Every finding on record at Biltmore Haven Nursing and Rehabilitation

Based on record review and staff interviews, the facility failed to accurately code Minimum Data Set (MDS) assessments in the areas of range of motion, dental, Preadmission Screening and Resident Review (PASRR), physical restraints, and active diagnoses for 5 of 36 assessments reviewed for MDS accuracy (Residents #4, #13, #49, #50, and #59).Findings included:a. Resident #4 was admitted to the facility on [DATE]. His cumulative diagnoses included hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction (stroke) affecting the right dominant side and contracture of muscle-left upper arm.An activities of daily living (ADL) care plan initiated on 10/10/18 revealed Resident #4 had a self-care performance deficit related to limited mobility as evidenced by right sided upper and lower extremity weakness, hemiplegia/hemiparesis and bilateral upper extremity contractures. Interventions included a right resting hand splint for 2 hours during the day or as tolerated and side rails: left side mobility aide.A bed rail assessment signed by Resident #4 and dated 06/17/26 revealed Resident #4 utilized a left side rail/assist bar as an enabler to promote independence.The annual MDS assessment dated [DATE] revealed Resident #4 had intact cognition and no impairment of the upper or lower extremities. He was independent with rolling left and right and required supervision or touching assistance with moving from a sitting-to-lying position, lying-to-sitting position, and sit-to-stand position. The MDS indicated Resident #4 used a physical restraint daily and bed rail was marked as the type of restraint utilized.The quarterly MDS assessment dated [DATE] revealed Resident #4 had intact cognition, no impairment of the upper extremity and impairment of both sides of the lower extremities. He was independent with rolling left and right and required supervision or touching assistance with moving from a sitting-to-lying position, lying-to-sitting position, and sit-to-stand position. The MDS indicated Resident #4 used a physical restraint daily and bed rail was marked as the type of restraint utilized.During an interview on 07/30/26 at 1:37 PM, the MDS Coordinator revealed the facility used to have another staff member that assisted with completing MDS assessments; however, the staff member was no longer employed due to the inaccuracy errors discovered in the MDS assessments she completed. The MDS Coordinator explained the side rail used by Resident #4 was an enabler to promote independence and should not have been coded as a physical restraint. The MDS Coordinator also stated Resident #4 had a right hand contracture and the MDS assessments should have reflected he had an impairment of the upper extremity.b. Resident #13 was admitted to the facility on [DATE].A dental progress note dated 01/16/26 revealed Resident #13 was edentulous (missing all natural teeth).The annual MDS assessment dated [DATE] revealed Resident #13 had no dental issues.During an interview on 07/31/26 at 10:25 AM, the Regional MDS Consultant confirmed Resident #13 was edentulous and the MDS assessment dated [DATE] was coded incorrectly.c. Resident #49 was admitted to the facility on [DATE] with diagnoses that included bipolar disorder and anxiety disorder. A PASRR Level II determination notification letter dated 06/17/25 revealed Resident #49 had a Level II PASRR with no expiration date.The annual MDS assessment dated [DATE] revealed Resident #49 was not currently considered by the state Level II PASRR process to have a serious mental illness and/or intellectual disability or a related condition.During an interview on 07/30/26 at 1:37 PM, the MDS Coordinator revealed she completed the PASRR section of the MDS assessment. The MDS Coordinator reviewed Resident #49's Level II PASRR determination notification letter dated 06/17/25 and explained when completing the MDS assessment, she looked at the year wrong thinking the letter was dated 2026 and not 2025. She stated it was an honest mistake and the MDS assessment dated [DATE] should have been coded to reflect Resident #49 had a Level II PASRR.d. Resident #50 was admitted to the facility on [DATE] with diagnoses that included a group of permanent movement and posture disorders that affects muscle control, coordination and balance.A bed rail assessment dated [DATE] revealed Resident #50 utilized bilateral half-side rails as an enabler to promote independence.The quarterly MDS assessment dated [DATE] revealed Resident #50 had severe cognitive impairment and had impairment on both side of the upper and lower extremities. He required substantial/maximal assistance with rolling left-to-right and partial/moderate assistance with moving from a sitting-to-lying position, lying-to-sitting position, and sit-to-stand position. The MDS indicated Resident #50 used a physical restraint daily and bed rail was marked as the type of restraint utilized.During an interview on 07/30/26 at 1:37 PM, the MDS Coordinator revealed the facility used to have another staff member that assisted with completing MDS assessments; however, the staff member was no longer employed due to the inaccuracy errors discovered in the MDS assessments she completed. The MDS Coordinator explained the side rail used by Resident #50 was an enabler to promote independence and should not have been coded as a physical restraint on the MDS assessment dated [DATE].e. Resident #59 was admitted to the facility on [DATE] with diagnoses that included major depressive disorder (other than bipolar) and anxiety disorder.A Psychiatric FNP (Family Nurse Practitioner) progress note dated 05/01/25 revealed Resident #59 required follow-up of chronic psychiatric conditions that included paranoid schizophrenia and depression. The Psychiatric FNP noted Resident #59 received bupropion 150 milligrams (mg) for major depression and although she met the criteria for paranoid schizophrenia, he would not be starting her on an antipsychotic medication because she was unlikely to provide consent due to family reporting Resident #4 had little insight that her delusions were not real.The admission MDS assessment dated [DATE] revealed schizophrenia was not coded as an active diagnosis.During an interview on 07/30/26 at 1:37 PM, the MDS Coordinator revealed she had been in her position since 10/05/25. The MDS Coordinator explained that even though Resident #59 refused medications, she did have hallucinations and delusions and the diagnosis of schizophrenia should have been coded on the MDS assessment.During interviews on 07/30/26 at 1:45 PM and 07/30/26 at 4:30 PM, the Regional MDS Consultant revealed they had discovered inaccuracies in coding and completing late MDS assessments and put a performance improvement plan into effect. He explained the inaccuracies were discovered by utilizing a software program that ran a scrubber report which he described as a report that provided compliance alerts (late completion/transmission) and quality alerts (coding/Care Area Assessments/care plans) based on the information entered in the MDS assessments that was used to ensure MDS assessments were completed accurately. The Regional MDS Consultant stated the MDS Coordinator was to run a scrubber report after each MDS assessment was completed and review with the clinical team prior to submission. During an interview on 07/30/26 at 4:45 PM the Administrator stated he expected for all MDS assessments to be completed accurately.The facility provided a plan of correction that was not accepted by the state agency due to the initial audit the facility conducted to identify other residents that had the potential to be affected only included open, unsubmitted and recently submitted MDS assessments which was not sufficient to capture all late completion or discrepancies in inaccurate coding of MDS assessments. In addition, the facility's plan of correction did not identify how visual assessments of the MDS would be identified for coding inaccuracies.

Based on observations, record reviews, and resident, staff, and Nurse Practitioner interviews, the facility failed to ensure oxygen was delivered at the prescribed rate for 1 of 2 resident reviewed for respiratory care (Resident #73).Findings included: Resident #73 was admitted to the facility on [DATE] with diagnoses that included chronic respiratory failure and chronic obstructive pulmonary disease (COPD).A review of Resident #73's care plan area revised on 06/27/26 revealed a focus indicating Resident #73 required oxygen therapy due to a history of shortness of breath and hypoxemia (low oxygen in the tissues). Interventions included administration of oxygen per physician orders.Review of Resident #73's quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated she was cognitively intact. Resident #73 was coded as receiving oxygen therapy.A review of Resident #73's active orders included an order dated 03/12/25 for continuous oxygen at 2 liters per minute (LPM) via nasal cannula to maintain SpO2 (oxygen saturation level of the blood) 90% or greater every shift for COPD. The normal range for oxygen level for someone with COPD is 88% to 92%.A review of the July 2026 Medication Administration Record (MAR) revealed an entry for continuous oxygen at 2 LPM via nasal cannula to maintain SpO2 at 90% or greater every shift for COPD. The MAR had a daily check mark with Medication Aide (MA) #1's initials during morning shifts on 07/26/26 and 07/27/26. The flow rate was charted on the MAR by MA #1 as 2 LPM with a SpO2 of 96% on 07/26/26 and 2 LPM with a SpO2 of 95% on 07/27/26.An observation of Resident #73's oxygen concentrator was conducted on 07/27/26 at 10:51 AM. The oxygen flow rate was noted to be set at 4 LPM when viewed at eye level. Resident #73 was lying in bed wearing her nasal cannula and did not exhibit symptoms of shortness of breath or respiratory distress.An interview was conducted with Resident #73 at the time of the observation, and she denied any shortness of breath or respiratory distress. Resident #73 stated she was ordered 2 LPM of oxygen and did not know why it was set at 4 LPM.MA #1 was interviewed on 07/27/26 at 2:04 PM, and he confirmed he provided care for Resident #73 from 7:00 AM through 7:00 PM on 07/26/26 and 07/27/26. He explained he completed rounds with Resident #73 around 9:00 AM on 07/27/26 and her SpO2 was 95%. MA #1 stated the oxygen concentrator flow rate should be checked when obtaining a resident SpO2 but he had not checked the flow rate on 07/27/26. He confirmed the oxygen concentrator flow rate should have been set at 2 LPM. He stated he did not know who changed the oxygen flow rate on Resident #73's concentrator.On 07/27/26 at 12:44 PM, an observation and interview were conducted with Nurse #2, who was assigned as the nurse supervisor for MA #1. Nurse #2 was accompanied to Resident #73's room and viewed the oxygen concentrator setting at eye level. Nurse #2 verified the flow rate was set at 4 LPM upon viewing and stated the flow rate should have been set at 2 LPM. She stated she was not sure why Resident #73's oxygen flow rate was set at 4 LPM, as MA #1 had charted Resident #73's SpO2 at 95% during his morning rounds.The Nurse Practitioner (NP) was interviewed on 07/30/26 at 09:21 AM and stated staff should verify a resident's oxygen concentrator was set to the physician order by checking whether the bottom of the ball in the flow meter was sitting on the correct flow rate. The NP verified Resident #73 had an order for continuous oxygen at 2 LPM via nasal cannula to maintain SpO2 at 90% or greater every shift. The NP stated she evaluated Resident #73 prior to the interview and Resident #73 did not show any adverse effects related to the increased oxygen flow rate.The Director of Nursing (DON) was interviewed on 07/31/26 at 4:35 PM and stated staff should check an oxygen concentrator at eye level and verify the flow rate matched the physician's order when checking the residents SpO2 levels. The Administrator was interviewed on 07/31/26 at 5:24 PM and stated staff should verify the oxygen concentrator was set at the ordered flow rate.

Based on observations, record review, residents, staff, and Nurse Practitioner (NP) interviews, the facility failed to ensure resident's toenails were trimmed and podiatry services were arranged for 3 of 3 residents reviewed for foot care (Resident #34, Resident #44, and Resident #65). The findings included: 1. Resident #34 was admitted to the facility on [DATE] with diagnoses which included vascular dementia, heart disease, and muscle weakness. Review of revised care plan dated 4/24/26 revealed Resident #34 was care planned for activities of daily living (ADL) self-care performance deficits related to her disease process. Resident #34 was dependent on staff for her ADL care. Review of quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #34 was cognitively intact and had been assessed as requiring substantial assistance from staff with all ADL care. Resident #34 was also coded as having no refusals with care. Review of Resident #34's weekly nursing assessments from January 2026 through July 2026 revealed no notation that her toenails were long and thick and needed trimmed. Review of the facility's podiatry clinic schedules for 4/07/26, 4/28/26, and 6/26/26, revealed Resident #34 was not seen by the podiatrist. There were no consultation reports or notations in Resident #34's Electronic Medical Record (EMR) that she had been referred to or seen by a podiatrist since her admission to the facility. A telephone interview with Resident #34's Responsible Person (RP) on 7/29/26 at 8:59 AM revealed she visited daily and would assist Resident #34 with fingernail care. She stated that due to Resident 34's toenails being long and thick she could not assist with her toenail care and did not believe Resident #34's had been cut or trimmed since she had been admitted to the facility. Resident #34's RP revealed that about 4 months ago, Resident #34 had complained about her toenails being long and that her left great toenail was a little tender on the side and she believed her toenail had become ingrown. Resident #34's RP stated that she and Resident #34 informed Nurse Aide (NA) #1 on that date about Resident #34's toenails and NA informed them the facility held a podiatry clinic each month and to speak with social worker (SW) #1 about adding Resident #34's name to the schedule so she could be seen by podiatry. Resident #34's RP revealed that she went that day or the following day and spoke with SW #1 about Resident #34's toenails and asked that she be added to the schedule to be seen at the next scheduled podiatry clinic. Resident #34's RP stated SW #1 informed that she would send the referral to podiatry that day and they should be able to add Resident #34 to the next scheduled clinic. Resident #34's RP stated her conversation with SW #1 about adding Resident #34's name to the podiatry clinic schedule was 4 months ago, Resident #34's name had still not been added to the schedule, and she still had not been seen by podiatry. Resident #34's RP revealed she had followed up with SW #1 about Resident #34's podiatry clinic referral and asked how long it took to add a resident's name to the schedule and each time SW #1 stated the referral had been completed, Resident #34 should be on the following months schedule, but Resident #34 had still not been added to the schedule or seen by the podiatrist. Resident #34's RP stated Resident #34 had not complained of any pain as of now with her toenails only that the area around her left great toenail was a little tender. Resident #34's RP revealed Resident #34's had recently started to receive physical therapy which required her to wear shoes. She stated that she was concerned the rubbing Resident #34's shoes against her toenails could cause them to become irritated and begin to cause her pain. An interview was conducted with the Nurse Practitioner (NP) on 7/29/26 at 9:30 AM. The NP stated that she was not aware of the condition of Resident #34's toenails but given her disease process she could see how her toenails may require podiatry services. She revealed the nurses were supposed to complete weekly skin and nail assessments on each resident and if a resident had nail issues that required podiatry services, they were supposed to notify the social worker to have their name added to the podiatry list. An interview and observation with Resident #34 were conducted on 7/30/26 at 2:55 PM. Resident #34 stated that she did not believe her toenails had been cut since her admission and that she also had not been seen by podiatry. Resident #34 revealed that her left great toenail was tender to the touch and she believed that her toenail had become ingrown. She stated that she had informed nursing staff about it over the past few months, and they had told her that she would need to see podiatry, but she had not been seen by podiatry yet and was not aware if an appointment had been made. Observation of Resident #34's right and left foot revealed thick, long toenails. Resident #34's right great toenail was thick and raised away from skin and her left great toenail was also thick and raised away from skin and the skin was slightly red in color on the side she believed to be ingrown. An interview and observation were conducted with Nurse #3 on 7/30/26 at 2:55 PM. Nurse #3 routinely cared for Resident #34 during the 7AM to 7 PM shift. Nurse #3 stated that she could not recall the condition of Resident #34's toenails but believed she had overheard Resident #34's RP speaking about Resident #34 needing to be seen by podiatry or was waiting to be seen by podiatry. Nurse #3 observed Resident #34's toenails and stated that due to the condition of Resident #34's toenails being that long and that thick nursing staff would not have been able to care for them in-house and agreed that Resident #34 should have been seen by a podiatrist. Nurse #3 explained that usually when nursing staff saw a resident who required more toenail care then she felt comfortable providing they would tell SW #1 who was responsible for adding the resident to the podiatry list. Nurse #3 further explained that she was not exactly sure the exact time frame but she did believe typically once a podiatry referral was completed for a resident, they were usually seen at the next scheduled clinic and if a resident's toenails were bad enough, they could even arrange some type of emergency visit if needed. An interview was conducted with Social Worker (SW) #1 on 7/30/26 at 3:30 PM. SW #1 stated that she handled the schedule for the podiatry clinic, and the podiatry clinic was held every other month or every month depending on how many residents needed to be seen. SW #1 further explained that the last podiatry clinic was held 6/26/26 and the next podiatry clinic was scheduled for 8/17/26. SW #1 stated that she did not recall any nursing staff or Resident #34's RP requesting Resident 34 to be added to the podiatry prior to this week. SW #1 revealed she had completed a referral for Resident #34 to be seen by the podiatrist and for her name to be added to the next podiatry clinic scheduled for 8/17/26. An interview was conducted with NA #1 on 7/31/26 at 10:35 AM. NA #1 stated that she had noticed Resident #34's right and left great toenails being long and very thick. NA #1 revealed about 4 months ago Resident #34 and her RP had complained of Resident #34's toenails needed to be cut and that her left great toenail was feeling a little tender and they were concerned that the toenail had become ingrown. NA #1 stated that she informed Resident #34 and her RP that Resident #34 would need to be seen by the podiatrist and to speak with SW #1 about having Resident #34 added to the podiatry clinic schedule. NA #1 revealed a day or two after her conversation with Resident #34 and her RP regarding the podiatry clinic, Resident #34's RP stated that she had spoken with SW #1 about adding Resident #34 to the podiatry clinic schedule and that SW #1 was supposed to be completing the referral for Resident #34 to be seen at the next clinic. NA #1 stated after Resident #34's RP had spoken with SW #1, Resident #34's RP checked each month to see if Resident #34 had been added to the podiatry clinic schedule and each month Resident #34 name was still not on the list and to her knowledge Resident #34 had not been seen or treated by the podiatrist. An interview was conducted with the Director of Nursing (DON) on 7/31/26 at 5:05 PM. The DON stated that nursing staff discussed nail care and toenail care daily during the nursing huddles. The DON further explained that she was not aware of any issues with Resident #34's toenail care. The DON stated that podiatry clinic was held frequently and SW #1 was responsible for scheduling residents for the podiatry clinic. The DON also stated that nursing staff should be assessing nail care for all residents and referrals for the podiatry clinic should be completed timely whether the resident requests podiatry services or they are required. An interview was conducted with the Administrator on 7/31/26 at 5:40 PM. The Administrator stated that he understood the concerns with Resident #34's toenails. The Administrator stated that nursing staff should observe resident's toenails when they complete their skin assessments and referrals should be completed promptly for any resident who requested or required podiatry services. 2. Resident #65 was admitted to the facility on [DATE] with diagnoses which included acidosis (too much acid in one's body), chronic bronchitis, asthma and diabetes mellites. Review of comprehensive care plan dated 5/04/26 revealed Resident #65 was care planned for functional limitation of self-care skills related to deconditioning with interventions that included for aides to check nail length and trim and clean on bath day and as necessary. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #65 was cognitively intact and required moderate assistance with oral and personal hygiene and was dependent on staff for toileting, showers and baths, lower body dressing and putting on footwear. Resident #65 was also coded as having no rejection of care and was unable to walk. Resident #65's weekly nursing assessments from May 2026 through July 2026 revealed no notation that her toenails were long, thick and needed trimmed. An observation and interview of Resident #65 were conducted on 7/28/26 at 4:06 PM. Resident #65's right great toe was visible, protruding from under the bed covers while the rest of her lower extremities remained covered. The right great toe had a long, thick toenail extending about three quarters of an inch beyond the tip of the toe. When asked, Resident #65 stated she would refuse fingernail trimming but did not care if someone trimmed her toenails. An interview with Nurse Aide (NA) #1 on 7/29/2026 at 3:07 PM revealed that she had given Resident #65 a shower earlier that day (7/29/2026) and that Resident #65 refused fingernail care and needed toenail care. NA #1 stated that Resident #65 would not let her scrub or clean the fingernails or toenails during the shower. NA #1 stated she was going to inform the Social Worker that Resident #65 needed a podiatry appointment. An interview with the Social Worker on 7/30/26 at 3:30 PM revealed Resident #65 had not been seen by podiatry but was added to the list to be seen as a new patient at the next podiatry visit. An interview conducted with NA #2 on 7/31/26 at 9:54 AM revealed that she had assisted Resident #65 with showers and did not remember anything unusual about Resident #65's toenails. NA #2 stated she had no experience with Resident #65 refusing care. NA #2 stated she would let the nurse know if she had noticed long toenails during showers. An interview with Nurse #1, who was assigned to Resident #65, on 7/31/26 at 1:00 PM revealed that he knew nothing about the resident's toenails. He stated he expected his aides to tell him of any refusals of care or any concerns they had regarding providing care to Resident #65. An interview and observation conducted with the Director of Nursing (DON) on 7/31/26 at 3:01 PM showed that the toenails on both of Resident #65's feet were very long and thick, overhanging the great toes by approximately three quarters of an inch. Resident #65's other toenails were long enough to curl over the ends of the toes. The DON stated she expected NAs to make more than one attempt to provide care if Resident #65 refused, and to inform the nurse of any refusals of care. The DON stated that on shower days NAs fill out a shower sheet and let the nurse know if there are any concerns regarding skin and fingernails and toenails. The assigned nurse was expected to assess the toenails and let the Social Worker know if the resident needs to be added to the podiatry list. An interview conducted with the Administrator on 7/31/26 at 5:41 PM revealed that when Resident #65 refused care, additional attempts with other aides needed to be made. The Administrator stated he expected aides to notify nursing immediately if a resident required a podiatry referral. 3. Resident #44 was admitted on [DATE] with diagnoses including methicillin-resistance staphylococcus aureus (MRSA) infection (antibiotic resistant infection), peripheral vascular disease (circulation disorder of the veins in the arms and legs), multiple skin cancers, hypertension, gait abnormalities, coordination deficits, malignant neoplasm (cancer) of the sigmoid colon, thrombocytosis (high platelet count), long term antibiotic use, atherosclerotic heart disease (plaque buildup in arteries), and history of pulmonary embolism (blockage of arteries in lung), and was receiving Hospice care. Review of a care plan dated 4/21/26 revealed Resident #44 had an activities of daily living (ADL) self-care performance deficit related to cancer of left cheek/nostril/shoulder. Interventions included bathing/showering: Check nail length and trim and clean on bath day and as necessary. Report any changes to the nurse. A significant change Minimum Data Set (MDS) dated [DATE] revealed that Resident #44 was cognitively intact with no behaviors or rejection of care. He had no impairment of the upper or lower extremities and used a walker and wheelchair for mobility. Resident #44 needed set-up for personal hygiene and partial assistance for showering. A podiatry referral made by the Social Worker dated 7/6/26 identified thickened, dystrophic (caused by faulty nutrition, poor development, or degeneration of body tissues), or painful toenails requiring podiatry evaluation. The facility podiatry appointment schedules from April 2026 through August 2026 revealed Resident #44 was never added to the podiatry clinic list and had not been scheduled for evaluation for the 8/17/26 visit. An observation on 7/27/26 at 11:05 AM of Resident #44's toenails on both the left and right feet including all 10 toes showed them to be elongated approximately 0.25 inches with thick red brown buildup beneath and around the nail and the cuticles were caked with red brown buildup approximately 0.25 inches. An observation on 7/29/26 at 2:10 PM of Resident #44's toenails on both the left and right feet including all 10 toes showed them to be elongated approximately 0.25 inches, thick, brown reddish in color with buildup beneath and around the nail, cuticles caked approximately 0.25 inches. An interview on 7/29/26 at 2:35 PM with Resident #44 revealed that he was agreeable with going to podiatry services for toenail care. An interview on 7/29/26 at 2:14 PM with Nurse #2 revealed when she observed Resident #44's toenails the growth and buildup on both the left and right feet for all 10 toenails was not recent, and Resident #44 had previously been agreeable to toenail trimming and cleaning. Nurse #2 indicated that Resident #44's toenails should have been cleaned and trimmed. An interview on 7/29/26 at 2:20 PM with Nurse Aide #3 revealed that Resident #44 refused his scheduled shower on 7/28/26. She stated the Hospice Aide assisted her on 7/29/26 to encourage Resident #44 to shower. Nurse Aide #3 reported Resident #44 refused nail cleaning and trimming during the shower and attempted to put on soiled clothing from the prior day before being convinced to change into clean clothing. She further indicated that Nurse Aides were responsible for the cleaning and trimming of a resident's toenails unless the resident was diabetic or to be seen by podiatry. Nurse Aide #3 further indicated that even if the resident was to be seen by podiatry or diabetic she could still clean the resident's toenails. An interview on 7/29/26 at 2:34 PM with the Director of Nursing revealed that Resident #44's toenails should have been trimmed by Podiatry due to their anatomy. She acknowledged podiatry care should have been arranged much sooner. She stated that she initiated a consultation that day. She further indicated that Resident #44's toenails on both the left and right feet should have been cleaned and that was her expectation. An interview on 7/29/26 at 3:06 PM with the Social Service Director revealed that she sent the referral on 7/6/26 but stated enrollment could take up to a month. She confirmed Resident #44 was not seen at the 6/26/26 podiatry clinic and was not scheduled for the upcoming 8/17/26 clinic and she did not know why. An interview on 7/31/26 at 5:10 PM with the Administrator revealed that he was unsure why Resident #44's toenails on both the left and right feet were not cleaned and trimmed, and confirmed staff should refer residents to Podiatry when trimming was unsafe. He stated that his expectation was that staff clean the resident's toenails during shower days or when the resident permitted.

Based on observations, record reviews, Nurse Practitioner (NP), staff, and resident interviews, the facility failed to follow through with the eye physician's recommendations for an Ophthalmology consult for cataract surgery. This practice occurred for 1 of 1 resident reviewed for care and treatment to maintain vision (Resident #57).The findings included: Resident #57 was admitted to the facility on [DATE] with readmission on [DATE]. Diagnoses included type 2 diabetes, chronic obstructive pulmonary disease (COPD), and chronic pain. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #57 was cognitively intact and was dependent on staff with activities of daily living (ADL). Resident #57 was coded for adequate vision. Review of Optometrist progress note from facility vision clinic for Resident #57 dated 3/03/26 revealed cataracts were visually significant in both eyes. The Optometrist recommended cataract surgery, an Ophthalmology consult, and inform facility physician. Resident #57 wanted to proceed with surgery. An interview was conducted with Resident #57 on 7/27/25 at 10:45 AM. Resident #57 revealed that she had been seen by the facility eye doctor in March 2026. She stated during that visit, the eye doctor had informed her that she had cataracts that would require surgery. Resident #57 revealed that she agreed with the eye doctor about needing surgery to remove her cataracts and the eye doctor was supposed to put in a referral for cataract surgery. Resident #57 stated to her knowledge no appointment had been made for her to have her cataracts removed and she would like to have the surgery as soon as possible so that her vision does not continue to get worse. An interview was conducted with the Nurse Practitioner (NP) on 7/29/26 at 9:30 AM. The NP revealed that she came here in February 2026. She stated that she was not aware of previous orders for cataract surgery or that those orders had not been completed. The NP revealed she was not aware of any current vision problems with Resident #57 but agreed the order or referral for cataract surgery should have been completed as ordered. An interview was conducted with the facility scheduler on 7/30/26 at 12:45 PM. She stated she had not received any orders or referrals for Resident #57 to be seen for cataract surgery. An interview was conducted with the Director of Nursing (DON) on 7/31/26 at 5:05 PM. The DON stated she was not aware of Resident #57 having a previous order for a referral to be made to the Ophthalmologist for cataract surgery. She revealed typically when a resident was seen at the in-house facility eye clinic, the clinician would email her their treatment report with their recommendations. The DON stated she would review the report, notify nursing staff of the recommendations, notify the facility physician, and obtain any orders needed for further treatment. She revealed she could not explain why Resident #57's recommendation for cataract surgery had not been scheduled, other than it had just been overlooked. The DON stated that all physician orders, recommendations, and referrals should be scheduled as ordered and in a timely manner. An interview was conducted with the Administrator on 7/31/26 at 5:40 PM. The Administrator revealed that he expected nursing staff to review all physician orders and assure any order or referrals for appointments are being scheduled as ordered and in a timely manner.

Based on observations, record reviews, and Nurse Practitioner (NP), staff, and resident interviews, the facility failed to follow physician order for referral to Gastrologist for routine endoscopy (procedure to examine esophagus, stomach, and upper part of small intestine) and colonoscopy (procedure to examine large intestine and rectum). These practices occurred for 1 of 3 residents reviewed for care to maintain wellbeing (Resident #57).The findings included: Resident #57 was admitted to the facility on [DATE]. Diagnoses included type 2 diabetes, chronic obstructive pulmonary disease (COPD), and Barrett's Esophagus (condition where the flat lining of the lower esophagus becomes damaged due to long term acid reflux). Review of physician progress note for Resident #57 written by the previous Nurse Practitioner (NP) dated 1/21/26 revealed Resident #57 requested a referral to for endoscopy and colonoscopy. Resident #57 had Barrett's esophagus and had recurring endoscopy every 3 years, was due for a colonoscopy, and was previously seen by gastrology. Entered order for referral to gastrology for Resident #57. Review of physician order for Resident #57 written and entered by the previous NP dated 1/21/26 revealed referral to Gastrologist for endoscopy and colonoscopy for Barrett's Esophagus. One time order for 30 days. Attempted to contact previous NP and they were unable to be reached. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #57 was cognitively intact. An interview was conducted with Resident #57 on 7/27/25 at 10:45 AM. Resident #57 revealed that she had a diagnosis of Barrett's Esophagus and earlier this year she had spoken with the previous NP about a referral for scheduling a routine endoscopy and colonoscopy. Resident #57 stated the previous NP stated that she would make the referral for the gastrologist and to her knowledge that appointment had not been made and she had not received her endoscopy or colonoscopy. She revealed she had not asked nursing staff or the new facility NP about her appointment because she assumed they were working on it and would let her know when the appointment had been scheduled. Resident #57 stated that she was not having any current flare ups with her disease but would like to see the gastrologist and have her routine endoscopy and colonoscopy to make sure there were no issues or concerns. An interview was conducted with the Nurse Practitioner (NP) on 7/29/26 at 9:30 AM. The NP revealed that she began working at the facility in February 2026. She stated that she was not aware of previous orders for an endoscopy or colonoscopy or that those orders had not been completed. The NP revealed she was not aware of any current flare ups from Resident #57's disease but agreed that routine colonoscopy should be completed as ordered. Review of physician order for Resident #57 dated 7/29/26 written by the NP revealed referral to Gastrologist for endoscopy and colonoscopy for Barrett's Esophagus. An interview was conducted with the facility Scheduler on 7/30/26 at 12:45 PM. She stated she was responsible for scheduling all the outside medical appointments for the residents. The Scheduler stated that she believed she had not received any referrals for scheduling an appointment for Resident #57 to see the Gastrologist until yesterday (7/29/26). She revealed Resident #57 had an appointment with gastrology for an endoscopy and colonoscopy scheduled for 9/04/26. An interview on 7/31/26 at 5:05 PM with the Director of Nursing (DON). The DON stated she was not aware of Resident #57 having a previous order for a referral to be made to the Gastrologist. She revealed in that past they had problems with their NPs and physicians writing and entering their own orders with a stop or discontinued date. The DON stated the facility NPs and physicians were not informing nursing staff or the Scheduler about the orders and then the orders would discontinue after their stop date, which she believed might have been what happened with this order. She revealed in her opinion this was just an oversight on the previous NP and nursing staff's part. The DON indicated they have asked the facility NPs and physicians to please stop putting a stop or discontinued date on their orders and to notify the nursing staff and the Scheduler when they have written a new order or entered a new order for a resident so staff will know and they can follow-up with the order. The DON stated she expected nursing staff to review all physician orders and any referrals for appointments were scheduled as ordered and in a timely manner. An interview was conducted with the Administrator on 7/31/26 at 5:40 PM. The Administrator revealed that he expected nursing staff to review all physician orders and assure any order or referrals for appointments are being scheduled as ordered and in a timely manner.

Based on observations, record review, resident and staff interviews, the facility failed to provide showers as scheduled to a resident dependent on staff assistance for bathing for 1 of 6 residents reviewed for activities of daily living (Resident #13).Findings included:Resident #13 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease (trouble breathing), chronic respiratory failure, and seizure disorder.The annual Minimum Data Set (MDS) dated [DATE] documented Resident #13 had severe cognitive impairment. She was dependent on staff assistance with showering/bathing and transfers. She displayed no behaviors and did not reject care during the MDS assessment period.An activities of daily living (ADL) care plan last revised on 06/03/26 revealed Resident #13 had an ADL self-care performance deficit related to encephalopathy (disturbance of brain function that causes altered mental state) and impaired mobility. Interventions included dependence on staff with showering per resident's requested schedule and routine. Further review revealed no care plan for refusal of care or a care plan for cognitive loss.Review of the June 2026 and July 2026 staff progress notes revealed no entries related to Resident #13 refusing showers and/or bathing assistance.A Nurse Practitioner (NP) progress note dated 07/09/26 revealed Resident #13 was alert and oriented to person, place and time. The NP further noted Resident #13's speech was clear and she was able to provide answers to questions asked.Review of the Nurse Aide (NA) point of care documentation report for July 2026 revealed Resident #13 was scheduled to receive a shower on Monday and Thursday during the hours of 7:00 PM to 7:00 AM and as needed. Further review revealed the only shower Resident #13 received was documented as provided on 07/27/26, the other scheduled shower days (07/02/26, 07/06/26, 07/09/26, 07/13/26, 07/16/26, 07/20/26, and 07/30/26) were documented as not attempted and/or refused.Review of the July 2026 shower sheets provided by the Assistant Director of Nursing (ADON) revealed Resident #13 received a bed bath on 07/09/26 and showers on 07/22/26 and 07/27/26. The ADON was unable to provide any additional shower sheets for Resident #13 for the month of July 2026.During an observation and interview on 07/27/26 (a Monday) at 12:13 PM, Resident #13 was lying in bed wearing a hospital gown and her hair was noted to have been disheveled and had an oily sheen. Resident #13 was alert and able to answer simple, direct questions. Resident #13 reported she was supposed to receive two showers a week, but she didn't always get them as scheduled. Resident #13 stated she received a shower last Thursday (07/23/26) which was the first one she had received in over three weeks. Resident #13 could not recall the name of the staff member she spoke with but stated she had voiced her concerns about not receiving her showers as scheduled.An unsuccessful telephone attempt was made on 07/31/26 at 7:49 AM for an interview with NA #6 who documented Resident #13's shower was not attempted or provided on 07/02/26.A phone interview was conducted on 07/31/26 at 8:10 AM with NA #7 who documented Resident #13 refused showers on 07/06/26, 07/09/26, 07/13/26, and 07/20/26. NA #7 revealed she was routinely assigned to provide Resident #13's care during the hours of 7:00 PM to 7:00 AM. NA #7 reported Resident #13 was dependent on staff for care and did have confusion at times, but she was able to voice her needs. NA #7 stated Resident #13 frequently refused her scheduled showers. She explained Resident #13 would state she did not feel like getting a shower if it was offered too late in the evening or she would forget a shower was offered and then state she didn't receive her scheduled shower. NA #7 stated when Resident #13 refused a shower, she always offered to give her a bed bath and change her bed linens, sometimes Resident #13 would agree and other times she wouldn't. NA #7 stated when Resident #13 refused a shower, she documented the refusal in the computer, informed the hall nurse and then informed the oncoming NA (7:00 AM to 7:00 PM) for them to try and provide the resident with a shower.An unsuccessful telephone attempt was made on 07/31/26 at 8:42 AM for an interview with NA #8 who documented Resident #13's shower was not attempted or provided on 07/30/26.During an interview on 07/31/26 at 5:13 PM, Confidential Staff Member #1 revealed Resident #13 did have confusion at times but for the most part she was alert and oriented and able to voice her needs. Confidential Staff Member #1 recalled Resident #13 was begging for a shower just last week and seemed to remember Resident #13 had talked to the Administrator. Confidential Staff Member #1 reported that the NAs on the evening shift frequently did not provide resident showers as scheduled but was not sure why. Confidential Staff Member #1 stated Resident #13 was provided with a shower this past Monday (07/27/26) and Resident #13 had voiced it was the first shower she had in weeks. Confidential Staff Member #1 stated anytime they provided care or offered a shower to Resident #13, she never refused.During an interview on 07/31/26 at 5:03 PM, the Director of Nursing (DON) could not recall the date but stated Resident #13 had mentioned missing one shower and she (DON) made sure a shower was provided to Resident #13 the next day. The DON explained Resident #13 would refuse care at times but not constantly.During an interview on 07/31/26 at 6:10 PM, the Administrator stated staff were expected to provide residents with their showers as scheduled. The Administrator revealed Resident #13 had behaviors of refusing care, including showers, that should have been documented in her medical record. He explained Resident #13 was on his daily room rounds and any time she mentioned not receiving her scheduled shower, he made sure one was provided.

Based on record review and staff interviews, the facility failed to complete a comprehensive Minimum Data Set (MDS) assessment no later than 14 calendar days of the Assessment Reference Date (ARD, referring to the last day of the assessment period) for 1 of 36 sampled residents (Residents #13).Findings included:Resident #13 was admitted to the facility on [DATE].Review of Resident #13's electronic medical record revealed an annual MDS assessment dated [DATE] that was marked as completed on 06/03/26. The MDS assessment should have been completed on 05/20/26 (ARD plus 14 calendar days) but was not completed until 06/03/26 which made the assessment 14 days late.During an interview on 07/30/26 1:37 PM, the MDS Coordinator revealed she had been in her position since 10/05/25. She explained at the time the assessment was completed for Resident #13, the facility had a lot of new admissions and she got overwhelmed with completing MDS assessments. The MDS Coordinator verified Resident #13's MDS assessment was not completed within the regulatory timeframe.During interviews on 07/30/26 at 1:45 PM and 07/30/26 at 4:30 PM, the Regional MDS Consultant revealed they had discovered inaccuracies in coding and completing late MDS assessments and put a performance improvement plan into effect. He explained the inaccuracies were discovered by utilizing a software program that ran a scrubber report which he described as a report that provided compliance alerts (late completion/transmission) and quality alerts (coding/Care Area Assessments/care plans) based on the information entered in the MDS assessments that was used to ensure MDS assessments were completed accurately. The Regional MDS Consultant stated the MDS Coordinator was to run a scrubber report after each MDS assessment was completed and review with the clinical team prior to submission. The Regional MDS Consultant confirmed Resident #13's annual MDS assessment was completed late and stated he was not sure what happened.During an interview on 07/30/26 at 4:45 PM the Administrator stated it was his expectation for MDS assessments to be completed and submitted within the regulatory timeframes.The facility provided a plan of correction that was not accepted by the state agency due to the initial audit the facility conducted to identify other residents that had the potential to be affected only included open, unsubmitted and recently submitted MDS assessments which was not sufficient to capture all late completion or discrepancies in inaccurate coding of MDS assessments. In addition, the facility's plan of correction did not identify how visual assessments of the MDS would be identified for coding inaccuracies.

Based on record review and staff interviews, the facility failed to document a resident's discharge from the facility, ensure nurse assessments were accurately documented in the electronic medical record and ensure medications were accurately documented on the medication administration record for 1 of 5 discharged residents reviewed for complete and accurate medical records (Resident #81).Findings included:Resident #81 admitted to the facility on [DATE].A discharge MDS assessment dated [DATE] revealed Resident #81 discharged to the community.A staff progress note written by the Administrator and dated 05/16/26 at 8:12 AM revealed Resident #81 signed out of the facility on 05/15/26 at 4:00 PM to go the store to buy shoes. Further review revealed no entry related to Resident #81 not returning to the facility after signing himself out to go to the store.Review of the medication administration record (MAR) for May 2026 revealed Nurse #3 initialed Resident #81's medications scheduled for 9:00 PM and 10:00 PM as administered per physician order.Review of Resident #81's electronic medical record revealed a nurse assessment dated [DATE] at 1:43 AM written by Nurse #3 that revealed the following:Temperature 98.2 degrees Fahrenheit - 05/15/26 at 11:01 PM, route: forehead (non-contact).Blood pressure 132/74 - 05/15/26 at 11:01 PM, position: lying right arm.Pulse 76 - 05/15/26 at 11:01 PM, pulse type: regular.Respiration 18.0 - 05/15/26 at 11:01 PM.Oxygen 98% - 05/15/26 at 11:01 PM, method: room air.Weight 161.4 pounds - 05/12/26 at 2:10 PM, scale: standing.Pain issue: no change. Location: generalized. Pain score: 7.PERRLA (pupils equal, round, reactive to light and accommodation):Resident follows commands. Denies weakness, tremors, numbness or tingling. Alert and Oriented times 3. Mood is pleasant, no unwanted behaviors witnessed. Skin warm and pink with brisk capillary refill (test that measures how long it takes for color to return to the skin after applying pressure). No edema present. Abdomen flat, non-tender. Bowel sounds present times 4. Denies indigestion, nausea, vomiting, diarrhea, constipation or bowel incontinence. Taking nutrition and hydration orally. No complaints of thirst. No signs or symptoms of a swallowing disorder. Mucous membranes (moist, inner lining of some organs and body cavities such as the nose, mouth, lungs and stomach). Resident continent of bladder. Urine clear yellow. Denies urinary complaints.Skin issue: has not been evaluated. Location: front right knee. Laterality/Orientation: distal. Additional location information: outer right lower extremity incision closed with 14 staples present. Issue type: surgical wound. Wound was present on admission. Undermining: No. Tunneling: No.A nurse progress note written by Nurse #3 and dated 05/16/26 at 1:45 AM revealed in part, Resident #81's skin was warm and dry with normal skin color and normal turgor (the skin's ability to change shape and quickly return to normal).During a phone interview on 07/30/26 at 10:43 AM, Nurse #3 confirmed she worked on 05/15/26 to 05/16/26 during the hours of 7:00 PM to 7:00 AM and was assigned to provide care to Resident #81. Nurse #3 recalled on 05/15/26 when doing her evening medication pass, she pulled Resident #81's medications that were scheduled for 9:00 PM and 10:00 PM, signed the medications off on the MAR and when she went into Resident #81's room to administer his medications, she realized he was not there. She stated she was not informed that Resident #81 had signed himself out of the facility during shift report. She further stated she destroyed the medications she had pulled to administer to Resident #81 and then sent a text message to the former Unit Manager to inform her that Resident #81 was not at the facility. Nurse #3 recalled she received a response back from the former Unit Manager at 8:00 AM stating she would notify the Administrator. Nurse #3 could not explain why she documented an assessment was completed on Resident #81 when he was not at the facility.During an interview on 07/31/26 at 4:23 PM, the Director of Nursing (DON) stated from what she could recall, Resident #81 signed himself out of the facility to go to a store on 05/15/26 and did not return. She did not know why Nurse #3 documented an assessment was completed after Resident #81 signed himself out of the facility on 05/15/26. She stated Nurse #3 should have documented a progress note and notified her and/or the Administrator when Resident #81 did not return to the facility. The DON explained Nurse #3 should have accurately documented medication administration on Resident #81's MAR by striking out the PM medications were administered and noted Resident #81 was on a leave of absence at the time of the scheduled medications.During an interview on 07/31/26 at 6:10 PM, the Administrator stated Nurse #3 should have accurately documented Resident #81's medications were not administered on his MAR and documented a progress note in Resident #81's electronic medical record when he did not return to the facility.

Based on observations, record review and interviews with resident, staff, Nurse Practitioner and Medical Director, Driver #1 failed to provide safe transportation on 03/02/2026 when Resident #1's lap belt and front retractor tie-downs (retractor tie-down systems are often called a 4-point securement system) were not correctly applied per manufacturer's instructions leaving Resident #1 not fully secured while in his wheelchair in the facility transport van. Resident #1, who only had one leg, and no hands, was being transported to a medical appointment by Driver #1. As the vehicle accelerated from a full stop at a traffic light, Resident #1's wheelchair tipped over backward with Resident #1 in the wheelchair resulting in the resident hitting his head on the van floor. Resident #1 sustained a hematoma (a localized collection of blood that pools outside of a blood vessel, usually due to trauma or injury) and abrasion to the mid to top area on the back of his head. A computed tomography (CT) scan revealed Resident #1 had no intracranial injury (no recent or urgent problems inside the skull). This non-compliance had a high likelihood of resulting in serious injury, harm, impairment, or death. The deficient practice occurred for 1 of 3 sampled residents reviewed for accidents (Resident #1).The findings included: Review of the manufacturer instructions for the operation of the facility van's wheelchair securement system dated February 2011 indicated the following: - Attach to Wheelchair: Starting with the rear retractors, pull out the webbing (the heavy-duty, high-strength strap that connects the wheelchair's frame to the vehicle floor) and place the S-hook securely around a structural member (the wheelchairs welded main frame) of the wheelchair. Pull on the S-hook to ensure full engagement around the structural member. Repeat procedure for other retractors. Tension the front or rear retractors as needed by turning the handles until the tie-downs are tight. - Caution: Do not attach tie-downs to the wheels or any detachable portion of the wheelchair. Tie-down must have a clear, straight path from floor to where it attaches to the wheelchair. Do not allow tie-downs to conform or bend around any object, for example the wheels or footrests. Keep tie-downs away from sharp edges or corners. - Tension the Lap Belt: Insert the buckle connector into the push-button buckle. Tension the buckle connector belt comfortably using the web adjuster. Ensure the lap belt is worn low across the front of the pelvis, bearing upon the bony structure of the body and that the push button buckle is located near the occupant's hip opposite of the side from where the shoulder belt is anchored. Pull on the lap belt to ensure attachment of the triangular fittings to the rear retractor studs and the connection of the push button buckle and buckle connector. - Caution: Always ensure that the shoulder belt is properly extended over the shoulder and across the upper torso the occupant. When connecting the shoulder belt to the lap belt, always ensure that the push-button buckle and buckle connector are located at the occupant's hip opposite of the vehicle sidewall where the shoulder belt anchorage is installed. Ensure that the lap belt buckle is located in such a way that it is clear and is not in contact with any of the wheelchair components or any structures during operation as to minimize any potential contact during its use or in case of an accident. - Never place the lap belt over the wheelchair arm rests and side panels or above the occupant's abdominal area. - Adjust occupant restraints as firmly as possible consistent with user comfort. Do not twist webbing from sharp edges and corners. Resident #1 was admitted to the facility on [DATE] with diagnoses that included type 2 diabetes mellitus, acute respiratory failure with hypoxia, cognitive communication deficit, acquired absence of left leg above knee, acquired absence of right hand, and acquired absence of left hand. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 was cognitively intact and had functional limitations in range of motion to both sides of upper and lower extremities. Resident #1 required substantial/maximum assistance with transfers and locomotion via manual wheelchair. Resident #1 experienced no pain during the MDS look back period and had not received blood thinners. A telephone interview was conducted with Nurse Aide (NA) #1 on 5/6/2026 at 7:48 AM, she stated she was familiar with Resident #1 and she was assigned to Resident #1's hall on 3/2/2026. NA #1 stated she saw Resident #1 on 3/2/2026 and asked him why he was back so early from his appointment, and he said his wheelchair tipped over in the van. NA #1 stated she did not report the fall to anyone because she thought Driver #1 had reported it. An interview was conducted with Driver #1 on 5/5/2026 at 12:35 PM and Driver #1 stated he was the driver for the facility's transport van and was the driver for Resident #1's appointment on 3/2/2026. Driver #1 stated he was in a hurry on the morning of 3/2/2026 when he loaded Resident #1 onto the facility transport van. Driver #1 stated due to being in a hurry he didn't realize one of wheelchair retractor tie-downs was loose, and he had not secured the lap belt around Resident #1 properly due to placing the belt through the opening in the side panels of the wheelchair rather than placing the lap belt directly next to the resident. Driver #1 stated while driving to Resident #1's appointment, not far from the facility, he (Driver #1) came to a stop at a stop light, and when it was clear to proceed Driver #1 accelerated slowly and then heard a loud bump sound. He indicated he stopped the vehicle as far over on the roadway as he was able to, explaining that there was a sidewalk beside the road. He revealed he saw Resident #1 had fallen backwards in his wheelchair, and Resident #1's head was on the van floor. Driver #1 stated he made his way to the back of the van next to Resident #1 and asked him if he was OK. Driver #1 stated Resident #1 was laughing and said he was fine. Driver #1 stated he raised Resident #1 back to a seated upright position in his wheelchair. Driver #1 stated that Resident #1 was laughing and repeated that he was fine when Driver #1 lifted him up. Driver #1 stated when he lifted Resident #1 and his wheelchair up, he noted the wheelchair's right arm rest panel was not in place and was loose. Driver #1 stated he panicked when he saw Resident #1 had fallen backwards, and since Resident #1 was laughing and said he was fine, Driver #1 resecured Resident #1 and returned to the facility. Driver #1 indicated he did not recall all the specifics related to how he secured the resident for the trip back to the facility. Driver #1 stated he took Resident #1 back to his hall and reported what happened to a staff member on the hall. Driver #1 stated he thought he reported the incident to an NA working on Resident #1's hall, but he recognized faces and didn't recall the names of the staff, so he did not recall the specific person he told. Driver #1 stated he did not see any injury or bleeding to Resident #1, but a bump was found on his head later that day. Driver #1 stated he could not remember the exact date he became the van driver at the facility but thought it was around June of 2025. Driver #1 stated he did some education on the computer regarding driving, and the former driver showed him how to secure wheelchairs in the facility transport van, but Driver #1 stated he had not completed a return demonstration for the former driver when he was initially trained. Driver #1 verified after review of his education record with the surveyor during this interview, that he had received training in February of 2025 that included Defensive Driving Basics, Provide Safe Transportation, and Transport Vehicle Lift Operation. A telephone interview was conducted with Medication Aide (MA) #1 on 5/6/2026 at 8:37 AM. She stated she was familiar with Resident #1 and was assigned to medication pass on Resident #1's hall on 3/2/2026. MA #1 stated on 3/2/2026 Resident #1 had asked her to cut his hair which was not unusual as she often cut Resident #1's hair at his request. MA #1 stated she took Resident #1 to the shower room, she did not recall the exact time and did not know Resident #1 had fallen in the facility van at that time. MA #1 stated she began to cut Resident #1's hair and noted a large bump to the back of Resident #1's head, asked Resident #1 what happened and Resident #1 stated he had fallen backwards in his wheelchair on the facility van and hit his head. MA #1 stated she immediately reported the injury and what Resident #1 had said to the Director of Nursing (DON) and then nurses began to assess Resident #1. MA #1 stated she did not see any bleeding on Resident #1's head, just the bump with an abrased area. A facility incident report for Resident #1 dated 3/2/2026 written by the Assistant Director of Nursing (ADON) revealed the ADON was asked by MA #1 to assess the back of Resident #1's head where he had hit it, and then the NA stated that Resident #1 fell out of his wheelchair in the facility transport van. The report indicated Resident #1 stated the arm of his wheelchair pulled up when the driver started moving forward in the van, which caused Resident #1 to fall backward in his wheelchair and hit his head on the van floor. Driver #1 stated he was able to sit Resident #1 back up and re-secure him with wheelchair and seatbelt and Driver #1 brought Resident #1 immediately back to the facility. A change in condition progress note dated 3/2/2026 written by the ADON revealed Resident #1 was noted to have laceration/raised area to back of his head and stated he fell back in his wheelchair and hit his head. The note indicated Resident #1 had no pain. An interview was conducted with the ADON on 5/5/2026 at 2:40 PM that revealed the ADON was working on 3/2/2026 and was the nurse assigned to cover Resident #1's hall. The ADON stated she was asked to assess Resident #1 after MA #1 had cut his hair and noted an injury. The ADON stated she assessed Resident #1, noted a hematoma and abrasion to the back of Resident #1's head and neurochecks were initiated. The ADON verified she had documented a laceration in the chart, but that was in error and it was an abrasion on the hematoma. The ADON stated she asked Resident #1 what happened and Resident #1 laughed and told her his wheelchair fell backwards in the van. The ADON stated Resident #1's vitals and neurochecks were normal and Resident #1 did not complain of pain. The ADON stated she notified the Nurse Practitioner (NP) and since Resident #1 was stable the NP recommended to continue to monitor and perform neurochecks. A progress note dated 3/2/2026 written by the Nurse Practitioner revealed Resident #1 was assessed after a fall in the facility transport van and noted Resident #1 fell backwards in a transport van after the wheelchair arm detached. Resident #1 obtained a large hematoma to posterior (back) occipital scalp region (relating to the back of the head or skull) and noted resident was alert and oriented. Plan included neurological checks initiated, family was notified and the resident will have a follow up on 3/3/2026 to ensure no delayed symptoms developed. An interview was conducted with Resident #1 on 5/5/2026 at 9:45 AM. Resident #1 stated he remembered when his wheelchair fell backwards in the facility transport van and stated he had hit his head on the floor of the van when his wheelchair fell backwards. Resident #1 stated Driver #1 was not driving bad or too fast and that the wheelchair fell backwards when Driver #1 pulled out from a stop light not far from the facility. Resident #1 stated there were no other issues with his transport to appointments and he had gone to appointments since that time without any issues. Resident #1 stated he had a bump on the back of his head after he fell backwards in the wheelchair, but it was better now. Resident #1 stated he did not experience pain when he fell backwards in his wheelchair on the facility transport van. A physician progress note dated 3/3/2026 written by the Medical Director revealed Resident #1 was going to an appointment in the facility transport van seated in his wheelchair when the wheelchair fell backwards and Resident #1 hit his head on 3/2/2026 and had evidence of a hematoma in the occipital area which was resolved on 3/3/2026 with a healing wound on the skin. The note indicated a plan to obtain a CT scan to rule out any intracranial hemorrhage (brain bleed). During an interview with the ADON on 5/5/2026 at 2:40 PM she indicated Resident #1's family requested a head CT on 3/3/2026, and Resident #1 had a CT completed on 3/3/2026 and it was normal. Resident #1's physicians' orders revealed an order dated 3/3/2026 that read CT of head without contrast to rule out hemorrhage. Resident #1's report from the head CT dated 3/3/2026 revealed no acute intracranial abnormality. Resident #1's Medication Administration Record (MAR) dated 3/2/2026 through 3/9/2026 revealed Resident #1 reported a pain level of zero (on a scale of 0 to 10 with 0 being no pain and 10 being the worst pain possible). An observation of the facility transport van with Driver #1 was conducted in conjunction with a follow up interview on 5/5/2026 at 4:30 PM. Driver #1 demonstrated how Resident #1 was improperly secured on 3/2/2026. Driver #1 stated and demonstrated he attached the rear retractors and then the front retractors to the resident's wheelchair. Driver #1 stated on 3/2/2026 he incorrectly attached the front retractors to the outer structure of the wheelchair rather than on a secure structure underneath the wheelchair. Driver #1 stated and demonstrated that on 3/2/2026 he placed the tension lap belt though the opening located on the side panels of the wheelchair instead of directly next to the resident. Driver #1 stated when he saw Resident #1's wheelchair tipped backwards he noted the right-side panel of the wheelchair's arm rest had come loose and the front right wheel retractor webbing was loose. A telephone interview was conducted with the Nurse Practitioner (NP) on 5/6/2026 at 2:33 PM, she stated she was very familiar with Resident #1. The NP stated she was in the ADON's office on 3/2/2026 and sometime between 10:00 AM and 11:00 AM Resident #1 had returned from an appointment, and when an MA cut his hair and noted a large hematoma to the back of Resident #1's head. The NP stated she thought neurochecks were initiated and thought the resident had a CT scan the following day. The NP stated when she assessed Resident #1 on 3/2/2026 he was alert and oriented. The NP stated Resident #1's cognition varied day to day and stated Resident #1 sometimes had hallucinations. An interview was conducted with the Medical Director on 5/5/2026 at 11:40 AM. He revealed Resident #1's family had requested a head CT be completed after the fall, and to rule out intracranial hemorrhage a CT was ordered the day after Resident #1 had fallen in the wheelchair van. The Medical Director stated he thought it was appropriate that the resident was not sent to the hospital on 3/2/2026 due to Resident #1's neurochecks being stable and Resident #1 did not have anticoagulants ordered. The Medical Director stated the CT showed no abnormality and the hematoma healed well. A telephone interview conducted with the Director of Nursing (DON) on 5/6/2026 at 9:03 AM revealed she was familiar with Resident #1. The DON stated she, the ADON and NP were notified by MA #1 around 10:30 AM on 3/2/2026 that Resident #1 reported falling backwards in the facility transport van and hit his head. The DON stated Resident #1 was assessed by the ADON and the NP and was found to have a slightly raised, reddish area with an abrasion to the back center area of his head. The DON stated she and the Administrator had talked to Driver #1 after they became aware of the van incident, and she thought the reason Resident #1's wheelchair fell backwards on the facility transport van was due to the wheelchair not being secured properly by Driver #1. An interview with the Administrator conducted on 5/5/2026 at 4:40 PM revealed he was familiar with Resident #1. The Administrator stated on 3/2/2026 Resident #1 was being transported to a medical appointment in the facility transport van by Driver #1. The Administrator stated Driver #1 had not properly secured Resident #1 in his wheelchair prior to leaving the facility and on the way to the appointment Resident #1's wheelchair tipped backwards on the facility transport van and Resident #1 hit his head on the van floor. The Administrator stated after the van incident on 3/2/2026 Driver #1 demonstrated how he had secured Resident #1 on the morning of 3/2/2026 and it was noted that Driver #1 had incorrectly secured the right front retractor and the lap belt prior to leaving the facility with Resident #1. The Administrator stated Driver #1 had been educated in February 2025 on Defensive Driving Basics, Provide Safe Transportation, and Transport Vehicle Lift Operation. The Administrator stated he thought Driver #1 had been instructed on correct procedures per manufacturer's instructions for securing residents in wheelchairs in the facility transport ban by the previous van driver. The Administrator stated he expected van drivers to ensure residents were properly secured in the facility transport van prior to each van transport. The facility was notified of immediate jeopardy on 5/6/2026 at 10:35 AM. The facility provided the following corrective action plan: How will corrective action be accomplished for those residents affected by the deficient practice? On March 2, 2026, Driver #1 failed to follow established transportation safety procedures when Resident #1 was being transported in the facility van and failed to secure the resident's wheelchair with all 4 tie-downs and improperly secured the resident with the safety belt and shoulder belt per manufacturer instruction during transportation to an appointment. This deviation from the policy created an avoidable risk to Resident #1's safety and resulted in a minor head contusion and hematoma when Resident #1's wheelchair fell backwards causing Resident #1 to hit his head on the van floor.March 2, 2026, the Driver #1 returned Resident #1 to the facility after a van incident that occurred around 9:30am.March 2, 2026, at 10:30am Executive Director and Director of Nursing were notified by a Certified Nurse Assistant of the incident.March 2, 2026, at 10:30am Resident #1 was assessed by Director of Nursing and Assistant Director of Nursing.March 2, 2026, at 11:30 Director of Nursing had Nurse Practitioner evaluate Resident #1. Nurse Practitioner determined that Resident #1 was stable at that time and determined that he needed no further treatment.March 3, 2026, Medical Director evaluated Resident #1 with request for computed tomography scan to rule out any intracranial hemorrhage.March 3, 2026, Resident #1 received a computed tomography scan with results of this scan revealing no acute inner-cranial abnormalities.Neurological checks completed by Director of Nursing on March 3, March 4, and March 5 with no negative findings noted.March 2, 2026, Driver #1 was removed from transport duties pending investigation and provided immediate re-education by Executive Director on securement and safety protocols including verbalization and return demonstration on how passengers are to be secured before transport per manufacturer instructions and emergency procedures during trips. Education materials included the facility policy and procedure for resident transportation, transport van securement checklist, and manufacturer instructions on proper securement of the wheelchair and proper use of lap belt and shoulder belt. March 2, 2026, van securement system including tie-downs, belts, shoulder harnesses, and lift were all inspected by Executive Director and Maintenance Director and placed back in service only after passing function check. No deficient or non-functioning equipment was noted.March 3, 2026, the transportation vehicle safety equipment was scheduled to be inspected by a company that is certified to inspect, install, and service wheelchair van lift and securement equipment. March 4, 2026, transportation van lift and securement equipment was inspected and determined to be functional and properly operational.How will the facility identify other residents having the potential to be affected by the same deficient practice?March 4, 2026, using the transportation schedule, all residents transported on the facility van over the past 30 days were interviewed to identify any concerns, issues, or incidents by the Social Services Director. No negative findings were noted as a result of this audit.March 2, 2026, van driver was interviewed by the Executive Director and the van driver confirmed that he had no other incidents or accidents with any other residents prior to the incident on March 2, 2026.What measures or Systemic Changes have been made to Prevent Recurrence?March 2, 2026, Driver #1 was provided immediate re-education by Executive Director on securement and safety protocols including verbalization and return demonstration on how passengers are to be secured before transport and emergency procedures during trips. Education materials included the facility policy and procedure for resident transportation, transport van securement checklist, and manufacturer instructions on proper securement of the wheelchair and proper use of lap belt and shoulder belt.March 2, 2026, transportation binder was implemented by the Executive Director to include the transportation safety policy, a step-by-step guide and checklist for wheelchair securement, seatbelt and shoulder belt application, all per manufacturer instructions. This binder was placed in the van for the driver to complete the checklists for every resident transportation. Executive Director notified the Driver #1 on March 3, 2026, of this new process. March 3, 2026, Maintenance Director was notified of the responsibility by the Executive Director to ensure all new hire van drivers are to be educated in-person on the proper use of wheelchair securement system and seatbelt and shoulder belt to secure residents during transport per manufacturer instructions. New van drivers will perform a return demonstration to ensure he/she has a good understanding of how to properly implement safety equipment in the van per manufacturer instructions. As of March 2, 2026, except for the Executive Director, the facility only utilizes Driver #1 as a van driver. How will the facility monitor its corrective actions to ensure the deficient practice will not recur? March 2, 2026, the Executive Director notified the Maintenance Director and Receptionist who manages the transportation schedule of this monitoring responsibility.Using the weekly transportation schedule, Executive Director, Maintenance Director, and/or designee will ensure all residents transported in the van are in a standard wheelchair, are secured correctly using the four-point wheelchair securement system and seatbelt/shoulder belt is secured correctly by the van driver, per manufacturer instructions, by direct observation 3x per week for 4 weeks, 2x per week for 4 weeks, then 1x per week for 4 weeks, then 1x per month for 3 months. Results will be reported to interdisciplinary team during Quality Assurance Performance Improvement each month for 12 months for continued compliance and/or further revision.In the event of the facility using contract van transportation, Executive Director or designee will ensure that the resident is safely secured in the contract transportation vehicle.The Director of Nursing and Executive Director introduced the plan of correction to the Ad-Hoc Quality Assurance Performance Improvement Committee on March 2, 2026. The Director of Nursing is responsible for implementing this plan. Findings will be reviewed by Quality Assurance Performance Improvement Committee monthly and Quality monitoring (audit) updated if changes are needed based on findings. The Quality Assurance Performance Improvement Committee consists of but not limited to the Executive Director, Director of Nursing, Assistant Director of Nursing, Social Services Manager, Business Office Manager, Activities Director, Human Resources, Pharmacist, Medical Director, Certified Nurse Assistant, Dietary Manager, Maintenance Director, Housekeeping Supervisor, Admissions, Medical Records, and Minimum Data Set Nurse. The Quality Assurance Performance Improvement Committee meets monthly and quarterly at a minimum. Alleged date of immediate jeopardy removal and compliance: March 5, 2026 The facility's corrective action plan was validated by the following: Interview with facility transport van drivers revealed they had received education on the restraint system in the facility transport van and how to properly secure a resident in the van as well as the driver safety checklist that was to be completed prior to leaving facility with residents. The facility transport van drivers also stated they had to verbalize their understanding of the education they had received and complete a demonstration showing they were capable of securing residents in the facility transport van properly for transport. Review of facility orientation paperwork for new facility van drivers verified the Maintenance Director now included in-person education on the proper use of wheelchair securement system and seatbelt and shoulder belt to secure residents during transport per manufacturer instructions. New van drivers will perform a return demonstration to ensure they have a good understanding of how to properly implement safety equipment in the van per manufacturer instructions. Review of the audit tools and driver safety checklist was completed with no issues noted. An observation was made on 5/5/2026 of a resident in their wheelchair in the facility van secured by Driver #1 in accordance with the manufacturer's operation instructions with no issues identified. Interviews were conducted with alert and oriented residents who had been transported since 3/5/2026 with no concerns identified. No additional transportation incidents were identified since 3/5/2026. Review of the facility audits revealed no issues. The facility's immediate jeopardy removal date and compliance date of 3/5/2026 was validated.

Based on record review, resident, staff, Nurse Practitioner and Medical Director interviews, Driver #1 failed to have Resident #1 assessed for injury by a qualified medical professional prior to moving the resident following a fall in the transportation van. Resident #1's wheelchair tipped over backwards with Resident #1 in the wheelchair resulting in the resident hitting his head on the van floor. Driver #1 lifted Resident #1 while in his wheelchair back to the upright position and returned to the facility without calling Emergency Medical Services for assistance. Driver #1 was not qualified to provide a comprehensive physical assessment to determine if Resident #1 had sustained any injuries. Upon arrival at the facility, Driver #1 did not notify the Administrator or Director of Nursing and returned Resident #1 back to his hall and told a staff member that Resident #1 had fallen backwards in the wheelchair on the facility transport van. When Medication Aide (MA) #1 gave Resident #1 a haircut, a raised area was noted on the back between the middle and top of Resident #1's head and Resident #1 reported what had occurred in the facility transport van. MA #1 then notified the Director of Nursing (DON) and Assistant Director of Nursing (ADON) of the injury. The Assistant Director of Nursing assessed Resident #1 who sustained a hematoma (a localized collection of blood that pools outside of a blood vessel, usually due to trauma or injury) and an abrasion to the mid to top area on the back of Resident #1's head. A computed tomography (CT) (imaging procedure) scan revealed Resident #1 had no intracranial injury (anything occurring within the skull). This deficient practice occurred for 1 of 3 sampled residents reviewed for quality of care (Resident #1). There was a high likelihood of further injury from moving a resident after a fall and prior to clinical assessment of injury and not immediately informing the Director of Nursing or a Nurse delayed the assessment of any injuries that Resident #1 may have sustained.The findings included: Resident #1 was admitted to the facility on [DATE] with diagnoses that included type 2 diabetes mellitus, acute respiratory failure with hypoxia, cognitive communication deficit, acquired absence of left leg above knee, acquired absence of right hand, and acquired absence of left hand. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 was cognitively intact and had functional limitations in range of motion to both sides of upper and lower extremities. The assessment indicated Resident #1 required maximum assistance with transfers and locomotion via manual wheelchair. Resident #1 experienced no pain during the MDS look back period and had not received blood thinners. A facility incident report for Resident #1 dated 3/2/2026 written by the Assistant Director of Nursing (ADON) revealed the ADON was asked by a Nurse Aide (NA) to assess the back of Resident #1's head where he had hit it, and then the NA stated that Resident #1 fell out of his wheelchair in the facility transport van. The report indicated Driver #1 stated he was able to sit Resident #1 back up and re-secure him with wheelchair and seatbelt and Driver #1 brought Resident #1 immediately back to the facility. A change in condition progress note dated 3/2/2026 written by the ADON revealed Resident #1 was noted to have laceration/raised area to back of his head and stated he fell back in his wheelchair and hit his head. The note indicated Resident #1 had no pain. An interview was conducted with the ADON on 5/5/2026 at 2:40 PM that revealed the ADON was working on 3/2/2026 and was the nurse assigned to cover Resident #1's hall. The ADON stated she was asked to assess Resident #1 after MA #1 had cut his hair and noted an injury. The ADON stated she assessed Resident #1 on 3/2/2026 and noted a hematoma and abrasion to the back of Resident #1's head and neurological checks were initiated. The ADON stated she asked Resident #1 what happened and Resident #1 laughed and told her his wheelchair fell backwards in the van, then Driver #1 brought Resident #1 back to the facility. The ADON stated Resident #1's vital signs and neurological checks remained normal, and Resident #1 did not complain of pain. The ADON stated she notified the Nurse Practitioner (NP) and since Resident #1 was stable the NP recommended to continue to monitor and perform neurological checks. The ADON stated Resident #1's wife requested a head CT on 3/3/2026, and Resident #1 had a CT completed on 3/3/2026 and it was normal. The ADON stated Driver #1 should not have moved Resident #1 after the fall to prevent any further injury and Driver #1 should have called 911 so trained medical personnel could have assessed Resident #1 for injury. The ADON also stated Driver #1 should have reported the incident to the Administrator, DON or a nurse as soon as he was back at the facility so Resident #1 could have been assessed immediately. A telephone interview was conducted with MA#1 on 5/6/2026 at 8:37 AM, she stated she was familiar with Resident #1 and was assigned to the medication pass on Resident #1's hall on 3/2/2026. MA #1 stated on 3/2/2026 Resident #1 had asked her to cut his hair. MA #1 stated she took Resident #1 to the shower room; she did not recall the exact time and did not know Resident #1 had fallen in the facility van at that time. MA #1 stated she began to cut Resident #1's hair and noted a large bump to the back of Resident #1's head and asked Resident #1 what happened and Resident #1 stated he had fallen backwards in his wheelchair on the facility van and hit his head on the floor of the van. MA #1 stated she immediately reported the injury and what Resident #1 had said to the Director of Nursing (DON), and then the nurses began to assess Resident #1. MA #1 stated she did not see any bleeding on Resident #1's head, just the bump with an abrased area. A telephone interview was conducted with NA #1 on 5/6/2026 at 7:48 AM, she stated she was familiar with Resident #1 and verified she was assigned to Resident #1's hall on 3/2/2026. NA #1 stated she saw Resident #1 and asked him why he was back so early from his appointment, and he said his wheelchair tipped over, NA #1 did not recall the specific time this occurred. NA #1 stated she did not report the incident to a nurse because she did not think she was the first-person Driver #1 notified about the wheelchair falling backwards in the facility transport van and thought the nurses had already been notified when she became aware. An interview was conducted with Driver #1 on 5/5/2026 at 12:35 PM and Driver #1 stated he was the driver for the facility's transport van and was the driver for Resident #1's appointment on 3/2/2026. Driver #1 stated he accelerated slowly from a stop light and heard a loud bump sound and stopped the vehicle and saw Resident #1 had fallen backwards in his wheelchair, and Resident #1's head was on the van floor. Driver #1 stated he made his way back in the van next to Resident #1 and asked him if he was OK. Driver #1 stated Resident #1 was laughing and said he was fine. Driver #1 stated he raised Resident #1 back to a seated upright position in his wheelchair and returned Resident #1 to the facility. Driver #1 stated as he walked back into the facility, he informed the Receptionist that Resident #1 had fallen in the van and that's why they were back so soon and did not inform the Administrator because he was in a meeting. Driver #1 stated he took Resident #1 back to his hall. Driver #1 stated he thought he reported it to a nurse aide working on Resident #1's hall, but he recognized faces and didn't recall the names of the staff, so he did not recall the specific person he told. Driver #1 stated after he returned Resident #1 to his hall, Driver #1 went back to his regular work. Driver #1 stated the Administrator and Director of Nursing talked to him a little while later about the incident. Driver #1 stated he had not noticed any injury or bleeding to Resident #1, but a bump was found on his head later that day. Driver #1 stated he should not have moved Resident #1 because he was not qualified to assess Resident #1 for injury after a fall and could have caused further injury by moving Resident #1. Driver #1 stated he should have called 911 so Resident #1 could be assessed by trained medical personnel. Driver #1 stated he had been trained in February 2025 regarding calling for medical attention after an accident. Driver #1 stated he knew he should not have moved Resident #1 after the fall before he was assessed by medical personnel, but he panicked and since Resident #1 stated he was fine, Driver #1 just wanted to get the Resident back to the facility. Driver #1 verified he had no medical training that made him qualified to assess a resident for injury after a fall. A telephone interview was conducted with the Receptionist on 5/6/2026 at 9:54 AM, she stated she was responsible for making the appointments and transportation schedule for the facility transport van. The Receptionist stated on the morning of 3/2/2026 Driver #1 returned to the facility with Resident #1. The Receptionist stated she was on a phone call and Driver #1 stopped in her doorway and told her Resident #1 had fallen backward in his wheelchair in the facility transport van and Resident #1 had not made it to his appointment. The Receptionist called the doctor's office to let them know Resident #1 would not be making it to the appointment on 3/2/2026. Resident #1 went to a rescheduled appointment on 3/17/2026. The Receptionist stated she did not report the incident to anyone else because she thought Driver #1 had reported the incident. An interview was conducted with Resident #1 on 5/5/2026 at 9:45 AM. Resident #1 stated he remembered when his wheelchair fell backwards in the facility transport van and he hit his head on the van floor. Resident #1 stated Driver #1 lifted him and his wheelchair back up and brought him back to the facility. Resident #1 stated he did not experience any pain when he fell backwards in his wheelchair on the facility transport van on 3/2/2026. Review of the progress note dated 3/2/2026 written by the Nurse Practitioner (NP) revealed Resident #1 was assessed after a fall in the facility transport van and noted Resident #1 fell backwards in a transport van after the wheelchair arm detached. Resident #1 obtained a large hematoma to the posterior (back) occipital (relating to the back of the head or skull) scalp and noted the resident was alert and oriented. The plan included neurological checks initiated, family was notified and will follow up on 3/3/2026 to ensure no delayed symptoms developed. A telephone interview was conducted with the NP on 5/6/2026 at 2:33 PM, she stated she was very familiar with Resident #1. The NP stated she was in the Assistant Director of Nursing's (ADON) office on 3/2/2026 and sometime between 10:00 AM and 11:00 AM Resident #1 had returned from an appointment, and when a NA cut his hair and noted a large hematoma to the back of Resident #1's head. The NP stated she thought neurological checks were initiated and thought the resident had a CT scan the following day. The NP stated when she assessed Resident #1 on 3/2/2026 he was alert and oriented. The NP stated Driver #1 should not have moved Resident #1 after his wheelchair fell backwards on the facility transport van and should have called 911 to have Resident #1 assessed by emergency medical personnel, and Driver #1 should have reported the incident to the Administrator or DON as soon as possible. The NP stated it is not safe to move a resident after a fall until the resident has been assessed by trained medical personnel for injuries and to prevent further injury. Review of the physician progress note dated 3/3/2026 written by the Medical Director revealed Resident #1 was going to an appointment in the facility transport van seated in his wheelchair when the wheelchair fell backwards and Resident #1 hit his head on 3/2/2026 and had evidence of a hematoma in the occipital area which was resolved on 3/3/2026 with a healing wound on the skin. The note indicated a plan to obtain a CT scan to rule out any intracranial hemorrhage. Review of Resident #1's physicians' orders revealed an order dated 3/3/2026 that read CT of head without contrast rule out hemorrhage. Review of Resident #1's report from head CT dated 3/3/2026 revealed no acute intracranial abnormality. Review of Resident #1's medical record revealed neurological checks were initiated by the ADON on 03/2/2026 and completed on 3/5/2026 and were within normal limits. An interview was conducted with the Medical Director on 5/5/2026 at 11:40 AM he revealed Resident #1's family had requested a head CT be completed after Resident #1 had fallen backward in wheelchair on the transportation van to rule out intracranial hemorrhage. The Medical Director stated he ordered a CT on 3/3/2026. The Medical Director stated he thought it was appropriate that he was not sent to the hospital on 3/2/2026 due to Resident #1's neurological checks were stable and Resident #1 did not have anticoagulants (blood thinner) ordered. The Medical Director stated the CT showed no abnormality and the hematoma healed well. The Medical Director stated Resident #1 should have been assessed by emergency medical personnel prior to being moved after the fall in the facility transport van so he could be assessed for injury and to prevent the possibility of further injury. A telephone interview was conducted with the DON on 5/6/2026 at 9:03 AM and revealed she was familiar with Resident #1. The DON stated she, the ADON and NP were notified by MA #1 around 10:30 AM on 3/2/2026 that Resident #1 reported falling backwards in the facility transport van and hit his head. The DON stated Resident #1 was assessed by the ADON and the NP and was found to have a slightly raised, reddish area with an abrasion to the back center area of his head. The DON stated she and the Administrator had talked to Driver #1 after they became aware of the van incident, and she was not sure why Driver #1 did not immediately call 911. The DON stated Driver #1 should have immediately called 911 when he saw Resident #1 had fallen backwards in his wheelchair so he could be assessed by emergency medical personnel for injuries and to prevent further injury. An interview with the Administrator was conducted on 5/5/2026 at 4:40 PM revealed he was familiar with Resident #1. The Administrator stated on 3/2/2026 Resident #1 was being transported to a medical appointment in the facility transport van by Driver #1. The Administrator stated Driver #1 had not properly secured Resident #1 in his wheelchair prior to leaving the facility and on the way to the appointment Resident #1's wheelchair tipped backwards on the facility transport van and Resident #1 hit his head on the van floor. The Administrator stated Driver #1 had been educated in February 2025 on Defensive Driving Basics, Provide Safe Transportation, and Transport Vehicle Lift Operation. The Administrator stated he expected Driver #1 to call 911 to assess a resident after a van accident or resident fall on the van, and for the driver not to move a resident after a fall until the resident was assessed by emergency medical personnel. The Administrator verified Driver #1 had been trained in February 2025, and the training included the reporting procedure in the case of an accident, which included calling for medical attention. The facility was notified of immediate jeopardy on 5/6/2026 at 10:35 AM. The facility provided the following corrective action plan: Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice. On March 2, 2026, Driver #1 failed to follow company Transportation policy by returning Resident #1 to the facility after an incident in the van when he should have immediately called emergency services so the resident could be evaluated by emergency medical services. He also did not notify the Director of Nursing or Executive Director of the incident when he returned the resident to the building resulting in a delay in the facility's ability to properly provide adequate care to Resident #1. On March 2, 2026, Driver #1 returned Resident #1 to the facility after a van incident that occurred around 9:30am.On March 2, 2026, at 10:30am Executive Director and Director of Nursing were notified by a Certified Nurse Assistant of the incident.March 2, 2026, at 10:30am Resident #1 was assessed by Director of Nursing and Assistant Director of Nursing.March 2, 2026, at 11:30 Director of Nursing had Nurse Practitioner evaluate Resident #1. Nurse Practitioner determined that he was stable at that time and determined that he needed no further treatment.On March 2, 2026, Executive Director provided education to the Driver #1 using facility policy and procedure for accidents and incidents on stopping the van in a safe location and calling 911 and waiting till emergency medical services arrives to assess the resident. The education also included notifying the Executive Director and Director of Nursing immediately of any incident involving a resident.On March 3, 2026, facility physician also evaluated Resident #1 with request for Computed Tomography scan to rule out any intracranial hemorrhage which resulted in no acute inner-cranial abnormalities.Neurological checks initiated on 3/2/2026 by the ADON and completed on 3/5/2026 with no negative findings noted. Address how the facility will identify other residents having the potential to be affected by the same practice.On March 2, 2026 through March 3, 2026, Director of Nursing and Assistant Director of Nursing completed audit of current residents for the past 30 days including incidents, accidents, change in condition reported as soon as possible, situation background assessment recommendation completed, family/responsible party notified, physician order for treatment if indicated, appropriate documentation, interventions to prevent further changes and/or worsening of conditions, and appropriate care plan interventions put in place if indicated. No other residents determined to be at risk. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur. On March 2, 2026, Executive Director provided education to the van driver using facility policy and procedure for accidents and incidents on stopping the van in a safe location and calling 911 and waiting till emergency medical services arrives to assess the resident. The education also included notifying the Executive Director and Director of Nursing immediately of any incident involving a resident.March 3, 2026, through March 4, 2026, re-education by Director of Nursing, Assistant Director of Nursing, and Executive Director to all current staff including department leaders, dietary, housekeeping and laundry, therapy, and nursing was performed regarding immediate reporting of any accident or incident to Director of Nursing and Executive Director using facility policy and procedure for accidents and supervision, and incidents and accidents to ensure that the Director of Nursing and/or designee can ensure assessments have been completed.March 3, 2026 through March 4, 2026, nursing department staff including Registered Nurses, Certified Nursing Assistants, Licensed Practical Nurses, and Medication Aides were provided re-education regarding immediate reporting of any accident or incident to Director of Nursing and/or Executive Director, changes in condition reported as soon as possible, situation background assessment recommendation completed, physician notification, physician order if indicated, treatments have been performed per physician's order and documented, physician and responsible party notification of changes, appropriate care plan in place, accurate documentation, and continued monitoring for change of condition to ensure that the Director or Nursing and/or designee can ensure assessments have been completed. This education was provided in a group setting by the Director of Nursing and Executive Director with verbal education and question and answer with the staff. As needed staff or staff on vacation at the time were called on the telephone and educated verbally by the Executive Director and the Scheduling Coordinator as a witness.On March 3, 2026, Executive Director notified the Director of Nursing of the responsibility that all newly hired staff including van drivers, Registered Nurses, Licensed Practical Nurses, medication aides, certified nursing assistants, department leaders, will be educated during the Orientation process on facility policy and procedure for immediately reporting incidents and accidents. This education will be provided by the Director of Nursing and/or Assistant Director of Nursing going forward. The facility does not use contract agency staff. In the event of the facility using contract van transportation, Executive Director or designee will ensure that the resident is safely secured in the contract transportation vehicle and that the driver is informed on the facility policy and procedure for notifying the Director of Nursing and Executive Director in the event of an incident or accident.Indicate how the facility plans to monitor its performance to ensure that the solutions are sustained.Starting on March 3, 2026, the Director of Nursing and/or designee will perform Quality Improvement monitoring for notification to the Director of Nursing and/or Executive Director of all residents who experienced an accident or incident. The audit will include regarding immediate reporting of any accident or incident to Director of Nursing and Executive Director, changes in condition reported as soon as possible, situation background assessment recommendation completed, physician notification, physician order if indicated, treatments have been performed per physician's order and documented, physician and responsible party notification of changes, appropriate care plan in place, accurate documentation, and continued monitoring for change of condition. Monitoring to be completed five times a week for four weeks, then twice a week for four weeks, then once a week for four weeks. The Director of Nursing and Executive Director introduced the plan of correction to the Ad-Hoc Quality Assurance Performance Improvement Committee on March 2, 2026. The Director of Nursing is responsible for implementing this plan. Findings will be reviewed by Quality Assurance Performance Improvement Committee monthly and Quality monitoring (audit) updated if changes are needed based on findings. The Quality Assurance Performance Improvement Committee consists of but not limited to the Executive Director, Director of Nursing, Assistant Director of Nursing, Social Services Manager, Business Office Manager, Activities Director, Human Resources, Pharmacist, Medical Director, Certified Nurse Assistant, Dietary Manager, Maintenance Director, Housekeeping Supervisor, Admissions, Medical Records, and Minimum Data Set Nurse. The Quality Assurance Performance Improvement Committee meets monthly and quarterly at a minimum. Alleged date of immediate jeopardy removal and compliance: 3/5/2026 The facility's corrective action plan was validated on 5/12/2026 by the following: Interviews with facility staff revealed all facility staff, including facility van drivers had received education on proper procedures if a resident was to have a fall, injury, or accident in the facility van, that 911 was to be called immediately, do not move resident until assessed by a medical professional and to notify the Administrator or DON immediately of an incident. The education was included as a component of the orientation for new hires. Review of the incident/accident logs was completed with no issues noted. Interviews were also conducted with alert and oriented residents who had been transported since 3/5/2026 with no concerns, incidents or accidents identified. Review of the facility audits revealed no issues. The facility's immediate jeopardy removal and compliance date of 3/5/2026 was validated.

Based on record review and staff interviews, the facility failed to submit accurate payroll data on the Payroll Based Journal (PBJ) report to the Centers for Medicare and Medicaid Services (CMS) related to Registered Nurse (RN) hours and licensed nursing coverage 24-hours per day. This was for 1 of 3 quarters reviewed for sufficient nurse staffing (Quarter 1: October 1-December 31, 2024). Findings included: The PBJ report for the Fiscal Year Quarter 1 2025 (October 1 through December 31, 2024) revealed there were no Registered Nurse (RN) hours for 10/12/24, 10/13/24, 11/17/24, 12/14/24, 12/15/24, and 12/22/24. The PBJ report also noted the facility failed to have licensed nursing coverage 24 hours a day for 10/12/24, 10/13/24, 11/09/24, 11/10/24, 11/17/24, and 12/14/24. The daily staff schedules for 10/12/24, 10/13/24, 12/14/24, 12/15/24, and 12/22/24 revealed there was a RN onsite for at least 8 hours a day. Further review revealed on 11/17/24 there was no RN onsite for at least 8 hours a day. The nursing staff time detail reports for 10/12/24, 10/13/24, 11/17/24, 12/14/24, 12/15/24, and 12/22/24 revealed there was no RN onsite for at least 8 hours a day. The daily staff schedules revealed there was no licensed nursing coverage at the facility 24 hours a day on 10/12/24 and 10/13/24. Further review revealed there was licensed nursing coverage at the facility 24 hours a day on 11/09/24, 11/10/24, 11/17/24, and 12/14/24. The nursing staff time detail reports revealed there was no licensed nursing coverage at the facility 24 hours a day on 10/12/24, 10/13/24, 11/09/24, 11/10/24, 11/17/24, and 12/14/24. During an interview on 04/28/25 at 10:26 AM, the Regional [NAME] President of Operations revealed for the dates of 10/12/24, 10/13/24, 11/09/24, 11/10/24, 11/17/24, 12/14/24, 12/15/24, and 12/22/24, the facility did have an RN 8 hours a day and licensed nursing coverage for 24 hours a day. He explained the facility did not use agency staffing and on the above dates, the Administrator at the time, who was an RN, and Director of Nursing both worked shifts as nurses on various days but since they were both salaried they did not clock in or out and their hours would not show on the time detail reports. He stated the corporate office had to manually adjust and input any hours salaried nursing staff worked covering shifts. He explained when nurses from sister facilities worked shifts at this facility, their hours would not show up on the time detail reports because they were only able to clock in and out at their home facility. He stated the corporate office had to manually adjust their hours from the home facility and input the hours at the facility where they had worked. The Regional [NAME] President of Operations revealed the corporate office was not always consistent with the process of manually adjusting and inputting nursing staff hours for payroll data to accurately reflect nursing staff coverage on the PBJ reports submitted to CMS which was why no RN coverage and no licensed nursing staff coverage triggered.

Based on observations and staff interviews the facility failed to remove food stored past the use by date from the dry goods storage area. Additionally, the facility failed to clean a circulatory fan cover and prevent water from dripping onto stored food in 1 of 2 kitchen refrigerators (the walk-in refrigerator). This practice had the potential affect food served to residents. The findings included: a. On 4/27/25 at 10:20 AM an observation of the dry goods storage area's bread rack with a fill in Dietary Manager (DM #2) from a sister facility found stored bread past the use by date. DM #2 stated the facility's Dietary Manager (DM #1) was not available on 4/27/25, and he was filling in for the day. The bread rack contained 8 loaves of sliced bread with a use by date of 4/25/25 and 3 packages of hamburger buns with a use by date of 4/23/25. The DM #2 stated during the observation the procedure was to remove the bread from the [NAME] rack and place it into the freezer before the use by date. The DM #2 stated the DM #1 was responsible for ensuring the bread was removed before the use by date. b. On 4/27/25 at 10:27 AM an observation of the walk-in refrigerator with the fill in DM #2 found the refrigeration unit leaking water. The water was a steady drip coming from a pipe connected to the back of the refrigeration unit to the wall. The water was dripping onto a lid of a container labeled pickles, and water was observed on the floor of the walk-in refrigerator. The circulatory fan cover was also observed to contain a thick buildup of crumbly black and gray substance on the cover. The DM #2 stated he did not know how long the refrigerator unit had been dripping water and would notify maintenance about the water and the fan cover. The DM #1 was interviewed on 5/1/25 at 1:43 PM. He stated he had not seen the refrigerator unit dripping water before and the circulatory fan cover would be included on a regular cleaning schedule. The DM #1 said the bread was ultimately his responsibility to ensure it was frozen by the use by date. The Maintenance Supervisor was interviewed on 5/1/25 at 2:00 PM. She stated a refrigerator repair company was called and came to the facility on 4/28/25 to fix the water leak and she had not been aware of the leaking water prior to 4/28/25. The Maintenance Supervisor stated a pipe was not fully insulated and was causing condensation to drip and was fixed. The Maintenance Supervisor stated the fan cover was not on a routine cleaning schedule, and she would include it. The Administrator was interviewed on 5/1/25 at 5:24 PM. She stated the bread should have been removed or frozen by the use by date and the walk-in refrigerator fan cover should be cleaned routinely. She also stated the water dripping from the refrigeration unit should be repaired to prevent any potential contamination of food.

Based on record review, observations and interviews with staff, the facility failed to follow the meal spreadsheet and posted menu when they ran out of a food item while plating meals. This deficient practice impacted 7-9 residents who did not receive regular consistency carrots for their lunch meal. Findings included: The facility's menu spreadsheet for the lunch meal dated 4/29/25 was reviewed. The spreadsheet read Swedish meatballs with gray, buttered noodles, and sliced carrots. On 4/29/25 at 11:40 AM an observation of the lunch meal tray line found the posted lunch meal was Swedish Meatballs with gravy, buttered noodles, and carrots. An observation of the tray line on 4/29/25 at 12:12 PM found the [NAME] plating the last available serving of regular consistency carrots from the trayline. On 4/29/25 at 12:14 PM the [NAME] stated there were not enough regular consistency carrots to finish serving the 300 hall residents (7-9) for the meal. The [NAME] said she had used all the carrots available in the kitchen for the meal. She also said the District Dietary Manager was cooking capri vegetables (mixed vegetables) as a substitute for carrots. On 4/29/25 at 12:16 PM the District Dietary Manager was observed cooking the capri vegetables. On 4/29/25 at 12:17 PM the [NAME] stated she normally needed 6 bags of carrots to prepare a meal for all the residents, and she only had 5 bags to use for the lunch meal. An observation on 4/29/25 at 12:22 PM found the substituted capri vegetable were placed on the tray and the [NAME] resumed plating the lunch meal with the capri vegetables. On 4/29/25 at 12:35 PM the [NAME] stated she did not notify the Dietary Manager that she might not have enough carrots for the meal until the lunch meal tray line had started. The Dietary Manager stated on 5/01/25 at 1:43 PM the cook should have notified the Dietary Manager when she was preparing the meal. The Dietary Manager stated the facility would have purchased more carrots from a store to make sure there were enough for the meal. The Administrator was interviewed on 5/01/25 at 5:24 PM. She stated the posted menu should be followed and accurate. The Administrator stated the cook should have communicated to the DM there were not enough carrots when she first knew the amount on hand was not going to be enough.

Based on observations, record review, and staff interviews the facility failed to record opened dates on multi-dose oral inhalers and label and date opened multi-dose bottles of eye drops on 3 of 4 medication carts (400 Hall, 200 Hall, and 300 Hall) reviewed for medication storage. Findings included: 1. An observation was made of the 400 Hall medication cart on 05/01/25 at 2:35 PM in the presence of Medication Aide (MA) #1. The observation revealed the following: (a). An opened and undated 7.5 milliliter (ml) multi-dose bottle of Neomycin and Polymyxin (antibiotics) eye drops were stored on the medication cart. The manufacturer recommended dating the eye drops when they were opened and discarding on or before the expiration date. (b). An opened and undated multi-dose bottle of Prednisolone Acetate (steroid) 1% eye drops was stored on the medication cart. The manufacturer recommended dating the eye drops when they were opened and discarding them on or before the expiration date. (c). An opened, undated, and unlabeled 15 ml multi-dose bottle of Polyethylene Glycol 400 4% and Propylene Glycol 0.3% (eye lubricants) was stored on the medication cart. The manufacturer recommended dating the eye drops when they were opened and discarding on or before the expiration date. (d). An opened and undated multi-dose oral inhaler containing Fluticasone Propionate (a steroid) 250 micrograms (mcg) and Salmeterol Xinafoate (medication to keep airways open) 50 mcg was stored on the medication cart. The manufacturer recommended discarding one month after opening the foil pack. (e). An opened, undated, and unlabeled multi-dose oral inhaler containing Fluticasone Propionate 250 mcg and Salmeterol Xinafoate 50 mcg was stored on the medication cart. The medication did not include the name of the resident it had been dispensed for. The manufacturer recommended discarding one month after opening the foil pack. An interview with MA #1 on 05/01/25 at 2:35 PM revealed she was not sure why the eye drops and inhalers did not have an opened date or why the Fluticasone Propionate and Salmeterol Xinafoate inhaler did not have a resident name on it. 2. An observation of the 200 Hall medication cart was conducted in the presence of Nurse #5 on 05/01/25 at 2:56 PM. The observation revealed the following: (a). An opened and undated multi-dose oral inhaler containing Fluticasone Propionate 100 mcg and Salmeterol 50 mcg was stored on the medication cart. The manufacturer recommended discarding one month after opening the foil pack. An interview with Nurse #5 on 05/01/25 at 2:56 PM revealed all multi-dose oral inhalers should be dated when opened and she did not notice the inhaler did not have a date. 3. An observation of the 300 Hall medication cart was conducted in the presence of Medicatio Aide (MA) #2 on 05/01/25 at 3:11 PM. The Assistant Director of Nursing (ADON) was also present for part of the observation. The observation revealed the following: (a). Two opened and undated 2.5 ml bottles of Latanoprost 125 micrograms (mcg) were stored on the medication cart. The manufacturer recommended dating the medication when opening and discarding within 6 weeks after opening. (b). An opened and undated 5 ml bottle of Levobunolol 0.5% drops (drops that lower pressure inside the eye) was stored on the medication cart. The manufacturer recommended dating the eye drops when they were opened and discarding on or before the expiration date. (c). An opened and undated multi-dose oral inhaler containing Umeclidinium 62.5 mcg and Vilanterol 25 mcg (medications used to relax airways) was stored on the medication cart. The manufacturer recommended dating the inhaler when removing from the foil pack and discarding the medication 6 weeks after opening. (d). An opened and undated multi-dose oral inhaler containing Fluticasone Propionate 250 mcg and Salmeterol Xinafoate 50 mcg was stored on the medication cart. The manufacturer recommended discarding one month after opening the foil pack. (e). An opened and undated multi-dose oral inhaler containing Olodaterol (medication used to relax airways) 2.5 mcg was stored on the medication cart. The manufacturer recommended discarding within 3 months of first use. An interview with MA #2 on 05/01/25 at 3:11 PM revealed all opened medication should have an opened date and he was not sure why the eye drops and inhalers were undated. An interview with the Director of Nursing (DON) on 05/01/25 at 4:38 PM revealed all opened medications should be labeled with the resident's name and date they were opened by the staff member who opened the medication. The DON stated third shift was responsible for checking medication carts nightly to ensure all medications were labeled and dated and the staff member assigned to the medication cart was also responsible for ensuring medications were labeled and dated. An interview with the Administrator on 05/01/25 at 5:39 PM revealed she expected all medications to be labeled and dated at the time they were opened.

Based on record review and interviews with the Law Enforcement Detective and staff, the facility failed to protect the residents' rights to be free from misappropriation of controlled medication for 4 of 4 residents reviewed for misappropriation of resident property (Residents #173, #174, #175, and #176). The findings included: The facility's Abuse, Neglect, Exploitation and Misappropriation policy, last revised on 11/16/22, revealed in part the facility would ensure all residents were free from misappropriation of property. a. Resident #173 was admitted to the facility on [DATE] with diagnoses that included bipolar disorder and anxiety disorder. The physician's order dated 01/16/25 revealed Resident #173 had an order to receive one tablet of clonazepam 0.5 milligrams (mg) by mouth every morning (6:00 AM) and at bedtime (9:00 PM) for anxiety/panic attacks. The pharmacy proof of delivery shipment summary sheet revealed 60 tablets of clonazepam 0.5 mg were shipped on 02/18/25 for Resident #173 and was received by the facility on 02/19/25 at 3:13 AM. The February 2025 Medication Administration Record (MAR) revealed starting on 02/19/25 Resident #173 received a total of 5 tablets of clonazepam 0.5 mg. The clonazepam was documented as administered per physician order on 02/19/25 at 6:00 AM and 9:00 PM, 2/20/25 at 6:00 AM and 9:00 PM, and 02/21/25 at 6:00 AM. No further doses were documented as administered for the remainder of the month and there should have been 55 tablets left remaining. The shift change controlled substance inventory count sheet revealed the former Director of Nursing (DON) initialed that she removed one card of clonazepam 0.5 mg tablets for Resident #173 from the medication cart on 02/21/25 and noted the medication was being returned to the pharmacy. The initial allegation report dated 03/01/25 revealed the facility became aware of an incident on 02/28/25 at 7:54 PM when the Administrator was notified by Medication Aide (MA) #3 that Resident #173's clonazepam (medication used to treat panic disorders and seizures) and declining count sheets were missing, and Law Enforcement was notified. A telephone attempt on 05/01/25 at 2:43 PM for interview with MA #3 was unsuccessful. The investigative report dated 03/08/25 revealed the facility completed a review of pharmacy and facility documentation which revealed on 02/21/25 the former DON removed Resident #173's clonazepam from the medication cart and noted on the controlled substance shift change report that the medications were sent back to the pharmacy and the declining count sheet could not be located. The pharmacy sent 60 tablets of clonazepam on 02/18/25 and review of Resident #173's medication administration record (MAR) revealed 55 of the 60 tablets were unaccounted for. It was noted that Resident #173 did not suffer any harm or mental anguish, and the medication was replaced at the facility's expense. The former DON's last day worked was on 02/25/25 and she did not return back to the facility after that date. Resident #173 passed away at the facility on 04/01/25. b. Resident #174 was admitted to the facility on [DATE] with diagnoses that included chronic pain. The physician's order dated 01/30/25 revealed Resident #174 had an order to receive one tablet of oxycodone 5 mg by mouth every 6 hours as needed for pain. The pharmacy proof of delivery shipment summary sheet revealed 30 tablets of oxycodone 5 mg were shipped on 01/30/25 for Resident #174 and was received by the facility on 01/31/25 at 2:08 AM. The January 2025 MAR for Resident #174 revealed he received a total of 2 tablets of oxycodone 5 mg. The oxycodone was documented as administered per physician order on 01/31/25 at 3:47 PM and 10:09 PM. After the last dose was administered on 01/31/25, there should have been 28 tablets remaining. The February 2025 MAR for Resident #174 revealed he received a total of 5 tablets of oxycodone 5 mg. The oxycodone was documented as administered per physician order on 02/01/25 at 9:14 PM, 02/02/25 at 11:00 AM, 02/03/25 at 9:46 PM, 02/06/25 at 2:35 PM, and 02/07/25 at 9:56 AM. After the last dose was administered on 02/07/25, there should have been 23 tablets of Oxycodone left remaining. Resident #17 discharged to the hospital on 02/08/25 and had not returned to the facility at the time of this investigation. The shift change controlled substance inventory count sheet revealed the former DON initialed that she removed one card of oxycodone 5 mg tablets for Resident #174 from the medication cart on 02/21/25. The initial allegation report dated 03/04/25 revealed the facility became aware on 03/04/25 at 4:40 PM during a narcotic audit that 20 tablets of Resident #174's oxycodone (opioid pain medication) was unaccounted for, and Law Enforcement was notified. The investigative report dated 03/08/25 revealed during a narcotic audit, it was discovered that the former DON removed Resident #174's oxycodone from the medication cart and the medication was missing along with the declining count sheet. c. Resident #175 was admitted to the facility on [DATE] with diagnoses that included chronic pain. The physician's order dated 02/10/25 revealed Resident #175 had an order to receive one tablet of oxycodone 5 mg by mouth every 6 hours as needed for pain. The pharmacy proof of delivery shipment summary sheet revealed 28 tablets of oxycodone 5 mg were shipped on 02/10/25 for Resident #175 and was received by the facility on 02/10/25 at 6:15 PM. The February 2025 MAR for Resident #175 revealed she received at total of 10 tablets of oxycodone 5 mg. The oxycodone was documented as administered per physician order on 02/10/25 at 10:12 PM, 02/11/25 at 10:38 AM, 02/12/25 at 9:22 AM and 3:35 PM, 02/13/25 at 9:40 AM, 02/14/25 at 8:47 AM, 02/15/25 at 2:54 PM and 10:20 PM, and 02/16/25 at 10:04 AM and 10:16 PM. After the last dose was administered on 02/16/25, there should have been 18 tablets remaining. The shift change controlled substance inventory count sheet revealed the former DON initialed that she removed one card of oxycodone 5 mg tablets for Resident #175 on 02/21/25 and noted the medication was being returned to the pharmacy. Resident #175 discharged to the hospital on 02/26/25 and had not returned to the facility at the time of this investigation. The initial allegation report dated 03/04/25 revealed the facility became aware on 03/04/25 at 4:40 PM during a narcotic audit that 18 pills of Resident #175's oxycodone was unaccounted for and Law Enforcement was notified. The investigative report dated 03/08/25 revealed during a narcotic audit, it was discovered that on 02/21/25 the former DON removed Resident #175's oxycodone from the medication cart and the medication was missing along with the declining count sheet. d. Resident #176 was admitted to the facility on [DATE] with diagnoses that included fracture of the lower end of the left radius (one of the two long bones in the forearm located on the thumb side). The physician's order dated 01/13/25 revealed Resident #176 had an order to receive one tablet of oxycodone 5 mg by mouth every 6 hours as needed for pain. The physician's order dated 01/15/25 revealed Resident #176 had an order to receive one tablet of oxycodone-acetaminophen 5-325 mg by mouth every 6 hours as needed for pain for one day and to discontinue when the oxycodone 5 mg arrived. The pharmacy proof of delivery shipment summary sheets for Resident #176 revealed the following: - 30 tablets of oxycodone 5 mg were shipped on 01/14/25 and was received by the facility on 01/15/25 at 3:57 AM. - 30 tablets of oxycodone 5 mg were shipped on 01/24/25 and was received by the facility on 01/25/25 at 3:08 AM. - 30 tablets of oxycodone 5 mg were shipped on 02/04/25 and was received by the facility on 02/04/25 at 6:11 PM. - 30 tablets of oxycodone 5 mg were shipped on 02/14/25 and was received by the facility on 02/15/25 at 2:34 AM. The January 2025 MAR for Resident #176 revealed she received one tablet of oxycodone-acetaminophen 5-325 mg on 01/15/15 at 1:24 PM. The January 2025 MAR for Resident #176 further revealed she received a total of 48 tablets of oxycodone 5 mg. The oxycodone was documented as administered per physician order on: -01/13/25 at 4:00 PM -01/14/25 at 12:16 AM -01/15/25 at 2:36 AM and 9:54 PM -01/16/25 at 5:31 AM, 11:55 AM and 5:57 PM -01/17/25 at 12:21 AM, 10:28 AM and 5:52 PM -01/18/25 at 12:33 AM, 6:34 AM, 1:04 PM, and 9:35 PM -01/19/25 at 5:42 AM and 10:07 PM -01/20/25 at 9:09 AM, 4:57 PM and 11:44 PM -01/21/25 at 5:48 AM, 12:56 PM and 7:12 PM -01/22/25 at 2:45 AM, 9:09 AM and 3:30 PM -01/23/25 at 2:05 AM, 9:00 AM, 3:23 PM, and 11:58 PM -01/24/25 at 11:11 AM and 5:26 PM -01/25/25 at 8:13 PM -01/26/25 at 7:02 PM -01/27/25 at 2:35 AM, 10:15 AM and 5:12 PM -01/28/25 at 5:10 AM, 12:39 PM and 7:19 PM -01/29/25 at 6:21 AM and 4:54 PM -01/30/25 at 12:16 AM, 6:20 AM, 1:34 PM, and 8:27 PM -01/31/25 at 3:03 AM, 9:57 AM and 7:06 PM. The February 2025 MAR for Resident #176 revealed she received a total of 51 tablets of oxycodone 5 mg. The oxycodone was documented as administered per physician order on: -02/01/25 at 4:06 AM, 10:27 AM, 5:12 PM, and 11:45 PM -02/02/25 at 5:47 AM, 1:10 PM and 8:26 PM -02/03/25 at 6:00 AM, 12:56 PM and 7:37 PM -02/04/25 at 5:01 AM and 11:01 AM -02/05/25 at 9:11 AM, 3:28 PM and 9:30 PM -02/06/25 at 5:41 AM, 12:50 PM and 8:49 PM -02/07/25 at 5:56 AM, 12:55 PM and 7:50 PM -02/08/25 at 4:28 AM, 10:59 AM, 5:38 PM, and 11:47 PM -02/09/25 at 12:28 PM and 8:15 PM -02/10/25 at 5:02 AM, 11:16 AM, 5:35 PM, and 11:45 PM -02/11/25 at 6:45 PM -02/12/25 at 1:20 AM, 11:45 AM and 5:58 PM -02/13/25 at 5:02 AM and 8:51 PM -02/14/25 at 4:27 AM, 11:19 AM and 6:35 PM -02/15/25 at 2:51 AM and 8:53 PM -02/16/25 at 5:59 AM and 7:13 PM -02/17/25 at 9:43 AM and 5:49 PM -02/18/25 at 6:49 AM, 1:08 PM and 8:23 PM -02/19/25 at 4:06 AM and 10:24 AM. Resident #176 discharged home on 02/19/25. The shift change controlled substance inventory count sheet was signed by MA #2 on 02/21/25 indicating one card of oxycodone 5 mg tablets for Resident #176 was removed from the medication cart. There was no other signature verifying the narcotics were removed. Included in the facility's investigation documentation was a typed statement dated 03/01/25 written by the current DON that revealed in part, on 02/21/25 MA #2 and the former DON were observed at the 400 Hall medication cart. The former DON was observed removing several narcotic cards and declining count sheets from the medication cart and then walked back up the hallway away from the medication cart with the narcotics and count sheets in hand. The initial allegation report dated 03/04/25 revealed the facility became aware on 03/04/25 at 4:40 PM that 18 pills of Resident #176's oxycodone was unaccounted for and Law Enforcement was notified. The investigative report dated 03/08/25 revealed during a narcotic audit, it was determined that between 01/14/25 to 02/14/25 the pharmacy sent 120 tablets of oxycodone for Resident #176 of which she received 100 doses. There were 20 tablets of oxycodone unaccounted for and the medication was missing along with the declining count sheet. During phone interviews on 04/29/25 at 12:36 PM and 04/30/25 at 4:42 PM, the former DON stated her last day working at the facility was on 02/25/25 and she left without notice because she no longer felt safe working at the facility. The former DON could not recall the date but stated an Officer came to speak with her to get a statement and hinted that she was being accused of narcotic diversion, but he did not go into the specifics of what she was being accused of. She stated she never and would never take any medication from a facility or resident. The former DON stated during her employment at the facility, narcotic medication that needed to be returned to the pharmacy was kept locked in the medication cart. She explained that was not a process she was comfortable with and felt that the narcotic medication should be locked up in the DON's office until the pharmacy picked them up. She could not recall the exact date but stated it was a day or two before the last day she worked (02/25/25) when the Assistant Director of Nursing at the time, who was now the facility's current DON, asked if she would clear the carts, which she explained meant removing narcotic medication that needed to be returned to the pharmacy, and help her finish up the pharmacy returns. The former DON stated she removed some narcotic medication with the associated declining count sheets from the 300 Hall medication cart, but she did not recall the name of the resident the medication belonged to or the name of the medication she removed. She scanned the cards to create a pharmacy return, faxed the log to the pharmacy and placed the narcotic medication into a sealed bag for the pharmacy to pick up. She then handed the bagged medication to Nurse #6 to place back on the medication cart until the pharmacy picked it up. The former DON stated she felt that someone was forging her initials on the narcotic count sheets and just before she left, she had voiced her concerns to the Administrator and ADON that she felt there was some drug diversion going on and there needed to be an audit, but they did not seem to take her concerns seriously. The former DON stated she felt this entire accusation was retaliatory on the facility's part because she quit without notice. She restated she never took any narcotic medication and someone at the facility forged her initials. During a phone interview on 05/01/25 at 9:25 AM, Nurse #6 revealed she no longer worked at the facility. Nurse #6 could not recall the date but stated the former DON had given her some medications that were sealed in a bag for the pharmacy to pick up and she placed the bag in the 100 Hall medication cart because pharmacy usually didn't pick up medications at night which was when she worked. During a phone interview on 04/29/25 at 4:11 PM, the Law Enforcement Detective stated he and the Drug Enforcement Administration (DEA) Officer spoke with the former DON together and she denied taking any medications from the facility. The Law Enforcement Officer stated when he reviewed the facility's records, the documentation was not as clean cut as he would have liked. He explained there were gaps from the date the former DON initialed the sheets as having removed the medications and when the medications were noticed missing which meant others had access to the medications during the time frame. The Law Enforcement Detective stated he was closing his investigation, and no charges were filed as he could not determine what actually happened to the medications but felt there was definitely a breakdown in the facility's process that allowed the diversion to occur. A joint interview was conducted with the current DON, Administrator and Regional [NAME] President of Operations on 04/30/25 at 1:26 PM. The Administrator stated on 02/28/25, MA #3 came to let her know that she (MA #3) had tried to get Resident #173's clonazepam refilled but the pharmacy stated it was too soon to refill the medication. The Administrator stated she immediately reviewed the pharmacy sheets for deliveries and then she along with the current DON started looking everywhere to see if Resident #173's clonazepam had been placed in another location by mistake which included checking all medication carts, offices, filing cabinets, desk, and the non-narcotic pharmacy return box. She stated when Resident #173's clonazepam couldn't be located, she called the Regional [NAME] President of Operations to inform him of the situation, and he instructed them to start an investigation and conduct a narcotic audit going back 30 days. She stated the Pharmacy Account Manager came to the facility to help with the investigation and completed a reconciliation of all resident narcotic medications. The Administrator stated during the narcotic audit they discovered that there were a total of 11 narcotic cards with the declining count sheets that had been removed from the medication carts and 4 of the 11 narcotic cards could not be accounted for, there were no narcotic card, declining count sheets or record of return to the pharmacy. She stated there was one common denominator, the former DON had signed off as having removed all 11 narcotic cards/sheets from the medication carts and they were all removed on the same day. She explained she started comparing the narcotic sheets they were able to locate that the former DON had signed as removing the medication from the medication cart with the pharmacy delivery sheets and report of pharmacy returns. Through that process, she was able to determine what medications were unaccounted for and verify there was no pharmacy order for the unaccounted medications to be returned. She then compared the unaccounted medications with the pharmacy delivery sheets and confirmed there was no order from the pharmacy for a return. She stated they determined the medications that were unaccounted for belonged to Resident #173, #174, #175 and #176. She explained Resident #173 was the only resident still at the facility when the incident occurred and her clonazepam was replaced at the facility's expense. Resident #174 and Resident #175 both had discharged to the hospital and Resident #176 had discharged home. The Administrator stated when the current DON talked to Resident #176, she confirmed no medication was provided to her upon her discharge, but she did get a prescription to have filled. The Administrator stated they could not prove that the former DON took the medications, but it was the only thing they could determine likely happened based on their investigation and the former DON was not returning their calls. The Administrator stated the last day the former DON actually worked at the facility was on 02/25/25 and then she sent a text message on 02/28/25 to the current DON (who was the ADON at the time) stating that she was quitting. She stated the Law Enforcement Detective and DEA Officer came to the facility, talked to each of them individually and then came back to the facility to talk to them again after speaking with the former DON. She stated the Law Enforcement Detective and DEA Officer stated that the former DON denied taking the medications and was basically putting the blame for the missing medications on the current DON. The interview continued with the current DON, Administrator and Regional [NAME] President of Operations all stating the former DON never voiced any concerns of diversion to them and as the DON of record at the time, she could have initiated an investigation if she did have concerns but didn't. They all explained the process at the time was for the DON to pull narcotic medications from the medication cart, scan the bar code to initiate a return to the pharmacy, seal the medication in a bag with the bag number for the return, place the bag on the locked medication cart until pharmacy arrived to pick it up and when pharmacy arrived to pick up the medication, they provided a receipt of return. The Administrator and Regional [NAME] President of Operations both stated they realized the protocol was not being consistently followed and a corrective action plan was discussed at QAPI and implemented. The facility provided the following corrective action plan with a completion date of 03/06/25: How will corrective action be accomplished for those residents found to have been affected by the deficient practice? On Friday, February 28, 2025, the Executive Director was notified by a Medication Aide that Resident #173 Clonazepam 0.5mg tablets and declining count sheet was missing. The current Director of Nursing phoned the pharmacy. The pharmacy checked on the missing Clonazepam 0.5 mg tablets and explained to the DON that the Clonazepam was never returned to the pharmacy. The pharmacy replaced the Clonazepam 0.5 mg rapid tablets on the same day as phoned and the charge for those was billed to the facility. A search of the facility was completed by the Executive Director and the Director of Nursing. This included all offices to included desks, filing cabinets, drawers, bookshelves, boxes, shred boxes, removing locks on any locked drawers, filing cabinets, desks, etc. When the search was completed and the missing medication and declining count sheets could not be located, the Regional [NAME] President of Operations, the Regional Clinical Director of Nursing were notified via telephone conference. It was decided that an audit needed to be started and that an ADHOC QAPI needed to be held to discuss and formulate an action plan. On 2/28/25, the Executive Director and the Director of Nursing conducted a Root Cause Analysis regarding the missing controlled medication for Resident #173. It was determined through the root cause analysis, the system for removing narcotics from the medication cart was not always followed with 2 signatures. It was also identified that shift change controlled substance inventory count sheet was not thorough for accurately tracing of narcotics removed from the cart. Through the review of the Shift Change Controlled Substance Count Sheets, it was identified that the previous Director of Nursing had signed the narcotics off of the cart on 2/21/25. The pharmacy return record of controlled substances was reviewed for the date that the narcotics were signed as removed from the medication cart, lock box and the missing narcotics did not appear on the pharmacy return record of controlled substances. The Medical Director, The Regional [NAME] President of Operations, and the Regional Director of Clinical Services was made aware of this root cause analysis. On 2/28/25, an ADHOC QAPI was held with the following quality assurance performance improvement team members: Executive Director, Director of Nursing, Business Office Manager, Social Worker, Medical Records, Maintenance Director, Rehab Manager, Housekeeping Supervisor, and the Medical Director attended by phone. The proposed plan of correction was reviewed, discussed, and agreed upon regarding the corrections needed to attain and sustain compliance. On 3/1/2025, local law enforcement, the regulatory agency and the Board of Nursing were notified of the missing narcotics. The Board of Nursing was notified of the former Director of Nursing potential involvement in regard to the missing narcotics. How will the facility identify other residents having the potential to be affected by the same deficient practice? The Executive Director and the Director of Nursing completed a quality review of prescribed controlled medications that were received from or returned to the pharmacy over the prior 30 days. This review was conducted from 2/28/25 through 3/4/25 to identify other residents having the potential to be affected by the same deficient practice. Included in the 30-day review were the following: Shift Change Controlled Substance Count Sheets- which indicates how many narcotic cards/containers are active on the cart and also reveals when controlled substances are added and or removed from the cart. -Pharmacy Delivery Sheets -Destruction History -Current Residents with an order for controlled substances -Discharge Residents that had an order for controlled substances -Controlled Substance Declining Count Sheets, Controlled Substances in Medication Carts -Medication administration records related to controlled substances At the conclusion of this process on 3/4/25, 3 other residents were affected by this deficient practice. Included here are the results of the audit: Resident #176 was admitted to the Oaks at Sweeten Creek on 01/13/2025 and discharged home 02/19/2025. Resident #176 had a physician's order for Oxycodone 5mg tablet every 6 hours as needed for pain. The pharmacy delivery report indicated the following was delivered to the facility: 02/14/2025 Oxycodone 5mg tablet- 30 pills-7 day supply. The last dose being administered on 02/19/2025. The shipment that was received on 02/14/2025 including 30 pills had 18 pills remaining that were unaccounted for, and the declining count sheet was also missing. The DON contacted Resident #176 to ask if she was discharged with the narcotic card of medication. Resident #176 indicated she was not discharged with the medication; but that she received a prescription for the medication. The previous DON removed the controlled substance and the declining count sheet from the cart on 02/21/2025. On 03/04/2025, The Executive Director and Pharmacy representative reviewed medications returned to the pharmacy and there was no indication this controlled substance medication was returned, and the declining controlled substance count sheet could not be located. Resident #174 was admitted to the Oaks at Sweeten Creek in 01/27/2025 and discharged to the hospital on 02/08/2025. On 01/30/2025, Resident #174 received a physician's order for Oxycodone 5mg tablet every 6 hours as needed for pain. The pharmacy delivery report indicated the following was delivered to the facility: 01/30/2025 Oxycodone 5mg tablet- 30 pills- 7-day supply. A review of the Medication Administration Record indicated that Resident #174 had 7 pills administered to him during his stay, with the last dose being administered on 02/07/2025. The 23 remaining pills were unaccounted for. It is noted that the previous DON removed the controlled substances and the declining count sheet from the medication cart on 02/25/2025. On 03/04/2025, The Executive Director and Pharmacy representative reviewed medications returned to the pharmacy and there was no indication this controlled substance medication was returned to the pharmacy, and the declining controlled substances count sheet could not be located. Resident #175 was admitted to the Oaks at Sweeten Creek on 02/08/2025 and discharged to the hospital on 02/26/2025. On 02/10/2025, Resident #175 received a physician's order for Oxycodone 5mg tablet every 6 hours as needed for pain. The pharmacy delivery report indicated the following was delivered to the facility: 02/10/2025 Oxycodone 5mg tablet- 28 pills- 7-day supply. A review of the Medication Administration Record indicated that Resident #175 received 10 pills with the last dose being administered on 02/16/2025. The controlled substance medication was discontinued on 02/17/2025. There were18 pills remaining that were unaccounted for. It is noted that the previous DON removed the controlled substance from the medication cart on 02/21/2025. On 03/04/2025, The Executive Director and Pharmacy representative reviewed medications returned to the pharmacy and there was no indication this controlled substance medication was returned to the pharmacy, and the declining controlled substances count sheet could not be located. On 3/4/25, the Pharmacy Account Manager came to the facility to assist with the quality review and concurred with the findings. A licensed nurse completed pain assessments on all current residents on the dates of 3/3/25 through 3/5/25 and there were no residents identified as having pain. On 3/3/2025, the Social Worker conducted interviews with residents with a BIMS of 8 or greater to determine if any of them were in pain, if they received pain medication when they are experiencing pain, and if they have had any issues with receiving pain medications and there were no issues identified. On 3/2/2025, the Executive Director reviewed the grievances for the months of January and February for any issues related to the medication without any concerns noted. What measures will be put into place or systemic changes made to ensure that the deficient practice will not occur? On 3/1/2025, the VP of Clinical Services educated the Executive Director and Director of Nursing via telephone to ensure narcotic control sheets were being utilized per policy, removing controlled substances from the medication carts that are ZEROs (with no pills remaining), removing controlled substances with pills remaining and utilizing the company's policy regarding the returning/ destruction process. On 3/1/2025, The Director of Nursing and Executive Director began education for licensed nurses and medication aides on the policy to ensure proper documentation on controlled substances/ narcotic count sheet and ZERO TOLERANCE- Diversion of Drugs, this education was completed by 3/4/2025 and is included in orientation for newly hired nurses and medication aides. On 03/04/2025, the Pharmacy Account Manager educated the Executive Director and Director of Nursing on delivery and receipt of controlled substances on 3/4/25. Storage and inventory of medications, controlled substances, and products, returns and disposal of medications and controlled substances, maintenance and the file system of controlled substance declining count sheets, delivery and returns to include 2 nurse or 1 nurse and 1 medication aide verification for receiving controlled substances, how to waste/destroy medications, and the Director of Nursing only is to remove narcotics from medication cart along with 1 nurse or 1 medication aide for verification. Per policy, controlled substances are to be removed by the Director of Nursing, any wasted controlled substance is to be performed by two licensed nurses or a licensed nurse and a medication aide. On 03/04/2025, the Executive Director and Director of Nursing educated licensed nurses and medication aides on the new Shift Change Controlled Substances Inventory Count Sheet and delivery and receipt of controlled substances, Storage and Inventory of medications, controlled substances, and products, returns and disposal of medications and controlled substances, maintenance and file system of controlled substance declining count sheets, delivery and returns to include 2 nurse or 1 nurse and 1 medication aide verification for receiving controlled substances, waste/destroy, with the Director of Nursing only to remove narcotics from medication cart with 1 nurse or 1 medication aide for verification. Medication Aides cannot add, remove, destroy/waste of controlled substances without the presence of 1 nurse or the Director of Nursing. Nurses cannot add, remove, destroy/waste of controlled substances without the presence of 1 med aide, another nurse or the Director of Nursing. Newly hired staff will be educated upon hire. The shift change form has been replaced with the Shift Change Controlled Substances Inventory Count Sheet that now includes the following: number of cards, number of count sheets in medication cart, controlled substances added and remove include residents name, medication, strength, number of cards, number of declining count sheets, verified by 2 nurses or 1 nurse and 1 medication aide. Count to be completed with the change of keys from nurse/med aide to nurse/med aide, or when DON is removing controlled substance cards/sheets with doses remaining. It includes the date, time, controlled substance medications at start of the count, declining narcotic count sheets at the start of the count, with 2 signature verification. Also included is the date, time, controlled substance medications at start of the count, declining narcotic count sheets at the start of the count, with 2 signature verification. The directions included on each Shift Change Controlled Substance Inventory Count Sheet are as follows: -Oncoming Nurse/Med Aide must verify count of all controlled substances anytime the keys are changed. If the keys are changed out several times in one day because working partial shifts, then a new row is to be used stating the date and time the controlled substances are inventory count was completed. Only full legible signatures are to be used, NOT INITIALS. -Nurse/Med Aide must count the actual total # of Cards/Containers AND actual total # of count sheets for all supplies in the drawer. -When cards are added, 2 nurses or 1 nurse/1 Med Aide are to [TRUNCATED]

Based on record review and resident, Family Member and staff interviews, the facility failed to have a discharge planning process in place that included documentation of referrals submitted to other skilled nursing facilities (SNF) and documenting the responses to the referrals submitted for a resident who wished to discharge to another SNF closer to family for 1 of 1 sampled resident (Resident #41). Findings included: Resident #41 was admitted to the facility on [DATE] with diagnoses that included quadriplegia (form of paralysis that affects all four limbs and torso, pressure ulcer of the sacral region, osteomyelitis (bone infection), bipolar disorder, and anxiety disorder. Resident #41's comprehensive care plans included a discharge care plan, initiated on 06/13/23 and last revised on 02/02/24, that revealed Resident #41 wished to return to a facility closer to her family and would remain at the current facility for long-term care until a transfer could be made. Review of the Social Services progress notes for Resident #41 for January 2024 to April 2025 revealed the following: - An entry dated 06/14/24 written by the former SW revealed a referral was emailed to a SNF located close to Resident #41's Family Member at the Family Member's request. There was no entry after 06/14/24 noting the SNF's response to the referral sent on 06/14/24. Other than the referral submitted to a SNF on 06/14/24, there were no further entries indicating additional referrals were made to other SNF closer to Resident #41's Family Member during the period January 2024 to April 2025. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #41 had intact cognition and there was no active discharge plan in place. During a phone interview on 04/28/25 at 1:19 PM, Resident #41's Family Member expressed she wanted Resident #41 to move to a SNF closer to her so that she could be more involved in her care. The Family Member revealed she had asked the SW multiple times to send referrals to a SNF near where she lived but when she (Family Member) called the SNF, they had not received any referrals from the SW. The Family Member stated when she tried to call the SW to follow-up on the referrals, the SW didn't call her back. During an interview on 04/28/25 at 3:04 PM, Resident #41 expressed she wanted to transfer to a SNF closer to her home but only if it was an hour or less from her Family Member, otherwise she would just stay at this facility. The former SW was unable to be interviewed during this investigation. During an interview on 04/28/25 at 3:42 PM, the SW revealed she had only been back at the facility since January 2025. The SW stated she had sent several referrals to SNF closer to Resident #41's Family Member but she would have to look through her files to see where and when the referrals were sent. The SW stated she did not follow-up with the SNF after she sent the referral. She explained if the SNF was willing to accept Resident #41, they would contact her but so far she had not received any responses. She stated the Administrator recently printed off a list of SNF close to Resident #41's Family Member and they were currently working on sending additional referrals. During a follow-up interview on 04/30/25 at 12:15 PM, the SW stated she faxed referrals to SNF located close to Resident #41's Family Member on 02/07/25, 02/25/25, 03/03/25, 03/24/25, 04/01/25, and 04/11/25. The SW explained she did not write down the names or contact information of the SNF she faxed the referrals to, only the city where the SNF was located. During an interview on 05/01/25 at 3:02 PM, the Administrator revealed she recently printed off a list of SNF and highlighted each one within a 50 mile radius of Resident #41's Family Member for referrals to be sent. She stated that she knew the SW had previously sent referrals to SNF for Resident #41 but she was not sure if it was feasible for the SW to follow-up on each referral as the other SNF didn't always respond if they were not wanting to make a bed offer. The Administrator stated there should be documentation in the resident's medical record noting where and when referrals were sent when requested by the resident or Responsible Party.

Based on record review, resident and staff interviews, the facility failed to reschedule and hold a care plan meeting that was previously cancelled and invite the resident to participate in the care planning process for 1 of 1 sampled resident (Resident #43). Findings included: Resident #43 was admitted to the facility on [DATE]. Review of a Care Conference Record dated 12/02/24 revealed a quarterly care plan meeting was held with Resident #43 in attendance. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #43 had intact cognition. Review of a Social Worker (SW) progress note dated 03/11/25 revealed Resident #43 was currently in the hospital and his care plan meeting would be rescheduled upon his return to the facility. Review of a physician progress note dated 03/17/25 revealed Resident #43 was seen for a post-hospitalization visit following his hospital stay on 03/08/25 through 03/14/25. Review of Resident #43's electronic medical record revealed no documentation that a care plan meeting was held or Resident #43 was invited to attend a care plan meeting following his return from the hospital on [DATE]. During an interview on 04/28/25 at 9:50 AM, Resident #43 stated he had attended care plan meetings in the past but could not recall attending one this year (2025). Resident #43 stated he was usually notified of upcoming care plan meetings and expressed that he wanted to participate in the care plan meetings so he could communicate and provide input about his care. During an interview on 04/30/25 at 12:15 PM, the SW revealed she was the one responsible for keeping track of the schedule for care plan meetings and invited alert and oriented residents to attend when a care plan meeting was due. The SW confirmed the care plan meeting scheduled for Resident #43 in March 2025 was cancelled due to him being in the hospital. The SW explained she had planned on rescheduling the care plan meeting once Resident #43 returned from the hospital but she dropped the ball and the meeting was never rescheduled. During an interview on 05/01/25 at 5:37 PM, the Administrator explained the SW was very good at keeping track of the care plan meeting schedule and Resident #43's care plan not getting rescheduled following his hospital stay was an oversight. The Administrator stated she would have expected for the SW to make a follow-up note to reschedule Resident #43's care plan meeting when he returned from the hospital and a care plan meeting held with Resident #43.

2. Resident #19 was admitted on [DATE] and re-admitted on [DATE]. Resident #19's diagnoses included paranoid schizophrenia that was present on admission [DATE]). Resident #19 was care planned for receiving antipsychotic therapy (haloperidol) for diagnosis of paranoid schizophrenia dated 10/28/24. Resident #19's annual Minimum Data Set (MDS) assessment dated [DATE] included an active diagnosis of schizophrenia. A review of Resident #19's physician orders revealed an order for haloperidol 0.5 milligrams 2 times daily for diagnosis of paranoid schizophrenia dated 3/14/25. Resident #19's quarterly Minimal Data Set (MDS) assessment dated [DATE] did not include an active diagnoses of schizophrenia. On 5/01/25 at 11:57 AM the MDS Nurse stated Resident #19 was readmitted to the facility on [DATE] with a diagnosis of paranoid schizophrenia. The MDS Nurse stated she was directed to not code a diagnosis of schizophrenia on the MDS by direction of the facilities corporate office after Resident #19's annual MDS assessment had been completed and submitted. She stated Resident #19 did not have enough supporting documentation available when admitted to the facility and the MDS assessment dated [DATE] should not have included the diagnosis of schizophrenia and that was a coding error. The Administrator was interviewed on 5/01/25 at 5:24 PM and stated MDS assessments should be coded accurately. Based on record review and staff interviews, the facility failed to accurately code Minimum Data Set (MDS) assessments in the area of active diagnosis for 2 of 23 residents reviewed for MDS accuracy (Resident #16 and Resident #19). Findings included: 1. Resident #16 was admitted to the facility 03/28/25 with a diagnosis including depression. Resident #16's admission Minimum Data Set (MDS) assessment dated [DATE] indicated she had a diagnosis of post-traumatic stress disorder (PTSD). Review of a Psychiatry evaluation note for Resident #16 dated 04/04/25 read in part as, She did not [have] a history of PTSD. In an interview with the MDS Coordinator on 05/01/25 at 11:57 AM she confirmed she completed Resident #16's admission MDS dated [DATE]. She stated the MDS should not have been coded to reflect Resident #16 had a diagnosis of PTSD and this was a coding error. An interview with the Director of Nursing (DON) on 05/01/25 at 4:38 PM revealed she expected MDS assessments to be coded accurately. An interview with the Administrator on 05/01/25 at 5:39 PM revealed she expected MDS assessments to be coded correctly.

Based on observations, record reviews, staff and resident interviews, the facility failed to assess residents for the ability to self-administer medications for 1 of 1 resident reviewed for self-administering medications (Resident #59). The findings included: Resident #59 was admitted on [DATE] with diagnosis that included type 2 diabetes and gastroesophageal reflux disease. Resident #59 had a physician's order for calcium carbonate antacid 2 tablets every 6 hours as needed for gastroesophageal reflex disease ordered 10/9/24. Resident #59's quarterly minimum data set (MDS) assessment dated [DATE] coded her as cognitively intact. A review of Resident #59's care plan dated 3/7/25 revealed no care plan for self-administration of medication. A review of Resident #59's medical record found no assessment for self-administration of medication. An observation in Resident #59's room on 4/28/25 at 10:58 AM found a partially used bottle of liquid bismuth, a bottle of chewable antacids, and an unopened box of [topical treatment for the mouth and gums that may be used to relieve pain] on her bedside table. The resident stated she had the medications for a long time and would take them when her stomach was hurting. Resident #59 said she had the medications ordered and delivered to her. On 4/28/25 at 2:19 PM an observation with Nurse #2 in Resident #59's room found the medications remained at bedside. Resident #59 stated to Nurse #2 she had always had the medications and that she bought them from a store. Nurse #2 told the resident she was not allowed to keep the medications in her room or take them without a nurse giving them to her to take. On 4/28/25 at 2:19 PM Resident #59's assigned Nurse #2 was interviewed. Nurse #2 stated she had administered Resident #59's medication that morning and had not noticed any medications in Resident #59's room. Nurse #2 said Resident #59 was not assessed to take her own medications and should not have any medications stored in her room. Nurse #2 was observed removing the bottle of bismuth, antacid chewable, and the unopened box of [topical treatment for the mouth and gums] from the bedside table. The Nurse stated she was unaware the Resident had those medications at bedside and did not see them in the room when she administered Resident #59's morning medications. The Director of Nursing (DON) was interviewed on 5/1/25 at 4:37 PM. She stated that Resident #59 would often order items that included medications to be delivered to her at the facility. The DON said Resident #59 would not let the facility search her items or her room for any medications she may have ordered. Additionally, the DON stated Resident #59 needed to have a self-administration of medication assessment completed by a nurse and needed a physician's order for her to self-administer medication. The DON said medications should not be stored in the resident's room and needed to be stored on the nurse's medication cart.

Based on record review and staff interviews, the facility failed to complete a baseline care plan that addressed the resident's immediate needs within 48 hours of admission for 4 of 13 sampled residents (Residents #73, #16, #72, and #323). The findings included: 1. Resident #73 was admitted to the facility on [DATE] with diagnoses that included diabetes, chronic respiratory failure with hypoxia (absence of enough oxygen in the tissues to sustain bodily functions) and chronic obstructive pulmonary disease (difficulty breathing). The nursing admission data collection assessment initiated on 04/28/25 and completed on 04/29/25 revealed Resident #73 received insulin injections, antidepressant and diuretic medications. Review of Resident 73's electronic medical record on 04/29/25 revealed no evidence a baseline care plan that addressed her immediate needs was initiated or completed within 48 hours of her admission to the facility on [DATE]. During an interview on 04/30/25 at 9:13 AM, the Director of Nursing (DON) explained when residents admitted after-hours (after normal business hours) or over the weekend, nursing staff called her and she assisted them with entering physician orders and starting a baseline care plan for the resident. The DON could not explain why a baseline care plan was not initiated for Resident #73 and stated either she or the nurse should have completed a baseline care plan within 48-hours of Resident #73's admission to the facility on [DATE]. During an interview on 05/01/25 at 5:37 PM, the Administrator stated baseline care plans should be completed within 48 hours of a resident's admission. She stated the baseline care plan should contain pertinent information that addressed a resident's immediate care needs for staff until the comprehensive care plans were developed. 2. Resident #72 was admitted to the facility on [DATE] with a diagnosis including muscle weakness. Resident #72 discharged home on [DATE]. Review of Resident #72's medical record revealed there was no baseline care plan included in the medical record. An interview with the Director of Nursing (DON) on 05/01/25 at 4:38 PM revealed the interdisciplinary team initiated the baseline care plan upon admission and it was sent to the MDS Coordinator to assist with developing the comprehensive care plan. She stated once the comprehensive care plan was initiated, the baseline care plan was sent to medical records to be scanned into the electronic medical record. The DON confirmed Resident #72 should have had a baseline care plan and it was overlooked. An interview with the Administrator on 05/01/25 at 5:39 PM revealed she was unaware a baseline care plan was not completed for Resident #72. The Administrator stated she expected all residents to have a baseline care plan completed within 48 hours of the resident's admission. 3. Resident #16 was admitted to the facility 03/28/25 with a diagnosis including colostomy status (having a colostomy in place). Review of Resident #16's baseline care plan dated 03/28/25 did not reflect she had a colostomy (a surgically created opening that connects one end of the large intestine to the abdomen). Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #16 had a colostomy. An interview with the Director of Nursing (DON) on 05/01/25 at 4:38 PM revealed the interdisciplinary team initiated the baseline care plan upon admission and it was sent to the MDS Coordinator to assist with developing the comprehensive care plan. She stated once the comprehensive care plan was initiated, the baseline care plan was sent to medical records to be scanned into the electronic medical record. The DON stated Resident #16's baseline care plan should have reflected that she had a colostomy, and it was an oversight. An interview with the Administrator on 05/01/25 at 5:39 PM revealed she expected baseline care plans to be accurate. 4. Resident #323 was admitted to the facility on [DATE] with diagnoses that included lack of coordination and dementia. Review of Resident #323's medical record revealed there was no baseline care plan completed within 48 hours of Resident #323's admission. An interview with the Director of Nursing (DON) on 5/01/25 at 5:15 PM revealed that she had medical records look for Resident #323's baseline care plan. She stated that a baseline care plan could not be found. She stated that the interdisciplinary team (IDT) was responsible for completing the baseline care plan. An interview with the Administrator on 5/01/25 at 5:44 PM revealed that her expectation was that a baseline care plan be completed within 48 hours of a resident's admission to provide comprehensive care.

Based on record review, observations, and interviews with resident, staff, Nurse Practitioner, Medical Director and Police Officer, the facility failed to discuss with Resident #52 the presence of many needles found in her possession at the hospital, monitor for illegal substances in her room and supervise Resident #52 for triggers of illegal substance abuse for a resident with a known history of substance abuse. Resident #52 was found with many needles in her room while in the hospital on 9/22/23. On 10/5/23, Resident #52 was sent to the hospital after a sudden onset of lethargy, low oxygen saturation and increased heart rate. Hospital staff documented suspicion of illicit drug use. Staff observed drug paraphernalia in her room including vape pens (a handheld device consisting of a battery attached to a cartridge filled with a concentrate), syringes (some used with old blood in the syringe and some with medication residual), medicine cups with medication residual, and flushes. The facility failed to notify law enforcement and obtain Resident #52's consent to search her room to remove any additional illegal drugs or drug paraphernalia. On 12/28/23, a bag with approximately 10-20 insulin syringes with clear and red liquid and another bag with lighters and a vape pen were found in Resident #52's room. Upon investigation on 12/29/23, a folded-up piece of paper with crystals was discovered in one of the bags. Police were notified and identified the crystals as methamphetamine. The facility failed to obtain consent to search Resident #52's room for any additional illegal drugs or drug paraphernalia. This was for 1 of 3 residents reviewed for supervision to prevent accidents. Immediate jeopardy started on 10/5/23 when Resident #52 had a change of condition and staff found drug paraphernalia in her room. Immediate jeopardy was removed on 1/12/24 when the facility implemented an acceptable credible allegation on immediate jeopardy removal. The facility remains out of compliance at a lower scope and severity of E (no actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure education is completed and monitoring systems put in place are effective. The findings included: Resident #52 was admitted to the facility on [DATE] with diagnoses that included quadriplegia (form of paralysis that affects all four limbs and torso), C1-C4 incomplete, respiratory failure with hypoxia (absence of enough oxygen in the tissues to sustain bodily functions), chronic osteomyelitis (bone infection), bipolar disorder, intraspinal abscess, anxiety disorder, chronic pain, opioid dependence with other opioid-induced disorder, obstructive hepatitis, and neuromuscular dysfunction of bladder. Resident #52's care plan initiated on 8/22/23 indicated Resident #52 had chronic pain. Interventions included to administer analgesia as per orders and to give a half hour before treatments or care, evaluate the effectiveness of pain interventions, monitor/document for side effects of pain medication and notify physician if interventions were unsuccessful or if current complaint was a significant change from resident's past experience of pain. Resident #52 did not have a care plan to address her history of substance use disorder. The hospital records for Resident #52's hospital stay from 9/15/23 through 9/28/23 indicated Resident #52 who had a history of intravenous drug abuse-related cervical spine infection was transferred from the facility to the hospital on 9/15/23 due to worsening of a known pressure ulcer. She was noted to have purulent (containing or consisting of pus) drainage. She was on Hydromorphone for chronic pain due to her sacral wounds. The History & Physical dated 9/16/23 indicated she reported to the Emergency Department (ED) doctor that she had used alcohol and methamphetamine in the past with her last use approximately a year ago. A hospital physician note dated 9/22/23 indicated many needles and contraband were found in her room last night. Urine drug screen was not helpful as she had been getting opioids at the hospital although she tested positive for cannabis. She told the doctor that her last intravenous drug use was several months ago in her facility. The urine drug screen done on 9/22/23 indicated Resident #52 was positive for benzodiazepine, cannabinoid, opiate and tricyclic antidepressant. PICC (peripherally inserted central catheter) line was placed on 9/26/23 for intravenous antibiotics. Resident #52 was discharged back to the facility on [DATE] with an order for intravenous antibiotics every 6 hours. The Nurse Practitioner's progress note dated 9/29/23 indicated under history of present illness: The hospital discharge summary reports contraband was found in Resident #52's room on the night of 9/22/23 but she stated that her last intravenous drug abuse was prior to coming to the facility. Left upper extremity had an occlusive superficial vein thrombosis (inflammation of the superficial vein) in the basilic and cephalic veins but no deep vein thrombosis. Plan included to continue (antibiotic medication) via PICC line every 6 hours scheduled until 11/2/23 and current pain regimen included Hydromorphone (opioid medication used to treat moderate to severe pain), Oxycodone (opioid medication used to treat moderate to severe pain), Pregabalin (nerve pain medication), Acetaminophen (analgesic used to treat mild to moderate pain) and Tizanidine (muscle relaxant). An interview with the Nurse Practitioner (NP) on 1/12/24 at 9:02 AM revealed she did not remember asking Resident #52 about the contraband that was found while she was in the hospital in September. The NP stated she might have reviewed the hospital discharge summary after she had already seen Resident #52 and was doing her documentation at the end of the day. The NP stated she did not call the hospital to get more information regarding this incident about Resident #52. She also did not remember if she had talked to the nursing staff about Resident #52 having been found with contraband in the hospital. An interview with the Director of Nursing (DON) on 1/12/24 at 9:42 AM revealed she did not know anything about Resident #52 having been found with contraband and testing positive for cannabinoid while she was at the hospital in September. The DON stated she started working as the DON in the middle of August 2023 but had to take a medical leave for two weeks and then worked a few hours from home and then a few hours at the facility afterwards in September 2023. The DON stated they had an interim Administrator at that time, but she did not find any investigation regarding this incident with Resident #52. A review of Resident #52's Medication Administration Record for September 2023 indicated she received the following medications: * Hydromorphone 8 milligrams (mg) oral tablet 1 tablet by mouth every 8 hours scheduled for chronic pain * Alprazolam 0.5 mg oral tablet 1 tablet by mouth every 8 hours as needed for anxiety * Pregabalin 200 mg oral capsule 1 capsule by mouth three times a day for nerve pain * Oxycodone 10 mg oral tablet 1 tablet by mouth every 6 hours as needed for pain * Tizanidine 6 mg oral capsule 1 capsule by mouth three times a day and 2 mg 1 tablet by mouth every 8 hours as needed for muscle spasms The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #52 was cognitively intact, had no behaviors and had range of motion impairment on both sides of the upper and lower extremities. She required set-up or clean-up assistance with eating and oral hygiene but was totally dependent on staff assistance with other activities of daily living. The MDS further indicated Resident #52 received scheduled and as needed pain medication regimen and complained of frequent pain at a level of 6 (moderately stronger pain). Frequent pain rarely or not at all affected Resident #52's sleep at night and rarely or not at all interfered with her day-to-day activities. Resident #52 had one stage 4 pressure ulcer present upon admission. She received antipsychotic, antianxiety, antidepressant, antibiotic, opioid and hypoglycemic medications. She also received intravenous medications and had an intravenous access while a resident at the facility. The Nurse Practitioner's progress note dated 10/5/23 indicated Resident #52 was seen for concerns of hypovolemia. Recurrent fever of 102.0 (normal body temperature is around 98.6 degrees). The NP ordered intravenous fluids and laboratory studies this morning. Nursing reported Resident #52 had been non-compliant with the intravenous antibiotics and had skipped two doses. Upon initial assessment, she was awake and appropriate. Color pale but last hemoglobin was 8.5 (normal hemoglobin level for females is 12 to 16). Lips dry and urine dark. At that point, the NP was going to continue intravenous fluids and obtain blood cultures. Approximately two hours later, nursing requested reassessment. She was very pale, oxygen saturation 40s (normal level of oxygen is usually 95% or higher), lethargic, with heart rate 120-130s (normal resting heart rate for adults ranges from 60 to 100 beats per minute) and systolic blood pressure 80 (normal blood pressure for most adults is systolic pressure of less than 120 and a diastolic pressure of less than 80). She appeared to be intoxicated. 911 was called for transfer to the emergency room (ER). She was placed on non-rebreather with oxygen saturation up to the 90s. She was more alert and talking. She did receive Hydromorphone scheduled, Oxycodone for breakthrough, and Alprazolam 0.5 mg every 8 hours as needed. She had been given one (dose of Alprazolam) around 12 PM which was two hours prior. Found paraphernalia in her room including vape pens, cigarettes, syringes (some used with old blood in the syringe and some with medication residual), medicine cups with medication residual, and flushes. When questioned she denied using any of the supplies found in her room. She became very tearful. The NP called and discussed with her (family member). Plan included due to fever, tachycardia (fast heart rate) and hypoxia to send to ER for evaluation and treatment. Concerned for possible endocarditis (inflammation of the heart valve). The hospital records for Resident #52's hospital stay from 10/5/23 through 10/25/23 indicated Resident #52 was sent to theER on [DATE] for decreased responsiveness and hypoxia. Resident #52 appeared to be poor historian and was in severe distress with pain and crying during the encounter. She reported that the staff at the facility was not able to wake her up and she was very low on oxygen and was transferred to the hospital. Per ED report, Resident #52's oxygen saturation dropped down to 50% and she was put on 15 liters with a non-rebreather when (her oxygen saturation came up to) around 90%. The urine drug screen dated 10/5/23 indicated Resident #52 was positive for benzodiazepine, cannabinoid, opiate, oxycodone and tricyclic antidepressant. ED note also mentioned concern that Resident #52 might have been crushing up her pain medications and injecting them into her PICC line and possibly also having benzodiazepines snuck into the facility. Toxicology screen on admission was positive for benzodiazepines, cannabinoids, opiates, and tricyclics (although she was prescribed many of these medications chronically). The Infectious Disease (ID) Consultation note dated 10/6/23 indicated the ID doctor recorded that he thought Resident #52 was illicitly injecting/using drugs and this was likely what caused her hypoxia/unresponsiveness/current presentation/readmission rather than a new infection, although they had not ruled this out yet. (She could have a PICC-related bacteremia [presence of bacteria in the bloodstream] or fungemia [presence of fungi or yeasts in the blood] especially if she was using the line illicitly). The ID doctor was also concerned about the possibility of endocarditis given evidence suggesting pulmonary and splenic emboli (sudden blocking of an artery) and recent bacteremia with enterococcus and Klebsiella, but she had been on Ampicillin/Sulbactam covering both of these organisms so he doubted even if she had endocarditis that it would explain this readmission. She was nearly ready to discharge back to the facility on [DATE] when she had recurrent fever to 102.0 and she reported chills, so they requested ID to re-evaluate her to see if any changes were needed. At this point, she had completed four weeks of Ampicillin/Sulbactam and it seemed unlikely that (antibiotic) failure was the cause of her fevers, so ID stopped antibiotics in favor of monitoring fever curve/vitals. Resident #52 had a PICC line that was removed on 10/16/23 and a right-sided internal jugular central venous line was placed. She was transitioned to oral medications and was determined to be stable for discharge on 10/25/23. An interview with Resident #52 on 1/10/24 at 1:08 PM revealed the syringes including the vape pens that were found in her room in October 2023 originally came in with her when she was first admitted to the facility. Resident #52 stated she did not feel comfortable answering more questions because she was trying to transfer to another facility which was closer to her family. She said that if she divulged more information, she felt that this might jeopardize her chances of moving to another facility. An interview with Nurse #2 on 1/10/24 at 9:09 AM revealed she usually took care of Resident #52, but she did not work with Resident #52 on 10/5/23 when she was found non-responsive. Nurse #2 stated that she heard Resident #52 was just checked by the Nurse Practitioner (NP), and she was fine initially. She also heard that they observed paraphernalia in her room including vape pens, cigarettes, syringes, medicine cups with medication residual, and flushes. She heard there was a box of insulin syringes. Nurse #2 stated she had asked Resident #52 later on whether she had used the syringes and she denied having used them. She also asked Resident #52 where she obtained the box of insulin syringes and she stated to her that she had brought them from home before she was admitted to the facility. Nurse #2 stated Resident #52 had no visitors because her family lived six hours away and she had no friends. Nurse #2 stated she could have only gotten the vape pens from staff. Nurse #2 further stated that she remembered Resident #52 having a dresser in her room that she kept locked up so that might have been where she was hiding the paraphernalia found in her room. Nurse #2 also shared that when Resident #52 came back to the facility from her hospitalization in October 2023, they started crushing her medications and putting them in applesauce to make sure that she swallowed her pills. Nurse #2 stated that they thought she might have been cheeking (pretending to swallow medications but actually hiding the pills in the part of the mouth between the gum and the cheek) her pills, crushing them later and then injecting them directly into her PICC line. An interview with the Unit Manager (UM) on 1/8/24 at 3:27 PM revealed she was aware of Resident #52's history of drug use and remembered sometime in October 2023 when she was sick and was receiving intravenous antibiotics through a PICC line. The UM stated all of a sudden she became very lethargic and was not responding. The UM stated they found a box of insulin syringes in her room and then Resident #52 was sent to the hospital. While at the hospital, they ran a drug panel which showed positive for a bunch of substances but then she also received a lot of medications. They kept her at the hospital for a long time before she came back to the facility. Back in October 2023, Resident #52 denied having used any intravenous medications, but the staff speculated that she might have been crushing her oral pills and injecting them directly into her PICC line. The UM stated she remembered one of the ports in Resident #52's PICC line being clogged all the time. When Resident #52 came back to the facility, they started crushing all of her medications and placing them in applesauce to make sure she swallowed her pills. During a follow-up interview with the UM on 1/11/24 at 12:15 PM, she stated that she remembered Resident #52 being non-responsive on 10/5/23 and she reported this to the NP and the Director of Nursing. The UM stated she remembered seeing at least three vape pens in addition to the box of insulin syringes at Resident #52's bedside. The UM stated they suspected Resident #52 of cheeking her oral pills, crushing them and then injecting them directly into her PICC line. After they removed everything they found at Resident #52's bedside, they discarded everything. She remembered trying to find out what kind of vape pens they were, but they thought one was for sure a weed pen. The police were not notified, and they did not come to the facility that day. An interview with the Nurse Practitioner (NP) on 1/10/24 at 9:24 AM revealed she had assessed Resident #52 on 10/5/23 and she was fine but two hours later, she was unresponsive. When she went into her room, they found all kinds of drug paraphernalia including vape pens, syringes, and medicine cups with medication residual. The NP stated there was blood in some of the syringes, so she suspected Resident #52 of not swallowing her pills, crushing them later and then injecting them directly into her skin and into her vein. The NP stated she did not see any marks on Resident #52's skin that day and when she asked her about the syringes in her room, she just cried and denied everything. The NP stated that she told Resident #52 on 10/5/23 that injecting drugs to herself could kill her. The NP also stated that she called Resident #52's family member that day but all she told her was that this was her history and that she had done this before. The NP stated she discussed with Resident #52's family member what actions to take but there was nothing they could do when there were no facilities that would take her. The NP stated that Resident #52 required a facility that offered drug rehabilitation as well as skilled nursing services and this facility was not ideal for her. She shared that when Resident #52 came back to the facility from the hospital in October 2023, she was switched to oral antibiotics, and they decided to crush all her medications. She also shared that Resident #52 was manipulative and tried to trick some of the nurses, so she gave them an order to crush all of her medications. While discussing the drug tests at the hospital, the NP stated that Resident #52 tested positive for cannabinoid which was probably from the vape pens which were found in her room. Her Oxycodone was changed to Hydromorphone while she was at the hospital because it was the medication that was controlling her pain the best. The NP shared she was also hesitant about prescribing Hydromorphone because it was ten times more potent than Oxycodone and was also not ideal with her history of drug abuse. The NP stated Resident #52 was ordering the syringes online. An interview with the Social Worker (SW) on 1/10/24 at 8:74 AM revealed after Resident #52 was readmitted to the facility from the hospital in October 2023, she knew that the nurses had started crushing up her medications whenever they gave them, and she was instructed to open any package together with Resident #52. The SW stated she had been doing this for the last few months and she made sure that there were no suspicious materials or drug paraphernalia such syringes or illegal drugs. An interview with the Director of Nursing (DON) on 1/9/24 at 2:31 PM revealed Resident #52 always had make-up size bags and one fell out into the floor in October 2023. There were insulin syringes and saline flushes with no needles attached with white residue inside. Resident #52 never admitted to doing anything in October 2023, but they thought she had figured out a way to cheat with her medications. The DON stated they thought she was self-injecting her oral pain medications into her PICC line so when she came back to the facility, they started crushing all her medications. The DON also shared that Resident #52 had two different stories regarding how she obtained the insulin syringes: one was that she ordered them online and one was that she had brought them in to the facility when she was first admitted . During a follow-up interview with the DON on 1/11/24 at 11:06 AM, she stated that they were more concerned about sending Resident #52 out to the hospital after she was found unresponsive on 10/5/23 and when she left, she thought she was no longer in danger. The DON stated she didn't know why they didn't call the police to search her room, but they didn't think there were drugs in the vape pens. She stated she thought the vapes were cigarette pens. An interview with the Administrator on 1/10/24 at 3:05 PM revealed he didn't know anything about the incident on 10/5/23 when Resident #52 was unresponsive and was observed with paraphernalia in her room. The Administrator stated there was an interim Administrator at that time, but he hadn't seen any investigation into the incident. A review of the Facility-Reported Incident dated 12/28/23 indicated an original allegation regarding a staff member allegedly brought syringes and/or drugs to Resident #52 sometime on or before 12/28/23. The accused individual's employment was terminated on 1/4/24 and the termination was related to the allegation. Summary of Facility Investigation: Discovery was made by day shift nurse of several used needles in Resident #52's room in a bag near her bed. The Unit Manager verified the same, confiscated the items and kept until police picked them up. Interviews with Resident #52 by the Social Worker, the Administrator and the Director of Nursing verified that Nurse Aide (NA) #1 was supplying Resident #52 with methamphetamine and syringes/needles. Interviews conducted with alert and oriented residents turned up with no further evidence. Skin checks with those residents who were not alert and oriented were completed with no further evidence. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #52 was cognitively intact, had no behaviors and had range of motion impairment on both sides of the upper and lower extremities. She required set-up or clean-up assistance with eating and oral hygiene but was totally dependent on staff assistance with other activities of daily living. The MDS further indicated Resident #52 received scheduled and as needed pain medication regimen and was in almost constant pain at a level of 10 (most severe pain). Frequent pain made it hard for Resident #52 to sleep at night and occasionally limited her day-to-day activities. Resident #52 had one stage 4 pressure ulcer present upon admission. She received antipsychotic, antianxiety, antidepressant, opioid and antiplatelet medications. Resident #52's care plan last reviewed on 12/20/23 indicated Resident #52 had chronic pain. Interventions included to administer analgesia as per orders and to give a half hour before treatments or care, evaluate the effectiveness of pain interventions, monitor/document for side effects of pain medication and notify physician if interventions were unsuccessful or if current complaint was a significant change from resident's past experience of pain. An interview with Resident #52 on 1/8/24 at 10:09 AM revealed she had been completely paralyzed but she was now able to move both arms and could lift her left leg a little. She stated she couldn't sit up on her own. Resident #52 stated NA #1 had been bringing her drugs whenever she worked on the night shift. She shared that this got started after she talked to NA #1 about how she ended up with her medical issues which was from doing intravenous drugs. Resident #52 stated that NA #1 mentioned to her that she did them as well, so they started talking about it and NA #1 offered to bring her some drugs. Resident #52 stated she was still in the beginning of her recovery phase of her drug addiction, and this was not something she should have been exposed to, but it was hard for her to say no. Resident #52 stated NA #1 was bringing methamphetamine to her for free but that this didn't help with her goal of trying to get closer to her family. Resident #52 shared that she didn't have a family member close by and they lived six hours away. The interview further revealed that Resident #52 received the methamphetamine in crystal form, dissolved it with water and shoot it with a syringe. Resident #52 stated she had been doing this for about two months a couple of times a day. Resident #52 denied having experienced any withdrawal symptoms after her drugs were removed from her room. She shared that the methamphetamine gave her more energy and that she was not using it often enough to make her experience withdrawal symptoms. Resident #52 explained that when she went to take a shower, the staff went through her bags and found the drugs, but nobody said anything to her right away. Resident #52 stated nobody talked to her for five days except for Nurse #2 who told her that she could get in trouble for it, and she could get arrested. They called her family member and told her that they were worried because the drugs came from an employee. Resident #52 denied having gone through any drug test or talking to the police about the drugs. Resident #52 explained that some of the liquid in the syringes were red due to blood, but the clear liquid was diluted methamphetamine in water. A follow-up interview with Resident #52 on 1/10/24 at 1:08 PM revealed she didn't remember any of the nurses doing full head-to-toe skin assessments on her. Resident #52 stated that she was re-using the syringes that were discovered and that NA #1 was also supplying her those. Resident #52 shared that she injected the methamphetamine straight into whatever vein she could find on her hands and arms. They sometimes left a bump on her skin but no bruising. During the interview, Resident #52 was wearing long sleeves and kept both hands under her bed sheet. When she occasionally pulled out her hands from under her sheet, no marks were observed on her hands. Resident #52 added that she didn't really time the two doses of methamphetamine injection and she just did them whenever she wanted to. Resident #52 stated that her privacy screen was always pulled up around her bed because staff wanted her door open all the time. She reiterated that she never paid for the methamphetamine and that she didn't have enough money to pay for them. She also shared that the vape that was discovered recently was a vape that she kept with her when she went to the hospital back in October 2023 and she didn't need to refill the cartridge because she didn't use it that often. Multiple attempts were made to contact NA #1 during the investigation, but they were all unsuccessful. A written signed statement dated 12/29/23 by Nurse #2 revealed: On 12/28/23, Resident #52 got up for her shower. Nurse #2 went to wipe Resident #52's bed down with bleach wipes, moved her red and black blanket and her cheetah print bag fell over on the bed. In the bag were needles (several), tissue with blood on them, vapes. Nurse #2 took bag to DON. Resident #52 was upset and crying. Nurse #2 informed Resident #52 that her bag was with the DON. An interview with Nurse #2 on 1/8/24 at 11:59 AM revealed she was wiping Resident #52's bed and sanitizing it while she was getting a shower in the shower room on 12/28/23 when her bag fell over after she moved her blanket. The contents of the bag spilled onto Resident #52's bed and revealed some bloody tissues in the bag, and several insulin syringes. Nurse #2 stated she was not sure whether all the insulin syringes were used but some of them had red liquid, and some had a clear substance. Nurse #2 stated she didn't look at all the contents of the bag because Resident #52 had a bloodborne illness, and she didn't want to touch the used syringes without gloves. Nurse #2 stated they later discovered that there was a folded piece of paper in a perfect square and inside was crystal methamphetamine after the police officer identified it the next day. Nurse #2 stated she did not ask Resident #52 about the contents of her bag because she was already upset and crying. She later found out that Resident #52 said that NA #1 had been bringing the drugs to her for free, but she stated that she did not believe that she was getting them for free. Nurse #2 stated she brought Resident #52's bag to the DON's office and they kept it. A follow-up interview with Nurse #2 on 1/10/24 at 9:09 AM revealed she had been doing skin assessments on Resident #52 and did not notice any marks on Resident #52's arms and hands. Nurse #2 stated Resident #52's arms had always looked gray, and she did not notice anything unusual with her skin or her behavior. An interview with NA #3 on 1/9/24 at 12:41 PM revealed she got Resident #52 up out of the bed because she was scheduled to receive a shower. NA #4 along with another nurse aide were assigned to do showers on 12/28/23. NA #3 helped Nurse #2 wipe Resident #52's bed when her cheetah print bag fell over on her bed and some of the needles/syringes fell out of the bed. NA #3 stated she didn't look much inside the bag but the syringes she saw had caps and she was unsure if they had been used. Nurse #2 took the bag to the DON's office. NA #3 stated that while Resident #52 was receiving a shower in the shower room, she must have known that they were going to discover her bag because she sent NA #4 to retrieve her bag, but they had already given it to the DON. When they put Resident #52 back into bed, she must have realized that her bag was gone because she started screaming and yelling about the bag. She kept crying and told them that she had some needles and vape in there. Resident #52 told her that the nurse gave her the vape but she didn't think that was right and she thought that Resident #52 was just making up that statement. Resident #52 also told her that she had brought in the syringes from when she was admitted to the facility. An interview with NA #4 on 1/11/24 at 9:01 AM revealed while assisting Resident #52 with her shower on 12/28/23, she sent her back into her room to get her pouch from her bed. When she went into Resident #52's room, staff had already gotten her bag, so she went back to tell Resident #52 that she didn't see it. NA #4 stated after she put Resident #52 back into bed, she was crying and said that she was mad about the pouch being gone. Resident #52 told her while she was getting her dressed that she had some needles, syringes and a vape in the pouch. Resident #52 later told her around 5:00 PM that she also had some methamphetamine in the pouch which was brought in to her by NA #1. NA #4 stated she reported this information to the Unit Manager. A written signed statement dated 12/29/23 by the Unit Manager (UM) revealed: On 12/28/23, NA #3 brought her two bags and stated while Resident #52 was getting a shower she was making up her bed and cleaning her room up when she noted these two bags on her bedside table. One bag was green and blue, and the other was leopard print. NA #3 told the UM to look in the bags. Upon observation, the UM noted several needles both used and full of clear or red substances. This was in the green and blue bag. In the leopard print bag, there were lighters and a weed vape. The DON, the Administrator and the Social Worker were informed. Another nurse aide came to the DON's office and stated that Resident #52 told her, while getting her shower, that NA #1, the night shift nurse aide, had been supplying needles and methamphetamine to her when she was working. An interview with the Unit Manager on 1/8/24 at 3:27 PM revealed NA #3 brought to her the two bags that were in Resident #52's room while she was in the shower room. The UM stated she remembered because NA #3 had asked for some bleach wipes to sanitize Resident #52's bed while she was in the shower. The UM looked inside the green and blue bag and saw some needles and syringes which some had clear liqu [TRUNCATED]

Based on record review, observation, and interviews with resident, staff, Nurse Practitioner, Medical Director and Police Officer, the facility failed to provide effective leadership and implement effective systems to manage and supervise a resident with a history of substance abuse after syringes were found in Resident #52's room and protect all residents after Resident #52 reported Nurse Aide #1 was providing her with methamphetamine and syringes. This failure had a high likelihood of affecting other facility residents. Immediate jeopardy started on 10/5/23 when after observing drug paraphernalia in Resident #52's room the facility's administrative team failed to identify the seriousness of the situation and put effective systems in place. Immediate jeopardy was removed on 1/12/24 when the facility implemented an acceptable credible allegation on immediate jeopardy removal. The facility remains out of compliance at a lower scope and severity of E (no actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure education is completed and monitoring systems put in place are effective. The findings included: This tag is cross-referenced to: F607 - Based on record review and interviews with the resident and staff, the facility failed to follow their abuse policy for protection after Resident #52 reported on 12/28/23 that Nurse Aide (NA) #1 had been providing her with methamphetamine and syringes. The facility failed to suspend NA #1 and allowed her to work her scheduled shift on 12/28/23 from 7:00 PM to 7:00 AM on 12/29/23. There were a total of 10 residents with a history of substance abuse. This deficient practice affected 1 of 3 residents reviewed with a history of substance abuse. F689 - Based on record review, observations, and interviews with resident, staff, Nurse Practitioner, Medical Director and Police Officer, the facility failed to discuss with Resident #52 the presence of many needles found in her possession at the hospital, monitor for illegal substances in her room and supervise Resident #52 for triggers of illegal substance abuse for a resident with a known history of substance abuse. Resident #52 was found with many needles in her room while in the hospital on 9/22/23. On 10/5/23, Resident #52 was sent to the hospital after a sudden onset of lethargy, low oxygen saturation and increased heart rate. Hospital staff documented suspicion of illicit drug use. Staff observed drug paraphernalia in her room including vape pens (a handheld device consisting of a battery attached to a cartridge filled with a concentrate), syringes (some used with old blood in the syringe and some with medication residual), medicine cups with medication residual, and flushes. The facility failed to notify law enforcement and obtain Resident #52's consent to search her room to remove any additional illegal drugs or drug paraphernalia. On 12/28/23, a bag with approximately 10-20 insulin syringes with clear and red liquid and another bag with lighters and a vape pen were found in Resident #52's room. Upon investigation on 12/29/23, a folded-up piece of paper with crystals was discovered in one of the bags. Police were notified and identified the crystals as methamphetamine. The facility failed to obtain consent to search Resident #52's room for any additional illegal drugs or drug paraphernalia. This was for 1 of 3 residents reviewed for supervision to prevent accidents. An interview with the Administrator on 1/10/24 at 3:05 PM revealed when staff found the syringes in Resident #52's bag on 12/28/23, they did not know what were in the syringes and at that point, he did not suspect her of any drug abuse. He acknowledged that he waited another 12 hours before notifying the police, but this was after he discovered the folded-up piece of paper with crystals that was tucked in a pocket of the bag. The Administrator stated he wanted to be sure that there were illegal drugs before notifying the police. He stated that corporate staff advised him on the steps to take in reporting and monitoring regarding Resident #52 after she alleged that Nurse Aide (NA) #1 had been bringing her methamphetamine and syringes to the facility. He further stated that they instructed him on how to do a 4-point plan of correction. He added that once Nurse Aide #1 was terminated on 1/4/24 for not cooperating with the investigation, he didn't see anything else happening to Resident #52. He started talking about having done an ad hoc QAPI (Quality Assurance and Performance Improvement) meeting related to this incident but after he looked at his QAPI folder, he realized that there wasn't one done. The Administrator stated the administrative staff started monitoring Resident #52's room daily through rounds and looking for any obvious signs of illegal drugs in the room. The nurses also monitored Resident #52 for changes in behavior. They also did in-services to all staff regarding abuse and their abuse policy. The Administrator added that after he talked to Resident #52, she promised him that she would not engage in illicit drug use anymore while she was at the facility. The Administrator was notified of immediate jeopardy (IJ) on 1/11/24 at 1:37 PM. The facility provided the following credible allegation IJ Removal. * Identify those recipients who have suffered, or are likely to suffer a serious adverse outcome as a result of the noncompliance. The facility failed to provide leadership and effective systems related to a resident with a history of drug abuse not being protected from illegal substances. The facility failed to provide leadership and effective systems related to the protection of all residents after an abuse allegation was made. * Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring and when the action will be complete. The Regional [NAME] President of Operations (RVPO) educated the Executive Director (ED) on 1/11/24 in regard to implementing effective systems or processes to protect residents with a history of substance abuse. The RVPO also educated the ED on the importance of immediate suspension of any suspect in an abuse allegation to ensure the protection of all residents until the investigation is completed. The Regional Director of Clinical Services and the [NAME] President of Clinical Services provided education to the Director of Nursing and Nurse Mangers on the Abuse Policy including the immediate suspension of any suspect until the investigation is completed. The Nurse Managers educated the Department Heads of this process. The ED understands that law enforcement is to be notified at the time of the identification of any suspicion or evidence of any illegal substance abuse. During the facility stand up and stand down meeting residents' with a history of substance abuse will be discussed and reviewed for any signs of substance abuse. The Director of Nursing/Nurse Manager will report to the Executive Director daily during stand up/stand down meetings if any residents have exhibited signs of substance abuse. Upon any receipt of an allegation of abuse, the ED will notify both the RVPO and the Regional Director of Clinical Services (RDCS). Upon notification, the RVPO and/or RDCS will provide additional guidance as needed related to any investigation. The RDCS will provide additional oversight to the center leadership team on implementation of policies to ensure the center has effective systems. As stated in the Employee Handbook, possession of illegal drugs on company property is a Level 2 violation and is grounds for immediate termination. The alleged date of IJ removal is 1/12/24. On 1/12/24, the facility's credible allegation of immediate jeopardy removal was validated by an interview with the Administrator. He stated that he received education by the Regional [NAME] President of Operations regarding processes related to substance abuse which included immediately suspending any suspect and calling the police if they suspected any resident with drug abuse. As the abuse coordinator, he was responsible for conducting the investigation and doing interviews with residents and staff. The facility's date of immediate jeopardy removal of 1/12/24 was validated.

Based on record review and interviews with the resident and staff, the facility failed to follow their abuse policy for protection after Resident #52 reported on 12/28/23 that Nurse Aide (NA) #1 had been providing her with methamphetamine and syringes. The facility failed to suspend NA #1 and allowed her to work her scheduled shift on 12/28/23 from 7:00 PM to 7:00 AM on 12/29/23. This deficient practice had the high likelihood of serious adverse outcome for 10 residents with history of substance abuse which included Resident #52. Immediate jeopardy started on 12/28/23 when the facility failed to follow their abuse policy and protect all residents with a history of substance abuse including Resident #52 by not suspending NA #1 after Resident #52 alleged that NA #1 had been supplying her with methamphetamine and syringes at the facility. Immediate jeopardy was removed on 1/12/24 when the facility implemented an acceptable credible allegation on immediate jeopardy removal. The facility remains out of compliance at a lower scope and severity of E (no actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure education is completed and monitoring systems put in place are effective. The findings included: Review of the facility's Abuse, Neglect, Exploitation & Misappropriation Policies and Procedures revised on 11/16/22 indicated under Protection: Any suspect(s), who is an employee or contract service provider, once he/she has (have) been identified, will be suspended pending the investigation. A review of the Facility-Reported Incident dated 12/28/23 indicated an original allegation regarding a staff member allegedly brought syringes and/or drugs to Resident #52 sometime on or before 12/28/23. An interview with Resident #52 on 1/8/23 at 10:09 AM revealed while she received a shower on 12/28/23, they went through her bags and found the methamphetamine and the syringes. She told NA #4 on 12/28/23 after she received her shower that NA #1 had been bringing her methamphetamine and syringes whenever she worked. Review of NA #1's time sheet for 12/28/23 indicated NA #1 clocked in at 7:26 PM on 12/28/23 and clocked out at 7:23 AM on 12/29/23. Multiple attempts were made to contact NA #1 during the investigation, but they were all unsuccessful. An interview with NA #4 on 1/11/24 at 9:01 AM revealed on 12/28/23, Resident #52 told her while she was getting her dressed that she had some needles, syringes and a vape in the pouch. Resident #52 later told her around 5:00 PM that she also had some methamphetamine in the pouch which were brought in to her by NA #1. NA #4 stated she reported this information to the Unit Manager. A written signed statement dated 12/29/23 by the Unit Manager (UM) revealed: Another nurse aide came to the DON's office and stated that Resident #52 told her, while getting her shower, that NA #1, the night shift nurse aide, had been supplying needles and methamphetamine to her when she was working. During an interview with the Unit Manager (UM) on 1/11/24 at 12:15 PM, she stated that Resident #52 told NA #4 after she gave her a shower on 12/28/23 that NA #1 had been bringing her methamphetamine. The UM indicated she learned about this information from Nurse #6. Nurse #6 told the UM that NA #4 did not want to report it directly to the UM because she was scared that she would get in trouble with Resident #52 if she learned that NA #4 was the one who reported it. After hearing about this information, the UM talked to NA #4 in the DON's office on 12/28/23 and confirmed this story from NA #4. Attempts were made to contact Nurse #6 but they were unsuccessful. An interview with the Director of Nursing (DON) on 1/12/24 at 1:13 PM revealed that she was aware of Resident #52's allegation about NA #1 bringing her drugs on 12/28/23 but their only evidence at that time were the syringes with clear and red liquids. She stated that NA #1 should not have worked on the night of 12/28/23 and they should have suspended her that night. The DON remembered calling NA #1 on 12/29/23 to let her know that she was going to be suspended due to Resident #52's allegations. An interview with the Administrator on 1/10/24 at 3:05 PM revealed that he believed the nurses and the nurse aides discovered the syringes in a bag when it fell over while she was getting a shower on 12/28/23. He and the DON talked to Resident #52, and she admitted to them that NA #1 gave her the syringes and the methamphetamine. Review of a credible allegation of immediate jeopardy removal plan dated 1/11/24 revealed there were currently 10 residents with a history of substance abuse including Resident #52. During a follow-up interview with the Administrator on 1/12/24 at 2:14 PM, he stated that NA #1 should not have worked on the night of 12/28/23 and they should have suspended her immediately when they became aware of Resident #52's allegation on 12/28/23. The Administrator was notified of immediate jeopardy (IJ) on 1/10/24 at 4:16 PM. The facility provided the following credible allegation of IJ removal. * Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance. Resident #52 has a history of drug abuse. On 12/28/23 a bag with approximately 10-20 insulin syringes, some with clear liquid and some with red liquid, was found in the Resident #52's room. Items were removed and placed in the Director of Nursing office. Resident #52 reported Nurse Aide #1 had been providing her with methamphetamine and syringes. The center failed to suspend Nursing Assistant #1 until 12/29/23 and Nursing Assistant #1 worked 7p-7a on 12/28/23. The center failed to provide protection to Resident #52 by not suspending Nurse Aide #1 on 12/28/23. Current residents in the facility have the potential to be affected by the deficient practice. * Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete. On 1/11/24 the [NAME] President of Clinical Services provided education to the Executive Director, Director of Nursing and Nurse Manger about Abuse, Neglect, Exploitation and Misappropriation. Education included implementing effective systems or processes to protect residents with a history of substance abuse. The [NAME] President of Clinical Services also educated the Executive Director, Director of Nursing and Nurse Manger on the importance of immediate suspension of any suspect in an abuse allegation to ensure the protection of all residents until the investigation is completed. Starting on 1/11/24 all current staff, including contract employees, will be educated by the Director of Nursing, Assistant Director of Nursing and/or the Unit Managers on Abuse Policy including the immediate suspension of any suspect until the investigation is completed. Staff members not educated on 1/11/2024 will not work their next shift until their education has been provided. On 1/11/24 the Director of Nursing, Assistant Director of Nursing and/or the Unit Managers will track who has received and not received education daily by using the facility employee roster. The Director of Nursing, Assistant Director of Nursing and the Unit Managers have been notified of this responsibility. On 1/12/24, the Director of Nursing, Assistant Director of Nursing and/or the Unit Managers will continue to provide abuse education to all current employees including contract employees. Education will include the following: the immediate suspension of any suspect until the investigation is completed. Education will continue throughout the night shifts and weekend by Director of Nursing, Assistant Director of Nursing and/or the Unit Managers until current staff have been completed. This will include calling staff who are not on the schedule and are not scheduled to work. The Director of Nursing, Assistant Director of Nursing and the Unit Managers were notified of this responsibility on 1/11/2024. Newly Hired staff will be educated during the Orientation process by the Director of Nursing going forward. The Director of Nursing was notified of this responsibility on 1/11/24. The alleged date of IJ removal is 1/12/24. On 1/16/24, the facility's credible allegation of immediate jeopardy removal was validated by review of documentation regarding staff training on the systems and interventions to protect residents from abuse and the importance of immediate suspension of any suspect in an abuse allegation. Staff interviews revealed receipt of training regarding abuse including immediate suspension of any suspect until the investigation is completed. The facility's date of immediate jeopardy removal of 1/12/24 was validated.

Based on record review, resident and staff interviews the facility failed to obtain dental services when ordered by the medical provider for 1 of 1 resident reviewed for dental services (Resident #52). The findings included: Resident #52 was admitted on [DATE]. with diagnosis that included quadriplegia. Resident #52's quarterly Minimal Data Set (MDS) dated [DATE] coded Resident #52 as cognitively intact and with no dental concerns. A review of a Nurse Practitioner (NP) progress note dated 7/14/23 read in part Resident #52 was seen for reports of dental pain and possible infected gum. The NP additionally wrote the resident had a cavity in the left lower molar and a referral to the inhouse dentist was made. The NP's plan of treatment included using a numbing gel to help numb the pain and clindamycin (antibiotic) 150 mg capsules 2 times daily for 5 days. A review of Resident #52's physician orders revealed an order dated 7/14/23. The order read to set up in-house dental referral for dental abscess/pain/cavities for 7 days. The 7/14/23 order was signed completed on 7/21/23. The previous Social Worker (SW) for the facility stated on 1/12/24 at 12:55 PM a referral to the in-house dentist was submitted for Resident #52 on 7/14/23. The SW recalled and confirmed the order on 7/14/23 and the Resident's insurance status. Resident #52's was on short term Medicaid at that time, and it did not cover an in-house dental visit. Resident #52's long term Medicaid insurance was approved on 10/1/23. The SW stated Resident #52's first in-house dental visit was on 12/20/23 and she was scheduled to have an extraction 1/22/24. The SW said Resident #52 should have been sent out to a dentist when the referral was made but was overlooked. A review of dental visits to the facility revealed the dentist was at the facility on 10/16/23, and 12/20/23. The dental hygienist visited the facility on 10/2/23, 11/9/23, and 11/20/23. Resident #52 was not seen by the dentist or dental hygienist until 12/20/23. Additional NP progress notes revealed Resident #52 was seen on 11/20/23 for reported tooth pain and for a follow up visit on 11/22/23 for reported tooth pain. The NP's assessment revealed the gum around the left bottom back molar was inflamed and edematous and the resident had trouble chewing. Resident # 2 was started on amoxicillin (antibiotic) 500 mg 3 times daily for 3 days and vicious lidocaine (numbing liquid) 2 times daily for 3 days (11/20/23). On 11/20/23 an order read to begin Amoxicillin 500 mg give 1 capsule by mouth 3 times a day for 3 days and viscous lidocaine 2% swish 10 mL 2 times daily for 3 days for dental abscess. The facility's current SW stated on 1/12/24 at 10:00 AM she started working at the facility in October 2023. The SW said she relied on the staff and the residents to let her know who needed to see the dentist. The SW was not aware Resident #52 needed to see the dentist until the referral made on 11/20/23 and Resident #52 was placed on the list to be seen when dental came back to the facility on [DATE]. The SW stated Resident #52 was scheduled to have a tooth extracted on 1/22/24 by the in-house dentist. A review of Resident #52's dental progress noted dated 12/20/23 revealed the resident was seen for a comprehensive oral exam. The Dentist note included the resident needed an extraction of a molar. On 1/8/24 at 10:19 AM Resident #52 stated she had been waiting a couple months to get her tooth pulled. The resident stated she thought she was seen by a dentist a couple weeks ago and was supposed to come back and extract her tooth that had been bothering her. The resident did not report any difficulty or pain with eating or swallowing and the medicine she had taken for her tooth had helped, and she did not have pain. The Nurse Practitioner (NP) stated on 1/12/24 at 9:38 AM a referral was made for Resident #52 to see the in-house dentist on 7/14/23. The NP said Resident #52 had pain in her tooth and gum from a cavity and it was treated with an antibiotic and numbing gel. The NP stated Resident #52 did not see a dentist after the referral on 7/14/23 and was not sure why the resident didn't see a dentist. The NP stated the Resident did not complain of any tooth pain after she was treated on 7/14/23 until she saw the resident 11/20/23 for complaints of tooth pain. Resident #52 had pain in the same tooth and was treated with antibiotics and numbing gel. Resident #52 was referred to see a dentist on 11/20/23 and was seen the following month by a dentist on 12/20/23. Resident #52 was scheduled for a tooth extraction on 1/22/24. The Director of Nursing (DON) stated on 1/12/24 at 1:16 PM she was unaware of the referral written on 7/14/23 to see a dentist for tooth pain. Resident #52 should have been sent out to a dentist when the referral was made, and all dental referrals needed to be reviewed and discussed. The Administrator stated on 1/12/24 at 2:07 PM the resident should have been sent out to see a dentist after the referral was made on 7/14/23.

Based on observation, record review and resident, staff, Nurse Practitioner and Medical Director interviews, the facility failed to safely transfer a resident from the bed to the wheelchair when one staff member used a mechanical lift resulting in the resident falling to the floor for 1 of 4 sampled residents reviewed for accidents (Resident #1). On 04/09/23, Resident #1 fell out of the sling attached to the mechanical lift landing on the floor on his back, hitting his head, sustaining an abrasion to the left elbow, and experiencing increased pain. Resident #1 was transported to the hospital for evaluation, diagnosed with an age-indeterminate (unable to determine if new or old) right L2 (second lumbar spinal vertebrae) transverse process fracture (bony projection on either side of the bones that make up the spinal column) and returned to the facility on [DATE]. As a result, Resident #1 voiced feeling fearful of falling whenever staff transferred him using a mechanical lift. Findings included: Resident #1 was admitted to the facility on [DATE]. His current diagnoses included spinal cord injury and chronic pain syndrome. A Transfer Mobility Status assessment dated [DATE] indicated Resident #1 required a mechanical lift with a full body sling. The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #1 had intact cognition and required total assistance of two staff members with bed mobility and transfers. Resident #1's Activity of Daily Living (ADL) care plan, last reviewed/revised 04/12/23, included an intervention initiated on 07/21/2020 that noted Resident #1 required a mechanical lift with full body sling and two-person assistance for all transfers. During an observation and interview on 05/02/23 at 10:45 AM, Resident #1 was sitting up in his power wheelchair, covered with a blanket and displayed no signs of discomfort. Resident #1 stated he fell out of the mechanical lift during a transfer from his bed to his wheelchair on 04/09/23 and it was the second time staff had dropped him from the mechanical lift, the first time occurring last year. Resident #1 stated typically there were two-staff members present when using the mechanical lift to transfer him but on 04/09/23, he stated Nurse Aide (NA) #3 couldn't find anyone to help her with the transfer so she used the mechanical lift by herself even after he had told her not to. Resident #1 recalled as NA #3 was assisting him out of bed, he was in the sling in the highest position on the mechanical lift when he fell out of the sling to the floor hitting his head and landing on his back. In addition, he also stated he had scraped his left elbow. Resident #1 could not recall how he came out of the sling but stated he was taken to the Emergency Department where he was diagnosed with a brain bleed and lumbar fracture. Resident #1 voiced he was now fearful of falling when staff transferred him using the mechanical lift. During a telephone interview on 05/03/23 at 11:03 AM, NA #3 confirmed she attempted to transfer Resident #1 using a mechanical lift without additional staff assistance on 04/09/23 and he had fallen to the floor during the transfer. NA #3 recalled she had asked other staff for assistance prior to attempting the transfer but they all told her no and she proceeded with transferring him independently because Resident #1 was yelling at her and pressuring her to get him up out of bed. She stated Resident #1 kept telling her that other staff do it all the time and even though she knew better than to transfer him without additional staff assistance she decided to go ahead and transfer him by herself since Resident #1 was getting so angry. NA #3 recalled once she had secured Resident #1 in the sling and lifted him above his bed, the mechanical lift controls stopped working properly and she couldn't get the mechanical lift to raise up or down. NA #3 stated Resident #1 was suspended above his bed and when she tried to move the sling manually, Resident #1 came out of the sling and dropped to the floor. NA #3 could not state for certain how Resident #1 was able to come out of the sling and stated the sling hooks just came loose from the mechanical lift and Resident #1 fell to the bed and then floor. NA #3 stated she immediately went and informed the nurse who came to assess Resident #1. NA #3 confirmed she was instructed to have two-persons during any mechanical lift transfers and stated, I shouldn't have transferred him by myself and feel really bad that it happened. A nurse progress note dated 04/09/23 and written by Nurse #1 read in part, called to resident's room by floor staff. Upon entry, Resident #1 was observed on the floor laying on his back next to his bed. Staff indicated he had fallen out of the mechanical lift. Resident #1 was noted with a small abrasion to his right arm and bleeding noted around his suprapubic catheter site. Resident #1 complained of severe pain all over. Emergency Medical Services (EMS) were called and arrived at the facility with the Fire Department who assisted Resident #1 off of the floor and onto the stretcher. Resident #1 left the facility at 12:00 PM with EMS. An interview was conducted with Nurse #1 on 05/02/33 at 3:50 PM. Nurse #1 confirmed she was working at the facility on 04/09/23 as the Manager on Duty when she was notified Resident #1 was on the floor and immediately went to the room to assess the situation. Nurse #1 stated when she got to Resident #1's room, he was lying on the floor flat on his back, he was alert and complaining of severe pain. Nurse #1 added Resident #1 reported hitting his head when he fell to the floor but upon assessment, she felt no bumps or cuts to the back of his head and the only injury she noted was an abrasion to his left elbow. Nurse #1 stated Resident #1 was not moved and made as comfortable as possible until EMS and the Fire Department arrived to assist him up off the floor and transport him to the hospital for evaluation. Nurse #1 confirmed NA #3 reported transferring Resident #1 using the mechanical lift without additional staff assistance and stated mechanical lifts were supposed to be completed with two-person assistance. Nurse #1 stated when she had NA #3 reenact what she had done during the transfer, the only thing she could figure happened was that NA #3 didn't have the sling hooks attached correctly to the mechanical lift and when NA #3 lifted him, the strap came loose causing Resident #1 to fall out of the sling onto the floor. During an interview on 05/03/23 at 3:44 PM, the Director of Nursing (DON) recalled being notified by Nurse #1 on 04/09/23 of Resident #1's fall during a mechanical lift transfer and came straight to the facility to assist in the investigation. The DON stated on 04/09/23, she started immediate re-education of nursing staff regarding mechanical lift transfers that included observations of nursing staff performing a mechanical lift transfer. The DON stated mechanical lifts should always be completed with two-person assistance for safety reasons and it was never appropriate for a staff member to attempt a mechanical lift transfer independently, they should always wait for additional staff assistance. During an interview on 05/03/03 at 8:03 AM, the Administrator revealed she was notified by Nurse #1 on 04/09/23 Resident #1 had fallen to the floor when NA #3 had attempted to transfer him using a mechanical lift without additional staff assistance. The Administrator recalled when she spoke with NA #3 about the incident, NA #3 reported she wasn't able to find anyone to help her with the transfer and felt Resident #1 was getting mad at her and pressuring her to transfer him out of bed, so she attempted the transfer without additional staff assistance. The Administrator stated it was facility protocol there were 2-persons present for all transfers using a mechanical lift and felt NA #3 had made a poor judgement call by not waiting for other staff to assist. The Administrator explained following the incident, NA #3 was immediately suspended pending an investigation, transfer assessments were completed on all residents, and residents' care plans/Kardex were updated. In addition, she stated all nursing staff completed mechanical lift competencies with return demonstration and were reeducated on mechanical lift procedure that included where to locate information regarding a resident's transfer status and to always have two-person assistance with all mechanical lift transfers. An Emergency Department (ED) report dated 04/09/23 for Resident #1 read in part, presents to the ED after being dropped essentially out of the lift at his skilled nursing facility. The patient apparently was lifted fairly high in his lift chair, he was dropped to the ground landing essentially on his back, he did strike his head but did not have loss of consciousness. The patient is complaining of considerable pain in the mid to upper back, some of which may be chronic. Physical exam: extremities show normal range of motion, no bony or joint deformity, no unilateral calf swelling or tenderness. Alert and oriented to person, place, time, and situation, upper extremities are strong bilaterally, lower extremities are immobile and he has diminished sensation below the knees bilaterally which is chronic. No step off (bones are not lined up properly which can be seen and felt by the examiner) or deformity to the back, considerable low thoracic and upper vertebral tenderness without step off or deformity. The patient's work-up is reviewed, his head Computed Tomography (CT; scan that uses x-rays to create pictures of the head) show possible focal subarachnoid hemorrhage (bleeding inside the brain) along the left frontal lobe without mass effect or evidence of territorial infarct (area of dead tissue resulting from inadequate blood supply) or mass-like lesion. The patient does not have a headache, he continues to complain primarily of back pain. For the most part , his back looks uninjured other than an age-indeterminate right L2 transverse process fracture. Repeat head CT in four hours, if there is no change it may be related to either artifact (something artificial seen on an image but not actually present) or potential inconsequential (not significant) subarachnoid hemorrhage. An ED report addendum dated 04/10/2023 for Resident #1 read in part, He had a CT scan of the head that showed possible focal subarachnoid hemorrhage along the left frontal lobe. Otherwise, his trauma work up was negative for acute injuries. The repeat head CT which was completed at 5:40 PM noted the possible small subarachnoid hemorrhage adjacent to the left frontal lobe is less apparent, may be artifactual. No other evidence of intracranial abnormality. During an interview on 05/03/23 at 11:59 AM, the facility's Interim Maintenance Director revealed the mechanical lift and sling used to transfer Resident #1 on 04/09/23 was immediately placed out of service until a thorough inspection was completed. On 04/13/23, he inspected the mechanical lift which included checking the boom (crane-like arm that uses hydraulics to lift up and down), legs (base of the mechanical lift) breaks, remote, and emergency stop button and all worked properly. He did a thorough check of the sling used during the transfer and there were no rips or tears and the sling hooks were intact. He then used the same sling to hook himself up to the mechanical lift, used the remote to raise himself up and down and everything worked properly. He also completed a thorough check of all the other mechanical lifts in the facility with no concerns identified. The Maintenance Director explained the mechanical lift used to transfer Resident #1 had a hook that spiraled and curved inward and if the sling was attached properly, the weight of the person helped hold the sling and hooks in place and there was no way the sling could have come loose or slid off. The Maintenance Director stated when placing a resident in the sling, the straps should be crossed when attaching the sling hooks to the mechanical lift to secure the resident and ensure there were no exposed areas and his best guess, was that the sling was not attached properly which was how Resident #1 most likely slid out of the sling. A Nurse Practitioner (NP) progress note dated 04/10/23 read in part, Resident #1 seen today following a fall from mechanical lift on 04/09/23. Head CT initially showed a possible small subarachnoid hemorrhage adjacent to the left frontal lobe but with recheck it was less apparent and likely artifactual. Thoracic and lumbar CT showed an age indeterminate right L2 transverse process fracture. He returned to the facility this morning. During an interview on 05/03/23 at 1:56 PM, the Nurse Practitioner (NP) revealed she was notified of Resident #1's fall during a transfer and when she reviewed Resident #1's hospital records, it was noted the L2 fracture was age-indeterminate which meant it could not be determined how or when the fracture occurred. In addition, the NP stated what initially appeared to be a subarachnoid hemorrhage to his left frontal lobe was actually artifactual. The NP explained when she evaluated Resident #1 on 04/10/23 he was already receiving scheduled and PRN (as needed) medications for chronic pain but was complaining of being sore all over and she didn't want to increase the current dosage due to possible sedation but did adjust the scheduled times for his pain medications to be administered. During a telephone interview on 05/03/23 at 4:03 PM, the Medical Director (MD) stated when he reviewed Resident #1's hospital records, the ED report noted the lumbar fracture was age-indeterminate which meant they couldn't tell how old it was or when it happened. The MD explained the fracture could have been the result of the fall on 04/09/23 or something that happened previously, there was just no way to know for sure. The MD stated when Resident #1 returned back to the facility, he was back to his baseline with no apparent residual effects as a result of the fall. The facility provided the following Corrective Action Plan with a completion date of 04/10/23: 1. On 04/09/23, resident was being transferred from the bed to wheelchair by one Nurse Aide utilizing the mechanical lift. Upon interviewing the Nurse Aide, she stated that she was unable to get help and decided to transfer the resident herself due to being pressured by the resident. She stated that she did not feel comfortable but wanted to get the resident up. The Nurse Aide was able to demonstrate how she utilized the sling and how it was hooked up to the mechanical lift. She stated that once she raised the lift it was stuck and she began to pull on it. At that time the strap was under the resident's leg and slipped off the hook causing the resident to slide to the floor and landing on the legs of the lift, back down. The assigned nurse along with the nurse on duty assessed the resident and it was determined the resident would be sent to the ED for evaluation. The resident was alert and oriented and able to answer all questions surrounding the incident. Resident stated he did hit his head and that his back was hurting. Nurses present did not move resident to complete a skin assessment on his back, due to resident complaining of pain. EMS in facility to take resident to hospital for evaluation. X-rays completed at ED did reveal L2 fracture indeterminate age and CT scan revealed a hemorrhage but could be artifactual. Resident remained in the ED overnight and returned to the facility on [DATE]. 2. Nurse Aide involved was immediately suspended pending investigation and educated regarding use of mechanical lift and appropriate positioning of resident. Nurse Aide was also asked to do a return demonstration using the mechanical lift. Mechanical lift that was utilized was taken out of service until inspected by the Maintenance Director, sling that was used was also taken off hallway. Administrator and Director of Nursing met with the Nurse Aide on 04/10/23, written statement received, education provided, written corrective action completed, and mechanical lift competency completed with return demonstration. 3. Reeducation to nursing staff to include Nurse Aides, Nurses and Med Aides initiated on 04/09/23 by the Administrator and Director of Nursing. Education included proper use of the lift, positioning of the slings, and where to find information regarding how residents transfer and if mechanical lift, what sling size to use. All nursing staff will receive education prior to next scheduled shift. Education is ongoing for new hired and contracted staff. a) Mechanical lift competencies completed on all Nurse Aides, Med Aides and Nurses before use of mechanical lifts. b) Transfer assessments completed on 100% of all residents. c) 100% audit of all slings in facility to ensure they were in good condition. d) 100% audit of all care plans and Kardex to ensure correct information in place and updated as needed with new assessment information. e) Director of Nursing or designee will complete random weekly observations of transfers for three (3) employees to ensure that appropriate transfer technique is being done using a mechanical lift three times a week for twelve weeks. 4. Results of random weekly observations will be discussed at the monthly Quality Assurance and Performance Improvement (QAPI) meeting for three (3) months to sustain substantial compliance. 5. Allegation of Compliance Date: 04/10/23. The Corrective Action plan was validated on 05/03/23 and concluded the facility had implemented an acceptable corrective action plan on 04/10/23. Interviews with nursing staff, including agency staff, revealed the facility had provided education and training on use of mechanical lift transfers that included requiring two-person assistance, where to locate information on resident transfer status and what size sling to use if mechanical lift needed. Staff interviewed all verbalized they were observed performing a mechanical lift transfer after receiving reeducation and prior to starting their next shift. Review of the monitoring tools of mechanical lift transfers that began on 04/12/23 were completed weekly as outlined in the corrective action plan with no concerns identified.

Based on record review and staff and Nurse Practitioner (NP) interviews the facility failed to obtain laboratory testing as ordered for a resident with complaints of abdominal pain and decreased appetite. Resident #3 was sent to the Emergency Department (ED) after a change in condition and diagnosed with a urinary tract infection ([CONDITION(S)]) requiring hospitalization . This was for 1 of 1 resident reviewed for hydration. Findings included: Resident #3 was admitted to the facility 08/21/15 with diabetes and adult failure to thrive (a state of decline). Review of NP #1's note dated 02/14/22 revealed she saw Resident #3 for decreased appetite and epigastric discomfort (upper abdominal pain just below the ribs). The note stated she would check a complete blood count (abbreviated as CBC and meaning a blood test which can check for a variety of conditions including [CONDITION(S)], infection, and kidney function), and a comprehensive metabolic panel (abbreviated as CMP and meaning a test which checks the body's chemical balance and metabolism) for leukocytosis (a check of white blood cells that can indicate infection if elevated) and electrolyte balance. A Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of NP #1's note dated 02/15/22 revealed laboratory results were still pending and if they revealed evidence of dehydration intravenous (abbreviated as IV and meaning in the vein) fluids would be ordered. Review of Resident #3's medical record did not reveal any results for a hemoglobin A1C, a CBC, or a CMP obtained on 02/15/22. A nurse's note written by Nurse #1 dated 02/20/22 revealed Resident #3 was sent to the hospital at the request of her Responsible Party (RP) to be evaluated because she was not eating or drinking, not taking her medications, and was having a hard time swallowing. A hospital discharge summary dated 03/01/22 revealed Resident #3 was hospitalized from 02/20/22 to 03/01/22. The summary stated Resident #3 present to the ED on 02/20/22 with decreased responsiveness and being more withdrawn for the past week. The summary noted Resident #3 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #3 completed a 7-day course of [MEDICATION(S)] (an antibiotic) and continued to remain very lethargic. She required a one-to-one caregiver for meals and there was a concern that she would not maintain adequate nutrition and hydration as an outpatient. Resident #3's family declined a feeding tube and she was discharged back to the facility 03/01/22. Discharge diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The significant change Minimum Data Set (MDS) dated [DATE] revealed Resident #3 was severely cognitively impaired and did not reject care. An interview with NP #1 on 06/24/22 at 10:35 AM revealed she saw Resident #3 on 02/14/22 because she was having a poor appetite and abdominal pain. She stated she ordered laboratory tests to be collected 02/15/22 to aide in evaluating Resident #3's condition. NP #1 stated when she saw Resident #3 on 02/15/22 the laboratory tests were still pending. NP #1 stated she was not notified the blood for the laboratory tests ordered for 02/15/22 had not been collected and she should have been notified the tests had not been done. She stated she had no way of knowing if she had received Resident #3's laboratory tests ordered for 02/15/22 if that would have prevented Resident #3 from being hospitalized on [DATE]. During an interview with the Assistant Director of Nursing (ADON) on 06/24/22 she confirmed the hemoglobin A1C, CBC, and CMP ordered 02/15/22 had not been collected. She stated an outside laboratory company was unsuccessful in obtaining the laboratory specimen on 02/15/22 and came again to collect the specimen on 02/16/22. The ADON stated the laboratory company was unable to collect the laboratory specimen on 02/16/22. She stated she was off 02/17/22 and assumed the Unit Manager working 02/17/22 would follow-up on making sure Resident #3's laboratory specimen was collected but the order for Resident #3's lab work ordered 02/15/22 fell through the cracks. During an interview with Unit Manager #1 on 06/24/22 at 03:54 PM she confirmed she worked 02/17/22 and was not aware she needed to follow-up on obtaining lab work for Resident #3. A joint interview with the Administrator and Director of Nursing (DON) on 06/24/22 at 06:23 PM revealed laboratory tests should be collected as ordered.

Based on record review, staff interviews, interviews with the Local Health Department Nurses, an interview with the facility's Medical Director, and review of the facility's COVID-19 Pandemic Plan, the facility failed to conduct required COVID-19 testing on 84 of 84 residents after receiving a positive test result for Nurse Aide #1 on 9/18/2020. Additionally, after completing 76 staff tests on 9/16/2020 and receiving a positive result for Nurse Aide #1 on 9/18/20 the facility failed to continue testing staff every 3 days to 7 days. These failures occurred during a COVID-19 pandemic. From 09/18/20 to 10/12/2020 a total of 53 residents and 18 staff tested positive for COVID-19. Findings included: A review of the facility's policy titled, COVID-19 Pandemic Plan revised 09/21/20 under the section titled, Testing, read in part: Centers will follow Federal and State regulations for testing of staff and residents. Under the section titled, Outbreak Testing read in part: Test all staff and residents in response to an outbreak (defined as any single new infection in staff or any nursing home onset infection in a resident). On 09/16/20 the facility tested sixty staff for the COVID-19 virus utilizing a Real-Time Reverse Transcription Polymerase Chain Reaction (RT-PCR) test (a test considered highly sensitive for the identification of COVID-19). On 09/18/20 one positive COVID-19 result was reported to the facility which identified Nurse Aide (NA) #1. On 09/17/20 sixteen staff were tested utilizing the RT-PCR test and each of these staff tests were negative. Review of the facility's COVID-19 test results revealed no further staff were tested for [MEDICAL CONDITION] from 09/18/20 to 09/27/20 with the exception of NA #1 being retested on [DATE] and 9/23/20. Review of the facility's COVID-19 test results from 09/18/20 to 09/26/20 revealed the facility did not test any residents for the COVID-19 virus during this time period. During a telephone interview on 10/08/20 at 9:54 AM the Director of Nursing (DON) explained she called the Administrator at 8:00 PM on 09/18/20 to inform him of NA #1's positive COVID-19 test result. She then called NA #1 and directed her not to return to work and to self-quarantine. During a telephone interview on 10/07/20 at 3:26 PM the Administrator revealed on 09/18/20 at 8:00 PM he received a message from the DON informing him NA #1 tested positive for COVID-19. The administrator stated he communicated this information to his Local Health Department (LHD) by leaving a voice message with LHD Nurse #2. A conference telephone interview was conducted on 10/08/20 at 11:29 AM with the Administrator and DON. The administrator stated the facility did not test residents on 09/21/20 when their COVID-19 Pandemic Plan was revised because they were going by the guidance from the Local Health Department which was 2 or more positive results constituted an outbreak. The DON revealed their Corporate Nurse Consultant provided clarification on 09/25/20, of what constituted an COVID-19 outbreak. The DON explained their nurse consultant defined an outbreak as being one positive test result and the facility began testing all staff and residents on 09/27/20. On 09/27/20 the facility began testing residents using the Rapid Point of Care (POC) test (a test used for quick detection of an active infection of COVID-19 with moderate sensitivity). The POC results noted that on 09/27/20 one resident was identified as having COVID-19 while at the hospital. The POC results from 09/27/20 to 10/04/20 noted a total of 43 residents had tested positive for the COVID-19 virus. On 09/28/20 the facility began using the Real-time Reverse Transcription Polymerase Chain Reaction (RT-PCR) to test residents for the COVID-19. Review of the 09/28/20 RT-PCR resident test results revealed 27 of 79 residents tested positive for COVID-19, Additionally, from 09/29/20 to 10/02/20 a total of 7 of 82 staff who were tested using the RT-PCR test were positive for COVID-19. On 10/06/20 thirty residents were tested using the RT-PCR test and none of these residents tested positive for COVID-19. A telephone interview on 10/8/20 at 1:24 PM with Local Health Department (LHD) Nurse #2 revealed she was the facility's contact but did not work from 09/04/20 through 10/07/20. LHD Nurse #2 stated when she received a phone call, during this time period that she was not working, her phone's voice message would have provided the caller with instructions to call an alternate phone number if assistance was needed. On 10/07/20 at 11:24 AM a telephone interview was conducted with the Local Health Department (LHD) Nurse #1. Nurse #1 explained she received results from the state surveillance system on 09/26/20 that confirmed NA #1 resulted positive for COVID-19 on 09/23/20. Nurse #1 revealed she contacted the facility on 09/28/20 and was informed testing of residents had begun and the facility was in an outbreak. LHD Nurse #1 recommended the facility test all staff and residents and indicated the facility began testing for COVID-19 on 09/28/20 and sent her those results. Nurse #1 confirmed the test results in the state system for NA #1 was for the 1 positive test on 09/23/20. She stated the facility should report any positive case to their LHD. Nurse #1 revealed if she would have received the lab results of NA #1 being positive on 09/18/20 that would constitute facility wide testing of all staff and residents and her recommendation would have been to begin facility wide testing. A telephone interview was conducted with the facility's Medical Director on 10/09/20 at 12:28 PM. During the interview the facility's Medical Director revealed his criteria was to do what was best for the resident. When the facility first identified NA #1 as being positive for COVID-19 resident testing should have been implemented without delay. The Medical Director indicated the delay in testing and isolating positive residents may have contributed to the facility's outbreak of COVID-19. The Medical Director did not recommend retesting after a positive result was received instead stated the guidance was for health care personnel to self-quarantine and residents be placed on isolation and/or the COVID-19 unit. The facility provided the following Performance Improvement Plan with the plan of correction date of 09/30/2020. The facility staff failed to conduct required COVID-19 testing of 84 residents after receiving a positive test result from nurse aide #1 on 9/18/2020. After completing 76 staff tests on 9/16/2020 a positive nurse aide #1 result came back on 9/18/2020 and the facility failed to continue testing staff every 3 days to 7 days. All residents and staff have the potential of being impacted due to the noncompliant practice on 9/18/2020. Residents #1 and #3 were identified as having the potential of being impacted. On 9/19/2020 resident #1 developed a temperature of 102 degrees Fahrenheit. She was then moved to room [ROOM NUMBER] B on the quarantine hall due to a refusal for COVID testing. Resident #1 was under hospice care and the resident's responsible party was notified and requested comfort care only. Resident #1 did receive a COVID test on 9/28/2020 with a result of positive and resident #1 passed on 10/1/2020. On 9/16/2020, 60 samples were collected from staff. On 9/17/2020, 16 samples were collected from staff. Nurse Aide (NA#1) received a COVID-19 positive result on 9/18/2020. On 9/18/2020 59 staff results were negative. On 9/18/2020 DON alerted Administrator of (NA#1) positive results and also alerted Nurse Aide (NA#1) of results and advised to call her MD and to self-quarantine. Nurse Aide stated understanding. On 9/21/20, 16 samples were reported back as negative. On 9/26/2020 Resident #3, of room [ROOM NUMBER], was discharged to the hospital for [MEDICAL CONDITION]. On 9/27/2020 facility received notification from family that resident #3 tested positive for COVID in hospital. On 9/27/2020 Rapid Point of Care testing was done on 20 residents with 11 resident positive results and 9 resident negative results. On 9/28/2020 79 residents were tested with PCR testing. On 9/30/2020 27 residents test results positive and 52 residents test results negative. On 9/28/2020 1 staff tested with PCR with a result on 10/1/2020 that was negative. On 9/29/2020 58 staff were tested with PCR testing with results on 10/2/2020 of 4 positive and 54 negatives. On 9/30/2020 17 staff were tested with PCR testing with results on 10/3/2020 of 3 positive and 14 negatives. On 10/6/2020 46 staff test with PCR testing with results on 10/8/2020 of 2 positive and 44 negatives. On 10/5/2020 38 residents were tested with PCR testing. On 10/8/2020, 9 resident test results were positive and 29 resident test results were negative. On 10/7/2020 10 staff were tested with PCR testing with results on 10/9/2020 of 2 positive and 8 negatives. On 10/8/2020 4 staff were tested and are currently pending. During the period of 9/18/2020 till 10/12/2020 the facility has confirmed 53 residents positive COVID cases and 18 staff positive COVID cases. On 9/27/2020 the Regional Director of Clinical Services provided education to the Executive Director and Director of Clinical Services on conducting outbreak testing for one positive resident and/or staff to include immediate testing of all negative residents and staff and then continued testing every 3-7 days for at least two consecutive weeks with no new positive results. On 9/29/2020 the Regional Director of Clinical Services provided education to the facility's Interdisciplinary Team (Quality Assurance Performance Improvement Team) to include but not be limited to the Executive Director, Director of Clinical Services, Assistant Director of Clinical Services, Medical Director and at least 1 direct care staff member to review CMS's process on COVID testing and the facility's pandemic plan (revision date 9/28/2020) to include outbreak testing and regulation F 886. The facility infection control policy and procedure (pandemic plan) was updated on 9/28/2020 and is current with CMS guidance on facility testing requirements. The plan is as follows; the facility will immediately conduct outbreak testing for one positive resident and/or staff to include immediate testing of all negative residents and staff and then continued testing every 3-7 days for at least two consecutive weeks with no new positive results. Testing of all staff and residents in response to an outbreak will ensue with any single new infection in staff or resident. For routine testing, the Administrator and/or Director of Nursing and/or Assistant Director of Nursing, who is responsible for testing, will monitor the county positivity rate every other week and adjust the frequency of performing routine staff testing based on the county positivity rate; <5% testing will occur once a month, 5%-10% testing will occur once a week and >10% testing will occur twice a week. If the 48-hour turn-around time cannot be met by the processing lab for any reason, the center will have documentation of its efforts to obtain quick turnaround testing results and contact with the local and state health department. Staff experiencing symptoms will be tested and restricted from facility pending results. Residents with signs or symptoms will be tested and placed on transmission-based precautions pending results. For any residents who refuse testing, those residents will be moved to a warm unit for persons under investigation and placed on transmission-based precautions for the duration of the pandemic. For staff members who refuse testing, they will be sent home until they are either tested or until the pandemic has ended. The DON and/or designee conducted COVID testing for all negative staff members starting on 9/28/2020, 9/29/2020 and 9/30/2020. Staff tested was reconciled against the staff roster to verify all staff were tested . The 4 PRN staff that were not tested on [DATE] were identified and have been notified they have been removed from the schedule until they are able to produce a negative COVID test result that coincides with the current test week. Staff testing continued on 10/6/2020, 10/7/2020 and 10/8/2020. The next scheduled testing will be provided on 10/12/2020 and continue every 3 to 7 days until testing identifies no new cases of COVID-19 infection among staff or residents for a period of at least 14 days since the most recent positive result. Staffing agencies were contacted to inform their staff assigned to the facility to be tested in the facility and/or to bring test results done within prior 7 days with them when reporting for duty for the 1st time. Newly hired staff members must provide initial COVID test results prior to their start date to the Director of Nursing and/or Assistant Director of Nursing. If they have not been tested the facility will complete the initial testing prior to work and any subsequent testing every 3 to 7 days or at the frequency indicated by the county positivity rate. The Director of Nursing and/or designee conducted COVID testing for all negative residents starting on 9/27/2020 and 9/28/2020. Resident testing continued on 10/5/2020. The next scheduled testing will be provided on 10/12/2020 and continue every 3 to 7 days until testing identifies no new cases of COVID-19 infection among staff or residents for a period of at least 14 days since the most recent positive result. On 9/29/2020 The Executive Director, Director of Nursing and/or Assistant Director of Nursing validated (Quality Monitoring) and will continue weekly times 8 weeks, then every other week times 4 weeks and monthly times three months of all negative staff and/or residents that have been tested based off the current CMS guidance on facility testing requirements. The CMS guidance is as follows; the facility will immediately conduct outbreak testing for one positive resident and/or staff to include immediate testing of all negative residents and staff and then continued testing every 3-7 days for at least two consecutive weeks with no new positive results. Testing of all staff and residents in response to an outbreak will ensue with any single new infection in staff or resident. For routine testing, the Administrator and/or Director of Nursing and/or Assistant Director of Nursing, who is responsible for testing, will monitor the county positivity rate every other week and adjust the frequency of performing routine staff testing based on the county positivity rate; <5% testing will occur once a month, 5%-10% testing will occur once a week and >10% testing will occur twice a week. If the 48-hour turn-around time cannot be met by the processing lab for any reason, the center will have documentation of its efforts to obtain quick turnaround testing results and contact with the local and state health department. Staff experiencing symptoms will be tested and restricted from facility pending results. Residents with signs or symptoms will be tested and placed on transmission-based precautions pending results. For any residents who refuse testing, those residents will be moved to a warm unit for persons under investigation and placed on transmission-based precautions for the duration of the pandemic. For staff members who refuse testing, they will be sent home until they are either tested or until the pandemic has ended. The Regional Director of Nursing introduced the plan of correction to the Quality Assurance Performance Improvement Committee on 9/29/2020. The Director of Nursing will report on the results of the quality monitoring (audits) to the Quality Assurance Performance Improvement committee. Findings will be reviewed by QAPI committee monthly and Quality monitoring (audit) updated if changes are needed based on findings. The Quality Assurance Performance Improvement Committee consists of but not limited to the Executive Director, Director of Nursing, Assistant Director of Nursing, Unit Manager, Social Services Manager, Business Office Manager, Activities Director, Human Resources, Pharmacist, Medical Director, CNA, Dietary Manager, Maintenance Director, Housekeeping Supervisor, Admissions, Medical Records, and MDS Nurse. The Quality Assurance Performance Improvement Committee meets monthly and quarterly at a minimum. The Facility alleges the removal of the immediate jeopardy on 9/30/2020. On 10/19/20 the facility's action plan was validated by the following: Interviews with the facility's Interdisciplinary Team which included the Executive Director, Director of Clinical Services, Assistant Director of Clinical Services, and other Department Heads of what constitutes an outbreak and testing requirements. Review of the Quality Assurance Performance Improvement Meeting conducted by the Regional Director of Clinical Services on 09/29/20 with the Interdisciplinary Team on the subject titled, COVID Positive Cases and Mitigation of Transmission of [MEDICAL CONDITION]. Review of the facility's Pandemic Plan revised on 09/28/20 which defined a COVID outbreak and routine testing and using the CMS county positivity rate. Interviews with the Interdisciplinary Team on the facility's surveillance plan of COVID to include delegation of monitoring and reporting to Quality Assurance Performance Improvement Committee. The facility's date of Immediate Jeopardy removal on 09/30/20 was validated.

Based on record review and staff interviews, the facility failed to protect 1 of 3 sampled residents (Resident #1) from physical abuse inflicted by a staff member that resulted in bruising and an abrasion to Resident #1's right cheek. The findings included: Resident #1 was admitted on [DATE] with a [DIAGNOSES REDACTED]. Review of Minimum Data Set (MDS) assessment dated [DATE] revealed Resident#1 was moderately cognitively impaired, had behavioral symptoms that significantly interfered with care and social interaction. The MDS further revealed Resident #1 required limited assistance with bed mobility and extensive assistance with transfers with a 1-person physical assist. Review of Resident #1's care plan dated 12/6/19 revealed a focus area for the problematic manner in which Resident #1 had impaired decision making and ineffective coping skills that included cursing and yelling at staff and peers, refusing care, urinating in courtyard/smoking area, spitting on floor and walls, and throwing medical equipment. The interventions included administration of medications, intervene as necessary to protect the rights and safety of others, provide opportunity for positive interactions, and praise any indication of the resident's progress/improvement in behavior. Review of nursing note dated 1/27/20 revealed a late entry note that stated an altercation had occurred with Resident #1 and 3rd shift Nursing Assistant #1 (NA). The note continued that Resident #1 presented with bruising noted to right cheek and complaints of pain. The physician was contacted and order was received to send Resident#1 to the emergency department for evaluation. Review of Resident #1's Shower Review/skin assessment dated [DATE] revealed bruising and abrasion to right cheek. The assessment stated Resident #1 would not allow nursing staff to complete a full assessment. Review of physician order [REDACTED].#1 to hospital for evaluation and treatment. Review of the 24-hour Report dated 1/27/20 revealed an allegation of physical abuse of Resident #1 by NA #1 that occurred on 1/27/20 at 6:00AM. Notification was made to law enforcement. The 24-hour Report was signed by the Administrator on 1/27/20. Review of the 5-Working Day Report dated 1/29/20 revealed the allegation of abuse of Resident #1 was investigated and substantiated. The report stated on 1/27/20 at approximately 6:00AM, Nurse #1 overheard a commotion on 300 Hall. Nurse #1 entered Resident #1's room (room [ROOM NUMBER]) and observed Resident #1 and NA #1 were in an altercation. NA #1 stated to Nurse #1 that Resident #1 hit her, so she hit him back. NA #1 was asked to leave the building. NA #1 and NA #2 were providing care to another resident when Resident#1 struck NA#1, NA#1 then hit Resident#1. Resident #1 sustained a minor abrasion to the right cheek. Resident #1 was sent to the emergency room for evaluation. NA #1 was suspended on 1/27/20 with termination on 1/29/20. Review of the hospital discharge summary dated 1/27/20 revealed Resident #1 entered hospital following an altercation with an NA at the facility. Resident #1 presented with an abrasion to right cheek and complaints of right facial pain. Resident #1 walked out of the emergency room prior to completion of work up. An interview was attempted on 2/5/20 at 2:40PM with NA #1 via telephone. There was no answer and no message could be left. An interview with NA #2 on 2/5/20 at 3:12PM revealed on 1/27/20 at 6:00AM, NA #2 was providing care to the roommate of Resident #1 (room [ROOM NUMBER]). NA #2 indicated she had asked NA #1 to aid with incontinence care. During this time, Resident #1 became upset stating NA #1, NA #2, and the roommate were too loud. Resident #1 further stated that if they didn't stop, he would hit NA #1 and the roommate. NA #1 responded to Resident #1 using explicit language, you aren't going to do anything. Resident #1 then came behind NA #1 while she was providing care to the roommate and hit her in the face in the area of her eye and cheek bone. NA #1 then swung her arm while turning around and back handed Resident #1, resulting in a cut around Resident #1's right eye. NA #2 believed the cuts on Resident #1's eye were due to NA #1 wearing rings. Resident #1 threatened to sue and to call the police, while attempting to hit NA #1 again. Nurse #1 heard the commotion and came to the room. At this time NA #1 informed Nurse #1 she had hit Resident #1. Nurse #1 removed NA #1 from the floor and asked her to write a statement. Before exiting the building, NA #1 made a call to law enforcement. An interview with Nurse #1 on 2/6/20 at 10:23AM revealed on 1/27/20 while passing meds, she heard a commotion on the 300 Hall. When she arrived at Resident #1's room (room [ROOM NUMBER]), NA #1 and NA #2 were finishing incontinence care with Resident #1's roommate. Resident #1 was observed to be screaming at NA #1. Resident #1 revealed NA #1 had hit him, and NA #1 revealed Resident #1 hit her first. NA #1 indicated she was going to call law enforcement due to Resident #1 assaulting her, which she did prior to leaving the building. Nurse #1 indicated she attempted to assess Resident #1 for injuries, but he refused. Although Resident #1 refused, a small cut was observed under his right eye and the corner of his right eye. The cuts had minimal bleeding and Resident #1's right eye had ruptured blood vessels. Resident #1 originally stated he did not want to go to the emergency room but later stated he wanted to go. Nurse #1 stated she contacted the administrator to make him aware of the incident and the facility physician who provided verbal order to send Resident #1 to the hospital. An interview with Nurse #2 on 2/6/20 at 10:45AM revealed she was not in the facility at the time of the incident on 1/27/20 but did observe Resident #1 on his way out to hospital that same day. He was agitated and she noted a bruise that was blue in color on his right cheek. An interview of Director of Nursing (DON) on 2/6/20 at 1:15PM revealed she was notified via phone on 1/27/20 regarding the incident of abuse between NA #1 and Resident #1. The DON spoke with the Administrator and Nurse #1 and was notified NA #1 had left the building. The DON stated that staff should not get back at residents if a resident was aggressive, staff should ensure the resident's safety and approach later. An interview of Administrator on 2/6/20 at 1:20PM revealed he had been notified of the incident on 1/27/20 at 6:12AM. He immediately came into the building. The Administrator stated NA #1 should have walked away from Resident #1 when he showed agitation. The NA should have reported the incident to the responsible staff member so relief could have been provided and the situation de-escalated. On 2/6/20 at 11:00AM, the facility provided shared the following plan to address the incident: The corrective action for the alleged deficient practice was accomplished by: Resident #1 was offered a focal assessment from witness, on 1/27/2020 but refused full assessment. Resident was observed to have an abrasion on his right check. The local Police Department was notified and arrived at the facility on 1/27/2020 to investigate incident. The Primary Care Physician was notified with orders to transfer resident to Emergency Department of local hospital for assessment. Resident's responsible party was notified by licensed nurse of incident and transfer. Residents with the potential to be affected by alleged deficient practice: Current facility residents who could be interviewed with a BIMS of 8 and above were asked if they had any concerns about their safety by Social Services on 1/27/2020 to include: If anyone has mistreated you since residing here? Has anyone threatened you or verbally abused you since residing here? Are you fearful of anyone while residing here? Do you feel like you are receiving the care that you need while residing here? None voiced concerns. The skin of current residents residing in the facility was checked for suspicious injuries or injuries of unknown origin that would be indicative of abuse/neglect by licensed nurse by 1/28/2020. No issues were found. Employee files for accused, witnesses were reviewed by facility HR Coordinator and Regional HR for background checks and abuse training. Their background checks were clear and all three employees had received Abuse/Reporting education. The facility's grievance book was reviewed by the Regional Director of Clinical Services on 1/27/2020 and no allegations of abuse were noted that needed to be reported to the State of North [NAME]ina. All current employee files were reviewed by the facility HR Coordinator and Regional HR 1/27/2020 thru 1/30/2020. Interdisciplinary Team met on 01/28/2020 to ensure residents with targeted behaviors are documented, care planned, and appropriate interventions are in place. No new concerns were identified. Systemic Changes: Abuse and Abuse Reporting education related to staff acknowledgment that they were aware of the different types of abuse/neglect and who to report it to and how soon to report it began immediately by Nursing Administration with validation of understanding on the morning of 1/27/2020. Education completed as of midnight on 1/27/2020 with 7 nursing employees remaining, one (1) employee with Dietary and (2) two Rehabilitation employees. These were all completed prior to the employee's next scheduled shift. 100% staff education was completed by 1/29/2020. Abuse and Abuse Reporting education included all contract staff of Healthcare Services Group (Dietary, Laundry and Housekeeping) and Genesis Rehabilitation Department. Validation of education was obtained. Each employee reviewed and signed the Abuse and Abuse Reporting Policy and Procedure. QAPI: Ad Hoc QAPI was held on 01/28/2020 and PIP was developed and accepted by the IDT team. QI monitoring will be conducted by the Director of Clinical Services or designee in questioning at least 10 residents and 5 employees 5 x weekly for 4 weeks, 1 x weekly for 4 weeks and then monthly. Quality Improvement Monitoring on abuse and neglect will be accomplished by using: Resident and staff interviews Skin sweeps Chart reviews Facility concerns Employee personnel files. The Director of Nursing Services or designee will report results of QI monitoring to the Quality Assurance Performance Improvement Committee weekly. The QAPI committee will monitor the plan on Abuse/Abuse Reporting. Results of the monitoring will be reported monthly to the QA Committee with revision of plan as identified by the committee. As part of the validation process on 2/6/20, the plan of correction was reviewed and included the in-services related to Abuse and Abuse Reporting for all staff members, including contracted staff, documentation that revealed 100% of all residents with a Brief Interview of Mental Status (BIMS) of 8 or higher were interviewed regarding concerns about safety/abuse, all in- house residents had a skin assessment conducted on 1/27/20, employee files were reviewed to verify background checks and abuse training was completed upon hire, the grievance logs were reviewed to verify no complaints related to abuse were reported, and the QAPI plan to include monitoring to be completed. Date of correction action completion. Final Compliance date 1/31/20.

Based on record review, observations, and staff interviews the facility failed to supervise a cognitively impaired resident with wandering behaviors from exiting the facility for 1 of 1 resident reviewed for accidents related to unsafe wandering/elopement (Resident #74). Immediate Jeopardy (IJ) began on 11/03/18 when Resident #74 was able to exit from the facility without the knowledge of staff. Resident #74 was found approximately 205 feet away from the main entrance door and approximately 85 feet from a stop sign exiting the facility parking which headed towards a long, steep hill and connected to the main highway. Immediate Jeopardy was removed on 12/20/18 when the facility provided an acceptable credible allegation of compliance. The facility will remain out of compliance at a lower scope and severity of D (isolated with no actual harm with potential for more than minimal harm that is not immediate jeopardy) to complete education and ensure monitoring systems put into place are effective to prevent accidents related to wandering/elopement. The findings included: Resident #74 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The baseline care plan initiated 03/07/18 identified elopement and safety with the goal for Resident #74 to remain free of injury. Interventions included a wander risk assessment and to maintain safe environment. Review of an admission assessment dated [DATE] included the elopement/wander risk assessment. The assessment revealed Resident #74 was cognitively impaired, was independently mobile, and had the ability to exit the facility. There were no exit seeking behaviors identified, the resident did not wander oblivious to safety needs, had no history of elopement, and did not demonstrate poor decision making skills. Based on the information it was determined Resident #74 was not at risk for elopement. A Medical Doctor (MD) progress note revealed on 03/08/18 Resident #74 reported his goal was to return to home. Review of the nurse's documentation related to wandering read in part on 03/12/18 from 7:00 AM to 7:00 PM reported by other resident behavior of wandering throughout their room this morning. Staff monitored closely and resident voiced the need of wanting to go home. Was easily redirected by family phone calls. Further review of MD progress notes revealed on 03/16/18 the resident was seen per nursing request of persistent agitated behavior, had been going in and out of other patient rooms consistently day and night, and had not been sleeping. Continued to state, Wants to go home, however cannot tell you where home was. The nurse's note dated 06/04/18 from 7:00 AM to 3:00 PM read in part resident wanders about unit and goes into other resident rooms and occasionally takes their belongings. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] assessed cognitive patterns were severely impaired and wandering behaviors occurred 1 to 3 days during the look back period. For locomotion off the unit Resident #74 required supervision with 1 person and for locomotion on the unit required supervision with setup help by staff. Documentation of a Psychiatric evaluation done 06/13/18 read in part, wandering was problematic at times. Review of nurses' documentation related to wandering read in part: 06/18/18 at 11:30 AM resident has been wandering about facility and going into other resident rooms. 06/23/18 at 11:30 AM resident has been wandering in and out of other resident rooms. 10/19/18 at 11:54 PM resident continues to wander and needs re-directing at times. 10/28/18 at 1:52 AM resident self-propels up and down hall ways in wheelchair during shift. Resident redirected throughout the shift about taking items that does not belong to him. 11/01/18 at 3:42 PM resident up in wheelchair wandering in hallway. 11/01/18 at 10:05 PM resident spent most of shift rolling up and down hallway. 11/02/18 at 12:31 PM resident up in wheelchair wandering in hallway. An elopement incident report completed by the Unit Manager revealed the resident was found unattended outside on 11/03/18 at 9:25 AM. The report revealed Resident #74 was seen outside of the building by another nurse while taking her break. The description of what was observed read in part: resident was wheeling himself outside of the building towards the top of the hill in the driveway by another nurse while outside taking an employee break. No security alarm sounded. The physician was notified on 11/03/18 at 10:00 AM and family was notified 11/03/18 at 10:30 AM. A wander guard was placed and 15 minute checks were initiated. On 11/03/18 at 10:57 AM, Nurse #1 documented while outside on break at the back picnic table, she noted Resident #74 rolling toward the entrance of the building. Upon her investigation of the incident the resident stated, He was going to the bottom of the hill to catch a cab. She was able to coerce the resident back into the building after approximately 10 minutes of negotiating. Resident #74 was deemed an elopement risk and a wander guard was placed and frequently monitoring for placement of the wander guard was initiated. Review of the elopement risk evaluation dated 11/03/18 identified potential risk factors as being cognitively impaired, independently mobile, poor decision-making skills, and had demonstrated exit seeking behaviors with the ability to exit the facility. Risk factors not identified included did not wander oblivious to safety needs with no history of elopement. Based on the assessments potential risk factors Resident #74 was determined to be at risk for elopement. During an interview conducted on 12/19/18 at 10:58 AM, Nurse #1 explained she was not assigned to Resident #74's care and didn't recall noticing him prior to the elopement. She identified the resident had a history of [REDACTED]. While on her break in a designated employee area outside the facility she noted Resident #74 in the driveway leading to the parking lot. The resident was close to a large rock with the facility's name. She estimated it was approximately 10:00 AM when she seen the resident unattended outside and stated, she just happened be there at the right time. After getting the resident back into the facility she informed the Unit Manager who completed an incident report. On 12/19/18 at 11:52 AM, the Maintenance Director and the Administrator measured the distance from the main entrance door to the rock identified by Nurse #1 as where she had seen the resident outside and found it was 205 feet. A second measurement from the rock to the stop sign measured 85 feet. Going from the stop sign forward there was a long, steep hill which lead to the main highway. During an interview conducted on 12/19/18 at 12:03 PM, Nurse Aide (NA) #1 recalled the elopement incident and explained she was assigned to provide direct care for the resident. She explained Resident #74 was already dressed when she first saw him but couldn't provide a description of the clothes he was wearing. She did recall seeing him roam the hallway multiple times prior to the elopement. She estimated it was around breakfast because third shift was gone and it was sunny outside. She recalled seeing Resident #74 approximately 20-30 minutes before hearing he had gotten out of the facility. She was not actively looking for him prior to the elopement, she had not been asked to look for him, and was not aware the resident was missing. During an interview conducted on 12/19/18 at 1:01 PM, NA #2 explained she worked the day of the elopement and was assigned the split which included the hallway Resident #74 resided. She wasn't assigned to provide direct care for Resident #74 and didn't recall seeing the resident prior to the elopement. She wasn't aware of the elopement, was not asked to look for the resident, and did not know the resident was missing. She was asked to get a clean pair of pants for the resident because the pants he was wearing were dirty but couldn't provide a better description of what the resident was wearing. During an interview conducted on 12/19/18 at 2:45 PM, Nurse #2 recalled the elopement and was assigned to provide his care. She was unaware the resident had left the building and no one had alerted her he was missing until after the incident. She could not recall when she last seen him prior to the elopement, but thought he was eating breakfast because other residents were still eating. She explained the resident had not previously tried to leave but would wander throughout the facility. She couldn't provide any information related to the clothes the resident was wearing the day he eloped. During an interview conducted on 12/19/18 at 5:41 PM, the Director of Nursing (DON) explained she doesn't remember what time she was notified by the Unit Manager Resident #74 was found outside of the facility. She explained Nurse #1 brought the resident back into the facility, an elopement assessment was done, and a wander guard placed. She further explained an elopement assessment would be done for a resident who demonstrated exiting seeking behaviors. If the resident was at risk for elopement a wander guard would be placed and the care plan updated. According to the DON, Resident #74 had never demonstrated any signs of trying leave the building or other exit seeking behaviors. She revealed signs for risk of elopement were beating on the door, trying to get out the door, packing bags, and personal items. She explained it had been discussed with staff how to identify signs of elopement and exit seeking behaviors. The resident was not identified as an elopement risk prior to the incident and therefore staff wouldn't have been looking for him. All he had previously done was wander around the facility and wasn't exit seeking. All staff know which residents to look out for and staff who have offices close to the main entrance know to look for residents' leaving the facility. During an interview conducted on 12/19/18 at 5:41 PM, the Regional Director of Clinical Services explained all the doors either have magnetic locks or sounding alarms and the main entrance door had a wander guard alarm. After talking to the staff related to the elopement investigation it was determined Resident #74 was outside for a short period of time. During an interview conducted on 12/19/18 at 5:50 PM, the Administrator revealed he was familiar with Resident #74 who never demonstrated signs of being at risk for elopement or exit seeking behaviors. He explained the resident rolls in the hallways and was never at the exit doors and never talked about going somewhere. The Administrator further explained the resident would stay close to his room and knew where his room was located. According to the Administrator there were no reasons/signs for staff to identify he was at risk for elopement and after the elopement the appropriate actions were taken. During an interview conducted on 12/21/18 at 3:35 PM, the Staff Development/Infection Nurse explained she does the elopement risk assessment for residents already identified at risk for elopement and maintains those quarterly. She does weekly checks which include if the resident was evaluated on admission, quarterly, after being readmitted , and if a significant change was noted. She explained the floor nurse or the MDS Nurse would do the quarterly assessments on all the residents and confirmed Resident #74 had no quarterly elopement assessments available in his chart and no elopement assessment had been done since admission on 03/07/18. An interview conducted on 12/21/18 at 4:20 PM, the Unit Manager (UM) revealed Nurse #1 reported to her between 9:00 AM and 10:00 AM she had seen Resident #74 while on her break outside the facility. He was located in the driveway of the facility but had not made the turn towards the decline in the road. Nurse #1 returned the resident to the facility and the UM documented the incident report, notified the MD, and placed the information in elopement book. She denied Resident #74 had exit seeking behaviors prior to the elopement but had said he was trying to catch a cab. An observation on 12/19/18 at 12:57 PM, Resident #74 was sitting in his wheelchair at the room entrance doorway of his room and was noted to propel himself throughout the hallway. He was wearing a wander guard bracelet on his left wrist. An online website named Weather Underground was used to obtain the outside temperatures in the Asheville area. On 11/03/18 at 8:00 AM the temperature was 38 degrees Fahrenheit with no precipitation with wind speeds of 8 miles per hour (mph). At 10:00 AM the outside temperature was 43 degrees Fahrenheit with no precipitation with wind speeds of 10 mph. The Administrator was notified of the immediate jeopardy on 12/19/18 at 6:10 PM. On 12/20/18 at 2:24 PM, the facility provided the following Credible Allegation of Compliance: Plan for Removal of Immediate Jeopardy: Corrective action for areas affected: On 11/3/2018 at approximately 9:25 am resident #74 exited the building without staff knowledge. Resident #74 exited through the front door and proceeded into the parking lot. Resident # 74 had no injury related to elopement on 11/3/2018. Resident #74 had an elopement assessment completed on 11/3/2018 and a wander guard placed. Resident #74's picture and information was added to the elopement binders, and Clipboard. The elopement binders are located at the nurses' station and in the admissions office by the front door. The clipboard is at the nurses' station and the Interdisciplinary team also have the clipboard. Resident #74 was seen by the Nurse Practitioner on 11/5/18 for routine follow up, no changes in orders on that day. Once the wander guard was applied to resident #74 the front door will lock down if he tries to exit. The staff providing direct care to resident #74 was provided with education on reporting when a resident verbalizes they want to leave and if a resident begins to have exit seeking behaviors when they previously had not on 12/20/2018 by the Director of Nursing. The main front facility entrance and the therapy hall (100 hall) are wired for wander guard. All other facility doors have a magnetic locking system on them except the kitchen delivery door that residents do not have access too. Entrance into the kitchen is locked. The front door is visible from the nursing station but he had not had exiting seeking behavior prior so he didn't have a wander guard on or had been deemed at risk. Other areas having the potential to be affected and corrective actions: 100% of residents currently in the building were re-assessed by Nursing Administration to identify any further residents at risk for elopement on 12/19/2018. No further residents were identified as a new risk. Residents deemed at risk for elopement are added to the elopement binder and added to the facility clip board. Care plans of residents at risk were review/updated to reflect current resident needs by the Minimum Data Assessment Nurse on 12/19/2018. Care plans available through Point Click Care and Point of Care, appearing on the Kardex for the CNA's. Residents are assessed on admission, re admission, quarterly and/or significant change in condition by the licensed nurse. The Regional Director of Clinical Services in-serviced Nursing Administration on Event Management specific to elopements and root cause analysis on 12/19/2018. Licensed Nurses, Certified Nurse Aides, Dietary Staff, Housekeeping Staff, Therapy staff, Maintenance Director, Business Office, Human Resources, were educated on Wandering/Missing Person/Elopement and identifying behaviors of residents who might be exit seeking by Nursing Administration by 12/20/2018. This includes reporting to administration if a resident expresses the desire to leave the facilely and/or has new behaviors of exit seeking, and that residents identified at risk appear on the kardex. The facility does have an elopement policy and elopement is included in the emergency preparedness plan. Measures to ensure practice does not recur: The Regional Director of Clinical Services and/or Nursing Administration in-serviced Licensed Nurses, Certified Nurse Aides, Dietary Staff, Housekeeping Staff, Therapy staff, Maintenance Director, Business Office, Human Resources, 12/98/18-12/20/18 were educated on Wandering/Missing Person/Elopement and identifying behaviors of residents who might be exit seeking and where to locate the elopement binders, and to notify facility ED and/or DON if the behaviors are observed or if the resident verbalizes the intent to try and leave. The training will also be added to the facility orientation agenda for all new employees to be completed by the Nurse Educator or Director of Nursing. All new hires regardless of discipline are to be oriented/trained upon hire about elopement/wandering/missing resident policy and how to identify behaviors of a resident who may be exit seeking. This will include them reporting to leadership if a resident voices the desire to leave the facility. All Staff that were on vacation or FMLA will be in-serviced prior to returning to their work duties. Administrator will maintain a list of staff not in-serviced due to FMLA, vacation, etc. The elopement binders are maintained by the Staff Development Coordinator as changes occur. Once a resident who had not previously been identified is assessed as identified, the clinical team will do an assessment, care plan, update clipboard and the Staff Development Coordinator will update the elopement binders. The facility will interview staff on identifying residents at risk, knowledge of behaviors that can identify someone as exit seeking and their knowledge of where to get current list of residents already identified. Interviews started 12/20/18 with a minimum of 10 staff members. Ten random staff members will be interviewed weekly two times a week for four weeks. The Staff Development Coordinator/Nursing Administration will be responsible for the interview process. The facility Maintenance Director and/or Staff Development will perform Wandering/Missing Person/Elopement drill every shift one time a week for four weeks, then monthly thereafter beginning on 12/19/18. Signs were posted on exit doors for visitors not to assist residents out of the building on 12/19/2018 by the MDS coordinator. This corrective action will be monitored by: Regional Director of Clinical Services will assist with on-site visits to review facility progress with obtaining and maintaining compliance with the plan of correction a minimum of one time a week until substantial compliance is achieved starting 12/19/2018. Corporate staff will provide policies, procedures, education material as needed in order to assist the facility with acquiring and maintaining compliance. The facility QAPI committee had a meeting on 12/19/18 and were informed of the IJ being called and the plan to address the issue. The QAPI committee will monitor the progress of the plan. The QAPI committee will monitor staff interviews on identifying residents at risk, knowledge of behaviors that can identify someone as exit seeking and their knowledge of where to get current list of residents already identified. Elopement drill results will also be reviewed at the QAPI meeting. The date of removal of Immediate Jeopardy was 12/20/2018. The credible allegation was verified on 12/21/18 11:26 AM as evidence by staff interviews. Staff education was initiated on 12/19/18 related to wandering/missing person/elopement and identifying behaviors of residents who might be exit seeking and who to notify if the behaviors were observed or if the resident verbalizes the intent to try and leave. Staff interviewed were able to described the procedure of locating a missing resident which included identification, who and when to notify, and delegating search areas to staff. Included in the training was how to recognize a resident demonstrating elopement behaviors and what to do when the behavior was recognized. Elopement binders were reviewed and location verified.

Based on observations, record review, resident, staff and Family Nurse Practitioner (FNP) interviews, the administration failed to ensure a resident was afforded necessary care and services during facility van transport. This is evident in 1 of 1 sampled resident (Resident #4). Immediate Jeopardy began on 08/10/17 when Resident #4 was being transported to a medical appointment by a facility driver when Resident #4's specialized wheelchair fell backwards resulting in his head hitting the floor of the facility van. Immediate Jeopardy was removed on 08/17/17 when the facility provided and implemented an acceptable credible allegation of compliance. The facility remains out of compliance at a lower scope and severity of D (isolated with no actual harm with potential for more than minimal harm that is not immediate jeopardy) to allow the facility time to monitor and fully implement the new procedure for residents transportation to appointments and other activities and to complete education and ensure monitoring systems put into place are effective related to training of facility van drivers and how to respond in the event of an accident in the facility van and re-education of licensed nursing staff. The findings included: 1. Cross refer to F309: Based on record reviews, resident, and staff interviews the facility failed to get professional staff to assess the resident for possible injury after a fall in the facility transport van and before moving and driving the resident to the facility for 1 of 1 sampled resident (Resident #4) with a van accident. 2. Cross refer to F323: Based on record reviews, resident, and staff interviews the facility failed to secure a resident and his wheelchair during van transportation from the facility to a medical appointment. The driver hit a speed bump in the parking lot and the resident fell backward in his specialized wheelchair resulting in the resident hitting his head. This is evident in 1 of 3 sampled residents (Resident #4). The facility Administrator was informed of Immediate Jeopardy on 08/16/17 at 8:44 AM. The facility provided a credible allegation of compliance on 08/17/17 as follows: On August 10th, 2017, at approximately 8:30 AM, Resident #4 was transported by facility staff to a physician appointment. Resident #4 does utilize a specialized modified wheelchair due to [DIAGNOSES REDACTED].#4, who was in a specialized/non-traditional wheelchair, was secured in the van per the facility procedure for Loading and Unloading a Resident with a (traditional) Wheelchair Lift on a Transport Van. Procedure includes loading resident onto the lift, locking brakes while on the lift, transporting resident from lift into van, proper placement of resident within van, securing the resident on the van, unloading the resident onto the lift, and safely removing the resident from the van. Non-traditional wheelchairs will be evaluated by the Maintenance Director prior to transport to validate if the chair can safely be secured within the company van or if alternate contracted transportation vendors may be necessary to maintain safety. On 8/10/17 at 8:45 AM, during the transport of Resident #4, per the assigned the van driver, the van experienced a bump during locomotion into the parking lot of scheduled appointment. The van driver looked back and noted the resident wheelchair had tipped backward with the resident remaining secured in the wheelchair. The van driver parked the van, tipped the wheelchair into an upright position, and immediately responded to the resident by visually observing the back of the head for any bruising or cuts, and none were visualized. Resident did have initial complaint of headache which did self-resolve prior to returning to facility. On 8/10/17 at 11:00 AM, Resident #4 returned to the facility and the van driver alerted the registered nurse assigned to Resident #4 of the occurrence in the van during transport. The nurse assessed the resident with no injuries noted, no complaints of pain or discomfort. Vital Signs were obtained by the registered nurse that were inclusive of blood pressure 124/55, Pulse 113, Respiration Rate of 18 per minute, and pulse oximetry of 99% and recorded utilizing documentation in the Situation Background Appearance and Review, Fall Risk Evaluation, and Interdisciplinary Progress Note. On 8/10/17 at 12:15 PM, the registered nurse assigned to Resident #4 administered one 650mg tablet of Tylenol by mouth per physicians as needed orders for headache with positive results documented on the Medication Administration Record. On 8/10/17 at 1:30 PM, the registered nurse assigned to Resident #4 notified the facility nurse practitioner with no new orders received for treatment. Resident #4 is his own responsible party. Resident #4 continued to be monitored in excess of 72 hours for changes in condition. No new orders were received and resident did receive two doses of as needed 650 mg Tylenol that was previously ordered for generalized pain. Neurological checks were not documented per policy and procedure for residents who hit their head due to the nurse not being notified that the resident had struck his head during the incident. On 8/15/17 at 11:00 AM, the Maintenance Director completed education and observed reverse demonstration of the facility procedure for Loading and Unloading a Resident with a Wheelchair Lift on a Transport Van to facility designated drivers, inclusive of the Maintenance Assistant and Central Supply Coordinator. The Maintenance Director administered a Safe Driving Quiz with successful results, and reviewed facility policy and procedure S-390 the Fleet Safety Program Motor Vehicle Safety. Facility policy S-390 describes the expectations for transportation employees to operate company vehicles safely and prevent accidents, including but not limited to, training standards, accident reporting, vehicle inspections and maintenance and general safety regulations. On 8/15/17 at 12:00 PM, the Interdisciplinary Team consisting of the Executive Director, Regional Director of Clinical Services, Regional Vice Presidents of Operations, and the Maintenance Director elected to conduct all medically and non-medically related transportation via the contracted providers until completion of appropriate vehicle inspections, education, equipment validation, and appropriation of cellular phone for post incident/accident access to licensed facility staff and/or emergency responders. On 8/15/17 at 2:00 PM the Maintenance Director began reviewing current facility residents to identify any specialty or adaptive wheelchairs or durable medical equipment that may prevent them from transporting safely in a traditional wheelchair. Maintenance Director completed the audit 8/16/17 at 10 AM. Identified residents will be transported with a contracted transportation service that will ensure resident safety during future medically related transports. On 8/16/17 the MDS nurse updated the identified residents ' safety care plan to reflect the contracted transport needs due to specialized and/or modified, non-traditional wheelchair transport needs. A master Non-Facility Transportation log will be maintained in the van and at the nurses' station indicating the appropriate plan of care for safe transport. The master Non-Facility Transportation log will be updated by the Maintenance Director as needed for changes. Drivers will review the master Non-Facility Transportation posted at the nurses station and within the van prior to transport. On 8/16/17 at 10:15 AM, a Quality Assurance Performance Improvement Committee meeting was held with the Executive Director, Regional Director of Clinical Services, Regional Vice President of Operations, Division Vice President of Clinical Services, Vice President of Safety, Division Director of Safety, Vice President of Clinical Education, and Chief Nursing Officer to determine the root cause analysis and develop corresponding action plan to ensure appropriate supervision is provided to prevent accidents during resident report and residents' needs are being met. Through Root Cause Analysis, it was determined that the facility failed to 1) properly train designated non-medically licensed transport staff on proper procedure for response to resident incident/accident that may occur during transport and licensed nurse post-incident/accident procedure 2) identify non- traditional wheelchair equipment that may require additional or alternate transport mechanisms or considerations and 3) provide an individualized care plan to meet the safety needs of each resident. On 8/16/17 at 11:48 AM, the Nurse Practitioner evaluated Resident #4 who denies any injury. He denies visual changes, headache, bump, loss of consciousness, nausea or pain from the fall. Denies abrasions, bruises, or injury. He is alert today, calm and pleasant and denies fever, cough, congestion, dyspnea, chest pain, or GI complaints. On 8/16/17 at 12:30 PM, the Regional Director of Clinical Services provided education to all facility designated drivers, inclusive of the Maintenance Director, Maintenance Assistant, and Central Supply Coordinator who was providing transport for Resident #4, who transport residents in the transport van. The training included the process for responding to resident incidents/accidents during van transport. The education included contacting 911 for medically related emergencies, contacting facility licensed nurse for non-emergent incidents/accidents, and not moving or assessing the resident until licensed assistance arrives. The trained transportation staff will be equipped with a cellular phone 8/17/17 to contact licensed facility staff or emergency medical responders in the event of resident incident/accident during transport. Facility designated drivers will receive reeducation on the process for responding to incidents/accidents during van transport bi-annually completed by the Maintenance Director. Newly hired transportation staff will receive education upon hire and bi-annually thereafter on facility process for responding to resident incident/accidents during van transport by the Maintenance Director. On 8/16/17 at 1:00 PM the MDS nurse updated the Care Plan for Resident #4 to indicate that he will be transported via contracted transportation services that will ensure resident safety during future medically related transports due to the resident utilization of specialized modified wheelchair. Resident #4 will continue to be evaluated quarterly by a MDS nurse and members of the Interdisciplinary team and as needed for any changes to the care plan. Newly hired transportation staff will receive education upon hire and bi-annually thereafter on procedure for safely loading and unloading a Resident, facility process for responding to resident incident/accidents during van transport, the Fleet Safety Program Motor Vehicle Safety completed by the Maintenance Director. On 8/16/17 at 3:40 PM the MDS nurse reeducated licensed nurses on post incident/accident procedure, including but not limited to, initial resident assessment, vital signs, pain assessment, fall assessment (if fall related accident), neurological assessment (if unwitnessed fall or head injury), notification to physician/responsible party and ongoing monitoring for changes in condition for 72 hours. Licensed nurses will not be permitted to work until education is completed. Newly hired nurses will be educated upon hire. On 8/16/17 at 4:30 PM the District Director of Safety completed education to the Maintenance Director on the utilization and completion of the Daily Vehicle Inspection Report and Transport Van Securement Checklist prior to initiating transport of residents in the facility van. Transportation staff will not be permitted to transport residents until completion of this education. Newly hired transportation staff will be educated upon hire and biannually thereafter. On 8/16/17 at 5:00 PM the District Director of Safety completed a visual van equipment inspection to identify any potential safety hazards. No additional hazards were identified. The Director of Maintenance will ensure completion of bi-annual van inspections by a preferred service provider inclusive of the wheelchair securement system. The facility will provide supervision to prevent and properly respond to resident incidents /accidents by ensuring appropriate training to non- medically licensed and licensed nurses to maintain safety during medically related transport. The designated transporter will reference the Daily Vehicle Inspection Report and Transport Van Securement Checklist prior to initiating transport of residents in the facility van. The checklists, along with additional training and reference materials will be maintained and updated by the Maintenance Director and located in a Safety Reference Manual accessible to facility transport staff on van. In the event of a transport incident/accident, the non-medically licensed employee will contact emergency medical responders for life-threatening emergencies and will contact the facility for licensed nurse assistance. The licensed nurse will properly assess resident and complete the post incident/accident procedure as indicated above. The registered nurse assigned to Resident #4 will be provided one to one education by the Regional Director of Clinical Services on obtaining detailed information post incident/accident from the resident and/or witnesses to the event to perform a comprehensive assessment to determine appropriate plan of care. Education will include performing neurological observation for residents' who have hit their head. Education occurred via telephone on August 17, 2017 at 11:10 AM. The Executive Director will be responsible for implementing this credible allegation of compliance. The facility administration will not tolerate failure to adhere to established policies, procedures, training, and other specified guidelines or indications for proper utilization of equipment, supplies, and resources in accordance with manufacturer guidelines to ensure care is provided per resident's individualized plan of care. Failure to adhere to aforementioned criteria can and will result in disciplinary action up to and including termination and reporting to governmental licensing boards and agencies. The credible allegation was verified on 08/17/17 as evidenced by the following: observations of each facility van driver securing a wheelchair in the facility van, verification of re-education for licensed nurses on post incident/accident procedure, education to all facility designated drivers of contacting 911 for medically related emergencies, contacting facility licensed nurse for non-emergent incidents/accidents, and not moving or assessing the resident until licensed assistance arrives, validating the nurse assigned to Resident #4 on the day of the accident was provided re-education regarding gathering post incident/accident information from the resident and/or witnesses to the event to perform a comprehensive assessment and neurological observations for residents' who have hit their head and updated care plans for residents with specialty wheelchairs. Also reviewed were the facility van driver's statement of the accident on 8/10/17, Transport Van Securement Checklist, Non-Facility Transportation Log, Transportation Log, Daily Vehicle Inspection Report, Policies and Procedures for Neurological Assessment and Notification of Change in Condition, Neurological Assessment Flow Sheet, Fall Risk Evaluation, Fall Investigation and Documentation Checklist, SBAR (Situation, Background, Assessment, Review/Request), Fall Response Action Plan and the Root Cause Analysis Investigation.

Based on record reviews, resident, and staff interviews the facility failed to get professional staff to assess the resident for possible injury after a fall in the facility transport van and before moving and driving the resident to the facility for 1 of 1 sampled resident (Resident #4) with a van accident. Immediate Jeopardy began on 08/10/17 when Resident #4 was being transported to a medical appointment by a facility driver when Resident #4's wheelchair fell backwards resulting in his head hitting the floor of the facility van. Resident #4 reported a headache to the facility van driver who had assisted him into an upright position in his wheelchair in the facility van. The facility van driver reported he looked at the back of Resident #4's head to ensure there was no visible injury. The facility van driver assisted Resident #4 to his wound care appointment. After Resident #4's wound care appointment, the resident was transported back to the facility by the facility van driver. The facility van driver reported the accident to the nurse for Resident #4 upon return to the facility. Immediate Jeopardy was removed on 08/17/17 when the facility proved and implemented an acceptable credible allegation of compliance. The facility remains out of compliance at a lower scope and severity of D (isolated with no actual harm with potential for more than minimal harm that is not immediate jeopardy) to complete education and ensure monitoring systems put into place are effective related to training of facility van drivers and how to respond in the event of an accident in the facility van. The findings included: Resident #4 was admitted to the facility 03/02/16. The significant change Minimum Data Set ((MDS) dated [DATE] indicated Resident #4 was alert and oriented with no recent changes in condition or mental status. The MDS also indicated Resident #4 had a [DIAGNOSES REDACTED]. During an interview on 08/15/17 at 10:44 AM Resident #4 stated he had a wound care appointment on 08/10/17 that required the use of the transport van. Resident #4 stated as they were driving and went over a bump his wheelchair fell backward and he hit his head on the floor. Resident #4 stated the facility van driver assisted him back to an upright position in his wheelchair. Resident #4 stated he reported to the facility van driver that he had a headache and the driver checked the back of his head and saw no injury so Resident #4 went on to his wound care appointment. Resident #4 stated no one at his wound care appointment examined his head and after his appointment he was transported back to the facility. Resident #4 stated the nurse came to assess him for injuries at the facility and he reported to the nurse that he had a headache. Resident #4 stated the nurse gave him Tylenol for his headache. Resident #4 denies any further pain or discomfort related to the fall. During an interview on 08/15/17 at 11:02 AM with the facility van driver he stated he was transporting Resident #4 to a medical appointment on 08/10/17 in the facility van. The facility van driver stated they were in the parking lot where Resident #4's appointment was and went over a speed bump and he heard a thump and looked back and saw Resident #4 had fallen backward in his wheelchair. The facility van driver stated the tie down straps had loosened which allowed the wheelchair to fall backwards but Resident #4 was still strapped securely in his wheelchair when he assisted him back into an upright position. The facility van driver stated Resident #4 told him he hit his head on the floor and the driver looked at the back of his head and did not see any redness, bruising or bleeding. The facility van driver stated he re-secured the wheelchair of Resident #4 until they were parked and then he assisted him out of the facility van for his medical appointment. After his medical appointment, Resident #4 was transported back to the facility and the facility van driver stated he told the nurse for Resident #4 about the accident and that Resident #4 had hit his head. The facility van driver stated he was not sure what happened after he told the nurse. During a phone interview on 08/15/17 at 1:10 PM with the nurse who assessed Resident #4 on the day of his accident, she stated she had been told by the facility van driver that Resident #4 had fallen out the wheelchair in the van. The nurse stated that she went to Resident #4 ' s room and assessed him and he had no injuries and no pain. The nurse also stated that she let the Family Nurse Practitioner know and completed an accident/incident report. The nurse stated that she did give Resident #4 Tylenol for a headache but it was unrelated to him having an injury from the accident as he already had this available for pain and headache and requested it regularly. During an interview on 08/15/17 at 1:47 PM with the Director of Nursing (DON), she stated she had been notified that Resident #4 had an accident on the van and went to his room on 08/10/17 to check on him. The DON stated Resident #4 stated that he was okay and that he was not hurt. The DON stated she told the facility van driver to write up his statement about what happened and submit it to her. The DON stated the facility van driver turned in his statement the next day and when she read it found out that Resident #4 had hit his head. The DON stated she went back down to see Resident #4 and he told her that he was fine, had no pain, and no injury from the accident. The DON stated her expectations were for the facility van driver to have called the facility when the accident occurred and let someone know what happened so it could be determined what medical treatment may be necessary. During an interview on 08/16/17 at 3:35 PM with the Family Nurse Practitioner (FNP), she stated she had been made aware of the incident on 08/10/17 but was not aware he had bumped his head at that time. The FNP further stated she had assessed him on 08/16/17 and Resident #4 stated he had bumped his head but had no injury from the incident that occurred on 08/10/17. On 08/16/17 at 8:44 AM the Administrator was informed of the Immediate Jeopardy. The facility proved a credible allegation of compliance on 08/17/17 at 11:55 AM. The allegation of compliance indicated the following: To remove the immediacy, the facility has initiated and/or completed the following: On August 10th, 2017, at approximately 8:30 AM, resident #4 was transported by facility staff to a physician appointment. Resident #4 does utilize a specialized modified wheelchair due to [DIAGNOSES REDACTED]. On 8/10/17 at 8:45 AM, during the transport of Resident #4, per the assigned the van driver, the van experienced a bump during locomotion into the parking lot of scheduled appointment. The van driver looked back and noted the resident's wheelchair had tipped backward with the resident remaining secured in the wheelchair. The van driver parked the van, tipped the resident, who was still seated in his wheelchair, into an upright position, and immediately responded to the resident by visually observing the back of the head for any bruising or cuts, and none were visualized. The resident stated to the van driver that he hit his head on the floor of the van when he fell . Resident did have initial complaint of headache which did self-resolve prior to returning to facility. The van driver did not contact the facility's licensed staff or call 911 to inform them that the resident fell and hit his head. The van driver noticed the van's floor straps that were affixed to the front of the resident's wheelchair were now loose and he secured the straps to the wheel chair and transported the resident onto his appointment. On 8/10/17 at 11:00 AM, resident returned to the facility and the van driver alerted the registered nurse assigned to Resident #4 of the occurrence in the van during transport, but did not inform her that the resident hit his head when he fell per the nurse. The nurse assessed the resident with no injuries noted, no complaints of pain or discomfort. Vital Signs were obtained by the registered nurse that were inclusive of blood pressure 124/55, Pulse 113, Respiration Rate of 18 per minute, and pulse oximetry of 99% and recorded utilizing documentation in the Situation Background Appearance and Review and Notify form, Fall Risk Evaluation, and Interdisciplinary Progress Note. On 8/10/17 at 12:15 PM, the registered nurse assigned to resident #4 administered one 650mg tablet of Tylenol by mouth per physicians as needed orders for headache with positive results documented on the Medication Administration Record. On 8/10/17 at 1:30 PM, the registered nurse assigned to Resident #4 notified the facility nurse practitioner with no new orders received for treatment. Resident #4 is his own responsible party. Resident continued to be monitored daily for changes in condition or complaints of headache and none were observed or reported. Neurological checks were not documented per policy and procedure for residents who hit their head due to nurse not being notified that the resident had struck his head during the incident. The registered nurse assigned to Resident #4 will be provided one to one education by the Regional Director of Clinical Services prior to her next work shift on obtaining detailed information post incident/accident from the resident and/or witnesses to the event to perform a comprehensive assessment to determine appropriate plan of care. Education will include performing neurological observation for residents ' who have hit their head. Education occurred via telephone on August 17, 2017 at 11:10 AM. On 8/16/17 at 10:15 AM, a Quality Assurance Performance Improvement Committee meeting was held with the Executive Director, Regional Director of Clinical Services, Regional Vice President of Operations, Division Vice President of Clinical Services, Vice President of Safety, Division Director of Safety, Vice President of Clinical Education, and Chief Nursing Officer to determine the root cause analysis and develop corresponding action plan to ensure quality care is provided by qualified personnel to meet the needs of the resident. Through Root Cause Analysis completed on 8/16/17 at 11:15 AM, it was determined that the facility failed to properly train designated non-medically licensed transport staff on proper procedure and response to resident incident/accident that may occur during transport. On 8/16/17 at 11:48 AM, the Nurse Practitioner evaluated Resident #4 who denies any injury. He denies visual changes, headache, bump, loss of consciousness, nausea or pain from the fall. Denies abrasions, bruises, or injury. He is alert today, calm and pleasant and denies fever, cough, congestion, dyspnea, chest pain, or GI complaints. On 8/16/17 at 12:30 PM, the Regional Director of Clinical Services provided education to all facility designated drivers, inclusive of the Maintenance Director, Maintenance Assistant, and Central Supply Coordinator who was providing transport for Resident #4, who transport residents in the transport van. The training included the process for responding to resident incidents/accidents during van transport. The education included contacting 911 for medically related emergencies, contacting facility licensed nurse for non-emergent incidents/accidents, and not moving or assessing the resident until licensed assistance arrives. The trained transportation staff will be equipped with a cellular phone 8/17/17 to contact licensed facility staff or emergency medical responders in the event of resident incident/accident during transport. Facility designated drivers will receive reeducation on the process for responding to incidents/accidents during van transport bi-annually completed by the Maintenance Director. Newly hired transportation staff will receive education upon hire and bi-annually thereafter on facility process for responding to resident incident/accidents during van transport by the Maintenance Director. On 8/16/17 at 3:40 PM the MDS nurse reeducated licensed nurses on post incident/accident procedure, including but not limited to, initial resident assessment, vital signs, pain assessment, fall assessment (if fall related accident), neurological assessment (if unwitnessed fall or head injury), notification to physician/responsible party and ongoing monitoring for changes in condition for 72 hours. Licensed nurses will not be permitted to work until education is completed. Newly hired nurses will be educated upon hire. The Executive Director will be responsible for implementing this credible allegation of compliance. The credible allegation was verified on 08/17/17 as evidenced by observations of each facility van driver securing a wheelchair in the facility van, verification of re-education for licensed nurses on post incident/accident procedure, education to all facility designated drivers of contacting 911 for medically related emergencies, contacting facility licensed nurse for non-emergent incidents/accidents, and not moving or assessing the resident until licensed assistance arrives, validating the nurse assigned to Resident #4 on the day of the accident was provided re-education regarding gathering post incident/accident information from the resident and/or witnesses to the event to perform a comprehensive assessment to determine appropriate plan of care and performing neurological observation for residents' who have hit their head.

Based on record reviews, resident, and staff interviews the facility failed to secure a resident and his wheelchair during van transportation from the facility to a medical appointment. The driver hit a speed bump in the parking lot and the resident fell backward in his specialized wheelchair resulting in the resident hitting his head. This is evident in 1 of 3 sampled residents (Resident #4). Immediate Jeopardy began on 08/10/17 when Resident #4 was being transported to a wound care appointment by a facility driver when Resident #4's wheelchair fell backwards resulting in his head hitting the floor of the facility van. Resident #4 reported a headache to the facility van driver who had assisted him into an upright position in his wheelchair in the facility van. The facility van driver reported he looked at the back of Resident #4's head to ensure there was no visible injury. The facility van driver assisted Resident #4 to his wound care appointment and called back to the facility to speak with the Maintenance Assistant for further instructions on securing the wheelchair. After Resident #4's wound care appointment, the resident was transported back to the facility by the facility van driver. The facility van driver reported the accident to the nurse for Resident #4 upon return to the facility. Immediate Jeopardy was removed on 08/17/17 PM when the facility provided and implemented an acceptable credible allegation of compliance. The facility remains out of compliance at a lower scope and severity of D (isolated with no actual harm with potential for more than minimal harm that is not immediate jeopardy) to complete education and ensure monitoring systems put into place are effective related to training of facility van drivers and how to respond in the event of an accident in the facility van. The findings included: Upon review of the manufacturer's instructions for inspection and maintenance for wheelchair securement and occupant restraint systems with a revision date of 02/11, it was noted there were no instructions listed for securing a specialized wheelchair. Resident #4 was admitted to the facility 03/02/16. The significant change Minimum Data Set ((MDS) dated [DATE] indicated Resident #4 was alert and oriented (BIMS of 15) with no short or long term memory problems. The MDS also indicated Resident #4 had [DIAGNOSES REDACTED]. During an interview on 08/15/17 at 10:44 AM Resident #4 stated he had a wound care appointment on 08/10/17 that required the use of the transport van. Resident #4 stated as they were driving and went over a bump his wheelchair fell backward and he hit his head on the floor. Resident #4 stated the facility van driver assisted him back to an upright position in his wheelchair. During an interview on 08/15/17 at 11:02 AM with the facility van driver he stated he was transporting Resident #4 to a medical appointment on 08/10/17 in the facility van. The facility van driver stated they were in the parking lot where Resident #4's appointment was and went over a speed bump. The facility van driver stated he heard a thump and looked back and saw Resident #4 had fallen backward in his wheelchair. The facility van driver stated the tie down straps had loosened which allowed the wheelchair to fall backwards but Resident #4 was still strapped securely in his wheelchair when he assisted him back into an upright position. The facility van driver stated Resident #4 told him he hit his head on the floor and had a headache. The facility van driver stated he looked at the back of his head and did not see any redness, bruising or bleeding. The facility van driver stated he re-secured the wheelchair of Resident #4 by tightening the tie down straps then he assisted him out of the facility van once they had parked for his medical appointment. While Resident #4 was at his medical appointment the facility van driver called the facility and spoke with the Maintenance Assistant for instructions to strap in his wheelchair securely. After his medical appointment, Resident #4 was transported back to the facility and the facility van driver stated he told the nurse for Resident #4 about the accident and that Resident #4 had hit his head. The facility van driver stated he had completed training just over two years ago regarding driving the van and transporting residents but had no in-service or retraining since then. The facility van driver also stated this was the first time he had transported Resident #4 and had secured him the way he had been trained. The facility van driver further stated he had been unaware at the time of transport for Resident #4 that the rear axle on his wheelchair allowed the wheels to spin even when the chair was strapped down, so the straps loosened during transport and the wheelchair fell backward. The facility van driver denied having any accident where someone had flipped over in the wheelchair or been injured in any way during any time he had driven the facility van until this occurrence with Resident #4 in his wheelchair. During an interview on 08/15/17 at 11:45 AM with the Maintenance Assistant, he stated that the facility van driver had called him on 08/10/17 requesting assistance on how to safely strap Resident #4's wheelchair in the van. The Maintenance Assistant stated the facility van driver did not inform him at the time of the call that an incident with Resident #4 had taken place on the van. The Maintenance Assistant stated he told the facility van driver he needed to get to the highest point on the frame of his wheelchair to strap it down. The Maintenance Assistant also stated Resident #4 had something very different about his wheelchair and it looked to be designed like an Olympic racing wheelchair. The Maintenance Assistant further stated he had transported Resident #4 several weeks ago and had no problems with his wheelchair. The Maintenance Assistant also stated he had not had an accident where someone had flipped over in the wheelchair or been injured in any way during any time he had driven the facility van. During an interview on 08/15/17 at 12:20 PM with the Maintenance Director, he stated the facility had a full time driver up until about 2 months ago. Since then the Maintenance Assistant and the Central Supply Clerk (facility van driver at the time of the accident) had been the 2 facility van drivers until someone could be hired for that position. The Maintenance Director also stated he believed that Resident #4's wheelchair was strapped in correctly but because of the bouncing around in the van and the tension it may have loosened the tie down straps. During the interview on 08/15/17 at 12:20 PM the Maintenance Director and the facility van driver during the incident demonstrated how Resident #4 had been secured in the facility van using Resident #4's wheelchair. The Maintenance Director stated the straps were to be ratcheted into place so there is very little, if any movement, from the wheelchair. During an interview on 08/17/17 at 4:37 PM, the Administrator acknowledged her expectations were for the wheelchair to have been evaluated prior to use in the van to transport the resident because of the wheelchair's modified nature. On 08/16/17 at 8:44 AM the Administrator was informed of the Immediate Jeopardy. The facility provided a credible allegation of compliance on 08/17/17 at 11:55 AM. The allegation of compliance indicated the following: To remove the immediacy, the facility has initiated and/or completed the following: On August 10th, 2017, at approximately 8:30 AM, Resident #4 was transported by facility staff to a physician appointment. Resident #4 does utilize a specialized modified wheelchair due to [DIAGNOSES REDACTED].#4, who was in a specialized/non-traditional wheelchair, was secured in the van per the facility procedure for Loading and Unloading a Resident with a (traditional) Wheelchair Lift on a Transport Van. Procedure includes loading resident onto the lift, locking brakes while on the lift, transporting resident from lift into van, proper placement of resident within van, securing the resident on the van, unloading the resident onto the lift, and safely removing the resident from the van. Non- traditional wheelchairs will be evaluated by the Maintenance Director prior to transport to validate if the chair can safely be secured within the company van or if alternate contracted transportation vendors may be necessary to maintain safety. A master Non-Facility Transportation log will be maintained in the van and at the nurses' station indicating the appropriate plan of care for safe transport. The master Non-Facility Transportation log will be updated by the Maintenance Director as needed for changes. Drivers will review the master Non-Facility Transportation log posted at the nurses' station and within the van prior to transport. On 8/10/17 at 8:45 AM, during the transport of Resident #4, per the assigned van driver, the van experienced a bump during locomotion into the parking lot of scheduled appointment. The van driver looked back and noted the resident's wheelchair had tipped backward with the resident remaining secured in the wheelchair. The van driver parked the van, tipped the wheelchair into an upright position, and immediately responded to the resident by visually observing the back of the head for any bruising or cuts, and none were visualized. Resident did have initial complaint of headache which did self-resolve prior to returning to facility. On 8/15/17 at 11:00 AM, the Maintenance Director completed education and observed reverse demonstration of the facility procedure for Loading and Unloading a Resident with a Wheelchair Lift on a Transport Van to facility designated drivers, inclusive of the Maintenance Assistant and Central Supply Coordinator. The Maintenance Director administered a Safe Driving Quiz with successful results, and reviewed facility policy and procedure S-390 the Fleet Safety Program Motor Vehicle Safety. Facility policy S-390 describes the expectations for transportation employees to operate company vehicles safely and prevent accidents, including but not limited to, training standards, accident reporting, vehicle inspections and maintenance and general safety regulations. On 8/15/17 at 12:00 PM, the Interdisciplinary Team consisting of the Executive Director, Regional Director of Clinical Services, Regional Vice Presidents of Operations, and the Maintenance Director elected to conduct all medically and non-medically related transportation via the contracted providers until completion of appropriate vehicle inspections, education, equipment validation, and appropriation of cellular phone for post incident/accident access to licensed facility staff and/or emergency responders. On 8/15/17 at 2:00 PM the Maintenance Director began reviewing current facility residents to identify any specialty or adaptive wheelchairs or durable medical equipment that may prevent them from transporting safely in a traditional wheelchair. Maintenance Director completed the audit 8/16/17 at 10 AM. Identified residents will be transported with a contracted transportation service that will ensure resident safety during future medically related transports. On 8/16/17 the MDS nurse updated the identified residents' safety care plan to reflect the contracted transport needs due to specialized and/or modified, non-traditional wheelchair transport needs. A master Non-Facility Transportation log will be maintained in the van and at the nurses' station indicating the appropriate plan of care for safe transport. The master Non-Facility Transportation log will be updated by the Maintenance Director as needed for changes. Drivers will review the master Non-Facility Transportation posted at the nurses station and within the van prior to transport. On August 16, 2017 the Executive Director provided education to the Maintenance Director on the Non-Facility Transportation log inclusive of the storage location and parameters for updating as necessary upon any changes or newly identified non-facility transport equipment. Education will be completed with the scheduler and other designated van drivers, inclusive of the Maintenance Assistant and Central Supply Coordinator with education completion on August 17, 2017. On 8/16/17 at 10:15 AM, a Quality Assurance Performance Improvement Committee meeting was held with the Executive Director, Regional Director of Clinical Services, Regional Vice President of Operations, Division Vice President of Clinical Services, Vice President of Safety, Division Director of Safety, Vice President of Clinical Education, and Chief Nursing Officer to determine the root cause analysis and develop corresponding action plan to ensure appropriate supervision is provided to prevent accidents and residents needs are being met. Through Root Cause Analysis, it was determined that the facility failed to 1) properly train designated non-medically licensed transport staff on proper procedure for response to resident incident/accident that may occur during transport and licensed nurse post-incident/accident procedure 2) identify non- traditional wheelchair equipment that may require additional or alternate transport mechanisms or considerations and 3) provide an individualized care plan to meet the safety needs of each resident. On 8/16/17 at 1:00 PM the Registered Nurse updated the Care Plan for Resident #4 to indicate that he will be transported via contracted transportation services that will ensure resident safety during future medically related transports due to the resident utilization of specialized modified wheelchair. Resident #4 will continue to be evaluated quarterly by a Registered Nurse and members of the Interdisciplinary team and as needed for any changes to the care plan. A master Non-Facility Transportation log will be maintained in the van, at the nurses' station, and provided to the scheduler indicating the appropriate plan of care for safe transport. The master Non-Facility Transportation log will be updated by the Maintenance Director as needed for changes. Drivers will review the master Non-Facility Transportation log posted at the nurses' station and within the van prior to transport. Newly hired transportation staff will receive education from the Maintenance Director upon hire and bi-annually thereafter on procedure for safely loading and unloading a Resident, facility process for responding to resident incident/accidents during van transport, the Fleet Safety Program Motor Vehicle Safety. The facility will provide supervision to prevent and properly respond to resident incidents /accidents by ensuring appropriate training to non- medically licensed and licensed nurses to maintain safety during medically related transport. In the event of a transport incident/accident, the non-medically licensed employee will contact emergency medical responders for life-threatening emergencies and will contact the facility for licensed nurse assistance. The licensed nurse will properly assess resident and complete the post incident/accident procedure as indicated. The Executive Director will be responsible for implementing this credible allegation of compliance. The credible allegation was verified on 08/17/17 as evidenced by observations of each facility van driver securing an occupied wheelchair in the facility van, verification of the Non-Facility Transportation Log which indicated the residents with specialty wheelchairs, and the updated care plan for Resident #4. Each driver was interviewed after a return demonstration of securing the wheelchairs in the facility van and verified they had all been retrained, had reviewed policies and procedures for securing residents in wheelchairs in the facility van and had reviewed and knew how to utilize the transport van securement checklist, and document in the transportation log and on the daily vehicle inspection report.

Based on staff and resident interviews, medical record review, and facility record review, the facility failed to keep one (1) of three (3) cognitively impaired residents free from abuse (Resident #1). The findings are: A policy entitled Resident Abuse and dated 03/12, provided by the facility, read in part: "No employee may at any time commit an act of physical, psychological, or emotional abuse, neglect, mistreatment, and/or misappropriation of property against any resident." Resident #1 was admitted to the facility on [DATE] with dementia. The latest Minimum Data Set (MDS), dated [DATE], revealed the resident had short and long term memory problems and was moderately impaired in cognitive skills for daily decision making. The MDS also revealed the resident required limited to extensive assistance with most activities of daily living, including supervision with meals. A 5-Working Day Report, dated 04/06/12, filed by the facility with the State Health Care Personnel Registry, was reviewed. It contained the results of the facility investigation of an alleged incident of employee to resident abuse that occurred on Saturday, 03/31/12, at 8:10 AM. The facility investigation substantiated the allegation, based on witness statements from three alert and oriented residents and from one Nursing Assistant (NA), NA #2. The investigation concluded that NA #1 assisted Resident #1 back to her table at breakfast in the main dining room and then slapped the resident on the right side of her face. Resident #1 began to cry. The report noted that NA #2 immediately reported the incident to Registered Nurse (RN) #1 and to the weekend administrative Manager on Duty (MOD). The MOD immediately contacted the Administrator and the Director of Clinical Services (DCS) by phone and instructed NA #1 to immediately leave the building until contacted by the Administrator, which she did. The report also noted that Resident #1 had pain at the time of the incident with no further injury. The report further noted that the County Department of Social Services and local law enforcement were notified with a police report filed on 03/31/12 which prompted an investigation by a detective. The employee was terminated at completion of the facility investigation. On 04/09/12 at 9:33 AM, the facility Maintenance Director who was the MOD on 03/31/12, was interviewed. He reported that on that Saturday he was approached by NA #2 who reported that NA #1 had just slapped Resident #1 and left the dining room. He stated he called the Administrator who told him to send NA #1 home immediately which he did. He also called the DCS to report the incident. He stated both the Administrator and the DCS arrived at the facility within a few minutes. On 04/09/12 at 10:03 AM, the Administrator and DCS were interviewed. They reported that on 03/31/12 the MOD implemented the facility abuse policy by informing the Administrator and DCS of the alleged abuse and suspending NA #1 pending an investigation. The DCS stated that before leaving for the facility she called back and spoke to RN #1. She instructed her to do a skin sweep and body audit of Resident #1, to notify the resident's family, and to complete an incident report. The DCS stated the skin sweep and body audit revealed no bruising, red marks, or other injuries to Resident #1. The Administrator and DCS reported they arrived at the facility within a few minutes, checked on the safety and condition of Resident #1, and began their investigation. They took statements from the three alert and oriented residents and NA #2, who had all witnessed the incident. All witnesses agreed that Resident #1 had attempted to leave the breakfast table in her wheelchair and been returned to the table by NA #1 who then slapped her on the right side of her face, making the resident cry. NA #2 went to console the resident as NA #1 left the dining area. She then reported the incident to RN #1 and the MOD. The DCS further stated that the physician and the local police department were notified. An officer arrived on 03/31/12 and filed a report and a detective has continued the investigation. The Administrator and DCS made multiple attempts to contact NA #1 as part of their investigation, but she did not answer or return calls. A certified letter was sent to NA #1 who did not respond and she has since been terminated from employment. She noted that after investigation of the incident, abuse and neglect inservices for all staff were begun on 04/03/12 and completed on 04/10/12. On 04/10/12 at 3:15 PM Resident #5, who was considered alert and oriented by the facility, was interviewed. She stated that at breakfast in the dining room on 03/31/12, she was sitting at a table with Resident #1. She stated she witnessed NA #1 slap Resident #1 on the side of her head. She stated she did not see any visible injury but that Resident #1 cried momentarily. On 04/12/12 at 3:15 PM the Administrator was again interviewed. She stated all staff had been inserviced on abuse and neglect since the incident. She stated some random residents and staff had been interviewed regarding possible incidents of abuse and some random residents had been screened for injuries of unknown origin. No incidents or injuries had been found. However, the Administrator further stated that a complete audit of all residents and staff had not been performed. On 04/12/12 at 3:20 PM NA #2 was available for interview. She stated that on 03/31/12 at approximately 8:10 AM she was working in the dining room assisting residents with breakfast. She stated she witnessed Resident #1 being brought back to the table by NA #1. She stated NA #1 looked at her and said, "This is the third time I've brought her back here." Then she witnessed NA #1 slap Resident #1 on the side of the head. Resident #1 started crying and NA #1 left the dining room. NA #2 stated she went to Resident #1 to comfort her, then immediately went to RN #1 and the MOD to report the incident. She stated the MOD escorted NA #2 from the building. An unsuccessful attempt was made by phone to contact NA #1 who did not return the call.