties when you are assigned to the fire watch? She answered, I pass ice and answer call lights. If someone needs something I let the nurse know. The Surveyor asked, do you know what Code F means? She answered, no. The Surveyor asked, do any residents in this facility smoke? She answered, yes. Some do. They have a smoking schedule. They smoke outside of the 400-hall end door. 9. A Fire Watch Log Sheet provided by the Administrator on 1/10/23 at 9:55 a.m. documented, The Fire Watch Log Sheet is to be maintained at the facility until the re-establishment of fire alarm service. The form did not include monitoring of the secure unit doors or exit doors for elopement. 10. On 1/10/23 at 10:15 a.m., the Surveyor asked the Administrator, have your staff who are assigned to fire watches been trained or in-serviced? He answered, No. Just verbal instructions. As you can see, I started the fire watches in the middle of the night. We have an in-service on January 27th, and this will be included in that training. The Surveyor asked, when are the sprinkler systems due to be repaired? He answered, International Fire Protection told me it could be anywhere between a week and a half and three weeks. They are waiting on a part. 11. On 1/10/23 at 10:30 a.m. the Surveyor asked Licensed Practical Nurse (LPN) #2, have you ever done fire watches here? She answered, no. The Surveyor asked, what do you do if there is a fire? She answered, the alarm will go off and the doors close. We secure the area and get a fire extinguisher. 12. On 1/10/23 at 10:35 a.m., the Surveyor asked Housekeeping Staff #1, have you ever done fire watches here? She answered, no. The Surveyor asked, what do you do if there is a fire? She answered, I'm new here. I know what you do at a hospital but I'm not sure what to do here. 13. On 1/10/23 at 10:40 a.m., the Surveyor asked CNA #1, have you ever done fire watches here? She answered, Yes. The Surveyor asked, what were you trained to do? She answered, check the red box and it tells us where the fire is. We evacuate the residents. Call over the phone Fire at such-and-such area. 14. On 1/10/23 at 10:45 a.m., the Surveyor asked LPN #1 have you ever done fire watches here? She answered, No. The Surveyor asked, what do you do if there is a fire? She answered, if the alarm goes off, check the board. Call code red over the intercom and say what area. But our phones are out at the nurse's station so we would have to call from some other phone. Get the fire extinguisher and check rooms and close the doors. The Surveyor asked, since your sprinklers aren't working and your alarm system isn't working, what do you do if there is a fire now? She answered, that's a good question. the Surveyor asked, do any residents here smoke? Yes. Outside the 400-Hall door. 15. On 1/10/23 at 1:10 p.m., the Life Safety Code Surveyor made fire watch rounds with Hospitality Assistant #1. On the 100 Hall there were 8 doors locked before room [named] and 2 locked doors by [named] rooms. She did not open those locked doors or check those rooms and check for fire. On 200 Hall 7 doors before [named] room were locked, 3 with codec pads, the rest had locks that required a key. She did not open those locked doors or check those rooms and check for fire. Room by [named] had a lock. Room by [named] was locked with a code pad. She did not open those doors and check those rooms for fire. On the 300 Hall outside the secured unit there were 2 rooms with keypads. She did not open those locked doors and check for fire. On the secured unit by the nurse station there were 2 rooms with locked doors, 1 with a code pad and 1 with a key. She did not open those locked doors and check for fire. On the 400 Hall there were 3 doors with code pads, 4 with locks, a mechanical room by [named], and a storage room by [named room] that were locked. She did not open those locked doors and check the rooms for fire. A male staff member in green scrubs was sitting outside the 400 Hall exit door smoking. It was noted the door to the storage supply room that contained care items on the 400 Hall was still propped open with the metal weight. The Surveyor asked, do you open all the locked doors? She answered, Yes. She walked past a locked door and without opening it she stated, I think that is a bathroom. The Surveyor asked, do you have keys to the locked doors? She answered, no. 16. On 1/10/23 at 3:00 p.m., the facility front door was standing open. Two staff members walked toward the door and exited the building, closing the door behind them. 17. On 1/10/23 at 3:55 p.m., the Surveyor asked the Administrator, have you notified OLTC (The Office of Long-Term Care) of the issues with the sprinkler system and fire alarms? He stated, I am writing a letter now and will send it to the office via email. I will copy all the information from the letter and paste it on a 7734 form and send to the office. 18. A Policy titled, Administrator provided by the Administrator on 1/11/23 at 7:55 a.m. documented, A licensed administrator is responsible for the day-to-day functions of the facility . The administrator is responsible for, but not limited to: . implementing established . policies and procedures necessary to remain in compliance with current laws, regulations and guidelines governing long term care facilities . 19. A Policy titled Hazardous Areas, Devices and Equipment, provided by the Administrator on 1/11/23 at 7:55 a.m. documented, All hazardous areas, devices, and equipment in the facility will be identified and addressed appropriately to ensure resident safety and mitigate accident hazards to the extent possible . Any element of the resident environment that has the potential to cause injury and that is accessible to a vulnerable resident is considered hazardous . Interventions will be accompanied by communication with staff and leadership, residents, family, and visitors . 20. On 1/11/23 at 8:35 a.m., the Surveyor asked CNA #3, who takes the residents to smoke? She answered, It's not assigned. Anyone can do it. The Surveyor asked, have you been told about any changes to the smoking activities today? She answered, No. 21. On 1/11/23 at 8:38 a.m., the Surveyor asked CNA #4, who takes the residents to smoke? She answered, It's not assigned. Anyone can do it. The Surveyor asked, have you been told about any changes to the smoking activities today? She answered, No. 22. On 1/11/23 at 9:10 a.m., the Surveyor asked the Administrator, should OLTC be notified in the event of any unusual occurrence? He answered, Yes ma'am. The Surveyor asked, should fire doors be propped open in a manner that would require more than one motion to close the door? He answered, Absolutely not. The Surveyor asked, what could happen? He answered, In the event of a fire, the doors may not close and there could be injury or loss of life. The Surveyor asked, should storage rooms containing care items be propped open and not monitored by staff? He answered, absolutely not. The Surveyor asked, what could happen? He answered, A resident could go in there and be harmed if they ingested a chemical or care item. The Surveyor asked, should there be a process in place to monitor exit doors and the secured unit doors in the event of the magnetic locks not functioning? He answered, Yes. The Surveyor asked, what could happen? He answered, There could be an elopement. The Surveyor asked, should the facility follow their own policy and procedures? He answered, Yes. The Surveyor asked, should staff members be adequately trained on all new and existing processes? He answered, Yes. The Surveyor asked, what could happen if they were not trained? He answered, It could lead to the injury of a resident. 23. The Immediate Jeopardy was removed on 1/10/23 at 3:55 p.m. when the facility implemented the following Plan of Removal: Step #1: Corrective Action: Upon notification to the facility on [DATE], the administrator notified [state] Department of Health by a letter of notice transmitted through email before 5:00pm (end of business) of the non-functioning fire alarm and sprinkler system. Upon notification to the facility on [DATE], at 12:45 p.m., the facility administrator verified that all fire doors could be easily and quickly closed in the event of a fire, the front entry door was closed, supply room storage door was closed, and at 1:30 pm, an employee was stationed at the secured unit entrance for monitoring access and egress to the 300 Hall unit. At 1:45 p.m., Administrator immediately begin reeducation on 1/10/2023 on the following: fire watch procedures and what to do in the event of a fire. All staff received education on emergency preparedness including what to do in the event of a fire on hire during orientation and required quarterly fire drills. Step #2: Identification of others with the potential to be affected: Administrator made fire watch rounds at 1:00 p.m. on 1/10/2023 with no negative findings. Census rounds also completed at 1:05 p.m. by Administrator on 1/10/2023 to ensure all residents are accounted for with no negative findings. Step #3: To ensure deficient practice does not occur: On 1/10/2023, at 4:15 p.m. the Administrator reeducated staff on fire watch procedures and what to do in the event of a fire as well as educating staff on q (every) 15-minute census rounds. Step 4: Monitoring: Administrator/designee will monitor staff preforming fire watches and q 15 min census rounds and verify documentation daily until fire alarm and sprinkler system in good working order. Administrator will also maintain weekly contact with [fire department] until repairs are completed. Step 5: QA: Administrator/designee will present findings to the monthly QA committee x (times)1 quarter for further review and recommendations.

Based on observation, record review and interview the facility failed to administer in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident as evidenced by the failure to notify the Office of Long-Term Care (OLTC) of the non-functioning fire alarm and sprinkler system. The failed practice resulted in Immediate Jeopardy, which caused or could have caused serious harm and/or injury to affect all 80 residents who resided in the facility, as documented on the Midnight Census Report which was provided by the Administrator on 1/10/23 at 9:15 a.m. The facility Administrator was notified of the Immediate Jeopardy on 1/10/23 at 12:00 p.m. The findings are: 1. On 1/10/23 at 8:00 a.m., the Surveyor entered facility through front entrance. The front door was standing open. There were no staff members present. A sign on the door documented, Please pull door closed. 2. On 1/10/23 at 8:05 a.m., the fire doors on the 100 Hall were propped open with folded cardboard, preventing closure. The fire doors on the 200 Hall were propped open with a chair on the right-side door and a Personal Protective Equipment (PPE) cart on the left side door preventing closure. 3. On 1/10/23 at 8:15 a.m., the Surveyor entered the double doors of the 300 Hall secured dementia unit without entering a code on the code pad. After rounding on the hall, the Surveyor asked Certified Nursing Assistant (CNA) #2 for the code to exit the hall. She stated, You can just push the door. 4. On 1/10/23 at 8:27 a.m., the fire doors on the 400 Hall were propped open with folded cardboard preventing closure. The door to a storage room that contained personal care items was propped open with metal weight. 5. On 1/10/23 at 8:30 a.m., the Administrator stated, We are going through a renovation and then right before Christmas we had some pipes burst and flood the building. We never ran out of water. The pipes that burst were to the sprinkler system. The Surveyor asked, are the sprinklers working now? He answered, no we are doing fire watches. The Surveyor asked him to provide documentation of the fire watches. 6. On 1/10/23 at 9:15 a.m., the Surveyor asked the Administrator, have you notified OLTC of the issues with the sprinklers? He answered, No. From what I understand, we only have to notify the office for loss of water that affects the residents. The Surveyor asked, would this be considered an unusual occurrence? He answered, It is unusual. The Surveyor asked, what is the procedure for fire watches? He answered, we have a designated staff member who is assigned every shift who does not have any other duties assigned. They make rounds every 15 minutes and fill in the log. The Surveyor asked, who is assigned today? He answered, Hospitality Assistant #1. The Surveyor asked, why are all the fire doors propped open? He answered, because the alarm system is deactivated while the sprinklers are turned off. They kept notifying the fire department. The Surveyor asked, how is your dementia unit monitored to prevent elopement? He answered, the staff member who is assigned fire watches also watches the door to the unit. And the staff is also diligent. The Surveyor asked, is there a log for that door? He answered, It's all part of the fire watch. 7. On 1/10/23 at 9:40 a.m., The Facility Emergency Preparedness program which was provided by the Administrator on 1/10/23 at 9:15 a.m. showed, The Loss of Utilities Action Plan, documented, In the event of extended interruptions, contact the local fire department as per the fire watch procedures. The Fire Watch policy documented, If the fire alarm system or sprinkler system goes out of service, a fire watch will be conducted immediately following the procedures below . In the event the fire alarm system goes out of service for more than 4 hours in a 24-hour period, call the authorities having jurisdiction . State Department of Health . Local Fire Department . State Fire Marshall Office . A fire watch is a temporary measure . by one or more trained individuals for controlling and identifying fire hazards, detecting early signs of unwanted fires, . and notifying the fire department . Staff will be designated for the sole purpose of fire watch (this is the only dedicated job they can have during this time) to physically inspect and complete 15 minute rounds and record findings .Every 15 minutes someone must physically inspect all spaces . including opening all locked and secured rooms . If the fire alarm system is not operating/sounding, then the code phrase 'Code F' will be communicated through the facility among staff, residents, and visitors . Upon initiation of a fire watch, this facility will adhere to a strict no smoking policy on or around the own properties - including outdoors, parking lot, or any other area on the owned property . 8. On 1/10/23 at 9:50 a.m., An observation of the fire alarm panel read, Silenced. The Surveyor asked Hospitality Assistant #1, have you been trained on fire watch? She answered, Not really. I was told to go around every 15 minutes to look for fire and mark it on this sheet. The Surveyor asked, do you have any other duties when you are assigned to the fire watch? She answered, I pass ice and answer call lights. If someone needs something I let the nurse know. The Surveyor asked, do you know what Code F means? She answered, No. The Surveyor asked, do any residents in this facility smoke? She answered, Yes. Some do. They have a smoking schedule. They smoke outside of the 400-Hall end door. 9. A Fire Watch Log Sheet provided by the Administrator on 1/10/23 at 9:55 a.m. documented, The Fire Watch Log Sheet is to be maintained at the facility until the re-establishment of fire alarm service . The form did not include monitoring of the secure unit doors or exit doors for elopement. 10. On 1/10/23 at 10:15 a.m., the Surveyor asked, have your staff who are assigned to fire watches been trained or in-serviced? He answered, No. Just verbal instructions. As you can see, I started the fire watches in the middle of the night. We have an in-service on January 27th, and this will be included in that training. The Surveyor asked, when are the sprinkler systems due to be repaired? International Fire Protection told me it could be anywhere between a week and a half and three weeks. They are waiting on a part. 11. On 1/10/23 at 10:30 a.m. the Surveyor asked Licensed Practical Nurse (LPN) #2 have you ever done fire watches here? She answered, No. The Surveyor asked, what do you do if there is a fire? She answered, the alarm will go off and the doors close. We secure the area and get a fire extinguisher. 12. On 1/10/23 at 10:35 a.m., the Surveyor asked Housekeeping Staff #1, have you ever done fire watches here? She answered, No. The Surveyor asked, what do you do if there is a fire? She answered, I'm new here. I know what you do at a hospital but I'm not sure what to do here. 13. On 1/10/23 at 10:40 a.m., the Surveyor asked CNA #1, have you ever done fire watches here? She answered, Yes. The Surveyor asked, what were you trained to do? She answered, check the red box and it tells us where the fire is. We evacuate the residents. Call over the phone Fire at such-and-such area. 14. On 1/10/23 at 10:45 a.m., the Surveyor asked LPN #1, have you ever done fire watches here? She answered, No. the Surveyor asked, what do you do if there is a fire? She answered, If the alarm goes off, check the board. Call code red over the intercom and say what area. But our phones are out at the nurse's station so we would have to call from some other phone. Get the fire extinguisher and check rooms and close the doors. The Surveyor asked, since your sprinklers aren't working and your alarm system isn't working, what do you do if there is a fire now? She answered, that's a good question. The Surveyor asked, do any residents here smoke? Yes. Outside the 400-Hall door. 15. On 1/10/23 at 1:10 p.m., the Life Safety Code Surveyor made fire watch rounds with Hospitality Assistant #1. On the 100 hall there were 8 doors locked before (named room) and 2 locked doors by [named] rooms. She did not open those locked doors or check those rooms and check for fire. On 200 Hall there were 7 doors before [named] room locked, 3 with codec pads, the rest had locks that required a key. She did not open those locked doors or check those rooms and check for fire. Room by [named] had a lock. Room by [named room] was locked with a code pad. She did not open those doors and check those rooms and check for fire. On the 300 Hall outside the secured unit there were 2 rooms with keypads. She did not open those locked doors and check those rooms and check for fire. On the secured unit by the nurse station 2 rooms with locked doors, 1 with code pad and 1 with a key. She did not open those locked doors and check those rooms and check for fire. On the 400 Hall there were 3 doors with code pads, 4 with locks, a mechanical room by [named room], and a storage room by [named room] that were locked. She did not open those locked doors and check the rooms for fire. A male staff member in green scrubs was observed sitting outside the 400 Hall exit door smoking. On the 400 Hall, the door to the storage supply area that contained care items was still propped open with the metal weight. The Surveyor asked, do you open all the locked doors? She answered, Yes. She walked past a locked door and without opening it she stated, I think that is a bathroom. The Surveyor asked, do you have keys to the locked doors? She answered, No. 16. On 1/10/23 at 3:00 p.m., the facility front door was standing open. Two staff members walked toward the door and exited the building and closed the door behind them. 17. On 1/10/23 at 3:55 p.m., the Surveyor asked the Administrator, have you notified OLTC (The Office of Long-Term Care) of the issues with the sprinkler system and fire alarms? He stated, I am writing a letter now and will send it to the office via email. I will copy all the information from the letter and paste it on a 7734 form and send to the office. 18. A Policy titled, Administrator provided by the Administrator on 1/11/23 at 7:55 a.m. documented, A licensed administrator is responsible for the day-to-day functions of the facility . The administrator is responsible for, but not limited to: . implementing established . policies and procedures necessary to remain in compliance with current laws, regulations and guidelines governing long term care facilities . 19. A Policy titled Hazardous Areas, Devices and Equipment, provided by the Administrator on 1/11/23 at 7:55 a.m. documented, All hazardous areas, devices, and equipment in the facility will be identified and addressed appropriately to ensure resident safety and mitigate accident hazards to the extent possible . Any element of the resident environment that has the potential to cause injury and that is accessible to a vulnerable resident is considered hazardous . Interventions will be accompanied by communication with staff and leadership, residents, family, and visitors . 20. On 1/11/23 at 8:35 a.m., the Surveyor asked CNA #3, who takes the residents to smoke? She answered, it's not assigned. Anyone can do it. The Surveyor asked, have you been told about any changes to the smoking activities today? She answered, no. 21. On 1/11/23 at 8:38 a.m., the Surveyor asked CNA #4, , who takes the residents to smoke? She answered, it's not assigned. Anyone can do it. The Surveyor asked, have you been told about any changes to the smoking activities today? She answered, no. 22. On 1/11/23 at 9:10 a.m., the Surveyor asked the Administrator, should OLTC be notified in the event of any unusual occurrence? He answered, Yes ma'am. The Surveyor asked, should fire doors be propped open in a manner that would require more than one motion to close the door? He answered, Absolutely not. The Surveyor asked, what could happen? He answered, In the event of a fire, the doors may not close and there could be injury or loss of life. The Surveyor asked, should storage rooms containing care items be propped open and not monitored by staff? He answered, Absolutely not. The Surveyor asked, what could happen? He answered, A resident could go in there and be harmed if they ingested a chemical or care item. The Surveyor asked, should there be a process in place to monitor exit doors and the secured unit doors in the event of the magnetic locks not functioning? He answered, Yes. The Surveyor asked, what could happen? He answered, There could be an elopement. The Surveyor asked, should the facility follow their own policy and procedures? He answered, Yes. The Surveyor asked, should staff members be adequately trained on all new and existing processes? He answered, Yes. The Surveyor asked, what could happen if they were not trained? He answered, it could lead to the injury of a resident. 23.The Immediate Jeopardy was removed on 1/10/23 at 3:55 p.m. when the facility implemented the following Plan of Removal: Step #1: Corrective Action: Upon notification to the facility on [DATE], the administrator notified the Department of Health by a letter of notice transmitted through email before 5:00 p.m. (end of business) of the non-functioning fire alarm and sprinkler system. Upon notification to the facility on [DATE], at 12:45 p.m., the facility administrator verified that all fire doors could be easily and quickly closed in the event of a fire, the front entry door was closed, supply room storage door was closed, and at 1:30 p.m., an employee was stationed at the secured unit entrance for monitoring access and egress to the 300 Hall unit. At 1:45 p.m., Administrator immediately begin reeducation on 1/10/2023 on the following: fire watch procedures and what to do in the event of a fire. All staff received education on emergency preparedness including what to do in the event of a fire on hire during orientation and required quarterly fire drills. Step #2: Identification of others with the potential to be affected: Administrator made fire watch rounds at 1:00 p.m. on 1/10/2023 with no negative findings. Census rounds also completed at 1:05 p.m. by Administrator on 1/10/2023 to ensure all residents are accounted for with no negative findings. Step #3: To ensure deficient practice does not occur: On 1/10/2023, at 4:15 p.m. the Administrator reeducated staff on fire watch procedures and what to do in the event of a fire as well as educating staff on q (every) 15-minute census rounds. Step 4: Monitoring: Administrator/designee will monitor staff preforming fire watches and q 15 min census rounds and verify documentation daily until fire alarm and sprinkler system in good working order. Administrator will also maintain weekly contact with [fire department] until repairs are completed. Step 5: QA: Administrator/designee will present findings to the monthly QA committee x (times)1 quarter for further review and recommendations.

Based on observation, interview, and record review, the facility failed to ensure a pressure ulcer to the left heel, and a wound to the penis were identified, treated, and assessed weekly for 1 (Resident #1) of 2 (Residents #1 and #2) sampled residents who had pressure ulcers. The failed practice resulted in Immediate Jeopardy which caused or could have caused serious harm, injury, or death to Resident #1, who had pressure ulcers to his left heel, and penis that weren't treated. This failed practice had the potential to affect six residents with pressure ulcers according to a list provided by the Director of Nursing (DON) on 10/05/22 at 1:07 P.M. The facility was informed of the Immediate Jeopardy on 10/04/22 at approximately 3:03 PM. The facility failed to ensure an infection to the right leg was identified and treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . The findings are: 1. Resident #1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Significant Change Minimum Data Set (MDS) with an Assessment Reference Date of 08/03/22 documented the resident was in a persistent vegetative state and/or no discernable consciousness and required extensive physical assistance of two plus persons for bed mobility and transfers, urinary continence was not rated, and was always incontinent of bowel, was at risk of developing pressure ulcers/injuries and had one unstageable pressure ulcer/injury. a. The Care Plan with a revision date of 8/11/22 documented, .Resident has hx [history] of multiple pressure ulcers, current stage 4 pressure ulcer to right hip . Evaluate pressure ulcer and document findings weekly and PRN [as needed] .Observe/report PRN signs/symptoms of infection .Notify DR [doctor] of abnormal findings .valuate wound/document for: Size, Depth, Margins . b. The Hospital Record dated 09/24/22 provided by the Administrator on 10/04/22 at 11:45 AM documented, .Date of service: 9/24/22 . Patient arrived via [Ambulance] from [Facility] with chief complaint of wound check. EMS [Emergency Medical Service] reported family requested they be called as they believe he is not receiving the care that he needed. Patient presents with several injuries - R [right] hip, both lower legs, coccyx region. Patient is on a [CONDITION(S)] collar at 4 L [liters] NC [nasal cannula], quadriplegic with a reported [CONDITION(S)] brain injury. He is completely nonverbal. Patient presented with a foley catheter; orders will be obtained from MD [medical doctor] .Called to room by nursing to evaluate new wound. After foley catheter was replaced, nurse noted a small, open wound to base of posterior penis . c. On 10/04/22 at 12:11 PM, the Treatment Nurse provided wound care for Resident #1. A pressure ulcer was observed to his right lower leg and left heel. Both areas were cleaned with wound cleansers. A loud foul odor was smelled when the foam borders were removed from the wounds. Iodosorb and a Silver Alginate dressing were applied to his right leg. The Treatment Nurse applied skin prep around the wound on the right leg, and then a foam border. The area on top of his left foot was cleaned with wound cleanser. He cleaned the left heel with wound cleaner, and applied skin prep around wound. Resident #1 had an unstageable pressure ulcer to his left heel. The Treatment Nurse applied Silver Alginate and a foam border dressing to the left heel. He cleaned the top of the left foot with wound cleanser, applied Silver Alginate and a foam border dressing. The Surveyor asked the Treatment Nurse, Can you lift [Resident #1's] penis so I can see the back of it. The Treatment Nurse raised up Resident #1's penis and a small open area was observed on the backside of the penis. d. On 10/04/22 at 12:53 PM, the Surveyor asked the Treatment Nurse, How long has [Resident #1] had the open area on his penis and the wound on his left heel? He stated, I didn't know about that one. No one informed me. e. On 10/04/22 at 12:57 PM, the Treatment Nurse returned to the Resident #1's room. He stated, I'm just going to clean it, and cover it until I talk to the APN [Advanced Practice Nurse]. f. On 10/04/22 at 1:00 PM the Treatment Nurse cleaned Resident #1 left heal with wound cleanser and applied an island dressing. g. As of 10/04/22 at 1:20 PM, the Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . h. On 10/04/22 at 1:59 PM, the Surveyor asked the Treatment Nurse, How long had [Resident #1] had a pressure ulcer on his left heel and his scrotum? He stated, Left heel to be honest they discovered it last night. Last Friday, I did rounds with the APN, and it was not there. We looked at it then and I did not see anything on his penis then. We didn't pick it up and look at his penis so I can't say it was there then. The Surveyor asked, When did you get the orders for his heels? He stated, Today. The Surveyor asked, Did you get the order for the heels and scrotum after you completed the treatment? He stated, Yes, she had me to remove the dressing, and we're going to paint it with [MEDICATION(S)]. We are going to apply boots and offload his heels. The Surveyor asked, How long have you been doing his treatments? He stated, About 2 months. The Surveyor asked, What days do you do treatments? He stated, On Fridays I come in and do rounds with the APN. The Surveyor asked, Did you do a skin assessment Friday? He stated, No, I was off, and the APN was off too. The Surveyor asked, Is there a reason why the boots weren't ordered if you noticed that his left heel was soft? He stated, We should have, but I called the APN and we're going to get it started today. I know you smelled it, but I called the APN. We sent off a culture for his right lower leg. i. The Lab Results Report dated 10/04/22 documented, .Collection Date 10/04/22 14:20 [2:20 PM] .Wound Culture .Site .Leg, right: Moderate Gram-Positive Cocci . j. The Weekly Wound Note dated 10/04/22 at 14:44 (2:44 PM) provided by the Treatment Nurse on 10/04/22 at 3:40 PM documented, .Fistula secondary to indwelling catheter . Onset Date: 10/04/22 . Length (cm [centimeters]) 1.2 . Width (cm) 0.4 . Depth (cm) 0.4 . Site: Left Heel, Type: Pressure, Stage: Unstageable . k. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Order summary: Paint left heel w [with] [MEDICATION(S)] air dry and put on heel protector boots . l. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .Order summary: Paint fistula penile shaft w/ TAO [Triple antibiotic ointment] daily and prn for fecal contamination every 8 hours as needed for fecal contamination to be done post BM [bowel movement] and every day shift . m. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .Order summary: Wound culture RT [right] lower leg one time only for wound odor . n. On 10/05/22 at 9:30 AM, the Surveyor asked Licensed Practical Nurse (LPN) #1, How long has [Resident #1] had open areas on his penis and his left heel? She stated, I didn't know about his penis, his heel was last week. I haven't been here in a couple of months. I was just as surprised as you were. I feel like it was between Friday and Monday. o. On 10/05/22 at 10:40 AM, the Surveyor asked LPN #2, How long has [Resident #1] had open areas on his penis and his left heel? She stated, I didn't know he had any. The Surveyor asked, Who's responsible for wound care? She stated, Our treatment nurse, and if the treatment nurse isn't here it would be the nurse on the floor. p. On 10/05/22 at 11:00 AM, the Surveyor asked LPN #3, Do you ever provide wound care for [Resident #1]? She stated, Yes, I have when we don't have a treatment nurse. The Surveyor asked, How long has [Resident #1] had open areas on his penis and his left heel? She stated, I didn't know about that until yesterday. q. On 10/05/22 at 11:25 AM, the Surveyor asked Certified Nursing Assistant (CNA) #3, Do you ever assist the treatment nurse when they are doing wound care for [Resident #1]? She stated, No ma'am they usually have another person with him. The Surveyor asked, Do you have to give him a shower or a bath? She stated, Yes ma'am. The Surveyor asked, How long has [Resident #1] had open areas on his penis and his left heel? She stated, I really don't know how long he's had it. I usually don't work with him like that. r. On 10/05/22 at 12:40 PM, the Surveyor asked the Director of Nursing (DON), How long has [Resident #1] had open areas on his penis and his left heel? She stated, I'm unsure. The Surveyor asked, When were you informed about the wounds on his penis and left heel? She stated, It may have been yesterday morning. The Consultant said he had an area on his penis. His foot, the nurse that worked Monday had documented something about his heel. The Surveyor asked, Did the nurse inform the doctor? She stated, I don't believe so. 2. The facility policy titled, Pressure Ulcers/Skin Breakdown-Clinical Protocol, provided by the Administrator on 10/05/22 at 10:38 AM documented, Assessment and Recognition . 2. In addition, the nurse shall describe and document/report the following: a. Full assessment of pressure sore including location, stage, length, width and depth, presence of exudates or necrotic tissue . Treatment/Management 1. The physician will order pertinent wound treatments, including pressure reduction surfaces, wound cleansing and debridement approaches, dressings (occlusive, absorptive, etc. [etcetera]), and application of topical agents . 2. The physician will help identify medical interventions related to wound management; for example, treating a soft tissue infection surrounding an ulcer, removing necrotic tissue, addressing comorbid medical conditions . Monitoring 1. During resident visits, the physician will evaluate and document the progress of wound healing-especially for those with complicated, extensive, or poorly-healing wounds . 3. The facility policy titled, Wound Care, provided by the Administrator on 10/05/22 at 10:38 AM documented, . Documentation The following information should be recorded in the resident's medical record: 1. The type of wound care given. 2. The date and time the wound care was given . 4. The name and title of the individual performing the wound care . 6. All assessment date ( .wound bed color, size, drainage, etc.) obtained when inspecting the wound . 4. The Immediate Jeopardy (IJ) was removed on 10/04/22 at 4:06 PM, when the facility implemented the following Plan of Removal: Step #1: Corrective Action: A. Upon notification to the facility on [DATE], the nurse consultant performed a head to toe assessment on Resident to ensure all pressure ulcers were identified, assessed, and appropriate treatments are in place. Step#2: Identification of others with the potential to be affected: On 10/04/22, the DON initiated head to toe assessments for all residents residing in the facility to ensure there were no unidentified wounds and will be completed 10/4/2022. Any negative findings will be corrected immediately by DON/designee. Step #3: To ensure deficient practice does not occur: On 10.04/22, the DON/designee initiated inservices for the following for all nursing staff: a. Completion of accurate head to toe skin checks weekly on all residents. b. Completion of head to toe skin check upon admission/readmission to the facility. Step 4: Monitoring DON/designee through EMR [Electronic Medical Record] review will audit daily to ensure weekly skin checks are being completed timely for all residents. DON/designee will complete 5 body audits weekly for comparison to ensure accurate assessments are being completed. Monitoring will be documented on monitoring calendar and negative findings will be corrected immediately by Administrator/designee. Step 5: QA [Quality Assurance] Administrator/designee will present findings to the monthly QA committee x1 quarter for further review and recommendations.

Complaint # (AR 050) was substantiated, all or in part, with these findings. Based on observation, record review and interview, the facility failed to ensure adequate supervision was provided to prevent accidents, as evidenced by failure to ensure staff utilized and maintained a mechanical lift in accordance with manufacturer's instructions, which resulted in a lift accident with injury for 1 (Resident #1); and failure to ensure the cause of the accident was fully investigated, to include a review of the manufacturer's instructions, which resulted in failure to identify all contributing factors and an ongoing failure of staff to correctly utilize the lift to prevent further potential accidents for 3 (Residents #1, #3, and #4) of 5 (Residents #1 - #5) case mix residents who required a mechanical lift for transfers. These failed practices resulted in Immediate Jeopardy, which caused or could have caused serious harm, injury or death to Resident #1, who was being transferred via mechanical lift when the lift tipped over, causing the resident to fall to the floor and sustain a fractured ankle, and had the potential to cause more than minimal harm to 13 residents who required mechanical lift transfers, as documented on a list provided by the Administrator on 2/13/18 at 3:01 p.m. The Administrator was informed of the Immediate Jeopardy condition on 2/13/18 at 1:45 p.m. The findings are: 1. The User Manual for the Invacare Reliant 450 RPL450-2 mechanical lift documented, WARNING: When using an adjustable base lift, the legs MUST be in the maximum Opened/Locked position before lifting the patient . Invacare does not recommend locking of the rear casters of the patient lift when lifting an individual. Doing so could cause the lift to tip and endanger the patient and assistants. Invacare does recommend that the rear casters be left unlocked during lifting procedures to allow the patient lift to stabilize itself when the patient is initially lifted from a chair, bed or any stationary object . After the first year of use, the hooks of the hanger bar and the mounting brackets of the boom should be inspected every three months to determine the extent of wear . Casters and axle bolts require inspections every six months to check for tightness and wear . Regular maintenance of patient lifts and accessories is necessary to assure proper operation . The manual also documented that if the lift was used in an institutional setting, the caster base, mast, boom, hanger bar, [MEDICATION NAME] assembly, slings and hardware were to be inspected and adjusted monthly. 2. Resident #1 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/18/17 documented the resident scored 9 (8-12 indicates moderately impaired) on a Brief Interview for Mental Status (BIMS) and was totally dependent on the assistance of two or more people for transfers. a. The Care Plan dated 2/5/18 documented, 4/11/17 - Needs assistance with ADLs (Activities of Daily Living) . Assist with transfers as needed . using total lift. b. An Incident/Accident Report dated 2/5/18 at 2:00 p.m. documented, Called to resident room by CNA (Certified Nurse Assistant) and notified that lift had fallen over with resident in it. Noted resident to be seated on floor beside lift and bed . Based on the gathered facts, what may have caused the event to occur? Loose legs to lift . What immediate interventions have you initiated to prevent this event from occurring again? Maintenance to assess lift, lift pad size, Hoyer lift removed from service. c. The Office of Long Term Care (OLTC) Incident and Accident Report, Division of Medical Services (DMS) form 7734, dated 2/5/18 documented, LPN (Licensed Practical Nurse) was called to resident's room at approximately 2:00 p.m. by (Certified Nursing Assistant (CNA) #1) and (CNA #2). The nurses' assistants reported to (LPN #1) that the lift had fallen over with the resident in it. When the nurse arrived, the resident was seated on the floor between lift and bed. (CNA #1) stated 'Around 2 p.m. we were getting (Resident #1's) weight. As I was pulling her back from the wheelchair, the lift tilted over on the side. Reported it to nurse and lifted her off the floor with lift and back into bed.' (CNA #2) stated, 'I was helping get the weight of the resident with the lift and as we turned it to put her back in the bed it tilted over. I stayed with the resident while the other person went for help. The nurse came, and we got her back in bed with the lift.' LPN notified the DON (Director of Nursing) of the incident at 3:30 p.m. Upon DON assessment of the resident, the resident stated that she hit her head, and had pain to the right side of her head. Unable to describe pain at this time on a 0-10 scale. Resident noted to be holding the right side of her head, moaning, and had facial grimacing. Also, the DON noted that resident had swelling and redness to left medial ankle area. When touched resident stated, 'Ouch that hurts'. Had facial grimacing and moaning. Notified . APRN (Advanced Practice Registered Nurse) of finding and resident was sent to (hospital) emergency department. When the DON asked the CNAs what happened they stated that the lift pad moved out of place at the bottom when they were transferring her. They also stated that the legs were partially closed on the lift during transfer . 1:1 inservice with CNAs on proper technique, sling size, lift function and maintenance. CNAs involved suspended pending investigation. All residents who use a lift assessed for proper sling size by physical therapy and DON. All CNAs checked off on lift technique, sling size, and maintenance of lift by DON/designee. All lifts in facility checked for proper functioning by the maintenance director, physical therapy, DON, and administrator. The lift that was involved with the resident fall was noted to have loose base legs when the lift was in the closed and open position. The lift was an Invacare Reliant 450. It was removed from commission until fixed or replaced. Inservice given to all staff on abuse and neglect. d. A hospital X-ray report dated 2/5/18 documented, Left ankle . Findings and Impression: Obliquely oriented mildly displaced intra-articular [MEDICAL CONDITION] malleolus is seen. Remote trauma to the deltoid ligament attachment sites of the medial malleolus and medial talar processes are seen . e. On 2/12/18 at 2:00 p.m., the resident was lying in bed. She was asked if she had recently been involved in an incident with the lift and stated, Yes. She then pulled back the covers to show that her left leg and foot was wrapped and had what appeared to be a splint. The resident stated, The lift fell on me. He knows he was going too fast . f. On 2/12/18 at 2:55 p.m., LPN #1 was asked what happened with Resident #1 on 2/5/18 and stated, (CNA #1) came and got me and said the lift had fallen over with (Resident #1). I went down there, and she was sitting in the floor. The other CNA was helping to hold her head up. I assessed her where she was and didn't see anything wrong with her, so we put her back in bed. Later there was some ankle swelling, so we sent her out to the ER (emergency room ). He was asked about the position of the lift and the lift pad when he entered the room and stated, The lift was upright when I went in the room, and the lift pad was under her. I think they took that lift out of commission, because the legs were loose or something. g. On 2/12/18 at 3:08 p.m., CNA #1 was asked what happened with Resident #1 on 2/5/18 and stated, I was in the room getting the resident's weight and the other CNA was with me. Everything was good. We had her hooked up right. When we turned to put her back in bed, the lift tilted and turned over, with her in it. The CNA was asked what happened to make the lift turn over. The CNA stated, I can't say what happened. All I know is, once we turned her, all that weight . I don't know. I don't know if the lift pad slid or what. I was shocked. The CNA was asked about the color (size) of the pad and stated, It was blue, I believe. And I think that's extra-large. It just happened so fast. The CNA was asked about the statement that was documented on the investigation, regarding 'the lift pad moved out of place at the bottom' and stated, I didn't see her slip in the pad. The CNA was asked whether the lift legs were in the open position or closed position and stated, The legs were open, because the lift won't fit up under her chair if they're not. The CNA was asked about the statement in the investigation regarding 'the legs were partially closed on the lift during transfer' and stated, No, as far as I know, the legs were open. The CNA was asked if he locked the rear casters on the base of the lift when he was lifting the resident and stated, We lock the wheels on the lift until we get ready to move them to the bed. The CNA was asked if he locks the casters as the resident is being lifted and he stated, Yes, so there's no movement. The CNA was asked if he had been trained on how to use a lift prior to the incident on 2/5/18 and stated, Yes. I have been doing this a long time, and this ain't ever happened to me. He was asked if he had been in-serviced since the incident and stated, Yes, and had to do return demonstration. h. On 2/12/18 at 3:20 p.m., CNA #2 was asked what happened with Resident #1 on 2/5/18 and stated, We went in the room. (CNA #1) was going to help me put her in the bed because he needed a weight. He lifted her and as we turned, she just flipped. We tried to stop it but couldn't. She hit the floor. I stayed with her, and he got the nurse. The CNA was asked what happened to make the lift turn over and stated, I am not sure. It happened really fast. The CNA was asked about the statement that was documented in the investigation regarding 'the lift pad moved out of place at the bottom' and stated, I told the DON that I wonder if someone pulled her up in the dining room and maybe that moved the lift pad. I thought I was seeing her come out the bottom of the pad before the lift tilted, but (CNA #1) said he didn't see that, so I don't know. The CNA was asked about the color (size) of the pad being used and she stated, It is blue, I think. The CNA was asked if the lift legs were in the open position or closed position and stated, They were spread open. If they're not, it won't go up under her wheelchair. The CNA was asked about the statement in the investigation regarding 'the legs were partially closed on the lift during transfer ' and stated, I don't remember saying anything like that. The CNA was asked if the rear casters on the base of the lift were locked during the transfer procedure and stated, I'm not sure, but he probably did, because he needed a weight. But sometimes, we do lock the wheels. Like, there's a resident who shakes a lot, so we lock the wheels as she is going up to keep it from moving. The CNA was asked if she had been trained on how to use a lift prior to the incident on 2/5/18 and stated, Yes, and it's been redone since then. i. On 2/12/18 at 3:40 p.m., CNA #1 and #2 were asked to demonstrate how they transferred the resident with the mechanical lift that was used on 2/5/18. The demonstration was done in an empty room without a resident in the lift. There was no problem observed at this time. j. On 2/12/18 at 3:58 p.m., the Maintenance Director was asked if there was anything wrong with the mechanical lift that was involved in the incident on 2/5/18 and stated, The lift was taken outside, and they told me it was rocky. The Maintenance Director was asked who 'they' were and he stated, I can't remember. Somebody took it outside and said that. The Maintenance Director was asked what he meant by the lift being 'rocky' and stated, Loose. Like the legs. They weren't so loose that the bolt was about to fall out, but I tightened them up and put a washer on them. The Maintenance Director was asked what kind of routine checks he did on the lifts in the facility and stated, Before the new company took over (2/1/18), if someone told me about a problem I just went and fixed it. But now, I check them monthly. The Maintenance Director was asked if there was not a system in place to check for things like loose base legs on the lift prior to 2/1/18 and stated, That's right. He was asked if anyone had reported a problem to him about the lift in question and he stated, No. The Maintenance Director was asked how long he had been the Maintenance Director and he stated, Since June 2017. k. On 2/13/18 at 11:19 a.m., CNAs #1, #3 and #4 transferred Resident #1 from the bed to a Broda chair using a mechanical lift. CNA #3 was operating the lift. The lift pad was positioned underneath the resident and the lift base was pushed underneath the bed with the base legs closed. The rear casters of the base were locked at this time. The pad loops were then connected to the hooks of the hanger bar and the resident was raised with the rear casters still locked. The casters were then unlocked and the lift was pulled out from underneath the bed. The base legs were placed in the open position, but when the lift was turned to go toward the Broda chair, the base legs went back to the closed position. CNA #3 stated to CNA #1, The legs just closed up on their own. The CNA opened them again and pushed the lift to position the resident over her Broda chair. The base legs were locked, and the resident was lowered into the chair. l. On 2/14/18 at 9:56 a.m., the Administrator was asked how she became aware of the incident involving Resident #1 and stated, I was notified by the DON that the lift had tipped. The lift was removed from service. All of the lifts were pulled so we could look at them and we started an inservice right away. The Administrator was asked if the facility identified at that time that staff was locking the casters during the lifting of the residents and stated, No, not until yesterday. The Administrator was asked when the lift was purchased by the facility and stated, 2009. m. On 2/14/18 at 10:25 a.m., the DON was asked about the incident involving Resident #1 and stated, I immediately had them show me what happened. Then I went and assessed her. She was holding her head and I asked her if she hit her head and she said 'yes'. Then I noticed her ankle was swollen. I had her sent out, and then her daughter called and said her ankle was broken. Reassessments were done on everyone and a reportable was started. The DON was asked if the facility identified that staff was locking the rear casters of the lift during the lifting of residents and stated, No. The DON was asked about the statements in the facility's investigation about the CNAs stating that the legs of the lift were partially closed and the lift pad moved and stated, I wrote down what they told me. 3. Resident #3 had [DIAGNOSES REDACTED]. The Annual MDS with an ARD of 12/19/17 documented the resident was severely impaired in cognitive skills for daily decision making per a Staff Assessment of Mental Status (SAMS) and was totally dependent on the assistance of two or more people for transfers. a. The Care Plan dated 12/20/17 documented, Requires total assistance with ADLs . OOB (out of bed) daily into high back wheelchair as tolerated using total lift. b. On 2/13/18 at 10:44 a.m., CNAs #1 and #4 transferred the resident from bed to a wheelchair using the mechanical lift. CNA #4 was operating the lift. The lift pad was positioned underneath the resident and the lift base was pushed underneath the bed with the base legs closed. The rear casters of the base were locked at this time. The pad loops were then connected to the hooks of the hanger bar, and the resident was raised with the rear casters still locked. The casters were then unlocked and the lift was pulled out from underneath the bed. The base legs were placed in the open position and the CNA pushed the lift to position the resident over the wheelchair. The base legs were again locked, and the resident was lowered into the wheelchair. 4. Resident #4 had [DIAGNOSES REDACTED]. The Quarterly MDS with an ARD of 12/21/17 documented the resident scored 3 (0-7 indicates severely impaired) on a BIMS and was totally dependent on two or more people for transfers. a. The Care Plan dated 12/22/17 documented, 4/14/17 - Is at risk for falls with a history of falls with decreased mobility to right side from [MEDICAL CONDITION] . Approach . Transfer assist of two using total lift. b. On 2/13/18 at 11:45 p.m., CNAs #2 and #5 transferred the resident from the bed to a wheelchair. CNA #5 was operating the lift. The lift pad was positioned underneath the resident and the lift base was pushed underneath the bed with the base legs closed. The rear casters of the base were locked at this time. The pad loops were then connected to the hooks of the hangar bar and the resident was raised with the rear casters still locked. The casters were then unlocked, and the lift was pulled out from underneath the bed. The base legs were placed in the open position and the CNA pushed the lift to position the resident over the wheelchair. The base legs were left unlocked as the resident was lowered into the wheelchair. 5. On 2/13/18 at 10:55 a.m., an Invacare representative was asked during a telephone interview if the Reliant 450 lift would tip over if used correctly. The representative stated, That should not happen if it's being used properly. 6. The Immediate Jeopardy was removed and the scope and severity was lowered to G on 2/13/18 when the facility implemented the following plan of removal: a. Goal / objective: Lift maintenance will be completed appropriately per manufacturer's guidelines. 1.) Administrator will in-service Maintenance Director on manufacturer's guidelines regarding lifts, lock out / tag out procedure, and monthly maintenance to be completed on lifts on 2/13/18 at 2:10 p.m. Person responsible - Administrator. Target date of completion - 2/13/18. 2.) Maintenance Director will complete and maintain monthly checks and maintenance on lifts on 2/13/18 at 2:15 p.m. prior to releasing for resident care, per manufacturer's guidelines and then every month. Person responsible - Maintenance Director. Target date of completion - 2/13/18 and ongoing thereafter. 3.) Maintenance Director will ensure any lifts removed from facility use by lock out / tag out procedure are kept secure until repaired and in proper working condition effective 2/13/18 at 2:10 p.m. Person responsible - Maintenance Director. Target date of completion - 2/13/18. 4.) Administrator will monitor maintenance logs (lift inspection form) for accuracy and completion monthly. Person responsible - Administrator. Target date of completion - 2/13/18. b. Goal/Objective: Facility staff will provide supervision of lift procedure to prevent accidents and environment remains as free of accident hazards as possible for all residents, including (Residents #1, #3 and #4). 1.) Facility lifts will be removed from resident care 2/13/18 at 1:49 until staff competencies have been verified. Person responsible - DON/Designee. Target date of completion - 2/13/18 at 1:49 p.m., completed at 2:00 p.m. 2.) DON/Designee will educate all present nursing staff by watching Invacare Lift Video on 2/13/18 beginning at 2:00 p.m. Staff will then complete return demonstration checkoff with DON/Designee, ensuring that prior to using lift for resident transfers, and caster wheels are to not be locked during the lift of the resident. Only lock the caster wheels when applying and removing the sling before and after the lift transfer. Person responsible - DON/Designee. Target date of completion - 2/13/18. 3.) DON/Designee will educate all subsequent scheduled nursing staff by watching Invacare Lift Video prior to schedule shift change. Staff will then complete return demonstration checkoff with DON/Designee ensuring that prior to using lift for resident transfers, and that caster wheels are to not be locked during the lift of the resident. Only lock the caster wheels when applying and removing the sling before and after the lift transfer. Person responsible - DON/Designee. Target date of completion - 2/13/18 and ongoing thereafter. 4.) DON/Designee will educate all nursing staff currently on vacation, FMLA (Family Medical Leave Act) or LOA (Leave of Absence) prior to returning to work by watching Invacare Lift Video prior to schedule shift change. Staff will then complete return demonstration checkoff with DON/Designee ensuring that prior to using lift for resident transfers, and that caster wheels are to not be locked during the lift of the resident. Only lock the caster wheels when applying and removing the sling before and after the lift transfer. Person responsible - DON/Designee. Target date of completion - 2/13/18. 5.) DON/Designee will educate all new nursing staff during orientation prior to working in resident care by watching Invacare Lift Video prior to schedule shift change. Staff will then complete return demonstration checkoff with DON/Designee ensuring that prior to using lift for resident transfers, and that caster wheels are to not be locked during the lift of the resident. Only lock the caster wheels when applying and removing the sling before and after the lift transfer. 6.) DON/Designee will educate all nursing staff annually watching Invacare Lift Video and return demonstration checkoff ensuring that when using lift for resident transfers, and that caster wheels are to not be locked during the lift of the resident. Only lock the caster wheels when applying and removing the sling before and after the lift transfer. 7.) DON/Designee will educate all facility staff regarding lock out/tag out procedure on 2/13/18 at 2:00 p.m. 8.) DON/Designee will monitor, beginning 2/13/18, three resident lift transfers five times per week x (times) 4 weeks, then 3 resident lift transfers 3 times per week x 2 weeks, then 3 resident lift transfers 1 time per week x 2 weeks or until compliance is met (verified) by OLTC. Any negative findings will be corrected immediately and presented to weekly QA (Quality Assurance) committee for further review and recommendations.

Complaint # (AR 910) was substantiated, all or in part with these findings. Based on observation, record review and interview, the facility failed to ensure bedside rails (side rails) that had hazardous protrusions, broken areas and / or sharp edges were promptly removed, repaired, or replaced to prevent injuries for 2 (Residents #1 and #2) and potential injuries for 2 (Residents #3 and #4) of 6 case mix residents (Residents #1 through #6) who had side rails in place on their beds. This failed practice resulted in a pattern of actual harm to Residents #1 and #2, who sustained lacerations and skin tears to their lower extremities, and had the potential to affect 47 residents who had side rails that were not actually in use but were installed on their beds and 27 residents who utilized side rails, according to a list provided by the Director of Nursing (DON) on 1/25/18. The findings are: 1. Resident #1 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/4/17 documented the resident scored 3 (0-7 indicates severe cognitive impairment) on a Brief Interview for Mental Status (BIMS), required extensive assistance of one person for bed mobility and transfer, had functional limitation in range of motion in the upper extremity on one side and the lower extremities on both sides, and had no documented skin problems. a. The Office of Long Term Care (OLTC) Incident and Accident Report (I&A) dated as submitted on 1/7/18 documented. Summary of Incident: CNA (Certified Nursing Assistant) was transferring (Resident #1) from her wheelchair to the bed. When the CNA raised the resident's legs to place them in the bed, she started screaming The CNA looked down and noticed blood coming from the right, lateral, lower shin area . (Ambulance company) here at 145 pm (1:45 p.m.) to transfer resident to (hospital) ER (emergency room ) for evaluation . Upon investigation of the room and bed, LPN (Licensed Practical Nurse) and DON (Director of Nursing) identified a broken piece of resident's bed with sharp edge. There was dried blood noted to the frame of the bed and a small amount noted below the sharp edge of the side rail on the floor . During the transfer, resident scraped her leg on the broken part of the side rail of the bed, causing the laceration to her right, lateral, lower shin area .Resident immediately assessed for further injury. CNA was in serviced one on one about proper transfers. All staff in serviced on proper transfers. Maintenance Supervisor to fix broken part of bed immediately. Maintenance supervisor to audit all bed frames and side rails for proper functionality . b. The hospital record dated 1/7/18 documented, .14 cm (centimeter) laceration to R (right) lateral tib (tibia) fib (fibula) . presents with a large laceration to the right lateral lower leg that she sustained in unknown fashion .She came from the nursing home for evaluation. Her wound was repaired and .Keflex (antibiotic) 500 mg (milligram) capsule was ordered. c. Nurses Notes dated 1/14/18 at 8:19 a.m. documented, Notified by CNA of resident on floor. Observed resident lying on left side of bed on floor .Skin tear observed to left shin .APN (Advanced Practice Nurse), DON (Director of Nursing) and Administrator notified. d. A Resident Incident Report dated, 1/14/18 at 6:00 a.m. documented, Notified by CNA of resident on floor . Skin tear observed to left shin, 5 cm (centimeters) (by) 10 cm. Immediate post-incident action: Replaced bed in resident's room due to defective left side rail . e. On 1/24/18 at 8:50 a.m., the side rail on the right side of the resident's bed had sharp, rough edges on the plastic trim at the top of the side rail. f. On 1/24/18 at 8:50 a.m., CNA #1 was asked to describe Resident #1's right side rail. She felt the side rail and stated .kinda (kind of) rough and scratched. She was asked, Do you think it could injure a resident? She stated Yes. g. On 1/24/18 at 9:00 a.m., the Administrator was asked to inspect the resident's side rail. The Administrator felt the resident's side rail and stated there was, .a little place, a bump, raised, a little sharp on one side. She was asked if the sharp edge could injure a resident and stated, Yes. h. On 1/24/18 at 9:08 a.m., the Director of Nursing (DON) was asked to describe Resident #1's side rails. She stated, Rough around the edges. The Maintenance Man was to replace the rails. i. On 1/25/18 at 11:25 a.m., the Administrator was asked if, prior to Resident #1's leg injury on 1/7/18, the facility had any type of inspection / audit system in place to ensure the side rails were maintained. She stated, No, not before January 7, 2018. I did do an in-service with the Maintenance Supervisor on 1/7/18. 2. Resident #2 had [DIAGNOSES REDACTED]. A Significant Change MDS with an Assessment Reference date of 10/27/17 documented the resident was moderately impaired in cognitive skills for daily decision making on the staff assessment for mental status, required extensive assistance with two plus people for bed mobility, limited assistance with one person for transfer and had no documented skin conditions. a. A Resident Incident Report dated 9/13/17 at 6:40 a.m. documented, Two CNAs were in the process of transferring (Resident #2) from w/c (wheelchair), wheels were locked, while transferring resident, (Resident #2) began to lose balance . while being sat down, (Resident #2) bumped her right leg against bed rail. CNAs notified nurse that resident started bleeding from right lower leg .orders send resident to (Hospital) . b. The hospital record dated 9/13/17 documented, [DIAGNOSES REDACTED]. Patient has laceration to the right leg under the knee . c. The Resident Incident Report dated 10/25/17 at 7:30 p.m. documented, Resident observed with skin tear to left lower shin . Transported to ER for stitches . Narrative of investigation: Upon investigation, it appears that resident may have hit leg on side rail and caused the skin tear. The rail is missing plastic cover piece. 3. Resident #4 had [DIAGNOSES REDACTED]. A Quarterly MDS with an ARD of 12/15/17 documented the resident scored 4 (0-7 indicates severely impaired) on a BIMS, was independent in bed mobility and required supervision only for transfer. a. The Care Plan dated 12/18/17 documented, .Hx (history) of skin tears . b. On 1/24/18 at 9:30 a.m., LPN #1 accompanied the surveyor to Resident #4's room to observe the side rails. The lower section of the left side rail had a broken area with a sharp edge. LPN #1 was asked, Do you feel anything that would be a concern? She stated, Yes. She was asked, Do you feel it could cause injury? She stated, Yes, I am going to take care of that right now. c. On 1/24/18 at 9:35 a.m., the DON and the Administrator accompanied the surveyor to Resident #4's room. A piece of tape had been placed over the sharp edge of the side rail. The Administrator and DON were asked to feel the resident's side rails. The Director of Nursing stated, There is a piece of tape on the left lower side rail, but it is broken with a sharp edge. The Director of Nursing was asked, Do you feel like that could cause injury? She stated Yes. 4. Resident #3 had [DIAGNOSES REDACTED]. The Quarterly MDS with an ARD of 12/25/17 documented the resident scored 14 (13-15 indicates cognitively intact) on a BIMS and was independent with bed mobility and transfer. a. The Care Plan dated 10/26/17 documented, .Has a skin tear to left lower leg . 12/8/17 Noted skin tear from previous skin tear to right lower leg reopened . Cleanse skin tear to left lower leg with normal saline or wound cleanser, pat dry, apply skin prep . b. On 1/24/18 at 9:45 a.m., Resident #3's side rails were inspected. The left side rail was in the raised position, and the lower section of the plastic trim was split in half, leaving a rough area exposed. The right side rail was in the raised position, and the plastic trim-piece was missing, leaving a rusted metal area exposed. c. On 1/24/18 at 9:46 a.m., the DON was asked to describe Resident #3's side rails. She stated, It is broken on the left side. The second protector is missing and rusty. I will have maintenance to remove the side rails; he was supposed to have checked the side rails on everybody. 6. On 1/25/18 at 2:30 p.m., the Administrator stated the Maintenance Supervisor was not available for interview, because he had been suspended and was sent home until further notice.

Complaint # (AR 597) was substantiated, all or in part, with a deficiency cited at F309. Based on observation, record review and interview, the facility failed to ensure necessary care and services were provided for management of non-pressure-related wounds, as evidenced by: Failure to consistently conduct and document thorough weekly wound assessments to allow tracking of healing progress or prompt identification of deterioration of wounds for 3 (Residents #11, #14 and #16) of 15 (Residents #2, - #9, #11, #13, - #17 and #19) case mix residents who had wounds; Failure to consistently provide the physician-ordered wound treatments and / or only document the treatments as administered when the treatments were actually provided, in order to prevent potential deterioration and promote healing of wounds and allow accurate determination of whether current treatment orders were effective for 5 (Residents #8, #9, #11, #13, #16) of 15 (Residents #2, - #9, #11, #13, - #17 and #19) case mix residents who had physician orders [REDACTED]. Failure to provide the correct, most recently ordered wound treatment to promote healing for 1 (Resident #8) of 1 case mix resident who had a physician order [REDACTED]. These failed practices resulted in actual harm to Residents #9, #8 and #11, whose wounds deteriorated or failed to improve, and had the potential to affect 39 residents who had wounds, as documented on list provided by the Director of Nursing on 10/19/17. 1. The facility's Policy on Pressure and Wound Care, received from the Administrator on 10/18/17 at 5:10 p.m., documented, .Any pressure sore, stasis ulcer or other skin disorder will be assessed as ordered on a weekly basis or as needed . F. Documentation will include: date wound developed, stage of wound, length and width in CM (centimeters), depth in CM, tunneling, wound color, drainage (amount and type), presence of odor, culture results (if culture ordered by MD (Medical Doctor)), and any other pertinent information by a licensed nurse, Nurse Practitioner, or Physical Therapist . Policy on weekly skin assessments . Skin assessment will be documented on residents weekly. An identified skin condition will be documented and treatment initiated. Continued assessment and documentation of identified areas will occur on a weekly basis . RESPONSIBILITY: Director of Nursing Services / Licensed Nurses / Medical Records . PR(NAME)EDURE: 1. Every resident will have a complete review of their skin condition documented on a weekly basis. The review will be documented on the Weekly Skin Assessment or in the computer in the SMART Chart program . Any skin abnormalities identified during this review are to be documented in the Interdisciplinary Notes . 2. Resident #9 had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) with an assessment reference date of 8/23/17 documented the resident scored 15 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status (BIMS), required extensive assistance of one person with bed mobility, transfers, and dressing, was at risk for pressure ulcers, and did not have any venous or arterial ulcers presents. a. The Care Plan dated 5/9/17 documented, Potential for alteration in skin integrity . Resident will have no undetected skin alterations through next review date . Weekly body audit by nurse, preventive skin care as needed, report all skin issues to MD . report any redness or skin breakdown to nurse . b. The post-hospitalization admission Nurses Note dated 8/16/17 at 7:38 p.m. documented, One wound to right leg 4.1 x (by) 3.7 that is scabbed over . a 1x1 fluid filled blister on his second toe on his left foot that is intact and a 3 x 2.1 scabbed wound on his left leg. c. A Nurses Note dated 8/29/17 documented, Resident received a new order for [MEDICATION NAME] 100 mg (milligram) tab (tablet) po (per mouth) BID (two times daily) x (times) 10 days. Cleanse ulcer BLE (bilateral lower extremities) with wound cleanser. Apply Medi-Honey and cover with a dressing three times a week per the APRN (Advanced Practice Registered Nurse). d. Nurses Note dated 9/6/17 at 2:53 p.m. documented, Resident received a new order to apply Silversorb to bilateral legs then cover with Kerlix and wrap with Coban three days a week to assist with wounds and swelling. e. Nurse Notes dated 9/27/17 at 2:13 p.m. documented, New Order: D/C (discontinue) Medi-Honey tx (treatment) to BLE. f. Nurses Notes dated 10/2/17 at 12:30 p.m. documented, New Order: Apply compression stockings on BLE every morning and take off at night. g. The Electronic Medication Administration Record [REDACTED]. h. Nurses Notes dated 10/11/17 at 5:07 p.m. documented, New Order: Cleanse left heel abscess with wound cleanser, apply silver antibacterial gel border foam and wrap with Kerlix MWF (Monday, Wednesday and Friday). i. The Electronic Treatment Administration Record (ETAR) for October 2017 documented the order for dressing changes three times weekly. The treatments were signed as completed by the Administrator on 10/9/17, 10/11/17, 10/13/17, and 10/16/17. j. On 10/16/17 at 12:13 p.m., the resident was sitting in a wheelchair in his room, watching TV. There was a soiled dressing to the left mid-lateral area of his left leg. There was also a soiled dressing to the left inner aspect of the right leg and an uncovered green tinged wound located on the frontal region of the right leg. There was dried drainage visible on the dressings and no dates visible on the left or right leg dressings and no odors from the soiled dressings. The resident was asked how often the dressings were changed. He stated they were changed last week and that, They change it every now and then. k. On 10/16/17 at 3:13 p.m., the resident was sitting in a wheelchair in his room, watching TV. There was a soiled dressing to the left leg and an open area below the knee with serous drainage present. There was a yellowish-brown drainage visible on the outside of the right leg dressing. The resident stated that the dressings were not being changed three times a week, as ordered. l. On 10/16/17 at 5:40 p.m., Resident #9 was asked if the Administrator ever performed a dressing change to his legs. He stated, No, she has never touched me. m. On 10/16/17 at 4:16 p.m., the Administrator was asked if she signed the eTAR for this resident's treatments. She stated, I sign the eTAR when a nurse calls in. I am an LPN (Licensed Practical Nurse) and I work the floor sometimes. She was asked if she worked the floor today and stated, No not today. She was asked, Have you given any wound care treatments in the last week? She stated, No. n. On 10/17/17 at 9:52 a.m., the Administrator was asked, Who is responsible for making sure the residents receive their wound care treatments? She stated, DON (Director of Nursing). She was asked, When was the last time you worked the floor and/or performed patient care? She stated, I took the keys yesterday morning, because the nurse was running late, and the other nurse wanted to leave. I didn't give any meds (medications); I just held keys for about 45 minutes. She was asked, Have you ever provided any care, in particular dressing changes, to (Resident #9's) lower extremities? She stated, No. She was asked, Did you sign the eTAR yesterday morning for the treatment to (Resident #9's) bilateral lower extremities? She stated, I cleared them, yes. I think the treatments were done by (Physician). She was asked, So is there a reason why you signed them off? She stated, I cleared them for the new treatment nurse, so she would know where she was. I probably shouldn't have done that. She was asked, How long has your treatment nurse been here? She stated, Since Monday (10/16/17), yes. She was asked, How long have you been without a treatment nurse? She stated, At least 2 and a half weeks. o. Nurses Notes dated 10/18/17 documented, Late entry for 10/17/17: New Order to bilateral lower extremities. Cleanse with wound cleanser. Pat dry. Apply [MEDICATION NAME]. Cover with ABD (abdominal) pad. Wrap with Kerlix and cover with Coban MWF and prn (as needed). p. On 10/18/17 at 10:35 a.m., LPN #3 unwrapped Resident #9's left leg. There was visible yellowish, purulent drainage on the ABD pad. The Kerlix wrap was removed from the right leg, and there was yellowish-green drainage and spots of blood present. LPN #3 measured the left leg wound as 8 centimeters in length, and 4.5 centimeters in width. The right leg wound measured 13.5 centimeters in width and 6.75 centimeters in length. q. On 10/18/17 at 4:03 p.m., Resident #9 was asked, When was the last time the dressings to your legs were changed before we arrived on Monday (10/16/17)? He stated, Sometime last week. He was asked, Do you feel they are changing your dressings like they should? He stated, No. He was asked, How many times did you have your dressing changed last week? He stated, Once maybe. 3. Resident #8 had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/7/17 documented the resident was moderately impaired in cognitive skills for daily decision making per the staff assessment for mental status (SAMS), was totally dependent on the assistance of two plus people for bed mobility, was totally dependent on the assistance of one person for personal hygiene and bathing, required extensive assistance of one person for transfer, was frequently incontinent of bladder and bowel, was at risk of developing a pressure ulcer and had no pressure ulcers or venous or arterial ulcers. a. The Plan of Care dated 8/11/17 documented, Potential for alteration in skin integrity related to bowel and bladder incontinence . Resident will have no undetected skin alterations through next review date . Weekly body audit by nurse, turn and reposition every 2 hours and prn, (as needed) preventive skin care as needed . report all skin issues to MD and RP. b. A Physician's Telephone Order dated 9/22/17 documented, Cover left heel blister with TAO (triple antibiotic ointment) then wrap in Kerlix, change daily . c. The September 2017 Treatment Administration Record (TAR) documented, Cover left heel with TAO and 4x4 (4-inch by 4-inch gauze pad), then wrap with Kerlix QD (every day) . This treatment was initialed as completed by the Administrator on 9/22/17, 9/23/17, 9/24/17, 9/25/17, 9/26/17, and 9/28/17. d. A Nursing Note dated 10/8/17 at 7:05 p.m. documented, Area to L (left) heel appeared blackish and slightly reddened at the peri-wound. Skin appears intact current tx (treatment) applied to heel. Admin (Administrator), DON and a.m. (morning) hall nurse aware of change. Resident to be seen by wound MD in the a.m. Will continue to monitor for changes. e. A Wound Assessment Report dated 10/9/17 documented, .Wound type/location: [MEDICAL CONDITION]; Wound location: Left bottom of heel; Date wound identified: 10/7/17. Measurements: Length-3.60 cm, Width 3.50 cm, Depth-0.0. Date Physician notified: 10/9/17. Treatments: (9/22/17) cover left heel with TAO and 4 x 4, then wrap with Kerlix QD . f. A Progress Note Detail dated 10/9/17 from the Wound Physician documented, .new left heel wound; wound draining pus, will adjust tx and start pt (patient) on po (per mouth) antibiotics. Integumentary . Wound #2 left heel has a primary etiology of diabetic wound of the lower extremity, neuropathic and is a Wagner Grade 3 Diabetic Ulcer and has received a status of Open. Subsequent wound encounter measurements are 4.5 cm length x 4.5 cm width, with an area of 20.25 sq (square) cm. There is a small amount of purulent drainage noted. Wound bed had 25-50% adherent, yellow slough, 1-25% granulation . The peri-wound skin exhibited: [DIAGNOSES REDACTED]. General Notes: Nonviable tissue covering most wound will need debridement to promote healing and prevent an infection . Plan Wound Orders: Wound #2 Wound Cleansing & (and) Dressings - Cleanse wound with cleanser apply to wound bed: Medi-honey Alginate cover wound with: dry 2 D(NAME) (dressing of choice) Change MWF (Monday, Wednesday, Friday). Change PRN (as needed) for soiling and/or saturation . g. A Nursing Note dated 10/9/17 10:43 p.m., documented, Temp (temperature) is 97.1 started on [MEDICATION NAME] d/t (due to) wound to left heel, no ASE (adverse side effects) noted, no c/o (complaint of) pain or discomfort to site. Drsg (dressing) in place . h. The October 2017 TAR documented, Cover left heel with TAO and 4 x 4, then wrap with Kerlix QD . This treatment was initialed as completed by the Administrator on 10/9/17, 10/10/17, 10/11/17, and 10/13/17. i. A Physician's Telephone Order dated 10/11/17 documented, Cleanse left heel with wound cleaner apply silver antibacterial gel, cover with border foam, wrap with Kerlix until abscess heals MWF. j. The October 2017 TAR entry dated as initiated 10/11/17 documented, Cleanse left heel with wound cleanser and apply silver antibacterial gel cover with border foam and wrap with [MEDICATION NAME] until abscess heals . This treatment was initialed as completed by the Administrator on 10/13/17 and 10/16/17. k. A Physician's Telephone Order dated 10/12/17 documented, New order - Cleanse left heel SDTI (suspected deep tissue injury) with NS (normal saline) and apply [MEDICATION NAME] daily and off load heels apply border dressing on left heel. l. The October 2017 TAR entry dated as initiated 10/12/17 documented, Cleanse left heel SDTI with normal saline and apply [MEDICATION NAME] daily, then apply border dressings on left heel then off load both heels .This treatment was initialed as completed by the Administrator on 10/13/17 and 10/16/17. m. A Progress Note Detail dated 10/16/17 from the Wound Physician documented, .new left heel wound; wound improved, pt (patient) still on antibiotics - will debride nonviable skin due to increased risk of an infection and wound unlikely to heal with nonviable skin covering wound . Wound #2 left heel has a primary etiology of diabetic wound of the lower extremity, neuropathic and is a Wagner Grade 3 Diabetic Ulcer and has received a status of Open, Initial wound encounter measurements are 3.6cm length x 3.5 cm width, with an area of 12.6 sq. cm. There is a small amount of purulent drainage noted . The peri-wound skin exhibited: [DIAGNOSES REDACTED]. Peri-wound skin presents with s/s (signs/symptoms) of infection. Confirmation Description & (and) Treatment Plan is: Confirmed Local, Systemic Antibiotics prescribed, topical antibiotics prescribed . Wound Orders: Wound #2 left heel Wound Cleansing & Dressings cleanse wound with cleanser apply Silver gel to wound bed Cover wound with - dry 2 D(NAME) (dressings of choice) change daily, change prn for soiling and/or saturation . medications: [REDACTED]. n. A Wound Assessment Report dated 10/16/17 documented, Wound location: Left bottom of heel; Measurements: Length - 4.5 cm, Width 4.5 cm, depth 0.0 cm . Date electronically signed: 10/17/17 (Registered Nurse (RN) #1) Treatments (10/13/17) cleanse left heel SDTI with Normal Saline and apply [MEDICATION NAME] daily, then apply border dressing on left heel then off load both heels (10/14/17) [MEDICATION NAME] 100 mg cap give one capsule per gastrostomy tube twice daily x (times) 10 days (10/11/17) cleanse left heel with wound cleanser and apply silver antibacterial gel cover with border foam and wrap with Kerlix until abscess heals. o. On 10/17/17 at 5:08 p.m., LPN #3 measured the wound. It measured 4.5 cm x 4.5 cm and the wound base was red. She cleaned the wound with [MEDICATION NAME] and placed a dressing over the wound. The LPN did not apply the silver antimicrobial gel, border dressing and Kerlix wrap, as ordered by the physician on 10/16/17. p. On 10/17/17 at 9:52 a.m., after being questioned about the multiple occasions when the resident's treatments were signed off by the Administrator as completed, the Administrator provided the following written statement: When clearing treatments from computers (for) treatments (that were) not done, I hit 'sign' instead of 'not administered' by accident, going back to mid Sept. (September) for the new treatment nurse, due to unable to tell what was needed, see what needed to be done. When everything is pink, it is hard to see what is due. The statement was signed by the Administrator. 4. Resident #11 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Admission MDS with an ARD of 10/2/17 documented the resident was comatose, totally dependent on the assistance of two plus people for bed mobility and transfers, was totally dependent on the assistance of one person for personal hygiene and bathing, had an indwelling catheter, an ostomy, had one stage 4 pressure ulcer that measured 14.2 cm by 17.1 cm and was 4.0 cm deep. a. Hospital Discharge Instructions dated 9/25/17 documented, .Give PRN (as needed) pain medication prior to dressing change 30 minutes, if he has just gotten a dose recently of PRN ok (okay) to get an additional dose for dressing changes. Clean sacral area with NS (Normal Saline) Sureprep to peri skin pack with gauze moistened with Dakins 0.25% cover with dry dressing change BID (twice a day) . b. admission orders [REDACTED].Clean sacral area with NS pat dry, apply sure prep to peri skin, pack with gauze moistened with Dakins 0.25% cover with dry dressing and change BID . c. The Plan of Care dated 9/26/17 and updated on 10/3/17 did not address the resident's wounds. d. The Treatment Administration Record (TAR) for September 2017 documented, Clean Sacral area with normal saline pat dry, apply sure prep to peri skin, pack with gauze moistened with Dakins 0.25% cover with dry dressing and change twice daily There was no documentation that the treatment was administered on 9/25/17. e. An Initial Nursing Home History and Physical dated 9/26/17 documented, .Assessment: [DIAGNOSES REDACTED] originating from infected ischial ulcer that involved the entire scrotum, all the skin of the penis, portion of skin of the thigh with massive debridement. He has undergone several debridements since and skin graft to testicles and penis. Most of wound is healed except for persistent area in the deep ischial region involving some sacral coccygeal area. All this was debrided. The exposed tip of coccyx which almost had osteo[DIAGNOSES REDACTED] involved was taken down with a Rongeur. Acute resp (respiratory) failure, difficult vent (ventilation) wean, wound care, IV (intravenous) ABT (antibiotic). Penis implant (with) urology started having problems appear went to OR (operating room) for [DIAGNOSES REDACTED] 7/7/(17) per (Physician) taken back to OR for laparotomy sigmoid [MEDICAL CONDITION] 7/10/(17) consider SNF (Skilled Nursing Facility) placement for wound care. Skin Graft 8/16/(17) . f. A Nurse's Notes dated 9/28/17 documented, D/C (Discontinue) previous TX (treatment) order to sacrum. Clean sacrum with Dakin's 0.25% apply wound vac (vacuum) with black foam. Set 125 mm (millimeters) continuous and change Q (every) M-W-F (Monday-Wednesday-Friday) . Wound care doctor to see Q week at facility . g. The TAR for September 2017 documented, Clean sacrum with Dakins 0.25% apply sure prep to peri skin apply wound vac and black foam set 125 mm continuous change every Monday Wednesday Friday order date: 9/28/17 start date: 9/29/17 Discontinue date: 9/30/17. There was no documentation that this wound care was applied on 9/28/17 as ordered. h. The Admission Nursing assessment dated [DATE] at 2:33 p.m. documented, .admitted : 9/25/17 . What is resident's mental status? Alert-oriented (times) 3 . wnd (wound) vac change BID (two times daily) or Q 12 hours . sacral wnd with wound vac edges red L (left) graft site red . Skin Care/Pressure Ulcers . TX as ordered . Turn and reposition q 2 hours and prn (as needed) . weekly body audit by licensed nurse . Report any changes in skin condition to nurse . L (left) thigh skin graft . Sacral wnd debridement with wnd vac . i. A Nursing Departmental Note dated 9/29/17 at 2:02 p.m. documented, Spoke with resident on 9/28/17 and again today about adjustment to facility, wound care and pain management. (Resident #11) voiced fear and concern about taking shower and when wound care should be done. He said he was embarrassed to shower and his wound should be changed twice daily. I explained to him that shower is very important to wound healing and it has been set up so that on days of wound vac change which is MWF now (no longer 2x/day since wound vac in use) we will disconnect vac let you get a good shower then nurse will come in and reapply wound vac as MD ordered . j. A Nursing Departmental Note dated 9/30/17 at 4:30 p.m. documented, 1524 (3:24 p.m.) observed necrotic tissue to edges of wound. Removed wound vac. Necrotic tissue noted to wound bed. Contacted (Physician). Per (Physician) DC (discontinue) wound vac and restart previous TX to sacrum. Resident is aware. k. A Telephone Order dated 9/30/17 documented, 1) DC wound vac. 2) Restart previous TX to sacrum. l. There was no documentation on the September 2017 TAR to indicate the treatment to the sacrum was provided on 9/30/17 after the [DEVICE] was discontinued. m. There was no documentation on the October 2017 TAR to indicate the physician-ordered treatment was provided to the sacral wound on 10/1/17 or on 10/2/17. n. A Progress Note Detail dated 10/2/17 documented, .Chief Complaint: Wound Sacral . Diabetic Type 2 pt (patient) presenting with large sacral wound, some odor and nonviable tissue noted, will adjust tx as cannot exclude hx (history) wound infection. Pt. reports hx of wound debridements and recent antibiotics while pt in hospital . Integumentary (Hair, Skin) poor skin turgor Wound # 1 Sacral has primary etiology of Pressure Ulcer and is an unstageable pressure injury obscured full thickness skin and tissue loss Pressure Ulcer and has received a status of Open. Initial wound encounter measurements are 14.2 cm (centimeters) length x 17.1 cm width, with an area of 242.82 sq (square) cm. General notes: Wound at least 4 cm deep but may get deeper when slough removed . o. A Nursing Home Patient Progress Note dated 10/2/17 and signed by (Physician #1) documented, Chief Complaint/Review of Systems: (Increased) odor to wound, increased eschar noted notified by facility this weekend and this am of wound changes . Today's Assessment: Wound noted to have increased foul odor and more eschar tissue to wound bed. (Physician #2) wound care doctor saw resident this am (morning) and new tx orders given. Facility contacted and notified me of changes to wound and tx orders given. Brother of patient stated he was moving patient to (other nursing facility) today. That facility contacted and they have not accepted patient to their facility. Patient has been compliant and staying off wound while in bed. Will need further surgical debridement. Patient to be admitted back to (Local Hospital) Tuesday/Wed (Wednesday) started [MEDICATION NAME] 300 mg po QID and Prostat 30 ml po bid today . p. A Telephone Order dated 10/2/17 documented, 1) [MEDICATION NAME] 300 mg po qid x 5 days r/t wound infection 2) Will direct admit to (Local Hospital) Tues or Wed for surgical debridement of wound. q. A Telephone Order dated 10/2/17 documented, Clean sacral area with NS apply silver gel pack with Dakin's soaked gauze and cover with ABD (abdominal) pads, change daily. r. A Nursing Departmental Note dated 10/2/17 at 12:50 p.m. documented, (Physician #1) and (Physician's Nurse #1) over to see resident, observed his wound more necrotic tissue noted. N.O. (new orders) received and noted. Prostat 30 ml (milliliters) po (by mouth) bid for wound healing. [MEDICATION NAME] 300 mg po qid (4 times daily) x 5 days r/t (related to) wound infection. Will direct admit to (Local Hospital) Tues (Tuesday) or Wed (Wednesday) for surgical debridement of wound . s. A Nursing Departmental Note dated 10/3/17 (Tuesday) at 1:53 p.m. documented, (1:50 p.m.) Left facility via company van for direct admit to (Local Hospital). t. On 10/19/17 at 12:25 p.m., LPN #1 was asked, When (Resident #11) was here, did you observe his wound? She stated, No, I saw a dressing on it, but I didn't measure it. u. On 10/19/17 at 4:26 p.m., LPN #1 was asked, What treatments were being done on (Resident #11?) She stated, Dakin's soaked gauze with a dry dressing. She was asked, Was there ever a time that you may have gotten busy and passed the treatment on to the next nurse to do? She stated, Probably, yes. v. On 10/20/17 at 12:29 p.m., LPN #1 was asked, When (Resident #11) was admitted , did you measure his wound? She stated, No. She was asked, What is your policy and procedure for measuring wounds on new admits? She stated, Supposed to be done within 2 hours. She was asked, What are you supposed to do when a resident comes in with a wound? She stated, You are supposed to look at it, measure it and put your own description in the (computer) wound module. She was asked, Would the skin assessment include the wound size and depth when admitted and what treatment to apply? She stated, Yes. She was asked, Who is responsible for the treatments? She stated, The treatment nurse when we have one; if not, the charge nurse. 5. Resident #13 had [DIAGNOSES REDACTED]. The MDS with an Assessment Reference Date (ARD) of 7/17/17 documented the resident had modified independence in cognitive skills for daily decision making per a staff assessment for mental status, required extensive assistance of one person for transfer, bed mobility and personal hygiene, and was frequently incontinent of bowel and bladder and was at risk for developing pressure ulcer and has a [MEDICAL CONDITION], rash or cut. a. The September 2017 Electronic Treatment Record (eTAR) documented an order dated 7/10/17 to, Cleanse left hip abscess with wound cleanser, pack with Dakin's soaked packing strips, cover with dry gauze, cover with silicon dressing every day and as needed until healed. This order was documented as discontinued on 9/22/17. The treatment order was changed on 9/25/17 to, Cleanse Left Hip Abscess with wound cleanser, pack with Dakin's soaked gauze, and cover with silicon dressing every day and as needed until healed. This order was documented as discontinued on 10/2/17. The physician-ordered wound treatments were initialed as provided by the Administrator on 9/25/17, 9/26/17, 9/28/17 and 9/30/17. b. The eTAR for October 2017 documented the physician order [REDACTED]. The physician-ordered wound treatments were initialed as provided by the Administrator on 10/9/17, 10/11/17 and 10/16/17. c. On 10/17/17 at 9:52 a.m., the Administrator provided the following written statement: When clearing treatments from computers (for) treatments (that were) not done, I hit 'sign' instead of 'not administered' by accident, going back to mid Sept. (September) for the new treatment nurse, due to unable to tell what was needed, see what needed to be done. When everything is pink, it is hard to see what is due. The statement was signed by the Administrator. 6. Resident #16 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set with an Assessment Reference Date (ARD) of 7/31/17 documented the resident was moderately impaired in cognitive skills for daily decision making per a Staff Assessment for Mental Status (SAMS) was totally dependent on the assistance of one person for toileting, personal hygiene, and bathing, required extensive assistance of 1 person for transfer and bed mobility and was always incontinent of bowel and bladder, was at risk for developing pressure ulcer and had one venous and arterial ulcer. a. The October 2017 Wound Healing Progress Report documented the stasis ulcer to the right lateral shin measured 0.7 centimeters (cm) wide by (x) 1.0 cm long x 0.10 cm deep. There were no further weekly wound assessments documented until 10/18/17, at which time the wound measurements indicated slight improvement, at 0.5 cm x 1.0 cm x 0.0 cm. b. The eTAR for October 2017 documented a physician order [REDACTED]. This order was documented as discontinued on 10/2/17. The new physician order [REDACTED]. This order was documented as discontinued on 10/16/17. The physician-ordered wound treatments were initialed as provided by the Administrator on 10/11/17 and 10/16/17. c. On 10/17/17 at 9:52 a.m., the Administrator provided the following written statement: When clearing treatments from computers (for) treatments (that were) not done, I hit 'sign' instead of 'not administered' by accident, going back to mid Sept. (September) for the new treatment nurse, due to unable to tell what was needed, see what needed to be done. When everything is pink, it is hard to see what is due. The statement was signed by the Administrator. 7. Resident #14 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an assessment reference date of 9/4/17 documented the resident was severely impaired in cognitive skills for daily decision making per a staff assessment for mental status, had one stage 4 pressure ulcer and no venous or arterial ulcers. a. The Care Plan dated 6/19/17 documented, Resident is at risk for potential alteration in skin integrity . [DIAGNOSES REDACTED] and MASD (Moisture-Associated Skin Damage) and a history of skin tears and venous stasis ulcers . Resident will have no undetected skin alterations through next review date . Weekly body audit by nurse, preventive skin care as needed, report all skin issues to MD (Medical Doctor) and RP (Responsible Party), report any redness or skin breakdown to nurse, Consult with wound MD as needed . b. The Wound Healing Progress Report dated 8/3/17 documented the measurements of the pressure ulcer on the right 2nd toe were 0.50 cm x 0.50 cm. On 10/16/17, the measurements were documented as 0.60 cm x 0.50 cm. c. The Physician order [REDACTED]. d. The eTAR for September 2017 and October 2017 documented, Right second toe ulcer: Cleanse with wound cleanser then paint with [MEDICATION NAME] and leave open to air M-W-F . e. On 10/18/17 at 4:20 p.m., the Quality Assurance Nurse and LPN #4 were in the resident's room to measure the wound to the resident's right 2nd toe. The wound measurements were 0.70 cm x 0.50 cm.

Complaint # (AR 162) was substantiated, (all or in part), in these findings. Based on record review and interview, the facility staff failed to ensure the physician was consulted about low blood sugar readings for 2 (Resident #1 and #3) and a blood sugar above 400 for 1 (Resident #2) of 5 (Residents # 1- # 5) case mix residents who had [DIAGNOSES REDACTED]. These failed practices resulted in Immediate Jeopardy which caused or could have caused serious harm, injury or death to Resident #1 who was symptomatic with a low blood sugar for which the physician was not informed of, the Residents insulin dosages were not changed and the resident became unresponsive with a blood sugar of 28 on 4/25/14 which resulted in hospitalization for [DIAGNOSES REDACTED] and had the potential to cause more than minimal harm for 10 residents who received insulin and had physician orders [REDACTED]. The facility Administrator was notified of the Immediate Jeopardy condition on 5/29/14 at 1:50 p.m. The findings are: 1. Resident #1 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/25/14 documented the resident scored 14 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status (BIMS), had Diabetes Mellitus and received insulin injections 7 out of 7 days. a. The admission orders [REDACTED].S (sliding scale) 150-199 - 2 U (units) 200-249 - 4 U 250-299 6 U 350-399 - 8 U call MD. (medical doctor) (greater than) 400 (less than) 65..." A physician order [REDACTED].I. D. (twice a day)." b. The Plan of Care documented a review date of 4/27/14. The Plan of care documented, "Problem onset 3/25/14...Resident is at risk for Hypo/[MEDICAL CONDITION] and signs and symptoms related to Medication usage, unstable blood sugars, or poor diet choices... Goal and Target Date: Resident will have no undetected signs and symptoms of hypo/[MEDICAL CONDITION] Approaches: Administer insulin and oral agents as ordered... obtain and monitor accu-check as ordered per MD (Medial Doctor)... observe for signs of low blood sugar: sweating, nervousness, faintness, confusion, fatigue, weakness, headaches, inappropriate behavior, visual problems, inability to concentrate, [MEDICAL CONDITION], or increasing stupor... notify (Medical Doctor) of any significant abnormalities." c. The Nurses Notes dated 4/23/14 at 6:50 a.m. documented, "BS (blood sugar) 43 (at) 6:10 a.m. gave peanut butter, cracker, and 160 cc (cubic centimeters) of (orange juice) at 6:55 a.m. (blood sugar) was 64 and coming up." This entry was signed by Licensed Practical Nurse (LPN) #6. There was no documentation in the Nurses Notes that the physician was consulted about the blood sugar results that were less than 65. d. The Nurses Notes dated 4/23/14 at 8:00 a.m. documented, "(Blood Sugar) 120. Will continue TX (treatment) monitor (docsers)." This entry was signed by LPN #7. The April 2014 Medication Sheet dated 4/23/14 documented, Insulin Detemir 20 units subcutaneous two times a day at 9:00 a.m. and 6:00 p.m. The 9:00 a.m. dose was initialed with LPN #6's initials and circled, indicating the 9:00 a.m. dose of insulin was not given. On 5/29/14 at 7:20 a.m., LPN #6 was asked, "Did you call the doctor on 4/23/14 when (Resident #1's) blood sugar was 43?" LPN #6 stated, "If I didn't document it I didn't do it. I just don't recall, of course it would go into the nurses notes and in the orders." LPN #6 was asked if that was his initials on the Medication Record on 4/23/14 and why they were circled. LPN #6 stated, "I did not stay late. I don't know, I told the other nurse what was going on and I left. Yes, that looks like my initials, that means I held the medication." LPN #6 was asked, "Is there any protocols or standing orders in place regarding holding or administering insulin?" LPN #6 stated, "I know we are suppose to call the doctor if below 70." LPN #6 was asked, "Are you suppose to hold the insulin?" LPN #6 stated, "I think so, I would check with the doctor." LPN #6 was asked, "What are some of the signs and symptoms of [DIAGNOSES REDACTED]?" LPN #6 stated, "Sweating, not able to talk right." LPN #6 was asked, "What was Resident #1's symptoms when you first observed her?" LPN #6 stated, "She was sweaty, wringing wet is what the CNA (Certified Nursing Assistant) told me. I asked her how she was feeling and she said she was feeling fine." e. The Nurses Notes dated 4/25/14 at 4:50 a.m. documented, "On round to check on (resident) around 4:05 a.m. (resident) was unresponsive. I checked her blood sugar it was 28. I tried to give her med pass (with) some sugar but she was unable to swallow. Paged (doctor) through medical exchange but (no) answer @ (at) 4:08 a.m. I gave her a shot of [MEDICATION NAME] 1 (milliliter) (at) 4:15 a.m. Rechecked blood sugar it came up to 32 (at) 4:35 a.m. (Ambulance) called (at) 4:25 a.m. Second [MEDICATION NAME] given (at) 4:35 a.m. (blood sugar) up to 41. Ambulance arrived (at) 4:38 a.m... (doctor) who was covering for (doctor) called back (at) 5:37 a.m. I told him that she has been sent out already. Ambulance left (with) resident (at) 4:40 a.m. via stretcher to (hospital)." This entry was signed by LPN #5. On 5/29/14 at 12:28 p.m., LPN #5 was asked, "What did you mean by unresponsive?" LPN #5 stated, "She wasn't talking, but making mmm sounds, sweating, I checked her blood sugar, got med pass and sugar and she wouldn't take it... her eyes were open, mmm sounds to me, she wasn't out. I told the other nurse, grabbed the glucometer and tried to call the doctor but he didn't respond. I just gave [MEDICATION NAME] and it came up to 30 something." LPN #5 was asked, "Is their any protocol or standing orders in place regarding holding or administering insulin?" LPN #5 stated, "Suppose to be in the standing orders on the MAR (Medication Administration Record)." There were no orders on the April 2014 MAR to hold the resident's scheduled insulin. Facility standing orders received from the DON on 5/29/14 did not document any standing orders to withhold scheduled insulin. f. On 5/29/14 at 11:08 a.m. the DON was asked, "Are their any specific orders regarding holding insulin?" The DON stated, "Not unless the doctor specifies." The DON was asked, "When is the staff suppose to call the doctor regarding low or high blood sugars?" The DON stated, "Order specific." The DON was asked, "If a resident's blood sugar was 43 and the resident was symptomatic would you expect your staff to notify the doctor?" The DON stated, "Yes." The DON was asked, "Were you aware of the events documented in the nurses notes from 4/23 to 4/25/14? The DON stated, "No." The DON was asked, "Were any corrective actions or inservices regarding low and high blood sugars implemented?" The DON stated, "No." 2. Resident #2 had a [DIAGNOSES REDACTED]. The Significant Change (MDS) with an ARD of 5/26/14 documented the resident scored 3 (0-7 indicates severe impairment) on a BIMS, had Diabetes Mellitus and received insulin injections 7 out of 7 days. a. A physician order [REDACTED]. (less than) 60 call MD 151-200=2 units 201-250=4 units 251-300=6 units 301-350=7 units 351 or (greater)=9 units (greater than) 400 call MD..." A physician order [REDACTED].@ noon to [MEDICATION NAME] Insulin 15 U SQ QD (every day) @ noon." A physician order [REDACTED].." b. The Plan of Care documented a review date of 4/27/14. The Plan of care documented, "Problem onset 3/25/14...Resident is at risk for Hypo/[MEDICAL CONDITION] and signs and symptom related to Medication usage, unstable blood sugars, or poor diet choices... Goal and Target Date: Resident will have no undetected signs and symptoms of hypo/[MEDICAL CONDITION] Approaches: Administer insulin and oral agents as ordered... obtain and monitor accu-check as ordered per MD... observe for signs of low blood sugar: sweating, nervousness, faintness, confusion, fatigue, weakness, headaches, inappropriate behavior, visual problems, inability to concentrate, [MEDICAL CONDITION], or increasing stupor...notify (Medical Doctor) of any significant abnormalities." c. The May 2014 Diabetic MAR documented, "Accuchecks AC & HS with [MEDICATION NAME]([MEDICATION NAME]) 100 units/ml SQ per SS (less than) 60 call MD... (greater than) 400 call MD Start Date: 3/10/14." d. The May 2014 Medication Sheet documented, "Humalog 100 units/ml administer SQ per sliding scale AC & HS... (less than) 60 = call (medical doctor)....351 or (greater) 9 units.." There was no documentation of a start date. The Medication Sheet documented the resident's blood sugar was 425 on 5/27/14 and 9 units of Humalog insulin given. As of 5/29/14, there was no documentation in the nurses notes or on the Medication Sheet that the physician was consulted about the elevated blood sugar. e. On 5/29/14 at 10:14 a.m., LPN #7 was asked, "Did you recheck (Resident #2's) blood sugar?" LPN #7 stated, "No, I don't think I did. They were ordered (four times a day) and I knew the next nurse would check it." LPN #7 was asked, "Did you call the doctor) regarding the 425 blood sugar?" LPN #7 stated, "No." LPN #7 asked, "Did you put a note in the nurses notes?" LPN #7 stated, "No." LPN #7 asked, "Is there any standing orders or protocol regarding high or low blood sugars?" LPN #7 stated, "Not that I'm aware of." 3. Resident #3 had a [DIAGNOSES REDACTED]. The Quarterly MDS with an ARD of 3/18/14 documented the resident scored a 15 (13 - 15 indicates cognitively intact) on the Brief Interview for Mental Status and received insulin injections for 7 of the past 7 days.. a. A physician order [REDACTED].= (equal) call (physician)..." b. The Care Plan dated 12/18/13 and reviewed on 3/18/14 documented, "Problem/Need: Has a (diagnosis) of Diabetes and is at risk for Hypo/Hyper glycemia and s/s related to Diabetes ... Approaches: ... Administer insulin and oral agents as ordered ... Obtain and monitor Accu-check (finger stick blood sugars) as ordered per (physician) ... Notify (physician) of any significant abnormalities." c. The March 2014 MAR documented, "FSBS sliding scale ... If blood sugar is (less than) 60 = call (physician)..." On 3/11/14 the MAR documented the resident's blood sugar at 7:00 a.m. was 59 and was initialed by LPN #2. There was no documentation on the back of the MAR to indicate the physician was notified of the low blood sugar. There were no Nurse's Notes for 3/11/14. On 5/29/14 at 8:02 a.m., the DON stated that LPN #2 no longer worked at the facility and had moved out of state. On 5/29/14 at 9:35 a.m., the DON was asked to review the Nurse's Notes and 24 hour reports for 3/11/14. The DON was asked, "For the blood sugar on 3/11/14 which was documented as 59, can you find doctor notification?" The DON stated, "No. We looked at all of this last night, it's not there." d. The March 2014 MAR documented on 3/20/14 the resident's blood sugar at 7:00 a.m. was 54 and was initialed by LPN # 3. There was no documentation on the back of the MAR to indicate the physician was notified of the low blood sugar. There were no Nurse's Notes for 3/20/14 that addressed the low blood sugar or physician notification. On 5/29/14 at 8:02 a.m., the DON stated that LPN #3 no longer worked at the facility. On 5/29/14 at 9:35 a.m. the DON was asked, "For the blood sugar of 54 on 3/20/14, can you find any doctor notification?" The DON stated, "No." e. The March 2014 MAR documented on 3/27/14 the resident's blood sugar at 7:00 a.m. was 58 and was initialed by LPN #5. There was no documentation on the back of the MAR to indicate the physician was notified of the low blood sugar. There were no Nurse's Notes for 3/27/14. On 5/29/14 at 8:17 a.m., LPN #5 was asked, "On 3/27/14 at 7:00 a.m. the finger stick blood sugar was documented as 58, did you call the doctor about the low blood sugar less than 60 as per the physician order?" LPN #5 stated, "I don't remember if I called him or if I just gave her something to bring the blood sugar up." LPN #5 was asked, "Did you know the order is if the blood sugar is less than 60 it says to call the physician?" LPN #5 stated, "I don't ... (did not say anything else)." On 5/29/14 at 9:35 a.m., the DON was asked, "For the blood sugar of 58 on 3/27/14, can you find any doctor notification?" The DON stated, "No." f. The April 2014 MAR documented, "FSBS sliding scale ... If blood sugar is (less than) 60 = call (physician)..." On 4/6/14 the resident's blood sugar at 7:00 a.m. 58 and was initialed by LPN #5. There was no documentation on the back of the MAR to indicate the physician was notified of the low blood sugar. There were no Nurse's Notes for 4/6/14. On 5/29/14 at 8:17 a.m. LPN # 5 was asked, "On 4/6/14 did you call the doctor for the blood sugar of 58 at 7:00 a.m.?" LPN #5 stated, "I don't know if I called then. I'd given her something to bring the blood sugar back up." There was no documentation on the April 2014 MAR of another blood sugar being done until 12:00 p.m. On 5/29/14 at 9:35 a.m. the DON was asked, "On 4/6/14 at 7:00 a.m. the blood sugar was documented as 58, can you find any doctor notification?" The DON stated, "No." 4. On 5/29/14 at 9:35 a.m., the DON was asked, "Have any in-services been done after 4/25/14 to current, on [DIAGNOSES REDACTED], insulin administration, diabetes, or doctor notification of abnormal blood sugars?" The DON stated, "No, that's correct." 5. The Immediate Jeopardy was removed and the scope/severity reduced to a "G" on 5/29/14 at 4:20 p.m. when the facility implemented the following Plan of Removal: Plan of Removal for Immediate Jeopardy "Insulin administration, physician notification to Physician." Identification: On 5/29/14 at 2:00 p.m., the Director of Nurses identified 11 residents who have physician orders [REDACTED]. 7 residents were identified with insulin orders other than sliding scale. Assessments: Assessments inclusive of Visual/Physical Assessments and Physician order [REDACTED]. that none of these identified residents had any signs of [DIAGNOSES REDACTED]. Any negative findings were addressed immediately and physician notified if new orders were required. All of the identified resident's were also physically assessed for [DIAGNOSES REDACTED] by the Nurse Consultant, the Director of Nurses and by the RN Charge Nurse. There were no negative findings. Training: Training/In-service was immediately begun on 5/29/14 at 2:05 p.m., for the 7:00 a.m., to 3:00 p.m., LPN's and RN's (Registered Nurses) was conducted by the Director of Nurses and will be ongoing to include new hires and staff returning from leave, training will take place before staff are allowed to work on floor. All Nurses will be in-serviced immediately on the facility protocols for insulin parameters and documentation prior to their administering of any medications as of 5/29/14 at 2:05 p.m. With return verbalized/signature understanding of the parameters. Inservice: effective immediately Insulin Protocols as follows: Unless otherwise specified any and all sliding scale insulin's shall include these parameters. Call the Doctor with blood sugars of less than (<) 60 or greater than (>) 400. This MUST be documented in Nurse's note, EVERYTIME. This must be on the 24 hour report as well. To sign off on the back of the MAR and/or TAR (Treatment administration record) anything that you circled on the front of the MAR/TAR. There will be a spot for you to enter the information into. This has always been the rule, this must be documented in the Nurses note of the chart also. The doctor must be notified. This must be on the 24 hour report as well. You cannot give a medication without an order. You cannot hold a medication without an order/notification to the doctor. Via verbal order, standing order, telephone order, you must have an order. Doing so without an order is the same as you acting as the doctor and is fraud. You must not hold insulin without notification to the Physician. You must not hold any medications/treatments without notification to the Physician. If any treatments/medications are help per physician and /or physician was notified the notification must be documented. Effective Immediately Monitoring Trends/Problems Identified: Insulin orders and protocols, circling of items on the MARS and not documenting them. Plan of Action: The DON/Designee will monitor every day for issues with MARs RE (concerning): insulin's and medications, as well as documentation related to these to ensure those that are circled are documented on, the doctor has been notified of any held medication/insulin. Any issues identified shall be brought to the attention of the DON/Administrator/Nurse Consultant immediately. All Nurses will be in-serviced immediately on the facility protocols for insulin parameters and documentation. With return verbalized/signature understanding of the parameters. The Nurse Consultant will do monthly audit of the MARs to ensure this issue is resolved and that further in-servicing is done immediately if indicated. Negative findings will immediately be reviewed for further revisions in Daily QA (Quality Assurance) Clinical Meeting directed by the DON.

Complaint # (AR 162) was substantiated, (all or in part), in these findings. Based on record review and interview, the facility failed to ensure the provision of necessary care and services for Residents #1, #2, and #3 to attain or maintain the highest practicable physical well-being, in accordance with the comprehensive assessment and plan of care. The facility failed to ensure the physician was consulted about low blood sugar readings for 2 (Resident #1 and #3) and a blood sugar above 400 for 1 (Resident #2) of 5 (Residents # 1- # 5) case mix residents who had [DIAGNOSES REDACTED]. The facility failed to ensure the correct dosages of insulin were provided for 2 (Resident #2 and #3) of 5 case mix residents (Resident # 1 thru #5) who had [DIAGNOSES REDACTED]. The facility failed to ensure parameters for notification of low and/or high blood sugar levels were transcribed on physician orders and the Medication Administration Record (MAR) for 1 (Residents #2) of 5 (Residents #1 through #5) case mix residents who received insulin. These failed practices resulted in Immediate Jeopardy which caused or could have caused serious harm, injury or death to Resident #1 who was symptomatic with a low blood sugar for which the physician was not informed of, the Residents insulin dosages were not changed and the resident became unresponsive with a blood sugar of 28 on 4/25/14 which resulted in hospitalization for [DIAGNOSES REDACTED] and had the potential to cause more than minimal harm for 11 residents who had orders for sliding scale insulin, 7 residents who had orders for insulin other than sliding scale, and 10 residents who received insulin according to the listings received from the DON on 5/29/14. The facility Administrator was notified of the Immediate Jeopardy condition on 5/29/14 at 1:50 p.m. The findings are: 1. Resident #1 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/25/14 documented the resident scored 14 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status (BIMS), had Diabetes Mellitus and received insulin injections 7 out of 7 days. a. The admission orders [REDACTED].S (sliding scale) 150-199 - 2 U (units) 200-249 - 4 U 250-299 6 U 350-399 - 8 U call MD. (medical doctor) (greater than) 400 (less than) 65..." A physician order dated 4/18/14 documented, "Determir Insulin 20 units sub Q (subcutaneous) B.I. D. (twice a day)." b. The Plan of Care documented a review date of 4/27/14. The Plan of care documented, "Problem onset 3/25/14...Resident is at risk for Hypo/[MEDICAL CONDITION] and signs and symptoms related to Medication usage, unstable blood sugars, or poor diet choices... Goal and Target Date: Resident will have no undetected signs and symptoms of hypo/[MEDICAL CONDITION] Approaches: Administer insulin and oral agents as ordered... obtain and monitor accu-check as ordered per MD (Medial Doctor)... observe for signs of low blood sugar: sweating, nervousness, faintness, confusion, fatigue, weakness, headaches, inappropriate behavior, visual problems, inability to concentrate, [MEDICAL CONDITION], or increasing stupor... notify (Medical Doctor) of any significant abnormalities." c. The Nurses Notes dated 4/23/14 at 6:50 a.m. documented, "BS (blood sugar) 43 (at) 6:10 a.m. gave peanut butter, cracker, and 160 cc (cubic centimeters) of (orange juice) at 6:55 a.m. (blood sugar) was 64 and coming up." This entry was signed by Licensed Practical Nurse (LPN) #6. There was no documentation in the Nurses Notes that the physician was consulted about the blood sugar results that were less than 65. d. The Nurses Notes dated 4/23/14 at 8:00 a.m. documented, "(Blood Sugar) 120. Will continue TX (treatment) monitor (docsers)." This entry was signed by LPN #7. The April 2014 Medication Sheet dated 4/23/14 documented, Insulin Detemir 20 units subcutaneous two times a day at 9:00 a.m. and 6:00 p.m. The 9:00 a.m. dose was initialed with LPN #6's initials and circled, indicating the 9:00 a.m. dose of insulin was not given. On 5/29/14 at 7:20 a.m., LPN #6 was asked, "Did you call the doctor on 4/23/14 when (Resident #1's) blood sugar was 43?" LPN #6 stated, "If I didn't document it I didn't do it. I just don't recall, of course it would go into the nurses notes and in the orders." LPN #6 was asked if that was his initials on the Medication Record on 4/23/14 and why they were circled. LPN #6 stated, "I did not stay late. I don't know, I told the other nurse what was going on and I left. Yes, that looks like my initials, that means I held the medication." LPN #6 was asked, "Is there any protocols or standing orders in place regarding holding or administering insulin?" LPN #6 stated, "I know we are suppose to call the doctor if below 70." LPN #6 was asked, "Are you suppose to hold the insulin?" LPN #6 stated, "I think so, I would check with the doctor." LPN #6 was asked, "What are some of the signs and symptoms of [DIAGNOSES REDACTED]?" LPN #6 stated, "Sweating, not able to talk right." LPN #6 was asked, "What was Resident #1's symptoms when you first observed her?" LPN #6 stated, "She was sweaty, wringing wet is what the CNA (Certified Nursing Assistant) told me. I asked her how she was feeling and she said she was feeling fine." e. The Nurses Notes dated 4/25/14 at 4:50 a.m. documented, "On round to check on (resident) around 4:05 a.m. (resident) was unresponsive. I checked her blood sugar it was 28. I tried to give her med pass (with) some sugar but she was unable to swallow. Paged (doctor) through medical exchange but (no) answer @ (at) 4:08 a.m. I gave her a shot of [MEDICATION NAME] 1 (milliliter) (at) 4:15 a.m. Rechecked blood sugar it came up to 32 (at) 4:35 a.m. (Ambulance) called (at) 4:25 a.m. Second [MEDICATION NAME] given (at) 4:35 a.m. (blood sugar) up to 41. Ambulance arrived (at) 4:38 a.m... (doctor) who was covering for (doctor) called back (at) 5:37 a.m. I told him that she has been sent out already. Ambulance left (with) resident (at) 4:40 a.m. via stretcher to (hospital)." This entry was signed by LPN #5. 1) The hospital Emergency Department records dated 4/25/14 at 6:54 a.m. documented, "Chief Complaint: [DIAGNOSES REDACTED] ...HPI Comments: The pt (patient) is a resident of Valley Ranch NH (nursing home). She was recently discharged after treatment for [REDACTED]. She is diabetic, and gets a long acting insulin BID (two times a day), as well as a regular insulin sliding scale. This morning, nurses performed her routine AM accucheck, and her glucose was noted to be 28. She had been given D ([MEDICATION NAME])50 and oral glucose enroute. She is quite somnolent and not able to cooperate with hx (history) on arrival... Patient is a 68 y.o. (year old) female presenting with altered mental status and diabetes problem. The history is provided by the EMS (emergency medical services) personnel. Altered Mental Status Presenting symptoms: confusion, lethargy and unresponsiveness... Physical Exam... Constitutional: She is oriented to person, place, and time... she appears lethargic. She is sleeping and cooperative. She has a sickly appearance. She appears ill... Basic Metabolic Panel ...Glucose...Value 61... Range...65-105 mg (milligrams)/dl (deciliter)..." 2) On 5/29/14 at 12:28 p.m., LPN #5 was asked, "What did you mean by unresponsive?" LPN #5 stated, "She wasn't talking, but making mmm sounds, sweating, I checked her blood sugar, got med pass and sugar and she wouldn't take it... her eyes were open, mmm sounds to me, she wasn't out. I told the other nurse, grabbed the glucometer and tried to call the doctor but he didn't respond. I just gave [MEDICATION NAME] and it came up to 30 something." LPN #5 was asked, "Is their any protocol or standing orders in place regarding holding or administering insulin?" LPN #5 stated, "Suppose to be in the standing orders on the MAR (Medication Administration Record)." There were no orders on the April 2014 MAR to hold the resident's scheduled insulin. 3) The DMS (Division of Medical Services) 762, Facility Investigation Report for Resident Abuse, Neglect, Misappropriation of Property, And Exploitation of Residents in Long Term Care Facilities documented the Date and Time of Incident as 4/25/14 and the time as unknown, the Date and Time of Discovery as 4/27/14 at 4:40 p.m. and Type of Incident neglect. Section II - Complete Description of Incident documented, "...On 4/27/14 the resident returned from the Hospital. Hospital discharge records documented upon admission on 4/25/14: 'Acute [MEDICAL CONDITION] was sent from the NH with [DIAGNOSES REDACTED] and weakness. The patient states the (Nursing Home) personnel did not care for her last night when she got weak and felt very hot. She was noted to have low (blood sugar) of 30 and when she got here it was 61." f. Facility standing orders received from the DON on 5/29/14 did not document any standing orders to withhold scheduled insulin. On 5/29/14 at 11:08 a.m. the DON was asked, "Are their any specific orders regarding holding insulin?" The DON stated, "Not unless the doctor specifies." The DON was asked, "When is the staff suppose to call the doctor regarding low or high blood sugars?" The DON stated, "Order specific." The DON was asked, "If a resident's blood sugar was 43 and the resident was symptomatic would you expect your staff to notify the doctor?" The DON stated, "Yes." The DON was asked, "Were you aware of the events documented in the nurses notes from 4/23 to 4/25/14? The DON stated, "No." The DON was asked, "Were any corrective actions or inservices regarding low and high blood sugars implemented?" The DON stated, "No." 2. Resident #2 had a [DIAGNOSES REDACTED]. The Significant Change (MDS) with an ARD of 5/26/14 documented the resident scored 3 (0-7 indicates severe impairment) on a BIMS, had Diabetes Mellitus and received insulin injections 7 out of 7 days. a. A physician order dated 3/10/14 documented, "Accu Checks AC (before meals) & (and) HS with [MEDICATION NAME] Insulin ([MEDICATION NAME]) 100 units/ML (milliliter) SQ Per SS. (less than) 60 call MD 151-200=2 units 201-250=4 units 251-300=6 units 301-350=7 units 351 or (greater)=9 units (greater than) 400 call MD..." A physician order dated 5/5/14 documented (change) [MEDICATION NAME] 12 U SQ @ noon to [MEDICATION NAME] Insulin 15 U SQ QD (every day) @ noon." A physician order dated 5/6/14 documented, "(change) [MEDICATION NAME] form 12 units to 15 units SQ Q noon.." b. The Plan of Care documented a review date of 4/27/14. The Plan of care documented, "Problem onset 3/25/14...Resident is at risk for Hypo/[MEDICAL CONDITION] and signs and symptom related to Medication usage, unstable blood sugars, or poor diet choices... Goal and Target Date: Resident will have no undetected signs and symptoms of hypo/[MEDICAL CONDITION] Approaches: Administer insulin and oral agents as ordered... obtain and monitor accu-check as ordered per MD... observe for signs of low blood sugar: sweating, nervousness, faintness, confusion, fatigue, weakness, headaches, inappropriate behavior, visual problems, inability to concentrate, [MEDICAL CONDITION], or increasing stupor...notify (Medical Doctor) of any significant abnormalities." c. The May 2014 Diabetic MAR documented, "Accuchecks AC & HS with [MEDICATION NAME]([MEDICATION NAME]) 100 units/ml SQ per SS (less than) 60 call MD... (greater than) 400 call MD Start Date: 3/10/14." d. The May 2014 Medication Sheet documented, "Humalog 100 units/ml administer SQ per sliding scale AC & HS... (less than) 60 = call (medical doctor)....351 or (greater) 9 units.." There was no documentation of a start date. The Medication Sheet documented the resident's blood sugar was 425 on 5/27/14 and 9 units of Humalog insulin given. As of 5/29/14, there was no documentation in the nurses notes or on the Medication Sheet that the physician was consulted about the elevated blood sugar. e. On 5/29/14 at 10:14 a.m., LPN #7 was asked, "Did you recheck (Resident #2's) blood sugar?" LPN #7 stated, "No, I don't think I did. They were ordered (four times a day) and I knew the next nurse would check it." LPN #7 was asked, "Did you call the doctor) regarding the 425 blood sugar?" LPN #7 stated, "No." LPN #7 asked, "Did you put a note in the nurses notes?" LPN #7 stated, "No." LPN #7 asked, "Is there any standing orders or protocol regarding high or low blood sugars?" LPN #7 stated, "Not that I'm aware of." 3. Resident #3 had a [DIAGNOSES REDACTED]. The Quarterly MDS with an ARD of 3/18/14 documented the resident scored a 15 (13 - 15 indicates cognitively intact) on the Brief Interview for Mental Status and received insulin injections for 7 of the past 7 days.. a. A physician order dated 9/13/13 documented, "[MEDICATION NAME] 100 units/ml - administer 25 units sq (every) a.m. ... FSBS (Finger Stick Blood Sugar) sliding scale - [MEDICATION NAME]100 units/ml ac & hs sq - if blood sugar is (less than) 60 = (equal) call (physician)..." b. The Care Plan dated 12/18/13 and reviewed on 3/18/14 documented, "Problem/Need: Has a (diagnosis) of Diabetes and is at risk for Hypo/Hyper glycemia and s/s related to Diabetes ... Approaches: ... Administer insulin and oral agents as ordered ... Obtain and monitor Accu-check (finger stick blood sugars) as ordered per (physician) ... Notify (physician) of any significant abnormalities." c. The March 2014 Medication Administration Record (MAR) documented, "[MEDICATION NAME] ... administer 25 units sq..." On 3/3/14 the 6:00 a.m. dose was initialed and circled to document the medication was not given. The nurse's initials on this date were for LPN #1. There was no documentation on the back of the MAR to indicate why the medication was held, there were no Nurse's Notes for 3/3/14 and there was no physician order to hold the [MEDICATION NAME] insulin. The March 2014 MAR documented the resident had a blood sugar of 91 on 3/3/14 at 7:00 a.m. and was initialed by LPN #2. On 5/29/14 at 10:55 a.m. LPN # 1 was asked, "On 3/3/14 at 6:00 a.m. there are initials on the MAR for (Resident #3) of (initials), is that your initials?" LPN #1 stated, "Yes." LPN #1 was asked, "The [MEDICATION NAME] for 3/3/14 is initialed and circled, did you give it?" LPN #1 stated, "No, if it's circled I held it." LPN #1 was asked, "Why did you hold it?" LPN #1 stated, "There's a facility protocol if it's (blood sugar) less than 70 do not give any scheduled insulin." LPN #1 was asked, "Did you notify the doctor that you held it?" LPN #1 stated, "No." d. On 5/29/14 at 9:35 a.m. the DON was asked, "The [MEDICATION NAME] was held on 3/3/14, can you find a nursing note as to why it was held or a physician order?" The DON stated, "No." On 5/29/14 at 11:12 a.m. the DON was asked "Is there any facility protocol that nurses are to hold all insulin for blood sugars less than 70?" The DON stated, "No they are to call the doctor if it's at a range they are not comfortable with before giving insulin. They are not to hold insulin without a doctor's order." e. The March 2014 Medication Administration Record (MAR) documented, "[MEDICATION NAME] ... administer 25 units sq..." On 3/4/14 the 6:00 a.m. dose of [MEDICATION NAME] was initialed and circled to document the medication was not given. The nurse's initials on this date were for LPN #2. The MAR for March 2014 documented the 7:00 a.m. blood sugar as 97 and was initialed by LPN # 2. There was no documentation on the back of the MAR to indicate why the medication was held, no Nurse's Notes for 3/4/14 and no physician order to hold the [MEDICATION NAME] insulin. The March 2014 MAR documented on 3/4/14 the 7:00 a.m. blood sugar was 97 and was initialed by LPN #2. On 5/29/14 at 9:35 a.m. the DON was asked, "The [MEDICATION NAME] was held on 3/4/14, can you find a nursing note as to why it was held or a physician order?" The DON stated, "No." f. The March 2014 MAR documented, "FSBS sliding scale ... If blood sugar is (less than) 60 = call (physician)..." On 3/11/14 the MAR documented the resident's blood sugar at 7:00 a.m. was 59 and was initialed by LPN #2. There was no documentation on the back of the MAR to indicate the physician was notified of the low blood sugar. There were no Nurse's Notes for 3/11/14. On 5/29/14 at 8:02 a.m., the DON stated that LPN # 2 no longer worked at the facility and had moved out of state. On 5/29/14 at 9:35 a.m., the DON was asked to review the Nurse's Notes and 24 hour reports for 3/11/14. The DON was asked, "For the blood sugar on 3/11/14 which was documented as 59, can you find doctor notification?" The DON stated, "No. We looked at all of this last night, it's not there." g. The March 2014 MAR documented on 3/20/14 the resident's blood sugar at 7:00 a.m. was 54 and was initialed by LPN # 3. There was no documentation on the back of the MAR to indicate the physician was notified of the low blood sugar. There were no Nurse's Notes for 3/20/14 that addressed the low blood sugar or physician notification. On 5/29/14 at 8:02 a.m., the DON stated that LPN #3 no longer worked at the facility. On 5/29/14 at 9:35 a.m. the DON was asked, "For the blood sugar of 54 on 3/20/14, can you find any doctor notification?" The DON stated, "No." h. The March 2014 MAR documented, "[MEDICATION NAME] ... administer 25 units sq..." On 3/26/14 the 6:00 a.m. dose was initialed and circled to document the medication was not given. The nurse's initials on this date were for LPN #4. The MAR for March 2014 documented the 7:00 a.m. blood sugar as 63 and was initialed by LPN #4. There was no documentation on the back of the MAR to indicate why the medication was held, no Nurse's Notes on 3/26/14 that addressed the low blood sugar and there was no physician order to hold the [MEDICATION NAME] insulin. On 5/29/14 at 9:35 a.m. the DON was asked, "On 3/26/14 at 6:00 a.m., can you find why the [MEDICATION NAME] was held?" The DON stated, "No." The DON was asked, "Should it have been held for a blood sugar documented as 63?" The DON stated "No." On 5/29/14 at 10:33 a.m. LPN # 4 was called. This Surveyor left a voice mail and requested a call back. As of 5/29/14 at 6:00 p.m., when the team exited, LPN #4 had not returned this Surveyor's phone call. i. The March 2014 MAR documented on 3/27/14 that the 6:00 a.m. dose of [MEDICATION NAME] was initialed and circled to indicate the medication was not given. The nurse's initials on this date were for Licensed Practical Nurse LPN #5. There was no documentation on the back of the MAR to indicate why the medication was held, there were no Nurse's Notes for 3/27/14 and there was no physician order to hold the [MEDICATION NAME] insulin. The MAR also documented the resident's blood sugar at 7:00 a.m. was 58 and was initialed by LPN #5. There was no documentation on the back of the MAR to indicate the physician was notified of the low blood sugar. There were no Nurse's Notes for 3/27/14. On 5/29/14 at 8:17 a.m. LPN #5 was asked, "On 3/27/14 at 7:00 a.m. the finger stick blood sugar was documented as 58, did you call the doctor about the low blood sugar less than 60 as per the physician order?" LPN #5 stated, "I don't remember if I called him or if I just gave her something to bring the blood sugar up." LPN #5 was asked, "Did you know the order is if the blood sugar is less than 60 it says to call the physician?" LPN #5 stated, "I don't ... (did not say anything else)." LPN #5 was asked, "On 3/27/14 the 6:00 a.m. [MEDICATION NAME] is initialed and is circled, what does that mean?" LPN #5 stated, "I didn't give it." LPN #5 was asked, "Did you get a doctor's order to hold it, the [MEDICATION NAME]?" LPN #5 stated, "I don't remember if I got it or not." LPN #5 was asked "Before you hold a medicine should you get a doctor's order to hold it?" LPN #5 stated "Yes" LPN #5 was asked, "For [MEDICATION NAME]do you know the onset and peak times?" LPN # 5 stated, "No." On 5/29/14 at 9:35 a.m. the DON was asked, "For the blood sugar of 58 on 3/27/14, can you find any doctor notification?" The DON stated, "No." The DON was asked, "On 3/27/14 at 6:00 a.m., can you find why the [MEDICATION NAME] was held?" The DON stated, "No." The DON was asked, "Should it have been held for a blood sugar documented as 58?" The DON stated, "No." j. The March 2014 MAR documented, the 6:00 a.m. dose for [MEDICATION NAME] was initialed and circled to indicate the medication was not given. The nurse's initials on this date were for LPN # 1. The MAR for March 2014 documented the 7:00 a.m. blood sugar as 68 and was initialed by LPN #1. There was no documentation on the back of the MAR to indicate why the medication was held, there were no Nurse's Notes for 3/29/14 and no physician order to hold the [MEDICATION NAME] insulin. On 5/29/14 at 9:35 a.m. the DON was asked, "On 3/29/14 at 6:00 a.m., can you find any reason why the [MEDICATION NAME] was held?" The DON stated, "No." The DON was asked, "Should it have been held for a blood sugar documented as 68?" The DON stated "No". On 5/29/14 at 10:55 a.m. LPN #1 was asked, "On 3/29/14 the 6:00 a.m. [MEDICATION NAME] is circled, did you give it?" LPN #1 stated, "No." LPN #1 was asked, "Did you call the doctor and let him know?" LPN #1 stated, "No." LPN #1 was asked, "Why was it held?" LPN #1 stated, "The blood sugar was low." k. The April 2014 MAR documented the 6:00 a.m. dose on 4/1/14 was initialed and circled to indicate the medication was not given. The nurse's initials on this date were for LPN #5. On 3/4/14 the MAR for April 2014 documented the 7:00 a.m. blood sugar as 74 and was initialed by LPN # 5. There was no documentation on the back of the MAR to indicate why the medication was held, no Nurse's Notes for 4/1/14 and no physician order to hold the [MEDICATION NAME] insulin. On 5/29/14 at 8:17 a.m., LPN # 5 was asked, "On 4/1/14 the 6:00 a.m. [MEDICATION NAME] is initialed with your initials and circled, did you give it?" LPN #5 stated, "No, not if it's circled?" LPN #5 was asked, "Did you call the doctor to get an order to hold it?" LPN # 5 stated, "No." On 5/29/14 at 9:35 a.m. the DON was asked, "On 4/1/14 at 6:00 a.m., can you find any reason why the [MEDICATION NAME] was held?" The DON stated, "No." The DON was asked, "Should it have been held for a blood sugar documented as 74?" The DON stated, "No." l. The April 2014 MAR documented, "FSBS sliding scale ... If blood sugar is (less than) 60 = call (physician)..." On 4/6/14 the resident's blood sugar at 7:00 a.m. 58 and was initialed by LPN #5. There was no documentation on the back of the MAR to indicate the physician was notified of the low blood sugar. There were no Nurse's Notes for 4/6/14. On 5/29/14 at 8:17 a.m. LPN # 5 was asked, "On 4/6/14 did you call the doctor for the blood sugar of 58 at 7:00 a.m.?" LPN #5 stated, "I don't know if I call then. I'd given her something to bring the blood sugar back up." There was no documentation on the April 2014 MAR of another blood sugar being done until 12:00 p.m. On 5/29/14 at 9:35 a.m. the DON was asked, "On 4/6/14 at 7:00 a.m. the blood sugar was documented as 58, can you find any doctor notification?" The DON stated, "No." m. The April 2014 MAR documented the 6:00 a.m. dose of [MEDICATION NAME] for 4/23/14 was initialed and circled to document the medication was not given. The nurse's initials on this date were for LPN #6. On 4/23/14 the MAR Record for April 2014 documented the 7:00 a.m. blood sugar as 65 and was initialed by LPN # 6. The Nurse's Notes dated 4/23/14 at 6:10 a.m. documented, "(Blood sugar) (at) 6:10 a.m. was 68, held 6:00 a.m. insulin for low blood sugar." This entry was signed by LPN #6. There was no physician order to hold the 6:00 a.m. [MEDICATION NAME] insulin. On 5/29/14 at 7:35 a.m. LPN #6 was asked, "Are these your initials for the 7:00 a.m. blood sugar on 4/23/14?" LPN #6 stated, "Yes." LPN #6 was asked, "What was the blood sugar?" LPN #6 stated, "65." LPN #6 was asked, "Did you give the 6:00 a.m. [MEDICATION NAME] on 4/23/14?" LPN #6 stated, "No, it's circled I didn't give it." LPN #6 was asked, "Can you find a doctor order to hold it or notify the physician that you held the [MEDICATION NAME]?" LPN #6 stated, "Not on this, I passed it on." LPN #6 was asked to review the Nursing 2013 Drug Handbook for [MEDICATION NAME] insulin. The Nursing 2013 Drug Handbook. Philadelphia: Wolters Kluwer, Lippincott Williams & Wilkins, 2013. Print. Pages 739 - 740 documented "Insulin Determir ... [MEDICATION NAME] ... Action: Regulates glucose metabolism by binding to insulin receptors, facilitating cellular uptake of glucose into muscle and fat, and inhibiting release of glucose from live. Route: (Subcutaneous). Onset: Unknown. Peak: 6 - 8 (hours). Duration: 6 - 23 (hours) ... Patient Teaching: ... Caution patient not to stop insulin abruptly or change the amount or type of insulin used without consulting physician ...". LPN # 6 was asked "What is the onset time for [MEDICATION NAME] insulin?" LPN # 6 stated "Unknown". LPN # 6 was asked "What is peak time?" LPN # 6 stated "6 to 8 hours". LPN # 6 was asked "What good is holding [MEDICATION NAME] going to do for the blood sugar at 6:00 a.m.?" LPN # 6 stated "None." LPN # 6 was asked, "Should you hold medications without a doctor's order?" LPN #6 stated, "No." On 5/29/14 at 9:35 a.m. the DON was asked, "On 4/23/14 at 6:00 a.m., can you find any reason why the [MEDICATION NAME] was held. The DON stated, "Per the nurses notes it was held for a low blood sugar." The DON was asked, "Was the doctor notified?" The DON stated "No." The DON was asked, "Can you find any order to hold the [MEDICATION NAME] insulin?" The DON stated, "No." The DON was asked "If [MEDICATION NAME] has an onset of unknown and peak of 6 to 8 hours, should it have been held?" The DON stated "No". 4. On 5/29/14 at 9:35 a.m. the DON was asked, "Who monitors the MARs to ensure meds are given?" The DON stated, "I check the MARs. I can't say I do it every day and the nurse supervisor checks them." The DON was asked, "Did you notice that insulin is being held, not administered, and there is not a doctor's order to hold it?" The DON stated, "No." The DON was asked, "Have any in-services been done after 4/25/14 to current on [DIAGNOSES REDACTED], insulin administration, diabetes, or doctor notification of abnormal blood sugars?" The DON stated, "No, that's correct." 5. The Immediate Jeopardy was removed and the scope/severity reduced to a "G" on 5/29/14 at 4:20 p.m. when the facility implemented the following Plan of Removal: Plan of Removal for Immediate Jeopardy "Insulin administration, physician notification to Physician." Identification: On 5/29/14 at 2:00 p.m., the Director of Nurses identified 11 residents who have physician orders for Sliding Scale Insulin. 7 residents were identified with insulin orders other than sliding scale. Assessments: Assessments inclusive of Visual/Physical Assessments and Physician order review for the 11 identified resident's who receive Sliding Scale Insulin and for the 7 residents identified with insulin orders were started immediately on 5/29/14 at 2:30 p.m., by the Director of Nurses to ensure the sliding scale orders include correct parameters and that none of these identified residents had any signs of [DIAGNOSES REDACTED]. Any negative findings were addressed immediately and physician notified if new orders were required. All of the identified resident's were also physically assessed for [DIAGNOSES REDACTED] by the Nurse Consultant, the Director of Nurses and by the RN Charge Nurse. There were no negative findings. Training: Training/In-service was immediately begun on 5/29/14 at 2:05 p.m., for the 7:00 a.m., to 3:00 p.m., LPN's and RN's (Registered Nurses) was conducted by the Director of Nurses and will be ongoing to include new hires and staff returning from leave, training will take place before staff are allowed to work on floor. All Nurses will be in-serviced immediately on the facility protocols for insulin parameters and documentation prior to their administering of any medications as of 5/29/14 at 2:05 p.m. With return verbalized/signature understanding of the parameters. Inservice: effective immediately Insulin Protocols as follows: Unless otherwise specified any and all sliding scale insulin's shall include these parameters. Call the Doctor with blood sugars of less than (<) 60 or greater than (>) 400. This MUST be documented in Nurse's note, EVERYTIME. This must be on the 24 hour report as well. To sign off on the back of the MAR and/or TAR (Treatment administration record) anything that you circled on the front of the MAR/TAR. There will be a spot for you to enter the information into. This has always been the rule, this must be documented in the Nurses note of the chart also. The doctor must be notified. This must be on the 24 hour report as well. You cannot give a medication without an order. You cannot hold a medication without an order/notification to the doctor. Via verbal order, standing order, telephone order, you must have an order. Doing so without an order is the same as you acting as the doctor and is fraud. You must not hold insulin without notification to the Physician. You must not hold any medications/treatments without notification to the Physician. If any treatments/medications are help per physician and /or physician was notified the notification must be documented. Effective Immediately Monitoring Trends/Problems Identified: Insulin orders and protocols, circling of items on the MARS and not documenting them. Plan of Action: The DON/Designee will monitor every day for issues with MARs RE (concerning): insulin's and medications, as well as documentation related to these to ensure those that are circled are documented on, the doctor has been notified of any held medication/insulin. Any issues identified shall be brought to the attention of the DON/Administrator/Nurse Consultant immediately. All Nurses will be in-serviced immediately on the facility protocols for insulin parameters and documentation. With return verbalized/signature understanding of the parameters. The Nurse Consultant will do monthly audit of the MARs to ensure this issue is resolved and that further in-servicing is done immediately if indicated. Negative findings will immediately be reviewed for further revisions in Daily QA (Quality Assurance) Clinical Meeting directed by the DON.

Based on observation, record review and interview, the facility failed to ensure nutritional interventions and recommendations by the Registered Dietitian to monitor and decrease the potential for further weight loss were promptly developed and implemented for 2 (Resident #4 and 9) of 3 (Residents #1, #4 and #9) case mix residents with severe weight loss in 3 months. This failed practice resulted in a pattern of actual harm to Resident #9, who experienced a severe weight loss of 16.26% in 3 months, and had the potential to cause more than minimal harm to 4 residents with severe weight loss, according to the facility's Weight Change History dated 3/19/13 at 9:29 a.m. The findings are: 1. Resident #9 had [DIAGNOSES REDACTED]. The Admission Minimum Data Set (MDS) with an Assessment Reference Date of 12/29/12 documented the resident scored 12 (8-12 indicates moderate cognitive impairment) on the Brief Interview For Mental Status, was independent for eating with set-up help, had no weight loss or gain and did not receive a therapeutic diet. The MDS recorded no height or weight for the resident. a. The resident's March 2013 Physician order [REDACTED]. b. The Weight Change History provided by the Administrator on 3/19/13 documented the resident weighed 126 pounds on 12/18/12, 126 pounds on 12/22/12 and 122 pounds on 1/1/13. c. The Nutritional Progress Notes entry dated 1/30/13 documented, "RD (Registered Dietician) Note: New Admission Wt (weight) 126 (pounds) ...Recommend obtaining Pre-Alb (pre-[MEDICATION NAME]) level for protein assessment." There was no pre-[MEDICATION NAME] laboratory result in the resident clinical record, as of 3/20/13. d. The Weight Change History provided by the Administrator on 3/19/13 documented the resident weighed 110 pounds on 2/4/13 and 107.5 pounds on 2/11/13. e. The Nutritional Progress Notes entry dated 2/13/13 documented, "RD Note: Wt 110 (pounds) down from 126 (pounds). Question accuracy of wt. Will ask for re-weigh (and) add 2 cal supplement BID (twice daily) 60 ml (milliliter) for wt loss (and) protein. Will monitor." f. The Weight Change History provided by the Administrator on 3/19/13 documented the resident weighed 107.5 pounds on 2/21/13, 106 pounds on 2/26/13, 106 pounds on 3/5/13 and 106.5 pounds on 3/11/13. g. On 3/19/13 at 1:00 p.m., during the lunch meal, and on 3/19/13 at 6:10 p.m., during the evening meal, the resident did not receive a supplement with her meal. 1) On 3/21/13 at 8:40 a.m., Certified Nursing Assistant (CNA) #1 was asked if the resident received any supplements on her meal tray. The CNA stated, "No." 2) On 3/21/13 at 10:50 a.m., Licensed Practical Nurse (LPN) #2 was asked if the resident received 2 cal supplements. She stated, "No." 3) On 3/21/13 at 1:20 p.m., the Dietary Manager was asked if the resident received 2 cal supplements. She stated, "I just started. I don't see her on the supplement list. I asked a dietary worker who has been here and she stated the resident wasn't receiving any supplements." 4) On 3/21/13 at 3:45 p.m., CNA #3 was asked if the resident received supplements. She stated, "No." At this time, CNA #4 stated the resident did not receive supplements. h. As of 3/20/13 at 1:40 p.m., the resident's Care Plan dated 12/18/12 did not address the resident's weight loss. i. On 3/21/13 at 9:20 a.m., the resident was weighed standing and weighed 105 pounds, per Certified Nursing Assistant (CNA) #5 and CNA #6. The CNAs were asked if the resident was weighed standing all the time. They stated, "Yes, and seldom in the wheelchair." The CNAs were asked to weigh the resident in the wheelchair. The weight obtained was 105.5 pounds, a severe weight loss of 16.26% since the resident's weight of 126 on 12/22/12. j. On 3/21/13 at 3:20 p.m., the Administrator was informed that the recommendations the Registered Dietician made on 2/13/13 had not been carried out to prevent further weight loss for the resident. The Administrator stated, "We looked for the lab (pre-[MEDICATION NAME]), but it wasn't done. We will get it done stat today." k. On 3/21/13 at 3:51 p.m., the Administrator, Regional Nurse Director of Operations, Director of Nursing (DON) and the Regional MDS Coordinator was informed of the facility's to failure to implement the recommendations from the RD to prevent further weight loss for the resident. The Director of Operations stated, "The RD did not give the facility a copy of the recommendations. She put them in the file and those were not carried out." When asked if they had identified a problem with the resident's weight, the Administrator stated, "No." l. On 3/22/13 at 9:40 a.m., the Administrator was asked for the Physician's number for interview. She stated, "The physician is out of town, but we can call him on his cell phone." At 11:10 a.m., the Administrator stated, "We put in a call to him, but he has not called back. The APN (Advanced Practice Nurse) is here, you can talk to her if you want to." At 11:20 a.m., the APN was asked if she and the physician were aware of the resident's weight loss. She stated, "I don't know anything about it, but I will check his notes to see if he may have written something in the chart in the progress notes. Usually if there is an issue, nursing directs it to us, document it somewhere so that we can see it, otherwise we won't know anything about it." The physician's progress notes were reviewed. There was no documentation that the physician had been notified regarding the resident's weight loss. m. On 3/22/13 at 10:20 a.m., a laboratory report dated 3/21/13 at 4:05 p.m. documented, "...Pre-Alb 4.5 L (low)... (Reference Range) 20.0- 40.0." 2. Resident #4 had [DIAGNOSES REDACTED]. a. The Nutritional Progress Note dated 1/7/13 documented, "Current weight is 138 (pounds)." b. The Plan of Care dated 2/6/13 documented, "Resident has had weight loss. Present weight 122.5 (pounds) RD (Registered Dietician) to evaluate on next visit. Food preferences to be done. Add Supercereal." c. The Nutritional Progress Note dated 2/13/13 documented, "RD Note: Weight 122 (pounds) down from 135 (pounds). Elder was hospitalized . Diet Puree. Meds include Alendronate, Donepezil, [MEDICATION NAME]. Was on Antibiotic for 14 days. Please ask MD (medical doctor) to consider medications to provide appetite friendly medication. Recommend adding 2 cal supplement 60 ml (milliliter) BID (twice a day) for weight stabilization." d. A physician progress notes [REDACTED]. Also has been verbally aggressive and angry, which may be related to Alzheimer type Dementia. She has been discussed with son today. He will discuss with brother to make decision about feeding tube placement. Start [MEDICATION NAME] 400 mg (milligram) BID. Start Metazipine ([MEDICATION NAME]) 7.5 mg at bedtime." e. The Plan of Care dated 2/27/13 documented, "Weight 119 (pounds). Continue to offer Supercereal, [MEDICATION NAME] and [MEDICATION NAME] and snacks between meals." f. As of 3/19/13 at 5:00 p.m., supercereal was not listed on the facility's Diet List, Dietary Supplement Lists or the Individual Dietary Tray Card provided by the Assistant Dietary Manager. The 2 cal supplement was not listed on the physician's orders [REDACTED]. She stated, "I didn't know she (resident) was supposed to have it." The Director of Nursing stated there had never been an order obtained to give the 2 cal supplement to the resident and that it had not been started yet. 3. The facility's Diet Changes and Reports policy provided by the Administrator on 3/22/13 at 9:58 a.m. documented, "...The nurse supervisor / charge nurse is responsible for notifying the dietary manager on duty of any changes in the resident's diet or meal service... Nursing services (i.e., director of nursing services, nurse supervisor, charge nurse) is responsible for notifying the dietary manager when a nutritional problem has been identified (i.e., weight loss, pressure ulcer, eating problem, dehydration, etc.)... Nutritional services / needs shall be provided in accordance with the resident's assessment and plan of care." The Diet Policy provided by the Administrator on 3/22/13 at 9:58 a.m. documented, "...The nurse will: Monitor the weight monthly or as ordered. Report significant weight loss to the physician. Consult with the Registered Dietician as needed. Observe for signs and symptoms of [MEDICAL CONDITION] Monitor lab values and report abnormal results to the physician. Monitor the use of dietary supplements..." The Notification of the RD Policy provided by the Administrator on 3/21/13 at 5:10 p.m. documented, "...The Director of Nursing should maintain a copy of the RD notification form as a copy of the nutritional recommendations made by the RD. Any nutritional problem should be addressed on the total care plan..." The facility's Weight Monitoring Program policy and procedure received from the Administrator on 3/21/13 at 5:10 p.m. documented, "It is the policy of this facility that each residents weight is monitored monthly, or as indicated by the residents condition or physician's orders [REDACTED]. The Dietary Manager will notify the RD."

Based on observation, interview and record review, the facility failed to ensure a resident received pain medication prior to pressure ulcer treatment and that the resident was placed in a comfortable position in bed to decrease the resident's discomfort during the treatment, which lasted one hour and 20 minutes, for 1 (Resident #9), failed to ensure a wound treatment was provided in accordance with the Physician's plan of care to promote healing for 1 (Resident #4) and failed to ensure the physician was promptly consulted upon identification of a new wound to prevent a delay in treatment for 1 (Resident #1) of 3 (Residents #1, #4, and #9) case mix residents with Physician orders [REDACTED].#9, who complained of severe pain throughout a 1 hour/20 minute pressure ulcer treatment, during which she received no pain management interventions. The facility also failed to assess and document the level of pain prior to administering as needed (PRN) pain medications and assess and document the effectiveness of the medications for 2 (Residents #3 and #8) of 9 (Residents #1, #3, #4, #5, #6, #7, #8, #9 and #10) case mix residents with physician orders [REDACTED]. 1. Resident #9 had [DIAGNOSES REDACTED]. The Admission Minimum Data Set (MDS) with an assessment reference date (ARD) of 2/1/12 documented the resident was admitted [DATE], scored 5 (0-7 severe cognitive impairment) on the brief interview for mental status (BIMS), had experienced no pain in the last 5 days, had a fall resulting in a fracture in the last 6 months and had an unstageable pressure ulcer that measured 2.5 centimeters (cm) long by 2.0 cm wide by 0.4 cm deep. a. The resident's February 2012 Physician order [REDACTED].) wrap with kerlix QD (everyday)... 12/16/11 ... Cleanse left ankle wound with NS (normal saline), apply TAO (triple antibiotic ointment), cover with foam, wrap with gauze QD... 1/26/12... Wound Vac (vacuum) to left lateral malleolus surgical site continuous. Change dressing Q (every) Monday, Wednesday and Friday... " b. The resident's Care Plan last updated 2/15/12 documented, "Problem Onset: 1/26/2012... Alteration in comfort level r/t (related to) s/p (status [REDACTED]. (Goal) Resident to have no undetected unidentified complaints of pain... Provide comfort measures to help alleviate the pain... Administer meds (medications) as ordered per MD (medical doctor)... Monitor and document the location, duration and intensity of the pain / discomfort as indicated with s/s (signs / symptoms) or c/o (complaint of) pain... Notify MD if pain medications are ineffective..." c. On 2/13/12 at 4:49 p.m., the resident was lying in bed and voiced no complaints of pain or discomfort. d. On 2/14/12 at 9:00 a.m., the resident was sitting in a wheelchair in the 300-Hall corridor with a [DEVICE] in place. The resident voiced no complaints of pain or discomfort. e. On 2/14/12 at 9:30 a.m., the resident was sitting in the shower room with the [DEVICE] disconnected. The resident voiced no complaints of pain or discomfort. f. On 2/14/12 at 11:28 a.m., the resident was sitting in a wheelchair with a [DEVICE] in place. The resident voiced no complaints of pain or discomfort. g. On 2/14/12 at 11:35 a.m., Licensed Practical Nurse (LPN) #4 entered the resident's room and stated, "I hope this ([DEVICE]) can be fixed; her suction is not good." The resident was sitting in a wheelchair. The LPN cut a soiled bandage from the resident's left ankle and foot. When the resident's lower left leg was manipulated or moved, the resident cried out in pain and stated her foot, "hurt so bad." The LPN stated, "I can't get the leg lifted high enough to do this properly. I'm going to get help." The LPN left the room, but returned with only additional supplies. The LPN left the resident in the wheelchair and began the treatment before assistance arrived. She removed an Opsite-secured transparent dressing from the resident's left outer ankle/foot, which was elevated in the wheelchair leg rest. The LPN stated she had never performed this treatment on the resident while the resident was in a wheelchair. The LPN asked the resident if she could raise her left leg up, but the resident was unable to comply. The LPN attempted to lift the resident's left leg to place a rolled up sheet under it. The resident began to cry. The LPN removed the leg rest and lowered the resident's left lower extremity to rest on top of a rolled up sheet. The resident continued to moan and cry softly. When the LPN removed the dressing, tissue slough was noted. The wound was bleeding and the blood was running down the resident's foot and onto the rolled up sheet that was serving as a foot rest. The wound was between 4 and 5 inches long and at least 1-inch wide at the middle. The LPN trimmed the edges of the transparent dressing. The resident cried, "My foot; it hurts me so bad." The LPN repositioned the resident's foot on the sheet. As the wound was cleansed with normal saline and gauze, the resident continued to whimper. The LPN stated, "She had an ankle fracture and had a repair with a lot of hardware; she wore a cast for 2 weeks, then an air boot. Her surgical site kept getting worse. I asked if I could remove the air boot and they said no. She kept getting worse, so they x-rayed her to rule out Osteo[DIAGNOSES REDACTED]. The x-ray was negative. That was on a Friday. When I came back on Monday, you could see her metal, so we sent her back to the doctor's. Anyway, to make a long story short, we had to send her back again. They removed all the hardware and we are keeping on the wound vac." LPN #7 entered the resident's room and put on a gown and gloves; the LPN then held the resident's lower left extremity as LPN #4, the treatment nurse, applied a transparent dressing over the entire site in an attempt to get a complete seal for the [DEVICE]. When the [DEVICE] was turned on, the absorbent dressing deflated. The entire foot was wrapped in rolled gauze and secured with tape. A foam cushion was applied to the heel before wrapping. LPN #7 left the room. LPN #4 replaced the left foot and leg rest back on the resident's wheelchair and off-loaded the resident's left heel. The resident stated, "It hurts so bad." LPN #4 cleaned up the supplies from the procedure. LPN #7 brought a lunch tray to the resident. The resident was moaning, not attempting to eat. LPN #4 exited the room at 12:55 p.m. and never offered the resident medication for pain throughout the 1 hour and 20 minute procedure. h. On 2/14/12 at 3:40 p.m. and on 2/15/12 at 8:50 a.m., the resident was lying in bed with a [DEVICE] in place. The resident voiced no complaints of pain or discomfort. i. On 2/16/12 at 3:20 p.m., LPN #4 was asked if the resident had been administered pain medication prior to the onset of the one hour and twenty minute long [DEVICE] procedure. The LPN stated, "I don't remember. I don't give the pain meds." When asked if she thought the resident should have been pre-medicated, the LPN stated, "Probably, but I don't give medications." j. As of 2/16/12 at 3:30 p.m., the resident's February 2012 PRN (as needed) Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. LPN #1 (a medication nurse) stated, "I will work with (LPN #4) and we will give pain meds before those treatments. She (Resident #9) needs it." k. On 2/16/12 at 5:20 p.m., the Director of Nursing (DON) was asked about residents who experienced pain during care; the DON stated, "Yes, if a resident is crying out during a prolonged treatment or services, the staff should stop and seek treatment for [REDACTED]. 2. Resident #4 had [DIAGNOSES REDACTED]. The Annual Minimum Data Set with an assessment reference date of 2/4/12 documented the resident was severely impaired in cognitive skills for daily decision making per staff assessment for mental status, was at risk for the development of pressure ulcers and had one Stage II pressure ulcer. a. The Physician order [REDACTED]. b. On 2/15/12 at 2:30 p.m., the resident returned to bed in his room, after a shower; a body audit was performed at this time. The resident had a rash on both upper buttocks. Certified Nursing Assistant (CNA) #1 stated, "The Treatment Nurse will be in to do his treatment soon." At 4:30 p.m., the treatment to the resident's hip had not been administered. c. On 2/15/12 at 4:55 p.m., Licensed Practical Nurse (LPN) #4, the Treatment Nurse, was asked about the resident's treatment. She stated, "...his hips were okay, the [MEDICATION NAME] was discontinued..." At this time, the resident's clinical record was checked; no order to discontinue the [MEDICATION NAME] was found. d. On 2/16/12 at 5:50 p.m., the Assistant Director of Nursing (ADON) was asked when the resident's treatment of [REDACTED].#4)'s left hip..." The ADON was asked if the resident should have received the treatment; she stated, "Yes." 3. Resident #1 had [DIAGNOSES REDACTED]. The Admission MDS with an assessment reference date of 8/1/11 documented the resident scored 15 (13 - 15 independent cognitive skills) on the brief interview for mental status, was totally dependent on the physical assistance of two people for bed mobility, transfers, toileting and bathing, was at risk for developing pressure ulcers, had a Stage I or higher pressure ulcer and had a Stage IV pressure ulcer. a. The Care Plan dated 8/7/11 documented, "...at Risk for Fluid Volume Deficit Related to Dependant on Staff for ADLS (activities of daily living)... Monitor Skin Integrity, Notify MD (medical doctor) of any Abnormal Findings..." b. On 2/15/12 at 10:45 a.m., while preparing to do wound care, Licensed Practical Nurse (LPN) #4 noted a wound on the resident's right upper thigh that was approximately 2-inches long and 1/4-inch wide; the wound was covered with a fluid filled sac. During wound care, this area was not cleansed or treated. c. On 2/16/12 at 2:55 p.m., when asked about the blister area on the resident's right upper thigh, LPN #4 stated, "I've never seen that on her leg." When asked to provide documentation to show when she had contacted the resident's physician regarding the blistered area observed on 2/15/12, LPN #4 stated, "I'll call him and tell him now." 4. Resident #3 had [DIAGNOSES REDACTED]. The Annual MDS with an ARD of 8/23/11 documented the resident had modified independence in cognitive skills for daily decision making per a staff assessment of mental status, usually understood others and was able to make herself understood. a. The Care Plan dated 8/16/11 documented, "Potential for Alteration in Comfort Level ...Assess and document the location, duration and intensity of the pain/discomfort..." b. The Pain Evaluation assessment form dated 8/16/11 documented the resident said she did not have pain. The form further documented the resident had no non-verbal signs or symptoms of pain. c. The resident's February 2012 PRN (as needed) Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Staff initials on 2/1/12, 2/2/12, 2/4/12, 2/5/12, 2/6/12, 2/7/12 and 2/13/12 documented administration of the [MEDICATION NAME]. The comments section on the back of the February 2012 MAR indicated [REDACTED]. 1) The Nurse's PRN/Medication Notes (a page of the MAR) did not have any documentation regarding any prn medication given between 2/1/12 and 2/13/12. 2) The Pain Flow Sheet (a page of the MAR indicated [REDACTED]. d. The Narcotics sign out sheet for the resident's [MEDICATION NAME] 5/325 mg documented, as of 2/17/12 at 8:45 a.m., staff signed out one dose on 2/2/12 at 9:00 a.m., 2/3/12 at 9:00 a.m., 2/6/12 at 9:00 a.m., 2/7/12 9:00 a.m., 2/7/12 at 7:00 p.m., 2/8/12 at 9:00 a.m., 2/9/12 at 5:00 p.m., 2/10/12 at 9:00 a.m., 2/13/12 at 9:00 a.m. and 2/14/12 at 9:00 a.m. e. The untimed Nurse's Notes dated 2/1/12 documented, "...No c/o (complaints of) pain/distress..." The untimed Nurse's Notes dated 2/2/12 documented, "...No c/o pain/distress..." and "...No c/o pain." The Nurse's Notes dated 2/4/12 at 2:30 p.m. documented, "...No c/o pain." The Nurse's Notes dated 2/5/12 at 3:35 p.m. documented, "...No c/o pain." The untimed Nurse's Notes dated 2/6/12 documented, "...No c/o pain." The untimed Nurse's Notes dated 2/7/12 documented, "...No c/o pain." The untimed Nurse's Notes dated 2/13/12 documented, "...No c/o pain." 5. Resident #8 had [DIAGNOSES REDACTED]. The Admission MDS with an ARD of 11/18/11 documented the resident scored 2 (0 - 7 severe cognitive impairment), required the limited assistance of one person for transfers and walking in the corridor, used a walker or wheelchair for mobility, had received a scheduled pain medication and an as needed pain medication in the last 5 days. a. The Care Plan dated 11/11/11 documented, "Potential for Alteration in Comfort ...Observe resident for s/s (signs and symptoms) of pain, document the effectiveness of pain med (medication)..." b. The Pain Evaluation assessment form dated 11/11/11 documented the resident said she had sharp pain in the last five days which was increased by weight bearing to the left knee which caused a decrease in physical/social activity. c. The February 2012 PRN MAR indicated [REDACTED]." Staff initials documented the [MEDICATION NAME] was administered on 2/14/12, 2/15/12 and 2/16/12. d. The Narcotics sign out sheet for Resident 8's [MEDICATION NAME] 50 mg documented staff signed out one dose on 2/15/12 at 9:00 a.m. e. The untimed Nurse's Notes dated 2/14/12 documented, "...No c/o pain/distress..." The untimed Nurse's Notes dated 2/15/12 documented, "...No c/o pain..." The untimed Nurse's Notes dated 2/16/12 documented, "...No c/o pain..." 6. On 2/16/12 at 5:20 p.m., the DON was asked about documentation of pain assessments related to PRN pain medication administration and stated, "It (assessments prior to and after the administration of pain meds) is supposed to be documented on the back of the MAR indicated [REDACTED]. It should definitely be on the back of a MAR." Residents #3's and Resident #8's MARs were examined with the DON; no documentation was found regarding assessments prior to and after the administration of pain medications. The DON stated, "...when they sign they give it (a prn medication) they should be charting then, and chart the date, the time, what they are giving and why, then go back and chart the effectiveness of the medication." 7. The facility's undated policy titled, "Pain Management" documented, "...resident pain level will be assessed and pain medication administration as ordered. Cognitively impaired residents will be assessed utilizing behavioral or visual indicators... Documentation guidelines, date, time (or shift) as appropriate on MAR, other documentation may include, pain level using the Pain Assessment..."

Based on record review and interview, the facility failed to provide Resident #6 sufficient fluid intake to maintain proper hydration and health. he facility failed to ensure fluid intake was monitored and documented to ensure adequate daily fluid intake and specific interventions to prevent dehydration were developed, communicated to staff and implemented for 1 (Resident #6) of 4 (Residents #6, #7, #8, and #9) case mix residents who were at risk for dehydration. The failed practice resulted in a pattern of actual harm to Resident #6, who experienced an episode of dehydration that resulted in emergency room hospitalization for dehydration, and had the potential to cause more than minimal harm to 22 residents who were at risk for dehydration as documented by the Licensed Practical Nurse (LPN) #6 on 4/4/11. The findings are: 1. Resident #5 had [DIAGNOSES REDACTED]. a. The Living Will dated 7/12/06 documented, "...If I have check "Yes" to the following, my attorney(s)-in-fact may have a feeding tube or other forms of non-oral nutrition and hydration withheld or withdrawn from me, unless my physician has advised that, in his or her professional judgment, this will cause me pain or will reduce my comfort...Withhold or withdraw a feeding tube or other forms of non-oral nutrition and hydration (checked)Yes..." There was no documentation in the Living Will that indicated the resident wished to have oral hydration withheld. b. The Physician Orders dated 7/20/10 documented, "Regular with Pureed Meat" diet. c. The Nutritional Evaluation History and Data Collection dated 9/9/10 documented, "Estimated Fluid Needs 62.09 Wt/Kg (Weight/kilograms) X (times) 25 Fluid Factor = 1550 mL's (milliliters) fluid ...Fluid [MEDICAL CONDITIONS] 25 ml/Kg..." d. The Significant Change Minimum Data Set (MDS) with an Assessment Reference Date of 1/23/11 documented a Staff Assessment for Mental Status as moderately impaired and the resident was totally dependent on staff for eating and drinking. e. The Care Plan dated 1/23/11 documented, "Problem Onset: 1/23/11 Resident at Risk for Fluid Volume Deficit R/T (related to) Diuretic use D/T (due to) [MEDICAL CONDITION]; Needs Total Assist for Fluids and meals R/T Decreased self awareness R/T Alzheimer's Dementia Goal Resident will have no signs or symptoms of dehydration through next review 4/23/11 Approaches Monitor intake and output every shift. Obtain labs as ordered. Provide adequate hydration. Monitor skin integrity. Notify MD (medical doctor) of any abnormal findings. Meds as ordered. Monitor for signs and symptoms of dehydration i.e. (for example) cracked lips, flaky skin, decreased urinary output, poor skin turgor, elevated temp, sunken eyes etc. (etcetera)... Problem onset: Potential for alteration in skin integrity R/T (related to) impaired mobility & incontinent of B & B (bowel and bladder)... Encourage adequate hydration..." f. The Physician's Progress Notes-Geriatrics dated 1/26/11 documented, "...BUN (blood urea nitrogen) 29 Creatinine 1.30 ...CRD (Chronic [MEDICAL CONDITION]) Stage 3-(at) baseline monitoring." g. The Nurse Aide's Information Sheet documented, "...Meals...Assist and /or prompt ...Comments: Encourage Fluids..." h. The March 2011 Physician Orders did not document any oral fluid restrictions. i. The March 2011 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]@ (at) 10 AM ...breakfast fluids 3/21/11 (initialed with a circle indicated not taken) lunch fluids (not legible) ...3/24/11 lunch fluids (not marked) supper fluids 50..." The record documentation did not indicate if the amount "50" was recorded as a percentage of total amount or if the amount "50" was milliliters. j. The March 2011 24 Hour Resident Care Sheet documented: "...Feeds self No... Spoonfed: Yes... Consumption/Snacks ...3/23 Breakfast % 100/240 Lunch % 80/240 Supper % Blank Snack 10 AM Snack % 3 PM Blank Snack % HS (bedtime) Blank 3/24 Breakfast % 70/120 Lunch % 60/120 Supper % R (refused) Snack 10 AM 3PM HS 3/25 Breakfast 80/240 Lunch 100/240 Supper Hosp (hospital) Snack 10AM Snack 3 PM..." with initials documented. On 3/12/11 and 3/13/11 there was no documentation on these dates that indicated the resident received meal, fluid, or snack intake. The total amount of fluids documented for the 24 hour period prior to the resident's hospitalization for 3 consecutive meals from 3/24/11 Supper through to the 3/25/11 HS (bedtime) snack was 960 ml (milliliters) and included the medication on the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. This total was less than the recommended daily fluid amount of 1550 ml. k. Nurses Notes dated 3/25/11 7-3 documented and signed by LPN #5, "...Res (resident) not eating/or communicating. Place a call in to (doctor) office to get appointment recd (received) for April 12, 2011. (ambulance service) called (and) set appointment. Family notified of appointment. Resident is to be assessed for hernia..." There was no documentation that indicated whether or not the resident had taken oral fluids. There was no documentation that the physician was advised of the status of oral fluid intake. 1) On 4/1/11 at 2:40 p.m., LPN #5 was asked what was done for the resident on 3/25/11 and the LPN stated, "Because I'm new to the hall and the aide told me she's not eating, (LPN was asked if the CNA was asked if the resident was drinking fluids) she didn't say anything about if she was drinking or not, she just told me she (the resident) was not eating, we (LPN #5) and (LPN #3), went to her (resident) and looked at her. (LPN #3) worked that hall a long time and she said we can call the doctor cause she has a hernia and the (physician) was here so I paged him and he came, he said it was fine for a consult... I just told him she wasn't eating and has a history of a hernia and he said get a consult." 2) On 4/1/11 at 6:40 p.m., LPN #3 was asked what the resident's physician was informed of when the resident was seen on 3/25/11. The LPN stated, "He assessed her, he looked at her, asked me about her eating and drinking. That she wasn't taking in much. That she was taking some fluid that was the report I got." The LPN was asked how much fluids the resident had taken and if it was the amount required for this resident. The LPN stated, "I honestly don't know. I just went by what the nurse told me. I'd have to look at her ADL's." The LPN then reviewed the meal consumption sheet dated March 2011 and stated, "She looks like at least 100cc of fluid at every meal." The LPN was asked what the amount of fluid was taken by the resident the day before the resident went to the hospital (3/24/11) and the LPN stated, "Looks like approximately 500 cc." The LPN was asked how much fluid the resident should have received daily and the LPN stated, "Probably anywhere from a 1000 cc to 1500 cc." The LPN was asked if a resident was on a diuretic did they lose fluid and the LPN stated, "Yes." The LPN was asked if this resident had any type of fluid restriction and the LPN stated, "She doesn't have any fluid restrictions. The dietician, the nutrition assessment for September 2010 documented 1550 cc per day." The LPN was asked if the resident had received the required amount of fluid per day and the LPN stated, "No, not according to this, the ADL." The LPN was asked if a resident was dependent when should they receive fluids and the LPN stated, "Yes, as often as possible." The LPN was asked if the amount of fluids offered, taken, and refused was documented and the LPN stated, "I don't see anything documented in the actual chart but we do look at our flow sheets everyday." The LPN was asked if the resident would drink if fluids were offered and the LPN stated, "Yes." The LPN was asked if the resident could drink thin liquids and water and the LPN stated, "Yes." The LPN was asked if staff had to offer the liquids to the resident and the LPN stated, "Yes." l. As of 4/1/11 at 7:45 p.m., there was no documentation in the Nurses Notes dated 1/3/11 through 3/25/11 to indicate the resident was offered and refused fluids, intake and output was monitored, and if the resident was monitored for signs and/or symptoms of dehydration. m. Staff interviews regarding the resident's fluid intake: 1) On 4/1/11 at 12:07 p.m., LPN #4 was asked how intake and output was monitored and the LPN stated, "We have I & O sheets. Each hall has a folder, then we file it under vital signs." The LPN was asked if an I & O was done on each resident and the LPN stated, "Tube feeding, Foley, ADL (activity daily living) sheets, some spots on the MAR (medication administration record)." The LPN accompanied the surveyor then went to the nurses station and picked up a folder. The LPN was asked who received I & O on the hall where Resident #6 resided and the LPN stated, "(non-case mix resident)." The LPN was asked if Resident #6 was someone at risk and should get an I & O and the LPN stated, "I don't think that she is at risk." The LPN was asked if the resident was on diuretics and the LPN stated, "Yes." LPN #4 was asked if the resident ever refused to drink and the LPN stated, "No, she drinks real good. Right before she went to the hospital she started having problems with her eating. The doctor ordered a swallowing study from us." The LPN was asked what type of problem the resident had and the LPN stated, "It was reported to me that she was holding food in her mouth. She was swallowing the liquids, it was just the food." The LPN was asked how it was known the resident could swallow liquids and the LPN stated, "She was swallowing with medications." The LPN was asked where it was documented what liquids the resident took with the medication pass and the LPN stated, "Usually we don't keep up with what she took on med pass." At 12:25 p.m., LPN #4 was asked if the resident could get her water pitcher and drink on her own and the LPN stated, "No she could not comprehend." The LPN was then asked if the staff had to offer and hold the water to get the resident to drink and the LPN stated, "Yes. Did not have any difficulty swallowing water. 2) On 4/1/11 at 1:25 p.m., Certified Nursing Assistant (CNA) #2 was asked if there was any resident on the hall where Resident #6 resided that was to be monitored for intake and output (I & O) and the CNA stated, "No one on my hall." 3) On 4/1/11 at 1:32 p.m., CNA #1 was asked if Resident #6 required assistance with meals and fluids and the CNA stated, "Yes." The CNA was asked if the resident was dependent on staff for her oral intake and the CNA stated, "Yes." The CNA was asked how much fluid intake the resident had taken each day and the CNA stated, "The little 120 cc carton. She gets it after every meal." The CNA was asked where the fluid intake was documented and the CNA stated, "Meal percent sheets." The CNA was asked how much fluid the resident needed and received each day and the CNA stated, "I can only go by what I gave her. She had her health shake. She would have one around 10:00 a.m. or 10:15 a.m. and after lunch around 2 or 2:15 p.m..." The CNA was asked if the resident swallowed liquids and the CNA stated, "Liquids she would swallow." The CNA was asked how often the resident was offered water and the CNA stated, "After I got her care." CNA #1 was then asked how much water the resident would take and the CNA stated, "Not that much, just a little bit, it wasn't that much, she spit it out." The CNA was asked approximately how much water the resident would take and the CNA stated, "She drank 10 cc of water and had no problems swallowing water." The CNA was asked what condition the resident was in before transferred to the hospital and the CNA stated, "The lips were a little cracked, gums had food in them. Tongue was cracked..." 4) On 4/1/11 at 3:03 p.m., LPN #1 was asked how it was determined if a resident was at risk for dehydration and the LPN stated, "First off before I ever lay eyes on her, I look at her medications, her cognitive level, physical abilities, look at lab studies, and diagnosis." The LPN was asked how it was determined that Resident #6 was at risk for dehydration and the LPN stated, "She takes daily diuretic use and that automatically triggers MDS (Minimum Data Set) for dehydration or fluid volume deficit. She needs total assist for her nutritional assist for hydration. Because of her Alzheimer's dementia because she had a decreased self awareness for needs for fluid." LPN #1 was asked where the amount of fluid intake was recorded and if there was an I & O sheet and the LPN stated, "Meal percent on ADL flow sheet. Nurses notes." The LPN was asked if resident was at risk for dehydration, was fluid intake to be documented and the LPN stated, "I would assume so." The LPN was then asked who was at risk for dehydration and the LPN stated, "Everyone that is on a diuretic." n. Nurses Notes dated 3/25/11 at 1800 (6 p.m.) occurrence 1720 (5:20 p.m.) documented: " This nurse was in office...when heard a person yelled 'somebody fell '...Found (Resident #6) on floor in fetal position in front of w/c (wheelchair). Blood noted on floor...Hematoma noted to (left) side of forehead (with) abrasion...911 called by nurses...(ambulance service) left (with) resident 1750 (5:50 p.m.)." 1) The Emergency Medical Services narrative dated 3/25/11 at 5:26 p.m. documented, "Narrative... Crew unable to establish IV (intravenous) due to poor veins..." 2) The emergency room Physicians Orders dated 3/25/11 documented, "...NS (normal saline) @ (at) 100 ml/hr (hour) [MEDICATION NAME] 500 cc (cubic centimeters) [MEDICATION NAME] 500 ml... Head & Eyes Appears dry... Clinical Impression ...Dehydration, Acute [MEDICAL CONDITION]" 3) The ER Nursing Record dated 3/25/11 thru 3/26/11 at 0153 (1:53 a.m.) documented, "...mouth care done for 2nd time, unable to get all the caked on dried stuff off her lips & (and) mouth..." 4) The Lab Results dated 3/25/11 at 8:25 p.m. documented, "...Sodium 166 (reference range 138-146 mmol/L) ...BUN 100 H (high) (8-26 mg/dL milligrams diluted) Creatinine 3.4 H (0.6-1.3)..." 5) The Hospital History and Physical dated 3/26/11 documented, "Chief Complaint: Fall... History of Present Illness: ...The patient was found to be severely dehydrated with a sodium of 166 and creatinine of 3.4 with BUN of 100 in the emergency room ... This morning the patient is very lethargic and nonverbal, cannot voice any complaints, and obtaining the medical information was a challenge... She is currently being hydrated... Diagnostic Data: Labs: Sodium 166, BUN 100, creatinine 3.4, hemoglobin 16.2 hematocrit 47.2... HEENT (head, eyes, ears, nose, throat) Dry mucous membranes... Assessment and Plan: ...status [REDACTED]. 1. Severe dehydration. We will hydrate aggressively, and follow up on BUN, creatinine, and sodium... 3. [MEDICAL CONDITION] with underlying severe dementia secondary to severe dehydration... 5. Acute kidney injury with [MEDICAL CONDITION] secondary to severe dehydration. Will hydrate and continue to monitor. 7. [MEDICAL CONDITION]. No signs or symptoms noted currently. Will hold all the medications and once the dehydration is taken of will resume the medications..." 6) The Hospital admission orders Admission Information:... Diagnosis: [REDACTED]. IV Fluids and Therapy... IVF (intravenous fluids) NS at 100 ml/hr..." 7) The Physicians Orders dated 3/26/11 at 3:00 p.m. documented, "...(change) IVF to D5 1/2 NS ([MEDICATION NAME] 5 percent one-half normal saline) (at) 100cc/hr..." 8) A Physician Consultation dated 3/29/11 documented, "...History of Present Illness: ...Her baseline creatinine is 0.9, and is now 2.0. Sodium currently is 173 with a BUN of 53. ...ASSESSMENT: 1. Acute [MEDICAL CONDITION] secondary to decreased intravascular volume. The patient's [MEDICAL CONDITION] also increases the risk of acute tubular necrosis. 2. Severe [MEDICAL CONDITION] secondary to dehydration... PLAN: I will plan to place a PICC (peripherally inserted central catheter) line, and if unable a CVL (central venous line). The patient requires significant IV ...and maintain strict I's and O's and start D5W ([MEDICATION NAME] 5 % water) at 125 ml an hour... I have asked Nursing to call me every 4 hours regarding serial BMP (basic metabolic profile) to help guide fluid management..." o. On 4/1/11 at 2:15 p.m., the Director of Nursing (DON) #1 was asked how the facility determined a resident was at risk for dehydration?She stated, "It is kind of on admit, we do an assessment to see if someone is not eating or drinking." The DON was asked if a resident was identified as at risk would the resident be monitored? She stated, "Not on everyone, if they have a Foley or feeding tube we document. It's difficult sometimes we'll call the RD (registered dietitian), sometimes we'll call the family, the kitchen has a pitcher of water and juice they offer at meal times." The DON was asked if a resident was dependent and could not get self drink of water what is done? She stated, "We pour it for them, we offer it, we don't have that many that can voice their needs with dementia and we are aware of that ..." The DON was asked if there were residents that had care plans that directed to do an I & O and monitor fluids. The DON stated, "Everyone is supposed to have intake. As staff is informed. We don't do accurate outputs on our residents. The only way we can monitor (output) is by her (Resident #6) output in her brief." The DON was asked if Resident #6 was dependent on staff for intake and the DON stated, "She pretty much is dependent on staff for eating and drinking. She has Alzheimer's. She is quite dependent. She is spoonfed, a pureed meat diet." The DON was then shown the documented risk of fluid volume deficit on the care plan and the DON gave no comment. p. On 4/1/11 at 7:30 p.m., the DON #2 was asked how much fluid do residents need each day and the DON stated, "I don't actually know. Most people not on a fluid restriction should get at least 2000-3000 cc a day if not on fluid restriction." The DON was asked if nurses notes documented monitoring of Resident #6 for signs and symptoms of dehydration and the DON stated, "No." The DON was asked if the resident was at risk for dehydration and the DON stated, "I would say yes. From the dementia she has and fact of pocketing food. Yes she would be." q. On 4/1/11 at 8:12 p.m., the Administrator was asked if there was a hydration policy or procedure and the Administrator stated, "No. We have they are to round every 3 hour and we provide fluids."

Complaint # substantiated (all or in part) in these findings. Based on record review and interview, the facility failed to ensure allegations of spouse mistreatment/abuse was reported and thoroughly investigated and protection of the resident was provided for 1 of 1 case mix resident (Resident #15) who staff observed abusive behaviors from the spouse and failed to intervene. This failed practice resulted in immediate jeopardy which caused or could have caused serious harm, impairment or death for Resident #15 whose spouse was not prevented from physically and emotional abusing the resident from 6/20/10 through 1/7/11. The facility removed the immediate jeopardy prior to the survey but did not correct the underlying failed practices. On 3/4/11 at 4:55 p.m., the Administrator was informed of the Immediate Jeopardy (removed). The facility also failed to ensure allegations of abuse and neglect were thoroughly investigated and reported to the local law enforcement in the time frames established by state law for 2 of 2 (Residents #21 and #22) case mix residents. These failed practices had the potential to affect all 79 residents as documented on the Resident Census and Conditions of Residents dated 3/1/11. The findings are: 1. Closed Record Review: Resident #15 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Discharge Assessment-Return Anticipated Minimum Data Set with an Assessment Reference Date of 11/9/10 documented the resident had a Brief Interview for Mental Status (BIMS) score of 1 (0-7 indicates severe impairment) and required extensive assistance of 2 staff for transfers and ambulation. a. The Nurses' Notes dated 6/20/10 at 8:25 a.m. and signed by LPN (Licensed Practical Nurse) #8 documented, "Resident sitting up in the wheelchair at the table in the dining room. Husband at side eating out of resident's plate while resident is eating. Encouraged resident to eat & (and) husband to order a tray for himself..." The Nurses' Notes dated 8/2/10 at 1:30 a.m. and signed by LPN #9 documented, "This nurse overheard (resident's) husband tell her 'You're not gonna freeze to death, now shut the hell up'... (Resident #15) appeared upset, was wearing a jacket at this time..." The Nurses' Notes dated 8/11/10 at 8:00 p.m. and signed by LPN #5 documented, "...LPN (Licensed Practical Nurse) suggested that husband give remainder of drink to (Resident #15). (Resident #15) stated, 'No' and physically pulled back as if she'd been struck. (Resident #15) behaved (with) fear toward her husband." The Nurses' Notes dated 8/17/10 at 7:00 p.m. and signed by LPN #5 documented: "(Resident #15's) husband came to desk and asked for copy of (Resident #15's) medications. LPN stated that a copy of physician's orders [REDACTED]. (appointment) for (Resident #15). Husband became very angry and said I just need a simple list. He had exited the DR (dining room) (with) (Resident #15) in W/C (wheelchair) (after the supper meal). He then took (Resident #15) outside in the heat. @ (At) that (time) 2 Certified Nurse Assistants (CNAs) came from the Dining Room and stated that husband had pushed (Resident #15's) W/C (wheelchair) into the wall hitting bil (bilateral) knees to the wall. This occurred @ 1845 (6:45 p.m.). Two witnesses statements were obtained from the CNAs regarding this incident. Husband kept (Resident #15) outdoors for 10-15 minutes. 1915 (7:15 p.m.): (Resident #15's) husband re-entered blg (building) and came to nurses' station and asked LPN to write list of all (Resident #15's) meds (medications), times, etc. LPN stated that he should speak (with) Director of Nursing (DON) in a.m. regarding this matter. He then once again exited the bldg (building) (with) (Resident #15) in W/C. It should be noted that while outside with (Resident #15), was observed having (Resident #15) propel W/C on her own in the heat. Husband was cautioned that it was hot outside and that he should limit (time) outside due to (Resident #15's) physical condition. Advice not taken..." b. An Incident/Accident report dated 8/17/10 at 6:45 p.m. signed by LPN #5 documented, "CNAs observed husband pushing (Resident #15's) W/C in DR. He pushed W/C into wall hitting Bil knees against wall. He then took (Resident #15) outside in heat X (times) 2 for twenty minutes each (time)..." Witness statements were written by CNAs #12 and #13. No interventions were documented. An Incident/Accident report dated 8/17/10 with no time documented and signed by LPN #5 documented, "CNA reported to LPN that (Resident #15's) husband was jogging while propelling (Resident #15's) W/C down hill in back parking lot of VRNR (Valley Ranch Nursing and Rehab). Other CNA observed from Activity Room, Husband holding gate open and (Resident #15) propel self quickly and husband pulled (Resident #15) in W/C through gate." The witness statement was written by CNA #13. No interventions were documented. c. The Nurses' Notes dated 10/30/10 at 2:09 p.m. and signed by LPN #5 documented, "...Husband was eating (Resident #15's) food off tray and drinking milk from carton..." The Nurses' Notes dated 11/1/10 at 8:00 a.m. and signed by Registered Nurse (RN) #2 documented, "LPN and this RN were informed of bottles of pills in (Resident #15's) drawer. We went to (Resident #15's) room and removed 6 bottles of meds from drawer. Facility policy states that residents can't have meds in their room. (Resident #15's) husband confronted me and stated, 'You are stealing'. I informed him to please take to his car the meds. He walked off (with) bag of meds. He went into (Resident #15's) room, then (approximately) 10 minutes later took bag of medication to his vehicle." The Nurses' Notes dated 11/4/10 at 7:45 p.m. and signed by LPN #10 documented, "Spouse returned to facility and stated that, 'You forgot to give me the Insulin. I checked the blood sugar myself. It was 212. Just give me the Insulin and needle'. Spoke (with) RN who stated spouse must demonstrate proper Insulin administration per physician order [REDACTED].' This nurse called daughter to notify of incident." The Nurses' Notes dated 11/9/10 at 12:30 p.m. and signed by LPN #7 documented, "(Resident #15's) husband was walking the resident from her room to DR (after) he has been asked and instructed not to D/T (due to) her strong Hx (history) of falls (with) significant inj (injury). (Resident #15) was c/o (complaining), 'It's too far'. (Resident #15's) spouse became angry and raised his voice at this LPN when she tried to assist. (Resident #15's) husband stuck his elbow into LPN's side blocking any attempt @ staff's assistance. When (Resident #15) sat in chair, she almost missed it, didn't reach back for side rails and husband let go of her. Again, spouse was reminded to not amb (ambulate) (without) staff assist." The Nurses' Notes dated 11/10/10 at 5:30 p.m. and signed by LPN #5 documented, "(Resident #15) sitting in DR eating dinner, LPN observed (Resident #15's) husband eating food off (Resident #15's) tray. Husband consumed 90% of (Resident #15's) food from tray." The Nurses' Notes dated 1/18/10 with no time documented and signed by LPN #5 documented, "...Husband con't (continues) to eat from (Resident #15's) tray @ meal (times)..." The Nurses' Notes dated 11/26/10 at 7:30 a.m., with the signature non- legible, documented, "... (Resident #15) not quite as alert today. Husband forcing (Resident #15) to keep pushing ahead on RW (rolling walker) and pushing W/C back from her as witnessed by 2 Restorative CNAs." The Nurses' Notes dated 12/3/10 at 10:00 p.m. and signed by LPN #5 documented, "...Husband was observed eating (Resident #15's) food off tray..." The Nurses' Notes dated 12/7/10 at 6:15 p.m. and signed by LPN #5 documented: "Supervisor informed (Resident #15's) husband, who often takes food from (Resident #15's), tray was for resident and that he could purchase a tray for himself @ a cost of $3. Husband stated that he didn't want to purchase tray. After Husband departed, (Resident #15) offered another supper tray and consumed 100%." The Nurses' Notes dated 12/8/10 at 1:15 p.m., with the signature non-legible, documented, "Res. amb (with) husband. He is pulling W/C behind him instead of having it behind resident. Insistent that she walk entire route from DR (to) (room) 106..." The Nurses' Notes dated 12/17/10 at 11:30 p.m. and signed by LPN #5 documented, "(Resident #15) returned from ER (emergency room ) @ 1600 very tired. Husband amb (Resident #15) to DR (with) gait belt. (Resident #15) SOB (short of breath) while amb. LPN stated, '(Resident #15) is very tired, maybe she could go to DR via W/C due to her SOB'. Husband stated, 'She's all right. She's just been sitting for 3 hours doing nothing.'..." The Nurses' Notes dated 12/29/10 at 2:50 p.m. and signed by LPN #6 documented, "This nurse was called outside D/T (Resident #15's) husband attempted to transfer (Resident #15) (without) help into his car and (Resident #15) slid down between car seat and W/C. (Resident #15) was assisted into car by this nurse and (LPN #7). (Resident #15's) husband would not allow (Resident #15) to be taken inside and assessed. He stated, 'Put her in the car, we are leaving!' This nurse began speaking (with) (Resident #15) asking her if she was ok, if anything was hurting. Husband stated, very loudly, 'She's fine.' I continued to speak (with) (Resident #15) and (Resident #15) stated nothing was hurting, she was ok, (Resident #15's) husband then began bumping nurse over and over (with) W/C, and stated 'Excuse me'. Husband wanted me to move away from (Resident #15). This nurse walked back into building." d. The Interdisciplinary Progress Notes dated 1/7/11 at 1145 and signed by LPN #7 documented, "Met (with) 2 daughters, DON, MD (Medical Doctor), Administrator, Activities Dir (Director), and Soc (Social) Worker to discuss facility's concern re: 1. Spouse medicating (Resident #15) at home (colon cleanse and Insulin). 2. Spouse refusing assist (with) (Resident #15's) transfers and amb. 3. Spouse verbally abusive to (Resident #15) and staff. 4. Spouse physically to staff. 5. Spouse dropped her while trying to get her in the car, then refused staff's assist and evaluation. 6. Spouse refused anti-tippers to W/C and low bed as interventions for fall preventions. 7. Spouse eats (Resident #15's) food and has been witnessed taking food from other residents and off of snack cart. 8. Spouse gives (Resident #15) food not on approved diet, then accuses our staff of not controlling her blood sugars. 9. Spouse takes supplies from carts and closets, either to his car or to (Resident #15's) room, sometimes from other resident room. 10. (Resident #15) has bouts of diarrhea (after) (every) trip out (with) spouse D/T colon cleanse. 11. Spouse observed throwing (Resident #15's) walker across DR (after) (Resident #15) refused to amb/transfer, he then raised his voice and quickly walked off. 12. Incident of elbowing staff member while LPN was giving assist (with) amb. Dtrs (daughters) agreed to take their father to his PCP (Private Care Physician) for eval (evaluation) and to talk to him re: safety of (Resident #15)..." e. The Nurses' Notes dated 1/7/11, with no time documented, and signed by the DON documented, "Care plan meeting today (with) (Resident #15's) two daughters re: (regarding) (Resident #15"s) spouse (behaviors). After care plan meeting, daughters left. (Resident #15's) spouse was in dining room when CNA noted (husband) giving his wife a pill and eating her food. Daughter was notified, came back to facility and will take father home and talk to him. (Daughter) was notified that (husband) cannot be here at facility without at least one daughter here until (husband) is cleared of all physical and mental disorders causing his behaviors. She was also notified if no mental or physical disorders were found and he continued his behaviors, we would have to issue a 30 day notice. Daughter thanked this RN and praised facility for the good care and stated she did not want her mother to be placed anywhere else. She accompanied her father out of facility and stated she would talk to him." f. A physician telephone order dated 1/13/11 at 12:15 p.m., documented to send the resident to the emergency room for pain in the neck, shoulder and arm. As of 3/3/11 there was no documentation in the clinical record of the resident's discharge from the facility after being sent to the hospital. g. On 3/3/11 at 1:50 p.m. the Administrator stated, "No [MEDICATION NAME] (DMS-762 or DMS-7734) or internal investigations that I can locate on (Resident #15)." h. On 3/3/11 at 3:45 p.m., Licensed Practical Nurse (LPN) #5 was asked "Have you ever seen any resident's spouse or family member talking with them rudely or abusively?" LPN # 5 stated, "Yes, (Resident #15's) husband." LPN #5 was asked "What did the husband say?" LPN # 5 stated "You're too fat. We need to put you on a diet. He would go to the dining room and would eat food off of the resident's tray. When we told him we would provide him with a tray for $3.00, he said he wouldn't pay for it." LPN #5 was asked "Any other comments to the resident?" LPN #5 stated "It was just his over all manner. He was never nice to her. I felt like he pushed her. One day he wanted her to ambulate to and from the dining room, that night and on several other occasions she would say 'I'm just too tired' and he would say 'You need to, you've been sitting all day'. LPN #5 was asked "Did anything he said seen abusive to you?" LPN #5 stated "Yes, his tone, he belittled her." LPN #5 was asked "If a CNA had treated the resident in the way the husband treated (Resident #15) what would you have done?" LPN #5 stated "I would have said clock out, go home". LPN #5 then looked thru her Nurses' Notes and stated "I was concerned that he was giving her insulin via the old sliding scale and him running her into the wall on her knees. It was like his actions did not jive with his concerns. He didn't treat her right." LPN #5 was asked "Did you get witness statements from the staff members related to the wheelchair incident?" LPN #5 stated "Yes". LPN #5 was asked "If a CNA had treated a resident this way (running resident into the wall with the wheelchair) what would you have done?" LPN #5 stated "Taken the resident away, told them to clock out and go home." LPN #5 was asked "Did you think (husband) was abusive?" LPN #5 stated, "I feared he was. I reported these incidents to my DON (Director of Nurses) - not the current DON". LPN #5 was asked "Did you tell the Administrator?" LPN #5 stated "Yes, she was aware of several incidents. She told me to write it up and document." LPN #5 was asked "What did they do?" LPN # 5 stated, "They talked with the family about it. I documented every thing I could and they were aware and they knew. I don't know what they did about calling the authorities to get his rights terminated." LPN #5 was asked "What did the Administrator say?" LPN #5 stated, "Continue to document, keep good records of his behaviors. I always watched her as much as we could - the aides would watch him." LPN #5 was asked "Did you have any staff to monitor (husband) when he came in after the wheelchair incident?" LPN #5 stated, "No, I didn't have enough staff for that?" i. On 3/3/11 at 5:00 p.m., CNA #12 was asked, "Do you have any concerns that abuse or neglect is occurring in the facility?" CNA #12 stated, "Not at this time. The only thing I ever saw was an incident with a man and wife. I reported it to the nurse and the DON. I filled out a statement." CNA #12 was asked, "Who was the resident?" CNA #12 stated "(Resident #15)". CNA # 12 was shown the statement dated 8/17/10 at 6:45 p.m. and was asked, "Is this the statement you are talking about?" CNA #12 stated ,"Yes". CNA #12 was asked, "What happened?" CNA #12 stated, "She was in the dining room and he parked her in one spot and she was to stay there. He left and she moved and he came and looked around for her. When he found her he took the wheelchair and ran it into the wall. I went to nurse and let her know what he had done." CNA #12 was asked, "Did you remove the resident from the situation?" CNA #12 stated, "No, I got the nurse because (spouse) gets confrontational. I got the nurse and she talked with him, he got nasty and he left." CNA #12 was asked, "After this were you told to stay with the resident when he visited?" CNA #12 stated, "No, I took it upon myself to watch if he took her outside. I'd go room to room looking out the windows watching him with her?" CNA #12 was asked, "Were you worried that he was abusive?" CNA #12 stated "Yes". CNA #12 was asked, "Did you talk with any one about this?" CNA #12 stated "Yes, (former DON) and (former Administrator) and (former ADON). They all talked with him." j. On 3/4/11 at 8:20 a.m., LPN #7 and Social Services Staff #1 were asked if they had been involved in any family meetings with (Resident #15). Social Services Staff #1 stated "Yes with his 2 daughters about his behaviors on 1/7/11." Social Services #1 was asked, "Did you attend any meetings about his treatment/behaviors of (Resident #15) prior to this time?" Social Services Staff #1 stated, "No". Social Services Staff #1 was asked, "Did you talk with the husband about his behaviors?" Social Services Staff #1 stated, "No." Social Services Staff #1 was asked, "Did you know about the fall in the parking lot on 12/29/10?" Social Services Staff #1 stated, "Yes, he was getting her out of the car and she fell ." Social Services Staff #1 was asked, "Did you have any meetings regarding the resident fall and safety issues with the husband taking her out of the facility?" Social Services Staff #1 stated, "No". LPN #7 and Social Services Staff #1 were asked if they thought the husband had behavior problems. LPN #7 stated, "His behaviors went out of control. I remember him taking her out in the heat in July and pushing her up to Highway 10 in the wheelchair. We told him not to do that. He was very resistant to suggestions." LPN #7 was asked, "Did you contact the Ombudsman, state (OLTC) or Adult Protective Services (APS) about the husbands behaviors?" LPN #7 stated, "I talked with Administrator, (previous Administrator) about APS and that was met with resistance and in the end I wanted to call the police on him myself. That's when the department heads decided we need a family meeting to see if they could step in to help control their father's actions. That was on 1/7/11. His behaviors had escalated..." k. On 3/4/11 at 10:50 a.m. Nurse Consultant #1 and the Administrator were asked, "Did you find any [MEDICATION NAME] or internal investigations for (Resident #15)?" The Administrator stated no. l. The Immediate Jeopardy was removed and the scope/severity reduced to "H" when the facility held the family conference on 1/7/11 which limited the husband to supervised visits. When the husband was observed giving the resident medications in the dining room, which was supervised by staff, following this conference, the family was notified and required to return and remove the husband from the facility. The family was informed the husband could not return to the facility unless another family member was with him. As of 3/4/11, the Administrator could not provide any documentation where the staff were inserviced about reporting this type of abuse. 2. Resident #22: a. A Facility Investigation Report for Resident Abuse, Neglect, Misappropriation of Property, And Exploitation of Residents in Long-Term Care Facilities (DMS-762) Reporting Form was reviewed on 3/3/11 at 1:35 p.m. regarding Resident #22. Section 1-Reporting Information, Page 2 of 9 documented: "... Date Incident Reported to OLTC (Office of Long Term Care): 1/20/11, Time:11:00 a.m. Date and Time of Incident (if known): 1/17/11, Time: 1:00 p.m. Date and Time of Discovery: 1/19/11, Time: 2:00 p.m. Type of Incident: Neglect..." Section II - Complete Description of Incident, Page 3 of 9 documented, "Family care plan meeting was arranged at daughter's request for January 19, 2011 at 2:00 p.m. Daughter, (daughter's name) and resident's son, (son's name) arrived for the meeting regarding concerns of resident's care. Daughter, (daughter's name) commented she felt her mother had been 'neglected' due to her room was not picked up and the floor 'looked' dirty. (Daughter) continued, she found her mother to have long and unkept fingernails. She continued that her mother's nose was not properly covered with the Band-Aid she provides the facility with in order to cover the resident's nose. Resident has been observed by staff removing the bandage repeatedly. Regional Director of Operations, (name) asked (daughter) if she indeed felt the resident had been neglected. (Daughter) responded that she did not feel that it was really neglect at this point and that she only wanted to bring it to the staff's attention to be corrected. She continued, this was the first time she has ever found her mother's room to unkept and her nails to be unkept." Section III - Findings and Actions Taken, Page 4 of 9 documented, "Administrator notified the police department of the issue and filed a report. Report is attached with this documentation. Witness statements have been obtained. (Daughter) was asked to fill out a witness statement at which she agreed but has not been compliant in bringing the statement back to the facility. Housekeepers have been inserviced on cleaning protocol for floors and tidiness of resident room. Staff inserviced on appropriate nail care and encouraging resident to leave bandage on her nose. No staff suspended at this time as resident has been observed removing the bandage herself. resident underwent [REDACTED]. Resident at one point used a prosthetic nose, but became aggravated and continued to remove it. Family has since provided Band-Aid to place on resident's nose." This was dated 1/24/11 and signed by the Administrator. Section IV - Notification/Status, Page 5 of 9 documented, "... Family Notified: Yes, (Date and Time were blank)... Doctor Notified: Yes, Date: 1/20/11, Time: 3 p.m. ... Law Enforcement Must Be Notified For Abuse And Neglect: Date: 1/21/11, Time: 9:30 a.m..." The remaining file included Inservice documentation dated 1/20/11 titled "housekeeping - Cleaning" with 3 staff signatures and another inservice dated 1/20/11 titled "Nursing- Nail Care" with 7 staff signatures and the Police Report. There were no witness statements in the file. On 3/3/11 at 2 p.m. the Administrator was asked if there were any witness statements. The Administrator stated, "I did not get any witness statements." She was asked if she interviewed any residents on the hall. She answered, "No". The Administrator was asked why she did not contact the police until 1/21/11. She stated, "I forgot." She was also asked if any other dependent residents were observed for long, unkept fingernails. The Administrator stated, "No." b. Another Facility Investigation Report for Resident Abuse, Neglect, Misappropriation of Property, And Exploitation of Residents in Long-Term Care Facilities (DMS-762) Reporting Form was reviewed on 3/3/11 at 1:45 p.m. regarding Resident #22. Section 1-Reporting Information, Page 2 of 9 documented: "... Date Incident Reported to OLTC (Office of Long Term Care): 2/15/11, Time:11:00 a.m. Date and Time of Incident (if known): 2/14/11, Time: 9 a.m. Date and Time of Discovery: 2/14/11, Time: 9:00 a.m. Type of Incident: Neglect. ...". Section II - Complete Description of Incident, Page 3 of 9 documented: "Daughter, (Name), approached Social Director, (Name) regarding resident's toothbrush was too dry to have been used lately. She also reported resident's bra was not on the resident and that her eyeglass strap was missing. She stated resident would never had removed the eyeglass strap. Daughter stated, 'I feel there is some neglect going on mainly on the 11p-7a shift since they are getting Mother up in the morning.' Administrator contacted (the daughter) at approximately 10:30 a.m. on 2/15/11 to ask her to complete a witness statement. (The daughter) declined and stated she did not wish to have this reported to OLTC due to she worked for the State. She further stated she would prefer that the facility not report this incident, but would insist any further incidents to be reported." Section III - Findings and Actions Taken, Page 4 of 9 documented: "Since (daughter) used the verbage of 'neglect', Administrator chose to report incident to OLTC. (Police Department) was notified and a report made on 2/15/11. A copy is included in this packet. Daughter declined to complete a witness statement. Following the report from (daughter), Administrator and CNA accompanied daughter to resident's room where daughter stated she was wrong and that resident did in fact have on a bra. After searching the resident's room the eyeglass string could not be located. (The daughter) denied her mother's ability to ever remove the string from the eyeglasses. Resident has a history of dementia like behavior although she does not have a [DIAGNOSES REDACTED]. either on herself or other furniture, i.e. tablecloths. Administrator and CNA inspected the resident's toothbrush. Daughter stated we would not be able to tell how dry it was due to she has just brushed resident's teeth. Toothbrush was located in resident's bathroom in an individual toothbrush container. Toothbrush was still wet and Administrator was unable to determine if toothbrush had not been used for a significant period of time. Resident appeared content and in no distress. Resident is not able to verbally or physically make her needs or concerns known due to her medical condition. Eyeglass string was replaced by facility on 2/15/11. CNAs were inserviced regarding proper oral care by Assistant Director of Nursing. Witness statements were obtained by the third shift staff as well as the first shift nursing staff who were assigned to give direct care to resident. Based on the information and evidence available, it has been determined by the Administrator that not enough evidence is available to determine neglect had in fact occurred." Section IV - Notification/Status, Page 5 of 9 documented, "... Family Notified: Yes, Date: 2/14/11, Time: 9 a.m. ... Doctor Notified: Yes, Date: 2/15/11, Time: 3 p.m. ... Law Enforcement Must Be Notified For Abuse And Neglect: Date: 2/15/11, Time: 11:00 a.m..." The remaining file included staff witness statements and the Police Report. On 3/3/11 at 2 p.m. the Administrator was asked if any other residents were interviewed. The Administrator stated, "No." She was also asked if any other dependent resident's teeth were observed. The Administrator stated, "No." 3. Resident #21: A Facility Investigation Report for Resident Abuse, Neglect, Misappropriation of Property, And Exploitation of Residents in Long-Term Care Facilities (DMS-762) Reporting Form was reviewed on 3/3/11 at 1:40 p.m. regarding Resident #21. Section 1-Reporting Information, Page 2 of 9 documented, "... Date Incident Reported to OLTC (Office of Long Term Care): 2/2/11, Time:11:00 a.m. Date and Time of Incident (if known): 2/1/11, Time: Between 7 a.m. and 3 p.m. Date and Time of Discovery: 2/1/11, Time: 3:00 p.m. Type of Incident: Physical Abuse..." Section II - Complete Description of Incident, Page 3 of 9 documented, "Staff reported to Nurse Consultant, (Name), she found resident to have a small cut on the back, top left side of her head at approximately 3:30 p.m. Second shift LPN and CNAs stated they had not received any report of the injury." Section III - Findings and Actions Taken, Page 4 of 9 documented, "Resident's cut was cleaned immediately by nurse and resident was assessed by Nurse Consultant and DON. DON instructed charge LPN to contact PCP to obtain an order to send resident to local ER for further eval. Order was obtained immediately and resident was sent to (ER) by (Ambulance). Son was notified by phone. Police also notified by Administrator due to the injury being of unknown origin. All first shift staff who were assigned to provide direct care to resident were contacted and asked to return to facility to complete witness statements and interviews by Administrator. Witness statements were obtained with no one reporting any knowledge of the injury. CNAs did report resident has history of resisting care with ADLs (Activities of Daily Living) and 'bucking' while attempting to provide care. When asking the CNA what she meant by 'bucking' she stated, the resident 'throws herself back and forward' when receiving care. (Police Department) was contacted by Administrator and a report was filed. A copy of the report is included. Witness statements were obtained from staff. Resident was sent back from ER the same night. Treatment started to the cut immediately. No sign in the room of a struggle. No evidence of abuse." Section IV - Notification/Status, Page 5 of 9 documented, "... Family Notified: Yes, Date: 2/1/11, Time: 3:30 p.m... Doctor Notified: Yes, Date: 2/3/11, Time: 3 p.m... Law Enforcement Must Be Notified For Abuse And Neglect: Date: 2/3/11, Time: 3:53 p.m..." The remaining file included staff witness statements and the Police Report. On 3/3/11 at 2:00 p.m. the Administrator was asked if any other residents were interviewed. The Administrator stated, "No." The Administrator was asked why she did not contact the police until 2/3/11. She stated, "I can't think of any specific reason." She was also asked if any other residents who were dependent on staff for care were observed for injuries. The Administrator stated, "No." At 6:00 p.m. the Administrator was asked what was done to protect the resident. She stated, "Sent the resident to the hospital."

Complaint # substantiated (all or in part) in these findings. Based on record review and interview the facility failed to ensure their abuse prohibition policy and procedure regarding reporting/investigation allegations of abuse and providing protection from the further potential abuse was implemented. The facility failed to ensure allegations of spouse mistreatment/abuse was reported and thoroughly investigated and protection of the resident was provided for 1 of 1 case mix resident (Resident #15) who staff observed abusive behaviors from the spouse and failed to intervene. This failed practice resulted in immediate jeopardy which caused or could have caused serious harm, impairment or death for Resident #15 whose spouse was not prevented from physically and emotional abusing the resident from 6/20/10 through 1/7/11. The facility removed the immediate jeopardy prior to the survey but did not correct the underlying failed practices. On 3/4/11 at 4:55 p.m., the Administrator was informed of the Immediate Jeopardy (removed). The facility also failed to ensure allegations of abuse and neglect were thoroughly investigated and reported to the local law enforcement in the time frames established by state law for 2 of 2 (Residents #21 and #22) case mix residents. These failed practices had the potential to affect all 79 residents as documented on the Resident Census and Conditions of Residents dated 3/1/11. The findings are: 1. The Abuse Prevention Program Policy received from the Administrator on 3/1/11 at 9:20 a.m. documented, "...Purpose: Our residents have the right to be free from abuse, neglect, misappropriation of resident property, corporal punishment and involuntary seclusion. Steps in the Procedure: 1. Our facility is committed to protecting our residents from abuse by anyone including, but not necessarily limited to: facility staff, other residents, consultants, volunteers, staff from other agencies providing services to our residents, family members, legal guardians, surrogates, sponsors, friends, visitors, or any other individual. Screening... 3. Comprehensive policies and procedures have been developed to aid our facility in preventing abuse, neglect, or mistreatment of [REDACTED]. The protection of residents during abuse investigations will be implemented on an individual basis; ... Identification:... 4. 'Verbal Abuse' is defined as any use of oral, written, or gestured language that includes disparaging and/or derogatory terms directed to, or within the hearing range of, the resident and/or families or visitors. Additionally, threats of corporal punishment to control behavior are considered verbal abuse... 6. 'Mental Abuse' is defined as humiliation, harassment, threat of punishment, or deprivations. 7. 'Physical Abuse' is defined as hitting, slapping, pinching, kicking, biting, spitting, etc. Additionally, it includes acts of corporal punishment to control behavior. 8... b. Identify, correct and intervene in situations in which abuse, neglect, and/or misappropriation of resident property is more likely to occur... 4. The assessment, care planning, and monitoring of residents with needs and behaviors which might lead to conflict or neglect, such as residents with a history of aggressive behaviors, residents who have behaviors such as... those that require heavy nursing care and/or are totally dependent on staff. Investigation: 9. The facility will thoroughly investigate all alleged violations under the direct supervision of the Administrator... Any employee of the facility suspected of abuse or neglect will be suspended pending an investigation until such time as the investigation is complete... Reporting:... A written complaint will be filed by the person making the complaint or filed by a staff member assisting the person making the complaint. The complaint will be immediately turned in to the Administrator and/or Director of Nursing... Reporting to Office of Long Term Care:... Any alleged, suspected or witnesses occurrences of abuse or neglect to residents... Suspected abuse, neglect, or exploitation must also be reported to the lo al law enforcement agency... The Investigation: Refer to The Abuse Investigation Protocol." 2. The Abuse Investigation Protocol Policy documented: "...1. Should an incident or suspected incident of resident abuse, neglect, injury of unknown origin, resident-to-resident abuse, misappropriation of resident property be reported the administrator and/or his/her designee will promptly and thoroughly investigate the incident. 2. The individual conducting the investigation will:... b. Maintain resident safety during the investigation... f. Interview and obtain a statement from the person reporting the incident. g. Interview and obtain statements from all witnesses. h. Interview and obtain a statement from the resident (as medically appropriate)... Tj. Interview and obtain statements from staff members on all shifts who have had contact with the resident during the 48-72 hour period prior to the alleged incident. k. Interview and obtain a statement from the resident's roommate (if appropriate). l. Interview and obtain a statement from the resident's family members and visitors who have had contact with the resident during the 48-72 hour period prior to the alleged incident. m. Interview and obtain a statement from the accused individual(s), if known... o. Interview and obtain statements from other residents assigned to the accused staff member to determine if they have any complaints or concerns about the individual. p. Interview and obtain statements from co-workers to determine if they have ever witnessed other incidents of mistreatment involving the accused staff member..." 3. Closed Record Review: Resident #15 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Discharge Assessment-Return Anticipated Minimum Data Set with an Assessment Reference Date of 11/9/10 documented the resident had a Brief Interview for Mental Status (BIMS) score of 1 (0-7 indicates severe impairment) and required extensive assistance of 2 staff for transfers and ambulation. a. The Nurses' Notes dated 6/20/10 at 8:25 a.m. and signed by LPN (Licensed Practical Nurse) #8 documented, "Resident sitting up in the wheelchair at the table in the dining room. Husband at side eating out of resident's plate while resident is eating. Encouraged resident to eat & (and) husband to order a tray for himself..." The Nurses' Notes dated 8/2/10 at 1:30 p.m. and signed by LPN #9 documented, "This nurse overheard (resident's) husband tell her 'You're not gonna freeze to death, now shut the hell up'... (Resident #15) appeared upset, was wearing a jacket at this time..." The Nurses' Notes dated 8/11/10 at 8:00 p.m. and signed by LPN #5 documented, "...LPN (Licensed Practical Nurse) suggested that husband give remainder of drink to (Resident #15). (Resident #15) stated, 'No' and physically pulled back as if she'd been struck. (Resident #15) behaved (with) fear toward her husband." The Nurses' Notes dated 8/17/10 at 7:00 p.m. and signed by LPN #5 documented: "(Resident #15's) husband came to desk and asked for copy of (Resident #15's) medications. LPN stated that a copy of physician's orders [REDACTED]. (appointment) for (Resident #15). Husband became very angry and said I just need a simple list. He had exited the DR (dining room) (with) (Resident #15) in W/C (wheelchair) (after the supper meal). He then took (Resident #15) outside in the heat. @ (At) that (time) 2 Certified Nurse Assistants (CNAs) came from the Dining Room and stated that husband had pushed (Resident #15's) W/C (wheelchair) into the wall hitting bil (bilateral) knees to the wall. This occurred @ 1845 (6:45 p.m.). Two witnesses statements were obtained from the CNAs regarding this incident. Husband kept (Resident #15) outdoors for 10-15 minutes. 1915 (7:15 p.m.): (Resident #15's) husband re-entered blg (building) and came to nurses' station and asked LPN to write list of all (Resident #15's) meds (medications), times, etc. LPN stated that he should speak (with) Director of Nursing (DON) in a.m. regarding this matter. He then once again exited the bldg (building) (with) (Resident #15) in W/C. It should be noted that while outside with (Resident #15), was observed having (Resident #15) propel W/C on her own in the heat. Husband was cautioned that it was hot outside and that he should limit (time) outside due to (Resident #15's) physical condition. Advice not taken..." b. An Incident/Accident report dated 8/17/10 at 6:45 p.m. signed by LPN #5 documented, "CNAs observed husband pushing (Resident #15's) W/C in DR. He pushed W/C into wall hitting Bil knees against wall. He then took (Resident #15) outside in heat X (times) 2 for twenty minutes each (time)..." Witness statements were written by CNAs #12 and #13. No interventions were documented. An Incident/Accident report dated 8/17/10 with no time documented and signed by LPN #5 documented, "CNA reported to LPN that (Resident #15's) husband was jogging while propelling (Resident #15's) W/C down hill in back parking lot of VRNR (Valley Ranch Nursing and Rehab). Other CNA observed from Activity Room, Husband holding gate open and (Resident #15) propel self quickly and husband pulled (Resident #15) in W/C through gate." The witness statement was written by CNA #13. No interventions were documented. c. The Nurses' Notes dated 10/30/10 at 2:09 p.m. and signed by LPN #5 documented, "...Husband was eating (Resident #15's) food off tray and drinking milk from carton..." The Nurses' Notes dated 11/1/10 at 8:00 a.m. and signed by Registered Nurse (RN) #2 documented, "LPN and this RN were informed of bottles of pills in (Resident #15's) drawer. We went to (Resident #15's) room and removed 6 bottles of meds from drawer. Facility policy states that residents can't have meds in their room. (Resident #15's) husband confronted me and stated, 'You are stealing'. I informed him to please take to his car the meds. He walked off (with) bag of meds. He went into (Resident #15's) room, then (approximately) 10 minutes later took bag of medication to his vehicle." The Nurses' Notes dated 11/4/10 at 7:45 p.m. and signed by LPN #10 documented, "Spouse returned to facility and stated that, 'You forgot to give me the Insulin. I checked the blood sugar myself. It was 212. Just give me the Insulin and needle'. Spoke (with) RN who stated spouse must demonstrate proper Insulin administration per physician order [REDACTED].' This nurse called daughter to notify of incident." The Nurses' Notes dated 11/9/10 at 12:30 p.m. and signed by LPN #7 documented, "(Resident #15's) husband was walking the resident from her room to DR (after) he has been asked and instructed not to D/T (due to) her strong Hx (history) of falls (with) significant inj (injury). (Resident #15) was c/o (complaining), 'It's too far'. (Resident #15's) spouse became angry and raised his voice at this LPN when she tried to assist. (Resident #15's) husband stuck his elbow into LPN's side blocking any attempt @ staff's assistance. When (Resident #15) sat in chair, she almost missed it, didn't reach back for side rails and husband let go of her. Again, spouse was reminded to not amb (ambulate) (without) staff assist." The Nurses' Notes dated 11/10/10 at 5:30 p.m. and signed by LPN #5 documented, "(Resident #15) sitting in DR eating dinner, LPN observed (Resident #15's) husband eating food off (Resident #15's) tray. Husband consumed 90% of (Resident #15's) food from tray." The Nurses' Notes dated 1/18/10 with no time documented and signed by LPN #5 documented, "...Husband con't (continues) to eat from (Resident #15's) tray @ meal (times)..." The Nurses' Notes dated 11/26/10 at 7:30 a.m., with the signature non- legible, documented, "... (Resident #15) not quite as alert today. Husband forcing (Resident #15) to keep pushing ahead on RW (rolling walker) and pushing W/C back from her as witnessed by 2 Restorative CNAs." The Nurses' Notes dated 12/3/10 at 10:00 p.m. and signed by LPN #5 documented, "...Husband was observed eating (Resident #15's) food off tray..." The Nurses' Notes dated 12/7/10 at 6:15 p.m. and signed by LPN #5 documented: "Supervisor informed (Resident #15's) husband, who often takes food from (Resident #15's), tray was for resident and that he could purchase a tray for himself @ a cost of $3. Husband stated that he didn't want to purchase tray. After Husband departed, (Resident #15) offered another supper tray and consumed 100%." The Nurses' Notes dated 12/8/10 at 1:15 p.m., with the signature non-legible, documented, "Res. amb (with) husband. He is pulling W/C behind him instead of having it behind resident. Insistent that she walk entire route from DR (to) (room) 106..." The Nurses' Notes dated 12/17/10 at 11:30 p.m. and signed by LPN #5 documented, "(Resident #15) returned from ER (emergency room ) @ 1600 very tired. Husband amb (Resident #15) to DR (with) gait belt. (Resident #15) SOB (short of breath) while amb. LPN stated, '(Resident #15) is very tired, maybe she could go to DR via W/C due to her SOB'. Husband stated, 'She's all right. She's just been sitting for 3 hours doing nothing.'..." The Nurses' Notes dated 12/29/10 at 2:50 p.m. and signed by LPN #6 documented, "This nurse was called outside D/T (Resident #15's) husband attempted to transfer (Resident #15) (without) help into his car and (Resident #15) slid down between car seat and W/C. (Resident #15) was assisted into car by this nurse and (LPN #7). (Resident #15's) husband would not allow (Resident #15) to be taken inside and assessed. He stated, 'Put her in the car, we are leaving!' This nurse began speaking (with) (Resident #15) asking her if she was ok, if anything was hurting. Husband stated, very loudly, 'She's fine.' I continued to speak (with) (Resident #15) and (Resident #15) stated nothing was hurting, she was ok, (Resident #15's) husband then began bumping nurse over and over (with) W/C, and stated 'Excuse me'. Husband wanted me to move away from (Resident #15). This nurse walked back into building." d. The Interdisciplinary Progress Notes dated 1/7/11 at 1145 and signed by LPN #7 documented, "Met (with) 2 daughters, DON, MD (Medical Doctor), Administrator, Activities Dir (Director), and Soc (Social) Worker to discuss facility's concern re: 1. Spouse medicating (Resident #15) at home (colon cleanse and Insulin). 2. Spouse refusing assist (with) (Resident #15's) transfers and amb. 3. Spouse verbally abusive to (Resident #15) and staff. 4. Spouse physically to staff. 5. Spouse dropped her while trying to get her in the car, then refused staff's assist and evaluation. 6. Spouse refused anti-tippers to W/C and low bed as interventions for fall preventions. 7. Spouse eats (Resident #15's) food and has been witnessed taking food from other residents and off of snack cart. 8. Spouse gives (Resident #15) food not on approved diet, then accuses our staff of not controlling her blood sugars. 9. Spouse takes supplies from carts and closets, either to his car or to (Resident #15's) room, sometimes from other resident room. 10. (Resident #15) has bouts of diarrhea (after) (every) trip out (with) spouse D/T colon cleanse. 11. Spouse observed throwing (Resident #15's) walker across DR (after) (Resident #15) refused to amb/transfer, he then raised his voice and quickly walked off. 12. Incident of elbowing staff member while LPN was giving assist (with) amb. Dtrs (daughters) agreed to take their father to his PCP (Private Care Physician) for eval (evaluation) and to talk to him re: safety of (Resident #15)..." e. The Nurses' Notes dated 1/7/11, with no time documented, and signed by the DON documented, "Care plan meeting today (with) (Resident #15's) two daughters re: (regarding) (Resident #15"s) spouse (behaviors). After care plan meeting, daughters left. (Resident #15's) spouse was in dining room when CNA noted (husband) giving his wife a pill and eating her food. Daughter was notified, came back to facility and will take father home and talk to him. (Daughter) was notified that (husband) cannot be here at facility without at least one daughter here until (husband) is cleared of all physical and mental disorders causing his behaviors. She was also notified if no mental or physical disorders were found and he continued his behaviors, we would have to issue a 30 day notice. Daughter thanked this RN and praised facility for the good care and stated she did not want her mother to be placed anywhere else. She accompanied her father out of facility and stated she would talk to him." f. A physician telephone order dated 1/13/11 at 12:15 p.m., documented to send the resident to the emergency room for pain in the neck, shoulder and arm. As of 3/3/11 there was no documentation in the clinical record of the resident's discharge from the facility after being sent to the hospital. g. On 3/3/11 at 1:50 p.m. the Administrator stated, "No [MEDICATION NAME] (DMS-762 or DMS-7734) or internal investigations that I can locate on (Resident #15)." h. On 3/3/11 at 3:45 p.m., Licensed Practical Nurse (LPN) #5 was asked "Have you ever seen any resident's spouse or family member talking with them rudely or abusively?" LPN # 5 stated, "Yes, (Resident #15's) husband." LPN #5 was asked "What did the husband say?" LPN # 5 stated "You're too fat. We need to put you on a diet. He would go to the dining room and would eat food off of the resident's tray. When we told him we would provide him with a tray for $3.00, he said he wouldn't pay for it." LPN #5 was asked "Any other comments to the resident?" LPN #5 stated "It was just his over all manner. He was never nice to her. I felt like he pushed her. One day he wanted her to ambulate to and from the dining room, that night and on several other occasions she would say 'I'm just too tired' and he would say 'You need to, you've been sitting all day'. LPN #5 was asked "Did anything he said seen abusive to you?" LPN #5 stated "Yes, his tone, he belittled her." LPN #5 was asked "If a CNA had treated the resident in the way the husband treated (Resident #15) what would you have done?" LPN #5 stated "I would have said clock out, go home". LPN #5 then looked thru her Nurses' Notes and stated "I was concerned that he was giving her insulin via the old sliding scale and him running her into the wall on her knees. It was like his actions did not jive with his concerns. He didn't treat her right." LPN #5 was asked "Did you get witness statements from the staff members related to the wheelchair incident?" LPN #5 stated "Yes". LPN #5 was asked "If a CNA had treated a resident this way (running resident into the wall with the wheelchair) what would you have done?" LPN #5 stated "Taken the resident away, told them to clock out and go home." LPN #5 was asked "Did you think (husband) was abusive?" LPN #5 stated, "I feared he was. I reported these incidents to my DON (Director of Nurses) - not the current DON". LPN #5 was asked "Did you tell the Administrator?" LPN #5 stated "Yes, she was aware of several incidents. She told me to write it up and document." LPN #5 was asked "What did they do?" LPN # 5 stated, "They talked with the family about it. I documented every thing I could and they were aware and they knew. I don't know what they did about calling the authorities to get his rights terminated." LPN #5 was asked "What did the Administrator say?" LPN #5 stated, "Continue to document, keep good records of his behaviors. I always watched her as much as we could - the aides would watch him." LPN #5 was asked "Did you have any staff to monitor (husband) when he came in after the wheelchair incident?" LPN #5 stated, "No, I didn't have enough staff for that?" i. On 3/3/11 at 5:00 p.m., CNA #12 was asked, "Do you have any concerns that abuse or neglect is occurring in the facility?" CNA #12 stated, "Not at this time. The only thing I ever saw was an incident with a man and wife. I reported it to the nurse and the DON. I filled out a statement." CNA #12 was asked, "Who was the resident?" CNA #12 stated "(Resident #15)". CNA # 12 was shown the statement dated 8/17/10 at 6:45 p.m. and was asked, "Is this the statement you are talking about?" CNA #12 stated ,"Yes". CNA #12 was asked, "What happened?" CNA #12 stated, "She was in the dining room and he parked her in one spot and she was to stay there. He left and she moved and he came and looked around for her. When he found her he took the wheelchair and ran it into the wall. I went to nurse and let her know what he had done." CNA #12 was asked, "Did you remove the resident from the situation?" CNA #12 stated, "No, I got the nurse because (spouse) gets confrontational. I got the nurse and she talked with him, he got nasty and he left." CNA #12 was asked, "After this were you told to stay with the resident when he visited?" CNA #12 stated, "No, I took it upon myself to watch if he took her outside. I'd go room to room looking out the windows watching him with her?" CNA #12 was asked, "Were you worried that he was abusive?" CNA #12 stated "Yes". CNA #12 was asked, "Did you talk with any one about this?" CNA #12 stated "Yes, (former DON) and (former Administrator) and (former ADON). They all talked with him." j. On 3/4/11 at 8:20 a.m., LPN #7 and Social Services Staff #1 were asked if they had been involved in any family meetings with (Resident #15). Social Services Staff #1 stated "Yes with his 2 daughters about his behaviors on 1/7/11." Social Services #1 was asked, "Did you attend any meetings about his treatment/behaviors of (Resident #15) prior to this time?" Social Services Staff #1 stated, "No". Social Services Staff #1 was asked, "Did you talk with the husband about his behaviors?" Social Services Staff #1 stated, "No." Social Services Staff #1 was asked, "Did you know about the fall in the parking lot on 12/29/10?" Social Services Staff #1 stated, "Yes, he was getting her out of the car and she fell ." Social Services Staff #1 was asked, "Did you have any meetings regarding the resident fall and safety issues with the husband taking her out of the facility?" Social Services Staff #1 stated, "No". LPN #7 and Social Services Staff #1 were asked if they thought the husband had behavior problems. LPN #7 stated, "His behaviors went out of control. I remember him taking her out in the heat in July and pushing her up to Highway 10 in the wheelchair. We told him not to do that. He was very resistant to suggestions." LPN #7 was asked, "Did you contact the Ombudsman, state (OLTC) or Adult Protective Services (APS) about the husbands behaviors?" LPN #7 stated, "I talked with Administrator, (previous Administrator) about APS and that was met with resistance and in the end I wanted to call the police on him myself. That's when the department heads decided we need a family meeting to see if they could step in to help control their father's actions. That was on 1/7/11. His behaviors had escalated..." k. On 3/4/11 at 10:50 a.m. Nurse Consultant #1 and the Administrator were asked, "Did you find any [MEDICATION NAME] or internal investigations for (Resident #15)?" The Administrator stated no. l. The Immediate Jeopardy was removed and the scope/severity reduced to "H" when the facility held the family conference on 1/7/11 which limited the husband to supervised visits. When the husband was observed giving the resident medications in the dining room, which was supervised by staff, following this conference, the family was notified and required to return and remove the husband from the facility. The family was informed the husband could not return to the facility unless another family member was with him. As of 3/4/11, the Administrator could provide no documentation where staff were inserviced about reporting this type of abuse. 4. Resident #22: a. A Facility Investigation Report for Resident Abuse, Neglect, Misappropriation of Property, And Exploitation of Residents in Long-Term Care Facilities (DMS-762) Reporting Form was reviewed on 3/3/11 at 1:35 p.m. regarding Resident #22. Section 1-Reporting Information, Page 2 of 9 documented: "... Date Incident Reported to OLTC (Office of Long Term Care): 1/20/11, Time:11:00 a.m. Date and Time of Incident (if known): 1/17/11, Time: 1:00 p.m. Date and Time of Discovery: 1/19/11, Time: 2:00 p.m. Type of Incident: Neglect..." Section II - Complete Description of Incident, Page 3 of 9 documented, "Family care plan meeting was arranged at daughter's request for January 19, 2011 at 2:00 p.m. Daughter, (daughter's name) and resident's son, (son's name) arrived for the meeting regarding concerns of resident's care. Daughter, (daughter's name) commented she felt her mother had been 'neglected' due to her room was not picked up and the floor 'looked' dirty. (Daughter) continued, she found her mother to have long and unkept fingernails. She continued that her mother's nose was not properly covered with the Band-Aid she provides the facility with in order to cover the resident's nose. Resident has been observed by staff removing the bandage repeatedly. Regional Director of Operations, (name) asked (daughter) if she indeed felt the resident had been neglected. (Daughter) responded that she did not feel that it was really neglect at this point and that she only wanted to bring it to the staff's attention to be corrected. She continued, this was the first time she has ever found her mother's room to unkept and her nails to be unkept." Section III - Findings and Actions Taken, Page 4 of 9 documented, "Administrator notified the police department of the issue and filed a report. Report is attached with this documentation. Witness statements have been obtained. (Daughter) was asked to fill out a witness statement at which she agreed but has not been compliant in bringing the statement back to the facility. Housekeepers have been inserviced on cleaning protocol for floors and tidiness of resident room. Staff inserviced on appropriate nail care and encouraging resident to leave bandage on her nose. No staff suspended at this time as resident has been observed removing the bandage herself. resident underwent [REDACTED]. Resident at one point used a prosthetic nose, but became aggravated and continued to remove it. Family has since provided Band-Aid to place on resident's nose." This was dated 1/24/11 and signed by the Administrator. Section IV - Notification/Status, Page 5 of 9 documented, "... Family Notified: Yes, (Date and Time were blank)... Doctor Notified: Yes, Date: 1/20/11, Time: 3 p.m. ... Law Enforcement Must Be Notified For Abuse And Neglect: Date: 1/21/11, Time: 9:30 a.m..." The remaining file included Inservice documentation dated 1/20/11 titled "housekeeping - Cleaning" with 3 staff signatures and another inservice dated 1/20/11 titled "Nursing- Nail Care" with 7 staff signatures and the Police Report. There were no witness statements in the file. On 3/3/11 at 2 p.m. the Administrator was asked if there were any witness statements. The Administrator stated, "I did not get any witness statements." She was asked if she interviewed any residents on the hall. She answered, "No". The Administrator was asked why she did not contact the police until 1/21/11. She stated, "I forgot." She was also asked if any other dependent residents were observed for long, unkept fingernails. The Administrator stated, "No." b. Another Facility Investigation Report for Resident Abuse, Neglect, Misappropriation of Property, And Exploitation of Residents in Long-Term Care Facilities (DMS-762) Reporting Form was reviewed on 3/3/11 at 1:45 p.m. regarding Resident #22. Section 1-Reporting Information, Page 2 of 9 documented: "... Date Incident Reported to OLTC (Office of Long Term Care): 2/15/11, Time:11:00 a.m. Date and Time of Incident (if known): 2/14/11, Time: 9 a.m. Date and Time of Discovery: 2/14/11, Time: 9:00 a.m. Type of Incident: Neglect. ...". Section II - Complete Description of Incident, Page 3 of 9 documented: "Daughter, (Name), approached Social Director, (Name) regarding resident's toothbrush was too dry to have been used lately. She also reported resident's bra was not on the resident and that her eyeglass strap was missing. She stated resident would never had removed the eyeglass strap. Daughter stated, 'I feel there is some neglect going on mainly on the 11p-7a shift since they are getting Mother up in the morning.' Administrator contacted (the daughter) at approximately 10:30 a.m. on 2/15/11 to ask her to complete a witness statement. (The daughter) declined and stated she did not wish to have this reported to OLTC due to she worked for the State. She further stated she would prefer that the facility not report this incident, but would insist any further incidents to be reported." Section III - Findings and Actions Taken, Page 4 of 9 documented: "Since (daughter) used the verbage of 'neglect', Administrator chose to report incident to OLTC. (Police Department) was notified and a report made on 2/15/11. A copy is included in this packet. Daughter declined to complete a witness statement. Following the report from (daughter), Administrator and CNA accompanied daughter to resident's room where daughter stated she was wrong and that resident did in fact have on a bra. After searching the resident's room the eyeglass string could not be located. (The daughter) denied her mother's ability to ever remove the string from the eyeglasses. Resident has a history of dementia like behavior although she does not have a [DIAGNOSES REDACTED]. either on herself or other furniture, i.e. tablecloths. Administrator and CNA inspected the resident's toothbrush. Daughter stated we would not be able to tell how dry it was due to she has just brushed resident's teeth. Toothbrush was located in resident's bathroom in an individual toothbrush container. Toothbrush was still wet and Administrator was unable to determine if toothbrush had not been used for a significant period of time. Resident appeared content and in no distress. Resident is not able to verbally or physically make her needs or concerns known due to her medical condition. Eyeglass string was replaced by facility on 2/15/11. CNAs were inserviced regarding proper oral care by Assistant Director of Nursing. Witness statements were obtained by the third shift staff as well as the first shift nursing staff who were assigned to give direct care to resident. Based on the information and evidence available, it has been determined by the Administrator that not enough evidence is available to determine neglect had in fact occurred." Section IV - Notification/Status, Page 5 of 9 documented, "... Family Notified: Yes, Date: 2/14/11, Time: 9 a.m. ... Doctor Notified: Yes, Date: 2/15/11, Time: 3 p.m. ... Law Enforcement Must Be Notified For Abuse And Neglect: Date: 2/15/11, Time: 11:00 a.m..." The remaining file included staff witness statements and the Police Report. On 3/3/11 at 2 p.m. the Administrator was asked if any other residents were interviewed. The Administrator stated, "No." She was also asked if any other dependent resident's teeth were observed. The Administrator stated, "No." 5. Resident #21: A Facility Investigation Report for Resident Abuse, Neglect, Misappropriation of Property, And Exploitation of Residents in Long-Term Care Facilities (DMS-762) Reporting Form was reviewed on 3/3/11 at 1:40 p.m. regarding Resident #21. Section 1-Reporting Information, Page 2 of 9 documented, "... Date Incident Reported to OLTC (Office of Long Term Care): 2/2/11, Time

Complaint # was substantiated, all or in part, in these findings. Based on observation, record review and interview, the facility failed to ensure 1 (Resident #8) of 9 (Resident #1, 2, 4, 5 and 7 - 11) cognitively impaired case mix residents was free from verbal and mental abuse as evidenced by the facility's failure to conduct a thorough investigation after an incident of abuse was reported by a licensed nurse and failure to take steps to ensure residents were not subjected to further abuse. The failed practice resulted in Immediate Jeopardy, which caused or could have caused serious harm, injury or death to Resident #8 and had the potential to affect 61 residents who were cognitively impaired as documented on a list provided by the Director of Nursing (DON) on [DATE] at 11:10 a.m. The facility was informed of the Immediate Jeopardy condition on [DATE] at 3:57 p.m. The findings are: Resident #8 had [DIAGNOSES REDACTED]. The Minimum (MDS) data set [DATE] documented the resident had modified independence in cognitive skills for daily decision making, periods of altered perception, variation in mental function over the course of the day and deterioration in cognitive status. a. The Plan of Care dated [DATE] documented, "At risk for social isolation r/t (related to) [DIAGNOSES REDACTED]." b. A handwritten statement dated [DATE] (not timed) by Licensed Practical Nurse (LPN) #1 documented, "I want to bring something to your attention. Today, I was sitting at the Nurse's Station when a CNA (Certified Nursing Assistant #1) came to the desk bragging and laughing about telling (Resident #8) that DHS (Department of Human Services) was coming to get her baby (doll carried by Resident #8). (Resident #8) became very upset and kept coming to the desk explaining that her baby's clothes are drying then she would put them back on. That she is a good mother and please don't let them take her baby. It was also reported to me that during this past week that the same CNA took the baby, wrapped it in plastic, put it in the whirlpool and told (Resident #8) that her baby drowned. This caused the resident to become very upset. This baby is very real to this resident. I think this behavior by staff members is very cruel." On [DATE] at 1:45 p.m., LPN #1 was asked about the written statement and stated "I wrote the statement on [DATE] regarding (Resident #8). I was at the Nursing Station. (LPN #2), (LPN #3), (CNA #4), (CNA #2) and a few others were at the desk at shift change. I heard (CNA #1) laughing and she said she told (Resident #8) that DHS was going to come and take her baby because the baby did not have any clothes on. (Resident #8) came to the desk with her doll, (male name), (Resident #8) said not to let the police take her baby that his clothes were drying and that she was going to put them back on him. (Registered Nurse (RN) #1) took (Resident #8) to her room to try to calm her down. (Resident #8) made two more trips to the Nursing Station stating that she was a good mother. (LPN #2) gave her an updraft. (Resident #8) was begging to keep (male name). She was distraught. (LPN #2) told (CNA #1) to go to work. (CNA #4) reported about drowning the baby." c. A handwritten statement dated [DATE] (not timed) by CNA #1 documented, "To whom it may concern: The employees were playing with the resident and it was not one employee, it was all employees and we said that don't have the baby naked in the hallway because DHS don't like that and that's as far as that went. Then a aide was whispering something in her (Resident #8) ear at the Nurse's Station that set (Resident #8) off. As to what was said, I don't even know. Even (LPN #2) had to stop the aide at the desk." d. A handwritten statement dated [DATE] (not timed) by the Administrator documented, "Talked to (CNA #1). Not trying to upset her (Resident #8). Was telling her about the baby's neck, it ok... (CNA #1) explained how she was talking to (Resident #8) and only trying to explain to her to go in the room and dress the baby. 'DHS don't want you to have him out in the hall naked.' Not trying to joke with her or upset her but she brought the baby out into the hall asking them something about the baby. No one was making fun of her or trying to upset her. They also talked to her about the baby's neck. The sewing fabric was messed up and she was worried that something was wrong with him. Tried repeatedly to tell her it was ok." e. On [DATE] at 12:30 p.m. and 2:01 p.m., [DATE] at 8:33 a.m., 11:00 a.m. and 3:33 p.m. and [DATE] at 8:41 at 8:44 a.m., the resident had a doll that she called (male name) in her possession. f. On [DATE] at 2:25 p.m., the Director of Nursing stated "(LPN #1) left me a note on my desk regarding the doll and (Resident #8). She said the aides were making fun of the doll. She said an aide put it in a bag and was going to drown it. I talked to the staff and (CNA #1) said the baby was naked and needed clothes. (CNA #2) said the baby's neck had a problem. (CNA #1) said (LPN #2) said (LPN #1) is trying to get you all fired. I did not find anything abusive going on." g. On [DATE] at 9:08 a.m., CNA #1 stated "That morning, rather that evening ([DATE]) around 3:00 p.m. (Resident #8) came to the 200 hall around where we clock out. A CNA said her baby was naked. I said 'Don't have your baby naked in the hallway, DHS won't like that.' I left. I was just playing with her. The next day, (Dietary Aide #1) told me that somebody put the baby in a plastic bag and put it in the tub. (CNA #3) whispered in her (Resident #8) ear on [DATE] and that set (Resident #8) off. (LPN #2) said that CNA (CNA #3) continued to go on with (Resident #8) and that she (LPN #2) finally got mad and told her to be quiet about (Resident #8's) baby. I think (Resident #8) had every right to be upset. It was harassment and abuse. The Administrator did not interview me about any of this." h. On [DATE] at 10:17 a.m., CNA #2 stated "I worked on [DATE]. At about 2:50 p.m., the nurses were at the desk and some of the day and evening CNA's were there. (Resident #8) walked up to the desk. She had a doll with no clothes. She said (Hospital) had messed her baby's neck up. I told her I would give her a girl doll. She said she could barely take care of him. (CNA #1) said to (Resident #8) 'If you don't put the baby's clothes on that DHS will take your baby. I went to clock out. (Director of Nursing) talked to me about this and I wrote a statement. I don't think (CNA #1's) words were appropriate. It could have been offensive and maybe verbal abuse." i. On [DATE] at 10:00 a.m., CNA #3 stated "I worked [DATE] on days. About 2:45 p.m. (Resident #8) came to the desk. (LPN's #1, #2 and #3) were at the desk. I was there, (CNA #2), (CNA #1) and (CNA #4). (Resident #8) came to the desk and said that (male name), her baby, had something on the back of his neck. The baby did not have clothes on. She said that she had been at (Hospital) all night and something was wrong with the baby. (CNA #1 and #2) came up. (CNA #1) said to (Resident #8) 'You need to go put that baby on some clothes. You know that's called abuse and we have already called DHS to come pick up your baby'. (Resident #8) looked upset and said 'No one is going to take my baby, I am a good mother'. I told her I would check the baby's vital signs. I took a stethoscope and listened to his back and chest and told her he was ok. She said 'Thank you'. More words were said by the staff and some giggling and (Resident #8) walked off. (LPN #2) later asked me to go sit with (Resident #8) because she was real upset. (CNA #1) was the one that kept on with (Resident #8) that afternoon. My opinion, I thought it was verbal abuse. No one has asked me any questions about the incident." j. On [DATE] at 9:08 a.m., CNA #4 stated "I worked [DATE]. (Resident #8) was stopped between the employee lounge and the desk by (CNA #1 and #2) and was told that she couldn't be in the hall with (male name), her doll, without clothes on because she was being unfit as a mother. (Resident #8) got upset. (CNA #1) said that DHS was coming to get her baby. By that time they were at the desk. (CNA #2) left. (CNA #1) continued to laugh and joke about (male name). (Resident #8) was distraught that DHS was coming to get her baby. (LPN #1 and #2) wrote (CNA #1) up and filled out witness statements, made copies and put under the Administrator's, Director of Nursing's and Assistant Director of Nursing's doors. Around 6:45 p.m. on [DATE], (CNA #1) took (male name) into the whirlpool room. I was standing in the hall. (Resident #8) was in the hall with her walker. I followed (CNA #1) into the whirlpool room. (CNA #1) placed (male name) in a plastic trash bag and sat him in the whirlpool chair but did not turn the water on. (Resident #8) came into the whirlpool room and (CNA #1) told (Resident #8) that (male name) had drowned. (Resident #8) went to the Nursing Station with (male name) and wanted someone to do CPR (cardiopulmonary resuscitation). I took him and told (Resident #8) that (male name) was fine. She was upset. (LPN #2) got her a breathing treatment and I left." k. On [DATE] at 11:00 a.m., LPN #3 stated "On [DATE], myself, (LPN #2), (LPN #1) and (CNA #4) and a lot of CNA's from days and evenings were at the desk at change of shift. (Resident #8) came up with her baby doll. It didn't have any clothes on. (CNA #1) said 'I need DHS's number so I can call them because they are going to take your baby'. (Resident #8) held her baby closer. Then (CNA #2) said 'They take people's babies if you don't put clothes on them.' (LPN #2) had (CNA #3) to go down with (Resident #8). It took hours to calm her (Resident #8) down. It was horrible. I even baby sat for (Resident #8). I reported this to (Director of Nursing). I made a note of this and put it under the Director of Nursing's door. (Director of Nursing) and I talked Monday morning about this via phone. I felt this was verbal abuse." l. On [DATE] at 2:31 p.m., LPN #2 stated "I was working [DATE]. I was at the desk (CNA #1) came up and said that she told (Resident #8) that she was going to have DHS come and pick up her baby because he was naked in the hallway. (Resident #8) came up to the desk and was shaking, face red, upset and she begged that no one should take her baby. (CNA #2) said something to her. (Resident #8) kept begging not to take her baby. I told her no one was going to take her baby. I sent (CNA #3) to sit with her in her room. She had to have an updraft due to shortness of breath. She remained upset that evening. I sat with her later and dressed her baby. I took (CNA #1) aside and counseled her. I thought it was abusive. I was her (Resident #8's) nurse. I did not call the Administrator because I talked to the CNA myself. (LPN #1) wrote a letter about it to the Administrator." m. On [DATE] at 3:43 p.m., RN #1 stated "I worked [DATE]. Right about shift change, (Resident #8) was at the desk with her baby undressed. Two CNA's (CNA #1) and (CNA #2) were telling her that DHS was going to come get her baby because she was neglectful walking around with her baby naked. She was very upset, had bad anxiety. Apparently, they had been doing it before (Resident #8) got to the Nursing Station. I told the CNA's not to do that to her. I separated the CNA's from the resident. I provided reassurance. (Resident #8) came back to the Nursing Station extremely upset, almost an anxiety attack. (LPN #2) sent a CNA to sit with her. (LPN #1) said she would report it. I thought it was abusive." n. On [DATE] at 1:15 p.m., the Administrator stated: "I was told about the [DATE] incident with (Resident #8) by virtue of (LPN #1's) statement under my door on [DATE]. After reading it, I talked to (Director of Nursing). We started questioning the staff. Based on the statements of the staff, I did not consider it abuse. I did not consider the written statement an allegation of abuse." o. The Immediate Jeopardy was removed and the scope/severity reduced to "G" on [DATE] at 11:55 a.m. when the facility implemented the following Plan of Removal: 1) The investigation into the allegation of mental abuse involving (Resident #8) was reopened on [DATE] and interviews with all parties involved and/or having knowledge of the alleged incident are being scheduled for ,[DATE]-,[DATE]. One C.N.A. (C.N.A. #1) involved in the incident was not scheduled to work on [DATE] and the other was suspended pending investigation on [DATE] by the Director of Nursing. The other C.N.A. (C.N.A. #2) had left the facility prior to the investigation being reopened and had left the faciity on [DATE]. She was not scheduled to return to work on [DATE] and the Director of Nursing contacted her on [DATE] and suspended her pending completion of the investigation. 2) The OLTC (Office of Long Term Care) and the Little Rock Police Department were notified of the allegation on [DATE] by the Administrator. The resident's Nurse Practitioner was informed of the allegation by the Quality Assurance Nurse on [DATE]. The resident's responsible party was informed of the allegation by the Quality Assurance Nurse on [DATE]. 3) The Nurse Consultant will review all grievances, accidents and incidents and 24 hour Nurse's Report for the past 30 days by end of day and will interview residents on the halls assigned to the two C.N.A.'s involved on [DATE] to identify any allegations of abuse that were not reported and/or thoroughly investigated by the facility staff. 4) The Nurse Consultant began training staff including the Administrator and Director of Nurses at 6:30 p.m. on [DATE] on the facility Abuse Policy including identifying different forms of abuse, intervening when abuse is identified, protection of the resident, reporting and investigating allegations of abuse. The Administrator and Director of Nursing were trained on the Abuse Investigation Protocol by the Nurse Consultant on [DATE]. All employees will be retrained on the facility Abuse Policy by [DATE] by the Nurse Consultant/designee prior to being allowed to report to their work stations. Post training testing will be done by all employees to verify that they were able to comprehend the training provided by the Nurse Consultant/designee. Any employee scoring less than 80% will be required to attend additional training and retake the post test. Any employee who has not attended the training and/or passed the post test by [DATE] will not be allowed to return to work until this has been done. The Abuse Post Test will become part of the Orientation Packet for all new hires and will be used during annual Abuse training to verify that employees are able to answer questions appropriately concerning identifying, reporting and investigating abuse allegations and maintaining the safety of a resident during the investigative process. 5) Charge Nurses will observe Certified Nursing Assistants with resident interaction every shift. They will intervene immediately and report and document for any abusive action. Effective [DATE] the Administrator and Director of Nursing will review the 24 Hour Nursing Report, Accident and Incident Log and the Grievance Log daily Monday-Friday and the Nursing Supervisor will review them on Saturday and Sunday to identify any allegations of abuse that were not reported and initiate disciplinary action if any allegations of abuse are noted that were not reported. All Abuse Investigations will be reported to the Nurse Consultant who will review the completed investigation to ensure that a thorough investigation was completed and appropriate action was initiated to protect the resident during the investigation and to prevent future occurrences."

Complaint # was substantiated, all or in part, in these findings. Based on record review and interview, the facility failed to ensure: an allegation of verbal and mental abuse was immediately reported to the Administrator of the facility/Designee; was thoroughly investigated; further potential abuse was prevented during the investigation; and the allegation was reported to officials in accordance with state law for 1 (Resident #8) of 9 (Resident #1, 2, 4, 5 and 7 - 11) cognitively impaired case mix residents. The failed practice resulted in Immediate Jeopardy, which caused or could have caused serious harm, injury or death to Resident #8 and had the potential to affect 61 cognitively impaired residents according to a listing received from the Director of Nursing on [DATE] at 11:10 a.m. The facility was informed of the Immediate Jeopardy condition on [DATE] at 3:57 p.m. The findings are: Resident #8 had [DIAGNOSES REDACTED]. The Minimum (MDS) data set [DATE] documented the resident had modified independence in cognitive skills for daily decision making, periods of altered perception, variation in mental function over the course of the day and deterioration in cognitive status. a. The Plan of Care dated [DATE] documented, "At risk for social isolation r/t (related to) [DIAGNOSES REDACTED]." b. A handwritten statement dated [DATE] (not timed) by Licensed Practical Nurse (LPN) #1 documented, "I want to bring something to your attention. Today, I was sitting at the Nurse's Station when a CNA (Certified Nursing Assistant #1) came to the desk bragging and laughing about telling (Resident #8) that DHS (Department of Human Services) was coming to get her baby (doll carried by Resident #8). (Resident #8) became very upset and kept coming to the desk explaining that her baby's clothes are drying then she would put them back on. That she is a good mother and please don't let them take her baby. It was also reported to me that during this past week that the same CNA took the baby, wrapped it in plastic, put it in the whirlpool and told (Resident #8) that her baby drowned. This caused the resident to become very upset. This baby is very real to this resident. I think this behavior by staff members is very cruel." On [DATE] at 1:45 p.m., LPN #1 was asked about the written statement and stated "I wrote the statement on [DATE] regarding (Resident #8). I was at the Nursing Station. (LPN #2), (LPN #3), (CNA #4), (CNA #2) and a few others were at the desk at shift change. I heard (CNA #1) laughing and she said she told (Resident #8) that DHS was going to come and take her baby because the baby did not have any clothes on. (Resident #8) came to the desk with her doll, (male name), (Resident #8) said not to let the police take her baby that his clothes were drying and that she was going to put them back on him. (Registered Nurse (RN) #1) took (Resident #8) to her room to try to calm her down. (Resident #8) made two more trips to the Nursing Station stating that she was a good mother. (LPN #2) gave her an updraft. (Resident #8) was begging to keep (male name). She was distraught. (LPN #2) told (CNA #1) to go to work. (CNA #4) reported about drowning the baby." c. A handwritten statement dated [DATE] (not timed) by CNA #1 documented, "To whom it may concern: The employees were playing with the resident and it was not one employee, it was all employees and we said that don't have the baby naked in the hallway because DHS don't like that and that's as far as that went. Then a aide was whispering something in her (Resident #8) ear at the Nurse's Station that set (Resident #8) off. As to what was said, I don't even know. Even (LPN #2) had to stop the aide at the desk." d. A handwritten statement dated [DATE] (not timed) by the Administrator documented, "Talked to (CNA #1). Not trying to upset her (Resident #8). Was telling her about the baby's neck, it ok... (CNA #1) explained how she was talking to (Resident #8) and only trying to explain to her to go in the room and dress the baby. 'DHS don't want you to have him out in the hall naked.' Not trying to joke with her or upset her but she brought the baby out into the hall asking them something about the baby. No one was making fun of her or trying to upset her. They also talked to her about the baby's neck. The sewing fabric was messed up and she was worried that something was wrong with him. Tried repeatedly to tell her it was ok." e. On [DATE] at 12:30 p.m. and 2:01 p.m., [DATE] at 8:33 a.m., 11:00 a.m. and 3:33 p.m. and [DATE] at 8:41 at 8:44 a.m., the resident had a doll that she called (male name) in her possession. f. On [DATE] at 2:25 p.m., the Director of Nursing stated "(LPN #1) left me a note on my desk regarding the doll and (Resident #8). She said the aides were making fun of the doll. She said an aide put it in a bag and was going to drown it. I talked to the staff and (CNA #1) said the baby was naked and needed clothes. (CNA #2) said the baby's neck had a problem. (CNA #1) said (LPN #2) said (LPN #1) is trying to get you all fired. I did not find anything abusive going on." g. On [DATE] at 9:08 a.m., CNA #1 stated "That morning, rather that evening ([DATE]) around 3:00 p.m. (Resident #8) came to the 200 hall around where we clock out. A CNA said her baby was naked. I said 'Don't have your baby naked in the hallway, DHS won't like that.' I left. I was just playing with her. The next day, (Dietary Aide #1) told me that somebody put the baby in a plastic bag and put it in the tub. (CNA #3) whispered in her (Resident #8) ear on [DATE] and that set (Resident #8) off. (LPN #2) said that CNA (CNA #3) continued to go on with (Resident #8) and that she (LPN #2) finally got mad and told her to be quiet about (Resident #8's) baby. I think (Resident #8) had every right to be upset. It was harassment and abuse. The Administrator did not interview me about any of this." h. On [DATE] at 10:17 a.m., CNA #2 stated "I worked on [DATE]. At about 2:50 p.m., the nurses were at the desk and some of the day and evening CNA's were there. (Resident #8) walked up to the desk. She had a doll with no clothes. She said (Hospital) had messed her baby's neck up. I told her I would give her a girl doll. She said she could barely take care of him. (CNA #1) said to (Resident #8) 'If you don't put the baby's clothes on that DHS will take your baby. I went to clock out. (Director of Nursing) talked to me about this and I wrote a statement. I don't think (CNA #1's) words were appropriate. It could have been offensive and maybe verbal abuse." i. On [DATE] at 10:00 a.m., CNA #3 stated "I worked [DATE] on days. About 2:45 p.m. (Resident #8) came to the desk. (LPN's #1, #2 and #3) were at the desk. I was there, (CNA #2), (CNA #1) and (CNA #4). (Resident #8) came to the desk and said that (male name), her baby, had something on the back of his neck. The baby did not have clothes on. She said that she had been at (Hospital) all night and something was wrong with the baby. (CNA #1 and #2) came up. (CNA #1) said to (Resident #8) 'You need to go put that baby on some clothes. You know that's called abuse and we have already called DHS to come pick up your baby'. (Resident #8) looked upset and said 'No one is going to take my baby, I am a good mother'. I told her I would check the baby's vital signs. I took a stethoscope and listened to his back and chest and told her he was ok. She said 'Thank you'. More words were said by the staff and some giggling and (Resident #8) walked off. (LPN #2) later asked me to go sit with (Resident #8) because she was real upset. (CNA #1) was the one that kept on with (Resident #8) that afternoon. My opinion, I thought it was verbal abuse. No one has asked me any questions about the incident." j. On [DATE] at 9:08 a.m., CNA #4 stated "I worked [DATE]. (Resident #8) was stopped between the employee lounge and the desk by (CNA #1 and #2) and was told that she couldn't be in the hall with (male name), her doll, without clothes on because she was being unfit as a mother. (Resident #8) got upset. (CNA #1) said that DHS was coming to get her baby. By that time they were at the desk. (CNA #2) left. (CNA #1) continued to laugh and joke about (male name). (Resident #8) was distraught that DHS was coming to get her baby. (LPN #1 and #2) wrote (CNA #1) up and filled out witness statements, made copies and put under the Administrator's, Director of Nursing's and Assistant Director of Nursing's doors. Around 6:45 p.m. on [DATE], (CNA #1) took (male name) into the whirlpool room. I was standing in the hall. (Resident #8) was in the hall with her walker. I followed (CNA #1) into the whirlpool room. (CNA #1) placed (male name) in a plastic trash bag and sat him in the whirlpool chair but did not turn the water on. (Resident #8) came into the whirlpool room and (CNA #1) told (Resident #8) that (male name) had drowned. (Resident #8) went to the Nursing Station with (male name)and wanted someone to do CPR (cardiopulmonary resuscitation). I took him and told (Resident #8) that (male name)was fine. She was upset. (LPN #2) got her a breathing treatment and I left." k. On [DATE] at 11:00 a.m., LPN #3 stated "On [DATE], myself, (LPN #2), (LPN #1) and (CNA #4) and a lot of CNA's from days and evenings were at the desk at change of shift. (Resident #8) came up with her baby doll. It didn't have any clothes on. (CNA #1) said 'I need DHS's number so I can call them because they are going to take your baby'. (Resident #8) held her baby closer. Then (CNA #2) said 'They take people's babies if you don't put clothes on them.' (LPN #2) had (CNA #3) to go down with (Resident #8). It took hours to calm her (Resident #8) down. It was horrible. I even baby sat for (Resident #8). I reported this to (Director of Nursing). I made a note of this and put it under the Director of Nursing's door. (Director of Nursing) and I talked Monday morning about this via phone. I felt this was verbal abuse." l. On [DATE] at 2:31 p.m., LPN #2 stated "I was working [DATE]. I was at the desk (CNA #1) came up and said that she told (Resident #8) that she was going to have DHS come and pick up her baby because he was naked in the hallway. (Resident #8) came up to the desk and was shaking, face red, upset and she begged that no one should take her baby. (CNA #2) said something to her. (Resident #8) kept begging not to take her baby. I told her no one was going to take her baby. I sent (CNA #3) to sit with her in her room. She had to have an updraft due to shortness of breath. She remained upset that evening. I sat with her later and dressed her baby. I took (CNA #1) aside and counseled her. I thought it was abusive. I was her (Resident #8's) nurse. I did not call the Administrator because I talked to the CNA myself. (LPN #1) wrote a letter about it to the Administrator." m. On [DATE] at 3:43 p.m., RN #1 stated "I worked [DATE]. Right about shift change, (Resident #8) was at the desk with her baby undressed. Two CNA's (CNA #1) and (CNA #2) were telling her that DHS was going to come get her baby because she was neglectful walking around with her baby naked. She was very upset, had bad anxiety. Apparently, they had been doing it before (Resident #8) got to the Nursing Station. I told the CNA's not to do that to her. I separated the CNA's from the resident. I provided reassurance. (Resident #8) came back to the Nursing Station extremely upset, almost an anxiety attack. (LPN #2) sent a CNA to sit with her. (LPN #1) said she would report it. I thought it was abusive." n. On [DATE] at 1:15 p.m., the Administrator stated: "I was told about the [DATE] incident with (Resident #8) by virtue of (LPN #1's) statement under my door on [DATE]. After reading it, I talked to (Director of Nursing). We started questioning the staff. Based on the statements of the staff, I did not consider it abuse. I did not consider the written statement an allegation of abuse." o. The Immediate Jeopardy was removed and the scope/severity reduced to "G" on [DATE] at 11:55 a.m. when the facility implemented the following Plan of Removal: 1) The investigation into the allegation of mental abuse involving (Resident #8) was reopened on [DATE] and interviews with all parties involved and/or having knowledge of the alleged incident are being scheduled for ,[DATE]-,[DATE]. One C.N.A. (C.N.A. #1) involved in the incident was not scheduled to work on [DATE] and the other was suspended pending investigation on [DATE] by the Director of Nursing. The other C.N.A. (C.N.A. #2) had left the facility prior to the investigation being reopened and had left the faciity on [DATE]. She was not scheduled to return to work on [DATE] and the Director of Nursing contacted her on [DATE] and suspended her pending completion of the investigation. 2) The OLTC (Office of Long Term Care) and the Little Rock Police Department were notified of the allegation on [DATE] by the Administrator. The resident's Nurse Practitioner was informed of the allegation by the Quality Assurance Nurse on [DATE]. The resident's responsible party was informed of the allegation by the Quality Assurance Nurse on [DATE]. 3) The Nurse Consultant will review all grievances, accidents and incidents and 24 hour Nurse's Report for the past 30 days by end of day and will interview residents on the halls assigned to the two C.N.A.'s involved on [DATE] to identify any allegations of abuse that were not reported and/or thoroughly investigated by the facility staff. 4) The Nurse Consultant began training staff including the Administrator and Director of Nurses at 6:30 p.m. on [DATE] on the facility Abuse Policy including identifying different forms of abuse, intervening when abuse is identified, protection of the resident, reporting and investigating allegations of abuse. The Administrator and Director of Nursing were trained on the Abuse Investigation Protocol by the Nurse Consultant on [DATE]. All employees will be retrained on the facility Abuse Policy by [DATE] by the Nurse Consultant/designee prior to being allowed to report to their work stations. Post training testing will be done by all employees to verify that they were able to comprehend the training provided by the Nurse Consultant/designee. Any employee scoring less than 80% will be required to attend additional training and retake the post test. Any employee who has not attended the training and/or passed the post test by [DATE] will not be allowed to return to work until this has been done. The Abuse Post Test will become part of the Orientation Packet for all new hires and will be used during annual Abuse training to verify that employees are able to answer questions appropriately concerning identifying, reporting and investigating abuse allegations and maintaining the safety of a resident during the investigative process. 5) Charge Nurses will observe Certified Nursing Assistants with resident interaction every shift. They will intervene immediately and report and document for any abusive action. Effective [DATE] the Administrator and Director of Nursing will review the 24 Hour Nursing Report, Accident and Incident Log and the Grievance Log daily Monday-Friday and the Nursing Supervisor will review them on Saturday and Sunday to identify any allegations of abuse that were not reported and initiate disciplinary action if any allegations of abuse are noted that were not reported. All Abuse Investigations will be reported to the Nurse Consultant who will review the completed investigation to ensure that a thorough investigation was completed and appropriate action was initiated to protect the resident during the investigation and to prevent future occurrences."

Complaint # was substantiated, all or in part, in these findings. Based on observation, record review and interview, the facility failed to implement their Abuse Prohibition policies and procedures regarding reporting, investigating and protecting following an allegation of verbal and mental abuse for 1 (Resident #8) of 9 (Resident #1, 2, 4, 5 and 7 - 11) cognitively impaired case mix residents. The failed practice resulted in Immediate Jeopardy, which caused or could have caused serious harm, injury or death to Resident #8 and had the potential to affect 61 cognitively impaired residents according to a listing received from the Director of Nursing on [DATE] at 11:10 a.m. The facility was informed of the Immediate Jeopardy condition on [DATE] at 3:57 p.m. The findings are: 1. The facility's Nursing Policies and Procedures, Resident Abuse, received from the Administrator on [DATE] at 3:15 p.m. documented: "1. Any employee who has actual knowledge or suspects abuse or neglect of a resident or misappropriation shall report the circumstances immediately to the Administrator/Designee without fear of reprisal. 2. The facility will ensure that further potential abuse will not occur while the investigation is in progress. Based on the results of the quick internal investigation, appropriate action will be taken. If the suspected abuser is an employee of the facility, that employee will immediately be suspended pending the outcome of further investigation. 3. The Administrator or Designee will conduct a quick internal investigation of the incident. Under Arkansas law, the Administrator or his/her Designee will complete the DHS (Department of Human Services) 7734 (OLTC (Office of Long Term Care) Incident & Accident Form). This form will be submitted to OLTC by 11:00 a.m. on the next business day. 4. The Administrator will immediately contact the Police Department and the resident's responsible party or guardian. 5. At no time will handwritten statements by employees or witnesses or Abuse Incident Report forms be submitted until approved by the Director of Clinical Services. 6. There will be a report (DHS 762) completed immediately following a thorough investigation of the incident. Attach written statements of interviews with Resident, suspects (if identified), eyewitnesses and circumstantial witnesses. The facility incident report form is not to be used for this purpose. Under Arkansas law, the Administrator or his/her designee will complete the DHS 762 OLTC form and submit to the OLTC within 5 business days." 2. Resident #8 had [DIAGNOSES REDACTED]. The Minimum (MDS) data set [DATE] documented the resident had modified independence in cognitive skills for daily decision making, periods of altered perception, variation in mental function over the course of the day and deterioration in cognitive status. a. The Plan of Care dated [DATE] documented, "At risk for social isolation r/t (related to) [DIAGNOSES REDACTED]." b. A handwritten statement dated [DATE] (not timed) by Licensed Practical Nurse (LPN) #1 documented, "I want to bring something to your attention. Today, I was sitting at the Nurse's Station when a CNA (Certified Nursing Assistant #1) came to the desk bragging and laughing about telling (Resident #8) that DHS (Department of Human Services) was coming to get her baby (doll carried by Resident #8). (Resident #8) became very upset and kept coming to the desk explaining that her baby's clothes are drying then she would put them back on. That she is a good mother and please don't let them take her baby. It was also reported to me that during this past week that the same CNA took the baby, wrapped it in plastic, put it in the whirlpool and told (Resident #8) that her baby drowned. This caused the resident to become very upset. This baby is very real to this resident. I think this behavior by staff members is very cruel." On [DATE] at 1:45 p.m., LPN #1 was asked about the written statement and stated "I wrote the statement on [DATE] regarding (Resident #8). I was at the Nursing Station. (LPN #2), (LPN #3), (CNA #4), (CNA #2) and a few others were at the desk at shift change. I heard (CNA #1) laughing and she said she told (Resident #8) that DHS was going to come and take her baby because the baby did not have any clothes on. (Resident #8) came to the desk with her doll, (male name), (Resident #8) said not to let the police take her baby that his clothes were drying and that she was going to put them back on him. (Registered Nurse (RN) #1) took (Resident #8) to her room to try to calm her down. (Resident #8) made two more trips to the Nursing Station stating that she was a good mother. (LPN #2) gave her an updraft. (Resident #8) was begging to keep (male name). She was distraught. (LPN #2) told (CNA #1) to go to work. (CNA #4) reported about drowning the baby." c. A handwritten statement dated [DATE] (not timed) by CNA #1 documented, "To whom it may concern: The employees were playing with the resident and it was not one employee, it was all employees and we said that don't have the baby naked in the hallway because DHS don't like that and that's as far as that went. Then a aide was whispering something in her (Resident #8) ear at the Nurse's Station that set (Resident #8) off. As to what was said, I don't even know. Even (LPN #2) had to stop the aide at the desk." d. A handwritten statement dated [DATE] (not timed) by the Administrator documented, "Talked to (CNA #1). Not trying to upset her (Resident #8). Was telling her about the baby's neck, it ok... (CNA #1) explained how she was talking to (Resident #8) and only trying to explain to her to go in the room and dress the baby. 'DHS don't want you to have him out in the hall naked.' Not trying to joke with her or upset her but she brought the baby out into the hall asking them something about the baby. No one was making fun of her or trying to upset her. They also talked to her about the baby's neck. The sewing fabric was messed up and she was worried that something was wrong with him. Tried repeatedly to tell her it was ok." e. On [DATE] at 12:30 p.m. and 2:01 p.m., [DATE] at 8:33 a.m., 11:00 a.m. and 3:33 p.m. and [DATE] at 8:41 at 8:44 a.m., the resident had a doll that she called (male name) in her possession. f. On [DATE] at 2:25 p.m., the Director of Nursing stated "(LPN #1) left me a note on my desk regarding the doll and (Resident #8). She said the aides were making fun of the doll. She said an aide put it in a bag and was going to drown it. I talked to the staff and (CNA #1) said the baby was naked and needed clothes. (CNA #2) said the baby's neck had a problem. (CNA #1) said (LPN #2) said (LPN #1) is trying to get you all fired. I did not find anything abusive going on." g. On [DATE] at 9:08 a.m., CNA #1 stated "That morning, rather that evening ([DATE]) around 3:00 p.m. (Resident #8) came to the 200 hall around where we clock out. A CNA said her baby was naked. I said 'Don't have your baby naked in the hallway, DHS won't like that.' I left. I was just playing with her. The next day, (Dietary Aide #1) told me that somebody put the baby in a plastic bag and put it in the tub. (CNA #3) whispered in her (Resident #8) ear on [DATE] and that set (Resident #8) off. (LPN #2) said that CNA (CNA #3) continued to go on with (Resident #8) and that she (LPN #2) finally got mad and told her to be quiet about (Resident #8's) baby. I think (Resident #8) had every right to be upset. It was harassment and abuse. The Administrator did not interview me about any of this." h. On [DATE] at 10:17 a.m., CNA #2 stated "I worked on [DATE]. At about 2:50 p.m., the nurses were at the desk and some of the day and evening CNA's were there. (Resident #8) walked up to the desk. She had a doll with no clothes. She said (Hospital) had messed her baby's neck up. I told her I would give her a girl doll. She said she could barely take care of him. (CNA #1) said to (Resident #8) 'If you don't put the baby's clothes on that DHS will take your baby. I went to clock out. (Director of Nursing) talked to me about this and I wrote a statement. I don't think (CNA #1's) words were appropriate. It could have been offensive and maybe verbal abuse." i. On [DATE] at 10:00 a.m., CNA #3 stated "I worked [DATE] on days. About 2:45 p.m. (Resident #8) came to the desk. (LPN's #1, #2 and #3) were at the desk. I was there, (CNA #2), (CNA #1) and (CNA #4). (Resident #8) came to the desk and said that (male name), her baby, had something on the back of his neck. The baby did not have clothes on. She said that she had been at (Hospital) all night and something was wrong with the baby. (CNA #1 and #2) came up. (CNA #1) said to (Resident #8) 'You need to go put that baby on some clothes. You know that's called abuse and we have already called DHS to come pick up your baby'. (Resident #8) looked upset and said 'No one is going to take my baby, I am a good mother'. I told her I would check the baby's vital signs. I took a stethoscope and listened to his back and chest and told her he was ok. She said 'Thank you'. More words were said by the staff and some giggling and (Resident #8) walked off. (LPN #2) later asked me to go sit with (Resident #8) because she was real upset. (CNA #1) was the one that kept on with (Resident #8) that afternoon. My opinion, I thought it was verbal abuse. No one has asked me any questions about the incident." j. On [DATE] at 9:08 a.m., CNA #4 stated "I worked [DATE]. (Resident #8) was stopped between the employee lounge and the desk by (CNA #1 and #2) and was told that she couldn't be in the hall with (male name), her doll, without clothes on because she was being unfit as a mother. (Resident #8) got upset. (CNA #1) said that DHS was coming to get her baby. By that time they were at the desk. (CNA #2) left. (CNA #1) continued to laugh and joke about (male name). (Resident #8) was distraught that DHS was coming to get her baby. (LPN #1 and #2) wrote (CNA #1) up and filled out witness statements, made copies and put under the Administrator's, Director of Nursing's and Assistant Director of Nursing's doors. Around 6:45 p.m. on [DATE], (CNA #1) took (male name) into the whirlpool room. I was standing in the hall. (Resident #8) was in the hall with her walker. I followed (CNA #1) into the whirlpool room. (CNA #1) placed (male name) in a plastic trash bag and sat him in the whirlpool chair but did not turn the water on. (Resident #8) came into the whirlpool room and (CNA #1) told (Resident #8) that (male name) had drowned. (Resident #8) went to the Nursing Station with (male name)and wanted someone to do CPR (cardiopulmonary resuscitation). I took him and told (Resident #8) that (male name)was fine. She was upset. (LPN #2) got her a breathing treatment and I left." k. On [DATE] at 11:00 a.m., LPN #3 stated "On [DATE], myself, (LPN #2), (LPN #1) and (CNA #4) and a lot of CNA's from days and evenings were at the desk at change of shift. (Resident #8) came up with her baby doll. It didn't have any clothes on. (CNA #1) said 'I need DHS's number so I can call them because they are going to take your baby'. (Resident #8) held her baby closer. Then (CNA #2) said 'They take people's babies if you don't put clothes on them.' (LPN #2) had (CNA #3) to go down with (Resident #8). It took hours to calm her (Resident #8) down. It was horrible. I even baby sat for (Resident #8). I reported this to (Director of Nursing). I made a note of this and put it under the Director of Nursing's door. (Director of Nursing) and I talked Monday morning about this via phone. I felt this was verbal abuse." l. On [DATE] at 2:31 p.m., LPN #2 stated "I was working [DATE]. I was at the desk (CNA #1) came up and said that she told (Resident #8) that she was going to have DHS come and pick up her baby because he was naked in the hallway. (Resident #8) came up to the desk and was shaking, face red, upset and she begged that no one should take her baby. (CNA #2) said something to her. (Resident #8) kept begging not to take her baby. I told her no one was going to take her baby. I sent (CNA #3) to sit with her in her room. She had to have an updraft due to shortness of breath. She remained upset that evening. I sat with her later and dressed her baby. I took (CNA #1) aside and counseled her. I thought it was abusive. I was her (Resident #8's) nurse. I did not call the Administrator because I talked to the CNA myself. (LPN #1) wrote a letter about it to the Administrator." m. On [DATE] at 3:43 p.m., RN #1 stated "I worked [DATE]. Right about shift change, (Resident #8) was at the desk with her baby undressed. Two CNA's (CNA #1) and (CNA #2) were telling her that DHS was going to come get her baby because she was neglectful walking around with her baby naked. She was very upset, had bad anxiety. Apparently, they had been doing it before (Resident #8) got to the Nursing Station. I told the CNA's not to do that to her. I separated the CNA's from the resident. I provided reassurance. (Resident #8) came back to the Nursing Station extremely upset, almost an anxiety attack. (LPN #2) sent a CNA to sit with her. (LPN #1) said she would report it. I thought it was abusive." n. On [DATE] at 1:15 p.m., the Administrator stated: "I was told about the [DATE] incident with (Resident #8) by virtue of (LPN #1's) statement under my door on [DATE]. After reading it, I talked to (Director of Nursing). We started questioning the staff. Based on the statements of the staff, I did not consider it abuse. I did not consider the written statement an allegation of abuse." o. The Immediate Jeopardy was removed and the scope/severity reduced to "G" on [DATE] at 11:55 a.m. when the facility implemented the following Plan of Removal: 1) The investigation into the allegation of mental abuse involving (Resident #8) was reopened on [DATE] and interviews with all parties involved and/or having knowledge of the alleged incident are being scheduled for ,[DATE]-,[DATE]. One C.N.A. (C.N.A. #1) involved in the incident was not scheduled to work on [DATE] and the other was suspended pending investigation on [DATE] by the Director of Nursing. The other C.N.A. (C.N.A. #2) had left the facility prior to the investigation being reopened and had left the faciity on [DATE]. She was not scheduled to return to work on [DATE] and the Director of Nursing contacted her on [DATE] and suspended her pending completion of the investigation. 2) The OLTC (Office of Long Term Care) and the Little Rock Police Department were notified of the allegation on [DATE] by the Administrator. The resident's Nurse Practitioner was informed of the allegation by the Quality Assurance Nurse on [DATE]. The resident's responsible party was informed of the allegation by the Quality Assurance Nurse on [DATE]. 3) The Nurse Consultant will review all grievances, accidents and incidents and 24 hour Nurse's Report for the past 30 days by end of day and will interview residents on the halls assigned to the two C.N.A.'s involved on [DATE] to identify any allegations of abuse that were not reported and/or thoroughly investigated by the facility staff. 4) The Nurse Consultant began training staff including the Administrator and Director of Nurses at 6:30 p.m. on [DATE] on the facility Abuse Policy including identifying different forms of abuse, intervening when abuse is identified, protection of the resident, reporting and investigating allegations of abuse. The Administrator and Director of Nursing were trained on the Abuse Investigation Protocol by the Nurse Consultant on [DATE]. All employees will be retrained on the facility Abuse Policy by [DATE] by the Nurse Consultant/designee prior to being allowed to report to their work stations. Post training testing will be done by all employees to verify that they were able to comprehend the training provided by the Nurse Consultant/designee. Any employee scoring less than 80% will be required to attend additional training and retake the post test. Any employee who has not attended the training and/or passed the post test by [DATE] will not be allowed to return to work until this has been done. The Abuse Post Test will become part of the Orientation Packet for all new hires and will be used during annual Abuse training to verify that employees are able to answer questions appropriately concerning identifying, reporting and investigating abuse allegations and maintaining the safety of a resident during the investigative process. 5) Charge Nurses will observe Certified Nursing Assistants with resident interaction every shift. They will intervene immediately and report and document for any abusive action. Effective [DATE] the Administrator and Director of Nursing will review the 24 Hour Nursing Report, Accident and Incident Log and the Grievance Log daily Monday-Friday and the Nursing Supervisor will review them on Saturday and Sunday to identify any allegations of abuse that were not reported and initiate disciplinary action if any allegations of abuse are noted that were not reported. All Abuse Investigations will be reported to the Nurse Consultant who will review the completed investigation to ensure that a thorough investigation was completed and appropriate action was initiated to protect the resident during the investigation and to prevent future occurrences."