Every finding on record at Barbour Court Nursing and Rehabilitation Center

Based on record review and staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) assessment in the areas of medications (Resident #8, Resident #4, and Resident #5) and Pneumococcal Vaccine (Resident #18). This was for 4 of 28 residents whose MDS assessments were reviewed.Findings included:a. Resident #8 was admitted to the facility on [DATE].Resident #8's physician orders included Novolog (a rapid acting insulin) injection solution 100 units/milliliter inject 10 units subcutaneously (beneath the skin) with meals. Hold for blood sugar less than 150 with a start date of 3/18/25.Resident #8's December 2025 Medication Administration Record (MAR) noted Novolog was administered subcutaneously to him on 12/25/25 at 11:30 AM, on 12/26/25 at 6:30 AM, on 12/27/25 at 6:30 AM, 11:30 AM, and 5:30 PM, on 12/28/25 at 6:30 AM and 11:30 AM, on 12/29/25 at 6:30 AM and 5:30 PM, on 12/30/25 at 11:30 AM and 5:30 PM, and on 12/31/25 at 6:30 AM and 5:30 PM.Resident #8's quarterly MDS assessment dated [DATE] revealed he received both injections and insulin injections on 5 of the 7 look back days of the assessment.On 2/25/26 at 10:50 AM during an interview MDS Nurse #1 stated she coded the medication section of Resident #8's MDS assessment dated [DATE]. She reported she should have coded the section to indicate Resident #8 received both injections and insulin injections for 7 of the 7 look back days of the assessment period. She reported this was an error.b. Resident #4 was admitted to the facility on [DATE].Resident #4's physician orders included Dulaglutide (non-insulin medication to improve blood sugar control) Solution Pen-injector 0.75 milligrams per 0.5 milliliter inject 0.75 mg subcutaneously one time a day every Saturday related to Type 2 Diabetes Mellitus with a start date of 12/6/25. There were no physician orders in December 2025 for Resident #4 to receive insulin.Resident #4's December 2025 Medication Administration Record (MAR) noted Dulaglutide was administered subcutaneously to him on 12/27/25.Resident #4's quarterly MDS assessment dated [DATE] revealed he received both an injection and an insulin injection on 1 of the 7 look back days of the assessment period.On 2/25/26 at 10:50 AM during an interview MDS Nurse #1 stated she coded the medication section of Resident #4's MDS assessment dated [DATE]. She reported that she coded the section to indicate Resident #4 received both an injection and an insulin injection on 1 of the 7 look back days of the assessment period. She stated she coded this medication as an insulin because it was prescribed for Resident #4's diabetes.c. Resident #5 was admitted to the facility on [DATE].Resident #4's physician's orders for January and February 2026 did not reveal any orders for anticoagulant medication.Resident #4's January and February 2026 Medication Administration Records (MAR) did not reveal any documentation indicating anticoagulant medication had been administered.Resident #5's annual MDS assessment dated [DATE] noted she received anticoagulant medication during the 7 look back days of the assessment period.On 2/25/26 at 10:43 AM during an interview MDS Nurse #2 stated she coded the medications section of Resident #5's MDS assessment dated [DATE]. She reported her coding that Resident #5 received anticoagulant medication was an error. She stated Resident #4 had not received any anticoagulant medication during the look back period of the assessment.d. Resident #18 was admitted to the facility on [DATE].Resident #18's quarterly MDS assessment dated [DATE] revealed she was up to date with her pneumococcal vaccine.The immunization section of Resident #18's medical record revealed documentation indicating Resident #18 had historically received a single dose of Pneumovax (Pneumovax, also known as Pneumococcal Polysaccharide Vaccine or PPSV23) on 6/1/2014. There was no documentation discovered in Resident #18's medical record to indicate she received any further pneumococcal vaccines.On 2/26/26 at 10:07 AM during an interview MDS Nurse #1 stated she coded Resident #18's MDS assessment dated [DATE] to indicate Resident #18's pneumococcal vaccine was up to date. She reported this was not correct. She went on to explain she had just gone back to the Resident Assessment Instrument (RAI) manual and checked the most recent Centers for Disease Control and Prevention (CDC) guidelines and discovered a single historical dose of Pneumovax would not make Resident #18's pneumococcal vaccine up to date. MDS Nurse #1 reported she could not find a record indicating Resident #18 had received any other pneumococcal vaccines. She reported she must have looked at old CDC guidelines when she coded Resident #18's 11/15/25 MDS assessment.During an interview on 2/26/26 at 11:19 AM the Director of Nursing (DON) stated resident MDS assessments should be coded accurately.During an interview on 2/26/26 at 11:31 AM the Administrator stated resident MDS assessments should be coded accurately.

Based on observations, record review, and interviews with staff and the Nurse Practitioner (NP), the facility failed to ensure the resident's need for insulin (a hormone that regulates blood sugar levels) administration in accordance with the parameters provided by the physician before administering the insulin. This deficient practice affected 1 of 5 residents (Resident #8) reviewed for unnecessary medications.Findings included:Resident #8 was admitted to the facility on [DATE] with a diagnosis of diabetes mellitus type 2 (DM II).A current active physician's order for Resident #8 with a start date of 3/18/25 revealed Novolog injection solution (a type of fast acting insulin)100 units per milliliter inject 10 units subcutaneously (SQ is beneath the skin) with meals and to hold (do not give) for blood sugar (BS) less than 150 (a normal adult BS before eating is between 70 to 99.A review of Resident #8's December 2025 Medication Administration Record (MAR) revealed documentation by Nurse #1 indicating that Resident #8's BS at 6:30 AM on 12/13/25 was 122 and she administered 10 units of Novolog insulin to Resident #8. Resident #8's BS at 11:30 AM on 12/13/25 was 236. On 12/15/25 at 6:30 AM Nurse #1 documented Resident #8's BS was 122 and she administered 10 units SQ to Resident #8. Resident #8's BS at 11:30 AM on 12/15/25 was 205. On 12/27/25 at 6:30 AM Nurse #1 documented Resident #8's BS was 122 and she administered 10 units SQ to Resident #8. Resident #8's BS at 11:30 AM on 12/27/25 was 134. On 12/29/25 at 6:30 AM Nurse #1 documented Resident #8's BS was 106 and she administered 10 units SQ to Resident #8. Resident #8's refused to have his BS checked at 11:30 AM on 12/29/25. On 2/25/26 at 9:25 AM in a telephone interview Nurse #1 stated she was familiar with Resident #8. She reported she did not recall Resident #8 having any parameters for the administration of his Novolog insulin. She stated normally, if a resident had BS parameters for the administration of insulin, it would show on the resident's electronic MAR on her computer screen. She went on to say her documentation on Resident #8's December 2025 MAR on 12/13/25, 12/15/25, 12/27/25 and 12/29/25 would indicate she administered 10 units of Novolog insulin SQ to Resident #8 at 6:30 AM each of those days.Resident #8's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed he was cognitively intact. He had no behaviors or rejection of care. He received injections, and insulin injections on 5 of the 7 look back period days of the assessment.On 2/26/26 at 10:58 AM an interview with the NP indicated she was familiar with Resident #8. She reported he frequently refused his BS checks and his insulin despite many conversations with him on the importance of these for managing his DM II. She stated because of this, his BS tended to run on the higher side. She went on to say as a result the instances of administration of 10 units of Novolog insulin to Resident #8 when his BS was less than 150 had not caused Resident #8 any harm. She reported there was always the possibility of harm to a resident, which included an unsafe drop in BS level, if insulin was administered to them outside of the parameters of the physician's order as this insulin would not be needed. She stated nurses should always follow the parameters for administering insulin.On 2/25/26 at 1:53 PM in an interview the Director of Nursing stated she would consider the administration of insulin to a resident outside the parameters of the physician's order to be a serious medication error. She reported that the potential harm to a resident receiving insulin that was not indicated by their blood sugar level would be an unsafe lowering of their blood sugar. On 2/25/26 at 3:14 PM an interview with the Administrator indicated nurses should be adhering to the parameters in the physician's order when administering insulin. He stated the facility did not have a corrective action plan in place for this.

Based on record review and interviews with residents and staff, the facility failed to ensure the residents' right to receive mail delivered on Saturdays and on the date it was received. This had the potential to affect 136 of 136 residents in the facility.Findings included:During the Resident Council meeting on 2/25/26 at 2:08 PM Resident #26, Resident #39, Resident #54, Resident #73, Resident #94, Resident #95, and Resident #13 reported they did not get their regular mail delivered as the facility received the mail, including Saturdays. Resident #26, the Resident Council President, stated regular mail was delivered to Receptionist #1 Monday through Friday. Receptionist #1 sorted the mail and gave the residents' mail to the activities department to be delivered, but it was hit or miss how quickly the mail was delivered. The Resident Council President further stated Saturday's mail was held at the front desk and given to Receptionist #1 on Monday to sort and the residents' mail was then taken to activities to be delivered. The Resident Council President stated regular mail sometimes sat in the activities room for a week before it was delivered. The Resident Council President stated he was aware of this issue because his trade/professional magazines, outdoor sporting magazines, and product catalogues had been in the activities room for a week before he collected them himself after Resident #39 informed him the magazines were in the activities room. Resident #39 then confirmed this by stating he often read Resident #26's outdoor sporting magazines in the activities room before he told Resident #26 his magazines were in the activities room. Resident #26 stated the times he was concerned his mail sat in the activities room were not when he was out of the facility or hospitalized and he usually had to collect his magazines from the activities room.During an interview on 2/26/26 at 9:40 AM Resident #95 stated she went to the activities room after lunch daily just to check in with them and color her coloring pages. She further stated most of the time she went into the activities room, the rack that held the sorted, regular mail for residents was often full. She stated the same mail, such as the Resident Council President's magazines, remained in the activities room for a week before it disappeared and she assumed it was delivered or the residents picked it up themselves. She stated the magazines were the easiest to identify as the same mail sitting for a long time because the magazine cover image was different for each issue, but the same cover sat in the activities room for many days. She stated there was not a set pattern or day that the mail was taken out of the activities room, but it was very obvious to her that the same items of mail sat in the activities room for multiple days before being delivered or picked up by the residents.During an interview on 2/26/26 at 7:58 AM Receptionist #1 stated each weekday, Monday through Friday between 1:00 PM and 1:30 PM, she got the mail from the mailbox and went to the post office to pick up the mail at the post office. She then returned to the facility and sorted the mail and put the residents' mail in the box in the activities room. She stated on Saturdays when she was not at the facility, the mail was put in her box at the front, and she sorted Saturday's mail on Mondays. She stated that most Mondays she sorted residents' mail that was delivered on Saturday and put the mail in the box in the activities room to be delivered to the residents on Monday. During an interview on 2/26/26 at 8:34 AM the Activities Director stated she worked some Saturdays and when she worked on Saturdays the mail was sorted and delivered to the residents. She stated someone from activities was in the facility every day and the mail should be sorted and delivered on Saturdays by activities staff. The Activities Director stated she knew sometimes if there was a question of whether a resident should receive an item like a bill, activities staff would put it in Receptionist #1's box to be sorted Monday. So, there were times when Saturday's mail was not delivered until Monday if there were questions about whether it should go to the resident or another party. She concluded she was not aware of any time any resident's mail sat in the activities room and was not delivered for a week unless the resident was in the hospital and mail was held for them secured in an office belonging to activity staff.During an interview on 2/26/26 at 8:07 AM the Administrator stated it was his expectation that mail was delivered daily to residents, including Saturdays. It was his understanding that regular mail was being distributed as it arrived by the activities department, including Saturdays. The Administrator stated he was not aware that the Receptionist sorted mail delivered on Saturday on most Mondays for residents or that residents had concerns with mail not being delivered daily throughout the week as no grievances had been completed about timely mail delivery.

Based on record review and resident and staff interviews, the facility failed to ensure a copy of the resident's advanced directive was included in the resident's record (Resident #10) and failed to provide written advance directive information and/or an opportunity to formulate an advance directive (Residents #18, #51, and #84). This was for 4 of 17 residents reviewed for advance directives. The findings included: a. A review of the facility's policy titled Documentation of Advanced Directives dated 2/2007 revealed in part It is the policy of the facility to document in the residents' medical record whether or not the resident has executed an advanced directive. If the resident or resident's family or representative indicates that the resident has executed an advanced directive, facility staff will request that a copy of the advanced directive be provided to the facility for inclusion in the resident's record as soon as possible. Resident #10 was admitted to the facility on [DATE] with a diagnosis of respiratory failure. A review of Resident #10's admission Minimum Data Set (MDS) assessment dated [DATE] revealed she was cognitively intact. On 11/14/24 at 12:47 PM an interview with Resident #10 indicated her family member was her Power of Attorney (POA) and that family member had the written paperwork for this. She stated she did not recall anyone asking her if she had a POA when she was admitted to the facility or asking her to provide a copy of the document. On 11/14/24 at 1:00 PM a review of Resident #10's medical record did not reveal evidence of Resident #10's POA document. On 11/15/24 at 1:03 PM an interview with the Admissions Director indicated she was aware that Resident #10 had a POA document when Resident #10 was admitted to the facility. She stated she had spoken with the Social Worker at another facility, who informed her that Resident #10 had one. She went on to say she had not asked Resident #10 or her family member to provide a copy of the POA or documented this in Resident #10's medical record. On 11/15/24 at 1:57 PM an interview with the Administrator indicated typically the facility's Business Office Manager requested copies of the Living Will and/or the POA, if the resident had these, during the financial interview upon admission. He stated the Business Office Manager had been out on leave. He reported he felt a copy of Resident #10's POA had not been obtained for Resident #10's medical record because the Business Office Manager normally did this. 43222 b. Review of Resident #18's medical record revealed the Resident was readmitted to the facility on [DATE] with diagnoses that included dementia, Parkinson's disease, and cardiovascular disease. The review revealed a full code status was care planned on 5/20/23. There was no documentation in the record for education regarding a formulation of an advance directive and/or an opportunity to formulate an advance directive was offered. c. Review of Resident #51's medical record revealed the Resident was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease, dementia, and hypertension. The review revealed a full code Physician order dated 11/5/24. There was no documentation in the record for education regarding a formulation of an advance directive and/or an opportunity to formulate an advance directive was offered. d. Review of Resident #84's medical record revealed the Resident was admitted to the facility on [DATE] with diagnoses that included a history of a stroke and diabetes. The review revealed a full code Physician order dated 11/5/24. There was no documentation in the record for education regarding a formulation of an advance directive and/or an opportunity to formulate an advance directive was offered. An interview was completed on 11/13/24 at 11:15 AM with the facility's Admissions Director. She revealed that either she or the Social Worker discussed only code status with residents. A further discussion about advance directives did not take place, and there is no documentation to show the Resident's understanding beyond code status. An interview was completed on 11/13/24 at 11:50 AM with the facility's Social Worker #1. Social Worker #1 stated she only discussed code status with the Resident and/or their responsible party (RP). An interview was completed with the facility's Administrator on 11/13/24 at 2:15 PM. He revealed SW #1 documented the code status discussion in the medical record, but there was not a form for advance directives with an explanation that was signed by the Resident or the RP. The Administrator stated the only document that went into the chart was the Do Not Resuscitate (DNR) form itself and the order verification form that the physician signed.

Based on record review, resident, Resident Representative (RR) and staff interviews, the facility failed to conduct care plan meetings or invite residents to their care plan meetings for 4 of 9 residents reviewed for care plans (Residents #39, #40, #100, and 117). Findings included: 1. Resident #39 was admitted to the facility on [DATE] with diagnoses which included Alzheimer's disease and aphasia (unable to speak). The quarterly Minimum Data Set assessment dated [DATE] indicated that Resident #39 was severely cognitively impaired. An interview on 11/12/24 at 11:13 AM with Resident #39's Resident Representative (RR) revealed she had not been invited to a care plan meeting since Resident #39's admission. She stated she would like to attend a care plan meeting. An interview on 11/13/24 at 1:21 PM with the Social Worker (SW) #1 revealed that based on Resident #39's record, it appeared she had not had a care plan meeting since 4/5/2018. The SW indicated he was aware of the requirement to hold care plan meetings quarterly. An interview on 12/13/24 at 2:55 PM with the Administrator revealed he was unaware that Resident #39 had not had a care plan meeting since 2018. He stated SW #1 made the care plan meeting schedule and sent the invitations by mail to residents' RRs, or hand delivered them to residents who were their own responsible party. 41009 2. Resident #100 was admitted to the facility on [DATE]. A review of Resident #100's care plan revealed it was last updated on 10/6/24. A review of Resident #100's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed he was moderately cognitively impaired. On 11/12/24 at 1:35 PM an interview with Resident #100 indicated he did not recall ever being invited to attend a care plan meeting. He stated he would like to be invited to attend. On 11/13/24 a review of Resident #100's medical record did not reveal any documentation that a care plan meeting was conducted since Resident #100's admission to the facility. On 11/13/24 at 11:03 AM an interview with MDS Nurse #1 indicated Resident #100's Social Worker (SW) was responsible for sending the invitations and for arranging Resident #100's care plan meetings. She reported a care plan schedule calendar was generated based on the MDS assessment dates and provided to the SW. She further indicated Resident #100 would have been scheduled for a care plan meeting in accordance with his 10/25/24 MDS assessment. On 11/13/24 at 12:42 PM an interview with SW #2 indicated Resident #100 was due for a care plan meeting around the time of the 10/25/24 MDS assessment. He stated he was responsible for providing the invitation to the meeting, and for maintaining the documentation of the meeting including those who attended. SW #2 stated care plan meetings included the resident and their Representative if this applied, a Nurse, a Nurse Aide, Activities, Dietary, and Therapy if this applied. He reported he had been Resident #100's SW since Resident #100's admission to the facility. SW #2 stated he had not invited Resident #100 to a care plan meeting and had no documentation that a meeting occurred. He went on to say care plan meetings were important and should be held at least quarterly and as needed. SW #2 stated he did not have a reason why a care plan meeting for Resident #100 had not been held. On 11/13/24 at 1:42 PM an interview with the Director of Nursing (DON) indicated care plan meetings should be held at specific intervals for residents. She stated she did not have any documentation that a care plan meeting had been held for Resident #100 since his admission to the facility. On 11/15/24 at 11:57 AM an interview with the Administrator indicated care plan meetings were required for residents. He stated the resident needed to be invited to the meetings, and all disciplines needed to be represented at the meeting. The Administrator stated care plan meetings should be held on admission, quarterly, and any time there was a significant change with the resident. 3. Resident #40 was admitted to the facility on [DATE]. A review of Resident #40's quarterly MDS assessment dated [DATE] revealed she was cognitively intact. A review of Resident #40's care plan revealed it was last revised on 10/22/24. On 11/12/24 at 2:24 PM an interview with Resident #40 indicated she did not recall being invited to a care plan meeting. She stated she would like to be invited to attend. On 11/12/24 a review of Resident #40's medical record did not reveal any documentation that a care plan meeting was conducted for Resident #40 since her admission to the facility. On 11/13/24 at 11:03 AM an interview with MDS Nurse #1 indicated Resident #40's SW was responsible for sending the invitations and arranging Resident #40's care plan meetings. She reported a care plan schedule calendar was generated based on the MDS assessment dates and provided to the SW. She further indicated Resident #40 would have been scheduled for a care plan meeting in accordance with her 10/18/24 MDS assessment. On 11/13/24 at 12:42 PM an interview with SW #2 indicated Resident #40 was due for a care plan meeting around the time of the 10/18/24 MDS assessment. He stated he had been Resident #40's SW since her admission to the facility. SW #2 reported he was responsible for providing the invitation to the meeting, and for maintaining the documentation of the meeting including those who attended. SW #2 stated care plan meetings included the resident and their Representative if this applied, a Nurse, a Nurse Aide, Activities, Dietary, and Therapy if this applied. He reported he had not invited Resident #40 to a care plan meeting and had no documentation that a meeting occurred since Resident #40's admission to the facility. He went on to say care plan meetings were important and should be held at least quarterly and as needed. SW #2 stated he did not have a reason why a care plan meeting for Resident #40 had not been held. On 11/13/24 at 1:42 PM an interview with the Director of Nursing (DON) indicated care plan meetings should be held at specific intervals for residents. She stated she did not have any documentation that a care plan meeting had been held for Resident #40 since her admission to the facility. On 11/15/24 at 11:57 AM an interview with the Administrator indicated care plan meetings were required for residents. He stated the resident needed to be invited to the meetings, and all disciplines needed to be represented at the meeting. The Administrator stated care plan meetings should be held on admission, quarterly, and any time there was a significant change with the resident. 50404 4. Resident #117 was admitted to the facility on [DATE], and her diagnoses included acute cerebrovascular insufficiency, vascular dementia, hypertension, and diabetes. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #117 was moderately cognitively impaired. Review of Resident #117's care plan revealed it had been reviewed and revised on 9/12/24 and 10/23/24 by the interdisciplinary team. Review of the care plan meeting signature sheet dated 9/12/24 showed those in attendance were the Social Worker, Activity Director and Resident #117's Representative (via telephone). Resident #117 had not attended the care plan meeting. Review of the care plan meeting signature sheet dated 10/23/24 showed those in attendance were the Social Worker, Activity Director, and a registered nurse who worked on the hall. Resident #117's Representative attended via telephone. Resident #117 had not attended the care plan meeting. Attempts were made to reach Resident #117's Representative to obtain an interview via telephone with no return call. The Social Worker was interviewed on 11/12/24 11:00 AM, and stated if the resident was alert and oriented, she verbally notified the resident of a care plan meeting. She had not invited Resident #117 to care plan meetings because she did not consider the resident to be alert and oriented. An interview with Resident #117 was held on 11/13/24 at 2:45 PM, during which she stated she would like to be invited and involved in the planning of her care. The Assistant Administrator was interviewed on 11/14/24 at 9:12 AM. She revealed that the Social Worker initiated the care plan meeting. If a resident was not alert and oriented the resident representative was invited to attend the meeting. The Assistant Administrator explained that the Social Worker referenced the Brief Interview for Mental Status (BIMS) in the MDS assessment to determine if a resident was alert and oriented. The Social Worker verbally notified residents of the upcoming care plan meetings. If the BIMS of a resident was 12 or higher the Social Worker invited them to participate in the planning of care. An interview with the Administrator on 11/15/24 at 1:27 PM revealed his expectation was that the resident was invited to care plan meetings and that written invitations were given to both the resident and resident representative.

Based on record review and resident, staff, and Medical Director interviews the facility failed to protect a resident's right to be free from the misappropriation of controlled medication for 1 of 2 residents (Resident #40) reviewed for misappropriation. Findings included: A review of the facility's policy titled Abuse, Neglect, or Misappropriation of Resident Property dated last revised on 3/10/2017 revealed in part The facility believes that our residents have the right to be free from abuse, neglect, involuntary seclusion, exploitation or misappropriation of property. The facility will do whatever is in it's control to prevent mistreatment, neglect, exploitation, and abuse of our residents or misappropriation of their property. Resident #40 was admitted to the facility on [DATE] with a diagnosis of chronic pain. A physician's order for Resident #40 dated 5/17/24 indicated to administer oxycodone (a narcotic pain medication) 10 milligrams (mg)/acetaminophen (a non-narcotic pain medication) 325 mg one tablet by mouth to Resident #40 four times daily for chronic pain. A review of Resident #40's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed she was cognitively intact and on a scheduled pain medication regime. She received as needed medication for pain. Resident #40 had pain of an 8 on a 0 to 10 scale almost constantly with 0 being no pain and 10 being the most pain imaginable. A review of a pharmacy packing slip dated 6/20/24 revealed the facility received 120 doses of oxycodone 10 mg/acetaminophen 325 mg tablets for Resident #40. Two nurse signatures appeared on the bottom of the packing slip acknowledging that the medication was received. The same two nurse signatures appeared at the top of the controlled substance count records for the medication which were labeled one of four, two of four, and three of four. The controlled substance count sheet four of four was missing. A review of Resident #40's Medication Administration Record (MAR) for June 2024 revealed documentation oxycodone 10 mg/acetaminophen 325 mg one tablet was administered to Resident #40 four times a day on 6/20/24 through 6/30/24 at 12:00 AM, 6:00 AM, 12:00 PM and 6:00 PM as ordered by her physician. A review of Resident #40's Medication Administration Record (MAR) for July 2024 revealed documentation oxycodone 10 mg/acetaminophen 325 mg one tablet was administered to Resident #40 four times a day on 7/1/24 through 7/6/24 at 12:00 AM, 6:00 AM, 12:00 PM and 6:00 PM as ordered by her physician. A review of the Shift Change Controlled Substances Count Check dated 7/3/24 at 7:00 AM revealed the off-going Nurse #5's and the oncoming Nurse #4's signature on the log verifying there were 23 controlled substance count sheets present. On 7/3/24 at 3:00 PM the off-going Nurse #4's and oncoming Nurse #3's signatures were present on the log verifying that there were 23 controlled substance count sheets present. On 7/3/24 at 11:00 PM the off-going Nurse #3 and the oncoming Nurse #2's signature were present on the log indicating there were 23 controlled substance count sheets present. On 7/4/24 at 7:00 AM the off-going Nurse #2's and the oncoming Nurse #4's signatures were present on the log, but the number 23 was crossed out and the number 22 was written indicating there were 22 controlled substance count sheets present with a note that the count was verified. On 11/12/24 at 2:24 PM an interview with Resident #40 indicated she had a history of chronic pain. She stated she received medication in the facility for her pain that helped her. She stated she did not recall ever not receiving the pain medication she needed to control her pain. On 11/15/24 at 12:39 PM an interview with Central Supply Clerk #1 indicated on 7/3/24 after 3:00 PM he needed to check the medication room to see what supplies needed to be restocked. He stated normally, the nurse would open the door to the medication room and be present while he did this, but on this occasion Nurse #3 gave him the keys, he used them to open up the medication room door. He went on to say he propped the door open with his cart while he restocked the supplies, and when he turned around to give Nurse #3 back her keys, she was gone. He reported he had not been in the medication room with the keys for very long, he thought maybe about 30 seconds. Central Supply Clerk #1 recalled he saw Nurse #4 and the Unit Nurse Manager at the nurses' station, and when he attempted to give the keys to the medication room to the Unit Nurse Manager, Nurse #4 reached out her hand, said I'll take them and took the keys from him. Central Supply Clerk #1 stated Nurse #4 told him she would give the keys to Nurse #3 when Nurse #3 got back from the bathroom. He went on to say approximately 3 to 5 minutes later he saw Nurse #3 in the hallway, asked her if she had gotten her keys back, and she told him she had. On 11/15/24 a review of a written witness statement by Nurse #3 dated 7/8/24 revealed on 7/3/24 at the start of her 3:00 PM to 11:00 PM shift Nurse #3 completed the controlled substance reconciliation count with the off going Nurse #4. This was her first time working at the facility. Although there had been only 22 controlled medication cards in the medication cart and there were 23 listed on count sheet, when she asked Nurse #4 about it, Nurse #4 had given her an explanation for it, and so she signed the count sheet for 23 controlled medications and sheets. Nurse #3 remembered giving Central Supply Clerk #1 the keys to the medication room and leaving the medication cart at the nurse's station while she went to the bathroom. When Nurse #3 returned from the bathroom, Nurse #4 gave these keys back to her. On 11/15/24 at 10:19 AM, 12:42 PM and 3:07 PM attempts to reach Nurse #3 for a telephone interview were unsuccessful. Nurse #3 no longer worked at the facility, and no other method of contact for her was available. On 11/15/24 at 10:18 AM a telephone interview with Nurse #4 indicated she was assigned to care for Resident #40 on 7/3/24 from 7:00 AM until 3:00 PM. Nurse #4 explained Nurse #3 was new to the and she had taken Nurse #3 around the facility, given her report on the residents, and done the controlled medication reconciliation with Nurse #3 before giving Nurse #3 the keys to the controlled substances and the medication cart at about 3:30 PM on 7/3/24. Nurse #4 reported she recalled there being 23 controlled medications and 23 controlled substance count record sheets present. She stated she stayed for a while after her shift ended that day and was at the nurses' station at about 3:45 PM on 7/3/24 when Central Supply Clerk #1 came up to the nurses' station where she was seated looking for Nurse #3. Nurse #4 reported Central Supply Clerk #1 had the keys to the medication cart which included the keys to the controlled substances and wanted to return them to Nurse #3. She went on to say she had not seen Nurse #3 give the keys to the medication cart to Central Supply Clerk #1. She reported the medication cart had been in the hallway next to the nurses' station where she was seated. Nurse #4 indicated she had not seen Central Supply Clerk #1 access the medication cart or use the keys to access the locked medication room which was about 3 doors down from the nurse's station, although she could see both the cart and the room from where she was seated. Nurse #4 stated she told Central Supply Clerk #1 that Nurse #3 was in the bathroom, and that he could lay the keys on the counter at the nurses' station, which he did. Nurse #4 reported that she could see the keys to the medication cart lying on the counter at the nurse station the entire time until Nurse #3 came out of the bathroom and picked them up a few minutes later. The interview further revealed when she returned to the facility on [DATE] for her 7:00 AM to 3:00 PM shift and was reconciling the controlled medication in the medication cart with Nurse #2, she noticed Resident #40 was missing a card of 30 doses of oxycodone 10 mg/acetaminophen 325 mg and the controlled substance count record sheet that went with the medication. She reported the shift change controlled substance count check sheet indicated there should be 23 count sheets and 23 narcotic medications in the cart, but there had only been 22. She went on to say Nurse #2 asked her how she knew Resident #40 was missing a card of 30 doses of oxycodone 10 mg/acetaminophen 325 mg and the controlled substance count record sheet for this medication before they had finished reconciling the controlled medication, and she told her she knew what was supposed to be in the cart because she was very familiar with that medication cart and was the regular nurse for that hall. Nurse #4 indicated she did not know what happened to the medication or the sheet and she and Nurse #2 had immediately reported the discrepancy to the Unit Nurse Manager. On 11/15/24 at 9:25 AM a telephone interview with Nurse #2 indicated she was assigned to care for Resident #40 on 7/3/24 from 11:00 PM until 7/4/24 at 7:00 AM. She stated when she counted the controlled narcotic medication on 7/4/24 at 11:00 PM with the off going Nurse #3 who was assigned to care for Resident #40 on 7/3/24 from 3:00 PM until 11:00 PM she noticed the number of controlled medications and the number of the controlled substance count record sheets did not match what was on the shift-change controlled substance count check log. She stated the shift change controlled substance count check log indicated there should be 23 controlled medication cards and 23 controlled substance count records but there had only been 22. Nurse #2 reported she had asked Nurse #3 why this was, and Nurse #3 informed her Nurse #4, who had been assigned to care for Resident #40 on 7/3/24 from 7:00 AM until 3:00 PM, had instructed her that the 2 cards of a narcotic medication in a bag were supposed to be counted as 2. Nurse #2 stated she had been working at the facility for the past 3 years, and she didn't think this was correct, but if she counted the medication in the bag as 2 then there would have been 23 controlled medications. She went on to say the pharmacy had come to deliver medications while she was performing the controlled substance reconciliation with the off going Nurse #3 on 7/3/24, and she had accepted the keys to the medication cart without completing the controlled substance reconciliation and signed the shift change controlled substance count check log to indicate there were 23 medication cards present. Nurse #2 reported she thought she would figure out why the narcotic count seemed to be incorrect later on in her shift, but she had gotten busy and had not. She went on to say the next morning, on 7/4/24 at 7:00 AM when she and the oncoming Nurse #4 began to perform the narcotic reconciliation, she asked Nurse #4 whether or not she instructed Nurse #2 to count the narcotic medication in the bag as 2 and Nurse #4 told her she had not said this. Nurse #2 stated before she and Nurse #4 finished the controlled medications reconciliation, Nurse #4 told her Resident #40 was missing a whole card of 30 doses of oxycodone 10 mg/acetaminophen 325 mg. Nurse #2 went on to say she thought this was strange, because she and Nurse #4 had not even finished reconciling the controlled medications when Nurse #4 said this. Nurse #2 reported she had asked Nurse #4 how she knew what was missing, and Nurse #4 told her she knew how much of this medication Resident #40 was supposed to have because she was Resident #40's regularly assigned nurse. Nurse #2 indicated she did not know what happened to the missing medication or the record sheet. She stated the discrepancy had been reported to the Unit Nurse Manager on 7/4/24. On 11/15/24 at 8:35 AM an interview with the Unit Nurse Manager indicated on 7/3/24 after 3:00 PM she was in the hallway and heard Central Supply Clerk #1 ask Nurse #4 for assistance with getting into the medication room. The Unit Manager stated she heard Nurse #4 ask Central Supply Clerk #1 to wait a moment and she would help him. She reported a few minutes later that Central Supply Clerk #1 attempted to give her some keys, but Nurse #4 offered to take the keys from him. She reported she saw Central Supply Clerk #1 give the keys to Nurse #4. The Unit Nurse Manager did not discuss why she allowed Central Supply Clerk #1 to give the keys to Nurse #4, or why she had not questioned the situation on 7/3/24. She went on to say on 7/4/24, Nurse #2 and Nurse #4 reported to her that there was a card of 30 doses of Resident #40's oxycodone 10 mg/acetaminophen 325 mg and the controlled substance count record sheet that went with the medication missing from the medication cart. She reported she verified the medication, and the record sheet were missing, and immediately reported the medication discrepancy to the Director of Nursing. The Unit Nurse Manager stated Nurse #4 should not have had the keys to the medication cart and the controlled substances after she passed the keys to Nurse #3 at the end of her shift on 7/3/24, and Central Supply Clerk #1 should never have been allowed to have these keys or access to the areas where medications were kept unsupervised. On 11/15/24 at 11:47 AM a telephone interview with the Pharmacy Manager indicated on 6/20/24 the pharmacy dispensed 120 doses of oxycodone 10 mg/acetaminophen 325 mg to the facility for Resident #40. He stated Resident #40 took one dose of this medication 4 times daily. He went on to say the 120 doses should have been a 30 day supply of the medication for Resident #40. The Pharmacy Manager reported on 7/10/24, the pharmacy had to reissue a 10 day supply of the medication early, billed to the facility and not to Resident #40, because of diversion of the medication by someone at the facility. On 11/15/24 at 1:18 PM an interview with the Director of Nursing (DON) indicated a full card of 30 doses of Resident #40's oxycodone 10 mg/acetaminophen 325 mg medication and the controlled substance count record sheet for the medication had gone missing by the Unit Nurse Manager on 7/4/24 between 7:00 AM and 8:00 AM. She stated she had been involved in the investigation. The DON reported there should always be clarification immediately prior to accepting the keys to the medication cart as soon as there was any question about the accuracy of the controlled substance reconciliation. She stated she had not been made aware of any concern with the controlled substance reconciliation count until 7/4/24. The DON stated the nurse should never pass the keys to their medication cart to anyone after they had counted the narcotic medications and accepted responsibility for the medication cart. She reported Nurse #4 should not have had access to the medication cart keys after she performed the controlled substance reconciliation with Nurse #3 at the end of her shift on 7/3/24. The DON stated although these were things that she felt should just be basic nursing knowledge, since this incident the facility had done in-service education with all nurses and medication aides, and it was included in the facility's orientation process. She went on to say a corrective action plan for the incident had been implemented. She reported the follow-up audits had not revealed any additional concerns. The DON stated she continued to periodically monitor and reconcile the controlled substances in the medication carts. On 11/15/24 at 1:57 PM an interview with the Administrator indicated the facility had confirmed that Resident #40's 30 doses of oxycodone 10 mg/acetaminophen 325 mg medication and the controlled substance count record sheet for the medication had gone missing on 7/4/24. He stated an investigation had been competed, replacement medication had been ordered from the pharmacy and billed to the facility, and Resident #40 had not missed any doses of the medication. He reported Nurse #4 had been hired at the facility in August 2023, and the facility had been aware that she had a reprimand on her nursing license from the North Carolina Board of Nursing (NCBON) related to concerns about missing narcotic medications and the documentation of controlled substances by Nurse #4 when she was hired. He stated Nurse #4 had not had any restrictions on her nursing license and had been allowed to handle and administer controlled substance medications. He went on to say although he could not prove it, he believed Nurse #4 was responsible for Resident #40's missing medication. The Administrator stated Nurse #4 no longer worked at the facility, and he had reported the incident to the NCBON. He reported an initial and 5 day investigation report had been submitted to the State Agency, Adult Protective Services and the Medical Director had been notified of the incident, and a report to law enforcement had been made. He went on to say the missing controlled medication had been reported to the Drug Enforcement Agency. The Administrator stated the facility completed an investigation of the incident and implemented a performance improvement plan. He went on to say there had been no additional concerns on their follow-up audits. He stated this incident, and the follow-up audits had been discussed in the Quality Assurance and Performance Improvement meetings. On 11/15/24 at 11:49 AM an interview with the Medical Director indicated she had not been the Medical Director for the facility when the incident occurred. She went on to say the previous Medical Director no longer worked for the company, and no contact for him was available. She stated the positive thing was that Resident #40 had not missed any doses of her oxycodone 10 mg/acetaminophen 325 mg medication and had not suffered any negative outcome. The facility provided the following corrective action plan: Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice; - On 7/4/2024, the Administrator and Director of Nursing (DON) were notified of missing medication from the medication cart for a resident. The Administrator and Director of Nursing initiated an investigation regarding missing medications. - The resident was assessed by nursing staff for signs and symptoms of pain on 7/4/2024. No significant findings noted from the assessment. The resident was able to receive pain medication from remaining doses on the medication cart. The resident and the Resident Representative (RR) were made aware of the missing medication. The medication was reordered from the pharmacy. - Initial allegation report was submitted to Division of Health Service Regulation (DHSR) on 7/4/2024 by the Administrator. - The local law enforcement agency was made aware of the missing medication on 7/4/2024 by the Administrator. A report was completed for the missing medication. - The facility Medical Director and the resident's RR were made aware of the missing medication on 7/4/2024 by the Administrator and Director of Nursing. The Medical Director had no new orders. - The Drug Enforcement Agency was notified of the missing medication on 7/5/2024 by the Administrator. - NCBON was notified of the missing medication on 7/8/2024 by the Director of Nursing. - APS made aware of the investigation on 7/4/2024 by the Administrator. Address how the facility will identify other residents having the potential to be affected by the same deficient practice; - On 7/4/2024 the Unit Managers completed an audit of the last 30 days of ordered narcotic medications to ensure the medications were in the medication cart, administered, or returned to pharmacy per protocol. No concerns were noted during the audit. - On 7/4/2024, the Director of Nursing reviewed packing slips for the past 30 days to ensure all narcotic medications were checked in appropriately and accounted for. No concerns were noted from the audit. - On 7/4/2024, the Director of Nursing completed an audit of 100% of all resident's Controlled Substance Count sheets in comparison to the narcotic medication blister packs in the medication cart to ensure there were no discrepancies in the count of the medications. No concerns were noted from this audit. - On 7/4/2024, the Unit Managers inspected the narcotic blister pill packages for any tampering of medications. No concerns with tampering were noted. - On 7/4/2024, the Unit Managers and Assistant Director of Nursing initiated assessment of all residents for pain. The Director of Nursing will address will initiate non-pharmacological interventions, pain medication, and/or physician notification for any identified areas of concern during the audit. The audit was completed by 7/5/2024. No concerns were noted from this audit. - On 7/5/2024, the Accounts Payable completed an audit of all nurses and medication aides' license verification and HCPI checks. No concerns were noted from this audit. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur; - On 7/4/2024, the Staff Development Coordinator initiated an in-service with all nurses and medication aides regarding Controlled Substance Diversion to include: the definition, implications, the process for returning narcotic medications, and not removing the declining count sheet from the controlled substance book until the end of the shift to ensure it is signed by 2 nurses. The in-service also will discuss reporting discrepancies immediately to the nurse manager, not accepting a medication cart until the discrepancy is investigated and not allowing any other nurse to have access to the medication cart if it is not their assigned medication cart. The in-service was completed by 7/5/2024. After 7/5/2024, any nurse or medication aide that had not worked or received the in-service will complete it upon the next scheduled work shift. All newly hired nurses or medication aides will be educated during orientation by the Staff Development Coordinator regarding Controlled Substance Diversion. On 7/5/24, the Administrator notified the Director of Nursing her responsibility to monitor and to ensure all in-services are completed per the plan of correction. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained; and - 100 % of all ordered narcotic medications will be reviewed by the Assistant Director of Nursing 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 and there are no signs of drug diversion utilizing a Controlled Substance Audit tool. All areas of concern will be addressed during the audit including re-educating nurses. The DON will review and initial the audits weekly x 4 weeks then monthly x 1 month to ensure all areas of concern were addressed appropriately. - The Administrator or DON will present the findings of the Audit Tools to the Quality Assurance Performance Improvement (QAPI) Committee monthly for 2 months. The QAPI Committee will meet monthly for 2 months and review the audit tools to determine trends and/or issues that may need further interventions and the need for additional monitoring. Include dates when corrective action will be completed. - Corrective action was completed on 7/6/2024. Onsite validation of the facility's Plan of Correction was completed on 11/15/24. The initial audit results were reviewed. The in-service education record dated 7/5/24 was reviewed. Interviews with nurses and medication aides indicated they attended and/or received in-service training on misappropriation of controlled substances and handling of the medication cart and controlled substance medications. The follow-up audit results were reviewed. The QAPI meeting minutes were reviewed. The facility's completion date of 7/6/24 was validated.

Based on observations, record review, resident and staff interviews the facility failed to provide nail care for a dependent resident for 1 of 7 residents reviewed for activities of daily living (ADL) (Resident #18). The findings included: Resident #18 was readmitted to the facility on [DATE] with diagnoses that included dementia, Parkinson's disease, and early onset cerebellar ataxia (lack of voluntary coordination of muscle movement beginning at the cerebellum of the brain). A review of a care plan dated 5/5/22 revealed Resident #18 had activities of daily living and personal care deficit with interventions which included Resident #18 was totally dependent on staff for bathing and preferred bed baths. A review of a quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #18 was moderately cognitively impaired and was not coded for rejection of care. Resident #18 required total dependence with bathing and grooming An observation and interview with Resident #18 were conducted on 11/12/24 at 11:54 AM. Resident #18 was observed to have approximately half-inch long fingernails with jagged nails on both thumbs. Resident #18 could only respond with head movements to questions, and he nodded affirmatively that he wanted them trimmed. A review of the Electronic Health Record shower documentation from 11/10/24 until 11/12/24 revealed Resident #18 received bed baths on each day from Nurse Aide (NA) #1. An interview was conducted on 11/13/24 at 2:39 PM with NA #1. NA #1 stated Resident #18 was totally dependent on staff during bathing. She indicated she had given him a bath in the morning of 11/13/24 and cleaned his nails. NA #1 stated that Resident #18's nails were not at a length where they needed to be trimmed. An observation and follow-up interview with NA #1 were conducted on 11/13/24 at 2:48 PM. Resident #18 was observed to have half inch-long fingernails with thumbnails jagged at either side. She stated she would cut his nails today. An observation and interview were conducted with Nurse #1 on 11/13/24 at 2:52 PM. Nurse #1 stated Resident #18's nails should have been cut due to a few jagged edges on the thumbnails. The Director of Nursing (DON) was interviewed on 11/14/24 at 12:36 PM. She stated she expected nails to be checked every time care was provided. The DON indicated nails should be cut/trimmed as needed, especially if they were jagged. She stated that Resident #18's nails should have been cut previously when observed to be jagged. During an interview with the Administrator on 11/14/24 at 2:46 PM, he revealed that if Resident #18's nails needed to be cut, then they should have been cut in a timely manner.

Based on observations and staff interviews the facility failed to discard expired medication that remained on the medication cart available for use. This was for 1 of 4 medication carts (Upper 300 Hall) reviewed for medication storage. Findings included: On 11/14/24 at 4:11 PM an observation of the Upper 300 Hall medication cart and interview with the Unit Manager occurred. The observation of the medication cart revealed an opened 355 milliliter (ml) bottle of Antacid Liquid medication with an expiration date of July 2024. The bottle contained liquid medication. An interview with the Unit Manager at that time indicated there was liquid medication remaining in the bottle. She reported this Antacid Liquid medication was expired and should not have been on the medication cart available for use. She stated she checked this medication cart weekly for expired medications and had last checked it on 11/11/24 or 11/12/24. She went on to say she must have missed this bottle. On 11/15/24 at 1:18 PM an interview with the Director of Nursing (DON) indicated the medication carts were monitored weekly by the Unit Manager for expired medications and these were discarded. She stated there should not be any expired medications on any medication carts available for use. On 11/15/24 at 1:57 PM an interview with the Administrator indicated there should not be expired medication on a medication cart available for use.

Based on record review and staff interviews the facility failed to ensure advanced directive information matched throughout the medical record for 1 of 1 resident (Resident #67) reviewed for advanced directives. Findings included: Resident #67 was admitted to the facility on [DATE]. Resident #67's electronic medical record revealed an active physician's order dated [DATE] that read DNR (Do Not Resuscitate). A review of Resident #67's paper medical chart revealed there was no advanced direction information in the paper medical chart. The facility did not have an additional notebook with resident DNRs at the nursing station. Resident #67's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #67 was cognitively intact. An interview was conducted on [DATE] at 8:38 A.M. with Resident #67. Resident #67 indicated she was unable to recall when, but she told someone at the facility she did not want her chest pumped or someone to breathe for her if her body stopped working. She stated she was unable to remember what it was called or who asked her about her code preference. An interview was conducted on [DATE] at 12:11 P.M. with Nurse #1. During the interview, Nurse #1 stated she was unfamiliar with Resident #67's code status. Nurse #1 explained if something happened and Resident #67's code status was needed, she would look in Resident #67's paper medical chart at the nurse's station to determine if CPR (Cardiopulmonary Resuscitation) was required to be administered. Nurse #1 looked in Resident #67's paper medical chart and stated there was no DNR paperwork on file. Nurse #1 stated if Resident #67's code status was needed, she would check Resident #67's paper medical chart at the nurse's station and without seeing an advanced directive, she would have started CPR (cardiopulmonary resuscitation) on Resident #67. An interview was conducted on [DATE] at 12:14 P.M. with Unit Manager #1. The Unit Manager looked in Resident #67's paper medical chart at the nurse's station and stated Resident #67's DNR form was not in the medical chart. During the interview, the Unit Manager stated DNR forms were kept at the nurse's station in the resident's paper medical chart. Unit Manager #1 explained Resident #67 had signed a DNR form and the form was placed in Resident #67's paper medical chart. She stated Resident #67 may have had an outside medical appointment and the DNR form was not returned to Resident #67's paper medical chart when she returned from the appointment. The Unit Manager stated Resident #67 had several appointments and she was unable to determine when the DNR form was misplaced. An interview was conducted on [DATE] at 12:45 P.M. with the Director of Nursing (DON). During the interview, the DON stated Resident #67's DNR form should be in her paper medical chart located at the nurse's station. The DON stated she was unsure why Resident #67's DNR was not located in her paper medical chart and explained the form may have been misplaced when Resident #67 had a medical appointment, and the form was removed to be transferred with her to the outside medical appointment. The DON further explained the assigned nurse when Resident #67 returned from her appointment was responsible to ensure the DNR was received and returned to Resident #67's paper medical chart. The DON was unsure when Resident #67's DNR form was misplaced, or which nurse was assigned Resident #67 when the form was misplaced.

Based on record review, observations, resident interview and staff interviews, the facility's Quality Assessment and Assurance Committee failed to maintain implemented procedures and monitor interventions that the committee had previously put in place following the recertification and complaint survey of 4/8/2022. This was for two recited deficiencies on the current recertification and complaint investigation survey of 9/01/23. The deficiencies included Baseline Care Plan (F655) and Resident Allergies, Preferences and Substitutes (F806). The continued failure during two federal surveys of record showed a pattern of the facility's inability to sustain an effective Quality Assurance Program. Findings included: This tag is cross-referenced to: F-655 Based on record review and staff interviews, the facility failed to develop and implement an individualized person-centered baseline care plan that included the use of an indwelling urinary catheter for elimination for 1 of 2 residents reviewed for urinary catheters (Resident #240). During the recertification and complaint survey of 4/8/2022, the facility was cited for failure to complete a baseline care plan within 48 hours for a newly admitted resident. In an interview with the Administrator on 9/1/2023 at 1:13 p.m., he stated baseline care plans were added to the admission checklist for unit managers to ensure baseline care plans were started on new admissions. He explained the admission checklist was sent to Quality Assurance Performance of Improvement (QAPI) to review for completion of tasks on the admission checklist. He stated all nurses were trained on how to initiate a baseline care plan, and care plans were reviewed in interdisciplinary (IDT) meetings. He reported since November 2022, there had been no issues identified with the initiation of a baseline care plan for new admissions. F-806 Based on record review, observations, resident interview and staff interviews, the facility failed to honor food preferences for 1 of 2 residents reviewed for food preferences (Resident #100). During the recertification and complaint survey of 4/8/2022, the facility was cited for failure to provide resident's food preferences as listed on the meal tray ticket for a resident. In an interview with the Administrator on 9/1/2023 at 1:13p.m., he stated there had been no concerns identified with residents not receiving their dietary preferences in Quality Assurance Performance of Improvement (QAPI) meetings. He explained due to the Dietary Manager being out of work for medical reasons and employment of some new staff members in the dietary department, he had assigned the Assistant Administrator to oversee the operations of the dietary department.

Based on record review, observations, resident interivew and staff interviews, the facility failed to honor food preferences for 1 of 2 residents reviewed for food preferences (Resident #100). Findings included: Resident #100 was admitted to the facility on [DATE]. Resident #100's care plan dated 4/25/2023 included a focus for nutrition with actual weight loss due to cardiac disease. Interventions included providing diet as ordered and referencing dietician evaluations and recommendations. Physician orders dated 5/2/2023 included an order for a regular texture no added salt diet and to encourage fluids and offered hydration periodically every day for hydration. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #100 was moderately cognitively impaired and independently fed herself after the meal tray was set up. Dietary documentation dated 7/18/2023 indicated Resident #100 was receiving a regular textured no added salt diet with thin liquids and was consuming 50-100% on her dietary meals. The dietary note warranted no nutrition concerns although Resident #100 had experienced a 11.3% weight loss in last 90 days because Resident #100's weight had stabilized in the last 30 days. There were no recommendations for dietary changes. On 8/30/2023 at 12:45 p.m., Resident #100 was observed sitting up in wheelchair eating lunch. Resident #100's meal ticket read regular diet, eight-ounce water, two eight-ounce teas and wants some kind of fruit every meal. There was no eight-ounce water and no fruit observed on the meal tray. There was only one eight-ounce tea observed on the meal tray. Resident #100 stated she had her own water pointing to her water container and requested two teas for her meal trays. She explained she usually only received one tea and stated instead of receiving fruit on the lunch tray, she received a cookie. On 8/30/2023 at 1:17 p.m. in an interview with Dietary Aide #1, she stated she was responsible for informing the dietary staff on the lunch serving line of the preferences listed on Resident #100's meal ticket. She explained she forgot and did not call out to the dietary staff for Resident #100 to get two glasses of tea and fruit for the lunch meal tray. O 8/30/2023 at 1:13 p.m. in an interview with Dietary Supervisor, she stated residents should receive requested items on the meal tickets unless the food items are not available and stated fruit and teas were available for lunch meal trays. She explained dietary staff on the serving line were informed fruit for the lunch tray was bananas, and there were plenty of teas to provide Resident #100 two teas because there were cups of tea left at the completion of the lunch meal trays. She said Resident #100 not receiving tea eight-ounce teas and fruit on the meal tray as indicated on the meal ticket was an error on the serving line. She explained there was new dietary staff members on the serving line, and she would re-educate the dietary staff on granting resident's preferences and checking resident meal trays against the meal ticket for accuracy. On 9/01/2023 at 11:17 a.m. in an interview with the Administrator, he stated Resident #100 should had received items listed as preferences on the meal ticket on the lunch meal tray. He stated he had not received any dietary concerns from Resident #100's family or the Resident Council with the dietary department not honoring resident preferences.

Based on record review, observations and staff interviews, the facility failed to discard a resident's unlabeled opened Humalog insulin vial from 1 of 3 medication storage rooms observed (Specialized Programming for Alzheimer's Related Care [SPARC] unit). Findings included: Resident #119 was admitted to the facility on [DATE]. Physician orders dated 7/25/2023 included an order for Humalog solution 100unit/ml (Insulin Lispro (Human) inject as per sliding scale subcutaneously before meals for diabetes mellitus: if 0-150=0 units, 151-200= 2 units, 251-250=4 units, 251-300=6 units, 301-350=8 units, 351-400 =10 units; 401+ =12 units or above. Call MD if patient symptomatic. The order stated to discard the medication 28 days after opening and to check the expiration date. The order for Humalog insulin was started on 7/25/23 and was discontinued on 7/31/23. A review of Resident #119's Medication Administration Record for July 2023 indicated blood glucose monitoring was conducted three times a day and blood glucose levels were recorded less than 150 requiring no Humalog insulin administration to Resident #119. On 8/30/2023 at 11:40 a.m. during observation of the medication storage area for the SPARC unit with Nurse #2, a vial of Resident #119's Humalog insulin was observed open in a medication bottle with no vial cap located on top of the vial in the medication storage area refrigerator. The manufacture's expiration date on the vial of Humalog insulin read 3/13/2026. A label on the Humalog insulin vial read to discard in twenty-eight days, and there was no open date indicated on the label. The label on the outside of the medication bottle indicated the vial of Humalog Insulin was dispensed from the pharmacy on 7/27/2023. On 8/30/2023 at 11:40 a.m. in an interview with Nurse #2, she stated she was unsure when Resident #119's vial of Humalog insulin was opened and based on the date the pharmacy dispensed the medication (7/27/2023), the vial of Humalog insulin was expired and discarded the vial of Humalog insulin into the sharp's container on the SPARC's medication cart. She said Resident #119 had not received any of the Humalog insulin and explained refrigerated medications in the SPARC unit medication storge area were checked weekly for expiration date. In a follow up phone interview with Nurse #2 on 9/1/2023 at 1:15 p.m., she stated on 8/30/2023 she was assigned to the SPARC unit medication cart and had not had a chance to check the medication refrigerator on the SPARC unit for expired medications. On 8/30/2023 at 11:42 a.m. in an interview with the Director of Nursing (DON), she explained Resident #119's vial of Humalog insulin should have been discarded when the physician's order was written on 7/31/2023 to discontinue Resident #119's order for Humalog insulin and stated medications in the medication storage areas were to be checked daily for expired medications. In a follow up interview with the DON on 9/1/2023 at 11:57 a.m., she explained there was no reason for Resident #119's vial of Humalog insulin to be opened because Resident #119 had not required the use of Humalog insulin since ordered. She stated they were unable to determine when and why the cap was removed from Resident #119's vial of Humalog insulin and open vials of Humalog insulin expired in twenty-eight days after opening.

Based on record review and staff interviews, the facility failed to develop and implement an individualized person-centered baseline care plan that included the use of an indwelling urinary catheter for elimination for 1 of 2 residents reviewed for urinary catheters (Resident #240). Findings included: Resident #240 was admitted to the facility on [DATE] and diagnoses included fracture right femur. The nursing admission assessment dated [DATE] at 10:37 p.m. recorded Resident #240's indwelling urinary catheter was draining clear yellow urine. Physician orders dated 2/2/2023 included providing urinary catheter care with soap and water every shift. Physician progress notes dated 2/3/2023 recorded use of the indwelling urinary catheter was due to Resident #240's inability to sit up and use a urinal after surgery of to the right femur. The baseline care plan dated 2/3/2023 for Resident #240 did not address the use of an indwelling catheter for urine elimination. On 9/01/2023 at 9:30 a.m. in an interview with Nurse #2, he stated the unit manager or assigned admission nurse on evenings and weekends started residents' electronic baseline care plans within forty-eight hours of admission. In a follow up interview on 9/1/2023 at 12:53 p.m., Nurse #2 explained Resident #240 was admitted to the facility late in the evening of 2/2/2023 and admission assessments were completed the following morning on 2/3/2023. He stated baseline care plans were based on items triggered on the admission assessment, and the indwelling urinary catheter should had been addressed on Resident #240's baseline care plan. Nurse #2 stated unit managers were responsible for checking the admission checklist which included the baseline care plan for completion of all items and stated asthe unit manager, he dropped the ball with Resident #240's baseline care plan. On 9/01/2023 at 12:00 p.m. during an interview with the Director of Nursing, she stated after Resident #240's admission process was completed, the unit manager was to check that the baseline care was started within forty-eight hours and included the use of the indwelling urinary catheter.

Based on record review and staff interviews, the facility failed to ensure a resident with a mental disorder had received a Preadmission Screening and Resident Review (PASRR) prior to admission to the facility for 1 of 4 residents reviewed for PASRR (Resident #100). Findings included: Resident #100 was admitted to the facility on [DATE] from another nursing home with a diagnosis of bipolar disorder. Resident #100 was discharged to the hospital on 3/18/2023 and was readmitted on [DATE]. The admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #100 was not considered by the state Level II PASRR process to have a serious mental illness. There were no Level II PASRR conditions marked for serious mental illness. The MDS indicated Resident #100's diagnoses included bipolar disorder. Resident #100 was noted as receiving an antipsychotic (treatment for mental health conditions) medication daily. Resident #100's care plan dated 4/22/2023 included a focus for the use of psychotropic drugs for diagnosis of bipolar disorder, and interventions included evaluating the effectiveness and side effects of psychotropic medications. The care plan did not include PASRR information. A psychiatric evaluation progress note dated 5/9/2023 recorded Resident #100 with a long history of bipolar disorder and treatment included administration of lurasidone, an antipsychotic medication used to treat mental health conditions like bipolar disorder. Physician orders dated 7/25/2023 included lurasidone hydrochloride 20 milligram tablet at bedtime for bipolar disorder. On 8/29/2023 at 2:33 p.m. the Administration provided a copy of Resident #100's PASRR Level II determination notification letter dated 3/15/2023. Resident #100's physical and mental needs had been evaluated and deemed nursing facility placement was appropriate for Resident #100. There was no end date or limitation unless Resident #100 had a change in her condition. On 9/1/2023 at 11:00 a.m. during an interview with the Admission Coordinator, she reviewed emails and information received from the transferring facility and stated they did not share any information indicating a new diagnosis for Resident #100 or submission of a Level II PASRR screening prior to her admission. She explained she ensured new admissions had a Level I PASRR, and Level II PASRR screenings were submitted by the Social Workers. On 9/1/2023 at 8:47 a.m. in an interview with MDS Nurse #1, she stated according to Resident#100's FL2 (Medicaid form) information, she had a Level I PASRR determination. She explained she had not received any information that Resident #100 had a Level II PASRR determination. On 9/1/2023 at 9:54 a.m. in an interview with Social Worker #1, she explained she was the assigned social worker for Resident #100 and did not have a Level II PASRR determination for Resident #100. She stated Resident #100 was admitted from another nursing home with a Level I PASRR noted on the FL2 form. Therefore, she did not think Resident #100 needed a Level II PASRR evaluation submitted for her diagnosis of bipolar disorder. She stated this was the first time she was seeing the Level II PASRR Determination Notification letter provided to the surveyor by the Administration on 8/29/2023. In a follow up interview with Social Worker #1 on 9/1/2023 at 11:04 a.m., she stated she was new to the position, and they were responsible for submitting Level II PASRR information for determination. She explained since Resident #100 had a diagnosis of bipolar disorder, she thought the transferring facility had completed the Level II PASRR screening process, and the Level I PASRR was current. She stated she should have checked the North Carolina Medicaid Uniform Screening Tool (NC MUST) system to confirm Resident #100 had been screened for a Level II PASRR determination. On 9/1/2023 at 10:51 p.m. in an interview with Social Worker #2, he stated based on the NC MUST report, the transferring facility submitted Level II PASRR information for Resident #100 on 3/9/2023 due to a change in condition. The report noted the Level II PASRR screening was completed and listed the start date as 3/15/2023. He explained the PASRR information printed on 8/29/2023 was different from information received from the transferring facility for Resident #100. He stated Resident #100's FL2 form recorded a Level I PASRR with a diagnosis of bipolar disorder on admission and a Level II PASRR evaluation should have been submitted. On 9/1/2023 at 10:00 a.m. in an interview with the Administrator, he explained the new Level II PASRR Determination Notification letter for Resident #100 was printed from the NC MUST program on 8/29/2023 by Social Worker #2. He explained it was after the PASRR information was requested they became aware of Resident #100's Level II PASRR status. He explained the transferring facility only provided Level I PASRR information for Resident #100. They thought since Resident #100 was being admitted from another nursing home she had been screened for Level II PASRR by the other facility and remained a Level I PASRR. He stated Resident #100 had arrived on 3/15/2023 at 1:00 p.m. and he understood the transferring facility received the Level II PASRR information at 3 p.m. on 3/15/2023 but did not call or email the facility to share the information. He said the facility was not aware of the Level II PASRR for Resident #100 until 8/29/2023. In a follow up interview on 9/1/2023 at 11:10 a.m., the Administrator stated residents' diagnoses warranting Level II PASRR screening were discussed in the interdisciplinary morning meetings. He explained if Resident #100 had transferred in from the hospital initially, her diagnosis of bipolar disorder would have triggered a Level II PASRR screening, but because she transferred from another nursing home facility, a Level II PASRR was not triggered for initiation. He stated the transferring nursing home failed to share the information about Resident #100's Level II PASRR Screening results with them and this facility did not verify Resident #100's Level II PASRR status in the NC MUST program.

Based on observations, interviews with facility staff and the physician and record review the facility failed to prevent a severely cognitively impaired resident (Resident #102) from exiting the facility without supervision for 1 of 2 residents reviewed for accidents. Receptionist #1 let Resident #102 out of the locked front door, without notifying nursing staff and he was left outside unattended and out of visual sight of the facility staff. There was a high likelihood of Resident #102 suffering serious harm. The findings included: Resident #102 was admitted to the facility on [DATE]. His diagnoses included [CONDITION(S)] without behavioral disturbance, repeated falls, and [CONDITION(S)]. The Care Plan focus dated 11/8/21 for Resident #102 documented he had chronic progressive decline in intellectual functioning characterized by a decline in memory, judgement, decision making, and thought processes. Another Care Plan focus dated 11/9/21 documented Resident #102 had wandering and was at risk for unsupervised exits from the facility related to new admission. The interventions included to allow him to wander on the unit, to document episodes of wandering per facility protocol. The Care Plan focus revised on 12/3/21 documented Resident #120 was at risk for falls characterized by a history of actual falls related to impaired mobility, psychoactive medications, and decreased safety awareness. The interventions included to assist him to negotiate barriers as necessary and brake extenders for visual cues to lock wheelchair. The most recent fall risk assessment dated [DATE] indicated Resident #102 was at high risk for falls. A Wandering Risk Evaluation dated 2/8/22 completed by Nurse #5 indicated Resident #102 was not at risk. He had no known history of attempts to leave the facility or wander. He was ambulatory and or self-mobile by wheelchair with mild cognitive loss. Resident #102 had no verbal statements of desire or intent to leave the facility. The quarterly Minimum Data Set (MDS) dated [DATE] indicated Resident #102 was severely cognitively impaired. He was usually understood and usually understands. He had behavioral symptoms not directed towards other for 1-3 days. Resident #102 had no rejection of care or wandering. He required supervision for walking in his room and locomotion on the unit. He required extensive assistance for locomotion off the unit. Resident #102 was not steady but able to stabilize without staff assistance for moving from seated to standing position, walking, turning around and surface to surface transfers. He had no range of motion impairment. He had one fall with no injury since the last MDS assessment. Nursing notes entered into the electronic medical record by Nurse #10 on 3/25/22 (late entry note) documented on 3/22/22 Resident #102 was noted outside of the building by the sidewalk by the Main Entrance sign by another nurse (Nurse #1) at approximately 7:30 PM. The note revealed the nurse brought Resident #102 back to the unit where the resident's room was located. A head to toe assessment was completed and no injuries were noted. A wander guard (an electronic alert system that alarms and locks the facility exit doors when cognitively impaired residents with wandering behaviors attempt to exit the building) was placed to resident's left ankle. Resident was assisted to bed and was placed on 1 to 1 observation. On 4/7/22 at 2:44 PM Receptionist #1 who worked the 3:00 PM to 11:00 PM shift on 3/22/22 stated Resident #102 wheeled himself in his wheelchair into the lobby around 6:00 PM where he remained for approximately 1 hour. Receptionist #1 indicated the lobby doors were locked at all times and required a code to open the doors. She said a family member visiting a different resident needed to be signed out so they could leave the building, so she documented the time on the log then put in the code to unlock the front door to let the person out. She said after the door closed Resident #102 asked if he could go outside. Receptionist #1 said she then entered the code to unlock the door a 2nd time and allowed Resident #102 out of the front door at approximately 7:00 PM. She said she saw Resident #102 turn right out of the doorway to remain on the sidewalk then she returned to her desk in the lobby. She said from her desk she could not see Resident #102 and she did not know where he went. Receptionist #1 did not inform the nursing staff she let him outside. Receptionist #1 reported approximately 10 minutes later a staff member (Nurse #1) brought Resident #102 back into the building and asked Receptionist #1 if she allowed the resident out of the building. Receptionist #1 told the staff member no she did not let Resident #102 out of the building because she thought she would get in trouble. Later she received a phone call from the Administrator, and she told the Administrator she did let Resident #102 out of the front door. Receptionist #1 stated she was not aware Resident #102 was cognitively impaired and was not safe to go out of facility without supervision. She said she had not received education prior to the 3/22/22 incident about how to identify residents who were unsafe to go out of the facility without supervision. On 3/22/22 at 7:10 PM the temperature was approximately 70 degrees Fahrenheit (www.wunderground.com). Sunset occurred at 7:20 PM (www.sunrisesunset.com). An observation of the front lobby area on 4/7/22 at 2:10 PM revealed the receptionist desk was located 15 feet from the front door. The desk was facing the front door. A telephone interview was conducted with Nurse #1 on 4/7/22 at 12:34 PM. Nurse #1 stated she worked on Unit 2 on the 3:00 PM-11:00 PM shift on 3/22/22. She said she was returning to the facility from her break time at approximately 7:10 PM and as she was turning her vehicle into the parking lot, she saw Resident #102 seated in his wheelchair near the blue Main Entrance sign. Nurse #1 stated she parked her vehicle then walked up to Resident #102. She said he was facing the street with the sign and the building at this back. She stated Resident #102 had his television remote control up to his left ear as if it was a telephone. Nurse #1 asked Resident #102 why he was outside, and he responded he was waiting for his son. She then told Resident #102 he should wait inside the building. Nurse #1 stated she pushed him in his wheelchair back into the building and then to his assigned unit (Unit #1). Nurse #1 said she did not see Resident #102's nurse but she told someone, although she was unable to recall who she told, he was found outside the building. Nurse #1 said Resident #102 was not safe to be outside unsupervised. She added Resident #102 normally talked like he was coherent, but he was not cognitively intact. Nurse #1 then said she was previously told during a shift report that Resident #102 was a fall risk so if he tried to transfer out of the wheelchair he could fall. A measurement of the exterior of the building on 4/7/22 at 9:00 AM with the Therapy Director revealed the distance of the sidewalk from the lobby exit door to the end of the sidewalk where the Main Entrance sign was located measured 119.5 feet in length. The sidewalk was parallel to the building. An observation on 4/7/22 at 2:00 PM of the left edge of sidewalk which was adjacent to the pavement of the driveway to the front entrance varied from 0 inches closest to the front entrance to 6 inches approximately 6 feet from the blue Main Entrance sign where the resident was observed. The sidewalk was 120 feet from the city street. The speed limit for the city street was 35 miles per hour. During a telephone interview with Nurse #2 on 4/7/22 at 11:00 AM he reported he was working 3:00 PM to 11:00 PM on 3/22/22 and Resident #102 was on his assignment. Nurse #2 stated he saw Resident #102 on the 400 hall, so he gave Resident #102 his medications. (Resident #102's room was on the 100 hall.) Nurse #2 added Resident #102 usually went to bed around 7:30 PM so he was giving the resident his medications prior to going on his break time. Nurse #2 stated the nursing supervisor called him on his telephone while he was on break to tell him Resident #102 had gotten out of the facility. Nurse #2 stated Resident #102 was not safe to be outside alone and if the resident had asked him to go outside, he would not have allowed him to be out of the building unsupervised. On 3/22/22, following the incident, Nurse #10 also completed a Wander risk evaluation on 3/22/22 which indicated Resident #102 was at high risk for wandering. Resident #102's physician was interviewed on 4/7/22 at 1:39 PM. The physician stated Resident #102 was a high risk for falls due to his severe dementia. He stated he was informed by the Director of Nursing that Resident #102 was outside of the facility alone on 3/22/22. The physician stated Resident #102 should not be out of the building without supervision due to his dementia and high risk for falls. He could have gone into the street or could have fallen on the concrete. On 4/8/22 at 9:30 AM the Administrator stated the facility identified that Receptionist #1 allowed a cognitively impaired resident out of the building on 3/22/22, so they began education with Receptionist #1 and then the other facility staff including the other receptionist. He stated they updated the Wander Identification Book which would be kept at the reception area. He said the book contained pictures of the residents who were consider at risk for wandering and should not be allowed out of the building unsupervised. He said Resident #102 was not listed in the book until it was updated after he was found outside the building. An observation of Resident #102 on 4/4/22 at 1:11 PM revealed he was in the hall near nursing station #1. He was seated in his wheelchair and was holding a white plastic bag. During the observation Resident #102 stated he needed to go somewhere. Resident #102 was wearing a wander alarm band on his ankle. The facility provided the following corrective action plan with a completion date of 3/25/22. · Resident #102 was in the front lobby around 7:00 pm on 3/22/22 and asked permission to step outside. The resident was allowed to go outside by Receptionist #1. The resident's last wandering assessment on 2/8/22 had identified him as not at risk. The wandering assessment completed on 3/22/22 identified him as at risk, he was placed on 1:1 monitoring, and a wander guard was placed. The Wandering Book was updated to include this resident's picture. The resident was allowed to exit due to a lack in knowledge of the receptionist to check with the nurse prior to letting the resident outside unsupervised. The resident was placed on 1:1 for 24 hours to ensure no more exit seeking behaviors and that the wander guard intervention was effective. · On 3/22/22 100% head count of all residents were completed by the assigned hall nurses to ensure all residents were present and accounted for. This included wandering risk residents and severely cognitive impaired residents. There were no other concerns. · On 3/22/22 100% of all residents to include severely cognitive impaired residents wandering assessments were redone by the Nursing Supervisor. This was to ensure assessments were completed accurately and appropriate interventions were put into place for residents with elopement risk. This audit was completed on 3/23/22. · On 3/22/22 the Nursing Supervisor started staff questionnaires regarding: Do you know of any residents that has verbalized wanting to leave the facility and/or is exit seeking. The questionnaire was completed with 100% of all staff on 3/25/22. · On 3/22/22 an Inservice was started by the Administrator with Receptionist #1 regarding: unsupervised exits to include staff should never assist the resident out of the facility unless they have checked with the nurse to ensure the resident is not at risk for wandering and checking the elopement book. The in service was completed on 3/25/22. · On 3/22/22 an Inservice was started by the Nursing Supervisor with all facility staff on unsupervised exits to include staff should never assist the resident out of the facility unless they have checked with the nurse to ensure the resident is not at risk for wandering. The Inservice was completed on 3/25/22. All newly hired employees will receive the Inservice by the Nursing Supervisor or Director of Nursing during orientation. · On 3/24/22 100% of wander guards and door alarms were checked by the Maintenance Director as a precaution to ensure alarms were functioning properly and being monitored per facility protocol. There were no issues identified during the audit. · On 3/25/22 the wander guard book at the receptionist desk was updated by the Administrator to ensure all residents at risk for wandering to include wandering severely cognitively impaired residents are identified. · The nursing administrative team will interview 10 staff weekly for 4 weeks to identify any residents to include severely cognitively impaired residents that may be at risk for wandering and ensure the elopement book at the receptionist desk is updated and interventions initiated. · A Quality Assurance meeting was held on 3/22/22 to discuss the plan of correction. · The Administrator and Director of Nursing are responsible for implementing the plan of correction. An onsite validation was completed on 4/8/22 through staff interviews and record review. Staff were interviewed to validate the in-service education was completed on using the Wander Identification Book and communicating with the nurse prior to allowing a resident out of the building without supervision. A record review revealed the facility was interviewing staff to ensure the staff were identifying residents who may have wandering behaviors. The facility's corrective action plan was validated to be completed as of 3/25/22.

Based on record review, resident and staff interviews the facility failed to provide sufficient staffing to assist with Activities of Daily Living (ADL) care for residents (Resident #106, Resident #77, Resident #21 and Resident #114) who were dependent on facility staff for ADL care. This affected 4 of 42 residents reviewed for staffing. Findings included: Review of the working schedules for March 2022 revealed there were 2 Nursing Assistance (NA) scheduled on the 7:00am to 3:00pm shift for approximately 44 residents on the following dates, March 19 and 27. The working schedules for March 2022 also showed there were 3 NAs scheduled for approximately 44 residents on the following dates, March 6 - 7:00am to 3:00pm, March 19 - 3:00pm to 11:00pm and March 25 - 7:00am to 3:00pm. During an interview with NA #10 on 4-7-22 at 1:39pm, the NA stated She had been assigned to Resident #106, Resident #77, Resident #21 and Resident #114 during the month of March. She discussed on the weekends there were usually only 2 NAs for approximately 44 residents, and she was unable to provide baths to all the residents assigned to her. NA #10 also said when there were only 2 NAs present, the nurses were supposed to help with ADL care but that did not occur. NA #1 was interviewed on 4-7-22 at 5:10pm. The NA stated he was unable to document or provide scheduled showers on the weekends due to only 2 NAs scheduled for the shift. He also discussed the 11:00pm to 7:00am shift stating he worked the night shift and there were usually only 2 NAs for approximately 44 residents. An interview with the facility scheduler occurred on 4-8-22 at 10:06am. The scheduler discussed trying to over staff each shift because she was aware there would be staff call outs. She discussed if the call outs occurred before 5:00pm, she would ask staff to stay over to work an extra shift and she would call the agency to see if there were staff available. The scheduler stated if the call outs occurred after 5:00pm, the nurse on call would be responsible for arranging coverage. She confirmed, if the facility was unable to arrange coverage, each staff present would be expected to care for up to 20-22 residents. The scheduler discussed March 19 and 27 and confirmed only 2 NAs were scheduled but stated the floor nurses were expected to assist the NAs in providing ADL care. During an interview with the Director of Nursing (DON) on 4-8-22 at 11:20am, the DON stated the facility was in the process of trying to hire more staff. She discussed care not being completed was a problem and she was aware the floor nurses were not assisting the NAs in providing ADL care. The DON said she was working with staff to work together as a team. The Administrator was interviewed on 4-8-22 at 12:30pm. The Administrator stated financially the facility was over staffed and there were enough staff to provide care to the residents.

Based on observations, record review and staff and physician interviews the facility failed to apply a left knee brace as recommended by physical therapy (PT) services (Resident #75) and failed to apply a hand roll and elbow brace (Resident #9) for 2 of 2 Residents reviewed for positioning and mobility. This placed Resident #75 and Resident #9 at risk for a decrease in range of motion. Findings included: 1. Resident #75 was admitted to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] A review of the 03/14/2022 quarterly Minimum Data Set (MDS) assessment for Resident #75 revealed she was severely cognitively impaired. She rejected care on one to three days of the seven day look back period of the assessment. Resident #75 required extensive 2 person assistance for bed mobility. She required the extensive assistance of one person for dressing. She did not walk. She had no functional limitation in the range of motion of her lower extremities. It further revealed Resident #75 received physical therapy (PT) for a total of 169 minutes in the last 7 days beginning on 03/08/2022. A review of the PT Daily Treatment Note for Resident #75 dated 03/08/2022 revealed the treatment diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . She was discharged from therapy services on 03/29/2022. A review of a Functional Maintenance Recommendations form dated 03/29/2022 for Resident #75 revealed recommendations by PT to encourage range of motion (ROM) to bilateral lower extremities during activities of daily living (ADL) care and for Resident #75 to wear her left knee extension brace up to 6 hours. The form was signed by Nurse Aide (NA) #7, NA #8, and the Therapy Director on 03/29/2022 indicating in-service training related to the application of Resident #75's left knee brace was provided to NA #7 and NA #8 on that date. On 04/04/2022 at 2:39 PM Resident #75 was observed in bed. She was not wearing a left knee brace. No brace was observed in Resident #75's room. On 04/06/2022 at 8:53 AM Resident #75 was observed in bed. She was not wearing a left knee brace. No brace was observed in her room. On 04/06/2022 at 1:09 PM an interview with the Therapy Director indicated Resident #75 was discharged from therapy services on 03/29/2022 with the recommendation for her to continue wearing her left knee extension brace for up to 6 hours daily as tolerated. She went on to say she provided training to NA #7 and NA #8 on 03/29/2022 and the Functional Maintenance Recommendation form was provided to Unit Manager (UM) #1 either that day or the following day. The Therapy Director indicated she normally would train the NAs and Nurse regularly assigned to Resident #75 but NA #7 and NA #8 were the only people available to train that day. She indicated NA staff were to apply Resident #75's knee brace. She went on to say UM #1 was to place the recommendation on Resident #75's care plan for the NAs to carry out. On 04/06/2022 at 1:22 PM an observation of Resident #75 revealed she did not have her left knee brace on. An interview with NA #9 indicated she was regularly assigned to Resident #75 at least five days weekly and familiar with her care. She stated Resident #75 did have a left knee brace, but she had not seen it on her lately. She stated therapy staff applied Resident #75's brace. NA #9 went on to say the knee brace was kept in Resident #75's closet. She further indicated she had not been trained or instructed to apply it. She stated if NA staff were to apply a resident's brace it would appear on the resident's care plan which NAs had access to. On 04/06/2022 at 1:26 PM an interview with Nurse #6 indicated she was regularly assigned to Resident #75 five days weekly. She stated Resident #75 had been receiving therapy services but they had been discontinued. She went on to say Resident #75 had a left knee brace that therapy staff applied. She indicated she had not been instructed to apply Resident #75's left knee brace. Nurse #6 stated it was not on Resident #75's care plan. She stated she had not seen the brace on Resident #75 lately. On 04/06/2022 at 1:29 PM an interview with Unit Manager (UM) #1 indicated she received the Functional Maintenance Recommendation form for Resident #75 but could not recall when. She stated therapy staff normally gave these to her after residents were discharged from therapy and NA staff were trained. She went on to say Resident #75's form had been on her desk. She further indicated she tried to enter the recommendations onto care plans as soon as she got them but she had gotten behind on therapy recommendations and had not entered Resident #75's. A review of the comprehensive care plan for Resident #75 revealed a focus area initiated on 11/25/2021of activities of daily living (ADL). The goal last updated on 12/15/2021 was for Resident #75 to receive ADL care with staff support as required to maintain or achieve her highest practicable level of function through the next review. A goal initiated on 04/06/2022 was mobility functional maintenance, left knee extension brace up to 6 hours as tolerated. On 04/06/2022 at 1:36 PM an interview with MDS Nurse #2 indicated the Therapy Manager called her a few minutes ago and told her about Resident #75's left knee brace so she just added it to Resident #75's care plan. On 04/06/2022 at 1:45 PM an interview with Resident #75's Physical Therapist (PT #1) indicated Resident #75's PT treatment began on 03/08/2022 because of a contracture of her left knee. She stated this meant Resident #75 did not have full functional range of motion in her left knee and could not straighten it all the way. PT #1 went on to say Resident #75 continued to have this knee contracture on 03/29/2022 when Resident #75 was discharged from therapy services. She indicated Resident #75 was discharged from therapy with instructions to nursing staff to begin applying Resident #75's left knee extension brace for up to 6 hours a day five days a week as tolerated to prevent Resident #75's contracture from worsening. PT #1 stated she would expect NA staff to begin applying the knee brace as recommended the day they were instructed or the next day. She went on to say she would not expect it to take eight days for this to happen. PT #1 further indicated going that long without the application of her left knee brace put Resident #75 at risk for worsening of the contracture and further decrease in the range of motion of her left knee. On 04/26/2022 at 2:06 PM an interview with NA #7 revealed she did recall being instructed on the application of Resident #75's left knee brace by therapy staff although she could not recall the exact date. She stated she had not been instructed to pass this information onto anyone and had not done so. She stated she was rarely assigned to Resident #75 and had not applied her knee brace again since being trained. On 04/06/2022 at 2:21 PM an interview with NA #8 revealed she did recall being instructed on the application of Resident #75's left knee brace by therapy staff although she could not recall the exact date. She stated she was not instructed to pass this information on to anyone and had not done so. She went on to say she had not been assigned to Resident #75 since being instructed and had not applied Resident #75's left knee brace again since being trained. On 04/06/2022 at 2:47 PM an interview with the Director of Nursing (DON) indicated when Resident #75 was discharged from therapy services with the recommendation for nursing staff to continue the application of her left knee brace, UM #1 should have made sure this information was placed on Resident #75's care plan. She stated placing the information on the care plan would ensure NA staff caring for Resident #75 had access to the recommendation. She stated when the information was entered on the care plan it would then be available for the NAs to know they needed to apply the brace. The DON went on to say NA staff who were trained on the application of Resident #75's brace should have passed the information on in report to ensure continuity of care. She further indicated she did not feel eight days was a reasonable amount of time for this to happen. On 04/06/2022 at 2:56 PM a follow up interview with the Therapy Director indicated she assessed Resident #75's left knee contracture and there had been no decrease in her range of motion. She went on to say she also instructed Nurse #6 in the application of Resident #75's knee brace. 2. Resident #9 was admitted to the facility on [DATE] with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly MDS dated [DATE] revealed Resident #9 was moderately cognitively impaired. Resident #9's care plan dated 3-24-22 revealed a goal that activities of daily living/personal care will be completed with staff support to maintain or achieve highest level of functioning. The interventions for the goal were in part encourage resident to allow passive range of motion during care and encourage the resident to wear right elbow splint up to 3 hours and right hand roll up to 8 hours. A review of the NA care guide revealed instructions to the NA to apply a right elbow extension splint and a hand roll as tolerated. Resident #9 was interviewed on 4-4-22 at 10:55am. The resident stated she did not have any braces for her arm or anything for her hand. Resident #9 clarified she had not had any brace or hand roll applied. Observation of Resident #9 on 4-5-22 at 1:00pm revealed she did not have a hand roll or brace applied to her right upper extremity. On 4-6-22 at 12:50pm, Resident #9 was observed and revealed no brace or hand roll had been applied to her right upper extremity. During an interview with the Therapy Director on 4-6-22 at 4:05pm, the Therapy Director stated Resident #9 was supposed to have an elbow splint and a hand roll for her right upper extremity that was contracted. She discussed Resident #9 having difficulty wearing the elbow splint and would wear it for 3 hours at a time and the hand roll the resident would wear up to 5 hours. The Therapy director explained Resident #9's therapy ended in January 2022 and the NAs were educated on how to apply the elbow splint and hand roll. An interview with NA #3 occurred on 4-6-22 at 4:40pm. The NA confirmed she was familiar with Resident #9 but stated she was not aware the resident was supposed to have an elbow splint or hand roll applied. NA #3 stated she did see the instructions on Resident #9's care guide but thought therapy was applying the splint and hand roll. NA #4 was interviewed on 4-7-22 at 3:35pm. The NA stated she was familiar with Resident #9 but was unaware the resident was supposed to have an elbow splint or hand roll applied. She stated she had received training by one of the therapists today (4-7-22) on how to apply the elbow splint and hand roll. The facility Physician was interviewed on 4-7-22 at 1:21pm. The Physician stated applying the elbow brace and hand roll to Resident #9 was a low priority and explained due to the length of time the resident had [CONDITION(S)] he would not expect to see much improvement.

Based on observations, record review, and staff interviews the facility failed provide assistance with transfers and assistance with toileting (Resident #217), failed to keep dependent residents' fingernails clean (Resident #16, Resident #82, Resident #97, and Resident #88), and failed to provide baths (Resident #77, Resident #21, Resident #114, and Resident #106) for 9 of 10 resident reviewed for activities of daily living (ADL) care. Findings included: 1. Resident #217 was admitted to the facility 3/30/22. Her active diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #217 did not have a completed Minimum Data Set (MDS) assessment. Review of the completed Brief Interview for Mental Status (BIMS) signed 3/31/22 revealed she was assessed as cognitively intact. Resident #217's care plan dated 3/31/22 revealed she was care planned for activities of daily living care. The interventions included to provide one-person guidance and physical assistance with transfers and provide one-person physical extensive assistance for safety with toileting, adjusting clothing, washing hands, and pericare. During an interview on 4/4/22 at 3:06 PM Resident #217 stated early that morning she had to go to the bathroom. She rang the call bell around 6:00 AM. She was previously told not to get out of bed herself by therapy and the staff in the facility. After she had waited thirty minutes, she was able to reach her wheelchair and transferred herself to the wheelchair. She went to the door to the hall in order to turn the light on and a male nurse aide (NA #1) opened the door and said, What do you need? Resident #217 told NA #1 she needed to use the restroom and she had rung, and no one answered. He told her, well go. She informed him she was not supposed to transfer alone. She stated NA #1 then pushed her briskly into the bathroom and left without assisting her on to the toilet. He was gone before she could say anything to him. REsidnet #217 stated she transferred herslef to the toilet and went to the bathroom but could not transfer herself back to the wheelchair as the wheelchair was higher than the toilet seat and she was not supposed to transfer herself. Resident #217 said she turned on the call light in the bathroom. She pulled the call light three or four times, but no one came. She started yelling from the bathroom for help and banging the wall. After about fifteen minutes of shouting for help she started to cry, and NA#1 came in and asked sharply What's wrong? She told him she could not get off the toilet. He then attempted to assist her by her left arm but her left arm was swollen and painful due to a [CONDITION(S)] shunt issue, so she told him not to use her left arm for transfers. NA #1 then took ahold of her nightgown by her right shoulder in his hand and pulled her up by the night gown. Resident #217 said it was uncomfortable but enough support to help her transfer to the wheelchair. He brought her in the room and put her beside the bed and did not transfer her to the bed or assist with her transfer. Resident #217 stated NA #1 left the room quickly before she could ask for assistance back to the bed. She knew at that point she was not going to get help back to bed so she attempted herself. She was able to transfer herself to her bed and by that point her legs were shaking. She concluded it made her feel deeply concerned she was not going to get the care and assistance she needed in the facility and it caused her to cry. Resident #219 resided across the hall from Resident #217 and a review of her Minimum Data Set assessment dated [DATE] revealed she was assessed as cognitively intact. During an interview on 4/4/22 at 2:44 PM Resident #219 stated that morning for about 15 minutes a resident was shouting for help across the hall. The resident was shouting for someone to help her, banging on the walls, and crying. Eventually a staff member must have responded because the noise ended after 15 to 20 minutes. Review of the assignment sheet for the 11 PM to 7 AM shift for 4/3/22 through 4/4/22 revealed NA#1 was assigned Resident #217. During an interview on 4/7/22 at 4:52 PM NA#1 stated the morning of 4/4/22 Resident #217 had turned her call light on and he went to her room. She asked for assistance to the bathroom. He stated she was still in the bed, and he asked her how she needed assistance as it was his first time working with her. She asked him to guide her by her left arm to her wheelchair and then she could go to the bathroom. He assisted her by her left arm to the wheelchair and then they entered the bathroom he then assisted her by her left arm to the toilet and told her to ring the call bell when she was done, and he would give her privacy. He stated he then left. About 5 minutes later the resident rang the call bell from the bathroom and he returned when he saw the light turn on over her room. He stated she had transferred herself back to the wheelchair and was in her room. He stated while trying to transfer the resident back to bed, she indicated she was too weak, so he got assistance from NA#5. Together they were able to transfer the resident to her bed. During an interview on 4/7/22 at 5:33 PM NA#5 stated she did work on 4/3/22 through 4/4/22 and never assisted NA #1 with Resident #217. She further stated she did not like working with NA#1 because he would clock in to work and then disappear. She stated he did not answer his call lights and would have a bad attitude in order to avoid work. The nurse aide concluded she would spend the shift working with NA#1 answering his call lights and providing care in order to assure his residents as well as her own received care. During an interview on 4/8/22 at 7:58 AM Nurse #4 stated NA#1 was always late and always had complaints from his residents about him. Nurse #4 filed grievances about NA#1 on behalf of the residents. NA#1 was fired from the facility a long time ago and came back with an Agency. NA#1 was then identified as do not return to the facility with his agency but when the Administrator changed, NA#1 would return through an agency. The nurse would inevitably have to file a grievance about NA#1 for a resident and the nurse aide would be labeled as do not return again. This had happened multiple times. During an interview on 4/8/22 at 9:34 AM the Director of Nursing stated nurse aides should assist with transfers and activities of daily care in accordance with their plan of care. Based on the information provided she felt this was an activities of daily living concern for Resident #217 and she would follow up with the resident and the nurse aide. 2. Resident #16 was admitted to the facility on [DATE]. His active diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #16's quarterly minimum data set assessment dated [DATE] revealed he was assessed as severely cognitively impaired. He had no moods and no behaviors. He was totally dependent on one staff member for personal hygiene. A review of Resident #16's care plan dated 2/16/22 revealed he was care planned for activities of daily living care. The interventions included to provide extensive physical assistance with personal hygiene. During observation on 4/4/22 at 12:24 PM Resident #16 was observed to have black debris caked under his fingernails. During observation on 4/5/22 at 10:00 AM Resident #16 was observed to still have black debris caked under his fingernails. During an interview on 4/5/22 at 10:09 AM NA #6 stated Resident #16's fingernails were very dirty and did have black debris caked under the nails and should have been cleaned. She stated she had never known Resident #16 to refuse care and she would clean them that morning when she provided his bed bath. During observation on 04/05/22 10:10 AM NA #6 was observed to ask Resident #16 if his nails needed to be cleaned and if he would let her. Resident #16 nodded and smiled. During an interview on 4/5/22 at 10:14 AM Nurse #4 observed Resident #16's fingernails and stated they should have been cleaned before now as they had black debris caked under the nails. He concluded Resident #16 never refused care in his experience. During an interview on 4/5/22 at 10:15 AM the Director of Nursing, upon observing Resident #16's nails, stated his nails should have been cleaned prior to now as they had black debris caked under the fingernails. During an interview on 4/5/22 at 10:52 AM the Cooperate Clinical Director stated cooperate staff had rounded this morning on 4/5/22 and identified multiple residents with nail concerns and Resident #16 was one of the residents identified to have not received proper nail care. She concluded staff had not gotten around to cleaning his nails yet. 3. Resident #82 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly MDS dated [DATE] indicated Resident #82 was cognitively intact. She had no behaviors. She required extensive to total assistance with activities of daily living. The care plan focus area of bathing last updated 9/15/20 and indicated Resident #82 was totally dependent on staff for bathing. On 4/4/4/22 at 2:30 PM Resident #82 was observed to have dirty fingernails on both hands. The fingernails were caked with dark brown and black debris. On 4/4/22 at 2:30 PM Resident #82 stated she did not know when her fingernails were last cleaned. She reported she had received her bed bath this morning and the previous morning. On 4/5/22 at 11:00 AM Resident #82's fingernails continued to contain dark brown and black debris. On 4/5/22 at 11:05 AM NA #2 observed Resident #82's fingernails. NA #3 stated the fingernails were dirty and needed to be cleaned. On 4/5/22 at 11:15 AM Nurse #11 observed Resident #82's fingernails. She stated the Residents' fingernails were dirty and also needed to be trimmed because they had jagged edges. Nurse # 11 then said the NA can clean the fingernails and should report to the nurse if the fingernails need to be trimmed since Resident #82 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] On 4/5/22 at 2:29 PM the Director of Nursing (DON) said she expected resident's fingernails to be kept clean even if the resident only received a bed bath. She added NAs and nurses should notice if fingernails are dirty or long and clean and trim them as soon as possible. 4. Resident #97 was admitted to the facility on [DATE], Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The annual MDS dated [DATE] indicated Resident #97 was moderately cognitively impaired. She had rejection of care 1-3 days. She required extensive assistance for dressing, toilet use and personal hygiene. She was totally dependent on staff for bathing. On 4/5/22 at 10:34 AM Resident #97 was observed to have brown and black debris under her fingernails. On 4/7/22 at 12:04 PM Resident #97 stated she received a bath last night and her hair was washed. She said her nails were not cleaned during her bath and an observation during the interview revealed her fingernails continued to contain brown and black debris. On 4/8/22 at 12:06 PM an observation of Resident #97's fingernails revealed they continued to contain brown and black debris. The fingernails were now noted to be jagged. On 4/8/22 at 12:49 PM NA #15 stated she had enough time to give residents a bath but often did not have time to clean or trim a resident's fingernails. On 4/5/22 at 2:29 PM the Director of Nursing (DON) said she expected residents' fingernails to be kept clean even if the resident only received a bed bath. She added NAs and nurses should notice if fingernails are dirty or long and clean and trim them as soon as possible. 5. Resident #88 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The annual MDS dated [DATE] indicated Resident #88 was moderately cognitively impaired. She required extensive assistance with activities of daily living except she was totally dependent on staff for toileting and bathing. On 4/4/22 at 12:56 PM Resident #88 was observed to have brown and black debris under the fingernails of both hands. Her fingernails were noted to be more than ¼ inch in length. On 4/5/22 at 11:08 AM NA #2 observed Resident #88's fingernails. NA #3 stated the fingernails were dirty and needed to be cleaned. She stated Resident #88 had diabetes so she the nurse was responsible to trim her fingernails. On 4/5/22 at 11:18 AM Nurse #11 observed Resident #88's fingernails. She stated the Residents' fingernails were dirty and also needed to be trimmed because they were long. Nurse #11 then said the NA can clean the fingernails and should report to the nurse if the fingernails need to be trimmed since Resident #88 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] On 4/5/22 at 2:29 PM the DON said she expected residents' fingernails to be kept clean even if the resident only received a bed bath. She added NAs and nurses should notice if fingernails are dirty or long and clean and trim them as soon as possible. 6. Resident #106 was admitted to the facility on [DATE] with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #106's care plan dated 2-27-22 revealed a goal that she would be neat, clean and odor free. Maintain good oral hygiene. The interventions for the goal were in part bathing required total dependance with one person, provide intermittent supervision, repetitive cues, aid with set up of oral/dental supplies. The significant change Minimum Data Set (MDS) dated [DATE] revealed Resident #106 was cognitively intact and required extensive assistance with 2 people for bed mobility, total assistance with one person for transfers, bathing and toileting, extensive assistance with one person for personal hygiene. Review of the March 2022 ADL documentation revealed there was no documentation of baths/showers being provided for the following dates, March 3, 19, 20, 22, 24, 27. Resident #106 was interviewed on 4-4-22 at 12:00pm. The resident discussed not receiving a bath on a regular basis and stated her baths were not provided mostly on the weekends. During an interview with NA #10 on 4-7-22 at 1:30pm, the NA confirmed she was assigned to Resident #106 most of the days in March. She stated if the missing documentation for a bath/shower was on a weekend (March 19, 20, & 27) she did not provide a bath or shower to Resident #106 due to not having enough staff. NA #10 said on March 3, 22 and 24 she probably had provided a bath/shower and forgot to document. The Director of Nursing (DON) was interviewed on 4-8-22 at 11:20am. The DON stated ADL care not being provided to the residents was a problem and she was aware the nurses were not assisting the NA's when there were not enough NA's present to complete ADL care. The DON discussed the facility trying to hire more staff to alleviate the care issue. 7. Resident #77 was admitted to the facility on [DATE] with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #77's care plan dated 2-7-22 had a goal of ADL/personal care would be completed with staff support. The interventions for the goal were in part bathing extensive assistance with one person. The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #77 was cognitively intact and required extensive assistance with one person for bed mobility, transfers, dressing, toileting and personal hygiene and total assistance with one person for bathing. Review of Resident #77's ADL documentation for March 2022 revealed no documentation the resident received a bath/shower on the following dates, March 3, 10, 15, 19, 20, 24, 27. Resident #77 was interviewed on 4-4-22 at 11:35am. The resident stated she felt the facility was short staffed because there were many days, she did not get a bath or shower and the NA would tell her there were not enough staff to give everyone a bath. During an interview with NA #3 on 4-6-22 at 8:35am, the NA stated she may have been assigned to Resident #77 on one of the dates in March but could not remember. She said if there was not any documentation of a bath or shower provided, she probably was not able to complete the task because there were not enough staff. During an interview with NA #10 on 4-7-22 at 1:30pm, the NA confirmed she was assigned to Resident #77 most of the days in March. She stated if the missing documentation for a bath/shower was on a weekend (March 19, 20, 27) she did not provide a bath or shower to Resident #77 due to not having enough staff. The DON was interviewed on 4-8-22 at 11:20am. The DON stated ADL care not being provided to the residents was a problem and she was aware the nurses were not assisting the NA's when there were not enough NA's present to complete ADL care. The DON discussed the facility trying to hire more staff to alleviate the care issue. 8. Resident #21 was admitted to the facility on [DATE] with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly MDS dated [DATE] revealed Resident #21 was cognitively intact and required extensive assistance with one person for toileting and personal hygiene and physical help with one person for bathing. Resident #21's care plan revealed a goal that he would bath safely and appropriately. The interventions for the goal were in part requires set up help provided by staff. Review of Resident #21's ADL care documentation for March 2022 revealed there was no documentation of Resident #21 had received a bath on the following dates, March 3, 6, 9, 12, 17, 19, 20, 24, 25, 27. An interview occurred with Resident #21 on 4-4-22 at 12:15pm. Resident #21 discussed being mostly independent with his bathing but required help with set up and washing some parts of his body. He stated he had not received the help necessary to have a bath on a regular basis. During an interview with NA #3 on 4-6-22 at 8:35am, the NA stated she may have been assigned to Resident #21 on one of the dates in March but could not remember. She said if there was not any documentation of a bath provided on the weekend, she probably was not able to complete the task because there were not enough staff. During an interview with NA #10 on 4-7-22 at 1:30pm, the NA confirmed she was assigned to Resident #21 most of the days in March. She stated if the missing documentation for a bath/shower was on a weekend (March 12, 19, 20, 27) she did not provide a bath or shower to Resident #21 due to not having enough staff. The DON was interviewed on 4-8-22 at 11:20am. The DON stated ADL care not being provided to the residents was a problem and she was aware the nurses were not assisting the NA's when there were not enough NA's present to complete ADL care. The DON discussed the facility trying to hire more staff to alleviate the care issue. 9. Resident #114 was admitted to the facility on [DATE] with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly MDS dated [DATE] revealed Resident #114 was moderately cognitively impaired and required total assistance with one person for dressing, toileting personal hygiene and bathing. Resident #114's care plan dated 3-22-22 revealed a goal that Activities of ADL/personal care would be completed with staff support. The interventions for the goal were in part bathing total dependance with one person. Review of Resident #114's ADL documentation for March 2022 revealed there was no documentation Resident #114 received a bath/shower on the following dates, 1, 2, 3, 5, 6, 7, 9, 10, 14, 16, 19, 25, 26, 27, 28. Resident #114 was interviewed on 4-4-22 at 10:53am. The resident stated she did not receive a bath daily and emphasized especially on the weekends. During an interview with NA #3 on 4-6-22 at 8:35am, the NA stated she may have been assigned to Resident #114 on one of the dates in March but could not remember. She said if there was not any documentation of a bath provided on the weekend, she probably was not able to complete the task because there were not enough staff. During an interview with NA #10 on 4-7-22 at 1:30pm, the NA confirmed she has been assigned to Resident #114 in March 2022. She stated if the missing documentation for a bath/shower was on a weekend she did not provide a bath or shower to Resident #114 due to not having enough staff. NA #1 was interviewed on 4-7-22 at 5:10pm. NA #1 stated he had been assigned to Resident #114 in March 2022 but could not remember which days. He stated if there was not documentation of a bath/shower being provided then he had forgotten to document. The NA also stated if he had worked on a weekend, it was possible, he did not provide a bath or shower due to the number of residents he was assigned. The DON was interviewed on 4-8-22 at 11:20am. The DON stated ADL care not being provided to the residents was a problem and she was aware the nurses were not assisting the NA's when there were not enough NA's present to complete ADL care. The DON discussed the facility trying to hire more staff to alleviate the care issue.

Based on record review and staff, resident, and resident representative interviews the facility failed to invite a resident or resident representative to participate in the development or revision of the care plan for 5 of 8 residents reviewed for care plan meetings (Resident #91, Resident #16, Resident #46, Resident #97, and Resident #43). Findings included: 1. Resident #91 was admitted to the facility on [DATE]. His active diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #91's Minimum Data Set assessment dated [DATE] revealed the resident was assessed as cognitively intact. During an interview on 4/4/22 at 11:43 AM Resident #91 stated he had never had a care plan meeting but was not entirely sure what a care plan meeting was. During an interview on 4/6/22 at 8:15 AM Social Worker #1 stated Resident #91 was admitted [DATE] and there were two social workers who worked at the facility until early 2/2022. Resident #91 was on Social Worker #2's caseload, and he was unable to find any documentation of any care plan meetings with the resident. There was also no documentation of the resident being invited to any care plan meetings. He concluded he was unaware of any reason the resident did not have any care plan meetings or invitations to care plan meetings documented and could not speak to if a care plan meeting ever happened for Resident #91 due to lack of documentation. He stated when Social Worker #2 left in 2/2022 the facility began looking for another social worker and in the interim, he was keeping up with the whole building. Social Worker #1 concluded he was unaware the resident had not been having his routine care plan meetings. During an interview on 4/6/22 at 9:52 AM the Administrator stated in early 3/2022 they had identified care plan meetings as an issue due to the loss of a staff member. The facility was hiring for a new social worker and the current social worker had not completed the backlog of care plan meetings that had been missed. He stated currently they have letterheads they had implemented to invite residents and resident representatives to care plan meetings and had implemented a weekly calendar and the letters were sent out on Mondays. The Administrator concluded Resident #91 should have had a care plan meeting and been invited. Social Worker #2 was unavailable for interview. 2. Resident #16 was admitted to the facility on [DATE]. His active diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #16's Minimum Data Set assessment dated [DATE] revealed he was assessed as severely cognitively impaired. During an interview on 4/4/22 at 1:58 PM Resident #16's responsible party stated he was not aware of ever being involved in or invited to a care plan meeting. During an interview on 4/6/22 at 8:15 AM Social Worker #1 stated Resident #16 was admitted [DATE] and there were two social workers who worked at the facility until early 2/2022. Resident #16 was on Social Worker #2's caseload, and he was unable to find any documentation of any care plan meetings with the resident's responsible party as the resident was severely cognitively impaired. There was also no documentation of the resident's responsible party being invited to any care plan meetings. He concluded he was unaware of any reason the resident did not have any care plan meetings documented or invitations of the resident's responsible party to care plan meetings documented. He could not speak to if a care plan meeting ever happened for Resident #16 due to lack of documentation. He stated when Social Worker #2 left in 2/2022 the facility began looking for another social worker and in the interim, he was keeping up with the whole building. Social Worker #1 concluded he was unaware the resident had not been having his routine care plan meetings. During an interview on 4/6/22 at 9:52 AM the Administrator stated in early 3/2022 they had identified care plan meetings as an issue due to the loss of a staff member. The facility was hiring for a new social worker and the current social worker had not completed the backlog of care plan meetings that had been missed. He stated currently they have letterheads they had implemented to invite residents and resident representatives to care plan meetings and had implemented a weekly calendar and the letters were sent out on Mondays. The Administrator concluded Resident #16 should have had a care plan meeting and been invited. Social Worker #2 was unavailable for interview. 3. Resident #46 was readmitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The most recent Minimum Data Set (MDS) was a quarterly assessment dated [DATE]. The MDS indicated Resident #46 was cognitively intact. During an interview with Resident #46 on 4/5/22 at 10:54 AM she stated she had not attended a care plan meeting and had never heard of a care plan meeting or what it was for. On 4/6/22 at 8:59 AM Social Worker (SW) #1 stated he reviewed the documentation and there was no record of a care plan meeting for Resident #46. SW #1 said the care plan meeting should be scheduled after each MDS assessment was completed. He said the last MDS for Resident # 46 was dated 2/11/22 so there should have been a care plan meeting within 14 days of that MDS. SW #1 said SW #2 was responsible for this resident prior to 2/2022 when SW #2 was no longer employed by the facility. On 4/6/22 at 11:30 AM the Administrator reported the facility had identified care plan meetings were not being conducted since one of the two social workers left employment. He said the current social worker had not completed the backlog of care plan meeting that had been missed. This included resident #46. The Administrator stated care plan meeting should be scheduled and the residents or their responsible party should be invited to attend. 4. Resident #97 was admitted [DATE]. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The most recent MDS an annual MDS dated [DATE] indicated Resident #97 was moderately cognitively impaired. She was able to make herself understood and she was able to understand others with clear comprehension. On 4/5/22 at 2:03 PM Resident #97 stated she had not attended a care plan meeting. On 4/6/22 at 8:55 AM SW #1 stated there was no documentation of a care plan meeting for Resident #97. He said he review her medical record back to June 2021 and there were no notes about any care plan meetings. SW #1 stated the other SW left in February 2022 and SW #1 thought SW #2 had completed her assignments. He reported he just started conducting care plan meetings that were previously assigned to SW #2. SW #1 stated Resident # 97 must have been missed. On 4/6/22 at 11:35 AM the Administrator reported the facility had identified care plan meetings were not being conducted since one of the two social workers left employment. He said the current social worker had not completed the backlog of care plan meeting that had been missed. This included resident #97. The Administrator stated care plan meeting should be scheduled and the residents or their responsible party should be invited to attend. 5. Resident #43 was admitted to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] A review of the quarterly MDS assessment for Resident #43 dated 02/10/2022 revealed she was severely cognitively impaired. She required the extensive assistance of two people for bed mobility and extensive assistance of one person for dressing. It further revealed Resident #43 required the total assistance of one person for toileting, personal hygiene, and bathing. A review of her medical record revealed no evidence of care plan meetings or care plan meeting attendance signature sheets. On 04/04/2022 at 4:41 PM a telephone interview with Resident #43's family member revealed he was her Representative (RP). He stated although the facility kept him informed of any falls or other issues with Resident #43, he had not received any invitation to or participated in any care plan meetings. On 04/07/2022 at 9:46 AM an interview with SW #1 indicated Resident #43 had not previously been assigned to him. He stated he took over the assignments for all residents in February 2022. He went on to say normally care plan meetings were held based on a calendar the MDS Nurse sent out. SW #1 indicated he would send out the invitation letters to the scheduled care plan meetings to residents and their RPs. He went on to say he did not have any record of Resident #43's scheduled care plan meetings and had not sent her RP any invitation letters. On 04/07/2022 at 10:08 AM an interview with MDS Nurse #1 indicated she sent out the care plan schedule to the SW based the day a resident's MDS assessment was due. She stated Resident #43's 02/10/2022 MDS assessment date would have been on this care plan schedule but she did not keep any records of this. On 04/7/2022 at 5:43 PM an interview with the facility Corporate Clinical Director indicated the facility had no record of any care plan meetings or care plan meeting attendance sheets for Resident #43. She stated if a care plan meeting was held, there should have been documentation in the progress notes or a care plan meeting signature sheet to indicate who attended the meeting. On 04/08/2022 at 8:10 AM an interview with the facility's Mobile Administrator indicated she was the facility's previous Administrator and now served as a Mobile Administrator. She stated she thought she recalled a care plan meeting for Resident #43 in December 2021, although she could not recall the exact date. She stated she did not recall the names of the people who attended and there was no documentation of this and no care plan meeting signature sheets in Resident #43's record. She further indicated care plan meetings for residents should be held at least every 3 months and occur after any change in condition. She went on to say she was not aware of any other care plan meetings for Resident #43. On 04/08/2022 at 3:19 PM an interview with the Administrator indicated Resident #43 did not have care plan meetings as required. He stated due to the transition of administration and the loss of the social worker who arranged the meetings they had not happened.

Based on record review, observations and interviews with the resident and facility staff the facility failed to honor a resident ' s preference for time of day to receive a shower for 1 (Resident #39) of 3 reviewed for choices. The findings included: Resident#39 was admitted to the facility on [DATE]. The care plan initiated on 6/10/19 revealed Resident #39 required assistance for bathing related to impaired mobility and documented he preferred showers about 11:00 AM. The care plan again documented Prefers shower at around before lunch. The quarterly Minimum Data Set assessment dated [DATE] documented Resident #39 was cognitively intact. He required extensive assistance with most activities of daily living and was totally dependent for bathing. On 4/4/22 at 1:22 PM Resident #39 stated his shower schedule changed to the 3:00 PM to 11:00 PM shift because they did not have time on the 7:00 AM - 3:00 PM shift to give him a shower. Resident #39 also said his shower schedule was changed but he still does not get a shower when he wants one. On 4/8/22 at 9:13 AM Resident #39 said they changed his shower schedule about 3 months ago and he had been very unhappy since that happened. He stated he was never told why his shower schedule changed but he told the nurse aide he did not like it. He added he did not remember which nurse aide it was. Resident #39 said he felt he had to go with what they say. On 4/8/22 at 12:13 PM Nurse #4 stated he was unsure why the shower schedule changed but the schedule was based on the resident ' s room number, and he thought Resident #39 ' s shower schedule changed when he moved to his current room. On 4/8/22 at 2:20 PM the Director of Nursing stated she was unaware Resident #39 ' s shower schedule was changed, and she was not aware he preferred to have a shower on the 7:00 AM to 3:00 PM shift.

Based on staff, nurse practitioner, and physician interviews and record review the facility neglected to communicate, accurately track, document, assess and provide medical treatment as ordered for pressure ulcers on a resident's sacrum/buttocks area for 1 of 2 residents who was at high risk for wound development and experienced a significant change in wound condition (Resident #1). This resident's stage II pressure ulcer deteriorated to be an unstageable pressure ulcer, growing from 1.2 centimeters by 0.2 centimeters to 6 centimeters by 10 centimeters. Resident #1 was admitted to the hospital and was diagnosed with [REDACTED]. Findings included: Resident #1 was admitted to the facility on [DATE]. Resident #1's active [DIAGNOSES REDACTED]. A wound care note by the wound care nurse dated 6/11/2020 revealed two stage 2 pressure ulcers were found on Resident #1's buttock. Treatment was implemented and the responsible party was notified. Frequent turning was recommended while in bed. Limited time up in wheelchair was also recommended. Resident #1's physician's orders [REDACTED]. This order was unchanged until 8/10/2020 when Resident #1 was discharged to the hospital. The wound did not resolve prior to this discharge. A wound assessment dated [DATE] by the wound care nurse revealed pressure ulcer #1 to Resident #1's buttock measured 2.5 centimeters by 0.5 centimeters with less than 0.1 centimeters of depth. Pressure ulcer #2 on the resident's buttocks measured 1.0 centimeters by 0.5 centimeters with less than 0.1 centimeters of dept. They were both documented as stage II pressure ulcers with scant amounts of serosanguineous drainage. The wound beds were red, granular tissue. There was no documentation on pressure ulcer #2 after 6/11/2020. A wound assessment dated [DATE] completed by the wound care nurse revealed pressure ulcer #1 to Resident #1's buttock was measured. This wound was 0.4 centimeters by 1.0 centimeters with no depth. There was no drainage noted and the wound bed had a light brown scab. A wound assessment dated [DATE] completed by the wound care nurse revealed pressure ulcer #1 measured 1.2 centimeters by 0.2 centimeters and was a stage II pressure ulcer. It had scant amounts of serosanguineous drainage, dry red granular tissue on wound bed, and the area around the wound was emaciated. The wound assessments and nursing notes revealed there were no wound care measurements or notes for the pressure ulcer to her buttock from 6/24/2020 through 7/30/2020. Resident #1's quarterly minimum data set assessment dated [DATE] revealed she was assessed as severely cognitively impaired. She was assessed to have no pressure ulcers at that time. She required extensive assistance with bed mobility, transfers, locomotion on unit, dressing, eating, and personal hygiene. She was totally dependent on staff for toilet use. She was always incontinent of bowel and bladder. Resident #1's care plan dated 7/20/2020 revealed her pressure ulcer had not been addressed in the care plan. The treatment record for Resident #1 for June 2020 through July of 2020 revealed Resident #1 was not documented to have received wound care to her pressure ulcers on 6/12, 6/19 through 6/21, and 6/26 through 6/30. There was no treatment record documentation for July 2020. A wound assessment dated [DATE] completed by the wound care nurse revealed pressure ulcer #1 now measured 6 centimeters by 10 centimeters. It was documented now as a suspected deep tissue injury. The wound had moderate amounts of serosanguineous drainage. A wound note dated 8/6/2020 written by the wound care nurse revealed pressure ulcer #1 had 75% deep tissue injury, 25% granulation tissue, and moderate amounts of serosanguineous drainage from the wound. The wound care nurse documented no signs or symptoms of infection to the area. The treatment record for Resident #1 for August 2020 revealed Resident #1 was not documented to have received wound care to the pressure ulcer on her buttocks on 8/1 through 8/3, 8/5, 8/8, and 8/9. She was then discharged on [DATE] to the hospital. A nurse practitioner's visit note dated 8/10/2020 revealed Resident #1's nurse practitioner saw Resident #1 on 8/10/2020. She documented staff requested resident be seen for continuing decline with poor meal intake. Resident #1 showed continued evidence of physical and cognitive decline and due to this she was at high risk for developing pressure ulcers and weight loss among other complications. She ordered labs and had all medications held after assessment of the resident. Resident #1 was not awakened and was lying in bed with no distress. The nurse practitioner documented due to the multiple comorbidities and complexities; she was at high risk for complications. A communication note dated 8/10/2020 revealed Resident #1 sustained a change in condition with a blood pressure of 111/60, regular pulse of 92, respiratory rate of 20, temperature of 97.2, weight of 148 pounds, oxygen saturation of 95%, and blood sugar of 188. Her level of consciousness was altered. Resident #1 was lethargic and did not respond to tactile stimuli as she previously had. A new order was received to send Resident #1 to the emergency room . The hospital records dated 8/14/2020 revealed Resident #1 was admitted to the hospital on [DATE] with a [DIAGNOSES REDACTED]. She was transitioned to comfort care and passed away 8/13/2020. There were no measurements of the wound. The wound care nurse no longer worked at the facility and was unavailable for interview after multiple attempts to contact her. During an interview on 10/12/2020 at 10:42 AM Nurse #1 stated she remembered Resident #1. She stated the treatment nurse would perform wound treatment for [REDACTED]. She stated she thought she changed the wound dressing once otherwise she would notify the wound care nurse if she was in the facility. She stated when she cared for Resident #1 the wound on her coccyx was about 3 inches by 3 inches of necrotic tissue with red around the edges. She stated she did not inform the physician of the wounds or measure it as that was the responsibility of the treatment team. She concluded she did not remember discharging Resident #1 but must have been the nurse to discharge the resident since she documented it. During an interview on 10/12/2020 at 11:13 AM Nurse #2 stated she remembered Resident #1. She further stated she worked with Resident #1 regularly. She stated she was out for three weeks and when she came back on 8/10/2020 to the facility she asked Nurse #1 why Resident #1 was not behaving normally. She stated Resident #1 did not appear as she had prior to her leaving for three weeks. She stated she did not see the wound and how it had progressed, but she shared her concern with Nurse #1 who then got an order to send Resident #1 to the hospital. During an interview on 10/13/2020 at 11:38 AM Nurse Aide #2 stated she was very familiar with Resident #1 and was her regular nurse aide. She further stated she remembered many times in June and July of 2020 she would notice the dressing to Resident #1's buttock was soiled or not changed. She stated she would let the nurse know of the concern and it usually took one or two days of reminding the nurses the wound dressing to her buttock needed to be changed before they would change it. She stated she knew the dressings were old because the dates written on the dressing would be a couple days old or the soiled dressing remained soiled in the same way as when she first identified it was soiled two days prior. She stated eventually the nurse would get the wound care nurse to change the dressing and then it would happen again. She stated the wound smelled a little 'raw' and she reported this odor to the nurse as well. She stated she would report these concerns and the nurses would call the wound care nurse and then inform the nurse aide the wound care nurse was busy. She again stated it would usually take more than a day to get the wound care nurse to perform the dressing change. During an interview on 10/13/2020 at 10:03 AM Nurse Practitioner #1 stated she was Resident #1's primary nurse practitioner stated unless the treatment nurse informed her wounds for a resident were getting worse and needed a new order, she did not visualize the wounds. The nurse practitioner stated she did not think she visualized Resident #1's wound as the wound care nurse did not share any concerns about the wound deterioration with her. She stated the wound care nurse did not mention any concerns about the wound to Resident #1's buttock. She further stated she was not notified by the wound care or other nurses of this change in wound size. She stated with a change in the wound status from 6/24/2020 to 7/30/2020 it would have been helpful to be informed. She stated she was not informed by any staff of the change in size to Resident #1's pressure ulcer to her buttock. She concluded she did not remember the wound deterioration ever being brought to her attention. She stated with Resident #1's deterioration the main concern was Resident #1 was not eating well and not allowing herself to be turned and repositioned. It was a steady and continued decline in her status which resulted in her not eating, dehydration which lead to urinary tract infections and her advanced dementia. She stated the main concern with not being notified of this change in the wound is the wound care nurse did not realize or convey the need to change the wound care order in order to treat the pressure ulcer effectively. She concluded there appeared to be concerns with the wound care for Resident #1 after reviewing the measurements, however given her comorbidities and complexity with her deterioration prior to the development of the pressure ulcers, her outcome would not have changed with appropriate wound care. During an interview on 10/13/2020 at 1:56 PM Physician #1 stated he vaguely remembered the name of Resident #1 but did not remember her baseline condition in detail. He further stated he did not remember if it was ever brought to his attention that Resident #1 had pressure ulcers, but it was possible it was. He stated he did not recall being notified of any deterioration to the wound. He stated he did not recall visualizing the wound. He stated the nurses had a scope of practice and they had a protocol to follow. Resident #1 was clearly declining, and the outcome would not have change with wound care, therefore he did not feel it was critical the wound care nurse notified him about the deterioration of the wound. He stated with wounds it was always good to inform the nurse practitioner or physician of changes, however he did not believe it to be critical to inform in all cases including this resident who was declining. He concluded wound care should be performed as ordered. During an interview on 10/13/2020 at 2:26 PM the Director of Nursing stated they could not find the July 2020 treatment record for Resident #1. She further stated due to the missing treatment record for July as well as the missing documentation of treatments in June and August 2020 she could not say if Resident #1 received wound care or not as ordered by the physician. She further stated the wound care nurse should have been providing wound treatments per orders. She stated the treatment nurse should have notified the nurse practitioner or physician of the change in the wound condition. She stated the wound care nurse documented that she had notified the medical doctor and was unsure why it appeared the information did not reach the physician and nurse practitioner. The Director of Nursing stated as the orders were never changed, and both the physician and nurse practitioner did not indicate they were aware of the change in the wound it did not appear they were notified. She stated any change in condition should trigger the nurse to notify the physician or nurse practitioner including wound changes even if the resident was declining overall. She stated when she came to the facility July 13th, a plan of correction had already been put in place and she was informed there were wound concerns at the facility. She stated the assistant director of nursing was working with the wound care nurse because the wound care nurse clearly had issue with measure wound accurately as well as what wound dressing products should be used. The Director of Nursing stated she had a wound care nurse from a sister facility come and spend a day with the wound care nurse in the facility to go over every patient with her. The Director of Nursing stated this was done on 8/21/2020. She stated she then initiated meeting with the wound care nurse weekly to go over all residents and rounded with the wound care nurses to observe their technique. She stated the plan of correction completion date was 10/18/2020. The facility had identified the wound care nurse was not recognizing when to request wound care order changes, request wound center appointments, or knowledgeable of the products available for wound care. She concluded the assistant director of nursing and the wound care nurse no longer worked for the facility; however, the plan of correction had not been completed as of this date.

Based on observations, interviews with staff, resident, van driver, wound clinic staff, Physician, legal guardian, security officer and a citizen, viewing of security videos and record reviews the facility failed to accompany a cognitively impaired resident, who resided in the facility's secured memory care unit, to a medical appointment and failed to implement planned interventions to prevent falls for 2 of 8 sampled residents (Resident #399 and Resident #39) reviewed for supervision to prevent accidents. Resident #399 was dropped off at a wound clinic by a facility van driver and was left unsupervised at the clinic. The resident left the premises of the wound clinic and was located in the community with the involvement of security personnel and a local citizen. This resulted in Resident #399 being out in the community unsupervised by facility staff or her responsible party for one hour and twelve minutes which placed her at risk for serious injury and/or accidents. The resident was located without any apparent injuries and returned to the facility. The facility also failed to implement planned fall risk interventions for Resident #39. Immediate Jeopardy began on 3/4/2020 when Resident #399 was left by a facility van driver at a wound clinic appointment without supervision, the resident left the wound clinic in her wheel chair with an unknown man and for an hour and twelve minutes she was in the community in her wheel chair crossing road ways, going to a bank and a drug store, smoking a cigarette and interacting with people she did not know. Immediate jeopardy was removed on 3/7/2020 when the facility provided and implemented an acceptable allegation of Immediate Jeopardy removal. The facility remains out of compliance at a lower scope and severity of D (no harm with the potential for more than minimal harm that is not immediate jeopardy) to ensure monitoring systems put in place are effective. Example #2 related to Resident #39 was cited at a scope and severity of a D where a plan of correction is required. Findings Included: 1. The facility's missing resident policy dated 1/2009 read in part (2) out of facility search (a) search the grounds as assigned by the license nurse (b) after the initial search of the grounds is completed and resident's location is not determined, notify the law enforcement agency (c) notify the attending physician (d) notify the responsible party or legal representative (e) continue search procedure as indicated and directed (f) The administrator or designee will notify and or update the regional vice president of the occurrence, as appropriate (g) notify and or update Risk Management as directed by the Regional Vice President. (3) (a) document event as appropriate (b) document any injuries (c) complete the resident QI reporting form according to procedure including witness statements for the internal QI process. Resident #399 was admitted to the facility on [DATE] from the hospital with an order on motion for appointment of an interim legal guardian that was signed on 2/10/2020. The motion stated Resident #399 had experienced a mental and physical decline which resulted in several hospitalization s and surgeries in 2020. The motion specified the resident had very poor decision-making capacity, was unable to understand anything complex, and unable to appreciate any serious weighing of risks and benefits of potential interventions. The motion also stated the resident lacked the capacity to understand, complete, or sign a Medicaid application or admission paperwork. Resident #399's was admitted to the facility [DIAGNOSES REDACTED]. The Physician order [REDACTED].#399 could leave the facility as permitted by stable health status and accompanied by responsible party. The Wandering Risk assessment dated [DATE] revealed Resident #399 had one or more attempts to leave home/facility and or wander in the past three months, had frequent periods of fidgeting, repetitive physical movements, or verbalizations of fear, anxiety 4-6 of last 7 days, chair-bound total assist with transport, had dementia or moderate cognitive loss, had frequent periods of confusion and mental impairment, and was moderately impaired. The assessment also showed the resident's decisions were poor, cues and supervision were required and sometimes understands and was understood, responds adequately to simple, direct communication only, ability was limited to making concrete requests. A review of the admission Minimum Data Set ((MDS) dated [DATE] revealed Resident #399 had moderately impaired cognition. The MDS showed the resident's speech was clear and she was able to understand others, had no behaviors and took an antipsychotic medication 7 days during the assessment look back period. The MDS further showed the resident required supervision with locomotion off the unit. Resident #399 was assessed to have a lower extremity impairment on one side and had a surgical wound. The Care plan dated 2/26/2020 for Resident #399 revealed a plan which specified the resident was at risk for unsupervised exits from facility related to cognitive impairment. The care plan interventions included; to allow resident to wander on unit, to approach wandering resident in non-threatening manner, and a wander guard alarm bracelet to left ankle. A review of a smoking evaluation form dated 2/26/2020 revealed the Resident did not have adequate cognitive function, did not have adequate hand dexterity and use of upper extremities. The smoking evaluation also revealed the resident was an unsafe smoker and required direct supervision while smoking. During an interview with Resident #399 on 3/6/2020 at 10:25 am the Resident stated on Wednesday (3/04/2020) she went to the wound doctor without a staff member with her. The Resident stated she left the wound clinic and a friend rolled her across the street to the bank to withdraw some money and then to the store to buy cigarettes and a drink. Resident #399 also stated she smoked a cigarette and then went to the mental health place (located across the street from the wound clinic) where a security person came and got her and called the facility to come pick her up. During an interview with the facility's van driver on 3/10/2020 at 3:20 pm, he stated on 03/04/2020 he took Resident #399 to the wound clinic for an appointment and checked her in with the wound clinic's receptionist. He stated he gave the receptionist the resident's paperwork and told the receptionist to call him when the resident was finished with the appointment. He stated the receptionist called him to tell him to pick up the resident because she had missed the appointment. The van driver stated the receptionist told him the resident said she wanted something to drink and left to get a drink. He stated the receptionist ended the call and went to look for the resident. The receptionist called the van driver again to let him know the resident was not found. The van driver said when he got to the wound clinic, he went to every medical office in the building looking for Resident #399 and when he did not find her, he requested assistance from the hospital security office. The driver stated the Director of the Wound Clinic asked the hospital security staff to review the security video footage and a security officer informed him the video showed the resident in her wheelchair being pushed by an unknown man to the north exit door of the building. The van driver stated he went to the nearby bank and drug store to look for the resident. He stated the security officer notified him the resident was found and where to locate the resident. The van driver stated when he reached the resident's location there were two security officers with Resident #399 in the hospital's parking lot. The van driver stated he loaded the resident into the van and transported her back to the facility. The van driver stated he was aware Resident #399 was a memory care resident but did not alert the wound clinic staff to this fact when he checked the resident in for her appointment. He also stated normally a memory care resident was accompanied by a staff member for an appointment, but he did not know why Resident #399 was not accompanied by a staff member. During an interview with the receptionist at the wound clinic on 3/6/2020 at 3:30 pm, she stated Resident #399 was not checked in for her appointment at the wound clinic on 03/04/2020 and this was the resident's first appointment at the wound clinic. The receptionist specified the resident came into the wound clinic's waiting area accompanied by the van driver at 9:20 am and the driver opened the receptionist's window and shoved the resident's paperwork through the window. She stated the van driver provided no information about the resident. The receptionist stated she called the resident's name at 9:25 am and when she did not answer, she went to look for her on the benches outside of the office but she was not there. The receptionist stated she waited until after Resident #399's appointment would need to be cancelled to see if she would show up. She further stated after 20 minutes she called the van driver to inform him the resident was not present for her appointment and informed the wound clinic's director the resident was not in the clinic. The receptionist stated during the call with the van driver, he informed her that Resident #399 resided in the facility's memory care unit. During an interview with the Director of the wound clinic on 3/6/2020 3:45 pm she stated she was informed by the clinic's receptionist that Resident #399 was dropped off for an appointment on 3/04/2020 and was no longer in the clinic. The director stated she called hospital security to report the resident was missing and provided the security officer with a photo from Resident #399's last hospital admission. The director stated the receptionist called the facility to report the resident was not at the facility while she viewed the security footage. She said the security video showed an unknown man pushing Resident #399 to the building's north exit door. The director stated there was no security footage recorded outside of the building to show what transpired after the resident and unknown man exited the building. The director further stated the wound clinic policy was a memory care resident was required to have someone accompany them to their appointment. She then stated if the clinic's staff had been informed by the facility that Resident #399 resided on the facility's memory care unit, she would have placed the resident in a room where she would have been observed more frequently. During an interview with Nurse #5 on 3/6/2020 at 5:20 pm, she revealed she received a call on 03/04/2020 from the wound clinic to inform the facility Resident #399 was not at her wound clinic appointment. Nurse #5 stated she notified the DON (Director of Nursing) and the resident's responsible party (RP) was called to see if she had picked the resident up from the would clinic appointment and the RP stated she had not picked up the resident. Nurse #5 specified the resident's RP called the facility and informed the DON that Resident #399 called her, and the RP provided the phone number the resident used to call her. Nurse #5 said she called the phone number provided by the resident's RP and her call was answered by an unknown woman (Citizen #2) who stated the resident was trying to go to the drug store to buy cigarettes. Nurse #5 stated the van driver was called and directed to the drug store where Citizen #2 stated the resident was at and the facility's Social Worker and Maintenance supervisor were sent to assist with finding the resident. On 03/07/2020 at 9:54 am the drug store's security video was viewed. This video showed on 03/04/2020 at 9:50 am Citizen #2 (an unknown woman) pushing Resident #399 in her wheelchair to the drug store (which was on the same side of the road as the wound clinic). In the video the resident can be seen giving money to Citizen #2. Citizen #2 entered the drug store and left the resident unattended outside. Citizen #2 purchased a soda and cigarettes in the drug store. At 9:56 am Citizen #2 exited the drug store and gave her the resident her soda and cigarettes. At 9:59 am Citizen #2 lit Resident #399's cigarette and the resident began smoking as she talked to Citizen #2. At 10:02 am Citizen #2 pushed the resident toward the road and out of the view of the drug store's video camera. On 03/07/2020 at 11:22 am the hospital's security video was viewed. This video showed on 03/04/2020 at 10:09 am Resident #399 was in the health department's parking lot (which was located across the road from the wound clinic) being pushed in her wheelchair to the health department. It could not be determined if the person pushing the resident in her wheelchair in the video was Citizen #2 or someone else. At 10:30 am the resident was observed on the video to be alone and leaving the health department parking lot. Resident #399 can be seen on the video in her wheelchair crossing a road (with a 10 mile per hour speed limit) without assistance. A white truck was seen in the video to have to stop to let Resident #399 cross the road. Resident #399 entered the hospital parking lot in her wheelchair and went behind a row of bushes. At 10:38 am hospital security pulled up to the bushes where Resident #399 was located and stopped. At 10:46 the video showed the facility's transport van pull up to the bushes and picked up Resident #399. During an interview with the hospital security officer on 3/6/2020 at 4:00 pm, he stated he received a call on 03/04/20 at 9:50 am that Resident #399 was not in the wound clinic. The officer stated he obtained a description of the resident. He and another officer then checked the hospital's security camera video. The officer stated the video showed at 9:26 am an unknown man pushing the resident in her wheelchair to the wound clinic's north exit door. He stated he found the resident by herself in the hospital's parking lot. The officer stated a Social Worker and another individual arrived and stayed with the resident until the facility's transport van came to pick up the resident. During an interview with the Director of Nursing (DON) on 3/6/2020 at 10:45 am she stated Resident #399 went to her wound clinic appointment on 3/04/20 without a facility escort. The resident was assisted in her wheelchair by an unknown woman to go to a drug store to purchase cigarettes. The DON also stated when transport went to pick the resident up from the appointment, she was not at the wound clinic. The DON said Nurse #5 informed her that the wound clinic called and said Resident #399 was not at the clinic for her appointment. She stated she called Citizen #1 to help look for Resident #399 because he was in the vicinity of the wound clinic and could get there quickly. The DON stated she did not notify law enforcement because she did not consider the resident was missing. An interview with Citizen #1, who the DON called to search for Resident #399, was conducted on 3/6/2020 at 1:55 pm. The interview revealed on 03/04/2020 Citizen #1 was on the way to town when he received a call from the DON, and she asked him to go by the drug store to see if he could find Resident #399. Citizen #1 stated he passed an alley and saw Resident #399 in a wheelchair smoking a cigarette. Citizen #1 stated at 10:39 am he saw Resident #399 with two security officers in the hospital's parking lot and felt she was safe. An interview with the facility's Social Worker (SW) and the facility's Maintenance Supervisor was conducted on 3/6/2020 at 5:35 pm. The interview revealed after the facility received a call from the wound clinic on 3/04/20, the maintenance supervisor and SW were asked to go find Resident #399. The Maintenance Supervisor stated they found the resident in the hospital parking lot and the resident stated she had gone to the bank and the hospital. The SW stated the resident was her normal self and did not have any injuries. The SW stated the hospital security officer was with the resident. The SW said he and the maintenance supervisor stayed with the resident until the facility's transport van came to pick the resident up. The SW stated Resident #399 was dressed in a long sleeve shirt and pants which were appropriate for the weather. On 3/7/2020 at 9:50 am an interview was conducted with Nurse #4, who worked on the facility' s secured memory care unit on 3/04/2020, when Resident #399 returned to the facility. Nurse #4 stated a nursing assessment or skin assessment was not completed when Resident #399 returned to the facility on [DATE] because she was not informed the resident was missing and her whereabouts was unknown when she was to be at an appointment earlier in the day. On 03/06/2020 at 4:30 pm observations were made of the area Resident #399 traversed in her wheelchair while out in the community on 3/4/2020. The observation revealed the distance from the wound clinic to the bank, where the resident was seen withdrawing money, was approximately 540 feet. The approximate distance from the bank to the drug store, where the resident was observed with Citizen #2, was an approximate distance of 360 feet and the resident had to cross a 2-lane road with a posted speed limit of 10 miles per hour (mph) to get to the drug store. The distance from the drug store to the hospital parking lot, where the resident was found, was approximately 1,500 feet and the resident had to cross a four-lane road which had a posted speed limit of 35 mph to get to the hospital parking lot. The weather on 3/4/2020, in the city where the wound clinic was located, revealed the temperature was 60 degrees Fahrenheit and it was partly cloudy per the computer website weather.com. An interview with the facility's appointment scheduler on 3/6/2020 at 11:00 am revealed she normally would send an escort to an appointment with a resident who reside in the facility's secured memory care unit. She stated Resident #399's room number confused her because she forgot the secured memory care unit was expanded to include Resident #399's room. The scheduler further stated she did not think Resident #399 resided on the secured memory care unit because she seemed coherent and her mind together, so she did not send an escort to accompany Resident #399 to her wound clinic appointment on 03/04/2020. During an interview with Resident #399's legal guardian on 3/10/2020 at 12:20 pm, she stated the facility informed her the resident left the wound clinic on 3/4/2020 and went to the drug store to buy cigarettes. The legal guardian also stated she felt the facility did everything they could to find the resident when she left the clinic. She stated Resident #399 should have never been left alone to start with because she was a resident on the facility's memory care unit. The legal guardian said the resident was on the memory care unit because on two occasions she had gotten out of the facility while unsupervised. The primary care physician for Resident #399 was interviewed on 3/6/2020 at 1:55 pm. The physician revealed he only saw Resident #399 once and could not remember the resident's cognitive status or the specifics of the case. The physician stated because the resident was in the facility's secured memory care unit, was incompetent, and had a guardian, he would think the resident going to the wound clinic appointment unescorted would be a problem. He stated he was informed by the facility of the occurrence. During an interview 3/7/2020 at 9:57 am the DON stated a nursing assessment was not completed when Resident #399 returned to the facility and the facility's missing resident policy was not followed because Resident #399 was not considered a missing resident. During an interview with the DON on 3/7/2020 at 2:02 pm the DON stated Resident #399 had a [DIAGNOSES REDACTED]. She stated residents of the facility's memory care unit should never be off the unit without supervision. The DON further stated Resident #399 should have been accompanied by a staff member to her wound care appointment on 3/4/2020. She further indicated Resident #399 would go to all upcoming appointments accompanied by a staff member. The Administrator and DON were notified of Immediate Jeopardy on 3/6/2020 at 6:30 pm. On 3/07/2020 at 12:25 pm the facility provided the following credible allegation of Immediate Jeopardy removal: F 689- Free of Accidents/Hazards/Supervision/ Devices Resident #399 had an initial BIM's completed on 2/25/2020 by the Social Worker which was a 12. On 3/7/2020 Resident #399 had a new BIM's assessment completed by the Social Worker which is now a 15. On 3/5/2020 the Director of Nursing audited the transportation log to ensure that all residents with a BIM's of 12, having cognitive deficits and/or disabilities will be supervised during the appointment and until the resident is returned to facility. On 3/5/2020 and 3/6/2020 all other residents on the transport log were reviewed by the Director of Nursing to ensure they had a safe plan for transport. The Unit managers, transportation scheduler, and C.N.A.'s received in-service by the ADON to ensure residents that have an appointment and require supervision have a staff or family member to accompany them. This in-service was completed by 3/6/2020. The in-service covered appointment scheduling and transportation of residents with a BIM's of 12 or less or other cognitive deficits and/or disabilities will be supervised during the transport, appointment time, and return transport. On 3/6/2020 the ADON and LPN/Resource Nurse completed a new smoking assessment on all residents in the facility that smoke. Resident #399 had a smoking evaluation completed on 3/6/2020 by the ADON, the smoking assessment indicated resident #399 as a safe smoker. Resident #399 will be accompanied when smoking secondary to being in the SPARK unit. The smoking policy was reviewed with all unsupervised smokers and placed in their chart. Actions taken to alter the process or system failure to prevent a serious adverse outcome for occurring or recurring: Residents that are scheduled for an appointment outside of the facility that are not alert and oriented have the potential to be affected. On 3/6/2020 the Regional VP completed an in-service on the Missing Persons Policy to include the Administrator, Director of Nursing, Assistant Director of Nursing, and the Unit Managers. On 3/6/2020 the Assistant Director of Nursing initiated an in-service for licensed nurses on performing the smoking evaluation and review of the smoking policy. This in-service will be completed by 3/7/2020. After 3/7/2020 the receptionist will mail the in-service education via certified mail to all remaining staff who has not worked and not received the in-service with instruction to review, sign the in-service, and return to the staff facilitator or Director of Nursing prior to their next scheduled work shift. On 3/7/2020 Unit Managers audited rooms of residents who smoke to ensure they had no smoking paraphernalia in their possession. During this process, they educated residents on the importance of complying with the facility smoking policy. A letter will be sent to resident families of those who smoke to educate them on how to safely provide their loved one with smoking items. 0n 3/6/2020 the Assistant Director of Nursing initiated an in-service for all staff in all departments on the Missing Person Policy. This in-service will be completed by 3/7/2020. After 3/7/2020 the receptionist will mail the in-service education via certified mail to all remaining staff who has not worked and not received the in-service with instruction to review, sign the in-service, and return to the staff facilitator or Director of Nursing prior to their next scheduled work shift. On 3/6/2020 the Resource Nurse completed new wander/risk assessments on all residents that have a wander guard, care plan will be reviewed by the Director of Nursing and updated if needed, the elopement board in the break room which identifies all Residents at risk for wandering was audited by the Medical Records Coordinator to assure it is up to date. All needed changes will be completed immediately. On 3/6/2020, 3-11 shift, an elopement drill was conducted by the Assistant Director of Nursing. On 3/7/2020 the 11-7 shift the Director of Nursing will conduct an elopement drill and the maintenance director will conduct an elopement drill on the 7-3 shift. The transportation scheduler and unit managers will review appointments that require transportation Monday thru Friday to ensure that the resident being transported have been evaluated for the need to be supervised. The Transportation scheduler and/or the unit managers will contact family to see if they will be accompanying them to the appointment. If the family is not available a staff member will be assigned to go on the appointment with the resident. Director of Nursing or Assistant Director of Nursing will validate if a resident will require supervision during an appointment. This will occur Monday thru Friday during Cardinal IDT with each new appointment scheduled. The Administrator and Director of Nursing were responsible for the implementation of corrective actions to include 100% in-services and audits. Immediate Jeopardy Removal Date will be 3/7/2020 The credible allegation for Immediate Jeopardy removal was validated on 3/07/2020, which removed the Immediate Jeopardy on 3/07/2020 as evidenced by staff interviews, in-service record reviews, and observations. The in services included information on the missing resident policy, smoking, providing an escort with transportation for appointments. 2.Resident #39 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the most recent quarterly MDS assessment for Resident #39 dated 1/1/2020 indicated he was comatose and required the total assistance of one person for all activities of daily living. The resident required the total assistance of two persons for bed mobility. He had one fall since admission without major injury. A review of Resident #39's most recent falls risk assessment indicated he was at risk for falls. A review of the current care plan for Resident #39 updated 1/16/2020 indicated a focus area of at risk for falls related to impaired cognition (thinking). This risk area indicated a goal of will not experience major injury through next review. The interventions included bed in lowest possible position (3/18/19), observe resident position in bed and make sure he is not close to the edge of the bed and use wedge pillows for positioning (12/20/19). A nursing progress note dated 12/11/19 indicated at 3:30 AM Resident #39 was found with his feet on the bed and his upper body on the floor. It further indicated his bed was in the low position, his face was reddened, his lips were swollen, and a small amount of blood was noted to his face. The note went on to say Resident #39 was sent to the emergency room (ER) for evaluation. A nursing progress note dated 12/11/19 at 6:30 AM indicated Resident #39 returned to facility and all imaging tests done in the ER were normal. A review of a fall investigation report dated 12/11/19 indicated Resident #39 had an unwitnessed fall from a low bed and was found with his head on the floor and his feet still on the bed. It further indicated Resident #39 was at times restless in bed and determined a root cause for the fall to be this restless movement. The fall investigation report indicated wedge pillows would be implemented to assist with positioning and to help Resident #39 remain centered in bed. On 3/5/2020 at 8:04 AM Resident #39 was observed centered in bed with his bed elevated approximately two and one-half (2.5) feet from the floor and not in the lowest possible position (one foot). Resident #39 was observed with his eyes open. He made brief eye contact but did not respond verbally. Resident #39 was observed to be making non-purposeful movements with his right arm. His wedge pillow was observed on a chair beside his bed. A continuous observation of Resident #39 made from 8:04 AM to 8:42 AM revealed the following: On 3/5/2020 at 8:16 AM the Administrator was observed to enter Resident #39's room and provide fresh ice water to Resident #39's roommate. She did not provide any care to Resident #39. Resident #39 was in bed and his bed continued to be approximately two and one half (2.5) feet from the floor and no wedge pillows were in the resident's bed. On 3/5/2020 at 8:19 AM Resident #39 was observed centered in bed with his bed elevated approximately two and one half (2.5) feet from the floor. His wedge pillow was not in his bed and remained on a chair in his room. On 3/5/2020 at 8:28 AM Social Worker #2 was observed to enter Resident #39's room to provide his roommate with a meal tray. He did not provide any care to Resident #39. Resident #39's wedge pillow remained on a chair in his room. On 3/5/2020 at 8:32 AM Resident #39 was observed centered in bed with his bed elevated approximately two and one half (2.5) feet from the floor. His wedge pillow remained on a chair in his room. On 3/5/2020 at 8:35 AM interview with Nurse Aide (NA) #9 indicated she was currently responsible for the care of Resident #39. She stated Resident #39 was at high risk for falls because he sometimes moved around in bed, wedge pillows were used to keep him centered in bed, and his bed was supposed to be in the lowest position possible as this minimized the risk of serious injury if Resident #39 fell from the bed. NA #9 further stated Resident #39's bed was currently not in the lowest position possible but was elevated. She stated she did not know why, and she had not been in his room yet that day. On 3/5/2020 at 8:38 AM an interview with Nurse #3 indicated she was currently responsible for the care of Resident #39. She stated she had been in his room to check on him at 7:07 AM after receiving report but had not noticed whether his bed was in the lowest position possible. Nurse #3 went on to say Resident #39's bed did not need to be in the lowest position possible as he was not at risk for falls because he was not able to walk. She further indicated she was an agency nurse and had last cared for Resident #39 about a month ago. On 3/5/2020 at 8:42 AM an observation of Resident #39 was made with the Director of Nursing (DON) present. An interview with the DON at that time indicated Resident #39's bed was not in the lowest position possible and should have been. She then lowered Resident #39's bed as far as it would go to approximately one (1) foot from the floor. The DON stated the care planned interventions for Resident #39 of keeping his bed in the lowest position and the use of wedge pillows were designed to protect Resident #39 and prevent major injuries in the event Resident #39 fell from bed. She stated this was still appropriate for Resident #39 as he was still at risk for falls as he sometimes had restless movements and had fallen from bed in the past. The DON went on to say Nurse #9 had access to Resident #39's care plan and should have reviewed it before providing care to him and should have known the resident was at risk for falls. On 3/5/2020 at 8:50 AM a follow up interview with Nurse #9 indicated she had access to Resident #39's care plan but had not reviewed it before providing care to him. She went on to say she reviewed it after the DON spoke with her and Resident #39 was at risk for falls and should have had his bed in the lowest position possible to prevent major injury in the event of a fall from bed. On 3/6/2020 at 1:23 PM an interview with Administrator #2 indicated going forward the facility would ensure all staff were aware of the safety measures in place for residents.

Based on observation, record review, staff interview, family interview, nurse practitioner interview, neurological physician assistant interview, and physician interview the facility failed to provide supervision to prevent falls for one (Resident # 2) of three sampled residents who were reviewed for falls. Resident #2, suffered a laceration to his head and was identified to have a worsening of a subdural hematoma which was deemed subacute or chronic in nature. The findings included: Resident # 2 was initially admitted to the facility on [DATE] after a hospital stay for an acute [MEDICAL CONDITION] (bleeding into the brain area). According to the hospital discharge summary, dated 10/31/19, the resident's initial CT Scan when he first presented to the hospital showed a left occipital parenchymal hemorrhage with extension to the left lateral ventricle and third ventricle and a left subdural hematoma. Other [DIAGNOSES REDACTED]. Resident # 2's admission Minimum Data Set assessment, dated 11/6/19, revealed the resident was severely cognitively impaired, and needed extensive to total assistance with his activities of daily living. He was dependent on staff for transfers. The resident's care plan revealed it had last been updated on 11/28/19. This current care plan noted the resident was at risk for falls because of his history of falls, actual falls and multiple risk factors. The care plan also noted the resident had a history of [REDACTED]. Care planned interventions were listed as the following: Assist the resident to negotiate his barriers as necessary; Rehab therapy as ordered; fall mat on the floor when in bed; Fall preventive intervention: toilet about 2 hours after lunch meal for BM; Fall Risk Protocol; MD evaluation and review of resident's fall potential, possible causative and/or contributing factors; observe and intervene for factors causing falls, i.e. bowel/bladder needs, mobility, transfers, etc.; Resident to wear proper and no slip footwear. Resident # 2's nursing notes between 11/08/19 to 12/24/19 revealed the following incidents. On 11/8/19 at 3:15 PM Nurse # 1 documented in the medical record Resident # 2 was found on the floor on the right side of his bed and was trying to sit up. He was alert and confused. The nurse documented the resident had no injury from the fall. Interview with Nurse # 1 on 1/7/20 at 4:05 PM revealed she worried about the resident because he tended to sit on the side of the bed. She had assessed the resident following the 11/8/19 fall and he had no injuries. On 1/8/20 at 9:15 AM the facility's 11/8/19 investigation was reviewed with the DON (Director of Nursing). According to the investigation and the DON interview, following the 11/8/19 fall the facility educated the staff the resident would need increased supervision with his new environment and also educated the resident to use his call bell. According to the DON, the resident was new to the facility and they were in the phase in which they were trying to determine his level of calling for help and compliance with doing so. According to the DON, the resident was placed in a low bed, which was close to the floor, upon admission. On 11/10/19 at 2:42 PM Nurse # 2 documented in the medical record Resident # 2 was noted lying on the floor on his right side in a fetal position with a small cut above the left eye. The nurse noted no other injury was found and neurological checks were initiated. The nurse also noted she talked to staff and the family about not leaving the resident unattended in his room while in a wheelchair and that staff were to take the resident to the nursing station if in a wheelchair. On 1/8/20 at 2:15 PM Nurse # 2 was interviewed and reported she did not recall any further injury other than the small cut from the fall of 11/10/19. On 1/8/20 at 9:15 AM the facility's 11/10/19 investigation was reviewed with the DON. According to the investigative report and the DON interview, the incident had occurred on 11/10/19 at 12:30 PM and was documented at 2:42 PM in the medical record. The resident had sustained a small cut above the left eye with no other injury noted. The facility's new intervention was not to leave the resident up in a wheelchair while in his room. Staff were to take him to the nursing station. On 11/14/19 at 11:38 AM Nurse # 2 documented in the medical record Resident # 2 was noted lying on the floor on his left side. According to the note, the resident had been at the nursing station at the time of the incident. A witness had stated he had been standing at the nursing station and heard a loud thump on the wall of the nurse's station. When he turned around Resident # 2 was on the floor. The resident was assessed for injury and none found. After the family member was contacted a determination was made to send the resident out to the hospital for evaluation. On 1/9/20 at 2:15 PM Nurse # 2 was interviewed and reported the resident had no visible injury from the 11/14/19 fall. Therapy had finished working with the resident and had left him at Nursing Station # 1 for supervision on 11/14/19, but he stood up and fell . On 1/8/20 at 9:15 AM the facility's 11/14/19 investigation was reviewed with the DON. According to the investigative report and the DON interview, the incident had occurred on 11/14/19 at 10:45 AM. The resident was at the nursing station and a maintenance staff member was present but did not reach the resident in time to avoid the incident. After Resident # 2 returned to the facility from the hospital the DON stated a mattress was placed by the bedside in his room. Review of hospital records revealed Resident # 2 was hospitalized from [DATE] to 11/15/19. During this time, it was determined the resident had a urinary tract infection. A head CT scan was conducted on 11/14/19 at the hospital which revealed no [MEDICAL CONDITION] or acute process. Resident # 2 returned to the facility on [DATE] with orders for antibiotics for a urinary tract infection. On 11/30/19 at 1:04 PM Nurse # 3 documented in the medical record that a Nurse Aide had been walking past Resident # 2's room at 12:00 PM and observed the resident crawling around on the floor mat. The resident was assessed, found to have no injury, and the resident was assisted to bed. At the time of the incident the nurse documented the bed was in the lowest position and the fall mat was in place. On 1/9/20 at 2:50 PM Nurse # 3 was interviewed and reported the resident had been making multiple attempts to get up that day and swinging his legs over the bed. When he was found, he was on the floor mat and was not hurt. On 1/8/20 at 9:15 AM the facility's 11/30/19 investigation was reviewed with the DON. According to the investigative report and the DON interview, the fall mat had successfully prevented injury and it was continued as part of his care plan. On 12/3/19 at 4:26 PM Nurse # 2 documented in the medical record Resident # 2 had been found lying on the floor at the entrance of his room on his right side. The resident was assessed and found to have no injuries. He began to independently get up on his hands and knees to attempt to stand. Staff then assisted him to stand. He started to walk in the hallway and he was assisted to do so. The staff noted the resident smelled of feces, and they placed him on the toilet at which time he had a large bowel movement. Nurse # 2 was interviewed on 1/9/20 at 2:15 PM and reported the resident had last been seen in bed before he was found at the entrance to his room on the floor. It appeared as if he was starting to have a bowel movement and therefore, they toileted him. He was not hurt. On 1/8/20 at 9:15 AM the facility's 12/3/19 investigation was reviewed with the DON. According to the investigative report and DON interview the incident had occurred at 2:40 PM on 12/3/19 and had been documented at 4:26 PM. The resident had been restless at the time of the incident and toileting seemed to help. A new intervention was added to the resident's care that he should be toileted after lunch. On 12/5/19 at 3:01 PM Nurse # 2 documented in the medical record Resident # 2 was found sitting at the foot of his bed on the floor. The nurse noted the Nurse Practitioner (NP) assessed the resident following the fall. He was assisted to the bathroom. Nurse # 2 was interviewed on 1/9/20 at 2:15 PM and reported Resident # 2 had no signs of injury on 12/5/19 following the fall. On 1/8/20 at 9:15 AM the facility's 12/5/19 investigation was reviewed with the DON. According to the investigative report and DON interview the incident had occurred at 8:15 AM on 12/5/19 and had been documented at 4:26 PM. The DON stated the new intervention was to toilet the resident after all meals and staff were directed to do so. On 12/7/19 at 6:40 PM Nurse # 4 documented in the medical record the following. An overhead page was heard at 5:55 PM noting a Code Green (the facility's code to signify a resident has fallen). The nurse responded and found Resident # 2 lying in the hallway near another resident's room. There were moderate amounts of blood on the floor and the resident had a deep laceration above his right eye and two small cuts to the top of his head and back of his head. The resident could not state what had occurred. The physician was notified and emergency services was called at 6:05 PM. The resident was transferred to the hospital. Review of the 12/7/19 assignment sheet for the 3:00 to 11:00 PM shift revealed NA # 11 was assigned to care for all of the residents who resided on the 800 hall and all of the residents who resided on the 200 hall with the exception of residents who resided in of the two rooms on this hallway. The assignment sheet indicated NA # 11 was assigned to Resident # 2 on this shift. Nurse Aide (NA) # 11 had been assigned to care for Resident # 2 on the 3:00 PM to 11:00 PM shift of 12/7/19. Nurse Aide # 11 was interviewed on 1/8/20 at 9:50 PM via phone and reported the following regarding the evening of 12/7/19. Resident # 2 had been steady-steady trying to get up. She checked on him often and had to redirect him four or five times before supper. She offered to toilet him, but he kept trying to get up. The resident did not want her to touch him in anyway, and would say stop if she tried to help him. He was very active. On that evening, she was assigned residents on the 200 hall, where Resident # 2 resided, and on the 800 hall also. She was not on the 200 hall when Resident # 2 fell . She was on the 800 hall helping with dinner trays and was not able to see that he had tried to get up out of bed or what had happened to him. Nurse # 4 was interviewed on 1/9/20 at 3:03 PM and reported the following. Nurse #4 stated she was assigned to care for Resident #2 on 12/07/19 during the 3:00 PM to 11:00 PM shift. The nurse stated at the first of the evening shift on 12/7/19 she had been told in report Resident # 2 had been trying to get up and taking him to the rest room would help. That evening the resident was constantly trying to get up and they did try toileting him, but that did not help. She was on the 800 hall busy with medication administration when she heard the page he had fallen. She was not sure who had found him but thought it had been a housekeeper or dietary aide. After the page, she arrived to find him in the hallway with blood around his head. She assessed him and paged EMS (Emergency Medical Services) from the hallway phone to transfer the resident to the hospital. She felt the resident had needed one on one supervision that evening prior to the fall but she did not have enough staff to assign someone to watch him one on one. It had also been difficult for her to watch him because she was assigned to residents on the 800 hall and he was on the 200 hall. The 200 hall could not be observed while she was doing her duties on the 800 hall. Therefore, there were periods of time when she nor the resident's assigned NA were able to see what he was doing on the evening of 12/7/19. Observations on 1/7/20 at 9:22 AM revealed the 200 hall was adjacent to the 800 hall, but the rooms on the 200 hallway could not be observed if you were on the 800 hallway. Nurse # 5 was interviewed on 1/9/20 at 5:20 PM and reported he had heard the page while working on the 100 hall signifying the resident had fallen on 12/7/19. He had been busy on the 100 hall and had not witnessed the resident fall. He did respond and assisted with the transfer to the hospital. Nurse # 5 did not know who had found the resident on the floor. A medical records employee was interviewed on 1/9/20 at 5:22 PM. She reported she had been seated at Nursing Station # 1, which was situated at the end of the 200 hall. She recalled someone had called out to page Code Green (indicating a fall) but she had not seen the resident until she stood up from the nursing desk and did not know what had occurred or recalled who had found the resident. She was able to see the resident when she stood up from the desk. According to hospital records Resident # 2 was hospitalized from [DATE] to 12/11/19. Upon admission a head CT showed a right subdural fluid accumulation which was likely a subacute or early chronic hematoma. According to hospital records a neurosurgical consult was obtained due to the subdural hematoma. For the consult, the resident was evaluated by a neurosurgeon's physician assistant (PA). The PA noted the neurosurgeon was in agreement with the PA's assessment and plan. The family was given an option to have the subdural hematoma drained or to consider comfort care. The family opted for comfort care measures. On Resident # 2's discharge summary, subacute/chronic right subdural hematoma was listed as one of the resident's diagnoses. Also on the 12/11/19 hospital discharge summary it was noted that the 12/7/19 fall was suspected to have been due to a mechanical fall and not to [MEDICAL CONDITION] activity. The hospital discharge summary noted the resident's [MEDICATION NAME] (medication for [MEDICAL CONDITION] and mood disorder) level was therapeutic and he had not had [MEDICAL CONDITION] while hospitalized ; thereby making it less likely that [MEDICAL CONDITION] had caused him to fall on 12/7/19. On 1/8/20 at 9:15 AM the facility's 12/7/19 investigation was reviewed with the DON and the DON was interviewed. There was no notation in the investigation file regarding who had found the resident and what had occurred prior to him being found. There was no mention in the investigation file in regards to the facility assessing if the staff had been able to supervise the resident on 12/7/19 and complete their other job tasks. According to the investigation, the resident had been found in the hallway approximately four rooms down from his room. There was a notation under intervention put into place post-incident which noted sent to ER-Admission-(hospital) added [MEDICATION NAME] 5 mg (milligrams) on tongue nightly-questionable fall versus [MEDICAL CONDITION]. The DON did not know who had found the resident on the evening of the 12/7/19 incident. According to the interview with the DON, the [MEDICATION NAME] (an antipsychotic medication) had been added to the resident's drug regimen while he was hospitalized following the 12/7/19 fall, and it was being tapered down in the facility in an effort to discontinue it because the resident did not have a supporting [DIAGNOSES REDACTED]. In a follow up interview with the DON on 1/9/20 at 11:00 AM the DON stated the resident had come to the end of his [MEDICATION NAME] taper during the current week and the geriatric Nurse Practitioner was evaluating the resident for other medication that might help the resident as an alternative to the [MEDICATION NAME]. The DON also stated it was her understanding the resident had never suffered any further [MEDICAL CONDITION] while residing at the facility. A follow up interview was conducted with the DON on 1/14/20 at 4:37 PM via phone. The DON reported the following. Although she was not aware a new subdural hematoma had formed while the resident resided in the facility, she did not think this would have changed what they did. Their goal remained that they would try to prevent injury because they could not keep him from always falling. The DON stated on multiple occasions their inventions had worked to keep the resident safe. Since the date of 1/9/20 she had been trying to find out more about who had found Resident # 2 on the night of 12/7/19 when he went out to the hospital with the head injury. She had validated it was not a nursing staff member, and she did not know who had found him. According to the DON and a review of the 12/7/19 assignment sheets, there was another NA who was assigned mainly rooms on the 100 hall and two rooms on the 200 hall on the 3:00 to 11:00 PM shift on 12/7/19. According to the DON, this second NA had not found the resident and did not know what had happened. The DON stated the medical records employee, who had been seated at the Nursing Station 1 desk, just recalled someone alerting her that the resident had fallen and a Code Green needed to be called. The DON was interviewed regarding what staff are directed to do when they have a resident who is repeatedly trying to get up and toileting and redirection are not helping. The DON stated the staff could have called her and she would have seen if there had been someone on another unit on 12/7/19 who might have assisted with supervising the resident or the family could have been contacted for assistance as well in supervising the resident. According to the DON, the 200 hall mainly consisted of rehab residents and the facility's rehab census had been low that night on the 200 hall. Therefore, they were not short staffed, but because their census was lower Nurse # 4 and NA # 11 had assigned residents on two halls. The DON stated no staff member had called her on the evening of 12/7/19 to alert her that they felt more supervision was needed than they could provide that evening. According to the DON, the facility investigation had not revealed a lack of supervision on the night of 12/7/19 had contributed to the problem and the staff had not shared the concern with her. On 1/9/20 at 1:18 PM Resident # 2's Nurse Practitioner (NP) was interviewed. According to the NP she had not identified from reviewing the hospital records that the resident had experienced any new subdural hematoma which had originated in the resident's head while he had resided at the facility. The Physician's Assistant (PA) who conducted the neurological consult at the hospital on [DATE] was interviewed on 1/14/20 at 3:57 PM via phone. The PA reported the following. Based on the comparison of a CT that was done during the resident's hospitalization of 11/14/19 and a CT that was done on 12/7/19, the resident had developed a new subdural hematoma sometime between these two interval dates. It was located in the right parietal area. A small part of the subdural hematoma was considered to be new and due to the fall of 12/7/19, but most of it had occurred sometime between the interval of 11/14/19 to 12/7/19. The 12/7/19 fall probably worsened the hematoma that was there. In his opinion the most likely reason for the subdural hematoma was the resident's falls but he could not definitively rule out spontaneous development was the cause. According to the PA, the resident was more at risk for head injury due to his age and vascular changes. There was more room in his skull for his brain to move around and shift. On 12/11/19 Resident # 2 was discharged from the hospital back to the facility for care. On 12/15/19 at 7:45 AM Nurse # 6 documented in the medical record she was called to Resident # 2's room at 7:45 AM because he was sitting on the floor mat beside his bed. The nurse noted no injuries. An investigation summary into the 12/15/19 incident revealed the fall mat had effectively prevented injury and no new intervention was needed. On 12/24/19 at 3:22 PM Nurse # 7 documented in the medical record that Resident # 2 was on the floor and found to be without injuries. An investigation summary into the 12/24/19 incident revealed the fall mat had effectively prevented injury and the resident was in the process of going through a discontinuation of his [MEDICATION NAME] medication. The resident's facility physician was interviewed on 1/9/20 at 4:05 PM and again on 1/14/20 at 5:19 PM. According to the physician, the resident could have possibly not shown any symptoms of the chronic subdural hematoma he developed because chronic subdural hematomas develop over time and do not always present with symptoms as they start to form. They do not have as high as a mortality rate when compared to acute subdural hematomas and do not present as much of an emergency when compared to acute subdural hematomas. According to the physician, since the neurologist thought the subdural hematoma identified on 12/7/19 was considered chronic/subacute in nature, it was possible that the incident which precipitated the development of this was when he fell on [DATE] (at which time he was in a supervised area and the maintenance staff member did not get to him quickly enough). The initial CT of 11/14/19 would not have necessarily shown the slow bleed that started to form. He did feel the staff were working to keep the resident safe and the DON could better address specific interventions. The resident was observed on 1/9/20 at 9:35 AM in his room on a bed which was very close to the ground. A mattress was by the floor. The resident was awake and alert but appeared confused and would not converse or seem to understand questions. His responsible party (RP) was at the bedside and indicated she visited often. According to the RP the resident had been calmer in the past few weeks and she felt his calmer behavior had led to less falls

Based on observation, record review and staff and nurse practitioner interviews and physician interview the facility failed to allocate sufficient staff to supervise one (Resident # 2) of three sampled residents reviewed for falls when his individualized needs indicated more staff were needed to keep him safe. Resident #2, suffered a laceration to his head and was identified to have a worsening of a subdural hematoma which was deemed subacute or chronic in nature. The facility also failed to allocate sufficient staff to assure ambulation services were provided for two (Residents # 7 and #9) of two sampled residents reviewed for range of motion. The findings included: This tag is cross referenced to: 1. F-689: Based on observation, record review, staff interview, family interview, nurse practitioner interview, neurological physician assistant interview, and physician interview the facility failed to provide supervision to prevent falls for one (Resident # 2) of three sampled residents who were reviewed for falls. Resident #2, suffered a laceration to his head and was identified to have a worsening of a subdural hematoma which was deemed subacute or chronic in nature. An interview was conducted with the Director of Nursing on 1/9/20 at 3:42 PM who indicated she was responsible for developing the facility's nursing staffing schedule. She reported that the schedule was based on the resident census and she felt staffing was enough for the number of residents in the facility. She indicated she had not been made aware by residents or staff that the number of staff members being scheduled were not adequate to meet resident needs. 2. F-688: Based on record review, resident and staff interviews the facility failed to provide ambulation as specified in the plan of care for 2 of 2 residents reviewed for range of motion (Resident #7 and Resident # 9). During an interview with Restorative Aide #2 on 1/9/20 at 2:50 PM, the Restorative Aide stated she was pulled to the floor most of her time that she was scheduled to work as a nurse aide rather than do restorative services. She stated when she was pulled to work the floor the other nurse aides were to provide restorative services to their assigned residents. An interview was conducted with the Director of Nursing (DON) on 1/9/20 at 3:42 PM who indicated she was responsible for developing the facility's nursing staffing schedule. She reported that the schedule was based on the resident census and she felt staffing was enough for the number of residents in the facility. She further stated she was aware that restorative aides were being pulled to work the floor based on the census. She stated she was not aware that resident ambulation was not being done by the nurse aides. The DON stated each aide was trained on how to provide restorative services.

Based on medical record review and staff and family interviews, the facility failed to implement measures for one of two sampled residents (Resident #2), to prevent recurrence of physically aggressive behavior by a resident (Resident #2), toward another resident (Resident #1) in the locked Alzheimer ' s unit. Immediate Jeopardy began on 3/4/2015 at 8:00 PM, when Resident #2 grabbed both of Resident #1 ' s wrists and began to shake her. The facility failed to have interventions in place to prevent Resident #2 from this physical aggression. The Immediate Jeopardy was identified to the administrator on 3/13/2015 at 11:25 AM. Immediate Jeopardy was removed on 3/13/2015 at 5:35 PM when the facility implemented a credible allegation of compliance. The facility remains out of compliance at a lower scope and severity level D (no actual harm with the potential for more than minimal harm that is not immediate jeopardy) to complete employee education and ensure monitoring systems are in place that are effective. The findings included: Resident #1 was admitted on [DATE] with [DIAGNOSES REDACTED]. The annual Minimum Data Set ((MDS) dated [DATE] noted Resident #1 to be severely impaired for cognition and needed limited assistance for all Activities of Daily Living (ADLs) with the physical assistance of one person. The Care Area Assessment (CAA) indicated that Resident #1 had behavioral symptoms, and this area went to care plan. The care plan dated 2/15/2015 noted a focus of ineffectual coping during physical aggression related to cognitive impairment of Resident #1. The goal was to ensure safety for the resident and staff. Interventions included monitoring the resident closely, psychiatric consult, medication or treatment as prescribed by physician, document behaviors per facility protocol. Resident #2 was admitted [DATE] with [DIAGNOSES REDACTED]. A review of the clinical record progress note on 2/8/2015 at 9:15 PM revealed that Resident #2 was found in Resident #1 ' s room standing in front of her, holding her wrists with Resident #1 pinned up against the sink. Both were yelling at the other. Both residents were assessed for injuries with none noted. A review of a written statement dated 2/8/15, by Nurse #2 indicated the physician was contacted to send Resident #2 to the hospital ED. A review of the hospital Emergency Department (ED) records dated 2/8/15, revealed that Resident #2 was pleasantly confused at the ED. The ED patient Summary Report noted the Primary Impression: dementia with aggressive behavior. Under medications listed, it was indicated that Xanax (antianxiety medication) 0.5 milligrams (mg.) was given in the ED. Also listed was a prescription for Xanax 0.5mg 1 by mouth at bedtime for 30 days. A review of the Resident Concern Review dated 2/9/2015 revealed that 1) Resident #2 was sent to the local hospital ED on 2/8/2015 per doctor order. 2) In-service was started on 2/9/2015 on how to monitor residents with dementia and Alzheimer ' s. 3) Social Worker spoke with Resident #2 ' s responsible party (RP) to schedule a care plan meeting. The progress note on 2/9/2015 at 12:08 PM noted that Resident #1 had purple bruises on lower arms, wrists and hands. The care plan dated 2/10/2015 noted a focus of problematic manner in which Resident #2 acts characterized by ineffective coping, physical aggression or combativeness related to: anger, loss of control, unfamiliar environment. The goal was that safety would be ensured for the residents and staff. Interventions included: Medication as prescribed by physician, Monitor and document behavior per facility protocol. The admission MDS dated [DATE] noted Resident #2 to be severely impaired for cognition and needed only supervision for walking and eating but needed extensive assistance for transfers, personal hygiene, using the toilet and bathing with the physical assistance of one person. The CAA indicated areas of cognitive loss/dementia and behavioral symptoms which were care planned. The CAA described behaviors of refusing care, holding a resident against their will, attempting to hit staff and cussing and threatening staff. A review of the clinical record revealed in the nurse notes that on 3/4/2015 at approximately 8:00 PM, Resident #2 walked to the sofa where Resident #1 was sitting and grabbed both of her arms and began shaking her. A review of incident reports dated 3/4/2015, for both Resident #1 and Resident #2 revealed that neither of the residents were taken to the hospital, no injuries were observed and the physician and Responsible Parties (RP) were notified. Both incident reports stated that Resident #2 grabbed Resident #1 by the arms and began shaking her. On 3/10/2015 a review of Resident #2 ' s care plan revealed that an intervention of 1:1 had been added at 5:00 PM, to continue indefinitely for the resident. On 3/10/2015 at 2:30 PM, in an interview, Nursing Assistant #1 stated that on 3/4/2015 she was in a room with a resident and heard noise. NA #1 stated that when she got to the residents, Nurse #1 and NA #2 had the residents separated. NA #1 stated that the following day the NAs watched the residents because of what had happened, but there was not a meeting or a discussion of what should be done to protect Resident #1 from Resident #2. NA #1 stated 1:1 supervision was not implemented at this time for Resident #2. On 3/10/2015 at 2:50 PM, in an interview, Nurse #1 indicated that she was at a resident ' s door giving medications on 3/4/2015 when she turned around and observed Resident #2 walking toward the back of the common room. The nurse stated that she tried to walk between Resident #2 and Resident #1, but Resident #2 got past her and went straight to Resident #1 and grabbed her by the arms and then by the leg. Nurse #1 indicated that she and NA #2 got them separated, and Resident #2 was taken to a chair and, he sat down. Nurse #1 stated she assessed Resident #1 and found no obvious injury. Nurse #1 stated that she called the supervisor and informed her of what happened. Nurse #1 indicated that the supervisor came to the unit and suggested that Resident #2 be medicated and calls be made to family and the physician. Nurse #1 stated she filled out incident reports. Nurse #1 stated she worked the following day, and staff did not implement any new interventions to protect Resident #1 from Resident #2. Nurse #1 specified that 1:1 was not implemented at this time for Resident #2. On 3/10/15 at 3:02 PM, in an interview, NA #2 stated that she was in the large common room with all of the residents on 3/4/2015, when Resident #2 grabbed Resident #1. NA #2 indicated that she and Nurse #1 and NA #1 got Resident #2 to let go of Resident #1 and Resident #2 was taken to the other end of the room, and he continued to be agitated. NA #2 stated Resident #1 was taken to her room and assessed by Nurse #1, and the supervisor came to the unit. NA #2 stated that the NAs talked among themselves about watching Residents #1 and #2 more closely because of what happened. NA #2 stated there was no meeting about anything they should do to protect Resident #1 from Resident #2. On 3/11/2015 at 10:30 AM, in an interview, NA #2 stated that Resident #1 and Resident #2 are not around each other. NA #2 stated when the incident happened on 3/4/2015, Resident #1 was very upset and asked why Resident #2 did that to her, then she asked to go to bed. NA #2 stated the next day Resident #1 was fine and did not act scared at all and does not act scared now. On 3/11/2015 at 3:45 PM, in an interview, the Director of Nursing (DON) stated she got a call from a nurse on 3/4/2015 saying Resident #2 had grabbed Resident #1. Nurse #1 assessed Resident #1 and could not find any injury. The DON indicated she told Nurse #1 to give Resident #2 the intramuscular (IM) antianxiety medication. The DON stated the incident was spoken of in the daily staff meeting on 3/5/2015 and also spoken of in the clinical meeting after staff meeting, but nothing was decided in regard to actions to be taken to protect Resident #1 from Resident #2. As far as other measures that would be put into place at that time to protect other residents, the DON stated that there was a meeting with Resident #2 ' s family on 3/11/15 at 10:38 AM, to talk about all of the things we could do to calm him down when he became agitated. The DON noted that there was an order from the physician to medicate Resident #2 with the IM antianxiety medication. The DON stated the facility does not have a policy to monitor residents in the locked unit, but the facility does orient staff to deal with behaviors when they are hired. The DON confirmed that no interventions were implemented by staff to protect Resident #1 from Resident #2 until 3/10/15 when 1:1 supervision was implemented for Resident #2. The Administrator was interviewed on 3/11/2015 at 4:00 PM and stated she did not recall when she learned of the incident that occurred on 3/4/2015 between Residents #1 and #2.The Administrator also stated staff was supposed to notify her immediately for any occurrence of abuse. The Administrator stated her expectation was staff should contact her immediately when abuse occurs. The Administrator stated that no interventions were implemented by staff to protect Resident #1 from Resident #2 from 3/4/15 until 3/10/15 when 1:1 supervision was implemented. On 3/12/2015 at 9:10 AM, in an interview, the Administrator stated all residents on the locked Alzheimer ' s unit were on every 15 minute checks all day, every day. The family member (RP) of Resident #2 was interviewed on 3/12/2015 at 9:22 AM and stated the facility offered psychiatric services for the resident after the first incident on 2/8/2015, and she refused. As far as the incident on 3/4/2015, the family member stated Resident #2 was sitting at a table, got up and grabbed another resident ' s arms, and the staff got him away and called and told the family member that Resident #2 would be medicated with the IM antianxiety medication. The family member stated that she came to a meeting with the facility and it was decided that for the future, if Resident #2 cannot be calmed, then the resident will be sent to the hospital. The family member stated the facility offered psychiatric services and she refused. The family member stated if the facility called her, then she could get Resident #2 to calm down. An interview was conducted with a family member of Resident #1 on 3/12/2015 at 11:35 AM, who stated they received a call from Nurse #1 saying there had been an altercation on the Alzheimer ' s unit, and the family member stated they would come in the next day. The family member indicated they came in on 3/5/2015 and saw Resident #1 had bruises on both her wrists. The family member stated to Nurse #2 she was upset, and then she asked one of the NAs to look in the direction of the person who had been involved with Resident #1, and the NA looked at Resident #2. The family member stated when they came to the facility on [DATE], and the Administrator was not there, and the receptionist took them to the Resident Liaison ' s office who wrote out a Resident Concern Form and told the family member that the form would go to the Administrator, and a plan would be formulated. The family member stated she told the Liaison that she was afraid Resident #2 was going to hurt Resident #1. The family member stated when she came to the facility on [DATE] around 3:00 PM, Resident #1 was sitting on the love seat in the large common room and right beside resident #1, at about arm ' s length in a wingback chair was Resident #2. The family member indicated she took Resident #1 home with her for the afternoon, because she was afraid of what might happen. The family member further stated there was a staff person behind the desk and there were NAs in the room. An attempt was made by phone to reach the resident ' s private physician on 3/12/2015 at 12:34 PM and the physician could not be reached. A second attempt was made to reach the physician on 3/12/2015 at 1:30 PM without success. A second interview was conducted with NA #2 on 3/12/2015 at 3:00 PM. The NA stated she was on the locked unit on 3/4/2015 when the incident occurred between Resident #1 and Resident #2. When asked to describe the incident in detail, NA #2 stated she was in the large common room and Resident #1 was quietly sitting on a sofa and not interacting with anyone. NA #2 stated Resident #2 was standing beside the television. NA #2 indicated she turned to help another resident to the bathroom when she heard Resident #1 yell " Get away from me. " NA #2 stated when she turned around, she saw Resident #2 approach Resident #1 and grab both of her wrists. NA #2 indicated she, Nurse #1 and NA #1 went immediately to the two residents, and it took all three of them to pry Resident #2 ' s hand off of Resident #1 ' s left wrist. NA #2 stated while the staff were trying to get Resident #2 to let go, Resident #1 held both of her legs straight out in an attempt to push him away, and Resident #2 then grabbed Resident #1 ' s leg and was holding Resident #1 by the right leg and right wrist. NA #2 stated it took all three staff members to get Resident #2 to let go, as he was a very strong man. NA #2 indicated she noticed Resident #1 was red on both of her lower arms afterward. NA #2 stated Nurse #1 assessed Resident #1 right away, and Nurse #1 then gave Resident #2 an injection. NA #2 said " It took a long time for him to calm down. " NA #2 stated she worked with both Resident #1 and Resident #2 every day, and she had never seen Resident #1 interact with Resident #2 at all and she further stated she had never seen Resident #1 provoke Resident #2 in any way. NA #2 stated when she came to work the following day, the arms of Resident #1 were starting to show bruising. On 3/13/2015 at 4:53 PM, in an interview, the ED coordinator stated that the hospital can do psychiatric evaluations 24 hours a day, 7 days per week. The ED coordinator stated that a psychiatric evaluation was not done on Resident #2 when he came to the ED on 2/8/2015, because the resident was having no behaviors that would trigger for a psychiatric evaluation, and that the decision is up to the ED physician. On 3/13 /15 at 11:25 AM the Administrator was notified of immediate jeopardy for failing to put measures in place to keep Resident #1 safe from Resident #2 after Resident #2 physically grabbed Resident #1 on 3/4/2015. The facility provided and acceptable credible allegation of compliance on 3/13/2015 at 4:50 PM. The following measures were put into place to remove the immediate jeopardy. Allegation of compliance: On 3/4/2015, at approximately 8:07 PM, CNA and Hall Nurse witnessed Resident #1 and Resident #2 in a physical altercation. The CNA and Hall Nurse immediately separated Resident #1 and Resident #2. On 3/4/15, the Hall Nurse assessed Resident #1 for any injuries with no negative findings. On 3/4/15, the MD and RP of Resident #1 and Resident #2 were notified by Hall Nurse regarding the resident to resident altercation. Resident #1 was reassessed by the hall nurse for injuries on 3/5/15 with a bruise observed to her lower arm. The MD and RP was notified of resident #1 of the bruise on 3/5/15. On 3/5/15, Resident #2 was seen by the MD for behaviors. On 3/10/15 resident # 2 was placed on 24 hour 1:1 monitoring at 5 pm and has continued on 1:1 supervision on 3/11, 12, 13/2015 and presently remains on 24 hours 1:1 supervision. Resident #2 will remain on 1:1 supervision until he is discharged , experiences a decline in functioning or no longer would meet the criteria to be placed on a designated Alzheimer ' s unit. On 3/12/15 the RN Administrator completed a drug regimen review with the MD via telephone with no medication changes identified. On 3/13/15 the consultant pharmacist completed the drug regimen review with no recommendation for medication changes. The MDS Nurse reviewed and updated resident #2 ' s care plan on 3/11/15. On 3/10/15 a 100% head to toe assessment was completed by the MDS nurse, Assistant Director (ADON) of Nursing, Staff facilitator, treatment nurse, and Quality Improvement (QI) nurse on all residents in the locked dementia unit to include resident #1 and #2 to check for any signs and symptoms of injury or suspected signs of resident abuse. An incident report was completed, MD and RP notified, and an investigation was initiated by the QI Nurse for any injuries observed during the audit on 3/10/15. There were six residents observed with bruise like areas during this audit that needed completion of an incident report which was completed on 3/10/15 with appropriate follow up with MD and RP notification by the ADON, MDS Nurse, Staff Facilitator Treatment Nurse, and QI Nurse. On 3/13/15 the head to toe skin assessment was expanded and will be completed by ADON, MDS Nurse, Staff Facilitator Treatment Nurse, and QI Nurse to the remaining residents in the facility for any signs and symptoms of injury or suspected signs of resident abuse. An incident report will be completed, MD and RP notified, and an investigation initiated by the QI Nurse for any injuries observed during the audit by 3/13/15. On 3/10/15, 100% review of all resident ' s progress notes to include resident #1 and resident #2 from 3/4/15-3/10/15 was completed by the RN-Corporate Nurse to ensure that all documentation of resident to resident altercations have been documented appropriate, interventions implemented and MD/RP notified. No negative findings were found during this audit. On 3/11/15, all resident behavior records to include resident #1 and #2 were reviewed to assure these records were not related to resident to resident altercations by the RN Corporate Consultant. No areas of concern were identified during this audit. On 3/10/15, the RN-corporate nurse consultant completed a review of all resident to resident altercations from 3/4/15 -3/10/15 to ensure appropriate interventions were provided related to all identified altercations to include resident #1 and #2. There were no other resident to resident altercations identified during the audit. The RN Nurse Consultant, ADON, Treatment Nurse, Staff Facilitator, MDS Nurse, Nursing Supervisor and QI nurse initiated on 3/13/15 a 100% resident to resident altercation questionnaire with all staff to include license nurses, CNAs, dietary staff, therapy staff, housekeeping staff, maintenance staff, activities, payroll, bookkeeping receptionist and social workers staff on resident to resident altercation. Staff answering any question inappropriately will be re-educated upon identification by the RN Nurse Consultant, ADON, Treatment Nurse, Staff Facilitator, MDS Nurse, Nursing Supervisor and QI nurse. No staff will be allowed to work until the questionnaire has been completed. On 3/10/15 an in-service was initiated for all staff that have worked and will be completed by 3/13/15 with all staff to include license nurses, CNAs, dietary staff, therapy staff, housekeeping staff, maintenance staff, activities, payroll, bookkeeping receptionist and social workers on the resident-to-resident abuse policy by the staff facilitator. This in-service included that Residents have the right to be free from verbal or physical abuse or other mistreatment by other residents. Incidents of aggressive, sexual, or abusive behavior by one resident toward another resident must be reported immediately to the supervisor and the resident protected from harm. The supervisor and/or employee must report the inappropriate behavior to the Administrator and/or DON. Any employee who fails to immediately report suspected abuse or inappropriate behavior by one resident to another resident will face disciplinary action up to and including termination of employment. As of 3/13/15, 6 staff have not received the in-service. They will not be allowed to work until the in-service has been completed. On 3/11/15 an in-service was initiated and completed on 3/11/15 with the DON, Administrator, ADON, treatment nurse, staff facilitator, MDS nurses, Nursing Supervisor, QI nurse, and second shift LPN by the RN-Corporate nurse consultant regarding those residents that exhibit combative behaviors and are a danger to other residents need to be closely monitored i.e. 1:1 to ensure other incidents do not occur. This in-service was expanded by the RN Nurse Consultant on 3/12/15 to all licensed nurses to include placing residents on 1:1 supervision, sending the resident to the ER and notifying the Administrator and DON immediately notified of all resident to resident altercations including after hours and weekends. As of 3/13/15, 3 licensed nurses have not received the in-service. They will not be allowed to work until the in-service has been completed. An in-service was initiated on 3/10/15 by the Director of Nursing to the Licensed Nurses and Certified Nursing Assistants. This in-service included how imperative it is to monitor residents with Dementia and Alzheimer ' s very closely. If you are working in the SPARKS unit, you should be making rounds and checking on the residents frequently if they are not visible in the common areas then you need to seek them out and assure their safety. It only takes a " moment " for someone to fall or become engaged in an undesirable activity related to these declines in cognition. The in-service was amended on 3/13/15 on how to identify a resident that is becoming agitated or beginning to exhibit signs and symptoms of agitation and what appropriate interventions would be to decrease the resident ' s agitation to include, redirection, snacks, family interaction, reminiscing and music. If the resident ' s behavior is unable to be redirected the nurse must be notified. The nurse will notify the MD and RP and send to the ER per MD order. Once an employee has identified a resident to resident altercation the following will be completed: 1. Employee witnesses the altercation and intervenes to protect the resident from harm. Then notifies the supervisor. 2. The nurse will assess resident(s) involved in the altercations for any signs or symptoms of injury and notify the MD and RP. 3. An immediate plan to protect the resident and others will be identified and implemented by the licensed nurse; to include 1:1 supervision and or sending the resident to the emergency room for evaluation of aggressive behavior. 4. The supervisor will notify the Administrator and Director of Nursing for further recommendations and interventions as indicated. The resident ' s behavior and interventions will be documented in the medical record by the licensed nurse. Immediate jeopardy was removed on 3/13/2015 at 5:35 PM when verification of the credible allegation of compliance was evidenced by record review and interview. Surveyors confirmed the facility put into place continuing 1:1 supervision for Resident #2, an updated care plan for Resident #2. In-service for resident to resident altercation and steps to interventions. Interviews revealed licensed nurses throughout the facility were thoroughly knowledgeable in regard to resident to resident altercation.

Based upon observations, record reviews and staff interviews the facility failed to implement a fall prevention intervention for a mechanical recliner that resulted in an injury for 1 of 2 sampled Resident ' s (Resident #186) at risk for falls. Findings Include: Resident #186 had [DIAGNOSES REDACTED]. The 5-day Minimum Data Set ((MDS) dated [DATE] indicated he required extensive to total assistance with his activities of daily living and had poor balance. The care area assessment dated [DATE] revealed he had triggered for falls due his poor balance skills, decline in cognition and incontinence. The care plan dated 3/26/12 revealed he was at risk for fall due to the history of falls, actual falls, injury and multiple risk factors. The interventions for this fall risk were the following: 1. assist during transfer and mobility, 2. place his bed in the lowest position, 3. have his call bell pinned to his gown when in bed and 4. have commonly used articles within easy reach. A record review of the facility incident report dated 2/16/12 revealed Resident #186 was on the floor in front of his mechanical recliner. The mechanical recliner was in the upright position. There was a skin tear noted to the left arm. The immediate action was to have Resident #186 placed back into the mechanical lift recliner and the remote control for the mechanical recliner to be placed out of reach. The call light was to be placed within reach. The predisposing environmental factor to the fall was deemed the mechanical recliner. The predisposing physiological factors were decreased functional status, safety awareness and mobility and cognitive status. The predisposing situation factor was that Resident #186 was in the mechanical recliner at the bedside. The Nursing Assistant (NA) did not know not to leave the controls within reach due to Resident #186 was playing with controls. The NA was educated. Resident #186 was able to push the lift button until it lifted enough to slide him out of the chair. The NA ' s were educated not to have controls in reach of Resident #186 due to him playing with the buttons while seated in the mechanical recliner. A record review of the facility incident report dated 5/19/12 revealed Resident#186 had an unobserved fall. Resident #186 was found on the floor in front of the mechanical recliner by Nurse #2. Resident #186 had pushed up the chair with the remote control. He had the recliner at a high level. The immediate action taken was for Resident #186 to be assessed for injuries and contact the physician and supervisor. There were no found injuries at the time of the assessment. The predisposing environmental factor was the mechanical recliner. The predisposing physiological factors were an unsteady gait, muscle weakness, impaired vision, decreased mobility and safety awareness and alzheimer ' s disease. The predisposing situation factor was Resident #186 sitting in the mechanical recliner that had a remote to rise for easy standing. The notations were to apply a dycen to the mechanical chair per therapy recommendations on 5/23/12. The staff was educated to use the dycen in the mechanical recliner. A record review of the facility physician notes was conducted. The note dated 5/22/12 indicated Resident #186 had a fall over weekend with pain in the left elbow and increased pain in the left rib with respiration. The note dated 5/29/12 indicated the Nurse Practitioner was called to see Resident#186 wound. The wound was initially treated with cipro and switched to augmentin on 5/28/12. There was a large amount of purulent bloody drainage from the elbow. It was reddened and painful. Resident #186 was sent to the emergency room (ER) to be evaluated for a septic elbow. A record review of the May 2012 MAR revealed ultram medication 50mg was given to Resident #186 on 5/21/12 for complaints of pain in his side. A record review of the hospital ER history and physical dated 5/29/12 indicated a fracture of the elbow was reported on the CT scan. The left elbow was weeping with red skin. There was an elevated white blood cell count. He was admitted to the hospital on [DATE]. The orthopedic consult wanted to treat for bursitis and provide intravenous antibiotics. A record review of the hospital radiology report dated 5/29/12 revealed the following: 1.probable humeral fracture of the left arm and 2. possible radial fracture of the left arm versus old trauma. A record review of the facility physician orders [REDACTED]. An interview with Nurse #2 on 6/4/12 at 3:45 pm revealed Resident#186 had a recent fall from his mechanical recliner by the bed and sustained an arm fracture. He had used the remote to rise up the recliner and slid onto the floor. The mechanical recliner was still in his room. The remote was taken away. An interview with Nurse#1 on 6/6/12 at 11:53 am revealed Resident #186 had a fall on Friday, May 19th evening around 5:00 pm after she left for her shift earlier that day. When she came back to work on Monday, she saw his elbow was swollen and red. His left side had some red spotted areas. It was reported to her that he complained of pain over weekend in his arm. He was on an as needed pain medication. He was started on cipro that Monday. She had x-rays ordered for his ribs and elbow. The x-rays were negative. The Treatment Nurse was wrapping up his arm for that week due to some drainage. She had not recalled him complaining of pain that week. By end of week, the Treatment Nurse indicated the arm did not look better. The arm had increased swelling and drainage. They did attempt to change the antibiotic based upon the Responsible Party (RP) said the cipro made him feel loopy. The antibiotic was changed to augmentum. By the following Monday, they had called the physician about the arm. The physician wanted him sent out for further evaluation. The CT scan at the hospital indicated a small fracture. Nurse #2 has indicated she has seen him sitting in the mechanical recliner in the evening ' s at times watching television. After incident, they did not like having mechanical recliner remain in his room. Nurse#2 had told the RP about the mechanical recliner and wanted the RP to get the mechanical recliner from Resident #186 room. The mechanical recliner remained in his room. An observation with Nurse #1 on 6/6/12 at 12:04 pm in Resident #186 room revealed the mechanical recliner chair was located beside his bed. The recliner remote was connected to the recliner by a cord. The remote was placed in the open pocket on the right side of the recliner. The mechanical recliner was plugged into the wall. Nurse #1 demonstrated how to push the button up with her hand to raise the mechanical recliner. The mechanical recliner rose at an angle and to the height of about 2 feet from the ground. An Interview with the PT on 6/6/12 at 1:00 pm revealed Resident #186 revealed she knew that Resident #186 liked to be put into the mechanical recliner. She recalled the Nurse told the family about not have the mechanical recliner in the room but the family really wanted him to have the mechanical recliner. She did not know the mechanical recliner was still in his room. She would not recommend a mechanical recliner chair for a non-ambulatory resident. An interview with Nurse #2 on 6/6/12 at 3:35 pm revealed she worked the evening of Resident#186 fall on 5/19/12. Nurse#2 was at the end of the hall when she heard Resident#186 had yelled for help. She came to his room and found him on the floor between the recliner and his roommate ' s bed. She saw the mechanical recliner elevated in the air. She asked Resident #186 what had happened. He indicated he had pushed the remote on the mechanical recliner. Resident #186 indicated he liked to be high. Nurse#2 assessed Resident #186. He did not complain of pain. She did not see any injuries. She assessed him throughout her shift and did not see any changes in his elbow. She thought the remote was to be kept somewhere at the nurse station area. She had seen him before in the recliner but he has not been in it since the fall. She could not recall him falling prior to this fall on 5/19/12. An interview with NA#2 on 6/6/12 at 3:35 pm revealed she was working the evening of Resident #186 fall on 5/19/12. She indicated Resident #186 liked to play with buttons. NA#4 assumed the remote was kept at the side of the chair. They would place him in the recliner using the mechanical lift. Before the fall on 5/19/12, NA#4 could not recall any instruction about not being in his mechanical recliner or placement of the remote. After his fall on 5/19/12, she has not placed him in the mechanical recliner. An observation on 6/6/12 at 3:40 pm with Nurse #2 revealed the mechanical recliner beside Resident #186 bed. The remote was attached to the chair with a cord. The mechanical recliner was plugged into the wall. The remote was located in the open pocket on the right side of the chair. An interview with the prior Quality Improvement (QI), Nurse#3 and new QI Nurse was conducted on 6/6/12 at 4:09 pm. Nurse #3 indicated they have monthly and quarterly meetings for falls. The monthly meetings were for the discussion of falls and interventions. The quarterly meetings were for the number of falls and trends. Resident #186 was discussed in the monthly meetings. The 5/19/12 was related to him using the remote on the mechanical recliner. The intervention was for the dycen pad to be used in the mechanical recliner. They thought the dycen pad would help him from sliding from the recliner. They thought it was the best intervention at that time. Typically Nurse#3 indicated she has only seen residents with mechanical recliners in the rehabilitation unit or if the resident was incapable of the use of buttons. The 2/16/12 fall intervention was to put the remote in the pocket of the mechanical recliner so it could be out of reach of Resident #186. An interview with the Director of Nursing on 6/7/12 at 1:46pm revealed they think they should have either unplugged the mechanical recliner remote or kept the remote out of Resident #186 reach.

Based on record review and staff interviews the facility failed to assess a resident with an elevated BUN (blood urea nitrogen) for dehydration and failed to provide the resident with adequate fluids per PEG (Percutaneous Endoscopic [MEDICAL CONDITION]) Tube to prevent dehydration for 1 of 3 sampled residents with PEG tubes (Resident #1). The resident was on a diuretic. Immediate Jeopardy began on 12/28/10 at 5:54 PM and was identified on 02/21/11 at 3:55 PM. Immediate Jeopardy was removed on 02/22/11 at 6:22 PM when the facility provided a credible allegation of compliance. The facility will remain out of compliance at a scope and severity level D (with potential for more than minimal harm that is not immediate jeopardy) until all of the nursing staff can be in-serviced and the facility will implement monitoring of its corrective action. The findings include: Resident #1 was originally admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Resident Assessment Protocol Summary (RAP ' s) dated 08/02/10 for Cognitive Loss/Dementia showed that the resident had deficits in memory, decision making and thought processes related to a [MEDICAL CONDITION]. The RAP for Dehydration/Fluid Maintenance read that tube feeding and water flushes were to be given as ordered. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] showed that the resident had no speech and was rarely/never understood by others. The MDS showed that the resident received nutrition via feeding tube. The resident ' s Care Plan dated 11/12/10 for dehydration showed a goal that the resident would not demonstrate signs or symptoms of dehydration without appropriate nursing intervention. The interventions were to monitor for signs and symptoms of fluid volume deficit and to monitor lab results and report abnormal findings to the physician. The Dietary Supplemental Assessment completed by the Dietician Assistant dated 10/28/10 showed that the resident received a diet of tube feeding only and received 60 cc ' s (cubic centimeters) of formula/hour and water flushes of 240ccs every 4 hours. The assessment showed that the resident ' s total daily fluid requirements were 2,100ccs. The actual daily fluid intake was 2,562ccs. A progress note by the Dietician dated 11/30/10 showed that the resident ' s weight had slowly increased since admission and a recommendation was made to reduce the tube feeding to 58ccs/hour and to decrease the water flushes to 200ccs every 4 hours. The Dietician stated in a telephone interview on 02/10/11 at 9:05 AM that she probably thought that the resident was getting excess fluids and recommended a reduction in the water flushes. The resident ' s Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The MAR for December 2010 showed that the resident was on [MEDICATION NAME], a diuretic used for hypertension, 25mg once a day and showed an order date of 07/20/10. A nursing progress note dated 12/26/10 at 10:28 PM showed that the resident was observed with cool, clammy skin and with a small jerk every 20 seconds or so. The progress notes showed that the physician was notified and a CBC (complete blood count) and a chem (chemistry) 7 was ordered. There was an order from the resident ' s physician dated 12/26/10 at 10:20 PM for a CBC and Chem (Chemistry) 7. Review of the medical record revealed laboratory (lab) results completed by an independent lab dated 12/28/10 that included a BUN (blood urea nitrogen) of 57 (normal range 5-20) and flagged on the report as being high indicating dehydration. The Creatinine was 0.6 (normal range 0.3-1.5). The CBC report dated 12/28/10 showed a white blood cell count (WBC) of 14.6 (normal range 4.4-11.3) and flagged as being high indicating an infection.. A progress note written by the Physician ' s Assistant (PA), dated 12/29/10 showed that the PA was requested by nursing to see the resident due to an elevated white blood cell count. The BUN of 57, creatinine of 0.6 and the WBC of 14.6 were documented in the progress notes. The progress notes showed that the resident ' s skin was warm, dry and intact. The assessment/Plan read in part: " (arrow up) WBC R/O (rule out) urosepsis/infiltrate. " The progress notes showed a plan for a urinalysis, culture and sensitivity and a chest x-ray and to continue the present care plan. There was not a note to indicate possible dehydration. The physician's order [REDACTED]. There was no documentation on the record to indicate that the resident was assessed for dehydration by the nursing or dietary staff related to the elevated BUN on 12/28/10. A progress note written by the PA dated 01/03/11 showed that the PA again saw the resident related to the elevated white blood count and addressed the results of a positive urine culture. There was no documentation related to the elevated BUN or of dehydration. The resident ' s Physician at the facility stated in an interview on 02/09/11 at 5:37 PM that the BUN of 57 should have been addressed. The Physician stated that the BUN showed that the resident was obviously dehydrated. In an interview with the PA on 02/10/11 at 8:57 AM, the PA indicated that he was aware of the elevated BUN and stated that apparently he did not feel that the resident was clinically dehydrated. A nursing progress note dated 01/04/11 showed that at 4 AM the resident was found to have a temperature of 102.4 degrees Fahrenheit and a blood sugar of 482. The progress notes revealed that a Tylenol suppository and regular insulin was given. The progress note showed that at 6:30 AM the resident ' s temperature was 103 degrees Fahrenheit, the blood sugar was 468 and the physician was notified and the resident was sent to the emergency room (ER) for evaluation. The nursing progress notes during the month of December 2010 showed no documentation of signs or symptoms of dehydration. There were no nursing progress notes for January 2011 until the note dated 01/04/11 when the resident was sent to the emergency room . In an interview with Nursing Assistant (NA) #1 on 02/10/11 at 2:59 PM, the NA stated that the resident did not seem any different and had no change in the color or odor of her urine prior to going to the hospital. NA #2 stated in an interview on 02/10/11 at 5:00 PM that the resident had no changes in mental status or changes in the color or odor of the urine prior to going to the hospital. Nurse #3 stated in an interview on 02/10/11 at 5:04 PM that just before going to the hospital the resident was a little less alert but he did not see any other changes in her condition. Review of the ER Record revealed that on 01/04/11 at 8:25 AM the resident ' s BUN was 89 (normal range 0-17), creatinine was 0.88 (normal range 0.70-1.20), sodium was 158 (normal range 137-145) and the potassium was 5.1 (normal range 3.6-5.0). [DIAGNOSES REDACTED]. " Hospital records showed that the resident was discharged from the hospital on [DATE] and the Transfer Summary dictated 01/25/11 revealed [DIAGNOSES REDACTED]. " Hospital lab results dated 01/25/11 showed a BUN of 10 (normal range 0-17), creatinine of 0.39 (normal range 0.70-1.20), sodium 139 (normal range 137-145) and a potassium of 4.1 (normal range 3.6-5.0). The facility nursing progress notes showed that Resident #1 returned to the facility on [DATE] at 5:33 PM with an axillary temperature of 97.5, pulse 66, respirations 16 and blood pressure 138/80. A review of the admission orders [REDACTED]. The Nurse that admitted the resident on 01/25/11 (Nurse #3) stated in an interview on 02/21/11 at 2:54 PM that when a new resident was admitted , the nursing supervisor and the charge nurse would go over the orders together to get the admission done in a timely manner. The Nurse stated that it was noted that the resident was a diabetic and that the tube feeding formula needed to be changed to a diabetic formula. The Nurse indicated that the flushes were not addressed. Nursing Supervisor #2 stated in an interview on 02/21/11 at 3:45 PM that during the admission process on 01/25/11 the flush order of 50cc ' s every 8 hours was not addressed. The Supervisor stated that it was the admitting nurse ' s responsibility to look at the orders and the supervisor was to see that the orders were carried out. The Supervisor stated that the 50cc water flushes every 8 hours would not provide adequate fluids. There was a physician's order [REDACTED]. The order was signed by Nurse #2. There were no additional physician's order [REDACTED]. In an interview with Nurse #2 on 02/09/11 at 10:58 PM, the Nurse stated that on the night shift of 01/25-26/11 there were no water flushes on the resident ' s MAR. The Nurse stated that she looked at the admission orders [REDACTED]. The Nurse stated that she passed this information on to Nursing Supervisor #1 at shift change on the morning of 01/26/11. Nursing Supervisor #1 stated in an interview on 02/09/11 at 6:05 PM that she questioned the PA about the 50cc water flushes on 01/26/11 and the PA told her to get a BMP (Basic Metabolic Panel) to make sure that the resident was not dehydrated. Nursing Supervisor #1stated in an interview on 02/21/11 at 2:09 PM that before the resident went to the hospital the resident received more water flushes and did not know the reason that the resident returned with orders for the decreased amount of water flushes. The Supervisor stated that she did not know how to determine the resident ' s fluid requirements but could go to dietary to find out. The Supervisor stated that she did not ask dietary about the fluid requirements and was not aware if dietary saw the resident after she returned from the hospital. A progress note written by the PA and dated 01/26/11 revealed that the PA saw the resident at the request of nursing to assess the resident after a recent admission to the hospital for urosepsis, acute [MEDICAL CONDITION] and dehydration. According to the progress note the resident was alert, non-verbal, the oro-pharynx was moist and skin was warm and dry. It was noted on the progress notes that the resident was a [DEVICE] feeder and a plan to obtain a BMP (Basic Metabolic Panel). There was not an order to change the resident ' s water flushes. A laboratory report that showed a collection time of 01/27/11 at 6:30 AM, revealed a BUN of 14 (normal range 5-20), creatinine of 0.4 (normal range of 0.3-1.5), sodium of 137 (normal range of 135-148) and a potassium of 4.6 (normal range 3.5-5.3). There were no physician's order [REDACTED]. Nursing Supervisor #1 stated in the interview on 02/09/11 at 6:05 PM that she showed the results of the BMP done on 01/27/11 to the PA and that he said the resident was not dehydrated and that there was nothing new at that time. A Review of the Dietary Supplemental assessment dated [DATE], completed by the Dietician Assistant revealed that the resident was receiving a diet of tube feeding at 58ccs/hour with water flushes of 50ccs every 8 hours. The medication section of the assessment noted that the resident was on [MEDICATION NAME]. The assessment noted that the resident ' s total daily fluid requirements were 2100ccs and that the actual fluid intake was 1263ccs. On the assessment under Nutritional Requirements and beside E. Nutrition and/or Hydration Interventions, " none " was documented. The Dietary Assistant stated in an interview on 02/10/11 at 8:50 AM that this was an oversight on her part. The Dietary Assistant indicated that she should have made a recommendation to increase the residents water flushes. The Dietary Assistant stated that the resident went back to the hospital (02/03/11) before the Dietician could evaluate the resident. The Dietary Assistant stated in an interview on 02/21/11 at 1:20 PM that she was not aware that the resident was not receiving enough fluids until Friday (02/04/11) when the Director of Nursing questioned her about the assessment completed on 01/26/11. The Dietary Assistant stated that if a resident was not getting enough fluids she normally would have called the dietician or notified the nurse on the hall. The Dietician stated in a telephone interview on 02/21/11 at 1:45 PM that the resident was not getting enough fluids and that the Dietary Assistant failed to make a recommendation for additional fluids. The Dietician stated that had she seen the resident she would have recommended that the resident receive the 200cc ' s every 4 hours that she was getting before she went to the hospital. The Director of Nursing (DON) stated in an interview on 02/10/11 at 9:14 AM that she conducted a discharge chart review of the resident ' s chart on Friday (02/04/11) and saw that the resident received 50cc water flushes every 8 hours. The DON stated that she interviewed the Dietician Assistant who admitted that she had should have made a recommendation to increase the resident ' s water flushes. The resident ' s Physician at the facility stated in an interview on 02/09/11 at 5:37 PM that tube feedings and flushes were usually adjusted per dietary recommendations. The Physician stated that he was not called about the G ([MEDICAL CONDITION])-tube flushes. A progress note written by the PA revealed that the PA saw the resident on 02/01/11 and noted that the resident was alert, her skin was warm and dry and she had no extremity [MEDICAL CONDITION]. There were no orders to change the resident ' s water flushes. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED].The MAR indicated [REDACTED]. The PA stated in an interview on 02/10/11 at 9:14 AM that when the resident returned from the hospital he did not increase her flushes. The PA indicated that he should not have signed off on the normal BUN without reviewing the resident ' s chart. The PA stated that if dietary had made a recommendation to increase the water flushes he would have done so. The PA stated: " Looks like she shouldn ' t have been on [MEDICATION NAME]. " The PA stated in an interview on 02/21/11 at 1:25 PM that he was not aware of the admission order from the hospital for [MEDICATION NAME] and that the resident did not have a [DIAGNOSES REDACTED]. A nursing Progress Note dated 02/03/11 at 7:07 AM revealed that the resident was noted to have a temperature of 101.1 degrees Fahrenheit and a decreased level of consciousness. The physician was notified and the resident was sent to the hospital for evaluation. The ER record showed that on 02/03/11 at 8:55 AM the resident ' s BUN was 67 (normal range 0-17), creatinine 0.77 (normal range 0.70-1.20), sodium 147 (normal range 137-145) and the potassium 5.6 (normal range 3.6-5.0). The resident was admitted to the hospital with [REDACTED]. The ER record showed that a CAT (Computerized Axial Topography) of the head was done that showed no acute changes. The urine culture completed on 02/06/11 showed a heavy growth of Proteus Mirabilis. Blood cultures dated 02/03/11 were negative. At the end of the survey the resident was still in the hospital. The DON stated in an interview on 02/10/11 at 9:14 AM that she had in-serviced the admission nurses to notify dietary of all new admissions with [DEVICE]s to look at the resident for adequate [DEVICE] nutrition and flushes and had in-serviced the Dietary Assistant. The DON indicated that she had initiated a Plan of Correction and was still in-servicing the staff. The Administrator was notified of the Immediate Jeopardy on 02/21/11 at 3:55 PM. The facility provided a credible allegation of compliance on 02/22/11 at 6:22 PM. The allegation of compliance indicated: ? Resident #1 no longer resides in the facility. The resident was discharged from the hospital to another facility. ? Nurses involved in the care of the resident during the period of time the deficient practice occurred have received in-services related to the requirement to report all lab results reflecting hydration status to the physician upon receipt of the lab results by the facility. ? A 100% hydration audit review of tube fed residents was completed on 02/21/11 by the facility Registered Dietician to ensure residents were receiving required fluid amounts via tube feedings and flushes. ? In-servicing was initiated on 02/21/11 with 100% licensed staff related to the requirement to verify that fluid requirements are being met to include tube fed residents through tube feedings and flushes. In-servicing included the requirement to ensure fluids were calculated to provide 30cc ' s per Kg (kilogram) for 24 hours and that requirements were verified with dietary upon admission. ? A fluid requirement cheat sheet as a calculation guide was provided on each medication cart on 02/21/11. ? All licensed staff will receive in-servicing related to calculation and responsibility for ensuring resident fluid requirements are being met prior to taking a resident assignment until 100% of nurses have received the in-servicing. ? The Dietary Assistant and the Registered Dietician will conduct hydration requirement assessments per RAI (Resident Assessment Instrument) assessment schedule and with resident changes in condition. ? In-servicing was completed with the Dietary Assistant and with the Dietary Manager related to calculation of fluid requirements for residents to include residents being tube fed. ? Admitting Nurses will continue to review residents upon admission to include tube fed residents. ? Fluid requirements for tube fed residents will be reviewed by the admission review nurse and the Dietary Manager or Dietary Assistant during the Admission review process and will continue indefinitely. ? Nurses functioning as Admission Review Nurses were in-serviced related to the use of the Admission Checklist with focus on the addition of fluid requirement calculation. ? The Admission Checklist will be forwarded to the Director of Nursing for compiling and review. The director of Nursing will complete the Fluid Requirement Audit Review Tool. ? The Licensed Staff and the Registered Dietician will continue to routinely review residents upon receipt of tube feeding and flush orders to include tube fed residents after admission to the facility as per policy to aide with monitoring to ensure adequate fluids are being provided. ? The QI (Quality Improvement) tools will be reviewed by the Quality Improvement Nurse and the Director of Nursing upon completion with follow up as deemed necessary for any identified concerns. ? Findings will be compiled and forwarded to the facility Quality Improvement Executive Committee monthly for review for a minimum of 6 months. On 02/22/11 at 6:22 PM, the credible allegation was validated by reviewing the audit completed by the Dietician on 02/21/11 of the 24 tube fed residents within the facility. Random interviews were conducted with the licensed staff in the facility from all three shifts and it was determined that the staff interviewed had received training as stated in the credible allegation.

Based on record review and staff interviews the facility failed to notify the physician immediately of a positive urine culture for 1 of 4 sampled residents (Resident #1) resulting in a delay in treatment. The resident went to the hospital and was diagnosed with [REDACTED]. Immediate Jeopardy began on 01/01/11 at 10:56 AM and was identified on 02/21/11 at 3:55 PM. Immediate Jeopardy was removed on 02/22/11 at 6:22 PM when the facility provided a credible allegation of compliance. The facility will remain out of compliance at a scope and severity level D (with potential for more than minimal harm that is not immediate jeopardy) until all of the nursing staff can be in-serviced and the facility implement the monitoring of its corrective action. The findings include: Resident #1 was originally admitted to the facility on [DATE] and had [DIAGNOSES REDACTED].. The Resident Assessment Protocol (RAP) Summary for Cognitive Loss/Dementia dated 08/02/10 indicated that the resident had deficits in memory, decision making and thought processes related to [MEDICAL CONDITION]. The RAP for Communication dated 08/02/10 revealed that the resident was sometimes able to make herself understood by making gestures. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident had no speech, sometimes understood others and was sometimes understood by others. The MDS revealed that the resident was dependent on staff for all activities of daily living and received nutrition and fluids by PEG tube. The MDS indicated that the resident was incontinent of bowel and bladder. The resident ' s Care Plan dated 11/12/10 for urinary incontinence directed staff to monitor the resident for signs and symptoms of a urinary tract infection. Review of the resident ' s clinical record showed that on 12/28/10 the resident had a white blood cell count (WBC) of 14.6 (normal range 4.4-11.3) indicating an infection. The blood urea nitrogen (BUN) was 57 indicating dehydration (normal range 5-20). A progress note written by the Physician's Assistant (PA) dated 12/29/10 showed that the PA was requested to see the resident by nursing due to an elevated white blood count. The WBC of 14.6 and BUN of 57 were documented on the progress note. The PA ' s assessment was elevated WBC and R/O (rule out) urosepsis. The progress note did not address the elevated BUN. an order written [REDACTED]. " A lab report showed that a urine sample was collected on 12/30/10 and the culture was completed on 01/01/11. The urinalysis and culture report showed over 100,000 colonies/ml (milliliter) of [DIAGNOSES REDACTED] pneumoniae. The lab sheet showed that the culture results were faxed to the facility on [DATE] at 10:56 AM. The lab sheet contained initials identified by Nursing Supervisor #1 as the initials of Nurse #1 and the date 01/3/11. The report sheet also contained the initials of the PA and the date 01/3/11. The nursing progress notes did not indicate that the urine culture report had been received or that the report had been called to the physician or the PA. There were no physician's order [REDACTED]. In an interview with Nurse #1 on 02/10/11 at 4:08 PM, the nurse was unable to recall when the urine culture was received or what action was taken and was unable to recall whether or not a conversation took place with the physician or the PA regarding the urine culture results. Nursing Supervisor #2 stated in an interview on 02/11/11 at 3:20 PM that she worked the day shift on 01/01/11 but did not see the urine culture report. The Supervisor stated that she was working on the hall as well as doing her supervisory duties and did not pull labs from the fax machine that day. There was an order written [REDACTED]. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The Administrator stated in an interview on 02/22/11 at 11AM that she had not determined why the antibiotic was not started until 01/04/11 but that according to facility policy they had until 12 Noon the next day to start an antibiotic unless a specific start date or time was ordered. A nursing progress note dated 01/04/11 at 7:57 AM noted that the resident was observed at 4:00 AM to be sweating all over her body, her body was cool to touch and her temperature was 102.4 degrees Fahrenheit. According to the progress note, at 7:05 AM the resident ' s temperature was 103 degrees Fahrenheit and the resident was sent to the hospital for evaluation per physician's order [REDACTED]. The emergency room (ER) record dated 01/04/11 showed that the resident had a temperature of 104.7 degrees Fahrenheit upon admission to the ER and was admitted to the hospital with [REDACTED]. Laboratory studies done in the ER showed a WBC (white blood count) of 15.6 (normal range 4.8-10.8), BUN (blood urea nitrogen) of 89 (normal range 0-17), sodium 158 (normal range 137-145) and potassium 5.1 (normal range 3.6-5.0). The Transfer summary with an admission date of [DATE] and a discharge date of [DATE] showed [DIAGNOSES REDACTED]. The Director of Nursing (DON) stated in an interview on 02/10/11 at 12:22 PM that abnormal lab results should be taken to the physician or PA if in the building and if not the physician should be called right away. Nursing Supervisor #1 stated in an interview on 02/10/11 at 3:17 PM that lab results were faxed (facsimile) to the facility to the fax machine at Station 1. She stated that the Nursing Supervisors were responsible for checking the fax machine during their shift and date and initial the report when taken off the fax machine. The Nursing Supervisor stated that if the report was normal, the report was placed in a box for the physician or PA to see on the next visit and abnormal lab results were called to the physician, usually by the supervisor. An interview was conducted with Nursing Supervisor #1 and Nursing Supervisor #2 on 02/10/11 at 3:22 PM. Both supervisors stated that the positive urine culture report should have been called to the physician when received by the facility on 01/01/11. Nursing Assistant (NA) #1 stated in an interview on 02/10/11 at 2:59 PM that there were no changes in the resident ' s mental status and there was no change in the color or odor of the resident ' s urine prior to going to the hospital. NA #2 stated in an interview on 02/10/11 at 5:00 PM that the resident had no changes in mental status and no changes in the color or odor of the urine prior to going to the hospital. Nurse #3 stated in an interview on 02/10/11 at 5:04 PM that just before going to the hospital the resident was a little less alert but no other symptoms were noted. The Administrator stated in an interview on 02/11/11 at 11:45 AM that the Nursing Supervisor was responsible for checking the fax machine for lab results. The Administrator stated that if the lab results were abnormal the supervisor was to notify the Physician, PA or the NP (Nurse Practitioner). The Administrator stated that the physician should have been notified of the positive urine culture report when received on 01/01/11. The PA stated in an interview on 02/16/11 at 11:55 AM that he was unable to recall if the facility notified him of the positive urine culture received by the facility on 01/01/11. The PA stated that if he had been called he would have started the resident on an antibiotic at that time. The Physician stated in an interview on 02/16/11 at 11:55 AM that he was unable to recall if the facility notified him of the positive urine culture received by the facility on 01/01/11. The Physician stated that if he was called he would have questioned the staff to find out what was going on with the resident and responded accordingly. The Administrator was notified of the Immediate Jeopardy on 02/21/11 at 3:55 PM. The facility provided a credible allegation of compliance on 02/22/11 at 6:22 PM. The allegation of compliance indicated: ? Resident #1 no longer resides in the facility. The resident was discharged from the hospital to another facility. ? Nurses involved in the care of Resident #1 during the period of time the deficient practice occurred have received in-servicing related to the requirement to report all lab results to the physician to include urinalysis, culture and sensitivities (C&S) and labs reflecting hydration status upon receipt of the lab results by the facility. ? A 100% lab order audit review of individual labs ordered was completed on 02/21/11 for all residents by the administrative staff. It was determined that all lab orders for current facility residents to include urinalysis, C&S had labs obtained and had received follow up to abnormal results as appropriate to include notification of the physician. ? The facility implementation of a full time Lab Nurse was initiated on 02/11/11 and a Lab Monitoring Tool was designated as the Quality Improvement (QI) tool for lab tracking. A copy of the " lab process guide " was placed in the lab book and at each nurses ' station as a reference. ? The lab nurse assigned the responsibility of monitoring and oversight of labs and ensuring physician notification of labs upon receipt was in-serviced by the Director of Nursing on 02/04/11 and again on 02/21/11. The lab nurse will track the lab based on the date the order was received as recorded on the lab log, will ensure that all individual lab orders are logged upon receipt of order for tracking on the QI Lab Monitoring Log Tool and ensure that the physician is notified upon receipt of the lab results by the facility. The Lab nurse is responsible for reviewing the lab result to ensure documentation has been written on the result by the nurse reporting the results to the physician, reflecting notification has occurred. In the event the notification has not occurred by the hall nurse or supervisor the lab nurse is responsible for notifying the physician. The lab nurse will assume this responsibility Monday through Friday which will include lab nurse audit of lab results received on the weekend. The lab nurse will ensure that notification of the physician is indicated on the lab log to aide with monitoring and tracking. The supervisor will assume the responsibility of lab oversight on the weekends. The in-servicing of this process was included in nursing in-services initiated on 02/21/11 and will continue to be completed with all nurses prior to the nurse assuming a resident assignment. ? In the event the attending physician is not available to address the lab result the Medical Director will be contacted. ? The Director of Nursing (DON), Assistant Director of Nursing (ADON) and the Quality Improvement (QI) Nurse were in-serviced on 02/21/11 by the Facility Consultant related to their responsibility to review and monitor for use and completion of the Lab Log Tool by the Lab Nurse. The DON, ADON or the QI Nurse will review the lab log monitoring tool on a weekly basis for 6 months to ensure the tool is being completed in it ' s entirety to include physician notification. This review will be documented on the lab log audit tool. Any concerns will be immediately addressed by the Director of Nursing. ? The QI tools will continue to be completed and will be reviewed by the QI Nurse and the DON upon completion with follow up as deemed necessary for any identified concerns. ? Findings will be compiled and forwarded to the facility QI Executive Committee monthly for review and for the identification of trends, development of action plans as indicated, and to determine the need and/or frequency of continuing QI monitoring. This process will continue for a minimum of 6 months. On 02/22/11 at 6:22 PM, the credible allegation was validated by reviewing the 100% chart audit of labs completed on 02/21/11. Random interviews with staff from all 3 shifts showed that the staff had received in-services on the process for documenting ordered labs on the lab tool and notifying the physician immediately of abnormal lab results. In an interview with the designated Lab Nurse on 02/22/11 at 3:13 PM, it was determined that the Lab Nurse was aware of the process for documenting on the lab tool and was aware of her responsibilities regarding the process of ensuring that lab results were documented and that the physician was to be notified immediately of abnormal lab results.

Based on record review and staff interviews the facility failed to notify the physician immediately of a positive urine culture for 1 of 4 sampled residents (Resident #1). The resident went to the hospital and was diagnosed with [REDACTED]. Immediate Jeopardy began on 01/01/11 at 10:56 AM and was identified on 02/21/11 at 3:55 PM. Immediate Jeopardy was removed on 02/22/11 at 6:22 PM when the facility provided a credible allegation of compliance. The facility will remain out of compliance at a scope and severity level D (with potential for more than minimal harm that is not immediate jeopardy) until all of the nursing staff can be in-serviced and the facility will implement monitoring of its corrective action. The findings include: Resident #1 was originally admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Resident Assessment Protocol (RAP) Summary for Cognitive Loss/Dementia dated 08/02/10 indicated that the resident had deficits in memory, decision making and thought processes related to [MEDICAL CONDITION]. The RAP for Communication dated 08/02/10 showed that the resident was sometimes able to make herself understood by making gestures. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident had no speech, sometimes understood others and was sometimes understood by others. The MDS revealed that the resident was dependent on staff for all activities of daily living. The MDS indicated that the resident was incontinent of bowel and bladder. The resident ' s Care Plan dated 11/12/10 for urinary incontinence directed staff to monitor the resident for signs and symptoms of a urinary tract infection. A review of the resident ' s medical record showed laboratory results that were conducted by an independent laboratory. A CBC (complete blood count) dated 12/28/10 showed that the resident had a white blood cell count (WBC) of 14.6 (normal range 4.4-11.3) indicating an infection. A physician ' s progress notes written by the Physician ' s Assistant (PA), dated 12/29/10 showed that the PA was requested by nursing to see the resident due to an elevated white blood count (WBC). The PA ' s assessment was elevated WBC and R/O (rule out) urosepsis. an order written [REDACTED]. " The urinalysis report showed that the report was faxed (facsimile) to the facility on [DATE] and had a handwritten date of 12/31/10 and the initials of Nurse #4. The report showed negative [MEDICATION NAME] (normal range, negative), trace of leukocytes (normal range, negative), WBCs 8-12 (normal range 0-4) and 2+ bacteria (normal range-none). The urine culture report showed that the report was faxed to the facility on [DATE] at 10:56 AM and was positive for [DIAGNOSES REDACTED] pneumoniae, greater than 100,000 colonies/milliliter. The nursing progress notes did not indicate that the urine or urine culture report had been received or that the reports had been called to the physician or the PA. There were no physician's order [REDACTED]. The urine culture report showed a hand written date of 01/03/11 and the initials of Nurse #1. The report also showed the handwritten date of 01/03/11 and the initials of the PA. In an interview with Nurse #1 on 02/10/11 at 4:08 PM, the nurse was unable to recall the culture report received on 01/01/11 or any discussions about the report with the PA or the physician. Nurse #4 stated in an interview on 02/10/11 at 4:20 PM that the physician/PA did not want to be called with urine reports until the culture report came back to see what the sensitivities were before ordering antibiotics. There was an order written [REDACTED]. The nursing progress notes dated 01/04/11 at 7:57 AM showed that the resident was observed to be sweating all over her body and had a temperature of 102.4 degrees Fahrenheit. The resident was sent to the emergency room (ER) for evaluation per physician orders. A review of the hospital records showed that the resident had a temperature of 104.7 degrees Fahrenheit on arrival to the emergency room . A CBC done at the hospital laboratory, dated 01/04/11 at 8:25 AM, showed that the resident had a white blood count of 15.6 (normal range 4.8-10.8), blood urea nitrogen of 89 (normal range 0-17), sodium of 158 (normal range 137-145) and potassium of 5.1 (normal range 3.6-5.0). The resident was discharged from the hospital on [DATE] with [DIAGNOSES REDACTED]. The Director of Nursing (DON) stated in an interview on 02/10/11 at 12:22 PM that abnormal lab reports should be taken to the physician or PA if they were in the building and if not the report should be called to the physician or PA right away. The DON stated that the physician/PA did not want to be called with the urinalysis report until the culture report came back. Nursing Assistant (NA) #1 stated in an interview on 02/10/11 at 2:59 PM that the resident did not seem any different and had no change in the color or odor of her urine prior to going to the hospital. An interview was conducted with Nursing Supervisor #1 and Nursing Supervisor #2 on 02/10/11 at 3:17 PM. Nursing Supervisor #1 stated that lab results were faxed to the fax machine at station 1 and that the shift supervisors were responsible for checking the fax machine. The Nursing Supervisor stated that when the lab results were taken off the fax machine the supervisor was supposed to date and initial the report and if the report was abnormal, call the physician/PA. Nursing Supervisor #2 stated that abnormal urine reports were put in the physician ' s lab box for his review on the next visit. The Supervisor stated that the physician/PA did not want to give orders for an antibiotic until the culture returned. Nursing Supervisor #1 stated that Nurse #1 dated and initialed the culture report for Resident #1 received on 01/01/11. Both Nursing Supervisors indicated that the urine culture report should have been called to the physician/PA when received on 01/01/11. NA #2 stated in an interview on 02/10/11 at 5:00 PM that the resident had no changes in mental status or changes in the color or odor of the urine prior to going to the hospital. Nurse #3 stated in an interview on 02/10/11 at 5:04 PM that just before going to the hospital the resident was a little less alert but no real changes. The Nurse stated that when asked about pain the resident would shake her head to indicate that she had no pain. The Administrator stated in an interview on 02/10/11 at 11:45 AM that the shift nursing supervisor was responsible for checking the fax machine for lab results. The Administrator stated that the supervisor was to review the results and if abnormal, notify the physician/PA if in house and if not call the physician/PA. The Administrator reviewed the urine culture report received on 01/01/11 and stated that the report should have been called to the physician/PA. Nursing Supervisor #2 stated in an interview on 02/10/11 at 3:20 PM that she was working on the day shift on 01/01/11and was assigned to a medication cart as well as doing her supervisory duties. The Supervisor stated that more than likely she did not pull labs from the fax machine that day and stated that she did not see the culture report. The resident ' s Physician stated in an interview on 02/11/11 at 2:15 PM that he did not like to be called with urine reports until the culture was back. The PA stated in an interview on 02/16/11 at 11:50 AM that he was not called about the positive urine culture received by the facility on 01/01/11. The PA stated in an interview on 02/21/11 at 1:25 PM that the urine culture results that were faxed to the facility on [DATE] were in the lab book on 01/03/11. The PA stated that he would have expected the staff to call the culture results to the resident ' s physician or to the person that was on call. The Physician stated in an interview on 02/16/11 at 11:55 AM that he was unable to recall if the facility notified him of the positive urine culture received by the facility on 01/01/11. The Physician stated that if he was called he would have questioned the staff to find out what was going on with the resident and responded accordingly. The Administrator was notified of the Immediate Jeopardy on 02/21/11 at 3:55 PM. The facility provided a credible allegation of compliance on 02/22/11 at 6:22 PM. The allegation of compliance indicated: ? Resident #1 no longer resides in the facility. The resident was discharged from the hospital to another facility. ? Nurses involved in the care of Resident #1 during the period of time the deficient practice occurred have received in-servicing related to the requirement to report all lab results to the physician to include urinalysis, culture and sensitivities (C&S) and labs reflecting hydration status upon receipt of the lab results by the facility. ? A 100% lab order audit review of individual labs ordered was completed on 02/21/11 for all residents by the administrative staff. It was determined that all lab orders for current facility residents to include urinalysis, C&S had labs obtained and had received follow up to abnormal results as appropriate to include notification of the physician. ? The facility implementation of a full time Lab Nurse was initiated on 02/11/11 and a Lab Monitoring Tool was designated as the Quality Improvement (QI) tool for lab tracking. A copy of the " lab process guide " was placed in the lab book and at each nurses ' station as a reference. ? The lab nurse assigned the responsibility of monitoring and oversight of labs and ensuring physician notification of labs upon receipt was in-serviced by the Director of Nursing on 02/04/11 and again on 02/21/11. The lab nurse will track the lab based on the date the order was received as recorded on the lab log, will ensure that all individual lab orders are logged upon receipt of order for tracking on the QI Lab Monitoring Log Tool and ensure that the physician is notified upon receipt of the lab results by the facility. The Lab nurse is responsible for reviewing the lab result to ensure documentation has been written on the result by the nurse reporting the results to the physician, reflecting notification has occurred. In the event the notification has not occurred by the hall nurse or supervisor the lab nurse is responsible for notifying the physician. The lab nurse will assume this responsibility Monday through Friday which will include lab nurse audit of lab results received on the weekend. The lab nurse will ensure that notification of the physician is indicated on the lab log to aide with monitoring and tracking. The supervisor will assume the responsibility of lab oversight on the weekends. The in-servicing of this process was included in nursing in-services initiated on 02/21/11 and will continue to be completed with all nurses prior to the nurse assuming a resident assignment. ? In the event the attending physician is not available to address the lab result the Medical Director will be contacted. ? The Director of Nursing (DON), Assistant Director of Nursing (ADON) and the Quality Improvement (QI) Nurse were in-serviced on 02/21/11 by the Facility Consultant related to their responsibility to review and monitor for use and completion of the Lab Log Tool by the Lab Nurse. The DON, ADON or the QI Nurse will review the lab log monitoring tool on a weekly basis for 6 months to ensure the tool is being completed in it ' s entirety to include physician notification. This review will be documented on the lab log audit tool. Any concerns will be immediately addressed by the Director of Nursing. ? The QI tools will continue to be completed and will be reviewed by the QI Nurse and the DON upon completion with follow up as deemed necessary for any identified concerns. ? Findings will be compiled and forwarded to the facility QI Executive Committee monthly for review and for the identification of trends, development of action plans as indicated, and to determine the need and/or frequency of continuing QI monitoring. This process will continue for a minimum of 6 months. On 02/22/11 at 6:22 PM, the credible allegation was validated by reviewing the 100% chart audit of labs completed on 02/21/11. Random interviews with staff from all 3 shifts showed that the staff had received in-services on the process for documenting ordered labs on the lab tool and notifying the physician immediately of abnormal lab results. In an interview with the designated Lab Nurse it was determined that the Lab Nurse was aware of the process for documenting on the lab tool and was aware of her responsibilities regarding the process of ensuring that lab results were documented and that the physician was to be notified immediately of abnormal lab results.