Every finding on record at Willowbend Health and Rehabilitation, LLC

Number of residents sampled: Number of residents cited: Based on observations, interviews, record review, and facility policy review, it was determined the facility failed to store and serve food in accordance with professional standards for food safety services for three (Resident #43, #38 and #109) of 19 residents reviewed. Specifically, meats were not served at the acceptable temperature of 135 degrees, food was not appropriately sealed and stored in the freezer, there were expired foods stored in the dry food storge area, and prepared liquids were not dated and sealed when stored in the refrigerator. The findings include: During an observation on 08/02/2026 at 10:05 AM, three items were observed in the freezer open and unsealed. The item labels indicated the contents of the bags were as follows: beef patty, sausages and smiling fries. In the refrigerator 14 cups were observed sitting on a black tray on a shelf with no date(s) on the lids or the tray. During an interview on 08/02/2026 at 10:05 AM, [NAME] #10 identified the open and unsealed items as beef patties, hammock sausages and smiling fries. [NAME] #10 stated, yes, the bags were opened. [NAME] #10 indicated food not sealed in a freezer could damage the food if not stored properly. [NAME] #10 also identified the 14 cups on the black tray in the refrigerator as drinks from last night's supper and confirmed the drinks did not have preparation dates on the lids. During an interview on 08/04/2026 at 11:20 AM, the Dietary Manager indicated all food stored in the freezer should be sealed. The Dietary Manager also indicated all food in the refrigerator that has been prepared with a lid should be dated, and expired items should be removed from the canned/dried food area to avoid consumption. Resident #38 A review of an admission Record indicated the facility admitted Resident #38 on 05/06/2026 with diagnoses that included chronic gout. A review of Resident #38's Diet Order revealed Resident #38 had allergies to red meat, sea food, and shellfish. Resident #43 A review of an admission Record indicated the facility admitted Resident #43 on 06/04/2026 with diagnoses that included acute kidney failure, vitamin deficiency and dysphagia. A review of Resident #43's Diet Order revealed Resident #43 was on a mechanical soft diet with no further instructions on meat preference. Resident #109 A review of an admission Record, indicated the facility admitted Resident #109 on 05/09/2023 with diagnoses that included type-2 diabetes, immunodeficiency, obesity, heart failure, and GERD A review of Resident #109's Diet Order, revealed No Chicken and Pork listed as special instructions. During a lunch observation on 08/04/2026 at 12:25 PM, this surveyor observed the following: Resident #38 was served chicken. Resident #43 was served a mechanical soft prepared riblet. Resident #109 was served a beef patty. During an observation in the kitchen on 08/04/2026 at 11:20 AM, this surveyor observed that the steam table did not have knobs to turn the steam table on and off, in their place the dietary staff used the protruding prongs to operate the steam table. There were four areas on the steam table; the first, third and fourth areas on the steam table had a red light, to indicate the steam table was on and operating, above a prong that protruded from the table where the knobs should be. The second space on the steam table did not have a prong that the dietary staff could use to operate the steam table, and the red light was not lit to indicate this section was operating. The hamburger patties and riblets later served to residents, were in the second space on the steam table above the area that did not have a knob, a prong or a red light. During an observation in the kitchen on 08/04/2026 at 11:50 AM, there was food observed on the steam table waiting to be served. [NAME] # 8 collected food temperatures that read as follows: riblet meat (for the mechanical soft diet) at 98 degrees, burger patties at 125 degrees, chicken breast at 110 degrees, and pork riblets at 106 degrees. The food was plated and placed on the 100 Hall cart for distribution to the residents residing on 100 Hall. At 12:05 PM [NAME] #8, and #9 and the Dietary Manager agreed the food was ready to be served. During an interview on 08/04/2026 at 12:14 PM, with [NAME] #8 and #9, [NAME] #8 indicated hot food should be 135 degrees or higher. [NAME] #8 indicated that she usually temperature checked the food on the stove and was unaware she needed to temperature check the food away from the steam table. [NAME] #8 stated she had been a cook at this facility since last year, 2025 and the steam table was broken, and the second knob had not worked since she started. [NAME] #9 indicated he had worked in the kitchen for more than 6 months and the steam table had been broken the whole time. [NAME] # 9 indicated meats should be at 155 degrees [when served]. During an interview on 08/05/2026 at 2:30 PM, the DON stated if food was consumed after being held at the incorrect temperature, they could have gotten food poisoning [referring to facility residents]. During an interview on 08/05/2026 at 2:51 PM, the Administrator indicated she was aware there was an issue with the steam table not working but that she was under the impression it was fixed. The Administrator indicated the temperature logs she had reviewed to be within normal limits. The Administrator indicated there were safety concerns of bacteria if foods were not held at the appropriate temperatures. The Administrator stated, No this is not a professional standard for food safety. A review of an undated blank facility log titled, Prepared Food Temperature Log,, indicated, hot foods to be held at 135 degrees or higher. A review of the facility's undated policy titled Temperature Danger Zones, indicated, pathogens grow well in the temperature range from 41F to 135F. This is called the temperature danger zone. Temperature and Time Control System (TCS) food must be kept out of this range. You must be able to tell when food was stored and what date it must be used. Ready to eat food must be marked if it will be held longer than 24 hours. Certain groups of people may have weaker immune systems they have a higher risk of getting food borne illnesses.

Number of residents sampled: Number of residents cited: Based on observation, record review, interview, and facility policy review, the facility failed to ensure the medication error rate was less than five percent during a medication administration observation of one (Residents #86) of five residents. This surveyor observed 26 opportunities for medication administration, with 2 of the 26 medications not being administered in accordance with the Physician's Orders, resulting in a medication error rate of 7.6 percent. The findings include: Resident #86 During a medication administration observation on 08/04/2026 at 8:00 AM, the Registered Nurse (RN) #2 prepared Resident #86's medications. She placed a strip of [a topical nonsteroidal anti-inflammatory drug (NSAID) in gel form] on a ruler, but she did not fill the box for the entire length of the physician ordered 2.2 inches. She crushed Resident #86's medications, that included [an extended-release prescription beta-blocker used to treat high blood pressure, chest pain (angina), and heart failure]. At 8:35 AM, RN #2 placed pudding in a pill cup with the crushed medications, took the medication cup to the resident, and administered the crushed medications with a spoon to Resident #86. Review of Resident #86's Physician Orders with a revised date of 09/03/2025 revealed the resident was admitted to long term care. The Physician Orders also revealed [topical NSAID gel] with a start date of 09/10/2024 and the extended-release prescription beta blocker with a start date of 09/04/2024. Review of Resident #86's electronic Medication Administration Record (eMAR) indicated [extended-release prescription beta blocker] with instructions of DO NOT CRUSH OR CHEW with a start date of 09/04/2024. The eMAR also indicated [topical NSAID gel] with instructions to apply one gram using ruler provided, with a start date of 09/10/2024. Review of Resident #86's Care Plan revealed diagnoses that included pain in arm and hypertensive heart disease with heart failure. During an interview on 08/04/2026 at 1:38 PM, RN #2 stated she, believed she filled in the entire space on the ruler for the pain cream. When this surveyor showed RN #2 the picture of the ruler with the gel that was administered taken by this surveyor after RN #2 placed the cream on the ruler, RN #2 confirmed the whole box was not filled in. RN #2 stated she did not give the entire dose of one gram. She was asked how she administered the [extended-release beta blocker] pill to Resident #86 and RN #2 stated the pill was crushed. She was asked to review the Physician's Order, and she stated the pill was not to be crushed or chewed, and she should have left the pill whole. She stated an extended-release medication should not be crushed because that interfered with the medications, half-life. Review of a Preparation and General Guidelines policy, with a revised date of 05/01/2019, revealed medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. The policy indicated the pharmacist should be contacted to review all medications being considered for crushing, whether a physician's order is present or not. The pharmacist can assist in finding appropriate alternatives to medications that should be crushed, and the instructions for crushing medications should be included on the residents' orders and the MAR/eMAR. The policy also indicated the five rights were right resident, right drug, right dose, right route and right time and applied for each medication being administered.

Number of residents sampled: Number of residents cited: Based on record review, interview, and facility policy review, the facility failed to ensure a resident's rights to decline a shower were accommodated for one (Resident #108) of one resident reviewed. The findings include: During an interview on 08/02/2026 at 3:15 PM, Resident #108 stated a 'girl' had come into their room and told Resident #108 they were about to take Resident #108 to the shower. Resident #108 could not recall who the staff member was, or the date or time they were given a shower. Resident #108 stated they told the female staff member [later identified as Certified Nursing Assistant #1] they did not want a shower at that time, but CNA #1 told Resident #108 they had to receive a shower and rolled Resident #108 into the bathroom and gave Resident #1 a shower. Review of Resident #108's admission Record indicated the facility admitted the resident on 09/03/2025 with diagnoses that included muscle weakness (generalized) and polyosteoarthritis, unspecified. Review of Resident #108's Physician's Orders indicated the resident was admitted to skilled care, with a revision date of 09/03/2025. Review of Resident #108's annual Minimum Data Set (MDS) with an Assessment Reference date of 07/13/2026 indicated a Brief Interview for Mental Status score of 08, which indicated moderate cognitive impairment. The MDS also indicated Resident #108 required substantial/maximal assistance, which the helper does more than half the effort, for shower/bathe self, personal hygiene and was dependent for chair/bed-to-chair transfer. Review of Resident #108's Care Plan, with a review history date of 05/18/2026, indicated a problem list which included: No discharge plans are anticipated at this time, and the current plans were for [Resident #108] to remain in facility for long term care. Interventions included that staff were to honor [Resident #108's] customary routine for preferred activities, bathing, dressing, snacks, sleep routines. Care preferences with approaches/tasks that included for bathing schedule, Resident #108 had no specific preferences on the bathe schedule and sometimes refused baths. During a telephone interview on 08/04/2026 at 2:56 PM, Certified Nursing Assistant (CNA) #1 stated she was on the shower team with CNA #11. CNA #1 stated Resident #108 did refuse to be showered on June 1 or June 2, (2026), and she reported this to Registered Nurse (RN) #2. She stated RN #2 told her Resident #108 had to receive a shower whether the resident wanted one or not, because Resident #108's family member would be upset if Resident #108 did not receive a shower. CNA #1 stated she did return to Resident #108's room and Resident #108 began to curse at both her and CNA #11. CNA #1 reported Resident # 108 stated, I don't want y'all to give me a shower. CNA #1 stated she and CNA #11 did shower Resident #108 against her wishes. CNA #1 stated she did not work with Resident #108 after this incident but was allowed to work in the facility for almost two more weeks before she was called to the Director of Nursing (DON)'s office after she had completed a shower. CNA #1 stated she was told she was being suspended and later told she was being let go because rumors were going around that I was rude to [Resident #108] and I put my hands on [the resident]. CNA #1 stated she had only worked at the facility for about two months, and she may have, seen some papers on abuse. CNA #1 did not recall receiving information on resident's rights. Review of a Notice of Separation form dated 06/18/2026, indicated CNA #1's date of hire was 03/13/2026, last day worked was 06/10/2026, and date of separation was 06/18/2026. The reason indicated for the separation was violation of resident rights. During a telephone interview on 08/05/2026 at 3:23 PM, the DON stated RN #2 told her the CNAs (did not state which CNAs) had told her Resident #108 did not want to take a bath on the date of the incident. The DON stated she told the nurse to call Resident #108's family member. The DON stated no CNA had spoken to her about Resident #108 being showered against their wishes. She stated the day the facility completed the reportable [06/10/2026] was the date she was made aware that Resident #108 was showered against their wishes. She stated residents have the right to refuse a shower, and her expectation was for residents' rights to be honored at all times. During a telephone interview on 08/05/2026 at 4:37 PM, the Administrator stated her expectation regarding resident rights was residents have the right to choose and a right to refuse when they want to receive services and when they do not. Review of the Resident Rights and Responsibilities Policy, not dated, indicated the facility will protect and promote the rights of each resident. This policy also indicated residents/elders will be free from interference, coercion, discrimination or reprisal from the nursing facility in exercising their rights.

Based on record review, interview and facility policy review, the facility failed to protect a resident from verbal abuse and intimidation by an employee for one (Resident #108) of four residents reviewed.The findings include:Review of Resident #108's admission Record revealed the facility admitted the resident on 09/03/2025 with diagnoses that included muscle weakness (generalized) and polyosteoarthritis, unspecified.Review of Resident #108's Physician Order, revised date of 09/03/2025, revealed the resident was admitted to skilled care.Review of Resident #108's annual Minimum Data Set with an Assessment Reference date of 07/13/2026, revealed Resident #108 had a Brief Interview for Mental Status score of 8, which indicated the resident had moderate cognitive impairment. The MDS revealed Resident #108 required substantial/maximal assistance, which the helper does more than half the effort, for shower/bathe self, personal hygiene, and was totally dependent on chair/bed-to-chair transfer.Review of Resident #108's Care Plan, with a review history date of 05/18/2026, indicated a problem of:-No discharge plans are anticipated at this time, and the current plans are for [Resident #108] to remain in facility for long term care and interventions included staff were to honor [Resident #108] customary routine for preferred activities, bathing, dressing, snacks, and sleep routines.-Care preferences with approaches/tasks that included for bathing schedule, Resident #108 had no specific preferences on the bathe schedule and sometimes refused baths.During an interview on 08/02/2026 at 3:15 PM, Resident #108 stated a 'girl' came into their room and told Resident #108 they were about to take Resident #108 to the shower. Resident #108 could not recall who the staff member was, or the date or time of the incident. Resident #108 stated they told the female staff member [later identified as Certified Nursing Assistant (CNA) #1] they did not want a shower at that time, but CNA #1 told Resident #108 they had to receive a shower and rolled Resident #108 into the bathroom and showered the resident anyway.Review of Resident # 108's reportable dated 06/10/2026 revealed the following:-The summary of incident revealed that at approximately 2:20 PM during a follow-up telephone conversation, Resident #108's family member stated they did not want CNA #1 assigned to the shower team to provide showers for Resident # 108 any longer. The summary indicated CNA #1 reported she was encouraging Resident # 108 to participate in the shower as part of the routine care and denied forcing Resident # 108 to accept the shower. -The findings and actions taken revealed that CNA #1 failed to follow facility policy regarding resident rights, resident choice, and person-centered care, and was summarily terminated. -CNA #1's witness statement included in the reportable revealed on 06/01/2026, she and CNA #11 went to Resident #108's room. The statement indicated CNA #11 told Resident #108 it was shower day and Resident #108 told both CNAs no, indicating the resident did not wish to receive a shower. The statement revealed that CNA #1 and CNA #11 did provide Resident #108 a shower.-CNA #3's witness statement included in the reportable revealed on 06/01/2026, she was approached by CNA #1 who requested assistance with transferring Resident #108 using a sit to stand lift for a scheduled shower. CNA #3's statement indicated Resident #108 stated they did not want to take a shower. CNA #3's statement indicated during the conversation, Resident #108 began swinging their arms in CNA #1's direction. CNA #3's statement indicated CNA #1 stated, If you hit me I will sue you, I will send you to jail.-CNA #11's witness statement included in the reportable revealed that she entered Resident #108' room with CNA #1 as it was time for Resident #108's shower. The statement indicated Resident #108 refused and CNA #1 and CNA #11 left the room. The statement indicated CNA #11 and CNA #1 went back to Resident #108's room around 2:00 PM to try again. CNA#11's statement indicated she did not hear CNA #1 being loud or rude to Resident #108 and that CNA #1 was trying to get Resident #108 to take a shower. CNA #11 statement indicated CNA #11 and CNA #1 did give Resident #108 a shower. -On 06/10/2026 an in-service, included in the reportable, on Prevention and Prohibition of Abuse was completed and had CNA #1's name with no signature next to it to indicate they attended the in-service. CNA #3's name had a signature next to her name indicating she was present for the in-service.-On 06/12/2026 Registered Nurse (RN) #2 was in-serviced on a resident refusing ADL (activities of daily living) care bathing/showers, that was included in the reportable. During a telephone interview on 08/04/2026 at 2:56 PM, CNA #1 stated she was on the shower team with CNA #11 the day of the incident. CNA #1 stated Resident #108 did refuse to be showered on 06/01/2026 and 06/02/2026. She stated she reported this to Registered Nurse (RN) #2. She stated RN #2 told her Resident #108 had to receive a shower whether they wanted one or not, because the resident's family member would be upset if Resident #108 had not received a shower. CNA #1 stated she returned to Resident #108's room and Resident #108 began to curse at her and CNA #11 and stated, I don't want y'all to give me a shower. She stated she and CNA #11 did shower Resident #108. She stated she did not work with Resident #108 after this incident but was allowed to work in the facility for almost two more weeks before she was called to come into the Director of Nursing (DON)'s office. She stated she was told she was being suspended. CNA #1 stated later she was told she was being let go because rumors were going around that I was rude to [Resident #108] and I put my hands on her. CNA #1 stated she had only worked at the facility for about two months, and she may have, seen some papers on abuse, but did not recall receiving information on resident rights. Review of a Notice of Separation form dated 06/18/2026, revealed CNA #1's date of hire was 03/13/2026, last day worked was 06/10/2026, and date of separation was 06/18/2026. The reason indicated for the separation was violation of resident rights.During an interview on 08/04/2026 at 3:38 PM, RN #2 stated the shower team, which she added she did not know the staff's names, came and told her Resident #108 did not want to take a shower. She stated she told the shower team to go back and encourage Resident #108 to take a shower. RN #2 stated she did not tell CNA #1 that Resident #108 had to be showered whether or not the resident refused. RN #2 stated she told the shower team to go and encourage the resident because Resident #108's daughter wanted the resident showered regularly and that she did not hear anything additional about Resident #108. During a telephone interview on 08/05/2026 at 1:55 PM, Certified Nursing Assistant Supervisor (CNAS) #7 stated she was not made aware by CNA #3 of the alleged statements made by CNA #1 to Resident #108 on 06/01/2026, the date of the incident. CNA #7 stated she was not made aware of the alleged statements CNA #1 made to Resident #108 until the Director of Nursing (DON) and Administrator spoke with her after they began investigating the concern. She stated she was not sure of the date the administration spoke to her.During a telephone interview on 08/05/2026 at 3:23 PM, the DON stated no CNAs notified her on 06/01/2026, about the alleged statements of CNA #1 telling Resident #108 she would call the police and have Resident #108 put in jail if the resident hit her. She stated the day the facility completed the reportable on 06/10/2026 was the date she was made aware of statements made by CNA #1 to Resident #108 on 06/01/2026. She stated she expected staff to report abuse immediately.During a telephone interview on 08/05/2026 at 4:37 PM, the Administrator stated it was not until she began the investigation on 06/10/2026 of Resident #108's shower concern that she was made aware of statements made by CNA #1 to Resident #108. She stated the CNAs should have reported the statements made by CNA #1 immediately to their supervisor. The Administrator stated she expected staff to report abuse as they had been trained, immediately, and either to their supervisor, to me, or to [CNA #7].During a telephone interview on 08/05/2026 at 6:38 PM, CNA #3 stated the day Resident #108 was refusing to be showered by CNA #1, she was in the room. She stated she heard CNA #1 tell Resident #108 they were going to take a shower or she would get fired. CNA #3 stated Resident #108 began to wave their hand and told CNA #1 to get out of the room, and they [Resident #108] were not taking a shower. CNA #3 stated, That's when the girl started getting mad. [CNA #1] said if you hit me I'm gonna call the police and have you put in jail. CNA #3 was asked if she reported the verbal exchange between CNA #1 and Resident #108 to anyone and stated she reported this to CNAS #7 the day of the shower (June 1, 2026).Review of an undated facility policy titled Abuse, Neglect, and Maltreatment Investigation & [and] Reporting, revealed the facility will endeavor to protect resident/elders from maltreatment, which means adult abuse, exploitation, neglect, physical abuse, sexual abuse, neglect, and the misappropriation of resident/elder property.

Number of residents sampled: Number of residents cited: Based on record review and interview, the facility failed to ensure a gradual dose reduction (GDR) was completed, acknowledged, and the decision documented by the medical provider for one (Resident #108) of five residents reviewed. The findings include: Review of Resident #108's admission Record indicated the facility admitted the resident on 09/03/2025 with diagnoses that included muscle weakness (generalized) and polyosteoarthritis. Review of Resident #108's Physician's Orders revealed an order for the resident to be admitted to skilled care with a revised date of 09/03/2025. The Physician's orders also revealed an order for [an oral prescription medication used to treat generalized anxiety disorder (GAD) and relieve anxiety symptoms] 7.5 mg (milligrams) with a start date of 01/17/2026. Review of Resident #108's annual Minimum Data Set with an Assessment Reference Date of 07/13/2026, revealed Resident #108 had a Brief Interview for Mental Status score of 8, which indicated the resident had moderate cognitive impairment. Review of Resident #108's Care Plan, with a reviewed history date of 05/18/2026, indicated a the resident used anti-anxiety medications. Care Plan interventions included to observe for occurrences for target behavior symptoms (specify pacing, wandering, disrobing, inappropriate response to verbal communication, violence/aggression towards staff/others). Review of Resident # 108's Pharmacy MRR (Medication Regimen Review)-Anxiolytics form with an effective date of 05/20/2026, revealed [an oral prescription medication used to treat GAD and relieve anxiety symptoms] 7.5 mg was ordered two times a day. The form revealed the Consultant Pharmacists documented to review tapering to [an oral prescription medication used to treat GAD and relieve anxiety symptoms] 5mg PO (by mouth) BID (twice daily)and was electronically signed (e-signed) by the pharmacist on 05/20/2026. As of 08/04/2026, the recommendation had not been addressed by the medical provider. During a telephone interview on 08/05/2026 at 3:23 PM, the Director of Nursing (DON) stated that when the Pharmacist completed a gradual dose reduction recommendation, the information goes in the facility's computer system. She stated the provider received the information through the facility's computer system, but she stated she sometimes had to remind the provider to complete the form. She stated she or the Assistant Director of Nursing (ADON) were responsible for following up with the provider to ensure he/she had reviewed the GDR recommendation. She stated they tried to have the GDRs completed within seven days after the pharmacist wrote the GDR. She stated it was important for the provider to address a GDR for psychotropic/antipsychotic medications for the residents benefit and to gradually wean the resident off those medications. She stated she expected GDRs to be done in a timely manner. During a telephone interview on 08/05/2026 at 4:37 PM, the Administrator stated she expected GDRs to be completed per the requirements in the allotted time frame. The Administrator was asked to provide a policy on gradual dose reduction. The survey team was notified on 08/05/2026 that the facility did not have a policy for GDR.

Number of residents sampled: Number of residents cited: Based on interviews, record review and facility policy review, it was determined that the facility failed to provide a bed hold notification to the resident or resident's representative for two (Resident #116 and Resident #5) of two residents reviewed for hospitalizations. The findings include:Resident #116 A review of the admission record revealed that the facility admitted Resident #116 on 05/08/2026 with diagnoses that included congestive heart failure, type 2 diabetes, chronic kidney disease and depression. A review of the discharge return anticipated Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/09/2026, revealed Resident #116 had a Staff Interview for Mental Status (SAMS) score of 1 which indicated the resident had modified independence with some difficulty in new situations only regarding daily decision making. A review of Progress Notes dated 05/09/2026, revealed Resident #116 had agitation, an elopement attempt and suicidal ideation and was sent to the emergency room (ER) per the Nurse Practitioner. Resident #5 A review of the admission Record revealed that the facility admitted Resident #5 on 03/10/2026 with diagnoses that included pain, dizziness and collapse, chronic kidney disease and a history of falling. A review of the admission MDS with an ARD of 03/19/2026, revealed Resident #5 had a Brief Interview for Mental Status of 3, which revealed the resident had severe cognitive impairment. A review of Progress Notes per the Situation, Background, Assessment and Recommendations (SBAR) Summary on 03/12/2026, Resident #5 was sent to the ER from dialysis due to chest pains. The Progress Notes revealed that Resident #5 returned to the facility on [DATE]. During an interview on 08/05/2026 at 12:13 PM, the Business Office Manager (BOM) stated that a Bed Hold Notification was to be completed anytime a resident went to the hospital. The BOM stated that a Bed Hold Notification was sent to the representative if needed and given to the resident. The BOM also stated the Emergency Transfer List was sent to the Ombudsman monthly. During an interview on 08/05/2026 at 12:20 PM, the Social Service Director stated that she was the one who filled out the Bed Hold Notifications once she was notified that a resident was in the hospital. When asked if a resident went to the hospital from dialysis should a bed hold notification be completed. The Social Service Director responded, Yes, if they are our resident and they are in the hospital and not in the facility. The Social Services Director also stated that she would complete a Bed Hold Notification on Monday if she was told that the resident went to the hospital on a weekend. During an interview on 08/05/2026 at 3:02 PM, the Director of Nursing (DON) stated that a Bed Hold Notification should be completed when a resident was sent to the hospital and given to the residents and residents' representatives. The DON reported that the Social Services Director was responsible for completing the Bed Hold Notifications and the Assistant BOM sent them to the [resident] representative and resident. The DON stated that she expected Bed Hold Notifications to be completed and sent out when a resident went to the hospital. During an interview on 08/05/2026 at 3:53 PM, the Administrator stated that the Social Services Director completed the Bed Hold Notification form and the Assistant BOM sent them out to representatives. The Administrator stated she expected that Bed Hold Notifications were completed when they need to be done in a timely manner. The Administrator also stated that there was not a bed hold [form] for Resident #5 or Resident #116 for their hospital stays. The Assistant BOM was not available for interview. A review of a facility provided note dated 08/05/2026 and signed by the Administrator indicated that the facility did not have a bed hold form on file for [Resident #116 or #5]. A review of an undated facility policy titled Bed Hold revealed that The nursing facility follows federal and state law defining when and how it is required to hold a bed for a Resident/Elder receiving health service at another health facility or while resident is on therapeutic home leave. Facility shall also provide resident and residents representative with all required information at the time of admission and at any time of transfer for hospitalization or therapeutic leave. If the transfer is of an emergency nature, notice of the required information shall be provided with twenty-four (24) hours.

Number of residents sampled: Number of residents cited: Based on observation, record review and interview, the facility failed to ensure a glucometer machine was properly cleansed after use and before being placed inside of a medication cart for one (Resident #15) of one resident reviewed. The findings include: During an observation on 08/04/2026 at 4:35 PM, Licensed Practical Nurse (LPN) #6 entered Resident #15's room with the glucometer machine, test strip, alcohol swab, medications and an insulin pen. After administering Resident #15's medications, LPN #6 completed a fingerstick glucometer check for this resident. Once she had received the results and administered the prescribed amount of insulin, she discarded the gloves and sanitized her hands. LPN #6 then placed the glucometer machine in the top drawer of the medication cart without cleaning the machine. Review of Resident 15's admission Record revealed the facility admitted the resident on 06/03/2013 with diagnoses that included type-2 diabetes mellitus without complications with an onset date of 06/03/2013. Review of Resident #15's Physician's Orders revealed an order for Resident #15 to be admitted to long term care with a revision date of 08/03/2022. Review of the electronic medication administration record (eMAR) revealed for the Fiasp injection to be held for a blood sugar less than 150, the start date was 05/15/2026. For the 4:30 PM check, 123 was indicated in the bs (blood sugar) slot for 08/04/2026 and LPN #6's initials were in the box with the number 4 to indicate vitals outside of parameters for administration. During an interview on 08/04/2026 at 4:46 PM, LPN #6 stated she did not clean the glucometer machine before placing the machine in her medication cart. She stated the glucometer machine should be cleaned when she comes in [for work] and after she uses the machine. LPN #6 stated she uses alcohol wipes to clean the glucometer but had not cleaned the machine [after this use] it had been an oversight by her. She stated the glucometer machine should have been cleansed for cross-contamination reasons. During a telephone interview on 08/05/2026 at 3:23 PM, the DON stated her expectations for nurses was that the glucometer would be cleaned each time before and after use and before putting the glucometer machine in the medication cart.

Based on interview, record review, facility document review, and facility policy review, the facility failed to ensure 1 (Resident #25) of 4 sampled residents reviewed for neglect received adequate supervision and assistance to prevent accidents. Specifically, the facility failed to ensure 2 staff members transferred Resident #25 using the appropriate lift based on Resident #25's needs and care plan which resulted in Resident #25 sustaining a dislocated right shoulder. It was determined the facility's non-compliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) was related to State Operations Manual, Appendix PP, 483.25 (Quality of Care) at a scope and severity of J. The IJ began on 12/18/2024 at approximately 8:45 AM. While CNA #1 was transferring Resident #25, the resident began to complain of pain in their right arm. CNA #1 called for help and CNA #10 came into the room and assisted CNA #1 with transferring Resident #25 into the wheelchair. CNA #1 notified Registered Nurse (RN) #11 that Resident #25 was complaining of pain. RN #11 assessed the resident and noted the resident was still complaining of pain in the right shoulder. RN#11 notified the Nurse Practitioner and received an order for pain medication and an order to get a mobile x-ray due to the continued compliant of pain. The mobile x-ray company arrived at the facility around 10:16 AM and completed the x-ray. The Medical Director was at the facility when the results of the x-ray were received. The Medical Director gave an order to RN#11 for the resident to be sent to the emergency room (ER) for evaluation due to the results of the x-ray and continued complaints of pain. The ambulance arrived at the facility around 10:53AM and transported Resident #25 to the ER. At approximately 11:15 AM RN#11 received notification from the ER that Resident #25's right shoulder was dislocated. The Administrator was notified of the Past Noncompliance Immediate Jeopardy (IJ) on 2/6/2025 at 12:40PM. The facility implemented corrective actions which were completed prior to the State Agency's entry into the facility; thus, it was determined to be a Past Noncompliance citation. The facility had implemented the following corrective actions to correct the deficient practice effective 12/30/2024: 1. 12/19/2024, all residents re-assessed for transfer status by DON (Director of Nursing). Start date:12/19/2024. Completion date:12/30/2024. Comments: facility staff reviewed ADL/Transfer report to ensure all residents have appropriate transfer status documented. a. 02/06/2025- Facility provided evidence of all residents being re-assessed for transfer status prior to survey. 2. 12/19/2024, All care plans reviewed by DON and updated as needed to ensure accuracy. Start date: 12/29/2024 Completion date: 12/27/2024. Comments: Care Plans reviewed by MDS coordinator are ongoing. a. 02/06/2025- Care plans were updated and the facility provided evidence of in services on following the individual care plans. 3. 12/19/2024, an in service for all clinical staff started by the DON on following the individual care plan for transfer status and how to use the kiosk. Start date: 12/19/2024 Completion date: 12/26/2024. Comments: in services in progress. a. 02/06/2025- Facility provided evidence of in services on following the individual care plans. 4. 12/19/2024, the DON/designee began staff transfer/lift competency check off. Start date: 12/19/2024. Completion date: 12/26/2024. a. 02/06/2025- Facility provided evidence of staff transfer/lift competency check offs. 5. 12/19/2024, the DON/designee started monitoring transfers of 5 residents twice a week for 4 weeks to ensure transfers are being completed correctly and safely. Start date: 12/19/2024. Completion date: ongoing. a. 02/06/2025-Facility provided evidence of monitoring transfers of 5 residents twice a week. The findings are: 1. Review of a facility's undated policy titled Accident Hazards Prevention indicated, Residents will receive adequate supervision and assistance devices to prevent accidents. The resident will be assessed upon admission and through the Minimum Data Set (MDS) process to individualize care plan interventions. a. A review of Resident #25's Admission Record revealed the resident was admitted to the facility with a diagnosis of a stroke. b. A review of Resident #25's quarterly MDS with an Assessment Reference Date (ARD) of 12/04/2024, revealed the resident was assessed with a Brief Interview for Mental Status (BIMS) score of 3, (0-7 indicates severe cognitive impairment). c. Review of Resident #25's Care Plan, updated 10/2/2024, revealed the resident was to be transferred with a mechanical lift with two staff assisting. d. Review of a facility incident report dated 12/19/2024 indicated Certified Nursing Assistant (CNA) #1 was transferring Resident #25 and failed to use the correct lift and proper amount of assistance (number of staff), causing the resident ' s right shoulder to be dislocated. e. A review of the hospital Summary Episode Note, dated 12/29/205, revealed in the section Imaging Narrative Note identified the significant finding was that Resident #25's right shoulder was dislocated f. During an interview on 2/5/2025 at 12:20 PM, CNA #10 stated she remembered the incident. She was asked to describe what happened. She stated when she heard CNA #1 calling for help, so she went to help. CNA #10 stated CNA #1 had the sit-to-stand lift instead of the mechanical lift that was supposed to be used for Resident #25 and that CNA#1 did not have another employee assisting. CNA #10 said the resident was sliding to the floor, so CNA #1 and CNA #10 lowered Resident #25 to the floor to prevent the resident from falling. CNA #10 stated they (CNA #1 and CNA #10) lifted the resident by sliding their arms under the resident's arms and holding on to the back of the resident's pants. CNA #10 stated they (CNA #1 and CNA #11) sat the resident into the wheelchair. CNA #10 was asked how she knew which lift and how many people Resident #25 required for transfers. CNA #10 said the care plan identifies which lift and how many people are required to assist. g. During an interview with RN #11 on 2/5/2025 at 1:00 PM, she said she remembered the incident of Resident #25's shoulder being injured. She was asked to describe what happened. RN #11 said that on 12/19/2025 she heard Resident #25 hollering out due to pain. She stated after she assessed Resident #25, notified the Nurse Practitioner, received an order to get a mobile x-ray, and that the x-ray results revealed that Resident #25's right shoulder was dislocated. She said the Medical Director was at the facility and gave an order for Resident to be sent to the ER for evaluation of right shoulder pain. RN #11 was asked how CNAs would know which lift to use and how many people Resident #25 required the assistance of for transfers. RN #11 stated the care plan for Resident #25 identifies what kind of lift and how many people are required for a safe transfer. h. During an interview with the DON on 2/6/2025 at 10:45 AM, she confirmed the residents' care plans identified which type of lift is required and how many people are required for a safe transfer. The DON also confirmed that CNA #1 did not read the care plan and did not utilize the correct lift and the correct amount of people. The DON stated this failed practice resulted in an injury to Resident #25's right shoulder. i. During an interview with the Administrator on 2/6/2025 at 11:10 AM regarding Resident #25, she confirmed that CNA #1 did not read the care plan and did not utilize the correct lift and the correct amount of people. The Administrator stated this failed practice resulted in an injury to Resident #25's right shoulder. 49689 -The following was also cited under F689 at a lower severity. The facility also failed to ensure aerosols, medications, perfumes, and creams were not easily accessible to a resident to prevent accidental exposure for the 15 residents on the 100 Hall and 1 (Resident #93) of 8 sampled residents. 2. A review of the facility policy titled, Accident Hazards Prevention, stated, Resident Environment. The environment will be free from accident hazards as is possible; 3. Engages all staff, residents and families in training on safety, and promotes ongoing discussions about safety with input from staff at all levels of the organization. a. On 02/04/2025 at 2:20 PM, during a concurrent observation and interview, Certified Nursing Assistant (CNA #12) was observed by Surveyor picking up a clear plastic bag and putting it back on the counter, wheelchair height, at the 100 Hall nurses station leaving it easily accessible to residents. CNA #12 stated, [Resident #19] could come up here, grab this bag and take off down the hall with it. CNA #12 then took the trash and linen in barrels down the hall leaving the bag unattended. Resident #19 is observed wandering up and down the hallway. Surveyor observed that the clear plastic bag with a lighter and keys on the outside of it hanging off of one of the black handles, inside the bag was a medication bottle, a lighter, creams, alcohol sprays, and perfumes were observed. b. On 02/04/2025 at 2:27 PM, CNA #12 stated that the inside of the bag contained, [Name Brand] antibiotic ointment, alcohol spray, perfume, a lighter, Ibuprofen, and aerosol deodorant spray. CNA #12 stated that the bag was easily accessible to residents who wander up and down the hall, should have been stored out of reach and behind a door to keep residents out of it. CNA #12 continued stating that the items were hazardous to the residents, and they could drink something, or injure themselves with the contents in the bag. LPN #14 stated that hazardous materials should be kept out of reach of the residents. c. On 02/06/2025 at 8:09 AM, during an interview the Director of Nursing (DON) stated that hazardous items such as perfumes, medications, and aerosol sprays should not be left out unattended and easily accessible by residents. The DON stated that a resident could get injured if items are left out unattended. 51477

Based on record review and interview, the facility failed to accurately indicate hospice care and dialysis on Section O of the Minimum Data Set (MDS) for 1 (Resident #75) of 2 sampled residents for hospice and 1 (Resident #34) of 1 sampled resident for dialysis. The findings are: 1. A review of an Order Summary Report, indicated the facility admitted Resident #75 with diagnoses of dementia, cognitive communication deficit, need for assistance with personal care, and reduced mobility. A review of an Order Summary Report, indicated an order to admit to hospice with a diagnosis of senile degeneration of brain active as of 10/02/2024. The quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/17/2025, revealed Resident #75 had a Staff Assessment for Mental Status (SAMS) which indicated the resident was moderately cognitively impaired for daily decision making. A review of Section J 1400 revealed that Resident #75 had a prognosis with a life expectancy of six months or less. A review of Section O revealed that Hospice was not marked for Resident #75. Review of Resident #75's Care Plan, initiated on 10/03/2024, revealed that Resident #75 had requested palliative care and had chosen hospice; the goal is to keep the resident comfortable this review period. On 02/06/2025 at 7:55 AM, during an interview the MDS Coordinator reviewed Resident #75's quarterly MDS and confirmed that Section O was not marked for Hospice. The MDS Coordinator continued stating, I know the resident is on Hospice, should be marked yes for Hospice Care. The MDS Coordinator stated that the MDS is important, as the information goes on the care plan to let the staff know how to care for the resident. 2. Review of Resident #34's Admission Record, noted the resident had an initial admitted [DATE]. Review of Resident #34's Order Summary Report, noted dialysis was provided on Monday, Wednesday, and Friday. Review of Resident #34's quarterly MDS with an ARD of 01/18/2025 with a Brief Interview for Mental Status (BIMS) score of 10 (08-13 indicates moderately cognitively impaired). Under Section O, Special Treatments, Procedures, and Programs, noted Dialysis, No. On 02/06/2025 at 09:28 AM, during an interview- with the MDS Coordinator regarding Resident #34's quarterly MDS, the MDS Coordinator confirmed Resident #34 was currently receiving dialysis. She also confirmed dialysis should be marked yes, and it was currently marked no under section O. On 02/06/2025 at 8:09 AM, during an interview the Director of Nursing (DON) stated that a correct MDS was important to let the staff know how to care for the residents. 50923

Based on observation, interviews, and record review it was determined that the facility failed to document and complete a person-centered care plan to facilitate the ability to plan and provide necessary care and services for 3 (Residents #92, #104, and #107) of 30 sample mixed residents whose care plans were reviewed. The findings included: 1. A review of Resident #104's Admission Record, with a date of 08/07/2024, indicated the facility admitted Resident 104 with diagnoses that included hyperlipidemia (high levels of fat particles in the blood) and Covid-19 (Corona Virus 19). The quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/15/2024, revealed Resident #104 had a Brief Interview for Mental Status (BIMS) score of 12 (8-12 indicates moderately cognitively impaired.) Review of Resident #104's care plan, initiated 08/07/2024, revealed the resident did not have person-centered activities, Covid-19 or isolation precautions care planned as well as interventions for each one. A review of Resident #104's, Order Summery Report, revealed an order for: Isolation Precautions: Airborne Isolation related to COVID-19 every shift for 5 Days, order date 01/30/2025, start date 02/03/2025, end date 02/08/2025. A review of Resident #104's Medical Diagnoses indicated a diagnosis of Covid-19 on 01/30/2025. On 02/03/2025 at 3:56 PM, this surveyor observed Resident #104 in the resident's room with a COVID door sign and a Personal Protective Equipment (PPE) container outside of the door. Isolation bins were observed for both linen and trash inside the resident's room. During an interview with the MDS Coordinator on 02/06/2025 at 1:24 PM, she confirmed activities and COVID-19 should be on the care plan. 2. A review of Resident #107's Admission Record with a date of 09/13/2024 indicated the facility admitted Resident #107 with a diagnosis of dementia (a group of thinking and social symptoms that interferes with daily functioning.) The quarterly MDS with an ARD of 01/13/2025 revealed Resident #107 had a BIMS score of 4, (0-7 indicates severely cognitively impaired.) A review of Resident #107's Urine Culture Lab dated 01/25/2025 revealed the resident was positive for ESBL in the urine. Review of Resident #107's, Care Plan, initiated 09/13/2024, revealed the resident did not have person-centered Extended-spectrum beta-lactamase (ESBL) an antibiotic-resistant bacterium, or contact precautions care planned as well as interventions for each one. During an interview with the MDS Coordinator on 02/06/2025 at 1:24 PM, she confirmed ESBL and contact precautions should be on the care plan. 3. A review of the Order Summary Report, indicated the facility admitted Resident #92 with diagnoses that included chronic obstructive pulmonary disorder, acute and chronic respiratory failure with low oxygen, and bronchitis. A review of the Order Summary Report indicated these orders for Resident #92: [antibiotic mediation name] Table 250 MG given by mouth one time for cough and congestion for four days, with a start day of 02/01/2025 and end date of 02/05/2025 and Mucus Relief Tablet 400 MG give one tablet by mouth two times a day for cough and congestion for five days with a start date of 01/31/2025 and end date of 02/05/2025. The quarterly MDS with an ARD of 01/18/2025 reveals that Resident #92 had a BIMS of 12 (indicates moderate cognitive impairment). A review of the Care Plan initiated on 09/25/2024, revealed that no interventions were added to the care plan for antibiotics with resident having increased cough and congestion. A review of the Progress Notes revealed on 01/30/2025 stated, All test were negative. chest x-ray showed no significant findings. Advanced Practical Nurse with new orders for z-pack for cough and congestion. A review of the progress notes revealed on 02/01/2025, No side effects or adverse reactions from antibiotic from upper respiratory infection. Occasional cough and congestion noted. On 02/06/2025 at 7:55 AM, the MDS Coordinator reviewed Resident #92's care plan and confirmed that interventions were not added for upper respiratory infections. The MDS Coordinator stated that it should have been added to the care plan, so staff were made aware of any additional things they need to do for that resident. On 02/06/2025 at 8:09 AM, during an interview the Director of Nursing (DON) stated that when a resident was on antibiotics for an upper respiratory infection it was a change in condition and should be added to the care plan so the staff knows how to care for them. 51477

Based on observation, interviews, record review, facility document review, and facility policy review, it was determined that the facility failed to ensure over-the-counter medications, and a narcotic medication prescribed to Resident #71, stored in the medication carts were not expired for 2 of 2 medication carts sampled. The findings include: Review of a facility policy titled, Medication Storage in the Facility, dated 1/1/2015, indicated All expired medications will be removed from the active supply and destroyed in the facility, regardless of amount remaining. The medication will be destroyed in the usual manner. Controlled substances remaining in the facility after the order has been discontinued or the resident has been discharged are retained in the facility in a securely locked area with restricted access until destroyed. A review of Resident #71's Admission Record, initiated on 10/02/2020, indicated the facility admitted Resident #71 with Parkinson's disease without dyskinesia, without mentions of fluctuations (disorder of central nervous system that affects movement). The annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/07/2025, revealed Resident #71 had a Brief Interview for Mental Status (BIMS) score of 13, (13-15 indicates cognitively intact.) Review of Resident #71's care plan, initiated 04/03/2023, revealed the resident was at risk for pain. Interventions included administer pain medications as ordered/needed. Notify MD [Medical Director]/Practitioner if not effective. On 02/04/2025 at 3:10 PM, this surveyor observed Registered Nurse (RN) #21 during inspection of medication cart #1. This inspection revealed 6 medications that were expired. Medications found that were out of date were (Name Brand) Regular Strength Antacid/anti-gas medication; (Name Brand) Multipurpose Nail Repair, Docusate Calcium (stool softener) 240 milligrams, two calorie and protein dense nutritional drinks 2.0 Cal 237 milliliters, Extended Release Acetaminophen 650 milligrams, and Active Liquid Protein 887 milliliters. On 02/04/2025 at 3:30 PM, this surveyor observed RN #17 during inspection of medication cart #2. This inspections revealed 7 medications that were expired. Medications found that were expired were Acetaminophen 500 milligrams, Extended Release Acetaminophen 650 milligrams, Aspirin 81 milligrams, Ibuprofen 200 milligrams, Milk of Magnesium 1200 milligrams, Aspirin 325 milligrams, and Morphine 20 milligrams/milliliter solution (this medication was prescribed to Resident #71). During an interview with RN #11 on 02/05/2025 at 11:30 AM, she confirmed that when there was an order to discontinue or change an order for medications, those medications were taken to the medication room and stored in a container. She confirmed that narcotics were given to the Assistant Director of Nursing (ADON) and the ADON recorded the medication in a logbook. She revealed that she notified the ADON and DON if there was a change in medication. During an interview with the ADON on 02/05/2025 at 11:37 AM, she confirmed that she handles the discontinued narcotics. She confirmed that any expired medications, discontinued medications, over the counter (OTC) medications from the medication carts were pulled from the carts, taken to the medication room, and the pharmacist destroyed them. The ADON confirmed the pharmacist did a match back from the medication destruction book and the medication card and then destroyed them. She confirmed if a narcotic had expired, or the resident had been discharged , the medication was removed, double signed in the narcotic book, and removed from the medication cart. She completed a form and put the resident's name on the form along with the dosage, strength, prescriber, and how much medication was left for surrendering. She revealed two people placed the medications along with the form in a box and send them back to the state for destruction. During an interview with the DON on 02/05/2025 at 11:43 AM, she confirmed that over the counter medications, and prescribed medications were taken to the medication room and listed in the destruction book, placed in a locked trash can, then the pharmacist destroyed them. The DON confirmed she had a drawer that was double locked in her office for expired narcotic medications. She revealed the medication stayed locked in her office until the pharmacist came to the facility, or they have two people to verify the information and send it back to the pharmacy to be destroyed. A review of the Acetaminophen capsules or tablets Safety Data Sheet, revised 8/14/2023 revealed, To get rid of medications that are no longer wanted or have expired: Take the medication to a medication take-back program. Ask your pharmacy or law enforcement to find a location. If you cannot return the medication, check the label or package insert to see if the medication should be thrown out in the garbage or flushed down the toilet. If you are not sure, ask your care team. If it is safe to put it ill the trash, empty the medication out of the container. Mix the medication with cat litter, dirt, coffee grounds, or other unwanted substances. Put it in the trash. A review of the Acetaminophen Extended Release tablets Safety Data Sheet , revision on 8/14/2023, reveals To get rid of medications that are no longer needed or have expired: Take the medication to a medication take back program. Check with your pharmacy or law enforcement to find a location. If you cannot return the medication, check the label or package insert to see if the medication should be thrown out in the garbage or flushed down the toilet. If you are not sure, ask your care team If it is safe to put it in the trash, empty the medication out of the container. Mix the medication with cat litter, dirt, coffee ground or other unwanted substance. Seal the mixture in a bag or container. Put it in the trash. A review of the Aluminum Hydroxide Magnesium Hydroxide Simethicone Safety Data Sheet, revision on 12/11/2024, reveals contain aspirin, ibuprofen, naproxen. Always read labels carefully. To get rid of medications that are no longer needed or have expired: Take the medication to a medication take-back program. Check with your pharmacy or law enforcement to find a location. If you cannot return the mediation, check the label or package insert to see if the medication should be thrown out in the garbage or flushed down the toilet. If you are not sure, ask your care team. If it is safe to put it in the trash, empty the medication out of the container. Mix the medication with cat litter, dirt, coffee grounds, or other unwanted substance. Seal the mixture in a bag or container. Put it in the trash. A review of the Aspirin Tab lets Safety Data Sheet, revision date of 12/11/2024, revealed, To get rid of medications no longer needed or have expired: Take the medication to a medication take-back program. Check with your pharmacy or law enforcement to find a location. If you cannot return the medication, check the label or package insert to see if the medication should be thrown out in the garbage or flushed down the toilet, If you [NAME] not sure, ask your care team If it is safe to put it in the trash, empty the medication out of the container and mix the medication with cat litter, dirt coffee grounds, or other unwanted substance. Seal the mixture in a bag or container. Put it in the trash. A review of the Ibuprofen Capsules or Tablets Safety Data Sheet, revision on 12/12/2024, revealing, To get rid of medications that are no longer needed or have expired: take medication to a take back program. A review of the Magnesium Hydroxide Solution Safety Data Sheet, revision on 5/9/2024, revealed Throw away any unused medication after the expiration date. A review of the Morphine Solution Safety Data Sheet, revision on 12/4/2024, revealed, Misuse of this medicine can cause addiction or overdose. Take it exactly as prescribed. Store it in a safe place to prevent stealing or abuse. It is illegal to sell it or give it away. It is important to get rid of the medication as soon as you no longer need it or it is expired. To get rid of this medication: Take the medication to a take-back program. Check with your pharmacy or law enforcement to find location. Follow the steps given to you by your pharmacy. You may be given a pre-paid mail-back envelope or disposal product to safely get rid of your medication. If other options are not available, flush the medication down the toilet.

Based on observation, record review and interview, the facility failed to ensure meals were prepared and served in accordance with the planned written menu to meet the nutritional needs of the residents for 2 of 2 meals observed. The findings are: 1. The week 1, Day-2 supper menu for Fall/Winter 2024 to 2025 specified for the residents on mechanical soft diets to receive 4 ounces of dressing and 4 ounces of turkey and all residents were to receive 1/2 cup of broccoli. 2. On 02/04/2025 at 3:49 PM, the following observations were made during supper meal preparation and service: a. Dietary [NAME] (DC) #2 weighed turkey meat to be served to the residents for supper as follows. The first one weighed 4.5 ounces, second 5.9 ounces, third 3.7 ounces, fourth 3.6 ounces, fifth 3.2 ounces, and sixth 2.1 ounces. Total of 23 ounces. DC #2 placed a total of 23 ounces of turkey into the blender, ground and poured into a pan, then placed the pan in the oven to be served to 21 residents who received mechanical soft diets. b. On 02/04/2025 at 5:58 PM, as DC #2 was ready to put more turkey meat into a blender to ground and serve to the 2 residents, DC #2 was asked to weigh turkey meat. After weighing it, DC #5 stated it was 5.1 ounces, which brought the total amount prepared to 28 ounces, instead of the intended 84 ounces. c. On 02/05/2025 at 11:06 PM, DC #2 was interviewed, and asked how much mechanical soft turkey she had prepared for the supper meal on 02/04/2025. After I showed her the calculation, she confirmed that the amount she had prepared was correct but would not be enough for 21 residents. 2. On 02/04/2025 at 5:35 PM, during observation of the supper meal service, DC #3 used a #12 scoop (3 ounces) to serve a single portion of ground turkey to the residents on mechanical soft diets, instead of 4 ounces. 3. On 02/04/2025 at 5:56 PM, the kitchen ran out of stuffing and broccoli. After running out of stuffing and broccoli, DC #3 switched to a #12 scoop, (3 ounces or 1/3 cup) to serve a single serving of stuffing. This portion was 1 ounce less than what the menu specified. DC #3 served cut green beans to 4 residents, instead of broccoli. Resident #51 asked the Dietary Manager for broccoli. The Dietary Manager informed the resident that they had run out of it. 4. The week 1, Day-3 menu for Fall/Winter 2024 to 2025 breakfast specified for the residents on pureed diets were to receive a #8 scoop of pureed hash browns and a #16 scoop of pureed biscuits. On 02/05/2025 at 8:30 AM, during the breakfast meal service, there were no pureed hash browns or pureed biscuits served to the residents who required pureed diets for breakfast. At 9:10 AM, DC #2 was interviewed and was asked if there was a reason why residents on pureed diets were not served hash browns or biscuits and she stated she forgot. 51477

Based on observation, interview, and facility policy review, the facility failed to ensure food items in the refrigerator, freezer and storage room were covered, sealed and dated; 2 of 2 ice machines was maintained in clean and sanitary condition; dietary staff washed their hands before handling food or clean equipment; kitchen storage area was maintained clean; and hot food items were maintained at temperature of 135 degrees or above for 2 of 2 meals observed. The findings are: 1. On 02/03/2025 at 10:46, during the initial rounds with the Dietary Manager, the following observations were made: a. A one-pound bag of marshmallows with no received date. The Dietary Manager confirmed the findings. b. A cardboard box of pasta with two full ten-pound bags with no received date. The Dietary Manager confirmed the findings. 2. On 02/03/2025 at 11:03 AM, the following findings were observed in the walk-in freezer: a. A cardboard box with 16.8 pounds of hash brown patties with no received date. The Dietary Manager confirmed the findings. b. A cardboard box with five pounds of beef franks with no received date. The Dietary Manager confirmed the findings. c. Two cardboard boxes of chocolate ice cream, two cardboard boxes of strawberry ice cream, and one cardboard box of vanilla ice cream, all 1.5 gallons, with no received date. 3. On 02/03/2025 at 11:14 AM, the following findings were observed in the walk-in fridge: a. A cardboard box with twenty-eight tomatoes with no received date or opened date. The Dietary Manager confirmed the findings. b. A cardboard box with thirty pounds of scrambled eggs with no received date. The Dietary Manager confirmed the findings. c. A cardboard box with nine half gallons of buttermilk with no received date or opened date. The Dietary Manager confirmed the findings. d. A plastic bag of raw chicken wings was found on the third shelf next to other boxes of food with no date. The Dietary Manager stated it is roughly two to three pounds. e. A cardboard box of bologna with no opened or received date, only one left out of two. The Dietary Manager stated that each one is five pounds and confirmed the findings. f. A plastic container of cucumber and onion mix, about half full, had no opened or received date. The Dietary Manger confirmed the findings. g. A plastic container wrapped in a supermarket bag, that was a staff member's lunch. The Dietary Manager confirmed the findings. h. A plastic bag of shredded lettuce, that was browning with liquid at the bottom was left unsealed with no date. The Dietary Manager confirmed the findings. i. A plastic container of ten pounds of coleslaw with no received date. The Dietary Manager confirmed the findings. j. A plastic bag of raw chicken drumsticks found on the third shelf in the back corner, dripping liquid out of the right bottom corner. The Dietary Manager stated that raw chicken, such as those in the two bags found, were to be stored on the bottom to prevent cross contamination. k. On 02/03/2025 at 11:25 AM, in the two-door cooler, a full pitcher of pink flavored drink mix was found with no date and no lid. l. On 02/03/2025 at 11:27 AM, the Dietary Manager pulled out the grease drip pan. The first half was filled over halfway with grease and food drippings. The last half was filled with crumb coatings, that when pulled out the crumbs fell on to the floor of the kitchen. The Dietary Manager then pulled out the drip pan below the stove top. Lima beans covered the back half with burnt food debris and grease covering the rest. The back splash of the stove was covered in a thick layer of yellow grease. The Dietary Manager stated that all three of these are to be done daily and that they have not been cleaned as they should be. 4. On 02/03/2025 at 11:30 AM, this surveyor observed on the spice shelf a bag of grits, a fourth of the way full, had no opened or received date. The Dietary Manager confirmed the findings. 5. 02/04/2025 03:16 PM, the following observations were made in the kitchen area: a. The edges of the steam table had food stains on it. b. The shelf below the steam table where clean pans were kept had loose food crumbs on it. c. The shelf below the food preparation counter, where pots and pans were kept, had loose food crumbs on it. d. There were loose greasy food particles on top of the oven. 6. On 02/04/2025 at 3:20 PM, Dietary [NAME] (DC) #2 was wearing gloves on her hands when she used a knife to cut open the wrap covering the turkey meat. After unwrapping the meat, DC #2 placed it on the cutting board and using her gloved hands, sliced the meat and placed it into a pan. DC #2 did not change her gloves or wash her hands before continuing to slice the meat. DC #2 was interviewed and was asked what she should have done after touching dirty objects and before handling food items. She confirmed she should have changed gloves and washed her hands before proceeding. 7. On 02/04/2025 at 3:25 PM, DC #3 picked up a spoon from a measuring cup inside the dirty sink and used it to scoop a serving of broccoli from a pan on the steam table. As DC #3 was about to transfer it into a blender, DC #3 was stopped and was asked if the spoon had been washed and sanitized. DC #3 confirmed that she should have washed and sanitized it before using it. 8. On 02/04/2025 at 3:28 PM, DC #3 placed gloves on her hands. DC #3 then moved the blender motor towards the edge of the counter, contaminating her gloves. Without changing her gloves and washing her hands, DC #3 picked up a clean blade and attached it to the base of the blender to be used in pureeing food items to be served to the residents on pureed diets. 9. On 02/04/2025 at 3:43 PM, the panel below the ice machine in the kitchen where the ice forms before dropping into the ice collector had wet black residue hanging down from it. The corners inside the ice machine had black residue settled on them. The area was pointed out to the Dietary Manager, and he was asked if the residue buildup could be wiped off. He used tissue paper and wiped it off. The black, and slimy residue easily transferred to the tissue. The Dietary Manager was asked how often the kitchen staff cleaned the ice machine and who used the ice from the machine. He stated the ice machine had been cleaned by the maintenance man once a month, and the kitchen staff used it to fill beverages served to the residents at the mealtimes. The Dietary Manager was interviewed and was asked to describe what he observed on the panel below the area where the ice forms before dropping into the ice collector. He stated there was black residue on the panel and he will start cleaning it 2 times a week. 10. On 02/04/2025 at 4:45 PM, the temperatures of the food items on the steam table when checked and read by DC #3 were as follows: a. Ground turkey - 125 degrees Fahrenheit. b. Pureed bread - 91 degrees Fahrenheit. 11. On 02/04/2025 at 4:59 PM, the walk-in refrigerator was 39 degrees Fahrenheit. An opened box of turkey sausage was on a shelf in the walk-in refrigerator. The box was not covered or sealed. 12. On. 02/04/2025 4:05 PM, the following observations were made on a shelf in the freezer: a. An opened box of burritos. The box was not covered or sealed. b. An opened box of cookie dough. The box was not covered or sealed. 13. On 02/04/2025 at 5:48 PM, Dietary Aide (DA) #4 who was on the tray line assisting with the supper meal, picked up condiments and supplements with his bare hands and placed them on the trays, contaminating his hands. Without washing his hands, he picked glasses that contained beverages by their rims and placed them on the meal trays to be served to the residents for the supper meal. 14. On 02/05/2025 at 7:38 AM, the left inside corner of the ice machine in the nourishment room on the 300 Hall had wet black residue on it. The area was pointed out to the Dietary Manager, and he was asked if the residue buildup could be wiped off. The Dietary Manager used tissue paper and wiped it off. The black residue easily transferred to the tissue. The Dietary Manager was interviewed and was asked to describe what he observed on the panel close to the area where the ice forms before dropping into the ice collector and who uses the ice from the ice machine. He stated there was black residue on it, that's the ice that the CNAs use for the pitchers in the residents' rooms. Maintenance was asked how often he cleaned the ice machine, and he stated CNA #12 cleans it. CNA #12 was asked how often she cleaned the ice machine. He stated once a month we treat the inside and wipe the panel every two weeks. 15. A review of facility policy titled, Handwashing and Glove Usage in Food service, initiated 2016, provided by the Dietary Manager on 02/05/2025 indicated that food handlers should wash their hands before starting work, after touching dirty dishes or clothing and after touching anything else such as dirty equipment.

Based on record review and interview, the facility failed to ensure a Preadmission Screening and Resident Review (PASARR) was completed prior to admission to ensure the resident received the needed care and services in the most appropriate setting for 1 (Resident #6) of 1 sampled resident whose records were reviewed for the PASARR screening information. The findings are: Review of Resident #6's quarterly Minimum Data Set (MDS) with an Assessment Reference Date of 01/09/2025 noted a Brief Interview for Mental Status (BIMS) score of 10 (08-13 indicates moderately cognitively impaired). Under the Active Diagnosis (Section I), sub section Psychiatric/Mood Disorder, Psychotic Disorder 15950 (other than schizophrenia) is selected. Under the Neurological sub section, non-Alzheimer's Dementia 14800 is also selected. Review of Resident #6's Admission Record, noted the resident was initially admitted on [DATE]. Review of Resident #6's electronic medical record- did not contain PASARR documentation is noted. During an interview with the Social Director on 02/05/2025 at 11:30 AM, this surveyor requested a PASARR for Resident #6. The Social Director stated she could not locate it. During an interview with the Director of Nursing (DON) on 02/05/2025 at 3:52 PM, this surveyor requested a PASARR for Resident #6. She confirmed staff could not locate it in the chart or in the facility. On 02/06/2025 at 12:05 PM, this surveyor reviewed Resident #6's electronic medical records and discovered Division of Medical Services (DMS) Form 703 Med Needs Application was submitted on 2/6/2025. On 020/6/2205 at 3:45 PM, the DON provided a PASARR dated 2/6/2025.

Based on record review and interview, the facility failed to fully assess a resident experiencing respiratory distress in a timely manner, failed to follow physician's order during an acute incident which resulted in a change of condition, and failed to notify the physician of the change in condition in a timely manner for 1 (Resident #368) of 3 sampled residents reviewed for a change in condition. It was determined the facility's non-compliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) was related to State Operations Manual, Appendix PP, 483.25 (Quality of Care) at a scope and severity of J. The IJ began on [DATE] at 07:33 pm, when Resident #368 was in respiratory distress and was not fully assessed which resulted in the resident being sent to a local hospital and expired before arriving at the hospital. The Administrator was notified of the IJ on [DATE] at 01:26 PM. A Removal Plan was requested. The Removal Plan was accepted by the State Survey Agency on [DATE] at 11:36 AM. The IJ was removed on [DATE] at 11:00 AM after the survey team performed onsite verification that the Removal Plan had been implemented. Noncompliance for F684 remained at the lower scope and severity of no actual harm with an isolated potential for more than minimal harm that was not immediate jeopardy. The facility also failed to ensure medications received at home were continued after admission to the facility for 1 (Resident #105) sampled resident. The findings are: 1. Resident #368: A review of the Order Summary Report, indicated the facility admitted Resident #368 with diagnoses that included a history of stroke, atrial fibrillation (an irregular heart rhythm), pulmonary hypertension (high blood pressure that affects the lungs and heart), high blood pressure, seizures, cognitive communication deficit, adult failure to thrive, anxiety, and pulmonary edema (when fluid accumulates in lung and can cause shortness of breath, wheezing and coughing up blood). The 5-day Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of [DATE], revealed Resident #368 had a Brief Interview for Mental Status (BIMS) score of 12 which indicated the resident had moderate cognitive impairment. a. Review of Progress Notes by Licensed Practical Nurse (LPN) #1 dated [DATE] at 07:33 PM revealed Resident #368 was having difficulty breathing and LPN #1 started a breathing treatment per standing order of facility. Resident #368's pulse oximetry (a noninvasive method of measuring the saturation of oxygen in a person's blood) was 33% during the breathing treatment. Resident #368's family member informed LPN #1 that the family member was going to call Emergency Medical Services (EMS). LPN #1 indicated the supervisor and LPN #1 attempted sternal rubs but Resident #368 became increasingly unresponsive. LPN #1 indicated Resident #368's hands and feet had mottled (occurs when blood flow has been disrupted, resulting in a blue-red discoloration of the skin) and the resident's lips were increasingly blue. LPN #1 indicated EMS arrived at the facility at 7:47 PM and EMS and the resident's family member were notified that Resident #368 had a Do Not Resuscitate (DNR) order. LPN #1 indicated that cardiopulmonary resuscitation (CPR) had been initiated but did not indicate by whom, while the resident was in respiratory distress. LPN #1 indicated Resident #368's eyes were unresponsive to light and the resident did not respond to their name being called. LPN #1 indicated EMS transferred Resident #368 to the local hospital at 07:57 PM. b. Review of a narrative received from Emergency Medical Service (EMS) dated [DATE] documented, .responded emergent to [facility] gave conflicting down times, approximately 15 minutes, non-witnessed, EMS initiated CPR . EMS obtained DNR order from [facility] Nursing Staff. EMS initiated ventilation with bag valve mask .EMS discontinued CPR at this time. EMS placed definition pads onto patient, showing Asystole .EMS is transporting the patient to local emergency department . c. Review of Emergency Department [ED] Provider Notes created on [DATE] at 07:45 PM by an emergency room physician indicated the physician received a call from the nursing home facility that a resident was in route to the hospital but had a DNR order. The physician met the resident in the ambulance bay at the hospital and evaluated the resident to be cold and stiff to touch and the resident's pupils were fixed and dilated. The physician also indicated there were no signs of trauma, no spontaneous respirations, no spontaneous cardiac movement, no radial or carotid pulses on either side. An EKG, which measures the hearts electrical activity, had been completed and indicated the resident's heart had stopped and the time of death was 07:38 PM. The final diagnosis within the ED Provider Notes indicated cardiac arrest (heart attack). d. Review of Grievance Form dated [DATE] documented Resident #368's family member reported Resident #368 called the family member and reported the resident was short of breath (SOB). Resident #368 told the family member (the resident) had gone to therapy and was in the resident's room and was experiencing SOB. The family member advised the resident that therapy may have made the resident tired and to lay down and rest. The family member told the resident that they would call back in approximately 10 minutes. When the family member called back, the resident stated they felt worse. The family member drove to the facility to check on the resident. The family member did not see a nurse and asked a CNA (Certified Nursing Assistant) to go get a nurse. The family member asked LPN #1 what the resident's oxygen saturation was, and LPN #1 stated she didn't know. LPN #1 went and got a breathing treatment to give to the resident and the resident became worse as it was being administered. The family member was upset with the resident's condition and stated they were going to call 911. The family member complained to the ADON (Assistant Director of Nurse) that LPN #1 had been rude with the family member and the family was upset with the rudeness and Resident #368's condition. Emergency Medical Service arrived and transported the resident to a local hospital. The form indicated the ADON resolved the grievance by talking to LPN #1. There was no indication of what was discussed between the ADON and LPN #1. A comment at the end of the form indicated that Resident #368 expired, and the family member came back to the facility to remove the resident's belongings. e. A review of Resident #368's electronic health record, including physician's orders did not indicate the resident had a physician's order for oxygen or a breathing treatment as indicated in LPN #1's progress note on [DATE] at 07:33 PM. A review of Standing Orders revised on [DATE], revealed a physician's order to administer oxygen ,d+[DATE] L/NC [liters/nasal cannula] as needed SOB [shortness of breath], notify MD [medical doctor] IMMEDIATELY if patient suddenly requires supplemental oxygen. This is a change in condition and abnormal vital sign that requires immediate attention. Further review of the standing orders indicated if a resident was short of breath or had a pulse oximetry of less than 90%, to provide 2 to 4 liters of oxygen per nasal canula as needed. A review of Physical Therapy Treatment Encounter Note(s) with a date of service as [DATE] indicated therapy services were provided to Resident #368. f. During a telephone interview on [DATE] at 08:45 AM, Registered Nurse (RN) #1 stated they were familiar with Resident #368. RN #1 stated they were on duty the evening that Resident #368 went into respiratory distress. RN #1 stated that around 05:00 PM on the night of the incident, a CNA notified her that a family member wanted a resident sent to the hospital due to severe respiratory distress. RN #1 stated, she was told the resident was in severe respiratory distress and the resident was walking down the hall with the family member. RN #1 stated, when she got to the resident's room, the resident was in severe respiratory distress and barely breathing and the family member had already called 911. RN #1 stated, a CNA got a crash cart, and RN #1 got an Ambu bag, (which is used to provide respiratory support to patients), and then the ambulance arrived. RN #1 stated the resident was a DNR and they did not start CPR, however, EMS started CPR but not in facility. RN #1 stated she did not see CPR performed. RN# 1 stated, she was in the room about 5 minutes before the ambulance arrived. RN #1 stated she did not document the event anywhere at all, let the floor nurse (LPN #1) do the documenting, and stated she probably should have. RN #1 stated, as a supervisor she did not review the nurse's notes until a week later. RN #1 stated nurses are trained to do a complete assessment of a resident depending on whether the resident is receiving skilled services. RN #1 stated if a resident had an oxygen saturation of 33%, she would call an ambulance. RN #1 stated Resident #368 was a fairly new resident, and never had any issues before. g. On [DATE] at 10:15 AM, the DON and Administrator were interviewed about completing an investigation for Resident #368. The DON stated she was not aware of an investigation. At this time the DON reviewed LPN #1's documentation on Resident #368, and she did not see anything different that should have been done and she did not have any concerns. The DON stated she did not see any procedures not followed. The DON was asked what nursing staff should do if a resident had an oxygen saturation of 33%, and the DON did not answer. The Administrator responded and stated she would call an ambulance. The Administrator stated since LPN #1 was no longer employed at the facility, she could not give the Surveyor LPN #1's phone number but stated that she would call LPN #1 and ask LPN #1 to contact Surveyor. The Administrator returned and stated she called the numbers listed in LPN #1's personnel chart with no answer and a message was left to call the Surveyor. The Surveyor was not contacted by LPN #1. h. On [DATE] at 11:59 AM, the Surveyor received a text message from Resident #368's family member stating the family member wanted to know why the facility thought giving a heart patient a breathing treatment was a good idea and wanted to know who ordered the breathing treatment to be given to the resident and why facility staff did not check Resident #368's oxygen level when the family member was at the facility when Resident #368 was having difficulty breathing. The family member also asked why no facility staff had a stethoscope with them to listen to the resident's heart or check the resident's blood pressure. The family member stated there was nothing done by facility staff to help Resident #368 other than telling the family member to elevate Resident #368's bed and facility staff providing the breathing treatment which took Resident #368's life. The family member stated the facility had no sense of urgency and the family member felt dismissed. i. On [DATE] at 03:05 PM, CNA #1 stated she was familiar with Resident #368. CNA #1 stated around 05:30 PM on the night of the incident, Resident #368's call light came on. The resident's family member stated the resident was having trouble breathing and asked if she could get a nurse. CNA #1 stated she notified LPN #1 who then went to the resident's room. CNA #1 stated she went back to the dining room and did not know what happened afterwards. j. On [DATE] at 08:54 PM, the family member called the Surveyor to explain more of the scenario of the night in question. The Surveyor asked the family member if CPR was ever started while the family was in the facility. The family member stated no, the CNA came out in the hall and asked the family member about the DNR status because the nurse asked the family member to leave the resident's room. The family member stated they called 911 around 06:30 PM. The family member stated they filed a grievance about what happened with the facility after the resident's death. The family member stated before the resident received the breathing treatment the resident was able to talk but the facility never applied oxygen on the resident or took vital signs. The family member stated the resident was short of breath but was talking and wanted to go for a walk; the resident thought that might help. The family member stated they walked by the nurse's station, and the family member asked LPN #1 who was at the nurse's station what Resident #368's oxygen levels were. The family member stated LPN #1 said the oxygen was at 98% 20 minutes ago. The family member stated the resident was given 2 breathing treatments. The family member stated the first breathing treatment wasn't given correctly because the breathing treatment machine wouldn't work, and LPN #1 left to get another machine. There was no urgency from facility staff. k. On [DATE] at 08:02 AM, the Social Director (SD) stated the grievance process starts when a facility staff member completes a grievance and turns it into the SD, who then was responsible for inputting the grievance into the computer system. The SD stated a grievance date indicates the date the grievance was reported. The SD reviewed the grievance associated with Resident #368 that occurred on [DATE] and stated the weekend RN (RN #1) who was the Supervisor was the staff member who took the grievance. l. On [DATE] at 10:45 AM, The Occupational Therapist (OT) stated therapy sessions are not usually provided on the weekends but if a resident missed a session during the week, it would be made up either in the evening or on weekends. The OT stated therapy is provided Monday through Friday, with skilled residents receiving therapy 5 times a week. The OT stated if a resident started having shortness of breath or fatigue during therapy OT check the resident's vitals and would document it especially if the resident had a diagnosis of something like COPD (Chronic Obstructive Pulmonary Disease). The OT stated she was familiar with Resident #368 and did not recall Resident #368 complaining of experiencing shortness of breath or fatigue during the therapy session on [DATE], but it would have been documented in resident's chart. m. On [DATE] at 11:30 AM, during a phone interview, the Medical Director stated he was not made aware of Resident #368's change in condition on [DATE]. The Medical Director stated the weekend tele-med services are on call with the APRN (Advanced Practiced Registered Nurse) or PA (Physician's Assistant) to do assessments over the phone and provide facilities with orders if needed. The Medical Director stated there are standing orders for something minor like [named brand of acetaminophen] or oxygen as needed for shortness of breath. The Medical Director stated if a resident needed to be assessed quickly, or if oxygen was needed, facility staff should notify the APRN or himself. The Medical Director stated a breathing treatment was not a standing order unless the resident already had an as needed order due to their condition and diagnosis. The Medical Director stated during the week, the APRN was at the facility Monday through Friday, 08:00 AM to 04:30 PM. If a resident had a change in condition, staff would contact the APRN first, then the APRN will contact me if needed. n. During the survey, 11 other facility staff members that had worked around the time of the incident were contacted to interview, however, the staff were either no longer employed, were on a leave of absence, or did not work with the resident. o. Removal Plan: 1. Notified on [DATE] at 01:53 PM by Surveyor that facility was receiving an IJ level deficiency for failure to properly assess a resident in respiratory distress, failure to follow physician's order during an acute incident, and failure to immediately notify a physician of a change in condition on [DATE]. 2. On [DATE] at 07:33 PM, documentation in medical record states Resident #368 experienced a change in condition involving respiratory distress. Documentation does not include proper assessment, following physician orders, or immediate notification to physician. 3. On [DATE] at 02:00 PM, the Minimum Data Set Nurse, Assistant Director of Nursing, Quality Assurance Nurse, and Social Worker Nurse immediately initiated assessments of all current residents for change in condition. Completed [DATE] at 04:50 PM with no negative findings. 4. On [DATE] at 02:00 PM, the Nurse Consultant immediately in-serviced the Director of Nursing on assessment with change of condition, following physician orders, notification of Medical Doctor/Provider for change in condition, and abuse and neglect. The Director of Nursing then immediately initiated in-service to all licensed nurses on duty on assessment with change in condition, following physician orders, notification of Medical Doctor/Provider for change in condition, and abuse and neglect. The Director of Nursing/Designee will in-service all oncoming licensed nurses at the beginning of their shift on assessment with change in condition, following physician orders, notification of Medical Doctor/Provider for change in condition and abuse and neglect. The Director of Nursing/Designee will in-service all oncoming Certified Nurses Aids at the beginning of their shift on change in condition and notifying nurse immediately. 5. On [DATE] at 02:00 PM, the facility immediately initiated a review of medical record documentation to identify changes of condition dating back to [DATE] to ensure residents with change in condition received proper assessment, physician orders were followed, and immediate notification of provider was made. 6. On [DATE] at 02:00 PM, once the facility was notified of the allegation of neglect, the Administrator immediately initiated a reportable to the Office of Long-Term Care for allegations of neglect. 7. On [DATE] at 03:15 PM, the Administrator initiated a report to the Arkansas State Board of Nursing for the nurse against whom the allegation of neglect was made. 8. On [DATE], the Administrator implemented procedures for the Minimum Data Set (MDS) Nurse, Director of Nursing, Assistant Director of Nursing, Quality Assurance Nurse, Social Worker Nurse, and Weekend Registered Nurse Supervisor to review medical record documentation daily for change in condition, and if change in condition is noted will ensure proper assessment, immediate notification to provider and physician orders were followed. 9. On [DATE], the facility implemented procedures for Director of Nursing/Designee to complete clinical observation rounds daily on each resident to assess for change in condition and if change in condition is noted will ensure proper assessment, immediate notification to provider, and physician orders were followed . p. Onsite Verification: The IJ was removed on [DATE] at 11:00 AM, after the survey team performed onsite verification that the Removal Plan had been implemented. Onsite verification of the Removal Plan began on [DATE] at 05:00 PM, when a review of assessments initiated on all current residents for 100, 200, 300 and 400 Halls by the MDS nurse, the ADON, the QA nurse and Social LPN were reviewed with no negative findings. A review of medical records dated [DATE] through [DATE] for each resident for change of condition was reviewed by the DON, QA nurse and Social Worker LPN, with no negative findings. A facility procedure was implemented for the DON/Designee to complete clinical observation rounds daily on each resident to assess for change in condition and if change in condition is noted will ensure proper assessment, immediate notification to provider, and physician orders were followed. A total of 14 staff interviews were conducted with staff from the day shift to verify training had been completed. The staff interviewed included 5 CNAs, 2 floor LPNs, 2 floor RNs, the MDS LPN, the Quality Assurance LPN, the Social LPN, the ADON and the DON. The staff interviewed verified in-services were provided on 1) Resident Rights, Dignity, 2) Nail Care, 3) Providing Perineal Care, 4) Hand Hygiene, 5) PPE use, 6) Assessing Residents for change in condition, 7) Reporting to Provider, 8) Following Physician Orders, 9) Routine PRN Standing Orders and 10) Abuse and Neglect. A review of the in-service sheets provided indicated 24 nurses of 25 listed had been provided with training and 50 CNAs of 56 listed had been provided training, (3 staff who were not physically present due to being on leave of absence (LOA). 49688 2. Resident #105: Resident #105 had diagnoses of Chronic inflammatory demyelinating polyneuropathy (a neurological disorder that involves progressive weakness and reduced senses in the arms and legs) and Chronic pain. The 5-Day MDS with an ARD of [DATE] documented Resident #105 scored 15 (,d+[DATE] indicates cognitively intact) on a BIMS and that Resident #105 received antidepressants, pain medications, and blood thinner medications during the 7 day lookback period and had no potential clinically significant medication issues identified during the drug regimen review. On [DATE] at 09:48 AM, Resident #105 reported that the resident had been waiting for a transfusion that the resident receives every month but has not received it at this time. Resident #105 had been told since December the facility was trying to figure out who would be responsible for it. Resident #105 stated the medication cost like $1,000.00 so the resident was wondering if that was the reason. On [DATE] at 10:15 AM, Resident #105 reported last year when he/she was here it was an issue then as well, and the resident paid for it themself. There is a transfusion nurse waiting for the medication to arrive so she can transfuse it. The medication was identified as intravenous immunoglobulin (IVIg), which is a biological agent used to manage various immunodeficiency, autoimmune, infectious, and inflammatory states. On [DATE] at 08:45 AM, the DON was asked if she was aware of the medication IVIG for Resident #105. The DON answered, yes and the Advance Nurse Practitioner was checking on it yesterday. On [DATE] at 10:34 AM, during a phone interview the Infusion Nurse confirmed the delay and was waiting on a return call from the regional manager to confirm orders from the pharmacy and confirm the medication is effective in Resident #105's treatment. On [DATE] at 02:05 PM, Resident #105 stated to the Surveyor, This is why I need the medication. The Surveyor asked resident on a scale from ,d+[DATE] how would you rate your pain, and Resident #105 stated, A nine out of ten. On [DATE] at 03:48 PM, in a phone conversation the APRN confirmed awareness of the needed medication. The APRN reported they have been trying to figure out the process to get this medication and is working with the facility to coordinate with the pharmacy on the correct protocol. 49981

Based on observation, interview, and record review, the facility failed to care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for 2 (Residents #21, #81) of 2 sampled Residents. The findings are: 1. Resident #81 had diagnoses of Schizophrenia, Mild cognitive impairment, and Major depression. According to a Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/15/2024, Resident #81 scored 0 (0-7 indicates severe cognitive impairment) on the Brief Interview of Mental Status (BIMS) and had a feeding tube while a resident. a. On 03/26/2024 at 01:00 PM, Licensed Practical Nurse (LPN) #2 pulled a blanket back exposing Resident #81's abdomen, incontinence brief, and partial thigh. The resident's window faced the parking lot to the front of the building, the blinds were open while LPN #2 administered medication via the feeding tube. b. On 03/26/2024 at 01:39 PM, the Surveyor asked LPN #2 what should you have done prior to providing care in reference to the blinds? LPN #2 stated, I forgot to close them. The Surveyor asked why should the blinds be closed when providing care. LPN #2 stated, For privacy. c. On 03/27/2024 at 11:41 AM, the Surveyor asked the Director of Nursing (DON) when providing care to a resident, should the blinds be closed on a window facing the parking lot? The DON stated, Yes. The Surveyor asked why the blinds should be closed when providing care. The DON stated, Dignity. 2. Resident #21 had diagnoses of Depression and Senile degeneration of brain. According to the Annual MDS with an ARD of 01/18/2024 documented that Resident #21 had short-term and long-term memory loss. Resident #21 had an indwelling catheter and was always incontinent of bowel. a. On 03/27/2024 at 11:06 AM, the Surveyor observed Certified Nursing Assistant (CNA) #2 and #4 providing perineal care to Resident #21 who had been incontinent of bowel. b. On 03/27/2024 at 11:14 AM, CNA #2 while at the bedside of Resident #21 stated to CNA #4, [The resident] is going to go and go. CNA #2 then stated, One time it took us an hour to clean [the resident] up. c. On 03/27/2024 at 11:32 AM, the Surveyor asked CNA #2 if it was standard practice to have a discussion at the bedside about a resident's incontinence? CNA #2 stated, I shouldn't have done that; that was wrong on my behalf. d. On 03/28/2024 at 09:56 AM, the Surveyor asked the DON if staff is having a conversation about the resident's incontinence while providing incontinence care, is that standard practice? The DON stated, I wouldn't say talking about it in front of the Resident I wouldn't. The Surveyor asked what issue could that cause? The DON stated, It could cause the resident to feel bad and embarrassed. e. On 03/25/2024 at 11:30 AM, a policy titled, Summary of Residents' [NAME] of Rights documented, .AS A RESIDENT YOU HAVE T.E RIGHT TO BE: Free from mental and physical abuse (mental abuse includes humiliations, harassment, and threats of punishment or deprivation .) .Every Resident has the right to: considerate and respectful care. Every resident will be treated with consideration, respect, and full recognition of his/her dignity and individuality. Privacy during treatment and care of personal needs .

Based on interview and record review, the facility failed to accurately document a Discharge Minimum Data Set assessment for 1 (Resident #117) sampled resident. The findings are: Resident #117 had diagnoses of Unilateral primary osteoarthritis, Right knee arthroplasty, Generalized anxiety, Spondylosis, Lumbar prosthetic device, and Aftercare following joint replacement surgery. On 03/26/2024 at 02:45 PM, through record review it was determined the Discharge Minimum Data Set (MDS) information for Resident #117 was documented incorrectly as 04 Short-Term General Hospital (acute hospital, IPPS) in Section A1805. On 03/27/2024 at 10:11 AM, the MDS Coordinator in which they confirmed Resident #117 was discharged home, but the previous MDS Coordinator had incorrectly documented the Resident was discharged to the hospital which could affect billing issues and required correcting immediately.

Based on observation, interview and record review, the facility failed to ensure services were provided to minimize the potential for further decline in Range of Motion (ROM) for 1 (Resident #20) of 1 sampled resident who had limited range of motion. The findings are: 1. Resident #20 had diagnoses of Hemiplegia and Hemiparesis following cerebral infarction affecting right dominant side. 2. On 03/25/2024 at 11:21 AM, Resident #20's right hand was observed with the fingers curved into the palm of the hand, making a fist. The Surveyor asked Resident #20 if the resident had been provided with anything to put in the hand to prevent further contraction. Resident #20 stated, Sometimes they put a washcloth in there, but it's been a while. 3. On 03/27/2024 at 11:10 AM, the resident was sitting up in bed. Resident #20's right hand was empty. The Surveyor asked Resident #20 if the resident had been provided with some type of device to prevent further contracture. Resident #20 stated, Not today. You know, it ' s been a long time. 4. On 03/27/2024 at 12:30 PM, the Director of Nursing (DON) accompanied this Surveyor to Resident #20's room. The Surveyor asked if the residents who are experiencing contractures are provided measures to prevent the condition from worsening. The DON stated, They should be. The DON asked the resident if they had been given anything for their hand today. The Resident stated, They used to put a rolled-up towel in my hand, but it's been a long time. The DON asked Resident #20 how long it had been, and the Resident stated, At least two or three months. 5. On 03/28/2024 at 9:12 AM, the Administrator reported that there was not a policy specific to ADL's. 6. On 03/28/2024 at 11:00 AM, CNA #9 was asked to identify some of the interventions used for residents with hand contractions. CNA #9 reported that recommendations usually come from therapy and that a hand roll is one thing that almost everyone receives. CNA #9 was asked to identify the benefits of a hand roll for a resident with a hand contracture. CNA #9 stated, It helps to increase their ability to use their hand or to keep it from getting worse. I have also had a resident who said [the resident's] hand hurt less when [the resident] used a hand roll.

Based on observation, interview and record review, the facility failed to review and revise a resident's care plan with the participation of the resident's representative for 1 (Resident #39) of 111 residents who received a care plan. The findings are: 1. Resident #39 had diagnoses of Senile degeneration of the brain, Malignant neoplasm of ethmoidal sinus; Neoplasm of uncertain behavior of trachea, bronchus, and lung; Alzheimer's disease with early onset essential (primary) hypertension; Hypotension, stricture of artery; Syncope and collapse, Neoplasm of uncertain behavior of carotid body, and Bradycardia. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/21/24 showed a Brief Interview for Mental Status (BIMS) of 00 (0-7 indicates severe cognitive impairment). a. On 03/27/2024 at 08:57 AM, Resident 39's family member asked to speak with a Surveyor. Resident 39's family member told the Surveyor that the family member was involved in the first care plan meeting but none since then. b. On 03/27/2024 at 09:45 AM, documentation showed that the resident's family member was involved in the initial care plan meeting. Resident #39 was admitted to the facility on [DATE]. It was documented in the resident's chart that there have been quarterly care plan meetings since the initial care plan meeting: 08/15/2023, 10/04/2023, and 01/05/2024. c. On 03/28/24 at 09:23 AM, the Surveyor asked the MDS Coordinator, Who schedules the care plan meetings? The MDS Coordinator said that she does sometimes and sometimes the Social Services Director does. The Surveyor asked the MDS Coordinator, Do you contact the resident representative to invite them to participate in the care plan meeting? The MDS Coordinator said she does if the representative wants to be included. The Surveyor asked the MDS Coordinator, Where would the documentation be found where the representative was contacted? The MDS Coordinator said it would be found in their chart. d. On 03/28/2024 at 09:35 AM, the Surveyor asked the Social Services Director (SSD), Who schedules the care plan meetings? The SSD said that her and the MDS Coordinator share the responsibility. The Surveyor asked the SSD, Do you contact the resident representative to invite them to participate in the care plan meeting? The SSD said she does if the representative requests to be included. The Surveyor asked, Where would the documentation be found where the representative was contacted? The SSD said she charts it on a progress note in their medical chart. e. On 03/28/2024 at 05:01 PM, the MDS Coordinator stated that there was not a specific policy for care planning.

Based on observation, interview, and record review, the facility failed to ensure services were provided to minimize the potential for further decline in range of motion (ROM) for 1 (Resident #20) of 1 sampled resident who had limited range of motion. The findings are: 1. Resident #20 had diagnoses of Hemiplegia and Hemiparesis following cerebral infarction affecting right dominant side. 2. On 03/25/2024 at 11:21 AM, Resident #20 was sitting up in bed. Resident #20's right hand was observed with the fingers curved into the palm of the hand, forming a fist. Resident #20 was asked if the resident had been provided anything to put in the hand to prevent further contraction. Resident #20 stated, Sometimes they put a washcloth in there, but it's been a while. 3. On 03/27/2024 at 11:10 AM, Resident #20's right hand was observed to be empty. Resident #20 was asked if the resident had been provided with some type of device to prevent further contracture. Resident #20 stated, Not today. You know, it's been a long time. 4. On 03/27/2024 at 12:30 PM, the Director of Nursing (DON) accompanied this Surveyor to the Resident #20's room. The DON was asked if residents' who are experiencing contractures are provided measures to prevent worsening. The DON stated, They should be. The DON asked Resident #20 if they had been given anything for the resident's hand today. Resident #20 stated, They used to put a rolled-up towel in my hand, but it's been a long time. The DON asked Resident #20 how long it had been, and Resident #20 stated, At least two or three months. 5. On 03/28/2024 at 09:12 AM, the Administrator reported that there was not a policy specific to ADL's (Activities of Daily Living). 6. On 03/28/2024 at 11:00 AM, CNA #9 was asked to identify some of the interventions used for residents with hand contractions. CNA #9 reported that recommendations usually come from therapy and that a hand roll is one thing that almost everyone receives. CNA #9 was asked to identify the benefits of a hand roll for a resident with a hand contracture. CNA #9 stated, It helps to increase their ability to use their hand or to keep it from getting worse. I have also had a resident who said [their] hand hurt less when [the resident] used a hand roll.

Based on observation, record review and interview, the facility failed to ensure planned interventions were consistently implemented to address a severe weight loss and the plan of care to address the weight loss was updated to include current orders for supplements and the frequency at which the supplements were to be offered to facilitate continuity of care and minimize the potential for further weight loss for 1 (Resident #6) of 2 (Residents #6 and #14) case mix residents who had a significant weight loss. The failed practices resulted in a pattern of actual harm for Resident #6, who experienced a severe weight loss, and had the potential to cause more than minimal harm for 4 residents who were at risk for weight loss, as documented on a list provided by the Director of Nursing (DON) / Administrator on 11/17/16. The findings are: Resident #6 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set with an assessment reference date of 9/1/16 documented the resident had severely impaired cognitive skills for daily decision making per a staff assessment for mental status, was totally dependent on staff for assistance with eating, had experienced a weight loss of 5% or more in the past 30 days or 10% or more in the past 180 days, was not on a physician-prescribed weight loss regimen, required a mechanically altered diet, had a Stage III pressure ulcer and had an unstageable pressure area. a. The Plan of Care dated 1/22/15 documented, Problem: I am at risk for weight loss r/t (related to) mechanically altered diet and nectar thick liquids Pureed Diet . Approaches: Offer me bedtime snacks. I need my meals served as ordered by my physician. Weigh me as appropriate. Nectar thick liquids. House shakes with all meals. Thrive nutritional treat one container bid (twice daily) with breakfast and dinner. I need my current food likes and dislikes maintained by dietary. I need my medications ordered by my physician. Have the dietician re-evaluate my nutritional status as needed . Problem: I have altered diet needs . Approaches: Maintain my current listing of food likes and dislikes. I need my diet served to me as ordered. Dietician to evaluate my current nutritional status. b. The Weight Change History received from the Food Service Supervisor on 11/14/16 documented the following weights for this resident: 8/2/16 - 158 Pounds 8/30/16 - 149 Pounds This resident experienced a weight loss of 9 pounds (5.69%) in less than 1 month (from 8/2/16 to 8/30/16). c. A Registered Dietitian (RD) Note dated 8/17/16 documented, PO (oral) intake averaged 75% of past 10 meals. Rec (receives) magic cup tid (3 times per day) and house shakes all meals. Recommend: 1. SF (sugar free) Prostat AWC (Advanced Wound Care) 30 ml (milliliters) daily. 2. d/c (discontinue) magic cups tid. 3. Offer Thrive 1 container BID (two times per day). Will follow up as needed. A physician's orders [REDACTED]. SF (sugar free) Pro Stat AWC liquid 30 ml by mouth daily. d. A Registered Dietitian (RD) Note dated 9/20/16 documented, Resident continues tx (treatment) to left heel Stage III 2.0 x (by) 2.0 x 0.3 cm (centimeters) and left upper back Stage IV 4.5 x 4.5 x 3.0 cm. House shakes with meals. Thrive nutritional treat bid with breakfast and dinner. e. The Weight Change History report documented the resident's weight on 9/27/16 was 145 pounds. The resident had lost an additional 4 pounds since the 8/30/16 weight, for a total of 13 pounds (8.22%) in less than 2 months (8/2/16 to 9/27/16). f. The RD Note dated 10/22/16 documented, Resident referred for skin and weight.House shakes all meals and nutritional treat (Thrive) with Breakfast and Dinner. PO (Oral) intake averaged past 12 meals 69%. Rec sf prostat awc 30 ml bid since 9/21/16. Weight decreased 4# in 30 days and 8# in 91 days. Recommend: 1. Increase prostat awc 30 ml bid to TID (3 times daily). 2. D/C (Thrive) nutritional treat bid with meals. 3. Offer nutritional treats bid between meals. A Physician order [REDACTED]. Increase SF Pro Stat AWC 30 ml TID daily. Medication Administration Records (MARs) dated August 2016 through October 2016 documented the Prostat AWC was administered to the resident at the frequency ordered by the physician. g. The Weight Change History received from the Food Service Supervisor on 11/14/16 documented the resident's weight on 10/26/16 was 144 pounds. The resident had lost a total of 14 pounds (8.86%) in the slightly less than 3-month period from 8/2/16 through 10/26/16. h. As of 11/16/16, the Plan of Care dated 1/22/15 had not been updated to inform nursing staff that the Thrive nutritional treats were to be provided to the resident between meals. i. The October 2016 Snack Roster documented the resident was offered and accepted snacks on 10/1/16, 10/2/16, 10/12/16, 10/14/16 and 10/30/16. No percentage of consumption was documented on these dates. j. A Resident Dining Details Report dated 11/1/16 included categories for documentation of the resident's Diet Order, allergies [REDACTED]. k. On 11/14/16 at 5:28 p.m., during the supper meal, the resident was served a tray that consisted of pureed chicken and dumplings, pureed vegetables, bread crumbs, pureed rosey pears, nectar thick milk and nectar thick water. No house shake or other supplement was served with the meal tray or during the meal. l. On 11/15/16 the Director of Nursing provided a current weight for the resident as 140 pounds. The resident had lost a total of 18 pounds (11.39%) in the 3-month period from 8/2/16 to 11/15/16. m. On 11/15/16 at 8:00 a.m., during the breakfast meal, the resident was in bed and was served a pureed diet tray. There was no house shake or other supplement served with the tray or during the meal. Certified Nursing Assistant (CNA) #1, who was assisting the resident during the meal, was asked if the resident received a shake and stated, Not today. n. A Snack List provided by the Director of Nursing on 11/15/16 at 4:25 p.m., documented the resident was to receive a pureed snack for the morning snack and evening snack pass on 11/16/16. o. On 11/15/16 from 9:45 a.m. until 11:25 a.m., the resident was in his room, and the surveyor continuously observed the door to the room to determine if the resident would receive a snack during the 10:00 a.m. snack pass. No Thrive nutritional treat, snacks, shakes or other supplements were taken into the resident's room at any time. p. On 11/15/16 at 12:20 p.m., the resident was in his room and was served a lunch tray of pureed pork chop, pureed peas, pureed greens, pureed cornbread and pureed banana split dessert. There was no House Shake or other supplement served with the meal tray or during the meal. q. On 11/15/16 at 2:30 p.m., the resident was in his room. At this time, CNA #2 was passing snacks from the snack cart to residents who resided on the same hall as Resident #6. The CNA did not offer a snack to this resident. CNA #2 was asked if there were specific residents who were to receive snacks and stated, They (facility) used to have a list (of residents who were to receive snacks), but they don't have a list anymore. r. On 11/15/16 at 3:55 p.m., Licensed Practical Nurse (LPN) #1, the nurse assigned to this resident's hall, was asked if she gave anything to this resident besides medicine, such as snacks or supplements. The LPN stated, The CNA gives the resident snacks; sherbet, applesauce and thickened water. s. On 11/15/16 at 3:58 p.m., CNA #3 was asked if she gave anything to this resident, like supplements or snacks, and stated, If there is anything on the snack cart that he can eat - he is on thickened liquids - I will give it to him. I give him applesauce, magic cup or sherbet when on the cart. t. The November 2016 Snack Roster documented that from 11/1/16 through 11/15/16, the resident was offered and accepted a snack on only one date, 11/14/16. No consumption information was documented on 11/14/16, and for all other dates, the snacks were documented as refused, including the morning and evening snacks on 11/15/16, during which the surveyor observed that no snacks were offered to the resident. u. On 11/15/16 at 4:03 p.m., the Food Service Supervisor was asked if she was aware the resident was losing weight and stated, Yes, I am aware. He gets Magic Cup. The Food Service Supervisor then provided a Dietary Communication Slip with no date, which documented the resident was to receive Thrive supplements. v. On 11/15/16 at 4:13 p.m., the DON was asked if she was aware the resident was losing weight and stated, Yes. We give him Thrive supplements. w. The resident's tray card, provided by the Food Service Supervisor on 11/15/16 at 4:54 p.m. documented for Breakfast, Lunch and Dinner, Preferences Nectar thick: Juice, milk, water and tea. Pureed Diet. There was no documentation that indicated the resident was to receive any type of supplement or House Shake with meals. x. On 11/16/16 at 11:35 a.m., the DON was asked when the resident was taken off the weekly weights. She stated, The facility follows the RD recommendations, and the RD documented the resident had a [DIAGNOSES REDACTED]. She was asked if the weekly weights were restarted in August 2016 (when the resident began losing significant amounts of weight). She stated, No, the facility follows the RD recommendations, and the RD documented the resident had a [DIAGNOSES REDACTED].

Based on observation, record review and interview, the facility failed toensure Residents #1 and #3 received necessary treatment and services to promote healing and prevent new sores from developing. The facility failed to ensure full assessments to include stage, measurements and full description of wounds were immediately completed/documented upon identification of pressure sores and weekly reassessments were completed fully describing the pressure sores to ensure prompt identification of deterioration or lack of healing for 2 (Residents #1 and #3) of 5 (Residents # 1 - #5) case mix residents who had or were at risk for developing pressure sores. The facility failed to ensure weekly reassessments were completed and documented for identified areas of deep tissue injury to ensure prompt identification of deterioration or failure to improve for 1 (Resident #3) of 1 case mix resident with identified areas of deep tissue injury. The facility failed to ensure the physician was immediately consulted regarding treatment when pressure sores were first identified for 2 (Residents #1 and #3) of 5 (Residents # 1 - #5) case mix residents who had or were at risk for developing pressure sores. The failed practices resulted in a pattern of actual harm for Residents #1 and #3 who developed pressure sores or was admitted with pressure sores that deteriorated and had the potential to cause more than minimal harm for 12 residents who had pressure sores and 54 who were at risk for developing pressure sores, as documented on the Census list provided by the Director of Nursing on 8/15/12 at 2:38 p.m. The findings are: 1. Resident #3 had [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/17/12 documented the resident was severely impaired in cognitive skills for daily decision making per a Staff Assessment of Mental Status, required extensive 2 + person assist for bed mobility, was always incontinent of urine and bowels, was at risk for pressure sores and had no pressure ulcers. a. The Care Plan last reviewed/revised dated 5/17/12 documented in the Problem section, "Problem 8/25/11 - At risk for skin breakdown due to episodes of urinary incontinence... Approach Monitor skin condition for signs of breakdown or redness." b. A Nurse's Note dated 6/30/12 at 2:00 p.m. documented the resident was sent to the hospital due to a low O2 (oxygen) saturation. c. A Hospital Consultation reported dictated 7/2/12 documented, "...Skin: ...The patient has an old healed ulceration in his sacral area. Otherwise, no rashes. A hospital Consultation report dated 7/9/12 documented, "...Skin: Superficial excoriation is noted on both buttocks, perineum, and sacrum, and early decubitus ulcer." d. A facility Admission Evaluation and Interim Care Plan dated 7/15/12 at 5:00 p.m. documented the resident returned from the hospital with multiple areas including "areas to bilateral hips." The Skilled Daily Nurses Note dated 7/15/12 documented, "Services Provided ...wound care and pressure ulcer management checked...3-11 p.m ...long red like blister area to outer side of foot. Bil (bilateral) heels (with) dark unstageable areas. (L) (left) hip (with) deep red excoriation ...(R) (Right) hip with deep red excoriation...Coccyx (and) buttocks (with) beef red excoriation ..." e. The Skilled Daily Nurses Note dated 7/16/12 documented, "7/17/12 (7/16/12 notes written prior to 7/16/12 evening shift) 1220 (12:20 p.m.) ...Buttocks (with) multiple stage II (at) (L) (and) (R) buttock, buttocks completely excoriated in areas (with) 3 stage II (at) (L) buttock (and) 3 stage IIs (at) (R) buttock. Bilateral heels (with) noted DTIs (deep tissue injuries) black, hard eschar noted surrounded by redden areas. Scrotum (with) stage II noted posteriorly. (Physician) notified ...(with) new orders rec'd (received) for [MEDICATION NAME] to buttock Q(every) day ...noted (at) (R) lateral foot, purplish/black in color intact, (no) drainage/odor noted." A Physician Telephone Order dated 7/16/12 documented, "Add [DIAGNOSES REDACTED]. A Physician Telephone Order dated 7/16/12 documented, "Clean buttocks (with) wound cleaner, pat dry, apply silverdene ([MEDICATION NAME])1% to buttock Q day (and) prn (as necessary)." f. Facility Body Audit sheets dated 7/20/12 and 7/27/12 documented excoriation on the buttocks and perineal area. There was no documentation on the body audit sheets addressing the right hip. g. A Dietary Consult Referral form dated 8/1/12 and signed by the Registered Dietician (RD) documented, "Reason for Consult: Wt (weight) loss - 7 pounds... Skin Problems: No... Recommendations: Obtain BNP. May want to try offering pudding or yogurt 1 meal." The RD documented no skin problems and did not address additional caloric/ protein needs to promote healing of pressure sores. 1) On 8/15/12 at 10:50 a.m., the surveyor asked the Dietary Manager (DM) about the Dietary Consult Referral dated 8/1/12 and why she waited until then to make the referral since the resident returned from the hospital on [DATE] (with multiple skin issues). She stated, "I do it as soon as possible but, it could've fallen through the cracks. If I had known he had skin issues, I would've done it sooner." The surveyor asked why she didn't know the resident had skin issues. The DM stated, "The skin reports. He wasn't on the one I was given." 2) On 8/15/12 at 11:15 a.m., the surveyor asked the Registered Dietician about the referral and if it would have made a difference in her recommendations if she had known the resident had skin problems. She stated, "Yes. I would have calculated his needs higher." h. A facility Body Audit sheet dated 8/2/12 documented excoriation was present on the buttocks area. There was no documentation addressing the right hip. The Other Skin Condition Weekly Status Report dated 8/3/12 documented, "Wound Site Buttocks ...Type of Wound 8 (Excoriation) ...no odor no drainage ..." The right hip was not addressed nor were the lower extremities addressed. The form was blank regarding size, status, or any other descriptions. i. The Nurses Notes dated 8/6/12 at 1:25 a.m. and the Resident Transfer Form at 1:20 a.m. documented the resident was sent to the emergency room for decreased oxygen saturation. The ED (Emergency Department After Care Instructions dated 8/6/12 documented, "...Your [DIAGNOSES REDACTED]. The Hospital Order and Progress Notes dated 8/6/12 at 2:15 a.m. documented, "(1) Apply Podus Suspension boots to bilateral lower extremities. (2) Wound care nurse to further eval (evaluate) (and) treat stage II Decubitus Ulcers ..." The Nurses Notes dated 8/6/12 at 3:00 a.m. documented the resident returned to the facility with no new orders. A Physician Telephone Order dated 8/6/12 time 10:00 a.m. documented, "(1) Apply Podus Suspension boots to bilateral lower extremities. ...(2) Wound care nurse to further eval and treat Stage II decubitus ulcers." The Nurses Notes dated 8/6/12 did not document an assessment of any pressure sores. j. A Weekly Pressure Ulcer QI Log dated 8/10/12 documented the first assessment of the right hip. "...Date ...admitted with 7/12/12 Site (R) hip Stage III ...Size (cm (centimeters)) L (length) x (times) W (width) 7.1 x 3.0 Depth (cm) 0.2 no odor ...drainage S (small amount) ...Cleanse (with) wound cleaner, pat dry, apply [MEDICATION NAME] ..." The Log did not include any other pressure sores for this resident. k. On 8/14/12 at 10:50 a.m., the resident was lying in bed and Certified Nursing Assistants (CNAs) #1 and #2 provided incontinent care. When the resident was turned to his left side, a large open area was visible on the right trochanter area. A small amount of yellow colored drainage was on the brief. No dressing was present. The surveyors asked the CNAs why there was no dressing on the area. CNA #1 stated, "I don't know. The dressing is not in his brief either. That (pressure sore on right hip) has been on him since he got back from the hospital." l. On 8/14/12 at 11:00 a.m., the surveyor asked the treatment nurse to see the Treatment Administration Record (TAR) for the resident in order to know what the current treatment order was. The July and August 2012 TAR were reviewed and had no documentation a treatment order was obtained or treatments were provided for the right trochanter ulcer from the time the resident returned from the hospital on [DATE] to 8/14/12. On 8/14/12 at 11:05 a.m., the surveyor asked the treatment nurse why a treatment order had not been obtained for the right trochanter. She stated, "I thought I got one." m. On 8/14/12 at 11:36 a.m., the surveyor observed the treatment nurse providing treatment for [REDACTED].< 0.2 cm. and had a red wound base with white edges. No odor was noted. The surveyor asked the treatment nurse what stage the wound was. She stated, "Stage 3." The surveyor observed 3 stage II open areas on the sacrum with the following measurements: 2.7 cm x 1.0 cm x < 0.2 cm; 0.9 cm x 0.4 cm x < 0.2 cm; and 1.0 cm x 0.4 cm x < 0.2 cm. The left heel had deep tissue injury with black tissue covering the whole heel and dried bloody drainage was observed on the resident's sock. The right outer foot and heel had black tissue with bloody drainage. A Nurse's Note dated 8/14/12 at 11:45 a.m. and signed by the Treatment Nurse documented, "... Stage III noted to right hip, wound bed red with white edges, flat, no drainage noted, no odor. (L) buttock (with) stage II top and bottom...(physician) notified with new orders received. Clean right hip with wound cleanser, pat dry, apply Hydrogel gauze and dry dressing..." n. On 8/14/12 at 3:00 p.m., the surveyor asked the Director of Nursing if she knew about the area on the right hip, that there was no treatment order for it and that there were no assessments or monitoring of the area. She stated, "No." 2. Resident #1 had [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 7/17/12 documented the resident was moderately impaired in cognitive skills per a staff assessment of mental status, required extensive 2 plus person assist for bed mobility, had an indwelling urinary catheter, was incontinent of bowel, had no pressure sores and was at risk for pressure sores. The July 2012 Treatment Administration Record documented the urinary catheter was discontinued on 7/24/12. a. The Care Plan last updated on 4/17/12 documented, "At risk for skin breakdown, related to incontinent episodes - Approaches: provide pressure relieving, monitor skin and report any changes of condition promptly ...weekly body audits by skin tx (treatment) nurse or floor nurse ...report any changes to MD (medical doctor)..." b. The facility's 24-hour Report dated 7/21/12 documented, "(Resident #1) - Open raw area - inner R (right) thigh and L (left) buttock." The facility's 24-hour Report dated 7/22/12 documented, "(Resident #1) - open area R inner thigh and L buttock Tx LPN (Licensed Practical Nurse) needs to eval (evaluate)." The facility's 24-hour Report dated 7/23/12 documented, "(Resident #1) - family upset about fingernails being dirty, open area R thigh and L Buttock (told to nurse)." c. The Nurse's Note dated 7/26/12 at 1:00 a.m. documented, "...Areas red to R inner thigh and an area to L buttock cleansed and [MEDICATION NAME] applied after each incont. (incontinent) episode..." The Nurse's Note dated 7/26/12 at 3:30 p.m. documented, "...repositioned to R side to find buttocks excoriated at buttock/rectal area, R inner thigh excoriated noted. (Physician) notified with new orders rec'd (received). Buttock red without drainage or odor noted. Family member notified..." A Physician Telephone Order dated 7/26/12 at 4:25 p.m. documented, "Clean wound at buttock and R inner thigh with wound cleaner and pat dry, apply [MEDICATION NAME] dressing change every 3 days." d. The July 2012 Treatment Administration Record (TAR) documented the treatment was completed each day from 7/26/12 - 7/31/12, with exception of 7/30/12. There was no documentation the areas declined. e. The Body Audit dated 7/27/12 documented, "Buttock and R inner thigh excoriation." There were no measurements or description of the areas documented. The Care Plan updated 7/27/12 documented, "At risk for skin breakdown, related to incontinent episodes - Approaches: ...prostat/vitamin C/multivitamin added for wound healing, air mattress." f. The Nurse's Note dated 7/28/12 at 12:05 a.m. documented, "...family here at this time wanted to see resident's buttocks at this time. ...drsgs (dressings) intact to R inner thigh x (times) 2 and L buttock and coccyx area. RP (responsible party) asked resident if she could take a picture of her, resident stated I don't care. RP took pictures of resident's thighs and buttocks with cell phone. RP crying stated 'Oh, my God, those are bed-sores'. Tried to explain to RP that those are excoriations to explain to RP that these are excoriations and not bedsores. ...Resident has pink bright area to L inner thigh at this time with numerous small pink areas 3 to crease at the base of each buttock. RP aware cleansed with warm H20 (water) and [MEDICATION NAME] applied in RP's presence..." On 8/15/12 at 11:12 a.m., LPN #1, the nurse on the 11:00 p.m. - 7:00 a.m. shift who documented the Nurse's Note on 7/26/12 and 7/28/12, stated when she first saw the area, it was not deep, it was not broken and, "(The granddaughter (RP)) was acting like it was to the bone, a huge, deep hole." The surveyor asked LPN #1 to describe the areas. LPN #1 stated, "The coccyx was a small pink area, not open ... There was no raw meat, it looked like it was fixing to open. You can tell if you didn't do something, it was going to open. It looked like it needed to be treated. We were treating per the treatment nurse. When I had her (was assigned to care for the resident), we were putting [MEDICATION NAME] on it. I reported it 7/22/12. I reported to the floor nurse coming on and I reported it to the DON, so it would be reported to the treatment nurse. The surveyor asked LPN #1 if she documented it anywhere. The LPN stated, "Yes ... if I didn't in the Nurses' Notes then, look on the 24 hour report." The area of skin breakdown was documented on the 24 hour report on 7/21/12, 7/22/12 and 7/23/12. g. The facility's Grievance/Complaint Report dated 7/30/12 documented, "...c/o (complained of) open areas on her (resident's) bottom and inner thighs - stated she heard conflicting stories on when they were found and c/o (Resident #1) left wet at times. ...Explained POC (Plan of Care) re: open areas on bottom and keeping dry and turned." The report documented the complaint was made by the responsible party (granddaughter). On 8/14/12 at 2:30 p.m., the surveyor asked the Director of Nursing (DON) if she looked at the resident's wounds after the facility received the grievance/complaint from the responsible party on 7/30/12. The DON stated, "Yes. It was a Stage II. It had opened. I advised (treatment nurse) to get an order for [REDACTED]. A statement written and provided by the DON dated 8/15/12 at 12:50 p.m. documented, "On July 30, 2012, I was called down to (Resident #1)'s room by the Tx Nurse to look at (Resident #1)'s wounds. Discussed with Tx Nurse the type of wounds, which were Stage 2 wounds. Wounds had no odors or drainage. Advised Tx Nurse to call MD for Tx orders and ok for air mattress. Advised/reminded Tx nurse to call POA (power of attorney) and family to inform them about the wounds and treatment." h. The Weekly Body Audit dated 8/1/12 documented, "Stage III (coccyx), Stage II (2) areas at the bottom crease of the buttock, Stage II (2) areas to inner R thigh." There were no documented measurements or descriptions of the wounds. A Physician's Telephone Order dated 8/1/12 documented, "Discontinue previous orders at coccyx, start in a.m. with wound cleaner, apply santyl ointment to Stage III and [MEDICATION NAME]/dry dressing." The physician's orders [REDACTED]. i. The Weekly Pressure Ulcer Record dated 8/3/12 documented, "...8/3/12 Stage III 5.0 x 2.5 (centimeters (cm)) depth .3 small serous drainage reddish pink wound bed with surrounding skin color brown. Stage 3. Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. ...(found) L buttock... 8/3/12 Stage II 3.0 x (by) 1.2 depth < (less than) .02 small serous drainage, red wound bed with pinkish red surrounding skin color. ...Stage 2. Partial Thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough. May also present as an intact or open/ruptured blister." The first documented measurements or descriptions of the wounds were dated 8/3/12. On 8/14/12 at 2:00 p.m., the Treatment Nurse stated these were the only documented measurements for these wounds. The Treatment Nurse stated, she actually measured the wounds on 7/26/12 but did not document the measurements until 8/3/12. The Treatment Nurse was asked how could she document measurements from 7/26/12 as the measurements for 8/3/12 (8 days after obtaining them). The Treatment Nurse stated the Quality Improvement (QI) Report for the wounds had been completed for the week and so she used the measurements for the 8/3/12 QI Report as she was taught. The nurse stated there were no other measurements obtained from 7/26/12 - 8/7/12, a total of 12 days, when the resident was admitted to the hospital. j. The August 2012 Treatment Administration Record (TAR) documented, "8/1/12 Clean Stage III at coccyx with would cleaner, pat dry, apply Santyl ointment and [MEDICATION NAME] with dry dressing BID (2 times daily)." The TAR did not document the treatment was completed for 5 of 13 scheduled treatments from 8/1/12 - 8/7/12. On 8/14/12 at 2:00 p.m., the surveyor asked the Treatment Nurse if she knew why there was no documentation of completion of the treatment for 5 different occasions from 8/1/12 - 8/7/12. The nurse stated she had no idea. k. The hospital admission History and Physical dated 8/8/12 documented the resident was admitted to the hospital on [DATE] and, "Impression: Hypercalcemia secondary to [MEDICAL CONDITION] ...Sacral Ulcer, Stage II to III."

Based on record review and interview, the facility failed to ensure that an allegation of abuse was immediately reported to the Administrator/Designee, was thoroughly investigated, residents were protected from potential further abuse, and the allegation was reported to the local law enforcement and the Office of Long Term Care in accordance with state law for 1 (Resident #12) of 11 (Residents #2, #5 through #12, #15 and #16) case mix residents who were cognitively impaired. This failed practice resulted in Immediate Jeopardy that likely caused or could have caused serious harm for Resident #12, who alleged that Certified Nursing Assistant (CNA #5) was physically abusive to him and had the potential to affect 60 residents who were cognitively impaired (of a total census of 89), according to the Roster Sample Matrix received from the Administrator on 4/9/11. The facility was informed of the Immediate Jeopardy condition on 4/11/11 at 2:00 p.m. The findings are: 1. On 4/10/11 Group Interviewee #1 and Group Interviewee #4 both stated that they had witnessed a male Certified Nursing Assistant (CNA) in the dining room put a belt around a blind resident's neck and lead him back to the table. 2. Resident #12 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 2/3/11 documented the resident had highly impaired vision, had short/long-term memory problems with moderately impaired cognitive skills for daily decision making per staff assessment for mental status, scored a total score of 3 (1-4 indicates minimal depression) per staff assessment of resident mood, had highly impaired vision, required limited assistance of one person for transfers, required extensive assistance of one person for personal hygiene and used a wheelchair for mobility. a. The "Grievance/Complaint Report" dated 10/19/10 signed by the Admission Coordinator documented, "(Resident #12) said (CNA #5) roughly put him back in his chair. He (Resident #12) doesn't like being restrained. He (Resident #12) said (CNA #5) had his (Resident #12) military belt and he doesn't know how he (CNA #5) got it. He said he doesn't like (CNA #5) and (CNA) hits him in the head and on the shoulders and he (Resident #12) tells him to quit. He said (CNA) yells in his ears and doesn't like it. He wanted to talk to someone in the morning. Told Nurse, (LPN #7) (Resident #12) said, (LPN #7) said she seen what happened ...Documentation of Facility Follow-up: Admin (Administrator) and DON (Director of Nursing) did investigation with staff and other residents that was in DR (dining room) at the time of complaint, found to be untrue ...Resolution of Grievance/Complaint: Complaint was unfounded true, staff statement given. Pt (patient) has history of confusion." Another "Grievance/Complaint Report" dated 10/19/10 signed by the Admission Coordinator documented, "...(Resident #26) brought me (Admission Coordinator) a letter where he wrote down what had taken place in the dining room with (CNA #5) and (Resident #12). See attached note." The Attached Note documented, "(CNA #5) at supper time ingored (ignored) his duties and let (Resident #12) get out of his wheel chair and walk around in the dinning (dining) room in front (of) a lot of people. He then took a strap made a loop and through (threw) it around (Resident #12's) neck from the back all the while making jokes and playing around with (Resident #12) He rough(ed) him around mistreating him and then took him to his room. You can ask anyone in the room." The "Grievance QA (Quality Assurance) Log documented, "10/19/10 (Resident #26) reported that a CNA was ruff (rough) (with) a resident ...investigation done statement found untrue..." A witness statement dated 10/19/10 and signed by Licensed Practical Nurse (LPN) #7 documented, "While passing medications in the day room I saw (CNA #5) assist (Resident #12) who was standing up out of his w/c (wheel chair) (and) out of control by using a gait belt. The gait belt was used correctly." LPN #7 was no longer employed by the facility and was unavailable for interview during the survey. b. On 4/11/11 at 8:15 a.m., the Admission Coordinator was asked if CNA #5 was on duty the night of 10/19/10. The Admission Coordinator stated, "Almost positive he was." The Admission Coordinator was asked, "What did you do?" The Admission Coordinator stated, "I told the nurse." c. On 4/11/11 at 8:15 a.m., the Administrator was asked, "Did the Nurse notify you?" The Administrator stated, "No, I found out the next morning. We went and talked to (Resident #12) and he was so confused. He was going back in Vietnam something crawling under his bed and hearing gun shots, really, really confused." The Administrator was asked if they had investigated the allegation reported on the Grievance QA (Quality Assurance) Log on 10/19/10. The Administrator stated, "I did investigate, but we can't find it (documentation of investigation)." The Administrator stated, "The resident was confused." The Administrator was asked which residents were most likely to be abused. The Administrator stated, "Confused (residents)." The Administrator was asked what the facility protocol was for suspected abuse. The Administrator stated, "Investigate, suspend while investigating." The Administrator was asked, "Did you suspend (CNA #5)?" The Administrator stated, "I did an investigation, but I can't find it (documentation of investigation)." d. On 4/11/11 at 8:20 a.m., Licensed Practical Nurse (LPN) #1, the CNA Supervisor, was asked if CNA #5 was suspended after the allegation made on 10/19/10. The LPN stated, "No, not at that time." The LPN was asked if CNA #5's signature was on the in-service for "Abuse, Neglect, Types of Abuse, Reporting Abuse, Who We Report Abuse To" dated 10/20/11. The LPN stated, "No." On 4/11/11 at 8:50 a.m., the Nurse Consultant was asked if CNA #5's name was on the in-service form for Abuse that was held on 10/20/10. The Nurse Consultant stated, "No." e. On 4/11/11 at 10:21 a.m., Resident #12 was interviewed regarding CNA #5. The Resident stated, "I have asked him (CNA #5) several times not to do it and he does it after I ask him not too. Taps me on my head, shoulder neck and back..." f. On 4/11/11 at 11:05 a.m., CNA #5 was asked if he had ever hit (Resident #12). The CNA stated, "I pat him on the back. I do it all the time in greeting." The CNA was asked if a resident had ever asked him not to? The CNA stated, "Maybe so." The CNA was asked, if he continued to pat the resident after being asked not to. The CNA stated, "Of course not, sometimes he (Resident #12) is jumpy so I don't do it. I don't take care of him. Occasionally I have to assist with him, been a while, can't remember exactly. The CNA was asked if he had ever popped up the wheelchair on the front or back wheels. The CNA stated, "No he (Resident #12) is pretty heavy." 3. On 4/11/11 at 5:35 p.m., the facility removed the Immediate Jeopardy and the scope/severity was reduced to "G" when the following plan of removal was implemented: Employee named in the allegation of abuse was suspended immediately. Investigation of allegation of abuse on October 19, 2010, has been initiated immediately and a report will be filed with the Office of Long Term Care on April 12, 2011 by 11(:00 a.m.) All cognitive residents will be immediately interviewed for the possibility of abuse and neglect. Residents will be asked if anyone has been verbally, physically, mentally or sexually abusive to them. Also, will advise/remind residents to report any abuse to the Administrator / DON / nurse immediately. A body audit will be performed on all cognitively impaired residents and residents unable to communicate verbally to assess for the possibility of abuse and neglect. These residents will be assessed for any unusual bruising or any other unusual marks on their bodies. Any negative findings to be investigated immediately in accordance with facility policy and procedure for abuse and neglect. All nursing staff will be inserviced at the beginning of each shift, beginning on (A)pril 11, 2011 at 2(:00 p.m.) and will be ongoing, to include new hires and staff returning from leave. Training will take place before staff returns to work on the floor. Training will be done by DON / Designee and in-serviced with sign-in sheets being used. Training will include facility policy and procedure for abuse, neglect, and incidences before being allowed to return to work. Consultant for Corporate Office will inservice Administrator and sign her off on facility policy and procedure regarding abuse and neglect, reporting and investigating. Grievance logs, I&A (Incident and Accident) reports and 24 hr (hour) reports for the last 6 months will be reviewed for any possible un-investigated abuse and neglect. This will be completed by 6(:00 p.m.) on April 11, 2011. All of the body audits, interviews and in-services to be performed by Administrator / DON / Designee. Administrator / Designee will monitor all grievance logs / reports, I&A reports and 24 hr reports daily for compliance for suspected abuse. The Administrator will review all grievances to ensure compliance with Abuse policy and procedure.

Based on record review and interview, the facility failed to ensure the Abuse Prohibition policy and procedures were consistently implemented to protect Resident #12 from potential further abuse. The facility failed to ensure an allegation of abuse was immediately reported to the Administrator/Designee, was thoroughly investigated, residents were protected from potential further abuse and the allegation was reported to the local law enforcement and the Office of Long Term Care in accordance with state law for 1 (Resident #12) of 11 (Residents #2, #5 through #12, #15 and #16) case mix residents who were cognitively impaired. This failed practice resulted in Immediate Jeopardy that likely caused or could have caused serious harm for Resident #12, who alleged that Certified Nursing Assistant (CNA) #5 was physically abusive to him and had the potential to affect 60 residents who were cognitively impaired (of a total census of 89), according to the Roster Sample Matrix received from the Administrator on 4/9/11. The facility was informed of the Immediate Jeopardy condition on 4/11/11 at 2:00 p.m. The findings are: 1. The Facility Policy and Procedure entitled "Abuse, Neglect, Incidences" received from the Administrator on 4/9/11 documented: "Alleged or suspected abuse or neglect of residents,accidents, including accidents resulting in death, unusual deaths or deaths from violence. Unusual occurrences, and exploitation of residents or any misappropriation of resident property. Resident problem/concern/grievance. The staff reports to their immediate supervisor. Supervisor reports to Charge Nurse, Charge Nurse evaluates the situation, notifies the Administrator, DON (Director of Nurses), Police and family if applicable and the Physician ... Protection: During the investigation if there is alleged abuse/neglect all resident will be protected from harm. This can include, but not limited to: Emergency seclusion for the alleged perpetrator until the investigation is completed, but no longer than 24 hours, or one-on-one supervision for the alleged perpetrator... Investigation: All I/A's (Incident and Accidents) that pertain to allegations of abuse, neglect, and/or Misappropriation of Property will be investigated using the form developed by DHH (Department Health Services). During the investigation, staff members, residents, family members, and visitors will be interviewed, as applicable for the alleged incident. This information will be documented and placed with the incident report, will consist of at least information from the alleged perpetrator, if known. The Resident, if cognitively capable and the conclusion from the Administrator as to the findings. The Facility's investigating will be in conformance with the process and documentation requirements as set forth by OLTC (Office of Long Term Care) and will prevent further potential incidents while the investigation in progress. The DON (Director of Nursing) or her designee will continue to monitor I/A's daily and refer to QA (Quality Assurance) Team if applicable for further review... Reporting/Response, The following shall be reported to OLTC by fax of the completed form DMS-7734 no later than 11:00 a.m. on the next business day following discovery by the facility and the local authorities, if applicable, any alleged, suspected, or witnessed occurrences of abuse or neglect to resident, misappropriation of a resident by any individual... The results of all investigations will be reported to the Facility's Administration or designated representative, and to other officials in accordance with state law, including the OLTC within 5 working days of the facility's knowledge of the incident. If the alleged violation is verified, appropriate corrective action will be immediately taken. This Facility will report to the State CNA (Certified Nursing Assistant) registry or appropriated licensing board/authority, any knowledge it has of any actions by a Court of Law which would indicate any employee is unfit for service/employment..." 2. On 4/10/11 Group Interviewee #1 and Group Interviewee #4 both stated that they had witnessed a male Certified Nursing Assistant (CNA) in the dining room put a belt around a blind resident's neck and lead him back to the table. 3. Resident #12 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 2/3/11 documented the resident had highly impaired vision, had short/long-term memory problems with moderately impaired cognitive skills for daily decision making per staff assessment for mental status, scored a total score of 3 (1-4 indicates minimal depression) per staff assessment of resident mood, had highly impaired vision, required limited assistance of one person for transfers, required extensive assistance of one person for personal hygiene and used a wheelchair for mobility. a. The "Grievance/Complaint Report" dated 10/19/10 signed by the Admission Coordinator documented, "(Resident #12) said (CNA #5) roughly put him back in his chair. He (Resident #12) doesn't like being restrained. He (Resident #12) said (CNA #5) had his (Resident #12) military belt and he doesn't know how he (CNA #5) got it. He said he doesn't like (CNA #5) and (CNA) hits him in the head and on the shoulders and he (Resident #12) tells him to quit. He said (CNA) yells in his ears and doesn't like it. He wanted to talk to someone in the morning. Told Nurse, (LPN #7) (Resident #12) said, (LPN #7) said she seen what happened ...Documentation of Facility Follow-up: Admin (Administrator) and DON (Director of Nursing) did investigation with staff and other residents that was in DR (dining room) at the time of complaint, found to be untrue ...Resolution of Grievance/Complaint: Complaint was unfounded true, staff statement given. Pt (patient) has history of confusion." Another "Grievance/Complaint Report" dated 10/19/10 signed by the Admission Coordinator documented, "...(Resident #26) brought me (Admission Coordinator) a letter where he wrote down what had taken place in the dining room with (CNA #5) and (Resident #12). See attached note." The Attached Note documented, "(CNA #5) at supper time ingored (ignored) his duties and let (Resident #12) get out of his wheel chair and walk around in the dinning (dining) room in front (of) a lot of people. He then took a strap made a loop and through (threw) it around (Resident #12's) neck from the back all the while making jokes and playing around with (Resident #12) He rough(ed) him around mistreating him and then took him to his room. You can ask anyone in the room." The "Grievance QA (Quality Assurance) Log documented, "10/19/10 (Resident #26) reported that a CNA was ruff (rough) (with) a resident ...investigation done statement found untrue..." A witness statement dated 10/19/10 and signed by Licensed Practical Nurse (LPN) #7 documented, "While passing medications in the day room I saw (CNA #5) assist (Resident #12) who was standing up out of his w/c (wheel chair) (and) out of control by using a gait belt. The gait belt was used correctly." LPN #7 was no longer employed by the facility and was unavailable for interview during the survey. b. On 4/11/11 at 8:15 a.m., the Admission Coordinator was asked if CNA #5 was on duty the night of 10/19/10. The Admission Coordinator stated, "Almost positive he was." The Admission Coordinator was asked, "What did you do?" The Admission Coordinator stated, "I told the nurse." c. On 4/11/11 at 8:15 a.m., the Administrator was asked, "Did the Nurse notify you?" The Administrator stated, "No, I found out the next morning. We went and talked to (Resident #12) and he was so confused. He was going back in Vietnam something crawling under his bed and hearing gun shots, really, really confused." The Administrator was asked if they had investigated the allegation reported on the Grievance QA (Quality Assurance) Log on 10/19/10. The Administrator stated, "I did investigate, but we can't find it (documentation of investigation)." The Administrator stated, "The resident was confused." The Administrator was asked which residents were most likely to be abused. The Administrator stated, "Confused (residents)." The Administrator was asked what the facility protocol was for suspected abuse. The Administrator stated, "Investigate, suspend while investigating." The Administrator was asked, "Did you suspend (CNA #5)?" The Administrator stated, "I did an investigation, but I can't find it (documentation of investigation). d. On 4/11/11 at 8:20 a.m., Licensed Practical Nurse (LPN) #1, the CNA Supervisor, was asked if CNA #5 was suspended after the allegation made on 10/19/10. The LPN stated, "No, not at that time." The LPN was asked if CNA #5's signature was on the in-service for "Abuse, Neglect, Types of Abuse, Reporting Abuse, Who We Report Abuse To" dated 10/20/11. The LPN stated, "No." On 4/11/11 at 8:50 a.m., the Nurse Consultant was asked if CNA #5's name was on the in-service form for Abuse that was held on 10/20/10. The Nurse Consultant stated, "No." e. On 4/11/11 at 10:21 a.m., Resident #12 was interviewed regarding CNA #5. The Resident stated, "I have asked him (CNA #5) several times not to do it and he does it after I ask him not too. Taps me on my head, shoulder neck and back..." f. On 4/11/11 at 11:05 a.m., CNA #5 was asked if he had ever hit (Resident #12). The CNA stated, "I pat him on the back. I do it all the time in greeting." The CNA was asked if a resident had ever asked him not to? The CNA stated, "Maybe so." The CNA was asked, if he continued to pat the resident after being asked not to. The CNA stated, "Of course not, sometimes he (Resident #12) is jumpy so I don't do it. I don't take care of him. Occasionally I have to assist with him, been a while, can't remember exactly. The CNA was asked if he had ever popped up the wheelchair on the front or back wheels. The CNA stated, "No he (Resident #12) is pretty heavy." 4. On 4/11/11 at 5:35 p.m., the facility removed the Immediate Jeopardy and the scope/severity was reduced to "G" when the following plan of removal was implemented: Employee named in the allegation of abuse was suspended immediately. Investigation of allegation of abuse on October 19, 2010, has been initiated immediately and a report will be filed with the Office of Long Term Care on April 12, 2011 by 11(:00 a.m.) All cognitive residents will be immediately interviewed for the possibility of abuse and neglect. Residents will be asked if anyone has been verbally, physically, mentally or sexually abusive to them. Also, will advise/remind residents to report any abuse to the Administrator / DON / nurse immediately. A body audit will be performed on all cognitively impaired residents and residents unable to communicate verbally to assess for the possibility of abuse and neglect. These residents will be assessed for any unusual bruising or any other unusual marks on their bodies. Any negative findings to be investigated immediately in accordance with facility policy and procedure for abuse and neglect. All nursing staff will be inserviced at the beginning of each shift, beginning on (A)pril 11, 2011 at 2(:00 p.m.) and will be ongoing, to include new hires and staff returning from leave. Training will take place before staff returns to work on the floor. Training will be done by DON / Designee and in-serviced with sign-in sheets being used. Training will include facility policy and procedure for abuse, neglect, and incidences before being allowed to return to work. Consultant for Corporate Office will inservice Administrator and sign her off on facility policy and procedure regarding abuse and neglect, reporting and investigating. Grievance logs, I&A (Incident and Accident) reports and 24 hr (hour) reports for the last 6 months will be reviewed for any possible un-investigated abuse and neglect. This will be completed by 6(:00 p.m.) on April 11, 2011. All of the body audits, interviews and in-services to be performed by Administrator / DON / Designee. Administrator / Designee will monitor all grievance logs / reports, I&A reports and 24 hr reports daily for compliance for suspected abuse. The Administrator will review all grievances to ensure compliance with Abuse policy and procedure.

Based on record review and interview, the Facility Administration failed to ensure the facility was administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being for Resident #12 who alleged that CNA #5 was abusive to him. The facility Administration failed to ensure that an allegation of abuse was immediately reported to the Administrator/Designee, was thoroughly investigated, residents were protected from potential further abuse, and the allegation was reported to the local law enforcement and the Office of Long Term Care in accordance with state law for 1 (Resident #12) of 11 (Residents #2, #5 through #12, #15 and #16) case mix residents who were cognitively impaired. This failed practice resulted in Immediate Jeopardy that likely caused or could have caused serious harm for Resident #12, who alleged that Certified Nursing Assistant (CNA #5) was physically abusive to him and had the potential to affect 60 residents who were cognitively impaired (of a total census of 89), according to the Roster Sample Matrix received from the Administrator on 4/9/11. The facility was informed of the Immediate Jeopardy condition on 4/11/11 at 2:00 p.m. The findings are: 1. The Administrator Job Description received from the Director of Nursing (DON) on 4/13/11 documented: "Administrator, A. Summary: Supervises and manages the entire program of the (Facility's) Nursing Home. Responsibility: The welfare and safety of all residents, the building, the equipment and personnel, as well as for compliance with all pertinent rules and regulations. 2. On 4/10/11 Group Interviewee #1 and Group Interviewee #4 both stated that they had witnessed a male Certified Nursing Assistant (CNA) in the dining room put a belt around a blind resident's neck and lead him back to the table. 3. Resident #12 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 2/3/11 documented the resident had highly impaired vision, had short/long-term memory problems with moderately impaired cognitive skills for daily decision making per staff assessment for mental status, scored a total score of 3 (1-4 indicates minimal depression) per staff assessment of resident mood, had highly impaired vision, required limited assistance of one person for transfers, required extensive assistance of one person for personal hygiene and used a wheelchair for mobility. a. The "Grievance/Complaint Report" dated 10/19/10 signed by the Admission Coordinator documented, "(Resident #12) said (CNA #5) roughly put him back in his chair. He (Resident #12) doesn't like being restrained. He (Resident #12) said (CNA #5) had his (Resident #12) military belt and he doesn't know how he (CNA #5) got it. He said he doesn't like (CNA #5) and (CNA) hits him in the head and on the shoulders and he (Resident #12) tells him to quit. He said (CNA) yells in his ears and doesn't like it. He wanted to talk to someone in the morning. Told Nurse, (LPN #7) (Resident #12) said, (LPN #7) said she seen what happened ...Documentation of Facility Follow-up: Admin (Administrator) and DON (Director of Nursing) did investigation with staff and other residents that was in DR (dining room) at the time of complaint, found to be untrue ...Resolution of Grievance/Complaint: Complaint was unfounded true, staff statement given. Pt (patient) has history of confusion." Another "Grievance/Complaint Report" dated 10/19/10 signed by the Admission Coordinator documented, "...(Resident #26) brought me (Admission Coordinator) a letter where he wrote down what had taken place in the dining room with (CNA #5) and (Resident #12). See attached note." The Attached Note documented, "(CNA #5) at supper time ingored (ignored) his duties and let (Resident #12) get out of his wheel chair and walk around in the dinning (dining) room in front (of) a lot of people. He then took a strap made a loop and through (threw) it around (Resident #12's) neck from the back all the while making jokes and playing around with (Resident #12) He rough(ed) him around mistreating him and then took him to his room. You can ask anyone in the room." The "Grievance QA (Quality Assurance) Log documented, "10/19/10 (Resident #26) reported that a CNA was ruff (rough) (with) a resident ...investigation done statement found untrue..." A witness statement dated 10/19/10 and signed by Licensed Practical Nurse (LPN) #7 documented, "While passing medications in the day room I saw (CNA #5) assist (Resident #12) who was standing up out of his w/c (wheel chair) (and) out of control by using a gait belt. The gait belt was used correctly." LPN #7 was no longer employed by the facility and was unavailable for interview during the survey. b. On 4/11/11 at 8:15 a.m., the Admission Coordinator was asked if CNA #5 was on duty the night of 10/19/10. The Admission Coordinator stated, "Almost positive he was." The Admission Coordinator was asked, "What did you do?" The Admission Coordinator stated, "I told the nurse." c. On 4/11/11 at 8:15 a.m., the Administrator was asked, "Did the Nurse notify you?" The Administrator stated, "No, I found out the next morning. We went and talked to (Resident #12) and he was so confused. He was going back in Vietnam something crawling under his bed and hearing gun shots, really, really confused." The Administrator was asked if they had investigated the allegation reported on the Grievance QA (Quality Assurance) Log on 10/19/10. The Administrator stated, "I did investigate, but we can't find it (documentation of investigation)." The Administrator stated, "The resident was confused." The Administrator was asked which residents were most likely to be abused. The Administrator stated, "Confused (residents)." The Administrator was asked what the facility protocol was for suspected abuse. The Administrator stated, "Investigate, suspend while investigating." The Administrator was asked, "Did you suspend (CNA #5)?" The Administrator stated, "I did an investigation, but I can't find it (documentation of investigation)." d. On 4/11/11 at 8:20 a.m., Licensed Practical Nurse (LPN) #1, the CNA Supervisor, was asked if CNA #5 was suspended after the allegation made on 10/19/10. The LPN stated, "No, not at that time." The LPN was asked if CNA #5's signature was on the in-service for "Abuse, Neglect, Types of Abuse, Reporting Abuse, Who We Report Abuse To" dated 10/20/11. The LPN stated, "No." On 4/11/11 at 8:50 a.m., the Nurse Consultant was asked if CNA #5's name was on the in-service form for Abuse that was held on 10/20/10. The Nurse Consultant stated, "No." e. On 4/11/11 at 10:21 a.m., Resident #12 was interviewed regarding CNA #5. The Resident stated, "I have asked him (CNA #5) several times not to do it and he does it after I ask him not too. Taps me on my head, shoulder neck and back..." f. On 4/11/11 at 11:05 a.m., CNA #5 was asked if he had ever hit (Resident #12). The CNA stated, "I pat him on the back. I do it all the time in greeting." The CNA was asked if a resident had ever asked him not to? The CNA stated, "Maybe so." The CNA was asked, if he continued to pat the resident after being asked not to. The CNA stated, "Of course not, sometimes he (Resident #12) is jumpy so I don't do it. I don't take care of him. Occasionally I have to assist with him, been a while, can't remember exactly. The CNA was asked if he had ever popped up the wheelchair on the front or back wheels. The CNA stated, "No he (Resident #12) is pretty heavy." 4. On 4/11/11 at 5:40 p.m., the facility removed the Immediate Jeopardy and the scope/severity was reduced to "G" when the following plan of removal was implemented: Employee named in the allegation of abuse was suspended immediately. Investigation of allegation of abuse on October 19, 2010, has been initiated immediately and a report will be filed with the Office of Long Term Care on April 12, 2011 by 11(:00 a.m.) All cognitive residents will be immediately interviewed for the possibility of abuse and neglect. Residents will be asked if anyone has been verbally, physically, mentally or sexually abusive to them. Also, will advise/remind residents to report any abuse to the Administrator / DON / nurse immediately. A body audit will be performed on all cognitively impaired residents and residents unable to communicate verbally to assess for the possibility of abuse and neglect. These residents will be assessed for any unusual bruising or any other unusual marks on their bodies. Any negative findings to be investigated immediately in accordance with facility policy and procedure for abuse and neglect. All nursing staff will be inserviced at the beginning of each shift, beginning on (A)pril 11, 2011 at 2(:00 p.m.) and will be ongoing, to include new hires and staff returning from leave. Training will take place before staff returns to work on the floor. Training will be done by DON / Designee and in-serviced with sign-in sheets being used. Training will include facility policy and procedure for abuse, neglect, and incidences before being allowed to return to work. Consultant for Corporate Office will inservice Administrator and sign her off on facility policy and procedure regarding abuse and neglect, reporting and investigating. Grievance logs, I&A (Incident and Accident) reports and 24 hr (hour) reports for the last 6 months will be reviewed for any possible un-investigated abuse and neglect. This will be completed by 6(:00 p.m.) on April 11, 2011. All of the body audits, interviews and in-services to be performed by Administrator / DON / Designee. Administrator / Designee will monitor all grievance logs / reports, I&A reports and 24 hr reports daily for compliance for suspected abuse. The Administrator will review all grievances to ensure compliance with Abuse policy and procedure.