Every finding on record at Van Buren Healthcare and Rehabilitation Center

Number of residents sampled: Number of residents cited: Based on record review, interview and facility policy review, the facility failed to develop and implement a person-centered comprehensive care plan that included dementia care needs for one (Resident #37) of one resident reviewed. The findings include: Review of Resident #37's admission Record revealed the facility admitted Resident #37 on 08/05/2023 with diagnoses that included dementia in other diseases classified elsewhere, unspecified severity, with other behavioral disturbance with an onset date of 09/02/2025. Review of Resident #37's Physician Orders revealed Resident #37 was admitted to [the facility] long-term care (LTC) with an order date of 11/03/2025. Review of Resident #37's quarterly Minimum Data Set (MDS) with an Assessment Reference Date of 03/08/2026, revealed Resident #37 had a Brief Interview for Mental Status score of 10, which indicated Resident #37 had moderate cognitive impairment. The MDS also revealed active diagnoses in the last seven days that included non-Alzheimer's dementia. Review of Resident #37's Care Plan, with a review date of 03/11/2026, revealed the Care Plan did not indicate a focus or interventions for dementia care. During an interview on 05/20/2026 at 10:53 AM, MDS Coordinator #1 reviewed Resident #37's quarterly MDS with an ARD of 03/08/2026 and confirmed there was an active diagnosis for non-Alzheimer's dementia. MDS Coordinator #1 reviewed the Care Plan and confirmed there was no focus area for dementia care included. During an interview on 05/20/2026 at 10:58 AM, MDS Coordinator #2 stated she completed Care Plans prior to MDS Coordinator #1 at the facility. MDS Coordinator #2 stated she completed the Care Plan for Resident #37. She stated Resident #37 was originally admitted in 2023, the dementia diagnosis was not added until 2025, and she did not catch it When that occurred. MDS Coordinator #2 stated a diagnosis of dementia should be added to Resident #37's Care Plan and any specific interventions needed. When she was asked why dementia should be care planned, she stated, residents with dementia may have fluctuations of behavior and may have moments of confusion that staff should address. MDS Coordinator #2 stated that she updated Care Plans quarterly at minimum. She stated a daily report was run and anything on the order listing report would be added on the Care Plan. She stated she and MDS Coordinator #1 were the only staff who updated resident Care Plans. During an interview on 05/21/2026 at 11:12 AM, the Director of Nursing (DON) stated that MDS Coordinator #1 and #2 were responsible for developing residents' Care Plans. She stated the Certified Nursing Assistants (CNAs) had access to resident Care Plans in the electronic computer system. She stated dementia should be care planned, to individualize the resident's care so that staff is aware the resident has dementia and to individualize the interventions so the staff will take better care of the residents. Review of a facility policy titled, Care Plans-Comprehensive with a revision date 03/01/2022, revealed that each comprehensive care plan has been designed to incorporate identified problem areas, incorporate risk factors associated with identified problems and identify the professional services that are possible for each element of care.

Based on observation, interview, and record review, the facility failed to ensure the care plan was followed related to fall interventions for 1 (Resident #32) of 1 sampled resident with a history of falls. The findings are: On 09/20/2024 at 2:45 PM, the Surveyor observed one fall mat in place on the right side of Resident #32's bedside. The Surveyor observed adhesive strips on the left side of Resident #32's bedside. On 09/22/2024 at 09:00 AM, review of the Care Plan, with an initiated date of 06/19/24, noted Resident #32 was a moderate risk for falls, with falls recorded on 7/21/2024, 7/27/2024, and 9/11/2024 without injury. Interventions include a fall mat placed on both sides of the bed. On 09/22/2024 at 09:30 AM, review of the Medical Diagnosis sheet reported Resident #32 had diagnoses of unspecified lack of coordination, severe protein calorie malnutrition, reduce mobility, muscle wasting, and abnormalities of gait and mobility. On 09/22/2024 at 11:51 AM, the Surveyor observed one fall mat in place on the right side of Resident #32's bedside. No fall mat was observed on the left side of Resident #32's bedside. The Assistant Director of Nursing (ADON) was interviewed and confirmed the was not a fall mat in place on the left side of the bed and no additional fall mat was stored elsewhere in the room. The ADON could not verify if the care plan required two fall mats to be at Resident #32's bedside. The ADON reported she would find a fall mat and put it in place.

Based on observation, interview, and record review, the facility failed to provide alternative communication methods for 1 (Resident #15) of 1 sampled resident who required alternative formats for communication. The findings are: On 09/16/2024 at 2:00 PM, during initial rounds and interviews with the residents, Resident #15 indicated they wanted to speak with the Surveyor. Upon entering the Resident #15's room, the Surveyor became aware that Resident #15 struggled to communicate verbally. No communication board or note tablet was visible in the resident's room. Resident #15 became agitated as the Surveyor struggled to understand what Resident #15 was trying to communicate. When asked if there was a way Resident #15 could communicate with the Surveyor easily, Resident #15 looked around room then indicated no. On 09/16/2024 at 10:00 AM, review of Resident #15's Medical Diagnosis sheet reported a history of traumatic brain injury, and dementia. On 09/16/2024 at 10:30 AM, review of Resident #15's Care Plan, with an initiated date of 12/15/21, noted Resident #15 had a communication problem Interventions for communicating with Resident #15 indicated staff were to identify self at each interaction, face Resident #15 when speaking, make eye contact, and reduce distractions. Resident #15 had communication problems. Interventions were to anticipate and meet needs, Monitor/document frustration level. Resident #15 uses Resident #15's computer to communicate, staff to plug in every evening per Resident #15's request. Use communication techniques which enhance interaction: allow adequate time to respond, repeat as necessary, do not rush, request feedback, clarification from Resident #15 to ensure understanding. Ask yes/no questions if appropriate. Use simple brief, consistent words/cues. Use alternative communication tools as needed such as communication book/board, writing pad, gestures, signs, and pictures. On 09/17/2024 at 11:54 AM, the Surveyor observed Housekeeper #1 exiting Resident #15's room. When interviewed, Housekeeper #1 reported there was no note pad or communication board that she was aware of, she communicates with Resident #15 using hand gestures. On 09/17/2024 at 12:00 PM, during an interview with the Treatment Nurse, she indicated Resident #15 has a laptop that can be used for communication. When asked what staff do if Resident #15 is unable to use the laptop for communication, the Treatment Nurse reported that simple yes/no questions are asked of Resident #15. The Treatment Nurse confirmed there was no communication board or note pad present for Resident #15. On 09/17/2024 at 12:30 PM, during an interview with Resident #15 regarding the ease of using the laptop for communication. Resident #15 indicated the laptop was difficult to use as Resident #15 did not have full use of the resident's hands and fingers. On 09/17/2024 at 12:49 PM, during an interview, the Activity Director was asked how she communicated with Resident #15. The Activity Director reported she has known Resident #15 for a long time and is able to understand Resident #15's nonverbal cues. The Activity Director verified that if someone has not known Resident #15 for a long period of time, alternative forms of communication would be necessary to understand Resident #15's needs/wants.

Based on interviews, record review, and facility policy review, it was determined the facility failed to ensure 1 (Resident #4) of 7 residents reviewed for accidents and hazards received adequate supervision to prevent the potential for accidents. Specifically, the facility failed to ensure Resident #4 was supervised to prevent the access and potential for ingestion of hand sanitizer, on the overbed table next to a cup of water in Resident #4's room. Findings included: A review of the Admission Record, indicated the facility admitted Resident #4 with diagnoses that included senile degeneration of the brain, benign neoplasm of prostate, unspecified dementia, and metabolic encephalopathy. The quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/14/2024 revealed Resident #4 had a Brief Interview for Mental Status (BIMS) score of 1 which indicated the resident had severe cognitive impairment. Resident #4's functional abilities indicated resident required set up and clean up assistance with eating and oral hygiene. Resident #4 utilized a manual wheelchair for ambulation and required partial to moderate assistance with ambulation. A review of Resident #4's care plan initiated on 10/11/2023, revealed the resident had a terminal prognosis, was a wanderer, and was at was at risk for behaviors that included being up at night, roaming hallways, and taking hand sanitizer back to Resident #4's assigned room. Interventions included removing items from Resident #4's room when discovered. A review of the Nursing Medication Administration Record (MAR), revealed Resident #4 had a device to monitor wandering, was receiving hospice care, and behaviors were being monitored. During an interview on 09/16/2024 at 2:16 PM, a family member (Family Member #1) of Resident #4 stated, Resident #4 had a diagnosis of dementia and was concerned about finding a pump bottle of hand sanitizer, with the lid off, on Resident #4's over bed table. Family Member #1 stated there was also a clear plastic cup with a clear fluid in it, a regular sip or drink cup with a straw in it, and a lined cup (like a graduated medication cup) containing 4 to 5 sealed straws, napkins, and the pump lid from the sanitizer bottle on the overbed table. Family Member #1 stated they called another family member, (Family Member #2), who had been in the facility during breakfast, and Family Member #2 said there was no sanitizer in Resident #4's room at breakfast. Family member #1 said they asked an aide to come to Resident #4's room to remove the sanitizer, but Family Member # 1 could not recall who the aide was. Family Member #1 stated their concern was that Resident #4 would drink the open hand-sanitizer. A review of an Incident and Accident Report dated 09/06/2024 at 11:45 AM, revealed a statement given by Certified Nursing Assistant (CNA) #2 which indicated an opened sanitizer bottle was located next to a cup of water with a straw in Resident #4's room, and Family Member #1 t voiced concern Resident #4 had the opened sanitizer bottle next to a cup of water with a straw. A review of the Progress Notes revealed a Nurses Notes on 09/06/2024 at 1:42 PM which revealed staff reported that a family member said Resident #4 drank hand sanitizer. Resident #4 did not recall drinking hand sanitizer. A review of the Progress Notes revealed a Nurses Notes on 09/08/2024 at 10:14 PM, Resident #4 was observed roaming and removed a box of tissues from the nurse's station. A review of the in-services done with staff on 09/06/2024, included a facility policies titled, Abuse & Neglect, with a revision date of 08/10/2022, that indicated neglect is failing to provide services to avoid physical harm to a resident and an adverse event is or risk of an untoward, undesirable, and unanticipated event. Prevention, protection and response procedures of neglect included dementia management, a review of federal rules and regulations, ongoing resident assessment, care planning behaviors, and observation; and Storage of Supplies and Equipment, with a revised date of 04/2008, that indicated Hazardous/toxic materials must be properly stored. During an interview on 09/18/2024 at 4:24 PM, CNA #2 stated Resident #4's family member approached the nurse's desk and requested CNA #2 accompany the family member to Resident #4's room, worried Resident #4 opened a bottle of sanitizer and a cup next to the open sanitizer had water in it. Upon entry of Resident #4's room, CNA #2 stated she observed a cup containing water, a bottle of sanitizer, a cup containing unopened straws with the pump top of the sanitizer in it. CNA #2 described the hand sanitizer as one used by the facility, [brand name] brand with the pump on top. CNA #2 stated they were not sure if a staff member left the sanitizer in Resident #4's room and that Resident #4 was up at night and searched through items and may have taken the bottle of hand sanitizer from the nurse's medication cart. CNA #4 stated we have to keep an eye on him. During an interview on 09/18/2024 at 4:35 PM, the Director of Nursing (DON) stated she was notified of the family member's concern of hand sanitizer being in Resident #4's room and stated Resident #4 wanders the halls in evening and grabs things. Education was done with staff to keep things put up and out of reach of dementia residents due to the hazard it poses.

Based on observation and interview, the facility failed to ensure food items stored in the refrigerator/freezer were covered, sealed and dated; expired food items were promptly removed/discarded by the expiration or use by dates to prevent potential food borne illness for residents who received meal trays from 1 of 1 kitchen; and dietary staff washed their hands before handling clean equipment or food items to prevent potential food borne illness for residents who received meals from 1 of 1 kitchen. The failed practices had the potential to affect 97 residents who received meals from the kitchen (total census: 98), as documented on a list provided by the Dietary Supervisor on [DATE] at 2:22 AM. The findings are: 1. On [DATE] 10:33 AM, the following observations were made in the walk-in refrigerator: a. A container of leftover apple cobbler dated [DATE]. b. An opened box of sausage not covered or sealed. 2. On [DATE] at 10:34 AM, the following observation was made in the in the walk-in freezer: a. An opened box of egg omelets not covered. 3. On [DATE] at 11:22 AM, there were 9 cartons of pineapple juice on a shelf in the storage room with an expiration date of [DATE]. 4. On [DATE] at 12:01 PM, an opened box of egg rolls was in the freezer in the Nourishment Room on the South Hall not covered or sealed. 5. On [DATE] at 12:02 PM, the following observations were made in the refrigerator in the Nourishment Room on the South Hall: a. A carton of skin milk with an expiration date of [DATE]. b. A container of egg soup with no name or date when stored. c. Three boxes of cooked white rice with no name or date when stored. d. A plate full of wafers with no name or date when stored. 6. On [DATE] at 12:30 PM, Dietary Employee (DE) #3 was on the tray line assisting with lunch with gloves on her hands. She picked up the tray cards and placed them on the trays, contaminating her gloved hands. Without changing gloves and washing her hands, she picked up the plates to be used in portioning food items to be served to the residents for lunch with her gloved fingers touching the plates' interior surfaces. 7. On [DATE] at 12:34 PM, DE #3 untied a bag of hamburger buns on the counter while still wearing the same gloves. She removed a bun from the bag and placed it on the tray. She unwrapped a slice of cheese wrapped in plastic wrap and used her contaminated gloved hands to remove slice of cheese and place it on the bun. She picked up another slice of cheese in plastic wrap, unwrapped it, and without changing gloves and washing her hands, she removed the slice of cheese and placed it on another bun to be served to the residents who requested a cheeseburger with their lunch meal. She then used a tong to remove tomatoes and lettuce from a container. 8. On [DATE] at 12:38 PM, DE #3 held a box of gloves as she removed gloves from the box and placed them on her hands, contaminating the gloves. She used the same gloved hand to remove chips from a bag and placed them on a plate. She then picked up a bowl with her gloved fingers inside the bowl. She spooned a serving of vegetables into the bowl to serve to the residents who requested soup with their lunch meal. 9. On [DATE] at 12:48 PM, DE #4 walked out of the walk-in refrigerator with a container of grape jelly in her hand. She placed the container on the counter, contaminating her hands. Without washing her hands, she united a bag of bread, used her contaminated hand to remove slices of bread from the bag and placed them on plastic wrap. She used a spoon to remove peanut butter and jelly and spread them on the slices of bread to be served to the residents who requested a peanut butter and jelly sandwich with their lunch meal. 10. On [DATE] at 3:18 PM, DE #4 turned on the hand washing sink faucet in the dish washing machine room and washed her hands. After washing her hands, she turned off the sink faucet with her hands, contaminating them. She picked up clean plates and placed them on the clean side of the cabinet and touched the inside of them. The Surveyor asked what she should have done after she touched dirty dishes and before she handled clean objects. She stated, Rewashed my hands. 11. On [DATE] at 4:18 PM, DE #5 turned on the two-compartment sink and washed the blender bowl. After rinsing and sanitizing the bowl, she turned off the sink faucet with her hands, contaminating them. She picked up a clean blade and attached it to the base of the blender to be used in pureeing food items to be served to the residents who required pureed diets. The Surveyor asked what she should have done after touching dirty dishes and before handling clean objects. She stated, I should have washed my hands. I will go and rewash it. 12. A document titled, General Food Preparation and Handling, provided by the Dietary Supervisor on [DATE] at 11:24 AM documented, .2.b.Food is covered for storage . 4.d. Leftovers must be dated, labeled, covered, cooled, and stored (within ,d+[DATE] hour after cooking or service) in a refrigerator.Leftovers are not to be used as pureed food. Use leftovers within 3 days or discard . 13. The facility policy titled, When Should You Wash Your Hands?, provide by the Dietary Supervisor on [DATE] at 1:08 PM documented, . Immediately before working in food preparation where exposed food, clean equipment and utensils, or unwrapped single-service or single-use articles are present . During food preparation, as often as necessary to remove soil and contamination, and to prevent cross-contamination when changing tasks . Before donning gloves to initiate a task that involves working with food After engaging in other activities that contaminates the hands.

Based on observation and interview, the facility failed to ensure privacy and confidentiality of personal and medical information was maintained during medication administration by not locking the computer screens when not in use for 2 (Residents #29 and #59) of 2 sampled residents. The findings are: 1. On 07/12/23 at 8:33 AM, on the East Hall the medication cart was left unattended with the laptop screen opened and unlocked with Resident #29's name, information, and photo visible. 2. On 07/12/23 at 8:33 AM, the Surveyor asked Licensed Practical Nurse (LPN) #3 to look at the computer on the medication cart and tell this Surveyor what was wrong. LPN #3 stated, I left it open. The Surveyor asked if she should lock the laptop computer when she left her medication cart unattended. LPN #3 stated, Yes. The Surveyor asked what could happen if she didn't lock her laptop screen and left it unattended for others to see. LPN #3 stated, A violation of HIPPA [Health Insurance Portability and Accountability Act]. 3. On 07/13/23 at 3:49 PM, on the North Hall the medication cart was unattended with the laptop screen opened and unlocked with Resident #59's name, information, and photo visible. There were no nurses around the cart or at the desk. A form with Resident #59's name and health information were lying on top of the cart that was left unattended. 4. On 07/14/23 at 10:06 AM, the Surveyor asked the Director of Nursing (DON) what should happen when a nurse is passing medications and walks away from the medication cart. The DON stated, They should lock the screen to hide any resident information. The Surveyor asked what could happen if they didn't do those things. The DON stated, It is a HIPPA violation. 5. A facility policy titled, Confidentiality of Information and Personal Privacy, provided by the DON on 07/14/23 at 9:06 AM documented, .Our facility will protect and safeguard resident confidentiality and personal privacy . 1. The facility will safeguard the personal privacy and confidentiality of all resident personal and medical records. 2. The facility will strive to protect the resident's privacy . 4. Access to resident personal and medical records will be limited to authorized staff and business associates . 7. Release of resident information, including .computer stored information, will be handled in accordance with resident rights and privacy policies .

Based on interview and record review, the facility failed to accurately record the resident assessment for 4 (Resident #6, #48, #86, #89) of 4 sampled residents. The findings are: 1. Resident #6 had a diagnosis of Bipolar Disorder. a. Resident #6's electronic medical records contained a Preadmission Screening and Resident Review (PASARR) Level II dated 12/23/20. b. The Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) dated 03/24/23 documented the resident was not currently considered by the state level II PASRR process to have a serious mental illness and/or intellectual disability or a related condition. 2. Resident #48 had a diagnosis of Schizoaffective Disorder. a. A letter from [State Designated Professional Associates] dated 01/30/20 regarding Resident #48's documented Resident #48 does not require specialized services and recommended the following rehabilitative services: Mental health Evaluation/Diagnosis; Pharmacological Management by Physician; Periodic Review of Master treatment Plan; Psychological Evaluation; Master Treatment Plan and Individual Psychotherapy. b. The Care Plan with an initiated date of 02/16/20 documented, .had a PASRR screening according to regulatory guidelines. This was completed and sent to [State Designated Professional Associates] and recv'd [received] on 1/24/20 and revealed no need for specialized services . is a level 2 PASSR .and [State Designated Professional Associates] recommendations are: provision of a structured environment, daily living skills training, adl [activities of daily living] program to increase independence, mental health eval [Evaluation]/dx [diagnosis], pharmacologic management by a physician, medication management/monitoring, periodic review of master treatment plan, psychological eval, master tx [treatment] plan, and individual psychotherapy . c. The Annual MDS with an ARD of 01/15/23 documented the resident was not currently considered by the state level II PASRR process to have a serious mental illness and/or intellectual disability or a related condition. 3. Resident #86 had a diagnosis of Mild Neurocognitive Disorder Due to Known Physiological Condition with Behavioral Disturbance a. The Pharmacy Consultant Visit - MRRs (Medical Record Reviews) documented the following: i) 12/13/22 - Resident #48 was on the medication Seroquel and had no behaviors attempt reduction - reduced. ii) 01/17/23 - Resident #48 had no noted issues/behaviors since reduction of Seroquel, consider further reduction to find lowest effective dose - ok reduced. iii) 04/28/23 - Resident #48's Seroquel was reduced. b. The Quarterly MDS with an ARD of 03/08/23 documented the resident received antipsychotic medications on a routine basis and had not had a gradual dose reduction (GDR) attempted. c. The Quarterly MDS with an ARD of 06/06/23 documented the resident received antipsychotic medications on a routine basis and had not had a GDR attempted. 4. Resident #89 had a diagnosis of Delirium due to KNOWN Physiological Condition. a. The Physician Orders documented the resident was to receive Buspirone (Buspar) two times a day for anxiety Order Date 02/17/23 and Seroquel three times a day related to Alzheimer's Disease, Unspecified Order Date 02/22/23. There was no order for an antidepressant of opioid on the Physician Orders. b. The Quarterly MDS with an ARD of 05/01/23 documented the resident did not receive an antianxiety medication during the 7 day lookback period and received an antidepressant for 7 days and an opioid for 4 days of the 7 day lookback period. c. The April 2023 Medication Administration Record (MAR) documented the resident received Buspirone and Seroquel. No antidepressant or opioid was on the MAR. 5. On 07/12/23 at 1:31 PM, the MDS Coordinator stated when completing section A1500, on the resident assessment, she looks at the resident's documents in their electronic medical record to see if they have a level II PASARR. The MDS Coordinator opened Resident #6's Annual MDS dated [DATE] and reviewed section A1500. The MDS Coordinator stated, It says no. The MDS Coordinator opened Resident #6's chart and reviewed the PASARR II. She stated, It should have been marked yes. When I go through my MDS sections, it is my responsibility to go through to make sure all of the information is right. The Surveyor asked the MDS Coordinator when Section N GDR was to be marked. The MDS Coordinator stated, GDR are done on all of the Omnibus Budget Reconciliation Act [OBRA] when the physician has come in and we have received a dose reduction on antipsychotics. When I go through my MDS section it is my responsibility to go through the documents to make sure all information is accurately entered. I rely on Medical Records for the information. The MDS Coordinator reviewed Resident #86 ' s documentation on the MRR and the Quarterly MDS and stated, Yes [Resident #86] had a dose reduction in January 2023. Based on that, it would not be accurate. 6. On 07/12/23 at 2:06 PM, the MDS Coordinator informed the Surveyor she had reviewed the PASARR letter for Resident #48 and that Resident #48's MDS needed a modification due to being incorrectly marked. 7. On 07/12/23 at 3:28 PM, the Surveyor asked the MDS Coordinator to look at Resident #89's MDS with an ARD of 05/01/23 to see if an antidepressant or opioid was captured on the MDS section N0410. She stated, Yes, it is. The Surveyor asked if there was an order for an antidepressant or opioid. The MDS Coordinator stated, No ma'am. The Surveyor asked should an antianxiety and opioid be captured on this MDS. She stated, No, that's on me. The Surveyor asked her to look at the Physicians Orders during the 7 day lookback period to see if there was a Physicians Order for an antianxiety medication. She stated, Yes, Buspirone. The Surveyor asked her to look at the MDS to see if it was captured under section N0410. She stated, No, I don't know what I was looking at. It should have been captured on the MDS. I will modify it now. 8. On 07/13/23 at 2:38 PM, the Surveyor asked the Director of Nursing (DON) why all residents MDSs should be accurately coded. The DON stated, It is about their specific care and their specific diagnoses. 9. Section 1 of The RAI (Resident Assessment Instrument) Manual documented, .The RAI process has multiple regulatory requirements . the assessment accurately reflects the resident status . 46868 48388

Based on record review and interview, the facility failed to develop and implement a comprehensive person-centered plan of care for 2 (Residents #27 and #86) of 13 (Residents #6, #27, #29, #48, #55, #59, #63, #71, #84, #86, #89, #91 and #96) sampled residents whose Care Plans were reviewed. The findings are: 1. Resident #27 was admitted on [DATE] with a diagnosis of Bipolar Disorder. a. The Care Plan with an initiated date of 10/06/21 did not address interventions and care related to Bipolar Disorder. b. A Physicians Orders dated 05/08/23 indicated the resident was to receive Depakote Sprinkles (Divalproex Sodium) 125 milligrams one time a day related to Bipolar Disorder, Current Episode Depressed, Mild. c. Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/15/23 documented the resident had a diagnosis of Bipolar Disorder. d. On 7/12/23 at 3:17 PM, the Surveyor asked the MDS if all serious mental health diagnoses should be represented on a resident's Care Plan. The MDS Coordinator stated, Yes. Upon request by the Surveyor, the MDS Coordinator read all serious mental health diagnoses documented on the Resident #27's Care Plan. The MDS Coordinator stated, Dementia and Depression. The MDS Coordinator reviewed the diagnoses list for Resident #27. The MDS Coordinator stated Bipolar was on the diagnoses list and should be addressed on the Care Plan but had never been included on the Care Plan for Resident #27. 2. Resident #86 was readmitted on [DATE] with diagnoses of Dementia in Other Diseases Classified Elsewhere, Mild, with Other Behavioral Disturbance and Dementia in Other Diseases Classified Elsewhere, Unspecified Severity, with Other Behavior Disturbance. a. The Quarterly MDS with an ARD of 06/06/23 documented the resident had a diagnosis of Dementia. b. The Care Plan with an initiated/revision date of 06/12/23 does not address Dementia or behavior. c. On 07/13/23 at 11:24 AM, the Surveyor asked the MDS Coordinator how a resident's care who had a diagnosis of Dementia was represented on the Care Plan. The MDS Coordinator stated, It should be added as a focus area on the Care Plan. The MDS Coordinator viewed Resident 86's Care Plan and stated, I don't see that [Dementia] specified on there. It is not listed. [Resident #86] does not have the behaviors care planned either. I look in the nursing notes for behaviors. [Resident #86] attempted to hit a nurse. It [behaviors] should have been on the Care Plan the day after the note was put in on 6/12/23. 3. On 07/13/23 at 11:30 AM, the MDS Consultant stated, Our protocol is to run the 24 hour report and care plan the behaviors every day. [MDS Coordinator] should have already done it. 4. On 07/13/23 at 2:38 PM, the Surveyor asked the Director of Nursing (DON) what was included on a Care Plan. The DON stated, Lots of things, behaviors, preferences, psychosocial, diagnosis, individual to the resident. Anything individualized and specific to the resident. PASARR [Preadmission Screening and Resident Review]. The DON stated that for a resident with a Bipolar diagnosis and behaviors the Care Plan documented their PASARR and the diagnoses. and for a resident with a Dementia diagnosis and behaviors the Care Plan documented any of their behaviors, their type of diagnosis, any antipsychotic medication, and any specific care they need. The Surveyor asked the DON the outcome of Dementia, Bipolar and related behaviors not documented on a resident's Care Plan. The DON stated, They would not be getting taken care of properly. 5. The facility policy titled Care Planning-Interdisciplinary Team, provided by the DON on 07/13/23 at 11:50 AM documented, .1. A comprehensive care plan for each resident is developed within seven (7) days of completion of the resident assessment (MDS) . 48388

Based on observation, record review and interview, the facility failed to ensure Activities of Daily Living (ADL) care was provided to promote cleanliness and good personal hygiene for 1 (Resident # 71) of 10 (Residents #15, #20, #30, #63, #65, #68, #71, #86, #89 and #91) sampled residents who required staff assistance with shaving on the South Hall (Secure Unit). This failed practice had the potential to affect 24 residents who required assistance on the South Secured Unit with ADL care as documented on a list provided by the Director of Nursing (DON) on 07/14/23 at 9:06 AM. The findings are: 1. Resident #71 had diagnoses of Unspecified Dementia, unspecified Severity, without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance and Anxiety and Unspecified Lack of Coordination. a. On 07/10/23 at 11:37 AM, Resident #71 was sitting in the Dayroom. She had 1/2 inch long facial hair on her chin. b. On 07/11/23 at 8:37 AM, Resident #71 was in the Dayroom for breakfast. She had facial hair on her chin approximately 1/2 inch long. c. On 07/12/23 at 8:51 AM, Resident #71 was lying on the bed. She continues to have chin hair approximately 1/2 inch long. The Surveyor asked her if she wanted the chin hair. She stated, No. I'm not a man. d. On 07/13/23 at 8:52 AM, Resident #71 was lying in her bed. Her chin hair remained approximately 1/2 inch long. e. On 07/13/23 at 8:53 AM, the Surveyor asked Certified Nursing Assistant (CNA) #3 who was responsible for shaving residents. She stated, The shower team, but sometimes she refuses. The Surveyor asked what her responsibility was when a resident refuses ADL care. She stated, We document refusals and notify the nurse. The Surveyor asked if she felt that a female with this much facial hair was appropriate. She stated No, oh no. f. On 07/13/23 at 2:19 PM, the Surveyor asked the Director of Nursing (DON) who she expected to monitor the residents to ensure ADLs were being provided. She stated, All nursing staff. The Surveyor asked what staff were taught to provide when bathing. She stated, Peri care, nail care and shaving. g. On 07/13/23 the July 2023 Bathing Task sheet documented Resident #71 was scheduled for bathing every Wednesday, Friday and Sunday on the second shift and had received one shower/bath on 07/07/23. h. The Progress Notes dated 06/13/23 to 07/13/23 revealed the resident refused a shower on 06/18/23. There was no mention of the resident ' s chin hair or that the resident refused to be shaved. i. The facility policy titled, Shaving the Resident, provided by the DON on 07/13/23 at 12:11 PM documented, Purpose: The purpose of this procedure is to promote cleanliness and to provide skin care .

Based on observation, record review and interview, the facility failed to ensure an indwelling catheter bag was covered to maintain privacy for 1 (Resident #63) of 6 (Residents #12, #22, #29, #51, #63 and #78) sampled residents who had an indwelling catheter. The findings are: 1. Resident #63 had diagnoses of Alzheimer's Disease with Early Onset, Neuromuscular Dysfunction of Bladder, Unspecified and Chronic Kidney Disease, Unspecified. a. A Physicians Order dated 01/01/23 indicated the resident had a 16 Fr (french) foley catheter due to Neurogenic Bladder. b. A Care Plan with an initiated date of 01/12/23 indicated to position the catheter bag and tubing below the level of the bladder and away from entrance room door. The Care Plan did not address a privacy bag. c. On 07/10/23 at 3:13 PM, Resident #63 was sitting in his wheelchair in the Dayroom. His catheter bag was hung under the wheelchair approximately half full of a clear yellow liquid. No cover was on the bag. d. On 07/11/23 at 8:50 AM, Resident #63 was sitting in his wheelchair eating breakfast. The catheter bag was hanging under the wheelchair approximately one fourth full of a clear yellow liquid. No cover was on the bag. e. On 07/11/23 at 2:32 PM, a staff person took Resident #63 in his wheelchair to his room to empty the urine from the catheter bag. He was brought back to the Dayroom with his catheter bag located under his wheelchair and was visible to anyone. No cover was on the bag. f. On 07/12/23 at 7:28 AM, Resident #63 was sitting in a wheelchair in the Dayroom with his catheter bag hanging under the wheelchair. The bag was approximately one fourth full of a clear yellow liquid. No cover was on the bag. g. On 07/13/23 at 12:31 PM, Resident #63 was sitting at the dining table. His catheter bag was hanging under his wheelchair. The bag was approximately three fourth full of a clear yellow liquid. No cover was on the bag. h. On 07/13/23 at 1:32 PM, Resident #63 was sitting at the dining room table. The Surveyor asked Certified Nursing Assistant (CNA) #3 if she could see Resident #63's urine collection bag. CNA #3 looked and stated, He should have his bag in a privacy bag. The Surveyor asked why it is necessary to have a catheter bag in a privacy bag. She stated, For privacy and dignity and it can get yanked out. i. On 07/13/23 at 2:19 PM, the Surveyor asked the Director of Nursing (DON), What have you educated your staff on concerning urinary drainage bags? The DON stated, Keep it secured and in a privacy bag. The Surveyor asked why it was important to train on this subject. She stated, It's a dignity issue and it's to prevent trauma. j. The facility policy titled, Catheter Care, Urinary, provided by the DON on 07/13/23 at 12:11 PM documented, .General Guidelines: .13. Place Drainage bag in a privacy cover when exposed to the public .

Based on observation, record review, and interview, the facility failed to ensure meals were prepared and served according to the planned written menu to meet the nutritional needs of the residents for 1 of 1 meal observed. This failed practice had the potential to affect 71 residents who received regular diets, 18 residents who received mechanical soft diets, and 6 residents who received pureed diets from the kitchen according to a list provided by the Dietary Supervisor on 07/11/23. The findings are: 1. The facility lunch menu provided by the Dietary Supervisor on 07/10/23 at 1:37 PM documented that each resident who received a regular diet was to receive 3 ounces of honey glazed turkey. All residents were to receive baked sweet potatoes and residents on a pureed diet were to receive one 2 inch by 3 inch square of pureed marble cake with frosting. 2. The following observations were made during preparation of the noon meal: a. On 07/10/23 at 11:44 AM, Dietary Employee (DE) #1 was wearing gloves on her hands while she transferred slices of marble cake into individual plates with a metal spatula. As she transferred slices of cake, she used her gloved hand to push the filling from the cake that stuck on the spatula into a pan. At 11:49 AM, DE #1 scrapped a few cake crumbs from the pan into the filling. There was no sliced marble cake added in the filling that was to be pureed to serve to the residents who required pureed diets. At 11:55 AM, DE #1 used a #12 scoop to place 9 servings of the filling and crumb mixture into a blender. When she was ready to puree it. The Surveyor immediately stopped DE #1 and asked her if what she had put into the blender to puree had slices of marble cake like the ones she will serve to the residents on regular and mechanical soft diets. She stated, I was using the fillings stuck on the spatula that I had pushed into a pan and the crumbs that I scrapped from the pan. The Surveyor asked if there was a reason that they couldn't have pureed slices of cake like the other residents served to them. She stated, We don't have enough cake. 3. On 07/10/23 at 12:28 PM, the following observations were made during the noon meal service: a. DE #2 served a small slice of turkey to the residents on regular diets for lunch. On 07/11/23 at 7:49 AM, the Surveyor asked DE #2 how many residents received a slice of turkey at the lunch meal on 07/10/23. She stated, The North Hall, East Hall and [NAME] Hall received 2 slices of turkey by the time I cut it. The rest received one slice. 38 residents received one slice of turkey that weighed 1.4 ounces and 33 residents received 2 slices of turkey that weighed 2.6 ounces. b. All residents were served mashed potatoes, instead of baked sweet potato as specified on the menu. On 07/11/23 at 7:49 AM, the Surveyor asked DE #2 the reason sweet potatoes were not served to the residents. She stated, I saw that on the menu, but I was following the other sheet. The Dietary Supervisor stated, I wrote the wrong potato on the posted menu. It was supposed have been baked sweet potato, instead of mashed potatoes. c. On 07/10/23 at 1:36 PM, the Surveyor asked DE #5 to weigh the same amount of sliced turkey served to the residents at the lunch meal. She weighed one slice and the slice weighed 1.4 ounces. The Surveyor asked her to weigh another slice of turkey. She did so, and it weighed 1.2 ounces. She was asked to weigh both slices. She did and they both weighed 2.6 ounces, instead of 3 ounces as specified on the menu.

Based on observation, interview, and record review, the facility failed to ensure a comfortable, homelike, social dining experience was provided for residents who resided on the facility's Secure Unit. This failed practice had the potential to affect 31 residents as documented on the Census for the Secure Unit South Hall provided by the Registered Nurse (RN) Consultant on 07/10/23 at 1:39 PM. The findings are: 1. On 07/10/23 at 1:20 PM, the Dining Room area of the Secure Unit contained two tables on one side with two chairs near a piano and a recliner, and 3 tables pushed together and a table in the corner on the other side with 4 chairs. 2. On 07/10/23 from 12:45 PM to 1:35 PM, Resident #55 was going back and forth from her room to the Secure Unit Dining Room. At 1:59 PM, the Surveyor asked Resident #55 if she preferred to eat in her room. Resident #55 stated, Yes, it's too crowded out there. There is not enough room. The Surveyor asked would you eat in the Dining Room if there was more room. Resident #55 stated, Yes, probably. 3. On 07/12/23 at 12:40 PM, there were no empty chairs in the Dining Room and Resident #91's family member was standing to feed him. 4. On 07/13/23 at 12:15 PM, there were 9 residents, and 2 family members in the Dining Room awaiting lunch. There were no empty chairs. Resident #84 came into the Dining Room in a wheelchair bumping into tables and other residents' chairs spilling drinks. There were not enough chairs available again today and Resident #91's family member was scrunched standing between two chairs attempting to feed Resident #91. 5. On 07/13/23 at 12:45 PM, Resident #89 was in her room sitting in a chair at the end of her bed. Her lunch tray was sitting on the foot of her bed, and she was leaning over the footboard eating her lunch. The Surveyor asked if she wanted to eat in the dining area. Resident #89 stated, That's the place where all those people that live here come together. I only go to play the piano. 6. On 07/13/23 at 12:58 PM, the Surveyor asked Resident #96 if she ate meals in the dining area. Resident #96 stated, Only some days sweetie. Most of the time there are too much women down there. 7. On 07/13/23 at 1:11 PM, in the Dining Room, Resident #91's family member was standing over Resident #91 to assist with feeding her. 8. On 07/13/23 at 1:29 PM, the Surveyor asked Certified Nursing Assistant (CNA) #4, How many tables and chairs were in the Secure Unit Dining Room, can all the residents eat in the Secure Unit Dining Room, and was it a comfortable and homelike environment. CNA #4 stated, Not near enough. Just over a handful. About 12-15 [residents] at most. Pretty much everybody we have would eat down here if there was enough room. We only have one that I know would never come. We have tried to get more chairs to no avail. We have told the nurses, DON [Director of Nursing], Administrator and at meetings. There are residents that come down every day that want to sit down here and eat and cannot. Due to the behaviors here, we need to be able to space them out more and we can't. I would love to have more down here eating. It gives them more social time and time not being stuck in their room. 9. On 07/13/23 at 2:45 PM, the Surveyor accompanied the DON to the South Hall Secure Unit dining area and asked how many tables and chairs were in the Secure Unit Dining Room, how can all the residents eat in the Secure Unit Dining Room and was it a comfortable and homelike environment. The DON stated, 6 tables and 8 chairs if you count the recliner. No, not to space them out. If all wanted to, then no, but we do have the other two dining areas that all 30 residents can eat at if they wanted. The Surveyor asked if all Secure Unit residents were able to and if staff had been educated that the residents were able to. The DON stated, Technically this is just a Dayroom. I am not sure if they were officially trained, but it should be general knowledge. 10. On 07/13/23 at 3:08 PM, the Surveyor asked CNA #5 if education or training had been provided to her that all residents on the Secure Unit were able to eat in the Main and 100 Hall dining areas and if she had ever let a Secure Unit resident off the unit to eat breakfast, lunch, or dinner in either of those areas. CNA #5 stated, Oh, no! No. 11. On 07/13/23 at 3:10 PM, the Surveyor asked CNA #6 if education or training had been provided to her that all residents on the Secure Unit were able to eat in the Main and 100 Hall dining areas and if she had ever let a Secure Unit resident off the unit to eat breakfast, lunch, or dinner in either of those areas. CNA #6 stated, No! Only a few of them I have let out to go to the other Dining Room for bakery activities. 12. On 07/13/23 at 3:13 PM, the Surveyor asked Licensed Practical Nurse (LPN) #2 if education or training had been provided to her that all residents on the Secure Unit were able to eat in the Main and 100 Hall dining areas and if she had ever let a Secure Unit resident off of the unit to eat breakfast, lunch, or dinner in either of those areas. LPN #2 stated, No. For activities we take a few of them to the 100 Hall one. 13. On 07/13/23 at 8:09 AM, the Administrator informed the Surveyor the facility did not have a training regarding Secure Unit resident dining. 14. The facility policy titled, Activities and Social Events provided by the DON on 07/13/23 at 3:30 PM documented, .1. Residents have the right to choose the types of activities, dining, and social events in which they prefer to participate. 2. When developing the resident's activity, dining and social care plan, the resident should be given the opportunity to choose when, where, and how he or she will participate in activities, dining and social events . 15. The facility policy titled, Eating Environment, provided by the Administrator on 07/14/23 at 8:09 AM documented, .The staff shall strive to create an appropriate dining environment . 1. The direct care staff, Dietician, and Food Services Department will collaborate in developing an appropriate congregate eating environment. 2. Staff will develop appropriate measures, such as a seating chart and selection of dining area to try to maximize appropriate seating, positioning, and interactions among residents . 3. Nursing Services personnel will help to seat and position residents and identify factors that might adversely affect food intake (e.g., excessive noise or disruptive behaviors). Some residents may need staff to accompany them to meals, depending on the resident's choice of dining location, to ensure safety. Residents may eat in any dining area, including their own room .

Based on observation, record review and interview, the facility failed to ensure food preparation, service areas, and resident areas were free from visible signs of rodents and pests. This failed practice had the potential to affect 98 residents who received a meal tray from the kitchen as documented on a list provided by the Dietary Supervisor on 07/11/23 at 2:22 PM. The findings are: 1. On 07/10/23 at 12:16 PM, the following observations were made around the food preparation area: a. There was a fly crawling on the back of a saucepan hanging on the bar above the food preparation counter. b. A fly was on a pole. c. A fly was on a whisk. d. A fly was a sifter, one was crawling on a knife, and one was flying around the food area. The flies were shown to the Dietary Supervisor. e. A fly was on the wall by the hand washing sink. f. 4 flies were on a food cart close to the hand washing sink. g. A fly was on the wall by the dish window, and one was on the floor close to the food cart. The flies were shown to the Dietary Supervisor. 2. On 07/10/23 at 12:19 PM, the Surveyor asked the Dietary Supervisor the reason there were so many flies in the kitchen. She stated, They are coming through the door. 3. On 07/10/23 at 4:59 PM, a fly was crawling on a spatula inside of a pan and was also crawling inside the pan. The pan was to be sent to the dish washing machine to be washed. 4. On 07/11/23 at 9:22 AM, one roach was crawling on the floor and along the wall on the East Hall. 5. On 07/12/23 at 8:03 AM, a roach was crawling on the door facing in Room S-5. The roach was shown to Licensed Practical Nurse (LPN) #2 who used tissue paper to kill it. 6. On 07/12/2023 at 8:10 AM, a roach was crawling on the ceiling on the North Hall near room [ROOM NUMBER]. 7. On 07/11/23 at 12:31 PM, the Dietary Supervisor provided the following (Pest Elimination Service Company) Invoices: a. An Invoice dated 06/06/23 indicated some roaches were found in two rooms on E hall and laundry room, the facility was treated for roaches and flies in the Breakroom, Common Areas, Entry Points, Dining Room, Kitchen, Lobby, Storage Rooms, Kitchen, Restrooms, Closets, Cabinets, Bedrooms and Baseboards. b. An Invoice dated 06/08/23 indicated roaches were found by the exterminator in the back wall behind dishwasher and on the adjacent wall under milk crates and the Kitchen was treated for roaches. c. An Invoice dated 06/27/23 indicated the dish room was treated for roaches with service completed on 07/22/23. d. An Invoice dated 06/29/23 indicated the Common Areas, Entry Points and Kitchen were spot treated for flies and roaches. e. An Invoice dated 07/05/23 indicated a nest of roaches was found in the Dish Room, and staff had reported sightings of roaches in rooms behind cable boxes throughout the facility and in the basement. The Kitchen was treated for roaches. f. An Invoice dated 07/10/23 indicated roach activity was observed in the laundry room, laundry office, rooms S4, S6, and S2 and roach activity in the kitchen had gotten significantly better and 10 roaches were seen in the kitchen. The Kitchen, Laundry Room, Office, Restrooms, Common Areas, Dining Room, Entry Points, Breakrooms, common areas, dining room, entry points, Lobby, Offices and Restrooms were treated for roaches and the Common Areas, Dining Room, Entry Points, Kitchen and Windowsill/Trim were treated for flies.

Based on observation, record review and interview, the facility failed to ensure meals were served at temperatures that were acceptable to the residents to improve palatability and encourage good nutritional intake during 2 of 2 meals observed. The failed practice had the potential to affect 8 residents who received meal trays in their room on the 100 Hall; 31 residents who received meal trays in their room on the South Hall (Secure Unit); 16 residents who received meal trays in their room on the [NAME] Hall; 17 residents who received meal trays in their room on the North Hall and 26 residents who received meal trays in their room on the East Hall, as documented on a list provided by the Dietary Supervisor on 07/11/23 at 6:30 PM. The findings are: 1. On 07/11/23 at 5:07 PM, an unheated cart containing 6 meal trays for the assist residents for supper was delivered to the East Hall by Certified Nursing Assistant (CNA) #1. At 5:34 PM, Immediately after the last resident received their tray in their room, the temperatures of the food items on a test tray from the cart were checked and read by the Dietary Supervisor with the following results: a. Milk 50 - degrees Fahrenheit. b. Ground hamburger patties - 105 degrees Fahrenheit. c. Fries - 96.4 degrees Fahrenheit. d. Pureed marinated vegetables - 93 degrees Fahrenheit. e. Pureed bread with apple juice - 96 degrees Fahrenheit. 2. On 07/11/23 at 5:21 PM, an unheated meal cart containing 7 trays for supper was delivered to the 100 Hall by License Practical Nurse (LPN) #1, At 5:36 PM, immediately after the last resident was served in their room, the temperature of the food items on the test tray were checked and read by the Dietary Supervisor with the following results: a. Milk - 46.6 degrees Fahrenheit. b. Fried fish - 109.7 degrees Fahrenheit. c. Potato wedges - 110 degrees Fahrenheit. d. Marinated vegetables - 46 degrees Fahrenheit. 3. On 07/11/23 at 5:38 PM, an unheated cart containing 31 trays for supper was delivered to the Secure Unit by Registered Nurse (RN) #1. At 6:05 PM, immediately after the last resident received their tray in their room, the temperatures of the food items on a test tray from the cart were checked and read by the Dietary Supervisor with the following results: a. Fortified pudding - 61 degrees Fahrenheit. b. Milk - 47 degrees Fahrenheit. c. Pureed marinated vegetable - 66 degrees Fahrenheit. d. Pureed bread with juice - 93 degrees Fahrenheit. e. Pureed ground fish - 100 degrees Fahrenheit. f. Potato wedges - 90 degrees Fahrenheit. g. Marinated vegetables - 54 degrees Fahrenheit. h. Fried fish - 101 degrees Fahrenheit. 4. On 07/11/23 at 6:10 PM, CNA #2 stated, Food is always cold, and late.

Based on record review and interviews the facility failed to ensure that narcotics which had been surrendered and packaged for return to the state for destruction were kept secure and were picked up at the facility as evidenced by: 1. On 8/4/22 at 1:41 PM, the DON [Director of Nursing] was asked, Have you been notified of any discrepancy with surrendered narcotics? She stated, Yes, on morning of 8/2/22 approximately 9 AM I received a call from [Health Department Employee]. She requested a copy of narcotic page for prescription number 8 for [MEDICATION(S)] 100mg[milligrams]/5ml [milliliters]. There were 2 separate pages in 2 separate books, so I copied with ending balance showing 16ml. I sent it to her. It was a couple of hours later and she called me back and she said the discrepancy continues. I went and recalculated the doses that had been administered and still 16ml. I called her back and she told me I would need to fill out the Report of Loss of Controlled Substance Form. It was 10ml deficit. The ADON [Assistant Director of Nursing] and I called the Pharmacy Consultant and reported to him and he went over our protocol. Informed him the ADON generally receive meds form the nurses and count verified at that time. They are stored in a safe and when they are sent to the state, they are verified again with myself and the ADON or one of us with another nurse. It is then packaged and sealed. The Business Office calls Fed Ex and Fed Ex comes and picks up. [Pharmacy Consultant] said the box should not leave our custody after packaged up and her and I should take to the post office together. I called [Health Department Employee] back and asked her if there was any spillage noted and she said, No. She had even taken to pharmacist to verify. This was surrendered to them on 6/2 and we got the phone call 2 months after. After checking this we found Fed Ex did not pick up here but was taken from here by someone on 6/13 to Fed Ex office, I think the 13th. No signature of who took from here. We are still currently investigating this. a. On 8/5/22 at 9:13 AM, the Surveyor asked the Administrator, Were you able to find out when the surrendered [MEDICATION(S)] was taken to Fed Ex? He stated, I called on 8/3 probably around 11 or noon to see if they could tell me when the box was sent and told them who it was being sent to. They were able to find it and told me it was shipped out on the 11th (June). They said it was just dropped off and no one from here signed. b. On 8/5/22 at 9:29 AM, the Surveyor interviewed the previous Business Office Manager by phone and asked, Do you remember a box being brought to your office in June that needed to be sent out by Fed Ex? She stated, Sometime in June the box was brought to my office by [ADON] I think. It was all taped up and I know those are going back to the state pharmacy. The Surveyor asked, Did you call Fed Ex to pick it up? She stated, 'No, we take it to Fed Ex. The Surveyor asked, Who went with you? She stated, My husband went with me, we went on lunch break together. I did get a receipt and it was put in top drawer in the Business Office. c. On 8/5/22 at 10:16 AM, the Surveyor asked the ADON, Did you take the surrendered narcotics to the Business Office Manager in June? She stated, Yes. The Surveyor asked, Did anyone go with you? She stated, No. The Surveyor asked, Did you tell her what it was? She stated, yes, I told her it was the narcotics that needed to be sent off. She would then let Fed Ex know to stop and pick up. I didn't know until yesterday that Fed Ex didn't pick up here, but somebody had taken and dropped it off. We didn't have a name of who took it. d. On 8/5/22 at 10:23 AM in a telephone interview the previous Business Office Manager was asked, Can you tell me why the box was in your office from June 2nd until June 11th? She stated, Yes, honestly I couldn't always get out of office before Fed Ex closed. I put it under my desk and forgot about it. When I first started and was told to call Fed Ex to pick them up, they wouldn't because I didn't have the account information, so I was told to take them to Fed Ex. The Surveyor asked, Who told you to take it to Fed Ex? She stated, It was [Previous Administrator]. 2. The Narcotic Log received from the pharmacy on 4/29/22 for Prescription Number 8 showed 30ml. On 5/10/22 at 12:42 the last dose of 0.25ml was administered and the balance was 16ml. 3. The Report of Drugs Surrendered Form dated 6/2/22 documented, . RX [Prescription] Number . 8 . [MEDICATION(S)] 100/5ml Amount 16ml . This was signed by the DON and ADON. 4. The Report of Drugs Surrendered Form dated 6/2/22 that the facility received back from the State? documented, . RX Number . 8 . [MEDICATION(S)] 100/5ml. The 16ml had line drawn through it and 6ml was written in. 5. The Facility's Policy for Discarding and Destroying Medications documented, . Policy Interpretation and Implementation 1. All controlled substances shall be retained in a securely locked area with restricted access until authorized individuals destroy them. 2. All controlled medications that are pulled for destruction will be counted by 2 licensed staff members, this will need to be verified with the narcotic count sheet and initialed by the staff members verifying the count is correct. 5. Medications that are in the safe, (Controlled medications), cannot be pulled for destruction without two licensed staff members and/or Administrator. There will be a constant chain of custody until the medications are counted. The controlled med box will then be sealed and signed at the seal by two licensed staff. 6. The meds shall then be placed in a locked location for pickup that includes a tracking mechanism or return receipt.

Based on observation, record review, and interview, the facility failed to ensure the ice scoop holder, meat slicer, can opener, fan guard, and the main dining room's ice dispenser were maintained in a clean condition to minimize the risk of food borne illness for residents who received meals from the kitchen. These failed practices had the potential to affect 92 residents who received meals from the kitchen (total census 93), based on a list provided by dietary employee #2 on 4/8/22. On 4/4/2022, the following observations were made: 1. At 10:21 AM, the blue ice scoop holder mounted to the side of the ice machine in the kitchen had an unidentified blackish, gritty substance in the bottom of it. Dietary Employee #2 was asked what she saw in the holder, and she said, Dirt. She was asked, How often is the ice scoop holder cleaned? Dietary Employee #2 said, It should be washed three times a day. Dietary Employee #2 was asked when the last time the ice scoop holder was washed and Dietary Employee #2 said, Last night after supper. a. At 10:24 AM, there was an electric slicer covered with plastic sitting on a worktable next to the ice machine. There was sticky yellowish debris beneath the blade guard of the slicer. Dietary Employee #2 was asked to describe what she saw, and she said, It's dirty and needs to be cleaned. Dietary Employee #2 was asked when the last time the slicer had been used. Dietary Employee #2 said, I don't know for sure. It's been a few days. b. At 10:33 AM, there was a mushy, black substance behind the can opener's blade and a thick, gummy, black accumulation of an unknown substance on the surrounding can opener base. Dietary Employee #2 was asked what she saw, and she said, It's dirty and a build-up. c. At 10:55 AM, there were whitish grey particles covering an inch of the outer edges of the fan guard in the walk-in refrigerator. Dietary Employee #2 was asked what the particles were, and she said, It's lint, I believe. 2. On 04/04/2022 at 11:05 AM, the chute of the main dining room's ice dispenser had an accumulation of an unidentified pinkish slimy substance which came off on a white napkin. Dietary Employee #2 was asked, Is this clean? Dietary employee #2 said, No. I will get it cleaned right away.

Based on observation, interview, and record review, the facility failed to ensure residents receives prompt identification and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The findings are: Resident #49 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/4/22 documented the resident scored 11 (8-12 indicates cognitively impaired) on the Brief Interview for Mental Status (BIMS), required limited assistance of 1 staff bed mobility and transfer and had functional limitation in the upper and lower extremity on one side. a. A Care Plan dated 2/10/22 documented, .is at risk for impaired skin integrity and or pressure ulcer r/t [related to] immobility and inct [incontinent] . Follow facility policies/protocols for the prevention/treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] b. The April 2022 weekly/monthly skin evaluation documented no negative skin issues. c. On 04/04/22 at 12:31 PM, Resident #49 was sitting in a wheelchair (w/c) in the hallway. There was an open red, swollen area to the right hand, in between the middle finger and ring finger knuckle. There was no dressing on the wound. The resident was asked, Does it hurt? The resident stated, Yes. The resident was asked, When did it happen? The resident stated, Last night. The resident was asked, Does the nurse know? The resident stated, Yes. The resident was asked, Did she put anything on it? Resident #49 stated, No. d. On 04/04/22 at 01:50 PM, Resident #49 was ambulating in a w/c in the hallway. The area to the top of the right hand was not covered and was red and swollen. e. On 04/05/22 at 12:12 PM, Resident #49 was sitting in a wheelchair in the hallway. The area in between the ring finger and the middle finger knuckle on the right hand, remained red and swollen with no dressing. f. On 04/06/22 at 11:28 AM, Licensed Practical Nurse (LPN) #2 was asked, Do you know what happened [R #49]'s hand, and can you describe it? LPN #2 stated, It's red, looks like she hit it on something, it looks swollen, it's open with no drainage, it's about 1 cm x 1. cm. [centimeter] g. On 04/06/22 at 01:57 PM, Certified Nursing Assistant (CNA) #3 was asked, Who is responsible for ensuring and reporting resident's changes of condition? CNA #3 stated, We are, CNAs to nurses, whoever sees it. CNA #3 was asked, What do staff do if they notice a new abrasion or wound or bruise on a resident? CNA #3 stated, Report it to the nurse or wound care nurse. CNA #3 was asked, Why should staff report new skin issues, such as abrasions, wounds, or bruises? CNA #3 stated, So they can find out what happened and get them doctored. CNA #3 was asked, Do you know what happened to [R #49] hand? CNA #3 stated, I have no idea. h. On 04/06/22 at 02:02 PM CNA #4 was asked, Who is responsible for ensuring and reporting resident's changes of condition? CNA #4 stated, CNAs to the nurse, then nurse follows chain of command. CNA #4 was asked, What do staff do if they notice a new abrasion or wound or bruise on a resident? CNA #4 stated, Report to the nurse, report to wound care nurse. CNA #4 was asked, Why should staff report new skin issues, such as abrasions, wounds, or bruises? CNA #4 stated, Because if they are not cared for properly, they can become worse. CNA #4 was asked, Do you know what happened to [R #49] hand? CNA #4 stated, I don't know. i. On 04/06/22 at 02:23 PM, LPN #4 was asked, Who is responsible for ensuring and reporting resident's changes of condition? LPN #4 stated, Anybody that notices a change of condition reports to the charge nurse. LPN #4 was asked, What do staff do if they notice a new abrasion or wound or bruise on a resident? LPN #4 stated, If I'm in the facility, they come get me, and if I'm not here, the charge nurse takes care of it. LPN #4 was asked, Why should staff report new skin issues, such as abrasions, wounds, or bruises? LPN #4 stated, So they can be documented, assessed, and provide treatment or interventions. LPN #4 was asked, Do you think 3 days is too long for someone to notify of the change with [R #49] hand? LPN #4 stated, I found out about it today, but yes, 3 days is too long. j. A policy on Acute Condition Changes provided by the Administrator on 4/6/22 at 1:18 pm documented, .the nursing staff will make pertinent observations and collect appropriate information to report to the physician . phone calls to attending or on-call physicians should be made by an adequately prepared nurse who has collected pertinent information, including the resident's current symptoms and status .

Based on observation, record review, and interview, the facility failed to ensure oxygen was administered at the physician ordered prescribed rate to prevent potential respiratory complications for 1 (Resident #30) of 8 (R21, R38, R82, R72, R30, R11, R37, and R4) sampled residents dependent on oxygen. The failed practice had the potential to affect 12 facility residents who had physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] Resident #30 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/21/22 documented the resident scored 15 (13-15 indicates cognitively intact) on the Brief Interview for Mental Status (BIMS), received oxygen while a resident and had Shortness of breath .with exertion .when sitting at rest, and .when lying flat. a. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] @ [at] 2 Lpm [liters per minute] as needed. b. On 04/04/22 at 11:59 AM, the resident was lying in bed with O2 via nasal cannula at 2.5 lpm. c. On 04/05/22 at 09:10 AM and at 1:36 PM, Resident #30 was in the room with O2 in use via nasal canula. O2 was set between 2.25 and 2.5 lpm. d. On 04/06/22 at 10:28 AM, the resident was in her room with O2 in use via nasal cannula. The resident was asked if she adjusted her O2. She stated, No, that is 'unintelligible sound' job (exhale sound) pointing toward door to the hallway. e. On 04/06/22 at 10:30 AM, Licensed Practical Nurse (LPN) #2 was asked to accompany this surveyor to the resident's room. LPN #2 was asked what O2 was set at. She stated, It's at 2.5. LPN #2 was asked what R 30's order was for O2. LPN #2 stated, I'm not 100% sure. LPN #2 went to nurses' station and checked computer and stated to surveyor, It should be at 2.0. I need to go adjust it now. LPN #2 was asked how often the O2 is checked. LPN #2 stated, I check it once a shift. I don't know about the others. LPN #2 was asked what the adverse effects could be if a resident was receiving too much O2. LPN #2 stated, If the O2 is too high it takes away their drive. f. The Oxygen Administration policy provided by the Administrator on 04/06/22 at 1:18 PM documented, i.Preparation 1.Review physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . ii.Steps in the Procedure .8. Adjust the oxygen delivery device so that .the proper flow of oxygen is being administered .

Based on observation of the 12:00 p.m., medication pass on 4/5/22 and the 8:00 a.m. medication pass on 4/6/22, record review, and interview, the facility failed to ensure physician's orders were followed to maintain a medication error rate of less than 5% to prevent potential complications for 2 (Residents #38, and #72) of 10 residents observed during the medication passes resulting in medication errors. Medication errors were made by 1 Licensed Practical Nurse (LPN); (LPN #2) of 2 LPNs who administered medications in the facility. The medication error rate was 5.88% based on observation of 34 medications administered, and a total of 2 errors detected. The findings are: 1. Resident #38 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] a. A Physician Order with a start date of 12/21/21 documented, .Novo Log Flex Pen Solution Pen-injector 100 units/ml [milliliter] (Insulin [MEDICATION(S)]) . Inject 20 units subcutaneously before meals and at bedtime . b. On 04/05/22 at 12:03 PM, Licensed Practical Nurse (LPN) #2 checked Resident #38's blood sugar glucose. The results were 187. c. On 04/05/22 at 01:17 PM, LPN #2 primed the pen with 2 units of insulin, then administered 20 units of Insulin [MEDICATION(S)] Flex Pen 100 units/ml to Resident #38's left posterior arm, pushed in the plunger, and pulled the needle from the arm. LPN #2 did not wait or count to 10 prior to removing the needle from the resident's arm. 2. Resident #72 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] a. A Physician Order with a start date of 11/17/21 documented, .[MEDICATION(S)] KwikPen Solution Pen-injector 100 UNIT/ML (Insulin [MEDICATION(S)] (1 Unit Dial)) Inject as per sliding scale . leave needle inserted x [times] 6 seconds . b. On 04/05/22 at 12:31 PM, LPN #2 checked Resident #72 blood sugar glucose. The results were 358. c. On 04/05/22 at 01:20 PM, LPN #2 primed the pen with 2 units of insulin, then administered 16 units of Insulin [MEDICATION(S)] Injection 100 units/ml into Resident #72's left lower abdomen. LPN #2 pushed in the plunger and pulled the needle from the resident's abdomen. LPN #2 did not wait or count to six prior to removing the needle from the resident's abdomen. d. On 04/06/22 at 11:19 AM, LPN #2 was asked, What does the physician order say for counting prior to removing the insulin pen after administration for Resident #72. LPN #2 stated, We got new needles and I thought you just poked, and it was done . I know now I'm supposed to wait 10 seconds. LPN #2 was asked, How long are you supposed to count prior to removing the insulin pen after administration for R#72. LPN #2 stated, I would wait 10 seconds to be on the safe side. 3. On 04/07/22 at 10:58 AM, the Director of Nursing (DON) was asked, Why should physician orders and the manufacturer's guidelines be followed when administering insulin pens? The DON stated, For safety of the residents. 4. A document titled, .Instructions for use [MEDICATION(S)] Flex Touch Pen provided by the Director of Nursing (DON) on 4/5/22 at 4:04 PM documented, .insert the needle into your skin . press and hold down the dose button until the dose counter shows 0 .keep the needle in your skin after the dose counter has returned to 0 and slowly count to 6 . when the dose counter returns to 0, you will not get your full dose until 6 seconds later . 5. A policy on .Administering Medications provided by the Administrator on 4/6/22 at 1:18 PM documented, .Medications shall be administered in a safe and timely manner, and as prescribed . medications must be administered in accordance with the orders, including any required time frame .

Based on observation, record review and interview, the facility failed to ensure staff sat at eye level with the resident while assisting with eating to promote dignity for 1 (Resident #82) of 1 sampled resident who required assistance with meals. The findings are: Resident #82 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/12/22 documented the resident scored 4 (0-7 indicates severe impairment) on the Brief Interview for Mental Status (BIMS) and required one staff to assist with eating. a. On 04/04/22 at 01:28 PM, Certified Nursing Assistant (CNA) #1 delivered Resident #82's meal tray to her room. CNA #1 offered Resident #82 a drink of punch from a straw. The CNA stood between the wall and the head of the bed, chopped the resident's food and started feeding the resident. CNA #1 gave the resident a bite of beans from the spoon while she continued to stand while assisting the resident to eat. b. On 04/04/22 at 01:54 PM CNA #1 was asked, Why did you stand up while assisting Resident #82 with her lunch meal? CNA #1replied, There is nowhere to sit down. I didn't have a chair. CNA #1was asked, Why should staff sit at eye level when assisting residents with meal service? CNA #1 replied, So they can make sure they are comfortable. CNA #1 was asked, Would you considered it a dignity issue standing over the resident while assisting them with eating? CNA #1 stated, Yes, it would be a dignity issue. c. On 04/06/22 01:57 PM, CNA #3 was asked, Why should staff sit at eye level while assisting residents with eating? CNA #3 stated, So the residents doesn't feel like you're hovering over them, to be at their level.

Complaint # (AR 063) was substantiated, all or in part, with these findings. Based on record review and interview, the facility failed to ensure a resident was free from abuse and neglect, as evidenced by failure Licensed Practical Nurse (LPN) #1 to respond to and address repeated reports from Certified Nursing Assistants (CNAs) that a resident was yelling, complaining of abdominal pain and experiencing nausea and vomiting; failure to assess the resident in an attempt to determine the cause of the resident's complaints; failure to make any attempt to relieve the resident's pain; failure to immediately consult with the physician regarding the pain, nausea/vomiting, and the results of a blood glucose test that indicated the resident was hyperglycemic; as well as LPN #1's failure to refrain from making disparaging comments about the resident while failing to address his needs for 1 (Resident #2) of 1 case mix resident who experienced an acute change in condition in the past 30 days. The failed practices resulted in past noncompliance at the level of immediate jeopardy for Resident #2, who experienced an acute change in condition which went unassessed and untreated, after which the resident expired. The failed practices also had the potential to cause more than minimal harm to 7 residents who experienced changes in condition in the past month, as documented on a Monitoring Tool form provided by the facility on [DATE] at 9:15 a.m. The Interim Administrator and Director of Nursing (DON) were informed of the past immediate jeopardy condition on [DATE] at 10:50 a.m. The findings are: 1. The facility's Abuse & (and) Neglect Policy & Procedure, revised [DATE], documented, .Abuse - is the willful infliction of injury . also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being . Neglect - is defined as the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress . The facility will act immediately upon notification when an individual has been witnessed, suspected or alleged to have caused abuse . 2. Resident #2 had [DIAGNOSES REDACTED]. The Annual Minimum Data Set with an Assessment Reference Date of [DATE] documented the resident scored 13 (13 - 15 indicates cognitively intact) on a brief interview for mental status; had severely impaired vision; was able to understand others and make himself understood; had no physical, verbal or other behavioral symptoms; required limited assistance of 1 person for transfer; was on a scheduled pain management regimen; had not had pain in the 5 days preceding the assessment; received insulin injections on 7 of the past 7 days; and, received a diuretic on 7 of the past 7 days. a. The Medication Review Report (printed [DATE]) documented the resident had the following physician orders: 1.) [DATE] - CBG (capillary blood glucose) AC and HS (before meals and at bedtime) related to diab (diabetes) . Must wear life vest 23 hours a day every shift related to Heart Failure . 2.) [DATE] - Insulin . 100 units/ mL (milliliter) inject as per sliding scale . [MEDICATION NAME] tablet sublingual 0.4 mg give 1 tablet sublingually every 5 minutes as needed for chest pain . [MEDICATION NAME] 100 units/mL 9 units subcutaneously three times a day . Ticagrelor tablet 90 mg 1 tablet one time a day related to ST elevation [MEDICAL CONDITION] infarction ([MEDICAL CONDITION]) . b. Progress Notes dated [DATE] through [DATE] documented the following occasions when the resident exhibited yelling behaviors: 1.) [DATE] at 9:09 p.m. - resident was cussing and yelling at staff stating he was mad at staff due to not having a ride to his dad's house . 2.) [DATE] at 6:29 a.m. - Went to give resident a.m. (morning) meds (medications) . When I woke him and told him I had his meds . he stated, 'I don't want the (expletive - GD) pills, why can't y'all just leave me the (expletive - F) alone' . 3.) [DATE] at 5:43 a.m. - Resident sitting up in wheelchair screaming with call light in hand. Calling staff inappropriately (sic) names and cursing at them, as well as yelling and mocking his roommate . (Physician) notified . c. Nurses Notes dated [DATE] at 11:08 p.m. and signed by Licensed Practical Nurse (LPN) #1 documented, At 2307 (11:07 p.m.) this writer was called into resident's room by CNA . stating resident was unresponsive . this writer assessed resident for responsiveness and pulse . resident's life vest was alarming to stay clear of resident . once cleared, this writer started chest compressions . continued until EMT (Emergency Medical Technicians) arrived . 2320 (11:20 p.m.) EMT arrived to facility, chest compression continued until EMT said stop, at which time they started giving their services and assessment . at 2334 (11:34 p.m.) EMT called time of death . 2344 (11:44 p.m.) . notified resident mother and father of resident's change of condition . These were the only Nurses Notes documented by LPN #1 regarding Resident #2's condition on [DATE]. d. The Office of Long Term Care (OLTC) Incident and Accident (I&A) Report, Division of Medical Services (DMS) form 7734 dated [DATE] documented the following: 1.) .Date and Time Submitted . [DATE] at 2PM (2:00 p.m.) .Date and Time of Discovery: [DATE] at 12:45 PM . Type of Incident: Neglect . 2.) .Summary of Incident . On [DATE] (Administrator #1) was notified by witness statements about (Resident #2), who passed away on [DATE] at approximately 11:34 PM. (Administrator #1) , (MDS Coordinator - Licensed Practical Nurse (LPN) #1 and (Staff Development Nurse - Registered Nurse (RN) #1) interviewed on the phone (CNAs #1, #2 and #3), who stated that they notified (LPN #1) about (Resident #2) being in pain, but they never saw (LPN #1) check on (Resident #2). (Administrator #1, MDS Coordinator, and Staff Development Nurse) interviewed (LPN #1) on the phone and (she) stated she checked on (Resident #2) when she was told by the CNA that his stomach was hurting at approximately 9:30 PM on [DATE]. (LPN #1) checked CBGs (Capillary Blood Glucose) and it showed high (high - indicating the blood glucose level was higher than the glucometer could accurately determine or display). (LPN #1) stated that she didn't give (Resident #2) anything for his stomach pain. Life vest (monitor) alerted staff at 11:07 PM . at that time staff intervened with CPR (cardiopulmonary resuscitation) initiated until EMS (Emergency Medical Services) arrived and took over CPR efforts. Phone calls were completed at [DATE] at 12:45 PM . b. An OLTC Witness Statement dated [DATE] and signed by CNA #1 documented, .I was here from ,[DATE] (7:00 a.m. to 3:00 p.m.), and (Resident #2) was yelling most of the day and wasn't feeling well. I was also here on the ,[DATE] (3:00 p.m. to 11:00 p.m.) shift. (Resident #2) was still yelling that he wasn't feeling well. I went in to assist him at about 9:45 pm and he ask(ed) to get his (blood) sugar checked, so I told him I would go tell (LPN #1). (LPN #1) . 'I already checked it'. So (Resident #2) was yelling again, and I went back in his room and asked if he needed something, and he said to get his sugar checked, so I went back to (LPN #1) and told her again. (Resident #2) was yelling again, so I went back to his room, and (CNA #3) was in his room when I went in, and (Resident #2) said his arms and stomach was (sic) hurting. I went to (LPN #1) about his arms and stomach hurting and her reply was, 'He is being a (expletive - slang for penis)' . (LPN #1) never checked his sugar that I know of . c. An OLTC Witness Statement dated [DATE] and signed by CNA #2 documented, .At 8:15 pm on [DATE], (Resident #2) was yelling for help . I went and checked on him. He told me he needed to throw up. I then assisted him to sitting position and held a bucket, so he could throw up. He did throw up and was complaining of his stomach hurting. I then went to my charge nurse (LPN #1), told her that he was throwing up and complaining of stomach pain. (LPN #1) told me that he is just yelling to be an (expletive - slang for buttocks) and that she would check on him when she gets there. To my knowledge I never seen (sic) her check on him after I reported to her about (Resident #2) . d. An OLTC Witness Statement dated [DATE] and signed by CNA #3 documented, .Resident #2) had been yelling ask(ing) for help when I came in to work at 3:00 p.m. Day shift reported he had started yelling when he woke up that morning and continued all day and thru the evening . Around 10:30 p.m., (Resident #2) started yelling out again, I asked what he needed. 'I'm hurting'. I asked him what is hurting? 'My arms and stomach are hurting'. I told him I would tell his Nurse (LPN #1) he was hurting. I went to tell his nurse (LPN #1) who was coming down the hall. When I told the nurse why (Resident #2) was yelling because his arms and stomach are hurting, (LPN #1) said 'No, (Resident #2) is yelling because he's a (expletive - slang for penis), but I will go check on him'. I told the ,[DATE] CNAs the nurse was going to check on him because he was yelling out he is hurting. I do not know if the Nurse went and checked on him because (CNA #2) and myself were helping other residents on our last round. Then we gave report to coming CNAs, then we left the building, my shift was over . e. An OLTC Witness Statement dated [DATE] and documented to have been conducted with LPN #1 via telephone by RN #1 documented, .She was asked to tell them what happened with (Resident #2) during her shift on [DATE] prior to him coding .(LPN #1) stated (Resident #2) was 'yelling all shift like he normally does, you know, help me, now (expletive)'. Asked her 'how often did you check on him'. She replied, 'Periodically'. Asked her 'do you recall checking his CBG?' She said 'yes, I checked his CBG, but I didn't have an order to check it. The CBG reading was Hi (high)'. I asked her if she notified the physician and she stated 'No' she did not notify the physician of the Hi CBG reading because she did not have an order to check his CBG. The notification policy was then explained to her. She then replied 'yes that's right but I did not have an order to check his CBG. I checked his CBG because I don't normally work that hall'. Then she said 'If you don't have an order to check a CBG you don't have an obligation to notify the physician of the reading'. It was then explained to her she did have an obligation as a nurse to notify the physician of the reading . She was asked why she felt the need to check his CBG. She said that the aides had reported to her that his stomach was hurting, and 'I took it upon myself to check his CBG to make sure it wasn't too low'. She was asked if the aides had reported to her that (Resident #2's) arms and stomach were hurting or that he had vomited. She stated the only report she got from the aides was that his stomach was hurting. She was then asked 'what did you do about his stomach hurting'. She said she asked him to lay down and settle down a little bit. She was then asked 'did you give him anything for pain'. She said, 'no, he had a stomach ache, that is not pain, he just said his stomach hurt. When I went to check his CBG, he was sitting up on the side of the bed. I asked him why he was yelling, and he said I don't know. I then asked him to settle down and lay down .She was asked if she had called him any names like (expletive A (buttocks)) or (expletive D (penis)) when the aides reported all this to her, she said 'no, I don't have to, that's what he acts like' . f. On [DATE] at 10:00 a.m., the Interim Administrator was asked about the facility's investigation of Resident #2's condition. She stated she called LPN #1, .on Monday ([DATE]) after reviewing the CNAs' witness statements, who all said they had repeatedly told her (LPN #1) about (Resident #2's) complaints of his stomach and arms hurting, along with vomiting. We then discovered the CBGs were not the sole issue here. It was her (LPN #1's) lack of assessment, notification of the MD (Medical Doctor) and interventions immediately prior to him coding . After speaking with (LPN #1), she was terminated because we could never get through to her what her issue was and why she shouldn't have blown him off with his complaints. Had she done a thorough assessment after being told what had been occurring most of the day, she might have picked up on his acute change in condition . g. On [DATE] at 10:20 a.m., the Director of Nursing (DON) stated she was on sick leave at the time of the resident's death and that the Interim Administrator took the lead on the investigation because the former Administrator left during that time. h. The facility removed the immediate jeopardy and corrected the failed practices on [DATE], as evidenced by the following: 1.) The Office of Long Term Care (OLTC) Incident and Accident (I&A) Report, Division of Medical Services (DMS) form 7734 dated [DATE] documented, .Steps Taken to Prevent Continued Abuse or Neglect During the Investigation . (LPN #1) was suspended pending the outcome of this investigation. (RN #2) was suspended for not reporting incident in a timely manner . In-services on reporting in a timely manner and abuse and neglect has (sic) also started . 2.) The Facility Investigation Report for Resident Abuse, Neglect, Misappropriation of Property and (&) Exploitation of Residents in Long Term Care Facilities, DMS form 762, dated [DATE] documented, .Section III - Findings and Actions Taken . (LPN #1) was suspended immediately and is no longer employed with the facility. (RN #2) was written-up for not reporting in a timely manner. (RN #2) was given a 1:1 (one-on-one) in-service on abuse/neglect and reporting in a timely manner and returned to work . In-services on reporting in a timely manner, abuse and neglect, abuse / neglect policy and procedure, CBG policy / what to do when glucometer is high, notifying physician of clinical issues, assessment of resident and documentation of assessment in-services were given to all staff . 3.) In-service Sign-In sheets dated [DATE] documented staff were retrained on abuse, neglect and misappropriation, immediate reporting (of abuse / neglect), assessing for changes in condition and reporting changes to the physician, and CBG testing and documentation guidelines. 4.) On [DATE] at 10:00 a.m., the Interim Administrator stated, We immediately began in-servicing all staff about assessment and identification of acute changes in resident's condition, notification and involvement of their MD and interventions. We also started monitoring of all residents' changes in condition at our daily meetings, with follow-up, and this included conversations and input from our Medical Director . 5.) A Q/A (Quality Assurance) Monitoring Tool provided by the DON and Administrator on [DATE] documented the facility, on [DATE], initiated an ongoing monitoring plan, to ensure nursing staff properly responded to changes in condition, including physician notification. The entries dated [DATE] through [DATE] documented the physician was consulted as appropriate and no further negative findings had been identified. 6.) Case Mix Residents #1, #2, #4 and #5's closed records were all reviewed by the surveyors during the survey conducted from [DATE] through [DATE]. All 4 residents expired in the facility in the last 3 months, according to a list provided by the MDS Coordinator on [DATE] at 9:30 a.m. No additional negative findings were identified in these records, to indicate further failed practices with abuse, neglect, assessments / response to changes in condition, or physician notification.

Complaint # (AR 063) was substantiated, all or in part, with these findings. Based on record review and interview, the facility failed to ensure necessary care and services were provided to address a change in condition, as evidenced by failure of a licensed nurse to respond to repeated reports from Certified Nursing Assistants (CNAs) that a resident was yelling, complaining of abdominal pain and experiencing nausea and vomiting; failure to assess the resident in an attempt to determine the cause of the resident's complaints; failure to make any attempt to relieve the resident's pain; and failure to immediately consult with the physician regarding the acute changes in condition for 1 (Resident #2) of 1 case mix resident who experienced an acute change in condition in the past 30 days. The failed practices resulted in past noncompliance at the level of immediate jeopardy for Resident #2, who experienced an acute change in condition which went unassessed and untreated, after which the resident expired. The failed practices also had the potential to cause more than minimal harm to 7 residents who experienced changes in condition in the past month, as documented on a Monitoring Tool form provided by the facility on [DATE] at 9:15 a.m. The Interim Administrator and Director of Nursing (DON) were informed of the past immediate jeopardy condition on [DATE] at 10:50 a.m. The findings are: Resident #2 had [DIAGNOSES REDACTED]. The Annual Minimum Data Set with an Assessment Reference Date of [DATE] documented the resident scored 13 (13 - 15 indicates cognitively intact) on a brief interview for mental status; had severely impaired vision; was able to understand others and make himself understood; had no physical, verbal or other behavioral symptoms; required limited assistance of 1 person for transfer; was on a scheduled pain management regimen; had not had pain in the 5 days preceding the assessment; received insulin injections on 7 of the past 7 days; and, received a diuretic on 7 of the past 7 days. a. The Medication Review Report (printed [DATE]) documented the resident had the following physician orders: 1.) [DATE] - CBG (capillary blood glucose) AC and HS (before meals and at bedtime) related to diab (diabetes) . Must wear life vest 23 hours a day every shift related to Heart Failure . 2.) [DATE] - Insulin . 100 units/ mL (milliliter) inject as per sliding scale . [MEDICATION NAME] tablet sublingual 0.4 mg give 1 tablet sublingually every 5 minutes as needed for chest pain . [MEDICATION NAME] 100 units/mL 9 units subcutaneously three times a day . Ticagrelor tablet 90 mg 1 tablet one time a day related to ST elevation [MEDICAL CONDITION] infarction ([MEDICAL CONDITION]) . b. Progress Notes dated [DATE] through [DATE] documented the following occasions when the resident exhibited yelling behaviors: 1.) [DATE] at 9:09 p.m. - resident was cussing and yelling at staff stating he was mad at staff due to not having a ride to his dad's house . 2.) [DATE] at 6:29 a.m. - Went to give resident a.m. (morning) meds (medications) . When I woke him and told him I had his meds . he stated, 'I don't want the (expletive - GD) pills, why can't y'all just leave me the (expletive - F) alone' . 3.) [DATE] at 5:43 a.m. - Resident sitting up in wheelchair screaming with call light in hand. Calling staff inappropriately (sic) names and cursing at them, as well as yelling and mocking his roommate . (Physician) notified . c. Nurses Notes dated [DATE] at 11:08 p.m. and signed by Licensed Practical Nurse (LPN) #1 documented, At 2307 (11:07 p.m.) this writer was called into resident's room by CNA . stating resident was unresponsive . this writer assessed resident for responsiveness and pulse . resident's life vest was alarming to stay clear of resident . once cleared, this writer started chest compressions . continued until EMT (Emergency Medical Technicians) arrived . 2320 (11:20 p.m.) EMT arrived to facility, chest compression continued until EMT said stop, at which time they started giving their services and assessment . at 2334 (11:34 p.m.) EMT called time of death . 2344 (11:44 p.m.) . notified resident mother and father of resident's change of condition . These were the only Nurses Notes documented by LPN #1 regarding Resident #2's condition on [DATE]. d. The Office of Long Term Care (OLTC) Incident and Accident (I&A) Report, Division of Medical Services (DMS) form 7734 dated [DATE] documented the following: 1.) .Date and Time Submitted . [DATE] at 2PM (2:00 p.m.) .Date and Time of Discovery: [DATE] at 12:45 PM . Type of Incident: Neglect . 2.) .Summary of Incident . On [DATE] (Administrator #1) was notified by witness statements about (Resident #2), who passed away on [DATE] at approximately 11:34 PM. (Administrator #1) , (MDS Coordinator - Licensed Practical Nurse (LPN) #1 and (Staff Development Nurse - Registered Nurse (RN) #1) interviewed on the phone (CNAs #1, #2 and #3), who stated that they notified (LPN #1) about (Resident #2) being in pain, but they never saw (LPN #1) check on (Resident #2). (Administrator #1, MDS Coordinator, and Staff Development Nurse) interviewed (LPN #1) on the phone and (she) stated she checked on (Resident #2) when she was told by the CNA that his stomach was hurting at approximately 9:30 PM on [DATE]. (LPN #1) checked CBGs (Capillary Blood Glucose) and it showed high (high - indicating the blood glucose level was higher than the glucometer could accurately determine or display). (LPN #1) stated that she didn't give (Resident #2) anything for his stomach pain. Life vest (monitor) alerted staff at 11:07 PM . at that time staff intervened with CPR (cardiopulmonary resuscitation) initiated until EMS (Emergency Medical Services) arrived and took over CPR efforts. Phone calls were completed at [DATE] at 12:45 PM . b. An OLTC Witness Statement dated [DATE] and signed by CNA #1 documented, .I was here from ,[DATE] (7:00 a.m. to 3:00 p.m.), and (Resident #2) was yelling most of the day and wasn't feeling well. I was also here on the ,[DATE] (3:00 p.m. to 11:00 p.m.) shift. (Resident #2) was still yelling that he wasn't feeling well. I went in to assist him at about 9:45 pm and he ask(ed) to get his (blood) sugar checked, so I told him I would go tell (LPN #1). (LPN #1) . was 'I already checked it'. So (Resident #2) was yelling again, and I went back in his room and asked if he needed something, and he said to get his sugar checked, so I went back to (LPN #1) and told her again. (Resident #2) was yelling again, so I went back to his room, and (CNA #3) was in his room when I went in, and (Resident #2) said his arms and stomach was (sic) hurting. I went to (LPN #1) about his arms and stomach hurting and her reply was, 'He is being a (expletive - slang for penis)' . (LPN #1) never checked his sugar that I know of . c. An OLTC Witness Statement dated [DATE] and signed by CNA #2 documented, .At 8:15 pm on [DATE], (Resident #2) was yelling for help . I went and checked on him. He told me he needed to throw up. I then assisted him to sitting position and held a bucket, so he could throw up. He did throw up and was complaining of his stomach hurting. I then went to my charge nurse (LPN #1), told her that he was throwing up and complaining of stomach pain. (LPN #1) told me that he is just yelling to be an (expletive - slang for buttocks) and that she would check on him when she gets there. To my knowledge I never seen (sic) her check on him after I reported to her about (Resident #2) . d. An OLTC Witness Statement dated [DATE] and signed by CNA #3 documented, .(Resident #2) had been yelling ask(ing) for help when I came in to work at 3:00 p.m. Day shift reported he had started yelling when he woke up that morning and continued all day and thru the evening . Around 10:30 p.m., (Resident #2) started yelling out again, I asked what he needed. 'I'm hurting'. I asked him what is hurting? 'My arms and stomach are hurting'. I told him I would tell his Nurse (LPN #1) he was hurting. I went to tell his nurse (LPN #1) who was coming down the hall. When I told the nurse why (Resident #2) was yelling because his arms and stomach are hurting, (LPN #1) said 'No, (Resident #2) is yelling because he's a (expletive - slang for penis), but I will go check on him'. I told the ,[DATE] CNAs the nurse was going to check on him because he was yelling out he is hurting. I do not know if the Nurse went and checked on him because (CNA #2) and myself were helping other residents on our last round. Then we gave report to coming CNAs, then we left the building, my shift was over . e. An OLTC Witness Statement dated [DATE] and documented to have been conducted with LPN #1 via telephone by RN #1 documented, .She was asked to tell them what happened with (Resident #2) during her shift on [DATE] prior to him coding .(LPN #1) stated (Resident #2) was 'yelling all shift like he normally does, you know, help me, now (expletive)'. Asked her 'how often did you check on him'. She replied, 'Periodically'. Asked her 'do you recall checking his CBG?' She said 'yes, I checked his CBG, but I didn't have an order to check it. The CBG reading was Hi (high)'. I asked her if she notified the physician and she stated 'No' she did not notify the physician of the Hi CBG reading because she did not have an order to check his CBG. The notification policy was then explained to her. She then replied 'yes that's right but I did not have an order to check his CBG. I checked his CBG because I don't normally work that hall'. Then she said 'If you don't have an order to check a CBG you don't have an obligation to notify the physician of the reading'. It was then explained to her she did have an obligation as a nurse to notify the physician of the reading . She was asked why she felt the need to check his CBG. She said that the aides had reported to her that his stomach was hurting, and 'I took it upon myself to check his CBG to make sure it wasn't too low'. She was asked if the aides had reported to her that (Resident #2's) arms and stomach were hurting or that he had vomited. She stated the only report she got from the aides was that his stomach was hurting. She was then asked 'what did you do about his stomach hurting'. She said she asked him to lay down and settle down a little bit. She was then asked 'did you give him anything for pain'. She said, 'no, he had a stomach ache, that is not pain, he just said his stomach hurt. When I went to check his CBG, he was sitting up on the side of the bed. I asked him why he was yelling, and he said I don't know. I then asked him to settle down and lay down .She was asked if she had called him any names like (expletive A (buttocks)) or (expletive D (penis)) when the aides reported all this to her, she said 'no, I don't have to, that's what he acts like' . f. On [DATE] at 10:00 a.m., the Interim Administrator was asked about the facility's investigation of Resident #2's condition. She stated she called LPN #1, .on Monday ([DATE]) after reviewing the CNAs' witness statements, who all said they had repeatedly told her (LPN #1) about (Resident #2's) complaints of his stomach and arms hurting, along with vomiting. We then discovered the CBGs were not the sole issue here. It was her (LPN #1's) lack of assessment, notification of the MD (Medical Doctor) and interventions immediately prior to him coding . After speaking with (LPN #1), she was terminated because we could never get through to her what her issue was and why she shouldn't have blown him off with his complaints. Had she done a thorough assessment after being told what had been occurring most of the day, she might have picked up on his acute change in condition . g. On [DATE] at 10:20 a.m., the Director of Nursing (DON) stated she was on sick leave at the time of the resident's death and that the Interim Administrator took the lead on the investigation because the former Administrator left during that time. h. The facility removed the immediate jeopardy and corrected the failed practices on [DATE], as evidenced by the following: 1.) The Office of Long Term Care (OLTC) Incident and Accident (I&A) Report, Division of Medical Services (DMS) form 7734 dated [DATE] documented, .Steps Taken to Prevent Continued Abuse or Neglect During the Investigation . (LPN #1) was suspended pending the outcome of this investigation. (RN #2) was suspended for not reporting incident in a timely manner . In-services on reporting in a timely manner and abuse and neglect has (sic) also started . 2.) The Facility Investigation Report for Resident Abuse, Neglect, Misappropriation of Property and (&) Exploitation of Residents in Long Term Care Facilities, DMS form 762, dated [DATE] documented, .Section III - Findings and Actions Taken . (LPN #1) was suspended immediately and is no longer employed with the facility. (RN #2) was written-up for not reporting in a timely manner. (RN #2) was given a 1:1 (one-on-one) in-service on abuse/neglect and reporting in a timely manner and returned to work . In-services on reporting in a timely manner, abuse and neglect, abuse / neglect policy and procedure, CBG policy / what to do when glucometer is high, notifying physician of clinical issues, assessment of resident and documentation of assessment in-services were given to all staff . 3.) In-service Sign-In sheets dated [DATE] documented staff were retrained on abuse, neglect and misappropriation, immediate reporting (of abuse / neglect), assessing for changes in condition and reporting changes to the physician, and CBG testing and documentation guidelines. 4.) On [DATE] at 10:00 a.m., the Interim Administrator stated, We immediately began in-servicing all staff about assessment and identification of acute changes in resident's condition, notification and involvement of their MD and interventions. We also started monitoring of all residents' changes in condition at our daily meetings, with follow-up, and this included conversations and input from our Medical Director . 5.) A Q/A (Quality Assurance) Monitoring Tool provided by the DON and Administrator on [DATE] documented ongoing monitoring was initiated to verify that nursing staff properly responded to changes in condition by consulting with the physician. The initial monitoring date on the form was [DATE] and the most recent monitoring date, as of [DATE], was [DATE]; and no further negative findings had been identified or documented as of the survey exit date of [DATE]. 6.) Case Mix Residents #1, #2, #4 and #5's closed records were all reviewed by the surveyors during the survey conducted from [DATE] through [DATE]. All 4 residents expired in the facility in the last 3 months, according to a list provided by the MDS Coordinator on [DATE] at 9:30 a.m. No additional negative findings were identified in these records, to indicate further failed practices with neglect, assessments / response to changes in condition, or physician notification.

Based on observation, record review and interview, the facility failed to ensure panic bar and wander-guard system alarms were maintained in proper working order, as evidenced by failure to ensure wander-guard bracelets were placed on the residents' ankle as per the manufacturer's instructions; failure to ensure the wander-guard system was tested for proper functioning at the frequency specified by the manufacturer; failure to ensure an identified problem with the wander-guard system was promptly rectified; and that adequate visual supervision was provided by staff to prevent a severely cognitively impaired resident from eloping from the facility undetected for 1 (Resident #17) of 5 (Residents #17, #20, #21, #22, and #23) case mix residents with a history of wandering/wander-guard placement. The failed practices resulted in immediate jeopardy, which caused or could have caused serious harm, injury or death to Resident #17, who eloped from the facility on 7/18/17 and was located by the occupant of a neighboring residence, and had the potential to cause more than minimal harm to 11 residents who had a history of [REDACTED]. 1. Resident #17 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/17/17 documented the resident scored 3 (0-7 indicates severe cognitive impairment) on a Brief Interview for Mental Status (BIMS); exhibited physical and verbal behavioral symptoms directed toward others and rejection of care on 1-3 of the past 7 days; exhibited wandering behaviors daily for the past 7 days; was independent with locomotion; and had unsteady balance but was able to stabilize without staff assistance when moving from seated to standing position, walking, turning around, moving on and off the toilet and with surface to surface transfers. a. A Nurse's Note dated 6/6/17 at 10:09 p.m. documented, Resident very confused this shift. Wandering most shift, exit seeking. b. A Nurse's Note dated 6/7/17 at 1:43 p.m. documented, Resident very confused, wandering all over facility and attempting to get outside several times this shift. Resident easily redirected . 9:47 p.m. Resident very confused, wandering all over facility and attempting to get outside several times this shift . c. A Nurse's Note dated 6/8/17 at 11:37 p.m. documented, Resident is exit-seeking. Resident has went (sic) to several doors and pushed on them and set off the alarm. Resident is going in and out of rooms pilfering through others belongings. Just administered prn (as needed) Xanax 1 mg (milligram) still awaiting to see if it's effective and redirection with ineffective results. Gave resident water and gave resident snack, resident is still wanting to go home, stating, 'I just want to go home, I don't want to stay here'. d. A Nurse's Note dated 6/10/17 at 11:00 p.m. documented, Resident still up exit seeking, pushing on doors, asking residents and staff, 'How do I get out of here?' Attempts to redirect unsuccessful. Resident refuses to wear wander-guard bracelet, resident removes bracelet. e. A Nurse's Note dated 6/11/17 at 12:34 a.m. documented, Resident up pacing, exit seeking, pushing on the doors to outside, going in other resident's rooms yelling and agitated, attempted to redirect resident, attempts are unsuccessful . 10:03 p.m. Staff reported client attempting to elope, client attempted to go out the door to the smoking area . f. A Nurse's Note dated 6/12/17 at 2:17 a.m. documented, Resident is actively exit seeking. Resident's wander guard in place at this time. Resident is up wandering the halls and have asked several staff members to let her out and let her go home. Offered snack and offered fluids. Resident noted to still be up wandering around the halls and pushing on several of the exit doors . 3:53 a.m. Resident noted to be up wandering halls most the night. Resident is following staff members and other residents stating 'Are you going home, will you take me home?' Asking other residents to let her outside. Resident noted to be packing up her belongings and dragging them around the facility looking for a way out. Resident has been in the day room in north hall and has pushed the elevator buttons several times and tried to get on the elevator. Attempted redirection several times with fluids, snacks, and explanation to resident and all were ineffective. Resident continues to wander . 5:00 a.m. Resident is still exit seeking. The resident has also been wandering in and out of rooms on west hall and noted to have some possessions of other residents in her hands like shoes and a blanket. Resident stated, 'I'm packing and I'm getting the hell out of here, now will you take me and let me go.' Resident is still attempting to talk other residents into letting her out. Resident is also pushing on the north-west exits and banging the doors with her fists stating, 'I don't understand how I can be locked in, I have never been locked in before, I have always been locked out.' Resident is extremely confused. Offered snack, fluids, and resident denies any pain at this time. Resident refuses fluids and snacks . 10:29 a.m. Resident noted to be going in and out of resident's rooms and causing residents to become upset. Resident has been exit seeking this morning. When redirected, resident becomes agitated and pulls away from staff. Resident has been noted to be standing at nurse's station this morning attempting to remove wander-guard. g. A Care Plan dated 6/13/17 documented, Behaviors: Resident exhibits/at risk for wandering . exit seeking. Wander-guard in place . h. A Social Services Note dated 6/14/17 documented, (Resident #17) speech is clear, she is confused, can use her call light, has her meals in the dayroom, has very good family support and visits, she wanders up and down the hall ways, trying to get out, she was moved to the secure unit yesterday . i. A Nurse's Note dated 7/18/17 at 6:45 p.m. documented, .This nurse was notified by (Nurse's name) that a resident was reported to be outside the facility at approximately 18:20 (6:20 p.m.). I last saw (Resident #17) at approximately 18:10 (6:10 p.m.) standing in the day room, I was nearby in hall with medication cart. Resident returned to the facility at 18:30 (6:30 p.m.) by car with Certified Nursing Assistant (CNA). No injuries noted. Son notified. Administrator notified. j. The Facility Investigation Report for Resident Abuse, Neglect, Misappropriation of Property, And Exploitation of Residents in Long-Term Care Facilities, Division of Medical Services (DMS) form 762 dated 7/18/17 documented, 7/18/17 (at) 1810 (6:10 p.m.) (Resident #17), seen in south hall day room, during meal time. (at) 1817 (6:17 p.m.) facility received phone call, elderly female found at a neighboring house sitting under a tree. Head count done at facility, resulting in 1 missing resident on south hall. The south hall Activity Director was sent to residence (at) 1830 (6:30 p.m.) the resident, (Resident #17) returned to the facility. Resident was alert, no visible s/s (signs/symptoms) of distress, v/s (vital signs) stable, skin pale, warm, intact. No injuries noted. (Local Law Enforcement) notified, officer presented to the facility. (Resident's son), Administrator, (Medical Doctor) and DON (Director of Nursing) notified. k. An Office of Long Term Care (OLTC) Witness Statement Form dated 7/18/17 at 6:35 p.m. and signed by CNA #7, documented, At 6:10 p.m. was the last time that I saw (Resident #17) she was in the hallway walking around like usual. I had just picked up trays and came back on the hall, walked to feeder room (room where dependent residents are assisted to eat) walked in 5 mins (minutes) later the nurse came asking if we was missing someone in pjs (pajamas). I went out the door started looking around 6:25 p.m., was told she was at duplex up the street. l. A Progress Note dated 7/20/17 at 6:38 p.m. documented, Care Plan Update: Resident remains 1:1 (one on one) at this time r/t (related to) elopement. Resident with wander guard intact, non-compliant with wander guard, able to remove at times. Staff reports the band of the guard stretches after time allowing the band to slip off resident's wrist, also reporting she begs them to cut it off . m. On 7/25/17 at 11:31 a.m., the Administrator was asked, How did (Resident #17) get out of the facility? She stated, She had to exit the front doors of the unit, she must have followed a family member out. The reason I say that is, I had another resident to wander out with that family member. The Administrator was asked, The same family member? She stated, Yes, I had an employee that assisted another resident back into the unit, and she did not see (Resident #17). The reason I say that was the way she got out, my Activity Director was out in the garden pulling weeds out of her garden . and I also had employees in the dining room. The Administrator was asked if this was on the secure unit and stated, Yes. The employees in the dining room did not see her leave either. She had to come straight up the hallway, out the therapy doors. Those doors have two alerts - one is a code alert, where if they wear those bracelets, an alarm sounds - the other is if you hold it (panic bar) down for 15 seconds, it will buzz and it breaks that barrier, and that alarm was not working when I checked the doors that night. The code alert was working at the time. She had to go out to the courtyard by the solarium - therapy was locked - and behind the kitchen. If she had come around the front area, she would have been in that area. The last time any of my staff saw her was at 6:10 (p.m.), and they brought her back at 6:30 (p.m.). That's when they got her back in the building. She was found at a lady's house, out in the yard, and the lady found her. She had some dirt on her, so the lady brushed it off and took her into the house and called us. The police and ambulance were both called. The Administrator was asked, By you or the lady? She stated, That lady. The Administrator was asked, Where was the house? She stated, It was the second house on the left-hand side of (Street Name). The Administrator was asked, Was there dirt on her, like she had fallen? She stated, I don't know. I know there is a hill back here, but she (occupant of neighboring home) did say she (resident) was sitting down in her (occupant's) yard when she (occupant) found her (resident), so that may have been where the dirt came from. I don't know. But she didn't have any scrapes, bumps or bruises. She did typically wear a code alert (wander-guard). We have an audit showing that she had it on that morning, but she did not have it on when we found her. The Administrator was asked, Could she take it off? She stated, I don't know. The staff seems to think she could. She must have had it off, because that code alarm did work on that door back there. The Administrator was asked, Did she have a history of wandering or trying to get out? She stated, Yes, she came to us from home. She did live by herself, and her son said she would leave the house and get to his. The Administrator was asked, Did she have a history of exit seeking at the facility? She stated, I don't know if she ever attempted to leave up here (prior to being moved to the secure unit), because we placed a wander-guard on her when she got here, but then she was aggravating everyone up here, going into other resident's rooms, so then we moved her back there (to the secure unit). She did remove the wander-guard a couple of times up here, and we had to replace them. The Administrator was asked, Where was her wander-guard? She stated, On her wrist. The Administrator was asked if the resident could remove the wander-guard bracelet from her wrist and stated, Yes. The Administrator was asked, When she had it on her wrist and you had to replace it, where did you put it? She stated, Back on her wrist. We found out if we put it on their ankles, it didn't alarm the doors all the time. The Administrator was asked, Have you had all the alarms checked? She stated, Yes, he (alarm technician) said a wire had come loose in the box and it didn't alarm the (panic) bar. The Administrator was asked, Have you had the wander-guard alarms checked? She stated, Yes, we had all the alarms checked. The Administrator was asked, What was (Resident #17) wearing when she eloped? She stated, She had on pink sweated pajamas, I believe, and had shoes on. The Administrator was asked, If you knew she could take the wander-guard off, did you put anything else in place to ensure she didn't get out? She stated, Other than just watching her. The Administrator was asked, How often do you check for wander-guard placement? She stated, Every day; except Saturday and Sunday, they are not checked. She (CNA #8) checks all the alarms too. The Administrator was asked, Why are they not checked on Saturday and Sunday? She stated, I don't have an answer for that one. The Administrator was asked, Does she (CNA #8) check to ensure they (wander-guard bracelets) are functioning? She stated, Yes, she actually walks the resident through the doors or takes the wheelchair through the doors. The Administrator was asked, Is there is not a wander-guard alert at the doors of the (secure) unit? She stated, No, you actually have to key (a code) in and out to go through them. The Administrator was asked, What have you done to ensure a resident doesn't follow family members out? She stated, We sent out letters to all family members to inform them that residents will wander out with them and to alert them to that. A letter dated July 19, 2017 and signed by the Administrator documented, ATTENTION ALL FAMILY AND FRIENDS, As you are aware we have a Secure Unit here at (Name of Facility). We ask that when you are visiting your family and friends to please make sure no one if following you out the door. If you have any questions please do not hesitate to call and speak with someone. n. On 7/25/17 at 12:09 p.m., the Administrator was asked to accompany and show the surveyor the path the resident was determined to have walked when she eloped from the facility on 7/18/17. The Surveyor and the Administrator walked from the secure unit, past the dining room doors to the exit door, which had a panic bar delayed-release system, a key pad release, and a wander-guard antenna in place; exited through a second unlocked door into a small fenced courtyard, then through the gate; walked behind the facility along a small path to a gravel driveway that ran behind the facility, to the paved area of the driveway, which sloped downward to a two-lane paved road. On the left of the paved road, there was a ditch approximately 3 to 3 1/2 feet deep and 10 feet long. The inner edge of the ditch had tall weeds and could not be safely traversed, and the outer edge of the ditch was immediately adjacent to the paved road, which caused the Surveyor and the Administrator to have to walk in the left lane of the paved, two-lane road for approximately 10 feet. Approximately 4 to 5 feet from the end of the ditch, there was a paved driveway, which sloped upward to a duplex, with a tree in the yard, where the resident was found sitting on the ground by the occupant of the duplex. The distance of the alleged path the resident had walked was measured to be one-tenth of a mile. According to www.timeanddate.com, the temperature in the neighboring city of Van Buren, Arkansas, on 7/18/17 at 6:00 p.m. when the resident eloped, was 91 degrees Fahrenheit. o. On 7/25/17 at 2:35 p.m., Licensed Practical Nurse (LPN) #1 was asked, When do the wander-guards get checked? The LPN stated, The nurses check them and make sure they are on; the RNA checks that they are functioning. The LPN was asked, How does she check them? She stated, She doesn't take the residents to the door; she has her own monitor she takes to the door and makes sure the alarm goes off. They are on our Treatment Administration Record (TAR) and we check to make sure they are on. The LPN was asked, You just check to make sure they are on? She stated, Yes, every shift and the aides, if they notice they are gone, they will tell us, and we put another one on. The LPN was asked, Had you seen (Resident #17) take her wander-guard off? She stated, No, but other people had seen her pulling on it, trying to get it off. p. On 7/25/17 at 3:00 p.m., the Director of Nursing (DON) was asked, How do you monitor your nurses to ensure they are checking for functioning of the wander-guards? She stated, I don't; every now and then, I will see someone do it. The CNAs and nurses have told me that with just the weight of the sensor, the bands will stretch, and they (residents) can get them off their wrists. I've told Corporate about it, and they are supposed to be checking on different bands. We have had no luck with the alarms going off when the wander-guards are on the wheelchairs or their (residents') legs, so we put them on their wrists. q. On 7/28/17 at 11:59 a.m., CNA #8 was asked, Are you in charge of checking the wander-guards? She stated, Every morning. The CNA was asked, How do you check them? She stated, I have a spare wander-guard. I go around and check all the doors in the morning and make sure they are working properly. The CNA was asked, How do you know the alarms on the doors are working properly? She stated, It goes off overhead, and some of them whistle, to let you know they (doors) have been opened; all of them should go off overhead to let you know they have been opened. Some of them, you can open if you hold them (panic bars) down for 15 seconds, not all of them. The CNA was asked, Do you check the wander-guard by just holding it in your hand near the doors? She stated, Yes. The CNA was asked, Is there any kind of monitor that you use to ensure the wander-guard (bracelet) on the resident is functioning? She stated, I just check the date on the bracelet to make sure the expiration date is still good. The CNA was asked, Do you have anything to check to ensure the bracelet has not malfunctioned and will still alert? She stated, No, I need a little wand or something to do that. The CNA was asked, Do you know, if a resident has it on anywhere other than on their wrist, if it would alert? She stated, When we had it on the ankle, it would not alarm; they would have to move their leg up for it to alarm. That's the reason we had to put them on their wrists. The CNA was asked, How long have you been checking the wander-guards? She stated, At least 5 years. The CNA was asked, Have they ever been able to alert on the ankle? She stated, No. The CNA was asked, When do you check the wander-guards and alarms? She stated, Every day but weekends. The CNA was asked, Who checks them on the weekends? She stated, We didn't have anyone doing it on weekends. I think (Administrator) said something about getting someone to check them on weekends. The CNA was asked, When did she say that? She stated, This week, Monday (7/24/17) or Tuesday (7/25/17), because I asked if she wanted me to start doing them on the weekends, and she said the RN (Registered Nurse) Supervisor can do them. But, I am going to start working every other weekend, and I will do them. r. The (Wander-Guard) Products User Guide, provided by the Administrator on 7/26/17 at 9:05 a.m., documented, .Operations and Maintenance Note: The Wander-Guard System is not a substitute for careful identification and monitoring by professional staff. (Wander-guard) software, parts and products have been designed to augment a facility's reasonable procedures for protecting residents and patients, however no system or combination of procedures and equipment can eliminate all risk or assure complete security. (Wander-guard) system is not intended as a substitute for careful identification and monitoring of residents and patients by a facility's professional staff . Transmitter Application and Replacement . The ankle transmitter should be properly fitted to the residents' ankle . Wheelchair Restrictions . If the resident is confined to a wheelchair, but still able to get up and walk, the transmitter must be worn on the ankle of a leg that is not elevated. All transmitters must be worn on the ankle. If both legs are elevated, and the resident is not capable of getting up and walking, then the transmitter may be put in the upright position on the rod/leg above the wheel of the wheelchair . Daily Transmitter Testing . Each day, the aide responsible for the care of the residents utilizing the (Wander-guard) must ensure that the ankle transmitter is in place. This must be done at each shift change. Documentation of this check should be made by the nurse's aide. This should be recorded on the aide's daily checklist for the particular resident. Each transmitter should be checked for expiration date at this time. The #707 Tester is available to purchase for fast, easy checking of all transmitters. A documented test of each transmitter at the facility must be made each day . The procedure involves using the #707 Transmitter Tester and/or the Exit Panel on the wall by the exit, and documenting the performance of the transmitter . s. The facility's policy and procedure titled, Wandering, Unsafe Resident, provided by the DON on 7/27/17 at 3:08 p.m., documented, .The facility will strive to prevent unsafe wandering while maintaining the least restrictive environment for residents who are at risk for elopement . Staff will institute a detailed monitoring plan, as indicated for residents who are assessed to have a high risk of elopement or other unsafe behavior. 7. Staff will notify the Administrator and Director of Nursing immediately, and will institute appropriate measures (including searching) for any resident who is discovered missing from the unit or facility. 8. All incidents will be reported to the appropriate corporate officials. t. The immediate jeopardy was removed, and the scope/severity reduced to E, on 7/26/17 at 11:39 a.m. when the facility implemented the following Plan of Removal: (Resident #17) is currently in Geri-Psych (geriatric-psychiatric facility) and will not return to the building. Identification: Seven residents currently have Wander Guard bracelets in place for exit seeking behavior. Assessment: On 7/25/17 all residents that have Wander Guard as an intervention were assessed for appropriate application of Wander Guard device and ensuring the device is operating appropriately. In-service: All staff in the building was educated on the following in-service which was initiated on 7/25/17 for staff on all shifts, and any staff not working at this time will be in-serviced before they are allowed to work. No staff will be allowed to work until they have been educated on how to proceed if the following indications occur: Residents are assessed on admission for wandering / elopement risk, if deemed at risk, a wander guard is placed on them for safety. If a resident removes his / her wander guard the staff should: The resident is to be placed 1:1 (one on one) immediately. Notify the Administrator, DON and Medical Director, immediately. The resident is to be reassess immediately and individualized interventions care planned. Staff is to be in serviced on new elopement risk care plan intervention. Once individualized interventions are implemented 1:1 may be discontinued. Residents noted attempting to remove wander guards or improperly fitting wander guards the staff should: Notify charge nurse, Administrator and DON immediately. Wander guard band to be replaced if indicated immediately. Resident to be placed 1:1 immediately if indicated. The resident is to be reassess immediately and individualized interventions care planned if indicated. Staff is to be in serviced on new elopement risk care plan intervention. Once individualized interventions are implemented 1:1 may be discontinued. Technician who works on this particular device was notified and arrived to inspect the Wander Guard (system) on the evening of 7/25/17 at approximately 7:00 p.m. for proper operation and functioning of the system to meet specifications. The technician checked each door and found them to be functioning. The technician will adjust the trajectory of the antennae to provide better reception of the signal from the Wander Guard transmitter. Monitoring of doors by staff has been initiated as another level of deterrence for exit seeking. Monitoring of doors will continue until Wander Guard System is operating at optimum level. Monitoring: Daily monitoring of Wander Guard placement each shift and documented on the Treatment Record will be done by the Charge Nurse on each hall. Monitoring will continue until substantial compliance is obtained and reviewed by QA/A (Quality Assessment and Assurance) Committee has reviewed. Daily testing (including weekends and holidays) of the Wander Guard bracelets to ensure proper function of the alarm and that the doors sound a verbal alarm of potential exit, will be done by DON or RN (Registered Nurse) designee. Any evidence of improper function will require immediate notification of Maintenance Department Manager and the Administrator for appropriate measures to rectify and maintain proper function of the system. Documentation of ongoing monitoring will be done by nursing on the resident TAR and other monitoring of daily testing will be done on monitoring form. B. Based on observation, record review and interview, the facility failed to ensure the treatment cart was locked when unattended on 1 (North Hall) of 4 halls, to prevent cognitively impaired, independently mobile residents from potentially accessing hazardous items. This failed practice had the potential to affect 4 cognitively impaired, independently mobile residents who resided on the North Hall, as documented on a list provided by the Director of Nursing (DON) on 7/28/17 at 9:03 a.m. The findings are: 1. On 7/26/17 at 8:51 a.m., the treatment cart was located on the North Hall, unlocked and unattended. a. At 8:55 a.m., Registered Nurse (RN) #1 exited a resident's room and went to the unlocked treatment cart. The RN was asked if she could see the cart while she was in the resident's room and stated, No. The RN was asked, Should the cart be left unlocked and unattended? She stated, No. b. According to a list received from the DON on 7/26/17 at 9:41 a.m., the contents of the medication cart and the related warnings / precautions were as follows: Econazole Nitrate Cream 1% (percent): Warnings: .For external use only. Avoid induction of Econazole Nitrate Cream, 1% into the eyes. Nystop (Nystatin Topical Powder): The Material Safety Data Sheet (MSDS) for this product documented, .Potential Acute Health Effects: Hazardous in case of eye contact (irritant), of ingestion, of inhalation. Slightly hazardous in case of skin contact (irritant, permeator) . Section 11: Toxicological Information: Other Toxic Effects on Humans: Hazardous in case of ingestion, of inhalation. Slightly hazardous in case of skin contact (irritant, permeator). Dyna Lube: The label documented, Warning: Keep out of eyes and ears . Ketoconazole 2%: The MSDS documented, .Potential Acute Health Effects: Slightly hazardous in case of skin contact (irritant), of eye contact (irritant). Severe over-exposure can result in death . Hemorrhoidal Ointment. The MSDS documented, .First-Aid Measures: Eye: Eye irritation. Flush immediately with large amount of water. Eyelids should be held away from the eye ball to ensure through rinsing. Get immediate medical attention. Skin: Itching or burning of skin. Immediately flush with plenty of soap and water. Get immediate medical attention . Ingestion: Get immediate medical attention and contact poison control agency . Muscle Rub Cream: The MSDS documented, .Health Hazards . Ingestion: May be harmful if swallowed . Vitamin A & (and) D Ointment: The tube label documented, Warnings: For external use only, when using this product do not get into eyes . If swallowed, get medical help or contact a Poison Control Center right away . Formula 3 Antifungal. The label documented, .If swallowed, get medical help or contact a Poison Control Center right away . Sting Free Liquid Skin Prep & Protectant. The label documented, Warnings: Avoid contact with eyes . DermaPrep Liquid Barrier Skin Prep: The label documented, Warnings . Avoid contact with eyes . Super Sani-Cloth Germicidal Disposable Wipes: The MSDS documented, .Emergency overview . Causes irreversible eye damage. Harmful if absorbed through skin. Do not get in eyes, on skin or on clothing . General advice: Avoid contact with eyes and skin . Hydrophor Ointment: The label documented, Warnings: For External Use only . DermaSarra Anti-Itch Lotion. The label documented, Warnings for external use only . In case of accidental ingestion contact a physician or Poison Control Center right away. DermaPhor Skin Protectant Moisturizing Ointment. The label documented, Warnings for external use only . In case of accidental ingestion contact a physician or Poison Control Center right away. PrimaGuard Moisturizing Cream. The label documented, Warnings for external use only . If swallowed, get medical help or contact a Poison Control Center right away. PrimaGuard Calma FX Moisture Barrier Ointment. The label documented, Warnings external use only . If swallowed, get medical help or contact a Poison Control Center right away . CalaGuard micro zinc oxide for compromised skin. The label documented, .If swallowed, get medical help or contact a Poison Control Center right away. SoothGuard: The label documented, Warnings for external use only . If swallowed, get medical help or contact a Poison Control Center right away. Purell Advanced Refreshing Gel. The label documented, Warnings . for external use only . If swallowed, get medical help or contact a Poison Control Center right away.

Complaint # (AR 496) was substantiated (all or in part) with these findings: Based on record review and interview, the facility failed to ensure 2 (Residents #1 and #6) of 6 (Residents #1-6) male case mix residents were free from staff-to-resident sexual abuse. The facility failed to ensure staff immediately reported an allegation of staff-to-resident sexual abuse for Resident #6, which resulted in a delay in initiating an investigation and protective measures to prevent a subsequent incident of sexual abuse against Resident #1. The failed practices resulted in immediate jeopardy, which caused or could have caused serious harm, injury, or death to Residents #1 and #6, and had a potential to cause more than minimal harm to 50 residents who were male, as documented on a list provided by the Director of Nursing (DON) on 9/29/16. 1The facility was informed of the immediate jeopardy condition on 9/28/16 at 2:50 p.m. The findings are: 1. Resident #1 had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/7/16 documented the resident scored12 (8-12 indicates moderately impaired) on a Brief Interview for Mental Status (BIMS), had no behaviors, and required extensive assistance with most activities of daily living. a. A typed letter dated 9/14/16, addressed to the Administrator and signed by Resident #1's son, documented, On 09/13/2016, I received a phone message from my father that it was very important that I return his phone call. Upon returning his call he asked me to come by and see him. When I got there he painstakingly told me that he was a victim of sexual abuse as a resident of your facility. The worker named (Certified Nursing Assistant (CNA) #1) who wants everyone to call him 'ornery', came into my father's room on the 8th between 3 p.m. and 11 p.m. two separate times. The first time he sat on the bed, started rubbing his stomach, and was called away then later he returned, sat on the bed, started rubbing my father's stomach, and started going lower and lower until my father kicked at him. (CNA #1) was very surprised by the kick, stopped and left the room. (CNA #1) instructed my parents he was putting in his notice to transfer to Fort Smith but when they asked him later if he put in his notice he said no he had not done that. On the 12th (CNA #1) came again into his room and sat on his bed, proceeded to rub my father's stomach and to go lower and lower. My father kneed at him and he stopped. My father told me that the 12th was (CNA #1's) day off so why was he there? My wife has contacted Arkansas Adult Protective Services and filed a complaint making them aware of what has happened to my father while in your care. I am disappointed because going into a nursing home is mentally hard enough let alone having to deal with sexual abuse from the employees. Employees are there to take care of residents and put the family's minds at ease. I have no tolerance for this type of behavior and I want it stopped immediately. To resolve the problem, I would like you to take action against the employee (CNA #1) and make it where he can no longer do this to another person . A handwritten witness statement dated 9/14/16 and signed by CNA #1 documented, I am a courteous employee that works at (facility), known by all employees and residents as kind and caring. To my knowledge, stand by my testimony, of outrageous accusations of any charge against me of my work record. For 2 years, I have been employed here with no previous charges or write ups during my work period. I stand in complete disagreement with any embellishment against my person, and if so needed, can and will provide many sources to clear myself. b. An Office of Long Term Care (OLTC) Division of Medical Services ((DMS) -762) form dated 9/15/16 documented, Administrator received a call from the Office of Long Term Care stating they had a complaint called in. The complaint was that employee (CNA #1) had been accused of sexually abusing resident (Resident #1). The report was that he had inappropriately touched (Resident #1). (Resident #1) medical condition is stable. Employee (CNA #1) was removed from the working schedule and asked not to come into the facility until this investigation was complete. Police was notified. (Resident #1) was interviewed by the Director of Nursing. (Resident #1) stated that he was touched inappropriately . (Resident #1) told her that this male sat on his bed, rubbed his stomach gradually getting lower . It happened again Monday. The male was off but was at the facility . Administrator then received a letter on 9/15/16 from the son by email from the daughter-in-law. He had received a call from his dad on 9/13/16. He came to the facility and his dad told him that the worker named (CNA #1) on the 8th between 3:00 p.m. and 11:00 p.m. on two separate times came into his room and inappropriately touched him. The Director of Nursing and the Administrator have interviewed all interviewable residents as to if any employee has been inappropriate with them. All stated no. All staff that has worked with employee (CNA #1) were interviewed with all reporting not ever seeing employee (CNA #1) being inappropriate with any resident. (CNA #1) was not working on the 8th of September. He was off on the 12th, was at the facility as he has been several times on his days off. Spoke with (Resident #1's) roommate, he stated he did not ever see or hear any employee being inappropriate with (Resident #1). He did overhear (Resident #1) telling his son something about this. The facility is unable to make a finding so employee (CNA #1) will not be allowed to return to work until the Office of Long Term Care has a finding. A witness statement (written by DON) dated 9/15/16 and signed by Resident #1 documented, Touched inappropriately. He has a beard, two teeth missing. He was here this morning, brought me a cup of coffee. He was off Monday but still came into my room. He sits down on bed, rubs slowly on stomach in circular motion, moving down to where he's rubbing over my penis over my clothes. Three times since I've been here. I don't want him fired. I just don't want him taking care of me. Didn't report it to anyone but my wife. c. A Police Offense/Incident Report dated 9/15/16 documented, Type of Incident: Sexual Assault 4th Degree . stated that allegations were made that a resident, (Resident #1), had been sexually abused by a male from the nursing staff . I advised (Administrator) that this report would be filed. d. On 9/27/16 at 4:45 p.m., Resident #1 was asked to explain the incident involving (CNA #1) and stated, He approached me three different times. He talked to me like a man would talk to a woman, trying to con them into doing something. That made me very uneasy. He sat down on my bed and started rubbing my stomach in a circular motion, but he got called away to do something. He came back again later. This last time he sat on my bed after he had pulled the curtain and started rubbing my stomach, then kept going lower and was rubbing on top of my penis. On top of my clothes. I jerked my leg up and kicked at him. That made him stop and he seemed surprised that I could do that. It was embarrassing, but I called my wife and told her about it. I didn't tell anybody else because (CNA #1) had told us he was putting in his notice because he was moving, so I figured since he'd be gone, I wouldn't have to worry about it. But then I found out he had not put in his notice. He did ask me how I felt about two women giving me a shower. I told him I didn't think anything about it because they had a job to do and I'm the patient; they have to do it. Resident #1 was asked when had all of this happened and stated, The first time was on the 8th of this month. He (CNA #1) was off work, but came up here just to do this to me. The last time was on the 12th of this month. e. On 9/28/16 at 11:08 a.m., during a telephone interview, CNA #1 was asked to explain the incident involving Resident #1 and stated, I have been suspended because a resident stated I touched him in a sexually inappropriate manner. I am hurt by this. I would never do that. CNA #1 was asked why that resident would allege such a thing and stated, I don't know, to be honest with you. He told me about a week or two after he got here that he don't like gays. I didn't tell him I was gay but he might have found out. I'm sorry, but I've got standards. They have to be less than [AGE] years old, still be able to get it hard, and be at least 7 or 8 inches. Now, I may be gay, but I've got standards. I've given that resident showers and I only do the back; he does the front. The CNA was asked if any residents have complained about him before and stated, There are no residents that have complained about me that I know of. This has never happened to me before. The CNA was asked if he had a habit of coming to the facility on his off days and stated, Yes I do. I try to put a smile on the residents' faces because some of them have no one. That's why I wear crazy scrubs and stuff. There's another resident who sometimes runs out of cigarettes, so I like to make sure he doesn't run out. The CNA was asked if he had ever sat on Resident #1's bed and stated, One day I did sit on the bed to talk to him about his wife being sick. He was asked if he pulled the privacy curtain and stated, I did not pull the privacy curtain because (Resident #2) is always in there and likes to watch (Resident #1's) TV. CNA #1 was asked if he had ever done incontinent care on Resident #1 and stated, I have never done incontinent care on him. I do empty his urinal occasionally. If they're able to take care of themselves in that area, I don't go down there. f. On 9/29/16 at 9:44 a.m., the DON was asked to explain how she became aware of the allegation regarding Resident #1 and stated, I was called into the Administrator's office and she told me she received a call from the Office of Long Term Care (OLTC) concerning (Resident #1) and (CNA #1). She asked me to go and interview (Resident #1) so I did. I asked him if anyone had been inappropriate with him. He did not mention any names, but he described the CNA as having a beard and a few other things that told me it was (CNA #1). He also said he was here that Monday night, even though he was off work. He said he sat down on the side of the bed and started rubbing his stomach in a circular motion and worked his way down to where he was rubbing on top of his penis. I hated to ask him this, but I asked him if he did it on top of his clothes or underneath. He said it was on top of his clothes. I asked him if this had happened before and he said that was the third time. He told me he had not reported it to anyone at the facility, but had told his wife. I wrote it all down and took it to the Administrator. We called his wife. She had planned on coming up here and talking to us about it, but she had been sick. She talked to her son and he then talked to his wife, who is a mandated reporter so she called OLTC. When we asked (Resident #1) and his wife why they didn't report this to us, they said (CNA #1) told them he was turning in his notice because he had recently bought a house and was moving so they didn't feel a need to report it at that time. But they found out later he had not turned in his notice. The DON was asked if she felt (Resident #1) was being truthful regarding the allegation and stated, Yes. for me, there was so much emotion in his statement. He wasn't just trying to get someone in trouble. It had bothered him. It embarrassed him. He just didn't want it to happen again. 2. Resident #6 had [DIAGNOSES REDACTED]. The Quarterly MDS with an ARD of 8/23/16 documented the resident scored 15 (13-15 indicates cognitively intact) on a BIMS, had no behaviors, and was independent with most activities of daily living. a. On 9/28/16 at 2:08 p.m., CNA #2 was asked if she knew CNA #1 and stated, I have never worked with him, but I know who you're talking about. He's okay, but he's odd. He is bossy. CNA #2 was asked if any resident had told her that CNA #1 had done or said anything inappropriate to them and stated, There is one resident that said (CNA #1) asked him if he could touch him. CNA #2 was asked what she meant by that and stated, A resident told me that (CNA #1) asked him if he could touch him. The CNA was asked which resident and stated, Can I tell you that? The CNA was informed she could and stated, (Resident #6). The CNA was asked if the resident was referring to touching in a sexual manner and stated, Yes. The CNA then stated, I already know I'll be fired, because I didn't report that. You're supposed to report that immediately. I don't know why I didn't. I haven't had a chance to talk to anyone. And maybe, because I didn't know if it was true. The CNA was asked how long ago this happened and stated, I don't know. It's been a while, and he said he only did it once. I even thought about going to (CNA #1) and asking him about it. b. On 9/28/16 at 2:25 p.m., Resident #6 was asked if he knew CNA #1 and stated, Yeah I know him. The resident was asked if CNA #1 had ever done anything to him he felt was inappropriate. At that time, the resident looked away from the surveyor and did not answer the question. The resident was told it was okay to talk, because he was not the only person the surveyor had spoken with today about CNA #1. Resident #6 then looked at the surveyor and stated, He asked me if I knew he was gay. I told him no, then he said can I touch you. I told him no. The resident was asked if CNA #1 ever touched him in a sexual manner and stated, No. I wasn't about to let him. I'm so glad he doesn't work here anymore, but you know I heard he's starting to work at another place today. What about those poor people? Resident #6 was asked if (CNA #1) ever did anything else to him and stated, You know, I carry my hair dryer with me . I used to put on a gown after my shower and he would take my hairdryer, put it up underneath my gown and say 'we've got to make sure and get precious dry.' That's not right to say stuff like that. It's inappropriate. He was strange. I asked a while back that he not take care of me anymore, because I found a pill on the floor and put it up on the counter. He yelled at me for that! The resident was asked how long ago (CNA #1) asked if he could touch him and stated, Oh I don't know. It's been a while. The resident was asked how long ago the hairdryer incident occurred and stated, That too. I'm not sure. The resident was asked if he had reported this to anyone in the facility and stated, Yes. I've told some folks. c. A written witness statement dated 9/28/16 and signed by CNA #2 after being interviewed by the Surveyor documented , .He (Resident #6) didn't want his shower. (CNA #1) said he needed it. (Resident #6) said (CNA #1) wanted him to touch him or vice versa. Asked (CNA #1) about it and he said he reported what I asked him about. Nothing else was talked about. d. On 9/29/16 at 9:44 a.m., the DON was asked if the facility interviewed Resident #6 and CNA #2 as part of their investigation after they became aware of the allegation involving Resident #1 and stated, No, we didn't. 3. The immediate jeopardy was removed and the scope and severity lowered to H on 9/28/16 at 3:00 p.m. when the facility implemented the following Plan of Removal: 1.) Starting immediately at 3:00 p.m. on 9/28/16: The aide in question (CNA #1) was suspended on 9/15/16. He has not returned to the facility since 9/15/16. He was formally terminated on 9/28/16. 2.) The aide who did not report the initial allegation, (CNA #2) was immediately suspended at 3:00 p.m. on 9/28/16. She was also terminated on 9/28/16. 3.) All non-interviewable male residents on the West Hall will have a body audit documented by 7:00 a.m. on 9/29/16. 4.) All interviewable male residents in (CNA #1) assignment range in the 6 weeks prior to 9/15/16 will be interviewed regarding abuse/neglect. 5.) The DON or designee will provide 1:1 in-service with all staff regarding the facility's abuse/neglect policy immediately. Each employee will be asked if there is anything they need to or have failed to report at this time. 6.) Each staff member will be given a copy of the abuse/neglect policy. 7.) Staff will also be in-serviced on the appropriate action to take if (CNA #1) is seen on the facility grounds at any time, which is to ask him to leave, and for the employee to call Administrator and police immediately. 8.) No staff will be allowed to work the floor until they are in-serviced on abuse/neglect policy, and protocol related to (CNA #1) 9.) All staff will complete a post-test on the abuse/neglect policy within 24 hours of being in-serviced. If they are in-serviced over the phone, the post-test will be taken over the phone with the DON/designee. 10.) Any staff who is unable (PRN or weekend or out of town) will not be allowed to return to work until they are in-serviced either in person or over the phone, and complete the post-test. 11.) These interventions will be completed by 7:30 a.m. on 9/29/16. 12.) A current list of all employees completing the above in-services and post-test will be maintained and updated every shift for the first 24 hours. 13.) Any employee off, on leave or vacation will be in-serviced on the abuse and neglect policy and the post-test will be taken within 24 hours of being in-serviced. 14.) A post-test on abuse and neglect will be completed every week times four weeks. 15.) The employee/in-service/testing list will be reviewed in the morning meeting on 9/29/16 and then taken to QA (Quality Assurance) for immediate follow up. QA will be done daily for 30 days or until all staff is documented as being in-serviced and post-tested . 16.) At 30 days, the QA committee will review all weekly post-tests, until all staff has completed these post-tests weekly x 4.

Complaint # (AR 496) was substantiated (all or in part) with these findings: Based on record review and interview, the facility failed to ensure staff immediately reported an allegation of staff-to-resident sexual abuse to the Administrator for 1 (Resident #6), which resulted in a delay in initiating an investigation and protective measures to prevent a subsequent incident of sexual abuse against 1 (Resident #1) of 6 (Residents #1-6) case mix residents who were male. The failed practices resulted in immediate jeopardy, which caused or could have caused serious harm, injury, or death to Residents #1 and #6, and had a potential to cause more than minimal harm to 50 residents who were male, as documented on a list provided by the Director of Nursing (DON) on 9/29/16. The facility was informed of the immediate jeopardy condition on 9/28/16 at 2:50 p.m. The findings are: 1. Resident #1 had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/7/16 documented the resident scored12 (8-12 indicates moderately impaired) on a Brief Interview for Mental Status (BIMS), had no behaviors, and required extensive assistance with most activities of daily living. a. A typed letter dated 9/14/16, addressed to the Administrator and signed by Resident #1's son, documented, On 09/13/2016, I received a phone message from my father that it was very important that I return his phone call. Upon returning his call he asked me to come by and see him. When I got there he painstakingly told me that he was a victim of sexual abuse as a resident of your facility. The worker named (Certified Nursing Assistant (CNA) #1) who wants everyone to call him 'ornery', came into my father's room on the 8th between 3 p.m. and 11 p.m. two separate times. The first time he sat on the bed, started rubbing his stomach, and was called away then later he returned, sat on the bed, started rubbing my father's stomach, and started going lower and lower until my father kicked at him. (CNA #1) was very surprised by the kick, stopped and left the room. (CNA #1) instructed my parents he was putting in his notice to transfer to Fort Smith but when they asked him later if he put in his notice he said no he had not done that. On the 12th (CNA #1) came again into his room and sat on his bed, proceeded to rub my father's stomach and to go lower and lower. My father kneed at him and he stopped. My father told me that the 12th was (CNA #1's) day off so why was he there? My wife has contacted Arkansas Adult Protective Services and filed a complaint making them aware of what has happened to my father while in your care. I am disappointed because going into a nursing home is mentally hard enough let alone having to deal with sexual abuse from the employees. Employees are there to take care of residents and put the family's minds at ease. I have no tolerance for this type of behavior and I want it stopped immediately. To resolve the problem, I would like you to take action against the employee (CNA #1) and make it where he can no longer do this to another person . A handwritten witness statement dated 9/14/16 and signed by CNA #1 documented, I am a courteous employee that works at (facility), known by all employees and residents as kind and caring. To my knowledge, stand by my testimony, of outrageous accusations of any charge against me of my work record. For 2 years, I have been employed here with no previous charges or write ups during my work period. I stand in complete disagreement with any embellishment against my person, and if so needed, can and will provide many sources to clear myself. b. An Office of Long Term Care (OLTC) Division of Medical Services ((DMS) -762) form dated 9/15/16 documented, Administrator received a call from the Office of Long Term Care stating they had a complaint called in. The complaint was that employee (CNA #1) had been accused of sexually abusing resident (Resident #1). The report was that he had inappropriately touched (Resident #1). (Resident #1) medical condition is stable. Employee (CNA #1) was removed from the working schedule and asked not to come into the facility until this investigation was complete. Police was notified. (Resident #1) was interviewed by the Director of Nursing. (Resident #1) stated that he was touched inappropriately . (Resident #1) told her that this male sat on his bed, rubbed his stomach gradually getting lower . It happened again Monday. The male was off but was at the facility . Administrator then received a letter on 9/15/16 from the son by email from the daughter-in-law. He had received a call from his dad on 9/13/16. He came to the facility and his dad told him that the worker named (CNA #1) on the 8th between 3:00 p.m. and 11:00 p.m. on two separate times came into his room and inappropriately touched him. The Director of Nursing and the Administrator have interviewed all interviewable residents as to if any employee has been inappropriate with them. All stated no. All staff that has worked with employee (CNA #1) were interviewed with all reporting not ever seeing employee (CNA #1) being inappropriate with any resident. (CNA #1) was not working on the 8th of September. He was off on the 12th, was at the facility as he has been several times on his days off. Spoke with (Resident #1's) roommate, he stated he did not ever see or hear any employee being inappropriate with (Resident #1). He did overhear (Resident #1) telling his son something about this. The facility is unable to make a finding so employee (CNA #1) will not be allowed to return to work until the Office of Long Term Care has a finding. A witness statement (written by DON) dated 9/15/16 and signed by Resident #1 documented, Touched inappropriately. He has a beard, two teeth missing. He was here this morning, brought me a cup of coffee. He was off Monday but still came into my room. He sits down on bed, rubs slowly on stomach in circular motion, moving down to where he's rubbing over my penis over my clothes. Three times since I've been here. I don't want him fired. I just don't want him taking care of me. Didn't report it to anyone but my wife. c. A Police Offense/Incident Report dated 9/15/16 documented, Type of Incident: Sexual Assault 4th Degree . stated that allegations were made that a resident, (Resident #1), had been sexually abused by a male from the nursing staff . I advised (Administrator) that this report would be filed. d. On 9/27/16 at 4:45 p.m., Resident #1 was asked to explain the incident involving (CNA #1) and stated, He approached me three different times. He talked to me like a man would talk to a woman, trying to con them into doing something. That made me very uneasy. He sat down on my bed and started rubbing my stomach in a circular motion, but he got called away to do something. He came back again later. This last time he sat on my bed after he had pulled the curtain and started rubbing my stomach, then kept going lower and was rubbing on top of my penis. On top of my clothes. I jerked my leg up and kicked at him. That made him stop and he seemed surprised that I could do that. It was embarrassing, but I called my wife and told her about it. I didn't tell anybody else because (CNA #1) had told us he was putting in his notice because he was moving, so I figured since he'd be gone, I wouldn't have to worry about it. But then I found out he had not put in his notice. He did ask me how I felt about two women giving me a shower. I told him I didn't think anything about it because they had a job to do and I'm the patient; they have to do it. Resident #1 was asked when had all of this happened and stated, The first time was on the 8th of this month. He (CNA #1) was off work, but came up here just to do this to me. The last time was on the 12th of this month. e. On 9/28/16 at 11:08 a.m., during a telephone interview, CNA #1 was asked to explain the incident involving Resident #1 and stated, I have been suspended because a resident stated I touched him in a sexually inappropriate manner. I am hurt by this. I would never do that. CNA #1 was asked why that resident would allege such a thing and stated, I don't know, to be honest with you. He told me about a week or two after he got here that he don't like gays. I didn't tell him I was gay but he might have found out. I'm sorry, but I've got standards. They have to be less than [AGE] years old, still be able to get it hard, and be at least 7 or 8 inches. Now, I may be gay, but I've got standards. I've given that resident showers and I only do the back; he does the front. The CNA was asked if any residents have complained about him before and stated, There are no residents that have complained about me that I know of. This has never happened to me before. The CNA was asked if he had a habit of coming to the facility on his off days and stated, Yes I do. I try to put a smile on the residents' faces because some of them have no one. That's why I wear crazy scrubs and stuff. There's another resident who sometimes runs out of cigarettes, so I like to make sure he doesn't run out. The CNA was asked if he had ever sat on Resident #1's bed and stated, One day I did sit on the bed to talk to him about his wife being sick. He was asked if he pulled the privacy curtain and stated, I did not pull the privacy curtain because (Resident #2) is always in there and likes to watch (Resident #1's) TV. CNA #1 was asked if he had ever done incontinent care on Resident #1 and stated, I have never done incontinent care on him. I do empty his urinal occasionally. If they're able to take care of themselves in that area, I don't go down there. f. On 9/29/16 at 9:44 a.m., the DON was asked to explain how she became aware of the allegation regarding Resident #1 and stated, I was called into the Administrator's office and she told me she received a call from the Office of Long Term Care (OLTC) concerning (Resident #1) and (CNA #1). She asked me to go and interview (Resident #1) so I did. I asked him if anyone had been inappropriate with him. He did not mention any names, but he described the CNA as having a beard and a few other things that told me it was (CNA #1). He also said he was here that Monday night, even though he was off work. He said he sat down on the side of the bed and started rubbing his stomach in a circular motion and worked his way down to where he was rubbing on top of his penis. I hated to ask him this, but I asked him if he did it on top of his clothes or underneath. He said it was on top of his clothes. I asked him if this had happened before and he said that was the third time. He told me he had not reported it to anyone at the facility, but had told his wife. I wrote it all down and took it to the Administrator. We called his wife. She had planned on coming up here and talking to us about it, but she had been sick. She talked to her son and he then talked to his wife, who is a mandated reporter so she called OLTC. When we asked (Resident #1) and his wife why they didn't report this to us, they said (CNA #1) told them he was turning in his notice because he had recently bought a house and was moving so they didn't feel a need to report it at that time. But they found out later he had not turned in his notice. The DON was asked if she felt (Resident #1) was being truthful regarding the allegation and stated, Yes. for me, there was so much emotion in his statement. He wasn't just trying to get someone in trouble. It had bothered him. It embarrassed him. He just didn't want it to happen again. 2. Resident #6 had [DIAGNOSES REDACTED]. The Quarterly MDS with an ARD of 8/23/16 documented the resident scored 15 (13-15 indicates cognitively intact) on a BIMS, had no behaviors, and was independent with most activities of daily living. a. On 9/28/16 at 2:08 p.m., CNA #2 was asked if she knew CNA #1 and stated, I have never worked with him, but I know who you're talking about. He's okay, but he's odd. He is bossy. CNA #2 was asked if any resident had told her that CNA #1 had done or said anything inappropriate to them and stated, There is one resident that said (CNA #1) asked him if he could touch him. CNA #2 was asked what she meant by that and stated, A resident told me that (CNA #1) asked him if he could touch him. The CNA was asked which resident and stated, Can I tell you that? The CNA was informed she could and stated, (Resident #6). The CNA was asked if the resident was referring to touching in a sexual manner and stated, Yes. The CNA then stated, I already know I'll be fired, because I didn't report that. You're supposed to report that immediately. I don't know why I didn't. I haven't had a chance to talk to anyone. And maybe, because I didn't know if it was true. The CNA was asked how long ago this happened and stated, I don't know. It's been a while, and he said he only did it once. I even thought about going to (CNA #1) and asking him about it. b. On 9/28/16 at 2:25 p.m., Resident #6 was asked if he knew CNA #1 and stated, Yeah I know him. The resident was asked if CNA #1 had ever done anything to him he felt was inappropriate. At that time, the resident looked away from the surveyor and did not answer the question. The resident was told it was okay to talk, because he was not the only person the surveyor had spoken with today about CNA #1. Resident #6 then looked at the surveyor and stated, He asked me if I knew he was gay. I told him no, then he said can I touch you. I told him no. The resident was asked if CNA #1 ever touched him in a sexual manner and stated, No. I wasn't about to let him. I'm so glad he doesn't work here anymore, but you know I heard he's starting to work at another place today. What about those poor people? Resident #6 was asked if (CNA #1) ever did anything else to him and stated, You know, I carry my hair dryer with me . I used to put on a gown after my shower and he would take my hairdryer, put it up underneath my gown and say 'we've got to make sure and get precious dry.' That's not right to say stuff like that. It's inappropriate. He was strange. I asked a while back that he not take care of me anymore, because I found a pill on the floor and put it up on the counter. He yelled at me for that! The resident was asked how long ago (CNA #1) asked if he could touch him and stated, Oh I don't know. It's been a while. The resident was asked how long ago the hairdryer incident occurred and stated, That too. I'm not sure. The resident was asked if he had reported this to anyone in the facility and stated, Yes. I've told some folks. c. A written witness statement dated 9/28/16 and signed by CNA #2 after being interviewed by the Surveyor documented , .He (Resident #6) didn't want his shower. (CNA #1) said he needed it. (Resident #6) said (CNA #1) wanted him to touch him or vice versa. Asked (CNA #1) about it and he said he reported what I asked him about. Nothing else was talked about. d. On 9/29/16 at 9:44 a.m., the DON was asked if the facility interviewed Resident #6 and CNA #2 as part of their investigation after they became aware of the allegation involving Resident #1 and stated, No, we didn't. 3. The immediate jeopardy was removed and the scope and severity lowered to H on 9/28/16 at 3:00 p.m. when the facility implemented the following Plan of Removal: 1.) Starting immediately at 3:00 p.m. on 9/28/16: The aide in question (CNA #1) was suspended on 9/15/16. He has not returned to the facility since 9/15/16. He was formally terminated on 9/28/16. 2.) The aide who did not report the initial allegation, (CNA #2) was immediately suspended at 3:00 p.m. on 9/28/16. She was also terminated on 9/28/16. 3.) All non-interviewable male residents on the West Hall will have a body audit documented by 7:00 a.m. on 9/29/16. 4.) All interviewable male residents in (CNA #1) assignment range in the 6 weeks prior to 9/15/16 will be interviewed regarding abuse/neglect. 5.) The DON or designee will provide 1:1 in-service with all staff regarding the facility's abuse/neglect policy immediately. Each employee will be asked if there is anything they need to or have failed to report at this time. 6.) Each staff member will be given a copy of the abuse/neglect policy. 7.) Staff will also be in-serviced on the appropriate action to take if (CNA #1) is seen on the facility grounds at any time, which is to ask him to leave, and for the employee to call Administrator and police immediately. 8.) No staff will be allowed to work the floor until they are in-serviced on abuse/neglect policy, and protocol related to (CNA #1) 9.) All staff will complete a post-test on the abuse/neglect policy within 24 hours of being in-serviced. If they are in-serviced over the phone, the post-test will be taken over the phone with the DON/designee. 10.) Any staff who is unable (PRN or weekend or out of town) will not be allowed to return to work until they are in-serviced either in person or over the phone, and complete the post-test. 11.) These interventions will be completed by 7:30 a.m. on 9/29/16. 12.) A current list of all employees completing the above in-services and post-test will be maintained and updated every shift for the first 24 hours. 13.) Any employee off, on leave or vacation will be in-serviced on the abuse and neglect policy and the post-test will be taken within 24 hours of being in-serviced. 14.) A post-test on abuse and neglect will be completed every week times four weeks. 15.) The employee/in-service/testing list will be reviewed in the morning meeting on 9/29/16 and then taken to QA (Quality Assurance) for immediate follow up. QA will be done daily for 30 days or until all staff is documented as being in-serviced and post-tested . 16.) At 30 days, the QA committee will review all weekly post-tests, until all staff has completed these post-tests weekly x 4.

Complaint # (AR 496) was substantiated (all or in part) with these findings: Based on record review and interview, the facility failed to ensure its abuse prohibition policies and procedures were implemented, as evidence by failure to ensure staff immediately reported an allegation of staff-to-resident sexual abuse to the Administrator for 1 (Resident #6), which resulted in a delay in initiating an investigation and protective measures to prevent a subsequent incident of sexual abuse against 1 (Resident #1) of 1 (Residents #1-6) case mix residents who were male. The failed practices resulted in immediate jeopardy, which caused or could have caused serious harm, injury, or death to Residents #1 and #6, and had a potential to cause more than minimal harm to 50 residents who were male, as documented on a list provided by the Director of Nursing (DON) on 9/29/16. The facility was informed of the immediate jeopardy condition on 9/28/16 at 2:50 p.m. The findings are: 1. The facility's Abuse and Neglect Policy and Procedure, revision date 8/9/16, documented, The facility is charged with the safeguard of each resident and will follow a consecutive plan in the pursuit of maintaining a safe environment. Suspected actions or allegations of abuse including physical, mental, verbal, sexual, involuntary seclusion, neglect or misappropriation of property by any individual including resident to resident altercations with injury will be reported to local authorities, state and federal agencies, and other appropriate agencies as required by law . Any employee that witnessed, suspected, alleged statements of abuse including injuries of an unknown source, or unusual deaths must report to the Administrator or Designated Representative and the Nurse on call immediately . 2. Resident #1 had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/7/16 documented the resident scored12 (8-12 indicates moderately impaired) on a Brief Interview for Mental Status (BIMS), had no behaviors, and required extensive assistance with most activities of daily living. a. A typed letter dated 9/14/16, addressed to the Administrator and signed by Resident #1's son, documented, On 09/13/2016, I received a phone message from my father that it was very important that I return his phone call. Upon returning his call he asked me to come by and see him. When I got there he painstakingly told me that he was a victim of sexual abuse as a resident of your facility. The worker named (Certified Nursing Assistant (CNA) #1) who wants everyone to call him 'ornery', came into my father's room on the 8th between 3 p.m. and 11 p.m. two separate times. The first time he sat on the bed, started rubbing his stomach, and was called away then later he returned, sat on the bed, started rubbing my father's stomach, and started going lower and lower until my father kicked at him. (CNA #1) was very surprised by the kick, stopped and left the room. (CNA #1) instructed my parents he was putting in his notice to transfer to Fort Smith but when they asked him later if he put in his notice he said no he had not done that. On the 12th (CNA #1) came again into his room and sat on his bed, proceeded to rub my father's stomach and to go lower and lower. My father kneed at him and he stopped. My father told me that the 12th was (CNA #1's) day off so why was he there? My wife has contacted Arkansas Adult Protective Services and filed a complaint making them aware of what has happened to my father while in your care. I am disappointed because going into a nursing home is mentally hard enough let alone having to deal with sexual abuse from the employees. Employees are there to take care of residents and put the family's minds at ease. I have no tolerance for this type of behavior and I want it stopped immediately. To resolve the problem, I would like you to take action against the employee (CNA #1) and make it where he can no longer do this to another person . A handwritten witness statement dated 9/14/16 and signed by CNA #1 documented, I am a courteous employee that works at (facility), known by all employees and residents as kind and caring. To my knowledge, stand by my testimony, of outrageous accusations of any charge against me of my work record. For 2 years, I have been employed here with no previous charges or write ups during my work period. I stand in complete disagreement with any embellishment against my person, and if so needed, can and will provide many sources to clear myself. b. An Office of Long Term Care (OLTC) Division of Medical Services ((DMS) -762) form dated 9/15/16 documented, Administrator received a call from the Office of Long Term Care stating they had a complaint called in. The complaint was that employee (CNA #1) had been accused of sexually abusing resident (Resident #1). The report was that he had inappropriately touched (Resident #1). (Resident #1) medical condition is stable. Employee (CNA #1) was removed from the working schedule and asked not to come into the facility until this investigation was complete. Police was notified. (Resident #1) was interviewed by the Director of Nursing. (Resident #1) stated that he was touched inappropriately . (Resident #1) told her that this male sat on his bed, rubbed his stomach gradually getting lower . It happened again Monday. The male was off but was at the facility . Administrator then received a letter on 9/15/16 from the son by email from the daughter-in-law. He had received a call from his dad on 9/13/16. He came to the facility and his dad told him that the worker named (CNA #1) on the 8th between 3:00 p.m. and 11:00 p.m. on two separate times came into his room and inappropriately touched him. The Director of Nursing and the Administrator have interviewed all interviewable residents as to if any employee has been inappropriate with them. All stated no. All staff that has worked with employee (CNA #1) were interviewed with all reporting not ever seeing employee (CNA #1) being inappropriate with any resident. (CNA #1) was not working on the 8th of September. He was off on the 12th, was at the facility as he has been several times on his days off. Spoke with (Resident #1's) roommate, he stated he did not ever see or hear any employee being inappropriate with (Resident #1). He did overhear (Resident #1) telling his son something about this. The facility is unable to make a finding so employee (CNA #1) will not be allowed to return to work until the Office of Long Term Care has a finding. A witness statement (written by DON) dated 9/15/16 and signed by Resident #1 documented, Touched inappropriately. He has a beard, two teeth missing. He was here this morning, brought me a cup of coffee. He was off Monday but still came into my room. He sits down on bed, rubs slowly on stomach in circular motion, moving down to where he's rubbing over my penis over my clothes. Three times since I've been here. I don't want him fired. I just don't want him taking care of me. Didn't report it to anyone but my wife. c. A Police Offense/Incident Report dated 9/15/16 documented, Type of Incident: Sexual Assault 4th Degree . stated that allegations were made that a resident, (Resident #1), had been sexually abused by a male from the nursing staff . I advised (Administrator) that this report would be filed. d. On 9/27/16 at 4:45 p.m., Resident #1 was asked to explain the incident involving (CNA #1) and stated, He approached me three different times. He talked to me like a man would talk to a woman, trying to con them into doing something. That made me very uneasy. He sat down on my bed and started rubbing my stomach in a circular motion, but he got called away to do something. He came back again later. This last time he sat on my bed after he had pulled the curtain and started rubbing my stomach, then kept going lower and was rubbing on top of my penis. On top of my clothes. I jerked my leg up and kicked at him. That made him stop and he seemed surprised that I could do that. It was embarrassing, but I called my wife and told her about it. I didn't tell anybody else because (CNA #1) had told us he was putting in his notice because he was moving, so I figured since he'd be gone, I wouldn't have to worry about it. But then I found out he had not put in his notice. He did ask me how I felt about two women giving me a shower. I told him I didn't think anything about it because they had a job to do and I'm the patient; they have to do it. Resident #1 was asked when had all of this happened and stated, The first time was on the 8th of this month. He (CNA #1) was off work, but came up here just to do this to me. The last time was on the 12th of this month. e. On 9/28/16 at 11:08 a.m., during a telephone interview, CNA #1 was asked to explain the incident involving Resident #1 and stated, I have been suspended because a resident stated I touched him in a sexually inappropriate manner. I am hurt by this. I would never do that. CNA #1 was asked why that resident would allege such a thing and stated, I don't know, to be honest with you. He told me about a week or two after he got here that he don't like gays. I didn't tell him I was gay but he might have found out. I'm sorry, but I've got standards. They have to be less than [AGE] years old, still be able to get it hard, and be at least 7 or 8 inches. Now, I may be gay, but I've got standards. I've given that resident showers and I only do the back; he does the front. The CNA was asked if any residents have complained about him before and stated, There are no residents that have complained about me that I know of. This has never happened to me before. The CNA was asked if he had a habit of coming to the facility on his off days and stated, Yes I do. I try to put a smile on the residents' faces because some of them have no one. That's why I wear crazy scrubs and stuff. There's another resident who sometimes runs out of cigarettes, so I like to make sure he doesn't run out. The CNA was asked if he had ever sat on Resident #1's bed and stated, One day I did sit on the bed to talk to him about his wife being sick. He was asked if he pulled the privacy curtain and stated, I did not pull the privacy curtain because (Resident #2) is always in there and likes to watch (Resident #1's) TV. CNA #1 was asked if he had ever done incontinent care on Resident #1 and stated, I have never done incontinent care on him. I do empty his urinal occasionally. If they're able to take care of themselves in that area, I don't go down there. f. On 9/29/16 at 9:44 a.m., the DON was asked to explain how she became aware of the allegation regarding Resident #1 and stated, I was called into the Administrator's office and she told me she received a call from the Office of Long Term Care (OLTC) concerning (Resident #1) and (CNA #1). She asked me to go and interview (Resident #1) so I did. I asked him if anyone had been inappropriate with him. He did not mention any names, but he described the CNA as having a beard and a few other things that told me it was (CNA #1). He also said he was here that Monday night, even though he was off work. He said he sat down on the side of the bed and started rubbing his stomach in a circular motion and worked his way down to where he was rubbing on top of his penis. I hated to ask him this, but I asked him if he did it on top of his clothes or underneath. He said it was on top of his clothes. I asked him if this had happened before and he said that was the third time. He told me he had not reported it to anyone at the facility, but had told his wife. I wrote it all down and took it to the Administrator. We called his wife. She had planned on coming up here and talking to us about it, but she had been sick. She talked to her son and he then talked to his wife, who is a mandated reporter so she called OLTC. When we asked (Resident #1) and his wife why they didn't report this to us, they said (CNA #1) told them he was turning in his notice because he had recently bought a house and was moving so they didn't feel a need to report it at that time. But they found out later he had not turned in his notice. The DON was asked if she felt (Resident #1) was being truthful regarding the allegation and stated, Yes. for me, there was so much emotion in his statement. He wasn't just trying to get someone in trouble. It had bothered him. It embarrassed him. He just didn't want it to happen again. 3. Resident #6 had [DIAGNOSES REDACTED]. The Quarterly MDS with an ARD of 8/23/16 documented the resident scored 15 (13-15 indicates cognitively intact) on a BIMS, had no behaviors, and was independent with most activities of daily living. a. On 9/28/16 at 2:08 p.m., CNA #2 was asked if she knew CNA #1 and stated, I have never worked with him, but I know who you're talking about. He's okay, but he's odd. He is bossy. CNA #2 was asked if any resident had told her that CNA #1 had done or said anything inappropriate to them and stated, There is one resident that said (CNA #1) asked him if he could touch him. CNA #2 was asked what she meant by that and stated, A resident told me that (CNA #1) asked him if he could touch him. The CNA was asked which resident and stated, Can I tell you that? The CNA was informed she could and stated, (Resident #6). The CNA was asked if the resident was referring to touching in a sexual manner and stated, Yes. The CNA then stated, I already know I'll be fired, because I didn't report that. You're supposed to report that immediately. I don't know why I didn't. I haven't had a chance to talk to anyone. And maybe, because I didn't know if it was true. The CNA was asked how long ago this happened and stated, I don't know. It's been a while, and he said he only did it once. I even thought about going to (CNA #1) and asking him about it. b. On 9/28/16 at 2:25 p.m., Resident #6 was asked if he knew CNA #1 and stated, Yeah I know him. The resident was asked if CNA #1 had ever done anything to him he felt was inappropriate. At that time, the resident looked away from the surveyor and did not answer the question. The resident was told it was okay to talk, because he was not the only person the surveyor had spoken with today about CNA #1. Resident #6 then looked at the surveyor and stated, He asked me if I knew he was gay. I told him no, then he said can I touch you. I told him no. The resident was asked if CNA #1 ever touched him in a sexual manner and stated, No. I wasn't about to let him. I'm so glad he doesn't work here anymore, but you know I heard he's starting to work at another place today. What about those poor people? Resident #6 was asked if (CNA #1) ever did anything else to him and stated, You know, I carry my hair dryer with me . I used to put on a gown after my shower and he would take my hairdryer, put it up underneath my gown and say 'we've got to make sure and get precious dry.' That's not right to say stuff like that. It's inappropriate. He was strange. I asked a while back that he not take care of me anymore, because I found a pill on the floor and put it up on the counter. He yelled at me for that! The resident was asked how long ago (CNA #1) asked if he could touch him and stated, Oh I don't know. It's been a while. The resident was asked how long ago the hairdryer incident occurred and stated, That too. I'm not sure. The resident was asked if he had reported this to anyone in the facility and stated, Yes. I've told some folks. c. A written witness statement dated 9/28/16 and signed by CNA #2 after being interviewed by the Surveyor documented , .He (Resident #6) didn't want his shower. (CNA #1) said he needed it. (Resident #6) said (CNA #1) wanted him to touch him or vice versa. Asked (CNA #1) about it and he said he reported what I asked him about. Nothing else was talked about. d. On 9/29/16 at 9:44 a.m., the DON was asked if the facility interviewed Resident #6 and CNA #2 as part of their investigation after they became aware of the allegation involving Resident #1 and stated, No, we didn't. 4. The immediate jeopardy was removed and the scope and severity lowered to H on 9/28/16 at 3:00 p.m. when the facility implemented the following Plan of Removal: 1.) Starting immediately at 3:00 p.m. on 9/28/16: The aide in question (CNA #1) was suspended on 9/15/16. He has not returned to the facility since 9/15/16. He was formally terminated on 9/28/16. 2.) The aide who did not report the initial allegation, (CNA #2) was immediately suspended at 3:00 p.m. on 9/28/16. She was also terminated on 9/28/16. 3.) All non-interviewable male residents on the West Hall will have a body audit documented by 7:00 a.m. on 9/29/16. 4.) All interviewable male residents in (CNA #1) assignment range in the 6 weeks prior to 9/15/16 will be interviewed regarding abuse/neglect. 5.) The DON or designee will provide 1:1 in-service with all staff regarding the facility's abuse/neglect policy immediately. Each employee will be asked if there is anything they need to or have failed to report at this time. 6.) Each staff member will be given a copy of the abuse/neglect policy. 7.) Staff will also be in-serviced on the appropriate action to take if (CNA #1) is seen on the facility grounds at any time, which is to ask him to leave, and for the employee to call Administrator and police immediately. 8.) No staff will be allowed to work the floor until they are in-serviced on abuse/neglect policy, and protocol related to (CNA #1) 9.) All staff will complete a post-test on the abuse/neglect policy within 24 hours of being in-serviced. If they are in-serviced over the phone, the post-test will be taken over the phone with the DON/designee. 10.) Any staff who is unable (PRN or weekend or out of town) will not be allowed to return to work until they are in-serviced either in person or over the phone, and complete the post-test. 11.) These interventions will be completed by 7:30 a.m. on 9/29/16. 12.) A current list of all employees completing the above in-services and post-test will be maintained and updated every shift for the first 24 hours. 13.) Any employee off, on leave or vacation will be in-serviced on the abuse and neglect policy and the post-test will be taken within 24 hours of being in-serviced. 14.) A post-test on abuse and neglect will be completed every week times four weeks. 15.) The employee/in-service/testing list will be reviewed in the morning meeting on 9/29/16 and then taken to QA (Quality Assurance) for immediate follow up. QA will be done daily for 30 days or until all staff is documented as being in-serviced and post-tested . 16.) At 30 days, the QA committee will review all weekly post-tests, until all staff has completed these post-tests weekly x 4.

Complaint # was substantiated (all or in part) with these findings. Based on observation, record review and interview, the facility failed to ensure Residents #1 and #4 received the necessary care and services for non-pressure-related wounds to promote healing and prevent deterioration in wounds. The facility failed to ensure Resident #4 received the necessary care and services for urinary catheter maintenance to prevent trauma to the urinary meatus and reduce the risk of infection. The facility failed to ensure dressing changes for non-pressure-related wounds were completed as ordered and were maintained in clean and dry condition to decrease the potential for deterioration and infection for Residents #1 and to ensure clean technique was followed during non-pressure-related wound care to decrease the potential for infection for 1 (Resident #4) of 2 (Residents #1 and 4) case mix residents who had physician orders for wound care. These failed practices resulted in a pattern of actual harm to Resident #1, who acquired multiple additional areas of skin breakdown, and had the potential to affect 4 residents who had physician's orders for wound care, according to a list received from the Treatment Nurse on 5/31/12. The facility failed to ensure urinary catheter tubing was secured to prevent potential trauma to the urinary meatus for 1 (Resident #4) of 2 (Residents #4 and 5) case mix residents with a urinary catheter. The failed practice had the potential to affect 5 residents who had urinary catheters, according to a list provided by the Administrator on 5/31/12. The findings are: 1. Resident #1 had [DIAGNOSES REDACTED]. The Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/18/12 documented the resident scored 10 (8 - 12 indicates moderately impaired) on the Brief Interview for Mental Status (BIMS), was independent for bed mobility, required limited assistance with transfers, had one unhealed Stage 2 pressure ulcer with an onset date of 3/5/12 and had two venous and arterial ulcers present. a. The Hospital Consultation Note dated 12/29/11 documented, "...Reason for Consultation: Bilateral lower extremity wounds. History of Present Illness: ...On admission, he was noted to have bilateral lower extremity [MEDICAL CONDITION] with multiple wounds noted... Assessment: 1.Venous ulcers with venous stasis changes of the bilateral lower extremities, extending up into the thighs... 3. [MEDICAL CONDITION]. 4. [MEDICAL CONDITION]" b. The hospital wound clinic "Nursing Assessment and Treatment" form dated 3/29/12, documented, "...Wound Number: 3; Location: (Left) posterior upper thigh; Length: 0.3 cm (centimeters); Width: 0.3 cm; Depth: 0.2 cm... Wound Grade/Stage/Type: Pressure... Wound Number: 4; Location: (Right) posterior upper thigh; Length: 0.3 cm; Width: 0.7 cm; Depth: 0.2 cm... Wound Grade/Stage/Type: Pressure..." The hospital wound clinic "Nursing Assessment and Treatment" form dated 4/12/12 documented, "...Wound Number: 3; Location: (Left) posterior upper thigh; Healed... Wound Number: 4; Location: (Right) posterior upper thigh; Healed... Wound Number: 5 New; Location: (Right) 2nd toe (lateral); Length: 2.5 cm; Width: 1.0 cm; Depth: 0.1 cm... Wound Grade/Stage/Type: Diabetic ulcer of the foot... Wound Number: 6; Location: (Right) 2nd toe (medial); Length: 0.8 cm; Width: 2.4 cm; Depth: 0.2 cm... Wound Grade/Stage/Type: Diabetic ulcer of the foot..." c. Physician orders dated 3/29/12 and 4/12/12 from the hospital wound clinic documented, "Wound Location: Bilateral Lower Extremities; Dressing: [MEDICATION NAME] (10%) or [MEDICATION NAME] 0.05% to both legs (and) wrap with Xeroform and then wrap Unna boot from base of toes to top of calf, and secure with case pad (and) Coban; Frequency: 2 (times) weekly..." d. The April 2012 Treatment Administration Record (TAR) documented, "Apply [MEDICATION NAME] to (bilateral) lower legs, cover open areas with Xeroform, wrap with Unna boot, cover with cast pad, or ABD pads and secure with Coban twice weekly: Order date 3/5/12". This treatment was initialed as done on 4/2/12, 4/5/12, 4/9/12 and 4/12/12. [MEDICATION NAME] was not ordered by the wound clinic physician and there was no documentation of an order dated 3/5/12 from the wound clinic. The April 2012 TAR also documented, "Apply [MEDICATION NAME] 1% (did not match the physician order, which documented 10%) to bilateral lower legs, cover open areas with Xeroform, wrap with Unna boot, cover with cast pad and Coban. Order date: 3/5/12." This treatment was initialed as done on 4/16/12 and 4/19/12. This treatment was documented as "2 (2 = Drug refused)" on 4/23/12. e. The Care Plan dated 4/26/11 and updated on 4/18/12 documented, "...has actual impairment to skin integrity R/T (related to) rash and venous stasis ulcers... Interventions: ...Monitor/document location, size and treatment of [REDACTED]. (et cetera) to M.D. (physician)... Perform skin treatment per M.D. order... Identify/document potential causative factors and eliminate/resolve where possible... Wound clinic as ordered 4/18/12." f. A report provided by the Administrator on 5/30/12 at 11:40 a.m. documented the resident received a shower on 4/22/12, 4/23/12 and 4/26/12. There was no documentation of dressing changes done on these dates on the TAR or in the Progress Notes, Nurses Notes or Skin/Wound Notes. g. The facility's "Skin/Wound Note" dated 4/21/12 at 1:52 p.m., written by the Treatment Nurse, documented, "...(bilateral) lower legs with Unna boot have no open areas 4/19/12..." This was the only documentation regarding the dressings on the resident's lower extremities from 4/19/12 through 4/26/12. h. The hospital wound clinic "Nursing Assessment and Treatment" form dated 4/26/12 documented a total of 14 wounds to the lower extremities and, " ...11:10 a.m. Dressing removed from right leg, (upper) portions of dressing embedded into skin and circling around towards back of calf. (Dressing) (with) odor (and) wetness. Upon removing (dressing) from (left) leg, this nurse noted (dressing) embedded into calf also, (dressing) wet, strong odor, and discoloration from leg (and) what appears to be mold on part of (dressing). (Physician) notified". The hospital wound clinic provided color photographs illustrating the dressings, black discolored areas on the dressings and multiple wounds. The wound measurements were documented as follows: "Wound Number: 5 New; Location: (Right) 2nd toe (lateral); Length: 0.7 cm; Width: 2.5 cm; Depth: 0.2 cm. Wound Number: 6; Location: (Right) 2nd toe (medial); Length: 0.3 cm; Width: 0.4 cm; Depth: 0.2 cm. Wound Number: 7 (times) 3; Location: (left) (posterior) (lower extremity); Length: 0.3 cm; Width: 5.9 cm; Depth: 0.2 cm. Wound Number: 8; Location: (left) (anterior) (lower extremity); Length: 0.3 cm; Width: 1.2 cm; Depth: 0.2 cm. Wound Number: 9; Location: (left) (anterior) (medial) (lower extremity); Length: 0.7 cm; Width: 1.8 cm; Depth: 0.2 cm. Wound Number: 10; Location: (left) (anterior) (inferior) (lower extremity); Length: 5.0 cm; Width: 0.6 cm; Depth: 0.2 cm. Wound Number: 11; Location: (left) (medial) (lower extremity) (superior); Length: 0.4 cm; Width: 2.8 cm; Depth: scab. Wound Number: 12; Location: (left) (medial) (lower extremity) (inferior); Length: 0.3 cm; Width: 3.5 cm; Depth: 0.2 cm. Wound Number: 13; Location: (right) (anterior) (ankle); Length: 0.4 cm; Width: 1.4 cm; Depth: 0.2 cm. Wound Number: 14; Location: (right) (posterior) (lower extremity); Length: 0.3 cm; Width: 17.9 cm; Depth: 0.2 cm." 1) The hospital Physician Progress/Procedure Note dated 4/26/12 documented, "Chief Complaint: (Multiple) wounds. History of Present Illness: ...Unna boots wet, wrapped very tight (and) cutting into his legs, mold growing on Xeroform on (left) (lower extremity)... Assessment / Diagnosis: [REDACTED]. (Left) Unna boot was wet (and) cast padding to both was turning brown. The Xeroform that was removed from (patient's) left leg had mold growing on it (and) the whole dressing smelled of must (and) mildew. (Patient) had at least 12 open areas where the wrap had cut into his legs (and) had created sores (and) new tissue was trying to grow into the Unna boot wrap. (Patient) is unsure of the last time his dressing had been changed but from appearance they had been in place for at least the past (week). There was no date on his dressings. The blue Coban had begun to fade in places. (Patient) states that he had been complaining to (nursing home) staff for the past week of pain in his legs (and) states that no one ever removed the wraps to evaluate further. He is unsure of how long dressings have been wet." 2) A physician order dated 4/26/12 from the hospital wound clinic documented, "...Sponge bath only. No shower or whirlpool..." 3) The hospital note, written by the wound care physician on 4/26/12 documented, "Spoke (with) (Treatment Nurse), wound care nurse (at) (nursing home). Case (and) concerns discussed with her. She states she will be (with) patient for his next wound care appointment for teaching on proper dressing placements. (Treatment Nurse) states that dressings had been on for the past (week) (and) that (patient) refused dressing change on Monday (4/23/12) (and) that he has not been elevating as he should." i. The hospital wound clinic "Nursing Assessment and Treatment" form dated 5/14/12, documented, "...Wound Number: 5; Location: (Right) 2nd toe (lateral); Length: 0.4 cm; Width: 0.4 cm; Depth: 0.2 cm... Wound Number: 7 (times) 3; Location: (left) (posterior) (lower extremity); Healed... Wound Number: 8; Location: (left) (anterior) ... (lower extremity); Length: 0.2 cm; Width: 1.5 cm; Depth: 0.2 cm ... Wound Number: 10; Location: (left) (anterior) (inferior) (lower extremity); Length: 0.3 cm; Width: 1.2 cm; Depth: 0.2 cm... Wound Number: 11; Location: (left) (medial) (lower extremity) (superior); Healed... Wound Number: 12; Location: (left) (medial) (lower extremity) (inferior); Length: 0.3 cm; Width: 1.8 cm; Depth: 0.2 cm... Wound Number: 13; Location: (right) (anterior) (ankle); Length: 0.3 cm; Width: 1.7 cm; Depth: 0.3 cm... Wound Number: 14 (times) 3; Location: (right) (posterior) (lower extremity); Length: 0.4 cm; Width: 6.0 cm; Depth: 0.2 cm..." 1) The hospital Physician Progress/Procedure Note dated 5/14/12 documented, "Chief Complaint: (Bilateral) (Lower extremity) wounds. History of Present Illness: ...Dressings were soaked again (with) foul odor (and) mold. (Patient) states that they have been giving him a shower again... Procedure Notes: Spoke (with) (Nursing Home) (Administrator) (Director of Nurses) and (Treatment Nurse) ... (regarding) dressing condition. They state that they were aware that (patient) was to have sponge bath only; that dressings were to be kept clean and dry (and) intact. They are unsure of when dressings got wet, but (Treatment Nurse) states that they were dry when she left on Friday... Assessment/Diagnosis: [REDACTED]. 2) A physician order dated 5/14/12 from the hospital wound clinic documented, "...Frequency: (Monday) - (Wednesday) - (Friday) (and) as needed for soiled or wet dressings... Clean legs with cleansing bath oil (and) moist towels..." j. On 5/31/12 at 2:22 p.m., Certified Nursing Assistant (CNA) #2 was asked, "Did you ever give (Resident #1) showers?" CNA # 2 stated, "Yes". CNA #2 was asked, "What did you do to keep his dressings dry?" CNA # 2 stated, "He had some plastic stretchy bags with elastic above his knees. We'd put those on for the shower. After the shower, we'd take them off and dry him down." CNA #2 was asked, "Did you ever give a shower without the plastic stretchy bags?" CNA #2 stated, "Yes, we'd take clean trash bags and put tape around the top of the plastic bag." CNA # 2 was asked, "Did his dressings ever get wet?" CNA # 2 stated, "Yes, once when he was scratching his leg and the bag tore. There was a small hole the size of a dime." CNA # 2 was asked, "Did a nurse change the dressing?" CNA # 2 stated, "(Treatment Nurse) cut the wet section off and put a new section on it." k. On 5/31/12 at 2:50 p.m., Licensed Practical Nurse (LPN) #2 was asked, "Any concerns with (Resident #1's) dressings being wet or any other problems?" LPN # 2 stated, "Since I've been here, he's had several different kinds of dressings and when I was doing the dressings, there was about half of the time he would not let me. It's been a good 4 or 5 months since I was responsible for them." LPN #2 was asked, "The initials on the 4/23/12 treatment (Treatment Administration Record) to his legs; are these yours?" LPN #2 stated, "Yes". LPN #2 was asked, "Why did he refuse?" LPN #2 stated, "He wanted (Treatment Nurse) to do it." l. On 5/31/12 at 3:52 p.m., the Treatment Nurse was asked, "How is (Resident #1) with dressing changes?" The Treatment Nurse stated, "Most of the time, he is compliant. We had an issue where I was off and he wouldn't let the nurse change it and we got a call from the wound clinic with what a mess his leg was in." The Treatment Nurse was asked, "What happened on 4/26/12?" The Treatment Nurse stated, "(Resident #1) went to the wound clinic and he'd not had a dressing change done. I was off on 4/23/12; no one told me he'd refused treatment or that his dressings were wet." The Treatment Nurse was asked, "What happened on 5/14/12?" The Treatment Nurse stated, "We assume it (dressing) got wet over the weekend, but we don't know how." The Treatment Nurse was asked, "Since the wound clinic called on 5/14/12, what's been done?" The Treatment Nurse stated, "After we were shown the second set of pictures and (physician) said they were wet, (Director of Nurses) reassured (physician) that we would fix it. On the days he has a wound clinic doctor's appointment I come in at 6:30 a.m. and we check him before he goes and if they are wet I'm to change them. I check them every day to be sure they are not wet... Now the wound clinic is seeing him on Monday, Wednesday and Friday and we aren't doing any dressings." 2. Resident #4 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/23/12 documented the resident was severely impaired in cognitive skills for daily decision making per a Staff Assessment of Mental Status, had an indwelling catheter, was at risk for pressure ulcers, had no pressure ulcers, had no venous or arterial ulcers and had a surgical wound. a. The Care Plan dated as reviewed on 4/17/12 documented, "Focus: ...has skin breakdown related to immobility... Interventions: ...Assess / record / monitor wound healing per facility protocol. Measure length, width and depth where possible. Assess and document status of wound perimeter, wound bed and healing progress. Report improvements and declines to the (physician)..." 1.) A physician order dated 5/22/12 documented, "Gently clean outer right foot with NS (Normal Saline), pat dry, apply Silver Alginate to open area, Xeroform 4 (by) 4... cover with bordered gauze... every day." 2.) On 5/31/12 at 1:00 p.m., the Treatment Nurse gathered an opened bottle of Normal Saline dated 5/10/12, an opened packet of [MEDICATION NAME] AG, and 5 packets of 4 by 4-inch gauze pads (4x4's), a 6 by 6-inch island dressing, a bio-hazardous bag, gloves and measuring tape for the treatment to the resident's right foot. The Treatment Nurse sat the supplies up on a clean field on the resident's overbed table. The Treatment Nurse removed the soiled dressing and changed gloves. The outside of the resident's right foot had two areas on the incision line. The area toward the toes had a buildup of tissue and appeared dry and callused. The lower end of the incision line, toward the heel, had an open area that measured 1.75 centimeters by 1.4 centimeters with a depth of 0.2 centimeters, according to the Treatment Nurse. There was a crescent shaped area of tissue that was dark and the center wound bed had a yellow tissue present. The Treatment Nurse poured Normal Saline into an opened packet of 4 by 4s. The Treatment Nurse folded the 4 by 4 and cleaned the healing area on the incision line that was toward the toes using a back and forth motion across the area, recontaminating the wound bed with each wipe. The Treatment Nurse then unfolded the used 4 by 4 and used the inner surface to clean the open area on the incision line that was closest to the heel area. The Treatment Nurse used a circular motion multiple times in the open area toward the heel. 3.) On 5/31/12 at 3:52 p.m., the Treatment Nurse was asked, "During the dressing change today a 4x4 was used on the area toward the toes, and then you folded it inside out. Should you have done that?" The Treatment Nurse stated, "No I should have used a new one." The Treatment Nurse was asked, "With the circular motion multiple times over the open area, does that clean the wound?" The Treatment Nurse stated, "No, it just moves things around." b. The Care Plan dated 12/1/11 documented, "Focus: ...has an indwelling Foley catheter..." The Care Plan did not address the need to secure the catheter. 1.) On 5/29/12 at 2:00 p.m. and 5/30/12 at 8:02 a.m. and 10:02 a.m., the resident's urinary catheter was not secured with a leg strap or any other device, to prevent potential trauma to the urethral meatus and bladder. 2.) On 5/30/12 at 10:02 a.m. Certified Nurse's Assistant (CNA) # 1 was asked, "Why doesn't (Resident #4) have a leg band to secure his catheter?" CNA #1 stated, "This is only my second day of taking care of him. I'm not sure what that is." CNA #1 was asked, "Was there anything, a leg band, tape, et cetera to secure his catheter yesterday?" CNA #1 stated, "No, it was just like it is today." 3.) The facility policy titled, "Catheter Care, Urinary", provided by the Administrator on 5/31/12, documented, "...15. Ensure that the catheter remains secured with a leg strap to reduce friction and movement at the insertion site... 16. Report unsecured catheters to the supervisor..."

Complaint # was substantiated (all or in part) in these findings. Based on record review and interview, the facility failed to ensure adequate supervision was provided to Resident #6 to prevent injuries to other residents due to physically aggressive behaviors. The facility failed to develop and implement interventions to protect other residents from the physically aggressive behaviors of 1 (Resident # 6) of 6 (Residents #1 through #4, #6 and #7) case mix residents who resided on the closed unit and had behaviors. These failed practices resulted in Immediate Jeopardy which resulted in or was likely to result in serious injury, harm or death for Residents #2 and #3, who were choked by Resident #6. These failed practices were also likely to affect 39 residents who resided on the closed unit, according to a list provided by the Administrator on 4/21/11. The Immediate Jeopardy was removed by the facility on 4/7/11 at 1:51 p.m. (prior to surveyor entrance) when the facility identified the issue and initiated corrective action; however, the facility had not corrected the underlying deficient practice at the time of the survey. The facility was informed of the Immediate Jeopardy removed on 4/21/11 at 3:25 p.m. The findings are: 1. The facility policy titled "Secure Unit" documented, "...Policy: Prior to admission or transfer to (facility) secure unit, a formal assessment process will occur to determine the appropriateness of the transfer or admission of any resident to or on the secure unit... 11. An individualized care plan will be implemented for each resident on the unit addressing their specialized needs and need for placement on the unit... 14. Behavioral monitoring will occur as per policy and procedure for identified residents..." 2. The facility policy titled "Behavior Assessment and Monitoring" documented, "...Policy Statement: 1. Problematic behavior will be identified and managed appropriately. 2. Resident will have minimal complications associated with the management of problematic behavior... Assessment: 1. As part of the initial assessment, the nursing staff and Attending Physician will identify individuals with a history of impaired cognition (e.g. dementia, mental retardation) problematic behavior, or mental illness (e.g. bipolar disorder or schizophrenia). 2. The nursing staff will identify, document, and inform the physician about an individual's mental status, behavior, and cognition, including: a. Onset, duration and frequency of problematic behaviors or changes in behavior, cognition or mood; b. Any precipitating or relevant factors (e.g. medication changes, infection, recent transfer from hospital) ...Monitoring: 1. If the resident is being treated for [REDACTED]. 2. The staff will document (either in progress notes, behavior assessment forms, or other comparable approaches) the following information about specific behaviors: a. Number and frequency of episodes; b. Preceding or precipitating factors; c. Interventions attempted... and d. Outcomes associated with intervention..." 3. Resident #6 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 11/9/10 documented the resident had short/long-term memory problems and was severely impaired in cognitive skills for daily decision making per staff assessment for mental status, was inattentive, had disorganized thinking and psychomotor retardation, displayed physical behavioral symptoms directed toward others which occurred 1 to 3 days and had verbal behavioral symptoms directed toward others which occurred 1 to 3 days. a. The "Resident Plan of Care" last reviewed on 2/9/11 had no identified specialized needs or need for placement on the unit. b. The Nurse's Notes dated 3/20/11, with no time indicated, documented, "Res (Resident) roommate (Resident #2) reports this res (Resident #6) was (up) in (wheelchair), came over (and) put her hands around her neck. (Resident #6) admits she did just that, denies any provocation, shrugs her shoulders (and) grins when asked why, res mat alarm had been pushed aside, res nods when asked if she did so, res placed 1 on 1 with staff (and) Administrator notified." c. The Incident/Accident Facility Report for Resident #2 dated 3/20/11 at 11:30 p.m. documented, "...Location of Incident: Room; Description of Incident / Accident: Res report roommate (Resident #6) put her hands around her neck. No injuries or marking noted. ...Interventions / Follow Up: Roommate (Resident #6) 1 on 1 (with) staff. Will monitor (Resident #2) closely for bruising or (shortness of breath) ...Roommate sent to (Geriatric Psychiatric) 3/21/11..." 1) The Nurse's Notes dated 3/21/11 at 2:00 a.m. documented, "Res (Resident) remains one on one, no behaviors noted (at) this time." 2) The Nurse's Notes dated 3/21/11 at 9:00 a.m. documented, "Remains (with) 1:1 (with) staff, (no) further (signs/symptoms) of any aggression. All pertinent paperwork faxed to (Geriatric Psychiatric). Will (continue) 1:1." 3) The Nurse's Notes dated 3/21/11 at 3:20 p.m. documented, "Out at this (time) to (Geriatric Psychiatric)..." d. The (hospital) Psychosocial Assessment for the admitted [DATE] documented, "...Presenting Data: The patient is a [AGE] year old white female who was admitted to (Geriatric Psychiatric) due to combative behavior. She choked her roommate, she isolates, and is difficult to redirect... (Resident #6) was unable to complete Mini Mental Status Examination Geriatric Depression Scale, or Cornell Depression and Dementia assessments due to cognitive deficits, poor memory retrieval and marked confusion. Due to the patient's cognitive deficits as a result of her brain injury, she is a poor historian..." The "Discharge and Continuing Care Plan" from (hospital) dated 3/30/11 documented, "I. Problems still evident at time of discharge that will require continuing care... A. (Resident #6) continues to be at risk for relapse of behavioral disturbances and aggression... II. Proposed follow-up for these problems... A. Follow up psychiatric therapy/medication management will be provided by (facility)..." e. The Nurse's Notes dated 3/30/11 at 3:00 p.m. documented, "Resident arrived to facility..." f. There was no documented update to the "Resident Plan of Care" addressing monitoring or interventions to prevent/minimize the re-occurrence of aggressive behaviors until 4/7/11. g. The Nurse's Notes dated 3/30/11 at 4:30 p.m. documented, "Resident became agitated when placed in her assigned (room) and the other resident (Resident #3) in the (room) was yelling out. She began grunting and moving toward the doorway of the (room). Resident was placed in front of the nurse's station (and) resident then became calm..." h. The Nurse's Notes dated 4/7/11 at 1:51 p.m. documented, "While walking hall this LPN (Licensed Practical Nurse) heard groaning coming from (room) ...Upon entry I noted res (Resident #6) to have both hands around roommates (Resident #3's) throat attempting to choke roommate. I immediately removed res (resident) hands from throat and placed res on 1 on 1 care and notified DON (Director of Nursing), Admin (Administrator), family, police. Awaiting police arrival at this time." i. The "Resident Plan of Care" updated on 4/7/11 documented, "Physical aggression towards roommate... 1. Removed from room. 2. 1:1. 3. Transfer to (Geriatric Psychiatric). 4. Search for other placement." j. The Nurse's Notes dated 4/7/11 at 11:09 p.m. documented, "...One on one all shift (with) CNA (Certified Nursing Assistant). No aggressive behaviors noted." k. The Nurse's Notes dated 4/8/11 at 2:36 p.m. documented, "Left facility (at) 9:30 a.m. via company van." l. The Nurse's Notes dated 4/11/11 at 11:07 a.m., written by LPN #2, documented, "Res sent to a geri-psych (Geriatric Psychiatric) unit for (evaluation) and treatment of [REDACTED]." m. On 4/20/11 at 2:37 p.m., CNA #1, who worked on the closed unit, was asked, "What do you do if there is a resident to resident altercation?" The CNA stated, "Pull residents apart and report to charge nurse and unit manager. Policy is 1 to 1, arm length away from us and around no other residents at all. Never leave them alone even if wandering up and down hallway. Not counted as staff due to 1 to 1." The CNA was asked, "After (Resident #6) was moved in with (Resident #3), did you do anything different?" CNA #1 stated "No." n. On 4/20/11 at 3:47 p.m., CNA #2, who worked on the closed unit, was asked, "What do you do if there is a resident to resident altercation?" The CNA stated, "Try to separate them and tell the nurse. They have to go out, change meds (medications)." CNA #2 was asked, "Would you do 1 to 1?" The CNA stated, "Any time altercation, resident to resident or resident acting out it's always 1 to 1... Stay close make sure not harm to themselves or anyone else..." The CNA stated she had heard "(Resident #6) attacked (Resident #2) and then (Resident #3)." CNA #2 was asked, "When (Resident #6) returned to the facility did you do anything different for (Resident #6)?" CNA # 2 stated "No." o. On 4/20/11 at 4:00 p.m. CNA #3, who worked on the closed unit, was asked, "What do you do if there is a resident to resident altercation?" The CNA stated, "Try to separate, get apart, take resident out of room and take one resident with me to notify charge nurse." The CNA was asked "(Do you do) 1 to 1?" CNA #3 stated, "Yes ...arms reach of resident at all times and not around other residents, in room at meal time." The CNA was asked, "Has any resident ever choked another resident?" CNA #3 stated, "(Resident #6), (Resident #2)" The CNA was asked, "What happened?" CNA #3 stated, "Immediately removed (Resident #6) from room, asked (Resident #2) if okay; didn't see red marks or anything. Let nurse take control of that situation." CNA #3 was asked, "(Resident #6) on one to one?" The CNA stated, "Yes." CNA #3 was asked, "Did (Resident # 6) go the (Geriatric Psychiatric)?" The CNA stated, "Yes." CNA #3 was asked, "Did the facility do anything different when (Resident #6) returned?" The CNA stated, "Put (Resident #6) in (Resident #3's) room down the hall, away from (Resident #2)." p. On 4/20/11 at 4:20 p.m., CNA #4, who worked on the closed unit, was asked, "What do you do if there is a resident to resident altercation?" The CNA stated, "Try to remove resident that started altercation, separate them, keep them away from other residents; also one to one when resident is really combative to another resident or staff, just keep them away from everybody." CNA #4 was asked, "Has any resident ever choked another resident?" The CNA stated, "(Resident #6) was here but in another resident's (Resident # 2's) room. She was removed from the room and someone sat with her one on one in the feeder room. (When she came back she) was put in with (Resident #3); figured she wouldn't (choke her) but she did." CNA #4 was asked, "Was (Resident #3) able to call for help or move away from her at that time?" CNA # 4 stated, "No." q. On 4/20/11 at 4:37 p.m., LPN #3, who worked on the closed unit, was asked, "What do you do if there is a resident to resident altercation?" The LPN stated, "Step in the middle secure both sides and call for aide to come. Remove one of them, automatically start one to one with the one who is the aggressor, sometimes for 2 or 3 days, usually go to (Geriatric Psychiatric), notify (DON) and (Unit Manager, LPN #2)." r. On 4/21/11 at 11:12 a.m., LPN #2, the Unit Manager for the closed unit, presented "Behavior Weekly Progress Note" for Resident #6 dated from 2/17/11 through 4/1/11. The "Behavior Weekly Progress Note" dated 2/17/11 documented, "...Behavior Exhibited in last 7 days: 1. Combative with staff; Number of episodes that occurred: 1. One; Interventions utilized in last 7 days: 1. Re-approach, 2. Re-direct ...IDT (Interdisciplinary Team) Notes/Recommendations: Problem: Combative with staff; Intervention: Re-approach, re-direction; Evaluation: Positive outcome; Recommendation: (Continue) current POC (plan of care)." LPN #2 was asked, "Did you find out the trigger for the behavior?" The LPN stated, "No." When asked, "Is there a behavioral plan of care for (Resident #6)?" LPN #2 stated, "No." LPN #2 was asked to review the Nurses Notes dated 3/20/11. The LPN was asked, "Was the other resident (Resident #2)?" LPN #2 stated, "Yes." LPN # 2 was asked, "Did you ever figure out why this happened?" LPN #2 stated, "No." the LPN was asked, "Was there any follow-up later with (Resident #6) to ask her why she choked her roommate?" LPN #2 stated, "No, she went to Geri-psych the next day." LPN #2 was asked, "Did you do anything different on (Resident #6's) return to the facility 3/30/11?" The LPN stated, "Moved resident's room." LPN #2 was asked to review the Nurses Notes dated 3/30/11 at 4:30 p.m. The LPN was asked, "Did you know about (Resident #6's) behavior to new roommate hollering?" The LPN stated, "No, I didn't know about this and I don't make room assignments." LPN #2 was asked, "Did the facility consider a private room on return to the facility?" The LPN stated, "It was never brought up as a concern. After the (Resident #2) incident we felt if we moved (Resident #6) to another room that would be sufficient, obviously it was not effective." LPN #2 was asked, "How was (Resident #3) when (Resident #6) moved into the room?" The LPN stated, "She used to say 'Oh, my God, Oh, my God' and count very loudly because she was hard of hearing." LPN #2 was asked, "Was (Resident #3) able to defend herself on 4/7/11?" The LPN stated, "She would hit or try to knock you away, medicated probably no, un-medicated probably yes." LPN #2 was asked, "On 3/30/11, when (Resident #6) returned, did you all contact (attending physician) about the psych (psychiatric) meds since Remeron and Seroquel were discontinued and the Klonopin was decreased by Geri-psych?" The LPN stated, "Our usual practice is to continue what meds Geri-psych sent her back on." LPN #2 was asked, "Did you know the 'Discharge and Continuing Care Plan' from (hospital) dated 3/30/11 documented medication management was to be done by (facility)?" The LPN stated, "No." LPN #2 was asked, "Did you know the 'Discharge and Continuing Care Plan' documented (Resident #6) was at risk for aggressive behaviors?" The LPN stated, "No." LPN # 2 was asked, "Any current resident on the closed unit with aggressive behaviors?" The LPN stated, "No." s. On 4/21/11 at 12:55 p.m., the DON was asked, "If a resident has behaviors what happens?" The DON stated, "That behavior is documented and interventions are done; redirection, non-restraints, move to a different environment, re-approach is effective." The DON was asked, "Is there any one to one documentation form?" The DON stated, "No." The DON was asked, "Any documentation on assignment sheets that someone is doing one to one?" The DON stated, "No." The DON was asked, "What is your behavior management program?" The DON stated, "They are monitored for any behavior and if we can note any pattern of behavior, that's helpful, especially what precipitates behaviors. During the weekly behavior meeting we bring those behaviors forward and talk about what interventions could be put into place to try and head off behaviors." The DON was asked, "Any documented in-services after your weekly meetings to update staff on new interventions for residents?" The DON stated, "No." The DON was asked, "What did you do differently with (Resident #6) after she returned to the facility on [DATE]?" The DON stated, "Talked about room placement, it was brought up that (Resident #3) hollered out from time to time and she wasn't doing that now. We thought the room placement would work." The DON was asked, "Did you discuss not taking (Resident #6) back after the 3/20/11 incident?" The DON stated, "We did and we decided we would give her one more chance." The DON was asked, "Any increased monitoring of (Resident #6) on return to facility on 3/30/11?" The DON stated, "No, no more than any other resident on the unit." The DON was asked, "Is it your practice to check with the attending Physician regarding psych meds on return from Geri-psych?" The DON stated, "No." The DON was asked, "Did you identify that cursing/yelling caused (Resident #6) agitation?" The DON stated, "Yes, but we felt (Resident #3) would not be as agitating as other residents" The DON was asked, "Did you think about putting (Resident #6) in a private room?" The DON stated, "No. After 4/7/11 we decided not to take her back." t. The "Weekly QA Meeting" form for "Behavior" dated 4/8/11 documented, "(Resident #6) out to (Geriatric Psychiatric) - aggression." There was no identification of the cause of behaviors, who Resident #6 was aggressive toward, how often this behavior had occurred, what interventions had been tried that failed, etc. The form further documented, "(Resident #3) - yells out - redirect not as affective - has UTI (Urinary Tract Infection) - hope for improvement." 4. Resident #3 had a [DIAGNOSES REDACTED]. a. The Nurses Notes dated 4/7/11 at 1:54 p.m. documented, "While walking hall this LPN heard groaning coming from rm (room)... I entered room and found roommate (Resident #6) with both hands around res (Resident #3) throat attempting to choke (resident) causing abrasion to (bilateral) throat. DON (Director of Nursing), Adm (Administrator), family and police notified. Awaitin(g) police at this time. Roommate removed from room and placed on 1 on 1 care at this time." b. On 4/20/11 at 9:50 a.m., LPN #1 was asked, "Who was (Resident #3's) roommate who choked her?" The LPN stated , "(Resident #6), she's not here anymore." LPN #1 was asked, "Any other residents with aggressive behaviors currently on the secure unit?" The LPN stated, "No." 5. The facility removed the Immediate Jeopardy and reduced the scope/severity to "G" on 4/7/11 when the following corrective actions were implemented: a. Resident #6 was removed from the room shared with Resident #3 at approximately 1:51 p.m. (paragraphs 3-h through 3-l). b. Resident #6 was immediately placed under 1:1 supervision until transfer could take place (paragraphs 3-h through3-l). c. Resident #6 was transferred to (Geriatric Psychiatric) unit on 4/8/11 at 9:30 a.m. (paragraphs 3-k and 3-l). d. Resident #6 was discharged from the facility (paragraph 3-s). e. Since the time of Resident #6's transfer and during the survey there were no other residents on the secure unit with aggressive behaviors: 1) On 4/20/11 at 9:50 a.m., LPN #1 was asked "Any other residents with aggressive behaviors currently on the secure unit?" LPN #1 stated "No." On 4/21/11 at 11:12 a.m., LPN #2 was asked, "Any current resident on the closed unit with aggressive behaviors?" LPN #2 stated, "No." 2) On 4/22/11 at 11:42 a.m., the Administrator was asked per telephone "Are there currently any residents on the closed unit with aggressive behaviors?" The Administrator stated, "No." On 4/22/11 at 11:45 a.m., the DON was asked per telephone "Are there currently any residents on the closed unit with aggressive behaviors?" The DON stated, "No." The DON was asked, "Any time a resident has aggressive behaviors what do you do?" The DON stated, "We put resident on one to one, notify the physician and administrator and do one to one until transfer to Geri-psych." On 4/22/11 at 11:47 a.m., LPN #1 was asked again per telephone "Are there currently any residents on the closed unit with aggressive behaviors?" LPN #1 again stated, "No." LPN #1 was asked, "What is your policy when residents have aggressive behaviors?" LPN #1 stated, "Put CNA one to one with resident, call physician, call DON, call Administrator."

Complaint # was substantiated (all or in part) with these findings: Based on record review and interview, the facility failed to ensure that residents with a [MEDICAL CONDITION] received proper treatment and care to prevent complications as evidenced by the facility ' s failures to ensure care/suctioning was provided per the plan of care; replacement supplies needed for oxygen administration for a resident who required non standard equipment was available; staff were competent and comfortable in [MEDICAL CONDITION] and responding promptly to the need for suctioning; and that the resident ' s condition was monitored to determine the need for suctioning for 1 (Resident #5) of 2 (Resident # 3 and #5) case-mix residents who had a [MEDICAL CONDITION] (trach) and physician orders [REDACTED].#5 who had a change in respiratory status and had the potential to affect 1 other resident who had a [MEDICAL CONDITION] as documented on a list provided by the MDS (Minimum Data Set) Coordinator on 9/2/10 at 9:58 a.m. The facility was notified of the Immediate Jeopardy on 9/1/10 at 4:25 p.m. The findings are: 1. Resident #5 had [DIAGNOSES REDACTED]. a. A Hospital "Discharge Summary" dated discharged [DATE] documented: ... Hospital Course: The patient is a [AGE] year old white female that initially was admitted to (hospital) intensive care unit on 6/12/10 secondary to ventilator dependent [MEDICAL CONDITION] from [MEDICAL CONDITION] exacerbation and [MEDICAL CONDITION]- resistant Staphylococcus aureus pneumonia. She required ventilatory support since that admission. She received a [MEDICAL CONDITION] on 6/23/10, and then was transferred to (Hospital) on 6/24/10. She remained in (Hospital) on the ventilator with [MEDICAL CONDITION] consultation to assist weaning off the ventilator. The patient slowly improved with weaning. The patient was put on a [MEDICAL CONDITION] collar and the patient was stable. For her pneumonia, the patient was initially treated with [MEDICATION NAME] and [MEDICATION NAME]. The patient also was admitted with acute -on- [MEDICAL CONDITION] for which she had renal following and she was on [MEDICAL TREATMENT] every other day. Her renal function was improved as well. . .The patient also had a history of [REDACTED]. She responded well to an occasional low dose of intravenous [MEDICATION NAME]. . .[MEDICAL CONDITION] managed with [MEDICATION NAME] and Atrovent updrafts. . .The patient had episodes of [MEDICAL CONDITIONS] flutter and sinus arrhythmia. . .At this time the patient is off the ventilator, she is on a [MEDICAL CONDITION] collar and tolerating it very well. ...During this admission in (Hospital), the patient also developed a urinary tract infection. . .Discharge instructions: . . .3. Follow up with (Pulmonology) in one month. Suction the [MEDICAL CONDITION] as needed. . . b. Nursing home facility admission orders . . . [MEDICAL CONDITION] per protocol. . .[MEDICAL CONDITION](as needed)." c. Nurses Notes dated 7/26/10 at 6:00 p.m. and signed by License Practical Nurse (LPN) #1 documented, "Resident entered facility via our transport from (hospital) in wheel chair. (Resident ) has O2 at 40 % via trach. [AGE] year old white female. (Left) lung clear. Crackles in (right) lung. . . " d. The Significant Change Minimum Data Set (MDS) with an Assessment Reference date of 7/27/10 documented the resident had moderate impaired cognitive skills for daily decision making, short and long term memory problems, had shortness of breath and [MEDICAL CONDITION] in the last 7 days, received oxygen therapy, suctioning and [MEDICAL CONDITION] care in the last 14 days. e. Nurses Notes dated 7/27/10 at 7:00 p.m. and signed (LPN) #1 documented, "(Resident) called nurse into room (with) complaints of respiratory problems. O2 sat (saturation) at 94 %. Dr. (Doctor) paged, order received to give [MEDICATION NAME] 1 (milligram) IM (intramuscular) and call back with results in one hour. (Resident) was given IM injection. O2 sat 95 %, (resident) still having complaints of unable to breathe. 8:00 p.m. contacted Dr. again and explained (resident) still (complaining) of labored (respirations). (Resident) sat up in recliner, resident also given updrafts with no relief. Order received to transport to (hospital). EMS (Emergency Medical System) notified ..." There was no documentation of an assessment that included breath sounds, [MEDICAL CONDITION], rate or rhythm of respirations, heart rate, or vital signs. There was no documentation that the resident was suctioned. 1) On 9/1/10 at 3:58 p.m., LPN #1 stated, "We admitted her one night. We had to send her right back to the ER. She had a [DIAGNOSES REDACTED]. She was asked, "What assessment did you do on 7/27/10 when the resident was having respiratory problems?" She stated, "I took a pulse ox, it was 94 %. She has been in and out (of hospital) several times. I called the Dr. and he told me to send her to the ER for eval (evaluation) and treatment. That was at 7:00 p.m. At first I thought she might have anxiety and he gave me an order for [REDACTED].?" She stated, "No, [MEDICAL CONDITION] clear." She was asked, "How do you know that?" She stated, "There were no obstructions. She was mouth breathing. She was asked, " Did you listen to her lung sounds and did you perform any respiratory assessment?" She stated, "Yes." She was asked, "Where is that documented?" She stated, "I guess I didn't listen to her lungs. If it's not documented, you didn't do it." She stated, "At first she was having a little problem breathing so we sat her up 90 degrees in the recliner and I called the Dr." 2) On 8/31/10 at 4:15 p.m., the Minimum Data Set (MDS) Coordinator was asked, "Are there any more records for this resident that are not in the chart?" She stated, "Not that I know of, I will look. " As of 9/2/10, there were no Treatment Administration Records (TAR) that verified the resident had been suctioned anytime during the month of July 2010. On 9/2/10 at 3:22 p.m., the Director of Nurse's stated, "I cannot find that TAR. I have looked through everything we have and I just cannot find it." 3). As of 8/31/10 at 5:00 p.m., there was no documentation in the Nurses Notes or the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. f. The ED (Emergency Department) Note -per the ER Physician dated 7/27/10 at 11:00 p.m. documented: " History of present illness: ...presents with a complaint of shortness of breath, cough, congestion. Duration [MEDICATION NAME] 1 day. The degree of severity is moderate. . .Patient states having increasing cough and congestion. Pt. states can't get anything up. ... " g. The Hospital History and Physical dated 7/28/10 documented: " . . .Respiratory System: Wheezes and coarse breath sounds heard. There is an increased effort of breathing, but no crackles. . . Assessment and Plan: . . .[MEDICAL CONDITION] exacerbation. Continue on oxygen, given a updraft, Solu-[MEDICATION NAME], and put in on ventilator. . . " h. The Hospital Discharge Summary Report dated 8/18/10 documented: " ... Course of hospitalization : This patient is well known to us with end stage [MEDICAL CONDITION] and also severe coronary obstructive [MEDICAL CONDITION] disease. She was intubated when she came in, and in the ICU, her blood pressure went up and then we started her on Cardene. With some difficulty her Cardene drip was turned off and she was started on blood pressure medicines. . .The [MEDICATION NAME] was tapered off and she was weaned off from the vent. (Dr.) was kind enough to do [MEDICAL TREATMENT] on her and finally, she was weaned off from the vent. She has [MEDICAL CONDITION] in place. She will continue [MEDICAL CONDITION]. . . " i. Facility Admission Physician orders [REDACTED]. . .O2 on via NC (Nasal Cannula) at 15 L (Liters) / Min (Minute). " Physician orders [REDACTED]. OK to remain on 10 L overnight. Change to 15 L of O2 in a.m. " On 9/1/10 at 11:50 a.m., LPN #3 stated, " I readmitted her on 8/18/10. She had O2 at 15 L. . .They had made up a hose from the hospital." She stated, " I don't remember [MEDICAL CONDITION] for her." She was asked, "Did you ever suction her?" She stated, "No." She was asked what training she received regarding assessments [MEDICAL CONDITION]?" She stated, " Listen to lungs, suction if coughing, if can't cough up, suction. If suction doesn't work, you call the Dr and send to the ER. I don't remember being trained here. I don't recall when I was trained. I believe I had inservice but I just don't know." j. The Temporary Care Plan dated 8/18/10 documented, " Problem: Special Care Needs Assessment: [MEDICAL CONDITION]/Laryngectomy (checked with a check mark). . .Intervention: Clean [MEDICAL CONDITION] per orders. . .O2 (Oxygen) [MEDICAL CONDITION] 15 L (liters) / (minute). [MEDICAL CONDITION] indicated. Problem: High risk for infection (related to ) . . .[MEDICAL CONDITION]. Intervention: [MEDICAL CONDITION] per orders. " k. Nurses Notes dated 8/20/10 at 9:00 p.m. and signed by LPN #2 documented: " Returned from [MEDICAL TREATMENT], breathing labored. Returned to concentrator from portable O2, running 15 L , Pulse ox is 88 %. 9: 45 p.m., breathing remains labored, Pulse ox is 86 %. Dr. answering service paged, awaiting return call. 9:55 p.m. (Dr.) returned call due to labored shallow breathing. Send to (Hospital) ER for eval and possible admit. 10:00 p.m., resident left facility in route to (Hospital) " There was no documentation that the resident had been suctioned. 1) On 9/1/10 at 9:45 a.m., LPN #2 stated, "She was a trach, she was on 15 L of oxygen via trach. . .Her breathing was getting more labored and I sent her to the hospital (on 8/20/10). I worked a double that day. That morning she was fine. She got back from [MEDICAL TREATMENT] at 9:00 p.m. She was having labored breathing, more like stomach breaths than with her chest. She had been on the ventilator before coming to us. She did not want to go back to the hospital. " LPN #2 was asked, "From 9:00 p.m. to 9:45 p.m., why did you not call the Doctor." She stated, "I'm reasonably sure it was because she told me she didn't want to go back to the hospital." She was asked, "What type of assessment did you do?" She stated, " Vital signs, pulse ox, listened to lungs. She had shallow diminished sounds, about the same as when she came back to us." She was asked, "Did you document that?" She stated, "No. " She was asked, "How often did you do an O2 sat?" She stated, "Probably the one time. " She was asked, "What did her O2 sats usually run?" She stated, "Around 90-92." She was asked, "Where was that documented?" She stated, "I guess they aren't." She was asked, "When she came back from [MEDICAL TREATMENT] and her pulse ox was 88 %, did that concern you?" She stated, "Yes enough that I knew I needed to watch her." She was asked, "So, it was 45 minutes before you went back and assessed her?" She stated, "No, I know that's what I charted but no way. " She was asked, "Why didn't you document your assessment?" She stated, "I didn't document it but I assessed her." She was asked, "Did she have orders [MEDICAL CONDITION]?" She stated, "I'm reasonably sure she did. She [MEDICAL CONDITION]. " She was asked, "Did you [MEDICAL CONDITION]?" She stated, "No, but she didn't have anything in the trach." She was asked, "How do you know that?" She stated, "I pulled the cup down and looked." She was asked, "Did you ever suction her?" She stated, "No." She was asked, "What training have you received regarding assessments [MEDICAL CONDITION]?" She stated, "We have a protocol book out there (at the nurses station) . We read that to refresh ourselves. I know how to suction and do [MEDICAL CONDITION]. " She was asked, " When did you receive training?" She stated, "In school." She was asked, "How long ago was that?" She stated, "4 years." She was asked, " Did anyone ever observe you [MEDICAL CONDITION]?" She stated, "Yes, another LPN, we had another resident who had [MEDICAL CONDITION] I was uncomfortable doing it so I asked her to come with me and she did. I would have felt comfortable if I had [MEDICAL CONDITION]." She was asked, "What symptoms would require suctioning? " She stated, "If I heard or saw fluid, if she told me she felt like she was choking or something. I wouldn't just suction on a routine basis. " She stated, "She had O2 on via trach, she had 2 concentrators, one on 10 L and one on 5 L. " She stated, " All of the tubing was connected to the trach. I didn't connect it, all I did was disconnect the bottom part. . .The cup completely covered the trach." She was asked, "Was there any leakage?" She stated, "Not that I saw, you could hear the O2 going into the cup with the audible ear." 2) On 8/31/10 at 10:35 a.m., the resident was asked, " Did the facility staff do any thing with your trach?" She stated, "No." She was asked, "Did they clean your trach?" She stated, "No." She was asked, if she was ever suctioned while at the facility. She stated, "They didn't suction me the whole time I was there." 3) As of 8/31/10 there was no documentation on the August 2010 Medication Administration Record, [REDACTED]' s transfer to the hospital emergency room . 4) On 9/1/10 at 10:50 a.m., the Unit Manager was asked, "Did (Resident #5) have orders [MEDICAL CONDITION]?" She stated, "Trach Care per facility policy." She was asked, "What is facility protocol?" She stated, "Every day and PRN unless they have an order otherwise." She was asked, "Where [MEDICAL CONDITION] documented?" She stated, "Should be on the TAR. " She was asked, " What symptoms would [MEDICAL CONDITION] or suctioning?" She stated, "If they are wheezing, cough, can't breathe, complaining of shortness of breath or obvious difficulty breathing. . . " She was asked, " How are the staff trained [MEDICAL CONDITION] and signs/symptoms to observe for?" She stated, "The old DON (Director of Nurse's) done that. He ran thru what you need to know a couple of months ago. " m. An ED (Emergency Department) Triage and Assessment Adult-Text dated 8/20/10 documented: " Performed 8/20/10 11:00 p.m. . . Activity Tolerance: Dyspnea/Fatigue at rest. Cardiopulmonary Assessment: Difficulty breathing at rest, Difficulty breathing with activity, Shortness of Breath. System Review 2: ...Respiratory System: Respirations: Hyperpnea, Labored, Use of Accessory Muscles. . .Cough: Occasional. Breath Sounds Assessment Grid: LUL (Left Upper Lobe) Diminished, Expiratory Wheeze. RUL (Right upper lobe) Diminished. RML (Right Middle Lobe) Diminished. LLL (Left lower lobe) Diminished, Expiratory wheeze. RLL: Diminished, Expiratory wheeze. " n. A Hospital Physician "Progress Record" dated 8/21/10 12:30 documented: " ...(Patient) was recently discharged for severe [MEDICAL CONDITION] exacerbation and VDRF (Ventilator Dependent [MEDICAL CONDITIONS]. She had no suctioning while in nursing home. In addition, [MEDICAL CONDITION] was not hooked up correctly and she had O2 leakage. Currently she is much improved (after ) suctioning, updrafts, O2. " o. A Hospital History and Physical dated 8/21/10 documented: " Chief complaint: Patient brought via EMS from nursing home in (town) because of fever and worsening shortness of breath. History of present illness: This [AGE] year old Caucasian female with multiple medical problems, including end stage-[MEDICAL CONDITION], Diabetes Mellitus type 2, [MEDICAL CONDITION], obesity, who was previously hospitalized in this facility because of [MEDICAL CONDITION] exacerbation requiring mechanical ventilation in the ICU, and subsequently [MEDICAL CONDITION] placement. The patient ended up with [MEDICAL CONDITION] and later placed on [MEDICAL TREATMENT]. The patient was discharged from this facility 2 days ago to a skilled nursing facility in (town). The patient is brought via EMS to (Hospital) to the ER because of worsening shortness of breath and spiking fever around 103 (Fahrenheit). . . Physical Assessment: Decreased generalized breath sounds, bilateral scattered moderate wheezing and rhonchi. The respiratory effort is labored. She mobilized a lot of secretions. . .Laboratory: . . .5. Chest X-Ray: I personally compared the chest x-ray taken today with the one taken 3 days ago, and I can see new infiltrate in the right lower lobe that was not present on the previous chest x-ray. . . Assessment and Plan: . . .1. Hospital -Acquired Pneumonia. . .We will order also updrafts and aggressive [MEDICAL CONDITION] toilet, and suction of secretions. At this point I think she will benefit from [MEDICATION NAME] updrafts as well since she is having a lot of secretions with mucus plug. . ." p. On 9/1/10 at 10:50 a.m., the nursing home facility Unit Manager was asked what type of O2 set up the resident had. She stated, "The respiratory therapist set up the O2 set up for us. We didn't have that type of tubing, that came from the hospital." She was asked, "What would you have done if there was something wrong with her set up?" She stated, "I would have had to have gone to the hospital. " She was asked, "And if it were 2:00 a.m., in the morning?" She stated, " I would call 911." q. On 9/1/10 at 2:40 p.m., the Medical Director who is the resident's primary care physician was asked, "How often [MEDICAL CONDITION] be done?" He stated, "At least once a day. If someone is having hypersecretions, more. It depends on the situation. " He was asked, if a resident with [MEDICAL CONDITION] complaining of respiratory problems what would he expect the facility to do? He stated, " I would expect them to try to clear any plugs, suction, put them on supplemental O2 if not already on it and listen to their lungs. " He was read the Nurse's Note for 8/20/10 at 9:00 p.m. and 9:45 p.m. and asked, "What would you have expected (staff) to have done?" He stated, "I would expect them to have listened to her lungs and suction. If that did not work then I think it's appropriate to send her out. It would not have been appropriate not to have suctioned. It might have put them in some distress." 2. The Immediate Jeopardy was removed on 9/2/10 at 1:15 p.m. and the scope and severity reduced to " H " when the facility implemented the following Plan of Removal: a. A list of all residents with respiratory [DIAGNOSES REDACTED]. Any abnormal findings will be dealt with immediately by the charge nurse. Twenty eight residents were assessed with [REDACTED]. b. Immediate In-service on proper assessment of resident with respiratory conditions by DON or designee for 100 % nursing personnel, initiated on 9/1/10 for all nurses and to be completed prior to next shift and ongoing for all new employees. In-services to include but not limited to full lung assessment, pulse oximetry results, vital signs, onset, duration, frequency and severity of symptoms. c. Education on the following policies and procedures by DON or designee; [MEDICAL CONDITIONS] Clinical Protocol, Pneumonia, [MEDICAL CONDITION], and Lower Respiratory Infections-clinical Pulse Oximetry, (Assuring Oxygen Saturation), Suctioning the lower airway (Endotracheal (ET) or [MEDICAL CONDITION]), [MEDICAL CONDITION] Care, Proper Application of oxygen delivery devices, and change in a Resident's Condition or status for 100 % nursing personnel, initiated on 9/1/10 for all nurses and to be completed prior to next scheduled shift and ongoing for all new employees. d. In-service with return demonstration for all nurses of [MEDICAL CONDITION] care and suctioning procedure to be carried out by DON or designee starting 9/1/10 for 100 % nursing personnel and to be completed by next scheduled shift and ongoing for all new employees. e. Education on appropriate documentation of Respiratory Assessment and signs and symptoms of abnormal findings will be initiated on 9/2/10for 100 % nursing personnel and to be completed by next scheduled shift and ongoing for all new employees by DON or designee. f. Educate staff on use of Change of Condition form utilizing SBAR communication for resident with [MEDICAL CONDITION] by DON or designee, 9/2/10 for 100 % nursing personnel and to be completed by next scheduled shift and ongoing for all new employees. g. All charge nurses to be In-serviced that if a resident is admitted with unfamiliar equipment or disease processes DON or designee will be notified immediately. h. Monitoring of residents with respiratory [DIAGNOSES REDACTED]. New residents will be assessed upon admission by the charge nurse and reviewed the following day by DON or designee, ensuring accuracy of completion of assessments, appropriateness and ensure that a care plan is initiated immediately. i. The one current resident with a [MEDICAL CONDITION] will be monitored daily by the DON or designee to [MEDICAL CONDITION] is done. Documentation [MEDICAL CONDITION] and assessment of resident status, will be monitored by the DON or designee daily. Any identified failed practice of performing [MEDICAL CONDITION] (identified by observation of clean [MEDICAL CONDITION] by DON or designee) will be dealt with by immediate education and counseling. Any nurse with continued failed practice will receive immediate disciplinary counseling with suspension and possible termination.