Every finding on record at Autumn Care of Statesville

Based on record reviews and interviews with staff and the Pharmacist, the facility failed to have effective systems in place for the return of discontinued controlled medications to the pharmacy for 1 of 2 residents reviewed for pharmacy services (Resident #41). The findings included:Review of Resident #41's medical record revealed an order dated 01/21/26 for Oxycodone/Acetaminophen 10/325 milligrams (mg) every six hours as needed for pain. The medication was discontinued on 01/22/26.Review of Resident #41's medical record revealed an order dated 01/22/26 for Oxycodone/Acetaminophen 5/325 mg one tablet by mouth every eight hours as needed for pain and was written by Nurse Practitioner #1.Review of the pharmacy delivery sheet revealed Resident #41's Oxycodone/Acetaminophen 10/325, 30 tablets were delivered to the facility on [DATE] at 11:16 PM and was received by Nurse #5.An interview was conducted with Nurse #5 on 07/01/2026 at 4:20 PM. The Nurse confirmed that she remembered receiving Resident #41's Oxycodone/Acetaminophen 10/325 mg, 30 tablets on 01/22/26.Interviews were conducted with Nurse #1 on 06/30/26 at 1:40 PM and 07/01/26 at 3:15 PM. The Nurse explained that before the drug diversion happened the discontinued controlled medications were left on the medication cart until the nurse managers removed the medications from the medication cart.An interview was conducted with Medication Aide (MA) #1 on 06/30/26 at 9:35 AM. The MA explained the discontinued controlled medications were left on the medication cart until the nurse managers removed them from the cart, but she was not sure how often it was that they were removed from the medication cart.An interview was conducted with Nurse #4 on 06/30/26 at 10:23 AM. The Nurse stated she worked as a nurse manager, and the facility recently had issues with drug diversion. Nurse #4 explained that before the diversions, the discontinued controlled medications remained on the medication carts until they were removed by the nurse managers.Interviews were conducted with the Director of Nursing (DON) on 06/29/26 at 1:15 PM and 06/30/26 at 4:50 PM. The DON explained Resident #41's Oxycodone/Acetaminophen 10/325 mg was ordered on 01/21/26 and delivered on 01/22/26 and although it was discontinued on 01/22/26 the medication remained in the medication cart. The DON continued to explain that on the morning of 01/28/26, Medication Aide (MA) #1 looked to see what time she administered Resident #41 her pain medication the day before and the MA could not find the declining count sheet for that controlled medication. The MA notified the DON, and the DON conducted an investigation of the missing controlled pain medication and discovered the last count was on 01/28/26 shortly after midnight between Nurse #4 and Nurse #3 and there were 28 tablets left on the medication card. She stated the system for returning controlled medications during that time was for the discontinued controlled medications to remain in the medication carts until the nurse managers, including myself, the administrative nurses, removed the medications which was about twice a week.On 07/01/26 at 3:10 PM an interview was conducted with the Administrator who explained that after the facility investigated the drug diversion, they discovered that the nurses and medication aides were not required to have two nurses' signatures on shift change control inventory sheets, the pharmacy delivery sheets or the declining count sheet for that specific controlled medication. The Administrator indicated that because stricter systems were not in place, she could see that the potential was there to divert narcotics.The facility did not present a plan of correction to the survey team before the exit.

Based on observation, record reviews, and interviews with residents, Pharmacist and Nurse Practitioner, the facility failed to have effective systems in place to prevent misappropriation of two resident's controlled opioid pain medications. Resident #41's had 28 tablets of Oxycodone/Acetaminophen 10/325 milligrams (mg) and Resident #34 had 30 tablets that were discovered missing from the medication cart and were never located. This deficient practice affected 2 of 2 residents reviewed for misappropriation of resident property.The findings included:1. Resident #41 was admitted to the facility on [DATE] with diagnoses that included polyneuropathy (a neurological condition characterized by the simultaneous damage of multiple peripheral nerves throughout the body).Review of Resident #41's medical record revealed an order dated 01/21/26 for Oxycodone/Acetaminophen 10/325 mg one tablet every six hours as needed for pain. The medication was discontinued on 01/22/26.Review of Resident #41's Medication Administration Record for January 2026 indicated Resident #41 was given Oxycodone/Acetaminophen 10/325 mg tablet at 12:03 AM on 01/22/26.Review of the pharmacy delivery sheet revealed Resident #41's Oxycodone/Acetaminophen 10/325, 30 tablets were delivered to the facility on [DATE] at 11:16 PM and was received by Nurse #5.During a telephone interview with Nurse #5 on 07/01/26 at 4:20 PM the Nurse explained that she remembered she received Resident #41's Oxycodone/Acetaminophen 10/325 mg 30 tablets in on 01/22/26 but could not remember the time.Review of Resident #41's medical record revealed an order dated 01/22/26 for Oxycodone/Acetaminophen 5/325 mg one tablet by mouth every eight hours as needed for pain and was written by Nurse Practitioner #1.Review of Resident #41's medical record revealed an order dated 01/23/26 for Oxycodone/Acetaminophen 5/325 mg give two tablets by mouth every six hours.Review of Resident #41's admission Minimum Data Set assessment dated [DATE] revealed her cognition was moderately impaired and revealed she received scheduled pain medication and pain medication as needed.Review of a Progress Note written 01/27/26 at 11:21 AM written by Nurse #4 revealed Resident #41 was out of the Percocet (Oxycodone) 5/325 mg but did have Percocet 10/325 mg that were previously discontinued. Verbal order given by Nurse Practitioner #1 to give one Oxycodone/Acetaminophen 10/325 mg with an Acetaminophen 325 mg tablet to equal the ordered dose of two 5/325 mg until the medication came in from the pharmacy.Review of a Facility Reported Incident (FRI) Investigation Report dated 02/01/26 submitted by the Administrator revealed in part: an allegation of Diversion of Resident of Drugs discovered on 01/28/26 at 11:00 AM. The facility identified a card of Oxycodone 10/325 mg missing from the 500-hall medication cart (belonging to Resident #41). The facility has audited all narcotic cards and (declining) count sheets to verify no other cards were missing and the (shift change controlled substance inventory) count sheets were correct. The agency Nurse in question, Nurse #3, was gone when the card was noticed missing. The agency was notified and made aware Nurse #3 could not return to work pending the investigation. Summary of Investigation: The facility concluded an assumption of diversion due to the Oxycodone 10/325 card and declining count sheet not being found however, the facility could not definitively determine by whom. Following extensive search, the card and declining count sheet were not found. Nurse #3 denied seeing the card in the medication cart. The facility staff stated the card was in the medication cart when the medications were counted. Narcotic count sheet appeared to be altered. The Director of Nursing (DON), Assistant Director of Nursing (ADON), Nurse #4 and Medication Aide (MA) #1 were drug tested and the results were negative. Nurse #3 did not show up for the drug test. The agency was notified of the facility's expectations and Nurse #3 was marked as do not return. The allegation was substantiated.Review of a Drug Enforcement Administration form dated 01/29/26 revealed the facility reported the loss or theft of 28, Oxycodone/Acetaminophen 10/325 mg tablets.On 06/28/26 at 11:26 AM an interview was conducted with Resident #41 who explained that she had back problems and had endured pain for years which caused her to have to take pain medication to control her pain. The Resident continued to explain that she had never had a problem getting her pain medication when she requested it.An interview was conducted with MA #1 on 06/30/26 at 9:35 AM. The MA explained that on 01/28/26 Resident #41 asked her when she last had her pain medication and the MA looked for the declining count sheet for Resident #41's Oxycodone/Acetaminophen 10/325 mg to determine what time the Resident had her last dose that the MA had taken from that specific card on 01/27/26. The MA explained that the order for Oxycodone/Acetaminophen 10 mg had been discontinued but the supply remained on the medication cart. The MA stated she had to use one of the pills (Oxycodone 10 mg) to give to Resident #41 the day prior on 01/27/26 at 12:00 PM which left the remaining count of 28 pills so she knew there should have been 28 pills left in the card and the declining count sheet recorded 28 remaining the last time she saw the sheet 01/27/26. The MA could not find both the card of the Oxycodone/Hydrocodone 10/325 mg tablets or the declining count sheet for that medication. While looking at the narcotic notebook, MA #1discovered that the shift inventory count sheet had been altered because the signature was not her signature as she signed her name nor was it the same inventory count sheet that she initiated the day prior on 01/27/26. The MA stated she immediately reported what she discovered to the DON. The MA stated she was drug tested and the result was negative.On 06/29/26 at 1:25 PM and 07/01/26 at 2:13 PM interviews were conducted with the Director of Nursing who explained that on the morning of 01/28/26 Medication Aide #1 informed her that Resident #41 asked the MA what time she had her pain medication (Oxycodone/Acetaminophen 10/325) the previous day (01/27/26). The MA looked for the declining count sheet for the Oxycodone/Acetaminophen 10/325 mg tablets because the MA had used one of the discontinued 10/325 mg pills that were stored on the medication cart to equal the new dose of 5/325 mg 2 tablets that was ordered for a one-time dose on 01/27/26. The declining count sheet would have the documented time that the MA gave Resident #41 the pain medication on 01/27/26 but the MA could not find the declining count sheet, nor could she find the card of the medication for the 10/325 mg Oxycodone/Hydrocodone. The MA also noticed that the shift change controlled substance inventory count sheet (a form that indicated how many narcotic cards and declining count sheets were on the medication cart) had been altered. MA #1's signature and Nurse #4's signature had been altered. Nurse #4 worked 01/27/26 until 01/28/26 shortly after midnight and gave report to Nurse #3 who was an agency Nurse that had never worked at the facility. The DON continued to explain that they called Nurse #4 into the facility and the Nurse explained that there should have been 28 Oxycodone/Acetaminophen 10/325 mg tablets left in the card and the declining count sheet had a balance of 28 when the Nurse reported off to Nurse #3 shortly after midnight on 01/28/26. Nurse #4 also reviewed the shift change controlled substance inventory count sheet and noticed her signature had been altered as well. The DON continued to explain that four staff, MA #1, Nurse #4, the Assistant Director of Nursing (ADON) and the DON submitted to a drug test and all results were negative. The ADON and DON were drug tested because they had keys to the medication cart. The facility made numerous attempts to call Nurse #3, and the Nurse returned their call on 01/29/26. Nurse #3 reported that she had no knowledge of Resident #41's missing narcotic card and declining count sheet nor did she know anything about an altered inventory count sheet. Nurse #3 agreed to come to the facility for a drug test but did not return to the facility. The DON stated they continued to call Nurse #3, but the Nurse would not answer their calls. The DON explained that she determined that Nurse #3 must have taken Resident #41's narcotic pain medication and declining count sheet and altered the inventory count sheet because she had never had issues with MA #1 and Nurse #4 and she knew they were trustworthy and had a negative drug test. An interview was conducted with Nurse #4 on 06/30/26 at 10:53 AM. Nurse #4 explained that she was notified on the morning of 01/28/26 and asked to come to the facility because there was an issue with the narcotic count for Resident #41's Oxycodone/Acetaminophen 10 mg every six hours as needed. When she arrived at the facility, she discovered that Resident #41's pain medication was missing along with the declining count sheet, and the shift change inventory count sheet had been altered. The Nurse reported that she knew that there should have been 28 pills left in the narcotic card and the declining count sheet had 28 remaining on the sheet because the day prior on 01/27/26 she had to call the Nurse Practitioner to get a onetime order to use one of the Oxycodone tablets along with one Acetaminophen 325 mg tablet to equal the current dose of Oxycodone/Acetaminophen 5/325 mg dose that Resident was currently on in order for MA #1 to give the Resident her 12:00 PM medication. Nurse #4 stated when she reviewed the shift inventory count sheet, she knew it was altered because her initials had been forged and it was not the same sheet that was there when she left shortly after midnight on 01/28/26 when she counted with Nurse #3 because the sheet did not have the controlled medications that she added to the sheet when the pharmacy delivered medications on 01/27/26. The Nurse stated she was drug tested and the results were negative.Multiple attempts were made to interview Nurse #3 through both voice message and texts, but the attempts were unsuccessful.An interview was conducted with the Pharmacist on 06/30/26 at 1:01 PM who explained that Resident #41's Oxycodone/Acetaminophen 10/325 mg, 30 tablets were delivered to the facility on [DATE] at 11:16 PM and received by Nurse #5.On 06/30/26 at 1:34 PM during an interview with Nurse Practitioner (NP) #1 the NP explained that Resident #41 was admitted to the facility on [DATE] with an order of Oxycodone/Acetaminophen 10/325 mg every six hours as needed. The NP changed the order on 01/22/26 to Hydrocodone 5/325 every eight hours as needed because Resident #41 was sedated. When the NP came in on 01/23/26 Resident #41 was not sedated and demanded to be put back on her original dose of Oxycodone/Acetaminophen 10/325 mg so the NP changed the order to Oxycodone/Acetaminophen 5/325 mg give 2 tablets every six hours routinely. The NP stated she gave a one-time order to Nurse #4 to give one Oxycodone/Acetaminophen 10/325 mg and one Acetaminophen 325 mg on 01/27/26 until the new supply of pain medication came from the pharmacy. The NP stated she was made aware of the drug diversion from the facility management and indicated she felt that the facility had put new systems in place to prevent further drug diversion.On 07/01/26 at 3:10 PM an interview was conducted with the Administrator who explained that after the facility investigated the drug diversion, she acknowledged the potential was there to divert narcotics and indicated she felt the facility put systems in place to prevent further drug diversion.2. Resident #34 was admitted to the facility on [DATE] with diagnoses that included osteoarthritis.Review of Resident #34's medical record revealed an order dated 10/23/24 for Hydrocodone/Acetaminophen 5/325 mg by mouth four times a day.Review of Resident #34's Medication Administration Record for February 2026 revealed the Hydrocodone/Acetaminophen 5/325 mg four times a day was administered as scheduled for the month of 02/2026.Review of a pharmacy delivery sheet dated 02/03/26 indicated 120 tablets of Hydrocodone/Acetaminophen 5/325 mg were delivered to the facility on [DATE] at 10:45 PM and received by Nurse #6.On 07/01/26 at 10:34 AM a telephone interview was conducted with Nurse #6 who explained that she worked the night of 02/03/26 when the pharmacy delivered Resident #34's Hydrocodone/Acetaminophen 5/325 mg, 120 tablets that came in 4 cards of 30 tablets each.Review of a Facility Reported Incident (FRI) Investigation Report dated 03/02/26 submitted by the Administrator revealed in part: an allegation of Diversion of Resident of Drugs discovered on 02/25/26 at 9:12 PM for Resident #34. Summary of Investigation: The facility identified a card of Hydrocodone/Acetaminophen 5/325 mg missing from the 400-hall medication cart. The declining count sheet was also reported missing. The shift change controlled substance inventory count sheet (a form that indicates how many narcotic cards and declining count sheets were on the medication cart) had been restarted without a previous sheet to verify the card count. When interviewed Nurse #2 stated she started a new sheet because there was not one present. The facility conducted 100% audit of all narcotic cards/count sheets/pharmacy deliveries. Nurses, medication aides and nurse management who would have access to the medication cart were drug tested. Findings: The facility cannot say with certainty that the medication was taken or by whom. The facility also cannot say the missing medication is the result of improper processes. The allegation was unsubstantiated. An interview was conducted with Nurse #8 on 06/29/26 at 3:03 PM and 07/01/26 at 11:10 AM. The Nurse explained that she worked 400 hall medication cart on 02/05/26 and 02/06/26 from 7:00 AM to 7:00 PM and all the medication cards, declining count sheets and the shift change inventory sheet were correct and accounted for. She stated she was careful to sign off on the sheets where she was supposed to and if there was anything out of the norm, she would have notified the management team. Nurse #8 indicated she stated she was drug tested and the result was negative.Review of a written statement by Nurse #10 dated 02/26/26 revealed Nurse #10 worked on 400 hall medication cart on 02/05/26 from 7:00 PM to 7:00 AM on 2/06/26 and received report from Nurse #8. Nurse #10 followed the narcotic protocol for counting the narcotics with Nurse #8. All narcotic sheets and cards were accounted for and correct.Attempts were made to interview Nurse #10, but the attempts were unsuccessful.On 07/01/26 at 10:34 AM a telephone interview was conducted with Nurse #6 who explained she worked 02/06/26 from 7:00 PM to 7:00 AM and received report from Nurse #8 when she signed the shift control inventory sheet and the count was correct. Nurse #6 stated she reported off to Nurse #2 on the morning of 02/07/26 and signed the shift control inventory sheet with Nurse #2 but could not remember the count on the sheet.A telephone interview was conducted with Nurse #2 on 07/01/26 at 9:51 AM. Nurse #2 explained that she was notified by the facility (could not remember the date) that she started a new shift control inventory sheet on 02/07/26 for the 400-hall medication cart and the facility wanted to know why she started the new sheet. Nurse #2 continued to explain that when she began her shift on 02/07/26 at 7:00 AM there was not a shift control inventory sheet on the medication cart, so she started a new sheet. The Nurse also stated that the facility informed her that Resident #34's Hydrocodone pain medication was also missing along with the declining count sheet. She reported that she could not remember the count left on the declining count sheet, but it was correct because she did not have any discrepancies for the count. The Nurse reported that she did not know when or how the medication went missing and agreed to take a drug test and the result was negative.A telephone interview was conducted with Nurse #1 on 06/30/26 at 1:40 PM and 07/01/26 at 3:15 PM. The Nurse explained that she could not remember which day it was that she had asked Nurse Practitioner (NP) #2 for a new prescription for Resident #34's Hydrocodone before they ran completely out and the NP assured her that she had already sent the prescription. Then on 02/26/26 the medication had not been delivered so the Nurse called the pharmacy to follow up on the delivery. The pharmacy informed Nurse #1 that it was too early for a refill because there should be at least 30 pills remaining from the 02/03/26 delivery of 120 pills. The Nurse stated she looked through the medication cart again for the 30 pills of Hydrocodone/Acetaminophen belonging to Resident #34 and could not find the medication, so she informed the DON of the situation. The Nurse stated she and the DON investigated the 400-hall medication cart and could not find the medication, but they discovered that the shift control inventory sheet was missing for 02/06/26 as well. The Nurse continued to explain that a new shift control inventory sheet had been started on 02/07/26 by Nurse #2. Nurse #1 explained Nurse #1 stated she took a drug test and the result was negative.A telephone interview was conducted with Nurse #11 who explained that the facility called her (did not remember the day) and informed her that Resident #34's narcotics and declining count sheet were missing. Nurse #11 continued to explain that she worked on 400 hall medication cart on 02/19/26 from 7:00 PM to 7:00 AM and there were no discrepancies with the narcotic count for Resident #34's medication or the declining count sheet for the medication. The Nurse stated the shift control inventory sheet was correct as well. Nurse #11 stated she submitted to a drug test and the result was negative.On 06/27/26 at 2:27 PM and 07/01/26 at 11:20 AM interviews were conducted with the Director of Nursing who explained that on 02/19/26 Nurse #1 who was working on Resident #34's hall (400 medication cart) noticed that the Resident was running low on her Hydrocodone/Acetaminophen 5/325 mg tablets and left a message in the provider book to send a prescription to the pharmacy for a refill. On 02/23/26 Nurse #1 realized that Resident #34's medication had not been delivered from the pharmacy, so she called the Pharmacy to follow up with the new prescription. The pharmacy informed Nurse #1 that the request for refill was too early and the earliest the pharmacy could send a refill would be 03/04/26. The pharmacy informed Nurse #1 that they delivered a supply of 120 tablets of Hydrocodone/Acetaminophen 5/325 mg for Resident #34 on 02/03/26. The DON continued to explain that she audited the 400-hall medication cart by using the delivery slip from the pharmacy the shift control inventory sheet and verified that the Hydrocodone/Acetaminophen was delivered in 4 separate cards on 02/03/26 but she was unable to locate the declining count sheet and one card of the medication. The DON stated the shift control inventory sheet ran through 02/05/26 and the next shift control inventory sheet was started on 02/07/26 by Nurse #2. She stated she asked Nurse #2 why she started a new sheet and the Nurse informed her that there was not a current shift control inventory sheet on the cart, so she started a new one. The DON explained that she interviewed all nurses and medication aides who worked on 400 hall medication cart between 02/03/26 to 02/26/26 and all denied having any knowledge of what happened to the Hydrocodone/Acetaminophen that belonged to Resident #34. The DON stated all the nurses and medication aides were drug tested and all test results were negative. The DON explained that the medication was replaced and charged to the facility. She stated she could not determine what happened to Resident #34's medication and could not rule out that it was accidentally thrown away.Review of a Pharmacy receipt dated 02/27/26 revealed a bill of $4.68 for 120 tablets of Hydrocodone/Acetaminophen paid for by the facility and approved by the Director of Nursing (DON).On 06/30/26 at 6:35 PM a telephone interview was conducted with Nurse #9 who explained that he was drug tested because he worked on the 400-hall medication cart during a certain time frame that he could not remember because it had been several months ago. He stated the results were negative. Nurse #9 stated to his knowledge he has never not had Resident #34's pain medication to give her and if he did not have the medication, he would resort to the automated medication dispensing system which had a backup supply of medications.On 06/28/26 at 4:22 PM an interview was conducted with Resident #34 who explained that she has taken pain medication for years to help control the pain she had daily. She stated the facility was good to give her the pain medication when it was scheduled and the medication was always available for her.Attempts were made to interview Nurse Practitioner #2 who no longer worked for the facility, but the attempts were unsuccessful.On 07/01/26 at 3:10 PM an interview was conducted with the Administrator who explained that after the facility investigated the drug diversion, she acknowledged the potential was there to divert narcotics and indicated she felt the facility put systems in place to prevent further drug diversion.The facility provided the following corrective action plan:Address how the corrective action will be accomplished for those residents found to have been affected by the deficient practice:On 1/28/26 Medication Aide #1 informed the Director of Nursing that she was unable to locate 1 card of Oxycodone 10/325 for Resident #41 and the descending count sheet, as well as the shift change controlled substance inventory sheet appeared to have been altered.On 1/28/26 the Director of Nursing or designee completed a narcotics count of all medication carts and Medication Aide #1's cart and reviewed all shift change controlled substance inventory sheets.On 1/28/26 the Nursing Home Administrator contacted the staffing agency to obtain license and background information and contact information for Nurse #3.On 1/28/26 the Director of nursing or designee completed a head-to-toe assessment of Resident #41 for pain. Pain control was stable at that time. Oxycodone 10/325 had been discontinued and was to be sent back to the pharmacy for destruction.On 1/28/26 the Nursing Home Administrator or designee drug tested the Director of Nursing the Assistant Director of Nursing, Medication aide #1, and Nurse #1. All drug tests were negative.On 1/28/26 the Administrator and Director of nursing interviewed all staff working 3rd shift on 1/27/26.On 1/28/26 the Nursing Home Administrator reported the missing medication to the Regional Director of Clinical Services, the [NAME] President of Operations, the Pharmacy, the Medical Director and the local police department.On 1/29/26 the Nursing Home Administrator and Director of Nursing interviewed Nurse #3 over the phone. Nurse #3 stated she did not recall seeing an Oxycodone 10/235 card for Resident #1. Nurse #3 stated that she would come into the facility to take a drug test and give her statement but never came to the facility.On 1/29/26 the Nursing Home Administrator reported the missing medication for Resident #41 to the North Carolina Division of Health Services Regulation, and the Drug Enforcement Agency.On 2/1/26 the Investigation Report was sent to Division of Health Services Regulation and Adult Protective Services.During an interview with the Director of Nursing, she reported that on 01/28/26 she called board of nursing and reported Nurse #3 for suspected drug diversion.On 2/26/26 Nurse #1 was informed by the pharmacy that Resident #34 who resided on 400 hall hydrocodone 5-325mg refill request was too soon due to it being filled on 2/3/26. The Pharmacy stated there should have been another full card still available and the script could not be filled until 3/4/26.On 2/26/26 the Director of Nursing was notified by Nurse #1, and the Administrator was then notified by The Director of Nursing of possible missing medication card and descending count sheet.On 2/26/26 the Regional Nurse Consultant was made aware by the Director of Nursing, and the Regional [NAME] President of Operations was made aware by the Administrator of the missing medication card and descending count sheet.On 2/26/26 a head-to-toe assessment completed by Nurse #1 for Resident #34 with no complaints of pain.On 2/27/26 all nurses that had received/logged in narcotics on 2/3/26 and 2/19/26 were interviewed. Staff administering medication between 2/5/26-2/7/26 and 2/19/26-2/23/26 on 200 and 400 halls were interviewed. The Director of Nursing reported they did not notice medication was missing, denied removing sheets, staff indicated they completed the shift inventory sheet each shift and do not recall a missing sheet. Statements were obtained by all nurses and medication aides who had access to the medication cart as well as were drug tested by the Human Resources Coordinator or designee.On 2/27/26 the Nursing Home Administrator reported the missing medication to the North Carolina Division of Health Services Regulation and Statesville Police Department.On 2/27/26 the Medical Director and pharmacy were notified by the Director of Nursing of the missing medication. Replacement medication ordered at the facility's expense by the Director of Nursing.On 3/1/26 the Nursing Home Administrator submitted the 5-day investigation report to the North Carolina Division of Health Service Regulation and Adult Protective Services.Address how the facility will identify other residents having the potential to be affected by the same deficient practice:On 2/26/26 the Director of Nursing audited the 400-hall medication cart using the pink delivery slip and shift change controlled substance inventory sheet. It was verified the medication was delivered on 2/3/26 with four sheets and four cards of hydrocodone 5-325mg. One card and one descending count sheet was noted missing. It was noted the shift change controlled substance inventory sheet for the 400-hall cart ended 2/5/26 was also missing, the next sheet started on 2/7/26 by Nurse #2. On 2/26/26 the Director of Nursing interviewed Nurse #2 who reported the shift change controlled substance inventory sheet was missing so she started a new sheet.On 2/26/26 prescription delivery slips and Omnicare proof of delivery were used to audit all narcotics on all other medication carts that had been delivered to the facility in the month of February 2026 by the Director of Nursing or designee. During the audit it was noted Oxycodone-acetaminophen 5-325mg belonging to Resident #119 delivered on 2/19/26 was missing. The pink delivery slip noted 90 tabs were sent on 2/19/26, one card and two descending count sheets were unable to be located. A head-to-toe assessment completed by the Director of Nursing or designee for Resident #119. Resident #119 did not miss a dose and denied pain.On 2/26/26 the facility Social Worker (SW) interviewed all alert and oriented residents with Brief Interview for Mental Status (BIMS) of 12 or higher to ensure they did not have any concerns for medication administration, unrelieved pain, and if they felt their needs were being met.On 2/26/26 pain assessments were conducted for all non-alert and oriented residents by the Director of Nursing or designee.Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur:The Facility Human Resources/Payroll Coordinator conducts criminal background checks, license checks, pre-employment drug tests, and completes reference checks from previous employers for all newly hired employees. Any contracted agency is responsible to conduct pre-employment drug screening, license, reference and background checks and provide documentation at the Administrator or designee's request.Beginning on 2/26/26, the Director of Nursing or designee educated all licensed nurses and certified medication aides on the requirement of two people signing the narcotic descending sheets and delivery sheets when receiving narcotics from the pharmacy. Education also included listing the number of cards and sheets received from the pharmacy, how to properly fill out the shift change controlled substance inventory count sheet, including to start a new sheet the sheet must be filled out by two people and the number of cards and sheets must be listed in the indicated spot. Empty narcotic blister packs and the corresponding narcotic descending sheets must stay on the cart until the Director of Nursing or designee can remove the cards and initial the removal on the shift change controlled substance inventory sheet daily. In addition, the Director of Nursing or designee removes all discontinued medications from the medication carts daily including weekends. Staff were required to take a test to ensure understanding and competence of the process. The Director of Nursing or designee reviewed the test to ensure that the staff understood the education. Any nurse or medication aide who had not been educated by 3/5/26 will not be permitted to work until education and test are completed by the Director of Nursing or designee. The Regional Nurse Consultant educated the clinical nurse management team on 3/2/26 of pharmacy services: receiving controlled substances inventory shift sheets, how to audit system, how to perform staff observations.All newly hired licensed nurses will be educated on said process during orientation by the Director of Nursing or designee. The Administrator contacted the Drug Enforcement Agency on 3/1/26 and NCDHHS Drug Control Unit on 3/4/26 to schedule an onsite inspection to occur at the earliest convenience.On 3/31/26 the Regional Director of Clinical Services contacted [NAME] Healthcare Corporate Compliance to conduct training for all licensed nurses and certified medication aides on penalties and consequences of drug diversion, which took place on 4/1/26.Indicate how the facility plans to monitor its performance and make sure that solutions are sustained:Beginning the week of 3/1/26 the Director of Nursing or Designee will interview 3 nurse/medication aides at random times for the element of surprise to ensure they can verbalize the narcotics process x 12 weeks. Any nurse/medication aide who cannot verbalize the process will be re-educated and made to retake and pass a test.Interviews were conducted with 5 alert and oriented residents to identify issues with medication administration or unrelieved pain. Five non-alert and oriented residents were assessed by the Director of Nursing or designee for any indicators of pain. These audits were started the week of 3/1/26 and conducted x 8 weeks.Likewise, the Regional Nurse Consultant will conduct random weekly audits on varying days of the week with nurse/medication aides to ensure they can verbalize the narcotics process x 4 weeks, then monthly x 2 months.Director of Nursing or designee will randomly defined as different shifts, days for the element of surprise, audit narcotic count sheets and shift inventory sheets. Likewise, the Director of Nursing or designee will check all medication carts daily for zeroed out descending count sheets and medication cards for removal.The pharmacist will conduct monthly audits to ensure compliance.The facility completed and accepted an ad hoc QAPI meeting on 3/1/26. The QAPI team implemented the above plan to ensure compliance. The QAPI team consists of the Director of Nursing, Administrator, Medical Director, Social Worker, Business Office Manager, Life Enrichment Director, Admissions Director, MDS nurse, Dietary Manager, Human Resources Manager, and Assistant Director of Nursing. The QAPI committee will continue to review the audit findings for 3 months to ensure compliance is met. The QAPI committee determined the new date of compliance will be 04/02/26.The facility's corrective action plan with a correction date of 04/02/26 was validated onsite on 7/1/26 by observations and interviews.Multiple observations were conducted of nurses removing controlled medications from the locked box and comparing the count to the declining sheet and documenting on the declining sheet during the medication administration. All four medication carts were reviewed for correct controlled medication counts and matching declining sheets. Correct shift change inv

Based on observations, record review, and staff and resident interviews, the facility failed to assess a resident's ability to self-administer medications for 1 of 1 resident reviewed for self-administering medications (Resident #76). The findings included: Resident #76 was admitted to the facility on [DATE] with diagnoses that included chronic respiratory failure, history of stroke, hemiplegia and hemiparesis following a stroke, hypertension, and heart failure. Review of Resident #76's quarterly Minimum Data Set assessment dated [DATE] revealed Resident #76 was cognitively intact with no delusions, behaviors, or rejection of care. Review of Resident #76's medical record revealed no documentation that Resident #76 had been assessed to self-administer medications. Further review of Resident #76's medical record revealed no care plan for self-administration of medications. An observation of Resident #76 on 04/14/25 at 10:51 AM revealed her to be in her room, sitting in her wheelchair watching television. On Resident #76's overbed tray was a medicine cup that contained 2 blue capsules, 1 pink capsule, 4 white tablets, and 2 beige tablets. An interview with Resident #76 on 04/14/25 at 10:52 AM revealed that Nurse #4 came in and gave her the medication but that she didn't want to take it right then, so Nurse #4 left the medicine cup and left the room. Resident #76 reported she thought the medicine cup included her potassium and a bunch of other stuff. Resident #76 indicated she was unsure what other medications were in the cup. An interview with Nurse #5 on 04/14/25 at 10:59 AM revealed she was the nurse assigned to Resident #76 but that an orientee, Nurse #4, was the nurse that passed Resident #76's medications that morning. Nurse #5 reported that Resident #76 did not have a self-administration order, and that the medication should not have been left at her bedside. An interview with Nurse #4 on 04/16/25 at 10:24 AM via telephone revealed she had worked at the facility for approximately 2 weeks. She verified she was the nurse assigned to Resident #76 on 04/14/25 and had given her medication that morning. Nurse #4 continued, stating she was unaware if Resident #76 had a self-administration order or if she had been assessed to safely administer her own medications. Nurse # 4 reported when she walked into the room, Resident #76 stated she was not quite ready to take her medications and would take them later so Nurse #4 left them on her overbed table. Nurse #4 reported she could not recall what medications had been given to Resident #76 on 04/14/25. An interview with the Director of Nursing on 04/16/25 at 11:58 AM revealed she was not very familiar with Resident #76 but reported that she did not believe the facility had any residents who had the ability to self-administer medications. She reported for residents who wished to self-administer medications, the facility would complete an assessment to ensure the resident was safe to self-administer medications and would then obtain a physician's order which would indicate which medications the resident would be able to self-administer. She indicated without the assessment and the physician's order, no medications should be left at a resident's bedside. An interview with the Administrator on 04/16/25 at 12:38 PM revealed there were no residents in the facility that were currently able to self-administer medications. She stated that unless a resident had been assessed and the facility had obtained a physician's order indicating a resident was safe to self-administer medications, she expected her staff to remain in the residents' rooms and observe them taking their medications.

Based on record reviews and staff interviews, the facility failed to ensure the code status information was accurate throughout the medical record for 1 of 1 resident (Resident #10) reviewed for advanced directives. The findings included: Resident #10 was admitted to the facility on [DATE]. A review of Resident #10's hospital discharge summary dated 12/11/24 indicated Resident #10 was a Do Not Resuscitate (DNR). A review of Resident #10's physician orders revealed an order for DNR dated 12/12/24. A review of the code status notebook kept at the nursing desk revealed Resident #10 did not have a DNR form in the book. On 04/15/25 at 10:44 AM an interview was conducted with Nurse #1 who explained that if she had to immediately determine a resident's code status, she would look in the resident's medical record on the computer but if the computer was not booted up at that time, she would look in the code status notebook kept at the desk. The Nurse reported if there was no DNR form in the code status notebook then the resident was determined to be a full code. Nurse #1 looked in the code status notebook for Resident #10's DNR form and acknowledged the form was not in the book. The Nurse stated she would determine Resident #10 to be a full code. An interview was conducted with the Director of Nursing (DON) on 04/15/25 at 10:46 AM. The DON explained that if a resident was a DNR then there should be a DNR form in the code status notebook at the desk. The DON looked in the code status notebook for Resident #10's DNR form and acknowledged the form was not there. The DON stated the Social Worker was responsible for the advanced directives. During an interview with the Social Worker (SW) on 04/15/25 at 11:55 AM the SW explained that on admission the nurse verified the residents' code status, and their code status was also discussed in the morning clinical meeting the next day. She continued to explain that she was responsible for auditing the code status and the last audit she completed for DNR status was on 04/07/25. A review of the audit revealed Resident #10 was not listed on the audit. When the SW was asked why Resident #10 was not on the audit, she looked in the Resident's medical record and acknowledged the DNR status and stated she could not explain why the Resident did not populate to the audit because the list for the audit came directly from the residents' code status from their medical record. An interview was conducted with the Administrator on 04/16/25 at 12:23 PM. The Administrator stated that she was aware of the problem with Resident #10's code status not matching both in the medical record and the code status notebook. She indicated that not having the residents' code status match throughout the medical record could be a problem and that the facility would be putting new systems in place to prevent the discrepancy from occurring again. The Administrator reported that after researching the issue it was discovered that Resident #10 should have been a full code.

Based on observations, staff interviews and record reviews, the facility failed to clean and disinfect an individually assigned glucometer stored outside of the resident's room per manufacturer's recommendations for 1 of 1 resident observed to have their blood glucose level checked (Resident #13). The facility also failed to provide enhanced barrier precautions (EBP) during wound care by failing to wear a gown during wound care provided to 1 of 1 resident observed (Resident #39). The findings included: 1.The glucometer manufacturer's recommendations for cleaning and disinfecting of Resident #13's individually assigned glucometer recommended the Environmental Protection Agency (EPA)'s registered germicidal and disinfectant wipes that the facility used. The manufacturer's instructions noted, The meter should be cleaned and disinfected after use on each patient. On 04/15/2025 at 11:27 AM Nurse #2 was continuously observed performing a glucometer check on Resident #13. The nurse obtained a glucometer from a plastic bag labeled with Resident #13's name from the medication cart drawer. She failed to clean and disinfect the glucometer prior to using it to obtain a fingerstick blood glucose monitoring reading. Nurse #2 performed the blood glucose monitoring for Resident #13 and placed the meter back into the plastic bag and stored it in the medication cart drawer without cleaning or disinfecting it. Upon interviewing Nurse #2 on 04/15/2025 at 11:34 AM about the cleaning and disinfecting process for glucometers, she stated, I think they get cleaned once a day unless they are visibly soiled. I think they are cleaned on nightshift because I know I don't do it. On 04/15/2025 at 12:36 PM an interview with the Unit Manager for Resident #13 was conducted. When asked about the cleaning and disinfecting process for glucometers, she explained the nurses were supposed to clean and disinfect the glucometer using an EPA registered disinfectant in accordance with the manufacturer's instructions prior to performing blood glucose monitoring and after completion even if the resident had their own glucometer. The Unit Manager stated that the facility used one of the wipes recommended by the glucometer manufacturer. The Assistant Director of Nursing who served as the Staff Development Coordinator and Infection Preventionist was interviewed at 12:38 PM on 04/15/2025. She revealed that the nursing staff received recent glucometer cleaning and disinfecting education, and Nurse #2 attended the training. During this session and upon hire, each nurse was instructed to clean and disinfect the glucometer prior to and after each use of the glucometer using the wipe that the manufacturer recommended. At 12:44 PM on 04/16/2025, the Director of Nursing revealed during interview that the nurses were just retrained to clean and disinfect glucometers before and after use of the glucometer. One EPA registered disinfectant towelette was used to clean the glucometer and another towelette was used to disinfect it after use. Then the glucometer was to be air dried. An interview with the Administrator was conducted on 04/16/2025 at 1:20 PM and revealed that the facility policy was for the nurse to clean and disinfect the glucometer using an EPA registered disinfectant in accordance with the manufacturer's instructions prior to and after use. The Administrator explained that Nurse #2 didn't use the glucometer on any other resident and received training less than one month prior to observation on 04/15/2025. 2. A review of the facility policy for Transmission-Based Precautions and Isolation Policy last revised on 03/20/2025 revealed four types of precautions including Enhanced Barrier Precautions (EBP). EBP were indicated for high contact care activities for a resident with a chronic wound. A continuous observation of wound care on 04/16/2025 at 10:40 AM was conducted and revealed that the Wound Care Physician Assistant (PA) nor the Wound Care Nurse donned a gown for wound care provided to Resident #39. The PA measured and debrided the unstageable pressure ulcer to Resident #39's sacral area, and the Wound Care Nurse provided cleaning, treatment and dressing to the sacral wound as ordered. An interview was conducted with the Wound Care Nurse at 11:03 AM on 04/16/2025 and revealed that if Resident #39 was on EBP, she would have used mask, gloves and gown. When asked if she thought that Resident #39 should be on EBP she stated that she wondered that this morning and that the resident had been on EBP. When the PA was interviewed at 11:03 AM on 04/16/2025, she stated that Resident #39 used to be on EBP, but someone took down the sign. When asked if she thought Resident #39 should be on EBP, she stated that she wondered about it and, Yeah. The PA revealed that today the wound was now Stage 3. On 04/16/2025 at 11:10 AM, the Assistant Director of Nursing (ADON who served as Staff Development Coordinator and Infection Preventionist was interviewed and revealed that EBP with gown and gloves would be used if there was any drainage. She explained that EBP would be used for any chronic wound, and a closed surgical incision would not need EBP. The ADON stated that she would expect Resident #39 to be on EBP and reported that Resident #39 has had the sign, but it isn't there right now. She explained that she conducted audits every so often due to one resident on another hall removing his post EBP sign. An interview with the Director of Nursing (DON) was conducted at 11:19 AM on 04/16/2025 that any type of chronic wound would have EBP using gown and gloves. The DON stated that an unstageable wound or Stage 3 pressure ulcer should have EBP.

Based on observations, record review, resident, staff, and Nurse Practitioner interviews the facility failed to administer oxygen at the prescribed rate of liters for 1 of 2 residents reviewed for respiratory care (Resident #92). The findings included: Resident #92 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease, congestive heart failure, and history of pulmonary embolism. A physician order dated 01/07/24 read, oxygen at 3 liters via nasal canula for respiratory failure. A comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #92 was severely cognitively impaired, had shortness of breath when lying flat and wore oxygen and a non-invasive mechanical ventilator during the assessment reference period. An observation and interview were conducted with Resident #92 on 02/05/24 at 10:56 AM. Resident #92 was resting in bed with oxygen in place via nasal canula at 4 liters per minute. He stated that he wore his oxygen all the time since being at the facility and also wore his continuous positive airway pressure (CPAP) at night when he was sleeping. An observation of Resident #92 was made on 02/06/24 at 8:36 AM. Resident #92 was in bed with the head of his bed elevated and was eating breakfast. He had oxygen in place via nasal canula at 4 liters per minute. An observation and interview were conducted with Resident #92 on 02/07/24 at 3:01 PM. Resident #92 stated the staff had just assisted him back to bed and he was noted to have no oxygen in place. Resident #92 was asked if he needed his oxygen and he stated I ain't thought nothing about it and reached for the cannula and put the canula back in his nose. The oxygen concentrator sitting next to his bed was set to deliver 4 liters of oxygen. Resident #92 was asked how much oxygen he required, and he stated, not much. Nurse #1 was interviewed on 02/07/24 at 3:05 PM and stated that Resident #92 required 2 liters of oxygen via nasal cannula and stated, to be honest I have not looked at his oxygen concentrator today. He stated that night shift nurses were responsible for changing out the oxygen tubing, humidifiers, and nebulizer sets weekly. Nurse #1 further stated that the Nurse Aides (NA) were not able to adjust the oxygen rate that would be the responsibility of the nurse. Nurse #1 was asked to verify the physician order for Resident #92's oxygen and when he did, he stated Resident #92was actually supposed to be on 3 liters of oxygen via nasal cannula. Nurse #1 was asked to visual Resident #92's oxygen rate during the interview and confirmed that it was on 4 liters per minute and adjusted it to the correct dose of 3 liters. Nurse #1 also placed a pulse oximeter on Resident #92's finger and it indicated his oxygen saturation level was 95%. The Director of Nursing (DON) was interviewed on 02/07/24 at 3:58 PM and stated oxygen tubing was changed every Sunday night by the nursing staff. She further explained that the nursing staff changed the oxygen tubing, cleaned the filters, and humidifiers as needed and then signed off on it in the medical record. The DON stated the hall nurse should be ensuring that the residents were receiving the correct dose of oxygen, in addition oxygen rate was apart of the guardian angel rounds that the management staff conducted every morning. The facility also had a list of devices that included oxygen and reviewed it weekly to ensure the correct amount of oxygen was being delivered. The Nurse Practitioner (NP) was interviewed on 02/07/24 at 11:56 AM who stated when she first met Resident #92, he had lots of generalized edema and she knew she had to get that fluid off of him due to his history of heart failure. The NP stated they used diuretics to pull the extra fluid off of Resident #92 to the amount of about 40 pounds. She stated that initially Resident #92 was non complaint and combative and was not aware of what was going on but since his admission he had really improved a great deal and was very alert and oriented. She added Resident #92 was very compliant with care at this time and with his oxygen. The NP stated that Resident #92's oxygen setting of 4 liters instead of 3 liters did not appear to have any ill effect on him with his pulse oximeter level of 95%.

Based on observations, record reviews, resident, and staff interviews, the facility's Quality Assessment and Assurance (QAA) committee failed to maintain implemented procedures and monitor interventions the committee put into place for Infection Control (F880) following the complaint survey conducted on 01/07/22, and for Respiratory Care (F695) following a recertification and complaint survey on 08/25/22. The two deficiencies were recited during the recertification and complaint survey on 02/08/24. The repeat deficiencies during three federal surveys of record showed a pattern of the facility's inability to sustain an effective QA program. The findings included: This tag is cross referred to: F880 D: Based on observation, record review, and staff interviews, the facility failed to implement their policy for Personal Protective Equipment (PPE) when Nurse Aide (NA) #1 failed to clean her hands and don personal protective equipment as directed before entering 1 of 3 residents' room on transmission-based precautions (Resident #1). During the complaint investigation of 01/07/22 the facility failed to follow the CDC guidance regarding appropriate Personal Protective Equipment (PPE) for counties of high county transmission rates when 1 of 2 wound care personnel failed to wear eye protection while performing wound care for 1 of 3 residents who required wound care, 3 of 6 Nurse Aides (NA) provided care to 4 of 4 residents without wearing eye protection, 1 of 6 NAs delivered meal trays to 4 of 4 residents without wearing eye protection, and 1 of 4 nurses failed to don eye protection when entering a resident room on enhanced droplet isolation. These practices had the potential to affect all residents who received care from the facility staff. These failures occurred during a COVID-19 pandemic. F695: Based on observations, record review, resident and staff interview the facility failed to administer oxygen at the prescribed rate of liters for 1 of 2 residents reviewed for respiratory care (Resident #92). During the recertification and complaint survey on 08/25/22 the facility failed to secure an oxygen tank that was stored upright on the floor in a resident room for 1 of 2 residents reviewed for respiratory therapy. The Administrator and the Director of Nursing (DON) were interviewed on 02/08/24 at 12:22 PM. The Administrator stated that the Quality Assurance (QA) committee met monthly and included Administration, all department heads, Pharmacy, and their Medical Director. She stated occasionally they invited a direct care staff member for front line staff input. Additionally, they had two top performance improvement plans in place for falls and reducing hospital readmission. The Administrator stated the QA committee members were very committed to quality improvement and their meetings were very active, effective, and efficient. Additionally, they reviewed all serious incidents and grievances and they tracked and trended all that information for improved resident safety.

Based on observation, record review, and staff interviews, the facility failed to implement their policy for Personal Protective Equipment (PPE) when Nurse Aide (NA) #1 failed to perform hand hygiene and don personal protective equipment as directed before entering 1 of 3 residents' room on transmission-based precautions (Resident #1). The findings included: Review of the facility's Transmission Based Precaution Policy dated 01/2024 read in part, Contact Precautions: intended to prevent transmission of infectious agents which are spread by direct or indirect contact with the patient or the patient's environment. Contact precautions also apply where the presence of excessive wound drainage, urine, or fecal incontinence, or other discharges from the body suggest an increased potential for environmental contamination and risk of transmission. Personal Protective Equipment recommended: Gloves: whenever touching the resident's intact skin or surfaces and articles in close proximity to the resident. Gowns: whenever anticipating that clothing will have direct contact with the patient or potentially contaminated environmental surfaces or equipment in close proximity to the resident. According to the facility protocol document titled Hand Hygiene/Handwashing Policy revised [DATE], hand hygiene should be performed before and after contact with residents, after removing gloves, and should be performed after contact with inanimate objects including medical equipment in the immediate vicinity of the resident. A continuous observation was made on 02/06/24 at 8:39 AM to 8:45 AM. Resident #1's call light was noted to come on at 8:39 AM and signage on door that stated Contact Precautions everyone must: clean their hands, including before entering and when leaving the room, put on gloves before room entry, discard before room exit, put on gown before room entry, and discard gown before room exit. There was also a container of PPE sitting directly outside of Resident #1's door that was well stocked with gowns and gloves. At 8:41 AM Nurse Aide (NA) #1 knocked on the door and entered Resident #1's room and proceeded to her bedside without cleaning her hands or applying gloves or gown. NA #1 was observed to touch Resident #1's bedrail and call light which were in close proximity to the resident and then was observed to go to the closet and obtain a towel and washcloth then returned to Resident #1's bedside where she placed the towel and washcloth on Resident #1's bed. NA #1 then exited the room and was observed using hand sanitizer that was on the wall across from Resident #1's room. NA #1 was interviewed on 02/06/24 at 8:42 AM. NA #1 stated Resident #1 was on contact precautions for something in her urine, so if I am doing something with her urine then I would put on PPE. NA #1 further stated she did not think she had to apply PPE unless she had contact with Resident #1's urine and the resident wanted some towels for when she got up later in the morning. The Director of Nursing (DON) was interviewed on 02/06/24 at 9:50 AM who stated she also served as the facility's Infection Preventionist. The DON explained that Resident #1 was on contact precautions for extended spectrum beta lactamases (ESBL) which was a type of infection and staff were expected to follow the directions of the signage on the door. She explained the sign directed them to clean their hands before they enter the room, apply gown, and gloves before they enter the room, and remove gown and gloves before exiting the room and clean hands when they leave the room. The DON explained the importance of staff applying PPE anytime they go into the room or cross the threshold to prevent the spread of infection or risk of contamination. The Administrator was interviewed on 02/08/24 at 9:13 AM and explained they had done a great deal of training on infection control and the importance of applying PPE during their town hall (staff meeting) and even had a demonstration of the correct way to don and doff PPE in the last few months.

Based on observations, record review, staff, family, and Nurse Practitioner (NP) interviews the facility failed to have a working call bell for the resident to use to call for help and the resident attempted to get up and fell into the floor and then the facility failed to investigate the fall out of bed which required the resident to be sent to the emergency room (ER) and was diagnosed with an acute nondisplaced nasal fracture (Resident #156). Resident #156 fell from his bed during the night and was transferred off the floor back to bed and developed a nosebleed and had to be transferred to the ER where he was diagnosed with a nondisplaced nasal fracture and required silver [MEDICATION(S)] (used to burn the skin to stop bleeding). The facility also failed to transfer a resident using the correct mechanical lift which resulted in the resident falling from the lift (Resident #66) for 2 of 3 residents reviewed for accidents. The finding included: 1. Resident #156 was admitted to the facility on [DATE] with diagnoses that included: [CONDITION(S)], right above knee amputation, and others. Review of physician orders dated 06/17/22 included the following medications: Aspirin 81 milligrams (mg) by mouth every day, [MEDICATION(S)] (blood thinner) 5 mg by mouth every day, and [MEDICATION(S)] (blood thinner) 75 mg by mouth every day. Review of the Admission Minimum Data Set (MDS) dated [DATE] indicated that Resident #156 was moderately cognitively impaired and required extensive assistance of two staff members for bed mobility and transfers. The MDS further indicated that Resident #156 had a fall history prior to admission but had no falls since admission to the facility. Review of Resident #156's medical record revealed no documentation of a fall occurring. Review of a Skilled Nursing Facility (SNF) to Hospital transfer form dated 06/26/22 at 9:13 AM read in part; Reason for transfer: Fall. The form indicated that Resident #156 was capable of decision making and ambulated independently and the family and NP were made aware of the transfer. The form was signed by Nurse #2. Resident #156's family member was interviewed on 08/23/22 at 5:01 PM. The family member stated that he came to the facility on [DATE] between 10:00 AM and 11:00 AM and when he walked into the room, he noted a bloody towel laying on the bed. The son stated a staff member whom he did not know stated that Resident #156 had a nosebleed, and they were trying to get it stopped. The staff member also informed him that Resident #156 had fallen out of bed on the previous shift, but no one had reported it to them except Resident #156. He added that Nurse Aide (NA) #18 was also trying to get the bleeding stopped. The family member stated that he stayed with Resident #156 until breakfast came and after breakfast, he began to shave Resident #156 and during that time he kept having to stop because Resident #156's nose kept dripping with blood and it kept dripping then became a steady stream of blood. The family member stated he went to the staff and stated that he was concerned that Resident #156's nose kept bleeding and he was on a blood thinner and did not want him to bleed out. The staff member returned about 15 minutes later and stated she had gotten authorization to transfer him to the ER and Resident #156 was transferred to the ER where they discovered he had a nasal fracture. Resident #156 was discharged to the hospital on 06/26/22. Review of an ER to Hospital admitted d 06/26/22 read in part, Fall: right epistaxis (nosebleed) improved. Management of epistaxis included the use of silver [MEDICATION(S)] which stopped the bleeding. Nondisplaced nasal fracture. Review of the facility schedule for 06/25/22 revealed that Nurse #4 was assigned to the unit where Resident #156 resided from 7:00 PM to 7:00 AM, Nurse #5 was schedule on a unit next to where Resident #156 resided from 7:00 PM to 7:00 AM, Nurse #6 and Nurse #7 were scheduled on the other side of the facility from 7:00 PM to 7:00 AM. Review of the facility schedule for 06/26/22 revealed that Nurse #2 was assigned to the unit where Resident #156 resided from 7:00 AM to 7:00 PM and NA #18 was assigned to care for Resident #156 from 7:00 AM to 11:00 PM. NA #18 was interviewed on 08/24/22 at 12:33 PM and confirmed that she had worked with Resident #156 on 06/26/22 at 7:00 AM until he was transferred to the hospital. She stated she had not received any report that morning because she was running late to work. NA #18 stated when she got to work, she went to check on Resident #156 and he stated he had fallen out of bed during the night and laid in the floor for 2 hours and then when the staff came in, they were stern with him about not using his call bell, which he stated did not work. NA #18 stated that while she was in the room with Resident #156 his nose started bleeding and she applied pressure and immediately went and got Nurse #2 who immediately came to the room and tried to get the bleeding stopped by applying pressure, but his nose kept dripping then became a steady stream. She stated that Resident #156 told Nurse #2 the same story about falling out of bed during the night, but the fall never got reported to Nurse #2 from the previous shift. NA #18 stated that NA #17 had cared for Resident #156 through the night and added Resident #156 would not be able to get himself up if he fell out of bed. NA #18 stated that while she was in the room with Resident #156 his family came in and when they saw the nosebleed, they requested him to be sent to the ER for evaluation and so Nurse #2 arranged the transfer. NA #18 stated she saw no other injuries except the nosebleed. NA #17 was interviewed on 08/24/22 at 5:36 PM and confirmed that she was working with Resident #156 on 06/25/22 at 7:00 PM to 7:00 AM on 06/26/22. NA #17 stated that when she arrived for her shift at 7:00 PM she had made a round and Resident #156 was resting in bed, and she stated she again checked on him between 11:00 PM to 12:00 AM and again was resting in bed. She stated that when she made her third round between 2:00 AM and 3:00 AM she found Resident #156 on the floor. NA #17 stated she asked Resident #156 why he had not turned on his call light if he needed something and Resident #156 indicated that he had turned the call light on, and it was not working. NA #17 stated she pressed the call light to test it out and it was in fact not working. NA #17 stated she went and got a nurse but did not know who the nurse was. She stated that they picked Resident #156 up off the floor and placed him back in the bed, but she did not see any injuries, no bleeding or bruising and no knots on his head. NA #17 stated that once Resident #156 was back in the bed she left the room while the nurse remained at bedside. She stated she did not get any vital signs nor was she asked to get vital signs. NA #17 stated she did not do anything with the call bell but did let the nurse know that it was not working. NA #17 was informed that Nurse #4 was scheduled to be on the unit where Resident #156 resided, and she stated she was certain the nurse was not Nurse #4 but did not know who the nurse was that assisted her in getting Resident #156 out of the floor that night. Nurse #5 was interviewed on 08/24/22 at 5:51 PM and stated she had no knowledge of Resident #156 falling out of bed. She stated if a resident fell , she would have to complete all the required paperwork in addition to the head-to-toe assessment and notify the provider/family but again she stated she knew nothing about Resident #156 falling out of bed nor did she assist in getting him back in the bed. Nurse #7 was interviewed on 08/24/22 at 6:02 PM and confirmed that she worked at the facility through an agency. She stated she had no recollection of Resident #156 and had no knowledge of a fall or transfer to the hospital. Nurse #4 was interviewed on 08/24/22 at 6:07 PM and stated that had no knowledge of Resident #156 falling out of bed or being transferred to the hospital. She stated if a resident fell during her shift she would immediately complete a head-to-toe assessment including range of motion, administer any first aide that was needed, notify the provider/family, and document the fall in the medical record. Nurse #6 was interviewed on 08/24/22 at 6:29 PM and confirmed that she worked at the facility through an agency. She stated she had no recollection of Resident #156 or any fall out of bed or transfer to the hospital. Attempts to speak to Nurse #2 were made on 08/23/22, 08/24/22, and 08/25/22 without success. The interim Director of Nursing (DON) was interviewed on 08/24/22 at 3:52 PM and confirmed that she had worked at the facility since March 2022 but had only been the interim DON since 08/23/22. She stated she recalled discussing Resident #156 in the clinical stand-up meeting because he had gone out to the hospital because he stated he fell and wanted to go to the hospital. The interim DON stated she did not believe he fell and knew nothing about a nosebleed and knew nothing about how or why he fell . She added she knew that staff were interviewed by one of the previous DON's but there was no documentation of those interviews. The Interim DON stated she had no incident report, no investigation, no documentation that she could find regarding a fall for Resident #156. The former DON was interviewed on 08/25/22 at 7:14 PM who confirmed that she was the DON during the time Resident #156 was in the building. She stated she vaguely recalled the event. She stated that when Resident #156 went to the hospital he reported a fall, and we had no record of the fall, and she was very confused because he could not have gotten himself up. The former DON stated she believed that they had interviewed the staff that worked that night and she had placed the interviews in a folder and left them in the facility. She stated that the current DON should be able to locate them. The NP was interviewed on 08/25/22 at 3:42 PM and stated that sometime on the morning of 06/26/22 someone from the facility had called her but she could not recall who and stated that Resident #156 reported he fell out of bed and wanted to go to the ER to be evaluated. She stated that she agreed, and he was transferred to the ER. The NP stated to her knowledge there was no injuries, and she was not aware of any nosebleed. The NP stated that after she arrived at work that morning there was discussion in the morning meeting about it and she was told that they had talked to the staff that worked and no one saw him fall so she did not believe that there was a fall. The Administrator was interviewed on 08/25/22 at 5:18 PM and stated she had been at the facility for three months. She stated that she recalled Resident #156 reporting that he fell during the night and discussing that he would not have been able to put himself back into bed because of his recent amputation. The Administrator stated that from what she could remember Resident #156 had a nosebleed and the family wanted him transferred to the ER. She stated that when a resident fell , she expected the staff to report the fall, complete the required head to toe assessment and a full investigation should have been conducted by the former DON. 2. Resident #66 was admitted to the facility on [DATE] with diagnoses that included [CONDITION(S)], chronic pain, and [CONDITION(S)] (OA). A therapy screen form dated 3/30/22 indicated Resident #66 was screened by physical therapy and was appropriate for the use of a total body lift with 2 person staff assistance due to decrease range of motion (ROM) of the bilateral upper extremities (BUE) and OA of bilateral knees. A quarterly Minimum Data Set (MDS) dated [DATE] indicated Resident #66 was cognitively intact and required total dependence of 2 staff for transfers. An incident report dated 6/2/22 at 2:37 PM written by MDS Nurse #1 revealed Resident #66 experienced a fall in the bathroom. The incident report indicated a Nurse Aide (NA) #21 transferred Resident #66 from the commode using a sit to stand lift when her knees buckled, and Resident #66 slid out of the lift pad and onto the floor. An interview on 8/23/22 at 2:40 PM with MDS Nurse #1 revealed she attended the huddle immediately, (facility meeting to discuss a resident fall or incident) following Resident #66's fall on 6/2/22. MDS Nurse #1 indicated she assisted in completing the incident report; however, she only entered data related to the details of the fall. An interview with NA #21 on 8/24/22 at 1:58 PM revealed she was the NA assigned to Resident #66 on 6/2/22 and verified she and another agency NA, whom she could not recall the NA's name, transferred Resident #66 to the commode using a sit to stand lift after Resident #66 requested to go to the toilet. NA #21 stated she was new to the facility at that time and was not familiar with Resident #66 so when Resident #66 requested to go to the commode using the sit to stand lift she did not verify what transfer status she was assigned through the use of the Kardex or the EMR (electronic medical record), but instead asked the Medication Aide assigned to her hall who told her if Resident #66 requested to go to the bathroom with the lift to take her. She could not recall the MA's name whom she had asked. NA #21 stated when she and another agency NA used the sit to stand lift to transfer Resident #66 from the commode, Resident #66's knees buckled and she let go of the lift with her hands causing her to fall out of the bottom of the lift sling and to the floor landing on her right side and bumping her head on the floor. NA #21 explained when Resident #66 fell she put a pillow under her head and went to the resident's door to summon other staff for assistance. NA #21 indicated multiple staff came to the room to assist and examine Resident #66 while she was in the floor before she was transferred back to her bed using the Hoyer lift. NA #21 stated she recalled Resident #66 complaining of her head hurting after she fell but did not recall any open area or bleeding. NA #21 said she thought the straps had been placed on the correct position. NA #21 stated she had never been shown how to use the sit to stand lift and she could not recall being asked to write or give a verbal account of what occurred following the huddle meeting. An interview with NA #20 on 8/24/22 at 1:42 PM revealed she was not assigned to Resident #66 on the 6/2/22, the date of the fall; however, was assigned to Resident #66's hall. NA #20 stated when she arrived at the time of the fall, Resident #66 was lying in the floor on her right side with her head in the direction of the toilet. NA #20 stated she assisted Resident #66 to be transferred from the floor to the resident's bed with the use of a Hoyer lift after her fall. NA # 20 stated she was aware in the past Resident #66 would request to go to the bathroom and wanted to use the sit to stand lift, but Resident #66's correct transfer status was a Hoyer lift for safety. An interview on 8/23/22 at 3:19 PM with Nurse #8 revealed she attended the huddle immediately following the fall and assessed Resident #66 for injuries. She indicated Medication Aide #1 (MA #1) was assigned to the hall on the date of the fall; however, MAs were unable to assess and she took over the care for Resident #66. Nurse #8 verified Nurse Practitioner (NP) #1 assessed Resident #66 and gave authorization to assisting her back to bed. A progress note dated 6/2/22 written by NP #1 revealed Resident #66 experienced a fall. The note indicated NP #1 was summoned to the room of Resident #66 where she was found to be in the bathroom floor lying on her right side. Resident #66 and staff had reported the fall occurred when Resident #66 fell from the sit to stand lift in the bathroom and had reported the only pain she had at the time was in the back of the head. At the time of the fall on 6/2/22, NP #1 indicated there was no visible swelling or open areas on the head nor loss of consciousness immediately post fall to the floor. An interview with NP #1 on 8/24/22 at 9:55 AM revealed she was summoned to the room of Resident #66 on the date of her fall (6/2/22). NP #1 verified she assessed the resident for injuries after she fell in the bathroom because NA #21 transferred Resident #66 to the toilet with a sit to stand lift despite her need for a total body lift which was her assigned transfer status. NP #1 verified Resident #66 complained of head pain, but upon exam, there were no open areas or visible swelling. A progress note dated 6/3/22, with no time of note, written by NP #1 revealed Resident #66 was up in her wheelchair and complained of right upper extremity pain with movement. The note indicated during the examination, family entered the room and agreed to allow for an x-ray of the right shoulder and elbow to be performed. A physician's order dated 6/3/22 revealed Resident #66 had an order which requested a right shoulder and elbow x-ray STAT. An x-ray report of the right shoulder and elbow dated 6/4/22 indicated Resident #66 had a no acute injury to the right elbow; however, she had a right anterior dislocation of the glenohumeral (shoulder) joint and no acute fracture present. A nurse progress note dated 6/6/22 at 2:20 PM indicated Resident #66's x-ray reports had been received by the facility and indicated a right shoulder dislocation and the NP was notified. The note further explained the NP ordered Resident #66 to be referred to orthopedic for follow-up care for the acute right shoulder dislocation. The note referenced attempts to make an appointment for Resident #66 with an orthopedic office and they refused to see Resident #66 without an emergency room examination. Resident #66's responsible party was contacted and agreed to transfer to the emergency room and was transported via emergency medical services (EMS) on 6/6/22 at 4:20 PM. An emergency room report dated 6/6/22 indicated Resident #66 was examined for a fall from a sit to stand lift 4 days prior and x-rays of the right and left shoulder were ordered and obtained. Upon examination, Resident #66 vocalized a pain level of a #7 of 10 to the right shoulder. The report further indicated an x-ray of the right shoulder indicated there was no dislocation of the glenohumeral found; however, the joint space as not well demonstrated. An interview with the former DON #3 on 8/24/22 at 3:55 PM revealed she was the DON at the time of Resident #66's fall, but vaguely recalled hearing about the incident. She indicated she could not recall if any investigation was completed by herself; however, stated if she had been involved, she would have obtained statements from the resident and staff involved, determined the root cause of the incident, and provided education to staff to prevent further incidents from occurring. She indicated to her knowledge, NA #21 should have been trained by her agency prior to working in the facility and she was unable to verify if any additional education had been provided to NA #21 regarding the proper use of the lifts and how to identify the assigned transfer status for each resident. She stated all NAs in the facility should follow the proper transfer status for each resident for safety. An interview with the Interim Director of Nursing and Administrator on 8/25/22 at 4:39 PM revealed all NAs should transfer residents using the designated transfer status assigned to each resident to ensure safety. The Interim DON verified Resident #66's transfer status was a total body lift at the time of the incident.

Based on observation, record review and resident, staff, pharmacy, and Nurse Practitioners (NP) interviews, the facility failed to manage a resident's pain when she was provided the incorrect dosage of a narcotic pain medication for 1 of 1 resident reviewed for pain management (Resident #38). Findings included: Resident #38 was admitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #38's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The order read as follows: An order dated 3/25/21 for [MEDICATION(S)] 10/325mg (milligram)- give 1 tablet by mouth every 6 hours PRN (as needed) for pain. A review of Resident #38's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] An order dated 8/19/21 for [MEDICATION(S)] 100 mg- give 1 capsule twice daily for [CONDITION(S)] pain. An order dated 4/6/22 for [MEDICATION(S)] 5mg- give 1 tablet twice daily for back pain. A Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #38 was cognitively intact and had no episodes of refusals of care. The assessment further indicated she received scheduled pain medications, received PRN (as needed) pain medications, had occasionally experienced pain over the last 5 days and had received 7 days of opioid medications during the reference period of 7 days. A review of Resident #38's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The order read as follows: An order dated 7/4/22 for [MEDICATION(S)] 5/325mg now x 1 dose due to medication not available from pharmacy. A progress note dated 7/5/22 written by Nurse Practitioner #2 revealed Resident #38 had polyosteoarthritis which she had a current medication regimen that included [MEDICATION(S)] 10-325 mg every 6 hours as needed for pain - and the recommendations was to continue the same medication regimen for pain. A review of Resident #38's July 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . It also indicated [MEDICATION(S)] 10/325mg was administered 7/1, 7/4, 7/5, 7/6, 7/7, 7/8, 7/9, 7/10, 7/11, 7/12, 7/13, 7/14, 7/15, 7/17, 7/18, 7/19, 7/20, 7/21, 7/22, 7/23, 7/24, 7/25, 7/26, 7/27, 7/28, 7/29, 7/30, and 7/31. The July MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . According to a Controlled Medication Utilization Record dispensed from the pharmacy on 7/25/22 indicated Resident #38 was administered [MEDICATION(S)] 5/325 mg on 7/26, 7/27, 7/28, 7/29, 7/30, and 7/31. According to pain documentation for July 2022 in addition to the levels listed on the July MAR, Resident #38 had a pain level that reached a level #7 on 7/26/22. A comparison of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . However, the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #38's August 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . It also revealed Resident #38's pain level had reached a level #8 on 8/3, #6 on 8/4, #7 on 8/6, #8 on 8/7. According to a Controlled Medication Utilization Record dispensed from the pharmacy on 7/25/22 indicated Resident #38 was administered [MEDICATION(S)] 5/325 mg on 8/1, 8/2, 8/3, 8/4, 8/5, 8/6, and 8/7. According to pain documentation for August 2022, in addition to the levels listed on the August MAR, Resident #38 had a pain level that reached a level #8 on 8/2/22. A comparison of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . However, the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . A progress note dated 8/2/22 written by Nurse Practitioner #2 revealed Resident #38 had polyosteoarthritis which she had a current medication regimen that included [MEDICATION(S)] 10-325 mg (milligram) every 6 hours as needed for pain - and the recommendations was to continue the same medication regimen for pain. An observation and interview with Resident #38 on 8/22/22 at 1:39 PM revealed she was sitting in her recliner and voiced she had concerns that her pain was not controlled during July and part of August 2022. Resident #38 stated, at times, her pain had reached a level #10 and she indicated she was unsure if she was being administered her pain medication because her pain was not being controlled like it had previously been when she received her pain medication consistently. Resident #38 vocalized she was aware there had been some concerns with the facility not having her [MEDICATION(S)] available from the pharmacy and she had to go without it at times. Resident #38 was unable to identify specific dates, but clarified her pain was unmanaged for periods during July and August. She vocalized, my pain has been so bad at times, I almost think I wasn't given anything but Acetaminophen. A follow-up interview with Resident #38 on 8/24/22 at 9:34 AM revealed that during parts of July and August 2022 she had experienced pain in her lower back and legs which she described as achy with frequent cramps that went down the backs of both legs. She indicated she had made staff administering medications, the DON, and her NP that she was having pain and did not feel like her pain was being managed correctly but was not provided a solution and could not recall the dates she spoke with individuals. A telephone interview with the dispensing pharmacy on 8/24/22 at 8:00 AM revealed they had record of Resident #38 receiving [MEDICATION(S)] 10/325 mg since admission; however, after a telephone conversation with the facility about dispensing concerns, the pharmacy received a faxed prescription written by NP #2 on 7/25/22 which read [MEDICATION(S)] 5/325 mg: give one tablet every 6 hours PRN for pain with a quantity written for #120; therefore, the pharmacy filled the order despite not receiving notification through the electronic medical record the order had been received by the facility. An interview with Nurse Practitioner #2 on 8/24/22 at 8:53 AM revealed she had taken over the primary care of Resident #38 and was aware she had chronic pain. Nurse Practitioner #2 stated she had been made aware early in July 2022 that the facility was experiencing difficulty obtaining Resident #38's narcotic pain medications and new scripts had to be written frequently and sent in order for the pharmacy to be able to dispense small quantities at a time. She stated Resident #38 had been consistently receiving [MEDICATION(S)] 10/325 mg which was effective in managing her pain. She indicated NP #1, the Director of Nursing (DON), the pharmacy, and herself had a telephone conference call. After concluding the call, she faxed a prescription into the pharmacy which read [MEDICATION(S)] 5/325 mg give 1 every 6 hours as needed for pain. NP #2 stated she did not verify the current order before writing the script and inadvertently had written the prescription for the incorrect dosage. She stated this was discovered within a couple days of writing the prescription because she notified the facility Resident #38 had been complaining of pain after Resident #38 had approached her with pain management concerns. She indicated she spoke with the DON and notified her the resident should be receiving [MEDICATION(S)] 10/325 mg every 6 hours PRN for pain and that the [MEDICATION(S)] 5/325 mg was a one-time order and she had inadvertently faxed the pharmacy a script that included the incorrect dosage. The DON indicated she would correct the concern. NP #2 stated she had not heard anything else from the DON or staff and was not aware Resident #38 continued to receive the incorrect dose of [MEDICATION(S)] 5/325 mg until 8/7/22. An interview with the Interim Director of Nursing, Administrator, and Corporate Nurse Consultant on 8/24/22 at 9:00 AM revealed they had no knowledge Resident #38 had received the incorrect dosage of a controlled opioid during July and August 2022. An interview with NP #1 on 8/24/22 at 9:55 AM revealed she had assisted in managing the care of Resident #38 in the absence of NP #2 being in the building and recalled that Resident #38 had approached her during July 2022 and indicated her pain was not being managed well. NP #1 stated that she, NP #2, and the DON had a telephone conference call with the pharmacy related to the dispensing of Resident #38's opioid medication. NP #1 stated there had been difficulty obtaining her medication when requested and had to write a new script every 3 days or so because the pharmacy was not dispensing more than 12 at a time. NP #1 stated she was aware NP #2 had faxed in a new script to the pharmacy for Resident #38's medication; however, had never been notified the incorrect dose had been written on the script faxed nor that Resident #38 was receiving the dosage of [MEDICATION(S)] 5/325 mg without a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A telephone interview with the DON on 8/24/22 at 1:08 PM revealed she was not longer employed at the facility; however, she recalled the telephone conference call between herself, the two facility NP's, and the pharmacy related to concerns with the dispensing of Resident #38's ordered medication: [MEDICATION(S)] 10/325 mg and the need for the providers being asked to write a new prescription every few days due to the pharmacy only dispensing a very small quantity at a time. She could not recall the exact date of the conference call; however, stated she thought NP #2 was going to fax in a new script to the pharmacy following the call. The DON did indicate NP #2 had spoken with her regarding the incorrect dosage being dispensed from the pharmacy and to her recollection, the concern had been corrected. She did not know Resident #38 had continued to receive the incorrect dosage until 8/7/22. A follow-up interview with the Interim Director of Nursing and the Administrator on 8/25/22 at 4:39 PM revealed the Interim DON stated all staff administering medications should compare the order written in the electronic medical record to the controlled medication utilization record as well as to the card dispensed from pharmacy before administering any medication to any resident. All staff administering medications should follow the 6 Rights: right resident, right medication, right dose, right time, right route, and right documentation. The Interim DON indicated the [MEDICATION(S)] 5/325 should not have been administered except on 7/4/22 when the one-time order was obtained from the provider when the medication was unavailable from pharmacy. She stated Resident #38 should have received [MEDICATION(S)] 10/325mg every 6 hours PRN pain and that the staff should not have signed they provided a medication that was not available in the facility.

Based on observations, record reviews, staff and resident interviews the facility failed provide bathing assistance to dependent residents for 3 of 5 residents (Resident #1, Resident #81 and Resident #82) reviewed for activities of daily living. The findings include: 1. Resident #1 was admitted to the facility on [DATE]. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 was cognitively intact and totally dependent on staff for bathing. The MDS also indicated the Resident had the behavior of rejecting care 1 to 3 days in the look back period. Resident #1's care plan revised on 06/02/22 revealed he was at risk for altered moods and behaviors related to behavioral disturbances. The goal that his mood and behavior would remain stable would be attained by utilizing interventions such as always approach in a calm relaxed manner and to explain procedures before providing assistance. The Resident did not have a care plan that was specific to refusing showers. A review of the facility's shower schedule revealed Resident #1 was scheduled to receive his shower on Wednesday and Saturday on second shift. A review of Resident #1's medical record for the month of August 2022 revealed there was no documentation of the Resident refusing his showers. A review of Resident #1's bathing record revealed there was no documentation of showers given from 08/01/22 through 08/20/22. The facility could not provide a Bath/Shower sheets for Resident #1 for 08/01/22 through 08/20/22. On 08/22/22 at 12:01 PM during an observation and interview with Resident #1, the Resident was lying on his bed watching TV. The Resident's hair was dry and stiff, and he had facial hair (beard and mustache) that was approximately a quarter inch long. The Resident stated he was used to shaving every day when he was at home. Resident #1 explained that he was supposed to get two showers a week, but it had been about a month since he has had his shower which was given to him by his daughter. The Resident remarked the staff gave him bed baths instead. The Resident stated he did not know what days he was supposed to get his showers because he did not get them consistently to keep up with what day he was supposed to get them. The Resident stated he has never been asked his preference of what days he would prefer his showers. On 08/23/22 at 1:26 PM Resident #1 was lying in bed with a goatee well defined. The Resident explained that he received a bed bath and was shaved. The Resident continued to explain that he would have rather had a shower, but he was not given a choice of which he preferred. On Wednesday 08/03/22 Nurse Aide #1 and Nurse Aide #2 was scheduled to work with Resident #1 for the second shift. On Saturday 08/06/22 Nurse Aide #3 and Nurse Aide #4 was scheduled to work with Resident #1 for the second shift. On Wednesday 08/10/22 Nurse Aide #3 and Nurse Aide #5 was scheduled to work with Resident #1 for the second shift. On Saturday 08/13/22 Nurse Aide #6 and Nurse Aide #4 was scheduled to work with Resident #1 for the second shift. On Wednesday 08/17/22 Nurse Aide #1 and Nurse Aide #5 was scheduled to work with Resident #1 for the second shift. On Saturday 08/20/22 Nurse Aide #3 and Nurse Aide #5 was scheduled to work with Resident #1 for the second shift. An interview was conducted with Nurse Aide (NA) #1 on 08/24/22 at 3:31 PM. The NA stated she worked from 7:00 AM to 7:00 PM and confirmed she worked with Resident #1 on 08/03/22 and 08/17/22. The NA explained that she had never given the Resident a shower or bed bath but that her coworker could have showered him after she left for the day. The NA stated they were supposed to complete a Bath/Shower sheet on every resident scheduled for a shower even if the resident refused their shower. Multiple attempts were made to interview Nurse Aide #2 and Nurse Aide #6, but the attempts were unsuccessful. On 08/24/22 at 9:20 AM an interview was conducted with Nurse Aide (NA) #3. The NA stated she worked from 7:00 AM to 7:00 PM and confirmed she worked with Resident #1 on 08/06/22, 08/10/22 and 08/20/22. The NA explained that she had never given the Resident a shower but that his showers were scheduled for second shift and the NA who relieved her was responsible for his showers. The NA stated they were supposed to complete a Bath/Shower sheet on the resident even if the resident refused their shower. On 08/24/22 at 4:10 PM an interview was conducted with Nurse Aide #4 who explained that she had never worked with Resident #1. On 08/24/22 at 3:54 PM an interview was conducted with Nurse Aide (NA) #5. The NA stated she worked from 7:00 PM to 7:00 AM and confirmed she worked with Resident #1 on 08/10/22, 08/17/22 and 08/20/22. The NA explained that every time she approached the Resident about his shower, he states that he gets his shower during the day, but she knew that wasn't true. The NA continued to explain that she had never reported to management that he refused his showers on second shift or that he would prefer his showers on first shift. The NA stated she has never showered Resident #1. The NA reported they were supposed to fill out a Bath/Shower sheet when they gave the residents a shower and even if the resident refused their shower. On 08/24/22 at 5:03 PM an interview was conducted with Nurse #1 who stated she worked from 7:00 AM to 7:00 PM and was frequently assigned to Resident #1. The Nurse explained that the nurse aides were supposed to report shower refusals so that they could speak with the residents and coax them into taking their showers. She continued to explain that if they can't get the resident to take their showers then they were supposed to document the refusal in the residents' medical record. The Nurse stated she has never been told that Resident #1 refused his showers. The Nurse reported the staff were supposed to complete a Bath/Shower sheet on the resident even if the resident refused their shower. During an interview with Nurse Aide (NA) #7 on 08/25/22 at 9:07 AM the NA explained that she was scheduled to give showers that shift. She stated having a person scheduled to give showers was hit and miss, there was no consistency in it. She continued to explain that she knew some staff would fill out shower sheets on residents that they were given showers but she knew for a fact that the resident was not given a shower because she was assigned to the resident that day. An interview was conducted with the Administrator and Director of Nursing on 08/25/22 at 1:32 PM. The Administrator explained that they had identified issues with the residents' showers and developed a Performance Improvement Plan (PIP) last week. She stated they obtained shower preferences from the residents and updated their shower schedules. She continued to explain that her expectation was for the nurse aides to complete Bath/Shower sheets on the residents when they give showers even if the resident refuses the showers. She stated the nurse aides should also report shower refusals to the nurses so that they can document the refusals in the residents' medical record and investigate why they were refusing their showers. The Administrator stated the residents should receive two showers a week unless they preferred to have more. 2. Resident #81 was admitted to the facility on [DATE]. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #81 was cognitively intact and required total assistance with bathing. The MDS indicated the Resident had no behaviors of rejection of care. A review of the facility's shower schedule revealed Resident #81 was scheduled to receive his shower on Tuesday and Friday on first shift. A review of Resident #81's medical record revealed there was no documentation of the Resident refusing his showers. A review of Resident #81's bathing record revealed he received a shower on: Monday, 08/02/22 by Nurse Aide #3 and Tuesday 08/16/22 by Nurse Aide #3. It is noted that on 08/05/22, 08/12/22 and 08/19/22 the record indicated Resident #81 received a bed bath. The facility provided a Bath/Shower sheet for Resident #81 for: Friday, 08/12/22 by Patient Care Aide (PCA) #1 that indicated Resident #81 refused a bed bath after asking three times before his appointment. No shave or nail care was marked as being provided. Tuesday, 08/16/22 by an unidentified staff that indicated only nail care had been provided. Friday, 08/19/22 by Nurse Aide #3 that indicated Resident #81 received a bed bath and no nail care or shave was provided. The record stated the Resident had [CONDITION(S)] that day. Tuesday, 08/23/22 by unidentified staff that indicated Resident #81 received a shower, shave and nail care. On 08/22/22 at 4:25 PM an interview and observation were conducted with Resident #81. The Resident was sitting in his wheelchair, his facial hair (beard) was approximately a half inch long and his hair was dry. There were no odors of incontinence about the Resident. The Resident explained that he didn't like a beard and the staff were supposed to shave him when they gave him a shower. The Resident continued to explain that he was supposed to receive two showers a week which was what he wanted, but they were hit and miss. He stated he got a shower one day during the previous week. On 08/23/22 at 1:39 PM during an interview and observation of Resident #81, the Resident was lying in bed, well groomed and shaven. The Resident stated he got a shower that morning and they shaved his facial hair off which he appreciated because he didn't like facial hair. On 08/24/22 at 9:25 AM during an interview with Nurse Aide (NA) #3 she explained that Resident #81 was alert and oriented and did not refuse care. She stated the Resident was scheduled for his showers on Tuesday and Friday for first shift and when she worked, she tried to give him his showers in the mornings before he left for his appointments if it was possible but sometimes she gave him bed baths. She reported the last time she showered the Resident was on 08/16/22. The NA explained that they were supposed to complete a Bath/Shower sheet on the residents whether they gave them a shower or not and if they refused the shower they were supposed to document it on the shower sheet and give it to the nurse so they could document their refusal. An interview was conducted with Nurse Aide (NA) #1 on 08/24/22 at 3:36 PM who confirmed she worked with Resident #81 on 08/12/22 on the 7:00 AM to 7:00 PM shift. The NA explained that she gave the Resident a shower about 2 weeks ago but could not remember if it was on 08/12/22. Attempts were made to interview PCA #1, but the attempts were unsuccessful. Attempts were made to interview Nurse Aide #8, but the attempts were unsuccessful. On 08/24/22 at 5:03 PM an interview was conducted with Nurse #1 who stated she worked from 7:00 AM to 7:00 PM and was frequently assigned to Resident #81. The Nurse explained that the nurse aides were supposed to report shower refusals so that they could speak with the residents and coax them into taking their showers. She continued to explain that if they can't get the resident to take their showers then they were supposed to document the refusal in the residents' medical record. The Nurse stated she has never been told that Resident #81 refused his showers and in fact, the Resident looked forward to his showers. The Nurse reported the staff were supposed to complete a Bath/Shower sheet on the resident even if the resident refused their shower. During an interview with Nurse Aide (NA) #7 on 08/25/22 at 9:07 AM the NA explained that she was scheduled to give showers that shift. She stated having a person scheduled to give showers was hit and miss, there was no consistency in it. She continued to explain that some staff would fill out shower sheets on residents that they were given showers, but she knew for a fact that the resident was not given a shower because she was assigned to the resident that day. An interview was conducted with the Administrator and Director of Nursing on 08/25/22 at 1:32 PM. The Administrator explained that they had identified issues with the residents' showers and developed a Performance Improvement Plan (PIP) last week. She stated they obtained shower preferences from the residents and updated their shower schedules. She continued to explain that her expectation was for the nurse aides to complete Bath/Shower sheets on the residents when they give showers even if the resident refuses the showers. She stated the nurse aides should also report shower refusals to the nurses so that they can document the refusals in the residents' medical record and investigate why they were refusing their showers. The Administrator stated the residents should receive two showers a week unless they preferred to have more. 3. Resident #82 was admitted to the facility on [DATE]. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #82's cognition was moderately intact and had no behaviors of rejection of care. The MDS noted the Resident required physical help in part of bathing with the assist of one staff. A review of the facility shower schedule revealed Resident #82 was scheduled to receive showers on Monday and Thursday second shift. The facility could not provide a Bath/Shower sheet for Resident #82 for August 1, 2022 through August 22, 2022. A review of Resident #82's medical record revealed there was no documentation that the Resident had refused his scheduled showers. A review of Resident #82's bathing record revealed he received a shower on: Thursday 08/18/22. The schedule revealed Nurse Aide #1 and Nurse Aide #5 worked on the second shift. There were no scheduled showers marked as received from Monday, 08/01/22 through Monday, 08/15/22. On 08/22/22 at 10:39 AM during an interview and observation with Resident #82 the Resident was lying in bed with hair disheveled and dry. The Resident had facial hair (beard) approximately one fourth inches long and explained that he normally did not wear a beard. The Resident continued to explain that he was supposed to get two showers a week, but it had been months since he had had a shower and his hair hadn't been washed in that amount of time as well. The Resident added they ask me what I want, and I tell them showers, but they give me bed baths instead. He added that he didn't know what days he was supposed to get his shower because he doesn't get them enough to know. During an interview with Resident #82 on 08/23/22 at 1:30 PM the Resident was lying on his bed. The Resident pointed to his beard and stated he still had his beard and he had not received a shower. On 08/24/22 at 1:19 PM Nurse Aide (NA) #3 confirmed she worked with Resident #82 during the 3:00 to 11:00 PM shift on 08/01/22, 08/11/22 7:00 AM to 7:00 PM shift, and 08/15/22 7:00 AM to 7:00 PM shift. The NA stated she did not give the Resident a shower that in fact, she has never given the Resident a shower. The NA explained that Resident #82 was scheduled to receive his showers on the second shift. On 08/24/22 at 3:42 PM an interview was conducted with Nurse Aide (NA) #1. The NA stated she worked with Resident often from 7:00 AM to 7:00 PM. The NA explained that she has never given Resident a shower that maybe her coworker had. The NA stated they were supposed to complete a Bath/Shower sheet on every resident scheduled for a shower even if the resident refused their shower. An interview conducted with Nurse Aide (NA) #10 on 08/24/22 at 3:57 PM. The NA explained that he worked the 11:00 to 7:00 AM shift and had never given Resident #82 a shower. An interview was conducted with Nurse Aide (NA) #9 on 08/24/22 at 4:18 PM. The NA confirmed she worked with Resident #82 on 08/08/22 but stated she had never given the Resident a shower. On 08/24/22 at 4:42 PM an interview was conducted with Nurse Aide (NA) #5. The NA explained that she often worked with Resident #82 on the 7:00 PM to 7:00 AM shift. The NA stated had never given the Resident a shower because he always refused. She continued to explain that the staff were supposed to complete a shower sheet when they complete a shower and report it to the nurse if the residents refused their showers, but she did not always do that. Attempts were made to interview Nurse Aide #12 who worked on 08/15/22 but the attempts were unsuccessful. On 08/24/22 at 5:03 PM an interview was conducted with Nurse #1 who stated she worked from 7:00 AM to 7:00 PM and was frequently assigned to Resident #82. The Nurse explained that the nurse aides were supposed to report shower refusals so that they could speak with the residents and coax them into taking their showers. She continued to explain that if they can't get the resident to take their showers then they were supposed to document the refusal in the residents' medical record. The Nurse stated she has never been told that Resident #82 refused his showers and in fact, the Resident looked forward to his showers. The Nurse reported the staff were supposed to complete a Bath/Shower sheet on the resident even if the resident refused their shower. During an interview with Nurse Aide (NA) #7 on 08/25/22 at 9:07 AM the NA explained that she was scheduled to give showers that shift. She stated having a person scheduled to give showers was hit and miss, there was no consistency in it. She continued to explain that she knew that some staff would fill out shower sheets on residents that they were given showers, but she knew for a fact that the resident was not given a shower because she was assigned to the resident that day. An interview was conducted with the Administrator and Director of Nursing on 08/25/22 at 1:32 PM. The Administrator explained that they had identified issues with the residents' showers and developed a Performance Improvement Plan (PIP) last week. She stated they obtained shower preferences from the residents and updated their shower schedules. She continued to explain that her expectation was for the nurse aides to complete Bath/Shower sheets on the residents when they give showers even if the resident refuses the showers. She stated the nurse aides should also report shower refusals to the nurses so that they can document the refusals in the residents' medical record and investigate why they were refusing their showers. The Administrator stated the residents should receive two showers a week unless they preferred to have more.

Based on observation and staff interview, the facility failed to discard out of date food items in the dry storage area in the kitchen. The facility also failed to maintain a clean kitchen when appliances and kitchen surfaces were found to be greasy and with leftover food particles were still attached in the kitchen. These practices had the potential to affect food served to residents. The findings included: An observation of the kitchen was made on [DATE] at 9:53 AM with the Day shift cook (Cook #1). The following items were observed: In the general kitchen preparation area: -Two metal food tray pans were left sitting on top of the oven with food particles attached after meal service line -Thick heavy grease buildup and food debris were visible on the fryer and in the floor surrounding the fryer -Dried food particles were noted on the shelf below the oven -Thick grease buildup and food remnants were visible on the shelf below the steam table with water running down the side of the steam table and puddling onto the floor surface -Grill was visibly greasy with a thick dark colored substance attached and food particles on the front doors. -Meat slicer with visible pink colored pieces of meat substance attached -Plate warmer with top plate containing visible dry egg particles -Side by side refrigerator were greasy and contained a sticky substance on each door -Racks below the tea picture contained a dark colored substance -The icemaker machine had an electric razor, a magnifying glass, a container of toothpicks, and a slinky on its shelf next to the ice scooper In the dry storage area: -8 boxes of unopened oatmeal which contained a use by date of [DATE] -A bag of flour tortillas which contained a use by date of [DATE] -A 4 qt plastic container of pinto beans that contained a label with a use by date of [DATE] An interview with the Dietician on [DATE] at 9:53 AM revealed all dry foods should be discarded when the item has met its use by date. She explained the Dietary Manager was not in the facility because she was having to work as the evening shift cook on [DATE]. An interview with the Dietary Manager (DM) on [DATE] at 11:15 AM revealed her current staff completed essential functions of the kitchen first and then tried to complete additional tasks as time would allow, but unfortunately, recently staffing crunches had left the kitchen with some strains which decreased its potential to be fully efficient. The DM indicated the expectation would be all kitchen surfaces were cleaned and sanitized daily and expired items were discarded.

Based on observations, record review, staff and Resident interviews the facility failed to obtain routine dental services for a resident (Resident #81) who reported chipped teeth for 1 of 1 resident reviewed for dental services. The finding included: Resident #81 was admitted to the facility on [DATE]. The admission Minimum Data Set assessment dated [DATE] revealed Resident #81 was cognitively intact and had inflamed bleeding gums or loose natural teeth. The quarterly Minimum Data Set assessment dated [DATE] indicated Resident #81 had no issues with his dental/oral status. A review of Resident #81's medical record indicated a steady weight gain from 04/11/22 at 121 pounds to 08/12/22 at 133.8 pounds. Resident #81 consumed an average meal intake of 75-100%. Further review of the medical record revealed the Resident had not received attention from a dentist since admission. A review of the facility's record of dental visits to the facility on [DATE], 05/04/22, 08/01/22 and 08/10/22 revealed Resident #81 was not on the lists. On 08/22/22 at 4:25 PM during an interview with Resident #81 he explained that his bottom back teeth were chipping, and he had not seen a dentist for a routine exam and cleaning since before he was admitted to the facility. Unable to visualize the back teeth due to the position of him sitting in his wheelchair but his front teeth were noted to be yellow. The Resident continued to explain that shortly after he was admitted to the facility, Facility Transporter #1 made him an appointment to see a local dentist which was in July, but they had to cancel the appointment because he had to be on a stretcher for the visit and the dental office could not accommodate a stretcher. On 08/24/22 at 9:18 AM an observation and interview were conducted with Resident #81. The Resident explained that he had dental pain on and off (but not at the time of the interview) and thought his back-bottom teeth were chipping. The Resident's right back bottom tooth was noted to be black but was unable to determine if the tooth was chipped. The Resident's gums were not noted to be red or inflamed. The Resident denied having oral abscesses and stated he had no difficulty in chewing his food. When asked if he had reported these issues to anyone the Resident stated he reported them to Facility Transporter #1 when she made his dental appointment that was cancelled. During a telephone interview the Facility Transporter #1 on 08/25/22 at 5:17 PM she explained that Resident #81's nurse (who was no longer at the facility) came to her shortly after his admission to the facility and told her that he needed a dental appointment and it took her a while to find a dentist who would accept his insurance. She continued to explain that she found a dentist and made an appointment for July 5th for the non-emergent services to transport so he could be on a stretcher but before he could go to the appointment, the dentist cancelled because they were not able to get his insurance approved in time because the Resident's brother had his insurance card. She stated she learned about the cancellation when she returned to work on July 6th and she called the dentist back to reschedule the appointment but the office told her that they could not accommodate a stretcher, therefore, she was not able to obtain a dental appointment for Resident #81 before she left her employment from the facility. The transporter stated she was not able to orient her replacement to the position she vacated and did not report what was left undone. On 08/25/22 at 11:15 AM during an interview with the Social Worker (SW), she explained that she was responsible for completing the paperwork and enrolling the residents with the professionals that come to the facility such as the dentists, eye doctors and podiatrists. The SW sent Resident #81's referral to the dentist who services the facility, but the dentist would not accept the Resident's insurance but stated they would see him if the Resident agreed to pay out of pocket which would have been $165.00. The SW discussed it with Resident #81, but he chose to see a local dentist who would accept his insurance. The SW stated she informed the Director of Nursing on (who was no longer at the facility) on 04/19/22 and that was the last she had heard anything about the situation. The SW stated she did not follow up on the situation. The SW explained that Facility Transporter #1 who was referenced by Resident #81 was no longer at the facility. The SW reviewed the facility's calendar of scheduled appointments and stated she could not locate where Resident #81 had seen a dentist or was scheduled to see a dentist. An interview was conducted with the Nurse Practitioner (NP) on 08/25/22 at 12:01 PM. The NP explained that Resident #81 had not reported any issues with his teeth nor had his appetite or weight been affected but nevertheless she stated the facility should have followed through with obtaining the Resident a dental appointment. An interview was conducted with the Administrator and the Director of Nursing on 08/25/22 at 2:00 PM. The Administrator explained that she was not aware of any dental issues that Resident #81 was having but that the dental appointment should have been followed up on.

Based on record review and staff and resident interviews, the facility failed to ensure a resident's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . (Resident #45) The Findings Included: Resident #45 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] A review of Resident #45's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The medication was to be not given if Resident #45's systolic blood pressure was below 100 and or his heart rate was less than 45 and the physician should be notified. A review of Resident #45's August Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of staffing schedules revealed Nurse #1 was scheduled as the nurse for Resident #45 on 08/03/22, 08/05/22, and 08/17/22 at the time the 4:00PM dose of [MEDICATION(S)] was due to be administered. During an interview with Nurse #1 on 08/24/22 at 4:19 PM, she verified she worked on 08/03/22, 08/05/22, and 08/17/22 and was assigned to Resident #45. She stated she remembered the medication as she knew she had to take Resident #45's blood pressure and heart rate before knowing whether she should have given him the medication. She reported she did not know why the medication was not signed off as being given but stated she was pretty confident she had given Resident #45 the [MEDICATION(S)] Tablet 3.125mg at 4:00 PM on 08/03/22, 08/05/22, and 08/17/22. She continued, stating she most likely forgot to sign off on the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview with the Director of Nursing on 08/25/22 at 2:17 PM, she reported she expected nurses to sign off on the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on record review, family, and staff interview the facility failed to ensure a call light was functioning for 1 of 3 residents reviewed for accidents (Resident #156). The findings included: Resident #156 was admitted to the facility on [DATE] with diagnoses that included: [CONDITION(S)], right above knee amputation, and others. Review of a Fall Care plan initiated on 06/19/22 read in part; Resident #156 was at risk for falls related to decreased mobility, weakness, and status post right above knee amputation. The goal read; Resident #156 will have no preventable injury from falls through review period. The interventions included: call bell within reach. Review of an Admission Minimum Data Set (MDS) dated [DATE] revealed that Resident #156 was moderately cognitively impaired. Review of the facility schedule for 06/25/22 revealed that Nurse #4 was assigned to the unit where Resident #156 resided from 7:00 PM to 7:00 AM and NA #17 was assigned to care for Resident #156 from 7:00 PM to 7:00 AM. The schedule further revealed Nurse #5 was working on the same side of the building where Resident #156 resided just on a different hall. Nurse Aide (NA) #17 was interviewed on 08/24/22 at 5:36 PM and confirmed she was working with Resident #156 on 06/25/22 at 7:00 PM to 7:00 AM on 06/26/22. She stated that when she made her third round between 2:00 AM and 3:00 AM she found Resident #156 on the floor. NA #17 stated she asked Resident #156 why he had not turned on his call light if he needed something and Resident #156 indicated that he had turned the call light on, and it was not working. NA #17 stated she pressed the call light to test it out and it was in fact not working and did not come on. NA #17 stated she did not do anything with the call bell but did let the nurse know that it was not working. Resident #156's family member was interviewed on 08/23/22 at 5:01 PM via phone. The family member stated that he came to the facility on [DATE] between 10:00 AM and 11:00 AM. The staff member informed him that Resident #156 had fallen out of bed on the previous shift. The family member stated he asked Resident #156 what happened, and he stated that he had fallen out of bed and laid in the floor for a couple of hours and when the staff finally came in, they had fussed at Resident #156 for not using his call light to call for assistance. The family member stated that Resident #156 stated that he had used his call light, but it was not working and the NA that came in also tried the call light and confirmed that it did not work. Nurse #5 was interviewed on 08/24/22 at 5:51 PM and stated she no longer worked at the facility but stated when she did work at the facility approximately 2-3 months ago, she had a few call lights that did not work on the unit where Resident #156 resided but could not recall specifically which rooms. Nurse #5 stated if she was aware a call light was not working, she would go to an empty room and take the call light cord and replace the one that did not work, if that did not fix the issue Nurse #5 stated she would notify someone in the Maintenance Department. Nurse #5 stated a few times we had to scramble to find a working call bell. She added that she had no knowledge of Resident #156's call light not working, or she would have replaced it with a working one. Nurse #4 was interviewed on 08/24/22 at 6:07 PM and stated that had no knowledge of Resident #156 call light not working or Resident #156 falling out of bed. The Maintenance Director was interviewed on 08/24/22 at 6:22 PM and confirmed he had worked at the facility since June 21, 2022. The Maintenance Director stated that he checked call lights 1-2 times a week by sporadically going in/out of rooms and bathrooms to ensure that call light came on and sounds at the appropriate places. When asked if he had logs of his call light checks the Maintenance Director stated, sometimes I keep up with which rooms I check but I don't log them anywhere. He continued to say that he has had no issues with the call light system but stated he recently had 2 rooms that the call light was not working, and he replaced the cords and that fixed the issue. He indicated if there was an issue with the call light system on the weekend the staff would call him, and he would come and fix the issue. The Maintenance Director stated he was not aware that the call light in Resident #156's room was not working on 06/25/22, but stated he kept extra call light cords in his office if anyone needed one. The Maintenance Director stated that standard procedure for reporting an item that needed repair was the staff would complete a work order and turn into him and then he would repair the issue. He added that he did not have any work order for a call light issue for Resident #156's room. The Administrator was interviewed on 08/25/22 at 5:18 PM who stated she had been at the facility since May 2022. The Administrator stated she had no work order for call light issues and had not heard about any issues with call lights not working.

Based on record review, resident, staff, and Nurse Practitioner interview the facility failed to ensure the correct medications were administered to the correct resident (Resident #153) and failed to administer an antianxiety medication as ordered (Resident #403) for 2 of 4 residents reviewed for unnecessary medications. The findings included: 1. Resident #153 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of an Admission Minimum Data Set (MDS) dated [DATE] revealed that Resident #153 was cognitively intact and had no behaviors or rejection of care. The MDS further revealed that Resident #153 required limited to extensive assistance with activities of daily living and received 5 days of an antidepressant and 6 days of a diuretic during the assessment reference period. Review of the medications that Resident #153 received on 08/22/22 that were not prescribed for her included: [MEDICATION(S)] HCL 300 milligrams (mg), Vitamin D 125 microgram (mcg), [MEDICATION(S)] 6 mg, [MEDICATION(S)] 220 mg, Vitamin C 500 mg, [MEDICATION(S)] 10 mg, [MEDICATION(S)] (used to treat high blood pressure) 12.5 mg, [MEDICATION(S)] (pain medication) 7.5/325 mg, and Senna/[MEDICATION(S)] 8.6/50 mg. Review of an Incident Audit Report dated 08/22/22 at 10:27 AM read that Resident #153 had been given the wrong medications. Description of actions taken read; Unit Manager (UM) #2 notified the Nurse Practitioner (NP), orders were obtained to hold some of Resident #153's medications and to increase monitoring of the resident. The report was electronically signed by the Director of Nursing (DON). Resident #153 was interviewed on 08/22/22 at 12:35 PM and stated that this morning Nurse #9 brought her medication in and when she looked at the pills in the cup, they did not look like her usual pills, and she questioned Nurse #9 about one of the pills in the cup and Nurse #9 stated she did not know what the pill was and would have to check on that. Resident #153 stated as she was swallowing the medication Nurse #9 stated that she had her eye drops and insulin and Resident #153 stated I don't take eye drops or insulin and then asked Nurse #9 whose medication did you just give me? Nurse #9 left the room and then UM #2 came in. Resident #153 stated she told UM #2 that I thought Nurse #9 had given me the wrong medication and she stated that she would go and check on that. Resident #153 stated that UM #2 returned about 15-20 minutes later and stated that Nurse #9 had given me another residents medication and that they had spoken to the NP, and she had given the staff some orders and that they would keep a close eye on her for any adverse reactions. Resident #153 added that Nurse #9 had come back in and apologized to her for the mistake. The NP was interviewed on 08/23/22 at 3:34 PM and stated that she was notified of the medication error with Resident #153. She stated that she reviewed the medications that Resident #153 had gotten by accident and then reviewed what medications she should have gotten. She stated that Resident #153 was prescribed a blood pressure medication and because she had received another residents blood pressure medication, she held the prescribed medication for Resident #153. The NP stated that there was no adverse outcome from the medication and a lot of the medications were similar in nature and she had asked the staff to monitor Resident #153 closely and let her know of any changes and there had been none reported. Nurse #9 was interviewed on 08/22/22 at 3:54 PM and stated that this was her first day at the facility and I just made a mistake. She explained that the computer on the medication cart did not work for some reason, so she was having to look at one cart at the computer and the other cart to pull the medications and she had pulled the wrong medication and administered them to Resident #153. Nurse #9 stated that she pulled the resident in the next room's medication and did not verify the picture in the electronic record to ensure she was giving the correct medications to the correct resident. Nurse #9 stated she realized she had given the wrong medication to the wrong resident when she was about to give insulin and Resident #153 stated she did not receive insulin. She stated she immediately went and looked at the medications she had given, notified UM #2 and the NP. Nurse #9 stated she had also apologized to Resident #153 and before she could resume her medication pass the facility had re-educated her on medication administration and they were still working to get the computer fixed. She added the NP had given an order to hold some of Resident #153 medications and to monitor her closely through the shift. Nurse #9 stated she could not say for sure what caused the mistake but stated going between two medication carts contributed to the error. UM #2 was interviewed on 08/24/22 at 3:39 PM and reported that she was notified of the medication error with Resident #153 immediately after it occurred. She stated that Nurse #9 had the medication cart parked outside of one resident room and pulled the medication for the next room down on the hallway and did not look at the picture to verify who she was administering medication too. UM #2 stated that she was aware that the computer was not working but Nurse #9 never came to her and stated that using another computer was an issue or she would have just given her laptop to Nurse #9 to use. UM #2 stated that she went down to Resident #153's room and examined her and spoke to her then notified the NP of the error. She stated she went through the medications that Resident #153 had received by mistake and the NP had given an order to hold Resident #153's blood pressure medication. She added that she had checked on Resident #153 throughout the day, and she had no adverse effects from receiving the wrong medication. The Director of Nursing (DON) was interviewed on 08/24/22 at 4:30 PM and reported that she was made aware of the medication error with Resident #153 and as soon as the error was reported it was reported to the NP and the resident was assessed. The DON stated that she immediately went and re-educated Nurse #9 on the five rights of medication administration before allowing her to resume her medication pass. The DON stated that she had completed the incident report and they determined that the rooms were right next to each other, and it was accident that she went in the wrong room. The DON stated she also educated Nurse #9 on reviewing the picture in the electronical medical record and asking the resident their name and date of birth before administering the medication. The DON further stated that she was aware that the computer on the medication cart was not working, and they had put an Information Technology (IT) ticket in, and the computer had since been fixed. 2. Resident #403 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] A review of Resident #403's admission minimum data set assessment was unable to be completed due to her recent admission to the facility. Review of Resident #403's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #403's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of staffing schedules for 08/21/22 and 08/22/22 revealed Nurse #1 to be scheduled as the nurse for Resident #403. During an interview with Nurse #1 on 08/25/22 at 6:53 AM, she verified she did not give Resident #403 two doses of her scheduled [MEDICATION(S)] HCl tablet 30mg on 08/21/22 at 8:00 PM or on 08/22/22 at 6:00 AM. She reported she was unable to give Resident #403 because she did not have any on the medication cart for Resident #403 and she did not have access to the facility's back-up medication system. During an interview with the Nurse Practitioner on 08/25/22 at 10:15 AM, she reported that although it was best not to miss doses of [MEDICATION(S)] HCl, the medication builds up in the system and it is not a fast acting medication and it would not, in her opinion, be a significant medication error. During an interview with the Director of Nursing on 08/25/22 at 2:30 PM, she reported if a medication was not available on the cart to be dispensed, then the nurse should go to the facility's back-up medication system and see if the medication was kept there and provide the right dose to the resident if so. If the facility's back-up medication system did not have the medication, then the nurse should sign off the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The Director of Nursing reported someone working in the facility at that time would have had access to the back-up medication system and would have been able to access it for Nurse #2. She reported she was unsure if [MEDICATION(S)] HCl was carried in their system, but it should have been checked. She reported she would speak with Nurse #1 to ensure she knew the process.

Based on observations, record review and interviews the facility failed to secure an oxygen tank that was stored upright on the floor in a resident room for 1 of 2 residents (Resident #16) reviewed for respiratory therapy. The finding included: Resident #16 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly Minimum Data Set assessment dated [DATE] revealed Resident #16 was cognitively intact and did not receive oxygen therapy. During an initial tour of Resident #16's room on 08/22/22 at 11:52 AM an observation was noted of an oxygen tank standing unsecured beside the Resident's bedside table and approximately one fourth amount of oxygen left in the tank. On 08/22/22 at 4:06 PM a second observation was made of the unsecured oxygen tank in Resident #16's room during an interview with Nurse #1. The Nurse acknowledged the oxygen tank standing unsecured beside the Resident's bedside table. The Nurse explained that the oxygen tank should not have been left in the Resident's room but should have been taken to the medication room where the oxygen tanks were stored. The Nurse continued to explain that it was a safety hazard to store the oxygen tank upright, especially if the tank contained oxygen, for fear of explosion. She stated Resident #16 used to be on oxygen but was recently weaned off but as many times as she had been in the Resident's room, she had not noticed the free standing oxygen tank. The Nurse took the oxygen tank to the medication room for safe storage. An interview was conducted with Resident #16 on 08/23/22 at 1:11 PM. The Resident explained that she used to be on supplemental oxygen but as of a couple of months ago, she didn't need to oxygen any longer. During an interview with the Unit Manager (UM) #1 on 08/23/22 at 1:31 PM the UM explained that the oxygen tanks should not have been stored in Resident #16's room but should have been taken to the medication room where they stored the oxygen tanks in a holder to prevent them from falling over. On 08/23/22 at 5:13 PM during an interview with the Administrator, she stated the oxygen tank should not have been stored in the Resident's room, but it should have been taken to the storage room and put in a container to prevent accidents. During an interview with the Director of Nursing on 08/25/22 at 1:53 PM she explained that Resident #16 was recently weaned off the supplemental oxygen and the oxygen tank should have been taken back to the storage room for safe storage.

Based on record review and staff interviews, the facility failed to complete a quarterly Minimum Data Set (MDS) assessment within the regulatory timeframes for 1 of 6 residents reviewed for MDS (Resident #69). Findings included: Resident #69 was admitted to the facility on [DATE]. A review of Resident #69's medical record revealed the most recent quarterly MDS had an assessment reference date (ARD, the last day of the assessment period) of 7/14/22. The assessment had not been signed as completed by the registered nurse until 8/02/22. An interview with MDS Nurse #2 was completed on 8/24/22 at 10:24 AM. MDS Nurse #2 indicated she completed individual sections on the MDS for Resident #69 on 7/29/22 but did not sign it as completed until 8/02/22. She stated she had been taught that all quarterly MDS's were to be completed within 14 days of the ARD. She explained the facility had an abundance of admissions and both she and MDS Nurse #1 had taken vacation days which caused the facility to get behind on completing assessments timely. An interview with the Director of Nursing and Administrator on 8/25/22 at 4:39 PM revealed they expected MDS's to be completed in the designated timeframe.

Based on observation, record reviews, resident, staff, Nurse Practitioner, and family interviews, the facility failed to notify the responsible party of fall when a resident (Resident #66) fell from a lift for 1 of 2 residents reviewed for falls. Findings included: Resident #66 was admitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A quarterly Minimum Data Set (MDS) dated [DATE] indicated Resident #66 was cognitively intact and required total dependence of 2 staff for transfers. An incident report dated 6/2/22 at 2:37 PM revealed Resident #66 experienced a fall in the bathroom. The incident report indicated a Nurse Aide transferred Resident #66 from the commode using a sit to stand lift when her knees buckled and Resident #66 slid out of the lift pad and onto the floor. The incident report listed a granddaughter being notified of the fall on 6/2/22 at 2:49 PM. However, a review of the notification was placed to Resident #66's granddaughter who is not listed as a contact party in the resident's electronic medical record. A progress note dated 6/2/22 written by Nurse Practitioner (NP) #1 revealed Resident #66 experienced a fall. The note indicated NP #1 was summoned to the room of Resident #66 where she was found to be in the bathroom floor lying on her right side. Resident #66 and staff had reported the fall occurred when Resident #66 fell from the sit to stand lift in the bathroom and had reported the only pain she had at the time was in the back of the head. At the time of the fall on 6/2/22, NP #1 indicated there was no visible swelling or open areas on the head nor loss of consciousness immediately post fall to the floor. A progress note dated 6/3/22 written by NP #1 revealed Resident #66 was up in her wheelchair and complained of right upper extremity pain with movement. The note indicated during the examination, family entered the room and agreed to allow for a x-ray of the right shoulder and elbow to be performed. A telephone interview with Family Member (FM) #1 was conducted on 8/23/22 which revealed she nor Resident #66's responsible party had been notified of Resident #66's fall until she arrived at the facility to visit on 6/3/22 and found Resident #66 to being examined by NP #1 who explained to her that Resident #66 had a fall on 6/2/22 from a sit to stand lift. FM #1 indicated she had spoken with the nurse on 6/3/22 who explained she was unsure why the family had not been notified of the fall. FM #1 stated the nurse told her Resident #66 had the fall after she was improperly transferred using a sit to stand lift and had bumped her head and her right shoulder during the fall. An interview on 8/23/22 at 2:40 PM with MDS Nurse #1 revealed she attended the huddle immediately following Resident #66's fall on 6/2/22. MDS Nurse #1 indicated she assisted in completing the incident report; however, she only entered data related to the details of the fall and she did not contact a member of Resident #66's family to notify them of the fall. An interview on 8/23/22 at 3:19 PM with Nurse #8 revealed she attended the huddle immediately following the fall and assessed Resident #66 for injuries. Nurse #8 explained she did not recall notifying Resident #66's family at the time of the fall, but she thought the Director of the Nursing (DON) at the time had planned to notify the family of the fall. An interview with a former DON (DON #3) on 8/24/22 at 3:55 PM revealed she was the DON at the time of Resident #66's fall, but vaguely recalled hearing about the incident. She indicated she had not contacted Resident #66's responsible party to notify them of the incident. She was usure who had contacted the family but stated if the granddaughter was not listed on the emergency contact screen in Resident #66's medical record, no information should have been provided to her. An interview with the Regional Clinical Nursing Director (a former interim DON #2) on 8/25/22 at 9:57 AM revealed she had assisted with some investigations for incidents around this time; however, she could not recall any details of the fall for Resident #66 and did not remember notifying Resident #66's family of the fall.

Based on observations, record review, and staff interview the facility failed to apply a left-hand splint as ordered for 1 of 4 residents reviewed with limited range of motion (Resident #91). The findings included: Resident #91 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a care plan updated on 04/13/22 read in part; alteration in musculoskeletal status related to contracture of left hand and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The goal read; Resident #91 will remain free of complications related to left hand contracture through the review date. The interventions included: resident to wear left hand splint as tolerated throughout the day and night with the splint being removed at least each shift for range of motion and hygiene. Review of a quarterly Minimum Data Set (MDS) dated [DATE] revealed that Resident #91 was moderately cognitively impaired and required extensive to total assistance with activities of daily living and had an impairment to one upper extremity. An observation of Resident #91 was made on 08/22/22 at 3:08 PM. Resident #91 was resting in bed and appeared to be sleeping. She was observed to have no splint in place to her left hand that was resting on top of her blanket on her bed. An observation of Resident #91 was made on 08/23/22 at 12:57 PM. Resident #91 was up in her wheelchair in the dining room eating the last few bites of her lunch. She was observed to have no splint in place to her left hand. An observation of Resident #91 was made on 08/23/22 at 3:21 PM. Resident #91 remained in the dining room drinking of cup of coffee with no splint observed on her left hand. Resident #91 was observed to have a rolled-up wash cloth in her left hand. An interview with the Rehab Director was conducted on 08/24/22 at 9:38 AM. The Rehab Director stated that yesterday (08/23/22) the staff came and asked about Resident #91's splint. She stated the facility maintenance department had been stripping and waxing the floors in Resident #91's room so all her personal belongings had been boxed up and moved into the hallway. The Rehab Director stated that she personally went through all the boxes of Resident #91's belonging and was unable to find her left-hand splint. She stated she was unsure of how long the left-hand splint had been missing but when she was unable to find the splint, she had gone to the dining room and placed a rolled-up wash cloth in Resident #91's left hand for protection and then ordered her a new left-hand splint. The Rehab Director stated that Resident #91 had a lot of arthritic changes in her left arm/hand and that at the end of her recent therapy treatment in April 2022 Resident #91 was tolerating the splint most days and when she was tired of it, she wound ask for the splint to be removed. Nurse Aide (NA) #7 was interviewed on 08/24/22 at 1:53 PM who confirmed that she cared for Resident #91 on 8/22/22 and 8/23/22 NA #7 stated that Resident #91 had a splint that she had been applying to her left hand but for the last 3 weeks the splint had been missing and she had reported it to Nurse #1 yesterday (08/23/22) about the missing splint and Nurse #1 had replied that there was nothing she could do about the missing splint. NA #7 stated that when she had the splint to apply to Resident #91, she generally wore it for most of her shift. NA #23 was interviewed on 08/24/22 at 2:02 PM who confirmed that she cared for Resident #91 on Monday 08/22/22. She stated that she was not aware of any splint that Resident #91 had, and she had never seen Resident #91 wear a splint. An observation of Resident #91 was made on 08/24/22 at 2:06 PM. Resident #91 has just returned to her room from the shower room and was resting in bed. She was observed to have no splint in place to her left hand but did have a rolled-up wash cloth in her left hand. Nurse #1 was interviewed on 08/24/22 at 3:27 PM who confirmed that she routinely cared for Resident #91 2-3 days a week. Nurse #1 stated she was not aware of any splint that Resident #91 had. She stated that she would look on the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Nurse #1 again stated she knew nothing about Resident #91's splint nor had any staff member reported anything to her about the splint being missing. Review of Resident #91's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . May use wash cloth until splint arrives. The Interim Director of Nursing (DON) was interviewed on 08/24/22 at 4:35 PM who stated that Resident #91 had a splint and she had been wearing it. She stated that yesterday (08/23/22) she heard that Resident #91 ' s left hand splint was missing, and we put a rolled-up wash cloth in her left until the new splint arrived. The DON stated she did not know how long the left-hand splint had been missing and that when it went missing it should have been reported to the nurse who should have notified the therapy department. The DON added that the NAs or the nurses should be applying the splint as ordered and that information could be in the electronic medical record.

Based on observations, record reviews, and wheelchair manufacturer securement system review, staff interviews, van manufacturer representative interview and resident interviews, the facility failed to secure 2 of 2 sampled residents (Resident #38 and #84) in the facility van while being transported to medical appointments. Neither Resident #38's wheelchair nor Resident #84's wheelchairs were attached to the van floor securement system with a four point safety restraint applied to their wheelchairs as specified by the manufacturer, resulting in Resident #38 from his wheelchair during transport. Immediate Jeopardy began on 1/15/2018 for Resident #38 when the facility did not secure him before transporting him back to the facility from a medical appointment resulting in the resident falling and hitting his head. Immediate Jeopardy began on 2/28/2018 for Resident #84 when the facility did not secure her before transporting her back to the facility. Immediate Jeopardy was removed for both Resident's #38 and #84 on 3/2/2018 at 11:00AM when the facility implemented a credible allegation of compliance. The facility remains out of compliance at the lower scope and severity of D (no actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure monitoring systems are in place and the completion of employee education. The findings included: The facility Director of Nursing provided a document outlining how to secure wheelchairs in the facility van wheelchair securement system. The document read in part: 1. J Hooks must be attached to a solid wheelchair frame (no spokes or movable components) at an approximate 45 degree angle with floor 2. Do not allow webbing to get twisted inside the retractors 3. Attach 4 retractors into floor anchorage points and lock them in place, with an approximate distance of 48 inches to 54 inches between the front and rear retractors 4. Move wheelchair forward and back to remove webbing slack or manual tension webbing with retractor knobs 1. Resident #38 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #38 required extensive physical assistance of one person for transfers and set up assistance for locomotion off the unit. The MDS further revealed Resident #38 was coded as being cognitively intact. Review of Resident #38's incident report dated 1/15/2018 revealed Resident #38 was being transported to an outside medical appointment by Transportation Aide/Nurse Aide #1 in the facility transportation van. The report further indicated that on the way back from the medical appointment Resident #38 fell out of his wheelchair when Transportation Aide/Nurse Aide #1 accelerated when the traffic light turned green. The report stated his chair slightly moved back and Resident #38 fell over the back of his wheelchair. The immediate action taken stated Transportation Aide/Nurse Aide #1 pulled over and contacted the Director of Nursing (DON) and Emergency Medical Services (EMS). An interview with Resident #38 on 2/27/2018 at 4:30 PM revealed that he fell from his wheelchair while being transported back from a medical appointment on the facility van on 1/15/2018. He stated Transportation Aide/Nurse Aide #1 was driving the van and accelerated once the traffic light turned green. He further stated that once she accelerated his wheelchair moved and he fell out of the chair and hit the right side of his head on the metal portion of the stationary van seat located directly behind him. He stated the DON came to the site of incident along with EMS and he refused to go to the hospital and was transported back to the facility. An additional interview was conducted with Resident #38 on 2/28/2018 at 9:30 AM regarding the van incident of 1/15/2018. During this interview, he stated the straps (of the retractors) on his wheelchair were loose the entire trip back to the facility from his medical appointment. He stated he heard some clicking noise coming from the belts of the retractors connected to his chair. The resident stated that he asked the staff to tighten them but stated she did not and continued with the drive back to the facility. Interview with Transportation/Nurse Aide #1 on 2/28/2018 at 10:04 AM revealed that she had been driving the facility's new van since it was delivered to the facility at the beginning of (MONTH) (YEAR). She reported that this was a new van, delivered in (MONTH) (YEAR), and 1/15/2018 was the first time she had transported Resident #38 in this vehicle. She reported that her training for securing a wheelchair during transportation consisted of performing a hands-on demonstration and a return demonstration by a representative from the company, who manufactured the van with the wheelchair securement system. She stated she had demonstrated proper securing of residents' wheelchairs using the wheelchair securement system. The Transportation/Nurse Aide #1 revealed that on 1/15/2018 she transported Resident #38 to a medical appointment. During the trip back from the appointment, she stated she heard clicks coming from the retractors connected to Resident #38's wheelchair. She further stated she pushed pressed on the van's gas pedal when a traffic light turned green and Resident #38 came forward and backwards in his chair and fell out of the chair onto the van floor, hitting his head on the stationary seat located behind him. She stated the DON and Scheduler/NA#2 came to the site of the incident and encouraged Resident #38 to go to the hospital, but stated he refused and was transported back to the facility. Transportation Aide/Nurse Aide #1 stated after the fall I showed them how I hooked him. She stated she connected 2 of the retractors to the front and connected 2 of the retractors on the side of the wheelchair to the wheels of Resident #38's chair during transportation. She further stated that she always connected the retractors to his wheels on his chair during transport. An observation was conducted of Transportation/Nurse Aide#1 on 2/28/18 at 10:30 AM in which she demonstrated how she secured Resident #38's wheelchair during transportation on 1/15/18 (date of van incident). She used Resident #38's customized wheelchair for this demonstration. Transportation/Nurse Aide #1 was observed to place Resident #38's chair in the front wheelchair position of the van. She proceeded to attach 2 front retractors (one of the outside track and one on the inside track of the van securement system) to the outer rim of the wheel. She was further observed to place the 2 back retractors to the wheels of the resident's chair. After placing the 4-point locking system (retractors) to Resident #38's chair, the chair was observed to move greater than 3 inches to the front when manipulated. The belts of the retractors to the front left were noticeably twisted. The Transportation/Nurse Aide #1 seat belt was secured during demonstration. The wheelchair was noted to be secured in a side way position between the two tie down bars Transportation/Nurse Aide #1 indicated that after the incident she was told by the DON that it would be better to use the T-bar located in the back of the resident's chair instead of the wheels of the resident's chair. Transportation/Nurse Aide #1 was observed next to perform a demonstration of the 4-point locking system with a standard non-customized wheelchair. She placed the 2 front retractors to the front base of the chair, and she placed 2 retractors to the side of the wheelchair, secured to the base of the chair. There were no retractors securing the back of the wheelchair. The belts of the retractors to front left were noticeably twisted. The seat belt was secured during demonstration. Transportation Aide/Nurse Aide #1 stated that this was her complete procedure for securing the wheelchair for transportation. Once she secured the chair, with mild manipulation the chair moved greater than 3 inches and locked in an angled position. 2. Resident #84 was admitted to the facility 12/8/17 with [DIAGNOSES REDACTED]. The admission minimum data set (MDS) assessment dated [DATE] coded Resident #84 as being cognitively intact, and as having clear speech. She required Extensive Assistance with transfer and limited assistance with most other activities of ADLs. The MDS noted Resident #84 as having no memory impairments and having no difficulty with decision making also read that she required a wheelchair for mobility. Resident #84 was observed on 2/28/18 at 2:40 PM on the facility's transportation van after returning from a medical appointment. Resident #84 was observed in her wheelchair in the front position on the van with two retractors in the front connected to the base of the wheelchair and two retractors on the sides of the chair connected to the base of the chair. The belts on the left side of the wheelchair were noted to be twisted both belts of the retractor. There were no retractors at the back of Resident #84's wheelchair, as specified in the manufacturer specifications. Interview with Resident #84 on 3/1/18 at 3:20 PM revealed that her wheelchair was generally secured when in the van. She also stated that her wheelchair sometimes moved forward or backwards when being transported on the van but for the most part it is secure. Interview with Scheduler/NA#2 on 2/28/2018 at 3:57 PM revealed on 1/15/2018 she arrived at the incident location with the DON. She stated that due to entering the rear of the van she was only able to make an observation of the back wheelchair retractors. Scheduler/NA#2 stated the rear wheelchair retractors were attached to the rear wheels of Resident #38's wheelchair. She stated the chair was in an upright position. The Scheduler/NA#2 revealed she did not provide transportation for the facility but was previously trained that retractors were to only be attached to frame of a wheelchair and not the wheels. She further stated that she was trained to secure 2 retractors to the front of a wheelchair and 2 to the back of a wheelchair. She stated that placing 2 retractors on the side of a wheelchair would not be appropriate to secure a wheelchair for transportation, according to her training. An interview was conducted via telephone with the vendor that sold the van to the facility with the wheelchair securement system on 2/28/2018 at 4:10 PM. During this interview, he stated his driver who delivered the van in (MONTH) (YEAR) reviewed the wheelchair lift, wheelchair securement system, to include the use of the retractors and placement of retractors and operation of the vehicle with facility staff. He reported that wheelchairs should be secured with a 4-point retractor lock system. He stated 2 retractors should be in the front of the wheelchair chair connected to the base of the chair and 2 retractors should be located in the back of the chair connected to the base of the chair. He also stated that all slack should be taken out of the belts (by using the retractor knob or by moving the chair forward and backwards prior to transport) prior to transport. He further stated that the belts should be flat, with no twist in the belts. He stated that retractors should have never been secured on wheels or any part of the wheels. An interview was conducted with the DON and Regional Nurse Consultant on 2/28/2018 at 2:58 PM. They both stated the van was a new van delivered to the facility in (MONTH) (YEAR). They stated the driver who delivered the van demonstrated the appropriate use of the wheelchair securement system, and a returned demonstration was performed by facility transportation staff to include Transportation Aide/Nurse Aide #1.The DON reported on the date of 1/15/2018, she got a call from Transportation/Nurse Aide #1 stating that Resident #38 fell out of his wheelchair during transport. She stated she told Transportation Aide/Nurse Aide #1 to call 911. The DON stated she went to assess Resident #38 along with Scheduler/Nurse Aide #2. She further stated when she got to the location, Resident #38 was on the van floor. She stated Resident #38 wanted to be put back in the chair, but she told him to wait until EMS arrived. The DON stated that after EMS arrived, and Resident #38 refused to go to the hospital, they put the resident back in the chair and transported him back to the facility. She stated she interviewed Resident #38, and he stated, when they went to take off he went backwards and kept going backwards. The DON reported that she and the previous Administrator conducted the re-in-service after the incident on 1/15/2018 on how to secure a wheelchair during transportation. Additionally during this interview the DON was informed of the observation of Resident #84 on 2/28/2018 at 2:40PM, in which the resident was observed to be transported without the required specification of the wheelchair securement system. The DON and Regional Nurse Consultant suspended all van transport at that time. The Administrator was informed of Immediate Jeopardy on 2/28/2018 at 5:30PM for Resident #38 and #84. A Credible Allegation of Compliance was accepted on 3/1/2018 at 6:05PM as follows: Credible Allegation of Compliance: The plan of correcting the specific deficiency. The plan should address the processes that lead to the deficiency cited: On the day of (MONTH) 15th, (YEAR) resident was in the facility transport van on way back from MD appointment. The van was at a stop light. When the driver pressed the gas to go forward as the light turned green the resident leaned back into the chair. The chair slightly moved back and the resident fell over the back of his wheelchair. A detailed analysis of the incident took place. This included the Director of Nursing going to site of incident. The chair remained strapped in the seatbelt. The resident is a paraplegic with bilateral above knee amputations. This resident has his own personal wheelchair which he chooses to use for comfort and mobility to ensure peak independence in mobility. The resident's wheelchair has a low back. Once incident occurred the transporter notified the Director of Nursing and EMS. The Director of Nursing immediately went to the scene. She arrived before Emergency Medical Services. At that time the chair was in the upright position and had to be moved in order to get to the resident. The resident was lying on the floor of van the transporter was next to him. The resident was alert and verbal. The nurse assisted the resident to an upright position after assessing him for range of motion and injury. Soon after Emergency Medical Services arrived and took over the evaluation of the resident. The resident refused to go to the hospital for evaluation. He was educated by the Director of Nursing at this time. She explained risks and benefits regarding going to the hospital and reminded the resident he was on an anticoagulant which increased his risk of bleeding. She informed him hitting his head put him at more risk for bleeding. The resident stated understanding and he did not want to go. The director of nursing inspected his chair for any obvious signs of damage. None noted. Upon arrival back to the facility the chair was again inspected along with the administrator. None noted. The chair was taken to the back of the van and reenactment created. Anti-tippers noted to be working properly. During observation by state surveyors of resident affected during return demonstration by the transportation aide of reenactment of method used to secure resident's wheelchair on (MONTH) 15th, (YEAR) it was noted wheelchair was not properly secured using the wheelchair securement systems specifications. The two front anchor straps were connected to the outside anchors of the floor. However, the two back anchor straps were also anchored to the outside tracks in the floor. This does not follow manufacturer's instructions. The J hook attaching wheelchair securement system to the wheelchair was not connected to a stationary site of the chair. It was connected to the wheelchair wheel which is not following manufacturer's specifications. States surveyors also noted some twisting in one of the anchor straps which is contraindicated in manufacturer instructions. State surveyors also observed transportation aides method of wheelchair securement using another type of wheelchair where again the improper usage of the wheelchair securement system was observed. The misuse of the system was the same as listed above. Front two straps anchored to outside anchor strip, however back anchor straps were anchored to outside anchor strips as well as opposed to the manufacturer instructions for the straps to be anchored in the middle locking strip located in the van floor. During this demonstration the J hook was properly attached to a nonmoving part of the chair. However, the same twisting in one anchor strap remained present. In addition state surveyors observed another resident on (MONTH) 28th, (YEAR) returning from appointment on facility van and was also noted wheelchair was not properly secured per manufacturer recommendations. At this observation the front straps were anchored to the outside anchoring strips in the van floor, however rear straps were located being anchored to the outside strip of van floor as opposed to middle strip which allows anchorage directly behind the chair as per manufacturer recommendations. Upon surveyors discussions related to proper methods of wheelchair securement with Administrator, Director of Nursing, and Regional Director of Clinical Services immediate action was taken to stop all further transportations on facility van until further notice. The procedure for implementing the acceptable plan of correction for the specific deficiency cited: The facility corrected the impact of the deficient practice regarding safety measures associated with wheelchair restraint system via completion of the following actions. Correction occurred on 2/28/2018. The Director of Nursing immediately corrected this issue with (#1) immediate decommissioning of facility transport van. The reason for the removal from service for this vehicle was due to the need for education associated with proper wheelchair restraint for the wheelchair restraint system, which had to be completed correctly with all transport staff, all department heads, and all other appropriate personnel as deemed so per the Director of Nursing. After fully removing van from service, (#2) in aims of providing continuity in the provision of care related to transport, the Director of Nursing contacted transport services and successfully transitioned all future transports into their schedule. After appointing all further transports, the Director of Nursing began the task of identifying best practices for the Wheelchair Restraining System for immediate implementation into facility transport educational protocol. In an effort to provide the most accurate and up-to-date, best practice educational information, the Director of Nursing contacted the facility van's manufacturer. At the time of contact, the manufacturer provided online resources for education. In addition, Director of Nursing, Administrator, and Regional Director of Clinical Services received training via teleconference and the use of educational videos, where instruction was provided by the manufacturer representative. Post teleconference, Director of Nursing, Administrator, and Regional Director of Clinical provided education through the use of the pre-screened video, class discussion, and finalization of the education with a quiz provided for each person attending. In attendance were all heads of departments, all transport staff, and all others deemed prudent by the Director of Nursing. Demonstration and Return demonstration were conducted. All transport staff returned proper demonstration three times to Regional Director of Clinical Services, Director of Nursing, Therapy Director, and Maintenance Director. Due to the Maintenance Director's role in completing annual competencies, he also demonstrated proper procedure three times. All other attendees were required to observe once. This concluded all necessary requirements to be in full compliance with safety practices and accident prevention related to facility van transports. However, continued education to assist in retention of information is planned, with a live video demonstration for all required staff, being presented by the manufacturer's representative. This education will be followed with a question and answer session. Additional education is planned for (MONTH) 22, (YEAR). This education is webinar-based training covering best practices, securing equipment, operation, securing the ambulation wheelchair, securing the occupant, and pre-trip inspection, and basic maintenance. 100% of all staff with potential to drive transport vehicle, and all staff who would participate in training and/or auditing safety practices were trained and marked with successful completion of training on (MONTH) 28, (YEAR). The monitoring procedure to ensure that the plan of correction is effective and that specific deficiency cited remains corrected and/or in compliance with the regulatory requirements; The facility will assure appropriate monitoring of all transports daily, Monday through Friday for a total of four weeks. Staff who will be monitoring the process will include Maintenance Director, Director of Nursing, and Assistant Director of Nursing. The Director of Nursing has developed a schedule for auditors to be present for transports. After completion of the four weeks of initial monitoring, facility will monitor transports once weekly for four weeks. Once completion of the secondary monitoring occurs, facility will complete one random review per month for the next 6 months. The expectation for annual training for all department heads and competencies of transportation staff will be completed by the maintenance director, who will report results annually in QAPI. AS well as new hire training or competencies as indicated. Monitoring and results will be discussed in monthly QAPI as information is available from analysis of audit tool. Annually, the administrator will be responsible to audit training of associated staff to ensure its completion. For ongoing actions, the facility has placed visual reminders of proper procedure in the transport van. These visual reminders are training posters, one large and one small, with step-by-step instruction, as well as illustration of correct procedure, providing explicit detail if needed. These posters have been placed in the transport van and can be used as a quick reference or constant reminder of correct procedure. As referenced afore, additional education via web-based training and video conference will be completed within the next thirty days as scheduled. Monthly, information will discussed in QAPI and analysis of the results completed. The QAPI Committee will review the results from the analysis and audits in order to ascertain the effectiveness of current training and intervention and the need for amended training and/or further intervention. The first review by QAPI Committee will be (MONTH) 13, (YEAR), at which time phase one monitoring results that are available will be presented and reviewed. The title of the person responsible for implementing the acceptable plan of correction. The facility administrator will be responsible for implementing the acceptable plan of correction. Immediate Jeopardy was lifted on 3/2/2018 at 11:00AM. The facility provided evidence of additional in-service training for all transportation staff. Interviews and observations of transportation staff securing wheelchair bound residents in the facility van were completed. Interviews of transportation staff revealed that they are now aware of the correct securement procedures for wheelchairs on the van during transportation.

Based on observation, record review, physician interview, and staff interviews for 1 of 3 sampled residents (Resident #3) with a history of falls, the facility failed to have two staff members during a transfer when using a mechanical lift. The fall from a sit-to stand mechanical lift resulted in the resident being transferred to the hospital, and a [DIAGNOSES REDACTED]. The findings included: Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission Minimum Data Set ((MDS) dated [DATE], indicated the resident required extensive, 2-person assistance for transfers, balance was unsteady, and she received an anticoagulant medication 7 of 7 days during the assessment period. The cognition portion of the MDS had not been completed. The Care Plan, most recently updated on 6/14/17, indicated the resident was at risk for falls and decreased mobility. Record review revealed lab work drawn on 5/31/17 which indicated the resident had a hemoglobin of 9.6 grams per deciliter (g/dL) with a Reference Range of 11.7-15.5g/dL. Hemoglobin is a protein molecule in red blood cells that carries oxygen from the lungs to the body tissues. Record review revealed a Resident Mobility Transfer Profile, completed by Physical Therapy on 6/5/17, which indicated the resident was to be transferred with a sit-to-stand mechanical lift. A physician order [REDACTED]. (The INR is a test used to determine the clotting tendency of blood.) On 6/14/17 the INR was 2.5. The physician was notified and an order was received to restart the Coumadin at 2mg and recheck the PT/INR on 6/22/17. A nursing note dated 6/21/17 at 4:24 PM indicated the resident had a fall. The note stated, Resident was being transferred from w/c (wheelchair) to bed with sit-to-stand (lift) and slipped out of the bottom landing on her buttock in an upright position. The note also indicated the resident had not hit her head but was complaining of pain of 7 on a scale of 1 to 10. It also indicated the resident had skin tears on both hands. Neuro checks were started. Vital Signs at the time of the fall were Blood Pressure (BP) 141/83, Pulse 83, Respirations 18, and Temperature 97.4 The incident report dated 6/21/17 at 4:24 PM, specified that the physician was notified on 6/21/17 at 4:35 PM, one-on one training was done with a staff member and the resident was placed on total lift status until a complete assessment by physical therapy could be completed. Record review revealed a Resident Mobility Transfer Profile, completed by Physical Therapy on 6/21/17 which indicated the resident was to be transferred with a total passive mechanical lift. On 6/22/17, the physician was notified that Resident #3's INR was greater than 8. The physician examined the resident that day and gave orders to hold the Coumadin and repeat the INR on 6/23/17. A Nurse's Note on 6/23/17 at 8:04 AM, stated the resident's Vital Signs were BP 113/65, Pulse 70, Respirations 18, Temperature 98.2. A Nurse's Note on 6/23/17 at 12:12 PM indicated Resident #3's INR was greater than 8, and the nurse notified the resident's physician, who was in the facility at the time. The physician gave orders for Vitamin K 2.5mg (to promote blood clotting) to be administered orally and to check INR in 24 hours again. A Nurse's Note on 6/24/17 at 8:04 AM specified the resident reported her pain was 0 out of 10, and Vital Signs were BP 95/58, Pulse 66, Respirations 18, and temperature was 98.3. A Nurse's Note on 6/24/17 at 2:41 PM indicated the nurse spoke to the on-call physician, reported the resident's INR was 7.1 and that the resident had extensive bruising over the left upper side of the body. The on-call physician was also informed the resident had a recent fall. There were no new orders. On 6/24/17 at 5:30 PM, the regular attending physician called the facility, said he had spoken to Resident #3's family member and gave orders to send the resident to the hospital for evaluation. The hospital Emergency Department dated 6/24/17 was reviewed. It revealed Resident #3 had bleeding into the muscle tissue, had a hemoglobin of 5.9g/dL and was admitted to the hospital with [REDACTED]. During an interview on 7/26/17 at 4:09PM, the Director of Nursing (DON) stated the she went in to see the resident immediately after the fall. The DON indicated the resident had been transferring with the sit-to-stand lift but her knees became weak and she just slid down. The DON stated she re-educated staff and took the mechanical lift out of service until it could be inspected. An immediate intervention was to use the total lift as the resident stated she just got weak. She also indicated the bruising on the left upper chest and left arm did not start to become evident until the day after the fall. The only injury noted on 6/21/17 were two skins tears to the resident hand and arm. On 7/ 27/17 at 9:15 AM, Resident #3's attending physician was interviewed. He stated the facility immediately informed him about the fall on 6/21/17 and he examined the resident the next day. The physician stated he wanted to be sure there was no head injury and no broken bones. He also stated that after the resident was sent out to the hospital on [DATE], he had called the hospital and spoken to the Emergency Department physician because this resident had a number of pre-existing conditions. He stated the hospital physician informed him there was no bleeding into the abdominal cavity, just the muscle tissues. He also stated the facility had kept him informed of the resident's status in the days after the fall. Nursing Assistant (NA) #1, who was with the resident during the transfer and fall on 6/21/17, was interviewed on 7/27/17 at 12:58 PM. NA #1 said Resident #3 wanted to go to bed so she was transferring her with the mechanical lift. The NA indicated that after the resident was in the air, she started to slip, so I pushed her to the bed so if she did slip it would be on the bed. The NA stated the resident slid off the bed and onto the floor. When asked if there were any concerns with how she had transferred the resident, NA #1 said maybe the sling wasn't as tight as it could have been. At 1:48PM on 7/27/17, NA#1 and NA #2 demonstrated a transfer. She stated two staff were required for a transfer by mechanical lift. NA #1 manipulated the lift control and NA #2 stood by and indicated she was the spotter to ensure the resident's safety. On 7/27/17 at 2:04 PM, NA #1 explained how she had transferred Resident #3. When asked if there had been a second staff member during the transfer, NA #1 said Yes. but she could not remember who was with her. On 7/27/17 at 2:51 PM, the Administrator was interviewed about the second staff member present for Resident #3's transfer. The Administrator indicated NA #1 had done the transfer without a second staff member present even though the policy and all training specified that mechanical lift transfers required two staff. Plan of correction: Improper transfer by certified nursing assistant using the sit to stand lift. Date of event: 06/21/2017 Corrective action for resident affected: This resident no longer resides at this facility. It is the policy of this facility that there will always be two staff members present during the transfer, one present to support the resident and one present to manipulate the lift. Immediate action taken on 06/21/2017 the DON removed the lift/sling until inspection for proper function could be identified. The DON also provided counseling to CNA involved concerning following facility lift policy for mechanical lifts and always having two staff members present. Corrective actions taken for resident potentially affected: On 06/22/2017 the DON reviewed incident reports for the past thirty days and those residents who were assessed to require the use of mechanical lift to determine if policy was followed. No other residents were identified to be affected. Dates of 06/21/2017 thru 06/23/2017 the DON performed reeducation for certified nursing assistants on the policy specific to using two person transfer for mechanical lift. The facility will continue to assess proper lift status for residents upon admission and status change. The assessment will be performed by physical therapy and will be documented on the resident mobility/transfer profile assessment form. The physical therapist will communicate information verbally and via the assessment to DON/designee. The DON/designee will continue to place the residents lift status inside their closet door and the assessment will continue to be scanned into the resident's electronic health record. Systemic Changes: Beginning 06/26/2017 the DON/designee will perform visual observation audits specific to the mechanical lift use to ensure two person utilized during transfer with lift. These audits will be performed three times weekly for one month, and then weekly for three months. Quality Assurance: The DON will submit circumstances of event and related audits to the QAPI committee July 11th, 2017 and monthly until determined substantial compliance sustained. Effective date of compliance June 23rd, 2017. As part of the validation process on 7/26/17 through 7/28/17, the plan of correction was reviewed including the re-education of staff and observations of transfers to or from wheelchairs using the mechanical lift. All transfers observed were completed correctly. Interviews with nursing assistants revealed they were retrained in the areas of transfers, falls, where to obtain the information of what type of transfer should be used for a resident and to always have two staff present when using a mechanical lift. A review of the monitoring tools revealed that the facility completed the audit of transfers as noted in their POC. All in-servicing of nursing assistants was completed on 6/23/17 including NA#1 who had transferred Resident #3 on 6/21/17. A review of the audits revealed audits had been conducted two to three times per week between 6/26/17 and 7/24/17. The Administrator provided evidence the issue of transfers had been discussed in the Quality Assurance meeting that had taken place on 7/11/17 and the facility was monitoring falls for trends. The final correction date was 6/23/17.

Based on observations, record review, physician and staff interviews, and family interview, the facility failed to follow the bowel protocol and/or administer medications to a resident who had not had a bowel movement for 14 days for 1 of 5 sampled residents reviewed for unnecessary medications and the facility failed to follow a physician's orders [REDACTED].#92 and #30). The findings included: 1) Review of a document titled "Admission Protocols" with a revised date of 03/01/12 read in part the following: ? Admission protocols are considered part of the initial care plan ? Milk of Magnesia (MOM) 30 milliliters (ml) by mouth (PO): Give Day 3 if no bowel movement (BM) ? [MEDICATION NAME] 10 milligrams (mg) suppository: Give Day 4 if no BM from laxative ? Enema: Give Day 5 if no BM from suppository Resident #92 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. The instructions specified for Resident #92 to be given MOM 30 ml orally on day 3 if no BM, [MEDICATION NAME] 10 mg rectal suppository on day 4 if no BM from the MOM, and if no BM on day 5 from the suppository, give Enema one bottle rectally. Further review of the physician's orders [REDACTED]. A review of the Medication Administration Record [REDACTED]. Review of the admission Minimum Data Set ((MDS) dated [DATE] indicated Resident #92 demonstrated severe impairment of cognition, required extensive assistance with bed mobility and toileting, was totally dependent on staff for transfers, dressing, bathing, and personal hygiene, and required assistance with eating of a regular diet. Resident #92 was coded as being administered antipsychotic and antidepressant medications for 7 out of 7 days, and always incontinent of bowel and bladder. The MDS revealed that no medications were coded to be administered for the [DIAGNOSES REDACTED]. A care plan dated 10/07/14 specified Resident #92 was at risk for constipation due to dementia and a history of constipation. The care plan goal was for the resident to have a regular BM pattern. Care plan interventions included monitor and chart bowel movements and administer medications per physician's orders [REDACTED]. A review of a Bowel Movement Monitoring Assessment Report dated 11/01/14 through 01/16/15 revealed no bowel movement was recorded for Resident #92 for 14 days from 12/01/14 through 12/14/14. A review of the Nurses Progress Notes dated 11/29/14 through 01/16/15 revealed no documentation to indicate a bowel movement assessment was completed and/or that the BM protocol had been initiated. Further review of the nurse's notes revealed Resident #92 was sent to the emergency roiagnom on [DATE] related to a fall. A review of the dietary notes dated 12/01/14 through 01/16/15 revealed Resident #92 has had a decline in weight, with refusals to eat, and an intake of 0-25% with each meal. A review of hospital records dated 12/16/14 revealed Resident #92 was admitted to the hospital on [DATE] and discharged on [DATE]. The record revealed Resident #92 was admitted to the hospital for a urinary tract infection [MEDICAL CONDITION], diverticulitis, abdominal pain, severe constipation. Further review of the hospital records indicated a section titled "Impression" which revealed there was severe fecal impaction in the rectum per the Computerized Tomography (CT) scan and the physician's diagnosis. Resident #92 was sent back to the facility with orders which included Senna Laxative, [MEDICATION NAME] (a laxative), and 4 prunes with breakfast every day related to severe constipation. An interview was conducted on 01/15/15 at 6:12 AM with Nurse #8. She stated the Nursing Assistants (NAs) were expected to inform the nurses if a resident had not had a BM during their shift. She indicated at that time the nurse should do an assessment of the resident's abdomen, check for bowel sounds, and check the resident's medical record for verification of the last BM. She confirmed there was no documentation to indicate Resident #92 had a BM from 12/01/14 through 12/14/14 and she was unable to recall if she had been informed by an NA that Resident #92 had not had a BM. She stated the nursing staff had an in-service in December and was advised that the 2nd shift charge nurse would initiate the BM protocol for those residents' who had not had a documented BM in 3 days. She further stated she did not know why the BM protocol was not initiated for Resident #92. An interview on 01/15/15 at 12:29 PM was conducted with NA #4. She stated Resident #92 was given prunes every day at breakfast and that most of the time she would eat the prunes. She stated the NAs were expected to document in the computer when a resident had a BM or inform the nurse should a resident not have a BM by the end of their shift. She confirmed she had not documented a BM for Resident #92 from 12/01/14 through 12/14/14 and was unable to recall if she had informed a nurse of no BM. An interview on 01/15/15 at 12:52 PM was conducted with the Regional Dietary Manager (RDM). She stated she was unaware Resident #92 had not had a BM for 14 days in December 2014. She further stated Resident #92 was to eat 4 prunes with her breakfast meal every day, was to be given a high calorie liquid supplement with each medication pass, a supplement called magic cup with each meal, and an appetite stimulant called [MEDICATION NAME] related to her constipation, decrease in meal intake, and weight loss. An interview on 01/15/15 at 1:39 PM was conducted with NA #3. She stated the NAs were expected to document in the computer system if a resident had a BM and/or inform the nurse if a resident had not had a BM by the end of their shift. She confirmed that she had not documented any BMs for Resident #92 from 12/01/14 through 12/14/14 and was unable to recall if she had informed the nurse of no BMs for Resident #92. An interview on 01/15/15 at 1:59 PM was conducted with Nurse #5. He stated he was unable to recall if he had been informed by the NAs of no BM for Resident #92. He indicated Resident #92 was sent to the hospital for a fall and was diagnosed with [REDACTED]. not had a documented BM in 3 days. He stated he did not know why the BM protocol was not initiated for Resident #92 and he confirmed that no BM had been documented for Resident #92 from 12/01/14 through 12/14/14. An interview on 01/16/15 at 11:41 AM was conducted with Nurse #3. She stated she was the nurse responsible for Resident #92 on the 1st shift (7:00 AM through 3:00 PM). She confirmed Resident #92's BM protocol was signed by the resident's physician upon admission to the facility. She stated there was no documentation to indicate that Resident #92 had a BM from 12/01/14 through 12/14/14 or that the facility had initiated the BM protocol. She further stated she was not working on 12/14/14 but was aware that Resident #92 was sent to the hospital on [DATE] and that she was diagnosed with [REDACTED]. She indicated the nursing staff had an in-service in December, 2014 and was advised the 2nd shift charge nurse would initiate the BM protocol for those residents' who had not had a documented BM in 3 days. She stated she did not know why the BM protocol was not initiated for Resident #92. An interview on 01/16/15 at 3:47 PM was conducted with Resident #92's family. The family stated they had met the resident at the hospital on [DATE] and Resident #92 was diagnosed with [REDACTED]. An interview on 01/16/15 at 5:38 PM was conducted with the Director of Nursing (DON). She stated her expectation was that the facility BM protocol was to be followed, however the DON acknowledged the BM protocol was not followed for Resident #92. She stated she was aware of the grievance filed on 12/22/14 and the family had informed her of Resident #92's constipation and she had to have stool removed manually during her hospital admission. She further stated the nurses were provided an in-service related to the 2nd shift charge nurse initiating the BM protocol for those residents' with no documented BM in 3 days. She stated she was unaware Resident #92 had not had a BM in 14 days but felt that having someone responsible for reviewing and initiating the BM protocol would alleviate any future problems. 2. Resident #30 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the most recent quarterly Minimum Data Set ((MDS) dated [DATE] indicated Resident #30 had no short term or long term memory problems and was cognitively intact for daily decision making. The MDS further indicated Resident #30 required extensive assistance by staff for activities of daily living. A review of a care plan titled skin integrity needs dated 11/14/14 indicated interventions in part for persistent [MEDICAL CONDITION], dressing change every week on Monday, Thursday and Saturday and as needed for wound on left arm dorsal (forearm) until healed. A review of a physician's orders [REDACTED]. A review of a nurse's progress note dated 12/12/14 at 4:34 PM indicated in part left forearm is noted to have improved with treatments 3 times a week and as needed dressing changes. The notes revealed the skin to this area is mostly intact with some very small superficial (located on the surface of the skin) open areas that are moist and the surrounding skin appears very fragile. The notes further revealed resident complained of tenderness. A review of a handwritten physician's orders [REDACTED]. Treat wound with [MEDICATION NAME] and non-stick gauze. A review of a nurse's progress note dated 12/26/14 at 1:42 PM indicated in part the area on the left forearm was showing signs of improvement but had some areas that were superficially open. A review of a nurse's progress note dated 01/12/15 at 1:25 PM indicated A&D (Vitamin A&D applied to the skin to moisturize and seal the skin) ointment applied to left forearm and monitor for changes. A review of a nurse's progress note dated 01/13/15 at 1:54 PM indicated A&D ointment applied to left arm prior to replacing dressing due to build-up of [MEDICATION NAME] Cream to help with moistening of area. The notes further indicated to continue to monitor and note any changes. A review of a nurse's progress note dated 01/14/15 at 9:20 AM indicated in part left forearm wound continued with a small amount of [MEDICATION NAME] cream to arm but was improving with the use of A&D ointment. The notes also revealed there were some small open areas with a small amount of blood noted and Resident #30 complained of tenderness and discomfort during treatment and assessment and scheduled pain medicine was given prior to treatment. During an observation of wound care on 01/15/15 at 2:12 PM the Wound Care Nurse (WCN) took a treatment cart into Resident #30's room, washed her hands, organized supplies on top of the treatment cart and put gloves on. She started to remove a non-stick dressing from Resident #30's left arm but the dressing was stuck to the wound. She picked up a spray bottle of wound cleanser and sprayed it on the dressing as she peeled the dressing off Resident #30's arm and then dabbed the wound with a gauze dressing. The wound was located on the top of Resident #30's left forearm from just above her wrist to below the crease in her arm at her elbow and was raw with open skin. There were also numerous small deeper open areas inside the area of raw skin that were oozing blood. The WCN picked up a packet of A&D ointment and squeezed the A&D ointment onto the glove of her hand and rubbed it onto the open wound on Resident #30's forearm. She placed a clean non-stick dressing on the wound and wrapped it with a gauze wrap and then discarded her supplies into a plastic trash bag, removed her gloves, washed her hands and took the treatment cart out of Resident #30's room. During an interview on 01/15/15 at 2:35 PM the WCN explained when Resident #30 was admitted to the facility she had a cast on her left arm due to a fracture. She explained when the cast was removed several months later a skin tear was present on her arm. She stated they treated it but it was not responding so the wound doctor was consulted and ordered treatments and it healed. The WCN explained Resident #30 was admitted to the hospital in September 2014 and when she came back it looked like the superficial layer of skin was gone on top of her left arm. She stated the wound doctor looked at Resident #30's arm and recommended for her to see a Dermatologist and he ordered [MEDICATION NAME] cream and a non-stick dressing for her left arm. She explained the [MEDICATION NAME] cream had built up on the wound and was difficult to get off when she tried to clean it. She stated she had stopped using the [MEDICATION NAME] cream on the wound and had used the A&D ointment as a trial and error effort to soften and get the [MEDICATION NAME] cream off. During a follow up interview on 01/16/15 at 10:37 AM the WCN confirmed she had not called the Dermatologist about her concerns with the [MEDICATION NAME] build up on the wound on Resident #30's left arm. She stated she should have called the physician and should have gotten a physician's orders [REDACTED]. She explained she realized she had made an error by not following the physician's orders [REDACTED]. During a telephone call on 01/16/15 at 3:21 PM with the facility Medical Director he stated it was his expectation for nurses to follow physician's orders [REDACTED]. During an interview on 01/16/15 at 5:41 PM the Director of Nursing stated it was her expectation for nurses to follow physician's orders [REDACTED]. She further stated if the nurse had a question about the order or wanted to change a treatment order they should call the physician first to discuss it and get a new order if the physician wanted the treatment changed.

Based on observations, staff interviews and record review the facility's Quality Assessment and Assurance Committee failed to maintain implemented procedures and monitor the interventions that the committee put in place in [DATE]. This was for three re-cited deficiencies that were originally cited on a recertification survey in [DATE] and on a recertification survey on [DATE]. The deficiencies were in the areas of investigating and reporting allegations of abuse and neglect, developing and implementing abuse and neglect policies and medication administration. The continued failure of the facility during two federal surveys of record shows a pattern of the facility's inability to sustain an effective Quality Assessment Assurance Program. The findings included: This tag is cross referenced to: F225: Investigate and Report Allegations of Abuse and Neglect: Based on record review and staff interviews the facility failed to thoroughly investigate an allegation of abuse by staff for 1 of 3 residents reviewed for abuse. F226: Develop and Implement Abuse and Neglect Policies: Based on record review and staff interviews the facility failed to follow their abuse policy for investigating an allegation of abuse by staff for 1 of 3 residents reviewed for abuse. F333: Pharmaceutical Services: Based on observations, record review and staff interviews the facility failed to accurately dispense medications as ordered for 2 of 11 residents whose medications were reviewed. During the last recertification survey in [DATE], the facility was cited for F225 for failing to report an allegation of abuse to the North Carolina Health Care Personnel Registry (NCHCPR), F226 for failing to follow their Abuse and Neglect Policy on reporting all allegations of abuse and neglect to the NCHCPR and F333 for failing to administer medications accurately and as they were ordered. On the survey of [DATE] the facility was cited for failing to thoroughly investigate an allegation of abuse, failing to follow their abuse policy for investigating an allegation of abuse and failing to administer medications accurately in accordance with current physician's orders [REDACTED]. During an interview on [DATE] at 6:22 PM with the Administrator, he stated the felt like the facility had worked really hard on the areas that were cited on the [DATE] survey and he thought they had corrected the problem with reporting and investigating abuse. He had no comment on the continued non-compliance with F333 and stated they will continue to work on improving the areas of concern.

Based on record review and staff interviews, the facility failed to follow the care plan to initiate the bowel movement protocol for a resident with no bowel movement in 14 days and failed to keep a resident's bed in the lowest position for a resident with a history of falls for 2 of 25 sampled residents (Resident #92 and #140). The findings included: 1) Review of a document titled "Admission Protocols" with a revised date of 03/01/12 read in part the following: ? Admission protocols are considered part of the initial care plan ? Milk of Magnesia (MOM) 30 milliliters (ml) by mouth (PO): Give Day 3 if no bowel movement (BM) ? [MEDICATION NAME] 10 milligrams (mg) suppository: Give Day 4 if no BM from laxative ? Enema: Give Day 5 if no BM from suppository Resident #92 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. The instructions specified for Resident #92 to be given MOM 30 ml orally on day 3 if no BM, [MEDICATION NAME] 10 mg rectal suppository on day 4 if no BM from the MOM, and if no BM on day 5 from the suppository, give Enema one bottle rectally. Further review of the physician's orders [REDACTED]. A review of the Medication Administration Record [REDACTED]. Review of the admission Minimum Data Set ((MDS) dated [DATE] indicated Resident #92 demonstrated severe impairment of cognition, required extensive assistance with bed mobility and toileting, was totally dependent on staff for transfers, dressing, bathing, and personal hygiene, and required assistance with eating of a regular diet. Resident #92 was coded as being administered antipsychotic and antidepressant medications for 7 out of 7 days, and always incontinent of bowel and bladder. The MDS revealed that no medications were coded to be administered for the [DIAGNOSES REDACTED]. A care plan dated 10/07/14 specified Resident #92 was at risk for constipation due to dementia and a history of constipation. The care plan goal was for the resident to have a regular BM pattern. Care plan interventions included monitor and chart bowel movements and administer medications for constipation per physician's orders [REDACTED]. A review of a Bowel Movement Monitoring Assessment Report dated 11/01/14 through 01/16/15 revealed no bowel movement was recorded for Resident #92 for 14 days from 12/01/14 through 12/14/14. A review of the Nurses Progress Notes dated 11/29/14 through 01/16/15 revealed no documentation to indicate a bowel movement assessment was completed and/or that the BM protocol had been initiated. Further review of the nurse's notes revealed Resident #92 was sent to the emergency roiagnom on [DATE] related to a fall. An interview was conducted on 01/15/15 at 6:12 AM with Nurse #8. She stated the Nursing Assistants (NAs) were expected to inform the nurses if a resident had not had a BM during their shift. She indicated at that time the nurse should do an assessment of the resident's abdomen, check for bowel sounds, and check the resident's medical record for verification of the last BM. She confirmed there was no documentation to indicate Resident #92 had a BM from 12/01/14 through 12/14/14. An interview on 01/15/15 at 12:29 PM was conducted with NA #4. She stated Resident #92 was given prunes every day at breakfast and that most of the time she would eat the prunes. She stated the NAs were expected to document in the computer when a resident had a BM or inform the nurse should a resident not have a BM by the end of their shift. She confirmed she had not documented a BM for Resident #92 from 12/01/14 through 12/14/14 and was unable to recall if she had informed a nurse of no BM. An interview on 01/15/15 at 1:39 PM was conducted with NA #3. She stated the NAs were expected to document in the computer system if a resident had a BM and/or inform the nurse if a resident had not had a BM by the end of their shift. She confirmed that she had not documented any BMs for Resident #92 from 12/01/14 through 12/14/14 and was unable to recall if she had informed the nurse of no BMs for Resident #92. An interview on 01/15/15 at 1:59 PM was conducted with Nurse #5. He stated he was unable to recall if he had been informed by the NAs of no BM for Resident #92. He indicated Resident #92 was sent to the hospital for a fall and was diagnosed with [REDACTED]. not had a documented BM in 3 days. He stated he did not know why the BM protocol was not initiated for Resident #92 and he confirmed that no BM had been documented for Resident #92 from 12/01/14 through 12/14/14 An interview on 01/16/15 at 11:41 AM was conducted with Nurse #3. She stated she was the nurse responsible for Resident #92 on the 1st shift (7:00 AM through 3:00 PM). She confirmed Resident #92's BM protocol was signed by the resident's physician upon admission to the facility. She stated there was no documentation to indicate that Resident #92 had a BM from 12/01/14 through 12/14/14 or that the facility had initiated the BM protocol. She further stated she was not working on 12/14/14 but was aware that Resident #92 was sent to the hospital on [DATE] and that she was diagnosed with [REDACTED]. She indicated the nursing staff had an in-service in December, 2014 and was advised the 2nd shift charge nurse would initiate the BM protocol for those residents' who had not had a documented BM in 3 days. She stated she did not know why the BM protocol was not initiated for Resident #92. An interview on 01/16/15 at 5:38 PM was conducted with the Director of Nursing (DON). She stated her expectation was that the facility BM protocol was to be followed, however the DON acknowledged the BM protocol was not followed for Resident #92. She stated she was aware of the grievance filed on 12/22/14 and the family had informed her of Resident #92's constipation and she had to have stool removed manually during her hospital admission. She stated she was unaware Resident #92 had not had a BM in 14 days but felt that having someone responsible for reviewing and initiating the BM protocol would alleviate any future problems. She stated she expected the nursing staff to follow the resident's care plan. 2) Resident #140 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set ((MDS) dated [DATE] indicated Resident #140 was cognitively intact and capable of making daily decisions. Resident #140 was coded to need limited assistance with personal hygiene and bathing, and extensive assistance with bed mobility, transfers, dressing, and toileting. A care plan dated 12/16/14 specified Resident #140 was at risk for falls related to an unsteady gait and unsteady balance, history of falls, which included a [MEDICAL CONDITION]. The care plan goal was to keep the resident free from a fall related injury. Care plan interventions included call light within resident's reach, concave mattress, bilateral half side rails, and bed at lowest position while occupied. Review of Resident #140's medical record revealed an unwitnessed fall on 09/03/14 at 3:00 AM. The nurse's entry specified the resident was found on the floor near the bathroom door and Resident #140 had sustained skin tears to both elbows and that the physician and the resident's family were notified. Further review of the medical record revealed an intervention of toileting the resident every 2 hours. Further review of Resident #140's medical record revealed a fall on 09/28/14 at 3:05 AM. The nurse's entry specified Resident #140 sustained an injury to the left hip due to the fall with an intervention which included a sensor pad to the resident's bed due to falls occurring at night. The resident's family and the physician were notified. The medical record revealed Resident #140 had an unwitnessed fall on 01/06/15 at 3:10 AM. The nurse's entry specified the resident slid out of bed, into the floor, with his arm between the mattress and the side rail, the bed alarm was ringing and the resident was calling out for assistance. The nurse's entry indicated the physician and the resident's family were notified. On 01/14/15 at 8:43 AM, Resident #140 was observed sitting up in bed eating breakfast with bilateral half side rails in the upright position, call light within reach, and the bed not in the lowest position but at waist level. On 01/15/15 at 6:37 AM, Resident #140 was observed to be asleep, bilateral half side rails upright, and the bed was noted to be at waist level and not in the lowest position. On 01/15/15 at 10:12 AM, Resident #140 was observed sitting upright in bed with bilateral half side rails upright, call light within reach, and the bed was noted to be at waist level and not in the lowest position. On 01/15/15 at 10:14 AM, an interview was conducted with Resident #140. He stated he was unaware the bed would go lower to the floor. He indicated the bed stayed in the same position all the time except when he ate his breakfast and the nursing assistant would raise the head of his bed up. On 01/16/15 at 3:07 PM, an interview was conducted with Nursing Assistant (NA) #5. She stated she thought Resident #140 was a fall risk because he had a history of [REDACTED].#140 be a fall risk it would be indicated on his care guide which was located on the inside of his closet door. After reviewing the resident's care guide, she confirmed Resident #140 was at risk for falls and was to have his "bed at the lowest position while occupied." She indicated she had not placed Resident #140's bed in the lowest position as to not allow his catheter bag to touch the floor. On 01/16/15 at 3:12 PM, an interview was conducted with NA #6. She stated the nursing staff was supposed to inform them if a resident was at risk for falls. She indicated she was unaware that Resident #140 was at risk for falls and that his bed was supposed to be kept at the lowest position. On 01/16/15 at 3:31 PM, an interview was conducted with Nurse #7. She confirmed Resident #140's bed was at waist level and not in the lowest position. She manually lowered the bed to the floor to demonstrate the lowest position and stated the bed was supposed to be next to the floor at all times when occupied by Resident #140. On 01/16/15 at 5:38 PM, an interview was conducted with the Director of Nursing (DON). She stated she expected Resident #140's bed to be in the lowest position when occupied. She further stated she would have expected the nursing staff to have followed the resident's care plan.

Based on observations, record reviews, staff interviews, and resident interviews, the facility failed to secure 2 of 2 sampled residents (Resident #70 and #5) in the facility van being transported to dialysis. Neither Resident #70's wheelchair nor Resident #5's wheelchairs were attached to the van floor securement system with four point safety restraints. Both residents also had their lap belts secured across their chests instead of their laps. Immediate Jeopardy began on 09/06/13 for Resident #70 and Resident #5. Immediate Jeopardy was removed on 09/07/13 at 5:20 PM when the facility implemented a credible allegation of compliance. The facility remains out of compliance at the lower scope and severity of D (no actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure monitoring systems are in place and the completion of employee education. The findings included: The facility Maintenance/Safety Driver Director provided a document outlining how to secure wheelchairs in the facility van entitled " Ride Safe" and dated 2005. The document read in part: 1. It is important to use a complete wheelchair tie down and occupant restraint system to secure the wheelchair and provide the wheelchair occupant with a properly designed and tested seatbelt system. The most common type of wheelchair tie down uses four straps to secure the wheelchair to the vehicle. 2. When securing a wheelchair, attach the four tie down straps to the securement points provided on the wheelchair. It is best to attach the tie down straps to welded junctions of the wheelchair frame or to other structural areas where the frame is fastened together with hardened steel bolts indicated by six raised lines or bumps on the bolt head. Do not attach tie downs to adjustable, moving, or removable parts of the wheelchair such as armrests, footrests, and wheels. 3. In addition to securing the wheelchair, it is important to provide effective restraint for the wheelchair user with a crash-tested lap and shoulder belt. The lap belt should be placed low across the front of the pelvis near the upper thighs, not high over the abdomen. The lap belt should be angled between 45 and 75 degrees to the horizontal when viewed from the side. Resident #70 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission Minimum Data Set ((MDS) dated [DATE] coded Resident #70 as being understood, having clear speech, understanding, and requiring limited assistance with most activities of daily living (ADL). The MDS noted Resident #70 had no memory impairments and had no difficulty with decision making. Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent quarterly Minimum Data Set ((MDS) dated [DATE] coded Resident #5 as being understood, having clear speech, understanding, and requiring one-person physical assistance with most activities of daily living (ADL). On 09/05/13 at 4:00 PM, Resident #70 was interviewed. She stated Van Transporter #1 rarely secured her wheelchair to the van when going to the dialysis center. She stated by the time she would arrive to dialysis and/or back to the facility her wheelchair would be turned around in a 45 degree turn facing the side door of the van and not the way she was initially put into the van facing forward. She stated she feared she would fall out of the van door. She stated her wheelchair would be locked and she would always be secured with the lap belt but she never felt as secured as she did with other van transporters. She further stated when she was put in the van by other van transporters her wheelchair would not move at all. On 09/06/13 at 7:25 AM, Resident #70 and Resident #5 were observed being placed in the van by Van Transporter (VT) #1. VT #1 was observed to get into the driver ' s seat, close the driver ' s door, start the van, and shift the van into drive in preparation to pull away from the front of the facility. Before the van was able to move, Surveyor #2 approached the driver ' s side window and asked VT #1 if Surveyors #1 and #2 could enter the van to speak with the residents. VT #1 was observed to shift the van into park and open the side door for the surveyors to enter the van. Surveyor #1 and Surveyor #2 entered the van, walked down the van aisle to the back of the van where the two residents were sitting in their wheelchairs. Observations revealed the wheels were locked on both wheelchairs, and lap belts were placed across the chests of both residents instead of across their laps. The 4 point tie down restraints was observed lying in the floor of the van, unsecured to either resident ' s wheelchairs. VT #1 got out of the driver seat and came to the back of van. VT #1 stated she always pulled forward to allow room for possible visitors and/or Emergency Medical Staff (EMS) vehicles before she would secure the residents' wheelchairs. Residents were questioned at that time as to whether wheelchairs moved during transport and Resident #70 stated " Yes, sometimes " and pointed with her left hand index finger toward the right side of van where residents are loaded onto the van by the vans lift. Resident #5 nodded her head up & down in agreement with Resident #70 ' s statement. VT #1 then proceeded to apply the floor securement system restraints to the front and back of both wheelchairs. On 09/06/13 at 8:00 AM, VT #1 was interviewed. She stated she had been driving the facility ' s van approximately 2 years. She stated her training included watching a video, a class, performing hands on demonstration, a return demonstration, and that she received annual in-service training/review performed by the Maintenance Director. She stated she had not had the in-service/training this year but did have the in-service/training last year. She stated she had demonstrated proper securing of residents ' wheelchairs using the 4 point tie down restraints to the frame of the wheelchairs along with properly using the safety seatbelt in addition to locking residents ' wheelchairs during the annual training. She stated there would be minimal movement of the wheelchair and stated that a resident ' s body would have minimal movement when the van brakes were applied if a resident were properly secured. She offered no explanation as to why Resident #70 had reported her wheelchair was able to move during transportation. VT #1 admitted she would often load the residents onto the van unsecured, proceed to move the van forward approximately 30 feet, just in case visitors and/or EMS vehicles would come to the facility. She stated she would then finish securing the residents. She stated this was not part of her training; this was something that she did on her own. VT #1 also stated the lap belt should be fastened across the lap. On 09/06/13 at 1:00 PM, Resident #70 was interviewed. She stated that VT #1 would not drive fast but when going around corners her wheelchair would always move, she would yell out, " whoa " her wheelchair would turn to the side on a 45 degree angle, and she would not be facing forward. She stated while being transported by the facility contracted transport company, from dialysis to the facility, her wheelchair never moved. Resident #70 ' s family member was present during this interview and stated the resident had voiced concern to her numerous times related to her wheelchair turning to the side at a 45 degree angle, and not facing forward during transport to dialysis and/or to facility. On 09/06/13 at 1:10 PM, Resident #5 was interviewed. She stated even though her wheelchair is often not fastened to the straps from the floor, her wheelchair doesn ' t move much during transport to appointments, but she observed Resident #70 ' s wheelchair frequently move several inches to either side and its position changed from facing forward to facing the right side of the van. Resident #5 said the first time she noticed VT #1 not fastening the floor straps was about a month ago. On 09/07/13 at 10:54 AM, Maintenance/Driver Safety Director was interviewed. He stated he went through a training called " Special Needs " and received his certification in driver safety. He stated he trained all facility van transporters using the " Ride Safe " document which outlined the proper use of the four point restraint floor securement system and proper use of the lap belt. The facility van transporters were trained as follows: place residents on the lift, place the residents in the van, lock the residents ' wheelchairs, secure the 4 point tie down restraints to the wheelchairs using right front restraint first, left front restraint next, right back restraint, then left back restraint; after 4 point tie down restraints are secured, place the safety seatbelt around the residents lap from the hip area up to belly button area, depending on the size of the resident, not on the chest. He stated the resident had to be completely secured before moving the van at all. He stated he expected all van transporters to follow this procedure. He further stated the van transporter training should be completed on an annual basis with each van transporter and/or as he received updates related to driving safety. He verified VT #1 received her annual in-service/training 06/2012 but had not had the annual renewal training as of 09/07/13. On 09/07/13 at 2:35 PM, VT #2 was interviewed by telephone. She stated she had the in-service/training on 09/06/13 and the van transporters have the in-service/training annually given by the Maintenance/Driver Safety Director. She stated during the training she had to demonstrate putting residents on the lift, placing the residents in the van, locking the residents wheelchairs, securing the 4 point tie down restraints, right front restraint first, left front restraint next, right back restraint, then left back restraint, after 4 point tie down restraints are secured, then place the safety seatbelt around the residents lap; from hip area up to belly button area, depending on the size of the resident. She stated the residents had to be completely secured before moving the van. The Administrator was informed of Immediate Jeopardy on 09/06/13 at 10:35 AM for Resident #70 and Resident #5. A Credible Allegation of Compliance was accepted on 09/07/13 at 8:43 AM as follows: Credible Allegation of Compliance: Supervision to Prevent Accidents Resident #70 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #5 admitted to the facility 10/08/12 with [DIAGNOSES REDACTED]. On 09/06/13, Transport Aide #1 was preparing to transport Resident #70 and Resident #5 to their dialysis appointment in the facility ' s van. Transport Aide #1 failed to secure Resident #70 and Resident #5 wheel chairs to the van with four point safety restraints as specified by the manufacturer and was observed by state surveyors to put the van in drive gear to transport the resident to their appointment. Transport Aide #1 was stopped by the state surveyors and transport aide confirmed that both residents were not properly secured for transport. Transport Aide #1 was observed to properly secure both of the resident ' s wheel chairs to the van using four point safety restraints and then proceed to transport Resident #70 and Resident #5 to the dialysis clinic. The residents were not injured in route. The state surveyors informed the facility's administrator of the incident. The administrator arranged for Resident #70 and Resident #5 to be returned to the facility by a contract transport agency. Transport Aide #1, who failed to properly secure the wheel chairs of Resident #70 and Resident #5 on 09/06/13, was immediately suspended upon return to the facility by the administrator. When Resident # 70 and Resident #5 were returned to the facility they were assessed by the Director of Nursing for signs and symptoms of injuries and no injuries were noted. The administrator received certificate of completion for Transporting Passengers with Special Needs February 13, 2008. On 09/06/13 the maintenance supervisor was reeducated by the administrator on how to properly secure wheel chair bound residents to the van for safe transport which included return demonstration. The facility has two transport aides currently employed, other than transport aide #1. On 09/06/13 both of the transport aides were reeducated by the Administrator and Maintenance Supervisor on how to properly secure wheel chair bound residents to the van for safe transport which included a skills checklist with return demonstration. This training included: return demonstration proper lift techniques-boarding and leaving the vehicle, watching heads, hand. Securing wheel chair including wheel chair tie-downs, proper angles and points on the chair, need for additional belts, securing seated passengers, seat belts. If Transport Aide #1 is reinstated by the facility as a transport aide she will be reeducated by the maintenance supervisor on how to properly secure wheel chair bound residents to the van for safe transport before being allowed to return to work including skills checklist and return demonstration. Transport Aides will be required to complete an annual skills checklist with return demonstration which will be provided by the maintenance supervisor to ensure the following: proper wheel chair lift techniques including boarding and exiting the vehicle, securing wheel chair including wheel chair tie-downs, proper angles and points on the chair, need for additional belts, in all aspects of securing seated passengers. All newly hired transport aides are educated and trained by the Maintenance Supervisor or Administrator for skills check off, return demonstration of proper wheel chair lift techniques including boarding and exiting the vehicle, securing wheel chair including wheel chair tie-downs, proper angles and points on the chair, need for additional belts, in all aspects of securing seated passengers. The facility van will not be utilized for resident transport until transport aides have been reeducated on how to properly secure wheel chair residents during transport in accordance with facility policy. Review of facility appointment calendar revealed 7 residents with outside appointments through Tuesday, September 10, 2013. The facility will utilize a contract transport agency for resident transportation to appointments scheduled outside the facility until Wednesday, September 11, 2013. Beginning 09/11/13 the facility van will be utilized for resident transportation. Alternate transport arrangements were made for residents #70 and #5 to return to facility from their respective appointments. Transportation was arranged to the facility with a contract transport agency who returned both residents to the facility on [DATE]. Both dialysis residents will be transported by a contract transport agency to dialysis on Monday, September 9, 2013. On Wednesday September 11, 2013 residents will be transported via facility staff for appointments by the maintenance supervisor or the alternate van driver. No van driver will be allowed to transport residents until trained and competency has been determined. To prevent any further occurrence: ? Van driver #1 has been suspended indefinitely pending investigation. ? The maintenance supervisor was observed by the administrator for compliance, via return demonstration on 9/6/13. The administrator received certificate of completion for Transporting Passengers with Special Needs February 13, 2008. ? The facility has 2 remaining van drivers, who were both retrained, re-educated, using skills check list, and performed return demonstration for safety during resident transfer using facility van on 9/6/2013. Training included the facility certified trainer (maintenance supervisor). The training included: return demonstration proper lift techniques-boarding and leaving the vehicle, watching heads, hand, etc. Securing wheel chair including wheel chair tie-downs, proper angles and points on the chair, need for additional belts, etc. Securing seated passengers, seat belts. The maintenance supervisor was checked by the Administrator. The other trained driver was checked off by the Maintenance Supervisor. Annual skills check off and training is provided by the maintenance supervisor to ensure the following: ? Return demonstration proper lift techniques-boarding and leaving the vehicle, watching heads, hands, etc. ? Securing wheel chair including wheel chair tie-downs, proper angles and points on the chair, need for additional belts, etc. ? Securing seated passengers, seat belts. Immediate Jeopardy was lifted on 09/07/13 at 5:20 PM. The facility provided evidence of additional in-service training for all transportation staff. Interviews and observations of transportation staff securing wheelchair bound residents in the facility van by the administrator and maintenance director were completed. Interviews of transportation staff revealed each staff had been securing the wheelchairs differently and now they were aware of the proper technique for safe transport.