Every finding on record at Ayden Court Nursing and Rehabilitation Center

Based on record review and staff interviews, the facility failed to designate a qualified Infection Preventionist (IP) who had completed specialized training in infection prevention and control, to be responsible for the facility's Infection Prevention and Control Program. This had the potential to affect all residents in the facility.Findings included:In an interview on 5/5/2026 at 12:10 pm with Director of Nursing (DON), in the presence of the Regional Nurse Consultant, the DON stated the Infection Preventionist position was currently vacant, however she and the Assistant Director of Nursing (ADON) shared in the responsibilities of Infection Preventionist. She stated they both completed the programs out of state and she would work on retrieving the documentation. DON could not remember the name of the infection prevention and control program she completed in Ohio but stated it was similar to the Statewide Program for Infection Control and Epidemiology (SPICE) program offered in North Carolina.On 5/6/2026 at 10:00 am in an interview with the DON in the presence of ADON and the Regional Nurse Consultant, the DON stated that she had been unable to locate documentation for herself or the ADON but she believed the Staff Development Coordinator (SDC) completed the Statewide Program for Infection Control and Epidemiology (SPICE) and would get the documentation.In a subsequent interview with the DON on 5/6/2026 at 3:16 pm she stated that she was unable to obtain documentation to show that there was a qualified Infection Preventionist at the facility.The Administrator was not available for interview during the survey.

Based on record review, and interviews with the Resident Representative, staff, Medical Director, and Nurse Practitioner (NP), the facility failed to ensure a resident had an indication and a diagnosis for the use of an antipsychotic medication and failed to administer the antipsychotic medication on an as needed basis as specified in the hospital discharge summary. This was for 1 of 6 residents reviewed for chemical restraints (Resident #32).The findings included: Resident #32's hospital Discharge summary dated [DATE] revealed a physician's order for Olanzapine (antipsychotic) 2.5 mg take 1 tablet by mouth at bedtime as needed (if agitated at night causing increased fall risk). Resident #32 was admitted to the facility on [DATE] with diagnoses which included Alzheimer's disease unspecified, chronic pain, hyperlipidemia (condition characterized by high levels of lipids (condition of high cholesterol or fats in the blood), and radiculopathy of the cervical region (the cervical spine is compressed or inflamed which results in radiating pain, numbness, or muscle weakness from the neck down to the shoulder and arm). Review of Resident #32's electronic medical record (EMR) revealed a signed informed consent dated 4/10/26 by the Resident Representative for the use of antipsychotic medication. Review of Resident #32's physician order dated 4/9/26 revealed an order for Olanzapine (antipsychotic) 2.5 milligrams (mg) to be administered at bedtime for if agitated at night causing increased fall risk. A review of Resident #32's April 2026 Medication Administration Record (MAR) documented Olanzapine 2.5 mg was administered from 4/9/26 through 4/30/26 at bedtime. A review of Resident #32's May 2026 MAR documented Olanzapine 2.5 mg was administered from 5/1/26 through 5/7/26 at bedtime. A review of Resident #32's admission Minimum Data Set Assessment (MDS) dated [DATE] revealed Resident #32 was cognitively intact. She was coded for antipsychotic medications. Resident #32's care plan dated 4/20/26 revealed a focus for psychotropic drugs with interventions which included administering medications as ordered by physician, evaluating effectiveness and side effects of medications for possible reduction/elimination of psychotropic drugs, and pharmacy review of medications monthly and/or as ordered. A phone interview was conducted on 5/12/26 at 12:05 pm with the Nurse Practitioner (NP). The NP stated Resident #32 was admitted to the facility from the hospital with an order for Olanzapine. The NP further stated she continued the Olanzapine order for agitation and reported increased falls and considered these conditions to be supporting indications for the medication. The NP stated the nursing staff had not reported any agitation, behaviors, or falls for Resident #32 following admission to the facility. When asked whether the Olanzapine was intended to be administered as a scheduled medication or on an as-needed (PRN) basis, the NP stated, the medication should have been administered on a PRN basis for agitation. The NP further stated she did not have concerns regarding Resident #32 receiving the Olanzapine every night. When asked whether the Olanzapine should have been discontinued due to no documented signs or symptoms of agitation, behaviors, or falls, the NP replied, no. In a phone interview conducted on 5/12/26 at 1:58 pm, the Medical Director stated he did not typically use Olanzapine on a PRN basis; however, Resident #32 was admitted to the facility from the hospital with an order for Olanzapine. The Medical Director stated Resident #32 had received the medication during her hospital stay and the Nurse Practitioner (NP) continued the medication upon her admission to the facility. The Medical Director stated the medication order should have been entered correctly to reflect PRN administration of Olanzapine for Resident #32; however, he expressed no concern regarding the resident receiving the medication daily because Resident #32 experienced decreased agitation and no falls while residing in the facility. When asked whether the Olanzapine should have been discontinued due to no documented signs or symptoms of agitation, behaviors, or falls, the Medical Director replied, the outcome was good with the medication.

Based on record review and staff interviews, the facility failed to accurately code a Minimum Data Set Assessment for Antipsychotic Medication Review for 1 of 21 residents reviewed for unnecessary medications (Resident #32). The findings included: Resident #32 was admitted to the facility on [DATE] with a diagnosis of unspecified Alzheimer's disease. Review of Resident #32's physician order dated 4/9/26 revealed an order for Olanzapine (antipsychotic) 2.5 milligrams (mg) to be administered at bedtime. A review of Resident #32's April 2026 Medication Administration Record (MAR) documented Olanzapine 2.5 mg was administered from 4/9/26 through 4/15/26 at bedtime. A review of Resident #32's admission Minimum Data Set Assessment (MDS) dated [DATE] revealed she received antipsychotic medications. The Antipsychotic Medication Review Section was coded as not receiving antipsychotic medication since admission. During an interview with MDS Coordinator #1 on 5/5/26 at 1:10 pm, she stated she completed this section of the admission MDS and should have indicated Resident #32 had received antipsychotic medications since admission. She verified the Minimum Data Set Assessment was inaccurate and that antipsychotic use should have been coded. During an interview on 5/6/26 at 4:45 pm with the Facility Nurse Consultant and the Director of Nursing (DON), both stated Resident #32's MDS assessments should have been coded accurately to reflect the use of antipsychotic medication since admission.

Based on record review and interviews with facility staff, pharmacy staff, Nurse Practitioner, and Medical Director, the Pharmacy Consultants failed to identify and report medication irregularities related to antipsychotic medication (primarily used to manage symptoms of psychosis, such as hallucinations, delusions, and paranoia) that included a medication transcription error and no adequate indication and diagnosis for use. This deficient practice affected 1 of 6 residents reviewed for unnecessary medications (Resident #32). The findings included: Resident #32's hospital Discharge summary dated [DATE] revealed a physician's order for olanzapine (antipsychotic medication) 2.5 milligrams (mg) take 1 tablet by mouth at bedtime as needed (if agitated at night causing increased fall risk). Resident #32 was admitted to the facility on [DATE] with diagnoses which included Alzheimer's disease. The resident had no mental health diagnoses. A physician's order dated 4/9/26 for Resident #32 indicated olanzapine 2.5 mg at bedtime for if [sic] agitated at night causing increased fall risk. An admission Medication Regimen Review (MRR) was conducted by Pharmacy Consultant #2 for Resident #32 on 4/10/26 with no potential clinically significant medication issues noted. Pharmacy Consultant #2 identified the resident was on olanzapine and recommended a Dyskinesia (a movement disorder characterized by involuntary and uncontrollable muscle movements) Identification System Condensed User Scale (DISCUS) evaluation. There were no other recommendations made related to Resident #32's olanzapine. In a phone interview with the Pharmacy Regional Clinical Manager on 5/12/26 at 1:16 pm, she stated Pharmacy Consultant #2 was unavailable for interview. Resident #32's admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #32 was cognitively intact. She was coded for antipsychotic medications. A review of Resident #32's April and May 2026 Medication Administration Records (MARs) documented olanzapine 2.5 mg was administered once daily from 4/9/26 through 5/7/26 at bedtime. A DISCUS evaluation was completed on 4/13/26 with no concerns identified. An MRR dated 5/6/26 completed by Pharmacy Consultant #1 indicated no drug irregularities were identified and no recommendations were made related to Resident #32's olanzapine. During a phone interview conducted on 5/12/26 at 1:16 pm Pharmacy Consultant #1 he stated he completed an MRR on 5/6/26 for Resident #32 and made no recommendations regarding the resident's antipsychotic medication (olanzapine). Pharmacy Consultant #1 stated he was unable to locate a documented supporting diagnosis for the antipsychotic medication in Resident #32's electronic medical record on 5/6/26; however, he reviewed the hospital discharge summary (dated 4/9/26) on 5/6/26 and noted documentation of worsening mentation, agitation, decline in functioning over the past several months, and recurrent falls. Pharmacy Consultant #1 stated he used that information to support the continued use of the antipsychotic medication and therefore did not make a recommendation. Pharmacy Consultant #1 further stated that if he had not located this information in the hospital discharge summary, he would have recommended obtaining a supporting diagnosis and a psychiatric evaluation to justify continuation of the antipsychotic medication. When asked whether the olanzapine was intended to be administered as a scheduled medication or on an as-needed (PRN) basis, Pharmacy Consultant #1 stated he was not sure and indicated he should have clarified the medication order with the Nurse Practitioner (NP). The Director of Nursing (DON) was interviewed via phone on 5/12/16 at 2:57 pm. The DON indicated there were no pharmacy recommendations requesting additional diagnoses to support the use of the olanzapine. A phone interview was conducted on 5/12/26 at 12:05 pm with the NP. The NP stated Resident #32 was admitted to the facility from the hospital with an order for olanzapine. The NP further stated she continued the olanzapine order for agitation. When asked whether the olanzapine was intended to be administered as a scheduled medication or on an as-needed (PRN) basis, the NP stated the medication should have been administered on a PRN basis for agitation as ordered from the hospital physician. The NP stated she had not received a recommendation from the Pharmacy Consultant indicating the need for an additional diagnosis or other documented clinical indication to support the continued use of olanzapine. In a phone interview conducted on 5/12/26 at 1:58 pm, the Medical Director stated Resident #32 was admitted to the facility from the hospital with an order for as needed (PRN) olanzapine. The Medical Director stated Resident #32 had received the medication during her hospital stay and the NP continued the medication upon the resident's admission to the facility. The Medical Director stated the Pharmacy Consultant should have identified and recommended whether an additional supporting diagnosis, beyond Alzheimer's disease, was necessary to support the continued use of the medication. The Medical Director stated the medication order should have been entered correctly to reflect PRN administration of olanzapine for Resident #32 and the Pharmacy Consultant should have questioned this irregularity.

Based on observation, record review, and staff interviews, the facility failed to implement infection prevention and control practices when a nurse provided tracheostomy care and did not wear a gown. This deficient practice occurred for 1 of 3 staff observed for infection control practices (Nurse #1).Findings included:A review of the facilities Infection Control Manual version date 04/2023 and page revision date of 06/13/2024 revealed:Enhanced Barrier Precautions (EBP) are used in conjunction with Standard Precautions to reduce the risk of MDRO (multidrug resistant organism) transmissions during high-contact resident care activities. Includes the use of both gowns and gloves. EBP are meant to be in place for the duration of the resident's stay or until resolution of a wound or discontinuation of an indwelling medical device occurs.Enhanced Barrier Precautions apply to residents with any of the following:Infection with a CDC (The Centers for Disease Control and Prevention)-targeted MDRO when Contact Precautions do not otherwise apply.Colonization with a CDC-targeted MDROWounds with or without the presence of an MDRO infection.Presence of indwelling medical devices with or without the presence of an MDRO infection or colonization.MDROs for which EBP applies are based on local epidemiology. At a minimum they should include resistant organisms targeted by the CDC but may also include other epidemiologically important MDROs.Resident #36 was readmitted to the facility on [DATE] with a tracheostomy. A tracheostomy is a surgically created opening (stoma) in the windpipe (trachea).On 5/4/2026 at 10:30 am a blue sign was observed to be on outside of the door for Resident #36 that stated Enhanced Barrier Precautions. The Enhanced Barrier Precautions signage instructed staff to wear a gown and gloves for high contact activities such as device care for tracheostomy. The PPE was available outside of the room on a cart.On 5/4/2026 at 2:00 pm Nurse #1 was observed to perform tracheostomy care for Resident #36. He performed hand hygiene and put on gloves; however, he did not put on any additional personal protective equipment (PPE) such as gown as required for Enhanced Barrier Precautions.An interview with Nurse #1 on 5/4/2026 at 2:16 pm immediately following procedure revealed that he was aware resident was on Enhanced Barrier Precautions. When asked why he did not wear gown Nurse #1 replied oh yeah.On 5/4/2026 at 3:42 pm an interview was conducted with the Director of Nursing (DON). She acknowledged that Nurse #1 needed additional education around infection control practices and PPE. She stated that Nurse #1 should have worn a gown and gloves while doing tracheostomy care for Resident #36.On 5/6/2026 at 10:52 am an interview with the Assistant Director of Nursing (ADON) was conducted. ADON stated it was necessary to wear PPE since Resident #36 was on Enhanced Barrier Precautions. She stated that Nurse #1 should have worn a mask and gown in addition to the gloves on 5/4/2026 while providing tracheostomy care. The ADON told you mask on the previous version.An interview with the Medical Director on 5/6/2026 at 12:44 pm revealed that although he was not that familiar with performing tracheostomy care, he expected that nursing staff should do the procedure according to whatever policies or protocols were in place.

Based on observation, record review, and interviews with facility staff, the Medical Director, the Nurse Consultant, Emergency Medical Services (EMS) paramedic, and the [NAME] President of Clinical Education and Research for the Passy-Muir Valve medical device company, the facility failed to maintain a staff member with the resident who had stopped breathing, immediately initiate a code, and immediately remove the Passy-Muir Valve (one-way speaking valve) to provide effective ventilation through the tracheostomy site (surgical opening made through the front of the neck into the trachea (windpipe)) during cardiopulmonary resuscitation (CPR) for Resident #1 when she was observed to have stopped breathing and had only a faint pulse. Resident #1's Passy-Muir Valve, which closed during respiration breathes to allow for speaking, was not immediately removed when she went into respiratory distress, allowing for secretions and/or a mucus plug to be drawn up to her tracheostomy site during CPR. Resident #1 was transferred to the hospital, admitted to the intensive care unit, and subsequently expired. This was for 1 of 2 residents who received tracheostomy care and were reviewed for emergency care (Resident #1). Immediate Jeopardy began on [DATE] when Resident #1, who was a full code, was not provided airway ventilation through the tracheostomy site as a part of CPR prior to the arrival of emergency medical services (EMS). Immediate Jeopardy was removed on [DATE] when the facility implemented a credible allegation of immediate jeopardy removal. The facility will remain out of compliance at a lower scope and severity of D (no actual harm with a potential for minimal harm that is not immediate jeopardy) to ensure education is completed and monitoring systems put into place are effective.Findings included:Record review of the undated instruction booklet for the Passy-Muir Valve, used by Resident #1, revealed that the valve allowed for inhalation through the tracheostomy tube and exhalation through the upper airway for voice production. The instructions further stated that if a resident exhibited signs of respiratory distress, the Passy-Muir Valve should be removed and the airway reassessed, and that the valve was contraindicated when a resident was unconscious. Review of the facility's 2013 tracheostomy/CPR and rescue breathing policy revealed that staff were required to check for consciousness, call 911, check for breathing, position the resident, assess for chest movement, check for pulse, suction the tracheostomy tube if needed, determine whether the tracheostomy was plugged or dislodged, and initiate 2 breaths to the tracheostomy using a resuscitation bag.Resident #1 was admitted to the facility on [DATE] with cumulative diagnoses which included respiratory failure with hypoxia (low levels of oxygen in body tissue), tracheostomy status, chronic obstructive pulmonary disease, and cerebral infarction affecting the left non-dominant side.Resident #1 had a physician's order initiated on [DATE] for a full code with cardiopulmonary resuscitation (CPR).Resident #1 had a care plan focus area initiated on [DATE] for end-of-life/advanced care planning directives/advanced directives with the intervention of CPR full code.Resident #1 had a physician's order initiated on [DATE] for a 0.5-2.5 milligram per 3 milliliters of Ipratropium-Albuterol Solution to be inhaled orally via a nebulizer every 6 hours for shortness of breath and wheezing. Albuterol is a bronchodilator that works quickly to relax the smooth muscles around the airways (bronchi).Resident #1 had a physician's order initiated on [DATE] for the performance of tracheostomy care to include dressing changes as well as suctioning of the tracheostomy to clear secretions every shift and as needed.Resident #1 was coded on an admission Minimum Data Set assessment dated [DATE] as cognitively intact and as receiving continuous oxygen therapy, as-needed suctioning, and tracheostomy care while a resident of the facility.A health status note dated [DATE] at 6:57 AM written by Nurse #1 documented that at 5:00 AM Resident #1 was alert and oriented and received medications, tracheostomy care, and a breathing treatment. At 6:10 AM, a nurse aide summoned Nurse #1 to Resident #1's room. Nurse #1 found Resident #1 to have a faint pulse; CPR was initiated. EMS was called, resumed CPR upon arrival, and transported Resident #1 to the hospital. Documentation on the March Medication Administration Record revealed Nurse #1 administered to Resident #1 the breathing treatment Ipratropium-Albuterol solution scheduled at 12:00 AM and 6:00 AM on [DATE].Nurse Aide (NA) #2 was interviewed via telephone on [DATE] at 3:58 PM. NA #2 stated she was assigned to provide care for Resident #1 during the shift beginning on [DATE] at 11:00 PM and ending on [DATE] at 7:00 AM. NA #2 reported at approximately 4:30 AM on [DATE], Resident #1 informed her that she required incontinence care. NA #2 stated Resident #1 required two staff members for incontinence care, and she informed Resident #1 she would return once she located another nurse aide to assist. NA #2 stated she returned to Resident #1's room at approximately 6:00 AM with NA #3. According to NA #2, she announced to Resident #1 that she was present to change her incontinence brief, but Resident #1 did not respond. NA #2 stated she proceeded around the privacy curtain and observed Resident #1 covered in blankets. NA #2 again attempted to speak to Resident #1 who remained unresponsive and did not move. NA #3 felt for a pulse on Resident #1 and informed NA #2 that they needed to find the nurse. NA #2 reported that she and NA #3 went to Nurses' Station 2 to find Nurse #1. Nurse #1 was notified by NA #2 that Resident #1 was not responding. Nurse #1 walked to Resident #1's room. NA #2 checked the code status of Resident #1 in the electronic medical record at Nurses' Station 2. NA #2 and NA #3 went to Resident #1's room and observed Nurse #1 assessing Resident #1 who continued to be unresponsive. Nurse #1 walked back to Nurses' Station 2 telling NA #2 and NA #3 that she needed to check the code status of Resident #1. NA #2 and NA #3 followed Nurse #1 back to Nurses' Station 2. Nurse #1 checked the code status of Resident #1 in the electronic medical record and then asked NA #2 and NA #3 how to call a Code Blue on the overhead paging system. (A Code Blue means a resident is in life threatening or immediate distress.) NA #2 and NA #3 told Nurse #1 they did not know how to use the overhead paging system, but Nurse #1 was able to activate the overhead paging system independently. NA #2 and NA #3, along with NA #1 and Nurse #2 went to Resident #1's room. Nurse #1 then arrived with the emergency cart and NA #1 and Nurse #1 put a backboard obtained from the emergency cart under Resident #1. Nurse #1 started doing compressions on Resident #1 and Nurse #2 left the room. Nurse #1 told NA #1 to put the resuscitation bag over Resident #1's mouth and assist with cardiopulmonary resuscitation. NA #1 complied with what Nurse #1 told him to do. NA #2 stated she did not observe Nurse #1 check or perform any intervention involving Resident #1's tracheostomy during this time. Nurse #2 returned to the room with an automated external defibrillator (AED) and paperwork. Nurse #2 handed the paperwork to NA #2 and instructed NA #2 and NA #3 to go to the front door and let emergency medical services (EMS) into the building. At that moment, NA #2 indicated she heard the front doorbell ring and she and NA #3 ran to let the policemen who were at the front door into the building. NA #2 brought the policemen to Resident #1's room and returned to the front of the building to lead EMS to Resident #1's room. NA #2 stated she did not reenter Resident #1's room after EMS arrived, because she did not want to interfere with emergency personnel. During a telephone interview conducted on [DATE] at 4:42 PM, NA #3 stated she was working the shift beginning on [DATE] at 11:00 PM and ending on [DATE] at 7:00 AM. NA #3 reported that she accompanied NA #2 to Resident #1's room to assist with care. Upon entering the room, NA #3 and NA #2 observed that Resident #1 was unresponsive and not breathing. NA #3 stated she checked Resident #1's pulse, found none, and informed NA #2 that they needed to get Nurse #1 immediately. According to NA #3, she and NA #2 found Nurse #1 at Nurses' Station 2 and informed her Resident #1 had no pulse. Nurse #1 walked to Resident #1's room and then walked back to Nurses' Station 2. Nurse #1 then asked NA #1, NA #2, and NA #3, who were all at the nurses' station, how to call a Code Blue. None of the nurse aides were able to provide this information to Nurse #1. Nurse #1 noticed written directions on the phone and used them to page a Code Blue overhead for Resident #1's room. NA #3 stated that Nurse #1 then pushed the emergency cart toward Resident #1's room, as NA #1, NA #2, NA #3, and Nurse #2 proceeded ahead of her. NA #3 reported that NA #1 and Nurse #1 placed a backboard underneath Resident #1 and Nurse #2 left the room. Nurse #1 started several rounds of compressions and then requested the resuscitation bag. NA #3 reported Nurse #1 instructed NA #1 to put the resuscitation bag over Resident #1's mouth. NA #3 stated that she did not observe Nurse #1 check Resident #1's tracheostomy or touch it at any time while she was in the room. NA #3 stated that NA #1 and Nurse #1 continued with CPR. NA #3 reported Nurse #2 returned with the AED and paperwork and directed NA #2 and NA #3 to go to the front door to let EMS into the building. NA #3 stated that she and NA #2 let for two police officers in the front door, followed shortly thereafter by EMS personnel.During a telephone interview conducted on [DATE] at 6:47 PM, Nurse #1 stated she was assigned to care for Resident #1 for the shift beginning at 7:00 PM on [DATE] and ending at 7:00 AM on [DATE]. Nurse #1 revealed that at 12:00 AM on [DATE], she provided tracheostomy care to Resident #1 and removed her Passy-Muir Valve. Nurse #1 reported Resident #1 did not require suctioning at that time. Nurse #1 further stated that at approximately 5:15 AM she administered morning medications to Resident #1 and again provided full tracheostomy care. Nurse #1 reported that she administered a breathing treatment to Resident #1 and returned 15 minutes later, at around 5:30 AM, at which time she performed light suctioning of the tracheostomy and replaced the Passy-Muir Valve. Nurse #1 stated that she then returned to Nurses' Station 2. Nurse #1 stated that at approximately 6:00 AM she observed a nurse aide coming down the hallway calling her name. Nurse #1 could not recall which nurse aide was calling her name. The nurse aide informed her that Resident #1 was gone. Nurse #1 reported she went to Resident #1's room to assess her and found the resident unresponsive, warm and with a faint pulse. Nurse #1 stated she returned to Nurses' Station 2, called Code Blue, obtained the emergency cart, and returned to Resident #1's room. Nurse #1 reported she and NA #1 placed the back board from the emergency cart underneath Resident #1. Nurse #1 stated she began chest compressions and instructed NA #1 to use the resuscitation bag. Nurse #1 confirmed she did not check the tracheostomy airway or remove the Passy-Muir Valve from Resident #1 at any point. Nurse #1 stated she continued chest compressions and confirmed that NA #1 used the resuscitation bag, while Resident #1's chest was rising and falling. Nurse #1 stated she did not suction Resident #1's tracheostomy during the event because she knew it had been done recently. Nurse #1 reported she performed five or more rounds of chest compressions while NA #1 used the resuscitation bag over the tracheostomy. Nurse #1 stated that Nurse #2 entered the room with the AED and placed the pads on Resident #1. Nurse #1 reported that the AED did not activate but instructed that the compressions must be done harder. Nurse #1 again confirmed that continued compressions, and use of the resuscitation bag, Resident #1's chest continued to rise and fall, indicating she was receiving air. Nurse #1 stated that she did not recall policemen entering the room. Nurse #1 reported Nurse #3 entered the room and took over the use of the resuscitation bag from NA #1. EMS then arrived and took over chest compressions and used the resuscitation bag. Nurse #1 stated that EMS removed the Passy-Muir Valve, suctioned Resident #1, and ultimately obtained a pulse. EMS transferred Resident #1 to a stretcher and removed her from the room for transport to the hospital.During a subsequent interview conducted on [DATE] at 10:29 AM, Nurse #1 clarified that NA #1 had not switched the resuscitation bag from Resident #1's mouth to the tracheostomy with her direction but instead kept the resuscitation bag on Resident #1's mouth for all respirations he performed.NA #1 was interviewed via telephone on [DATE] at 6:27 AM and provided the following information. NA #1 was working on the back hall of the facility on the shift that began at 11:00 PM on [DATE] and ended on [DATE] at 7:00 AM. NA #1 recalled NA #2 came to Nurses' Station 2 as NA #1 was walking up to the desk, informing Nurse #1 that Resident #1 was not breathing. Nurse #1 walked to Resident #1's room with NA #1 and NA #2 and then they all returned to the desk. Nurse #1 obtained the emergency cart while NA #1, NA #2 and NA #3 ran to Resident #1's room. When Nurse #1 arrived with the emergency cart NA #1 and Nurse #1 slid the back board underneath Resident #1. Nurse #1 initiated chest compressions and instructed NA #1 to place the resuscitation bag over Resident #1's mouth. NA #1 stated that Nurse #1 did not give him any instructions regarding the tracheostomy, nor did she check the tracheostomy. NA #1 reported that he and Nurse #1 performed several rounds of chest compression and ventilation. Nurse #2 arrived and put the AED pads on the resident and NA #1 reported the AED kept instructing to Press Harder with the compressions. NA #1 reported that two policemen arrived in the room and took over performing compressions from Nurse #1. NA #1 stated that Nurse #3 entered the room and informed him she would take over the use of the resuscitation bag. NA #1 stated that EMS arrived immediately thereafter. According to NA #1, EMS removed the cap from the tracheostomy, and he observed it was filled. EMS suctioned Resident #1's tracheostomy using their own suction machine. NA #1 stated that at that point he left Resident #1's room to return to his assigned hallway. NA #1 stated he was trained in CPR, but this was his first time using a resuscitation bag and participating in assisting with a person requiring CPR.Documentation in a health status note written by Nurse #2 at 6:14 AM on [DATE] revealed that she was notified that Resident #1 was not breathing. Nurse #2 and staff members went to Resident #1's room and observed her with no respirations and no pulse. Nurse #2 called 911 while staff positioned Resident #1 for CPR, placed a board under Resident #1 with the use of the emergency cart and AED. The AED was activated, and CPR continued until EMS arrived to take over. Resident #1 was transferred to the hospital.Nurse #2 was interviewed via telephone on [DATE] at 2:31 PM. Nurse #2 stated she was working on the 300 hallway during the nursing shift that began at 7:00 PM on [DATE] and ended at 7:00 AM on [DATE]. Nurse #2 reported she was walking down the hallway toward Nurses' Station 2 when she heard a nurse aide calling her name. Nurse #2 stated that one of the three nurse aides at the nurses' station informed her that Resident #1 was not breathing. Nurse #2 observed that Nurse #1 had already grabbed the emergency cart. Nurse #2 stated she used her personal cell phone to call 911 and followed the nursing staff to Resident #1's room. Nurse #2 stated she observed NA #1 and Nurse #1 place a backboard underneath Resident #1 on the bed. Nurse #2 noticed that Nurse #1 had not brought the AED with the emergency cart, so she ran back to Nurses' Station 2 to retrieve it. Nurse #2 revealed she quickly printed off a face sheet and medication list for Resident #1 and returned to Resident #1's room to put the pads from the AED machine onto Resident #1. Nurse #2 reported she then instructed NA #1 and NA #2 to go to the front door to let EMS into the building and direct them to Resident #1's room. Nurse #2 stated the AED did not deliver a shock to Resident #1 and that Nurse #1 continued performing compressions. Nurse #2 reported she was focused on observing Nurse #1's compressions and did not recall or notice where NA #1 had placed the resuscitation bag on Resident #1. Nurse #2 stated that two policemen arrived and took over performing compressions for Nurse #1. Nurse #2 reported Nurse #3 entered the room and shortly thereafter EMS arrived. Nurse #2 stated that prior to moving Resident #1 to the stretcher, EMS was able to get a pulse and low blood pressure.Documentation in a health status note written on [DATE] at 7:15 AM by Nurse #3 revealed the following information. At approximately 6:10 AM Nurse #3 was notified of the Code Blue. When Nurse #3 arrived in Resident #1's room, NA #1 was using a resuscitation bag. Nurse #3 assisted with the code.Nurse #3 was interviewed via telephone on [DATE] at 6:22 PM and provided the following information. Nurse #3 was working on the shift that began at 7:00 PM on [DATE] and ended at 7:00 AM on [DATE]. Nurse #3 reported that she was returning from a 30-minute break that ended at 6:08 AM on [DATE], when NA #3 notified her that Resident #1 was not breathing and Code Blue had been called. Nurse #3 stated that she ran to Resident #1's room and observed a policeman performing compressions on Resident #1 while NA #1 was using the resuscitation bag over Resident #1's mouth. Nurse #3 stated that she instructed NA #1 to move so she could take over providing respirations for Resident #1. Nurse #3 explained that she immediately noticed NA #1 was not providing respirations through the tracheostomy and felt she needed to take over for life saving procedures to be done correctly. Nurse #3 stated that EMS arrived directly behind her and assumed care for Resident #1. Nurse #3 reported that EMS immediately took off the Passy-Muir Valve covering the tracheostomy of Resident #1 and she observed that the tracheostomy was full of secretions. EMS used their own suction machine to clear out the secretions from the tracheostomy before providing respirations at the tracheostomy site with the resuscitation bag. Nurse #3 confirmed Resident #1 did have a suction machine and tracheostomy supplies already available in her room prior to EMS arrival. Nurse #3 further explained that EMS provided additional life-saving measures and were able to find a femoral pulse before transferring Resident #1 to the stretcher and removed her from the facility.Documentation on an EMS record revealed a call was received from the facility for a resident in cardiac arrest at 6:12 AM on [DATE]. EMS documented they arrived at the bedside of Resident #1 at 6:21 AM. EMS changed the AED to a cardiac monitor. EMS took over the airway of Resident #1 to use the resuscitation bag at the tracheostomy site. The tracheostomy tube was noted to be plugged and cleared through suction. Resident #1 was administered 1000 milliliters of Lactated Ringer's intravenously. (Lactated Ringer's is a concentrated infusion of a balanced salt solution used to assist in quickly restoring blood volume and raising blood pressure.) Resident #1 was also administered 1 milligram of epinephrine intravenously. (Epinephrine is used to relax airways muscles, to improve blood pressure, and reduce swelling.) After a third pulse check by EMS, Resident #1 was noted to have a return of a heart rhythm and a pulse. CPR was stopped, vitals were assessed, she was moved to the stretcher, and then to the ambulance. EMS documented they left the facility at 6:47 AM. During transport to the hospital Resident #1's blood pressure dropped. Two additional doses of 10 micrograms of epinephrine, 4 micrograms of norepinephrine drip, and 1 liter of intravenous fluids (IVF) were administered intravenously enroute to the hospital. (Norepinephrine is a medication used in emergency settings to raise and maintain blood pressure in patients with severe, critically low blood pressure.) Resident's #1's blood pressure stabilized prior to EMS moving her to the hospital trauma bay at 7:02 AM.An interview was conducted on [DATE] at 11:58 AM with Paramedic #1 from the EMS team who responded to the facility on [DATE], to provide services to Resident #1. Paramedic #1 explained that upon arrival at the resident's bedside, approximately three or four facility staff members were actively performing CPR. The facility had an AED attached, staff were administering chest compressions, and a resuscitation bag was being used over the resident's mouth and nose, although the bag was not connected to oxygen. Paramedic #1 stated that Resident #1 was in cardiac arrest but remained warm to the touch. She removed the Passy-Muir Valve from the resident's tracheostomy tube and observed that it was filled with secretions and buildup. Because the resuscitation bag was not achieving good compliance at the tracheostomy site, she performed deep suctioning. With each attempt to ventilate using the resuscitation bag, it was evident that the resident sounded congested and full of secretions, requiring multiple rounds of suctioning. Paramedic #1 confirmed that EMS was able to obtain a normal sinus rhythm before transferring Resident #1 out of the facility.An interview was conducted with a facility Nurse Consultant and Administrator on [DATE] at 10:57 AM. The Nurse Consultant explained that performing respirations with a resuscitation bag over the mouth of a tracheostomy resident can be effective; however, she confirmed it was best practice to perform respirations with a resuscitation bag over the tracheostomy. The Administrator stated she thought the nursing staff used good nursing judgement and were focused on initiating CPR immediately when Resident #1 was found unresponsive.An interview with the facility's Medical Director via telephone was conducted on [DATE] at 11:18 AM. The Medical Director stated that respirations during CPR must be done at the tracheostomy site for a resident with a tracheostomy. The Medical Director further stated that the airway of a tracheostomy resident must be checked prior to the start of the respirations. The Medical Director reported that failing to provide respirations through the tracheostomy and failing to check the airway of a tracheostomy resident prior to performing respirations during CPR can lead to respiratory arrest and cardiac arrest.A telephone interview was conducted on [DATE] at 12:57 PM with the [NAME] President of Clinical Education and Research for the Passy-Muir Valve medical device company, used by Resident #1. The [NAME] President explained that the Passy-Muir Valve used by Resident #1 would open for breathing in through the tracheostomy and closed when Resident #1 was breathing out or speaking. The [NAME] President stated that the first step when a resident with a tracheostomy was in respiratory distress was to remove the Passy-Muir Valve. The [NAME] President further stated that the appropriate and most effective point of ventilation during CPR is the tracheostomy site, where a bag valve mask should be applied. The [NAME] President explained that the Passy-Muir Valve, when in place over the tracheostomy, assists in moving secretions. If the Passy-Muir Valve remains in place while a bag valve mask is used over the mouth, secretions and/or a mucus plug may be drawn upward toward the tracheostomy site. The [NAME] President stated that if the Passy-Muir Valve was removed and ventilation was provided directly at the tracheostomy during CPR, secretions and/or a mucus plug would be expelled rather than drawn upward.Review of the hospital discharge summary for Resident #1, related to her [DATE] admission, revealed that EMS staff reported to the emergency room staff that Resident #1 was receiving CPR upon their arrival at the facility. The hospital record revealed EMS reported they found a large mucus plug in Resident #1's tracheostomy and that life-saving measures were performed prior to transport to the hospital. The documentation indicated that Resident #1 was placed on a ventilator in the intensive care unit after admission and was removed from the ventilator on [DATE] at family's request.Review of the death certificate for Resident #1 revealed she expired on [DATE], with the immediate cause of death listed as acute on chronic respiratory failure, with underlying causes of anoxic brain injury, mucous plug, and tracheal stenosis status post tracheostomy.The Administrator was notified of Immediate Jeopardy on [DATE] at 2:28 PM.The facility provided the following credible allegation of immediate jeopardy removal:Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance:Resident #1 was admitted to the facility on [DATE] with diagnoses of aortic abdominal aneurysm (AAA), renal cancer status post (s/p) nephrectomy (one kidney), high blood pressure, chronic obstructive pulmonary disease, obstructive sleep apnea, chronic kidney disease, hypothyroidism, history of stroke with hemiplegia, tracheomalacia with tracheostomy placement, stridor, and recurrent airway concerns. (Tracheomalacia is a condition where the windpipe cartilage is weak or floppy, causing the airway to partially collapse during breathing.) (Stridor is a symptom of high pitched, turbulent, and noisy breathing sound caused by a partial obstruction or narrowing in the upper airway.) Resident #1 had a brief interview for mental status (BIMs) score of 14 out of 15 indicating Resident #1 was alert and oriented. Per staff reports, Resident #1 was able to call for assistance and ask for tracheal suctioning between care when needed. On [DATE] at approximately 5:00am-5:15am, Nurse #1 reports Resident #1 was alert and oriented. Medication was given without difficulty. Resident #1 requested more water and Nurse #1 provided thickened water. Tracheostomy care was completed and the inner cannula was noted to be clean without mucus noted. Resident #1 had no wheezing, coughing, or shortness of breath (SOB). Following tracheostomy care, Nurse #1 administered nebulizer treatment per physician order and suctioned Resident #1 for a small amount of clear thin secretions. Resident #1 remained alert, oriented, and talkative with staff with no complaints verbalized. Her vital signs included respirations 18 and oxygen saturation 96% on tracheostomy collar 2 liters. At approximately 6:10am-6:15 am NA #2 and NA #3 entered Resident #1's room and noted Resident #1 was not responding. NA #2 notified Nurse #1 that the resident was not responding. Nurse #1 immediately went to Resident #1's room, noted Resident #1 was unresponsive, and warm to touch with a faint pulse. Nurse #1 obtained the crash cart. NA #2, Nurse #2, and NA #1 entered Resident #1's room and slid Resident #1 onto the back board. While staff positioned Resident #1 onto the back board, Nurse #2 activated 911. Nurse #1 initiated cardiopulmonary resuscitation (CPR) compressions. Nurse #1 states she did not attempt suctioning of the tracheostomy at that time as Nurse #1 had just recently suctioned Resident #1 and felt initiating CPR was the priority. NA #1 reported that he assisted by bagging Resident #1 with resuscitation bag by covering Resident #1's mouth and nose, per Nurse #1 instructions. Nurse #2 obtained the automatic external defibrillator (AED) and applied on Resident #1's chest. The AED did not initiate a shock and instructed staff to continue compressions. CPR compressions were continued. At approximately 6:15am the police and emergency medical staff (EMS) arrived and took over CPR. EMS continued several more rounds of CPR and applied EMS AED onto Resident #1. The AED did not deliver a shock and CPR continued. Epinephrine and intravenous fluids (IVF) were administered by EMS staff. EMS staff attempted deep suctioning of the resident's tracheostomy for what EMS reported as a mucus plug. At approximately 7:00 am, return of spontaneous circulation was obtained and Resident #1 was transferred to the hospital for further evaluation and treatment. Enroute to the hospital, Resident #1 required 2 push doses of 1-100,000 epinephrine, a norepinephrine drip and 1 liter of IVF. At approximately 7:15am, Nurse #1 notified the Director of Nursing (DON) of the code. At approximately 7:15am, Nurse #1 attempted to notify Resident #1's Resident Representative (RR) but had to leave a voice mail message. Resident #1's second emergency contact was notified. Resident #1 was removed from the ventilator and passed away on [DATE].The Administrator completed a root cause analysis on [DATE] to determine why basic life support was not provided in accordance with physician's orders for Resident #1 who had a tracheostomy requiring emergency care, including CPR. During the investigation, it was determined that staff didn't assess whether Resident #1's tracheostomy was plugged or dislodged prior to beginning CPR, due to a lack of knowledge regarding CPR procedure for residents with a tracheostomy. Nurse #1 was CPR certified per the American Heart Association, however upon review there was opportunity to strengthen staff education and competency validation related to tracheostomy care in emergency situations including delegation of bagging the resident over the tracheostomy instead of over the nose and mouth. It was identified during the interview with Nurse #1, she confirmed that direction was provided to assist with bagging the resident. However, specific instructions regarding placement over tracheostomy was not clearly communicated. Resident #1 had a Passy Muir Valve and the manufacturer's instructions indicate to remove the Passy Muir Valve if the patient exhibit signs of respiratory distress. Nurse #1 stated that she believed that the Passy Muir Valve was off during that time.On [DATE], the Director of Medical Records, under the supervision of the Assistant Director of Nursing (ADON) completed an audit of progress notes for all discharged residents over the last 30 days to identify any resident who received or required cardiopulmonary resuscitation (CPR) in the facility. The purpose of the audit is to validate that CPR was initiated per facility protocol to include but not limited to 1. Activation of the crash cart/ automated external defibrillator (AED), 2. Announcing code blue, and 3. Performing CPR using the appropriate technique to include but not limited to when providing respiratory assistance for a tracheostomy resident. There were no additional concerns identified during the audit.Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance:On [DATE], the Staff Development Coordinator (SDC) initiated an audit of all Licensed Nurses' cardiopulmonary resuscitation (CPR) certifications to ensure all current Licensed Nurses on all shifts were certified in CPR with a copy of the CPR card. The audit was completed by [DATE]. The Administrator set up a CPR class on [DATE] for any Licensed Nurse who could not provide proof of CPR certification, and a class was completed on [DATE]. There were five nurses identified during the audit that were not able to provide proof of CPR certification. Four of the nurses identified completed CPR certification during the training on [DATE]. On [DATE] the audit was expanded to include agency. There were no agency staff identified on [DATE] without having CPR certification. No nurse including agency will work after [DATE] that does not have a validation of CPR certification. The Staff Development Coordinator will validate CPR certification for new nurses during orientation. Monthly audits will be conducted by the Director of Nursing to validate that CPR certifications are still in good standing and have not expired. Anyone identified will be removed from the schedule until CPR certification is renewed.On [DATE], the Director of Medical Records completed an audit with the oversight of the Assistant Director of Nursing (ADON) of all residents' code status to ensure current code status matches the physicia[TRUNCATED]

Based on observation and interviews with staff and a family member, the facility failed to provide a clean homelike environment for 1 of 5 resident rooms on 1 of 6 halls reviewed for the environment (room [ROOM NUMBER]). The findings included: In an interview on 2/5/25 at 2:15 PM with a family member she stated there was an issue concerning the ceiling vent in resident room [ROOM NUMBER]. On 2/6/25 at 8:46 AM an observation was conducted of the ceiling vent in resident room [ROOM NUMBER]. The observation revealed the outside area around the ceiling vent was in disrepair with a black colored substance on one side of ceiling vent. The surrounding area of ceiling vent, approximately 2 inches in width, had the appearance of possible water damage that had been repaired with a white spackle-like substance. An interview was conducted on 2/6/25 at 8:53 AM with the Maintenance Director. He stated vent inspections were done once or twice a month. He reviewed his electronic service logs and stated there was no work order found for the ceiling vent in resident room [ROOM NUMBER]. On 2/6/25 at 8:57 AM a visual inspection was conducted with the Maintenance Director concerning the ceiling vent in resident room [ROOM NUMBER]. He stated that the ceiling vent in disrepair had been overlooked. He further stated the damage appeared to be from condensation. An interview and visual inspection of the ceiling vent in resident room [ROOM NUMBER] was conducted on 2/6/25 at 9:01 AM with the Administrator. She stated it was her expectation that maintenance staff conducted inspections and made repairs when needed.

Based on observations, record reviews, and staff, Pharmacist, and Pharmacy Consultant interviews, the facility failed to protect the resident's right to be free from misappropriation. This affected 1 of 1 resident reviewed for misappropriation of property (Resident #223). The findings included: Resident #223 was admitted to the facility on [DATE]. Resident #223 expired on [DATE]. Review of the facility reported incident investigation summary completed by the Regional Consultant dated [DATE] revealed on [DATE] the Unit Manager (UM) and Assistant Director of Nursing (ADON) completed a Return of Drug form with 63 Oxycodone HCL 5 mg tablets (2 cards of 30 and 1 card of 3) along with Lorazepam, Ultram, Oxycodone HCL 2.5 mg (4 cards), Oxycodone HCL 5 mg (1 card), and Morphine Sulfate (29.0 ml). The medications were placed in a sealed bag and the controlled bag number was 1787430. The UM attempted to fax the Return of Drugs form to the pharmacy two times. The UM noticed the first time the form did not go through and therefore faxed it again but did not wait for verification. The UM returned the Return of Drugs form to the hall nurse and asked her to place it in the lock drawer with the sealed bag of medications. On [DATE] the UM was notified by a nurse, but did not remember the nurse's name, there was a bag of medications in the 600-hall medication cart locked narcotic drawer waiting to be returned to the pharmacy. The UM asked Nurse #2, who was on the 600-hall medication cart, for the Return of Drug form so she could fax it to the pharmacy. The UM noticed the control bag number on the Return of Drug form had been altered. She returned the Return of Drug form to the medication cart and placed it in the locked narcotic drawer with the medications. On [DATE] the UM asked the floor nurse for the Return of Drug form and the bag of medications. The UM and floor nurse opened the sealed bag of medications and verified that one card of Resident #223's Oxycodone HCL 5 mg which contained 30 tablets was missing. The controlled bag number on the Return of Drug form had been altered. The 3 was changed to 2 and the 0 was changed to 9 to match the number of 1787429 on the bag. In conclusion, the return of controlled substance policy was not followed appropriately. Review of the Return of Drugs form dated [DATE] revealed the sealed control bag number of 1787430 with handwritten notes indicating the form was faxed 3 times and also a handwritten note indicating pharmacy did not pick up. Review of a second Return of Drugs form dated [DATE] revealed the sealed control bag number had been altered to read 1787429. During an interview with the Assistant Director of Nursing (ADON) on [DATE] at 11:25 am, she confirmed she verified the narcotic count with the Unit Manager (UM) and packed the discontinued medications which included 63 Oxycodone HCL 5 mg tablets (2 cards of 30 and 1 card of 3) along with Lorazepam, Ultram, Oxycodone HCL 2.5 mg (4 cards), Oxycodone HCL 5 mg (1 card), and Morphine Sulfate (29.0 ml) in a sealed bag on [DATE]. The ADON stated all the medications were placed in one sealed bag which could not be re-opened. She indicated the UM returned the sealed bag of medications to the 600-hall medication cart and placed them in the locked narcotic drawer on [DATE]. The ADON did not recall how long the medications stayed in the medication cart. She stated she remembered the medications did not go back to the pharmacy that night ([DATE]) or the next night ([DATE]). Review of a faxed copy of the Return of Drugs form dated [DATE] revealed the form was faxed on [DATE] at 7:56 pm with a result of busy/no signal and faxed again on [DATE] at 7:57 pm with a result of busy/no signal. In an interview on [DATE] at 11:41 am with the Unit Manager (UM), she stated Resident #223's discontinued medications were verified, packaged and sealed on [DATE] with the Assistant Director of Nursing (ADON). The UM explained she made a copy of the return of drug form and gave the copy to the Director of Nursing (DON). She further explained she returned the medications with the Return of Drug form to the locked narcotic drawer on the 600-hall medication cart. The UM indicated she faxed the return of drug form to the pharmacy once on [DATE] but did not verify the fax was accepted. She did not recall who faxed the return of drug form the second time. The UM stated she should have followed up on the fax to the pharmacy. On [DATE] the UM stated a nurse, but did not recall who brought it to her attention that medications were on the cart in the locked narcotics drawer. The UM asked Nurse #2, the nurse on the 600-hall medication cart, if there were still medications in the locked narcotic drawer. The UM stated she was unsure why the medications were still in the locked narcotic drawer. Nurse #2 brought her the Return of Drug form on [DATE] and she noticed that the control number on the Return of Drug form had been altered. The UM further stated she returned the Return of Drug form back to the medication cart. The UM explained she should have notified the DON at that time; however, she wanted to be sure the Return of Drug form had been altered. On [DATE], the UM asked the DON to pull the copy of the Return of Drug form she had given him on [DATE] and at that time the UM realized there was a discrepancy. The UM explained the medications had been removed from the control sealed bag with the number of 1787430 to a completely new sealed bag with the control number of 1787429. The Return of Drug form had been altered to match the new control number on the new bag. The UM and the DON opened the bag of medications and counted the medications. The UM and the DON verified a card of 30 Oxycodone HCL 5 mg pills were missing. The medications should have been returned to the pharmacy on [DATE] or [DATE]. The DON took control of the incident at this point. During an interview with Medication Aide (MA) #1 on [DATE] at 12:18 pm, she stated she was scheduled to work on [DATE] but could not recall if she saw a bag of sealed medications in the cart. An interview with Medication Aide (MA) #2 on [DATE] at 12:24 pm, she stated the on-coming nurse or MA pulled out the resident's narcotic cards and verified the count of each narcotic. MA #2 further stated she was scheduled on [DATE] and remembered she saw a bag of sealed narcotics in the cart and attempted to separate each card to verify the count. She further stated it was difficult to count each card due to the number of cards in the bag and the bag could not be opened. MA #2 stated she reported this bag of medications in the cart but could not remember who she reported this to. During a phone interview with Unit Manager (UM) #1 on [DATE] at 12:50 pm, she stated she did not recall an issue with narcotics left on the medication cart. A phone interview with the Pharmacy Consultant on [DATE] at 9:51 am, she explained she did a monthly inspection at the facility which included checking the medication carts. Her medication cart review included the controlled substance count records to ensure the math and count were correct. The Pharmacy Consultant was unaware of any discrepancies in the facility for [DATE]. She further stated the facility called her if any discrepancies arose. During an interview with the Director of Nursing (DON) on [DATE] at 9:08 am, he stated he started in this position in [DATE]. The nursing staff was scheduled for 8-hour shifts and after the incident was found the nursing shifts were changed to 12-hour shifts for better accountability of the medication carts. The facility's policy concerning controlled substances being returned to the pharmacy stated the controlled substances should be returned immediately upon discontinuation, discharge of the resident, or death of the resident. The DON stated the facility employed agency nurses and these nurses did not package medications for return to the pharmacy. The DON indicated the only way the pharmacy knew there were medications that needed to be returned to the pharmacy was the Return of Drug forms which were filled out by the nursing staff and faxed to the pharmacy. The DON stated he did not have an answer as to why he was not notified when the discrepancy was first realized on [DATE]. His expectation was the nursing staff should have brought it to his attention on [DATE]. The DON explained it was brought to his attention on [DATE] by the Unit Manager (UM). He further explained he and the UM opened the bag on [DATE] and verified the medications. At this time the missing card of Oxycodone 5 HCL mg was confirmed. The DON indicated the narcotic medications that were to be returned to the pharmacy were kept in the locked narcotic drawer on the medication carts. He also stated the nursing staff were responsible for including these narcotics in the narcotic counts at each shift change. The DON indicated he started an investigation into the missing narcotics on [DATE]. He contacted the police department. In an interview with the Administrator on [DATE] at 4:25 pm, she stated the nursing staff should be verifying the narcotic counts at the end of the shift which included any discontinued narcotics being stored in the narcotic drawer of the medication carts for pharmacy return. The facility provided the following plan of correction (POC): Problem: On [DATE] a drug diversion was identified. o Address how corrective action will be accomplished for the resident found to have been affected by the deficient practice include: Resident #223 expired on [DATE]. o Address how the facility will identify other residents having the potential to be affected by the same deficit practice include: On [DATE] the Staff Development Nurse (SDC) and Assistant Director of Nursing (ADON) completed an audit of the last 30 days of ordered narcotic medication to ensure the medications were in the cart, administered, or returned to the pharmacy per protocol. On [DATE] the Treatment Nurse initiated assessment of all residents for pain. On [DATE] the Social Worker (SW) completed interviews with all alert and oriented residents regarding any concerns with medication administered to include pain medication. o Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur include: The police were called on [DATE]. A report was filed with North Carolina Department Health and Human Services (NCDHHS) on [DATE]. The SDC nurse initiated an in-service with all nurses and medication aides regarding Controlled Substance Diversion to include: the definition, implications, and the process for returning narcotic medications. All in-services will be completed by [DATE]. After [DATE], all nurses and medication aides that have not worked and received the in-service will complete upon their next scheduled shift or via phone. o Indicate how the facility plans to monitor its performance to make sure that solutions are sustained: Beginning [DATE] the Quality Improvement Nurse and/or Unit Manager will complete 5 shifts change narcotic count observations to ensure outgoing and incoming nurses perform a correct and accurate count of narcotics. The DON will review and initial the Controlled Substance Audit Tool weekly x 4 weeks to ensure all areas of concern were addressed. 100% of all ordered narcotic medications will be reviewed by the ADON/SDC weekly x 4 weeks and compared to the Controlled Substance Count sheets, medication administration record and/or return of drug slips to ensure the narcotic medications are being administered or have been returned to pharmacy as required per policy. The decision to take to Quality Assurance and Performance Improvement (QAPI) was made on [DATE]. The QAPI Committee will meet monthly for 2 months and review the Audit Tools. The Regional Nurse Consultant stated she was responsible for this POC. Compliance Date: [DATE] On [DATE] the facility's corrective action plan was validated by the following: The initial audit was conducted on [DATE] and monitoring audits began on [DATE]. No issues were identified. The North Carolina Department of Health and Human Services report was submitted on [DATE] and police were notified on [DATE]. The Treatment Nurse completed assessments of all residents for pain on [DATE] and the SW completed interviews with all alert and oriented residents regarding any concerns with medication administered to include pain medication on [DATE]. No issues were identified. Interviews and record review verified education was conducted for staff as indicated in the POC. The facility's compliance date was validated as [DATE].

Based on record review and staff interviews, the facility failed to code cognition and mood (Resident #58), and discharge destination (Resident #70) for 2 of 26 residents reviewed for Minimum Data Set (MDS) accuracy. The findings included: 1. Resident #58 was admitted to the facility on [DATE] with diagnoses that included chronic kidney disease. Resident #58's most recent annual Minimum Data Set (MDS) assessment dated [DATE] revealed the Mood and Cognition sections noted he was rarely/never understood and the staff assessments were not completed for these sections. During an attempted interview on 2/4/25 at 10:25 AM, Resident #58 was unable to answer questions. An interview was conducted with the facility Social Worker on 2/5/25 at 4:49 PM who stated she was responsible for conducting the cognition and mood section of the MDS assessment. She reported she was not aware a staff assessment needed to be done if the resident could not be understood. The facility Social Worker stated she had received some training from the corporate MDS consultant and had been made aware of this requirement. An interview was conducted with the Administrator on 2/6/25 at 4:10 PM who stated Resident #58's assessment should have been completed accurately. 49502 2.Resident #70 was admitted to the facility on [DATE]. Review of Resident #70's discharge Minimum Data Set (MDS) dated [DATE] revealed he was cognitively intact and was discharged to an acute hospital. Review of a progress note dated 11/15/24 documented Resident #70 was to be transported from the facility to home. During an interview with the MDS Coordinator on 2/5/25 at 12:08 pm, she explained the MDS discharge for Resident #70 dated 11/15/24 should have been coded as discharged to home and this was coded incorrectly. During an interview with the Director of Nursing (DON) on 2/6/25 at 9:24 am, he stated the residents' discharge MDS should accurately reflect the discharge status. During an interview with the Administrator on 2/6/25 at 4:00 pm, she indicated the MDS should be completed accurately.

Based on record review, physician, and staff interviews, the facility failed to administer medications to Resident #21 as ordered when Resident #21 received the incorrect dose of Oxycodone Hydrochloride (HCL) on two occasions. This affected 1 of 1 resident reviewed for services provided meet professional standards (Resident #21). The findings included: Resident #21 was admitted to the facility on [DATE] with diagnoses which included osteomyelitis of vertebra (an infection of the spinal column which causes inflammation and pain), left elbow pain, and trigeminal neuralgia (a chronic pain disorder that affects the main sensory nerve in the face). A physician's order for Resident #21 dated 6/20/24, read Oxycodone HCL 10 mg to be administered one tablet every 4 hours for chronic osteomyelitis of vertebra. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #21 was cognitively intact. Resident #21 was interviewed on 2/6/25 at 8:30 am and she had no concerns or complaints related to her medications. A review of the narcotic controlled substance count record for Resident #21 revealed one Oxycodone HCL 5 mg was removed on 5/17/24 at 8:00 pm by Medication Aide (MA) #1 and one Oxycodone HCL 5 mg was removed on 5/18/24 at 4:00 pm by MA #4. Review of Resident #21's May Medication Administration Record (MAR) documented Resident #21 received Oxycodone HCL 10 mg on 5/17/214 at 8:00 pm administered by MA #1 and Oxycodone HCL 10 mg on 5/18/24 at 4:00 pm administered by MA #4. In an interview on 2/6/25 at 10:00 am with MA #1 she stated she gave Resident #21 only 1 tablet of Oxycodone HCL 5 mg on 5/17/24 at 8:00 pm. The MA explained she had only administered one tablet because she was confused about the dosage. Attempts made to interview MA #4 were unsuccessful. During an interview on 2/6/25 at 8:57 am with the Director of Nursing (DON), his expectation was the residents needed to receive the correct dosage of medications. In an interview with the Administrator on 2/5/25 at 4:25 pm, she stated her expectation was for the residents to receive the correct dose of medications.

Based on observations, staff interviews, and record review, the facility failed to apply a left-hand palm guard for 1 of 2 residents reviewed for a range of motion (Resident #30). The findings included: Resident #30 was admitted to the facility on [DATE] with diagnoses which included hemiplegia (complete paralysis) and hemiparesis (partial weakness) following cerebrovascular disease affecting the left dominant side, contracture left hand, and dementia. Review of Resident #30's quarterly Minimum Data Assessment (MDS) dated [DATE] revealed she was moderately cognitively impaired. Resident #30 had impairments on one side of her upper and lower extremities. Records review of the nursing progress notes revealed no documentation for Resident #30's refusal to have the carrot placed in her left hand. An observation was made on 2/3/25 at 3:23 pm revealed Resident #30 lying in bed on her back and appeared to be sleeping. The resident's left hand was resting on her chest with her fingers balled into a fist. This surveyor observed a piece of paper taped to the wall at the end of Resident #30's bed dated 9/2/24 by physical therapy which read in part Attn Staff: Keep carrot in left hand except during bathing. A second observation was made on 2/4/25 at 9:12 am revealed Resident #30 sitting up in her bed awake and when asked if she could open her left-hand Resident #30 tried but the left hand stayed closed. In an interview and observation with Nurse #1 on 2/5/25 at 8:22 am of Resident #30, she indicated Resident #30 was supposed to have a carrot in her left hand to protect the skin from moisture, pressure and nail puncture injuries. When asked where the carrot was, Nurse #1 presented the carrot from a basket located on Resident #30's bedside table. Nurse #1 stated Resident #30 would refuse at times to have the carrot placed in her left hand. During a subsequent observation on 2/5/25 at 10:20 am revealed Resident #30 sitting up in her bed awake. Resident #30's left hand was on her chest under the sheet. This surveyor asked Resident #30 could the cover sheet be pulled back to see her left hand and Resident #30 answered yes. Resident #30's left hand was empty. The carrot was still located in the basket on the bedside table. In an interview and observation with NA #1 on 2/5/25 at 11:00 am, she stated Resident #30 was resistive to care. NA #1 further stated she would make the nurse aware of her refusals. NA #1 explained to Resident #30 that she was putting the carrot in her left hand and Resident #30 shook her head and responded verbally yes. NA #1 proceeded to put the carrot in Resident #30's left hand while talking to Resident #30. NA #1 finished placing the carrot in Resident #30's left hand and asked Resident #30 was she okay. Resident #30 responded yes. In an interview with the Physical Therapy (PT) Director on 2/5/25 at 10:18 am, he explained Resident #30 had been seen by therapy since her admission. The PT Director further explained the nursing staff would make referrals for Resident #30 for therapy services and Resident #30 would be picked up on caseload. The therapy department would evaluate and work with Resident #30. The PT Director explained a physician's order was not needed for the carrot. The PT Director stated Resident #30 was to have the carrot placed in her left hand except during bathing. He further stated he had in-serviced the nursing staff on how to place the carrot in Resident #30's left hand. The PT Director further stated Resident #30 could be resistive to care at times. During an interview with the Director of Nursing (DON) on 2/5/25 at 10:25 am, he stated he was unaware of Resident #30's situation with the left-hand palm guard. The DON further stated he would investigate this concern. The DON indicated the nursing staff should have attempted to place the carrot in her left hand and if Resident #30 refused, the nursing staff should have documented the refusals.

Based on observations, record reviews, and staff interviews, the facility failed to post cautionary signage outside the resident's room to indicate supplemental oxygen (O2) was in use for 1 of 6 residents reviewed for respiratory care (Resident #174). The findings included: Resident #174 was admitted to the facility on [DATE] and was readmitted on [DATE]. Resident #174's diagnoses included acute respiratory failure with hypoxia (a medical condition where the lungs are unable to adequately provide oxygen to the body, resulting in a dangerously low level of oxygen in the blood) and chronic obstructive pulmonary disease (an ongoing lung condition caused by damage to the lungs). Review of Resident #174's physician's orders revealed she had an oxygen order dated 2/2/25 for oxygen supplementation at 2L (liters) via nasal cannula (a device that delivers extra oxygen through a tube and into the nose) or mask if oxygen saturation (the amount of oxygen you have circulating in your blood) is less than 90%. Resident #174's Admission Minimum Data Set, dated dated dated [DATE] revealed she was cognitively intact. Observations on 2/3/25 at 12:14 PM, 2/4/25 at 9:01 AM, and 2/5/25 at 5:41 AM revealed Resident #174 was in her room, lying in bed, wearing a nasal cannula for supplemental oxygen. There was no signage outside Resident #174's room indicating supplemental oxygen was in use. An interview was conducted on 2/5/25 at 5:44 AM with Nurse #8 who stated residents who received oxygen should have an oxygen sign on their door. She further stated the oxygen sign was put on the door upon a resident's admission. An interview was conducted on 2/5/25 at 10:11 AM with Unit Manager #1. She stated staff were supposed to put an oxygen sign on a resident's door immediately when admitted . An interview was conducted on 2/5/25 at 8:18 AM with the Director of Nursing (DON). He stated a sign was placed on a resident's door for any resident on oxygen upon admission and for any resident who experienced a change in condition requiring new oxygen therapy. He further indicated that an oxygen sign should have been placed on Resident #174's door.

Based on observations and staff interviews, the facility failed to secure residents' medications in a locked medication cart for 1 of 4 medication carts observed (Station 1 medication cart). Findings included: A continous observation was conducted on 2/5/25 from 6:47 am until 6:52 am of the Station 1 medication cart. The medication cart was observed unlocked and located outside the nurse's station in the hallway. There were no medications observed on top of the medication cart. There was no nurse observed at Station 1 medication cart or in the nursing station. There were no residents in the hallway, but staff was observed on the adjacent 100-hall coming in and out of the residents' rooms. On 2/5/25 at 6:52 am, Nurse #7 was observed walking down the 100-hall towards the unlocked Station 1 medication cart. Nurse #7 observed this surveyor standing beside Station 1 medication cart and locked the medication cart. On 2/5/25 at 6:52 am during an interview with Nurse #7, she was observed locking Station 1 medication cart. She stated she had left her cart unlocked. Nurse #7 further stated the medication cart was to be locked before leaving the medication cart unattended. When asked why Station 1 medication cart was observed unattended and unlocked, Nurse #7 did not provide a reason. In an interview with the Director of Nursing (DON) on 2/6/25 at 9:24 am, he stated Sation 1 medication cart was to be locked at all times when the nurse was not present at the medication cart.

Based on record review, staff interviews, the facility failed to ensure the medical record was accurate regarding administration of Oxycodone Hydrochloride (HCL) (an opioid medication which is a controlled substance) for 1 of 1 resident (Resident #21) reviewed for accuracy of medical records. The findings included: Resident #21 was admitted to the facility on [DATE] with diagnoses which included osteomyelitis of vertebra (an infection of the spinal column which causes inflammation and pain), left elbow pain, and trigeminal neuralgia (a chronic pain disorder that affects the main sensory nerve in the face). A physician's order for Resident #21 dated 6/20/24, read Oxycodone HCL 10 mg to be administered 1 tablet every 4 hours for chronic osteomyelitis of vertebra. A review of the narcotic controlled substance count record for Resident #21 revealed one Oxycodone HCL 5 mg on 5/17/24 at 8:00 pm was signed out by Medication Aide (MA) #1 and one Oxycodone HCL 5 mg on 5/18/24 at 4:00 pm MA #4. Review of Resident #21's May Medication Administration Record (MAR) revealed documentation the resident received Oxycodone HCL 10 mg on 5/17/214 at 8:00 pm administered by MA #1 and Oxycodone HCL 10 mg on 5/18/24 at 4:00 pm administered by MA #4. In an interview on 2/6/25 at 10:00 am with MA #1 she stated she gave Resident #21 only 1 tablet of Oxycodone HCL 5 mg on 5/17/24 at 8:00 pm. Attempts made to interview MA #4 were unsuccessful. During an interview on 2/6/25 at 8:57 am with the Director of Nursing (DON), his expectation was the residents' medical records needed to reflect the correct dosage of administered medications. In an interview with the Administrator on 2/5/25 at 4:25 pm, she stated her expectation was for the residents' medical records to be accurate and reflect the correct dosage of medications when they were administered.

Based on resident and staff interviews and medical record reviews, the facility failed to invite a cognitively intact resident to participate in the planning of the resident's care for 2 of 3 residents (Resident #46 and Resident #125) reviewed for participation in care plans. The findings included: 1. Resident #46 was admitted to the facility on [DATE]. Diagnosis included, in part, chronic kidney disease. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #46 had intact cognition. Resident #46's medical record was reviewed and revealed the comprehensive care plan had been updated on 1/20/23, 4/7/23, 5/5/23 and 7/5/23. During an interview with Resident #46 on 11/14/23 at 2:02 PM, she stated she had not been invited to care plan meetings but would like to be included in the development of her care plan and participate in the process. The medical record demonstrated no evidence Resident #46 had been invited to care plan meetings. MDS Nurse #1 was interviewed on 11/14/23 at 10:29 AM. She stated that each month, she printed a list of residents who were scheduled for a care plan review and gave the list to the Social Worker (SW). MDS Nurse #1 did not know how the SW invited residents and families to care plan meetings and was unsure if Resident #46 had been invited to her care plan meetings. On 11/14/23 at 1:50 PM, an interview was conducted with the SW. She explained MDS Nurse #1 gave her a list of residents who were due to be reviewed in care plan meetings. The SW called and invited families a few days before the scheduled meeting. She also invited residents to participate in the care plan meeting. The SW shared she had worked at the facility since January 2023 but had not met with Resident #46 and reviewed her care plan, nor had the facility invited the resident to participate in a care plan meeting. The SW added it was her responsibility to schedule care plan meetings with residents and families and said, I've just not been consistent with it. An interview was conducted with Mobile Administrator #1 and Mobile Administrator #2 on 11/14/23 at 4:38 PM. Mobile Administrator #2, who had been at the facility for a few weeks, explained he typically asked during the department head morning meeting if there were any care plan meetings scheduled for the day. He shared the SW was responsible to invite residents to care plan meetings. Mobile Administrator #1 said she worked at the facility from April through June 2023. She stated she wasn't necessarily asking the SW who she had coming to care plan or who she had invited. During her time at the facility, Mobile Administrator #1 said she had not confirmed with the SW if she had been inviting the residents to their care plan meeting but had only asked who was scheduled for care plans. 41387 2. Resident #125 was admitted to the facility on [DATE]. Resident #125 was discharged on [DATE] to the hospital and was readmitted to the facility on [DATE]. His diagnoses included a lower respiratory infection. The most recent 5-day Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #125 was cognitively intact and independent in performing his activities of daily living. A care plan was initiated for Resident #125 on 10/06/2023 and additional focuses were added to the care plan on 10/13/2023. A revision to Resident #125's care plan was made on 11/15/2023 related to his code status. On 11/12/2023 at 2:29 p.m., an interview was conducted with Resident #125, and Resident #125's spouse was present. Both Resident #125 and Resident #125's spouse (who reported she was staying with Resident #125 around the clock/24 -hours during his admission to the facility) stated a care plan meeting with interdisciplinary members of the staff to discuss his care had not been scheduled or conducted with Resident #125 or Resident #125's wife since his admission to the facility. On 11/15/2023 at 10:16 a.m. in an interview with Social Worker #1, she stated she was responsible for scheduling care plan meetings for residents within 14 days of admission to the facility. She stated she was not aware of Resident #125 having a care plan meeting since his admission. She explained Resident #125 was admitted while she was on a leave for absence, and she was unsure who was responsible for the care plan meeting while she was on leave. She further stated since returning to work one week ago, she had not scheduled a care plan meeting for Resident #125. On 11/15/23 at 3:24 p.m. in a phone interview with the former Administrator #3, she stated while Social Worker #1 was on leave, she assumed the responsibilities of the Social Services Department. She explained discharges and home health referrals were the priority, and she attempted to conduct care plan meetings with new admissions. She stated care plan meetings needed to be held on admission and quarterly. She said she didn't know why Resident #125's care plan meeting was not held and explained she was also out of work herself due to illness during the first part of October 2023. On 11/16/2023 at 2:45 p.m. in an interview with Mobile Administrator #1, she stated a care plan meeting should be held within twenty-one days of admission and quarterly afterwards. She explained the social worker had been out on leave, and former Administrator #3 assumed the responsibilities of scheduling care plan meetings.

Based on observations and staff interviews, the facility failed to (1) discard expired medications in 1 of 3 medication storage rooms (Nurse Station #2 medication storage room) and (2) discard expired medications in 2 of 4 medication carts (600-hall medication cart and 300-hall medication cart) observed for storage and labeling. Findings included: 1. On 11/15/2023 at 3:55 p.m. in the observation of Nurse Station #2 medication storage room with the Director of Nursing (DON), the following were observed: - Six unopened vials of Ampicillin (an antibiotic for reconstitution) in a clear plastic bag with no label and each vial with a manufacturer's expiration date of 10/2023 were observed on a cart on the shelf underneath the locked emergency medication box. The DON removed the six vials of Ampicillin from the shelf to return the medication to pharmacy. -Four unopened 100 milliliter (mL) bags of normal saline (NS) with a manufacturer's expiration date 10/2023 located on a cart on the shelf underneath the locked emergency medication box. The DON removed the four bags of NS from the shelf to return the medication to pharmacy. -Two unopened bottles of Calcium 250 milligrams (mg) and Vitamin D3 with a manufacturer's expiration date 6/2023 located in storage cabinet. The DON was given the two bottles of Calcium 250 milligrams (mg) and Vitamin D3 from the cabinet, and the DON stated the bottles would be returned the to pharmacy to discard. - Seven pharmacy mixed and issued intravenous containers of Ampicillin 1 gram labeled delivered on 10/23/2023 and expired on 10/26/2023 located in the medication refrigerator. The DON removed the seven containers of Ampicillin 1 gm from the refrigerator to return to the pharmacy. - Two pharmacy mixed and issued intravenous containers of Daptomycin 500mg labeled delivered on 10/17/2023 and expired 10/27/2023 located in the medication refrigerator. The DON removed the two containers of Daptomycin from the refrigerator to return to the pharmacy. - Ten pharmacy mixed and issued intravenous containers of Merophenem 500 mg labeled delivered on 11/9/2023 and expired 11/14/2023 located in the medication refrigerator. The DON removed the ten containers of Merophenem from the refrigerator to return to the pharmacy. In an interview with the Director of Nursing on 11/15/2023 at 3:55 p.m., he stated he did not know why the six vials of Ampicillin for reconstitution and four bags of normal saline were located on the shelf underneath the emergency medication box. He stated those medications (Ampicillin vials and NS bags) should have been in the locked emergency medication box, and a new locked emergency medication box was exchanged with pharmacy daily. The DON explained the expired intravenous medications observed in the refrigerator were for residents with no IV access, no current order to administer IV medications or had been discharged , and the nurses had not returned the medications to the pharmacy. The DON said the nurse working the night shift (11p-7a) was to check the medication room each night for expirations, and the assigned nurse or the unit nurse manager was to return expired and discontinued resident medications to the pharmacy. On 11/16/2023 at 1:43 p.m. in an interview with the Unit Nurse Manager #1, she stated unit nurse managers were responsible for checking all the medications on the medication carts and in the medication storage rooms for expired medications on Monday, Wednesday, and Friday, and there were no medication storage room and medication cart audit written reports. She explained when checking the medication storage rooms, she had not been checking the medication refrigerator and the cart where the emergency medication box was located for expired medications. She further stated she did not know the procedure in returning medications to the pharmacy. Attempts to interview the night shift nurse were unsuccessful. On 11/16/2023 at 1:53 p.m. in a follow up interview with the Director of Nursing, he stated the medication storage rooms and the medication carts were to be checked by the night shift nurses and the pharmacy monthly. 2. a. On 11/15/2023 at 4:10 p.m., observation of the 600-hall medication cart was conducted with the Director of Nursing (DON). One opened vial of Glarsol Insulin 100 units per milliliter in a medication bottle was observed with an expiration date of 10/5/2023 written on the label of the medication bottle. The label on the vial of Glarsol Insulin recorded the vial was opened on 9/8/2023 and expired in twenty-eight days on 10/6/2023. The DON removed and discarded the expired vial of Glarsol Insulin for Resident #47. On 11/15/2023 at 4:10 p.m. in an interview with the DON, he stated the vial of Glarsol Insulin should had been removed for the 600-medication cart by the nurses assigned the medication cart and on the night shift (11 p.m. to 7a.m.) by the nurse when checking the 600-hall medication cart for expirations. The DON also stated the pharmacy checked the medication carts monthly for expiration but did not know when the pharmacy came last to the facility to check the medication carts. On 11/16/2023 at 11:34 a.m. in an interview with Nurse #1, she stated the assigned nurse to the medication cart was responsible for checking the medication for expiration, and expired medications were to be removed and discarded from the medication cart. b. On 11/15/2023 at 5:37 p.m., observation of the 300-hall medication cart was conducted with the Director of Nursing (DON), and the following expirations were observed in the top drawer: -Two expired boxes of facility stocked Bisacodyl 10 milligrams (mg) suppositories (one box had 10 bisacodyl suppositories and the other box had 9 bisacodyl suppositories) with a manufacturer's expiration of 6/2023 at the end of each box. The DON removed the two boxes of Bisacodyl suppositories to return to the pharmacy to discard. - Fourteen Promethazine 25 mg suppositories in a clear plastic bag labeled delivered 1/2022 for a resident not residing at the facility with an expiration of 1/24/2023. Each of the fourteen promethazine suppositories were observed stamped with a manufacturer's expiration of 4/2023. The DON removed the fourteen Promethazine suppositories to return to the pharmacy to discard. On 11/15/2023 at 5:37 p.m.in an interview with DON, he stated the unit nurse manager was to check the 300-hall medication cart and return expired medications to the pharmacy. On 11/16/2023 at 1:43 p.m. in an interview with the Unit Nurse Manager #1, she stated unit nurse managers were responsible for checking all the medications on the medication carts and in the medication storage rooms for expired medications on Monday, Wednesday, and Friday, and there were no medication storage room and medication cart audit written reports. She explained the reason for expired medications on the medication carts was due to multiple nurses rotating in the facility and not placing medications in the right place on the medication cart and were missed during the medication audits. Attempts to interview the pharmacist were unsuccessful. Attempts to interview the night shift nurse were unsuccessful. On 11/16/2023 at 1:53 p.m. in a follow up interview with the Director of Nursing, he stated the medication storage room, and the medication carts were to be checked by the night shift nurses and the pharmacy monthly.

Based on record review, resident interview and staff interviews, the facility failed to ensure a resident's code status was accurately recorded on the electronic and paper medical record for 1 of 18 residents reviewed for advance directives (Resident #125). Findings included: Resident #125 was admitted to the facility on [DATE]. Resident #125 was discharged on [DATE] to the hospital and was readmitted to the facility on [DATE]. A discontinued physician order on the electronic medical record (EMR) dated [DATE] indicated Resident #125 was a full code (attempt resuscitation). There was no physician order for Resident #125's code status since his re-admission on [DATE]. The discharge summary from the hospital dated [DATE] reported Resident #125's code status as a Do Not Resuscitate (DNR). A physician's progress note dated [DATE] indicated Resident #125's code status was a full code. There was no code status indicated on Resident #125's profile on the electronic medical record (EMR). There was no Do Not Resuscitate form in Resident #125's paper medical record. The 5-day admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #125 was cognitively intact. On [DATE] at 8:05 a.m. in an interview with Resident #125, he explained a code status of DNR was decided when he was at the hospital. He stated he had not signed papers indicating his code status was a DNR since admission to the facility and was willing to sign forms for a code status of DNR. On [DATE] at 8:06 a.m. in an interview with Nurse #1, she stated Resident #125's code status was on the EMR. After reviewing the EMR, Nurse #1 stated Resident 125's code status and a physician order for Resident #125's code status was not in the EMR. When Nurse #1 checked the paper medical record located at nurse's station #3, there was no signed DNR form in Resident #125's paper medical record. Nurse #1 stated based on the white name label on the paper medical record, Resident #125's code status was a full code currently. She explained blue name labels identified a resident's code status as a DNR. She stated Social Worker #1 was responsible for discussing code status with residents after admission to the facility. On [DATE] at 9:00 a.m. in a follow- up interview with Resident #125, he stated he did not recall anyone asking him on admission to the facility about his code status and had not told anyone at the facility he wanted to be a full code. He stated if anyone would have asked, he would had told them he was a no code because it was decided at the hospital. On [DATE] at 9:47 a.m. in a further interview with Resident #125, he said Social Worker #1 came to his room to discuss his code status after the interview at 8:05 a.m. on [DATE]. He explained he informed Social Worker #1 his wish for cardiopulmonary resuscitation (CPR) not to be performed, and she provided him some documents to sign. Resident #125 said he was currently working with Social Worker #1 in signing some forms for a code status of DNR. On [DATE] at 10:20 a.m. in an interview with Social Worker #1, she stated she was responsible for initially addressing residents' code status when residents were admitted to the facility, and when a resident requested a change in code status. She explained Resident #125's initial admission statement conducted in the admission office on admission indicated Resident #125's code status was a full code. She stated she went to discuss code status with Resident #125 after Nurse #1 informed her there was no code status on Resident #125's EMR or paper medical record and per a request of the Director of Nursing. She explained she did not set the code status on the EMR and was currently working with Resident #125 to prepare his DNR documents. On [DATE] at 10:42 a.m. in an interview with Admission Office Staff, he explained he was responsible for asking residents on admission about code status: DNR or full code. He stated by default, the resident's code status would be a full code if there was no documentation of a DNR code status, and residents were asked to sign a code status statement when the resident requested a code status of DNR. He stated he did not have access to Resident #125's hospital discharge summary for code status information, only nurses and the physician had access. He explained at the direction of an unnamed former Administrator, he was responsible for entering an order for residents' code status on admission and recalled Resident #125 requested to be a full code on the [DATE] admission. The Admission Office Staff stated when Resident #125 was readmitted to the facility on [DATE], Resident #125 stated he wanted to remain a code status of full code. The Admission Office Staff explained the reason Resident #125's EMR did not show a current code status was because he did not realize when Resident #125 was discharged from the facility on [DATE] and was readmitted to the facility on [DATE], a code status order had to be re-entered into the EMR. On [DATE] at 1:53 p.m. in an interview with the Director of Nursing, he explained identifying a resident's code status was included on the admission check list. He stated after confirming Resident #125's code status, the nurse re-admitting Resident #125 on [DATE] should have entered an order for Resident #125's code status, not the Admission Office Staff. On [DATE] at 2:45 p.m. in an interview with the Administrator #1, she explained as part of the admission process to the facility, the interdisciplinary team (IDT) discussed residents' code status and was responsible for ensuring resident's code status had been entered in the EMR correctly. She stated she did not know why the IDT did not identify after Resident #125's re-admission on [DATE] there was no code status on the EMR and clarify Resident #125's code status since there was no physician order.

Based on record review, observations and staff interviews, the facility failed to develop a person-centered comprehensive care plan for 1 of 23 residents (Resident #125) reviewed for comprehensive care plans. Finding included: Resident #125 was admitted to the facility on [DATE]. Resident #125 was discharged on [DATE] to the hospital and was readmitted to the facility on [DATE]. His diagnoses included lower respiratory infection. Nursing documentation dated 10/6/2023 reported Resident #125 was admitted to the facility with a peripherally inserted central catheter (PICC) and was receiving intravenous antibiotics. Physician orders dated 10/6/2023 included changing PICC line dressing one time a week and as needed. Physician orders dated 10/23/2023 included changing PICC line dressing to upper right arm every seven days and administering Piperacillin Sodium-Tazobactam Solution (an antibiotic) 3.375grams intravenously every eight hours for lower respiratory infection for 36 days. The most recent 5-day admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #125 was cognitively intact, had intravenous access and was receiving intravenous medications and antibiotics. A review of Resident #125's care plan dated revised on 11/15/2023 did not include a focus for intravenous therapy. On 11/15/2023 at 7:58 a.m., Nurse #1 was observed connecting Piperacillin Sodium-Tazobactam Solution 3.375grams intravenously to Resident #125's PICC located in the right upper arm. On 11/16/2023 at 9:40 a.m. in an interview with MDS Nurse #1, she stated the MDS staff was responsible for the initial comprehensive care plan, and Resident #125 had received antibiotics per intravenous therapy since admitted to the facility on [DATE]. After reviewing Resident #125's care plan, she said the use of intravenous therapy for antibiotics was not included in Resident #125's comprehensive care plan, and she couldn't explain why intravenous therapy for antibiotics was not a part of the care plan. On 11/16/2023 at 2:45 p.m. in an interview with Administrator #1, she stated MDS #1 or Nurse Manager on the unit was to complete a comprehensive person-centered care plan for Resident #125 that included the use of a PICC for intravenous antibiotic therapy.

Based on record review, observations, resident interview and staff interviews, the facility failed to change a dependent resident's incontinent soiled brief due to meal trays being passed on the hall (Resident #30) and to provide mouth care after a resident requested mouth care (Resident #4) for 2 of 8 residents reviewed for activities of daily living. Findings included: 1. Resident #30 was admitted to the facility on [DATE], and diagnoses included stroke and dementia. Resident #30's care plan dated 11/8/2022 for urinary incontinence included an intervention to provide perineal care after each incontinent episode. The care plan for activities of daily living reviewed last on 8/28/2023 included interventions for providing total assistance in toileting for incontinence of urine and stool. The annual Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #30 was moderately cognitively impaired and was dependent on assistance with toileting. The MDS further indicated Resident #30 was always incontinent of urine and stool. On 11/12/2023 at 10:41 a.m. in an interview with Resident #30, she stated she was lying in mess and needed to be changed since this morning before breakfast. Resident #30's call light was observed on. There were no foul odors noted. On 11/12/2023 at 10:41 a.m. in an interview with Resident #30's assigned Nurse #3 who was standing in the hall at a medication cart, she stated she had told assigned Nurse Aide (NA) #4 Resident #30 needed her adult brief changed. On 11/12/2023 at 10:43 a.m., the Business Office Manager was observed entering Resident #30's room and informing Resident #30 she would get someone to help her because NA #4 was with another resident. On 11/12/2023 at 10:51 a.m., NA #4 was observed entering Resident #30's room with wash clothes to provide incontinent care. On 11/12/2023 at 11:32 a.m. in a follow up interview with Nurse #3, she stated she reported to work at 7:00 a.m. and Resident #30's call light had not been on. She explained her assignment consisted of the 300-hall, 400-hall and 500-hall, and she had arrived on the 500-hall when Resident #30's call light came on. She said Resident #30 reported she needed her adult brief changed which she informed NA #4 and forgot to turn off the call light. On 11/12/2023 at 12:22 p.m. in an interview with NA #4, she stated her assignment consisted of eight residents on the 500-hall. She said she arrived to work at 8:00 a.m. and began helping pass out the breakfast trays. She said Resident #30 told her when passing out the breakfast trays that she needed to be changed, and stated the nursing staff were not allowed to change adult briefs while meal trays were out on the hall. NA #4 explained she had not been able to return to change Resident #30's adult brief due to assisting three residents on the hall with their breakfast meal and bathing another resident who had stool on their hands. NA #4 stated she did not ask for another staff member to provide Resident #30 incontinent care. On 11/16/2023 at 1:53 p.m. in an interview with the Director of Nursing (DON), he stated nurse aides were to check and provide residents incontinent care every two hours and as needed. He explained incontinent care could be provided when meal trays were on the hall. However, meal trays could not be in residents' rooms when incontinent care was provided. The DON stated when NA #4 was assisting another resident with feeding, she could not leave that resident to assist Resident #30 with incontinent care. He explained NA #4 should have gone between assisting other residents with feeding to provide Resident #30 her incontinence care. 2. Resident #4 was admitted to the facility on [DATE] with diagnoses including contractures and paraplegia (paralysis of lower body). Resident #4's care plan last reviewed on 8/31/2023 included a focus for activities of daily living/personal care, and interventions included providing constant supervision with physical assistance for personal hygiene and grooming that included cleaning upper dentures daily. The resident guide revised on 10/5/23 included removing dentures nightly and soaking in denture cup with water and denture tablet and brushing and applying the dentures in the morning. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #4 was cognitively intact, required total assistance with bathing and needed assistance setting up or cleaning up with oral hygiene and eating. On 11/12/2023 at 12:09 p.m., Resident was observed with contractures to the left and right hand with 2nd through 5th fingertips turning inward into the palm of the both hands. Resident #4 was unable to extend the left and right fingers to an open palm position voluntarily. She stated staff did not always assist in cleaning her dentures when she stayed laying in the bed during the day instead of getting up in her chair. On 11/15/2023 at 5:15 p.m., Resident #4 was observed lying in the bed with clean dry lips and a dull red tongue with no coating covering the tongue. Upper and lower dentures were observed in the mouth with small food particles lying in the space between the teeth on the upper denture. On 11/15/2023 at 5:45 p.m. in an interview with Resident #4 while lying in the bed, she said when she received her bath that day, she requested Nurse Aide (NA) #3 to provide her mouth care and denture care. She said NA #3 told her he was too busy and did not provide mouth care and denture care as requested. On 11/16/2023 at 12:10 p.m. in a phone interview with Nurse Aide (NA) #3, he stated Resident #4 requested him to provide mouth care on 11/15/2023 after performing her bath and assisting her to dress. He explained by the time he finished dressing Resident #4 after her bath, he didn't have time to provide mouth care because he was assigned to go to the dining room to assist with lunch trays. NA #3 stated he forgot to return to Resident #4 and provide her oral hygiene because he was busy with the lunch trays in the dining room and on his assigned hall as well as answering call lights. On 11/16/2023 at 1:53 p.m. in an interview with the Director of Nursing, he stated oral hygiene should have been provided as part of Resident #4's activities of daily living daily.

Based on record reviews, observations, and interviews with staff and Physician #1, the facility failed to clarify an order for psychotropic medication for 1 of 5 residents reviewed for unnecessary medications (Resident #55). The findings included: Resident #55 was admitted to the facility on [DATE] with diagnoses that included depression. The quarterly Minimum Data Set, dated dated dated [DATE] revealed Resident #55 was cognitively intact with no behaviors. Review of Resident #55's physician orders revealed an order dated 10/19/23 Duloxetine HCL (an antidepressant) 60 milligrams once a day for depression. Review of Resident #55's physician orders revealed an order dated 11/1/23 for Cymbalta (Duloxetine HCL) 30 milligrams once a day for depression. Review of a physician progress note dated 11/7/23 read in part, I did restart Cymbalta at 30 mg daily. May increase to 60 mg at a later date if appropriate. He was chronically on 60 milligrams in the past. Review of Resident #55's November Medication Administration Record (MAR) revealed he received 90 milligrams of Duloxetine HCL November 1 -November 14, 2023. An interview was conducted with Resident #55 on 11/16/23 at 1:120 PM who stated he did not feel any different after the increase in Duloxetine HCL. An interview was conducted with the Medical Director on 11/15/23 at 2:30 PM who stated he made a mistake in prescribing 30 milligrams of Duloxetine HCL on 11/1/23. He reported facility staff should have noticed his error. He reported there was no harm to Resident #55 due to the additional medication. An interview was conducted with the DON on 11/15/23 at 3:00 PM who indicated the dosage of Duloxetine HCL should have been verified.

Based on resident interview, staff interviews, physician interview and record review the facility failed to ensure a resident was free of physical abuse for 1 of 3 residents reviewed for allegations of abuse (Resident #61). This occurred when Nurse Aide #2 slapped Resident #61 with an open hand twice on the left side of the head and hit Resident #61 once with a closed fist in a facility hallway. The physical abuse resulted in Resident #61 having a red mark on the left side of his head. The findings included: Resident #61 was admitted to the facility on [DATE]. Resident #61's annual Minimum Data Set assessment dated [DATE] revealed he was assessed as cognitively intact. He was assessed to have adequate hearing, clear speech and was able to make himself understood by others. He had no behaviors during the look back period. Resident #61's active care plan initiated on 9/23/20 revealed he was care planned for ineffective coping with verbal/physical behavior. The interventions included for Resident #61 to receive behavior management and psychiatric consults, give medication as prescribed by the physician, and remove resident from public area when behavior is disruptive. He was also care planned for resistance to treatment and care related to inappropriate behavior. During an interview with Resident #61 on 3/2/21 at 4:05 PM he stated on 2/27/21 at 8:05 PM he was in the hallway ambulating with his electric wheelchair when he observed two female residents calling out. He stated he notified Nurse Aide #1 (NA #1) that he had observed two female residents calling out for help. Resident #61 stated while he was speaking with NA #1 another nurse aide, Nurse Aide #2 (NA #2), walked by them. He reported NA #2 stated he needed to stop being a hall monitor and mind his own business. Resident #61 stated he told NA #2 he was not speaking with her and she needed to go back to work. He reported a verbal altercation occurred and NA #2 began to approach him. Resident #61 stated he then asked NA #2 to leave him alone and she asked, what he was going to do about it. He stated he spit at NA #2 and she slapped him with an open hand twice on his head. Resident #61 reported NA #2 also struck him with a closed fist on the left side of his head. He then said he was unsure if he spit at her prior to her striking him or after she hit him. Resident #61 stated he contacted the police. An interview was conducted with NA #1 on 3/3/21 at 10:56 AM who stated she was working on 2/27/21 and Resident #61 was one of her assigned residents. She stated at approximately 8:05 PM Resident #61 approached her and stated two residents down the hall needed assistance. She reported that while she was speaking with the resident, NA #2 approached them and stated to the resident, he needed to mind his own business. As NA #2 continued walking towards the 600 hall Resident #61 told her NA#2 needed to do her job. NA #1 stated they began arguing loudly. NA #2 turned around to come closer to the Resident. NA #1 stated she observed NA #2 strike Resident #61 three or four times on the left side of his head. She stated she told NA #2 to stop and she did so. NA #1 stated NA #2 said the resident spit on her. She reported she did not witness any spitting. NA #1 indicated she did not require any assistance from NA #2 during this interaction with Resident #61. She stated Resident #61 left the area in his electric wheelchair. NA #1 stated she found Nurse #1 to report what happened. An interview was conducted with NA #2 on 3/3/21 at 12:32 PM. She reported on 2/27/21 at approximately 8:05 PM she saw Resident #61 in the hallway. NA #2 stated that Resident #61 liked to be the hall monitor and tell people how to do their jobs. She stated she told Resident #61 to go back to his room and mind his business. NA #2 stated Resident #61 called her a profane name (b-----) and asked who she was talking to. NA#2 stated she replied she was talking to him. NA #2 stated Resident #61 pursued her and spit on her. She stated she slapped him with an open hand to the left side of his face. NA #2 stated Resident #61 spit on her again and she slapped him again with an open hand to the left side of his face. NA#2 then stated he spit on her a third time, so she struck him with a closed fist on the left side of his head. NA #2 stated, I hit him with a closed fist because obviously he was not getting my drift and the slaps were not working. When I hit him, he stormed off to the lobby to call the police. NA #2 stated she went outside and contacted the Administrator while Resident #61 contacted the police. She stated she went to her assigned unit and told Nurse #1 about the altercation. She stated she then left the unit to wait for the police. NA #2 stated this was her third encounter with Resident #61, but he had never spit at her before. She reported that he had yelled and been disrespectful. NA #2 stated she was told he had spit on other staff members in the past. Review of a witness statement completed by NA #2 dated 2/27/21 read in part, After speaking with the police and the Administrator, I left the facility. I was trained on abuse, the definition and trained to not to hit a resident. I did not walk away because he spit on me and it was just a reaction. An interview was conducted with Nurse #1 on 3/4/21 at 9:02 AM. She reported that on 2/27/21 at approximately 8:05 PM she was informed by NA #2 that she had struck Resident #61. She indicated she advised NA #2 to leave the hall to await the police. Nurse #1 stated she did not see the incident. She stated NA #2 left the 600 hall to get linens. Nurse #1 stated Resident #61 was not on NA #2's assignment and wasn ' t sure how the incident occurred. Nurse #1 stated she then went and assessed Resident #61 for injury. She reported he described the incident to her and stated he was fine. Nurse #1 stated she assisted Resident #61 in contacting his family. Review of a police report dated 2/27/21 revealed police officers were dispatched to the facility at 8:13 PM for a possible assault that occurred between a resident and caregiver. The report stated the officer was met outside the facility by NA #2 who stated she was fed up with Resident #61. The report revealed NA #2 told the officer Resident #61 spit on her and she slapped him. NA #2 further reported every time he spit on her she slapped him. The report stated Resident #61 was interviewed and he stated NA #2 came at him and hit him for being involved in someone else's business. According to the report both parties refused to press charges. The report stated the Administrator was interviewed and stated the matter would be handled internally. The officer's report indicated NA #2 left the facility prior to law enforcement leaving the facility. An interview was conducted with the Medical Director of the facility on 3/3/21 at 2:40 PM who stated he was contacted on the evening of 2/27/21. He reported he was advised that Resident #61 spit on a staff person and Resident #61 was assaulted. The Medical Director stated he examined Resident #61 on 3/2/21 and saw no lingering evidence of injury. He stated that the aide was provoked, and she should have walked away. He further stated Resident #61 was provocative but that does not excuse striking him. An interview was conducted with the Administrator on 3/3/21 at 3:15 PM who stated he spoke with NA #2 on the evening of 2/27/21 after she had spoken with the police. The Administrator indicated he was contacted by NA #2 via phone that she had struck a resident. He stated he advised her to wait for the police outside the facility and drove to the facility. He stated that she left the facility after being interviewed by himself and Corporate Consultant #1. The Administrator stated he had not advised NA #2 of her termination, but she would not be allowed back in the facility. The facility provided a corrective action plan with a correction date of 2/28/21. The corrective action plan included F600. F 600-Abuse · Recipients who have suffered or are likely to suffer, a serious adverse outcome as a result of the non-compliance On 2/27/2021, 100% skin checks were initiated on all residents who are unable to report signs/symptoms of abuse by the hall nurse and will continue to be completed by the treatment nurse, and/or director of nursing. A skin check assessment tool will be utilized with documentation in the electronic medical record. The skins checks will be completed by 2/28/21. On 2/28/21, 100% of all alert and oriented residents will be interviewed by the Nursing Supervisor in regards to: Do you know what abuse means? Are there any instances that you felt you were abused in any way that has not bee addressed? Do you know who to report abuse to? Do you feel safe here? On 2/28/21, education will be initiated and completed with 100 % of all alert and oriented residents by the Nursing Supervisor regarding abuse to include the definitions, resident rights, what to do in an abusive situation and how to report abuse. The education will be complete on 2/28/21. · Actions taken to alter the process or system failure to prevent a serious outcome for occurring or recurring On 2/27/21, a questionnaire was initiated by the Administrator and will continue to be completed by the Corporate Consultants and Nursing Supervisors with 100% of all staff to include nurses, nursing assistants, medication aides, dietary staff, housekeeping staff, therapy staff, Administrator, Admissions Coordinator, Accounts Receivable, Account Payable, Activities Director, Medical Records, Central Supply Clerk, Maintenance Director, Social Worker and receptionist regarding: Do you know of any resident that you have witnessed or that has been reported abuse to you that has not been addressed? If yes: Please explain. The questionnaire will be completed by 2/28/21. After 2/28/21 any staff that has not worked and not completed the questionnaire will complete prior to the start of next scheduled shift. The DON and Nursing supervisors are responsible to ensure that staff receive the questionnaire prior to the next scheduled shift. On 2/28/21, 100% of staff to resident interaction observations will be initiated with all staff to include nurses, nursing assistant, medication aides, dietary staff, housekeeping staff, therapy staff, Administrator, Admissions Coordinator, Accounts Receivable, Account Payable, Activities Director, Medical Records, Central Supply Clerk, Maintenance Director, Social Worker, and receptionist by the Corporate Consultant, Director of Nursing, and Nursing Supervisors. The purpose of the interactions are to ensure that residents remain free form abuse when interacting with staff. The interactions will be completed by 2/28/21. After 2/28/21 any staff that has not worked and not been observed interacting with residents, will have observation completed during next scheduled shift. The DON and Nursing supervisors are responsible to ensure that the interactions are completed prior to the start of the next scheduled shift. On 2/27/2021, an in-service was initiated by the Administrator and will continue to be completed by the Corporate Consultants and Nursing Supervisor with 100% of all staff to include nurses, nursing assistant, medication aides, dietary staff, housekeeping staff, therapy staff, Administrator, Admissions Coordinator, Accounts Receivable, Account Payable, Activities Director, Medical Records, Central Supply Clerk, Maintenance Director, Social Worker and receptionist regarding burn out, abuse and what to do when residents display aggressive behaviors. The in-service included the definition of physical abuse and the consequences if found guilty of abuse. In-services to be completed by 2/28/2021. After 2/28/21, the Administrator will ensure the in-services are mailed to any remaining staff who has not worked and not received the in-service with instructions to review, sign the in-service and return to the staff facilitator or Director of Nursing prior to next scheduled work shift. On 2/28/21, Abuse Quizzes will be initiated by the Corporate consultants and Nursing Supervisors with 100% of all staff to include nurses, nursing assistants, medication aides, dietary staff, housekeeping staff, therapy staff, Administrator, Admissions Coordinator, Accounts Receivable, Accounts Payable, Activities Director, Medical Records, Central Supply Clerk, Maintenance Director, Social Worker and receptionist. The quizzes included questions in regards to (1) What to do immediately if you witness a resident being abused? (2) Who should you report abuse? (3) If a resident becomes combative or aggressive what should you do? (4) If you witness abuse when do you report it? (5) Who is the abuse officer/coordinator? (6) What are the consequences if you are found guilty of abuse? The purpose of the abuse quizzes are to ensure that all staff display successful knowledge and understanding of the abuse in-services. The abuse quizzes will be completed by 2/28/21. After 2/28/21, any remaining staff that has not worked and not received the quizzes will complete upon next scheduled shift. The DON and Nursing supervisors are responsible to ensure that staff receive the quiz prior to the start of their next scheduled shift. On 2/27/21 and 2/28/21, Resident #61 was offered 1:1 observation for emotional support and psychiatric services, however resident declined and stated he felt safe. Fax cover sheets were reviewed from attempts to fax the initial report to the Department of Health and Human Services from 2/27/21 at 11:19 PM, 2/28/21 at 11:38 AM and 2/28/21 at 2:47 PM. The report was successfully faxed on 3/1/21 at 9:00 AM. · The procedure for monitoring the plan of correction 10 Abuse/burn out Quizzes will be completed by the Nursing Supervisors, Staff Facilitator and/or Quality Assurance Nurse with staff weekly x 4 weeks. The quizzes are to ensure staff maintain knowledge and understanding of burn out, the abuse policy, reporting abuse, protection of the resident, and how to deal with aggressive residents. Staff will be immediately retrained during the quiz for any identified areas of concern. The DON will review and initial the abuse quizzes weekly X 4 weeks for completion and to ensure all areas of concern are addressed. The DON will present the Abuse/burn out Quizzes to the Executive Quality Assurance Performance Improvement (QAPI) committee monthly for 1 month. The Executive QAPI Committee will meet monthly for 1 month and review the Abuse/burn out Quizzes to determine trends and/or issues that may need further interventions put into place and to determine the need for further monitoring. · The title of the person responsible for implementing the plan of correction The Administrator and Director of Nursing are responsible for the implementation of corrective actions including all 100% audits, in-service and monitoring related to the plans of correction. Quality Assurance Meetings were held on 2/27/21 and 2/28/21 to discuss the plans of correction related to abuse. Date of corrective action plan completion: 2/28/21 The plan of correction was verified through review of verification of education provided to both residents and staff, a review of the audits and monitoring documentation and quality assurance meeting minutes. Staff interviews verified the education provided. The facility's date of compliance of 2/28/21 was verified.

Based on record review and resident, staff and physician interviews, the facility failed to place bilateral bed rails on the bed which were utilized by the resident for bed mobility and during the provision of care the resident fell from the bed for 1 of 2 sampled residents reviewed for accidents (Resident #11). Resident #11 sustained a fractured right hip as a result of his fall. The findings included: Resident #11 was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. A review of Resident #11's Care Plan revealed a focus dated 6/29/18 which read Use of bed rails for increasing or maintaining current bed mobility and transfer ability. A medical record review revealed an 8/13/18 Quality Assurance Note which stated Resident #11 requested to have bilateral side rails to aid in bed mobility and for ADL (activities of daily living) assistance with staff. The note stated a bed rail evaluation was completed and bed rails were installed. The resident was educated on the risk and benefits of the rails and how to use them. The note also stated the care plan and care guide were up dated. A review of the Minimum Data Set ((MDS) dated [DATE], a quarterly MDS revealed Resident #11 was cognitively intact (BIMS 15). He had no behaviors. He required extensive assistance of 1 staff for bed mobility and he was totally dependent of 1 staff for bathing. He had limited range of motion on both sides of the lower extremities. He was always incontinent of bowel and bladder. He had no falls. A review of the nursing progress note dated 10/30/18 written by Nurse #4 revealed at approximately 11:15 AM Resident #11 fell out of bed during morning care. The note stated the assessment showed no apparent injuries and the resident denied pain. He was transferred to the wheelchair. The note also stated he continued to be in good spirits at the end of the shift. A record review of the incident report dated 10/30/18 revealed at approximately 11:15 AM Nurse #4 was notified by the Director of Nursing that the resident (Resident #11) was on the floor. The report note read that several nurses and the administrator assisted the resident via lift into his wheelchair. The report stated the resident was assessed prior to transfer by Staff Development Coordinator (SDC) #1. The report also said the resident stated his hand slipped while being on his side during care. The report stated no injuries were observed at that time. Additional review of the report revealed the witnesses were Nursing Assistant (NA) #1, Nurse #4, Nurse Supervisor #1, Administrator #1, Nurse #5 and Staff Development Coordinator (SDC) #1. During an interview on 2/5/19 at 11:00 am Resident #11 stated he fell out of his bed while he received a bath because there were no rails for him to hold onto. He said his previous bed broke so the facility replaced his bed but did not put the bed rails back on it. He reported the fall happened a few months ago. During an additional interview with Resident #11 on 2/7/19 at 12:23 pm he stated when he returned for [MEDICAL TREATMENT] on Monday (10/29/18) he had a brand new bed with no side rails. He stated he remembered SDC #1 and Administrator #1 coming into his room looking at the bed and talking about getting bed rails for the bed. He said he knew he needed the bed rails but on the day he fell he wanted to get out of bed and did not want to wait for the rails so he told NA #1 to give him his bath now and not to wait for the rails to be installed. During an interview with the Nursing Assistant (NA) #1 on 2/5/19 at 2:50 PM she stated in (MONTH) (YEAR) Resident #11 told her his bed broke over the weekend and his new bed did not have bed rails. NA #1 said Resident #11 needed bed rails to assist him during care. She said he used his right arm to grab the rail for support for rolling over during his bath and when she was providing incontinent care. She stated he had a fall off of the bed on Tuesday (10/30/18) when she was giving him a bath. She stated he was holding onto the side of the bed with his right hand with his back facing her. NA #1 reported she was holding him with her left hand and using her right hand to clean his bottom when he rolled off of the left side of the bed. She stated she tried to stop him but she had cream on her right hand and when she grabbed the lower part of his back he continued to roll and fell off of the bed on the side opposite of where she was standing. She said she then ran to the hall to get a nurse. She stated she did not remember which nurse came in first. She said the code green was called and more staff arrived. The NA added the nurse checked him and during this he was laughing. She said she and the nurse gently rolled Resident #11 over and put a brief on him. She said he was still laughing and said for her to put his clothes on him while he was on the floor. NA #1 said they used a lift pad and the lift to put him in his wheelchair. She added 2 days later Resident #11 complained of pain and they found out his hip was broken. During additional interview with NA #1 on 2/7/19 at 12:00 PM she stated on 10/30/18 prior to Resident #11's fall from the bed she did lower his bed when she provided his care because she could not reach over him if the bed was as high as he kept it. She stated she lowered Resident #11's bed to about her hip level. A measurement was taken and the distance from NA #11's hip to the floor was 37.5 inches. During an interview on 2/7/19 at 10:24 AM Nurse Supervisor #1 stated on the day of the fall she heard NA #1 say Code Green so she went immediately into Resident #11's room and he was lying face down on the floor between the left side of the bed and the wall. He was not touching the bed or the wall. She stated the bed was approximately 4 feet high. She stated she and Nurse #5 asked him if he was in pain and he said no. Then she moved his joints and completed the full body assessment and no concerns were identified. He had his same normal demeanor. During an interview on 2/7/19 at 11:01 AM the Interim Maintenance Director reported she replaced the bed control for Resident #11 which fixed the bed for a few days but then it stopped working again so she put a new bed in his room. She said she began putting new beds together on 10/29/18 so that may have been when she put the bed into Resident #11's room. She stated she was not the person who put rails on beds but SDC #1 was the person who knew how to put bed rails on beds. During an interview with SDC #1 on 2/7/19 at 11:10 AM she stated she was the person who would be informed of any bed moves or changes because she was responsible for ensuring the interventions for the resident were in place whenever a change was made. She stated she was not informed of the new bed for Resident #11 until Tuesday (10/30/18) morning so she looked at his bed. She tried to find rails in her in house supply but there were none. She said she noticed there were no rail holders because it was a new bed so she asked Administrator #1 to help her find rails and figure out how to put them on. SDC #1 said she and Administrator #1 went together to look at Resident #11 ' s bed. She stated while she and Administrator #1 were in the room, NA #1 was present and giving a bath to the roommate for Resident #11. SDC#1 stated she told NA #1 that they would return with rails for Resident #11's bed. She stated Administrator #1 found a bed manual and that was when they determined they needed additional parts so they went outside to the barn to look for the proper rails and rail clamps. On 02/07/19 at 3:29 PM Nurse #5 was interviewed via telephone. She stated Resident #11 was alert and oriented, was verbal about his needs and let his needs be known. She reported he had a fall and she heard code green called. She added when she arrived at his room he was on the floor on his back with a pillow under his head. He was talking and carrying on. He was embarrassed he had fallen off of the bed. She added that she checked him and he had no pain, he was just embarrassed. She said she was told he fell off the bed but she was not present when it happened. Nurse #5 said Resident #11 had rails on his bed prior to that day but she didn't know why he did not have bed rails that day. Administrator #1 was not available for interview during the survey. Additional record review revealed a note written on 10/30/18 at 10:00 pm by Nurse #7 which stated Resident #11 had increased pain but no other symptoms based on the physical assessment. He was given a pain medication and the physician was informed. The physician ordered an x-ray to rule out fractures. A revive of the results of the x-ray report for Resident #11 dated 11/1/19 revealed no fracture. A nurse ' s note written on 11/1/18 read Resident #11 had a decrease in his oxygen saturation level at 4:00 PM but he refused to wear oxygen or to go to the hospital. His responsible party was notified and she convinced the resident to wear oxygen. Then at 10:00 PM he developed a low grade temperature so he received [MEDICATION NAME]. The physician was informed and the responsible party was informed. The nursing notes revealed at 10:36 PM the responsible party requested the resident be sent to the hospital so the physician was notified, the orders were received and the resident was sent to the emergency room for an evaluation at 10:52 PM. A review of the hospital discharge summary for Resident #11 dated 11/7/18 revealed a right femoral neck fracture was identified on 11/1/18 and he had surgical repair of the right hip on 11/3/18 then was discharged back to the facility on [DATE]. During an interview on 2/7/19 at 4:00 PM Physician #1 stated Resident #11 fell and broke his hip. He said he did not remember the details of the fall. He stated the resident had not had a decline in his functional abilities or his mental status because of the fall. During an interview with the Director of Nursing on 2/7/19 at 2:30 PM she stated she had a plan of correction for Resident #11's fall. She stated the investigation revealed he did not have side rails and the NA did not properly align the resident in the bed while providing care when Resident #11 fell from the bed on 10/30/18. On 2/7/19 at 8:29 PM the facility provided the plan of correction for tag F689 as follows: F 689 The process that lead to deficiency Resident # 11 is alert and oriented and has [DIAGNOSES REDACTED]. Resident # 11 is able to safely use the bed rails for positioning. On 10/29/2018 resident # 11's bed was changed to a bed without bed rails. On 10/30/2018 Nursing Assistant was turning resident to wash back and resident # 11's hand slipped from mattress causing resident #11 to fall off of the bed. Registered Nurse (RN) supervisor assessed resident # 11 and no injuries noted at this time. Attending physician and Resident Representative (RR) notified of resident # 11's fall. Later in the shift resident # 11 complained of pain in the right upper leg. Assigned hall nurse assessed resident # 11 and no [MEDICAL CONDITION] or deformity noted. Resident # 11 was able to move right upper leg. Assigned hall nurse called attending physician and orders received for an X-ray of bilateral upper legs. X-ray completed with no fracture noted at this time. On 11/1/2018 resident # 11 was sent to the emergency room for fever and found to have a right femoral fracture. The process that lead to the deficiency was that the NA failed to properly position resident # 11 in bed and bed rails absent from the bed. The procedure to implement a plan of correction for specific deficiency On 10/30/2018 at approximately 12:00pm resident # 11's bed rails were placed on bed by the Administrator and the Staff Facilitator (SF). The NA was educated by the Director of Nursing (DON) and SF in regards to proper positioning during care and ensuring all interventions to include bed rails were in place, once education provided NA completed a return demonstration of correct positioning. A 100% audit was completed on 11/3/2018 by the SF of all residents' care guides to ensure that if bed rails are need that bed rails were on the bed. There were 16 areas of concerns noted. All areas of concerns were corrected during the audit by the DON and SF. On 11/8/2018 a 100 % audit was initiated by the DON and the SF on turning and repositioning during care utilizing a Turning and Repositioning Care audit tool. Audits were completed on 11/12/2018. No negative findings noted during the audit. On 11/2/2018 a 100% audit was initiated by the DON and SF with all licensed nurse and NA's in regards to proper positioning during care and ensuring all interventions, to include bed rails, are in place. In-services completed on 11/12/2018. All newly hired licensed nurse and NA's will be in-serviced by the SF during orientation in regards to proper positioning during care and ensuring all interventions to include bed rails are in place. The procedure for monitoring the plan of correction All resident's with a bed change or a room change were audited by the SF to ensure all interventions to include bed rails were in place utilizing a Location Bed change tool 5 X week X 2 weeks, then 2 X a week X 1 week, then 1 X a week for a week. The DON reviewed and initialed the Location Bed change tool weekly for 4 weeks to ensure all areas of concerns were addressed. The title of person responsible for implementing the plan of correction The Administrator and DON were responsible for the implementation of corrective actions to include all 100% audits, in-service and monitoring related to the plan of correction. The DON presented the initial findings of the Location Bed Change tool and Turning and Repositioning care audit tool to the Executive Quality Assurance (QA) Committee on 11/3/2018. The DON presented the findings of the Location Bed change tools and turning and repositioning to the Executive QA Committee on 11/29/2018 and 12/14/2018. Date corrective action completion Final Compliance date was 11/12/2018. Observations of Resident#11's bed revealed bed rails were in place upon initial tour on 2/4/18 and have been in place throughout the survey. During the phone interview with Nurse #5 on 2/7/19 3:29 PM she stated, We received in-service education on positioning the residents in the bed when turning them and to roll them toward self not away from person giving care. He was a top heavy person He was the same after he returned from the hospital. He was able to do the same things and had not loss of function. The plan of correction was verified through review of the verification of education provided on both resident alignment in bed and use of bed rails, a review of the audits and monitoring documentation and the quality assurance meeting minutes. Staff interviews verified the education provided. A review of care plans for bed rails and observations of the rails in place as care planed was also completed. The facility's date of compliance of 11/12/18 was verified.

Based on observations, record reviews and staff and resident interviews, the facility failed to maximize a resident's potential for mobility and physical conditioning for 1 of 1 residents (Resident #1) assessed as needing a specialty order wheelchair, which resulted in the loss of mobility and decrease of physical conditioning. Findings included: Review of Resident # 1's medical record indicated that she was admitted to the facility on [DATE]. Her admitting [DIAGNOSES REDACTED]. The Quarterly MDS (Minimum Data Set) dated 1/10/18 revealed the resident had adequate speech, hearing and vision, could understand and be understood. She was cognitively intact and had not demonstrated any behaviors of rejection of care. Her functional status was determined as requiring extensive, two-person physical assistance with bed mobility, transfer activity occurred only once or twice with one-person physical assist, walking in room and locomotion on/off the unit did not occur. Additionally, she required extensive, one-person physical assistance with dressing, eating and toileting and totally dependent with one-person physical assistance for bathing. Review of the resident's Care Plan dated 01/10/18 addressed the area of immobility with the use of half rails (bed rails) to assist the resident with turning and repositioning. Consultation notes revealed the resident was seen by an Orthopedic physician on 01/17/18. The orthopedic doctor's report stated he had no recommendations, and If she was in therapy before I see no reason why she cannot try to continue. Investigation of the resident's mobility was initiated on 04/02/18. The chart review revealed an order for [REDACTED]. On 04/02/18 at 07:50 am, an observation was made of Resident #1. She was lying in the bed eating breakfast. On 04/03/18 at 03:36 pm, a second observation was made of the resident. She was lying in bed watching TV. On 04/04/18 at 07:57 am, an interview was conducted with Resident # 1. She stated she received a wheelchair in (MONTH) or before. She also stated, The lift was cutting into my leg, so I didn't get settled in it; they put me back in bed. She added she has not been up since her therapy was cut off in January. She, then pointed to the wheelchair that was previously ordered and stated it fit within the door frame but it was too small for her. Resident # 1 stated she wondered if the new wheelchair would fit through the doorframe. She stated she was awaiting another wheelchair that had been ordered. On 04/04/18 at 08:00 am, the Maintenance Director was asked the width of residents' doorframes. He replied he was not sure but thought it was 44 inches. On 04/04/18 at 08:08 am, an observation was made of the Maintenance Director measuring the width of the doorframe of Resident # 1's room. When asked what the measurement was, he stated it measured 44 inches. On 04/04/18 at 11:05 am, a facility staff member provided a copy of a document from rehab requesting a wheelchair measuring 46x 32. It was dated 12/14/17. A review of email correspondence, dated 12/19/17, revealed a request from the facility to its supply company for a price quote. On 12/21/17, a purchase order for a 46 wheelchair, categorized as nursing equipment, was obtained. Subsequent email correspondence, dated 02/01/18 at 04:55 pm, revealed a request from the supplier to verify wheelchair measurements. Email correspondence, dated 03/21/18 at 09:40 am, revealed an inquiry as to the delivery status of the wheelchair. The reply, on the same date at 11:05 am, indicated the delivery would be 4-16-18 8-10 WK LEAD TIME. On 04/04/18 at 5:04 pm, a third observation was made, and the resident was lying in bed watching TV. During an interview with the Physical Therapy Aide (PTA) at 09:16 am, on 04/05/18, the PTA revealed the extent of services rendered was sitting the resident on the side of the bed because we didn't have the right equipment. He also stated she was discharged from Physical Therapy (PT) by her insurance and stated She was maxed out with what we could do because, again, we didn't have the right stuff. She did the best that she could. Regarding mobility, the PTA stated the resident needed a larger wheelchair and she had not received it. At 09:43 am on 04/05/18, a telephone interview was done with a representative of the company where the facility ordered the wheelchair. She stated a quote was requested on 12/19/17. She stated the order was held due to the cost of the wheelchair requiring approval on three levels. She identified the three levels as Administrator, Regional Vice President of Operations (RVPO) and Chief Executive Officer (CEO). She added the final approval was not obtained until 02/02/18, and it usually took eight to ten weeks to make a special ordered wheelchair. On 04/05/18 at 10:15 am, an interview with the Admissions Coordinator was conducted. She indicated she was the person who admitted Resident # 1, but the process of admissions was once a referral is received from the hospital, it was given to the Director of Nursing (DON) for her to determine if the resident's needs can be met at the facility. If the DON agreed to the admission, the referral was given to the Bookkeeper to review the payor source. Upon agreement between the Bookkeeper and DON, the paperwork was returned to the admission's office, and a bed offer is made. During an interview with the DON on 04/05/18 at 10:40 am, she stated she did not do an onsite assessment of Resident # 1 prior to admission to the facility. She stated that she reviewed the discharge summary and it stated the resident could stand. The DON stated that she was told by the Vice President of Operations (VPO) the resident could walk but she had gotten weaker. She further added she told the Admissions Coordinator she was not for the idea of admitting the resident. She stated she told the Admissions Coordinator the facility had a Bariatric bed available. The DON stated the resident's decreased mobility was because she had pain in her left knee and would not do PT. She also stated the resident said her knee was sliding out of joint. The DON stated an Orthopedic appointment was made but there were no negative findings. The DON stated the resident's admission was anticipated for therapy only, but she knew it was going to be long term. During an interview on 04/05/18 at 10:47 am with the Supply Clerk (identified by the DON as responsible for ordering equipment), revealed she told the DON the facility could not accommodate the resident because there was not a wheelchair, mechanical lift or shower bed big enough. She stated it took a while to order some things, because the facility must obtain a price quote, write a purchase order and get approval from the home office. During an interview on 04/05/18 at 11:10 am with the VPO, she revealed Resident # 1 was a former employee at another facility. She stated she instructed staff to look at admitting the resident and added How could we not take her? She also stated at the time of the referral, the resident was walking. She further stated The failure to obtain the wheelchair has been a calamity of errors. We thought it was approved. On 04/05/18 at 11:39 am, an interview was conducted with the Administrator. He stated he got involved with admissions when there was no secondary insurance. He added if there were concerns about the staff's ability to take care of the resident, it was discussed prior to admission. When asked if he had any knowledge about Resident # 1's wheelchair, he stated he had just followed up and it was coming on or before the 16th. He added we thought she was walking before she came to the facility. He also stated when the wheelchair came, PT would start. When asked about the difference in the wheelchair width and the width of Resident # 1's doorframe, he replied that she would be transported to PT by stretcher as was done previously. When asked about the resident's ability to get out of the room, he added he would look at it when the time came. During an interview with a former Admissions Coordinator on 04/05/18 at 11:43 am, she revealed she was in that role at the time of Resident # 1's admission. She stated she did not do an onsite visit to see the resident prior to admission. She confirmed the current Admissions Coordinator's account of the facility's admissions process. On 04/05/18 at 03:15 pm, an interview was conducted with the Medical Director. He stated the resident has declined so much because she hasn't gotten up. He stated he referred the resident to an orthopedic doctor, but there was no problem. The Medical Director ordered a MRI (Magnetic Resonance Image), but it couldn't be done due to the resident's size. He demonstrated the resident's previous ability to move her left knee and leg at an approximate 45-degree angle and stated, now she cannot. In addition to decreased knee and leg flexibility, the Medical Provider stated that there had been a decrease in the resident's ability to bear weight on both legs. The Medical Provider was asked if not getting the resident up caused her decline, and he replied yes, to a certain extent. During an interview with the Physical Therapist at 11:48 am on 04/06/18, the therapist revealed physical therapy restarted on 04/05/18, and the resident was being assisted to sit on the side of the bed. She stated the previous PT sessions ended due to maximum progress was made. She stated the resident declined due to being mostly in bed. The therapist added the resident now had increased fluid in her thighs that was not there before. The medical record indicated the resident had a history of [REDACTED]. The therapist stated the right leg is weaker now due to inactivity. She added that there was a decrease in weight bearing tolerance of both legs.

Based on medical record review, observations, and staff interviews, the facility failed to provide hand hygiene, passive range of motion exercises, and splinting services to prevent the development of two wounds on the left hand for one of one resident, (Resident # 57.) The facility also failed to correctly calculate and assess the protein needs and provide an appetite stimulant ordered for one of one sampled resident (Resident # 21) who developed a necrotic toe during his nursing home stay. Findings included: 1. Resident # 57 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. A review of the Significant Change in Status assessment dated [DATE] revealed the resident had additional [DIAGNOSES REDACTED]. A review of Resident # 57's nursing care plan initiated on 05/29/13 revealed the resident was at risk for worsening of present contractures related to bilateral hand contractures. The goal stated for this problem was that the bilateral hand contractures would not worsen by the next review date of 08/29/13. Interventions listed for this problem included application of bilateral hand protectors 6-8 hours daily, monitoring of skin integrity under the applied brace, and documentation if the resident did not participate in the splint/brace program. A review of the medical record revealed that the resident received an Occupational Therapy (OT) evaluation on 05/21/13 and OT treatment from 05/21/13 until 06/10/13. The OT Discharge Summary revealed the resident had been provided with therapeutic exercises and activities, orthotics, manual therapy for bilateral hand contractures and maintenance of skin integrity. The same discharge note stated the resident had demonstrated progress toward goals, and that restorative nursing had been educated on providing passive range of motion to both hands, skin hygiene, and hand orthotics. The discharge note from OT was signed by the Occupational Therapist on 06/10/13. In an interview with the Occupational Therapist (OT) at 11:44 AM on 09/25/13, she stated that the goals for the resident's OT treatment in May and June of 2013 were: 1) to fit the resident with a soft support called a palm protector, and 2) to train restorative nursing staff to clean the area around his left hand pressure wounds, to perform passive range of motion (PROM) with both hands, and to apply the palm protector daily. The OT stated she provided education regarding the named goals and that the staff demonstrated they had appropriate understanding to perform the care for Resident # 57. In an interview with the Restorative/Rehabilitation Nurse # 8 on 09/26/13 at 2:20 PM, Nurse # 8 stated there should be a problem, goal, and interventions on the resident ' s care plan as follow through for the recommendations made by the OT. Nurse # 8 revealed in the electronic medical record that the resident was to receive bilateral hand protectors on 05/29/13 for 6-8 hours daily. Nurse # 8 reviewed the restorative care plans for Resident # 57 and stated she was unable to find interventions or directives to provide passive range of motion services for the resident. She also stated documentation for the PROM exercises or splint services provided for Resident # 57 would be completed by the assigned restorative nursing assistant (NA) in the electronic care tracker system. A review of the Resident Care Guide documentation in the electronic Care Tracker System revealed that no passive range of motion (PROM) or active range of motion AROM) care was entered into the electronic medical record in the months of May through September, 2013. In an interview with a restorative NA # 7 on 09/25/13 at 3:00 PM, she stated she always performed range of motion with Resident # 57's arms, but not his hands. She also stated she could not remember when she last time she provided any PROM or ROM with the resident. She further stated that if she tried to do provide PROM with the resident's hands, he would resist the care. A review of the nursing care plan initiated on 08/13/13 revealed that Resident # 57 was at risk for skin breakdown or development of further pressure ulcers related to bowel and/or bladder incontinence and immobility. The goal listed for this problem on the same nursing care plan was that the resident would have no further development of pressure ulcers through the next review of 09/25/13. Interventions listed on the care plan included: skin monitoring, ensuring that appropriate pressure relieving devices were in place during repositioning, lubricating the skin with moisturizing lotion, and providing supplements ordered by the physician. A review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident # 57 was at high risk for the development of pressure ulcers. The same assessment revealed that the resident required extensive assistance for dressing, personal hygiene, eating, and toileting, and that the resident had bilateral limitations for range of motion. An interview was conducted with Nursing Assistant (NA) # 3 on 09/27/13 at 10:40 AM in the presence of The Occupational Therapist. In the interview, NA #3 stated she discovered the wound on the resident's hand on 09/10/13 and immediately notified her supervisor. She also stated that when she came to provide care to Resident # 57, the resident was wearing the palm protector incorrectly and that the soft side of the palm protector was facing the back of the hand. NA # 3 demonstrated how the palm protector was found on the resident by placing it on the Occupational Therapist's hand. NA # 3 also stated that the trimming of and cleaning of the resident's fingernails was to be completed by a nurse because the resident is diabetic. A review of the Wound/Ulcer Flow Sheet dated 09/10/13 and signed by Nurse # 6 revealed that the resident had one stage 2 pressure ulcer and one stage 3 pressure ulcer located on his right hand and that both wounds had an odor and pain associated with it. A review of the facility Incident Note dated 9/10/13 revealed that upon removal of the resident's bilateral hand protectors, there was noted to be a bleeding wound to the webbing between the left thumb and forefinger of Resident # 57. The same incident note revealed the area was actively bleeding and that the resident was provided with pain medication. In addition the note stated that a stage 2 wound was located on the pad portion of the left middle finger which was severely contracted and tucked under the other fingers of his left hand. The same note dated 09/10/13 revealed the wounds of left hand were treated per protocol and that the physician and the responsible party (RP) were notified. A review of the MDS Significant Change in assessment dated [DATE] revealed that Resident # 57 had developed one stage 2 pressure ulcer and one stage 3 pressure ulcer, both of which were not present on the previous quarterly MDS assessment dated [DATE]. A review of the Care Area Assessment Worksheet dated 09/17/13 revealed that the limitation in range of motion was a factor that could cause complications or increase the risk of the pressure ulcers. A review of the Wound/Ulcer Flow Sheet dated 09/19/13 and signed by Nurse # 7 revealed a clarification regarding the location and stages of both pressure ulcers. This flow sheet indicated that the correct location of the stage 2 pressure ulcer was on the left hand between the thumb and tip of the forefinger, and that the correct location of the stage 3 pressure ulcer was on the third finger of the left hand. Further review of the Wound/Ulcer Flow Sheet dated 09/19/13 indicated that both wounds were facility acquired and that the measurements of the stage 2 pressure wound located between the thumb and pointing finger of the left hand were 2.5 centimeters (cm) in length, 0.8 cm in width, and 0.1 cm in depth. The same Wound/Ulcer Flow Sheet indicated that the measurement of the stage 3 pressure ulcer located on the fourth finger of the left hand were 0.5 cm in length, 0.5 cm in width, and 0.1 cm in depth. A review of the resident's nursing care plan initiated on 09/10/13 indicated that the resident had ulceration or interference with structural integrity of layers of skin caused by prolonged pressure. The goal associated with this problem was that the current pressure ulcer would not worsen through the next review scheduled for 09/25/13. Interventions included: 1) Staff to report any red or open areas, 2) Apply protective barrier cream, 3) Cleanse perineal area with each incontinence episode, 4) Diet as ordered by physician, 5) Dietary consult, 6) Follow facility protocol/regime for treating breaks in skin integrity/pressure ulcers left hand and middle digit, 8) Monitor skin daily during care for any changes. Report any abnormal observations to nurse, 9) Record amount taken of supplemental nutrition consumed, 10) Vitamin C, Zinc, Multivitamin as ordered by physician, 11) Weekly assessment of wound/ulcer. Notify physician of changes as indicated. A review of the Treatment Record dated 09/10/13 through 09/18/13 revealed Resident # 57 received the following pressure ulcer treatments: clean both pressure ulcers with normal saline, apply [MEDICATION NAME] AG to both sights, and wrap both sights with Kerlix every other day. The Treatment Record also revealed that on 09/19/13 through 09/25/13 Resident # 57 received [MEDICATION NAME] 5% ointment to the left hand before/during any treatments. In addition, the Treatment Record revealed that the resident received [MEDICATION NAME] 50 mg 30 minutes prior to treatment care to the left hand wounds and/or 30 minutes before care to the contractured hands. The Treatment Record indicated that monitoring of the skin integrity of the resident's bilaterally contractured hands began on 09/19/13. A review of the medical record revealed physician's orders [REDACTED]. An observation of the resident's left and right hands was made on 09/25/13 at 9:25 AM during hand care provided by the Treatment Nurse, Nurse # 7. She removed the dressing to the resident's contractured left hand and partially extended the fingers on that hand. The resident's fingernails on the left hand were observed to be long and uneven and had black matter underneath them. A small amount of blood was observed when the nurse applied [MEDICATION NAME] under the left third finger. The palm of the left hand was reddened in the area where the fingertips had pressed into the left palm, and the fingernail on the third finger was missing. There was an ulcerated area noted in the crease between the left pointing finder and the left thumb. No odor was detected. At 2:30 PM on 09/25/13, the Administrator and the Facility's Consultant Nurse stated that they had realized there might be a problem with splint applications for residents in the facility and that they had initiated a plan of correction on 09/10/13. A review of the Plan of Correction (POC) dated 09/10/13 revealed that Resident # 57 was the only resident affected by the skin splint application, and that the wound was identified and a treatment plan is currently in place. It also stated that the skin integrity check has been placed on the Treatment Administration Record for the treatment nurse to document that skin integrity is checked daily. In addition, the POC stated that a 100% audit of the facility was conducted and there were nine other residents found in the facility with skin protectors/contracture prevention/splinting/immobilizers in place. An audit was conducted of these individuals to check skin integrity, skin protectors/contracture prevention/splinting/immobilizers in place. The POC also indicated that an in-service training was conducted with 100% of nursing staff to educate them that all residents with hand protectors, splints, and braces are to have them placed for 6-8 hours only then removed unless otherwise specified. The in-service training also educated the nurses that the splints, braces, hand protectors are to be removed, skin is to be cleaned, dried, and assessed for any abnormalities. The POC further stated that if anything abnormal is noted, it should be reported to a charge nurse and/or treatment nurse who will initiate a skin referral and follow up by the treatment nurse. The POC also indicated that an audit would be conducted twice a week for 2 weeks, weekly for 2 weeks, and monthly for 3 months by the DON and Administrator to (monitor) skin integrity for affected residents. The monitoring is to be checked and recorded on the Treatment Administration Record. The POC further stated that all audits will be taken to the Quarterly Quality Improvement meeting for review and adjustments to the audit schedule are to be made as needed. The last statement on the POC was, "Corrective action will be completed by September 19, 2013." Further review of the POC dated 09/10/13 revealed that education was not provided to the staff regarding trimming and cleaning the resident's fingernails. 2. a. Resident #21 was admitted to the facility on [DATE] and readmitted on [DATE]. The resident's documented [DIAGNOSES REDACTED]. A 08/09/13 hospital discharge summary did not document any problems with toes on Resident #21's right foot other than the removal of the second toe due to dry gangrene. The resident was admitted to the facility on [DATE] receiving vitamin C, Zinc, and a multi-vitamin to promote wound healing. A 08/09/13 Wound/Ulcer Flowsheet documented the resident was admitted with a surgical incision secondary to amputation of the right second toe and a stage II pressure ulcer to the sacrum. A 08/13/13 Dietary Supplemental Assessment, completed by the facility's dietary manager (DM), documented Resident #21 was on a regular no-added salt diet, was eating 46% of meals, weighed 116 pounds, and required 53 grams of protein, but was actually only receiving 46 grams of protein through his diet. The resident's 08/16/13 Admission Minimum Data Set (MDS) documented the resident's cognition was intact, eating only occurred once or twice during the assessment look back period, and the resident experienced a weight loss of 5% or more in the last month or 10% or more in the last six months. 08/19/13 lab results documented Resident #21's total protein and [MEDICATION NAME] were low. The resident's total protein was 5.1 grams/deciliter (g/L), with normal being 6.2 - 8.3 g/dL and [MEDICATION NAME] level was 2.9 g/dL, with normal being 3.4 - 4.9 g/dL. A 08/19/13 care plan identified "At risk for skin breakdown or development of further pressure ulcers related to [MEDICAL CONDITION]" and "State of nourishment less than body requirement characterized by weight loss prior to admission, inadequate intake, decreased appetite" as problems. Interventions to these problems included, "Monitor status of wound healing and re-evaluate nutritional requirements as needed" and "Refer to dietitian for evaluation/recommendations." A 08/20/13 Skin/Wound/Treatment Note documented, "...purple hard/soft blister to 3rd toe; purple discoloration underneath toe, mild swelling to top of right foot." A 08/22/13 Dietary Supplemental Assessment, completed by the facility's DM, documented Resident #21's current body weight was 117 pounds, he was eating 51 - 75% of his meals, required 53 grams of protein, and was receiving 72 grams of protein through his diet (average intake of meals recorded in the electronic record keeping system for 08/09/13 through 08/21/13 was 58%). A 08/23/13 vascular surgery clinic note documented, "...his wound today has not improved; in fact, his right third toe has become ischemic.... " A hospital discharge summary documented Resident #21 was hospitalized between 08/26/13 and 08/30/13 for a axillobifemoral bypass and aftercare. A 08/30/13 Wound/Ulcer Flowsheet documented there was bruising and necrotic tissue to the side and between the second and third toe and underneath the second toe of the right foot, and Resident #21 still had a stage II sacral pressure ulcer. A 09/05/13 Dietary Supplemental Assessment, completed by the facility's DM, documented Resident #21's current body weight was 126 pounds, he was eating 51 - 75% of his meals, required 57 grams of protein, and was receiving 55 grams of protein through his diet. A 09/06/13 Wound/Ulcer Flowsheet documented Resident #21 right third toe was unstageable and presented as 100% hard black necrotic tissue. A 09/12/13 Dietary Supplemental Assessment, completed by the facility's DM, documented Resident #21's current body weight was 126 pounds, he was eating 51 - 75% of his meals, required 57 grams of protein, and was receiving 71 grams of protein through his diet. At 2:20 PM on 09/26/13 the DM reported the facility's registered dietitian (RD) assessed residents in the facility once a month. She stated the RD was in the building on 08/26/13 and 09/24/13. According to the DM, the RD prepared her own list of residents to be assessed, but commented she had some input if there were specific residents she wanted assessments completed on. The DM commented the RD completed assessments on residents who experienced significant weight loss, who were fed by tube, and who had wounds each time she visited the facility. The DM stated she was responsible for completing the Dietary Supplemental Assessments. She reported she was not aware that in the electronic calculation of resident nutritional needs (a part of the Dietary Supplemental Assessment) she was supposed to adjust the protein factor based on conditions listed in the electronic worksheet (including using a protein factor of 1 - 1.2 grams per kilogram of body weight for [MEDICATION NAME] levels 2.8 - 3.5, and a factor of 1 - 2 grams per kilogram of body weight for surgery, and a factor of 1.2 grams per kilogram for body weight for a stage II wound). She explained she was using the protein factor of 1, which automatically populated in the program, for all residents regardless of nutrition issues such as wounds, low [MEDICATION NAME] levels, and post-surgery recovery. Review of Resident #21's paper and electronic medical records revealed as of 09/26/13 the resident had not been assessed by the facility's RD. Review of the Dietary Supplemental Assessments completed for Resident #21 revealed a more accurate protein factor was 1.5 (see interview with RD below). The resident received inadequate dietary protein, and there was no provision of protein supplementation. On 08/13/13 Resident #21's protein needs should have been 78 grams of protein with the DM reporting the resident was receiving 46 grams through his diet. On 08/22/13 Resident #21's protein needs should have been 78 grams of protein with the DM reporting the resident was receiving 72 grams through his diet. On 09/05/13 Resident #21's protein needs should have been 85 grams of protein with the DM reporting the resident was receiving 55 grams through his diet. On 09/12/13 Resident #21's protein needs should have been 85 grams of protein with the DM reporting the resident was receiving 71 grams through his diet. At 5:05 PM on 09/26/13, during a telephone interview with the facility's RD, she stated she used the facility's corporate nutrition-related factors in determining the protein factor to be used for each resident. She commented a resident with a surgical amputation, unstageable necrotic toe, and a stage II sacral ulcer would probably require a protein factor of 1.5. During each facility visit the RD reported she completed assessment on residents who were newly admitted , readmitted , and those experiencing significant weight loss. She explained she only assessed residents who were fed by tube or who had wounds quarterly unless they experienced significant weight loss or their wounds deteriorated. The RD reported she would be back in the facility on 10/01/13. At 12:54 PM on 09/27/13, during a telephone interview with the facility's RD, she stated the facility staff knew they could contact her between her monthly visits if there were changes in resident condition which might require new nutritional intervention. She reported she would consider the worsening or formation of new wounds to be a reason to contact her between visits. She explained nutritional interventions could help speed up the healing process and boost the immune system to help prevent the formation of new ulcers. At 4:35 PM on 09/27/13 the facility's director of nursing (DON) stated the RD visited monthly. She reported she was unsure if all facility staff knew they could contact her between her monthly visits, but definitely, she expected the DM who attended weekly wound meetings, to contact her if nutrition interventions needed to be put in place to promote wound healing or to prevent the formation of new ulcers. b. Resident #21 was admitted to the facility on [DATE] and readmitted on [DATE]. The resident's documented [DIAGNOSES REDACTED]. A 08/09/13 hospital discharge summary documented the resident's right second toe was amputated because of dry gangrene. The resident was admitted to the facility on [DATE] receiving vitamin C, Zinc, and a multi-vitamin to promote wound healing. The resident was also receiving 800 milligrams (mg) or 20 cubic centimeters (cc) of [MEDICATION NAME] (appetite stimulant) daily. Resident #21's weight record documented he weighed 117 pounds on 08/14/13. The resident's 08/16/13 Admission Minimum Data Set (MDS) documented the resident's cognition was intact, eating only occurred once or twice during the assessment look back period, and the resident experienced a weight loss of 5% or more in the last month or 10% or more in the last six months. A 08/19/13 care plan identified "State of nourishment less than body requirement characterized by weight loss prior to admission, inadequate intake, decreased appetite" as a problem. Interventions to these problems included diet as ordered, supplements as needed, and refer to dietitian for evaluation/recommendations. A 08/21/13 physician order [REDACTED]. The electronic record keeping system documented the resident's average meal intake between 08/09/13 and 08/21/13 was 58%. A hospital discharge summary documented Resident #21 was hospitalized between 08/26/13 and 08/30/13 for a axillobifemoral bypass and aftercare. The resident was readmitted to the facility on [DATE] with physician orders [REDACTED]. Resident #21's August 2013 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. However, [MEDICATION NAME] was not carried forward to the September 2013 MAR indicated [REDACTED]. The resident's Weight Record documented he weighed 126 pounds on 08/30/13. Resident #21's weight record documented he weighed 128 pounds on 09/24/13. The electronic record keeping system documented the resident's average meal intake between 08/22/13 and 09/25/13 was 55%. Review of Resident #21's paper and electronic medical records revealed as of 09/26/13 the resident had not been assessed by the facility's RD. At 5:22 PM on 09/26/13 the director of nursing (DON) stated she was not sure how the transcription error occurred that caused Resident #21's [MEDICATION NAME] not to be carried forward to his September 2013 MAR. She explained a 2-check process was in place to help prevent such errors. She explained when residents were admitted or readmitted at the end of the month a call was placed to the pharmacy to request a printed MAR for the upcoming month. She reported two different nurses checked this new MAR for accuracy, making sure all orders from the month before were carried forward and to make sure all the orders were accurate by matching them against the hospital discharge summary.

Based on observation, record review and staff interviews, the facility failed to implement effective fall interventions for prevention of falls for 3 of 6 residents (Resident #24, #64, and #109) who had a history of [REDACTED]. The facility also failed to monitor and/or evaluate the effectiveness of the fall interventions for 4 of the 6 residents (Resident #24, #64, #93, and #109) who were reviewed for falls. Findings included: 1. Resident #109 was admitted to the facility with a history of falls on 06/04/13 following a left hip fracture. She was sent out on 06/27/13 as a result of a fall and was re-admitted on [DATE] with a right hip fracture. She was discharged on [DATE]. Cumulative [DIAGNOSES REDACTED]. The Admission Minimum Data Set (MDS) of 06/21/13 indicated she had long and short term memory problems as well as impaired decision making skills. She needed extensive assistance from one person for transfers and toilet use. Resident #109 was not able to stabilize without the assistance of staff when moving from seated to standing position. Her balance was not steady when moving on and off the toilet and she needed assistance to stabilize. It was noted that Resident #109 had two or more falls since admission. According to the Care Area Assessment (CAA) detail, Resident #109 triggered in 6 areas including falls. Falls were to be carried to the care plan as she was identified as being at risk. A falls risk evaluation of 06/04/13 indicated Resident #109 was at high risk for falls with a score of 13. According to the risk evaluation any score above 10 placed the resident at a high risk for falls. It was noted that her last fall was prior to admission and fall precautions were in place. A falls risk evaluation of 06/17/13 indicated Resident #109 was at risk for falls with a score of 13. It was noted that her last fall was 06/27/13 and fall precautions were in place. An incident note of 06/22/13 at 8:30 PM written by Nurse #5 indicated Resident #109 had an unobserved fall from her low bed to the floor. Her wheelchair was beside the bed and she was found sitting on the floor between the bed and the wheelchair by staff. She complained of right ankle pain when touched. The physician was notified and gave orders to apply ice packs. A telephone interview was conducted with Nurse #5 on 09/27/13 at 9:00 AM. She stated she remember the incident of 06/22/13. Nurse #5 stated an incident report was completed. Nurse #5 stated when a resident was on fall precautions they were at risk for falling and were to be monitored more closely which meant that whenever staff walked past her room they were to look in on her. Nurse #5 stated that when the incident report was completed and footwear was checked it meant that the resident was not wearing the appropriate footwear. According to the June 2013 medication administration record (MAR), Resident #109 was receiving Macrobid (antibiotic) 100 milligrams twice daily for treatment of [REDACTED]. Resident #109's care plan of 06/25/13 identified her as being at risk for falls due to a history of falls and multiple risk factors related to impaired mobility as evidenced by a recent left femoral neck fracture. According to documentation in the intervention column, a winged mattress had been placed on 06/25/13, wear non slip footwear was initiated on 06/25/13. It was also noted on 06/25/13 for staff to provide frequent observation of Resident #109. It was noted that prompted toileting had been resolved as of 07/02/13. On 07/05/13, one on one supervision was implemented. An incident note written by Nurse #4 of 06/24/13 at 3:33 PM indicated Resident #109 was observed sitting on her buttocks beside the bed due to sliding out of bed. There were no injuries and she denied pain. Resident #109 was transferred to a low bed and non-skid socks were applied. Nurse #4 was interviewed on 09/26/13 at 4:35 PM. She stated she was working the night of 06/24/13 when Resident #109 fell . She stated Resident #109 was confused and would try to get up unassisted. Nurse #4 stated when she fell she was not wearing the non-skid socks. She added that Resident #109's family had been educated not to bring in socks due to someone had put regular socks on her feet instead of the non-skid socks. Nurse #4 commented Resident #109 had been placed on one on one supervision due to her unassisted transfers but was not sure when it was implemented. A health status note of 06/27/13 indicated that at 1:40 AM Resident #109 was sitting at the nurse's station in a recliner. It was noted that she had fallen out of the chair onto her right side and complained of right shoulder pain, right hip pain and pain to the back of her head. The physician was notified and gave orders to send her out for evaluation. She left the facility at 2:05 AM. An unsigned witness statement for the fall of 06/27/13, which appeared to be from the nurse working the night of 06/27/13, indicated Resident #109 was sitting in a recliner across from the nurse's station. NA #5 was sitting at the nurse's station. NA #4 was walking down the 400 hall towards the nurse's station when she yelled out, " --- (nurse's name) the patient is on the floor." The statement indicated the writer was in the office behind the nurse's station. The writer indicated a telephone call was made to the physician on call and orders given to send her out for evaluation. A telephone interview was conducted on 09/25/13 at 11:06 AM with the nurse aide (NA#4) who observed Resident #109 when she fell on [DATE]. She stated she was not assigned to work with Resident #109 that night. She stated Resident #109 was confused at times and wasn't aware of her having a history of falling. NA #4 stated she was walking down the hall that night and saw her sitting in a wheelchair at the nurse's desk. She stated the nurse was passing medications on the hall. NA #4 stated someone was working at the nurse's station but their head was down and she didn't remember who it was. NA #4 stated she observed Resident #109 attempt to rise from the chair and yelled out "no" but by the time she got to her she had already fallen. When questioned as to non-skid footwear being in place, NA #4 she wasn't sure if she was wearing non-skid socks or not. A telephone interview was conducted on 09/26/13 at 12:00 PM with the nurse aide (NA #5) who was assigned to work with Resident #109 on 06/27/13. She stated Resident #109 was total care and had to be monitored due to her attempts to get up unassisted. She stated she didn't remember if she had placed non-skid footwear on her that night or not but she did have a pair of yellow gripper socks. NA #5 stated when she came to work that night, Resident #109 was already in bed. NA #5 did report that Resident #109 was agitated at some point that night and she did get her out of bed and placed her in a chair at the nurse's station. NA #5 commented that she would have checked on her every 2 hours during incontinence rounds. A QI note from the QI nurse of 06/28/13 at 11:35 AM indicated Resident #109 had been admitted after a fall with a left hip fracture. It was noted that Resident #109 had intermittent confusion and decreased safety awareness. She had been placed on a low bed upon admission. It was noted she had multiple falls since admission from her low bed. According to this note, she had slid out of bed on 06/22/13 and 06/24/13. Action was to instruct staff to have Resident #109 out of the room for supervision if out of bed. She had not been wearing non-skid footwear with either fall. It was noted that all socks had been removed except the non-skid socks and staff were instructed to ensure non-skid footwear was in place. Posey lateral bolsters which were collapsible were placed on the low bed to prevent her from sliding off the foot of the bed and would not prevent her from getting out of bed. Another QI note from the QI nurse of 06/28/13 at 2:04 PM indicated Resident #109 had a fall on 06/27/13 from her wheelchair while sitting at the nurse's station for supervision. She noted that the nurse turned "her head for a split second" and Resident #109 attempted to stand from the wheelchair and fell . Resident #109 was sent out for evaluation. The action taken included all socks had been replaced with non-skid socks, posey lateral bolsters (pads that slip over the side rails) were placed on her bed as visual boundary but would not prevent her from transferring as they were collapsible. It was noted that Resident #109 was to be out of her room for supervision due to recurrent attempted unassisted transfers. It was noted that fall precautions were in place as well as therapy. A hospital discharge summary of 07/01/13 indicated Resident #109 was being sent back to the facility after a right hip hemiarthroplasty following a fracture of the right femoral neck on 06/27/13. It was noted that she had a history of [REDACTED]. A fall risk evaluation of 07/01/13 indicated Resident #109 was at risk for falls with a score of 13. It was noted that she ambulated independently with device and had fallen within the past 30 days. Fall precautions were in place which included bed in lowest position, a high winged mattress and appropriate footwear. The last fall was noted to be 06/27/13. A health status note from Nurse #9 of 07/04/13 at 4:31 PM indicated Resident #109 was found on the floor and complained of left hip and left shoulder pain. There was no other information included in this note. A physician's telephone order of 07/04/13 indicated to send Resident #109 to the emergency room for evaluation of possible left shoulder fracture and left hip. According to information provided by the facility, one on one supervision was implemented after her return from the emergency roiagnom on [DATE] at 10:19 PM. Nurse #9 was interviewed on 09/25/13 at 2:40 PM in reference to her note regarding Resident #109's fall of 07/04/13. She stated Resident #109 had a history of [REDACTED]. chart. After reviewing her chart, she stated Resident #109 was confused and attempted to get up unassisted on a constant basis. She stated she was usually at the nurse's station for close monitoring. Nurse #9 stated Resident #109 had been found on the floor beside her bed. She did not remember if she was wearing non-skid footwear. She did not remember who found her. Nurse #9 stated that the details of the incident would be included in the incident report that she completed on 07/04/13. Nurse #9 commented Resident #109 had been placed on one on one supervision but was not sure when it started. The QI note written by the QI nurse of 07/17/13 at 1:39 PM indicated Resident #109 was high risk for falls. It was noted that she fell on [DATE] due to an unassisted transfer. There were no other details describing the incident noted. It was also noted that staff were unable to redirect her due to her cognitive status. She was sent out for evaluation due to complaints of left shoulder pain. It was noted that upon return from the hospital there were no injuries. It was noted that Resident #109 was currently working with therapy and was on a low bed with a high winged mattress. One on one supervision was implemented upon her return due to the inability to stop unassisted transfers. The QI nurse was interviewed on 09/27/13 at 11:10 AM. She stated if a resident was admitted with a history of falls they were placed on a bed that was to be in the lowest position. She commented that all of the beds in the facility were such beds. The QI nurse reported using low beds which were in a fixed position and could not be raised. The QI nurse commented when she conducted her investigation of a fall, she reviewed the medical record for possible medications that might contribute to falling as well as any medical acute condition such as urinary tract infections that might place them at risk. The QI nurse stated if the resident was on therapy caseload she would discuss the fall with the therapy staff. The QI nurse stated if it was felt that there were equipment issues that might be altered, she worked with therapy to discuss options such as wedges, pommel cushions, scoot chairs, broda chairs or rock-n-go chairs depending upon the resident's status. As the interview continued, the QI nurse reported the process for fall investigation included an incident report which was completed by the staff person who responded to the resident fall. The QI nurse stated the nurse should have a thorough description on the incident report of what happened. She added that in order to do a complete investigation, she needed to know what the resident's vital signs were when found, what position the bed was in, if they were wearing non-skid footwear, any lighting issues, any spills on the floor and if possible what activity the resident was engaged in just prior to the fall. The QI nurse reported that the incident reports were given to her for review and investigation. She stated during her investigation she attempted to interview staff. If she did interview staff, she included their information in her QI note in the electronic record. The QI nurse stated once she had completed the investigation, she would make recommendations as to the appropriate intervention and the report was passed on to the Director of Nurses (DON) and the Administrator for final approval. The QI nurse reported that the facility was alarm free and only used physical restraints as a last resort. The QI nurse stated she reviewed effectiveness of the interventions on a quarterly basis but at one time she reviewed them weekly. She commented she was no longer able to review weekly due to having other duties in the facility. During the same interview of 09/27/13 at 11:10 AM, the QI nurse reported Resident #109 had been admitted after a fall at home. She stated Resident #109 had falls shortly after admission and was supposed to be wearing non-skid footwear and was not wearing at the time of the fall on 06/22/13 or the fall of 06/24/13. She reported Resident #109 was to be out of her room for supervision to prevent further falls. The QI nurse stated she educated the day shift staff as to the non-skid footwear and out of room supervision and she expected them to pass it on verbally from shift to shift. She had not provided any in-service or meeting to pass the information on. When questioned as to her idea of what out of room supervision meant, she commented that in her opinion and if she was the hall nurse, she would have her eyes on the resident even during medication pass. She stated the resident would be with her at the medication cart or a nurse aide would be asked to watch her. The QI nurse commented that currently when staff were monitoring more closely, staff were expected to "peep" in on the resident if they were in their room and to keep an eye on them if they were in the halls. She added that for out of room supervision, she recommends placing the resident in an area where they can be visually observed while out of the room. The QI nurse stated that after the fall of 06/24/13, bolster pads were added to her bed and out of room supervision was still an appropriate intervention. When questioned about the fall of 06/27/13, she responded that was the first fall from a chair and the out of room supervision intervention was an appropriate intervention. She stated a winged mattress was placed on her bed after that fall to prevent her from falling from her bed. The QI nurse stated Resident #109 had been placed on 1:1 (one on one) supervision after her last fall. The QI nurse agreed that Resident #109 had continued to have falls and the out of room supervision intervention was not effective in preventing her from falling. The QI nurse stated she had concerns regarding the frequency of the falls in the facility as well as the number of fractures sustained as a result of the falls and she had mentioned it during the morning meetings. Physical Therapist (PT #1) was interviewed on 09/25/13 at 12:10 PM. She stated she remembered working with Resident #109. She stated she was modified independence when she lived at home and fell . She stated she was sent to the facility for rehabilitation after a hip fracture. PT #1 stated cognition was her major issue as she had no carry over with instructions provided. When questioned about falls, she responded that she was working with her during the times of her falls but she did not make recommendations for interventions after falls. She added that therapy was involved in the process but it was the nursing department's responsibility to make that decision since it was based on the resident's situation. PT #1 reported Resident #109 would try to get up unassisted because that was the way she was before she fell and came here. PT #1 added that she had been sent out at some point with a fracture of the other hip and had a sitter as a reminder not to get up unassisted. She stated she knew her mattress was changed to a high winged mattress but she didn't know when. NA #10 was interviewed on 09/26/13 at 4:45 PM. She stated she had worked with Resident #109 and she was always trying to get up unassisted. She stated she was the aide who found her after one of her falls as she was trying to get out of bed and she found her on the floor on her right side. NA #10 stated she stated she was in a low bed and was identified as being high risk for falls. She commented that after several falls she was placed on 1:1 supervision. NA #10 stated Resident #109 did have gripper socks and wore them sometimes but not all the time. She stated she placed them on her if she was agitated. NA #10 remarked that close supervision meant to peak in on her every time she walked down the hall. The Director of Nurses (DON) was interviewed on 09/27/13 at 4:29 PM. She stated she was advised about all falls and if the fall occurred during off hours she would instruct staff on which immediate intervention they were to implement. The DON stated she gets the incident report online once the QI nurse has completed her investigation. She stated she expected staff to be thorough with their description of the incident. The DON stated the staff person should include where the resident was found, what the body position was, if pain was present, and whether or not range of motion was affected. She also commented any note about what it appeared that the resident was doing prior to the fall if it could be determined would be helpful. She stated she would expect staff to document any intervention such as non-skid footwear that was in place or not in place at the time of the fall. The DON stated the nurse should do a complete head to toe assessment. When questioned as to the meaning of out of room supervision, the DON responded that residents were to be placed in a place within the building where there was a lot of activity so they could be watched more closely. She commented those residents were usually sitting at the nurse's station. She added that keeping your eye on someone was not the same as one on one supervision. The DON commented that Resident #109 had been taken to the nurse's station for supervision and fell anyway. She stated she expected staff to ensure that interventions were in place and monitored for effectiveness. She remarked that she was aware that the frequency of falls had increased over the last quarter as several residents were falling during the same time frames. She also stated she was aware that Resident #109 had fallen several times and did sustain a fracture. The DON stated she relied upon the QI nurse to make sure the appropriate interventions were in place and only implemented physical restraints as a last resort. She also stated she expected the QI nurse to track and trend falls and report findings to her to discuss. The DON stated falls were discussed in the morning meetings. The DON stated that the out of room supervision had not been an effective tool to prevent Resident #109 from falling since apparently staff follow through did not occur. 2. Resident #64 was admitted to the facility following a fall on 06/20/13. Cumulative [DIAGNOSES REDACTED]. The Resident Care Guide for Resident #64, dated 06/20/13, indicated she was non-ambulatory. Interventions included non-skid footwear, winged mattress (added 6/25/13), prompted toileting for bowel every 4 hours initiated on 08/29/13. The Admission 5 day Minimum Data Set (MDS) assessment of 06/27/13 indicated she had cognitive loss and was moderately impaired with decision making. There were no behaviors noted. She required extensive assistance with bed mobility, transfer, toilet use and hygiene. It was noted that she had an indwelling urinary catheter and had a fall prior to admission. The Care Area Assessment (CAA) detail indicated she triggered in 8 areas including falls as she was identified as being at risk. Falls was to be carried to her care plan. Resident #64's care plan, last revised on 09/10/13, identified her as being at risk for falls characterized by history of falls with multiple risk factors related to unsteady gait and poor safety awareness. There was no mention of out of room supervision in the intervention section. According to the interventions mentioned in this care plan, the list contained: . 06/21/13 referral to therapy . 06/21/13 fall risk protocol . 06/21/13 have commonly used articles within easy reach . 06/21/13 keep call light within reach and answer timely . 06/21/13 provide frequent reminders to call for assistance before getting up . 06/25/13 lateral bolsters to bed (this was resolved on 07/02/13) . 06/26/13 prompted toileting every hour (this was resolved on 07/02/13) . 07/11/13 enabler/self release belt while up in wheelchair, can release . 07/25/13 winged mattress A health status note of 06/21/13 at 10:09 PM indicated Resident #64 had attempted to get out of the wheelchair several times on this shift. She was found standing at the nurse's station with a piece of paper in her mouth stating she was smoking a cigarette. It was noted that Resident #64 stated several times she wanted to go home. She was redirected and encouraged to ask for assistance before getting out of the wheelchair. A health status note written by the Director of Nurses (DON) of 06/24/13 at 4:35 PM indicated Resident #64 was not on 1:1 (one on one) observation. It was noted that she was under close supervision at the nurse's station and by other staff. It was noted Resident #64 still continued to make multiple attempts to stand independently and had fallen. The DON indicated to continue to monitor under supervision due to the lack of safety recognition. A Quality Improvement (QI) note written by the QI nurse on 06/26/13 indicated Resident #64 had an unassisted fall on 06/19/13 (prior to her admission) and was admitted on [DATE]. It was noted that staff were instructed to ensure non-skid footwear in place and Resident #64 was to be out of the room while awake for supervision. A health status note of 06/26/13 by Nurse #11 at 7:27 AM indicated that the writer was passing medications at 5:10 AM when she found Resident #64 on the floor in her room on her side. It was noted that she was barefoot. A telephone interview was conducted with Nurse #11 on 09/27/13 at 9:10 AM. She stated she remembered working with Resident #64 but did not remember the circumstances regarding the fall of 06/26/13. Nurse #11 reported Resident #64 was usually in bed on her shift as she worked third shift. She stated Resident #64 had a self release seat belt on her wheelchair that she could release at will. Nurse #11 stated she also had a winged mattress on her bed. She stated she was aware that if Resident #64 was out of bed she needed supervision. Nurse #11 remarked she was at high risk for falling, was anxious and yelled out for help at times. She couldn't remember if the bolsters were in place or not at the time of the fall on 06/26/13. A Quality Improvement (QI) note written by the QI nurse on 06/28/13 indicated Resident #64 had a fall from her low bed on 06/26/13. It was noted that lateral bolsters were supposed to be in place prior to the fall. According to the note, the lateral bolsters were not in place at the time of this fall as the room had been cleaned on 06/25/13 and the bolsters were not placed back on the bed. Staff was educated to report any intervention that was not in place to the nurse so the intervention could be placed. Staff was also educated to have resident out of room when awake for supervision. A bowel prompting toileting program was started. During an interview with the QI nurse on 09/26/13 at 11:40 AM, she stated during her investigation it was discovered that the lateral bolsters had been removed and were not replaced prior to the fall of 06/26/13. A QI falls review note from the QI nurse of 07/02/13 at 8:37 AM indicated Resident #64 was at high risk for falls. It was noted that she had a second fall on 06/29/13 at 11:05 AM. She had rolled out of bed with lateral bolsters in place and functioning. The bolsters were removed and the high winged mattress placed. It was noted that fall precautions remain. A health status note written by Nurse #6 on 07/03/13 at 10:30 AM indicated Resident #64 was found on the floor on her left side and was attempting to ambulate unassisted. She lost her balance and fell to the floor. She complained of right arm pain and stated she had hit her head. She was sent out for evaluation. The investigation follow-up written by Nurse #6 for the fall of 07/03/13 indicated Resident #64 was attempting to ambulate to the bathroom unassisted when she lost her balance and fell . She was in her room in her wheelchair and was wearing tennis shoes. It was noted that she had been sitting in the wheelchair prior to the fall. In the intervention taken to prevent reoccurrence section it was noted to continue therapy, to be out of her room for supervision when awake and continue the low bed with the high winged mattress. Neurological checks were started. The QI falls review note of 07/03/13 at 3:50 PM indicated Resident #64 had a fall on 07/03/13 while attempting to ambulate in her room unassisted. It was noted her cognition was impaired as well as her balance. It was noted that redirection was unsuccessful and she continued to make unsafe decisions. The action taken was that Resident #64 required supervision when awake. The QI nurse indicated she was on a low/low bed with a high winged mattress due to multiple falls from the bed. She was currently working with therapy and being treated for [REDACTED]. Fall precautions were to remain. A health status note written by Nurse #4 on 07/07/13 at 11:52 AM indicated Resident #64 was observed at 11:15 AM sitting on her buttocks on the floor beside her bed in her room. It was noted that Resident #64 was trying to get into bed from the wheelchair and lost her balance. No injuries were noted. Nurse #4 noted that close supervision was in place. A health status note written by Nurse #4 on 07/08/13 indicated Resident #64 was found at 8:00 AM on her left side in the floor in her room. She noted that Resident #64 stated she was trying to walk to the bathroom and fell . She was transferred to the wheelchair with close supervision. No injuries were noted. A telephone interview was conducted with Nurse #4 on 09/26/13 at 4:35 PM. She stated Resident #64 was confused and constantly attempted to get up unassisted. She stated she was not to be left in her room without supervision due to having several falls. A handwritten fall review form for the fall of 07/08/13 indicated Resident #64 was wearing shoes and at the time of the fall was in her wheelchair. It was noted that she reported she was trying to get to the bathroom. A health status note written by Nurse #6 on 07/10/13 at 3:48 PM indicated she responded to a code green and found Resident #64 lying on the floor on her right side underneath the bed of her roommate with the bedside table across her head. It was noted that Resident #64 stated she had hit her head and complained of head pain so was sent out for evaluation. A health status note of 07/10/13 at 8:06 PM indicated Resident #64 was shown how the safety belt worked on her wheelchair and was shown how to release it. It was noted she was able to release it 3 times and was told it was for safety only and could still get up if she released the belt. Nurse #6 was interviewed on 09/25/13 at 10:15 AM. She stated she had concerns about the number of falls that Resident #64 had since her admission in June 2013. She stated Resident #64 had bipolar disease and her psychiatry physician had been working with her on adjustment of her medications in an effort to decrease her symptoms. Nurse #6 stated she had spoken with management about the use of some type of physical restraint due to the number of falls and the frequency of them but management didn't want to use restraints of any kind. She added that sometimes that was the only intervention to prevent falls. Nurse #6 stated she had placed the self release seat belt on Resident #64 out of concern for her well-being and her frequency of falls. She stated since the self release seat belt had been applied to Resident #64's wheelchair, the falls had decreased but she was still falling and had sustained rib fractures. She stated Resident #64 could release the belt whenever she wanted to get up and she had concerns about her falling. Nurse #6 reported one of the falls that she responded to was on 07/10/13. She stated when she entered the room, the bedside table had been turned over and was positioned on top of Resident #64 who was under the roommate's bed. When questioned about fall interventions in place when Resident #64 was in bed, she stated the bed was to be in the lowest position, a winged mattress, nonskid footwear and call bell in reach. Nurse #6 commented that the facility did not use alarms of any kind. She stated there was nothing written for Resident #64 to be at the nurse's station for observation but she chose to have her there so she could watch her. Nurse #6 could not remember if any other types of chairs had been used for Resident #64. She reported there was a care guide inside each resident's closet which indicated care needs for the residents and the nurse aides were to follow those guides when providing care. An incident note of 07/15/13 at 7:05 PM indicated Resident #64 was found on the floor in her room following dinner. There were no other details included in the note. The investigation follow-up for the fall of 07/15/13 indicated that Resident #64 was on her side on the floor. It was noted in the contributing factors section that she "attempts task she is unable to perform if left unsupervised." The intervention taken to prevent reoccurrence was to be out of the room for supervision and to only be in her room for care and to sleep. It was noted that fall precautions of low bed with a high winged mattress, the enabler and therapy were in place. The witness statement from the nurse who found her indicated Resident #64 had slid on the floor and was wearing sneakers. The QI falls review note of 07/17/13 written by the QI nurse indicated the Resident #64's falls were reviewed. It was noted that she was at high risk for falls and had fallen on 07/07/13 and 07/08/13 due to unassisted transfers and unassisted ambulation. She had decreased safety awareness and was unable to be redirected due to her cognitive status. It was noted that her balance was impaired, she had an unsteady gait and was currently being treated for [REDACTED]. Once again, the action taken included staff was instructed to have her out of her room for supervision while awake. A QI falls review note of 07/17/13 at 3:16 PM indicated the QI nurse had reviewed falls risk for Resident #64. She was at high risk for falls and ha