Cottage Lane Health And Rehab Of Little Rock

F-F600 at a lower severity:

A facility policy titled, PP Abuse Prevention indicated To provide a safe environment for all residents free of abuse.

An Admission Record indicated the facility admitted Resident #3 with schizoaffective disorder.

The Admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/25/2024 revealed Resident #3 had a Brief Interview for Mental Status (BIMS) score of 7 which indicated the resident had significant cognitive impairment.

Review of Resident #3 Care Plan, initiated 10/23/2024, revealed the resident at risk for alteration psychosocial wellbeing related to living in skilled facility for long term care. No interventions in place at the time of review.

An OLTC Incident and Accident Report (I&A) dated 12/18/2024 revealed LPN #2 stated that CNA #1 confirmed that they popped the resident on the butt trying to get her to go the bathroom. LPN #2 revealed that they heard ouch with each of four swats. LPN #2 stated from the sound, it was not a clap that was heard. A witness statement from LPN #2 was included and read, This nurse was sitting at nurse ' s station . when [Resident #3] was screaming ouch, ouch from the swats from aide [CNA #1] x4 times. This nurse then asked aide if she hit resident. She [CNA #1] stated, No I was popping her on the butt.

During interview on 12/30/2024 at 1:50pm, Resident #3 stated that they (indicating CNA #1) hit me on the butt and I hit them back first.

During an interview on 12/30/2024 at 2:01pm, Human Resources (HR) stated CNA #1 was no longer with us.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 5 of 10 045458 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 045458 B. Wing 01/08/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Cottage Lane Health and Rehab of Little Rock 800 Brookside Drive Little Rock, AR 72205

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0600 During an interview on 12/30/2024 at 8:18am, LPN #2 indicated that CNA #1 wasn't very welcoming with the residents. LPN #2 noticed that CNA #1 didn't like to repeat herself. LPN #2 reported sitting at nurses station, Level of Harm - Immediate when CNA #1 went into Resident #3 room, then heard loud smacking sounds and CNA #1 saying, Get up jeopardy to resident health or and go to the bathroom. LPN #2 heard Resident #3 say ow, ow, ow with each hit. LPN#1 got the wound care safety nurse and informed CNA #1 that they had to leave. LPN#2 verbalized that they did not see Resident #3 being struck but heard her being struck. Residents Affected - Few

During an interview on 12/31/2024 at 9:24am, CNA #1 said they clapped their hands like it was time to get up, stating that Resident #3 and CNA #1 had a good relationship. CNA #1 pulled covers back, patted them

on their booty, and told Resident #3 time to get up and go to the bathroom, to which Resident #3 told the CNA to not do that. CNA #1 then took care of other resident in room. LPN #2 asked if they had hit Resident #3, to which CNA #1 stated, No I clapped my hands like I always do, I don't hit residents.

During an interview on 12/31/2024 at 11:52am, the DON stated that they were reported to by LPN #2 regarding the incident. A full body assessment and body audit was done on Resident #3 and their roommate

during that time. The DON reported the incident to the Administrator, provider, and family. I heard from LPN #2 loud [NAME] were heard at the nurses station. LPN #2 asked if CNA #1 hit Resident #3 and that CNA #1 stated that they clapped her hand but patted her buttocks.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 6 of 10 045458 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 045458 B. Wing 01/08/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Cottage Lane Health and Rehab of Little Rock 800 Brookside Drive Little Rock, AR 72205

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0609 Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Level of Harm - Minimal harm or potential for actual harm 51477

Residents Affected - Few Based on interview, record review, and facility policy review, it was determined the facility failed to report an alleged violation involving abuse to the proper state agency within the allotted time frame for 1 (Resident #3) of 1 sampled resident reviewed for abuse allegations.

The findings are:

Review of a facility policy titled Prevention and Prohibition of Abuse indicated The facility administrator or designee shall complete a report to be made to the mandated state agency and may also be made to the local law enforcement agency after corporate approval or immediately if the abuse constitutes an emergency. Administrator or designee will have 5 working days from the initial report of abuse to complete SIMS (Statewide Incident Management System) report. Immediately means as soon as possible, in the absence of a shorter State time frame requirement, but not later than 2 hours after the allegation is made, if

the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury.

A review of an Admission Record indicated the facility admitted Resident #3 with a diagnosis of schizoaffective disorder (combination of symptoms that affect a person's emotional state and a disorder that affects a person's ability to think, feel, and behave clearly).

A review of the admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/25/2024, revealed Resident #3 had a Brief Interview for Mental Status (BIMS) score of 07, which indicated the resident had severe cognitive impairment.

A review of Resident #3 ' s Reportable, dated 12/18/2024, indicated Nurse was at nurse ' s station and heard

a popping noise that they thought was a slap. Upon entering the resident's room, Certified Nursing Assistant (CNA) #1 was getting resident up to go use the bathroom. Licensed Practical Nurse (LPN) #2 asked CNA #1 if they hit the resident. CNA #1 answered back that she ' popped resident on the butt with the back of the hand ' trying to get her to go to the bathroom. LPN #2 dismissed CNA #1 from the room, assessment of resident completed with no negative findings. Resident stable with no distress noted. CNA #1 immediately suspended with investigation started.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 10 045458 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 045458 B. Wing 01/08/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Cottage Lane Health and Rehab of Little Rock 800 Brookside Drive Little Rock, AR 72205

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0609 During an interview with the Administrator on 12/31/2024 at 12:05pm, the Administrator was familiar with Resident #3 ' s care and confirmed knowledge of alleged abuse on 12/18/2024. The Director of Nurses Level of Harm - Minimal harm or (DON) notified the Administrator of the alleged abuse. The Administrator confirmed the incident and accident potential for actual harm was on 12/18/2024 at 6:00AM but notification was sent in on 12/19/2024 at 10:58AM. A body audit and assessment of Resident was completed, and the employee was suspended. The Administrator confirmed a Residents Affected - Few representative and the attending practitioner were both notified. The Administrator confirmed the abuse was reported to the Office of Long-Term Care. The Administrator confirmed that an investigation had been completed and was awaiting notice from the Office of Long-Term Care. The Administrator confirmed the employee was suspended and removed from facility for their actions and to protect the alleged victim from further abuse during the investigation process. The results of the investigation were founded, and the staff member was terminated. The Administrator revealed there were no warning signs to facility to indicate prior to the incident and the facility tried to send in the reportable within a timely manner but had difficulty.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 10 045458 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 045458 B. Wing 01/08/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Cottage Lane Health and Rehab of Little Rock 800 Brookside Drive Little Rock, AR 72205

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 48390

Residents Affected - Few Based on interview, record review, and policy review, the facility failed to develop a comprehensive care plan for one (Resident #5) of one resident reviewed for care plans, specifically that a resident ' s post-traumatic stress disorder diagnosis was addressed in the resident ' s care plan.

The findings are:

Resident #5 had diagnoses including schizoaffective disorder bipolar type, nightmare disorder, post-traumatic stress disorder, and type 2 diabetes mellitus without complications.

A review of the significant change in status Minimum Data Set (MDS) with an assessment reference date (ARD) of 12/04/2024, revealed the resident received a score of 1 (severely impaired) on the Brief Interview for Mental Status (BIMS). The resident required moderate assistance with bed mobility and transfers. The resident required substantial assistance with personal hygiene and dressing.

A review of Resident # 5's care plan, initiated on 02/13/2023, revealed the resident had an Activity of Daily Living (ADL) self-care performance deficit with poor safety awareness: interventions included the resident could perform most ADL functions with 1 person assist; had the potential to be physically aggressive related to dementia and schizoaffective disorder, was aggressive and hit at other residents on 12/20/2024: interventions included When the resident becomes agitated: intervene before agitation escalates; If response is aggressive, staff to walk calmly away and approach later. Resident #5 has a diagnosis of Post-Traumatic Stress Disorder, and a review of the care plan did not address this diagnosis.

A review of Resident #5 ' s Admission Record indicated that the resident was admitted to the facility on [DATE REDACTED] with diagnoses of schizoaffective disorder bipolar type, post-traumatic stress disorder, nightmare disorder, and pseudobulbar affect (a condition characterized by episodes of sudden uncontrollable and inappropriate laughing or crying).

On 01/03/2025 at 2:42 PM, Licensed Practical Nurse (LPN) #13 was asked who was responsible for completing resident care plans. LPN #13 indicated that she was responsible for completing the care plans. LPN #13 was asked if the care plan should address the goals, preferences, needs and strengths of Resident #5. LPN #13 indicated that it should. LPN #13 was asked what Resident #5's mental health diagnoses were. LPN #13 indicated schizoaffective, major depressive disorder (MDD), dementia, and pseudobulbar affect (a condition characterized by episodes of sudden uncontrollable and inappropriate laughing or crying). LPN #13 was asked how active diagnoses are identified for the care plan. LPN #13 indicated the physician would give

the orders on medications they [physician] let us know the diagnoses, upon admission with their paperwork and any physician they see and diagnosis they coordinate with us [facility]. LPN #13 was asked if the care plan described corresponding interventions for care that account for Resident #5's experiences and preferences to eliminate or mitigate triggers that may cause re-traumatization's? LPN #13 indicated that would be a question for the physician.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 10 045458 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 045458 B. Wing 01/08/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Cottage Lane Health and Rehab of Little Rock 800 Brookside Drive Little Rock, AR 72205

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 On 01/03/2025 at 3:01 PM, the Director of Nursing (DON) was asked who was responsible for completing

the care plans. The DON indicated LPN #13. The DON was asked how the active diagnoses are identified Level of Harm - Minimal harm or for the care plan. The DON indicated you look in the care plan. potential for actual harm

On 01/03/2025 at 3:12 PM, the Administrator was asked why it was important for the care plan to reflect Residents Affected - Few Resident #5's goals, preferences, needs, strengths and interventions for care.

The Administrator indicated so staff would know and understand how to provide proper care for the resident.

The Administrator was asked what the policy and procedure for completing the care plan was. The Administrator indicated it meets their needs assessment in the time frame and completed upon admission within 48 hours and person-centered care based on RAI, reviewed with resident Inter-Disciplinary Team (IDT) team and responsible party and updated quarterly and as needed.

A review of the facility's undated policy titled Care Plan Policy and Procedure, provided by the Administrator

on 01/03/2025, indicated Each resident's care plan will remain current and inform staff of resident's needs, strengths, goals, and approaches It is the policy of this facility to utilize an advanced care planning approach to review and determine patient centered care plans.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 10 045458