Every finding on record at Three Rivers Health and Rehabilitation Center

Number of residents sampled: Number of residents cited: Based on observation, interview and facility policy review it was determined that the facility failed to ensure hair restraints were consistently worn to prevent the potential for hair to contaminate resident food items in one of one kitchen observed. The findings include: During an observation on 04/14/2026 at 10:28 AM, Dietary Aide (DA) #1 was observed preparing sandwiches with a hair net covering the top part of their hair, from their ears up. There was uncovered hair out of the back of the hair net. DA #1 noticed this surveyor observing the kitchen, moved quickly to the outside door and called out to other workers requesting a hair net. DA #1 indicated they knew all their hair should have been covered by the hair net and that it had just fallen out. DA #1 indicated that the length of their hair was 28 inches long, and it should have been contained in a hair net. DA #2 was also observed preparing food into bowls during DA #2 had approximately two inches of hair hanging out on each side of their head not confined by the hair net. DA #2 reported that all their hair should have been up in the hair net. During an interview on 04/14/2026 at 11:00 AM, the Dietary Manager (DM) confirmed that all hair should be confined with a hair net and that extra-large hair nets were available to ensure that dietary staff with a lot of hair can keep it all put up. The DM confirmed that all staff were trained on how to keep their hair contained in a hair net and that there was a sign on the entry door explaining how to keep their hair restrained. During an interview on 04/16/2026 at 9:30 AM, the Administrator indicated that Dietary Staff were trained during initial hire training in the kitchen regarding wearing hair restraints, but the DM did not have the Dietary Staff sign an in-service training document. During an interview on 04/16/2026 at 11:22 AM, the Administrator reported that their expectation of the Dietary Staff was that all their hair should be covered while preparing food items to prevent the potential for contamination of resident food items. Review of a facility document titled In-Service Training dated 04/14/2026, revealed the topic of hairnets and beard guards. The document also revealed make sure all hair is under the hairnet and do not to walk through the kitchen without hair being covered. This document was signed by seven employees including DA #2 indicating they received this in-service. DA#1 signature was not on the in-service sheet. Review of an undated document taped to the entry door of the kitchen revealed that all employees must wear effective hair restraints in the food preparation areas. The hair restraints must be worn in a manner that prevents hair from contaminating food, equipment or single use items. Review of a facility Kitchen Inspection Checklist dated 04/08/2026 revealed the Registered Dietician documented a completed inspection and that hair and beard coverings were worn correctly. Review of a facility policy titled Employee Sanitary Practices dated 2013 revealed, the food service manager assures all of the following which included all personnel follow sanitary practices and all employees would wear hair restraints to prevent hair from contacting exposed food.

Based on observations, interview, and record review the facility failed to ensure hand hygiene was performed properly in one of one kitchen. The findings are: On 08/27/2024 at 10:45 AM, Dietary Aide #8 donned gloves to remove the middle blade of the food processor, Dietary Aide #8 then added the pureed spaghetti to a medium rectangular steam table pan with gloves still on. Dietary Aide #8 then proceeded to put the food processor back together, she took off her gloves and did not wash hands. She then added the rest of the regular spaghetti into the food processor from a medium rectangular steam table pan. Dietary Aide #8 was observed pouring the puree spaghetti into the same steam table pan with the rest of the pureed spaghetti. Dietary Aide #8 then cleaned the area up to puree green beans. The Surveyor observed Dietary Aide #8 putting the food processor back together and put on a glove on the left hand. The Surveyor then observed seven 4-ounce scoops were added in the food processor, the Dietary Aide #8 then removed the glove with no handwashing and ran the food processor. After running the food processor Dietary Aide #8 poured the pureed green beans into a medium rectangular steam table pan. Dietary Aide #8 then added the rest of the regular green beans left in the pan into the reassembled food processor. The Surveyor observed the Dietary Aide #8 run the food processor and add the puree green beans into the same steam table pan with the rest of the pureed green beans. Dietary Aide #8 then cleaned up the preparation table and the food processor and washed her hands. On 08/27/2024 at 12:00 PM, the Surveyor observed Dietary Aide #9 put on gloves then take off his gloves, he did not wash his hands. Dietary Aide #9 proceeded to put on oven mitts and pull-out garlic bread, he took off the oven mitts and put on gloves. He put the garlic bread in a steam table pan and covered it with cling wrap. The Surveyor observed Dietary Aide #9 add both pans to the steam table serving line, and then proceeded to wash his hands. On 08/28/2024 at 3:00 PM, during an interview the Dietary Manager stated that you wash hands in between tasks, changing gloves, when pureeing, you cannot wash your hands enough. The Dietary Manager stated it is important to wash hands to prevent food borne illness. On 08/29/2024 at 8:45 AM, during an interview Dietary Aide #8 stated that you wash hands as soon as you finish puree, when you start something again, and anytime you touch something, you wash hands. Dietary Aide #8 stated it is important to wash hands to prevent disease or infection. On 08/29/2024 at 8:47 AM, during an interview Dietary Aide #9 stated that you wash hands anytime you are handling food from one place to another. I always try to wash my hands. Dietary Aide #9 stated you wash your hands as you do not want to spread bacteria, infection and prevent cross contamination of food. A review of the facility policy, Handwashing and Glove Usage in Food Service, states that Objectives: 1. Understand the importance of handwashing in prevention of illness; 2. Identify when hands need to be washed.

Based on observation, interview, and record review, the facility failed to ensure an accident/hazard free environment was provided for 2 (Residents #6 and #64) of 2 sampled residents. The findings are: 1. Review of a facility policy titled; Accident Hazards Prevention indicated, The environment will be free from accident hazards as is possible. A review of the Admission Record, indicated the facility admitted Resident #6 with a diagnosis of heart disease that included dementia. A review of the annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/31/2024 revealed the resident had a Brief Interview for Mental Status (BIMS) of 2, which indicated the resident had severe cognitive impairment for their daily decision making. Review of Resident #6's Care Plan, initiated on 02/28/2023 and revised on 06/04/2024, revealed the resident was at risk for falls. Interventions included maintaining a low bed and placing a fall mat at the bed the right side of the bed (initiated 05/30/2024). On 08/26/2024 at 11:10 AM, Resident #6 was observed resting in bed. The bed was in a low position without a fall mat. On 08/26/2024 at 2:00 PM, Resident #6 was observed receiving care by Certified Nursing Assistant (CNA) #1 and Certified Nursing Assistant #2. After the care, they left the room. Both CNAs were asked if a fall mat was beside the bed, and they said it was not. During an interview on 08/26/2024 at 2:15 PM, Licensed Practical Nurse (LPN) #3 stated there should be a fall mat on the right side of the bed so that if the resident rolled off the bed, they would not fall on the floor. During an interview on 08/26/2024 at 3:30 PM, the Director of Nursing (DON) stated Resident #6 should have a fall mat down at all times to prevent injury if they rolled out of the bed. 2. A review of the Admission Record indicated the facility admitted Resident #64 with a diagnosis of dementia that included dysuria (pain or discomfort while urinating). A review of the admission MDS with an ARD of 04/10/2024 revealed the resident had a BIMS score of 13, which indicated the resident was independent for their daily decision making. Review of Resident #64's Care Plan initiated on 03/29/2024 indicated the resident had impaired cognitive function related to dementia. Interventions included cueing, reorienting, and supervising the resident as needed. On 08/26/2024 at 11:30 AM, a tube of hemorrhoidal ointment was observed in Resident #64's bathroom. The instructions on the tube included to keep out of the reach of children. During an interview on 08/26/2024 at 3:30 PM, LPN #3 said hemorrhoidal ointment should not be left in a resident's bathroom. During an interview on 08/26/2024 at 4:00PM the Director of Nursing stated that Resident #64 should not have a tube of hemorrhoidal ointment in their bathroom.

Based on observation, record review, and interview, the facility failed to ensure residents who required assistance with activities of daily living were regularly provided with the necessary assistance to maintain good hygiene and grooming for two (Residents #69 and #88) of two sampled residents. The findings are: 1. A review of the Order Summary revealed Resident #69 had diagnoses of dementia, depressive episodes, anxiety, and chronic kidney disease. A review of the quarterly Minimum Data Set (MDS) with an Assessment of Reference Date (ARD) of 06/27/2024 revealed Resident #69 scored a 3 (severe cognitive impairment) on the Brief Interview Mental Status (BIMS). A review of the Care Plan, initiated on 03/01/2023 revealed Resident #69 required assistance of two staff with bathing and used a shower bed. A review of the Bath Task revealed Resident #69 from 7/31/2024 to 8/26/2024 received a bed bath only. A review of the Behavior Monitoring Task sheet revealed that for Resident #69 from 07/30/2024 to 08/28/2024, no behaviors were charted. On 08/28/2024 at 3:05 PM, the Nurse Consultant stated the facility did not have a policy for activities of daily living. On 08/26/2024 at 11:23 AM, the Surveyor observed Resident #69 in bed, hair was greasy, sticking to the pillowcase and facial hair was observed to be curling on each corner of their chin. On 08/27/2024 at 10:00 AM, the Surveyor observed Resident #69 in bed, hair had not been washed, and resident had not been shaved. On 08/28/2024 at 10:45 AM, the Surveyor observed Resident #69 in bed, hair was greasy, and the resident had not been shaved. On 08/28/2024 at 10:45 AM, during an interview, Certified Nursing Assistant (CNA) #4 stated Resident #69's facial hair was long and needed shaved. CNA #4 stated that Hospice gave a complete bed bath yesterday and must have missed the facial hair as they usually get it. CNA #4 stated that Resident #69's hair is greasy, stringy, and long that it needs to be trimmed in the beauty shop. CNA #4 stated it would not feel good to have greasy hair or long facial hair. CNA #4 stated that baths are important to ensure they get the care they need. On 08/28/2024 at 10:52 AM, during an interview, Licensed Practical Nurse (LPN) #6 stated Resident #69 normally gets a complete bed bath with Hospice including a shower cap. LPN #6 stated that Resident #69 needs shaved, hospice usually get its and hair is oily, stringy, and long. LPN #6 stated that nobody would want to feel unclean with greasy hair or facial hair. LPN #6 stated that baths are important to make sure they are clean and presentable and if they go without baths, they end up with skin conditions like yeast, need them to be well taken care. 2. A review of the Order Summary revealed Resident #88 had diagnoses of type two diabetes, need for assistance with personal care, and dementia. A review of the Significant Change MDS with an ARD 07/29/2024 revealed Resident #88 scored a 2 (severe cognitive impairment) on the BIMS. A review of the Care Plan, initiated on 08/24/23 revealed Resident #88 was dependent for bathing; required assistance of two staff with bathing; and used a shower bed. A review of the Bathing Task sheet revealed that Resident #88 from 07/31/2024 to 08/28/2024, had only bed baths except one shower given on 08/05/2024. A review of the Behavior Monitoring sheets revealed that Resident #88 had no behaviors from 07/31/2024 to 08/28/2024. On 08/26/2024 at 11:37 AM, the Surveyor observed Resident #88 in bed, both hands had thick fingernails with a yellow brown substance around them, two of the nails on the left hand are longer and jagged. On 08/27/2024 at 10:05 AM, the Surveyor observed Resident #88 in bed, nails have not been trimmed or cleaned. On 08/28/2024 at 11:00 AM, the Surveyor observed Resident #88 in bed, nails have not been trimmed or cleaned. On 08/26/2024 at 12:15 PM, during an interview CNA #4 stated currently they have 13 to 14 baths to do in a day. CNA #4 then stated that usually only two CNAs work back there with all 27 residents, and some of the baths require two people to give them. CNA #4 stated that there is not a bathhouse on the unit, and they coordinate with other halls to be able to give baths, it is difficult to be able to get them done in a timely manner with the behaviors back here. On 08/28/2024 at 1:30 PM, during an interview with CNA #4 and CNA #5, CNA #4 stated Resident #88 had a dark substance under and around their nails and were jagged, long, and thick. CNA #4 stated that Resident #88 was diabetic, and the nurses do the nail care. CNA #5 stated that long nails can cause scratches and infections. On 08/28/2024 at 1:43 PM, during an interview Registered Nurse (RN) #7 stated Resident #88 ' s fingernails were long, dirty and jagged. RN #7 stated they need trimmed, for hygiene and bacteria and contamination, they could scratch themselves causing a sore or could put it in mouth or eyes could cause infections. On 08/28/2024 at 2:45 PM, during an interview the Director of Nursing (DON) stated that activity of daily living is important as they should be well groomed it is their right and without baths, they can get skin issues or infections.

Based on observation, record review, and interview, the facility failed to ensure residents who required assistance with foot care were regularly provided with the necessary assistance to maintain good hygiene and grooming, as evidenced by failure to ensure toenails were kept clean and trimmed for one (Resident #88) of one sampled resident. The findings are: A review of the Order Summary revealed Resident #88 had diagnoses of type two diabetes, need for assistance with personal care, and dementia. A review of the Order Summary reveals no standing order for podiatry. A review of the Significant Change Minimum Data Set (MDS) with an Assessment of Reference Date (ARD) of 07/29/2024 revealed Resident #88 scored a 2 (severe cognitive impairment) on the Brief Interview Mental Status (BIMS). A review of the Care Plan, initiated on 08/24/23revealed Resident #88 was dependent for bathing; required assistance of two staff with bathing; and used a shower bed. A review of the Bathing Task sheet revealed Resident #88 from 07/31/2024 to 08/28/2024, charted only bed baths except one shower given on 08/05/2024. A review of the Behavior Monitoring sheet revealed Resident #88 had no behaviors from 07/31/2024 to 08/28/2024. On 08/28/2024 at 03:05 PM, the Nurse Consultant stated there was no foot care policy. On 08/26/2024 at 11:37 AM, the Surveyor observed Resident #88 was lying in bed with legs contracted, a drawsheet bunched up underneath, Resident #88 was moving their feet a lot. Surveyor observed the resident ' s toenails were long, thick, and jagged. On 08/27/2024 at 10:05 AM, the Surveyor observed Resident #88 in bed, toenails had not been trimmed. On 08/28/2024 at 11:00 AM, the Surveyor observed Resident #88 in bed, toenails had not been trimmed. On 08/28/2024 at 1:30 PM, during an interview with Certified Nursing Assistant (CNA) #4 and CNA #5, CNA #4 stated Resident #88's feet were dry and scaly, and the toenails were long and jagged. CNA #4 stated the nails had been reported over a month ago for podiatry. CNA #5 then stated Resident #88 was diabetic, and the nurse is supposed to do the nail care. On 08/28/2024 at 1:43 PM, Registered Nurse (RN) #7 stated that Resident #88's toenails are a little long and jagged, they do need trimmed for hygiene reasons and to prevent infections, normally the treatment nurse does the diabetic nail care in house, and that they can trim the resident's toenails today. On 08/28/2024 at 2:00 PM, during an interview Licensed Practical Nurse (LPN) #6 stated Resident #88 gets diabetic nail care in house normally and that they had been added recently to the podiatry caseload.

Based on observation, interview, and record review the facility failed to ensure food items were maintained at acceptable temperature, failed to ensure employees washed hands between clean and dirty tasks and failed to obtain foods served to residents were from an approved source to prevent food borne illness. The failed practice resulted in 6 (Resident #11, #21, #30, #38, #50 and #87) residents experiencing food borne illness symptoms and had the ability to affect 93 residents who receive meals from 1 of 1 kitchen according to a list provided by the Director of Nursing on 08/17/2023 at 11:00 AM. The findings included: The situation resulted in a finding of Immediate Jeopardy. The facility's Regional [NAME] President and the Director of Nursing were notified of the findings of Immediate Jeopardy on 08/14/2023 at 3:23 PM. Observations on 08/14/2023 showed the following: a. At 10:45 AM, 3 Hoagie Rolls dated 07/31/2023 and 12 Hamburger buns dated 08/03/2023 were on top of a stack of bread racks in the kitchen. b. At 10:47 AM, fourteen, 5 Gallon containers of water with no use by date or received date on the bottom shelf in the dry storage area of the kitchen. c. At 10:48 AM, Dietary Aide #1 used a paper towel with a dark colored substance to wipe along the seal underneath the top of the ice machine. During observation on 08/14/2023 at 10:50 AM of the walk-in refrigerator/freezer. The temperature was 54 degrees Fahrenheit. Inside was a rolling cart filled with trays of cheesecake and pie. A Dietary Aide removed the tray of desserts from the walk-in refrigerator/freezer. When the Surveyor exited the walk-in refrigerator/freezer, the rolling cart of cheesecake and pie had ice cubes sprinkled over the top of the covered bowls. Some portions of desserts were in Styrofoam bowls with unsecure lids. During observation on 08/14/2023 at 11:04 AM with Dietary Aide #1 of an outside refrigerated trailer located at the back of the facility showed the following: a. No thermometer was found inside or outside of the trailer to monitor the temperature of the refrigerator. b. A noise was heard from the refrigerator motor on the outside of the trailer and the fans located inside the trailer showed no movement. c. The Surveyor requested a thermometer. Dietary Aide #1 obtained a thermometer from the kitchen and temperatures were as follows: 1. A large plastic bowl of milk sitting on top of three plastic milk crates had a temperature of 60 degrees Fahrenheit. 2. The second plastic crate had multiple 1/2 gallon containers of buttermilk had a temperature of 42 degrees Fahrenheit. 3.Three fourths way into the trailer were multiple containers of thickened sweet tea. The temperature was 50 degrees Fahrenheit. 4. On the left side of the trailer was a 1/2 steam table pan which contained 9 turkey and cheese sandwiches. The thermometer was inserted into the middle of the sandwich, between the bread and meat, and the temperature was 62 degrees Fahrenheit. 5. Eight single serving containers of yogurt were observed in a 1/2 steam table pan. The temperature was 60 degrees Fahrenheit. Also observed in the trailer, where multiple raw vegetables, a large roast, a box of hamburger meat, large plastic bag containing sliced cheese, a large plastic bag containing deli turkey and multiple cases of food products still in their case. On 8/14/23 at 11:43 AM, observed facility employees entering a room at the end of the building by the refrigerated trailer that had an Electric Room sign. When the employee returned to the trailer, the motor to the trailer came on. During observation on 08/14/2023 showed the following: a. At 11:23 AM, observed Dietary Aide #2 with gloved hands assembled a loaf of bread, a large zip lock plastic bag containing a large block of sliced cheese and a cutting board. With the same gloves, Dietary Aide #2 took the bag of bread and pulled 12 slices out of the bag, Dietary Aide #2 placed the slices on the cutting board and with the same gloves retrieved the bag of cheese, opened it, and reached in to obtain multiple slices. One cheese slice was placed on each stack of bread. With the same contaminated gloved hands, Dietary Aide #2 opened a large plastic bag and took out sliced turkey. With the same gloves, Dietary Aide #2 placed each sandwich into a plastic bag. b. Dietary Aide #2 at 11:30 AM placed an individual packet of mayonnaise on top of the bread contaminating the bread. c. A large plastic container of bacon was brought in from the refrigerated trailer at 11:45 AM. The Surveyor asked Dietary Employee #4 to take the temperature of the bacon. Dietary Aide #3 brought a thermometer from the steam table, and the temperature was 69 degrees Fahrenheit. Dietary Manager (DM) stated zeroing the thermometer was necessary. She obtained a cup of ice water and inserted the thermometer. After the process was completed, the DM handed the thermometer to Dietary Aide #3. Dietary Aide #3 inserted the thermometer into the bacon and the temperature was 78 degrees. The DM instructed Dietary Employee #4 to dispose of the bacon and wash the large plastic container. d. At 12:05 PM, kitchen staff performed no hand hygiene prior to putting food on serving trays, touching rolling trays and putting on gloves. e. Flies were landing on serving bowels sitting on the serving line. On 8/14/23 at 12:10 PM observed Dietary Aide #1 with a 1/2 gallon of buttermilk that was brought in from the refrigerated trailer to be used in the meal preparation. The Surveyor notified the Dietary Manager, and asked if it was safe to use milk that had a temperature of 60 degrees. The milk was not served after the surveyor's intervention. During observation of the dining room on 08/14/2023 at 12:27 PM, Certified Nursing Assistant (CNA) #9 touched Resident #38's meat and gravy ungloved and failed to replace the meal tray. During interview on 08/14/2023 at 12:28 PM, the Surveyor asked CNA #9, what are you supposed to do after touching food on a resident's meal tray? CNA #9 replied, get another tray. At 12:36 PM, CNA #9 was asked, why didn't you get Resident #38 a new tray after touching the meat? CNA #9 replied, I'm trying to get the dining room trays passed out so we can do the hall trays. During observation on 08/14/2023 of the kitchen/serving line showed the following: Dietary Aide #1 at 2:26 PM poured water from melted ice out of a bowl containing a serving of cheesecake and placed the bowl on a tray to be served to a resident. The Surveyor asked Aide #1 if the dessert is servable as it had been sitting in water from the melted ice. Dietary Aide #1 removed the bowl from the tray and asked a coworker to remove the desserts which had water standing in the bowl. Dietary Aide #1 was asked why some portions were in Styrofoam bowls. She stated, we don't have enough bowls to serve everyone. The dessert had been in the walk-in refrigerator, and had ice placed around them to keep them cool. On 8/14/23 at 12:29 PM observed 2 sandwiches which were made with ingredients from the refrigerated trailer were placed on a tray to be served. The Surveyor asked the DM if the sandwiches which were made from ingredients from the disabled trailer should be served to the residents. The sandwiches were removed from the tray and discarded after surveyor intervention. Review of the temperature log for the refrigerated trailer on 08/14/2023 at 12:50 PM provided by the DM showed no recordings for the current date. The DM reported that Dietary Aide #3 took the morning temperature. During interview with Dietary Aide #3, she said she failed to record the temperature this morning. DM said she checked the trailer this AM at 8:50 AM, and the temperature was 36.2 degrees Fahrenheit. The Surveyor accompanied DM to the outside refrigerated trailer and the temperature was 42.8 degrees Fahrenheit. On 08/15/2023 at 2:17 PM three sampled residents (Resident #87, Resident #11, and Resident #30) reported gastric symptoms on the weekend continuing through Monday on 08/14/2023. Certified Nursing Assistant CNA #6 and #7 confirmed all 3 residents experienced diarrhea. During interview on 08/14/2023 at 3:04 PM with Resident # 38 said diarrhea started about three days ago. Resident # 21 at 3:05 PM said stomach cramping and diarrhea since Friday. The Surveyor asked Resident #50 at 3:07 PM have you had any stomach problems like diarrhea or stomach cramping in the past few days? Resident #50 replied, yes, diarrhea, you can ask them at the nurses station. During interview on 08/14/2023 at 5:40 PM with Dietary Manager (DM) she said she had reported the issues with the walk-in refrigerator a month ago and got yelled at by the corporate maintenance guy for calling someone to get the refrigerator repaired on Sunday. During interview with the DM on 08/16/23 at 1:40 PM, the DM said first time she experienced problems with the walk-in refrigerator was June 19th. The Surveyor asked when the Okra served during the lunch meal on 08/14/2023 was brought to the facility. The DM said she was informed on Friday (08/11/2023) that a family was bringing Okra to the facility on Monday (08/14/2023). The Okra was brought to the facility, and it was cooked that morning. The DM said she wasn't sure if it had been in someone's house or out of a garden. The Surveyor asked the DM if she was aware of what the facility policy said concerning food brought in from the outside. DM thought for a minute and then stated, I'm going to say I'll check. Review on 08/15/2023 at 2:39 PM of the facility's policy titled Food and Nutrition Services undated showed the following: 1. To prevent contamination of food products and prevent foodborne illness. a. Obtain food only from approved sources. b. Maintain storage of perishable foods at 41degrees F (Fahrenheit) or below. c. Fruits, vegetables, dairy products, meat, and poultry must be stored at temperatures between 33-45 degrees F. d. All meat salads, cream-filled pastries and other potentially hazardous foods shall be prepared from chilled products and refrigerated below 41 degrees F immediately after preparation. Review of the facility's policy titled Infection Prevention and Control Program provided by the Administrator in Training (AIT) on 08/16/2023 at 12:54 PM showed, all staff working in all locations will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. Plan of Removal for Immediate Jeopardy received on 08/15/2023 from the Director of Nursing included the following: l. On 08/14/2023 at approximately 11:15 AM a temporary cooler was noted to not be functioning properly. 2. Maintenance noted temporary cooler plugged into GFCI (ground fault circuit interrupters) outlet and breaker was thrown. 3. Maintenance installed a standard outlet to prevent reoccurrence, completing replacement at 2:30 PM. 4. Dietary manager ensured all food items from cooler met temperature prior to serving. 5. All food in the temporary cooler removed and placed in dumpster. 6. The Dietary Manager ensured no items from temporary cooler to be served to residents. 7. Temporary cooler will not be used to store cold food until the temperature is restored and held in appropriate range. 8. Dietary manager obtained needed food items for supper today from local grocery store. 9. Dietary manager will obtain cold food items from local grocery store as needed until permanent cooler repaired. 10. Dietary manager contacted wholesale food supplier to replace all lost food from temporary cooler. 11. Dietary manager contacted Registered Dietician. 12. Dietary manager immediately initiated in-service for dietary staff to temp items from cooler to ensure meets proper storage temp of no greater than 41 degrees Fahrenheit prior to preparing. 13. All items pulled from the temporary cooler will be temperature monitored to ensure not greater than 41 degrees prior to preparing. 14. The Director of Nursing reviewed all resident charts and conducted interviews with nurses to determine any residents with nausea/vomiting/diarrhea over the weekend. All residents identified as having any signs and symptoms received an assessment and Medical Doctor notification. 15. Director of Nursing immediately initiated in-service on foodborne illness. 16. Medical Director and Advanced Practice Nurse (APN) were notified. The APN made in person visits as warranted, new orders processed. 17. All residents will be monitored for signs and symptoms of food borne illness every shift for 72 hours or until no further negative findings. Any negative findings will be addressed immediately. 18. Permanent cooler scheduled for repair on 08/15/2023.

Based on observation, interview and record review, the facility failed to ensure the facility was free of pests and insects to prevent potential for the spread of infectious disease or injury to residents who reside in the facility. This failed practice had the potential to affect 94 residents according to the census and condition provided by the Director of Nursing (DON) on 08/14/2023 at 1:00 PM. The findings included: On 08/14/2023 the following was observed: At 11:30 AM the hallway outside of Resident #51's room was full of bugs, spiderwebs along the corners of the ceilings, and the light fixture was full of bugs. During mealtime at 12:05 PM, flies were flying around food being served and landing on bowels sitting on the serving line. At 2:14 PM, flies and gnats were observed flying in Hall 400 and in a resident's room. At 2:21 PM five flies were observed flying in room [ROOM NUMBER] bathroom, and a sticky fly insect trap with flies was on top of paper towel holder in room [ROOM NUMBER] ' s bathroom. Resident #51's family member was sitting in a chair in the room with a fly swatter in hand at 2:33 PM, and said these flies are bad. At 2:53 PM, dead insects/bugs were observed in a light fixture on the wall. Spider webs were around a light fixture in the ceiling. On 08/15/23 the following was observed: At 9:06 AM, dead dried insects were inside a light fixture on the wall between rooms [ROOM NUMBERS]. In the hallway between rooms [ROOM NUMBERS] spiderwebs were around a light fixture on the ceiling At 9:12 AM, flies and gnats were flying in 400 Hall. During an interview on 08/17/23 at 10:39 AM, Housekeeper (HK) #2 said the facility and resident ' s rooms are cleaned daily. She said the hallways walls are spot checked and the light fixtures, handrails, pictures, and cobwebs are cleaned. The surveyor asked HK #2 to describe the light fixtures in hall 400. HK #2 said there looks like food is on the wall and the light fixture has dead bugs in it and cobwebs. During interview on 08/17/2023 at 1:01 PM, the Housekeeping (HK) Supervisor said there is not a set schedule for employees to clean the facility and resident's rooms, but cleaning is performed every day. The Surveyor asked, light fixtures, and walls cleaned? The HK Supervisor said, they are cleaned as needed. The Surveyor asked how long has the facility had a pest control problem? The HK Supervisor said, ants appear often, spiders sometime, and the flies are bad in the summer. During interview on 08/17/23 at 1:42 PM Maintenance #1 said environmental rounds are one time a month, and the traps outside from pest control are checked. During an interview on 08/17/23 at 1:01 PM the Housekeeping Supervisor (HK) said the facility does have ants that appear often, flies are bad in the summer, and sometimes there are spiders. During interview on 08/17/23 at 1:42 PM, Maintenance #1 said, pest control comes every month, if it's bad enough, they will come out more often. The Surveyor asked has the pest control company been notified the pest control is not effective? Maintenance #1 said no the flies are terrible this time of year. Review of facility's policy provided by the Administrator In Training (AIT) on 08/16/23 at 12:54 Housekeeping and Maintenance undated showed, all rooms and every part of the building exterior and interior, food areas and bath and toilet areas will be kept clean.

Based on record review and interview, the facility failed to ensure the Quality Assurance and Performance Improvement program (QAPI) Committee developed and implemented appropriate plans of action to prevent repeated deficiencies with medication storage. These failed practices had the potential to affect all 94 residents who resided in the facility as identified on the Resident Census and Condition which was provided by the Director of Nursing on 8/14/23 at 1:05 PM. The findings are: 1. An annual survey was completed on 06/9/2022. During the survey, the team identified concerns with storage of drugs and biologicals. 2. Review of the facility's plan of Correction, with a completion date of 07/8/2022 described the Director of Nursing (DON) /Designee as monitoring 3 times a week for 4 weeks. Facility observed the residents that reside on the hall where LPN #1 failed to store drugs appropriately; observed med carts to be locked; in-serviced all nurses to maintain all medications to remain secured from residents and locking med carts when not in use or in possession of nurse responsible for cart. DON will monitor medication carts to ensure medications are secured and stored per policy to ensure failed practice does not occur. Negative findings will be reported weekly. 3. The QAPI Plan noted it provides guidance for the quality improvement program. The documented focus areas will include all systems that affect resident and family satisfaction, quality of care and services provided, and all areas that affect the quality of life for personal living and working in our organization.

Based on observation, interview, and record review, the facility failed to ensure residents on special diets who required assistance for eating and hydration, received care and services to prevent the potential of dehydration and possible infections for 1 (Resident #51) of 1 sampled resident who had orders for thickened liquids. Review of Resident # 51's physician's Order Summary Report with an active order date of 08/17/202023 showed diagnoses of atrial fibrillation, dehydration, and extended spectrum beta lactamase (ESBL) in the urine, and a mechanical soft diet with nectar consistency. During observation on 08/14/2023 at 2:33 PM Resident #51was lying in bed with no liquids at the bedside. Family was at bedside. During observation on 08/15/2023 at 9:12 AM. Resident #51 had no source of hydration available, and no cup at bedside. During observation on 08/15/2023at 2:50 PM Resident #51 lying in bed with family at bedside. There were no cups or fluids available at the bedside. On 08/16/2023 at 2:01 PM Resident #51 was observed with 1 ounce of thickened brown substance in cup on the bedside table with a straw in it. During observation on 08/17/2023 at 09:39 AM, a water pitcher with 700 cc's (cubic centimeters) of clear liquid was observed on Resident #51's bedside table. During interview on 08/17/2023 at 9:44 AM, the Surveyor asked Licensed Practical Nurse (LPN) #3 what type of liquids is Resident #51 ordered to receive? LPN #3 replied, thickened liquids. LPN #3 confirmed there was a water pitcher of thin liquids on Resident #51's overbed table and did not remove the pitcher from the room. During interview on 08/18/2023 at 11:56 AM the Director of Nursing (DON) said, snacks, hydration, and ice are passed out to the residents at 10:00 AM, 2:00 PM, and bedtime. The Surveyor asked, how do you know how much fluid intake Resident #51 is receiving? The Don stated, we go by the meal ticket, but it doesn't include the fluid intake.

Based on observation, interview, and record review, the facility failed to ensure drugs and biologicals were stored in accordance with the facility's policy and procedure, currently accepted professional principles, and disposed of in accordance with manufacturer's instructions to prevent potential administration of medicines that had been opened and stored beyond the manufacturer's specified timeframes. The findings included: On 08/14/2023 at 2:13 PM a container of barrier cream was on back of the toilet in Resident #38's bathroom. During observation on 08/16/2023 at 11:06 AM of the 300 Medication Cart with Licensed Practical Nurse (LPN) #4, the following was found: 1. One opened tube of Clotrimazole & Betamethasone Dipropionate Cream USP 1% (0.05%) with a partial label and no full name. 2. One Albuterol Sulfate Inhaler Aerosol (Proair) HFA 90 mcg (micrograms) with a fill date of 08/28/2022 and an open date on package of 8/2023/2022 for Resident #34. 3. One opened bottle of dry eye drops undated and no name with an expiration date of 12/2022. 4. One Albuterol Sulfate Inhaler Aerosol HFA 90 mcg inhaler undated and a fill date of 7/8/2023 for Resident #76. During observation on 08/16/2023 at 11:28 AM a room in the secured unit had a plastic 3 drawer container with bottles of glue, medicated powders, bottles of mouthwash, and multiple vials of insulin. The unlocked medication cart and unlocked refrigerator contained multiple insulin pens, eye drops, and multiple vials of insulin were left in the room. Registered Nurse (RN) #1 and Licensed Practical Nurse (LPN) #4 left the room to assist Resident #63 and left the medication room open and unlocked, leaving access to the residents and visitors. When LPN #4 returned to the open and unlocked medication room the Surveyor asked, is the medication room supposed to be locked when no one is here? LPN #4 replied, No one told me about it. The Surveyor asked, have you had any training? LPN #4 replied, We get two or three days of orientation. During observation on 08/16/2023 at 1:20 PM of the Central Medication Room located on Hall 400 with LPN #1 the following was found: 1. 75 syringes of Heparin with a filled date of 7/26/2023. 2. 3 syringes of Heparin expired on 11/11/2022. 3. 16 syringes of Heparin expired on 12/21/2021. 4. 21 10 ml (milliliters) of Saline Flush expired on 5/13/2023. 5. 1-bag of 0.9% Normal Saline 1000 cc (cubic centimeters) with a torn off label. During observation on 08/16/2023 at 1:42 PM with LPN #1 the 100 Hall Medication Cart the following was found: A bag containing 2 unopened vials of Ceftriaxone. 1 opened 1 gram vial of Xylocaine undated LPN #1 stated, it was discontinued on Monday, and they should have been pulled it from the cart. A plastic bag containing 1 vial of cyanocobalamin 1000 mcg and 1 vial of medroxyprogesterone Depo-Provera 150 mg. (milligram). At 1:55 PM, LPN #1 confirmed the medications should be in its own bag. During observation on 08/17/2023 at 1:52 PM the door of the medication room on the secure unit of 300 Hall was left open with no nurse present. Certified Nursing Assistant (CNA) #8 was approximately 20 feet from the medication room sitting in a chair, and residents were ambulating in the hall. In the medication room was a plastic 3 drawer container with bottles of glue, medicated powders, and bottles of mouthwash, and a refrigerator containing multiple insulin pens and vials of insulin, and eye drops was unlocked and accessible. On 08/17/2023 at 1:53 PM Registered Nurse (RN) #1 approached the medication room and stated, CNA #8 was watching the med room. The Surveyor asked RN #1 is CNA #8 licensed to watch the medication room? RN #1 stated, CNA #8 is a Certified Nursing Assistant. The Surveyor asked, is CNA #8 licensed to watch the medication room? RN #1 did not answer. On 08/17/2023 at 2:17 PM the Assistant Director of Nursing (ADON) stated, the CNAs are not licensed to do anything with the medication room. Review of the facility's policy titled Medication Storage In The Facility provided by the Administrator in Training (AIT) on 8/16/2023 at 12:54 PM showed the following: Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier .the medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications .all medications dispensed by the pharmacy are stored in the container with the pharmacy label .outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed .disposed of according to procedures for medication disposal .medication storage conditions are monitored on a monthly basis by the consultant pharmacist or pharmacy designee and corrective action taken if problems are identified expiration dates .when the original seal of a manufacturer's container or vial is initially broken, the container or vial will be dated .all expired medications will be removed from the active supply and destroyed .

Based on observation, interview and record review, the facility failed to ensure staff assessed, reported, and notified the physician for residents who had skin tears/wounds to prevent infection and possible injury for 2 residents (Resident #8, and Resident #38) of 2 sampled residents. Finding included: Review of Resident # 8's Physician's Order Summary Report dated 08/16/2023 showed diagnoses of type 2 diabetes mellitus and malnutrition. On 08/14/2023 at 11:37 AM during observation Resident #8 had a bandage on the left hand with curled edges and a dark dried substance under the bandage and on the top of the Resident's left hand. There was no marked date on the bandage indicating when the bandage was placed on the resident's left hand. The surveyor asked Resident #8 what happened to your hand? Resident #8 stated I got a scratch a couple of days ago and they put a bandage on it. During observation on 08/14/2023 at 2:27 PM Resident #8 had a bandage on the left hand with the edges curled and a dark, dried substance under the bandage. The was no date on the bandage. On 08/15/2023 at 9:52 AM Resident # 8 was observed ambulating with a bandage to the left hand with curled edges and a dark dried substance underneath and on top of the bandage. There was no date on the bandage. On 08/15/2023 at 2:58 PM Resident #8 was observed with a bandage to the left hand with curled edges and a dark dried substance underneath and on top of the bandage. There was no date on the bandage. On 08/16/2023 at 10:30 AM Resident #8 was observed with a bandage to the left hand with curled edges and a dark dried substance underneath and on the top of Resident's #8 left hand. There is no date on the bandage. During an interview on 08/16/2023 at 10:37 AM, the Surveyor asked Licensed Practical Nurse (LPN) #2 who put the bandage on Resident #8's left hand, and what are the treatment orders? LPN #2 stated I'm unaware, and there are no orders for a bandage. The Surveyor asked when was the last time Resident #8's left hand assessed? LPN #2 replied, I don't know. Review of Resident #8's Body Audit dated 08/15/2023 at 6:00 AM showed skin condition clear. Review of the facility's Incidents by Incident Type list dated 04/15/2023 to 08/15/2023 provided by the Director of Nursing (DON) on 08/15/2023 at 3:36 PM did not document any incidents for Resident #8. Review of an Incident & Accident report dated 08/16/2023 provided by The Administrator in Training (AIT) on 08/16/2023 at 12:54 AM showed Resident #8 was assessed to have bandage on left hand, and Resident stated, I scratched it somewhere. Review of Resident #38's Body Audit dated 08/08/2023 showed skin condition clear. On 08/14/2023 at 11:49 AM Resident #38 was observed with a bandage on the left lateral forearm, and the bandage was not dated, and no order for wound care. On 08/14/2023 at 12:12 PM Resident #38 was observed with a bandage on the left lateral forearm, and the bandage was not dated. On 08/14/2023 at 4:32 PM Resident #38 was observed with a bandage on the left lateral forearm with no date and dried dark substance showing through the bandage. On 08/16/2023 at 10:34 AM Resident #38 was observed with a bandage on the left lateral forearm with a dark dried substance showing through the bandage, and no date on the bandage. The Surveyor asked Resident #38 what happened to your arm? Resident #38 stated, It happened when I fell . The Surveyor asked, has the bandage been changed since it was put on your arm? Resident #38 stated, no. On 8/16/2023 at 12:54 PM, the Administrator In Training (AIT) provided Resident #38's Incident and Accident (I & A) dated 08/07/2023 at 10:31 AM and 08/14/2023 at 6:19 AM, showed on 08/07/2023 Resident #38 fell against the bed transferring from bed to wheelchair, and no injuries observed post incident. On 08/14/2023 Resident #38 was on the floor with no injuries observed post incident. During an interview on 08/16/2023 at 9:21 AM, the Surveyor asked Registered Nurse (RN) #1 what are you supposed to do if a resident receives a skin tear? RN #1 said obtain a treatment order from the Advanced Practice Nurse (APN) put the order in, administer the treatment, and notify the family. The Surveyor asked RN #1 does the facility have standing orders? RN #1 said no. The Surveyor asked RN #1 where are skin treatments documented? RN #1 said in skin and wound assessments, progress notes, and in the treatment administration record. RN #1 was asked, where are treatment orders documented? RN #1 said in the orders. During an interview on 08/16/2023 at 10:37 AM, the Surveyor asked Licensed Practical Nurse (LPN) #2 what are you supposed to do if a resident receives a skin tear? LPN #2 said assess, treat, document, notify the DON, the doctor, or the APN, and get an order. On 08/16/2023 at 12:54 PM, Administrator in Training (AIT) stated, We don't have a policy on I & A's or skin treatments, we follow the federal guidelines for guidance.

46723 Based on observation and interview, the facility failed to ensure that a safe, clean, and homelike environment was provided for all 94 residents who reside in the facility according to the census & condition which was provided by the Director of Nursing on 08/14/2023 at 1:05 PM. The findings included: The following observations were made on 08/16/2023: On 300 Hall a baseboard was sticking out from the wall, and dead insects were at the end of the hall. The window seal had dead insects and spider webs, and the light fixture had no cover over the fixture. In the dining room, there were flies and 3 insect bait traps. In room [ROOM NUMBER] at 9:32 AM a baseboard was sticking out with a sharp pointed edge around the air conditioner. Outside room [ROOM NUMBER] at 9:34 AM in the hall a plug-in had a cover that was broken and protruding out. In room [ROOM NUMBER] at 9:35 AM the air conditioner cover was taped to stay on, and the tape was covered with dirt and dead flies. The trash can had a hole. Under the sink was a hole in the wall with the baseboard peeled from the floor, exposing approximately 6. The bathroom door had a hole approximately 2 centimeters in diameter. room [ROOM NUMBER] at 9:42 AM had a strong odor of urine. During observation on 08/17/2023 at 2:08 PM in the kitchen were 3 ant baits one on the floor, one in a corner and two on each side of the air conditioner. During interview with LPN #4, she confirmed if the residents on the locked unit had touched or ingested the bait they might become sick. During interview on 08/17/2023 at 3:41 PM, the Surveyor confirmed with the Maintenance Director the ant baits were out for a week and a half in the kitchen on the secured unit. The following observations were made on 08/14/2023: Resident #1's isolation room at 11:10 AM had wet towels under and beside the hall air conditioner, and behind the door into room. In the hallway from Resident #51's room, had light fixtures full of bugs, spiderwebs along the corners of the ceilings, wires exposed on the exit door to the outside, and a brown dried substance on the wall. On Hall 400 across from room [ROOM NUMBER] at 2:23 PM an outlet cover was pulled away from the wall. At 2:53 PM there were dead insects in a light fixture on the wall, and spider webs around the light fixture on the ceiling. A brown dried substance was observed on the wall in the hall outside room [ROOM NUMBER]. The following observations were made on 08/15/2023: At 9:06 AM a dark brown dried substance was on the wall outside of room [ROOM NUMBER]. Inside a light fixture on the wall between rooms [ROOM NUMBERS] had dried dead insects. The exit door at the end of Hall 400 had exposed wires. The personal protective equipment (PPE) cart in front of room [ROOM NUMBER] had black and brown dried pieces/substances (dirt and dust) on the drawers, handles and sides. At 09:12 AM the air conditioner at the end of Hall 400 was running with a large pool of water on the floor under the air conditioner flowing into room [ROOM NUMBER] without a wet floor sign. The electrical cord was in the water on the floor and plugged into the wall next to the air conditioner. Resident #33 entered room [ROOM NUMBER] with the water flowing into the room at 9:39 AM. During interview on 08/15/2023 at 10:03 AM Maintenance #1, said the air conditioner at the end of Hall 400 does not have a thermostat. He said the water should be dripping out of the back of the air conditioner. Maintenance #1 confirmed water on the floor could be considered a hazard and there should be a wet floor sign. During interview on 08/17/2023 at 10:39 AM Housekeeper (HK) #2 said the resident's rooms are cleaned every day, and the light fixtures, handrails and pictures are cleaned throughout the facility and residents ' rooms, and cobwebs are removed. HK #2 said needed repairs are reported to maintenance by listing what is needing repaired in a book. During interview on 08/17/2023 at 1:01 PM, the Housekeeping (HK) Supervisor said there is not a set schedule for employees to clean the facility and residents rooms, but cleaning is performed every day. The Surveyor asked, when are spiderwebs, light fixtures, and walls cleaned? The HK Supervisor said, they are cleaned as needed. HK Supervisor confirmed residents should be provided with a clean, homelike environment. On 08/17/23 at 1:52 PM, environmental rounds were made with Maintenance #1, and the following was confirmed in room [ROOM NUMBER]: a. Hole in the trash can. b. Taped air conditioner cover to block the gap to keep mosquitos out. c. A 2.5-inch hole at the bottom of the bathroom door. d. Cacked flooring tile under the sink about 6-7 inches long. e. During interview, Maintenance #1 said these repairs were not reported in the maintenance log? On 08/17/2023 Maintenance #1 confirmed the loose faucet in the bathroom of room [ROOM NUMBER], and the repair was not on the repair list. Review of facility's policy provided by the Administrator In Training (AIT) on 08/16/2023 at 12:54 PM titled Housekeeping and Maintenance undated showed, all rooms and every part of the building exterior and interior, food areas and bath and toilet areas will be kept clean.

Based on observation, interview, and record review, the facility failed to maintain privacy for 1 of 1 (Resident #8) sampled resident and failed to ensure residents dignity was maintained for 2 (Resident #37 and Resident #81) of 2 sampled residents. The findings included: On 08/14/2023 at 11:27 AM during observation of Resident #8, Licensed Practical Nurse (LPN) #2 performed a blood glucose check and did not pull the privacy curtain and left the door open. Resident #8 was exposed and could be seen from the hallway. During interview on 08/17/2023 at 9:28 AM, the Surveyor asked LPN #3 how do you maintain a resident's dignity when performing a blood glucose check procedure? LPN #3 said to maintain a resident's privacy the curtains should be pulled, and the door closed. On 08/17/2023 at 10:30 AM during an interview with the Assistant Director of Nursing (ADON) she said privacy curtains are pulled and doors are closed when performing blood glucose checks on a resident to provide dignity and privacy. Review of the Summary of Resident's [NAME] of Rights provided by the Director of Nursing (DON) on 08/15/2023 at 10:47AM showed, the facility must ensure every resident will be treated with respect and full recognition of his/her dignity and individuality and privacy during treatment and care of personal needs. During an interview on 08/16/2023 8:00 AM Resident #37 said these briefs remain open and not taped shut because shut it cuts into the upper legs and groin area. Resident #37 said the facility is not buying bariatric briefs. The Surveyor asked, has a company come and fitted you for a proper size brief? Resident #37 said, No. During interview on 08/16/2023 at 8:34 AM CNA #5 said, the residents are not getting fitted for the proper size briefs and thinks the facility has not ordered bariatric briefs since August of 2022. On 08/16/2023 at 9:40 AM during an interview with the Assistant Director of Nursing (ADON) said she does not think a company fits residents for the proper size briefs. During interview on 08/16/2023 at 10:18 AM the Nurse Consultant said the Director of Nursing (DON) determines the brief size by the residents height and weight, and a size chart. The Surveyor asked is the resident's size documented.? The Nurse Consultant stated,I do not know. During interview and observation on 08/16/2023 at 10:47AM, the Surveyor asked the DON is Resident #37 wearing the correct size brief for her height and weight? The DON said, Yes, she is. The DON, and CNA #5 compared two different briefs and one appeared larger than the other. The DON said, I will order the correct size on Friday. During an interview on 08/18/2023 at 10:00 AM with Resident #81 she said she was dissatisfied with the briefs offered. Resident #81 said she no longer is offered the largest white briefs and is provided a smaller brief that is short in the stride and too tight in the waist and legs. She continued to describe how the briefs are not as absorbent, and at night she frequently lays in urine. Resident #81 said she was told the briefs were unavailable for purchase and that the corporation refused to allow the briefs to be ordered. During an interview on 8/18/2023 at 10:10 AM the ADON described how the white brief had been removed from the formulary for a short time but had recently been made available again. 44852 46723

Based on observation, interview, and record review, the facility failed to ensure residents representatives/responsible party was notified of changes in condition for 1 (Resident #51) of 1 sampled resident. The findings Included: Review of Resident #51's physician orders with a start date of 08/07/2023 showed Resident #51 is in contact isolation. Review of Resident #51's progress notes with an effective date range of 01/01/2023 to 08/17/2023 showed no documentation of family notification of Resident being in isolation. On 08/16/2023 at 1:53 PM Resident #51's family members (responsible party) were observed visiting and not wearing personal protective equipment. The Surveyor asked the family members if they were contacted about Resident #51 being in isolation? The family members said no and did not know about the urinary tract infection. During interview on 08/17/2023 at 9:07 AM, Licensed Practical Nurse (LPN) #3 confirmed if a resident has a change of condition the family or emergency contact is notified. Review of the facility's policy titled Notification of Change provided by the Administrator In Training (AIT) on 08/16/2023 at 12:54 PM showed, the nursing facility will immediately inform the resident and consult with the resident's physician when a significant change occurs, and notify the resident's legal representative or a designated contact person.

Based on interview and record review, that facility failed to ensure that a resident and/or their representative was provided notification of their discharge and the possibility of appeal 2 days prior to discharge from skilled services for 1 of 1(Resident #27) sampled resident. The findings included: Review of Resident #27's physician Order Summary Report showed diagnoses of heart failure, and Chronic Obstructive Pulmonary Disease. Review of Resident #27's Quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 05/16/2023 showed the Resident requires extensive assistance with bed mobility, dressing, toileting, and personal hygiene. Review on 08/16/2023 at 11:33 AM of Resident #27's notification documents showed the following: a. Notice of Medicare Non-Coverage showed the effective date coverage of current skilled nursing services will end on 03/14/2023. b. Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNG ABN) noted, beginning on 3/15/2023, you may have to pay out of pocket for care if you do not have other insurance that may cover these costs. Option 3 was selected and showed, I don't want the care listed above. I understand that I'm not responsible for paying, and I can't appeal to see if Medicare would pay signed by Resident #27 and dated 3/13/2023. During interview on 08/17/2023 at approximately 3:00 PM, the Minimum Data Set Coordinator confirmed a resident/representative should receive two days notice when being discharged from a skilled stay.

Based on observation, record review, and interview, the facility failed to ensure the Van Driver safely transported a resident sitting in a wheelchair in the facility's van to prevent potential injury for 1 (Resident #1) of 13 residents who required transport in a wheelchair on the facility van in the past 2 weeks. This failed practice resulted in Immediate Jeopardy, which caused or could have caused serious harm, injury or death to Resident #1, who flipped over backwards in the wheelchair when the van accelerated out of a parking lot after failure to secure front wheels of wheelchair to J-hooks and had the potential to cause more than minimal harm to 13 residents who required wheelchairs during transport in the facility van in the past 2 weeks, as identified by the Administrator on 04/17/23 at 2:26 pm The Administrator and the Regional [NAME] President (RVP) were informed of the Immediate Jeopardy on 04/12/23 at 4:22 pm and the Plan of Removal was accepted on 04/12/23 at 5:26 pm. The findings are: 1. Resident #1 was admitted to facility on 10/20/21 with a diagnosis of COVID-19. The Quarterly Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 01/31/21 documented resident scored 15 (13-15 indicates cognitively intact) on the Brief Interview Mental Status (BIMS) required limited assistance with bed mobility, transfers, required extensive assistance with toilet use, independent with locomotion on and off the unit with the use of wheelchair for mobility. a. The Care Plan with an initiation date of 01/17/23 documented, Resident #1 has an ADL [Activity of Daily Living] self-care performance deficit . Resident #1 has limited physical mobility . LOCOMOTION: Resident #1 is independent with locomotion in w/c [wheelchair] . b. On 04/12/23 at 3:20 pm., the Surveyor asked the Director of Nursing (DON), Where was the resident going when the incident occurred? The DON stated, He went to the Imaging Center for a CT (Computed Tomography) Scan, and it happened as they were leaving. They called an ambulance, but he refused to go to the ER [emergency room ] because he has kidney stones and wanted to go to his Urology Appointment. When he was at Urology Appointment, he started having more pain and they called an ambulance, and he went to the ER then. c. On 04/12/23 at 3:28 pm., the facility provided a copy of Van Driver #1's witness statement which documented, .I loaded the resident into the van for his following appointment at Urology. After strapping the back straps to the wheelchair and putting the seatbelt on, I walked around to the right side of the van to strap the front straps but noticed a blue truck was parked too close to the van. I got into the van to back it up so that I would have enough room to strap the right side in but at this time the fire truck was pulling into the Imaging Center. Trying to make sure I got out of the fire truck's way; I pulled off not realizing that I forgot to strap the front straps. Pulling out the parking lot of the Imaging Center, I went up the hill and heard the straps retract and the resident flipped back in wheelchair, his feet in the air and back on the floor of the van. I immediately pull over to the [Medical Facility] parking lot to get out the van, opened the back of van to access the situation. I asked the resident if he was hurt, and he said his back hurt, but he was ok and was just a little uncomfortable because of how he was positioned. I immediately called 911 at 9:22 am followed by [Facility name] . d. On 04/12/23 at 3:40 pm., the Surveyor asked the Administrator, Who did Van Driver #1 speak to when she called the facility? The Administrator stated, I believe she spoke to Licensed Practical Nurse (LPN) #1. e. On 04/12/23 at 3:44 pm., the Surveyor asked the Assistant Director of Nursing (ADON), Where did the incident occur? ADON stated, At the Imaging Center. The resident had an appointment at the Imaging Center at 9:15am for a CT Scan then was going to his Urology Appointment. f. On 04/12/23 at 3:47 pm., the Surveyor asked LPN #1, Did you receive the phone call from Van Driver #1 when she called the facility? LPN #1 stated, Yes, I did. The Surveyor asked, What did she say when she called? LPN #1 stated, She stated we were in the van and the van hit a bump and the wheelchair went backwards and I called an ambulance. Then I asked her if the resident was ok, and alert and she said yes he seemed to be ok. g. On 04/12/23 at 4:03 pm., the facility provided a copy of Van Driver #1's competencies. Her last competency checkoff was completed on 03/16/22. The last correct lift operation/properly securing residents competency completed by the mobility company was completed on 08/23/22. h. On 04/12/23 at 4:12 pm., the RVP stated, I had her show me step by step a reenactment of what happened and there was no wavering from her witness statement in her demonstration. i. On 04/13/23 at 11:57 am., the facility emailed a copy of Resident #1's imaging results completed at the emergency room . The Magnetic Resonance Imaging (MRI) of the cervical spine without contrast completed on 04/12/23 documented, .There is increased signa; within the superior endplates of C4, C7 and T1 suggesting the presence of fractures involving the superior endplates with associated minimal loss of vertebral body height .The known C2 and C3 fractures are better evaluated on CT imaging .C3-C4 There is a small anterior epidural hematoma measuring 2 mm [millimeters] in width behind C3 vertebral body resulting in a mild to moderate canal stenosis The CT Scan of Cervical Spine without contrast completed on 04/12/23 documented, .Fractures of the right and left posterior C2 ring involving the posterior lamina. Fractures through the base of the C3 spinous process. Fracture of C4 superior endplate. Anterior wedging of C4 with approximately 20% [percent] vertebral body height loss .This favors hemorrhage/hematoma and increased density when compared to the CSF [Cerebrospinal Fluid] spaces of the heat CT. Epidural hematoma is not excluded on this examination .1. Nondisplaced fractures of the C2 lamina. 2. Mildly displaced fracture through the base of the C3 spinous process. 3. Compression fracture of C4 superior endplate with 20 % vertebral body height loss .Age-indeterminate C7 superior endplate compression deformity. 4. Increased density of the CSF space within the cervical spinal canal concerning for hemorrhage/hematoma MRI is recommended for further characterization . j. On 04/17/23 at 2:13 pm., the Administrator, the RVP, and the Surveyor went out to the van where the incident had occurred. It was a [named make and model] van that had a manual lift in the back. The back rises to open with a manual lift inside. Both sides of the door opened toward the back of the van. The Surveyor asked the Administrator, In Van Driver #1's witness statement, she stated there was a vehicle parked on the right side of the van and she was not able to open the door, why did she not go to the left side of the van to open that side door to secure the front wheels of the wheelchair? The Administrator stated, I do not know. k. The facility policy titled, Transportation Program Safety policy and Procedures, provided by the Administrator on 04/12/23 at 4:03pm documented, .Compliance with the Company Transportation program safety policies and procedures is not optional. Policy, Responsibility and Scope. It is the policy of [Facility name] to eliminate vehicular accidents, reduce injuries and mitigate associated insurance loss costs .Employees are required to immediately report all accidents and moving violations that occur during work-related activities, provided they are driving a company owned .3. Load and unload residents on level ground where both rear and side access areas are not obstructed .If you are loading a resident in a wheelchair into the vehicle using a manual ramp then .3. Apply parking brake .10. Lock both wheelchair brakes once the non-ambulatory resident is positioned in place inside the wheelchair cabin. 11. Install and attach rear retractable J-hooks to the wheelchair frame as instructed. 12. Install and attach front retractable J-hooks to the wheelchair frame as instructed. 13. Test to ensure that the retractable J-hooks have firm tension, and the wheelchair is free from any movement. 14. Install, adjust and secure lap and should restraint around resident as instructed . The Immediate Jeopardy Plan of Removal provided by the Administrator on 04/12/23 at 5:26pm reads as follow: 1. On 04/12/23 at 10:14am, the Administrator was notified of the van incident where the resident was not secured properly prior to van transport and the resident's wheelchair tipped over backwards. Resident refused ER transport at that time, but later agreed to go to ER for evaluation where he remains at this time. Tests pending. 2. Van Driver was suspended pending investigation. 3. Van where incident occurred was taken out of service until van inspection can be completed. 4. Customer Choice Mobility contacted with van inspection and training for van drivers scheduled for Friday 04/14/23. 5. Reviewed employee records to ensure all van drivers have been trained on safe transport. 6. All Van Drivers will receive a new training and check off prior to their next transport. 7. Immediately started in-service on abuse and neglect. 8. Incident accident report completed. 9. Every transport will be monitored by a second trained person prior to leaving facility to ensure resident is secured properly x4 weeks. 10. Implemented a log for van drivers to complete prior to each transport to sign off that they have secured the two front and the two back straps securely prior to removing van from park position.

Based on observation and interview, the facility failed to ensure trash was properly contained within 2 of 2 outside dumpsters to minimize the potential for pest infestation. This failed practice had the potential to affect all 96 residents who resided in the facility as documented on the Resident Census and Conditions of Residents provided by the director of nursing on 6/5/22. The findings are: 1. On 6/5/22 at 10:49 AM, the lids were open on two outdoor trash dumpsters. The was trash including a used adult brief on the surrounding ground, and flies swarming the dumpsters. 2. On 6/7/22 at 10:31 AM, the maintenance director was asked if he was asked if he is responsible for ensuring trash was contained in the dumpsters and the area was clean. The maintenance director replied, Yes. I try to keep the lids closed and the area clean. I monitor it several times throughout the day. He was asked if he was aware the dumpsters were open with trash on the ground on Sunday, the maintenance director said, No. 3. On 6/7/22 at 1:41 PM, the Disposal of Garbage Policy and Procedure provided by the Director of Nursing, documented, . 5. Outside dumpsters provided by garbage pickup services will be kept closed and the surrounding area will be kept free of litter .

Surveyor: [NAME], [NAME] A. Based on observation, record review and interview, the facility failed to ensure infection control practices were maintained during a stage 4 pressure ulcer dressing change for 1 (resident #47) of 2 (Resident #47, 58 and 2) final sample residents who had pressure ulcers. The findings are: Resident #47 had diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A Significant change Minimum Data Set with an Assessment Reference Date of 4/19/2022 documented the resident scored 09 [09-12 indicated moderately cognitively impaired] on a Brief Interview for Mental Status, was at risk for developing pressure ulcers and had one stage 4 pressure ulcer. a. The Care Plan documented, I will maintain or have improvement in my skin integrity . I need wound care as ordered by my physician . Start Date 3/21/22 b. The June 2022 physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Cover with bordered gauze change QD [every day] and PRN [as needed] . c. On 06/07/22 at 02:22 PM, RN [Registered Nurse]#1 was providing wound care to resident ' s sacrum. RN #1 opened the sterile gloves, pulled the side panels to open, they fell shut, RN#1 used her bare hands to push the flaps open, touching the inside of the sterile glove package insert holding the sterile gloves. RN #1 pushed the inside of the sterile glove insert down with enough force for the sides to stay down. RN #1 picked up the left hand sterile glove with her right hand placing her fingers inside the cuff and pulled the glove onto her left hand, then repeated the process with her right hand. RN#1 turned to the resident, explained that she would be removing the soiled dressing and proceeded to remove the soiled dressing, placing it in the trash bag at the foot of the resident ' s bed. She changed into gloves that she pulled from her pocket, sprayed the 4x4 gauze pads with wound cleanser, picked up several gauze pads and wiped the sacral wound. She repeated this step 4 times, each time wiping the wound and placing the soiled 4x4 into the trash bag at the foot of the bed. Without changing her gloves, she picked up the new clean dressing, placed it on the sacral wound, then picked up the island dressing, again without changing her gloves, and covered the sacral wound. RN #1 was asked, At what point after removing the soiled dressing, and changing your gloves, when cleaning the sacral wound, would your gloves be considered soiled? She stated, They weren't dirty. After you removed the dressing, changed your gloves and started to clean the wound, when would your gloves be considered soiled? She stated, Oh, I see what you mean. I should have changed my gloves after cleaning the wound and I didn't. She was asked, Did you touch the wound with the gloves you were cleaning the it with? She stated, It is possible, I could have touched it while I was cleaning it. She was asked, Should you have changed your gloves before placing the clean dressing on the sacral wound? She stated, Yes, I should have changed my gloves, before I placed the clean dressing. She was asked, What could potentially happen if soiled gloves are worn while placing a clean dressing on a wound? She stated, Cross contamination or it could cause an infection . d. On 06/08/22 at 09:46 AM, the Director of Nursing (DON) was asked, At what time, during the process of cleaning a wound, are gloves considered soiled? She stated, After you finish cleaning the wound. She was asked, What is the purpose of maintaining infection control during a dressing change? She stated, Prevention of infection. She was asked, During a dressing change would you expect infection control to be maintained for the resident? She stated, Yes, ma'am. She was asked, What is a potential complication when there is a break in infection control practice? She stated, Delay of wound healing. She was asked, Does that put the resident at risk for infection or contamination. She stated, Yes. She was asked, Do you expect the facility staff to follow the policies of the facility? She stated, Yes. She was asked, Does maintaining Infection control during a dressing change promote healing for [Resident #47]? She stated, Yes. e. On 06/08/22 at 10:57 AM, a Dressing Change, Clean Policy and Procedure . without a review date documented, .Purpose: To protect wound ., To prevent Irritation ., To prevent infection and spread of infection ., To promote healing .Procedure: .cleanse wound with prescribed solution ., Remove and Dispose of gloves in plastic bag . perform hand hygiene . Put on third pair of disposable gloves . Apply prescribed medication if ordered .

Based on observation, interview and record review the facility failed to store drugs and biologicals in the locked compartment on the medication cart with limited access for 1 of 4 medications carts. The findings are: 1. On 06/06/22 08:43 AM, Licensed Practical Nurse (LPN) #1 walked away from the medication cart up the hall to the medication storage room to retrieve a bottle of Iron, leaving 3 partially filled cards of medication laying on top of the cart. They were [MEDICATION(S)] 7.5 mg (milligrams), [MEDICATION(S)] 300mg, and Bethanicol 10 mg. LPN #1 was asked if any medication should be left on top of the cart when the cart is left unattended? She stated, No, but you were here . The LPN was asked, Do you usually have someone guarding your cart when you leave it unattended? She stated, No, I would put all of the meds in the cart and lock it. The LPN was asked, Do you have confused residents on this hall? She stated, Yes, I do The LPN was asked, Is it your facility policy to ensure all of the medications are secure when you leave your cart? She stated, Yes, I'm sure it is. She was asked, How far did you go when you left the cart? She stated, To the med room, I needed to get some iron. She was asked, Is that at the end of the hall? She stated, Yes. 2. On 06/08/22 at 10:13 AM, the DON [Director of Nursing] was asked, Explain how medications are secured on the medication cart? She stated, Well, they are supposed to keep the cart locked, the narcotics are locked separate. The DON was asked, Are medications to be left on top of the cart when unattended? She stated, That does not go with our policy. The DON was asked, Who is responsible for securing medications on the medication cart? She stated, The nurse passing meds. The DON was asked, The charge nurse? She stated, Yes. The DON was asked, When a nurse leaves the medication cart unattended, do you expect all medications to be secure? She stated, Yes. The DON was asked, What could be a potential outcome if medications are left out on the medication cart and left unattended? She stated, That somebody could pick them up. The DON was asked, Somebody being a resident? She stated, Resident, visitor or employee. The DON was asked, Do you have confused self-mobile residents on 100 hall? She stated, Yes, we do have. The DON was asked, Is it possible for confused, self-mobile residents to access medications left out on top of the medication cart, unsecure and unattended? She stated, Yes, ma'am. The DON was asked, What would be a potential outcome, if a resident took medications not intended for them, or in excess of the recommended dose due to having access to medications left on the medication cart, unattended? She stated, Cause harm. The DON was asked, Do you expect your staff to follow the policies of the facility? She stated, Yes, ma'am. 3. On 06/07/2022 at 1:39 PM a Medication storage Policy and Procedure without a review date, was received from the DON. It documented, .Purpose: to properly secure medications and biologicals according to CMS Guidelines ., Medications and biologicals will be maintained in a secured location only accessible to designated staff .

Based on observation, record review and interview the facility failed to ensure infection prevention and control practices were implemented for the prevention and transmission of Covid -19 and other communicable diseases and infections by 2 staff members entering a resident's room who was on quarantine without wearing PPE [personal protective equipment] for one (Resident #4) case mix resident who was on quarantine. This failed practice had the potential to affect 1 resident who had been on quarantine and one resident who was on contact isolation according to list received from the Assistant Director of Nurses (ADON)/Infection Control Preventionist (ICP) on 7/12/2021. The findings are: 1. On 7/12/2021 at 11:25 a.m., the Director of Nursing (DON) stated they were in outbreak testing due to a positive staff member. 2. On 7/14/2021 at 4:55 p.m., the ADON/ICP stated the county infection rate was 7.7% (percent). 3. Resident #4 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission assessment dated [DATE] documented, .the resident was AAOX3 [Alert and oriented times 3]. Required limited assistance with bed mobility, transfer, independent with eating and had no functional limitation in range of motion. a. The Covid Resident Screening on the Admission assessment dated [DATE] documented, Is the resident fully vaccinated against Covid 19? No (requires quarantine). b. The Admission Packet Covid 19 sheet documented the resident consented to the Covid Vaccine. The Covid consent form dated for 7/9/2021 had handwritten on the bottom of the page, 1st Covid Vaccine given 7/5/2021. c. The July 2021 Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Stop date 7/20/2021. d. On 7/12/2021 at 11:51 a.m., a sign on Resident #4's door on the 200 Hall documented, Quarantine, Respiratory Droplet, Contact Precaution, Stop before entering this room to provide care you must Sanitize hands, wear eye protection, gown, mask & [and] gloves. Stop after delivering care and before leaving room, you must Dispose of PPE in designated waste area. Sanitize hands. There were two Maintenance Men in Resident #4's room wearing a single surgical mask. The two Maintenance Men were standing within six feet of the resident touching the television and cable cords in the resident's room. Maintenance Man #1 left the room and entered another resident's room. e. On 7/12/2021 at 11:52 a.m., Certified Nursing Assistant (CNA) #1 was asked if the resident was on quarantine. CNA #1 stated, Yes. I didn't realize that they weren't dressed out in PPE. f. On 7/12/2021 at 11:53 a.m., there was a three drawer cart outside the resident's room with KN95 mask, gowns, gloves, face shields and red isolation bags. g. On 7/12/2021 at 11:59 a.m., Maintenance Man #1 stated, I didn't realize that they were on isolation. Maintenance Man #1 was wearing a single surgical mask. h. On 7/12/2021 at 12:01 P.M., the DON and ADON/ICP were notified of the issue with the Maintenance Men in the quarantine isolation room with no PPE and wearing a single surgical mask. The ADON/ICP stated, They had been trained on isolation. I will go and talk to them. i. The Facility Isolation Policy and Procedure received from the DON on 7/13/2021 documented, Purpose to prevent the spread of infections. Policy. Standard and transmission-based precautions will be followed to prevent the spread of infection. Isolation should be used for residents but not limited to: The type and duration of the isolation or precaution to be utilized with be depended upon the infectious agent or organism involved and the least restrictive possible for the resident and the circumstances. Each isolation and precaution taken will be determined individually for each resident to meet infection guidelines based on the resident status and infectious process .Contact Isolation 1. These infections are transmitted via direct contact (person-to-person) or indirect contact with the resident or the resident's environment .Droplet Precautions 1. Those infections are transmitted by contact via droplets during coughing, sneezing, and talking .Airborne 1. These infections are transmitted in the air through-inhalation. Small particles containing infectious agents may be dispersed over long distance by air currents and may be inhaled by individuals who [NAME] not had face to face contact with (or been in the same room with the infectious individual . j. An in-service dated 3/31/2021 conducted by Registered Nurse (RN) #1 with both Maintenance Man #1 and #2 signatures documented, New Covid 19 Policy and Procedures . b. Residents admitted or readmitted to the facility will be placed in isolation for quarantine to monitor for symptoms according to ADH guidelines. i. Residents should be quarantined utilizing transmission-based precautions following a known or potential COVlD-19 exposure, including on admission or return to the facility when the resident has been physically outside of the building for more than one (1) day. k. An in-service dated 4/8/2021 conducted by Registered Nurse (RN) #1 with both Maintenance Man #1 and #2 signatures documented, .Staff assigned to care for residents in quarantine will utilize KN95 throughout the shift and will be changed out weekly. (This includes anyone that goes into a quarantine resident room). Quarantine residents 1. HCW (Health Care Worker) assigned to quarantine rooms are to be provided with a KN95/N95 daily as source control. Surgical mask is to be put over the N95/N95 when entering a quarantine room to keep the KN95/N95 Clean and the surgical mask to be removed prior to leaving the quarantine room. 2. PPE is required and there is to be a PPE cart outside of each quarantine room. 3. PPE includes KN95/N95 with surgical mask, face shield/goggles, gown, and gloves. l. The CDC (Center for Disease Control and Prevention) Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic Updated Feb. 23, 2021 documented, CDC recommends using additional infection prevention and control practices during the COVID-19 pandemic, along with standard practices recommended as a part of routine healthcare delivery to all patients. These practices are intended to apply to all patients, not just those with suspected or confirmed [CONDITION(S)]-CoV-2 infection . The IPC recommendations described below also apply to patients who have met criteria for a 14-day quarantine based on prolonged close contact with someone with [CONDITION(S)]-CoV-2 infection. Patients in this 14-day quarantine period should be isolated in a single-person room and cared for by HCP [Healthcare Personnel] using all PPE recommended for a patient with suspected or confirmed [CONDITION(S)]-CoV-2 infection Personal Protective Equipment; HCP who enter the room of a patient with suspected or confirmed [CONDITION(S)]-CoV-2 infection should adhere to Standard Precautions and use a NIOSH [National Institute for Occupational Safety and Health]-approved N95 or equivalent or higher-level respirator, gown, gloves, and eye protection .The PPE recommended when caring for a patient with suspected or confirmed COVID-19 includes the following: .Gowns; Put on a clean isolation gown upon entry into the patient room or area. Change the gown if it becomes soiled. Remove and discard the gown in a dedicated container for waste or linen before leaving the patient room or care area.

Complaint # (AR 488) was substantiated, all or in part, with these findings. Based on observation, record review and interview, the facility failed to ensure a paraplegic resident was free from burn injury related to improper use of a hot pack on an area of decreased sensation for 1 (Resident #1) of 1 case mix resident who received Physical or Occupational Therapy and had impaired skin sensation. This failed practice resulted in past noncompliance at the level of actual harm for Resident #1, who sustained a burn and burn-related pain to his lower back, and had the potential to affect 29 residents with physician orders [REDACTED]. 1. The Manufacturer Use Manual for the Hydocollator heating units documented, Safety Precautions: .Constantly monitor Hot Pac application to ensure that the skin is not becoming too hot. Damage to skin can occur from exposure to extreme heat or cold. DO NOT apply over insensitive skin or in the presence of poor circulation. Never lay or sit on top of the HotPac. DO NOT use HotPac directly over cuts, abrasions or wounds . 2. Resident #1 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/3/18 documented the resident scored 15 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status, required the assistance of two plus people for bed mobility and transfer and had functional limitation in the lower extremities on both sides. a. Nurses Notes dated 5/15/18 at 2:26 a.m., documented, Resident reported to nurse that during therapy, heat was applied to his back for complaints of pain and he was burned by it. Nurse assessed resident's lower back. Lower back noted to be red with small blisters and one open area where skin had pulled back. MD (Medical Doctor) notified. New order noted and processed to apply [MEDICATION NAME] cream to lower back bid (two times daily) until healed . No other injuries noted . b. A Physician order [REDACTED]. c. A Physician order [REDACTED]. d. On 5/22/18 at 10:11 a.m. the Treatment Nurse provided wound care to the resident. After removing the soiled dressing, the Treatment Nurse cleansed the ointment from the wound. The wound was irregularly shaped and had a deep reddish/blue area with a smaller area of yellow drainage on the lower left border. The Treatment Nurse applied [MEDICATION NAME] to the wound, applied Calcium alginate and covered with [MEDICATION NAME] border gauze. e. On 5/22/18 at 11:35 a.m., the resident was asked about the burn injury he reported to the nurse on 5/15/18. He stated, My back was hurting, and he (Occupational Therapist) put a hot pack on me or something, but I'm paralyzed from here down (pointing at his sternum). He was asked, Can you feel the burn? He stated, Yeah, it hurts. I can feel some things, but not everything. I could feel the heat, but couldn't tell how hot it was . The pack was on in the late evening around 4 (4:00 p.m.). I noticed the pain within 30 minutes to an hour. The pain right now is a 7 (on a scale of 1 to 10, with 10 being the most severe). My back always hurts, but this is a different kind of pain . f. On 5/22/18 at 12:55 p.m., Licensed Practical Nurse (LPN) #1 was asked about Resident #1's burn injury on 5/15/18. She stated the resident complained his lower back was hurting and, He said the therapist burned him with a hot towel earlier that day. g. On 5/22/18 at 12:36 p.m., the Occupational Therapist - Registered/Licensed (OTR/L) was asked about the incident with Resident #1 on 5/15/18. He stated the resident, He complained of pain to his lower back, 5 on a scale of 1 to 10. He asked for hot packs, and I agreed. I applied the hot packs with a 7-layer wrapping of towels. I visually inspected the skin before and after treatment, and there was not any problems. He was asked, How long did the hot packs stay on his skin? He stated, Fifteen minutes . In hindsight I realize his sensation isn't the greatest back there, and it probably wasn't the smartest thing to do. (Resident #1) has a pacemaker, so other modality options were limited; at the time, it was the best I could offer. He was asked if this had ever happened before and stated, No. (Resident #1) is a big guy and has more insulation, and in his chair, the pressure could have caused the burn while leaning back in his chair. h. On 5/23/18 at 10:20 a.m., the Medical Director was interviewed via telephone and was asked about Resident #1's burn injury. He stated, The resident sitting in a wheelchair played a role in the injury to lower back, as there was no heat dissipation. He was asked if Resident #1 was at increased risk for this type of injury due to decreased sensation and [MEDICAL CONDITION]. He stated, Yes, he has impaired sensation and plants himself in his wheelchair and takes multiple narcotics. 2. The facility initiated corrective actions immediately after discovering the cause of the resident's injury on 5/15/18, as evidenced by the following: a. On 5/23/18 at 10:00 a.m., the Director of Nursing provided the facility's written corrective action plan, which documented: 1.) Stopped usage of [MEDICATION NAME] on 5/15/18. 2.) Body audit performed on resident (Resident #1) on 5/15/18. 3.) (Medical Equipment Supplier) notified on 5/15/18, came to facility on 5/18/18 and conducted an equipment safety and calibration check - equipment found to be in proper working order. 4.) Therapy department in-serviced on moist heat pack safety on 5/16/18. 5.) Spoke with Regional Office regarding facility no longer using the [MEDICATION NAME] 5/22/18. 6.) Spoke with Therapy Director for alternatives to heat therapy. Suggestions: Apply Bio freeze gel. Massage therapy. The plan is to remove [MEDICATION NAME] out of service. b. On 5/22/18 at 12:36 p.m., the OTR/L was asked about training / in-servicing on heat therapy since Resident #1's 5/15/18 incident. He stated he conducted an in-service, for the whole department last week, with information from the Hydro Guide and American Physical Therapy Association (APTA) website. The In-service sheet dated 5/16/18 documented the following: Area Discussed: Moist Heat Pack Safety. As therapist, we typically use moist heat packs for vasodilation to increase blood flow for relaxation of muscle spasm and decrease pain, via the gate-control mechanism of pain. Our goal is to increase elasticity of muscles in prep (preparation) for therapeutic exercise and ROM (Range of Motion) activities to improve our patient's mobility and self-care participation. Contraindication for moist heat packs include [MEDICAL CONDITION] ([MEDICAL CONDITION], skin disease, malignancy, impaired circulation or sensation, impaired cognition or communication. Risks of moist heat packs include burns, [MEDICAL CONDITION] or dizziness, and bleeding from open wounds. [MEDICATION NAME] temperature should be checked and documented in therapy at 150?F prior to application of moist heat pack to a patient. The moist heat pack should be layered in toweling 7 times including the hot packs cover to [MEDICAL CONDITION] treatment time never to exceed 30 minutes with documentation in therapy notes. Skin check pre-treatment, after 5 minute intervals, and at end of treatment session should be documented in therapy note along with pain rating pre and post treatment . This form was signed by the Certified Occupational Therapy Assistant, the Physical Therapist and the Physical Therapy Assistant. The Trainer was the Occupational Therapist - Registered/Licensed.

Complaint # (AR 820) was substantiated, all or in part, with these findings: Based on observation, record review, and interview, the facility failed to ensure transport staff utilized the van lift in accordance with the manufacturer's instructions during boarding of a resident in a wheelchair and failed to ensure the van manufacturer's instructions were readily available and that all transport staff members were properly trained on them to prevent a fall with serious injury for 1 (Resident #6) of 3 (Residents #1, #6, and #7) case mix residents who required a wheelchair during transport in the facility van since 12/1/17. This failed practice resulted in Immediate Jeopardy, which caused or could have caused serious harm, injury, or death to Resident #6, who was positioned incorrectly on the van lift and fell backward off of the lift during boarding, resulting in a large subdural hematoma and hospitalization requiring sedation and mechanical ventilation. The failed practices had the potential to cause more than minimal harm to 13 residents who required a wheelchair when being transported via the facility van since 12/1/17, according to a list provided by the Administrator on 12/14/17 at 10:50 a.m. The Administrator was informed of the Immediate Jeopardy condition on 12/12/17 at 4:53 p.m. The findings are: 1. The facility's Van / Bus Transportation Policy and Procedure, provided by the Administrator on 12/12/17 at 4:45 p.m., documented, .Purpose: To provide transportation as needed in a safe manner . Policy: Only trained transportation staff will utilize the van / bus lift for transports . Procedure: Staff transports using the van / bus lift shall be trained prior to doing any transports requiring the use of the lift . Lift training shall be completed by the Maintenance Supervisor or qualified trainer using the Manufacturer's Guidelines and Department of Transportation Educational tools . Staff utilizing the lift for transports will complete annual training with designated personnel . Proof of training will be kept in the employee file . The Maintenance Supervisor will complete monthly inspections of the lift . 2. Resident #6 had [DIAGNOSES REDACTED]. A Quarterly Minimum Data Set with an Assessment Reference Date of 10/10/17 documented the resident scored 15 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status (BIMS), had severely impaired vision, required extensive two-plus person assistance for transfers, was totally dependent on one person assistance for locomotion off unit, had functional limitation in range of motion on both sides of lower extremities, used a wheelchair, had no falls since admission or prior assessment, and received [MEDICAL TREATMENT] while a resident. a. A Nurses Note dated 12/8/17 at 7:59 a.m. and signed by Licensed Practical Nurse (LPN) #1 documented, .At approximately 0530 (5:30 a.m.) resident in wheelchair and was being placed on lift of facility van by transport aide to be transferred to go to [MEDICAL TREATMENT]. As transport aide and resident were on lift of van going up, resident began pushing back with her head. Transport aide was standing on lift behind resident. Transport aide and resident began to lose balance. Transport aide fell backwards off lift while lift was partially raised. Transport aide landed on the ground. Resident and wheelchair landed on transport aide. Transport aide assisted resident on ground to obtain assistance. Brakes on wheelchair in locked position on lift before lift was placed in motion. Immediately after incident occurred, nurse was notified. Resident assessed for injuries. ROM (range of motion) performed to all extremities without difficulty. Resident complained of headache and neck pain. Large hematoma noted to back of head . MD (Medical Doctor) notified. New order noted and processed to send to ER (emergency room ) for Tx / Eval (Treatment / Evaluation). (Family member) notified. (Ambulance Service) transported resident at 0615 (6:15 a.m.) to go to (local hospital name) . b. An Office of Long Term Care (OLTC) Incident and Accident Next Day Reporting Form, Division of Medical Services (DMS) form 7734, dated 12/8/17 at 9:14 a.m. and completed by the Administrator documented, .Resident was in wheelchair and was being loaded (into van) by facility transport aid for transport to [MEDICAL TREATMENT]. Resident was facing forward and transport aid was standing behind her on (the) lift. Resident's w/c (wheelchair) was in the locked position. Transport Aid began to raise wheelchair lift to the up position. The lift was approximately 12 inches off the ground. The resident began pushing back with her head on to transport aid. Transport aid lost her balance falling, and her and the resident fell backwards off the lift. Transport aid landed on the ground. Resident and w/c (wheelchair) landed on top of transport aid. Transport aid began hollering for assistance. Nurse and another CNA (Certified Nursing Assistant) came out to assist resident and transport aid. Nurse did note (a) hematoma to back of resident's head. Resident was assisted up by staff. Resident initially refused to go to ER (emergency room ), but did agree and was transported to ER via EMS (Emergency Medical Services) at approximately 6:15 a.m.Steps Taken to Prevent Continued Abuse or Neglect During the Investigation . Transport vehicle was immediately taken out of service by Administrator at 5:53 a.m . Transport aid was suspended pending investigation . Daily van inspections are being completed and are current . Maintenance monthly van inspection current. Maintenance will reassess lift today. Van lift inspected and serviced 11/15/17 . Administrator inspected and assessed van lift on 12/7/17 and lift in good working order . Staff interviews being conducted . In-service initiated on abuse and neglect policy and procedure and transport vehicle policy and procedure . Transport aid received training with return demonstration on loading, unloading, securing the wheelchair and passenger restraint system on 11/16/17 with competency check off by Administrator . (City) Police department notified of incident . c. An OLTC Witness Statement Form dated 12/8/17 at 5:40 a.m. and signed by CNA #1 documented, .I pushed her (resident) out the door to push her up on ramp (of van). I pushed her on the ramp and I was leaning toward the back of her chair and she told me to stop leaning on her and she was pushing her head backward. I was holding (on) to (the) bar with (my) right hand and had controlling lift with my left. I was just holding on, and half way up, the resident proceeded backward and me also. I fell and the resident fell on top of me. I asked her was she okay. I was waving and hollering for help. (CNA name) and a nurse from inside came out as well. We got her up . d. A Hospital History report dated 12/8/17 at 7:39 a.m. documented, .procedure . intubation . chief complaint . fall . Apparently she was dropped from her wheelchair getting into the transport van and fell on concrete. She has a bilateral below-the-knee [MEDICAL CONDITION]. She has a large occipital hematoma. The patient is alert and oriented and denies loss of consciousness or vision change. She does have a headache but denies nausea or vomiting. She reports neck pain and right shoulder pain . She does report right knee pain . Computed Tomography (CT) .there is a right-sided supratentorial hematoma which measures 7.7 mm (millimeters) in maximal thickness and 34 mm in maximal [MEDICATION NAME] diameter. It extends 57 mm in AP (anterior to posterior) dimension . There is an occipital scalp hematoma with no underlying fracture. There is a left mastoid effusion. There is a right prosthetic globe in place . 8:41 a.m.(Physician), accepting physician at (Trauma Center Name) . 9:45 a.m.Patient began to have mental status change. A stat (immediate) repeat head computed tomography (CT) scan was done showing worsening subdural (hematoma). Her Glasco coma scale (GCS) changed from 15 to a 10. Due to the rapid change in GCS and progressive subdural hematoma, the decision was made to intubate the patient for transfer (to Trauma center) for airway protection . 10:57 a.m . (Emergency Transport) left our facility at 9:50 a.m. to get vent due to being intubated. Medic One arrived back at our facility at 10:27 a.m., left our facility at 10:51 a.m. with patient for transfer (to Trauma Center) . Subdural Hematoma without coma, without loss of consciousness . e. A hospital report dated 12/8/17 at 1:05 p.m. from the Trauma Center documented, .There is acute subdural hemorrhage along the right tentorium extending into the interhemispheric fissure along the faix. In supratentorial location, it approximately 4 cm (centimeters) by 1.2 cm best seen on coronal image series 9-32. There is associated mass effect and mild superior displacement of the adjacent temporal lobe parenchyma. There is no significant midline shift. In the posterior interhemispheric fissure, it measures approximately 2 mm (millimeters) in maximum thickness .Acute subdural hemorrhage in the parafalcine and right supratentorial distribution, with measurements described above and mild mass effect on the subjacent right temporal lobe . patient on mechanical ventilation . f. On 12/12/17 at 2:55 p.m., CNA #1 was asked if she was trained how to use the lift on the facility van. She stated that the Administrator trained her. The CNA was asked if Resident #6 was facing the van when she was being loaded via the van lift on 12/8/17. She stated the resident was facing the van in her wheelchair. The CNA was asked if she was standing on the lift with Resident #6 and stated that she was. The CNA was asked how she was trained to have the resident facing when they were on the lift. The CNA stated that a video she watched showed that they could face either way, facing the vehicle or facing away from the vehicle. g. On 12/12/17 at 3:36 p.m., employee files for CNAs #1, #2, and #3 (all staff designated as Transport Staff) were reviewed. The files included a check-off competency list administered by the Maintenance Supervisor. The check-off lists for CNAs #2 and #3 were dated 12/11/17 and included an in-service presented to the Transport Staff and Maintenance Supervisor which documented, Bus: Manufacturer's Guidelines .Loading / Unloading Outward Facing is Recommended . Use safety seat belt before operating lift . Do not ride on lift with passenger . 6. Whenever a wheelchair passenger is on platform, the passenger must face outward, wheelchair brakes must be locked, inboard locator and outer barrier must be up . The check-off list for CNA #1 was dated and signed 11/16/17. The in-service dated 12/11/17 was signed only by CNAs #2 and #3, not CNA #1. h. The Operator's Manual for the NL955 Series van lift was provided by the Administrator on 12/12/17. The manual was dated January 2008 and documented, .Read and become familiar with all lift operation safety precautions, operation notes and details, operating instructions and manual operating instructions prior to operating the lift . Failure to do so may result in serious bodily injury and/or property damage . Whenever a wheelchair passenger (or standee) is on the platform, the . passenger must face outward . wheelchair brakes must be locked . inboard locator and outer barrier must be up (vertical) . outer barrier latch must be fully engaged . The wheelchair passenger must face outward whenever on the platform . Other persons should not ride on the platform with the wheelchair passenger . The wheelchair brakes must be locked . Wheelchair lift attendants should be instructed on any special needs and/or procedures required for safe transport of wheelchair passengers . On 12/12/17 at 3:45 p.m., the Administrator was asked if the Braun NL955 series lift was the lift used with Resident #6 on 12/8/17. The Administrator stated that it was. The Administrator was asked if the staff were trained not to stand on the lift when a resident in a wheelchair was on the lift. She stated, It was not. I have always trained the staff to ride on the lift with the resident. The Administrator was asked if the staff were trained to have the resident in a wheelchair facing away from the van when they were on the lift. She stated, On the video, it says the residents could be faced either way according to patient comfort. She also stated that the video did not give instructions regarding staff being on the lift platform when lifting a resident in a wheelchair. i. On 12/13/17 at 8:30 a.m., the facility Regional Director of Arkansas provided 2 other lift operation manuals. Neither of these manuals specifically addressed instructions for use of the NL955 series lift. One documented it was an Operator's Manual for the Braun NL Series and was dated December 2009. The other manual documented it was an Operator's Manual for the NCL Century 2 Series lift. Both of these manuals documented, .Inboard facing of wheelchair lift passengers is not prohibited, but outboard facing of passengers is recommended by the Braun Corporation . Both of the manuals also documented, .The lift attendant should not ride on the platform with the passenger . j. On 12/13/17 9:15 a.m., the Administrator accompanied the surveyor to the facility van. The Administrator stated this was the van and lift used when Resident #6 was being transferred and fell off of the lift. The lift on the van had an attached plate that documented, Braun Corporation, NL955SE, mfg (manufacturing) date 6/30/2008 . 3. The Immediate Jeopardy was removed, and the scope and severity reduced to G on 12/12/17 at 4:45 p.m., when the facility implemented the following Plan of Removal: On 12/8/17 at 5:50 a.m., the Administrator was notified of incident by QA (Quality Assurance) Nurse. The Administrator instructed the staff to not transport any residents until further notice. The Transport Aide (CNA #1) was suspended pending investigation. The resident was transferred to the ER (emergency room ) via EMS (Emergency Medical Services) from scene of incident at approximately at 6:15 a.m. on 12/8/17. On 12/8/17, an in-service was initiated on Abuse Policy and Procedure, as well as Van Transport Policy and Procedure. On 12/8/17, the Administrator and Maintenance Supervisor inspected the van lift and found the van lift was in good working order. The Transport Aide (CNA #1) was trained via Q-straint webinar with return demonstration and competency check-off on 11/16/17 by Administrator. The Administrator is monitoring 3 transports a week to ensure staff is properly loading, unloading, and applying safety restraints per manufacturer's instructions. There have been no negative findings up until this point. Daily van inspections completed and current. Maintenance monthly check list current. The facility vehicles have been pulled from all transports until further notice. On 12/8/17 an in-service was conducted for all staff on facility vehicles out of commission until further notice. On 12/8/17 an in-service was initiated on Manufacturer's Guidelines on lift loading / unloading with transport aide. On 12/11/17 the Maintenance Supervisor from (sister facility name) who was trained, with letter on 12/5/17, came to facility and trained the Maintenance Supervisor and Transport aides with return demonstrations on bus / van lift. On 12/12/17, CNA #1 was in-serviced by the Administrator regarding, ' .Residents are only loaded / unloaded (on the van) outward facing . Use safety belt on lift . Do not ride with passenger on lift at any time . If an accident occurs, do not move resident until assessed by nurse . Do not transport until training 12/15/17 at facility and demonstrated competency .' An in-service for all transport aids, Maintenance Supervisor and Administrator has been scheduled with (Mobility Company) for 12/15/17 at 11:00 a.m. for loading, unloading, securing passengers and wheelchairs.

Complaint # (AR 736) was substantiated, all or in part, in these findings: Based on record review and interview, the facility failed to ensure wheelchairs were secured in the transport van in accordance with the manufacturer's instructions during transport to prevent potential injury for 1 (Resident #2) of 5 (Residents #1-5) case mix residents who were transported in the van via the use of a wheelchair. This failed practice resulted in Immediate Jeopardy, which caused or could have caused serious harm, injury or death to Resident #2, who was not properly secured in the transport van and fell forward in the van during transport, and had the potential to cause more than minimal harm to 21 residents who required wheelchair transport, as documented on a list provided by the Administrator on 11/15/17 at 3:00 p.m. The Administrator was informed of the Immediate Jeopardy condition on 11/15/17 at 2:30 p.m. The findings are: 1. The facility's Van/Bus Transportation Policy and Procedure, provided by the Administrator on 11/15/17 at 3:43 p.m., documented, .Purpose: To provide transportation as needed in a safe manner .Policy: Only trained transportation staff will utilize the van/bus lift for transports .Procedure: 1. Staff transports using the van/bus lift shall be trained prior to doing any transports requiring the use of the lift. A. Lift training shall be completed by the maintenance supervisor or qualified trainer using the manufacturer guidelines and Department of Transportation educational tools. B. Staff utilizing the lift for transports will complete annual training with designated personnel. C. Proof of training will be kept in the employee file. 2. The maintenance supervisor will complete monthly inspection of the lift . 2. The Skills Check-Off Form used to train transport staff was provided by the Administrator on 11/15/17 at 10:45 a.m. and documented the following: .Steps of Procedure .1. Wheel-chaired Residents .A. If the resident has a physician ordered restraint, it must remain on during all transports. The restraint must be on prior to loading the resident in the van (See manufacturer's guidelines for applying restraint) .B. Load resident into the van. Follow the manufacturer's recommended guidelines for use of the lift .E. Using the straps provided, strap each front wheel of the wheelchair to the floor brackets .F. Synch (sic) the straps as tight as possible. Wiggle the wheelchair several times until the synch is as tight as possible .H. Using the seatbelt provided ensure that each end of the seat belt is secured to the floor and place the other end of the seat belt through the arms of the wheelchair and buckle in front of the resident .As part of my job duties of being a van driver for this Facility, I understand: .2. The resident that is being transported in a wheelchair will have the wheelchair securely attached to the body of the van during transport .3. The wheelchair and resident will have a properly adjusted and fastened seatbelt on at all times when the vehicle is moving . 3. Resident #2 had [DIAGNOSES REDACTED]. A Quarterly Minimum Data Set with an Assessment Reference Date of 10/10/17 documented the resident scored 15 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status, required extensive assistance of 2 plus persons for transfers, had functional limitation in range of motion of both lower extremities, did not ambulate, and used a wheelchair for mobility. a. An Incident and Accident Report dated 11/13/17 at 7:15 a.m. documented, .Resident was being transferred to dialysis in facility van. Resident starting hollering and transport aid pulled over to side of road to check on her. Resident fell forward out of her w/c (wheelchair) before aid could get to her. Seat belt was in place at time of incident .Resident was transferred to ER (emergency room ) via ambulance service .Interviews being conducted .Van taken out of service and taken to (wheelchair van dealership) place for inspection .In-service initiated on abuse and neglect policy and procedure and transport vehicle policy and procedure .Transport aid removed from transports until investigation completed . b. An Office of Long Term Care (OLTC) Witness Statement Form documented, .Date: November 13 2017 .Witness Full Name: (Certified Nursing Assistant (CNA) #1) .Job Title: CNA/Transport .We was almost to (city approximately 30 miles from facility), and I heard (Resident #2) holler and tell me she is falling. I immediately stop (sic) the van and went to check on her, she was leaned over and I put her back up in the chair and called the facility and told the nurse that (Resident #2) was leaning over in the chair and I asked (Resident #2) 3 times if she wanted to go to the ER she said no all 3 times and said come on we going to be late for dialysis, so we head out again and this time she hollered louder and said I'm falling well I stopped the van and got half way back there from the front and she flipped out head first her head landed on the back of the back seat and I got to her and she said get the seat belt it's hurting me. I undone it and lowered her to the floor of the bus and I said (Resident #2) are you ok. She said yes but I (expletive for defecated) on myself and we talked (I made sure was ok). I called the ambulance and the nursing home and I sat with her until the ambulance arrived helped them get her back in her chair and then helped get her on the stretcher . The History and Physical Report from Emergency Department to Hospital Admission, dated 11/13/17 at 6:42 a.m., documented the following, .HPI (History of Present Illness): (Resident #2) is a 58 y.o. (year old) female who presented with a history of multiple CVAs (Cerebrovascular Accidents) .who presented to ED (emergency department) today after falling from her wheelchair in the .van that was transporting her to hemodialysis. She complains of generalized weakness as well and HA (headache) and neck pain. She reports she sees a pain manager for her neck pain and has an appointment Wednesday. Routine labs on admission noted elevated troponin. The patient apparently complained of chest pain upon presentation but presently denies this as well as SOB (shortness of breath), nausea, diaphoresis or palpitations . Assessment and Plan Neck Pain after fall CT neck: no post traumatic findings . c. On 11/13/17 at 5:25 p.m., the Administrator was asked, Where is (CNA #1)? She stated CNA #1 was working in the facility today and that she had been checked off on using the transport van. The Administrator was asked if, prior to the incident this morning, there was a check-off sheet for training staff on securing residents in the transport van. The Administrator stated, I have not been able to find one. She (CNA #1) was a re-hire in July (2017) I think, and she was not re-checked off. There is one from her previous employment in 2016. d. On 11/13/17 at 5:51 p.m., CNA #1 was asked, Will you tell me what happened with (Resident #2)'s transport today? The CNA stated, We got almost to (city approximately 30 miles away), and she yelled my name and said, 'I think I'm falling over.' So I pulled over, and she was leaned over, so I sat her upright. I asked her if she wanted to go to the ER, 'cause this wasn't like her. I called the facility, and the nurse told me to go ahead and get her to dialysis. We started back on the road, and she yelled my name again. I pulled over and I was midway back there, and it was like she didn't have any control of her upper body, and her head was against the seat in front of her. The seat belt was still snapped, so it never like came undone or anything. The CNA was asked, When were you trained on transport? The CNA stated, Last time I worked here (2016). (Maintenance Supervisor #1) fully trained me. When I started back this time I did not get re-trained. e. On 11/14/17 at 3:00 p.m., the resident was asked to explain what happened while being transported in the van on 11/13/17. The resident stated, Me and (CNA #1) were on our way to dialysis and I started to feel like I was falling. It felt like I could not control my upper body. She (CNA #1) came and sat me back up and we started again and the same thing happened. This time she called the ambulance. I was having chest pain and everything else. The resident was asked it this ever happened before and she stated no. f. On 11/15/17 at 8:40 a.m., the Administrator was asked if the van had returned from the van dealership. The Administrator stated, No, but he (representative of dealership) told me that the van was actually missing a part. The Administrator was asked which part was missing and stated, There should have been a male adapter for the lap belt, so they (transport staff) were just using the one shoulder strap. The Administrator was asked how long it had been that way and stated, For as long as I have been Administrator; one and a half years. The Administrator was asked, How is it that staff were being trained, if an entire piece was missing? The Administrator stated, The maintenance man who is no longer here was doing it (training), so I can't answer that question. The Administrator was asked for the manufacturer's instructions for the van's restraint system and stated, I just got them. I didn't have them before now. The Administrator was asked, So staff members weren't being trained according to manufacturer's instructions?' The Administrator stated, Apparently not. On 11/15/17 at 10:45 a.m., employee files (CNA #1, #2, and #3) were reviewed for all staff designated as Transport Staff. The files included a check-off list administered by the previous Maintenance Supervisor and a copy of their driving record. There was no documentation of any ongoing monitoring or scheduled retraining. The Check-off Lists did not include all of the manufacturer's recommendations. g. On 11/15/17 at 11:44 a.m., the manufacturer's representative was asked, Do you know when the Q-straint system was implemented in the van for this facility? The representative stated, On 11/6/2008. The representative was asked, Did your services include periodic quality inspections? The representative stated that was probably recommended. The representative was asked, Who trained the contact person for the facility? The representative stated that information was not available. The representative was asked if the van was inspected on 11/13/17 and stated there was no record of an inspection. The representative was asked, In 2008, did your company train anyone from the facility on the correct way to use the system? The representative stated, I cannot honestly answer that, since it was in '08, but I know now and since '12 (2012), if we put a set of tie-downs in a van, then we send the literature and we demonstrate the proper way to use. The representative was asked, If they (facility's transport staff) were using just the shoulder belts and no lap belt, would that be safe? The representative stated, Well, without seeing it and just going by what you are telling me, that does not sound safe at all. If you lost the shoulder belt, then the lap belt could be used in an emergency .Just using a shoulder belt would not be safe at all . h. On 11/15/17 at 12:00 p.m., the local manufacturer's representative was asked, What are the results of the inspection (on 11/13/17)? The representative stated, On 11/13/17, we did a 6-month lift service. We disabled the OEM shoulder harnesses. They have been using them for the wheelchairs so we put in new wheelchair retractors and we put in a new lap belt. The representative was asked, So they did not have lap belts? The representative stated, They had them; they just weren't using them. We found them in the vehicle. One they were using with the OEM shoulder harness and one had been unclipped and was underneath the drivers' seat. The representative was asked, What makes the OEM shoulder belt unsafe to be used with wheelchairs? The representative stated, They don't hold or support the person when they are in a wheelchair. The representative was asked, You mentioned that you did a 6-month service. How often have these been done for this vehicle? The representative stated, We suggest they do the service every six months. The representative was asked, Do you have records of the last time this vehicle was serviced? The representative stated, 3/24/17; at that time, they got a full set of retractors, correct shoulder belts, and lap belts. We have ordered a training video for them as well. The representative was asked, When was this system installed in this van? The representative stated, 2008, yes they got their lift, occupant restraints, and belts. We stopped doing the on-site training ourselves 2 years ago. The representative was asked, Do you have a record of on-site training having been done? The representative stated, No. I wouldn't have that, but if it was done, then they would have been given certificates for all who were trained. The representative was asked, Do you show that they have purchased the (training) video? The representative stated, We have no record of them purchasing the video prior to 11/14/17. i. On 11/15/17 at 12:30 p.m., CNA #2 was asked, What is your position? The CNA stated, Transport aide. The CNA was asked, Who trained you on the proper way to strap residents in the van? The CNA stated, I first started driving the van as the CNA supervisor and I was trained by the maintenance man, (Maintenance Supervisor #1). The CNA was asked, Can you describe the way you were trained to seatbelt residents in the van when they are in a wheelchair? The CNA stated, We would take the shoulder strap and put it across their chest and slide it under the arm of the wheelchair kind of like on the opposite side and down to the floor. The CNA was asked, So it is the same strap and not 2 different straps? The CNA stated, No, just one strap. The CNA was asked, Have you ever seen this (manufacturer's guidelines)? The CNA stated, No. The CNA was asked, Will you look at it and tell me if the way you were trained is different from what this says? The CNA stated, Okay. So, it says that there is supposed be another strap that you cross over the lap. So, they have a shoulder strap and a lap strap in these instructions. The CNA was asked, So you have never actually seen 2 straps (shoulder and lap) in the van? The CNA stated, No. I have not seen it in the van but I have seen it in the bus. The CNA was asked, How often would you say you transport in the van as opposed to the bus? The CNA stated, I might drive the van once a month cause I would usually use the bus. At 3:50 p.m., CNA #2 demonstrated the proper way to strap a wheelchair in the van following the manufacturer's guidelines. j. On 11/15/17 at 12:44 p.m., the Administrator was asked, Was (Maintenance Supervisor #1) here in (2008)? The Administrator stated, Yes. The Administrator was asked, Do you have any records of the training that he received? The Administrator stated, I have his certification. What I did, I pulled up on-line video in October (2017) and had everyone who could possibly transport watch it. And (vehicle dealership) said that we had purchased the videos but I don't know if we did or where they are. They are going to re-order them for me. k. On 11/15/17 at 12:57 p.m., CNA #3 was asked, Were you trained regarding transporting residents in wheelchairs and seat-belting the wheelchair (in the van)? The CNA stated, I got trained on transport for activity stuff. The CNA was asked, Can you describe what you were trained to do? The CNA stated, Grab the shoulder strap weave it through the chair arm then through the other chair arm and then to the floor. The CNA was asked, So just to clarify, you were trained to use the shoulder strap for the one and only belt and there was no separate lap belt? The CNA stated, Yeah. It went from the shoulder to under the arms of the wheelchair down to the van floor where it got buckled. The CNA was asked, Have you ever seen these manufacturer instructions? The CNA stated, No. The CNA was asked, Will you read them over and tell me how these instructions differ from the way you were trained? The CNA stated, We don't have that connector that female and male connector - we don't have that. The CNA was asked, Who trained you? The CNA stated, (Maintenance Supervisor #1). The CNA was asked when she was trained and she stated approximately 2.5 years ago. The CNA was asked, Have you ever actually transported a resident in the van? The CNA stated, Yes, I would say about 10 a year. 4. On 11/15/17 at 3:45 p.m , the Immediate Jeopardy was removed and the scope and severity was reduced to E when the facility implemented the following plan of removal: Resident was transferred to ER via EMS (emergency medical services) from scene of incident at approximately 6:14 a.m. on 11/13/17. Per EMS report resident was alert and oriented x (times) 3 upon arrival. Transport van was immediately removed from service and taken to dealership for inspection at approximately 9:30 a.m. on 11/13/17. There were no further transports in the facility van. Transport aid (CNA #1) was removed from transporting residents on 11/13/17 after incident. 11/13/17 in-service was initiated on abuse and neglect procedure and resident transports. On 11/14 17 at 8:30 a.m., transport van was taken from the dealership to (wheelchair van dealership) for inspection of lift and passenger restraint system. As of 11/13/17, there have been no further transports in facility van. The facility van remains at (wheelchair van dealership) at this time. Upon van returning from (wheelchair van dealership) and deemed safe for transports, all employees responsible for transporting residents will be in-serviced via training video with return demonstration of proper loading, unloading, and passenger safety restraint. Transport aids will complete a daily inspection of facility van once in commission to ensure all seat belts functional and lift operational. Any issues will be reported immediately and van taken out of service until further inspection. Every 6 months and as needed, the facility van lift and passenger restraint system will be inspected and serviced at (wheelchair van dealership). Any concerns will be addressed immediately and corrected before facility van in commission. Daily van walk around inspection checklist to be completed by transport staff. Lift Service to be completed every 6 months (November and May) at (wheelchair van dealership) and as needed. Administrator will monitor 3 transports a week to ensure staff is properly loading, unloading, and applying safety restraints per manufacturing guidelines. Any negative findings will be corrected immediately by Administrator.

Complaint # (AR 588) was substantiated, all or in part, with these findings. Based on record review and interview, the facility failed to ensure adequate supervision was provided and interventions were developed and consistently implemented to prevent elopement for 1 (Resident #1) of 3 (Residents #1, #6 and #7) case mix residents who had a history of [REDACTED]. The failed practices resulted in past noncompliance at the level of immediate jeopardy, which caused or could have caused serious harm, injury or death for Resident #1, who eloped from the facility at night and was not discovered missing until the following morning. The failed practices also had the potential to cause more than minimal harm to 7 residents with a history of wandering, according to a list provided by the Administrator on 10/5/17 at 10:10 a.m. The Administrator was informed of the past immediate jeopardy condition on 10/5/17 at 4:19 p.m. The findings are: Resident #1 was readmitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. An Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/21/17 documented the resident scored 1 (0-7 indicates severely impaired) on a Brief Interview for Mental Status (BIMS); exhibited verbal behavioral symptoms toward others which put the resident at significant risk for physical illness or injury, significantly interfered with the resident's care, and interfered with the resident's participation in activities and social interactions; exhibited rejection of care; had wandering behaviors which placed the resident at significant risk of getting to a potentially dangerous place; required limited assistance of one person for transfer, and required supervision after set-up for ambulation. a. The Care Plan dated 8/14/17 documented, .I am an elopement risk r/t (related to) I am a wanderer . Approaches: Place monitoring device on me that sounds alarms when I leave building; Alert staff to my wandering behavior . Assign staff to account for my whereabouts throughout the day . Monitor Wander-guard placement Q (every) shift . b. Nurse's Notes dated 9/4/17 at 11:42 a.m. documented, Resident returns today from LOA (leave of absence) with family. His daughter-in-law entered the building and asked if we could help get him to come in because he would not get out of the truck. She went on to explain the family had been trying to get (Resident #1) to return for 2 days and he would not. He had even become aggressive with her and she had called the police but they told her there was nothing they could do. The Administrator and Director of Nursing (DON) went outside and attempted to speak to (Resident #1) and convince him to get out of the truck and come into the building. He began talking to us and asking when the doctor would be here, at this point one of his sons sitting next to him in the truck nudged him toward the exit and (Resident #1) became very angry with him. As we continued to talk, a Certified Nurse Assistant (CNA) walked past and (Resident #1) called out to her. She came over to the truck and was able to convince him to get out of the truck, finish his cigarette and come in the building. His belongings were brought in as well by his family. His family also let the DON know what (Resident #1) had said in Spanish about the CNA. He had indicated she was the only reason he was coming back to the facility and he wanted her to be his girlfriend. He also wants his hair cut and colored to cover up his gray. The DON spoke with the family about the need to send this resident back to (geriatric-psychiatric (geri-psych) facility). The family completely understands and realizes how upset this gentleman will become when he realizes they have left. Resident's charge nurse to contact (geri-psych facility). c. The Wander Data Collection Tool form dated 9/15/17 documented, .Evaluation Factors: Has the resident wandered? Did the resident wander at home, in previous living settings, family/significant others voiced concerns? Yes . Does the wandering place the resident at significant risk of getting to a potentially dangerous place (stairs, outside the facility)? Yes . Is the resident cognitively impaired with poor decision-making skills (i.e. (such as), poor decisions, cues, intermittent confusion, inattention, disorganized thinking)? Yes . Is the resident seeking to find spouse/family? Yes . Summary: Based off of Summary of Findings, resident is: A wander/elopement risk. Select all interventions utilized: Personal safety alarm devices; Frequent monitoring . d. Nurse's Note dated 9/15/17 at 9:32 p.m. documented, Wander guard applied to right wrist due to resident wandering throughout facility and trying to go home with (name). Wander guard noted to be working properly. Staff will continue to monitor for safety. e. Nurse's Notes dated 9/30/17 at 10:59 a.m. documented, CNA notified nurse at (5:20 a.m.) during morning rounds that resident could not be located. Nurse and CNA checked common areas and smoking area. Nurse and CNAs on all halls walked facility checking all rooms in facility. (6:05 a.m.) Weekend RN (Registered Nurse) notified that staff was unable to locate resident. Weekend RN notified Administrator and authorities. Staff continued to walk facility and grounds looking for resident. Family notified. 11:31 a.m., family notified Administrator via cell phone at 9:45 a.m. stating that resident had called (family member) and he was at the (store name) in (Town). Administrator immediately left facility to meet resident. (At) 9:52 a.m. resident noted to be ambulating with a male in parking lot of (store name). Resident alert and in no acute distress when Administrator arrived. Family notified and in route to meet resident. Resident had been found ambulating around a residence approximately 1.3 miles from the facility. Resident did verify with family that he climbed over the fence in the smoke area last p.m. (night). Resident was transported via (ambulance service) to (Hospital) ER (emergency room ) for evaluation. Family present and accompanied resident to ER. Police Dept. (department), DON and Corporate notified of resident whereabouts at 9:47 a.m. Medical Director notified of whereabouts at 10:39 a.m. f. An Office of Long Term Care (OLTC) Witness Statement form dated 9/30/17 at 6:00 a.m., signed by RN #1, documented, I arrived at the facility at 4:50 a.m., clocked in, spoke with charge nurses and asked if there were any issues. Both said no. I was organizing my workers for the day, when the 6-2 (6:00 a.m. to 2:00 p.m.) staff began to come in around 5:30, around 0600 (6:00 a.m.) the CNAs (Certified Nursing Assistants) notified me (Resident #1) was not in the building. I instructed all staff to stop and everyone look for resident. Myself and another weekend RN began to go room to room, sent other staff outside to search property, and I opened every door in every room looking. At (6:15 a.m.) I notified Administrator of situation, at (6:20 a.m.) (Local Police Department) was called. I called family and spoke to (family member) at (6:30 a.m.). I continued to have staff search property. At 0705 (7:05 a.m.) I called police again, and instructed them we needed a Silver Alert and APB (all-points bulletin) on resident. Administrator notified staff she was on her way. I called police again at 0750 (7:50 a.m.) to give information on resident, gave family name and number to police. At 0820 (8:20 a.m.) called police to check on update on Silver Alert. Was told it was in process now. I was notified by (Police) a Silver Alert had been issued by AR (Arkansas) State Police. After being notified around 0945 (9:45 a.m.) resident had been located, I called (local police) to cancel Silver Alert at 1052 (10:52 a.m.). g. An OLTC Witness Statement form dated 9/30/17 at 6:30 a.m. and signed by Licensed Practical Nurse (LPN) #4 documented, Arrived (at) facility (at) 5:30 p.m. for shift, resident at nurse's station asking to use phone. Nurse dialed number for daughter-in-law, no answer. 7:00 p.m. resident out to smoking area supervised by CNA. Returned to room, 8:30 p.m., fire alarm sounded, CNA in breakroom popping popcorn in microwave, burn smoky. Alarm reset. CNA for each hall checked doors on hall as well as front door & (and) door in kitchen area and hall leading to laundry, all doors secure. Residents accounted for on all halls. Resident in common area accounted for at that time. 10 p.m. shift change CNA (name) did rounds (at) that time stated resident in room. 2430 (12:30 a.m.) in resident's room administering roommate's medication. Resident was in room standing next to bed moving clothing from closet to bed then to drawers & bag. Resident frequently moves his clothing and belongings around room. 0130 (1:30 a.m.) (CNA #4) checked on resident, resident was ambulating in dayroom & (and) dining room. 0520 (5:20 a.m.) doing morning rounds getting residents out of bed for day, (CNA #4) stated, 'Have you seen resident? He is not in his room'. CNA & nurse checked common areas and smoking porch walked facility checking rooms on all halls, resident often goes in other resident's room has to be redirected. Alerted CNAs on all halls to assist looking in each room of facility. Nurse walked grounds. 0605 (6:05 a.m.) weekend nurse notified that staff was unable to locate resident. Staff continued to look. Weekend RN notified Administrator, Authorities and family. Resident noted to be wearing brown shoes, blue jeans, blue and black flannel shirt this shift. h. An OLTC Witness Statement form dated 9/30/17 at 7:00 a.m. signed by RN #2 documented, Around 6 a.m., LPN (Licensed Practical Nurse) notified (RN #1) and I about missing resident (Resident #1). I immediately went to resident room to check & checked bathroom after not finding him went to smoke area, while observing smoking area seen 3 milk crates stacked on top of one another with a concrete block beside them directly in front of the fence. Interviewed a male & female resident that was waiting to go outside & smoke to see if they had seen the resident or when the last time they had seen him. The male resident stated, 'He was here last night.' I continued searching facility & facility grounds for resident without success. i. An OLTC Witness Statement form dated 9/30/17 at 7:10 a.m., signed by CNA #4, documented, (CNA #4) arrived at work at 9:50 p.m. Upon arrival I started my round at 11:30 p.m. (Resident #1) was in his room. I continued to do my round. At around 1:15 a.m. I checked on another resident, talked to the nurse, got a dollar, went to breakroom after getting a soda. (Resident #1) was in the dayroom . j. An OLTC Witness Statement form dated 9/30/17 at 10:00 a.m. and signed by the Administrator documented, Resident stated to daughter-in-law per her interpretation that he jumped the fence on the smoke porch at approximately 9 p.m. Resident states he wants to leave because he wants a woman. k. An OLTC Witness Statement form dated 9/30/17 at 4:00 p.m. and signed by the Administrator documented, Interpreted by family member. Resident reported to family that he went out sometime last p.m. with other smokers. When they went in he hid behind wall & waited til no one was outside. He stacked the milk crates & climbed the fence. Stated he was trying to scare everyone. l. An OLTC Witness Statement form dated 9/30/17 at 4:30 p.m., signed by CNA #5, documented, I took the smokers out at 7:00 p.m. (Resident #1) went out he proceeded that he wanted a cigarette I told him that he didn't have any cause he had (smoked all his) cigarettes. He (had) a cigarette and a lighter that the nurse asked us CNAs to get later if we could because he is combative. When I came off smoke porch I brought all residents including (Resident #1) in for the night. When I left at 10:00 he was in the day room. m. On 10/5/17 at 11:28 a.m., the Administrator was asked, What can you tell me about when (Resident #1) got out of the facility? She stated, I was notified at 6:10 a.m. by the weekend RN that they were unable to locate him and, at that time, they had searched the facility looking. The staff had reported at 5:20 a.m. the CNA had gone to get him ready for the day. That's when they realized he was not in his room and began searching the facility. When the weekend RN started making her rounds to search for him in the smoke area, they noticed three milk crates stacked on top of each other at the fence. The police department was notified at 6:11 a.m. Per staff interviews, he was last seen at 1:15 a.m. in the dayroom. I got here at 6:55 a.m. and started coordinating with local authorities. The Administrator was asked, Where was he found? She stated, About 1.3 miles from the facility. We found his Wander guard bracelet outside of the smoke gate, it had been torn. It was ripped to pieces. At 9:45 a.m. the facility called me; the daughter-in-law stated she had received a phone call and (Resident #1) was at the (store name) in (town). I left the facility and went to (store). As I pulled down the street to go to the (store), I saw (Resident #1) and another fell ow walking into the parking lot going into the gas station. The male with him found (Resident #1) on his residence and (Resident #1) had a phone number in his pocket. The gentleman helped him make a phone call and told (Resident #1's) family that he was taking him to the (store) to meet them. If you go out the back of the facility here, there is a subdivision, and he found him (Resident #1) in his yard. The man was out there watching his horses and saw (Resident #1) out there by his barn. He traveled 1.3 miles behind the facility. The man helped him make a phone call, then drove him to the gas station to meet his family. I got there first, then notified the family and they met me and the local authorities at the (store). He did tell the family that he stacked the milk crates up and jumped the fence, that he was looking for a woman. He was not in any acute distress. At 10:00 a.m., he was transported to (Hospital) for evaluation. The Administrator was asked, How did he get out of the facility? She stated, He told his family that he went out with some smokers. When they came in, he hid behind the wall, stacked up the milk crates and jumped the fence. The Administrator was asked, Did the CNAs take the smokers out or was it smokers who went out on their own? She stated, Residents who went out on their own. The Administrator was asked, Why did someone not hear the Wander-guard alarm? She stated, I can't answer that. That door on 200 hall was inconsistently sounding on 9/30/(17) at 1:30 p.m. (after the incident). n. The facility removed the immediate jeopardy and corrected the failed practices on 9/30/17, as evidenced by the following: 1.) During the interview with the Administrator on 10/5/17 at 11:28 a.m., the Administrator stated, .We put somebody one-on-one at that door (200 Hall), and maintenance increased the sensitivity. The Administrator was asked, What have you put into place to keep an incident like this from happening again? She stated, We have increased the sensitivity on all the Wander-guards in the whole building, changed all the door codes, put an elopement book in place at the nurse's station with pictures, all residents with Wander-guards were placed on q (every) one hour checks, one-on-one at the smoke porch door until 10/2/17, changed the smoking policy to supervised only and alarm door checks once a day. 2.) A Q (every) 15 Minute Check Sheet dated 9/30/17 documented the resident's name and 15 minute checks were conducted from 1:10 p.m. until 4:30 p.m., at which time the resident left the facility with his family. 3.) An In-service form dated 9/30/17 documented, Res (residents) at risk for elopement / Res with Wander-guard must be checked every hour to ensure Wander-guard is in place. Report any concerns to Charge Nurse immediately. This form was signed by 50 staff members. 4.) An In-service form dated 9/30/17 documented, All residents are now supervised smokers. Residents must be taken out promptly. If you are unable to take residents out at your assigned time, you must find someone to do so. This form was signed by 29 staff. 5.) On 10/5/17 at 12:21 p.m., the Maintenance Director was observed checking the sensitivity of the Wander-guard bracelets. 6.) The Daily Exit Door Inspections form was completed on the following days by the Maintenance Director: 9/30/17, 10/2/17, 10/3/17, 10/4/17 and 10/5/17. 7.) On 10/5/17 at 2:25 p.m., the DON was asked, How often do the CNAs check on residents who have wandering and exit seeking behaviors? She stated, If they have a Wander-guard on, they do checks every hour. She was asked for the documentation of Resident's #1 hourly checks (for the night of 9/29/17 and morning of 9/30/17) and stated, I don't have anything documented that it was done. 8.) On 10/5/17 at 3:38 p.m., the Administrator was asked, Who checks the Wander-guard system? She stated, Maintenance checks the exit doors 5 days a week and the bracelets are checked for placement and functioning every shift by the nurses.

Based on observation, record review and interview, the facility failed to ensure mechanical lift slings were routinely monitored for signs of excessive wear and were laundered in accordance with manufacturer's instructions to prevent potential heat damage to the slings or straps and failed to ensure a lift sling with worn, frayed straps was promptly removed from service to prevent an accident with injury for 1 (Resident #1) of 3 (Residents #1, #4 and #5) case mix residents who required a two-person mechanical lift transfer. This failed practice resulted in past noncompliance at the level of immediate jeopardy, which caused or could have caused serious harm, injury or death to Resident #1, who was dropped from a mechanical lift sling and sustained a spinal fracture, and had the potential to cause more than minimal harm to 19 residents who required a 2-person mechanical lift transfer, according to a list provided by the Director of Nursing (DON) on 5/24/17. The Administrator was informed of the past noncompliance at immediate jeopardy level on 5/24/17 at 2:49 p.m. The findings are: 1. The Invacare Lifts and Slings manufacturer's instructions documented, .Sling Sizes .Green L (large) . Note: Sling size and fit can vary significantly depending on patient weight and girth . Washing instructions are on each sling label. Washing temperature should not exceed 120 degrees F (Fahrenheit). Air-dry or dry at low temperatures . 2. The Drive Full Body Patient Sling manufacturer's instructions documented, .Washing Instructions . 1. Machine wash in warm or cold water. a. Maximum washing temperature 185 degrees F. b. Wash at 160 degrees F for 3 minutes. c. Wash at 145 degrees F for 10 minutes. d. Air Dry, or Tumble Dry at cool or very low temperature. e. Do NOT Tumble Dry at high temperature. 2. Use Non-Enzyme detergent. 3. DO NOT USE BLEACH! 4. DO NOT wash with other colors . Warning Inspect patient slings for wear prior to use. If signs of tearing, fraying or wear are found discard the sling immediately; worn out slings are not safe for use and may result in injury or death . a. On 5/24/17 at 12:08 p.m., the Laundry Supervisor was asked how she laundered the slings or transfer pads for the mechanical lifts. The Laundry Supervisor stated, They probably come through 3-4 times a day, and we wash them. They say to air dry them but most of the time we have to dry them (in the dryers), no bleach. A normal wash, certain settings for whites and colors, 150-160 degrees, I would say. b. On 5/25/17 at 10:10 a.m., the Administrator was asked to provide documentation of the highest temperatures for washer and dryer usage. The documentation provided by the Administrator documented the dryers' high temperature was 180 degrees F. and the washers' high temperature was 160 degrees F. 3. Resident #1 had [DIAGNOSES REDACTED]. The Annual Minimum Data Set with an Assessment Reference Date of 5/2/17 documented the resident scored 15 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status, required extensive assistance of two plus people for transfer and bed mobility and had impairment of lower extremities on both sides. a. The Office of Long Term Care (OLTC) Incident and Accident Report (I&A), Division of Medical Services (DMS) form 7734 dated 3/7/17 documented, .Date of I & A (Incident and Accident): 3/7/17 at 7:11 AM . Summary of Incident . While (Resident #1) was being transferred from bed to shower bed via mechanical lift, three straps of lift sling broke and (Resident #1) fell into the floor landing on legs of the mechanical lift. Lift sling straps noted to be broken at seams that attaches to lift sling. Lift sling inspected by maintenance and QA (Quality Assurance) nurse, noted to show no signs of fraying or obvious wear and tear. (Resident #1) most current weight was 246 lbs (pounds) from previous day. Weight capacity for lift sling is 450 lbs. Mechanical lift noted to be in good working order. (Resident #1) noted to have small abrasion to right elbow and skin tear to right great toe. First Aid provided by nursing staff. (Resident #1) was sent to ER (emergency room ) for further evaluation and treatment . lift sling removed from service. Inspection performed on all lift slings and mechanical lifts with no negative findings . Steps Taken to Prevent Continued Abuse or Neglect during the Investigation . Staff interviews being conducted related to incident. All CNAs (Certified Nursing Assistants) to be re-inserviced and checked off for competency using mechanical lift. All slings to be numbered and any new slings to be dated and numbered at time of put into service. Continue to be checked weekly by Restorative Nursing and will be inspected prior to each use by CNA. In-service initiated immediately for CNAs, Nursing, and laundry staff on how to properly check lift slings for wear and tear and when to remove from service . b. An OLTC Witness Statement form dated 3/7/17 at 8:00 a.m. and signed by CNA #1 documented, State in your own words what you witnessed (be very descriptive) and sign below: I went in to assist (CNA #2) in putting (Resident #1) on the shower bed. Once he was lifted in the air to be put on the bed all 4 straps on the lift broke and the resident hit the floor. He fell on the legs of the lift . c. An OLTC Witness Statement form dated 3/7/17 at 7:30 a.m. and signed by CNA #2 documented, I, (CNA #2), was assisting (Resident #1) onto the shower bed. Once he was lifted in the air, all the 4 straps broke and (Resident #1) hit the floor. He fell on the legs of the lift . d. The Hospital Emergency Department Notes dated 3/7/17 at 8:53 a.m. from Local Hospital #1 documented, .HPI (history and physical information) Comments: Patient was transferred from bed to WC (wheelchair) and fell . Patient is a 56 y.o. (year old) male presenting with trauma . CT (computed tomography) Cervical w/o (without) contrast. Impression: 1. No acute findings appreciated. 2. Solid bony fusion at C6-7 (cervical vertebrae #6 and #7) .CT Spine Lumbar w/o contrast. Impression: No acute findings appreciated . Admit 3/7/17, D/C (discharge) 3/7/17 . e. The Hospital Record dated 3/8/17 from Hospital #2 documented, .History of Present Illness . Initial Comments: Patient is a [AGE] year old male that presents for evaluation of shortness of breath. EMS (emergency medical services) reports they were contacted secondary to gurgling. Earlier today he was at another facility for evaluation of a fall . ER records from (Hospital #1) reveal he had fallen while transferring from the bed to wheelchair. Record from there also states he was being transferred via a lift when straps broke and he fell on his back. CT scan of lumbar and cervical reports from (Hospital #1) showed no acute fracture. He was discharged from (Hospital #1) ED (emergency department) back to NH (Nursing Home) and tonight EMS (Emergency Medical Services) was called when the patient was reportedly 'gurgling' . 3/11/17 . Lumbar Spine 2 View AP (anterior posterior) Lat (lateral) Impression: 1. Subacute to remote L5 (Lumbar) compression deformity. 2. Mild degenerative disease of the lumbar spine . CT/Lumbar Spine WO (without) Contrast Exam Date: 3/12/17 Impression: Stable CT scan of the lumbar spine since an abdomen pelvis CT dated 12/10/2016, please note there are new fractures of the lumbar spine seen since the previous CT scan of the lumbar spine dated 1/4/16 . XR (X-ray) / Thoracic Spine 3 View . Exam date: 3/11/17 . Impression: Findings of diffuse idiopathic skeletal [DIAGNOSES REDACTED] . discharge date : 3/16/17 . Discharge Summary .15. Compression of the lumbar vertebrae . f. As of 5/23/17, the Weekly Lift Sling Form dated January 2017 to March 2017 documented weekly inspections of the lift pads by the 2 Restorative Aides. The March 2017 Lift Pad Inspection List documented 8 lift pads in service with Sling #38 reportedly used on Resident #1 on 3/7/17. g. On 5/23/17 at 1:13 p.m., the Administrator provided a signed form that documented, We currently have 9 lift pads in use at this time. I am unsure of how many were in use as of 3/7/17 or the age of these pads. The pads in use are all Invacare or Drive brand. Attached is the invoices from the last 6 months showing product activity from the suppliers we use where lift slings have routinely been purchased for the facility. There were a total of 10 lift pads purchased 3/17 (March 2017). We currently do not have anyone providing routine maintenance on the lift pads. If a pad is inspected and defective, it is disposed of at the time. h. On 5/23/17 at 2:13 p.m., CNA #1 was asked about the incident involving Resident #1 on 3/7/17 and whether any other lift sling malfunctions had occurred recently. CNA #1 stated, No sir, it has been longer than 3 years that a transfer pad has broken. We are supposed to make sure everything is intact before using the lift pad. If a little piece of thread is out of place, we would replace. If it seemed like it was going to break, show it to the nurse. We would show it to the nurse even before this happened. We have routine training on how to use the lift, now. New employees are trained monthly. I have been a CNA for [AGE] years and never seen one break like that. He was on a lift pad; we checked it before we used it. We were going to put him on the shower bed. I can't remember if it was the mesh one or the solid one. It broke all together at once; he just fell . 'Oh, my back!' is what he started saying. He said we didn't have to apologize. We left him down there until the ambulance came. No, we used another lift pad and got him up and put him in bed. The nurse checked him out and everything. i. On 5/23/17 at 2:29 p.m., CNA #4 was asked about the incident involving Resident #1 on 3/7/17 and whether any other lift sling malfunctions had occurred recently. CNA #4 stated, No other mechanical lift slings breaking. I would know about all of them, because we do communicate with each other . Honestly, it looked like a freak accident. It looked like a good pad. I couldn't tell you where it broke; wish they still had the pad . j. On 5/24/17 at 11:43 a.m., The CNA Supervisor, (CNA #4) presented Sling #38, the sling utilized during Resident #1's fall on 3/7/17, to the surveyor. The number 38 was written in black marker on the sling. The ends of the 3 broken straps were all frayed. The cloth material making up the eyelets colored blue, green, and purple were dried, stiff, and visibly worn. These eyelets were compared to newer versions of the slings and the newer versions were much more pliable and flexible. An invoice dated 6/29/16 from Supplier #3 documented, .Product - Sling, Mesh, Large (Invacare Style R111)/ . Quantity 3 . Sling #38 was among the 3 slings purchased in June 2016, according to the Administrator. k. On 5/24/17 at 12:31 p.m., Resident #1 was asked if he remembered the straps of the lift sling breaking and if he could describe the events. Resident #1 stated, One broke, and then all of them broke. I don't think all of them stayed on there. Even the guy said they all broke. It's possible I was taking a bath. I was right over the concrete and as high as I could go. They started to get me over to the bed, but didn't have a chance. When that one broke, they were plumb (completely) rotten. That (CNA #2) showed me. They came all to pieces, disintegrated. They didn't even inspect them, before. It happened again when they were weighing me in the shower room. I could hear it ripping; she put me right back in the chair. This was after the first time. It looked terrible; they showed it to me. I didn't see them inspecting it before they started raising me up. They are bad about putting it on the black strap. I tell them they are supposed to use the blue strap. I always tell them, but they don't listen to me . The ambulance driver told me that I had broke (sic) my tailbone . l. On 5/24/17 at 12:47 p.m., CNA #3 was asked about the alleged incident that occurred in the shower room with Resident #1 when the resident stated he heard the sling straps ripping. CNA #3 stated, I always check my lift pad before using. I use the same one for weights - it is not mesh - its number 30. The mesh ones are usually only used for showers. I forgot what number that one was. It started popping like it was going to tear. We lowered him down into his electric wheelchair. Somebody got wrote up for that. It was starting to rip; it was popping and I grabbed the lift pad around his waist and let him back down. I got the QA (Quality Assurance) nurse; I don't know what she did. m. On 5/24/17 at 2:42 p.m., the Director of Nursing (DON) was asked to compare the old sling (#38) with a sling purchased in March 2017 and describe the differences. The DON did so, then stated, The newer one is softer . n. On 5/24/17 at 2:50 p.m., the Administrator was asked to compare sling #38 with a newer sling purchased in March 2017 and to describe the differences. The Administrator stated, It is stiffer, the older one. The ends are frayed because it has been in that sealed plastic bag since 3/7/17. The Administrator was also asked about the incident with Resident #1 in the shower room when the sling or straps began to rip. The Administrator stated, The CNA was disciplined and the sling was taken out of service. I did not see it; the QA nurse was supposed to be taking care of it. That happened 3/9/17, she had done the check sheet, was just doing 1 time a day. We are changing that. The Restorative Aides were checking on a weekly basis, the lift pads. Now, the aides have been trained to check the lift pads before using. They know to look for tears, loose threads. They know to notify the nurse if something doesn't look right. o. On 5/25/17 at 8:09 a.m., an Invacare Representative was interviewed via telephone and asked what factors could cause the transfer pad straps to break from the arms of the mechanical lift. The representative stated, .It would depend on how many patients it was used on, how often it was used, how often it was washed, and if dried on a low temperature. The sling has a full year warranty. It needs to be returned for inspection. p. The facility removed the immediate jeopardy and corrected the failed practices on 3/17/17 when the following corrective actions were completed: 1.) The facility's written corrective action plan dated 3/7/17 documented, .3/7/17 Lift sling (#38) was pulled from operation immediately, inspected by maintenance and QA nurse with no signs of fraying or obvious wear and tear. All lift slings were inspected with no negative findings . (Resident #1) was sent to ER for evaluation and Lumbar and Cervical CT scan was performed no acute findings. Resident returned to facility with no new Orders . On 3/7/17 in-service on proper observation of lift slings for tears, fraying and worn areas of lift sling prior to using this was started for nursing and laundry department. Current observation process was in place as of 3/7/17 and all lift slings were inspected by Restorative Aide including this particular sling. 4) On 3/7/17, 4 lift slings were purchased from (Supplier #1). On 3/17/17, 9 lift slings were purchased from (Supplier #2). 5) A list of mechanical lift residents was generated . Implemented a tracking process for condition of lift sling for each resident, monitored by CNA supervisor. 6) In-service and competency check offs were performed on (CNA #1 and CNA #2). 7) On 3/7/17, started mechanical lift competency check-offs for CNAs . 2.) The invoice dated March 2017 from Supplier #2 documented the facility purchased or ordered 4 different types of slings after the 3/7/17 incident occurred. 3.) The Staff In-service form dated 3/7/17 at 2:00 p.m. documented, .Method of Presentation: Written / Verbal - Lift Pad Inspection before Use . Reaction from Participants: Acknowledges understanding by signing the attached sign in sheet . The Attendance sign-in sheet documented 82 staff signatures. 4.) A Staff In-service form dated 5/19/16 at 5:00 a.m. documented, .Mechanical / Manual lift . Reaction from Participants: Acknowledges understanding by signing the attached sign-in . The attendance sign-in sheet documented 28 staff signatures. Return demonstrations were documented on check-off sheets on this date, and were documented as completed satisfactorily for the CNA staff. q. The following observations / interviews were conducted during the survey to verify correction and ongoing compliance: 1.) On 5/23/17 at 9:15 a.m., CNAs #9 and #10 were observed preparing to transfer Resident #1 via a mechanical lift. The CNAs inspected the lift pad and eyelets for rips or tears with no negative findings and documented this information on the check off sheet. The CNAs used the Reliant 450 mechanical lift to transfer Resident #1 from his chair to the bed. The transfer was completed correctly. 2.) On 5/23/17 at 9:53 a.m., CNAs #7 and #8 prepared to provide a mechanical lift transfer for Resident #5. The CNAs did a visual inspection of the pad prior to placing it under the resident. The transfer was completed correctly. 3.) On 5/23/17 at 2:29 p.m., CNA #4 was asked about the facility's training with regard to inspection of the mechanical lift slings. The CNA stated, We know how to check the pads, check them over. If we see a torn spot, we know we cannot use. They do a check-off sheet when they are hired. Supposed to do every month, check off to use the lift. We started doing this after the fall (referring to Resident #1's fall on 3/7/17), the documentation part. 4.) On 5/24/17 at 9:16 a.m., CNA #5 was asked to describe the facility's training related to inspection of the lift slings. The CNA stated, One time a week, we check them. With a tear or kind of unthread, anything coming loose, we would have to turn them in. After the fall (referring to Resident #1's fall on 3/7/17), they changed to the aides on the hall having to do the inspections. They are supposed to inspect them before using . They started air drying (the slings). I could tell, because I could feel the heat on them. We look for wear and tear; they were just tearing up. They showed us what to look for. On the straps, on the whole lift pad. They have some new training every year on the lift, on the lift pads. We have a check-off that we do; they started the check sheet after the fall . 5.) On 5/24/17 at 9:16 a.m., CNA #6 was asked to describe the facility's training related to inspection of the mechanical lift slings. CNA #6 stated, Since I started in Restorative, we would check the transfer pads every Tuesday. We would tell the nurse if there were any issues. Check for tears, see if the threads were loose, then we would turn it in, dispose of it and order new ones. Two months ago, the aides started checking the transfer pads before using; they have a check sheet. 6.) On 5/24/17 at 9:22 a.m. and 5/25/17 at 8:25 a.m. the facility's eight mechanical lift slings were inspected by the Surveyor. All of the slings and straps were intact and in good condition.

Complaint # was substantiated (all or in part) with these findings: Based on observation, record review and interview, the facility failed to ensure that Resident #1 received the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. The facility failed to develop and implement a method to ensure hydration was provided while the resident was out and about outside in his electric wheel chair and failed to provide treatment for [REDACTED]. was aware of the resident's destination in case of an emergency for 1 of 1 case-mix resident (Resident #1) who was cognitive alert and oriented, identified to be at risk for dehydration and frequently signed himself out of the facility to travel about town in electric wheel chair. These failed practices resulted in Immediate Jeopardy which likely caused or could have caused serious injury, harm or death for Resident #1, who was found .6 miles from the nursing home at a nearby cemetery sitting in a wheelchair unresponsive, required hospitalization for dehydration and burns, and later died from [MEDICAL CONDITION]. The failed practices were not likely to affect any other residents as Resident #1 was the only cognitive alert and oriented resident who had the ability to sign out and leave the facility alone according to a list provided by the Director of Nursing (DON) on [DATE] at 9:24 a.m. The facility was informed of the Immediate Jeopardy on [DATE] at 3:35 p.m. The findings are: 1. Resident #1 had [DIAGNOSES REDACTED]. a. Social Progress notes dated [DATE] documented, "Called social about c/o (complaints of) public fear about (Resident #1) in w/c, attempts to redirect, son voiced concern - 'ya'll do the best you can'." b. Social Progress Notes dated [DATE] documented: "Received call from area farmer who stated, "ya'll need to keep (Resident #1) off the 'G. D. (expletive) road' - spoke with resident about complaints - he became very upset. 'I am not a prisoner. I have the right to go out.' - then he asked 'who called.' I informed him that the man did not give his name - Son informed - stated, 'I don't know what to tell you to do. He won't listen to me either.' Police chief called - stated he had gotten c/o (complains of) from citizens about (Resident #1) being out on the road. I informed him that I had talked with (Resident #1), but that I would talk to him again. Spoke with resident in his room about the call from Police Chief - I informed him he needed to be safe, get his fluids and not stay out too long - shook head yes." c. Social Progress Notes for 2006 documented: "[DATE] - Received phone call at 2:00 pm from a concerned citizen that resident was in w/c (wheel chair) out on Hwy (Highway) 75 by the baptist church and this person observed resident out on the highway and was almost hit by a gravel truck. Alerted DON (Director of Nursing), ... It was decided to go out to look for resident and ask to come back to the nursing facility. Saw (Resident #1) was going off and pulled into graveyard. (Resident #1) communicating he would/could go where he wanted to go. When asked if he almost got hit - (Resident #1) denied the accusations. He then communicated he would be back in a little while. Resident did arrive a few minutes later." "[DATE] - Received phone call from concerned citizen that (Resident #1) was out in the community near the country club... Administrator advised Social Worker to go out into the community to assure that he was okay. Went and found (Resident #1) who was at the country club driveway. Asked (Resident #1) if he was okay he shook his head 'yes' as if he needed anything - he stated or shook his head 'No.' He typed out on his computer 'Toodle Loo.' (Resident #1) rolled back to the nursing home shortly afterwards." d. Social Progress Notes for 2008 documented: "[DATE] - Meeting Attending was (Resident #1's son), Ombudsman, Administrator and Social Worker. Discussed concerns of (Resident #1). Ombudsman stated as long as (Resident #1) signs himself out, he is responsible for he -(his) own person, the nursing home has no liability according to (Representative) from the Office of Long Term Care. Administrator discussed that (Resident #1) goes out into the community and staff is concerned about his whereabouts, etc. Ombudsman re-enterated (reiterated) that (Resident #1) can do as he pleases to a point - The point being when he is at risk for his safety or health concerns. Discussed that (Resident #1) to be accountable and told that actions can be taken - a 72 hr (hour) hold to a geri psychiatric facility. His son stated that he may try to get more involved with him. However, they have not been very close and he has bad feelings toward his father due to their upbringings. He said he would talk to him about his behaviors. It was decided to talk to (Resident #1) about going to a geri psych facility on his own whether have a 72 hr hold, will follow up on res (resident). Went to look for (Resident #1) after his son left - he had left. Will try again tomorrow." "[DATE] - Met with (Resident #1), discussed with him that due to his most recent behaviors, it was felt that he should be evaluated by a geri psych facility. He stated that he would see (Representative) from (geri psych) who is the contact therapist at this facility. He wanted to know how he felt about the situation. Called (Therapist) and set up appt. (appointment)... Discussed 72 hr. hold also with (Resident #1), he stated he understood but did not feel that he had really done anything wrong. Social when gave example of being outside during the storm the other day, he did not respond." "[DATE] - Set up meeting with resident and therapist, ...Prior to session, discussed concerns with therapist, discussed what behaviors and requested that he assist with any recommendations etc. to regards to (Resident #1). Therapist not (met) with him for approximately one hour... after session met with therapist, he stated (Resident #1) did accept some responsibility for some of his actions. He stated (Resident #1) did not want to go to a (geri psych facility) at this time. However, it was explained to him about a 72 hr. hold if he does act out in regards to his health and safety." "[DATE] - Received information that resident head butted an aide this am (morning) and attempting to control every situation. Met with DON /Adm. (Administrator) stated to refer (Resident #1) to geri psyche facility, contact Ombudsman and family..(Resident #1) went to (geri psyche facility). (Resident #1) returned to facility on [DATE], 12 days later. " e. Social Progress Notes dated [DATE] documented, ""[DATE] - Made referral to (geri-psych facility)" 1) The Psychiatric Evaluation dated [DATE] documented, "...Subjective/Objective: The patient was referred by his primary care provided (Doctor). The patient is communicating via special board to complete [MEDICAL CONDITION]. ...The patient suffers from Presenile [MEDICAL CONDITION] following cerebralvascular accident with severe dysarthria and [MEDICAL CONDITION]. He also suffers from some depression-apparently exacerbated recently... Exam: ...suffers from severe disfiguration of both his hands, however he is still able to communicate to a certain extent by using a special board with simple answers and basic signs/letters. ...He likes to keep a fresh cloth in his mouth... Assessment: ...AXIS V: GAF (Global Assessment of Functioning) at this time seems to be around 25((Behavior is considerably influenced by [MEDICAL CONDITION] or hallucinations or serious impairment in communications or judgement or inability in all areas.) GAF at the time of discharge will be hopefully 40+ (Some impairment in reality testing or communication or major impairment in several areas, such as work or school, family relations, judgement, thinking, or mood.)" Reference for GAF:http://www.disabilitylawclaims.com/library/53.cfm 2) "[DATE] - Resident recently returned from geri psych facility appears to be in better mood, continues to have anxious concerns regarding his care." f. The Annual Minimum Data Set (MDS) with an Assessment Reference Date of [DATE] documented the resident had moderately independent cognitive skills for daily decision making, had some difficulty in new situations only and required supervision with set up help for transfers on and off the unit, required extensive assistance of one person for transfers, required total assistance of one person for dressing, eating, toilet use and personal hygiene/bathing and had functional limitation in range of motion on both sides with partial loss in his arms, hands, legs and feet. The Resident Assessment Protocol Summary dated [DATE] documented the resident triggered for "Cognitive Loss, Communication, Mood State, Behavioral Symptoms and Dehydration/Fluid Maintenance. "Rap Problem Area 2: Cognitive Loss/Dementia: Staff Notes: Altered Thought process R/T (related to) difficulty making decisions at risk of further decline staff will provide daily reorientation, cue and redirect, give simple choices, use simple direct statements... 5. ADL (Activities of Daily Living) Functional/Rehabiliation Potential: Staff Notes: Unable to meet ADLs, at risk of not having needs met, staff will provide needed supplies for ADLs, give care, ...and safety. ...4. Dehydration/Fluid maintenance status: Staff Notes: Requires tube feeding nutritional needs at risk of fluid imbalance staff will give feeding and H2O as ordered..." g. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date of [DATE] documented the resident scored 6 (,[DATE] indicates severe impairment) on a Brief Interview for Mental Status, required total assistance with activities of daily living, was continent of bowel and bladder, the resident's behaviors were not addressed, had functional limitation in range of motion in lower extremities (hip, knee, ankle, foot) with impairment on both sides, was mobile in an electric wheelchair (w/c), had a gastrostomy tube and did not have a UTI. On [DATE] at 1:10 p.m., Licensed Practical Nurse (LPN) #3 (MDS/Medical Records) was asked about (Resident #1). The LPN stated, "(Resident #1) required assistance of one person to get him into a w/c and help to the bathroom. He had a PEG tube and would let us know what he wanted with his computer or made gestures. He had a communication board, he would type things. He had nothing by mouth at all. He could not stand or pivot. He did not have full range of motion to his arms, but could move them. He was able to move enough to press keys on the key board. His routine would be to sign himself out. He's been to the Flea Market and to the Dollar Store." She was asked where is the Flea Market? She stated, "...the flea market is across the over pass, go over the bridge. They would call us and let us know he was there. We have gone to pick up his w/c because it was running dead. We went in the nursing home van and followed him back to make sure he made it back before. He would go anywhere." She stated, "there was no trail to the cemetery. The only way to get to the cemetery from the nursing home was to get on the road in front of the nursing home." She was asked if in her opinion did Resident #1 make good decisions? She stated, "We could tell him what we thought, but he was stubborn and he would do what he wanted to do." She was asked how do you know he was in his right mind? She stated, "Because he was able to type out everything he wanted, he never not made sense. Everytime he typed he was with it..." She was asked, "If (Resident #1) was oriented times 3 (to name, place and time) and in his right mind, why did you assess him as having a total BIMS score of a 6 (,[DATE] indicates severe impairment) on the MDS assessment dated [DATE]? She stated, "I'm still learning. I've been doing it for a week. I didn't know how long to allow him to answer the questions." h. The care plan updated [DATE] documented, "..XXX[DATE]: Impaired thought processes - ...Mental Disorder Approaches: Provide 24 hour reality orientation, Cue and redirect, keep resident environment free of ...safety hazards..." "Difficulty making self understood d/t (due to) [MEDICAL CONDITION] - Mouth open desires to have folded wash cloth placed in mouth r/t (related to) excessive drooling Approaches: provide writer board on w/c, keep wash cloth in mouth per resident request... Potential for fluid volume deficit r/t tube feeding - [DATE] Increased risk related to wanting to go LOA (leave of absence) during hot weather - discussed with son and resident, resident acknowledged by shaking head in a "yes" motion Approaches: give feeding and H2O (water) as ordered, encourage compliance with feeding/fluids, discuss risk factors, observe for changes..XXX[DATE]: ...Going LOA without assistance - ...encourage him to be careful when on LOA..." The resident's Care Plan dated [DATE] and reviewed [DATE], documented a problem for a potential for fluid volume deficit related to tube feeding with an approach, "Obtain lab work as ordered by physician. Report results to physician when available." i. Social Progress Notes dated [DATE] documented, "Resident came to my office and asked if I would call his son to tell him he wanted to 'go riding.' I offered to have the van take him and he shook his head in a back/forth 'No' motion. I then called the son and told him his Dad he wanted to go riding. He stated, 'I'm really busy with work right now, tell him I'll get over there as soon as I can.' - I repeated the conversation to (Resident #1) who was sitting in front of my desk waiting for a reply. He stared over his glasses at me. I told the son I didn't think that was the answer his Dad (Resident #1) wanted. He replied, 'I know how he is.' I then replied, yes he can be very hard headed and I hate for him to be out in the heat. I told the son I offered his Dad a van ride and he declined. He replied, 'Well he'll have to wait on me and I can't get over there right now' ..." j. Nurse's Notes dated [DATE] at 1:30 p.m. documented the resident had vomited three times that day. Notes at 1:35 p.m. documented an on-call physician was consulted and new orders for [MEDICATION NAME] (an anti-emetic medication) 25 milligrams (mg) intramuscular (IM) every 6 hours as needed for nausea/vomiting. Notes at 1:40 p.m. documented administration of the [MEDICATION NAME] IM injection. The Medication Administration Records (MARs) dated for May and [DATE] documented the resident received [MEDICATION NAME] IM one time. k. Nurse's Notes dated [DATE] at 10:15 a.m. documented, "Resident (with) c/o (complaint of) discomfort during (and) upon urination, (new order) noted and processed for UA with C&S (urinalysis with culture and sensitivity)." The same Notes documented the urine specimen was collected that day. 1) laboratory results dated [DATE] at 5:38 p.m. documented abnormal UA results (Protein-20 mg/dl, normal=negative; White Blood Cells (WBCs) - Too numerous to count (TNTC), normal = ,[DATE]; Bacteria - rare, normal=none, Leukocyte Esterase-large, normal=negative) and, " Faxed & (and) called to MD [DATE]. " Nurses Notes dated [DATE] at 1:00 a.m., 9:00 a.m. and 9:30 p.m., and [DATE] at 9:30 p.m., [DATE] at 7:00 a.m., 8:50 a.m., and 6:00 p.m. did not document new orders received for treatment of [REDACTED]. 2) UA C&S laboratory results dated [DATE] at 9:21 a.m. documented greater than 100,000 CFU/ml of the organism [DIAGNOSES REDACTED] pneumoniae and, "Faxed MD notified ,[DATE] (2011)." Nurse ' s Notes dated [DATE] at 9:15 a.m., 5:00 p.m. and [DATE] and 4:00 a.m. and 9:20 a.m., 24 Hour Report/Change of Condition Report sheets (400 Hall) dated [DATE] and [DATE], Physician order [REDACTED]. 3) On [DATE] at 12:06 p.m., the resident's physician was contacted via phone and asked if he remembered speaking to anyone from the facility about the results of the resident's UA with C&S and he stated he was not working that week, "I didn't talk to anyone." 4) On [DATE] at 9:38 a.m., the Administrator and Director of Nursing were asked to provide evidence of treatment provided to the resident after receipt of the UA with C&S laboratory results dated [DATE] and [DATE]. On [DATE] at 11:03 a.m., the Administrator stated, " We don ' t have any further information. " l. According to the resident's sign out sheets dated ,[DATE] - ,[DATE], (Resident #1) would type his request for LOA (leave of absence) and print it off from a computer. Staff would sign their initials to the printed request and place in (Resident #1's) clinical record. An example of a typed request: "I want to be sign out to go riding no body can sue anyone in this nursing center for what happens to me while I'm out I was in my stable mind when I wrote this." m. The [DATE] Medication Administration Record (MAR) documented, "[DATE] - 2 cal HN 1 can [MEDICATION NAME] via 60cc (cubic centimeter) syringe 4 times daily, [DATE] - Flush G (gastrostomy)-tube with 30 cc's of H2O before and after each med (medication) administration and Flush [DEVICE] with 100 ccs of H2O before and after each feeding daily." 1) The [DATE] MAR and a witness statement signed by Licensed Practical Nurse (LPN) #1 documented, the resident received his scheduled and last [MEDICATION NAME] feeding of 2 Cal HN and a 100cc H2O flush on [DATE] at 12:00 p.m., prior to leaving the facility at 12:20 p.m. on [DATE]. 2) A typed sign out sheet dated [DATE] at 12:20 p.m. indicated Licensed Practical Nurse (LPN) #1 signed the resident out of the facility. n. On [DATE] at 11:45 a.m., Licensed Practical Nurse (LPN) #1, who signed the resident out of the facility at 12:20 on [DATE] was asked about the resident. The LPN stated, "He (Resident #1) could move his arms a little bit not a lot. He used his knuckles to hit stuff on the key board. He could bend his legs a little but could not walk or stand. The electric keyboard and an alphabet board/keyboard was the only thing he used to communicate with. He only received nutrition and fluids through his G/T (Gastrostomy Tube), nothing by mouth." She stated that (Resident #1) refused care at times, he would get in his moods. She stated, "He wanted things his way or no way." She was asked to describe Resident #1's cognitive status. LPN #1 stated, "He knew everything, very oriented." She was asked what about the day ([DATE]) he left the facility in his wheel chair? She stated, "The day he left, there was nothing out of the ordinary with him. I tried to tell him it was too hot to go outside. I told him he could get dehydrated and could have a stroke. He liked to have things his way..." LPN #1 was asked, if she was sure the resident understood what he was being told. She stated, "I'm sure he understood." She was asked where did (Resident #1) go when he signed himself out? LPN #1 stated, "All over town." The LPN was asked if he (Resident #1) was his own responsible party. She stated, "Yes." LPN #1 stated, "I don't think the relationship between the son and (Resident #1), was a very good relationship." LPN #1 stated, "At 12:20 p.m., I made him print out that little sheet stating he wanted to be signed out." LPN #1 was asked knowing the condition (Resident #1) was in, being totally dependent on nursing staff to provide fluids for hydration, only being able to communicate through the keyboard and gesturing, and knowing there was a heat advisory for that day, did you ever think about sending someone with him? She stated, "No, this was not out of the ordinary, it did not occur to me to send anyone with him. He's always gone out when he wanted to. He would go around town, he's done it since I've worked here. He had his right mind." How do you know he had his right mind? She stated, "He seemed oriented to everything, he could tell you what he wanted, he could answer yes and no questions." LPN #1 was referred to the MDS which documented Resident #1 had a BIMS score of 6 (,[DATE] indicates severely impaired), she was asked if she was aware of the current assessment? LPN #1 stated, "I've never known him to have any problem mentally." The National Weather Service Climate Data internet website at (http://www.weather.gov/climate/getclimate.php?wfo=lzk) dated [DATE] documented, "Temperature Maximum: 99R (Record High) at 1:58 p.m." Resident was found unresponsive at 2:30 p.m ., at a nearby cemetery approximately .6 miles from the facility. o. An Incident and Accident (I/A) dated [DATE] at 2:30 p.m. documented 2 hours, 10 minutes later, "...R (resident) was out of facility using power chair and was found at the cemetery by (CNA #1) who stated that he was unresponsive. ...Transferred to hospital." 1) On [DATE] at 2:05 p.m., CNA #1 stated, "I worked 300 hall that day. To my knowledge, I didn't know (Resident #1) was even outdoors. In my opinion, I feel we should have known he was outside. I live out 75, I was on my way home when I seen (Resident #1) at the cemetery. I stopped to encourage him to go back to the nursing home, because it was too hot." She was asked who was already at the cemetery with (Resident #1) when she stopped? CNA #1 stated, "a man (1st Responder), (my hairdresser), and a police officer was out there." CNA #1 stated the "resident was breathing really funny and he was really hot. ...(Resident #1) carries washcloths, so I poured water on the washcloth and we wiped (Resident #1's) head with wet washcloth because I knew we needed to cool him down." CNA #1 indicated, "The nursing home had already been called, then a nurse from the nursing home drove up after (Resident #1) was in the ambulance." CNA #1 stated she tried to take a pulse, "...he had a pulse and he was still breathing." CNA #1 was asked in your opinion, do you think he was oriented? She stated, "Yes, ma'am. He left the facility a lot by himself. As far as I know before I worked here you would see him everywhere." The CNA was asked what the resident was wearing that day ([DATE]). She stated, "He had on a white short sleeved shirt with a yellow button up, short sleeved and pants on ...We did pick him up from the chair, he had a bowel movement. I did not see any urine. I knew he was red on his arms, he was really sweaty." 2) On [DATE] at 5:25 p.m., the Fire Chief was asked about the incident that occurred with (Resident #1) on [DATE], he stated, "When I got there (First Responder) told me his (Resident #1) w/c was caught. His wheel chair (w/c) was on a slope and he couldn't move it." The Fire Chief was asked if the battery on the w/c was charged? The Fire Chief stated, "I don't know, I didn't check that." He was asked if they had checked (Resident #1's) temperature? He stated, "No and they couldn't get it." He stated he wasn't sure if it was because he (Resident #1) was so hot the thermometer couldn't read it or if the thermometer wasn't working right. 3) On [DATE] at 5:30 p.m., the First Responder was asked about the incident that occurred with (Resident #1) on [DATE], he stated when he got to the cemetery the resident's left front wheel of the w/c was in the grass off the cemetery road and the right back wheel was up in the air. The w/c was caught and he (Resident #1) couldn't get back up on the road. He was slumped over and exposed on his right side. The First Responder stated (Resident #1's) right side was red, sunburned and both his arms were burned. He was asked was there any blistering? He stated there was no blistering at that time. On [DATE] at 5:10 p.m., the First Responder was asked did (Resident #1) have a canopy over his w/c when he arrived on the scene at the cemetery on [DATE]? He stated, "No, he didn't. There was an umbrella in the truck, I got it and we held it over him until we got him into the ambulance." 4) On [DATE] at 9:15 a.m., LPN #2 (who was the on-coming nurse for the 2p.m. to 10 p.m. shift on [DATE]) was asked about (Resident #1). She stated, I know (Resident #1) was alert/oriented and made his own decisions. He had a PEG (percutaneous [MEDICAL CONDITION] gastrostomy) tube, used a keyboard for communication. He could not stand, or bear weight at all. He was NPO (nothing by mouth), incontinent and nonverbal. He could make some movements with his arms to get attention. He could nod his head yes and no to answer questions." She was asked about (Resident #1) leaving the facility on [DATE], was this routine for him? She stated, "Yes, ma'am, he did that quite often. He signed himself out and would be alone." She was asked where would he go? She stated, "All around town, wherever he wanted to go..." LPN #2 also stated, "Well as far as Resident #1, that was his decision to do that. I know it was explained to him the risk versus benefit. It didn't matter what you told him. If that's what he wanted, that's what he was going to do." She was asked with his disabilities and the fact it was so hot outside that day, weren't you concerned about his safety? She stated, "Sure it concerned me, it did. But I know that all the risk versus benefits were explained to him." LPN #2 stated, "I got a call at the nursing home from a girl named (CNA #1), who worked at the nursing home. She (CNA #1) said (Resident #1) was in the cemetery, he was unresponsive, the ambulance had been called and the police was there. CNA #1 had indicated the ambulance had not arrived yet and wanted to know if anyone from the nursing home was coming to the cemetery. I called the (DON) and told her what had happened. I called (Administrator). He told me to go down there. When I got there the ambulance pulled up at the same time. The paramedics got (Resident #1) into the ambulance. I didn't get a chance to assess him. What I did see of (Resident #1) was that he was very pale, very sweaty, he was alert, he wasn't communicating, he was lethargic." LPN #2 was asked how could he be alert if he was lethargic? She stated, "Well that may not be the right word. He was alert, he looked at me, but I guess he seemed tired." She was asked if she saw his skin? She stated, "No, I didn't. I pretty much just saw his face." She was asked if she got any vital signs? She stated, "No, they did, a pulse and pulse ox. I wasn't in the ambulance for anything else." 5) The Fire Department Ambulance Report dated [DATE] documented, "Arrived at 2:38 p.m., Chief Complaint (C.C.): Heat Stroke - B/P(Blood Pressure) ,[DATE], pulse 142, Resp. (Respirations) 16 - Respond to ...cemetery for person unconscious ...found ...w/m (white male) sitting in a wheelchair. Police officer advised Pt (patient) was unresponsive and hanging ,[DATE] way out of chair. By standers started put cold rags on pt's neck. Pt was conscious once this unit arrive on the scene. At this time pt does respond to commands. ...put pt on O2 (Oxygen) by nc (nasal cannula) at 3 lpm (liters per minute). Since being enroute Pt's O2 Sat down to 83% put pt on NRB (nonrebreather) O2 Sat increased to 97%. ...Arrived at hospital 3:14 p.m. ..." p. The "ER (emergency room ) Physician Documentation (Hospital #1)" dated [DATE] documented, "Vital signs at 3:18 p.m. - pulse rate: 142 H, respiratory: 42 H, blood pressure: ,[DATE], O2 Sat by pulse oximetry: 96%. Pt found in cemetery sitting in his wheelchair slumped forward by EMS (Emergency Medical Service) not very responsive. Pt wheelchair bound from NH (nursing home) personal let him out of NH to go where he wants. Pt with sunburn in chest abdomen and legs. ...Psychosocial History: Anxiety, Panic Disorder, Mental [MEDICAL CONDITION]. ...At 3:41 p.m. Pt awake alert, lying in stretcher. has sunburn in abdomen, right arm and leg, foot, BSA (body surface area) 12% approx. superficial partial thickness and 15 deep partial thickness. At 5:19 p.m. Pt HR (heart rate) improved from 140 to 120 after 500cc (cubic centimeter) [MEDICATION NAME] and at 200cc/hr LR ([MEDICATION NAME] ringers) dx (diagnosis) with dehydration, metabolic acidosis and second [MEDICAL CONDITION] 12% TBSA (total body surface area) and 1% deep partial thickness..." Hospital laboratory results dated [DATE] at 4:06 p.m. documented the results of a urinalysis, with worsening of the UTI, as follows: cloudy urine, specific gravity of 1.025 mg/dl, normal=1.016 - 1.022; large amount of blood, normal=negative; protein-100 mg/dl, WBCs-TNTC; Red Blood Cells-TNTC, normal=,[DATE] and Bacteria-4+. q. The (Hospital #2) documented, "[DATE] at 1930 (7:30 p.m.) History & (and)Physical CC: Sunburn/found (12% TBSA) down in sun. HPI (History of Present Illiness): 65 y/o (year old) M (male) history of (history of) Hypertension, Mental [MEDICAL CONDITION], Perpheral Vascular Disease ([MEDICAL CONDITION]), Panic Disorder, Anxiety?[MEDICAL CONDITION]. Who lives in nursing home, S/P (status [REDACTED].#1) on arrival to ER tachy ([MEDICAL CONDITION] (at) 142, RR (respiratory rate) 42, BP ,[DATE], ...Burn: (R) Lat (lateral) hip/Ant. (anterior) ABD. (abdomen) 5% with 1% 3 degree in central region, Ant/Lat (R) knee... B/L (bilateral/lower) Dorsal Feet, Ant/Lat chin... [DATE] at 1940 - Total % Burned: 2nd degree (11), 3rd degree (1)...Describe wound bed: Pink, blanching, nonintact skin. small area of whitish/mottled skin over right hip. ...skin color pale, (R) foot mottled-cold, (R) leg mottled, cool up to knee. [DATE] - ...pt expire 0536. ...Cause of Death: [MEDICAL CONDITION]." Hospital #2 Lab Report dated collected on [DATE] at 2115 documented as follows: BUN - 33 high Normal: 6 -20 mg/dL (milligrams per deciliter) Creatinine - 1.9 High 0XXX,[DATE].2 mg/dL Sodium - 146 High ,[DATE] mmol/L Phosphorous - 5.1 High 2XXX,[DATE].6 mg/dL Magnesium - 3.4 High 1XXX,[DATE].5 mg/dL HGB (hemoglobin) 18.4 - High ,[DATE] g/dL (grams per deciliter) HCT (Hematocrit) 54.9 - High ,[DATE]% r. On [DATE] at 3:00 p.m., the Director of Nursing (DON) was asked about (Resident #1). The DON stated, "(Resident #1) was kinda like a dare devil. Once his mind was made up, he was going to do what he wanted to do. I've never come across a resident like him before." The DON was asked did it ever occur to the staff to send someone with the resident knowing how hot it was that day? The DON stated, "I don't think it crossed their minds, he's done this before." She was asked what does the facility do when a resident who was unable to verbally communicate, was totally dependent on facility staff for hydration and nutrition and a paraplegic makes a decision that places himself at risk for injury or harm and the staff is aware of this decision, what does the facility do about it? The DON stated, "Notify the Doctor, ombudsman and family. I'm almost sure the Ombudsman had been contacted. These nurses do not want to cross resident rights, they notify (Administrator (Adm)). The DON was asked did it ever occur to her or anybody that just the fact the resident would be out on the road would have been a potential for harm? She stated, "The Administrator handled it." The DON was asked, " With you being the DON, you should have had input in this, how did you feel about this? " She stated, "I know (Adm) had addressed it. He has. We talked about this issue. He dealt with the Ombudsman before on it." The DON was asked didn't she question (Resident #1's) safety when he left the facility? The DON stated, "I've questioned it. But (Adm.) just always did it. (Resident #1) was going to go directly to (Adm.)." s. On [DATE] at 3:35 p.m., the Administrator (Adm.) was asked about (Resident #1). The Adm stated,

Based on record review and interview, the facility failed to ensure the Physician was immediately consulted regarding the resident's return from the [MEDICAL TREATMENT] treatment center without completion of [MEDICAL TREATMENT] treatment on 3/7/11 and refusal of [MEDICAL TREATMENT] on 3/9/1. The facility also failed to notify the family member of return from [MEDICAL TREATMENT] without completion of [MEDICAL TREATMENT] treatment on 3/7/11, refusal to keep the [MEDICAL TREATMENT] appointment on 3/8/11, refusal of [MEDICAL TREATMENT] on 3/9/11 and diarrhea and vomiting with change in medications for 1 (Resident #3) of 2 (Resident's #2 and #3) case mix resident requiring [MEDICAL TREATMENT]. The failed practice resulted in a pattern of harm for Resident #3 who required hospitalization for emergent [MEDICAL TREATMENT], [MEDICAL CONDITION], and rebound [MEDICAL CONDITION] Fibrillation and had the potential to affect 2 residents who required [MEDICAL TREATMENT] according to a list received from the Administrator on 3/28/11 at 1:52 p.m. The findings are: 1. The facility's Change of Condition policy documented that a change of condition includes in part " complaints nausea, vomiting dizziness " and the procedure documented in part " 2. Notify the attending physician promptly " and " 3. Notify the family." 2. Resident #3 had [DIAGNOSES REDACTED]. The Minimum Data Set with an Assessment Reference Date of 1/13/11 documented the resident had a score of 12 (8-12 moderately impaired) for a Brief Interview for Mental Status, was always incontinent of bowel and bladder (B/B), had an active [DIAGNOSES REDACTED]. a. A letter dated 3/30/11, signed by the attending physician documented the resident received [MEDICAL TREATMENT] treatments three days per week. b. An Emergency Medical System (EMS) Patient Care Report dated 3/7/11 (Monday) at 1:00 p.m. documented, " ...called to trans (transport) pt (patient) to [MEDICAL TREATMENT]. Pt found without complaint in bed non-ambulatory. " c. Nurse ' s Notes dated 3/7/11 at 1:15 p.m. documented, "alert-verbal-shunt site without redness or drainage-went to [MEDICAL TREATMENT] by ambulance, resp (respirations) even and unlabored upon leaving-B/P (blood pressure) 138/78-P (pulse) 70-R (respirations) 18 temp (temperature) 97.6." Nurse's Notes dated 3/7/11 at 1:15 p.m. documented, "Rec (received) call from [MEDICAL TREATMENT]. (Staff Member) stated unable to finish res (resident) tx (treatment) d/t (due to) diarrhea. " There was not documentation the physician had been notified. 1) On 3/28/11 at 2:12 p.m., LPN #2 stated, "I was on duty 3/7/11 when (Resident #3) came back from [MEDICAL TREATMENT]. The [MEDICAL TREATMENT] unit called and said she had got a majority of the treatment but had a bowel movement and was sent back. " 2) On 3/29/11 the Clinic Manager of the [MEDICAL TREATMENT] Unit stated, " The treatment was started on 3/7/11 but due to a bowel movement and after the resident was cleansed, the resident wanted to go back to the facility. We sent her back. " 3) The EMS Patient Care Report dated 3/7/11 at 4:40 p.m. documented, " ...called to trans pt home (skilled care facility). Pt found A & O (alert and oriented) x (times) 3 without complaint in chair non-ambulatory. " d. Nurse's Notes dated 3/7/11 at 4:30 p.m. documented, "Res ret (returned) to facility. No diarrhea noted. Res a & o (alert and oriented). " The March 2011 ADL (Activities of Daily Living) Flow Sheet documented 2 stools for the 24 hour period for 3/7/11. e. Nurse's Notes dated 3/8/11 (no time) documented, "[MEDICAL TREATMENT] was called this a.m. State appt (appointment) at 1:20 p.m." 1) An EMS Patient Care Report dated 3/8/11 at 1:11 p.m. documented, " ...called to transport patient from nursing home to [MEDICAL TREATMENT] at ([MEDICAL TREATMENT] Center). Upon arrival found patient A & O x 3 lying semi-fowlers in bed w/o (without) complaint. Patient was transferred to the stretcher using the draw sheet w/o incident and secured with straps x 3. Patient was transferred to the ambulance w/o incident. " 2) An EMS Patient Care Report dated 3/8/11 at 1:28 p.m. documented, " ...patient reported having defecated and requested to return to the nursing home. Upon returning to nursing home patient was transferred inside and to her bed using the draw sheet w/o incident. Patient stated she didn't want to attempt transport again and signed the refusal. " f. Nurse's Notes dated 3/8/11 at 2:15 p.m. documented, "Ambulance back with resident. Resident had BM (bowel movement) also resident refused to go to [MEDICAL TREATMENT]. New order for 1 x (time) order for [MEDICATION NAME] 2 tabs (tablets) for diarrhea. 2 tabs [MEDICATION NAME] given. Non-compliant to diet and fluid restrictions. " There was no documentation that the physician had been notified. 1) A Physician's telephone order dated 3/8/11 (no time) documented, " [MEDICATION NAME] ii (two) tabs 1 x (one time) order for diarrhea. " 2) On 3/29/11 at 8:30 a.m., Licensed Practical Nurse (LPN) #1 (Charge Nurse on 3/8/11) stated, "On 3/8/11 (Resident #3) had a bowel movement in the ambulance and they brought her back to the facility to clean up. She refused to go back to [MEDICAL TREATMENT]. I called (Attending Physician) and told him she had diarrhea. I got a one time order for [MEDICATION NAME]. I told him she refused to go back to [MEDICAL TREATMENT]. " g. Nurse's Notes dated 3/8/11 at 5:30 p.m. documented, "No diarrhea noted. Alert and verbal of needs. Confusion noted at x's (times). Feeds self with good po (oral) intake. No c/o (complaints of) pain." The March 2011 ADL Flow Sheet documented one stool for the 24 hour period dated 3/8/11. h. Nurse's Notes dated 3/9/11 at 2:30 a.m. documented, "Resting in bed (with) yes closed. Resp (respirations) e/u (even and unlabored). [MEDICAL TREATMENT] site to L (left) arm (without) [MEDICAL CONDITION] or [DIAGNOSES REDACTED]. [MEDICAL TREATMENT] port to L chest (without) [MEDICAL CONDITION] or [DIAGNOSES REDACTED]. Dressing clean, dry and intact. No noted diarrhea this shift. No c/o-all needs met by staff. SR (siderails) up. " i. Nurse 's Notes dated 3/9/11 at 10:12 a.m. documented, " Resting in bed. Resp e/u. [MEDICAL TREATMENT] site (without) complications. Dressing clear and intact. No diarrhea this a.m. Will continue to monitor. " j. Nurse's Notes dated 3/9/11 (no time) documented, "Shunt to L arm clean/dry-no redness or [MEDICAL CONDITION] noted. Resp even nonlabored. No c/o pain or distress noted. Will continue to monitor." 1) The March 2011 ADL (Activities of Daily Living) Flow Sheet documented two stools for the 24 hour period for 3/9/11. 2) An EMS Patient Care Report dated 3/9/11 (no time) documented, " Pt was seated in bed. Pt refused [MEDICAL TREATMENT] apt (appointment)." 3) On 3/29/11 at 3:05 p.m., LPN #3 stated, "She (Resident #3) told me that morning (3/9/11) that she was going to [MEDICAL TREATMENT]. The ambulance came and she wouldn't go. I went and talked to her and asked her why. She said she was scared that she might have diarrhea. I did not call the doctor. I didn't tell the Director of Nursing ... " 4) On 3/29/11 at 2:15 p.m., the Attending Physician stated, "If (Resident #3) refuses [MEDICAL TREATMENT], I can't make her. I don't remember talking to anyone at the facility on 3/8/11 or 3/9/11." k. Nurse's Notes dated 3/10/11 at 2:05 a.m. documented, "Resting in bed with eyes closed. Resp e/u. Skin w/d (warm and dry) to touch. [MEDICAL TREATMENT] shunt to LUE (left upper extremity) (without) bleeding, [MEDICAL CONDITION] or [DIAGNOSES REDACTED]. No c/o, pain or distress noted. " l. Nurse's Notes dated 3/10/11 at 1:00 p.m. documented, "N.O. (new order) for stool culture, C & S, [MEDICAL CONDITION]. Alert, verbal, call light in reach. Loose stools noted. Shunt site without redness or drainage. Pericare PRN (as needed). No BM (bowel movement) noted this shift. " There was no documentation the physician had beem consulted regarding the failure of the resident to complete [MEDICAL TREATMENT] for the week. A Physician's telephone order dated 3/10/11 (no time) documented, "Stool culture, C&S (culture and sensitivity), [MEDICAL CONDITIONS]-DX (diagnosis): Diarrhea." m. Nurse's Notes dated 3/10/11 at 5:30 p.m. documented, "No stool this shift at this time. Resp e/u. No c/o pain. Incontinent of B/B . Pericare PRN. Shunt to L upper arm no [MEDICAL CONDITION] or bleeding noted. CL (call light) in easy reach. " n. Nurse's Notes dated 3/10/11 9:30 p.m. documented, "Res had med (medium) size emesis stated, 'I feel better now.' No c/o pain. " The March 2011 ADL sheet documented 2 stools for the 24 hour period for 3/10/11. o. Nurse's Notes dated 3/11/11 at 12:40 a.m. documented, "Remains in bed. Shunt to L arm without redness/drainage/[MEDICAL CONDITION]. No c/o nausea/vomiting thus far. No distress noted." Nurse's Notes dated 3/11/11 at 2:20 a.m. documented, "Resident c/o nausea (with) emesis x 's 2. (Attending Physician's) office notified. " Nurse's Notes dated 3/11/11 at 2:30 a.m. documented, "Received return call. New order N & P (noted and processed). Resident aware. " A Physician's telephone order dated 3/11/11 documented, "[MEDICATION NAME] 4 mg (milligrams) po (by mouth) q (every) 6 hours PRN nausea/vomiting." Nurse 's Notes dated 3/11/11 at 5:45 a.m. documented, "No further c/o nausea or reported episode of vomiting." p. The Nurse's Notes dated 3/11/11 at 10:02 a.m. documented, "Res noted to have resp (respiratory) difficult-nv (nausea vomiting) x 1. Change in cognition status. MD (Medical Doctor) notified." Nurse's Notes dated 3/11/11 at 10:05 a.m. documented, "N.O (new order) transfer to (hospital) for eval (evaluation) (and) tx (treatment)." A Physician's telephone order dated 3/11/11 documented, "Transfer to (hospital) to eval and tx." q. Nurse's Notes dated 3/11/11 at 10:20 a.m. documented, " ...late entry. Resident lying in bed. HOB (head of bed) up. Resp 20-SOB (shortness of breath) noted. Change of cognitive status noted. Resident reports that her stomach hurts. BP up. Labored respirations. Family notified. " The March 2011 ADL Flow sheet documented one stool prior to 11:00 a.m. for 3/11/11. r. A Patient Transfer Form dated 3/11/11 (no time) documented, "Has had n/v x 1 day, hasn't been to [MEDICAL TREATMENT] this week due to diarrhea x 4 days-change of cognitive status noted." Nurse's Notes dated 3/11/11 at 11:00 a.m. documented, "(Ambulance Service) here to transfer pt to (hospital)." s. The emergency room Physician's Record dated 3/11/11 documented, " ...needs urgent dialyzing ...admitting [DIAGNOSES REDACTED]." The Physician's History and Physical dated 3/11/11 documented a chief complaint of "shortness of breath." The history of present illness was documented as "The patient is a [AGE] year-old nursing home resident with past medical history significant for [MEDICAL CONDITION] on [MEDICAL TREATMENT], diabetes mellitus, hypertension, history of [MEDICAL CONDITION] status [REDACTED]. Per chart review and after discussions with nursing staff, the patient apparently missed some [MEDICAL TREATMENT] sessions because she was feeling unwell while at the nursing home. She also had diarrhea. No reports of fevers or chills. No reports of chest pain. The patient's main complaint is one of shortness of breath. The patient was reviewed in our emergency room . Routine laboratory review revealed significant [MEDICAL CONDITION] at 8.5 mEq (milliequivalents) per liter (reference range 3.5-5.0 mmol/L (millimoles per liter)) and the patient is currently being emergently dialyzed. " t. A physician progress notes [REDACTED].#3) was noted to have increasing nausea, vomiting and diarrhea. Telephone orders for stool cultures and [DIAGNOSES REDACTED] were given as well as order for [MEDICATION NAME] for antiemetics treatment on 3/10/11. The clinic was notified that patient refused transfer to [MEDICAL TREATMENT] secondary to gastroenteritis during this period of time from 3/7/11 to 3/11/11. " On 3/29/11 at 2:15 p.m., the Attending Physician stated, "If (Resident #3) refuses [MEDICAL TREATMENT], I can't make her. I don't remember talking to anyone at the facility on 3/8/11 or 3/9/11. " u. On 3/29/11 at 10:20 a.m., Resident #3's son and power of attorney stated, "I was not notified of her diarrhea or refusal to go to [MEDICAL TREATMENT], but on 3/11/11, they called me and said she had been refusing to go to [MEDICAL TREATMENT] and that she had diarrhea and had to go to the hospital."

Based on record review and interview, the facility failed to ensure staff provided the necessary care and services to ensure Resident #3 maintained the highest practicable physical well being. The facility failed to ensure the resident fully understood the consequences of refusal of [MEDICAL TREATMENT], to involve the family in emergent care planning when [MEDICAL TREATMENT] was refused, to provide for ongoing assessment with documentation of changes in condition with refusal of [MEDICAL TREATMENT] and ensure physician involvement for 1 (Resident #3) of 2 (Resident #2 and #3) case mix residents who required [MEDICAL TREATMENT]. The failed practice resulted in a pattern of harm for Resident #3 who required hospitalization for emergent [MEDICAL TREATMENT], [MEDICAL CONDITION], and rebound [MEDICAL CONDITION] Fibrillation and had the potential to affect 2 residents who required [MEDICAL TREATMENT] according to a list received from the Administrator on 3/28/11 at 1:52 p.m. The findings are: Resident #3 had [DIAGNOSES REDACTED]. The Minimum Data Set with an Assessment Reference Date of 1/13/11 documented the resident had a score of 12 (8-12 moderately impaired) for a Brief Interview for Mental Status, was always incontinent of bowel and bladder (B/B), had an active [DIAGNOSES REDACTED]. a. A letter dated 3/30/11, signed by the attending physician documented the resident received [MEDICAL TREATMENT] treatments three days per week. b. An Emergency Medical System (EMS) Patient Care Report dated 3/7/11 (Monday) at 1:00 p.m. documented, " ...called to trans (transport) pt (patient) to [MEDICAL TREATMENT]. Pt found without complaint in bed non-ambulatory. " c. Nurse ' s Notes dated 3/7/11 at 1:15 p.m. documented, "alert-verbal-shunt site without redness or drainage-went to [MEDICAL TREATMENT] by ambulance, resp (respirations) even and unlabored upon leaving-B/P (blood pressure) 138/78-P (pulse) 70-R (respirations) 18 temp (temperature) 97.6." Nurse's Notes dated 3/7/11 at 1:15 p.m. documented, "Rec (received) call from [MEDICAL TREATMENT]. (Staff Member) stated unable to finish res (resident) tx (treatment) d/t (due to) diarrhea. " There was not documentation the physician had been notified. On 3/28/11 at 2:12 p.m., LPN #2 stated, "I was on duty 3/7/11 when (Resident #3) came back from [MEDICAL TREATMENT]. The [MEDICAL TREATMENT] unit called and said she had got a majority of the treatment but had a bowel movement and was sent back. " On 3/29/11 the Clinic Manager of the [MEDICAL TREATMENT] Unit stated, " The treatment was started on 3/7/11 but due to a bowel movement and after the resident was cleansed, the resident wanted to go back to the facility. We sent her back. " The EMS Patient Care Report dated 3/7/11 at 4:40 p.m. documented, " ...called to trans pt home (skilled care facility). Pt found A & O (alert and oriented) x (times) 3 without complaint in chair non-ambulatory. " d. Nurse's Notes dated 3/7/11 at 4:30 p.m. documented, "Res ret (returned) to facility. No diarrhea noted. Res a & o (alert and oriented). " The March 2011 ADL (Activities of Daily Living) Flow Sheet documented 2 stools for the 24 hour period for 3/7/11. e. Nurse's Notes dated 3/8/11 (no time) documented, "[MEDICAL TREATMENT] was called this a.m. State appt (appointment) at 1:20 p.m." 1) An EMS Patient Care Report dated 3/8/11 at 1:11 p.m. documented, " ...called to transport patient from nursing home to [MEDICAL TREATMENT] at ([MEDICAL TREATMENT] Center). Upon arrival found patient A & O x 3 lying semi-fowlers in bed w/o (without) complaint. Patient was transferred to the stretcher using the draw sheet w/o incident and secured with straps x 3. Patient was transferred to the ambulance w/o incident. " 2) An EMS Patient Care Report dated 3/8/11 at 1:28 p.m. documented, " ...patient reported having defecated and requested to return to the nursing home. Upon returning to nursing home patient was transferred inside and to her bed using the draw sheet w/o incident. Patient stated she didn't want to attempt transport again and signed the refusal. " f. Nurse's Notes dated 3/8/11 at 2:15 p.m. documented, "Ambulance back with resident. Resident had BM (bowel movement) also resident refused to go to [MEDICAL TREATMENT]. New order for 1 x (time) order for [MEDICATION NAME] 2 tabs (tablets) for diarrhea. 2 tabs [MEDICATION NAME] given. Non-compliant to diet and fluid restrictions. " 1) A Physician's telephone order dated 3/8/11 (no time) documented, " [MEDICATION NAME] ii (two) tabs 1 x (one time) 1 order for diarrhea. " 2) On 3/29/11 at 8:30 a.m., Licensed Practical Nurse (LPN) #1 (Charge Nurse on 3/8/11) stated, "On 3/8/11 (Resident #3) had a bowel movement in the ambulance and they brought her back to the facility to clean up. She refused to go back to [MEDICAL TREATMENT]. I called (Attending Physician) and told him she had diarrhea. I got a one time order for [MEDICATION NAME]. I told him she refused to go back to [MEDICAL TREATMENT]. " g. Nurse's Notes dated 3/8/11 at 5:30 p.m. documented, "No diarrhea noted. Alert and verbal of needs. Confusion noted at x's (times). Feeds self with good po (oral) intake. No c/o (complaints of) pain." The March 2011 ADL Flow Sheet documented one stool for the 24 hour period dated 3/8/11. h. Nurse's Notes dated 3/9/11 at 2:30 a.m. documented, "Resting in bed (with) eyes closed. Resp (respirations) e/u (even and unlabored). [MEDICAL TREATMENT] site to L (left) arm (without) [MEDICAL CONDITION] or [DIAGNOSES REDACTED]. [MEDICAL TREATMENT] port to L chest (without) [MEDICAL CONDITION] or [DIAGNOSES REDACTED]. Dressing clean, dry and intact. No noted diarrhea this shift. No c/o-all needs met by staff. SR (siderails) up. " i. Nurse 's Notes dated 3/9/11 at 10:12 a.m. documented, " Resting in bed. Resp e/u. [MEDICAL TREATMENT] site (without) complications. Dressing clear and intact. No diarrhea this a.m. Will continue to monitor. " j. Nurse's Notes dated 3/9/11 (no time) documented, "Shunt to L arm clean/dry-no redness or [MEDICAL CONDITION] noted. Resp even nonlabored. No c/o pain or distress noted. Will continue to monitor." 1) The March 2011 ADL (Activities of Daily Living) Flow Sheet documented two stools for the 24 hour period for 3/9/11. 2) An EMS Patient Care Report dated 3/9/11 (no time) documented, "Pt was seated in bed. Pt refused [MEDICAL TREATMENT] apt (appointment)." 3) On 3/29/11 at 3:05 p.m., LPN #3 stated, "She (Resident #3) told me that morning (3/9/11) that she was going to [MEDICAL TREATMENT]. The ambulance came and she wouldn't go. I went and talked to her and asked her why. She said she was scared that she might have diarrhea. I did not call the doctor. I didn't tell the Director of Nursing ..." 4) On 3/29/11 at 2:15 p.m., the Attending Physician stated, "If (Resident #3) refuses [MEDICAL TREATMENT], I can't make her. I don't remember talking to anyone at the facility on 3/8/11 or 3/9/11." k. Nurse's Notes dated 3/10/11 at 2:05 a.m. documented, "Resting in bed with eyes closed. Resp e/u. Skin w/d (warm and dry) to touch. [MEDICAL TREATMENT] shunt to LUE (left upper extremity) (without) bleeding, [MEDICAL CONDITION] or [DIAGNOSES REDACTED]. No c/o, pain or distress noted. " l. Nurse's Notes dated 3/10/11 at 1:00 p.m. documented, "N.O. (new order) for stool culture, C & S, [MEDICAL CONDITION]. Alert, verbal, call light in reach. Loose stools noted. Shunt site without redness or drainage. Pericare PRN (as needed). No BM (bowel movement) noted this shift. " There was no documentation the physician had been notified that [MEDICAL TREATMENT] treatments for the week had not been completed. A Physician's telephone order dated 3/10/11 (no time) documented, "Stool culture, C&S (culture and sensitivity), [MEDICAL CONDITIONS]-DX (diagnosis): Diarrhea." m. Nurse's Notes dated 3/10/11 at 5:30 p.m. documented, "No stool this shift at this time. Resp e/u. No c/o pain. Incontinent of B/B . Pericare PRN. Shunt to L upper arm no [MEDICAL CONDITION] or bleeding noted. CL (call light) in easy reach. " n. Nurse's Notes dated 3/10/11 9:30 p.m. documented, "Res had med (medium) size emesis stated, 'I feel better now.' No c/o pain. " The March 2011 ADL sheet documented 2 stools for the 24 hour period for 3/10/11. o. Nurse's Notes dated 3/11/11 at 12:40 a.m. documented, "Remains in bed. Shunt to L arm without redness/drainage/[MEDICAL CONDITION]. No c/o nausea/vomiting thus far. No distress noted." Nurse's Notes dated 3/11/11 at 2:20 a.m. documented, "Resident c/o nausea (with) emesis x 's 2. (Attending Physician's) office notified. " Nurse's Notes dated 3/11/11 at 2:30 a.m. documented, "Received return call. New order N & P (noted and processed). Resident aware. " A Physician's telephone order dated 3/11/11 documented, "[MEDICATION NAME] 4 mg (milligrams) po (by mouth) q (every) 6 hours PRN nausea/vomiting." Nurse 's Notes dated 3/11/11 at 5:45 a.m. documented, "No further c/o nausea or reported episode of vomiting." p. The Nurse's Notes dated 3/11/11 at 10:02 a.m. documented, "Res noted to have resp (respiratory) difficult-nv (nausea vomiting) x 1. Change in cognition status. MD (Medical Doctor) notified." Nurse's Notes dated 3/11/11 at 10:05 a.m. documented, "N.O (new order) transfer to (hospital) for eval (evaluation) (and) tx (treatment)." A Physician's telephone order dated 3/11/11 documented, "Transfer to (hospital) to eval and tx." q. Nurse's Notes dated 3/11/11 at 10:20 a.m. documented, " ...late entry. Resident lying in bed. HOB (head of bed) up. Resp 20-SOB (shortness of breath) noted. Change of cognitive status noted. Resident reports that her stomach hurts. BP up. Labored respirations. Family notified. " The March 2011 ADL Flow sheet documented one stool prior to 11:00 a.m. for 3/11/11. r. A Patient Transfer Form dated 3/11/11 (no time) documented, "Has had n/v x 1 day, hasn't been to [MEDICAL TREATMENT] this week due to diarrhea x 4 days-change of cognitive status noted." Nurse's Notes dated 3/11/11 at 11:00 a.m. documented, "(Ambulance Service) here to transfer pt to (hospital)." s. The emergency room Physician's Record dated 3/11/11 (no time) documented, " ...needs urgent dialyzing ...admitting [DIAGNOSES REDACTED]." The Physician's History and Physical dated 3/11/11 (no time) documented a chief complaint of "shortness of breath." The history of present illness was documented as "The patient is a [AGE] year-old nursing home resident with past medical history significant for [MEDICAL CONDITION] on [MEDICAL TREATMENT], diabetes mellitus, hypertension, history of [MEDICAL CONDITION] status [REDACTED]. Per chart review and after discussions with nursing staff, the patient apparently missed some [MEDICAL TREATMENT] sessions because she was feeling unwell while at the nursing home. She also had diarrhea. No reports of fevers or chills. No reports of chest pain. The patient's main complaint is one of shortness of breath. The patient was reviewed in our emergency room . Routine laboratory review revealed significant [MEDICAL CONDITION] at 8.5 mEq (milliequivalents) per liter (reference range 3.5-5.0 mmol/L (millimoles per liter)) and the patient is currently being emergently dialyzed. " t. A physician progress notes [REDACTED].#3) was noted to have increasing nausea, vomiting and diarrhea. Telephone orders for stool cultures and [DIAGNOSES REDACTED] were given as well as order for [MEDICATION NAME] for antiemetics treatment on 3/10/11. The clinic was notified that patient refused transfer to [MEDICAL TREATMENT] secondary to gastroenteritis during this period of time from 3/7/11 to 3/11/11. " On 3/29/11 at 2:15 p.m., the Attending Physician stated, "If (Resident #3) refuses [MEDICAL TREATMENT], I can't make her. I don't remember talking to anyone at the facility on 3/8/11 or 3/9/11. " u. On 3/29/11 at 8:35 a.m., the resident stated, "I refused to go to [MEDICAL TREATMENT] because I was sick. I was running off (diarrhea). I kept going (having bowel movements) and finally went to the hospital. I am ok now. " v. On 3/29/11 at 10:20 a.m., Resident #3's son and power of attorney stated, "I was not notified of her diarrhea or refusal to go to [MEDICAL TREATMENT], but on 3/11/11, they called me and said she had been refusing to go to [MEDICAL TREATMENT] and that she had diarrhea and had to go to the hospital."