Every finding on record at Bermuda Commons Nursing and Rehabilitation Center

Based on record review, observations and staff interviews, the facility failed to discard expired nutritional supplement drinks that were past the use by date in 2 of 2 nourishment rooms (300 Hall and 500 Hall Nourishment rooms). The findings included: An observation was made on [DATE] at 2:33 PM of the nourishment room on the 300 Hall. The observation revealed that there were 17 individual nutritional supplement drink cartons with a use by date of [DATE] available for use located on a lower shelf in the nourishment room. An observation was made on [DATE] at 2:44 PM of the nourishment room on the 500 Hall. The observation revealed that there were 121 individual nutritional supplement drinks with a use by date of [DATE] available for use located on a lower shelf in the nourishment room. An interview and tour of the nourishment room on the 300 Hall on [DATE] at 3:00 PM with the Dietary Manager revealed she was responsible for stocking snacks and the fortified nutritional shakes. She stated Central Supply was responsible for stocking the nutritional supplement drinks and should have pulled the out of date items. An interview and tour of the nourishment rooms on 300 Hall and 500 Hall on [DATE] at 3:05 PM with Central Supply revealed that she checked the nourishment rooms once a week for expired items. She checked both rooms last week and did not know why the out of date nutritional supplement drinks had not been removed. An interview on [DATE] at 4:32 PM with the Administrator and the Dietary Manager revealed they were unsure why the expired nutritional supplement drinks had not been removed from stock. The Dietary Manager stated that Central Supply should have pulled the out of date nutritional supplement drinks. The Administrator indicated all food/drink items should have been removed from stock as soon as they expired.

Based on record review and staff interviews, the facility failed to document education was provided in the medical record regarding the benefits and potential side effects of the influenza and pneumonia vaccines prior to the administration of vaccines. This occurred for 4 of 5 residents (Resident #98, Resident #77, Resident #262, and Resident #27) reviewed for vaccines. The findings included: a. Resident #98 was admitted to the facility on [DATE]. The resident's immunization record was reviewed and revealed that staff answered no under the education provided tab for influenza vaccine administered by Nurse #7 on 10/03/24 and for pneumonia vaccine administered by Nurse #7 on 10/18/24. The immunization record review also revealed that nothing was documented under the education notes section on the immunization record for these doses. b. Resident #77 was admitted to the facility on [DATE]. The resident's immunization record was reviewed and revealed staff answered no under the education tab for influenza vaccine administered by Nurse #7 on 10/07/24, and pneumonia vaccine administered by Nurse #7 on 10/21/24. Review of the immunization record also revealed nothing was documented under the education notes section on the immunization record for these doses. c. Resident #262 was admitted to the facility on [DATE]. The resident's immunization record was reviewed and revealed staff answered no under the education tab for influenza vaccine administered by Nurse #7 on 02/12/25, and pneumonia vaccine administered by Nurse #7 on 02/15/25. Review of the immunization record also revealed nothing was documented under the education notes section on the immunization record for these doses. d. Resident #27 was admitted to the facility on [DATE]. The resident's immunization record was reviewed and revealed the education area was answered no under the education tab for influenza vaccine administered by Nurse #7 on 10/03/24. Review of the immunization record also revealed nothing was documented under the education notes section on the immunization record for these doses. An interview with the Infection Preventionist (IP) on 03/06/25 at 1:40 PM revealed that the floor nurse would administer the vaccines per the Medication Administration Record (MAR). She stated there should be education provided prior to administration of vaccines by the nurse administering the vaccine. The IP stated she and the Director of Nursing track which staff and residents received vaccines. An interview with Director of Nursing on 03/06/25 at 2:40 PM revealed she kept a record of the vaccines administered on the Vaccine Information Flowsheet. She stated the education should be provided to the resident or resident's representative prior to the vaccine being administered. The Director of Nursing stated the expectation was for the nurse that provided the education to document in the medical record that education had been provided on the immunization record. An interview with the Administrator on 03/06/25 at 5:05 PM revealed he expected the resident and/or the resident's legal representative to be provided with education regarding the benefits and potential side effects prior to offering vaccines. He stated the expectation of consistency and the procedures for providing vaccine education was not carried out.

Based on record review and staff interviews, the facility failed to document education was provided in the medical record regarding the benefits and potential side effects of the COVID-19 vaccines prior to administration of the vaccines. This occurred for 5 of 5 residents reviewed for immunizations (Resident #43, Resident #98, Resident #77, Resident #262, and Resident #27). The findings included: a. Resident #43 was admitted to the facility on [DATE]. The Resident's immunization record was reviewed and revealed that staff answered no under the education provided tab for COVID-19 vaccine administered by Nurse #7 on 11/06/24. The immunization record review also revealed that nothing was documented under the education notes section on the immunization record for this dose. b. Resident #98 was admitted to the facility on [DATE]. The resident's immunization record was reviewed and revealed that staff answered no under the education provided tab for the COVID-19 vaccine administered by Nurse #7 on 05/25/24. The immunization record review also revealed that nothing was documented under the education notes section on the immunization record for this dose. c. Resident #77 was admitted to the facility on [DATE]. The resident's immunization record was reviewed and revealed staff answered no under the education tab for the COVID-19 vaccine administered by Nurse #7 on 10/21/24. Review of the immunization record also revealed nothing was documented under the education notes section on the immunization record for this dose. d. Resident #262 was admitted to the facility on [DATE]. The resident's immunization record was reviewed and revealed staff answered no under the education tab for the COVID-19 vaccine administered by Nurse #7 on 02/12/25. Review of the immunization record also revealed nothing was documented under the education notes section on the immunization record for this dose. e. Resident #27 was admitted to the facility on [DATE]. The resident's immunization record was reviewed and revealed the education area was answered no under the education tab for the COVID-19 vaccine administered by Nurse #7 on 10/25/24. Review of the immunization record also revealed nothing was documented under the education notes section on the immunization record for this dose. An interview with the Infection Preventionist (IP) on 03/06/25 at 1:40 PM revealed that the floor nurse would administer the vaccines per the Medication Administration Record (MAR). She stated there should be education provided prior to administration of the vaccine by the nurse administering the vaccine. An interview with the Director of Nursing on 03/06/25 at 2:40 PM revealed she kept a record of the vaccine administered on the Vaccine Information Flowsheet. She stated the education should be provided to the residents or the resident's representative prior to the vaccine being administered. The Director of Nursing stated the expectation was for the nurse that provided the education to document in the medical record that education had been provided on the immunization record. An interview with the Administrator on 03/06/25 at 5:05 PM revealed he expected the resident and/or the resident's legal representative to be provided with education regarding the benefits and potential side effects prior to offering vaccines. He stated the expectation of consistency and the procedures for providing vaccine education was not carried out.

Based on review of Resident Council meeting minutes, and resident and staff interviews, the facility failed to resolve and communicate the facility's efforts to address repeated concerns by residents of noise at night during Resident Council meetings for 3 of 10 months reviewed (January 2024, February 2024 and October 2024). The findings included: The Resident Council meeting minutes were reviewed for January 2024. Under the heading New Business, minutes noted residents' complaints of noise in the hallway at around 4:00 AM and a plan by the Activities Director to notify the Director of Nursing (DON) about the issue. In the February 2024 meeting minutes, under the heading Old Business, there was no documented follow up for the January 2024 noise complaint. The February 2024 minutes, under the heading New Business made note that the noise at night was persisting and a plan was made to speak with the DON about the issue. Meeting minutes for March 2024 revealed no documented follow up on the noise complaints from February 2024 under the heading of Old Business. New Business showed no documentation of new noise complaints. The April 2024 meeting minutes revealed no documented follow up on noise complaints under the heading of Old Business for past noise complaints from February 2024. New Business showed no documentation of new noise complaints. Meeting minutes reviewed for May 2024 revealed no documented follow up on noise complaints under the heading of Old Business for past noise complaints from February 2024. New Business showed no documentation of new noise complaints. The June 2024 meeting minutes showed no documented follow up on noise complaints under the heading of Old Business for past noise complaints from February 2024. New Business showed no documentation of new noise complaints. There was no Resident Council meeting in July 2024 per the Activities Director. Meeting minutes reviewed for August 2024 revealed no documented follow up on noise complaints under the heading of Old Business for past noise complaints from February 2024. New Business showed no documentation of new noise complaints. There were no September 2024 meeting minutes provided following two requests. Review of October 2024 Resident Council meeting minutes revealed no documented follow up on noise complaints under the heading of Old Business for past noise complaints from February 2024. New Business showed a resident complaint of having been woken up in the middle of the night from noise and staff talking loudly. There was no plan documented for resolution of the new noise complaint in the October 2024 minutes, however the Administrator and the DON were noted as being in attendance at the meeting. The November 2024 meeting minutes revealed under Old Business that the DON had spoken with staff about the noise at night. There were no new noise complaints under New Business. The DON was noted as in attendance at the meeting. The December 2024 meeting minutes showed under Old Business a repetition of the noise complaint from October 2024. New Business noted the repetition that the DON had spoken to staff about the noise and that the issue was resolved. The DON was noted as in attendance at the meeting. In a Resident Council meeting on 03/05/25 at 11:08 AM, six members of the Resident Council who attended meetings regularly (Resident #93, Resident #50, Resident # 76, Resident #11, Resident #77 and Resident #84), reported that they knew how to complete an individual grievance form and that they knew where the forms were located. All Residents present reported that they were not aware of separate forms to be filled out regarding concerns that were brought forward at their Resident Council meetings with staff. When the surveyor inquired about whether there was any noise at night, all residents present stated that there was sometimes noise at night but that they understood that this happened sometimes and that they knew there were shift changes at night. In an interview with the Activities Director on 03/05/25 at 09:50 AM the Activities Director reported that she documented resident concerns from the meetings in the Resident Council meeting minutes. She stated follow up from Resident Council concerns were then documented in subsequent months' meeting minutes as Old Business and then noted as resolved or not resolved. The Activities Director reported that she did not document resident concerns brought forward at Resident Council meetings separately as a resident grievance or group concern. She reported that she shared all concerns with the Administrator, the DON and whatever person would be responsible for the resolution. On 03/06/25 at 2:47 PM, during a follow up interview with Activities Director, she reported resident/group concerns were documented in Resident Council meeting minutes, then she would go to the person responsible for resolution and discuss with that person how to resolve a given complaint/concern. She reported that all concerns were shared with the Administrator or DON every month. The Activities Director confirmed all resolution efforts were conducted verbally. She said once a resolution of a complaint was reached, this was documented in the next months' meeting minutes as resolved. The Activities Director confirmed residents were not given any kind of written notation of resolution of concerns. The Activities Director confirmed any follow-up with residents was conducted verbally. In an interview with the Director of Nursing (DON) on 03/06/25 at 3:32 PM, the DON confirmed that any concerns brought forward at the Resident Council meeting were followed up on at next month's Resident Council meeting. The DON confirmed that any follow up was done verbally with the person responsible for resolution. She explained that any concerns from Resident Council meetings were brought forward to facility staff at staff meetings. The DON confirmed that she had spoken to staff about the residents' complaints of noise at night. The DON also confirmed there was no written documentation of concerns brought forward apart from the meeting minutes, and no written follow-up documentation was provided to the resident council. On 03/05/25 at 10:03 AM, an interview was conducted with the Administrator, the Social Worker (SW) and the Activities Director. The Administrator stated that the facility's practice was to document any resident concerns brought forward at Resident Council meetings on the meeting minutes and that follow-up was documented on subsequent months' meeting minutes as either resolved or not resolved. The Administrator said that the Activities Director reported concerns to the Administrator, the DON and whatever person was responsible for the resolution. The Activities Director reported that facility leadership conducted these efforts verbally, there was no written documentation. She said leadership spoke with the person who they believed would best be able to resolve the issue. That person then took their own steps to do so. The Administrator confirmed that there was no other documentation of resident group concerns attached or documented with Resident Council minutes. The SW reported that she was instructed by her corporate team to keep all resident grievances separate from Resident Council meeting minutes. The Administrator confirmed he was aware of the noise complaints, and he reported that facility staff were addressed about noise at staff meetings and that noise issue was resolved. In a follow-up interview with the Administrator on 03/06/25 at 3:46 PM, he confirmed that resident concerns mentioned at Resident Council meetings were documented on the meeting minutes including any planned follow-up actions. He said facility leadership was responsible for coordinating resolution of concerns. He verbalized that follow up was then documented on the next month's meeting minutes. The Administrator confirmed any resident or group concerns were then verbally brought to the attention of the person responsible for the resolution and that documentation was in the next months' meeting minutes as resolved or not resolved. The Administrator confirmed resolution efforts were conducted verbally and that there was no written follow-up provided to residents. He voiced that if a concern was not resolved in the next month, that he would then share a new proposed plan to the Resident Council. He reported that he was made aware of issues and/or concerns brought forward at Resident Council meetings. The Administrator confirmed any new resolution plans were also conducted verbally and that there was no written process for staff to follow.

Based on record review, resident and staff interviews, the facility failed to have a signed Medical Orders for Scope of Treatment (MOST) form for 1 of 7 residents reviewed for advance directives (Resident #55). The findings included: Resident #55 was admitted to the facility on [DATE] with diagnoses that included diabetes mellitus, congestive heart failure and hypertensive heart disease. A review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #55 was cognitively intact. A review of the active care plan dated 12/22/2022 revealed that Resident #55 had goals and interventions for Do Not Resuscitate (DNR). A review of the medical record revealed an order from the Nurse Practitioner (NP) dated 07/11/2024 for Do Not Resuscitate (DNR): Intubation if only temporary; hospitalization if needed; IV (intravenous) fluids if needed; Antibiotics if needed; Feeding tube if only temporary. A review of the Nurse Practitioner (NP) note dated 07/11/2024 revealed that the NP had reviewed advance directives with Resident #55 and had confirmed Resident #55's wishes to remain a DNR. The MOST form completed on 07/11/2024 was found in the advance directive's binder at the nurse's station but had not been signed by Resident #55 or her representative. An interview on 03/04/2025 at 9:33 AM with Resident # 55 revealed she had discussed her wishes regarding advanced directives with her representative and thought someone from the facility had discussed this with her as well. She did not recall ever signing a document regarding advanced directives. An interview on 03/04/2025 at 3:54 PM with Social Worker #1 revealed the nurse usually handled the completion of the MOST form and obtained the required signatures. Social Worker #1 indicated she reviewed the resident's wishes as part of the care conference but did not complete the forms if any changes were identified. She did not know why the MOST form was not signed by Resident #55. An interview on 03/04/2025 at 04:01 PM with the Physician revealed the NP had reviewed Resident #55's wishes regarding advance directives on 07/11/2024. The physician did not know why the MOST form was never signed by Resident #55 and thought this was a nursing responsibility to obtain the signature. An interview on 03/06/2025 at 10:21 AM with the Director of Nursing (DON) indicated it was the responsibility of social services to obtain the resident's or representative's signature required on the MOST form. An interview on 03/06/2025 at 4:39 PM with the Administrator revealed he was not sure why the MOST form was not signed by Resident #55. An interview on 03/06/2025 at 4:48 PM with the Medical Records Specialist indicated she assumed the responsibility for the monthly MOST form audit two months ago. The last audit was 02/15/2025. She stated the MOST form should have been signed by Resident #55 and the previous person who audited should have noted the form was missing the signature as Resident #55 had been at the facility for a long time.

Based on observations and interviews with a resident and staff, the facility failed to provide an adequate supply of bath linens for 3 of 6 halls (Halls 100, 500, and 600) observed for a homelike environment. The findings included: Observations of linen carts on 3/3/25 between 11:40 AM and 11:50 AM on halls 100, 500 and 600 revealed no washcloths or towels on the linen carts. No linen carts were available for observation on halls 200, 300 or 400. An interview conducted with Resident #90 was completed on 3/3/25 at 11:29 AM. Resident #90 was cognitively intact according to Minimum Data Set (MDS) dated [DATE]. Resident #90 stated she was told she could not get a bath at this time because there were no washcloths available. An interview with Nurse Aide (NA) #1 was completed on 3/3/25 at 11:35 AM. NA #1 stated there were no washcloths available for showers and baths and baths would be on hold until washcloths were available. NA #1 also stated there were no washcloths available on Sunday 3/2/25 when she worked and there had been a shortage of washcloths since she started in January of 2025. On 3/6/25 at 9:33 AM Nurse #1 (worked on the 100 and 200 halls) stated she worked on 3/3/25 and the washcloths were out for a short period of time until the laundry was able to provide more washcloths. Nurse #1 reported she found 5 washcloths on 3/3/25 that she provided to 3 residents that wanted a shower while waiting for laundry to provide more washcloths. An interview was conducted on 3/6/2025 at 10:20 AM with NA #2. NA #2 stated on Monday 3/3/2025 at 7:15 AM there were no washcloths or towels. NA #2 reported she had to use washcloths and towels from another hall and waited for laundry to provide more. An interview was conducted on 3/6/25 at 10:25 AM with NA #3 (worked on the 400, 500, and 600 halls). NA #3 reported it had been difficult to locate a washcloth for the past month. During the tour of the laundry room with the Administrator on 3/6/25 at 9:45 AM, it was observed that shelves labeled washcloths and towels were empty. At 9:49 AM on 3/6/25 an interview with the Housekeeping Supervisor was completed. The Housekeeping Supervisor stated when she arrived at 7:00 AM on 3/3/25 there were not enough washcloths. The Housekeeping Supervisor reported she provided clean washcloths to all the halls at 8:00 AM on 3/3/25. The Housekeeping Supervisor stated she continued to supply the halls with washcloths in 15-minute increments on 3/3/25 for the rest of the day. The Housekeeping Supervisor stated if the hall linen carts did not have washcloths or towels, the staff would sometimes stash the washcloths and towels away or use them up. The Housekeeping Supervisor also stated she purchased 54 washcloths on 3/3/25, 72 washcloths on 3/6/25 and was expecting a shipment on 3/10/2025 of 300 washcloths that she ordered 2 weeks ago. The Housekeeping Supervisor confirmed the shelves labeled washcloths and towels observed in the clean linen entrance of the laundry room was the only storage area for clean washcloths and towels. An interview with the Director of Nursing (DON) was completed on 3/6/25 at 11:00 AM. The DON stated housekeeping nor staff reported a shortage of washcloths on Monday 3/3/25. The DON reported she was aware that housekeeping placed an order for 300 washcloths about a week ago because washcloths were running low and informed the staff. An interview was conducted with the Administrator on 3/6/25 at 09:42 AM. The Administrator stated he was not aware of the washcloth shortage. The Administrator reported all laundry was completed in the facility during first and second shifts and there was no staff in laundry during third shift. The Administrator stated there should be enough washcloths available each day to provide resident care.

Based on observation, record review, and resident, staff and Medical Director interviews, the facility failed to provide humidified oxygen (oxygen that has been moistened with water vapor) as ordered by the physician for 1 of 1 resident reviewed for respiratory care (Resident #20) The findings included: Resident #20 was admitted to facility on 12/20/19 with diagnoses that included chronic obstructive pulmonary disease with acute exacerbation, chronic respiratory failure and dependence on supplemental oxygen. Resident #20's physician orders dated 11/15/24 revealed oxygen at 4 liters per minute by nasal cannula continuously for chronic obstructive pulmonary disease Resident #20's care plan dated 12/30/24 noted a focus area for chronic obstructive pulmonary disease and interventions including the use of continuous oxygen and BIPAP (a bi-level positive airway pressure machine used to aid breathing) every night with oxygen bleed-in and water (which produces humidification of the inhaled oxygen). The quarterly Minimum Data Set (MDS) dated [DATE] noted Resident #20 was cognitively intact and coded for oxygen. Resident #20's physician orders dated 2/4/25 revealed BIPAP 15/5 centimeters of water with oxygen at 2 liters per minute bleed-in with a large full-face mask every night for obstructive sleep apnea. The Medication Administration Record (MAR) dated 3/2/25 revealed documentation that Resident #20 received humidified oxygen therapy for the night of 3/2/25. On 03/03/25 at 12:01 PM, Resident #20 was observed to be on 4 liters of oxygen by nasal canula via oxygen concentrator with a water canister for humidified oxygen. The canister was observed empty and attached to the oxygen concentrator. The MAR dated 3/3/25 revealed documentation that Resident #20 received humidified oxygen therapy for the night of 3/3/25. On 03/04/25 at 08:08 AM, the water canister on Resident #20's oxygen concentrator remained empty. On 03/04/25 at 03:01 PM, the water canister on Resident #20's oxygen concentrator remained empty. In an interview with Resident #20 on 03/04/25 at 3:03 PM, he stated that his nose was not dry without the use of the humidification. He stated that he had not had any nose bleeds and that his nose was not hurting at that time. During the interview, Resident #20 was wearing his oxygen cannula and the flow regulator on the oxygen concentrator was set to 4 liters per minute. Nursing Assistant (NA) #5 was interviewed on 3/4/25 at 3:11 PM. The NA reported she assisted if the nasal cannula was off or not in place and turned the concentrator on if it was off. NA #5 reported she did not do anything else related to the concentrator or oxygen. During an interview with Medication Aide (MA) #1 on 3/4/25 at 3:20 PM, she reported that she checked the concentrator if it was beeping. Med Aide #1 stated she would change out the water canister if it was empty. She also reported the machine would beep when water was getting low, but she was not allowed to assess Resident #20's oxygen level. On 03/04/25 at 04:04 PM Nurse #6 was interviewed and reported Resident #20 liked to wear his oxygen connected to his BIPAP and was currently on 4 liters by nasal cannula. Nurse #6 reported the concentrator machine would sound an alarm when the water was getting low and self-muted when water canister was full. Nurse #6 reported that staff checked for water in the canister every time the BIPAP was applied. Upon observation with Nurse #6 on 3/4/25 at 4:10 PM of Resident #20's oxygen concentrator, the water canister was still empty. Nurse #6 noticed this and proceeded to remove the empty canister and stated that the canister should have water in it and reiterated that canisters were to be monitored and replaced as needed when empty. Nurse #6 proceeded to obtain new/full canister. The Director of Nursing (DON) was interviewed on 3/4/25 at 4:35 PM and reported oxygen concentrator settings should be correct, water canisters should be full for humidification and canisters should be assessed every shift and as needed. The DON reported nurses refilled water canisters from the supply cabinet. On 03/05/25 at 03:12 PM the Medical Director was interviewed by telephone. The Medical Director stated, not good when the humidifying bottle is empty for several days. She also stated Resident #20 needed humidified oxygen during the day and while using the BIPAP machine at night. The Medical Director said she thought that the humidification mentioned in the BIPAP order was sufficient for Resident #20's daytime oxygen as well. She reported that there were no long-term effects from not having the humidification but there were short-term effects such as discomfort. On 03/06/25 at 5:00PM The Administrator reported nursing monitored all oxygen administration and concentrators.

Based on observations and staff interviews the facility failed to (1a.) date an open bottle of eyedrops and an open bottle of nasal spray with an open/discard by date for 1 of 4 medication carts (500 hall cart), (1b.) failed to dispose of a loose pill in 1 of 4 medication carts (100 hall cart) and (2.) and failed to secure medication left at 1 of 1 resident (Resident #19) bedside reviewed for medication storage. The findings included: 1a. An observation of the 500 hall medication cart was conducted with Nurse #3 on 03/05/25 at 4:40 PM. An open bottle of moxifloxacin (a medication used to treat eye infections) solution 0.5% was observed in a small plastic container with no open date. An open bottle of fluticasone (a medication used to treat allergies) nasal spray 50 microgram was observed in a small plastic container with no open date. Both bottles of medication were verified as open by Nurse #3. An interview with Nurse #3 on 03/05/25 at 4:42 PM revealed she didn't work often at the facility and did her best to keep up with what was on the medication cart. She indicated the open dates should have been documented when the medications were opened. b. An observation of the 100 hall medication cart was conducted with Nurse #4 on 03/05/25 at 3:50 PM. An unidentified white round pill was observed loose in the top right drawer of the medication cart. Nurse #4 revealed she didn't know how the pill got there as she checked the cart regularly and the pill shouldn't have been loose and unsecured in the medication cart. On 03/06/25 at 2:16 PM an interview with the Director of Nursing (DON) revealed the third shift (11:00 PM to 7:00 AM) nurse conducted a weekly audit of all the medication carts. She indicated nurses should date medications when they were opened and discard according to expiration dates, and that pills should not be loose and unsecured in the medication carts. An interview with the Administrator on 03/06/25 at 2:25 PM revealed he expected nurses who opened medications to label them upon opening and that pills should not be loose and unsecured in the medication carts. 52236 2. Resident #19 was admitted to the facility on [DATE] with diagnoses including late onset Alzheimer's disease and dementia. The quarterly Minimum Data Set (MDS) dated [DATE] noted Resident #19 had moderate cognitive impairment. On 03/03/25 at 12:14 PM Resident #19 was observed to have a tube of antibiotic/pain reliever ointment on her bedside table. Resident #19 stated I put it on my forehead, but reported she did not remember why she was using it. When asked, she said she did not remember where she got the ointment. During an observation of Resident #19's room on 03/04/25 at 8:10 AM the tube of antibiotic/pain reliever ointment remained on her bedside table. During an interview with Nurse #1 on 3/4/25 at 2:06 PM, she reported that she was not aware of any medication on Resident #19's bedside table. On 03/04/25 at 3:08 PM the tube of antibiotic/pain reliever ointment was observed still on Resident #19's bedside table. Resident #19 again reported she put the ointment on her forehead about three times a day, it itches sometimes. Upon observation of Resident #19's bedside table with Nurse #2 on 3/4/25 at 4:27 PM, Nurse #2 observed the antibiotic/pain relieving ointment on the bedside table and removed the tube and took it to the nurse's station. Nurse #2 reported that it should not have been on the resident's bedside table. On 03/05/25 at 2:19 PM the Director of Nursing (DON) reported that a physician's order was required to have any medication at a resident's bedside. In a telephone interview with the Medical Director on 3/5/25 at 3:12 PM, she reported that Resident #19's family member probably brought the medicated ointment. The Medical Director stated she was surprised the staff had not seen the medicated ointment before it was brought to their attention. She also stated she would have expected the staff to see the medicated ointment and remove it from Resident #19's room. In an interview with the Administrator on 3/5/25 at 5:15 PM. The Administrator confirmed that residents and family were educated to not bring in medications from home and leave them at resident's bedside.

Based on observations and staff interviews, the facility failed to post a list of names, addresses (mailing and email), and telephone numbers of all pertinent State agencies and advocacy groups, such as the State Survey Agency, the State licensure office, adult protective services where state law provides for jurisdiction in long-term care facilities, the Office of the State Long-Term Care Ombudsman program, the protection and advocacy network, home and community based service programs, and the Medicaid Fraud Control Unit for 4 of 4 days of the recertification survey. The findings included: On 3/3/2025 at 11:18 AM, an observation of the facility (inclusive of all hallways) revealed no postings of name or contact information for the following: the local department of social services, the State Long Term Care Ombudsman or the resident advocacy group. On 3/4/2025 at 9:50 AM, an observation of the facility (inclusive of all hallways) revealed no postings of name or contact information for the following: the local department of social services, the State Long Term Care Ombudsman or the resident advocacy group. An observation of the facility (inclusive of all hallways) on 03/05/25 at 2:56 PM, revealed there were no postings of name or contact information for the following: the local department of social services, the State Long Term Care Ombudsman or the advocacy group. During a walking tour of the facility and interview on 3/6/25 at 3:46 PM with the Administrator, there were no postings of name or contact information for the local department of social services, the State Long Term Care Ombudsman or the advocacy group. The Administrator reported it was the Administrator's responsibility to ensure that postings of name and contact information for the local department of social services, the State Long Term Care Ombudsman and advocacy group were present. The Administrator confirmed that all residents and their representatives should be informed of all available resources and that the postings be in a location easily visible and accessible if any resident or their representative should need them.

Based on record review, staff, and Medical Director interviews the facility failed to provide care in a safe manner to prevent a resident from rolling out of bed during incontinent care for 1 of 6 residents reviewed for accidents (Resident #344) . During incontinence care Resident #344 was rolled onto her side by staff and then rolled out of the bed onto the floor. She was admitted to the hospital for five days due to worsening atrial fibrillation with rapid ventricular response (very fast heartbeat) caused by significant sympathetic response (the body's response to stress) from pain from the fall. The findings included: Resident #344 was admitted to the facility on [DATE] and expired in the facility on [DATE]. Resident #344's diagnoses included: atrial fibrillation, age related osteoporosis, and dementia. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed that Resident #344 was moderately cognitively impaired and required extensive assistance of one staff member for bed mobility and total assistance of two staff members for toileting. Review of a care plan that was updated on [DATE] read in part, Resident #344 has an activities of daily living self-care performance deficit related to dementia. The goals read; I will maintain current level of function in bed mobility, transfers, eating, dressing, toilet use, and personal hygiene and I will receive staff assistance with all aspects of my daily care to ensure that all of my needs are met. The interventions included staff assistance to reposition and turn in bed, staff assistance to use the toilet, and staff assistance with grooming and personal hygiene. NA #1 was interviewed via phone on [DATE] at 5:22 PM. NA #1 stated that she worked at the facility through an agency and recalled the fall that occurred in [DATE] with Resident #344. NA #1 stated that she had cared for Resident #344 prior to the fall on [DATE] and provided care to her by herself with no issues. She stated it was later in the evening and dark outside, but she could not recall the exact time, but she was providing incontinent care to Resident #344. She stated that she turned Resident #344 onto her right side toward the window in the room and away from her (NA #1) and I don't know what happened, but she fell and I tried to catch her but couldn't. NA #1 stated that there was no rail on the bed, and Resident #344 was positioned in the middle of the bed then rolled onto her right side then rolled out of the bed to the floor and there was no fall mat, so she hit the tile floor. NA #1 stated that the bed height was above her waist, and she was approximately 5 foot 3 inches tall. She confirmed that Resident #344 was total assistance with activities of daily living and that she was providing incontinent care to her alone without assistance from other staff. NA #1 stated that she immediately alerted the nurse working the hall that night, but she could not recall who that was but believed it was Nurse #1. She added that Resident #344 had a dark purple bruise on her face and was complaining of pain, but she could not recall where her pain was at. NA #1 stated that Nurse #1 came to the room and assessed her, but they did not move Resident #344 from the floor. She stated that she stayed with Resident #344 until EMS arrived and when they loaded Resident #344 to the stretcher she vomited. NA #1 recalled that Resident #344 did not return to the facility on her shift but stated she did return several days later. Review of a facility incident report dated [DATE] at 8:15 PM read; nurse was informed that the resident fell out of bed during a brief change. Upon the nurse entering the room, the nurse noted that resident was on the ground between the bed and the air conditioning unit. The resident's head was under the bed at the head of bed with her body lying on her right side with her legs spread out (in a V) towards the foot of the bed. The report was completed by Nurse #1. Review of a nurses note dated [DATE] at 10:30 PM read in part, nurse was informed that resident fell out of bed during a brief change. Upon the nurse entering the resident room, the nurse noted that the resident was on the ground between the bed and the air conditioning unit. The resident's head was under the bed at the head of the bed with her body lying on her right side with legs spread out (in a V) towards the foot of the bed. Resident stated that she was in pain. Stated that her head, right arm, and bilateral knees were hurting her. Nurse did a head-to-toe assessment and obtained a set of vital signs. Blood Pressure ,d+[DATE], Pulse 66, Temperature 98 oxygen saturation level 95% and blood sugar 185. Called on call provider and got an order to send to the emergency room (ER). Family notified of the fall and that she was being sent out via Emergency Medical Services (EMS) to be evaluated at the hospital. Once EMS arrived nurse noted that resident started to vomit. The note was electronically signed by Nurse #1. Nurse #1 was interviewed via phone on [DATE] at 12:23 PM. Nurse #1 stated that she no longer worked at the facility but had worked there for approximately seven months and recalled Resident #344's fall that occurred in [DATE]. Nurse #1 stated that she had just finished her medication pass that evening and was at the nursing station charting and Nurse Aide (NA) #1 called her to come to Resident #344's room. When Nurse #1 entered Resident #344's room she asked NA #1 what had happened and was told that she had rolled out of bed. Nurse #1 stated that Resident #344 was on the floor between the bed and the air conditioning unit. She explained that at baseline Resident #344 was bed bound and could not hold onto or move anything and added that she could move her hands but had no lower body control and she had no way to protect herself from the fall. When Nurse #1 entered Resident #344's room the bed was a couple of feet off the floor, it was not in the highest position but was not in the lowest position and could not recall if the bed had grab rails on it or not but stated 95% of the beds in the facility had them. Nurse #1 stated that she did a head-to-toe assessment of Resident #344 while she was on the floor and was able to do range of motion to her arms, legs, and hand grasp. Nurse #1 stated knowing how she fell I was concerned about the back of her head that was under the bed resting on the bottom of the bed wheel locks. Nurse #1 explained that she did not want to move Resident #344, so she felt the back of her head and noted a bump or indentation, and she was concerned about that. Nurse #1 stated that after she completed the head-to-toe assessment, she called the on-call provider and got an order to send Resident #344 out to the ER. She called EMS and they came quickly and transferred Resident #344 from the floor to the stretcher and when they started moving Resident #344 around, she began to vomit. She added that she did not see any obvious injuries, no bleeding or bruising just the bump or indentation to the back of her head and stated that Resident #344 did not return on her shift and stayed a few nights in the hospital. The Discharge Summary from the local hospital dated [DATE] read in part; patient had significant fall resulting in age indeterminate T11 (vertebrae in back) fracture with 25% height loss likely causing worsening of her Atrial Fibrillation with rapid ventricular response due to significant sympathetic response from pain. She was better rate controlled with intravenous (IV) Metoprolol (beta blocker used to lower blood pressure) 5 milligrams (mg) times 2 and was given p.o (by mouth) 12.5 mg with heart rates remaining slightly above 110. She was transitioned to Metoprolol 25 mg every 6h hours and unfortunately, she then had heart rates in the 50's. Her Metoprolol was then transitioned to 37.5 mg which still caused her to have rates in the 40's so her beta blockers was discontinued. Her Diltiazem (calcium channel blocker used to lower blood pressure) was increased to 300 mg and her heart rate remained in the ,d+[DATE]'s after cessation of the beta blockage. Medication Aide (MA) #1 was interviewed on [DATE] at 3:25 PM. She stated that she had worked at the facility for 2 years and was familiar with Resident #344. She stated that Resident #344 was bed bound, total care but could feed herself with setup. MA #1 stated that Resident #344 was incontinent of bowel and bladder and required two-person assistance with bed mobility and incontinent care. She explained that she was working the medication cart that night passing medications and NA #1 came out of Resident #344's room and stated that she had fallen during a brief change. MA #1 stated that they alerted Nurse #1 of the fall, and she immediately went to Resident #344's room and assessed her. MA #1 stated that when they entered the room Nurse #1 had asked NA #1 what had happened, and NA #1 explained that when she rolled Resident #344 towards the window and away from her (NA #1) and she rolled out of the bed to the floor. She stated that when she entered Resident #344's room she was lying on the floor between the bed and the air conditioning unit and had no visible injuries that she could see. MA #1 stated that EMS arrived very quickly after Nurse #1 called and they transported Resident #344 to the hospital, and she did not return on her shift. An attempt to speak to the former Director of Nursing (DON) on [DATE] at 9:19 AM was unsuccessful. The Administrator was interviewed on [DATE] at 11:48 AM who stated that Resident #344 was a bed bound patient who required one person assistance with her activities of daily living. She recalled that on [DATE] during incontinent care NA #1 had turned Resident #344 toward the window in her room and had grabbed the draw sheet to pull Resident #344 back to the middle of the bed and before she could do that Resident #344 rolled out of bed to the floor. The Administrator stated that they asked Resident #344 what happed, and she replied, it happened so quickly. She stated that they (she and the former DON) had thoroughly investigated the fall and because of the fall they made Resident #344 a two person assist for activities of daily living. She added that Resident #344 did go to the hospital because she was complaining of pain and returned, and the Administrator stated she thought she had a fracture of T11. The Medical Director (MD) was interviewed on [DATE] at 2:17 PM. The MD explained that she was not the MD at the time of Resident #344's fall but that she did care for her prior to her passing. After reading the hospital records for Resident #344 she stated that Resident #344 had an age indeterminate fracture of T11 which probably did not come from the fall and compression fractures of T2, T3, and T4 which certainly did not come from the fall. The MD explained that Resident #344 had osteopenia which is weak bones but once she had a fracture the osteopenia becomes osteoporosis which caused her compression fractures of T2-T4. The report was not clear if the fracture of T11 came from the fall or consequences of her osteoporosis. The MD explained that the majority of Resident #344's hospital stay was regulating her heart rate. She further explained that when you are in pain your heart rate goes up and will put people into Atrial Fibrillation (heart arrythmia) or switch the patient to rapid ventricular response which is when your heart beats so fast that you wear it out. The treatment for both of those conditions is to control the heart rate. The hospital doctors started with IV metoprolol and then made adjustment from there to get her heart rate controlled and at that point she was stable enough to return to the facility. The facility provided the following corrective action with a compliance date of [DATE]. Corrective action taken for resident involved: On [DATE] at approximately 8:20 PM NA was attempting to assist Resident #344 with perineal care and resident attempted to turn over on side and rolled to the floor. Resident #344 was assessed by the nurse. MD notified and order was given to send Resident #344 to the hospital for evaluation and treatment. Corrective action for potentially impacted residents: On [DATE] the Director of Nursing and Assistant Director of Nursing identified residents that were potentially impacted by this practice by completing fall review audits for all current residents to determine if any falls occurred with patient care during bed mobility or while performing incontinent care. This was completed on [DATE]. The results included: No other residents identified with falls during patient care. Systemic changes: On [DATE], the Administrator in-serviced all full time, part time, and as needed clinical staff (including agency) on falls, bed mobility/positioning, Kardex process, and ADL care for dependent residents. This training will include all current staff including agency and has been added to the new hire orientation. As of [DATE] 10% of staff members have not attended the in-service. The Director of Nursing will ensure that any of the above-mentioned staff who does not complete the in-service training by [DATE] will not be allowed to work until the training is completed. Quality Assurance: Beginning the week of [DATE] the Director of Nursing will monitor fall/injury using the quality assurance tool for falls with injury to ensure staff are complying related to falls while providing incontinent care. This will be completed weekly for 2 weeks and monthly for 3 months or until resolved. Reports will be presented to the weekly QA committee by the Administrator or Director of Nursing to ensure corrective action initiated as appropriate. Compliance will be monitored, and ongoing auditing program reviewed by the weekly QA meeting. The weekly QA meeting is attended by the Administrator, DON, MDS coordinator, Therapy Director, Heath Information management director, and Dietary Manager Date of compliance [DATE]. The plan of correction was validated on [DATE] which included reviewing the initial audits of falls that identified residents that may have potentially been affected. The education used for training was reviewed and included incident/fall education and reporting, ADL care provided for dependent residents, bed mobility/positioning, and Kardex process. Staff signatures sheets reviewed indicating that all staff had been educated in the above-mentioned subjects. Audits of 5 residents were observed during care to ensure two-person assistance were completed on [DATE], [DATE], [DATE], [DATE], and [DATE] and were taken to QA on [DATE], [DATE], [DATE], and [DATE]. Interviews with current staff members revealed that they recalled having education on falls, bed mobility/positioning, Kardex, and providing ADL care to dependent residents. They verbalized that the facility adapted the policy that all dependent residents would require 2-person assistance with ADLs. Observation of ADL care throughout the survey revealed the correct number of staff were present for care according to the resident's plan of care and facility policy. The facility's compliance date of [DATE] was validated.

Based on observations, resident, and staff interviews the facility failed to provide a clean homelike environment for 1 of 6 units (Unit 600). The facility failed to repair a missing lower closet door and failed to repair a upper closet door, failed to repair missing and cracked dry wall at the base of the air conditioning unit that daylight could be seen through and had the potential to allow small rodents into the facility (room [ROOM NUMBER]), failed to clean a privacy curtain that was noted to have a white outline of hand print and a brown stain that was approximately 3 centimeters by 5 centimeters, failed to repair chipped and missing dry wall near the bathroom, failed to clean the brown ring of dirt and grim around the base of the toilet (room [ROOM NUMBER]), and failed to clean and repair the floor at the bathroom room threshold (room [ROOM NUMBER]), and failed to secure baseboard to the wall (room [ROOM NUMBER]). The findings included: 1a. An observation of room [ROOM NUMBER] was conducted on 01/08/24 at 5:20 PM revealed that there was a lower closet door missing from the wardrobe and one of the upper closet doors was hanging unevenly and would not close unless the door was lifted into place. The wall next to the air conditioning unit was broken and missing and daylight could be seen through the cracks. An observation of room [ROOM NUMBER] was conducted on 01/09/24 at 5:05 PM revealed that there was a lower closet door missing from the wardrobe and one of the upper closet doors was hanging unevenly and would not close unless the door was lifted into place. The wall next to the air conditioning unit was broken and missing and daylight could be seen through the cracks. An observation of room [ROOM NUMBER] was conducted on 01/10/24 at 11:39 AM revealed that there was a lower closet door missing from the wardrobe and one of the upper closet doors was hanging unevenly and would not close unless the door was lifted into place. The wall next to the air conditioning unit was broken and missing and daylight could be seen through the cracks. The Maintenance Director was observed sitting in the upper cabinet and was working on repairing the upper closet door. An observation of room [ROOM NUMBER] was conducted on 01/11/24 at 10:40 AM revealed that there was a lower closet door missing from the wardrobe. The wall next to the air conditioning unit was broken and missing and daylight could be seen through the cracks. An interview with Resident #69 who resided in room [ROOM NUMBER] stated that the closet door had been missing since he came to that room which had been over a year ago. 1b. An observation of room [ROOM NUMBER] was conducted on 01/08/24 at 5:15 pm revealed the privacy curtain between the two beds had a white outline of a handprint along with a brown stain that measured approximately 3 centimeters (cm) by 5 cm, there was chipped and missing dry wall to the right of the sink, and the toilet was noted to have a brown ring around the base of it. An observation of room [ROOM NUMBER] was conducted on 01/09/24 at 5:00 PM revealed the privacy curtain between the two beds had a white outline of a handprint along with a brown stain that measured approximately 3 cm by 5 cm, there was chipped and missing dry wall to the right of the sink, and the toilet was noted to have a brown ring around the base of it. An observation of room [ROOM NUMBER] was conducted on 01/10/24 at 11:37 AM revealed the privacy curtain between the two beds had a white outline of a handprint along with a brown stain that measured approximately 3 cm by 5 cm, there was chipped and missing dry wall to the right of the sink, and the toilet was noted to have a brown ring around the base of it. An observation of room [ROOM NUMBER] was conducted on 01/11/24 at 10:32 AM revealed the privacy curtain between the two beds had a white outline of a handprint along with a brown stain that measured approximately 3 cm by 5 cm, there was chipped and missing dry wall to the right of the sink, and the toilet was noted to have a brown ring around the base of it. Housekeeper #1 was interviewed on 01/11/24 at 2:38 PM. Housekeeper #1 confirmed that she was responsible for cleaning the 600 unit including room [ROOM NUMBER]. She stated that she started by spraying the bathroom with disinfectant and while that sits on the surfaces, she would sweep the floors in the room and bathroom. Then she would wipe down all the surfaces in the room including frequently touched surfaces like light switches and door handles and then she would mop the floor before moving to the next room. She stated that she checked the privacy curtains in the rooms and if they were dirty or needed to be replaced, she would let the Maintenance Director know and he would change them. Housekeeper #1 stated that she had not noticed the dirty privacy curtain in room [ROOM NUMBER] when she cleaned yesterday but stated she would have it changed today when she cleaned that room. 1c. An observation of room [ROOM NUMBER] was conducted on 01/08/24 at 5:30 PM revealed the floor outside the threshold of the bathroom was bubbled and cracked and was dirty with brown dirt and grim. An observation of room [ROOM NUMBER] was conducted on 01/09/24 at 5:02 PM revealed the floor outside the threshold of the bathroom was bubbled and cracked and was dirty with brown dirt and grim. An observation of room [ROOM NUMBER] was conducted on 01/10/24 at 11:41 AM revealed the floor out side the threshold of the bathroom was bubbled and cracked and was dirty with brown dirt and grim. An observation of room [ROOM NUMBER] was conducted on 01/11/24 at 10:33 AM revealed the floor outside the threshold of the bathroom was bubbled and cracked and was dirty with brown dirt and grim. 1d. An observation of room [ROOM NUMBER] was conducted on 01/08/24 at 5:25 PM revealed the baseboard behind the bed closest to the door was held in place with white paper tape and was loose in places. An observation of room [ROOM NUMBER] was conducted on 01/09/24 at 5:04 PM revealed the baseboard behind the bed closest to the door was held in place with white paper tape and was loose in places. An observation of room [ROOM NUMBER] was conducted on 01/10/24 at 11:43 AM revealed the baseboard behind the bed closest to the door was held in place with white paper tape and was loose in places. An observation of room [ROOM NUMBER] was conducted on 01/11/24 at 10:34 AM revealed the baseboard behind the bed closest to the door was held in place with white paper tape and was loose in places. The Maintenance Director was interviewed on 01/11/24 at 1:28 PM. The Maintenance Director observed Room's #601, 603, 605, and 607 and stated that he had been working at the facility for a year and had been working diligently to get all the repairs done that needed to be done. He stated that when he came to work at the facility, he discovered a lot of projects that had been started but not finished like they would patch the dry wall but not sand or paint it. He further explained that another staff member had told him about the upper closet in room [ROOM NUMBER] on 01/10/24 but he could not recall which staff alerted him to the issue. He stated that he was able to repair the upper closet door, but the lower closet door was not attached and would either need to be repaired or replaced and he would work on that. He stated he was not aware until he went into fix the upper closet that the lower closet needed repaired as well. The Maintenance Director added that when staff see something that needed to be repaired, they need to fill out the repair slip in the electronic system and then he would repair the needed item. He added that the long-term plan in the facility was to upgrade some of the things identified but he was not sure the time frame of that plan. The Housekeeping Director was interviewed on 01/11/24 at 1:41 PM and again at 2:33 PM. He explained that the housekeepers on the hall should be checking the privacy curtains daily and if they were soiled or needed to be changed, they would let him, or the Maintenance Director know, and they would take care of it. The Housekeeping Director added that the housekeepers cleaned all resident rooms daily and had a scraper that they could use to get the dirt and grim off the floor if needed. He added t that they had done a lot of work on the resident rooms on some of the other units but not much on the rooms on the 600 unit and he had heard that the facility was going to undergo a remodel this year but could not say for sure when it would start. The Administrator was interviewed on 01/11/24 at 4:43 PM who stated that the company had planned to replace the floors on the back half of the facility including unit 600 this year sometime but it was going to be quite expensive. She added that there was things that they could do on the 600 unit in the meantime to make the rooms better in appearance.

Based on observations, record review and staff interviews, the facility failed to secure a urinary catheter tubing to prevent tension or trauma and failed to prevent the catheter bag and tubing from touching the floor to reduce the risk of infection for 1 of 2 residents reviewed for urinary catheters (Resident #66). The finding included: Resident #66 was admitted to the facility on [DATE] with diagnoses that included stage IV sacral pressure ulcer. A review of Resident #66's physician order dated 07/07/23 for a #14 French urinary catheter with 5 cc (cubic centimeters) of water due to stage IV pressure ulcer. Ensure leg band in place. A review of Resident #66's care plan dated 12/22/23 revealed the Resident had a urinary catheter related to stage IV pressure ulcer to sacrum. The goal that the Resident would remain free from catheter related trauma would be attained by utilizing interventions such as checking for kinks in the catheter tubing, applying a leg stabilization device to prevent pulling or trauma and positioning the catheter bag below the level of the bladder. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #66's cognition was severely impaired and was dependent on staff for activities of daily living. The MDS indicated the Resident had an indwelling urinary catheter and four (4) stage IV pressure ulcers. On 01/08/24 at 2:41 PM an observation was made of Resident #66 lying in bed on her back sleeping. There was a stabilizing device attached to the upper catheter tubing, but the device was not anchored to the Resident's thigh to prevent pulling or trauma. The catheter drainage bag and tubing were touching the floor. An observation made on 01/08/24 at 4:08 PM revealed the catheter bag and tubing touching the floor. An observation on 01/09/24 at 9:05 AM was made of Resident #66 lying in bed sleeping. The stabilizing device was not attached to the Resident's thigh and was folded in half with the taped sides stuck to each other. The Resident's urinary catheter bag was touching the floor. During an observation made on 01/09/24 at 12:55 PM the urinary catheter bag remained on the floor. An interview was held on 01/09/24 at 2:45 PM with Nurse Aide (NA) #2 who was responsible for Resident #66 on 01/09/24 explained that Resident #66 was total care and had an indwelling urinary catheter. The NA continued to explain that the Resident had multiple pressure ulcers and she had to turn and reposition her about every two hours and provide incontinent care if needed. The NA indicated she made sure Resident #66's stabilizing tape was in place taped to her thigh to prevent pulling and the catheter bag was not on the floor. On 01/09/24 at 3:25 PM Nurse Aide #2 accompanied to room observe Resident #66 who was lying in bed sleeping. At the time, the Resident's catheter bag and tubing were touching the floor. The NA remarked the bag and tubing should not be touching the floor because it could cause infection. The NA also looked at the stabilizing device and noted the device was not attached to the Resident's thigh. The NA remarked that she knew it was not attached earlier that morning and reported it to Nurse Manager #1 because she could not get the supplies to replace it. During an interview with Nurse Manager #1 on 01/10/24 at 9:07 AM the Nurse confirmed that she was responsible for Resident #66 on 01/09/24 and did not notice the Resident's catheter bag touching the floor. The Nurse explained that the bag should never touch the floor due to possible infection and there should be a stabilizing device in place to prevent pulling or trauma. The Nurse continued to explain that Resident #66 was known to pull the taped stabilizing device from her thigh and added that they should be more vigilant to that in the future. The Nurse Manager denied being told by NA #2 that the stabilizing device on Resident #66 needed to be replaced. Nurse Aide #3 who was assigned to Resident #66 was not able to be interviewed during the survey. On 01/09/24 at 3:40 PM an interview was held with the Director of Nursing (DON) and an observation was made of Resident #66. The DON observed the Resident's stabilizing device was not attached to her thigh and the catheter bag and tubing was touching the floor. Informed the DON of the multiple observations made of the Resident's urinary catheter during the survey and the DON explained that the stabilizing device should have been replaced when it was noted to be detached and the catheter bag and tubing should never touch the floor. The DON corrected the concerns. An interview conducted with the Administrator on 01/11/24 at 4:42 PM revealed her expectation was for the residents with urinary catheters to have stabilizing devices in place and the catheter bag and tubing should not be touching the floor.

Based on observations, record reviews and staff and resident interviews the facility failed to administer supplemental oxygen as prescribed by the physician for 2 of 3 residents reviewed for respiratory care (Resident #4 and #10) and failed to ensure oxygen concentrator filters were clean for 2 of 3 residents ( Resident #10 and Resident #69) reviewed for respiratory care. The findings included: 1. Resident #4 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease. A review of Resident #4's quarterly Minimum Data Set assessment dated [DATE] revealed the Resident was cognitively intact and received supplemental oxygen. A review of Resident #4's physician orders revealed an order dated 01/04/24 for supplemental oxygen continuously at 2 liters per minute per nasal cannula. A review of Resident #4's care plan dated 01/04/24 revealed the Resident wore supplemental oxygen and the goal to have no signs or symptoms of poor oxygenation would be attained by interventions such as ensuring oxygen setting as prescribed by the physician. On 01/08/24 at 11:57 AM an interview and observation were made of Resident #4 who was sitting in her recliner positioned adjacent to the head of the bed and the oxygen concentrator was positioned at the foot of her bed near the wall. The Resident was receiving oxygen via nasal cannula at a flow rate of 3 liters on the oxygen concentrator. Resident #4 advised that she recently returned from the hospital for respiratory problems and had to wear the oxygen all the time. She indicated she did not know what the flow rate of the oxygen should be set on. On 01/09/24 at 8:48 AM Resident #4 was in bed with her breakfast tray in front of her on the over bed table. The Resident wore the oxygen cannula, but the oxygen concentrator was not on. The oxygen setting was on 0. The Resident displayed no visual signs or symptoms of respiratory distress. During an observation of Resident #4 on 01/09/24 at 12:56 PM the Resident was in bed with the oxygen infusing at 3 liters per minute via nasal cannula. An observation was made of Resident #4 on 01/10/24 at 9:50 AM. The Resident was sitting in her wheelchair at her bedside with the oxygen concentrator behind the wheelchair near the wall. The Resident wore the oxygen cannula, and the oxygen setting was on 3 liters per minute. On 01/10/24 at 11:53 AM during an interview with Nurse #2 the Nurse confirmed she was responsible for Resident #4 on 01/08/24. The Nurse acknowledged by reviewing the Resident's Treatment Administration Record (a record used to record the administration of oxygen prescribed to the Resident) that Resident #4's oxygen setting should be set at 2 liters per minute. Accompanied Nurse #2 to Resident #4's room where the Nurse observed the oxygen setting which was at 3 liters per minute and the Nurse adjusted the oxygen rate to the prescribed setting. Nurse #2 offered no comment on the discrepancy in the flow rate. An interview was made with Nurse Manager #1 on 01/10/24 at 12:00 PM who confirmed she was responsible for Resident #4 on 01/09/24 and 01/10/24. The Nurse explained that Resident #4 had recently returned from the hospital (01/04/24) and her oxygen setting was prescribed at 3 liters per minute. The Nurse observed the oxygen order at 2 liters per minute and the Nurse was informed that the Resident's oxygen setting had been on 3 liters since 01/08/24. The Nurse stated she thought it was supposed to be at 3 liters since her return from the hospital. On 01/11/24 at 4:42 PM during an interview with the Administrator and Director of Nursing the Administrator stated she expected the oxygen concentrators to be set at the rate prescribed by the physician. 2. Resident #10 was admitted to the facility on [DATE] with diagnoses that included heart failure. A review of Resident #10's physician orders revealed an order dated 08/03/23 for continuous supplemental oxygen at 3 liters per minute via nasal cannula and to clean oxygen filter every weeknight on Thursday for oxygen use. A review of Resident #10's care plan revised 10/24/23 revealed that the Resident received continuous oxygen with the goal that there would be no signs and symptoms of poor oxygen absorption. The interventions included ensuring the oxygen was set at the prescribed rate. A review of Resident #10's Minimum Data Set assessment dated [DATE] revealed the Resident was cognitively intact and received supplemental oxygen. During an observation of Resident #10's room on 01/08/24 at 2:13 PM, the Resident was out of the facility to dialysis. The Resident's oxygen concentrator was positioned adjacent to her bed near the wall. The oxygen filter connected to the back of the concentrator was light gray with thick dust that rippled down when touched. An interview and observation were made of Resident 10 on 01/08/24 at 4:18 PM. The Resident had recently returned from dialysis and was sitting up in her bed wearing the oxygen nasal cannula. The oxygen flow rate was set at 4 liters per minute on the oxygen concentrator. The filter remained unchanged. Resident #10 explained that her oxygen setting should be set at 4 liters. She indicated that she did not ever change the setting on the concentrator (nor could she reach it) because it was always supposed to be set at 4 liters. An observation made on 01/09/24 at 1:11 PM revealed Resident #10 in her room sitting in the wheelchair beside her bed. The Resident wore an oxygen nasal cannula that was connected to the portable oxygen tank attached to the back of her wheelchair. The oxygen flow rate was set at 3 liters per minute. The oxygen filter remained unchanged. An observation made on 01/10/24 at 9:40 AM revealed Resident #10 was out of the room to dialysis. The oxygen filter remained dusty gray. An interview was conducted with Nurse #2 on 01/10/24 at 11:35 AM who confirmed she worked with Resident #10 on 01/08/24. The Nurse explained that the oxygen filters were cleaned by the third shift nurses on assigned days. She offered that she did not routinely check the oxygen filters for cleanliness when she worked. Accompanied Nurse #2 to the Residents room who was out to dialysis. The Nurse noted the filter on the oxygen contractor being dusty gray and commented it was dirty and needed cleaning which she removed the filter and cleaned it at that time. An interview was conducted with Nurse #3 on 01/10/24 at 5:05 PM. The Nurse confirmed she worked on Thursday night 01/04/24 and initialed the Treatment Administration Record (TAR, a record of ordered treatments) for Resident #10. The Nurse explained she did not change the oxygen filter because she did not have access to the supply room to get a new filter. When it was explained that the order was not to change the filter but to clean the filter the Nurse stated she did not clean the filter either. On 01/11/24 at 1:02 PM an interview and observation were made of Resident #10 who was sitting up in bed with her dinner tray on her over bed table in front of her. The Resident was wearing the oxygen cannula with the oxygen concentrator delivering oxygen at 4 liters. The Resident stated, it was set at 4 liters. A review of Resident #10's Treatment Administration Record on 01/11/24 at 1:24 PM revealed Nurse Manager #2 initialed that Resident #10 was wearing continuous oxygen set at 3 liters per minute via nasal cannula. During an interview with Nurse Manager #2 on 01/11/24 at 1:25 PM the Nurse explained that she had a lot of work to do and was not able to verify that every resident's oxygen setting was set at the prescribed rate and Resident #10 was one of the residents she did not get to. She continued to explain that she initialed that the flow rate was correct because the Resident had been on that setting for a long time and assumed it was set on 3 liters per minute. The Nurse Manager adjusted the flow rate to 3 liters per minute as the order was prescribed. An interview was held with the Director of Nursing (DON) and Administrator on 01/11/24 at 4:42 PM. The DON explained that she did not think the nurses knew about the oxygen filters needing to be cleaned but regardless the Administrator stated that she expected the oxygen concentrators to be set at the prescribed rate and the filters to be cleaned as ordered. 35789 3. Resident #69 was admitted to the facility on [DATE] with diagnoses that included obstructive sleep apnea and congested heart failure. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #69 was cognitively intact and required limited to extensive assistance with activities of daily living. The MDS further revealed that Resident #69 had shortness of breath when lying flat and required oxygen therapy during the assessment reference period. Review of a physician order dated 11/23/22 read, clean oxygen filter weekly. Review of Resident #69's Medication Administration Record (MAR) dated January 2024 revealed that Nurse #5 had signed off on cleaning the oxygen concentrator filter weekly on 01/03/24. An observation of Resident #69 was made on 01/08/24 at 5:15 PM. Resident #69 was resting in bed with oxygen via nasal cannula set to deliver 3 liters of oxygen in place. The black oxygen concentrator was covered in a white dust powder on the top, sides, front, and back of the concentrator. The seams of the concentrator where the machine came together was noted to have white/grey dust particles coming from within the machine. No filter was observed at this time. An observation of Resident #69 was made on 01/09/24 at 5:05 PM. Resident #69 was resting in bed with oxygen via nasal cannula set to deliver 3 liters of oxygen in place. The black oxygen concentrator was covered in a white dust powder on the top, sides, front, and back of the concentrator. The seams of the concentrator where the machine came together was noted to have white/grey dust particles coming from within the machine. No filter was observed at this time. Nurse #5 was interviewed on 01/10/24 at 5:07 PM. Nurse #5 stated she had worked at the facility for 9 years. She stated that third shift staff were responsible for cleaning the oxygen filters weekly. She added that it appeared on the MAR and would alert the appropriate staff when it was due to be done. Nurse #5 stated if the filter or tubing or oxygen concentrator were dirty, they could always be cleaned more frequently than every week. Nurse #5 added that she believed all oxygen concentrators had a filter. Nurse #5 accompanied the surveyor to Resident #69's room to observe the black oxygen concentrator. Resident #69 was resting in bed with oxygen cannula set to deliver 3 liters of oxygen. The black concentrator was covered in white dust powder on the top, sides, front, and back of the concentrator. While observing the concentrator there was a release button noted that when pushed opened the back of the concentrator to reveal a black filter that was white with approximately quarter inch of dust. Nurse #5 stated that she would clean the filter and concentrator immediately and did not recall ever cleaning Resident #69's filter or concentrator before. The Director of Nursing (DON) was interviewed on 01/11/24 at 11:57 AM. The DON stated third shift staff were responsible for changing the respiratory supplies and cleaning the oxygen concentrators and filters. She added that they had a company that came to the facility every 3 months to clean the internal filter of the oxygen concentrators, but the nursing staff were responsible for cleaning the external filter and concentrator weekly. The Administrator was interviewed on 01/11/24 at 4:41 PM. The Administrator stated that oxygen filters should be cleaned as ordered.

Based on record reviews and staff interviews the facility failed to have a system for disposition and an accurate reconciliation of controlled medications for 1 of 1 resident (Resident #24) reviewed for pharmacy services. The finding included: Resident #24 was admitted to the facility on [DATE] with diagnoses that included peripheral vascular disease and fibromyalgia. A review of Resident #24's physician orders dated: -[DATE] revealed Hydrocodone/Acetaminophen ,d+[DATE] milligrams (mg) take one tablet by mouth every 6 hours as needed for pain. -[DATE] revealed Hydrocodone/Acetaminophen ,d+[DATE] mg take one tablet by mouth every 6 hours for pain. A review of a pharmacy delivery sheet (a list of controlled medications delivered to the facility) dated [DATE] revealed 60 tablets of Hydrocodone/Acetaminophen ,d+[DATE] mgs was sent for Resident #24. The delivery sheet was signed by Nurse #6. Review of Resident #24's Medication Administration Record (MAR) dated ,d+[DATE] revealed that staff had initialed the MAR every 6 hours beginning on [DATE] indicating the Hydrocodone had been administered. However, the facility was unable to locate the reconciliation sheet for Resident #24's Hydrocodone. An attempt to interview the former Director of Nursing was made on [DATE] at 9:19 AM without success. During an interview with the Administrator and Director of Nursing (DON) on [DATE] at 11:02 AM the Administrator explained that on [DATE] she and the former DON were notified by the pharmacy of a potential drug diversion in the facility. The Administrator stated that they immediately began an investigation of the residents in the facility at that time. They had the pharmacy send them delivery sheets of all controlled substances that were delivered to the facility for the 3 previous months. The Administrator stated that the former DON and the Assistant Director of Nursing began comparing the reconciliation record to the delivery sheets. During these audits they discovered that they could not account for Resident #24's Hydrocodone as they could not locate the reconciliation record associated with the Hydrocodone sent for Resident #24 on [DATE] that Nurse #6 signed for. The DON stated that the MAR indicated that Resident #24 received the medication, but they could not verify that because they could not locate the reconciliation record then nor has the reconciliation ever been found. She continued to explain that once they learned that Resident #24's Hydrocodone was unaccounted for they reported the missing medication to the appropriate agencies and Nurse #6 was terminated because once she signed for the narcotics, she was responsible for the putting the card of medication into the medication cart and the reconciliation record in the binder on the medication cart. The DON added that after this event the facility amended their policy that all controlled substances required 2 nurse signatures upon delivery and when a controlled substance medication supply was depleted or discontinued only a supervisor could remove the empty card or discontinued medications and reconciliation records from the binder located on each medication cart. An attempt to interview Nurse #6 was made on [DATE] at 12:25 PM but was unsuccessful. The facility provided the following corrective action plan: Corrective Action for Resident Involved: On [DATE] the Pharmacy notified the former Director of Nursing that a card of Hydrocodone/Acetaminophen (20) 5mg-325mg tablets were delivered to Bermuda Commons Nursing and Rehabilitation Center on [DATE] by mistake. The resident was not a resident of the facility. The Director of Nursing began to search for the 20 tablets of 5mg-325mg Hydrocodone/Acetaminophen with the resident's name on the card. The Director of Nursing was unable to locate the narcotic card for the resident. The Director of Nursing notified the Pharmacy that the facility was not able to locate the narcotic card for the resident and the Director of Nursing asked for the pharmacy to fax the pharmacy narcotic delivery sheet to verify the nurse who signed for the narcotics for the resident. On the pharmacy delivery sheet there were two residents that were listed to have had narcotics delivered on [DATE]. The narcotic card was found for the resident who resided in the facility and reconciled as received and administered. The nurse that signed for each narcotic card was RN #6. RN #6's signature was on the pharmacy delivery sheet signified as accepting both the resident's narcotics. On [DATE] at 3:45 pm the Administrator notified [NAME] County Sheriff's department of alleged narcotic diversion. On [DATE] the facility self-reported 24-hour/5-day to NCDHHS of alleged diversion pertaining to the resident that did not reside in the facility. The Director of Nursing called RN #6 who was scheduled to work second shift on [DATE] to ask if RN #6 was coming in to work. The nurse was late for her shift, but stated she was coming to work. The Director of Nursing and the Administrator were sitting in the Administrator's office awaiting the arrival of RN #6. When RN #6 walked in the front door the Director of Nursing asked to come into the Administrator's office and to have a seat. The Director of Nursing began to question RN #6 as to the delivery of the 2 narcotics delivered for the 2 residents on [DATE]. RN #6 stated she remembered the narcotic for the resident who resided in the facility but did not recall her receiving the narcotic for the resident who did not reside in the facility. The Administrator presented the pharmacy narcotic delivery sheet to the RN and asked if the signature on the delivery sheet was her signature? RN #6 verified the signature on the delivery sheet was hers. The Administrator asked RN #6 if she recalled where she put the narcotics for the resident that did not reside in the facility and the RN stated she did not remember receiving the resident's narcotics but took the resident's narcotics who resided in the facility and placed them in the perspective cart. The Administrator asked RN #6 to go with the Assistant Director of Nursing to obtain a serum drug test, but the RN refused to submit to the serum drug test. The Administrator explained to RN #6 that if she refused to submit to a serum drug test she would be terminated. RN #6 stated she understood. RN #6 stood up and walked out of the Administrator's office and out of the front door. RN #6 did not work on or after [DATE] and was terminated. Corrective Action for Potentially Impacted Residents: On [DATE], Education started immediately with all nurses that two nurses must sign for all narcotics that arrive in the building either sent by pharmacy or brought in from an outside pharmacy. On [DATE] audits and reconciliation began for narcotics delivered to the facility for [DATE]. December narcotics were reconciled. Findings: 18 tabs Norco 5mg-325mg missing for resident #3, 42 tabs Oxycontin 5mg tabs missing for resident #4, 15 tabs Norco 5mg-325mg missing for resident #5. On [DATE], November narcotics were reconciled. Findings: 57 tabs Norco 5mg/325mg tabs missing. October narcotic reconciliation had 4 tabs of ,d+[DATE] missing, 39 tabs of Oxycontin, and 16 tabs of Oxycontin 5mg missing. September had no missing narcotics. RN #6 worked [DATE], [DATE], [DATE] and [DATE]. Therefore, audits for those residents residing in the facility on those dates were reviewed for any change of conditions including increased complaints of pain, with no negative findings. No residents were found to be affected by deficient practice. Systemic Changes: On [DATE], the Staff Development Coordinator began in servicing all full-time, part-time, PRN and agency nurses and Medication Aides on the Drug Keeping Policy, which included narcotic delivery sheets from pharmacy must have a nurse manager and one other nurse sign the narcotics packing slip. The two nurses must be at least one nurse manager and one additional nurse signing the narcotic countdown sheet agreeing the card was added to the cart plus shift change card and count sheet verification. As of [DATE] any staff members that have not received the education will have to be educated before they can work the floor. Director of Nursing, Assistant Director of Nursing, and Support Nurses will do daily cart audits Monday through Friday, removing completed narcotics. The audits will also include removing narcotics that have expired, been discontinued, non-utilized narcotics from all carts and returned to pharmacy for destruction. The pharmacy representative is to email all narcotic delivery sheets to the Director of Nursing every 15 days to ensure reconciliation of narcotics delivered to the facility is occurring every 15 days. Quality Assurance: Beginning [DATE] the Director of Nursing, Assistant Director of Nursing, Staff Development Coordinator and Support nurses will monitor narcotic receivable process weekly indefinitely for correct drug record keeping. Audits will verify narcotic count sheets to ensure accurate narcotic record keeping and signatures are legible and to verify that all ordered narcotics have been entered appropriately onto the narcotic count sheets. Reports will be presented to the weekly QA meeting by the Administrator or Director of Nursing to ensure corrective action is maintained as appropriate. Compliance will be monitored, and ongoing auditing program reviewed at the weekly QA meeting including but not limited to the Administrator, Director of Nursing, MDS Coordinator, Therapy, Dietary Manager. Compliance date of [DATE]. The plan of correction was validated on [DATE] which included reviewing the facility's initial audits that discovered Resident #24's unaccounted for hydrocodone and the reconciliation of other residents' medications. The current residents-controlled substances were verified with no discrepancies noted during a controlled medication count and interviews with staff revealed that they were able to verbalize the new policy for receiving narcotic that now required a signature from 2 staff members (the supervisor and nurse) and when a card of controlled substance was empty or discontinued only a supervisor could remove the card along with the reconciliation sheet. Ongoing audits every 15 days continue of all controlled substances sent. The facility's compliance date of [DATE] was validated.

Based on observations, record review, staff, and Medical Director interviews the facility failed to ensure they had a medication error rate less than 5 % by having 2 errors out of 32 opportunities resulting in a 6.25% medication error rate for 1 of 3 residents observed during medication pass (Resident #97). The findings included: Resident #97 was initially admitted to the facility on [DATE] with diagnoses that included acute/chronic respiratory failure, chronic obstructive pulmonary disease, diabetes, unspecified convulsions, and others. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed that Resident #97 was cognitively intact and required extensive to total assistance with activities of daily living. Review of a physician order dated 01/02/24 read; Neurontin 400 milligrams (mg) by mouth at bedtime for pain. Do not Crush. Review of a physician order dated 01/02/24 read; Gabapentin (Neurontin) 100 mg by mouth twice a day for pain. Do not Crush. Review of a physician order dated 01/02/24 read; Fluticasone Propionate 50 micrograms (mcq) one spray each nostril one time a day for allergies. Shake before use. An observation of Medication Aide (MA) #2 preparing Resident #97's medication was made on 01/09/24 at 8:55 AM. The medications were prepared for administration included: Neurontin 300 mg and Fluticasone 50 mcq. After preparing Resident #97's medication, MA #2 entered Resident #97's room to administer the medications. Resident #97 was observed to take the cup of pills that included Neurontin 300 mg and put them in her mouth and swallow them. MA #2 was then observed to open the Fluticasone bottle, shake it, and sprayed one spray up in the air. MA #2 then proceeded to place two sprays in each of Resident #97's nostrils and then exited the room. MA #2 was interviewed on 01/09/24 at 10:02 AM which revealed that Resident #97 had both Neurontin 300 mg and 100 mg in the medication cart, and she just accidentally pulled the 300 mg instead of the 100 mg that was ordered to be given at 9:00 AM. MA #2 also stated that she always gave Resident #97 2 sprays of Fluticasone because one spay did not always come out and she wanted to ensure she had the full dose of medication. Nurse Manager #1 was interviewed on 01/09/24 at 10:06 AM who stated that Resident #97 had recently returned from the hospital and she thought that she had new orders upon readmission to the facility. She added she would get a clarification order on the Fluticasone spray so the staff could give 2 sprays instead of 1 to ensure she received the full dose. The Director of Nursing was interviewed on 01/10/24 at 2:25 PM who stated that MA #2 had informed her of the medication errors that occurred with Resident #97. She explained she educated MA #2 that those were both considered medication errors and they had to be written up and the Medical Director (MD) notified. The DON stated that MA #2 explained she had given 2 sprays of the Fluticasone because she wanted to be sure Resident #97 received the full dose of medication and stated she had grabbed the incorrect dose of Neurontin. The DON explained that Resident #97 had recently had a hospital stay and the facility usually kept the medication for 7 days before pulling it and returning it to the pharmacy. The DON stated the facility staff were probably aware Resident #97 was returning to the facility and that was why we kept the medication which included Neurontin 300 mg. The Neurontin had been increased to 400 mg while she was in the hospital. The DON added that she was going to call the pharmacy and see if they could send the Neurontin 400 mg and they would pull the 300 mg off the medication cart and return it to the pharmacy. The Consultant Pharmacist was interviewed via phone on 01/10/24 at 3:09 PM. She stated she was not familiar with the procedures for returning medication to the pharmacy when a resident discharged to the hospital. She stated that it would probably depend on if the resident was going to return to the facility or not. If the resident was going to return to the facility, then they would hang on to the medication for a while before returning them. The MD was interviewed on 01/10/24 at 4:47 PM. She stated the Fluticasone was not a significant error and giving an increased dose of Neurontin could potentially make Resident #97 more sleepy, but that would also not be a significant medication error.

Based on observations, record reviews and staff and resident interviews, the facility failed to secure medicated creams that were stored at bedside for 2 of 2 residents (Resident #8 and Resident #66) reviewed for medication storage. The findings included: 1. Resident #8 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease. A review of Resident #8's physician order dated 07/26/23 revealed an order for Minerin cream apply to arms and legs topically every evening shift for dry skin. The quarterly Minimum Data Set assessment dated [DATE] revealed that Resident #8 had moderately impaired cognition. A review of Resident #8 care plan revised 12/13/23 indicated no care plan to self-administer medication. On 01/08/24 at 10:50 AM during an interview and observation of Resident #8 a medicine cup that contained a creamy white substance approximately 3/4 full was noted to be sitting on top of the Resident's bedside table. Written on the medicine cup was minerin to upper legs. Upon inquiry, Resident #8 explained that they put that on my legs, but it's all cleared up now. Resident #8 advised she could not apply the cream on herself. An observation on 01/08/24 at 3:26 PM revealed that the medicine cup with the creamy white substance remained on the Resident's bedside table. During an observation made on 01/09/24 at 8:42 AM, the medicine cup with the creamy white substance remained on the Resident's bedside table. Observations on 01/09/24 at 12:56 PM and 01/09/24 at 3:52 PM remained unchanged. On 01/09/24 at 3:52 PM an interview conducted with the Director of Nursing (DON) revealed that for the residents to be allowed to keep medications at their bedside they had to have an order to do so, and they should be mentally and physically able to take their medications and apply their treatments. The DON was shown the medication cup with the white creamy substance that remained on Resident #8's bedside table and the DON explained that she did not know what the white substance was but that it should not have been left on the bedside table. The DON expressed that she had educated the staff to monitor medications left at bedside. An interview was conducted with Nurse Manager #1 on 01/10/24 at 9:16 AM. The Nurse Manager confirmed that she was responsible for Resident #8 on 01/09/24 on first shift. The Nurse explained that the residents had to have an order to be able to keep medications or treatments at their bedside and they had to be care planned to do so. The Nurse stated Resident #8 would not be able to self-administer medication or apply treatments. She indicated she did not notice the cream on the Resident's bedside table when she made rounds the day before. On 01/10/24 at 11:33 AM during an interview with Nurse #2, the Nurse confirmed she was responsible for Resident #8 on 01/08/24 on first shift and stated she did not notice the medicine cup with the substance in it on her bedside table. The Nurse indicated that the residents could not keep their medications at their bedside without an order to self-administer medication. She indicated Resident #8 would not be able to self-administer or physically apply creams efficiently. During an interview with the Administrator on 01/11/24 at 4:42 PM the Administrator stated her expectation was medications or treatments are not stored at bedside unless the resident had an order to do so. 2. Resident #66 was admitted to the facility on [DATE] with diagnoses that included unspecified dementia. A review of Resident #66's care plan revised 12/22/23 revealed that there was no care plan to self-administer medications. The quarterly Minimum Data Set assessment dated [DATE] revealed that Resident #66 had short and long term memory problems. A review of Resident #66's physician orders revealed no order to self-administer medications. On 01/08/24 at 2:41 PM an observation was made of Resident #66 lying in bed sleeping. At that time, a medicine cup that contained a creamy clear substance approximately 3/4 full was noted to be sitting on top of the Resident's bedside table. Subsequent observations were made on 01/08/24 at 4:08 PM, 01/09/24 at 9:05 AM, 01/09/24 at 12:55 PM and 01/09/24 at 3:50 PM of the clear creamy substance in the medicine cup on the Resident's bedside table. During an interview with the Director of Nursing on 01/09/24 at 3:40 PM who was at Resident #66's bedside, the DON was informed that the medicine cup with the clear creamy substance had been on the bedside table since the morning of 01/08/24. The DON acknowledged the substance sitting on the bedside table and explained that the Resident had multiple pressure ulcers and it could be that the wound nurse left the medication/ointment on the bedside table by mistake. The DON continued to explain that Residents had to be mentally and physically capable to apply treatments and medications and Resident #66 could not do that for herself. An interview was conducted with Nurse Manager #1 on 01/10/24 at 9:07 AM. The Nurse Manager explained that the residents had to be assessed to be mentally and physically able to self-administer medications and apply treatments and Resident #66 would not be able to do so. The Nurse confirmed that she was responsible for Resident #66 on 01/09/24 on first shift and stated she did not notice the creamy substance on her bedside table, or she would have removed it. On 01/10/24 at 11:33 AM during an interview with Nurse #2, the Nurse confirmed she was responsible for Resident #66 on 01/08/24 on first shift and stated she did not notice the medicine cup with the substance in it on her bedside table. The Nurse indicated that the residents could not keep their medications at their bedside without an order to self-administer medication. She indicated Resident #66 would not be able to self-administer medication or physically apply creams efficiently. During an interview with the Administrator on 01/11/24 at 4:42 PM the Administrator stated unless a resdient had an order for self administration of medication, medications should not be stored at bedside.

Based on record review, observations, staff and resident interviews, and test tray, the facility failed to provide palatable food to a resident that was appetizing in temperature for 1 of 3 residents reviewed for food palatability. (Resident #29) The findings included: Resident #29 was admitted to the facility on [DATE]. A review of Resident #29's significant change Minimum Data Set assessment dated [DATE] revealed him to be cognitively intact with no psychosis or behaviors. During an initial interview with Resident #29 on 01/08/24 at 11:20 AM, he reported he did not like the food, and it was often served cold. Resident #29 reported the the food ain't fit to feed a dog. A test tray was completed for the lunch meal on 01/09/24. The test tray was plated in the kitchen at 12:35 PM. At 12:37 PM, the test tray left the kitchen and headed to a hall adjacent to the hall where Resident #29 resided. The test tray consisted of baked ham, pinto beans with onions, braised cabbage, cornbread, and a frosted, chocolate cake. Upon removal of the lid, there was no visible steam coming from the food on the tray and there did not appear to be a metal hotplate underneath the food plate. At 12:41 PM the Dietary Manager tasted the [NAME] and cabbage. The Dietary Manager reported the pinto beans were cool and could have cooked a little longer. An observation of the pinto beans revealed them to be clumped together and were crunchy when tasted. She also reported the cabbage was ok but needed more seasoning and should be hotter. The Dietary Manager reported she would relay the information to her cooks and try to figure out where they were losing heat causing the meals to be cooler than they should be. During a follow-up interview with Resident #29 on 01/09/24 at 12:56 PM, he reported the lunch meal was fair but could not have been much warmer than room temperature when he got it. He reported he did not end up eating much of the meal and sent it back to the kitchen. Resident #29 reported he did not request an alternative meal. An additional observation of Resident #29 was completed on 1/11/24 at 12:45 PM during his mealtime. Resident was observed in his room, in bed with his lunch meal tray on his overbed table. Resident #29 had not tried any of his food. An interview with Resident #29 on 1/11/24 at 12:46 PM revealed he had no intention on eating the meal served as it did not appear appetizing to him and he did not know if it was cold or not and did not plan on eating any of the meal. Resident #29 denied wanting an alternative meal at that time. A follow-up interview with the Dietary Manager completed on 1/11/24 at 1:02 PM revealed she did not know why the meals were not holding heat. She reported the facility utilized plate warmers and dome lids, but stated there were two halls that meals went out on open-air carts. She insisted that all food items temped above recommended holding temps. She also reported not hearing a lot of complaints from residents regarding the quality of the food coming out of the kitchen. She reported most of the complaints she heard were regarding the types of food served. She reported she had not heard complaints regarding the temperature of the food when it reached the residents. During an interview with the Administrator on 01/11/24 at 4:03 PM revealed she expected food to be served to residents that was hot, fresh, and palatable. The Administrator also reported she was aware there had been issues with the kitchen and the quality of food coming out of the kitchen. She reported she was trying to fix the issues but did not have an answer on how to resolve it. The Administrator reported the kitchen should be using a metal hot plate under the serving plate to try and retain as much heat to the food as possible.

Based on observations, record reviews, resident, and staff interviews, the facility's Quality Assessment and Assurance (QAA) committee failed to maintain implemented procedures and monitor interventions the committee put into place following the recertification and complaint survey conducted on 05/05/22 and for the complaint investigation conducted on 09/14/23. This failure was for three deficiencies that were originally cited in the areas of Resident Rights (F584), Quality of Care (F689), and Dietary Services (F804) that were subsequently recited on the current recertification and complaint investigation survey of 01/11/24. The repeat deficiencies during three federal surveys of record showed a pattern of the facility's inability to sustain an effective QA program. The findings included: This tag is cross referred to: F584: Based on observations, resident, and staff interviews the facility failed to provide a clean homelike environment for 1 of 6 units (Unit 600). The facility failed to repair a missing lower closet door and failed to repair a upper closet door, failed to repair missing and cracked dry wall at the base of the air conditioning unit that daylight could be seen and had the potential to allow small rodents into the facility (room [ROOM NUMBER]), failed to clean a privacy curtain that was noted to have a white outline of hand print and a brown stain that was approximately 3 centimeters by 5 centimeters, failed to repair chipped and missing dry wall near the bathroom, failed to clean the brown ring of dirt and grim around the base of the toilet (room [ROOM NUMBER]), and failed to clean and repair the floor at the bathroom room threshold (room [ROOM NUMBER]), and failed to secure baseboard to the wall (room [ROOM NUMBER]). During the recertification and complaint survey of 05/05/22 the facility failed to maintain resident rooms and bathrooms for 4 of 6 halls. F689: Based on record review, staff, and Medical Director interviews the facility failed to provide care in a safe manner to prevent a resident from rolling out of bed during incontinent care (Resident #344) for 1 of 6 residents reviewed for accidents. During incontinent care Resident #344 was rolled onto her side by staff and then rolled out of the bed onto the floor. She was admitted to the hospital for five days due to worsening atrial fibrillation with rapid ventricular response (very fast heartbeat) caused by significant sympathetic response (your body's response to stress) from pain from the fall. During the complaint survey of 09/14/23 the facility failed to ensure the lift gate (a mechanical platform designed to raise and lower to allow an individual with a wheelchair to enter and exit a vehicle) was in the elevated position before unloading a resident from the back of the facility van. On 08/11/23 Resident was rolled out of the back of the transportation van in her wheelchair and fell approximately 2.5 feet to the ground landing on her right side and hitting the back of her head. F804: Based on observations, staff and resident interviews, and test trays, the facility failed to provide palatable food to residents that was appetizing in temperature for 1 of 3 residents reviewed with food concerns. (Resident #29) During the recertification and compliant survey of 05/05/22 the facility failed to serve palatable food that was appetizing in taste and temperature. The Administrator was interviewed on 01/11/24 at 5:47 PM. The Administrator stated that the Quality Assurance (QA) committee met monthly and included all department heads and if had safety concerns to discuss they invited direct care to staff to join. The Administrator stated that they had revamped the QA process because they were reporting numbers but not really discussing what those numbers meant. She further explained that now they were really diving into what the numbers meant and how we could affect the numbers going forward. Additionally, they have performance improvement plans in place for antipsychotic medications, dietary issues, and falls with injury and they continue to work on those plans to improve the system in place. The Administrator stated that she generally kept performance improvement plans in place longer than she should, but she wanted to ensure long-term compliance.

Based on observations, record reviews and interviews, the facility failed to implement their policy for Personal Protective Equipment (PPE) when Nurse #4 failed to don protective eyewear (goggles or face shield) before entering 1 of 4 resident's room with signage for transmission-based precautions (Resident #85). The finding included: Review of the facility's Infection Control policy for COVID-19 infection revised 05/2023 indicated Healthcare Personnel who enters the room of a patient with confirmed COVID-19 should adhere to Standard Precautions and use a NIOSH-approved respirator with N95 filters or higher, gown, gloves and eye protection (goggles or a face shield that covers the front and sides of the face). This type of Transmission Based Precautions is Special Droplet Contact Precautions. An observation on 01/11/24 at 8:43 AM revealed signage posted on Resident #85's door for Special Droplet Contact Precautions which directed all healthcare personnel must: wear a gown when entering room and remove before leaving, wear N95 or higher-level respirator before entering the room and remove after exiting, protective eyewear (face shield or goggles) and wear gloves when entering room and remove before leaving. A PPE tower was hanging on the door with all the listed items available for use. During an observation made on 01/11/24 at 9:04 AM Nurse #4 stood outside of Resident #85's room looking at the Special Droplet Contact Precaution signage which was posted on the residents' door. The Nurse sanitized her hands then donned a gown, gloves and N95 face mask then proceeded to enter Resident 85's room. At 9:13 AM on 01/11/24 Nurse #4 was observed to exit Resident #85's room. During an interview at that time, Nurse #4 explained that the reason the room was posted for Special Droplet Contact Precautions was that Resident #85 tested positive for COVID-19 the day before on 01/10/24. The Nurse was asked what she did while she was in the room and the Nurse explained she changed the oxygen tubing for Resident #85. When the Nurse was asked what PPE she donned for the COVID-19 positive room, Nurse #4 stated she put on all the PPE that was checked on the sign for Special Droplet Contact Precaution except for the face shield which was not stocked in the tower on the door. At that time the Nurse was directed to the second pocket on the PPE tower where there was a face shield available for use. The Nurse stated she did not see the face shield while she was preparing to go into the room. Nurse #4 was asked what she should have done if there were no PPE available to don before entering the COVID-19 positive rooms and the Nurse stated, 'go to the supply room and get some. When asked why she did not do that the Nurse stated ignorance. An interview was held with the Infection Preventionist (IP) on 01/11/24 at 9:22 AM. The IP explained that all staff were educated on PPE procedures and the differences in the types of Transmission Based Precautions and what PPE to apply related to the specific signage. The IP stated Nurse #4 should have donned the PPE as specified on the signage before she entered the room per the policy. During an interview with the Administrator and Director of Nursing made on 01/11/24 at 4:42 PM the Administrator explained that her expectation was for the staff to follow the instructions on the specific Precautions and retrieve the PPE necessary if the supply had been depleted from the tower on the door.

Based on record review and staff interviews, the facility failed to accurately code Minimum Data Set assessments when they failed to document a gradual dose reduction for an antipsychotic medication and documented the use of an ostomy for a resident without an ostomy, for 4 of 23 residents reviewed. (Resident's #35 and Resident #50) The findings included: Resident #35 admitted to the facility on [DATE] with diagnoses that included unspecified mood disorder. A review of Resident #35's annual Minimum Data Set assessment dated [DATE] revealed she was cognitively intact with no psychosis, behaviors, or rejection of care. Resident #35 was coded as receiving antipsychotics on a routine basis, a gradual dose reduction (GDR) had not been attempted and a GDR was not clinically contraindicated. Review of Resident #35's electronic physician orders revealed the following order: Abilify Oral Tablet 2 milligrams - Give 1 tablet by mouth, once daily for psychotic mood disorder. During an interview with the Pharmacist on 01/10/24, she revealed she was familiar with Resident #35 and was aware she was taking an antipsychotic. The Pharmacist reported Resident #35 had a gradual dose reduction in March of 2023 when the dose of her Abilify went from 4milligrams, down to 2 milligrams. A review of Resident #35's quarterly Minimum Data Set assessment dated [DATE] which would have been the first Minimum Data Set assessment completed after the GDR revealed Resident #35 was coded as receiving an antipsychotic on a routine basis, a GDR had not been attempted, nor was a GDR clinically contraindicated. During an interview with MDS Nurse #1, she verified she was the MDS nurse that completed the 05/06/23 quarterly assessment for Resident #35 and reported she just missed the GDR attempt that happened in March, 2023. She reported she would immediately modify the assessment to accurately reflect the GDR. During an interview with the Director of Nursing on 01/11/24 at 3:55 PM, she reported she expected Minimum Data Set assessments to be completed accurately and thoroughly and that MDS nurses should monitor new orders to catch and antipsychotic medication changes. 35789 4. Resident #50 was admitted to the facility on [DATE] and most recently readmitted to the facility on [DATE]. Resident #50's diagnoses included chronic respiratory failure, diabetes, congestive heart failure and others. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed that Resident #50 was cognitively intact and had an ostomy. The MDS further revealed that Resident #50 was coded as always incontinent of bowel. The MDS was completed by MDS Nurse #1. An observation and interview were conducted with Resident #50 on 01/08/24 at 10:57 AM. Resident #50 was resting in bed with his eyes open. Resident #50 stated that he wore briefs for his incontinent episodes of bowel. Resident #50 stated he did not have an ostomy of any kind. Review of a health status note dated 01/09/24 at 2:18 PM revealed that Resident #50 was incontinent of bowel. MDS Nurse #1 was interviewed on 01/10/24 who stated that Resident #50 did not have an ostomy and that was coding mistake on her part. MDS Nurse #1 stated that she would correct the mistake immediately. The Administrator was interviewed on 01/11/24 at 4:39 PM. The Administrator stated that she expected all MDSs to be coded as accurately as possible.

Based on observations, record reviews and resident, staff, and Medical Director (MD) interviews the facility Transport Driver failed to ensure the lift gate (a mechanical platform designed to raise and lower to allow an individual with a wheelchair to enter and exit a vehicle) was in the elevated position before unloading a resident from the back of the facility van. On 08/11/23 Resident #1 was rolled out of the back of the transportation van in her wheelchair and fell approximately 2.5 feet to the ground landing on her right side and hitting the back of her head. The Resident complained of mid back pain and right rib pain at 9 out of 10 (10 being the worst pain imaginable) and pain in her head at a 7 out of 10. Resident #1 was sent to the emergency department for evaluation and diagnosed with right 4th and 5th nondisplaced rib fractures. This occurred for 1 of 3 residents sampled for accidents (Resident #1). The findings included: Resident #1 was admitted to the facility on [DATE] with diagnoses that included myasthenia gravis (neuromuscular disease that leads to skeletal muscle weakness) and long-term use of anticoagulant (blood thinner). Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 was cognitively intact and required limited to extensive assistance of one staff member with activities of daily living. The MDS also revealed that Resident #1 used a wheelchair and walker for mobility and complained of pain frequently of an 8 on a pain scale. The assessment also revealed that Resident #1 received scheduled pain medications and received as needed pain medication or was offered and declined. Resident #1 received 6 days of anticoagulant therapy during the assessment reference period. Review of Resident #1's physician order sheet dated August 2023 revealed the following active orders: Eliquis (blood thinner) 5 milligram by mouth twice a day and Oxycodone 10 mg give half tab (5mg) by mouth as needed for pain every 8 hours. Review of an incident report dated 08/11/23 read, Resident #1 had returned from a medical appointment and was being unloaded from the facility van and fell to the ground. Resident #1 was immediately assessed, and Emergency Medical Services (EMS) was called. The report was electronically signed by the Assistant Director of Nursing (ADON). The Transport Driver was interviewed on 09/13/23 at 12:41 PM and confirmed that she had been driving the facility van since February/March of 2023. The Transport Driver confirmed that she transported Resident #1 to her medical appointment on 08/11/23. She stated upon picking Resident #1 up after her medical appointment on 8/11/23 Resident #1 had complaints of pain. She explained she was familiar with the resident, and this was normal for her to complain of pain. She stated she had told Resident #1 that she would get her back to the facility as quickly as possible so that she could lay down and get something for her pain and hopefully that would help her feel better. She stated when they returned to the facility, she pulled the van up to the front door under the awning and put the van in park. She indicated she engaged the parking brake, exited the driver's seat to the rear of the van, and opened the back double doors. The Transport Driver stated that she was so focused on getting Resident #1 out of the van and back into the facility so that she could get something to ease her pain that she lowered the lift gate to the ground instead of putting it in the up position for unloading. The Transport Driver stated she did not realize what she had done until she entered the van via the side door and un-secured Resident #1's wheelchair from the floor. Once the Transport Driver had removed her seat belt and began pushing her backwards out of the van, she realized the lift gate was on the ground instead of the up position. The Transport Driver stated that she and Resident #1 both fell out of the back of the van to the ground. She explained that she tried to wrap her arms around Resident #1 like a koala bear to break her fall and so the wheelchair would not land on Resident #1. The Transport Driver stated that she and Resident #1 came to rest on the ground. The staff had either heard the commotion or someone told them because the Transport Driver explained everyone came running out to help them and asked them if they were ok. The Transport Driver stated she was able to get up and went to check on Resident #1 and stayed by her side until EMS arrived and loaded her on the stretcher and then left the facility to go the emergency room (ER). The Transport Driver stated that she was suspended from work that day and was sent home and then was called to the facility on [DATE] where she gave her statement and was re-educated on the unloading/loading procedures from a staff member from the facility's corporation. Then on 08/15/23 she began driving the van again. She added that she had never had any incidents like this before or since the accident but stated she was just so distracted and focused on getting Resident #1 off the van and into the facility that she just made a mistake with the lift gate. An observation of the facility van was made on 09/13/23 at 3:53 PM along with the Maintenance Director. The Maintenance Director measured the distance from the lift gate in the elevated/unloading position to the ground to be 2.5 feet. Medication Aide (MA) #1 was interviewed via phone on 09/13/23 at 12:03 PM who confirmed that she was working on 08/11/23. She stated that she and Nurse Assistant (NA) #1 were carrying lunch trays down the hallway and NA #1 stated oh my goodness someone fell out of the van. She stated she sat her tray down and ran outside where she found Resident #1 lying on the ground on her back with her wheelchair flipped over next to her and the Transport Driver lying on her back about a foot away. MA #1 stated Resident #1 was complaining of pain on her left side. She explained that it was crowded outside at that time because there were so many employees outside. She further explained that she came back in the facility to finish collecting her meal trays while the Administrator and other staff waited on EMS to arrive. NA #1 was interviewed on 09/13/23 at 3:18 PM and confirmed that he was working on 08/11/23. He stated that he saw a commotion at the front of the facility and went to see what was going on. NA #1 stated that when he got outside, he saw Resident #1 laying on the ground on the lift gate and the Transport Driver was laying on the concrete beside her. NA #1 stated he asked Resident #1 if she was ok and if she had hit her head and she stated she was ok, but she had hit her head. NA #1 stated that the Wound Nurse was coming over to take a look at Resident #1 and NA #1 did not want to be in the way, so he came back into the facility and continued with his assignment. The Unit Manager (UM) was interviewed on 09/13/23 at 11:57 AM who confirmed she was working on 08/11/23. She stated she was at the front nursing station and heard staff yelling to call EMS. The UM stated she looked up and saw Resident #1 lying on the ground outside of the facility. She stated that there were so many staff members outside that she really could not tell what had occurred, but she did as she was told and called EMS. She explained it took them about 10 minutes to arrive at the facility, once at the facility they loaded Resident #1 on the stretcher and took her to the local ER. The Wound Nurse was interviewed on 09/13/23 at 3:29 PM who confirmed that she was working on 08/11/23. She stated she was coming up the hall and looked out the front door and saw people lying on the ground and then heard someone say that Resident #1 had fallen. The Wound Nurse stated that she closed her computer and headed outside where there were already a lot of staff gathered. The Wound Nurse asked Resident #1 if she was hurting and she replied that she was hurting but no more than she previously did before the incident. Wound Nurse indicated she completed an assessment of Resident #1's head, and extremities for any obvious signs of injury and could not find any. She added that Resident #1 was wanting to sit up and once EMS arrived at the facility, they allowed the staff to stand Resident #1 up so she could get on the stretcher and then took her to the ER. The Wound Nurse could not say where Resident #1's wheelchair was at because people started moving things around when she arrived, she proceeded straight to Resident #1 and stayed with her until EMS arrived and she was loaded on the stretcher. Review of emergency room (ER) records dated 08/11/23 read in part, Resident #1 had past medical history significant for prior deep vein thrombosis and pulmonary embolism on Eliquis (blood thinner) presented after a fall that happened earlier today. Resident #1 fell backward from the wheelchair lift and had the wheelchair on top of her. She hit her head but did not lose consciousness. She was endorsing pain in the back of her head and pain on right chest wall. The patient was prepared and sent to computerized tomography (CT) for a full trauma scan (scan of entire body). Significant findings from the CT included non-displaced fracture on right fourth and fifth ribs and osteopenia (low bone density). Resident #1 returned to the facility on [DATE]. Review of a physician order dated 08/13/23 read: Oxycodone 5 mg by mouth every 4 hours as needed for pain. An interview was conducted with Resident #1 on 09/13/23 at 10:14 AM who confirmed that she had been to a medical appointment in the facility van on 08/11/23 and when they (she and the Transport Driver) returned to the facility the Transport Driver pushed her wheelchair out of the back of the van without the lift gate elevated. She explained the lift gate was on the ground. Resident #1 stated the next thing she knew my wheelchair went airborne and flipped because I fell out of it, and it landed on my lower legs. Resident #1 stated that her body hit the concrete and she hit her head on the concrete. All of the staff including the Administrator came outside. She stated, my chest was hurting really bad on the right side but staff would not move her until EMS came to transport her to the ER. Resident #1 stated that her right rib area was hurting at a 9 on a pain scale of 1-10 (10 is the worse pain imaginable) and her head was hurting at a 7 on a pain scale. Resident #1 stated that she normally had pain in her back area that range from 6-10 on a pain scale. She stated that EMS came rather quickly and took her straight to the ER as a trauma patient and they did full CT scan of her body and her 4th and 5th ribs on the right side were fractured but not displaced. Resident #1 stated she had a history of osteopenia, but the hospital staff stated her fractured ribs were due to the trauma of her fall from the van. She stated that after they got her settled in the ER, they gave her something for pain which helped. In addition, Resident #1 stated that they increased the frequency of her pain medication for a few weeks which was helping her pain and they also instructed Resident #1 to keep moving around, to use incentive spirometer (handheld medical device to help patients improve lung function), and to work with therapy. Resident #1 stated that the Transport Driver had driven her to many appointments before and never had any issues and she has also driven her to another appointment since 08/11/23 and had no issues. The MD was interviewed on 09/13/23 at 2:57 PM and confirmed that she had been made aware of Resident #1's fall from the van. She stated if Resident #1 had a history of osteopenia that would place her at increased risk of fractures. However, if the fractures were not present prior to the accident and after they accident they were present then one would presume they came from the fall from the van. She added that they adjusted Resident #1's pain medication after the accident to ensure her pain was controlled as much as possible. The Administrator was interviewed on 09/13/23 at 5:00 PM who confirmed that she was in her office on 08/11/23 when someone told her that Resident #1 and the Transport Driver were lying on the ground outside the facility. She stated she proceeded outside and saw Resident #1 and the Transport Driver lying on the ground and she asked them how they were doing. She stated that Resident #1 stated she was hurting but not anymore than she hurt before the incident and there was no bleeding. The Wound Nurse did a head-to-toe assessment and could not identify any injuries, and someone had already called EMS and they arrived and loaded Resident #1 on the stretcher and took her to the ER. Resident #1's wheelchair was lying off to the side of the van. The Administrator stated that the Transport Driver tried to take the brunt of the fall so Resident #1 would not get hurt when she realized that the lift gate was down and not in the up position. The Administrator stated that after Resident #1 had gone to the ER and they ensured the Transport Driver was ok they suspended her and sent her home. She stated she notified the people within her corporation that she needed to notify and brought Resident #1's wheelchair into her office and the van was parked out of use pending the investigation. The Administrator confirmed that the facility had video cameras but stated that they were only good for 14 days and so the video of the accident on 08/11/23 was unavailable. The Administrator stated she interviewed residents that had been transported on the facility van and driven by the Transport Driver for the last 6 months and no other issues were identified. On 08/14/23 the Transport Driver returned to the facility and gave her account of what had occurred. The Transport Driver indicated she was so focused on Resident #1's pain and getting Resident #1 back into the facility that she did not realize the lift gate was down and not in the up position. Also, on 08/14/23 the Transport Driver went through the extensive education program on van safety and driving safety given by the insurance agent and director of transportation for the facility. The Administrator stated that she had been monitoring the Transport Driver at least weekly since the accident and had no issues. The Administrator added that they took the issue to the Quality Assurance (QA) committee on 08/15/23 as well. The Administrator was notified of immediate jeopardy on 09/13/23 at 5:21 PM. The facility provided the following corrective action plan: Corrective Action for resident involved: On August 11, 2023, around 2:10 pm, Facility Transport Driver arrived at the facility with Resident #1 and parked in front of the facility. At approximately 2:15pm, Transport Driver prepared to unload resident. Transport Driver placed the lift gate all the way to the ground and then Transport Driver unbuckled resident's seatbelt and removed seatbelt harness from wheelchair and proceeded to move resident to back lift gate. Upon reaching lift gate with Resident #1, Transport Driver realized the lift was in the down position. Resident #1's wheelchair started to disembark, and the Transport Driver attempted to prevent wheelchair from rolling out of van by grabbing hold of the wheelchair pedals which was unsuccessful therefore transport driver threw her body over resident to attempt to break fall while kicking wheelchair out of way resulting in resident and Transport Driver resting approximately two and one-half feet from the van to ground level. Administrator and Nurse #l responded to the incident immediately. Resident #1 was assessed by Nurse #l at the site of incident where she remained until Emergency Medical Service arrived. Resident #1 was assessed for increased pain and any injury on the resident's body as a result of the van incident while Unit Manager #1 notified Emergency Medical Services. The assessment revealed no obvious bruising, redness, or visible injuries noted to Resident #1. Resident #1 verbalized she was not hurting any more than she had been before the incident occurrence and denied hitting head. At approximately 2:25pm, Emergency Medical Services arrived and transported resident to hospital for evaluation and treatment. On 8/11/2023, the Administrator obtained a statement from the Transport Driver and instructed the Transport Driver to complete a reenactment of the incident and following this the Transport Driver was immediately suspended pending investigation. On 8/11/2023, the Transportation van was parked and taken out of use pending an investigation and inspection and the facility scheduled all transports with outside transportation service for the following Monday. Also, Resident #1's wheelchair was taken out of use and placed in the Administrator's office for inspection. On 8/11/2023, the Director of Nurses notified Resident #1's responsible party and the Medical Director of the van incident. On 8/12/2023 at 08:30am, resident returned to facility from the hospital with diagnosis of nondisplaced rib fractures of right fourth and fifth ribs with no new orders. On 8/14/2023, the transport van and resident wheelchair was inspected by the risk management insurance agent. The inspection revealed no malfunctioning components of van's lift or wheelchair. On 8/14/2023, Transport Driver was re-educated on safety protocols with skills checkoff and the need to make sure if she was distracted due to resident continued complaint of pain to immediately pull over facility transport van and call facility to speak with Administrator or Director of Nursing to receive instruction. Transport Driver was educated to pull over and call facility if a resident complained of pain or is having issues as well as if resident may need to go to hospital for evaluation if applicable. On 8/14/2023, Administrator concluded the van incident investigation and based on investigation findings root cause analysis of the incident was due to the Transport Driver being distracted by Resident #1's complaints of pain and lack of knowledge/skills of the Transport Driver to assess resident's pain. On 8/14/2023, a Quality Assurance and Performance Improvement meeting was held with the Interdisciplinary Team to review findings of investigation with no additional findings. Corrective Action for potentially impacted residents: Beginning 8/11/2023, the Administrator and Director of Nursing identified residents that would be potentially impacted by the alleged deficient practice by completing facility transportation audits for all current resident that had appointments in the past six months that had been transported by the facility van and asked if they had any issues or concerns when the Transport Driver transported them to or from an appointment. The results of the audit revealed no other residents identified with any issues or concerns with transports to or from appointments. On 8/11/2023, facility van was parked and taken out of use and all appointments scheduled for the following Monday were scheduled with outside transportation service. On 8/14/2023, after concluding investigation, the Quality Assurance Committee convened to discuss the alleged van incident and the status of the investigation. There were no additional findings at that time. Systemic Changes: On 8/14/2023 the Administrator in-serviced the facility's only Transport Driver on safety protocols pertaining to driving the van with skills checkoff. The training included reviewing van safety equipment, van system checklist, operations and skills which included observations of loading and unloading residents prior to and following transports. The Administrator will ensure that any newly hired facility transportation staff will receive this training during orientation. Quality Assurance: Beginning the week of 8/14/2023, The Administrator or designee will monitor the issue using the QA Tool for Transportation Van Training Skills Checkoff for Wheelchair Transport to ensure Transport Driver is operating facility van equipment correctly and loading and unloading residents according to facility policy. The monitoring will be completed weekly for 4 weeks and then monthly for 2 months or until resolved. Reports will be presented to the weekly Quality Assurance Committee by the Administrator or Director of Nursing to ensure corrective action initiated as appropriate. Compliance will be monitored, and ongoing auditing program reviewed at the weekly Quality Assurance Meeting. The weekly Quality Assurance Meeting is attended by the Administrator, Director of Nursing, MDS Coordinator, Therapy Manager, Health Information Manager, and the Dietary Manager. Date of completion: 08/15/23. The corrective action plan was validated on 09/13/23 and 09/14/23 and verified the corrective action plan was completed on 08/15/23. The Transport Driver who was the only employee that was able to drive the facility van was re-educated on the unloading/loading process, driving safety, and what to do if the driver became distracted by the residents' complaints of pain. The education also included return demonstration. The van was inspected by the insurance agent and Director of Transportation at the facility and no issues were found with the van, lift, or safety mechanisms. The facility interviewed residents in the last 6 months that had been transported by the facility van and driven by the Transport Driver and no other incidents were reported. The facility's QA committee was updated on the plan on 08/15/23 and the Administrator had been conducting weekly audits of the Transport Driver unloading/loading procedures with no other issues identified. During the validation the Transport Driver was observed to load/unload a resident on/off the van with no issues noted. The lift gate was placed in the correct position each time. The corrective action plan's completion date of 08/15/23 was verified.

Based on staff interviews, phlebotomist and physician interviews and record review the facility failed to honor a resident's refusal to have her blood draw when a contract phlebotomist held a resident's arm down and forced the resident against her will to have blood drawn for 1 of 3 sampled residents for resident rights (Resident #3). Immediate Jeopardy began on [DATE] when phlebotomist #1 held the resident's arm with force to obtain Resident #3's blood specimen against her will. Immediate jeopardy was removed on [DATE] when the facility implemented a credible allegation of compliance. The facility remains out of compliance at a lower scope and severity level D (no actual harm with the potential for more than minimal harm that is not immediate jeopardy) to complete both facility and contractual employees education and ensure monitoring systems in place are effective. The findings included: Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent Minimum Data Set ((MDS) dated [DATE] specified the resident had clear speech and was usually able to make herself understood and usually able to understand others. The MDS also specified the resident had moderately impaired cognition but did not resist care and took anticoagulant medication daily. In addition, the resident was receiving Hospice Care. A care plan updated [DATE] for impaired cognition identified the following approaches for staff: - Approach me in a calm unhurried manner - Ask yes/no questions to determine my needs - Validate my thoughts and feelings when I get confused or anxious Review of the medical record revealed a physician progress notes [REDACTED].#3 was seen for a routine visit and assessed the resident's [MEDICAL CONDITION] was controlled with [MEDICATION NAME] (anticoagulant medication). The note also specified the dose had been increased due to low INR (International Normalized Ratio) and the next INR check was scheduled for [DATE]. The physician also documented to limit bloodwork with goal of comfort since the resident was on Hospice. Laboratory test results found in the medical record revealed: - On [DATE] the resident's INR was 1.5 (low) and the physician ordered to increase [MEDICATION NAME] and recheck on [DATE]. - On [DATE] the resident's INR was 3.0 (high) and physician ordered to decrease [MEDICATION NAME] and recheck INR on [DATE]. - On [DATE] the resident's INR was 4.9 (critical) A progress note dated [DATE] made by Nurse #1 read in part, two lab phlebotomists in resident's room attempting to collect ordered blood work. Resident was lying in bed with eyes closed mumbling. A staff member (housekeeper #1) entered the resident's room to console resident while blood draw completed. Resident then got notably louder and could be heard from the adjoining room. I (Nurse #1) entered resident's room and noted blood on the bed linen. Resident was bleeding from 2 separate sites and the gauze with tape was not intact to resident's arm. A large blood blister was noted forming to the inside of the left forearm. The note specified the Nurse called physician #2 and nurse #2 into the room to help assess the resident. Resident #3 died on [DATE]. A document titled Investigation Report dated [DATE] specified Resident Abuse was investigated for Resident #3 and determined that the resident suffered physical harm/injury and mental anguish from the incident. The injury was a 12-centimeter by 13-centimeter hematoma on the left antecube. and bruising consistent of fingerprints to the left wrist. The report specified the resident suffered mental anguish in response by guarding her arm throughout the day and cried out, no, no, no when staff entered the room. There was one accused individual (Phlebotomist #1) and two witnesses (Housekeeper #1 and Nurse #1). The facility's investigation substantiated the allegation of abuse. On [DATE] at 10:12 AM Housekeeper #1 was interviewed and described that on [DATE] in the morning she heard Resident #3 from inside her room crying out no, no, NO and sounded agitated. The housekeeper stated she had a good relationship with the resident and was aware phlebotomists had entered the room to draw blood. Housekeeper #1 stated she asked Nurse #1 if she could go in the room. Housekeeper #1 reported that when she entered the room Resident #3 was in bed and she saw phlebotomist (PH) #1 standing on the left side of the bed holding the resident's left arm. Phlebotomist #2 was standing on the right side of the bed holding the resident's right arm and appeared as if they were going to attempt to draw blood at the same time. The Housekeeper added that when she entered the room, PH #2 let go of the resident's arm and stepped away from the bed. She went on to explain that she could see the resident had already been stuck once by PH #1 as evidenced by a needle stick to the left wrist that was bleeding. The Housekeeper described the resident was visibly upset and she went to the resident to console her; and while the housekeeper was consoling the resident, PH #1 made a second attempt to draw blood. The second attempt made the resident become upset again which caused the Housekeeper to raise her head from having it rested on the resident's shoulder to see PH #1 holding the resident's left arm with force at the elbow. The Housekeeper described that PH #1 had the resident's left arm trapped between her legs pressed against the bed with a firmer than she needed hold of the arm at the elbow, then lifted the elbow to draw blood from the ante cube, sticking the resident a second time. The resident was fighting PH #1 saying STOP, STOP, STOP! The housekeeper said that she realized PH #1 was too rough and not listening to the resident but the blood draw was over. Housekeeper #1 left the room and notified Nurse #1 of what had occurred. On [DATE] at 11:08 AM Nurse #1 was interviewed and reported on [DATE] she attempted to administer morning medications to Resident #3 but the resident had refused, shaking her head no, no and had the covers pulled over her head. The Nurse added that the resident had been up most of the night and wanted to rest that morning. The Nurse described that she proceeded to gather medications for another resident and just as she was about to enter another resident's room, Housekeeper #1 asked if she could console Resident #3 while she got her blood drawn. Nurse #1 stated she told Housekeeper #1 that would be fine and continued into the adjoined room. She stated she was able to hear slight moaning coming from Resident #3's room but added that as she exited the room she was in, she could hear that Resident #3 was agitated and got the sense something had escalated. Nurse #1 reported she was met by Housekeeper #1 who asked the nurse to look at Resident #3's left arm. The nurse explained that when she entered the room the resident was in bed shaking her head, no, no and the phlebotomists had finished the blood draw and left the room but the resident was bleeding. Nurse #1 reported she called for Nurse #2 and physician #2 to assess the Resident's arm. On [DATE] at 11:36 AM Nurse #2 was interviewed and reported that on [DATE] Nurse #1 stated to her, I need you! Nurse #2 described going into Resident #3's room and observing the resident cradling her left arm, her eyes were closed and she was shaking her head saying no, no, no. In the same interview the nurse reported she calmed the resident down to assess the left arm. Nurse #2 measured a 12 centimeter by 13-centimeter hematoma that covered the resident's left forearm below the ante cube. Nurse #2 also stated that there was the appearance of fresh fingerprints marks on the resident's left wrist. Nurse #2 explained that she called PH #1 into the room to ask her how the resident sustained [REDACTED].#1 became belligerent and defensive stating you ain't going to blame this on me. Nurse #2 added the PH reported that she had to get the blood sample but the resident was being resistant and refusing to let the PH draw her blood so she had to hold the resident's arm down. Nurse #2 stated she informed the phlebotomist that Resident #3 had the right to refuse the blood draw and the phlebotomist denied knowing that a resident had the right to refuse a treatment. On [DATE] at 2:33 PM the Director of Nursing (DON) was interviewed on the telephone and explained that on [DATE] she was in a meeting when she made aware of an incident regarding Resident #3 and phlebotomist #1. She stated she instructed staff to have phlebotomist #1 wait in the front of building to meet with her. The DON reported when she spoke with PH #1, the phlebotomist stated she didn't know it was wrong to hold down a resident's arm or that a resident could refuse to have their blood drawn. The DON added she was shocked by the answer and asked the phlebotomists to leave the building. The DON added she proceeded by filing an abuse allegation and notified the lab company that their services were being suspended pending an abuse investigation. On [DATE] at 4:00 PM Phlebotomist (PH) #2 was interviewed on the telephone and explained that it was her first time trying to collect Resident #3's blood on [DATE]. She described that she entered the room, startled Resident #3 who began shaking her head no. The phlebotomist stated she told Resident #3 she wasn't there to get her out of bed just to draw her blood. She stated she realized she was going to need help with the resident and called for phlebotomist #1 to come into the room. She went on to describe that for the most part the resident was okay until PH #1 stuck the needle in and then she (Resident #3) started to get real cranky. PH #2 was asked to define cranky and she stated Resident #3 started pulling her arm away, moaning, yelling and fighting us and PH #1 had to pull the needle out of the resident's wrist because of the risk for injury. Then she went on to describe that Housekeeper #1 entered the room and attended to Resident #3 and calmed the resident down slightly by resting her head on the resident's head and singing in her ear. PH #2 explained that during this time, a second attempt was made to draw blood which upset the resident again and PH #1 had to grab the resident's arm to hold the arm still because the needle was in the arm. On [DATE] at 1:10 PM Phlebotomist (PH) #1 was able to be reached for a telephone interview and described having been a phlebotomist for a long time and had drawn Resident #3's blood before. The PH described Resident #3 as being a little difficult at times and understood why phlebotomist #2 asked for help because the resident had her good days and not good days. She went on to describe that as she entered the room Resident #3 was whining and moaning a lot and did not want to be bothered. The PH reported that she told the resident she needed to draw her blood. The phlebotomist proceeded to draw the blood and reported that things were going fine until the resident became anxious and started fighting the needle so she held the resident's arm because the resident was trying to jerk the needle out. The PH acknowledged Housekeeper #1 came in the room and calmed the resident but denied that she stuck the resident twice in the arm. The PH offered no explanation why the resident was bleeding from two separate sticks on her left arm. The PH added that it was very important that she got Resident #3's blood sample because later she found out the INR was critical. On [DATE] at 4:10 PM the Medical Director (MD) was interviewed on the telephone and stated she had been made aware of an unfortunate incident with Resident #3 which resulted in traumatic bruising. The MD described that she assessed the resident on [DATE] later in the day and noted the bruising was consistent with a traumatic event and noted the bruising to be deep, deep, purple. On [DATE] at 10:10 AM the Administrator was notified of Immediate Jeopardy. On [DATE] at 5:05 PM the facility provided an acceptable credible allegation of compliance that included: Plan for correcting specific area of concern identified, include the process that led to the concern: · On [DATE] a housekeeper witnessed phlebotomist (PH) #1 use unnecessary force to obtain a blood specimen from Resident #3 who was resisting the procedure. A second phlebotomist (PH) #2 was in the room during the incident. Housekeeper #1 immediately reported the incident to the nurse. The DON was notified of the incident. · Resident #3 was assessed by nurse #2 and the physician for injuries. · PH #1 had no further interaction with residents following the incident and was asked about the bruising sustained during the blood draw. · PH #1 stated she was unaware a resident had a right to refuse. Nurse #1 educated the PH on Resident Rights. The PH left the facility. · On [DATE] the facility filed a 24-hour abuse allegation and notified the lab company of the incident. · On [DATE] the facility temporarily suspended the lab company from entering the facility pending an investigation. · Facility staff, trained on resident rights and abuse, were allowed to perform blood draws on residents with orders for laboratory testing. · On [DATE] a meeting was held with the lab company to notify them of the temporary suspension of services until the following terms were met: · Full Names of both Phlebotomists involved in the incident. We have to provide this to the Health Care Personnel Registry. (Name, Full Social Security, DOB, Job Title, Date of Hire, Last known mailing address, Phone number) · Statements from both Phlebotomists as to what occurred. · A copy of the training the lab company will provide for all their staff members who will be at any of our facilities with first priority being the facility. This training should include Abuse prevention, what an employee should do when a resident refuses to get services done, what to do with a combative resident, how and when to report incidents to the facility receiving the service. · Please note-the two accused Phlebotomists cannot return to the facility and any other company facility going forward to provide any services. You will have to send any other phlebotomists to the facility, who have received the above training after our review of the education/ training you provide us. · The facility will need documentation from the lab company indicating when this education was done and also completed. This will be included in our investigation report which we will send to the Health Care Personnel Registry. Representatives from the lab company Lab met with the Director of Nursing and Administrator on [DATE] to discuss the event. The housekeeper and nurse was interviewed by the representatives. It was determined that the root cause was lack of knowledge. This is due to the fact that the phlebotomist reported to the nurse that she did not know that the patient had the right to refuse treatment and she did not recognize that the resident pushing her hand away was a refusal. Procedure for implementing an acceptable Quality Improvement Plan. Systematic Changes and Education provided: The lab company was contacted and notified on [DATE] by the Quality Assurance Nurse Consultant and informed that: Phlebotomist #1 and Phlebotomist #2 will not be allowed to return to the facility to provide any services moving forward. Phlebotomist # 1 and Phlebotomist # 2 have not been allowed to provide any direct patient care services since [DATE]. On [DATE] the facility determined that all services provided by the lab company would be suspended pending investigation. The lab company provided education to phlebotomists regarding resident rights and abuse. The lab company provided the facility with a copy of the education provided: Phlebotomy Continuing Education A patient has the right to refuse care. When a patient refuses to consent to have a phlebotomy procedure initiated or completed this is considered a patient refusal. Procedure 1. Patient refuses to have venipuncture started by any means including a verbal indication or a physical behavior. 2. Phlebotomist will not proceed with the procedure and will locate a nurse at that time. 3. The patient consents to the venipuncture and if at any time during the venipuncture the patient refuses to continue by verbally requesting the needle be removed or becoming combative the phlebotomist will immediately stop the procedure, bandage the site, safely dispose of the venipuncture device and locate a nurse. 4. Once the nurse is notified the phlebotomist may return to the room with the nurse. If the patient consents to the nurse ' s request for the phlebotomist to perform the venipuncture, then the phlebotomist may only continue with the nurse present in the room. 5. If the patient still refuses the phlebotomist will document the refusal in the lab company Phlebotomy log at the facility. The refusal along with the nurse ' s name who assisted will be documented. The facility will follow their Standard Operating Procedure to inform the patient ' s physician. The lab company provided signed attestations on [DATE] of receiving resident rights and resident abuse education. The lab company phlebotomists were allowed to resume services to the facility on [DATE]. On [DATE], the nurse managers completed skin checks on all non interviewable residents to determine if there was any unreported bruising that could indicate that a patient was forcibly restrained in denial of their right to refuse. It was determined that one out of thirty-seven patients has a bruise that was not previously address. The bruise in on the forearm of a patient who is able to move on his own. An investigation as to the etiology of the bruise and a 24-hour report injury of unknown origin was initiated by the Director of Nursing on [DATE]. On [DATE], the nurse managers also interviewed all interviewable patients to see if staff/vendors had not honored their right to refuse care/treatments. Forty-six residents were interviewed and no resident reported that either of these circumstances had occurred. On [DATE] Director of Nursing and nurse management initiated education to staff at the facility (This includes all RN, LPN, NA, nursing staff, therapy, activities, social services, dietary and housekeeping): A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident ' s individuality. The facility must protect and promote the rights of the resident. A resident has the right to select or refuse specific treatment or nursing care. Treatment refers to medical care, nursing care, and interventions provided to maintain or restore health and well-being, improve functional level, or relieve symptoms. Residents cannot be restrained in any form in order to provide care or treatment. Ex: include- holding a resident ' s arm or hand down to provide care or treatment. Applying any form of physical restraint in order to complete care or treatment. Resident refusals should be reported to the ADON or DON and documented in the medical record. Notify the physician/clinician of refusals. If you see a violation of resident refusal of care/treatment: Immediately STOP the person involved violating the resident ' s right. (staff, vendor, visitors, volunteers). Assure the resident(s) safety. Immediately report the incident to the nurse/ADON/DON/Administrator. Continue to monitor resident(s) as appropriate interventions are initiated to maintain their safety. The nurse is to notify the clinician. This training is ongoing but beginning [DATE] on evening shift no employee will be allowed to work until education has been completed. The Director of Nursing will ensure that this education is completed by all employees. Training was incorporated into the general orientation program and will be discussed during all general orientation programs that is completed for identified staff. Monitoring Procedure to ensure that the identified areas for improvement are effective and change is sustained. As of [DATE] The Director of nursing and /or Administrator will begin monitoring compliance by: interviewing 5 alert and oriented residents weekly in reference to: if staff/vendors had not honored their right to refuse care/treatments. This will be done on weekly basis for 4 weeks then monthly for 3 months by the Support Nurse, Unit Manager, or designee. As of [DATE] the support nurse will monitor compliance by: observing the phlebotomist obtain lab specimens for 5 non- alert and oriented residents weekly to ensure that right to refusal is honored. This will be done on weekly basis for 4 weeks then monthly for 3 months by the Support Nurse, Unit Manager, or designee. Phlebotomist routinely come to the facility to obtain specimens on Monday and Thursday. The Support Nurse will validate that the phlebotomist who arrive to obtain specimens have received the training by comparing their names to those listed on the attestation forms. If a lab company employee who is not on the list arrives at the facility, they will not be allowed to obtain specimens and the lab company leadership will be notified that the education should be completed and that labs need to be obtained by another staff member. Before any new phlebotomists are sent to the facility---Lab Manager has been requested to send their name as well as a signed attestation to DON. As of [DATE] reports will be presented to the weekly Quality Assurance committee by the Administrator or Director of Nursing to ensure corrective action initiated as appropriate. Compliance will be monitored and ongoing auditing program reviewed at the weekly QA Meeting. The weekly QA Meeting is attended by the Administrator, DON, MDS Coordinator, Therapy, HIM, and the Dietary Manager. Immediate Jeopardy was removed on [DATE] at 8:45 AM when the facility demonstrated that staff had been trained to verify a phlebotomist had been educated and trained on residents ' rights and abuse before allowing him/her access to residents.

Based on staff, physician and phlebotomist interviews and record review the facility failed to protect a resident's right to be free from abuse when a contract phlebotomist held a resident's arm down and forced the resident against her will to have blood drawn. The abuse resulted in injuries and mental anguish for 1 of 3 sampled residents for abuse (Resident #3). Immediate Jeopardy began on [DATE] when phlebotomist #1 held the resident's arm with force to obtain Resident #3's blood specimen against her will. Immediate jeopardy was removed on [DATE] when the facility implemented a credible allegation of compliance. The facility remains out of compliance at a lower scope and severity level D (no actual harm with the potential for more than minimal harm that is not immediate jeopardy) to complete employee education and ensure monitoring systems in place are effective. The findings included: Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent Minimum Data Set ((MDS) dated [DATE] specified the resident had clear speech and was usually able to make herself understood and usually able to understand others. The MDS also specified the resident had moderately impaired cognition but did not resist care and took anticoagulant medication daily. In addition, the resident was receiving Hospice Care. A care plan updated [DATE] for risk for toxicity and abnormal bleeding related to anticoagulant therapy. Interventions to prevent adverse reactions from the medication included: - Daily skin inspections report abnormalities to the nurse - Labs as ordered and report abnormal lab results to the physician - Observe for bruising Review of the medical record revealed a physician progress notes [REDACTED].#3 was seen for a routine visit and assessed the resident's [MEDICAL CONDITION] was controlled with [MEDICATION NAME] (anticoagulant medication). The note also specified the dose had been increased due to low INR (International Normalized Ratio) and the next INR check was scheduled for [DATE]. The physician also documented to limit bloodwork with goal of comfort since the resident was on Hospice. Laboratory test results found in the medical record revealed: - On [DATE] the resident's INR was 1.5 (low) and the physician ordered to increase [MEDICATION NAME] and recheck INR on [DATE]. - On [DATE] the resident's INR was 3.0 (high) and physician ordered to decrease [MEDICATION NAME] and recheck INR on [DATE]. - On [DATE] the resident's INR was 4.9 (critical) A progress note dated [DATE] made by Nurse #1 read in part, two lab phlebotomists in resident's room attempting to collect ordered blood work. Resident was lying in bed with eyes closed mumbling. A staff member (housekeeper #1) entered the resident's room to console resident while blood draw completed. Resident then got notably louder and could be heard from the adjoining room. I (Nurse #1) entered resident's room and noted blood on the bed linen. Resident was bleeding from 2 separate sites and the gauze with tape was not intact to resident's arm. A large blood blister was noted forming to the inside of the left forearm. The note specified the Nurse called physician #2 and nurse #2 into the room to help assess the resident. A document titled Initial Allegation Report dated [DATE] indicated an allegation of Resident Abuse had been reported on [DATE] at 9:15 AM. The allegation was that a lab phlebotomist was rough with Resident #3 when trying to obtain labs and the violated the resident's rights by not allowing the resident to refuse the lab draw. This report was faxed to the Complaint Intake and Health Care Personnel Investigations on [DATE] at 11:54 AM. Resident #3 died on [DATE]. A document titled Investigation Report dated [DATE] specified Resident Abuse was investigated for Resident #3 and determined that the resident suffered physical harm/injury and mental anguish from the incident. The injury was a 12-centimeter by 13-centimeter hematoma on the left ante-cube and bruising consistent of fingerprints to the left wrist. The report specified the resident suffered mental anguish in response by guarding her arm throughout the day and cried out, no, no, no when staff entered the room. There was one accused individual (Phlebotomist #1) and two witnesses (Housekeeper #1 and Nurse #1). The facility's investigation substantiated the allegation of abuse. On [DATE] at 10:12 AM Housekeeper #1 was interviewed and described that on [DATE] in the morning she heard Resident #3 from inside her room crying out no, no, NO and sounded agitated. The housekeeper stated she had a good relationship with the resident and was aware phlebotomists had entered the room to draw blood. Housekeeper #1 stated she asked Nurse #1 if she could go in the room. Housekeeper #1 reported that when she entered the room Resident #3 was in bed and she saw phlebotomist (PH) #1 standing on the left side of the bed holding the resident's left arm phlebotomist PH #2 was standing on the right side of the bed holding the resident's right arm and appeared as if they were going to attempt to draw blood at the same time. The Housekeeper added that when she entered the room, PH #2 let go of the resident's arm and stepped away from the bed. She went on to explain that she could see the resident had already been stuck once by PH #1 as evidenced by a needle stick to the left wrist that was bleeding. The Housekeeper described the resident was visibly upset and she went to the resident to console her; and while the housekeeper was consoling the resident, PH #1 made a second attempt to draw blood. The second attempt upset the Resident again which caused the Housekeeper to raise her head from having it rested on the resident's shoulder to see PH #1 holding the resident's left arm with force at the elbow. The Housekeeper described that PH #1 had the resident's left arm trapped between her legs pressed against the bed with a firmer than she needed hold of the arm at the elbow, then lifted the elbow to draw blood from the ante cube, sticking the resident a second time. The resident was fighting PH #1 saying STOP, STOP, STOP! The housekeeper said that she realized PH #1 was too rough and not listening to the resident but the blood draw was over. Housekeeper #1 left the room and notified Nurse #1 of what had occurred. On [DATE] at 11:08 AM Nurse #1 was interviewed and reported on [DATE] she attempted to administer morning medications to Resident #3 but the resident had refused, shaking her head no, no and had the covers pulled over her head. The Nurse added that the resident had been up most of the night and wanted to rest that morning. The Nurse described that she proceeded to gather medications for another resident and just as she was about to enter another resident's room, Housekeeper #1 asked if she could console Resident #3 while she got her blood drawn. Nurse #1 stated she told Housekeeper #1 that would be fine and continued into the adjoined room. She stated she was able to hear slight moaning coming from Resident #3's room but added that as she exited the room she was in, she could hear that Resident #3 was agitated and got the sense something had escalated. Nurse #1 reported she was met by Housekeeper #1 who asked the nurse to look at Resident #3's left arm. The nurse explained that when she entered the room the resident was in bed shaking her head, no, no and the phlebotomists had finished the blood draw and left the room but the resident was bleeding. Nurse #1 reported she called for Nurse #2 and physician #2 to assess the Resident's arm. On [DATE] at 11:36 AM Nurse #2 was interviewed and reported that on [DATE] Nurse #1 stated to her, I need you! Nurse #2 described going into Resident #3's room and observed the resident cradling her left arm, her eyes were closed and she was shaking her head saying no, no, no. In the same interview the nurse reported she calmed the resident down to assess the left arm. Nurse #2 measured a 12 centimeter by 13-centimeter hematoma that covered the resident's left forearm below the ante cube. Nurse #2 also stated that there was the appearance of fresh fingerprints marks on the resident's left wrist. Nurse #2 explained that she called PH #1 into the room to ask her how the resident sustained [REDACTED].#1 became belligerent and defensive stating you ain't going to blame this on me. Nurse #2 added the PH reported that she had to get the blood sample but the resident was being resistant and refusing to let the PH draw her blood so she had to hold the resident's arm down. Nurse #2 stated she informed the phlebotomist that Resident #3 had the right to refuse the blood draw and the phlebotomist denied knowing that a resident had the right to refuse a treatment. On [DATE] at 2:33 PM the Director of Nursing (DON) was interviewed on the telephone and explained that on [DATE] she was in a meeting when she made aware of an incident regarding Resident #3 and phlebotomist #1. She stated she instructed staff to have phlebotomist #1 wait in the front of building to meet with her. The DON reported when she spoke with PH #1, the phlebotomist stated she didn't know it was wrong to hold down a resident's arm or that a resident could refuse to have their blood drawn. The DON added she was shocked by the answer and asked the phlebotomists to leave the building. The DON added she proceeded by filing an abuse allegation and notified the lab company that their services were being suspended pending an abuse investigation. The DON explained she conducted a thorough investigation that became apparent the phlebotomist had forced the resident to have a blood draw and was too rough based on the extent of the injuries sustained. The DON concluded Resident #3 had been physically abused and substantiated the allegation stating, Resident #3 was absolutely abused by the phlebotomist, there was no doubt. On [DATE] at 4:00 PM Phlebotomist (PH) #2 was interviewed on the telephone and explained that it was her first time trying to collect Resident #3's blood on [DATE]. She described that she entered the room, startled Resident #3 who began shaking her head no. The phlebotomist stated she told Resident #3 she wasn't there to get her out of bed just to draw her blood. She stated she realized she was going to need help with the resident and called for phlebotomist #1 to come into the room. She went on to describe that for the most part the resident was okay until PH #1 stuck the needle in and then she (Resident #3) started to get real cranky. PH #2 was asked to define cranky and she stated Resident #3 started pulling her arm away, moaning, yelling and fighting us and PH #1 had to pull the needle out of the resident's wrist because of the risk for injury. Then she went on to describe that Housekeeper #1 entered the room and attended to Resident #3 and calmed the resident down slightly by resting her head on the resident's head and singing in her ear. PH #2 explained that during this time, a second attempt was made to draw blood which upset the resident again and PH #1 had to grab the resident's arm to hold the arm still because the needle was in the arm. On [DATE] at 1:10 PM Phlebotomist (PH) #1 was able to be reached for a telephone interview and described having been a phlebotomist for a long time and had drawn Resident #3's blood before. The PH described Resident #3 as being a little difficult at times and understood why phlebotomist #2 asked for help because the resident had her good days and not good days. She went on to describe that as she entered the room Resident #3 was whining and moaning a lot and did not want to be bothered. The PH reported that she told the resident she needed to draw her blood. The phlebotomist proceeded to draw the blood and reported that things were going fine until the resident became anxious and started fighting the needle so she held the resident's arm because the resident was trying to jerk the needle out. The PH acknowledged Housekeeper #1 came in the room and calmed the resident but denied that she stuck the resident twice in the arm. The PH offered no explanation why the resident was bleeding from two separate sticks on her left arm. The PH added that it was very important that she got Resident #3's blood sample because later she found out the INR was critical. On [DATE] at 4:10 PM the Medical Director (MD) was interviewed on the telephone and stated she had been made aware of an unfortunate incident with Resident #3 which resulted in traumatic bruising. The MD described that she assessed the resident on [DATE] later in the day and noted the bruising was consistent with a traumatic event and noted the bruising to be deep, deep, purple. On [DATE] at 4:25 PM physician #2 was interviewed on the telephone and described being called into Resident #3's room after the incident and seeing a huge traumatic bruise caused by the blood draw. On [DATE] at 10:10 AM the Administrator was notified of Immediate Jeopardy. On [DATE] at 5:05 PM the facility provided an acceptable credible allegation of compliance that included: Plan for correcting specific area of concern identified, include the process that led to the concern: · On [DATE] a housekeeper witnessed phlebotomist (PH) #1 use unnecessary force to obtain a blood specimen from Resident #3 who was resisting the procedure. A second phlebotomist (PH) #2 was in the room during the incident. Housekeeper #1 immediately reported the incident to the nurse. The DON was notified of the incident. · Resident #3 was assessed by nurse #2 and the physician for injuries. · PH #1 had no further interaction with residents following the incident and was asked about the bruising sustained during the blood draw. · PH #1 stated she was unaware a resident had a right to refuse. Nurse #1 educated the PH on Resident Rights. The PH left the facility. · On [DATE] the facility filed a 24-hour abuse allegation and notified the lab company of the incident. · On [DATE] the facility temporarily suspended the lab company from entering the facility pending an investigation. · Facility staff assumed, trained on resident rights and abuse, were allowed to perform blood draws on residents with orders for laboratory testing. · On [DATE] a meeting was held with the lab company to notify them of the temporary suspension of services until the following terms were met: · Full Names of both Phlebotomists involved in the incident. We have to provide this to the Health Care Personnel Registry. (Name, Full Social Security, DOB, Job Title, Date of Hire, Last known mailing address, Phone number) · Statements from both Phlebotomists as to what occurred. · A copy of the training the lab company will provide for all their staff members who will be at any of our facilities with first priority being the facility. This training should include Abuse prevention, what an employee should do when a resident refuses to get services done, what to do with a combative resident, how and when to report incidents to the facility receiving the service. · Please note-the two accused Phlebotomists cannot return to the facility and any other company facility going forward to provide any services. You will have to send any other phlebotomists to the facility, who have received the above training after our review of the education/ training you provide us. · The facility will need documentation from the lab company indicating when this education was done and also completed. This will be included in our investigation report which we will send to the Health care Personnel Registry. Representatives from the lab company met with the Director of Nursing and Administrator on [DATE] to discuss the event. The housekeeper and nurse was interviewed by the representatives. It was determined that the root cause was lack of knowledge. This is due to the fact that the phlebotomist reported to the nurse that she did not know that the patient had the right to refuse treatment and she did not recognize that the resident pushing her hand away was a refusal. Procedure for implementing an acceptable Quality Improvement Plan. Systematic Changes and Education provided: The lab company was contacted and notified on [DATE] by the Quality Assurance Nurse Consultant and informed that: Phlebotomist #1 and Phlebotomist #2 will not be allowed to return to the facility to provide any services moving forward. Phlebotomist # 1 and Phlebotomist # 2 have not been allowed to provide any direct patient care services since [DATE]. On [DATE] the facility determined that all services provided by the lab company would be suspended pending investigation. The lab company provided education to phlebotomists regarding resident rights and abuse. The lab company provided the facility with a copy of the education provided: This training included: Phlebotomy Continuing Education As defined by the Centers for Medicare and Medicaid Services: Abuse. Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. 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. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Restraint. As described under Definitions, a physical restraint is any manual method, physical or mechanical device/equipment or material that limits a resident ' s freedom of movement and cannot be removed by the resident in the same manner as it was applied by staff. For example: Holding down a resident in response to a behavioral symptom or during the provision of care if the resident is resistive or refusing the care; As defined above by the Centers for Medicare and Medicaid Services any act of restraint is considered abuse of a patients ' rights. Procedure 1. Patient refuses to have venipuncture started by any means including a verbal indication or a physical behavior. 2. Phlebotomist will not proceed with the procedure and will locate a nurse at that time. 3. The patient consents to the venipuncture and if at any time during the venipuncture the patient refuses to continue by verbally requesting the needle be removed or becoming combative the phlebotomist will immediately stop the procedure, bandage the site, safely dispose of the venipuncture device and locate a nurse. 4. Once the nurse is notified the phlebotomist may return to the room with the nurse. If the patient consents to the nurse ' s request for the phlebotomist to perform the venipuncture, then the phlebotomist may only continue with the nurse present in the room. 5. If the patient still refuses the phlebotomist will document the refusal in the lab company Phlebotomy log at the facility. The refusal along with the nurse ' s name who assisted will be documented. The facility will follow their Standard Operating Procedure to inform the patient ' s physician. At no time will a phlebotomist restrain a patient by any manual or physical method in order to obtain blood. At any time a patient appears agitated or combative a nurse will be informed and it will be their decision as to whether to try to continue with the procedure. The phlebotomist will document all decisions in the lab company phlebotomy manual along with informing their phlebotomy manager. The phlebotomy manager will then follow up with the facilities unit manager or DON about the incident to ensure that all policies and procedures of both the lab company and the facility have been appropriately followed. The lab company operates on the belief that the best standards of care can only be maintained with consistent, complete and accurate communicate between themselves and the facilities they serve. Phlebotomy contractors, phlebotomy managers and laboratory staff will immediately inform the facility of any matter that could be considered an incident. All incidents are documented in the lab company Phlebotomy Manual and will include documenting the incident itself and who it was reported to. All incidents will be reported to the phlebotomy manager for follow up with facility supervisors. The lab company provided signed attestations on [DATE] of receiving resident rights and resident abuse education. The lab company phlebotomists were allowed to resume services to the facility on [DATE]. On [DATE] Director of Nursing and Nurse Manager interviewed all alert and oriented residents and asked if they had felt abused by staff, residents, or anyone else in the facility. No new allegations were reported. On [DATE]-there were no incidents reported of new bruising, skin tears, abuse or neglect on any of the facility residents. No new skin issues such as bruising were found during weekly skin checks. [DATE]-during daily clinical there were no staff reports or notes of any concerns of abuse or neglect of any of the facility Residents. Daily clinical meeting is a part of the facility ' s quality assurance program and is held daily Monday thru Friday. It is attended by the director of nursing, assistant director of nursing, and the MDS nurse. During the meeting the electronic health record is reviewed. This review would have included incident reports, progress notes, new orders, and newly completed abnormal skin assessments. This information would have assisted the nurse managers identify any new bruises or skin tears that could have indicated that an abuse or neglect investigation should be initiated. On [DATE], the nurse managers completed skin checks on all non interviewable residents to determine if there was any unreported bruising that could indicate that a patient was forcibly restrained or abused. It was determined that one out of thirty-seven patients has a bruise that was not previously address. The bruise in on the forearm of a patient who is able to move on his own. An investigation as to the etiology of the bruise and a 24-hour report injury of unknown origin was initiated by the Director of Nursing on [DATE]. On [DATE] Director of Nursing initiated education to staff at the facility in reference to abuse, resident rights, and also what to do in the event of a resident refusing care such as lab services or blood work. Education was completed for all staff on [DATE]. This training was incorporated into the general orientation program and will be discussed during all general orientation programs that is completed for identified staff. Monitoring Procedure to ensure that the identified areas for improvement are effective and change is sustained. As of [DATE] the Director of Nursing and /or Administrator will monitor compliance by: interviewing 5 alert and oriented residents weekly in reference to: Have they felt abused by staff, residents, or anyone else in the facility, and if yes did they report it to staff. This will be done on weekly basis for 4 weeks then monthly for 3 months by the Support Nurse, Unit Manager, or designee. As of [DATE] the support nurse will monitor compliance by: observing the phlebotomist obtain lab specimens for 5 non- alert and oriented residents weekly to ensure that residents are not abused. This will be done on weekly basis for 4 weeks then monthly for 3 months by the Support Nurse, Unit Manager, or designee. Phlebotomist routinely come to the facility to obtain specimens on Monday and Thursday. As of [DATE] the Support Nurse will validate that the phlebotomist who arrive to obtain specimens have received the training by comparing their names to those listed on the attestation forms. If the lab company employee who is not on the list arrives at the facility, they will not be allowed to obtain specimens and the lab company leadership will be notified that the education should be completed and that labs need to be obtained by another staff member. Before any new phlebotomists are sent to the facility---Lab Manager has been requested to send their name as well as a signed attestation to the DON. As of [DATE] reports will be presented to the weekly QA committee by the Administrator or Director of Nursing to ensure corrective action initiated as appropriate. Compliance will be monitored and ongoing auditing program reviewed at the weekly QA Meeting. The weekly QA Meeting is attended by the Administrator, DON, MDS Coordinator, Therapy, HIM, and the Dietary Manager. Immediate Jeopardy was removed on [DATE] at 8:45 AM when the facility demonstrated that staff had been trained to verify a phlebotomist had been educated and trained on residents ' rights and abuse before allowing him/her access to residents.

Based on staff, physician and phlebotomist interviews and record review the facility failed to follow policy and procedure for Abuse Prohibition for protecting a resident after an assault for 1 of 3 sampled residents (Resident #3). A contract phlebotomist forced a resident against her will to have blood drawn that resulted in injuries and mental anguish and local law enforcement was not notified. Immediate Jeopardy began on [DATE] when phlebotomist #1 used force to obtain Resident #3's blood specimen against her will and did not contact local law enforcement. Immediate jeopardy was removed on [DATE] when the facility implemented a credible allegation of compliance. The facility remains out of compliance at a lower scope and severity level D (no actual harm with the potential for more than minimal harm that is not immediate jeopardy) to complete employee education and ensure monitoring systems in place are effective. The findings included: A policy titled Abuse Prohibition revised ,[DATE] read in part, The facility will develop and implement a system for identifying, investigating, preventing and reporting any incident or suspected incident of abuse as defined above. A policy titled Reporting Suspected Crimes under the Federal Elder Justice Act dated [DATE] read in part, It is our policy to comply with the Elder Justice Act about reporting suspicion of a crime under Section 1150B of the Social Security Act, as established by the Patient Protection and Affordable Care Act. Specifically, it is our policy to: - Report a suspected crime against a resident to the Social Security Act and one or more local law enforcement entities for the political subdivision in which the facility is located. Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent Minimum Data Set ((MDS) dated [DATE] specified the resident had clear speech and was usually able to make herself understood and usually able to understand others. The MDS also specified the resident had moderately impaired cognition but did not resist care and took anticoagulant medication daily. In addition, the resident was receiving Hospice Care. A document titled Initial Allegation Report dated [DATE] indicated an allegation of Resident Abuse had been reported on [DATE] at 9:15 AM. A witness alleged that a lab phlebotomist was rough with Resident #3 when trying to obtain labs and the violated the resident ' s rights by not allowing the resident to refuse the lab draw. This report was faxed to the Complaint Intake and Health Care Personnel Investigations on [DATE] at 11:54 AM. Resident #3 died on [DATE]. A document titled Investigation Report dated [DATE] specified Resident Abuse was investigated for Resident #3 and determined that the resident suffered physical harm/injury. The injury was a 12-centimeter by 13-centimeter hematoma on the left ante-cube and bruising consistent of fingerprints to the left wrist. The report specified the resident suffered mental anguish in response by guarding arm throughout the day and cry out, no, no, no when staff entered the room. There was one accused individual (Phlebotomist #1) and two witnesses (Housekeeper #1 and Nurse #1). The facility's investigation substantiated the allegation of abuse. Further review of the Investigation Report section titled Law Enforcement revealed there was no documentation local law enforcement had been contacted. The section on the document was left blank. On [DATE] at 10:12 AM Housekeeper #1 was interviewed and described that on [DATE] in the morning she heard Resident #3 from inside her room crying out no, no, NO and sounded agitated. The housekeeper stated she had a good relationship with the resident and was aware phlebotomists had entered the room to draw blood. Housekeeper #1 stated she asked Nurse #1 if she could go in the room. Housekeeper #1 reported that when she entered the room Resident #3 was in bed and she saw phlebotomist (PH) #1 standing on the left side of the bed holding the resident's left arm phlebotomist PH #2 was standing on the right side of the bed holding the resident's right arm and appeared as if they were going to attempt to draw blood at the same time. The Housekeeper added that when she entered the room, PH #2 let go of the resident's arm and stepped away from the bed. She went on to explain that she could see the resident had already been stuck once by PH #1 as evidenced by a needle stick to the left wrist that was bleeding. The Housekeeper described the resident was visibly upset and she went to the resident to console her; and while the housekeeper was consoling the resident, PH #1 made a second attempt to draw blood. The second attempt made the resident became upset again which caused the Housekeeper to raise her head from having it rested on the resident's shoulder to see PH #1 holding the resident's left arm with force at the elbow. The Housekeeper described that PH #1 had the resident's left arm trapped between her legs pressed against the bed with a firmer than she needed hold of the arm at the elbow, then lifted the elbow to draw blood from the ante cube, sticking the resident a second time. The resident was fighting PH #1 saying STOP, STOP, STOP! The housekeeper said that she realized PH #1 was too rough and not listening to the resident but the blood draw was over. Housekeeper #1 left the room and notified Nurse #1 of what had occurred. On [DATE] at 1:10 PM Phlebotomist (PH) #1 was able to be reached for a telephone interview and described having been a phlebotomist for a long time and had drawn Resident #3's blood before. The PH described Resident #3 as being a little difficult at times and understood why phlebotomist #2 asked for help because the resident had her good days and not good days. She went on to describe that as she entered the room Resident #3 was whining and moaning a lot and did not want to be bothered. The PH reported that she told the resident she needed to draw her blood. The phlebotomist proceeded to draw the blood and reported that things were going fine until the resident became anxious and started fighting the needle so she held the resident's arm because the resident was trying to jerk the needle out. The PH acknowledged Housekeeper #1 came in the room and calmed the resident but denied that she stuck the resident twice in the arm. The PH offered no explanation why the resident was bleeding from two separate sticks on her left arm. The PH added that it was very important that she got Resident #3 ' s blood sample because later she found out the INR was critical. On [DATE] at 8:25 AM the Director of Nursing (DON) was interviewed and explained that the incident on [DATE] was reported and investigated as abuse. The DON added through her investigation, she concluded abuse had occurred and substantiated the allegation. However, she did not contact local law enforcement after the incident had occurred because she didn't believe phlebotomist #1 intended to harm Resident #3. On [DATE] at 8:40 AM the Administrator was interviewed and agreed with the decision to not contact local law enforcement because they did not believe phlebotomist #1 intended to harm Resident #3. On [DATE] at 8:41 AM the Administrator was notified of Immediate Jeopardy. On [DATE] at 5:05 PM the facility provided an acceptable credible allegation of compliance that included: Plan for correcting specific area of concern identified, include the process that led to the concern: · On [DATE] a housekeeper witnessed phlebotomist (PH) #1 use unnecessary force to obtain a blood specimen from Resident #3 who was resisting the procedure. A second phlebotomist (PH) #2 was in the room during the incident. Housekeeper #1 immediately reported the incident to the nurse. The DON was notified of the incident. · Resident #3 was assessed by nurse #2 and the physician for injuries. · PH #1 had no further interaction with residents following the incident and was asked about the bruising sustained during the blood draw. · PH #1 stated she was unaware a resident had a right to refuse. Nurse #1 educated the PH on Resident Rights. The PH left the facility. · On [DATE] the facility filed a 24-hour abuse allegation and notified the lab company of the incident. · On [DATE] the facility temporarily suspended the lab company from entering the facility pending an investigation. · Facility staff assumed, trained on resident rights and abuse, were allowed to perform blood draws on residents with orders for laboratory testing. · On [DATE] a meeting was held with the lab company to notify them of the temporary suspension of services until the following terms were met: · Full Names of both Phlebotomists involved in the incident. We have to provide this to the Health Care Personnel Registry. (Name, Full Social Security, DOB, Job Title, Date of Hire, Last known mailing address, Phone number) · Statements from both Phlebotomists as to what occurred. · A copy of the training the lab company will provide for all their staff members who will be at any of our facilities with first priority being the facility. This training should include Abuse prevention, what an employee should do when a resident refuses to get services done, what to do with a combative resident, how and when to report incidents to the facility receiving the service. · Please note-the two accused Phlebotomists cannot return to the facility and any other company facilities going forward to provide any services. You will have to send any other phlebotomists to the facility, who have received the above training after our review of the education/ training you provide us. · The facility will need documentation from the lab company indicating when this education was done and also completed. This will be included in our investigation report which we will send to the Health Care Personnel Registry. Representatives from the lab company Lab met with the Director of Nursing and Administrator on [DATE] to discuss the event. The housekeeper and nurse was interviewed by the representatives. 24-hour report was sent to the Health Care Registry Personnel for each Phlebotomist on [DATE]. The allegation of abuse was substantiated. The police were not called on [DATE]. The root cause of the police not being called was that staff did not think that the actions of the phlebotomist was a crime. On [DATE], the administrator contacted the police regarding the events that occurred on [DATE]. Procedure for implementing an acceptable Quality Improvement Plan. Systematic Changes and Education provided: On [DATE], the nurse managers completed skin checks on all non interviewable residents to determine if there was any unreported bruising that could indicate that a patient was forcibly restrained or abused that would require the notification of the police. It was determined that one out of thirty-seven patients has a bruise that was not previously address. The bruise in on the forearm of a patient who is able to move on his own. An investigation as to the etiology of the bruise and a 24-hour report injury of unknown origin was initiated by the Director of Nursing on [DATE]. On [DATE], the nurse managers also interviewed all interviewable patients to see if they had been the victim of an event that should be reported to the police such as being forcibly restrained by staff/vendors or if staff/vendors had been forced to receive care or treatments that they were refusing. Forty-six residents were interviewed and no resident reported that either of these circumstances had occurred. On [DATE], the Vice President of Clinical Serviced educated the administrator and director of nursing on the elder justice act policy. It is our policy to comply with the Elder Justice Act (EJA) about reporting a reasonable suspicion of a crime under Section 1150B of the Social Security Act, as established by the Patient Protection and Affordable Care Act (ACA), § 6703(b)(3). Specifically, it is our policy to report a suspected crime against a resident to the SSA and one or more local law enforcement entities for the political subdivision in which the facility is located. 1. When staff (staff herein refers to covered individuals) suspect a crime has occurred against a resident at the facility, they must report the incident to SSA and local law enforcement. 2. Staff must report a suspicion of a crime to the state survey agency and at least one local law enforcement entity within a designated time frame by e-mail, fax or telephone. The individual does not need to determine which local law enforcement entity to report a suspicion of crime; but, must report to at least one local law enforcement entity. This will meet the individual ' s obligation to report. 3. If the reportable event results in serious bodily injury, the staff member shall report the suspicion immediately, but not later than 2 hours after forming the suspicion. 4. If the reportable event does not result in serious bodily injury, the staff member shall report the suspicion not later than 24 hours after forming the suspicion. 5. Failure to report in the required time frames may result in disciplinary action, including up to termination. 6. Any event where there is an allegation of abuse or if a patient is forced to receive treatments that they were refusing should be reviewed to determine if there is a reasonable suspicion of a crime that should be reported to the police. Monitoring Procedure to ensure that the identified areas for improvement are effective and change is sustained. As of [DATE] the Director of nursing and /or Administrator will monitor compliance by: interviewing 5 alert and oriented residents weekly in reference to: If they had an event that could be considered a crime such as forcibly being restrained by staff/vendors or if staff/vendors have forced them to receive care that they were trying to refuse. This will be done on weekly basis for 4 weeks then monthly for 3 months by the Support Nurse, Unit Manager, or designee. As of [DATE] the Director of nursing and /or nurse managers will monitor compliance by: assessing 5 non interviewable residents weekly to identify if they have bruises of unknown origin that could indicate that abuse or a crime has been committed. This will be done on weekly basis for 4 weeks then monthly for 3 months by the Support Nurse, Unit Manager, or designee. As of [DATE] reports will be presented to the weekly QA committee by the Administrator or Director of Nursing to ensure corrective action initiated as appropriate. Compliance will be monitored and ongoing auditing program reviewed at the weekly QA Meeting. The weekly QA Meeting is attended by the Administrator, DON, MDS Coordinator, Therapy, HIM, and the Dietary Manager. Immediate Jeopardy was removed on [DATE] at 8:45 AM when the facility demonstrated that staff had been trained on suspicion of crime and reporting to local law enforcement.

Based on staff, family and physician interviews and record review the facility failed to follow manufacturer's recommendations for using a mechanical lift when transferring a resident from a wheelchair to a commode. The resident was in a standing position, not secured in the lift and fell striking the back of her head on the commode and sustained a brain bleed for 1 of 4 sampled residents (Resident #6). Immediate Jeopardy began on [DATE] when nurse aide #1 failed to use a mechanical lift according to manufacturer's recommendations. A resident fell , struck the back of her head on a commode and suffered a brain bleed. Immediate Jeopardy was removed on [DATE] when the facility implemented a credible allegation of compliance. The facility remains out of compliance at a lower scope and severity level D (no actual harm with the potential for more than minimal harm that is not immediate jeopardy) to complete employee education and ensure monitoring systems in place are effective. The findings included: Manufacturer's recommendations for a Sit-to-Stand lift (a mechanical lift used to assist residents with transfers) specified the following: - Fit the sling to the resident ensure chest strap is fastened securely and resident's arms are outside the sling. - Using the handset raise the resident to a standing position. - Close legs and transport resident to bed, toilet or chair. - Position the resident in front of the bed, toilet or chair with the back of their legs gently touching the chair and lower to a sitting position. - Release the tension on the sling and remove the sling from the Sit-to-Stand. - Remove the sling from around the resident. Resident #6 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. A document titled Nursing Referral for Rehab Screening dated [DATE] specified the resident needed extensive assistance to stand and required the sit-to-stand lift (a mechanical lift) for transfers. The document was signed by the physician on [DATE]. The most recent Minimum Data Set ((MDS) dated [DATE] specified the resident's cognition was moderately impaired, the resident required extensive two-person assistance with transfers, was always incontinent, had two or more falls since the prior assessment and took an anticoagulant medication daily. Review of the Medication Administration Record [REDACTED] - Aspirin 81 milligrams daily for stroke prevention - Eliquis 5 milligrams twice daily for stroke prevention The resident's Kardex (instructions for staff specific to each resident) specified the Resident #6 required 2 staff for the sit-to-stand lift. Further review of the medical record revealed on [DATE] the resident was sent by the physician to the Emergency Department for evaluation of a head injury from a fall. An incident report dated [DATE] made by Nurse #3 specified Resident #6 had fallen in the floor of the bathroom after being assisted by one nurse aide that used the sit-to-stand lift. The nurse assessed Resident #6 and documented the resident had slurred speech, inability to have small conversation. The resident had an injury to the back of her head. The nurse noted that family was present in the room after the fall and physician #3 was called in the room. Physician #3 documented on [DATE] that Resident #6 was being seen after a fall and had slurred speech. The physician documented that according to nursing staff, the resident fell out of a lift, hit the back of her head against the toilet and was initially confused. The progress note specified the resident had a head injury status [REDACTED]. On [DATE] Resident #6 underwent a computerized tomography (CT) scan that revealed a hematoma of the right frontal lobe (blood in the brain) which measured 3.2 centimeters by 2.8 centimeters. The resident was admitted to the hospital and the resident's anticoagulant medications were discontinued because of the brain bleed. The resident was transferred to a trauma center and after arrival had two tonic [MEDICAL CONDITION] and was treated with [MEDICATION NAME] (antianxiety) and intramuscular [MEDICATION NAME] (anti-[MEDICAL CONDITION]) medications. According to the hospital reports, no further [MEDICAL CONDITION] activity was noted. Resident #6's care plan for falls was updated on [DATE] that specified staff re-educated on use of lift and required 2 two-person assistance with all lift transfers. A document titled Investigation Report dated [DATE] specified the facility substantiated neglect for nurse aide (NA) #1's failure to follow safety precautions when transferring Resident #6. The report also specified the actions of NA #1 resulted in harm to the resident and the NA was terminated. The report was completed by the Director of Nursing (DON) who documented that the NA failed to use two people to operate the lift when transferring Resident #6, failed to use the legs straps and then released the waist strap before sitting the resident on the toilet. The resident fell from a standing position and hit the back of her head on the toilet. According to hospital records, on [DATE] Resident #6 was discharged to another skilled nursing facility. Additional hospital paperwork dated [DATE] revealed the resident was found unresponsive and sent to the Emergency Department for evaluation. Resident #6 was diagnosed with [REDACTED]. The resident remained in rapid [MEDICAL CONDITION]. The family was notified of poor prognosis and decided to place resident on comfort care. Resident #6 was discharged from the hospital on [DATE] and died on [DATE]. On [DATE] at 10:31 AM nurse aide (NA) #1 was interviewed on the telephone and explained she no longer worked at the facility. She reported that on [DATE] she was assigned Resident #6 and was asked by the family to help the resident go to the bathroom. The NA described that she was familiar with the resident and knew she was transferred with a sit-to-stand lift but sometimes she transferred the resident by picking her up underneath her armpits. The NA went on to state, she was trained to have two staff to use the sit-to-stand lift but felt she didn't always need two people because several of the nurse aides only used one person, including herself. So, she decided to transfer the resident without the assistance of another staff member. NA #1 stated that on [DATE] she proceeded to use a sit-to-stand lift by securing the waist strap around the resident and rolled the resident into the narrow bathroom and had her in front of the toilet. The NA reported that before seating the resident on the toilet, she removed the waist strap, assuming the resident would be able to bear her own weight but instead, the resident fell backwards and hit her head on the toilet. On [DATE] at 10:50 AM a family member of Resident #6 was interviewed on the telephone and described that on [DATE] in the afternoon she was visiting her mother. During the visit, she requested for a nurse aide to assist Resident #6 with incontinence care. The family member explained that she left the room while the resident received care and within minutes of leaving the room, heard a call for help and learned Resident #6 had fallen. On [DATE] at 11:16 AM the Maintenance Director was interviewed and stated that he trained all new employees how to safely use mechanical lifts per manufacturer's recommendations. He explained that the facility's policy was to have two staff to assist with all lift transfers. On [DATE] at 11:20 AM the Director of Nursing (DON) was interviewed and stated Resident #6's family member was in her office when the fall occurred. The DON stated that she had instructed the ADON and Maintenance Director to pull the lift and mark it out of order to be inspected. The DON stated she obtained a statement from NA #1 and asked her to reenact the way she transferred Resident #6. The DON stated that in the reenactment the nurse aide demonstrated she used the lift incorrectly by not having two staff present to assist with the transfer, the legs straps were not utilized and the waist strap was released before the resident was seated on the toilet. The DON explained she suspended the nurse aide and started an investigation. She added it did not take long to complete the investigation because the evidence was clear the nurse aide did not safely transfer the resident, the nurse aide was terminated and the DON substantiated neglect. The DON explained that the facility immediately started educating all staff to make sure that an incident of this magnitude never happened again. On [DATE] at 1:02 PM the medical director was interviewed on the telephone and stated she was made aware of the incident with Resident #6 and that she learned a staff member failed to follow safety guidelines for transfers. The MD stated that the biggest problem when using a lift would be risk for injury. The MD explained that Resident #6 was on anticoagulant medication for [MEDICAL CONDITION] and discontinuation of the medications would place the resident at risk for ischemic stroke. On [DATE] at 3:06 PM Nurse #3 was interviewed and stated she was on the hall when the fall occurred and entered Resident #6's room to see the resident in the floor. Nurse #3 explained that NA #1 used the sit-to-stand lift by herself and dropped the resident from the lift. Nurse #3 stated she assessed the resident to have signs and symptoms of a head injury because her speech was slurred and cognitive difficulties following commands. The nurse added she called for physician #3. Physician #3 was unable to be reached for an interview. On [DATE] at 1:15 PM the Administrator was notified of immediate jeopardy. On [DATE] at 4:34 PM the facility provided an acceptable credible allegation of compliance that included: Plan for correcting specific area of concern identified, include the process that led to the concern: (Include RCA) On [DATE] a resident family member of resident NP asked that resident be toileted. CNA-1 brought the sit-to-stand lift (referred to as lift) into the resident ' s room-buckled the waist strap-but failed to buckle the leg straps. Once in the doorway of restroom in resident room - CNA 1 unbuckled the waist strap prior to ensuring resident safely on the toilet. Resident let go of the lift and subsequently fell to the floor hitting head. CNA-1 notified assigned Nurse-1 immediately at 4:36 PM. Nurse then notified family member as well as the Assistant Director of Nursing ADON and Director of Nursing DON at 4:40 PM as well as on site clinician. All times verified by video footage. Orders were received to send resident to ED for evaluation. Resident has not been readmitted to this facility. Root Cause is identified as failure of the CNA to follow facility policies related to transferring a resident with a mechanical lift. The investigation revealed that the NA-1 used the appropriate type of lift for the resident and that the staff responded appropriately to the event. However, the NA-1 admitted that she was working hastily and did not get the necessary assistance -as she had been trained to do-to complete the transfer. In addition-the CNA-1 admitted that again, trained policy was not followed as she did not properly attach the calf strap and unbuckled the waist strap prior to ensuring resident safely on the toilet which resulted in the resident fall. The nurse aide offered no explanation for why she failed to attach the leg strap. She stated she was in a hurry. The nurse aide acknowledged she had been trained to attach them. Procedure for implementing an acceptable Quality Improvement Plan. Systematic Changes and Education provided (education should continue until all relevant employees are trained) All residents who require the use of a mechanical lift have the potential to be affected by this practice. An investigation into the incident was immediately conducted and revealed: · The Maintenance Director immediately removed the lift and pad from floor and put a stop/watch on until investigation could be completed. DON and Maintenance Director inspected the pad for any signs of fraying or tears-none were found. Lift was tested for malfunction-malfunction not found. · The DON, ADON and Maintenance Director then asked the CNA-1 to give a return demonstration of incident after resident was out of building. All went into an empty room and asked for a staff volunteer to act as resident. CNA-1 verbalized and demonstrated steps taken. · CNA-1 states the she did not attach the leg straps-no explanation given. CNA-1 did attach the waist straps and instructed resident to place arms on the lift and to hold onto the handles. CNA-1 then pushed the lift and resident towards the bathroom-once to the door---CNA-1 stated that she knew that she would not be able to get into the bathroom around the lift-so she reached in at that time and unbuckled the waist strap. · CNA-1 states that resident then yelled my back my back, raised her arm from the lift and immediately fell to the ground. DON asked why there was not a 2nd staff member in the room---and CNA-1 stated that she did not see anyone available to assist · DON then re asked the question-CNA-1 then stated that she did not get anyone to assist---because she knew that the daughter had wanted resident to be toileted before she left-so she wanted to make sure it was done-and did not go to get another staff member for assistance. · DON suspended the CNA-1 until investigation could be completed and then assisted the ADON in completing and submitting a 24-hour report. · On [DATE] the DON observed the camera footage. The DON watched for 1 hour prior to incident up to 30 minutes post incident. At approximately 4:25 PM family member is seen interacting with staff. CNA-1 is seen at approximately at 4:31 PM going towards room with lift and at 4:33 PM CNA-1 is seen going into resident room by herself with lift. At that time-multiple staff members are seen including the 400 hall Nurse1 who is walking down the 400 hallways. · DON then requested the ADON to come and watch the footage as well. Both then went back into the office---and discussed camera findings as well as ADON ' s first hand observations as she had responded to the fall herself. · DON reviewed resident ' s chart, including care plan to make sure that appropriate transfer had been attempted. Care plan revealed that resident was a stand-assist lift. · DON interviewed Nurse-1, Nurse-2, Nurse-3, Med Aide-1, NA-2, to ensure that this was the appropriate lift for resident and that she had safely been transferred with this lift prior to incident. · The investigation revealed: that the CNA-1 used the appropriate type of lift for the resident and that the staff responded appropriately to the event. However, the CNA-1 did not get the necessary assistance to complete the transfer. Additionally, the CNA-1 admitted that they did not properly attach the calf strap. On [DATE] an audit of all residents requiring use of a mechanical lift was done to assure that each resident ' s Kardex and care plan accurately reflected use of the appropriate lift. Results revealed that 18 out of 83 residents requiring transfers via a mechanical lift were in compliance. Re-education with return demonstration of appropriate use of mechanical lifts, along with accessing the mechanical lift/sling type via the Kardex prior to the initiation of the transfer was initiated on [DATE], by the DON/ADON/SDC and Maintenance Director. As of [DATE], 90% of the nurses, nursing aides, medication aides and therapists have been observed with 100% demonstrating competency. All remaining staff will not be allowed to work until education and return demonstration is given. Beginning [DATE] all nursing staff including: LPNs, RNs, Nursing Managers, CNAs and Med. Aides were in-serviced on the importance of checking the resident Kardex prior to initiating any transfers in order to ensure that the safest transfer technique is used. All staff were in-serviced on the importance of always having 2 staff members present when utilizing lift. Any in-house nursing staff who did not receive in-service training by [DATE] will not be allowed to work until training is completed. All staff had been called and verbally given the education with the expectation of the attestation being signed on next work date. This information has been integrated into the standard orientation training and in the required in-service refresher courses for all employees and will be reviewed by the Quality Assurance Process to verify that the change has been sustained. During the Weekly QA ([DATE]) ---the REQ (Review to Ensure Quality) and education were reviewed---and although education had been verbalized in the earlier training concerning the 2nd staff member be in place in the bathroom to ensure the safety of the resident-it had not been documented in the written education. A decision was made to initiate additional training to ensure that the training was formalized in writing. Secondary training was initiated on [DATE] and completed on [DATE]. New education was given either in person or verbalized over phone to all staff members. Monitoring Procedure to ensure that the identified areas for improvement are effective and change is sustained. The DON, ADON, SDC, RD and Maintenance Director have reviewed proper lift protocols and checked each staff member as part of their yearly skills check by [DATE]. As of [DATE] 100% of education has been completed. A weekly audit beginning the week of [DATE] will be completed by DON, ADON and Maintenance Director or appointed designee x 2 months and then monthly x 2 months. The audit will include ensuring that staff are checking the Kardex prior to transferring a resident for proper transfer method as well as watching staff during a transfer to ensure that policy and procedures are being followed. A minimum of 3 transfers will be monitored. The DON will present findings to the weekly Quality of Life- QA committee and corrective action initiated as appropriate. The Quality of Life committee consists of the Director of Nursing, Administrator, Staff Development Coordinator, Unit Managers, Dietary Manager, Wound Nurse, Minimal Data Assessments Nurse and Health Information Management and meets weekly. Immediate Jeopardy was removed on [DATE] at 5:00 PM when the facility demonstrated that staff had been trained and educated on the use of mechanical lifts.

Based on staff interviews and record review the facility failed to implement effective interventions to protect a resident from injury, the resident fell 7 times in 11 days. One fall resulted in an Emergency Department visit to repair a facial laceration for 1 of 1 sampled residents (Resident #75). The findings included: Resident #75 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission Minimum Data Set ((MDS) dated [DATE] specified the resident's cognition was intact, he required limited one person assistance with activities of daily living. The MDS also specified the resident was not steady with balance during transitions and walking and needed stabilization with staff assistance; the resident had a history of [REDACTED]. The MDS also specified the resident was occasionally incontinent of bladder and frequently incontinent of bowel. Resident #75 was discharged to a Memory Care Unit before Care Area Assessments could be completed. A care plan dated 05/08/17 for the resident's risk for falls specified interventions that included: - Remind resident to use call light with transfers - Staff to ensure nonskid socks were in place when out of bed - Anticipate needs as much as possible - Activities to minimize potential for falls while providing diversion and distraction - Staff to make more frequent care rounds to offer toileting - Remind resident to use call light with assistance to the bathroom - Ensure personal items were in reach before leaving the room - Continue current interventions The facility provided incident reports for Resident #75 which identified he had fallen 7 times in 11 days. On 05/25/17 at 9:35 AM the Unit Manager was interviewed and described Resident #75 to be very confused, restless, agitated, impulsive and needed constant reminding to sit down; and stated the resident did not know what he was doing because of dementia. The Unit Manager explained that she, the Administrative nurses and Administrator reviewed falls each day Monday through Friday to determine root cause analysis for each fall and implement interventions to prevent injuries from falls and fall reoccurrences. The Unit Manager reviewed Resident #75's 7 falls while in the facility and the interventions implemented after the fall occurred. The Unit Manager used the incident reports and care plan to review the following falls: a. On 04/29/17 at 12:15 PM the resident stood up from his wheelchair and fell in the floor without injury. The interventions implemented was to remind the resident to call for assistance. The Unit Manager stated that due to the resident cognition this intervention was not effective but the facility wanted to try it because the facility preferred to use least restrictive measures. Review of the medical record revealed a nurse's entry made by Nurse #2 that stated the resident fell in his room trying to get up out of his wheelchair without assistance. Nurse #2 was unable to be interviewed. b. On 05/01/17 9:53 AM the resident was found in the floor in the bathroom without injury. The Unit Manager stated the facility implemented non-skid socks when out of bed after this fall. A nurse's entry dated 05/01/17 made by Nurse #1 specified the resident was found in the bathroom floor and had attempted to ambulate unassisted. On 05/25/17 at 8:28 AM Nurse #1 was interviewed and explained Resident #75 was confused and did not ask for assistance because he tried to do things for himself such as walking to the bathroom. She explained that the resident thought that if he could be independent then his family would take him home. The nurse added that Resident #75's cognition was such that you could tell him to call for assistance but 5 minutes later he had forgotten. c. On 05/02/17 at 1:03 PM the resident was found sitting in the floor beside the bathroom without injury. The Unit Manager stated the facility reminded the resident to use call light to ask for assistance to the bathroom and that this was the same intervention as on 04/29/17. No nurse's entry was made in the medical record related to this fall on 05/02/17. The nurse assigned to the resident was Nurse #3. Attempts were made to contact Nurse #3. d. On 05/05/17 at 7:50 PM the resident was found in the floor lying on his back and the floor was wet from a water pitcher that was knocked over by the resident. The resident had a skin tear to his right elbow. The Unit Manager reported that the intervention implemented was to remind staff to keep personal items in reach. A nurse's entry dated 05/05/17 made by Nurse #4 read in part, the resident was found lying on his back and had apparently knocked over his water pitcher. The resident reported that she had slipped on the water. Nurse #4 was unable to be interviewed. e. On 05/08/17 at 11:00 PM the resident was found under the sink in his bathroom bleeding from his head. Orders were obtained and the resident was sent to the Emergency Department and returned to the facility with sutures to his head. The Emergency Department report dated 05/08/17 specified the resident presented with a facial laceration that required sutures. The Unit Manager reported that staff were educated to provide more frequent rounds on the resident. She stated that this information was provided orally to nurse aides assigned to the resident. A nurse's entry made by Nurse #1 dated 05/09/17 at 1:10 AM read in part that on 05/08/17 at 11 PM the resident was found in the floor of the bathroom bleeding after he tried to ambulate to the bathroom. On 05/25/17 at 8:28 AM Nurse #1 was interviewed and explained Resident #75 was confused and did not ask for assistance because he tried to do things for himself such as walking to the bathroom. Nurse #1 reported that she was assigned to the Resident on 05/08/17 on the 3 PM to 11 PM shift when the resident was found in the bathroom floor bleeding. She stated an order was received to send the resident to the Emergency Department. The nurse stated she had suggested using a personal alarm for the resident but was told the facility did not use personal alarms on residents. The nurse added that Resident #75's cognition was such that you could tell him to call for assistance but 5 minutes later he had forgotten. Nurse #1 reported that the facility had adequate staffing to monitor the resident but he almost required a sitter. The nurse was unaware of interventions in place to keep the resident from falling other than constant reminding not to get up unassisted. The nurse reported that interventions for the resident had not changed because the resident was ambulatory and confused and needed constant redirection and monitoring. On 05/25/17 at 11:11 AM nurse aide (NA) #1 was interviewed on the telephone and stated she worked as needed but was assigned to Resident #75 on 05/08/17 from 3 PM to 11 PM. She explained this was the 2nd or 3rd time she had cared for the resident and that she was aware the resident needed assistance to the bathroom and had fallen but was not aware she was to provide more frequent monitoring. The NA reported that on 05/08/17 the resident appeared to be his usual self. The NA stated that she was on lunch break when the resident fell but estimated that she checked on the resident about 30 minutes prior to the fall. f. On 05/09/17 the resident was found in the floor in his room without injury. The Unit Manager stated no new interventions were developed to keep the resident from falling. No nurse's entry was made in the medical record related to this fall on 05/02/17. The nurse assigned to the resident was Nurse #3. Attempts were made to contact Nurse #3. g. On 05/09/17 the resident was in the floor beside his bed without injury. The Unit Manager stated no new interventions were developed to keep the resident from falling. A nurse's entry made by Nurse #5 on 05/09/17 read in part the resident was found in the floor and did not appear injured. Nurse #5 was unable to be interviewed. Resident #75 was discharged on [DATE]. In the same interview, after reviewing Resident #75's falls, the Unit Manager reported the interventions had not been effective. On 05/25/17 at 10:02 AM the MDS Coordinator was interviewed and explained that all residents admitted to the facility at risk for falls received an interim care plan with basic interventions that included: anticipate needs, wear non-skid socks, keep personal items in each and remind to call for assistance. She added that once a resident started falling in the facility, she and the Administrative nursing team would start to drill down and individualize the care plan. On 05/25/17 at 2:08 PM the Director of Nursing (DON) was interviewed and stated that facility had made changes to Resident #75's care plan to address falls. The DON explained the facility tried to utilize the least restrictive safety measures.

Based on record review and resident and staff interviews the facility failed to immediately notify the administrator or Director of Nursing (DON) of an allegation of abuse for 1 of 3 residents sampled for abuse (Resident #237) which resulted in a delay of reporting an allegation of abuse to the North Carolina Health Care Personnel Registry (state agency). Findings included: Resident #237 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the comprehensive admission minimum data set ((MDS) dated [DATE] indicated that Resident #237 was cognitively intact and required one person limited assistance with bed mobility, transfers, toileting, and personal hygiene. The MDS further revealed that Resident #237 required extensive assistance of one staff member with dressing and had no impairment to bilateral upper or lower extremities. A review of the facility's abuse policy dated 07/15 read, in part, It is the responsibility of our employees, facility consultants, attending physicians, family members, visitors, etc. to promptly report any incident or suspected incident of neglect or resident abuse, including injuries of unknown source and theft or misappropriation of resident property, to facility management. Review of a physician order [REDACTED]. Review of a physician order [REDACTED]. Review of a care plan dated 04/18/16 stated that Resident #237 was on an anticoagulant with risk for toxicity and abnormal bleeding. The goal for the care plan problem stated Resident #237 was to be free from discomfort or adverse reactions related to anticoagulant use through the next review date. The intervention included draw labs as ordered and report abnormal labs to the physician. Review of PT laboratory report dated 04/25/16 read that the collection date and time was 04/25/16 at 1:27 AM and was received in the laboratory on 04/25/16 at 9:12 AM. Interview with Resident #237 on 04/25/16 at 2:54 PM revealed that at 4:30 AM on 04/25/16 a laboratory employee came into her room to draw her blood. Resident #237 stated that when the laboratory employee turned on the light it startled her from sleep and she asked the laboratory employee to please turn the light off and the laboratory employee ignored her request so Resident #237 again asked the laboratory employee to please turn the light off and again the laboratory employee ignored her request. Resident #237 stated that then the laboratory employee proceeded to very roughly draw blood from her right antecubital (the region of the arm in front of the elbow) and after applying a cotton ball and piece of tape over the site slapped her antecubital area as if slapping on a Band-Aid. Resident #237 stated she was crying because when the laboratory employee turned on the light it startled her and caused her to have a back spasm and then the behavior and the actions of the laboratory employee added to her stress. Resident #237 stated she was afraid of this laboratory employee and did not want her coming back into her room. Resident #237 stated she had reported the incident to her nurse. Interview with Nurse #3 on 4/26/16 at 4:21 PM revealed that on 04/25/16 at 8:30 AM Resident #237 stated to her that she wanted someone else to draw her blood. Resident #237 stated to Nurse #3 that the laboratory employee that drew her blood that morning was really rough while drawing her blood and then slapped the middle of her arm as if slapping on a Band-Aid. Resident #237 also reported to Nurse #3 that the lab employee had told her to stop crying and that she was fearful of this laboratory employee and did not want her to draw her blood anymore. Nurse #3 stated that she immediately reported the incident to Supervisor #1 and Supervisor #2 as soon as she exited Resident #237's room approximately 5 to 10 minutes later. Interview with Supervisor #1 on 04/26/15 at 4:40 PM revealed that Nurse #3 reported to her and Supervisor #2 at approximately 9:00 AM on 04/25/16 that the laboratory employee that drew Resident #237's blood that morning was really rough and jabbed the needle in her arm and was not gentle. Supervisor #1 stated that Nurse #3 stated that Resident #237 was uncomfortable and did not want the laboratory employee back into her room. Supervisor #1 stated she could not recall if Nurse #3 stated that Resident #237 was fearful of the laboratory employee and could not recall if Nurse #3 stated that the laboratory employee had slapped the arm of Resident #237. Supervisor #1 stated she would have to ask Nurse #3 exactly what she had reported to her. Supervisor #1 stated that she had instructed Supervisor #2 to call the laboratory and tell them to not send that employee back to the facility. Supervisor #1 stated she did not follow up with Supervisor #2 and was not aware of the laboratory employee's name. Supervisor #1 stated that she did not go talk to Resident #237 and did not assess the resident. Supervisor #1 also stated she did not inform the DON of the incident. Interview with Supervisor #2 on 04/26/16 at 4:58 PM revealed that Nurse #3 had reported to her and Supervisor #1 at approximately 9:00 AM on 04/25/16 that Resident #237 did not want the laboratory employee that drew her blood on 04/25/16 back into her room, Resident #237 stated that the laboratory employee was verbally nasty to her and had slapped her in the arm as if slapping a Band-Aid on her arm. Supervisor #2 stated that Nurse #3 reported that Resident #237 was fearful of this laboratory employee. Supervisor #2 stated that she had reported this to the DON and then called the laboratory and told them the employee was no longer welcome in their facility. Supervisor #2 was unaware of the laboratory employee's name. Supervisor #2 stated that she did go and talk to Resident #237 around 5:00 PM that afternoon and apologized for the laboratory employee's behavior. Interview with the DON on 04/26/16 at 5:07 PM revealed she had not previously been made aware of the incident with Resident #237 and the laboratory employee by the facility staff. The DON confirmed that she was not made aware of the incident until the surveyor brought it to her attention. The DON stated that after hearing the information she considered this an allegation of abuse. The DON stated she would have expected Supervisor #1 and/or Supervisor #2 to immediately report this to her so she could have immediately started an investigation, notified the laboratory of the incident and filed a 24 hour working report to the state agency. In a follow up interview the DON on 04/26/16 at 6:03 PM revealed that she had started the investigation, completed and submitted the 24 hour report to the state agency and had attempted to talk to the laboratory supervisor and left multiple message with no return call. The DON was still unaware of the laboratory employee's name that drew Resident #237 blood on 04/25/16. Interview with the Administrator on 04/28/16 at 2:51 PM revealed that she expected Supervisor #1 and Supervisor #2 to immediately report the allegation of abuse to the DON or herself so that the investigation could be started and the 24 hour report filed with the state agency timely.

Based on record review and resident and staff interviews the facility failed to treat a resident with respect and dignity when a laboratory employee spoke and acted in a manner that caused a resident to be fearful and tearful for 1 of 1 residents sampled for respect and dignity (Resident #237). The findings included: Resident #237 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the comprehensive admission minimum data set ((MDS) dated [DATE] indicated that Resident #237 was cognitively intact and required one person limited assistance with bed mobility, transfers, toileting, and personal hygiene. The MDS further revealed that Resident #237 required extensive assistance of one staff member with dressing and had no impairment to bilateral upper or lower extremities. Interview with Resident #237 on 04/25/16 at 2:54 PM revealed that at 4:30 AM a laboratory employee came into her room to draw her blood. Resident #237 stated that when the laboratory employee turned on the light it startled her from sleep and she asked the laboratory employee to please turn the light off and the laboratory employee ignored her request so Resident #237 again asked the laboratory employee to please turn the light off and again the laboratory employee again ignored her request. Resident #237 stated that then the laboratory employee proceeded to very roughly draw blood from her right antecubital and after applying a cotton ball and piece of tape over the site slapped her antecubital area as if slapping on a Band-Aid. Resident #237 stated she was crying because when the laboratory employee turned on the light it startled her and caused her to have a back spasm and then the behavior and the actions of the laboratory employee added to her stress. Resident #237 stated the laboratory employee stated stop crying. Resident #237 further stated she was afraid of this laboratory employee and did not want her coming back into her room. Resident #237 stated she had reported the incident to her nurse. Interview with Nurse #3 on 4/26/16 at 4:21 PM revealed that on 04/25/16 at 8:30 AM Resident #237 stated to her that she wanted someone else to draw her blood. Resident #237 stated to Nurse #3 that the laboratory employee that drew her blood that morning was really rough while drawing her blood and then slapped the middle of her arm as if slapping on a Band-Aid. Resident #237 also reported to Nurse #3 that the lab employee had told her stop crying and that she was fearful of this laboratory employee and did not want her to draw her blood anymore. Nurse #3 stated that Resident #237 was no longer crying when she reported the incident but was visibly shaken up by the event. Nurse #3 stated that she apologized for the behavior of the laboratory employee behavior and reassured her that she would take care of the situation. Nurse #3 stated that she immediately reported the incident to Supervisor #1 and Supervisor #2 as soon as she exited Resident #237's room approximately 5 to 10 minutes later. In a follow up interview with Resident #237 on 04/26/16 at 6:35 PM revealed that the management staff had come and talked to her today about the incident and informed her that the laboratory employee would not be allowed back into the building. Resident #237 stated she breathed a sigh of relief when she heard this information. Resident #237 further stated that she was a nervous wreck every time her door would crack open not knowing if the laboratory employee was coming back into her room. Interview with Supervisor #2 on 04/27/16 at 10:55 AM revealed Nurse #3 had reported at approximately 9:00 AM on 04/25/16 the incident with Resident #237 and the laboratory employee. Supervisor #2 stated she went to Resident #237 and apologized for the laboratory employee's behavior, Supervisor #2 reassured Resident #237 that all employees were expected to be respectful to the residents and not talk harshly to them, this included laboratory employees. Interview with the DON on 04/27/16 at 12:00 PM revealed that she expected all employees including laboratory employees to be respectful to the residents and not speak harshly to them and certainly not make the resident fearful of them. The DON stated she had contacted the laboratory and made them aware of the incident and informed them that the employee is no longer allowed back into the facility. Interview with the Administrator on 04/28/16 at 2:51 PM revealed that she expected all employees including laboratory employees to be respectful to the residents and not speak harshly to them and absolutely not make the resident fearful of them. The administrator confirms this laboratory employee will no longer be allowed back into the facility.

Based on record review and resident and staff interviews the facility failed to honor a resident request to not have her blood drawn at 4:30 AM for 1 of 1 residents sampled for choices (Resident #237) when a laboratory employee did not ask permission or explain the procedure prior to obtaining the blood from the resident. The findings included: Resident #237 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the comprehensive admission minimum data set ((MDS) dated [DATE] indicated that Resident #237 was cognitively intact and required one person limited assistance with bed mobility, transfers, toileting, and personal hygiene. The MDS further revealed that Resident #237 required extensive assistance of one staff member with dressing and had no impairment to bilateral upper or lower extremities. Review of a physician order [REDACTED]. Review of a physician order [REDACTED]. Review of a care plan dated 04/18/16 stated that Resident #237 was on an anticoagulant with risk for toxicity and abnormal bleeding. The goal for the care plan problem stated Resident #237 was to be free from discomfort or adverse reactions related to anticoagulant use through the next review date. The intervention included draw labs as ordered and report abnormal labs to the physician. Review of PT laboratory report dated 04/25/16 read that the collection date and time was 04/25/16 at 1:27 AM and was received in the laboratory on 04/25/16 at 9:12 AM. Review of a physician order [REDACTED]. Review of PT laboratory report dated 04/27/16 read that the collection date and time was 04/27/16 at 5:36 AM and was received in the laboratory on 04/27/16 at 2:03 PM. Interview with Resident #237 on 04/25/16 at 2:54 PM revealed that at 4:30 AM a laboratory employee came into her room to draw her blood. Resident #237 stated that the lab employee never asked her permission to draw her blood, the lab employee did not explain what she was going to do, and the lab employee stated I am going to draw your blood. Resident #237 stated she was not sure why they had to wake her up at 4:30 AM to draw her blood. Resident #237 further stated each time that the laboratory employee had drawn her blood which had been 2 times, it had been during the early morning hours around 4:00 AM to 5:00 PM and she did not like not having a choice in the matter. Resident #237 also stated I get up at 8:00 AM they could just do it then. Interview with the Unit Director on 04/27/16 at 11:20 AM revealed that the laboratory employees are in the building between 4:00 AM and 5:00 AM on Monday's and Thursday's because they travel to different buildings in the area. The Unit Director confirmed that Resident #237 blood had been obtained between 4:00 AM and 5:00 AM on 04/25/16 but did know the exact time. The Unit Director stated that the laboratory employees are usually here and gone by 5:00 AM. The Unit Director further stated that if a blood draw is ordered on days other than Monday's and Thursday's the facility staff is responsible for drawing the blood. Interview with the DON on 04/27/16 at 12:00 PM revealed that she expected all employees including laboratory employees to be respectful to the residents and that the laboratory employee should ask permission and explain the procedure prior to starting the blood draw. Interview with the Administrator on 04/28/16 at 2:51 PM revealed that she expected all employees including laboratory employees to be respectful to the residents and would expect the laboratory employee to ask permission from the resident prior to starting the procedure.

Based on staff interviews and record review the facility failed to position a weak resident with poor upper body strength safely on the side of an air mattress with the bed in high position for 1 of 3 residents that fell (Resident #2). The findings included: Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #2's care plan revised on 01/13/14 specified the resident had a self care deficit with activities of daily living (ADL) and for staff to encourage the resident to participate to the fullest extent possible in her activities of daily living. Resident #2 also had a fall risk care plan dated 01/13/14 with an intervention to keep the environment safe. The Minimum Data Set ((MDS) dated [DATE] specified Resident #2 had no impaired cognition. The MDS also specified the resident was involved in ADL but 2 staff persons had to provide the weight bearing support with bed mobility, transfers, personal hygiene and dressing. Additional MDS information for Resident #2 revealed the resident was not steady and only able to stabilize with staff assistance when completing surface to surface transfers. The MDS also specified Resident #2 had not fallen and was working with Physical and Occupational therapy. Review of Resident #2's therapy notes included a Physical therapy (PT) plan of care and progress note dated 05/13/14 that specified Resident #2 "was very frail and severely debilitated." The PT progress note specified Resident #2's level of function as of 05/13/14. The note revealed Resident #2 was able to stand for 3 minutes at best with maximum assistance, did not have control of her lower extremities to slow descent, and required maximal assistance to maintain position. Further review of Resident #2's medical record revealed a nurses' entry made by Nurse #2 dated 05/19/14 that read, "resident transferred to emergency department for laceration to right knee, shin area. Resident slipped from bed." A physician's orders [REDACTED]. A document titled "Emergency Department Clinical Report" dated 05/19/14 at 10:51 AM specified Resident #2 presented with trauma to her right knee after a fall in the nursing home. The report specified Resident #2 was alert and oriented to person, place, time and location and "was waiting on the edge of her bed to be transferred to a chair and she slid off and landed on her right knee." The report also specified Resident #2 sustained a large horizontal laceration 8 centimeters across the tibia plateu area and required 6 sutures and 25 staples to repair. Resident #2 returned to the facility on [DATE]. On 08/25/14 at 10:30 AM nurse aide (NA) #1 was interviewed and reported she was assisting Resident #2 on 05/19/14 when she fell . NA #1 described Resident #2 as being able to only bear weight on her left leg and having weak upper body strength. NA #1 added that Resident #2 was alert and oriented but it took 2 people to provide assistance. NA #1 stated that Resident #2 was working with physical and occupational therapy and always had 2 therapists in the room for transfers. NA #1 reported that she had been trained by the physical therapy department to transfer the resident using the sit to stand lift (a mechanical lift) using 2 people. During the interview NA #1 described the events of 05/19/14. NA #1 explained that 05/19/14 was the first time she ever gave Resident #2 a bed bath by herself. She added that a therapist or another nurse aide had always been in the room with her but on 05/19/14 she had been very busy and was rushing to complete her assignment and did not ask for assistance. NA #1 demonstrated that Resident #2 was seated on the edge of an air mattress dressed only from the waist up with the bed raised to a height that caused the resident's feet to dangle. NA #1 reported that she walked away from Resident #2 positioned on the edge of the air mattress to call for assistance before using the sit to stand lift to transfer Resident #2. NA #1 stated her back was to the resident when she heard Resident #2 yell that she was slipping. NA #1 was unable to reach the resident before the resident fell to the floor striking her right knee on the floor. NA #1 stated that she yelled for help and Nurse #2 entered the room. On 05/25/14 at 11:10 AM Nurse #2 was interviewed and reported that she was the first to respond to NA #1's call for help on 05/19/14. She stated she entered Resident #2's room and observed the resident sitting on the floor bleeding heavily from her right knee. Nurse #2 stated the resident had a 4-5 inch long laceration just below the right knee cap. Nurse #2 reported that the resident was injured and ordered to be sent to the Emergency Department for evaluation. Nurse #2 added that it was okay for NA #1 to be in the room alone with Resident #2 because she was not transferring the resident. On 08/25/14 at 1:50 PM the Physical Therapist (PT) was interviewed and reported she had worked with Resident #2. The PT described Resident #2 as requiring 2 person assistance with care because the resident was "very weak and had very poor core strength." The PT added that during therapy sessions they always had 2 people in the room and they never allowed the resident to sit on the side of the bed because of her poor strength. The PT reported that Resident #2 was unable to support herself to sit on the side of the bed and did not have the strength to stop herself from sliding off the bed. The PT stated that she assumed staff were aware of the resident' s limitations. The PT explained that she had educated NA #1 how to transfer Resident #2 and added that Resident #2 should have always had 2 persons to provide assistance with care and transfers. On 08/26/14 at 10:00 AM the Director of Nursing (DON) was interviewed and reported that all falls were investigated to determine the root cause for the fall. She stated that she had investigated Resident #2's fall and determined that the resident slid off the bed. She explained that staff were trained to position a resident on the side of the bed by adjusting the height of the bed to maintain a 3-point position (feet flat on the floor, knees bent at 90 degrees and ankles bent to 90 degrees). The DON stated that she assumed Resident #2 was positioned correctly at the time of the fall but did not ask NA #1 how the resident was positioned or the height of the bed. The DON reported that Resident #2's bed should not have been raised to a position that allowed her feet to dangle.

Based on observations, staff interviews and record review the facility failed to implement fall precautions for a resident who fell and broke her wrist and sustained a head injury for one (1) of three (3) sampled Residents (Resident #2). The findings are: Resident #2 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #2's care plan for falls updated on 4/13/12 and on 6/8/12 revealed the resident was at an increased risk for having a fall related injury and specified the resident fell on [DATE], 4/15/12, 4/16/12 and 6/8/12. The care plan's interventions for the resident specified she was to be supervised and monitored closely at all times. The most recent quarterly Minimum Data Set ((MDS) dated [DATE] specified the resident had short and long term memory impairment and moderately impaired cognitive skills for daily decision making. The MDS also specified the resident required extensive assistance with Activities of Daily Living (ADLs), was not steady walking or moving from a seated to standing position, ambulated with assistance and had fallen two or more times with injury. Review of Resident #2's medical record revealed a nurses' entry dated 6/8/12 that specified the resident was sent to the Emergency Department for evaluation after she fell and sustained a laceration to her forehead and complained of right hand pain. The Emergency Department discharge report dated 6/8/12 was reviewed and revealed Resident #2 had a right distal radius fracture and laceration to the face that required sutures. A document titled "Resident Incident Report" dated 6/8/12 was reviewed and specified Resident #2 stood up unassisted from her wheelchair, walked two steps and fell striking her head on a hand rail. On 9/4/12 at 2:30 p.m. Resident #2 was observed in her wheelchair participating in a group activity. After the activity a staff member assisted the resident to the nurses' station. During this observation licensed nurse (LN) #1 was interviewed and stated that Resident #2 was kept at the nurses' station for close supervision and monitoring. She added that the resident would attempt to get up unassisted and was at risk for falls. On 9/4/12 at 3:30 p.m. nurse aide (NA) #1 was interviewed. NA #1 stated that she worked the 3 p.m. to 11 p.m. shift on 6/8/12, but was not assigned to care for Resident #2. NA #1 reported on 6/8/12 at 5:15 p.m. she was half way down the 500 Hall assisting her assigned residents and observed Resident #2 ambulating unassisted near the nurses' station. NA #1 stated Resident #2 fell before she was able to respond to the resident. NA #1 specified there were no other staff members near the nurses' station at the time of the fall. She added Resident #2 was at risk for falls and was to be observed at all times for attempts to stand. On 9/4/12 at 4:00 p.m. licensed nurse (LN) #2 was interviewed. LN #2 reported Resident #2 required close supervision because of her advanced dementia and history of falls. She added that the resident was kept near the nurses' station for close monitoring because it was a highly trafficked area. LN #2 reported that on 6/8/12 at 5:15 p.m. she was administering medications on the 400 Hall while staff were assisting residents to the dining room for the evening meal. LN #2 reported that she heard NA #1 call for help and observed Resident #2 on the floor. She added that the nurse aides assigned to Resident #2 had left the hall to go on break without reporting to her. LN #2 confirmed that Resident #2 was not being closely monitored at the time of the fall because the nurse aides left their assignments without notifying other staff. LN #2 stated that she expected nurse aides to report to her when they needed to leave their assignment, including bathroom breaks. On 9/4/12 at 4:15 p.m. NA #2 was interviewed. NA #2 reported that on 6/8/12 she shared an assignment with NA #3 on the 400 Hall which included ensuring the Resident #2 was properly supervised. NA #2 stated that on 6/8/12 at 5:15 p.m. she left the hall to go to the bathroom without notifying her licensed nurse (LN #2). She added that NA #3 was also on break at this time and that while she was in the bathroom no one had been asked to monitor Resident #2. She reported that while she was in the bathroom Resident #2 fell and sustained an injury. She stated that she was not aware she needed to report to someone when she left the hall to go to the bathroom. On 9/4/12 at 5:00 p.m. the Director of Nursing (DON) was interviewed and stated she would expect the nurse aides to report to the licensed nurse as well as another nurse aide before leaving their assignments to ensure the residents were being monitored. The DON also reported that Resident #2 was very much at risk for falls because of her advanced dementia. She added that Resident #2 had required one on one supervision but currently only needed close supervision that meant she was to be monitored at all times. The DON explained that close supervision meant that the resident was not left unattended for long periods because of her risk for falling. She stated that to monitor the resident, she was kept active by attending group activities and was also kept close to the nurses' station most days. The DON also stated the licensed nurses would at times keep Resident #2 near their medication carts to monitor her attempts to stand unassisted. The DON was aware that the nurse aide assigned to care for Resident #2 on 6/8/12 left the hall without notifying another staff member and would have expected her to notify the licensed nurse and the other nurse aide assigned to the 400 Hall. On 9/7/12 at 8:00 a.m. a telephone interview was conducted with NA #3. During this interview NA #3 stated she was assigned to care for Resident #2 on 6/8/12. She stated that Resident #2 had to be carefully watched because of her fall risk status and frequent attempts to stand unassisted. She stated that "carefully watched" meant that someone was watching the resident at all times. She added that unless the resident was in bed she was not to be left alone. The NA reported that she would place Resident #2 in her wheelchair at the nurses' station so someone at the desk could monitor the resident closely. She stated that she was trained to report to the other nurse aide assigned to the hall and her licensed nurse that she was going on break to ensure that her residents would be monitored. She stated that on 6/8/12 at 5:00 p.m. she left Resident #2 at the nurses' station and left the hall to go on break. She added she could not remember if there were other staff members at the nurses' station when she left the resident. She stated that she thought she notified NA #2 but did not report to LN #2 that she was leaving the hall to go on break. She stated that she left Resident #2 at the nurses' station along with other residents who were being assisted to the dining room for the evening meal and added she assumed another nurse aide would assist Resident #2 to the dining room. NA #3 reported that Resident #2 did not get assisted to the dining room and was left alone at the nurses' station at the time of the fall. NA#3 stated she was gone five (5) minutes when she was notified the resident had fallen.