Every finding on record at White River Healthcare

Based on observation, interview and facility document review, the facility failed to ensure the food preparation equipment and environment were maintained in a clean and sanitary condition to prevent contamination and the potential development of foodborne pathogens during an observed meal service in one of one facility kitchen. The findings include: During a tour of the kitchen with [NAME] #1 on 07/20/26 at 9:10 AM the following was observed:-A brown dry substance on the refrigerator floor. -A plastic container of peaches in the refrigerator was without an opened date.- A bag of corn dogs and garlic sticks was observed in the freezer, uncovered with frost on them. During an observation that began on 07/22/2026 at 10:45 AM, this surveyor observed the following:- [NAME] #1's oven mitt touched the inside of the cooked pork while [NAME] #1 removed the pork from the oven. -While transferring pureed Brussel Sprouts out of the mixer to the pan, food splashed on [NAME] #1's shirt. [NAME] #1 used their finger to remove the food, placed the food from their shirt on aluminum foil, used the same finger to remove the splashed [NAME] Sprouts from the pan and placed it on the aluminum foil sitting on the food prep table. No hand hygiene was observed after [NAME] #1 touched their shirt making their hands contaminated.-Cook #1 removed the sweet potatoes, that were in an aluminum pan from the oven with oven mitts, took off the oven mitts. Without performing hand hygiene [NAME] #1 removed the aluminum foil lid and picked up the lid to the mixer with their fingers which touched the inside lid. -Cook #1 wiped the workstation with a cloth containing sanitizer and inserted the mixing blade in the mixer without sanitizing their hands. During an observation on 07/22/2025 at 11:10 AM, Dietary Aid pressed the pie crust into the pie pans with gloved hands, then after, opened a package of pie crust with the gloved hands, placed and pressed the new pie crust into a pan with the same contaminated gloves. During an observation on 07/22/2026 at 11:25 AM, [NAME] #2, while taking the temperature of the broccoli, inserted the thermometer probe into the broccoli past the metal probe, touching the plastic portion near the display screen of the thermometer. [NAME] #2 did not fully wipe the thermometer off after checking the broccoli temperature, and broccoli particles was found on other food items that the temperature had been obtained with the same thermometer. During an observation on 07/22/2026 at 12:00 PM, [NAME] #2 did not wash their hands before meal prep. [NAME] #2 handled a stack of plates and the palm of their hand touched the food surface of the plate. During an observation on 07/22/2026 at 12:01 PM, this surveyor observed loose hair outside the hair net on the Dietary Aid, [NAME] #1 and [NAME] #2. During an interview on 07/22/2026 at 11:20 AM, the Dietary Aid stated, they put on their hair net when arriving in the kitchen and washed their hands. The Dietary Aid stated, I should have washed my hands during the food prep task. During an interview on 07/22/2026 at 12:00 PM, [NAME] #2 indicated we [staff] are supposed to sanitize the thermometer after each temperature test to ensure it is clean to prevent the spread of germs. It does look like broccoli was still on the thermometer. During an interview on 07/22/2026 at 12:01 PM, [NAME] #1 stated I should wash my hands when touching surfaces, as well as before and after gloving. I did not realize I touched my shirt; I should have washed my hands after sanitizing the prep surface. [NAME] #1 stated hair needs to be in the hair net, we have a mirror in the bathroom we can use, and we can tell each other if hair is loose. During an interview on 07/23/2026 at 9:00 AM, The Dietary Manager explained the brown substance on the refrigerator floor, looked like cardboard box debris which could collect contaminates and build up mold. It should be cleaned by whoever sees it. The Dietary Manager stated the opened package of corn dogs and garlic sticks from the freezer needed to be disposed of due to being open to air and having frost on them. The Dietary Manager stated they expect staff to wash hands after bathroom breaks, upon entering the kitchen, when they touch something dirty, before they glove up and after taking gloves off. Hair nets need to be on as soon as staff walk in the door and make sure all hair is in the hair net. If staff, see hair out they should tell each other. The Dietary Manager stated while taking temperatures of food, staff do not need to put the thermometer in past the metal probe. The thermometer needs to be completely cleaned off between each food temperature test. During an interview on 07/23/2026 at 9:15 AM the Dietary Aid indicated hair nets prevent hair from getting in the food. We put on hair nets when we walk in the door, if our hair comes out, we need to put it back in and tell each other if our hair is out. During an interview on 07/23/2026 at 10:04 AM, the Administrator stated kitchen staff need to follow the policy of handwashing which says washing hands while in the kitchen prevents cross contamination. Hair nets need to be on, and hair covered to prevent hair from getting in and to cross contaminating the food. The food stored in the freezer needs to be stored properly, covered and dated at the correct temperature to keep it frozen. During an interview on 07/23/2026 at 10:13 AM, the DON stated, dietary staff needed to be educated on hand washing while handling food and after going to the bathroom. Hand washing was for infection control and cross contamination prevention. Review of in-service dated 01/15/2026, titled Stocking, Handwashing, Food Texture indicated There are signs above all sinks on how to properly wash hands, remember you must wash hands upon arriving at work, after your hair net is put on, after you make food, before serving out, if you touch your face clothing, hair anything. This is important to prevent cross contamination. [NAME] #1 and the Dietary Aid signed the in-service. Review of the in-service record, titled Proper Handling of Food and Dishware Proper Food Temps, dated 02/06/26 revealed Remember you must wash hands before and after making food, if you touch any clothing, face, after using the restroom and then again after leaving the restroom, anytime you take something to dish area. The in-service was signed by [NAME] #1, [NAME] #2 and Dietary Aid. Review of an undated facility policy titled, Infection Control Policy revealed, Hair must be completely covered by a bouffant disposable cap. The Handwashing guidelines in the Infection Control Policy, state, Wash hands, Before beginning shift, after breaks, after going to the restroom, after smoking or eating, after blowing your nose, after disposing of trash or food, after handling dirty dishes, after handling raw meat, eggs or poultry, after picking up anything off the floor, after any possible contamination. The policy also indicated Frozen foods must be well sealed to prevent freezer burn. Review of an undated facility policy titled Food Storage Policy revealed, all food must be stored in a manner to protect it from contamination.

Through observation, interviews, and policy review, the facility failed to ensure that equipment was in a clean, safe, useable condition and food was stored in a safe and sanitary manner. The findings are: During an observation on 11/19/2024 at 6:20AM, 20 small bowls were placed in a pan on the steam table serving side up without a covering. During an observation on 11/19/2024 at 6:32AM, Refrigerator #2 ' s left, and right door seals held a brownish color with dark brown and black spots along the inside seals. During an observation on 11/19/2024 at 6:33AM, Refrigerator #3 ' s left, and right door seals held a brownish color with dark brown and black spots along the inside seals. The seal contained a purplish discoloration of the seal. During an interview on 11/19/2024 at 6:34AM, the Dietary Manager stated the purplish discoloration was from chemicals used to clean the seals of the brownish color with the dark brown and black spots. Cleaning was unable to remove the unknown substance. The seals look dirty, like there is mold on the seals. The concern is cross contamination from not being able to clean spots off the seals. During an observation on11/19/2024 at 6:35 AM, the stand-up deep freezer had two 4 fluid ounce strawberry flavored ice creams squeezable to the touch; 72 four fluid ounce vanilla fortified shakes, 26 four fluid ounce strawberry fortified shakes; 29 four fluid ounce chocolate fortified shakes had thawed. 63 four fluid ounce chocolate ice cream cups had become pliable. The left and right-side doors of the stand-up deep freezer were wobbly, with condensation water droplets formed on the top portion of the stand-up deep freezer outside center which began to flow down the front surface. Dietary Manager confirmed the ice cream needed to be firm not soft, and the fortified shakes needed to be handed out, not re-frozen. During an observation on 11/19/2024 at 6:44AM, the industrial can opener blade contained a crusty yellowish orange and white unknown substance adhered to the blade. During an observation on 11/19/2024 at 6:28 AM, the standup refrigerator #2 had an unknown black substance on the seal going around the right center door. Dietary Manager stated the seal looks dirty like there is mold on it and there is concern of cross-contamination. During an observation on 11/19/2024 at 6:57AM, dry goods storage room chest freezer #3 seal on the right front corner was peeled back with a hole. The Dietary Manager stated facility was supposed to be replacing the deep freezer. During an observation on 11/19/2024 at 6:59 AM, dry storage room stand up freezer #2 contained two rust lines on the bottom shelf that go from the back freezer wall to the front opening. On the bottom, left-hand corner of the freezer, a switch for the light had holes between the plate and the bottom freezer wall. The freezer's bottom right-hand corner was missing approximately 2 .5-inch plastic that left the insulation exposed. Dietary manager confirmed the rust on the lower shelf could cause cross contamination. The Dietary Manager stated there was not a concern of the exposed insulation or hole by the light switch. During an observation on 11/19/2024 at 7:22AM, the Dietary [NAME] used food tongs to pick up toast wrapped in aluminum foil, then pick up bacon with the same food tongs. Dietary Manager stated the tongs used for the toast should not be used to pick up the bacon. During an interview on 11/19/2024 at 7:24AM, the Dietary Manager confirmed the 20 small bowls on the steam table should be flipped over or have the serving side covered to keep from cross contamination. During an observation on 11/19/2024 at 7:25AM, two deep fryer baskets had a black unknown substance built up on the wire grating throughout both fryer baskets. Wire grating had become loose from the top left side of both deep fryer baskets, this left wire grating end exposed and unsecured. The tall metal wall of the grease catch area, at the back of the deep fryer, showed a built up sticky grimy, black unknown substance. The open compartment at the back of the deep fryer contained brown unknown substance particles suspended within a yellowish grimy build up on the inside back wall, back edges and the front left and right corners. Dietary Manager confirmed there was a concern of wire pieces falling into the food being cooked for the resident's consumption. Dietary Manager stated there was an uncertainty if anything could go back there to clean the area. Dietary Manager wiped the area down. During an observation on 11/19/2024 at 7:31AM, a grey double shelf attached to the wall held four boxes of gloves used for food service. The grey double shelf had an unknown brownish substance that contained various white, black and brown unknown particles on the bottom shelf edging and both side edges. Directly under the double shelf were two boxes of uncovered plastic wrap used to cover residents' meal items. On 11/21/2024, a review of kitchen policy for kitchen sanitation, provided by Dietary Manger showed dietary department will be operated and maintained to meet federal and state guidelines. On 11/21/2024, a review of kitchen policy for storage of frozen foods, provided by the Dietary Manager showed dietary department will adhere to all federal and state regulations regarding refrigerated and frozen foods.

Based on observations, interviews, record review, facility document review, and facility policy review, it was determined that the facility failed to ensure proper hand hygiene was performed between residents, failed to ensure cleaning of personal equipment (fan) to prevent contamination and failed to ensure Enhanced Barrier Precautions (EBP) were followed for a tube fed resident (Resident #7) of 1 resident reviewed for infection prevention and control. Findings include: A review of a facility policy titled, Handwashing/Hand Hygiene, revised in August 2019, indicated the primary purpose of hand hygiene was to prevent the spread of infections and that all personnel will follow the hand hygiene procedures to help prevent the spread of infections to others. A review of a facility policy titled Policies and Practices-Infection Control, revised in October, 2018, indicated the objectives for infection control policies were to maintain a safe, sanitary and comfortable environment; prevent, detect and investigate and control infections; implementing isolation precautions when necessary; provide supplies and equipment necessary for isolation precautions; maintaining records and corrective actions related to infections; and providing guidelines for safe cleaning of reusable resident-care equipment. A review of a facility policy titled Enhanced Barrier Precautions, revised in August 2022, stated the use of EBP is to prevent the spread of multi-drug-resistant organisms and that targeted gown and glove use is to be utilized during high contract resident care activities. EBP's are to be used for residents with wounds and/or indwelling medical devices. During an observation on 11/19/2024 at 6:25 AM, C.N.A. #2 was observed assisting with residents on 100 hall. C.N.A. pushed one resident in wheelchair to the dining room, placed resident at the dining table, left resident went over to another resident sitting further down the table and adjusted the wheelchair, then C.N.A. #2 left the dining room. C.N.A. #2 went back down 100 hall and went straight into a resident's room without performing hand hygiene. C.N.A.#2 in view of the surveyor applied a pair of gloves, then came over and shut the door to the room. During an interview on 11/19/2024 at 6:28 AM, C.N.A. #2 was asked what should happen prior to beginning care on a resident and statement was given, Wash my hands. C.N.A. #2 confirmed that prior to entering the resident's room after pushing the wheelchair to the dining room, hand hygiene should have been performed. A review of Resident #7 ' s Admission Record, indicated the facility admitted Resident #7 with diagnoses that included gastrostomy status, cerebral infarction, vascular dementia and congestive heart failure. Review of Resident #7 ' s annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/20/2024, revealed Resident #7 had a Staff Interview for Mental Status (SAMS) score of 3 which indicated the resident was severely impaired for daily decision making. Resident #7 was marked as having a feeding tube. A review of Resident #7's Care Plan, initiated on 12/07/2017, revealed the resident required tube feeding related to dysphagia. Intervention created 04/04/2024, Enhanced Barrier Precautions related to feeding tube. On 11/28/2023 a care plan was initiated for increased perspiration with body odor related to inability to regulate body temperature secondary to paralysis/hemiplegia. Intervention included, may keep fan in room related to resident's perfuse perspiration. A review of an Order Summary Report, revealed Resident #7 received water flushes, tube feeding product, and medications which were to be administered through the feeding tube. No order was documented for Enhanced Barrier Precautions or personal fan. During an observation on 11/18/24 at 11:27 AM, Resident #7 was noted to have a white fan on top of a cabinet with a grayish-brownish residue on the fan blades, around the edges of the blades and the screen. During an observation on 11/19/24 at 09:02 AM, LPN #3 was preparing medications for Resident #7 and proper technique was used during the process. LPN #3 entered Resident #7's room and placed items for the medication administration on the over-the-bed table. LPN #3 went into the resident's restroom to obtain tap water, came back to bedside, put on gloves, checked for placement by aspiration, placed syringe in feeding tube, mixed medications in water, flushed the feeding tube with 90 milliliters (ml) of water prior to administering medications. Administered the medications then flushed feeding tube with 90 ml of water. LPN #3 removed the syringe, closed the tube with plug, went to the restroom to wash out the syringe and came back to bedside and placed the syringe in a plastic bag. LPN #3 then collected remaining supplies to discard and left the resident's room. During an observation on 11/19/2024 at 9:05, Resident #7's fan was sitting on small cabinet against the wall at the foot of the bed, blowing towards the resident. The fan blades, the edges around the fan blades and the screen covering the fan were covered in a grayish-brownish residue. During an interview on 11/19/2024 at 9:10 AM, LPN #3 confirmed that the red heart signage on the name plate to Resident #7's room meant enhanced barrier precautions. LPN #3 stated I forgot all about it. Sorry, I have not worked in two months. During a concurrent observation and interview on 11/21/2024 at 10:10 AM, the Infection Preventionist (IP) nurse went with the surveyor to Resident #7's room. Upon entering the room, the fan was observed sitting on the cabinet with a grayish-brownish residue still present. IP nurse confirmed the fan was dirty and that housekeeping would be responsible for cleaning. When asked what the importance would be for the fan to remain clean, IP nurse stated that when the fan was dirty it would be blowing the dirt at the resident. During a concurrent observation and interview on 11/21/2024 at 10:17 AM, the Administrator confirmed that the fan in Resident #7's room didn't look very clean. When asked what could happen with the fan being dirty, the Administrator says it would blow the dust into the air and could cause infection and stated Resident #7 was on EBP.

Based on record review and record interview, it was determined that the facility failed to notify the resident/representative or Power of Attorney (POA) in writing of the resident's transfer/discharge to the hospital as required for Resident #5 of 1 resident reviewed for the process of notification at time of transfer/discharge. Findings include: A review of a facility policy titled, Transfer or Discharge Notice, revised in December 2016, made no indication of notifying the resident/representative or POA. The policy indicated that a written notice would be sent in the event of an impending transfer or discharge within 30 days. A review of Resident #5 ' s Admission Record, indicated the facility admitted Resident #5 with diagnoses that included congestive heart failure, atrial fibrillation, stage 3 chronic kidney disease and a personal history of urinary tract infections. Review of the annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/06/2024, revealed Resident #5 had a Brief Interview for Mental Status (BIMS) score of 3 which indicated Resident #5 had severe cognitive impairment. Resident #5 was indicated as always incontinent of bowel and bladder and was receiving antibiotic therapy. The discharge return anticipated MDS, with and ARD of 08/13/2024 was completed. A review of Resident #5 ' s order details dated 08/13/2024, noted to send Resident #5 to the emergency room (ER) for evaluation and treatment. A review of the progress notes revealed on 08/13/2024 that Resident #5 was having labored respirations with use of accessory muscles and periods of apnea. Resident #5 was unresponsive to verbal stimulus. Family wanted Resident #5 sent to the ER. A review of the computerized telephone message on 11/21/2024, revealed that the facility sent the message on 08/14/24 at 3:51 pm. The message sent stated, state regulations require the facility send out a letter to the family, along with notification by phone. During an interview on 11/21/2024 at 10:55 AM, the social service director stated that the way the facility communicates with resident/representatives was with the computerized telephone message system and that the facility does not send anything in writing for the bed hold policy nor the reason why the resident was sent to the hospital. The facility does not have a business office manager currently.

Based on record review and interview, it was determined that the facility failed to notify resident representatives or Power of Attorney (POA) in writing of the bed hold policy upon a resident's transfer to the hospital and/or discharge as required for 1 (Resident #5) of 1 resident reviewed for bed hold notification. Findings include: A review of a facility policy titled, Transfer or Discharge Notice, revised in December 2016 made no indication of notifying the resident/representative or POA. The policy indicated that a written notice would be sent in the event of an impending transfer or discharge within 30 days. A review of Resident #5 ' sAdmission Record, indicated the facility admitted Resident #5 with diagnoses that included congestive heart failure, atrial fibrillation, stage 3 chronic kidney disease, and a personal history of urinary tract infections. The annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/06/2024, revealed Resident #5 had a Brief Interview for Mental Status (BIMS) score of 3 which indicated Resident #5 had severe cognitive impairment. Resident #5 was indicated as always incontinent of bowel and bladder and was receiving antibiotic therapy. The discharge return anticipated MDS, with and ARD of 08/13/2024 was completed. A review of Resident #5 ' s order details dated 08/13/2024, noted to send Resident #5 to the emergency room (ER) for evaluation and treatment. A review of Resident #5 ' s progress notes revealed on 08/13/2024, indicated that Resident #5 was having labored respirations with use of accessory muscles and periods of apnea. Resident #5 was unresponsive to verbal stimulus. Family wanted Resident #5 sent to the ER. A review of the computerized telephone message on 11/21/2024 revealed that the facility sent the message on 08/14/24 at 3:51 pm. The message sent indicated with each transfer it was required that the facility send a copy of the bed hold policy. During an interview on 11/21/2024 at 10:55 AM, the social director stated that the way the facility communicates with resident/representatives was with the computerized telephone message system and that the facility does not send anything in writing for the bed hold policy nor the reason why the resident was sent to the hospital. The facility does not have a business office manager currently. The social director stated that the notifications were sent by the social department.

Through observation, record review, and interview, the facility failed to ensure one of one resident sampled (Resident #31) environment remained free of accident hazards as was possible. The findings are: Record review of quarterly Minimum Data Set with an Assessment Reference Date of 09/10/2024, revealed for Section C, Cognitive Patterns, Resident #31 showed a Brief Interview for Mental Status of 15. Record review of Resident # 31 ' s Admission Record showed two Power of Attorneys for Care Conference. Record review of a Care Plan dated 9/10/2024, did not have documentation to support Resident # 31 to self-administer medicine. During an observation on 11/18/2024 at 11:05AM, in Resident # 31 ' s room a bottle of nasal spray was on rolling bedside table, while cough drops and wound cleanser were on the dresser. During an interview on 11/18/2024 at 11:09AM, LPN #1 confirmed wound cleanser should not be in Resident # 31 ' s room. LPN #1 stated she did not know where the nose spray or cough drops came from and should not be in Resident # 31 ' s room either. During an interview on 11/20/24 at 2:21PM, Director of Nursing confirmed the nose spray, cough drops nor wound cleanser should be in Resident # 31 ' s room. Resident # 31 should not be self-administering and the nose spray, cough drops, and wound cleanser should have been brought out if nurses administered. There was a concern the medicine could be used improperly by Resident #31. On 11/21/2024 a review of Self Administration of Medication Policy from Nursing Policy and Procedure Manual for Long-Term Care 2001 MED-PASS, Inc. (Revised February 2010) showed the interdisciplinary team (IDT) is to assess each resident to determine if self-administration is safe and clinically appropriate for the resident. The following was considered for self-administration; is the medication appropriate for self-administration, is resident able to follow directions and tell time to know when to take the medication, does resident understand the proper dosage, side effects and what to report to staff. When self-administration is considered, appropriate documentation is made in the medical record and the care plan. Self-administered medications are stored in a safe and secured area where other residents do not have access.

Through investigation and record review the facility failed to employ staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service. The findings are: During an investigation on 11/19/2024 at 7:43AM, the Dietary Manager confirmed classes have not been started for dietary certification. During an investigation on 11/21/2024 at 9:02AM, the Administrator confirmed the Dietary Manager took position on 12/31/2022. Facility was working on Dietary Manager to be enrolled in a program, paperwork had not been finished. Review of an email dated 08/8/2024 at 7:00AM, from Dietary Consultant provided a list of online programs to the Dietary Manager and the Administrator.

Through record review, interviews and policy of arbitration agreement the facility failed to ensure that four of four residents sampled for arbitration agreements (Resident #7, #13,#16 and #22) or representative were clearly informed that arbitration is to be a neutral site that both parties agree to The findings are: Review of arbitration agreements signed by Resident #7, Resident #13, Resident #16, and Resident #22 with the current arbitration agreement in use, failed to provide the resident or the resident's representative notice of the fact that both parties must agree to a neutral place. During an interview on 11/20/24 at 1:30PM, the Social Director confirmed there was not anything about a neutral meeting place stated in the contracts. During an interview on 11/20/24 at 1:47PM, the Administrator stated the facility may have left something out.

Based on observation, interview and record review the facility failed to ensure Activities of Daily Living were maintained to prevent the potential for injury, infection, and to promote personal hygiene and sense of wellbeing for 3 sampled residents (Resident #15, #22, and #25). This failed practice had the potential to affect 6 case mix residents from halls 100 and 200 dependent for ADL/Nail Care based on a list provided by the Director of Nursing (DON) on 11/8/23 at 11:45 AM. The findings are: 1. Resident #15 had diagnoses of flaccid hemiplegia affecting left nondominant side, cerebral infarction due to embolism of left middle cerebral artery, dysphagia following cerebral infarction, and other specified diabetes mellitus with diabetic neuropathy, unspecified. A Minimum Data Set (MDS) with an assessment review date of 8/24/23 documented a Staff Assessment for Mental Status (SAMS) for, Cognitive skills for daily decision making Severely Impaired requiring extensive assistance with 2- person physical support for bed mobility, toileting, and personal hygiene. a. Physicians orders dated 11/8/23 documented, Bactrim DS Oral Tablet 800-160 MG (Sulfamethozazole-Trimethoprim) Give 1 tablet via PEG (Percutaneous Gastrostomy Tube)-tube two times a day for UTI (urinary tract infection) for 5 days and Obtain UA (urinalysis) with C&S (culture and sensitivity) one time only for urine with foul odor for 1 day laboratory. b. A Care Plan with an initiation date of 5/28/2019 documented, .[name] has an ADL self-care performance deficit r/t hemiplegia, and cognitive deficits . and .Resident will have a neat clean appearance, and no skin breakdown this review period . and .Staff to attempt to keep her clothing and linens as dry as possible and free of odors .and .Check nail length and trim and clean on bath day and as needed . c. On 11/06/23 at 12:36 PM the Surveyor observed Resident #15 awake sitting up in bed. Breath was foul smelling white particles noted between teeth. Hair was uncombed, and the was a strong body odor noted. Both hands were severely contracted. The left thumb was folded under and both hands smelled of a foul odor. The right thumbnail was visible and 1/4 -inch past fingernail tip. Toenails had jagged and sharp edges visible on both feet and several were1/4 -inch past tips of toes. Both eyes had dried matter in corners and eye lashes. Resident was tearful and shaking head back and forth. There was a dried substance noted on the resident ' s face from left corner of mouth to chin. d. On 11/07/23 at 9:05 AM Resident #15 had foul body odor and foul-smelling breath. Hair remained uncombed. The left thumbnail looked blackened on the nail from the middle of the nail to the tip of the nail. Bleeding noted left corner of cuticle on left thumbnail. The right hand had skin peeling between middle and ring finger. e. On 11/07/23 at 1:59 PM the Surveyor observed approximately 12 dark whiskers on right side of chin. There was a thick mucus colored substance running from the right corner of Resident #15's mouth. Hair remained uncombed and unkept. Breath had foul odor. The Surveyor asked Resident #15 if her teeth were brushed today. She shook her head no. There were no blue braces on contracted hands. No hand rolls were in place. There was a heel protector in place on the right heel. The heel protector on the left heel was not positioned correctly. Toenails remained the same. f. On 11/07/23 at 3:34 PM, Resident ' s right hand had powder between fingers. The Left heel protector misplaced, and nails remained the same. There was no moisture rub visible between toes. The Surveyor asked Resident #15 if she had gotten her bath today. Resident #15 shook her head no. g. On 11/08/23 at 9:55 AM, Resident #15 was lying in bed asleep, and wearing soft hand rolls on both hands were fasted. The room had a foul odor of body fluids and human waste and there was an oscillating fan going. Lips appeared dry and cracked. Hair looked uncombed and disheveled. There was both dried and wet milky colored substance draining down the left side of mouth and on face. Black whiskers remained on the right side of chin. Breath had foul odor. Wearing the same Green Choose Happy night shirt as yesterday. h. On11/08/23 at 9:59 AM LPN #1 entered Resident #15's room and gave oral care with mouthwash and toothette with sponge on the end and water rinse. Some of the liquids from oral care dripped onto the resident's shirt. The Surveyor accompanied LPN #1 out of room and asked LPN#1 to describe what the room smelled like. The LPN #1 answered, It might be urine. [Roommate ' s name] refuses her bed bath a lot. The Surveyor asked LPN #1 if anything else could be done with regard to Resident #5 ADL care. LPN #1 answered, Her oral care could be improved, but the resident would not allow me to finish this morning. She doesn't like it. The Surveyor asked LPN#1 to look at Resident #15 ' s hands and feet at the nails, and describe what he saw and smelled. LPN #1 answered, the large toenails look long. The Surveyor asked who was responsible for toenail care for Resident #15 and if she was diabetic or not. LPN #1 answered, Yes, she is diabetic. I need to have them trimmed or filed. The white powder between her fingers was ordered. The Surveyor asked LPN#1 to look at the fingernails and describe what was seen. LPN#1 answered, The nails look like they could be shorter. The Surveyor asked LPN #1 if he noticed anything different about the left thumbnail specifically and what might have caused it to look like that. LPN #1 answered, It looks black. That could have been caused by her hands being contracted. LPN#1 pulled the covers back to observe that Resident #15 needed incontinent care. The Surveyor asked the LPN who was responsible for ADL and peri care for Resident #15. LPN #1 answered, The CNA's and myself. I will get some help and have the CNA's give her peri-care. 2. Resident #22 had diagnoses of acute and chronic respiratory failure with hypoxia, chronic systolic (congestive) heart failure, and gout, unspecified. A Quarterly MDS with an ARD of 10/24/23 documented a BIMS score of 15 with no impairment upper or lower extremities for functional range of motion. A 5-day MDS documented extensive assistance with 1 person support and assistance for personal hygiene. a. A Care plan with an initiation date of 7/18/23 documented, .[name] has and ADL self-care performance deficit r/t (related to) weakness . and .Check nail length and trim and clean on bath day and as necessary. Report any changes to the nurse . b. On 11/07/23 at 10:43 AM Resident # 22 was lying in bed awake. Both fingernails and toenails were observed to be more than 1/4 - 1/2 inches in length past tips of toes and tips of nails. There was dark brown substance under the 3rd and 4th fingernail on right hand, and second and third fingernail on the left hand. Great Toenails on both feet were thick, yellow in with gray streaks. The smaller toes on both feet had toenails that were 1/4-inch-long past tips of toes with sharp, jagged edges. The Surveyor asked the resident if he liked the way his finger and toenails were. Resident #22 answered, No, they are pretty long. I think it's about time to get them trimmed. c. On 11/07/23 at 2:09 PM, Resident #22 was in bed on the left side. The Surveyor asked Resident #22 if he had ADL care done. He answered, No . Fingernails and toenails remained the same. d. On 11/08/23 at 9:44 AM, Resident #22 was lying in bed awake. Nails remained long with uneven edges. The Surveyor asked Resident #22 if he had nail care done. Resident #22 answered, Well, they cleaned them yesterday some time, but they didn't trim them. The Surveyor asked if Resident #22 liked them like they were? Resident #22 answered, Well they are ok, but I'd really like to have them trimmed. The Surveyor asked Resident #22 if they had cleaned or trimmed his toenails. Resident # 22 answered, No they didn't do anything to my toes. e. On 11/08/23 at 02:32 AM, the Surveyor accompanied CNA #2 into Resident #22's room and asked who did nailcare and ADL care for Resident #22. CNA#2 answered, Anybody. Any CNA if not diabetic. The Surveyor asked CNA #2 how often nail care or ADL care should be done for Resident #22. CNA #2 answered, Monday Wednesday and Friday. We try to do them mostly on shower days. The Surveyor asked CNA #2 to look at Resident #22 toenails and describe them. CNA #2 answered, Some of his toenails are too thick to cut. That one had a lot of fungus, other than that, they look pretty clean. The Surveyor asked CNA #2 if she thought the edges looked smooth and if they were long enough to need a trim. CNA #2 answered, They could be clipped a little bit. Resident #22 commented, Yes, they need it. The Surveyor asked CNA#2 to look at Resident #22 fingernails and asked if the resident needed nail care. The CNA#2 answered, They look pretty good. It wouldn't hurt to clip them a little bit. 3. Resident #25 had diagnoses of Parkinson's Disease with dyskinesia, without mention of fluctuations, type 2 Diabetes Mellitus without complications. A Quarterly MDS with an ARD of 9/18/23 documented a BIMS score of 15 requiring extensive assistance with 1 person support and assistance for Personal Hygiene and Toileting. a. A Care Plan with an initiation date of 1/27/21 documented, .The resident has an ADL self-care performance deficit r/t weakness and cognitive loss . and .Check nail length and trim and clean on bath day and as necessary. Report any changes to the nurse . and .the resident requires assistance by 1 staff with personal hygiene and oral care . b. On 11/06/23 at 01:16 PM the Surveyor observed R#25 sitting up in wheelchair in room. The Surveyor observed fingernails and toenails were 1/4 - 1/2 inch in length past fingertips with jagged edges. The Surveyor asked if she liked her nails like that. Resident #25 answered, Not particularly. My toenails are really long, and my feet are swollen. The Surveyor asked if Resident #25 thought she needed to have them trimmed. She answered, Yes. The Surveyor asked Resident #25 if she had asked staff to trim nails for her. Resident # 25 stated, Oh yeah. Some of them just don't pay attention. c. On 11/07/23 at 03:35PM the Surveyor observed Resident #25 sitting up in wheelchair in hallway. Fingernails remained the same length with chipped nail polish, and there was a medium brown substance visible under the right thumbnail. The Surveyor asked Resident #25 if her nails had been trimmed or manicured. Resident #25 stated No. d. On 11/08/23 at 08:55 AM the Surveyor observed Resident # 25 sitting up in wheelchair during medication pass. Nails remained the same with 1/4-1/2 inch in length past fingertips. Edges were uneven with some jagged edges noted. There was light pink chipped nail polish on most of the fingernails, and a light brown substance was visible under the right thumbnail. e. On 11/08/23 at 03:04 PM the Surveyor accompanied CNA #1 to room [ROOM NUMBER] where Resident # 25 was sitting up in wheelchair. The Surveyor asked CNA #1 to describe Resident #25 fingernails. CNA #1 answered, Yes, they are a pretty color. They are long and have things like dirt or food under the nails and her hands look dry. Her right thumbnail looks partially cracked on one side so the nurse probably needs to look at that. The Surveyor asked the CNA #1 if nails needed trimmed and how often nail care was done. CNA #1 answered, They need to be trimmed and they need to be cleaned frequently. The Surveyor asked how nail care for Resident #25 is usually done. The CNA#1 answered, They should be done during showers or as needed. Nails should be checked daily. The Surveyor asked CNA #1 why nail care on a regular basis was important. The CNA#1 answered, It's dignity and basic hygiene. It's also a hazard for skin tears. f. On 11/08/23 at 10:37 AM the Surveyor asked the Director of Nursing (DON) who was responsible for giving ADL and nail care to residents. The DON answered, The CNA's do the ADL care and the nail care unless they are diabetic, then the nurse does it. The Surveyor asked the DON how often ADL care and nail care was done. The DON answered, Typically on shower days for the ADL care. Nail care is at least every 2 weeks for the clipping and filing if diabetic, and as needed. Cleaning is done as needed. Oral care is done every shift. The Surveyor asked the DON why nail care and ADL care on a regular basis was important. The DON answered, To help keep them clean, and to keep them from being injured by scratching themselves or getting nails caught on something. The Surveyor asked the DON what could possibly happen if ADL and nail care wasn't done, or the resident injured themselves. The DON answered, Infection. g. On 11/08/23 at 11:45 AM The DON provided documentation entitled, Fingernails/Toenails, Care of which documented, .purpose of this procedure are to clean the nail bed, to keep the nails trimmed, and to prevent infections . General Guidelines section documented, .1. nail care includes daily cleaning and regular trimming .4. Trimmed and smooth nails prevent the resident from accidently scratching and injuring his or her skin . and .5.Watch for and report any changes in the color of the skin around the nailbed, blueness of the nails, any signs of poor circulation, cracking of the skin between the toes, any swelling, bleeding, etc

Based on observation and interview the facility failed to ensure that standard and transmission-based precautions of sanitizing, handwashing, and or donning gloves between residents during morning medication pass were followed to prevent the possible spread of infections. This failed practice had the potential to affect 26 residents administered medications during morning medication pass based on a list provided by the Director of Nursing on 11/9/23 at 915 AM. The findings are: 1. On 11/08/23 at 8:05 AM, the Surveyor observed Licensed Practical Nurse (LPN) #1 standing at the medication cart in hall 200. The LPN #1 had prepared by mouth and liquid medications that were sitting on top of medication cart. The Surveyor accompanied LPN #1 into room [ROOM NUMBER] and observed medication administration of medications and leave the room without washing hands or sanitizing. 2. On 11/08/23 at 8:11 AM, LPN #1 prepared medications in hallway 100 at the medication cart for the resident in room [ROOM NUMBER]-A without sanitizing, donning gloves, or washing hands. After preparing medications at med cart the LPN#1 carried a pair of gloves along with medications into room [ROOM NUMBER]. LPN#1 gave the medications, donned gloves, and gave the resident 1 drop of eye lubricant in each eye. LPN#1 assisted the resident in putting on her cloth boots and helped transfer from bed to chair. LPN #1 walked out of the room wearing dirty gloves and carrying the resident's breakfast tray. LPN #1 opened the medication cart drawer with one gloved hand and placed the eye drops back into the medication cart, then removed the dirty gloves and carried the resident's breakfast tray down the hall into the dining room. LPN#1 did not sanitize hands upon returning to the medication cart and prepared medications for the next resident in room [ROOM NUMBER]-B. On 11/8/23 at 8:27 AM, the Surveyor observed as LPN #1 placed a medication cup on top of the medication cart, that was not sanitized, and filled it with applesauce. LPN#1 then picked up the applesauce in the medication cup and stacked it on top of the medications that were sitting on top of the cart in a separate medication cup. The bottom of the medication cup that had been in contact with the medication cart came into contact with the medications. The Surveyor accompanied LPN#1 into room [ROOM NUMBER]-B and observed medication administration followed with spoonsful of applesauce. On 11/08/23 at 11:45 the Director of Nursing (DON) provided documentation entitled, Administering Medications which documented on page 6, .25. Staff follows established facility infection control procedures (e.g., handwashing and antiseptic technique, gloves, isolation precautions, etc.) for the administration of medications as applicable .

Based on record review and interview, the facility failed to ensure a Surety Bond was current and up to date, to assure the security of all personal funds in the resident trust funds to prevent financial loss. The failed practice had the potential to affect the 40 residents who had a trust fund account managed by the facility according to a list provided by the Business Office Manager [BOM] on [DATE] at 10:10 am. The finding are: 1. On [DATE] at 10:10 am, a review of Trust - Current Account Balance dated [DATE] showed an ending balance of $18,101.16. 2. A Surety Bond provided by [Company Name] provided by the BOM on [DATE] at 10:10 am. The document had an original effective date of [DATE] and was issued by [Company Name] as Surety, in the amount for $35,000. The bond documented .In witness whereof, the said [SURETY COMPANY] has caused these presents to be execute by .with the corporate seal affixed this 19th day of [DATE]. The Rider attached documented .This rider became effective on the 19th day of July, 2019 . and was signed the 19th day of July, 2019. The Notary Public's commission expired [DATE]. 3. On [DATE] at 12:30 pm, the surveyor returned the certificate to the BOM and requested a copy of the surety bond currently in effect to be provided. The BOM stated, I don't know, I will have to look for it. At 12:50 pm The Chief of Business Operations [CBO] came to surveyor and asked if there was a problem with the surety bond. The CBO was shown the date of the bond. The CBO stated, I think that is good, that the bond is for three years and was paid in 2022 which would make it good until 2025. The surveyor asked if documentation of payment could be provided. The CBO stated, I'll look and see. 4. On [DATE] at 2:16 pm the CBO provided a copy surety bond with a rider dated [DATE] in the amount of $35,000. 5. On [DATE] at 10:30 am, the surveyor was in the BOM's office and the administrator asked the surveyor if a copy of the new surety bond was provided. The administrator stated, I guess that was overlooked, but we got it taken care of.

Based on observation, interview and record review the facility failed to develop and implement a comprehensive care plan to address the need for oxygen for 1 (Resident #20) sampled resident. The findings are: Resident #20 had a diagnosis [dx] of congestive heart failure. On Admission MDS with Assessment Reference Date [ARD] 8/22/23. a. Review of the resident's care plan on 11/07/23 at 3:13 pm did not address the potential need for oxygen as identified in the physician's order dated 10/31/23. b. Review of the physician order dated 10/31/23 showed resident #20 to have oxygen at 2 liters as needed to maintain oxygen saturation above 90%. b. On 11/08/23 at 10:45 AM, the surveyor Interviewed Licensed Practical Nurse (LPN #1). Surveyor asked what the order was for resident's oxygen. LPN#1 answered, The resident physician order is for 2 liters per minute. c. During interview on 11/09/23 at 1:59 PM, the MDS Coordinator reported that they are responsible for completing the MDS and the care plans for the residents in LTC. MDS Coordinator was asked what the possible complications are of not identifying the resident ' s health concerns upon admission. The MDS Coordinator stated, .would mess up the quality measures and staff would not know how resident needs taken care of . The MDS Coordinator was then asked what problems could arise if the care plans are not updated. The MDS Coordinator, .This would mean changes are not communicated and staff would not be able to look for it . The MDS Coordinator was then asked when updates should be completed. The MDS Coordinator stated, .Updated quarterly and admission by 14th day for care plans and quarterly/annually for MDS. d. On 11/09/23 at 1:59 PM the MDS Coordinator was asked if the respiratory care of the resident as ordered by the physician should be addressed on the care plan. The MDS Coordinator stated, .should be care planned for communication and how resident needs to be taken care of . e. On 11/09/23 at 2:10 PM the Director of Nursing (DON) was asked if the respiratory care of the resident as ordered by the physician should be addressed on the care plan. The DON stated, .yes if needed .

Based on observations, interview and record review the facility failed to ensure that physicians orders were followed for oxygen flow rates for 2 sampled residents (Resident #20 and #22) receiving oxygen therapy. This failed practice had the potential to affect 3 sampled residents on halls 100 and 200 based on a list of residents with orders for oxygen therapy provided by the Director of Nursing (DON) on 11/8/23 at 11:45 AM. The Findings are: 1. Resident #20 had diagnoses of chronic combined systolic (congestive) and diastolic (congestive) heart failure. A Minimum Data Set (MDS) dated [DATE] documented a BIMS (Brief Interview for Mental Status) score of 9 (8-12 moderate cognitive impairment) requiring extensive assistance with toileting with 1-person physical assist, and minimum assistance for bed mobility and transfers with 1-person physical assist and support. a. A Care Plan initiated 8/22/23 documented no oxygen/respiratory status goals or interventions. b. A Physician's order dated 10/31/23 documented, PRN O2 @ 2L to maintain sats above 90% as needed for low sats . c. On 11/07/23 at 1:57 PM, Resident # 20 was lying in bed asleep receiving O2 via nasal cannula at 1.5 Liters/Minute. Tubing was dated 11/7/23. The humidifier bottle was swollen, and not dated. d. On 11/07/23 at 3:31 PM, Resident # 20 was lying in bed asleep with nasal prongs in her mouth. O2 flow meter was set at 1.5 Liters/Minute. The humidifier remained the same. e. On 11/08/23 at 8:30 AM, Resident # 20 was lying in bed asleep receiving O2 via nasal cannula. The flow meter was set at 1.5 Liters/minute. Humidifier bottle and tubing remained the same. f. On 11/08/23 at 10:45 AM, the Surveyor asked LPN #1 to look at Resident # 20's concentrator and read the flow rate. LPN#1 answered It ' s about 1.5 Liters per minute or 3/4 liters per minute. The Surveyor asked where should the ball be for flow rate and what the order was. LPN#1 answered, Her order is for 2 liters per minute. The Surveyor asked how often flow rate should be checked. LPN#1 answered, It should be checked every shift. The Surveyor asked what can happen if the orders are not followed correctly? LPN#1 answered, It is a detriment to the resident if it's not followed or ordered. The Surveyor asked what specifically can happen, LPN#1 answered, This could lead to adverse health outcomes like Hypoxia. 2. Resident #22 had diagnoses of Acute and chronic Respiratory Failure with Hypoxia. An Admission MDS with an ARD of 7/24/23 documented a BIMS score of 15. a. A Physicians order dated 8/8/23 documented, .Oxygen at 2-5 L/M via nasal cannula for SOB. as needed for Shortness of Breath Change and date o2 tubing and water bottle q week . b. A Care Plan with an initiation date of 8/8/23 documented, .[name] requires the use of oxygen PRN . and .Change oxygen humidifier and tubing as ordered and PRN. Monitor concentrator for appropriate settings on rounds, when in use . and .Oxygen at 2L-5L/M via nasal cannula for SOB PRN . c. On 11/06/23 at 02:35 PM Resident # 22 was lying on left side asleep receiving oxygen via nasal canula at .5 Liters/minute. Humidifier bottle dated 11/6 /23. Tubing was not dated. d. On 11/07/23 at 10:42 AM Resident # 22 was lying awake in bed receiving oxygen via nasal canula at .5 Liters/minute. The humidifier bottle was dated 11/6. The tubing was not dated. e. On11/07/23 at 02:11 PM Resident # 22 was lying in bed on right side receiving oxygen via nasal canula. The flow meter was set at .5 Liters/Min. The tubing was not dated. The humidifier bottle was dated. f. On 11/08/23 at 10:56 AM the Surveyor accompanied LPN#2 to Resident # 22 room and asked what the flow meter was set at on the oxygen concentrator. LPN#2 answered, 1 Liter The Surveyor asked LPN#2 what the physician's order was for R#22 oxygen flow rate. LPN#2 answered, I believe it's 2 Liters/minute The Surveyor asked the LPN#2 how often flow rates for residents should be checked. The LPN#2 answered, Every shift, every time someone comes into the room. g. On 1/08/23 at 10:33 AM, the Surveyor asked the Director of Nursing (DON) who was responsible for checking flow rates on residents on oxygen therapy and how often flow meters should be checked on the concentrators. The DON answered, The Floor Nurses, (Certified Nursing Assistants) CNAs are not allowed to mess with oxygen. It should be checked every shift, or every time someone goes into the room. The CNAs are allowed to check and let the nurse know to make sure it is on the correct Liters. The Surveyor asked DON what could happen if not checked. The DON answered, They could get the incorrect amount, or no oxygen. The Surveyor asked the DON why the correct amount is important. The DON answered, They need their oxygen, or their sats [saturation] could drop. The Surveyor asked the DON if oxygen tubing should be bagged for nebulizer tubing when not in use. The DON answered, Yes. The Surveyor asked the DON why keeping tubing contained was important. The DON answered, It keeps the tubing clean. The Surveyor asked the DON what could happen if the tubing isn't kept clean. The DON answered, Increased risk of infection. h. On 11/08/23 at 11:45 AM The DON provided documentation entitled, Oxygen Administration that documented on page 15 under Preparation, .1. Verify that there is a Physician's order for this procedure. Review the Physician's orders or facility protocol for oxygen administration .2. Review the resident's care plan to assess for any special needs of the resident . and documented on page 16 under Steps in Procedure, .8. Unless otherwise ordered, start the flow of oxygen at the rate of 2-3 liters per minute . and .10. Adjust the oxygen delivery device so that it is comfortable for the resident and the proper flow of oxygen is being administered .

Based on record review and interview, the facility failed to prevent a cognitively impaired resident from exiting the facility without staff supervision for 1 (Resident #1) of 3 (#1, #2, and #3) sampled residents that are at risk for wandering and elopement. The findings are: 1. Resident #1 was readmitted to the facility on [DATE] with diagnoses of Unspecified Dementia, Unspecified Severity, with Agitation. The Quarterly Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) of 3, which indicates severe impairment. a. Review of the Care Plan revealed a Care Plan for elopement risk was developed on 06/12/23 a day after Resident #1 eloped on 06/11/23. There were no interventions documented before 06/12/23 to monitor and assist with wandering behaviors. b. On 06/14/23 at 10:52 AM, the Surveyor asked the Director of Nursing (DON) if Resident #1 had tried to elope before. The DON stated, No, not to my knowledge. He does wander from office to office and up and down halls but he does not threaten to leave. c. On 06/14/23 at 12:05 PM, the Surveyor interviewed Certified Nursing Assistant (CNA) #1 by phone. CNA #1 stated, Resident #1 asked if he could go home with me. I had a feeling he wanted to go. I was at the Nurses' Station for a while watching them then I went into a resident's room. I thought I heard a beep. I thought I had heard the door alarm. I asked the other staff that were on the hall if they heard the door, and they said no. I received a call from a staff member off the clock from CNA #3 she told me that she saw Resident #1 going toward the road. I ran toward the door yelling that Resident #1 was out in the parking lot. When I got out the door, I could see there was a man with him (I heard from the church across the street). CNA #1 stated, Resident #1 has tried to leave many times before and we always put him at the Nurse's Station to watch him. When he is missing, we look in the other residents' rooms and we find him. d. On 06/14/23 at 12:15 PM, the Surveyor interviewed CNA #2 via phone. The Surveyor asked which of her residents go to the doors to try to get out. CNA #2 stated, Resident #1. CNA #2 also stated, He wanders. e. On 06/14/23 at 12:20 PM, the Surveyor interviewed CNA #3 by phone. She stated, I was on lunch with CNA #2. We went to [named restaurant] and then we headed to the gas station. I saw a man standing by someone in a wheelchair. It dawned on me that it was Resident #1. I called CNA #1 to let her know that Resident #1 was out by the road. We did not stop because he had someone with him. I did not know who the man was. He doesn't work with us. f. On 06/14/23 at 12:58 PM, the Surveyor asked CNA #4 if anyone had gotten out of the facility before. CNA #4 stated, Not when I was at work. The Surveyor asked, Which resident tries to open the doors (Exit Seeking)? CNA #4 stated, Resident #1 does. g. On 06/14/23 at 1:04 PM, the Surveyor asked CNA #5 if anyone had gotten out of the facility. CNA #5 stated No. The Surveyor asked, Which resident tries to open the doors (Exit Seeking)? CNA #5 stated, Resident #1. h. On 06/14/23 at 1:06 PM, the Surveyor asked CNA #6 if anyone had gotten out of the facility before. CNA #6 stated she heard Resident #1 had. The Surveyor asked, Which resident tries to open the doors (Exit Seeking)? CNA #6 stated, Resident #1 is (Exit Seeking). He tries everything to open the door. i. On 06/14/23 at 1:16 PM, the Surveyor asked LPN #3 by phone to share the information concerning Resident #1's elopement. LPN #3 stated, I was down the hall passing medication. It was around 7:00 PM or maybe a little after when she heard the front door alarm. There were two employees that were trying to leave for a meal break. Resident #1 was trying to follow them out. LPN #1 came and moved Resident #1 back from the door. Resident #1 refused to go through the second door. (The facility key padded main front door opens into the Dayroom area. The second door which leads to the Nurses' Station and the resident's rooms is closed but does not lock). I sat Resident #1 in the Dayroom by the door. I left him there. I should have not done that. He told me he would not try to go outside. So, I left him sitting at the door. I went back to passing the medications. I heard the phone ring and went to answer but the caller had hung up. I heard the front door alarm. I went out the door and saw Resident #1 at the end of driveway. The man with him stated he had seen him from the church, and he had come over to help. Two other CNAs helped me get Resident #1 back in the facility. He could not have been gone any longer than 10 minutes at the most. j. The facility policy titled, Wandering and Elopements, provided by the DON on 06/15/23 at 2:29 PM documented, The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents.

Based on record review and interview, the facility failed to develop and implement a Care Plan for a resident exhibiting exit seeking behaviors for 1 (Resident #1) of 3 (#1, #2 and #3) sampled residents reviewed who require supervision to prevent accidents. The findings are: a. Resident #1 had diagnoses of Unspecified Dementia, Unspecified Severity with Agitation. b. Review of nursing progress note dated 5/3/23 at 11:34 PM revealed Resident #1 was exhibiting exit seeking behaviors and set off the 400-hall door alarm twice. c. Review of the Facility Investigation Report for Resident Abuse, neglect, Misappropriation of Property and Exploitation of Residents in Long-Term Care Facilities revealed on 6/12/23 Resident #1 was found outside the front door in the parking lot, and based on investigation was outside for less than 10 minutes. d. The Care Plan initiated on 06/12/23 for Resident #1 which was the day after the resident eloped from the facility on 06/11/23. documented, Resident #1 is at risk for elopement attempts r/t [related to] wandering/confusion. e. On 06/14/23 at 10:52 AM, the Surveyor asked the Director of Nursing (DON) if Resident #1 had tried to elope before. The DON stated no not to her knowledge. The DON stated, Resident #1 does wander from office to office and up and down halls. He does not threaten to leave. f. On 06/14/23 at 12:05 PM, the Surveyor interviewed Certified Nursing Assistant (CNA) #1 on the cell phone. The Surveyor asked if Resident #1 had tried to leave before. CNA #1 stated, Resident #1 has tried to leave many times before, and we always put him at the nurse station to watch him. When he comes up missing, we look in the other residents' rooms and we find him. g. On 06/14/23 at 12:15 PM, the Surveyor asked CNA #2 which one of her residents go to the doors and attempts to get out. CNA #2 stated, Resident #1. She also stated He wanders. h. On 06/14/23 at 12:58 PM, the Surveyor asked CNA #4 if anyone had gotten out of the facility before and she stated not when she was at work. The Surveyor also asked which residents tried to open the doors (Exit Seeking). CNA #4 stated Resident #1 does. i. On 06/14/23 at 1:06 PM, the Surveyor asked CNA #6 which residents try to open the doors (Exit Seeking). CNA #6 stated, Resident #1. She also stated that Resident #1 tries everything to open the door. j. On 06/14/23 at 1:13 PM, the Surveyor asked Licensed Practical Nurse (LPN) #2 which resident tried to leave the facility. LPN #2 stated that the wanderer was Resident #1. k. On 06/15/23 at 11:33 AM, the Surveyor asked the DON if Resident #1 should have had a Care Plan for his wandering before 06/12/23. The DON stated Yes. l. The facility policy titled, Care Plans, Comprehensive Person-Centered. Policy statement A comprehensive, provided by the DON on 06/15/23 at 2:37 PM documented, Person centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.

Based on observation, staff interview, and record review, the facility failed to maintain an accurate medical record regarding a resident's behaviors for 1 (Resident #3) of 3 (#1, #2 and #3) sampled residents reviewed for wandering. The finding include: 1. Resident #3 had a diagnosis of Alzheimer's Disease, Unspecified. The Quarterly Minimum Data Set (MDS) dated [DATE] documented the resident was severely impaired in cognitive skills for daily decision-making per a Staff Assessment for Mental Status (SAMS). a. On 06/14/23 at 9:27 AM, Resident #3 was in a wheelchair self-propelling himself around the Nurse's Station. b. On 06/14/23 at 12:58 PM, the Surveyor asked Certified Nursing Assistant (CNA) #4, Which resident tries to open the doors (Exit Seeking)? CNA #4 stated, Resident #3 does that. He does it quite often. c. On 06/14/23 at 1:04 PM, the Surveyor asked CNA #5 Which residents tries to open the door (Exit Seeking)? CNA #5 stated Resident #3 does. She also stated, Resident #3 pushes until the door alarm goes off. d. On 06/14/23 at 1:11 PM, the Surveyor asked Licensed Practical Nurse (LPN) #1 Which resident tries to get out of the facility? LPN #1 stated, Resident #3 has set the alarm off the other day on the door by the juke box. He was redirected back up the hall. e. On 06/14/23 at 1:13 PM, the Surveyor asked LPN #2, Which resident tries to get out of the facility? LPN #2 stated, Resident #3. f. The Surveyor noted that no documentation of the exit seeking behavior described by LPN #1 was noted in Resident #3's medical record. The last documentation addressing behaviors/wandering was on 06/01/23. g. On 06/15/23 at 9:20 AM, the Surveyor interviewed LPN #1. She stated I did not document Resident #3 trying to get out because he is not my resident. I did go get him the door alarm went off and I moved him back. I had to go back and get him again because he was trying to get out again and the door alarm was going off. I moved him to the Nurse's Station. This occurred either Friday or Sunday. I don't remember which day. h. On 06/15/23 at 2:24 PM, the Surveyor asked the Director or Nurses (DON) if behaviors should be documented. The DON stated, Yes. i. The facility policy titled, Charting and Documentation provided by the DON on 06/15/23 at 2:57 PM documented, Policy Statement: All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical condition and response to care.

Based on observation and interview the facility failed to ensure dishware is stored in a clean location, not exposed to dust, dietary equipment is cleaned and maintained in good working condition, and nutritional supplements are dated with a use by date in the nourishment refrigerator to minimize the potential for food borne illness for residents who receive meals from the kitchen. The failed practice had the potential to affect 49 residents who receive meals from the kitchen and nourishment room refrigerator as documented on a list provided by the Director of Nursing (DON) on 8/11/22. The findings are: a. On 08/08/22 at 10:48 AM, there were fuzzy translucent particles on the wall behind a rack with disposable foam cups, and clean plastic coffee mugs stored on it. b. On 08/08/22 at 10:50 AM, the hood vents above the stoves were covered with gritty, brownish buildup. The Surveyor asked the Dietary Manager to turn on the hood lights. She said, They don't work. The sticker posted on the hood reflected the last professional cleaning was completed April 2021. The Surveyor asked the Dietary Manager if the date of the last cleaning was April 2021 and she said, It looks like it. I'm not sure. When asked if the dietary staff is responsible to clean the hood vents in between professional cleanings, the Dietary Manager said, No. It has pipes and we don't mess with it. c. On 08/08/22 at 11:17 AM, There were eight vanilla, four chocolate, and five strawberry nutritional milkshakes in the nourishment refrigerator located on hall 400. Documented on the flap of the shakes are manufacture's guidance to . use within 14 days after thawing . The Surveyor asked the Dietary Manager if the shakes should have a use by date on them and she said, They have a ticket on them when they leave the kitchen. If a resident refuses a shake the ticket is taken off and the shake is put in the refrigerator. When the Surveyor asked if the shakes should have a use by date on them, the Dietary Manager said, Yes. Honestly we try to monitor and maintain the overage and keep them cleaned out. Surveyor asked it the nourishment refrigerator is used for all residents in the facility and the dietary manager said, Yes. d. On 08/10/22 at 11:41 AM, Dietary manager provided a safety inspection report completed by a contract company. The report did not specify any cleaning done during the inspection. e. On 08/10/22 at 01:21 PM, The Surveyor asked the Maintenance Employee if he was aware of the lights not working in the hood above the stoves in the kitchen. The Maintenance Employee said, No, I did not know. They didn't tell me. When asked if he was aware of the last time the hood was cleaned professionally, the Maintenance Employee said, I just gave that to her earlier today. Surveyor asked, Are you referring to the safety inspection report? The Maintenance Employee said, Yes. Surveyor asked, Was the hood cleaner or inspected at that time? The Maintenance Employee replied, It was cleaned and inspected. f. On 08/10/22 at 01:24 PM, the Surveyor asked the Business Office Manager from the Safety Inspector's office for a report for the last service provided to the facility. The Business Office Manager replied, Someone called this morning and I sent it over to them. Surveyor asked, Can you verify if the hood over the stoves in the kitchen were cleaned on May 25, 2022 and the business office manager replied, Ma'am we don't clean the hoods, we just inspect them. g. On 08/10/22 at 02:09 PM, Dietary Manager stated there are no facility policies for dietary equipment cleaning, clean dish storage or food storage. The surveyor was referred to the DON for policies regarding food storage in the nourishment refrigerator. h. On 08/10/22 at 04:01 PM, the DON reported to the surveyor that the facility had no policies for food stored in the nourishment refrigerator.

Based on observation, record review and interview, the facility failed to ensure a bruise of unknown origin was investigated, reported to the Office of Long-Term Care and other state agencies in accordance with state law for 1 of 1 (Resident #6) who had bruising observed on 08/08/22 during survey initial rounds. This finding had the potential to affect all 50 Residents that reside at the facility based on the list provided by the DON (Director of Nursing) on 08/08/22. The findings are: 1. Resident #6 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Significant Change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/04/22 documented the resident scored 3 (Severely impaired) on a Staff Assessment for Mental Status (SAMS) and required extensive assistance of one to two staff for bed mobility, dressing, toileting, personal hygiene, transfers, locomotion, eating and total dependence for bathing. a. On 08/08/22 at 11:41 AM, Resident #6 was lying in bed with blanket up to chest, there were bruises to bilateral and anterior hands, [NAME] size. The Resident was asked. How did you get those bruises?, she stated I get them all over the place, even on the bottoms of my feet. b. On 08/10/22 at 01:53 PM, RR-Care Plan documented- .o The resident has potential for impairment to skin integrity of the BUE [Bilateral Upper Extremities]and BLE r/t [Bilateral Lower Extremities related to] fragile skin . Monitor skin during daily care and notify charge nurse of any changes in skin integrity noted . c. On 08/10/22 a review of Physician Orders, ASA [Aspirin] 81 mg [milligrams] daily, no Anti-Coagulants ordered. d. On 08/10/22 a review of the 8/04/22 Skin Assessment documented, no concerns at this time. No open areas or redness r/t [related to] moisture. Turgor fair. e. On 08/10/22 at 02:22 PM, the Surveyor asked the DON to follow this Surveyor to R#6's room (room number identified). Resident was sitting in her recliner. The Surveyor asked the DON look at resident's hands for bruising. R#6 stated, I'm (I am) ashamed to show my hands and arms. I've (I have) got bruises on them. Observed [NAME] brownish area to left hand and a nickel size bluish bruise to the top of her right hand. The DON observed R#6's hands and asked the resident, Have you hit them on something? R#6 stated, No. The DON began to pull up the resident's sleeves of her top, her stomach and removed both of her socks. There were no other bruises identified. f. On 08/10/22 at 03:15 PM, The DON stated, There was nothing about the bruise on the skin audit on August. The bruises were not reported to us. We will start an investigation for the unidentified bruising. The Surveyor asked, What is a potential negative outcome of bruising not being reported to you or the Administrator? She stated, It's (it is) a possible sign of abuse. g. On 08/10/22 at 03:52 PM, a document provided by the DON titled Abuse prevention program documented, .4. Require staff training/orientation programs that include topics as abuse prevention, identification and report of abuse .6. Identify and assess all possible incidents of abuse .

Based on record review and interview, the facility failed to ensure education on the the risks versus benefits of the COVID-19 vaccine was provided and documented for 43 of 77 employees who worked in the facility to assure staff were able to make an informed decision regarding the vaccine. This failed practice had the potential to affect 43 staff members who were unvaccinated, according to a list provided by the Director of Nursing (DON) on 7/19/21 and 51 residents who resided in the facility and received care/services from those staff, per verbal information from the Administrator on 7/27/21. The findings are: 1. On 7/18/21 at 12:13 pm, five unvaccinated staff members' Human Resource records were reviewed for COVID-19 for education and / or documentation of refusal of the immunization. The DON provided documentation in which 2 in-services on 4/9/21 and 6/28/21 were completed; both in-service records documented, COVID-19 vaccinations are available at [Name] Pharmacy. They are working with us to give vaccinations to residents and staff. If you would like to get your COVID-19 vaccination, please let me know and we will setup as soon as possible. If you would like more information, please see [Name], DON on more information on the [Name] vaccination. 2. On 7/18/21 at 11:29 am, the DON was asked, Were the employees offered the COVID-19 vaccination? She stated, Yes, the vaccination was offered on 12/18/20, 12/22/20, 12/29/20, 4/19/21 and 6/28/21, by text, verbally and in-services. The DON was asked, How many staff members are not vaccinated? The DON replied, Not sure, I would have to look. The DON was asked, Has the staff been educated on the benefits and potential side effects of the COVID-19 vaccine? She replied, Yes. The DON was asked, Do you have any documentation where the staff was educated regarding the benefits and potential side effects of the COVID-19 vaccine? The DON replied, No I do not. The DON was asked, Do you have any documentation on the staff members that did not receive the vaccine due to refusal, prior vaccination or contraindication to having the COVID-19 vaccine? She stated, No I do not have any documentation where staff have signed that they have been educated or that they declined, when we offered the COVID-19 vaccination.

Based on observation, interview and record review, the facility failed to ensure kitchen equipment was clean and free of stains; food items stored in the freezer and dry goods area were labeled and dated; expired food items were promptly removed and or discarded by the expiration or use by dates, and foods were dated as when received to assure first in first out usage to prevent potential for food borne illness for residents who received meals from 1 of 1 kitchen. These failed practices had the potential to affect 54 residents who received a tray from the kitchen as documented on a list provided by the Director of Nursing (DON) on [DATE]. The findings are: 1. On [DATE], the following observations were made during initial kitchen rounds with the Dietary Manager (DM). a. At 12:00 P.M., the ice maker had a white unknown substance inside the ice dispenser and the metal grate in the bottom of the tray had a white unknown substance. b. At 12:02 P.M., there were 7 boxes of 46 ounce containers of grape juice with a use by date of [DATE] on the second metal shelf in the dry storage area. c. At 12:05 P.M., there were 5 containers of 16 ounce Chicken flavored base with an expiration date of [DATE] on the second metal shelf in the dry storage area. d. At 12:06 P.M., there were 2 containers of 16 ounce Beef flavored base with an expiration date of ,d+[DATE] on the second metal shelf in the dry storage area. e. At 12:10 P.M., there was a bottle of 21 ounce garlic powder with no date on it on the top metal shelf in the dry storage area. f. At 12:11 P.M., there was a box with 50 packets of chicken bouillon with no date on it on the top metal shelf in the dry storage area. g. At 12:11 P.M., there was an 8 ounce container of whole bay leaves with no date on it on the top metal shelf in the dry storage area. h. At 12:12 P.M., there was a container of 22 ounces of garlic, [MEDICATION(S)], and lemon rub was expired on the top metal shelf in the dry storage area. i. At 12:13 P.M., there was a 25 pound bag of sugar with no date on it on the bottom shelf in the dry storage area. j. At 12:22 P.M., there was a ziploc bag of 9 pieces of frozen chicken with no date or label on the bag on the second shelf in the one door standup freezer in the dry storage area. k. At 12:23 P.M., there was a bag of 12 frozen enchiladas with no date or label on the bag on the top shelf in the one door standup freezer in the dry storage area. l. At 12:24 P.M., there was a bag of frozen chicken wings with no date or label on the bag on the third shelf in the one door standup freezer in the dry storage area. m. At 12:24 P.M., there was a bag of frozen chicken legs with no date or label on the bag in the bottom container of the one door stand up freezer in the dry storage area. n. At 12:24 P.M., there was one bag of frozen chicken thighs with no date or label on the bag in the bottom container of the one door stand up freezer in the dry storage area. o. At 12:26 P.M., there were 5 bottles of 25.4 ounces of sparkling white grape juice with a best by date of [DATE] on the top wooden shelf in the dry storage area. p. At 12:36 P.M., there was a ziploc back of potato chips with no date or label on it on the middle shelf in the dry storage area. q. At 12:37 P.M., there was a 5 pound bag of devil's food cake mix with no date on it on the second wooden shelf in the dry storage area. r. At 12:37 P.M., there was a box of [NAME] Mayo individual packages with no date on it on the second wooden shelf in the dry storage area. s. At 12:38 P.M., there was a case of Thousand Island individual packages with no date on it on the second wooden shelf in the dry storage area. t. At 12:38 P.M., there was a case of 1.5 ounce single serving syrup cups with no date on it on the second wooden shelf in the dry storage area. u. At 12:40 P.M., there was a ziploc bag of frozen french fries with no date or label on it in the standup two door freezer in the kitchen. v. At 12:46 P.M., there were two, 1 gallon opened whole milk with no date on it on the top shelf in the standup refrigerator in the kitchen. w. At 12:47 P.M., there were four, 16 ounce frozen whipped topping in a bag with no date on it setting in the metal basket on the right in the deep freezer. 2. On [DATE] at 12:52 P.M., the can opener had a dirty towel down inside the can opener stand that attached to the table. The can opener had a thick blackish substance on the opener and a thick black substance on the opener stand. 3. On [DATE] at 12:58 P.M., a brown substance was on both sides of the top of the dishwasher. 4. On [DATE] at 1:02 P.M., the hot waterspout on the coffee maker had approximately ,d+[DATE] inch of a white substance around the dispensing spout. 5. On [DATE] at 9:04 A.M., the DM was asked, Should food be labeled and dated when received into the facility? The DM stated, Yes, Absolutely. The DM was asked, Should expired food be discarded? The DM stated, Yes, ma'am. 6. On [DATE] at 9:38 A.M., the Administrator was asked, Should food be labeled and dated when received into the facility? The Administrator stated, Yes, month, day, year. The Administrator was asked, Should expired food be discarded? The Administrator stated, Yes. 7. A Food Storage policy provided by the DM on [DATE] at 9:32 A.M. documented, Federal and state guideline will be followed for storage of all food in the Dietary Department .2) Food will be dated as stocked, with month and year .

Complaint # (AR 522) substantiated (all or in part) in these findings. Based on observation, record review, and interview, the facility failed to ensure the transport van's wheelchair restraints were securely and properly applied, which resulted in a resident tipping over backward and hitting her head; failed to ensure the van / wheelchair restraint manufacturer's instructions were readily available and that transport staff members were trained on them; and failed to ensure the van restraints were routinely inspected by a qualified professional to ensure they were in proper working order, to prevent potential injuries for 1 (Resident #1) of 2 (Residents #1 and #3) case mix residents who were transported in the van while in a wheelchair since 9/22/16. The failed practices resulted in Immediate Jeopardy, which caused or could have caused serious harm, injury, or death to Resident #1, whose wheelchair tipped over backward during transport, and had the potential to cause more than minimal harm to 4 residents who were transported in the facility van while in a wheelchair since 9/22/16, according to a list provided by the Director of Nursing on 10/20/16 at 8:50 a.m. The facility was informed of Immediate Jeopardy on 10/19/16 at 3:52 p.m. The findings are: 1. Resident #1 had [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) with an assessment reference date of 10/5/16 documented the resident scored 11 (8-12 indicates moderately impaired) on a Brief Interview for Mental Status (BIMS), required extensive assistance of 2 plus persons for transfers, had functional limitation in range of motion of one lower extremity, did not ambulate, and used a wheelchair for mobility. a. An Incident and Accident Report dated 9/22/16 at 5:45 p.m. documented, (Resident #1) was taken to doctor's appointment in facility van. Upon leaving appointment the chair restraint came loose and the wheelchair (Resident #1) was in, tipped back and she hit her head on the van. The CNA (Certified Nursing Assistant) she was with reported that she stopped van and set chair and (Resident #1) up and checked her to see if she was injured. When she saw no visible injury, she called the Director of Nursing and reported what had happened. Director of Nursing called Administrator and was directed to have CNA take (Resident #1) to (local hospital) ER (emergency room ). b. An Emergency Department Note dated 9/22/16 at 7:34 p.m. documented, Pt (Patient) was being driven back to NH (nursing home) from a doctor's appt (appointment) and the wheelchair she was in tipped over and Pt fell back and hit her head on ramp. Has hematoma to back of head and c/o (complained of) neck pain. c. On 10/19/16 at 1:07 p.m., CNA #1 was asked if she had been trained on the proper way to secure a wheelchair in the facility van prior to transporting a resident. She stated, Yes. (CNA #2) showed me how to do it. The CNA was asked what happened on 9/22/16 with Resident #1 in the van. CNA #1 stated, We had gone to (local city) for a doctor's appointment. Loaded her up in the van. Locked wheelchair. Strapped the 2 back straps first. I put the seat belt on her. I went to each side and hooked the straps to the front and made sure they were locked before I got in myself. Had two stop lights. Last stop light we turned and the strap came unlocked which made the wheelchair tip back. The CNA also stated that the straps stayed attached to the chair, but they extended out further. The CNA then stated that there had been a problem with the unit not locking in place correctly before this, but the Maintenance Supervisor and Operating Manager were notified and that they did lock after that. d. On 10/19/16 at 1:37 p.m., the Maintenance Supervisor was asked if staff were trained on the way to secure a wheelchair in the facility van prior to transporting residents. The Maintenance Supervisor stated, Yes. Same girls do it all the time. The Maintenance Supervisor was asked if the wheelchair restraints were checked prior to the incident with Resident #1. The Maintenance Supervisor stated, Yes. When we got it we had to figure out how it worked. The Maintenance Supervisor was asked if there had ever been a problem with the front restraints not locking prior to the incident with Resident #1. He stated, Not that I know of. The Maintenance Supervisor was asked if there was any routine monitoring or maintenance prior to the incident with Resident #1. He stated, No. It is a closed unit inside a casing. Straps are inside a metal case. The Maintenance Supervisor was asked if there was a manufacturer's guidelines for the wheelchair restraints. He stated, No. I think we lease the van. We didn't buy the restraints; it already had them. e. On 10/19/16 at 1:55 p.m., the Administrator was asked if the wheelchair restraints were ever checked prior to the incident with Resident #1. The Administrator stated, I don't have documentation of that. The Administrator was asked if there was any routine maintenance or monitoring of the wheelchair restraints prior to the incident with Resident #1. The Administrator stated, I don't have documentation of it. The Administrator was asked if staff were trained on the way to secure a wheelchair in the facility van prior to transporting residents. The Administrator stated, As far as I know, yes. The Administrator was asked if there was any documentation of the training. The Administrator stated, I am not sure. I do not have a check off sheet for it. The Administrator was asked if the facility had the manufacturer's instructions for the wheelchair restraints. The Administrator stated, I don't have them, if there is. The Administrator was asked if there had ever been a problem with the front restraints not locking prior to the incident with Resident #1. The Administrator stated, I was not aware of that. f. On 10/19/16 at 2:03 p.m., the Operating Manager was asked if there was any routine maintenance or monitoring of the wheelchair restraints in the facility van prior to the incident with Resident #1. The Operating Manager stated, Not on the seat belt inside. The Operating Manager was asked if there had ever been a problem with the front straps not locking prior to the incident with Resident #1. The Operating Manager stated, We never had a problem before that. The Operating Manager was asked if there was a manufacturer's guidelines for the wheelchair restraints. The Operating Manager stated,No. The Operator Manager was asked when the facility got the van. The Operator Manager stated, Believe we got it in the spring of 15 (2015). g. On 10/19/16 at 2:15 p.m., CNA #1 was loading the Administrator in the van while in a wheelchair. The wheelchair was pushed up the ramp into the van. A seat belt and shoulder strap were applied. The back straps were crossed The front straps were wrapped around the front part of the wheelchair on both sides and then hooked to seats that were located on both sides of the wheelchair. The CNA stated the front straps were not applied that way when Resident #1 tipped back. The CNA stated that the front straps were applied the same as the back straps at that time. The CNA also stated that at a later time the straps quit locking. h. On 10/19/16 at 2:30 p.m., the Maintenance Supervisor pointed out an area on the front restraints and stated, Been spraying it with WD 40. He also stated that he showed them a way to connect the straps to a seat to make sure it didn't happen again. He also stated, Not much maintenance to them. i. On 10/20/16 at 8:50 a.m., the Administrator was asked if there was any training provided to staff related to the use of the facility van during orientation. The Administrator stated, No. Only train the ones we put on our insurance. The Administrator was asked if the facility had any policy or procedures related to transporting residents in the facility van. The Administrator stated, I don't think we have anything in writing. j. On 10/20/16 at 10:00 a.m., Resident #1 was asked if she had ever been transported in the facility van. She stated, Yes. I have a foot doctor in (local city) to get checked every week. She was asked if she ever experienced any problems while being transported in the van. She stated, Yes. Coming from up there, all at once, it let loose, broke loose from the front. Hit my shoulder and back of my head. They didn't find anything very serious, but you know it could have killed me. She also stated that the driver and herself were the only ones in the van at the time. k. On 10/26/16 at 9:10 a.m., the Administrator was asked if the facility van had ever been inspected by a dealer or professional since the facility bought it. The Administrator stated, I don't know. l. On 10/26/16 at 9:20 a.m., the Operating Manager was asked if the van and restraint system had been inspected by a dealer or professional since the facility bought it. The Operating Manager stated, No. 2. On 10/19/16 at 5:10 p.m., the Immediate Jeopardy was removed and the scope and severity was reduced to E when the following Plan of Removal was implemented: The van being used by (facility) will be taken out of service effective 10/19/16 pending repair or replacement. Van will be taken to qualified person for inspection and repair before returning to use or van will be replaced. Residents will be taken to appointments by local Emergency Medical System service until van is approved by qualified person for use. 10/19/16 4:44 p.m. Manufacturer instructions for use, inspection, and maintenance of restraints will be acquired by facility before placing van back in use. All transport staff will be inserviced on uses of van restraints with return demonstration before being allowed to transport residents by Maintenance Director/qualified personal and documented on log kept by Maintenance Director. Training will be refreshed quarterly. Restraint system will be checked weekly by maintenance personnel/qualified designee and documented on log kept by Maintenance Director. Also van driver will check the restraint system before each use. If problem is identified van driver will alert Administrator and Maintenance Director. Van will be checked by qualified person per manufacturer's guidelines.

Based on observation, record review and interview, the facility's administration failed to identify and intervene to correct failures to ensure resident safety during van transport, as evidenced by failure of transport staff to ensure the van's wheelchair restraints were securely and properly applied, which resulted in a resident tipping over backward and hitting her head; failure to ensure the van / wheelchair restraint manufacturer's instructions were readily available and that transport staff members were trained on them; and failure to ensure the van restraints were routinely inspected by a qualified professional to ensure they were in proper working order, to prevent potential injuries for 1 (Resident #1) of 2 (Residents #1 and #3) case mix residents who were transported in the van while in a wheelchair since 9/22/16. This failed practice resulted in Immediate Jeopardy, which caused or could have caused serious harm, injury, or death to Resident #1 whose wheelchair tipped over backward during transport, and had the potential to cause more than minimal harm to 4 residents who were transported in the facility van while in a wheelchair since 9/22/16, according to a list provided by the Director of Nursing on 10/20/16 at 8:50 a.m. The facility was informed of Immediate Jeopardy on 10/19/16 at 3:52 p.m. The findings are: 1. The facility's Job Description for the Administrator, received on 10/20/16, documented, .Position Summary: The primary purpose of your job position is to direct the day-to-day functions of the facility in accordance with current federal, state, and local standards, guidelines, and regulations that govern long-term care facilities to assure the highest degree of quality of care can be provided to our residents at all times . Essential Job Functions: . Assume the administrative authority, responsibility and accountability of directing the activities and programs of the facility . Make routine inspections of the facility to assure that established policies and procedures are being implemented and followed . Personnel Functions: Ensure that an adequate number of appropriately trained professional and axillary personnel are on duty at all times to meet the needs of the residents . 2. The Job Description for Maintenance Worker received on 10/20/16 documented, Position Summary: Is responsible for developing preventative maintenance programs, inspecting the . equipment, making necessary repairs . The maintenance department works in cooperation with the nursing department . The maintenance workers will regularly assist with the safety program and will identify and correct workplace hazards . 3. Resident #1 had [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) with an assessment reference date of 10/5/16 documented the resident scored 11 (8-12 indicates moderately impaired) on a Brief Interview for Mental Status (BIMS), required extensive assistance of 2 plus persons for transfers, had functional limitation in range of motion of one lower extremity, did not ambulate, and used a wheelchair for mobility. a. An Incident and Accident Report dated 9/22/16 at 5:45 p.m. documented, (Resident #1) was taken to doctor's appointment in facility van. Upon leaving appointment the chair restraint came loose and the wheelchair (Resident #1) was in, tipped back and she hit her head on the van. The CNA (Certified Nursing Assistant) she was with reported that she stopped van and set chair and (Resident #1) up and checked her to see if she was injured. When she saw no visible injury, she called the Director of Nursing and reported what had happened. Director of Nursing called Administrator and was directed to have CNA take (Resident #1) to (local hospital) ER (emergency room ). b. An Emergency Department Note dated 9/22/16 at 7:34 p.m. documented, Pt (Patient) was being driven back to NH (nursing home) from a doctor's appt (appointment) and the wheelchair she was in tipped over and Pt fell back and hit her head on ramp. Has hematoma to back of head and c/o (complained of) neck pain. c. On 10/19/16 at 1:07 p.m., CNA #1 was asked if she had been trained on the proper way to secure a wheelchair in the facility van prior to transporting a resident. She stated, Yes. (CNA #2) showed me how to do it. The CNA was asked what happened on 9/22/16 with Resident #1 in the van. CNA #1 stated, We had gone to (local city) for a doctor's appointment. Loaded her up in the van. Locked wheelchair. Strapped the 2 back straps first. I put the seat belt on her. I went to each side and hooked the straps to the front and made sure they were locked before I got in myself. Had two stop lights. Last stop light we turned and the strap came unlocked which made the wheelchair tip back. The CNA also stated that the straps stayed attached to the chair, but they extended out further. The CNA then stated that there had been a problem with the unit not locking in place correctly before this, but the Maintenance Supervisor and Operating Manager were notified and that they did lock after that. d. On 10/19/16 at 1:37 p.m., the Maintenance Supervisor was asked if staff were trained on the way to secure a wheelchair in the facility van prior to transporting residents. The Maintenance Supervisor stated, Yes. Same girls do it all the time. The Maintenance Supervisor was asked if the wheelchair restraints were checked prior to the incident with Resident #1. The Maintenance Supervisor stated, Yes. When we got it we had to figure out how it worked. The Maintenance Supervisor was asked if there had ever been a problem with the front restraints not locking prior to the incident with Resident #1. He stated, Not that I know of. The Maintenance Supervisor was asked if there was any routine monitoring or maintenance prior to the incident with Resident #1. He stated, No. It is a closed unit inside a casing. Straps are inside a metal case. The Maintenance Supervisor was asked if there was a manufacturer's guidelines for the wheelchair restraints. He stated, No. I think we lease the van. We didn't buy the restraints; it already had them. e. On 10/19/16 at 1:55 p.m., the Administrator was asked if the wheelchair restraints were ever checked prior to the incident with Resident #1. The Administrator stated, I don't have documentation of that. The Administrator was asked if there was any routine maintenance or monitoring of the wheelchair restraints prior to the incident with Resident #1. The Administrator stated, I don't have documentation of it. The Administrator was asked if staff were trained on the way to secure a wheelchair in the facility van prior to transporting residents. The Administrator stated, As far as I know, yes. The Administrator was asked if there was any documentation of the training. The Administrator stated, I am not sure. I do not have a check off sheet for it. The Administrator was asked if the facility had the manufacturer's instructions for the wheelchair restraints. The Administrator stated, I don't have them, if there is. The Administrator was asked if there had ever been a problem with the front restraints not locking prior to the incident with Resident #1. The Administrator stated, I was not aware of that. f. On 10/19/16 at 2:03 p.m., the Operating Manager was asked if there was any routine maintenance or monitoring of the wheelchair restraints in the facility van prior to the incident with Resident #1. The Operating Manager stated, Not on the seat belt inside. The Operating Manager was asked if there had ever been a problem with the front straps not locking prior to the incident with Resident #1. The Operating Manager stated, We never had a problem before that. The Operating Manager was asked if there was a manufacturer's guidelines for the wheelchair restraints. The Operating Manager stated,No. The Operator Manager was asked when the facility got the van. The Operator Manager stated, Believe we got it in the spring of 15 (2015). g. On 10/19/16 at 2:15 p.m., CNA #1 was loading the Administrator in the van while in a wheelchair. The wheelchair was pushed up the ramp into the van. A seat belt and shoulder strap were applied. The back straps were crossed The front straps were wrapped around the front part of the wheelchair on both sides and then hooked to seats that were located on both sides of the wheelchair. The CNA stated the front straps were not applied that way when Resident #1 tipped back. The CNA stated that the front straps were applied the same as the back straps at that time. The CNA also stated that at a later time the straps quit locking. h. On 10/19/16 at 2:30 p.m., the Maintenance Supervisor pointed out an area on the front restraints and stated, Been spraying it with WD 40. He also stated that he showed them a way to connect the straps to a seat to make sure it didn't happen again. He also stated, Not much maintenance to them. i. On 10/20/16 at 8:50 a.m., the Administrator was asked if there was any training provided to staff related to the use of the facility van during orientation. The Administrator stated, No. Only train the ones we put on our insurance. The Administrator was asked if the facility had any policy or procedures related to transporting residents in the facility van. The Administrator stated, I don't think we have anything in writing. j. On 10/20/16 at 10:00 a.m., Resident #1 was asked if she had ever been transported in the facility van. She stated, Yes. I have a foot doctor in (local city) to get checked every week. She was asked if she ever experienced any problems while being transported in the van. She stated, Yes. Coming from up there, all at once, it let loose, broke loose from the front. Hit my shoulder and back of my head. They didn't find anything very serious, but you know it could have killed me. She also stated that the driver and herself were the only ones in the van at the time. k. On 10/26/16 at 9:10 a.m., the Administrator was asked if the facility van had ever been inspected by a dealer or professional since the facility bought it. The Administrator stated, I don't know. l. On 10/26/16 at 9:20 a.m., the Operating Manager was asked if the van and restraint system had been inspected by a dealer or professional since the facility bought it. The Operating Manager stated, No. 4. On 10/19/16 at 5:10 p.m., the Immediate Jeopardy was removed and the scope and severity was reduced to E when the following Plan of Removal was implemented: The van being used by (facility) will be taken out of service effective 10/19/16 pending repair or replacement. Van will be taken to qualified person for inspection and repair before returning to use or van will be replaced. Residents will be taken to appointments by local Emergency Medical System service until van is approved by qualified person for use. 10/19/16 4:44 p.m. Manufacturer instructions for use, inspection, and maintenance of restraints will be acquired by facility before placing van back in use. All transport staff will be inserviced on uses of van restraints with return demonstration before being allowed to transport residents by Maintenance Director/qualified personal and documented on log kept by Maintenance Director. Training will be refreshed quarterly. Restraint system will be checked weekly by maintenance personnel/qualified designee and documented on log kept by Maintenance Director. Also van driver will check the restraint system before each use. If problem is identified van driver will alert Administrator and Maintenance Director. Van will be checked by qualified person per manufacturer's guidelines.

Based on observation, record review and interview, the facility failed to ensure an allegation of sexual abuse was promptly reported and interventions were immediately developed to prevent the potential for further abuse for 1 (Resident #3) and a thorough investigation of an allegation of sexual abuse was completed for 2 of 2 (Resident #3 and #13) case-mix residents after allegations of sexual abuse were reported. These failed practices resulted in Immediate Jeopardy which caused or could have caused serious harm, injury or death to Residents #3 and #13 and was likely to affect 24 female residents who resided in the facility as documented on the list provided by the Director of Nursing (DON) on 1/13/13 at 9:05 a.m. The facility was informed of the Immediate Jeopardy on 1/12/12 at 3:33 p.m. The findings are: 1. Resident #13 had [DIAGNOSES REDACTED]. The Quarterly MDS with an ARD date of 12/22/11 documented the resident scored 8 (8-12 indicated moderately impaired), required limited assistance of one person with transfer and dressing, and had no behaviorial problems. a. An Incident and Accident Next day Reporting form, DMS 7734, dated 11/27/11 at 6:45 a.m. documented, "On 11/27/11 at approximately 06:45 a.m. the resident reported to the day shift CNA's that when she woke up that a man was getting off the top of her. I, DON arrived at 8:10 a.m. and spoke with the resident... I asked her if something happened to her, she stated, 'Yes when I woke up last night that man was getting off me.' When I asked her what man, she stated, 'that little one.' When I asked if little meant skinny or short she stated, 'the short one.' Then she stated, 'I don't think he has worked here long.' I then asked her if it was this morning, she stated, 'No, it was last night.' When I asked her about what time it was, she stated 'I don't know.' I asked resident if she was hurt anywhere she stated, 'No.' I then asked her if she thought anything had happened or if she thought he did anything to her, she stated, 'I think so.' I asked her if she could tell me what he had done to her, she stated, 'I think he put his thang up in me.' I asked resident if she was scared or if she felt safe here. She stated, 'I was scared last night, but I'm not scared now.' I asked her if she told anybody when it happened and she stated, 'No.' I then notified the MD (medical doctor) and facility Medical Director at 0830 a.m. He advised me to send the resident to the emergency room (ER) for evaluation. Staff begin to prepare resident for transfer to medical center. At 08:45 a.m., I notified daughter of resident's report to staff and of transfer to ER. Bed sheets sent in bag with resident. At 09:20 a.m. sheriff's office was notified. At 09:30 a.m. deputy arrived at ER. Information was provided him about resident's allegations." b. The Facility Investigation Report for Resident Abuse, Neglect, Misappropriation of Property & Exploitation of Residents in Long Term Care Facilities form, DMS 762, documented the following witness statements: 1) On 11/27/10 at 6:30 a.m., CNA #5 documented, "I walked into the resident's room and said good morning. I asked her if she was ready to get up. She then stated, 'that she woke up with the man on top of her.' I asked the man. She said yes, I then asked if it was the man that wonders in here sometimes and uses the restroom, (Resident #12). She said no, it was one of the workers. I then noticed a yellow, mucous substance on her sheet with a little blood in it. I asked the other CNA to grab the nurse. They came and told me to watch when she wipes after using the bathroom. I walked her to the bathroom, once she was finished, I wiped her and noticed on the paper was discharge and another yellow substance the same color as was on the sheet. Took place around 06:30 a.m." 2) On 11/27/11 at 6:55 a.m., a witness statement was written for CNA #6 (the alleged perpetrator), by LPN #1 (the 11:00 p.m. - 7:00 a.m. nurse), that documented, "I was in the resident's room one time to add ice to her cup. She did not wake up all night." As of 1/12/12 there was no other documentation of interviews from other female residents in the facility. c. An EMT (Emergency Medical Technician) note dated 11/27/11 at 8:53 a.m. documented, "Responded to facility for alleged sexual assault per report of staff at facility. Upon arrival, received linens from pt's (patient's) bed. Assisted to cot . . . linens in unit with pt. A (alert)/O (oriented) X (times) 3. Detailed physical assessment not done due to nature of call and need to preserve evidence. Pt. did not verbalize any pain at this time." d. An ER report dated 11/27/11 at 9:05 a.m. documented, "[AGE] year old . . . she does not state anything happened when questioned in ER and denies any pain. She is oriented to name/place. Registered Nurse collected specimens for rape kit, officers called and present in ER. May return to facility as long as no exposure to male staff which was present in last 12 hours." e. A Police Report dated dated 11/27/11 at approximately 9:36 a.m. documented, "Deputy arrived at the facility and met with resident. The resident was not real vocal but did state that she had been violated by a male subject sometime last night. The possible subject has been working in the facility for approximately 3 months. The resident did give a written statement to his employer that he was in the resident's room only one time last night to pass ice. According to the nursing staff the subject does not write and the statement was written for him by a fell ow employee (LPN #1). I took the Chain of Custody from Registered Nurse at facility, one brown bag that has a pillow case sealed shut . . . which contains the sheets from the resident's bed and a sexual assault sheet. The Subject stated that they have a resident named (Resident #12) who wanders around the halls at night, and has been found sitting in other rooms but he has never done anything to any resident that he knows of." f. On 1/12/12 at 8:58 a.m., the DON was asked about the incident on 11/27/11 and she reiterated what she stated in the DMS 762. She stated the resident was sent to the ER and they found nothing and that a rape kit was done. The DON was asked for results of rape kit and she stated, "It takes 3-6 months to get results." The DON was asked if CNA #6 still worked at the facility and she stated, "Yes, the nurses goes in with him now." At 11:30 a.m., the DON was asked if she had taken the staff member to the resident so she could identify the perpetrator and he stated, "No. I asked her who and she said the skinny one." When asked if CNA #6 was skinny, she stated, "Yes, very skinny." The DON was asked what was done since the incident to protect the resident and she stated, "The nurses go into the room with the male CNA's." The DON was asked if she had done inservices and she stated, "Yes we did one when it happened." The DON was asked what had been done to prevent a recurrence of the incident and she stated, "Well, the nurses were going into the rooms with the male CNA's." When asked if anything else had been put in place to monitor the male CNA's she stated, "No." 2. Resident #3 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/11/11 documented the resident scored 15 (13-15 indicates cognitively intact) on the Brief Interview for Mental Status (BIMS), required limited assistance of one person for transfers and toilet use, had functional limitation in range of motion in upper and lower extremities on one side, and had no behaviorial problems. a. A Nurses Note dated 10/23/11 at 11:15 p.m. documented, "Resident wanted to speak with the nurse, so this nurse went to see what she needed. Resident told this nurse, 'Remember what I told you the other night about that aid?' This nurse answered I remember that you told me you didn't want him to take care of you so I came in with him every time you turned your light on. The resident stated, 'I know but remember what I told you the other night?' This nurse answered, No, I was only here last night. Resident then said, 'No, remember me telling you the other night that he (CNA #6) grabbed my breast'. . ." b. A Grievance Form dated 10/24/11 documented, "Date the incident occurred: 10/23/11... Resident States, 'I think it was Saturday Night, I was up to the bathroom and (Certified Nursing Assistant (CNA) #6) helped me. When I stood up he grabbed my breast. I lunged forward, he had one hand on my shoulder." Actions to be taken documented, "Resident request that (CNA #6) not come into her room or that he be accompanied by another staff member. Spoke with employee (CNA #6) and he stated, 'Resident was on call light and I asked her what could I do for her, she wanted up to the bathroom so I helped her into the BR (bathroom). I got her into the BR and helped her stand up. I placed one hand on her shoulder and she begin to twist her upper body. I accidently touched her breast while she was twisting cause I didn't want her to fall. She told me to get out and go get the nurse, so I did. Nurse (Licensed Practical Nurse (LPN) #1) instructed me to have her present anytime I have to go back into room. . ." 1) On 1/11/12 at 3:40 p.m., the Director of Nursing (DON) was shown the nurses note dated 10/23/11 and asked if she knew about it and she stated, "Yes." There were no statements from the resident nor were there any from other staff or residents. The DON was asked if the incident was reported to the Office of Long Term Care (OLTC) she stated, "No, the Grievance is all I have." She also stated, "Resident makes allegations, frequent allegations." When asked if the CNA was suspended she stated, "No, he was off his regular days on 10/24/11 and 10/25/11." 2) On 1/11/12 at 3:50 p.m., LPN #1 was asked about the incident involving Resident #3 and she stated, "I told her that I was not working the night that she said the incident happened." The LPN was asked if she had reported the incident she stated, "I tried to call the DON that night, but couldn't reach her so I told the nurse that was coming on before I got off duty, and I put a note under the DON's door to inform her." When asked if the CNA continued to go into the resident's room after the allegation she stated, "I did not let the CNA go back into the resident's room alone." 3) On 1/11/12 at 4:35 p.m., the resident was asked about the incident. She stated, "He (male CNA (CNA #6)) grabbed my breast when he came in to assist me to the bathroom." When asked if she thought this was an accidental act she stated, "No, he grabbed it and sort of twisted it like this (the resident demonstrated, turning hands in a twisting motion), and I pushed him away. He apologized and has been nice since." The resident was asked if this made her feel uncomfortable and she stated, "Yes, very uncomfortable." The resident was asked if she had reported this and she stated, "Yes to the nurse." The resident was asked if the CNA continued to work with her after the incident and she stated, "Yes, but the nurse would come in with him." c. On 1/12/12 at 8:58 a.m., the DON was asked if the facility had reported the allegation to OLTC (Office of Long Term Care) and she stated, "I called OLTC (complaint department) on that one and was told if we investigated it and determined it's unfounded, it doesn't have to be investigated." When asked for if she had documentation of this she stated she could not find any. On 1/12/12 at 9:58 a.m. this Surveyor called OLTC complaint department and spoke with the person that the DON said she spoke with. The Surveyor informed the person in the complaint department what the Surveyor was told. The person from the Complaint Department stated, "No, I did not tell her that. She must have misunderstood something that I said." d. The Plan of Care reviewed on 10/9/11 and 1/10/12 did not document the resident made allegations frequently in reference to staff displaying inappropriate sexual behaviors toward the resident. e. The Behavior Symptoms Checklist dated 11/15-12/14/11 did not document any allegations of inappropriate sexual behaviors or hallucinations. f. On 1/13/11 at 10:00 a.m., the DON was asked for the resident's last psychiatric evaluation. At 11:32 a.m., the last psychiatric evaluation was received and dated 7/21/05 with admission for mood changes including worsening irritability and moodiness. 3. On 1/12/12 at 10:40 a.m., a Group Meeting was held consisting of 5 cognitively alert females. When asked if staff had ever harmed them? They all stated, "No." When asked if they had ever heard of any residents being abused in any way? They all stated, "No." When asked if they had male CNA's? They stated, "Yes, 2 on the night shift, 1 has been here for a long time and 1 (CNA #6) hasn't been here that long, about 3 months." When asked if either of the male CNA's had ever harmed them? They all stated, "No." a. On 1/12/12 at 2:20 p.m., the DON was asked if the nurses were still going into the resident rooms with the male CNA and she stated, "Yes, as far as I know." The DON was asked what resident rooms does the nurse go into with the male CNA and she stated, "Resident #3 and #13." She stated there were 4 night nurses. At 2:28 p.m., LPN #1 was asked if she went into the resident room with CNA #6 on the night shift and she stated, CNA #6 normally works the west hall and if he goes into Resident #3 and #13's room she goes in with him. At 2:35 p.m., LPN #2 stated, "since the allegation, when I work with him (male CNA #6), another CNA or myself go into the room with him." LPN #2 was asked if the nurses accompany the CNA in the other female residents room? She stated, "No, just Resident #3 and #13." At 2:59 p.m., LPN #3 stated, "Yes, I still go in with (CNA #6),when he goes into Resident #3 or Resident #13 room." 4. On 1/12/12 at 6:32 p.m., the Immediate Jeopardy was removed and the scope/severity lowered to an "E" when the following Plan of Removal was implemented: a. On Thursday, January 12, at 4:10 p.m. alleged employee was suspended until further notice, to ensure safety of all residents. b. Interviews began at 4:00 p.m. on January 12, of all cognitive, interviewable residents. Interviews were completed by Social Director and designated LPN at 5:20 p.m. We currently have 41 residents in the facility, 2 in the hospital of these 17 cognitive women were interviewed with no negative findings, 7 non-cognitive women were interviewed. 15 cognitive men were interviewed with no findings. There were 2 non-cognitive males who were not interviewed. c. Body Audits will be completed on all residents, both cognitive and non-cognitive, by 11:00 a.m. on January 13, 2012. Body Audits were completed on 1/13/2012 at 10:35 a.m. by DON/designee, with no negative findings. d. An active investigation is in progress at present time regarding allegations from the one negative finding. This report was an allegation from 10/23/11. e. Beginning immediately, when an allegation is received, an I and A (Incident and Accident) will be initiated and the Administrator and DON will be notified. An investigation will take place and a report will be sent to OLTC by 11:00 a.m. the next business day or the first business day if the event occurs on the week-end. The accused party will be suspended immediately, authorities will be notified as well as family members. All residents and staff will be interviewed and questioned. Based on allegations made, a decision will be made within 72 hours on the status of the accused employee/resident. Employee will be terminated, in the event that findings are sufficient to the allegations alleged. This will be done, in order to protect the safety and well being of other residents. f. A mandatory inservice will be held immediately with the staff presently on duty, and oncoming shifts before the beginning of their shift, to ensure that all staff are aware of the policies and procedure to follow when an abuse allegation is received. No employee will begin their shift prior to being inserviced on what to do when an abuse allegation is received. Administrator, DON or management designee will review I/A 's daily for 30 days, then weekly to ensure abuse Prohibition policies and procedure are followed.

Based on observation, record review and interview, the facility failed to ensure the Abuse Investigation and Reporting Guidelines were implemented as evidences by the facility's failure to ensure an allegation of sexual abuse was promptly reported and interventions were immediately developed to prevent the potential for further abuse for 1 (Resident #3) and a thorough investigation of an allegation of sexual abuse was completed for 2 of 2 (Resident #3 and #13) case-mix residents after allegations of sexual abuse were reported. These failed practices resulted in Immediate Jeopardy which caused or could have caused serious harm, injury or death to Residents #3 and #13 and was likely to affect 24 female residents who resided in the facility as documented on the list provided by the Director of Nursing (DON) on 1/13/13 at 9:05 a.m. The facility was informed of the Immediate Jeopardy on 1/12/12 at 3:33 p.m. The findings are: 1. The facility's "Abuse Policy And Procedure", provided by the Administrator on 1/9/12 documented, "Investigation Protocol: Any staff member that is a witness to or has knowledge of abuse, neglect, or misappropriation of property will immediately report the incident to their direct supervisor... the supervisor will then inform the resident's charge nurse of the allegation and the charge nurse will begin the investigation with the appropriate staff (or other witness). The charge nurse will immediately assess the resident for injuries, and take the appropriate steps to insure the safety of the resident. The charge nurse will notify the Director of Nursing, Administrator (or designee), the resident's physician, and the resident's family or legal representative. The Administrator (or designee) will notify the appropriate agencies, to include the Office of Long Term Care (OLTC) and the police department and will then supervise the investigation and ensure that the appropriate steps have been taken to prevent further harm to the resident...the Administrator will submit or cause to be submitted to the OLTC and other agencies, all reports as required." "Protection of residents from abuse or neglect during an investigation: Upon notification of abuse, neglect or misappropriation of resident property... the affected resident will be removed from the immediate area of the incident or alleged incident. If the allegation pertains to an employee or employees, that employee or those employees shall be suspended from duty, pending the outcome of investigation. The resident will be monitored until a complete assessment has been performed and will continue to be monitored until such time as the incident or situation has been resolved." 2. Resident #13 had [DIAGNOSES REDACTED]. The Quarterly MDS with an ARD date of 12/22/11 documented the resident scored 8 (8-12 indicated moderately impaired), required limited assistance of one person with transfer and dressing, and had no behaviorial problems. a. An Incident and Accident Next day Reporting form, DMS 7734, dated 11/27/11 at 6:45 a.m. documented, "On 11/27/11 at approximately 06:45 a.m. the resident reported to the day shift CNA's that when she woke up that a man was getting off the top of her. I, DON arrived at 8:10 a.m. and spoke with the resident... I asked her if something happened to her, she stated, 'Yes when I woke up last night that man was getting off me.' When I asked her what man, she stated, 'that little one.' When I asked if little meant skinny or short she stated, 'the short one.' Then she stated, 'I don't think he has worked here long.' I then asked her if it was this morning, she stated, 'No, it was last night.' When I asked her about what time it was, she stated 'I don't know.' I asked resident if she was hurt anywhere she stated, 'No.' I then asked her if she thought anything had happened or if she thought he did anything to her, she stated, 'I think so.' I asked her if she could tell me what he had done to her, she stated, 'I think he put his thang up in me.' I asked resident if she was scared or if she felt safe here. She stated, 'I was scared last night, but I'm not scared now.' I asked her if she told anybody when it happened and she stated, 'No.' I then notified the MD (medical doctor) and facility Medical Director at 0830 a.m. He advised me to send the resident to the emergency room (ER) for evaluation. Staff begin to prepare resident for transfer to medical center. At 08:45 a.m., I notified daughter of resident's report to staff and of transfer to ER. Bed sheets sent in bag with resident. At 09:20 a.m. sheriff's office was notified. At 09:30 a.m. deputy arrived at ER. Information was provided him about resident's allegations." b. The Facility Investigation Report for Resident Abuse, Neglect, Misappropriation of Property & Exploitation of Residents in Long Term Care Facilities form, DMS 762, documented the following witness statements: 1) On 11/27/10 at 6:30 a.m., CNA #5 documented, "I walked into the resident's room and said good morning. I asked her if she was ready to get up. She then stated, 'that she woke up with the man on top of her.' I asked the man. She said yes, I then asked if it was the man that wonders in here sometimes and uses the restroom, (Resident #12). She said no, it was one of the workers. I then noticed a yellow, mucous substance on her sheet with a little blood in it. I asked the other CNA to grab the nurse. They came and told me to watch when she wipes after using the bathroom. I walked her to the bathroom, once she was finished, I wiped her and noticed on the paper was discharge and another yellow substance the same color as was on the sheet. Took place around 06:30 a.m." 2) On 11/27/11 at 6:55 a.m., a witness statement was written for CNA #6 (the alleged perpetrator), by LPN #1 (the 11:00 p.m. - 7:00 a.m. nurse), that documented, "I was in the resident's room one time to add ice to her cup. She did not wake up all night." As of 1/12/12 there was no other documentation of interviews from other female residents in the facility. c. An EMT (Emergency Medical Technician) note dated 11/27/11 at 8:53 a.m. documented, "Responded to facility for alleged sexual assault per report of staff at facility. Upon arrival, received linens from pt's (patient's) bed. Assisted to cot . . . linens in unit with pt. A (alert)/O (oriented) X (times) 3. Detailed physical assessment not done due to nature of call and need to preserve evidence. Pt. did not verbalize any pain at this time." d. An ER report dated 11/27/11 at 9:05 a.m. documented, "[AGE] year old . . . she does not state anything happened when questioned in ER and denies any pain. She is oriented to name/place. Registered Nurse collected specimens for rape kit, officers called and present in ER. May return to facility as long as no exposure to male staff which was present in last 12 hours." e. A Police Report dated dated 11/27/11 at approximately 9:36 a.m. documented, "Deputy arrived at the facility and met with resident. The resident was not real vocal but did state that she had been violated by a male subject sometime last night. The possible subject has been working in the facility for approximately 3 months. The resident did give a written statement to his employer that he was in the resident's room only one time last night to pass ice. According to the nursing staff the subject does not write and the statement was written for him by a fell ow employee (LPN #1). I took the Chain of Custody from Registered Nurse at facility, one brown bag that has a pillow case sealed shut . . . which contains the sheets from the resident's bed and a sexual assault sheet. The Subject stated that they have a resident named (Resident #12) who wanders around the halls at night, and has been found sitting in other rooms but he has never done anything to any resident that he knows of." f. On 1/12/12 at 8:58 a.m., the DON was asked about the incident on 11/27/11 and she reiterated what she stated in the DMS 762. She stated the resident was sent to the ER and they found nothing and that a rape kit was done. The DON was asked for results of rape kit and she stated, "It takes 3-6 months to get results." The DON was asked if CNA #6 still worked at the facility and she stated, "Yes, the nurses goes in with him now." At 11:30 a.m., the DON was asked if she had taken the staff member to the resident so she could identify the perpetrator and he stated, "No. I asked her who and she said the skinny one." When asked if CNA #6 was skinny, she stated, "Yes, very skinny." The DON was asked what was done since the incident to protect the resident and she stated, "The nurses go into the room with the male CNA's." The DON was asked if she had done inservices and she stated, "Yes we did one when it happened." The DON was asked what had been done to prevent a recurrence of the incident and she stated, "Well, the nurses were going into the rooms with the male CNA's." When asked if anything else had been put in place to monitor the male CNA's she stated, "No." 3. Resident #3 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/11/11 documented the resident scored 15 (13-15 indicates cognitively intact) on the Brief Interview for Mental Status (BIMS), required limited assistance of one person for transfers and toilet use, had functional limitation in range of motion in upper and lower extremities on one side, and had no behaviorial problems. a. A Nurses Note dated 10/23/11 at 11:15 p.m. documented, "Resident wanted to speak with the nurse, so this nurse went to see what she needed. Resident told this nurse, 'Remember what I told you the other night about that aid?' This nurse answered I remember that you told me you didn't want him to take care of you so I came in with him every time you turned your light on. The resident stated, 'I know but remember what I told you the other night?' This nurse answered, No, I was only here last night. Resident then said, 'No, remember me telling you the other night that he (CNA #6) grabbed my breast'. . ." b. A Grievance Form dated 10/24/11 documented, "Date the incident occurred: 10/23/11... Resident States, 'I think it was Saturday Night, I was up to the bathroom and (Certified Nursing Assistant (CNA) #6) helped me. When I stood up he grabbed my breast. I lunged forward, he had one hand on my shoulder." Actions to be taken documented, "Resident request that (CNA #6) not come into her room or that he be accompanied by another staff member. Spoke with employee (CNA #6) and he stated, 'Resident was on call light and I asked her what could I do for her, she wanted up to the bathroom so I helped her into the BR (bathroom). I got her into the BR and helped her stand up. I placed one hand on her shoulder and she begin to twist her upper body. I accidently touched her breast while she was twisting cause I didn't want her to fall. She told me to get out and go get the nurse, so I did. Nurse (Licensed Practical Nurse (LPN) #1) instructed me to have her present anytime I have to go back into room. . ." 1) On 1/11/12 at 3:40 p.m., the Director of Nursing (DON) was shown the nurses note dated 10/23/11 and asked if she knew about it and she stated, "Yes." There were no statements from the resident nor were there any from other staff or residents. The DON was asked if the incident was reported to the Office of Long Term Care (OLTC) she stated, "No, the Grievance is all I have." She also stated, "Resident makes allegations, frequent allegations." When asked if the CNA was suspended she stated, "No, he was off his regular days on 10/24/11 and 10/25/11." 2) On 1/11/12 at 3:50 p.m., LPN #1 was asked about the incident involving Resident #3 and she stated, "I told her that I was not working the night that she said the incident happened." The LPN was asked if she had reported the incident she stated, "I tried to call the DON that night, but couldn't reach her so I told the nurse that was coming on before I got off duty, and I put a note under the DON's door to inform her." When asked if the CNA continued to go into the resident's room after the allegation she stated, "I did not let the CNA go back into the resident's room alone." 3) On 1/11/12 at 4:35 p.m., the resident was asked about the incident. She stated, "He (male CNA (CNA #6)) grabbed my breast when he came in to assist me to the bathroom." When asked if she thought this was an accidental act she stated, "No, he grabbed it and sort of twisted it like this (the resident demonstrated, turning hands in a twisting motion), and I pushed him away. He apologized and has been nice since." The resident was asked if this made her feel uncomfortable and she stated, "Yes, very uncomfortable." The resident was asked if she had reported this and she stated, "Yes to the nurse." The resident was asked if the CNA continued to work with her after the incident and she stated, "Yes, but the nurse would come in with him." c. On 1/12/12 at 8:58 a.m., the DON was asked if the facility had reported the allegation to OLTC (Office of Long Term Care) and she stated, "I called OLTC (complaint department) on that one and was told if we investigated it and determined it's unfounded, it doesn't have to be investigated." When asked for if she had documentation of this she stated she could not find any. On 1/12/12 at 9:58 a.m. this Surveyor called OLTC complaint department and spoke with the person that the DON said she spoke with. The Surveyor informed the person in the complaint department what the Surveyor was told. The person from the Complaint Department stated, "No, I did not tell her that. She must have misunderstood something that I said." d. The Plan of Care reviewed on 10/9/11 and 1/10/12 did not document the resident made allegations frequently in reference to staff displaying inappropriate sexual behaviors toward the resident. e. The Behavior Symptoms Checklist dated 11/15-12/14/11 did not document any allegations of inappropriate sexual behaviors or hallucinations. f. On 1/13/11 at 10:00 a.m., the DON was asked for the resident's last psychiatric evaluation. At 11:32 a.m., the last psychiatric evaluation was received and dated 7/21/05 with admission for mood changes including worsening irritability and moodiness. 4. On 1/12/12 at 10:40 a.m., a Group Meeting was held consisting of 5 cognitively alert females. When asked if staff had ever harmed them? They all stated, "No." When asked if they had ever heard of any residents being abused in any way? They all stated, "No." When asked if they had male CNA's? They stated, "Yes, 2 on the night shift, 1 has been here for a long time and 1 (CNA #6) hasn't been here that long, about 3 months." When asked if either of the male CNA's had ever harmed them? They all stated, "No." a. On 1/12/12 at 2:20 p.m., the DON was asked if the nurses were still going into the resident rooms with the male CNA and she stated, "Yes, as far as I know." The DON was asked what resident rooms does the nurse go into with the male CNA and she stated, "Resident #3 and #13." She stated there were 4 night nurses. At 2:28 p.m., LPN #1 was asked if she went into the resident room with CNA #6 on the night shift and she stated, CNA #6 normally works the west hall and if he goes into Resident #3 and #13's room she goes in with him. At 2:35 p.m., LPN #2 stated, "since the allegation, when I work with him (male CNA #6), another CNA or myself go into the room with him." LPN #2 was asked if the nurses accompany the CNA in the other female residents room? She stated, "No, just Resident #3 and #13." At 2:59 p.m., LPN #3 stated, "Yes, I still go in with (CNA #6),when he goes into Resident #3 or Resident #13 room." 5. On 1/12/12 at 6:32 p.m., the Immediate Jeopardy was removed and the scope/severity lowered to an "E" when the following Plan of Removal was implemented: a. On Thursday, January 12, at 4:10 p.m. alleged employee was suspended until further notice, to ensure safety of all residents. b. Interviews began at 4:00 p.m. on January 12, of all cognitive, interviewable residents. Interviews were completed by social director and designated LPN at 5:20 p.m. We currently have 41 residents in the facility, 2 in the hospital of these 17 cognitive women were interviewed with no negative findings, 7 non-cognitive women were interviewed. 15 cognitive men were interviewed with no findings. There were 2 non-cognitive males who were not interviewed. c. Body Audits will be completed on all residents, both cognitive and non-cognitive, by 11:00 a.m. on January 13, 2012. Body Audits were completed on 1/13/2012 at 10:35 a.m. by DON/designee, with no negative findings. d. An active investigation is in progress at present time regarding allegations from the one negative finding. This report was an allegation from 10/23/11. e. Beginning immediately, when an allegation is received, an I and A (Incident and Accident) will be initiated and the Administrator and DON will be notified. An investigation will take place and a report will be sent to OLTC by 11:00 a.m. the next business day or the first business day if the event occurs on the week-end. The accused party will be suspended immediately, authorities will be notified as well as family members. All residents and staff will be interviewed and questioned. Based on allegations made, a decision will be made within 72 hours on the status of the accused employee/resident. Employee will be terminated, in the event that findings are sufficient to the allegations alleged. This will be done, in order to protect the safety and well being of other residents. f. A mandatory inservice will be held immediately with the staff presently on duty, and oncoming shifts before the beginning of their shift, to ensure that all staff are aware of the policies and procedure to follow when an abuse allegation is received. No employee will begin their shift prior to being inserviced on what to do when an abuse allegation is received. Administrator, DON or management designee will review I/A 's daily for 30 days, then weekly to ensure abuse Prohibition policies and procedure are followed.