Every finding on record at The Springs of Red Oak

Based on observation, interview, and facility policy review, it was determined that the facility failed to ensure food preparation and serving pieces were washed, dried, and stored in sanitary conditions for one of one kitchen. Based on observation, interview, and facility policy review, it was determined that the facility failed to ensure food preparation and serving dishware were washed, dried, and stored in sanitary conditions for one of one kitchen that served 35 residents with regular diets, 11 with mechanical soft diets, and two with pureed diets. The findings include: During an observation and concurrent interview on 05/16/2026 at 11:25 AM, the Dietary Manager (DM) retrieved pans that were stored on a shelf under the serving table. Five quarter sheet pans were observed. One had particles, described as brown and soft by the DM, in it, and the particles transferred to a white napkin when the pan was wiped by the DM. The DM stated that because they were soft, it was probably breadcrumbs. Three of the other quarter sheet pans were observed by this surveyor and DM to be wet inside. Six full sheet pans were observed. One full sheet pan was observed, by this surveyor and the DM to be wet inside. The DM indicated that pans stored wet could grow mold, and pans not entirely clean of food could cause cross-contamination During an additional interview on 05/13/2026 at 3:00 PM, the DM indicated that the reason the pans were wet and not entirely clean was because the kitchen was small and there was no place to let the pans air dry, as appropriate. During an interview on 05/14/2026 at 9:06 AM, the Infection Preventionist (IP), also the acting Director of Nursing (DON), indicated that pans/serve ware/dishware should not be stored wet or with food residue. The IP also indicated that storing the items unclean or wet could result in mold and bacteria growth, and ultimately residents could get bacterial infections, gastro-intestinal, and/or respiratory issues. During an interview on 05/14/2026 at 01:00 PM, the Administrator indicated that pans should not be stored wet and/or unclean. A review of the facility document titled Quick Resource Tool: QRT Warewashing issued 09/01/2021, revealed that all dishware, service ware, and utensils will be cleaned and sanitized after each use. The document also revealed that all dishware will be air dried and properly stored.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure proper infection prevention measures during a medication administration for 1 resident (Resident #40) out of 4 residents observed to be given medications. Based on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure proper infection control during medication administration for one (Resident #40) of four residents observed during medication administration. The findings include: Review of Resident #40's admission Record revealed the facility admitted Resident #40 on 03/02/2026 with diagnoses that included diabetes mellitus, dementia, and hypertension. Review of a Brief Interview for Mental Status (BIMS) dated 03/03/2026, indicated Resident #40 had a score of 13, which indicated the resident was cognitively intact. Review of Resident #40's Order Summary revealed resident received (generic) medication for hypertension, with a start date of 03/03/2026. During an observation and concurrent interview on 05/13/2026 at 8:54 AM, this surveyor observed Medication Assistant, Certified (MAC) #1 preparing oral medications for Resident #40 by popping the medications out of a blister pack, directly into a medicine cup. Resident #40's (generic) antihypertensive pill, bounced out of the cup and landed on the floor, under the medication cart, and close to the wall. MAC #1 picked the antihypertensive pill off the floor with bare hands and placed the medication back into the cup, with the other medication. Without performing hand hygiene, MAC #1 proceeded to pick up the medicine cup, handed the cup to Resident #40, and Resident #40 took the medications. MAC #1 indicated that she would not usually pick up medications off the floor and administer them to a resident, but the (generic) antihypertensive medication was the last one in the blister pack. During an additional interview on 05/13/2026 at 1:40 PM, MAC #1 indicated that instead of putting the medication that was dropped on the floor back into the cup, the medication should have been disposed of because it was contaminated, and hand hygiene should have been performed before completing the medication administration. MAC #1 also indicated that the risk to a resident could be cross-contamination. During an interview on 05/13/2026 at 2:45 PM, Registered Nurse (RN) #2 indicated that the process for medications that have been dropped on the floor was to dispose of the medication, perform hand hygiene, and obtain another pill/tablet prior to completing the medication administration. During an interview on 06/13/2026 at 3:30 PM, Registered Nurse (RN) #3 indicated that if a medication was dropped, the proper process would be to dispose of the medication, perform hand hygiene, and obtain another pill/tablet prior to completing the medication administration. During an interview on 05/14/2026 at 9:01 AM, the Director of Nursing (DON), who was also the Infection Preventionist (IP), indicated that if an employee administering medications dropped a medication on the floor, they should dispose of the medication, sanitize their hands and then get a new medication, prior to completing the medication administration. The DON also indicated that the risk of a resident being administered medications off the floor and staff not performing adequate hand hygiene could result in the resident getting sick. During an interview on 05/14/2026 at 1:00 PM, the Administrator indicated that medications that have been on the floor should not be administered, and hand hygiene should be performed prior to administering medications. Review of a facility policy titled Handwashing/Hand Hygiene revised in August 2019, revealed that alcohol-based hand rub or soap and water is to be used, before preparing or handling medication. Review of a facility policy titled Administering Medications revised in August 2019, revealed that staff are to follow established facility infection control procedures, like handwashing, for the administration of medications. Review of MAC #1's Medication Administration Skills Competency dated 05/11/2026, revealed pills/capsules should not be touched with bare hands.

Based on observations, interview, record review, and facility policy review the facility failed to ensure dignity was maintained for 1(Resident #21) of 1 sampled resident reviewed for dignity. The findings include: A review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/08/2024, revealed Resident #21 had a Brief Interview of Mental Status (BIMS) score 10 indicating moderately impaired cognition. Review of a Plan of Care for Resident #21 initiated 08/07/2024, revealed Resident #21 had an Activities of Daily Living (ADL) self-care performance deficit related to (r/t) needing assistance with ADLs. On 1/08/25 at 11:17 AM, this surveyor observed Certified Nursing Assistant (CNA) #2 push Resident #21 past the nurse's station in a shower chair. This surveyor noted Resident #21 was not fully covered. On 1/08/25 at 12:54 PM, during an interview CNA #2 stated Resident #21 was not fully covered while being transported through a common area which could be a dignity issue. On 01/09/25 at 8:40 AM, during an interview the Director of Nursing (DON) stated staff should ensure residents are fully covered prior to transporting, to maintain dignity and keep the resident warm. A policy titled Dignity noted residents are always treated with dignity and respect.

Based on observations, interviews, record review, and facility policy review the facility failed to ensure confidentiality of personal and medical information was protected for 1 (Resident #21) of 1 sampled resident reviewed for personal and medical information confidentiality. The findings include: A review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE], revealed Resident #21 had a Brief Interview of Mental Status (BIMS) score of 10 indicating moderately impaired cognition. Review of a Plan of Care for Resident #21 initiated [DATE], revealed Resident #21 requested that no cardiopulmonary resuscitation (CPR) measures be performed. On [DATE] at 11:50 AM, this surveyor observed an unattended, unlocked tablet which displayed Resident #21 ' s personal and medical information. This surveyor was able to visualize Resident 21's name, date of birth, code status, and physician's order on the unlocked tablet. On [DATE] at 12:00 PM, during an observation and interview the Nursing Consultant stated the tablet should be locked to protect the resident's personal and medical information. On [DATE] at 8:40 AM, during an interview, the Director of Nursing (DON) stated nurses should lock unattended tablets and/or computers to ensure the resident's personal and medical information was protected. A policy titled Confidentiality of Information and Personal Privacy noted the facility will safeguard the personal privacy and confidentiality of all resident personal and medical records.

Based on record review, interview, and facility policy review the facility failed to coordinate with state authority to determine if placement in the facility was appropriate or incorporate the Pre-Admission Screening and Resident Review (PASARR) assessment with if any recommendations from the level II determination and the PASARR evaluation report into the resident assessment, care planning, and transition of care for 1 (Resident #46) of 1 sampled resident reviewed. The findings include: A review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/11/2024, revealed Resident #46 had a Brief Interview of Mental Status (BIMS) score of 06 indicating severely impaired cognition. Resident #46 had diagnoses of anxiety, bipolar disorder, and Schizophrenia. A review of a Plan of Care revised 10/28/2024, for Resident #46 revealed Resident #46 received antipsychotic medication related to (r/t) bipolar disorder and behaviors. On 01/07/25 at 2:20 PM, this surveyor requested the level II evaluation report for Resident #46 from the Director of Nursing (DON). On 01/07/25 at 3:3 PM, the Administrator Consultant stated the facility was unable to locate the level II evaluation report for Resident #46. The Administrator Consultant stated without the level II evaluation report the facility would not know if the resident required any specialized services or had any recommendation from the state authority. On 01/08/25 at 9:34 AM, the Director of Nursing (DON) provided a level II evaluation dated 01/08/2025. On 01/09/25 at 9:48 AM, the DON stated she was unaware Resident #46 was considered by the state as PASARR level II. On 01/08/25 at 10:00 AM, the Nurse Consultant stated we knew we would still get a tag, because the facility failed to follow through with the state on the resident PASARR status until now. On 01/09/25 at 8:40 AM, the DON stated the facility was not aware Resident #46 was considered by the state as PASARR level II, therefore the facility did not have the level II evaluation report readily available. The DON stated this failure could have potentially affected Resident #46 ' s care. A policy titled Admission Criteria noted all new admissions and re-admissions are screened for mental disorders (MD), intellectual disabilities (ID) or related disorders (RD) per the Medicaid Pre-Admission Screening and Resident Review (PASARR) process. Upon completion of the level II evaluation, the state PASARR representative determines if the individual has a physical or mental condition, what specialized or rehabilitative services he or she needs, and whether placement in the facility is appropriate.

Based on observation, record review, and interviews, the facility failed to ensure a comprehensive care plan was developed to address the necessary monitoring and precautions related to the use of tobacco products to meet the needs of the resident and minimize the potential for complications for 1 (Resident #55) of 1 sampled resident who was reviewed for tobacco use. The findings are: 1.Review of an admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/17/2024, indicated Resident #55 had diagnoses of heart failure, stroke, and tobacco use, scored 15 (13-15 indicates cognitively intact) on the Brief Interview for Mental Status (BIMS) and was a current tobacco user. a. On 01/07/25 at 1:40 PM, Resident #55 was observed in the facility ' s designated smoking area, sitting in their wheelchair with a smoking apron on, smoking a cigarette. A staff member was present supervising the residents that were smoking. b. A form titled Smoking Safety Screen dated 11/13/2024, indicated Resident #55 was safe to smoke with a smoking apron and staff supervision. c. Resident #55 ' sCare Plan with an initiation date of 11/13/2024, did not address that Resident #55 smoked tobacco products. d. On 01/08/2025 at 1:15 PM, the Minimum Data Set Coordinator (MDS) confirmed during interview that Resident #55 smoked tobacco products and Resident #55 ' s Care Plan did not address the resident was a current smoker who required supervision and a smoking apron when smoking. The MDS coordinator stated Residents #55's Care Plan should have addressed smoking due to safety, as well as so the resident could be monitored for possible side effects to smoking. e. 01/08/25 at 1:25 PM, the Director of Nursing (DON) confirmed during interview that Resident #55 smoked and required supervision when smoking. The DON stated Resident #55's Care Plan should have addressed that Resident #55 smoked since resident care plans should be individualized to meet the resident's needs. f. On 01/08/25 at 3:15 PM, the Director of Nursing was asked if the facility had a policy on care plans. The DON stated she would check and see. g. On 01/08/25 at 3:35 PM, the policy titled Care Planning - Interdisciplinary Team (Revised March 2022), provided by the Assistant Director of Nursing (ADON) indicated that the interdisciplinary team was responsible for the development of resident care plans that are comprehensive, and person-centered based on the resident assessment.

Based on record review, interview, and facility policy review the facility failed to develop a discharge summary which included a recapitalization of the resident's stay, a final summary of the resident's status, and reconciliation of all pre and post discharge medications for 1 (Resident #111) of 3 sampled residents. The findings include: A review of the admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/20/2024, revealed Resident #111 had a Brief Interview of Mental Status (BIMS) score of 12 indicating moderately impaired cognition. Review of a Plan of Care for Resident #111 initiated 10/17/2024, revealed Resident #111 or representative wished to be discharged home with home health and durable medical equipment (DME) as needed. A review of the Discharge Note dated 11/01/2024, indicated Resident #111 was discharged home with home health. On 01/09/25 at 8:40 AM, during an interview the Director of Nursing (DON) stated the discharge summary was not completed for Resident #111. A policy titled Discharge Summary and Plan indicated when a resident's discharge is anticipated, a discharge summary and post-discharge plan will be developed to assist the resident to adjust to his/her new living environment.

Based on record review, interview, and facility policy review the facility failed to ensure 1 (Resident #39) of 1 sampled resident received wound care according to the physician's order. The findings include: A review of the annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/20/2024, revealed Resident #39 had a Brief Interview of Mental Status (BIMS) score of 04 indicating severely impaired cognition. A review of a Plan of Care for Resident #39, revised 11/20/2024, revealed Resident #39 had a pressure ulcer to left heel. According to the Treatment Administration Record (TAR), Resident #39 had a physician's order for treatment for left heel. The order noted, clean heel with wound cleanser, pat dry, apply collagen and hydrogel, then cover with dry dressing daily until wound is resolved. The TAR noted treatment was completed on 1/01/2025 and 1/05/2025. On 1/08/2025 at 12:53 PM, during an interview the Director of Nursing (DON) stated treatment to Resident #39 ' s left foot should be done daily, but it was not signed off on the TAR indicating completion. The DON stated if it was not documented it was not done. On 1/09/2025 at 8:40 AM, the DON stated no, there was not documentation to show that the treatment was done daily. A policy titled Pressure Injuries Overview did not contain any pertinent information related to the deficient practice.

Based on document review, observations, interviews, and facility policy review, the facility failed to post the nurse staffing information on a daily basis, to include the facility name, the current date, the number and actual hours worked by staff, and the resident census. The deficient practice had the potential to affect all residents. The findings are: a. On 01/07/25 at 8:30 AM, this surveyor noted nursing staffing posted for Monday 1/6 at the beginning of the shift which included facility name, date, and the total number and actual hours worked per shift for RNs, LPN, CNAs who are responsible for resident care. b. On 01/08/25 at 11:30 AM, this surveyor noted nursing staffing posted for Monday 1/6. c. On 01/08/25 at 4:45 PM, this surveyor noted nursing staffing posted remained Monday 1/6. d. During an interview on 01/09/25 at 8:16 AM, with the Administrator regarding nursing staff posting remained Monday 1/6. The Administrator stated Human Resources does that and she was not present, and she forgot. e. During an interview on 01/09/25 at 9:01 AM, with the Director of Nursing (DON) and the Administrator regarding posting of staffing schedule not being updated, the Administrator responded she, Human Resources forgot, however, the DON updated and posted. f. During an interview on 01/09/25 at 9:32 AM, this surveyor asked the Administrator for a policy regarding posting of nurse staffing daily. g. On 01/09/25 at 9:45 AM, this surveyor received the facility policy provided by the Administrator titled Staffing. It did not have any pertinent information related to the deficient practice.

Based on record review, interview, and facility policy review the facility failed to ensure gradual psychotropic (anti-anxiety) dose reductions (GDR) were attempted in the absence of a physician's documented evaluation of the specific risks versus benefits of continuing the as needed (PRN) medication past 14 days and a documented explanation as to why a dose reduction attempt would be contraindicated, in order to ascertain the smallest effective dose and minimize the potential for adverse drug effects for 1(Resident # 43) of 1 sampled resident. The findings include: A review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/10/2024, revealed Resident #43 had a Staff Assessment of Mental Status (SAMS) which indicated memory problems. A review of a Plan of Care for Resident #43 initiated 11/05/2024, revealed Resident #43 used anti-anxiety medications related to anxiety disorder. A review of the Pharmacy [ Medication Regimen Review] MRR - Nursing Recommendation dated 06/17/2024, indicated Resident #43 had an order for [name brand anti-anxiety medication] (a medication used to treat anxiety disorders) injection solution 2 milligram (MG)/milliliter (ML) inject 1 milligram intramuscularly every 24 hours as needed for increased behaviors and PRN orders for psychotropic medications are limited to 14 days. On 01/08/25 at 11:16 AM, the Director of Nursing (DON) stated the facility does not have any documentation completed by the Medical Doctor (MD) to continue the [name brand anti-anxiety medication] past 14 days. On 01/09/25 at 8:40 AM, the DON stated there should be documentation completed by the MD in place for regulation purposes. The DON stated the facility should not administer as needed psychotropic drugs past the 14 days without documentation and regulation. A policy titled Medication Therapy indicated, the physician will identify situations where medications should be tapered, discontinued, or changed to another medication, for example: when a medication is being given in excessive dose, for excessive periods of time, without adequate monitoring, or in the absence of a valid clinical rationale.

Based on record review and interview, the facility failed to develop and/or implement a water management program with measures to minimize the risk for Legionella and other waterborne opportunistic pathogens to reduce the risk for potential infections. This failed practice had the potential to affect 38 residents who resided in the facility. The findings are: 1. On 2/22/24 at 2:06 PM, the Maintenance Supervisor was asked, Do you handle water management here? The Maintenance Supervisor stated, No, I'm not sure what you mean. The Surveyor asked, If the water system has to be tested or checked here, would you be the one doing that? The Maintenance Supervisor stated, Well I'm sure I would be involved in that. The Surveyor asked, Have you assessed the water system regarding Legionella and other water borne opportunistic pathogens since you've been here? The Maintenance Supervisor stated, No, I've never done that. The Surveyor asked, Do you know if there are measures in place to prevent growth of Legionella and other opportunistic water borne pathogens? The Maintenance Supervisor stated, Not that I'm aware of. 2. On 2/22/24 at 2:08 PM, the Administrator handed the Maintenance Supervisor information regarding Legionella (Legionella Surveillance Policy and Water Management Program to Reduce Legionella Growth & [and] Spread from the CDC (Centers for Disease Control)). The Maintenance Supervisor stated, Let me see what it is that she just gave me. While looking down at the paper the Maintenance Supervisor stated, Oh, you can breathe it in. The Maintenance Supervisor confirmed he was not familiar with the information. 3. On 2/22/24 at 4:26 PM, the Administrator was asked, How have you been monitoring the water system for waterborne pathogens or Legionella? The Administrator stated, We would have to listen to the city. We're not testing as of right now because it's so new and it's so expensive. The company, [Name], is in the process of coming up with an active policy and testing kits. 4. A Legionella Surveillance Policy, provided by the Administrator on 2/22/24 at 2:08 PM documented, .It is the policy of this facility to establish primary and secondary strategies for the prevention and control of Legionella infections . Definitions: .Legionella is a bacteria found in water that can cause a serious type of pneumonia, Legionnaires' disease .

Based on record review, observation, and interview, the facility failed to ensure the indwelling catheter tubing was anchored to prevent trauma and positioned to allow the urine to flow down away from the bladder for 1 (Resident #30) of 1 sampled resident and failed to ensure a catheter bag was not touching the floor to decrease the potential for infection for 2 (Residents #4 and #30) of 2 sampled residents who had a physician's order for an indwelling catheter. The findings are: 1. Resident #30 had a diagnosis of Flaccid (Not Firm) Neuropathic (Nerve Problem) Bladder. a. A Physician's Order with a start date of 9/29/23 documented, .Change [Brand of indwelling catheters] . catheter monthly on the 5th, every day shift . b. A Care Plan with a revision date of 12/20/23 documented, .The resident has indwelling Catheter: Neurogenic bladder . Monitor/document for pain/discomfort due to catheter . c. On 2/20/24 at 10:22 AM, Resident #30 was lying in bed awake and the door was open. A catheter bag with a privacy cover and tubing was visible from the doorway and the resident's top cover was down and the right leg was exposed. The catheter tubing was coming from the right side of the resident's brief, looped over the right upper thigh and the end of the catheter that connects to the tubing was visible at this time and not secured to (Resident #30's) leg. This surveyor asked Resident #30 if there was anything on Resident #30's left leg and the resident exposed the upper leg and there was nothing to secure the catheter tubing. d. On 2/22/24 at 9:14 AM, Resident #30 was lying in bed with the head of bed up and eyes closed. The catheter bag was hooked on the right side of bed frame and sitting directly on the floor. e. On 2/22/24 at 9:16 AM, Certified Nursing Assistant (CNA) #1 was asked to accompany this Surveyor to Resident #30's room. The Surveyor asked where (Resident #30's) catheter bag was. CNA #1 confirmed that it was on the floor and should not have been. The Surveyor asked why it should be off the floor. CNA #1 stated, Because it could get dirty or stepped on, or it could get a hole in it, and [Resident #30's] urine flow should flow down so it should be below the leg, but not on the floor. CNA #1 was asked to remove [Resident #30]'s covers, with the resident's consent first, so this Surveyor could check it. She pulled the covers back and a stat lock was in place to the right inner lower thigh just above Resident 30's knee, but it was not dated to reflect the date it was placed. CNA #1 said the nurses places the stat locks to the residents. f. On 2/23/24 at 2:12 PM, Licensed Practical Nurse (LPN) #2, was asked, When a resident has an indwelling catheter in place, how is it secured? LPN #2 stated, With a stat lock. So, we put the stat lock on the leg, and clean it with the pad they provide in the package, and we snap the tubing into the stat lock. LPN #2 was asked who was responsible for performing that task. LPN #2 confirmed it was the nurses. LPN #2 was asked, When should this be done? LPN #2 stated, As soon as the patient arrives with a catheter, we need to make sure it's secured and throughout their stay. LPN #2 was asked, What if the catheter is placed at this facility, when should it be secured? LPN #2 confirmed after it's inserted. LPN #2 was asked, Is this documented anywhere? LPN #2 stated, It should be on the MAR [Medication Administration Record] to secure placement of the catheter. LPN #2 confirmed there should be a physician's order for it. g. On 2/22/24 at 2:18 PM, the Director of Nursing (DON) was asked, Should there be a Physician's order for an indwelling catheter to be secured? The DON stated, Yes. The Surveyor asked, Tell me why a catheter bag should not on the floor? The DON stated, Well it has a chance of getting punctured and it could be a risk of being pulled out. The Surveyor asked, Does that cause a potential risk for infections? The DON stated, Yes. The Surveyor asked, Tell me where the tubing should be for an indwelling catheter? The DON stated, It should've been down more mid-thigh a stat lock. The Surveyor asked, Tell me why? The DON stated, To prevent the urine from backing up to allow it to drain appropriately. 2.Resident #4 had a diagnosis of Neuromuscular dysfunction of bladder, unspecified. a. On 02/20/24 at 10:18 AM, Resident #4 was lying in bed with a catheter bag lying on the floor wedged under the bed with the bed on top of it. b. On 02/20/24 at 03:24 PM, Resident #4 was lying in bed with the catheter bag folded and lying on the floor. c. On 02/21/24 at 08:25 AM, Resident # 4 was eating in bed. The head of the bed was rolled up. One third of the catheter was lying on the floor. d. A Physicians Order dated 2/6/24 documented, Change [Brand of indwelling catheters] . Catheter q [every] 15th of month and prn [as needed]. e. A Care Plan dated 2/6/24 documented, The resident has INDWELLING FOLEY Catheter: Neurogenic bladder Date Initiated: 02/06/2024 Revision on: 2/22/24 . f. On 2/22/24 at 3:18 PM, the DON was asked to look at the position of the catheter bag was in, folded under the bed with the bed lying on the catheter bag. The DON stated, That's unacceptable. The DON was asked to explain why it was unacceptable. The DON stated, It can crush the catheter tubing and urine will backflow into the bladder. g. A Policy titled, Catheter Care, Urinary provided by the DON on 2/22/24 documented, Purpose .prevent catheter-associated urinary tract infections .Maintaining Unobstructed Urine Flow 1. Check the resident frequently to be sure he or she is not lying on the catheter .Infection Control 1.b. Be sure the catheter tubing and drainage bag are kept of the floor . 37925

Based on observation, interview and record review, the facility failed to ensure multi-dose insulin vials were dated when opened and discontinued or expired medications were removed and placed into an area for destruction to prevent potential administration to residents. The findings are: On 02/21/2024 at 10:50 AM, the following observations were made on the 100/200 Halls medication cart with Licensed Practical Nurse (LPN) #1: a) An open multi-dose vial of (rapid acting insulin) with an open date of 01/12/2024. b) An open multi-dose vial of (short acting insulin) with no open date. c) An open multi-dose vial of (long acting insulin) with an expiration date of 01/31/2024. d) A partially used (long acting) insulin pen with an expiration date of 02/02/2024. On 02/21/2024 at 11:10 AM, the Surveyor asked LPN #1, What is your process when opening a new insulin vial? LPN #1 replied, Open the vial and date. LPN #1 was asked, What is the importance of dating an open vial? LPN #1 replied, To make sure the medication is still effective and to reorder in a timely manner. The Surveyor asked, What is the process for checking the medication cart for expired medications and how often? LPN #1 replied, The pharmacy rep [representative] does sometimes. The Assistant Director of Nursing (ADON) did weekly when still here. I don't check for the dates. LPN #1 was asked, What is the importance of checking for expired medications? LPN #1 replied, They are not as effective. On 02/21/2024 at 11:30 AM, the Surveyor asked the Director of Nursing (DON), What is the process once a multi-dose vial has been opened? The DON stated, It needs to be dated? The DON was asked, What is the reason for dating an open multi-dose vial? The DON stated, It is for the timeframe of use depending on the manufacture guidelines. The Surveyor asked, How often are the medication carts checked for expired medications? The DON replied, We do match back every thirty days. On 02/22/2024 at 2:17 PM, the DON provided a policy titled, Storage of Medications, which documented, .4.Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed . On 02/22/2024 at 04:09 PM, the DON stated there was no policy on multi-dose vials.

Based on observation, record review and interview, the facility failed to ensure parameters were put in place to ensure the correct dosage of oxygen was administered to enable the Physician to determine the dosage needed for 1 (Resident #4) sampled resident. The findings are: 1. On 02/20/24 at 10:16 AM, Resident #4 was lying in the bed receiving oxygen via nasal cannula (NC) at 3 liters per minute (LPM). 2. On 02/20/24 at 03:16 PM, Resident #4 was lying in bed receiving oxygen at 3 LPM via N/C. 3. On 02/21/24 at 08:27 AM, Resident #4 was lying in bed receiving oxygen at 2 LPM via N/C. 4. A Physicians Order dated 2/19/24 documented, O2 [oxygen] @ [at] 2L [liters] /NC. Titrate to remain > [greater than] 90% every shift related to SHORTNESS OF BREATH Titrate to remain >90% . 5. A Care Plan documented, The resident has oxygen therapy r/t [related to] ineffective gas exchange Promote lung expansion Date Initiated: 02/20/2024: OXYGEN SETTINGS: O2 via nasal cannula @ 2L titrate [adjust rate] to remain >90% Revision on: 02/20/2024 . 6. The Medication Administration Record (MAR) contained no documentation of pulse oximetry results to follow for correct dosage of oxygen administration. 7. On 02/21/24 at 10:27 AM, Licensed Practical Nurse (LPN) #2 was asked, how do you know when to increase or decrease the oxygen on Resident #4. LPN #2 stated, We check [Resident #4's] pulse ox [pulse oximeter, or Pulse Ox, is an electronic device that measures the saturation of oxygen carried in your red blood cells]. LPN #2 was asked if she could verify when the liter flow rate should be titrated. LPN #2 stated, It should be on the MAR, let me look. It's not on there but it should be so we can alert the Physician that [Resident #4's] needing more oxygen or that [Resident #4's] oxygen is dropping. LPN #2 was asked if there was any other place it could be documented LPN #2 stated, On my notebook. LPN #2 was asked what was documented yesterday for Resident #4's oxygen saturation. LPN #4 looked at the notebook and stated, I forgot. 8. On 2/22/24 at 3:22 PM, the Director of Nursing (DON) was asked to explain how he/she expected the nurses to determine what an oxygen flow rate should be. The DON said that the physician's orders should be followed. The DON was asked to look at the electronic record and read the current physician's order. The DON stated, We would check the pulse ox. The Surveyor asked how often it should be checked and where it would be documented. The DON stated, The order would need to be clarified and parameters be set up. The DON was asked the importance in setting parameters. The DON stated, To alert the nurses and doctor the need to increase or decrease the amount of oxygen needed. 9. On 2/22/24 at 2:16 PM, the DON provided a policy titled, Oxygen Administration, which documented, The purpose of this procedure is to provide guidelines for safe oxygen administration . 1. Review the Physicians order . Before administering oxygen, Assessment 6 .oxygen saturation . Documentation 6. All assessment data obtained before .

Based on record review and interview, the facility failed to ensure a Medication Regimen Review (MRR) was performed by the pharmacist on 2/15/24 regarding the use of a psychotropic medication, Clonazepam, and was reviewed by the physician to minimize adverse consequences related to medication therapy for 1 (Resident #34) of 1 sampled resident who had a physician's order for PRN (as needed) Clonazepam. The findings are: 1. Resident # 34 had a diagnosis of Antianxiety Disorder. a. A Physician's Order dated 12/19/23 documented, .clonazePAM Oral Tablet 0.5 MG [milligrams] (Clonazepam) *Controlled Drug* Give 1 tablet by mouth every 6 hours as needed for anxiety . start date 12/19/23 . b. A Pharmacy MRR-PRN Psychotropic Medication > [greater than] 14 Days dated 2/15/24 at 14:45 (2:45 PM) documented, . This resident is receiving the following PRN psychotropic medication: clonazePAM Oral Tablet 0.5 MG . every 6 hours as needed . 3. Psychotropic medication order date 12/19/23 . 1. According to CMS [Centers for Medicare and Medicaid Services] guideline . PRN orders for psychotropic meds are limited to 14 days. If attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should evaluate the resident for the appropriateness and document their rationale in the resident's medical record and indicate the duration for the PRN order . c. On 2/22/24 at 3:00 PM, Resident #34's Electronic Health Record (EHR) had no documentation from the physician regarding the pharmacist's recommendations related to the PRN use of Clonazepam. d. On 02/23/24 8:48 AM, the Director of Nursing (DON) was asked to provide the Gradual Dose Reduction (GDR) for [Resident #34] regarding the pharmacist recommendation on 2/15/24. The DON stated, We are waiting on the doctor to address it. The DON was asked, How does the doctor know when he has a GDR to address? The DON stated, We print them out and tell [the doctor] that [the doctor] has things here. The DON was asked, Does someone take them to [the doctor]? The DON stated, No, [the doctor] likes to come here because [the doctor] likes to talk to the resident. e. A MRR policy provided by the DON on 2/23/24 documented, . 4. The goal of the MRR is to promote positive outcomes while minimizing adverse consequences and potential risks associated with medication . 8. Within 24 hours of the MRR, the consultant pharmacist provides a written report to the attending physicians for each resident identified as having a non-life threatening medication irregularity . 12. The attending physician documents in the medical record that the irregularity has been reviewed and what (if any) action was taken to address it .

Based on record review and interview, the facility failed to ensure the medication regimen review was reviewed by the physician regarding the as needed (PRN) use of a psychotropic medication, Clonazepam, before it was renewed to promote or maintain the highest practicable mental, physical, and psychosocial wellbeing for 1 (Resident #34) of 1 sampled resident who had PRN physician's orders for Clonazepam. The findings are: 1. Resident #34 had a diagnosis of Antianxiety Disorder. a. A Physician's Order dated 12/19/23 documented, .clonazePAM Oral Tablet 0.5 MG [milligrams] (Clonazepam) *Controlled Drug* Give 1 tablet by mouth every 6 hours as needed for anxiety . start date 12/19/23 . b. The February 2024 electronic Medication Administration Record (eMAR) documented Resident #34 received an as needed dose of Clonazepam 0.5 mg on 2/20/24 at 0405 (4:05 AM) and the regular scheduled doses at 0600 (6:00 AM), 1200 (12:00 PM), 1800 (6:00 PM) and 0000 (12:00 AM). d. On 02/23/24 8:48 AM, the Director of Nursing (DON) was asked to provide the Gradual Dose Reduction (GDR) for [Resident #34] regarding the pharmacist recommendation on 2/15/24. The DON stated, We are waiting on the doctor to address it. The DON was asked, How does the doctor know when [the doctor] has a GDR to address? The DON stated, We print them out and tell [the doctor] that [the doctor] has things here. The DON was asked, Does someone take them to [the doctor]? The DON stated, No, [the doctor] likes to come here because [the doctor] likes to talk to the resident. e. On 2/23/24 at 11:40 AM, the DON asked, Is the GDR regarding the Clonazepam for [Resident #34]? The Surveyor confirmed it was. The DON stated, It's not 14 days until the 27th and the APN [Advanced Practicing Nurse] will be here in a few days to look at that and I'm sure she's going to dc [discontinue] it. f. On 2/23/24 at 11:40 AM, a Gradual Dose Reduction of Psychotropic Drugs provided by the Director of Nursing (DON) documented, . Policy: Residents who use psychotropic drugs receive gradual dose reductions and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs . Definitions: Psychotropic Drug is defined as any drug that affects brain activities associated with mental process and behavior. Psychotropic drugs include, but are not limited to the following categories: antipsychotics, antidepressants, antianxiety, and hypnotics .

Based on record review and interview, the facility failed to ensure Pneumococcal immunizations were administered to eligible residents and the immunization records were updated in the electronic health records (EHR) for 1 (Resident #22) of 5 (Residents #4, #5, #21, #22 and #32) sampled residents whose immunization information was reviewed. The findings are: 1. On 2/22/23 at 3:00 PM, review of Resident #22's immunization information in the electronic health record revealed no documentation that a pneumonia immunization was offered, administered, or if the Resident or Resident's Representative consented or declined the immunization. a. A Physician's order dated 11/07/23 documented, May have Pneumococcal Vaccine per consent . b. A Care Plan with a revision date of 1/18/24 documented the resident smokes. c. A review of Resident #22's November 2023 electronic Medication Administration Record (eMAR) revealed no documentation regarding administration of the pneumonia vaccine. d. On 2/22/24, the Director of Nursing (DON) was asked for information to show if Resident #22 received a pneumonia vaccine. At 4:08 PM, the DON confirmed there was no information pertaining to this resident receiving or declining the pneumonia vaccine or any education offered in the EHR. e. On 2/23/24 at 2:25 PM, the DON confirmed after reviewing Resident #22's EHR that Resident #22 did sign the consent that he wanted to receive the pneumonia vaccination in November 2023, but she could not see where it was administered. f. A Pneumococcal Vaccine Policy, provided by the Administrator on 2/21/24, documented, Policy Statement All residents are offered Pneumococcal vaccines to aid in preventing pneumonia/Pneumococcal infections . 4. Pneumococcal vaccines are administered to residents (unless medically contraindicated, already given, or refused) per our facility's physician-approved Pneumococcal vaccination protocol .

Based on observation, record review, and interview, the facility failed to ensure transportation provider safely off-loaded a resident in a wheelchair from the facility transportation van to prevent potential injury for 1 (Resident #1) of 2 (Residents #1 and #2) sampled residents who required transport in a wheelchair on the transportation provider's van. The failed practice had the potential to affect 46 residents that resided in the facility per census received 2/7/2024. This failed practice resulted past Immediate Jeopardy, which caused or could have caused serious harm, injury, or death to Resident #1, who rolled out of the van in a manual wheelchair and fell on the lift that was ground level resulting in a back injury. The facility was notified of the past Immediate Jeopardy on 2/8/2024 at 2:00 pm. The findings are: 1. Resident #1's was admitted on [DATE] with diagnoses of Multiple Sclerosis, Muscle Wasting and Atrophy. The Admission Minimum Data Set (MDS) with an Assessment Reference Date of 12/28/2023 documented the resident scored 15 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status and required the use of a wheelchair for mobility. a. On 2/7/2024 at 9:15 am, the Surveyor asked Resident #1 to recall the incident that occurred 12/4/2023 during the off-loading from the van. Resident #1 stated, I was in a manual wheelchair and the aide was trying to do something with the attachments on the floor of the van or something and when she was doing that, I rolled out of the van and hit the concrete. I was in the chair. I had to go to the hospital and had surgery the next day on my back. b. On 2/7/2024 at 12:45 pm, a Progress Note dated 12/4/23 at 3:43 pm by Licensed Practical Nurse (LPN) #1 stated, . CNA [Certified Nursing Assistant] called out for a nurse outside in front, Patient was lying on the lift to the van on right side in fetal position c/o [complaint of] back pain. Pt [Patient] was alert and talking MD [Medical Doctor] [Name] notified, Administrator [Name] Nursing consultant [Name], ADON [Assistant Director of Nursing] [Name], pt was sent to [Hospital] via ambulance for eval [evaluation] and tx [treatment] per v/o [verbal order] MD [Name]. CNA stated I was getting him off the van in the chair when i went to push w/c [wheelchair] on the lift the patient fell out of the chair onto the lift . c. On 2/8/2024 at 8:00 am, the Surveyor asked the Director of Nursing (DON) for the investigation information regarding Resident #1's fall on 12/4/23 during the off-loading from the facility van. She replied, They should be in the reportable. Oh, that's right one was not done on the fall. The Surveyor asked for the incident report if available. The DON replied, I will get that for you. At 10:20 am, an Incident Report dated 12/4/23 at 2:33 pm completed by LPN #1 documented, .Type Fall . Incident Location Grounds . Activity Transfer . Witness [CNA #1] . d. On 2/8/2024 at 10:20 pm, the Auto Accident Report form completed on 12/4/23 at 2:37 pm stated under Accident Details, .Van driver [CNA #1] was getting the resident off the van, went to push the wheelchair to the ramp and patient fell backwards out of the wheelchair and fell on the lift that was lowered . e. On 2/8/2024 at 10:55 am, a Witness Statement form dated 12/4/23 at 3:10 pm completed by CNA #1 stated, .Job Title CNA/Van Driver .I picked up [Resident #1] from the mall, got to the facility. I got the electric wheelchair off first, I got back on the van to get [Resident #1] off, had him already unhooked from everything he started rolling himself backward toward the lift. I was telling him to keep it straight when I heard the alarm going off. I told him to stop and grabbed the wheelchair. I thought the lift was up, but unfortunately it was not so his wheelchair fell off the van, he landed on his side on the lift . This happened about 2:35pm . f. On 2/8/2024 at 12:10 pm, the Surveyor asked the Administrator to recall the incident regarding Resident #1 on 12/4/2023. The Administrator stated, I did not witness the actual incident. I was in my office, and I heard the commotion occur, and when I looked out the window, I seen the facility van sitting in the drive under the awning and I could see a little of [CNA #1] and [Resident #1] at the back of the van. [CNA #1] said she had taken the residents electric wheelchair off the van using the lift and moved it to the side of the van because they take it with them on the trip so [Resident #1] will be able to use it at the mall, but he has to sit in the facility manual wheelchair during the transport on the van. [CNA #1] had walked around to the side of the van and was getting up in the van and noticed the resident rolling himself backwards toward the back of the van. She started screaming at him to stop and she seen him roll out of the back of the van. He had thought the lift was up, but it was not. It was ground level and he rolled out backwards and fell from van level to ground level on the lift on the ground in the wheelchair. g. On 2/8/2024 at 12:45 pm, the Surveyor asked the Administrator, Has there been any other incidents of falls or issues with transport since the incident on 12/4/23. The Administrator stated, No we have not had any other issues or falls/incidents. I did what I knew I needed to do. I did the investigation and the in-services. h. On 2/8/2024 at 1:50 pm, the surveyor asked the MDS Nurse to recall the incident on 12/4/23 regarding Resident #1. The MDS Nurse replied, I was standing at the nurse's station desk when [CNA #1] came in and said [MDS Nurse's name], I need your help right now. I went out front with [CNA #1] and found [Resident #1] lying on his right side on the lift that was down, ground level. [Resident #1] kept saying he was sorry, he was sorry. We assessed him and kept him still until the ambulance could arrive because he was complaining of pain in his back. The ambulance came and he went to the hospital. i. On 2/8/2024 at 2:00 pm, Surveyor notified the Administrator of the Past Immediate Jeopardy for Accidents/Supervision related to Resident #1's 12/4/2023 fall from the facility van during offloading by staff. The following Inservices were provided: 12/4/2023: by the Administrator and Corporate Maintenance and Safety Officer documented, No one is to drive the facility van without FIRST being trained and checked off by someone that is fully trained to do so . 1/30/24: Correct Lift Operation/Properly Securing Residents. Items Covered: correct operation of the lift; correct procedure for loading/unloading resident on lift; correctly securing resident with proper tie down procedures; manual operation of the lift.

Based on record review and interviews, the facility failed to ensure all alleged violations involving a fall with major injury was reported immediately, but not later than 2 hours after major injury was discovered for 1 (Resident #1) of 1 sampled resident who had a report for fall during off-loading from facility transport van since December 2023. The findings are: 1. Resident #1's was admitted on [DATE] with diagnoses of Multiple Sclerosis, Muscle Wasting and Atrophy. The Admission Minimum Data Set with an Assessment Reference Date of 12/28/2023 documented the resident scored 15 (13 - 15 indicates cognitively intact) on a Brief Interview for Mental Status and required the use of a wheelchair for mobility. a. On 2/7/2024 at 11:30 am, received 5 reportable files for the last 3 months that were sent in to report any incident by the facility. No reportable regarding Resident #1 found. b. On 2/7/2024 at 12:45 pm, a Progress Note dated 12/4/23 at 3:43 pm by Licensed Practical Nurse (LPN) #1 stated, . CNA [Certified Nursing Assistant] called out for a nurse outside in front, Patient was lying on the lift to the van on right side in fetal position c/o [complaint of] back pain. Pt [Patient] was alert and talking MD [Medical Doctor] [Name] notified, Administrator [Name] Nursing consultant [Name], ADON [Assistant Director of Nursing] [Name], pt was sent to [Hospital] via ambulance for eval [evaluation] and tx [treatment] per v/o [verbal order] MD [Name]. CNA stated I was getting him off the van in the chair when i went to push w/c [wheelchair] on the lift the patient fell out of the chair onto the lift . c. On 2/8/2024 at 8:00 am, the Surveyor asked the Director of Nursing (DON) for the investigation information regarding Resident #1's fall on 12/4/23 during the off-loading from the facility van. She replied, They should be in the reportable. Oh, that's right, one was not done on the fall. d. On 2/8/2024 at 12:45 pm, the Surveyor asked the Administrator for the witness statements and reportable information for 12/4/2023 on Resident #1. The Administrator replied, I did the investigation and the in-services, and had started the information for the reportable and I was told by the regional team that I did not need to send in a reportable due to we know how the resident got hurt. It was a witnessed incident. I can give you my van incident protocol information I have my notes on to show you.

Based on record review and interview, the facility failed to review and revise the care plan and reassess the effectiveness of interventions to meet the resident needs for 2 (Residents #1 and #3) of 3 sampled residents. The findings are: 1. On 2/7/2024 at 10:20 am, Resident #1's Physicians Orders and Treatment Record documented, .TX [Treatment]: skin tear to left hand. Clean with wound cleanser. Pat dry. Apply [Fine mesh gauze occlusive dressing] Gauze. Cover with border foam dressing. one time a day every 3 day(s) for skin tear . ordered dated 1/20/24 and start date 1/21/24. The Treatment Record documented the treatment was done by a nurse starting 1/21/2024 and every three days through 2/8/2024. a. On 2/7/2024 at 2:30 pm, review of the Care Plan with a revision date of 12/11/23 did not address Resident #1's skin tear or the treatment every three days. 2. On 2/7/2024 at 2:30 pm, Resident #3's Physicians Orders and Treatment Record documented, .TX: Clean buttocks affected area with wound cleanser. Apply border foam dressing for protection. May change as needed if dressing becomes soiled. three times a day for Skin breakdown ., order dated 1/20/2024 and start date 1/20/2024. Treatment Record documented treatment was done by a nurse starting 1/20/24 through 2/8/2024. a. On 2/7/2024 at 2:30 pm, review of the Care Plan with a revision date of 02/02/24 did not address Resident #3's wound care to the buttocks. 3. On 2/8/2024 at 12:00 pm, the Surveyor asked the Director of Nursing (DON), Who is responsible for a resident's care plan revisions and when should a residents care plan be revised? She replied, Any change in condition, any new therapy or orders for medications, or wound care. The MDS [Minimum Data Set] nurse is doing the revisions right now. We have a treatment nurse that will officially start in that position this Monday. The Surveyor asked if anyone else could revise a care plan. The DON stated, Well I guess I can, and the Social can, and therapy, but we are trying to keep it to a select few, not all the nurses can do it. The Surveyor asked if a resident has orders for wound care, new wound care orders on the 20th of January, should the care plan reflect a revision for that care ordered by this time, February 8th. The DON replied, Yes it should, I would think. 4. On 2/8/2024 at 2:20 pm, the Surveyor asked the MDS Nurse Who was responsible for revision of care plans in the facility, and when should residents care plans be revised? The MDS Nurse replied, I do the revisions and I have not gotten some of them done lately. We have a treatment nurse that starts Monday, really anyone can revise them, like the therapy, social, the dietician, and the nurses. They should be revised, when there is a change in condition, a new treatment, as needed and quarterly, I know. The Surveyor asked if a resident has an order for wound care, should the care plan be revised within 5 to 10 days after the wound care is ordered? The MDS Nurse replied, Yes, it should reflect the change. 5. On 2/8/2024 at 2:39 pm, the DON provided a policy titled Care Plans, Comprehensive Person-Centered. The Policy stated, .Assessments of resident are ongoing and care plans are revised as information about the resident and the residents' conditions change .

Complaint # (AR 446) was substantiated (all or in part) with these findings: Based on observation, record review, and interview, the facility failed to ensure the corridor was free of clutter or obstructions that presented trip / fall hazards to prevent a fall with injury for 1 of 1 (Resident #4) case mix residents who were independently ambulatory. The failed practice resulted in past noncompliance at the level of actual harm for Resident #4, who fell and fractured her patella when attempting to walk down a cluttered corridor, and had the potential to cause more than minimal harm for 9 residents who were independently ambulatory, as documented on the list provided by the Administrator on 9/27/17. The findings are: Resident #4 had [DIAGNOSES REDACTED]. The Minimum Data Set with an Assessment Reference Date of 09/06/17 documented the resident scored 5 (0-7 indicates severely impaired) on a Brief Interview for Mental Status (BIMS) and was independent with ambulation. a. A Therapist Progress and Discharge Summary dated 03/01/17 documented, .Goal met - on 3/01/17 . Ambulates 250 feet with independence and no AD (assistive device). b. The Plan of Care dated 7/11/17 stated, .resident walking independent, and (at) Xs (times) R (resident) will use R/W (rolling walker) - mostly self-ambulatory. c. The Facility Investigation Report for Resident Abuse, Neglect, Misappropriation of Property, and Exploitation of Residents in Long Term Care Facilities, Division of Medical Services (DMS) form 762 dated 8/27/17 documented, Date of incident: 08/27/17 . Time: 9:30 a.m. Date and Time of Discovery: 08/27/17 . Time: 9:30 a.m. Section II Complete Description of Accident - Resident fell at front of 400 hall and nursing noted her laying (sic) on left side with knees bent. Noted with small purple area to left elbow, right knee swollen red / purple and painful . Findings and Actions Taken .During the investigation it was noted that facility restorative CNA (Certified Nursing Assistant) had the wheelchair weights (scale) on 400 hall doing weekly weights and nursing had their med (medication) cart parked on 400 hall when resident fell . Resident always walks on her own throughout facility and always had appropriate shoes and socks. d. An Office of Long Term Care (OLTC) Witness Statement dated 08/27/17 and signed by the Restorative Certified Nursing Assistant (RCNA) documented, I did not witness R (resident) fall. I took the scale down on 4 hall to get a couple R (resident) weights, when they came back from smoking their cigarettes. And before I could get R's weight the R in question (Resident #4) had a fall. e. A Nurse's Note dated 08/27/17 at 9:50 a.m. documented, .0920 (9:20 a.m.) I heard a thud at 400 hall entrance states was amb (ambulating) and fell was lying on L (left) side. Assessment reveals a 2.5 cm (centimeter) discolored edematous injury to L elbow and r (right) knee with edema discoloration and malformation, kept immobile and ice pack utilized, EMT (Emergency Medical Technician), notified MD (Medical Doctor), notified orders to transfer for eval (evaluation) at npmc (hospital) and dtr (daughter) (name) notified. EMTs arrived shortly and transferred res (resident) to ER (emergency room ). f. A Nurse's Note dated 8/27/17 at 1:15 p.m. documented, (Hospital) called to say res (resident) admitted with Fx (fracture) of r (right) patella. g. On 9/15/17 at 10:58 a.m., the RCNA was asked why the weight scale was left unattended on the 400 hall on 8/27/17. The RCNA stated, A couple of residents get weights, then smoke, and then I was waiting on those coming in. It shouldn't have been (left unattended), I know. The RCNA was asked if the scale was left in the hallway while she was on break and stated, Yes. I already got the residents' weights and should've put it up, no excuses. The RCNA was asked, Where is the scale usually stored? She stated, Down 300 hall by therapy. h. On 9/15/17 at 1:07 p.m., the 400 Hall corridor, medication cart and weight scale were measured by Licensed Practical Nurse (LPN) #4. The corridor was 7 feet /10 inches in width. The medication cart was 2.5 feet from front to back and the weight scale was 36 by 38 inches, with a platform height of 2 inches. Having the medication cart and weight scale positioned on either side of the corridor left a walking space of approximately 2.5 feet, during which the residents would have to walk in the middle of the corridor without the benefit of a hand rail. i. The facility corrected the failed practice on 8/27/17 prior to the survey, as evidenced by the following: 1.) An In-service document dated 8/27/17 at 9:40 a.m. indicated staff were educated that, All items in hallway are to only be on one side of the hall. The RCNA was documented as having attended this in-service. 2.) The facility's Monitoring sheets documented the hallways were monitored for compliance on 8/14/17, 8/15/17, 8/16/17, 8/23/17, 8/28/17 and 9/12/17. 3.) On 9/14/17 at 9:00 a.m., and throughout the survey, the corridors were free of any unnecessary items or clutter. Any items in the hallways were placed on the same side of the hall, to allow residents to ambulate and grasp the hand rails as needed.

Complaint # (AR 797) was substantiated, all or in part, with these findings: Based on observation, record review and interview, the facility failed to ensure residents were free from neglect due to a licensed nurse who slept intermittently throughout his shift, which resulted in failure to provide tracheal suctioning when needed to prevent anxiety and potential [MEDICAL CONDITION] or other respiratory complications for 1 (Resident #1) of 1 case mix resident who had a [MEDICAL CONDITION] (trach) and failure to administer pain medications when scheduled or needed to prevent unrelieved severe pain for 3 (Residents #2, #4 and #5) of 5 (Residents #1, #2, #3, #4, and #5) case mix residents who resided on the 100 and 500 Halls and experienced pain symptoms. The facility also failed to ensure the neglect by Licensed Practical Nurse (LPN) #1 was immediately reported to administration by multiple staff members who witnessed the LPN sleeping, which resulted in failure to protect the residents in LPN #1's care from further neglect, while LPN #1 was allowed to finish his shift and return to work the following night, during which he also slept for part of the shift. These failed practices resulted in Immediate Jeopardy which caused or could have caused serious harm, injury, or death to 32 residents who resided on the 100 Hall and 500 Hall where LPN #1 was assigned, including 1 resident on 100 Hall who had a [MEDICAL CONDITION] and 22 residents on those halls who had physician orders [REDACTED]. 1. Resident #1 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/6/16 documented the resident scored 15 (13-15 indicates cognitively intact) on the Brief Interview for Mental Status (BIMS), had no behaviors in the 7 days prior to the assessment reference date, was totally dependent on two plus person physical assistance for bed mobility and transfer, had range of motion limitations of both sides of upper extremities and both sides of lower extremities, and required suctioning and [MEDICAL CONDITION] care. a. The Interdisciplinary Care Plan with a revised date of 12/6/16 documented in the Problem section, .Resident has potential for difficulty breathing related to chronic condition: .[MEDICAL CONDITION], Chronic Resp (Respiratory) Failure . Approach . Suction PRN (as needed) . b. A Physician order [REDACTED].Suction PRN excessive secretions . c. On 3/8/17 at 10:35 a.m., Resident #1 was in his motorized wheelchair in his room. He was asked if the facility had ever run out of supplies to suction his trach. He stated, Yeah. Just this past weekend, they ran out of (suction) catheters. (LPN #1, LPN #2) and another nurse was looking for them and could not find any. I was needing to be suctioned like around 4:00 a.m., but it was around 7 or 8 when I finally got suctioned. I do not understand. How can they run out of stuff like that? He was asked if he had any trouble breathing during that time. He stated, No, I just get anxious if I know I need to be suctioned, and they do not, or cannot do it. I have to keep telling myself 'stay calm, stay calm'. He was asked if anyone monitored his oxygen saturation during this time. He stated, No. He was asked how often he had to be suctioned. He stated, It depends. If Housekeeping uses a lot of air freshener, that makes a difference. I might be good one day and bad the next. He was asked if the facility had ever been without suction/trach supplies prior to this past weekend. He stated, Yes. Last year. Resident #1 was asked if he remembered his nurse from the past weekend during the time suction catheters could not be located. He stated, (LPN #1). He's not any good. The resident was asked what he meant by that. He stated, He's lazy. He used to work here before, but was fired. And, he needs to learn how to suction. 2. Resident #2 was admitted to the facility 10/31/16 and had [DIAGNOSES REDACTED]. The Quarterly MDS with an ARD of 2/10/17 documented the resident scored 15 (13-15 indicates cognitively intact) on the BIMS, had no behaviors in the 7 days prior to the assessment reference date, received scheduled pain medication, and experienced severe pain almost constantly that limited daily activities and made it difficult to sleep. a. The Care Area Assessment (CAA) Summary dated 11/11/16 documented, .Pain: Triggered related to pain interview . Voices does have presence of pain . States pain occurs almost constantly . Rates pain as 9 out of 1-10 and describes pain as being severe . He states his pain occurs at right arm / wrist / thumb; back of head; and left ankle . He had a recent fall at home in which he was sent to ER (emergency room ) and treated for [REDACTED]. He also had recent surgery of the cervical spine . He has [DIAGNOSES REDACTED].#6 and #7), status [REDACTED]. b. The Interdisciplinary Care Plan for Pain with a revised date of 2/10/17 documented in the Problem section, .Pain: Breakthrough, complaints of pain related to Arthritis, Herniated Disc; chronic pain, left ankle; back of head; right arm / wrist . [MEDICATION NAME] 600 mg (milligrams) every 4 hours PRN (as needed); Increase [MEDICATION NAME] 10/325 mg 1 four times daily scheduled . c. A Progress Note dated 2/27/17 documented, .He had recent fall and sustained closed nasal fracture . Past surgical history . fusion foot bones, mid-tarsal .wrist fusion bilateral, ankle; history of carpal tunnel release bilateral wrists . history cervical fusion . external nose with depressed left nasal bone and tenderness . septum deviated to left . will schedule for closed reduction later this week . Will give prescription for [MEDICATION NAME] 10/325 mg for pain control . d. A hospital Discharge Summary dated 3/4/17 documented, .The patient was admitted on [DATE] for surgery . Pain was adequately controlled by PO (by mouth, oral) pain medication . e. The March 2017 Medication Administration Record [REDACTED] f. The Narcotic Log documented the resident received [MEDICATION NAME] 10/325 mg on 3/4/17 at 6:00 a.m., 12:00 p.m., and 6:00 p.m. The next dose of [MEDICATION NAME] 10/325 mg was documented as administered on 3/5/17 at 7:45 a.m. There was no documentation in the narcotic log indicating the resident received his midnight dose of [MEDICATION NAME] 10/325 mg on 3/4/17. g. On 3/8/17 at 4:35 p.m., Resident #2 was in a wheelchair in his room. He was asked if he had any problems with the care he received over the past weekend. He stated, Huh! Yeah. That male nurse (LPN #1). I wanted to break his neck. First, he forgot my medicine. My pain killer. I think it was Sunday (3/5/17) morning early. I had just had surgery Friday (3/3/17) on my nose, because I broke it, and then when I asked him about it, he got smart with me. I told him I was supposed to get it at midnight. I could feel the tension in his voice, so I did the right thing by turning away, because I was about to hit him. I finally got it around 5:30 a.m. or 6:00 a.m. I also got the other one that I normally get at 6:00 a.m., both of them, within an hour of each other. I know what I take, but I do not know what I take, if you understand what I am saying. I was supposed to get a blood pressure medicine and did not get it. I went to (DON) Monday (3/6/17) morning and told her about it, but that other nurse was a smart (expletive). Resident #2 was asked if the nurse told him why he did not bring his pain medication to him at midnight. He stated, He told me he was busy. The whole side of my face was hurting. Throbbing. He was asked how he would rate his pain on a scale from 1 to 10, with 10 being the worst. He stated, Nine. But that is not the only pain I have. I have titanium everywhere; wrist, back. The next night, I got my meds, but only because the other nurse told him (LPN #1) to give them. 3. Resident #4 was admitted to the facility 1/10/17 and had [DIAGNOSES REDACTED]. The Admission MDS with an ARD of 1/19/17 documented the resident scored 13 (13-15 indicates cognitively intact) on the BIMS, had no behaviors in the 7 days prior to the assessment reference date, and experienced frequent severe pain that made it difficult to sleep and limited his daily activities. a. A Physician order [REDACTED].[MEDICATION NAME] 10/325 mg (milligrams) 1 tab PO (by mouth) every 6 hours PRN . b. The CAA Summary dated 1/19/17 documented, .Pain: Triggered related to voiced presence of pain during pain interview . He stated he has pain almost constantly. States pain occurs at groin area . Rates worse pain as 10 on scale of 1-10 and describes pain as severe . He is being treated for [REDACTED]. He also has [DIAGNOSES REDACTED]. c. The Interdisciplinary Care Plan for Pain dated 1/20/17 documented in the Problem section, .Pain . breakthrough, complaints of pain . Bladder Spasms, [MEDICAL CONDITION] Bladder, groin . [MEDICATION NAME] 10/325 mg 1 every 6 hours PRN . Approach .Administer and monitor for effectiveness and for possible side effects from PRN pain medication . d. On 3/9/17 at 9:30 a.m., Resident #4 was asked about the care he received over the past weekend. He stated, Yeah. I remember I had to ask several times for my pain medicine, but I do not remember what medicine it was. I had to ask like three different times. I finally got it a few hours after the fact. He was asked if he remembered what shift this occurred on. He stated, Night shift. 4. Resident #5 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Quarterly MDS with an ARD of 2/7/17 documented the resident scored 15 (13-15 indicates cognitively intact) on the BIMS, had no behaviors in the 7 days prior to the assessment reference date, received PRN pain medications and experienced pain that limited her daily activities almost constantly, rated as an 8 on a scale of 1 to 10, and described it as very severe / horrible. a. A Physician order [REDACTED].[MEDICATION NAME] 10/325 mg 1 tab PO every 4 hours PRN pain . b. The CAA Summary for pain dated 11/7/16 documented, .She did voice presence of pain that occurs almost constantly . Describes pain as severe and rates it as 8 on scale of 1-10 . She states the pain is mostly in her back . States she broke her back last year and a metal rod is in place . She also has [DIAGNOSES REDACTED]. c. The Interdisciplinary Care Plan for Pain with a revised date of 2/7/17 documented in the Problem section, .Pain: .breakthrough, complaints of pain . [MEDICAL CONDITION], back . [MEDICATION NAME] 10/325 mg every 4 hours PRN . Approach . Administer and monitor for effectiveness and for possible side effects from PRN pain medication . d. On 3/9/17 at 9:45 a.m., Resident #5 was asked about the care she received over the past weekend. She stated, (LPN #1)! Dumb (LPN #1)! He's so dumb! The resident began to cry. She stated, He said my pain pills were not due and he would not bring them to me! The resident was sobbing at this point. She was asked where she was hurting when LPN #1 would not bring her pain medication. She stated, I have back pain due to breaking my back in two places a few years ago. She was asked how she would rate her pain at that time, on a scale from 1 to 10, with 10 being the worst. She stated, Normally my pain is about a 6, but that night it was a 10. I told him (LPN #1) I get them every 4 hours and that he needed to look at the order. He said, 'I did look. How do you think I know you get them every 6?' It was terrible! 5. On 3/8/17 at 11:15 a.m., LPN #2, who worked the 11:00 p.m. to 7:00 a.m. (11 to 7) shift on 3/4/17, was asked if there were any issues on her shift that night. She stated, Any issues? How long do you have? I wasn't going to say anything about it unless it was brought up, but I almost called (DON) Sunday (3/5/17). I prayed a lot about it. (LPN #1) slept pretty much the whole shift. His CNAs complained all night because they had to tell him over and over that residents needed things, like pain pills, et cetera. We were busy that night, but he sat at the nurse's station sleeping. We could not even get him awake. He went to my med (medication) cart and was going through my narc (narcotic) book, and I am very particular about my narcs (narcotics), but he was falling asleep standing up. I think he needs to be drug tested . He missed (Resident #2's) narcotic that was due at 12 (midnight). He wound up giving it to him around 4 (a.m.), but the resident had another one due at 6 (a.m.). (Resident #2) came to the nurse's station very upset that he missed his midnight narcotic. I do not know if he gave him the other one at 6 or not. He claims the reason he missed giving his meds was that he could not get into the computer. We found (LPN #1) at one point on 400 Hall laying on the couch. There was another resident who requested pain meds during the night, but (LPN #1) said it was too early . that it was not due until 3:45 a.m. Four o'clock came around and we reminded him, and he said he gave it, but we all knew he did not. It was so bad, I told my trainee I would make sure I did not have to work with him again. LPN #2 was asked if she knew of any problems with Resident #1 that night. She stated, I do know there was no suction tubing. I got up and helped look for that. I think that was between 2 a.m. and 4 a.m. We looked in the supply room, treatment cart, med room, and could not find any. There could have been some, and I overlooked it. The CNA (Certified Nursing Assistant) said that (Resident #1) needed to be suctioned. (Resident #1) is very particular about [MEDICAL CONDITION] wants to be suctioned a lot. She was asked if she knew if the resident was in distress during this time. She stated, I do not know. He was not gurgling when we went in to check on him. He was just asking to be suctioned. LPN #2 was asked if the Administrator or DON knew about all of this. She stated, I have no idea. I have not told them. I do not want to get in the middle of it. I do not do drama, but I refuse to work with him again. She was asked if she considered LPN #1's actions neglectful. She stated, Yes I do. And you can ask his CNAs from that night, and they will tell you the same thing. a. On 3/8/17 at 11:50 a.m., LPN #3, who worked the 7:00 a.m. to 11:00 p.m. (7 to 11) shift on 3/4/17 and 3/5/17, was asked if she had any issues on her shift over the past weekend. She stated, We had some staffing issues, but that's pretty ordinary. I had a nurse who thought we were out of some supplies, but he's new, and I showed him where to look. He was looking for suction supplies, in particular, and he just didn't recognize the box. I believe he had the sister facility down the road bring some here, but we had some in the supply room. He was embarrassed. Him being new, I can understand. She was asked if she had to suction Resident #1 when she came in to work Sunday morning, 3/5/17. She stated, Yes I had to suction him within the first hour of me getting here. She was asked if Resident #1 complained to her that he was not suctioned. She stated, No. He did not complain about anything when I went in there. LPN #3 was asked if any other resident on that hall complained about anything from Saturday (3/4/17) night. She stated, (Resident #2) stated he did not get his pain med on time. And (LPN #2) said (LPN #1) slept. (LPN #1) did tell me he could not get into the electronic med system. I had no trouble getting into the system. b. On 3/8/17 at 1:08 p.m., LPN #4, who worked the 11 to 7 shift on 3/4/17, was asked during a telephone interview how long she had worked at the facility. She stated, Two days. I was in orientation with (LPN #2) Saturday night. She was asked how LPN #1 was acting that night. She stated, He was acting like he was out of it. He was snoring at the desk. He was standing in front of the med cart with his eyes closed, rocking back and forth, falling onto the cart. He even went to our cart trying to get into it, not even realizing he was on the wrong cart. Residents were calling for their midnight meds, and he did not give them. He went back on the unit and went to sleep on the couch. I did not see him do any paperwork. He claimed he could not get into the computer. She was asked about Resident #1 and if he needed anything that night. She stated, He kept calling to be suctioned. (LPN #1) kept saying, 'I just suctioned him. He don't need to be suctioned.' Then he did not have any supplies. I told him to call the nursing home up the street for supplies. Instead, he just went over and sat down. So, he finally did call them, and someone went and picked up two suction catheters. Now whether he went and suctioned him or not, I do not know. And when we told him to go give residents their meds, he said 'I already did' and we know he did not because he was sleeping. She was asked if she called to report this nurse's actions to the Director of Nursing or Administrator. She stated, I did not. She was asked why. She stated, Well there's no excuse. I mean, he was sleeping. She was asked if she felt his actions were neglectful. She stated, I can't say he was neglectful. I do not know what all he did not do. c. On 3/8/17 at 2:38 p.m., CNA #1, who worked the 11 to 7 shift on 3/4/17, was asked if anything odd happened during her shift this past weekend. She stated, You want the truth? She was told it would be best if she told the truth. She stated, Saturday night, (Resident #1) needed to be suctioned, so we go tell (LPN #1). He went down there. Then, maybe around 3:00 a.m., I told him (Resident #1) wanted to be suctioned, and he could not find any supplies. So, I went to (nursing home down the street) and got two suction catheters. That was probably around 4:00 a.m. I handed them to (LPN #1). She was asked if Resident #1 needed to be suctioned often. She stated, When I first told (LPN #1) that (Resident #1) needed to be suctioned, he had secretions coming out and he was very anxious. She was asked if the LPN went down to suction the resident after she brought the suction catheters from the other facility. She stated, I know (Resident #1) put his light on, so I went to check on him, and he said he needed to be suctioned, so I told (LPN #1), and he just sat there. (Resident #1) put his light on again, so I went down there, and he said, 'I still need to be suctioned', so I told (LPN #1) that he still needs to be suctioned. I do not know if he went and did it. He sleeps the entire time. He clocked in, sat down, sleeps. If you go bug him, which we have to, because there are a few residents who want their narcotics, if you bug him, he will go sleep on the unit. I will end up quitting if he stays. I even videoed him on my cell phone sleeping. The CNA showed the surveyor video footage on her cellular phone of a male, sitting slumped in a chair at a nurse's station, with his head down on the desk snoring. The CNA stated the man in the video was LPN #1 sleeping at the nurse's station on the 11 to 7 shift on 3/4/17. She stated, (Resident #1) does not lie. If he says he was not suctioned, he was not suctioned. d. On 3/8/17 at 3:00 p.m., CNA #2, who worked the 11 to 7 shift on 3/4/17, was asked what happened this past weekend on his shift. He stated, (Resident #1) needed to be suctioned. I had to go around looking for the nurse to find him, because he would be sleeping. He was asked how many times he had to look for the nurse during the shift. He stated, At least five different times. And it was not just (Resident #1) that needed him. Other residents needed stuff. The first time I told him (Resident #1) needed suctioned, he raised his head up off the desk and said 'OK, I'll go down there in a little while,' and he went back to sleep. He was asked where the nurse was sleeping. He stated, At the nurse's station. Then (Resident #1) had to get on his light again because (LPN #1) never went. Then, when he finally got up, he could not find the equipment. The CNA was asked if he knew if Resident #1 ever did get suctioned during the shift. He stated, When I talked to (Resident #1) at 1:00 a.m., he said he had been suctioned. A little later, he said he did not feel like he got suctioned good enough and he needed it again. This time, when I went looking for the nurse, I found him on the couch on the unit. That was around 2:30 a.m. The CNA was asked if the resident was okay during this time of waiting. He stated, He was restless. He gets anxious. He was asked if he actually saw LPN #1 suction Resident #1 during the shift. He stated, No. And there were a few residents who were upset because they did not get their meds. I never saw him actually go into any rooms unless they were on their lights. CNA #2 was asked if he considered the actions of LPN #1 that night neglectful. He stated, Yes, very much so. He was asked if he reported this to anyone. He stated, I told the other nurse, but she was also seeing him do this. e. On 3/8/17 at 3:30 p.m., the DON was asked if she had been made aware of there being a problem with anything over the past weekend. She stated, I am hearing about the suction catheters just now, since you came in. I think it was (LPN #3) that told me they could not find the suction catheters. I worked a few hours Sunday, and no one said anything. (LPN #1) got 2 or 3 days of orientation, so he should have known where to find them. The DON was informed of the information obtained in staff interviews related to residents possibly not getting their medications. She stated, This is the first I'm hearing about this. f. On 3/8/17 at 4:20 p.m., the Administrator was asked if she had been made aware of any problems that occurred over the past weekend. She stated, When I came in on Monday (3/6/17), (LPN #6), the nurse, met me and asked if she could get her check. She asked me if I heard about (LPN #1) sleeping. I said 'no'. Then I immediately tried to call him, and he has not returned my calls. She was asked if she initiated an investigation at that point to determine if the residents received proper care, considering the nurse in charge of two halls allegedly spent the shift sleeping. She stated, She did not say whether he slept 5 minutes, all night, or what. I did not do anything, because I did not know if this was a rumor. I did not know any details. Plus, I could not get in touch with him. Wait, we did investigate. Everything on the computer was in red because he could not use his password. But the meds were gone. We did look at the med cards and the meds were given that night. She was asked if any residents were interviewed or if any witness statements had been collected from staff. She stated, No. She was asked if she was aware of Resident #1 not being suctioned in a timely manner the night of 3/4/17. She stated, This is the first I'm hearing about a problem with (Resident #1). g. On 3/8/17 at 5:00 p.m., LPN #5, who helped train LPN #1 on the 11 to 7 shift on 3/1/17, was asked if LPN #1 was shown where [MEDICAL CONDITION] were at any time during that shift on 3/1/17. She stated, He was with me on Wednesday night (3/1/17). There was so much going on. I know I went down to suction (Resident #1), but he did not go with me, because he was on his break. That's the only time I remember (Resident #1) wanting to be suctioned that shift. Friday night, 3/3/17, he worked the opposite side of the hall. The side (Resident #1) is not on. The suction catheters are always in that bottom drawer in his room. h. On 3/8/17 at 5:12 p.m., LPN #6, who helped train LPN #1, was asked if she had a problem with keeping LPN #1 awake. She stated, Yeah I had a little trouble. He would doze off, but he would wake up if we called his name. She was asked if she heard about any problems over the weekend. She stated, I did hear that he did not give (Resident #2) his pain meds. I woke him up Sunday night and told him to go give him his pain meds, so he did. She was asked if she reported this to anyone. She stated, I told (Administrator) the next morning. 6. LPN #1 worked the 11 to 7 shift on Saturday, 3/4/17. After sleeping during his shift and not performing tracheal suctioning or giving pain medications on 3/4/17, he was allowed to return to work 11 to 7 shift on Sunday, 3/5/17, working his entire scheduled shift. 7. The Immediate Jeopardy was removed and the scope and severity reduced to H on 3/9/17 at 11:10 a.m., when the facility implemented the following Plan of Removal: 1.) Administrator/Designee will start in-service on 3/8/17 at 6:35 p.m. and will be completed 3/10/17 on failure to report abuse or neglect and facility Abuse Policy. Also, the consequences if an employee fails to report per state regulations such as suspension, termination, and/or reported to the proper agencies. In-service will be ongoing each shift including weekend staff until all staff is trained and before going to the floor. All new hires will be trained during orientation and any staff off work for vacation sickness, etc. (et cetera) will be trained before working on the floor. 2.) All cognitive residents were interviewed by Administrator/Designee starting on 3/9/17 to ensure free of mental, physical abuse or neglect. Any negative findings will be corrected immediately and reported to all proper agencies. 3.) Administrator/Designee will interview cognitive residents and random staff 3 times weekly for 4 weeks, then weekly, and Administrator/Designee will spot check each shift to ensure staff is not sleeping so residents are free of mental and/or physical abuse and neglect, and staff is aware of facility's Abuse Policy and failure to report. Administrator/Designee will spot check 2 times weekly for 4 weeks, then every two weeks after. Any negative finding will be corrected immediately. Administrator will bring to monthly QA (Quality Assurance) Committee for further review and/or recommendations. 4.) DON/Designee will ensure all nursing staff knows where all medical supplies are located during orientation before letting the new hire work on the floor alone. 5.) Witness statements will be gathered on incident of failure to report from employees and Administrator; will do (Division of Medical Services (DMS) form) 7734 and (DMS form) 762 reportable on nurse in question concerning this incident.

Complaint # (AR 797) was substantiated, all or in part, in these findings: Based on observation, record review and interview, the facility failed to ensure multiple staff immediately reported to administration, witnessed neglect by a licensed nurse who slept intermittently throughout his shift, which resulted in failure to protect the residents in Licensed Practical Nurse (LPN) #1's care from further neglect, while LPN #1 was allowed to finish his shift and return to work the following night, during which he also slept for part of the shift. The failed practices resulted in failure to provide tracheal suctioning when needed to prevent anxiety and potential [MEDICAL CONDITION] or other respiratory complications for 1 (Resident #1) of 1 case mix resident who had a [MEDICAL CONDITION] (trach) and failure to administer pain medications when scheduled or needed to prevent unrelieved severe pain for 3 (Residents #2, #4 and #5) of 5 (Residents #1, #2, #3, #4, and #5) case mix residents who resided on the 100 and 500 Halls and experienced pain symptoms. The facility also failed to ensure that administration immediately initiated an investigation upon being informed by staff of allegations that LPN #1 slept and failed to administer medications timely during his shift. These failed practices resulted in Immediate Jeopardy which caused or could have caused serious harm, injury, or death to 32 residents who resided on the 100 Hall and 500 Hall where LPN #1 was assigned, including 1 resident on 100 Hall who had a [MEDICAL CONDITION] and 22 residents on those halls who had physician orders [REDACTED]. 1. Resident #1 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/6/16 documented the resident scored 15 (13-15 indicates cognitively intact) on the Brief Interview for Mental Status (BIMS), had no behaviors in the 7 days prior to the assessment reference date, was totally dependent on two plus person physical assistance for bed mobility and transfer, had range of motion limitations of both sides of upper extremities and both sides of lower extremities, and required suctioning and [MEDICAL CONDITION] care. a. The Interdisciplinary Care Plan with a revised date of 12/6/16 documented in the Problem section, .Resident has potential for difficulty breathing related to chronic condition: .[MEDICAL CONDITION], Chronic Resp (Respiratory) Failure . Approach . Suction PRN (as needed) . b. A Physician order [REDACTED].Suction PRN excessive secretions . c. On 3/8/17 at 10:35 a.m., Resident #1 was in his motorized wheelchair in his room. He was asked if the facility had ever run out of supplies to suction his trach. He stated, Yeah. Just this past weekend, they ran out of (suction) catheters. (LPN #1, LPN #2) and another nurse was looking for them and could not find any. I was needing to be suctioned like around 4:00 a.m., but it was around 7 or 8 when I finally got suctioned. I do not understand. How can they run out of stuff like that? He was asked if he had any trouble breathing during that time. He stated, No, I just get anxious if I know I need to be suctioned, and they do not, or cannot do it. I have to keep telling myself 'stay calm, stay calm'. He was asked if anyone monitored his oxygen saturation during this time. He stated, No. He was asked how often he had to be suctioned. He stated, It depends. If Housekeeping uses a lot of air freshener, that makes a difference. I might be good one day and bad the next. He was asked if the facility had ever been without suction/trach supplies prior to this past weekend. He stated, Yes. Last year. Resident #1 was asked if he remembered his nurse from the past weekend during the time suction catheters could not be located. He stated, (LPN #1). He's not any good. The resident was asked what he meant by that. He stated, He's lazy. He used to work here before, but was fired. And, he needs to learn how to suction. 2. Resident #2 was admitted to the facility 10/31/16 and had [DIAGNOSES REDACTED]. The Quarterly MDS with an ARD of 2/10/17 documented the resident scored 15 (13-15 indicates cognitively intact) on the BIMS, had no behaviors in the 7 days prior to the assessment reference date, received scheduled pain medication, and experienced severe pain almost constantly that limited daily activities and made it difficult to sleep. a. The Care Area Assessment (CAA) Summary dated 11/11/16 documented, .Pain: Triggered related to pain interview . Voices does have presence of pain . States pain occurs almost constantly . Rates pain as 9 out of 1-10 and describes pain as being severe . He states his pain occurs at right arm / wrist / thumb; back of head; and left ankle . He had a recent fall at home in which he was sent to ER (emergency room ) and treated for [REDACTED]. He also had recent surgery of the cervical spine . He has [DIAGNOSES REDACTED].#6 and #7), status [REDACTED]. b. The Interdisciplinary Care Plan for Pain with a revised date of 2/10/17 documented in the Problem section, .Pain: Breakthrough, complaints of pain related to Arthritis, Herniated Disc; chronic pain, left ankle; back of head; right arm / wrist . [MEDICATION NAME] 600 mg (milligrams) every 4 hours PRN (as needed); Increase [MEDICATION NAME] 10/325 mg 1 four times daily scheduled . c. A Progress Note dated 2/27/17 documented, .He had recent fall and sustained closed nasal fracture . Past surgical history . fusion foot bones, mid-tarsal .wrist fusion bilateral, ankle; history of carpal tunnel release bilateral wrists . history cervical fusion . external nose with depressed left nasal bone and tenderness . septum deviated to left . will schedule for closed reduction later this week . Will give prescription for [MEDICATION NAME] 10/325 mg for pain control . d. A hospital Discharge Summary dated 3/4/17 documented, .The patient was admitted on [DATE] for surgery . Pain was adequately controlled by PO (by mouth, oral) pain medication . e. The March 2017 Medication Administration Record [REDACTED] f. The Narcotic Log documented the resident received [MEDICATION NAME] 10/325 mg on 3/4/17 at 6:00 a.m., 12:00 p.m., and 6:00 p.m. The next dose of [MEDICATION NAME] 10/325 mg was documented as administered on 3/5/17 at 7:45 a.m. There was no documentation in the narcotic log indicating the resident received his midnight dose of [MEDICATION NAME] 10/325 mg on 3/4/17. g. On 3/8/17 at 4:35 p.m., Resident #2 was in a wheelchair in his room. He was asked if he had any problems with the care he received over the past weekend. He stated, Huh! Yeah. That male nurse (LPN #1). I wanted to break his neck. First, he forgot my medicine. My pain killer. I think it was Sunday (3/5/17) morning early. I had just had surgery Friday (3/3/17) on my nose, because I broke it, and then when I asked him about it, he got smart with me. I told him I was supposed to get it at midnight. I could feel the tension in his voice, so I did the right thing by turning away, because I was about to hit him. I finally got it around 5:30 a.m. or 6:00 a.m. I also got the other one that I normally get at 6:00 a.m., both of them, within an hour of each other. I know what I take, but I do not know what I take, if you understand what I am saying. I was supposed to get a blood pressure medicine and did not get it. I went to (DON) Monday (3/6/17) morning and told her about it, but that other nurse was a smart (expletive). Resident #2 was asked if the nurse told him why he did not bring his pain medication to him at midnight. He stated, He told me he was busy. The whole side of my face was hurting. Throbbing. He was asked how he would rate his pain on a scale from 1 to 10, with 10 being the worst. He stated, Nine. But that is not the only pain I have. I have titanium everywhere; wrist, back. The next night, I got my meds, but only because the other nurse told him (LPN #1) to give them. 3. Resident #4 was admitted to the facility 1/10/17 and had [DIAGNOSES REDACTED]. The Admission MDS with an ARD of 1/19/17 documented the resident scored 13 (13-15 indicates cognitively intact) on the BIMS, had no behaviors in the 7 days prior to the assessment reference date, and experienced frequent severe pain that made it difficult to sleep and limited his daily activities. a. A Physician order [REDACTED].[MEDICATION NAME] 10/325 mg (milligrams) 1 tab PO (by mouth) every 6 hours PRN . b. The CAA Summary dated 1/19/17 documented, .Pain: Triggered related to voiced presence of pain during pain interview . He stated he has pain almost constantly. States pain occurs at groin area . Rates worse pain as 10 on scale of 1-10 and describes pain as severe . He is being treated for [REDACTED]. He also has [DIAGNOSES REDACTED]. c. The Interdisciplinary Care Plan for Pain dated 1/20/17 documented in the Problem section, .Pain . breakthrough, complaints of pain . Bladder Spasms, [MEDICAL CONDITION] Bladder, groin . [MEDICATION NAME] 10/325 mg 1 every 6 hours PRN . Approach .Administer and monitor for effectiveness and for possible side effects from PRN pain medication . d. On 3/9/17 at 9:30 a.m., Resident #4 was asked about the care he received over the past weekend. He stated, Yeah. I remember I had to ask several times for my pain medicine, but I do not remember what medicine it was. I had to ask like three different times. I finally got it a few hours after the fact. He was asked if he remembered what shift this occurred on. He stated, Night shift. 4. Resident #5 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Quarterly MDS with an ARD of 2/7/17 documented the resident scored 15 (13-15 indicates cognitively intact) on the BIMS, had no behaviors in the 7 days prior to the assessment reference date, received PRN pain medications and experienced pain that limited her daily activities almost constantly, rated as an 8 on a scale of 1 to 10, and described it as very severe / horrible. a. A Physician order [REDACTED].[MEDICATION NAME] 10/325 mg 1 tab PO every 4 hours PRN pain . b. The CAA Summary for pain dated 11/7/16 documented, .She did voice presence of pain that occurs almost constantly . Describes pain as severe and rates it as 8 on scale of 1-10 . She states the pain is mostly in her back . States she broke her back last year and a metal rod is in place . She also has [DIAGNOSES REDACTED]. c. The Interdisciplinary Care Plan for Pain with a revised date of 2/7/17 documented in the Problem section, .Pain: .breakthrough, complaints of pain . [MEDICAL CONDITION], back . [MEDICATION NAME] 10/325 mg every 4 hours PRN . Approach . Administer and monitor for effectiveness and for possible side effects from PRN pain medication . d. On 3/9/17 at 9:45 a.m., Resident #5 was asked about the care she received over the past weekend. She stated, (LPN #1)! Dumb (LPN #1)! He's so dumb! The resident began to cry. She stated, He said my pain pills were not due and he would not bring them to me! The resident was sobbing at this point. She was asked where she was hurting when LPN #1 would not bring her pain medication. She stated, I have back pain due to breaking my back in two places a few years ago. She was asked how she would rate her pain at that time, on a scale from 1 to 10, with 10 being the worst. She stated, Normally my pain is about a 6, but that night it was a 10. I told him (LPN #1) I get them every 4 hours and that he needed to look at the order. He said, 'I did look. How do you think I know you get them every 6?' It was terrible! 5. On 3/8/17 at 11:15 a.m., LPN #2, who worked the 11:00 p.m. to 7:00 a.m. (11 to 7) shift on 3/4/17, was asked if there were any issues on her shift that night. She stated, Any issues? How long do you have? I wasn't going to say anything about it unless it was brought up, but I almost called (DON) Sunday (3/5/17). I prayed a lot about it. (LPN #1) slept pretty much the whole shift. His CNAs complained all night because they had to tell him over and over that residents needed things, like pain pills, et cetera. We were busy that night, but he sat at the nurse's station sleeping. We could not even get him awake. He went to my med (medication) cart and was going through my narc (narcotic) book, and I am very particular about my narcs (narcotics), but he was falling asleep standing up. I think he needs to be drug tested . He missed (Resident #2's) narcotic that was due at 12 (midnight). He wound up giving it to him around 4 (a.m.), but the resident had another one due at 6 (a.m.). (Resident #2) came to the nurse's station very upset that he missed his midnight narcotic. I do not know if he gave him the other one at 6 or not. He claims the reason he missed giving his meds was that he could not get into the computer. We found (LPN #1) at one point on 400 Hall laying on the couch. There was another resident who requested pain meds during the night, but (LPN #1) said it was too early . that it was not due until 3:45 a.m. Four o'clock came around and we reminded him, and he said he gave it, but we all knew he did not. It was so bad, I told my trainee I would make sure I did not have to work with him again. LPN #2 was asked if she knew of any problems with Resident #1 that night. She stated, I do know there was no suction tubing. I got up and helped look for that. I think that was between 2 a.m. and 4 a.m. We looked in the supply room, treatment cart, med room, and could not find any. There could have been some, and I overlooked it. The CNA (Certified Nursing Assistant) said that (Resident #1) needed to be suctioned. (Resident #1) is very particular about [MEDICAL CONDITION] wants to be suctioned a lot. She was asked if she knew if the resident was in distress during this time. She stated, I do not know. He was not gurgling when we went in to check on him. He was just asking to be suctioned. LPN #2 was asked if the Administrator or DON knew about all of this. She stated, I have no idea. I have not told them. I do not want to get in the middle of it. I do not do drama, but I refuse to work with him again. She was asked if she considered LPN #1's actions neglectful. She stated, Yes I do. And you can ask his CNAs from that night, and they will tell you the same thing. a. On 3/8/17 at 11:50 a.m., LPN #3, who worked the 7:00 a.m. to 11:00 p.m. (7 to 11) shift on 3/4/17 and 3/5/17, was asked if she had any issues on her shift over the past weekend. She stated, We had some staffing issues, but that's pretty ordinary. I had a nurse who thought we were out of some supplies, but he's new, and I showed him where to look. He was looking for suction supplies, in particular, and he just didn't recognize the box. I believe he had the sister facility down the road bring some here, but we had some in the supply room. He was embarrassed. Him being new, I can understand. She was asked if she had to suction Resident #1 when she came in to work Sunday morning, 3/5/17. She stated, Yes I had to suction him within the first hour of me getting here. She was asked if Resident #1 complained to her that he was not suctioned. She stated, No. He did not complain about anything when I went in there. LPN #3 was asked if any other resident on that hall complained about anything from Saturday (3/4/17) night. She stated, (Resident #2) stated he did not get his pain med on time. And (LPN #2) said (LPN #1) slept. (LPN #1) did tell me he could not get into the electronic med system. I had no trouble getting into the system. b. On 3/8/17 at 1:08 p.m., LPN #4, who worked the 11 to 7 shift on 3/4/17, was asked during a telephone interview how long she had worked at the facility. She stated, Two days. I was in orientation with (LPN #2) Saturday night. She was asked how LPN #1 was acting that night. She stated, He was acting like he was out of it. He was snoring at the desk. He was standing in front of the med cart with his eyes closed, rocking back and forth, falling onto the cart. He even went to our cart trying to get into it, not even realizing he was on the wrong cart. Residents were calling for their midnight meds, and he did not give them. He went back on the unit and went to sleep on the couch. I did not see him do any paperwork. He claimed he could not get into the computer. She was asked about Resident #1 and if he needed anything that night. She stated, He kept calling to be suctioned. (LPN #1) kept saying, 'I just suctioned him. He don't need to be suctioned.' Then he did not have any supplies. I told him to call the nursing home up the street for supplies. Instead, he just went over and sat down. So, he finally did call them, and someone went and picked up two suction catheters. Now whether he went and suctioned him or not, I do not know. And when we told him to go give residents their meds, he said 'I already did' and we know he did not because he was sleeping. She was asked if she called to report this nurse's actions to the Director of Nursing or Administrator. She stated, I did not. She was asked why. She stated, Well there's no excuse. I mean, he was sleeping. She was asked if she felt his actions were neglectful. She stated, I can't say he was neglectful. I do not know what all he did not do. c. On 3/8/17 at 2:38 p.m., CNA #1, who worked the 11 to 7 shift on 3/4/17, was asked if anything odd happened during her shift this past weekend. She stated, You want the truth? She was told it would be best if she told the truth. She stated, Saturday night, (Resident #1) needed to be suctioned, so we go tell (LPN #1). He went down there. Then, maybe around 3:00 a.m., I told him (Resident #1) wanted to be suctioned, and he could not find any supplies. So, I went to (nursing home down the street) and got two suction catheters. That was probably around 4:00 a.m. I handed them to (LPN #1). She was asked if Resident #1 needed to be suctioned often. She stated, When I first told (LPN #1) that (Resident #1) needed to be suctioned, he had secretions coming out and he was very anxious. She was asked if the LPN went down to suction the resident after she brought the suction catheters from the other facility. She stated, I know (Resident #1) put his light on, so I went to check on him, and he said he needed to be suctioned, so I told (LPN #1), and he just sat there. (Resident #1) put his light on again, so I went down there, and he said, 'I still need to be suctioned', so I told (LPN #1) that he still needs to be suctioned. I do not know if he went and did it. He sleeps the entire time. He clocked in, sat down, sleeps. If you go bug him, which we have to, because there are a few residents who want their narcotics, if you bug him, he will go sleep on the unit. I will end up quitting if he stays. I even videoed him on my cell phone sleeping. The CNA showed the surveyor video footage on her cellular phone of a male, sitting slumped in a chair at a nurse's station, with his head down on the desk snoring. The CNA stated the man in the video was LPN #1 sleeping at the nurse's station on the 11 to 7 shift on 3/4/17. She stated, (Resident #1) does not lie. If he says he was not suctioned, he was not suctioned. d. On 3/8/17 at 3:00 p.m., CNA #2, who worked the 11 to 7 shift on 3/4/17, was asked what happened this past weekend on his shift. He stated, (Resident #1) needed to be suctioned. I had to go around looking for the nurse to find him, because he would be sleeping. He was asked how many times he had to look for the nurse during the shift. He stated, At least five different times. And it was not just (Resident #1) that needed him. Other residents needed stuff. The first time I told him (Resident #1) needed suctioned, he raised his head up off the desk and said 'OK, I'll go down there in a little while,' and he went back to sleep. He was asked where the nurse was sleeping. He stated, At the nurse's station. Then (Resident #1) had to get on his light again because (LPN #1) never went. Then, when he finally got up, he could not find the equipment. The CNA was asked if he knew if Resident #1 ever did get suctioned during the shift. He stated, When I talked to (Resident #1) at 1:00 a.m., he said he had been suctioned. A little later, he said he did not feel like he got suctioned good enough and he needed it again. This time, when I went looking for the nurse, I found him on the couch on the unit. That was around 2:30 a.m. The CNA was asked if the resident was okay during this time of waiting. He stated, He was restless. He gets anxious. He was asked if he actually saw LPN #1 suction Resident #1 during the shift. He stated, No. And there were a few residents who were upset because they did not get their meds. I never saw him actually go into any rooms unless they were on their lights. CNA #2 was asked if he considered the actions of LPN #1 that night neglectful. He stated, Yes, very much so. He was asked if he reported this to anyone. He stated, I told the other nurse, but she was also seeing him do this. e. On 3/8/17 at 3:30 p.m., the DON was asked if she had been made aware of there being a problem with anything over the past weekend. She stated, I am hearing about the suction catheters just now, since you came in. I think it was (LPN #3) that told me they could not find the suction catheters. I worked a few hours Sunday, and no one said anything. (LPN #1) got 2 or 3 days of orientation, so he should have known where to find them. The DON was informed of the information obtained in staff interviews related to residents possibly not getting their medications. She stated, This is the first I'm hearing about this. f. On 3/8/17 at 4:20 p.m., the Administrator was asked if she had been made aware of any problems that occurred over the past weekend. She stated, When I came in on Monday (3/6/17), (LPN #6), the nurse, met me and asked if she could get her check. She asked me if I heard about (LPN #1) sleeping. I said 'no'. Then I immediately tried to call him, and he has not returned my calls. She was asked if she initiated an investigation at that point to determine if the residents received proper care, considering the nurse in charge of two halls allegedly spent the shift sleeping. She stated, She did not say whether he slept 5 minutes, all night, or what. I did not do anything, because I did not know if this was a rumor. I did not know any details. Plus, I could not get in touch with him. Wait, we did investigate. Everything on the computer was in red because he could not use his password. But the meds were gone. We did look at the med cards and the meds were given that night. She was asked if any residents were interviewed or if any witness statements had been collected from staff. She stated, No. She was asked if she was aware of Resident #1 not being suctioned in a timely manner the night of 3/4/17. She stated, This is the first I'm hearing about a problem with (Resident #1). g. On 3/8/17 at 5:00 p.m., LPN #5, who helped train LPN #1 on the 11 to 7 shift on 3/1/17, was asked if LPN #1 was shown where [MEDICAL CONDITION] were at any time during that shift on 3/1/17. She stated, He was with me on Wednesday night (3/1/17). There was so much going on. I know I went down to suction (Resident #1), but he did not go with me, because he was on his break. That's the only time I remember (Resident #1) wanting to be suctioned that shift. Friday night, 3/3/17, he worked the opposite side of the hall. The side (Resident #1) is not on. The suction catheters are always in that bottom drawer in his room. h. On 3/8/17 at 5:12 p.m., LPN #6, who helped train LPN #1, was asked if she had a problem with keeping LPN #1 awake. She stated, Yeah I had a little trouble. He would doze off, but he would wake up if we called his name. She was asked if she heard about any problems over the weekend. She stated, I did hear that he did not give (Resident #2) his pain meds. I woke him up Sunday night and told him to go give him his pain meds, so he did. She was asked if she reported this to anyone. She stated, I told (Administrator) the next morning. 6. LPN #1 worked the 11 to 7 shift on Saturday, 3/4/17. After sleeping during his shift and not performing tracheal suctioning or giving pain medications on 3/4/17, he was allowed to return to work 11 to 7 shift on Sunday, 3/5/17, working his entire scheduled shift. 7. The Immediate Jeopardy was removed and the scope and severity reduced to H on 3/9/17 at 11:10 a.m., when the facility implemented the following Plan of Removal: 1.) Administrator/Designee will start in-service on 3/8/17 at 6:35 p.m. and will be completed 3/10/17 on failure to report abuse or neglect and facility Abuse Policy. Also, the consequences if an employee fails to report per state regulations such as suspension, termination, and/or reported to the proper agencies. In-service will be ongoing each shift including weekend staff until all staff is trained and before going to the floor. All new hires will be trained during orientation and any staff off work for vacation sickness, etc. (et cetera) will be trained before working on the floor. 2.) All cognitive residents were interviewed by Administrator/Designee starting on 3/9/17 to ensure free of mental, physical abuse or neglect. Any negative findings will be corrected immediately and reported to all proper agencies. 3.) Administrator/Designee will interview cognitive residents and random staff 3 times weekly for 4 weeks, then weekly, and Administrator/Designee will spot check each shift to ensure staff is not sleeping so residents are free of mental and/or physical abuse and neglect, and staff is aware of facility's Abuse Policy and failure to report. Administrator/Designee will spot check 2 times weekly for 4 weeks, then every two weeks after. Any negative finding will be corrected immediately. Administrator will bring to monthly QA (Quality Assurance) Committee for further review and/or recommendations. 4.) DON/Designee will ensure all nursing staff knows where all medical supplies are located during orientation before letting the new hire work on the floor alone. 5.) Witness statements will be gathered on incident of failure to report from employees and Administrator; will do (Division of Medical Services (DMS) form) 7734 and (DMS form) 762 reportable on nurse in question concerning this incident.

Complaint # (AR 797) was substantiated, all or in part, in these findings: Based on observation, record review and interview, the facility failed to ensure their abuse / neglect prevention policies and procedures were implemented, by failing to ensure multiple staff immediately reported to administration, witnessed neglect by a licensed nurse who slept intermittently throughout his shift, which resulted in failure to protect the residents in Licensed Practical Nurse (LPN) #1's care from further neglect, while LPN #1 was allowed to finish his shift and return to work the following night, during which he also slept for part of the shift. The failed practices resulted in failure to provide tracheal suctioning when needed to prevent anxiety and potential [MEDICAL CONDITION] or other respiratory complications for 1 (Resident #1) of 1 case mix resident who had a [MEDICAL CONDITION] (trach) and failure to administer pain medications when scheduled or needed to prevent unrelieved severe pain for 3 (Residents #2, #4 and #5) of 5 (Residents #1, #2, #3, #4, and #5) case mix residents who resided on the 100 and 500 Halls and experienced pain symptoms. The facility also failed to ensure that administration immediately initiated an investigation upon being informed by staff of allegations that LPN #1 slept and failed to administer medications timely during his shift. These failed practices resulted in Immediate Jeopardy which caused or could have caused serious harm, injury, or death to 32 residents who resided on the 100 Hall and 500 Hall where LPN #1 was assigned, including 1 resident on 100 Hall who had a [MEDICAL CONDITION] and 22 residents on those halls who had physician orders [REDACTED]. 1. The facility's Abuse Policy and Prevention procedures, provided by the Administrator on 3/9/17, documented, .Neglect: .Intentional acts or omissions by a caregiver constituting negligently failing to provide necessary treatment . medical services to an endangered or impaired adult . negligently failing to carry out a prescribed treatment plan . The following are examples of acts of neglect and of failing to provide necessary services and care: Staff did not provide timely, safe or adequate medication . Staff did not provide medical help when needed . Neglect may or may not be intentional . What must be reported? All alleged, witnessed and/or suspected maltreatment .Investigation .When an allegation of abuse is made, the Administrator or other responsible individual will interview all parties involved which include: the individual making the complaint, any witnesses to the event, and the individual about whom the allegations are made .The appropriate authorities will be notified and depending upon the outcome of the investigation, disciplinary action will be taken .Protection .The residents will be protected to the extent possible. This can include suspending the accused individual until the investigation is completed, transferring the individual to another work area away from the resident in question, or other action. Any employee who has been found to have abused a resident will be terminated. Any time an action is thought to be abusive, it will be stopped immediately until an investigation can be conducted .All allegations of suspected resident abuse will be reported immediately to the Office of Long Term care and other agencies as prescribed by regulation .The investigation will also be forwarded to the appropriate agencies . 2. Resident #1 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/6/16 documented the resident scored 15 (13-15 indicates cognitively intact) on the Brief Interview for Mental Status (BIMS), had no behaviors in the 7 days prior to the assessment reference date, was totally dependent on two plus person physical assistance for bed mobility and transfer, had range of motion limitations of both sides of upper extremities and both sides of lower extremities, and required suctioning and [MEDICAL CONDITION] care. a. The Interdisciplinary Care Plan with a revised date of 12/6/16 documented in the Problem section, .Resident has potential for difficulty breathing related to chronic condition: .[MEDICAL CONDITION], Chronic Resp (Respiratory) Failure . Approach . Suction PRN (as needed) . b. A Physician order [REDACTED].Suction PRN excessive secretions . c. On 3/8/17 at 10:35 a.m., Resident #1 was in his motorized wheelchair in his room. He was asked if the facility had ever run out of supplies to suction his trach. He stated, Yeah. Just this past weekend, they ran out of (suction) catheters. (LPN #1, LPN #2) and another nurse was looking for them and could not find any. I was needing to be suctioned like around 4:00 a.m., but it was around 7 or 8 when I finally got suctioned. I do not understand. How can they run out of stuff like that? He was asked if he had any trouble breathing during that time. He stated, No, I just get anxious if I know I need to be suctioned, and they do not, or cannot do it. I have to keep telling myself 'stay calm, stay calm'. He was asked if anyone monitored his oxygen saturation during this time. He stated, No. He was asked how often he had to be suctioned. He stated, It depends. If Housekeeping uses a lot of air freshener, that makes a difference. I might be good one day and bad the next. He was asked if the facility had ever been without suction/trach supplies prior to this past weekend. He stated, Yes. Last year. Resident #1 was asked if he remembered his nurse from the past weekend during the time suction catheters could not be located. He stated, (LPN #1). He's not any good. The resident was asked what he meant by that. He stated, He's lazy. He used to work here before, but was fired. And, he needs to learn how to suction. 3. Resident #2 was admitted to the facility 10/31/16 and had [DIAGNOSES REDACTED]. The Quarterly MDS with an ARD of 2/10/17 documented the resident scored 15 (13-15 indicates cognitively intact) on the BIMS, had no behaviors in the 7 days prior to the assessment reference date, received scheduled pain medication, and experienced severe pain almost constantly that limited daily activities and made it difficult to sleep. a. The Care Area Assessment (CAA) Summary dated 11/11/16 documented, .Pain: Triggered related to pain interview . Voices does have presence of pain . States pain occurs almost constantly . Rates pain as 9 out of 1-10 and describes pain as being severe . He states his pain occurs at right arm / wrist / thumb; back of head; and left ankle . He had a recent fall at home in which he was sent to ER (emergency room ) and treated for [REDACTED]. He also had recent surgery of the cervical spine . He has [DIAGNOSES REDACTED].#6 and #7), status [REDACTED]. b. The Interdisciplinary Care Plan for Pain with a revised date of 2/10/17 documented in the Problem section, .Pain: Breakthrough, complaints of pain related to Arthritis, Herniated Disc; chronic pain, left ankle; back of head; right arm / wrist . [MEDICATION NAME] 600 mg (milligrams) every 4 hours PRN (as needed); Increase [MEDICATION NAME] 10/325 mg 1 four times daily scheduled . c. A Progress Note dated 2/27/17 documented, .He had recent fall and sustained closed nasal fracture . Past surgical history . fusion foot bones, mid-tarsal .wrist fusion bilateral, ankle; history of carpal tunnel release bilateral wrists . history cervical fusion . external nose with depressed left nasal bone and tenderness . septum deviated to left . will schedule for closed reduction later this week . Will give prescription for [MEDICATION NAME] 10/325 mg for pain control . d. A hospital Discharge Summary dated 3/4/17 documented, .The patient was admitted on [DATE] for surgery . Pain was adequately controlled by PO (by mouth, oral) pain medication . e. The March 2017 Medication Administration Record [REDACTED] f. The Narcotic Log documented the resident received [MEDICATION NAME] 10/325 mg on 3/4/17 at 6:00 a.m., 12:00 p.m., and 6:00 p.m. The next dose of [MEDICATION NAME] 10/325 mg was documented as administered on 3/5/17 at 7:45 a.m. There was no documentation in the narcotic log indicating the resident received his midnight dose of [MEDICATION NAME] 10/325 mg on 3/4/17. g. On 3/8/17 at 4:35 p.m., Resident #2 was in a wheelchair in his room. He was asked if he had any problems with the care he received over the past weekend. He stated, Huh! Yeah. That male nurse (LPN #1). I wanted to break his neck. First, he forgot my medicine. My pain killer. I think it was Sunday (3/5/17) morning early. I had just had surgery Friday (3/3/17) on my nose, because I broke it, and then when I asked him about it, he got smart with me. I told him I was supposed to get it at midnight. I could feel the tension in his voice, so I did the right thing by turning away, because I was about to hit him. I finally got it around 5:30 a.m. or 6:00 a.m. I also got the other one that I normally get at 6:00 a.m., both of them, within an hour of each other. I know what I take, but I do not know what I take, if you understand what I am saying. I was supposed to get a blood pressure medicine and did not get it. I went to (DON) Monday (3/6/17) morning and told her about it, but that other nurse was a smart (expletive). Resident #2 was asked if the nurse told him why he did not bring his pain medication to him at midnight. He stated, He told me he was busy. The whole side of my face was hurting. Throbbing. He was asked how he would rate his pain on a scale from 1 to 10, with 10 being the worst. He stated, Nine. But that is not the only pain I have. I have titanium everywhere; wrist, back. The next night, I got my meds, but only because the other nurse told him (LPN #1) to give them. 4. Resident #4 was admitted to the facility 1/10/17 and had [DIAGNOSES REDACTED]. The Admission MDS with an ARD of 1/19/17 documented the resident scored 13 (13-15 indicates cognitively intact) on the BIMS, had no behaviors in the 7 days prior to the assessment reference date, and experienced frequent severe pain that made it difficult to sleep and limited his daily activities. a. A Physician order [REDACTED].[MEDICATION NAME] 10/325 mg (milligrams) 1 tab PO (by mouth) every 6 hours PRN . b. The CAA Summary dated 1/19/17 documented, .Pain: Triggered related to voiced presence of pain during pain interview . He stated he has pain almost constantly. States pain occurs at groin area . Rates worse pain as 10 on scale of 1-10 and describes pain as severe . He is being treated for [REDACTED]. He also has [DIAGNOSES REDACTED]. c. The Interdisciplinary Care Plan for Pain dated 1/20/17 documented in the Problem section, .Pain . breakthrough, complaints of pain . Bladder Spasms, [MEDICAL CONDITION] Bladder, groin . [MEDICATION NAME] 10/325 mg 1 every 6 hours PRN . Approach .Administer and monitor for effectiveness and for possible side effects from PRN pain medication . d. On 3/9/17 at 9:30 a.m., Resident #4 was asked about the care he received over the past weekend. He stated, Yeah. I remember I had to ask several times for my pain medicine, but I do not remember what medicine it was. I had to ask like three different times. I finally got it a few hours after the fact. He was asked if he remembered what shift this occurred on. He stated, Night shift. 5. Resident #5 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Quarterly MDS with an ARD of 2/7/17 documented the resident scored 15 (13-15 indicates cognitively intact) on the BIMS, had no behaviors in the 7 days prior to the assessment reference date, received PRN pain medications and experienced pain that limited her daily activities almost constantly, rated as an 8 on a scale of 1 to 10, and described it as very severe / horrible. a. A Physician order [REDACTED].[MEDICATION NAME] 10/325 mg 1 tab PO every 4 hours PRN pain . b. The CAA Summary for pain dated 11/7/16 documented, .She did voice presence of pain that occurs almost constantly . Describes pain as severe and rates it as 8 on scale of 1-10 . She states the pain is mostly in her back . States she broke her back last year and a metal rod is in place . She also has [DIAGNOSES REDACTED]. c. The Interdisciplinary Care Plan for Pain with a revised date of 2/7/17 documented in the Problem section, .Pain: .breakthrough, complaints of pain . [MEDICAL CONDITION], back . [MEDICATION NAME] 10/325 mg every 4 hours PRN . Approach . Administer and monitor for effectiveness and for possible side effects from PRN pain medication . d. On 3/9/17 at 9:45 a.m., Resident #5 was asked about the care she received over the past weekend. She stated, (LPN #1)! Dumb (LPN #1)! He's so dumb! The resident began to cry. She stated, He said my pain pills were not due and he would not bring them to me! The resident was sobbing at this point. She was asked where she was hurting when LPN #1 would not bring her pain medication. She stated, I have back pain due to breaking my back in two places a few years ago. She was asked how she would rate her pain at that time, on a scale from 1 to 10, with 10 being the worst. She stated, Normally my pain is about a 6, but that night it was a 10. I told him (LPN #1) I get them every 4 hours and that he needed to look at the order. He said, 'I did look. How do you think I know you get them every 6?' It was terrible! 6. On 3/8/17 at 11:15 a.m., LPN #2, who worked the 11:00 p.m. to 7:00 a.m. (11 to 7) shift on 3/4/17, was asked if there were any issues on her shift that night. She stated, Any issues? How long do you have? I wasn't going to say anything about it unless it was brought up, but I almost called (DON) Sunday (3/5/17). I prayed a lot about it. (LPN #1) slept pretty much the whole shift. His CNAs complained all night because they had to tell him over and over that residents needed things, like pain pills, et cetera. We were busy that night, but he sat at the nurse's station sleeping. We could not even get him awake. He went to my med (medication) cart and was going through my narc (narcotic) book, and I am very particular about my narcs (narcotics), but he was falling asleep standing up. I think he needs to be drug tested . He missed (Resident #2's) narcotic that was due at 12 (midnight). He wound up giving it to him around 4 (a.m.), but the resident had another one due at 6 (a.m.). (Resident #2) came to the nurse's station very upset that he missed his midnight narcotic. I do not know if he gave him the other one at 6 or not. He claims the reason he missed giving his meds was that he could not get into the computer. We found (LPN #1) at one point on 400 Hall laying on the couch. There was another resident who requested pain meds during the night, but (LPN #1) said it was too early . that it was not due until 3:45 a.m. Four o'clock came around and we reminded him, and he said he gave it, but we all knew he did not. It was so bad, I told my trainee I would make sure I did not have to work with him again. LPN #2 was asked if she knew of any problems with Resident #1 that night. She stated, I do know there was no suction tubing. I got up and helped look for that. I think that was between 2 a.m. and 4 a.m. We looked in the supply room, treatment cart, med room, and could not find any. There could have been some, and I overlooked it. The CNA (Certified Nursing Assistant) said that (Resident #1) needed to be suctioned. (Resident #1) is very particular about [MEDICAL CONDITION] wants to be suctioned a lot. She was asked if she knew if the resident was in distress during this time. She stated, I do not know. He was not gurgling when we went in to check on him. He was just asking to be suctioned. LPN #2 was asked if the Administrator or DON knew about all of this. She stated, I have no idea. I have not told them. I do not want to get in the middle of it. I do not do drama, but I refuse to work with him again. She was asked if she considered LPN #1's actions neglectful. She stated, Yes I do. And you can ask his CNAs from that night, and they will tell you the same thing. a. On 3/8/17 at 11:50 a.m., LPN #3, who worked the 7:00 a.m. to 11:00 p.m. (7 to 11) shift on 3/4/17 and 3/5/17, was asked if she had any issues on her shift over the past weekend. She stated, We had some staffing issues, but that's pretty ordinary. I had a nurse who thought we were out of some supplies, but he's new, and I showed him where to look. He was looking for suction supplies, in particular, and he just didn't recognize the box. I believe he had the sister facility down the road bring some here, but we had some in the supply room. He was embarrassed. Him being new, I can understand. She was asked if she had to suction Resident #1 when she came in to work Sunday morning, 3/5/17. She stated, Yes I had to suction him within the first hour of me getting here. She was asked if Resident #1 complained to her that he was not suctioned. She stated, No. He did not complain about anything when I went in there. LPN #3 was asked if any other resident on that hall complained about anything from Saturday (3/4/17) night. She stated, (Resident #2) stated he did not get his pain med on time. And (LPN #2) said (LPN #1) slept. (LPN #1) did tell me he could not get into the electronic med system. I had no trouble getting into the system. b. On 3/8/17 at 1:08 p.m., LPN #4, who worked the 11 to 7 shift on 3/4/17, was asked during a telephone interview how long she had worked at the facility. She stated, Two days. I was in orientation with (LPN #2) Saturday night. She was asked how LPN #1 was acting that night. She stated, He was acting like he was out of it. He was snoring at the desk. He was standing in front of the med cart with his eyes closed, rocking back and forth, falling onto the cart. He even went to our cart trying to get into it, not even realizing he was on the wrong cart. Residents were calling for their midnight meds, and he did not give them. He went back on the unit and went to sleep on the couch. I did not see him do any paperwork. He claimed he could not get into the computer. She was asked about Resident #1 and if he needed anything that night. She stated, He kept calling to be suctioned. (LPN #1) kept saying, 'I just suctioned him. He don't need to be suctioned.' Then he did not have any supplies. I told him to call the nursing home up the street for supplies. Instead, he just went over and sat down. So, he finally did call them, and someone went and picked up two suction catheters. Now whether he went and suctioned him or not, I do not know. And when we told him to go give residents their meds, he said 'I already did' and we know he did not because he was sleeping. She was asked if she called to report this nurse's actions to the Director of Nursing or Administrator. She stated, I did not. She was asked why. She stated, Well there's no excuse. I mean, he was sleeping. She was asked if she felt his actions were neglectful. She stated, I can't say he was neglectful. I do not know what all he did not do. c. On 3/8/17 at 2:38 p.m., CNA #1, who worked the 11 to 7 shift on 3/4/17, was asked if anything odd happened during her shift this past weekend. She stated, You want the truth? She was told it would be best if she told the truth. She stated, Saturday night, (Resident #1) needed to be suctioned, so we go tell (LPN #1). He went down there. Then, maybe around 3:00 a.m., I told him (Resident #1) wanted to be suctioned, and he could not find any supplies. So, I went to (nursing home down the street) and got two suction catheters. That was probably around 4:00 a.m. I handed them to (LPN #1). She was asked if Resident #1 needed to be suctioned often. She stated, When I first told (LPN #1) that (Resident #1) needed to be suctioned, he had secretions coming out and he was very anxious. She was asked if the LPN went down to suction the resident after she brought the suction catheters from the other facility. She stated, I know (Resident #1) put his light on, so I went to check on him, and he said he needed to be suctioned, so I told (LPN #1), and he just sat there. (Resident #1) put his light on again, so I went down there, and he said, 'I still need to be suctioned', so I told (LPN #1) that he still needs to be suctioned. I do not know if he went and did it. He sleeps the entire time. He clocked in, sat down, sleeps. If you go bug him, which we have to, because there are a few residents who want their narcotics, if you bug him, he will go sleep on the unit. I will end up quitting if he stays. I even videoed him on my cell phone sleeping. The CNA showed the surveyor video footage on her cellular phone of a male, sitting slumped in a chair at a nurse's station, with his head down on the desk snoring. The CNA stated the man in the video was LPN #1 sleeping at the nurse's station on the 11 to 7 shift on 3/4/17. She stated, (Resident #1) does not lie. If he says he was not suctioned, he was not suctioned. d. On 3/8/17 at 3:00 p.m., CNA #2, who worked the 11 to 7 shift on 3/4/17, was asked what happened this past weekend on his shift. He stated, (Resident #1) needed to be suctioned. I had to go around looking for the nurse to find him, because he would be sleeping. He was asked how many times he had to look for the nurse during the shift. He stated, At least five different times. And it was not just (Resident #1) that needed him. Other residents needed stuff. The first time I told him (Resident #1) needed suctioned, he raised his head up off the desk and said 'OK, I'll go down there in a little while,' and he went back to sleep. He was asked where the nurse was sleeping. He stated, At the nurse's station. Then (Resident #1) had to get on his light again because (LPN #1) never went. Then, when he finally got up, he could not find the equipment. The CNA was asked if he knew if Resident #1 ever did get suctioned during the shift. He stated, When I talked to (Resident #1) at 1:00 a.m., he said he had been suctioned. A little later, he said he did not feel like he got suctioned good enough and he needed it again. This time, when I went looking for the nurse, I found him on the couch on the unit. That was around 2:30 a.m. The CNA was asked if the resident was okay during this time of waiting. He stated, He was restless. He gets anxious. He was asked if he actually saw LPN #1 suction Resident #1 during the shift. He stated, No. And there were a few residents who were upset because they did not get their meds. I never saw him actually go into any rooms unless they were on their lights. CNA #2 was asked if he considered the actions of LPN #1 that night neglectful. He stated, Yes, very much so. He was asked if he reported this to anyone. He stated, I told the other nurse, but she was also seeing him do this. e. On 3/8/17 at 3:30 p.m., the DON was asked if she had been made aware of there being a problem with anything over the past weekend. She stated, I am hearing about the suction catheters just now, since you came in. I think it was (LPN #3) that told me they could not find the suction catheters. I worked a few hours Sunday, and no one said anything. (LPN #1) got 2 or 3 days of orientation, so he should have known where to find them. The DON was informed of the information obtained in staff interviews related to residents possibly not getting their medications. She stated, This is the first I'm hearing about this. f. On 3/8/17 at 4:20 p.m., the Administrator was asked if she had been made aware of any problems that occurred over the past weekend. She stated, When I came in on Monday (3/6/17), (LPN #6), the nurse, met me and asked if she could get her check. She asked me if I heard about (LPN #1) sleeping. I said 'no'. Then I immediately tried to call him, and he has not returned my calls. She was asked if she initiated an investigation at that point to determine if the residents received proper care, considering the nurse in charge of two halls allegedly spent the shift sleeping. She stated, She did not say whether he slept 5 minutes, all night, or what. I did not do anything, because I did not know if this was a rumor. I did not know any details. Plus, I could not get in touch with him. Wait, we did investigate. Everything on the computer was in red because he could not use his password. But the meds were gone. We did look at the med cards and the meds were given that night. She was asked if any residents were interviewed or if any witness statements had been collected from staff. She stated, No. She was asked if she was aware of Resident #1 not being suctioned in a timely manner the night of 3/4/17. She stated, This is the first I'm hearing about a problem with (Resident #1). g. On 3/8/17 at 5:00 p.m., LPN #5, who helped train LPN #1 on the 11 to 7 shift on 3/1/17, was asked if LPN #1 was shown where [MEDICAL CONDITION] were at any time during that shift on 3/1/17. She stated, He was with me on Wednesday night (3/1/17). There was so much going on. I know I went down to suction (Resident #1), but he did not go with me, because he was on his break. That's the only time I remember (Resident #1) wanting to be suctioned that shift. Friday night, 3/3/17, he worked the opposite side of the hall. The side (Resident #1) is not on. The suction catheters are always in that bottom drawer in his room. h. On 3/8/17 at 5:12 p.m., LPN #6, who helped train LPN #1, was asked if she had a problem with keeping LPN #1 awake. She stated, Yeah I had a little trouble. He would doze off, but he would wake up if we called his name. She was asked if she heard about any problems over the weekend. She stated, I did hear that he did not give (Resident #2) his pain meds. I woke him up Sunday night and told him to go give him his pain meds, so he did. She was asked if she reported this to anyone. She stated, I told (Administrator) the next morning. 6. LPN #1 worked the 11 to 7 shift on Saturday, 3/4/17. After sleeping during his shift and not performing tracheal suctioning or giving pain medications on 3/4/17, he was allowed to return to work 11 to 7 shift on Sunday, 3/5/17, working his entire scheduled shift. 7. The Immediate Jeopardy was removed and the scope and severity reduced to H on 3/9/17 at 11:10 a.m., when the facility implemented the following Plan of Removal: 1.) Administrator/Designee will start in-service on 3/8/17 at 6:35 p.m. and will be completed 3/10/17 on failure to report abuse or neglect and facility Abuse Policy. Also, the consequences if an employee fails to report per state regulations such as suspension, termination, and/or reported to the proper agencies. In-service will be ongoing each shift including weekend staff until all staff is trained and before going to the floor. All new hires will be trained during orientation and any staff off work for vacation sickness, etc. (et cetera) will be trained before working on the floor. 2.) All cognitive residents were interviewed by Administrator/Designee starting on 3/9/17 to ensure free of mental, physical abuse or neglect. Any negative findings will be corrected immediately and reported to all proper agencies. 3.) Administrator/Designee will interview cognitive residents and random staff 3 times weekly for 4 weeks, then weekly, and Administrator/Designee will spot check each shift to ensure staff is not sleeping so residents are free of mental and/or physical abuse and neglect, and staff is aware of facility's Abuse Policy and failure to report. Administrator/Designee will spot check 2 times weekly for 4 weeks, then every two weeks after. Any negative finding will be corrected immediately. Administrator will bring to monthly QA (Quality Assurance) Committee for further review and/or recommendations. 4.) DON/Designee will ensure all nursing staff knows where all medical supplies are located during orientation before letting the new hire work on the floor alone. 5.) Witness statements will be gathered on incident of failure to report from employees and Administrator; will do (Division of Medical Services (DMS) form) 7734 and (DMS form) 762 reportable on nurse in question concerning this incident.

Complaint # (AR 797) was substantiated, all or in part, in these findings: Based on observation, record review, and interview, the facility failed to ensure necessary care and services were provided for respiratory / [MEDICAL CONDITION] maintenance and pain management as a result of Licensed Practical Nurse (LPN) #1 sleeping intermittently throughout his shift, as evidenced by failure of staff to promptly provide tracheal suctioning when needed to prevent anxiety and potential [MEDICAL CONDITION] or other respiratory complications for 1 (Resident #1) of 1 case mix resident who had a [MEDICAL CONDITION] (trach) that produced excessive secretions and failure to ensure pain medications were administered as scheduled or needed to prevent unrelieved severe pain for 3 (Residents #2, #4 and #5) of 5 (Residents #1, #2, #3, #4, and #5) case mix residents who experienced pain symptoms and resided on the 100 and 500 Halls where LPN #1 was assigned on 3/4/17 and 3/5/17. These failed practices resulted in Immediate Jeopardy, which caused or could have caused serious harm, injury or death to 32 residents who resided on the 100 Hall and 500 Hall, including 1 resident on 100 Hall who had a [MEDICAL CONDITION] and 22 residents who resided on the 100 and 500 Halls who had physician orders [REDACTED]. 1. Resident #1 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/6/16 documented the resident scored 15 (13-15 indicates cognitively intact) on the Brief Interview for Mental Status (BIMS), had no behaviors in the 7 days prior to the assessment reference date, was totally dependent on two plus person physical assistance for bed mobility and transfer, had range of motion limitations of both sides of upper extremities and both sides of lower extremities, and required suctioning and [MEDICAL CONDITION] care. a. The Interdisciplinary Care Plan with a revised date of 12/6/16 documented in the Problem section, .Resident has potential for difficulty breathing related to chronic condition: .[MEDICAL CONDITION], Chronic Resp (Respiratory) Failure . Approach . Suction PRN (as needed) . b. A Physician order [REDACTED].Suction PRN excessive secretions . c. On 3/8/17 at 10:35 a.m., Resident #1 was in his motorized wheelchair in his room. He was asked if the facility had ever run out of supplies to suction his trach. He stated, Yeah. Just this past weekend, they ran out of (suction) catheters. (LPN #1, LPN #2) and another nurse was looking for them and could not find any. I was needing to be suctioned like around 4:00 a.m., but it was around 7 or 8 when I finally got suctioned. I do not understand. How can they run out of stuff like that? He was asked if he had any trouble breathing during that time. He stated, No, I just get anxious if I know I need to be suctioned, and they do not, or cannot do it. I have to keep telling myself 'stay calm, stay calm'. He was asked if anyone monitored his oxygen saturation during this time. He stated, No. He was asked how often he had to be suctioned. He stated, It depends. If Housekeeping uses a lot of air freshener, that makes a difference. I might be good one day and bad the next. He was asked if the facility had ever been without suction/trach supplies prior to this past weekend. He stated, Yes. Last year. Resident #1 was asked if he remembered his nurse from the past weekend during the time suction catheters could not be located. He stated, (LPN #1). He's not any good. The resident was asked what he meant by that. He stated, He's lazy. He used to work here before, but was fired. And, he needs to learn how to suction. d. The facility's [MEDICAL CONDITION] Policy and Procedure dated 9/25/15 documented, .The purpose of this procedure is to provide guidelines for [MEDICAL CONDITION] care and for the cleaning of [MEDICAL CONDITION] . [MEDICAL CONDITION] care must be provided as needed . 2. Resident #2 was admitted to the facility 10/31/16 and had [DIAGNOSES REDACTED]. The Quarterly MDS with an ARD of 2/10/17 documented the resident scored 15 (13-15 indicates cognitively intact) on the BIMS, had no behaviors in the 7 days prior to the assessment reference date, received scheduled pain medication, and experienced severe pain almost constantly that limited daily activities and made it difficult to sleep. a. The Care Area Assessment (CAA) Summary dated 11/11/16 documented, .Pain: Triggered related to pain interview . Voices does have presence of pain . States pain occurs almost constantly . Rates pain as 9 out of 1-10 and describes pain as being severe . He states his pain occurs at right arm / wrist / thumb; back of head; and left ankle . He had a recent fall at home in which he was sent to ER (emergency room ) and treated for [REDACTED]. He also had recent surgery of the cervical spine . He has [DIAGNOSES REDACTED].#6 and #7), status [REDACTED]. b. The Interdisciplinary Care Plan for Pain with a revised date of 2/10/17 documented in the Problem section, .Pain: Breakthrough, complaints of pain related to Arthritis, Herniated Disc; chronic pain, left ankle; back of head; right arm / wrist . [MEDICATION NAME] 600 mg (milligrams) every 4 hours PRN (as needed); Increase [MEDICATION NAME] 10/325 mg 1 four times daily scheduled . c. A Progress Note dated 2/27/17 documented, .He had recent fall and sustained closed nasal fracture . Past surgical history . fusion foot bones, mid-tarsal .wrist fusion bilateral, ankle; history of carpal tunnel release bilateral wrists . history cervical fusion . external nose with depressed left nasal bone and tenderness . septum deviated to left . will schedule for closed reduction later this week . Will give prescription for [MEDICATION NAME] 10/325 mg for pain control . d. A hospital Discharge Summary dated 3/4/17 documented, .The patient was admitted on [DATE] for surgery . Pain was adequately controlled by PO (by mouth, oral) pain medication . e. The March 2017 Medication Administration Record [REDACTED] f. The Narcotic Log documented the resident received [MEDICATION NAME] 10/325 mg on 3/4/17 at 6:00 a.m., 12:00 p.m., and 6:00 p.m. The next dose of [MEDICATION NAME] 10/325 mg was documented as administered on 3/5/17 at 7:45 a.m. There was no documentation in the narcotic log indicating the resident received his midnight dose of [MEDICATION NAME] 10/325 mg on 3/4/17. g. On 3/8/17 at 4:35 p.m., Resident #2 was in a wheelchair in his room. He was asked if he had any problems with the care he received over the past weekend. He stated, Huh! Yeah. That male nurse (LPN #1). I wanted to break his neck. First, he forgot my medicine. My pain killer. I think it was Sunday (3/5/17) morning early. I had just had surgery Friday (3/3/17) on my nose, because I broke it, and then when I asked him about it, he got smart with me. I told him I was supposed to get it at midnight. I could feel the tension in his voice, so I did the right thing by turning away, because I was about to hit him. I finally got it around 5:30 a.m. or 6:00 a.m. I also got the other one that I normally get at 6:00 a.m., both of them, within an hour of each other. I know what I take, but I do not know what I take, if you understand what I am saying. I was supposed to get a blood pressure medicine and did not get it. I went to (DON) Monday (3/6/17) morning and told her about it, but that other nurse was a smart (expletive). Resident #2 was asked if the nurse told him why he did not bring his pain medication to him at midnight. He stated, He told me he was busy. The whole side of my face was hurting. Throbbing. He was asked how he would rate his pain on a scale from 1 to 10, with 10 being the worst. He stated, Nine. But that is not the only pain I have. I have titanium everywhere; wrist, back. The next night, I got my meds, but only because the other nurse told him (LPN #1) to give them. 3. Resident #4 was admitted to the facility 1/10/17 and had [DIAGNOSES REDACTED]. The Admission MDS with an ARD of 1/19/17 documented the resident scored 13 (13-15 indicates cognitively intact) on the BIMS, had no behaviors in the 7 days prior to the assessment reference date, and experienced frequent severe pain that made it difficult to sleep and limited his daily activities. a. A Physician order [REDACTED].[MEDICATION NAME] 10/325 mg (milligrams) 1 tab PO (by mouth) every 6 hours PRN . b. The CAA Summary dated 1/19/17 documented, .Pain: Triggered related to voiced presence of pain during pain interview . He stated he has pain almost constantly. States pain occurs at groin area . Rates worse pain as 10 on scale of 1-10 and describes pain as severe . He is being treated for [REDACTED]. He also has [DIAGNOSES REDACTED]. c. The Interdisciplinary Care Plan for Pain dated 1/20/17 documented in the Problem section, .Pain . breakthrough, complaints of pain . Bladder Spasms, [MEDICAL CONDITION] Bladder, groin . [MEDICATION NAME] 10/325 mg 1 every 6 hours PRN . Approach .Administer and monitor for effectiveness and for possible side effects from PRN pain medication . d. On 3/9/17 at 9:30 a.m., Resident #4 was asked about the care he received over the past weekend. He stated, Yeah. I remember I had to ask several times for my pain medicine, but I do not remember what medicine it was. I had to ask like three different times. I finally got it a few hours after the fact. He was asked if he remembered what shift this occurred on. He stated, Night shift. 4. Resident #5 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Quarterly MDS with an ARD of 2/7/17 documented the resident scored 15 (13-15 indicates cognitively intact) on the BIMS, had no behaviors in the 7 days prior to the assessment reference date, received PRN pain medications and experienced pain that limited her daily activities almost constantly, rated as an 8 on a scale of 1 to 10, and described it as very severe / horrible. a. A Physician order [REDACTED].[MEDICATION NAME] 10/325 mg 1 tab PO every 4 hours PRN pain . b. The CAA Summary for pain dated 11/7/16 documented, .She did voice presence of pain that occurs almost constantly . Describes pain as severe and rates it as 8 on scale of 1-10 . She states the pain is mostly in her back . States she broke her back last year and a metal rod is in place . She also has [DIAGNOSES REDACTED]. c. The Interdisciplinary Care Plan for Pain with a revised date of 2/7/17 documented in the Problem section, .Pain: .breakthrough, complaints of pain . [MEDICAL CONDITION], back . [MEDICATION NAME] 10/325 mg every 4 hours PRN . Approach . Administer and monitor for effectiveness and for possible side effects from PRN pain medication . d. On 3/9/17 at 9:45 a.m., Resident #5 was asked about the care she received over the past weekend. She stated, (LPN #1)! Dumb (LPN #1)! He's so dumb! The resident began to cry. She stated, He said my pain pills were not due and he would not bring them to me! The resident was sobbing at this point. She was asked where she was hurting when LPN #1 would not bring her pain medication. She stated, I have back pain due to breaking my back in two places a few years ago. She was asked how she would rate her pain at that time, on a scale from 1 to 10, with 10 being the worst. She stated, Normally my pain is about a 6, but that night it was a 10. I told him (LPN #1) I get them every 4 hours and that he needed to look at the order. He said, 'I did look. How do you think I know you get them every 6?' It was terrible! 5. On 3/8/17 at 11:15 a.m., LPN #2, who worked the 11:00 p.m. to 7:00 a.m. (11 to 7) shift on 3/4/17, was asked if there were any issues on her shift that night. She stated, Any issues? How long do you have? I wasn't going to say anything about it unless it was brought up, but I almost called (DON) Sunday (3/5/17). I prayed a lot about it. (LPN #1) slept pretty much the whole shift. His CNAs complained all night because they had to tell him over and over that residents needed things, like pain pills, et cetera. We were busy that night, but he sat at the nurse's station sleeping. We could not even get him awake. He went to my med (medication) cart and was going through my narc (narcotic) book, and I am very particular about my narcs (narcotics), but he was falling asleep standing up. I think he needs to be drug tested . He missed (Resident #2's) narcotic that was due at 12 (midnight). He wound up giving it to him around 4 (a.m.), but the resident had another one due at 6 (a.m.). (Resident #2) came to the nurse's station very upset that he missed his midnight narcotic. I do not know if he gave him the other one at 6 or not. He claims the reason he missed giving his meds was that he could not get into the computer. We found (LPN #1) at one point on 400 Hall laying on the couch. There was another resident who requested pain meds during the night, but (LPN #1) said it was too early . that it was not due until 3:45 a.m. Four o'clock came around and we reminded him, and he said he gave it, but we all knew he did not. It was so bad, I told my trainee I would make sure I did not have to work with him again. LPN #2 was asked if she knew of any problems with Resident #1 that night. She stated, I do know there was no suction tubing. I got up and helped look for that. I think that was between 2 a.m. and 4 a.m. We looked in the supply room, treatment cart, med room, and could not find any. There could have been some, and I overlooked it. The CNA (Certified Nursing Assistant) said that (Resident #1) needed to be suctioned. (Resident #1) is very particular about [MEDICAL CONDITION] wants to be suctioned a lot. She was asked if she knew if the resident was in distress during this time. She stated, I do not know. He was not gurgling when we went in to check on him. He was just asking to be suctioned. LPN #2 was asked if the Administrator or DON knew about all of this. She stated, I have no idea. I have not told them. I do not want to get in the middle of it. I do not do drama, but I refuse to work with him again. She was asked if she considered LPN #1's actions neglectful. She stated, Yes I do. And you can ask his CNAs from that night, and they will tell you the same thing. a. On 3/8/17 at 11:50 a.m., LPN #3, who worked the 7:00 a.m. to 11:00 p.m. (7 to 11) shift on 3/4/17 and 3/5/17, was asked if she had any issues on her shift over the past weekend. She stated, We had some staffing issues, but that's pretty ordinary. I had a nurse who thought we were out of some supplies, but he's new, and I showed him where to look. He was looking for suction supplies, in particular, and he just didn't recognize the box. I believe he had the sister facility down the road bring some here, but we had some in the supply room. He was embarrassed. Him being new, I can understand. She was asked if she had to suction Resident #1 when she came in to work Sunday morning, 3/5/17. She stated, Yes I had to suction him within the first hour of me getting here. She was asked if Resident #1 complained to her that he was not suctioned. She stated, No. He did not complain about anything when I went in there. LPN #3 was asked if any other resident on that hall complained about anything from Saturday (3/4/17) night. She stated, (Resident #2) stated he did not get his pain med on time. And (LPN #2) said (LPN #1) slept. (LPN #1) did tell me he could not get into the electronic med system. I had no trouble getting into the system. b. On 3/8/17 at 1:08 p.m., LPN #4, who worked the 11 to 7 shift on 3/4/17, was asked during a telephone interview how long she had worked at the facility. She stated, Two days. I was in orientation with (LPN #2) Saturday night. She was asked how LPN #1 was acting that night. She stated, He was acting like he was out of it. He was snoring at the desk. He was standing in front of the med cart with his eyes closed, rocking back and forth, falling onto the cart. He even went to our cart trying to get into it, not even realizing he was on the wrong cart. Residents were calling for their midnight meds, and he did not give them. He went back on the unit and went to sleep on the couch. I did not see him do any paperwork. He claimed he could not get into the computer. She was asked about Resident #1 and if he needed anything that night. She stated, He kept calling to be suctioned. (LPN #1) kept saying, 'I just suctioned him. He don't need to be suctioned.' Then he did not have any supplies. I told him to call the nursing home up the street for supplies. Instead, he just went over and sat down. So, he finally did call them, and someone went and picked up two suction catheters. Now whether he went and suctioned him or not, I do not know. And when we told him to go give residents their meds, he said 'I already did' and we know he did not because he was sleeping. She was asked if she called to report this nurse's actions to the Director of Nursing or Administrator. She stated, I did not. She was asked why. She stated, Well there's no excuse. I mean, he was sleeping. She was asked if she felt his actions were neglectful. She stated, I can't say he was neglectful. I do not know what all he did not do. c. On 3/8/17 at 2:38 p.m., CNA #1, who worked the 11 to 7 shift on 3/4/17, was asked if anything odd happened during her shift this past weekend. She stated, You want the truth? She was told it would be best if she told the truth. She stated, Saturday night, (Resident #1) needed to be suctioned, so we go tell (LPN #1). He went down there. Then, maybe around 3:00 a.m., I told him (Resident #1) wanted to be suctioned, and he could not find any supplies. So, I went to (nursing home down the street) and got two suction catheters. That was probably around 4:00 a.m. I handed them to (LPN #1). She was asked if Resident #1 needed to be suctioned often. She stated, When I first told (LPN #1) that (Resident #1) needed to be suctioned, he had secretions coming out and he was very anxious. She was asked if the LPN went down to suction the resident after she brought the suction catheters from the other facility. She stated, I know (Resident #1) put his light on, so I went to check on him, and he said he needed to be suctioned, so I told (LPN #1), and he just sat there. (Resident #1) put his light on again, so I went down there, and he said, 'I still need to be suctioned', so I told (LPN #1) that he still needs to be suctioned. I do not know if he went and did it. He sleeps the entire time. He clocked in, sat down, sleeps. If you go bug him, which we have to, because there are a few residents who want their narcotics, if you bug him, he will go sleep on the unit. I will end up quitting if he stays. I even videoed him on my cell phone sleeping. The CNA showed the surveyor video footage on her cellular phone of a male, sitting slumped in a chair at a nurse's station, with his head down on the desk snoring. The CNA stated the man in the video was LPN #1 sleeping at the nurse's station on the 11 to 7 shift on 3/4/17. She stated, (Resident #1) does not lie. If he says he was not suctioned, he was not suctioned. d. On 3/8/17 at 3:00 p.m., CNA #2, who worked the 11 to 7 shift on 3/4/17, was asked what happened this past weekend on his shift. He stated, (Resident #1) needed to be suctioned. I had to go around looking for the nurse to find him, because he would be sleeping. He was asked how many times he had to look for the nurse during the shift. He stated, At least five different times. And it was not just (Resident #1) that needed him. Other residents needed stuff. The first time I told him (Resident #1) needed suctioned, he raised his head up off the desk and said 'OK, I'll go down there in a little while,' and he went back to sleep. He was asked where the nurse was sleeping. He stated, At the nurse's station. Then (Resident #1) had to get on his light again because (LPN #1) never went. Then, when he finally got up, he could not find the equipment. The CNA was asked if he knew if Resident #1 ever did get suctioned during the shift. He stated, When I talked to (Resident #1) at 1:00 a.m., he said he had been suctioned. A little later, he said he did not feel like he got suctioned good enough and he needed it again. This time, when I went looking for the nurse, I found him on the couch on the unit. That was around 2:30 a.m. The CNA was asked if the resident was okay during this time of waiting. He stated, He was restless. He gets anxious. He was asked if he actually saw LPN #1 suction Resident #1 during the shift. He stated, No. And there were a few residents who were upset because they did not get their meds. I never saw him actually go into any rooms unless they were on their lights. CNA #2 was asked if he considered the actions of LPN #1 that night neglectful. He stated, Yes, very much so. He was asked if he reported this to anyone. He stated, I told the other nurse, but she was also seeing him do this. e. On 3/8/17 at 3:30 p.m., the DON was asked if she had been made aware of there being a problem with anything over the past weekend. She stated, I am hearing about the suction catheters just now, since you came in. I think it was (LPN #3) that told me they could not find the suction catheters. I worked a few hours Sunday, and no one said anything. (LPN #1) got 2 or 3 days of orientation, so he should have known where to find them. The DON was informed of the information obtained in staff interviews related to residents possibly not getting their medications. She stated, This is the first I'm hearing about this. f. On 3/8/17 at 4:20 p.m., the Administrator was asked if she had been made aware of any problems that occurred over the past weekend. She stated, When I came in on Monday (3/6/17), (LPN #6), the nurse, met me and asked if she could get her check. She asked me if I heard about (LPN #1) sleeping. I said 'no'. Then I immediately tried to call him, and he has not returned my calls. She was asked if she initiated an investigation at that point to determine if the residents received proper care, considering the nurse in charge of two halls allegedly spent the shift sleeping. She stated, She did not say whether he slept 5 minutes, all night, or what. I did not do anything, because I did not know if this was a rumor. I did not know any details. Plus, I could not get in touch with him. Wait, we did investigate. Everything on the computer was in red because he could not use his password. But the meds were gone. We did look at the med cards and the meds were given that night. She was asked if any residents were interviewed or if any witness statements had been collected from staff. She stated, No. She was asked if she was aware of Resident #1 not being suctioned in a timely manner the night of 3/4/17. She stated, This is the first I'm hearing about a problem with (Resident #1). g. On 3/8/17 at 5:00 p.m., LPN #5, who helped train LPN #1 on the 11 to 7 shift on 3/1/17, was asked if LPN #1 was shown where [MEDICAL CONDITION] were at any time during that shift on 3/1/17. She stated, He was with me on Wednesday night (3/1/17). There was so much going on. I know I went down to suction (Resident #1), but he did not go with me, because he was on his break. That's the only time I remember (Resident #1) wanting to be suctioned that shift. Friday night, 3/3/17, he worked the opposite side of the hall. The side (Resident #1) is not on. The suction catheters are always in that bottom drawer in his room. h. On 3/8/17 at 5:12 p.m., LPN #6, who helped train LPN #1, was asked if she had a problem with keeping LPN #1 awake. She stated, Yeah I had a little trouble. He would doze off, but he would wake up if we called his name. She was asked if she heard about any problems over the weekend. She stated, I did hear that he did not give (Resident #2) his pain meds. I woke him up Sunday night and told him to go give him his pain meds, so he did. She was asked if she reported this to anyone. She stated, I told (Administrator) the next morning. 6. LPN #1 worked the 11 to 7 shift on Saturday, 3/4/17. After sleeping during his shift, and not performing tracheal suctioning or giving pain medications on 3/4/17, he was allowed to return to work 11 to 7 shift on Sunday, 3/5/17, working his entire scheduled shift. 7. The Immediate Jeopardy was removed and the scope and severity reduced to H on 3/9/17 at 11:10 a.m., when the facility implemented the following Plan of Removal: 1.) Administrator/Designee will start in-service on 3/8/17 at 6:35 p.m. and will be completed 3/10/17 on failure to report abuse or neglect and facility Abuse Policy. Also, the consequences if an employee fails to report per state regulations such as suspension, termination, and/or reported to the proper agencies. In-service will be ongoing each shift including weekend staff until all staff is trained and before going to the floor. All new hires will be trained during orientation and any staff off work for vacation sickness, etc. (et cetera) will be trained before working on the floor. 2.) All cognitive residents were interviewed by Administrator/Designee starting on 3/9/17 to ensure free of mental, physical abuse or neglect. Any negative findings will be corrected immediately and reported to all proper agencies. 3.) Administrator/Designee will interview cognitive residents and random staff 3 times weekly for 4 weeks, then weekly, and Administrator/Designee will spot check each shift to ensure staff is not sleeping so residents are free of mental and/or physical abuse and neglect, and staff is aware of facility's Abuse Policy and failure to report. Administrator/Designee will spot check 2 times weekly for 4 weeks, then every two weeks after. Any negative finding will be corrected immediately. Administrator will bring to monthly QA (Quality Assurance) Committee for further review and/or recommendations. 4.) DON/Designee will ensure all nursing staff knows where all medical supplies are located during orientation before letting the new hire work on the floor alone. 5.) Witness statements will be gathered on incident of failure to report from employees and Administrator; will do (Division of Medical Services (DMS) form) 7734 and (DMS form) 762 reportable on nurse in question concerning this incident.

Complaint # (AR 964) and Complaint # (AR 83), were substantiated (all or in part) in these findings. Based on observation, record review and interview, the facility failed to ensure that a physician was immediately consulted after a significant change in condition for 1 (Resident #14) of 13 (Residents #1, 2, 4, 5, 6, 8, 10, 12, 16, 17, 22, 24 and 25) case mix residents who experienced significant changes in condition. The failed practice resulted in Immediate Jeopardy, which caused or could have caused serious injury, impairment or death, for Resident #14 who declined in her physical condition over a period greater than 4 days without physician evaluation or treatment and had the potential to cause more than minimal harm for 40 residents who had a significant change in the last thirty days. The facility was informed of the Immediate Jeopardy on 2/10/16 at 12:26 p.m. The findings are: Resident #14 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set with an assessment reference date of 12/4/15 documented the resident scored 12 (8 - 12 indicates moderately impaired) on a Brief Interview for Mental Status. a. The Care Plan dated 12/7/15 documented, Urinary Incontinence-Problem .UTI (Urinary Tract Infection). Approach-Report any changes in bladder status to Nurse: discolored urine .frequent urination .fever. Monitor labs as ordered and report results to physician Activities of Daily Living : Extensive assist of 1 staff for bed mobility, transfers, dressing, eating, toilet use, personal hygiene and bathing. b. Nurses Notes dated 12/10/15 at 6:35 p.m. documented, CNA's (Certified Nursing Assistants) reported resident is urinating more frequently. Resident continued to be agitated. Notified (name) APRN (Assistant Physician Registered Nurse). New orders received for STAT CBC (Complete Blood Count), STAT BMP (Basic Metabolic Panel), and STAT UA (Urinalysis) with C&S (Culture and Sensitivity) if indicated. Notified residents daughter of new orders by phone at 1820 (6:30 p.m.). Residents daughter stated, ' I'm glad these tests are being ordered. My mom was confused and agitated when I visited her earlier today. My mom said there were four people who stayed in her room with her and her roommate last night and she was very upset about it. ' UA collected via in and out catheter at 1830 (6:30 p.m.). c. Nurses Notes dated 12/11/15 at 1000 and 2235 documented, Awaiting results from U/A, CBC and BMP from 3-11 . 12/10. A Chemistry Laboratory reports dated 12/10/15 documented, Chemistry: BUN (Blood Urea Nitrogen)-40H (high) (normal range 7-18), Glucose-123 H (normal range 74-106). Urinalysis: Color Yellow, Protein: Negative, Glucose: 3+AB (abnormal) (normal range: negative). The report documented the information was faxed on 2/10/15 at 10:20 p.m. and awaiting C&S (Culture and Sensitivity) results. The Hematology Lab report dated 12/10/15 documented: WBC (White Blood Cell Count) H -10.31 (normal range 5.0-10.0), Hemoglobin-10.4 L (low) (normal range 12.0 to 16.0), Hematocrit 34.6 (normal range 37.0-47.0), RBC (Red Blood Cell Count)-3.89 L (normal range 4.0-5.5) The report documented the results were faxed to the APN on 2/11/16. Also had written on the report dated 2/11/16 (No) new orders . Also written on the report and with a line drawn through the written words was Temp (temperature) (every) shift (times) 48 (hours) notify MD (Medical Doctor). d. Nurses Notes dated 12/12/15 at 10:20 a.m. documented, Resident continues with confusion and agitation. Awaiting C&S results from UA. At 1430 Nurses Notes documented, Awaiting C&S from UA. At 9:25 p.m., the Nurses Notes documented, Resident continues with confusion and agitation. Awaiting C&S results from UA. There was no documentation the resident's physician was consulted about the changes in condition demonstrated by the resident's behaviors and that no results were received on UA with C&S. e. Nurses Notes dated 12/13/15 at 9:20 a.m., documented, . No C&S available at this time related to U/A from 12/10 940 (9:40 a.m.) Lab supervisor, sample urine too old for proper C&S processing (tech ' retrained ' ) recollect sample tonight for AM pick up (no req (requisition) required, per lab) As of 2/9/16 there was no documentation to indicate the urine for the UA was collected on 12/13/15 as requested by the lab. f. Nurses Notes dated 12/14/15 at 4:30 p.m., documented, Urine C&S done per clean catch. Urine dark brown .lab called to pick up sample. There was no documentation the resident's physician was consulted about the changes in the resident's urine and the failure to get UA with C&S as ordered on [DATE]. g. The next Nurses Notes was dated 12/15/15 at 1:40 a.m. and documented, Awaiting urine results from the lab. h. Nurses Notes dated 12/15/16 at 9:40 a.m. documented, 02 (oxygen) sats (saturations) 83% on room air. O2 placed at 2L (liters), with no return call from (medical doctor) (paged at 810). Call to (medical doctor) office-nurse to text him to call facility. i. Nurses Notes date 12/15/16 at 1010 (10:10 a.m.) documented, .orders received from (Medical Doctor) for 02 at 2L (Oxygen at 2 liters), send to hospital .eval (evaluate) and treat (lethargy, low 02 sats). Out via ambulance at 1020. Dtr (daughter) to follow. FSBS (Fingerstick Blood Sugar) at 87 at 940 (9:40 a.m.). Reported to DON (Director of Nursing) in person at 1025. At 15:10 (3:10 p.m.) reported to DON that resident admitted for dx ([DIAGNOSES REDACTED]. j. There was no documentation found in the Nurses Notes or in the Telephone Orders that indicated a new urine specimen had been collected after the initial specimen dated 12/10/15 and Urinalysis results had been received by the facility and prior to 12/15/15 when the resident was sent to the hospital and no documentation that any orders for treatment had been received or initiated related to the results of the initial urinalysis. k. The Hospital Admission Records dated 12/15/15 a 2:02 p.m. documented, History of present Illness XXX[AGE] year old female presents from the nursing home with altered mental status. Patient has had intermittent confusion and lethargy over the past week, this has worsened in the past day or 2. Patient was noted to be hypoxic and febrile at arrival. The daughter reports that she has noticed a cough this morning. Difficult to obtain any history from the patient as she is essentially noncommunicative at the current time. Presenting symptoms: disorientation and lethargy .Severity: Severe, Most recent episode: More than 2 days ago .Critical Care was necessary to treat or prevent imminent or life-threatening deterioration of the following condition: cardiac failure, circulatory failure, CNSX (Central Nervous System) failure or compromise, dehydration, metabolic crisis, [MEDICAL CONDITION], [MEDICAL CONDITIONS] and shock .she is febrile 102 at arrival, She is hypoxic in the low 80's, [MEDICAL CONDITION] .placed on 5 L (liters of Oxygen) nasal cannula. Patient appears dehydrated .patient has red urine out of the Foley with urinary tract infection. She does have elevated white blood count renal function. Patient covered with [MEDICATION NAME] and [MEDICATION NAME] after blood cultures were obtained. Cardiology consulted, will admit to ICU for further management. The patients [DIAGNOSES REDACTED]. l. On 2/10/16 at 3:00 p.m., the Immediate Jeopardy was removed and the severity / scope was reduced to an, H after the facility began implementation of the Plan of Removal as follows: 1) On 2/10/16 at 12:45 p.m., the DON/designee began conduction of audits on all 64 clinical records in the facility to ensure all physician orders, physician consults and lab/x-ray orders were completed. On 2/10/16 at 6:00 p.m., all audits were completed and if changes in residents' conditions were identified and had not been addressed, immediate corrective actions were taken. 2) All licensed nursing staff were in-serviced by the DON/designee beginning on 2/10/16 at 3:00 p.m. about following physician's orders [REDACTED]. Training would be on-going to include all new hire nurses and any that returned from leave, with all training done prior to staff working on floors. 3) All certified nursing assistants (CNA's) were in-serviced by the DON/designee beginning 2/10/16 at 3:00 p.m., about reporting any changes in condition of residents to charge nurses immediately. Training would be on-going to include all new hire CNA's and any that returned from leave, with all training done prior to staff working on floors. 4) The DON/designee will monitor all Telephone Orders and 24-hour Report sheets twice daily to ensure all nursing staff had followed physician orders [REDACTED]. Any negative findings would be corrected immediately and responsible staff members would be re-educated immediately. The DON/designee would document twice daily on a monitoring tool for all findings. Monitoring began on 2/11/16 at 7:30 a.m. and would be on-going.

Complaints # (AR 948), Complaint # (AR 964), Complaint # (AR 973), Complaint # (AR 974), and Complaint # (AR 983), were substantiated (all or in part) in these findings: Based on observation, record review and interview, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical well-being for Residents # 1, #14, and #26. The facility failed to ensure immediate consultation with physicians when lab/xray tests were delayed to ensure prompt treatment after significant changes in condition and failed to ensure consistent monitoring of resident condition for 2 (Residents #1 and #14) case mix residents who had significant changes in condition and required hospitalization s for treatment. The failed practices resulted in Immediate Jeopardy, which caused or could have caused serious injury, impairment or death, for Resident #14 who declined in her physical condition over a period greater than 4 days without physician evaluation or treatment and a pattern of actual harm for Resident #1, who had complaints of new, moderate to severe hip pain after an unwitnessed fall and received no evaluation for 5 hours and 38 minutes, and only then after the resident's family had requested a transfer to a local hospital. The facility was informed of the Immediate Jeopardy on 2/10/16 at 12:26 p.m. The failed practice also had the potential to cause more than minimal harm to 40 who had a significant change or unstable conditions as identified on a list provided by the Interim Administrator on 2/24/16. The facility also failed to ensure oncology visits were provided during Medicare days for 1 of 1 (Resident #26) case mix resident whose appointments were cancelled by the facility. The failed practice had the potential to affect 7 residents who received Medicare services on 2/10/16 as stated by the Business Office Manager. The findings are: 1. Resident #14 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set with an assessment reference date of 12/4/15 documented the resident scored 12 (8 - 12 indicates moderately impaired) on a Brief Interview for Mental Status. a. The Care Plan dated 12/7/15 documented, Urinary Incontinence-Problem .UTI (Urinary Tract Infection). Approach-Report any changes in bladder status to Nurse: discolored urine .frequent urination .fever. Monitor labs as ordered and report results to physician Activities of Daily Living : Extensive assist of 1 staff for bed mobility, transfers, dressing, eating, toilet use, personal hygiene and bathing. b. Nurses Notes dated 12/10/15 at 6:35 p.m. documented, CNA's (Certified Nursing Assistants) reported resident is urinating more frequently. Resident continued to be agitated. Notified (name) APRN (Assistant Physician Registered Nurse). New orders received for STAT CBC (Complete Blood Count), STAT BMP (Basic Metabolic Panel), and STAT UA (Urinalysis) with C&S (Culture and Sensitivity) if indicated. Notified residents daughter of new orders by phone at 1820 (6:30 p.m.). Residents daughter stated, ' I'm glad these tests are being ordered. My mom was confused and agitated when I visited her earlier today. My mom said there were four people who stayed in her room with her and her roommate last night and she was very upset about it. ' UA collected via in and out catheter .at 1830 (6:30 p.m.). c. Nurses Notes dated 12/11/15 at 10:00 a.m. and 10:35 p.m. documented, Awaiting results from U/A, CBC and BMP from 3-11 . 12/10. A Chemistry Laboratory reports dated 12/10/15 documented, Chemistry: BUN (Blood Urea Nitrogen)-40H (high) (normal range 7-18), Glucose-123 H (normal range 74-106). Urinalysis: Color Yellow, Protein: Negative, Glucose: 3+AB (abnormal) (normal range: negative). The report documented the information was faxed on 2/10/15 at 10:20 p.m. and awaiting C&S (Culture and Sensitivity) results. The Hematology Lab report dated 12/10/15 documented: WBC (White Blood Cell Count) H -10.31 (normal range 5.0-10.0), Hemoglobin-10.4 L (low) (normal range 12.0 to 16.0), Hematocrit 34.6 (normal range 37.0-47.0), RBC (Red Blood Cell Count)-3.89 L (normal range 4.0-5.5) The report documented the results were faxed to the APN on 2/11/16. Also had written on the report dated 2/11/16 (No) new orders . Also written on the report and with a line drawn through the written words was Temp (temperature) (every) shift (times) 48 (hours) notify MD (Medical Doctor). d. Nurses Notes dated 12/12/15 at 10:20 a.m. documented, Resident continues with confusion and agitation. Awaiting C&S results from UA. A 2:30 p.m. Nurses Notes documented, Awaiting C&S from UA. At 9:25 p.m., the Nurses Notes documented, Resident continues with confusion and agitation. Awaiting C&S results from UA. There was no documentation the resident's physician was consulted about the changes in condition demonstrated by the resident's behaviors and that no results were received on UA with C&S. e. Nurses Notes dated 12/13/15 at 9:20 a.m., documented, . No C&S available at this time related to U/A from 12/10 940 (9:40 a.m.) Lab supervisor, sample urine too old for proper C&S processing (tech ' retrained ' ) recollect sample tonight for AM pick up (no req (requisition) required, per lab). As of 2/9/16 there was no documentation to indicate the urine for the UA was collected on 12/13/15 as requested by the lab. f. Nurses Notes dated 12/14/15 at 4:30 p.m., documented, Urine C&S done per clean catch. Urine dark brown .lab called to pick up sample. There was no documentation the resident's physician was consulted about the changes in the resident's urine and the failure to get UA with C&S as ordered on [DATE]. g. The next Nurses Notes was dated 12/15/15 at 1:40 a.m. and documented, Awaiting urine results from the lab. h. Nurses Notes dated 12/15/16 at 9:40 a.m. documented, 02 (oxygen) sats (saturations) 83% on room air. O2 placed at 2L (liters), with no return call from (medical doctor) (paged at 810). Call to (medical doctor) office-nurse to text him to call facility. i. Nurses Notes date 12/15/16 at 1010 (10:10 a.m.) documented, .orders received from (Medical Doctor) for 02 at 2L (Oxygen at 2 liters), send to hospital .eval (evaluate) and treat (lethargy, low 02 sats). Out via ambulance at 1020. Dtr (daughter) to follow. FSBS (Fingerstick Blood Sugar) at 87 at 940 (9:40 a.m.). Reported to DON (Director of Nursing) in person at 1025 (10:25 a.m.). At 15:10 (3:10 p.m.) reported to DON that resident admitted for dx ([DIAGNOSES REDACTED]. j. There was no documentation found in the Nurses Notes or in the Telephone Orders that indicated a Urinalysis results had been received by the facility and prior to 12/15/15 when the resident was sent to the hospital and no documentation that any orders for treatment had been received or initiated related to the results of the initial urinalysis or the clean catch specimen specified in the Nurse Note dated 12/14/16. k. The Hospital Admission Records dated 12/15/15 a 2:02 p.m. documented, History of present Illness XXX[AGE] year old female presents from the nursing home with altered mental status. Patient has had intermittent confusion and lethargy over the past week, this has worsened in the past day or 2. Patient was noted to be hypoxic and febrile at arrival. The daughter reports that she has noticed a cough this morning. Difficult to obtain any history from the patient as she is essentially non-communicative at the current time. Presenting symptoms: disorientation and lethargy .Severity: Severe, Most recent episode: More than 2 days ago .Critical Care was necessary to treat or prevent imminent or life-threatening deterioration of the following condition: cardiac failure, circulatory failure, CNSX (Central Nervous System) failure or compromise, dehydration, metabolic crisis, [MEDICAL CONDITION], [MEDICAL CONDITIONS] and shock .she is febrile 102 at arrival, She is hypoxic in the low 80's, [MEDICAL CONDITION] .placed on 5 L (liters of Oxygen) nasal cannula. Patient appears dehydrated .patient has red urine out of the Foley with urinary tract infection. She does have elevated white blood count renal function. Patient covered with [MEDICATION NAME] and [MEDICATION NAME] after blood cultures were obtained. Cardiology consulted, will admit to ICU (Intensive Care Unit) for further management. The patients [DIAGNOSES REDACTED]. l. On 2/10/16 at 3:00 p.m., the Immediate Jeopardy was removed and the severity/scope was reduced to an, H after the facility began implementation of the Plan of Removal as follows: 1) On 2/10/16 at 12:45 p.m., the DON/designee began conduction of audits on all 64 clinical records in the facility to ensure all physician orders, physician consults and lab/x-ray orders were completed. On 2/10/16 at 6:00 p.m., all audits were completed and if changes in residents' conditions were identified and had not been addressed, immediate corrective actions were taken. 2) All licensed nursing staff were in-serviced by the DON/designee beginning on 2/10/16 at 3:00 p.m. about following physician's orders [REDACTED]. Training would be on-going to include all new hire nurses and any that returned from leave, with all training done prior to staff working on floors. 3) All certified nursing assistants (CNA's) were in-serviced by the DON/designee beginning 2/10/16 at 3:00 p.m., about reporting any changes in condition of residents to charge nurses immediately. Training would be on-going to include all new hire CNA's and any that returned from leave, with all training done prior to staff working on floors. 4) The DON/designee will monitor all Telephone Orders and 24-hour Report sheets twice daily to ensure all nursing staff had followed physician orders [REDACTED]. Any negative findings would be corrected immediately and responsible staff members would be re-educated immediately. The DON/designee would document twice daily on a monitoring tool for all findings. Monitoring began on 2/11/16 at 7:30 a.m. and would be on-going. 2. Resident #1 had [DIAGNOSES REDACTED]. The Quarterly MDS with an ARD of 1/18/16 documented the resident scored 9 (8 - 12 indicates moderately impaired) on a Brief Interview for Mental Status (BIMS); required one person physical assist with bed mobility, transfer, toilet use, dressing, hygiene, bathing; balance was not steady when moving from seated to standing position, only able to stabilize with human assistance, balance moving on and off toilet was not steady, only able to stabilize with human assistance and no falls since prior to or since admission. a. A Fall Risk Assessment Evaluation dated 1/16/16 documented, Total Score of 14. The form documented a total score of 10 or above represented a HIGH RISK. b. On 2/1/16 at 10:39 a.m. and 3:10 p.m. and on 2/2/16 at 8:40 a.m., 12:45 p.m. and 3:20 p.m., the resident was in her room and in bed. On 2/3/16 at 12:50 p.m., the resident stated she had used her call light the previous night about 6:30 p.m. to ask for help to get to her bedside commode. c. Nurses Notes for Shift 1 dated 2/7/16 and signed by LPN #3 documented, . (at) 1330 (1:30 p.m.) called to room (room number of resident), resident is assessed sitting on her buttocks next to the bed and the bed side commode is tipped over and urine has spilled on the floor. Resident stated, 'I was trying to get off the potty and turned around and my foot went under me and the next thing I knew I was on the floor.' upon assisting the resident up and back into the bed resident complained of pain 7/10 (pain scale of 7 out of 10) to her left hip and leg. New order for xray of left hip and a pad alarm was placed on the bed. Notified residents family. Notified administration. PRN (as needed) [MEDICATION NAME] given for Pain. d. A telephone physician order [REDACTED].bed alarm to bed. e. Nurses Notes for Shift 2 dated 2/7/16 and signed by LPN #3 documented, (at) 1940 (7:40 p.m.) New order send resident to (Hospital) ER (emergency room ) for eval (evaluation) and treatment per family request .(Ambulance Service) transferred resident at 1945 (7:45 p.m.). A telephone physician order [REDACTED].May send to (Hospital) for eval & (and) treatment of [REDACTED]. Family request ER. f. There was no documentation found in the Nurses Notes to indicate the resident had been reassessed for pain or physical status/condition and no documentation of any further attempt to consult physician regarding the facilitys' inability to obtain x-ray of left hip prior to the family request, found in the Nurses Notes, from 1:30 p.m. until 7:40 p.m. g. On 2/8/16 at 2:05 p.m., the DON was asked for a copy of the Left Hip X-Ray. The DON stated, I was informed about the fall at about 7:00 p.m., (the night before on 2/7/16) and was told that mobile X-ray had never showed up at facility and family had wanted her (Resident #1) sent out to the hospital and didn't want to wait any longer. She stated the resident had had surgery. On 2/10/16, the DON showed her cellphone, that showed a list of phone calls she had received from the facility on 2/7/16. The cell phone's screen documented one call from the facility on 2/7/16 at 7:08 p.m. The DON confirmed at that time she was not notified about the resident's fall until then, a period of 5 hours and 38 minutes after the discovery and initial documentation of the residents fall. h. On 2/9/16 at 9:54 a.m., (name of vice president of mobile X-Ray company) was in the facility. When questioned about what his company ' s turn around time for STAT X-Rays, he stated, 4 hour routine time for routine orders, 2 hour time frame for STAT X-Rays. He immediately picked up his phone and called to find out what had transpired on 2/7/16. He provided the following, Order for Lakewood Healthcare called in at 1352 hrs (1:52 p.m.) on 2/7/16 Hip Left ordered routine by (LPN #3) at 1352 hrs dispatched (name of mobile technician) arrived in the Lakewood area at 1930 hrs via GPS (Global Positioning System) Order canceled by (LPN#3) at 1927 (7:27 p.m.) hrs. When questioned where his company was located he stated that there is ALWAYS a mobile X-Ray truck stationed in Hot Springs. i. On 2/9/16 at 9:15 a.m., the resident's daughter was in the resident's room at the hospital. She stated she was told by (Licensed Practical Nurse (LPN) #3) when she got to facility that she (LPN) had ordered the X-Ray right away (STAT) and the X-Ray company was located way down in South Arkansas, that she had also called them several times to see why they were not at the facility. She stated she (the daughter) had finally demanded (LPN #3) to call for the ambulance and send her mother out to the hospital. The daughter stated, Mom told me when I got to the facility that she couldn ' t wait any longer. I kept talking to (LPN #3) and she kept saying she had just called x-ray and checking. Mom had one pill for pain when I just got there but nothing else until we got to the emergency room . She was hurting really bad. I asked (LPN #3) for something else for the pain and she told me she had called the doctor and was not getting any calls back. She could not give anything without a doctors order. j. On 2/9/16 Hospital records were obtained and they documented, Fall time since incident: 12 hours today at 1300 (1:00 p.m.), left [MEDICAL CONDITION] Unable to get xray at nursing home .patient reports she was transferring without assistance which she normally does not do and she fell landing on her left hip .A CT (computerized tomography) scan was performed which shows a small femur fracture at the distal end of the prosthesis. Patient states she would (want) to have [MEDICAL CONDITION] stabilized. Surgery will be scheduled in the near future. NPO (No food oral) for possible surgery today. 3. Resident #26 was admitted on [DATE] to Medicare skilled care services and had [DIAGNOSES REDACTED]. The Admission MDS with an ARD of 4/22/15 documented the resident scored 12 (8-12 indicates moderately impaired) on a BIMS, used a wheelchair, required extensive assistance of 1-2 persons for locomotion, had a [DIAGNOSES REDACTED]. a. The resident's Care Plan dated 4/27/15 did not document a problem [MEDICAL CONDITION] or planned interventions for the resident to see an Oncologist (a medical doctor that specializes [MEDICAL CONDITION] treatments). b. The July 2015 physician's orders [REDACTED]. c. On 2/10/16 at 9:00 a.m., the Business Office Manager (BOM) provided a Medicare Listing with residents' dates of service. The resident's dates of service were 4/15/15 through 7/15/15. d. On 2/10/16, the DON was asked to contact the resident's Oncologist (Oncologist #1) and ask for all appointments made for the resident during her time in the facility. On 2/10/16 at 4:00 p.m., the DON provided a written documentation that stated the resident had appointments made for 4/22/15 and 5/28/15 with her Oncologist, but both had been cancelled by the facility. e. A written statement dated 2/11/16 at 9:14 a.m. and signed by LPN #2 documented, I state that when (resident) was here for Medicare stay 4/15/15 - 7/15/15 for a (fractured) shoulder . (resident) had 2 appointments with (Oncologist #1) . was told to cancel d/t (due to) the fact that it wasn't related to her [DIAGNOSES REDACTED]. Resident had a [DIAGNOSES REDACTED]. An addendum to that statement was dated 2/16/16 and documented, The person who told me to cancel the appointment was Administrator (Administrator's name), and was signed again by LPN #2.

Complaints # (AR 948), Complaints # (AR 964), Complaints # (AR 973), Complaints # (AR 974), Complaints # (AR 978) and Complaints # (AR 83) were substantiated (all or in part) in these findings. Based on observation, record review and interview, the Facility Administration failed to manage the facility in a manner that enabled residents to effectively attain or maintain the highest practicable physical, mental, and psychosocial well-being: The facility failed to ensure Resident #1 and Resident #2 was free from staff to resident verbal and mental abuse. The facility failed to ensure staff immediately reported incidents of staff related verbal/mental abuse to appropriate persons, the State Agency, and local law enforcement; to ensure thorough investigations into the incidents; and that residents were protected from further abuse during the investigation for 2 of 2 (Resident #1 and #2) case mix residents. This failed practice resulted in a pattern of actual harm for Residents #1 who made verbal and written allegations of abuse to Licensed Practical Nurse (LPN) #3 on [DATE] and Resident #2 who made allegations of physical and mental abuse to LPN #1 approximately 1.5 -2 months prior to the survey dates. The failed practice also had the potential to cause more than minimal harm for 16 alert and oriented residents who resided in the facility as documented on a listing provided by the Interim Administrator on [DATE] at 1:06 p.m. The facility failed to ensure residents ' right to exercise his or her choices regarding what the resident considers to be important facets of his or her life for 1 (Residents #25) of 5 (Residents #3, 8, 12, 17 and 25) case mix residents who had behaviors of being resistant to receiving care according to a list provided by the Interim Administrator on [DATE]. These failed practices had the potential to affect 42 residents who required assistance with transfers and 53 residents who required assistance mobility and 12 residents who was resistant with care as identified by the Resident Census and Conditions of Residents form dated [DATE]. The facility failed to ensure current acceptable standards of nursing practice were met for 1 of 1 (Resident #3) case mix residents whose physician's telephone orders for Contact Isolation precautions were destroyed by Licensed Practical Nurse (LPN) #4. The facility failed to ensure that only nurses with current licenses performed wound treatments for 4 of 4 (Residents #3, #10, #17 and #24) case mix residents who had documentation of treatments conducted by the former Treatment Nurse #1 after her nursing license had expired. The facility failed to ensure that former Treatment Nurse #1 was not instructed by the Administrator to make false statements upon her license renewal application. The failed practices had the potential to affect 5 residents who had physicians' orders for Contact Isolation precautions since ,[DATE] as documented on the facility's Line Listing of Resident Infections Logs provided by the Director of Nursing (DON) on [DATE] at 6:00 p.m., 25 residents at risk for pressure ulcer development, 3 residents who had a history of [REDACTED]. The facility failed to provide Oncology office visits during Medicare days for 1 of 1 (Resident #26) case mix resident whose appointments were cancelled by the facility. The failed practice had the potential to affect 7 residents who received Medicare services on [DATE] as stated by the Business Office Manager on [DATE] via phone call. The findings are: 1. On [DATE] at 4:28 p.m., the Business Office Manager provided the, Job Description for the Nursing Home Administrator, that documented as follows: a. The Nursing Home Administrator directs the provision of skilled and intermediate care on a 24-hour basis and ensures a smooth, high quality and professionally acceptable operation .The Administrator develops and implements Nursing Home policies and procedures to comply with Federal, State and Local requirements and to fulfill licensure certification standards .The Administrator serves as the primary liaison for the Nursing Home with residents, their families and the general public.The Major challenge which faces the incumbent is informing County Board members of the problems of a long-term care facility so that changes can be effected in a timely manner .Minimum requirements necessary to effectively carry out position responsibilities requires the incumbent considerable knowledge of Federal and State Licensure requirements for Nursing Home Operations, and respect for the principles of resident rights Principal Accountabilities: Directs operations of facility to meet state, Federal regulations, and avoid violations or licensure decertification. Plans for quality assurance in all departments of the Nursing home and develops quality improvement plans with committee members .Serves as primary liaison with residents, their families and the general public. 2. Resident #1 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set ((MDS) dated [DATE] documented the resident scored 9 (8 - 12 indicates moderately impaired) on a Brief Interview for Mental Status (BIMS). a. On [DATE] at 2:00 p.m., The MDS Coordinator provided written witness statements submitted by Licensed Practical Nurse #3 dated [DATE] and signed by the resident and the resident's daughter. The statements documented, (resident) stated, 'Ms. Red (resident's nickname for Administrator) came in without knocking or introducing herself, started pointing (at) my belongings and yelled they have to come down, it's a fire hazard. Ms. Red said 'Let me tell you this!' and (Resident #1) said, 'No, let me tell you . I will just leave' and Ms. Red said, 'Oh no, I will find you a place to go!' . (Resident #1) told me 'Ms. Red came into my room (and) threw the mattress on the floor. She (Administrator) came back (and) told aide to pick the mattress up and make the bed correctly.' (Resident #1) stated, 'I started to get scared.' A written Incident Investigation Form (DMS-762) Witness Statement dated [DATE] at 9:00 am (collected by facility for abuse investigations) and signed by the Medical Records Nurse documented, It was reported to me by (Licensed Practical Nurse-(LPN) #3) that (Resident #1 ' s) daughter stated to her that (Administrator) had a screaming episode in her mother's room and threw the mattress off the bed into the floor. When ask if she would like to write a grievance she quickly told the nurse no she feared retaliation from (Administrator) but she was going to report it to state. b. On [DATE] at 12:20 p.m., Resident #1's daughter was asked if she had ever witnessed the Administrator hollering and yelling in front of any residents. The resident's daughter stated she had not, but (daughter's) mom has and told her (resident's daughter). Then the resident stated, About a month ago, (Certified Nursing Assistant (CNA) #7) didn't make bed up right and (the) Administrator came into my room and threw mattress on floor, hollered at (CNA #7) and made her remake the bed. (Administrator said) 'you need to make this bed and make it right.' (The Administrator) busted into my room, came in, didn't knock, had a (female housekeeping employee, unnamed) with her, looked at my TV (television) area, (and) said real loud, 'that stuff has got to come off the top of the closets.' I told her (Administrator) I guess I would have to leave, she hurt my feelings, she (Administrator) then told me that she would be happy to find somewhere for me to move to. I told her wouldn't move anywhere that she would recommend to me . I hear her calling names and hollering down the halls. I call her 'Red,' because she has a terrible temper. She does not seem able to control it . I fretted for several days where I would have to move to. The resident was asked how (above information) made her feel. The resident stated, Was scared. c. On [DATE] at 11:45 a.m., the resident was questioned to see if she remembered LPN #3 asking her about the 2 situations (documented above) and she stated, Yes. She was questioned if the signature on both of the witness statements was her signature and she stated, yes, both mine and my daughter's. When questioned if she had stated she was afraid to LPN #3 she stated, Oh yes, I was so happy that someone was even asking me about it. But it didn't stop. Red (the Administrator), she has a violent temper and I don't know if she is going to get more angry or what she is going to do next! When questioned if she was worried about anything or had any concerns, the resident became very tearful and said that she was still afraid of the Administrator and she had been frightened and said she layed and fretted about everything for several days. The resident stated she was still afraid, scared and, I have told my daughter I wish I could leave here. The resident had tear-brimmed eyes during the entire interview. 3. Resident #2 had [DIAGNOSES REDACTED]. The Admission Minimum Data Set with an Assessment Reference Date of [DATE] documented the resident scored 15 (,[DATE] indicates cognitively intact) on the Brief Interview for Mental Status, required total assistance of 2 plus person for all Activities of Daily Living (ADLs) except eating, was frequently incontinent of bladder and always continent of bowel. a. The Plan of Care dated [DATE] documented a problem, ADL self-care deficit, with an approach, . Resident prefers to lay in the bed naked with a sheet over her vs (versus) a gown .resident complains of back pain and left hip pain. b. On [DATE] at 4:05 p.m., the resident was asked, Has anyone ever yelled at you. The resident stated, Yes ma'am this morning, just rude, rude. I told her (indicating the Administrator) about my roommate keeping me awake all night and wanted someone more compatible with me. She came in and told me I had to get up and get a shower I was tired, but she doesn't listen to anything. It has to be her way. She acts like I have no rights. I've never saw anything like this. She was asked, Has she yelled at you? She stated; Yes. The resident was asked, Has she ever threatened you. She stated, Yes, she is just rude and mean, ugly doesn't listen. Everyone here has been nice, the best place I've ever been except for her. It has been a nightmare, it's terrible just terrible because of her rudeness. c. An individual resident interview was conducted on [DATE] at 12:00 p.m. and [DATE] at 10:00 a.m. The resident made the following comments: On [DATE] at 12:00 p.m., the resident was asked during the staff section of the resident interview, Tell me how you feel about the staff members at this facility and if they treat you with respect. The resident stated that yes she was treated with respect and there is only one person that I've had plenty of trouble out of and that is the Director (Administrator). When asked if staff members listened to her requests and responded appropriately, the resident further stated, (name of Administrator) makes me sit up for hours, it was torture, pure torture. I kept trying to tell her (but) she wouldn't listen. She's the only one that's been rude and cruel to me. The resident stated, She (Administrator) made sure that I knew I didn't have any rights. It's been like I've been in prison but in the last week to week and a half it has changed. On [DATE] at 10 a.m., the resident was asked, What is an example of not having a choice in what you want to do? The resident stated, When I was up in the chair and could not get off my behind. I would be crying and telling her (Administrator) I couldn't sit up for any length of time and she would tell me I had to sit there that she would make sure I sat there. The resident was asked, How did that make you feel? The resident stated, Like I was lower than a dog. The staff was upset with her making me do this but they had to do what she told them to do. d. On [DATE] at 12:10 p.m., LPN #1 reported to this surveyor the following: LPN #1 stated, This happened on (Resident # 2's name). (Administrator's name) had them get her up for meals, she was crying saying I haven't been up in 5 years my bottom can't take this. She had been up 1 ,[DATE] to 2 hours and I went to (name of Administrator) to see if I could get her laid back down and she wouldn't let us lay her down. LPN # 1 was asked, Why did you go to her to get the resident laid down? The LPN stated, Because she (the resident) was Adult Protective Services we had to go through her (Administrator) for anything we did to the resident. She was probably up another 45 minutes to an hour before she was laid down. The LPN was asked, How many times has this happened? The LPN stated, Too many to count. The LPN further stated, .one time she wanted seconds on her tray and (name of Administrator) said no. 4. On [DATE] at approximately 10:00 a.m., the State Agency was contacted to check the database to see if there was any reports/investigation of allegations of abuse for Resident #1 and Resident #2 from [DATE] to February 1, 2016. Surveyor was told there were no Incidents reported for the two residents. 5. Resident #25 had [DIAGNOSES REDACTED]. The 14 day MDS with an ARD of [DATE] documented the resident scored 9 (,[DATE] indicates moderately impaired cognitive skills) on the brief interview for mental status, required limited assistance for bed mobility, transfers and toilet use, was occasionally incontinent of urine and always incontinent of bowel. a. The Plan of Care dated, [DATE] and revised on [DATE] documented, Activities of Daily Living Problem- Resident refusing bath, Refusing Therapies, Refusing to be changed .Provide adaptive safety equipment-wheelchair, Provide only the amount of assistance/supervision that is needed: Contact guarding, Provide resident/family education to include Safety/Awareness. The Care Plan did not contain any Behavior Modification interventions of withholding smoking to address the resident ' s behaviors and refusal of care. On [DATE] at 11:10 a.m., the Social Service Director (SSD) was asked if any behavior modifications had been done regarding (Resident #25) refusing showers, and he stated, Not formerly, smoking is the only type of control we have. The resident refuses everything. On [DATE] at 10:40 a.m., the SSD was asked again if he was aware if (Resident #25) was on any type of Behavior Modification Program-regarding smoking when he was refusing care (therapy, medications, incontinent care, bathing etc) and the SSD stated, No I am not aware of any. b. Nurses Notes dated [DATE] and signed by Licensed Practical Nurse (LPN) #1 documented, 1400 hours (2:00 p.m.), R (resident) urinated on himself, and refuses to be changed. He refused his shower today and refused to change his clothes. He was denied smoke break due to the temp (temperature) outside and his clothing being wet. He agreed to change into dry clothing. Will cont (continue) to monitor. On [DATE] at 3:15 p.m., LPN #1 was asked if she remembered who told (Resident #25) he could not smoke as referenced in the nurses note dated [DATE] at 2:00 p.m. The LPN stated, Yes, it was right here beside the Nurses Station, The Administrator , (Name of Administrator) was yelling and hollering telling (Resident #25) that he was not going to be hanging around the halls stinking up, , her place and he could not go smoke until he cleaned up. There were other staff members and residents all hearing her yell at him .he did finally go clean up. c. On [DATE] at 11:00 a.m., the Assistant Director of Rehabilitation (ADOR) was asked if he had ever heard staff telling any resident they would lose their smoking privileges. The ADOR stated he had heard this happen one time with (Resident #25) and further stated, (Resident #25) was extremely hard to get down here (indicating for therapy). It may have been (Administrator), a while ago I do know he was eager to work with us after this was said to him, he never said anything. (Resident #25) was the resident. 6. Resident #3 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set with an Assessment Reference Date of [DATE] documented the resident scored 3 (,[DATE] indicates severely impaired) on the Brief Interview for Mental Status and required limited assistance for all Activities of Daily Living. a. A Nurses Note dated [DATE] at 9:51 a.m. documented, Order processed from APN (Advanced Practice Nurse) (Name) for U/A (Urinalysis) with C&S (Culture and Sensitivity) if indicated due to increased confusion . b. A Telephone Order dated [DATE] documented, Obtain urine tonight for (morning) lab (U/A (with) C & S if indicated) (Increased confusion). c. A Laboratory Report dated [DATE] documented, Final . greater than 100,000 CFU/ML (Colony Forming Unit per milliliter) gram negative rods/Escherichia Coli ESBL (Extended-spectrum beta-lactamases). Handwritten telephone orders signed by Licensed Practical Nurse (LPN) #4 per the Advanced Practice Registered Nurse (APRN) #1 documented Bactrim DS (Double Strength) one tablet by mouth every 12 hours times 14 days for UTI. A Physicians Telephone Order dated [DATE] at 1000a.m. documented, 1. Bactrim DS (Double Strength) % (one) po Q (Every) 12 hours x 14 days 2. Contact isolation per facility policy . d. A Telephone Order dated [DATE] at 2:00 p.m. documented, D/C (discontinue) Contact isolation d/t (due to) non-compliance by (resident). As of [DATE] at 12:15 p.m., the telephone order was not signed by APRN #1 or the Primary Care Physician. There was no documentation in the Nurses Notes for the month of [DATE] to indicate the precautions had been initiated or discontinued due to resident ' s non-compliance. The Nurses Notes did not document what non-compliance, the resident had exhibited. e. A Physician's Progress Note dated [DATE] and signed by APRN #1 documented, Extended-Spectrum beta-lactamase Escherichia-coli urinary tract infection. The patient is on Bactrim for 14 days. Order initially was given for contact isolation, however, that was discontinue due to noncompliance per staff report. The same Nurse's Notes did not document what non-compliance, the resident had exhibited. f. On [DATE] at 11:50 a.m., LPN #4 was asked about the orders for isolation written on the final report of the urine culture for the resident dated [DATE]. LPN #4 stated she had asked LPN #5 what the facility's policy was for residents who had orders for isolation precautions and lived on the secure unit. She stated that LPN #5 had told her she was going to talk to the Administrator, when LPN #5 returned she stated she had spoken to the Administrator, who instructed her to tell me to destroy this lab report, reprint another one, and only write the antibiotic order, no isolation (order). LPN #4 stated she and LPN #5 went to the Administrator when another resident, who was not on the unit, had orders to be placed on contact isolation precautions with lesser amounts of ESBL E-Coli. The LPN stated the Administrator, was very snappy about it, since (resident) was not on the unit, there's no way she'll stay in an isolation room. LPN #4 stated, I told (Administrator) that this will be a red flag. She (Administrator) then told me to go back and write an order for [REDACTED].#4 was asked if she followed the instructions given to her by the Administrator. LPN #4 stated, Yes, she was my boss. LPN #4 was asked how she had destroyed the lab report on which she had written the original orders. LPN #4 stated, shredded. LPN #4 was asked if isolation precautions were ever attempted for the resident. LPN #4 stated, (Resident #3) was never placed in isolation, never attempted. On [DATE], LPN #4 was asked to provide a written statement on the copied laboratory report about this incident. LPN #4's statement documented, This lab report is a reprinted lab (without) ' Contact Isolation order per facility policy ' via (telephone order) per (APRN #1). g. On [DATE] at 1:06 p.m., the Administrator was asked about the isolation order having been discontinued without attempts to put in place and if she had given those instructions to LPN #4. The Administrator stated, I have no knowledge about isolation. h. The facility ' s policy titled Initiation of Isolation Precautions provided by the DON on [DATE] documented, . those with a physician's orders [REDACTED]. A private room is indicated for residents with infections that are highly contagious or are caused by microorganisms that are likely to be virulent when transmitted. b. An isolation cart is kept outside the door of the resident's room for those articles used in the isolation room . 7. On [DATE] at 4:05 p.m., the Administrator was asked if she had knowledge of an LPN who had worked in the facility and had expired nursing license. The Administrator stated, (former Treatment Nurse #1), when we became aware (of license expiration) (she) applied that day ([DATE], a Thursday), and didn't work (rest of day), Friday ([DATE]) and was on vacation, Monday ([DATE]) call-in, and Tuesday ([DATE]) quit without notice. The Administrator stated the (former Treatment Nurse #1) had personal reasons to quit. a. A signed statement provided by the MDS Coordinator on [DATE] at 2:35 p.m. via text message from the former Treatment Nurse #1 that documented, The Administrator tried to get me to go back (to work) even though my license still hadn't been reinstated and offered that I could work under her sign in name (Administrator was an LPN) to sign off on treatments . I kept the texts (text messages to personal phone). I refused and said I wouldn't work until my license was current. My license was reinstated and my lawyer suggested I not go back. So I quit. I have been very stressed and am afraid to take a nursing job. I'm afraid she will turn on me and I will lose my license . I have never been in such a messed up situation . b. On [DATE] at 11:13 a.m., the former Treatment Nurse #1 was asked, during a phone interview, about her expired nursing license. The Former Treatment Nurse #1 stated the Administrator wanted her to go to a wound class. When she was signing up for the class, she had to look up her nursing license on the state board website, which was when she realized her nursing licensed had expired on [DATE], the last day of her birth month. She stated, in tears, I went to (Business Office Manager-BOM) . (BOM) talked to (Administrator), came back and said 'this is what (Administrator) wants you to do (on license renewal) (write) suspended since (date of expiration). Former Treatment Nurse #1 was asked if the Administrator actually told her to do that and she stated, (Administrator) told same thing, and had requested a copy of her receipt for the license renewal fee. The Former Treatment Nurse #1 was asked if she had documented she was suspended and did not work since [DATE] and she stated, Yes. On [DATE] at 8:50 a.m., a meeting with former Treatment Nurse #1 was held outside of the facility grounds. Former Treatment Nurse #1 stated, I wrote I was suspended since (nursing license) expired . then she (Administrator) told me not to tell anyone after I had done it. The former Treatment Nurse #1 provided screen-shots of text messages dated [DATE] at 7:05 a.m. that documented, (License) still expired. I (Administrator) can sign in and you sign under me (for treatments conducted by former Treatment Nurse #1) On [DATE] at 8:55 a.m., the DON and the facility's Board Vice President looked at the phone number documented at the top of the screen shot text message identified above and both confirmed the phone number used to send the text message was the Administrator. c. A written statement dated [DATE] at 12:39 p.m. and signed by the BOM documented the former Treatment Nurse #1 had come to her when she realized her nursing license was expired, was trying to renew it and, did not know how to answer some of the questions. I told her that I had no idea. I told her that she should go talk to (Administrator) because she needed to know and could probably answer her questions better than I could. We then went to (Administrator's) office together. (Former Treatment Nurse #1) asked what she should put for the question that asks have you worked since your license became expired. (Administrator) instructed her to put that she had been suspended pending the renewal of her license (and) had not worked. d. As of [DATE] at 3:15 p.m., the [DATE] Treatment Administration Records confirmed the former Treatment Nurse #1 provided treatments for 4 (Resident #s 3, 10, 17 and 24) case mix residents as identified by the nurse initials documented on the form on [DATE] and [DATE]. The Nurse ' s license had expired on [DATE]. 8. Resident #26 was admitted on [DATE] to Medicare skilled care services and had [DIAGNOSES REDACTED]. The Admission MDS with an ARD of [DATE] documented the resident scored 12 (,[DATE] indicates moderately impaired) on the BIMS; used a wheelchair; required extensive assistance of ,[DATE] persons for locomotion; had a [DIAGNOSES REDACTED]. a. The resident's Care Plan dated [DATE] did not document a problem [MEDICAL CONDITION] or planned interventions for the resident to see an Oncologist (a medical doctor that specializes [MEDICAL CONDITION] treatments). b. The [DATE] physician's orders [REDACTED]. On [DATE] at 9:00 a.m., the Business Office Manager provided a Medicare Listing with residents' dates of service. The resident's dates of service were [DATE] through [DATE]. c. On [DATE] at 3:34 p.m., the Administrator was asked if any residents with [MEDICAL CONDITION] had oncology visits and stated, I never saw an appointment with an oncologist, never took a resident with [MEDICAL CONDITION]. d. On [DATE], the DON was asked to contact the resident's Oncologist (#1) and ask for all appointments made for the resident during her time in the facility. On [DATE] at 4:00 p.m., the DON provided a written note that documented the resident had appointments made for [DATE] and [DATE] with her Oncologist, but both had been cancelled by the facility. e. A written statement dated [DATE] at 9:14 a.m. and signed by LPN #2 documented, I state that when (resident) was here for Medicare state [DATE] - [DATE] for a (fractured) shoulder . (resident) had 2 appointments with (Oncologist #1) . was told to cancel d/t (due to) the fact that it wasn't related to her [DIAGNOSES REDACTED]. Resident had a [DIAGNOSES REDACTED]. An addendum to that statement was dated [DATE] and documented, The person who told me to cancel the appointment was Administrator (Administrator's name). 9. Between [DATE] and [DATE], multiple interviews were conducted and written statements obtained from staff members in the facility who made statements that concerned the actions of the Administrator as follows: a. On [DATE] at 9:55 a.m., the Medical Records Nurse documented, The (administrator) has a very short temper she yells and cusses at .resident 's .(Administrator yells at and cusses staff in front of other staff, residents and anyone that happens to be around .she humiliated (staff member) by screaming at her in front of numerous staff members and residents at the nurses station at shift change . b. On [DATE] at 11:50 a.m., the Housekeeping/Laundry Supervisor documented in a written statement, . have heard Administrator yelling in front of Residents, cursing . On [DATE] at 7:56 a.m., she documented, (Administrator) yelling at (Resident #1) about labels being put in her clothes. (Resident #1) stated she didn't want them in her clothes, (Administrator) stated ' if you don't like how things are going here then we can find you another place. ' (Administrator) if she gets upset at something-at the nurses station- loud voice, waving hands, 'hell' has been said, residents are around. c. On [DATE] at 12:03 p.m., the ADON stated, yelled at (a resident) last week, told resident he had to get cleaned up . ' I won't have people smelling like Piss! ' The resident was standing by the Nurses desk. d. On [DATE] at 11:34 a.m., LPN #4 stated, Heard her (Administrator) scream at UPS man with residents around. e. On [DATE] at 12:26 p.m., via phone interview, APRN (Advance Physician Registered Nurse) #1 stated, (Administrator) said the (a foul word that begins with an ' F ' ) . I heard it out by the Nurses Station .she cusses at nurses station and it's hard to take, very gruff. f. On [DATE] at 8:50 a.m., former Treatment Nurse #1 stated, (Administrator) yelled and cussed around the nurses station all the time. Former Treatment Nurse #1 was asked if the Administrator yelled or cussed with residents around. Former Treatment Nurse #1 stated, Yes.

Complaint # (AR 948), Complaint # (AR 973) and # (AR 974) were substantiated (all or in part) in these findings. Based on observation, record review and interview, the facility failed to ensure that policies and procedures were developed and consistently implemented to prevent abuse / neglect for residents in the facility as evidenced by: The facility ' s failure to ensure staff immediately reported incidents of staff related verbal/mental abuse to appropriate persons, the State Agency, and local law enforcement; to ensure thorough investigations into the incidents; and that residents were protected from further abuse during the investigation for 2 of 2 (Resident #1 and #2) case mix residents. The facility ' s failure to ensure immediate protection was provided after the facility's Board President was notified of allegations of alleged abuse/neglect by the Administrator for 4 of 4 (Residents #2, #3, #16, and #17) case mix residents named in abuse / neglect allegations and the 58 other residents who resided in the facility and with whom the facility Administrator had potential contact. The facility ' s failure to ensure DMS-7734 reports to the state agency were not falsified in documentation of personnel who were completing the reports for 4 of 4 (Residents #2, #3, #16 and #17) case mix residents named in abuse / neglect allegations. The facility ' s failure to ensure immediate notifications were made to local law enforcement agencies for 4 of 4 (Residents #2, #3, #16 and #17) case mix residents named in abuse / neglect allegations. The facility failed to ensure a [MEDICAL CONDITION] of unknown etiology was investigated and reported to the state agency for 1of 1 (Resident #24) case mix residents with a [MEDICAL CONDITION] of unknown etiology. The facility failed to ensure alternate phone numbers of one or more Board Members were posted for employees to report allegations of abuse / neglect when the alleged perpetrator was the facility Administrator. The failed practices resulted in a pattern of actual harm for Residents #1 who made verbal and written allegations of abuse to Licensed Practical Nurse (LPN) #3 on 1/17/16 and Resident #2 who made allegations of physical and mental abuse to LPN #1 approximately 1.5 -2 months prior to the survey dates. The failed practice also had the potential to cause more than minimal harm for 16 alert and oriented residents in the facility as documented on a listing provided by the Interim Administrator on 2/17/16 at 1:06 p.m. The findings are: 1. On 2/1/16 at 11:20 a.m., the Administrator provided the facility's, Abuse Policy and Prevention, policies and procedures that documented as follows: a. It is the policy of (facility name) that all residents have the right to be free from verbal . and mental abuse . Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff . b. Definitions . Abuse: . Any intentional or demeaning act which subjects an endangered or impaired adult to ridicule or psychological injury in a manner to provoke fear or alarm . Mental Abuse: Includes, but not limited to, humiliation . threats of punishment or deprivation. c. The area of policies titled, Prevention, did not document the development of analyses for physical environment, nursing supervision, nurse staffing and the assessment, care planning and monitoring of those residents most at risk for abuse. On 2/9/16 and 2/10/16 the Interim Administrator was asked to locate policies that addressed the above issues and as of 2/10/16 at 7:02 p.m., the facility had not provided the requested information. d. The section of policies titled, What must be reported? documented, All alleged, witnessed and/or suspected maltreatment. e. The section titled, To whom must reports be made?, documented, Immediately to the Administrator or that person's designated agent and Immediately to the local law enforcement agency for the jurisdiction in which the long-term care facility is located. There was no documentation in those policies of alternate persons to report to if the Administrator was the alleged perpetrator. The same section documented, (reports to state agency) By 11 AM (11:00 a.m.) the next business day to (state agency). f. The policies documented, .It is the policy to suspend, pending investigation, any employee accused of patient abuse. 2. Resident #1 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set ((MDS) dated [DATE] documented the resident scored 9 (8 - 12 indicates moderately impaired) on a Brief Interview for Mental Status (BIMS). a. On 2/1/16 at 2:00 p.m., The MDS Coordinator provided written witness statements submitted by Licensed Practical Nurse #3 dated 1/17/16 and signed by the resident and the resident's daughter. The statements documented, (resident) stated, 'Ms. Red (resident's nickname for Administrator) came in without knocking or introducing herself, started pointing (at) my belongings and yelled they have to come down, it's a fire hazard. Ms. Red said 'Let me tell you this!' and (Resident #1) said, 'No, let me tell you . I will just leave' and Ms. Red said, 'Oh no, I will find you a place to go!' . (Resident #1) told me 'Ms. Red came into my room (and) threw the mattress on the floor. She (Administrator) came back (and) told aide to pick the mattress up and make the bed correctly.' (Resident #1) stated, 'I started to get scared.' A written Incident Investigation Form (DMS-762) Witness Statement dated 2/3/16 at 9:00 am (collected by facility for abuse investigations) and signed by the Medical Records Nurse documented, It was reported to me by (Licensed Practical Nurse-(LPN) #3) that (Resident #1 ' s) daughter stated to her that (Administrator) had a screaming episode in her mother's room and threw the mattress off the bed into the floor. When ask if she would like to write a grievance she quickly told the nurse no she feared retaliation from (Administrator) but she was going to report it to state b. On 2/2/16 at 12:20 p.m., Resident #1's daughter was asked if she had ever witnessed the Administrator hollering and yelling in front of any residents. The resident's daughter stated she had not, but (daughter's) mom has and told her (resident's daughter). Then the resident stated, About a month ago, (Certified Nursing Assistant (CNA) #7) didn't make bed up right and (the) Administrator came into my room and threw mattress on floor, hollered at (CNA #7) and made her remake the bed. (Administrator said) 'you need to make this bed and make it right.' (The Administrator) busted into my room, came in, didn't knock, had a (female housekeeping employee, unnamed) with her, looked at my TV (television) area, (and) said real loud, 'that stuff has got to come off the top of the closets.' I told her (Administrator) I guess I would have to leave, she hurt my feelings, she (Administrator) then told me that she would be happy to find somewhere for me to move to. I told her wouldn't move anywhere that she would recommend to me . I hear her calling names and hollering down the halls. I call her 'Red,' because she has a terrible temper. She does not seem able to control it . I fretted for several days where I would have to move to. The resident was asked how (above information) made her feel. The resident stated, was scared. c. On 2/3/16 at 11:45 a.m., the resident was questioned to see if she remembered LPN #3 asking her about the 2 situations (documented above) and she stated, yes. She was questioned if the signature on both of the witness statements was her signature and she stated, yes, both mine and my daughter's. When questioned if she had stated she was afraid to LPN #3 she stated, Oh yes, I was so happy that someone was even asking me about it. But it didn't stop. Red (the Administrator), she has a violent temper and I don't know if she is going to get more angry or what she is going to do next! When questioned if she was worried about anything or had any concerns, the resident became very tearful and said that she was still afraid of the Administrator and she had been frightened and said she laid and fretted about everything for several days. The resident stated she was still afraid, scared and, I have told my daughter I wish I could leave here. The resident had tear-brimmed eyes during the entire interview. d. On 2/4/16 at approximately 10:00 a.m., the State Agency was contacted to check the database to see if there were any reports/investigation of allegations of abuse for Resident #1 from October 1, 2015 to February 1, 2016. Surveyor was told there were no Incidents reported. 3. Resident # 2 had [DIAGNOSES REDACTED]. The Admission Minimum Data Set with an Assessment Reference Date of 1/8/16 documented the resident scored 15 (13-15 indicates cognitively intact) on the Brief Interview for Mental Status, required total assistance of 2 plus person for all Activities of Daily Living (ADLs) except eating, was frequently incontinent of bladder and always continent of bowel. a. The Plan of Care dated 1/12/16 documented a problem, ADL self-care deficit, with an approach, . Resident prefers to lay in the bed naked with a sheet over her vs (versus) a gown .resident complains of back pain and left hip pain. b. On 2/1/16 at 4:05 p.m., the resident was asked, Has anyone ever yelled at you. The resident stated, Yes ma'am this morning, just rude, rude. I told her (indicating the Administrator) about my roommate keeping me awake all night and wanted someone more compatible with me. She came in and told me I had to get up and get a shower I was tired, but she doesn't listen to anything. It has to be her way. She acts like I have no rights. I've never saw anything like this. She was asked; Has she yelled at you? She stated; Yes. The resident was asked, Has she ever threatened you. She stated, Yes, she is just rude and mean, ugly doesn't listen. Everyone here has been nice, the best place I've ever been except for her. It has been a nightmare, it's terrible just terrible because of her rudeness. c. An individual resident interview was conducted on 2/8/16 at 12:00 p.m. and 2/10/16 at 10:00 a.m. The resident made the following comments: On 2/8/16 at 12:00 p.m., the resident was asked during the staff section of the resident interview, Tell me how you feel about the staff members at this facility and if they treat you with respect. The resident stated that yes she was treated with respect and there is only one person that I've had plenty of trouble out of and that is the Director (Administrator). When asked if staff members listened to her requests and responded appropriately, the resident further stated, (name of Administrator) makes me sit up for hours, it was torture, pure torture. I kept trying to tell her (but) she wouldn't listen. She's the only one that's been rude and cruel to me. The resident stated, She (Administrator) made sure that I knew I didn't have any rights. It's been like I've been in prison but in the last week to week and a half it has changed. On 2/10/16 at 10 a.m., the resident was asked, What is an example of not having a choice in what you want to do? The resident stated, When I was up in the chair and could not get off my behind. I would be crying and telling her (Administrator) I couldn't sit up for any length of time and she would tell me I had to sit there that she would make sure I sat there. The resident was asked, How did that make you feel? The resident stated, Like I was lower than a dog. The staff was upset with her making me do this but they had to do what she told them to do. d. On 2/4/16 at 12:10 p.m., LPN #1 reported to this surveyor the following: LPN #1 stated, This happened on (Resident # 2's name). (Administrator's name) had them get her up for meals, she was crying saying I haven't been up in 5 years my bottom can't take this. She had been up 1 1/2 to 2 hours and I went to (name of Administrator) to see if I could get her laid back down and she wouldn't let us lay her down. LPN # 1 was asked, Why did you go to her to get the resident laid down? The LPN stated, Because she (the resident) was Adult Protective Services we had to go through her (Administrator) for anything we did to the resident. She was probably up another 45 minutes to an hour before she was laid down. The LPN was asked, How many times has this happened? The LPN stated, Too many to count. The LPN further stated, .one time she wanted seconds on her tray and (name of Administrator) said no. e. On 2/4/16 at approximately 10:00 a.m., the State Agency was contacted to check the database to see if there were any reports/investigation of allegations of abuse for Resident #2 from October 1, 2015 to February 1, 2016. Surveyor was told there were no Incidents reported. 4. Resident #24 had [DIAGNOSES REDACTED]. a. A Nurses Note dated 12/25/15 shift at 1:50 a.m. documented, Res (Resident) up in wheelchair in hallway. Resident c/o (complain of) pain in left groin area. This LPN assessed area, redness noted. Cream applied and PRN (as needed) pain medication given. b. A Nurses Note dated 12/26/15 shift 1 documented, Complains of having pain in her left groin . A Nurses Note dated 12/26/15 shift 2 documented, c/o pain in her left groin . c. A Nurses Note dated 12/28/15 shift 1 documented, c/o Left hip . and 1330 . Resident has c/o L hip pain at this time . d. Nurses Notes dated 12/30/15 at 1:30 p.m., documented, Resident has c/o L hip pain at this time . A Nurses Note dated 12/30/15 shift 2 at 5:58 p.m. documented, . Resident states she has pain in her left groin area. [MEDICATION NAME] PRN given and biofreeze. c/o Left hip. e. A Nurses Note dated 12/31/15 shift 1 at 10:15 a.m. documented, . Resident c/o l (L) hip pain, prn biofreeze applied per order. noted to have slight swelling to (L) hip area and under thigh APRN (Advanced Practice Registered Nurse) notified. STAT x-ray . A Nurses Note dated 12/31/15 shift 1 at 1300 documented, . APRN called with xray results . Send to ER( emergency room ). An onsite imaging solution report dated 12/31/15 report documented, . Impression: Left subcapital femoral neck fracture . f. An Operative Notes report dated 1/1/2016 documented, Pre-operative Diagnosis: [REDACTED]. g. There was no documentation that this injury was reported to the Administrator, no documentation to indicate an investigation was initiated and no documentation of any protective measures that were put in place at this time. On 2/10/16 at 6:00 p.m., the Assistant Director of Nursing (ADON) was asked if any incidents involving Resident #24 had been reported. She stated, Not to my knowledge; I don't know anything about it. The Director of Nursing (DON) was shown the Nurses' Note dated 12/25/15 -12/31/15 and was asked, If a resident has an injury of unknown origin , should an investigation and reportable be completed? The DON stated, Yes, there should have been an investigation done. 5. On 2/1/16 at approximately 9:05 a.m., the facility's Board President was notified by state agency personnel in a phone call of multiple allegations of abuse / neglect. The survey team entered the facility on 2/1/16 at 10:15 a.m. and the Administrator was not supervised or prevented from going throughout the facility between 10:15 a.m. and approximately 2:10 p.m., when facility Board Members met with the Administrator in her office. On 2/1/16 at 3:22 p.m., the facility's Administrator was informed of all allegations of abuse / neglect and informed that she could not be around residents during the investigations. The Administrator stayed in her office during work hours with direct supervision of different assigned staff members until 2/3/16 at 4:10 p.m., when the facility's Board Vice President escorted her out of the building until further notice. 6. The DMS (Department of Medical Services)-7734 OLTC Incident and Accident Reports dated 2/1/16 documented Residents #2, #3, #16, and #17 were named in allegations against the facility's Administrator. Those reports were faxed to the state agency on 2/2/16 and documented in the space for, Staff reporting I & A (Incident and Accident): (printed name of Business Office Manager (BOM)). On 2/12/16 at 2:30 p.m., the BOM faxed a written statement dated 2/11/16 at 9:10 a.m. that documented, I did not take any part in investigating or completing a form 7734 on the alleged allegations of abuse against (Administrator) on 2/1/16. On 2/2/16 at approximately 9:00 a.m., a law enforcement officer was in the Administrator's office. On 2/2/16 at 10:40 a.m., the Administrator was asked why the police officer was in the building. The Administrator stated, I called this morning about reports (DMS-7734's) from yesterday (2/1/16). 7. On 2/1/16 at 3:30 p.m., the Administrator was asked if any board members phone numbers were posted in the facility for reports allegations of abuse. The Administrator stated, No. 8. On 2/3/16 at 2:55 p.m., the facility's Board Vice President and Director of Nursing (DON) informed the surveyor that the Vice President's cell phone number had been posted in the facility for notification purposes. That was the first date the employees had access to the Board for immediate notifications of alleged abuse if the facility Administrator was the alleged perpetrator.

Complaint # (AR 948), Complaint # (AR 973) and # (AR 974) were substantiated (all or in part) in these findings. Based on observation, record review and interview, the facility failed to ensure Resident #1 and Resident #2 was free from staff to resident verbal and mental abuse. The facility failed to ensure staff immediately reported incidents of staff related verbal/mental abuse to appropriate persons, the State Agency, and local law enforcement; to ensure thorough investigations into the incidents; and that residents were protected from further abuse during the investigation for 2 of 2 (Resident #1 and #2) case mix residents. This failed practice resulted in a pattern of actual harm for Residents #1 who made verbal and written allegations of abuse to Licensed Practical Nurse (LPN) #3 on 1/17/16 and Resident #2 who made allegations of physical and mental abuse to LPN #1 approximately 1.5 -2 months prior to the survey dates. The failed practice also had the potential to cause more than minimal harm for 16 alert and oriented residents in the facility as documented on a listing provided by the Interim Administrator on 2/17/16 at 1:06 p.m. The findings are: 1. Resident #1 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set ((MDS) dated [DATE] documented the resident scored 9 (8 - 12 indicates moderately impaired) on a Brief Interview for Mental Status (BIMS). a. On 2/1/16 at 2:00 p.m., the MDS Coordinator provided written witness statements submitted by Licensed Practical Nurse #3 dated 1/17/16 and signed by the resident and the resident's daughter that documented, (resident) stated, 'Ms. Red (resident's nickname for Administrator) came in without knocking or introducing herself, started pointing (at) my belongings and yelled they have to come down, it's a fire hazard. Ms. Red said 'Let me tell you this!' and (Resident #1) said, 'No, let me tell you . I will just leave' and Ms. Red said, 'Oh no, I will find you a place to go!' . (Resident #1) told me 'Ms. Red came into my room (and) threw the mattress on the floor. She (Administrator) came back (and) told aide to pick the mattress up and make the bed correctly.' (Resident #1) stated, 'I started to get scared.' A written Incident Investigation Form (DMS-762) Witness Statement dated 2/3/16 at 9:00 a.m. (collected by facility for abuse investigations) and signed by the Medical Records Nurse documented, It was reported to me by (Licensed Practical Nurse-(LPN) #3) that (Resident #1 ' s) daughter stated to her that (Administrator) had a screaming episode in her mother's room and threw the mattress off the bed into the floor. When ask if she would like to write a grievance she quickly told the nurse no she feared retaliation from (Administrator) but she was going to report it to state. b. On 2/2/16 at 12:20 p.m., Resident #1's daughter was asked if she had ever witnessed the Administrator hollering and yelling in front of any residents. The resident's daughter stated she had not, but (daughter's) mom has and told her (resident's daughter). The resident stated, , About a month ago, (Certified Nursing Assistant (CNA) #7) didn't make the bed up right and (the) Administrator came into my room and threw the mattress on floor, hollered at (CNA #7) and made her remake the bed. (Administrator said) 'you need to make this bed and make it right.' (The Administrator) busted into my room, came in, didn't knock, had a (female housekeeping employee, unnamed) with her, looked at my TV (television) area, (and) said real loud, 'that stuff has got to come off the top of the closets.' I told her (Administrator) I guess I would have to leave, she hurt my feelings, she (Administrator) then told me that she would be happy to find somewhere for me to move to. I told her wouldn't move anywhere that she would recommend to me . I hear her calling names and hollering down the halls. I call her 'Red,' because she has a terrible temper. She does not seem able to control it . I fretted for several days where I would have to move to. The resident was asked how (above information) made her feel. The resident stated, was scared. c. On 2/3/16 at 11:45 a.m., the resident was questioned to see if she remembered LPN #3 asking her about the 2 situations (documented above) and she stated, yes. She was questioned if the signature on both of the witness statements was her signature and she stated, yes, both mine and my daughter's. When questioned if she had stated she was afraid to LPN #3 she stated, Oh yes, I was so happy that someone was even asking me about it. But it didn't stop. Red (the Administrator), she has a violent temper and I don't know if she is going to get more angry or what she is going to do next! When questioned if she was worried about anything or had any concerns, the resident became very tearful and said that she was still afraid of the Administrator and she had been frightened and said she laid and fretted about everything for several days. The resident stated she was still afraid, scared and, I have told my daughter I wish I could leave here. The resident had tear-brimmed eyes during the entire interview. 2. Resident # 2 had [DIAGNOSES REDACTED]. The Admission Minimum Data Set with an Assessment Reference Date of 1/8/16 documented the resident scored 15 (13-15 indicates cognitively intact) on the Brief Interview for Mental Status, required total assistance of 2 plus person for all Activities of Daily Living (ADLs) except eating, was frequently incontinent of bladder and always continent of bowel. a. The Plan of Care dated 1/12/16 documented a problem, ADL self-care deficit, with an approach, . Resident prefers to lay in the bed naked with a sheet over her vs (versus) a gown .resident complains of back pain and left hip pain. b. On 2/1/16 at 4:05 p.m., the resident was asked, Has anyone ever yelled at you. The resident stated, Yes ma'am this morning, just rude, rude. I told her (indicating the Administrator) about my roommate keeping me awake all night and wanted someone more compatible with me. She came in and told me I had to get up and get a shower I was tired, but she doesn't listen to anything. It has to be her way. She acts like I have no rights. I've never saw anything like this. She was asked; Has she yelled at you? She stated; Yes. The resident was asked, Has she ever threatened you. She stated, Yes, she is just rude and mean, ugly doesn't listen. Everyone here has been nice, the best place I've ever been except for her. It has been a nightmare, it's terrible just terrible because of her rudeness. c. An individual resident interview was conducted on 2/8/16 at 12:00 p.m. and 2/10/16 at 10:00 a.m. The resident made the following comments: On 2/8/16 at 12:00 p.m., the resident was asked during the staff section of the resident interview, Tell me how you feel about the staff members at this facility and if they treat you with respect. The resident stated that yes she was treated with respect and there is only one person that I've had plenty of trouble out of and that is the Director (Administrator). When asked if staff members listened to her requests and responded appropriately, the resident further stated, (name of Administrator) makes me sit up for hours, it was torture, pure torture. I kept trying to tell her (but) she wouldn't listen. She's the only one that's been rude and cruel to me. The resident stated, She (Administrator) made sure that I knew I didn't have any rights. It's been like I've been in prison but in the last week to week and a half it has changed. On 2/10/16 at 10 a.m., the resident was asked, What is an example of not having a choice in what you want to do? The resident stated, When I was up in the chair and could not get off my behind. I would be crying and telling her (Administrator) I couldn't sit up for any length of time and she would tell me I had to sit there that she would make sure I sat there. The resident was asked, How did that make you feel? The resident stated, Like I was lower than a dog. The staff was upset with her making me do this but they had to do what she told them to do. d. On 2/4/16 at 12:10 p.m., LPN #1 reported to this surveyor the following: LPN #1 stated, This happened on (Resident # 2's name). (Administrator's name) had them get her up for meals, she was crying saying I haven't been up in 5 years my bottom can't take this. She had been up 1 1/2 to 2 hours and I went to (name of Administrator) to see if I could get her laid back down and she wouldn't let us lay her down. LPN # 1 was asked, Why did you go to her to get the resident laid down? The LPN stated, Because she (the resident) was Adult Protective Services we had to go through her (Administrator) for anything we did to the resident. She was probably up another 45 minutes to an hour before she was laid down. The LPN was asked, How many times has this happened? The LPN stated, Too many to count. The LPN further stated, .one time she wanted seconds on her tray and (name of Administrator) said no. 3. On 2/4/16 at approximately 10:00 a.m., the State Agency was contacted to check the database to see if there were any reports/investigation of allegations of abuse for Resident #1 and Resident #2 from October 1, 2015 to February 1, 2016. Surveyor was told there were no Incidents reported for the two residents.

Complaint # (AR 964) and Complaint # (AR 983) were substantiated (all or in part) in these findings. Based on record review and interview, the facility failed to ensure that physician's orders [REDACTED].#14) case mix residents with physician's orders [REDACTED]. This failed practice resulted in a pattern of harm for Resident #14 who declined in her physical condition over a period greater than 4 days without physician evaluation or treatment and was hospitalized for [REDACTED]. The failed practice had the potential to affect 38 residents who had physicians' orders for laboratory testing of UA with C&S as documented on a listing provided via fax, by the Director of Nursing (DON) on 2/18/16 at 1:32 p.m. The findings are: Resident #14 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set with an assessment reference date of 12/4/15 documented the resident scored 12 (8 - 12 indicates moderately impaired) on a Brief Interview for Mental Status. a. The Care Plan dated 12/7/15 documented, Urinary Incontinence-Problem .UTI (Urinary Tract Infection). Approach-Report any changes in bladder status to Nurse: discolored urine .frequent urination .fever. Monitor labs as ordered and report results to physician Activities of Daily Living : Extensive assist of 1 staff for bed mobility, transfers, dressing, eating, toilet use, personal hygiene and bathing. b. Nurses Notes dated 12/10/15 at 6:35 p.m. documented, CNA's (Certified Nursing Assistants) reported resident is urinating more frequently. Resident continued to be agitated. Notified (name) APRN (Assistant Physician Registered Nurse). New orders received for STAT CBC (Complete Blood Count), STAT BMP (Basic Metabolic Panel), and STAT UA (Urinalysis) with C&S (Culture and Sensitivity) if indicated. Notified residents daughter of new orders by phone at 1820 (6:30 p.m.). Residents daughter stated, ' I'm glad these tests are being ordered. My mom was confused and agitated when I visited her earlier today. My mom said there were four people who stayed in her room with her and her roommate last night and she was very upset about it. ' UA collected via in and out catheter .at 1830 (6:30 p.m.). c. Nurses Notes dated 12/11/15 at 1000 and 2235 documented, Awaiting results from U/A, CBC and BMP from 3-11 . 12/10. A Chemistry Laboratory reports dated 12/10/15 documented, Chemistry: BUN (Blood Urea Nitrogen)-40H (high) (normal range 7-18), Glucose-123 H (normal range 74-106). Urinalysis: Color Yellow, Protein: Negative, Glucose: 3+AB (abnormal) (normal range: negative). The report documented the information was faxed on 2/10/15 at 10:20 p.m. and awaiting C&S (Culture and Sensitivity) results. The Hematology Lab report dated 12/10/15 documented: WBC (White Blood Cell Count) H -10.31 (normal range 5.0-10.0), Hemoglobin-10.4 L (low) (normal range 12.0 to 16.0), Hematocrit 34.6 (normal range 37.0-47.0), RBC (Red Blood Cell Count)-3.89 L (normal range 4.0-5.5) d. Nurses Notes dated 12/12/15 at 10:20 a.m. documented, Resident continues with confusion and agitation. Awaiting C&S results from UA. At 1430 Nurses Notes documented, Awaiting C&S from UA. At 9:25 p.m., the Nurses Notes documented, Resident continues with confusion and agitation. Awaiting C&S results from UA. There was no documentation the resident's physician was consulted about the changes in condition demonstrated by the resident's behaviors and that no results were received on UA with C&S. e. Nurses Notes dated 12/13/15 at 9:20 a.m., documented, . No C&S available at this time related to U/A from 12/10 940 (9:40 a.m.) Lab supervisor, sample urine too old for proper C&S processing (tech ' retrained ' ) recollect sample tonight for AM pick up (no req (requisition) required, per lab) As of 2/9/16 there was no documentation to indicate the urine for the UA was collected on 12/13/15 as requested by the lab. f. Nurses Notes dated 12/14/15 at 4:30 p.m., documented, Urine C&S done per clean catch. Urine dark brown .lab called to pick up sample. There was no documentation the resident's physician was consulted about the changes in the resident's urine and the failure to get UA with C&S as ordered on [DATE]. g. The next Nurses Notes was dated 12/15/15 at 1:40 a.m. and documented, Awaiting urine results from the lab. h. Nurses Notes dated 12/15/16 at 9:40 a.m. documented, 02 (oxygen) sats (saturations) 83% on room air. O2 placed at 2L (liters), with no return call from (medical doctor) (paged at 810). Call to (medical doctor) office-nurse to text him to call facility. i. Nurses Notes date 12/15/16 at 1010 (10:10 a.m.) documented, .orders received from (Medical Doctor) for 02 at 2L (Oxygen at 2 liters), send to hospital .eval (evaluate) and treat (lethargy, low 02 sats). Out via ambulance at 1020. Dtr (daughter) to follow. FSBS (Fingerstick Blood Sugar) at 87 at 940 (9:40 a.m.). Reported to DON (Director of Nursing) in person at 1025. At 15:10 (3:10 p.m.) reported to DON that resident admitted for dx ([DIAGNOSES REDACTED]. j. There was no documentation found in the Nurses Notes or in the Telephone Orders that indicated a new urine specimen had been collected after the initial specimen dated 12/10/15 and Urinalysis results had been received by the facility and prior to 12/15/15 when the resident was sent to the hospital and no documentation that any orders for treatment had been received or initiated related to the results of the initial urinalysis. k. The Hospital Admission Records dated 12/15/15 a 2:02 p.m. documented, History of present Illness XXX[AGE] year old female presents from the nursing home with altered mental status. Patient has had intermittent confusion and lethargy over the past week, this has worsened in the past day or 2. Patient was noted to be hypoxic and febrile at arrival. The daughter reports that she has noticed a cough this morning. Difficult to obtain any history from the patient as she is essentially noncommunicative at the current time.Presenting symptoms: disorientation and lethargy .Severity: Severe, Most recent episode: More than 2 days ago .Critical Care was necessary to treat or prevent imminent or life-threatening deterioration of the following condition: cardiac failure, circulatory failure, CNSX (Central Nervous System) failure or compromise, dehydration, metabolic crisis, [MEDICAL CONDITION], [MEDICAL CONDITIONS] and shock .she is febrile 102 at arrival, She is hypoxic in the low 80's, [MEDICAL CONDITION] .placed on 5 L (liters of Oxygen) nasal cannula. Patient appears dehydrated .patient has red urine out of the Foley with urinary tract infection. She does have elevated white blood count renal function. Patient covered with [MEDICATION NAME] and [MEDICATION NAME] after blood cultures were obtained. Cardiology consulted, will admit to ICU for further management. The patients [DIAGNOSES REDACTED].

Complaint # (AR 948), Complaint # (AR 973) and # (AR 974) were substantiated (all or in part) in these findings. Based on observations, record reviews and interviews: The facility failed to ensure staff immediately reported incidents of staff related verbal/mental abuse to appropriate persons, the State Agency, and local law enforcement; to ensure thorough investigations into the incidents; and that residents were protected from further abuse during the investigation for 2 of 2 (Resident #1 and #2) case mix residents. The facility failed to ensure immediate protection was provided after the facility's Board President was notified of allegations of alleged abuse/neglect by the Administrator for 4 of 4 (Residents #2, #3, #16, and #17) case mix residents named in abuse / neglect allegations and the 58 other residents who resided in the facility and with whom the facility Administrator had potential contact. The facility failed to ensure DMS-7734 reports to the state agency were not falsified in documentation of personnel who were completing the reports for 4 of 4 (Residents #2, #3, #16 and #17) case mix residents named in abuse / neglect allegations. The facility failed to ensure immediate notifications were made to local law enforcement agencies for 4 of 4 (Residents #2, #3, #16 and #17) case mix residents named in abuse / neglect allegations. The facility failed to ensure a [MEDICAL CONDITION] of unknown etiology was investigated and reported to the state agency for 1of 1 (Resident #24) case mix residents with a [MEDICAL CONDITION] of unknown etiology. The facility failed to ensure alternate phone numbers of one or more Board Members were posted for employees to report allegations of abuse / neglect when the alleged perpetrator was the facility Administrator. The failed practices resulted in a pattern of actual harm for Residents #1 who made verbal and written allegations of abuse to Licensed Practical Nurse (LPN) #3 on 1/17/16 and Resident #2 who made allegations of physical and mental abuse to LPN #1 approximately 1.5 -2 months prior to the survey dates. The failed practice also had the potential to cause more than minimal harm for 16 alert and oriented residents in the facility as documented on a listing provided by the Interim Administrator on 2/17/16 at 1:06 p.m. The findings are: 1. Resident #1 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 1/18/16 documented the resident scored 9 (8 - 12 indicates moderately impaired) on a Brief Interview for Mental Status (BIMS). a. On 2/1/16 at 2:00 p.m., The MDS Coordinator provided written witness statements submitted by Licensed Practical Nurse #3 dated 1/17/16 and signed by the resident and the resident's daughter. The statements documented, (resident) stated, 'Ms. Red (resident's nickname for Administrator) came in without knocking or introducing herself, started pointing (at) my belongings and yelled they have to come down, it's a fire hazard. Ms. Red said 'Let me tell you this!' and (Resident #1) said, 'No, let me tell you . I will just leave' and Ms. Red said, 'Oh no, I will find you a place to go!' . (Resident #1) told me 'Ms. Red came into my room (and) threw the mattress on the floor. She (Administrator) came back (and) told aide to pick the mattress up and make the bed correctly.' (Resident #1) stated, 'I started to get scared.' A written Incident Investigation OLTC (Office of Long Term Care) Witness Statement dated 2/3/16 at 9:00 am (collected by facility for abuse investigations) and signed by the Medical Records Nurse documented, It was reported to me by (Licensed Practical Nurse-(LPN) #3) that (Resident #1 ' s) daughter stated to her that (Administrator) had a screaming episode in her mother's room and threw the mattress off the bed into the floor. When ask if she would like to write a grievance she quickly told the nurse no she feared retaliation from (Administrator) but she was going to report it to state b. On 2/2/16 at 12:20 p.m., Resident #1's daughter was asked if she had ever witnessed the Administrator hollering and yelling in front of any residents. The resident's daughter stated she had not, but (daughter's) mom has and told her (resident's daughter). Then the resident stated, About a month ago, (Certified Nursing Assistant (CNA) #7) didn't make bed up right and (the) Administrator came into my room and threw mattress on floor, hollered at (CNA #7) and made her remake the bed. (Administrator said) 'you need to make this bed and make it right.' (The Administrator) busted into my room, came in, didn't knock, had a (female housekeeping employee, unnamed) with her, looked at my TV (television) area, (and) said real loud, 'that stuff has got to come off the top of the closets.' I told her (Administrator) I guess I would have to leave, she hurt my feelings, she (Administrator) then told me that she would be happy to find somewhere for me to move to. I told her wouldn't move anywhere that she would recommend to me . I hear her calling names and hollering down the halls. I call her 'Red,' because she has a terrible temper. She does not seem able to control it . I fretted for several days where I would have to move to. The resident was asked how (above information) made her feel. The resident stated, was scared. c. On 2/3/16 at 11:45 a.m., the resident was questioned to see if she remembered LPN #3 asking her about the 2 situations (documented above) and she stated, yes. She was questioned if the signature on both of the witness statements was her signature and she stated, yes, both mine and my daughter's. When questioned if she had stated she was afraid to LPN #3 she stated, Oh yes, I was so happy that someone was even asking me about it. But it didn't stop. Red (the Administrator), she has a violent temper and I don't know if she is going to get more angry or what she is going to do next! When questioned if she was worried about anything or had any concerns, the resident became very tearful and said that she was still afraid of the Administrator and she had been frightened and said she layed and fretted about everything for several days. The resident stated she was still afraid, scared and, I have told my daughter I wish I could leave here. The resident had tear-brimmed eyes during the entire interview. d. On 2/4/16 at approximately 10:00 a.m., the State Agency was contacted to check the database to see if there were any reports/investigation of allegations of abuse for Resident #1 from October 1, 2015 to February 1, 2016. Surveyor was told there were no Incidents reported. 2. Resident # 2 had [DIAGNOSES REDACTED]. The Admission Minimum Data Set with an Assessment Reference Date of 1/8/16 documented the resident scored 15 (13-15 indicates cognitively intact) on the Brief Interview for Mental Status, required total assistance of 2 plus person for all Activities of Daily Living (ADLs) except eating, was frequently incontinent of bladder and always continent of bowel. a. The Plan of Care dated 1/12/16 documented a problem, ADL self-care deficit, with an approach, . Resident prefers to lay in the bed naked with a sheet over her vs (versus) a gown .resident complains of back pain and left hip pain. b. On 2/1/16 at 4:05 p.m., the resident was asked, Has anyone ever yelled at you. The resident stated, Yes ma'am this morning, just rude, rude. I told her (indicating the Administrator) about my roommate keeping me awake all night and wanted someone more compatible with me. She came in and told me I had to get up and get a shower I was tired, but she doesn't listen to anything. It has to be her way. She acts like I have no rights. I've never saw anything like this. She was asked; Has she yelled at you? She stated; Yes. The resident was asked, Has she ever threatened you. She stated, Yes, she is just rude and mean, ugly doesn't listen. Everyone here has been nice, the best place I've ever been except for her. It has been a nightmare, it's terrible just terrible because of her rudeness. c. An individual resident interview was conducted on 2/8/16 at 12:00 p.m. and 2/10/16 at 10:00 a.m. The resident made the following comments: On 2/8/16 at 12:00 p.m., the resident was asked during the staff section of the resident interview, Tell me how you feel about the staff members at this facility and if they treat you with respect. The resident stated that yes she was treated with respect and there is only one person that I've had plenty of trouble out of and that is the Director (Administrator). When asked if staff members listened to her requests and responded appropriately, the resident further stated, (name of Administrator) makes me sit up for hours, it was torture, pure torture. I kept trying to tell her (but) she wouldn't listen. She's the only one that's been rude and cruel to me. The resident stated, She (Administrator) made sure that I knew I didn't have any rights. It's been like I've been in prison but in the last week to week and a half it has changed. On 2/10/16 at 10 a.m., the resident was asked, What is an example of not having a choice in what you want to do? The resident stated, When I was up in the chair and could not get off my behind. I would be crying and telling her (Administrator) I couldn't sit up for any length of time and she would tell me I had to sit there that she would make sure I sat there. The resident was asked, How did that make you feel? The resident stated, Like I was lower than a dog. The staff was upset with her making me do this but they had to do what she told them to do. d. On 2/4/16 at 12:10 p.m., LPN #1 reported to this surveyor the following: LPN #1 stated, This happened on (Resident # 2's name). (Administrator's name) had them get her up for meals, she was crying saying I haven't been up in 5 years my bottom can't take this. She had been up 1 1/2 to 2 hours and I went to (name of Administrator) to see if I could get her laid back down and she wouldn't let us lay her down. LPN # 1 was asked, Why did you go to her to get the resident laid down? The LPN stated, Because she (the resident) was Adult Protective Services we had to go through her (Administrator) for anything we did to the resident. She was probably up another 45 minutes to an hour before she was laid down. The LPN was asked, How many times has this happened? The LPN stated, Too many to count. The LPN further stated, .one time she wanted seconds on her tray and (name of Administrator) said no. e. On 2/4/16 at approximately 10:00 a.m., the State Agency was contacted to check the database to see if there were any reports/investigation of allegations of abuse for Resident #2 from October 1, 2015 to February 1, 2016. Surveyor was told there were no Incidents reported. 3. Resident #24 had [DIAGNOSES REDACTED]. a. A Nurses Note dated 12/25/15 shift at 1:50 a.m. documented, Res (Resident) up in wheelchair in hallway. Resident c/o (complain of) pain in left groin area. This LPN assessed area, redness noted. Cream applied and PRN (as needed) pain medication given . b. A Nurses Note dated 12/26/15 shift 1 documented, Complains of having pain in her left groin . A Nurses Note dated 12/26/15 shift 2 documented, c/o pain in her left groin . c. A Nurses Note dated 12/28/15 shift 1 documented, c/o Left (L) hip .and 1330 (1:30 p.m.) . Resident has c/o L hip pain at this time . d. Nurses Notes dated 12/30/15 at 1:30 p.m., documented, Resident has c/o L hip pain at this time . A Nurses Note dated 12/30/15 shift 2 at 5:58 p.m. documented, .Resident states she has pain in her left groin area. [MEDICATION NAME] PRN given and biofreeze . c/o Left hip. e. A Nurses Note dated 12/31/15 shift 1 at 10:15 a.m. documented, . Resident c/o L hip pain, prn biofreeze applied per order. noted to have slight swelling to L hip area and under thigh APRN (Advanced Practice Registered Nurse) notified .STAT x-ray . A Nurses Note dated 12/31/15 shift 1 at 1300 documented, .APRN called with xray results . Send to ER (emergency room ). An onsite imaging solution report dated 12/31/15 documented, . Impression: Left subcapital femoral neck fracture . f. An Operative Notes report dated 1/1/2016 documented, Pre-operative Diagnosis: [REDACTED]. g. There was no documentation that this injury was reported to the Administrator, no documentation to indicate an investigation was initiated and no documentation of any protective measures that were put in place at this time. On 2/10/16 at 6:00 p.m., the Assistant Director of Nursing (ADON) was asked if any incidents involving Resident #24 had been reported. She stated, Not to my knowledge; I don't know anything about it. The Director of Nursing (DON) was shown the Nurses' Note dated 12/25/15 -12/31/15 and was asked, If a resident has an injury of unknown origin , should an investigation and reportable be completed? The DON stated, Yes, there should have been an investigation done. 4. On 2/1/16 at approximately 9:05 a.m., the facility's Board President was notified by state agency personnel in a phone call of multiple allegations of abuse / neglect. The survey team entered the facility on 2/1/16 at 10:15 a.m. and the Administrator was not supervised or prevented from going throughout the facility between 10:15 a.m. and approximately 2:10 p.m., when facility Board Members met with the Administrator in her office. On 2/1/16 at 3:22 p.m., the facility's Administrator was informed of all allegations of abuse / neglect and informed that she could not be around residents during the investigations. The Administrator stayed in her office during work hours with direct supervision of different assigned staff members until 2/3/16 at 4:10 p.m., when the facility's Board Vice President escorted her out of the building until further notice. 5. The DMS (Department of Medical Services)-7734 OLTC Incident and Accident Reports dated 2/1/16 documented Residents #2, #3, #16, and #17 were named in allegations against the facility's Administrator. Those reports were faxed to the state agency on 2/2/16 and documented in the space for, Staff reporting I & A (Incident and Accident): (printed name of Business Office Manager (BOM)). On 2/12/16 at 2:30 p.m., the BOM faxed a written statement dated 2/11/16 at 9:10 a.m. that documented, I did not take any part in investigating or completing a form 7734 on the alleged allegations of abuse against (Administrator) on 2/1/16. On 2/2/16 at approximately 9:00 a.m., a law enforcement officer was in the Administrator's office. On 2/2/16 at 10:40 a.m., the Administrator was asked why the police officer was in the building. The Administrator stated, I called this morning about reports (DMS-7734's) from yesterday (2/1/16). 6. On 2/1/16 at 3:30 p.m., the Administrator was asked if any board members phone numbers were posted in the facility for reports allegations of abuse. The Administrator stated, No. 7. On 2/3/16 at 2:55 p.m., the facility's Board Vice President and Director of Nursing (DON) informed the surveyor that the Vice President's cell phone number had been posted in the facility for notification purposes. That was the first date the employees had access to the Board for immediate notifications of alleged abuse if the facility Administrator was the alleged perpetrator.

Complaints # (AR 948), # (AR 973), # (AR 974) and # (AR 978) were substantiated (all or in part) with these findings: Based on observation, record review and interview, the facility failed to ensure residents were treated with dignity in a manner that enhanced respect, as evidenced by failure of the Administrator to communicate with the resident without yelling or using foul language causing feelings of worthlessness and failure to honor a resident's request to be assisted back to bed after sitting in the chair which was causing the resident pain for 1 (Resident #2) of 8 (Residents #1, #2, #5 through #10) case mix residents who were alert, oriented and required total staff assistance for transfer. This failed practice resulted in a pattern of actual harm for Resident #2 who stated that she felt that she was in a prison and had the potential cause more than minimal harm for 6 residents who were dependent on staff for assistance with transfers according to a list provided by the Interim Administrator on 2/12/16 at 2:30 p.m. and 32 residents who ambulated independently throughout the facility and attended activities (in the day room approximately 10-2 feet from the Nurse ' s Station) as documented on a list provided by the Interim Administrator on 2/4/16 at 9:06 a.m. The findings are: 1. Resident # 2 had [DIAGNOSES REDACTED]. The Admission Minimum Data Set with an Assessment Reference Date of 1/8/16 documented the resident scored 15 (13-15 indicates cognitively intact) on the Brief Interview for Mental Status, required total assistance of 2 plus person for all Activities of Daily Living (ADLs), was frequently incontinent of bladder and always continent of bowel. a. The Plan of Care dated 1/12/16 documented, Activities of Daily Living (ADL) Self- Care Deficit . Resident prefers to lay in the bed naked with a sheet over her vs a gown .resident complains of back pain and left hip pain. b. On 2/1/16 at 4:05 p.m., the resident was asked, Has anyone ever yelled at you. The resident stated, Yes mam this morning, just rude, rude. I told her (indicating the Administrator) about my roommate keeping me awake all night and wanted someone more compatible with me. She came in and told me I had to get up and get a shower I was tired, but she doesn't listen to anything. It has to be her way. She acts like I have no rights. I've never saw anything like this. The resident was asked, Has she ever threatened you. She stated, Yes, she is just rude and mean, ugly doesn't listen. Everyone here has been nice, the best place I've ever been except for her. It has been a nightmare, it's terrible just terrible because of her rudeness. c. On 2/8/16 and 2/10/16 during an individual resident interview the resident made the following comments: 1.) On 2/8/16 at 12:00 p.m., resident was asked how she felt about the staff members at this facility and if they treated her with respect. The resident stated that yes she was treated with respect and there is only one person that I've had plenty of trouble out of and that is the Director (Administrator). The resident further stated, (name of Administrator) make me sit up for hours, it is was pure torture, pure torture. I kept trying to tell her but she wouldn't listen. The resident was asked, Do you feel the staff members listen to your requests and respond appropriately? The resident stated, No, I haven't had a choice about anything. The resident was asked, Can you choose how to spend the day? The resident stated, No, but I have been able to this last week or week and a half since you all have been here. The resident stated, She (Administrator) made sure that I knew I didn't have any rights. It's been like I've been in prison but in the last week to week and a half it has changed. 2.) On 2/10/16 at 10:00 a.m., the resident was asked, What is an example of not having a choice in what you want to do? The resident stated, When I was up in the chair and could not get off my behind. I would be crying and telling her I couldn't sit up for any length of time and she would tell me I had to sit there that she would make sure I sat there. The resident was asked, How did that make you feel? The resident stated, Like I was lower than a dog. The staff was upset with her making me do this but they had to do what she told them to do. d. On 2/4/16 at 11:35 a.m., Licensed Practical Nurse (LPN) #1 came to this surveyor and made the following statements: When they moved (name of non case mix resident) in with (Resident # 2), I went to (Administrator) and told her that (Resident #2) wasn't getting any rest and (Administrator) said that if she wanted a private room she would have to pay for it. When (name of resident) first got here she was perky in the mornings now she's sleepy and groggy all the time stating she's not getting any rest. At 12:10 p.m., LPN #1 stated, .(Administrator's name) had them get her up for meals, she was crying saying I haven't been up in 5 years my bottom can't take this. She had been up 1 1/2 to 2 hours and I went to (name of Administrator) to see if I could get her laid back down and she wouldn't let us lay her down. LPN # 1 was asked, Why did you go to her to get the resident laid down? The LPN stated, Because she (the resident) was Adult Protective Services we had to go through her (Administrator) for anything we did to the resident. She was probably up another 45 minutes to an hour before she was laid down. The LPN was asked, How many times has this happened? The LPN stated, Too many to count. The LPN further stated, .one time she wanted seconds on her tray and (name of Administrator) said no. 2. During the survey process, multiple interviews were conducted and the following written statements were obtained from staff members who were employed at the time of the prior Administrator: a. On 2/2/16 at 9:55 a.m., the Medical Records Nurse documented, the (Administrator) has a very short temper she yells and cusses at .residents . b. A written statement dated 2/2/16 at 11:50 a.m. and signed by the Housekeeping/Laundry Supervisor documented, I have heard (Administrator) yelling in front of residents, cursing in front of her staff. It can happen at anytime. Telling residents they can't do something. A written statement dated 2/3/16 at 7:56 a.m. and signed by the Housekeeping/Laundry Supervisor documented, (Administrator) yelling at (Resident #1) about labels being put in her clothes. (Resident #1) stated she didn't want them in her clothes, (Administrator) stated if you don't like how things are going here then we can find you another place. (Administrator) if she gets upset at something-at the nurses station- loud voice, waving hands, 'hell' has been said, residents are around. c. On 2/2/16 at 12:03 p.m., the Assistant Director of Nursing stated, (Administrator) yelled at (a resident) last week, told resident he had to get cleaned up . ' I won't have people smelling like Piss ' The resident was standing by the Nurses desk. d. On 2/3/15 at 11:34 a.m., Licensed Practical Nurse #4 stated, Heard her (Administrator) scream at UPS (United Postal Service) man with residents around. e. On 2/3/16 at 12:26 p.m., via phone interview, the Advance Practice Registered Nurse #1 stated, (Administrator) said the (a foul word) . I heard it out by the Nurses Station .she cusses at nurses station and it's hard to take, very gruff. f. On 2/5/16 at 8:50 a.m., the former Treatment Nurse #1 stated, (Administrator) yelled and cussed around the nurses station all the time. The Former Treatment Nurse #1 was asked if the Administrator yelled or cussed with residents around and the Nurse stated, Yes.

Complaint # was substantiated all or in part with this deficiency. Based on record review and interview, the facility failed to ensure causative factors of falls were thoroughly assessed to ensure appropriate interventions to prevent the recurrence of falls were developed and implemented for 1 (Resident #7) of 4 (Resident #2, 3, 5, and 7) case mix residents who had falls. The failed practice resulted in a pattern of actual harm for Resident #7 who fell and fractured the right hip on 6/22/12 and had the potential to cause more than minimal harm for 22 residents who had falls according to the Roster Sample Matrix provided by the Medicare Coordinator on 7/9/12. The facility failed to ensure interventions to address the recurrence of falls were planned or implemented for 4 (Resident #1, 2, 3, and 5) of 5 (Resident #1, 2, 3, 5, and 7) case mix residents who had falls according to the Roster Sample Matrix, and 2 (Resident #2 and 8) of 4 (Resident #s 2, 4, 5, and 8) case mix residents who were care planned to have clip alarms. These failed practices had the potential to affect 22 residents who had falls according to the Roster Sample Matrix provided by the Administrator on 7/10/12 and 15 residents who were care planned to have clip alarms according to the lists provided by the Assistant Director of Nursing on 7/11/12. The findings are: 1. The Policy and Procedure for Fall Evaluation and Monitoring provided by the Administrator on 7/12/12 documented, "All Elders will be assessed for the potential of a falls on admission, quarterly, significant change of condition or after actual fall. If the fall risk assessment documents high risk, Elder will be placed on monitoring program until such time as documentation changes to reflect low or moderate risk. After a fall, Elder will be placed on monitoring program until such time as IDT (Interdisciplinary Team) determines resident is no longer at risk. Elder on fall monitoring program will be identified by a falling star symbol on the outside of room. Interventions will be reflected on care plan." 2. Resident #7 had [DIAGNOSES REDACTED]. The Care Area Assessment (CAA) Summary Information Sheet dated 2/13/12 documented, "Triggered Area: Falls. Description of problem with contributing causes and risk factors: (Resident #7) is at risk for falls due to unsteady gait related to multiple mind altering drugs. Care Plan Consideration: Proceed. Interventions: 1. Nurse to monitor effects of medication. 2. Staff to make (sure) alarms are on & (and) working properly. 3. Staff to make sure all items of need are within reach. Observe & report problems." The Quarterly Minimum Data Set (MDS) Assessment with an Assessment Reference Date (ARD) of 5/13/12 documented the resident scored 9 (8-12 indicates moderately impaired) on the Brief Interview for Mental Status (BIMS); had verbal behaviors directed toward others 1-3 days out of 7; required extensive assistance of one person to transfer, did not walk in the room or corridor, was totally dependent on one staff member for locomotion, was not steady and only able to stabilize with human assistance for moving from seated to standing, moving on and off the toilet, and surface to surface transfers; and had fallen two or more times since the prior assessment with no injury. a. The Plan of Care dated 2/13/12 documented, "Problem #1: Risk for Recurrent Falls R/T (Related to); Unsteadiness when on her feet. AEB (As Evidenced By): Extensive help needed w/(with) transferring, fell in the past 30-180 days and use of Psychotropic medications. Interventions: Provide resident with adequate assist needed with transferring through out the day, report and record difficulties prn (as needed). Assess, record and report fall risk factors prn and at least qrtly (quarterly). Encourage AROM (active range of motion) exercises as much as possible, even while lying in bed. Assist to wear proper fitting shoes that are supportive with non-slip soles. Report and record prn. Assist resident with navigation by designated w/c (wheelchair) as needed when out of bed. Monitor Piremeter safety alarm while in bed and attach Safety belt while in w/c when resident out of bed, monitor, report and record effects prn." The last intervention beginning with "Monitor Piremeter safety alarm ... " had line drawn through the entry diagonally with a hand written " D/C (discontinue) 5/8/12." A hand written entry dated 5/16/12 documented, "Observe placement of overbed Piremeter motion alarm. Turn on while in bed. Monitor, report prn." b. The Incident/Accident Report dated 5/6/12 at 3:45 a.m. documented, "Resident condition before incident/accident: Sedated: Oxycodone 10 mg (milligrams) 0120 (1:20 a.m.). Was a restraint in use? Yes - PIR (Piremeter Alarm). Describe exactly what happened: CNA (Certified Nursing Assistant) find R (resident) on floor, gets me @ (at) 0345 (3:45 a.m.) find R laying parallel to bed on butt, leg in front of her. R arm on bed, said slid out of bed ... Additional comments and/or steps taken to prevent recurrence: R encouraged to call for help when needed & not to tamper (with) alarms." 1) The Fall Risk assessment dated [DATE] documented a total score of 12 (Total score of 10 or above represents high risk). On 7/11/12 at 11:50 a.m., Assistant Director of Nursing (ADON) was asked, "The incident dated 5/6/12 documented as the intervention that the resident was encouraged to call for help when needed and not to tamper with the alarm. What did the facility do to prevent tampering with the alarm?" The ADON shook her head and stated, "Nothing." c. The Incident/Accident Report dated 5/14/12 at 11:50 p.m. documented, "Resident condition before incident/accident: Normal. Confused. Was a restraint in use? No. Describe exactly what happened: CNA finds R in floor sitting, legs in front of her. ROM (Range of Motion) ok. Sm (small) ? " (inch) s/t (skin tear) on L (left) back/shld (shoulder). R says hit head. Possible bump on back of head... Additional comments and/or steps taken to prevent recurrence: R encouraged not to get up by self to call for help if wanting to get up." The Fall Risk assessment dated [DATE] documented a total score of 12 (Total score of 10 or above represents high risk). d. The Incident/Accident Report dated 5/15/12 at 6:15 a.m. documented, "Resident's condition before incident/accident: Normal. Confused. Describe exactly what happened: R found sitting on floor (with) back to bed legs in front of other sitting position... Additional comments and/or steps taken to prevent recurrence: Encourage R to use CL (call light) & get help (with) transfers or going to bathroom." 1) The Fall Risk assessment dated [DATE] documented a total score of 12 (Total score of 10 or above represents high risk). 2) The Nurse's Notes dated 5/15/12 at 6:15 a.m. documented the Advanced Practice Nurse (APN) was notified of the resident's confusion and falls and a Urinalysis was ordered. e. The Incident/Accident Report dated 5/15/12 at 3:50 p.m. documented, "Resident's condition before incident/accident: Confused. Were bed rails ordered? No. Were bed rails present? No. Was height of bed adjustable? No. Was a restraint in use? No. Describe exactly what happened: While this nurse & off going nurse was making rounds, R found sitting on bottom (with) legs crossed out in front of her. R stated, 'I was talking on the floor.' ... Additional comments and/or steps taken to prevent recurrence: R put into her bed & reminded to use call light when assistance is needed & not to get up (without) assis. (assistance)." 1) The Fall Risk assessment dated [DATE] documented a total score of 16 (Total score of 10 or above represents high risk). 2) On 7/11/12 at 11:50 a.m., the ADON was asked, "The intervention for the incidents dated 5/14/12 and the two dated 5/15/12 was to encourage or remind the resident to call and not to get up. That is the intervention?" The ADON stated, "Yes." The ADON was asked, "How was that working?" The ADON stated, "Not too well." f. The Nurse's Notes dated 5/18/12 documented the resident was started on Cipro 500 mg PO (by mouth) BID (twice a day) X (times) 3 days. g. The Physician's Progress Notes dated 5/20/12 documented, "...She had a fall with no apparent injuries. She has had episodes of lethargy and hallucination... Patient transfers from bed to wheelchair but is a high risk for falls. She can self propel in the wheelchair. She has to be fed. She is currently on Cipro for a UTI (Urinary Tract Infection)..." h. The Incident/Accident Report dated 6/8/12 at 12:05 a.m. documented, "Resident's condition before incident/accident: Sedated (Drug : Oxy (Oxycodone) Dose: ii (2) Time: 2300 (11:00 p.m.)) Describe exactly what happened: Heard crash of plate hitting floor, went into room & found R sitting in floor in front of w/c. R states she had been to B/R (bathroom) & was trying to get to bed... Additional comments and/or steps taken to prevent recurrence: (blank). " 1) The Nurse's Note dated 6/8/12 at 12:05 a.m. documented, "This nurse heard plate hit floor & went into room to investigate. Found R sitting in floor, plate next to her... Slight confusion noted earlier this shift (with) confusion noted @ this X (time)... R reminded to use C/L." 2) The Fall Risk assessment dated [DATE] documented a total score of 16 (Total score of 10 or above represents high risk). i. The Incident/Accident Report dated 6/9/12 at 9:00 p.m. documented, "Resident's condition before incident/accident: Confused. Describe exactly what happened: Called to rm (room) per CNA. Found R sitting on floor next to bed. R states she was reaching for her H2O (water) & slipped out of bed. States hit on knee & hip L (left). No apparent injury... Additional comments and/or steps taken to prevent recurrence: bedside table to be kept next to bed. R reminded to not reach for items. R reminded to use O2 (oxygen)." 1) The Fall Risk assessment dated [DATE] documented a total score of 16 (Total score of 10 or above represents high risk). 2) On 7/11/12 at 11:50 a.m., the Interim Director of Nursing (IDON), Assistant Director of Nursing (ADON) and Medicare Coordinator were interviewed. The ADON was asked, "The incident on 6/9/12 documented that the resident slid out of bed. The incident on 5/6/12 also documented the resident slid out of bed. What was done to prevent slipping out of bed." The Medicare Coordinator stated, "All our beds have Geomattresses. Regular mattresses. I don't know if we have any other kind." The ADON was asked, "No special mattress to decrease the potential for slipping was used on the resident?" The ADON stated, "No." The ADON was asked, "What kind of bed?" The ADON stated, "A standard bed." The ADON was asked, "No low bed?" The ADON stated, "No." The ADON was asked, "Is reminding or encouraging an effective intervention for a confused resident?" The ADON stated, "No." The ADON was asked, "Was (Resident #7) care plan updated with any new interventions to prevent the recurrence of falls?" The ADON stated, "No." j. The Incident/Accident Report dated 6/16/12 at 12:35 a.m. documented, "Resident's condition before incident/accident: (blank). Were bed rails ordered? No. Were bed rails present? No. Was height of bed adjustable? No. Describe exactly what happened: Elder fell & landed on buttock also struck occipital area on door leading to hallway causing 3 cm (centimeter) x 2 cm hematoma. Pressure failed to stop bleeding. Orders received to send to (hospital) for eval. (evaluation) & tx (treatment)... Additional comments and/or steps to prevent recurrence: PIR (Piremeter Alarm) on & functioning..." 1) The Fall Risk assessment dated [DATE] documented a total score of 16 (Total score of 10 or above represents high risk). 2) The Nurse's Note dated 6/16/12 at 13:30 documented, "Resident returned to facility @ 1300 (1:00 p.m.)... Reported R has six staples to back (occipital) of head (with) moderate drainage to site as well as localized swelling... verbalized understanding in using call light system and/or requesting for help in transfers to prevent injury or falls..." k. The Incident/Accident Report dated 6/22/12 at 10:50 a.m. documented, "Resident's condition before incident/accident: Confused. Describe exactly what happened: Resident attempted to walk from w/c to BR (bathroom) (without) assist and fell to right side in front of w/c in doorway of R room. R able to express what happened but not why... Additional comments and/or steps taken to prevent recurrence: Sent to (Hospital) for further eval (evaluation) per R (increased) pain + swelling to R hip/leg." 1) The Fall Risk assessment dated [DATE] documented a total score of 16 (Total score of 10 or above represents high risk). 2) The Physician's Progress Note dated 6/22/12 documented, "...Patient had a fall on 6/16/12. She fell on her way to the bathroom and sustained a laceration to the back of her head. She also has a skin tear in her right hand. She was sent to the ER (emergency room ). She received six staples and was sent back to the nursing home. She has had two other falls over the last month. She is able to answer simple questions. She does not want to ask for help. She just goes to the bathroom on her own. She also complains of low back pain. I tried to remind her again that it is important to ask for help. She is quite forgetful and confused... After I finished my rounds, she went to the bathroom and had a fall. She injured her right hip and she had to be sent to (hospital) ER for possible fracture..." 3) The Hospital History and Physical dated 6/22/12 documented, "Patient is a 59 y.o. (year old) female presents with fall in the NH (Nursing Home) and right hp pain, severe (+) (positive) Right hip Fracture, Acute... Right hip xray. Impression: Comminuted intertrochanteric right femur fracture..." l. The Nurse's Notes dated 6/27/12 at 3:40 p.m. documented the resident returned to the facility. The Nurses Notes dated 6/28/12 at 1:30 p.m. documented the resident was returned to the hospital due to the oxygen saturation level remaining at 86% on oxygen at 10 liters per minute. The resident was in the hospital at the time of the survey. m. On 7/11/12 at 11:50 a.m., the Interim Director of Nursing (IDON), Assistant Director of Nursing (ADON) and Medicare Coordinator were asked, "Were any witness statements taken from the people who found the resident on the floor?" The ADON stated, "I'm not sure... it could be in the nurses notes." The clinical record for Resident #7 was reviewed, with no statements in the clinical record. The Medicare Coordinator stated, "If it's not in the chart, most likely not." 3. Resident #1 had [DIAGNOSES REDACTED]. The Admission MDS with an ARD of 6/27/12 documented the resident scored 9 (8-12 indicates moderately impaired) on the BIMS, had limited range of motion of one upper extremity, was continent of bowel and bladder, and had one fall since admission with no injury, and two falls since admission with injury (not major). a. The Fall Risk Evaluation dated 6/22/12 documented a total score of 15. The legend on the form documented, "Total score of 10 or more represents high risk." b. The Plan of Care dated 6/22/12 documented, "Problem #2. Potential for Falls, resulting in Fractures R/T (Related to); Osteoarthritis. AEB (As Evidenced By); Unsteady at times, stabilizes without help, and recent fracture of Left shoulder (Rotator Cuff). Interventions: Administer Oscal w (with)/Vit (Vitamin)-D as prescribed, record, report persistent refusal. Encourage Elder to use rolling walker with seat built in throughout the day, report significant changes in gait and balance promptly. Evaluate and Record risk factors for falling prn. Monitor effects of Psychotropic medications closely, report adverse reactions prn." The care plan contained no documentation that the resident had any falls and did not contain any new interventions to prevent the recurrence of falls. c. The Incident/Accident Report dated 6/26/12 at 7:05 p.m. documented, "Resident's condition before incident/accident: Confused. Disoriented. Describe exactly what happened: R (Resident) standing next to nurses station (with) walker. This nurse heard a loud commotion, looked up & R noted to be sitting on bottom (with) shoulders/head up against wall under fish tank. Noted to have quarter sized knot to top of head. Level of Consciousness: Confused. Disoriented. Additional comments and/or steps taken to prevent recurrence: R instructed to be more careful & watch her footing when walking/turning around. R put in w/c @ this time to monitor due to head injury." d. The physician's orders [REDACTED]. Sling to L (left) arm as tolerated. 2. Clip alarm on w/c (wheelchair)." e. The Incident/Accident Report dated 6/27/12 at 3:45 p.m. documented, "Resident's condition before incident/accident: Confused. Describe exactly what happened: R noted to be sitting on bottom (with) back against w/c & legs stretched out in front of her pointing toward closet. R said she was trying to get to her belongings in drawers & next thing she knew she was on the floor. Level of Consciousness: Confused. Additional comments and/or steps taken to prevent recurrence: R instructed to ask for help or push call button when things are out of her reach. Call light placed in R hand." The Incident/Accident Report dated 6/27/12 at 9:45 p.m. documented, "Resident's condition before incident/accident: Confused. Disoriented. Describe exactly what happened: This nurse heard a door slam. I looked up from med cart & saw door closed, also heard someone screaming 'help', this nurse entered R's room ... found R (with) head leaning against corner btwn (between) door & wall. R stood up & noted to have tennis ball sized knot to left top of head (with) purple discoloration. Level of Consciousness: Confused. Disoriented. Additional comments and/or steps taken to prevent recurrence: R reminded not to get up (without) assistance & staff encouraged to keep a closer eye on R." The report documented that the Advanced Practice Nurse (APN) was notified of the fall. On 7/11/12 at 3:55 p.m., Licensed Practical Nurse (LPN) #1 was asked, "Do you remember the night of 6/27/12?" LPN #1 stated, "Yes. The first fall she was found on the floor. The drawers were open. I informed her to lock the wheels of the wheelchair." LPN #1 was asked, "Was this care planned?" LPN #1 stated, "No." LPN #1 stated, "The next incident, I was doing med pass and heard a door slam and calling for help. I had to go through (the next room) bathroom to get in. She had a large knot on her head." LPN #1 was asked, "Was an alarm sounding?" LPN #1 stated, "I don't believe she had an alarm." f. On 7/11/12 at 12:40 p.m., the Restorative Nurse was asked, "When you document that staff are encouraged to keep a closer eye on the resident, what does that mean?" The Restorative Nurse stated, "To check more frequently." The Restorative Nurse was asked, "How frequent?" The Restorative Nurse stated, "They check every 2 hours." The Restorative Nurse was asked, "Is this care planned? Are staff made aware?" The Restorative nurse stated, "No." g. The Nurse's Notes dated 6/28/12 at 3:00 p.m. documented, "Res (Resident) up in w/c in MDR (Main Dining Room) @ start of shift. Daughter @ facility @ approx 0730 (7:30 a.m.) to take res out on pass 'for a while' ..." The Nurse's Notes documented the resident was taken to the hospital by the family and was discharged to another facility. 4. Resident #5 had [DIAGNOSES REDACTED]. The Quarterly MDS with an ARD of 6/3/12 documented the resident scored 8 (8-12 indicates moderately impaired) on the BIMS, did not ambulate in the last 7 days, was mobile by wheelchair and had on fall will injury and 2 falls without injury since admission or last assessment. a. The Plan of Care documented a problem dated 12/7/11 of "Risk for falls, R/T; history of falls, and use of one or more psychotropic medications AB; balance unsteady only able to stabilize with help ... Interventions Remind resident of the importance of having help with transferring through out the day, monitor, report and record effects (attempt to get up alone) prn..." b. The Incident/Accident Report dated 5/2/12 documented the resident fell as he came out of the bathroom. The Additional comments and/or steps taken to prevent recurrence documented, "Reminded resident to lock w/c when transfer to bathroom and ask for assistance." c. The Incident/Accident Report dated 5/3/12 documented the resident fell as he was attempting to go to the bathroom. Additional comments and/or steps taken to prevent recurrence documented, "Resident reminded to use w/c when needing to go places and to ask for assistance." d. The Incident/Accident Report dated 5/11/12 documented the resident fell as he was walking to the bathroom while using a walking cane. Additional comments and/or steps taken to prevent recurrence documented, "Instructed CNAs to check and offer to toilet frequently. Cane removed from room." e. The Quarterly Review Assessment notes dated 6/4/12 documented, "Has memory loss and confusion secondary to [DIAGNOSES REDACTED]. Staff assists with decision making prn throughout the day. Requires limited to extensive assist of 1 staff member for most ADLs (activities of daily living) and transfers. Non-skid strips at bedside for safety." f. The Incident/Accident Report dated 6/17/12 documented the resident fell while walking from his wheelchair to his night stand. Additional comments and/or steps taken to prevent recurrence documented, "Reminded resident not to walk around by himself, call for assistance." There was no documentation of any new interventions. The Fall Risk assessment dated [DATE] documented a total score of 14 (Total score of 10 or above represents high risk). g. On 7/11/12 at 12:33 p.m., the ADON was asked if the facility should have implemented any other interventions to prevent falls. She stated, "We should have had some type of safety monitoring, alarms." The ADON was asked if an alarm should have been put in use. She stated, "Yes." 5. Resident #2 had [DIAGNOSES REDACTED]. The Admission MDS with an ARD of 4/17/12 documented the resident scored 15 (13 - 15 indicates cognitively intact) on the BIMS, required limited assistance with some areas of ADLs, was continent of bladder and bowel and a history of a month to 6 months prior to admission. a. The Care Plan documented a problem dated 4/17/12 of "Potential for falls resulting in fractures R/T; osteoarthritis, and chronic back pain. AEB; not steady, only able to stabilize with assistance, limited assistance provided with transferring and walking... Interventions...Provide reminders that assist is needed with transfers prn throughout the day, report significant changes in gait and balance promptly. Record risk factors for falling prn... Attach clip-on alarm to clothing and w/c when out of bed, monitor, record effect." b. The Incident/Accident Report dated 6/28/12 at 12:20 a.m. documented, "...resident called out for help to room ... found resident on floor lying on left side in front of red table, c/o (complains of) pain rt shoulder... call... ambulance..." The section for "Was person involved taken to hospital?" was checked yes. The section titled "Additional comments and/or steps to prevent recurrence" was blank. c. The Incident/Accident Report dated 7/2/12 at 3:20 p.m. documented, "(Resident) stated to this nurse 'I was trying to get out of bed into my w/c and fell ' ... found (resident) lying supine in front of bed. (Resident) stated, 'My back hurts." This nurse is instructed (resident) to use call lite or yell for help when trying to get up." d. The Incident/Accident Report dated 7/2/12 at 10:05 a.m. documented, "This nurse called to resident room @ 1005 (10:05 a.m.). Res noted sitting on floor (with) back against roommates refrigerator. Lt (left) elbow on floor no shoes or socks on feet... When asked was doing @ X of fall, res did not reply. CNA reported that she had jut put res in w/c (with( clip alarm attached and non-slip socks on feet." The section titled "Additional comments and/or steps to prevent recurrence" was blank. e. On 7/10/12 at 8:15 a.m., the resident was up in the wheelchair in her room. There was no alarm on the chair. She got up out of the wheelchair and walked to the bedside table then back to the wheelchair. There was no alarm sounding. f. On 7/11/12 at 8:40 a.m., the resident transferred herself from the bed to the wheelchair. The chair alarm was not attached to the resident. g. On 7/11/12 at 12:40 p.m. LPN #2 was asked, "How do you monitor residents who are supposed to have an alarm?" She replied, "All of us pretty much do rounds." The LPN was asked, "How do you ensure the alarms are in use?" She replied, "It takes everybody. When (the alarm is) on the back of the chair it should be clipped (to the resident), if the alarm is not on I get the Certified Nursing Assistant ( CNA) and show them." The LPN was asked how she knew which residents were to have alarms. She replied, "We have a list and they are in the ADL books for the CNAs." She was asked how often do you check the alarms?" She replied, "2 to 3 times a week." She was asked if the alarm checks were documented. She replied, "That's a good question." 6. Resident #3 had [DIAGNOSES REDACTED]. The Admission MDS with an ARD of 5/10/12 documented the resident scored 4 (0-7 indicates severely impaired) on the BIMS, was independent with ADLs, was continent of bladder and bowel and had a history of [REDACTED]. a. The Plan of Care, undated, documented a problem of "Risk for falls. R/T; History of falls in past 6 months. AEB; needs reminders to slow down when walking and walks with side steps... Interventions Provide direction ad standby assist with walking when possible, observe gait and balance, report problems PRN. Remind resident to slow down. Assess risk factors prn and record..." b. The Incident/Accident Report dated 6/28/12 documented, "CNA... heard loud noise to room resident on floor on side. Head to toe assessment done, no knot or bruises noted, skin tear to Rt outer ankle..." The section titled "Additional comments and/or steps to prevent recurrence" was blank. c. As of 7/11/12, there was no documentation the care plan was updated after the fall on 6/28/12. 7. Resident #8 had [DIAGNOSES REDACTED]. The Quarterly MDS with an ARD of 4/29/12 documented the resident scored 14 (13 - 15 indicates cognitively intact) on the BIMS, required limited assistance in some areas of ADLs, was continent of bladder and bowel and had one fall since admission or last assessment. a. The Plan of Care updated 5/1/12 documented a problem of "Risk for falls. r/t; routine use of one or more psychotropic medications... Interventions... Observe effectiveness of safety alarm over head of bed, keep device on when Elder in bed, report prn. Attach safety clip-on alarm to back of w/c and clothing when up in chair, monitor, record and report effects prn..." b. The Incident/Accident Report dated 7/2/12 at 8:00 p.m. documented, "(Resident) stated, 'She was trying to get her night gown, and lost her balance.' (Resident) was lying supine and (at) end of bed (with) shoulders against stand @ end of be. (Resident) was sore all over..." The section titled, "Additional comments and/or steps taken to prevent recurrence" documented, "This nurse encouraged (resident) to use call lite for assistance." c. On 7/9/12 at 2:25 p.m., the resident was standing up out of the wheelchair going through her closet. There was no alarm sounding. There was no alarm on her wheelchair. d. On 7/10/12 at 12:20 p.m., the resident was in her wheelchair in the room watching television. There was no chair alarm visible. At 1:00 p.m., the resident was in the wheelchair in the dining room. There was no chair alarm visible. e. On 7/11/12 at 8:35 a.m., the resident was in the wheelchair in the dining room eating breakfast. There was no chair alarm visible on the chair. At 10:00 a.m., the resident was in the recliner asleep. There was no alarm present. f. On 7/11/12 at 12:40 p.m. LPN # 2 was asked, "When a resident has a fall should the care plan be updated?" She replied, "Yes." As of 7/11/12 there were no new interventions documented on the care plan after the fall on 7/2/12.

A. Based on observation, record review, and interview the facility failed to ensure mechanical lift transfers were provided in a manner to prevent possible injury for 3 (Residents #6, 17, and 18) of 7 (Residents # 2, 6, 7, 17 and 18) case mix residents who required mechanical lift transfers. This failed practice resulted in Immediate Jeopardy which caused or could have caused serious harm, injury, or death to Residents #6 and 17 who fell during mechanical lift transfers due to the lift tipping over and had the potential to affect 9 residents who required mechanical lift transfers as documented on a list provided by the Minimum Data Set (MDS) Coordinator on 5/25/12 at 10:20 a.m. The facility was notified of the Immediate Jeopardy on 5/25/12 at 11:45 a.m. The findings are: 1. The facility policy on mechanical lifts titled "Hoyer Lift" documented, "Policy: The Hoyer lift must be utilized for those residents who need total assistance in transferring. Nursing personnel must know, and demonstrate the proper use of the lift before they are allowed to use it. This is done during their orientation. Hoyer lift points to remember: ... Never use the Hoyer lift alone ... Open the legs of the Hoyer prior to lifting the resident and the legs of the Hoyer must never be closed until the resident is on a stable surface i.e. (for example) the bed or chair ... Always use (2) two people when lifting someone up in the Hoyer. One person to guide and work the Hoyer and the other staff member to hold and steady the resident." The manufacturer's instructions for the Hoyer lift documented, "How to use a patient lifter: A positioning and transfer guide ... Safety Precautions: WARNING! Lifters may tip over if used improperly! Failure to observe the following warnings may result in serious injury to patient and/or attendant. ... The weight must be centered over the base. When lifting ALWAYS keep patient centered over the base and facing the attendant who is operating the lifter. ... To reduce the hazard of tipping over, spread adjustable base lifters to their widest position before lifting anyone. 2. Resident #17 had [DIAGNOSES REDACTED]. The Quarterly MDS with an Assessment Reference Date (ARD) of 5/6/12 documented the resident scored a 15 (13 - 15 indicates cognitively intact) on the Brief Interview for Mental Status (BIMS), was totally dependent on two plus persons for transfers, had 1 fall with no injury since the prior assessment and 1 fall with injury since the prior assessment. a. The "Nurse's Notes" dated 3/10/12 at 2:30 p.m. documented, "This nurse called to (resident) room (at) (approximately) 12:30 p.m. (Resident) noted lying on floor on back (at) end of bed, pillow placed under (resident's) head. Hoyer pad noted under (resident) on floor. (wheelchair) noted on 'A' side of room facing 'A' bed. Hoyer lift noted bedside (resident) (wheelchair). CNAs (Certified Nursing Assistants) in room reported that (resident) was up in the Hoyer left, legs of lift opened properly, Hoyer lift tipped over causing (resident) to fall. CNA (CNA #10) attempted to catch (resident), breaking her fall. ... Purple discolorations noted first and second finger on (right) hand. (Resident) reported that her (right) hand to caught between her body and the crossbar of the lift. ... APN (Advanced Practice Nurse) called. Order (received) for stat x-ray bilateral shoulders, (right) hand, (cervical) spine, thoracic spine, lumbar spine and bilateral hips ..." b. The "(facility) Fall Assessment" form dated 3/10/12 documented, "... 21. Ask the resident or any witnesses what they were doing when they fell ... CNAs reported that while (resident) was up in air in Hoyer lift, legs of lift open properly, lift tipped over causing (resident) to fall. ..." c. The witness statement dated 3/10/12, written by CNA #11, documented, "I am in orientation, (CNA #9) asked, me to stand over by the lift and let it down slow when she says. But before we could do anything she was moving (Resident #17) over in the lift so we could lower her into the wheelchair and it (mechanical lift) fell . (CNA #9) was on my right and (CNA #10) was on the left, and she tried catching (Resident #17) when the lift tipped over. ..." The statement did not document that any CNA was guiding/holding the resident while in the sling to prevent swaying/leaning of the resident's weight. d. The witness statement dated 3/10/12, written by CNA #9, documented, "On Saturday, March 10, 2012 CNAs (CNA #11 and CNA #10), and nursing assistant in orientation (CNA #11) was getting resident ... up into wheelchair. Hoyer lift base was out/open. Resident was ready to be in chair. As (CNA #11) starting to let down resident, resident went sideways. Hoyer lift tip over on top of resident." The statement did not document that any CNA was guiding/holding the resident while in the sling to prevent swaying/leaning of the resident's weight. e. The witness statement dated (3/10/12), written by CNA #10, documented, "Me, (CNA #9) and (CNA #11) was getting (Resident #17) up and she was in the lift and no one even touched or (pushed) lift and it started tipping ..." The statement did not document that any CNA was guiding/holding the resident while in the sling to prevent swaying/leaning of the resident's weight. f. The "Restorative Safety Screening" form dated 3/13/12, written by Licensed Practical Nurse (LPN) #5, documented, "(3/10/12 (at) 12:35 p.m.) CNAs report while resident was up in lift being transferred from bed to (wheelchair), lift tipped over causing resident to fall. Observed lying on floor on back, Hoyer pad under her and pillow under her head. Purple discoloration noted on first and second fingers of (right) hand. X-rays done. (Negative) findings. Plan: Lift not to be used. New piston (ordered) for lift per DON (Director of Nurses)." g. The "Plan of Care" dated 2/6/12 and reviewed on 5/7/12 documented, "Problem: Self Care Deficit (related to) Morbid Obesity and impairment in mobility ... Interventions: ... Assist with ... proper transfer to and from bed, (wheelchair), shower chair ... Problem: Risk for falls (related to) Obesity and total dependence in transferring ... Interventions: Obtain adequate help to assist in all transfers using mechanical Hoyer lift, report and record difficulties ... Ensure resident has adequate (amount) of assistance before transferring by Hoyer lift and lift is working properly (3/10/12)." 3. Resident #6 had [DIAGNOSES REDACTED]. The Quarterly MDS with an ARD of 2/19/12 documented the resident was severely impaired in cognitive skills for daily decision making per a Staff Assessment of Mental Status, totally dependent for transfers, and had no falls. a. The "Plan of Care" dated 5/24/11 and updated 11/23/11 documented, "Problem: Risk for additional falls (as evidenced by) severely impaired balance, unable to hold self up to stand ... Interventions: ... Provide assist of two when transferring by Hoyer lift ..." b. The "Nurse's Notes" dated 5/21/12 at 7:15 a.m., written by LPN #3, documented, "Observed CNA run (back) into elder's (room) in a quick motion, upon entering elder's (room), elder supine on the floor (next) to his bed, Hoyer lift tilted over with connections (and) pad still attached to elder. Elder awake, alert, oriented to name, yelling and cursing. Moving own (upper) extremities as exam attempted. No redness, bruising, bleeding observed ... Questioned three CNAs in the (room), all state 'The Hoyer tilted over'." Counseled (with) CNAs regarding resident safety while using the Hoyer lift and all must be watching and be in close proximity (at) all times to ensure safe transfers. ..." c. The "Incident/Accident Report" form dated 5/21/12 at 7:15 a.m., written by LPN #3, documented, "... Describe what happened ... Noticed CNA run into elder's (room), so this nurse ran also. On entering (room) observed elder supine on the floor (with) Hoyer lift pad under elder and Hoyer lift connected and tilted over to the floor. Three CNAs in the room with elder ... Additional comments and/or steps taken to prevent recurrence: Counseled (with) all three CNAs in room (at) time of occurrence on providing safety for elder (at) all time while using Hoyer lift." This "Incident/Accident Report" form was signed by the Director of Nurses and dated 5/21/12. d. The "(facility) Fall Assessment" form, undated, documented, "... 21. Ask the resident or any witnesses what they were doing when they fell ... Elder being transferred by Hoyer lift, from shower chair to bed to complete drying and dressing when Hoyer lift tilted over causing elder to fall supine on floor ... Comments: Elder connected to the Hoyer lift during occurrence." The form was signed by LPN #3. On 5/24/12 at 1:00 p.m. LPN #3 was asked, to review the "Incident/Accident Report" form dated 5/21/12 at 7:15 a.m. LPN #3 was asked, "Who were the CNA's in the room on 5/21/12?" LPN #3 stated,, "(CNA #3), (CNA #4), (CNA #6) and (CNA #7) came out of the room and then darted back into the room. That's when I came down." LPN #3 was asked, "What lift was used?" LPN #3 stated, "The cream colored one. He was still connected and was lying on the floor next to the bed and the loops were still connected." LPN #3 was asked, "Were the legs of the lift opened?" LPN #3 stated, "No, I think they were closed." LPN #3 was asked,, "Were they coming from or going to bed?" LPN #3 stated, "They were transferring him from the shower chair to the bed." LPN #3 was asked, to find the lift that was involved and an empty room to react what happened. LPN #3 found the "cream colored lift" which was a Hoyer lift model number HML400. A drawing was made of the room and staff location demonstrating where each staff member was when LPN #3 entered the room. LPN #3 stated, "CNA #6 was toward the head of the resident's bed (Bed A) behind the lift that was on the floor. CNA #4 was across the room in front of the resident's Broda chair by the foot of Bed B. CNA #3 was behind the shower chair in front of the bathroom door and next to a night stand with a TV on it, on the wall opposite the head of the resident's bed." LPN #3 was asked, "Did (Resident #6) have any injuries?" LPN #3 stated,, "No." LPN #3 was asked,, "What was the intervention?" LPN #3 stated, "I talked with all 3 CNAs to make sure they watch the resident, to make sure they maneuver the lift correctly. My first thing was 'What happened, there are three of you all in here?' One girl (CNA #6) said 'It just tipped over'." The surveyor requested the full incident and accident investigation of the incident of 5/21/12. e. A witness statement written by CNA #3 dated 5/21/12 documented, "While we were trying to get (Resident #6) off the shower chair this morning the lift tipped over and he slowly landed in the floor. (CNA #6) who was operating the lift slowly let it down so he would not hit the floor hard. (CNA #7), (CNA #4) and I were all in the room when it happened. I was holding the shower chair so that it would not move when he got lifted out." The following was attached to the witness statement: "I have received and read a copy of how to use the Hoyer lift and a copy of points to remember when using the Hoyer." The form was signed on 3/1/12 by CNA #3. On 5/24/12 at 1:37 p.m. CNA #3 was asked, "How long have you worked here?" CNA #3 stated,, "One and a half years". CNA #3 was asked, "When was your last in service on Hoyer/mechanical lifts?" CNA #3 stated, "I can't remember when, but I had one since I started." CNA #3 was asked, "Did you help with the transfer on 5/21/12 when the lift fell ?" CNA #3 stated, "Yes, (CNA #6) was pumping the hydraulic lift handle. The resident was in the shower chair. (CNA #4) was in the room behind the Broda chair in the opposite corner." CNA #3 was asked, "How was the resident?" CNA #3 stated, "He was agitated. He gets where he moves in the shower chair and lift." CNA #3 was asked, "Was the resident moving in the shower chair before the lift or while in the lift?" CNA #3 stated, "No, just verbal with us. (CNA #6) started pumping him up and when he got agitated, just verbal." CNA #3 was asked, "What were you doing?" CNA #3 stated, "I still had the chair because (CNA #6) was still raising the resident. I don't move the chair until we are ready to turn him into the bed. His bottom was level with the arms of the shower chair when (CNA #6) went to pull the lift back and the lift tilted." CNA #3 was asked, "Were the lift legs opened?" CNA #3 stated, "Yes because that's the only way you can get it around the shower chair. When the lift tilted the shower chair moved to the side. I had a hold of the lift pad so we could lower him without the lift arms (swivel bar) hitting (Resident #6)." CNA #3 was asked, "Did you have your hand on (Resident #6) while he was lifted?" CNA #3 stated, "To be honest, no probably not. ..." CNA #3 was asked, "Since this happened what has the facility done?" CNA #3 stated, "We've been talked to about checking the legs to make sure they are opened and locked." CNA #3 was asked, "Has the DON, ADON, etc. watched you do a lift since 5/21/12?" CNA #3 stated, "No." f. A witness stated, written by CNA # 7 documented, "At 7:15 a.m. on 5/21/12 I had given (Resident #6) a shower. I had taken him back to his room and (CNA #6), (CNA #3), (CNA #4) and I were in the room. (CNA #6) was lifting him up with the Hoyer lift. I was going out the door to get the small shower chair for (another resident) and talk to (LPN #3) and heard a loud noise. The lift tilted over while (Resident #6) was in it. I came back in the room and seen him in the floor. (LPN #3) came in, checked him out ..." The following was attached to the witness statement: "I have received and read a copy of how to use the Hoyer lift and a copy of points to remember when using the Hoyer." The form was signed on 3/1/12 by CNA # 7. On 5/24/12 at 5/24/12 at 1:58 p.m. CNA #7 was asked,, "How long have your worked here?" CNA #7 stated,, "2 years next month." CNA #7 was asked,, "When was your last in service on Hoyer/mechanical lifts?" CNA #7 stated,, "A couple of months ago. They did an exercise, a demonstration, and we had an in service. They gave us a packet and we had to read and sign on the proper way to use a Hoyer lift." CNA #7 was asked,, "Did anyone watch you do a lift after that?" CNA #7 stated,, "Yes, we've had nurses watch us about 2 or 3 times a month." CNA #7 was asked,, "What were you doing during the transfer with (Resident #6) on 5/21/12?" CNA #7 stated,, "I was at the end of the bed putting a pad on the bed. (CNA #6) was operating the lift, (CNA #3) was behind the shower chair and (CNA #4) was beside (CNA #3) to the left side. They got him suspended over the chair. They were pulling the shower chair out and (CNA #6) was in the process of opening the legs of the lift to turn (Resident #6) to put him on the bed. While she was lifting him I asked, them 'Do you have this, can you handle this because I'm going to talk with (LPN #3) and get the small shower chair to start another shower.' As I turned to walk out the door I heard the lift fall." CNA #7 was asked,, "How was (Resident #6) before the lift?" CNA #7 stated,, "He was cussing, spitting, hitting and kicking during the shower and right before the transfer and that wasn't just a one-time thing. He's like that every time we get him in the shower. I was leaving the room as (CNA #6) was lifting the resident and opening the legs of the Hoyer lift." CNA #7 was asked,, "Since this happened with the resident tilting over in the lift, what has the facility done?" CNA #7 stated,. "(LPN #3) talked with us and had us all write statements." CNA #7 was asked,, "What did (LPN #3) talk with you about?" CNA #7 stated, "She was asking what we were doing and if we were doing what we are supposed to, which we were." CNA #7 was asked,, "How are the lift legs supposed to be when you are lifting the resident?" CNA #7 stated,, "They are supposed to be closed and as you pull the chair back you are supposed to open the legs. That way it maintains the center of gravity." CNA #7 was asked,, "Did they re-inservice you on the lift?" CNA #7 stated, "No, they haven't yet." g. On 5/24/12 at 2:55 p.m. LPN # 5, the Restorative LPN, was asked, "Do you watch CNA's do Hoyer/mechanical lifts?" LPN #5 stated, "I have, yes." LPN #5 was asked,, "What do you look for?" LPN #5 stated, "The first thing I look for is a second person ... make sure they have the proper sling for size ... I make sure when they are moving from one surface to another that the legs are open." LPN #5 was asked,, "Clarify that, when should they open the legs?" LPN #5 stated, "After the resident is lifted and before they move to another destination." LPN #5 was asked, "What else do you look for?" LPN #5 stated, "Make sure the second person is guiding the resident and making sure the resident does no hit their head while the other person is working the lift." h. A witness statement written by CNA #4 documented, "I, (CNA #4), came into work at 7:00 a.m. on (5/21/12), went down to (Resident #6's) room (room number) ... (CNA #6) and (CNA #7) was getting (Resident #6) (out) of the shower chair with the lift. (CNA #7) walked out to talk to (LPN #3) and I turned to make sure the door was closing as well as trying to move his chair and I (looked) at (Resident #6) and seen the lift tilting with (CNA #6) holding on to it." The following was attached to the witness statement: "I have received and read a copy of how to use the Hoyer lift and a copy of points to remember when using the Hoyer." The form was signed on 3/28/12 by CNA # 4. On 5/24/12 at 3:25 p.m. CNA #4 was asked, "How long have you worked here?" CNA #4 stated,, "March 29, 2012." CNA #4 was asked, "Have you been in serviced on the Hoyer/mechanical lift?" CNA #4 stated, "Yes" CNA #4 was asked, "Were you in the room on Monday (5/21/12) when the Hoyer lift tilted over with (Resident #6)?" CNA #4 stated, "Yes." CNA #4 was asked, "What were you doing?" CNA #4 stated,"When I walked in (CNA #6) was holding the lift, (CNA #7) was holding the lift pad. The Broda chair was in front of the door and I pushed it over to Bed B's side." CNA #4 was asked, "Was the lift tilted over when you came in?" CNA #4 stated, "No, it was still standing cause (CNA #6) was pumping him up and getting ready to move him over to the bed.?" CNA #4 was asked, "How were the legs of the lift?" CNA #4 stated, "I believe they were opened but I'm not exactly sure." CNA #4 was asked, "Was (CNA #3) in the room?" CNA #4 stated, "Me and (CNA # 3) both went into the room at the same time. (CNA #7) who had been holding the lift pad left the room and I'm not sure (CNA #3) got a hold of the lift pad. As (CNA #7) left, I turned around to make sure the door closed and when I turned back I saw the lift already tilted ... I believed the lift was tilted because the floor was still wet from the shower chair." CNA #4 was asked, "When you walked into the room, what was the resident doing/like?" CNA #4 stated, "He was calm and still like he was trying to go to sleep. Normally he fights us when we try to get him up and down." CNA #4 was asked, "When they started pumping the Hoyer what was the resident doing?" CNA #4 stated, "He was calm. He never made a sound not even when we guided him to the floor." i. A witness statement written by CNA #6 and dated 5/21/12 documented, "I (CNA #6) (and) (CNA #3), (CNA #4) were transferring (Resident #6) out of the shower chair. When I went to pull back the lift and open the legs on it, the lift fell and (Resident #6) hit the floor. The nurse (LPN #3) came in and checked him." The following was attached to the witness statement: "I have received and read a copy of how to use the Hoyer lift and a copy of points to remember when using the Hoyer." The form was signed on 3/1/12 by CNA #6. On 5/24/12 at 4:52 p.m. CNA #6 was asked, "How long have you worked here?" CNA #6 stated, "On and off for 3 years." CNA #6 was asked, "Have you had any training on Hoyer/mechanical lifts recently?" CNA #6 stated, "Yes." CNA #6 was asked, "When?" CNA #6 stated, "A couple of months ago. They showed us and we had to read and sign a paper on Hoyer lifts." CNA #6 was asked, "Has anyone watched you do a lift transfer?" CNA #6 stated, "Yes, (LPN #3) did about 2 or 3 months ago." CNA #6 was asked, "Can you tell me about what happened with (Resident #6) on 5/21/12?" CNA #6 stated, "We, me, (CNA #3), and (CNA #4) and (CNA #7) were getting him out of the shower chair." CNA #6 was asked, "Were (CNA #3) and (CNA #4) already in the room when the transfer started?" CNA #6 stated, "Yes." CNA #6 was asked, "Were you behind the lift?" CNA #6 stated,, "Yes, I was the one working the lift." CNA #6 was asked, "Where was (CNA # 3)?" CNA #6 stated, "She was behind (Resident #6's) shower chair." CNA #6 was asked, "Where was (CNA #4)?" CNA #6 stated, "I couldn't tell you." CNA #6 was asked,, "Where was (CNA #7)?' CNA 6 stated, "Beside (CNA #3)." CNA #6 was asked, "What happened?" CNA #6 stated, "I was lifting him up and I went to open the legs and turn him and that's when he fell ." CNA #6 was asked, "You started lifting him up before you opened the legs of the lift?" CNA #6 stated, "Yes." CNA #6 was asked, "How high up was the resident?" CNA #6 stated, "He was all the way up on the lift and I started backing him up and opening the legs of the lift at the same time." CNA #6 was asked, "Was the resident still while he was in the lift or was he moving?" CNA #6 stated, "He was agitated and he was kind of punching, moving his arms in the air." CNA #6 was asked, "What happened next?" CNA #6 stated, "The lift tipped over and I caught the lift. It kind of fell on me. The top of it fell on me and I was holding the lift up." CNA #6 was asked, "Who was holding onto (Resident #6) before the lift fell ?" CNA #6 stated, "I think (CNA #3) was on the back of the lift pad." CNA #6 was asked, "Since this happened what has the facility done?" CNA #6 stated, "Told us about opening the legs of the Hoyer lift." CNA #6 was asked, "Has anyone watched you do a transfer since this happened?" CNA #6 stated, "No." CNA #6 was asked, "Was the floor wet?" CNA #6 stated, "Yes, it was under the shower chair, a few drops of water." CNA #6 was asked, "Did you know the floor was wet before you started lifting him?" CNA #6 stated, "Yea, I guess you could say that." CNA #6 was asked, "Once (Resident #6) fell , what happened?" CNA #6 stated, "The nurse came in. She was right outside and she came right in. I knew I'd messed up as soon as he hit the floor." CNA #6 was asked, "Why didn't you open the lift legs before the transfer?" CNA #6 stated, "I don't know. I really don't, that was a mistake." CNA #6 was asked, "Have you done any lifts since Monday (5/21/12)?" CNA #6 stated, "No, I haven't." CNA #6 was asked, "Has the facility done anything since then?" CNA #6 stated, "I signed an in service paper this morning." j. On 5/22/12 at 8:18 a.m., CNA #1 and 2 transferred Resident #6 from a Broda chair to bed via Hoyer lift. CNA #1 pushed the legs of the Hoyer lift under the seat of the Broda chair. The legs/base of the Hoyer lift were not opened. CNA #1 raised the resident, backed the lift up approximately 6 feet and then opened the legs/base of the Hoyer lift. CNA #1 guided the lift and CNA #2 guided the resident. The resident was moved over the bed and then lowered onto the bed with the lift legs/base opened. k. On 5/22/12 at 8:35 a.m., after providing incontinent care to Resident #6, CNA #1 and 2 transferred Resident #6 from bed to a Broda chair. CNA #1 moved the lift to the bed and opened the legs/base of the lift. CNA #1 guided the lift and CNA #2 guided the resident over to the Broda chair. When the lift was approximately 4 feet from the Broda chair, CNA #1 closed the legs/base of the lift and placed the legs under the seat of the Broda chair. CNA #1 lowered the resident into the Broda chair. On 5/25/12 at 9:40 a.m. CNA #1 was asked, "Have you had any training on mechanical lifts?" CNA #1 stated, "Yes." CNA #1 was asked, "What did you do for the training?" CNA #1 stated, "Papers on the process, step by step, do and don'ts and it was reviewed." CNA #1 was asked, "How are the lift legs supposed to be before you start lifting a resident?" CNA #1 stated, "Closed. You open them when you start doing the transfer, moving them." l. On 5/24/12 at 5:20 p.m. the Director of Nurses (DON) and Administrator were asked, "What have you done since the lift tipped over with (Resident #6) on 5/21/12?" The DON stated, "We started getting statements." The DON and Administrator were asked, "Any conclusions at this point?" The DON stated, "No, we've tried to determine what happened." The DON and Administrator were asked, "Have you had (LPN #5) re-evaluate (Resident #6) for safe transfers?" The DON stated, "No, we usually meet on Thursdays to discuss falls but you are here so we haven't had a meeting." The DON and Administrator were asked, "Have you talked with staff members yet about what happened?" The DON and Administrator stated, "No." The DON and Administrator were asked, "Since this happened have you had anyone monitoring these employees for mechanical lift transfers?" The DON stated, "Yes, (LPN #6) has an in service she's been doing with them." The DON and Administrator were asked, "Has anyone watched them doing mechanical lifts since this happened?" The Administrator stated, "I haven't told anyone to do that." 4. Resident #18 had [DIAGNOSES REDACTED]. The Quarterly MDS with an ARD of 3/18/12 documented the resident scored a 15 (13 - 15 indicates cognitively intact) on the Brief Interview for Mental Status, and was totally dependent on two plus persons for transfers. a. The "Plan of Care" dated 9/20/11 and reviewed on 3/19/12 documented, "Problem: (Activity of Daily Living) functional impairment (related to) History of fractured right hip and progressive Parkinson's Disease ... Interventions: ... Transfer to and from bed to chair, (wheelchair) by mechanical Hoyer lift ..." b. The Invacare mechanical lift manufacturer's instructions documented, "... Section 4 - Lifting the Patient. ... Invacare recommends that two assistants be used for all lifting preparation and transferring to/from procedures ... WARNING: The legs of the patient lift MUST be in the maximum open position for optimum stability and safety. If it is necessary to close the legs to maneuver the patient lift under a bed, close the legs only as long as it takes to position the patient lift over the patient and lift the patient off the surface of the bed. When the legs of the patient lift are no longer under the bed, return the legs to the open maximum open position. c. On 5/25/12 at 10:12 a.m., CNA #8 and 9 provided a mechanical lift transfers via Invacare lift. CNA #8 pushed the legs of the Invacare lift under the resident's Geri chair. The legs/base of the lift were not spread/opened. CNA #8 and 9 connected the lift pad to the lift frame. CNA #8 raised Resident #18 out of the Geri chair with the lift legs closed. CNA #8 backed the lift up approximately 4 feet, opened the legs/base of the lift and moved the resident via lift to the bed. CNA #9 guided the resident by holding onto the strap across the back of the lift pad. d. On 5/25/12 at 10:20 a.m. CNA #8 and 9 were asked, "Have you had any training on lift use?" CNA #8 and 9 stated, "Yes." CNA #9 stated, "Like about February or March. We had an inservice. They did a demo and we had to read a packet too and sign a paper." CNA #8 and 9 were asked, "Before you raise a resident, how are the legs/base of the lift supposed to be?" CNA #9 stated, "Opened because if the resident leans the center of gravity shifts." CNA #8 was asked, "Why didn't you open the legs/base of the lift?" CNA #8 stated, "I forgot." 5. The manufacturer's instructions for the Hoyer lift documented, "... Hoyer lifter maintenance: ... Regular maintenance of lifts and accessories is necessary to assure proper and safe operation. Read and observe the recommended instructions in the separate Assembly and Maintenance Manual ..." The "Hoyer Hydraulic Patient Lifters HML400 ... User Instruction Manual and Warranty" documented the swivel bar, pump assembly, lubrication and cleaning should be done bi-monthly. The Invacare "Owner's Operator and Maintenance Manual" documented the caster base, shifter handle, mast, boom, swivel bar, pump assembly, and slings and hardware are to be inspected monthly for institutional use. a. On 5/24/12 at 1:35 p.m. the Maintenance Supervisor stated, no routine checks of mechanical lifts were done. The Maintenance Supervisor stated, they do as needed repairs when told there was a problem. "I have had to replace pins and replaced hydraulic pumps and have had to add hydraulic fluid as needed." The Maintenance Supervisor was asked, for any maintenance request on mechanical lifts. b. On 5/24/12 at 2:32 p.m. the Director of Nurses stated, "No maintenance request related to mechanical lifts and no monthly maintenance was done on the mechanical lifts. c. On 5/24/12 at 5:20 p.m., the DON and Administrator were asked, "Does Maintenance do any routine checks of the mechanical lifts?" The DON stated, "No, he didn't know he was supposed to, but he's already added it to his routine rounds." 6. On 5/25/12 at 8:45 a.m. the Director of Nurses (DON) was asked, "Do you have any tracking of falls?" The DON stated, "Yes, (LPN (Licensed Practical Nurse) #5) does that, I'll get those." a. On 5/25/12 at 9:10 a.m., LPN #5 presented fall tracking from 3/1/12 through 5/22/12. The IDTM (Interdisciplinary Team Meeting) Fall Prevention Program form documented, "... (Resident #17); Date: 3/10/12; Determined Cause: Hoyer lift tipped; Intervention: Not use lift ..." b. On 5/25/12 at 2:17 p.m., the Administrator presented inservices that were requested. The inservice dated 1/24/12 documented, "How to use lifts." There was no attachment provided. The Administrator stated, "This was all the inservices I could find on mechanical lifts." 7. The Immediate Jeopardy was removed and the scope/severity reduced to "E" on 5/25/12 at 3:20 p.m. when the facility implemented the following Plan of Removal: "On 5/25/12 at 11:45 a.m. the facility was informed that an Immediate Jeopardy situation existed. There are 9 residents currently in the facility who require a mechanical lifts. All Department Heads were notified and training began immediately on 5/25/12 at 1:00 p.m. by (LPN #3) and (LPN #6). All nursing staff (CNA's, charge nurses and administrative nursing staff) will be in serviced at the beginning of each shift beginning on 5/25/12 at 1:00 p.m. and will be ongoing to include new hires and staff returning from leave. Training will take place before staff use the lift on any resident who require a Hoyer or Invacare lift transfer. Training will be done by DON/designee and in-service sign-in sheets will be used. Training will include a review of the Hoyer policy and procedure, safe use of mechanical lifts, and a return demonstration which includes a check off list of safety points. This immediate training will continue until all staff members have been retrained and can demonstrate understanding of how to transfer a resident using out manual lifts. All charge nurses will monitor each transfer using the Hoyer/Invacare mechanical lifts during each shift for 24 hours, then 3 times each shift when the lift is being used and (then) one time\ each shift when use of the lift is required. On the weekend the RN/charge nurse will continue to train, return demonstration and observe each CNA who had not been trained and completed check list prior to being allowed to use either lift. At no time are the legs on the lift to be in the closed position when a resident is in the lift. On 5/25/12 Maintenance has obtained the Operator and Maintenance Manuals for both the Invacare and Hoyer mechanical lift and devised a monthly check list f

Based on observation, record review, and interview the facility failed to ensure nursing administration had a system in place to ensure staff members were knowledgeable regarding safe mechanical lift transfers to prevent possible injury for 3 (Residents #6, 17, and 18) of 7 (Residents # 2, 6, 7, 17 and 18 ) case mix residents who required mechanical lift transfers. This failed practice resulted in Immediate Jeopardy which caused or could have caused serious harm, injury, or death to Residents #6 and 17 who fell during mechanical lift transfers due to the lift tipping over and had the potential to affect 9 residents who required mechanical lift transfers as documented on a list provided by the Minimum Data Set (MDS) Coordinator on 5/25/12 at 10:20 a.m. The Administrator was notified of the Immediate Jeopardy on 5/25/12 at 11:45 a.m. The findings are: 1. The job description for the Director of Nursing documented "... Job Purpose: The Director of Nursing is responsible for the supervision, direction, and staffing of all ensuring services in the facility; ... that compliance to all policies and procedures of (facility), with regard to nursing services, is followed; ... in order to provide quality patient care to resident in the facility. The Director of Nursing is responsible for the supervision of the Total Plan of Care for each resident. Key Job Functions: ... 2. Examination of any resident who had had an incident/accident ... 3. Supervision of all areas of responsibility in nursing department. ... 5. Evaluation, counseling, and disciplinary actions with regard to all nursing department personnel. ...". 2. The facility policy on mechanical lifts titled "Hoyer Lift" documented, "Policy: The Hoyer lift must be utilized for those residents who need total assistance in transferring. Nursing personnel must know, and demonstrate the proper use of the lift before they are allowed to use it. This is done during their orientation. Hoyer lift points to remember: ... Never use the Hoyer lift alone ... Open the legs of the Hoyer prior to lifting the resident and the legs of the Hoyer must never be closed until the resident is on a stable surface i.e. (for example) the bed or chair ... Always use (2) two people when lifting someone up in the Hoyer. One person to guide and work the Hoyer and the other staff member to hold and steady the resident." The manufacturer's instructions for the Hoyer lift documented, "How to use a patient lifter: A positioning and transfer guide ... Safety Precautions: WARNING! Lifters may tip over if used improperly! Failure to observe the following warnings may result in serious injury to patient and/or attendant. ... The weight must be centered over the base. When lifting ALWAYS keep patient centered over the base and facing the attendant who is operating the lifter. ... To reduce the hazard of tipping over, spread adjustable base lifters to their widest position before lifting anyone. 3. Resident #17 had [DIAGNOSES REDACTED]. The Quarterly MDS with an Assessment Reference Date (ARD) of 5/6/12 documented the resident scored a 15 (13 - 15 indicates cognitively intact) on the Brief Interview for Mental Status (BIMS), was totally dependent on two plus persons for transfers, had 1 fall with no injury since the prior assessment and 1 fall with injury since the prior assessment. a. The "Nurse's Notes" dated 3/10/12 at 2:30 p.m. documented, "This nurse called to (resident) room (at) (approximately) 12:30 p.m. (Resident) noted lying on floor on back (at) end of bed, pillow placed under (resident's) head. Hoyer pad noted under (resident) on floor. (wheelchair) noted on 'A' side of room facing 'A' bed. Hoyer lift noted bedside (resident) (wheelchair). CNAs (Certified Nursing Assistants) in room reported that (resident) was up in the Hoyer left, legs of lift opened properly, Hoyer lift tipped over causing (resident) to fall. CNA (CNA #10) attempted to catch (resident), breaking her fall. ... Purple discolorations noted first and second finger on (right) hand. (Resident) reported that her (right) hand to caught between her body and the crossbar of the lift. ... APN (Advanced Practice Nurse) called. Order (received) for stat x-ray bilateral shoulders, (right) hand, (cervical) spine, [MEDICATION NAME] spine, lumbar spine and bilateral hips ..." b. The "(facility) Fall Assessment" form dated 3/10/12 documented, "... 21. Ask the resident or any witnesses what they were doing when they fell ... CNAs reported that while (resident) was up in air in Hoyer lift, legs of lift open properly, lift tipped over causing (resident) to fall. ..." c. The witness statement dated 3/10/12, written by CNA #11, documented, "I am in orientation, (CNA #9) asked, me to stand over by the lift and let it down slow when she says. But before we could do anything she was moving (Resident #17) over in the lift so we could lower her into the wheelchair and it (mechanical lift) fell . (CNA #9) was on my right and (CNA #10) was on the left, and she tried catching (Resident #17) when the lift tipped over. ..." The statement did not document that any CNA was guiding/holding the resident while in the sling to prevent swaying/leaning of the resident's weight. d. The witness statement dated 3/10/12, written by CNA #9, documented, "On Saturday, March 10, 2012 CNAs (CNA #11 and CNA #10), and nursing assistant in orientation (CNA #11) was getting resident ... up into wheelchair. Hoyer lift base was out/open. Resident was ready to be in chair. As (CNA #11) starting to let down resident, resident went sideways. Hoyer lift tip over on top of resident." The statement did not document that any CNA was guiding/holding the resident while in the sling to prevent swaying/leaning of the resident's weight. e. The witness statement dated (3/10/12), written by CNA #10, documented, "Me, (CNA #9) and (CNA #11) was getting (Resident #17) up and she was in the lift and no one even touched or (pushed) lift and it started tipping ..." The statement did not document that any CNA was guiding/holding the resident while in the sling to prevent swaying/leaning of the resident's weight. f. The "Restorative Safety Screening" form dated 3/13/12, written by Licensed Practical Nurse (LPN) #5, documented, "(3/10/12 (at) 12:35 p.m.) CNAs report while resident was up in lift being transferred from bed to (wheelchair), lift tipped over causing resident to fall. Observed lying on floor on back, Hoyer pad under her and pillow under her head. Purple discoloration noted on first and second fingers of (right) hand. X-rays done. (Negative) findings. Plan: Lift not to be used. New piston (ordered) for lift per DON (Director of Nurses)." g. The "Plan of Care" dated 2/6/12 and reviewed on 5/7/12 documented, "Problem: Self Care Deficit (related to) [MEDICAL CONDITION] and impairment in mobility ... Interventions: ... Assist with ... proper transfer to and from bed, (wheelchair), shower chair ... Problem: Risk for falls (related to) Obesity and total dependence in transferring ... Interventions: Obtain adequate help to assist in all transfers using mechanical Hoyer lift, report and record difficulties ... Ensure resident has adequate (amount) of assistance before transferring by Hoyer lift and lift is working properly (3/10/12)." 4. Resident #6 had [DIAGNOSES REDACTED]. The Quarterly MDS with an ARD of 2/19/12 documented the resident was severely impaired in cognitive skills for daily decision making per a Staff Assessment of Mental Status, totally dependent for transfers, and had no falls. a. The "Plan of Care" dated 5/24/11 and updated 11/23/11 documented, "Problem: Risk for additional falls (as evidenced by) severely impaired balance, unable to hold self up to stand ... Interventions: ... Provide assist of two when transferring by Hoyer lift ..." b. The "Nurse's Notes" dated 5/21/12 at 7:15 a.m., written by LPN #3, documented, "Observed CNA run (back) into elder's (room) in a quick motion, upon entering elder's (room), elder supine on the floor (next) to his bed, Hoyer lift tilted over with connections (and) pad still attached to elder. Elder awake, alert, oriented to name, yelling and cursing. Moving own (upper) extremities as exam attempted. No redness, bruising, bleeding observed ... Questioned three CNAs in the (room), all state 'The Hoyer tilted over'." Counseled (with) CNAs regarding resident safety while using the Hoyer lift and all must be watching and be in close proximity (at) all times to ensure safe transfers. ..." c. The "Incident/Accident Report" form dated 5/21/12 at 7:15 a.m., written by LPN #3, documented, "... Describe what happened ... Noticed CNA run into elder's (room), so this nurse ran also. On entering (room) observed elder supine on the floor (with) Hoyer lift pad under elder and Hoyer lift connected and tilted over to the floor. Three CNAs in the room with elder ... Additional comments and/or steps taken to prevent recurrence: Counseled (with) all three CNAs in room (at) time of occurrence on providing safety for elder (at) all time while using Hoyer lift." This "Incident/Accident Report" form was signed by the Director of Nurses and dated 5/21/12. d. The "(facility) Fall Assessment" form, undated, documented, "... 21. Ask the resident or any witnesses what they were doing when they fell ... Elder being transferred by Hoyer lift, from shower chair to bed to complete drying and dressing when Hoyer lift tilted over causing elder to fall supine on floor ... Comments: Elder connected to the Hoyer lift during occurrence." The form was signed by LPN #3. On 5/24/12 at 1:00 p.m. LPN #3 was asked, to review the "Incident/Accident Report" form dated 5/21/12 at 7:15 a.m. LPN #3 was asked, "Who were the CNA's in the room on 5/21/12?" LPN #3 stated,, "(CNA #3), (CNA #4), (CNA #6) and (CNA #7) came out of the room and then darted back into the room. That's when I came down." LPN #3 was asked, "What lift was used?" LPN #3 stated, "The cream colored one. He was still connected and was lying on the floor next to the bed and the loops were still connected." LPN #3 was asked, "Were the legs of the lift opened?" LPN #3 stated, "No, I think they were closed." LPN #3 was asked,, "Were they coming from or going to bed?" LPN #3 stated, "They were transferring him from the shower chair to the bed." LPN #3 was asked, to find the lift that was involved and an empty room to react what happened. LPN #3 found the "cream colored lift" which was a Hoyer lift model number HML400. A drawing was made of the room and staff location demonstrating where each staff member was when LPN #3 entered the room. LPN #3 stated, "CNA #6 was toward the head of the resident's bed (Bed A) behind the lift that was on the floor. CNA #4 was across the room in front of the resident's Broda chair by the foot of Bed B. CNA #3 was behind the shower chair in front of the bathroom door and next to a night stand with a TV on it, on the wall opposite the head of the resident's bed." LPN #3 was asked, "Did (Resident #6) have any injuries?" LPN #3 stated,, "No." LPN #3 was asked,, "What was the intervention?" LPN #3 stated, "I talked with all 3 CNAs to make sure they watch the resident, to make sure they maneuver the lift correctly. My first thing was 'What happened, there are three of you all in here?' One girl (CNA #6) said 'It just tipped over'." The surveyor requested the full incident and accident investigation of the incident of 5/21/12. e. A witness statement written by CNA #3 dated 5/21/12 documented, "While we were trying to get (Resident #6) off the shower chair this morning the lift tipped over and he slowly landed in the floor. (CNA #6) who was operating the lift slowly let it down so he would not hit the floor hard. (CNA #7), (CNA #4) and I were all in the room when it happened. I was holding the shower chair so that it would not move when he got lifted out." The following was attached to the witness statement: "I have received and read a copy of how to use the Hoyer lift and a copy of points to remember when using the Hoyer." The form was signed on 3/1/12 by CNA #3. On 5/24/12 at 1:37 p.m. CNA #3 was asked, "How long have you worked here?" CNA #3 stated,, "One and a half years". CNA #3 was asked, "When was your last in service on Hoyer/mechanical lifts?" CNA #3 stated, "I can't remember when, but I had one since I started." CNA #3 was asked, "Did you help with the transfer on 5/21/12 when the lift fell ?" CNA #3 stated, "Yes, (CNA #6) was pumping the hydraulic lift handle. The resident was in the shower chair. (CNA #4) was in the room behind the Broda chair in the opposite corner." CNA #3 was asked, "How was the resident?" CNA #3 stated, "He was agitated. He gets where he moves in the shower chair and lift." CNA #3 was asked, "Was the resident moving in the shower chair before the lift or while in the lift?" CNA #3 stated, "No, just verbal with us. (CNA #6) started pumping him up and when he got agitated, just verbal." CNA #3 was asked, "What were you doing?" CNA #3 stated, "I still had the chair because (CNA #6) was still raising the resident. I don't move the chair until we are ready to turn him into the bed. His bottom was level with the arms of the shower chair when (CNA #6) went to pull the lift back and the lift tilted." CNA #3 was asked, "Were the lift legs opened?" CNA #3 stated, "Yes because that's the only way you can get it around the shower chair. When the lift tilted the shower chair moved to the side. I had a hold of the lift pad so we could lower him without the lift arms (swivel bar) hitting (Resident #6)." CNA #3 was asked, "Did you have your hand on (Resident #6) while he was lifted?" CNA #3 stated, "To be honest, no probably not. ..." CNA #3 was asked, "Since this happened what has the facility done?" CNA #3 stated, "We've been talked to about checking the legs to make sure they are opened and locked." CNA #3 was asked, "Has the DON, ADON, etc. watched you do a lift since 5/21/12?" CNA #3 stated, "No." f. A witness stated, written by CNA # 7 documented, "At 7:15 a.m. on 5/21/12 I had given (Resident #6) a shower. I had taken him back to his room and (CNA #6), (CNA #3), (CNA #4) and I were in the room. (CNA #6) was lifting him up with the Hoyer lift. I was going out the door to get the small shower chair for (another resident) and talk to (LPN #3) and heard a loud noise. The lift tilted over while (Resident #6) was in it. I came back in the room and seen him in the floor. (LPN #3) came in, checked him out ..." The following was attached to the witness statement: "I have received and read a copy of how to use the Hoyer lift and a copy of points to remember when using the Hoyer." The form was signed on 3/1/12 by CNA # 7. On 5/24/12 at 5/24/12 at 1:58 p.m. CNA #7 was asked,, "How long have your worked here?" CNA #7 stated,, "2 years next month." CNA #7 was asked,, "When was your last in service on Hoyer/mechanical lifts?" CNA #7 stated,, "A couple of months ago. They did an exercise, a demonstration, and we had an in service. They gave us a packet and we had to read and sign on the proper way to use a Hoyer lift." CNA #7 was asked,, "Did anyone watch you do a lift after that?" CNA #7 stated,, "Yes, we've had nurses watch us about 2 or 3 times a month." CNA #7 was asked,, "What were you doing during the transfer with (Resident #6) on 5/21/12?" CNA #7 stated,, "I was at the end of the bed putting a pad on the bed. (CNA #6) was operating the lift, (CNA #3) was behind the shower chair and (CNA #4) was beside (CNA #3) to the left side. They got him suspended over the chair. They were pulling the shower chair out and (CNA #6) was in the process of opening the legs of the lift to turn (Resident #6) to put him on the bed. While she was lifting him I asked, them 'Do you have this, can you handle this because I'm going to talk with (LPN #3) and get the small shower chair to start another shower.' As I turned to walk out the door I heard the lift fall." CNA #7 was asked,, "How was (Resident #6) before the lift?" CNA #7 stated,, "He was cussing, spitting, hitting and kicking during the shower and right before the transfer and that wasn't just a one-time thing. He's like that every time we get him in the shower. I was leaving the room as (CNA #6) was lifting the resident and opening the legs of the Hoyer lift." CNA #7 was asked,, "Since this happened with the resident tilting over in the lift, what has the facility done?" CNA #7 stated,. "(LPN #3) talked with us and had us all write statements." CNA #7 was asked,, "What did (LPN #3) talk with you about?" CNA #7 stated, "She was asking what we were doing and if we were doing what we are supposed to, which we were." CNA #7 was asked,, "How are the lift legs supposed to be when you are lifting the resident?" CNA #7 stated,, "They are supposed to be closed and as you pull the chair back you are supposed to open the legs. That way it maintains the center of gravity." CNA #7 was asked,, "Did they re-inservice you on the lift?" CNA #7 stated, "No, they haven't yet." g. On 5/24/12 at 2:55 p.m. LPN # 5, the Restorative LPN, was asked, "Do you watch CNA's do Hoyer/mechanical lifts?" LPN #5 stated, "I have, yes." LPN #5 was asked,, "What do you look for?" LPN #5 stated, "The first thing I look for is a second person ... make sure they have the proper sling for size ... I make sure when they are moving from one surface to another that the legs are open." LPN #5 was asked,, "Clarify that, when should they open the legs?" LPN #5 stated, "After the resident is lifted and before they move to another destination." LPN #5 was asked, "What else do you look for?" LPN #5 stated, "Make sure the second person is guiding the resident and making sure the resident does no hit their head while the other person is working the lift." h. A witness statement written by CNA #4 documented, "I, (CNA #4), came into work at 7:00 a.m. on (5/21/12), went down to (Resident #6's) room (room number) ... (CNA #6) and (CNA #7) was getting (Resident #6) (out) of the shower chair with the lift. (CNA #7) walked out to talk to (LPN #3) and I turned to make sure the door was closing as well as trying to move his chair and I (looked) at (Resident #6) and seen the lift tilting with (CNA #6) holding on to it." The following was attached to the witness statement: "I have received and read a copy of how to use the Hoyer lift and a copy of points to remember when using the Hoyer." The form was signed on 3/28/12 by CNA # 4. On 5/24/12 at 3:25 p.m. CNA #4 was asked, "How long have you worked here?" CNA #4 stated,, "March 29, 2012." CNA #4 was asked, "Have you been in serviced on the Hoyer/mechanical lift?" CNA #4 stated, "Yes" CNA #4 was asked, "Were you in the room on Monday (5/21/12) when the Hoyer lift tilted over with (Resident #6)?" CNA #4 stated, "Yes." CNA #4 was asked, "What were you doing?" CNA #4 stated,"When I walked in (CNA #6) was holding the lift, (CNA #7) was holding the lift pad. The Broda chair was in front of the door and I pushed it over to Bed B's side." CNA #4 was asked, "Was the lift tilted over when you came in?" CNA #4 stated, "No, it was still standing cause (CNA #6) was pumping him up and getting ready to move him over to the bed.?" CNA #4 was asked, "How were the legs of the lift?" CNA #4 stated, "I believe they were opened but I'm not exactly sure." CNA #4 was asked, "Was (CNA #3) in the room?" CNA #4 stated, "Me and (CNA # 3) both went into the room at the same time. (CNA #7) who had been holding the lift pad left the room and I'm not sure (CNA #3) got a hold of the lift pad. As (CNA #7) left, I turned around to make sure the door closed and when I turned back I saw the lift already tilted ... I believed the lift was tilted because the floor was still wet from the shower chair." CNA #4 was asked, "When you walked into the room, what was the resident doing/like?" CNA #4 stated, "He was calm and still like he was trying to go to sleep. Normally he fights us when we try to get him up and down." CNA #4 was asked, "When they started pumping the Hoyer what was the resident doing?" CNA #4 stated, "He was calm. He never made a sound not even when we guided him to the floor." i. A witness statement written by CNA #6 and dated 5/21/12 documented, "I (CNA #6) (and) (CNA #3), (CNA #4) were transferring (Resident #6) out of the shower chair. When I went to pull back the lift and open the legs on it, the lift fell and (Resident #6) hit the floor. The nurse (LPN #3) came in and checked him." The following was attached to the witness statement: "I have received and read a copy of how to use the Hoyer lift and a copy of points to remember when using the Hoyer." The form was signed on 3/1/12 by CNA #6. On 5/24/12 at 4:52 p.m. CNA #6 was asked, "How long have you worked here?" CNA #6 stated, "On and off for 3 years." CNA #6 was asked, "Have you had any training on Hoyer/mechanical lifts recently?" CNA #6 stated, "Yes." CNA #6 was asked, "When?" CNA #6 stated, "A couple of months ago. They showed us and we had to read and sign a paper on Hoyer lifts." CNA #6 was asked, "Has anyone watched you do a lift transfer?" CNA #6 stated, "Yes, (LPN #3) did about 2 or 3 months ago." CNA #6 was asked, "Can you tell me about what happened with (Resident #6) on 5/21/12?" CNA #6 stated, "We, me, (CNA #3), and (CNA #4) and (CNA #7) were getting him out of the shower chair." CNA #6 was asked, "Were (CNA #3) and (CNA #4) already in the room when the transfer started?" CNA #6 stated, "Yes." CNA #6 was asked, "Were you behind the lift?" CNA #6 stated,, "Yes, I was the one working the lift." CNA #6 was asked, "Where was (CNA # 3)?" CNA #6 stated, "She was behind (Resident #6's) shower chair." CNA #6 was asked, "Where was (CNA #4)?" CNA #6 stated, "I couldn't tell you." CNA #6 was asked,, "Where was (CNA #7)?' CNA 6 stated, "Beside (CNA #3)." CNA #6 was asked, "What happened?" CNA #6 stated, "I was lifting him up and I went to open the legs and turn him and that's when he fell ." CNA #6 was asked, "You started lifting him up before you opened the legs of the lift?" CNA #6 stated, "Yes." CNA #6 was asked, "How high up was the resident?" CNA #6 stated, "He was all the way up on the lift and I started backing him up and opening the legs of the lift at the same time." CNA #6 was asked, "Was the resident still while he was in the lift or was he moving?" CNA #6 stated, "He was agitated and he was kind of punching, moving his arms in the air." CNA #6 was asked, "What happened next?" CNA #6 stated, "The lift tipped over and I caught the lift. It kind of fell on me. The top of it fell on me and I was holding the lift up." CNA #6 was asked, "Who was holding onto (Resident #6) before the lift fell ?" CNA #6 stated, "I think (CNA #3) was on the back of the lift pad." CNA #6 was asked, "Since this happened what has the facility done?" CNA #6 stated, "Told us about opening the legs of the Hoyer lift." CNA #6 was asked, "Has anyone watched you do a transfer since this happened?" CNA #6 stated, "No." CNA #6 was asked, "Was the floor wet?" CNA #6 stated, "Yes, it was under the shower chair, a few drops of water." CNA #6 was asked, "Did you know the floor was wet before you started lifting him?" CNA #6 stated, "Yea, I guess you could say that." CNA #6 was asked, "Once (Resident #6) fell , what happened?" CNA #6 stated, "The nurse came in. She was right outside and she came right in. I knew I'd messed up as soon as he hit the floor." CNA #6 was asked, "Why didn't you open the lift legs before the transfer?" CNA #6 stated, "I don't know. I really don't, that was a mistake." CNA #6 was asked, "Have you done any lifts since Monday (5/21/12)?" CNA #6 stated, "No, I haven't." CNA #6 was asked, "Has the facility done anything since then?" CNA #6 stated, "I signed an in service paper this morning." j. On 5/22/12 at 8:18 a.m., CNA #1 and 2 transferred Resident #6 from a Broda chair to bed via Hoyer lift. CNA #1 pushed the legs of the Hoyer lift under the seat of the Broda chair. The legs/base of the Hoyer lift were not opened. CNA #1 raised the resident, backed the lift up approximately 6 feet and then opened the legs/base of the Hoyer lift. CNA #1 guided the lift and CNA #2 guided the resident. The resident was moved over the bed and then lowered onto the bed with the lift legs/base opened. k. On 5/22/12 at 8:35 a.m., after providing incontinent care to Resident #6, CNA #1 and 2 transferred Resident #6 from bed to a Broda chair. CNA #1 moved the lift to the bed and opened the legs/base of the lift. CNA #1 guided the lift and CNA #2 guided the resident over to the Broda chair. When the lift was approximately 4 feet from the Broda chair, CNA #1 closed the legs/base of the lift and placed the legs under the seat of the Broda chair. CNA #1 lowered the resident into the Broda chair. On 5/25/12 at 9:40 a.m. CNA #1 was asked, "Have you had any training on mechanical lifts?" CNA #1 stated, "Yes." CNA #1 was asked, "What did you do for the training?" CNA #1 stated, "Papers on the process, step by step, do and don'ts and it was reviewed." CNA #1 was asked, "How are the lift legs supposed to be before you start lifting a resident?" CNA #1 stated, "Closed. You open them when you start doing the transfer, moving them." l. On 5/24/12 at 5:20 p.m. the Director of Nurses (DON) and Administrator were asked, "What have you done since the lift tipped over with (Resident #6) on 5/21/12?" The DON stated, "We started getting statements." The DON and Administrator were asked, "Any conclusions at this point?" The DON stated, "No, we've tried to determine what happened." The DON and Administrator were asked, "Have you had (LPN #5) re-evaluate (Resident #6) for safe transfers?" The DON stated, "No, we usually meet on Thursdays to discuss falls but you are here so we haven't had a meeting." The DON and Administrator were asked, "Have you talked with staff members yet about what happened?" The DON and Administrator stated, "No." The DON and Administrator were asked, "Since this happened have you had anyone monitoring these employees for mechanical lift transfers?" The DON stated, "Yes, (LPN #6) has an in service she's been doing with them." The DON and Administrator were asked, "Has anyone watched them doing mechanical lifts since this happened?" The Administrator stated, "I haven't told anyone to do that." 5. Resident #18 had [DIAGNOSES REDACTED]. The Quarterly MDS with an ARD of 3/18/12 documented the resident scored a 15 (13 - 15 indicates cognitively intact) on the Brief Interview for Mental Status, and was totally dependent on two plus persons for transfers. a. The "Plan of Care" dated 9/20/11 and reviewed on 3/19/12 documented, "Problem: (Activity of Daily Living) functional impairment (related to) History of fractured right hip and progressive [MEDICAL CONDITION] ... Interventions: ... Transfer to and from bed to chair, (wheelchair) by mechanical Hoyer lift ..." b. The Invacare mechanical lift manufacturer's instructions documented, "... Section 4 - Lifting the Patient. ... Invacare recommends that two assistants be used for all lifting preparation and transferring to/from procedures ... WARNING: The legs of the patient lift MUST be in the maximum open position for optimum stability and safety. If it is necessary to close the legs to maneuver the patient lift under a bed, close the legs only as long as it takes to position the patient lift over the patient and lift the patient off the surface of the bed. When the legs of the patient lift are no longer under the bed, return the legs to the open maximum open position. c. On 5/25/12 at 10:12 a.m., CNA #8 and 9 provided a mechanical lift transfers via Invacare lift. CNA #8 pushed the legs of the Invacare lift under the resident's Geri chair. The legs/base of the lift were not spread/opened. CNA #8 and 9 connected the lift pad to the lift frame. CNA #8 raised Resident #18 out of the Geri chair with the lift legs closed. CNA #8 backed the lift up approximately 4 feet, opened the legs/base of the lift and moved the resident via lift to the bed. CNA #9 guided the resident by holding onto the strap across the back of the lift pad. d. On 5/25/12 at 10:20 a.m. CNA #8 and 9 were asked, "Have you had any training on lift use?" CNA #8 and 9 stated, "Yes." CNA #9 stated, "Like about February or March. We had an inservice. They did a demo and we had to read a packet too and sign a paper." CNA #8 and 9 were asked, "Before you raise a resident, how are the legs/base of the lift supposed to be?" CNA #9 stated, "Opened because if the resident leans the center of gravity shifts." CNA #8 was asked, "Why didn't you open the legs/base of the lift?" CNA #8 stated, "I forgot." 6. The manufacturer's instructions for the Hoyer lift documented, "... Hoyer lifter maintenance: ... Regular maintenance of lifts and accessories is necessary to assure proper and safe operation. Read and observe the recommended instructions in the separate Assembly and Maintenance Manual ..." The "Hoyer Hydraulic Patient Lifters HML400 ... User Instruction Manual and Warranty" documented the swivel bar, pump assembly, lubrication and cleaning should be done bi-monthly. The Invacare "Owner's Operator and Maintenance Manual" documented the caster base, shifter handle, mast, boom, swivel bar, pump assembly, and slings and hardware are to be inspected monthly for institutional use. a. On 5/24/12 at 1:35 p.m. the Maintenance Supervisor stated, no routine checks of mechanical lifts were done. The Maintenance Supervisor stated, they do as needed repairs when told there was a problem. "I have had to replace pins and replaced hydraulic pumps and have had to add hydraulic fluid as needed." The Maintenance Supervisor was asked, for any maintenance request on mechanical lifts. b. On 5/24/12 at 2:32 p.m. the Director of Nurses stated, "No maintenance request related to mechanical lifts and no monthly maintenance was done on the mechanical lifts. c. On 5/24/12 at 5:20 p.m., the DON and Administrator were asked, "Does Maintenance do any routine checks of the mechanical lifts?" The DON stated, "No, he didn't know he was supposed to, but he's already added it to his routine rounds." 7. On 5/25/12 at 8:45 a.m. the Director of Nurses (DON) was asked, "Do you have any tracking of falls?" The DON stated, "Yes, (LPN (Licensed Practical Nurse) #5) does that, I'll get those." a. On 5/25/12 at 9:10 a.m., LPN #5 presented fall tracking from 3/1/12 through 5/22/12. The IDTM (Interdisciplinary Team Meeting) Fall Prevention Program form documented, "... (Resident #17); Date: 3/10/12; Determined Cause: Hoyer lift tipped; Intervention: Not use lift ..." b. On 5/25/12 at 2:17 p.m., the Administrator presented inservices that were requested. The inservice dated 1/24/12 documented, "How to use lifts." There was no attachment provided. The Administrator stated, "This was all the inservices I could find on mechanical lifts." 8. The Immediate Jeopardy was removed and the scope/severity reduced to "E" on 5/25/12 at 3:20 p.m. when the facility implemented the following Plan of Removal: "On 5/25/12 at 11:45 a.m. the facility was informed that an Immediate Jeopardy situation existed. There are 9 residents currently in the facility who require a mechanical lifts. All Department Heads were notified and training began immediately on 5/25/12 at 1:00 p.m. by (LPN #3) and (LPN #6). All nursing staff (CNA's, charge nurses and administrative nursing staff) will be in serviced at the beginning of each shift beginning on 5/25/12 at 1:00 p.m. and will be ongoing to include new hires and staff returning from leave. Training will take place before staff use the lift on any resident who require a Hoyer or Invacare lift transfer. Training will be done by DON/designee and in-service sign-in sheets will be used. Training will include a review of the Hoyer policy and procedure, safe use of mechanical lifts, and a return demonstration which includes a check

Complaint # was substantiated (all or in part) in these findings. Based on observation, record review and interview, the facility failed to ensure acceptable parameters of nutrition were maintained as evidenced by the facility's failures to ensure resident's at nutritional risk were monitored consistently for parameters of nutrition and that interventions were developed/implemented to address continued weight loss for 1 (Resident #3) of 3 (Resident #2, #3 and #5) case mix residents with significant weight loss and for 1 (Resident #1) of 2 (Resident #1 and 4) case mix residents who had insidious weight loss. This failed practice resulted in a pattern of harm for Resident #3 who experienced a significant weight loss and for Resident #1 who experienced an insidious weight loss and had the potential to cause more than minimal harm to 8 residents with significant weight loss and 7 residents with weight loss, as identified on a list received from the Medicare Coordinator on 12/3/10. The findings are: 1. Resident #3 had [DIAGNOSES REDACTED]. An Annual Minimum Data Set (MDS) with an assessment reference date of 10/3/10 documented the resident was severely impaired in cognitive skills for daily decision making, required limited assistance of 1 person for eating, required extensive assistance of 1 person for bed mobility, was totally dependent on 1 person for toileting and personal hygiene, had a weight loss and had a stasis ulcer. a. A plan of care dated 12/1/10, documented, "...High risk for progressive weight loss... spoon feed (4/6/10), Record weight PRN (as needed) and weekly, report significant loss to MD (medical doctor) and family PRN, 6/9/10 Ensure Plus 8 ounces BID (twice a day) between meals record accurate amount, and Resource 2.0 2 ounces BID with med (medication) pass record tolerance 1/19/10." b. The Monthly Weight sheet documented the resident's weights as follows: 1) 6/3/10 - 125.5 pounds (lbs) 2) 7/11/10 - 125.6 lbs 3) August 2010 (no weights recorded) 4) 9/19/10 - 117.6 lbs 5) 10/10/10 - 115.2 lbs 6) 11/7/10 - 112.5 lbs 7) 12/1/10 - 111.0 lbs The above weights showed a 11.6% (14.5 lbs) weight loss in 6 months (from June 2010 to December 2010), a 5.10% weight loss (6 lbs) in 3 months (from September 2010 to December 2010) and a 3.64% weight loss (4.2 lbs) in 1 month (from October 2010 to December 2010). c. The Dietary Progress Notes dated 7/28/10 documented the resident was on a regular diet, was put on Ensure plus BID (twice a day) due to her weight being down 10 pounds, and was signed by the Certified Dietary Manager (CDM). The Dietary Progress Notes dated 8/24/10 documented the diet was the same, met the resident needs at that time, and was signed by the Registered Dietitian (RD). There was no documentation of any new recommendation to address the resident's weight loss. The Dietary Progress Notes dated 9/23/10 documented the resident's present weight was 116.6 which was down 8.9 lbs for 3 months and 10.6 lbs for 6 months and that the resident was on a regular diet with ensure plus 8 ounces BID. The note also documented, "Calories and protein are adequate for wound healing and to prevent further weight loss." The note was signed by the CDM. There was no documentation of any new recommendation to address the resident's weight loss. The Dietary Progress Notes dated 10/25/10 documented, "monthly weight 115.2, down 10.4 lbs in 3 months and 14.0 lbs in 6 months. Calorie and protein are adequate to promote weight gain if (Resident #3) will consume meals and supplements." The note was signed by the CDM. There was no documentation of any new recommendation to address the resident's weight loss. The Dietary Progress Notes dated 11/22/10 documented, "Weight 112.5 down 16.9 % in 180 days (6 months), requires much encouragement." The note was signed by the RD. There was no documentation of any new recommendation to address the resident's weight loss. d. The physician progress notes [REDACTED]. Her weight has decreased by 10 lbs to 125. She is refusing Ensure." The physician progress notes [REDACTED]. The physician progress notes [REDACTED]. She is still able to feed herself..." There was no documentation of resident's weight loss. The physician progress notes [REDACTED]. The physician progress notes [REDACTED]." There was no documentation in the physician progress notes [REDACTED]. e. The Careteam Meeting Interdisciplinary Progress Notes dated 7/21/10 documented under Weekly and Restorative Weights, "No wkly (weekly) wts provided this day d/t (due to) scale broken or being repaired." The Careteam Meeting Interdisciplinary Progress Notes dated 9/1/10 documented under Weekly and Restorative Weights, "No Weights: Scale broken. Will be getting one very soon." The Careteam Meeting Interdisciplinary Progress Notes dated 9/8/10 documented under Weekly and Restorative Weights, "No Weights - Scale broken." f. The Food Intake Sheets for September 2010 and October 2010 had no documentation of the amount of Ensure plus that the resident had accepted. g. The resident's November 2010 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. h. On 12/ 2/10 at 1:30 p.m., the resident was in the dining room at the eating assistance table. The resident received a ham slice, sweet potatoes, green beans, a roll, 1 pat margarine and 4 ounces of a strawberry colored milk product. The resident refused the food that had been served, but drank independently. No alternate foods were offered or obtained for the resident. At 1:50 p.m., Certified Nursing Assistant (CNA) #1 said to CNA #2, "Do you think the food is too hard for (Resident #3). Maybe she needs to be evaluated." The resident consumed 3 ounces of the strawberry colored milk product and three-fourths of a roll. No more of the milk product that the resident drank was obtained or offered. i. On 12/2/10 at 4:20 p.m., when asked for the weights for August 2010 the Administrator stated, "We don't have August (2010); that is when our scales were broke." j. On 12/2/10 at 4:24 p.m., the Medicare Coordinator was asked, "Why are there no August weights?" She stated, "At the end of July (2010), the wheelchair scale tore-up. The digital part would not display the weight. The part was ordered in July. It did not come in during August and it finally came in during September. Then the same part malfunctioned again in October (2010) for about 2 weeks and we got it fixed again." When asked how they weighed the residents she stated, "We had a regular scale like you have at home so the residents that could stand could be weighed. The Hoyer lift didn't weigh the residents right. They would either show a big weight gain or loss. It just didn't weigh right." k. On 12/3/10 at 10:58 a.m., the Dietary Manager (DM) was asked, "Can you tell why no interventions have been tried since 7/28/10 for (Resident #3)?" The DM stated, "We have her to be assisted fed if she will let us but, no ma'am, nothing else." The DM was asked, "Has anyone assessed her diet?" The DM stated, "We discussed getting speech to see her this morning." l. On 12/3/10 at 11:05 a.m., the DM was asked, "What is your system if a weight is abnormal?" The Medicare Coordinator answered, "If there is a weight out of whack I tell the rehabilitation nurse and they have a re-weigh done. Then if it is still abnormal we see how they weighed them." 2. Resident #1 had [DIAGNOSES REDACTED]. The MDS dated [DATE] documented the resident was moderately impaired in cognitive skills for daily decision making, required set-up assistance for eating, had chewing and swallowing problems, had no significant weight loss, left 25% or more food uneaten at most meals, was on a mechanically altered diet, was on a therapeutic diet and received a dietary supplement between meals. a. A Resident Assessment Protocol for Nutritional Status dated 8/10/10 by the CDM documented, Therapeutic diet, refusal to eat, high calorie needs (supplement) assist with all meals, history of weight loss, places at risk for [MEDICAL CONDITION]. b. A Plan of care dated 11/10/10 documented, "Potential risk for [MEDICAL CONDITION] ...will have weight loss minimized as much as allowed ...diet as ordered, encourage to eat and assist out of bed for all meals, record portion eaten, report to nurse refusal to get up or eat. Assess weight as needed record monthly. Encourage fluid intake between meals and at bedside. Encourage choice of snacks and fluids from hydration cart prn throughout the day and report effects prn." c. A monthly weight sheet showed the resident's weights as follows: 1) 5/8/10 - 106.6 lbs 2) 6/13/10 - 104.6 lbs 3) 7/11/10 - 106.9 lbs 4) August 2010 (no weights recorded) 5) 9/19/10 - 102.6 lbs 6) 10/10/10 - 100.8 lbs 7) 11/7/10 - 99.8 lbs d. The Dietary Progress note dated 9/13/10 documented, "No weight available. Intake of meals mostly poor - encourage to eat each meal and offered ms (mighty shake)." The note was signed by the RD. There was no documentation of any new recommendation to address the resident's insidious weight loss. The Dietary Progress note dated 10/27/10 documented weight 100.8, Sept. 102.6, July 106.9. Diet the same. The Note was signed by the RD. There was no documentation of any new recommendation to address the resident's insidious weight loss. The Dietary Progress note dated 11/10/10 documented the resident continued on a mechanical soft diet with 4 ounces of mighty shake with meals and super cereal at breakfast. Will continue to follow. Monthly weight 99.8 down 1 pound in 1 month. The note was signed by the DM. There was no documentation of any new recommendation to address the resident's insidious weight loss. The Dietary Progress Note dated 11/22/10 documented weight 99.8 Oct. (October) 100.8, May 106.6, down 6.4% in 180 days (6 months) down 1 lbs this month. Encourage intake all meals. The Note was signed by the RD. There was no documentation of any new recommendation to address the resident's insidious weight loss. e. On 12/3/10 at 11:15 a.m., the Certified Dietary Manager was asked if any interventions had been put in place for the resident for the weight loss. The DM stated, "No, Ma'am." 3. The policy and procedure "(Facility) procedure to address weight loss" was received from the Medicare Coordinator on 12/3/10 and documented, "All weights are reviewed and interventions are discussed and put into action; ---Upon admission ---Adon (Assistant Director of Nursing) reports during monthly rounds with physician ---At weekly team meetings and PRN. All team members discussed weights issues and the MDS coordinator notifies MD via fax and or phone for any significant weight loss. Insidious weight loss is monitored by the dietary manager and discussed at the weekly meetings." 4. The procedure for "Weighing Residents" was received from the Administrator on 12/3/10 at 1:25 p.m. and documented, "Residents are weighed on admit, re-admit, monthly and weekly (if on a weekly weight). Any resident who is able to be transferred into our standard weight chair is weighed in the same manner (considering clothing, shoes, ortho boots, ect. worn) each time they are weighed. If there is a weight gain of loss of 5 lbs or more, reweigh resident checking to make sure the manner is the same as the last weight. If the weight remains unchanged, notify the Restorative nurse or Charge nurse to verify the weight, checking for [MEDICAL CONDITION], considering if Resident has been ill, recently given diuretics or if there has been a change in appetite. For residents who are weighed in their own wheelchair or geri chair make sure it is the same chair taking into consideration what type and if cushions, pillows, footwear and weigh them in the same manner each week or month or both."