Every finding on record at Accordius Health at Rose Manor LLC

Based on observation, record review, staff, resident and Nurse Practitioner interviews, the facility failed to safely transfer a resident from his wheelchair to his bed with the use of a mechanical lift. The unsafe transfer resulted in a residents fall with injuries that included headache, arm pain, neck pain and a cut to his cheek. The resident was transported to the emergency department (ED) on 8/14/26 where he had a laceration repair to his left cheek that required 4 sutures/stitches. This was reviewed for 1 of 3 residents (Resident #48) reviewed for supervision to prevent accidents. The findings included:Resident #48 was admitted to the facility on [DATE] with a diagnosis that included Quadriplegia, stiff-man syndrome, bilateral hand contractures and need for assistance with personal care.Resident #48's care plan dated 4/30/26 revealed he had an activity of daily living (ADL) self-performance deficit. The goal stated Resident #48 would improve function in ADL's. The interventions were revised 8/7/26 and included total mechanical lift for all transfers with 2 staff for safety. Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #48 was cognitively intact. Resident #48 was dependent on staff for chair to bed mobility and had 2 upper and 2 lower extremity impairments. Nurse progress note written by Nurse #6, dated 8/14/26 stated a nursing assistant (NA) informed her Resident #48 slid from his wheelchair to the floor. There was a laceration observed to Resident #48's left cheek. Pressure was applied and the bleeding was controlled. The note continued with Resident #48 denied pain and no other injuries were noted. Resident #48 was able to move all his extremities at his baseline, and neurological checks were initiated. The progress note stated Resident #48 was assisted back to his bed with a mechanical lift by 2 staff. The Director of Nursing (DON) and Nurse Practitioner were notified. Orders were received to transfer Resident #48 to the emergency room (ER) for further evaluation and treatment. Review of incident accident report dated 8/14/26 stated Resident #48 slid from the mechanical lift pad to the floor during a transfer from his wheelchair to his bed. Resident #48's description stated he fell during transfer from his wheelchair to his bed. The immediate action taken revealed Resident #48 was assessed for injury and was noted to have a laceration to the left side of his face. The report further indicated pressure dressing was applied to the laceration, the bleeding stopped and no further injuries were noted. Resident #48 was assisted to bed with the use of a mechanical lift and orders were obtained to send Resident #48 to the ER for revaluation. The report was completed by Nurse #6. Nurse Practitioner note dated 8/14/26 indicated Resident #48 had a laceration to his left cheek. Pressure dressing was applied and the bleeding was controlled. Resident #48 denied pain at the time of the assessment. The note revealed an order to transfer Resident #48 to the ER.Review of emergency department provider note dated 8/14/26 revealed Resident #48 presented to the ER for evaluation following a fall. Just prior to arrival, Resident #48 was being lifted in a mechanical lift and was not properly secured. Resident #48 slid out of the lift and fell face first onto the ground. Resident #48 estimated he was about 4 feet off the ground. Resident #48 also landed on the left side of his face. He sustained a laceration to the left cheek and was experiencing headache and pain in the left arm. Resident #48 also felt a little sore, but he denied significant neck pain. The physical exam stated +2 centimeters (cm) laceration to his left cheek with no facial bone tenderness. Resident #48 had a computed tomography (CT) scan of the brain and C spine (medical imaging test that uses a combination of x-rays and computer processing to create detailed, cross -sectional pictures of the inside of the body) and would require laceration repair. The clinical impression stated acute post-traumatic headache and neck pain. The emergency department note did not indicate how many sutures/stiches Resident #48 received to repair the laceration to his left cheek.Review of nurse progress note dated 8/15/16 stated Resident #48 returned from the ER at 11:30PM with stiches/sutures to his left check laceration. The note further stated Resident #48 would continue to be monitored for safety and comfort.Resident #48 was interviewed on 8/24/26 at 2:36PM. Resident #48 revealed he fell from the mechanical lift about a week and half ago but could not recall the date. He stated he recalled being transferred by NA #3 without assistance from another staff member around 7:00PM. Resident #48 indicated he was being transferred from his wheelchair to his bed by NA #3. Resident #48 could not state exactly how NA #3 hooked the lift pad/sling, but NA #3 had incorrectly hooked the lift pad/sling to the mechanical lift and used the wrong mechanical lift. Resident #48 indicated he had not told NA #3 to stop, or he felt as though NA #3 was using the mechanical lift wrong. Resident #48 revealed as NA #3 was operating the mechanical lift and raising him, Resident #48 was dunked from the lift pad/sling headfirst on the mechanical lift. Resident #48 could not recall the height from which he fell. Resident #48 was sent to the ER where he received 4 stitches. Resident indicated he was told NA #3 was recently ill and NA #3 was terminated following the incident. Resident #48 stated before the incident there were 2 staff present when the mechanical lift was in use. Resident #48 stated he considered transferring to another facility following the incident because he did not feel safe when being transferred by mechanical lift. Resident #48 was observed to have a small, closed, healing scar on his left cheek below his eye during the interview. The scar was about 3 cm in length. Interview with NA #2 on 8/25/26 at 1:54PM revealed Resident #48 was totally dependent on staff to perform transfers by use of mechanical lift. NA #2 stated the facility policy indicated 2 staff were always needed when operating a mechanical lift. She further revealed she was not present during the fall but recalled the incident on 8/14/26 where Resident #48 had a fall from the mechanical lift. NA #2 indicated she recalled hearing a commotion in the hallway, so she followed staff to the location which was Resident #48's bedroom. She revealed when she arrived at Resident #48's bedroom he was observed on the floor lying on his left side. She recalled Nurse #6 and NA #3 were present when she arrived at the room. NA #2 observed blood that appeared to be coming from Resident #48's left cheek. The laceration appeared to be about 3cm in length. She further indicated NA #3 was assigned to Resident #48. She was unsure if NA #3 had any other staff present during the transfer but had overheard that he had used the mechanical lift to transfer Resident #48 by himself. NA #2 could not recall if the mechanical lift pad/sling was still attached to the lift when she entered the room, but the lift was observed to be raised about 4 inches off of the ground. NA #2 revealed she was not sure why NA #3 had not asked for assistance because she recalled the facility being well staffed 8/14/26. Interview with NA #4 was conducted on 8/25/26 at 3:02PM. She indicated she was assigned to work 2nd shift on 8/14/26. She stated she had not witnessed Resident #48's fall but Resident #48 was put on her assignment following the incident. Resident was noted to have a bandage to his left cheek, so the laceration was not visible. She recalled notifying the nurse there was a scant amount of blood coming through the bandage to Resident #48's left cheek. Resident #48 told NA #4 he had fallen from the mechanical lift because the lift pad had not been hooked to the mechanical lift correctly. NA #4 stated the facility had 2 types of lifts but regardless of the lift, 2 staff had to present to operate the mechanical lift. Resident #48 required total assistance with ADL's and used a mechanical lift for his transfers. She recalled the facility being well staffed prior to the incident and she had not had an issue with locating assistance for mechanical lift transfers. Resident #48 was transferred to the ED for evaluation shortly after he was put on her assignment.During an interview with NA #3 on 8/25/26 at 3:39PM, NA #3 stated he was previously ill which resulted in hospitalization in December 2025. When he was able to return to work, the facility had assigned him to provide one-on-one assistance. When the resident no longer required one-on-one, he was given an actual assignment which included Resident #48. NA #3 stated on 8/14/26 he recalled Resident #48 being in his wheelchair and wanting to be transferred to his bed. NA #3 stated he recalled around 3:30PM or 4:00PM he looked down the hallway but could not find anyone to assist him. After he could not locate a staff member, he obtained a lift from the hallway. NA #3 indicated the facility had 2 different types of mechanical lifts, but he did not recall which mechanical lift or lift pad he used. He estimated he raised Resident #48 up about 2 inches from the wheelchair with the mechanical lift and stated, everything went black. NA #3 further stated, my brain went off. NA #3 stated, when I came too, he (Resident #48) was on the floor. Following the incident he was told by an NA (name unknown) the lift he used required the lift pad to be crossed. NA #3 stated he was feeling ill that day and did not recall if the mechanical lift pad was connected to the mechanical lift following the fall and could not recall how he connected the lift pad/sling to the mechanical lift. NA #3 did recall the lift pad not being low enough below Resident #48's knees while he was in the lift pad. When NA #3 came was more alert, he stated Resident #48 had blood to the left side of his jaw. NA #3 stated he recalled notifying Nurse #6 who assessed Resident #48 for injuries. During the interview, NA #3 continued to state he just didn't feel well 8/14/26 and his brain was glitching. NA #3 stated he received training from the facility before being put on the schedule and knew he should not have used the mechanical lift without another staff person for the purpose of spotting him. NA #3 revealed he was told to go home, and he was not fit to perform the duties needed for care. He was not asked to conduct a return demonstration prior to his exit.An interview with Nurse #6 was conducted on 8/25/26 at 4:00PM. She indicated she was assigned to the 2nd shift (3:00PM through 11:00PM) on 8/14/26 and recalled being approached by NA #3 about 4:00PM. Nurse #6 indicated, NA #3 was hard to understand due to his accent, but she assumed he told her Resident #48 had fallen from either the lift or his wheelchair. She stated when she arrived at Resident #48's bedroom, she observed him on the floor, lying on left side. Resident #48 had a small amount of blood that was coming from a cut to his upper left cheek that was estimated 3cm in length. Nurse #6 stated while she was cleaning the cut to Resident #48's upper cheek, she identified the cut to be deep, so she contacted the Nurse Practitioner who gave orders to send Resident #48 to the ER for evaluation. Nurse #5 had also come into Resident #48's room to provide Nurse #6 assistance with obtaining supplies for bandaging Resident #48's cut. The lift pad used to transfer Resident #48 was observed in his wheelchair, but she was unsure if NA #3 had placed it there or if landed during the fall. Nurse #1 did not request NA #3 complete a return demonstration, so she was unaware of what steps were or were not completed before NA #2 used the mechanical lift. She also did not recall which lift pad was used because her main objective was to ensure Resident #48 was assessed and emergency services was contacted. At the time of the incident, she was unaware if NA #3 transferred Resident #48 without the assistance of another staff member.Interview with Nurse #5 on 8/26/26 at 10:40AM revealed when Resident #48 fell from the mechanical lift she was just getting off first shift. She indicated when she arrived to Resident #48's bedroom she saw Nurse #1 was already assessing the residents' injuries. She further stated she noticed Resident #48 had a small cut to his left cheek, but she could not estimate the length of the cut. All staff were trained and aware mechanical lift required 2 staff people. The DON was interviewed on 8/26/26 at 11:14AM. She stated all nursing staff were trained prior to employment that 2 people were to always be present when a mechanical lift was used. She further stated after his medical leave, NA #3 received training prior to being brought back to an assignment which included mechanical lift transfers on 8/13/26. The DON revealed she was approached by the Assistant Director of Nursing (ADON) that Resident #48 had a fall from the mechanical lift. The ADON told the DON, NA #3 had used the mechanical lift to transfer Resident #48 without another staff present. Resident #48 sustained a cut to his cheek that was estimated at about 2cm to 3cm in length. The DON stated she instructed the ADON to immediately send NA #3 home. She stated she was unsure if NA #3 was asked to complete a demonstration before he was sent home. The DON revealed she was unsure if the lift pad was connected incorrectly or if the lift was used incorrectly because there were no witnesses to the incident. The lift pad was assessed by ADON who indicated had no damage. NA #3 was later interviewed about why he did not get assistance from another staff member before it was used. NA #3 stated he did know why he used the lift by himself and he had a brain glitch. Interview with the ADON on 8/27/26 at 10:22AM revealed she was in the facility, in her office on 8/14/26 when she was approached by Nurse #6 at about 4:00PM or 4:15PM. Nurse #6 told the ADON, Resident #48 had fallen and had an injury. She stated when she arrived at Resident #48's bedroom, she observed him to be lying on his left side on the floor. Resident #48 had a small cut to his left cheek. The cut was c in shape, was about 2 to 3 cm in length. When Resident #48 fell from the mechanical lift. She stated she was so focused on providing Resident #48 care she was unsure where the lift pad was in proximity to the resident or the mechanical lift. The ADON revealed when she asked NA #3 what happened he stated Resident #48 fell. She contacted the DON to notify her of the fall and was notified to send NA #3 home immediately, so she did have NA #3 complete a demonstration of how the mechanical lift or lift pad/sling was used. The ADON stated she assisted Nurse #6 with transferring Resident #48 back into bed with the mechanical lift but could not recall which mechanical lift was used. She further stated before she and Nurse #6 transferred Resident #48 back to bed, she assessed the lift pad and the mechanical lift. The facility used 2 different types of use which all staff had been trained to use prior to employment. Following the incident, the ADON stated she asked NA #3 why he didn't wait for a spotter before using the mechanical lift, NA #3 stated everyone was busy. An interview was conducted with the Nurse Practitioner on 8/26/26 at 11:30AM. The Nurse Practitioner stated she recalled being notified that Resident #48 had a fall but could not recall if was from his bed or from his wheelchair. She stated she notified nursing staff to send Resident #48 to the ER for evaluation due to falling from a height (unknown) and hitting his head. Interview with the Administrator on 8/27/26 at 2:43PM revealed he was contacted by the DON on Friday (8/14/26) notifying him there was a mechanical lift incident and Resident #48 was being sent to the hospital. Resident #48 had a cut to left side of his face, and the incident was only observed by NA #3. He further indicated he was told NA #3 was transferring resident without a second staff and he was immediately suspended. As a result of fall, Resident #48 received 4 stiches to his left cheek and was transported back to the facility by ambulance within 24 hours. The Administrator revealed he interviewed Resident #48 following the incident and was told by Resident #48 he was sitting in lift sling and the next thing he knew he was on the floor. The Administrator further revealed he interviewed NA #3 who stated he had a brain glitch and did not know why he transferred Resident #48 with the mechanical lift without additional staff assistance. The facility submitted a draft plan of correction for past non-compliance consideration. The plan of correction was not accepted by the state as it did not address staff handling serious resident care equipment while ill.

Based on record review, resident, resident representative, and staff interviews, the facility failed to document and provide written information to residents/representatives regarding their right to refuse medical/surgical treatment or to formulate an advance directive (a legal document that states a person's wishes about receiving medical care if that person is no longer able to make medical decisions because of a serious illness or injury) for 13 of 14 residents reviewed for advance directives (Residents #1, #2, #4, #6, #7, #8, #10, #11, #13, #25, #43, #80, and #85). Findings included: a. Resident #25 was admitted to the facility on [DATE]. Resident #25 had a Full Code physician order dated [DATE]. An annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #25 was cognitively intact. An interview was conducted with Resident #25 on [DATE] at 3:34 PM. Resident #25 stated that he recalled discussing advance directives but did not receive written education regarding advance directives. There was no documentation in Resident #25's medical record for education regarding formulation of advance directives and/or an opportunity to formulate advance directives was offered. b. Resident #4 was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #4 had a Full Code physician order dated [DATE]. A quarterly MDS assessment dated [DATE] revealed Resident #4 was severely cognitively impaired. During an interview with Resident #4's Resident Representative (RR) on [DATE] at 6:22 PM she did not recall discussing advance directives and did not receive any written documentation regarding advance directives. There was no documentation in Resident #4's medical record for education regarding formulation of advance directives and/or an opportunity to formulate advance directives was offered. c. Resident #2 was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #2 had a Full Code physician order dated [DATE]. An admission MDS assessment dated [DATE] revealed Resident #2 was cognitively intact. An interview was conducted with Resident #2 on [DATE] at 3:40 PM. Resident #2 stated that he did not recall discussing advance directives and did not receive written education regarding advance directives. There was no documentation in Resident #2's medical record for education regarding formulation of an advance directive and/or an opportunity to formulate an advance directive was offered. d. Resident #13 was admitted to the facility on [DATE]. Resident #13 had a do not resuscitate (DNR; an official medical order telling healthcare providers not to perform CPR if a person's heart or breathing stops) physician order dated [DATE]. A quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #13 was severely cognitively impaired. There was no documentation in Resident #13's medical record for education regarding formulation of advance directives and/or an opportunity to formulate advance directives was offered. Attempts to contact Resident #13's Resident Representative (RR) were unsuccessful. e. Resident #80 was admitted to the facility on [DATE]. Resident #80 had a Full Code physician order dated [DATE]. A quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #80 was severely cognitively impaired. There was no documentation in Resident #80's medical record for education regarding formulation of advance directives and/or an opportunity to formulate advance directives was offered. Attempts to contact Resident #80's RR were unsuccessful. f. Resident #7 was admitted to the facility on [DATE]. Resident #7 had a Full Code physician order dated [DATE]. A quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #6 was assessed as being cognitively intact. During an interview with Resident #7 on [DATE] at 9:58 AM she stated that she did not recall receiving written education regarding advance directives or any discussion regarding advance directives. There was no documentation in Resident #6's medical record for education regarding formulation of advance directives and/or an opportunity to formulate advance directives was offered. g. Resident #43 was admitted to the facility on [DATE]. Resident #43 had a Full Code physician order dated [DATE]. A quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #43 was assessed as being cognitively intact. During an interview with Resident #43 on [DATE] at 11:08 AM she stated was not aware of her code status and stated she would like to be full code. She further stated she could not recall any discussions or code status and stated she had not received any written education regarding advance directives. There was no documentation in Resident #43's medical record for education regarding formulation of advance directives and/or an opportunity to formulate advance directives was offered. h. Resident #10 was admitted to the facility on [DATE]. Resident #10 had a Full Code physician order dated [DATE]. A quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #10 was assessed as being cognitively intact. During an interview with Resident #10 on [DATE] at 11:07 AM she stated that she did not recall receiving written education regarding advance directives. There was no documentation in Resident #10's medical record for education regarding formulation of advance directives and/or an opportunity to formulate advance directives was offered. i. Resident #1 was admitted to the facility on [DATE]. Resident #1 had advanced directives to not resuscitate (DNR) dated [DATE]. An admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 had moderate cognitive impairment. There was no documentation in Resident #1's medical record that education regarding formulation of advanced directives and/or an opportunity to formulate advanced directives were offered. An interview was conducted with Resident #1 on [DATE] at 11:03 AM. Resident #1 stated she recalled discussing advanced directives but did not receive written education regarding advanced directives. j. Resident #8 was admitted to the facility on [DATE]. Resident #8 had a physician order dated [DATE] that stated FULL CODE. An admission MDS assessment dated [DATE] revealed Resident #8 was cognitively intact. There was no documentation in Resident #8's medical record that education regarding formulation of advanced directives and/or an opportunity to formulate advanced directives were offered. An interview was conducted with Resident #8 on [DATE] at 2:03 PM. Resident #8 stated she recalled discussing advanced directives but did not receive written education regarding advanced directives. k. Resident #11 was admitted to the facility on [DATE]. Physician order dated [DATE] revealed Resident #11 was a FULL CODE. An admission MDS assessment dated [DATE] revealed Resident #11 had moderate cognitive impairment. There was no documentation in Resident #11's medical record that education regarding formulation of advanced directives and/or an opportunity to formulate advanced directives were offered. An interview was conducted with Resident #11 on [DATE] at 1:06 PM. Resident #11 stated he did not recall receiving written education regarding advanced directives. l. Resident #85 was admitted to the facility on [DATE]. Resident #85's physician order dated [DATE] indicated FULL CODE. An admission MDS assessment dated [DATE] revealed Resident #85 was cognitively intact. There was no documentation in Resident #85's medical record that education regarding formulation of advanced directives and/or an opportunity to formulate advanced directives were offered. An interview was conducted with Resident #85 on [DATE] at 3:23 PM. Resident #85 stated he recalled discussing something about advanced directives but did not recall receiving written education regarding advanced directives. An interview was conducted with the Social Worker (SW) on [DATE] at 8:25 AM. The SW stated education on advanced directives was provided during the 72hr (hour) care plan meeting. She stated she verbally explained difference between CPR (Cardiopulmonary Resuscitation: an emergency life-saving procedure done when someone's breathing or heartbeat stops) and DNR and asked residents and/or their representatives if they had a living will. The SW explained that during care conference meetings if a resident had a change in condition, the resident's current code status was verbally reviewed. The SW stated she was not aware that written education was required to be provided to residents and/or representatives. The SW elaborated she thought the acknowledgement form that residents or their representatives signed, which indicated that they were educated on advanced directives, was sufficient. An interview was conducted on [DATE] at 12:03 PM with the Director of Nursing (DON). The DON stated when a resident admitted to the facility they had an initial order for code status, were care planned for that code status, and a MOST form (Medical Orders for Scope of Treatment: a legal medical document that turns a seriously ill person's care preferences into actual medical orders) was completed. The DON stated the SW was responsible for providing education regarding advance directives. Additionally, the DON indicated that during each care conference meeting a resident's code status was addressed. The DON stated she was not aware that written education concerning advance directives was supposed to be provided to residents and/or their representative. During an interview on [DATE] at 1:12 PM with the Administrator he stated the SW verbally reviewed MOST forms with the resident and/or the representative which included an explanation of advance directives, and the physician signed the form. The Administrator stated code status was also addressed quarterly in care planning meetings. The Administrator stated he had assumed that because residents and/or their representatives signed the acknowledgment form that they received education regarding advanced directives, that was sufficient and he was unaware they needed to be provided with any additional information.

Based on record review and staff interviews, the facility failed to issue a complete and signed Notice of Medicare Non-Coverage (NOMNC) at least 2 days prior to discharge from Medicare Part A skilled services for 3 of 3 residents reviewed for beneficiary notification (Residents #103, #104, and #105).The findings included:a. Resident #103 was admitted to the facility on [DATE]. Record review revealed a NOMNC with Resident #103's name dated 7/22/26 stating Medicare Part A services would end on 7/23/26. The resident had not signed the form acknowledging it was received and the form did not contain information on how to appeal the decision. A discharge note documented Resident #103 was discharged from the facility on 7/23/26.b. Resident #104 was admitted to the facility on [DATE].Record review revealed an undated NOMNC with Resident #104's name stating Medicare Part A services would end on 7/15/26. The resident had not signed the form acknowledging it was received and the form did not contain information on how to appeal the decision.A discharge note documented Resident #103 was discharged from the facility on 7/15/26.c. Resident #105 was admitted to the facility on [DATE].Record review revealed an undated NOMNC with Resident #105's name stating Medicare Part A services would end on 7/27/26. The resident had not signed the form acknowledging it was received and the form did not contain information on how to appeal the decision.During an interview on 8/26/26 at 9:05 AM, the Social Worker stated she was unaware residents had the right to file an appeal when Medicare Part A services were ending and that this was a part of the NOMNC. The Social Worker further stated she did not get residents to sign the NOMNC because she asked them to sign the Advanced Beneficiary Notice (ABN). She stated she did not know the ABN was not required when residents do not remain in the facility. During an interview on 8/26/26 at 10:00 AM, the Administrator revealed he was unaware that the facility Social Worker was not completing the required forms correctly. He stated the facility would begin to provide education immediately.

Based on observations, resident and staff interviews, the facility failed to maintain a clean floor in a resident's room for 1 of 8 residents (Resident #7) reviewed for environment. Findings included:An observation on 8/24/26 at 12:00 PM of Resident #7's floor revealed a sticky substance on the floor throughout the room.Additional observations of Resident #7's room on 8/24/26 at 2:08 PM and 8/25/26 at 3:31 PM revealed a sticky substance on the floor throughout the room.An observation and interview with Resident #7 were conducted on 8/26/26 at 9:45 AM and revealed a sticky substance on the floor throughout the room. Resident #7 stated she did not stick to the floor when she exited the room. She was wearing lightweight, water-friendly foam footwear with a clog design and ventilation holes and was able to walk. Resident #7 stated she realized the floor was sticky but it did not keep her from walking. She did not recall if housekeeping mopped the floor 8/24/26-8/26/26. Resident #7 did not notify anyone about the sticky floor.During an interview with Housekeeper #1 on 8/26/26 at 9:50 AM she stated the floor had not been cleaned yet. She stated she typically mopped/cleaned the floors when she cleaned the room. Housekeeper #1 reported she was off on 8/24/26 and did not know who was responsible for cleaning Resident #7's room that day. Housekeeper #1 stated her supervisor cleaned the room on 8/25/26.An interview was conducted with the Environmental Services Supervisor on 8/26/26 at 9:55 AM who stated she cleaned Resident #7's floor on 8/25/26. She reported she did not notice any stickiness on the floor when she cleaned the room. The Environmental Services Supervisor stated she did notice the floor was very sticky on 8/26/26. She stated she would get the floor buffed to correct it.An interview was conducted with the Administrator on 8/26/26 at 10:00 AM who stated Resident #7's floor should not be sticky. He stated sometimes if housekeeping staff do not use the correct amount of floor cleaner the floor would still be sticky after it dried. The Administrator stated he would speak with the Environmental Services Supervisor to ensure the correct amount of floor cleaner was used.

Based on observation, record review, and interviews with residents, staff and Emergency Medical Technician (EMT), the facility failed to provide care in a safe manner when Resident #1 rolled off the bed to the floor while Nurse Aide #1 provided incontinence care for 1 of 3 residents reviewed for accidents (Resident #1).The findings included:Resident #1 was admitted to the facility on [DATE]. Her current diagnoses included a wound on her left lower leg, anxiety disorder, and arthritis. Review of a social work progress note dated 12/3/25 indicated Resident #1 was cognitively intact.A nursing progress note dated 12/4/25 revealed while Nurse Aide (NA) #1 was changing Resident #1 she rolled out of bed, away from NA #1, and landed on the floor towards the wall. Resident #1 was lying on her left side. Staff were unable to get her off the floor because she was complaining of right knee pain. Emergency Medical Services (EMS) was called. The resident assisted with a lift to the stretcher and was transported to the local emergency department.Review of NA #1's written statement dated 12/4/25 revealed she had provided incontinence care to Resident #1. She reported she was going to assist Resident #1 after a countdown. NA #1 stated the resident pulled on the transfer bar prior to her getting to the window side of the bed. She stated Resident #1's legs went off the bed and then her body followed, with her face hitting the wall and she slid out of the bed. NA #1 stated the resident began yelling for help. She stated she then notified the nurse.A phone interview was conducted with NA #1 on 12/8/25 at 11:45 AM. She explained that when she assisted residents with turning, she would count backwards from three and then turn the resident (3,2, 1, then begin turning the resident). NA #1 stated she was going to assist Resident #1 with turning to provide incontinence care at the count of three. NA #1 stated on 12/4/25 she had not started the countdown from three when Resident #1 placed her left leg over her left foot and fell off the bed while holding the transfer bar. She reported she did not touch the sheet and had not attempted to turn the resident. NA #1 stated she planned to move from one side of the bed to the other prior to turning the resident. She reported she was on the door side of the bed and the resident fell towards the opposite side of the bed. NA #1 stated Nurse #1 came in and assessed the resident. She stated after Nurse #1 assessed Resident #1 she and another nurse aide (NA #2) were going to place the resident back in bed. NA #1 stated when they attempted to get the sling under her to use the lift, Resident #1 complained of knee pain. Nurse #1 then instructed the nurse aides to stop and contacted EMS.Attempts to contact NA #2 were unsuccessful. A statement written by Nurse #1 stated she was approached by NA #1 who stated Resident #1 was on the floor and had rolled off the bed. She assessed the resident who stated she had pain in her knees. She conducted neurological checks, and the resident did complain of pain in her knees of 7 out of 10. Nurse #1 stated she instructed NA #1 and NA #2 to place the resident back in bed. The resident complained of pain while the nurse aides were attempting to place her back in bed, so Nurse #1 decided to contact EMS. A telephone interview was conducted with Nurse #1 on 12/10/25 at 3:42 PM. She reported she assessed Resident #1 on 12/4/25, did not find any injury, and instructed NA #1 and NA #2 to place her back in bed afterwards. Nurse #1 stated Resident #1 began complaining of severe knee pain and she decided to contact 911 to transport Resident #1 to the hospital. Nurse #1 stated she could not comment on the incontinence care as she was unsure of what happened.A phone interview was conducted with Resident #1 on 12/8/25 at 11:32 AM who remained in the hospital. Resident #1 stated she was at the edge of the bed and rolled off when NA #1 pulled the sheet. Resident #1 reported NA #1 was nice the previous evening but appeared short and in a hurry the evening of 12/4/25. She reported she used the transfer bar (a sturdy mobility device designed to provide a secure handhold for individuals entering, exiting, or repositioning themselves in bed) on the side of bed and rolled away from NA #1.An Emergency Medical Technician (EMT) report dated 12/4/25 revealed Resident #1 stated she was dropped from her bed after requesting to do her rehabilitation exercises. She was on a lift mat when EMT staff arrived, and Resident #1 stated she had pain in her head and back. A telephone interview was conducted with Emergency Medical Technician (EMT) #1 on 12/10/25 at 3:00 PM. She stated Resident #1 complained of pain in her head and back.Review of emergency department admission record dated 12/4/25 revealed Resident #1 was evaluated for a fall. She complained upon admission of pain in her upper back, head and knees. A computed tomography scan of her head, an x-ray of her hip and laboratory testing was done for infection. All studies were negative. As of 12/11/25 hospital notes indicated Resident #1 refused to return to the facility and remained in the hospital awaiting an alternate placementAn interview was conducted with the Director of Nursing on 12/8/25 at 3:05 PM. She stated NA #1 should have rolled Resident #1 towards her when providing incontinence care. During an interview with the Administrator on 12/8/25 at 2:05 PM he indicated NA #1 should have been at the correct side of the bed to roll Resident #1 towards her.The facility provided the following corrective action plan:Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice.On 12/4/25 Resident #1 experienced fall from a bed while Nurse Aide (NA) #1 was providing incontinence care. According to interviews conducted with Resident #1 and NA #1 Resident #1 was holding the grab bar when the fall occurred and NA #1 was on the opposite side of the bed at that time. NA #1 called for Nurse #1 and an assessment was completed. No gross injuries noted. Resident complained of generalized pain of a seven out of 10 in her knees. Neurological checks were within normal limits. When the nurse aides attempted to assist Resident #1 back to bed she complained of severe pain and Nurse #1 made the decision to call Emergency Medical Services. Nurse #1 remained with resident assessing and reassuring the resident. EMS transferred Resident #1 from floor to stretcher and Resident #1 then complained of pain of 10 of 10. Nurse #1 notified Resident #1's provider, resident representative, and Director of Nursing (DON).Address how the facility will identify other residents having the potential to be affected by the same deficient practice.On 12/4/25 the DON and Assistant Director of Nursing (ADON) reviewed the falls in the last six months. No other residents were identified as having experienced a fall from bed during care. The Nursing Home Administrator (NHA) reviewed the Grievance Log for the last six months with no concerns of accidents or injuries during care.Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur.On 12/4/25 the DON, ADON, and Unit Managers began education with the nursing staff (nurses and nurse aides) including agency staff on guiding the resident through provision of care before and as care was being provided and when turning the resident towards the staff member providing the care, turning towards oneself. Staff were educated to not to tilt resident more than 30 degrees if possible per policy and proper body alignment. Nursing staff was educated to kindly educate the resident not to assist during care unless and until instructed to do so. Nursing staff will not be permitted to work after 12/5/25 without having received the preceding education. Beginning 12/5/25 nursing orientation will be inclusive of the preceding education and will be educated by the DON or ADON prior to provision of care.Indicate how the facility plans to monitor its performance to make sure that solutions are sustained.Observation audits began on 12/4/25 by DON/ADON and/or unit managers observing 15 nursing staff a week for 12 weeks on all shifts including agency staff. The staff will be observed to determine if when turning a resident to side lying position are staff tilting resident more than 30 degrees, turning the resident towards staff, was resident guided through provision of care and was resident educated not to assist during care unless instructed to do so. Results of the observation audits will be presented by the DON in the facility monthly Quality Assurance and Performance Improvement Committee Meeting monthly for three months. The Quality Assurance and Performance Improvement Committee will make recommendations, as needed, to assure compliance is sustained ongoing.Date of compliance:12/6/25 Validation was completed 12/8/25 and included staff interviews regarding the in-service training that was received to ensure understanding and knowledge of the training provided. Staff members interviewed stated they had received training. In-service training included turning and positioning policy and training on body alignment which consisted of turning the resident towards the staff member, guiding residents through care provision, and educating the resident to not assist until instructed. Inservice logs and the initial and ongoing audits were verified. There were no concerns identified. Observations of incontinence care revealed residents were instructed to roll towards the staff member assisting with incontinence care and to not assist with care until instructed to do so. The corrective action plan compliance date of 12/6/25 was validated.

Based on observation and staff interviews, the facility failed to implement a system to air dry all cleaned dishes. The facility also failed to follow the manufacturer's instructions for a minimum temperature of 120 degrees Fahrenheit (F) and the sanitization up to the required level of at least 50 parts per million (ppm) for three of three observations. These practices had the potential to affect food served to residents. The findings included: An observation and interview with the Certified Dietary Manager (CDM) were conducted on 5/05/25 at 10:43 AM in the kitchen. The CDM stated that all dishes near the dish room were ready for service. The following cleaned dishes were observed wet and nesting: Plate warmers (92) and domes (8) were observed face down stacked on top of each other, small ceramic bowls (79) were stacked on top of each other on a mobile cart, and coffee cups (68) and juice cups (72) were placed face down on meal trays and then stacked on top of each other (at least 3 levels). The CDM stated that the health department and previous state surveyors told her that clean/wet dishes needed to be stacked so that the water could drain downward, but nothing was mentioned about the air-dry process. It was observed that the meal trays and remaining domes were air dried on 2 separate racks. At 10:49 AM, it was observed that the outside gauge to the dish machine was not oscillating. The CDM stated normally they use a temperature pad to measure the wash/rinse cycles for the dish machine temperature log. An interview was conducted with Dietary Aide (DA) #1 on 5/05/25 at 10:51 AM. He stated that he was instructed by the CDM to stack all dishes after being cleaned because there was not any room for the air-dry process. An observation and interviews with DA #1 and the CDM were conducted on 5/05/25 at 10:52 AM. The temperature pad placed on a dish rack and passed through the dish machine measured 115.7 degrees F for the wash/rinse cycles. The CDM stated the minimum required temperature of the dish machine was 120 degrees F. Also, the CDM used a testing strip to measure the dish machine sanitization level, and it remained without color and did not reach the 50 ppm minimum requirement. The dish machine temperature log for 5/7/25 was recorded as 100 ppm and 115 degrees F. DA #1 stated the minimum temperature was supposed to be 120 degrees F. The CDM stated DA #1 did not notify her that the dish machine did not meet the required temperature that morning. DA #1 stated he told the Maintenance Assistant about the inadequate temperature measurement but continued to wash the dishes from breakfast anyway. The CDM instructed DA #1 to rewash all dishes from breakfast once the dish machine temperature was brought up to the minimum requirement of 120 degrees F. An observation of the tray line area was conducted on 5/05/25 at 11:00 AM. Forty-nine dinner plates in the warmer ready for service were wet and nesting, and ten cereal bowls were stacked on top of each other on a rack wet and nesting. Dietary Aide #2 was interviewed on 5/05/25 at 11:03 AM. She revealed that she was taught by the CDM to store clean dishes stacked on top of one another and not air-dried. An interview was conducted with the Maintenance Assistant on 5/05/25 at 11:04 AM. He stated he was not made aware that the dish machine did not meet temperature or sanitization requirements this morning. The Maintenance Assistance indicated that he checked the dish machine weekly, but he was not aware of today's concerns. An observation and interview with the CDM were conducted on 5/07/25 at 9:40 AM. The dish machine measured 50 ppm for sanitization. However, the temperature gauge was not working at the time. The CDM stated that the temperature pad device was no longer working, but the dish machine gauge measured 120 degrees F earlier that morning, which was marked on the dish machine temperature log. It was observed that the dish machine gauge reached 118 degrees F. The CDM contacted the Maintenance Assistant, and he arrived shortly after. An observation of the kitchen was conducted on 5/07/25 at 9:41 AM. The plate warmers (42) and domes (17) were stacked wet on top of each other after being sent through the dish machine. The coffee cups (25), juice cups (29), and small plastic bowls (59) were also wet face down on meal trays and then stacked on top of each other (3 levels total). During a follow-up interview with the CDM on 5/07/25 at 11:26 AM, she revealed that she tried to purchase a new temperature pad from local sources, but it was not available. So, the Maintenance Assistant used a heat gun, and the temperature measured 119 degrees F. The CDM indicated that the Administrator purchased a new temperature pad, and it was scheduled to arrive on 5/8/25. An observation of the kitchen was conducted on 5/07/25 at 11:27 AM. The domes, plate warmers, and dinner plates were air dried prior to service. However, the coffee cups (25), juice cups (29), and small plastic bowls (59) were still wet and stacked on top of each other with a meal tray in between. An interview was conducted with the Administrator on 5/07/25 at 11:28 AM. He stated that the kitchen staff needed to use plasticware because the dish machine was unable to reach the minimum required temperature during use. During a follow-up interview with the CDM on 5/07/25 at 11:30 AM, she stated that the dish machine reached 121 degrees F on 5/6/25, and she was not sure why there was an issue today. During a follow-up interview with the Maintenance Assistant on 5/07/25 at 11:35 AM, he stated that the dish machine had reached 121 degrees F consistently with the heat gun after he inspected it. During a follow up interview with the Administrator on 5/08/25 at 3:59 PM, he revealed that the cleaned dishes should have been air dried and not stacked prior to service. Although there was limited space in the kitchen, it could have been used to manage the air-drying process. The Administrator indicated there was an issue with the dish machine reaching the required minimum temperature of 120 degrees F because the heating unit underneath had kicked off to prevent an electrical fire due to a buildup of water. Once the water buildup was addressed, the heating unit was turned back on. The flow of chemicals needed to be adjusted anytime the measurement did not reach at least 50 ppm.

Based on observations, record review, staff and a pest control service technician interviews, the facility failed to maintain an effective pest program that was free of roaches for 3 of 4 observations for pest control. The findings included: Review of the pest control invoices provided by the Administrator from February - April 2025 revealed the following information related to cockroach activity and pest control identification of problem areas: 2/21/25: Cockroach activity was not observed during service. Sanitation issues: kitchen area interior - spilled food material found on the floor. This has been like that for months and remained untouched. Structural concerns: kitchen area interior - floor tiles or baseboards loose/missing. Near Entry Interior - hole/gap noted exit door next to front desk. 3/25/25: Cockroach activity was not observed during service. Sanitation issues: kitchen area interior - Spilled food material found on the floor of the kitchen. This has remained untouched for months. Structural concerns: kitchen area interior - Hole/gap noted by the cooler in the kitchen. Also, floor tiles or baseboards missing/loose in the kitchen. 3/28/25: Cockroach activity was not observed during service. Sanitation issues: kitchen area interior - spilled food material found on the floor. This has been like that for months and remained untouched. Structural concerns: kitchen area interior - hole/gap noted by ice machine in scrapping area; Many areas in need of work and fixing; floor tiles or baseboards loose/missing. Near Entry Interior - exit door does not close/seal properly 1/4-inch gap or greater exists 4/24/25 Cockroach activity was not observed during service. Sanitation issues: kitchen area interior - spilled food material found on the floor. This has been like that for months and remained untouched. Structural concerns: kitchen area interior - hole/gap noted by ice machine in scrapping area; Many areas in need of work and fixing. Rear door introduction point -needs door sweeps Review of the facility's Pest Activity Log from March - May 2025 revealed the following sightings: 3/31/25: multiple cockroaches found in room [ROOM NUMBER]A 4/29/25: large-sized cockroaches found by activity room and near room [ROOM NUMBER] 4/30/25: medium-sized cockroach found near nursing station 2 5/1/25: large-sized cockroach found in conference room An observation and interview with the Certified Dietary Manager (CDM) were conducted on 5/05/25 at 10:37 AM. A live, brown roach was seen in the CDM's office adjacent to the kitchen. The CDM explained the pest control company sprayed recently for cockroaches, and the Maintenance Assistant also sprayed for cockroaches. She indicated she had seen more German cockroaches with the warmer weather. The CDM then stepped on the cockroach and killed it. During an observation outside of room [ROOM NUMBER] on 5/05/25 at 11:56 AM, a live, brown roach was noted climbing the wall in the hallway. An observation and interviews with Wound Nurse #1 and Wound Nurse #2 on 5/07/25 at 2:44 PM. During wound care in room [ROOM NUMBER], a live, brown roach came out from under the bed and moved towards the window. As soon as it sensed motion in the room, the roach went back under the bed towards the wall next to the door and could not be observed. Wound Nurse #1 stated that she had never seen roaches previously in the facility. An interview was conducted with the Maintenance Director on 5/08/25 at 8:40 AM. He revealed he began with the facility in August 2024. The Maintenance Director indicated when the pest control service technician visited the facility bimonthly, he accompanied him during the tours. He stated there was a pest control sighting log at each nursing station, to keep track of sightings of pests, where the pests were observed, and the pest control service technician used the logs as a reference of where to tend to in the building in addition to the routine monthly service. The common areas and the kitchen were treated at each visit. As far as the pest control recommendations included in the invoice to prevent further infestation, the Maintenance Director stated he would repair whatever was needed immediately if it was a small project and did not interrupt meal service. Bigger projects were reserved for a scheduled time. The Maintenance Director stated he had completed a lot of work in the kitchen, including floor tiles and baseboards. However, he stated he could not provide any receipts or work orders for the work completed in the kitchen. The hole/gap by the ice machine in the scrapping area was sealed a month ago. The gap at the exit door (courtyard) next to the front desk was filled. On 4/24/25, the Many areas in need of work and fixing in kitchen could not be explained by the Maintenance Director. The pest control service technician never discussed the spilled food in the kitchen with him, and perhaps the CDM would know more. The Maintenance Director revealed the details included in the 4/24/25 pest control invoice related to hole/gap noted by ice machine in scrapping area and 'Many areas in need of work and fixing' were incorrect. He revealed he did not accompany the pest control service technician during his visit on 4/24/25 and may have been busy with something else. The Maintenance Director stated the cockroach activity had improved since he was hired in August 2024; however, he could not give an expert opinion on why cockroaches were still being observed. However, a new pest control company was contacted to hopefully further improve the situation. During an observation of the kitchen and interview with the Maintenance Director on 5/08/25 at 9:01 AM, he showed where in the kitchen he had made repairs including the hole filled next to ice machine in scrapping area and holes sealed behind the sink in cook's area as well as tiles re-caulked, and baseboards replaced. However, the baseboard replaced was not completely sealed to the wall and had a 12-inch separation gap present. He also showed that he had replaced tiles and filled in holes behind the 3-compartment sink at the baseboard area; however multiple gaps were observed between tiles connected to the wall and the flooring where the sealant was missed. During a follow up interview and observation with the CDM on 5/08/25 at 9:07 AM. The CDM stated the pest control service technician never spoke to her about areas that needed attention in the kitchen. She further stated they did not normally spray well during their visits in the kitchen, and she had to guide them to additional areas before they left the area. The CDM indicated the Maintenance Director never discussed with her the spilled food descriptions included on the February - April 2025 pest control invoices. The dry goods area was observed, and seasoning, jelly, and food crumbs were on the floor in multiple areas. The CDM stated that kitchen staff swept and mopped the entire kitchen 3-4 times daily and all those spilled areas were new on 5/8/25. Dietary Aide #1 was interviewed on 5/08/25 at 9:11 AM. He revealed he saw cockroaches in the kitchen multiple times in the past with the most recent sighting today (5/8/25) when the silverware/condiment holders were replaced on the tray line. He stated that the CDM was present in the kitchen at that time and saw the roaches near the tray line. An interview was conducted with [NAME] #1 on 5/08/25 at 9:12 AM. She revealed she last saw cockroaches in the morning (5/8/25) on the steamer when it was turned on and the area where the silverware/condiment holders were replaced on the tray line. [NAME] #1 stated the CDM was also present when she saw the roaches near the tray line. During an interview with the pest control service technician on 5/08/25 at 9:41 AM, he revealed he serviced the facility for pest control monthly unless the facility called for other services in between. The pest control service technician stated none of the facility staff accompanied him during his monthly tours, and the issues he identified for the past few months had not changed. He stated he also took pictures of the repeat problem areas that were not addressed. The pest control service technician indicated he had spoken to the Administrator as well the Maintenance Assistant about these issues, and they told him that they would notify the kitchen staff to clean and work on the other areas such as the baseboards (brick or ceramic) in multiple areas. The spilled food was located under the coffee machine and power to the outlet near the coffee machine was needed so that the insect light could work properly. He stated he had changed the bulbs to the insect light but did not resolve the power source problem, so he notified the Maintenance Assistant. There were pest control logs at each nursing station, and he reviewed them every time he visited the facility. He explained the pest control logs did have pest activity recorded, and he addressed each area identified. An interview was conducted on 5/08/25 at 9:18 AM with Housekeeping Staff #2. She stated she had seen cockroaches in the hallways occasionally. She further stated she killed them and did not tell anyone when she saw them. During a follow up interview with the CDM on 5/08/25 at 9:29 AM, she confirmed that she did see 2-3 German cockroaches near the tray line when the silverware/condiment containers were replaced on 5/08/25. She stated the Maintenance Assistant walked in shortly after and was notified about the sightings in the kitchen that morning. An interview was conducted on 5/08/25 at 9:34 AM with Nurse Aide #4. She stated she saw cockroaches in the hallways occasionally, and she called maintenance immediately. An interview was conducted on 5/08/25 at 9:44 AM with Nurse #2. She stated she saw cockroaches in the hallways on occasion. She further stated she entered each sighting in the pest control logbook. The Maintenance Assistant was interviewed on 5/08/25 at 10:44 AM. When the pest control service technician visited the facility, the Maintenance Assistant revealed he tried to be present so he could be shown what needed to be addressed. The Maintenance Assistance stated he took pictures of the identified areas and would repair whatever was needed. When sightings of any pest were recorded in the pest control log, he would contact the pest control company to come out that day. The spilled food issue was discussed when the pest control service technician during the last visit on 4/24/25; however, every time there was a meal prepared, there was spilled food, but the kitchen staff cleaned after each meal. The Maintenance Assistant indicated he had recommended another pest control company to the Maintenance Director because he had experience with the current pest control company from a previous position and did not favor the chemicals used during service visits. Since he started 8 months ago, the Maintenance Assistant stated that the pest activity had improved. Wherever there were cracks in the walls located all over the facility, they would be filled because that was a common area where pests entered and exited. The more the facility was sprayed, the more pest activity because they would find new hiding spots. The Maintenance Assistant indicated he was not aware of the cockroach sightings in the kitchen this morning (5/8/25). An interview was conducted with the Administrator on 5/08/25 at 4:06 PM. He revealed he had given specific instructions for the pest control service technician to visit with maintenance upon entry and then speak with the Administrator when leaving the facility. The Administrator stated the pest control service technician would just leave the invoices on his desk and leave without talking with the Administrator during many of his visits. The Maintenance Director also treated the rooms in between service visits. The Administrator stated he did not contact a new pest control company within the last 12 months because there was more pest activity in the building due to the changing of seasons. The expectation was that no pests were present in the building and if present, they would be exterminated immediately.

Based on record review and staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) assessment in the areas of falls, gradual dose reduction (GDR), and diagnoses for 4 of 24 residents (Resident #7, Resident #9, Resident #44, and Resident #57) whose MDS assessments were reviewed. 1. Resident #7 was admitted to the facility on [DATE] with diagnoses that included falls, fracture of left radius, generalized muscle weakness, and abnormalities of gait and mobility. Review of Resident #7's progress notes revealed she sustained a fall with no injury on 10/15/24. Resident #7's care plan dated 10/15/24 revealed a focus for falls. Resident #7's annual Minimum Data Set (MDS) assessment dated [DATE] revealed she was cognitively intact and was not coded for falls. During an interview on 5/7/25 at 2:45 PM with the MDS Coordinator, she stated when updating the MDS she reviewed the fall risk section of a resident's record. She further stated that Resident #7's MDS should have been updated and coded for falls. In an interview with the Director of Nursing (DON) on 5/7/25 at 3:13 PM she stated her expectation was that the MDS should be done timely and coded accurately. She further stated Resident #7's MDS assessment should have been coded correctly for falls. 43222 2. Resident #9 was readmitted to the facility on [DATE] with a diagnosis including paranoid schizophrenia. A physician order dated 3/26/25 revealed Resident #9 received Quetiapine Fumarate (an antipsychotic medication used to treat they symptoms of schizophrenia) oral tablet 100 milligrams (mg) two times a day related to paranoid schizophrenia. Review of Resident #9's significant change MDS assessment dated [DATE] revealed the resident was coded as not receiving an antipsychotic. An interview was conducted with the MDS Nurse on 5/07/25 at 2:20 PM. She revealed she coded Resident #9 as receiving an antipsychotic 7 out of the 7 days during the review period. However, she did not notice that she had chosen no to the section of antipsychotic related to the gradual dose reduction (GDR) questions. The MDS Nurse stated she had missed this detail because she was the only MDS nurse for the last 2.5 years while the facility was looking for a new hire, and all the MDS activity was solely her responsibility. Psychiatric Nurse Practitioner (NP)#1 was interviewed on 5/08/25 at 10:11 AM. She revealed that Resident #9 received an antipsychotic to manage his symptoms and behaviors related to paranoid schizophrenia. During an interview with the Director of Nursing (DON) on 5/08/25 at 12:39 PM, she revealed that the MDS Nurse should have reviewed Resident #9's medical record to ensure the resident received an antipsychotic and code the MDS assessment accordingly. The Administrator was interviewed on 5/08/25 at 3:48 PM. He revealed that the MDS nurse should have coded Resident #9's MDS correctly related to receiving an antipsychotic. However, the interdisciplinary team (IDT) should have completed a final review of the assessment. 3. Resident #44 was readmitted to the facility on [DATE] with a diagnosis including stroke. A physician order dated 12/31/24 revealed Resident #44 received Risperdal tablet 0.5 mg daily in the afternoon for bipolar disorder. Review of Resident #44's annual Minimun Data Set (MDS) assessment dated [DATE] revealed the resident was coded as receiving an antipsychotic without a GDR attempted and the physician did not document a GDR as clinically contraindicated. A psychiatry follow up note dated 3/3/25 completed by Psychiatric Nurse Practitioner (NP) #1 revealed that Resident #44 had a diagnosis of bipolar disorder and received an antipsychotic. Documentation included that a GDR would be clinically contraindicated for Risperdal. An interview was conducted with the MDS Nurse on 5/07/25 at 2:20 PM. She revealed that she coded Resident #44 as receiving an antipsychotic, but she did not notice that a GDR was documented as clinically contraindicated by Psychiatric NP #1 in her note dated 3/3/25. The MDS Nurse stated she was the only MDS nurse for the last 2.5 years while the facility was looking for a new hire, and all the MDS activity was solely her responsibility. During an interview with the Director of Nursing (DON) on 5/08/25 at 12:39 PM, she revealed that the MDS nurse should have reviewed Resident #44's medical record to see if a GDR had been attempted before completing the MDS assessment. GDRs were also included in pharmacy recommendations, which the DON reviewed herself and all that information was uploaded to the resident's medical record. The Administrator was interviewed on 5/08/25 at 3:48 PM. He revealed that the MDS nurse should have identified the documentation in Resident #44's medical record that included a GDR as clinically contraindicated. However, the interdisciplinary team (IDT) should have completed a final review. 4. Resident #57 was admitted to the facility on [DATE] with a diagnosis including schizoaffective disorder. A physician order dated 4/17/25 revealed Resident #44 received Risperdal tablet 0.5 mg daily for schizophrenia. Review of Resident #57's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was coded as receiving an antipsychotic without a GDR attempted and the physician did not document a GDR as clinically contraindicated. A psychiatry follow up note dated 2/21/25 completed by Psychiatric NP #3 revealed that Resident #44 had a diagnosis of schizoaffective disorder and received an antipsychotic. Documentation included that a GDR would be clinically contraindicated for Risperdal. An interview was conducted with the MDS Nurse on 5/07/25 at 2:20 PM. She revealed that she coded Resident #57 as receiving an antipsychotic, but she did not notice that a GDR was documented as clinically contraindicated by Psychiatric NP #3 in her note dated 2/21/25. The MDS Nurse stated she was the only MDS nurse for the last 2.5 years while the facility was looking for a new hire, and all the MDS activity was solely her responsibility. During an interview with the Director of Nursing (DON) on 5/08/25 at 12:39 PM, she revealed that the MDS nurse should have reviewed Resident #57's medical record to see if a GDR had been attempted before completing the MDS assessment. GDRs were also included in pharmacy recommendations, which the DON reviewed herself and all that information was uploaded to the resident's medical record. The Administrator was interviewed on 5/08/25 at 3:48 PM. He revealed that the MDS nurse should have identified the documentation in Resident #57's medical record that included a GDR as clinically contraindicated. However, the interdisciplinary team (IDT) should have completed a final review.

Based on observation and staff interviews, the facility failed to close the doors to dumpsters that contained waste. This was for 2 of 3 dumpsters observed and the deficient practice had the potential to attract pests and rodents. The findings included: An observation of the dumpster area and interview with the Certified Dietary Manager (CDM) were conducted on 5/05/25 at 11:20 AM. Both doors to the middle dumpster area and the right door to the far-left dumpster were left open. The CDM stated the dumpsters were shared by all departments and they all were educated to keep all doors to the dumpsters closed. During an interview with the Administrator on 5/08/25 at 3:59 PM, he revealed that he checked the dumpsters routinely to ensure the area was clean and all doors were closed. Therefore, the doors to the dumpsters were rarely left open. The Administrator indicated that he was not on the property the morning of 5/6/25, and a housekeeper was discarding trash and left the doors open by mistake. They should have closed all the doors after the trash was placed in the dumpsters.

Based on staff and Nurse Practitioner (NP) interviews and record review, the facility failed to ensure a resident's code status information was consistent throughout the medical record for 1 of 2 residents reviewed for advanced directives (Resident #43). The findings included: Resident #43 was admitted to the facility on [DATE]. His diagnoses included malignant neoplasm of the right lung (lung cancer), secondary malignant neoplasm of the brain (when a cancer that started somewhere else in the body has spread to the brain), cerebral edema (brain swelling caused by an abnormal buildup of fluid in the brain's tissues), and seizure disorder. The electronic medical record (EMR) profile indicated Resident #43's code status as Do Not Resuscitate (DNR). Review of Resident #43's EMR revealed a signed Advance Directive form dated 3/8/24 which indicated no code (DNR) status. Review of Resident #43's physician orders dated 3/12/24 revealed he had an order for Do Not Resuscitate (DNR). Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #43 was cognitively intact. Further review of Resident #43's EMR revealed a signed Medical Orders for Scope of Treatment (MOST) form dated 4/17/25 which indicated attempt resuscitation. An interview was conducted on 5/6/25 at 11:57 AM with the Social Worker (SW). She stated when she spoke to Resident #43 on 4/17/25 he stated he wanted to be a full code (receive cardiopulmonary resuscitation). She stated Resident #43 understood the difference between full code and DNR status. She further stated she spent approximately 1 1/2 hours reviewing the MOST form and he changed his code status from DNR to full code. The SW stated she took the signed MOST form to the Admission Director, but did not verbally notify anyone about the change in his code status. An interview was conducted on 5/6/25 at 2:39 PM with the Admissions Director. She stated the facility completed an audit of advance directives in April 2025. The Admissions Director and SW divided the residents into 2 teams to review those residents who were missing MOST forms in their EMR. The Admissions Director stated any changes made to a resident's code status should have been communicated to the Director of Nursing (DON) immediately, who in turn changed the code status in the EMR system and notified the Unit Manager of the resident's hall. The MOST form for Resident #43 indicating a change in his code status may have been missed during the audit. An interview was conducted on 5/6/25 at 2:33 PM with the Director of Nursing (DON). She stated if a resident made a change to their code status, the person who was notified of the change in code status was supposed to notify the DON or the Unit Manager immediately. A nurse and a witness would discuss this change in code status with the resident and confirm the change. The Nurse Practitioner would be notified and an order for the new code status would be obtained. The DON further stated that on 5/6/25 once she was notified of the discrepancy in code status, she spoke to Resident #43 confirming full code status and notified the Nurse Practitioner. An interview was conducted on 5/7/25 at 10:29 AM with the Nurse Practitioner (NP). She stated that she typically was notified in a resident's change in code status by the staff member who spoke to the resident and/or family member, such as the DON, Unit Manager, or SW. She further stated she did not update the EMR to the new code status, but gave a verbal order to change code status and would sign the MOST form. An interview was conducted on 5/6/25 at 2:45 PM with the Administrator. He stated it was his expectation for staff to follow the change in code status process for the facility. Any changes in code status should be communicated with nursing and the SW. The Unit Managers and DON conducted daily clinical meetings and changes should be communicated during that time.

Based on record review, and staff and resident interviews, the facility failed to implement their abuse policy in the area of reporting and investigating. When there was an allegation of abuse the Administrator was not immediately notified (Resident #32 and Resident #331) and an investigation was not initiated at the time of the allegation (Resident #331) for 2 of 3 residents reviewed for abuse. Findings included: 1. Review of the facility policy entitled Prohibition of Abuse Administration, dated 12/24/21 revealed anyone who has any knowledge of abuse should report immediately to their immediate supervisor. All violations will be reported to the State agency within two hours if there is an allegation of abuse. Resident #32 was admitted to the facility on [DATE]. Resident #32's most recent Minimum Data Set (MDS) assessment dated [DATE] revealed he was cognitively intact with no behaviors. Review of a facility reported incident initial report completed by the Administrator dated 3/11/25 revealed on 3/10/25 at 1:30 AM Resident #32 stated Nurse Aide #5 struck him with a washcloth. The incident report revealed the Administrator was made aware of the incident on 3/11/25 at 7:15 AM. The Administrator notified the local Adult Protective Services on 3/11/25 at 8:30 AM, local law enforcement on 3/11/25 at 8:45 AM and the State agency on 3/11/25 at 8:17 AM. Review of the facility investigation revealed a statement written by Nurse Aide (NA) #6 who stated Resident #32 told her NA #5 struck him after supper on 3/10/25. She reported this disclosure occurred on 3/10/25 at 11:45 PM. A telephone interview was conducted with NA #6 on 5/8/24 at 8:26 AM who stated she informed Nurse #3 on 3/10/25 at approximately 11:50 PM that Resident #32 had stated he was struck by NA #5. NA #6 stated she also wrote a statement. During a telephone interview with Nurse #3 on 5/8/24 at 8:30 AM stated she was never made aware that Resident #32 was struck by NA #5. A telephone interview was conducted with Nurse #4 on 5/7/25 at 3:11 PM. She stated she was advised on 3/10/25 at 11:59 PM by NA #6 that Resident #32 had stated he was struck by NA #5. Nurse #4 stated she heard NA #6 tell Nurse #3. She reported she was not Resident #32's nurse and she believed Nurse #3 reported the incident. An interview was conducted with Resident #32 on 5/6/25 who reported he never stated Nurse Aide #5 struck him. During a telephone interview with Nurse #2 on 5/7/25 at 3:17 PM she stated she reported the allegation of abuse at 7:15 AM on 3/11/25 to the Administrator. She stated she contacted the Administrator when she was made aware of the allegations. Nurse #2 stated she wanted to ensure the allegations were reported. An interview was conducted with the Administrator on 5/8/25 at 10:15 AM. He stated he contacted local Adult Protective Services, law enforcement and the State agency within 2 hours of his notification of the incident. He further stated the allegations should have been reported to him or another manager when NA #6 was told by Resident #32 he had been struck by NA #5. 43222 2. Resident #331 was admitted to the facility on [DATE] and left against medical advice (AMA) on 11/12/24. Review of the 5-day Medicare Minimum Data Set (MDS) assessment revealed that Resident #331 was cognitively intact with adequate hearing/vision, clear speech, and understood/understands. A telephone interview was conducted with Resident #331 on 5/05/25 at 1:03 PM. He revealed that a female staff member (name unknown) came into his room on either 11/5/24 or 11/7/24 walked towards his bed near the window, groped his groin area over his clothing, and walked out while another female staff member (name unknown) stood at the doorway. Resident #331 stated that he did not notify anyone at the facility; however, he told Adult Protective Services (APS) when they visited his home after discharge (date unknown) because no one would believe him. He reported the alleged sexual abuse to the police department himself on 11/25/24. The Police Investigator assigned to Resident #331's case was interviewed via telephone on 5/06/25 at 12:52 PM. She revealed that the report was made on 11/25/24, and the date of the incident occurred either on 11/5/24 or 11/7/24. Resident #331 seemed confused because he forgot who the accused staff member was exactly; however, he described the alleged perpetrator as a black female, 5 foot 7 inches in height, and walked with a limp. The Police Investigator stated that she tried to reach the Administrator by phone but was unsuccessful. When she visited the facility on 1/14/25, the Administrator was away at a conference, so she spoke to the Social Worker Director. The Police Investigator provided a description of the alleged perpetrator, but the Social Worker Director told her that no staff member was a match. The case was inactivated on 1/14/25 due to lack of sufficient evidence. An interview was conducted with the Social Worker Director on 5/06/25 at 1:11 PM. She revealed that the Police Investigator and maybe an APS representative visited the facility on 1/14/25 and asked her if she recalled Resident #331 and how he had been discharged . She was also asked about any concerns with nonconsensual touching, but she could not recall Resident #331 ever saying that he was inappropriately touched. The Police Investigator provided a description of the alleged perpetrator, but the Social Worker Director told her that the facility did not have a staff member employed at the facility described by Resident #331. The Social Worker Director stated that she could not recall if the Police Investigator was looking for the Administrator but rather was at the facility to speak to her. She indicated that she did not report the Police Investigator's visit to anyone at the facility because there was not a specific person identified, and Resident #331 was often confused. The Social Worker Director recalled that Resident #331 often complained about his hospital experience, and she thought he referenced a hospital staff member. She stated that she was trained to report all abuse allegations to the Administrator. During an interview with the Director of Nursing (DON) on 5/08/25 at 12:42 PM, she revealed that she was not aware of the sexual abuse allegation made by Resident #331 until it was reported by the state on 5/06/25. However, an investigation was initiated immediately thereafter. The DON stated all abuse allegations should be reported to either the DON and/or the Administrator. The Administrator was interviewed on 5/08/25 at 3:53 PM. He revealed that he should have been notified immediately of the newly reported sexual abuse allegation by Resident #331 on 1/14/25, so that he could follow the abuse policy and procedures and report to the appropriate authorities. The Administrator stated that he would be the one to determine how to move forward with any abuse allegation, not the Social Worker Director.

Based on record review and staff interviews the facility failed to ensure a Preadmission Screening and Resident Review (PASRR) level II referral was resubmitted after a resident was given a new mental health diagnosis for 1 of 2 residents (Resident #44) reviewed for PASRR. The findings include: Review of Resident #44's medical record revealed the resident was originally admitted to the facility on [DATE] and a PASRR level I was completed. She qualified for PASRR level II that was halted on 11/8/24. The resident was diagnosed with depression upon admission and when readmitted on [DATE] was diagnosed with bipolar disorder. Review of physician orders for Resident #44 revealed that Psychiatric Nurse Practitioner (NP)#2 ordered Risperdal (an antipsychotic medication) 0.5 milligrams (mg) 1 tablet in the afternoon on 12/31/24 for bipolar disorder. A psychiatry follow up assessment dated [DATE] completed by Psychiatric NP #1 revealed that Resident #44 had a diagnosis of bipolar disorder and received an antipsychotic medication. Review of Resident #44's most recent comprehensive Minimum Data Set (MDS) dated [DATE] revealed the resident was coded for a level II PASRR and received antipsychotic medication on a routine basis. Psychiatric NP #2 was interviewed via telephone on 5/08/25 at 11:02 AM. He revealed that since Resident #44 had a previous depression diagnosis and was fairly young, he stated that she was misdiagnosed as unipolar and then correctly diagnosed her as bipolar on 12/31/24. An interview was conducted with the Director of Nursing (DON) on 5/08/25 at 3:43 PM. She revealed that if she had been notified when Resident #44 was diagnosed with bipolar disorder on 12/31/2 4, she would have notified the Social Worker Director, who would have then initiated the PASRR II resubmission for a significant change. The Administrator was interviewed on 5/08/25 at 3:52 PM. He revealed that when a resident was given a new mental illness diagnosis or a significant change occurred, a new PASRR II submission would be required. However, The Administrator stated that he was not notified of Resident #44's newly diagnosed bipolar disorder on 12/31/24. If he had been, he would have ensured the resubmission was done in a timely manner.

Based on record review and staff interviews, the facility failed to revise care plans in the areas of antipsychotic use, and a new mental illness diagnosis for 1 of 24 residents (Resident #44) whose comprehensive care plans were reviewed. The findings included: Resident #44 was readmitted to the facility on [DATE] with diagnoses including stroke and depression. A physician order dated 12/31/24 revealed Resident #44 received Risperdal antipsychotic tablet 0.5 milligrams (mg) daily in the afternoon for bipolar disorder. A psychiatry follow up note dated 3/3/25 completed by Psychiatric Nurse Practitioner (NP)#1 revealed that Resident #44 had a diagnosis of bipolar disorder and received an antipsychotic. Documentation included that a GDR would be clinically contraindicated for Risperdal. Review of Resident #44's annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was coded as receiving an antipsychotic without a gradual dose reduction (GDR) attempted and the physician did not document a GDR as clinically contraindicated. Review of Resident #44's care plan revealed no revision was made to address the use of Risperdal and the diagnosis of bipolar disorder that was identified on 12/31/24. The MDS Nurse was interviewed on 5/7/25 at 2:17 PM. She revealed that there should have been a care plan for the antipsychotic medication and the diagnosis associated with the physician order, which was bipolar disorder. The MDS Nurse stated that the care plan for both Risperdal and bipolar disorder were not added because she was never notified about the new diagnosis or the addition of an antipsychotic. During an interview with the Director of Nursing (DON) on 5/8/25 at 12:33 PM, she revealed that she would expect that the bipolar disorder and Risperdal were included in Resident #44's care plan when initiated. The care plans were given a final review by the MDS Nurse, so it would have been her responsibility. An interview was conducted with the Administrator 5/8/25 at 3:54 PM. He stated that Resident #44's care plan should have included bipolar disorder and Risperdal. Unfortunately, there was a breakdown of communication, and the appropriate departments were not aware of the new diagnosis.

Based on record review, staff interviews and Nurse Practitioner (NP) interviews, the facility failed to provide supportive documentation of a newly diagnosed mental illness associated with a newly ordered antipsychotic for 1 of 5 residents reviewed for unnecessary medications. The findings included: Resident #44 was readmitted to the facility on [DATE] with a diagnosis including stroke and depression. A psychiatry follow up assessment dated [DATE] completed by Psychiatric NP #2 revealed that Resident #44 was seen for a follow-up assessment due to depression per the facility's request. She was experiencing auditory hallucinations in the evening confirmed by staff and the resident. The note read in part: Continue Risperdal for auditory hallucinations. Monitor as patient is taking Risperdal which can affect morbidity mortality. Documentation did not include the newly diagnosed bipolar disorder or supportive evaluation of how the bipolar disorder (BPD) diagnosis was determined. A physician order dated 12/31/24 revealed Resident #44 received Risperdal tablet 0.5 milligrams (mg) daily in the afternoon for bipolar disorder entered by Psychiatric Nurse Practitioner (NP) #2. Psychiatric NP #2 was interviewed via telephone on 5/08/25 at 11:02 AM. He revealed that since Resident #44 had a previous depression diagnosis and was young, she was misdiagnosed as unipolar and then correctly diagnosed as bipolar on 12/31/24. Psychiatric NP #2 stated that some patients, such as Resident #44, get diagnosed with depression and then hallucinate or become manic or wander, etc. She was having auditory hallucinations when he assessed her on 12/31/24. Psychiatric NP #2 indicated that provisional diagnoses could take up to 6 months, and medications were prescribed before a diagnosis was confirmed. The bipolar disorder diagnosis was included in the psychiatry follow up assessment dated [DATE]. He stated that he could have documented better about how he concluded Resident #44 had bipolar disorder in the 12/31/24 note when looking back in hindsight. He said the bipolar disorder diagnosis was provisional based on her response to the Risperdal, and he made a mistake in the note when he listed Continue Risperdal in the Treatment Plan section of the note. A psychiatry follow up assessment dated [DATE] completed by Psychiatric NP #3 revealed that there was not any documentation that included bipolar disorder. Under current medications Risperdal oral tablet 0.5mg once daily in the afternoon for bipolar disorder was listed. Resident #44 told Psychiatric NP #3 that she felt sad. No hallucinations were noted in the assessment. A telephone interview was conducted with Psychiatric NP #3 on 5/08/25 at 3:20 PM. She revealed that she saw Resident #44 on 2/21/25 for insomnia and depression. Resident #44 did not have any concerns with auditory hallucinations on 2/21/25. Psychiatric NP#3 stated she was unaware of the newly diagnosed bipolar disorder and did not research it. She might have reviewed the psychiatry follow up assessment from 12/31/24 because she often reviewed prior notes to understand why the antipsychotic was prescribed. The assessment automatically generated the medication list, but she was not sure where the bipolar disorder diagnosis came from. Psychiatric NP #3 indicated Psychiatric NP #2 should have discussed the new diagnosis with the Director of Nursing (DON). A psychiatry follow up assessment dated [DATE] completed by Psychiatric NP #1 revealed that Resident #44 had a diagnosis of bipolar disorder and received an antipsychotic. Documentation included that a GDR would be clinically contraindicated for Risperdal. A telephone interview was conducted with Psychiatric NP #1 on 5/08/25 at 10:04 AM. She revealed that she began seeing residents at the facility in March 2025. The bipolar disorder diagnosis was automatically generated in the assessment for Resident #44 on 3/3/25. Psychiatric NP #1 stated that she did not know the origination of the diagnosis but rather that it was associated with the order for Risperdal on 12/31/24. Review of Resident #44's annual MDS assessment dated [DATE] revealed the resident was coded as receiving an antipsychotic without a gradual dose reduction (GDR) attempted and the physician did not document a GDR as clinically contraindicated. During a telephone interview with the Pharmacist on 5/08/25 at 1:10 PM, she revealed that she reviewed Resident #44's medical record and saw that Risperdal was ordered on 12/31/24 and associated with bipolar disorder. During her monthly medication reviews and a new antipsychotic was initiated, she would review the origination of the diagnosis. The Pharmacist stated she was required to ensure that any medication had an appropriate diagnosis. For Resident #44, she only looked at the Risperdal order dated 12/31/24, which had an appropriate diagnosis for the medication, and she did not question the bipolar disorder diagnosis. An interview was conducted with the Director of Nursing (DON) on 5/08/25 at 3:41 PM. She revealed that no provider had notified her of Resident #44's bipolar disorder diagnosis initiated on 12/31/24. Had they done so, she would have included this information in Resident #44's medical record and then notified all necessary personnel. The DON indicated that an assessment would support the order with a new diagnosis; however, an order with a new diagnosis would not support the assessment. The Administrator was interviewed on 5/08/25 at 4:13 PM. He revealed that Psychiatry NP#2 should have notified the DON as soon as bipolar disorder was decided as a new diagnosis, so that the appropriate departments could respond as instructed.

Based on observations, resident and staff interviews, and record review, the facility failed to apply a right-hand palm guard for 1 of 1 resident reviewed for a range of motion (Resident #15). The findings included: Resident #15 was admitted to the facility on [DATE] with diagnoses which included cerebral infarction, hemiplegia (complete paralysis) affecting the left nondominant side, contractures of multiple sites, and cognitive communication deficit. A physician's order for Resident #15 dated 1/26/23 revealed a green carrot (a green carrot palm guard is a therapeutic device designed to support and protect the fingers from the palm. It is typically made of smooth cotton fabric and packed with washable wool fleece, which helps keep the hand cool and dry while reducing friction and irritation.) applied to the right hand on at night and off during the day. Resident #15's quarterly Minimum Data Set assessment dated [DATE] revealed she was moderately cognitively impaired. Resident #15 had impairments on bilateral upper and lower extremities. Record review of the nursing progress notes for April and May 2025 revealed no documentation for Resident #15's refusal to have the carrot placed in her right hand. Resident #15's April 2025 Medication Administration Record (MAR) revealed no order for a green carrot to be placed in her right hand at night and removed the next morning. Resident #15's May 2025 MAR revealed no order for green carrot to be placed in her right hand at night and removed the next morning prior to 5/7/25. An interview and observation was made on 5/7/25 at 8:00 am revealed Resident #15 sitting up in her bed awake and her right hand resting on the right side of her bed without the carrot. When asked did the nursing staff place the carrot in her right-hand last night, she replied, No. Resident #15's right hand was observed, and her fingernails were neatly trimmed. There was no redness or irritation noted to her palm. In an interview with Nursing Assistant (NA) #1 on 5/7/25 at 9:29 am, she indicated Resident #15 was supposed to have a carrot in her right hand at night to protect the skin from moisture, pressure and nail puncture injuries. When asked where the carrot was, NA #1 presented the carrot from the second drawer of Resident #15's night stand. During an interview with the Unit Manager (UM) #1 on 5/7/25 at 11:15 am, she stated Resident #15 was supposed to have the carrot placed in her right hand at night and removed the next morning. She further stated the carrot was to be placed in Resident #15's right hand at 7:00 pm. UM #1 indicated the night shift and/or the day shift nursing staff would remove the carrot from Resident #15's right hand the next morning. When asked where the nursing staff documented the carrot being placed and being removed for Resident #15, she stated it was on the Medication Administration Record (MAR). The UM #1 looked on Resident #15's MAR and stated the order was placed in the wrong area and immediately corrected the error. In an interview with the Occupational Therapy (OT) Director on 5/7/25 at 10:31 am, she explained Resident #15 was not currently being seen by the therapy department. The OT Director further explained the nursing staff would make referrals for Resident #15 for therapy services and Resident #15 would be picked up on caseload. The therapy department would evaluate and work with Resident #15. The OT Director stated Resident #15 was to have the carrot placed in her right hand and was in the functional maintenance program. She further stated she had in serviced the nursing staff on how to place the carrot in Resident #15's right hand. A second observation made on 5/8/25 at 6:16 am revealed Resident #15 lying in bed on her back and appeared to be sleeping. The resident's right hand was resting on her waist with her fingers closed against her palm. In a telephone interview with NA #3 on 5/8/25 at 11:29 am, he stated he cared for Resident #15 on 5/7/25 during the 3:00 pm to 11:00 pm shift. When asked did he place the carrot in Resident #15's right hand, he replied day shift placed the carrot, and my shift removed the carrot. When asked did he remove the carrot from Resident #15's right hand during his shift on 5/7/25, he replied, No. After the order was recited to NA #3, he then indicated he had placed the carrot in Resident #15's right hand during his shift on 5/7/25. During an interview with NA #2 on 5/8/25 at 6:18 am, she stated she was assigned to care for Resident #15 during the night shift (from 11:00 pm on 5/7/25 until 7:00 am on 5/8/25). When asked did Resident #15 have a carrot in her right hand at the beginning of her shift, she replied, No. NA #2 further stated Resident #15 should have had the carrot in her right hand but did not know why the carrot was not in her right hand. NA #2 indicated the 3:00 pm to 11:00 pm shift placed the carrot in Resident #15's right hand and the 11:00 pm to 7:00 am shift removed the carrot from Resident #15's right hand. In an interview with Resident #15 on 5/8/25 at 6:20 am, she was asked if the carrot was placed in her right hand at 7:00 pm on 5/7/25, she replied, No. When asked if she refused to have the staff place the carrot in her right hand, she replied, No. Nurse #1 was interviewed on 5/8/25 at 6:30 am and stated did not see a carrot in Resident #15's right hand during her assessment. She further stated that she was an agency nurse and was not familiar with Resident #15. During an interview with the Director of Nursing (DON) on 5/7/25 at 11:15 am, she stated she was aware of Resident #15's right hand carrot palm guard and Resident #15 would refuse at times. The DON indicated the order should have been placed on the MAR for the nursing staff to document placement and refusals. The DON further indicated the nursing staff should have attempted to place the carrot in her right hand and if Resident #15 refused, the nursing staff should have documented the refusals.

Based on observations and staff interviews, the facility failed to provide maintenance to the following areas in resident rooms: missing and scraped paint to the doorway and bathroom door (room [ROOM NUMBER]), paint scraped from the walls (Rooms #068 and #074), maintain a clean wall from a red splattered substance (room [ROOM NUMBER]), and the bathroom sink free from buildup (room [ROOM NUMBER]) for 3 of 7 resident rooms reviewed for environment on 1 of 4 halls. The findings included: a. Observation of Resident room [ROOM NUMBER] on 5/5/25 at 11:42 AM revealed scuff marks and missing paint on both sides of the doorway entering the bathroom. The surface of the bathroom door facing inside the bathroom revealed scraped paint approximately 3 inches in height across the length of the bathroom door, exposing what appeared to be a wood-like color underneath. The bathroom sink interior basin was observed to have a light black colored film halfway up from the bottom surface of the sink. b. Observation of Resident room [ROOM NUMBER] on 5/5/25 at 11:47 AM revealed a linear area approximately 25 inches in length and 10 inches in width of scraped paint on the right wall upon entering the room. There was an additional area of scraped paint halfway up the wall behind the headboard measuring approximately 15 inches in length and 6 inches in width. c. Observation of Resident room [ROOM NUMBER] on 5/5/25 at 2:35 PM revealed the wall at the foot of bed A had a linear area of scraped paint approximately 40 inches in length and 5 inches in width. The wall next to the closet door had an area of approximately 10 inches in diameter of a white material where it appeared damage to the wall had been repaired but remained unpainted. The area around the upper part of the bathroom mirror had an area of exposed, crumbling dry wall measuring approximately 8 inches in width and 24 inches in length. There was a red splattered substance approximately 6 inches in length and 2 inches in width on the wall at the foot of bed A approximately 20 inches from the floor. An interview and observation were conducted with the Maintenance Director on 05/07/25 at 12:04 PM. Observations were conducted of rooms #066, #068, and #074. The observations conducted on 05/07/25 at 12:04 PM revealed the same issues discovered on 5/5/25. The Maintenance Director stated since he started in his current position in August 2024, the maintenance department had been in the process of redoing/painting resident rooms. He stated they had completed 7 rooms to date. He further stated some residents do not like them in their rooms so that slows the process down, as work cannot be done while the residents are in their room. An interview and observation were conducted with the Housekeeping Manager on 5/7/25 at 12:15 PM. Observations were conducted of room [ROOM NUMBER] and #074. The observations conducted on 05/07/25 at 12:04 PM revealed the same issues discovered on 5/5/25. She stated staff did a general cleaning of resident rooms each morning and rechecked each room again in the afternoon. The facility had a cleaning schedule which included specific cleaning tasks that were done on specific days. The housekeeping manager attempted to remove the light black colored film in the sink in Resident room [ROOM NUMBER] with water and a paper towel and could not. She stated the housekeeping staff would need to use a pumice stone to remove the film. Regarding the splatter on the wall in Resident room [ROOM NUMBER], she stated it would be taken care of right away. Work history reports dated November 2024 through May 2025 were reviewed. There were no entries found for repairs in Resident Rooms #066, #068, and #074. In an interview with the Administrator on 5/8/25 at 2:03 PM he stated there was a process for cleaning and he expected that process to be followed. He further stated staff had been working to improve the facility and the goal was to complete more resident rooms. He stated the facility had to prioritize the work that was needed to be completed, as they had to attend to other major repair issues that have come up.

Based on observations, record review, Emergency Medical Service (EMS) personnel interview, and staff interview the facility failed to provide supervision to prevent a resident with severe cognitive impairment from exiting the facility unsupervised and without staff's knowledge. On 1/22/24 Resident #83 was found by EMS personnel approximately 1.9 miles from the facility seated on the ground on a sidewalk outside at 3:05 AM with icicles hanging from his nose and beard. He was treated for hypothermia by EMS and was taken to the hospital. This was for 1 of 3 residents reviewed for accidents. Immediate Jeopardy began on 1/22/24 when Resident #83 exited the facility unsupervised and without staff's knowledge. Immediate Jeopardy was removed on 1/23/24 when the facility implemented an acceptable credible allegation of Immediate Jeopardy removal. The facility remains out of compliance at a lower scope and severity of D (no actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure education and monitoring systems put into place are effective. Findings included: Resident #83 was admitted to the facility on [DATE] with diagnoses that included aphasia (loss of the ability to understand or express speech) and hemiplegia (paralysis of partial or total bodily function) and hemiparesis (one sided weakness) following cerebrovascular disease (a group of conditions affecting blood flow and blood vessels to the brain) affecting right dominant side. Resident #83's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed he was assessed as severely cognitively impairment with no wandering or behaviors. He was assessed as having unclear speech with the inability to understand or be understood. He had no functional impairment with range of motion. Resident #83 required partial/moderate assistance in transitioning from sitting to standing and chair to bed, and wheeling himself in a manual wheelchair 150 feet. Review of a wandering assessment dated [DATE] revealed Resident #83 was at risk for wandering. The assessment revealed he was ambulatory with a diagnosis of cognitive impairment which led to a score of 9 indicating he was at risk for wandering. The scoring scale for the wandering assessment indicated the following: 0-8 was low risk, 9-10 was at risk, and 11 and up was high risk. Resident #83's active care plan as of 1/21/24 revealed there was no care plan in place related to wandering. An incident investigation completed by the Administrator dated 1/22/24 revealed Nurse #2 received a call on 1/22/24 at 3:45 AM from a local emergency department asking if Resident #83 was a patient of the facility as he was in the emergency department. He was brought to them via the police. Nurse #3 stated she last saw Resident #83 at 12:30 AM on 1/22/24. Nurse Aide #1 (NA) #1 stated she last saw Resident #83 between 1:00 AM and 2:40 AM. During a phone interview with Nurse #2 on 1/26/24 at 8:25 PM she stated she was notified by the local hospital on 1/22/24 at 3:45 AM Resident #83 was in the emergency room . She reported she notified his assigned nurse, and she had no other knowledge of the incident. A phone interview was conducted with Nurse #3 on 1/26/24 at 12:59 PM who stated on 1/22/24 at 3:45 AM she was notified by Nurse #2 Resident #83 was found by the police and transported by EMS staff to a local hospital. She stated she last saw Resident #83 on 1/22/24 at approximately 12:30 AM when she checked his BiPap machine (a machine that supplies pressurized air to airways). She reported he was lying in bed, and she was unsure if he was asleep. Nurse #3 reported she was unable to recall what he was wearing. She stated usually when she saw Resident #83, he was in his bed. She indicated she wasn't familiar with his ability to ambulate. During an interview with NA #1 on 1/25/24 at 4:03 PM she indicated she was Resident #83's assigned NA on 1/22/24 during the 3rd shift. She reported Resident #83 ate his dinner late on 1/22/24 and she collected his tray at approximately 11:30 PM. Initially she was unable to recall when she last saw Resident #83 so she walked through the events of that night/early morning. She stated around 2:30 AM they finished moving another resident to a different room and she knew she last saw Resident #83 before beginning that move. She estimated the last time she saw Resident #83 was at approximately 1:30 AM. NA #1 stated she was unsure about the exact time because she didn't wear a watch. She indicated the last time she saw Resident #83 he was lying in bed and was awake. She did not recall what he was wearing. She stated she was very surprised he left the building because he moved very slowly. NA #1 stated Resident #83 frequently would take a geriatric chair (a padded chair with a wheeled base) and push it slowly down the hall. EMS records indicated a call was received from law enforcement at 2:59 AM on 1/22/24 and they were dispatched at 3:00 AM. Resident #83 was found outside approximately 1.9 miles away from the facility at 3:05 am. He was sitting on the ground with icicles hanging from his nose and beard. He indicated he was attempting to walk from home to the hospital because he felt sick. Resident #83 was cold to the touch and his temperature when taken read low. The main impression listed on the EMS report was hypothermia. He was treated with active rewarming and a space blanket was applied. He was transported to the local hospital. A phone interview was conducted with EMS Staff on 1/29/24 at 4:07 PM who stated Resident #83 was found on the side of the road on a sidewalk in front of a house. He reported Resident #83 was very close to an interstate highway. EMS Staff stated it was very cold and he believed the wind chill was in the teens or single digits. He stated there was no precipitation at that time. He stated Resident #83 had icicles on his nose and beard. EMS Staff stated Resident #83's speech was very garbled, but he stated he had been outside for 4 hours. He stated treatment for hypothermia was provided on the scene which consisted of active warming, heat packs in the arm and groin and a tinfoil blanket with several blankets on top. He stated the 911 call came from the police. Review of hospital records for Resident #83 for 1/22/24 revealed he was seen with a chief complaint of cold exposure. The record indicated he walked out of his facility and was found near an interstate highway by police and EMS. He was wearing a t-shirt and it was currently 19 degrees Fahrenheit out. He was cold to the touch but his core temperature was 99.6. degrees Fahrenheit. He was noted to be alert to self and was aware he was at the local hospital. He was unaware of the situation and was noted to be confused. His family member informed the hospital he resided at the facility and stated he must have wandered off. His facility was called and staff member was unaware patient was missing from the facility. Family indicated he was confused at baseline and had a hard time speaking since his most recent CVA (cerebrovascular accident) a few months ago. Diagnostic testing was completed and he was discharged back to the facility later that morning. Review of a nursing progress note revealed Resident #83 returned to the facility at approximately 10:15 AM on 1/22/2. Observation on 1/25/24 at 6:35 PM of the intersection where Resident #83 was found by EMS revealed a four-lane road with a turning lane. The street had a posted speed limit of 35 miles per hour. There were sidewalks on each side of the street. Mapquest.com indicated the location Resident #1 was found was 1.9 miles from the facility and approximately 0.2 miles to the interstate highway. The estimated walking time from the facility to the location he was found was 42 minutes. On 1/26/24 at 11:41 AM an observation was conducted with the facility Rehabilitation Director who measured the distance from Resident #83's room to the front door. The measurement was 128 feet. Observation on 1/26/24 at 1:52 PM revealed the front door of the facility faced a four-lane road with a speed limit of 40 miles per hour. The recorded temperature on 1/22/24 at 2:51 AM in the area the facility was located was 22 degrees Fahrenheit (www.wunderground.com). Attempts to interview Resident #83 were not successful. An interview was conducted on 1/25/24 at 2:50 PM with NA #2 who reported she was familiar with Resident #83's care. She stated he never indicated he wanted to leave the facility and she never observed him leaving the facility. NA #2 stated Resident #83 was intelligent. She added the way to leave the building was to push the black key fob and then push the silver button. NA #2 stated there was someone at the reception desk until midnight. She stated she felt Resident #83 may have watched staff open the door and figured out how to open the door. During an interview with Receptionist #1 on 1/25/24 at 3:02 PM she stated the front desk was staffed until midnight and the front door was always locked. For someone to leave, either the receptionist electronically unlocked the door or there was a key fob hanging above the silver button you pushed to unlock the door. There was a camera located at the end of the lobby area that viewed the front door. An interview was conducted with the Administrator on 1/25/24 at 4:30 PM who stated the camera located in the lobby area was not operational. Observation and an interview were conducted with the Administrator on 1/26/24 at 11:40 AM. The front entrance had 2 sets of double doors. The Administrator indicated the interior door was opened using a black key fob that was observed hanging on the door. He further revealed after the black key fob was used the handicap access button could be used open to the interior door. The Administrator was observed to push the black key fob, push the handicap access button and the interior double door opened. The exterior door did not require a key fob to open. It was operated by using the handicap access button. The Administrator was notified of Immediate Jeopardy on 1/25/24 at 5:35 PM. The facility provided the following immediate jeopardy removal plan with a removal date of 1/23/24. Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance The facility failed to prevent a Resident from exiting the facility unsupervised. Per report of EMS resident was noted laying on the side of the road. The facility staff reported last seeing the resident at approximately 1:30-2:00 a.m.; the resident was lying in bed. At approximately 3:30 a.m. the Licensed Nurse was made aware by the Charge Nurse in the local emergency department that the resident was being evaluated there, but no treatment was indicated, and transportation would be arranged to transfer the resident back to the facility. When the resident left the facility, he was not appropriately dressed for the cold weather conditions. He was wearing shoes, jogging pants and a short-sleeve shirt. Resident #83 had been brought to the Emergency Department by Emergency Medical Services who treated the resident for hypothermia in route to the hospital. Resident #83 was evaluated at the local hospital with no treatment indicated. The DON, Administrator, and Medical Provider were immediately notified. Resident #83's wife was notified. Resident #83 was admitted to the facility for long-term care on 11/18/23 with diagnoses including cerebral vascular accident. Resident #83 was assessed upon admission for elopement. Resident #83 was not High Risk on Wander Assessment completed on 11/18/23 and 1/18/24. Resident #83 is alert and oriented to person and place with a Brief Interview Mental Status Score of 0 on 1/11/24 Minimum Data Set. On 1/22/24 at approximately 4:00 a.m. the Administrator (NHA) conducted an Ad Hoc Quality Assurance Performance Improvement (QAPI) Committee meeting via telephone conference with Director of Nursing (DON), and Regional [NAME] President of Operations to discuss incident, review facility elopement policy and to initiate an immediate performance improvement plan based on root cause analysis. Root cause analysis determined that the facility failed to prevent a resident from exiting the facility by failure to ensure a staff member noted Resident #83 exited the facility. The facility doors were all checked and were secured and functioning. The Root Cause analysis determined that the resident was able to exit the front door by pressing the exit button and key fob release. To prevent recurrence, the QAPI Committee initiated a Front Door Protocol for after hours. The Receptionists work until 11:00 p.m. or 12:00 a.m. seven days a week. The Front Door Protocol includes the key fobs will be secured after hours by the Receptionist. One key fob will be locked in the cabinet behind the receptionist desk. The other key fob will be stored behind the receptionist desk in the plastic storage bin which is not accessible to residents. Beginning 1/22/23 all staff will be educated on the Front Door Protocol by the NHA, DON, Assistant DON, Business Office Manager, or their respective Department Manager prior to the start of their next shift. On 1/22/24 Resident #83 returned to facility at approximately 10:15 a.m. and was assessed by the licensed nurse without injury or pain and vital signs at baseline. An updated Wandering Risk Assessment was completed by the Licensed Nurse and scored High risk for elopement based on exiting the facility on 1/22/24. A wander guard placed to his right ankle and continuous 1:1 staff supervision initiated. His care plan, care card, and physician orders were updated accordingly by the Licensed Nurse to reflect the resident is now High Risk for elopement. The Elopement Binder at the nurses' stations and Receptionist Desk was updated. An Elopement Risk Binder is a binder which contains pertinent information about residents who are at High Risk for Elopement. This includes resident description and picture of the resident. A Post Trauma Assessment was initiated and completed by the Licensed Nurse on 1/22/24 and 1/24/24 with no changes from baseline completed on 11/18/23. Effective 1/22/24 Resident #83 will remain on 1:1 supervision until no longer indicated as determined by the Interdisciplinary team, Medical Director, and reviewed and approved by the Quality Assurance Performance Improvement (QAPI) Committee. The Interdisciplinary Team includes the DON, Assistant DON, Social Worker, Activities Director, Unit Managers, and NHA. QAPI Committee includes the Medical Director, DON, Assistant DON, Social Worker, Activities Director, NHA, Business Office Manager, Maintenance Director, Rehab Coordinator, and Unit Managers. Residents who exhibit exit-seeking behaviors, residents with cognitive impairment, and residents who are assessed as High Risk for Elopement are at risk of exiting the facility without supervision. On 1/22/24 at approximately 3:30 a.m., the facility initiated a 100% census verification by the Licensed Nurses and all residents accounted for and safe. On 1/22/24 all facility doors and windows and wander guard system doors verified as secure and properly functioning by the Maintenance Director and NHA. No concerns identified. On 1/22/24, the licensed nurses completed an elopement audit by updating Wandering Risk Assessments for all current facility residents to identify those at risk for elopement and to ensure an appropriate care plan and care card in place and current wander guard orders with monitoring for proper placement and function. Elopement risk binders were verified for accuracy, completeness and placement at nurse stations and reception desk with copy of resident profile, photo, and care plan by the Director of Nursing (DON). Residents were also reviewed for any behavior of removing and/or attempting to remove wanderguard device. No additional residents were identified as a current risk. On 1/22/24 the Administrator, Admissions Coordinator, Regional Marketing Director, and Social Services Director re-educated all current cognitively intact residents, with a BIMS of nine or greater, who are not at high risk of elopement to please notify the nurse if they would like to exit the facility. Each resident who was educated validated their understanding of the education provided. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete. Effective 1/22/24 a Front Door Protocol was initiated for after hours. The Receptionists work until 11:00 p.m. or 12:00 a.m. seven days a week. The Front Door Protocol includes the key fobs will be secured after hours by the Receptionist. One key fob will be locked in the cabinet behind the receptionist desk. The other key fob will be stored behind the receptionist desk in the plastic storage bin. On 1/22/24 the Administrator, Director of Nursing, Assistant Director of Nursing, and Unit Managers educated nursing staff regarding Assessment Wander Protocol, visually seeing each resident every two hours and the requirement for cognitively intact residents to sign out prior to leaving the facility, for resident safety. The Director of Nursing and Assistant Director of Nursing will ensure no staff will be allowed to work, including any newly hired staff and agency staff, without first receiving this education. Effective 1/22/24 a keypad lock was ordered to be placed at the front door as an additional measure to prevent residents from exiting the facility unsupervised. A code will be required to be entered to exit the facility. This additional measure will be implemented in conjunction with the key fob securing the front door. On 1/22/24 the Administrator and DON conducted an elopement drill with current facility staff and initiated elopement education with all current facility and agency staff. Education included 1) review of the Elopement policy, 2) Special emphasis on providing routine care rounds every two hours and as needed and visually observing each resident 3) Special emphasis on Front Door Protocol initiated with education provided to all staff 4) IDT including the DON, Assistant DON, Social Worker, Activities Director, Unit Managers, were educated by the NHA to review of residents at-risk for elopement during Monday - Friday morning meeting for changes of condition and behaviors and/or need for revision of care plan with communication to nursing staff with any changes. The NHA was educated on the preceding information by the Regional [NAME] President of Operations on 1/22/24 in order for the NHA to educate the IDT. Facility and agency staff not receiving initial education on 1/22/24 will not be permitted to work until education is completed. The Assistant Director of Nursing will be responsible for ensuring education completion. On 1/22/24 at approximately 4:00 a.m. the Regional [NAME] President of Operations provided education to the Administrator and DON on the elopement policy and facility responsibility of maintaining an effective process to prevent residents from exiting the facility without supervision to ensure safety. 1) Completion of root cause analysis identified front door key fob was not secured allowing resident #83 to exit the facility unsupervised. 2) Front Door Protocol to be initiated to secure the front door key fob after the receptionists leave 3) keypad lock to be installed at front door requiring a code to exit the front door after the receptionist leaves 4) interventions to prevent an unsupervised exit from the facility of an at-risk resident and ongoing monitoring to include every 2 hours and as needed visual observations of each resident in the facility, 3) interventions to enhance staff awareness of residents identified at risk and ongoing monitoring and 4) maintaining an effective QAPI program whereby the Interdisciplinary Team (IDT) monitors the effectiveness of the corrective action plan of the elopement prevention program and makes changes to the plan as necessary to maintain compliance with preventing residents from unsupervised exits of the facility. Newly hired DONs will receive education during the orientation process. Alleged date of immediate jeopardy removal: 1/23/24 Onsite validation of the immediate jeopardy removal plan was completed on 1/26/24. Interviews verified the facility had implemented an afterhours front door protocol where key fobs are secured after the receptionist leaves for the evening. Interviews confirmed nursing staff were educated on visually seeing each resident every two hours and the requirement for cognitively intact residents to sign out prior to leaving the facility. Education included review of the new front door protocol. Record review revealed an elopement drill was conducted 1/22/24. Record review also revealed the administrator and Director of Nursing were educated by the Regional [NAME] President of Operations on the elopement policy and the facility responsibility of maintaining an effective process to ensure residents did not exit the facility without supervision. Observation revealed a new front door keypad with a code required for entry and exit for staff. The immediate jeopardy removal date of 1/23/24 was validated.

Based on record review and staff interviews, the facility failed to provide written documentation in the medical record that advance directives information and/or opportunity to formulate an advance directive was provided or discussed with the resident or resident representative for 4 of 6 residents reviewed for advance directives (Resident #1, #11, #22 and # 49). Findings included: 1. Resident #1 was admitted to the facility on [DATE], and diagnoses included Diabetes Mellitus, chronic obstructive pulmonary disease and osteoarthritis. The annual Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #1 was cognitively intact. There was no documentation of education regarding formulation of advance directives and/or an opportunity to formulate an advance directive was offered in Resident #1's medical record. In an interview with Social Worker #1 on 1/24/2024 at 1:58 p.m., she stated the Social Worker was responsible for discussing advance directives on admission and re-admission with the residents. She explained in October 2023, the Corporate Office sent an email informing the Social Workers of the process on providing and documenting advance directives for residents. She stated prior to October 2023 when residents were admitted , she was only collecting and documenting the residents' code status during the care plan meetings and was not providing residents advance directive information to formulate advance directives. In an interview with the Administrator on 1/24/2024 at 3:02 p.m., he explained he was not aware of a change in the process for providing residents' advance directive information and the opportunity to formulate an advance directive. He stated advance directive information should be reviewed with the residents or a resident representative and documented in the medical record. 2. Resident #11 was admitted to the facility on [DATE] with diagnosis of Diabetes Mellitus and Chronic Obstructive Pulmonary Disease. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #11 was cognitively intact. There was no documentation of education regarding formulation of advance directives and/or an opportunity to formulate an advance directive was offered in Resident #11's medical record. In an interview with Social Worker #1 on 1/24/2024 at 1:58 p.m., she stated the Social Worker was responsible for discussing advance directives on admission and re-admission with the residents. She explained in October 2023, the Corporate Office sent an email informing the Social Workers of the process on providing and documenting advance directives for residents. She stated prior to October 2023 when residents were admitted , she was only collecting and documenting the residents' code status during the care plan meetings and was not providing residents advance directive information to formulate advance directives. In an interview with the Administrator on 1/24/2024 at 3:02 p.m., he explained he was not aware of a change in the process for providing residents' advance directive information and the opportunity to formulate an advance directive. He stated advance directive information should be reviewed with the residents or a resident representative and documented in the medical record. 3. Resident #22 was admitted to the facility on [DATE]. Diagnoses included dementia and Alzheimer's. The quarterly Minimum Date Set (MDS) assessment dated [DATE] indicated Resident #22 was severely cognitively impaired. There was no documentation of education regarding formulation of advance directives and/or an opportunity to formulae an advance directive was offered in Resident #22's medical record. In an interview with Social Worker #1 on 1/24/2024 at 1:58 p.m., she stated the Social Worker was responsible for discussing advance directives on admission and re-admission with the residents. She explained in October 2023, the Corporate Office sent an email informing the Social Workers of the process on providing and documenting advance directives for residents. She stated prior to October 2023 when residents were admitted , she was only collecting and documenting the residents' code status during the care plan meetings and was not providing residents advance directive information to formulate advance directives. In an interview with the Administrator on 1/24/2024 at 3:02 p.m., he explained he was not aware of a change in the process for providing residents' advance directive information and the opportunity to formulate an advance directive. He stated advance directive information should be reviewed with the residents or a resident representative and documented in the medical record. 37983 4. Resident #49 was admitted to the facility on [DATE] with diagnoses that included, in part, coronary artery disease and diabetes. The quarterly Minimum Data Set assessment dated [DATE] revealed Resident #49 had intact cognition. Resident #49's medical record was reviewed and there was no documentation of education regarding formulation of advance directives. On 1/24/24 at 9:25 AM, an interview was conducted with the Admissions Director. She explained there was a statement about advance directives, specifically code status, located in the admissions packet. She stated she had not provided any other advance directive information to residents upon admission but that the Social Worker reviewed advance directives with a resident and/or resident representative (RR) when she met with them after admission. During an interview with Resident #49 on 1/25/24 at 9:58 AM, she said the facility provided her with written information regarding advance directives when she first arrived at the facility. Social Worker #1 was interviewed on 1/23/24 at 2:29 PM. She explained she typically reviewed advance directives with the resident and/or RR upon admission and documented the discussion in a care plan meeting note when she met with the resident and/or RR. She verified she had not documented that advance directive information was shared with the resident and RR since she had not formally met with the resident and RR in a scheduled care plan meeting. In an interview with the Administrator on 1/24/2024 at 3:02 PM, he stated advance directive information should be reviewed with the resident or a resident representative and documented in the medical record.

Based on record reviews, resident representative interview and staff interviews, the facility failed to conduct quarterly care plan meetings with cognitive residents and/or resident representatives (Resident #22 and Resident #59) and failed to revise a resident's care plan requiring 1:1 supervision for behaviors (Resident #70) for 3 of 28 residents reviewed for care planning. Findings included: 1. Resident #22 was admitted to the facility on [DATE], and diagnoses included dementia and Alzheimer's disease. The Social Worker recorded on 3/5/2023 an initial care plan meeting was held for Resident #22. There was no further documentation of care plan meetings held for Resident #22 in the medical record. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #22 was severely cognitively impaired and required assistance with all activities of daily living. Previous quarterly assessments for Resident #22 were conducted on 8/20/2023, 6/15/2023 and 3/15/2023. In a phone interview with Resident #22's Representative on 1/23/2024 at 8:04 a.m., she stated she had not received invitations from the facility for Resident #22's care plan meetings. In an interview with the Social Worker on 1/24/2024 at 2:11 p.m., she stated since the beginning of January 2024, the MDS department have been notifying her when to schedule care plan meetings. She explained prior to January 2024, she was responsible for scheduling initial care plan meetings and was finding it difficult to keep up with scheduling the care plan meetings based on the MDS schedule. She stated Resident #22 had his initial care plan meeting on 3/5/2023. She explained she preferred to coordinate care plan meetings with the resident and resident representatives and then send out invitation letters, and she had reached out to the Resident #22's Representative with no reply. She further stated the Interdisciplinary Team (IDT) had not conducted a care plan meeting for Resident #22 because no new issues had been identified to address for Resident #22. In an interview with the Administrator on 1/26/2023 at 3:24 p.m., he stated care plan meetings should have been scheduled for Resident #22 with the IDT, if Resident #22 and/or Resident #22's representative was not able to attend, and information from the care plan meeting should be shared with Resident #22 and/or Resident #22's Representative. 37468 2. Resident #59 was admitted to the facility on [DATE]. Review of Resident #59's Minimum Data Set assessment dated [DATE] revealed he was assessed as cognitively intact. Review of a note dated 2/8/23 revealed the Social Worker attempted to schedule a quarterly care plan meeting with the resident's responsible party on 2/8/23. Review of a note dated 4/24/23 revealed the Social Worker attempted to schedule a quarterly care plan meeting with the resident's responsible party on 4/24/23. The Social Worker left a voicemail. Review of a note dated 9/20/23 the Social Worker attempted to schedule an annual care plan meeting with the resident's responsible party on 9/20/23. The resident's responsible party told the social worker he would call her back with a day and time he would be available for an annual care plan meeting. Review of Resident #59's chart revealed no care plan meeting was documented to have been held for Resident #59 during the survey period of 9/17/22 through 1/29/24. During an interview on 1/22/24 at 2:38 PM Resident #59 stated he did not know what a care plan meeting was and did not believe he had been involved in a care plan meeting. During an interview on 1/24/24 at 10:00 AM the Social Worker stated Resident #59 had a friend he requested to participate in a care plan meeting, and they also invited Resident #59 to his care plan meetings. She attempted to schedule one on 9/20/23 with the responsible party as requested by resident. The friend never called back. He was scheduled for another one this month, but the friend had not responded again. She stated because the resident had a responsible party and they did not respond to the care plan invitation, they did not hold care plan meetings for the resident. She stated she and the resident have had one on one meetings, but the resident had not had an official care plan meeting with the interdisciplinary team since she began working in October of 2022. She concluded she was responsible for setting up care plan meetings for residents and due to the resident's responsible party not responding to requests, Resident #59 had not had a care plan meeting during her time in the facility. During an interview on 1/24/24 at 10:11 AM the Administrator stated even when responsible parties were not available for care plan meeting or did not respond to request for care plan meetings, the interdisciplinary team should still conduct a care plan meeting with the resident quarterly. 39731 3. Resident #70 was admitted to the facility on [DATE] with diagnoses that included heart failure and hypertension. Resident #70's most recent quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed she had moderate cognitive impairment with no behaviors. Review of Resident #70's care plan revealed a focus related to attempts to leave the facility and outbursts initiated on 9/25/23 and reviewed 11/13/23. An intervention to address this focus was 1:1 supervision when the resident was out of bed. Review of Resident #70's medical record revealed no order for 1:1 supervision. Observations conducted on 1/23/24, 1/25/24, and 1/26/24 revealed she was found in her room out of bed with no 1:1 supervision present. An interview was conducted with Nurse #5 on 1/25/24 at 1:37 PM who stated she could not recall Resident #70 having 1:1 supervision. During an interview with Nurse Aide #3 on 1/25/24 at 1:40 PM, he stated Resident #70 required 1:1 supervision but it was discontinued approximately two months ago. An interview was conducted with Nurse Aide #2 on 1/25/24 at 1:45 PM who stated she recalled Resident #70 being on 1:1 supervision but she believed it was discontinued one month ago. During an interview with the Director of Nursing (DON) on 1/26/24 at 10:17 AM she stated when a resident required 1:1 supervision she would assign a staff member on each shift to provide 1:1 supervision until the resident's behaviors improved. She stated the Administrator would make the decision to discontinue 1:1 supervision after improvement in behaviors for several consectuive days. She stated she was not employed by the facility when Resident #70 had 1:1 supervision. The DON further stated Resident #70 no longer required 1:1 supervision and it should not be on her care plan. She stated it should have been discontined on the care plan when 1:1 supervision ended. She reported the MDS assessment nurse was responsible for updating the care plan. The MDS Nurse was unavailable for interview. During an interview with the Administrator on 1/26/24 at 11:15 AM he stated Resident #70's 1:1 supervision was discontinued on 11/3/23.

Based on record review, observation and staff interviews, the facility failed to complete and document in the electronic medical record weekly assessments and measurements of a resident's pressure ulcers for 1 of 3 residents reviewed for pressure ulcers (Resident #10). Findings included: Resident #10 was admitted to the facility on [DATE] with diagnoses including a Stage 4 pressure ulcer to the buttocks. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #10 was cognitively intact and was receiving treatments for two pressure ulcers. Resident #10's care plan dated revised on10/24/2023 include a focus for pressure ulcers, and interventions included administering, documenting and monitoring effectiveness of medications and treatments as ordered. Dietary documentation dated 10/27/2023 reported Resident #10 had been readmitted from the hospital due to osteomyelitis to the left hip and had a stage 4 left hip and ischium pressure ulcer. She reported Resident #10 received double meat and protein on meal trays and had refused supplemental and nutritional interventions since March 2023 to aid in wound healing. A review of the physician notes dated 12/14/2023 reported Resident #10 was hospitalized from 10/05/2023 to 10/20/2023 for an infected pressure ulcer and right hip osteomyelitis. Nursing documentation dated 12/21/2023 reported Resident #10 was seen at the wound clinic on 12/15/2023 and received new orders for treatment. Nursing documentation also reported due to receiving no measurements of the pressure ulcers on 12/15/2023, the wound clinic was called to gather information on the pressure ulcers measurements. Physician orders dated 12/21/2023 included an order to cleanse the left trochanter (hip area) and left ischium (buttocks area) with Dakin's solution (use to treat and prevent infections) and allowing Dakin's moistened gauze to soak in wound bed for 10 minutes. No sting skin prep was to be applied around the wound and collagen particles were to be applied into the wound bed. Calcium silver alginate was to be placed directly to the wound bed and the center of the wound filled with fluffed gauze, covered with pad dressing and secured with tape every other day Monday, Wednesday and Friday and as needed. Treatments of Resident #10's pressure ulcers were recorded as completed as ordered on the December 2023 and January 2024 Treatment Administration Record (TAR) except on 1/12/2024, 1/19/2024 and 1/22/2024. A review of the weekly pressure ulcer observations/assessments from January 2023 to January 2024 documented in the electronic medical record included the following four assessments: - On 2/17/2023, Wound 1: Stage 4 left ischium improving with moist granulation present and measured 8 x 7.5 x .4 centimeters (cm). Wound 2: Stage 4 left trochanter healing and measured 5 x 6 x 0.2 cm. - On 7/7/2023, Wound 1: Stage 4 left buttocks was recorded as unchanged with slow and steady improvement, moist and granulated. Measurements were recorded as 9.2 x 7.8 and 1.7 cm and undermining. Wound 2, the left trochanter was recorded as unchanged, moist and granulated with no odor. Measurements were recorded as 4.5 x 4.7 x .4 cm. - On 7/21/2023, the left buttocks pressure ulcer was measured at 9.2 x 7.8 and 1.7cm and recorded no change in the pressure ulcer. - On 12/5/2023, wound observations reported notification of wound clinic for assessment of the pressure ulcer to left trochanter and left ischium. Wound observation stated Resident #10's pressure ulcer had a large amount purulent drainage with no odor and measured 9.5 x 8.5 x3 cm. There were no further weekly pressure ulcer observations/assessments found in the electronic record. A review of physician wound clinic notes in the electronic medical record from January 2023 to January 2024 included the following three assessments of Resident #10's pressure ulcers: - On 3/29/2023, the wound clinic recorded a large deep wound to the left buttocks area half of the size to the left side of the upper hip area (left trochanter and left ischium). There were no measurements recorded in the report. - On 8/9/2023, the wound clinic recorded the left trochanter (hip) had improved and measured 5 x 4.9 x .4 cm and was undermining. The left buttocks measured 7.3 x 9.5 x2 cm with undermining. - On 9/12/2023, the wound clinic reported moderate drainage from the pressure ulcers. The left ischium was recorded having 30 % granulation, no slough and 50 % exudate with a minimal odor that connects with the left trochanter pressure ulcer. The wound clinic recorded there were no signs of infection. The left trochanter pressure ulcer was recorded having 90% slough with no bone and no obvious impediments to healing and the area was debrided with minimal odor noted. The left hip and trochanter area was reported measuring 10 x 9.5 x 2 cm with undermining. The wound clinic also reported an odorless unstageable area to the sacrum measuring 0.8 x 0.6 x 0.2 with 100 % slough that was debrided. The physician wound clinic note recorded osteomyelitis to the left hip and regression of the healing process to the left trochanter pressure ulcer significantly worse and a new sacral injury due to unrelieved pressure. The facility did not provide any further physician wound clinic notes to review. On 1/26/2024 at 10:17 a.m., Wound Nurse #1 was observed providing treatment to Resident #10's left trochanter and left ischium pressure ulcer as ordered by the physician practicing infection control measures. The old dressing was saturated with large amounts of purulent drainage that had a momentarily mild foul odor and the pressure ulcer was covered with scattered areas of the purulent material with pink granulation tissue observed underneath to the pressure area. The left trochanter and left ischium pressure ulcer was observed with no purulent material and only pink granulated tissue after soaking and cleansing with the Dakin's solution for ten minutes. Wound Nurse #1 measured the pressure ulcer as 17.5x 7.5x 2.5cm and noted healing was occurring from the center at the bottom of the pressure ulcer in an upward direction. In an interview with the Wound Nurse #1 on 1/25/2024 at 11:11 a.m., she stated she had been the wound nurse for the facility since September 2023. She explained weekly assessments of pressure ulcers were conducted on Tuesdays when the facility's wound physician made rounds. She explained during these weekly rounds, pressure ulcers were assessed, measured and treatments changed as needed. She stated she was responsible for entering the assessments into the weekly wound care report on the electronic medical record (EMR). When asked why there were not weekly pressure ulcer assessments documented in Resident #10's EMR, she stated because Resident #10 was not seen by the facility's wound physician. She further stated she had not been conducting weekly assessments and measurements on Resident #10's pressure ulcers because Resident #10 was seen at a wound clinic outside the facility monthly. She explained Resident #10's pressure ulcer assessments were completed during wound clinic visits, and the assessments were not always received after the wound clinic visit to document in Resident #10's electronic medical record. She stated she changed Resident #10's dressing every other day on Monday, Wednesday and Friday as ordered, and Resident #10's pressure ulcer was improving. She said she forgot to document treatment was provided to the pressure ulcers on 1/12/2024, 1/19/2024, and 1/22/2024 on the TAR. In an interview with Director of Nursing on 1/25/2024 at 12:15 p.m., she explained pressure ulcer assessments and measurements were to be completed weekly. She stated Wound Nurse #1 was responsible for completing and documenting the weekly assessments, measurements and treatments for Resident #10's pressure ulcers in the electronic medical record.

Based on observations, staff interviews, interview with a local public health department nurse and review of the facility's COVID Response Plan (aka: COVID Management Plan) and Transmission Based Precautions Definitions Guidelines Policy, the facility failed to develop a plan that addressed transmission-based signage for the quarantine unit and the correct use of PPE by staff for residents who were new admissions and re-admissions. The facility failed to post the required enhanced droplet and contact precaution signage on the quarantine unit which specified the personal protective equipment (PPE) staff were to use on the unit, staff (Nurse #2, Activity Staff #1) failed to wear the required PPE, which included protective eyewear, gowns, N95 mask and gloves when they entered resident rooms on the unit and personal protective equipment (PPE) was not observed outside the rooms on the quarantine unit for newly admitted and readmitted residents. The Activity Staff #1 also failed to remove PPE before exiting Resident's #2 room. These failures affected 17 of 17 residents who resided on the facility's quarantine unit. These failures occurred during the COVID-19 pandemic.(Residents #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17). The facility failed to complete the screening process for 1 of 1 visitor. Immediate Jeopardy began on 10/20/20 when observations and staff interviews revealed COVID-19 infection control measures were not implemented on the designated quarantine unit including no transmission-based signage was posted, no PPE was available outside of resident rooms for staff to utilize and Nurse #2 failed to wear the required PPE when they entered resident rooms on the unit. On 10/27/20, activity staff #1 failed to wear the required PPE for enhanced droplet precautions into Residents #2 room and failed to removed the gown and gloves before exiting Resident's #2 room. The Immediate Jeopardy was removed on 10/28/20 when the facility provided and implemented an acceptable allegation for Immediate Jeopardy removal. The facility remains out of compliance at a lower scope and severity level of an E (no actual harm with the potential for more than minimal harm that is not immediate jeopardy) to ensure monitoring systems put into place are effective. Example # 2 is cited at a scope and severity of D. The findings included: 1. The facility's COVID Response Plan (aka: COVID Management Plan) updated June 2020 stated all new and readmissions are placed on the quarantine unit in a room by themselves for 14 full days, and the required PPE on quarantine units were N95 masks, gloves. A gown and face shields were worn as needed in resident rooms. The COVID Response Plan did not address transmission-based signage for the quarantine unit or the correct use of PPE for residents who were new admissions or readmissions. The facility's undated Transmission Based Precautions Definitions Guidelines Policy stated for contact isolation remove gloves before leaving the room and perform hand hygiene. Disposable gowns were worn upon entering the room and after removing the gown, do not allow clothing to contact portentially contaminated environmental surfaces. A positive COVID 19 person or a person under investigation for COVID-19 was on droplet precautions and included a mask, gown, and eye protective wear based on the Centers of Disease Control and Prevention guidelines. The policy did not state where or how to remove the gown, mask, or eye protective wear. The Centers of Disease Control and Prevention Create a Plan for Managing New Admissions and Readmissions Whose COVID-19 Status is Unknown dated June 25, 2020 states depending on the prevalence of COVID-19 in the community, this might include placing the resident in a single-person room or in a separate observation area so the resident can be monitored for evidence of COVID-19. HCP should wear an N95 or higher-level respirator (or facemask if a respirator is not available), eye protection (i.e., goggles or a face shield that covers the front and sides of the face), gloves, and gown when caring for these residents. Residents can be transferred out of the observation area to the main facility if they remain afebrile and without symptoms for 14 days after their admission. Testing at the end of this period can be considered to increase certainty that the resident is not infected. On 10/20/20 at 8:06am during the entrance conference, the Administrator stated the facility had a quarantine unit. He stated the quarantine unit was for new admission residents, residents readmitted after greater than 24 hours out of the facility, and COVID-19 positive residents that were asymptomatic for 10 days before moving to the quarantine unit for 10 days before returning to the general population of the facility. He explained there had been no positive staff or resident COVID-19 cases in the past 2 weeks, and the COVID-19 unit had been disassembled. The administrator stated since April 2020, there had been no Infection Preventionist in the facility, and the Director of Nursing and the Administrator were performing the infection control tasks. On 10/20/20 at 9:11am, the quarantine unit in the middle hallway (room [ROOM NUMBER]-74) of the facility was observed with no droplet and contact transmission-based signage noted at the entrance of the quarantine unit. There were six residents (Resident # 1, #2, #3, #4, #5, #6) located on this part of the quarantine unit. Residents #6 and #4, who were admitted on [DATE] and 9/24/20, were on contact isolation for shingles and extended spectrum beta-lactamase (ESBL) in urine, and a contact isolation signage and personal protective equipment was observed outside their rooms. The other four rooms were observed with no droplet and contact transmission-based precaution signage or PPE outside the room. Residents #1, #2 and #5 were new admissions on 10/6/20, 10/19/20 and 10/9/20, and the other Resident #3 was admitted on [DATE]. On 10/20/20 at 9:54am, the call light in Resident's #1 room on the quarantine unit was observed lit. Nurse #2 was observed entering the room wearing a KN95 mask only. No transmission-based precautions signage was observed outside on the door or wall. No PPE was observed outside the room for the staff to use. Resident #1 was admitted on [DATE] to the facility. On 10/20/20 at 10:13am, an interview was conducted with Nurse #2. She stated the quarantine hall was for residents on contact isolation and for residents admitted from the hospital. She stated PPE was required for the residents on contact isolation, and Resident #1 was not on contact isolation and only required a mask and gloves for resident care. Nurse #2 stated she had received in-services training on COVID to look for changes in the resident ' s status. On 10/20/20 at 9:58am, Nurse #3, who was assigned to the quarantine unit (Rooms 51 to 74) was interviewed. Nurse #3 stated standard precautions were used for the quarantine residents. He stated mask and gloves were only required unless the resident was on contact isolation for non-COVID related issues. Nurse #3 stated he had received COVID training on wearing a mask at all the time, hand sanitation and monitoring new and re-admissions for 14 days for signs and symptoms of COVID. Nurse #3 stated there was sufficient PPE in the facility. On 10/20/20 at 11:44am, an interview was conducted with the Director of Nursing (DON). The DON stated the quarantine unit was for re-admissions and new admissions, residents on isolation for other reasons than COVID and residents with signs and symptoms of COVID that had tested negative for COVID. The DON stated the quarantine unit had been set up for months and stated the CDC guidelines and the Corporate ' s COVID plan were used to set up the quarantine unit. The DON stated re-admission and admission residents required staff to just wear a KN95 mask and were quarantine for 10 days. She stated the type of isolation the resident was on determined the PPE requirements. The DON denied the facility having any issues with sufficient supply of PPE. The DON stated Nurse #3 ' s assignment consisted of the quarantine hall (Rooms 51 to 74), and all staff had been trained to work the quarantine unit. The DON stated since April 2020 the facility was without an infection preventionist or staff development person, and that she and the Administrator were addressing infection control concerns. On 10/20/20 at 4:22pm in another interview, the DON stated the quarantine rooms 51-62 were used for [MEDICAL TREATMENT], rehabilitation, and new admissions also if needed. On 10/20/20 at 4:40pm, the DON stated the facility was informed by Corporate on the COVID updates and infection control measures. On 10/20/20 at 1:20pm, an interview was conducted with the administrator. The Administrator stated there was no one in the facility trained as an infection preventionist. He stated the quarantine unit was used for new admissions, re-admissions and residents exposed to COVID. He stated the required PPE for the quarantine unit was a KN95 mask and gloves were located in the rooms. He specified full PPE was required if the residents on the quarantine unit were on any type of isolation other than COVID. The administrator explained the facility tried to use the same staff for the quarantine unit and were designated to staff only the quarantine unit which included rooms 51-74. He stated he conducted in-services to communicate which residents were on quarantine to the staff and quarantine meant assessing for sign and symptoms of COVID. On 10/20/20 at 4:22pm, in a follow up interview, the administrator stated new admissions were admitted to the quarantine unit rooms 63-74 first and to rooms 51-62 as needed. On 10/20/20 at 4:45pm in a follow up interview, the administrator noted he provided weekly updates with the Durham County Health Department. He stated he had informed the health department on how the units were set up, but he did not go into detail about signage or PPE requirements. On 10/20/20 at 5:20pm, the administration stated updated CDC guidelines were sent from Corporate and the Administrator and the DON were responsible for implementing new CDC guidelines. On 10/20/20 at 4:12pm, Nurse #4 of the Durham County Health Department stated a visit was made on 8/13/20 to the facility. She stated the facility was given guidance on setting up a COVID unit and recommended having a space for the new admissions to be quarantine for 14 days. The nurse stated the facility was informed to treat the quarantine unit like a COVID unit and wear full PPE (mask, gowns, gloves, eye wear). She reported the facility had a total of 5 residents (Residents #19, #22, #23, #24, #25) and 5 staff (Nurse # 5 and #6, Dietary staff #1, Housekeeping staff # 1, and Therapist #1) to test positive, and the last two weeks the facility reported no positive COVID-19 test for staff or residents. On 10/20/20 at 4:30pm, rooms 51-62 of the quarantine unit was observed with no transmission-based signage on entering the quarantine unit or posted on the resident doors, and no PPE was observed outside rooms 51-62 for staff to use. There were 11 residents (Residents #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17) residing on this part of the quarantine unit. Residents #7, #8, #10, and #14 were new admission or re-admission residents in the last 14 days. On 10/27/20 at 12:45pm, the activity staff #1 was observed exiting Resident's #2 room wearing a mask, gown and gloves. The activity staff #1 was not wearing protective eye wear. Resident's #2 room was located on the designated quarantine unit, and an enhanced droplet precautions signage was observed on Resident's #2 door. She walked down the hall before returning to Resident's #2 door. The activity staff #1 opened Resident's #2 door and reached inside the door before removing the gown and gloves in the hallway. The gown and gloves were placed in the trash can on the medication cart located in the hallway. On 10/27/20 at 12:47pm, an interview was conducted with the activity staff #1 . The activity staff #1 stated she was in Resident #2 room to gather a list of things the resident needed from the store. She stated she was aware Resident #2 was on the quarantine unit and required full PPE: mask, gloves, gown and protective eyewear. She admitted not wearing protective eye wear into Resident #2 room and noted eye wear was available outside the resident room inside the PPE containers, but she was only in the Resident's #2 room to ask the resident a question. She stated she had received training on donning and doffing PPE and did not remove the gown and gloves before exiting Resident's #2 room. She stated she walked down the hall to her office to get Resident's #2 social security card and identification card to return to the resident. A phone interview was conducted on 10/31/20 at 10:45 a.m. with the Administrator notifying him that Immediate Jeopardy was identified at tag F-880. The facility's credible allegation of immediate jeopardy removal for F-880 Infection Prevention and Control included the following: Allegation of Immediate Jeopardy removal F880 Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance: The initial deficient practice occurred when the facility failed to correctly screen visitors in a manner consistent with facility policy and guidance from the Centers for Disease Control and Centers for Medicare and Medicaid; and, when all residents in quarantine were placed at risk of being exposed to infection by staff who would enter rooms without signage to communicate precautions and the type of personal protective equipment required. One visitor was permitted to enter the facility without answering the screening questions included on the screening tool for signs and symptoms of COVID 19. Upon visitor ' s entry, Nurse #1 went to the medication cart, got a thermometer and took the visitor ' s temperature, then escorted the visitor to the front lobby without validating the screening questions with the visitor. Facility designated quarantine rooms 51-74 did not have signage to designate the type of isolation or PPE needed for safe caregiving. Staff could enter rooms without knowing the occupant's COVID status creating an opportunity for a staff person to be exposed to infection thus potentially spreading it to others. These practices were observed on 10/20/20. On 10/21/20, the director of nursing completed a review of all current residents and identified those who have been admitted to the facility within the last 14 days, residents who were discharged >24 hours, and those who were potentially exposed to COVID-19 to ensure that they are properly placed in designated quarantined rooms, that proper signage was outside of their doors and that PPE was readily available for staff use. October 27, 2020, during revisit of October 27, 2020, it was reported that surveyor observed the Activities Director coming out of a patient room in PPE (gown, gloves, mask) but was not wearing face shield/goggles. When the employee exited the room, she discarded of the PPE she was wearing inside of the trash bin located on the nurse medication cart. The Director of Nursing completed retraining with the Activities Director to provide re-education on COVID 19 precautions, including what PPE is to be worn in each quarantine room, (face covering or goggles, N95 mask, gloves and gown), that PPE is to disposed of prior to leaving resident ' s room, and to wash and sanitize hands when leaving the room. The Activities Director received a disciplinary coaching for not being donned in full PPE when entering resident ' s room and failing to dispose of it before exiting. Specify the Action the Facility will take to alter the process or system failure to Prevent a Serious Outcome from occurring or reoccurring and when the Action will be complete. 10/27/20, Corporate Support Nurse provided retraining to the Administrator, Director of Nursing and Unit Manager, regarding the requirements of wearing full PPE (i.e. mask, gloves, gown, eye protection) when entering resident rooms who have been placed on quarantine. The education included the cleaning process of eye protection, location of the quarantine rooms, appropriate signage of residents ' room door who are being quarantined, screening process of visitors, employees and contract vendors. The Administrator and Director of Nursing reeducated current staff onsite on 10/27/20 from all departments Including nursing, dietary, housekeeping, activities, social work, therapy and administration regarding the requirements for entering through a single point of entry and exit for the facility , the required use of the sign in log upon entry, the requirements of documenting their temperature and disclosure of any contacts or signs and symptoms. This procedure is required for every person who enters the facility, whether in contract capacity or an employee. Any such staff who was not in the facility on 10/27/20 was in-serviced by phone and competency evaluated by return demonstration by Administrator as they reported for their next assigned shift. All staff is required to complete this training prior to working in the facility. For those who are educated by a trained and competency evaluated staff person is responsible for either taking the individuals ' temperature or witnessing the individual properly taking their own temperature, validating the reading and observing the correct entry being made, and completing the screening questions. The facility administrator and Interdisciplinary team (includes social worker, MDS nurse, Activities Director, Director of Nursing, and Unit managers) will perform random interviews with staff to validate that the screenings questions have been asked and documented correctly on the screening tool. On 10/20/20 Implemented new process of screening from during 7am to 7am the following day. There is an employee assigned daily by the Administrator and ensures that all visitors and employees/visitor sign in and complete the questionnaire and temperatures are taken, and properly logged and the mask is obtained and donned. Designated employees have been trained by the administrator on the screening process to ensure thorough completion of the form and validity. All new hires will receive this education as part of orientation, by the DON and/or Administrative Nurse. Training on this process was performed again and provided to designated monitors of the screening process on 10/27/20. The Administrator, unit manager and Director of Nursing were re-educated by a SPICE TRAINED nurse from sister facility on 10/22/20 regarding the quarantine criteria that includes proper signage on a resident ' s door to indicate the type of PPE to be worn upon entering the room in addition to which residents require precautions. Once trained, the administrator and DON reeducated current staff including nursing, dietary, housekeeping, activities, social work, therapy and administrative staff, on 10/27/20, regarding infection control, including the use of appropriate PPE, enhanced droplet precautions, signage, hand hygiene, on the quarantine unit. The Enhanced droplet precautions included are to remain in place at a minimum of 14 days. The signage indicates what PPE is to be worn upon entering the room for an Enhanced droplet-contact precaution resident which are surgical mask, eye protection, gown and gloves. All requirements for the quarantine areas are mentioned in the Company ' s COVID Management Plan. The COVID Management plan is a document that the facility uses as guidance to minimize the potential for a COVID 19 outbreak in the facility, and how to properly manage it should one occur. The components mentioned in the plan on how to operationally manage the quarantine area, have been shaped by the Isolations-Precaution Policy. Every resident who resides in designated quarantine rooms, are to be cared for according to the Isolation-Precautions Policy which includes the use of full PPE (surgical mask, eye protection, gown and gloves). Should a resident complete their quarantine period and remain asymptomatic of COVID 19 symptoms, and a room not be available in the general population, that individual will remain on the designated quarantine unit until a room is available. Additionally, signage will be removed from the outside of their room, to indicate that the individual is no longer under quarantine observation, and can be cared for using standard PPE protocol, (N95 mask, K N95 mask, and gloves.) This reeducation also included the location of quarantine rooms, proper PPE to be worn while on a quarantine unit, proper donning and doffing of PPE. The remainder of staff will be in-serviced on this plan by telephone by the Unit manager and review the plan in person when they arrive for their next assigned shift. No person will be permitted to work on the floor until completing the in-service regarding this plan. The corporate COVID task force updated the COVID Management Plan as of 10/22/20 and will continue to update to remain current with Centers for Disease Control (CDC) guidance and Centers for Medicare and Medicaid (CMS) requirements as the information around managing the pandemic evolves. Any staff who would enter a room with enhanced droplet -contact precautions Isolation signage will understand that when entering the room for any reason the following personal protective equipment is worn at a minimum a surgical mask, face shield, a gown, and gloves. Corporate COVID task force will be responsible for updating the COVID-19 management plan based on CDC and CMS guidelines. The facility Administrator will ensure that any updates to the COVID-19 management plan will be implemented at the facility level through education completed by the Director of Nursing and/or administrative nurse with facility staff and conduct observation rounds to ensure compliance. As of 10/22/20 Rooms 53-62 have been designated as the quarantine rooms for 14-day observation period. During this quarantine, newly admitted , readmitted residents, and residents who have possibly had a COVID exposure, are housed in order to monitor for signs and symptoms of COVID 19. Signage has been placed on the door of each person in the quarantine area that requires enhanced droplet-contact precautions. Although our goal is for these residents to have specific staff in the case of staff member leaving this area to assist elsewhere the requirements for PPE must be maintained. The Admissions director, person responsible for assigning new and readmission room assignments has also been educated on the updated designated area for 14-day observation on 10/21/20 by Unit manager, as well as the Director of Nursing who will ensure proper signage for these individuals. Surveillance of proper signage of quarantined individuals as well as full PPE use while caring for these residents during this period, will be performed by the Director of Nursing and Admissions Director. On 10/21/20, the director of nursing completed a review of all current residents on quarantine unit to ensure proper placement of signage, PPE is readily available for staff use and all residents have been placed in designated quarantine rooms. Any individual found not to be in compliance with any of the COVID protocols set forth by the facility, will receive a disciplinary coaching as well as re-education on the correct practice. The facility alleges the removal of the immediate jeopardy on 10/28/20. The Administrator is responsible for assuring corrective actions to ensure continued compliance. As part of the validation process on 11/03/2020, the credible allegation was reviewed which included dates and content of the in-services that were conducted and dates and content of the audits that were completed. A review of all current residents and new admissions to the facility within the past 14 days who were potentially exposed to COVID-19 showed new admissions were placed in the designated quarantined rooms that had proper signage posted on the doors and PPE was readily available for staff to use. A review of the in-service dates and content of the screening process ensured that all visitors and employees/ visitors sign in and complete the questionnaire and temperatures are taken. A review of the COVID Management Plan revealed it was updated on 10/22/20. A review of rooms 53-62 showed that those rooms were designated as the quarantine rooms with proper signage posted. On 11/03/2020, the facility's Immediate Jeopardy removal date of 10/28/2020 was validated. 2) The facility's COVID Response Plan Policy (aka: COVID Management Plan) updated June 2020 stated all visitors and non-essential staff were restricted and 100% staff entering or exiting the center were screened with questionnaire and temperature checks by a competent staff member. The Centers of Disease Control and Prevention Preparing for COVID-19 in Nursing Homes updated July 15,2020 infection control guidance stated to screen everyone (patients, healthcare personnel, visitors) entering the healthcare facility for symptoms consistent with COVID-19 or exposure to others with [DIAGNOSES REDACTED]-CoV-2 infection. The screening consisted of actively taking a temperature and documenting absence of symptoms consistent with COVID-19. On 10/20/20 at 7:30am, the front door of the facility was locked, and a sign on the front door directed visitors to the employee entrance on the side of the building. On 10/20/20 at 7:33am, Nurse #1 unlocked the facility ' s employee entrance door for the surveyor to enter the building. There was no active screening station observed at the employee entrance. Nurse #1 requested the nurse to stand at the door and went to a medication cart for a thermometer. Nurse #1 checked the surveyor ' s temperature and then escorted the surveyor to the front lobby. Nurse #1 did not ask the surveyor any COVID-19 screening questions. On 10/20/20 at 8:06am, during the entrance conference the administrator stated employees were entering the side entrance of the building for COVID screening and the receptionist had a thermometer at the front desk to screen any visitors entering the front door. On 10/20/20 at 9:11am, a screening station was observed at the employee entrance. The activity staff #2 was observed sitting at the employee's entrance with a big 3-ring binder on an over-the-bed bedside table. The 3-ringer binder contained alphabetically each employee's screening log sheet. On 10/20/20 at 9:16am, an interview was conducted with the activity staff #2. She stated since COVID-19 she had been assigned to work the employee entrance from 9:00am to 5:00pm to screen individuals entering the facility. She stated when staff entered the employee's entrance door, she checked their temperature and asked them the COVID-19 questions before the staff were allowed to report to work. She stated the receptionist screened the staff entering the building before she reported to work. On 10/20/20 at 10:59am, an interview with Nurse #1 was conducted. She stated she arrived to work late that morning and entered the building at the employee's entrance. She stated a nurse performed her COVID-19 screening that included a temperature check, answering the COVID-19 screening questions and completing the employee log sheet. Nurse #1 stated, I didn't ask you the questions this morning and stated she did not because she was apprehensive due to the person being a surveyor. Nurse #1 further stated when the COVID-19 screener was not present at the employee ' s entrance, the nurse assigned the back hall conducted the COVID screening. She denied being trained on how to conduct the COVID-19 screening and stated, We just do it. On 10/20/20 at 11:12am, Nurse's #1 employee log sheet for 10/20/20 was observed completed with a temperature recorded and no answered for the questions. When the surveyor informed Nurse #1 no one recorded her temperature that morning upon entering the facility, Nurse #1 pointed to a log sheet at the front of the 3-ring binder. The state surveyor ' s name was observed on a log sheet with a temperature recorded and each COVID-19 question was answered with a no answer. At that time, Nurse #1 asked if the surveyor would answer the questions. Nurse #1 read each question and the surveyor answered, at that time, the COVID-19 screening questions No. On 10/20/20 at 11:29am, an interview was conducted with the receptionist staff #1. The receptionist staff #1 stated she reported to work that morning around 7:30am after the surveyor entered the building. She stated she worked the entrance screening area when needed and stated her temperature was checked and was asked the questionnaire by the activity staff #2 that day. On 10/20/20 at 4:20pm in a follow up interview, the receptionist stated she was assigned to work the front desk and denied normally working the employee screening area. She stated she went to work the employee entrance the morning of 10/20/20 because the Administrator asked her to fill in that morning. On 10/20/20 at 11:44am during an interview with the Director of Nursing (DON), the DON stated employees and visitors entered the building through the employee ' s entrance, and the back-hall nurse was responsible for conducting the screening process until the activity assistant reported to work. The DON stated staff had been in-serviced on the screening process, and Nurse #1 did not perform the screening process correctly when she screened the surveyor on 10/20/20. On 10/20/20 at 1:20pm, an interview was conducted with the administrator. He stated the COVID-19 screening process was conducted at the employee's entrance, and the screening process included a temperature check and the questionnaire recorded on the log sheet. The Administrator stated he monitored the log sheets daily for recorded temperatures and answers to the questions.

Based on observations, record review, staff interviews, the facility failed to provide supervision to prevent a cognitively impaired resident who exhibited exit seeking behaviors from exiting the facility while unsupervised for 1 of 4 residents (Resident #1) sampled for accidents. Resident #1 exited the facility and was unaccounted by staff for a 75 minute period in the late afternoon of 1/26/19, and was returned to the facility by the police with severe agitation, but without any physical injuries. Findings included: Resident #1 had been admitted on [DATE]. Her admitting [DIAGNOSES REDACTED]. On 1/9/19 an Unsafe Wandering Risk Evaluation was completed and was noted Resident #1 with impaired cognition, impaired decision making, decreased safety awareness and not at risk for elopement. On 1/18/19 an Admission Minimum Data Set (MDS) indicated Resident #1 had severe cognitive impairment. No wandering was noted and she did not ambulate. She required extensive assistance with mobility on and off of the unit, bed mobility, transfers, toileting and hygiene. She received insulin, antidepressant and anticoagulant medications. On 1/25/19 at 1:14 PM nursing documentation indicated Resident #1 had been alert, oriented and confused. She had an order for [REDACTED].#1 would stand and walk. She had been redirected every episode, and family members were notified. On 1/25/19 at 1:55 PM an Unsafe Wandering Risk Evaluation was completed by Nurse #8 and noted Resident #1 had been cognitively impaired, frequently paced or wandered in areas without purpose, impaired decision making with decreased awareness of safety. Resident #1 had expressed a desire to leave the center and anger at being in the facility. Wanderguard placement was recommended. On 1/25/19 at 3:08 PM nursing documentation, written by Nurse #8, noted Resident #1 had been discovered wandering all over facility this shift. Her cognition was impaired and a wanderguard had been placed on her right ankle to prevent elopement. Resident #1's Responsible Party (RP) had been made aware of the wanderguard placement. On 1/25/19 a care plan was initiated for Resident #1 regarding elopement risk and wandering as evidenced by Resident #1 having a decreased safety awareness, history of wandering, verbalization of wanting to leave and exit seeking. Interventions included to address wandering behavior, attempt to redirect from inappropriate areas, engage in diversional activity, at risk for fall, evaluate need for additional supervision, photo in wander notebook, wander alert bracelet place and check placement every shift. On 1/26/19 at 2:24 AM nursing documentation, written by Nurse #9, indicated Resident #1 had been alert and oriented to person and place and had appeared very confused this shift. Resident getting up and down out of bed throughout the night and staff had been unable to redirect her. On 1/26/19 at 5:13 AM nursing documentation, written by nurse #9, indicated Resident #1 had continued to be confused and had exit seeking behaviors. Resident #1 had been walking around the building going to every door pushing it trying to get out. The Nurse Aide (NA) and the nurse were monitoring Resident #1 as she walked around building, wanderguard intact. A time line of events of Resident #1's unsupervised exit from the facility on 1/26/19, was provided by the facility: On 1/26/19 at 4:15 PM Resident #1 had been seen by facility staff sitting in a wheelchair in her room and propelling herself in the wheelchair. Staff had asked Resident #1 if she needed anything and she declined. On 1/26/19 at 4:45 PM the NA #8 went into Resident #1's room to make rounds and noticed that Resident #1 was not in her room. The NA immediately began to look in the facility for Resident #1. A search was conducted per the elopement protocol. On 1/26/19 at 4:50 PM the nurse manager and staff were looking to determine whereabouts of Resident #1 in the facility. On 1/26/19 at 5:00 PM the Executive Director (ED), Director of Nursing (DON), Assistant DON (ADON), the RP, physician and the police were all contacted regarding Resident #1's status. On 1/26/19 between 5:00 PM-5:15 PM the search for Resident #1 was being conducted inside and outside of the building. NA #8 who was conducting a search outside of the building had gone to the auto parts store next door and she had been informed that Resident #1 had been seen getting in a police car. During this time the ED, Director of Maintenance (DM), ADON and DON had arrived in the facility to assist staff with the search and to ensure the elopement process was being completed. On 1/26/19 at 5:20 PM NA #8 returned to facility and informed the charge nurse of her discoveries, the charge nurse then called the police to determine the whereabouts of Resident #1. The charge nurse was informed by the police officer that Resident #1 had requested a ride to the YMCA and had indicated she was employed there. The police officer then informed the charge nurse he would go back to the YMCA to retrieve Resident #1. On 1/26/19 at 5:30 PM Resident #1 had been returned to the facility by the police officer. No injuries to Resident #1 were observed. On 1/26/19 between 5:30 PM and 5:45 PM Resident #1's family had been notified of Resident #1's return to facility and status. The physician had also been notified. On 2/8/19 at 1:00 PM a telephone interview was conducted with the Nurse Aide #8 who had cared for Resident #1 at the time of the elopement and was the last staff member to see her prior to her unsupervised exit from the facility on 1/26/19. NA #8 stated she had started her shift on 1/26/19 at 3:00 PM and had observed Resident #1 rummaging in her closet. Sometime after 4:00 PM, the NA had come around again to prepare Resident #1 for dinner but Resident #1 was no longer in her room. The NA stated she walked around the building looking for Resident #1 and asked other staff if they had seen her. An elopement code was then called by one of the nurses. The NA stated she looked out the front door and had observed Resident #1's wheelchair (WC) outside. The NA went outside and to the auto parts store next door. The clerk there had indicated Resident #1 had been there and had asked for a ride. The clerk had called the police who came and picked up Resident #1. The NA stated she returned to the nursing facility and reported all these findings to the supervisor. On 2/8/19 at 12:11PM an interview with Nurse #6 who had been present the time of the elopement. She stated she had been in a room and had not heard the elopement code called but stated she quickly learned a resident was missing and staff looking for her. She had been asked to call the police to ask about a resident having been picked up from the auto parts store, next door, and the location of the police and the resident. She stated the police operator had indicated Resident #1 had been taken to the YMCA and dropped off. The police operator was able to contact the officer to have Resident #1 picked up again and return her to the facility. On 2/8/19 at 1:41 PM a phone interview with Nurse #5 who had been present the day of the elopement was conducted. He stated he had seen Resident #1 on 1/26/19 and had spoken with her about 10 minutes before he heard the elopement code called. He stated a search was ongoing and staff had gone out of the building looking for Resident #1. A NA had reported back to him that Resident #1 had been seen at the auto parts store and that the police had picked her up. He stated the police were called to see where Resident #1 was, the ED and the RP were also called. He stated it was not long after this that the police brought Resident #1 back. The nursing staff, resident and the RP determined it was best for Resident #1 to go to hospital due to severe agitation. On 2/8/19 at 2:38 PM an interview was conducted with Nurse #7, who had cared for Resident #1 on the day of the elopement. She stated she observed Resident #1 on 1/26/19 when she first arrived at about 3:00 PM for the shift, and again about 4:00 PM in the front lobby talking with other residents and their visitors, having a nice conversation. The nurse stated she had not observed Resident #1 talking about leaving. Shortly after this, the NA alerted the nurse that Resident #1 was missing and an elopement code had been called. The NA had noticed Resident #1's WC outside and had discovered Resident #1 had been seen at the auto parts store and had been picked up by the police. The police, the RP, the physician and ED were all notified. The nurse stated after Resident #1 returned, she had been determined to leave the facility and had agreed with her daughter to go to the emergency room (ER). After Resident #1 left for the ER, the ED conducted elopement in-services with all of the staff and all residents with wanderguards had been checked for placement and function. On 2/8/19 at 3:00 PM an observation was made of the location of the auto parts store where Resident #1 was picked up by the police on 1/26/19 after she exited the facility while unsupervised. The observation revealed the auto parts store parking lot and the facility parking lot were separated by a narrow strip of grass and trees, approximately 10 feet wide, and the ground was level. The approximate distance between the facility front door and the auto parts door was 200 feet. Weather history, provided by Accuweather.com, indicated that on 1/26/19 Durham had a high of 50 degrees Fahrenheit (F) and a low of 24 degrees F, with no precipitation. On 1/26/19 at 7:46 PM facility documentation entered by the ED indicated Resident #1 continued to have exit seeking behaviors sitting while sitting in the lobby. Resident #1 had expressed she wanted to leave the facility, 911 to be called, the police called, and had become combative with the staff and her daughter. The physician had given an order for [REDACTED].#1 had been transported to the ER via the Emergency Medical System (EMS). On 2/8/19 at 10:45 AM an interview with the Executive Director (ED) was conducted. The ED stated closed circuit television (CCTV) had been reviewed and had observed on 01/26/19 a visitor coming in from the outside had let resident out the front door, which had been locked from the inside due to the wanderguard system had been activated. This had been about 4:40 PM. The ED stated after so much time, the recording gets erased and unable to review that day any longer. The ED stated when she had received a call regarding a missing resident, she came immediately to the facility and was present when the resident was returned by the police. The ED stated upon investigation it had been discovered when the wanderguard alarmed inside of the building at the front door, and the front door outside activation switch was activated, this turned off the wanderguard alarm. Staff had heard the wanderguard alarm, but it had turned off. The ED stated this malfunction had not been known previously to this incident but had been discovered on this occasion. The ED also stated the facility initiated a 4 point plan to prevent unsupervised resident exits from the facility. A copy of the plan had been provided at this time. The facility's plan indicated the following: 1. Resident affected: Resident #1 exited the facility through the main entrance door on 1/26/19. A family member of another resident assisted her out the door. Charge nurse and floor staff began a search for Resident #1 and were able to locate her. Charge nurse ensured Resident #1 was safe once she was back in the facility and 1:1 sitter placed with her. Nurse supervisor and charge nurse attempted to do a head to toe skin check upon immediate return to the facility however Resident #1 refused. The On call MD was made aware by the nurse supervisor and gave orders for [MEDICATION NAME] 50 mg which she also refused. Maintenance Director checked the wanderguard and the charge nurse checked for placement immediately upon return. The Executive director informed Resident #1 family of resident status. A phone care plan was held with daughter and executive director and the assistant DON in regard to Resident #1 status. The decision was made to send Resident #1 to the emergency room for evaluation by the family. ED and medical director per family and Resident #1 request. Daughter requested if Resident #1 could not be transferred prior to her arrival; Resident #1 continues with 1:1 until daughter arrival. Orders written by charge nurse for Resident #1 to be sent to the ER with daughter accompanying. Resident #1 to be evaluated for alternate placement. Charge nurse, floor nurses and staff completed a head count to ensure all residents were in the facility on 1/26/19. The maintenance director checked door function to ensure wanderguard system was functioning properly on 1/26/19. No issues found. 2. Residents with potential to be affected: On 1/26/19 Nurse Managers reviewed the current residents with wanderguard to ensure wanderguards are in place and functioning properly, for orders verifying placement and functioning, location included in the order, evaluation up to date and in wanderguard book with picture, and care plans up to date. 3. Systemic Change: Current residents with wanderguards will be reviewed in morning meeting to verify checks are occurring and signed off on the Medication Administration Record [REDACTED]. This review will be completed by the IDT consisting of the ED, DON, ADON, SDC, unit managers, Social Worker (SW), Culinary Manager (CM), Activities Director (AD), Director of Maintenance (DM) and MDS nurse. Beginning on 1/26/19 the DON will perform an audit that will be done 5 days per week for 4 weeks, then 3 days per week for 4 weeks, once a week for 4 weeks and randomly afterwards to ensure compliance. On 1/26/19; the DON, nurse managers and charge nurses completed head counts and door checks each shift for 72 hours and after resident incident and return. Beginning on 1/26/19 and continuing education was provided by the ED, DON, SDC, and the nurse managers on the following the elopement procedure and checking the wanderguard placement and function as ordered. An ad hoc QAPI was held on Monday 1/28/19 with the AQPI team consisting of the medical director, ED, DON, ADON, unit managers, SDC, SW, CM, AD, DM, MDS nurse, and Admissions Director. Newly hired staff will be educated during orientation and as needed. 4. Monitoring: The ED will review audits monthly for the next 3 months with the Quality Assurance and Performance Improvement (QAPI) meeting and the team consisting of the following: Medical Director, ED, DON, ADON, unit managers, SDC, SW, CM, AD, DM, MDS nurse, and Admissions Director. Verification of the above referenced plan of correction was completed on 2/8/19. Documentation was observed in the facility record and indicated that Resident #1 had been allowed to exit the facility through the front door by another resident's family member. Staff had begun search and Resident #1 had been located. After Resident #1 had returned to the facility a 1:1 sitter had been placed with her, the physician had been notified, her wanderguard had been checked for function and found to have been working properly. Family had also been notified. A decision had been made with the daughter to send Resident #1 to ED for evaluation. Documentation was observed in the facility record identifying other current residents with wanderguards. Verification for the other identified residents of wanderguard placement, functioning, physician orders, care plans and the wanderguard book were reviewed and updated as needed. Audit tools were observed in use for the monitoring of residents' wanderguard placement, function, and door alarm system and function. Maintenance and repair receipts were observed from the companies managing the wanderguard alarms and the automatic door systems. Evidence of staff education beginning on 1/26/19 through 2/7/19 was observed in the facility documentation regarding the elopement policy and procedure. Interviews were conducted with staff from various disciplines and shifts, and staff were able to verify in-services regarding elopement policy and procedure had been conducted. Documentation of an initial QAPI meeting had been held on 1/29/19 and included the ED, DON, ADON, DM, Unit Managers, Business Office Manager, all department heads, Rehab Manager, Social Worker, Activities, MDS Nurse, Human Resources Manager, Admission Manager, and the Medical Director. Observations of facility exit doors revealed signs were posted which alerted visitors not to open or assist residents out doors and that doors with wanderguard alarms functioned properly to prevent unsupervised resident exits. Staff interviews revealed staff were educated on the facility's elopement policy and no other residents had exited the facility while unsupervised since 1/26/19. The facility's date of compliance of 2/7/19 was validated.

Based on record review, Medical Director interview, Physiatrist interview, and staff interview the facility failed to notify the physician in a timely manner of x-ray results for one (Resident #1) of three residents reviewed for notification of radiology results. The facility Physiatrist was not notified of the abnormal x-ray results dated 8/3/17 and 8/29/17 until 9/13/17. The Medical Director was not notified of the abnormal x-ray results dated 8/29/17 until 9/13/17, when Resident #1 was discharged to the hospital for surgery. Findings included: Resident #1 was initially admitted to the facility on [DATE] for rehabilitation services with cumulative [DIAGNOSES REDACTED]. The most recent annual Minimum Data Set ((MDS) dated [DATE] coded Resident #1 as cognitively intact, requiring limited assistance with transfers, and extensive assistance with dressing. The resident was coded as having no falls since admission or the previous assessment and had been receiving physical therapy since 11/17/2016. The care plan for Resident #1 had a focus area initiated on 8/17/15 and revised on 9/29/17 which revealed Resident #1 had acute and chronic pain due to a history of multiple spinal fractures [MEDICAL CONDITION] arthritis, and a recent spinal [MEDICAL CONDITION]. Review of a 7/25/17 Physiatrist progress note revealed in the planning section of the note Resident #1 was, Making excellent progress with gait, and with recent progress, now goal is to return home. A nursing incident note, written by Nurse #2, dated 7/26/17 at 1:45 PM revealed a physical therapist and Resident #1 were in his room when the resident fell putting on his pants. The physical therapist called a nurse into the room. When asked about pain, the resident did not complain of pain. When asked if he hit his head, the resident stated no. Resident #1 was assisted back to bed with no problems. The resident was also educated to ask for assistance when needed. A Resident Event Report Worksheet filled out by PTA#1 provided the basic information of time, date, and location of the fall, resident name, and notifications. The worksheet documented the attending physician/medical director was notified of the fall on 7/26/17 at 1:00 PM. The worksheet documented the resident fell on his left hip. Review of the MAR for Resident #1 revealed on 7/26/17 the resident's pain level was coded as a 9 on a scale of 1 to 10. Resident #1 received the pain medication [MEDICATION NAME] as prescribed on 7/26/17. The medical chart contained documentation of a physician verbal order on 7/26/17 for Resident #1 requesting a left hip x-ray due to a fall. Radiology report results dated 7/26/17 revealed Resident #1 did not have a left [MEDICAL CONDITION] or dislocation but did have mild [MEDICAL CONDITION] of the left hip. The 7/26/17 X-ray result for Resident #1 was dated as reviewed by the attending physician on 7/27/17. An additional nursing incident note dated 7/27/17 at 3:55 AM revealed the x-ray results were negative for a fracture or dislocation but mild [MEDICAL CONDITION] of left hip was noted. The resident as well as the MD (medical doctor) were notified of the results. There were no further nursing progress notes after 7/27/17 documenting assessment of the resident's condition after the fall. The physician's orders [REDACTED]. The order stated it was a repeat x-ray due to continued pain. A second radiology report dated 8/3/17 revealed the results as, No dislocation or destructive bony process. Acute left hip intertrochanteric fracture. Conclusion: Acute left hip intertrochanteric fracture, unchanged. The 8/3/17 x-ray result for Resident #1 was dated as reviewed by the attending physician on 8/7/17. On 8/4/17 a nursing progress note written by Nurse #3 at 9:13 AM revealed, Radiology result viewed by MD (medical doctor) no new orders at this time. Review of an 8/15/17 Physiatrist progress note for Resident #1 revealed in the assessment, Left hip pain s/p (status [REDACTED]. The plan in the 8/15/17 progress note stated, Nursing monitoring skin closely, cardiac, respiratory, bowels/bladder, pain. No x-ray reports in the chart, asked nursing to find and place in chart. Verbal orders were documented on 8/29/17 for another left hip x-ray due to the fall and an orthopedic consult as soon as possible due to continued left hip pain. A third radiology report dated 8/29/17 concluded, No acute osseous abnormality. [MEDICAL CONDITION] changes. Stable proximal femoral fracture. The 8/29/17 x-ray result for Resident #1 was dated as reviewed by the attending physician on 9/13/17. Review of an 8/29/17 Physiatrist progress note revealed the Physiatrist was only aware of the x-ray results that were negative for a fracture. A hospital record review revealed Resident #1 was admitted to the hospital on [DATE] from an orthopedic appointment during which a left [MEDICAL CONDITION] was identified with imaging results obtained from the mobile imaging company. Resident #1 underwent surgical repair of his left [MEDICAL CONDITION] on 9/14/17. He was discharged back to the facility on [DATE] with slightly limited mobility and weakness in both legs. On 9/25/17 the facility Medical Director, who was also the attending physician, documented a readmission history and physical when Resident #1 returned to the facility from the hospital after a repair to his left [MEDICAL CONDITION]. The subjective portion of the note stated that Resident #1 returned to the facility after a repair for his left [MEDICAL CONDITION] due to a fall in the facility. The note stated that initially the x-ray results were negative for a fracture but since he was in persistent pain a referral was made to an orthopedic doctor. The note also revealed two x-ray results became available and showed a left [MEDICAL CONDITION]. Resident #1 was sent from the orthopedic physician's office to the hospital for surgery. Resident #1 was interviewed on 9/29/17 at 1:00 PM. Resident #1 revealed he was putting on his pants, lost his balance and fell in his room. He revealed a physical therapist was the only other person present in the room. He stated he had significant pain in his left hip for over a month. An interview was conducted on 9/29/17 at 2:35 PM with the physical therapy assistant (PTA #1) present at the time of the 7/26/17 fall of Resident #1. She revealed she had gone to the resident's room for a therapy session and was in the room when the resident lost his balance and fell . She confirmed he fell on his left side and she went to get assistance from the nurse. She said he did not appear to be in extreme pain. The facility Director of Nursing (DON) was interviewed on 9/29/17 at 3:45 PM. The DON revealed the facility had new ownership as of 9/1/17. Prior to the transition to new ownership the mobile imaging company the facility used, would upload the radiology results directly into the facility software for medical records as well as fax the results of radiology reports. The DON stated the mobile imaging company delayed sending the radiology reports for Resident #1. She stated the facility noticed the mobile imaging company was no longer interfacing with facility software for medical records. The facility Medical Director was interviewed on 9/29/17 at 4:20 PM. He stated, We did not initially have the results from the x-rays for (Resident #1) but when he went to the orthopedic appointment he was able to take the x-rays with him. The facility was transitioning with a new owner and we were not able to see the x-rays on software. This was probably why it was not seen. The Medical Director stated that sometimes he saw the labs or x-rays before he was notified by nursing, sometimes nursing put documents to be signed in the physician's box, or sometimes he collaborated with the other physicians in the building regarding a patient's care and found out results. The facility Physiatrist was interviewed on 9/29/17 at 4:45 PM. She stated, I never saw any of the x-rays that were ordered. I spent a significant amount of time after I found out he (Resident #1) had a [MEDICAL CONDITION] trying to figure out what happened. I called (the mobile x-ray company) and was unable to get an answer as why nobody called the facility with the abnormal result. The mobile x-ray company could not confirm the x-ray was faxed or that they communicated the results to the facility in any way. Luckily we were not pushing this guy to ambulate. He needed a significant amount of encouragement to participate in physical therapy prior to the fall and we knew he was in pain so we did not push him with physical therapy. Nurse #3, the unit manager, was interviewed on 10/6/17 at 11:45 AM. He stated, On 8/4/17 (Medical Director) saw the x-ray for results that were negative for the fracture. He saw the results ordered on [DATE]. He saw it, signed it, and I put it in the box to be filed. I saw the results for 7/27/17 but I was not aware of the physician's orders [REDACTED]. I never notified the physician of the 8/3/17 results because I never saw them. Before the transition (to a new facility ownership on 9/1/17) (the mobile imaging company) would fax results but now they fax results and we can go to the website to view the results if we don't receive a fax. On 10/6/17 the facility Medical Director was interviewed at 12:35 PM. He stated, I saw the x-ray results from 8/3/17 and I thought it was an old fracture. The first x-ray was negative and when I saw the second x-ray it said unchanged so I thought it was an old fracture. I did not see the x-ray results from 8/29/17 until 9/13/17. I do not think a delay in receipt of the x-rays contributed to any harm to the resident. I think it is questionable whether or not he needed the surgery (on his left hip). Nurse aide (NA #1), assigned to Resident #1 on the first shift on 7/26/17, and was interviewed at 7:18 PM on 10/6/17. NA #1 revealed Resident #1 never complained about pain before the fall but complained about hip pain daily after the fall. On 10/7/17 at 2:15 PM the facility Administrator provided the surveyor with fax confirmation sheets from the mobile imaging company confirming the x-ray results dated 7/26/17, 8/3/17, and 8/29/17 were all faxed to the facility on those days. The Administrator confirmed she did not know where the faxed results for Resident #1 went in the facility. She said she thought they were in medical records and she did not know why they did not get put in the chart. On 10/7/17 at 3:05 PM the facility Medical Director provided the surveyor with a case review note for Resident #1 dated 8/3/17. The note revealed another hip x-ray was taken due to continued complaints of pain from Resident #1. The note further revealed the physician thought the x-ray results from 8/3/17 were unchanged results of a chronic hip injury from a previous motor vehicle accident. The facility Medical Director was interviewed on 10/7/17 at 3:10 PM after receipt of the case review. He stated he signed a copy of the x-ray results on 8/3/17 and often signs multiple copies of the same x-ray result. He stated, If I am here in the facility and nursing hands me a copy of x-ray results I will sign another copy of the same results. I looked at the x-ray results on 8/3/17 and I thought the fracture was an old fracture. It is faulty recollection on my part of his injuries. I thought it was a chronic fracture and that no surgical intervention would be necessary. I don't think his life would have been worse off without surgery. He is transferring better after the surgery. The x-ray I saw in the hospital was mildly displaced with some degree of calcification. It was slightly healed. I was surprised they (hospital physicians) recommended surgery. He stated he did not see the resident on 8/3/17 but did a case review on 8/3/17. He stated the date of service was not automatically populated when the note was written. He stated the date of service was information entered by the physician. The Medical Director confirmed the case review was in his personal computer and not in the facility record until 10/7/17. The Administrator was interviewed on 10/8/17 at 8:05 AM. She stated it was her expectation the physician be notified immediately by the nursing staff of any abnormal x-rays or labs based on the potential outcome of the results. The Radiologist who interpreted the results from the 8/3/17 x-ray was interviewed on 10/9/17 at 4:10 PM. He stated, I said the results were unchanged because I was comparing the x-ray from 7/26/17 to the 8/3/17 x-ray. The 7/26/17 x-ray was not a good x-ray and was a very poor image. The 8/3/17 x-ray was a much better study so I could see the fracture much more clearly. I had the advantage of seeing the clearer image and could obviously see the fracture that was not seen on the 7/26/17 x-ray. I called it unchanged because the fracture was there on the 7/26/17 x-ray. The image was so poor I probably would have made the same mistake in saying there was no fracture on 7/26/17. On 10/6/17 at 9:38 AM the Director of Nursing was informed of the immediate jeopardy. The facility provided a credible allegation of compliance on 10/8/17. The credible allegation of compliance indicated: Credible Allegation of Compliance The following interventions have been effective - and will continue to be effective - to assure that, as of September 28, 2017, the Nursing Center has abated the immediate Jeopardy. What the problem is and why it happened: On 7/26/17 - Resident #1 had a witnessed fall while putting on his pants. Therapy was present in the room and was unable to single handedly stop the fall due to comparable size of resident to therapist. Resident #1 has a history of fractures and a [DIAGNOSES REDACTED].#1 was evaluated upon fall and assessed for pain. A post fall evaluation was completed by a nurse. Resident #1 was assisted back to bed from the floor after an assessment with no problems. X-ray results were obtained on date of fall which reflected negative for fracture. Because of ongoing complaints of pain, an additional x-ray was obtained 8/3/17. Per MD progress notes review on 8/3/17, MD stated this was a previous fracture. On 8/29/17 an additional x-ray was ordered due to continued pain after the fall on 7/26/17. Resident #1 had a history of [REDACTED]. Orthopedic appointment was arranged with earliest date available. An x-ray report for 8/29/17 x-ray was not available via the usual system of viewing or faxed to facility. Orthopedic consult was ordered after the fall and left hip pain and an appointment was made at the next available appointment time. Resident #1 was directed to the hospital after the orthopedic appointment. Resident #1 was admitted to hospital related to uncomplicated left [MEDICAL CONDITION] with uncomplicated open reduction and internal fixation left [MEDICAL CONDITION]. For the resident affected: All x-ray results for Resident #1 was verified and placed in chart 9/13/17. MD signature on the 8/3/17 x-ray was dated 8/7/17. MD signature of the 8/29/17 was dated 9/13/17. Based on a verbal statement from the attending Physician, Resident #1 quality of life was not compromised. The fracture is in process of healing. Plan to identify other residents who are at risk for the deficient practice: All x-ray reports have been reviewed on 9/14/17, including dates 9/4/17 and ongoing with no further fractures. Action taken to fix the problem: Upon notification from Orthopedic Physician that Resident #1 was being sent to hospital secondary to left [MEDICAL CONDITION], Executive Director and Director of Nursing immediately initiated a performance improvement plan In-services were initiated 9/19/17 with licensed nurses and nursing assistants staff on documentation of incidents. In-services also include MD notification. Based on the effectiveness of the performance improvement plan as outlined below the Nursing Center is alleging compliance as of September 28, 2017. On 9/13/2017 a designated bin was placed next to the fax machine for all faxed x-ray reports to be placed and the Unit Managers check the bin hourly. The unit managers will notify physician of abnormal x-rays results or designate the charge nurse to call the MD. The x-rays with the no abnormality x-rays are put in the MD communication book for review by the MD. Unit Managers check documentation to ensure physician were notified and follow up is provided timely on 9/13/17 regarding process of review of radiology reports. The process is to bring MD communications books and MD order log and progress notes to clinical morning meeting to make sure that the x-rays results are received and the MD was notified of the results. X-ray reports will be obtained during the clinical morning meeting via the Mobilex website. Unit Managers will be responsible for getting x-rays and appropriate follow up for MD signature. Mobilex will continue to fax results (will validate if duplicate). X-ray company directed to call facility for abnormalities. X-ray results called to facility and will be reported to assigned charge Nurse and MD. The assigned charge nurse will notify the MD of any abnormal results. X-ray results will be placed in MD communication for signature upon visit. If positive for fractures, X-ray reports will be called to facility. The daily x-ray monitoring tool to be reviewed during clinical rounds. The tool describes x-ray ordered, date of x-ray, finding, MD notification and if any initiation of treatment. The facility is directly obtaining x-ray results from Mobilex website. Nursing staff and Physicians have access for viewing of x-rays. Daily monitoring and direct access to Mobilex will ensure timely follow-up if x-ray result not obtained. Assessing a resident after fall for injuries to include documented Post Fall Evaluation. This includes ROM, pain monitoring, neuro-checks for unwitnessed fall or resident to have noted to hit head per protocol and a skin check. This will also involve MD and RP notification of fall. Licensed Nurses in-serviced by Director of Nursing focusing on Documentation expectations, process regarding follow up on X-ray orders was completed on 9/19/2017. The process for following up on orders is the following: Orders are reviewed daily during clinical meeting; nurses will notify MD of abnormal results; documentation is to include when an x-ray is obtained and when results are received; and notification of MD and RP with abnormal results. In-services were conducted on 9/19/17 by the Director of Nursing with Licensed Nurses, C.N.As. regarding accident/injury reporting to MD and required assessments, including pain. Post fall evaluations are reviewed daily during clinical rounds for ongoing education and compliance to expectations. Residents are assessed by means of ROM, resident questioning, pain assessment and skin checks. MD is notified of pain. Radiology and follow up per MD orders. The Executive Director held a meeting on 9/15/17 with the facility Physicians to discuss documentation expectations and process. All Physicians are to have progress notes to the facility within 48 hours of Physician visit. Physician log (List of residents seen) is reviewed daily during clinical rounds and supporting notes are audited. Immediate notification of MD to be made by Executive Director if supporting documentation was not signed and received within 48 hours. Documentation is faxed and emailed to the facility and once received, validated against the physician visit date log. Documentation once reviewed is provided to Medical records for filing. We were in compliance 9/28/17. Director of Nursing and Executive Director reviewed 9/13/2017 all Physician orders [REDACTED]. MD signature to verify results reviewed. It is an ongoing working document. Subsequent review of all x-ray results from 1/2017 to present was conducted 9/13/17 with no positive results and no other residents had been affected. Director of Nursing uses Fast Log to capture all pending x-ray results, and monitoring resident conditions using Physician orders, which is updated during Clinical Morning meeting Monday thru Friday. Licensed Nurses review all pending Physician orders [REDACTED]. All other x-ray reports are filed in MD communication book. The Executive Director and Director of Nursing held a meeting with Mobilex on 9/28/2017 to discuss x-ray result process to assure that all x-ray results are reported timely to the facility and entered in progress note in PCC Point Click Care) properly. MD and facility staff to have access for reports. The meeting including discussions on accessing x-ray reports via Mobilex website. Mobilex will notify the facility via phone of abnormal results. Once order is obtained for an x-ray from the physician, nursing will call Mobilex, place the order for x-ray, and obtain a claim number. Mobilex will arrive in the facility to obtain the image. Mobilex will fax results of x-rays to the facility. Nurses and MD will view x-rays via the Mobilex website. Mobilex notifies the facility of abnormal positive results. The facility notifies MD of the results and MD provides order for follow up. MD communication log to be audited daily Monday thru Friday by Unit Managers during clinical rounds. Review of weekend will occur on Monday. Documentation discussed and reviewed daily to identify MD notification of results, incidents, pain and evaluation of incidents. In-services ongoing and as needed with any future issues identified. Any negative findings will be reported monthly during PI meeting for review recommendations. Conclusion: Based on interview the MD was notified of accident, notified of x-ray results on 7/26 and 8/3/17 with no new orders. Systemic monitoring in place regarding x-ray notification and follow up. No other positive x-rays with fractures identified after audit. Process initiated with Mobilex prior to initial complaint survey on 9/29/17 for improvement of x-ray monitoring process. Meetings with Physicians initiated prior to complaint survey on 9/29/17. On 10/8/17 at 10:15 AM, the corrective action was validated. The validation included review of the MD communication log, the physician order [REDACTED]. Evidence of the in-servicing was also reviewed. Interviews with staff revealed the staff were aware of the facility corrective action plan and knew what they are supposed to do when there is an x-ray done to make sure the residents receive the services they need.

Based on record review, interviews with the medical director, physiatrist, staff and resident interviews the facility failed to fully assess, obtain x-ray results, follow through with physician requests and coordinate care for a resident after a fall with a fracture for 1 (Resident #1) of 6 sampled residents reviewed for falls. Resident # 1 was hospitalized and underwent surgical repair of his left [MEDICAL CONDITION] on 9/14/17. Postoperatively, the resident suffered from [MEDICAL CONDITION] due to blood loss. Findings included: Resident #1 was initially admitted to the facility on [DATE] for rehabilitation services with cumulative [DIAGNOSES REDACTED]. The most recent annual minimum data set assessment dated [DATE] coded Resident #1 as cognitively intact, requiring limited assistance with transfers, and extensive assistance with dressing. The resident was coded as having no falls since admission or the previous assessment and had been receiving physical therapy since 11/17/2016. The care plan for Resident #1 had a focus area initiated on 8/17/15 and revised on 9/29/17 which stated, (Resident #1) has acute/chronic pain r/t (relative to) chronic pain physical disabilities r/t (relative to) hx (history) of spinal multiple fractures, [MEDICAL CONDITION] arthritis & recent LT (left) [MEDICAL CONDITION]. Interventions for this portion of the care plan included; Administer medications as ordered. See medication record. Monitor for effectiveness and side effects; Administer narcotics as per orders, Give ½ hour before treatments or care; apply assistive braces and splints as ordered & maintain as tolerated by resident; assist w/ (with) toileting & incontinence changes routinely & prn (as needed) per shift; encourage (Resident #1) to report early signs of pain; encourage resident to call for assistance when in pain, ask for medication, tell you how much pain is experienced and what increases or alleviates pain; keep bed linen clean, dry and wrinkle free per shift; keep room quiet & calm promoting rest and comfort; record pain utilizing the 1-10 Pain level before pain med (medication) admin (administration) & after. Goal is a pain level of 3 or < after pain admin. Review of the physician orders [REDACTED].#1 was prescribed the following pain medications: [MEDICATION NAME] tablet 975 milligrams (mg) by mouth every 8 hours as needed (prn) for pain; [MEDICATION NAME] Tablet 2.5-325 mg 1 tablet by mouth every 8 hours as needed for uncontrollable hand, wrist, and lower back pain; and [MEDICATION NAME] Gel 1 % 2 grams [MEDICATION NAME] two times a day for arthritis pain to left hand and fingers then two times as needed for pain. Review of the Medication Administration Record (MAR) for Resident #1 from July 1 through 25, 2017 revealed the resident received [MEDICATION NAME] tablet 975 mg as ordered one time in July on 7/10/17. Resident #1 was documented on the MAR as receiving [MEDICATION NAME] as prescribed from July 1 through 25, 2017 thirty five times. Resident #1 was not documented on the MAR as receiving [MEDICATION NAME] Gel 1% from July 1 through 25, 2017. A nursing incident note, written by Nurse #2, dated 7/26/17 at 1:45 PM revealed, Called to room by PT (physical therapy) staff stating that resident was trying to pull up his pants when he slid to the floor. Resident noted on the floor in the seated position. The note indicated the resident was dry (did not need incontinence care) and he was returned back to the wheelchair with his legs sticking out at the wheelchair. When asked about pain, the resident did not complain of pain. When asked if he hit his head, the resident stated no. Resident #1 was assisted back to bed with no problems. The resident was also educated to ask for assistance when needed. Nurse #2 was interviewed on 9/29/17 at 6:01 PM. She stated she did not recall the fall of Resident #1 on 7/26/17. She stated, I know me and if I documented it then that is the way it happened. Nurse #2 was interviewed again on 10/6/17 at 11:30 AM and did not recall any more details of what happened when Resident #1 fell . Nurse #2 did not recall if she assessed resident prior to moving him or not. Nurse aide (NA #1), who worked on the first shift and was assigned to care for Resident #1 on 7/26/17, was interviewed at 7:18 PM on 10/6/17. NA #1 stated, He never complained about pain before the fall. I saw him every day. The only thing I had to do was make sure he had safe transfers. After he fell he complained about hip pain every day to me. I had to go and get the nurse to give him pain medication. It was pain in his left hip and the left hip was swollen. I worked at the facility and I had the same assignment until the end of August (2017). The medical chart contained documentation of a physician verbal order on 7/26/17 for Resident #1 requesting a left hip x-ray due to a fall. A radiology report results dated 7/26/17 revealed Resident #1 did not have a left [MEDICAL CONDITION] or dislocation but did have mild [MEDICAL CONDITION] of the left hip. Review of the MAR for Resident #1 revealed on 7/26/17 the resident's pain level was coded as a 9 on a scale of 1 to 10. Resident #1 received the pain medication [MEDICATION NAME] as prescribed on 7/26/17. An additional nursing incident note dated 7/27/17 at 3:55 AM revealed, Resident #1 complained of left hip pain during this shift. Prn (as needed) [MEDICATION NAME] was given and effective. The x-ray results revealed no fracture or dislocation with mild [MEDICAL CONDITION] of left hip noted. The resident as well as the MD (medical doctor) were notified of the results. The resident was resting quietly in bed with eyes closed at that time. The resident voiced no concerns. On 7/27/17 a pain evaluation was completed for Resident #1. The pain assessment revealed the resident verbalized significant pain in his left hip in relation to a fall. There were no further nursing progress notes after 7/27/17 documenting assessment of the resident's condition after the fall. Resident #1 was interviewed on 9/29/17 at 1:00 PM. Resident #1 revealed, It was one of those lazy days when I didn't feel like therapy. The therapist came to give me therapy. I was sitting on the side of the bed and was pulling my shorts up. I was ready to stand up and pull them up and I got off balance. I fell on my left side on my hip. I tried to get up but I needed help. My hip was hurting me so I couldn't do it by myself. The therapist tried to help me but she couldn't do it by herself so she got four or five more people to help me. They moved me from the floor to the wheel chair to the bed. I was in a lot of pain. It was pain like I never felt before. I couldn't lift my leg or do anything else. By the second or third day they got an x-ray. The x-ray was negative. I continued with rehab but I couldn't do anything. I couldn't transfer from the bed to the chair or stand and pivot anymore. I had a week of therapy and the pain was intense. The doctor said to get an x-ray again because swelling had gone down a little. That x-ray was negative too. It was three or four weeks and I was still in pain. I was still doing therapy and working through the pain. Gradually I was able to stand again but I couldn't put any weight on that left leg. The doctor said the hip should have gotten better by then. I got a third x-ray in the facility and it was negative again. After another week or two I got an appointment with an orthopedic doctor. After three sets of x-rays were done the orthopedic doctor said I had a broken hip. I was sent to the emergency room to have it fixed that day. Ever since the operation the pain has not been that bad. I was in pain for several weeks but the therapists were just doing their job. An interview was conducted on 9/29/17 at 2:35 PM with the physical therapy assistant (PTA #1) present at the time of the 7/26/17 fall of Resident #1. She revealed, I went by the room of (Resident #1) because it was time for his therapy session. He was in the process of getting dressed. (Resident #1) was able to get dressed by himself so I went around the edge of the curtain to provide him with privacy. I heard him starting to fall so I rushed around the curtain and tried to lower him to the ground. He landed on his backside on his left side. It took three or four of us to get him up in a wheel chair and then to the bed. He did not appear in extreme pain. Review of the MAR for Resident #1 revealed he received prn [MEDICATION NAME] as prescribed on 7/27/17, 7/30/17, 7/31/17 and 8/1/17. On 7/27/17 a physician's orders [REDACTED].#1 for [MEDICATION NAME] Gel 1% 4 grams [MEDICATION NAME] every 6 hours for pain to be applied to the left hip. In July 2017 [MEDICATION NAME] Gel 1% was administered as ordered to his left hip once on 7/27/17, twice on 7/28/17, three times on 7/29/17, once on 7/30/17, once on 7/31/17, twice on 8/1/17, twice on 8/2/17, and four times on 8/3/17. On 8/1/17 a verbal order was written for [MEDICATION NAME] tablet 2.5- 325 mg 1 tablet by mouth one time only for pain for 1 day. This order was discontinued on 8/2/17. On 8/1/17 an additional verbal order was written for [MEDICATION NAME] 5-325 mg 1 tablet by mouth every 6 hours as needed for left hip pain. This order was discontinued on 8/1/17. On 8/1/17 a verbal order was written for [MEDICATION NAME] 5-325 mg 1 tablet by mouth every 6 hours for uncontrollable hand, wrist and lower back pain. The August 2017 MAR for Resident #1 revealed he received [MEDICATION NAME] tablet 2.5-325 mg 1 tablet one time on 8/1/17. The MAR documented Resident #1 received [MEDICATION NAME] tablet 5-325 mg 1 tablet by mouth every 6 hours as needed for uncontrollable hand, wrist, and lower back pain three times on 8/2/17 and three times on 8/3/17. The physician's orders [REDACTED]. (Left) hip x-ray 2 view - pain s/p (status [REDACTED]. A second radiology report dated 8/3/17 revealed the results as, No dislocation or destructive bony process. Acute left hip intertrochanteric fracture. Conclusion: Acute left hip intertrochanteric fracture, unchanged. On 8/4/17 a nursing progress note written by Nurse #3 at 9:13 AM revealed, Radiology result viewed by MD (medical doctor) no new orders at this time. Nurse #3, the unit manager, was interviewed on 10/6/17 at 11:45 AM. He stated, On 8/4/17 (Medical Director) saw the x-ray for results that were negative for the fracture. He saw the results ordered on [DATE]. He saw it, signed it, and I put it in the box to be filed. I saw the results for 7/27/17 but I was not aware of the physician's orders [REDACTED]. I never notified the physician of the 8/3/17 results because I never saw them. Before the transition (the mobile imaging company) would fax results but now they fax results and we can go to the website to view the results if we don't receive a fax. Verbal orders were documented on 8/29/17 for another left hip x-ray due to the fall and an orthopedic consult as soon as possible due to continued left hip pain. A third radiology report dated 8/29/17 concluded, No acute osseous abnormality. [MEDICAL CONDITION] changes. Stable proximal femoral fracture. The x-ray report received from the facility during the survey on 9/29/17 at 3:45 PM was not signed by a physician. Review of the resident's MAR from August 4, 2017 to September 13, 2017 revealed Resident #1 received [MEDICATION NAME] tablet 5-325 mg every 6 hours as needed twenty two times from 8/4/17 to 8/15/17. Resident #1 received [MEDICATION NAME] tablet 5-325 mg every 8 hours as needed 33 times from 8/16/17 to 9/12/17. [MEDICATION NAME] Gel 1% was administered as ordered to his left hip four times of 8/4/17, four times on 8/5/17, three times on 8/6/17, four times on 8/7/17, three times on 8/8/17, three times on 8/9/17, three times on 8/10/17, four times on 8/11/17, four times on 8/12/17, four times on 8/13/17, four times on 8/14/17, two times on 8/15/17, four times on 8/16/17, one time on 8/17/17, two times on 8/18/17, four times on 8/19/17, four times on 8/20/17, three times on 8/21/17, five times on 8/22/17, and two times on 8/23/17. The facility's Physiatrist documented progress notes for Resident #1 on 7/25/17, 8/15/17, and 8/29/17. On 7/25/17 Physiatrist documented in the planning section of the note Resident #1 was, Making excellent progress with gait, and with recent progress, now goal is to return home. On 8/15/17 the Physiatrist progress note for Resident #1 stated in the assessment, Left hip pain s/p (status [REDACTED]. The plan in the 8/15/17 progress note stated, Nursing monitoring skin closely, cardiac, respiratory, bowels/bladder, pain. No x-ray reports in the chart, asked nursing to find and place in chart. The plan in the 8/29/17 Physiatrist progress note stated, In light of reported negative x-rays, have encouraged him oob (out of bed) as much as possible. He voices understanding and is in agreement. He is anxious to get back to walking. Nurse #1 who was working on 8/15/17 for the day shift when the physiatrist was working was interviewed on 9/29/17 at 5:30 PM. She did not recall getting the directive from the physiatrist to find the x-ray reports that were ordered on [DATE] and 8/3/17. Review of Physical therapy treatment notes revealed Resident #1 began to receive physical therapy on 11/17/16 and continued with physical therapy five times weekly after his fall on 7/26/17. Physical therapy (PT) notes documented Resident #1 was in pain and had decreased functional ability after his fall on 7/26/17. PT daily treatment notes dated 7/27/17 revealed, Attempted to roll (turn) patient into R (right) side lying in preparation for pain relief techniques however pt (patient) reporting increased pain and unable to roll (turn) at this time. PT notes dated 7/31/17 revealed, Patient in bed complaining of high pain level in left hip since fall last week. PT notes dated 8/10/17 revealed, Pt (patient) received in bed, continues to report increased pain and swelling in L hip and thigh and reports pain with any movements of LLE (left lower extremities). On 8/14/17 PT notes documented, Patient in bed in supine and admitting to decreased pain in left hip/thigh region yesterday and last night allowing him to sleep all night for the first time since the fall. Patient stated that rolling for hygiene today was painful however. On 8/31/17 PT notes revealed, PTA (physical therapy assistant) and patient conferred with (Physician Name) regarding patient presentation and (Physician Name) states he will write order for an orthopedic consult. On 9/1/17 the PT notes revealed, Pt stood (approximately) 2' (minutes) each trial and req (requested) rest breaks to relieve fatigue and hip pain. A hospital record review revealed Resident #1 was admitted to the hospital on [DATE] from an orthopedic appointment during which a left [MEDICAL CONDITION] was identified with imaging results obtained from the mobile imaging company. Resident #1 underwent surgical repair of his left [MEDICAL CONDITION] on 9/14/17. Post operatively he suffered from [MEDICAL CONDITION] due to blood loss. He was discharged back to the facility on [DATE] with slightly limited mobility and weakness in both legs. On 9/25/17 the facility medical director documented a readmission history and physical when Resident #1 returned to the facility from the hospital after a repair to his left [MEDICAL CONDITION]. The subjective portion of the note stated in part, (Resident #1) returns to the facility (after a stay) at (hospital) 9/13-9/22/17 for ORIF (open reduction and internal fixation) L (left) hip fx (fracture) (secondary) to fall. He had initial neg (negative) hip x-ray after the fall but because of persistent pain he was ordered repeat x-ray and referred to ortho (orthopedic). While waiting his ortho appointment two x-ray reports showing well positioned subacute L introchanteric fx became available. From his ortho appointment he was sent for surgery. His post-op course was characterized by blood loss [MEDICAL CONDITION] requiring 1 unit PRBC (packed red blood cells) and [MEDICAL CONDITION]. He remains dependent for transfer, hygiene care and toileting (secondary) to spinal cord injury with impaired mobility and is being readmitted for skilled nursing, PT/OT (physical therapy and occupational therapy) and wound care. The facility Administrator and Director of Nursing were interviewed on 9/29/17 at 3:45 PM. The Director of Nursing stated that mobile imaging company they used was found to be delaying in sending the radiology reports. She said previously, before the transition in ownership of the facility on 9/1/17, the mobile imaging company would upload the radiology results directly into the computerized medical record system, Point Click Care. Once the x-rays were in Point Click Care both nursing and the physician's would have had access to the radiology reports. She stated the facility noticed the mobile imaging company was no longer interfacing with Point Click Care. She further stated that now the facility can run a list of the imaging reports that have been ordered, discuss the reports in stand up meeting each morning, and make sure the results are available to be addressed as needed. The facility Medical Director was interviewed on 9/29/17 at 4:20 PM. He stated, We did not initially have the results from the x-rays for (Resident #1) but when he went to the orthopedic appointment he was able to take the x-rays with him. The facility was transitioning with a new owner and we were not able to see the x-rays on Point Click Care. This was probably why it was not seen. The Medical Director stated that sometimes he saw the labs or x-rays before he was notified by nursing, sometimes nursing put documents to be signed in the physician's box, or sometimes he collaborated with the other physicians in the building regarding a patient's care and found out results. The facility Physiatrist was interviewed on 9/29/17 at 4:45 PM. She stated, I never saw any of the x-rays that were ordered. I spent a significant amount of time after I found out he (Resident #1) had a [MEDICAL CONDITION] trying to figure out what happened. I called (the mobile x-ray company) and was unable to get an answer as why nobody called the facility with the abnormal result. The mobile x-ray company could not confirm the x-ray was faxed or that they communicated the results to the facility in any way. Luckily we were not pushing this guy to ambulate. He needed a significant amount of encouragement to participate in physical therapy prior to the fall and we knew he was in pain so we did not push him with physical therapy. The Director of Nursing (DON) was interviewed on 9/29/17 at 5:35 PM. She stated her expectation was for the staff to assess for pain and check for injury after a fall for at least 72 hours. The DON acknowledged she could not find the nursing assessment and monitoring in the notes for Resident #1 after the fall for the full 72 hours. She stated they may have done it but did not document it. On 10/6/17 at 11:00 AM the DON provided the surveyor with the signed and dated copies of the x-ray results the facility Medical Director had reviewed. The 7/26/17 X-ray result for Resident #1 was dated as reviewed by the physician on 7/27/17. The 8/3/17 x-ray result for Resident #1 was dated as reviewed by the physician on 8/7/17. The 8/29/17 x-ray result for Resident #1 was dated as reviewed by the physician on 9/13/17. On 10/6/17 the facility Medical Director was interviewed at 12:35 PM. He stated, I saw the x-ray results from 8/3/17 and I thought it was an old fracture. The first x-ray was negative and when I saw the second x-ray it said unchanged so I thought it was an old fracture. I did not see the x-ray results from 8/29/17 until 9/13/17. I do not think a delay in receipt of the x-rays contributed to any harm to the resident. I think it is questionable whether or not he needed the surgery (on his left hip). On 10/7/17 at 2:15 PM the facility Administrator provided the surveyor with fax confirmation sheets from the mobile imaging company confirming the x-ray results dated 7/26/17, 8/3/17, and 8/29/17 were all faxed to the facility on those days. The Administrator confirmed she did not know where the faxed results for Resident #1 went in the facility. She said she thought they were in medical records and she did not know why they did not get put in the chart. On 10/7/17 at 2:19 PM a representative, from the mobile imaging company contracted with the facility, was interviewed. He stated the mobile x-ray company confirmed the results of all three x-rays of the left hip of Resident #1 dated 7/26/17, 8/3/17, and 8/29/17 were faxed to the facility on the same day the results were finalized. On 10/7/17 at 3:05 PM the facility Medical Director provided the surveyor with a case review note for Resident #1 dated 8/3/17. The note stated, F/U (follow up) abnormal hip x-ray 62 - YO (year old) M (male) resident had rept (repeat) hip Xray done today due to contd (continued) L (left) hip pain. Report read as unchanged L (left) hip Fx (fracture) compared to 7/26/17. Will cont (continue) current [MEDICATION NAME] regimen with PT/OT pain mgmt. modalities as this is likely chronic from previous motor vehicle injuries. The Medical Director was interviewed on 10/7/17 at 3:10 PM, after receipt of the case review. He stated he signed a copy of the x-ray results on 8/3/17 and often signs multiple copies of the same x-ray result. He stated, If I am here in the facility and nursing hands me a copy of x-ray results I will sign another copy of the same results. I looked at the x-ray results on 8/3/17 and I thought the fracture was an old fracture. It is faulty recollection on my part of his injuries. I thought it was a chronic fracture and that no surgical intervention would be necessary. I don't think his life would have been worse off without surgery. He is transferring better after the surgery. The x-ray I saw in the hospital was mildly displaced with some degree of calcification. It was slightly healed. I was surprised they (hospital physicians) recommended surgery. The Medical Director stated the case review was printed on 10/7/17. He stated he did not see the resident on 8/3/17 but did a case review on 8/3/17. He stated the date of service was not automatically populated when the note was written. He stated the date of service was information entered by the physician. The radiologist who interpreted the results from the 8/3/17 x-ray was interviewed on 10/9/17 at 4:10 PM. He stated, I said the results were unchanged because I was comparing the x-ray from 7/26/17 to the 8/3/17 x-ray. The 7/26/17 x-ray was not a good x-ray and was a very poor image. The 8/3/17 x-ray was a much better study so I could see the fracture much more clearly. I had the advantage of seeing the clearer image and could obviously see the fracture that was not seen on the 7/26/17 x-ray. I called it unchanged because the fracture was there on the 7/26/17 x-ray. The image was so poor I probably would have made the same mistake in saying there was no fracture on 7/26/17. The facility Administrator provided a facility performance action plan dated as initiated on 9/13/17. The actions/interventions taken were: radiology reports to continue to be obtained per physician order, physician to review upon receipt; daily discussion of radiology reports due during clinical rounds; interdisciplinary team discussion to ensure we capture all clinical changes; discuss additional options for ability to review radiology reports/obtain full access; review radiology reports daily during clinical rounds/full discussion to obtain additional updates/[DIAGNOSES REDACTED]. The corrective action plan read as follows: What the problem was and why it happened: On 7/26/17 - Resident #1 had a witnessed fall while putting on his pants. Therapy was present in the room and was unable to single handedly stop the fall due to comparable size of resident to therapist. Resident #1 has a history of fractures and a [DIAGNOSES REDACTED].#1 was evaluated upon fall and assessed for pain. A post fall evaluation was completed by a nurse. Resident #1 was assisted back to bed from the floor after an assessment with no problems. X-ray results were obtained on date of fall which reflected negative for fracture. Because of ongoing complaints of pain, an additional x-ray was obtained 8/3/17. Per MD progress notes review on 8/3/17, MD stated this was a previous fracture. On 8/29/17 an additional x-ray was ordered due to continued pain after the fall on 7/26/17. Resident #1 had a history of [REDACTED]. Orthopedic appointment was arranged with earliest date available. An x-ray report for 8/29/17 x-ray was not available via the usual system of viewing or faxed to facility. Orthopedic consult was ordered after the fall and left hip pain and an appointment was made at the next available appointment time. Resident #1 was directed to the hospital after the orthopedic appointment. Resident #1 was admitted to hospital related to uncomplicated left [MEDICAL CONDITION] with uncomplicated open reduction and internal fixation left [MEDICAL CONDITION]. For the resident affected: All x-ray results for Resident #1 was verified and placed in chart 9/13/17. MD signature on the 8/3/17 x-ray was dated 8/7/17. MD signature of the 8/29/17 was dated 9/13/17. Based on a verbal statement from the attending Physician, Resident #1 quality of life was not compromised. The fracture is in process of healing. Plan to identify other residents who are at risk for the deficient practice: All x-ray reports have been reviewed on 9/14/17, including dates 9/4/17 and ongoing with no further fractures. Action taken to fix the problem: Upon notification from Orthopedic Physician that Resident #1 was being sent to hospital secondary to left [MEDICAL CONDITION], Executive Director and Director of Nursing immediately initiated a performance improvement plan In-services were initiated 9/19/17 with licensed nurses and nursing assistants staff on documentation of incidents. In-services also include MD notification. Based on the effectiveness of the performance improvement plan as outlined below the Nursing Center is alleging compliance as of September 28, 2017. On 9/13/2017 a designated bin was placed next to the fax machine for all faxed x-ray reports to be placed and the Unit Managers check the bin hourly. The unit managers will notify physician of abnormal x-rays results or designate the charge nurse to call the MD. The x-rays with the no abnormality x-rays are put in the MD communication book for review by the MD. Unit Managers check documentation to ensure physician were notified and follow up is provided timely on 9/13/17 regarding process of review of radiology reports. The process is to bring MD communications books and MD order log and progress notes to clinical morning meeting to make sure that the x-rays results are received and the MD was notified of the results. X-ray reports will be obtained during the clinical morning meeting via the (The company that did the x-rays) website. Unit Managers will be responsible for getting x-rays and appropriate follow up for MD signature. (The company that did the x-rays) will continue to fax results (will validate if duplicate). X-ray company directed to call facility for abnormalities. X-ray results called to facility and will be reported to assigned charge Nurse and MD. The assigned charge nurse will notify the MD of any abnormal results. X-ray results will be placed in MD communication for signature upon visit. If positive for fractures, X-ray reports will be called to facility. The daily x-ray monitoring tool to be reviewed during clinical rounds. The tool described x-ray ordered, date of x-ray, finding, MD notification and if any initiation of treatment. The facility is directly obtaining x-ray results from (The company that did the x-rays) website. Nursing staff and Physicians have access for viewing of x-rays. Daily monitoring and direct access to (The company that did the x-rays) will ensure timely follow-up if x-ray result not obtained. Assessing a resident after fall for injuries to include documented Post Fall Evaluation. This includes ROM (range of motion), pain monitoring, neuro-checks for unwitnessed fall or resident to have noted to hit head per protocol and a skin check. This will also involve MD and RP notification of fall. Licensed Nurses in-serviced by Director of Nursing focusing on Documentation expectations, process regarding follow up on X-ray orders was completed on 9/19/2017. The process for following up on orders is the following: Orders are reviewed daily during clinical meeting; nurses will notify MD of abnormal results; documentation is to include when an x-ray is obtained and when results are received; and notification of MD and RP with abnormal results. In-services were conducted on 9/19/17 by the Director of Nursing with Licensed Nurses, C.N.As (nursing assistants) regarding accident/injury reporting to MD and required assessments, including pain. Post fall evaluations are reviewed daily during clinical rounds for ongoing education and compliance to expectations. Residents are assessed by means of ROM, resident questioning, pain assessment and skin checks. MD is notified of pain. Radiology and follow up per MD orders. The Executive Director held a meeting on 9/15/17 with the facility Physicians to discuss documentation expectations and process. All Physicians are to have progress notes to the facility within 48 hours of Physician visit. Physician log (List of residents seen) is reviewed daily during clinical rounds and supporting notes are audited. Immediate notification of MD to be made by Executive Director if supporting documentation was not signed and received within 48 hours. Documentation is faxed and emailed to the facility and once received, validated against the physician visit date log. Documentation once reviewed is provided to Medical records for filing. We were in compliance 9/28/17. Director of Nursing and Executive Director reviewed all Physician orders [REDACTED]. MD signature to verify results reviewed. It is an ongoing working document. Subsequent review of all x-ray results from 1/2017 to present was conducted on 9/13/17 with no positive results and no other residents had been affected. Director of Nursing uses Fast Log to capture all pending x-ray results, and monitoring resident conditions using Physician orders, which is updated during Clinical Morning meeting Monday thru Friday. Licensed Nurses review all pending Physician orders [REDACTED]. All other x-ray reports are filed in MD communication book. The Executive Director and Director of Nursing held a meeting with a representative of (the company that did the x-rays) on 9/28/2017 to discuss x-ray result process to assure that all x-ray results are reported timely to the facility and entered in progress note in PCC Point Click Care) properly. MD and facility staff to have access for reports. The meeting including discussions on accessing x-ray reports via (the company that did the x-rays) website. (The company that did the x-rays) will notify the facility via phone of abnormal results. Once order is obtained for an x-ray from the physician, nursing will call (the company that did the x-rays), place the order for x-ray, and obtain a claim number. (The company that did the x-rays) will arrive in the facility to obtain the image. (The company that did the x-rays) will fax results of x-ra(TRUNCATED)