Every finding on record at Autumn Care of Raeford

Based on observations, record reviews, staff, Resident and Physician interviews, the facility failed to have a medication error rate of less than 5% as evidenced by 2 medication errors out of 30 opportunities, resulting in a medication error rate of 6.67% for 1 of 4 residents observed during the medication administration (Resident #116).The findings included:Review of Resident #116's physician orders revealed an order for aspirin, 81 milligrams (mg) chewable tablet, once a day for deep vein thrombosis (DVT) prevention dated 08/28/2025 and an order for polyethylene glycol 3350 powder; 17 grams, 1 scoop daily for constipation dated 08/28/2025. Review of Resident #116's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #116 was cognitively intact. On 02/26/2026 at 8:41 AM an observation of a medication pass was made of Nurse #1 who was medicating Resident #116. Nurse #1 was observed to remove one aspirin 8 mg enteric coated (EC) tablet from a stock bottle and placed it in a cup of medications she was preparing to administer to Resident #116. Nurse #1 was observed to administer the aspirin tablet to Resident #116. During the same medication observation, Nurse #1 did not administer the polyethylene glycol 3350 powder, 17 grams to Resident #116.At 8:50 AM on 02/26/2026 an interview was conducted with Nurse #1 who explained that she did not notice it was EC and not chewable aspirin. The Nurse stated she did not administer the polyethylene glycol because he refuses the medication and did not find the need to ask if he wanted the medication. An interview with Resident #116 was conducted on 02/26/2026 at 9:03 AM. He stated he moved his bowels every day to every other day and will let the nurse know if he did not have a bowel movement within that timeframe. An interview was conducted with the Director of Nursing (DON) on 02/26/2026 at 12:10 PM. The DON stated she expected the nurses to administer the medications according to the physicians' orders. The resident was assessed and there were no issues found from the EC aspirin that was administered. The DON also stated Resident #116 is alert and oriented and will make it known if he did not have a daily bowel movement.A telephone interview with the Medical Doctor (MD) was conducted on 02/26/2026 at 1:33 PM. She stated she was aware of the medication errors that Nurse #1 had made. There were no adverse reactions from the missing dosage of polyethylene and the administration of an EC aspirin instead of the chewable aspirin. She also stated she expected the nurses to look closer at the medication administration record to avoid making errors and to give the medications that were ordered.

Based on record reviews and interviews with staff, Responsible Party (RP), Emergency Medical Services (EMS) personnel, and the Medical Director, the facility failed to accurately transcribe necessary information from the FL2 (a medical form completed by a physician to document a patient's medical condition, necessary care, and recommended level of care) to ensure staff monitored a resident's blood glucose (sugar) and administered insulin or sought clarification from a medical provider for a resident with diabetes. Resident #1 was admitted to the facility from home on Friday 8/29/25 for respite care (short-term care that provides relief for caregivers) with an FL2 that indicated 5 units of Lantus (long-acting insulin used to manage blood glucose levels) at bedtime and continuous glucose monitoring. Lantus was not administered on 8/29/25 and 8/30/25 at bedtime and Resident #1's blood glucose was not monitored throughout his stay at the facility from 8/29/25 at approximately 1:45 PM through Sunday 8/31/25 at approximately 1:45 PM when he was discharged home with his RP. On 8/31/25 at approximately 2:06 PM after leaving the facility, the resident's continuous blood glucose monitoring device indicated HI (reading above 500) (normal blood glucose reference range is 70 -110 milligram [mg] per deciliter [dl]). A blood sugar of 500 is considered a medical emergency. The RP administered 5 units of Lantus to the resident. At 5:40 PM that same day (8/31/25), the RP contacted EMS who arrived at the resident's home at 6:09 PM and when they obtained Resident #1's blood glucose level it was 403. Resident #1 was transferred to the Emergency Department (ED) where he presented with an elevated blood glucose of 428 (7:17 PM), elevated heart rate and diarrhea. Resident #1 was monitored overnight at the ED and given intravenous (IV) fluids for persistent tachycardia (elevated heart rate above 100 beats per minute) and hyperglycemia (high blood glucose). This deficient practice affected 1 of 3 residents reviewed for diabetes care (Resident #1). The findings included:Resident #1's Long Term Care FL2 form signed by Resident #1's primary care provider on 8/11/25 included the following orders related to diabetes management: 1. Metformin (diabetes medication) 750 milligrams (mg) oral tablet twice a day with food 2. Empagliflozin (diabetes medication) 12.5 mg tablet by mouth daily 3. Lantus (long-acting insulin) 5 units subcutaneously at bedtime 4. Continuous glucose monitoring During an interview with the Admissions Director on 9/25/25 at 9:56 AM she indicated that a representative from the Veteran's Affairs (VA) had reached out to her to set up the respite care at the facility with a referral date of 8/27/25 for respite services from 8/29/25 through 8/31/25. She indicated that the VA sent her the required paperwork to include the FL2 form which she reviewed to ensure the facility was in a position to care for the resident. The Admissions Director stated that she called Resident #1's RP on 8/28/25 and informed her to bring his medicine when she brought the resident to the facility for admission on [DATE]. The Admissions Director stated that she took a hard copy of the FL2 form to the B-hall nurses' station because the nurse would need the FL2 form for admission orders and she gave it to a nurse, but she could not recall who the nurse was. She explained that she also scanned a copy into Resident #1's electronic record. During an interview with the Director of Nursing (DON) on 9/24/25 at 11:15 AM she indicated that Nurse #2 was initially supposed to admit Resident #1 and they thought that he was supposed to come to the facility on Thursday 8/28/25. The following orders were transcribed into Resident #1's electronic health record (EHR) by Nurse #2 on 8/28/25: 1. Albuterol sulfate 90 micrograms (mcg)/actuation hydrofluoroalkane (HFA) aerosol inhaler, administer two puffs every 6 hours as needed for shortness of breath/wheezing.2. Amlodipine 5 mg tablet, administer one tablet daily for hypertension.3. Cholecalciferol (vitamin D3) 50 mcg (2,000 unit) capsule, administer one tablet daily for vitamin D deficiency.4. Donepezil 5 milligram mg tablet, administer one tablet daily for dementia.5. Empagliflozin 25 mg tablet, administer half tablet orally daily for diabetes mellitus.6. Losartan 50 mg tablet, administer one tablet daily for hypertension.7. Metformin 750 mg tablet, administer one tablet twice a day with food.8. Pantoprazole 40 mg tablet, delayed release, administer one tablet daily for gastroesophageal reflux disease (GERD). There were no orders entered for 5 units Lantus at bedtime and/or continuous blood glucose monitoring. During an interview with Nurse #2 on 9/24/25 at 12:57 PM she indicated that she was initially supposed to admit Resident #1 to a room in her hallway (B-Hall) on 8/28/25, but he ended up in a different room and Nurse #1 completed the admission. Nurse #2 stated that she had transcribed Resident #1's orders from the FL2 form into the EHR on 8/28/25, but she was not sure why she did not enter the orders for blood glucose monitoring and 5 units of Lantus. Nurse #2 stated that the admitting nurse normally would transcribe the orders into the EHR and verify with the written orders to ensure they were entered correctly. She indicated that she would have verified the medicine brought in by the RP with the orders from the FL2. Resident #1 was admitted into the facility on 8/29/25 for respite care. His diagnoses included dementia, type 2 diabetes, hypertension and chronic kidney disease. An interview was conducted with Resident #1's RP on 9/24/25 at 3:56 PM. She indicated that Resident #1 had a continuous blood glucose monitoring device that functioned via a sensor on his arm that was linked to an application on her cellular phone. She indicated that she could not monitor the resident's blood glucose while the resident was at the facility because the application on her cellular phone had to be close to the sensor (approximately 30 feet) to capture the blood glucose reading. She indicated that the facility was aware the resident had diabetes and could have checked the resident's blood glucose by pricking his finger (and then utilizing a glucometer). The RP explained that the VA had organized the respite care stay for Resident #1 and sent the paperwork to the facility. She stated that nobody at the facility asked her about the continuous blood glucose monitoring sensor. She reported that after she brought the resident's medicine to the facility she expected the nursing staff to care for the resident and give him his medicine. She indicated that the resident's prescribed Lantus was with all the medicine she brought to the facility on admission as the Admissions Director instructed her to bring all of his medications. A progress note written by Nurse #1 dated 8/29/25 at 1:45 PM indicated Resident #1 was admitted to the facility from home via personal vehicle escorted by family. Resident #1 was alert, verbally responsive and only able to state his name and date of birth appropriately. A head to toe assessment was completed with no findings of open areas, bruises or unusual marks, and good skin care maintained. His vital signs included: blood pressure:145/90 (normal range: 90/60 to 120/80), pulse:102 (normal range: 60-100), respirations:18 (normal range: 12 to 18), temperature: 97.4, and oxygen saturations: 96 % (normal range 95%- 100%). Resident #1 was admitted to the facility for respite care with an expected discharge date of 08/31/25. All personal belongings were noted. Resident's RP stated that resident had a tendency to wander. Wanderguard bracelet was applied to his right ankle to prevent elopement. There was no information in the progress note related to a continuous blood glucose monitoring sensor for Resident #1.During an interview with Nurse #1 on 9/24/25 at 12:07 PM she indicated she admitted Resident #1 on 8/29/25 around 1:45 PM. She stated she completed a head-to-toe assessment, applied a wanderguard bracelet on Resident #1 and completed an admission note. Nurse #1 indicated Resident #1's RP gave her a plastic bag with Resident #1's medications which she put in the medication cart, but she (Nurse #1) did not look inside the bag to see what the medications were at the time she received the medications. She indicated that after Resident #1 was settled in his room she went to the medication cart to compare the medications in the plastic bag and the medications transcribed in the MAR and they matched. She stated that she did not see Lantus in the plastic bag. Nurse #1 explained that the orders had been transcribed by Nurse #2 the previous day (8/28/25) because initially, Nurse #2 was supposed to admit Resident #1 to a different hallway. She reported that the process for transcribing admission orders was for the admitting nurse to transcribe the orders into the EHR and verify with the written orders to ensure they were entered correctly. She indicated she did not verify the orders in the MAR with the orders on the FL2 form because Nurse #2 told her that she had entered all the orders into the EHR. Nurse #1 verbalized that the orders for blood glucose monitoring and 5 units Lantus were not entered in the EHR and she did not realize that all the orders were not entered because she did not look at the FL2 form. Nurse #1 indicated she transferred Resident #1 to the locked unit later that day (8/29/25) before the end of her shift at 7:00 PM because he had exit seeking behaviors. She stated she did not check or monitor Resident #1's blood glucose during her shift because she did not realize the resident was supposed to have his blood glucose monitored. She stated that she did not see the continuous blood glucose monitoring sensor on the resident's arm. She reiterated that did not realize that Resident #1 needed blood glucose monitoring because there was no order in the EHR. Resident #1's 5-day Medicare Minimum Data Set (MDS) assessment dated [DATE] indicated his cognition was severely impaired. Diabetes was listed as an active diagnosis and he was coded as taking hypoglycemic medication (medication utilized to lower blood glucose).Resident #1's Medication Administration Record (MAR) from admission on [DATE] through discharge on [DATE] indicated the medications that were entered in the EHR were administered as ordered. The MAR did not include any evidence that continuous blood glucose monitoring was completed and/or that 5 units of Lantus was administered at bedtime as indicated on the FL2. An interview was conducted on 9/25/25 at 2:55 PM with Nurse #4. She indicated she was assigned to care for Resident #1 during the night shift on 8/29/25 at 7:00 PM to 8/30/25 at 7:00 AM. Nurse #4 stated that Resident #1 was up at night walking in the hallways and his vital signs were stable. She stated that she did not monitor his blood glucose or administer any insulin because she did not see those orders in the MAR during her shift. Nurse #4 indicated that she did not see the continuous blood glucose monitoring sensor on the resident's arm. She reported that Resident #1's diabetes oral medications were not scheduled for the night shift and therefore she would not have thought that he needed glucose monitoring. Nurse #4 indicated that she did not look in Resident #1's medicine bag because he was not scheduled to get any medicine during the night shift. During an interview on 9/24/25 at 1:42 PM with Nurse #3 she indicated that she cared for Resident #1 on 8/30/25 during the day shift (7:00 AM- 7:00 PM). She verbalized that she had followed the orders on the MAR and did not monitor Resident #1's blood glucose because it was not on the MAR. She indicated that Resident #1's vital signs were stable throughout her shift. Nurse #3 stated that if she had seen the continuous blood glucose monitoring sensor on the resident's arm it would probably have jogged her memory that the resident required glucose monitoring, but she did not see it. She indicated that she administered the scheduled diabetes medicine to Resident #1 during her shift, she did not see Lantus in the bag that had the resident's medications, and she did not realize that he might need glucose monitoring. During an interview on 9/25/25 at 3:12 PM with Nurse #5 she stated that she had cared for Resident #1 during the night shift on 8/30/25 at 7:00 PM to 8/31/25 at 7:00 AM. She indicated that Resident #1's vital signs were stable during her shift and that she did not monitor Resident #1's blood glucose or administer insulin at bedtime because it did not come up on the MAR as orders to be completed. Nurse #5 stated that she did not see the continuous blood glucose monitoring sensor on the resident's arm and there were no diabetes medications scheduled for Resident #1 during the night shift. She indicated that she did not need to administer any medicine to the resident during the night shift so she did not look in his medication bag. During an interview on 9/24/25 at 2:00 PM with Nurse #6 she indicated that she had cared for Resident #1 with Nurse #3 on 8/31/25 because she was on orientation during the day shift (7:00 AM - 7:00 PM). Nurse #6 stated that Resident #1's vital signs were stable, and she administered the medications that were scheduled on the MAR during her shift but she did not realize that the resident needed glucose monitoring. She stated that she did not monitor Resident #1's blood glucose because she did not see an order for blood glucose monitoring and she did not see the continuous blood glucose monitoring sensor on the resident's arm. She also stated that she did not see any insulin in the plastic bag which had Resident #1's medications. She indicated she did not notice any signs of hyperglycemia when she worked with the resident (8/31/25). Nurse #6 stated that Resident #1 was given a bath by Nurse #3 and Nursing Assistant (NA) #1 because he had an incontinent episode just before he was discharged home around 2:00 PM on 8/31/25. During an interview with NA #1 on 9/24/25 at 3:18 PM she stated that she had cared for Resident #1 on 8/30/25 and 8/31/25 during the 7:00 AM to 3:00 PM shift. She stated that Resident #1 was able to feed himself and his nutritional intake on both dates was 76 - 100%. She indicated that she bathed Resident #1 with Nurse #3 on 8/31/25 between 1:00 PM and 2:00 PM just before he was discharged home because he had diarrhea. She indicated that was the first time he had loose stools. She stated that she did not notice any change in condition with Resident #1 during the two days she cared for him (8/30/25 and 8/31/25). A nursing progress note dated 8/31/25 at 2:31 PM written by Nurse #6 indicated Resident #1 was discharged home, via private vehicle. His RP signed discharge paperwork and a copy was provided to the RP. All personal belongings and medications were given to the resident's RP. There were no signs or symptoms of acute distress, respiratory distress/discomfort, or pain. Resident #1's RP was advised to contact the facility with any questions/concerns. On 9/24/25 at 12:08 PM Resident #1's RP shared a screen shot from the cellular application linked to the resident's continuous blood glucose monitoring sensor revealing a reading of HI on 8/31/25 at 2:06 PM.An interview was conducted with Resident #1's RP on 9/24/25 at 3:56 PM. She indicated that she came to the facility between 1:00 PM and 2:00 PM on 8/31/25 to take Resident #1 home after the 2-night stay for respite care at the facility. She indicated that when she got to the resident's room he was lying in bed and he was soiled. She reported that when she mentioned it to Nurse #3, the nurse offered to go and wash the resident up before the RP took him home. The RP stated that after she exited the facility with Resident #1, the application on her cellular phone linked to Resident #1's continuous blood glucose monitoring sensor kept on vibrating. She stated that the vibration started when she got the resident to the car at the facility parking lot and as she drove away from the facility the phone kept vibrating. She stated that she stopped on the side of the road at 2:06 pm, and it read HI which meant it was out of range (greater than 500) for the machine to read it. She stated that she stopped at the side of the road and administered 5 units of Lantus and 750 mg of metformin to the resident prior to returning home. She stated she also stopped at a store to buy water for Resident #1 to drink to dilute his blood glucose and lower it. The RP indicated that Resident #1 had a dry mouth, he was thirsty, clammy, tired and sleepy. She indicated that the drive from the facility to their home would normally take her one and a half hours without stopping, but that it took her a little bit longer on 8/31/25 because she had to stop at the side of the road to administer Lantus and metformin and stop at the store to buy water. She stated that after she got home, she checked Resident #1's blood glucose by pricking the resident's finger and using a glucometer and the blood glucose reading was 596. She stated that the resident was also having diarrhea, and she called EMS who came to assess Resident #1 and transferred him to the ED. An EMS report dated 8/31/25 indicated EMS received the phone call at 5:40 PM and paramedics were dispatched at 5:45 PM. Paramedics arrived at Resident #1's home at 6:09 PM and found him lying in bed and the chief complaint was hyperglycemia and diarrhea. His vital signs were as follows at 6:10 PM: heart rate:112 beats per minute, blood pressure:170/90, oxygen saturation: 99% on room air, temperature: 98.6 degrees Fahrenheit, and blood glucose: 403. The resident was alert. He was moved into the ambulance on a stretcher at 6:20 PM. A peripheral intravenous catheter was inserted, and 500 milliliter lactated ringer's (intravenous fluids used to replenish electrolytes and fluids) was administered at 6:33 PM. They arrived at the ED at 7:08 PM and report was given to the ED nurse. A phone interview was conducted on 9/29/25 at 9:18 AM with the Paramedic who had transferred Resident #1 from his home to the ED on 8/31/25. She indicated that when they arrived on scene Resident #1 was lying in bed. She indicated that Resident #1's skin was warm to touch, his blood glucose was 403, his RP reported that she had administered insulin and the resident was experiencing diarrhea so they decided to transfer him to ED for further evaluation. ED progress notes dated 8/31/25 indicated Resident #1 was seen by the ED provider at 7:45 PM for a chief complaint of symptomatic elevated blood glucose. His blood glucose at the ED at 7:17 PM was 428. His vital signs at 10:00 PM were as follows: blood pressure: 153/89, heart rate: 112, respirations: 28 beats per minute, and oxygen saturations: 96%. He was given intravenous fluids for an elevated heart rate and elevated blood glucose. He tested negative for Covid, influenza and respiratory syncytial virus (RSV). At 11:36 PM he had had 4 episodes of diarrhea at the ED, and an abdominal computed tomography (CT) scan was completed with no abnormal findings. A urinalysis test was negative for urinary tract infection. The urinalysis also revealed the following findings: Protein:1+ (normal reference range: negative), Glucose: 4+ (normal reference range: negative), and Ketones:1+ (normal reference range: negative). Positive glucose in the urine can be an indication of high blood glucose, kidney damage, uncontrolled diabetes or sodium-glucose cotransporter-2 inhibitors (medications that are used to lower blood glucose). Positive ketones and protein in the urine can be an indication of uncontrolled diabetes, kidney problems or dehydration. The resident's blood glucose was 312 at 10:37 PM on 8/31/25 and 251 at 3:49 AM on 9/1/25. There was no other treatment noted related to hyperglycemia. The final diagnosis was hyperglycemia without ketosis (a metabolic state where the body burns fat for energy instead of glucose due to a lack of enough carbohydrates in the body resulting in ketone bodies in the blood or urine). Resident #1 was discharged home on 9/1/25. An interview was conducted with the DON on 9/24/25 at 11:15 AM. She stated that Resident #1 was admitted on [DATE] by Nurse #1. The DON stated she became aware that Resident #1 did not receive insulin while he was admitted at the facility after Resident #1's RP contacted her on 9/1/25 and informed her that Resident #1 had been sent to the ED after he was discharged from the facility. The DON indicated that the admitting orders were on Resident #1's FL2 form which included 5 units Lantus at bedtime and continuous monitoring of blood glucose. She indicated that when she interviewed Nurse #1, the nurse told her (the DON) that Resident #1's RP brought his medications to the facility on admission [DATE]), but the medications did not include Lantus or the device that read his blood glucose level. She stated that the application that linked to the resident's blood glucose monitoring sensor was on the RP's phone. The DON reported that if the admitting nurse had verified the orders in the EHR with the orders on the FL2 and realized they did not have a way to check the resident's blood glucose she (the admitting nurse) should have reached out to the provider and the provider would probably have given an order to use a glucometer to ensure the resident's blood glucose was being monitored. The DON stated that Nurse #2 was initially supposed to admit the resident on 8/28/25 and when she entered the orders on 8/28/25 she omitted the orders for Lantus and blood glucose monitoring when she entered the orders from the FL2 form into the electronic record so the blood glucose was not monitored, and the Lantus was not administered. The DON stated that the admitting nurse was supposed to enter orders into the EHR, verify the written orders to make sure they were entered correctly, and was supposed to contact the provider if anything needed to be clarified. She indicated that once the admitting nurse verified the orders with the medications brought from home, a second nurse would not have necessarily checked behind the admitting nurse unless there was a problem. An interview was conducted on 9/24/25 at 4:45 PM with the Medical Director. She indicated that she did not get to see Resident #1 because he was at the facility for only 2 days and that the nursing staff did not reach out to her to clarify any of the resident's orders. The Medical Director indicated that nurses were supposed to contact her if they had any questions with an order or if a resident's blood glucose was too high or too low. She indicated that the blood glucose parameters that required reporting to the provider varied for different residents. She stated that normally the high parameters that would require notification to the provider would be greater than 400 - 450 and the low parameters would be less than 60 -70. She stated that if Resident #1's blood glucose had been monitored and it was above the high parameter she would have ordered insulin and intravenous fluids. She indicated that she expected nurses to transcribe orders correctly and call for clarification if there were any discrepancies or if they had any questions. The Medical Director stated that she did not expect Resident #1 to develop diabetic ketoacidosis [DKA] (a life-threatening condition due to insufficient insulin in the body that can lead to high blood glucose levels) because he had diabetes type 2. She stated that elevated blood glucose could lead to lethargy, extra thirst, dehydration and vascular problems. She further stated that unmonitored blood glucose could lead to hyperglycemia or hypoglycemia (low blood glucose) and can result in loss of consciousness, seizures and coma. During an interview on 9/24/25 at 5:29 PM with the Administrator he indicated that the nurses should have looked at the FL2 form and put the orders in correctly and if they had any questions they should have called the provider to clarify. The Administrator was notified of Immediate Jeopardy on 9/24/25 at 8:41 PM.The facility provided the following corrective action plan:1. Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice.Resident #1 was admitted to the facility on [DATE]th, 2025, for a 2-day respite stay. Resident #1discharged on Sunday August 31st, 2025. Resident #1's RP contacted the administrator on Monday September 1st, 2025, stating that Resident #1 did not receive any of his medications. The administrator informed Resident #1's RP that the Director of Nursing (DON) would investigate her concern and call her back. The DON completed an investigation by interviewing staff, reviewing surveillance footage and completing a chart audit. The DON determined during Resident #1 respite stay that an insulin order for Lantus 5 units at bedtime and an order for continuous blood glucose monitoring was omitted from the EHR. The DON identified that B-hall nurse transcribed orders on Thursday August 28th, 2025; however, Resident #1 did not admit to facility until Friday August 29th, 2025, and was admitted to a-hall. A-hall nurse reviewed orders transcribed into the EHR according to medications brought into facility by Resident #1's RP. A-hall nurse reported no insulin or blood glucose monitoring sensor being provided by Resident #1's RP. The lack of communication between the A Hall Nurse and B Hall nurse resulted in the omission of orders. The facility's provider was not contacted by the admitting nurse for clarification of orders. As a result, Resident #1 did not receive Lantus 5 units at bedtime on Friday August 29th, 2025, and on Saturday August 30th, 2025. Resident #1 did not have any blood glucose monitoring performed on Friday August 29th, Saturday August 30th, or Sunday August 31st, 2025. The DON contacted Resident #1's RP on 9/1/25 and informed her of the investigation findings and that a plan of correction would be implemented to prevent any further issues with order omissions upon admission of respite residents. The DON educated Resident #1's RP of signs and symptoms of hypo / hyperglycemia and to notify emergency services via 911 if Resident #1 exhibited any signs or symptoms. Resident #1s RP reported to DON that Resident #1 was taken to the emergency room on Sunday August 31st, 2025, and was admitted in ICU with a blood glucose of 700 (this was not confirmed with hospital records).2. Address how the facility will identify other residents having the potential to be affected by the same deficient practice.The DON performed an audit on all respite residents that admitted to the facility beginning August 1st, 2025. The DON compared orders transcribed in the EHR with FL2's to identify any discrepancies with order transcription. The audit revealed that Resident #2 admitted on Friday August 8th, 2025, with no discrepancies noted to FL2 and orders transcribed into the EHR. Resident #3 was admitted on [DATE]st, 2025, and discrepancies with FL2 and home medications were identified. Home medications were verified with the responsible party, and the provider was made aware of the discrepancy between home medications and FL2. An order was obtained to hold primidone (medication used to treat seizures), administer metoprolol (medication used to lower blood pressure and heart rate) once a day, and administer 20 milliequivalents of potassium chloride daily. 3. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur.The DON initiated staff education verbally to all nurses on Wednesday September 3rd, 2025, regarding omission of admission orders in regard to respite residents. The facility will continue to obtain an FL2 prior to providing an offer of respite admission to the facility. The facility Admissions Director will continue to communicate with RPs of each potential respite admission that home medications are required upon the resident's arrival to the facility. All nurses were instructed to utilize the FL2 to transcribe orders into the EHR, once the resident's medications are brought to the facility the assigned nurse will compare the medication bottle label with the orders transcribed into the EHR. If there are discrepancies, the assigned nurse will contact the family to determine the resident's current medication regimen. The assigned nurse will notify the provider of the discrepancies and the current home medication regimen reported by the family. If the family is unable to be reached, the assigned nurse will contact the provider for clarification of orders. In the event that medications are not provided by RP upon admission, the nurse will contact the provider and obtain medications from the facility's contracted pharmacy. All newly hired nurses to include facility hire, agency hire, and/or contract nurses will be provided verbal education regarding transcription of respite resident orders prior to beginning to train on the floor in a nursing role by the DON/designee.4. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained.The DON or in the absence of the DON, the designated nursing supervisor will complete audits of respite residents seven days a week in which the nurse will physically observe medications brought from home to ensure accurate transcription of all orders. The DON or designee will compare transcribed orders in the EHR to each resident's FL2 and home medications on day of admission for each respite resident to ensure accuracy of transcription of all orders. The DON or designee will complete the daily audits for 60 days. The audit will be reviewed at the next scheduled Quality Assurance Improvement Plan (QAPI) meeting. ADHOC QAPI was completed by the DON on September 3rd, 2025.Alleged date of immediate jeopardy removal and compliance: 9/4/25The corrective action plan was validated on 9/25/25 by reviewing the initial audits, monitoring audits, and the education the licensed nursing staff received which included utilizing the FL2 to transcribe orders for respite care residents into the electronic record, comparing the medication bottle label with the orders transcribed into the electronic record and clarifying any discrepancies with the provider. The licensed nursing staff were able to verbalize the education that was given to them. QAPI review was verified to have been completed on 9/3/25. The immediate jeopardy removal date and compliance date of 9/4/25 was verified.

Based on observation, record review and staff interviews, the facility failed to apply left hand splint as ordered for 1 of 3 sampled residents with limited range of motion/contractures (Resident #61). Findings included: Resident #61 was admitted to the facility on [DATE] with diagnoses that included generalized muscle weakness, dementia, need for assistance with personal care, reduced mobility, lack of coordination, and contracture of muscle, multiple sites. Resident #61's quarterly Minimum Data Set Assessment (MDS) dated [DATE] coded the resident as moderately cognitively impaired. He was coded as dependent with personal hygiene, bathing and toileting. He required setup/clean-up assistance with eating and oral hygiene. Review of Resident #61's medical records revealed an occupational therapy (OT) order dated 8/2/24 that indicated left hand roll with finger separators at all times except during hand hygiene daily. OT discharge note dated 8/2/24 indicated discharge recommendations: left hand roll with finger separators on at all times except during ROM (range of motion) and hand hygiene. Patient referred to restorative nursing program. A physician order dated 8/7/2024 indicated monitor splint to left hand. Left hand splint to stay in place at all times except during hand hygiene. Resident #61 was observed on 10/15/24 at 12:41 PM, 10/16/24 at 10:49 AM and 10/17/24 at 2:43 PM without a splint to the left hand and the left hand was noted to be contracted. During an interview with Restorative Aide #1 on 10/17/24 at 2:48 PM, she stated that she had Resident #61 on her case load for passive range of motion and application of the left-hand roll. Restorative Aide #1stated that she thought Resident #61 was supposed to have a rolled washcloth in the palm of his left hand and that she had never applied a splint or finger separators to Resident #61's left hand. An interview was conducted with the facility Occupational Therapist (OT) on 10/18/24 at 9:59 AM. The OT explained that a splint or hand roll with finger separators is used to decrease the risk of worsening contractures and developing skin breakdown. She further stated that if a splint or hand roll with finger separators is not utilized as ordered then there was potential for skin breakdown, wounds developing and worsening contractures. The OT indicated she had just evaluated Resident #61 prior to this interview and that Resident #61's left hand contracture had not gotten worse since the last evaluation on 8/2/24 and he had not developed any skin breakdown to the left-hand palm. OT further stated she had found Resident #61's hand roll in his room drawer and applied it to his left hand with the finger separators shortly before this interview. During an interview with Nurse #1 on 10/17/24 at 2:43 PM, the order for left hand splint for Resident #61 was verified with Nurse #1. Nurse #1 verified that Resident #61 did not have a splint on and indicated the restorative nurse aides were responsible for applying the splint to the left hand. During an interview on 10/17/24 at 2:55 PM with the Director of Nursing (DON), she stated nursing staff should have utilized a splint on Resident #61's left hand as ordered. During an interview with the facility Administrator on 10/17/24 at 2:58 PM, he indicated that if Resident #61 had an order for a splint his expectation was for nursing staff to use it.

Based on record review, observation, the facility's surveillance video, and interviews with staff and law enforcement, the facility failed to protect a cognitively impaired female resident's (Resident #1) right to be free from sexual abuse by a male visitor. On 03/28/24, the Visitor was at the facility visiting his family member (Resident #2) in a common area of the facility when he left that area and went to her (Resident #2's) semi-private room on the secured dementia unit where she resided with Resident #1. Resident #1 was in her bed when the Visitor was observed by Nursing Assistant (NA) #1 as he leaned over Resident #1 with his back to the door. NA #1 asked what he was doing and the Visitor turned around and adjusted the waist of his pants. The Visitor admitted to law enforcement that he took his hand and placed it on Resident #1's vagina. Resident #1 was incapable of giving consent for the Visitor to touch her. Resident #1 indicated the Visitor hurt me and that she was scared he was going to come back. This deficient practice was for 1 of 3 residents reviewed for abuse. The findings included: Resident #1 was admitted to the facility on [DATE] with diagnoses which included, in part, dementia with other behavioral disturbance, anxiety and depression. A review of Resident #1's care plan revealed a focus, revised on 08/28/23, that she had inappropriate behaviors such as agitation, altercations with roommate, refusing showers, and taking her roommate's belongings. There was no care plan in place related to sexual behaviors. A review of Resident #1's Minimum Data Set (MDS), dated [DATE], revealed that Resident #1 was moderately cognitively impaired and had no physical, verbal, or other behavioral symptoms and no rejection of care or wandering behaviors at the time of the assessment. The MDS indicated Resident #1 had no impairment in her upper and lower extremities. The assessment indicated the resident had been dependent on staff for assistance with dressing her lower body and toileting and that she had required substantial/maximal assistance with dressing her upper body, personal hygiene and bathing. An observation of Resident #1's room was conducted on 04/03/24 at 11:55 a.m. She resided on the secured unit with a roommate, Resident #2. Resident #1's bed was the A bed, closest to the door. Review of the facility's Initial Allegation Report, completed by Nurse #1 on 03/28/24, revealed an allegation of resident abuse on 03/28/24. The facility became aware of this allegation on 03/28/24 at 9:50 a.m. The allegation stated that NA #1 observed the Visitor (Resident #1's roommate's male family member) standing over her bed and as he turned around, he was observed tucking his penis back into his pants. The report indicated that the facility reported this incident to law enforcement on 03/28/24 at 10:00 a.m. and to the State agency on 03/28/24. A review of Resident #1's 03/28/24 Progress Notes revealed a note written by Nurse #1 at 9:50 a.m. which indicated she was called to the resident's room by NA #1 who reported she observed the Visitor standing over Resident #1 with his hand in his pants and when he turned around his penis outside of his pants. Nurse #1 wrote she moved the Visitor away from the resident and made the Administrator of the facility aware of the incident. A review of NA #1's written statement, dated 03/28/24, read as follows: I noticed [the Visitor] walk by and enter the resident's room (in which his [family member] shares a room with). So I followed him when he went back to the room where the incident occurred. He was standing over the resident and I asked what are you doing sir, he replied I'm fixing her back in the bed. He was putting his penis back in his pants and I immediately called for the nurse and ask him to leave the room and I checked on the resident to see if she was ok and she stated she wasn't. An interview was conducted with the Director of Nursing (DON) on 04/04/24 at 3:37 p.m. The DON explained she had not been at work on the day of the incident (3/28/24) however she had been informed of it via a telephone call from the facility on 3/28/24. The DON further explained she had returned to work on 03/29/24 and during her review of the incident and of the different written statements by staff, she questioned a discrepancy she noticed regarding whether or not NA #1 had witnessed the Visitor's penis. She reported a discussion was held with NA #1 and explained the nursing assistant had made an assumption when she saw the Visitor adjusting the waist of his pants as he turned to face her. The DON acknowledged she and the Administrator asked NA #1 to write an addendum to her original written statement which clarified what she had actually witnessed. A review of an undated addendum NA #1 had written to her original statement read as follows: I was going to assist a resident with a.m. care. Before I went in the room to assist a resident, I went in to [Resident #1] room to check on her to see if she was awake and upon me entering the room I witnessed [the Visitor] standing over her with his hands on her body. His hands was on her arm and thigh. I asked him what was he doing and as he turned towards me he was adjusting his pants (I did not see his penis out of his pants) and he stated he was helping her back on the bed. I asked him to leave the room and I yelled for the nurse to come. When the nurse escorted him out of the room, I checked on [Resident #1] and asked her if she was ok and she stated no I'm not ok. I observed her and noticed her brief the crotch part was moved to the side and I asked her if she was ok and she said no. I remained in with her until the nurse came back to the room to check on [Resident #1]. An interview was conducted with NA #1 on 04/03/24 at 12:43 p.m. NA #1 confirmed she had been assigned to care for Resident #1 on 03/28/24 from 7:00 a.m. until 3:00 p.m. NA #1 stated around 9:15 a.m. on 03/28/24 she had been doing her morning rounds on the dementia unit and had been ready to provide care to a resident who resided in the room across from Resident #1. She indicated because Resident #1 had been assessed as a fall risk, she had decided to pop her head into her room to quickly check on her before beginning care with the other resident. NA #1 explained she peeked into Resident #1's room and noticed the Visitor (family member of her roommate, Resident #2) standing over Resident #1's bed. NA #1 explained the Visitor had been standing beside the bed on the resident's right side, towards the middle of the bed. She further explained Resident #1 was lying on her back and he was leaning towards her with his left hand on her right upper arm and his right hand was on her right thigh. She stated the bed covers were pulled up to the resident's waist and that she had been wearing a hospital gown and an adult pull-up brief at the time of the incident. She clarified that the resident's brief was not exposed at the time of that observation. NA #1 described how she had asked the Visitor what he was doing and stated he stood up straight and turned towards her. As he was turning towards her, she said she noticed him adjusting his pants. When asked to explain, she stated he had been wearing a pair of jeans however could not recall if the buttons or zipper to his jeans were undone, or if he had been wearing a belt. She stated the Visitor then told her he was helping Resident #1 back on her bed. NA #1 denied seeing the man's penis. NA #1 said the Visitor started walking towards the doorway as if to leave the room and she immediately yelled for Nurse #1 to come to the room while the Visitor stood in the hallway outside the room. NA #1 stated as Nurse #1 approached the two of them (NA #1 and the Visitor) in the hallway, she told the nurse what she had witnessed, and then Nurse #1 asked the Visitor to go back to the dayroom where he had been visiting his family member (Resident #2) and escorted him to that area of the unit. NA #1 explained that she sat with Resident #1 until the Administrator and Nurse #2 got to her room. NA #1 indicated she had asked Resident #1 if she was okay and the resident said no. She stated she then pulled back the bed linens and saw that the leg opening part of her adult pull-up brief appeared to have been pulled away from her groin area which exposed her pubic hair and nothing else. A second interview, via telephone, was conducted with NA #1 on 04/04/24 at 8:25 a.m. to discuss the reason she had written an addendum to her original written statement. In that addendum, NA #1 clarified she had not seen the Visitor's penis. NA #1 explained after she had discussed the incident at length with the Administrator and DON, she had been asked to write an addendum which clarified that she did not see the Visitor tucking his penis back in his pants. NA #1 further explained that because she had seen the Visitor adjusting the waist of his pants as he turned to respond to her question, she had assumed that he was tucking his penis back into his pants. NA #1 indicated both the Administrator and DON had expressed to her they wanted the reports to the State to be accurate. A review of Nurse #1's written statement, dated 03/28/24, read as follows: [The Visitor] was visiting his [family member (Resident #2)] in the private dining room. This writer observed [the Visitor] going back and forth to [Resident #2's room number] with tissue in his hand on two occasions. The second time the CNA [certified nursing assistant] went to the room and called this writer to the room. I met [the Visitor] in the hallway. He stated he was 'getting tissue.' There was a box of tissue at the table with his [family member (Resident #2)]. An interview was conducted with Nurse #1 on 04/03/24 at 11:54 a.m. Nurse #1 confirmed she had been assigned to care for Resident #1 on 03/28/24 from 7:00 a.m. until 7:00 p.m. Nurse #1 explained she had been made aware of an incident involving Resident #1 at approximately 9:50 a.m. when NA #1 had called her name and motioned for her to come towards Resident #1's room. She noted that NA #1 was outside of Resident #1's room and the Visitor stood in an area between the 600 and 700 Hall. Nurse #1 explained she asked NA #1 what happened and said NA #1 told her that the Visitor had been in the room with Resident #1 alone. Nurse #1 stated she then asked the Visitor what he had been doing in there and stated he told her that he had gone into the room to get some tissue. Nurse #1 stated NA #1 then told her that the Visitor had been standing over Resident #1 while she was in her bed with his hand in Resident #1's adult brief and when he turned towards her, he put his penis back into his pants. Nurse #1 indicated she escorted the Visitor to the dayroom where he had been visiting with his family member (Resident #2) and stated she instructed him to stay there, which he agreed to do. Nurse #1 stated she had instructed the activities aide to go sit with Resident #1 and she left the secured dementia unit to get Nurse #2 and the Administrator who were in a meeting in the conference room. She expressed to them (the Administrator and Nurse #2) that she needed help and told them what had been reported to her by NA #1. Nurse #1 indicated both Nurse #2 and the Administrator then went to the dementia unit and she had been given instructions to begin the paperwork for an investigation as well as to call the police. Nurse #1 stated Resident #1 was sent to the hospital for evaluation. Nurse #1 acknowledged the police and Emergency Medical Services (EMS) got to the facility around the same time and both agencies looked over the resident before EMS took the resident to the hospital. She also stated the police officer took pictures of Resident #1's room and collected her bed linens. Nurse #1 said she then contacted Resident #1's medical doctor (MD) to inform them of the incident and reported no new orders were given at that time. Nurse #1 explained that the resident was normally anxious and took scheduled antianxiety medication but she (Nurse #1) worried the resident would experience increased anxiety later so she contacted the MD to see if she could get something else for Resident #1's anxiety if needed. Nurse #1 stated Resident #1 appeared a little anxious prior to going to the hospital. When asked about the Visitor, Nurse #1 stated he had visited his family member (Resident #2) on many occasions and had never displayed any inappropriate behavior during those visits. A second interview was conducted with Nurse #1 on 04/04/24 at 2:40 p.m. Nurse #1 stated Resident #1 was alert but confused and would often think staff or other residents on the dementia unit were arguing with her or would think the people on the television were arguing with her. Nurse #1 confirmed that Resident #1 would tell staff that this man or that man was her brother or her husband and quite frequently thought she was pregnant, however, never made sexualized remarks to people. Nurse #1 explained on the day of the incident, the Visitor had done nothing to cause suspicion during his visit with his family member. A third interview was conducted, via telephone, with Nurse #1 on 04/16/24 at 10:51 a.m. Nurse #1 stated when she escorted the Visitor down the hall and back to the dayroom, she instructed him to wait there and explained she had given instructions to the Life Enrichment Assistant to supervise the Visitor there until she returned. Nurse #1 stated the only other resident who was in the dayroom with Visitor was his family member (Resident #2). Nurse #1 explained approximately 5 minutes had elapsed from the time she left the unit until the time she returned to the unit along with Nurse #2 and the Administrator. A review of Nurse #2's written statement, dated 03/28/24, read as follows: After alleged allegations writer interviewed resident. Writer asked resident was she ok. Resident stated 'I'm scared. He's going to come back.' Writer asked who will come back and what did he do? Resident states 'he hurt me.' Writer states how and where did he hurt you. Resident places hands on genitalia and states 'right here.' Writer asked what did he do right there. Resident states 'he was doing something with his fingers and it hurts on the inside.' Writer then left resident's bedroom and informed administrator. Nurse #2 had written an addendum to her statement, dated 03/29/24. It read as follows: Prior to interviewing resident writer observed resident in bed gripping shirt and shaking. Brief was exposed and blanket was observed positioned below hip line. Writer later identified CNA [NA #1] pulled covers back. An interview was conducted with Nurse #2 on 04/04/24 at 11:05 a.m. Nurse #2 confirmed she worked on 03/28/24 as the wound care nurse during day shift hours. Nurse #2 stated she had been made aware of the incident involving Resident #1 when Nurse #1 came to the conference room and told her that she needed to speak with her. She stated she and Nurse #1 went to the Staff Development Coordinator's office where Nurse #1 shared the details of the incident and then she returned to the conference room and shared those details with the Administrator. Nurse #2 explained she and the Administrator immediately went to the dementia unit and stated she had been given instructions by the Administrator to interview Resident #1 while he went to talk with the Visitor. Upon entering Resident #1's room, Nurse #2 stated the resident appeared nervous and afraid and was noted to be trembling. The resident was gripping onto her gown and she was shaking. She noted the bed linens were pulled over Resident #1's legs to her waist and she was gripping her gown. Nurse #2 said she walked over to the resident's bed and asked her what was wrong and stated Resident #1 said, I'm scared to which she asked her what she was scared of. Nurse #2 stated the resident said, that man hurt me and then she asked the resident where he had hurt her and said the resident took her hands and patted the area at the top of her adult pull-up brief and said, right here. Nurse #2 asked the resident to elaborate and stated the resident said he had done something with his fingers, and it hurt on the inside. Nurse #2 acknowledged she assessed Resident #1 and pulled her bed linens back exposing her brief; however, Nurse #2 could not recall if the brief had been shifted to expose any of her private parts. Nurse #2 then described she pulled Resident #1's brief down and checked it but did not see any blood in it and did not see any signs of trauma to her external private parts. A review of the Administrator's written statement, dated 03/28/24, read as follows: Writer approached [the Visitor] at approximately 11AM while he was sitting in activities room with [his family member]. Writer informed [the Visitor] that he needed to leave the facility due to a report of inappropriate behavior. [The Visitor] collected his belongings and left the memory care unit with writer. As writer was escorting [the Visitor] to the front entrance, he told writer that he [the Visitor] messed up, because when he went into his [family member's] room to get something, the lady in the room with her [Resident #1] called him over to her bed and stated that she wanted him to 'f**k' her. He said he [the Visitor] only touched her leg and then the lady [NA #1] came to the room. Writer informed [the Visitor] that the police were being called and that he needed to wait in the social worker's office. [The Visitor] complied and was supervised by [Nurse #2] until police arrived. A review of the law enforcement report, completed on 03/28/24, revealed the incident had occurred on 03/28/24 and had been reported to them by the facility on 03/28/24 at 10:01 a.m. The report indicated the Visitor committed a forcible sexual offense by touching a disabled individual's private part (Resident #1). An interview was conducted with the local police department's lead detective on this case on 04/03/24 at 12:58 p.m. The Detective explained once she arrived at the facility, she had been briefed by the officers who had initially reported to the facility. She stated she did not speak with Resident #1 but had watched the responding officer's body camera footage and stated Resident #1 admitted to the officer that a man had touched her private parts. The Detective stated she had spoken with the accused individual (the Visitor), read him his rights, and then asked him to go to the police department so that she could conduct an interview with him privately. The Detective indicated the accused individual drove himself voluntarily to the police department as one of the police officers followed behind him. Before leaving the facility, the Detective spoke with Nurse #2 and the facility's Administrator and stated the Administrator informed her of his conversation with Nurse #1. The Detective acknowledged it had been suggested NA #1 had witnessed the accused individual tucking his penis back into his pants, however, she had been informed on 04/02/24 by the Administrator that the accused individual's penis had never been exposed. After speaking with the Administrator, the Detective then spoke with Nurse #2 who reported that the accused individual had told her that he had not had sex in a long time and that Resident #1 said to him, I want you to f**k me. The Detective stated Nurse #2 continued detailing her conversation with him and stated the accused individual had told her that he approached Resident #1 who had been in her bed and he had touched her in her private parts. The Detective stated Nurse #2 then told her that she had asked the accused individual if anything else had happened or did he touch himself and said Nurse #2 said he told her that he may or may not have touched himself on the outside of his pants, that he could not remember. The Detective stated the Administrator informed her that as he was walking the accused individual from the dementia unit to another office, the Visitor had apologized to him (the Administrator) and told him that he was embarrassed. The Detective stated she then left the facility to go interview the accused individual at the police department while another detective remained at the facility to gather evidence. When asked if the Detective considered the Visitor to be alert and oriented, she confirmed she had asked him questions such as the day, date and year and remarked he was correct on all accounts with the exception of getting the date wrong by one day. She also reported that he (the Visitor) was still able to drive a vehicle and had been able to describe his usual activities when he visited his family member at the facility. She stated he reported having a medical condition related to his blood pressure which required him to take medication. During the interview at the police department, the Detective explained the Visitor confessed to her and explained that he told her he had been thinking it had been so long since he had sex and that he had been attracted by the offer made by Resident #1. The Detective continued, stating the Visitor told her that he had approached Resident #1's bed and Resident #1 had been the one who pulled her bed linens down and pulled her underwear to the side exposing her vagina to him. The Detective stated the Visitor then said he took his hand and placed it on her (Resident #1's) vagina. The Detective then said she asked him if he had inserted a finger into her vagina and stated he told her (the Detective) that everything had happened so fast that he could not remember. The Detective stated she asked the Visitor to provide a DNA (a molecule that contains the genetic code that is unique to every individual) sample and he had done so voluntarily after which he was placed under arrest and charged with felony second-degree forceful sexual offense. When asked to explain the charges, the Detective explained that because Resident #1 was considered disabled and mentally incapable of giving consent, this offense could be anything but penetration. The Detective further explained the Visitor was processed in the county jail and there he remained on a high bond. She also stated that the Visitor was told that he can no longer go to the facility or have any contact with Resident #1. An interview was conducted with the Life Enrichment Assistant from the Activities Department on 04/04/24 at 1:16 p.m. The Life Enrichment Assistant confirmed she had been working on 03/28/24 during the day shift and at the time of the incident with the Visitor and Resident #1, she had been doing activities with the residents on the secured dementia unit in the activities/dining room area. The Life Enrichment Assistant stated she often interacted with Resident #1 during activities and explained she was familiar with Resident #1's usual moods and behaviors. The Life Enrichment Assistant further explained that she had been asked by the Administrator to sit with Resident #1 as they waited for EMS to arrive. The Life Enrichment Assistant stated while she sat with Resident #1, the resident appeared to be acting a little stressed or scared at that time. Because she had worked with her before, the Life Enrichment Assistant stated she knew that Resident #1 had those types of behaviors occasionally but was unsure of what had caused the resident to act that way on that date. During her interaction with Resident #1, the Life Enrichment Assistant said she asked her how she was doing and said the resident replied, I could be better to which she responded why, what's wrong? The Life Enrichment Assistant detailed how the resident then moved her hand to her perineal area (the area between a person's anus and vulva) and told her that the man (the Visitor) had touched her vagina. A second interview was conducted, via telephone, with the Life Enrichment Assistant on 04/16/24 at 10:10 a.m. The Life Enrichment Assistant stated upon entering the secured dementia unit to begin an activity with the residents, she observed NA #1 in the hall motioning for Nurse #1 to come to Resident #1's room. She stated she then observed Nurse #1 escorting the Visitor to the dayroom and heard her tell him to stay there. The Life Enrichment Assistant explained Nurse #1 did not give her any details of what had just occurred in Resident #1's room but asked her to supervise the Visitor in the dayroom while she went off the unit to talk with Nurse #2 and the Administrator. The Life Enrichment Assistant stated only the Visitor and the Visitor's family member (Resident #2) were in the dayroom during that time. She stated prior to the Administrator escorting the Visitor off the secured dementia unit, he instructed her to go to Resident #1's room and sit with her until EMS arrived. A review of Resident #1's emergency room visit notes on 03/28/24 at a local hospital revealed the following: -- Medical history and physical exam were completed by a Registered Nurse. Findings included vital signs within normal limits. An emotional assessment was documented as quiet and cooperative. A systems examination revealed no abnormalities. There were no signs of physical trauma noted on the anatomical drawing of the female body. A pelvic exam revealed no abnormalities. -- She was assessed by a medical doctor and his assessment read as follows: Chief Complaint: Sexual Assault. History of Presenting Illness: .female with a [past medical history] significant for dementia who presents to the ED [Emergency Department] via EMS for evaluation of an alleged sexual assault. Per EMS, patient comes from [name of skilled nursing home] and staff there reported her roommate's [Resident #2] [family member] confirmed that he [the Visitor] 'touched her inappropriately' this morning. Staff notes that he was in the room for quite a while and when he came out he was 'adjusting his pants.' Patient states that 'he started at my head and worked his way down' noting that he touched her head, her breasts and her vaginal area. He denied [the Visitor] any penetration on scene . Patient claims that he [the Visitor] did penetrate her. Patient reports that she did not give consent. Denies any injuries or pain, but history is severely limited secondary to her dementia . Physical Exam . general - she is not in acute distress . psychiatric .mood normal .behavior normal . Clinical Impressions - sexual assault of adult, initial encounter, prophylactic antibiotic, severe dementia without behavioral disturbance, psychotic disturbance, mood disturbance or anxiety . -- The record indicated Resident #1 was discharged back to the facility on [DATE]. During an interview conducted with Nurse #1 on 04/03/24 at 11:54 a.m., she stated after Resident #1 returned from the hospital (on 3/28/24 at approximately 4:00 p.m.), she and Nurse #2 completed a head-to-toe assessment on her which revealed no areas of trauma or bruising. Nurse #1 stated after Resident #1 returned from the hospital, she had been at her usual baseline mood and affect with no recollection of having gone to the hospital that day. Nurse #1 indicated Resident #1 returned from the hospital around 4:00 p.m. that afternoon. A review of Resident #1's Head to Toe Evaluation, completed by Director of Nursing (DON) and dated 03/29/24 at 5:12 p.m., revealed Resident #1 had a normal exam with no complaints of pain and displayed no significant behavioral changes within the last 24 hours. During an interview with the Director of Nursing (DON) on 04/04/24 at 3:37 p.m. she stated she had assessed Resident #1 on 03/29/24, just after lunch that day, and that there had been no signs or symptoms of trauma or distress. The DON remarked that Resident #1 seemed to be at her baseline regarding her behaviors, mood and affect; she also confirmed that the resident often thought she was pregnant or in labor. The DON confirmed Resident #1 was not seen by the facility's medical doctor after the incident of 03/28/24 but stated after the incident, the resident had been scheduled to see the facility's psych provider on 04/04/23. During an interview with Nurse #2 on 04/04/24 at 11:05 a.m. she described Resident #1's emotional state after her return from the local hospital. Nurse #2 stated Resident #1 appeared to be at her baseline in regard to mood and affect. She said she had asked the resident how she was doing and said that the resident told her she had been at the hospital having a baby which was a common theme when talking with the resident. Nurse #2 stated Resident #1 was taken to her room and a full assessment had been completed which revealed no signs of trauma including vaginal discharge or blood nor any bruising, redness, or trauma to that area. Nurse #2 stated she and the DON repeated this exam again on 03/29/24 with no signs or symptoms of any trauma. A review of the facility's surveillance video was conducted with the Administrator in attendance on 04/03/24 at 3:00 p.m. As the Administrator pulled up the surveillance video footage from their secured dementia unit on 03/28/24, he explained the times noted on the surveillance cameras were not 100% accurate but further explained the footage would show the length of time the Visitor was in Resident #1's room. According to the time stamps of the footage, the Visitor was observed approaching Resident #1's room at 9:16 a.m. and then entered her room at 9:16:16 a.m. The door to the room was never closed. NA #1 was observed walking down the hall towards Resident #1's room and then standing at the opening of the door and looking inside at 9:17:37 a.m. NA #1 then motioned to someone to come to the room. The Visitor was observed leaving the room at 9:17:56 a.m. which indicated he was in the room alone with Resident #1 for one minute and forty seconds. Attempts made to contact Resident #1's Responsible Party by phone on 04/04/24 were unsuccessful. An interview was conducted with the Administrator on 04/05/24 at 12:00 p.m. The Administrator detailed the 03/28/24 incident involving Resident #1 and the Visitor. He explained Nurse #1 had come to the conference room on 03/28/24 around 10:00 a.m. where he had been involved in their usual morning meeting and had asked to speak with Nurse #2 outside of the conference room. The Administrator explained both nurses (Nurse #1 and Nurse #2) returned to the conference room and informed him of what had just occurred on their secured dementia unit with Resident #1 and the Visitor and that he immediately went to that area. After locating the Visitor in the dayroom sitting with his family member and giving instructions to the staff about what needed to occur, he stated he escorted the Visitor off the dementia unit to the Social Worker's office where Nurse #2 supervised him while he waited for law enforcement to arrive to the facility. The Administrator stated he immediately began an investigation. The Administrator stated as he had been walking the Visitor to the Social Worker's office, the Visitor told him, I'm so sorry I got wrapped up in that, I went to get something for [Resident #2] but that lady [Resident #1] said come here, I want you to f**k me but all I did was touch her leg and then that lady [NA #1] came in. The Administrator, when asked, stated the Visitor had never displayed any inappropriate behaviors and did not know why the Visitor had done what had been reported to him. The Administrator said there had been no way he could have predicted what the Visitor did and felt he and the staff had followed their protocols after the incident by immediately securing the Resident #1's safety by removing the Visitor away from Resident #1 and beginning their investigation of the incident. The Administrator explained all staff from the different departments at the facility had been educated on their abuse policy and that they implemented a new policy which identified individuals that may be placed on a restricted visitation. The Administrator further explained the new policy included a notebook that contained a picture of the individual who had been placed on a restricted visitation and a log of the times the individual visited their facility and explained these individuals would only be allowed to visit the facility Monday through Friday, in the lobby, and t [TRUNCATED]

Based on record review and staff interviews the facility failed to code the Minimum Data Set (MDS) assessment accurately in the area of Preadmission Screening and Resident Review (PASRR) for 1 of 2 residents (Resident # 31) reviewed for PASRR. Findings included: Resident #31 was admitted to the facility on [DATE] and most recently readmitted on [DATE] after hospitalization with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review indicated Resident #31 had a Preadmission Screening and Resident Review (PASRR) Level II Determination Notification dated 11/12/15. The annual MDS assessment dated [DATE] was answered No to question A1500 which asked if Resident #31 had been evaluated by a level II PASRR and determined to have a serious mental illness and/or intellectual disability or a related condition. An interview was conducted on 4/27/22 at 2:12 PM with the MDS Nurse regarding PASRR documentation for Resident #31. The MDS Nurse stated the PASRR II documentation should have been completed when the Level II PASRR had been confirmed. She explained she was not working at the facility during that time and did not know why it was missed. An interview was conducted on 4/27/22 at 2:30 PM with the Administrator. The Administrator stated the MDS coding should have been completed for PASRR II residents on their annual MDS assessments.

Based on record review and staff interviews, the facility failed to make a referral for re-evaluation after a change in mental health status for 1 of 6 residents (Resident #62) reviewed for Pre-Admission Screening and Resident Review. Findings included: A review of the North Carolina Department of Health and Human Services, Division of Medical Assistance, Preadmission Screening and Annual Resident Review (PASRR) application, dated 10/28/17, revealed Resident #62's had no mental health diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident # 62 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] A review of Resident #62's annual Minimum Data Set (MDS), dated [DATE], revealed Resident #62 was moderately cognitive impaired and had not been considered by the State Level II PASRR process to have a serious mental illness. The MDS indicated Resident #62 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #62's Care Plan, last revised 03/25/22, revealed Resident #62 had been planned for a psychiatric disorder and having a mental illness/intellectual disability. During an interview with the Social Worker (SW) on 04/26/22 at 2:00 p.m., the SW stated she had been doing the PASRR tasks trying to catch up and had not submitted Resident #62 ' s changes yet. During an interview with the Administrator on 04/28/22 at 11:00 a.m., the Administrator stated he was aware of PASRR being updated and the staff is trying to catch them up. He stated he expected PASRRs are completed timely as per federal regulations.

Based on record review and staff interviews the facility failed to include all mental health diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Finding included: 1. Resident #12 was admitted [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS had Resident #12 coded as cognitively intact and needed extensive assistance. She also received an antipsychotic, antianxiety and an antidepressant for 7/7 days during the look back period. The comprehensive care plan dated 04/16/2022 had focus' of being on antipsychotic therapy daily due to delusional disorder and antianxiety therapy due to anxiety disorder. The diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The NCDHHS halted PASRR level II determination notification dated 04/21/2022 stated no further level I screen is required unless a significant change occurs with the individuals mental status which suggest a psychiatric disorder that is not dementia. The NC PASRR level I screen dated 04/15/2022 had Resident #12's disorder diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] The screen did not include the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . An interview with the Social Worker (SW) was conducted on 04/26/22 at 12:10 PM. The SW stated Resident #12 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . An interview with the Administrator was conducted on 04/02/2022 at 11:04 AM. The Administrator stated the staff was educated on PASRR procedures. All new mental health diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . 2. Resident #55 was admitted to the facility on [DATE]. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The North Carolina PASRR Level I form for Resident #55 submitted 8/18/2020 included dementia and [CONDITION(S)] diagnoses. Major depressive disorder diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The North Carolina Department of Health and Human Services halted PASRR level II determination notification dated 08/18/2020 revealed no further Level I screening was required unless a significant change occurred with the individual's mental status which suggested a psychiatric disorder that was not dementia. An interview was conducted on 04/26/22 at 03:12 PM with the facility Social Services Coordinator (SSC). She indicated it was an error and Resident # 55's Level I PASRR paperwork should have included depression diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . An interview was conducted on 04/28/22 at 09:44 AM with the facility Administrator. The Administrator stated the depression diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . He indicated going forward he would ensure all diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on staff and resident interviews, record review, and observations, the facility failed to serve palatable food for 2 of 2 residents (Resident #17, #18) reviewed for food palatability. Findings included: Record review of Resident Council Minutes for July 2021 indicated meals were cold when they arrived for service. During an interview 11/16/21 at 11:10 AM, Resident #18 indicated the food was not good and meat was often served tough and hard to chew. A test tray was requested at 11/17/21 at 8:00 AM regarding cold food served at breakfast. The test meal was plated at 8:26 AM and put onto a plastic base with a plastic lid on top. The grits were in a separate ceramic bowl placed on the plate under the lid. The tray was placed on an open delivery cart. The cart arrived to the 300 hall at 8:28 AM. Staff began delivering the trays immediately. The Certified Dietary Manager (CDM) was present on the 300 hall when the lid was removed and no visible steam was observed. The last tray was delivered at 8:37 AM. The surveyor sampled each item. Upon taste testing, the pancake was described as cold and tough. The scrambled eggs were barely warm. The sausage patty was barely warm. During an interview on 11/17/21 at 8:40 AM, the CDM indicated the foods should be hotter when they arrive to the resident to be served. During an interview on 11/17/21 at 9:40 AM, the resident council president (Resident #17) expressed previous issues of food being cold when it arrived for meals. During a follow-up interview on 11/17/21 at 10:15 AM, the CDM revealed the plate warmer was not working that morning and that was why the foods were cold. She was previously unaware it was not working. Maintenance fixed the plate warmer following breakfast, and it was working properly. She further stated if the food was cold, it should have been pulled and reheated. During an interview on 11/19/21 at 11:30 AM, the administrator stated he frequently discussed meals with residents, and they did not express any concerns about cold food. He further revealed the cold food situation was addressed as soon as the CDM was made aware.

Based on record review, staff interviews, and physician interviews for one (Resident # 1) of three sampled residents, the facility failed to consult with the physician when a resident was declining and orders had not been carried out per the physician's expectations. The findings included: Record review revealed Resident # 1 resided at the facility from 1/29/19 until his discharge to the hospital on 3/1/21. The resident had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the record revealed Resident # 1 had a MOST (Medical Orders for Scope of Treatment), which had originated on 1/31/19, for comfort measures. According to the form, the resident's RP (responsible party) had signed that the resident would not be transferred to the hospital unless comfort measures could not be provided at the facility. The form did reflect that the RP desired the resident have intravenous fluids if clinically indicated. Resident # 1's last quarterly minimum data set assessment, dated 2/25/21, coded the resident as severely cognitively impaired. The resident was also coded as totally dependent on staff for his hygiene, toileting, and eating needs. He was coded as needing supervision for transfers and walking. Review of nursing progress notes revealed an entry by Nurse # 3 on 2/23/21 at 10:36 PM noting Resident # 1 was sleeping more, had a decreased appetite, had a decline in his activities of daily living, and more malaise. The nurse noted therapy was working with the resident and the physician had ordered a decrease in his [MEDICATION(S)] (a medication used for his behaviors). The nurse further noted the resident's responsible party was notified. On 2/26/21 Resident # 1's physician saw the resident and documented the following information. The resident had very advanced dementia. The doctor was unable to communicate with him, but the resident seemed comfortable. The resident had some weight loss of unknown etiology and the doctor would do a further work up. The resident had been diagnosed with COVID in 2019. He also had had trouble in the past with maintaining weight due to his dementia. The doctor noted either the dementia or the history of COVID could be contributing to his issues. The physician noted he would leave new orders. One of the orders was for labs to be completed. This included a CMP (complete metabolic panel). According to the record, the CMP was drawn on 2/26/21 at 2:30 PM. Review of the CMP results revealed it was faxed to the facility on [DATE] at 1:02 AM. The resident's sodium level was noted to be a high panic level of 166 (normal sodium levels are 136-144). The resident's BUN (blood urea [MEDICATION(S)]) was 80 (normal 8-20), creatinine was 4.89 (.64-1.27), and his glomerular filtration rate was 12.8 which was noted on the lab report to indicate a level indicative of Stage 5 chronic renal failure. There was a notation on the lab report that Nurse # 1 was called by the lab at 12:57 AM on 2/27/21 and informed of the high panic sodium level. According to orders, on 2/27/21 at 2:00 AM Resident # 1 was ordered to receive 2 liters of .9 sodium chloride via intravenous infusion. The BMP was to be repeated following the completion of the second liter of fluid. The rate of infusion was 100 cc (cubic centimeters)/ hour. (This indicated the intravenous fluids should take 20 hours to infuse after initiation. At the time of the order, there were still 22 hours left in the day). On 2/27/21 at 2:10 AM Nurse # 1 noted IV attempted but unsuccessful. There were no further nursing progress notes regarding what was done regarding the IV after the 2:10 AM entry noting that attempts to start the IV were unsuccessful. The Resident's February 2021 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . There was a check made by the order for intravenous fluids on 2/27/21 at 11:26 AM by Nurse # 2. There was no further documentation on the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Nurse # 1 was interviewed on 9/9/21 at 2:50 PM and reported the following. She could not recall what happened on her shift after the IV could not be started. She reported if a nurse was unsuccessful in starting an IV, then they were to get another nurse to try. If the second nurse was unsuccessful, then they were to notify the doctor. Nurse # 2 cared for Resident # 1 from 7:00 AM to 3:00 PM on 2/27/21. Nurse # 2 was interviewed on 9/12/21 at 4:30 PM and reported the following. When she arrived Nurse # 1 had not been able to start the IV. The resident was in the bed at the time. She looked to see if she could find a place to start the IV, but the resident was combative. She only worked every other week-end and the resident did not know her. She felt that might be contributing to the issue. She therefore called the supervisor while thinking that the resident might respond to the supervisor (Nurse # 4) better. The supervisor could not find a place to start the IV, and decided they would administer the fluids via SQ (subcutaneous route) instead. The supervisor placed a butterfly needle in the resident's abdomen and started the fluids. She did not recall the time the fluids were started. She only recalled that it was in the morning on dayshift. The resident's facility physician was interviewed on 9/15/21 at 1:05 PM. The physician reported the following. The nursing staff did not call him again during the week-end of 2/27/21 and 2/28/21 after the order for the IV fluids was given. The physician stated they should have done so. With the sodium level high, the physician stated time was an important factor in getting the fluids started and he did not know until 3/1/21 about the delay in initiation orders. The physician also stated they should also have called if his status changed.

Based on record review, staff interviews, and physician interview for one (Resident # 1) of three sampled residents, the facility failed to carry out orders in a manner consistent with the physician's expectations and the resident's plan of care. The findings included: Record review revealed Resident # 1 resided at the facility from 1/29/19 until his discharge to the hospital on 3/1/21. The resident had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the record revealed Resident # 1 had a MOST (Medical Orders for Scope of Treatment) as part of his plan of care. The form had originated on 1/31/19 and was for comfort measures. According to the form, the resident's RP (responsible party) had signed that the resident would not be transferred to the hospital unless comfort measures could not be provided at the facility. The form did reflect that the RP desired the resident have intravenous fluids if clinically indicated. Resident # 1's last quarterly minimum data set assessment, dated 2/25/21, coded the resident as severely cognitively impaired. The resident was also coded as totally dependent on staff for his hygiene, toileting, and eating needs. He was coded as needing supervision for transfers and walking. Resident # 1's care plan, last reviewed on 2/21/21, revealed the facility identified the resident had increased hydration and nutrition needs due to his dementia. One of the goals for Resident #1 was that he be free of dehydration and electrolyte abnormalities. Staff were directed on the care plan to monitor the resident for signs of dehydration. Review of nursing progress notes revealed an entry by Nurse # 3 on 2/23/21 at 10:36 PM noting Resident # 1 was sleeping more, had a decreased appetite, had a decline in his activities of daily living, and more malaise. The nurse noted therapy was working with the resident and the physician had ordered a decrease in his [MEDICATION(S)] (a medication used for his behaviors). The nurse further noted the resident's responsible party was notified. On 2/26/21 Resident # 1's physician saw the resident and documented the following information. The resident had very advanced dementia. The doctor was unable to communicate with him, but the resident seemed comfortable. The resident had some weight loss of unknown etiology and the doctor would do a further work up. The resident had been diagnosed with COVID in 2019. He also had had trouble in the past with maintaining weight due to his dementia. The doctor noted either the dementia or the history of COVID could be contributing to his issues. The physician noted he would leave new orders. One of the orders was for labs to be completed. This included a CMP (complete metabolic panel). According to the record, the CMP was drawn on 2/26/21 at 2:30 PM. Review of the CMP results revealed it was faxed to the facility on [DATE] at 1:02 AM. The resident's sodium level was noted to be a high panic level of 166 (normal sodium levels are 136-144). The resident's BUN (blood urea [MEDICATION(S)]) was 80 (normal 8-20), creatinine was 4.89 (.64-1.27), and his glomerular filtration rate was 12.8 which was noted on the lab report to indicate a level indicative of Stage 5 chronic renal failure. There was a notation on the lab report that Nurse # 1 was called by the lab at 12:57 AM on 2/27/21 and informed of the high panic sodium level. According to orders, on 2/27/21 at 2:00 AM Resident # 1 was ordered to receive 2 liters of .9 sodium chloride via intravenous infusion. The BMP was to be repeated following the completion of the second liter of fluid. The rate of infusion was 100 cc (cubic centimeters)/ hour. (This rate indicated the intravenous fluids should take 20 hours to infuse after initiation of the IV. At the time of the order, there were still 22 hours left in the current day). On 2/27/21 at 2:10 AM Nurse # 1 noted IV attempted but unsuccessful. There were no further nursing progress notes regarding what was done regarding the IV after the 2:10 AM entry noting that attempts to start the IV were unsuccessful. There was not a repeat chemistry lab on the resident's record for the dates of 2/27/21 or 2/28/21. Nurse # 1 was interviewed on 9/9/21 at 2:50 PM and reported the following. She could not recall what happened on her shift after the IV could not be started. She reported if a nurse was unsuccessful in starting an IV, then they were to get another nurse to try. If the second nurse was unsuccessful, then they were to notify the doctor. Nurse # 2 cared for Resident # 1 from 7:00 AM to 3:00 PM on 2/27/21. Nurse # 2 was interviewed on 9/12/21 at 4:30 PM and reported the following. When she arrived Nurse # 1 had not been able to start the IV. The resident was in the bed at the time. She looked to see if she could find a place to start the IV, but the resident was combative. She only worked every other week-end and the resident did not know her well. She felt that might be contributing to the issue. She therefore called the supervisor while thinking that the resident might respond to the supervisor (Nurse # 4) better. The supervisor could not find a place to start the IV, and decided they would administer the fluids via SQ (subcutaneous route) instead. The supervisor placed a butterfly needle in the resident's abdomen and started the fluids. She did not recall the time the fluids were started. She only recalled that it was in the morning on dayshift. Nurse # 3 cared for Resident # 1 from 3:00 PM to 11:00 PM on 2/27/21. Nurse # 3 was interviewed on 9/13/21 at 2:00 PM and reported the following. Prior to the week-end of 2/27/21 and 2/28/21, Resident # 1 had been slowly declining over time. She knew his plan of care called for comfort measures. When she arrived on 2/27/21 the fluids were infusing and were still going when she left that night at 11:00 PM. Nurse # 5 cared for Resident # 1 from 11:00 PM on 2/27/21 to 7:00 AM on 2/28/21. Nurse # 5 was interviewed on 9/9/21 at 3:35 PM and reported she could not recall anything about the resident for this shift. Nurse # 4 cared for Resident # 1 from 7:00 AM to 11:00 AM. During the interview with Nurse # 4 on 9/9/21 at 2:30 PM. Nurse # 4 reported the following. She did not recall starting the IV fluids the previous day. She did recall the fluids finishing on her shift of 2/28/21 and she drew the lab and sent it to the hospital. Nurse # 3 cared for Resident # 1 from 11:00 AM to 11:00 PM on 2/28/21. During the interview with Nurse # 3 on 9/13/21 at 2:00 PM, Nurse # 3 reported the following. She did not know when the IV fluids had been completed, but knew they had not been infusing when she came to work at 11:00 AM on 2/28/21. There were no lab results on her shift for the lab work that had been done earlier on 2/28/21. She did not recall getting a message about problems with the lab being done as ordered. The facility's current Director of Nursing (DON) was interviewed on 9/9/21 at 4:30 PM and reported the following. The DON stated she had checked on 9/9/21 and found that the chemistry lab, which was sent on 2/28/21, had been sent to the hospital in the wrong vial and therefore the hospital could not run the lab. Therefore, the 2/28/21 chemistry was not done. The resident's facility physician was interviewed on 9/15/21 at 1:05 PM. He arrived Monday (3/1/21) to find that the repeat chemistry lab work was not available and therefore he did not have any current labs to assess the resident's status by and determine treatment. At that time he decided the best plan was to have the resident sent to the hospital where they could get the lab work done and the resident could be treated there.

Based on record review and staff interviews, the facility failed to notify the responsible party (RP) for 2 of 3 sample residents (Resident #1 and Resident #2). Resident #1 who had a downgrade in diet, and Resident #2 who had a dental appointment. The findings included: 1. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed he was mildly cognitively impaired and required extensive assistance with activities of daily living (ADLs). The resident was coded as being independent with eating, after setting up. Review of Resident #1's care plan dated 6/11/20 revealed Resident #1 had increased nutrition and hydration risk related to [MEDICAL TREATMENT], [MEDICAL CONDITION], and DM II. The goals were for Resident #1 to remain stable, consume a therapeutic diet, and show no signs and symptoms of dehydration. Interventions included encourage compliance with diet guidelines, monitor the need for increased nutrition, assist with meals, and provide supplements. Review of nursing note dated 6/29/20 revealed Resident #1 was coughing during meals, and his diet texture was changed to mechanical soft. Further review of the nursing note did not indicate Resident #1's family was notified of a change in the diet. A review of the Speech Therapist (ST) evaluation and plan of treatment dated 6/29/20 revealed Resident #1 had dysphagia, increased mastication timing and coughing episodes with meals. Further review of the documentation revealed a mechanical soft diet and nectar thick liquids were recommended. The treatment plan did not identify the RP was notified of the diet recommendation. A review of physician's orders [REDACTED].#1 was downgraded to mechanical soft. Further review of physician order [REDACTED].#1's diet was downgraded to pureed texture and nectar consistency. Review of the grievance log revealed a concern dated 7/7/20 on behalf of Resident #1 by his RP. The concern was regarding not being notified of a downgrade in the resident's diet. The concern form further revealed the staff would be in-serviced on notification of RP. An interview with Nurse #1 on 9/2/20 at 2:30 PM revealed Resident #1's diet was changed by ST to Puree on 7/3/20 due to resident holding food in his mouth. She stated she did not notify the RP of the new order. An interview with the Speech Therapist on 9/2/20 at 2:45 PM revealed Resident #1 was having a general decline. She stated his neck was in an upward position, thin liquids were running back to quickly, and he was unable to swallow or chew well enough due to his jaw muscles being tight. She stated she wrote an order for [REDACTED]. An interview with Nurse #2 on 9/3/20 at 3:00 PM revealed the nurse on the floor would notify families of new orders. She stated that Resident #1's RP was difficult to reach and sometimes they were unable to leave a message. She further stated she usually checked during the morning meeting to see if any follow up was needed such as family notification. She could not recall if she had contacted resident #1's RP with regards to the resident's downgraded diet. She stated she was aware that documentation was necessary for it to be considered done. An interview with the Director of Nursing (DON) on 9/3/20 at 11:55 AM revealed that the nurse noting the orders would notify the RP. She stated the Unit Managers would also notify families of new orders. An interview with the Administrator on 9/4/20 at 3:15 PM revealed that RP's should be notified of any changes. He further stated they have a clinical meeting Monday through Friday where they discuss if the nurse was not able to call the family, the unit manager would notify the family of new orders. He revealed he could not say what would be a reasonable time to notify families of changes. 2. Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #2 was cognitively impaired and required extensive assistance with activities of daily living. Review of facility grievance log revealed a grievance filed on behalf of Resident #2 by Resident #2 family member (responsible party) on 6/16/20. The concern form stated that Primary Representative (PR) was not notified of Resident #2 dental appointment. The concern form further stated the PR called the facility and was put on hold with no one answering or hung up on him. Documentation of facility follow up to the PR concern was staff was educated on phone etiquette. If the needed staff member was busy at the time of call, the staff member answering the phone was to take the message and relay it to the staff member that was needed at the time of call. Resident #2 dental appointment was not addressed in the concern. Review of Resident #2 physician progress notes [REDACTED]. Review of transportation request form dated 06/15/20 revealed Resident #2 had a dental appointment evaluation to be performed by a specialist. The follow-up date was 07/07/20. Review of late entry progress note dated 06/22/20 stated an attempt was made to notify responsible party (RP) regarding plan to replace dentures and left voicemail to return call. An interview was conducted with Nurse #3 on 09/04/20 at11:00 AM revealed she was the Unit Manager. Nurse #3 stated that whoever initiated an order, the nurse or unit manager, would be responsible for notifying a resident's responsible party and the notification should be documented in the progress notes. Interview with the Social Worker on 09/04/20 at 3:50 PM revealed the Transportation Scheduler was responsible for notifying the responsible party of resident's upcoming appointments. An interview was conducted with the Transportation Scheduler on 09/04/20 at 4:05 PM. The Transportation Scheduler stated that she was responsible for notifying Residents responsible party of any residents upcoming appointments as she scheduled them and logged them. She indicated that she was unable to provide the log because she shredded them after use. An interview was conducted with the Director of Nursing (DON) on 09/04/20 at 11:15 AM. The DON stated that responsible party was to be notified of any changes or appointments and that whoever put in the order was responsible for notifying the responsible party.

Based on record review and staff interview, the facility failed to refer residents for re-evaluation of the Preadmission Screening and Resident Review (PASARR) level II for 3 of 6 residents reviewed for PASARR. (Resident #22, #24, and #36). Findings included: 1. Resident #22 was admitted [DATE] with the last reentry dated 5/21/19 from an acute care hospital. The [DIAGNOSES REDACTED]. The PASARR Level I determination notification dated 11/24/2015 was for a Level I PASARR. There was no PASARR Level II screening found for this resident in the medical records. The annual comprehensive Minimum (MDS) data set [DATE] assessed Resident #22 as cognitively intact and needing extensive assistance for activities of daily living. He was not coded as having had a level II PASARR processed for having a serious mental illness. The care plan dated 2/14/17 with last revision on 1/30/19 had focus areas to include at risk for adverse effects related to psychoactive medication use secondary to anxiety, [MEDICAL CONDITION] and [MEDICAL CONDITION]. An additional focus area included impaired cognitive function/impaired thought processes related to impaired decision making, dementia, difficulty making decisions and [MEDICAL CONDITION]. [DIAGNOSES REDACTED].#22 dated 2/04/20 revealed [MEDICAL CONDITION] onset dated 1/10/18 and anxiety disorder dated onset 5/21/19. An interview with the Social Worker (SW) on 2/05/20 at 4:35 PM revealed Resident #22 was not reevaluated for a Level II PASARR when the [DIAGNOSES REDACTED]. She explained the resident should have been submitted for Level II PASARR evaluation. On 2/05/20 at 4:55 PM the Director of Nursing revealed the facility will be completing an audit of residents to assess who needs to be referred for Level II PASARR evaluation that may have been missed. An interview with the Administrator on 2/05/20 at 5:10 PM, he revealed the staff missed the submission for the Level II PASARR and the facility would be addressing the missed evaluation immediately. 2. Resident #24 was admitted [DATE] with [DIAGNOSES REDACTED]. The annual Minimum Data Set ((MDS) dated [DATE] had Resident #24 coded as severely cognitively impaired needing extensive assistance with personal hygiene, limited assistance with transfers, and dressing and supervision with eating, toilet use and bed mobility. The Annual MDS dated [DATE] was not coded as having had a level II PASRR processed for having a serious mental illness. The care plan dated 01/31/20 had focuses of at risk for adverse effects R/T psychoactive medication use: Dementia with behaviors. Resident shows signs and symptoms of physical behavior towards others. Resists when staff attempts activities of daily care. Resident has behaviors of yelling at staff 05/19 struck CNA and attempted to eat food from other residents; trays. The PASARR level I determination notification dated 04/5/17 read: this level I screening and PASRR number remains valid for the individuals stay. No further PASARR screening is required unless a significant change occurs with the individual's status which suggest a [DIAGNOSES REDACTED]. [DIAGNOSES REDACTED]. There was no PASARR level II screening found for this resident in her medical records. During an interview with the social worker (SW) on 02/05/2020 at 4:32 PM, the SW stated she did not put in for a PASARR level II screening because she did not know she had to apply for a PASARR level II. During an interview with the Director of Nursing (DON) on 02/05/2020 at 4:44 PM, the DON stated there should have been a screening for Resident #24 for a PASARR level II. During an interview with the Administrator on 02/05/2020 at 5:17 PM, the Administrator stated a PASRR level II should be completed for Resident #24. 3. Resident #36 was admitted [DATE] with [DIAGNOSES REDACTED]. The quarterly Minimum Data Set ((MDS) dated [DATE] had Resident #36 coded as moderately cognitively intact needing extensive assistance with bed mobility, personal hygiene, transfer, dressing, independent with eating, and total dependence for toilet use. Medication received: Days: Antipsychotic Medication received: Days: Antidepressant during the last 7 day look back period. The care plan dated 12/13/19 had the focus of at risk for adverse effects R/T psychoactive medication use secondary to Depression, [MEDICAL CONDITION]. The PASARR level I determination notification dated 04/5/17 read: this level I screening and PASARR number remains valid for the individuals stay. No further PASARR screening is required unless a significant change occurs with the individual's status which suggest a [DIAGNOSES REDACTED]. [DIAGNOSES REDACTED]. There was no PASARR level II screening found for this resident in her medical records. During an interview with the social worker (SW) on 02/05/2020 at 4:32 PM, the SW stated she did not put in for a PASARR level II screening because she did not know she had to apply for a PASARR level II. The SW also stated she would review all residents' records that have a [DIAGNOSES REDACTED]. During an interview with the Director of Nursing (DON) on 02/05/2020 at 4:44 PM, the DON stated there should have been a screening for Resident #36 for a PASRR level II. During an interview with the Administrator on 02/05/2020 at 5:17 PM, the Administrator stated a PASARR level II should be completed for Resident #36.

Based on record review, staff interviews, and resident interview the facility failed to provide showers as scheduled for 1 of 1 resident sampled for choices. (Resident #85). The findings included: Resident #85 was admitted [DATE] with [DIAGNOSES REDACTED]. The admission Minimum Data Set ((MDS) dated [DATE] had Resident #85 coded as cognitively intact and able to make needs known and was coded as having little interest or pleasure in doing things, feeling down, depressed, or hopeless, trouble falling or staying asleep, or sleeping too much and feeling tired or having little energy. She was also coded as it being very important to her to choose between a tub bath, shower, bed bath, or sponge bath. She was coded as needing extensive assistance with her activities of daily living (ADL). The care plan dated 01/27/2020 had the focus of her having a self-care deficit related to (r/t) impaired mobility, and weakness. There were no references to manipulative behaviors in the care plan. Reviewed the shower schedule for Resident #85 and her shower days were Monday and Thursday. Reviewed shower form dated 01/09/2020 resident refused, 01/14/2020 resident had shower, 01/20/2020 resident had a shower, 01/28/2020 resident had a shower and shampoo, 01/30/2020 resident had a shower, 02/03/2020 resident had bed bath but did not have refusal for shower checked. During an interview with Resident #85 on 02/04/20 at 03:21 PM, Resident #85 stated her shower days were Monday and Thursday and she did not receive a shower or bed bath on 02/03/2020 and she told NA#1 that it was her shower day and she still didn't get one. Resident #85 also stated she has not refused a shower but has asked the staff to come back at a later time for one because she always wants her showers on her shower days. During an interview with the Assistant Director of Nursing (ADON) on 02/05/20 at 04:03 PM, the ADON stated she signed the shower form on 02/03/2020 when NA#1 told her Resident #85 refused her shower for the day and had a bed bath. The ADON also stated she was new and was still learning how to fill out the paperwork and did not check the refusal box for Resident #85. During an interview with the Director of Nursing (DON) on 02/05/2020 at 4:44 PM, the DON stated the nursing assistants are supposed to check the shower log and follow the residents schedule for showers and document if they refused on the shower form and report it to the nurse on the hall. During a telephone interview with NA#1 on 02/05/2020 at 5:03 PM, NA#1 stated she was not familiar with that hall and did not look to check if she was supposed to have a shower and gave her a bed bath instead. NA#1 also stated she did not recall being told by Resident #85 that it was her shower day.

Based on record review, staff and pharmacist interviews, the facility failed to address a gradual dose reduction of an antipsychotic medication as required for 1 of 5 residents reviewed for unnecessary medication. (Resident #10). The findings included: Resident # 10 was admitted to the facility on [DATE] and had a [DIAGNOSES REDACTED]. Review of Resident # 10's physician order [REDACTED].# 10's anxiety. Review of the medical record revealed gradual dose reduction (GDR) had been requested by the pharmacist on 10/30/2019 but the physician had not addressed the pharmacist request for the drug reduction. The facility's Consulting Pharmacist stated in an interview on 2/6/2020 at 2:10 PM that he had requested a GDR on 10/30/2019 on antipsychotic medication [MEDICATION NAME] but he did not recall getting the response back from the physician. On 2/6/18 at 4:25 PM the Director of Nursing(DON) stated in an interview she expected the physician to had addressed a GDR of an antipsychotic medication from the pharmacist in (MONTH) of 2019. DON reported she will start reviewing all the pharmacist recommendations before filing in the residents medical records to make sure they had been addressed by the physician.

Based on observations and staff interviews, the facility failed to secure 1 of 5 medication carts observed. The findings included: During an observation on 2/04/20 at 10:00 AM, the 100/200/500 hall medication cart was observed to be unlocked with the push in lock observed to be in the out position and the nurse was not in view of the cart. The nurse was observed to return to the cart within 90 seconds coming out of the resident ' s room where the cart was parked in front of. There were no residents observed in the hallway near the cart at the time. There was no other facility staff in the hallway at the time of the observation. During an interview on 2/04/20 at 10:03 AM, Medication Aide #1 stated she should not have left the cart unlocked. She stated it was a new cart and she was getting used to the cart. An interview with the Director of Nursing on 2/04/20 at 11:25 AM revealed she had just reminded staff to lock and secure the carts. She explained all medication carts should be locked when it is out of view of the assigned nurse or medication aide. An interview with the Administrator on 2/05/20 at 11:00 AM revealed the staff should lock all medication carts when they leave the cart.

Based on observations, record review, and staff interviews, the facility ' s Quality Assessment and Assurance (QAA) Committee failed to maintain implemented procedures and monitor interventions previously put in place. This failure was related to non-compliance at the regulatory grouping of 483.45 on two consecutive annual recertification surveys. A deficiency in the area of medication storage at the regulatory grouping of 483.45 was cited during the facility's 1/26/19 annual recertification survey and was recited again on the current 2/07/20 annual recertification survey. The facility's continued failure during the recertification surveys showed a pattern of the facility's inability to sustain an effective QAA program. Findings included: This tag is cross referenced to: 483.45 - Labeling of Drugs and Biologicals: Based on medical record review, observation, and staff interviews the facility failed to secure 1 of 5 medication carts observed for medication storage. 483.45 was originally cited during the (MONTH) 2019 recertification survey for failing to secure 3 of 7 mobile medication carts observed during medication pass for 100, 200 and 500 halls. During an interview on 2/07/20 at 3:30 PM the Administrator acknowledged understanding of the reciting of the repeated deficiency F761 from the recertification survey of (MONTH) 2019. The Administrator stated he was aware of medication storage concerns and the facility will be addressing the concerns on an ongoing basis.

Based on record review, staff interviews and physician interview, the facility failed to utilize a mechanical lift to transfer a dependent resident from her wheelchair to her bed for 1 of 3 sampled residents reviewed for supervision to prevent accidents (Resident #1). Resident #1 was manually transferred by two nursing assistants instead of using a mechanical lift for the transfer, which resulted in the resident's foot getting caught in the rails on the bed and the resident sustained [REDACTED]. The findings included: A review of the facility's Resident Handling and Proper Body mechanics Training revealed Nursing Assistant #2(NA #2) had been trained on 08/12/19 and Nursing Assistant #1 (NA #1) had been trained on 10/17/19. The training indicated the nursing assistants had been proficiently trained on proper mechanics and mechanical lifts for resident transfers and repositions. By signing the training, the nursing assistants indicated they understood they were only allowed to manually lift a resident in an emergency. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #1's quarterly Minimum Data Set (MDS), dated [DATE], revealed Resident #1 was severely cognitively impaired and required the total assistance of staff with transfers. The MDS indicated Resident #1 had impairment on both sides of her lower extremities, was not steady during transfers and had only been able to stabilize with staff assistance when performing surface-to-surface transfers. Resident #1's Care Plan, which was in place on 12/11/19, revealed Resident #1 was at risk for falls related to a history of falls, impaired mobility, weakness, short- and long-term memory deficit and being non-ambulatory. Interventions included the use of a total lift for transfers using a two-person assist. Resident #1's incident report, dated 12/12/19 at 3:39 p.m., revealed Nurse #1 reported the following, On 12/11/19, this nurse was called to resident's room around 8:50 p.m. by care staff .resident alert. Resident grimacing and making verbal sounds of pain and trying to hold her left knee. Resident stated, 'my knee hurts.' No other sign of injury noted on resident; resident's level of awareness appears within normal limits .nurse called resident's medical doctor (MD) to notify and left a message; nurse called Director of Nursing (DON) and received permission to order a mobile x-ray; mobile x-ray contacted and x-ray ordered STAT (immediately); after resident calmed, she no longer complained of pain, but began to complain again at 10:00 p.m.; Tylenol given per her orders at that time . Resident #1's mobile radiology report revealed the x-rays taken on 12/11/19 of her left lower extremity noted a fracture in the femur (the bone that extends from the hip to the knee) closer to the knee. A nurse progress note, written by Nurse #2 on 12/12/19 at 3:54 a.m., indicated that she had notified the MD of Resident #1's x-ray results at 2:15 a.m. The nurse had received orders from the MD to send Resident #1 to the emergency room (ER) for evaluation and treatment. Nurse #2 indicated the resident left the facility with Emergency Medical Services (EMS) at 2:48 a.m. Resident #1's hospital discharge summary indicated resident had been admitted to the hospital on [DATE] and discharged on [DATE]. Her discharge [DIAGNOSES REDACTED]. The history of present illness related she had been sent to the ER from her nursing facility with complaints of leg pain. The emergency department provider stated Resident #1 had made statements to EMS saying that she had been pushed by a staff member which caused her to injure her left leg. X-ray of her femur showed left distal femur fracture and she had been hospitalized . An x-ray of her left femur taken at the hospital, revealed 1) acutely mildly displaced comminuted [MEDICATION NAME] fracture involving the distal shaft of the left femur with no evidence for intra-articular extension; 2) no additional acute fracture or dislocation; 3) severe [MEDICAL CONDITION] changes left hip; and 4) osteopenia. The hospital records indicated she had been seen by orthopedics and no surgery had been recommended and had been managed with pain control and supportive care. Resident #1 had also been seen by the hospital physical therapy department staff for consultation and no further physical therapy had been recommended. Resident #1 had been found to be at her baseline needing a total lift for transfers. The hospital records indicated Resident #1 had been discharged back to the skilled nursing facility as per the family's wishes. During an interview with NA #1 on 01/08/20 at 2:20 p.m., the NA stated she had been the NA assigned to care for Resident #1 on 12/11/19 from 3:00 p.m. to 11:00 p.m. NA #1 stated she had no knowledge of the facility having a no-lift policy and stated she had thought if she got assistance from another nursing assistant, she could provide a stand-pivot transfer on a resident even if the resident had been assessed for needing a total lift for transfers. NA #1 stated it had been her intention to get Resident #1 into her bed so she would be able to provide incontinent care before the next shift began. NA #1 stated when she and NA #2 performed a stand-pivot transfer, Resident #1's left foot got caught in the bed's side rails. NA #1 explained she had lowered the bed's side rails to the down position and then lowered the bed as far as it would go to the floor and by doing this, the bottom of the side rails had been very close to the floor. NA #1 stated Resident #1 had been seated in her wheelchair and the wheelchair had been facing the bed. NA #1 stated she and NA #2 got on either side of Resident #1 and lifted her and pivoted her body so that she would be seated on the side of the bed. NA #1 stated when Resident #1 had become seated on the bed she had noticed the resident's foot had become caught under the rail of the bed and stated it did not look right to her because it appeared twisted and stated she knew she needed to get it out from the rail. NA #1 stated she got the resident's foot free as fast and as gentle as she could. NA #1 stated the resident said, my leg, my leg. NA #1 stated she then picked up her legs while NA #2 got behind her back and together they positioned her on the bed. NA #1 stated she immediately got the resident's nurse, Nurse #1. NA #1 stated Nurse #1 came into the room and had assessed the resident and then left the room to call the doctor. When asked why her initial story had involved the resident being up in the total lift, NA #1 stated she had found out the facility was a no-lift facility and she had been initially scared to tell the truth about the injury. During an interview with NA #2 on 01/09/20 at 3:01 p.m. NA #2 stated she had been assigned to work at the facility on 12/11/19 from 3:00 p.m. to 11:00 p.m. NA #2 stated she had not been assigned to care for Resident #1 during that shift, however, she and NA #1 often worked together getting residents ready for bed and assisting each other. NA #2 stated NA #1 had asked for her assistance getting Resident #1 into bed and stated together they went into the room and two-manned the resident. When asked what two-manned meant, NA #2 stated they each got on one side of the resident and lifted the resident and provided a stand-pivot transfer from the wheelchair to the bed. NA #2 stated the side rails on the bed had been in the down position and felt they must have lowered the bed too low to the floor. NA #2 stated while she and NA #1 provided the stand-pivot transfer, Resident #1 had acted like she was going to sit down. NA #2 stated she had known an assist to the floor was considered a fall by the facility policy and they had not wanted that to occur, so they quickly pivoted the resident to the side of the bed. NA #2 stated NA #1 immediately noticed Resident #1's foot had been caught in the bed's side rails and had removed it. NA #2 stated as soon as they had placed Resident #1 in the bed Resident #1 had begun complaining about pain in her left leg. NA #2 stated prior to the two of them providing incontinent care to Resident #1 the resident's nurse, Nurse #1, had entered the room to administer medications to the resident. NA #2 stated Nurse #1 assessed Resident #1 and had asked her what was wrong and eventually left the room to call the doctor. NA #2 stated she had been assigned to care for Resident #1 in the past and while they sometimes had used the mechanical lift for transfers, they often two-manned her because the facility only had one working lift at the time and there had been other staff using it on other residents. During an interview with Nurse #1 on 01/08/20 at 3:39 p.m., Nurse #1 stated she had been assigned to care for Resident #1 on 12/11/19 from 7:00 a.m. until 11:00 p.m. Nurse #1 stated she had been out in the hall preparing residents' medications for administration when she got called to Resident #1's room by NA #1 and NA #2. Nurse #1 stated when she entered Resident #1's room, the resident had been guarding her left leg. Nurse #1 stated the two NAs initially told her they had injured her leg while using the total lift. Nurse #1 stated she had observed there was no lift pad in place underneath the resident at this time. Nurse #1 stated she had assessed Resident #1 who had been fine with the exception of her guarding her left leg which concerned her, and she left to contact the doctor. Nurse #1 stated she had been unable to get in touch with the doctor in a timely manner and stated she had contacted the DON and received instructions to have their mobile x-ray company come and get an x-ray of the leg. Nurse #1 stated she ordered the x-ray STAT (immediately). Nurse #1 stated she observed Resident #1 closely after the accident and her pain had appeared to ease a bit however the resident did begin complaining of pain around 10:00 p.m. which resulted in her administering [MEDICATION NAME] to the resident. Nurse #1 stated the mobile x-ray got to the facility close to the end of her shift and the results of the x-ray had not been available until the next shift. During an interview with Nurse #2 on 01/09/20 at 2:41 p.m., Nurse # 2 stated she had been assigned to care for Resident #1 on 12/11/19 from 11:00 p.m. until 7:00 a.m. Nurse #2 stated she had received report from Nurse #1 there had been an incident involving Resident #1 and a lift during a transfer. Nurse #2 stated Nurse #1 had explained an x-ray had been taken by their mobile x-ray company and [MEDICATION NAME] had been given to the resident for pain. Nurse #2 stated when she had entered Resident #1's room, she found her lying in her bed and stated when the resident had noticed her, she began rubbing her knee. Nurse #2 stated Resident #1 had told her they (the nursing assistants) had dropped her on the bed. Nurse #2 stated Resident #1 had been known to have confusion secondary to her dementia, so she had not really thought about the difference of how the injury occurred from what Nurse #1 had reported to her versus what the resident had been saying at the time. Nurse #2 stated she had received Resident #1's x-ray results and had called the doctor and had received orders to send the resident out to the hospital. Nurse #2 stated she began the transfer process which included calling 911 and preparing the paperwork required. During an interview with the facility's medical director (MD) on 01/09/20 at 9:33 a.m. the MD stated the actions of NA #1 and NA #2 were the likely cause of Resident #1's left femur fracture. The MD stated Resident #1 had many factors that caused her to be a high risk for fractures, including having been bed-bound, [MEDICAL CONDITION], chronic pain and very stiff contractures to both of her lower legs. The MD stated Resident #1 had been sent to the hospital after the mobile x-ray taken at the facility had revealed the fracture and stated because of Resident #1's overall condition had not been a candidate for a surgical correction of the fracture. The MD stated the orthopedic surgeons at the hospital had indicated Resident #1's fracture had been in fairly good position and had felt it could be managed with an immobilizer for approximately six weeks. During an interview with the Administrator and the DON on 01/09/20 at 1:57 p.m., the administrator stated he had no explanation for the reason the two nursing assistants had deviated from Resident #1's plan of care which included using a total lift for her transfers. The administrator stated he had never been given a clear excuse as to why the nursing assistants provided a stand-pivot transfer versus using the total lift. The administrator stated he and the DON had reviewed the surveillance video of the date and time in question and had noted the mechanical lift had been parked right outside of Resident #1's room. The DON explained the surveillance video only kept video for a certain number of days and 12/11/19 was no longer available to be reviewed however they both agreed they had watched the video many times and a time line of the events from the surveillance video which included, in part the following: Timeline 12/11/19 8:38 p.m. - Resident #1 left the room and entered into the hallway stopping to talk with the nurse at the cart. 8:51 p.m. - NA #2 entered the room 8:52 p.m. - Resident was escorted into the room by NA #1 8:52 p.m. - NA #1 left out of the room and went down the hallway 8:53 p.m. - NA 1 went back into the room with linen in hand 8:58 p.m. - NA #1 retrieved the lift from the hall (and brought it into the resident's room) 9:00 p.m. - Nurse #1 was called to the room 9:01 p.m. - Nurse #1 came out of the room 2:38 a.m. - EMS in facility 2:48 a. m. - EMS left the facility (with resident) via stretcher and 2 EMS The interview with the administrator and DON continued. The administrator stated he had become aware of the fracture of `Resident #1's left leg when he had arrived at the facility early on the morning of 12/12/19 and had spoken with Nurse #2. The administrator stated he informed the DON when she had arrived at the facility on 12/12/19. The DON stated when she had been called the previous night by Nurse #1, she had been told Resident #1 had bumped her leg on the total lift during a transfer performed by the two nursing assistants and had planned on discussing the incident during their usual morning meeting on 12/12/19. The DON stated she had even called the two nursing assistants back to the facility to have them do a demonstration of how Resident #1 had bumped her leg in the lift during the transfer. The DON stated after their interviews and the return demonstration, they had suspended the two nursing assistants pending further investigation. The administrator stated after the nursing assistants left the facility, he had just felt like things were not adding up and they kept reviewing the surveillance video. The administrator stated he and the DON had agreed it just did not make sense the two nursing assistants could have placed Resident #1 in a sling, connected the sling to the mechanical lift and then place her in the bed and just 2 minutes later call for Nurse #1 to come into the room. The administrator stated he and the DON brought the two nursing assistants back to the facility on [DATE] for further clarification and stated during these interviews the nursing assistants had decided to tell the truth about how the injury had occurred. The DON stated all nursing staff received training during their new employee orientation to the facility which included the use of mechanical lifts. The DON explained nursing assistants were supposed to review residents' care guides prior to beginning a shift which indicated how a resident transferred and other changes that may have occurred since an employee had last worked. When asked, the DON stated she had thought the two nursing assistants had attempted to save time by performing a stand-pivot transfer versus using the total lifting device when transferring Resident #1 to the bed from her wheelchair. During this interview, the administrator stated it was his expectation the nursing staff never deviate from the facility's policies and procedures when transferring residents. The DON stated it was her expectation nursing staff follow residents' plan of care when transferring residents. The facility's corrective action plan for past non-compliance, dated 12/13/19 included: 1. Identify those recipients who have suffered or likely to suffer as a result of the noncompliance: Resident #1 was assessed by the nurse on 12/11/2019 after resident complained of pain to the left leg after a transfer to bed. Medical Director and Director of Nursing were notified on 12/11/2019 and an order was obtained for a mobile x-ray. Tylenol was administered for pain on 12/11/2019 at 11:00 pm with relief and re-administered at 2:00 a.m. on 12/12/2019 with no further complaints of pain prior to going to the hospital. X-ray results were reported to the MD at 2:15 a.m. on 12/12/2019. Resident was sent to the ER for evaluation and treatment via EMS at 0248 on 12/12/2019. RP was notified of injury and transfer status. Staff interviews began on 12/11/2019 and it was determined on 12/13/2019 that resident #1 sustained an injury while being transferred from the wheelchair to the bed. During staff interviews on 12/13/2019 the two CNAs that were present admitted that they did not transfer the resident using the resident specific transfer status. 2. Residents likely to suffer a serious adverse outcome as a result of the noncompliance: All alert and oriented residents were interviewed as it relates to how they are transferred on 12/13/2019 with no issues identified. All residents that were not alert and oriented had a skin assessment completed on 12/13/2019 to ensure there were no un-identified injuries, with no issues identified. All Kardex were reviewed on 12/13/2019 to ensure that each resident had a resident specific transfer status listed and any identified issues were corrected. 3. The action the entity will take to alter the process/system failure to prevent an adverse outcome from occurring or reoccurring: All clinical staff were re-educated on Safe Resident Handling as it relates to following the designated transfer status including lift competencies and checking the Kardex for the resident specific transfer status prior to transferring a resident on 12/13/2019. All newly hired clinical staff will be educated on Safe Resident Handling as it relates to following the designated transfer status including lift competencies and checking the Kardex for the resident specific transfer status prior to transferring a resident on orientation. No employee will be allowed to work until all education and competencies have been completed. Five random resident interviews asking if they are being transferred appropriately will be conducted 5 days a week for 4 weeks then 3 days a week for 4 weeks and then weekly for 4 weeks. DON/designee will also do 3 random transfer observations 5 days a week for 4 weeks, then 3 days a week for 4 weeks and then weekly for 4 weeks. All interviews and transfer observations will be discussed weekly in the interdisciplinary team (IDT) meeting and monthly in Quality Assurance (QA) meeting. Changes will be made to the corrective action plan if the IDT team identifies issues. 4. Action Complete Date -12/13/2019. The Administrator will be the person responsible for implementing the Quality Assessment and Performance Improvement (QAPI) plan. As part of the validation process on 01/09/20, the entire plan of correction was reviewed including re-education of staff. Interviews of the nurse aides and nurses revealed they were aware of proper usage of the mechanical lift for the transfer of residents at the facility. A review of the monitoring tools revealed the facility had completed 100% in-service of the use of mechanical lift and return demonstration on 12/13/19. The facility had initiated a QAPI meeting on 12/13/19 which included the medical director, administrator, DON, social services, MDS nurses, dietary manager and business office manager. A review of the facility's Lift/Transfer audit tool revealed they had completed the audits as planned through 01/03/20. A review of the facility's resident interview audit tool revealed the facility had completed audits as planned through 01/06/20.

Based on record review, observations, staff interviews, resident interviews, nurse practitioner interview, the facility failed to implement their abuse policy in the area of reporting abuse to the administrator for two of three sampled residents reviewed for abuse (Residents #1 and #2). The findings included: The facility's policy entitled, North Carolina Abuse Policy with a revised date of 3/3/17 was reviewed. The policy specified that any suspicions of abuse would be reported to the Administrator. Record review revealed Resident # 1 was initially admitted to the facility on [DATE]. The resident had [DIAGNOSES REDACTED]. The resident was [AGE] years of age. Social service notes revealed on 2/11/19, the Social Worker (SW) noted his BIMS (brief interview for mental status) was 13 which indicated he was cognitively intact. On 2/18/19, the SW noted his BIMS was 14 which indicated cognitively intact. Resident # 1's last quarterly MDS (Minimum Data Set) assessment, dated 3/5/19, revealed the resident had a BIMS of a 10. This indicated the resident was moderately cognitively impaired. The resident was coded as being independent in his locomotion with the use of a wheelchair. During an interview with Resident # 1 on 5/3/19 at 4:45 PM, the resident acknowledged he had been in another resident's room. The resident denied he had touched any residents. During a follow up interview with Resident # 1 on 5/5/19 at 12:30 PM, the resident's ability to move was observed. It was observed that he could drive his motorized wheelchair both forward and backward without difficulties, and position himself easily within close proximity of a table where the interview was held. Resident # 1 was observed to move his arms freely, and wave them in the air. Record review revealed Resident # 2 was admitted to the facility on [DATE]. At the time of the resident's admission the resident had a history of [REDACTED]. Review of Resident # 2's annual MDS assessment, dated 4/24/19, revealed the resident had a BIMS score of 10, which indicated she was moderately cognitively impaired. Review of the BIMS assessment revealed the resident did not know the day of the week and needed cueing for memory recall. The resident also was coded as being able to independently move with the use of a wheelchair. The resident was coded as having little interest or pleasure in doing things and had no behaviors. Resident # 2 was interviewed on 5/5/19 at 1:31 PM and answered questions by nodding her head. The resident nodded she was not touched by a resident, did not want to be touched, and felt safe. Nurse Aide (NA) # 2 was interviewed on 5/2/19 at 12:15 PM. NA # 2 stated she often worked with Resident # 2, and stated her mind was like a child and she does what she is told. NA # 2 stated she had witnessed Resident # 1 touch Resident # 2's breast, and in her brief. When she would ask Resident # 2, Why do you let him do that to you? the resident would respond in a slurred voice, I don't know. NA # 2 stated Resident # 1 seeks Resident # 2 out, and Resident # 1 touching Resident's 2's body had been going on for months. NA # 2 stated the staff try to watch over Resident # 2, but she just knew what she observed happening to Resident # 2 was not right. During a follow up interview with NA # 2 on 5/4/19 at 5:00 PM, NA # 2 stated since (MONTH) 1, 2019 she witnessed Resident # 1 touching the breast of Resident # 2, and he had his hand in her brief. There was also an incident she observed in which Resident # 2 had her hand on the front of Resident # 1's pants. NA # 2 also stated Resident # 1 rubbed Resident # 2's thigh. NA # 2 stated these incidents occurred in the dining room or in the dayroom when there was no one around. During a follow up interview with NA # 2 on 5/6/19 at 11:20 AM, NA # 2 stated she did not report the incidents that she observed of Resident #1 touching Resident #2 or Resident #2 touching Resident #1 since (MONTH) 1, 2019. NA #2 specified she no longer reported her observations of what she believed was inappropriate touching between these residents because she had previously informed the Administrator about incidents of Resident # 1 touching Resident # 2's breast and having his hand in her brief and nothing was done. According to the NA, prior to (MONTH) 1, 2019, the Administrator blew her off when she tried to talk to him about Resident # 1 touching Resident #2's breasts and having his hand down the front of her brief, and she was never asked to write a statement about what she had observed. Nurse # 1, who routinely cared for Resident # 2, was interviewed on 5/2/19 at 10:00 AM and again on 5/6/19 at 9:20 AM. Nurse # 1 confirmed that she had received reports that Resident # 1 had touched Resident # 2 on her breasts and in her brief. The nurse did not recall the exact date of the reports, and stated she no longer reported any instances to the Administrator because it was her current understanding that Administration had said that Resident # 2 had the capability to say yes or no to being touched and therefore there was nothing that was going to be done about it. Nurse # 1 stated she did not think that Resident # 2 had the capability to say yes or no. Nurse # 3, who routinely cared for Resident # 2, was interviewed on 5/2/19 at 3:16 PM. Nurse # 3 reported that it was not unusual for Resident # 2 to go where she was alone with Resident # 1 such as an area of the dining room. Nurse # 3 reported that Resident # 1 called to Resident # 2 to follow him. Nurse # 3 stated She is like an adult to me with a child's mind-she is friendly and you would think she would know better but she doesn't. According to Nurse # 3, her current practice was to try to keep Resident # 1 and Resident # 2 separated. On 5/4/19 at 10:30 AM, the DON stated it was inappropriate for Resident #1 to be touching Resident #2's breast. The DON stated she was not aware Resident # 1 had ever had his hand on someone's crotch or breast, and it was her expectation that it would have been reported to her. Interview with the Director of Nursing on 5/8/19 at 12:39 PM revealed it was her expectation that behaviors of any kind would also be charted in either the episodic notes or the monthly summaries of a resident's medical record. On 5/3/19 at 3:55 PM, the facility Social Worker stated that she was not aware of Resident # 1 touching any resident in the crotch or the breast. On 5/3/19 at 8:45 AM, the Administrator stated he had no reports of Resident # 1 having his hands on a female resident's breasts or vaginal area before 5/1/19. The Administrator stated if Resident # 1 had been touching another resident's breast or vaginal area he would want to know about it to assess the situation, and if a resident was being abused it was his expectation that he or the DON would be informed.

Based on record review and staff and resident interviews the facility failed to implement or update the care plans to address inappropriate behaviors for 2 (Residents # 1, and # 2) of 9 sampled residents whose care plans were reviewed. The findings included. 1. Record review revealed Resident # 1 was initially admitted to the facility on [DATE]. Record review revealed the resident had [DIAGNOSES REDACTED]. Review of Resident # 1's last quarterly MDS (Minimum Data Set) assessment, dated 3/5/19, revealed the resident had a BIMS (brief interview for mental status) of a 10. This indicated the resident was moderately cognitively impaired. The resident was coded as being independent in his locomotion with the use of a wheelchair. The resident was not coded as having behaviors during the assessment period. Review of the resident's care plan, dated 3/27/19, revealed the resident had impaired thought processes related to his [MEDICAL CONDITION]. Additionally, the resident was noted to have a history of going into other resident's rooms uninvited. This was added to the care plan on 10/9/18 and continued to be a part of his 3/27/19 care plan. The care plan interventions, which were added on 10/9/18, were: Complete behavior contract as needed; Be reassuring and listen to concerns, Encourage family involvement, observe for and report any behavior issues, Redirect resident as needed and reinforce positive behaviors, Refer to psych as needed. Interview with the Administrator and Social Worker on 5/4/19 at 9:30 AM revealed the resident was observed going into rooms and touching residents on the hands or shoulder when the intervention to place him under a behavior contract was added to the care plan on 10/09/18. The Administrator stated he felt the resident's behavior was solely intended to be comforting to residents, but that some of the nurses had concerns about Resident # 1 being alone in rooms with female residents who might be confused. The Administrator and SW provided a copy of the resident's Behavior Contract. Resident #1's Behavior contract which was referenced in the resident's current care plan intervention of complete behavior contract as needed, and was initiated on 10/9/18 had two items checked on the contract as applicable to Resident # 1. They were I am not permitted to enter other resident's rooms. If a resident would like to visit with me it must occur in the back lobby, front lobby or the dining room only. I am not permitted to touch others residents in any way. This includes handshakes, pats or touches of any kind. There was a notation by the Social Worker at the bottom of the contract which noted, Resident refused to sign contract. Housekeeper # 1 was interviewed on 5/2/19 at 2:40 PM. Housekeeper #1 stated on 4/30/19 around 1:00 PM she was on the hallway when she saw Resident # 1 go into Resident # 3's room. She noticed he did not come out right away, so she went to the door and listened. She heard Resident # 1 ask Resident # 3 how old she was. She heard Resident # 3 reply her age, and then Resident # 1 told her she looked older than that. Then she heard Resident # 1 tell Resident # 3 that she was pretty, and he thought she needed some loving. Then Housekeeper # 1 stated she told Resident # 1 he needed to depart from the room, and she told Nurse # 7. Housekeeper # 1 stated NA # 10 went to tell the social worker. The housekeeper stated she did not see Resident # 1 touch Resident # 3. During an interview with Resident # 1 on 5/3/19 at 4:45 PM, the resident acknowledged he had been in another resident's room, but he denied that he had touched any residents. Nurse Aide (NA) # 2 was interviewed on 5/2/19 at 12:15 PM. NA # 2 stated she often worked with Resident # 2, and stated her mind was like a child and she does what she is told. NA # 2 stated she had witnessed Resident # 1 touch Resident # 2's breast, and in her brief. When she would ask Resident # 2, Why do you let him do that to you? the resident would respond in a slurred voice, I don't know. NA # 2 stated Resident # 1 seeks Resident # 2 out, and Resident # 1 touching Resident's 2's body had been going on for months. The NA stated the staff try to watch over Resident # 2, but she just knew what she observed happening to Resident # 2 was not right. During a follow up interview with NA # 2 on 5/4/19 at 5:00 PM, NA # 2 stated since (MONTH) 1, 2019 she witnessed Resident # 1 touching the breast of Resident # 2, and he had his hand in her brief. There was also an incident she observed in which Resident # 2 had her hand on the front of Resident # 1's pants. NA # 2 also stated Resident # 1 rubbed Resident # 2's thigh. NA # 2 stated these incidents occurred in the dining room or in the dayroom when there was no one around. Nurse # 7 was interviewed on 5/4/19 at 11:25 AM. Nurse #7 stated the nurses try to redirect Resident # 1 when he comes on the hall because he wants to go into others rooms, but when he is redirected he gets irritated. Nurse # 7 stated she had tried to explain to him that he could not be in rooms uninvited, and he had told her, I can go anywhere I want to go. Nurse # 7 also said that sometimes both the nurses and NAs were busy with other residents, and they could not watch Resident # 1 all the time. The nurse stated Resident # 1 had been in Resident # 3's room about two times in the past two months of which she was aware, and he did not reside on Resident # 3's hall. Nurse # 7 stated on 5/1/19 the facility put a velcro stop sign on the door entrance to Resident # 3's room, and that was the first time this intervention was attempted to keep Resident #1 out of Resident #3's room. NA # 10 was interviewed on 5/3/19 at 11:42 AM. NA # 10 stated that she was aware Resident # 3's RP did not want Resident # 1 in Resident # 3's room, but he would still go in the room and sit close to the bed by her anyway. NA #10 stated since (MONTH) 1, 2019 she observed Resident # 1 in Resident #3's room and he was rubbing her legs. She had redirected him out of the room, and let Nurse # 7 and the SW know. NA # 10 stated she reported everything she observed to the social worker, but Resident # 1 continued to enter other resident's rooms. NA # 10 stated on 4/30/19, Resident # 1 entered Resident # 3's room when no staff were in the room with Resident # 3. NA # 10 stated she informed the social worker of this incident. NA # 10 also reported that she had witnessed Resident # 1 holding onto Resident # 2's (who was another cognitively impaired resident) arm the past week-end and Resident # 2 was trying to get away from him. She reported this to Nurse # 7. Nurse Aide # 3 was interviewed on 5/2/19 at 11:45 AM. NA # 3 stated she observed Resident # 1 with his hand on Resident # 2's leg, and that it happened about every other day. NA # 3 described Resident # 2 as having the mind of a child. NA # 3 also stated that sometimes Resident # 1 will hold onto Resident # 2's wheelchair and not let her go. During a follow up interview with NA # 3 on 5/5/19 at 6:30 PM, NA # 3 clarified that she observed Resident #1 place his hand on Resident #2's mid- thigh area, and he rested it there. She stated this typically happened in the dining room, and she did not perceive Resident #1 touching Resident #2 in this manner to be appropriate behavior. She reported it to the nurses on duty when she saw it happen because that was what she was trained to do. On 5/2/19 at 3:45 PM an interview was conducted with NA # 6, who was an evening shift nurse aide. The NA reported that she had witnessed Resident # 1 with his hand on Resident # 2's thigh while they were alone in the middle of the hall. The NA specified, that this behavior had been going on for a couple of months and the last time she observed it was the last week in April, 2019. NA # 6 stated, She (Resident #2) is just like a little child. NA # 6 stated Resident # 1 was good to get her (Resident # 2) to follow him to the lobby or the dining room to be by themselves. NA # 6 stated when this occurred, she tried to separate them and she would tell the nurse who was on duty. During a follow up interview with NA # 6 on 5/5/19 at 6:50 PM, the NA reported that it was Resident # 2's mid-thigh area that she observed Resident # 1 rest his hand. During an interview with Resident #8 on 5/5/19 at 2:30 PM he stated sometime at the end of April, 2019 he was in the dining room participating in an art activity. He observed Resident # 1 and Resident # 2 off by themselves in the dining room sitting near each other and were not involved in the activity. Resident # 8 stated he saw Resident # 1's hand on Resident # 2's breast. Resident # 8 asked Resident # 1 what he was doing, and Resident # 1 looked at him with a smirk Review of Resident # 1's care plan, revealed no interventions were added or changed to the care plan between the dates of 1/27/19 and 5/1/19 to address the resident's behaviors of continuing to go into other residents' rooms uninvited and his touching of other residents which his behavior contract did not allow. On 5/4/19 at 10:30 AM, the DON stated it was inappropriate for Resident #1 to be touching Resident #2's breast. The DON stated she was not aware Resident # 1 had ever had his hand on someone's crotch or breast, and it was her expectation that it would have been reported to her. Interview with the Director of Nursing on 5/8/19 at 12:39 PM revealed it was her expectation that behaviors of any kind would also be charted in either the episodic notes or the monthly summaries of a resident's medical record. On 5/3/19 at 8:45 AM, the Administrator stated he had no reports of Resident # 1 having his hands on a female resident's breasts or vaginal area before 5/1/19. The Administrator stated if Resident # 1 had been rubbing another resident's breast, vaginal area, or thighs he would want to know about it to assess the situation. Interview with the Administrator on 5/5/19 at 10:34 AM revealed there should have been updates to the resident's care plan prior to 5/1/19 to address the resident going into other resident's rooms and his touching of other residents. 2. Record review revealed Resident # 2 was admitted to the facility on [DATE]. At the time of the resident's admission the resident had a history of [REDACTED]. Review of Resident # 2's annual MDS assessment, dated 4/24/19, revealed the resident had a BIMS score of 10, which indicated she was moderately cognitively impaired. Review of the BIMS assessment revealed the resident did not know the day of the week and needed cueing for memory recall. The resident also was coded as being able to independently move with the use of a wheelchair. The resident was coded during the MDS assessment period as having little pleasure in activities, but had no behavioral problems. Review of Resident # 2's care plan, dated 4/30/19, revealed the resident had impaired cognition and periods of disorientation and forgetfulness related to her [MEDICAL CONDITION]. This had been initially added to the resident's care plan on 5/31/18 and remained as an active problem on the resident's current care plan. Care plan interventions included to redirect when the resident made inappropriate actions, and to report changes to the physician. The care plan also noted the resident had a psychosocial well-being issue. Nurse Aide (NA) # 2 was interviewed on 5/2/19 at 12:15 PM. NA # 2 stated she worked often with Resident # 2, and her mind was like a child and she does what she is told. Nurse Aide # 3 was interviewed on 5/2/19 at 11:45 AM and reported, Resident # 2 had the mind of a child. On 5/7/19 a review of a psychosocial therapy consultants notes, dated 3/26/19, revealed that Resident # 2 did not socialize and that sometimes she would flash a male resident who would give her attention. The clinical social worker had documented that nursing staff had walked in on a gentleman fondling her. An interview with the clinical social worker, who saw Resident # 2 for psychosocial counseling, was conducted on 5/2/19 at 1:35 PM. The clinical social worker stated she had been informed by the nursing staff that Resident # 2 was being fondled and that Resident # 2 flashed people (exposed her breasts to others). The clinical social worker stated a psychological assessment had not been done, but she would recommend one be done. The clinical SW stated the way the resident acted did not correspond to her age, and that she would at times get giddy. A review of the resident's 4/30/19 care plan was conducted on 5/2/19. The review revealed no updates had been made regarding the resident being fondled and exhibiting behaviors of exposing her breasts to other residents. During an interview with the Administrator and Social Worker on 5/2/19 at 9:30 AM they both stated they were unaware Resident #2 was being fondled or was having behaviors that needed to be added to the care plan. The Administrator stated as of 5/2/19, they had no records from the clinical consulting social worker, and the facility was working on obtaining them. The facility social worker stated she thought the reason the resident was being seen by psychosocial therapy was because of other reasons related to her age.

Based on record review and staff interviews the facility failed to assure the medical record was complete for two (Residents # 1 and # 2) of three sampled residents reviewed for accuracy of records. The findings included: 1. Record review revealed Resident # 1 was initially admitted to the facility on [DATE]. Record review revealed the resident had [DIAGNOSES REDACTED]. Review of the resident's care plan, dated 3/27/19, revealed the resident had a history of [REDACTED]. Review of episodic nursing notes and nursing monthly summaries from 2/1/19 through 4/29/19 revealed no documentation that the resident was displaying any behaviors of wandering into rooms uninvited, verbally abusive behaviors, or any other type of behaviors. Nurse Aide (NA) # 2 was interviewed on 5/2/19 at 12:15 PM and reported the following. NA # 2 stated she had witnessed Resident # 1 touch Resident # 2's breast, and in her brief. During a follow up interview with NA # 2 on 5/6/19 at 11:20 AM, NA # 2 stated she was sure she had witnessed this behavior since (MONTH) 1, 2019, and that nurses were aware of the behavior. Interview with Nurse # 5 on 5/3/19 at 6:00 PM revealed she witnessed Resident # 1 curse at staff. Interview with NA # 10 on 5/3/19 at 11:42 AM revealed she had witnessed Resident # 1 in Resident # 3's room and rub the resident's legs. NA # 10 stated Resident # 3 had not been invited into the room. This occurred sometime between 2/1/19 and 4/29/19, and she reported the incident to the social worker and Nurse # 7. Interview with Nurse # 7 on 5/4/19 at 11:25 AM revealed she was aware Resident # 1 had entered Resident # 3's room sometime prior to 4/29/19 within the last two months, and he became loud and hard to redirect. According to Nurse # 7, Resident # 1 was not assigned to Nurse's # 7's hall for care and documentation. On 5/6/19 at 9:20 AM interview with Nurse # 1, who routinely cared for Resident # 1, revealed Resident # 1 was verbally abusive to residents and staff, and it was her current understanding that she was not to place this information in the resident's monthly summaries. Interview with the Director of Nursing on 5/8/19 at 12:39 PM revealed it was her expectation that behaviors of any kind would be charted in either the episodic notes or the monthly summaries, and that placing it in the episodic charting helped track the actual dates the behaviors were occurring. 2. Record review revealed Resident # 2 was admitted to the facility on [DATE]. An interview with a consulting clinical social worker (SW), who saw Resident # 2 for psychosocial counseling, was conducted on 5/2/19 at 1:35 PM. The consulting clinical social worker stated she had worked with Resident # 2 since 3/26/19. During the interview, the SW stated that she had been informed by nursing staff that the resident would sometimes flash a gentleman who would give her attention and she was being fondled. Review of Resident # 2's facility record from 2/1/19 to 5/1/19 revealed no documentation by nursing staff or the facility social worker that Resident # 2 was being fondled or that she had flashed a male resident for attention. On 5/4/19 at 9:30 AM, interview with the Administrator and facility Social Worker revealed the consulting clinical social worker, who saw Resident # 2, was part of a consulting psychosocial therapy group, and the facility had no documentation from the consulting social worker to incorporate into the facility record. It was their expectation that the consulting therapy group would have provided some documentation to the facility to incorporate into the facility record. Interview with the Director of Nursing on 5/8/19 at 12:39 PM revealed it was her expectation that behaviors of any kind would be charted in either the episodic notes or the monthly summaries by her nursing staff, and that placing it in the episodic charting helped track the actual dates the behaviors were occurring.

Based on observation, physician interview, staff interview, and record review the facility failed to prevent 1 of 6 sampled residents (Resident #24) reviewed for accidents from eloping out of an exit door in the facility's secure unit. The resident was unaccounted for during a 57 minute period in the late afternoon of 01/08/19, and was found walking along a path in a wooded area approximately 55 feet from the exit door without socks and shoes. The resident sustained [REDACTED]. Findings included: Record review revealed that Resident #24 was admitted to the facility on [DATE]. The resident's documented [DIAGNOSES REDACTED]. A 08/23/18 progress note documented Resident #24 experienced [MEDICAL CONDITION] activity and was sent to the emergency room for evaluation. Review of Resident #24's care plan revealed on 09/26/18 the following problem was added: Resident resides on a secured unit r/t (due to) elopement risk/wandering secondary to [DIAGNOSES REDACTED]. Interventions to this problem included, Assess for appropriate placement on the unit periodically. Review of Resident #24's care plan revealed on 10/22/18 the following problem was added: Resident is lower functioning, dependent on staff for activities, cognitive stimulation, social interaction related to: dementia. Resident diagnosed with [REDACTED]. Resident can also wander throughout day. Resident can have sun downing behaviors relating to dx (diagnosis) dementia. Interventions to this problem included, Position resident in locations that enable resident to have frequent contact with others during activities and social (events). Resident #24's 10/29/18 quarterly minimum data set (MDS) documented his cognition was severely impaired, he exhibited no behaviors including wandering during the look back period, he required extensive assistance from a staff member with walking in the room and corridor and locomotion on the unit, he required supervision by a staff member with locomotion off the unit, his balance during all transitions and walking was not steady and he was only able to stabilize with staff assistance, he was always incontinent of bowel and bladder, he had one fall since his last assessment without injury, he was five feet tall and weighed 90 pounds, and he had experienced significant weight loss. A 12/06/18 progress note documented Resident #24 was high risk for falls. Currently wears helmet while OOB (out of bed); resident is on frequent safety rounds; facility attempts to keep resident in non-skid socks or shoes (resident removes often); encourage resident to take rest breaks. A 12/14/18 psychiatry consult (the most recent in Resident #24's medical record) documented alert and pleasantly confused. The consult also documented the resident's only [MEDICAL CONDITION] medication was an anti-depressant medications which the resident received daily. A time line for 01/08/19 provided by the Director of Nursing (DON) documented that at 4:40 PM Resident #24 was observed ambulating in the hall on the secure unit, at 5:15 PM supper trays began to be passed on the unit, at 5:30 PM a nursing assistant (NA) questioned the whereabouts of the resident, at 5:35 PM it was discovered that one of the exit doors on the secure unit opened soundlessly, at 5:37 PM Resident #24 was found walking along a path in the woods, and at 5:41 PM the resident ambulated back into the building with staff. The time line also documented, Outside (temperature) was noted be 57 degrees. Resident was fully dressed except for socks (and shoes) and was wearing his helmet. Vitals were within normal limits. Skin assessment was done . A 01/08/19 Head to Toe Evaluation documented Resident #24's blood pressure was 138/78, his pulse was 80, his respirations were 18 per minute, his temperature was 98.8 degrees, and his respirations were unlabored. The assessment documented the resident had not experienced a significant change within the last 24 hours. During an interview with Nurse #4 on 01/25/19 at 11:10 AM she stated she was the staff member who found Resident #24 in the woods on 01/08/19. She reported Resident #24 wandered constantly on the unit, but did not seem to be truly exit seeking, and was easily redirected. She commented that after searching the unit twice when the resident could not be located at the supper meal, she assumed the resident must have left the unit through an exit door which was found unlocked during the search and did not alarm when opened. According to Nurse #4, she saw Resident #24 in the woods behind and to the side of the building, following a path that paralleled a property line fence. She stated the resident had on a sweat top and bottom, had his helmet on, but was barefoot. She commented dusk had just set in and the temperature was probably in the mid-50s. The nurse reported the resident did not seem anxious or distressed when she found him, and he followed staff back into the building without much persuasion. According to Nurse #4, she assessed the resident and found he had multiple scratches to his bilateral ankles and across the tops of his feet. This nurse stated staff did not go in and out of the exit doors in the unit because they did not have the code to use on the key pads. At 11:30 AM on 01/25/18 Nurse #4 identified the location in the woods where she found Resident #24. The resident was about 55 feet away from the exit door. He had to cross a gently sloping concrete sidewalk, cross a gently sloping lawn, and enter the woods where there were trees, bushes, vines, briars, and pine needles. The resident was about 25 feet into the woods before staff located him. During an interview with NA #8, a medication aide, on 01/25/19 at 11:18 AM she stated she worked until 3:00 PM on 01/08/19, and saw Resident #24 on and off during that shift. She explained she returned to the building around 5:00 PM to help with the supper meal, and alerted Nurse #4 when Resident #24 could not be found. She reported the resident usually ate his meals in the unit dining room, but she could not find him there, in his room, or in the hallway. According to NA #8, the last time she saw the resident he had on shoes and socks, but when he returned to the building with staff after being found in the woods he was barefoot. She commented Resident #24 wandered in the hallways, into resident rooms, and liked to play with locks, door, and alarms. At 12:25 PM on 01/25/19 Resident #24 kept getting up from the table in the dining room of the secure unit. He moved quickly with a slightly unsteady walk into the hallway where he was feeling along doorways, walls, and handrails. Staff would redirect the resident to the dining room, but he would be back out in the hallway in a matter of minutes. During an interview with NA #3 on 01/25/19 at 2:58 PM she stated that on first shift Resident #24 wandered throughout the unit, was easy to redirect, and was cooperative and mild mannered. During an interview with NA #6 on 01/25/19 at 3:43 PM she stated she helped care for Resident #24 on second shift. She reported the resident wore a helmet because he had impaired balance. She commented she was working on 01/08/19 and remembered seeing the resident sometime between 4:30 PM and 5:15 PM when supper trays began to be passed on the secure unit. The NA stated she was surprised that an exit door in the unit was found unlocked since staff did not have the code to go in and out. During an interview with NA #7 on 01/25/19 at 3:50 PM she stated she also cared for Resident #24 primarily on second shift, but she felt the resident became more anxious on second shift. She explained in the past the resident pulled items off the walls and got himself tangled up in curtains in another resident's room on second shift. She commented the resident did not like to stay in one place for very long. Beginning at 9:22 AM on 01/25/19 the Maintenance Manager (MM) stated there were nine exit doors in the building. The front door was Wanderguard protected, and the other eight doors were key pad protected. He reported that he checked the functionality of the Wanderguard door three times weekly, and was checking the key pad systems at the other eight doors monthly until his corporate supervisor suggested increasing the frequency to weekly in the fall/winter of (YEAR) due to remodeling which increased the traffic flow through the building. According to the MM, when checking the key pad doors he made sure they were locked, made sure the alarm sounded when he lifted the maglock override covers, and made sure the maglock switches were in the up or on position. During an interview with the DON on 01/25/19 at 9:52 AM she stated that once Resident #24 was safely back inside the building the door through which he exited was examined, and it was found that the maglock switch was flipped down (off) which prevented the door from alarming when the resident opened it and went through it. An employee was assigned to monitor this door until other doors in the building could be examined. According to the DON, pins were also found in the maglock override systems of three doors, including the exit doors at either end of the secure unit and one door in the front of the building outside of the unit. These pins prevented an alarm from sounding when the maglock override cover was lifted. The DON commented that Resident #24 had a tendency to tamper with switches and alarms during his wandering. During a telephone interview with Resident #24's primary physician and Medical Director (MD) of the facility on 01/26/19 at 10:55 AM he stated he was made aware of Resident #24's elopement on 01/08/19, the same evening the event occurred. He reported there was a lot of resident activity in the secure unit so it would be important to take extra precautions to make sure the exit doors on the unit were locked and alarmed. He commented that his main concern for Resident #24 related to the elopement was the resident's exposure to the weather for an undetermined period of time. The MD acknowledged that Resident #24 had some [DIAGNOSES REDACTED]. Corrective Action for Those Residents Having the Potential to be Affected by the Same Deficient Practice: Immediately following Resident #24's elopement the facility used its 01/08/19 census to do a total facility head count and all residents were accounted for. The facility also did an inspection of all nine exit doors in the facility to make sure they were functioning correctly. The functionality of the Wanderguard system on the front door was verified, and the other eight doors were checked to make they were locked and alarming properly. Pins were removed from three maglock override systems. By 01/09/19 elopement risk assessment were completed for all residents in the building with moderately or severely impaired cognition. Those residents found to be at high risk for elopement, outside of the secure unit, had Wanderguard bracelets applied. Measures to be Put in Place or System Changes to Ensure the Deficient Practice Would Not Reoccur: A facility-wide in-service was provided to all disciplines working in the facility on 01/09/19 during which the elopement policy and code green elopement protocol were reviewed. Any staff not able to attend was informed that they could not begin work again until they received the training and signed that they understand the information. It was determined all new staff members would receive education on the elopement policy and code green elopement protocol during orientation. An ad hoc session of the facility's Quality Assurance (QA) Committee met on 01/09/19, and determined the root cause analysis of Resident #24's elopement was inadequate monitoring of the doors in the building. Therefore, beginning on 01/09/19 all doors protected with the key pad system were monitored twice daily, in the AM and PM, rather than just weekly. On 01/09/19 education was provided to all maintenance personnel and department heads about the new schedule for door inspections and the need to make sure all doors were locked, the door alarmed when the maglock override cover was lifted, the maglock switch was in the on position (up), and there were no devices inserted into the maglock system which affected the integrity of the alarmed doors. Monitoring of Performance to Ensure Solutions are Sustained: On 01/09/19 the MM began keeping a log book in which he documented his twice daily checks of the exit doors in the building. Twice a day door monitoring was to be completed for 30 days, then the frequency of the monitoring was decreased to once daily for 30 days and then returned to weekly as was the frequency prior to the 01/08/19 elopement event. Effective 01/09/19 the DON monitored the MM log book weekly to ensure that the checks were being completed per the QA Committee's recommendations. After the new elopement risk assessments were completed on 01/09/19, eight residents outside the secure unit had Wanderguard bracelets applied. The medication administration and treatment administration records for these residents were updated to allow for documentation on each shift that the bracelets were in place and daily documentation that the bracelets were functional. Effective 01/09/19 the DON monitored these administration records weekly to make sure staff were documenting placement and functionality. Title of Person(s) Responsible for Implementing the Acceptable Plan of Correction: Effective 01/09/18 the facility Administrator and the DON were designated as being ultimately responsible for the implementation of this plan of correction to ensure the facility attained and maintained substantial compliance. Validation of the above referenced plan of correction was completed on 01/26/19 during an extended survey. Validation included inspection of all nine exit doors in the facility on 01/25/19 which revealed all doors were functioning and alarming per manufacturer expectations. Interviews were conducted with staff from various disciplines and shifts who were able to verify in-servicing on 01/09/19 about elopement policy and protocol. The MM's log book for door inspections and DON sign-offs were reviewed for frequency and documentation of door/alarm functionality. The placement of Wanderguard bracelets on the eight residents outside of the secure unit was verified, and a tester was used to determine that the bracelets were functional. The medication and treatment administration records and the DON sign-offs were reviewed to ensure the placement/functionality of the bracelets was being documented per the QA Committee's recommendations. Interviews with staff members verified that no residents had eloped since 01/08/19. The date of 01/09/19 was validated as the facility's date of compliance.

Based on record review and staff interviews the facility failed to consult with the physician regarding a change in condition for one (Resident # 1) of two sampled residents who experienced multiple falls. The resident was found to have a subdural hematoma, extensive bruising to multiple body parts, and [MEDICAL CONDITION] when she was transferred to the hospital. Immediate Jeopardy began [DATE] when facility staff failed to notify the physician that Resident # 1 was acting differently after sustaining falls and a bruise to her head while taking aspirin. On [DATE] the resident refused two meals and care before the staff contacted the physician to obtain new orders. Interview with the facility physician revealed the staff had not communicated the extent of bruising the resident had on her body or the change in her condition. The immediate jeopardy was removed on [DATE] when the facility provided an acceptable credible allegation of compliance. The findings included: Record review revealed Resident # 1 resided at the facility from [DATE] until [DATE]. According to the medical record the resident had the following Diagnoses: [REDACTED]. Review of physician orders [REDACTED].) Record review revealed the physician assessed the resident on [DATE] and noted that there was no bruising or abnormal bleeding as of the physician's assessment date, and the resident's last hemoglobin was noted by the physician to be 9.8 (Normal range ,[DATE]). Review of the resident's Minimum Data Set (MDS) assessment, dated [DATE], revealed the resident was cognitively impaired; needed extensive assistance from one staff member for bed mobility, transfers, dressing, toileting, hygiene, and bathing; and needed limited assistance for ambulation. This MDS assessment also coded the resident as having no falls or fractures within the last 6 months prior to her facility admission. Review of the resident's care plan, dated [DATE], revealed the staff identified Resident # 1 was at risk for falls. The facility's goal for the resident was that she not sustain injury due to a fall. Listed interventions added on [DATE] were: ambulation devices as needed; assess cognitive status, evaluate for unsteady gait, instruct on appropriate safety measures; maintain a safe environment, proper nonskid foot wear; therapy to evaluate and treat as ordered. On [DATE] anti rollback wheelchair brakes was added to the care plan interventions. On [DATE] assess for fatigue and provide rest periods PRN (as needed) and assist with transfers and ambulation was added to the care plan interventions. On [DATE] offer and assist resident to bed between 7 PM to 8 PM was added to the care plan interventions. Review of the nursing notes revealed Resident # 1 sustained a fall on [DATE] at 6:00 AM. Nurse # 2 documented at this time that Resident # 1 slid out of bed while getting into her wheelchair, and landed on her buttocks with her back against the bed. On [DATE] at 7:18 AM, Nurse # 2 documented that the resident had a bruise to her right flank but had no complaint of pain or discomfort. The note indicated the physician was made aware of the fall and bruise. Review of the record revealed that following the fall of [DATE], Resident # 1 did not sustain any further falls until the date of [DATE]. From [DATE] through [DATE], the resident was documented as falling three times within these four days. Record review revealed a nursing note on [DATE] (Tuesday) at 5:42 PM by Nurse # 3 noting Resident # 1 was observed sitting on the floor on her buttocks next to her bed. The note indicated the physician was made aware of the fall. On [DATE] (Thursday) at 7:55 PM Nurse # 2 documented Resident # 1 sustained another fall. The nurse noted Resident # 1 was sitting on the edge of her wheelchair and slid out of the chair onto the floor landing on her buttocks. Nurse # 2 noted the resident was cooperative, pleasant, and her skin tone was normal. There was no documentation of bruising or injury. The note indicated the physician was made aware of the fall. Nurse # 1 was interviewed on [DATE] at 2:00 PM and [DATE] at 9:46 AM. Nurse # 1 stated the resident had fallen on [DATE] (Friday) but the incident had been logged as occurring on [DATE]. The nurse pointed to an entry in the nursing notes which was dated [DATE] (Saturday) at 5:12 PM. Nurse # 1 stated this Saturday entry, which documented a fall, occurred on [DATE] (Friday) at 3:43 PM. The entry read, Writer called to TV room Resident observed with her right knee on the floor and her right elbow resting on an arm-chair. Resident assessed for injuries; no injuries noted. Resident had old bruising to her arms and the right temporal area. Resident had no complaints of pain. MD in facility, notified of unwitnessed fall. Writer attempted to contact RP (name of RP) to inform of unwitnessed fall. The note was signed by Nurse # 1. Interview with Nurse # 1 on [DATE] at 2 PM and [DATE] at 9:46 AM revealed she had been the nurse to respond to the fall on [DATE] at 3:43 PM. Nurse # 1 stated NA # 4 had been in attendance with Resident # 1 in the TV room, but was caring for another resident at the time and had not seen Resident # 1 fall. Interview with Nurse # 1 revealed she had checked Resident # 1 in the TV room, but did not take her back to her room and look at her entire body at the time of the incident. Nurse # 1 stated the resident had some yellow bruising on her arms and a purple bruise to the right temple area at the time of her assessment. Nurse # 1 stated the resident continuously wore either a wig or bonnet secondary to her hair loss. Nurse # 1 stated at the time of the incident the bruise did not extend under her bonnet, and she did not take the resident's bonnet off to assess her head further. Nurse # 1 stated she felt the Resident would not have let her remove the bonnet. Nurse # 1 stated she did let the physician know the resident had a bruise to her temple, but she had not noted a change in the resident in order to convey a change in condition to him. This interview also revealed the nurse had not questioned the physician about whether the aspirin dosage should be evaluated. Nurse # 2 was interviewed on [DATE] at 9:16 AM. According to facility staffing sheets, Nurse # 2 had been assigned to care for Resident # 1 from 7:00 PM on [DATE] (Friday) until 7:00 AM on [DATE] (Saturday). The nurse stated it often got hectic on the unit where Resident # 1 resided and things tended to run together. According to Nurse # 2 she thought she might have called and told Resident # 1's responsible party that Resident # 1 had hit her head, but she could not recall the reason she might have done so. According to Nurse # 2, she recalled the assistant director of nursing (ADON) talking to her the Friday evening of [DATE] about Resident # 1, and they discussed that Resident # 1 was acting differently and were wondering if she might have a urinary tract infection. Nurse # 2 did not recall speaking to the resident's physician regarding this. Interview with the ADON on [DATE] at 3:55 PM revealed she was responsible for following up on falls and accidents. The ADON stated she had checked on Resident # 1 on the morning of [DATE] (Friday) because the resident had fallen on [DATE] (Thursday). The ADON stated she had not noticed a bruise to Resident # 1's temple on the Friday morning of [DATE]. The ADON stated on Friday evening of [DATE] she went to check on the resident again, and noted she had a bruise to her temple which she had not seen earlier. According to the ADON on Friday evening of [DATE] she saw the resident reach one time into the air as if she was reaching for something that was not there, and her pupils seemed to be small. The ADON stated she did not have a pen light in her pocket to do a neurological check, but she had spoken to Nurse # 1 and it was her understanding that Nurse # 1 was going to follow up with the physician. According to the ADON she had not spoken to the physician directly about her observations. NA # 2 was interviewed on [DATE] at 11:10 AM. NA # 2 stated she had cared for Resident # 1 on the Friday of [DATE] from 3:00 PM until 7:00 PM. NA # 2 stated Resident # 2 reached for things in the air that were not there; as if she were hallucinating. NA # 2 stated this was different for Resident # 2 and she had told a nurse about it, but was not exactly sure which nurse it was. There was no documentation in the nursing notes noting NA # 2's observations or that the physician had been notified. NA # 3 was interviewed on [DATE] at 10:45 AM. NA # 3 stated she arrived to work at 7:00 PM on [DATE] (Friday) and stayed in the TV room with residents from 7:00 PM to 9:00 PM. Interview with NA # 3 revealed Resident # 1 was in the TV room when she arrived at work, kept trying to repeatedly stand up, and elbowed NA # 3 when she tried to redirect the resident to sit down. NA # 3 stated the resident would scream, became angry, and did not want to open her mouth for medications from the nurse. Interview with Nurse # 3 on [DATE] at 12:25 PM revealed she had been on duty during the dayshift on [DATE] (Saturday). Nurse # 3 stated she had not received anything in report when she reported to duty that Resident # 1 had been bruised or injured. Nurse # 3 stated she did not know the resident had been hurt until two dayshift NAs (NA # 6 and NA # 7) came to her and reported they had found bruises on her while giving her care. Nurse # 3 stated she immediately went to assess the resident and found her to have bruises on her back, legs, hip, and head. The nurse stated the bruises were red in color and she immediately called Nurse # 1, who was her supervisor. NA # 6 was interviewed on [DATE] at 4:35 PM. Interview with NA # 6 revealed she had routinely cared for Resident # 1, and the resident was usually very cooperative with care. NA # 6 stated prior to [DATE] (Saturday), she had last cared for her on [DATE] (Tuesday). NA # 6 stated on Saturday of [DATE], Resident # 1 was assigned to NA # 7 and she (NA # 6) had assisted with her. NA # 6 stated Resident # 1 would not eat nor drink for breakfast or lunch, and she refused care by swinging at them. NA # 6 stated after lunch they finally convinced Resident # 1 to let them assist her with care, and when they pulled back her covers and clothing to provide care there were dark purple bruises on her arms, breast, back, thighs, and legs. NA # 6 stated the bruising seemed like it was everywhere. NA # 6 stated they immediately got the nurse. NA # 6 stated the bruising had not been present when she had last cared for Resident # 1 on [DATE] (Tuesday). NA # 7 was interviewed on [DATE] at 12 noon. Interview with NA # 7 revealed she had not received a report when she reported to duty on [DATE] that there was anything wrong with Resident # 1. NA # 7 stated Resident # 1 would not eat breakfast nor lunch and refused morning care. NA # 7 stated the nurse also tried to assist her for lunch, and the resident refused. NA # 7 stated after lunch she and NA # 6 went together to provide care, and when they pulled back the sheet there were bruises on both arms, both hips, on her legs, under her arm, on the side of her chest by her breast, and on her right head. Interview with NA # 7 revealed she had not seen the bruise on her head earlier because the resident wore a bonnet and when they were providing care the bonnet tipped backward which revealed the bruising. NA # 7 stated the head bruise was about the size of her hand. Review of the record revealed no notation regarding the bruising that was found by NA # 6, NA # 7 and Nurse # 3 on [DATE]. According to the record Nurse # 1 noted on [DATE] at 5:38 PM new order noted-CT of hand. Called (responsible party) and left message to return call). This was the only notation in the nursing notes regarding any communication with the resident's physician since the resident had fallen on [DATE] (Friday) at 3:43 PM. Interview with Nurse # 1 on [DATE] at 9:46 AM revealed Nurse # 3 had called her at home on [DATE] and told her Resident # 1 had bruises everywhere. Nurse # 1 stated it was her understanding that the main concern was the bruising and not a change in mental status. Nurse # 1 stated she called the physician and he asked if the resident had been falling. Nurse # 1 stated she told the physician the resident had fallen, and he therefore wanted her sent for a CT scan at the hospital. The nurse clarified the order was for a CT of the head and not of the hand which had been indicated in the notes. The nurse stated it was arranged for Resident # 1 to go to the hospital out-patient department via way of a non-emergency transport service. Interview with the DON (Director of Nursing) on [DATE] at 5:25 PM revealed Nurse # 3 had called her at home and the main concern seemed to be the change in Resident # 1's mental status. The DON stated she had just recently been employed at the facility and therefore Nurse # 1 knew the resident much better than she did. The DON stated Nurse # 1 was planning to go in to work, and therefore she had Nurse # 1 communicate with the physician. The DON stated the extent of the bruising was not conveyed to her or she would have gone to the facility when she was called. A review of the resident's [DATE] Medication Administration Record [REDACTED]. There was no indication in the record the facility staff had consulted with the physician regarding if the Aspirin should be held when the resident began falling. Review of [DATE] ER medical records revealed the resident's bruising was extensive. The ER physician noted the resident had bruising on the right parietal area of her head; the right flank, the right elbow, the right hip, the right knee, and the left flank. He further noted she had critical [MEDICAL CONDITION] with a Hemoglobin level of 5.9 which the physician documented was likely secondary to a GI ([MEDICAL CONDITION]). The resident's stool was grossly guaiac positive for blood in the ER. A CT scan of the resident's head on [DATE] revealed she had a frontoparietal subdural hematoma measuring 5 mm (millimeters) in thickness. An interview with the resident's facility physician on [DATE] at 7:00 PM revealed the most likely reason for the resident's extensive bruising was her repeated falls. According to the physician the staff had notified him of the bruise to the temple on [DATE], but they had not notified him of any other changes in her mental status on Friday ([DATE]), the extent of the bruising, or consulted with him regarding the aspirin dosage. The physician stated he did not usually order aspirin at the dosage of 325 milligrams daily for residents, and Resident # 1 had been admitted with the dosage. Review of the resident's death certificate revealed she passed away on [DATE] at 6:30 PM. On the death certificate the physician had listed the cause of death as subdural hematoma and complications of a fall. On [DATE] at 4:52 PM, the administrator was informed of the immediate jeopardy. The facility provided a credible allegation of compliance on [DATE]. The allegation of compliance indicated: Credible Allegation of Compliance Resident # 1 has [DIAGNOSES REDACTED]. Upon admission, she was determined to be a risk for falls. Subsequently, she was care planned for a fall risk as to prevent injuries. Resident #1 sustained three separate falls on [DATE], [DATE] and [DATE] which resulted in bruising to multiple areas of her body. The fall on [DATE] was unwitnessed in the dayroom at approximately 3:45 pm. Resident #1 was noted to be on one knee with the other foot flat on the floor. Her right arm was on a chair and her left arm was on her wheelchair. Resident was observed on the floor by the Unit Manager and assisted to a chair in the dayroom and a head to toe assessment was not documented in the clinical record. The ADON observed a bruise to resident's forehead and spoke with the Unit Manager regarding the observation. The Unit Manager observed the area where the bruise was located on resident #1's forehead, but did not complete a head to toe assessment. The bruise to the forehead was not completely assessed by the UM and the extent could not be determined due to the UM not removing the cap from resident #1's head. The UM stated to DON that resident #1 didn't let UM remove her night cap. The Unit Manager failed to complete a head to toe assessment immediately following the observation of the bruise to the resident's forehead. UM notified the attending physician regarding the fall and bruise to head. MD was notified of the bruise to resident #1's forehead and ordered neuro checks at that time. Neuro checks were started following the MD order, but did not continue based on the facility's policy. On [DATE], resident #1 refused breakfast. She also refused to get out of bed or allow personal care offered by staff. She refused lunch, pushing staff away. Thru encouragement, staff were able to assist resident with ADL care and noted bruises on her body. At this time she was alert but not speaking. The nurse was informed and contacted the DON at 3:25 pm regarding the refusal of meals, refusal of care and multiple bruising. An order was obtained to send resident #1 to hospital for head CT. Resident was transported to hospital via wheelchair at 5:15pm. Resident was later transferred to hospital and admitted with subdural hematoma and GI bleed. Resident later expired at hospital. The nurse failed to complete a thorough head to toe assessment at time of fall per policy. The nurse also failed to contact the MD to report change to Resident #1. Resident #2 sustained a bruise to right armpit that was identified on [DATE]. The RP and MD were notified on that date, however, the nurses failed to continue to assess the bruise for any changes. In addition, the nurses also failed to advise the MD of changes to resident's #2 area to right armpit. The Nurse Practitioner saw resident #2 on [DATE] and ordered CT without contrast to the chest and X-Ray to right shoulder in which the results later revealed a hematoma with osteopenic bones. For the resident affected: All residents who sustained a fall since [DATE] were assessed by the DON/Designee by use of an audit tool to determine completion of head to toe assessments and MD notification regarding changes in resident condition. The assessment audit included a review of the medical record to ensure that all measures were in place to include contacting the MD of any changes to meet the current needs of the affected residents. A review of the medical record was conducted by the DON to review appropriate interventions and assessments subsequent to each fall. Based on findings, staff education was provided by DON. Plan to identify other residents who are at risk for the deficient practice Other residents who are at risk for deficient practice will be identified by an assessment audit that will be conducted for all current residents that have had falls since [DATE]st. Assessments will be reviewed by Director of Nursing or delegated persons for compliance. Based on findings education will be provided. Surveyor identified another resident that had been affected by the failure to conduct assessments according to policy. Resident #2 sustained a bruise on [DATE] to the right armpit. The MD and Responsible Party were both notified on that date. No further documentation to include head to toe assessments which would have indicated any change to area was noted until [DATE]. The resident was seen by the Nurse Practitioner. At that time a CT of chest without contrast, Right shoulder X-Ray and a CBC were ordered. The results of the tests revealed an intermuscular hematoma. It was determined from review of the medical record that no head to toe assessment was conducted for the resident. The medical record reflects compound fracture to the lower spine and there have been no follow up X-rays to address the affected area of the spine. The compression fractures were sustained prior to admission to the facility and are noted on admission evaluation by MD. Staff have observed resident #2 calling out in pain during ADL care. MD notified on [DATE] to have pain medication ordered for resident #2. Action Taken to Fix the Problem Re-education to all nurses and CNAs began on [DATE]. All Nursing staff to include licensed nurses and CNAs were educated on [DATE] either via phone or in person regarding the following: Fall Management, which includes Safe Handling of residents regarding transfers, Head to Toe Assessments, Abuse/Neglect policy and procedure, and Neurological Check Policy and Procedure. All CNAs have received education regarding reporting any change in condition to nurse through the use of a Stop and Watch Tool. All employees who received education via phone will receive written material upon returning to work. The Neurological checks education was provided on [DATE] to all licensed nurses to specifically address the frequency and duration: It is as follows: Every 15 minutes for 2 hours, then every 30 minutes for 4 hours, then every hour for 4 hours, then every 4 hours for sixteen hours, and every 8 hours for 48 hours. Education was provided to all nursing staff on [DATE] to include all assessment processes to include assessment for pain. The facility alleged IJ removal on [DATE]. The credible allegation was verified on [DATE] at 6:04 PM. Nurse #1 no longer worked at the facility and could not be reached by phone for interview. A sample of current resident records were reviewed for falls, injury and staff action. The Assistant Director of Nursing was interviewed on [DATE] at 5:07 PM. She provided the Fall Management Protocol, Assessment and Neurological Check policy inservice details. On [DATE] from 2:02 PM through 5:42 PM, random nursing staff as well as Nursing Assistants involved with Resident #1 following the falls, were able to articulate the steps of the Stop and Watch Tool for notification, assessment and reporting. Staff members interviewed were able to describe education received regarding falls, assessment, the policy regarding neurological checks, physician notification, neglect and how to respond to changes in condition. The facility was able to provide evidence that they had completed an audit of the residents and inserviced all staff on [DATE]. Other residents in the facility were observed and there were no concerns. The immediate jeopardy was removed on [DATE].

Based on observation, record review, staff interviews, family interview and physician interview for two (Residents # 1 and Resident # 2) of three residents who had sustained injuries the facility neglected to assess the residents and provide care. The facility failed to assess Resident # 1, communicate clearly to the physician the resident's status, and initiate emergency medical services when the resident was identified to have a head injury and a change in mental status after sustaining three falls within four days. When a decision was made to send the resident out for medical treatment, the facility failed to initiate emergency medical services. The resident was found to have extensive bruising, a subdural hematoma, and critical lab work when transferred to the hospital. The resident expired four days following her facility discharge. The facility failed to assess Resident # 2 following the identification of a painful armpit bruise. The resident was identified to have an intramuscular chest hematoma six days after the armpit bruise was identified for which she had received nothing for pain. The facility also failed to provide assessment and management of Resident # 2's pain she experienced while receiving transfer assistance from staff. The resident was observed to be in pain during transfers. Immediate jeopardy began on [DATE] when Resident # 2, who was cognitively impaired and needed staff's assistance for her care, was identified to have a painful armpit bruise. The facility failed to assess the resident and on [DATE] the resident was noted to also have a bruise to her chest. On [DATE] a computerized tomography scan revealed the resident had an intramuscular hematoma to her chest muscle for which she had not received anything for pain. Resident # 1 was also neglected at a level of IJ. On [DATE] the facility staff identified Resident # 1, who sustained three falls within four days, had a bruise to her head and they failed to assess the resident for further and worsening injury in order that they clearly communicate to the physician the resident's medical status. Following the identification of the head bruise staff were knowledgeable the resident picked at non-existent things in the air, refused fluids, refused meals, and refused care. Nurses did not identify the resident had extensive bruising on multiple areas of her body until the afternoon of [DATE]. The resident was transported out for medical care by a non- emergent transport. The immediate jeopardy was removed on [DATE]. The facility will remain out of compliance at a scope and severity level D (no actual harm with potential for more than minimal harm that is not immediate jeopardy) to allow the facility to monitor and fully implement the new procedures to assure residents are assessed and not neglected. The findings included: 1.The facility's neurological checks policy, last revised in [DATE], was reviewed. According to the policy neurological checks were to be completed if a resident was suspected of sustaining head trauma. The frequency of the checks were to be done as follows: every 15 minutes for 2 hours; every 30 minutes for four hours; every hour for 4 hours; every 4 hours for 16 hours; and every 8 hours for 48 hours. Record review revealed Resident # 1 resided at the facility from [DATE] until [DATE]. According to the medical record the resident had the following Diagnoses: [REDACTED]. Record review revealed the physician assessed the resident on [DATE] and noted that there was no bruising or abnormal bleeding as of his assessment date, and her last hgb (hemoglobin) was noted by the physician to be 9.8. (Normal range ,[DATE]) The physician noted in his [DATE] progress note, Please let me know about any changes in behavior that indicated an exacerbation of today's issues. Review of the resident's MDS (Minimum Data Set) assessment, dated [DATE], revealed the resident was cognitively impaired; needed extensive assistance from one staff member for bed mobility, transfers, dressing, toileting, hygiene, and bathing; and needed limited assistance for ambulation. This MDS assessment also coded the resident as having no falls or fractures within the last 6 months prior to her facility admission. From [DATE] through [DATE], the resident was documented as falling three times within these four days. Record review revealed a nursing progress note on [DATE] (Tuesday) at 5:42 PM by Nurse # 3 noting Resident # 1 was observed sitting on the floor on her buttocks next to her bed. The nurse noted the resident was assessed for injuries and none were noted. Nurse # 3 was interviewed on [DATE] at 12:25 PM. Nurse # 3 stated she had checked Resident # 1 and found no bruising or injury after her fall on [DATE]. A nursing progress note dated [DATE] (Wednesday) at 4:25 AM by Nurse # 3 contained documentation at this time that the resident was responsive and cooperative, and there was no notation made that the resident had sustained bruises or injuries. Nurse # 3 was interviewed on [DATE] at 12:25 PM. Interview with Nurse # 3 revealed the resident had no bruises on her assessment. A nursing progress note dated [DATE] (Thursday) at 4:25 AM revealed a nurse had completed a head to toe assessment, and the resident was found to be pleasant and cooperative. The note was signed by Nurse #4. There was no documentation within the note the resident had bruising or injuries. Review of a Bi Weekly Skin Check dated [DATE] at 12:30 PM revealed Resident # 1 had no current skin issues. Interview with Resident # 1's responsible party (RP) on [DATE] at 10:10 AM revealed she had visited Resident # 1 on [DATE] during the afternoon and stayed with her until 7 PM. The RP stated she had noted Resident # 1 had bruises on her arm and hand during the visit. A nursing progress note dated [DATE] at 7:55 PM documented Resident # 1 sustained another fall. The nurse noted Resident # 1 was sitting on the edge of her wheelchair and slid out of the chair onto the floor landing on her buttocks. The resident was cooperative, pleasant, and her skin tone was normal. The note was signed by Nurse #2. There was no documentation of bruising or injury. Nurse # 2 was interviewed on [DATE] at 9:15 AM. Nurse # 2 stated Resident # 1 had been in the TV room when she sustained the fall on [DATE] (Thursday) at 7:55 PM. According to the interview with Nurse # 2, she had taken the resident back to her room, lifted her clothes, found no evidence of bruising, and could not recall any injury noted on her shift which ended on [DATE] (Friday) at 7 AM. The next nursing progress note which noted an assessment of Resident # 1's condition was entered on [DATE] (Friday) at 3:25 AM by Nurse # 2. Nurse # 2 noted the resident was pleasant and cooperative, and her skin tone was normal. There was no documentation of bruising or injury. A nursing progress note was entered by Nurse # 2 on [DATE] at 6:56 AM noting the resident had a hematoma to her right elbow. There was no further information in the note. Nurse # # 2 was interviewed on [DATE] at 9:16 AM. Nurse # 2 could not recall any injury she had observed from her assessments of the resident during her shift from 7 PM on [DATE] until 7 AM on [DATE]. She did not recall observing the hematoma on Friday ([DATE]) morning before she left work, but recalled the resident's arm being puffy when she reported to work on Friday ([DATE]) evening for her next shift. A nursing progress note was entered into the record on [DATE] (Friday) at 2:56 PM by Nurse # 1. Nurses # 1 documented at this time that an order was received to x-ray Resident # 1's elbow and that the resident's RP (Responsible Party) was notified. There was no documentation of assessment of the resident's condition or of the hematoma in this note. Review of the record revealed a mobile x-ray was completed on [DATE] of the resident's elbow. The indication for the x-ray was noted to be pain. The X-ray report noted there was mild soft tissue swelling but no definite bony abnormalities. The report was electronically signed by the radiologist on [DATE] at 9:11 PM. Nurse # 1 was interviewed on [DATE] at 2:00 PM. According to the nurse the resident had a hematoma to her arm on the morning of [DATE] and no other injury. The nurse stated this had been communicated to the physician and an x-ray was done. Following the nursing progress note of [DATE] (Friday) at 2:56 PM there were no other nursing notations in the progress notes for [DATE]. It was confirmed with Nurse # 1 on [DATE] at 2:00 PM that the following entry was entered in the progress notes for [DATE], but was for an incident that occurred on [DATE] at 3:43 PM. The entry read, Writer called to TV room Resident observed with her right knee on the floor and her right elbow resting on an arm-chair. Resident assessed for injuries; no injuries noted. Resident had old bruising to her arms and the right temporal area. Resident had no complaints of pain. MD in facility, notified of unwitnessed fall. Writer attempted to contact RP (name of RP) to inform of unwitnessed fall. Interview with Nurse # 1 on [DATE] at 9:46 AM revealed she had been the nurse to respond to the fall on [DATE] at 3:43 PM. Interview with Nurse # 1 revealed she had checked Resident # 1 in the TV room, but did not take her back to her room and look at her entire body at the time of the incident. Nurse # 1 stated the resident had some yellow bruising on her arms and a purple bruise to the right temple area at the time of her assessment. Nurse # 1 stated the resident continuously wore either a wig or bonnet secondary to her hair loss. Nurse # 1 stated at the time of the incident the bruise did not extend under her bonnet, and she did not take the resident's bonnet off to assess her head further. Nurse # 1 stated she felt the Resident would not have let her remove the bonnet. Nurse # 1 stated she did let the physician know the resident had a bruise to her temple. Interview with Nurse # 1 revealed she left the facility around 7:00 PM on [DATE] (Friday), and she stated she had not noted a change in Resident # 1. According to Nurse # 1 she had started a neurological assessment flow sheet for the resident and completed neuro checks up until 6:45 PM. The nurse provided the copy of the neurological assessment flow sheet. The last neuro check documented on the flow record was 6:45 PM. The rest of the flow sheet was blank, and Nurse # 1 could not find any other records to show the neuro checks had been completed per the facility's protocol schedule. Nurse # 1 did not know why the next nurse did not continue the checks per schedule. NA # 4 was interviewed on [DATE] at 3:40 PM. NA # 4 stated she had been present when Resident # 1 fell on [DATE]. NA # 4 stated she did not recall helping with the Resident for the rest of Friday evening nor any bruises. On [DATE] there was one documented neurological check and assessment of Resident # 1's physical status for the entire day in the nursing progress notes. This was by Nurse # 2 on [DATE] at 12:25 AM. Nurse # 2 documented at this time that the resident's neurological checks were normal. There was no mention by Nurse # 2 of any of the bruising that had already been identified earlier by Nurse # 1 or if the bruising was extending. Nurse # 2 was interviewed on [DATE] at 9:16 AM. According to facility staffing sheets, Nurse # 2 had been assigned to care for Resident # 1 from 7 PM on [DATE] (Friday) until 7 AM on [DATE] (Saturday). Nurse # 2 stated she recalled when she came to work on [DATE] (Friday) at 7 PM that Resident # 1's right elbow was puffy and red but she did not recall other bruising. Nurse # 2 stated if she had done any neurological checks on the resident, she would have documented them. According to Nurse # 2, she recalled the ADON (assistant director of nursing) talking to her the Friday evening of [DATE] about Resident # 1, and they discussed that Resident # 1 was acting differently and wondering if she might have a urinary tract infection. The nurse did not recall exactly how the resident was acting differently. Interview with the ADON on [DATE] at 3:55 PM revealed she was responsible for following up on falls and accidents. The ADON stated she had checked on Resident # 1 on the morning of [DATE] (Friday) because the resident had fallen on [DATE] (Thursday). The ADON stated she had not noticed a bruise to Resident # 1's temple on the Friday morning of [DATE]. The ADON stated on Friday evening of [DATE] she went to check on the resident again, and noted she had a bruise to her temple which she had not seen earlier. According to the ADON on Friday evening of [DATE] she saw the resident reach one time into the air as if she was reaching for something that was not there, and her pupils seemed to be small. The ADON stated she did not have a pen light in her pocket to do a neurological check, but she had spoken to Nurse # 1 and it was her understanding that Nurse # 1 was going to follow up with the physician. NA # 2 was interviewed on [DATE] at 11:10 AM. NA # 2 stated she had cared for Resident # 1 on the Friday of [DATE] from 3 PM until 7 PM. NA # 2 stated Resident # 2 reached for things in the air that were not there; as if she was hallucinating. NA # 2 stated this was different for Resident # 2 and she had told a nurse about it, but was not exactly sure which nurse it was. NA # 2 stated the resident always had some bruises on her arms, but she had a cap on her head on the evening of [DATE] and she did not recall a bruise on her head. NA # 3 was interviewed on [DATE] at 10:45 AM. NA # 3 stated she arrived to work at 7 PM on [DATE] (Friday) and stayed in the TV room with residents from 7 PM to 9 PM. Interview with NA # 3 revealed Resident # 1 was in the TV room when she arrived at work, kept trying to repeatedly stand up, and elbowed NA # 3 when she tried to redirect the resident to sit down. NA # 3 stated the resident would scream, became angry, and did not want to open her mouth for the nurse to give medications. NA # 3 stated she had not assisted her to bed and thought NA # 2 had done so. NA # 5 was interviewed on [DATE] at 11:30 PM. Interview with NA # 5 revealed she recalled Resident # 1 slept Friday night during her shift which began at 11 PM on [DATE]. NA # 5 stated Resident # 1 normally did everything for herself and therefore she looked in on her, but did not awaken her and was not aware of bruises. Interview with Nurse # 3 on [DATE] at 12:25 PM revealed she had been on duty during the dayshift on [DATE] (Saturday). According to Nurse # 3 she had not received a report when she reported to duty that Resident # 1 had been bruised or injured which would have alerted her to do neurological checks. Nurse # 3 stated she did not know the resident had been hurt until two dayshift NAs (NA # 6 and NA # 7) came to her and reported they had found bruises on her while giving her care. Nurse # 3 stated she immediately went to assess the resident and found her to have bruises on her back, legs, hip, and head. The nurse stated the bruises were red in color and she immediately called Nurse # 1, who was her supervisor. NA # 6 was interviewed on [DATE] at 4:35 PM. Interview with NA # 6 revealed she had routinely cared for Resident # 1, and the resident was usually very cooperative with care. NA # 6 stated prior to [DATE], she had last cared for her on [DATE]. NA # 6 stated on Saturday of [DATE], Resident # 1 was assigned to NA # 7 and she (NA # 6) had assisted with her. NA # 6 stated Resident # 1 would not eat nor drink for breakfast or lunch, and she refused care by swinging at them. NA # 6 stated the nurse also tried to feed the resident lunch and she refused. NA # 6 stated after lunch they finally convinced Resident # 1 to let them assist her with care, and when they pulled back her covers and clothing to provide care there were dark purple bruises on her arms, breast, back, thighs, and legs. NA # 6 stated the bruising seemed like it was everywhere. NA # 6 stated they immediately got the nurse. NA # 6 stated the bruising had not been present when she had last cared for Resident # 1 on [DATE] (Tuesday). NA # 7 was interviewed on [DATE] at 12 noon. Interview with NA # 7 revealed she had not received a report when she reported to duty on [DATE] that there was anything wrong with Resident # 1. NA # 7 stated Resident # 1 would not eat breakfast nor lunch and refused morning care. NA # 7 stated the nurse also tried to assist her for lunch, and the resident refused. NA # 7 stated after lunch she and NA # 6 went together to provide care, and when they pulled back the sheet there were bruises on both arms, both hips, on her legs, under her arm, on the side of her chest by her breast, and on her right head. Interview with NA # 7 revealed she had not seen the bruise on her head earlier because the resident wore a bonnet and when they were providing care the bonnet tipped backward which revealed the bruising. NA # 7 stated the head bruise was about the size of her hand. Interview with Nurse # 1 on [DATE] at 9:46 AM revealed Nurse # 3 had called her at home on [DATE] and told her Resident # 1 had bruises everywhere. Nurse # 1 stated it was her understanding that the main concern was the bruising and not a change in mental status. Nurse # 1 stated she called the physician and he asked if the resident had been falling. Nurse # 1 stated she told the physician the resident had fallen, and he therefore wanted her sent for a CT (Computerized tomography) scan at the hospital. The nurse stated it was arranged for Resident # 1 to go to the hospital out- patient department via way of a non-emergency transport service. According to Nurse # 1 she had not thought Resident # 1's condition necessitated emergency transport to the emergency room . The nurse also stated it was her understanding the hospital non-emergency out- patient department was open on Saturday afternoons. Therefore Nurse # 1 stated she contacted a non-emergency transport service to take the resident to out-patient. The nurse did not know how the resident ended up in the emergency room . Interview with the DON (Director of Nursing) on [DATE] at 5:25 PM revealed Nurse # 3 had called her at home and the main concern seemed to be the change in Resident # 1's mental status. The DON stated Nurse # 1 knew the resident much better than she did. The DON stated Nurse # 1 was planning to go in to work, and therefore she had Nurse # 1 communicate with the physician. The DON stated the extent of the bruising was not conveyed to her or she would have gone to the facility when she was called. According to the DON the resident left the facility around 5:15 PM by non-emergency transport. A review of the resident's [DATE] MAR (medication administration record) revealed she had received her prescribed dosage of 325 milligrams of Aspirin daily from [DATE] through [DATE]. The MAR indicated [REDACTED]. Review of [DATE] emergency room (ER) medical records revealed the resident's bruising was extensive. The ER physician noted the resident had bruising on the right parietal area of her head; the right flank, the right elbow, the right hip, the right knee, and the left flank. He further noted she had critical [MEDICAL CONDITION] with a Hemoglobin level of 5.9 which the physician documented was likely secondary to a GI ([MEDICAL CONDITION]). The resident's stool was grossly guaiac positive for blood in the ER. A CT scan of the resident's head on [DATE] revealed she had a frontoparietal subdural hematoma measuring 5 mm (millimeters) in thickness. An interview with the resident's facility physician on [DATE] at 3 PM and again on [DATE] at 7 PM revealed the most likely reason for the resident's extensive bruising was her repeated falls. According to the physician the staff had notified him of the bruise to the temple on [DATE], but they had not notified him of any other changes on Friday ([DATE]), the extent of the bruising, or consulted with him regarding the Aspirin dosage. According to the physician any change in mental status in conjunction with a head injury would require an immediate evaluation at the emergency room . Review of the resident's death certificate revealed she passed away on [DATE] at 6:30 PM. On the death certificate the physician had listed the cause of death as subdural hematoma and complications of a fall. 2. Resident # 2 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. Record review revealed the resident was [AGE] years of age and her last weight, documented on [DATE], was 68.5 pounds. Review of the resident's quarterly MDS (Minimum Data Set) assessment, dated [DATE], revealed the resident had a BIMS (brief interview for mental status) score of 0. This indicated she did not answer any questions correctly on the assessment. The resident was assessed as needing extensive assistance with transfers, dressing, toileting, and hygiene. The resident was totally dependent on staff for her bathing. The resident's annual MDS assessment, dated [DATE], coded the resident as unchanged in these areas. Review of Resident # 2's current care plan, last updated on [DATE], revealed the resident could be resistive to care and combative. The care plan also noted the resident had potential for altered skin integrity. Although not all inclusive some of the listed care plan interventions included: skin assessments quarterly and as needed, and to notify MD of changes in skin as needed. According to the care plan the resident required a total lift for transfers. A problem was also on the resident's current care plan which identified the resident had chronic pain. Staff were directed on the care plan to assess the resident for pain. Review of the record revealed a dayshift nursing progress note by Nurse # 5 on [DATE] (Friday) at 8:56 AM noting that the resident had a bruise to her right arm pit which measured 8 X 5 centimeters (cm.) This same nurse noted at 10:48 AM on [DATE] the following information: the area was bluish/red and was under her right arm and inner upper arm, the ADON (assistant director of nursing) was notified, a physician communication note was completed, and that the resident complained that the area hurt when it was touched. Review of Resident # 2's [DATE] MAR indicated [REDACTED]. Nurse # 5 was not available for interview during the survey per an interview with the ADON on [DATE] at 1:06 PM. Following the nursing progress note of [DATE] (Friday) at 10:48 AM there was no documentation the bruise existed, an assessment of the bruise, or the resident's physical status in the nursing progress notes until [DATE] (Wednesday) at 2:30 PM. At this time Nurse # 5 noted the resident was seen by the NP (nurse practitioner) for a hematoma to the right axilla. Review of the NP's (Nurse Practitioner's) [DATE] note revealed the resident had a chest bruise in addition to the right axilla (armpit) bruise. The NP ordered a CT (computerized tomography) of the chest and blood work. Review of the CT report revealed it was completed on [DATE] which corresponded to Thursday after the bruise had been found on Friday [DATE]. The findings revealed the resident had a large area of high density within the right pectoralis major muscle measuring 8.5 X 4.1 X 4. 6 cm (centimeter) most likely representing intramuscular hematoma. The CT also showed the extent of the resident's compression fractures. The CT report noted the resident had diffuse osteopenia; prior cement augmentation of two of the compression fractures; three of the compression fractures were documented as mild; five of the compression fractures were documented as moderate; and two of the compression fractures were documented as severe. On the same day on which the CT was done ([DATE]) showing the hematoma, Nurse # 6 completed a Bi-weekly check of the resident's skin on [DATE]. Nurse # 6 documented the resident had no current skin issues. There was no assessment of the bruising in the nurse progress notes for [DATE]. Interview with Nurse # 6 on [DATE] at 3:15 PM revealed she had not included bruising on Resident # 2's [DATE] skin assessment check because she was assessing for and documenting for areas of pressure sores and not bruises. Review of Resident # 2's [DATE] MAR indicated [REDACTED]. The ADON (assistant director of nursing) was interviewed on [DATE] at 1:06 PM. During the interview the ADON reviewed Resident # 2's record. According to the ADON, on a scheduled basis, the facility's computer system prompts the nurses to complete an assessment after a bruise or injury is entered into a resident's computerized medical record every twenty four hours up until a seventy-two hour period post injury. The ADON stated if there are complications related to the bruise or injury then the assessments would be continued past the 72 hour period. In reviewing the record, the ADON stated Resident # 2's first 24 hour assessment following the identification of the bruise on [DATE] had not been completed by a nurse. According to the ADON the other assessments had not been done because the first 24 hour assessment had been missed and the nurses did not receive the prompting. The ADON did not know why the first 24 hour post injury assessment had been missed. Interview with the ADON revealed Resident # 2 had always required a mechanical lift for transfer since her admission. Interview with the ADON and a review of her investigation into the hematoma and bruising revealed some of the staff members had not been transferring and repositioning the resident correctly and the facility had concluded this potentially could have led to the resident's injury. Review of in-service materials following the incident revealed staff were to have her lean forward with her upper body in order that they guide her hips back in the wheelchair. Resident # 2 was observed on [DATE] at 3:55 PM as nursing assistant (NA) # 6 and NA # 9 transferred the resident from her wheelchair to bed using a mechanical lift in order to provide care. The resident was observed to appear extremely thin and frail. Her bones were very prominent. The NAs worked to try to position the mechanical lift sling back beneath the resident in order that they complete the transfer, and it was observed that the resident was not cooperative. The resident was observed to complain of pain as they worked to get the sling beneath her and transfer her into the bed, and she was not cooperative in leaning forward so that they could place the sling beneath her. NA # 6 stated the NA, who had gotten the resident out of bed earlier, should have left the sling beneath her so that they did not have to move the resident as much to get it positioned correctly. Upon completing the care the NAs again transferred the resident back from the bed to the wheelchair, and the resident complained once again she was hurting. According to these evening shift NAs the resident complained of pain anytime they transferred her. The NAs were asked if the nurse knew the resident hurt, and responded that the nurses did because the nurses heard her scream when she was transferred. Interview with the ADON on [DATE] at 3 PM revealed the facility used two different pain assessments. One assessment was intended for residents who were cognitively alert and could voice their pain level on a scale of ,[DATE]. The facility also had a pain assessment for the cognitively impaired, which required staff to assess if confused residents expressed pain in other ways such as striking out or pushing away. A review of Resident # 2's pain assessments with the ADON revealed since the hematoma had been identified on [DATE] the nurses had not completed a pain assessment using the assessment for a cognitively impaired resident. They had used a numeric evaluation of her pain. According to the ADON the nurses should have been using the pain assessment for cognitively impaired residents. The ADON stated the NAs would need to tell the nurses about how the resident tolerated her care so they could address her pain. Review of the Resident's [DATE] MAR indicated [REDACTED]. This was confirmed with Nurse # 4 on [DATE] at 10:25 AM. The nurse stated the resident did not have anything routinely ordered for pain, but she could have Tylenol if she needed it. NA # 8 was assigned to care for Resident # 2 on [DATE]. NA # 8 was interviewed at 10:30 AM on [DATE]. According to NA # 8, Resident # 2 would say she hurt sometimes, but then would say she was okay and therefore she concluded that the resident was okay and not in pain. On [DATE] at 5:15 PM, the administrator was informed of the immediate jeopardy. The facility provided a credible allegation of compliance on [DATE]. The allegation of compliance indicated: F 224 Neglect Credible Allegation of Compliance Resident # 1 has [DIAGNOSES REDACTED]. Upon admission, she was determined to be a risk for falls. Subsequently, she was care planned for a fall risk as to prevent injuries. Resident #1 sustained three separate falls on [DATE], [DATE] and [DATE] which resulted in bruising to multiple areas of her body. The fall on [DATE] was unwitnessed in the dayroom at approximately 3:45 pm. Resident #1 was noted to be on one knee with the other foot flat on the floor. Her right arm was on a chair and her left arm was on her wheelchair. Resident was assessed by the Unit Manager and assisted to a chair in the dayroom. The ADON observed a bruise to resident's forehead and spoke with the Unit Manager regarding the observation. The Unit Manager assessed the area where the bruise was located, but resident didn't let UM remove her night cap. The Unit Manager failed to complete a head to toe assessment immediately following the observation of the bruise to the resident's forehead. UM notified the attending physician regarding the fall and bruise to head. MD ordered neuro checks at that time. Neuro checks were started following the MD order, but did not continue based on the facility's policy. On [DATE], resident #1 refused breakfast. She also refused to get out of bed or allow personal care offered by staff. She refused lunch, pushing staff away. Thru encouragement, staff were able to assist resident with ADL care and noted bruises on her body. At this time she was alert but not speaking. The nurse was informed and contacted the DON at 3:25 pm regarding the refusal of meals, refusal of care and multiple bruising. An order was obtained to send resident #1 to hospital for head CT. Resident was transported to hospital via wheelchair at 5:15pm. Resident was later transferred to another hospital and admitted with subdural hematoma and GI bleed. Resident later expired at hospital. The nurse failed to complete a thorough head to toe assessment at time of fall per policy and the extent of resident #1's bruising was not assessed by the nurse. The actual bruising to resident #1. The n(TRUNCATED)

Based on observation, record review, staff interviews, family interview, and physician interview for two (Residents # 1 and Resident # 2) of three residents who had sustained injuries the facility failed to assess the residents and provide care. The facility failed to assess Resident # 1 and initiate emergency medical services when the resident was identified to have a head injury and a change in mental status after sustaining three falls within four days. The resident was found to have extensive bruising, a subdural hematoma, and critical lab work when transferred to the hospital. The resident expired four days following her facility discharge. The facility failed to assess Resident # 2 following the identification of a painful armpit bruise. The resident was identified to have an intramuscular chest hematoma six days after the armpit bruise was identified for which she received nothing for pain. The facility also failed to provide assessment and management of Resident # 2's pain she experienced while receiving transfer assistance from staff and the resident was observed in pain. Immediate Jeopardy began [DATE] when facility staff identified Resident # 2, who was cognitively impaired and needed staff's assistance for care, had a painful bruise to her armpit. The staff failed to assess the resident and on [DATE] the resident was identified to have a bruise also on her chest. On [DATE] the resident was identified to have an intramuscular chest hematoma for which she had not received anything for pain. For Resident # 1 the facility also failed to provide care and services at the immediate jeopardy level. On [DATE] facility staff identified Resident # 1, who sustained three falls within four days, had a bruise to her head and they failed to assess the resident for further and worsening injury. Nurses did not identify the resident had extensive bruising on multiple areas of her body until the afternoon of [DATE]. The resident was transported out for medical care by a non- emergent transport. The immediate jeopardy was removed on [DATE] when the facility provided an acceptable credible allegation of compliance. The facility will remain out of compliance at a scope and severity level D (no actual harm with potential for more than minimal harm that is not immediate jeopardy) to allow the facility to monitor and fully implement the new procedures to assure residents are assessed and receive care. The findings included: 1. The facility's neurological checks policy, last revised in [DATE], was reviewed. According to the policy neurological checks were to be completed if a resident was suspected of sustaining head trauma. The frequency of the checks were to be done as follows: every 15 minutes for 2 hours; every 30 minutes for four hours; every hour for 4 hours; every 4 hours for 16 hours; and every 8 hours for 48 hours. Record review revealed Resident # 1 resided at the facility from [DATE] until [DATE]. According to the medical record the resident had the following Diagnoses: [REDACTED]. Record review revealed the physician assessed Resident # 1 on [DATE] and noted that there was no bruising or abnormal bleeding as of his assessment date, and her last (hemoglobin) (Hgb) was noted by the physician to be 9.8. (Normal range ,[DATE]) The physician noted in his [DATE] progress note, Please let me know about any changes in behavior that indicated an exacerbation of today's issues. Review of the resident's minimum data set (MDS) assessment, dated [DATE], revealed the resident was cognitively impaired; needed extensive assistance from one staff member for bed mobility, transfers, dressing, toileting, hygiene, and bathing; and needed limited assistance for ambulation. This MDS assessment also coded the resident as having no falls or fractures within the last 6 months prior to her facility admission. From [DATE] through [DATE], the resident was documented as falling three times within these four days. Record review revealed a nursing progress note on [DATE] (Tuesday) at 5:42 PM by Nurse # 3 noting Resident # 1 was observed sitting on the floor on her buttocks next to her bed. The nurse noted the resident was assessed for injuries and none were noted. A nursing progress note dated [DATE] (Wednesday) at 4:25 AM by Nurse # 3 documented at this time the resident was responsive and cooperative, and there was no notation made that the resident had sustained bruises or injuries. Nurse # 3 was interviewed on [DATE] at 12:25 PM. Nurse # 3 stated she had checked Resident # 1 after her fall on [DATE] and found no bruising or injury. Interview with Nurse # 3 revealed the resident had no bruises on her assessment on [DATE]. A nursing progress note dated [DATE] (Thursday) at 4:25 AM revealed a nurse had completed a head to toe assessment, and the resident was found to be pleasant and cooperative. The note was signed by Nurse #4. There was no documentation in the note the resident had bruising or injuries. Review of a Bi Weekly Skin Check dated [DATE] at 12:30 PM revealed Resident # 1 had no current skin issues. A nursing progress note dated [DATE] at 7:55 PM documented Resident # 1 sustained another fall. The nurse noted Resident # 1 was sitting on the edge of her wheelchair and slid out of the chair onto the floor landing on her buttocks. The resident was cooperative, pleasant, and her skin tone was normal. The note was signed by Nurse #2. There was no documentation of bruising or injury. Nurse # 2 was interviewed on [DATE] at 9:15 AM. Nurse # 2 stated Resident # 1 had been in the TV room when she sustained the fall on [DATE] at 7:55 PM. According to the interview with Nurse # 2, she had taken the resident back to her room, lifted her clothes, found no evidence of bruising, and could not recall any injury noted on her shift which ended on [DATE] (Friday) at 7:00 AM. The next nursing progress note which noted an assessment of Resident # 1's condition was entered on [DATE] at 3:25 AM by Nurse # 2. Nurse # 2 noted the resident was pleasant and cooperative, and her skin tone was normal. There was no documentation of bruising or injury. A nursing progress note was entered by Nurse # 2 on [DATE] at 6:56 AM noting the resident had a hematoma to her right elbow. There was no further information in the note. Nurse # 2 was interviewed on [DATE] at 9:16 AM. Nurse # 2 could not recall any injury she had observed from her assessments of Resident #1 during her shift from 7:00 PM on [DATE] until 7:00 AM on [DATE]. She did not recall observing the hematoma on Friday ([DATE]) morning before she left work, but recalled the resident's arm being puffy when she reported to work on Friday ([DATE]) evening for her next shift. A nursing progress note was entered into the record on [DATE] at 2:56 PM by Nurse # 1. Nurses # 1 documented at this time that an order was received to x-ray Resident # 1's elbow and that the resident's RP (Responsible Party) was notified. There was no documentation of assessment of the resident's condition or of the hematoma in this note. Review of the record revealed a mobile x-ray was completed on [DATE] of the resident's elbow. The indication for the x-ray was noted to be pain. The X-ray report noted there was mild soft tissue swelling but no definite bony abnormalities. The report was electronically signed by the radiologist on [DATE] at 9:11 PM. Nurse # 1 was interviewed on [DATE] at 2:00 PM. According to the nurse the resident had a hematoma to her arm on the morning of [DATE] and no other injury. The nurse stated this had been communicated to the physician and an x-ray was done. Following the nursing progress note of [DATE] at 2:56 PM there were no other nursing notations in the progress notes dated [DATE]. It was confirmed with Nurse # 1 on [DATE] at 2:00 PM that the following entry was entered in the progress notes for [DATE], but was for an incident that occurred on [DATE] at 3:43 PM. The entry read, Writer called to TV room Resident observed with her right knee on the floor and her right elbow resting on an arm-chair. Resident assessed for injuries; no injuries noted. Resident had old bruising to her arms and the right temporal area. Resident had no complaints of pain. MD in facility, notified of unwitnessed fall. Writer attempted to contact (responsible party) to inform of unwitnessed fall. The entry was signed by Nurse # 1. Interview with Nurse # 1 on [DATE] at 9:46 AM revealed she had been the nurse to respond to the fall on [DATE] at 3:43 PM. Interview with Nurse # 1 revealed she had checked Resident # 1 in the TV room, but did not take her back to her room and assess her entire body at the time of the incident. Nurse # 1 stated the resident had some yellow bruising on her arms and a purple bruise to the right temple area at the time of her assessment. Nurse # 1 stated the resident continuously wore either a wig or bonnet secondary to her hair loss. Nurse # 1 stated at the time of the incident the bruise did not extend under her bonnet, and she did not take the resident's bonnet off to assess her head further. Nurse # 1 stated she felt the resident would not have let her remove the bonnet to assess for injury. Nurse # 1 stated she did let the physician know the resident had a bruise to her temple. Interview with Nurse # 1 revealed she left the facility around 7:00 PM on [DATE] (Friday), and she stated she had not noted a change in Resident # 1. According to Nurse # 1 she had started a neurological assessment flow sheet for the resident and completed neuro checks up until 6:45 PM. The nurse provided the copy of the neurological assessment flow sheet. The last neuro check documented on the flow record was 6:45 PM. The rest of the flow sheet was blank, and Nurse # 1 could not find any other records to show the neuro checks had been completed per the facility's protocol schedule. Nurse # 1 did not know why the next nurse did not continue the checks per schedule. Nursing Assistant (NA) # 4 was interviewed on [DATE] at 3:40 PM. NA # 4 stated she had been present when Resident # 1 fell on [DATE]. NA # 4 stated she did not recall helping with the resident for the rest of Friday evening nor any bruises. On [DATE] there was one documented neurological check and assessment of Resident # 1's physical status for the entire day in the nursing progress notes. This was by Nurse # 2 on [DATE] at 12:25 AM. Nurse # 2 documented at this time that the resident's neurological checks were normal. There was no mention by Nurse # 2 of any of the bruising that had already been identified earlier by Nurse # 1 or if the bruising was extending. Nurse # 2 was interviewed on [DATE] at 9:16 AM. According to facility staffing sheets, Nurse # 2 had been assigned to care for Resident # 1 from 7:00 PM on [DATE] until 7:00 AM on [DATE] (Saturday). Nurse # 2 stated she recalled when she came to work on [DATE] at 7:00 PM that Resident # 1's right elbow was puffy and red but she did not recall other bruising. Nurse # 2 stated if she had done any neurological checks on the resident, she would have documented them. According to Nurse # 2, she recalled the ADON (assistant director of nursing) talking to her the Friday evening of [DATE] about Resident # 1, and they discussed that Resident # 1 was acting differently and wondering if she might have a urinary tract infection. The nurse did not recall exactly how the resident was acting differently. Interview with the assistant director of nursing (ADON) on [DATE] at 3:55 PM revealed she was responsible for following up on falls and accidents. The ADON stated she had checked on Resident # 1 on the morning of [DATE] because the resident had fallen on [DATE]. The ADON stated she had not noticed a bruise to Resident # 1's temple on the Friday morning of [DATE]. The ADON stated on Friday evening of [DATE] she went to check on the resident again, and noted she had a bruise to her temple which she had not seen earlier. According to the ADON, on Friday evening of [DATE] she saw the resident reach one time into the air as if she was reaching for something that was not there, and her pupils seemed to be small. The ADON stated she did not have a pen light in her pocket to do a neurological check, but she had spoken to Nurse # 1 and it was her understanding that Nurse # 1 was going to follow up with the physician. NA # 2 was interviewed on [DATE] at 11:10 AM. NA # 2 stated she had cared for Resident # 1 on the Friday of [DATE] from 3:00 PM until 7:00 PM. NA # 2 stated Resident # 2 reached for things in the air that were not there; as if she was hallucinating. NA # 2 stated this was different for Resident # 2 and she had told a nurse about it, but was not exactly sure which nurse it was. NA # 2 stated the resident always had some bruises on her arms, but she had a cap on her head on the evening of [DATE] and she did not recall a bruise on her head. NA # 3 was interviewed on [DATE] at 10:45 AM. NA # 3 stated she arrived to work at 7:00 PM on [DATE] and stayed in the TV room with residents from 7:00 PM to 9:00 PM. Interview with NA # 3 revealed Resident # 1 was in the TV room when she arrived at work, kept trying to repeatedly stand up, and elbowed NA # 3 when she tried to redirect the resident to sit down. NA # 3 stated the resident would scream, became angry, and did not want to open her mouth for the nurse to give medications. NA # 3 stated she had not assisted her to bed and thought NA # 2 had done so. NA # 5 was interviewed on [DATE] at 11:30 PM. Interview with NA # 5 revealed she recalled Resident # 1 slept Friday night during her shift which began at 11:00 PM on [DATE]. NA # 5 stated Resident # 1 normally did everything for herself and therefore she looked in on her, but did not awaken her and was not aware of bruises. Interview with Nurse # 3 on [DATE] at 12:25 PM revealed she had been on duty during the dayshift (7:00 AM to 7:00 PM) on [DATE]. According to Nurse # 3 she had not received a report when she reported to duty that Resident # 1 had been bruised or injured which would have alerted her to do neurological checks. Nurse # 3 stated she did not know the resident had been hurt until two dayshift NAs (NA # 6 and NA # 7) came to her and reported they had found bruises on her while giving her care. Nurse # 3 stated she immediately went to assess the resident and found her to have bruises on her back, legs, hip, and head. The nurse stated the bruises were red in color and she immediately called Nurse # 1, who was her supervisor. NA # 6 was interviewed on [DATE] at 4:35 PM. Interview with NA # 6 revealed she had routinely cared for Resident # 1, and the resident was usually very cooperative with care. NA # 6 stated prior to [DATE], she had last cared for her on [DATE]. NA # 6 stated on Saturday of [DATE], Resident # 1 was assigned to NA # 7 and she (NA # 6) had assisted with her. NA # 6 stated Resident # 1 would not eat nor drink for breakfast or lunch, and she refused care by swinging at them. NA # 6 stated the nurse also tried to feed the resident lunch and she refused. NA # 6 stated after lunch they finally convinced Resident # 1 to let them assist her with care, and when they pulled back her covers and clothing to provide care there were dark purple bruises on her arms, breast, back, thighs, and legs. NA # 6 stated the bruising seemed like it was everywhere. NA # 6 stated they immediately got the nurse. NA # 6 stated the bruising had not been present when she had last cared for Resident # 1 on [DATE]. NA # 7 was interviewed on [DATE] at 12:00 noon. Interview with NA # 7 revealed she had not received a report when she reported to duty on [DATE] that there was anything wrong with Resident # 1. NA # 7 stated Resident # 1 would not eat breakfast nor lunch and refused morning care. NA # 7 stated the nurse also tried to assist her for lunch, and the resident refused. NA # 7 stated after lunch she and NA # 6 went together to provide care, and when they pulled back the sheet there were bruises on both arms, both hips, on her legs, under her arm, on the side of her chest by her breast, and on her right head. Interview with NA # 7 revealed she had not seen the bruise on her head earlier because the resident wore a bonnet and when they were providing care the bonnet tipped backward which revealed the bruising. NA # 7 stated the head bruise was about the size of her hand. Interview with Nurse # 1 on [DATE] at 9:46 AM revealed Nurse # 3 had called her at home on [DATE] and told her Resident # 1 had bruises everywhere. Nurse # 1 stated it was her understanding that the main concern was the bruising and not a change in mental status. Nurse # 1 stated she called the physician and he asked if the resident had been falling. Nurse # 1 stated she told the physician the resident had fallen, and he therefore wanted her sent for a CT (Computerized tomography) scan at the hospital. The nurse stated it was arranged for Resident # 1 to go to the hospital out-patient department via way of a non-emergency transport service. According to the interview with the nurse she had not thought Resident # 1's condition necessitated emergency transport to the emergency room . Nurse # 1 also stated it was her understanding the hospital non-emergency out-patient department was open on Saturday afternoons. Therefore Nurse # 1 stated she contacted a non-emergency transport service to take the resident to out-patient. The nurse did not know how the resident ended up in the emergency room . Interview with the Director of Nursing (DON) on [DATE] at 5:25 PM revealed Nurse # 3 had called her at home and the main concern seemed to be the change in Resident # 1's mental status. The DON stated Nurse # 1 knew the resident much better than she did. The DON stated Nurse # 1 was planning to go in to work, and therefore she had Nurse # 1 communicate with the physician. The DON stated the extent of the bruising was not conveyed to her or she would have gone to the facility when she was called. According to the DON the resident left the facility around 5:15 PM on [DATE] by non-emergency transport, over 24 hours after Resident #1 fell on [DATE] at 3:43 PM. Interview with Resident # 1's responsible party (RP) on [DATE] at 10:10 AM revealed she had visited Resident # 1 on [DATE] and had noted bruises on her arm and hand. The RP stated she stayed with the resident until 7:00 PM, and after leaving she later received a phone call at 10:45 PM that the resident had fallen but was okay. The RP stated she had received another call on [DATE] at 2:45 PM from a staff member letting her know Resident # 1 had fallen. The RP stated she was told it was possible the resident could have hit her head on another resident's wheelchair. A review of the resident's [DATE] Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. Review of [DATE] emergency room (ER) medical records revealed the resident's bruising was extensive. The ER physician noted the resident had bruising on the right parietal area of her head; the right flank, the right elbow, the right hip, the right knee, and the left flank. He further noted she had critical [MEDICAL CONDITION] with a Hemoglobin level of 5.9 which the physician documented was likely secondary to a GI ([MEDICAL CONDITION]). The resident's stool was grossly guaiac positive for blood in the ER. A CT scan of the resident's head on [DATE] revealed she had a frontoparietal subdural hematoma measuring 5 millimeters (mm) in thickness. An interview with the resident's facility physician on [DATE] at 3:00 PM and again on [DATE] at 7:00 PM revealed the most likely reason for the resident's extensive bruising was her repeated falls. According to the physician the staff had notified him of the bruise to the temple on [DATE], but they had not notified him of any other changes on Friday ([DATE]), the extent of the bruising, or consulted with him regarding the Aspirin dosage. According to the physician any change in mental status in conjunction with a head injury would require an immedicate evaluation at the emergency room . Review of the resident's death certificate revealed she passed away on [DATE] at 6:30 PM. On the death certificate the physician had listed the cause of death as subdural hematoma and complications of a fall. 2. Resident # 2 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. Record review revealed the resident was [AGE] years of age and her last weight, documented on [DATE], was 68.5 pounds. Review of Resident # 2's quarterly minimum data set (MDS) assessment, dated [DATE], revealed the resident was severely cognitively impaired. The resident was assessed as needing extensive assistance with transfers, dressing, toileting, and hygiene. The resident was totally dependent on staff for her bathing. The resident's annual MDS assessment, dated [DATE], coded the resident as unchanged in these areas. Review of Resident # 2's current care plan, last updated on [DATE], revealed the resident could be resistive to care and combative. The care plan also noted the resident had potential for altered skin integrity. Some of the listed care plan interventions included: skin assessments quarterly and as needed, and to notify MD of changes in skin as needed. According to the care plan the resident required a total lift for transfers. A problem was also on the resident's current care plan which identified the resident had chronic pain. Staff were directed on the care plan to assess the resident for pain. Review of the record revealed a dayshift nursing progress note by Nurse # 5 on [DATE] (Friday) at 8:56 AM noting that the resident had a bruise to her right arm pit which measured 8 X 5 centimeters (cm.) This same nurse noted at 10:48 AM on [DATE] the following information: the area was bluish/red and was under her right arm and inner upper arm, the ADON (assistant director of nursing) was notified, a physician communication note was completed, and that the resident complained that the area hurt when it was touched. Review of Resident # 2's [DATE] MAR indicated [REDACTED]. Following the nursing progress note of [DATE] (Friday) at 10:48 AM there was no documentation the bruise existed, an assessment of the bruise, or the resident's physical status in the nursing progress notes until [DATE] (Wednesday) at 2:30 PM. At this time Nurse # 5 noted the resident was seen by the NP (nurse practitioner) for a hematoma to the right axilla. Review of the nurse practitioner's (NP's) [DATE] note revealed the resident had a chest bruise in addition to the right axilla (armpit) bruise. The NP ordered a CT (computerized tomography) of the chest and blood work. Review of the CT report revealed it was completed on [DATE] which corresponded to Thursday after the bruise had been found on Friday [DATE]. The findings revealed the resident had a large area of high density within the right pectoralis major muscle measuring 8.5 X 4.1 X 4. 6 cm (centimeter) most likely representing intramuscular hematoma. The CT also showed the extent of the resident's compression fractures. The CT report noted the resident had diffuse osteopenia; prior cement augmentation of two of the compression fractures; three of the compression fractures were documented as mild; five of the compression fractures were documented as moderate; and two of the compression fractures were documented as severe. On the same day on which the CT was done ([DATE]) showing the hematoma, Nurse # 6 completed a Bi-weekly check of the resident's skin on [DATE]. Nurse # 6 documented the resident had no current skin issues. There was no assessment of the bruising in the nurse progress notes for [DATE]. Interview with Nurse # 6 on [DATE] at 3:15 PM revealed she had not included bruising on Resident # 2's skin assessment check because she was assessing for and documented for areas of pressure sores and not bruises. Review of Resident # 2's [DATE] MAR indicated [REDACTED]. The assistant director of nursing (ADON) was interviewed on [DATE] at 1:06 PM. During the interview the ADON reviewed Resident # 2's record. According to the ADON, on a scheduled basis, the facility's computer system prompts the nurses to complete an assessment after a bruise or injury is entered into a resident's computerized medical record every twenty-four hours up until a seventy-two hour period post injury. The ADON stated if there are complications related to the bruise or injury then the assessments would be continued past the 72 hour period. In reviewing the record, the ADON stated Resident # 2's first 24 hour assessment following the identification of the bruise on [DATE] had not been completed by a nurse. According to the ADON the other assessments had not been done because the first 24 hour assessment had been missed and the nurses did not receive the prompting. The ADON did not know why the first 24 hour post injury assessment had been missed. Interview with the ADON revealed Resident # 2 had always required a mechanical lift for transfer since her admission. Interview with the ADON and a review of her investigation into the hematoma and bruising revealed some of the staff members had not been transferring and repositioning the resident correctly and the facility had concluded this potentially could have led to the resident's injury. Review of in-service materials following the incident revealed staff were to have her lean forward with her upper body in order that they guide her hips back in the wheelchair. Resident # 2 was observed on [DATE] at 3:55 PM as nursing assistant (NA) # 6 and NA # 9 transferred the resident from her wheelchair to bed using a mechanical lift in order to provide care. The resident was observed to appear extremely thin and frail. Her bones were very prominent. The NAs worked to try to position the mechanical lift sling back beneath the resident to complete the transfer, and it was observed that the resident was not cooperative. The resident was observed to complain of pain as they worked to get the sling beneath her and transfer her into the bed, and she was not leaning forward so that they could place the sling beneath her. NA # 6 stated the NA who had gotten the resident out of bed earlier should have left the sling beneath her so that they did not have to move the resident as much to get it positioned correctly. Upon completing the care the NAs again transferred the resident back from the bed to the wheelchair, and the resident complained once again she was hurting. According to these evening shift NAs the resident complained of pain anytime they transferred her. The NAs were asked if the nurse knew the resident hurt, and responded that the nurses did because the nurses heard her scream when she was transferred. Interview with the ADON on [DATE] at 3 PM revealed the facility used two different pain assessments. One assessment was intended for residents who were cognitively alert and could voice their pain level on a scale of ,[DATE]. The facility also had a pain assessment for the cognitively impaired, which required staff to assess if confused residents expressed pain in other ways such as striking out or pushing away. A review of Resident # 2's pain assessments with the ADON revealed since the hematoma had been identified on [DATE] the nurses had not completed a pain assessment using the assessment for a cognitively impaired resident. They had used a numeric evaluation of her pain. According to the ADON the nurses should have been using the pain assessment for cognitively impaired residents. The ADON stated the NAs would need to tell the nurses about how the resident tolerated her care so they could address her pain. Review of the resident's [DATE] MAR indicated [REDACTED]. This was confirmed with Nurse # 4 on [DATE] at 10:25 AM. The nurse stated the resident did not have anything routinely ordered for pain, but she could have Tylenol if she needed it. NA # 8 was assigned to care for Resident # 2 on [DATE] and she was interviewed at 10:30 AM on [DATE]. According to NA # 8, Resident # 2 would say she hurt sometimes, but then would say she was okay and therefore she concluded that the resident was okay and not in pain. On [DATE] at 5:15 PM, the administrator was informed of the immediate jeopardy. The facility provided a credible allegation of compliance on [DATE]. The allegation of compliance indicated: F 309 Assessments of Residents Credible Allegation of Compliance Resident # 1 has [DIAGNOSES REDACTED]. Upon admission, she was determined to be a risk for falls. Subsequently, she was care planned for a fall risk as to prevent injuries. Resident #1 sustained three separate falls on [DATE], [DATE] and [DATE] which resulted in bruising to multiple areas of her body. The fall on [DATE] was unwitnessed in the dayroom at approximately 3:45 pm. Resident #1 was noted to be on one knee with the other foot flat on the floor. Her right arm was on a chair and her left arm was on her wheelchair. Resident was observed on the floor by the Unit Manager and assisted to a chair in the dayroom and a head to toe assessment was no documented in the clinical record. The ADON observed a bruise to resident's forehead and spoke with the Unit Manager regarding the observation. The Unit Manager observed the area where the bruise was located on resident #1's forehead, but did not complete a head to toe assessment. The bruise to the forehead was not completely assessed by the UM and the extent could not be determined due to the UM not removing the cap from resident #1's head. The UM stated to DON that resident #1 didn't let UM remove her night cap. The Unit Manager failed to complete a head to toe assessment immediately following the observation of the bruise to the resident's forehead. UM notified the attending physician regarding the fall and bruise to head. MD was notified of the bruise to resident #1's forehead and ordered neuro checks at that time. Neuro checks were started following the MD order, but did not continue based on the facility's policy. On [DATE], resident #1 refused breakfast. She also refused to get out of bed or allow personal care offered by staff. She refused lunch, pushing staff away. Thru encouragement, staff were able to assist resident with ADL care and noted bruises on her body. At this time she was alert but not speaking. The nurse was informed and contacted the DON at 3:25 pm regarding the refusal of meals, refusal of care and multiple bruising. An order was obtained to send resident #1 to hospital for head CT. Resident was transported to hospital via wheelchair at 5:15pm. Resident was later transferred to another hospital and admitted with subdural hematoma and GI bleed. Resident later expired at hospital. The nurse failed to complete a thorough head to toe assessment at time of fall per policy. The nurse also (TRUNCATED)

Based on observation, record review, staff interviews and family interview the facility failed to evaluate the adequacy of supervision for three (Resident # 1, Resident # 2, and Resident # 3) of three sampled residents who had experienced accidents in their secured unit; two (Residents # 1 and # 2) of whom had experienced hematomas. Immediate jeopardy began on [DATE] when Resident # 1 experienced her third fall within a four day period and was found to have bruising to her head. On [DATE] Resident # 1 was identified in an emergency room to have a subdural hematoma and bruising on multiple parts of her body. The resident was also receiving 325 milligrams of aspirin daily without any consultation from the staff to the physician in regards to whether the aspirin could be increasing her chance for injuries. The administrator and the Director of Nursing were not aware of the extent of the bruising until an outside entity (the county Department of Social Services) talked to them three days following the resident's discharge. The direct care staff had failed to document and convey the extent of the resident's injuries in order that administrative staff assess for any corrective measures which would need to be taken in regards to supervision for residents on their secured unit where Resident # 1 had resided. The immediate jeopardy was removed on [DATE] when the facility provided an acceptable credible allegation of compliance. The facility will remain out of compliance at a scope and severity level of D (not actual harm with the potential for more than minimal harm that is not immediate jeopardy) for the facility to complete staff training and to ensure monitoring systems put in place are effective. The facility is also out of compliance at the D scope and severity for Resident # 2 and Resident # 3. The findings included: 1. Record review revealed Resident # 1 resided at the facility from [DATE] until [DATE]. According to the medical record the resident had the following Diagnoses: [REDACTED]. Review of physician progress notes [REDACTED]. Review of Resident # 1's admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively impaired, needed extensive assistance from one staff member for bed mobility, transfers, dressing, toileting, hygiene, and bathing, and needed limited assistance for ambulation. This MDS assessment also coded the resident as having no falls or fractures within the last 6 months prior to her facility admission. Review of Resident # 1's care plan, dated [DATE], revealed the staff identified Resident # 1 was at risk for falls. The facility's goal for the resident was that she would not sustain injury due to a fall. Listed interventions added on [DATE] were: ambulation devices as needed; assess cognitive status, evaluate for unsteady gait, instruct on appropriate safety measures; maintain a safe environment, proper nonskid foot wear; therapy to evaluate and treat as ordered. On [DATE] anti rollback wheelchair brakes was added to the care plan interventions. On [DATE] assess for fatigue and provide rest periods PRN (as needed) and assist with transfers and ambulation was added to the care plan interventions. On [DATE] offer and assist resident to bed between 7 PM to 8 PM was added to the care plan interventions. Review of nursing notes revealed Resident # 1 was transferred to the secured facility unit on [DATE] due to exit seeking behavior and resided there until her discharge on [DATE]. Review of a nursing note dated [DATE] revealed Resident # 1 sustained a fall on [DATE] at 6:00 AM. The note indicated that Resident # 1 slid out of bed while getting into her wheelchair, and landed on her buttocks with her back against the bed. An additional nursing note dated [DATE] at 7:18 AM, revealed that the resident had a bruise to her right flank but had no complaint of pain or discomfort. Both notes were signed by Nurse #2. Review of the nursing notes revealed that following the fall of [DATE], there was no documentation that Resident # 1 sustained further falls until the date of [DATE]. A nursing note dated [DATE] (Tuesday) at 5:42 PM by Nurse # 3 indicated Resident # 1 was observed sitting on the floor on her buttocks next to her bed. The nurse noted the resident was assessed for injuries and none were noted. According to a nursing noted dated [DATE] (Thursday) at 7:55 PM Resident # 1 sustained another fall. The nurse noted Resident # 1 was sitting on the edge of her wheelchair and slid out of the chair onto the floor landing on her buttocks. The note was signed by Nurse #2. A nursing note dated [DATE] (Friday) at 6:56 AM by Nurse # 2 documented the resident had a hematoma noted to the right elbow. According to staffing sheets, Nurse # 2 was assigned to care for Resident # 1 during the shift which began at 7 PM on [DATE] (Thursday) until 7 AM on [DATE] (Friday). Nurse # 2 was interviewed on [DATE] at 9:16 AM. Nurse # 2 stated she recalled Resident # 1 had been in the TV room (activity room) when she sustained the fall on [DATE] (Thursday) at 7:55 PM. Nurse # 2 stated a nurse aide had been with the resident, but could not get to her in time to prevent the fall. Nurse # 2 stated she recalled she (Nurse # 2) had been in the hall outside of the TV room when the incident occurred and she did not recall the resident being hurt when she checked her right after the fall. According to Nurse # 2, she thought there had been three NAs on the unit when Resident # 1 had fallen on Thursday [DATE] and she could not recall what all was transpiring that evening or if there had been enough staff to supervise the residents. According to Nurse # 2 sometimes several residents could start displaying behaviors at the same time on the secured unit and therefore those residents on the unit would need more staff attention. The nurse stated on days like that it seemed as if they could use five or six staff members. Nurse # 2 stated, It just depends on the day if we have enough staff. NA # 4 was interviewed on [DATE] at 3:40 PM. Interview with NA # 4 revealed she had been present on [DATE] (Thursday) when Resident # 1 fell at 7:55 PM. NA # 4 stated she was not able to get to Resident # 1 in time to stop the fall. NA # 4 stated the resident had not appeared to be hurt. Interview with NA # 4 revealed she could not recall exactly what she was doing at the time of the incident and only that she was present and could not get to the resident before the fall. Resident # 1's responsible party (RP) was interviewed on [DATE] at 10:10 AM. According to the RP she had concerns related to the supervision on Resident # 1's unit. The RP stated she had visited Resident # 1 on the evening of [DATE] and she had arrived to find the resident in a man's sleeveless t-shirt which did not belong to the resident. The RP stated she noticed the resident had a bruise to her arm and her left hand. The RP stated she was concerned that evening at 5:12 PM when she saw a resident's food tray had been spilled in the TV/activity room and the tray's contents had extended from the activity room into the hall. The RP stated it took the staff an hour to clean it from the floor because it did not appear as if a housekeeper was available. The RP stated she stayed with Resident # 1 until 7 PM on [DATE] before leaving, and at 10:45 PM on [DATE] she received a phone call from the facility that Resident # 1 had fallen but did not appear to be hurt. Nurse # 1 was interviewed on [DATE] at 2 PM and [DATE] at 9:46 AM. Nurse # 1 stated the resident had fallen on [DATE] (Friday) at 3:43 PM but the incident had been logged as occurring on [DATE] in the nursing notes. The nurse pointed to an entry in the nursing notes which was dated [DATE] (Saturday) at 5:12 PM. This Saturday entry revealed a fall occurred on [DATE] (Friday) at 3:43 PM. The entry read, Writer called to TV room Resident observed with her right knee on the floor and her right elbow resting on an arm-chair. Resident assessed for injuries; no injuries noted. Resident had old bruising to her arms and the right temporal area. Resident had no complaints of pain. MD in facility, notified of unwitnessed fall. Writer attempted to contact RP (Name of RP) to inform of unwitnessed fall. The note was signed by Nurse #1. Interview with Nurse # 1 on [DATE] at 2:00 PM and [DATE] at 9:46 AM revealed she had been the nurse to respond to the fall on [DATE] at 3:43 PM. Nurse # 1 stated NA # 4 had been in attendance with Resident # 1 in the TV room, but was caring for another resident at the time and had not seen Resident # 1 fall. Interview with Nurse # 1 revealed she had checked Resident # 1 in the TV room, but did not take her back to her room and look at her entire body at the time of the incident. Nurse # 1 stated the resident had some yellow bruising on her arms and a purple bruise to the right temple area at the time of her assessment. NA # 4 was interviewed on [DATE] at 3:40 PM. According to NA # 4 she had been present in the TV room when Resident # 1 had fallen on Thursday of [DATE] at 3:43 PM. According to NA # 4 she had her back turned while attending to another resident who needed her attention, and when she turned back around she saw Resident # 1 was on her knee on the floor. NA # 4 stated she did not recall helping with the resident for the rest of Friday evening nor did she see any bruises. According to staffing sheets Nurse # 2 was assigned to care for Resident # 1 for the shift which began at 7 PM on [DATE] and ended at 7 AM on [DATE]. According to an interview with Nurse # 2 on [DATE] at 9:16 AM, she recalled the ADON (assistant director of nursing) talking to her the Friday evening of [DATE] about Resident # 1, and they discussed that Resident # 1 was acting differently and were wondering if she might have a urinary tract infection. According to Nurse # 2 it was difficult to remember how the resident was exactly acting differently and the details of any falls she had been experiencing because sometimes things got hectic on the unit where Resident # 1 resided. The nurse said sometimes things run together. According to Nurse # 2 she thought she recalled calling Resident # 1's responsible party and telling her the resident may have hit the side of her face but she did not remember the day on which she did this or the reason why she told her this. Review of the nursing notes revealed no entry by Nurse # 2 documenting an incident where the resident may have hit her head or that she called the responsible party and informed her of this. Interview with the ADON on [DATE] at 3:55 PM revealed she was responsible for following up on falls and accidents. The ADON stated she had checked on Resident # 1 on the morning of [DATE] (Friday) because the resident had fallen on [DATE] (Thursday). The ADON stated she had not noticed a bruise to Resident # 1's temple on the Friday morning of [DATE]. The ADON stated on Friday evening of [DATE] she went to check on the resident again, and noted she had a bruise to her temple which she had not seen earlier. According to the ADON on Friday evening of [DATE] she saw the resident reach one time into the air as if she was reaching for something that was not there, and her pupils seemed to be small. According to the ADON she had spoken to Nurse # 1 about this and it was her understanding Nurse # 1 was going to follow up with the physician. According to the ADON she had gone on her scheduled vacation following Friday [DATE]. On [DATE] administrative staff provided a copy of the facility schedule and had highlighted the NAs who had been assigned to care for Resident # 1 on [DATE] and [DATE]. According to this schedule, NA # 2's name was highlighted as the NA who had been assigned to care for Resident # 1 on the 3 PM to 11 PM shift on [DATE]. NA # 2 was interviewed on [DATE] at 11:10 AM. Interview with NA # 2 revealed she recalled only being assigned to Resident # 1 from 3 PM to 7 PM. NA # 2 stated she recalled only two NAs on the unit during that time and she had three residents who were at risk for falls trying to stand up, and Resident # 1 was one of them. According to NA # 2 she also noticed that Resident # 1 was picking at things in the air that were not there as if she was hallucinating and she had spoken to a nurse about it. She did not recall the exact nurse with whom she had spoken. NA # 2 stated she had not assisted Resident # 1 to bed since she was not assigned to her after 7 PM, and she thought NA # 3 had done so and she did not know what time Resident # 2 had gone to bed. NA # 3 was interviewed on [DATE] at 10:45 AM. NA # 3 stated she arrived to work at 7 PM on [DATE] (Friday) and stayed in the TV/activity room with residents from 7 PM to 9 PM. Interview with NA # 3 revealed Resident # 1 was in the TV room when she arrived at work, kept trying to repeatedly stand up, and elbowed NA # 3 when she tried to redirect the resident to sit down. NA # 3 stated the resident screamed and became angry. NA # 3 stated she had not assisted her to bed and thought NA # 2 had done so. NA # 3 did not know what time Resident # 1 had been assisted to bed. Resident # 1's RP was interviewed on [DATE] at 10:10 AM. The RP stated she had received two phone calls on [DATE] from staff letting her know that Resident # 1 had fallen. The RP stated her phone kept a log of when the phone calls were received and they were on [DATE] at 2:45 PM and [DATE] at 8:45 PM. The RP stated when she was called at 2:45 PM the staff member told her that Resident # 1 had fallen from her chair and had possibly hit her head on another person's wheelchair. The RP stated she was called again on [DATE] at 8:45 PM and was told Resident # 1 was found in front of her roommate's chair on the floor. The RP stated she asked if the resident was okay and was told she was just sitting there and they put her back to bed. There was no documentation in the nursing notes that the resident had sustained a fall on [DATE] at 8:45 PM. According to the staffing sheets provided by the facility, NA # 2 would have been assigned for her care at this time, but the interview on [DATE] at 11:10 AM with NA # 2 revealed she did not think Resident # 1 had been assigned to her after 7 PM. NA # 5 was interviewed on [DATE] at 11:30 PM. Interview with NA # 5 revealed she recalled Resident # 1 slept Friday night during her shift which began at 11:00 PM on [DATE]. NA # 5 stated Resident # 1 normally did everything for herself and therefore she looked in on her, but did not awaken her and was not aware of bruises. Interview with Nurse # 3 on [DATE] at 12:25 PM revealed she had been on duty during the dayshift on [DATE] (Saturday). Nurse # 3 stated she had not received a report that Resident #1 had been bruised or injured when she reported to duty at 7:00 AM on [DATE]. Nurse # 3 stated she did not know the resident had been hurt until two dayshift NAs (NA # 6 and NA # 7) came to her and reported they had found bruises on her while giving her care. Nurse # 3 stated she immediately went to assess the resident and found her to have bruises on her back, legs, hip, and head. The nurse stated the bruises were red in color and she immediately called Nurse # 1, who was her supervisor. NA # 6 was interviewed on [DATE] at 4:35 PM. Interview with NA # 6 revealed she had routinely cared for Resident # 1, and the resident was usually very cooperative with care. NA # 6 stated prior to [DATE] (Saturday), she had last cared for her on [DATE] (Tuesday). NA # 6 stated on Saturday of [DATE], she had assisted NA #7 with Resident #1. NA # 6 stated Resident # 1 would not eat nor drink for breakfast or lunch, and she refused care by swinging at them. NA # 6 stated after lunch they finally convinced Resident # 1 to let them assist her with care, and when they pulled back her covers and clothing to provide care there were dark purple bruises on her arms, breast, back, thighs, and legs. NA # 6 stated the bruising seemed like it was everywhere. NA # 6 stated they immediately got the nurse. NA # 6 stated the bruising had not been present when she had last cared for Resident # 1 on [DATE] (Tuesday). Interview with NA # 6 revealed no administrative staff member had spoken to her as of [DATE] regarding the bruises she had found and the events of the resident's day. NA # 7 was interviewed on [DATE] at 12 noon. Interview with NA # 7 revealed she had not received a report when she reported to duty on [DATE] that there was anything wrong with Resident # 1. NA # 7 stated Resident # 1 would not eat breakfast or lunch and refused morning care. NA # 7 stated the nurse also tried to assist her for lunch, and the resident refused. NA # 7 stated after lunch she and NA # 6 went together to provide care, and when they pulled back the sheet there were bruises on both arms, both hips, on her legs, under her arm, on the side of her chest by her breast, and on her right head. Interview with NA # 7 revealed she had not seen the bruise on her head earlier because the resident wore a bonnet and when they were providing care the bonnet tipped backward which revealed the bruising. NA # 7 stated the head bruise was about the size of her hand. Review of the [DATE] nursing notes revealed no documentation regarding the bruising that was found by NA # 6; NA # 7 and Nurse # 3 on [DATE]. Interview with Nurse # 1 on [DATE] at 9:46 AM revealed Nurse # 3 had called her at home on [DATE] and told her Resident # 1 had bruises everywhere. Nurse # 1 stated it was her understanding that the main concern was the bruising and not a change in mental status. Nurse # 1 stated she (Nurse # 1) called the physician and he asked if the resident had been falling. Nurse # 1 stated she told the physician the resident had fallen, and he therefore wanted her sent for a CT scan at the hospital. The nurse stated it was arranged for Resident # 1 to go to the hospital out- patient department via way of a non-emergency transport service. There was no notation in the nursing notes when the resident was transported out of the facility. The DON provided documentation that she was called on [DATE] by the non-emergency transport service at 5:15 PM in order to let her know they were in the facility and needed verification of Resident # 1's room number to pick her up for transport. Interview with the RP on [DATE] at 10:10 AM revealed she had received a voice mail on [DATE] at 4:50 PM from the facility asking that she call. The RP stated she returned the phone call at 6 PM and was told they were sending the resident to the hospital because she had slept all day and would not eat. According to the RP, when she arrived at the hospital she found the resident disoriented and with extensive bruising. According to the RP the resident was diagnosed with [REDACTED]. A review of the resident's [DATE] MAR (medication administration record) revealed she had received her prescribed dosage of 325 milligrams of Aspirin daily from [DATE] through [DATE]. There was no indication in the nursing notes the nurses had consulted with the physician regarding if the Aspirin should be held when the resident began falling in order to avoid further injuries from her falls. The MAR was reviewed with the ADON on [DATE] at 5:30 PM and it was confirmed with the ADON the MAR showed no documentation the Aspirin was held. Review of [DATE] emergency room (ER) medical records revealed the resident's bruising was extensive. The ER physician noted the resident had bruising on the right parietal area of her head; the right flank, the right elbow, the right hip, the right knee, and the left flank. He further noted she had critical anemia with a Hemoglobin level of 5.9 which the physician documented was likely secondary to a GI (gastrointestinal bleed). The resident's stool was grossly guaiac positive for blood in the ER. A CT scan of the resident's head on [DATE] revealed she had a frontoparietal subdural hematoma measuring 5 mm (millimeters) in thickness. An interview with the resident's facility physician on [DATE] at 7:00 PM revealed the most likely reason for the resident's extensive bruising was her repeated falls. According to the physician the staff had notified him of the bruise to the temple on [DATE], but they had not notified him of any other changes on Friday ([DATE]), the extent of the bruising, or consulted with him regarding the Aspirin dosage. Interview with the DON (Director of Nursing) on [DATE] at 5:25 PM and again on [DATE] at 11:40 AM revealed Nurse # 3 had called her at home on [DATE] (Saturday) and the main concern seemed to be the change in Resident # 1's mental status. The DON stated Nurse # 1 was planning to go in to work, and therefore she had Nurse # 1 communicate with the physician. According to the DON the staff had not conveyed to her the extent of the bruising or she would have gone to the facility on Saturday when she was called to look at the resident. According to the DON she had not been made aware there were concerns related to the resident being injured to the extent she was until an outside entity (the County Department of Social Services) spoke to her on Tuesday ([DATE]) about concerns. According to the DON that was the first date she started to get statements from her staff to determine what had happened regarding the resident's care and falls. The DON was not aware of any report that the resident had fallen a second time on [DATE] at 8:45 PM. Interview with the administrator on [DATE] at 1:00 PM revealed he relied on his clinical staff to alert him to clinical problems, and the ADON routinely did follow up to falls and injuries. Interview with the administrator revealed the ADON had been on vacation during the current week which began on [DATE]. According to the administrator the staff had not alerted him to the extent of the bruising which was found on Resident # 1 before she left the faciity on [DATE] in order that he follow up regarding the supervision she had received. According to an interview with the ADON on [DATE] at 3 PM, a staff member is required to stay within the secured unit's TV room/activity room anytime there is a resident within the room so that there can be supervision. According to the ADON there is a schedule for the NAs that is based upon their assigned room numbers. According to the ADON each NA is assigned an hour in the TV room/Activity room. The assigned hour corresponds to the NA room assignments. The ADON stated there are generally three NA room assignments: the back of the 600 hall; the split, and the back of the 700 hall. The ADON provided an example of the dayroom Activity Room Schedule for first shift. According to the schedule, a NA who is assigned to care for residents on the back of 600 is assigned to be in the TV/Activity room from 9:00 AM to 10:00 AM and from 12 noon to 1:00 PM. According to the schedule the NA assigned to care for residents on the split assignment was assigned to be in the TV/Activity room from 10:00 AM to 11:00 AM and again from 1:00 PM to 2:00 PM, and the NA who was assigned to care for the residents on the back of 700 was assigned to be in the TV/Activity room from 11:00 AM to 12 noon and again from 2:00 PM to 3:00 PM. There was no documentation in the facility's investigation of Resident # 1's falls showing they had reviewed the responsibilities of the NAs who were assigned for supervision to Resident # 1 when she was experiencing the falls. On [DATE] at 5:15 PM, the administrator was informed of the immediate jeopardy. The facility provided a credible allegation of compliance on [DATE]. The allegation of compliance indicated: Resident # 1 has [DIAGNOSES REDACTED]. Upon admission, she was determined to be a risk for falls. Subsequently, she was care planned for a fall risk as to prevent injuries. Resident #1 sustained three separate falls on [DATE], [DATE] and [DATE] which resulted in bruising to multiple areas of her body. The fall on [DATE] was unwitnessed in the dayroom at approximately 3:45 pm. Resident #1 was noted to be on one knee with the other foot flat on the floor. Her right arm was on a chair and her left arm was on her wheelchair. Resident was observed on the floor by the Unit Manager and assisted to a chair in the dayroom and a head to toe assessment was not documented in the clinical record. The ADON observed a bruise to resident's forehead and spoke with the Unit Manager regarding the observation. The Unit Manager observed the area where the bruise was located on the forehead, but did not complete a head to toe assessment. UM stated to DON that resident didn't let UM remove her night cap. UM notified the attending physician regarding the fall and bruise to head. MD was notified of the bruise to the forehead and ordered neuro checks at that time. On [DATE], resident #1 refused breakfast. She also refused to get out of bed or allow personal care offered by staff. She refused lunch, pushing staff away. Thru encouragement, staff were able to assist resident with ADL care and noted bruises on her body. At this time she was alert but not speaking. The nurse was informed and contacted the DON at 3:25 pm regarding the refusal of meals, refusal of care and multiple bruising. An order was obtained to send resident #1 to hospital for head CT. Resident was transported to (hospital) via wheelchair at 5:15pm. Resident was later transferred to (hospital) and admitted with subdural hematoma and GI bleed. Resident later expired at hospital. The nurse failed to complete a thorough head to toe assessment at time of fall per policy. For the resident affected: All residents who sustained a fall since [DATE] were assessed by DON/Designee for a head to toe assessment and appropriate MD notification by use of an audit tool. The assessment audit included a review of the medical record to ensure that all measures were in place to meet the current needs of the affected residents. A review of the medical record was conducted by the DON to review appropriate interventions and assessments subsequent to each fall. Based on findings, staff education was provided by DON. Plan to identify other residents who are at risk for the deficient practice Other residents who are at risk for deficient practice will be identified by an assessment audit that will be conducted on [DATE] for all current residents that have had falls since [DATE]st. The audit revealed that there 17 total falls that were comprised of 12 residents with three of those residents having repeated falls. Assessment audits will be reviewed by Director of Nursing or delegated persons for compliance. Education will be provided on [DATE]. Surveyor identified another resident that had been affected by the failure to conduct assessments according to policy. Resident (L.S.) sustained a bruise on [DATE] to the right armpit. The MD and Responsible Party were both notified on that date and a head to toe assessment was completed at that time. There was no further assessment to determine a change in identified area until [DATE]. No further documentation was noted until [DATE] when the resident was seen by the Nurse Practitioner. At that time a CT of chest without contrast, Right shoulder X-Ray and a CBC were ordered in which results revealed an intermuscular hematoma. It was determined that no head to toe assessment was conducted for the resident. Action Taken to Fix the Problem Re-education to all nurses and CNAs began on [DATE]. All Nursing staff to include licensed nurses and CNAs were educated on [DATE] either via phone or in person regarding the following: Fall Management, which includes Safe Handling of residents regarding transfers, Head to Toe Assessments, Abuse/Neglect policy and procedure, and Neurological Check Policy and Procedure. All CNAs have received education regarding reporting any change in condition to nurse through the use of a Stop and Watch Tool. All employees who received education via phone will receive written material upon returning to work. The facility alleged IJ removal on [DATE]. The credible allegation was verified on [DATE] at 6:04 PM. Nurse #1 no longer worked at the facility and could not be reached by phone for interview. A sample of current resident records were reviewed for falls, injury and staff action. The Assistant Director of Nursing was interviewed on [DATE] at 5:07 PM. She provided the Fall Management Protocol, Assessment and Neurological Check policy inservice details. On [DATE] from 2:02 PM through 5:42 PM, random nursing staff as well as Nursing Assistants involved with Resident #1 following the falls, were able to articulate the steps of the Stop and Watch Tool for notification, assessment and reporting. Staff members interviewed were able to describe education received regarding falls, assessment, the policy regarding neurological checks, physician notification, neglect and how to respond to changes in condition. The facility was able to provide evidence that they had completed an audit of the residents and inserviced all staff on [DATE]. Other residents in the facility were observed and there were no concerns. The immediate jeopardy was removed on [DATE]. 2. Record review revealed Resident # 2 was admitted to the facility on [DATE]. Record review revealed the resident had [DIAGNOSES REDACTED]. Review of the resident's annual Minimum Data Set (MDS) assessment, dated [DATE], revealed the resident had a BIMS (brief interview for mental status) score of 0 which indicated she did not answer any questions correctly on her cognitive ability assessment. The resident was assessed as needing extensive assistance with transfers, dressing, toileting, and hygiene. The resident was totally dependent on staff for her bathing. Review of the resident's care plan revealed the resident could be resistive to care. A problem was also listed on the resident's care plan dated [DATE] which noted she had the potential for altered skin integrity. Some of the listed care plan interventions included: skin assessments quarterly and as needed; assist resident to wear bilateral geri-legs at all times; and notify MD of changes in skin as needed. According to the care plan the resident required a total lift for transfers. Review of a nursing note by Nurse # 5 on [DATE] (Friday) at 8:56 AM revealed the resident had a bruise to her right arm pit which measured 8 X 5 centimeters (cm). Another nurse's note dated [DATE] at 10:48 AM revealed the area was bluish/red and was under her right arm and inner upper arm; the ADON (assistant director of nursing) was notified; a physician communication note was completed; and that the resident complained that the area hurt when it was touched. The note was signed by Nurse #5. Following the nursing entry of [DATE] (Friday) at 10:48 AM there was no documentation the bruise existed, an assessment of the bruise, or the resident's physical status in the nursing notes until [DATE] (Wednesday) at 2:30 PM. A nurse's note dated [DATE] at 2:30 PM revealed the resident was seen by the (nurse practitioner) NP for a hematoma to the right axilla. According to the note the NP ordered a CT of the chest, x-ray of the shoulder, and a Complete Blood Count for Resident #2. The note was signed by Nurse #5. A NP's (nurse practitioner's) note on [DATE] revealed staff(TRUNCATED)

Based on observation, record review and staff interviews, the facility did not monitor 1 of 2 cognitively impaired sampled residents (Resident #1) who exhibited exit seeking behaviors and exited the facility without staff knowledge and was found in the parking lot unattended placing Resident #1 at risk for serious bodily injury. Findings included: Immediate Jeopardy for Resident #1 began on 03/28/16 when Resident #1 exited the facility by going out of the 200 hall exit door into the parking lot unattended. Immediate Jeopardy was removed on 04/15/16 at 5:40 PM when the facility provided and implemented an acceptable credible allegation of compliance. The facility will remain out of compliance at a scope and severity of no actual harm with potential for more than minimal harm that is not immediate jeopardy (D). The facility was in the process of full implementation of corrective action at that time. Resident #1 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. An elopement assessment of 03/10/16 noted Resident #1 received a score of 8 which according to the document a score greater than 5 placed him at high risk for elopement. The assessment noted Resident #1 was mobile and cognitively impaired with poor decision making skills. It also noted Resident #1 verbalized statements such as wanting to go home or go on a trip or going to meet someone. Resident #1's care plan, dated 03/11/16, identified him as being at risk for falls related to dementia and impaired safety awareness. On 03/14/16, the care plan was revised to include being at risk for injury related to elopement and/or wandering and had impaired cognition. He was unaware of safety needs. The goal noted he would not elope from the facility through the next review. Interventions included: . assess risk factors per routine . family conference to discuss attempts to leave per routine . follow facility elopement procedures . involve in activities . monitor and report changes in behavior . re-direct as needed . wanderguard A physician's orders [REDACTED].#1. A progress note of 03/15/16 at 3:48 PM documented Resident #1 had been agitated throughout the shift and Ativan was given with effectiveness noted. It also documented he ambulated but his gait was unsteady. The Admission Minimum Data Set (MDS) assessment of 03/17/16 noted he was severely impaired in decision making and exhibited no behaviors and no wandering. The resident needed extensive assistance with transfers but needed limited assistance from staff for walking in his room. He was independent with locomotion on and off the unit. According to the care area assessment for this MDS, he triggered in several areas which included cognitive loss. A physician's orders [REDACTED].#1 was to have a wander guard to his ankle and it was to be checked for placement/functioning every shift. The electronic medication administration record (eMAR) of March 2016 noted Resident #1's wanderguard was checked for placement/functioning daily at 6:00 AM, 2:00 PM and 10:00 PM. An electronic medication administration (eMAR) note of 03/20/16 at 12:44 PM indicated Resident #1 was given Lorazepam 1 milligram (mg) for agitation due to he was looking for his keys and was asking if someone had stolen his car. He was redirected several times. There was a wanderguard in place to his ankle. A progress note written by Nurse #2 of 03/22/16 at 10:48 AM indicated Resident #1 had delusions and thought he was applying for a job. Nurse #2 was interviewed on 04/14/16 at 5:10 PM. She stated Resident #1 liked to sit at the nurse's station and would say he wanted to go home. She reported at times he was capable of walking but used his wheelchair most of the time to self-propel about the hall. Resident #1 was encouraged to go to activities and would attend. Nurse #2 stated he needed re-orientation often and would become more confused in the evenings. She stated she never observed Resident #1 try to get out and did not observe him sitting near the 200 hall exit door. She stated he would spend time in his room talking with his roommate. Nurse #2 stated she was surprised when she heard that Resident #1 had gotten out of the facility as she had never seen any exit seeking behaviors from Resident #1. Nurse #2 stated the exit door should have locked when he approached it wearing a wanderguard. She reported staff were monitoring him and did not know how he got out without staff seeing him. A progress note of 03/22/16 at 10:48 PM written by Nurse #3 documented Resident #1 was disoriented with confusion noted and wandered. A progress note of 03/23/16 at 10:48 PM written by Nurse #3 documented Resident #1 was disoriented. It noted he wandered and was easily re-directed. A nursing note of 03/24/16 at 4:50 AM written by Nurse #3 documented Resident #1 had been ambulating in the hallway seeking exits stating How the h--- do you get out of here? It noted he was walking from door to door attempting to open them. Resident #1 was resistive to re-direction and stated You can't make me stay here. Resident #1 was verbally abusive and made threats of physical harm towards staff. He was re-directed to his room without incident. The 14 Day MDS assessment of 03/24/16 noted no change in Resident #1's cognition but he exhibited verbal behavior symptoms towards others for 1 to 3 days, he rejected care for 1 to 3 days and was wandering 1 to 3 days. A skilled nursing note of 03/25/16 at 10:48 PM from Nurse #3 documented Resident #1 was disoriented and anxious looking for a way out stating he had to go. It documented he was wandering and looking for a way out but was easily re-directed. A skilled nursing note of 03/27/16 at 10:48 AM from Nurse #3 noted Resident #1 was anxious and wanted to go home. A skilled nursing note of 03/27/16 at 10:48 PM from Nurse #3 noted Resident #1 wandered and attempted to find exits. Nurse #3 was interviewed via telephone on 04/14/16 at 8:53 PM. He reported Resident #1 as being polite and ambulatory and used a wheelchair. He reported Resident#1 had frequent wandering and exit seeking behaviors on almost a daily basis. He reported Resident #1 would go from door to door trying to push the door open. Nurse #3 stated he always stayed on the A hall (a very long hall which extended from one end of the building to the other and included the 100 and 200 halls, both of which had an exit door). He stated the 200 hall exit door (located on the A hall) was Resident #1's favorite because it was close to his room. He stated there was another exit door at the end of the 100 hall (located on the A hall) and he had observed Resident #1 going to that door and would stand to push on it. He reported Resident #1 stated frequently that he wanted to go home. Nurse #3 stated staff monitored him closely and would go to the exit doors on the A hall and attempt to re-direct him away from the doors. He stated Resident #1 was usually easily re-directed and might curse at staff but would move. Nurse #3 reported everyone in the building was aware of his exit seeking behaviors but he had not personally reported them to management because all staff were aware. He stated staff that worked on the A hall knew Resident #1 roamed on the halls. Nurse #3 stated he felt Resident #1 was sun-downing because his exit seeking started almost the same time every night on the nights that he wandered. He commented that he had witnessed Resident #1 sitting in the foyer near the 200 hall exit door and just watch people come and go. He stated if someone went out of the 200 hall door, Resident #1 would ask them to let him out. Nurse #3 stated he really never thought Resident #1 would get out but felt Resident #1 was capable of it. He also stated Resident #1 was wearing a wanderguard that was functioning properly but if Resident #1 had the right code for the exit door keypad and if Resident #1 entered the right code then the door would open. When questioned about the night of 03/28/16, Nurse #3 stated he was working on the A hall and Resident #1 had told him that night he wanted to go outside but wasn't sure exactly when. Nurse #3 could not provide Resident #1's exact location prior to the incident. When questioned if staff had taken Resident #1 out under supervision, he responded that they had not. Nurse #3 stated he should have communicated Resident #1's exit seeking behaviors to the Director of Nurses (DON). Nurse #3 was interviewed again via telephone on 04/15/16 at 9:18 AM. He stated Resident #1 had exit seeking behaviors since the day he was admitted . He stated Resident #1 received physical therapy and as he became more mobile his behaviors increased. Nurse #3 stated staff had been out to smoke that night (03/28/16) but didn't remember what time. He added that he went out to smoke and thought he had been back in about 5 minutes prior to dietary staff calling to report Resident #1 was out of the building. Nurse #3 stated he was told that Resident #1 was sitting on the bench underneath the canopy just outside of the exit door when staff retrieved him. He was not aware that Resident #1 was found walking in the parking lot. A nursing note of 03/28/16 at 9:09 PM from Nurse #1 documented that around 7:40 PM Resident #1 was observed by kitchen staff (KS #1) coming out of the door in the smoking area. It noted that kitchen staff (KS #2) contacted the hall and staff had returned him to the inside of the building. His wanderguard was checked and was functioning properly. Nurse #1 noted the maintenance supervisor was contacted and came to the building to inspect the doors for malfunction. It noted all doors to be functioning properly. The codes were changed on all of the doors. The DON was made aware. Resident #1 was placed on 15 minute checks. Nurse #1 noted that Resident #1 was agitated and stated he wanted some fresh air. He also stated I told you I was getting out of here. Resident #1 reported when asked how he got out that he had watched people go out of that door all day. Nurse #1 was interviewed via telephone on 04/13/16 at 8:01 PM. She stated she was working on the 100 hall the night (03/28/16) that Resident #1 had gotten out. Nurse #1 stated Resident #1 usually self-propelled in his wheelchair but was capable of walking although his gait was unsteady at times. Nurse #1 stated she had not witnessed Resident #1 watching any of the exit doors when she worked. She stated she remembered he kept rolling around saying he was going home that night (03/28/16) but couldn't say where he was just prior to exiting the building. Nurse #1 stated she was notified by kitchen staff (KS #2) that Resident #1 was seen outside and she sent staff outside to retrieve him (she did not remember which staff). She stated the door alarm sounded when they were bringing him back inside but did not sound when he went out. She commented that Resident #1 must have gotten the code otherwise he couldn't have gotten out because the exit door locked automatically when a wanderguard was close by. When questioned about his statements of wanting to get out, she stated she thought he was just talking and didn't think he would actually try to get out. Nurse #1 stated he was placed on visual checks upon being brought back inside. Nurse #1 stated wanderguards were checked for placement every shift and she usually checked when she made rounds but had no specific time to do her rounds. Kitchen staff #1 (KS #1) was interviewed on 04/13/16 at 5:30 PM. She stated she had just walked over to the kitchen door (that had a small glass window and was located at the back of the kitchen that overlooked the parking lot in full view of the 200 hall exit doors) to look to see if her ride was in the parking lot. She stated she saw a man pushing a wheelchair standing by the transport van in the parking lot. KS #1 stated she asked KS #2 if she knew who it was and KS #2 responded it was Resident #1. KS #1 stated he was walking behind his wheelchair pushing his wheelchair. She stated she didn't see him exit from the 200 hall exit door and didn't know how long he had been in the parking lot. KS #1 stated KS #2 telephoned the nurse and they came outside and took him back inside the building. KS #2 was interviewed on 04/14/16 at 3:19 PM. She stated the door in the back of the kitchen had a window and the parking lot and the 200 hall exit door was visible from this door. She stated KS #1 went to the door to look for her ride and saw Resident #1 in the parking lot. KS #2 stated KS #1 asked her if she knew that man and when she looked out of the window, she saw Resident #1 pushing his wheelchair by the vans in the parking lot. She stated she went outside to check on him. She stated she immediately went back inside to alert the nurses that he was outside. KS #2 stated she asked KS #1 to watch him from inside the door while she placed the telephone call. KS #2 stated after she alerted the nurse she was headed back out to the parking lot to stay with him but staff had come out of the 200 hall exit door to get him before she could get there. A skilled nursing note of 03/28/16 at 10:48 PM from Nurse #3 documented Resident #1 was disoriented but alert with intermittent confusion. It documented he wandered seeking exits and was easily re-directed most of the time. A social services note of 03/29/16 at 5:40 PM noted Resident #1 had been moved from his room on the A hall to the locked unit. A skilled nursing note of 03/30/16 at 10:34 PM noted Resident #1 was anxious, combative and continuously attempting to call his family to pick him up. The note also indicated Resident #1 refused care most times and would ask staff to borrow money. When staff refused, he argued and cursed them. Resident #1 was discharged from the facility on 03/31/16 at 3:15 PM with his family. Nurse Aide #1 (NA #1) was interviewed on 04/13/16 at 5:05 PM. She had worked with Resident #1 and was familiar with him. She reported he rolled around the facility in his wheelchair. She denied ever noticing that he was watching the exit door of the smoking area (200 hall exit door). She reported Resident #1 had a wanderguard because she was the aide who had placed it initially. She commented if a resident was wearing a wanderguard and was within a certain distance from the exit doors the doors would lock automatically. NA #1 stated the door would not open even if the code was entered into the keypad beside the door if the wanderguard was working properly. NA #2 was interviewed on 04/13/16 at 6:12 PM. She stated she had worked with Resident #1 and was familiar with him. She stated Resident #1 was confused at times and would ask why he was in the facility. She stated Resident #1 made comments about going home. She reported never seeing Resident #1 sitting at or near the smoking area door (200 hall exit door) but he would ask staff to let him out. NA #2 stated Resident #1 had a wanderguard and if Resident #1 got too close to the exit door, the door would automatically lock and would not open even if the code was entered. Nurse #4 was interviewed on 04/14/16 at 10:25 AM. She stated Resident #1 was pleasantly confused and always wanted to call his family. She stated Resident #1 could walk but usually self-propelled around the facility in his wheelchair. Nurse #4 stated Resident #1 always talked about going home and wanting to get out and was at risk for elopement. She commented that she never witnessed Resident #1 sitting at any of the exit doors and didn't think it was possible for him to remember a code. She stated everyone including administration knew that Resident #1 talked about wanting to get out and wanting to go home. She reported being surprised when she was told that Resident #1 had gotten out of the building. Nurse #4 stated an elopement assessment was completed if a resident talked about leaving and if scored high enough they were deemed at risk and a wanderguard was placed on that resident. She went to the exit doors on the 200 hall with a wanderguard in hand. Both sides of the first double glass door were propped open with a wedge. When she approached the exit door, the red light was on in the box located to the right of the door. She stated even if she entered the code, the door would not open. She entered the code and the door remained locked. The maintenance supervisor was interviewed on 04/14/16 at 10:40 AM. He reported there were 3 doors in the facility which were wanderguard protected. He stated the side entrance next to the kitchen, the 200 hall exit door and the front door were wanderguard protected. He stated the front door had an automatic time lock for evenings. He stated the door at the end of A hall (the 100 hall) was keypad locked and wouldn't open unless the proper code was entered. The maintenance supervisor went to the side entrance exit door located near the kitchen to demonstrate how the wanderguard system worked. He stated the door locked automatically if a resident came within 2 feet of the door with a wanderguard in place. The maintenance supervisor commented that even if a resident was in the therapy room which was behind the foyer wall of the side entrance, the wanderguard would activate the locking system and no one would be able to go out. He stated the door would not open even if the employee code was entered unless it was the master code which would override the system. The maintenance supervisor commented that in case of emergencies there was an override switch that could be flipped on that would override everything and the door would open. He pointed to the override switch which was a red switch located underneath a hard plastic cover and stated if that switch was flipped, the door would open but a very loud alarm would sound. He flipped the switch and the alarm sounded. He commented the exit doors that had the wanderguard locks did not have alarms that sounded they just locked in response to the wanderguard. A clarification interview was conducted with the maintenance supervisor along with his 2 staff members (Staff #1 and Staff #2) on 04/15/16 at 10:40 AM. The maintenance supervisor stated there were 2 codes-an employee code and a master code and the only way Resident #1 could have gotten out of the 200 hall exit door without supervision was if he had the master code because the wanderguard system was functioning properly. He stated if Resident #1 was wearing a wanderguard the door would have locked preventing him from leaving if Resident #1 entered the employee code. The maintenance supervisor stated prior to Resident #1 exiting the building he had been checking all of the exit doors for proper functioning on a daily basis. He also stated that when he himself used any of the exit doors he didn't usually notice who was sitting at or around the doors because the system was functioning. Staff #1 and Staff #2 both stated they did not notice who would be sitting at or near the exit doors when they went out. Both Staff #1 and Staff #2 stated they used that door (200 hall exit door) on a daily basis as well as the other exit doors and used either the employee code or the master code to come and go. Staff #1 stated the first double glass door leading to the 200 hall exit door was usually left open. He also stated that some of the other staff in the building besides the maintenance staff had the master code as well and didn't know how they got it. The maintenance supervisor stated that the 200 hall exit door was also the emergency entrance for ambulances. None of the 3 staff remembered anything about events on 03/28/16 prior to Resident #1 going out of the building other than they had used that door (the 200 hall exit door) during the day and left between 4:00 PM and 4:30 PM. The maintenance supervisor commented that he was the only person who knew what the master code was now since the 03/28/16 incident because he was changing the codes weekly and was not giving it to anyone. NA #3 was interviewed on 04/14/16 at 3:30 PM. NA #3 had worked with Resident #1. He stated he remembered Resident #1 and he would sundown at night and become more confused. NA #3 stated one night Resident #1 wanted to go to his truck to go home. He stated as time went by, his behaviors became more frequent occurring daily. NA #3 stated Resident #1 was ambulatory but mostly used his wheelchair as a walker to get around. He commented Resident #1 would go to the 200 hall exit door and just sit there. NA #3 stated Resident #1 had told him previously he wanted to get out and he had passed it on to the nursing staff. He didn't remember who he told or when this happened. He stated because of Resident #1's behaviors, staff kept a close eye on him. NA #3 stated Resident #1 would become combative if staff attempted to remove him from the exit doors. He commented he had seen him go to the exit doors on A hall (100 hall) and attempt to push the door open. He also commented he had seen Resident #1 push and kick both of the doors on A hall (100 and 200 hall) trying to get out (he couldn't provide specific dates or times). NA #3 stated he spent as much time as he could sitting and talking with Resident #1 in an effort to decrease his anxiety level. He commented he was working the night Resident #1 went out of the building (03/28/16) but he was on the locked unit and didn't see anything. When questioned if he felt Resident #1 could have memorized a code, he stated he felt that Resident #1 could because some days he was having a good day and was totally alert. Transport staff #1 (TS #1) was interviewed on 04/15/16 at 3:05 PM. She stated Resident #1 would sit in front of the restroom that was adjacent to the 200 hall exit doors. She stated he liked to watch staff in the hall. TS #1 stated she had never seen him try to keypunch numbers into the keypad located just inside the 200 hall exit door. She also stated she had never observed him trying to exit the building. During an observation of the 200 hall exit doors which lead out into the smoking area and the parking lot, on 04/13/16 at 5:45 PM, it was noted that there were 2 sets of double glass doors. The first set of double glass doors was propped open with wedges underneath both doors. There was a short hallway (approximately 4 feet) between the 2 doors. There was a keypad on the left side of the door and another box on the right side of the door. The second double glass exit door was closed and was locked when pushed on. There was a bench noted on the left side just outside the exit door which was covered by a large canopy. There was a concrete drive which lead from the parking lot through the canopy area and back out into the parking lot. The facility's transport van was parked in the first parking space directly adjacent to the canopy approximately 25 feet from the exit door. The back door of the kitchen was visible from the 200 hall exit door. An observation was made of the 200 hall exit door foyer on 04/15/16 at 10:00 AM. The first set of double glass doors was propped open on both sides with wedges. The 200 hall exit door was closed and was locked when pushed. The DON was interviewed on 04/14/16 at 5:40 PM. She stated if a resident was identified as being an elopement risk, a wanderguard was placed on their person if their score on the elopement assessment was 5 or greater. She stated elopement assessments were completed upon admission, quarterly and as needed if a resident exhibited behaviors. She reported interventions in place prior to Resident #1 going out of the exit door included one on one social visits to occupy his attention and the placement of a wanderguard. She commented she was aware of his behaviors but was not informed of his specific exit seeking behaviors. The DON stated the exit doors had alarms. She commented that Resident #1 would sit at the nurses' station and liked to talk. She stated he was alert. She stated a wanderguard had been placed on Resident #1 on 03/18/16. The DON reported that she was on vacation when Resident #1 went out of the 200 hall exit door. She stated she received a telephone call from Nurse #1 informing her of his elopement. She stated she told Nurse #1 to verify that his wanderguard was in place. The DON stated there was an investigation completed but she had not been involved in it because of being out on vacation. She commented that she did not expect him to try to elope from the facility. During an interview with the Administrator, on 04/15/16 at 9:40 AM, she stated she had received a call from facility staff on 03/28/16 reporting that Resident #1 had gotten out of the building. She stated she immediately started asking questions. She stated she told the nurse to start visual checks on Resident #1. The Administrator stated she contacted the maintenance supervisor and asked him to come to the facility and check all of the exit doors. She stated Resident #1's wanderguard was in place and was functioning prior to his leaving out of the 200 hall exit door. She stated the wanderguard system was functioning properly when checked. The Administrator stated her investigation had shown that Resident #1 could not have been outside more than 3 minutes because dietary staff had seen him outside but no one actually saw him exit the door. She stated all wanderguards of the residents who had wanderguards were checked that night for proper functioning and no issues were identified. The Administrator stated the employee codes and the master codes were being changed on a weekly basis and all exit doors were being checked daily. She reported that she herself had checked the 200 hall exit door on 03/28/16 and the system was functioning properly. When questioned if she had been made aware of Resident #1's exit seeking behaviors on the 7:00 PM - 7:00 AM shift, she responded that she had not been informed. She reported that her expectation was for staff to report these behaviors to the management team. She commented that she had never witnessed any exit seeking by Resident #1 when she was in the building and only saw him going up and down the halls. She also commented that he was assessed for elopement upon his admission to the facility. On 04/13/16 at 2:30 PM, the Administrator provided the investigation of the incident of 03/28/16 regarding Resident #1, which was entitled Plan of Correction for Incident on 03/28/16, regarding Resident #1's elopement. It documented that on 03/28/16 at approximately 7:35 PM, dietary staff notified nursing staff that Resident #1 was outside the 200 hall doors. He was identified to be there less than 3 minutes and was brought back inside per staff. He was assessed with [REDACTED]. Resident #1 reported watching people go in and out of that door all day long and just went out. His wanderguard was checked. Door alarm did not sound with resident exiting the facility but alarmed when bringing resident back inside. The door and alarm was working properly but Resident #1 had observed the master code by employees. His wander guard was found to be in place and working properly. He was placed on 15 minute safety checks. All exit doors were checked to ensure locking and working properly. All employee codes and master codes were changed to all exit doors. All residents with wanderguards were checked for placement and function. In-services were started on 03/29/16 with maintenance staff regarding master codes not to be used except in emergencies. Effective 03/29/16 only the maintenance supervisor and his assistant would have access to this code. In-services were started with nursing staff regarding responding to residents voicing or showing exit seeking behaviors. It was noted that monitoring would include changing the master codes on a weekly basis for one month and if after one month no issues were noted, the facility would return to normal facility practices. A Wanderguard Door Alarm Check sheet for 03/28/16 noted that all of the doors in the building including the exit door on the 200 hall had been checked to ensure proper functioning and no concerns were noted on the document. The Administrator was notified of Immediate Jeopardy at 10:15 AM on 04/15/16. The facility provided an acceptable credible allegation of compliance as follows: For the resident affected: On 3/28/16 at approximately 7:35pm, dietary staff notified nursing staff that identified resident was outside the 200 hall doors. Resident was identified to be there for less than three minutes and was brought back inside per nursing staff. Resident was assessed with [REDACTED]. Resident then proceeded to tell nurse that he watches people go in and out of that door all day long, and just went out the door. Residents wanderguard was checked for Door alarm did not sound with resident exiting the facility, but alarmed when bringing resident back inside. This clarified that door and alarm was working properly, but upon investigation it was believed that resident may have entered the master code. Residents wanderguard was checked for placement and function. Wander guard found to be on resident and working properly. Resident was placed on Q 15 minute safety checks. On 3/29/16, Resident was moved to the secured unit. Resident was discharged home on[DATE]. For the resident with the potential to be affected: All exit doors in the facility were checked to ensure locking and working properly on 3/28/16 at approximately 2pm by Administrator. All exit doors found to be locked and working properly. On 3/28/16 at approximately 8pm, Maintenance Supervisor reported to facility to check all doors of locking and alarming properly. All exit doors were found to be locked and working properly. Maintenance Supervisor changed all employee codes and master codes to all exit doors in facility. All residents with wanderguards were checked for placement and function. All found to be on and working properly. All residents are assessed for elopement risk upon admission, quarterly, and as needed basis. Care plans updated accordingly. Measures put in place: All exit doors in the facility were immediately checked to ensure locking and working properly on 3/28/16 by Maintenance Supervisor. All found to be locked and working properly. All wanderguards were checked for placement and proper functioning. No issues were noted. In-service was started by Administrator on 3/29/16 with maintenance staff regarding master code to exit doors should not be used unless in emergency situations. Starting 3/29/16 only Maintenance Supervisor and Maintenance Assistant have access to the master code. In-service was started by Administrator on 3/29/16 with nursing staff regarding responding to residents voicing or showing exit seeking behaviors. On 4/14/16 an all staff in-service was initiated by Staff Development Coordinator regarding notifying management (DON and Administrator) when residents show signs of exit seeking behaviors and how to manage these behaviors. Identifying behaviors that may be considered as an elopement risk as of what to do if a resident appears to be attempting to elope to include immediate supervisor notification. All employees are to complete in-service before next scheduled shift and will not work until re-education completed. On 4/15/16, during complaint survey, elopement risk assessments were initiated on all residents currently in the facility with completion date of 4/15/16. For those that score high risk will be reviewed for further interventions as indicated. Monitoring: All master codes will be changed weekly X 1 month by Maintenance Supervisor. All exit doors in the facility will be checked daily X 1 month by Maintenance Supervisor and/or Administrator, DON, ADON, SDC, Nursing Supervisor. Validations of the above credible allegation of compliance were completed on 04/15/16 ending at 5:40 PM and included: In-services were provided to all staff (including maintenance, dietary and housekeeping) on all 3 shifts beginning on third shift 04/14/16 and ending on

Based on record review, staff, family and physician interviews, the facility failed to honor 1 (Resident #1) of 3 resident 's desires for code status who expired in the facility. The Immediate Jeopardy began on [DATE]. The administrator was notified of the Immediate Jeopardy on [DATE] at 6:20 pm. The Immediate Jeopardy was removed on [DATE] at 7:15 pm when the facility provided an acceptable Credible Allegation of Compliance. The facility will remain out of compliance at a scope and severity of no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy (D). The facility was in the process of full implementation and monitoring their corrective action. The findings included: Resident #1 was admitted to the facility on [DATE] with medical [DIAGNOSES REDACTED]. Her medical condition was diagnosed as terminal and guarded with a recommendation for hospice consultation. The resident had a living will dated [DATE] which indicated to "withhold or withdraw life prolonging measures." Section one (I) was not completed which indicated under which circumstances life prolonging measures were to be withheld. Item #6 of the Advanced Directive stated "If I have an Available Health Care Agent: If I have appointed a health care agent by executing a health care power of attorney or similar instrument, and that health care agent is acting and available and gives instructions that differ from this Advance Directive, then I direct that: Follow Advance Directive: This Advance Directive will override instructions my health care agent gives about prolonging my life." The most recent Minimum Data Set ((MDS) dated [DATE] indicated Resident #1 was cognitively intact, Brief Interview for Mental Status (BIMS) score 15. A review of Resident 's #1 care plan with effective date from [DATE] to [DATE] indicated "Advance Directive Needs: Code Status: DNR (Do Not Resuscitate)." A review of a physician order [REDACTED]. During a phone interview on [DATE] at 8:40 am, the family member stated she had received a phone call from the nurse the week prior to the resident passing away and informed of the order to change the resident code status to full code. During a phone interview on [DATE] at 2:05 pm, the family member stated she received a call on the afternoon of the 18th by the nurse that stated she made rounds with the doctor. The family member further stated she came in to the facility at approximately 6:40 pm and spoke with Nurse # 3 and told her that she was going to go and talk with Resident #1 about her decision for full code. The family member stated the resident confirmed with her that she wanted to be a full code at the time of the visit. She stated this was the last conversation she had with the resident or facility staff about the resident ' s advance directives. The family member stated the resident had been doing better medically since being at the facility and that she just wasn ' t ready to give up. A review of the facility Progress Note by the attending physician dated [DATE] revealed " Resident alert and oriented x 3. Pt request full code. " A review of a facility Physician order [REDACTED]." On [DATE] at 9:50 am, during an interview, Nurse #3 stated Resident #1 refused the hospital 's recommendation for hospice and wanted to be a full code. She further stated she was with the doctor when he made rounds and visited with the resident on [DATE] and the resident told the doctor she wanted to be a full code. Nurse #3 further indicated it was late on Friday afternoon on the 18th so it was on Monday October the 21st when she gave the social worker a copy of the order to get the family to sign the new order. Nurse #3 further indicated she was not familiar with the type of power of attorney the family member had for Resident #1. She further stated "All I know is that I was told by my supervisor, the ADON (Assistant Director of Nursing) that I could not take the order off until the family member gave permission because she was her power of attorney." On [DATE] at 2:19 pm, Nurse # 3 stated she recalled talking to the resident 's hcpoa on the phone and after she came in to the facility around 6:40 pm on [DATE] regarding the new doctor 's order for full code status for Resident #1. Nurse #3 further stated the resident ' s hcpoa did tell her that she was going to discuss with the resident her decision for full code status after she arrived in the building on the evening of [DATE]. She further indicated she did not speak to the hcpoa after the hcpoa visited with the resident because she had already left for the day. During an interview on [DATE] at 11:10 am, the Social Worker stated she did not accept the order from the nurse because there was nothing to get permission from the family for. The social worker further indicated Resident #1 was alert and oriented and could make her own decisions about her directives. She stated she told the nurse she would go in and speak with the resident because the resident told her she wanted to be a DNR when she completed her assessment with her. The Social Worker further indicated she did go in and speak with the resident on the afternoon of [DATE] prior to leaving work around 5 pm. She further stated the resident informed her she wanted to be a DNR when she went to see her before leaving work on the same date. The Social Worker stated she did not go back to the nurse and let her know that the resident told her she wanted to be a DNR after the discussion of the order for full code. The Social worker further stated she did not see the nurse again before she left the building. She further stated she did not tell the nurse on Monday the 21st of October of the resident ' s conversation with her about DNR after the discussion of the doctor ' s order for full code. The social worker further indicated it was the responsibility of the nursing staff to key in the order for the code status change into the computer system. The Social Worker stated she confirm the code status orders in the computers quarterly. Review of the nurse's note dated [DATE] at 6:31 pm by Nurse #1 revealed "writer into resident ' s room and unable to arouse resident, sternal rub and stimuli uneventful. 100 hall nurse assisted writer and still no arousal. No heartbeat or pulse felt. Resident is a DNR. Call placed to MD (medical doctor). RP (responsible party) made aware and stated "I will be there in a few minutes. Awaiting her arrival. (6:20 pm)." On [DATE] at 8:55 am, in an interview with Nurse #1 revealed she found Resident #1 unresponsive on [DATE] at approximately 6 pm. She stated she walked by Resident #1's room and noticed she had not touched her dinner tray which was unusual for the resident. Nurse #1 stated Resident #1 was without pulse or heartbeat and her body was warm. She further indicated the resident 's eyes were dilated. She stated she was unable to arouse Resident #1 by firmly rubbing on the resident 's chest so she went to get Nurse #2 to verify with her because the resident was a DNR. . Nurse #1 stated she checked the code status book on the floor and it contained the DNR order for Resident #1. On [DATE] at 12:02 pm, during a phone interview with the attending physician, he stated he expected the nursing staff to carry out the order as written. The physician stated he wrote the order because the resident was alert and oriented and requested it. He further stated because the resident and family made one decision at the hospital did not mean they could not change their minds about their directives later. The physician further indicated his plan was for the staff to contact the family member who was the health care power of attorney (hcpoa) to make sure she was aware of the resident 's decision for full code to ensure everyone was on the same page. In an interview on [DATE] at 12:13 pm, the Director of Nursing (DON) indicated the facility Physician order [REDACTED]. The DON further indicated she expected the nurse to process the order for the code status change into the computer, discontinue the DNR order and put in the full code order. The DON further indicated the nurse should have notified the physician that gave the order immediately if for any reason she was unable to carry out the doctor 's order. She further indicated the nurses are expected to verify the resident ' s code status via the quickest resource whether it is the computer or the code status book at the nurse 's station. On [DATE] at 3:48 pm, during an interview, the Assistant Director of Nursing (ADON) stated she was not aware of the order for full code for Resident #1 until after the resident had passed away. The ADON stated Nurse #3 came to her with the order the day after the resident had passed away. She stated she immediately called the administrator and the DON who was out of the building and informed them. The ADON stated she did not give instructions to Nurse #3 not to transcribe the order for code status change. The facility provided the following Credible Allegation on [DATE] at 7:15 pm. Credible Allegation of Compliance: F-Tag 242 For the Provision of Care to Maintain the highest level of function for residents. The area of concern identified during staff interviews revealed staff are unfamiliar with resident rights as it relates to resident wishes per state surveyor on [DATE]. Resident # 1 was admitted to facility on [DATE] and on [DATE] the attending physician wrote an order for [REDACTED].#1 to " withhold or withdraw life-prolonging measures " . Item #6 of the Advanced Directive states " If I have an Available Health Care Agent: If I have appointed a health care agent by executing a health care power of attorney or similar instrument, and that health care agent is acting and available and gives instructions that differ from this Advance Directive, then I direct that: Follow Advance Directive: This Advance Directive will override instructions my health care agent gives about prolonging my life. Advanced Directive was dated and notarized [DATE]. The discrepancy regarding F-Tag 242 was that a nurse was not aware that a Health Care Power of Attorney does not become effective and cannot make decisions for the resident until that resident is unable to make decision for self. In-service training began the morning of [DATE] by Director of Nursing for licensed nurses and the Social Worker on Resident Rights as it relates to honoring wishes of alert and oriented residents. Any alert and oriented resident who expresses a desire to change any aspect of their Advance Directive will be honored according to resident wishes. In the event a resident is unable to make decisions for themselves, the expressed wishes of the responsible party and/or POA then become effective and those wishes are honored. Once resident and/or POA/Patient Representative has conveyed wishes, licensed nurse will contact the attending physician for appropriate order. The nurse then writes the telephone order, transcribes the order into the Electronic Health Record and places a copy of the telephone order in to the code status notebook on the unit to replace the previous status sheet. The hand written order is then placed into the physician ' s folder to be signed upon his next visit. After the physician signs the order, the Medical Records Clerk then scans and attaches the order into the Electronic Health Record. Licensed nurses will continue to be in-serviced prior to beginning of next tour of scheduled duty. This facility will continue to provide resident rights education during orientation for new employees and at least annually on-going. A new code status communication form was implemented on [DATE] specifically for the Social Worker to utilize in the event the resident expresses wishes other than the current status order. Social Worker received in-service on [DATE] by Administrator to ensure the wishes of the resident are conveyed to the appropriate licensed nurse. Licensed nurses were in-serviced on the new communication form and on the importance of contacting the physician immediately once alerted that resident has requested a change in code status on [DATE]. Beginning [DATE], the Social Worker or designee began interviewing alert and oriented residents and contacting the POA/Responsible Party of the residents who are unable to make decisions to verify that their wishes are in agreement with the current code status in the Electronic Health Record. Two random interviews will be performed with licensed nursing staff per week x 4 weeks, then two interviews monthly x 6 months to in ensure licensed staff can demonstrate knowledge of resident rights as it relates to resident wishes with Advance Directives. DON, ADON or designee will continue to audit every admission for code status within 24 hours of admission continuously. The facility will continue to determine resident ' s desires and wishes upon admission related to code status by the Admission Coordinator. The Admission Coordinator will continue to communicate this information to Medical Records and the licensed nurse in order to review the resident ' s code status with the physician in order to obtain a physician's order [REDACTED]. Once resident and/or POA has conveyed wishes, licensed nurse will contact the attending physician immediately for appropriate order, according to Autumn policy. Autumn ' s Policy states that: Once a resident and/or POA/Patient Representative has conveyed wishes, licensed nurse will contact the attending physician for appropriate order. The nurse then writes the telephone order, transcribes the order into the Electronic Health Record and places a copy of the telephone order in to the code status notebook on the unit to replace the previous status sheet. The hand written order is then placed into the physician ' s folder to be signed upon his next visit. After the physician signs the order, the Medical Records Clerk then scans and attaches the order into the Electronic Health Record. In the event an alert and oriented resident expresses a desire to change code status, or the POA of a resident who is unable to make decisions expresses the desire to change code status, the social worker will notify a licensed nurse immediately via the Code Status Communication Form. The social worker then documents that she has verified the resident ' s or POA/Responsible party ' s wishes for code status. During the morning clinical meeting (Monday through Friday), with DON, ADON, Administrator, MDS nurses, Rehab Manager and Social Worker in attendance, MDS nurse will notify the social worker of the residents who are due for assessment on that day. The social worker will then take that list of residents and verify code status with resident, POA or Responsible party (whichever applicable) as it relates to patient wishes. On Fridays, MDS nurse will alert the social worker of the residents who are due for assessment that day as well as the residents who are due for an assessment for the coming weekend. The social worker will then verify code status with resident, POA or Responsible party (whichever applicable) as it relates to patient wishes. Social worker will also document this conversation in the Electronic Health Record immediately. The MDS Nurse will compare that the Social Workers documentation is in agreement with the current physicians order. On [DATE] at 7:15 pm, verification of the credible allegation was evidenced by interviews of licensed nursing staff and the social worker related to resident 's rights. The licensed nursing staff and the social worker verbalized understanding of the need to notify the physician immediately if a resident request a code status change. Staff also verbalized understanding of resident 's rights.

Based on record review, staff, family and physician interviews, the facility failed to activate the Emergency Medical Services system via 911 and provide Cardiopulmonary Resuscitation (CPR) per doctor 's order for 1 of 3 residents (Resident #1) that expired in the facility. The Immediate Jeopardy began on [DATE]. The administrator was notified of the Immediate Jeopardy on [DATE] at 6:20 pm. The Immediate Jeopardy was removed on [DATE] at 7:15 pm when the facility provided an acceptable Credible Allegation of Compliance. The facility will remain out of compliance at a scope and severity of no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy (D). The facility was in the process of full implementation and monitoring their corrective action. Review of the facility 's CPR policy dated [DATE] revealed "the facility recognizes the fundamental rights of an individual to control the decisions related to his or her medical care. It is the policy of this facility to communicate our CPR policy to all patients and/or their responsible party prior to admission and to ensure to the extent possible that a patient 's wishes regarding resuscitation and life sustaining treatment are honored. In the event a patient has expressed a desire to be a full code, and is found to be in cardiopulmonary arrest, licensed nursing staff will initiate basic life support and 911 emergency services will be called for transport to local hospital for further life support. All licensed nurses are CPR certified and will be recertified on an annual basis either through American Heart Association or American Red Cross. The findings included: Resident #1 was admitted to the facility on [DATE] with medical [DIAGNOSES REDACTED]. Her medical condition was diagnosed as terminal and guarded with a recommendation for hospice consultation. The resident had a living will signed [DATE] which indicated to "withhold or withdraw life prolonging measures." Section one (I) was not completed which indicated under which circumstances life prolonging measures were to be withheld. Item #6 of the Advanced Directive states "If I have an Available Health Care Agent: If I have appointed a health care agent by executing a health care power of attorney or similar instrument, and that health care agent is acting and available and gives instructions that differ from this Advance Directive, then I direct that: Follow Advance Directive: This Advance Directive will override instructions my health care agent gives about prolonging my life." The most recent Minimum Data Set ((MDS) dated [DATE] indicated Resident #1 was cognitively intact, Brief Interview for Mental Status (BIMS) score 15. A review of Resident 's #1 care plan with effective date from [DATE] to [DATE] indicated "Advance Directive Needs: Code Status: DNR (Do Not Resuscitate)." A review of a signed physician order [REDACTED]. During a phone interview on [DATE] at 8:40 am, the family member stated she received a phone call from the nurse the week prior to the resident passing away and was informed of the order to change the resident code status to full code. During a phone interview on [DATE] at 2:05 pm, the family member stated she received a call on the afternoon of the 18th by the nurse that stated she made rounds with the doctor. The family member further stated she came in to the facility at approximately 6:40 pm and spoke with Nurse # 3 and told her that she was going to go and talk with Resident #1 about her decision for full code. The family member stated the resident confirmed with her that she wanted to be a full code at the time of the visit. She stated this was the last conversation she had with the resident or facility staff about the resident ' s advance directives. The family member stated the resident had been doing better medically since being at the facility and that she just wasn 't ready to give up. A review of the facility Progress Note by the attending physician dated [DATE] revealed "Resident alert and oriented x 3. Pt request full code." A review of a facility Physician order [REDACTED]." On [DATE] at 9:50 am, during an interview, Nurse #3 stated Resident #1 refused the hospital 's recommendation for hospice and wanted to be a full code. She further stated she was with the doctor when he made rounds and visited with the resident on [DATE] and the resident told the doctor she wanted to be a full code. Nurse #3 further indicated it was late on Friday afternoon on the 18th so it was on Monday October the 21st when she gave the social worker a copy of the order to get the family to sign the new order. Nurse #3 further indicated she was not familiar with the type of power of attorney the family member had for Resident #1. She further stated " All I know is that I was told by my supervisor, the ADON (Assistant Director of Nursing) that I could not take the order off until the family member gave permission because she was her power of attorney." On [DATE] at 2:19 pm, Nurse # 3 stated she recalled talking to the resident 's hcpoa on the phone and after she came in to the facility around 6:40 pm on [DATE] regarding the new doctor 's order for full code status for Resident #1. Nurse #3 further stated the resident 's hcpoa did tell her that she was going to discuss with the resident her decision for full code status after she arrived in the building on the evening of [DATE]. She further indicated she did not speak to the hcpoa after the hcpoa visited with the resident because she had already left for the day. During an interview on [DATE] at 11:10 am, the Social Worker stated she did not accept the order from the nurse because there was nothing to get permission from the family for. The social worker further indicated Resident #1 was alert and oriented and could make her own decisions about her directives. She stated she told the nurse she would go in and speak with the resident because the resident told her she wanted to be a DNR when she completed her assessment with her. The Social Worker further indicated she did go in and speak with the resident on the afternoon of [DATE] prior to leaving work around 5 pm. She further stated the resident informed her she wanted to be a DNR when she went to see her before leaving work on the same date. The Social Worker stated she did not go back to the nurse and let her know that the resident told her she wanted to be a DNR after the discussion of the order for full code. The Social worker further stated she did not see the nurse again before she left the building. She further stated she did not tell the nurse on Monday the 21st of October of the resident 's conversation with her about DNR after the discussion of the doctor's order for full code. The social worker further indicated it was the responsibility of the nursing staff to key in the order for the code status changes into the computer system. The Social Worker stated she confirms the code status orders in the computers quarterly. A review of the Meal Service Times schedule revealed "Dinner- 5:30 pm. A- hall Cart 6:00 pm." On [DATE] at 1:35 pm, during an interview, NA #1 stated Resident #1 was sleepy on the evening of [DATE] but she responded appropriately when spoke to. NA #1 stated she went in to the resident 's room at the beginning of her shift and put the chairs up. She further stated she went back to check on the resident about 15 minutes before the meal trays came to the floor. NA #1 stated when she went back to deliver the dinner tray she stated to the resident for her to sit up so she could eat and the resident replied " I will baby." Review of the nurse 's note dated [DATE] at 6:31 pm by Nurse #1 revealed "writer into resident 's room and unable to arouse resident, sternal rub and stimuli uneventful. 100 hall nurse assisted writer and still no arousal. No heartbeat or pulse felt. Resident is a DNR. Call placed to MD (medical doctor). RP (responsible party) made aware and stated "I will be there in a few minutes. Awaiting her arrival. (6:20 pm)." On [DATE] at 8:55 am, in an interview with Nurse #1 revealed she found Resident #1 unresponsive on [DATE] at approximately 6 pm. She stated she walked by Resident #1 's room and noticed she had not touched her dinner tray which was unusual for the resident. Nurse #1 stated Resident #1 was without pulse or heartbeat and her body was warm. She further indicated the resident 's eyes were dilated. She stated she was unable to arouse Resident #1 by firmly rubbing on the resident 's chest so she went to get Nurse #2 to verify with her because the resident was a DNR. Nurse #1 stated she checked the code status book on the floor and it contained the DNR order for Resident #1. In an interview on [DATE] at 3:24 pm, Nurse #2 stated she was asked by Nurse #1 to come to Resident #1 's room to verify her death. Nurse #2 stated there were no pulse and no heartbeat. She further stated she verified with Nurse #1 that the resident had expired. Nurse #2 stated the resident 's body was still a little warm with her arms straight by her side. Nurse #2 stated she returned to her assigned area after advising Nurse #1 to call the doctor to pronounce the death. She further stated she did not verify the code status for Resident #1. She stated the assigned nurse for Resident #1, Nurse #1 had informed her that the resident 's code status was DNR. On [DATE] at 12:02 pm, during a phone interview with the attending physician, he stated he expected the nursing staff to carry out the order as written. The physician stated he wrote the order because the resident was alert and oriented and requested it. He further stated because the resident and the family made one decision at the hospital did not mean they could not change their mind about their directives later. The physician further indicated his plan was for the staff to contact the family member who was the health care power of attorney (hcpoa) to make sure she was aware of the resident ' s decision for full code to ensure everyone was on the same page. In an interview on [DATE] at 12:13 pm, the Director of Nursing (DON) indicated the facility Physician order [REDACTED]. The DON further indicated she expected the nurse to process the order for the code status change into the computer, discontinue the DNR order and put in the full code order. The DON further indicated the nurse should have pulled the DNR order out of the code status book at the nurse ' s station. She further indicated the nurses are expected to verify the resident ' s code status via the quickest resource whether it is the computer or the code status book at the nurse 's station. The DON further indicated the nurse should have notified the physician that gave the order immediately if for any reason she was unable to carry out the doctor 's order. On [DATE] at 3:48 pm, during an interview, the Assistant Director of Nursing (ADON) stated she was not aware of the order for full code for Resident #1 until after the resident had passed away. The ADON stated Nurse #3 came to her with the order the day after the resident had passed away. She stated she immediately called the administrator and the DON who was out of the building and informed them. The ADON stated she did not give instructions to Nurse #3 not to transcribe the order for code status change. The facility provided the following Credible Allegation on [DATE] at 7:15 pm. Credible Allegation of Compliance: F-Tag 309 For the Provision of Care to Maintain the highest level of function for residents. Resident # 1 was admitted to facility on [DATE] and on [DATE] the attending physician wrote an order for [REDACTED].#1 to "withhold or withdraw life-prolonging measures" . Item #6 of the Advanced Directive states "If I have an Available Health Care Agent: If I have appointed a health care agent by executing a health care power of attorney or similar instrument, and that health care agent is acting and available and gives instructions that differ from this Advance Directive, then I direct that: Follow Advance Directive: This Advance Directive will override instructions my health care agent gives about prolonging my life. Advanced Directive was dated and notarized [DATE]. After the physician order [REDACTED]. The social worker documented the "status is DNR " in her note that was written on [DATE] at 15:40. The resident was found to be unresponsive by licensed nurse on [DATE] at 18:00. The nurse documented at 18:31 that there was no pulse or heart beat and that the code status was DNR. This facility identified the discrepancy to be resident #1 's wishes to be DNR status conflicted with the most recent physician order [REDACTED]. An audit was completed on [DATE] for all new admissions from [DATE] through [DATE] in which no affected areas were found. There were three technical changes that were made during the audit which were as follows: A DNR order for resident E.G. was in the Electronic Health Record appropriately, but the physical order had not yet been scanned and attached to the order in the Electronic Health Record. Medical Records Clerk scanned the document into Electronic Health Record. In one case, the demographics section on resident S.W. showed a "yes" for having a living will but the resident does not have one. This was changed appropriately and does not affect resident 's code status. Also, resident S.C. 's " yes " / " no " question in Demographics section was marked "no" , however, there was a written order scanned in the system, the system accurately reflected DNR in the chart, and the yellow DNR form was in the Code Status Book at the appropriate nurses station. A new code status communication form was implemented on [DATE] specifically for the Social Worker to utilize in the event the resident expresses wishes other than the current status order. Social Worker received in-service on [DATE] by Administrator to ensure the wishes of the resident are conveyed to appropriate staff. Licensed nurses in-serviced on communication form implemented on [DATE] starting on [DATE] and any licensed staff who do not receive in-service education on [DATE] will be required to receive in-service training prior to their next scheduled tour of duty. The Administrator and Director of Nursing were out of town at a conference and mandated that a complete audit be performed on all other in-house residents to verify accuracy of code status reflected according to resident wishes by the Social worker, ADON and Medical Records. Audit consisted of validating the physician's order [REDACTED]. Educational In-Service was provided by ADON to Medical Records and Social Services staff for resident code status, HCPOA, Living Wills and verification in Electronic Medical Record and code status book, which is maintained on each unit on [DATE]. The in-service education provided consisted of verification of most recent physician 's order with the most current Advanced Directives documents in agreement as indicated. Licensed nurses received in-service training beginning on [DATE] on receiving physician orders [REDACTED]. Any licensed nurse not receiving the in-service on [DATE] will be required to receive in-service training prior to their next scheduled tour of duty. The facility will continue to determine resident ' s desires and wishes upon admission related to code status by the Admission Coordinator. The Admission Coordinator will continue to communicate this information to Medical Records and the licensed nurse in order to review the resident ' s code status with the physician in order to obtain a physician's order [REDACTED]. Once resident and/or POA has conveyed wishes, licensed nurse will call the attending physician for appropriate order. The nurse then writes the telephone order, transcribes the order into the Electronic Health Record and places a copy of the telephone order in to the code status notebook on the unit to replace the previous status sheet. The hand written order is then placed into the physician ' s folder to be signed upon his next visit. After the physician signs the order, the Medical Records Clerk then scans and attaches the order into the Electronic Health Record. In the event an alert and oriented resident or a POA/responsible party desires to change a resident ' s code status, the physician will be contacted immediately to request a telephone order to change the code status. The nurse will write physician telephone order, transcribe it into the Electronic Health Record, and place a copy of the telephone order in the code status notebook on the unit to replace the previous status sheet. The hand-written order is then placed into the physician 's folder to be signed upon his next visit. After the physician signs the order, the Medical Records Clerk then scans and attaches the order into the Electronic Health Record. All new physician orders [REDACTED]. On weekends and holidays, the RN supervisor or designee will review all new physicians orders on-going. All Physician orders [REDACTED]. In addition, if there is any questionable concern related to the physician 's order, the physician will be contacted by a licensed nurse to get clarification of order from physician. In the event an alert and oriented resident expresses a desire to change code status, or the POA of a resident who is unable to make decisions expresses the desire to change code status, the social worker will notify a licensed nurse immediately. According to Autumn policy, the nurse will call the physician immediately and obtain a telephone order. The nurse then writes the telephone order, transcribes the order into the Electronic Health Record and places a copy of the telephone order in to the code status notebook on the unit to replace the previous status sheet. The hand written order is then placed into the physician 's folder to be signed upon his next visit. After the physician signs the order, the Medical Records Clerk then scans and attaches the order into the Electronic Health Record. During the morning clinical meeting (Monday through Friday), with DON, ADON, Administrator, MDS nurses Rehab Manager and Social Worker in attendance, MDS nurse will notify the social worker of the residents who are due for assessment on that day. The social worker will then verify code status with resident, POA or Responsible party (whichever applicable) as it relates to patient wishes. Social worker will also document this conversation in the Electronic Health Record immediately. The MDS Nurse will verify that the Social Workers documentation is in agreement with the current physicians order. In-service training began [DATE] with licensed nurses related to properly receiving, writing and transcribing physician orders [REDACTED]. In-services will be complete on [DATE] and any nurse identified not attending will require in-service training prior to beginning their next scheduled tour of duty. To ensure that all new admissions are not affected, the admission coordinator will continue to discuss Advance Directives/Code Status with resident and/or POA and obtain/request copies of documents pertaining to Advance Directives. Admissions Coordinator then alerts Medical Records and Nurse in Charge of resident and/or POA of code status. Nurse will call Physician and request telephone order per residents' and/or POA 's code status. Medical records will obtain all pertinent documents related to code status and scan in to Electronic Medical Record. In the event that a resident ' s code status changes during their stay at the facility, the social worker and/or licensed nurse will notify attending physician or designee for an order to honor resident and/or POA wishes immediately. Licensed nurses received in-service education starting [DATE] in reference to resident 's who are alert and oriented having the right to convey choices and those choices are to be honored as it relates to code status. This facility will continue to ensure that current code status is reflected in the medical record and in the notebooks on each unit which contains the face sheets and code status sheets. After the nurse obtains the telephone order from the doctor to change the code status, the nurse will then remove the previous code status sheet and insert a copy of the telephone order. On [DATE] at 7:15 pm, verification of the credible allegation was evidenced by interviews of licensed nursing staff related to transcription of orders and the need to notify the physician immediately if an order needs to be clarified. Nurses verified orders for code status changes are to be transcribed as stat orders. Verification of the credible allegation continued with interviews of licensed nursing staff and social worker related to the new communication form if residents express a desire for code status change to the social worker. The social worker and nursing verified the form would be initiated by the social worker and forwarded to the nursing staff.