Every finding on record at Bellway Health and Rehabilitation Center

Based on interviews, record review, the facility policies titled, Social Media Use, Personal Cell Phones, Resident Photographs, and Abuse, Neglect and Exploitation, review of Facility Reported Incidents (FRIs) received by the Alabama State Survey Agency, review of the facility's investigative files, and review of an Incident/Offense Report, the facility failed to: 1) ensure Resident Identifier (RI) #101 was free from mental and physical abuse perpetrated by staff at the facility. On 04/24/2024, Certified Nursing Assistant (CNA) #19 used her phone to record a video of CNA #18 physically and mentally abusing RI #101, who was in bed. In the recording CNA #18 taunted and laughed at RI #101 as she used aggressive force to pull up the resident's pants into the resident's perineum and buttocks. After CNA #18 pulled the resident's pants up, RI #101 pointed at CNA #18 and CNA #18 slapped RI #101's hand. The video was posted and circulated on social media showing what had been done to the resident and showing the resident's face. The video was sent anonymously by a non-staff member to the Social Worker/Director of Social Service (DSS) who reported the video to the Administrator (ADM) on 05/06/2024. It was determined the facility's noncompliance with one or more requirements of participation had cause, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) was related to State Operations Manual, Appendix PP, 483.12 Freedom from Abuse, Neglect and Exploitation. On 07/15/2024 at 5:17 PM, the ADM and Director of Nursing (DON) were provided the IJ template and notified of the findings at the immediate jeopardy level and substandard quality of care in the area of Freedom From Abuse, Neglect, and Exploitation at F 600-Free from Abuse and Neglect. The IJ began on 04/24/2024 and continued until 05/14/2024 when the facility implemented corrective actions to correct the identified deficient practice and prevent reoccurrence. This deficiency was cited as a result of a Facility Reported Incident, complaint/report number AL00047806. The survey team applied the reasonable person concept to determine the severity of harm. 2) Further the facility failed to protect RI #43's right to be free from physical abuse by RI #86. On 03/06/2024 RI #86 hit RI #43. This deficient practice affected RI #43, but this did not rise to the Immediate Jeopardy Level. This deficiency was cited as a result of a Facility Reported Incident, complaint/report number AL00047108. 3) Further the facility failed to protect RI #59's right to be free from physical abuse by RI #108. On 04/27/2024 RI #108 hit RI #59. This deficient practice affected RI #59, but this did not rise to the Immediate Jeopardy Level. This deficiency was cited as a result of a Facility Reported Incident, complaint/report number AL00047709. 4) Further the facility failed to protect RI #95's right to be free from physical abuse by RI #48. On 05/06/2024 RI #48 slapped RI #95. This deficient practice affected RI #95, but this did not rise to the Immediate Jeopardy Level. This deficiency was cited as a result of a Facility Reported Incident, complaint/report number AL00047805. 5) Further the facility failed to protect RI #43's right to be free from physical abuse by RI #123. On 06/12/2024 RI #123 spit at RI #43 and RI #43 hit RI #123. This deficient practice affected RI #43 and RI #123, but this did not rise to the Immediate Jeopardy Level. This deficiency was cited as a result of a Facility Reported Incident, complaint/report number AL00048127. 6) Further the facility failed to protect RI #123's right to be free from physical abuse by RI #45. On 06/24/2024 RI #123 spit at RI #45 and RI #45 hit RI #123. This deficient practice affected RI #123 and RI #45, but this did not rise to the Immediate Jeopardy Level. This deficiency was cited as a result of a Facility Reported Incident, complaint/report number AL00048224. 7) Further the facility failed to protect RI #45's right to be free from physical abuse by RI #115. On 07/01/2024 RI #115 hit RI #45. This deficient practice affected RI #45, but this did not rise to the Immediate Jeopardy Level. This deficiency was cited as a result of a Facility Reported Incident, complaint/report number AL00048276 . These deficient practices affected seven of 17 residents reviewed for abuse. Findings Include: Review of a facility policy titled Social Media Use, with an implemented date of 08/30/2023, and a revised dated of 05/07/2024 revealed: Policy: It is the policy of this company to avoid inappropriate use of social media and to protect the residents . of this facility against misuse of social media content. Taking, keeping, or distributing unauthorized photographs or recordings of residents through multimedia messages or on social media networks is a violation of a resident's right to privacy and confidentiality. Staff members must recognize that they have an ethical and legal obligation to maintain resident privacy and confidentiality at all times. Policy Explanation and Compliance Guidelines: 1. Employees are strictly prohibited from transmitting by way of any electronic media any resident-related image or information that may be reasonable anticipated to violate resident rights to confidentiality or privacy. This includes information that could degrade or embarrass the resident. 2. Photographs or recordings of a resident and/or his or her private space without the resident's or designated representative's written consent, is prohibited. Examples include taking unauthorized photographs/videos of: a. a resident's room or furnishing (which may or may not include the resident). d. taking unauthorized photographs or recordings of residents in an state of dress or undress using any type of equipment . Review of a facility policy titled Personal Cell Phones, with a revised date of 05/07/2024 revealed: . Policy Explanation and Compliance Guidelines: 1. This facility prohibits employees from using personal cell phones for any reason, on the nursing units or in working areas of the facility . 3. Under no circumstances should employee take pictures, videos . of any resident . Review of a facility policy titled Resident Photographs, with a revised dated of 05/07/2024 revealed: Policy: Taking photographs and/or videos of residents or their personal belongings is a violation of residents' rights to privacy and confidentiality. Policy Explanation and Compliance Guidelines: . 3. Any employee or past employee that takes photographs or videos of any resident that is not authorized will be considered abuse. 4. No current or past employee will post pictures, videos, comments, etc., on social media of any kind that pertains to anyone within this facility . Review of the facility's policy titled, Abuse, Neglect and Exploitation, with an implemented date of 08/30/2023, and a revised date of 05/07/2024, revealed: Policy It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of property. Definitions: Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish, which can include staff to resident abuse and certain resident to resident altercations . Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology . Mental Abuse includes, but is not limited to, humiliation, harassment . Mental abuse also includes abuse that is facilitated or cued by nursing home staff taking or using photographs or recording in a manner that would demean or humiliate a resident(s) . Physical Abuse includes, but is not limited to hitting, slapping, punching, biting and kicking . Verbal Abuse means the use of oral, written or gestured communication or sounds that willfully includes disparaging and derogatory terms to residents . regardless of their age, ability to comprehend, or disability . RI #101 was admitted to the facility on [DATE], and readmitted on [DATE]. RI #101 had diagnoses that included Aphasia Following other Cerebrovascular Disease and Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Left Dominant Side. A review of RI #101's Quarterly Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 03/04/2024, indicated RI #101's Brief Interview Mental Status (BIMS) was ten of 15, which indicated that RI #101 had moderately impaired cognition. RI #101 also had impairment on one side of the upper and lower extremities during the assessment period. The Alabama Department of Public Health Online Incident Reporting System form, submitted on 05/06/2024 at 9:20 PM documented: . Incident Type . Abuse - Physical . Incident Detail . Name(s) of resident(s) involved: (RI #101) . Name of alleged perpetrator(s): (CNA #18) . Narrative summary of incident: The Social Worker called the administrator to inform the administrator that she received a video from an outside source of our employee (CNA #18) mistreating one of our residents , Action (s) taken by the facility in response to the incident. .The employee was contacted and asked not to come to work in the morning as scheduled. The employee will be called in for questioning and suspended pending investigation. The resident was assessed, and no injuries were noted. The resident was unable to answer question appropriately. The MD (Medical Director) and sponsor were notified. (local) Police Department was notified . Ombudsman was notified. The video of the incident was provided to ADPH. The video showed a resident, identified as RI #101, in the bed on his/her back clothed with pants and shirt. The resident was pointing with his/her right arm toward the right side of the bed where a CNA, identified as CNA #18, was standing. A smiley face emoji covered RI #101 for about ten seconds of the video as the CNA approached the bed. The staff recording the video, identified as CNA #19, and CNA #18 were speaking, but the audio was not clear enough to hear what was said. The emoji was removed, and RI #101 was positioned on his/her left side while his/her back was toward the camera and CNA #18. Next, CNA #18 grasped the top portion of RI #101's brief that was exposed above his/her pants and pulled upward forcible and with a jerking motion. Loud noises were heard on the video and CNA #18 stepped away from the resident. RI #101 repositioned himself/herself onto his/her back and immediately pointed at CNA #18. A staff's voice was heard saying you going to hell . (he/she) said stop playing with me . and laughing was heard. Another voice was heard saying, go on now while RI #101 was pointing at CNA #18. At this time, CNA #18 stepped back toward RI #101's bed and used the back of her right hand to swat at RI #101's right hand that was pointing at her. CNA #18 then swatted at RI #101's right hand with her left hand and appeared to swat his/her hand away. CNA #19 was laughing during the video. On 07/10/2024 at 2:39 PM, an interview was conducted with the DSS who said she became aware of the video and that it had been posted to social media in May of 2024 when an anonymous source sent a text to her phone. The DSS said when she first observed the video there was an emoji over RI #101's face. The DSS said CNA #18 pulled on the back of RI #101's pants extremely rough and after she pulled on RI #101's pants, RI #101 pointed at CNA #18. The DSS said RI #101's face was on the video. The DSS said she could see CNA #18 laughing and swinging her hands toward RI #101 and popping RI #101 on his/her hand. The DSS said CNA #19 was later identified as the person recording the video. The DSS said the incident would cause a reasonable person to feel embarrassed, like their privacy had been violated, and scared of the CNAs coming back and doing that to them again. The DSS said the incident was physical and emotional abuse. On 07/11/2024 at 5:47 PM, a follow-up interview was done with the DSS. The DSS said when she reviewed the video, RI #101 was not smiling from what she could see. When asked to describe RI #101's demeanor, the DSS said RI #101 looked frustrated to her. The facility's investigative file was reviewed and a handwritten EMPLOYEE STATEMENT dated 05/07/2024, and signed by CNA #18, documented the following: On April 24, I was in (RI #101's) room giving (him/her) care and getting (him/her) dressed another employee recorded . it was a playing matter that just was took into the wrong way . On 07/10/2024 at 4:16 PM, a telephone interview was conducted with CNA #18. When asked what she could tell the surveyor about an incident involving a video being made of RI #101 when she provided care for him; and the video ended up on social media. CNA #18 said she was aware CNA #19 had her cell phone out but she was not aware CNA #19 was recording her providing care for RI #101 until the video came out and she was called into the ADM office. CNA #18 said the ADM discussed with her how she had grabbed and pulled RI #101's pants up forcibly. CNA #18 said the ADM said it looked like she had given RI #101 a wedgie. CNA #18 said her being rough with RI #101 could be considered physical abuse. CNA #18 when she saw the video it seemed like she was making fun of RI #101 and mocking him/her. The facility's investigative file contained a handwritten EMPLOYEE STATEMENT dated 05/07/2024 and signed by CNA #19 that documented: I (CNA #19) recorded the video to show fell ow employes . the video was sent from my phone . On 07/11/2024 at 8:28 AM, a telephone interview was conducted with CNA #19. CNA #19 said RI #101 could not physically speak. CNA #19 said a CNA requested her assistance and when she entered RI #101's brief was already fastened. CNA #19 said when she began recording, the other CNA was in the process of pulling RI #101's pants up. CNA #19 said she knew she was not to record anything about the resident, but she recorded the incident to show other staff. CNA #19 denied posting the video on social media. On 07/15/2024 at 8:55 AM a follow-up interview was conducted with CNA #19 via phone. CNA #19 said she did not know the video was posted on social media until the other CNA (CNA #19) called her later the evening the video was recorded and asked her to remove it from social media. CNA #19 denied posting the video on social media but said no one else had access to her phone. CNA #19 said she must have accidentally posted the video on social media. On 07/10/2024 at 5:16 PM, an interview was conducted with the ADM. who said when she viewed the video. The ADM said she the video showed CNA #18 pull up RI #101's pants forcibly. The ADM said RI #101 was on his/her side, and when RI #101 turned on his/her back RI #101 started pointing at CNA #18 and CNA #18 walked away and was laughing. The ADM said when CNA #18 returned, CNA #18 and RI #101's hand made contact, then CNA #18 laughed and walked away again. The ADM said identified CNA #18 in the video and notified her to not report to work as scheduled. The ADM said when CNA #18 was initially interviewed she was asked when she last worked with RI #101. CNA #18 out of the blue said April 24th and said she knew why she was being interviewed. CNA #18 revealed to her that CNA #19 was doing the recording. The ADM said the incident was physical abuse and could have easily affected RI #101 mentally when the resident's pants were pulled up forcibly, staff laughed about the situation, and the video was posted on social media for everyone to see. On 07/12/2024 at 7:30 AM during a follow-up interview with the ADM, she said when she reviewed the video, RI #101's pants were pulled up with force. The ADM said when RI #101 tuned over he/she pointed his/her finger at CNA #18. The ADM said she did not think RI #101 was smiling. When asked to describe RI #101's demeanor, the ADM said when RI #101 turned over RI #101 made a noise, pointed his/her finger and it seemed like RI #101 may have been a little upset for what CNA #18 had done to him/her. On 07/10/2024 at 8:47 AM, a telephone interview was conducted with RI #101's Responsive Party (RP). The RP said the facility made him aware a video of RI #101 had been posted to social media. When asked how he thought RI #101 would feel to know someone had videoed him/her and posted the video to social media, the RP said RI #101 would have been mad and would not have liked that at all. Review of the reported results from an onsite visit made by IBH (Integrated Behavioral Health) after the incident on 05/09/2024, revealed the following: . History of Present Illness . patient was reportedly abuse by a CNA at the facility and that the incident was recorded by a separate CNA. The patient is non-verbal . (He/She) is calm and pleasant. Interview is limited due to patient being non-verbal but (he/she) is able to participate by shaking (his/her) head yes or no, giving a thumbs up . The facility's incident summary dated 05/13/2024, documented: Physical Abuse .CONCLUSION (RI #101), resident, was provided care by (CNA #18) on April 24, 2024. While in the room providing care for (RI #101) (CNA #19) videoed (CNA #18) as she finished the care of (RI #101). In the video it was noted that (CNA #18) used aggressive force to pull up the pants of (RI #101). After forcefully pulling up the resident's pants, the employee is shown laughing and the resident is shown pointing at her . we can substantiate physical abuse . A review of the facility's IMMEDIATE QUALITY ASSURANCE REVIEW documentation regarding the incident revealed corrective action was initiated from 05/07/2024 through 05/14/2024. Upon review and verification of the information provided in the facility's corrective action plan, in-service/education records, the facility's investigation, as well as staff interviews, the survey team determined the facility implemented corrective actions from 05/07/2024 to 05/14/2024, with on-going monitoring implemented; thus, immediate jeopardy past noncompliance was cited. 2) RI #43 admitted to the facility 05/07/2015, with a diagnosis of Anxiety Disorder and Aphasia following Cerebral Infarction. A Quarterly MDS assessment with an ARD date of 01/26/2024, identified RI #43 to score a 12 of 15 on the BIMS indicating RI #43 had moderately impaired cognition. RI #86 was admitted to the facility on [DATE] and readmitted [DATE], with a diagnosis of Cocaine Abuse, Insomnia and Dysphagia, Oropharyngeal Phase. An Annual MDS assessment with an ARD date of 05/21/2024, identified RI #86 to score a 12 of 15 on the BIMS indicating RI #86 had moderately impaired cognition. The Alabama Department of Public Health Online Incident Reporting System form, dated 03/06/2024 documented: . Incident Type . Abuse - Physical . Incident Detail . Name(s) of resident(s) involved: (RI #43) . Name of alleged perpetrator(s): (RI #86) . Narrative summary of incident: (RI #43) was rolling in (his/her) wheelchair down the hallway. (RI #86) was sitting in the hallway. (He/she) said (RI #43) ran over (his/her) foot and (he/she) hit (him/her) . The facility's incident summary dated 03/11/2024 documented: . Resident to Resident Physical Abuse . CONCLUSION (RI #86) was sitting on the hallway at the nurse's station. (RI #43) was ambulating down the hallway in (his/her) wheelchair and accidentally rolled over (RI #86's) foot. The two residents exchanged words and (RI #86), who has a history of trying to hit a resident (if) they try to run over (his/her) feet while (he/she) is sitting in the hallway, hit (RI #43) . we are substantiating resident to resident physical abuse with (RI #86) . On 07/11/2024 at 6:05 PM an interview was conducted with Licensed Practical Nurse (LPN) #11. She was asked to explain what she saw with RI #86 and RI #43, she said both were in wheelchairs in front of the nurses' station when she heard them cursing each other. LPN #11 said she saw RI #86 hit RI #43 on the arm and she and the CNA separated the two. LPN #11 said there was no sign of injury to either resident when assessed. LPN #11 said the incident was resident to resident physical abuse. 3) RI #59 was readmitted to the facility on [DATE] and readmitted on [DATE], with diagnoses to include Anxiety Disorder and End Stage Renal Disease. A Quarterly MDS assessment with an ARD of 04/11/2024 identified RI #59's had a BIMS score of 15 of 15 which indicated RI #59 was cognitively intact. RI #108 was admitted to the facility 03/02/2023, with diagnoses to include Adjustment Disorder with Mixed Anxiety and Depressed Mood. A review of RI #108's Annual MDS assessment with an ARD of 03/04/2024 indicated RI #108 had a BIMS score of 15 of 15 which indicated RI #108 was cognitively intact. The Alabama Department of Public Health Online Incident Reporting System form, dated 04/27/2024 documented: . Incident Type . Abuse - Physical . Incident Detail . Name(s) of resident(s) involved: (RI #59) . Name of alleged perpetrator(s): (RI #108) What was reported . (RI #59) reported that (RI #108) hit (him/her) in (his/her) face . Action(s) taken by the facility in response to the incident. The residents were separated . RI #108 is on one-to-one monitoring . No new injuries . The facility's incident summary dated 05/01/2024, documented that the facility's investigation determined: It was found that RI #108 engaged in a conversation with an employee in the dining room and proceeded to use profanity towards the employee. RI #59 intervened and asked RI #108 to leave the employee alone. The employee then witnessed RI #108 raising his/her hand at RI #59. As a result, RI #108 was escorted out of the dining room by the employee. Upon the employee's return, RI #59 informed her that RI #108 had hit him/her. Two other residents in the dining room confirmed witnessing RI #108 hit RI #59. Following a thorough review of acknowledgments and interviews, the facility confirmed resident-to-resident physical abuse. An interview was conducted with RI #59 on 07/12/2024 at 5:47 PM regarding the incident with RI #108. During the interview, RI #59 mentioned being in the dining room when RI #108 was verbally abusing an employee. RI #59 intervened and confronted RI #108 about the behavior, which resulted in RI #108 hitting RI #59, leaving a red mark on his/her face. RI #59 stated that there had been no additional incidents following the altercation. An interview was conducted with RI #108 on 07/13/2024 at 9:53 PM regarding the incident with RI #59. RI #108 said he/she was in the dining room and was talking to an employee. RI #108 said RI #59 got into the middle of the conversation and he/she told him/her to mind their own business. RI #108 said he/she raised his/her hand back but did not hit RI #59. An interview was conducted with Certified Nursing Assistant (CNA) #14 on 07/13/2024 at 10:44 AM regarding the incident involving RI #59 and RI #108. CNA #14 reported that while she was in the dining room, RI #108 became upset and started yelling and using profanity toward her. CNA #14 ignored RI #108, but RI #59 said something to RI #108 about the way he/she was talking. CNA #14 said she witnessed RI #108 approaching RI #59's table draw his hand back, but did not see RI #108 physically strike RI #59. CNA #14 intervened and separated the two residents and escorted RI #108 out of the dining room. Upon her return, RI #59 informed CNA #14 that RI #108 had hit him/her in the face. CNA #14 said RI #59's allegation was supported by two other residents who were sitting nearby. CNA #14 said this was considered physical abuse. An interview was conducted with the ADM on 07/13/2024 at 10:36 AM regarding the incident involving RI #59 and RI #108. The ADM stated that upon reviewing the investigation, she concluded that RI #108 physically abused RI #59. 4) RI #48 was admitted to the facility on [DATE], with diagnoses to include Vascular Dementia and Major Depressive Disorder. A Quarterly MDS assessment with an ARD date of 04/16/2024, identified RI #48's BIMS was 12 of 15 which indicated that RI #48 had moderately impaired cognition. RI #95 was admitted to the facility on [DATE], with diagnoses to include Schizophrenia and Generalized Anxiety. An Annual MDS assessment with an ARD date of 04/30/2024, identified RI #95's BIMS was nine of 15 which indicated that RI #95 had moderately impaired cognition. The Alabama Department of Public Health Online Incident Reporting System form, dated 05/06/2024 documented: . Incident Type . Abuse - Physical . Incident Detail . Name (s) of resident (s) involved: (RI #95) . Name of alleged perpetrator(s): (RI #48) . Narrative summary of incident: . The residents were out on smoke break when (RI #48) asked for a cigarette. (RI #95) stuck (his/her) foot out and (RI #48) . slapped (RI #95) . The residents were separated . (RI #48) was sent to the (emergency room ) . (RI #95) was placed on one-to-one monitoring . The facility's incident summary dated 05/12/2024, documented: . Physical Abuse (Resident to Resident) . CONCLUSION The residents were taken outside to smoke . While outside (RI #95) and (RI #48) were arguing about cigarettes . (RI #95) stuck (his/her) feet out, (RI #95) and (RI #48) exchanged words and (RI #48) slapped (RI #95) .(RI #48) fell to the ground . we can substantiate physical abuse with (RI #48) and (RI #95) . The facility's investigative file was reviewed and revealed an interview done by the ADM with RI #118, 05/07/2024, which documented the following: . Physical Abuse . (RI #118), can you tell me what happened on the back porch yesterday, May 6, 2024? Answer: the residents were going back and forth with each other . (RI #48) walked over and slapped (RI #95) . On 07/12/2024 at 2:22 PM, during an interview with the ADM, she stated she substantiated that abuse had occurred. The ADM said following the incident, the facility began to take residents out to smoke in two separate groups and times to limit the number of residents smoking at one time. 5) RI #123 was admitted to the facility on [DATE], with diagnoses to include Adjustment Disorder with Anxiety and Depression. A Quarterly MDS assessment with an ARD date of 04/15/2024, identified RI #123 BIMS was 15 of 15 which indicated that RI #123 was cognitively intact. The Alabama Department of Public Health Online Incident Reporting System form, dated 06/12/2024 documented: . Incident Type . Abuse - Physical . Incident Detail . Name(s) of resident(s) involved: (RI #43) . Name of alleged perpetrator(s): (RI #123) . Narrative summary of incident: There were 4 residents sitting at the table playing dominos. (RI #123) was asked to play, and (he/she) got mad and pushed the dominos down and spit on (RI #43). (RI #43) got up and hit (RI #123). Staff separated the residents . The facility's incident summary dated 06/19/2024, documented: . Physical Abuse . CONCLUSION The residents were in the dining room in an activity of [NAME]. It's usually the same group of people that play every day. (RI #123) is usually not in the dining room playing every day. (RI #123) was playing (his/her) dominos but was taking longer than the rest of the players. (RI #43) was trying to rush (RI #123) to play (his/her) dominos and they began to have a verbal altercation that led to a physical altercation . we can substantiate physical abuse . On 07/12/2024 at 12:04 PM, during an interview with the ADM, she recalled RI #43 and RI #123 were with a group playing dominos. RI #43 told RI #123 to hurry up and play and RI #123 said shut up and spit on RI #43. RI #43 got up to hit RI #123 but the CNAs got to them and separated them. RI #123 was placed on one-to-one supervision until he/she could be sent out when a bed became available. She said the form of abuse was resident to resident physical abuse. The ADM said following the incident interventions implemented included (but not limited to) education with the residents to not rush others while playing in the groups, and educated the staff when they first hear residents raise their voice to redirect or stop the games if necessary. 6) RI #45 was admitted to the facility on [DATE], readmitted on [DATE] and discharged on [DATE]. A Quarterly MDS assessment with an ARD date of 04/15/2024, identified RI #45's BIMS was 15 of 15 which indicated that RI #118 was cognitively intact. The Alabama Department of Public Health Online Incident Reporting System form, dated 06/24/2024 documented: . Incident Type . Abuse - Physical . Incident Detail . Name(s) of resident(s) involved: (RI #123) . Name of alleged perpetrator(s): (RI #45) . Narrative summary of incident: The residents were in the dining room playing a game and (RI #123) spit on (RI #45). (RI #45) hit (RI #123) in the face . The facility's incident summary dated 06/27/2024 documented: . The residents were in the dining room playing dominos and (RI #123) and (RI #45) began to tap each other on the hand. (RI #123) said (RI #45) tapped him/her on the hand harder than he/she tapped him/her and (RI #123) spit in (RI #45's) face. (RI #45) hit him/her in the face. (RI #123) went down the hallway and told the nurse what happened . we can substantiate resident to resident physical abuse . On 07/11/2024 at 6:15 PM, RI #104, another resident who witnessed the incident between RI #45 and RI #123 was interviewed. RI #104 said he/she was sitting at the table while they were playing dominos back on June 24. RI #104 said RI #123 spit in RI #45's face, then RI #45 hit RI #123 around the nose area. RI #104 said RI #123 raised his/her arm to block the hit. RI #104 said he/she did not know if RI #45 hit RI #123's arm or actually hit RI #123 on the nose, but RI #45 hit RI #123. RI #104 said RI #123 got up and went to the nurses' station. On 07/12/2024 at 4:44 PM, a telephone interview was conducted with LPN #21. LPN #21 said RI #123 reported to her that RI #45 had hit him/her in the face. LPN #21 said she took RI #123 to his/her room and assessed RI #123. LPN #21 said she left RI #123 in his/her room with a CNA and went to find the other resident involved, RI #45. LPN #21 said RI #45 said he/she hit RI #123 because RI #123 spit in his/her face. When asked what type of abuse would this incident be considered, LPN #21 said physical. On 07/09/2024 at 5:19 PM, RI #123 was observed sitting on the side of the bed in his/her room. There was a sitter in the room who said someone had to be with RI #123 at all times. The surveyor asked RI #123 had he/she ever been in any type altercation with another residents. RI #123 said someone hit him/her in the face when they were playing dominos. RI #123 said it made him/her feel mad to be hit in the face. When asked why the other resident hit him/her in the face, RI #123 said he/she did not know. On 07/12/2024 at 2:22 PM, an interview was conducted with the DON. The DON said RI #45 hitting RI #123 in the nose was physical abuse. When asked what the facility had put in place to ensure an incident like this one would not occur again, the DON said RI #123 was place on one-on-one monitoring and dominos was made a supervised activity. 7) RI # 115 was admitted to the facility on [DATE] and readmitted to the facility on [DATE], with diagnoses that included Schizophrenia and Anxiety Disorder. RI #115's Quarterly MDS with AR [TRUNCATED]

Based on observation, interview, the facility's 2024 Spring/Summer (S/S) Menu Diet Spreadsheets, the facility's production sheets, the facility's scoop/disher/dipper chart, and the facility's policies for The Dining Experience: Objectives, Menu Planning and Requirements, Menu Diet Spreadsheets/Portion Serving Communication Tool, Use of Production Sheets, and Menu Substitutions or Changes and Approval; the facility failed to provide pureed food items in the portions specified on the menu for supper on Tuesday, 07/09/2024 and for lunch on Thursday, 07/11/2024. The facility further failed to include cheese in the pureed entree as specified on the menu for supper on Tuesday, 07/09/2024 and did not receive approval from the Registered Dietitian (RD) to do so. In addition, the facility failed to provide the portion specified on the menu for Coleslaw on the Regular texture diets at supper on Tuesday, 07/09/202, for trays on the [NAME] Wing cart. the facility also failed to provide the portion of ground Bratwurst for the Mechanical Soft texture diets as specified on the menu for lunch on Thursday, 07/11/2024. This had the potential to affect 4 of 4 Pureed texture diets, 5 of 7 trays for the [NAME] Wing, and 19 of 19 Mechanical Soft texture diets. Findings include: The facility's policy for The Dining Experience: Objectives, dated 2020, included the following: . Procedure: . 4. Meals will be planned to meet nutritional adequacy and according to the resident's plan of care . The facility's policy for Menu Planning and Requirements, dated 2020, included the following: . Guideline: Menus are planned to provide nourishing, palatable, attractive meals that meet the nutritional needs of residents served, . in accordance with the Dietary Reference Intakes/Recommended Dietary Allowances as issued by the Food and Nutrition Board of the National Research Council, of the National Academy of Sciences, unless otherwise contraindicated by medical conditions and needs. Procedure: . 2. Menus are planned in advance . 8. Regular and therapeutic menus are planned by a nutrition professional in accordance to the community's approved diet manual. The planned menus are reviewed and approved by a registered dietitian (RD). The facility's policy for Menu Diet Spreadsheets/Portion Serving Communication Tool, dated 2020, included the following: . Guideline: Diet spreadsheets or similar meal and portion serving communication tools are available to the serving staff for reference and serving guidance. The facility's policy for Use of Production Sheets, dated 2020, included the following: . Guideline: A production chart/sheet is used during food preparation that lists the amounts to be prepared for all general food items and all modified diets in quantities needed for residents . The facility's policy for Menu Substitutions or Changes and Approval, dated 2020, included the following: . Guideline: . The registered dietitian (RD) . reviews . menu . changes for nutritional equivalency and appropriateness. On 07/09/2024 at 4:58 PM, preparation for Supper was observed. The PM [NAME] explained that the production slip for Supper was posted on the wall in the Cook's Area; it was a small paper square with the following information: 98 Reg (Regular), 4 Puree, and 20 M/S (Mechanical Soft). The Kitchen Supervisor then said Production Meetings were at 10:00 AM and 2:00 PM daily. The Kitchen Supervisor also pointed out the 2024 S/S Menu (Week 2 Diet Spreadsheet) with portion sizes, which was posted on the bulletin board in the main kitchen area. On 07/09/2024 at 5:14 PM, temperatures were being taken of the Supper items on the steamtable by the PM Cook. The Coleslaw was in a full pan, which was placed atop a pan of ice at the end of the steamtable. A 3-ounce spoodle was observed as the serving utensil for the Pureed Hamburger Patty and Bun and this was verified by the PM Cook. The PM [NAME] said Cheese was not included in the pureed entree because there might be a Renal puree to be served. The 2024 S/S Menu Diet Spreadsheet for Week 2, Tuesday, Supper listed Pureed Cheeseburger on Bun with a #6 dip (dipper) portion utensil (5.3 fluid ounces) for the Pureed texture diet. On 07/09/2024 at 5:35 PM, the Supper trayline began with the loading of the [NAME] Wing Cart. The Dietary Manager said, although the Dining Room was listed to be served first, it could not be served until Residents and CNAs were present and ready. At 5:40 PM, the [NAME] Wing Cart left the kitchen. At 5:41 PM, a scoop/disher/dipper was observed being used to serve the Coleslaw in insulated soup bowls. At 5:46 PM, the surveyor asked size of the Coleslaw scoop/disher/dipper and then saw it was a #16 scoop/disher/dipper (2 ounces) from the number 16 imprinted on the metal. When the Kitchen Supervisor realized a #16 scoop/disher/dipper was being used for serving the Coleslaw, instead of a #8 dip (4 ounces) as per the menu (2024 S/S Menu Diet Spreadsheet for Week 2, day 10, Tuesday, Supper); she told the PM [NAME] to serve half a scoop (half of a #16 scoop/disher/dipper). The Kitchen Supervisor was asked if there was a #8 scoop/disher/dipper in the kitchen. The Kitchen Supervisor went to the Cook's Area and came back with a 4-ounce spoodle. The Kitchen Supervisor said no #8 scoop/disher/dipper was available. On 07/09/2024 at 6:06 PM, the surveyor looked for any posting of a disher/scoop/dipper conversion chart in the kitchen, but there was not one. When asked about a disher/scoop/dipper conversion chart to identify the ounces or cup size for each number size of disher/scoop/dipper; the Dietary Manager said he had seen one in another facility recently and thought that would be good for his kitchen, but they did not currently have one. The Dietary Manager was asked if the RD had been told of the decision to leave cheese out of the pureed hamburger patty and bun mixture and if she had given approval for that change to the menu. The Dietary Manager said no. On 07/10/2024 at 5:20 PM, the Dietary Manager displayed a small conversion chart for scoops/dishers/dippers, spoodles, cup sizes, and ounces he had printed out. The Dietary Manager said he would be using it to teach the staff about portions and that he was going to post it on the wall by the steamtable. The Basics at a Glance conversion chart included the following: #6 scoop/disher/dipper equals 2/3 cup or 5.3 fluid ounces #8 scoop/disher/dipper equals 1/2 cup or 4 fluid ounces #16 scoop/disher/dipper equals 1/4 cup or 2 fluid ounces The Dietary Manager also said he was ordering more #8, #12, #16 scoops/dishers/dippers. On 07/11/2024 at 11:03 AM, the staff was preparing for the Lunch meal. At 11:21 AM, covered food pans were being placed on steamtable. At 11:30 AM, the food temperatures on the steamtable were being checked. The following serving utensils were observed to be incorrect for the portions listed on the 2024 S/S Diet Spreadsheet for Week 2, Day 12, Thursday, Lunch: Ground Bratwurst had a 3-ounce spoodle for service, but the menu listed a #8 dipper (4 ounces) for the Mechanical Soft (Mech Soft) diet entree. Pureed Bratwurst had a 3-ounce spoodle for service, but the menu listed a #8 dip (4 ounces) for the Pureed diet entree. Pureed Seasoned Diced Potatoes had a 3-ounce spoodle for service, but the menu listed a #8 dip (4 ounces) for the Pureed diet starch/potato. Service of the Lunch trayline began at 11:47 AM. On 07/11/2024 at 12:32 PM, the Kitchen Supervisor was asked for copies of the production sheets used for Supper on Tuesday (Day 10) and for Lunch today (Day 12, Thursday). The Kitchen Supervisor explained that the number of servings on the production sheets were not correct. The Kitchen Supervisor said they were mainly using the sheets for the menu items that needed to be prepared and for the portion sizes to be served. 1. The production sheet for Supper - Day10 - Tuesday included the following: . Pureed Cheeseburger on Bun (Pureed) . #6 dip . . Coleslaw . #8 dip . 2. The production sheet for Supper - Day12 - Thursday included the following: . Ground Bratwurst w/Gvy [with Gravy] (Dental Soft (Mech Soft)) . #8 dipper . . Pureed Bratwurst (Pureed) . #8 dip . . Pureed Seasoned Diced Potatoes (Pureed) . #8 dip . On 07/11/2024 at 12:46 PM, while the trayline was stopped to wait on additional sauteed peppers and onions, the AM [NAME] and the Diet Aide/Relief [NAME] were asked about Pureed diets. Each said there were only four Pureed diet plates for lunch today and none of the those were Renal diets. On 07/11/2024 at 1:02 PM, upon the completion of the trayline Lunch service; the Kitchen Supervisor, the AM Cook, and the Diet Aide/Relief [NAME] each confirmed that 3-ounce spoodles were used to serve the Pureed Bratwurst and the Pureed Seasoned Diced Potatoes. When asked if they had been instructed to use the 3-ounce spoodles for puree foods, the Kitchen Supervisor said yes. On 07/12/2024 at 10:33 AM, the Registered Dietitian (RD) was interviewed by phone. The RD was asked the problem with serving a smaller portion than listed on the menu. The RD said there was a potential of not meeting the residents' nutritional needs if the wrong scoop (scoop/disher/dipper) was consistently used. When asked why it was important to check with the RD before changing the menu; the RD said we are providing an adequately balanced diet throughout the day so we want to make an appropriate substitution if something is changed,

Based on observations, record review, interviews and review of a facility policy titled, Restraint Free Environment, the facility failed to ensure Resident Identifier (RI) #73's wheelchair (WC) seat belt was released during meal times on three of seven days of the survey 07/09/2024, 07/12/2024, and 07/15/2024. This deficient practice affected RI #73, one of one resident reviewed for the use of restraints. Findings include: RI #73 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses to include Unspecified Convulsions and Cerebral Palsy. Review of a facility policy titled, Restraint Free Environment, with a Copyright date of 2023, revealed the following: . Definitions: Physical Restraints refers to any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body . Compliance Guidelines: . 5. Before a resident is restrained, the facility will determine the presence of a specific medical symptom that would require the use of restraints, and determine: . b. the time and frequency that the restraint will be released . RI #73's care plan titled, (Name of RI #73) uses a physical restraints (lap belt) ., with an initiated date of 07/06/2022, revealed the following intervention * Apply seat belt restraint while up in wheelchair and release during meal times . On 07/09/2024 at 12:59 PM, RI #73 was observed sitting in a WC with a seat belt intact around his/her waist. On 07/09/2024 at 1:12 PM, RI #73's lunch meal was served and RI #73 began to feed him/herself. RI #73's seat belt remained intact at this time. On 07/09/2024 at 1:24 PM, RI #73 continued to feed him/herself with the seat belt remaining intact around his/her waist. On 07/09/2024 at 1:30 PM, RI #73 competed the lunch meal. The seat belt remained intact throughout the lunch meal. On 07/12/2024 at 8:19 AM, RI #73 was observed up in the WC feeding him/herself the breakfast meal. The surveyor again observed RI #73's seat belt intact around RI #73's waist. On 07/12/2024 at 12:45 PM, RI #73 was observed in his/her WC. RI #73's lunch tray was brought in and set up for resident to eat. RI #73's seat belt was again observed intact around RI #73's waist. On 07/12/2024 at 2:43 PM, an interview was conducted with Certified Nursing Assistant (CNA) #24. CNA #24 said RI #73 used a seat belt which should be released every two hours. CNA #24 said she did not know the seat belt should be released at meal times. On 07/12/2024 at 5:57 PM, an interview was conducted with Registered Nurse (RN) #25, the Unit Manager for the unit RI #73 resided on. RN #25 said RI #73 used a seat belt when up in the WC. RN #25 said according to RI #73's plan of care, the seat belt should be released during meal times. RN #25 said RI #73's belt is to be released to allow RI #73 free time from the restraint. On 07/12/2024 at 6:24 PM, an interview was conducted with the Licensed Practical Nurse/Minimum Data Set Coordinator (LPN/MDSC). The LPN/MDSC said any type devices that prevents a resident from rising or being able to freely move would be a restraint. The LPN/MDSC said a seat belt could keep a resident from being able to move freely. The LPN/MDSC said an intervention on RI #73's care plan was to apply the seat belt while up in the WC and release during meal times. When asked why it would be important to release the seat belt during meals times, the LPN/MDSC said one of the main reasons the seat belt was to be released was for free time for the resident. On 07/15/2024 at 6:00 PM, RI #73 was again observed feeding him/herself. RI #73's seat belt remained intact around RI #73's waist at this time.

Based on observations, review of the medical record, and staff interview, and review the facility policy titled Restorative nursing Programs, the facility failed to ensure a splinting device for Resident Identifier (RI) #64's hand was in place on 07/09/2024 and 07/11/2024 to prevent decreased Range of Motion (ROM). Findings Include: Review of an undated facility policy titled Restorative Nursing Programs documented: Policy: It is the policy of this facility to provide maintenance and restorative services designed to maintain or improve a resident's abilities to the highest practicable level. Definition: . This concept actively focuses on achieving and maintaining optimal physical, mental and psychosocial functioning. RI #64 was admitted to the facility on [DATE] with a diagnosis of Multiple Sclerosis. RI #64's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/24/2024 noted RI #64's Brief Interview for Mental Status (BIMS) score to be 15 of 15 which indicated intact cognition. Review of RI #64's July Physician Orders documented: . RESTORATIVE NURSING: SPLINTS: LEFT HAND SPLINT/PALM GUARD RESIDENT CAN WEAR SPLINT 6-8 HOURS . 03/9/2022 . BRACE FOR LEFT HAND TO KEEP FINGERS EXTENDED . Review of RI #64's Care Plan documented a follows: RI #64 . has limited physical mobility r/t Neurological deficits . Intervention: SPLINT: LEFT HAND SPLINT/ PALM GUARD TIME/DURATION: RESIDENT CAN WEAR SPLINT 6-8 HOURS DAILY . On 07/09/2024 at 1:25 PM RI #64 was observed with left hand contracted and no splinting device was observed on the left hand of the resident. On 07/09/2024 at 4:25 PM RI #64 was observed with no splint to the left hand. RI #64 said he/she was supposed to be wearing the splint daily but staff did not put it on. RI #64 said the splint was in the basket on the bedside table. On 07/11/2024 at 10:39 AM and on 07/11/2024 at 12:24 PM RI #64's splint was observed on the bedside table. 07/11/2024 at 5:54 PM RI #64's splint was observed on the bedside table. RI #64 said the hand brace/splint had not been on all day. 07/12/2024 at 11:13 AM during an interview with Certified Nursing Assistant CNA #16 she said RI #64 required assistance with bathing, dressing, and could only reach with the right hand. CNA #16 said RI #64 had weakness on one side related to a stroke, and was to have assistive devices of an arm brace to left hand. CNA #16 said it was to be applied by the restorative staff. On 07/12/2024 at 11:23 AM during an interview with the restorative aide CNA #14, said her job duties were to perform the residents functional maintenance program after a resident comes off therapy. She said that included exercises such as walking residents, range of motion, and applying splints. CNA #14 said RI #64 received range of motion and a splint to his/her left hand. CNA #14 said the purpose of the splint was to keep RI #64's hand from contracting further. She said it was an important device, RI # 64's plan was to have splint applied four to five hours a day five to six times a week. CNA #14 said on 07/09/2024, 07/11/2024 and 07/12/2024 she was out of the building on appointments and no one performed her job or interventions if she was out of the building. On 07/12/2024 at 4:01 PM during an interview with the Restorative Nurse she said she was to oversee the restorative aides. The Restorative Nurse said RI #64 was to have a brace/splint to the left hand due to contractures, and was to wear the splint daily six to eight hours to keep contractures from getting worse. She said restorative staff were responsible for ensuring the splints were applied. She said RI #64's splint should have been applied.

Based on interviews, record review, review of a facility policy titled, Abuse, Neglect and Exploitation, and review of information from the Alabama Department of Public Health's (ADPH) Online Reporting System, the facility failed to ensure Resident Identifier (RI) #51 was free from misappropriation of funds from his/her personal funds. On 05/30/2024 RI #51 reported she was missing his/her money pouch and money. The money pouch and some of the money was later located in RI #123's bedside drawer. This deficient practice affected RI #51, one of 17 residents sampled for abuse. This deficiency was cited as a result of the investigation of complaint/report number AL00048010. Findings Include: A review of the facility Abuse, Neglect, and, Exploitation Policy, , revealed: Policy: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit .misappropriation of resident property . Definitions: . Misappropriation of Resident Property: means deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a resident's belongings or money without the residents consent . RI #123 was admitted to the facility on [DATE]. RI #51 was readmitted to the facility on [DATE]. A review of Resident #51's 5-day Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/26/2024 revealed Resident #51 had a Brief Interview for Mental Status (BIMS) score of 14 of 15, which indicated the resident was cognitively intact. The ADPH Online Facility Report Incident dated 05/30/2024, identified . Incident Type . Abuse-Misappropriation of Resident Property . Narrative summary of Incident: (RI #51) reported that (he/she) was missing money that (he/she) received from the front office on 05/29/2024. (He/She) said their money pouch was also missing. Later, part of (RI #51)'s money was found in (RI #123)'s bedside drawer. On 07/11/2024 at 10:36 AM, an interview was conducted with RI #123. RI #123 was asked about a pouch with money being found in his/her bedside table in May of 2024. RI #123 said, he/she did not recall anything about a pouch of money. On 07/12/2024 at 11:30 AM, an interview was conducted with RI #51. RI #51 recalled when his/her money went missing in May of 2024. RI #51 said, after returning to the facility, he/she noticed his/her purse with $50.00 was missing. RI #51 said that he/she received the money back and received a lock box with a key to securely store his/her purse and money. On 07/11/2024 at 10:45 AM, an interview was conducted with the Administrator. The Administrator said that upon learning about RI #51's missing money, she initiated an investigation. She stated that during the investigation, another resident informed her that RI #123 had the missing pouch. The Administrator said that she visited RI #123's room and inquired about the missing money. She mentioned that RI #123 initially denied having the money, but when she opened RI #123's bedside drawer, the pouch with RI #51's name on it was found. The Administrator stated that some of the money had been spent, but the facility replaced the entire amount, and RI #51 expressed satisfaction with the outcome. The facility took immediate actions to correct the non-compliance and prevent reoccurrence by: ******************************************** - On 05/30/2024, RI #51, reported missing money received from the front office on 05/29/2024 and a missing money pouch. - A report was made to the Alabama Department of Public Health (ADPH) on 05/30/2024. - A report was made to the local police department 05/30/2024. - RI #51's money was replaced on 05/30/2024. - RI #51 was given a lock box with a key to keep in his/her room [ROOM NUMBER]/30/2024. - RI #123 was counseled that he/she could not take other residents money. - On 05/31/2024 All residents known to withdraw large amounts of money from the business office were offered a lockbox and a key. Residents were encouraged not to keep large amounts of money in their room but if they wanted, they could request a lock box. - All staff were educated on Misappropriation. Completed 05/31/2024. - Staff to monitor the residents for excess money in room and notify charge nurse or administrator so their money can be protected with a lock box 3 times a week x 2 weeks; then 2 times a week x 2 weeks; then 1 x a week x 4 weeks. Ongoing. - Compliance has been met no further concerns identified. ************************* After review of documentation supporting the above corrective actions, including the facility's investigation file, in-service/education records, and staff interviews, the survey team verified the facility implemented corrective actions including ongoing monitoring from 05/30/2024 to 05/31/2024; thus, past non-compliance was cited.

Based on interviews, record review, group council meeting, and review of facility policy titled Resident and Family Grievances, the facility failed to ensure grievances filed by Resident Identifier (RI) #40 and RI #116 on 05/14/2024, 05/21/2024, and 05/30/2024 were resolved in a timely manner. Further, the facility failed to take prompt action to update complainants of progress towards a resolution. This deficient practice affected two of two residents sampled for grievances. Findings Include: A review of an undated policy titled Resident and Family Grievances revealed the following: Policy: It is the policy of this facility to support each resident's and family member's right to voice grievances . Definitions: Prompt efforts to resolve include . actively working toward resolution of that complaint/grievance . Procedure: . d. The Grievance Official will take steps to resolve the grievance, and record information about the grievance, and those actions on the form . e. The Grievance Official, or designee, will keep the resident appropriately apprised of the progress towards resolution of the grievances . RI #116 was admitted to the facility on [DATE]. A review of RI #116 quarterly Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 05/17/2024 revealed RI #116's Brief Interview for Mental Status (BIMS) score was 15 of 15 which indicated intact cognition. RI #40 was readmitted to the facility on [DATE]. RI #40's quarterly MDS assessment with an ARD of 06/20/2024 revealed a BIMS score of 9 of 15 which indicated moderate cognitive impairment. On 07/10/2024 at 3:05 PM a resident council meeting was held. The residents were asked if the facility responded timely with a resolution when grievances were filed. Residents voiced concerns regarding prompt action when grievances filed. RI #116 said he/she filed a grievance in May of 2024 regarding personal items damaged or missing and had not been informed of the progress toward a resolution. On 07/10/2024 at 4:36 PM, a review of the facility grievance book revealed RI #116 had unresolved grievances filed on 05/14/2024 and 05/21/2024 concerning damaged personal items. Further review of the forms revealed no documented action or efforts taken toward resolving the concern filed on either grievance. On 05/30/2024, RI #40's Responsible Party (RP) filed a grievance concerning RI #40's missing clothing items. Again, the form revealed no documented action or efforts taken towards resolving the complaint. On 07/10/2024 at 6:23 PM, an interview with the facility's Social Worker (SW) was conducted and revealed she was the Grievance Official. The SW said, when a grievance was filed, it was written up and submitted to the responsible department and follow up was done with the family and or resident regarding a satisfactory resolution. When asked what facility considered a prompt response time when following up with family or resident regarding grievance, she said, five days. When asked if July would be considered a prompt response time in following up with grievances filed in May, the SW said no. When asked why RI #116 had not been updated on the facilities efforts to resolve the complaint, the SW said the efforts should have been documented on the form.

Based on observations, interviews, and the facility policy titled, Safe and Homelike Environment, the facility failed to ensure two of six shower rooms on the South unit in the facility were free of soap build up on the walls and dark coloring on the floors. This affected Resident Identifier (RI) #108, and two of 11 shower rooms in the facility; however, the deficient practice had the potential to affect all 60 residents residing on the South unit who used the shower rooms. This deficient practice was cited as a result of the investigation of complaint/report number AL00048274. The facility further failed to ensure the left arm rest on RI #73's wheelchair (WC) was not torn. This affected RI #73, one of one resident observed with a torn WC armrest. Findings Include: Review of an undated facility policy titled, Safe and Homelike Environment, documented: Policy: In accordance with resident rights the facility will provide a safe, clean, comfortable and homelike environment, . Sanitary includes, but is not limited to, preventing the spread of disease-causing organisms by keeping resident care equipment clean and properly stored. Resident care equipment includes, but is not limited to equipment used in completion of the activities of daily living. On 07/10/2024 at 8:25 AM, the shower rooms were observed, two of the shower rooms on South unit were found with stains, and dried soap on the walls and floors. RI #108 was admitted to the facility 03/02/2023. Review of RI #108's quarterly Minimum Data Set (MDS) assessment with an Assessment Reference Date of 06/03/2024 indicated RI #108 had a Brief Interview for Mental Status score of 15 of 15 which indicated RI #108 was cognitively intact. On 07/10/2024 at 8:25 AM RI #108 complained shower rooms were dirty and an immediate observation was made of all the shower rooms on the South unit. The second shower room on the South unit was observed with the Administrator (ADM) and the Maintenance Director (MtD). The ADM was interviewed during the observation. The ADM said she saw dried soap and stained dark colored substance on floors of the second shower room of the South hall. The ADM said it was not homelike when the shower rooms were dirty. The surveyor and ADM observed the third shower room. The ADM said she saw stains on the walls and floor and there was an odor in the third shower room. She described what she observed in the third shower room as a dark coloring on tile and around the base of the floor. The ADM said it was not homelike. The ADM said the shower rooms should have been cleaned better. On 07/11/2024 at 6:11 PM, the MtD was interviewed as he was present during the observation of the shower rooms with the ADM. He said the facility had six shower rooms, and five tub rooms. He observed the shower rooms on the South unit and said they needed some work. The MtD said he observed soap build up and dark spots where water built up and dried. He said the shower rooms were not homelike. 21055 RI #73 was admitted to the facility on [DATE] and readmitted on [DATE]. On 07/09/2024 at 12:59 PM, RI #73 was sitting up in a WC and the left arm rest on the WC was torn with a missing piece. On 07/10/2024 at 6:45 PM, RI #73's arm rest remained torn with a missing piece. On 07/11/2024 at 7:38 AM, the left arm rest remained the same. On 07/12/2024 at 8:19 AM, RI #73's left arm rest on the WC remained with the torn area. On 07/14/2024 at 1:14 PM, the left arm rest on RI #73's WC remained in the same condition. On 07/14/2024 at 1:27 PM, the ADM #20 was shown RI #73's left arm rest and asked, how should the arm rest on the resident's WC look. ADM #20 said it should not be torn and tattered. When asked to describe RI #73's arm rest, ADM #20 said the arm rest was torn and worn and was not in good repair.

Based on interviews, record reviews and review of facility policies titled Abuse Investigation and Reporting and Controlled Substances, review of APDH (Alabama Department of Health) Online Incident Reporting Systems, the facility failed to ensure [MEDICATION(S)]-Acetaminophen ([MEDICATION(S)]) and [MEDICATION(S)] ([MEDICATION(S)]) medication for Resident Identifiers (RI) #1 - 12 were not misappropriated when the Pharmacy delivery sheet indicated medications were delivered to the facility; however, not in the facility or documented as administered per facility investigation on 9/20/22. This affected 12 of 28 residents receiving either [MEDICATION(S)] or [MEDICATION(S)]. This deficient practice substantiated investigation of Complaint AL 086. Findings Include: A review of a facility policy titled Abuse Prevention Program, with a revised effective date of April 2019, revealed: Policy Statement . Our residents have the right to be free from . misappropriation of resident property . Definitions . 4. 'Misappropriation of Property,' the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent . A review of a facility policy titled Controlled Substances, with a revised date of December 2012. Policy Statement The facility shall comply with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of Schedule II, and other controlled substances. 3. Controlled substances must be counted upon delivery. The nurse receiving the medication, along with the person delivering the medication, must count the controlled substances together. Both individuals must sign the designated controlled substance record. 4. If the count is correct, an individual resident-controlled substance record must be made for each resident who will be receiving a controlled substance . This record must contain . c. Quantity received; . k. Signature of person receiving medication; and l. Signature of nurse administering medication. A review of a facility reported incident ADPH Online Incident Reporting System dated 9/20/22 revealed . Misappropriation of Resident Property . Names of resident involved (RI #1) . Narrative summary of incident: DON (Director of Nursing) was notified of the resident medication was out and it was not time for a refill. Alterations to the Control Drug sheet done to cover up the count . RI #1 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of RI #1's September physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Start Date 8/11/2022 . A review of a pharmacy Packing Slip dated 8/29/22 revealed . Resident name (RI) #1 Quantity 81.00 Medication Label Name [MEDICATION(S)]/APAP 7.5-325 (handwritten initials of Employee Identifier (EI) #4) . Pharmacy signature . Nurse signature EI #4 . Nurse signature EI #8 . A review of a facility form titled Controlled Drug Receipt Record/Disposition Form revealed resident name date received 8/29/2022 Drug name [MEDICATION(S)]/APAP TAB 7.5-325 . Quantity Received 81.00 with a line through 81.00 handwritten 60 and handwritten 30 . A review of a form from the facility pharmacy revealed the pharmacy dispensed [MEDICATION(S)]/APAP ([MEDICATION(S)]) quantity of 81 on 8/29/22 for RI #1. The facility match back revealed 21 tablets missing. RI #2 was admitted to the facility on [DATE]. A review of RI #2's Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of a pharmacy form revealed the pharmacy dispensed [MEDICATION(S)]-APAP 180 tabs on 8/22/22 for RI #2. The facility match back revealed 150 tabs unaccounted for. RI #3 was admitted to the facility on [DATE]. A review of RI #3's Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of a pharmacy form revealed the pharmacy dispensed 90 [MEDICATION(S)]/APAP 7.5-325 MG tabs on 8/30/22 for RI #3. The facility match back revealed 90 tabs missing. RI #4 was admitted to the facility on [DATE]. A review of RI #4's September physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of a pharmacy form revealed the pharmacy dispensed 120 [MEDICATION(S)]/APAP tablets on 8/10/22 for RI #4. The facility match back revealed 120 tablets missing. RI #5 was admitted to the facility on [DATE]. A review of RI #5's September physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of a pharmacy form revealed the pharmacy dispensed 120 [MEDICATION(S)]/APAP tablets on 8/11/22 for RI #5. The facility match back revealed 120 tablets missing. RI #6 was admitted to the facility on [DATE]. A review of RI #6's September Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of a pharmacy form revealed the pharmacy dispensed 60 [MEDICATION(S)] tablets on 8/12/22 for RI #6. A facility match back revealed 60 missing tablets. RI #7 was admitted to the facility on [DATE]. A review of RI #7's September Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of a pharmacy form revealed the pharmacy dispensed [MEDICATION(S)] 180 tablets on 8/15/22 for RI #7. A facility match back revealed 180 tablets missing. RI #8 was admitted to the facility on [DATE]. A review of RI #8's September Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of a pharmacy form revealed the pharmacy dispensed 90 [MEDICATION(S)]/APAP for RI #8. A facility match back revealed 90 tablets missing. RI #9 was admitted to the facility on [DATE]. A review of RI #9's September Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of a pharmacy form revealed the pharmacy dispensed 90 [MEDICATION(S)]/APAP tablets on 8/15/22 for RI #9. A facility match back revealed 90 missing tablets. RI #10 was admitted to the facility on [DATE]. A review of RI #10's September Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of a pharmacy form revealed the pharmacy dispensed 30 [MEDICATION(S)]/APAP tablets on 8/22/22 for RI #10. RI #11 was admitted to the facility on [DATE]. A review of RI #11's September Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of a pharmacy for revealed the pharmacy dispensed 90 [MEDICATION(S)]/APAP tablets for RI #11 on 8/29/22. A facility match back revealed 90 missing tablets. RI #12 was admitted to the facility on [DATE]. A review of RI #12's September Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of a pharmacy form revealed the pharmacy dispensed 120 [MEDICATION(S)]/APAP for RI #12 on 8/24/22. A facility match back revealed 120 tablets missing. A review of RI #2 through RI #12's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the facility interview conducted by EI #1, Administrator with Employee Identifier (EI) #4 was done after several unsuccessful attempts to reach EI #4. The interview was as follows: Interview of EI #4 . 9/19/22. EI #1 asked Did you receive some [MEDICATION(S)] for RI #1 on 8/29/22? EI #4's reply I don't remember. EI #1 ask . Did you change the count? EI #4's reply, I did I wrote 30. EI #1 ask Why? EI #4's reply, I don't know EI #1 ask . Did you sign for 81 [MEDICATION(S)] for RI #1 on 8/29/22? EI #4's reply Yes. EI #1 showed EI #4 both sheets of the Controlled Drug sheet and asked, for the difference. EI #4's reply, There is no difference. After showing how the control sheet was altered ask if she could explain? EI #4's reply I don't know how it happened. EI #1 ask . How many cards came in originally in the facility? EI #4's reply, 2. EI #1 ask, Any information to help us understand what has happened? EI #4's reply, No ma'am. EI #1 ask, Do you understand the seriousness of what is happening? EI #4's reply, yes maam. EI #1 ask If you said you received 2 cards where is the other card? EI #4's reply, I don't know . A review of a follow up interview with EI #1 and EI #5 on 9/23/22 revealed EI #1 ask EI #4 . did you take the medication out the facility? EI 4's reply, What is my options. On 10/5/22 at 7:20 PM a phone interview was conducted with EI #8, a Licensed Practical Nurse. EI #8 was asked, what was the policy on receiving medication and conducting card counts. EI #8 replied, two nurses go out to the pharmacy delivery person and count the medication, review the packing slip, then each nurse and the delivery person sign the packing slip. EI #8 was asked if she recalled how many pills were delivered for RI #1. EI #8 replied if it said 81 that was what was there. EI #8 was asked, if only 60 came and should be 81 what would she have done. EI #8 replied, notify the supervisor; if it came and the sheet said 81, that was delivered. EI #8 stated EI #4 and she signed for the medication at the front and then each nurse went to their respective carts. EI #8 was asked if she went to the front with nurse EI #4 on 8/29/22 to receive medication from the pharmacy. EI #8 replied, yes, EI #4 checked the medication, and the quantity then initialed each medication's quantity and signed her name at the bottom. Then EI #8 verified the medication and quantity and signed her name at the bottom of the packing slip beside EI #4's name. EI #8 was asked, what did she know about 81 [MEDICATION(S)] for RI #1 delivered, then the control sheet having 60. EI #8 replied, she did not know why, it had 81 when they checked it in and signed then EI #4 took the medications to her cart and EI #8 went to hers. On 10/6/22 at 12:30 PM, an interview was conducted with EI #2, the Director of Nursing. EI #2 was asked, when were you made aware of RI #1's medication of [MEDICATION(S)] missing. EI #2 replied, Monday 9/19/22. EI #2 was asked that did the facility do. EI #2 replied, she called the pharmacy, they said it was too soon to refill the medication, so she spoke to the pharmacist and told him she had a control sheet that had a total of 60 at the top, the pharmacist said the pharmacy sent 81 tablets. EI #2 said the facility policy was when nurses complete a narcotic sheet, they were to bring the original copy to the DON's office. EI #2 said she looked in her file and had a copy which was not the original, so she went to RI #1's chart and found another copy of the 60 tabs and also the original sheet with the 81 tabs. EI #2 was asked, what was the condition of the original sheet. EI #2 replied, the 81 was crossed out and a 60 was written in and then another sheet had 81 crossed out and a 30 written in. The sheet with 60 typed and 30 handwritten in. EI #2 said they noticed it appeared the sheet with the typed in 60 had been altered, in the chart they found three different sheets, two with 81 and a copy of one with 60. EI #2 was asked what were the dates on all of the copies. EI #2 replied, 8/29/22. EI #2 was asked, when did the facility start the investigation. EI #2 replied, 9/19/22 after they went and checked all the carts, and did 100 % audit they found several residents had narcotic pills missing also some requestion sheets missing. EI #2 said when they did audits and looked at requisitions and some were missing. EI #2 was asked how many doses of the [MEDICATION(S)] did RI #1 not receive. EI #2 replied, seven doses. EI#2 was asked, what did the facility determine happened to the [MEDICATION(S)]. EI #2 replied, the investigation determined the medication was missing. EI #2 was asked, what was the policy and procedure for accepting controlled medication in the facility at the time of the missing medications on 9/19/22. EI #2 replied, two nurses go to the lobby to accept medications with the pharmacy person. The nurses counted the medications together once the count was verified both nurses and pharmacy delivery person signed the requisition sheet and each nurse to took the medications to their units and put in the narcotic boxes. When asked if the policy was followed EI #2 replied, as far as they knew yes it was. EI #2 was asked, what was it when resident's medication was diverted. EI #2 replied, misappropriated of a resident's property, once the medication was assigned to the resident it became their property. EI #2 was asked, who was responsible for ensuring the narcotic medications were received at the facility. EI #2 replied, the two nurses. EI #2 was asked who was responsible for ensuring controlled medication was placed in the narcotic box on the medication cart. EI #2 replied, the nurse that received the medication, when the nurse went to their wing, they were to make sure it got to the narcotic boxes. EI #2 was asked, what had the facility done to decrease risks for misappropriation of resident's narcotic medications. EI #2 replied, now when nurses received medication two nurses went to lobby with pharmacy delivery person counted the medication, after the count was done both signed the requisition with pharmacy representative and instead of branching off to their units now both nurses went together, counted together, placed the medications in the locked narcotic box, and signed off together for each medications cart. Also, pharmacy requisitions were sent by email to the facility the next day, which was the packing slip or proof of delivery. EI #2 was asked who accepted the medication with nurse EI #4. EI #2 replied, EI#8. EI #2 was asked. EI #2 replied, where were the remaining [MEDICATION(S)]. EI #2 replied, the facility determined they were missing. EI #2 was asked, what should have been done to prevent missing medications. EI #2 replied, we had procedures in place if the procedure was followed, the requisition sheets were taken. EI #2 was asked, how do you know nurses counted and signed. EI #2 replied, by the packing slip, signatures were EI #4 and EI #8. EI #2 was asked, whose signatures were on the packing slip. EI #2 replied, EI #4 and EI #8. On 10/6/22 at 1:15 PM an interview was conducted with EI #1, the Administrator. EI #1 stated that she was in the DON's office during the conversation with the nurse about RI #1's missing [MEDICATION(S)]. EI #1 was asked, when did the facility do an investigation. EI #1 replied, at that time, we started immediately, the DON had been looking through control sheets, she recalled a control sheet that morning and it prompted her look closer. We discovered pharmacy sent 81 tabs for RI #1, we knew we had a problem, so we contacted the pharmacy and asked for a requisition from the pharmacy for all controlled medications delivered to the facility. EI #1 said they compared the list to the requisition and determined 12 residents on the list had medication ordered but the medication was not in the narcotic boxes. The packing slips for those residents' medications were not able to be found in the facility. EI #1 was asked, what did the investigation reveal. EI #1 replied, after finishing the audit for all residents, 12 were identified with missing medications, that included [MEDICATION(S)] and [MEDICATION(S)]. The investigation showed EI #4's name on all pieces of the forms we had, and all the medications that were missing EI #4's name was tied to them. EI #1 was asked, what type of incident would diversion of resident medication be. EI #1 replied, misappropriation of property. EI #1 was asked what policy and procedure did the facility have in place to prevent diversion prior to recent investigation. EI #1 replied, we had the procedure placed for two nurses to go to the front with the delivery person, the nurses would count to verify the medications, and both nurses would sign the packing slip as would the delivery person. The facility started counting narcotic cards and any medications added in the box would be added, and then two nurses would sign also when cards were completed. We also had the manifest sheets to compare to the cards in the carts and it was done daily. EI #1 was asked, what was the outcome of the plan. EI #1 replied, we followed the plan, were signing medication in, medication that was brought to cart was signed by two nurses. Some manifest sheets were not there so there was nothing to compare to; we called the pharmacy and now pharmacy sends signed packing sheet the next day. EI #1 was asked, where was the breakdown in the policy if medication continued to be diverted. EI #1 replied, when the two nurses signed the medication, then each went to their respective units/halls. EI #1 said currently, both nurses went to each cart and signed in the medications and added to the card counts or records. The nurses stayed for each medication to be logged on the card count and placed in the narcotic drawer.

Based on interviews, record review, review of facility policies titled Pharmacy Services Overview and Controlled Substances, and review of the facility's five (5) day summary report, the facility failed to ensure residents' controlled substances, [MEDICATION(S)]-Acetaminophen ([MEDICATION(S)]) and [MEDICATION(S)] ([MEDICATION(S)]) medications were available for administration; and further failed to ensure Resident Identifier (RI) #1's scheduled [MEDICATION(S)] 7.5 mg (milligram) was available for administration on 09/17/2022 at 6:00 AM, 2:00 PM and 10:00 PM, on 09/18/2022 at 6:00 AM, 2:00 PM and 10:00 PM, and on 09/19/2022 at 6:00 AM. This deficient practice affected 12 of 28 residents receiving the controlled medications [MEDICATION(S)] and [MEDICATION(S)]; and RI #1, one of three sampled residents receiving scheduled controlled medications. Findings include: Review of another facility policy titled Controlled Substances, with a revised date of 12/2012, revealed the following: Policy Statement The facility shall comply with all laws, regulations, and other requirements related to handling, storage . and documentation of Schedule II and other controlled substances. Policy Interpretation and Implementation . 4. an individual resident-controlled substance record must be made for each resident who will be receiving a controlled substance . 5. Controlled substances must be stored in the medication room in a locked container . Review of a facility policy titled Pharmacy Services Overview, with a revised date of 04/2019, revealed the following: Policy Statement The facility shall accurately and safely provide or obtain pharmaceutical services, including the provision of routine . medications . Policy Interpretation and Implementation . 3. Pharmacy services are available to residents 24 hours a day, seven days a week. 4. Residents have sufficient supply of their prescribed medications and receive medications (routine .) in a timely manner . 7. Medications are received . stored, administered . according to all applicable state and federal laws and consistent with standards of practice . A review of the facility's five-day summary dated 09/23/2022, revealed the following: . On September 19, 2022, at 1115 (11:15 AM) the administrator (Employee Identifier [EI] #1) was notified by (EI #2) DON (Director of Nursing) about (RI #1) was out of (his/her) medication . After speaking with (EI #12, the pharmacist) at the pharmacy, he informed us there were 81 pills dispensed to (RI #1). After looking at the Narcotic control sheet, it showed the quantity was 60. (EI #12) had (EI #2) to fax the Controlled Narcotic sheet to him . After examining the original Narcotic Control Sheet and the copy that was turned in to the DON, it was identified the Narcotic Control Sheet had been altered. This began an investigation because 21 pills were now missing . . (RI #1) did confirm he was out of his medication and staff did offer him something for pain. (He/She) said they offered (him/her) Tylenol, but (he/she) did not want it because it made (him/her) sick one time . (EI #4, the RN [Registered Nurse] assigned to care for RI #1 on 09/17/ 2022 at 6:00 AM, on 09/18/2022 at 10:00 PM and on 09/19/2022 at 6:00 AM) was interviewed concerning the missing [MEDICATION(S)]. When asked if she received (RI #1's) [MEDICATION(S)] on 8/29/22 she stated she did not remember. She was asked if she was in-serviced on not to change the number on the control narcotic she stated, Y'all said not to change the number. When asked why she changed the number she said, I don't know. (EI #5) RN (the licensed staff providing care for RI #1 on 09/18/2022 at 2:00 PM) was interviewed concerning if the resident (was) out of medication when she reported to work. She stated the resident had no [MEDICATION(S)] on the cart . A 100% audit was done on all resident(s) that have received narcotics in the facility. In this audit it was noted that 12 residents were affected with missing medication . There are two targeted medication(s) that are missing, the two types of medication are [MEDICATION(S)] and [MEDICATION(S)] . 1) RI #1 was admitted to the facility on [DATE] and readmitted on [DATE]. A review of RI #1's September 2022 Medication Review Report (Physicians Orders) revealed RI #1 had orders to receive [MEDICATION(S)]-Acetaminophen 7.5 mg by mouth every eight hours for pain related to his/her Unspecified Pain. A review of a Packing Slip from the pharmacy, dated 08/29/2022, revealed RI #1 received 81 [MEDICATION(S)]-Acetaminophen 7.5-325 mg (milligram) tablets. According to RI #1's September 2022 eMAR (electronic Medication Administration Record) on 09/16/2022 at 10:00 PM, 18 days later, RI #1 was administered the last available dose of his/her [MEDICATION(S)] medication. RI #1 missed receiving his/her scheduled [MEDICATION(S)] on 09/17/2022 at 6:00 AM, 2:00 PM and 10:00 PM, on 09/18/2022 at 6:00 AM, 2:00 PM and 10:00 PM, and on 09/19/2022 at 6:00 AM. 2) RI #2 was admitted to the facility on [DATE]. A review of RI #2's Physician orders for September revealed . [MEDICATION(S)]-Acetaminophen Tablet 5-325 Give 1 tablet (one) by mouth every 4 (four) hours as needed for pain . A review of a pharmacy form revealed the pharmacy dispensed [MEDICATION(S)]-APAP 180 tabs on 8/22/22 for RI #2. The facility match back revealed 150 tabs unaccounted for. 3) RI #3 was admitted to the facility on [DATE]. A review of RI #3's Physician orders for September 2022 revealed . [MEDICATION(S)] Tablet 7.5-325 MG (milligram) ([MEDICATION(S)]-Acetaminophen) Give 1 tablet by mouth every 6 hours as needed for pain. A review of a pharmacy form revealed the pharmacy dispensed 90 [MEDICATION(S)]/APAP 7.5-325 MG tabs on 8/30/22 for RI #3. The facility match back revealed 90 tabs missing. 4) RI #4 was admitted to the facility on [DATE]. A review of RI #4's September physician orders revealed .[MEDICATION(S)] Tablet 7.5-325 MG ([MEDICATION(S)]-Acetaminophen) Give 1 tablet by mouth every 8 hours as needed for pain . A review of a pharmacy form revealed the pharmacy dispensed 120 [MEDICATION(S)]/APAP tablets on 8/10/22 for RI #4. The facility match back revealed 120 tablets missing. 5) RI #5 was admitted to the facility on [DATE]. A review of RI #5's September physician orders revealed . [MEDICATION(S)]-Acetaminophen Tablet 10-325 MG Give 1 tablet by mouth every 4 hours as needed for pain . A review of a pharmacy form revealed the pharmacy dispensed 120 [MEDICATION(S)]/APAP tablets on 8/11/22 for RI #5. The facility match back revealed 120 tablets missing. 6) RI #6 was admitted to the facility on [DATE]. A review of RI #6's September Physician Orders revealed .[MEDICATION(S)] tablet 5 MG Give 1 tablet by mouth every 6 hours as needed for pain. A review of a pharmacy form revealed the pharmacy dispensed 60 [MEDICATION(S)] tablets on 8/12/22 for RI #6. A facility match back revealed 60 missing tablets. 7) RI #7 was admitted to the facility on [DATE]. A review of RI #7's September Physician Orders revealed . [MEDICATION(S)] Tablet 5-325 MG ([MEDICATION(S)]-Acetaminophen) Give 1 tablet by mouth every 4 hours as needed for pain. A review of a pharmacy form revealed the pharmacy dispensed [MEDICATION(S)] 180 tablets on 8/15/22 for RI #7. A facility match back revealed 180 tablets missing. 8) RI #8 was admitted to the facility on [DATE]. A review of RI #8's September Physician Orders revealed . [MEDICATION(S)]-Acetaminophen Tablet 10-325 MG Give 1 tablet by mouth every 6 hours as needed for severe pain . A review of a pharmacy form revealed the pharmacy dispensed 90 [MEDICATION(S)]/APAP for RI #8. A facility match back revealed 90 tablets missing. 9) RI #9 was admitted to the facility on [DATE]. A review of RI #9's September Physician Orders revealed . [MEDICATION(S)]-Acetaminophen Tablet 5-325 MG Give 1 tablet every 4 hours as needed for pain. A review of a pharmacy form revealed the pharmacy dispensed 90 [MEDICATION(S)]/APAP tablets on 8/15/22 for RI #9. A facility match back revealed 90 missing tablets. 10) RI #10 was admitted to the facility on [DATE]. A review of RI #10's September Physician Orders revealed .[MEDICATION(S)]-Acetaminophen Tablet 5-325 MG Give 1 tablet by mouth every 4 hours as needed for pain. A review of a pharmacy form revealed the pharmacy dispensed 30 [MEDICATION(S)]/APAP tablets on 8/22/22 for RI #10. 11) RI #11 was admitted to the facility on [DATE]. A review of RI #11's September Physician Orders revealed . [MEDICATION(S)] Tablet 5-325 MG ([MEDICATION(S)]-Acetaminophen) Give 1 tablet by mouth every 6 hours as needed for pain. A review of a pharmacy for revealed the pharmacy dispensed 90 [MEDICATION(S)]/APAP tablets for RI #11 on 8/29/22. A facility match back revealed 90 missing tablets. 12) RI #12 was admitted to the facility on [DATE]. A review of RI #12's September Physician Orders revealed . [MEDICATION(S)] Tablet 5-325 MG Give 1 tablet by mouth every 8 hours as needed for pain . A review of a pharmacy form revealed the pharmacy dispensed 120 [MEDICATION(S)]/APAP for RI #12 on 8/24/22. A facility match back revealed 120 tablets missing. On 10/05/2022 at 3:59 PM, the surveyor conducted a telephone interview with EI #12, the pharmacist. When asked what procedure the facility used to ensure residents medications were available for administration, EI #12 said the pharmacy received notification of the medications needed by way of fax or electronically. On 10/05/2022 at 4:38 PM, the surveyor conducted a telephone interview with EI #13, RI #1's physician. The surveyor asked EI #13 what would he expect the nursing home staff to do if there were no narcotic medications available for administration. EI #13 said if it was a scheduled II medication he would expect the facility staff to contact him and he would call the pharmacy or send an electronic prescription to the pharmacy if it was time for a refill. EI #13 said [MEDICATION(S)] was a schedule II medication. The surveyor asked EI #13 when was he notified RI #1 did not have his/her [MEDICATION(S)] available for administration. EI #13 said he was notified but he did not remember when. When asked what the facility determined happened to RI #1's [MEDICATION(S)], EI #13 said he was told two weeks ago a nurse was modifying the log and taking the pills. On 10/06/2022 at 8:23 AM, in the continued interview with EI #12, EI #12 said RI #1, nor any resident should ever have missed medications. On 10/06/2022 at 11:37 AM, an interview was conducted with EI #2, the Director of Nursing (DON). The surveyor asked EI #1 when was she made aware RI #1 did not have his/her [MEDICATION(S)] available for administration. EI #2 said it was on 09/19/2022. EI #2 said EI #11, the LPN (Licensed Practical Nurse) assigned to care for RI #1 on 09/19/2022 on the 7:00 AM - 7:00 PM shift came to her and said RI #1 was a little upset because his/her pain medication was not at the facility. When asked what was the facility's policy and procedure for ensuring medications were available for administration, EI #2 said when a doctor's order is received it is faxed to the pharmacy. EI #2 said if it was a narcotic medication the facility had to make sure a script was received from the doctor. The surveyor asked EI #2 what did the facility's investigation reveal happened to RI #1's [MEDICATION(S)]. EI #2 said the facility was never able to say what happened. EI #2 said when the facility did their investigation, they found that 21 of RI #1's [MEDICATION(S)]'s were missing. EI #2 said the facility started a 100% audit on everyone who was on narcotics and found several residents had [MEDICATION(S)] and [MEDICATION(S)] missing as well as the Controlled Drug Receipt/Record/ Disposition Forms were missing. When asked if RI #1's medication was delivered, received, and stored in the correct manner, should the [MEDICATION(S)] have been available for administration, EI #2 said yes.

Based on interviews, record review, review of a facility policy titled Administering Medications and review of the facility's investigative file, the facility filed to ensure two licensed nurses, Employee Identifier (EI) #'s 9 and 10 did not initial/document on the eMAR (electronic Medication Administration Record) Resident Identifier (EI) #1 had been administered [MEDICATION(S)]-Acetaminophen ([MEDICATION(S)]) 7.5 mg (milligrams) on 09/17/2022 at 2:00 PM and at 10:00 PM, when the [MEDICATION(S)] medication was not in the facility for administration. This deficient practice affected RI #1; one of three residents sampled for documentation of medication administration. Findings include: Review of a facility policy titled Administering Medications, with a revised date of 04/2019, revealed the following: . Policy Interpretation and Implementation . 22. The individual administering the medication initials the resident's MAR (Medication Administration Record) on the appropriation line after giving each medication . RI #1 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of RI #1's September 2022 Medication Review Report (Physicians Orders) revealed RI #1 had orders to receive [MEDICATION(S)]-Acetaminophen 7.5 mg by mouth every eight hours for pain related to his/her Unspecified Pain. A review of RI #1's September 2022 eMAR revealed EI #9, the LPN (Licensed Practical Nurse) assigned to care for RI #1 on 09/17/2022 at 2:00 PM, and EI #10, the LPN assigned to care for RI #1 on 09/17/2022 at 10:00 PM, initialed on the eMAR they administered RI #1 his/her [MEDICATION(S)] when the [MEDICATION(S)] medication was not in the facility for administration. On 10/04/2022 at 6:08 PM, the surveyor conducted a telephone interview with EI #9. EI #9 said she clicked she had administered RI #1 his [MEDICATION(S)] because it was a routine medication. EI #9 said when she checked the medication cart and the [MEDICATION(S)] was not on the cart, she could not unclick that she had administered the [MEDICATION(S)]. When asked when should the nurse initial/document on the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the facility's investigative file revealed a DISCIPLINARY ACTION RECORD done by telephone for EI #10. The form was dated 09/21/2022, and documented: . List below an account of the action(s) leading to disciplinary action: include dates, times and any other supporting information . Charted that she gave a [MEDICATION(S)] but no [MEDICATION(S)] was available . On 10/05/2022 at 7:39 PM, an interview was conducted with EI #10. The surveyor asked EI #10 why she documented she administered RI #1 [MEDICATION(S)] on 09/17/2022 at 10:00 PM when the medication was not at the facility, EI #10 said it was a mistake. When asked when should the nurse initial/document on the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . On 09/06/2022 at 10/06/2022 at 11:37 AM, an interview was conducted with EI #2, the Director of Nursing (DON). The surveyor asked EI #2 when should the nurses initial/document on the eMAR a resident's medication had been administered. EI #2 said after the nurse had administered the medication. These deficiencies were cited as a result of the investigation of complaint/report #AL 086.

Based on interviews, record review, review of facility policies titled Administering Medications and Pain Assessment and Management and review of the facility's investigative file, the facility failed to ensure Resident Identifier (RI) #1 received his/her [MEDICATION(S)]-Acetaminophen ([MEDICATION(S)]) 7.5 mg (milligrams) medication as ordered; and further failed to ensure RI #1's pain levels were monitored on 09/17/2022 at 6:00 AM, on 09/18/2022 at 6:00 AM, 2:00 PM and 10:00 PM, and on 09/19/2022 at 6:00 AM. This deficient practice affected RI #1; one of three residents sampled for pain medication administration/pain assessments. Findings include: Review of a facility policy titled Pain Assessment and Management, with a revised date of 03/2015, revealed the following: . Monitoring . Approaches: 1. Re-assess the resident's pain . at least each shift for acute pain or significant changes in levels of chronic pain . Documentation 1. Document the resident's reported level of pain . RI #1 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . RI #1's care plan titled The resident has potential for pain r/t (related/to) Disease process, with an initiated date of 05/06/2022, revealed the following: . Interventions *Administer analgesics as per orders . *Monitor/record pain . q (every) shift . Severity (1 to 10 scale) . A review of RI #1's September 2022 Medication Review Report (Physicians Orders) revealed RI #1 had orders to receive [MEDICATION(S)]-Acetaminophen 7.5 mg by mouth every eight hours for pain related to his/her Unspecified Pain. A review of RI #1's Controlled Drug Receipt/Record/Disposition Form for [MEDICATION(S)] revealed the final dose of resident's supply was documented as administered on 9/16/22 at 8:00 PM. A review of RI #1's September 2022 eMAR (electronic Medication Administration Record), and interview with the licensed nurses initialing RI #1 received the [MEDICATION(S)] on 09/17/2022 at 2:00 PM and 10:00 PM (when RI #1 did not receive the [MEDICATION(S)] or have a supply of [MEDICATION(S)] available for administration) revealed RI #1 did not received his/her [MEDICATION(S)] as ordered on 09/17/2022 at 6:00 AM, 2:00 PM and 10:00 PM, on 09/18/2022 at 6:00 AM, 2:00 PM and 10:00 PM, and on 09/19/2022 at 6:00 AM. Further review of the eMAR revealed RI #1 was not assessed for his/her pain levels on 09/17/2022 at 6:00 AM, on 09/18/2022 at 6:00 AM, 2:00 PM and 10:00 PM, and on 09/19/2022 at 6:00 AM. A review of the facility's investigative file revealed an interview was conducted with RI #1 on 09/20/2022. The following was documented: Did the staff give your [MEDICATION(S)] this weekend? No I was out . On 10/03/2022 at 6:12 PM, the surveyor conducted an interview with RI #1. The surveyor asked RI #1 how often did he/she receive his/her [MEDICATION(S)]. RI #1 said three time a day. When asked when had he/she not received the [MEDICATION(S)] as ordered, RI #1 said about a week ago. On 10/04/2022 at 2:54 PM, an interview was conducted with EI #5, the RN (Registered Nurse) assigned to care for RI #1 on 09/18/2022 at 2:00 PM when there was no [MEDICATION(S)] medication administered or pain level assessment completed. The surveyor asked EI #5, according to RI #1's September 2022 eMAR, what time was RI #1 scheduled to receive his/her [MEDICATION(S)] when she provided care for RI #1. EI #5 said 2:00 PM. When asked did RI #1 receive the [MEDICATION(S)] at 2:00 PM. EI #5 said no. The surveyor asked EI #5 why was RI #1 not administered the [MEDICATION(S)] as ordered. EI #5 said the [MEDICATION(S)] was not on the medication cart. When asked did she administer RI #1 anything for pain at that time. EI #5 said no. The surveyor asked EI #5 how would the nurse assess a resident for pain. EI #5 said with RI #1 could talk so you would ask him/her about his/her pain level on a scale of 0-10. EI #5 said the pain level would be documented in the nurses notes or on the eMAR. The surveyor showed EI #5 RI #1's eMAR and asked EI #5 did she see where she had assessed RI #1 for his/her pain level at 2:00 PM on 09/18/2022. EI #5 said no. A review of RI #1's nurse's notes also did not reveal EI #5 had documented RI #1's pain level in the nurse's notes on 09/18/2022. On 10/04/2022 at 6:08 PM, the surveyor conducted a telephone interview with EI #9, the LPN (Licensed Practical Nurse) assigned to care for RI #1 on 09/17/2022 at 2:00 PM when there was no [MEDICATION(S)] medication administered. EI #9 said she did not administer RI #1 his/her [MEDICATION(S)] medication because it was not on the medication cart. On 10/05/2022 at 9:30 AM and 4:11 PM, and on 10/06/2022 at 9:17 AM, unsuccessful telephone attempts were made to contact EI #4, the RN assigned to care for RI #1 on 09/17/2022 at 6:00 AM, on 09/18/2022 at 10:00 PM and on 09/19/2022 at 6:00 AM when there was no [MEDICATION(S)] medication administered or pain level assessments completed. On 10/05/2022 at 7:39 PM, an interview was conducted with EI #10, the LPN assigned to care for RI #1 on 09/17/2022 at 10:00 PM and on 09/18/2022 at 6:00 AM. EI #10 said RI #1 did not receive the [MEDICATION(S)] on 09/17/2022 at 10:00 PM and on 09/18/2022 at 6:00 AM. EI #10 did assess RI #1's pain level on 09/17/2022 at 10:00 PM; but failed to assess RI #1's pain level on 09/18/2022 at 6:00 AM. When asked how she would assess a resident for their pain level, EI #10 said she would ask them every shift. On 09/06/2022 at 11:37 AM, an interview was conducted with EI #2, the Director of Nursing (DON). EI #2 reported that RI #1 received his/her last dose of [MEDICATION(S)] on Friday the 16th (09/16/2022) and RI #1 missed Saturday (09/17/2022) and Sunday (09/18/2022) and one dose on Monday (09/19/2022), seven total doses. The surveyor asked EI #2 were the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] #2 said no. When asked where the nurses would document they were monitoring RI #1's pain levels, EI #2 said on the eMAR. EI #2 said the pain levels should be monitored every shift. The surveyor asked EI #2 what pain assessment scale was the facility using. EI #2 said the nurses would ask RI #1 his/her pain level on a scale from 0-10. The surveyor asked EI #2, looking at the dates of 09/17/2022, 09/18/2022 and 09/19/2022, on what dates and shifts were RI #1's pain levels not monitored. EI #2 said on 09/17/2022 at 6:00 AM, on 09/18/2022 at 6:00 AM, 2:00 PM and 10:00 PM, and on 09/19/2022 at 6:00 AM. When asked why it would be important to document a resident's pain levels, EI #2 said you need to see what the pain levels are so you can ensure the residents pain level is controlled.

Based on interviews, record review, review of a facility policy titled Pharmacy Services Overview and review of the facility's investigative file, the facility failed to ensure the licensed nurses notified the physician and pharmacy when Resident Identifier (RI) #1's [MEDICATION(S)]-Acetaminophen ([MEDICATION(S)]) 7.5 mg (milligrams) medication was not available for the nurses to administer on 09/17/2022, at 6:00 AM, 2:00 PM and 10:00 PM, on 09/18/2022 at 6:00 AM, 2:00 PM and 10:00 PM; and on 09/19/2022 at 6:00 AM. This deficient practice affected RI #1; one of three residents sampled for notification. Findings included: Review of a facility policy titled Pharmacy Services Overview, with a revised date of 04/2019, revealed the following: . Policy Interpretation and Implementation . 5. Nursing staff communicates prescriber orders to the pharmacy and are responsible for contacting the pharmacy if a resident's medication is not available for administration . RI #1 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of RI #1's September 2022 Medication Review Report (Physicians Orders) revealed RI #1 had orders to receive [MEDICATION(S)]-Acetaminophen 7.5-325 milligrams (MG) by mouth every eight hours for pain related to his/her Unspecified Pain. A review of RI #1's September 2022 eMAR (electronic Medication Administration Record), and interviews with the licensed nurses initialing RI #1 received the [MEDICATION(S)] on 09/17/2022 at 2:00 PM and 10:00 PM (when RI #1 did not receive the [MEDICATION(S)] at these times,) revealed RI #1 did not receive his/her [MEDICATION(S)] on 09/17/2022 at 6:00 AM, 2:00 PM and 10:00 PM, on 09/18/2022 at 6:00 AM, 2:00 PM and 10:00 PM; nor on 09/19/2022 at 6:00 AM. A review of the facility's investigative file revealed an interview conducted with Employee Identifier (EI) #5, the RN (Registered Nurse) assigned to care for RI #1 on 09/18/2022 at 2:00 PM. This interview was dated 09/20/2022 at 12:42 PM, and the following was documented: . Did you notify the doctor of the resident was (being) out of medication? . no . Do you remember the count of the narcotic sheet at the top of the control Drug sheet. (He/She) did not have [MEDICATION(S)] on the cart . On 10/04/2022 at 2:54 PM, an interview was conducted with EI #5. When asked what narcotic medication RI #1 received, EI #5 said [MEDICATION(S)]. EI #5 said on 09/18/2022 RI #1's [MEDICATION(S)] was not on the medication cart. EI #5 said RI #1 asked had it come in yet and she told him/her no. The surveyor asked RI #5, according to RI #1's September 2022 e-MAR, what did the number nine she wrote on 09/18/2022 at 2:00 PM mean. EI #5 said it meant refer to the progress note. EI #5 said she thought she wrote in the progress notes 'awaiting meds.' When asked did RI #1 receive his/her [MEDICATION(S)] 7.5 mg at 2:00 PM on 09/18/2022, EI #5 said no. EI #5 said she did not notify RI #1's doctor when his/her [MEDICATION(S)] could not be located in the narcotic box. A review of the facility's investigative file revealed a telephone interview was conducted with EI #9; the LPN (Licensed Practical Nurse) assigned to care for RI #1 on 09/17/2022 at 2:00 PM. This interview was dated 09/20/2022 at 12:38 PM, and the following was documented: . Did you notify pharmacy that (RI #1) was out of (his/her) medication? . No . Did you notify the doctor of the resident was (being) out of medication? . No . On 10/04/2022 at 6:08 PM, the surveyor conducted a telephone interview with EI #9. EI #9 said on 09/17/2022 at 2:00 PM she did not give RI #1 his/her [MEDICATION(S)]. EI #9 said she clicked she administered the [MEDICATION(S)] because it was routine but when she went to get the [MEDICATION(S)] there was none in the cart. EI #9 said she could not go back and unclick that it had not been given and she explained that to the Administrator when the Administrator called her and asked her if she had given the [MEDICATION(S)]. EI #9 said she told the Administrator she had not given the [MEDICATION(S)]. When asked when residents medications are not in the medication cart, who should be notified, EI #9 said the doctor. The surveyor asked EI #9 did she notify RI #1's doctor, or the pharmacy his/her [MEDICATION(S)] could not be located. EI #9 said no. On 10/05/2022 at 9:30 AM and 4:11 PM, and on 10/06/2022 at 9:17 AM, unsuccessful telephone attempts were made to contact EI #4, the RN assigned to care for RI #1 on 09/17/2022 at 6:00 AM, on 09/18/2022 at 10:00 PM and on 09/19/2022 at 6:00 AM. Review of the facility's investigative file revealed a DISCIPLINARY ACTION RECORD done by telephone for EI #10, the LPN assigned to care for RI #1 on 09/17/2022 at 10:00 PM and on 09/18/2022 at 6:00 AM. The form was dated 09/21/2022, and documented: . List below an account of the action(s) leading to disciplinary action: include dates, times and any other supporting information. Employee did not notify the MD (medical doctor) or pharmacy that the resident had no [MEDICATION(S)] on the cart. Charted that she gave a [MEDICATION(S)] but no [MEDICATION(S)] was available . Corrective Action: . Employee will notify the MD and contact pharmacy when a resident is out of medication . On 10/05/2022 at 7:39 PM, an interview was conducted with EI #10. When asked why she documented she administered she gave RI #1 [MEDICATION(S)] on 09/17/2022 at 10:00 PM when the medication was not at the facility, EI #10 said it was a mistake. The surveyor asked EI #10, when resident's medications are not in the medication cart, who should be notified. EI #10 said the doctor and pharmacy. When asked if she notified RI #1's doctor when RI #1's [MEDICATION(S)] could not be located in the narcotic box, EI #10 said she did not. EI #10 said she did not notify the doctor nor pharmacy when RI #1's [MEDICATION(S)] was not available because it was at night and the pharmacy was closed. EI #10 said she assumed the [MEDICATION(S)] was going to be delivered. On 10/05/2022 at 4:38 PM, the surveyor conducted an interview with EI #13, RI #1's physician. When asked what would he expect the nursing home staff to do if there were no narcotic medications available to administer to a resident, EI #13 said if it was a scheduled II medication, like [MEDICATION(S)], he would expect them to contact him and he would call the pharmacy or send an electronic prescription to the pharmacy if it was time for a refill. When asked was he notified on 09/17/2022, RI #1 did not have his/her [MEDICATION(S)] available for administration, EI #13 said the last time he remembered the facility contacting him about RI #1's [MEDICATION(S)] was 09/14/2022, for a refill of the [MEDICATION(S)]. On 10/06/2022 at 8:23 AM, the surveyor conducted a telephone interview with EI #12, the pharmacist. When asked when a resident did not have narcotic medication available for administration over the weekend, what would he expect the facility's nurses to do. EI #12 said he would expect the facility to notify them. On 10/06/2022 at 11:37 AM, an interview was conducted with EI #2, the Director of Nursing (DON). The surveyor asked EI #2, according to RI #1's September 2022 eMAR, how many does of the [MEDICATION(S)] did RI #1 not receive. EI #2 said RI #1 received his/her last dose on 09/16/2022 at 10:00 PM. EI #2 said RI #1 missed Saturday (at 6:00 AM, 2:00 PM and 10:00 PM) and Sunday (at 6:00 AM, 2:00 PM and 10:00 PM) and one does on Monday (at 6:00 AM) so that was seven doses. When asked what should the nurses had done when they realized RI #1 did not have his/her [MEDICATION(S)] available for administration, EI #2 said the nurses should have notified the pharmacy and the doctor. The surveyor asked EI #2, from the facility's investigation did the nurses notify the doctor and pharmacist when RI #1 did not have his/her [MEDICATION(S)] available for administration. EI #2 said on that Saturday (09/17/2022) and Sunday (09/18/2022), from her recollection no one notified the pharmacy or doctor.

Based on interviews, resident record review, review of a facility policy titled Emergency Procedure-Cardiopulmonary Resuscitation (CPR), and review of the 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care, Part 3: Adult Basic and Advanced Life Support, the facility failed to ensure licensed nursing staff assessed Resident Identifier (RI) #1, a full code resident, for a pulse, verified code status, and initiated CPR upon finding RI #1 unresponsive on [DATE]. On [DATE] RI #1 was found by Employee Identifier (EI) #3 and EI #4, both Licensed Practical Nurses (LPNs), during shift change at approximately 7:20 PM. EI #3 and EI #4 both stated the resident's eyes were open and appeared to be fixed, and said RI #1 did not appear to be breathing. Neither EI #3 (the off-going nurse) or EI #4 (the on-coming nurse) checked RI #1 to see if he/she had a pulse. EI #4 walked to RI #1's bed and placed her hand on RI #1's chest and reported she felt no movement. EI #3 then informed EI #4 that RI #1 was on hospice and hospice would take care of everything. Neither LPN verified RI #1's code status in the computer, or by utilizing the facility's dot system as outlined in their policy. No resuscitation efforts were made, and Hospice was notified the resident was deceased . After the hospice nurse's arrival to the facility at approximately 7:45 PM (about 25 minutes later), it was identified that RI #1 was a full code. The crash cart was taken into RI #1's room, but post-mortem care had already been provided. CPR was never initiated. Emergency Medical Services (EMS) was called at 8:10 PM and arrived to the facility at 8:15 PM. RI #1 was placed on a cardiac monitor, which showed asystole (a form of cardiac arrest in which the heart stops beating and there is no electrical activity in the heart). The physician was then contacted and RI #1 was pronounced deceased at 8:26 PM, a little more than an hour after being found unresponsive by facility staff. This deficient practice placed RI #1, one of four sampled residents reviewed for the provision of CPR, in immediate jeopardy, as it was likely to result in serious injury, serious harm, serious impairment or death. It also had the potential to affect any other resident in the facility who may be found unresponsive. The facility's Form CMS-672 Resident Census and Conditions of Residents reflected a census at the time of the survey of 116. On [DATE] at 5:11 PM, the Administrator and Director of Nursing (DON) were provided a copy of the immediate jeopardy template and notified of the findings of Substandard Quality of Care at the immediate jeopardy level in the area of Quality of Care, F678-Cardio-Pulmonary Resuscitation (CPR). Findings include: Cross Reference F726 and F835. On [DATE] at 6:54 PM, the facility submitted to the Alabama State Survey Agency an allegation of neglect. According to the report, EI #3 and EI #4, both LPNs, failed to initiate CPR on RI #1, a resident with Full Code status, who was found unresponsive on [DATE] at 7:20 PM. The facility's policy titled Emergency Procedure-Cardiopulmonary Resuscitation, with a revision date of February 2018, documented: .General Guidelines .4. The chances of surviving SCA (sudden cardiac arrest) may be increased if CPR is initiated immediately . If an individual (resident, visitor, or staff member) is found unresponsive and not breathing normally, a licensed staff member who is certified in CPR/BLS (basic life support) shall initiate CPR unless: a. it is known that a do not resuscitate (DNR) order that specifically prohibits CPR and/or external defibrillation exists for that individual; or b. there are obvious signs of irreversible death (e.g., rigor mortis). 5. If the resident's DNR status is unclear, CPR will be initiated until it is determined that there is a DNR or a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .Emergency Procedure-Cardiopulmonary Resuscitation 1. If an individual is found unresponsive, briefly assess for abnormal or absence of breathing. If sudden cardiac arrest is likely, begin CPR: a. Instruct a staff member to activate the emergency response system (code) and call 911. b. Instruct a staff member to retrieve the crash cart. c. Verify or instruct a staff member to verify the DNR or code status of the individual. If resident is deemed a DNR through physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . If no red label is identified, initiate basic life support sequence of events. The 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care, Part 3: Adult Basic and Advanced Life Support, dated [DATE], documented: .SEQUENCE OF RESUSCITATION Recognition of Cardiac Arrest . Recommendations for Recognition of Cardiac Arrest . If a victim is unconscious/unresponsive with absent or abnormal breathing (ie, only gasping), the healthcare provider should check for a pulse for no more than 10 s (seconds) and, if no definite pulse is felt, should assume the victim is in cardiac arrest .healthcare providers are directed to quickly check for a pulse and to promptly start compressions when a pulse is not definitively palpated . RI #1 was admitted to the facility on [DATE], with an admitting diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . RI #1's Order Summary Report included an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . This order remained active for the duration of RI #1's stay in the facility. RI #1's Care Plan-End of Life, dated [DATE], also indicated RI #1 was a Full Code. Review of the facility's communication calendar for [DATE] revealed the following handwritten note: Make sure you know (RI #1) is a full code. For other problems call (name of hospice provider) hospice first. Review of RI #1's Progress Notes revealed the following: .[DATE] 19:20 (7:20 PM) . wail (while) doing walk through with off going nurse (EI #3) found resident lying in bed unresponsive with eyes open. at this time I watched residents chest to see if it was raising and falling and didn't see any movement I then placed my hand on residents chest to assess for movement and there was none. the off going nurse then said she was going to notify hospice of residents findings . [DATE] 19:45 (7:45 PM) . Hospice nurse arrives to the facility to assess the resident . [DATE] 20:00 (8:00 PM) . EMS was called and notified that resident was unresponsive . [DATE] 20:15 (8:15 PM) . (EMS company) arrived to facility with 4 attendants they entered the room and checked the residents pulse and then place the resident onto the monitor. (EMS staff) stated the resident showed no signs of life and proceeded to call doctor . [DATE] 20:26 (8:26 PM) . (EMS staff) was on the phone with (name of physician) and he stated that the time of death was 2026 (8:26 PM) . These entries were all made and signed by EI #4, the on-coming nurse for the 7:00 PM shift on [DATE]. EI #3, the off-going nurse, also made the following late entry in RI #1's progress notes: .[DATE] 12:40 (12:40 PM) . Late Entry- Resident noted unresponsive at 1920 (7:20 PM) on [DATE]. Staring blankly, pupils fixed and dilated. Head of bed let down and resident gasped for breath. Called (name of hospice provider) answering service and notified them of change in status . Review of a hospice Visit Note Report dated [DATE], documented the following: . Narrative . (RI #1) WAS LAYING IN ROOM UNRESPONSIVE UPON ARRIVAL. UPON TRYING TO FIND NURSE, STAFF STATED THAT (EI #3, the off-going nurse) HAD ALREADY LEFT. ENDED UP SPEAKING WITH (EI #4) WHO WAS THE NURSE THAT JUST CAME IN BUT SHE STATED SHE DIDN'T KNOW ANYTHING. PT (patient) WAS A FULL CODE AND (EI #3's name), LPN DID NOT DO CPR. PT WAS DEAD APPROXIMATELY 30 MINUTES ALREADY . CALLED EMS. EMS TRIED EVERYTHING AND WAS UNABLE TO REVIVE PT . MD (medical doctor) PRONOUNCED PT DEAD [DATE] @ 20:26PM (8:26 PM) . ALL FACILITY STAFF SEEM LIKE THEY DIDN'T KNOW ANYTHING EXCEPT PT WAS DEAD . An EMS document labeled Chief Complaint, dated [DATE], documented: Chief Complaint: Cardiac Arrest/DOA (dead on arrival) . DATE: [DATE] . TIME OF CALL: 2010 (8:10 PM) . ON-SCENE: 2015 (8:15 PM) . NARRATIVE: .dispatched 911 to [NAME] H & R ([NAME] Health and Rehab, LLC) . to find (RI #1) lying supine on (his/her) hospital bed. Pt (patient) is cool pulseless and apneic (not breathing). Facility staff reports pt is a full code & not a DNR. Pt's nurse (hospice nurse) was called in . she arrived at facility . was told the pt had been deceased since they called her. (EMS ) received call @ (at) 20:10 (8:10 PM) and arrived @ (at) 2015 (8:15 PM) on arrival CPR had not been initiated at any point. Cardiac monitor shows asystole w/no (with no) cardiac activity. Physician (name of doctor) @ (at) (local hospital) ER was contacted & gave [NAME] (time of death) of 20:26 (8:26 PM) . On [DATE] at 2:38 PM, a telephone interview was conducted with RI #1's responsible party. RI #1's responsible party stated RI #1 had come to the facility for a five day respite stay, but died within two to three days of his/her stay at the facility. When asked what RI #1's wishes were regarding end-of-life decisions, RI #1's responsible party stated RI #1's wishes were for staff to attempt to revive him/her if needed. On [DATE] at 4:47 PM, a telephone interview was conducted with EI #3, the off-going LPN on [DATE] when RI #1 was found unresponsive. She stated on [DATE], at the end of her shift, she was making round with EI #4, the on-coming nurse. EI #3 reported that when they walked in RI #1's room, RI #1 was just staring blankly and it appeared he/she was not breathing. EI #3 further stated when EI #4 let the resident's head down, RI #1 took a gasping breath and his/her mouth opened wide. EI #3 indicated she let EI #4 know that RI #1 was on hospice, and then went to the computer to look up the contact number, so she could inform hospice of RI #1's change in condition. When asked if she verified RI #1's code status when she was in the computer, EI #3 said she did not see RI #1's code status listed on the facesheet or the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . EI #3 indicated she assumed RI #1 was a DNR since he/she was terminally ill and on hospice. EI #3 admitted there was no room for assumptions, but in her experience if someone was on hospice and terminally ill, they were a DNR. When asked how she became aware RI #1 had in fact been a full code, EI #3 stated she became aware when the Director of Nursing (DON) called her later that night around ,d+[DATE] PM. EI #3 was asked what should happen if she found a resident unresponsive. EI #3 stated, check for a pulse, check to see if resident is breathing and then call a code. EI #3 again stated in her previous experience any hospice patient was a DNR. EI #3 admitted that RI #1's vitals were not taken. When asked how to identify a resident's code status, EI #3 stated, go to the chart. EI #3 further stated she was later informed by the Administrator that DNR residents would have something on their door, but denied having any prior knowledge of this system. EI #3 stated the concern of not performing CPR on a full code resident when they become unresponsive is they will die. EI #3 admitted that CPR should have been performed on RI #1 and RI #1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] During a follow-up interview with EI #3 on [DATE] at 2:56 PM, EI #3 was asked if she had looked to see if RI #1 had a red dot on his/her door, indicating DNR status. EI #3 again denied having any knowledge of this process until the Sunday following the incident. EI #3 also confirmed she told EI #4 that since RI #1 was hospice, they did not have to do anything because hospice would take care of it. EI #4 again stated she assumed RI #1 was a DNR due to being on hospice, and said she felt it inhumane to attempt to revive him/her. When asked about honoring RI #1's end-of-life wishes, EI #3 agreed that if RI #1 was deemed a full code resident, she was supposed to provide CPR. On [DATE] at 6:23 PM, a telephone interview was conducted with EI #4, the on-coming LPN on [DATE] when RI #1 was found unresponsive. She stated on [DATE] around 7:20 PM she was doing rounds with EI #3. She stated when they entered RI #1's room, RI #1's eyes were open and it did not appear that RI #1 was breathing. She stated she put her hand on RI #1's chest and did not feel any movement. According to EI #4, EI #3 looked closer and informed EI #4 that RI #1 was expired. EI #4 reported that she asked EI #3 what the policy was and what they should do, and EI #3 told her hospice would do everything. EI #4 said they then left the room, and EI #3 went to the desk to contact hospice while she assisted another resident. After assisting the other resident, EI #4 said she checked in with EI #3 again, who told her hospice was on their way and she was leaving for the day. EI #4 said when the hospice nurse arrived, she asked if anyone had done CPR. EI #4 said she told the hospice nurse no, because she did not know RI #1 was a full code. According to EI #4, she was unable to login to the facility's computer system that night to look at RI #1's code status. However, EI #4 did confirm that once she was able to login to the system, she did see that RI #1 was listed as a full code. When asked what should be done when a resident is found unresponsive, EI #4 said their code status should be checked to determine if CPR should be initiated or not. EI #4 further stated if their was no code status, and no DNR order, CPR should be initiated. EI #4 admitted that physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . EI #4 stated the concern of not providing CPR on a full code resident when they became unresponsive is not following orders and possibly death. She stated if CPR was provided, it is possible RI #1 could have been revived. During a follow-up interview with EI #4 on [DATE] at 8:16 PM, EI #4 was asked what knowledge she had of the facility's red dot system to identify code status. EI #4 denied having any knowledge of the red dot system at the time this incident occurred, but said she was later informed the red dots on the residents' doors would indicate they were a DNR. On [DATE] at 6:10 PM an interview was conducted with EI #8, Registered Nurse (RN)/Unit Manager. EI #8 stated she was the nurse that admitted RI #1 to the facility. EI #8 confirmed RI #1's code status was full code. She stated she entered the order into RI #1's electronic chart and also made a note on the calendar that staff use as a communication tool. EI #8 stated she wrote on the calendar that RI #1 was a full code on Saturday and Sunday, [DATE] and [DATE]. EI #8 explained this was her way of communicating with staff on the weekends when she is not at the facility. When asked the ways staff can identify a resident's code status, EI #8 stated there are orders in the chart, and, if resident is DNR, there will be a red dot by their name on their door. EI #8 admitted that CPR should have been performed on RI #1 and that physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A telephone interview was conducted with RI #1's hospice nurse on [DATE] at 11:24 AM. The hospice nurse stated she was notified by the hospice answering service on [DATE] at 7:34 PM that EI #3 had reported RI #1 was expired. The hospice nurse said she then reported to the facility, and upon arrival, observed RI #1 lying in bed, and he/she felt cold. The hospice nurse said she went to find EI #3 and was informed she had already left the facility and EI #4, the nurse on duty, really did not know much. The hospice nurse stated she looked in RI #1's chart and noted RI #1 was a full code. She stated she asked if CPR was performed and was informed it was not. The hospice nurse stated she then called EMS and RI #1's responsible party. She stated she informed RI #1's responsible party that the resident had probably been gone for a while, and asked if she would like life saving measures performed. The responsible party stated yes. When asked if the facility ever initiated CPR, the hospice nurse said no, but it should have been. The hospice nurse explained the concern of not performing CPR on an unresponsive resident who is full code was the resident did not have a chance of living if CPR is not performed, as well as it was RI #1's wishes. The hospice nurse said after EMS arrived, the physician was contacted and RI #1 was pronounced dead at 8:26 PM. On [DATE] at 3:44 PM, an interview was conducted with EI #5, the medication tech assigned to RI #1 on [DATE]. EI #5 stated when she came back from her lunch break on [DATE], she was informed that RI #1 had expired. She stated she was informed by another staff member that CPR had not been performed. EI #5 indicated she was aware RI #1 was a full code status because she was informed at the start of her shift by EI # 6, Registered Nurse (RN). EI #5 indicated when she became aware of this information, she called EI #2, the Director of Nursing (DON) and informed her of what happened. An interview was conducted with EI #6, the night shift Unit Manager/RN, on [DATE] at 10:59 AM. EI #6 stated she gave report to both EI #3 and EI #5 on the morning of [DATE] before the end of her shift. EI #6 said she reminded both of them that RI #1 was a full code. EI #6 also confirmed that the order was in place and there was a note about RI #1's code status listed on the communication calendar. When asked what should be done when a resident is found unresponsive, EI #6 said staff should check for respirations, check for a pulse, check code status and initiate CPR if the resident is not a DNR. An interview was conducted on [DATE] at 8:25 AM with EI #9, an LPN working on a different hall the night of [DATE] when RI #1 was found unresponsive. EI #9 stated, EI #4 came over to her hall and informed her that she had an expired resident and the previous nurse (EI #3) left her. According to EI #9, EI #4 told her the hospice nurse was there and wanted a seasoned nurse to come speak with her. EI #9 stated when she got to RI #1's hall, she asked about RI #1's code status, and EI #4 was not sure. EI #9 stated the hospice nurse looked in the resident's chart and noted that resident was a full code. EI #9 stated she informed EI #4 that they had to do something. EI #9 stated she grabbed the crash cart and went into the hallway. However, EI #9 stated CPR was not initiated because it had been 35 to 40 minutes since they found RI #1 unresponsive, according to EI #4. EI #9 stated when she went into RI #1's room, Certified Nursing Assistants (CNAs) had already performed postmortem care on RI #1, and he/she was getting cool. When asked how staff should identify a resident's code status, EI #9 said DNR residents have a red dot on their doors and there are orders in the chart. EI #9 said staff should have immediately initiated CPR when they found RI #1 unresponsive On [DATE] at 10:05 AM, an interview was conducted with EI #2, the DON. EI #2 stated she became aware that RI #1 was unresponsive and had expired when EI #5 called and told her that RI #1 was a full code and CPR was not performed. EI # 2 stated she asked to speak with EI #3 but was informed she had already left the facility. EI #2 stated she text the administrator to inform her of what happened. EI #2 stated, she then called EI #3 and was informed RI #1 was found unresponsive while making rounds. She stated EI #3 told her she assumed RI #1 was a DNR because he/she was on hospice. She stated EI #3 told her CPR was not initiated. EI #2 confirmed RI #1's code status was full code and CPR should have been initiated. EI #2 stated the concern of not performing CPR on RI #1 is they will never know if he/she could have survived. When asked what her expectation of nurses was if they were unsure of code status, EI #2 stated, to start CPR. EI #2 stated RI #1's rights were neglected. On [DATE] at 11:24 AM, an interview was conducted with EI #1, the Administrator. EI #1 stated she became aware of RI #1 not receiving CPR when EI #2 called her on the night of [DATE]. EI #1 stated she interviewed the staff involved. According to EI #1, EI #3 told her she and EI #4 walked in RI #1's room and noticed his/her eyes were set and he/she was not breathing. EI #1 stated EI #3 told her they let RI #1's head down and he/she took a gasp. She stated EI #3 stated she did not check RI #1's code status because she assumed he/she was a DNR because he/she was on hospice. EI #1 said when she interviewed EI #4, EI #4 reported that RI #1 made a gurgling noise when they let the head of the bed down. She stated EI #4 said she asked EI #3 what the policy was and was informed RI #1 was hospice and hospice does everything. EI #1 stated EI #4 did not check the resident's code status. EI #1 admitted CPR should have been initiated and the nurses did not follow orders. EI #1 stated a resident's code status is not the facility's choice, it is up to the resident and their wishes. EI #1 explained that she could not say for sure if RI #1 would have lived or not, but it was up to the facility to do their part. Review of the facility's 5-Day Summary for (RI #1), dated [DATE], revealed the facility's investigation into this occurrence had the following outcome: .CONCLUSION . CPR was never initiated. EMS worked with the resident and pronounced him/her deceased at 8:26 PM .We substantiate the two nurses (EI #3) and (EI #4) failed to provided CPR on (RI #1) who was a hospice, full code patient . This deficiency was cited as a result of the investigation of complaint/report number AL 005. ************************* On [DATE] at 2:12 PM, the facility submitted an acceptable Removal Plan for F678 which documented the following: .1. Administrator and DON were informed of the incident of two nurses that failed to initiate CPR on an unresponsive resident on [DATE] by the Med Tech. 2. LPN #1 and LPN #2 (EI #3 and EI #4) were interviewed and suspended on [DATE] pending investigation by the Administrator. 3. LPN #1 and LPN#2 were reported to the Alabama Board of Nursing on [DATE] by the Administrator. 4. One to one education with LPN #1 and LPN #2 was done on [DATE] with the administrator on how to properly assess an unresponsive resident and how to identify the code status to initiate CPR utilizing the titled policy Emergency Procedure/CPR. 5. LPN#1 and LPN #2 were terminated on [DATE] 6. Initial QAPI meeting was held by the Administrator on [DATE] to determine areas and opportunity for improvement for staff identifying the code status of residents when entering the room. Subsequent QAPI meetings were held on [DATE] and [DATE]. On [DATE] a resident that was a full code and on hospice, CPR was not initiated because the nurse assumed she was a DNR. The following staff were in attendance for the QAPI meeting: Administrator, Regional Clinical Director, DON, Unit Manager, and the Medical Director. * The facility policy titled Emergency Procedure/CPR including the red dot was reviewed by the Administrator, DON, and Regional Nurse Consultant on [DATE] No discrepancies were found with the policy. * All staff to include all departments (nursing, housekeeping, dietary, maintenance, activities, social services, administrative staff) will be educated on identifying the resident's code status by the Administrator, DON, or designee utilizing the titled policy Emergency Procedure/CPR. The working scheduled was reviewed by the DON and Administrator to determine if any employee was on the schedule that would need training. For staff members that did not have documentation on file of education on the Emergency procedure policy was initiated on [DATE] will be completed by [DATE] by the DON or designee. All staff will be able to identify the code status by looking at the name plate on the door. For DNR status residents the door plate will be tagged with a red dot. * The DON or designee has educated all licensed nursing staff on how to assess an unresponsive resident and the initiation of CPR per the policy titled Emergency Procedure/CPR. Completed on [DATE]. Any staff member who did not completed the required training due to leave of absence or PRN status will not be allowed to work until education is completed. * All other unlicensed staff that are not CPR certified were educated to call for help when they identify a resident is unresponsive in their room. This information was obtained for the policy titled Emergency Procedure/CPR. It was presented by the Administrator on [DATE], [DATE] and [DATE] * New employees and agency staff will receive education upon hire to ensure the Emergency Procedure/CPR policy and code status is understood. This education and orientation were initiated on [DATE] was completed on [DATE] by the DON or designee. * A 100% audit of all physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . * An education was completed on [DATE] with all staff that new admission code status will be verified during the admission process. If no code status is indicated, the physician will be contacted by the admitting licensed nurse and orders obtained. Once obtained, the order will be written, and appropriate signage will be placed on the door name plate as indicated. This education was completed by Administrator and DON. This education was completed by [DATE]. * Any employee that has not received this education will not be allowed to work a shift prior to education being completed, (PRN, On leave, etc.) * Mock code drill was conducted on [DATE] on day shift and [DATE] on evening shift to ensure all staff responded appropriately with no discrepancies noted. * All licensed staff members CPR certification was verified by the Administrator and DON on [DATE] ************************* After reviewing the facility's information provided in their Removal Plan and verifying the immediate actions had been implemented, the scope/severity level of F678 was lowered to a D level on [DATE], to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance.

Based on record review, interviews, review of a facility investigative file regarding Resident Identifier (RI) #5's elopement from the facility, review of facility policies titled Elopements and Admission Assessment and Follow Up: Role of the Nurse, the facility failed to implement the elopement policy on 8/27/2022, when the weekend receptionist, Employee Identifier (EI) #10, allowed RI #5 to leave the premises without verifying the identity of the resident. RI #5 was admitted to the facility on [DATE], two days prior. The licensed nurse who admitted RI #5 to the facility on [DATE] failed to conduct a Wandering Risk Assessment within 24 hours of admission in accordance with facility admission procedures. A Wandering Risk Assessment was not completed until after RI #5 was returned to the facility on [DATE]. On the morning of 08/27/2022 RI #5 walked into the facility front lobby toward the automatic sliding doors. EI #10 told RI #5 to sign out before leaving. RI #5 walked to the reception desk in front of EI #10. EI #10 described the person who walked in front of her as confused, nervous, and shaking. EI #10 pointed to the podium located beside the exit and told RI #5 to sign out on the visitors' log before leaving. EI #10 did not ask for the resident's name, check the resident census list, or verify the name signed out on the visitor log. The facility received a call from someone who saw a person they thought might be a resident from the facility, walking down the road away from the facility. The Administrator, Director of Nursing (DON) and a Certified Nursing Assistant (CNA) drove down the road and found the resident and brought RI #5 back to the facility. RI #5 was found to be wearing a pink gown, a bonnet, yellow skid resistant socks, and no shoes. The visitor log was reviewed, RI #5 had signed his/her name on the log as a resident of the facility prior to exiting the facility as EI #10 had instructed him/her to do. This deficient practice affected RI #5, one of three residents sampled for wandering and elopement, and placed RI #5 in immediate jeopardy, as it was likely to result in serious injury, serious harm, serious impairment, or death. On 09/01/2022 at 6:53 PM, the Administrator and Director of Nursing were provided a copy of the immediate jeopardy template and notified of the findings of Substandard Quality of Care at the immediate jeopardy level in the area of Quality of Care, F689-Free of Accidents/Hazards/Supervision/Devices. Findings include: On 08/27/2022 at 11:20 AM, the facility submitted to the Alabama State Survey Agency an initial report related to RI #5 eloping from the facility. Per this initial report, RI #5 was located by staff and returned to the facility. The facility policy titled Elopements, with a revision date of 12/2007, documented . 1. Staff shall promptly report any resident who tries to leave the premises . to the Charge Nurse or Director of Nursing. 2. If an employee observes a resident leaving the premises, he/she should: a. Attempt to prevent the departure in a courteous manner; b. Get help from other staff members . The facility policy titled Admission Assessment and Follow Up: Role of the Nurse, with a revision date of 9/2012, documented: Purpose The purpose of this procedure is to gather information about the resident's physical, emotional, cognitive, and psychosocial condition upon admission for the purposes of managing the resident, . and completing required assessment instruments, . Steps in the Procedure . 9. Conduct supplemental assessments (following facility forms and protocol) including: . f. Wandering assessment; . RI #5 was admitted to the facility on [DATE]. Review of RI #5's medical record revealed a Wandering Risk Assessment was not conducted until after RI #5 was returned to the facility on [DATE]. The facility's investigative file contained an employee interview of EI #10, the weekend receptionist. The interview was dated 8/27/2022 at 10:03 AM, was signed by EI #10 and documented the following: .What time did .(RI #5's name) come to the door and lobby Around 920 (9:20 AM) What did .(RI #5) say to you. (RI #5) . was walking towards the door . walked in front of me. acted . confused. I asked if .(he/she) was okay. I told .(him/her) . to sign out before . (he/she) leaves.(RI #5) was walking towards the door I told .(him/her) . to sign out before you leave. I pointed over to the podium and (RI #5) signed out. I know .(he/she) had a bonnet on. I Received a call that . (someone) with pink .(and) blue night gown yellow slip resistance socks and bonnet was on Bell Road . Was this the first time .(RI #5) walked up front with you there? Yes. Do you think a visitor knows how to get back out the door Yes. Sometimes I have to remind them to sign out Did you notice .(he/she) had on a gown and some non skid socks I only noticed .(he/she) had on a bonnet cap. I did not notice .(he/she) had on a gown and no shoes. A facility statement dated 8/27/2022, signed by EI #1, the Administrator, documented: . (EI #10) received a call from a lady stating there was .(someone) walking on Bell Road that might be our patient.(EI #10) notified the administrator of the call at 9:15 AM. I called on of the CNA to come go with me to see if the .(person) walking the road is our resident. The .(person) was next to the Animal Shelter at the red light. I pulled over and asked .(his/her) name.(He/she) told me (RI #5's name). I asked .(him/her) to come with me. I assisted .(him/her) into my vehicle with 2 (two) other staff. We proceeded back to the nursing home. The facility's Final Summary, dated 8/29/2022, documented: . CONCLUSION: .(RI #5's name) was admitted to the facility on Thursday, August 25, 2022. On Saturday, August 27, 2022, the week (weekend) receptionist, .(EI #10's name) reported to work. She had never seen . (RI #5) before this day. (RI #5) came to the front lobby and walked towards the door. (EI #10), the receptionist, asked .(RI #5) to sign out because she thought .(RI #5) was a visitor. The receptionist told (RI #5) to sign out over there and pointed to the podium.(RI #5) went and signed out at the podium and left out the front door. Review of the facility's VISITOR SIGN IN LOG revealed RI #5's name was handwritten in the RESIDENT NAME column. The entry was not complete and was missing the date, time in, time out, and the visitor's name. On 8/29/2022 at 7:30 PM an observation was made of Bell Road, exiting right from the facility to the Animal Shelter at the red light. The road had no sidewalks. The road was noted to have cement curbs with grass and drive ways on each side. It was a busy road with businesses and a school. According to Google Maps, the distance from the facility to the Animal Shelter at the red light was 0.3 miles. On 8/30/2022 at 8:50 AM EI #10 was interviewed by phone. EI #10 was asked how long she had worked at the facility. EI #10 said, since 06/22/2022. When asked what she was hired to do, EI #10 said, work weekends and PRN (as needed) to answer phones and transfer phone calls, and screening for COVID for visitors and employees. Upon review of the facility interview/statement dated 8/27/2022 with EI #10, she stated that 9:20 AM was an estimate of when the resident came to the lobby. When asked how RI #5 acted confused, EI #10 said, RI #5 walked around the side of the desk looking toward the door, and she asked RI #5 to sign out. EI #10 said RI #5 came around in front of her. EI #10 said she thought RI #5 was confused about where to sign out and seemed nervous. EI #10 said, she asked RI #5 if he/she was ok. EI #10 said RI #5's arms were shaking. EI #10 said, she pointed to the podium for RI #5 to sign out. When asked what time she came to work on 8/27/2022, EI #10 said, 8:00 AM. When asked how many visitors she had come in from 8:00 AM until she saw the nervous, confused resident in the lobby, EI #10 said, she could not say exactly. When asked if all visitors signed in on the podium, EI #10 said, they were supposed to. When asked to describe the bonnet RI #5 was wearing, EI #10 said, she could not. When asked what time she received the phone call about the person on Bell Road, EI #10 said, about five to 10 minutes after she had the person sign out before they left. When asked how she did not notice the person had on a gown and skid resistant socks, EI #10 said, she just thought the person was nervous, she did not know why. When asked why she did not question the person about why they were nervous, EI #10 said, she just asked if they were okay. When asked if she had you ever seen that person before, EI #10 said, no. On 9/1/2022 at 11:13 AM a follow up interview was conducted with EI #10. When asked what she had access to at the receptionist desk that listed residents in the facility, EI #10 said, she had a roster and a wander book with residents' pictures for those identified as wanderers. When asked about the purpose of the roster, EI #10 said, if a visitor came in to see a resident, the roster would tell her if that resident was there or not. When asked how often her roster was updated, EI #10 said, almost every time, and when it was not left for her, she would ask another employee to print one for her. EI #10 said, EI #11, the Business Office Manager, would normally leave her a copy under the telephone at the receptionist desk. When asked who gave her the new updated roster on Saturday, 8/27/2022, EI #10 said, EI #11 did. When asked if she reviewed the roster to see if there were any new names, EI #10 said, she would scan the roster, but she did not have a photographic memory. When asked about the purpose of the visitor sign in log, EI #10 said, to make sure if anything accidental was to happen the facility would know who was in the building, and to review the times in and out. When asked who reviewed to ensure visitors were signing the TIME IN and the TIME OUT columns, EI #10 said, whoever was working the receptionist area. When asked what time RI #5 signed TIME OUT on the log on 8/27/2022, EI #10 said, she did not know. When asked when she looked at that sign out sheet to see what had been done, EI #10 said, she could not remember, but she did look at it. When asked if she noticed that RI #5 signed his/her name as the resident, EI #10 said she did not recall. On 8/31/2022 at 10:30 AM, EI #11, the Business Office Manager, was asked what training she provided to EI #10 about her receptionist duties. EI #11 said, she trained EI #10 on watching the area (as she was responsible for the entire lobby and the visual area outside), redirecting calls, watching residents when they went out the door, and if a resident did not feel good to call for the nurse. EI #11 said EI #10 was given complete census rosters to be able to find the residents' names and room numbers. EI #11 said she also let EI #10 know she was responsible for overseeing sign in and out for visitors and vendors entering the facility. When asked what should have been done to ensure a receptionist was able to identify a new admission, EI #11 said they would prepare a new census and she would leave it for her under the phone. EI #11 said EI #10 would have received another copy of the census list on Saturday morning (08/27/2022). When asked what should have been done so that the Receptionist could identify confused/nervous behavior of someone wearing a bonnet, gown, and socks, as a potential resident, EI #11 said, EI #10 should have asked the person's name, checked her roster, then there would not have been any further question as the resident would have been identified on the roster. EI #11 said EI #10 should be asking more questions to identify if a person is truly a visitor or a resident. EI #11 said when she trained EI #10 she told her specifically that the census list was like a Bible, and she needed to study it and know it, because residents come and go all the time. On 8/31/2022 at 11:35 AM, EI #8, Registered Nurse (RN)/Unit Manager, was asked when should the wander risk assessment be completed. EI #8 said, on admission. When asked what the time frame was, EI #8 said, on the day of admission. When asked for what reason RI #5's was not done on the day of admission, EI #8 said, she could not answer that question. When asked who would have been responsible for it, EI #8 said, the admission nurse, EI #12, Licensed Practical Nurse (LPN). On 8/31/2022 at 12:40 PM, EI #12, LPN, was asked why RI #5's wander risk assessment was not completed until after RI #5 eloped. EI #12 said, she had asked some questions of RI #5 but had not recorded them anywhere. On 8/31/2022 at 3:45 PM, EI #13, Licensed Master Social Worker, was asked who was responsible for completing Wander Risk Assessments. EI #13 said, she was or one of the nurses. When asked when the wander risk assessment was due for a new admission, EI #13 said, as soon as possible, but she did not know the timeframe. EI #13 said, after RI #5 eloped she noticed the Wander Risk Assessment had not been completed, so she did one then. On 9/1/2022 at 9:19 AM RI #5 was asked about having gone for a walk. RI #5 said, he/she did leave the facility but did not get hurt. RI #5 said he/she was walking down the road, but the facility staff got there in time. When asked where he/she was going, RI #5 said, to his/her sister's house. (Per information provided by RI #5, RI #5's sister lived approximately 4.7 miles from the facility). When asked how he/she was able to leave the facility, RI #5 said he/she did not know. RI #5 said he/she hoped that he/she had not said anything he/she should not have. On 9/1/2022 at 11:50 AM, EI #2, the DON, was asked who was responsible for the admission process once a new resident was in the building. EI #2 said, the nurse on the hall. EI #2 was asked which residents require a Wandering Risk Assessment to be completed upon admission. EI #2 said, all residents. When asked under what circumstances they would not do a Wandering Risk Assessment, EI #2 said, it was part of the admission process, and all admission assessments are to be completed, regardless of whether staff think the resident is a risk or not. EI #2 again stated all residents should have a Wandering Risk Assessment completed upon admission. When asked if she was able to locate a Wandering Risk Assessment from the day of admission for RI #5, EI #2 said, no, the first one was done on 8/27/2022 after RI #5's elopement. When asked what should have been implemented that would have prevented RI #5's elopement, EI #2 said, EI #10 should have looked at the roster/census list, asked for his/her name, and verified if they were on the roster as a facility resident or a visitor on the visitors' log. EI #2 further stated if EI #10 was not sure, she could have asked questions. On 9/1/2022 at 12:50 PM, EI #1, the Administrator, was asked how EI #10 should have known not to allow RI #5 to leave the facility. EI #1 said they keep a list of residents with their room numbers at the reception desk, and indicated EI #10 would be able to identify someone as a resident by comparing the names on the list to the name provided or documented on the visitors' log. EI #1 said the day this happened, RI #5 was in a pink gown, with nonskid socks and a bonnet on his/her head. EI #1 said typically this would not be a visitor. EI #1 further said she cannot imagine how EI #10 did not pick up on the attire of RI #5 that day or the fact the person she instructed to sign out before leaving left with no shoes. When asked what the expectation was for EI #10 knowing who she could let out, EI #1 said EI #10 should have asked the person their name and compared the name provided with the roster/census list and the visitor log book. EI #1 said if EI #10 was unsure, she could have asked the managers in the building. When asked about EI #10's training, EI #1 said, she was sure she was trained on the roster with updated names of residents in the facility, the elopement book, and how everyone has to sign in when the they enter the facility. EI #1 said EI #10 had access to all of the items needed to do her job. EI #1 said EI #10 was not paying attention to who she was talking to and did not ask the questions she should have, such as when did you come in to the facility and the name to compare to the roster/census. This deficiency was cited as a result of complaint/report number AL 014. *************************************************** On 09/02/2022 at 7:09 PM, the facility submitted an acceptable Removal Plan for F689 which documented the following: 1. The facility Policy on Elopements was reviewed by the Administrator and DON on 8/27/22. No Discrepancies were found with the policy. 2. Initiation of the Elopement protocol which included 100% head count was done of all residents that were in the facility were accounted for on 8/27/2022 prior to RI#5 being brought back to the facility. 3. Resident was assisted back in the facility and assessed by the nursing staff on 8/27/22 by the Administrator, DON, and CNA 4. A wandering risk assessment of the resident was completed on 8/27/22 by the social worker and the Unit manager. 5. New order for wander guard was given on 8/27/22 by the Medical Director. 6. Wander guard was placed on RI #5 left arm on 8/27/22 by the administrator 7. Care plan was developed by social worker on 8/27/22. The care plan included the interventions of distracting the resident from the elopement by offering diversions, structured activities, conversation, watching television, or a book. Other interventions are to identify their pattern and reorientation strategies. 8. Pain and skin assessment were completed by the Unit Manager on 8/27/22. No pain or injuries were noted. 9. Elopement book was updated after the wandering risk assessment was completed on RI #5. The face sheet and picture on 8/27/22 by the Social Worker. 10. Frequent checks on the resident every 30 minutes were done by staff with documentation beginning 8/27/22 and ending 8/30/22 11. Family and MD were notified of the elopement on 8/27/22. The sponsor was notified while in the facility by the administrator and the MD was notified by the Unit manager 12. EI #10, receptionist was immediately removed from the working schedule and suspended on 8/27/22 and terminated on 9/1/22 13. QAPI was held on 8/27/22 with the Administrator, DON, HR, BOM, Activities Director Maintenance, Dietary and Medical Director. The 2nd QAPI meeting was held on 8/28/22 with the Administrator, Director of Nursing, HR, Housekeeping and Maintenance, and Medical Director. Discussion on employee allowing the resident to exit the facility and how to prevent this from happening again was held on 8/27/22 100% audit of the 5 residents at risk for elopement on 8/27/22 100% audit of resident's orders to verify they had an order in place for the wander guard on 8/27/22 100% audit of care plans of the 5 resident that were at risk for elopement was done on 8/27/22 100% audit of the 5 residents to check placement and functionality of the wander guard was completed on 8/27/22. 100% audit of all residents wandering risk assessment was initiated on 8/27/22 and completed on 9/2/22 to ensure assessments were accurate and up to date by the DON. 14. Staff education was initiated on 8/30/22 and continued through 9/2/22 on the new procedure on visitors entering and exiting the facility by the DON and administrator. This staff education was presented to staff in all departments (licensed nursing 20/22 were educated, cna's 40/51 have been educated, housekeeping/laundry 14/15 have been educated, dietary 10/10 have been educated, maintenance 4/4 have been educated , activities 2/2 have been educated, social services 2/2 have been educated, therapy 2/8 have been educated and administrative staff 9/9 have been educated . For the remainder of the staff that have not received the education, they will not be placed on the schedule until the education on elopement has been completed. A list will be left with the night manager to ensure any staff that has not received the education is educated on elopement before allowed to work in the facility. The night manager will pass the list to the day shift manager to ensure the education is completed before staff receives a shift. Anyone that is not currently scheduled will not be scheduled until the education is completed. The visiting log was moved to the receptionist desk on 8/30/22. Visitor will sign the visiting log with the date and time. When the visitor is leaving the facility, the receptionist will verify the person that is leaving the facility is a visitor and not a resident. If the receptionist is unable to verify the visitor, he/she will contact the charge nurse to verify that it is not a resident. After hours and weekends, the doors are locked. Staff goes to the doors to unlock and let the visitors inside. Visitors sign in at the receptionist desk and are assessed by the staff. When visitors have completed their visits, they notify the nursing staff when they are ready to leave the facility. The nursing staff assist the visitors back to the receptionist desk to sign out, verify they are a visitor and open the door so they can exit. If the nursing staff is unsure if this person wanting to exit is not a visitor, the charge nurse is notified to verify it is not a resident. On weekends doors are still locked and staff must open doors to assist visitor in the facility. 15. All employee's education on the policy and protocol for elopement was initiated on 8/30/22 and continued through 9/2/22. The policy explained how we are to identify, notify and respond to a potential or actual elopement of a resident. The protocol shows staff how to respond when a resident is missing. This staff education was presented to staff in all departments (licensed nursing 20/22 were educated, cna's 40/51 have been educated, housekeeping/laundry 14/15 have been educated, dietary 10/10 have been educated, maintenance 4/4 have been educated , activities 2/2 have been educated, social services 2/2 have been educated, therapy 2/8 have been educated and administrative staff 9/9 have been educated . For the remainder of the staff that have not received the education, they will not be placed on the schedule until the education on elopement has been completed. A list will be left with the night manager to ensure any staff that has not received the education is educated on elopement before allowed to work in the facility. The night manager will pass the list to the day shift manager to ensure the education is completed before staff receives a shift. Anyone that is not currently scheduled will not be scheduled until the education is completed. 16. Education to all licensed staff about the assessments that must be done on a new admission within 24 hours will be done by the DON or designee. The education was initiated on 9/2/22 and includes the following topics. 21/24 licensed nurses were educated on 9/2/22. Two PRN nurses will not be scheduled and one full time nurse will not be allowed to work until education is completed on admission assessments. The night supervisor will educate the nurse before she works her shift. All licensed nurses will be educated on how to access the assessment in PCC and complete by clicking on the assessment tab and using the drop-down bar and clicking on the type of assessment that needs to be completed. If the assessment shows to be a risk, the nurse will immediately initiate a care plan to ensure the resident's needs are met. Assessments are to be completed upon admissions, quarterly, annually and significant changes. A copy of the admission checklist will be given to the licensed nurse and a copy will be placed at the nurse's station for reference. New admission charts will be reviewed in the following morning clinical meeting. The admission checklist will be monitored All admission assessment will be completed and verified by 2 nurses and dated Wandering assessment Braden scale Side Rail Assessment Morse Fall Scale Base line Care plan Admit/Readmit Screener Pain Assessment Bowel and Bladder Oral Observation Physician Orders ************************* After reviewing the facility's information provided in their Removal Plan and verifying the immediate actions had been implemented, the scope/severity level of F689 was lowered to a D level on 09/02/2022, to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance.

Based on interviews and review of the facility's Director of Nursing and Staff Development Coordinator job descriptions, the Director of Nursing failed to provide oversite to the Staff Development Coordinator to ensure all staff members, including agency staff, received orientation/training regarding the facility's policies and procedures about residents' code status. On [DATE], Resident Identifier (RI) #1, a full code resident, was found unresponsive by Employee Identifier (EI) #3 and EI #4. No cardiopulmonary resuscitation (CPR) was initiated by either LPN. This resident expired in the facility. EI #3 and EI #4, both agency nurses, indicated they had not been provided any orientation or training related to the facility's policies regarding code status. This deficient practice placed RI #1, one of four sampled residents reviewed for the provision of CPR, in immediate jeopardy, as it was likely to result in serious injury, serious harm, serious impairment or death. It also had the potential to affect any other resident in the facility who may be found unresponsive. The facility's Form CMS-672 Resident Census and Conditions of Residents reflected a census at the time of the survey of 116. On [DATE] at 5:11 PM, the Administrator and Director of Nursing were given a copy of the immediate jeopardy (IJ) template and notified of the findings of immediate jeopardy in the area of Administration, F835-Administration. Findings include: During the survey it was determined EI #3 and EI #4, both agency nurses, failed to initiate CPR on [DATE] when RI #1, a full code resident, was found unresponsive. The facility was unable to provide any documentation EI #3 and EI #4 had been oriented to the facility's policies and procedures related to CPR and code status. Cross Reference F678 and F726. Review of the facility's Staff Development Coordinator job description, effective [DATE], revealed the following: . Generally Reports to: DON (Director of Nursing) . SUMMARY Ensures facility is in compliance with regulatory requirements relating to staff credentialing and education . ESSENTIAL DUTIES AND RESPONSIBILITIES . * Conducts new employee orientation and coordinates competency completion. . Maintains employee education, training . Review of the facility's Director of Nursing job description, effective [DATE],revealed the following: . SUMMARY Plans, coordinates and manages the nursing department. Responsible for the overall direction, coordination and evaluation of nursing care and services provided to the residents . ESSENTIAL DUTIES AND RESPONSIBILITIES . Recruits, hires, provides orientation/training . On [DATE] at 1:15 PM, and interview was conducted with EI #2, DON. EI #2 said she did not know if EI #3 and EI #4 had been provided orientation to the facility. When asked how she ensures the Staff Development Coordinator (EI #7) is providing orientation to new staff, including agency staff, EI #2 stated, she gives EI #7 directions and instructions to provide general orientation and she takes her word that it was done. EI #2 admitted that she is ultimately responsible for ensuring all staff, including agency staff, are trained on policies and procedures of the facility. When asked how she monitors the Staff Development Coordinator to ensure she is doing her job, EI #2 stated, she asks if the orientation is complete, but does not request any documentation to verify. On [DATE] at 3:10 PM, an interview was conducted with EI #1, the Administrator. EI #1 stated, the DON (EI #2) was supposed to ensure new staff orientation is completed and make sure the Staff Development Coordinator (EI #7) is doing what she is supposed to be doing. This deficiency was cited as a result of the investigation of complaint/report number AL 005. ************************* On [DATE] at 2:12 PM, the facility submitted an acceptable Removal Plan for F835 which documented: * One to one Education with the DON was done on [DATE] by the Regional Nurse Consultant. She was trained on Emergency Procedures/ CPR. She was also educated on how the orientation process is to be completed. * Disciplinary action was given to the DON on [DATE] by the administrator for failure to oversee the orientation process being completed by the staff development nurse. * The former Staff Development nurse was disciplined on [DATE] because she failed to educate staff and ensure completion of orientation on Emergency procedures/CPR with new employees with signed documentation as validation. Her disciplinary action will be place in the HR office in her personnel file. As of [DATE] the former Staff Development is not longer in the Staff Development Nurse position unrelated to this event. The position of Staff Development Coordinator is currently vacant. The DON and HR Director will assume responsibility until a Staff Development Coordinator is hired. The DON or designee will complete the Emergency Procedure/CPR and other education included in the orientation packet with the new staff. Upon completion, the orientation packet will be taken to the HR Department for review for validation then filed in the employee's records. The orientation checklist was reviewed for new hires and contracted staff on [DATE]. A new check list was added on [DATE] to orientation package to include all subjects to be covered including Emergency Procedure/CPR. DON was trained on [DATE] by the Regional Nurse on the orientation checklist and the newly added checklist information. * The DON will conduct the orientation until a new Staff Development Nurse is hired. Once the orientation is completed, the DON will take the package to the HR department. The HR Manager will ensure all paperwork is completed and sign the acknowledgement form. When the new staff development nurse is hired, she will be trained by the DON on the new orientation process. She will also have to take her orientation package to HR and the HR Manager will review for validation and completion. The HR will bring the orientation packet to administrator for review with all new hires and agency staff to ensure all documents are completed in the packet. All education will be filed in the HR office in the employee's personnel file. ************************* After reviewing the facility's information provided in their Removal Plan and verifying the immediate actions had been implemented, the scope/severity level of F835 was lowered to a D level on [DATE], to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance.

Based on interviews, review of the Contract Agency's SERVICES AGREEMENT, review of the Staff Development Coordinator job description, and review of personnel files, the facility failed to ensure that all facility staff, including agency staff, were provided orientation and education regarding the facility's policies and procedures involving resident code status and resuscitation efforts. On [DATE] RI #1 was found by Employee Identifier (EI) #3 and EI #4, both Licensed Practical Nurses (LPNs), during shift change at approximately 7:20 PM. EI #3 and EI #4 both stated the resident's eyes were open and appeared to be fixed, and said RI #1 did not appear to be breathing. Neither EI #3 (the off-going nurse) or EI #4 (the on-coming nurse) checked RI #1 to see if he/she had a pulse. EI #4 walked to RI #1's bed and placed her hand on RI #1's chest and reported she felt no movement. EI #3 then informed EI #4 that RI #1 was on hospice and hospice would take care of everything. Neither LPN verified RI #1's code status in the computer, or by utilizing the facility's dot system as outlined in their policy. No resuscitation efforts were made, and Hospice was notified the resident was deceased . Both EI #3 and EI#4 denied having received any training related to the facility's policies and procedures on resident code status; nor could the facility provide documentation they had been trained on the topic. This deficient practice placed RI #1, one of four sampled residents reviewed for the provision of CPR, in immediate jeopardy, as it was likely to result in serious injury, serious harm, serious impairment or death. It also had the potential to affect any other resident in the facility who may be found unresponsive. The facility's Form CMS-672 Resident Census and Conditions of Residents reflected a census at the time of the survey of 116. On [DATE] at 5:11 PM, the Administrator and Director of Nursing were given a copy of the immediate jeopardy (IJ) template and notified of the findings of immediate jeopardy in the area of Nursing Services, F726-Competent Nursing Staff. Findings include: During the survey it was determined EI #3 and EI #4, both agency nurses, failed to initiate CPR on [DATE] when RI #1, a full code resident, was found unresponsive. Cross reference F678 and F835. The Contract Agency's SERVICES AGREEMENT , dated [DATE], documented: . WHEREAS, Client is duly licensed skilled nursing or other healthcare facility . NOW, THEREFORE, in consideration of the mutual covenants herinafter set forth, and intending to be legally bound thereby, the parties agree as follows: I. SCOPE OF SERVICES A. Agency shall make available to Client . Temporary Clinicians possessing a current and unrestricted license to practice as an .LPN . III. DUTIES OF CLIENT . D. Prior to commencement of services by any Temporary Clinician, Client maintains the responsibility to in-service and train each Temporary Clinician with respect to Client's policies ., procedures and any required start up processes . Review of the facility's Staff Development Coordinator job description, effective [DATE], revealed the following: . Generally Reports to: DON (Director of Nursing) . SUMMARY Ensures facility is in compliance with regulatory requirements relating to staff credentialing and education . ESSENTIAL DUTIES AND RESPONSIBILITIES . * Conducts new employee orientation and coordinates competency completion. . Maintains employee education, training . On [DATE] at 4:47 PM, at telephone interview was conducted with EI #3, LPN. EI #3 indicated she was an agency nurse and not a direct employee of the facility. EI #3 stated she was not provided any orientation to the facility and was never told code status would be on the residents' doors. EI #3 said after the incident involving RI #1 on [DATE], the Director of Nursing (DON) told her if a resident was DNR (do not resuscitate) they would have a red dot by their name on their door. In a follow-up interview with EI #3 on [DATE] at 2:56 PM, EI # 3 was asked what type of orientation she had received from the facility regarding their policies. EI #3 said she was never provided any orientation or copies of policies. EI #3 said she was just placed on the floor to learn as she went. On [DATE] at 6:23 PM a telephone interview was conducted with EI #4, LPN. EI #4 indicated she was an agency nurse and not a direct employee of the facility. She said [DATE] when RI #1 was found unresponsive was her third day working at the facility. When asked how she can verify a resident's code status, EI #4 said she did not know how that should be done in this facility. When asked how she was oriented to the facility, EI #4 said they went over privacy rules, handwashing, disasters, and did a COVID-19 test. EI #4 said she did not receive any orientation on the facility's computer system. EI #4 explained the nurse she relieved her first day showed her how to login to the computer, and from there she had to figure it out as she went. EI #4 said on [DATE] when RI #1 was found unresponsive she was not able to get into the computer system to review RI #1's code status because she was unable to login. In a follow-up interview with EI #4 on [DATE] at 8:16 PM, EI #4 stated she did not know anything the first day she started work in the facility. When asked if she was familiar with the facility's red dot system for identifying residents who are DNR, EI #4 stated she was not aware of the system when RI #1 was found unresponsive. She said she asked another nurse for future reference about codes, and she informed her residents who are DNR have a red dot on their charts and a red dot by their names on their doors. On [DATE] at 11:56 AM, a telephone interview was conducted with EI #7, Registered Nurse (RN)/Former Staff Development Coordinator. EI #7 stated for agency staff they go through an orientation checklist about nursing procedures. EI #7 stated agency staff are shown in the computer system where the code status is and informed there is a red dot by resident's name on the door if residents are Do Not Resuscitate (DNR). EI #7 stated if there is no red dot on the door, cardiopulmonary resuscitation (CPR) is to be performed. When asked if she had documentation that EI #3 and EI #4 had been oriented regarding code status, EI #7 stated they should have signed the orientation checklist. However, when asked for documentation of EI #3 and EI #4's checklists, EI #7 stated she was not at work, but the Director of Nursing (DON) or Administrator could provide the surveyor with the information. A letter dated [DATE], signed by EI #7, the Staff Development Coordinator, documented, I was not able to locate an orientation checklist on (EI #3), LPN. A letter dated [DATE], signed by EI #1, Administrator, documented, The Staff Development Coordinator (EI #7) was called to the facility to locate new orientee checklist for (EI #4), she was unable to locate the orientation checklist. During an interview with EI #2, the DON, on [DATE] at 10:05 AM, EI #2 was asked how agency staff are oriented to the facility. EI #2 said they should come in to go over facility policies and procedures. When asked if this had been done, EI #2 said she was not sure, that it would be EI #7, the Staff Development Coordinator's, responsibility. During a follow-up interview with EI #2 on [DATE] at 1:15 PM, EI #2 stated she does not know if EI #3 and EI #4 were trained on emergency procedures to include CPR and code status because she does not have any documentation. This deficiency was cited as a result of the investigation of complaint/report number AL 005. ************************* On [DATE] at 2:12 PM, the facility submitted an acceptable Removal Plan for F726 which documented: 1. The facility policy Emergency Procedure- Cardiopulmonary Resuscitation was reviewed by the Administrator, DON, Unit Manager, and the Regional Nurse Consultant [DATE]. No discrepancies found with the policy. 2. On [DATE] a 100% audit of all resident's code status was checked by the DON and Unit Managers to verify: a. Physicians order b. If verified as DNR, red dot placed on door plate c. Face sheet indicated the correct code status by physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] 3. LPN #1 and LPN #2 (EI #3 and EI #4) were interviewed and suspended on [DATE] pending investigation by the Administrator. 4. One to one education with LPN #1 and LPN #2 was done on [DATE] with the administrator on how to properly assess an unresponsive resident and how to identify the code status to initiate CPR utilizing the titled policy Emergency Procedure/CPR. 5. One-to One in-service with LPN #1 and LPN #2 on the policies and procedures of CPR was done on [DATE]. It was done while interviewing the nurses and correcting the mistakes that had been made on how to properly initiate CPR and when to perform CPR. They were also educated on how to properly assess an unresponsive resident. LPN #2 stated she knew how to do CPR, but she wanted to know the policy. 6. LPN #1 and LPN#2 were reported to the Alabama Board of Nursing on [DATE] by the Administrator. 7. LPN#1 and LPN #2 were terminated on [DATE] 8. All staff to include all departments (nursing, housekeeping, dietary, maintenance, activities, social services, administrative staff) will be educated on identifying the resident's code status by the Administrator, DON, or designee utilizing the titled policy Emergency Procedure/CPR. The working scheduled was reviewed by the DON and Administrator to determine if any employee was on the schedule that would need training. For staff members that did not have documentation on file of education on the Emergency procedure policy was initiated on [DATE] will be completed by [DATE] by the DON or designee. All staff will be able to identify the code status by looking at the name plate on the door. For DNR status residents the door plate will be tagged with a red dot. * No staff member to include agency staff will be allowed to work until education on Emergency Procedure/CPR is complete. * All new hired employees or contracted nurses will receive education upon hire to ensure the policy for code status is followed. No nurse will be allowed to work until education is completed. * The DON or designee validated that all current licensed staff members including agency staff have a current CPR Certification on [DATE]. * The licensed nurse orientation checklist list was reviewed by the Regional Nurse Consultant, and it was determined that it meets the orientation competency needs on [DATE]. * The current orientation policy has been reviewed by the Regional Vice President of Operations and the Regional Nurse Consultant. It was determined it meets the needs of orientation competency on [DATE]. * The facilities previous Staff Development Nurse is no longer in the Staff Development position and is unrelated to this event. Upon hire of a staff Development Coordinator, orientation and training will be provided by the DON or designee on job description and education requirements for the facility. Until this position is filled, the DON will be responsible for job duties of Staff Development. * One to one Education with the DON was done on [DATE] by the Regional Nurse Consultant. She was trained on Emergency Procedures/ CPR. She was also educated on how the orientation process is to be completed. * The former Staff Development nurse was disciplined on [DATE] because she failed to educate staff and ensure completion of orientation on Emergency procedures/CPR with new employees with signed documentation as validation. Her disciplinary action will be place in the HR file * All staff to include all departments (nursing, housekeeping, dietary, maintenance, activities, social services, administrative staff) will be educated on identifying the resident's code status by the Administrator, DON, or designee utilizing the titled policy Emergency Procedure/CPR. The working scheduled was reviewed by the DON and Administrator to determine if any employee was on the schedule that would need training. For staff members that did not have documentation on file of education on the Emergency procedure policy was initiated on [DATE] will be completed by [DATE] by the DON or designee. All staff will be able to identify the code status by looking at the name plate on the door. For DNR status residents the door plate will be tagged with a red dot. * The DON or designee has educated all licensed nursing staff on how to assess an unresponsive resident and the initiation of CPR per the policy titled Emergency Procedure/CPR. Completed on [DATE]. Any staff member who did not completed the required training due to leave of absence or PRN status will not be allowed to work until education is completed. * All other unlicensed staff that are not CPR certified were educated to call for help when they identify a resident is unresponsive in their room. This information was obtained for the policy titled Emergency Procedure/CPR. It was presented by the Administrator on [DATE], [DATE] and [DATE] * New employees and agency staff will receive education upon hire to ensure the Emergency Procedure/CPR policy and code status is understood. This education and orientation were initiated on [DATE] was completed on [DATE] by the DON or designee. * A 100% audit of all physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . * An education was completed on [DATE] with all staff that new admission code status will be verified during the admission process. If no code status is indicated, the physician will be contacted by the admitting licensed nurse and orders obtained. Once obtained, the order will be written, and appropriate signage will be placed on the door name plate as indicated. This education was completed by Administrator and DON. This education was completed by [DATE]. * Mock code drill was conducted on [DATE] on day shift and [DATE] on evening shift to ensure all staff responded appropriately with no discrepancies noted. ************************* After reviewing the facility's information provided in their Removal Plan and verifying the immediate actions had been implemented, the scope/severity level of F726 was lowered to a D level on [DATE], to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance.

Based on interviews, record reviews and a review of a facility policy titled, Abuse Prevention Program, and Controlled Substances, the facility failed to ensure Licensed staff members were following the facility policy on receiving medications and conducting counts, which resulted in missing medications. This deficient practice affected Resident Identifier (RI) #1, one of six residents who were investigated for missing narcotic medication. Findings Include: A review of a facility policy titled Abuse Prevention Program, with a revised effective date of April 2019, revealed: Policy Statement Our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. Definitions . 4. 'Misappropriation of Property,' the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent. Controlled Substances policy with a revised date of December 2012. Policy Statemen The facility shall comply with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of Schedule II, and other controlled substances. . 3. Controlled substances must be counted upon delivery. The nurse receiving the medication, along with the person delivering the medication, must count the controlled substances together. Both individuals must sign the designated controlled substance record. 4. If the count is correct, an individual resident-controlled substance record must be made for each resident who will be receiving a controlled substance. Do not enter more than one (1) prescription per page. This record must contain: . c. Quantity received; k. Signature of person receiving medication; and l. Signature of nurse administering medication. RI #1 was admitted to the facility on [DATE]. A review of RI #1's July 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . July 3, 2022, at midnight until July 7, 2022 at 12PM [MEDICATION(S)] was charted not given due to medication unavailable. On 8/8/2022 at 6:16 PM an interview was conducted with Employee Identifier (EI) #4. EI #4 was asked, what was the policy and procedure when receiving narcotics from the pharmacy. EI #4 replied, count the medication with the pharmacy staff and then two nurses check off the narcotics to the pharmacy sheet and then we sign the manifestation sheet (log sheet) then the nurse of the medication cart puts the medication in the narcotics box on the cart. EI #4 was asked, what did she do when she received the narcotics from the pharmacy on 6/20/2022. EI #4 replied, she took the narcotics from the pharmacy employee without counting the pills and then brought them into the facility and put them in the narcotic box on her medication cart. EI #4 was asked did she count with the pharmacist employee the narcotics received, EI #4 replied, no. EI #4 was asked, did two nurses look at and count the narcotics on 6/20/2022. EI #4 replied, no ma'am. EI #4 was asked, did she sign for two-hundred and thirty-six [MEDICATION(S)] for RI #1 on 6/20/2022. EI #4 replied, no. EI #4 was asked, what should have been done. EI #4 replied, the pills should have been counted in front of the delivery driver. EI #4 was asked, what was the risk of not counting the narcotics when receiving them. EI #4 replied, missing medications and the resident not receiving the medication and being in pain. EI #4 was asked, when she had counted the narcotics on the medication cart with the off-going nurse. EI #4 replied, never. EI #4 was asked, when she had not been able to give RI #1 pain medication. EI #4 replied, when the medication ran out (July 3, 2022). EI #4 was asked, what she did about the pain when the medication ran out. EI #4 replied, RI #1 could not get pain medication. EI #4 was asked, how many days was RI #1 out of pain medication. EI #4 replied, maybe a couple of days. On 8/9/2022 at 5:24 PM an interview was conducted with EI #3. EI #3 was asked, what was the policy and procedure when receiving narcotics. EI #3 replied, get the pharmacy staff to count it with them and then have them sign the sheet with you to verify the count and then another nurse counts the medications and signs the narcotic log sheet with the nurse and then put the count sheet in the red narcotics book on the medication cart. EI #3 was asked, on 6/4/2022 how much [MEDICATION(S)] did she sign for RI #1. EI #3 replied, according to the paper it said it was three hundred and fifty-six. EI #3 was asked, how many did you count. EI #3 replied, she was not sure, she just signed it. EI #3 was asked, what was the risk of not counting the narcotics with the pharmacy staff member. EI #3 replied, the pharmacy could say they sent more than what was received. EI #3 was asked, how much [MEDICATION(S)] were signed out for RI #1 from the 6/4/2022 pharmacy drop off. EI #3 replied, thirty tabs. EI #3 was asked, what happened to the other three hundred and twenty-six [MEDICATION(S)]. EI #3 replied, she had no idea. EI #3 was asked, what she thought happened to the [MEDICATION(S)] pills. EI #3 replied, she did not know. EI #3 was asked, what was the risk of the controlled medication count being wrong. EI #3 replied, risk the resident does not get the medication. EI #3 was asked, what should she have done on 6/4/2022 with the medications from the pharmacy. EI #3 replied, she should have opened the package with the driver present and counted the medications and then signed the controlled sheet. On 8/10/2022 at 10:23 AM an interview was conducted with EI #2 Director of Nursing (DON). EI #2 was asked, what was the procedure for accepting narcotics at this facility. EI #2 replied, meet the pharmacy employee at the front, take everything out of the bag and count all the medication and compare it to the packing list to make sure it was correct and then sign for the medication. EI #2 was asked, why on 5/23/2022 was two hundred and forty pills of [MEDICATION(S)] for RI #1 delivered from the pharmacy and only fifty-two pills were accounted for. EI #2 replied, the nurse did not count the pills. EI #2 was asked, where were the other one hundred and eighty-eight pills. EI #2 replied, she had no idea. EI #2 was asked, on 6/4/2022 the pharmacy delivered three hundred and fifty-six pills of [MEDICATION(S)] for RI #1, why was there only thirty pills accounted for. EI #2 replied, we did not count them. EI #2 was asked, what happened to the other three hundred and twenty-four pills of [MEDICATION(S)]. EI #2 replied, the nurse that received them did not count them. EI #2 was asked, on 6/20/2022 the pharmacy sent two hundred and thirty-six pills of [MEDICATION(S)] for RI #1, why were only sixty-four pills accounted for. EI #2 replied, the nurse did not count them. EI #2 was asked, what happened to the other one hundred and seventy-two pills of [MEDICATION(S)] for RI #1. EI #2 replied, she did not know. EI #2 was asked, why she did not know where the all the missing medication was. EI #2 replied, she could not locate the log sheets on the charts. EI #2 was asked, as the DON should she know where the medication was in the facility. EI #2 replied, yes, she should know. EI #2 was asked, what should have been done. EI #2 replied, the nurse should have been counting the narcotics when they received it and the nurses should have been counting with the other nurses, the log sheets should have been put on the charts when zeroed out. EI #2 was asked, was the facilities policy followed for the narcotic medication. EI #2 replied, no, it was not followed.

Based on interviews, record review, review of a facility policy Controlled Substances, review of a facility investigative file, and review of a report made to the Alabama Department of Public Health's (ADPH) Online Reporting System on 7/6/2022, the facility failed to maintain evidence of proper handling of controlled medications for Resident Identifier (RI) #1, RI #4, RI #5, and RI #6. This affected four of six residents sampled for controlled medications. Findings include: On 7/6/2022 the State agency received an online incident report of Misappropriation of Resident Property from the facility. Details of the incident for RI #1, the resident involved, were as follows : . The resident receives routine [MEDICATION(S)] 10 mg (milligram) every 6 hours. Pharmacy sent 236 pills of [MEDICATION(S)] 5 mg to the facility on [DATE]. The resident is now out of medication. The facility Final Summary report dated 7/13/2022 for the instance of Misappropriation of RI #1's [MEDICATION(S)] documented: . On Wednesday, July 6, 2022, the unit manager, . Employee Identifier (EI #7) RN and DON, . (EI #2) came to the administrator's office and reported they were having a problem getting some medication in for . (RI #1). (EI #7) . stated the pharmacy said we should already have the [MEDICATION(S)] for . (RI #1) in the facility because they had sent 356 tabs on June 4, 2022, and 236 tablets on June 20, 2022. CONCLUSION . (RI #1) has a physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Pharmacy was sending the medication to the facility as [MEDICATION(S)] 5 mg. The nurses were having to administer 2 tablets to equal the 10 mg of [MEDICATION(S)]. On June 20, 2022, pharmacy's manifest sheet stated 236 [MEDICATION(S)] 5 mg tablets were delivered to the facility. The charge nurse . (EI #4) . signed for the medication, but when interviewing admitted she did not count . She admitted she signed for the package and not for the number of medications in the package. On June 4, 2022, . (EI #3) . admitted she went to the door to receive a package pharmacy was delivering. She did not know what was in the package but signed for it. She never opened the package but delivered that package to the charge nurse . (EI #4). She never counted the medication with . (EI #4) . Review of the facility policy titled Controlled Substances with a revised date of December 2012, revealed: . Policy Statement The facility shall comply with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of Schedule II, and other controlled substances. 3. Controlled substances must be counted upon delivery. The nurse receiving the medication, along with the person delivering the medication, must count the controlled substances together. Both individuals must sign the designated controlled substance record. 4. If the count is correct, an individual resident controlled substance record must be made for each resident who will be receiving a controlled substance. Do not enter more than one (1) prescription per page. This record must contain: . c. Quantity received; d. Number on hand; . k. Signature of person receiving medication; and l. Signature of nurse administering medication. RI #1 was admitted to the facility on [DATE]. Review of RI #1's active physician orders as of 8/9/2022 revealed an order dated 6/13/2022 for [MEDICATION(S)] 5 mg tablet, give two tablets every six hours for pain. A form titled Packing Slip Proof of Delivery, used during delivery of medication from the pharmacy to the facility, dated 5/23/2022, signed by EI #4 RN, documented 240, 5 mg pills of [MEDICATION(S)] were delivered for RI #1. RI #1's Controlled Drug Receipt Record/Disposition Form, documented Quantity Received 240 pills of [MEDICATION(S)] 5 mg on 5/23/2022. Fifty-two pills were signed out and accounted for on the form from 5/30/2022 through 6/4/2022. The facility did not have any documentation or evidence of handling for the remaining 188 pills that had been delivered on 5/23/2022. A form titled Packing Slip Proof of Delivery, used during delivery of medication from the pharmacy to the facility, dated 6/4/2022, signed by EI #3 RN, documented 356, 5 mg pills of [MEDICATION(S)] were delivered for RI #1. RI #1's Controlled Drug Receipt Record/Disposition Form, documented Quantity Received 356 pills of [MEDICATION(S)] 5 mg on 6/4/2022. Thirty-two pills were signed out and accounted for on the form from 6/16/2022 through 6/20/2022. The facility did not have any documentation or evidence of handling for the remaining 324 pills that had been delivered on 6/4/2022. A form titled Packing Slip Proof of Delivery, used during delivery of medication from the pharmacy to the facility, dated 6/20/2022, signed by EI #4 RN, documented 236, 5 mg pills of [MEDICATION(S)] were delivered for RI #1. RI #1's Controlled Drug Receipt Record/Disposition Form, documented Quantity Received 236 pills of [MEDICATION(S)] 5 mg on 6/20/2022. This was documented on two different forms. One form documented twenty-four pills from 6/23/2022 through 6/27/2022 were signed out and accounted for. Another form documented forty pills from 6/28/2022 through 7/3/2022, were signed out and accounted for. The facility did not have any documentation or evidence of handling for the remaining 172 pills that had been delivered on 6/20/2022. RI #4 was readmitted to the facility on [DATE]. A form titled Packing Slip Proof of Delivery, used during delivery of medication from the pharmacy to the facility, dated 7/8/2022, signed by EI #4 RN, documented 120, 10/325 mg pills of [MEDICATION(S)]/Acetaminophen were delivered for RI #4. Controlled medications were reviewed with EI #5 RN on 8/9/2022 at 10:45 AM. RI #4 had a full card of sixty, 10/325 mg pills of [MEDICATION(S)]/Acetaminophen on a card in the medication cart and another card with twenty-five pills remaining from a card that originally had 60 pills. RI #4's Controlled Drug Receipt Record/Disposition Form, documented three pills were signed out and accounted for from 8/7/2022 through 8/8/2022. The facility did not have any documentation or evidence of handling for the other thirty-two pills that were removed from the card. RI #5 was readmitted to the facility on [DATE]. A form titled Packing Slip Proof of Delivery, used during delivery of medication from the pharmacy to the facility, dated 7/25/2022, documented 90, 7.5/325 mg pills of [MEDICATION(S)]/Acetaminophen were delivered for RI #5. Controlled medications were reviewed with EI #5 RN on 8/9/2022 at 10:45 AM. RI #5 had one Controlled Drug Receipt Record/Disposition Form with four signatures for administration of four pills, from 8/8/2022 through 8/9/2022, with a balance of fifty-six pills, from an original card of 60 pills, present in the medication cart. The facility did not have any documentation or evidence of handling for the remaining thirty pills that had been delivered on 7/25/2022. On 8/9/2022 at 3:27 PM an interview was conducted with EI #5. EI #5 was asked, what is the procedure when signing out narcotics. EI #5 replied, take out the medication and give the medication and then come back and sign the narcotics log. EI #5 was asked, where was the documentation located. EI #5 replied, narcotic logs are kept in the narcotics book and when they are zeroed out the log goes in the chart. EI #5 was asked, where were the thirty unaccounted [MEDICATION(S)]/APAP 7.5-325 mg pills for RI #5. EI #5 replied, she did not know. EI #5 was asked, where were the thirty-two unaccounted [MEDICATION(S)]/APAP 10-325mg pills for RI #4. EI #5 replied, she did not know. EI #5 was asked, what was the risk of medication unaccounted for. EI #5 replied, big risk, the nurse could have taken it, or the pharmacy could not have sent it, the resident could not get the medication ordered. EI #5 was asked, should the narcotic count be correct on the medication cart. EI #5 replied, yes always and documented correctly. EI #5 was asked, why was the narcotic count not right. EI #5 replied, she did not know, but it should have been. RI #6 was admitted to the facility on [DATE]. A form titled Packing Slip Proof of Delivery, used during delivery of medication from the pharmacy to the facility, dated 7/18/2022, documented 120, 5/325 mg pills of [MEDICATION(S)] were delivered for RI #6. Controlled medications were reviewed with EI #6 LPN on 8/9/2022 at 4:46 PM. RI #6 had one Controlled Drug Receipt Record/Disposition Form for [MEDICATION(S)] 5-325 mg, with a date received of 7/18/2022, and 16 pills signed for with a balance of forty-four pills, and a corresponding card of medication on the medication cart. The facility did not have any documentation or evidence of handling for the remaining 60 pills that had been delivered on 7/18/2022. On 8/9/2022 at 4:46 PM an interview was conducted with EI #6 LPN. EI #6 was asked, where were the narcotic log sheets for the [MEDICATION(S)] for RI #6. EI #6 replied, she did not know. EI #6 was asked where the remaining sixty [MEDICATION(S)] were located. EI #6 replied, she did not know. EI #6 was asked, where should it have been. EI #6 replied, it should have been signed out on a log sheet or on the medication cart. On 8/10/2022 at 10:23 AM an interview was conducted with EI #2 Director of Nursing (DON). EI #2 was asked, what was the procedure for accepting narcotics at this facility. EI #2 replied, meet the pharmacy employee at the front, take everything out of the bag and count all the medication and compare it to the packing list to make sure it was correct and then sign for the medication. EI #2 was asked, why on 5/23/2022 was two hundred and forty pills of [MEDICATION(S)] for RI #1 delivered from the pharmacy and only fifty-two pills were accounted for. EI #2 replied, the nurse did not count the pills. EI #2 was asked, where were the other one hundred and eighty-eight pills. EI #2 replied, she had no idea. EI #2 was asked, on 6/4/2022 the pharmacy delivered three hundred and fifty-six pills of [MEDICATION(S)] for RI #1, why was there only thirty pills accounted for. EI #2 replied, we did not count them. EI #2 was asked, what happened to the other three hundred and twenty-four pills of [MEDICATION(S)]. EI #2 replied, the nurse that received them did not count them. EI #2 was asked, on 6/20/2022 the pharmacy sent two hundred and thirty-six pills of [MEDICATION(S)] for RI #1, why were only sixty-four pills accounted for. EI #2 replied, the nurse did not count them. EI #2 was asked, what happened to the other one hundred and seventy-two pills of [MEDICATION(S)] for RI #1. EI #2 replied, she did not know. EI #2 was asked, why she did not know where the all the missing medication was. EI #2 replied, she could not locate the log sheets on the charts. EI #2 was asked, as the DON should she know where the medication was in the facility. EI #2 replied, yes, she should know. EI #2 was asked, what should have been done. EI #2 replied, the nurse should have been counting the narcotics when they received it and the nurses should have been counting with the other nurses, the log sheets should have been put on the charts when zeroed out. EI #2 was asked, was the facilities policy followed for the narcotic medication. EI #2 replied, no, it was not followed.

Based on observations, record review, interviews, review of the facility's investigative file and review of the facility policy titled, Care Plans, Comprehensive Person-Centered, the facility staff failed to use the Hoyer lift, as identified in the plan of care, when transferring RI #1 from the floor to bed after a fall on 11/28/2022. This failures affected one of three sampled resident's care plans reviewed. Findings include: Review of a facility policy titled, Care Plans, Comprehensive Person-Centered, Revised December 2016, documented: . A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. RI #1 was readmitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the facility's Investigation Template dated 11/28/2021, identified that between the hours of 4:00 AM and 5:00 AM, RI #1 fell out of bed while staff was providing ADL care. According to RI #1's plan of care facility staff did not follow the plan intervention when transferring the resident from the floor to the bed. The resident was transferred to the bed by two CNAs (EI #7 and EI #8) without using the Hoyer lift. RI #1's current comprehensive care plans, initiated 02/24/2020, included an approach that resident requires Mechanical Lift: Full Body with two staff assistances for transfers. On 01/26/2022 at 8:40 AM, Employee Identifier (EI) #8, Certified Nursing Assistant (CNA), was interviewed regarding RI #1's fall. EI #8 said she and EI #7 moved RI #1 from the floor after (his/her) fall on the morning of 11/28/2021. EI #8 said she got the upper part and EI #7, CNA, got the lower part of RI #1's body. EI #8 stated they did not use the mechanical lift to transfer the resident. Also, EI #8 said the lift should have been used as care planned to prevent further injury or pain. On 01/26/2022 at 9:05 AM, EI #7, CNA, was interviewed. EI #7 was said she and EI #8 helped RI #1 up off the floor after (his/her) fall the morning of 11/28/2021. EI #7 said she grabbed (his/her) hips and EI #8, CNA, held the top part. EI #7 said the mechanical lift was not used to transfer the resident from the floor to the bed. EI #7 also said, RI #1 was care plan to transfer using the mechanical lift and that she knew moving the resident could have made the situation worse. On 01/26/2022 at 2:54 PM, an interview was conducted with EI #4, Registered Nurse (RN) Supervisor. EI #4 said RI #1 should have been transferred with full Hoyer lift. EI #4 said when the CNAs moved (him/her) after the fall they did not follow the plan of care. EI #4 further stated not using a lift could cause possible injuries. On 01/27/2022 at 4:57 PM, an interview was conducted with EI #1, RN/Regional Nurse Consultant. EI #1 said the CNAs did not use a mechanical lift and the CNAs should have followed the care plan.

Based on a review of the Centers for Medicare & (and) Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, observations, record review and staff interviews, the facility failed to ensure Resident Identifier (RI) #1's 11/10/2021 Annual Minimum Data Set (MDS) was accurately coded for Range of Motion (ROM). This deficient practice affected RI #1, one of three sampled resident's MDS's reviewed. Findings Include: RI #1 was admitted to the facility on [DATE] and readmitted [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, Version 1.17.1, dated 10/2019 revealed the following: . SECTION G: FUNCTIONAL STATUS Intent: Items in this section assess the need for assistance with activities of daily living (ADLs), altered gait and balance, and decreased range of motion. G0400: Functional Limitation in Range of Motion . Intent: The intent of F0400 is to determine whether functional limitation in range of motion (ROM) interferes with the resident's activities of daily living or places him or her at risk of injury. Coding Instructions for G0400A, Upper Extremity (Shoulder, Elbow, Wrist, Hand); B, Lower Extremity (Hip, knee, Ankle, Foot) . Code 2, impairment on both sides: if resident has an upper and/or lower extremity impairment on both sides that interferes with daily functioning or places the resident at risk of injury. On 01/24/2022 at 04:58PM, RI #1 was observed lying in bed on his/her right side. The resident's legs were drawn up and his/her arms held close to the resident's trunk. On 01/25/2022 at 02:18 PM, RI #1 was observed lying in bed with legs drawn towards mid-torso. On 01/26/2022 at 10:23 AM, RI #1 was observed lying on his/her left side with legs drawn towards mid-torso. The Annual MDS assessment, dated 11/10/2021, indicated no impairment to any extremity. RI #1's Care Plan with an initiated date of 02/24/2020, documented the resident had bilateral upper and lower extremity contractures. In an interview on 01/26/2022 at 10:03 AM, EI #7, Certified Nursing Assistant (CNA), stated RI #1 had contractures. In an interview on 01/27/2022 at 02:41 PM, EI #3, Registered Nurse/MDS Coordinator, reported residents with bilateral contractures of the upper and lower extremities should be coded a 2 for impairment on both sides on the MDS. EI #3 stated RI #1 had contractures of the left elbow 09/21/2020 and the left hand 09/21/2020. EI #3 stated RI #1 was care planned for bilateral upper and lower contractures. EI #3 stated RI #1's 11/10/2021 was not coded correctly for functional limitations in range of motion as it should have been coded as a 2. EI #3 stated RI #1's assessment was not accurate for functional mobility. In an interview on 01/27/2022 at 04:57 PM, EI #1, Regional Nurse Consultant, stated the MDS should be coded a 2 for impairment on both sides if a resident had bilateral contractures on upper and lower extremities. EI #1 stated RI #1 had contractures on both upper and lower extremities. EI #1 reported RI #1's 11/10/2021 MDS was coded 0 for functional limitations in range of motion so the resident's MDS was not accurate for functional mobility. EI #1 stated RI #1 should have been coded as a 2.

Based on interviews and record reviews, the Administrator, Employee Identifier (EI) #1, who is responsible for the overall management of the facility and EI #2, the Director of Nursing (DON), who is responsible for ensuring nursing staff is providing quality and appropriate resident/patient care, failed to ensure all policies regarding Falls and Incident/Accidents were followed and implemented. This deficient practice affected RI #1, RI #5 and RI #11, three of six residents sampled for falls, and had the potential to affect all 123 residents who resided in the facility at the time of the survey and placed the health and safety of RI #1, RI #5 and RI #11 in immediate jeopardy, as it was likely to cause serious injury, harm or death. On 08/18/2016, at 2:00 p.m., EI #1, the Administrator and EI #2, the DON were notified of the findings of Immediate Jeopardy level J in the Area of Administration, F 490. The immediate jeopardy began on 02/24/2016, and was abated on 08/19/2016. Findings Include: Cross reference F 309 regarding the facility's failure to follow their Policy and Procedure for Fall Management for residents with potential head injuries. RI #1 fell on [DATE], and sustained an injury to the forehead and neck fractues. RI #5 fell on [DATE], and sustained a hematoma to the back of the head requiring seven staples. The Assistant Director of Nursing (ADON) admitted the facility did not follow their neurological assessment protocol. Cross reference F 323 regarding the facility ' s failure to follow their Incident/Accident Reporting for Residents and General Investigative Guidelines policies which directed staff to determine causative factors to prevent future falls from happening, to identify all potential witnesses, and ensure all incidents and accidents are thoroughly investigated for RI #1, #5, and #11. EI #1's Job Description Administrator with a revised date of 01/29/03, documents: . SUMMARY Responsible for the overall management of a facility . ESSENTIAL DUTIES AND RESPONSIBILITIES include the following. Other duties may be assigned . · Ensures compliance with applicable . regulatory . guideline and standards . EI #2's Job Description for Director of Nursing, with a revised date of 10/01/2003, documented: .SUMMARY . Responsible for the overall direction, coordination and evaluation of nursing care and services provided to the residents.Ensures nursing staff is providing quality and appropriate resident/patient care that meets or exceeds company and regulatory standards. On 08/12/2016, at 2:42 p.m., the surveyor conducted a phone interview with EI #2, the Director of Nursing (DON). The surveyor asked EI #2 what an investigation would consist of. EI #2 said, interviewing staff involved in the accident, attempting to interview the resident if they are interviewable, interviewing witnesses, making sure these things are documented and signed and kept together in a file. The surveyor asked EI #2 who is responsible for conducting investigations. EI #2 said ultimately the Administrator and whoever he gets to help him. The surveyor asked EI #2 had she ever reviewed the facility's General Investigation Guidelines policy. EI #2 said she was not familiar with what that policy looked like. On 08/17/2016, at 4:00 p.m., the surveyor asked EI #1, what training were you provided on the facility's policy titled, General Investigation Guidelines. EI #1 stated, No one sat down and gave me individual training. It would be something I would have to sit down and read if I did an investigation. EI #1 was asked according to the facility's General Investigation Guidelines policy, when should an incident be investigated. EI #1 replied, Immediately after an incident . The surveyor asked EI #1 what the policy said about witnesses. EI #1 replied, Interviews should be done and they should be questioned about the facts. The surveyor asked EI #1 what the policy said about notes during the interview. EI #1 said, Take notes during the interview and document the person you are interviewing, the persons position and the date and time of the interview. The surveyor asked EI #1 what the policy said about an investigative file. EI #1 said the policy said to maintain all interviews in an investigative file and to keep all interviews in the investigative file. EI #1 said the policy also said the conclusion should be documented and fact based. During this interview, EI #1 admitted the facility only conducted a .full blown . investigation when a resident sustained [REDACTED].#1 was asked where he had gotten this information from that only falls with injuries were investigated. EI #1 stated he did not know where he had gotten the information from, he just knew that was how the facility did investigations. On 08/19/2016, at 7:55 p.m., a follow up interview was conducted with EI #1. EI #1 was asked if he felt the facility did a complete and thorough investigation of falls after his review of the recent falls and re-investigations. EI #1 said no, they (facility) failed to understand and follow their General Investigation Guidelines and Fall Management Policy. This deficiency was cited as the result of the investigation of complaint/report #AL 564. ******************************************************** On 08/19/2016, at 8:12 p.m., the facility submitted an Allegation of Credible Compliance for F 490, which documented: This AOC preparation and/or execution does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The AOC is prepared and/or executed solely because it is required by the law provisions of federal and state law. August 19, 2016 F490 Administration Administration failed to ensure that policy and procedure related to incidents and accidents were followed and implemented for RI#I, #5, and #11. On 8/19/16, the District Director of Care Management re-educated the Administrator and Director of Nursing on the Fall Management System and Incident/ Accident Reporting for Residents. She reviewed with Administrator and Director of Nursing the investigative files for RI #5 and# 11 to ensure compliance per the General Investigation Guidelines. She also attended the Ad Hoc QAPI meeting on 8/19/16. The District Director of Care Management will provide oversight for the Administrator and Director of Nursing during her weekly visits starting 8/19/16. At that time, she will review with Administrator and Director of Nursing resident falls to ensure investigations are completed in accordance with the General Investigation Guidelines. All residents' falls will be reported by the Administrator/Director of Nursing/Designee to the District Director of Care Management the day of the fall or no later than the next business day for review starting 8/19/16. Rl #1 was discharged and is no longer in the facility. RI #5 fall 7/6/16 -On 8/18/16, this fall incident was investigated by licensed nurses per the General Investigation Guidelines. The investigation included the review of the incident report, the interdisciplinary post fall review, and the SBAR assessment for this resident. Witness statements were obtained from the CRNP who was in the facility and heard a noise that caused him to look into this resident's room. He saw the resident on the floor. Other witness statements included the resident, one LPN, and three Resident Care Specialists (RCS). After review of the findings, it was concluded that the casual factor for this incident was unassisted ambulation by a resident with an unsteady gait. The plan of care was updated on 7/6/16 for staff to ensure that the tab monitor is attached to the resident at all times. Results of this investigation was discussed at the Ad Hoc QAPI meeting on 8/19/16. RI #11 fall 11/3/15 -On 8/18/16 this fall incident was investigated by licensed nurse per the General Investigation Guidelines. The investigation included the review of the incident report, the interdisciplinary post fall review, and the SBAR assessment for this resident. Witness statements were obtained from the resident, resident's wife who is his roommate, two RNs, and one RCS. After review of the findings, it was concluded that the causal factor for this incident was that his walker collapsed as he was ambulating to the bathroom. The plan of care was updated on 11/3/15 for resident to call for assistance prior to attempts to ambulated. Results of this investigation was discussed at the Ad Hoc QAPI meeting on 8/19/16. ******************************************************* On 08/19/2016, EI #1, the Administrator, EI #2, the DON, EI #20, District Director of Care Management, EI #25, Staff Development Coordinator, and licensed nursing staff were interviewed regarding the Fall Management and Incident/Accident Reporting, according to the facility policy. After interviews were conducted, in-service records reviewed, fall investigations reviewed, and personnel files reviewed, it was determined the facility had implemented their AOCC and demonstrated their knowledge of the Fall Management policy and Incident/Accident Reporting procedure, allowing the survey team to exit the facility at 8:30 p.m.

Based on interviews, record reviews and review of a facility policy titled, Fall Management, the facility failed to assess Resident Identifier (RI) #1 and RI #5's neurological status, as directed in the policy, after both residents sustained a fall with injuries. RI #1 fell on [DATE], and sustained an injury to the forehead. The assigned nurse indicated she did not follow the facility's Policy and Procedure for Fall Management for residents with potential head injuries. RI #1 was sent out to the emergency room (ER) and the Computed Tomography (CT) revealed C1 (first cervical vertebrae) and C2 (second cervical vertebrae) neck fractures. RI #5 fell on [DATE], and sustained a hematoma to the back of the head. The Assistant Director of Nursing (ADON) admitted the facility did not follow the neurological assessment protocol. The resident was sent out to the local hospital and returned with seven staples. A review of the NON-PRESSURE SKIN CONDITION RECORD dated 12/01/15 documented, site measured when resident returned from the local hospital. Site measures 5 cm (centimeters) long. 7 staples intact to scalp. This deficient practice affected RI #1, and RI #5, two of six residents sampled for falls and placed the health and safety of RI #1, and RI #5 in immediate jeopardy, as it was likely to cause serious injury, harm or death. On 08/18/2016, at 2:00 p.m., Employee Identifier (EI) #1, the Administrator and EI #2, the Director of Nursing (DON) were notified of the findings of Immediate Jeopardy level J in the Area of Quality of Care, F 309. After reviewing the facility's information provided in their Allegation of Credible Compliance (AOCC), The immediate jeopardy began on 02/24/2016, and was abated on 08/19/2016. Findings Include: A facility policy titled Fall Management, with a revision date of August 2012, revealed the following: . RESIDENT WITH POTENTIAL HEAD INJURY .2. Complete the Neurological Record (see Forms Tab) per instructions . 1. RI #1 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. An Interdisciplinary Post Fall Review for RI #1, documented: Date of Fall: 7/24/16 Time of Fall: approx. (approximately) 1600 (4:00 p.m.) - 1630 (4:30 p. m.) . Unwitnessed (was checked) . Description of Fall: Resident noted lying on blue mat on floor . skin tear noted to mid - left forehead - TAO (Triple Antibiotic Ointment) applied . Transferred to ER (emergency room ) for evaluation . On 08/16/2016, at 2:15 p.m., the surveyor conducted an interview with EI #4, the Registered Nurse (RN) assigned to care for RI #1 on 07/24/2016, on the 3p-11p shift. The surveyor asked EI #4 did she observe RI #1 on the floor on 07/24/2016. EI #4 said she did. EI #4 said RI #1 was on a blue mat on the floor laying on his/her left side. The surveyor asked EI #4 what the facility ' s policy instructed her to do after finding a resident on the floor. EI #4 replied, To assess them, assist them back to bed . The surveyor asked EI #4 what she did after RI #1 was found on the floor. EI #4 said she asked the Certified Nursing Assistant (CNA) was there any reason RI #1 was on the floor. EI #4 said RI #1 had a scratch on his/her forehead and put triple antibiotic ointment on it. The surveyor asked EI #4 what type assessment did she perform on RI #1. EI #4 said she looked at RI #1 and saw that RI #1's right eye was opened. EI #4 said she asked the CNAs to put RI #1 back to bed and went to get a tab monitor. The surveyor asked EI #4 did she ask RI #1 anything while RI #1 was on the floor. EI #4 said when she realized who RI #1 was she realized RI#1 would not be able to tell her if (he/she) was hurting. The surveyor asked EI #4 what type of assessment is done when a resident is found on the floor. EI #4 said you had to make sure the resident is awake and alert. EI #4 said she did not know about the facility's policy but you would make sure the resident did not have any injuries, do vitals, and notify the family and physician. The surveyor asked EI #4 was RI #1 moving (his/her) extremities while on the floor. EI #4 replied, No, (he/she) was just lying there The surveyor asked EI #4 did she attempt to move RI #1's extremities. EI #4 said, No I didn't. The surveyor asked EI #4 did she palpate RI #1's head. EI #4 said no. The surveyor asked EI #4 were neuro checks done. EI #4 replied, Not that day . EI #4 was asked to review the Fall Management Policy and then was asked about the neurological assessment. EI #4 said a copy of the Neurological Assessment form was at the nurse's station. EI #4 went to the nurse ' s station and retrieved a copy of the Neurological Record, where the Neurological assessment findings are documented, was presented it to the surveyor for review. The surveyor asked EI #4 was the Neurological assess completed when a resident falls. EI #4 said if the resident was going to stay in the facility after a head injury then the Neurological assessment is completed. The surveyor asked EI #4 did she do level of conscious checks on RI #1. EI #4 replied, I didn't do pupil checks. I didn't do motor skill checks. I didn't do the form (Neurological Record) because we sent (him/her) out. The surveyor asked EI #4 about how long was it before RI #1 was sent out of the facility. EI #4 said about 30-35 minutes. A review of the Incident/Accident Report completed by EI #4, revealed RI #1 was transferred out of the facility at 5:05 p.m. On 08/18/2016 at 12:05 p.m., the surveyor conducted an interview with EI #2, the Director of Nursing (DON). The surveyor asked EI #2, what she expected her staff to do when a resident is observed on the floor. EI #2 replied, I expect the staff to assess the resident . The surveyor asked EI #2 what type assessment she would expect the nurse to perform. EI #2 said if the resident was alert the nurse would ask questions like if they are ok, in pain, and what happened (cause of the fall). EI #2 said the nurse would move the resident's extremities and usually feel the head, legs and palpate for any abnormalities. The surveyor asked EI #2 where the assessments would be performed. EI #2 said if the resident is found on the floor, then the assessment would be done on the resident while he/she is on the floor depending on the severity. 2. RI #5 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The most recent Minimum Data Set, with an Annual Assessment Reference Date of 06/07/2016, documented the following. Section C; Cognitive Patterns coded RI #5 with a Brief Interview for Mental Status (BIMS) score of 13 as being cognitively intact. A review of the Incident/Accident report dated 07/06/2016, documented RI #5 had a fall as 2:05 p.m. RI #5 sustained a hematoma to the right top of his/her head. The report revealed a Nurse Practitioner heard the fall and immediately into RI #5's room. A review of the Nurse Practitioner's Progress Note, dated 07/06/2016, documented the time of the fall as 11:30 a.m. The note revealed the following: . (RI #5) was in (his/her) room when I walked by and heard a crashing sound . Oblong, quarter sized hematoma noted . Neuro Checks initiated . The note also documented under Medical Decision Making: . neuro checks, monitor for changes A review of the Neurological Record dated 07/06/2016, documented the following: . Frequency: every 30 min. x 4; every 1 hour x 4 hours; every 4 hours x 24 hours; every 8 hours x for remaining 72 hours or as ordered by physician . A review of the neurological record for 07/06/2016, documented the first time entry as 2:35 p. m. (three hours and five minutes after the resident sustained [REDACTED]. There was no evidence that the resident was assessed under the Eye-Motor-Verbal Responses section. A review of the Neurological Record for 07/06/2016, documented the time as 3:35 p.m. and the nurses initials and vital signs. There was nothing documented under the LOC, Pupil Reaction and Eye Signs. A review of the neurological record for 07/06/2016, documented the times as 4:05 p.m., 5:05 p.m., 6:05 p.m., 7:05 p.m., and 8:05 p.m. There was no assessment documented for LOC, Pupil Reaction and Eye Signs and Eye-Motor-Verbal response. A review of the record for 07/06/2016, documented the time as 12:05 a.m. There was nothing documented under the nurses initials, vital signs, LOC, Pupil Reaction and Eye Signs, Eye-Motor-Verbal Responses. A review of the neurological record for 07/07/2016, revealed there were two entries for this date, but there was nothing documented under the nurses initials, vital signs, LOC, Pupil Reaction and Eye Signs, Eye-Motor-Verbal Responses. On 08/17/2016 at 4:50 p.m., an interview was conducted with EI #3, RN/Assistant Director of Nursing (ADON). The surveyor asked EI #3 to review the 07/06/2016 fall and RI #5's incomplete neurological assessment. When asked what the harm was in not completing the neuro checks EI #3 replied the resident could have had a change in status that staff could not have picked up on readily. The surveyor asked EI #3 why that would be harmful. EI #3 replied, we could have missed something that might have caused the resident to be sent out for further evaluation. On 08/18/2016, at 9:40 a.m., an interview was conducted with Employee Identifier (EI) #23/LPN Medication Nurse. The surveyor asked EI #23 to look at the Incident/Accident Report for 07/06/2016, and asked EI #23 if she completed the form. EI #23 stated to the surveyor, Yes, I did. EI #23 was asked if RI #5's injury was considered a head injury. EI #23 stated she would consider it a head injury because the resident hit their head. EI #23 was asked if she filled out the Neurological record for 07/06/2016. EI #23 admitted , she started the neurological assessment. When asked if she completed the Neurological Record according to facility Policy instructions. EI #23 replied, no, she missed several rows and it was not completed. When asked why the record was incomplete, EI #23 did not know. EI #23 was asked what harm could come to a resident with a head injury if neuro checks are not completed. EI #23 replied something bad could happen to the resident. On 08/18/2016, at 10:15 a.m., an interview was conducted with EI #24/RN Medication Nurse. The surveyor asked EI #24 if she remembered the fall RI #5 had on 07/06/16. EI #24 replied yes, she was the nurse coming on and it was reported that RI #5 had a fall and we needed to do neuro checks. EI #24 was asked if she completed the Neurological assessment checks for RI #5 on 07/06/16. EI #24 admitted she completed the 3:35 p.m., 4:05 p.m., 5:05 p.m., 6:05 p.m., 7:05 p.m. and 8:05 p.m. vital signs entries. When asked what the policy directed staff to do regarding Residents with Potential Head Injury, EI #24 replied to complete the Neurological Record according to instructions. EI #24 was asked if she completed the Neurological assessment checks according to the policy. EI #24 admitted she did not. When asked why not, EI #24 replied, because she did not think she read the Neurological form thoroughly. EI #24 was asked what could be the harm to a resident with a potential head injury if the neurological assessment is not completed. EI #24 replied, the resident's condition could deteriorate and you could miss the signs. These deficiency was cited as the result of the investigation of complaint/report #AL 564. ******************************************************** On 08/19/2016 at 8:12 p.m., the facility submitted an Allegation of Credible Compliance for F 309, which documented: This AOC preparation and/or execution does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The AOC is prepared and/or executed solely because it is required by the law provisions of federal and state law. F 309 Quality of Care On 7/24/16, RI # I had a fall that resulted in an injury to her forehead. The assigned nurse indicated she did not follow the procedure for residents with head injuries. On 7/6/16, RI #5 had a fall that resulted in hematoma to the back of her head on the right side. Nurses failed to complete the neurological assessment per policy and failed to complete the level of consciousness, pupil reaction, eye motion, and verbal response for these two residents. On 8/18/16, Administrator and Director of Nursing reviewed the fall logs since July 24, 2015 to identify any other resident with a potential head injury. Five residents were identified to have had falls with a possible head injuries. One was RI #11 had a fall on 11/3/15 with possible head injury and was investigated on 8/18/16. The second was RI #5 with a fall on 12/1/15 with possible head injury that was investigated 8/19/16. Rl #5 also had a fall 7/6/16 with a possible head injury that was investigated on 8/18/16. The third resident identified had a fall with possible head injury on 7/2/16 and was been discharged from the facility on 8/5/16. The fourth resident identified had a fall with possible head injury on 2/3/16 and was discharged from on 5/11/16. The fifth resident, RI # 1, had a fall on 7/24/16 with possible head injury was discharged from the facility on 7/24/16. On 8/18/16, Staff Development Coordinator/Designee inserviced all licensed nursing staff on the fall management system with emphasis on the need to complete a neurological assessment on any resident with potential head injury. All license nurses will be inserviced prior to returning to work by SOC/Designee. Director or Nursing and Assistance Director of Nursing will over see the SOC to ensure that all license nurses are inserviced. On 7/24/16, RI # 1 was discharged and is no longer in the facility. The identified nurse who was assigned to RI # 1 on said date has been removed from the schedule until re-education by Staff Development Coordinator/Designee. On 8/18/16, The identified nurse assigned to Rl #5 for fall on 7/6/16 who failed to complete the neurological assessment was re-educated by the Stair Development Coordinator. One nurse identified was re-educated on 8/19/16 on the need to complete the neurological assessment after a resident falls with potential head injury by the Staff Development Coordinator. The remaining identified nurse will be re-educated on the need to complete the neurological assessment for any resident fall with a potential head injury before returning to work. ******************************************************** On 08/19/2016, EI #1, the Administrator, EI #2, the Director of Nursing , EI #20, District Director of Care Management, EI #25, Staff Development Coordinator, and licensed nursing staff were interviewed regarding completing neurological assessments, according to facility policy. After interviews were conducted, in-service records reviewed, fall investigations reviewed, and personnel files reviewed, it was determined the facility had implemented their AOCC and demonstrated their knowledge of the Fall Management policy and procedure, allowing the survey team to exit the facility at 8:30 p.m.

Based on record review and interview, the facility failed to ensure the QA (Quality Assurance) Committee, which is led by the Administrator, developed and implemented an action plan to determine the cause of falls for residents whether or not injuries were sustained. This deficient practice affected RI #1, RI #5 and RI #11, three of six residents sampled for falls and placed the health and safety of RI #1, RI #5 and RI #11 in immediate jeopardy, as it was likely to cause serious injury, harm or death. On 08/18/2016, at 2:00 p.m., EI #1, the Administrator and EI #2, the DON (Director of Nursing) were notified of the findings of Immediate Jeopardy level J in the Area of Quality Assurance, F 520. The immediate jeopardy began on 02/24/2016 and was abated on 08/19/2016. Findings Include: Cross reference F 323 regarding the facility ' s failure to follow their Incident/Accident Reporting for Residents and General Investigative Guidelines policies which directed staff to determine causative factors to prevent future falls from happening, to identify all potential witnesses, and ensure all incidents and accidents are thoroughly investigated for RI #1, #5, and #11. A review of a facility policy titled, Quality Assurance and Performance Improvement Process with no date revealed: .Facilities are encouraged to look at their resident population as a whole, rather than addressing individual resident matters on the QAPI (Quality Assurance and Performance Improvement) Committee.The ultimate goal of all committees is to identify trends, perform root cause analysis and implement performance Improvement Project (PIP) Teams that address areas identified. Once the root cause of an OFI (Opportunities for Improvement) is identified, an effective and sustainable PIP should be developed, implemented, monitored, and sustained using the PDSA (Plan, Do, Study, Act) cycle of process improvement. On 08/18/2016, at 12:00 p.m., an interview was conducted with EI #1. EI #1 was asked if the facility had a QA Committee. EI #1 said yes. EI #1 was asked who was on the Committee. EI #1 said himself, the DON, the ADON (Assistant Director of Nursing), the Rehabilitation Manager, Pharmacy, Maintenance, the Medical Director, the Treatment Nurse, the MDS (Minimum Data Set) manager, the Business Office Manager, the Administrative Director, the Social Services Manager and a resident. EI #1 was asked how often the Committee met. EI #1 said monthly. EI #1 was asked what formal method the facility used to identify issues which required QA activity. EI #1 said they looked for trends. EI #1 said every discipline brought their issues and they sat down and decided what they needed to follow up on. EI #1 was asked what formal method the facility used to respond to identified quality deficiencies. EI #1 said they did a root cause analysis and identified a PIP. EI #1 said once that was identified, interventions were put in place to track and capture trends to get to the bottom of why it was happening. EI #1 was asked what formal method the facility used to evaluate the effectiveness of that response. EI #1 said the response had to be measurable and they identified if it had increased or decreased or stayed the same. EI #1 was asked to describe the types of quality deficiencies the facility was addressing and how it addressed them. EI #1 said he and a maintenance staff member had gone throughout the facility to find maintenance issues that they needed to improve on. EI #1 was asked if the QA Committee looked at all falls in the facility to determine causal factors. EI #1 said they have not done a PIP on falls. EI #1 was asked if the QA Committee had identified falls as an issue. EI #1 said, We have not. EI #1 was asked if the QA Committee had developed and implemented a plan to address falls. EI #1 said,We have not come up with a formal plan. We discuss them individually, but we haven't come up with a game plan. This deficiency was cited as the result of the investigation of complaint/report #AL 564. ******************************************************** On 08/19/2016, at 8:12 p.m., the facility submitted an Allegation of Credible Compliance for F 520, which documented: This AOC preparation and/or execution does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The AOC is prepared and/or executed solely because it is required by the law provisions of federal and state law. F 520 Quality Assessment and Assurance The facility failed to ensure that the QAPI committee developed and implemented action plan to determine the cause of residents' falls rather or not injuries were sustained. On 8/18/2016, The Staff Development Coordinator/Designee began inservice all licensed staff on ensuring residents who had a fall are thoroughly investigated to determine the cause of the fall whether or not injuries are sustained. All licensed nursing staff will be inserviced prior to returning to work. On 8/19/2016, District Director of Care educated members of the QAPI committee on their responsibilities to collect, analyze, and trend facility data and develop action plans as indicated per the Quality Assurance and Performance Improvement Process. On 8/19/2016, Ad Hoc QAPl meeting with QAPI members to review falls and identify causal factor of the falls. An action plan was developed to ensure all residents falls are thoroughly investigated in order to determine a causal factor. The Administrator is the driver and desired outcome is to complete a thorough investigation and be able to determine the cause of each fall. Rl # l was discharged and is no longer in the facility. RI #5 fall 7/6/16 -On 8/18/16, this fall incident was investigated by licensed nurses per the General Investigation Guidelines and determined the cause of the fall was unassisted ambulation and unsteady gait. This investigation was reviewed at the Ad Hoc QAPI meeting on 8/19/16. RI #11 fall 11/3/15 -On 8/18/16, this fall incident was investigated per the General Investigation Guidelines and determined the cause of the fall was his walker collapsed as he was ambulating to the bathroom. This investigation was reviewed at the Ad Hoc QAPI meeting on 8/19/16. ******************************************************** On 08/19/2016, EI #1, the Administrator, was interviewed regarding the Quality Assurance and Performance Improvement Process, according to the facility policy. After interviews were conducted, inservice records reviewed, fall investigations reviewed, and personnel files reviewed, it was determined the facility had implemented their AOCC and demonstrated their knowledge of the Quality Assurance and Performance Improvement Process policy and procedure, allowing the survey team to exit the facility at 8:30 p.m.

Based on interview and review of facility policies, the Corporate Division Director of Operations, Employee Identifier (EI) #31 failed to ensure the facility's Administrator EI #1, was provided oversite and guidance regarding the Fall Management, Incident/Accident and Fall Protocols. The Corporate Division Director of Operations, EI #31 acknowledged the facility did not conduct thorough investigations on each fall. This deficient practice affected RI #1, RI #5 and RI #11, three of six residents sampled for falls with injuries, i.e., scalp lacerations, hematomas to the head and cervical fractures, and placed the health and safety of RI #1, RI #5 and RI #11 in immediate jeopardy, as it was likely to cause serious injury, harm or death. On 08/18/2016, at 2:00 p.m., EI #1, the Administrator and EI #2, the DON (Director of Nursing) were notified of the findings of Immediate Jeopardy level J in the Area of Governing Body, F 493. The immediate jeopardy began on 02/24/2016 and was abated on 08/19/16. Findings Include: Cross reference F 490 regarding the Administrator's, Employee Identifier (EI) #1, and EI #2, the Director of Nursing's (DON), failure to ensure all policies regarding Falls and Incident/Accidents were followed and implemented. On 08/18/2016, at 12:28 p.m., a phone interview was conducted with the Corporate Division Director of Operations, EI #31. EI #31 was asked by the surveyor what his responsibilities were. EI #31 said he reviewed overall operations and looked at how things were operating in the facility. EI #31 said he looked at how the Administrator was doing and looked at any systems in the facility that there may be questions about. The surveyor asked EI #31 what he does to ensure the Administrator receives training/in-services on facility policies. EI #31 said the Administrator went through orientation and sometimes in-services were conducted. The surveyor asked EI #31 what training/in-services had been provided to the Administrator on the Fall Management and General Investigation Guidelines policies. EI #31 said as far as training on policies, the Administrator had attended a meeting in April (2016) and had attended a District meeting since then. The surveyor asked EI #31 what his expectations of staff were when a resident falls. EI #31 said to do incident reports and follow the fall protocol. EI #31 said the Post Fall Reviews were also a part of the fall protocol. EI #31 said it depended on the situation if the facility did .full blown investigations. The surveyor asked EI #31 if the facility's General Investigative Guidelines policy indicated an investigation was to be conducted immediately after an incident, questions were to be asked of each witness, notes were to be taken during the interview, interview were to be maintained in an investigative file and the conclusions were to be supported by written documentation, what was the expectation of the facility staff. EI #31 said he thought the policy said, It may call for an investigation. The surveyor read from the Incident/Accident Reporting for Residents policy under Note: All incidents whether Significant/Serious or not should be thoroughly investigated and asked EI #31, was the facility expected to follow this portion of the policy. EI #31 replied, Sure. The surveyor asked EI #31 were the staff at the facility following the policy. EI #31 said, I hope so, I can't tell you if they are or not. On 08/19/2016, at 7:17 p.m., an interview was conducted with EI #20, District Director of Care Management. EI #20 was asked what she determined after that visit to the facility concerning falls. EI #20 said she thought they (facility) needed to focus on the root cause and needed to do a deeper dive into falls. EI #20 was asked if it was an expectation of the Administrator, DON and District Director of Operations to know if policies and procedures were being implemented by their facility. EI #20 said yes. This deficiency was cited as the result of the investigation of complaint/report #AL 564. ******************************************************** On 08/19/2016 at 8:12 p.m., the facility submitted an Allegation of Credible Compliance for F 493, which documented: This AOC preparation and/or execution does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The AOC is prepared and/or executed solely because it is required by the law provisions of federal and state law. F 493 Governing Body On 8/18/16, The corporate District Director of Operation failed to ensure the Administrator was provided guidance related to incidents, accidents, and fall protocol. He acknowledged the facility failed to conduct a thorough investigation on each fall. On 8/19/16, the District Director of Care Management re-educated the District Director of Operations on the Fall Management System and Incident/ Accident Reporting for Residents. On 8/19/16, the District Director of Care Management attended the Ad Hoc QAPI meeting and reviewed fall investigations for RI #5 and # 11 with Administrator and Director of Nursing to ensure that the General Investigation Guidelines were followed. The District Director of Care Management will provide oversight for the District Director of Operations on a weekly basis starting 8/19/16. At that time, she will review with the District Director of Operations investigations related to residents falls to ensure compliance in accordance with the General Investigation Guidelines. ******************************************************** On 08/19/2016, EI #1, the Administrator, EI #2, the DON, EI #20, and District Director of Care Management were interviewed regarding the Fall Management and Incident/Accident Reporting, according to the facility policy. After interviews were conducted, in-service records reviewed, fall investigations reviewed, and personnel files reviewed, it was determined the facility had implemented their AOCC and demonstrated their knowledge of the Fall Management policy and Incident/Accident Reporting procedure, allowing the survey team to exit the facility at 8:30 p.m.

Based on interviews, record review and facility policy review, the facility failed to thoroughly investigate to determine causative factors of falls for RI #1, #5, and #11: The facility's Incident/Accident Reporting for Residents and General Investigative Guidelines policies directed staff to determine causative factors to prevent future falls from happening, to identify all potential witnesses, and ensure all incidents and accidents are thoroughly investigated. Resident Identifier (RI) #1, a resident with impaired cognition, who was a high risk for falls fell out of bed on 02/24/2016 with a side rail down. This fall was not investigated by the facility. On 07/24/16 RI #1 experienced another fall from bed and was transferred to a local emergency room (ER). The results of a Computed Tomography (CT) scan revealed RI #1 sustained two cervical spine fractures. On 11/03/2015, RI #11 had a fall sustaining a skin tear to the left lateral wrist and a hematoma to the right forehead. On 12/01/2015, RI #5 had a fall and sustained a laceration to the head, was sent to the ER and received 7 staples to the scalp. Neither of these falls were investigation to determine causal factors to prevent reoccurrence. These deficient practices affected RI #1, #5 and #11, three of six residents sampled for falls. These failures posed an immediate threat to the safety and health of RI #1, #5 and #11 because it was likely to cause serious harm, injury or death. On 08/18/2016, at 2:00 p.m., Employee Identifier (EI #1), the Administrator and EI #2, the DON (Director of Nursing), were notified of the findings of substandard quality of care at the Immediate Jeopardy level J in the area of Quality of Care, F 323. After reviewing the facility's information provided in their Allegation of Credible Compliance (AOCC), The immediate jeopardy began on 02/24/2016 and was abated on 08/19/2016. Findings Include: A facility policy titled, General Investigative Guidelines, with a revision date of June 2012, documented: POLICY Investigations should be conducted immediately after an incident . Investigations should be thorough, accurate, and fact based. Investigation findings should be well documented, concise, and understandable. Investigation findings should be communicated as needed to appropriate parties and corrective action implemented as necessary . PROCEDURE . 5. Identify and make a list of all potential witnesses, including staff, visitors, residents, and or outside professionals. When determining who should be considered a witness, err on the side of inclusion, where warranted . 8. Develop an outline of areas to be covered and/or questions to be asked of each witness based on reported facts . 9. d. Take notes during the interview. · Document the interview participants, each participant's position, and the date and time . g. Maintain all interviews in the investigative file . · 12. Review findings and determine a conclusion. · a. Conclusions should be supported by written documentation and factual information . · · A facility policy titled, Fall Management with a revision date of August 2012, documented: · OVERVIEW · . If a fall occurs, the IDT (Interdisciplinary Team) conducts an evaluation to ensure appropriate measures are in place to minimize the risk of future falls . · · FALLS DEFINED · Current CMS (Centers for Medicare and Medicaid Services) guidelines regarding falls state that a fall is defined as anytime a resident is found on the floor whether the event was witnessed/un-witnessed. · · CLARIFICATION . · When a resident is found on the floor, the facility is obligated to investigate to determine how he or she got there and put into place an intervention to minimize it from recurring . A facility policy titled, Incident/Accidents Reporting for Residents with a revision date of June 2013, documented: . FUNDAMENTAL INFORMATION . Note: All incidents whether Significant/Serious or not should be thoroughly investigated . 3. The facility initiates an investigation for all incidents . 1. RI #1 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. RI #1's Fall Risk Evaluation dated 01/26/2016, revealed RI #1 had a total score of 18 indicating RI #1 was at high risk for potential falls during this assessment period. An Interdisciplinary Post Fall Review for RI #1, documented: Date of Fall: 2/24/16 Time of Fall: 10:30 (10:30 a.m.) . Unwitnessed (was checked) . Description of Fall: Prior to fall resident noted shaking side rail as well as yelling out. There was a bump and yelling noted. Upon entering room resident noted on floor with side rail noted down. Resident noted laying lateral to (the) bed . RI #1's Fall Risk Evaluation dated 04/12/2016 revealed RI #1 had a total score of 18 indicating RI #1 remained at high risk for potential falls during this assessment period. An Annual Minimum Data Set (MDS) assessment, with an Assessment Reference Date of 06/27/2016, assessed RI #1 as having severely impaired vision and scoring a 2 on the Brief Interview for Mental status indicating severely impaired cognition. A review of RI #1's Side Rail Safety Review dated 06/27/2016, documented: . 11a. Is there a possibility the resident will climb over the side rails? Yes (was indicated) . An Interdisciplinary Post Fall Review for RI #1, documented: Date of Fall: 7/24/16 Time of Fall: approx. (approximately) 1600 (4:00 p.m.) - 1630 (4:30 p.m.) . Unwitnessed (was checked) . Description of Fall: Resident noted lying on blue mat on floor . skin tear noted to mid - left forehead - TAO applied (Triple Antibiotic Ointment) . Transferred to ER for evaluation . RI #1's Resident Transfer Form dated 07/24/2016, (no time), documented: . REASON FOR TRANSFER . c/o (complaint of) skin tear forehead . (possible head injury) . AT RISK ALERTS . Falls (was checked) . A review of RI #1's Diagnostic Imaging Report from the local ER, with an examination date of 07/24/2016, documented: . Reason for Exam: . CT (Computed Tomography) C (Cervical)-Spine W/O (without) Contrast Clinical history: fell out of bed, neck pain . Findings: CT of the cervical spine was performed. There is a nondisplaced fracture of the right lateral aspect of the posterior ring. There is also a nondisplaced vertical fracture of the right lateral mass of C2. That fracture extends into the right transverse process of C2. These fractures are all new . Impression: 1. Fracture of the right lateral posterior ring of C1. 2. Vertical fracture through the lateral mass of C2, extending to the right transverse process . On 08/11/2016 at 2:09 p.m., the surveyor conducted an interview with EI #28, the MDS (Minimum Data Set) Coordinator. The surveyor asked EI #28 who investigates falls. EI #28 said the person who completes the incident report also completes the Post Fall Review. EI #28 said a determination of the causative factor should be assessed at the time of the incident and an intervention should be put in place based on the causative factor. EI #28 said the next morning the IDT team is suppose to review and discuss the incident and the Post Fall Review to ensure that an intervention was put in place. The surveyor asked EI #28, looking at the 02/24/16, IDT Post Fall Review, what was the causative factors of the fall. EI #28 said the Post Fall Review indicated RI #1 was shaking the side rail and when staff went to investigate, RI #1 was on the floor. EI #28 said the Post Fall Review also indicated the side rail was down when staff entered the room. EI #28 replied, I don't see where it indicates what caused (him/her) to shake the side rail. On 08/11/2016 at 5:04 p.m., the surveyor conducted an interview with EI #3, the Assistant Director of Nursing (ADON). The surveyor asked EI #3, according to Post Fall Review from RI #1's fall on 02/24/16, what happened. EI #3 said the description of the fall read 'Prior to fall resident noted shaking side rail and yelling out. Then there was a bump and yelling noted. Upon licensed nurse entering room resident noted on floor with the side rail down.' The surveyor asked EI #3 who reviews the falls after they happen. EI #3 replied, after falls occur the IDT reviews them the next morning. The surveyor asked EI #3 what the causative factors of RI were #1's fall on 02/24/16. EI #3 replied, . there is nothing that states the cause of the fall on the incident report . The surveyor asked EI #3, when a resident has a fall from bed, what protocol does the facility use. EI #3 replied, We use our Fall Management Policy. On 08/12/2016 at 11:15 a.m., the surveyor conducted an interview with EI #6, the Registered Nurse (RN) Unit Manager of the South Wing. The surveyor asked EI #6 was she at the IDT meeting on 02/25/16. EI #6 said according to her signature she was. The surveyor asked EI #6 what was the reason for the meeting. EI #6 said the morning meeting was where they were notified of incidents or accidents. The surveyor asked EI #6 did the facility investigate the cause of RI #1's fall on 02/24/16. EI #6 said it was a part of the facility's protocol to investigate. The surveyor asked EI #6 if staff was interviewed after the fall. EI #6 said she was not the Unit Manager for RI #1 so she did not know. The surveyor asked EI #6 if she had been the Unit Manager, what would her responsibilities have been. EI #6 said she would look at the incident report, go and talk to the resident to see what happened if the resident was interviewable and she would do an investigation with all staff involved. On 08/12/2016 at 12:37 p.m., the surveyor conducted an interview with EI #16, the Licensed Practical Nurse (LPN) Treatment Nurse. The surveyor asked EI #16 was she at the IDT meeting on 02/25/16, where RI #1's 02/24/16 fall was discussed. EI #16 said she was. The surveyor asked EI #16 did the facility investigate the cause of RI #1's 02/24/16 fall. EI #16 said when the Post Fall Review was done it was a part of the investigation process as well as looking at the incident report. EI #16 said if there were any witnesses to the incident they would be interviewed. EI #16 said that was a part of the process. The surveyor asked EI #16 were non-witnesses interviewed as well. EI #16 said the person who heard the incident or the person who did the incident report, the nurse completing the report or any staff that assisted during the incident would be interviewed. The surveyor asked EI #16 were statements obtained. EI #16 replied, They would interview the staff, write down what was said and have staff to sign the interview. The surveyor asked EI #16 was this done with RI #1's 02/24/16 fall. EI #16 said she did not know. The surveyor asked EI #16 whose responsibility would it have been to do those things. EI #16 said she thought EI #3, the ADON. EI #16 said if it was the weekend, the Unit Manager would have been responsible for obtaining interviews. The surveyor asked EI #16 was it documented anywhere that an investigation was done. EI #16 replied, I'm not sure . I know the interviews would not have been part of the incident report or Post Fall Review form. The surveyor asked EI #16 how the facility would evaluate circumstances and probable causes of a fall. EI #16 replied, When the fall happens, the person who puts their eyes on the resident should be looking for causative factors initially. The Unit Manager and ADON look more in-depth on a follow up type investigation. The surveyor asked EI #16 what an investigation should consist of. EI #16 said she had not been part of an investigation as far as a fall but from knowing, she knew you would ask for actual facts of what happened and look around to see if there were any causative factors in the resident ' s environment. EI #16 said you would question staff, whether it be the nurse who did the incident report or who found the resident or anyone assisting with the resident. On 08/12/2016 at 2:07 p.m., the surveyor conducted a phone interview with EI #30, the former Unit Manager of the Unit RI #1 resided on. The surveyor asked EI #30 did the facility investigate the cause of RI #1's accident (fall) on 02/24/16. EI #30 said there was always an investigation that occurs after the fall if injury occurred. EI #30 replied, . Only when injury is involved is an investigation done. The surveyor asked EI #30 were staff interviewed after RI #1's 02/24/16 fall. EI #30 replied, No because there were no injuries or witnesses. On 08/12/2016 at 2:42 p.m., the surveyor conducted a phone interview with EI #2, the Director of Nursing (DON). The surveyor asked EI #2 did the facility investigate the cause of RI #1's accident (fall) on 02/24/16. EI #2 said the facility completed the Post Fall Review and that was considered an investigation of the incident. EI #2 said the incident report was considered as part of the investigation as well. The surveyor asked EI #2 was interviewing the resident a part of the investigation. EI #2 replied, it could be. The surveyor asked EI #2 was interviewing the staff a part of the investigation. EI #2 replied, Yes Ma'am. EI #2 said if staff witnessed anything or had any input into the incident the facility would interview them. The surveyor asked EI #2 if she knew if staff was interviewed. EI #2 said she did not know. EI #2 said she would consider EI #10's, the LPN assigned to care for RI #1 when RI #1 fell out of bed on 02/24/16, documentation on the incident report her input. The surveyor asked EI #2 how the facility evaluated circumstances and probable causes of RI #1's 02/24/16 fall. EI #2 replied, I think we figured (his/her) fall on 02/24/16 was caused by (him/her) shaking the side rail. The surveyor asked EI #2 did the facility investigate why RI #1 was shaking the side rail or look at causative factors for RI #1 shaking the side rails. EI #2 said the facility did not. The surveyor asked EI #2 what an investigation would consist of. EI #2 said, interviewing staff involved in the accident, attempting to interview the resident if they are interviewable, interviewing witnesses, making sure these things are documented and signed and kept together in a file. The surveyor asked EI #2 if the facility had an investigative file for RI #2's 02/24/16 fall. EI #2 said not to her knowledge. The surveyor asked EI #2 who is responsible for conducting investigations. EI #2 said ultimately the Administrator and whoever he gets to help him. The surveyor asked EI #2 had she ever reviewed the facility's General Investigation Guidelines policy. EI #2 said she was not familiar with what that policy looked like. The surveyor read the General Investigation Guidelines policy to EI #2. The surveyor asked EI #2, after the surveyor read what the policy instructed the facility to do, did the facility investigate RI #1's falls according to the policy. EI #2 said, not that she could recall on RI #1's 02/24/16 fall. On 08/16/2016 at 11:08 a.m., the surveyor conducted an interview with EI #27, the Certified Nursing Assistant (CNA) who assisted in getting RI #1 off the floor on 02/24/16, when the resident was found on the floor with the side rail down. The surveyor asked EI #27 did anyone ask her any questions or conduct an interview with her about how RI #1 fell out of bed on 02/24/16. EI #17 replied, No. On 08/16/2016 at 1:18 p.m., the surveyor conducted an interview with EI #10, the Licensed Practical Nurse (LPN) assigned to care for RI #1 on the 3p-11p shift on 02/24/16. The surveyor asked EI #10 how RI #1 got on the floor. EI #10 said the side rail was down and she thought RI #1 came out of bed that way. EI #10 said RI #1's left side rail was down. The surveyor asked EI #10 did anyone ask her questions or conduct an interview with her about how or why RI #1 fell out of bed or was observed on the floor on 02/24/16. EI #10 replied, No. The surveyor asked EI #10 did anyone question her about why RI #1 may have been shaking the side rails that night. EI #10 replied, No. The surveyor asked EI #10 did anyone question or ask her what other factors could have contributed to RI #1 shaking the side rails. EI #10 said no. The surveyor asked EI #10 if she interviewed or asked any staff on the shift RI #1 fell out of bed any questions as to why RI #1 had been shaking the side rails. EI #10 replied, No. EI #10 said that would be something the supervisors would do. When asked if anyone checked the side rail to see why it had come down, EI #10 said she did not know. On 08/17/2016 at 4:00 p.m., the surveyor asked EI #1, according to the facility's General Investigation Guidelines policy, when should an incident be investigated. EI #1 replied, Immediately after an incident . The surveyor asked EI #1 what the policy said about witnesses. EI #1 replied, Interviews should be done and they should be questioned about the facts. The surveyor asked EI #1 what the policy said about taking notes during the interview. EI #1 said, Take notes during the interview and document the person you are interviewing, the persons position and the date and time of the interview. The surveyor asked EI #1 what the policy said about an investigative file. EI #1 said the policy said to maintain all interviews in an investigative file and to keep all interviews in the investigative file. EI #1 said the policy also said the conclusion should be documented and fact based. The surveyor asked EI #1 were these things done when RI #1 was observed on the floor on 02/24/16. EI #1 replied, By my knowledge this type of investigation was not done. When asked why not, EI #1 said the facility used the Interdisciplinary Post Fall Review and Incident and Accidents forms as their investigation. When asked by the surveyor where he had gotten the information from that only falls with injuries were investigated, EI #1 said he did not know where he had gotten the information from, he just knew that was how the facility did investigations. The surveyor asked EI #1 what was determined to be the causative factors of RI #1's side rail being observed down on 02/24/16. EI #1 replied, the Interdisciplinary Post Fall Review and Incident and Accidents forms did not give any indication of the cause of the side rail being down. EI #1 said the forms just said RI #1 was shaking the side rails. 2. Resident Identifier (RI) #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent Minimum Data Set (MDS), with an Annual Assessment Reference Date (ARD) of 06/07/2016, documented the following: Section C; Cognitive Patterns coded RI #5 with a Brief Interview for Mental Status (BIMS) score of 13 as being cognitively intact. A review of the Incident/Accident Report dated 12/01/2015 documented that RI #5 fell and sustained a laceration to the head and was sent to emergency room (ER). A review of the NON-PRESSURE SKIN CONDITION RECORD dated 12/01/2015 documented site measured when resident returned from the local hospital. Site measures 5 cm (centimeters) long. 7 staples intact to scalp. On 08/17/2016 at 4:50 p.m., an interview was conducted with EI #3/Assistant Director of Nursing (ADON). The surveyor asked EI #3 who investigated RI #5's 12/01/15 fall. EI #3 replied, the Interdisciplinary Team met on 12/02/15 to discuss the fall. EI #3 was asked if there were other staff members on duty during the 12/01/15 fall. EI #3 stated yes, there should have been 2 others. The surveyor asked EI #3 if witness statements were obtained or if someone talked to them, EI #3 replied, No. EI #3 was asked if the 12/01/15 fall should have been thoroughly investigated. EI #3 replied, yes. When asked if the IDT team determined the casual factors for the 12/01/15 fall, EI #3 replied, we determined that RI #5 was going to the bathroom. The surveyor asked EI # 3 how the IDT team determined the cause of the fall. EI #3 replied, As a team we felt the information that was in the Incident/Accident Report and the Interdisciplinary Post Fall Review we didn't need to conduct an investigation. On 08/17/2015 at 7:45 p.m., an interview was conducted with EI #10/LPN West Unit Charge Nurse. The surveyor asked EI #10 if anyone investigated RI #5's 12/01/15 fall. EI #10 replied, no ma'am. 3. RI #11 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. A review of RI #11's most recent Significant Change Minimum Data Set (MDS), with an Assessment Reference Date of 02/15/2016, revealed the resident had a Brief Interview for Mental Status score of 14, which indicated the resident was cognitively intact. The MDS also revealed the resident needed extensive assistance of two persons. According to the Incident/Accident report, RI #11 had a fall on 11/03/2015, where the resident was found on the floor on his/her stomach and sustained a skin tear to the left lateral wrist and a hematoma to the right forehead. The fall was witnessed by the resident's spouse. A review of the Interdisciplinary Post Fall Review form revealed the facility failed to obtain witness statements and determine causative factors of RI #11's 11/03/2015 fall. On 08/17/2016, at 2:05 p.m., an interview was conducted with EI #19, the Registered Nurse (RN) who prepared the Incident/Accident Report for the 11/03/2015 fall. EI #19 confirmed that the Incident/Accident Report and the Interdisciplinary Post Fall Review was the completed investigation for the 11/03/2015 fall. EI #19 was asked what caused the resident's fall. EI #19 said the resident was going to the bathroom and the resident said the walker gave out. EI #19 was asked what the resident meant by gave out. EI #19 said that was just how the resident explained it to them, It gave out. According to EI #19, it did not appear to be anything wrong with the walker when they looked at it. EI #19 was asked who investigated to determine the cause of the fall. EI #19 stated she asked the resident who stated he/she was going to the bathroom. EI #19 was asked if the IDT should have determined a cause of the fall. EI #19 said yes. EI #19 was asked where the Interdisciplinary teams' decision is documented. EI #19 said it was not on the form. EI #19 was asked if the resident's spouse witnessed the fall. EI #19 acknowledged the spouse was in the room and witnessed the fall. When asked about witness statements, EI #19 said there were no witness statements. EI #19 was asked about the facility policy concerning a witnessed fall. EI #19 stated ask witnesses questions about the fall and what they saw. However, EI #19 was unable to provide witness statements for RI #11's fall. EI #19 was asked if the facility's fall policy was followed. EI #19 said as far as getting a statement from the witness, no. EI #19 was asked if the fall was investigated if the witness statement and IDT determination of causative factors were not done. EI #19 said no. On 08/19/2016 at 6:12 p.m., an interview was conducted with EI #16, LPN. EI #16 was asked when was the last time she was in-serviced on falls. EI #16 said yesterday (08/18/2016). EI #16 was asked before that in-service if she was following the facility policy on investigating falls. EI#16 not step by step by the policy. This deficiency was cited as the result of the investigation of complaint/report #AL 564. ******************************************************** On 08/19/2016 at 8:12 p.m., the facility submitted an Allegation of Credible Compliance for F 323, which documented: This AOC preparation and/or execution does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies, The AOC is prepared and/or executed solely because it is required by the law provisions of federal and state law, F 323 Accidents On 7/24/16, RI#1 had a fall that resulted in fractures to her neck. On 11/3/15, Rl#11 had a fall that resulted in a left lateral skin tear and hematoma to his right forehead. On 7/6/16, RI# 5 had a fall that resulted in a hematoma to the right side of her head on the back. The facility failed to follow the policy on General Investigation Guidelines and failed to interview all potential witnesses to determine the causal factor for each fall. On 8/18/16, Staff Development Coordinator/Designee began inservice licensed nursing staff on the General Investigation Guideline to ensure residents identified as having a fall are thoroughly assessed, documentation complete, and all potential witnesses are interviewed. All licensed nursing staff will be inserviced prior to returning to work by SDC/Designee. RI #1 was discharged on [DATE] and is no longer in the facility. RI #5 fall 7/6/16 -On 8/18/16, this fall incident was investigated by licensed nurses per the General Investigation Guidelines. The investigation included the review of the incident report, the interdisciplinary post fall review, and the SBAR assessment for this resident. Witness statements were obtained from · the CRNP who was in the facility and heard a noise that caused him to look into this resident's room. He saw the resident on the floor. Other witness statements included the resident, one LPN, and three Resident Care Specialists (RCS). After review of the findings, it was concluded that the casual factor for this incident was unassisted ambulation by a resident with an unsteady gait. The plan of care was updated on 7/6/16 for staff to ensure that the tab monitor is attached to the resident at all times. Results of this investigation was discussed at the Ad Hoc QAPI meeting on 8/19/16. RI #11 fall 11/3/15 -On 8/18/16 this fall incident was investigated by licensed nurses per the General Investigation Guidelines. The investigation included the review of the incident report, the interdisciplinary post fall review, and the SBAR assessment for this resident. Witness statements were obtained from the resident, resident's wife who is his roommate, two RN, and one RCS. After review of the findings, it was concluded that the causal factor for this incident was that his walker collapsed as he was ambulating to the bathroom. The plan of care was updated on 11/3/15 for resident to call for assistance prior to attempts to ambulated. ******************************************************** On 08/19/2016, EI #1, the Administrator, EI #2, the Director of Nursing, EI #20, District Director of Care Management, EI #25, Staff Development Coordinator, and licensed nursing staff were interviewed regarding the Incident/Accident Reporting, Fall Management and General Investigation Guidelines, according to the facility policy. After interviews were conducted, in-service records reviewed, fall logs reviewed, fall investigations reviewed, and personnel files reviewed, it was determined the facility had implemented their AOCC and demonstrated their knowledge of the Fall Management policy and procedure, allowing the survey team to exit the facility at 8:30 p.m.