Every finding on record at Brantwood Nh & Retirement Center

Based on record review and interviews with staff, and physician, the facility failed to protect residents' rights to be free from misappropriation of controlled medications (Morphine) for 1 of 1 resident reviewed for misappropriation of residents' property (Resident #76). This resulted in 3.75 milliliters (mL) of liquid Morphine missing.Findings included:The facility's Abuse and Neglect Prohibition policy last revised 12/12/25 indicated that each resident had the right to be free from abuse which included misappropriation of property which was defined as deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent.Resident was initially admitted on [DATE].Physician orders dated 3/12/25 directed Morphine Sulfate (Morphine) concentrate 20 milligrams/ milliliter (mg/mL), give 0.5 mL by mouth every hour as needed for shortness of breath or pain. The order was discontinued on 3/22/25. A new order dated 3/22/25 was directed at 0.25 mL every 4 hours as needed.Documentation on Resident #76's March 2025 Medication Administration Record (MAR) indicated the resident received 0.5 ml Morphine dosage every one hour as needed on each of the following dates/times: - On 3/12/25 medication was administered at 7:53 AM and at 3:42 PM. Pain was documented as 5 and 3. (Nurse #2)- On 3/13/25 at 7:15 PM. (Nurse #2).- On 3/14/25 at 9:02 PM, and at 10:23 PM. (Nurse #1).- On 3/15/25 at 9:14 PM, and at 10:22 PM. (Nurse#1).- On 3/16/25 at 6:15 AM, at 8:14 PM and at 9:43 PM. (Nurse 1).- On 3/17/25 at 6:26 AM. (Nurse #1).- On 3/19/25 at 9:51 PM. (Nurse #1).- On 3/20/25 at 12:11 AM and at 10:12 PM. (Nurse #1).- On 3/21/25 at 8:34 PM, at 9:58 PM and at 10:59 PM. (Nurse #1).Documentation also indicated the resident received 0.25 ml Morphine dosage every 4 hours as needed on each of the following dates/times: -On 3/24/25 at 9:11 AM and at 8:46 PM. (Nurse #1).- On 3/25/25 at 1:10 AM, at 7:48 AM and at 8:15 PM. (Nurse #1)-On 3/28/25 at 9:35 PM. (Nurse #1)-On 3/29/25 at 1:39 AM, at 6:12 AM and at 7:42 PM. (Nurse #1).- On 3/30/25 at 7:39 PM. (Nurse #1).-On 3/31/25 at 12:15 AM. (Nurse #1)Review of the controlled substance count record from 3/12/25 to 3/31/25 revealed the pharmacy sent a 30 ml Morphine 100 mg/ 5 ml solution. The label read in part, take 0.5 ml = 10 ml under tongue every hour as needed for pain- severe (scale 7-10). On 3/31/25 at 5:30 AM, Nurse #1 documented withdrawing 0.25 mL with a remaining amount of 13.5 mL.Review of hospice notes from 3/17/25 to 4/1/25 revealed the resident was not in any distress and did not state of any pain.There were no nursing notes from 3/12/25 to 4/1/25 that indicated the resident was in pain and discomfort.Review of the Initial Allegation Report dated 4/2/25 showed the facility became aware of a discrepancy involving Resident #76's liquid Morphine on 4/1/25 at 2:00 PM. The facility completed an audit of the medication on 4/1/25 and noted missing narcotics. The facility initiated an investigation on 4/1/25. Nurse #1, the suspected staff member, was suspended pending investigation. No resident injury/harm was identified. The facility's Investigation Report completed 4/9/25 by the Administrator, substantiated drug diversion and identified Nurse #1 as responsible. Law enforcement and the Drug Enforcement Agency (DEA) were notified on 4/2/25. Adult Protective Services (APS)/ (County Social Services (DSS) was not notified. The investigation (audits) identified discrepancies between doses logged out and doses documented as administered to Resident #76. It was determined that 3.75 mL of Morphine was missing. Nurse #1 refused to cooperate with the investigation and was terminated on 4/2/25.The DEA report dated 4/3/25 documented that 3.75 mL of Morphine was missing, with staff discovering the discrepancy during the count. Corrective actions included employee termination, increased monitoring, and securing controlled substances. An audit tool completed by the DON showed discrepancies for Nurse #1 involving medication removal, documentation timing, and unusually high administration frequency compared to other nurses.Nurse #1 and Nurse #2 were unavailable to be interviewed during the survey.During an interview on 3/18/26 at 3:42 PM, the Director of Nursing (DON) stated she received a message from the Staff Development Coordinator (SDC) on 3/31/25 indicating that Nurse #2 had noticed a discrepancy on the controlled substance count sheet for Resident #76. Nurse #2 had reported the discrepancy at the end of her shift (around 7 PM). The DON further stated it was initially explained to her that the discrepancy resulted from incorrect math when counting control substances, and that this error caused the number on the count sheet to differ from the amount in the bottle of morphine. An initial decision was made to complete a count for correction, and the count began early on 4/1/25. The DON stated that when she reviewed the documentation, she realized there was an actual discrepancy in addition to mathematical errors. She indicated she reviewed signatures on the controlled substance count sheets and noted that Nurse #1 had frequently administered the medication and was the last nurse to administer Morphine to the resident. Nurse #2 had taken charge of the medication cart early that morning on 3/31/25 and 4/1/25 and had possession of the keys to the locked controlled substances. On 4/1/25, the DON interviewed Nurse #2 and asked when she first noticed the discrepancy. Nurse #2 confirmed she identified the issue before the end of her shift on 3/31/25 while performing the count. The DON stated she asked Nurse #2 why the discrepancy had not been reported earlier in the shift, especially since Nurse #2 had accepted the keys that morning. The DON stated that Nurse #2 had not signed out any Morphine for the resident on 4/1/25 and was considered a suspect at that time because she did not report the discrepancy when she first noticed it yet continued her shift with the keys. The DON stated she immediately notified Human Resources (HR), and an audit tool was provided to determine whether to proceed with an investigation involving either nurse based on risk factors. The audit began on 4/1/25 and was completed on 4/2/25. Nurse #2 worked on 4/1/25 from 7:00 AM to 7:00 PM, and Nurse #1 was not at the facility; Nurse #1 typically worked the 7:00 PM to 7:00 AM shift. During the preliminary audit, the DON noted that Nurse #1 demonstrated multiple risk factors verses Nurse #2. The DON stated she contacted Nurse #1 on 4/1/25 and requested a meeting with HR due to concerns regarding medication. Nurse #1 refused to meet with HR. The DON reported that Nurse #1 was informed she could not work until the matter was resolved. Nurse #1 did not report to the facility and did not respond to subsequent outreach. She was informed of the consequences of failing to appear to answer questions regarding medication discrepancies; however, she did not return calls or come to the facility.During an interview on 3/18/26 at 3:39 PM, the Medical Director stated that due to advanced dementia, Resident #76 was enrolled in the hospice program. She stated that for discomfort and pain relief, the resident received as needed liquid Morphine, a narcotic medication. She stated the resident initially received 0.5 mL of Morphine every hour, which she described as a standard order for hospice residents. She stated that (on a date unknown/a few days later), she observed that Resident #76 was very drowsy and changed the medication administration regimen to decrease the amount of narcotic administered per day, adjusting the order to 0.25 mL of Morphine every 4 hours. The Medical Director stated she was made aware of the investigation regarding possible drug diversion. She stated she assessed Resident #76 during the investigation and identified no negative outcomes.During an interview on 3/19/26 at 9:41 AM, the Administrator stated the DON made her aware of the drug diversion and 3.75 mL of liquid Morphine missing. She stated the DON informed her that the SDC had reported a miscalculation on the count sheet involving liquid Morphine. She stated this was initially presented by the SDC as a mathematical error. She stated Nurse #2 notified the SDC at the end of her shift about the error. The Administrator indicated DON began auditing the medication in question and identified significant errors. She stated she was made aware on 4/1/25, at which time audits were already underway, and Nurse #1 had been called to come in for questioning, but Nurse #1 refused. The Administrator stated Resident #76 was evaluated by the physician and no negative or adverse effects were identified. The interview further revealed Resident #76 was under hospice care at the time, and Morphine had been ordered by hospice for comfort care.

Based on record review and staff interviews, the facility failed to report an allegation of misappropriation of resident property to Adult Protective Services for 1 of 1 resident reviewed for misappropriation of property (Resident #76).Findings included:The facility's Abuse, Neglect, or Misappropriation of Resident Property policy, last revised 12/12/25, stated that each resident had the right to be free from abuse, including misappropriation of property. The policy defined misappropriation as the deliberate misplacement, exploitation, or wrongful use of a resident's belongings or money without the resident's consent. The policy required the facility to report allegations immediately but no later than 2 hours if the allegation involved abuse or resulted in serious injury, and no later than 24 hours if the allegations do not involve abuse or result in serious injury. Reports were required to be submitted to other officials, including the State Survey Agency and Adult Protective Services (APS). The Administrator or designee was responsible for ensuring that all required agencies were notified. Review of the Initial Allegation Report dated 4/2/25 showed the facility became aware of a discrepancy involving Resident #76's liquid morphine on 4/1/25 at 2:00 PM. The facility completed an audit of the medication on 4/1/25 and noted missing narcotics. The facility initiated an investigation on 4/1/25. Nurse #1, the suspected staff member, was suspended pending investigation. No resident injury/harm was identified. Review of the Investigation Report, completed on 4/9/25, showed the facility substantiated the allegation of diversion of Resident #76's medication and identified Nurse #1 as responsible. The facility notified law enforcement on 4/2/25 and sent a Drug Enforcement Agency (DEA) report on 4/2/25. Investigation Report review indicated Adult Protective Services (APS) or Department of Social Services (DSS) were not notified. The facility completed an audit of all controlled substances and found multiple discrepancies between narcotics logged out and those documented as administered to Resident #76. The facility attempted to interview Nurse #1, but the staff member refused to cooperate. The facility notified Nurse #1's employment agency of the refusal to cooperate. The investigation determined that 3.75 milliliter (mL) of morphine sulfate (liquid morphine) was missing. No other medications were identified as missing. The facility terminated Nurse #1 on 4/2/25. The Administrator completed the investigation on 4/4/25. During an interview on 3/18/26 at 3:10 PM, the Administrator stated that the Staff Development Coordinator (SDC) notified the Director of Nursing (DON) on 4/1/25 of concerns regarding Resident #76's liquid morphine. The Administrator reported that the discrepancy was initially believed to be a calculation error. After a full audit, the DON confirmed that 3.75 mL of morphine sulfate was missing. The Administrator stated that the DON notified the North Carolina Board of Nursing and that the facility notified the DEA. The Administrator also stated that Resident #76 was under hospice care, the resident's treatment was not interrupted, and the facility reimbursed Hospice for the missing medication. The Administrator stated that she did not report the allegation to the State Agency until 4/2/25 because the facility was unsure whether narcotics were missing and believed the resident had not suffered serious injury or abuse. The Administrator further stated she missed reporting the diversion of a resident drug to Adult Protective Services, however the facility reported the incident to the State, law enforcement, DEA and the Board of Nursing.

Based on observations and staff interviews, the facility failed to keep food preparation areas and food service equipment clean, free from debris, grease buildup, and/or dried spills during two observations. The facility failed to clean the floor and ceiling vents located over the food preparation and food service areas. This practice had the potential to affect food served to residents. The findings included: During the initial kitchen tour on 12/15/24 from 9:30 AM to11:50 AM, the following observations were made with the dietary aides: a. The 6-compartment steam table had floating food particles in standing water; the lids of the steam table had large volumes of dried food and greasy build up around edges. The pans were heavily encrusted with brown matter and burnt food items. b. The 2 reach-in refrigerators had leftover food and dried liquids on the walls inside and outside from previous meals. There was dried milk, tea, spilled cheese, left over food on the walls and bottom of the refrigerators. c. The 6 meal carts with dry food crumbs, meat products and dried liquids and particles inside. The outside cart also had dried liquids from previous meals, stained tea, colored juices, leftover meat/bread particles. d. The 2 plate warmers had 2 rows of clean plates stored in the warmer. The inside of warmer had dried liquid spills and food particles inside and dried liquid spills on the outside. The inside also had old food crumbs all around. e. The 6 ceiling vents and 2 air conditioning units had large volumes of black dust/debris blowing over the steam table, food service and preparation surfaces. The dietary aides were preparing additional meals on request and the breakfast meal was still being served. Review of the undated kitchen checklist revealed that dietary aides had not signed off that the designated tasks had been cleaned. Cleaning and wiping down steam tables, sweeping/mopping floors, cleaning refrigerators and meal carts. There was no indication on the checklist that the identified kitchen equipment was deep cleaned or just wiped down. An interview was conducted on 12/15/24 at 9:50 AM with the Dietary Aide #1 who stated she has been working in the kitchen for 4 months and was unaware of when the kitchen equipment was last cleaned, and she was unaware of a cleaning checklist. An interview was conducted on 12/15/24 at 9:55 AM with the Dietary Aide #2 who stated he has been working in the kitchen for one year. Dietary Aide #2 indicated the posted kitchen checklist included all kitchen staff was responsible for wiping down kitchen equipment after each meal. A kitchen tour was conducted on 12/15/24 at 11:45 AM with the Nutritional Service Director who confirmed the identified observations of the kitchen equipment and the ceiling vents. She stated the staff were expected to clean the kitchen equipment in accordance too the kitchen checklist. She reviewed the current kitchen checklist and confirmed there were no specific areas for staff to sign off the responsibilities were completed after each shift. The Nutrtional Service Director further stated there should not be any heavy buildup of grease or dried debris on kitchen equipment. She stated staff were required to wipe down meal carts after each meal and deep clean carts weekly. The refrigerators, steam table, plate warmer should be wiped down after each meal and deep cleaned weekly. The Nutritional Service Director further stated she was responsible for ensuring the kitchen staff kept the equipment clean and orderly. The Nutritional Service Director confirmed the identified meal carts and kitchen equipment had not been cleaned. A telephone interview was conducted on 12/15/24 at 11:50 AM, with the Dietary Service Manager, who stated he was aware some things in the kitchen needed to be cleaned and he would develop an extensive cleaning list to review with all the staff to ensure the kitchen equipment was cleaned after each shift. He reported maintenance was responsible for cleaning the vents and they have been made aware of the condition of the vents, however, due to staffing they have not been able to come and clean them yet. Her further stated all the kitchen equipment should be cleaned weekly and monthly as maintenance. An interview was conducted on 12/17/24 at 3:20 PM with the Administrator who stated the Dietary Manager and Nutritional Service Director were responsible for ensuring the kitchen was cleaned and maintained. The expectation would be for the Dietary Manager to ensure all kitchen cleaning protocols were in place and followed in accordance with kitchen sanitation guidelines.

Based on the observations and staff interviews, the facility failed to remove an expired multi-dose vial of insulin and expired blister card of antihypertensive medication from 1 of 5 medication administration carts (200 hall medication cart) and failed to remove the expired medications from the refrigerator in 1 of 2 medication storage rooms. Findings Included: 1. On 12/16/24 at 8:45 AM, an observation of the 200 hall medication cart with Nurse #1 revealed one multi-dose vial of Insulin Novolog, opened on 11/5/24. A review of the manufacturer's literature indicated to discard Novolog multi-dose vial 28 days after opening (which would be on 12/3/24). In addition, there was one blister card of Apresoline 25 mg (milligrams) 5 tablets, expired on 11/29/24. On 12/16/24 at 8:50 AM, during an interview, Nurse #1 indicated that the nurses, who worked on the medication carts, were responsible for discarding expired multi-dose vials and expired medications. The nurse stated that she had not checked the date the insulin vials were opened in her medication administration cart at the beginning of her shift. Nurse #1 stated she did not administer the expired insulin this shift. On 12/16/24 at 9:00 AM, during an interview, the Director of Nursing (DON) indicated that all the nurses were responsible for checking all the medications in medication administration carts for expiration date and remove expired medications every shift. She expected that no expired items be left in the medication carts. 2. On 12/16/24 at 9:30 AM, an observation of the medication storage room refrigerator with Nurse #5 revealed: four opened plastic bags of Meropenem (antibiotic), 500 mg in 50 ml (milliliter) of Normal Saline, expired on 12/15/24. There were three opened plastic bags of Maxipime (antibiotic), 2 g (gram) in 100 ml of Normal Saline, expired on 12/9/24 and 2 sealed multi-dose vials of Insulin Semglee, expired in November 2024. On 12/16/24 at 9:35 AM, during an interview, Nurse #5 indicated that she had not checked the expiration date of medications in the medication storage room refrigerator at the beginning of her shift. On 12/16/24 at 9:45 AM, during an interview, the Director of Nursing indicated that all the nurses were responsible for checking all the medications in medication storage rooms for expiration date and remove expired medications every shift. She expected that no expired items be left in the medication storage room. On 12/18/24 at 11:30 AM, during an interview, the Administrator expected no expired items to be left in the medication administration carts or storage rooms.

Based on record review, resident and staff interviews, the facility failed to invite the resident or resident's responsible party to participate in the care planning process for 1 of 16 residents whose care plans were reviewed (Resident #42). Findings included: Resident #42 was originally admitted on [DATE] and readmitted on [DATE]. Resident #42's comprehensive care plan was completed on 8/23/23, however there was no indication that the resident or a resident's representative had participated in the care plan meeting or in development of his care plan. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #42 had been assessed as cognitively intact. There was no documentation that indicated the plan of care was discussed with the resident or resident's representative or that they were invited to a care plan meeting. During an interview on 11/06/23 at 9:22 AM, Resident #42 stated he had not been invited to attend a care plan meeting and did not recall participating in developing his plan of care since his admission into the facility. During an interview on 11/08/23 at 10:59 AM, the MDS Coordinator stated the resident's comprehensive care plan was completed on 8/16/23 and no care plan meeting was held with the resident or resident's family. The MDS coordinator indicated that care plan conference meetings were conducted only after quarterly assessments and/or when care plan review was completed. She indicated she was unaware that a care plan meeting should be conducted for comprehensive care plan as the families were updated about the baseline care plan during the meet and greet during admission. She stated if residents were admitted for short term stay then care plan meetings were not conducted. The MDS coordinator confirmed that a comprehensive care plan meeting was not held with the resident or resident representative. During an interview on 11/08/23 at 11:30 AM, The Administrator stated she was unaware that a comprehensive care plan meeting should be conducted with the residents and/or responsible party. She indicated she thought only quarterly care plan meetings were scheduled with the families and the residents.

Based on record review and staff interviews the facility failed to maintain accurate advanced directive (code status) information throughout the medical record for 1 of 26 residents reviewed for advanced directives (Resident #26). Findings included: Resident #26 was admitted on [DATE]. Review of Resident #26's paper medical record revealed a signed physician's order and a Do Not Resuscitate (DNR) form both dated 4/28/22 indicating Resident #26's DNR status. Resident #26's electronic medical record indicated DNR. Resident #26's most recent Minimum Data Set assessment dated [DATE] indicated she was cognitively intact. Review of Resident #26's care plans initiated on 8/1/21 and most recently noted as reviewed on 9/28/23 included: Resident's Advanced Directives. Goal: Wishes Will Be Known. Interventions included in part; Residents code status is: FULL CODE. An interview with the Minimum Data Set (MDS) Coordinator was conducted on 11/08/23 at 11:18 AM. She stated care plans were reviewed with every MDS assessment and the resident or family would be asked if this is still what they want to do or if they want to change things. She explained the last care plan meeting had been conducted with Resident #26's daughter and she had indicated no changes. She further stated the care plan and information in the record should match. On 11/08/23 at 3:34 PM an interview with the Director of Nursing (DON) was conducted. She stated the information on the care plans should not contradict the information in the medical record.

Based on record review, Responsible Party (RP), and staff interviews the facility failed to notify the RP and the Ombudsman in writing when 1 of 1 sampled residents was discharged to the hospital (Resident #6). Resident #6 had originally been admitted to the facility in 2009. She had been discharged to the hospital on 1/27/2023 and readmitted on [DATE]. Resident #6's most recent Minimum Data Set assessment dated [DATE] indicated she had severe cognitive impairment. An interview with Resident #6's Responsible Party (RP) was conducted on 11/07/23 at 1:29 PM. She stated she had been present when Resident #6 had been transferred to the hospital in January, but she had not received any a written explanation of the reason for discharge to the hospital. On 11/07/23 at 3:45 PM an interview with the Resident Care Coordinator was conducted. She explained she was new to the position and was unaware that anything had to be sent to the family in writing or to the Ombudsman regarding discharges. An interview on 11/08/23 at 3:36 PM was conducted with the Director of Nursing (DON). She stated she thought contacting the RP during an emergency was adequate for notification and was unaware of needing to send a written notice for discharge to the RP or the Ombudsman.

Based on record review, responsible party, and staff interviews the facility failed to provide written notice of bed hold policy upon transfer to the hospital for 1 of 1 resident reviewed for hospitalization (Resident #6). Resident #6 had originally been admitted to the facility in 2009. She had been discharged to the hospital on 1/27/2023 and readmitted on [DATE]. Resident #6's most recent Minimum Data Set assessment dated [DATE] indicated she had severe cognitive impairment. An interview with Resident #6's Responsible Party (RP) was conducted on 11/07/23 at 1:29 PM. She stated she had been present when Resident #6 had been transferred to the hospital in January, but she had not received any information regarding bed hold. On 11/07/23 at 3:45 PM an interview with the Resident Care Coordinator was conducted. She explained she was new to the position and recently learned the bed hold information needed to be given to the family when residents were discharged to the hospital. An interview on 11/08/23 at 3:36 PM was conducted with the Director of Nursing (DON). She stated she had recently become aware of the bed hold policy needing to be sent with the resident or to the RP upon transfer to the hospital.

Based on observation, record review and staff interview, the facility failed to accurately code nutrition and Pre-Admission Screening and Resident Review (PASRR) on the Minimum Data Set (MDS) assessments for 2 of 16 residents (Residents #63, and #53) reviewed for MDS accuracy. Findings included: 1. Resident #63 was admitted to the facility on [DATE] with diagnoses that included dementia, anxiety disorder and neuromuscular dysfunction of the bladder. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #63 was assessed as severely cognitively impaired and needed substantial /maximal assistance to partial / moderate assistance for Activities of Daily living. Assessment indicated for eating the resident needed setup or clean up assistance only. The assessment indicated the resident had significant weight loss. Assessment indicated the resident was on tube feeding and on mechanically altered diet. On 11/6/23 at 1:16 PM during an observation and interview, Resident #63 was observed during lunch. Resident #63 was eating her lunch in her room and was able to self-feed. The resident was monitored during meals and encouraged to consume her food. The resident was on a low sodium, pureed meat diet. The resident consumed 25% of her meals at the time of observation. Nurse Aide (NA) #1 was observed sitting with the resident during lunch and encouraging the resident to consume her food. NA #1 stated the resident could feed self but needed a lot of encouragement and cues to eat. NA #1 further stated, during meals a staff member would sit with the resident to encourage meal intake. NA #1 indicated the resident was assisted with feeding as needed. During an interview on 11/7/23 at 3:17 PM, the Registered Dietitian (RD) stated the resident was on a low sodium, mechanical soft, pureed meats, thin liquids diet. The resident could self-feed, however needed some encouragement and cues at mealtime. The RD indicated the resident did not receive any tube feeding and consumed 25-75% of her meals. During an interview on 11/8/23 at 11:50 AM the MDS Coordinator indicated it was an error that Resident #63 was marked for tube feeding. She indicated Resident #63 was not on tube feeding. The resident should be marked for therapeutic diet and mechanically altered diet in the MDS. During an interview on 11/8/23 at 2:45 PM, the Administrator stated it was a MDS error and would be corrected immediately. The Administrator further stated resident's MDS assessments should reflect current status of the resident. 35122 2. Resident #53 had been admitted on [DATE] with diagnoses including moderate intellectual disabilities and major depressive disorder. An undated care plan noted Resident #53 had a Level 2 Preadmission Screen and Annual Record Review (PASRR determination) related to moderate intellect disability. Resident #53's most recent annual MDS assessment dated [DATE] did not indicate she was considered by the state Level II PASRR process to have intellectual disability. An interview with the MDS Coordinator was conducted on 11/08/23 at 11:18 AM. She explained Resident #53 was technically considered as Level II PASRR, but she did not mark it on the MDS because there were no restrictions noted on the PASRR determination letter. An interview with the Director of Nursing (DON) was conducted on 11/08/23 at 3:36 PM. The DON stated the PASRR information should be correct on the MDS assessment.

Based on staff interviews, Physician interview, family interview, and record review, the facility failed to transport a resident (Resident #108) to scheduled oncologist (cancer doctor) appointments resulting in the resident missing two appointments. This was for 1 of 1 resident reviewed for medically related social services. The findings included: Resident #108 was admitted to the facility on [DATE] with diagnoses that included orthopedic aftercare (right lower leg fracture) and malignant neoplasm (breast cancer). She was discharged to the hospital on 11/27/21. The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #108 was cognitively intact. A nurse progress note dated 10/5/21 revealed Resident #108 had an appointment with her oncologist. Resident #108 did not go to the appointment because she had covid at the time. The appointment was rescheduled for 11/8/21. The care plan dated 10/14/21 revealed a focus area for Resident #108 receiving breast cancer treatment. Interventions included assisted with transportation arrangements and discussed issues with the resident and family regarding treatments. A progress note dated 10/29/21 by the former social worker revealed Resident #108's family was informed of the upcoming appointment with her oncologist on 11/8/21. A nurse progress note dated 11/8/21 revealed Resident #108 was unable to attend her oncology appointment due to transportation issues. The family was made aware. A nurse progress note dated 11/9/21 revealed the nurse notified Resident #108's family of the new appointment that had been rescheduled following the missed appointment on 11/8/21. The family expressed concern that the appointment was two weeks or more out. The appointment had been rescheduled for 11/24/21. Review of the transportation arrangement notification dated 11/19/21 and sent to the transportation company by the Director of Nursing (DON), revealed Resident #108 was scheduled for an appointment with the oncologist on 11/24/21 at 8:30 AM. She was to be transported to the appointment by stretcher. Resident #108 was transferred to the hospital on 11/27/21 and assessed for a urinary tract infection. An interview was conducted with Resident #108's family member on 8/29/22 at 9:42 AM. The family member stated Resident #108 had uncurable breast cancer and she received periodic infusions for treatment. The resident missed several appointments with her oncologist while she was admitted at the facility. During an interview with Nurse #1 on 8/30/22 at 2:30 PM, she stated Resident #108 had missed doctor's appointments. She did not recall the details of the missed appointments but stated it was an issue with the transportation company not picking up the resident. An interview was conducted with the resident care coordinator on 8/30/22 at 12:00 PM. She stated nursing staff made medical appointments and transportation arrangements for residents at the facility. On 8/31/22 and 9/1/22 multiple attempts to contact the transportation company manager were unsuccessful. During an interview with the DON on 9/1/22 at 9:45 AM, she stated at the time of Resident #108's missed appointments, the former social worker oversaw transportation arrangements. The DON took over the responsibility for arranging transportation sometime in November 2021. The DON stated Resident #108 missed her doctor's appointment on 11/8/21 due to transportation issues and the appointment was rescheduled for 11/24/21. The transportation company was aware of Resident #108's appointment on 11/24/21 but they did not pick up the resident that morning. On 11/24/21, the facility attempted to transport Resident #108 with emergency medical services (EMS) after the transportation service did not come get her for her oncology appointment. The doctor's office was unable to accommodate a different appointment time for Resident #108 on 11/24/21. During an interview with Physician #2 on 9/1/22 at 1:35 PM, he stated he did not recall Resident #108 missing doctor appointments. The Physician indicated he didn't think the missed appointments would have affected her outcome or prognosis. The Administrator was unable to be interviewed during the survey. An interview was conducted with the Chief Nursing Officer (CNO) on 9/1/22 at 3:24 PM. She stated residents should be transported to their medical appointments. She indicated there had been improvement with the transportation services that were contracted with the facility.

Based on observations and staff interviews, the facility failed to maintain walls in resident rooms in good repair (Room 405 and Room 206) and failed to secure the call bell box to the wall (Room 405). This was for 2 of 14 resident rooms reviewed for homelike environment. The findings included: 1. An observation on 8/30/22 at 9:39 AM of Room 405 revealed the wall behind the bed had a hole approximately measuring 11''X 3 long. Observation also revealed the call bell box near Bed A was not properly mounted to the wall. The cover of the call bell box was not attached to the wall. The call bell was tested and was working. During an interview on 8/31/22 at 10:51 AM, Nurse Aide #1 stated the call bell was working and she had not noticed the call bell box not mounted correctly on the wall. Nurse Aide further stated she had not noticed the hole on the wall behind the resident's bed. Nurse Aide #1 indicated when any repair were needed to be done in resident's rooms the Nurse was notified. Nurse Aide confirmed she had not notified the nurse as she had not observed it. During an interview on 8/31/22 at 11:08 AM, Nurse #2 stated the management was notified when any repairs were needed in resident's rooms. Nurse #2 further stated she was unaware of these repairs and the Nurse Aide had not notified her. Nurse #2 indicated the Administrator or Director of Nursing (DON) would place a work order for these repairs. During an interview on 8/31/22 at 11:15 PM, Interim DON stated the nurses would notify the Administrator or any management team when any repairs were needed in resident's rooms. The interim DON stated she was not notified of these repairs and there was no work order placed for these repairs. During an interview on 08/31/22 12:00 PM, The Director of Facility Services stated when any work order was received from the facility, the jobs were completed accordingly. The Director of Facility Services further stated all resident's rooms were inspected quarterly by the maintenance staff. Quarterly inspections were done to ensure that the resident's rooms were maintained in good condition. The Director of Facility Services indicated the staff moved the resident's beds too close to the wall resulting in the wall plaster getting peeled and walls damaged. The Director of Facility Services further indicated most the resident's room walls behind the bed were mounted with a protector sheet to prevent wall damage. This was an antimicrobial plastic sheet protector that protected the walls. The Director of Facility Services stated she would be ordering more of these sheets to ensure all resident's rooms had these sheets on the wall. The Director of Facility Services further stated the screws of the call bell box were tightened so that it was properly mounted on the wall. The Administrator was unable to be interviewed during the survey. During an interview on 09/01/22 03:05 PM, The Chief Nursing Officer stated she oversees the nursing home operation, and the Administrator reports/consults her. The Chief Nursing Officer further stated if any staff saw anything that needed to be repaired, it should be reported immediately so that appropriate action could be taken. She indicated the Director of Facility Services had ordered a few more wall protectors and these were on backorder. 2. An observation on 8/31/22 at 1:20 PM of Room 206 revealed the wall behind both beds (Bed A and Bed B) had holes and damaged dry wall. The wall behind Bed A and Bed B had overlapping rectangular marks of exposed dry wall measuring approximately 1-2 inches in width by 4-10 inches in length. Observation also revealed an additional hole behind Bed B measuring approximately 8 inches by 12 inches and was rectangular in shape. An interview was conducted with Nurse Aide #1 on 8/31/22 at 1:20 PM. She stated she had not known the walls in Room 206 were damaged. She indicated she typically reported damaged walls to the Administrator or to the Resident Care Coordinator (RCC). An interview was conducted with the RCC on 8/31/22 at 1:20 PM. She stated protective wall covers were on back order and that was why Room 206 did not have one behind the beds. During an interview on 08/31/22 12:00 PM, The Director of Facility Services stated when any work order was received from the facility, the jobs were completed accordingly. The Director of Facility Services further stated all resident's rooms were inspected quarterly by the maintenance staff. Quarterly inspections were done to ensure that the resident's rooms were maintained in good condition. The Director of Facility Services indicated the staff moved the resident's beds too close to the wall resulting in the wall plaster getting peeled and walls damaged. The Director of Facility Services further indicated most the resident's room walls behind the bed were mounted with a protector sheet to prevent wall damage. This was an antimicrobial plastic sheet protector that protected the walls. The Director of Facility Services stated she would be ordering more of these sheets to ensure all resident's rooms had these sheets on the wall. The Director of Facility Services further stated the screws of the call bell box were tightened so that it was properly mounted on the wall. The Administrator was unable to be interviewed during the survey. During an interview on 09/01/22 03:05 PM, The Chief Nursing Officer stated she oversees the nursing home operation, and the Administrator reports/consults her. The Chief Nursing Officer further stated if any staff saw anything that needed to be repaired, it should be reported immediately so that appropriate action could be taken. She indicated the Director of Facility Services had ordered a few more wall protectors and these were on backorder.

Based on record reviews and staff interviews, the facility failed to complete a Discharge Minimum Data Set (MDS) assessment and failed to transmit Quarterly MDS assessments within the required time frame for 3 of 3 residents (Resident # 1, Resident # 7, and Resident # 8) selected to be reviewed for Resident Assessments. Findings included: 1. Resident #1 was admitted on [DATE]. The last MDS assessment completed and transmitted was Medicare - 5-day Admission MDS dated [DATE]. Record review dated 4/12/22 revealed the resident was discharged home with home health. discharged note from physician dated 4/12/22 revealed the resident was discharged home with home health services. There was no discharge MDS completed for this resident. During an interview on 9/1/22 at 1:51 PM, the MDS coordinator indicated the resident was discharged on [DATE] and the discharge MDS was not completed. MDS coordinator further indicated it was during the transition period when the old MDS staff resigned. The MDS coordinator stated the assessment must have slipped through the cracks. Administrator was unavailable for interview. During an interview on 9/1/22 at 3:02 PM, The Chief Nursing Officer stated she oversees the nursing home operation, and the Administrator reports/consults her. The Chief Nursing Officer stated all assessment should be completed and transmitted on time. 2. Resident #7 was admitted on [DATE]. A review of resident's most recent MDS assessment revealed an Assessment Reference Date (ARD) of 7/25/22 and was coded as a quarterly assessment. The MDS was signed as completed by the MDS Coordinator on 8/7/22 and indicated as ready to export. The MDS assessment was not transmitted to the national database. During an interview on 9/1/22 at 1:51 PM, the MDS coordinator stated the assessment was completed and signed on 8/7/22. The MDS coordinator further stated the assessment should have been transmitted within 14 days of completion. The submit by date was 8/21/22. MDS coordinator indicated she was unsure why the assessment was not transmitted. She further indicated all completed MDS assessments were transmitted every other week. Administrator was unavailable for interview. During an interview on 9/1/22 at 3:02 PM, The Chief Nursing Officer stated she oversees the nursing home operation, and the Administrator reports/consults her. The Chief Nursing Officer stated all assessment should be completed and transmitted on time. 3. Resident #8 was readmitted on [DATE]. A review of resident's most recent MDS assessment revealed an ARD of 7/26/22 and was coded as a quarterly assessment. The MDS was signed as completed by the MDS Coordinator on 8/7/22 and indicated as ready to export. The MDS assessment was not transmitted to the national database. During an interview on 9/1/22 at 1:51 PM, the MDS coordinator stated the assessment was completed and signed on 8/7/22. The MDS coordinator further stated the assessment should have been transmitted within 14 days of completion. The submit by date was 8/21/22. MDS coordinator indicated she was unsure why the assessment was not transmitted. She further indicated all completed MDS assessments were transmitted every other week. Administrator was unavailable for interview. During an interview on 9/1/22 at 3:02 PM, The Chief Nursing Officer stated she oversees the nursing home operation, and the Administrator reports/consults her. The Chief Nursing Officer stated all assessment should be completed and transmitted on time.

Based on observations, resident and staff interviews, family interviews and record review, the facility failed to provide showers for residents who needed assistance for 5 of 8 sampled residents with a preference for showers (Resident #3, Resident #5, Resident #6, Resident #7 and Resident #8). The findings included: 1.Resident # 3 was admitted to the facility on [DATE]. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly Minimum Data Set (MDS) dated , 9/1/21, indicated Resident # ' 3 ' s cognition was impaired and required total assistance with activities of daily living. Review of the care plan dated 9/1/21 identified the problem as Resident #3 had activities of daily living (ADL) self-care performance deficit related to lupus, [CONDITION(S)], and muscle weakness. The goal included Resident #3 would maintain current level of ADL function. The interventions included allow time to perform tasks. Staff would perform resident morning routine for dressing/grooming routine by setting up basin at the bedside. The resident requires one person assist with bathing or showering. Resident #3 must be turned and repositioned by 1or 2 staff routinely. Review of the staff assignment/shower schedule presented by the Director of Nursing for August 2021-September 30,2021, there was no evidence that showers were being provided for Resident #3. A telephone interview was condcuted on 9/29/21 at 10:29 AM, the Responsible Person (RP) stated Resident #3 had reported to her that she had not received a shower for several weeks and it was making her body feel sticky and dry. The RP stated she had spoken with several different staff and director of nursing about Resident #3 ' s concerns with not getting a shower and have been told many times she would receive on at least once a week. The RP further stated the director of nursing was not very responsive with follow-up when she or Resident #3 voice their concerns about the showers. She added it was unacceptable that Resident#3 could not get a shower once a week, due to Resident #3 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] An interview was conducted on 9/30/21 at 5:06 PM, Resident #3 stated her scheduled shower days was Tuesday and Thursday, she had not received a shower since being on the COVID-19 unit (9/14/21), prior to moving to the COVID-19 unit her showers were being provided as a hit or miss. Resident stated she had been told by aides and nursing showers could not be provided due to limited staff. She stated she had been receiving bed baths based on the staffing issues, but it would be nice to at least have a shower on one of her scheduled days. It makes me feel good when I can get a full body wash. An interview was conducted on 9/30/21 at 5:45 PM, the NA#7 stated she was unable to give residents showers on the COVID-19 unit, due to lack of staff on the unit. NA#7 further stated with only nurse aide for 20 or more residents it was not feasible to provide showers. NA#7 reported bed bath were provided as often as possible. NA#7 further stated Resident#3 had been informed why showers could not be provided so bed baths were offered. She stated Resident #3 was not happy with the response but would accept the bed bath. NA#7 reported she had heard Resident #3 report to her family that showers were not being given and she was very upset. I can only do so much being the only aide on the unit. An interviewwas conducted on 9/30/21 at 6:48 PM, the Director of Nursing (DON)stated staffing was a major issue with the provision of showers for all residents. Staff assignments sheet should reflect when showers were provided, however, showers had not been consistently done. The DON presented a newly staff assignment sheet that would include when showers for residents would be done. The DON stated the assignment sheet had not been implemented. An interview was conducted on 9/30/21 at 6:58 PM, the Administrator stated she was aware the provision of showers was a concern due to staffing. She further stated bed baths were being provided regularly until proper staffing could be obtained. A telephone interview on 10/5/21 at 12:09 PM, Nurse#6 stated showers were not being provided to residents on the COVID-19 unit due to shortage of staff. Nurse #6 further stated residents were provided with bed baths in between incontinent care to the best of the 1 aide and 1 nurse ' s ability for 20 or more residents. Nurse#6 stated the administrator and director of nursing were aware of the showers not being done due to staffing, things were getting overwhelming with limited staff. Nurse #6 added Ms. [NAME] Resident #3 had asked for a shower a few times and had to be informed it could not be provided due to staffing, but she was offered a bed bath. A telephone interview was conducted on 10/5/21 at 3:20 PM, Nurse # 7 stated she worked 7P-7am. She further stated she had been working the COVID unit for the past 2 weeks. There had been 1 nurse and 2 aides, but other times there has been 1 aide and 1 nurse. The Covid unit really needs two aides to ensure that all resident needs were met. Nurse #7 stated when there were limited staff showers could not be provided, therefore the resident would receive a bed bath, the staff could only provide the basic care to ensure residents were cleaned and changed. 2. Resident # 5 was admitted to the facility on [DATE] The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly Minimum Data Set (MDS) 9/27/21, indicated Resident # ' 5s cognition was impaired and required one person assistance with activities of daily living. Review of the care plan dated 9/9/21, identified the problem as Resident #3 had activities of daily living (ADL) self-care deficits related to [CONDITION(S)] ([CONDITION(S)]) with [CONDITION(S)] risk for complications in range of motion (ROM), transfers, mobility, requires assist with transfers, mobility, meal set up. The goal included Resident #3 would maintain current level of functioning. The intervention included during bathing/showers check nail length and trim and clean on bath day and as necessary. Report any changes to the nurse. Provide sponge bath when a full bath or shower cannot be tolerated. Resident #3 can wash face and upper body but requires assistance with lower body. Observe for redness, open areas, scratches, cuts, bruises, and report changes to the Nurse. Document/report PRN any changes, any potential for improvement, reasons for self-care deficit, expected course, declines in function. Encourage the resident to discuss feelings about self-care deficit. Encourage the resident to fully participate possible with each interaction. Praise all efforts at self-care. Monitor/document/report PRN any signs/symptoms of acute eye problems: Change in ability to perform ADLs, decline in mobility, sudden visual loss, pupils dilated, gray or milky, complaint of halos around lights, double vision, tunnel vision, blurred or hazy vision. Review medications for side effects which affect vision. Tell the resident where you are placing their items. Be consistent. Review of the staff assignment/shower schedule presented by the Director of Nursing for August 2021-September 30,2021, there was no evidence that showers were being provided for Resident #5. An interview was conducted on 9/29/21 at 10:35 AM, Resident #5 stated that she had not had shower in two months due to shortage of staff. Resident #5 stated she liked to have showers in the morning and for the past two months she had been told by staff, director of nursing and the administrator, showers could not be provided due to short of staff. Resident #5 stated I have very bad skin and need and want to have my scheduled showers to so that it does not dry out and stop itching so much. I have asked the administrator and director of nursing for at least one shower and everyone seems to blow me off. I really like my showers and it was not my fault the facility couldn ' t keep staff. I feel so much better when I get my showers. A bed bath can only last for a few hours. An interview was conducted on 9/29/21 at 10:40 AM, the Nurse Aide (NA) #2/Activities Assistant stated she had been working as a nurse aide due to insufficient staffing about a month. Nurse Aide #2 stated she had been unable to perform resident showers. She was aware of Resident #5 ' s request to be showered in the morning, but due to staffing shortage, showers were not done. An interview was conducted on 9/29/21 at 11:40 AM, the NA #1/Activities Director stated she had been working as a nurse aide for about two weeks. During the two weeks she had not been able to perform showers for Resident #5 or other residents who request them due to shortage of staff. Residents would be offered a bed bath and a report would be given to the on-coming shift of the residents who requested a shower. There was not enough time on 1st shift to give showers with only two aides to 30 residents. An interview was conducted on 9/30/21 at 6:48 PM, the Director of Nursing (DON)stated staffing was a major issue with the provision of showers for all residents. Staff assignments sheet should reflect when showers were provided, however, showers had not been consistently done. The DON presented a newly developed staff assignment sheet that would include when showers for residents would be done. The DON stated the assignment sheet had not been implemented. An interview was conducted on 9/30/21 at 6:58 PM, the Administrator stated she was aware the provision of showers was a concern due to staffing. She further stated bed baths were being provided regularly until proper staffing could be obtained. A telephone interview was conducted on 10/5/21 at 12:09 PM, Nurse#6 stated when he worked the non-covid unit Resident #5 had requested a shower and had to be told showers could not be provided due to staffing. She would have been assisted with a bed bath or personal wash down. A telephone interview was conducted on 10/5/21 at 3:20 PM, Nurse # 7 stated she worked 7P-7AM, Resident #5 was one resident that had been requesting showers but had not been getting them when she requested them due to short staff. Resident #5 liked to shower in the morning. Resident #5 would Nurse #7 at night she did not get a shower in the morning due to staffing. 3. Resident #6 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #6's care plan dated 08/04/21 indicated a focus area for ADL self-care performance deficit and included interventions for assisting Resident #6 with bathing. Her annual MDS dated [DATE] revealed she needed physical help with bathing and extensive assistance with personal hygiene. She was assessed as cognitively intact. In an interview with Resident #6 on 09/29/21 at 2:40 PM, she expressed she wanted to take showers but there were no staff to help her. Resident #6 further explained staff were busy changing diapers and we ain't got nobody to assist residents. Observation of Resident #6 on 09/29/21 at 2:40 PM revealed she was in the bed facing her doorway and looking into the hallway. She was wearing a hospital gown. Observations completed while onsite from 9:00 AM to 4:30 PM on 09/29/21 and from 8:00 AM to 7:30 PM on 09/30/21 revealed no resident showers being completed. In an interview on 09/30/21 at 09:57 AM, Nurse Aide (NA) #1/Activities Director expressed no showers were given to residents in the last 2 weeks stating, there are only 2 of us working. She further indicated she had not observed showers being done by staff and she did not know where the shower schedule was located. On 9/29/21 at 2:01 PM, an interview was conducted with the Administrator. She indicated showers were not being done and the shower area was used for storage since 09/16/21. She further stated the facility was challenged with staffing for 2 1/2 weeks. Showers and activities were not done due to staffing issues. The Administrator stated the facility had exhausted emergency plan staffing resources. She indicated residents were being cared for and staff had been doing a good job caring for the residents. On 9/30/21 at 1:03 PM an interview was conducted with the Director of Nursing (DON). She revealed the facility shower room had been unavailable for 15 days. The DON indicated showers were not being provided and the issue had been identified. She further indicated a new process was created for documenting showers, but it was not implemented yet due to staffing issues. Currently, there was not a way to know if showers were being provided to residents. 4. Resident #7 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #7's care plan dated 07/15/21 revealed a focus area for ADL self-care performance deficit. Interventions included staff assistance with bathing and showering. Her quarterly MDS dated [DATE] revealed she was cognitively intact and totally dependent on staff for bathing. An interview was conducted with Resident #7 on 09/29/21 at 2:46 PM. Resident #7 stated she has not had a shower. Observations completed while onsite from 9:00 AM to 4:30 PM on 09/29/21 and from 8:00 AM to 7:30 PM on 09/30/21 revealed no resident showers being completed. In an interview on 09/30/21 at 09:57 AM, NA #1/Activities Director expressed no showers were given to residents in the last 2 weeks stating, there are only 2 of us working. She further indicated she had not observed showers being done by staff and she did not know where the shower schedule was located. On 9/29/21 at 2:01 PM, an interview was conducted with the Administrator. She indicated showers were not being done and the shower area was used for storage since 09/16/21. She further stated the facility was challenged with staffing for 2 1/2 weeks. Showers and activities were not done due to staffing issues. The Administrator stated the facility had exhausted emergency plan staffing resources. She indicated residents were being cared for and staff had been doing a good job caring for the residents. On 9/30/21 at 1:03 PM an interview was conducted with the Director of Nursing (DON). She revealed the facility shower room had been unavailable for 15 days. The DON indicated showers were not being provided and the issue had been identified. She further indicated a new process was created for documenting showers, but it was not implemented yet due to staffing issues. Currently, there was not a way to know if showers were being provided to residents. 5. Resident #8 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Her quarterly MDS dated [DATE] revealed she was not able to be assessed for cognition due to being rarely understood. The MDS further revealed Resident #8 was totally dependent on staff for bathing and needed extensive assistance with personal hygiene. Resident #8's care plan dated 7/23/21 revealed a focus area for ADL self-care performance deficit. Staff interventions included assistance for bathing. An interview was conducted with Resident #8's family member on 10/04/21 at 5:00 PM. The family member explained Resident #8 was paralyzed on her right side and therefore she required assistance from staff to perform ADLs. The family member further explained Resident #8 was not receiving showers and had received 2 showers since November 2020; one shower was received between November 2020 and March 2021 (the family member had a paid sitter with Resident #8) and a second shower more recently (date unknown). The family member verbalized her concerns to the Administrator and was informed residents received showers weekly. The Administrator relayed a new process for shower documentation was implemented 2 or 3 weeks ago at the time of her voiced concern. The family member believed insufficient staffing has led to Resident #8's lack of ADL care. Observations completed while onsite from 9:00 AM to 4:30 PM on 09/29/21 and from 8:00 AM to 7:30 PM on 09/30/21 revealed no resident showers being completed. In an interview on 09/30/21 at 09:57 AM, NA #1/Activities Director expressed no showers were given to residents in the last 2 weeks stating, there are only 2 of us working. She further indicated she had not observed showers being done by staff and she did not know where the shower schedule was located. On 9/29/21 at 2:01 PM, an interview was conducted with the Administrator. She indicated showers were not being done and the shower area was used for storage since 09/16/21. She further stated the facility was challenged with staffing for 2 1/2 weeks. Showers and activities were not done due to staffing issues. The Administrator stated the facility had exhausted emergency plan staffing resources. She indicated residents were being cared for and staff had been doing a good job caring for the residents. On 9/30/21 at 1:03 PM an interview was conducted with the Director of Nursing (DON). She revealed the facility shower room had been unavailable for 15 days. The DON indicated showers were not being provided and the issue had been identified. She further indicated a new process was created for documenting showers, but it was not implemented yet due to staffing issues. Currently, there was not a way to know if showers were being provided to residents.

Based on observations, family, staff and resident interviews, and record reviews, the facility failed to provide feeding assistance (Resident #1) and assistance with personal hygiene (Resident #7, Resident #8) for 3 of 5 residents who were dependent on staff for assistance with activities of daily living (ADLs). Findings included: 1. Resident #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . His quarterly MDS dated [DATE] revealed Resident #1 had impaired cognition and was totally dependent on staff for eating. Resident #1's dietary care plan dated 09/08/21 indicated he was at risk for altered nutrition due to his diet and diagnoses. In an interview with Nurse #2 on 09/29/21 at 3:11 PM, she stated Resident #1 did not get feeding assistance for a meal about a month ago. She explained Resident #1 was overlooked because of insufficient staffing. On 09/30/21 at 12:49 PM and 09/30/21 at 1:02 PM, attempted interviews with the Nurse Aide (NA #11) who was responsible for assisting Resident #1 to eat were unsuccessful. On 10/04/21 at 5:01 PM an attempted interview with Resident #1's representative was unsuccessful. An interview with the Director of Nursing (DON) on 09/30/21 at 1:03 PM revealed she was informed about Resident #1 missing breakfast on the day it occurred. The DON was not sure why the nurse aide (NA #11) did not feed him and explained managers have helped feed Resident #1 since that time. An interview was conducted with the Administrator on 10/04/21 at 10:10 AM. The Administrator stated she was aware Resident #1 was not fed a meal. The Administrator explained Resident #1 did end up getting fed his meal later after a new tray was ordered. She believed he missed the meal due to a miscommunication. As a response to Resident #1 not being fed, the Administrator stated managers were monitoring food trays being passed out as well as monitoring residents who required feeding assistance. 2. Resident #7 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #7's care plan dated 07/15/21 revealed a focus area for ADL self-care performance deficit. Interventions included staff assistance with bathing and showering. Her quarterly MDS dated [DATE] revealed she was cognitively intact and totally dependent on staff for bathing. An interview was conducted with Resident #7 on 09/29/21 at 2:46 PM. Resident #7 stated she did not get assistance combing her hair and cutting her nails. She verbalized, They don't comb your hair. They could at least comb hair. She further voiced she had asked staff to cut her nails, but they haven't done it and she had last asked for assistance the other day. Observation of Resident #7 on 09/29/21 at 2:46 PM revealed her hair was unkempt and her fingernails were long. On 9/29/21 at 2:01 PM, an interview was conducted with the Administrator. She stated the facility was challenged with staffing for 2 1/2 weeks. The Administrator stated the facility had exhausted emergency plan staffing resources. She indicated residents were being cared for and staff had been doing a good job caring for the residents. An interview with the DON on 09/30/21 at 1:03 PM revealed there were staffing issues. She stated staff have reported it was a lot to be able to provide care. In a follow up interview with the Administrator on 10/4/21 at 10:10 AM, she stated residents were not receiving the care that was typically provided, but at the end of the day they were cared for. 3. Resident #8 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Her quarterly MDS dated [DATE] revealed she was not able to be assessed for cognition due to being rarely understood. The MDS further revealed Resident #8 was totally dependent on staff for bathing and needed extensive assistance with personal hygiene. Resident #8's care plan dated 7/23/21 revealed a focus area for ADL self-care performance deficit. Staff interventions included assistance for bathing. Observation of Resident #8 on 09/29/21 at 9:40 AM revealed knotted hair on the back of her head. On 9/29/21 at 2:01 PM, an interview was conducted with the Administrator. She stated the facility was challenged with staffing for 2 1/2 weeks. The Administrator stated the facility had exhausted emergency plan staffing resources. She indicated residents were being cared for and staff had been doing a good job caring for the residents. An interview with the DON on 09/30/21 at 1:03 PM revealed there were staffing issues. She stated staff have reported it was a lot to be able to provide care. In a follow up interview with the Administrator on 10/4/21 at 10:10 AM, she stated residents were not receiving the care that was typically provided, but at the end of the day they were cared for. An interview was conducted with Resident #8's family member on 10/04/21 at 5:00 PM. The family member explained Resident #8 was paralyzed on her right side and therefore she required assistance from staff to perform ADLs. The family member explained staff were not assisting Resident #8 to brush her teeth or to comb her hair. The family member verbalized her concerns to the Administrator. The family member believed insufficient staffing has led to Resident #8's lack of ADL care.

Based on observations, family, resident and staff interviews, and record review, the facility failed to provide an ongoing activity program which met the individual interests and needs for 7 of 8 sampled residents (Resident #1, Resident #2, Resident #3, Resident #5, Resident #6, Resident #7 and Resident #8). The findings included: Resident Council minutes dated 08/19/21 revealed there was not enough staff to assist residents to get up for activities. Hallway activities would be conducted as of 08/25/21. Observations while onsite from 9:00 AM- 4:30 PM on 09/29/21 and 8:00 AM- 7:30 PM on 09/30/21 revealed no residents participating in or offered listed scheduled daily activities. No hallway activities were observed during these times while onsite. 1. Resident #1 was admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . His quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #1 had impaired cognition and required staff assistance. Resident #1's annual MDS dated [DATE] revealed the following activities were very important to him: listening to music, keeping up with the news, doing favorite activities, going outside, and participating in religious services or practices. Observation of Resident #1 on 09/29/21 at 12:20 PM revealed he was in bed, looking out the window. An Interview attempt with Resident #1's representative on 10/04/21 at 5:01 PM was unsuccessful. An interview with the Nurse Aide (NA) #2/Activities Assistant on 09/29/21 at 10:50 AM revealed she felt unable to complete her job duties during her shift. She had been working as a nurse aide due to insufficient staffing and had not conducted activities for residents in about a month. An interview was conducted with NA #1/Activities Director on 09/29/21 at 12:11 PM. She explained she was the Activities Director but was unable to provide any activities for residents while working as a nurse aide. She stated she had been working as a nurse aide for about two weeks. In an interview with Nurse #2 on 09/29/21 at 3:11 PM, the nurse stated no activities were being provided to residents. A follow up interview was conducted with NA #1/Activities Director on 09/30/21 at 9:57 AM. She voiced activities had not been provided to residents since 09/17/21. She stated, they are supposed to be done, but they are not. NA #1 further explained no intercom activities were provided to residents stating, if I don't do them, they are not done. Intercom activities were when staff played something through the overhead system for residents to listen to, including devotionals. On 9/29/21 at 2:01 PM, an interview was conducted with the Administrator. The Administrator stated the facility was challenged with staffing for the last 2 1/2 weeks. She explained activities were not done due to staffing issues. The Administrator stated the facility had exhausted emergency plan staffing resources. She indicated residents were being cared for and staff had been doing a good job caring for the residents. An interview with the Director of Nursing (DON) was conducted on 09/30/21 at 1:03 PM. She expressed activities had not been offered for about a week due to staffing issues. 2. Resident #2 was admitted to the facility on [DATE]. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . His cognition was not assessed on the most recent MDS quarterly assessment. Resident #2 required extensive assistance from staff. Progress notes dated 08/23/21 revealed Resident #2 attended some group activities and had 1:1 weekly visits. He was assessed to enjoy snacks, bingo, intercom devotion, sitting outside and horse racing. Resident #2 was non- interviewable. Observation of Resident #2 occurred on 09/30/21 at 5:37 PM and revealed he was wearing a hospital gown and slumped down in the bed. An interview with the Nurse Aide (NA) #2/Activities Assistant on 09/29/21 at 10:50 AM revealed she felt unable to complete her job duties during her shift. She had been working as a nurse aide due to insufficient staffing and had not conducted activities for residents in about a month. An interview was conducted with NA #1/Activities Director on 09/29/21 at 12:11 PM. She explained she was the Activities Director but was unable to provide any activities for residents while working as a nurse aide. She stated she had been working as a nurse aide for about two weeks. In an interview with Nurse #2 on 09/29/21 at 3:11 PM, the nurse stated no activities were being provided to residents. A follow up interview was conducted with NA #1/Activities Director on 09/30/21 at 9:57 AM. She voiced activities had not been provided to residents since 09/17/21. She stated, they are supposed to be done, but they are not. NA #1 further explained no intercom activities were provided to residents stating, if I don't do them, they are not done. On 9/29/21 at 2:01 PM, an interview was conducted with the Administrator. The Administrator stated the facility was challenged with staffing for the last 2 1/2 weeks. She explained activities were not done due to staffing issues. The Administrator stated the facility had exhausted emergency plan staffing resources. She indicated residents were being cared for and staff had been doing a good job caring for the residents. An interview with the Director of Nursing (DON) was conducted on 09/30/21 at 1:03 PM. She expressed activities had not been offered for about a week due to staffing issues. 3. Resident #6 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #6's care plan dated 08/04/21 indicated a focus area for activity attendance to meet emotional, intellectual and physical needs. Resident #6's goals included attending and participating in activities and maintaining involvement in cognitive stimulation. Staff interventions included inviting the resident to scheduled activities as well as a list of her preferred activities. Her annual Minimum Data Set (MDS) dated [DATE] revealed she was cognitively intact and activities that were important to her included going outside, participating in religious services, doing activities with groups of people and listening to music. Observation of Resident #6 on 09/29/21 at 2:40 PM revealed she was in the bed facing her doorway and looking into the hallway. She was wearing a hospital gown. An interview with Resident #6 was conducted on 09/29/21 at 2:40 PM. The resident revealed no activities were being offered inside or outside of the residents' rooms. She stated there was insufficient nursing staff for the facility to offer activities. An interview with the Nurse Aide (NA) #2/Activities Assistant on 09/29/21 at 10:50 AM revealed she felt unable to complete her job duties during her shift. She had been working as a nurse aide due to insufficient staffing and had not conducted activities for residents in about a month. An interview was conducted with NA #1/Activities Director on 09/29/21 at 12:11 PM. She explained she was the Activities Director but was unable to provide any activities for residents while working as a nurse aide. She stated she had been working as a nurse aide for about two weeks. In an interview with Nurse #2 on 09/29/21 at 3:11 PM, the nurse stated no activities were being provided to residents. A follow up interview was conducted with NA #1/Activities Director on 09/30/21 at 9:57 AM. She voiced activities had not been provided to residents since 09/17/21. She stated, they are supposed to be done, but they are not. NA #1 further explained no intercom activities were provided to residents stating, if I don't do them, they are not done. On 9/29/21 at 2:01 PM, an interview was conducted with the Administrator. The Administrator stated the facility was challenged with staffing for the last 2 1/2 weeks. She explained activities were not done due to staffing issues. The Administrator stated the facility had exhausted emergency plan staffing resources. She indicated residents were being cared for and staff had been doing a good job caring for the residents. An interview with the Director of Nursing (DON) was conducted on 09/30/21 at 1:03 PM. She expressed activities had not been offered for about a week due to staffing issues. 4. Resident #7 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #7's care plan dated 07/15/21 listed a goal for maintaining involvement in cognitive stimulation and social activities. Staff interventions included assisting and escorting the resident to activity functions. Resident #7's annual MDS dated [DATE] indicated activities important to her included listening to music, keeping up with the news, doing things with groups of people, going outside and participating in religious services. Her quarterly MDS dated [DATE] revealed she was cognitively intact. Observation of Resident #7 was completed on 09/29/21 at 2:46 PM. She was lying in the bed facing the hallway. An interview was conducted with resident #7 on 9/29/21 at 2:46 PM. Resident #7 revealed no activities were being offered to her. An interview with the Nurse Aide (NA) #2/Activities Assistant on 09/29/21 at 10:50 AM revealed she felt unable to complete her job duties during her shift. She had been working as a nurse aide due to insufficient staffing and had not conducted activities for residents in about a month. An interview was conducted with NA #1/Activities Director on 09/29/21 at 12:11 PM. She explained she was the Activities Director but was unable to provide any activities for residents while working as a nurse aide. She stated she had been working as a nurse aide for about two weeks. In an interview with Nurse #2 on 09/29/21 at 3:11 PM, the nurse stated no activities were being provided to residents. A follow up interview was conducted with NA #1/Activities Director on 09/30/21 at 9:57 AM. She voiced activities had not been provided to residents since 09/17/21. She stated, they are supposed to be done, but they are not. NA #1 further explained no intercom activities were provided to residents stating, if I don't do them, they are not done. On 9/29/21 at 2:01 PM, an interview was conducted with the Administrator. The Administrator stated the facility was challenged with staffing for the last 2 1/2 weeks. She explained activities were not done due to staffing issues. The Administrator stated the facility had exhausted emergency plan staffing resources. She indicated residents were being cared for and staff had been doing a good job caring for the residents. An interview with the Director of Nursing (DON) was conducted on 09/30/21 at 1:03 PM. She expressed activities had not been offered for about a week due to staffing issues. 5. Resident #8 was admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #8's annual MDS dated [DATE] revealed it was very important for her to listen to music, keep up with the news, do her favorite activities, go outside, and participate in religious services. Her quarterly MDS dated [DATE] revealed she was not able to be assessed for cognition due to being rarely understood. Her care plan dated 07/23/21 revealed a goal for Resident #8 to attend and to participate in activities of choice. An interview was conducted with Resident #8's family member on 10/04/21 at 5:00 PM. She stated the facility does not have enough staff to care for Resident #8. The family member explained Resident #8 enjoyed watching television but was unable to use the remote independently due to right side paralysis. The family member explained staff was not assisting Resident #8 to turn on the television or to change the channel. Observation of Resident #8 occurred on 09/29/21 at 2:49 PM and revealed she was sitting in her bed and looking at the window. An interview with the Nurse Aide (NA) #2/Activities Assistant on 09/29/21 at 10:50 AM revealed she felt unable to complete her job duties during her shift. She had been working as a nurse aide due to insufficient staffing and had not conducted activities for residents in about a month. An interview was conducted with NA #1/Activities Director on 09/29/21 at 12:11 PM. She explained she was the Activities Director but was unable to provide any activities for residents while working as a nurse aide. She stated she had been working as a nurse aide for about two weeks. In an interview with Nurse #2 on 09/29/21 at 3:11 PM, the nurse stated no activities were being provided to residents. A follow up interview was conducted with NA #1/Activities Director on 09/30/21 at 9:57 AM. She voiced activities had not been provided to residents since 09/17/21. She stated, they are supposed to be done, but they are not. NA #1 further explained no intercom activities were provided to residents stating, if I don't do them, they are not done. On 9/29/21 at 2:01 PM, an interview was conducted with the Administrator. The Administrator stated the facility was challenged with staffing for the last 2 1/2 weeks. She explained activities were not done due to staffing issues. The Administrator stated the facility had exhausted emergency plan staffing resources. She indicated residents were being cared for and staff had been doing a good job caring for the residents. An interview with the Director of Nursing (DON) was conducted on 09/30/21 at 1:03 PM. She expressed activities had not been offered for about a week due to staffing issues. Resident Council minutes dated 8/19/21 revealed there was not enough staff to assist residents to get up for activities. Hallway activities would be conducted as of 8/25/21. Review of the facility's scheduled calendar activities for 9/29/21, monthly birthday truck and for 9/30/21 hot apple cider and donut truck and hallway bingo was schedule but did not occur. 6. Resident #3 was admitted to the facility on [DATE]. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the activity assessment dated [DATE], revealed resident preference in group activities with interest in religious devotion, music, manicures, outdoor activities, current events, movies, and social events. The care plan dated 9/1/21, identified the problem as Resident #3 had concerns with emotional, social, and intellectual needs. The goal included Resident #3 would participate in activities of choice. The interventions included Resident #3 preferred to watch TV in room. The resident needed 1:1 bedside/in-room visits and activities if unable to attend out of room events. The resident had a psychosocial well-being problem related to disease process. The resident will verbalize feelings related to emotional state. Allow the resident time to answer questions and to verbalize feelings perceptions, and fears During an interview with Resident #3 on 9/30/21 at 5:06 PM, Resident #3 reported her interests included music, television, movies, bingo, religious/devotional activities, some arts and crafts and in-room talks and discussions. Resident #3 stated she would attend some of the group activities but liked the 1:1 activity best because it gave her more private time to talk about her feelings without feeling like others were listening to her problems. Resident #3 stated since the activities staff were now working on the unit, they have not been able to come by her room to talk with her. Resident #3 also stated they were not playing the devotional messages over the intercom. Resident #3 added she felt lonely when the activities staff didn't come by to talk to her and there were no hall activities. A telephone interview was conducted on 9/29/21 at 10:29 AM. The responsible person stated Resident #3 enjoyed some group activities and 1:1 interaction with the activities staff. The responsible person stated during the conversations with Resident #3, she would report she missed the weekly 1:1 time with the activities, because it gave her the opportunity to talk about her feelings and the things she likes and staff encouraging her to participate in other activities. Since she had been on the COVID unit, no-one came to see her. The responsible person stated since the activities staff were now working on the unit as aides, they were no longer able to meet with Resident #3 on a weekly basis and Resident #3 felt lonely. An interview was conducted on 9/29/21 at 10:50 AM. The Nurse Aide (NA) #2/Activities Assistant stated she felt unable to complete her job duties during her shift. She had been working as a nurse aide due to insufficient staffing and had not conducted activities for residents in about a month. An interview was conducted on 9/29/21 at 12:11PM. The NA #1/Activities Director stated she was the Activities Director but was unable to provide any activities for residents while working as a nurse aide. She stated she had been working as a nurse aide for about two weeks. A follow up interview was conducted with NA #1/Activities Director on 09/30/21 at 9:57 AM. She stated had not been provided to residents since 09/17/21. She stated, they are supposed to be done, but they are not. NA #1 further explained no intercom activities were provided to residents stated, if I don't do them, they are not done. An interview was conducted on 9/30/21 at 1:30 PM, the Social Worker stated Resident #3 benefitted from 1:1 activities and social interaction during hallway activities. Social Worker reported the resident was much more social when activities were being provided in the halls and when she received the 1:1 talk discussions with activities staff. An interview was conducted on 9/30/21 at 1:03 PM, the Director of Nursing (DON) stated activities had not been offered for about a week due to staffing issues. An interview was conducted on 9/29/21 at 2:01 PM, the Administrator stated the facility was challenged with staffing for the last 2 1/2 weeks. She further stated activities were not done due to staffing issues. 7. Resident #5 was admitted to the facility on [DATE]. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The care plan dated 9/9/21 identified the problem as Resident #5 had concerns with emotional, social, and intellectual needs. The goal included Resident #5 would maintain involvement in cognitive stimulation, social activities. The interventions included Resident #5 enjoyed and attended activities such as bingo, church services, musical programs, different parties, arts and crafts, manicures and movie and popcorn. Resident #5 preferred to socialize with family members and friends and familiar staff members. Provide the resident with an activities calendar and notify resident of any changes to the calendar of activities. Review of the activity assessment dated [DATE], revealed Resident #5 enjoyed intercom bingo, intercom devotion, intercom music, outside time, meal of the month, holiday socials, monthly birthdays, 1:1 activity, movies and popcorn. An interview was conducted on 9/29/21 at 10:35 AM, Resident #5 stated the activities have not been provided on a consistent basis due to activities staff working as aides on the unit. Resident #5 also stated she missed the 1:1 in-room activities, hall bingo, crafts, music, and intercom devotions. Resident #5 stated socialization was important to her to help keep her mind active. An interview was conducted on 9/29/21 at 10:50 AM, the Nurse Aide (NA) #2/Activities Assistant stated she felt unable to complete her job duties during her shift. She had been working as a nurse aide due to insufficient staffing and had not conducted activities for residents in about a month. An interview was conducted on 9/29/21 at 12:11 PM, the NA #1/Activities Director stated she was the Activities Director but was unable to provide any activities for residents while working as a nurse aide. She stated she had been working as a nurse aide for about two weeks. A follow up interview was conducted on 9/30/21 at 9:57 AM, the NA #1/Activities Director stated activities had not been provided to residents since 09/17/21. She stated, they are supposed to be done, but they are not. NA #1 further explained no intercom activities were provided to residents stated, if I don't do them, they are not done. An interview was conducted on 9/30/21 at 1:30 PM, the Social Worker stated Resident #5 benefitted from the group activities and 1:1 activity. The Social Worker stated Resident #5 was very active with group events and had reported she missed the activities. An interview was conducted on 9/30/21 at 1:03 PM, the Director of Nursing (DON) stated activities had not been offered for about a week due to staffing issues. An interview was conducted on 9/29/21 at 2:01 PM, the Administrator stated the facility was challenged with staffing for the last 2 1/2 weeks. She further stated activities were not done due to staffing issues.

Based on observations, family, staff and resident interviews, and record reviews, the facility failed to provide sufficient nursing staff for 7 of 8 (Resident #1, Resident #2, Resident #3, Resident #5, Resident #6, Resident #7 and Resident #8) sampled residents: 1) Provide sufficient staff to offer and assist with activities (Resident #1, Resident #2, Resident #3, Resident #5, Resident #6, Resident #7, Resident #8) 2) Provide assistance with activities of daily living to include feeding assistance (Resident #1) and assistance with personal hygiene (Resident #7, Resident #8) 3) Provide showers (Resident #3, Resident #5, Resident #6, Resident #7, Resident #8) for residents with preferences for showers. This tag is cross referenced with F679, F677 and F561. F679 - Based on observations, family, resident and staff interviews, and record review, the facility failed to provide an ongoing activity program which met the individual interests and needs for 7 of 8 sampled residents (Resident #1, Resident #2, Resident #3, Resident #5, Resident #6, Resident #7 and Resident #8). F677 - Based on observations, family, staff and resident interviews, and record reviews, the facility failed to provide feeding assistance (Resident #1) and assistance with personal hygiene (Resident #7, Resident #8) for 3 of 5 residents who were dependent on staff for assistance with activities of daily living (ADLs). F561 - Based on observations, resident and staff interviews, family interviews and record review, the facility failed to provide showers for residents who needed assistance for 5 of 8 sampled residents with a preference for showers (Resident #3, Resident #5, Resident #6, Resident #7 and Resident #8).

Based on observations and interviews, the facility failed to protect the private health information for 2 of 2 sample residents (Resident #5 and Resident #8) by leaving confidential medical information unattended and exposed in an area accessible to the public for 2 of 2 medication carts. The findings included: 1a. A continuous observation was made on 9/29/21 from 10:00 AM to 10:25 AM, of an unattended medication cart on the 300 halls. The electronic Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The electronic medication (MAR) computer screen was open for rooms [ROOM NUMBERS], which showed a picture of the residents on the 300 hall their room number list of medications, what the medication was used for and diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The electronic MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] An interview was conducted on 9/29/ 21 at 10:25AM, Resident #5 and #8 who resided on the 300 halls confirm they were waiting for medications from the nurse. b. A continuous observation was made on 9/29/21 at 11:00 AM to 11:20 AM, of an unattended medication cart was located at the doorway of room [ROOM NUMBER], the electronic Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Nurse#1 assigned to the cart left the computer screen open where eight resident names pictures, what medications was used for and the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . An interview was conducted on 9/29 /21 at 11:25 AM, Nurse#1 stated she should have not walked away from the cart without blocking the cart and closing the medication administration screen or closing out the medication administration program. An interview was conducted on 9/30/21 at 1:06 PM, the Director of Nursing (DON) stated the nurse was responsible for securing the medication administration screen by either closing out the medication administration program or closing the laptop screen. An interview was conducted on 9/29/21 at 3:30 PM, the administrator stated the nurse was expected to close out the computer screen for the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER]

Based on observation, staff interviews and record review, the facility failed to lock an unattended medication cart for 2 of 2 carts on the 300 and 400 hall. The findings included: 1a. A continuous observation on 9/29/21 at 10:00 AM-10:25 AM, revealed the medication cart on the 300 halls, the medication cart was unlocked and unattended. Nurse #1 left the medication cart unlocked with the push button in the sticking out position. The nurse went to the back end of the 200 halls, which was not in view of the cart. The medication cart was in front of rooms [ROOM NUMBERS], two other residents were observed in the hall. b. A continuous observation was made on 9/29/21 at 11:00 AM to 11:20 AM, the medication cart was located at the doorway of room [ROOM NUMBER], it was unlocked with the push button lock sticking out. Nurse #1 left the medication cart unlocked and unattended and went to the front nursing station. An interview was conducted on on 9/29/21 at 11:25 AM, Nurse#1 stated she should have not walked away from the cart without pushing the lock button in the lock position. An interview was conducted on 9/30/21 at 1:06 PM, the Director of Nursing (DON) stated the nurse was responsible for keeping the medication cart always locked when medication pass was not being done. An interview was conducted on 9/29/21 at 3:30 PM, the administrator stated the nurse was expected to lock the medication cart when they were away from the cart.

Based on observations, staff interviews and record review, the facility failed to post daily nurse staffing information for 2 of 2 days observed for posted staffing information. Additionally, the facility failed to post completed staffing information for 28 of 30 days reviewed for completed staffing information. Findings included: A review of facility staffing information dated 9/01/21 through 09/30/21, revealed total hours worked was not entered for 28 of 30 days. Observations on 09/29/21 at 3:00 PM revealed nurse staffing was posted on a bulletin board near the facility entrance for 09/22/21, 09/23/21 and 09/27/21. At the time of the observation, information was completed for night shift and day and evening shifts were incomplete. Observations on 09/30/21 at 11:36 AM revealed no nurse staffing information was posted. An interview was conducted on 9/30/2021 at 1:03 PM with the Director of Nursing (DON). The DON stated the third shift charge nurse completed staffing sheets for the next day. The DON further explained the third shift charge nurse was responsible for posting staffing daily and that staff posting should be updated daily. Attempts to contact third shift nurses (Nurse #9 and Nurse #10) that worked on 09/29/21 and 09/30/21 were unsuccessful. An attempt to contact Nurse #9 occurred on 10/04/21 at 3:09 PM and an attempt to contact Nurse #10 occurred on 10/04/21 at 3:06 PM. An interview with Nurse #3 on 10/04/21 at 3:10 PM revealed she did not complete the census information because she worked evening shift. Nurse #3 did not know the name of the nurse that was responsible for completing staff posting information on 9/29/21 or 09/30/21. An interview with Nurse #4 on 10/04/21 at 6:18 PM revealed she did not complete the census for 09/29/21 or 09/30/21. She also stated she did not post staffing on those days. The nurse stated the typical process for completing nurse staffing information was to print the midnight census, fill out the posting sheets, and then post the staffing information. An interview was conducted with the Administrator on 10/04/21 at 10:10 AM. The Administrator stated third shift charge nurses were responsible for posting staffing while daytime supervisors monitored the posted staffing. She stated that staffing changes should be reflected on the posted information. The administrator also stated the total hours were missing on staff postings in the last 30 days. In reviewing the staff postings, the administrator believed they were not being done properly.

Based on observations, resident interviews, staff interviews and review of resident council meeting minutes, the facility failed to resolve group grievance for food concerns reported in resident council 5 consecutive months for 5 of 5 (Resident #13, #21, #25, #40 and #50) that attend resident council meetings. The findings included: Resident council meeting was conducted on 4/6/21 at 3:10 PM, 5 of 5 residents were identified as alert and oriented. The residents of the group reported they were not getting food preferences and were receiving food items on their dislike list or wrong food items. Resident #40 stated they had to send food items back to the kitchen or ask for an alternate when they received items from dislike list, or the food items were not available. In addition, the residents stated in last two months coffee had been coming cold and they had to ask staff to reheat or get another cup of coffee. Resident #50 reported these concerns have been addressed several different times in the resident council meetings and the problem continue to happen, they have been told the issue would be corrected. Resident #25 stated the residents should not have to keep asking staff to bring items or remove items from the meal tray that were on their dislike list, if they are put on the resident meal cards. Resident #25 stated they would get something you don't like or don ' t get what you like. He added everyone's preferences likes and dislikes should be reviewed and checked before they send the trays out. Meal observation conducted on 4/7/21 at 12:00 PM, to 1:50 PM, Resident #25 ' s meal arrived 12:05 PM, resident ' s meal tray was missing coffee, dinner roll which was part of meal, dessert and banana peanut butter/jelly sandwich. Resident #25 requested unit staff to get the food items missing. Missing. Resident #25 stated he was tired of calling down for food items every meal. Observed Resident #40 ' s meal on 4/7/21/21 at 12:10 PM, the meal tray was missing dessert fruit cocktail, tea, condiments and collard greens. Resident had the nurse aide call down to the kitchen for the missing food items. Observed Resident #21 ' s meal on 4/8/21 at 8:45 AM, Resident #21 reported she wanted whole egg, the meal tray had scrambled eggs. Resident #21 asked unit staff to replace eggs from tray. Resident #21 stated she gets frustrating having to constantly ask staff to bring correct food items or remove items that were listed as dislike list. Review of the resident council minutes dated 7/23/20, documented concerns that food was being served cold, cold coffee and not receiving correct food. Review of the resident council minutes and response forms dated 8/31/20, 9/17/20, 11/12/20 and 12/20 did not indicated discussions and follow-up were held with resident regarding the resolution of the group concerns. During an interview on 4/8/21 at 12:00 PM, the Activities Director (AD) stated the residents had reported on-going food concerns regarding food choice, tasty/quality, receiving wrong food items in several group meetings. The concerns would be turned over to the department head for resolution and discussion at the next meeting. The resident council meetings were reviewed with AD for the response report and there were none for the identified concerns from 7/23/20 through 12/20. The AD reviewed group grievance response/plan action forms and there was no documented corrective action. During an interview on 4/8/21 at 12:15 PM, the Administrator stated the kitchen staff were responsible for checking resident meal cards for accuracy prior to leaving the kitchen. The dietary staff and RD were also responsible for reviewing/updating resident likes, dislikes and preferences to at least quarterly to ensure residents receive foods of choice. The group grievances should be submitted to each department head responsible for resolution and reviewed with the resident council the following month and/or individually to discuss and resolve the concern. The administrator reviewed the presented grievances for the identified months and confirmed there were no dietary response to the resident concerns. During an interview on 4/8/21 at 1:30 PM, the Dietary Aide (DA)#3 staff stated the food was prepared from the main kitchen with the meal card, and they dietary aides were responsible for checking the cards and prepare the trays. DA #4 stated they have been called by residents and staff when items were not on trays and they would have to call the main kitchen to get the item or a replacement. Both DA; s stated they were aware of the resident ' s concerns and try to replace or get the items of request but depend on the main kitchen to provide the preferred items on the tray. During an interview on 4/8/21 at 1:44 PM, the Registered Dietician (RD) stated she had not been invited to the resident council by the group but have spoken with residents individually about food concerns/preferences to review and update the meal cards. The RD stated the meal cards were prepared and checked at the main kitchen through the hospital production system before the food was sent to the facility kitchen. The facility staff were responsible for calling the main kitchen to get missing food items if the items were not available in the facility kitchen

Based on staff and physician interviews, and facility and hospital record reviews, the facility failed to develop a comprehensive person-centered care plan that accurately reflected the care needs and safety measures required to care for a resident, including the need for two-person assistance with transfers and the assistance required immediately after a transfer 1 of 3 sampled residents reviewed for accidents (Resident #3). Resident #3 experienced a fall from the side of her bed, while being assisted by one staff member which resulted in a fall and the resident experienced an injury to her forehead. Resident #3 was sent to the hospital for evaluation and treatment and passed away later that day from an [MEDICATION NAME] hemorrhage (bleeding around or within the brain itself). Immediate Jeopardy began on [DATE] when Nursing Assistant (NA) #1 transferred Resident #3 from her recliner to the bed with a stand and pivot maneuver without additional staff assistance and Resident #3 fell forward off of the bed, striking her head on the floor. At the time of the fall, the resident ' s Care Plan did not specify she required two-person assistance with transfers and was not stable sitting on the side of the bed by herself. Immediate Jeopardy was removed as of [DATE] when the facility implemented an acceptable allegation of Immediate Jeopardy removal. The facility remains out of compliance at a scope and severity level D (no actual harm with potential for more than minimal harm that is not immediate jeopardy) for the facility to continue staff education and ensure monitoring systems put into place are effective. The findings included: Resident #3 was admitted to the facility on [DATE]. Her cumulative [DIAGNOSES REDACTED]. Resident #3 ' s last annual Minimum Data Set (MDS) assessment dated [DATE] indicated the resident had severely impaired cognitive skills for daily decision making. Section G indicated the resident required extensive assistance with two plus (2+) persons physical assist for bed mobility and transfers A review of the resident ' s Care Area Assessment (CAA) Worksheet for ADL (Activities of Daily Living) / Functional / Rehabilitation Potential (dated [DATE]) included an analysis of findings. These findings read, in part: .She is alert to self only .She requires assistance with bed mobility, toileting and transfers . A review of the CAA Worksheet for Falls (dated [DATE]) included a description of the nature of this problem/condition, which noted the resident had a fall during the past quarter without injury, had a [DIAGNOSES REDACTED]. A decision was made to include both ADLs and Falls in the resident ' s care plan. Resident #3 ' s Care Plan (dated [DATE]) included the following areas of focus, in part: --Resident requires assist with ADLs on a daily basis related to a [DIAGNOSES REDACTED]. The care plan interventions indicated the resident, Can stand and pivot with transfers. The Care Plan did not indicate how many staff members were required to assist the resident with transfers. --Resident has a history of falls. --Resident is at risk for falls. Has impaired safety awareness. A review of Resident #3 ' s medical record revealed a Therapy Screen was requested by nursing staff on [DATE]. The screen was completed by a Physical Therapist (PT) on [DATE]. PT notations dated [DATE] indicated he spoke with nursing staff. Staff reported Resident #3 was having increased difficulty with transfers and would benefit from a Physical Therapy evaluation. The PT completed an evaluation on [DATE]. A Functional Assessment of the resident ' s sitting balance indicated she required contact guard assist (CGA) for both static and dynamic (gentle challenges to balance) balance while sitting on the side of a bed. The PT ' s Treatment Plan for Resident #3 read: Pt (patient) performs bed mobility, transfers and gait at baseline. No further skilled PT (physical therapy) is required at this time. Recommend NSG (nursing) perform OOB (out of bed) to chair daily by 2 person assist or Hoyer lift. Further review of Resident #3 ' s Care Plan dated [DATE] related to ADL care was conducted. No revisions had been made to the care plan interventions as a result of the [DATE] Physical Therapy evaluation. The Care Plan interventions continued to read, Can stand and pivot with transfers. The Care Plan did not indicate the resident needed two-person assistance with transfers (or a Hoyer lift) as recommended by PT, nor did it include safety measures required based on the PT ' s assessment of Resident #3 ' s instability while sitting on the side of the bed which included her need for contact guard assist with both static and dynamic balance. Resident #3 ' s quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated the resident had severely impaired cognitive skills for daily decision making. Section G indicated the resident required limited assistance with one person physical assist for bed mobility and extensive assistance with one person physical assist for transfers. A review of the resident ' s Care Plan (dated [DATE]) related to ADL care was conducted. The Care Plan interventions continued to read, Can stand and pivot with transfers. The Care Plan interventions continued to read, Can stand and pivot with transfers. The Care Plan did not indicate the resident needed two-person assistance with transfers (or a Hoyer lift) as recommended by PT on [DATE], nor did it include safety measures required based on the PT ' s assessment of Resident #3 ' s instability while sitting on the side of the bed which included her need for contact guard assist with both static and dynamic balance. Resident #3 ' s quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated the resident had severely impaired cognitive skills for daily decision making. Section G indicated the resident required extensive assistance with one person physical assist for bed mobility and extensive assistance with 2+ person physical assist for transfers. She required extensive assistance from staff for all of her other ADLs, with the exception of needing supervision only for eating and being totally dependent on staff for bathing. The resident ' s Care Plan, which was in place on [DATE], related to ADL care included interventions which continued to read, Can stand and pivot with transfers. The Care Plan did not indicate how many staff members were required to assist the resident with transfers or any additional safety measures required due the resident ' s instability while sitting on the side of the bed. Resident #3 ' s next Care Plan review date was scheduled for [DATE]. A review of Resident #3 ' s (undated) Individual Service Plan (ISP) which was in place on [DATE], was provided by the facility. An ISP (also known as a Care Guide) is a printed summary of individual patient needs, which includes information for direct care nursing staff on the assistance required to meet the ADL care needs for a resident. Each individual resident ' s ISP is posted on the inside of his/her closet door. Resident #3 ' s ISP included Special Instructions which read, in part: Resident with worsening dementia .Can stand and pivot with transfers . Additionally, the resident ' s ISP included a section entitled, Transferring. Comments noted in the transferring section read in its entirety, Can stand and pivot with transfers. Review of Resident #3 ' s medical record included a Nursing Note for Falls, written by Nurse #1 and dated [DATE] at 11:25 PM. The note indicated Nurse #1 was called to the resident ' s room at approximately 9:20 PM by a Nursing Assistant (NA). Upon entering the room, Resident #3 was lying on the floor on her left side. She was responsive and attempting to get up. Her vital signs were checked while she was lying on the floor. Her blood pressure was noted to be ,[DATE]; pulse 86; and respiration rate 18. The resident was able to state her name. She appeared to be shaken up and had a large knot above left eye. A partial assessment was done and the resident was moved to the bed with a Hoyer lift so a thorough assessment could be achieved. Once the resident was placed in bed, her vital signs were checked again. At that time, her blood pressure was ,[DATE], pulse 95, and respiration rate 20. The resident was asked her name again and she begin to state her first name but wasn't able to finish the rest because she became unresponsive. Vital signs where again checked at 9:43 PM and her blood pressure was noted to be ,[DATE]; pulse 69; and respirations were reported to be labored. Resident #3 ' s oxygen saturation (O2 sat) was taken and noted to be 75%. The resident was placed on 2 liters of oxygen/minute. Her O2 sat increased to 85% and 95%, but began to plummet back to ,[DATE]%. Her physician was called, informed of the fall and resident status, and an order was received to send Resident #3 to the Emergency Department (ED) for evaluation. Emergency Medical Services (EMS) were called and the resident was transported to the hospital. A review of Resident #3 ' s hospital records indicated the resident arrived at the ED on [DATE] at 10:10 PM. Hospital notes indicated the resident was unresponsive and experienced full [MEDICAL CONDITION]. Additional details in the hospital records indicated the resident had stable vital signs upon EMS arrival, but had pulseless electrical activity (PEA) on monitor prior to transport to the hospital. PEA refers to [MEDICAL CONDITION] in which the electrocardiogram shows a heart rhythm that should produce a pulse, but does not. The resident was reported as arriving to the ED with cardiopulmonary resuscitation (CPR) in progress. Resuscitation was discontinued on [DATE] at 10:18 PM. The treating physician noted, Given large trauma to the forehead and quick decline, I suspect she herniated acute [MEDICAL CONDITION] (a type of bleeding that occurs inside the skull or cranium condition). A review of Resident #3 ' s death certificate indicated her cause of death was [MEDICATION NAME] hemorrhage (bleeding around or within the brain itself); accidental fall. The approximate interval of onset to death was noted on the death certificate as, minutes. A review of Resident #3 ' s Fall Scene Investigation Report from [DATE] included a statement from the nursing assistant (NA #1) who was working with the resident at the time of the incident. A review of the statement written by NA #1 attached to Resident #3 ' s Fall Scene Investigation Report from [DATE] was completed. The statement read: (The resident) was an assist stand and pivot. After I helped get patient on the side of the bed. Bed was in a low position. Patient tried to take off her own shoes. Patient didn ' t give me time to put her feet on bed. When patient leaned forward all her weight went forward and couldn ' t stop her from falling. The patient did not fall during transfer. Patient fell after leaning forward trying to take off shoes. Patient is very heavy even though she is an assist and sometimes her weight just take her in whatever direction she going. Patient hit her head on the floor. After patient fell I immediately called my nurse. Nurse came patient was in shock but she started talking to my nurse. She was trying to get up. She said she wanted to get up. Me and nurse got patient up with Hoyer lift off the floor. Patient was responsive when asked her name again she said her name. Then patient went unresponsive. Incident happened at 9:20 PM. A telephone interview was conducted with NA #1 on [DATE] at 8:15 PM. The NA reported she worked at the facility as an Agency (temporary) nursing assistant approximately two times a week from (MONTH) (YEAR) to (MONTH) (YEAR). Her hall assignments at the facility rotated, but the NA reported she had worked with Resident #3 in the past. When asked about the resident ' s fall on [DATE], the NA reported she was helping her get ready for bed because she was 1 person assist. NA #1 reported she transferred Resident #3 from her recliner to the bed and positioned the resident sitting on the side of the bed. She stated, It was so weird .because she was sitting down on the bed and it was like she reached down to take off her shoes. The NA reported she saw and heard the resident hit her head on the floor. She noted the bed was in the low position. Immediately after the resident fell , NA#1 stated she went and got the nurse (who was nearby). The nurse started talking to the resident and she was able to say her full name. When asked, NA #1 reported she could not recall anything else the resident said. She reported another NA went to get the Hoyer lift. Resident #3 was transferred onto her bed and was reported to still be talking after the transfer. However, NA #1 stated the resident started shaking and was getting cool and then warm to the touch. She reported they knew something was wrong at that point, so the nurse told her to get another nurse (which she did). Upon further inquiry, the NA reported Resident #3 usually seemed to be stable sitting at the side of the bed. When the resident appeared to reach and lean forward, the NA reported she thought it might have been her weight that made her fall. NA #1 stated she (the NA) usually took the resident ' s shoes and socks off for her, so she was not sure why the resident would have tried to take her shoes off herself. When asked how she would know what a resident ' s individual needs were for safe transfers, for instance, she stated, I would look at the care guide, ask another aide that worked there more often, or the nurse. NA #1 reported after the incident with Resident #3 occurred on [DATE], she talked with other nursing staff and looked at the care guide in the resident ' s closet to be sure she had done everything right. When asked what the care guide noted, she reported she thought it indicated the resident was one person assist for transfers. She stated that a lot of people told her the resident was one-person assist. A follow-up telephone interview was conducted with NA #1 on [DATE] at 9:55 AM and on [DATE] at 4:08 PM. During the interviews, the NA reported Resident #3 ' s bed covers were only ½ way down when she transferred the resident and sat her on the side of the bed. After the resident was transferred and sitting on the side of the bed, the NA tried to pull the covers down more. NA #1 reported she was standing towards the foot of the bed on the same side the resident was sitting. She stated the, bed covers were just tiny bit under her. When asked, the NA stated she didn ' t think pulling those bed covers from under the resident would have made the resident fall forward. Upon further inquiry, the NA stated she thought the resident may have felt the bed covers move from under her when the NA tried to fix them. NA #1 stated her hands were on the bed covers at the time of the resident ' s fall; she was not touching the resident when she fell to the floor. When asked how long the resident was sitting on the bed before falling forward, NA #1 stated she had, literally just sat her down on the bed. When asked if the NA had ever been made aware that it may be unsafe for this resident to sit on the side of the bed, she stated she had not. During the interview, NA #1 was asked what kind of orientation she received before caring for residents at the facility. She reported the Agency she worked for required her to sign papers for every facility with job descriptions. However, the NA stated when she came to the facility, she did not know the residents. A telephone interview was conducted on [DATE] at 4:09 PM with the PT who completed Resident #3 ' s Physical Therapy screen on [DATE] and evaluation on [DATE]. During the interview, the PT reported he was familiar with the resident and her history at the time the evaluation was completed. The PT reported the resident ' s sitting balance was not great. He reported Resident #3 ' s history had shown that on one day the resident would do terrific and the next day she would barely do much at all. The PT stated he recommended a 2-person assist or Hoyer lift for transfers as a safety measure. He reported the CGA for static and dynamic sitting balance was technically an assessment of what he saw during the evaluation and was the reason why he made the recommendation for transfers using 2-person assist or a Hoyer lift. The PT noted sitting balance was evaluated on the side of a bed; and, the resident may or may not be holding on to a grab bar or something. When asked how Resident #3 ' s balance would have been in a regular chair or recliner with a back and arms, he reported this would be much different and she did not need CGA to be safe. A follow-up interview was conducted with the PT on [DATE] at 11:45 AM. During this interview, the PT reported he would have preferred to evaluate the resident for safety if her needs had changed and she required less assistance for transfers. However, he also indicated it would have been acceptable for a Registered Nurse (RN) at the facility to assess the resident and make such a change. When asked how results of resident screens and evaluations would be communicated to the facility ' s staff, the PT reported the facility ' s Rehab Manager would track these so he would be aware of any PT recommendations made. An interview was conducted on [DATE] at 9:22 AM with the MDS Nurse in the presence of the facility ' s Compliance Officer. During the interview, the nurse was asked how PT recommendations were communicated to the resident ' s direct care nursing staff. The MDS nurse reported a recommendation from PT was typically shared in the administrative morning meeting and communicated to the staff via the resident ' s care plan. She reported a change in the care plan would generate a change in the resident ' s ISP as well as the electronic information available to the direct care staff. When asked if the PT recommendations made for Resident #3 on [DATE] were reflected on the resident ' s care plan, the MDS nurse stated they were. Upon further inquiry, however, the MDS nurse was unable to locate this information on Resident #3 ' s care plan. An interview was conducted on [DATE] at 12:15 PM with Nurse #2. Nurse #2 was a hall nurse who reported she routinely cared for Resident #3. During the interview, the nurse was asked about the resident ' s need for staff assistance to transfer. In response, the nurse stated the resident was usually one person assist to transfer from her recliner chair to the bed. However, Nurse #2 reported that depending on the day and time of day, Resident #3 may need two-person assistance for a transfer. When asked how a NA would know whether 1 or 2 person assistance was required for a transfer, the nurse stated she would always tell a nursing assistant to look at the ISP located on the inside of the resident ' s closet. When informed the resident ' s ISP did not indicate whether she required 1- or 2-person assistance with transfers, the nurse added that she herself could also be a resource for the NAs to ask any questions they may have. Upon inquiry as to whether or not the resident could safely sit on the side of the bed, the nurse stated, For me, no. Nurse #2 reported that depending on the Resident #3 ' s state of mind and level of confusion, Resident #3 could decide to lean forward or to get up unsafely. An interview was conducted on [DATE] at 12:33 PM with NA #2. NA #2 reported she was routinely assigned to care for Resident #3. During the interview, the NA was asked to describe the process she used to transfer Resident #3 from her recliner to the bed. The NA started by stating, It depends. She reported if the resident was having a good day, she could transfer the resident herself. If Resident #3 wasn ' t having such a good day, the transfer would require 2-person assist. When asked how a new nursing assistant would know how to safely transfer the resident, NA #2 reported she may find out from the off-going NA during shift report or from review of the resident ' s ISP. Upon review of the Resident #3 ' s ISP, NA #2 confirmed the ISP did not indicate how many staff members were required to transfer the resident safely. When asked about Resident #3 ' s ability to sit on the side of the bed, the NA stated Resident #3 could not be left sitting on the side of the bed. NA #2 reported the resident needed the nursing assistant to finish the maneuver and to put her legs up on the bed after she was transferred to the bed. Upon further inquiry as to whether or not Resident #3 would be safe sitting on the side of the bed, NA #2 responded by saying, No, you would have to do what you ' re going to do right then. Upon request, a follow-up interview was conducted on [DATE] at 10:25 AM with NA #2. During the interview, the NA was asked how many people it took to safely transfer Resident #3 from her chair to the bed. The NA stated, It depends .on 4 days it may be 1 person and on 3 days of the week it may be two people. She reported this was not necessarily dependent on the day, but more dependent on the moment and circumstances of the resident ' s dementia at the time. When asked how a new NA or an Agency NA would know whether one or two people were required to safely transfer the resident, the NA stated they would get a report from the off-going NA. However, she also stated the report given at 3:00 PM may not reflect the resident ' s needs when the next NA actually needed to transfer her at 5:00 PM. Upon further inquiry, NA #2 reported the ISP (kept in the resident ' s closet) should have indicated the resident could transfer by stand and pivot with assist of 1 person or 2. She noted the second person would have been there for safety and extra man power. During the interview, NA #2 reported if the resident sat on the side of the bed, she would definitely have to be within arms ' reach of the nursing assistant. NA #2 added that she typically would not even do that and would not have left Resident #3 by the side of the bed if she had to do something. She stated, It was best to go ahead and swing her feet up. An interview was conducted on [DATE] at 3:35 PM with NA #3. NA #3 reported she was familiar with Resident #3 and had helped to care for her on multiple occasions. During the interview, the NA reported that she could usually transfer the resident herself but would need a second person if the resident seemed to be weak at the time of the transfer. When asked if the resident could safely sit at the side of the bed, NA #3 stated, No ma ' am .not at all. When asked to explain her response, the NA stated she would be worried about the resident falling. A telephone interview was conducted on [DATE] at 4:49 PM with Resident #3 ' s Medical Doctor (MD), who also served as the facility ' s Medical Director. During the interview, the MD was asked if it was possible the resident experienced an adverse event (such as a stroke) that may have caused her to fall on [DATE]. The MD stated it was possible, but it would be impossible to know for sure. At that time, staff accounts of the resident ' s fall were briefly discussed with the MD and included NA #1 ' s report of seeing and hearing Resident #3 hit her head and the resident having a large hematoma on her head. In response, the physician reported while this situation did not make it impossible that the resident had [MEDICAL CONDITION](stroke) prior to the fall, it made this scenario less likely. An interview was conducted on [DATE] at 5:40 PM with the facility ' s Administrator and Compliance Officer. During the interview, the Administrator confirmed Resident #3 ' s care plan (dated [DATE] through [DATE]) did not reflect the Physical Therapist ' s [DATE] recommendations which indicated the resident should be transferred with 2-person assist or a Hoyer lift. Resident #3 ' s care plan indicated she could stand and pivot for transfers, with no indication of how many staff members were required to assist her. Additionally, there was no documentation of another assessment being completed to reflect the staff assistance needed to transfer this resident safely or other safety measures required to ensure the resident was safe when sitting on the side of the bed. Upon inquiry, the Administrator reported PT recommendations were discussed in the stand-up interdisciplinary team meeting held each morning. The morning meeting included therapy staff and the MDS nurse. The Administrator stated the MDS nurse should have immediately put the PT ' s recommendation into the resident ' s electronic care plan. She reported this had not been done. The care plan updates would have automatically been incorporated into the resident ' s ISP to guide direct care staff on the ADL assistance required to safely meet the resident ' s needs. A follow-up interview was conducted on [DATE] at 11:16 AM with the facility ' s Administrator and Compliance Officer. When the Administrator was asked if she would expect a resident ' s care plan to reflect the staff assistance necessary to ensure a resident ' s safety, she stated, Absolutely. The Administrator also stated that if the resident ' s need for staff assistance changed, she would expect the change to be assessed and documented, and the care plan (along with the ISP) to be updated accordingly. A second follow-up interview was conducted on [DATE] at 10:20 AM with the Administrator. During this interview, the Administrator stated her expectation for care plans was that all of the information placed in the care plan took into consideration the holistic picture of the resident based on observations and assessments of the resident ' s care needs, documentation within the clinical records, and direct patient care staff feedback. She reported care plans should be completed in a way that would thoroughly educate patient care staff on the resident ' s needs, including needs for safety. On [DATE] at 1:00 PM, the facility ' s Administrator and Compliance Officer were informed of the immediate jeopardy. The facility provided an acceptable credible allegation of Immediate Jeopardy removal on [DATE] at 11:43 AM. The allegation of compliance indicated: Brantwood Nursing and Rehab ([DATE]) Credible Allegation of Removal of Immediate Jeopardy F656 Care Plans Resident 3 experienced a fall post-transfer of 1-person to the bed, at which point she was sat on the bed as the nurse aide removed her physical assistance to slide the linen further back. At this time, this resident leaned forward and fell on to the floor. Resident 3 was immediately sent to the Emergency Department of Granville Health Systems status [REDACTED]. The staff that left the resident sitting untouched while in the room is no longer working with the facility. 1. Resident 3 was sent to the Emergency Department as a result of the above incident. It was identified by analysis on [DATE] that the care plan failed to provide sufficient information regarding the resident ' s transferring needs as recommended by therapy via therapy evaluation documentation on [DATE] for a 2-person moderate to maximum assist during transfers. As a result, the resident was transferred via one person assist. 2. To address the particular process leading to the deficiency, an audit of 100% of resident care plans was initiated and to be completed on [DATE]. The resident ' s care plan are available to facility staff in order to identify areas of each resident ' s care plan needed for daily care and activities of daily living. The audit was conducted on [DATE] by the Treatment Nurse, Staff Development Coordinator, Clinical Nurse Manager, and Director of Nursing to cross-reference resident ' s care planned transfer needs to ensure that the information was correct and consistent with recommendations from the Rehabilitation department. All issues are to be corrected on the resident care plans by the MDS consultant and Director of Nursing immediately on [DATE] to reflect residents ' accurate needs for transfer assistance, to include number of staff to perform the tasks. Care Plan updates reflecting residents ' accurate needs for transfer assistance, to include number of staff to perform the tasks were completed, and each resident ' s updated care guide have been placed in resident ' s closet replacing the prior by administrative staff on [DATE]. 3. Facility MDS nurse, Treatment Nurse, Staff Development Coordinator, Clinical Nurse Manager and Director of Nursing were all educated on [DATE] by facility Administrator on the expectation that items generated in the resident ' s care plan, to include the need for transfer needs for each resident, are to reflect the resident ' s actual needs based on observations, documented assessments and data from direct care personnel, such as therapy evaluation documentation. A copy of all therapy recommendations will be submitted to the Telephone Order box for review by the clinical and interdisciplinary MDS team in order to communicate changes in resident needs for transfers during business days. A 100% in-service of all therapy staff regarding the placement of a copy of therapy documentation in the Telephone Order box for nurse management review was initiated on [DATE] provided by the facility Rehabilitation Department Director to be completed by [DATE] with no staff working beyond that date until he or she has received the education. All resident ' s on therapy caseload, to include Physical, Occupational and Speech Therapy will be reviewed on a daily basis with the MDS interdisciplinary team, with changes to resident ' s transfer needs being updated in the resident ' s care plan immediately by the Facility MDS nurse, Treatment Nurse, Staff Development Coordinator, Clinical Nurse Manager and/or Director of Nursing. All changes in transfer needs will be submitted to and reviewed by the Director of Nursing, or designee, for a period of 4 months beginning [DATE]. Education will be initiated on [DATE] with all nurses and nurse aides, to include agency staff working within the facility, regarding the process for updates to the resident ' s care plan, the location of the care plan data and the proper recourse for accessing the necessary information if the care plan data does not contain pertinent information for each resident ' s care. Facility staff as well as agency staff are to be educated upon orientation with the facility and/or the nurse staffing agency prior to working directly with residents within the facility on this information as well. 4. Monitoring will be done by facility Administrator, or designee, to ensure that the plan of correction is effective and that the specific deficiency cited remains corrected and/or in compliance with the regulatory requirements by auditing Medicare Worksheets using the Therapy Recommendation Audit Tool 5 x weekly for 4 weeks, then weekly x 4 weeks, then monthly x 2 months to ensure that all new recommendations for residents on therapy caseload have been reviewed by the interdisciplinary MDS team with the respective updates made to the care plan, as appropriate. Should the nurse completing the care plan updates have concerns regarding the recommendation for resident assistance need changes given by the therapy department, the nurse will be required to document an assessment and/or rationale for the changes to the care plan made based upon nursing judgement, observation, and documentation from direct care personnel. This rationale, should include validation of the assistance needed for the resident ' s activities of daily living to appropriately meet the resident ' s care needs. The attending physician is to then be notified of the care plan update generated based upon nursing judgement, observation, and documentation from direct care personnel along with the recommendation from therapy as soon as possible. The monitoring tool was developed on [DATE] following completion of the Care Plan audit by facility Treatment Nurse, Staff Development Coordinato

Based on staff and physician interviews, and facility and hospital record reviews, the facility failed to use two staff members to transfer a resident and provide the required assistance immediately after the transfer to ensure the resident sat safely on the side of her bed for 1 of 3 sampled residents reviewed for accidents (Resident #3). Resident #3 experienced a fall from the side of her bed, while being assisted by one staff member which resulted in an injury to the resident ' s forehead. Resident #3 was sent to the hospital for evaluation and treatment and passed away later that day from an [MEDICATION NAME] hemorrhage (bleeding around or within the brain itself). Immediate Jeopardy began on [DATE] when Nursing Assistant (NA) #1 transferred Resident #3 from her recliner to the bed with a stand and pivot maneuver and assist of one and Resident #3 fell forward off of the bed, striking her head on the floor. Immediate Jeopardy was removed as of [DATE] when the facility implemented an acceptable allegation of Immediate Jeopardy removal. The facility remains out of compliance at a scope and severity level D (no actual harm with potential for more than minimal harm that is not immediate jeopardy) for the facility to continue staff education and ensure monitoring systems put into place are effective. The findings included: Resident #3 was admitted to the facility on [DATE]. Her cumulative [DIAGNOSES REDACTED]. Resident #3 ' s last annual Minimum Data Set (MDS) assessment dated [DATE] indicated the resident had severely impaired cognitive skills for daily decision making. Section G indicated the resident required extensive assistance with two plus (2+) persons physical assist for bed mobility and transfers A review of the resident ' s Care Area Assessment (CAA) Worksheet for ADL (Activities of Daily Living) / Functional / Rehabilitation Potential (dated [DATE]) included an analysis of findings. These findings read, in part: .She is alert to self only .She requires assistance with bed mobility, toileting and transfers . A review of the CAA Worksheet for Falls (dated [DATE]) included a description of the nature of this problem/condition, which noted the resident had a fall during the past quarter without injury, had a [DIAGNOSES REDACTED]. A decision was made to include both ADLs and Falls in the resident ' s care plan. Resident #3 ' s Care Plan (dated [DATE]) included the following areas of focus, in part: --Resident requires assist with ADLs on a daily basis related to a [DIAGNOSES REDACTED]. The care plan interventions indicated the resident, Can stand and pivot with transfers. The Care Plan did not indicate how many staff members were required to assist the resident with transfers. --Resident has a history of falls. --Resident is at risk for falls. Has impaired safety awareness. A review of Resident #3 ' s medical record revealed a Therapy Screen was requested by nursing staff on [DATE]. The screen was completed by a Physical Therapist (PT) on [DATE]. PT notations dated [DATE] indicated he spoke with nursing staff. Staff reported Resident #3 was having increased difficulty with transfers and would benefit from a Physical Therapy evaluation. The PT completed an evaluation on [DATE]. A Functional Assessment of the resident ' s sitting balance indicated she required contact guard assist (CGA) for both static and dynamic (gentle challenges to balance) balance while sitting on the side of a bed. The PT ' s Treatment Plan for Resident #3 read: Pt (patient) performs bed mobility, transfers and gait at baseline. No further skilled PT (physical therapy) is required at this time. Recommend NSG (nursing) perform OOB (out of bed) to chair daily by 2 person assist or Hoyer lift. A review of Resident #3 ' s Care Plan dated [DATE] related to ADL care was conducted. No changes had been made to the care plan interventions as a result of the Physical Therapy evaluation. The Care Plan interventions continued to read, Can stand and pivot with transfers. The Care Plan did not indicate how many staff members were required to assist the resident with transfers. A review of the resident ' s medical record did not include another assessment (from any discipline) specifically related to a change in the staff assistance required to safely transfer Resident #3. Resident #3 ' s quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated the resident had severely impaired cognitive skills for daily decision making. Section G indicated the resident required limited assistance with one person physical assist for bed mobility and extensive assistance with one person physical assist for transfers. Further review of the resident ' s Care Plan (dated [DATE]) related to ADL care was conducted. The Care Plan interventions continued to read, Can stand and pivot with transfers. The Care Plan did not indicate how many staff members were required to assist the resident with transfers. Resident #3 ' s quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated the resident had severely impaired cognitive skills for daily decision making. Section G indicated the resident required extensive assistance with one person physical assist for bed mobility and extensive assistance with 2+ person physical assist for transfers. She required extensive assistance from staff for all of her other ADLs, with the exception of needing supervision only for eating and being totally dependent on staff for bathing. The resident ' s current Care Plan related to ADL care included interventions which continued to read, Can stand and pivot with transfers. The Care Plan did not indicate how many staff members were required to assist the resident with transfers. Resident #3 ' s next Care Plan review date was scheduled for [DATE]. A review of Resident #3 ' s most recent (undated) Individual Service Plan (ISP) was provided by the facility. An ISP (also known as a Care Guide) is a printed summary of individual patient needs, which includes information for direct care nursing staff on the assistance required to meet the ADL care needs for a resident. Each individual resident ' s ISP is posted on the inside of his/her closet door. Resident #3 ' s ISP included Special Instructions which read, in part: Resident with worsening dementia .Can stand and pivot with transfers . Additionally, the resident ' s ISP included a section entitled, Transferring. Comments noted in the transferring section read in its entirety, Can stand and pivot with transfers. Review of Resident #3 ' s medical record included a Nursing Note for Falls, written by Nurse #1 and dated [DATE] at 11:25 PM. The note indicated Nurse #1 was called to the resident ' s room at approximately 9:20 PM by a Nursing Assistant (NA). Upon entering the room, Resident #3 was lying on the floor on her left side. She was responsive and attempting to get up. Her vital signs were checked while she was lying on the floor. Her blood pressure was noted to be ,[DATE]; pulse 86; and respiration rate 18. The resident was able to state her name. She appeared to be shaken up and had a large knot above left eye. A partial assessment was done and the resident was moved to the bed with a Hoyer lift so a thorough assessment could be achieved. Once the resident was placed in bed, her vital signs were checked again. At that time, her blood pressure was ,[DATE], pulse 95, and respiration rate 20. The resident was asked her name again and she begin to state her first name but wasn't able to finish the rest because she became unresponsive. Vital signs where again checked at 9:43 PM and her blood pressure was noted to be ,[DATE]; pulse 69; and respirations were reported to be labored. Resident #3 ' s oxygen saturation (O2 sat) was taken and noted to be 75%. The resident was placed on 2 liters of oxygen/minute. Her O2 sat increased to 85% and 95%, but began to plummet back to ,[DATE]%. Her physician was called, informed of the fall and resident status, and an order was received to send Resident #3 to the Emergency Department (ED) for evaluation. Emergency Medical Services (EMS) were called and the resident was transported to the hospital. A review of the [DATE] EMS Records for Resident #3 was conducted. The records revealed EMS was dispatched to the facility at 9:40 PM and they arrived to the facility at 9:43 PM. Documentation on the EMS report indicated Resident #3 had a head injury after experiencing a fall, with [MEDICAL CONDITION] and progression to [MEDICAL CONDITION]. EMS left the facility at 10:10 PM with Resident #3, arriving at the hospital at 10:11 PM. A review of Resident #3 ' s hospital records indicated the resident arrived at the ED on [DATE] at 10:10 PM. Hospital notes indicated the resident was unresponsive and experienced cardiac full arrest. Additional details in the hospital records indicated the resident had stable vital signs upon EMS arrival, but had pulseless electrical activity (PEA) on monitor prior to transport to the hospital. PEA refers to [MEDICAL CONDITION] in which the electrocardiogram shows a heart rhythm that should produce a pulse, but does not. The resident was reported as arriving to the ED with cardiopulmonary resuscitation (CPR) in progress. Resuscitation was discontinued on [DATE] at 10:18 PM. The treating physician noted, Given large trauma to the forehead and quick decline, I suspect she herniated acute [MEDICAL CONDITION] (a type of bleeding that occurs inside the skull or cranium condition). A review of Resident #3 ' s death certificate indicated her cause of death was [MEDICATION NAME] hemorrhage (bleeding around or within the brain itself); accidental fall. The approximate interval of onset to death was noted on the death certificate as, minutes. A review of Resident #3 ' s Fall Scene Investigation Report from [DATE] included statements from the nursing assistant (NA #1) who was working with the resident at the time of the incident. It also included a statement from the hall nurse who initially responded to the NA ' s request for help after the fall. A review of the statement written by NA #1 attached to Resident #3 ' s Fall Scene Investigation Report from [DATE] was completed. The statement read: (The resident) was an assist stand and pivot. After I helped get patient on the side of the bed. Bed was in a low position. Patient tried to take off her own shoes. Patient didn ' t give me time to put her feet on bed. When patient leaned forward all her weight went forward and couldn ' t stop her from falling. The patient did not fall during transfer. Patient fell after leaning forward trying to take off shoes. Patient is very heavy even though she is an assist and sometimes her weight just take her in whatever direction she going. Patient hit her head on the floor. After patient fell I immediately called my nurse. Nurse came patient was in shock but she started talking to my nurse. She was trying to get up. She said she wanted to get up. Me and nurse got patient up with Hoyer lift off the floor. Patient was responsive when asked her name again she said her name. Then patient went unresponsive. Incident happened at 9:20 PM. A telephone interview was conducted with NA #1 on [DATE] at 8:15 PM. The NA reported she worked at the facility as an Agency (temporary) nursing assistant approximately two times a week from (MONTH) (YEAR) to (MONTH) (YEAR). Her hall assignments at the facility rotated, but the NA reported she had worked with Resident #3 in the past. When asked about the resident ' s fall on [DATE], the NA reported she was helping her get ready for bed because she was 1 person assist. NA #1 reported she transferred Resident #3 from her recliner to the bed and positioned the resident sitting on the side of the bed. She stated, It was so weird .because she was sitting down on the bed and it was like she reached down to take off her shoes. The NA reported she saw and heard the resident hit her head on the floor. She noted the bed was in the low position. Immediately after the resident fell , NA#1 stated she went and got the nurse (who was nearby). The nurse started talking to the resident and she was able to say her full name. When asked, NA #1 reported she could not recall anything else the resident said. She reported another NA went to get the Hoyer lift. Resident #3 was transferred onto her bed and was reported to still be talking after the transfer. However, NA #1 stated the resident started shaking and was getting cool and then warm to the touch. She reported they knew something was wrong at that point, so the nurse told her to get another nurse (which she did). Upon further inquiry, the NA reported Resident #3 usually seemed to be stable sitting at the side of the bed. When the resident appeared to reach and lean forward, the NA reported she thought it might have been her weight that made her fall. NA #1 stated she (the NA) usually took the resident ' s shoes and socks off for her, so she was not sure why the resident would have tried to take her shoes off herself. When asked how she would know what a resident ' s individual needs were for safe transfers, for instance, she stated, I would look at the care guide, ask another aide that worked there more often, or the nurse. NA #1 reported after the incident with Resident #3 occurred on [DATE], she talked with other nursing staff and looked at the care guide in the resident ' s closet to be sure she had done everything right. When asked what the care guide noted, she reported she thought it indicated the resident was one person assist for transfers. She stated that a lot of people told her the resident was one-person assist. A follow-up telephone interview was conducted with NA #1 on [DATE] at 9:55 AM and on [DATE] at 4:08 PM. During the interviews, the NA reported Resident #3 ' s bed covers were only ½ way down when she transferred the resident and sat her on the side of the bed. After the resident was transferred and sitting on the side of the bed, the NA tried to pull the covers down more. NA #1 reported she was standing towards the foot of the bed on the same side the resident was sitting. She stated the, bed covers were just tiny bit under her. When asked, the NA stated she didn ' t think pulling those bed covers from under the resident would have made the resident fall forward. Upon further inquiry, the NA stated she thought the resident may have felt the bed covers move from under her when the NA tried to fix them. NA #1 stated her hands were on the bed covers at the time of the resident ' s fall; she was not touching the resident when she fell to the floor. When asked how long the resident was sitting on the bed before falling forward, NA #1 stated she had, literally just sat her down on the bed. When asked if the NA had ever been made aware that it may be unsafe for this resident to sit on the side of the bed, she stated she had not. During the interview, NA #1 was asked what kind of orientation she received before caring for residents at the facility. She reported the Agency she worked for required her to sign papers for every facility with job descriptions. However, the NA stated when she came to the facility, she did not know the residents. A review of the statement written by Nurse #1 attached to Resident #3 ' s Fall Scene Investigation Report from [DATE] was completed. The statement read, in part: Follow-up on documentation which is noted in Residents chart at approx. (approximately) 2120 (9:20 PM), [DATE]. I was called into resident ' s room by the CNA (certified nursing assistant) and found the resident lying on the floor on left side partial assessment was performed on Resident. She was able to move both lower extremities and both upper extremities, pupils were checked and appeared WNL (within normal limits) resident was able to speak and give me full name. (Name) a floor nurse called EMS and RP (Responsible Party) simultaneously at approx. 2147 (9:47 PM) . Between 2120 (9:20 PM) and observing residents changing condition an assisting aid obtained the lift, resident was still responsive throughout the transfer. Once resident was placed in bed V/S (vital signs) were re-obtained resident was still responsive being able to state name. Upon entering room sheets were pulled back. An interview was conducted on [DATE] at 5:45 PM with Nurse #1. Nurse #1 confirmed she was the hall nurse who was assigned to care for Resident #3 on [DATE] at the time of her fall. The nurse reported she was passing meds around 9:20 PM when NA #1 peeked her head out Resident #3 ' s room and called for the nurse. Upon entering her room, she saw the resident was on the floor lying on her side. She was moving around a little bit and trying to get up. The nurse asked her name and she was responsive. Nurse #1 stated the resident wanted to get up; she was able to move her upper and lower extremities. Nurse #1 reported she did a mini-assessment and one set of vital signs while the resident was on the floor. The mini-assessment included a check for bleeding, a check of the resident ' s grips, movement of extremities and pupils, and asked the resident her name. The nurse and NA #1 then used a Hoyer lift to get Resident #3 onto the bed. Nurse #1 reported the resident was still responsive when she was sitting up in the Hoyer lift. Once they got the resident onto the bed, she got another set of vital signs, which were within normal limits and stable. The nurse reported Resident #3 was still able to state her name while she was in the bed and as the nurse began to start another assessment. When Resident #3 started shaking a little bit, the nurse felt she needed more assistance and another floor nurse came to help. Nurse #1 recalled the resident was still breathing but was no longer responsive; her eyes were open. A third nurse brought in oxygen and administered 2 liters per minute of oxygen via nasal cannula. The resident ' s code status was checked, 911 was called, and the MD and RP were notified of the situation. EMS arrived and the resident was taken to the hospital. A telephone interview was conducted on [DATE] at 4:09 PM with the PT who completed Resident #3 ' s Physical Therapy screen on [DATE] and evaluation on [DATE]. During the interview, the PT reported he was familiar with the resident and her history at the time the evaluation was completed. The PT reported the resident ' s sitting balance was not great. He reported Resident #3 ' s history had shown that on one day the resident would do terrific and the next day she would barely do much at all. The PT stated he recommended a 2-person assist or Hoyer lift for transfers as a safety measure. He reported the CGA for static and dynamic sitting balance was technically an assessment of what he saw during the evaluation and was the reason why he made the recommendation for transfers using 2-person assist or a Hoyer lift. The PT noted sitting balance was evaluated on the side of a bed; and, the resident may or may not be holding on to a grab bar or something. When asked how Resident #3 ' s balance would have been in a regular chair or recliner with a back and arms, he reported this would be much different and she did not need CGA to be safe. A follow-up interview was conducted with the PT on [DATE] at 11:45 AM. During this interview, the PT reported he would have preferred to evaluate the resident for safety if her needs had changed and she required less assistance for transfers. However, he also indicated it would have been acceptable for a Registered Nurse (RN) at the facility to assess the resident and make such a change. An interview was conducted on [DATE] at 9:22 AM with the MDS Nurse in the presence of the facility ' s Compliance Officer. During the interview, the nurse was asked how PT recommendations were communicated to the resident ' s direct care nursing staff. The MDS nurse reported a recommendation from PT was typically shared in the administrative morning meeting and communicated to the staff via the resident ' s care plan. She reported a change in the care plan would generate a change in the resident ' s ISP and the electronic information available to the direct care staff. When asked if the PT recommendations made for Resident #3 on [DATE] were reflected on the resident ' s care plan, the MDS nurse stated they were. Upon further inquiry, however, the MDS nurse was unable to locate this information on Resident #3 ' s care plan. The nurse then reported that even though PT made a recommendation, there may have been a discussion that the recommendations were not appropriate and the resident ' s care plan would reflect what staff should actually do. When asked if another assessment was done to ensure the resident ' s ADLs (including transfers) could be safely completed, the MDS nurse indicated she thought it was, but she was unsure where the assessment would have been documented. An interview was conducted on [DATE] at 12:15 PM with Nurse #2. Nurse #2 was a hall nurse who reported she routinely cared for Resident #3. During the interview, the nurse was asked about the resident ' s need for staff assistance to transfer. In response, the nurse stated the resident was usually one person assist to transfer from her recliner chair to the bed. However, Nurse #2 reported that depending on the day and time of day, Resident #3 may need two-person assistance for a transfer. When asked how a NA would know whether 1 or 2 person assistance was required for a transfer, the nurse stated she would always tell a nursing assistant to look at the ISP located on the inside of the resident ' s closet. When informed the resident ' s ISP did not indicate whether she required 1- or 2-person assistance with transfers, the nurse added that she herself could also be a resource for the NAs to ask any questions they may have. Upon inquiry as to whether or not the resident could safely sit on the side of the bed, the nurse stated, For me, no. Nurse #2 reported that depending on the Resident #3 ' s state of mind and level of confusion, Resident #3 could decide to lean forward or to get up unsafely. An interview was conducted on [DATE] at 12:33 PM with NA #2. NA #2 reported she was routinely assigned to care for Resident #3. During the interview, the NA was asked to describe the process she used to transfer Resident #3 from her recliner to the bed. The NA started by stating, It depends. She reported if the resident was having a good day, she could transfer the resident herself. If Resident #3 wasn ' t having such a good day, the transfer would require 2-person assist. When asked how a new nursing assistant would know how to safely transfer the resident, NA #2 reported she may find out from the off-going NA during shift report or from review of the resident ' s ISP. Upon review of the Resident #3 ' s ISP, NA #2 confirmed the ISP did not indicate how many staff members were required to transfer the resident safely. When asked about Resident #3 ' s ability to sit on the side of the bed, the NA stated Resident #3 could not be left sitting on the side of the bed. NA #2 reported the resident needed the nursing assistant to finish the maneuver and to put her legs up on the bed after she was transferred to the bed. Upon further inquiry as to whether or not Resident #3 would be safe sitting on the side of the bed, NA #2 responded by saying, No, you would have to do what you ' re going to do right then. Upon request, a follow-up interview was conducted on [DATE] at 10:25 AM with NA #2. During the interview, the NA was asked how many people it took to safely transfer Resident #3 from her chair to the bed. The NA stated, It depends .on 4 days it may be 1 person and on 3 days of the week it may be two people. She reported this was not necessarily dependent on the day, but more dependent on the moment and circumstances of the resident ' s dementia at the time. When asked how a new NA or an Agency NA would know whether one or two people were required to safely transfer the resident, the NA stated they would get a report from the off-going NA. However, she also stated the report given at 3:00 PM may not reflect the resident ' s needs when the next NA actually needed to transfer her at 5:00 PM. Upon further inquiry, NA #2 reported the ISP (kept in the resident ' s closet) should have indicated the resident could transfer by stand and pivot with assist of 1 person or 2. She noted the second person would have been there for safety and extra man power. During the interview, NA #2 reported if the resident sat on the side of the bed, she would definitely have to be within arms ' reach of the nursing assistant. NA #2 added that she typically would not even do that and would not have left Resident #3 by the side of the bed if she had to do something. She stated, It was best to go ahead and swing her feet up. An interview was conducted on [DATE] at 3:35 PM with NA #3. NA #3 reported she was familiar with Resident #3 and had helped to care for her on multiple occasions. During the interview, the NA reported that she could usually transfer the resident herself but would need a second person if the resident seemed to be weak at the time of the transfer. When asked if the resident could safely sit at the side of the bed, NA #3 stated, No ma ' am .not at all. When asked to explain her response, the NA stated she would be worried about the resident falling. A telephone interview was conducted on [DATE] at 4:49 PM with Resident #3 ' s Medical Doctor (MD), who also served as the facility ' s Medical Director. During the interview, the MD was asked if it was possible the resident experienced an adverse event (such as a stroke) that may have caused her to fall on [DATE]. The MD stated it was possible, but it would be impossible to know for sure. At that time, staff accounts of the resident ' s fall were briefly discussed with the MD and included NA #1 ' s report of seeing and hearing Resident #3 hit her head and the resident having a large hematoma on her head. In response, the physician reported while this situation did not make it impossible that the resident had [MEDICAL CONDITION](stroke) prior to the fall, it made this scenario less likely. An interview was conducted on [DATE] at 5:40 PM with the facility ' s Administrator and Compliance Officer. During the interview, the Administrator confirmed Resident #3 ' s care plan (dated [DATE] through [DATE]) did not reflect the Physical Therapist ' s [DATE] recommendations which indicated the resident should be transferred with 2-person assist or a Hoyer lift. Resident #3 ' s care plan indicated she could stand and pivot for transfers, with no indication of how many staff members were required to assist her. Additionally, there was no documentation of another assessment being completed to reflect the staff assistance needed to transfer this resident safely or other safety measures required to ensure the resident was safe when sitting on the side of the bed. Upon inquiry, the Administrator reported PT recommendations were discussed in the stand-up interdisciplinary team meeting held each morning. The morning meeting included therapy staff and the MDS nurse. The Administrator stated the MDS nurse should have immediately put the PT ' s recommendation into the resident ' s electronic care plan. She reported this had not been done. The care plan updates would have automatically been incorporated into the resident ' s ISP to guide direct care staff on the ADL assistance required to safely meet the resident ' s needs. A follow-up interview was conducted on [DATE] at 10:20 AM with the Administrator. During this interview, the Administrator stated her expectation was that the resident care needs and safety needs would be assessed and care plans updated as needed. She also reported she expected the residents ' plan of care to be utilized by the patient care staff in order to ensure that residents ' care needs and safety needs would be met. On [DATE] at 1:00 PM, the facility ' s Administrator and Compliance Officer were informed of the immediate jeopardy. The facility provided an acceptable credible allegation of Immediate Jeopardy removal on [DATE] at 11:43 AM. The allegation of compliance indicated: Brantwood Nursing and Rehab ([DATE]) Credible Allegation of Removal of Immediate Jeopardy F689-Accidents On (MONTH) 4, (YEAR) Resident 3 experienced a fall post-transfer of one person assist to the bed, at which point she sat on the bed as the nurse aide discontinued hands-on physical assistance in order to slide the linen further back. At this time, this resident leaned forward and fell on to the floor. Resident 3 was immediately sent to the Emergency Department of Granville Health System status [REDACTED]. The staff that left the resident sitting untouched while in the room is no longer working with the facility. 1. Resident 3 was sent to the Emergency Department as a result of the above incident. It was identified by analysis on [DATE] that the resident was not provided necessary balancing assistance post-transfer to prevent accidents and incidents per the recommendations provided by therapy via therapy evaluation documentation on [DATE] for a 2-person moderate to maximum assist during transfers. The staff working directly with the resident during the incident was not directly made aware of the safety concerns with sitting balance while on the side of the bed for this resident. 2. To address the particular process leading to the deficiency, an audit of 100% of resident care plans was initiated and to be completed on [DATE]. The residents ' care plans are available to facility staff in order to identify areas of each resident ' s care plan needed for daily care and activities of daily living. The audit was conducted on [DATE] by the Treatment Nurse, Staff Development Coordinator, Clinical Nurse Manager, and Director of Nursing to cross-reference transfer needs and other safety concerns identified, such as sitting balance on each resident ' s care plan to ensure that the information was correct and consistent with recommendations from the Rehabilitation Department. The MDS consultant and Director of Nursing corrected all resident care plans on [DATE] to reflect residents ' accurate needs for transfer assistance and identified safety concerns, to include the number of staff necessary to perform the tasks. On (MONTH) 30, 2019, care plan updates reflecting residents ' accurate needs for transfer assistance and safety concerns, to include number of staff necessary to perform the tasks, were completed and updated care guides were placed in each resident ' s closet by administrative staff replacing the existing care guides. Education will be initiated on [DATE] with all nurses and nurse aides, to include agency staff working within the facility, regarding the process for updates to the residents ' care plan, the location of the care plan data, and the proper recourse for accessing the necessary information if the care plan data does not contain pertinent information for each resident ' s care. Facility staff as well as agency staff are to be educated on this information upon orientation with the facility and/or the nurse staffing agency prior to working directly with residents within the facility. 3. Facility MDS nurse, Treatment Nurse, Staff Development Coordinator, Clinical Nurse Manager and Director of Nursing were all educated on [DATE] by facility Administrator on the expectation that the resident ' s care plan is to reflect the resident ' s actual needs and any additional key safety measures required, including transfer needs and other safety concerns, based on observations, documented assessments and data from direct care personnel, such as therapy evaluation documentation. A copy of all therapy recommendations will be submitted to the Telephone Order box for review by the clinical and interdisciplinary MDS team in order to communicate changes

Based on medical record review and staff and physician interview it was determined that the facility failed to provide supervision for 1 of 3 sampled residents who needed supervision while eating (Resident #1). Resident #1 consumed a snack bar which was provided by staff while unsupervised and was hospitalized for [REDACTED]. Immediate jeopardy began on [DATE] when Resident #1 was provided a snack to eat unsupervised and without feeding assistance. Immediate jeopardy was removed on [DATE] when the facility provided and implemented an acceptable credible allegation of immediate jeopardy removal. 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. Findings included: Resident #1 was admitted to the facility on [DATE], the resident's [DIAGNOSES REDACTED]. Medical record review of Speech Therapy Encounter form [DATE] revealed that Resident #1 was seen for dysphagia treatment at lunch. Patient received pureed tray with puree consistency chicken, mashed potatoes and vegetable. Patient feeding himself, but required max cues to decrease rate of intake and alternate consistencies between liquids and solids. Recommendations discussed with nurse. Patient is progressing towards meeting goals. Review of the Speech Therapy Encounter Form [DATE] stated, Patient agreeable to snack of pudding and honey-thick water. Patient tolerated in 22 out of 25 trials with overt signs/symptoms of aspiration. Patient applied double swallow during 90% of trails with verbal cues (moderate) provided. Education provided to CNA (certified nursing assistant) on recommendations/strategies. Patient has met 3 out of 4 goals and scored 4 of 7 on functional communication measures Levels for swallowing. Discharge from speech therapy max potential reached at this time. Medical record review revealed a nutrition/dietary note [DATE] which stated, Resident now needs feeding assistance at meals-previously could feed self. Nutritional supplement and extra portions in place. Review of the quarterly minimum data set assessment ((MDS) dated [DATE] revealed that the resident scored 6 on the brief interview of mental status indicating the resident had poor memory and some confusion. The resident had a mechanically altered diet and required a change in the texture of food or liquids. Per the MDS the resident required supervision and set up help only with eating. Review of the resident's care plan dated [DATE] revealed the resident was on a cardiac pureed diet with honey thick liquids. He had a goal to maintain adequate nutritional status as evidenced by maintaining adequate nutritional status as evidenced by maintaining weight with no signs/symptoms of malnutrition. The interventions included document/report as needed any signs/symptoms of dysphagia; pocketing, choking coughing, drooling, holding food in mouth and several attempts at swallowing, Puree diet, honey thick liquids and feeding assistance at meals. Nutrition/Dietary note [DATE] stated, Resident reports no nutritional problems and very good appetite. By mouth intake is ,[DATE]% at most meals. Resident now needs feeding assistance. Review of Nurses Notes (NN) written on [DATE] 4:31 AM stated, vital signs ,[DATE] (blood pressure), 99.1 oral (temperature). Resident diaphoretic. CNA (Certified Nursing Assistant) in to change and clean. Cool washcloths placed to head and groin. Blood sugar 225 at 4:30 AM. No complaints of pain or discomfort. No noted nausea and vomiting. No complaints of weakness or dizziness. Will continue to monitor. A NN dated [DATE] 7:40 AM stated, Resident laying bed with (snack) bar on clothing and bedside table. Skin hot. Resident tachypnea with nasal flaring vital signs taken. Resident hypoxic and [MEDICAL CONDITION] Resident placed on oxygen at this time. Attending physician messaged at this time. Review of vital signs [DATE] at 7:40 AM revealed the residents BP to be ,[DATE], temperature 98.1, pulse 109 beats per minute and respiration 33 breaths per minute. A NN dated [DATE] 8:20 AM stated, Attending physician called and gave order to send resident to the emergency department for [MEDICAL CONDITION] and possible aspiration pneumonia. A NN written [DATE] at 8:25 stated, 911 has been called. Report given to charge nurse. Review of the emergency room Provider Documentation dated [DATE] revealed Disposition Plan- Admission to Hospital. Condition-Good, Primary Impression-Aspiration Pneumonia, Qualifiers: Aspiration pneumonia type unspecified laterality: bilateral, Lung location: lower lobe of lung. Pneumonitis due to inhalation of food and vomit. Review of the hospital radiology report [DATE] revealed that the resident had an Endotracheal tube placement. Review of the discharge record from the hospital [DATE] revealed that Resident #1's discharge [DIAGNOSES REDACTED]. Review of a statement completed by the Director of Nurses dated [DATE] revealed the following, On [DATE] at approximately 6:00 AM resident rang his call light. I answered his light and asked him what he needed. He stated I'm hungry, can I have something to eat. Resident is alert and oriented X2. I knew he was on a specialized diet so I gave a (snack) bar because it is soft and crumbly and not as easily aspirated as a cookie or cracker. I showed him the bar, he said that was what he wanted. I set it onto his over bed table, but I did not open package. I did not notice any coughing episodes prior to or after. He was talking normally with no notice of slurred or garbled speech. He did not appear short of breath or [MEDICAL CONDITION]. Per medical record review Resident #1 was readmitted from the hospital to the facility on [DATE]. He expired in the facility on [DATE]. During interview with the Director of Nurses (DON) on [DATE] at 2:22 PM she stated that she saw Resident #1 at around 4:00 AM on [DATE] and he was not running a fever, he was not short of breath nor was he restless. She stated that he was able to speak and was as he normally presented. He was diaphoretic so she provided him a cold compress. She stated that she provided the resident a (snack) bar at around 6:00 AM. The DON said she knew that Resident #1 was on a special diet but she did not know that it was pureed. She had seen his food tray a while back and was under the impression that he was a mechanical soft diet. She stated she did not check the care guide in the resident's closet before giving him the (snack) bar. Interview with the registered dietician (RD) on [DATE] at 2:40 PM she stated that she received information from the speech therapist regarding resident diets. Resident #1 had been on the same diet since (MONTH) (YEAR). The RD stated that the snack bar was not considered a part of a pureed diet. During interview with the facility administrator and Director of Nurses at 2:50 PM on [DATE] both explained that residents on a puree diet received pudding for snack. Interview with the facility physician (MD) at 4 PM on [DATE] revealed that he had not met Resident #1. He stated that he was told the resident was supposed to be on a pureed diet. He was served something not pureed and had respiratory complications. The MD stated the bar might be tied to the respiratory complications if the food served, was a chunky material or grouped up food was taken from the back of the resident's throat. During interview with a registered nurse (RN) #1 at 2:47 PM on [DATE] the RN stated that she sent Resident #1 out to the hospital because he was in serious condition at that time. She gave him 5 liters of oxygen. The resident was responsive and he could talk to her even though his speech was broken. She stated that she felt that she had time to call the MD because once she gave him oxygen his saturation rose to approximately 83%. She stated that it was not much time between the provision of oxygen and the time he went out to the hospital. Interview at 4:40 PM on [DATE] with the Nursing Assistant (NA) #1 who worked first shift on [DATE] revealed that she remembered Resident #1 and she knew he was on a puree diet. She stated that she did not know if he required supervision with eating. She reported that she had fed him in the past but did not remember if she fed him on [DATE] during her shift. During interview with NA #2 at 4:45 PM on [DATE] she stated that Resident #1 received a puree diet with set up assistance. We were told about a month or so ago that (nursing assistants) we needed to feed him. She stated that he could feed himself if you sat him up straight in bed. She reported that the resident wanted staff to feed him recently. NA #2 said that she had never seen him grab a fork from staff. She reported that the resident was very talkative and did not sweat a lot. He could feed himself ok but sometimes he missed his mouth. She reported the DON told staff that he was to be fed and that they (NA's) needed to watch him. She reported that staff setup his tray and then went back to check on him and helped him finish up. She stated that sometimes he might be finished when staff returned. NA #1 further stated that anytime someone was on puree diet they received pudding or applesauce for snack. Interview with the DON on [DATE] at 5:17 PM revealed that there were times when Resident #1 needed supervision and times when he did not. She reported that he refused supervision a lot, saying no 9 times out of 10. She stated that she asked Resident #1 if he wanted her there with him after she gave him the bar and the resident said No. The DON stated that the resident needs assistance with eating but sometimes he refuses assistance. She said she did not unwrap the bar before she gave it him. Interview on [DATE] at 5:29 PM with a NA #3 who worked the morning of [DATE] revealed that Resident #1 was typically very talkative but that night ([DATE] early am) he wasn't talking. He mostly slept. She stated he was sweating and mostly soaked. She got the nurse and took his blood pressure. She stated the DON came in to check on him and put a cloth on him around 4:,[DATE]:30 AM. She stated she changed his gown and checked on him in about 2 hours. He was laid back with the washcloth on his face and he was just quiet. She stated that she was not used to him being quiet. She stated that she told the DON that he was sleeping more. The NA stated that she had not known Resident #1 to refuse to be fed but sometimes he might try to take the spoon out of someone's hand, depending on who was feeding him. The administrator and DON were notified of the immediate jeopardy on [DATE] at approximately 6:00 PM. The facility provided an acceptable credible allegation of Immediate Jeopardy removal on [DATE] which contained the following information. Resident #1 presented on [DATE] to the Emergency Department of Granville Health Systems with tachypnea, with nasal flaring, [MEDICAL CONDITION] and [MEDICAL CONDITION] It was identified that the resident had been consuming a nutria-grain bar prior to this event although he is on a pureed diet. Resident has a history of aspiration pneumonia and oropharyngeal dysphasia. The Director of Nursing that provided the bar to this resident, which was also done without direct supervision of the resident as directed by residents plan of care was addressed with disciplinary action guided by the Just Culture tool from the NC Board of Nursing and educated on the expectation that all residents are to be provided food and beverages based on their care plan. 1. Resident #1 was sent to the Emergency Department following the above incident. Resident was readmitted to the facility the evening of [DATE]. Resident returned with orders for nil per os (NPO) and was not provided food or beverages upon re-admission to the facility, as ordered. Resident was admitted for acute [MEDICAL CONDITION], aspiration pneumonia, septic shock, NSTEMI (Non-ST-elevation [MEDICAL CONDITION] infarction). Acute [MEDICAL CONDITION] on [MEDICAL CONDITIONS], [DIAGNOSES REDACTED], [DIAGNOSES REDACTED] and dementia. The resident was referred to comfort measures due to acute [MEDICAL CONDITION], septic shock and dementia. It was identified that failure to obtain sufficient information and utilize resources before acting on the behalf of the individual staff member involved was what led to the deficient practice to include lack of supervision during consumption of the (snack) bar. The staff member failed to assess resident's dietary needs prior to providing the snack which was not consistent with this resident's individual care plan. 2. To address the particular process leading to the deficiency, an audit of 100% of (residents) was conducted between [DATE] and [DATE] by facility Administrator to ensure that all Individual Service Plans identified the appropriate need for resident's feeding assistance and supervision and cross-referenced with the Dining Room and Café feeding assistance roster that is provided by facility Registered Dietician. All corrections were completed by [DATE]. A 100% audit was conducted on [DATE] by facility Director of Nursing, MDS Coordinator and Business Office Manager to ensure that all residents are being provided appropriate feeding assistance and supervision as required per their care plan to prevent accidents. All refusals or complications to assisting per the care plan will be communicated with the nurse and documented at that time. The RD obtains the information regarding residents that require feeding assistance from the admitting nurse who identifies each residents' feeding assistance needs via discharge information provided by the discharge facility, FL2, and/or initial admission assessment. 3. 100% of facility licensed nurses and certified nurse aides that provide feeding assistance to all residents daily are being in-serviced, and are being educated immediately upon reporting to duty, on the expectation that all residents are being provided appropriate feeding assistance as required per their care plan. This does not include Therapy staff, as they only provide feeding assistance when evaluating for level of feeding and dietary texture needs. Diet orders are communicated with all staff upon admission via the Dietary Order Form which is reviewed by the Therapy staff prior to working with any residents within the facility. All refusals or complications to assisting per the care plan will be communicated with the nurse and documented at that time. Licensed Nursing and Certified Nurse Aides have been completed immediately upon licensed nursing and certified nurse aide staff immediately upon reporting to duty. 11 Nursing staff have been in-serviced as of [DATE] with 47 remaining the facility MDS Coordinator initiated said in-service. Only nursing staff provide feeding assistance to the residents and pass snacks. 4. Monitoring will be done by facility Administrator, or designee to ensure that the plan of correction is effective and that the specific deficiency cited remains corrected to provide supervision to prevent accidents and/or in compliance with the regulatory requirements by observing 50% of resident population that requires feeding assistance via the Feeding Assistance audit tool by the Clinical nurse managers, MDS Coordinator and Director of Nursing to ensure that all residents are being provided appropriate feeding assistance as required per their care plan 5 times weekly for 3 weeks, weekly for 3 weeks and monthly for 2 months with all results communicated with the Quality Assurance Committee. The QA committee was notified and signed acknowledgement of this plan. Monitoring tool was developed [DATE] by facility Administrator. The QA committee was notified of this plan of correction on [DATE]. The credible allegation of Immediate Jeopardy removal was validated on [DATE] at 8:30 PM. The dinner meal was observed on [DATE]. Observation of 5 residents who required feeding assistance being fed in dining room or in their rooms by facility staff. Observation on [DATE] and [DATE] revealed a snack cart with 3 bins with clearly identified diet types; regular, mechanical soft and pureed. Observation of resident meal trays at lunch time revealed appropriate meal consistency based on review of MD orders and care plan. Interview with a nursing assistant at 8:40 PM on [DATE] revealed she looked at the care guide in the resident's closets or on the electronic record system prior to providing a snack for the resident. She stated that snacks are separated on the cart per diet type. Interview with a nursing assistant at 9:01 PM revealed that residents are provided a snack upon request based on the care guide in their closet. Review of the education attendance record revealed staff education on [DATE] regarding snack pass and diet texture type. The individual service plan, care guides and care plan updates were validated through observation and interview on [DATE]. Interview with the RD at 8:51 PM on [DATE] revealed that she received a diet sheet upon admission and on the FL2 there is a section for diet which she double checked with the physician orders. She stated that the speck and language pathologist (SLP) provided updates regarding resident diets in person or she would leave the information in her office. Interview with the administrator at 8:55 PM on [DATE] revealed that she provided in-service training regarding snack pass and resident diet type for the DON. Interview with a nurse at [DATE] at 9:00 PM revealed that prior to offering a resident a snack, staff are to go in the room and check the diet type on the care guide. A snack is then offered based on the diet type listed on the care guide.

Based on medical record review and staff interview it was determined that the facility failed to provide a pureed snack for a 1 of 1 residents with Dysphagia whose care plan stated a pureed diet (Resident #1). The resident was hospitalized with [DIAGNOSES REDACTED]. Immediate jeopardy began on [DATE] when Resident #1 was provided a snack bar which was not pureed. Immediate jeopardy was removed on [DATE] when the facility provided and implemented an acceptable credible allegation of immediate jeopardy removal. 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. Findings included: Resident #1 was admitted to the facility on [DATE], the resident's [DIAGNOSES REDACTED]. Medical record review of Speech Therapy Encounter form [DATE] revealed that Resident #1 was seen for Dysphagia treatment at lunch. Patient received pureed tray with puree consistency chicken, mashed potatoes and vegetable. Patient feeding himself, but required max cues to decrease rate of intake and alternate consistencies between liquids and solids. Recommendations discussed with nurse. Patient is progressing towards meeting goals. Review of the Speech Therapy Encounter Form [DATE] stated, Patient agreeable to snack of pudding and honey-thick water. Patient tolerated in 22 out of 25 trials with overt signs/symptoms of aspiration. Patient applied double swallow during 90% of trails with verbal cues (moderate) provided. Education provided to CNA (certified nursing assistant) on recommendations/strategies. Patient has met 3 out of 4 goals and scored 4 of 7 on functional communication measures Levels for swallowing. Discharge from speech therapy max potential reached at this time. Medical record review revealed a nutrition/dietary note [DATE] which stated, Resident now needs feeding assistance at meals-previously could feed self. Nutritional supplement and extra portions in place. Review of the quarterly minimum data set assessment ((MDS) dated [DATE] revealed that the resident scored 6 on the brief interview of mental status indicating the resident had poor memory and some confusion. The resident had a mechanically altered diet and required a change in the texture of food or liquids. Per the MDS the resident required supervision and set up help only with eating. Review of the resident's care plan dated [DATE] revealed the resident was on a cardiac pureed diet with honey thick liquids. He had a goal to maintain adequate nutritional status as evidenced by maintaining adequate nutritional status as evidenced by maintaining weight with no signs/symptoms of malnutrition. The interventions included document/report as needed any signs/symptoms of Dysphagia; pocketing, choking coughing, drooling, holding food in mouth and several attempts at swallowing, Puree diet, honey thick liquids and feeding assistance at meals. Nutrition/Dietary note [DATE] stated, Resident reports no nutritional problems and very good appetite. By mouth intake is ,[DATE]% at most meals. Resident now needs feeding assistance. Review of Nurses Notes (NN) written on [DATE] 4:31 AM stated, vital signs ,[DATE] (blood pressure), 99.1 oral (temperature). Resident diaphoretic. CNA (Certified Nursing Assistant) in to change and clean. Cool washcloths placed to head and groin. Blood sugar 225 at 4:30 AM. No complaints of pain or discomfort. No noted nausea and vomiting. No complaints of weakness or dizziness. Will continue to monitor. A NN dated [DATE] 7:40 AM stated, Resident laying bed with (snack) bar on clothing and bedside table. Skin hot. Resident tachypnea with nasal flaring vital signs taken. Resident hypoxic and [MEDICAL CONDITION] Resident placed on oxygen at this time. Attending physician messaged at this time. Review of vital signs [DATE] at 7:40 AM revealed the residents BP to be ,[DATE], temperature 98.1, pulse 109 beats per minute and respiration 33 breaths per minute. A NN dated [DATE] 8:20 AM stated, Attending physician called and gave order to send resident to the emergency department for [MEDICAL CONDITION] and possible aspiration pneumonia. A NN written [DATE] at 8:25 stated, 911 has been called. Report given to charge nurse. Review of the emergency room Provider Documentation dated [DATE] revealed Disposition Plan- Admission to Hospital. Condition-Good, Primary Impression-Aspiration Pneumonia, Qualifiers: Aspiration pneumonia type unspecified laterality: bilateral, Lung location: lower lobe of lung. Pneumonitis due to inhalation of food and vomit. Review of the hospital radiology report [DATE] revealed that the resident had an Endotracheal tube placement. Review of the discharge record from the hospital [DATE] revealed that Resident #1's discharge [DIAGNOSES REDACTED]. Review of a statement completed by the Director of Nurses dated [DATE] revealed the following, On [DATE] at approximately 6:00 AM resident rang his call light. I answered his light and asked him what he needed. He stated I'm hungry, can I have something to eat. Resident is alert and oriented X2. I knew he was on a specialized diet so I gave a (snack) bar because it is soft and crumbly and not as easily aspirated as a cookie or cracker. I showed him the bar, he said that was what he wanted. I set it onto his over bed table, but I did not open package. I did not notice any coughing episodes prior to or after. He was talking normally with no notice of slurred or garbled speech. He did not appear short of breath or [MEDICAL CONDITION]. Per medical record review Resident #1 was readmitted from the hospital to the facility on [DATE]. He expired in the facility on [DATE]. During interview with the Director of Nurses (DON) on [DATE] at 2:22 PM she stated that she saw Resident #1 at around 4:00 AM on [DATE] and he was not running a fever, he was not short of breath nor was he restless. She stated that he was able to speak and was as he normally presented. He was diaphoretic so she provided him a cold compress. She stated that she provided the resident a (snack) bar at around 6:00 AM. The DON said she knew that Resident #1 was on a special diet but she did not know that it was pureed. She had seen his food tray a while back and was under the impression that he was a mechanical soft diet. She stated she did not check the care guide in the resident's closet before giving him the (snack) bar. Interview with the registered dietician (RD) on [DATE] at 2:40 PM she stated that she received information from the speech therapist regarding resident diets. Resident #1 had been on the same diet since (MONTH) (YEAR). The RD stated that the snack bar was not considered a part of a pureed diet. During interview with the facility administrator and Director of Nurses at 2:50 PM on [DATE] both explained that residents on a puree diet received pudding for snack. Interview with the facility physician (MD) at 4 PM on [DATE] revealed that he had not met Resident #1. He stated that he was told the resident was supposed to be on a pureed diet. He was served something not pureed and had respiratory complications. The MD stated the bar might be tied to the respiratory complications if the food served, was a chunky material or grouped up food was taken from the back of the resident's throat. During interview with a registered nurse (RN) #1 at 2:47 PM on [DATE] the RN stated that she sent Resident #1 out to the hospital because he was in serious condition at that time. She gave him 5 liters of oxygen. The resident was responsive and he could talk to her even though his speech was broken. She stated that she felt that she had time to call the MD because once she gave him oxygen his saturation rose to approximately 83%. She stated that it was not much time between the provision of oxygen and the time he went out to the hospital. Interview at 4:40 PM on [DATE] with the Nursing Assistant (NA) #1 who worked first shift on [DATE] revealed that she remembered Resident #1 and she knew he was on a puree diet. She stated that she did not know if he required supervision with eating. She reported that she had fed him in the past but did not remember if she fed him on [DATE] during her shift. During interview with NA #2 at 4:45 PM on [DATE] she stated that Resident #1 received a puree diet with set up assistance. We were told about a month or so ago that (nursing assistants) we needed to feed him. She stated that he could feed himself if you sat him up straight in bed. She reported that the resident wanted staff to feed him recently. NA #2 said that she had never seen him grab a fork from staff. She reported that the resident was very talkative and did not sweat a lot. He could feed himself ok but sometimes he missed his mouth. She reported the DON told staff that he was to be fed and that they (NA's) needed to watch him. She reported that staff setup his tray and then went back to check on him and helped him finish up. She stated that sometimes he might be finished when staff returned. NA #1 further stated that anytime someone was on puree diet they received pudding or applesauce for snack. Interview with the DON on [DATE] at 5:17 PM revealed that there were times when Resident #1 needed supervision and times when he did not. She reported that he refused supervision a lot, saying no 9 times out of 10. She stated that she asked Resident #1 if he wanted her there with him after she gave him the bar and the resident said No. The DON stated that the resident needs assistance with eating but sometimes he refuses assistance. She said she did not unwrap the bar before she gave it him. Interview on [DATE] at 5:29 PM with a NA #3 who worked the morning of [DATE] revealed that Resident #1 was typically very talkative but that night ([DATE] early am) he wasn't talking. He mostly slept. She stated he was sweating and mostly soaked. She got the nurse and took his blood pressure. She stated the DON came in to check on him and put a cloth on him around 4:,[DATE]:30 AM. She stated she changed his gown and checked on him in about 2 hours. He was laid back with the washcloth on his face and he was just quiet. She stated that she was not used to him being quiet. She stated that she told the DON that he was sleeping more. The NA stated that she had not known Resident #1 to refuse to be fed but sometimes he might try to take the spoon out of someone's hand, depending on who was feeding him. The administrator and DON were notified of the immediate jeopardy on [DATE] at approximately 6:00 PM. The facility provided an acceptable credible allegation of Immediate Jeopardy removal on [DATE] which contained the following information. Resident #1 presented on [DATE] to the Emergency Department of Granville Health Systems with tachypnea, with nasal flaring, [MEDICAL CONDITION] and [MEDICAL CONDITION] It was identified that the resident had been consuming a nutria-grain bar prior to this event although he is on a pureed diet. Resident has a history of aspiration pneumonia and oropharyngeal dysphasia. The Director of Nursing that provided the bar to this resident, which was also done without direct supervision of the resident as directed by residents plan of care was addressed with disciplinary action guided by the Just Culture tool from the NC Board of Nursing and educated on the expectation that all residents are to be provided food and beverages based on their care plan. 1. Resident #1 was sent to the Emergency Department following the above incident. Resident was readmitted to the facility the evening of [DATE]. Resident returned with orders for nil per os (NPO) and was not provided food or beverages upon re-admission to the facility, as ordered. Resident was admitted for acute [MEDICAL CONDITION], aspiration pneumonia, septic shock, NSTEMI (Non-ST-elevation [MEDICAL CONDITION] infarction). Acute [MEDICAL CONDITION] on [MEDICAL CONDITIONS], [DIAGNOSES REDACTED], [DIAGNOSES REDACTED] and dementia. The resident was referred to comfort measures due to acute [MEDICAL CONDITION], septic shock and dementia. It was identified that failure to obtain sufficient information and utilize resources before acting on the behalf of the individual staff member involved was what led to the deficient practice to include lack of supervision during consumption of the (snack) bar. The staff member failed to assess resident's dietary needs prior to providing the snack which was not consistent with this resident's individual care plan. 2. To address the particular process leading to the deficiency, an audit of 100% of (residents) was conducted between [DATE] and [DATE] by facility Administrator to ensure that all Individual Service Plans identified the appropriate need for resident's feeding assistance and supervision and cross-referenced with the Dining Room and Café feeding assistance roster that is provided by facility Registered Dietician. All corrections were completed by [DATE]. A 100% audit was conducted on [DATE] by facility Director of Nursing, MDS Coordinator and Business Office Manager to ensure that all residents are being provided appropriate feeding assistance and supervision as required per their care plan to prevent accidents. All refusals or complications to assisting per the care plan will be communicated with the nurse and documented at that time. The RD obtains the information regarding residents that require feeding assistance from the admitting nurse who identifies each residents' feeding assistance needs via discharge information provided by the discharge facility, FL 2, and/or initial admission assessment. 3. 100% of facility licensed nurses and certified nurse aides that provide feeding assistance to all residents daily are being in-serviced, and are being educated immediately upon reporting to duty, on the expectation that all residents are being provided appropriate feeding assistance as required per their care plan. This does not include Therapy staff, as they only provide feeding assistance when evaluating for level of feeding and dietary texture needs. Diet orders are communicated with all staff upon admission via the Dietary Order Form which is reviewed by the Therapy staff prior to working with any residents within the facility. All refusals or complications to assisting per the care plan will be communicated with the nurse and documented at that time. Licensed Nursing and Certified Nurse Aides have been completed immediately upon licensed nursing and certified nurse aide staff immediately upon reporting to duty. 11 Nursing staff have been in-serviced as of [DATE] with 47 remaining the facility MDS Coordinator initiated said in-service. Only nursing staff provide feeding assistance to the residents and pass snacks. 4. Monitoring will be done by facility Administrator, or designee to ensure that the plan of correction is effective and that the specific deficiency cited remains corrected to provide supervision to prevent accidents and/or in compliance with the regulatory requirements by observing 50% of resident population that requires feeding assistance via the Feeding Assistance audit tool by the Clinical nurse managers, MDS Coordinator and Director of Nursing to ensure that all residents are being provided appropriate feeding assistance as required per their care plan 5 times weekly for 3 weeks, weekly for 3 weeks and monthly for 2 months with all results communicated with the Quality Assurance Committee. The QA committee was notified and signed acknowledgement of this plan. Monitoring tool was developed [DATE] by facility Administrator. The QA committee was notified of this plan of correction on [DATE]. The credible allegation of Immediate Jeopardy removal was validated on [DATE] at 8:30 PM. The dinner meal was observed on [DATE]. Observation of 5 residents who required feeding assistance being fed in dining room or in their rooms by facility staff. Observation on [DATE] and [DATE] revealed a snack cart with 3 bins with clearly identified diet types; regular, mechanical soft and pureed. Observation of resident meal trays at lunch time revealed appropriate meal consistency based on review of MD orders and care plan. Interview with a nursing assistant at 8:40 PM on [DATE] revealed she looked at the care guide in the resident's closets or on the electronic record system prior to providing a snack for the resident. She stated that snacks are separated on the cart per diet type. Interview with a nursing assistant at 9:01 PM revealed that residents are provided a snack upon request based on the care guide in their closet. Review of the education attendance record revealed staff education on [DATE] regarding snack pass and diet texture type. The individual service plan, care guides and care plan updates were validated through observation and interview on [DATE]. Interview with the RD at 8:51 PM on [DATE] revealed that she received a diet sheet upon admission and on the FL 2 there is a section for diet which she double checked with the physician orders. She stated that the speck and language pathologist (SLP) provided updates regarding resident diets in person or she would leave the information in her office. Interview with the administrator at 8:55 PM on [DATE] revealed that she provided in-service training regarding snack pass and resident diet type for the DON. Interview with a nurse at [DATE] at 9:00 PM revealed that prior to offering a resident a snack, staff are to go in the room and check the diet type on the care guide. A snack is then offered based on the diet type listed on the care guide.

Based on physician interview, staff interview, and record review the facility failed to ensure notification of the physician of a resident ' s unwitnessed fall from bed for one of four sampled residents (Resident #148) reviewed for accidents. Findings included: Resident #148 was admitted to the facility on Friday, 5/1/15 from a hospital with [DIAGNOSES REDACTED]. The nurse Admission Note written by Nurse #1 on 5/1/15 at 6:58 pm stated Resident #148 Arrived at this facility at approximately 3:30 pm. Being admitted with generalized weakness, failure to thrive, dementia, (urinary tract infection), (acute [MEDICAL CONDITION]). Resident is confused. He has a hard time hearing and you have to talk really loud to him. Review of the Fall Log for May 2015 revealed Resident #148 had an unwitnessed fall with injury on 5/1/15. Review of the Fall Scene Investigation Report completed on 5/1/15 by Nurse #1 indicated the following: · Resident #148 was alone and unattended at the time of the fall from his bed at 8:40 pm, he was confused , and stated he needed to get out and go bake a cake. · The resident ' s fall occurred next to transfer surface (bed). Instructions on the report stated to assess postural [MEDICAL CONDITION] (a form of low blood pressure that happens upon standing from sitting or lying down that can result in dizziness or [MEDICAL CONDITION]) and if fall within 5 feet of transfer surface do orthostatic (blood pressure) (blood pressure that is taken while the resident is lying down, then repeated after several minutes with the resident sitting up, then repeated after several minutes again while the resident is standing.) · Yes was checked at question asking if vital signs were out of normal range for this resident and orthostatic (blood pressures) were not done. There were no vital signs documented anywhere on the form or in the resident ' s chart until approximately 6 hours after the fall. · There was no root cause of Resident #148 ' s fall noted or interventions to prevent further falls. There were no fall team meeting notes on the report or indication of any review by the fall team. · The report noted the physician and responsible party were notified Review of the nurse notes for Saturday, 5/2/15 - Sunday 5/3/15 revealed Resident #148 was incontinent of bowel and bladder, restless (moving around in bed some calling out). The notes further indicated the resident was total care with his activities of daily living and that there were no complaints of pain. There were no nurse ' s notes until a late-entry note on 5/4/15 about Resident #148 having a fall on 5/1/15. Record review of the Medication Administration Record [REDACTED]. The Late Entry nurse note written by Nurse #1 on Monday, 5/4/15 indicated it was an Incident Note for 5/1/15 at 10:00 pm. The late entry incident note stated, The resident across the hall called out for help. I went to room and (Resident #148) had slid to the floor beside the bed. He stated, ' I screwed up. ' Vitals and assessment were done before the resident was put back to bed. He was assessed more thoroughly after being placed back in bed. There were no scratches, bruises, red areas or anything showing at that time. Also, when palpated at this time there were no facial grimaces or signs of pain. (Responsible party) was called, no answer. (Family member #3) was called, made aware. During an interview on 5/20/15 at 3:04 pm with Nurse #1, when asked about the events surrounding Resident #148 ' s fall on 5/1/15, she indicated she was doing the medication pass when the resident across the hall from Resident #148 called out for help because she saw Resident #148 fall out of bed. Nurse #1 stated, I locked the cart and went to the room. He was sitting beside the bed and said ' I messed up. ' I assessed him on the floor, got vitals and got help to put back in bed. I checked him head to toe. We rolled him over. There were no bruises or obvious injury. He denied hurting. He was in the bed before he was found on the floor. He was sitting on the floor with his back to the bed and the bed was in the lowest position. There were no other falls preventions in place like an alarm. When asked if she did neuro checks (a brief neurological exam done in intervals for a time period after a head injury) or other assessments after his fall Nurse #1 stated, If he was laying flat on the floor then I would have done neuro checks but he was sitting, not laying on the floor. He can reposition himself in bed some. I did not do neuro checks. He rolled over for me during the admission assessment. I filled out the incident report, called his wife but didn ' t get an answer and called the 2nd number to inform. I filled out the form to send to (Physician #1) but it is my understanding that she did not get it. Nurse #1 indicated she thought she faxed (Physician #1) around 10:30 pm to notify her of the 8:40 pm fall on Friday, 5/1/15 but could not definitively recall. Nurse #1 further stated, I palpated (Resident #148 ' s) hips and his whole body but there was no indication of pain. I had no phone contact or faxed confirmation that the physician was notified. I have heard by the rumor in the facility that she was not notified. Nurse #1 indicated she worked the following day, 5/2/15, but was working on another hall, not with Resident #148. Nurse #1 also stated, (Nurse Aide (NA) #3 and NA #4 helped me get him back in bed. I went back in before I left to re-check him. I cannot remember telling the nurse I gave report to, Nurse #5, about the fall. I can ' t remember if I did or I didn ' t. I did not put mats on floor or an alarm on the bed after the fall. I did an incident report in the computer on Friday but it disappeared so I came back in and put it in Monday. I did the paper report Friday. I did not report it to anyone that night. I would not call to report (to the physician) unless there was an injury. The report was put in the Director of Nursing (DON) box when I left. She had it Monday morning when I came back in. I am not aware that I am supposed to let the DON know or call the doctor if there is no injury. During an interview on 5/21/15 at 1:13 pm with NA #3 she indicated she assisted Resident #148 back to bed on 5/1/15 after his fall. She further indicated he showed no indication of pain that she could recall, but he kept asking for his wife. During an interview on 5/21/15 at 3:22 pm with NA #4 she indicated she assisted Resident #148 back to bed on 5/1/15 after his fall and stated, He didn ' t seem to be hurt. I changed him later and he was swinging his arms some so I asked someone to come help me because he is such a tall man. During an interview with Nurse #6 on 5/22/15 at 3:15 pm she indicated she worked night shift on 5/1/15 and stated, I came in at midnight that night and worked until 7 am. At the beginning of my shift about 1 am when the aide was doing her rounds she told me (Resident #148) was restless. I checked on him and he was restless but did not seem to be in pain, no moaning. He slept the rest of the night. I got report from (Nurse #5). She did not tell me anything about him falling. If I had known that he had fallen then I would have looked at him even more thoroughly through the night. She indicated there were no nurse ' s notes when she worked that night about Resident #148 having a fall on 5/1/15. During an interview on 5/19/15 at 1:42 pm with Family Member #1 she stated, (Staff) called me Friday night and said they checked him out and he had no injury. During an interview on 5/19/15 at 1:45 pm with Family Member #2 she indicated she and Family Member #4 were at the facility and visited Resident #148 over the weekend. Family member #2 stated, (Resident #148) wasn ' t talking much over the weekend but had his hand on his leg. On Monday I came in, tried to move his left leg over and he yelled out. I told the nurse I knew something was wrong. I said ' I know this man. ' I asked the head nurse, the director or something, about a written report about his fall. She said the nurse that was on duty had not written up anything. That was Monday. During an interview with Nurse #2 on 5/21/15 at 9:30 am she indicated she was the first-shift nurse assigned to Resident #148 on 5/2/15-5/4/15. She stated, I didn ' t know he had fallen on Friday. On Sunday his wife told me he had fallen when he came in Friday. The rehab therapist on Sunday said he could not stand him up because he was hurting. That was when we were changing shifts about 3pm. The resident never seemed to be hurting to me that weekend. He was new and report was he was non-ambulatory so we did not try to get him up that weekend. We would usually wait to get (a new admission resident) up until rehab evaluates to see what they need. I could never find the transfer assessment in the computer. His wife was talking about his pain that Sunday morning and said, ' He says he hurts. ' When I asked him he never said he was hurting. Nobody reported any pain to me during his care. I could not find a note or anything about a fall from Friday. I looked at the nurse ' s notes but there wasn ' t one about a fall. He seemed to be in more pain Monday than on Sunday. Nurse #2 indicated when there is a fall the nurse should notify the doctor, the family member, make a nurse ' s note in the computer, and complete the fall report by the end of the shift. Nurse #2 indicated she did not report a fall to the physician for Resident #148 over the weekend, but contacted the physician on Monday morning. During an interview with Nurse Aide (NA) #1 on 5/20/15 at 1:49 pm she stated, I worked with (Resident #148) on Saturday (5/2/15) first shift. (Family member #2) was here that morning and a male relative was here in the afternoon. (Resident #148) was incontinent of bowel and bladder. I was giving him his bath and turned him to the left side. He said, ' I hurt so bad ' and was holding his left leg. I told him I would let the nurse know. I told her. It was (Nurse #2). It was in the morning when I was doing my baths, but I don ' t remember exactly what time. During an interview with NA #2 on 5/20/15 at 2:00 pm she indicated she worked on Sunday, 5/3/15, first shift with Resident #148. She stated, In the morning I was trying to wash his feet and legs. He tried to go for his left leg like he was trying to keep me from moving him. (Family member #2) was here and told me he had a fall that Friday. I reported it to Nurse #2 and I went to the supervisor (Nurse #3). I let her know about his fall and that his wife wanted an alarm. Nurse #3 said she did not know about the fall, then Nurse #3 and Nurse #2 talked to each other. He did not have an alarm or anything on Sunday. I put the floor mats down on Monday. He still was hurting on Monday. The aide indicated that the resident ' s reaction on Sunday was of obvious pain with any movement of his left leg. During an interview on 5/21/15 at 10:22 am with Nurse #3 she indicated she was the weekend nurse supervisor who worked on 5/2/15-5/3/15 and stated, I work every other weekend. I don ' t recall knowing about (Resident #148 ' s) fall on Friday (May1) at all during that weekend. I go through the 24-hour reports that are generated from the nurse ' s notes and don ' t remember seeing that. Every nurse note is on the report and falls always stand out. The follow up on a fall should occur for 3 days after a fall, even one without an injury. The Physical Therapy Evaluation and Progress Note dated 5/3/15 indicated the following: · Resident #148 was evaluated for a primary [DIAGNOSES REDACTED]. · (Family member #2) reported (resident) was able to walk short distances and go up and down steps with assistance. · During the evaluation, Resident #148 was complaining of severe pain (left lower extremity) that was aggravated by movement. · (Physical therapy evaluation) complete. (Resident #148) unable to stand or (ambulate secondary to complaints of left lower extremity) pain. Nursing reports (resident) had a fall 5/1/15 out of bed. Nursing made aware of (complaints of) pain in (left lower extremity and limited mobility secondary to pain.) Nurse #2 ' s note on Monday 5/4/15 indicated Resident #148 was complaining of left hip pain and left leg pain, the physician was notified, and orders were given to send the resident to Granville Medical Center Emergency Department. The note further indicated (Family member #2) was at his bedside, his left knee was swollen and was slightly turned outward. Review of the Emergency Department (ED) notes dated 5/4/15 revealed: · Resident #148 was uncomfortable with any manipulation of either extremity, his left foot was slightly externally rotated and was very stiff. Resistant #148 was resistive to movement of his left leg. · Resident #148 had a left [MEDICAL CONDITION] and the note further stated, Labs are also notable for a hemoglobin drop from 10 to 8. The trauma/leg fracture could account for this. · Patient discharged from hospital on [DATE] to nursing home. Apparently fell down in the nursing home and he was having pain in left hip. Presented to ED. Was found to have left [MEDICAL CONDITION]. admitted to hospital for further (evaluation) and management. Impression - acute left [MEDICAL CONDITION] secondary to fall at nursing home. Consulting orthopedics for possible surgery tomorrow. Acute worsening of chronic [MEDICAL CONDITION]. Hemoglobin has dropped to 8 from 10.5 4 or 5 days ago. Ordering a cross match and he will likely need a transfusion. Review of the Consult report dated 5/5/15 stated, (Patient) admitted on [DATE] through ED for increasing left hip and leg pain. Nursing staff at Brantwood stated he fell on Friday 5/1/15. He had increasing pain over the course of the weekend and was brought to ED. X-rays taken through the ED demonstrated femoral neck fracture. The patient with dementia with limited historical input on questioning. No verbal response to direct questioning today. He does localize pain to the left hip with palpation and with any attempt at passive hip rotation. He does demonstrate pain withdrawal response. His left leg appears shorter than his right but with essentially neutral alignment. Anterior/posterior pelvis xray of left hip demonstrates a displaced angulated femoral neck fracture. Review of the Operative report dated 5/5/15 revealed Resident #148 had a left femoral neck fracture that was repaired by a left hip hemiarthroplasty (an operation to treat a [MEDICAL CONDITION] that replaces the femoral head - the ball part of the hip). During an interview on 5/20/15 at 11:38 am with the Director of Nursing (DON) when asked about the resident ' s fall and any fall investigation she stated, I knew to do an investigation and talked to (Nurse #1). There was a lapse on him falling on Friday to going out Monday. He was able to move without grimacing and didn ' t have external rotation. His wife never said he was in pain. Monday it was reported he was complaining of pain. When asked about monitoring after an unwitnessed fall to included documentation, neuro checks, and orthostatic blood pressures she stated, There is a period of monitoring the nurses will do. I have to check how often they are done. We rely on family members to guide and give us insight with the residents, especially the new admissions. During an interview with the Administrator on 5/20/15 at 3:40 pm she stated, (Resident #148) arrived at approximately 3:30 pm on Friday May 1st. If we suspect (a resident) fell unwitnessed and hit their head we would do neuro checks. From what I read in the nurse note, there was no indication that he hit his head. I do have an issue that report was not given. The Administrator indicated she expected the nurse who was caring for the resident to have informed the nurse who took over his care of the fall and to tell the supervisor on duty. She further indicated there were no fax confirmations of notification to the physician and the expectation is that Nurse #1 should have ensured the physician was notified of the fall as soon as possible after the fall. During an interview on 5/20/15 at 3:43 pm with the Director of Nursing (DON), when asked about what assessment and interventions should be done for a resident after a fall, she stated, Anytime there is a fall to the head or head injury or if we suspect head injury we would do neuro checks. Another resident across the hall saw (Resident #148 ' s fall) to say he did not hit his head. You use your judgment. If there is something that is going on with the resident then you should call the physician. We may fax. Initially we put the bed in low position and we increase monitoring, but no alarms or mats. A body alarm was placed on him. I don ' t know when. The DON indicated there was a charge nurse on duty at the facility the night of Resident #148 ' s fall and Nurse #1 should have informed the charge nurse of the fall. During an interview with Physician #1 on 5/22/15 at 12:00 pm, when asked about the notification she received of Resident #148 ' s fall on 5/1/15, she stated, (Facility staff) told me they sent a fax. I was notified on Monday when (Nurse #2) called and said he was in a lot of pain. I sent him to the ED. I have told them to not fax - to call. I saw (Resident #148) for the admission but (the fall) happened after I saw him. Most of the time (the facility) calls with falls, but they said they were following protocol. They know the office is closed (on evenings and weekends). They know better. I do not have Saturday office hours. If they had called, I would have asked them questions about Resident #148 ' s assessment, whether or not there were problems with his range of motion, ability to stand, then made a decision about his care. I keep my beeper on me and I am on call 24/7 for my patients. During an interview on 5/22/15 at 1:30 pm with Family Member #4, he indicated he visited Resident #148 on Saturday, May 2, 2015, that rehab therapy came in the room to work with Resident #148 and stated, When they tried to move him he yelled out with every attempt. He further indicated he informed the rehab therapist that Resident #148 had a fall on 5/1/15 and therapy stated they ' were not aware of any fall. '

Based on physician interview, staff interview, and record review the facility failed to effectively assess and monitor a resident after a fall from bed, failed to effectively communicate a fall among staff providing care, and failed to recognize pain and for one of four residents (Resident #148) reviewed for accidents. Findings included: Resident #148 was admitted to the facility on Friday, 5/1/15 from a hospital with [DIAGNOSES REDACTED]. Record review of Resident #148 ' s Morse Fall Scale completed on 5/1/15 revealed a score of 55 which indicated a high risk for falling. Record review of the Admission Screen dated 5/1/15 indicated Resident #148 required extensive assistance with bed mobility and transfer. The Interim Care Plan dated 5/1/15 at 4:30 pm stated Resident #148 is a fall risk. The nurse Admission Note written by Nurse #1 on 5/1/15 at 6:58 pm stated Resident #148 Arrived at this facility at approximately 3:30 pm. Being admitted with generalized weakness, failure to thrive, dementia, (urinary tract infection), (acute [MEDICAL CONDITION]). Resident is confused. He has a hard time hearing and you have to talk really loud to him. Review of the Fall Log for May 2015 revealed Resident #148 had an unwitnessed fall with injury on 5/1/15. Review of the Fall Scene Investigation Report completed on 5/1/15 by Nurse #1 indicated the following and is quoted in part as noted below: · Resident #148 was alone and unattended at the time of the fall from his bed at 8:40 pm, he was confused , and stated he needed to get out and go bake a cake. · The resident's fall occurred next to transfer surface (bed). Instructions on the report stated to assess postural [MEDICAL CONDITION] (a form of low blood pressure that happens upon standing from sitting or lying down that can result in dizziness or [MEDICAL CONDITION]) and if fall within 5 feet of transfer surface do orthostatic (blood pressure) (blood pressure that is taken while the resident is lying down, then repeated after several minutes with the resident sitting up, then repeated after several minutes again while the resident is standing.) Yes was checked at question asking if vital signs were out of normal range for this resident and orthostatic (blood pressures) were not done. There were no vital signs documented anywhere on the form or in the resident ' s chart until approximately 6 hours after the fall. Review of the nurse notes for Saturday, 5/2/15 - Sunday 5/3/15 revealed Resident #148 was incontinent of bowel and bladder, restless (moving around in bed some calling out). The notes further indicated the resident was total care with his activities of daily living and that there were no complaints of pain. There were no nurse ' s notes until a late-entry note on 5/4/15 about Resident #148 having a fall on 5/1/15. Record review of the Medication Administration Record [REDACTED]. The Late Entry nurse note written by Nurse #1 on Monday, 5/4/15 indicated it was an Incident Note for 5/1/15 at 10:00 pm. The late entry incident note stated, The resident across the hall called out for help. I went to room and (Resident #148) had slid to the floor beside the bed. He stated, ' I screwed up. ' Vitals and assessment were done before the resident was put back to bed. He was assessed more thoroughly after being placed back in bed. There were no scratches, bruises, red areas or anything showing at that time. Also, when palpated at this time there were no facial grimaces or signs of pain. During an interview on 5/20/15 at 3:04 pm with Nurse #1, when asked about the events surrounding Resident #148 ' s fall on 5/1/15, she indicated she was doing the medication pass when the resident across the hall from Resident #148 called out for help because she saw Resident #148 fall out of bed. Nurse #1 stated, I locked the cart and went to the room. He was sitting beside the bed and said ' I messed up. ' I assessed him on the floor, got vitals and got help to put back in bed. I checked him head to toe. We rolled him over. There were no bruises or obvious injury. He denied hurting. He was in the bed before he was found on the floor. He was sitting on the floor with his back to the bed and the bed was in the lowest position. He rolled over for me during the admission assessment Nurse #1 further stated, I palpated (Resident #148 ' s) hips and his whole body but there was no indication of pain. Nurse #1 indicated she worked the following day, 5/2/15, but was working on another hall, not with Resident #148. (Nurse Aide (NA) #3 and NA #4 helped me get him back in bed. I went back in before I left to re-check him. I cannot remember telling the nurse I gave report to, Nurse #5, about the fall. I can ' t remember if I did or I didn ' t. I did not report it to anyone that night. The report was put in the Director of Nursing (DON) box when I left. She had it Monday morning when I came back in. I am not aware that I am supposed to let the DON know or call the doctor if there is no injury. During an interview on 5/21/15 at 1:13 pm with NA #3 she indicated she assisted Resident #148 back to bed on 5/1/15 after his fall. She further indicated he showed no indication of pain that she could recall, but he kept asking for his wife. During an interview on 5/21/15 at 3:22 pm with NA #4 she indicated she assisted Resident #148 back to bed on 5/1/15 after his fall and stated, He didn ' t seem to be hurt. I changed him later and he was swinging his arms some so I asked someone to come help me because he is such a tall man. During an interview with Nurse #6 on 5/22/15 at 3:15 pm she indicated she worked night shift on 5/1/15 and stated, I came in at midnight that night and worked until 7 am. At the beginning of my shift about 1 am when the aide was doing her rounds she told me (Resident #148) was restless. I checked on him and he was restless but did not seem to be in pain, no moaning. He slept the rest of the night. I got report from (Nurse #5). She did not tell me anything about him falling. If I had known that he had fallen then I would have looked at him even more thoroughly through the night. She indicated there were no nurse ' s notes when she worked that night about Resident #148 having a fall on 5/1/15. During an interview on 5/19/15 at 1:45 pm with Family Member #2 she indicated she and Family Member #4 were at the facility and visited Resident #148 over the weekend. Family member #2 stated, (Resident #148) wasn ' t talking much over the weekend but had his hand on his (left) leg. On Monday I came in, tried to move his left leg over and he yelled out. I told the nurse I knew something was wrong. I said ' I know this man. ' I asked the head nurse, the director or something, about a written report about his fall. She said the nurse that was on duty had not written up anything. That was Monday. During an interview with Nurse #2 on 5/21/15 at 9:30 am she indicated she was the first-shift nurse assigned to Resident #148 on 5/2/15-5/4/15. She stated, I didn ' t know he had fallen on Friday. On Sunday his wife told me he had fallen when he came in Friday. The rehab therapist on Sunday said he could not stand him up because (his left leg was hurting). That was when we were changing shifts about 3pm. The resident never seemed to be hurting to me that weekend. Nurse #2 indicated Resident #148 did not appear to be in pain on Saturday, May 2nd and Sunday, May 3rd. She further stated, He was new and report was he was non-ambulatory so we did not try to get him up that weekend. We would usually wait to get (a new admission resident) up until rehab evaluates to see what they need. I could never find the transfer assessment in the computer. His (Family Member #2) was talking about his pain that Sunday morning and said, ' He says he hurts. ' When I asked him he never said he was hurting. Nobody reported any pain to me during his care. I could not find a note or anything about a fall from Friday. I looked at the nurse ' s notes but there wasn ' t one about a fall. He seemed to be in more pain Monday than on Sunday. Nurse #2 indicated when there is a fall the nurse should notify the doctor, the family member, make a nurse ' s note in the computer, and complete the fall report by the end of the shift. During an interview with Nurse Aide (NA) #1 on 5/20/15 at 1:49 pm she stated, I worked with (Resident #148) on Saturday (5/2/15) first shift. (Family member #2) was here that morning and a male relative was here in the afternoon. (Resident #148) was incontinent of bowel and bladder. I was giving him his bath and turned him to the left side. He said, ' I hurt so bad ' and was holding his left leg. I told him I would let the nurse know. I told her. It was (Nurse #2). It was in the morning when I was doing my baths, but I don ' t remember exactly what time. During an interview with NA #2 on 5/20/15 at 2:00 pm she indicated she worked on Sunday, 5/3/15, first shift with Resident #148. She stated, In the morning I was trying to wash his feet and legs. He tried to go for his left leg like he was trying to keep me from moving him. (Family member #2) was here and told me he had a fall that Friday. I reported it to Nurse #2 and I went to the supervisor (Nurse #3). I let her know about his fall. Nurse #3 said she did not know about the fall, then Nurse #3 and Nurse #2 talked to each other. He still was hurting on Monday. The aide indicated that the resident ' s reaction on Sunday was of obvious pain with any movement of his left leg. During an interview on 5/21/15 at 10:22 am with Nurse #3 she indicated she was the weekend nurse supervisor who worked on 5/2/15-5/3/15 and stated, I work every other weekend. I don ' t recall knowing about (Resident #148 ' s) fall on Friday (May1) at all during that weekend. I go through the 24-hour reports that are generated from the nurse ' s notes and don ' t remember seeing that. Every nurse note is on the report and falls always stand out. The follow up on a fall should occur for 3 days after a fall, even one without an injury. The Physical Therapy Evaluation and Progress Note dated 5/3/15 indicated the following: · Resident #148 was evaluated for a primary [DIAGNOSES REDACTED]. · (Family member #2) reported (resident) was able to walk short distances and go up and down steps with assistance. · During the evaluation, Resident #148 was complaining of severe pain (left lower extremity) that was aggravated by movement. · (Physical therapy evaluation) complete. (Resident #148) unable to stand or (ambulate secondary to complaints of left lower extremity) pain. Nursing reports (resident) had a fall 5/1/15 out of bed. Nursing made aware of (complaints of) pain in (left lower extremity and limited mobility secondary to pain.) Nurse #2 ' s note on Monday 5/4/15 indicated Resident #148 was complaining of left hip pain and left leg pain, the physician was notified, and orders were given to send the resident to the Emergency Department. The note further indicated (Family member #2) was at his bedside, his left knee was swollen and was slightly turned outward. Resident #148 ' s Discharge Minimum Data Set ((MDS) dated [DATE] indicated the following: · He had impaired hearing and vision, had clear speech, made himself understood and understood others. · He needed extensive assistance of one person for bed mobility, and transfer did not occur from his admission on 5/1/15 to his discharge on 5/4/15. · He did not have pain and did not receive any pain medication during his admission. · He did not have any falls one month prior to his admission and had no fractures related to any falls for 6 months prior to admission. · He had a fall during his admission from 5/1/15-5/4/15. Review of the Emergency Department (ED) notes dated 5/4/15 revealed: · Resident #148 was uncomfortable with any manipulation of either extremity, his left foot was slightly externally rotated and was very stiff. Resistant #148 was resistive to movement of his left leg. · Resident #148 had a left [MEDICAL CONDITION] and the note further stated, Labs (dated 5/4/15) are also notable for a hemoglobin drop from 10 to 8. The trauma/leg fracture could account for this. · Patient discharged from hospital on [DATE] to nursing home. Apparently fell down in the nursing home and he was having pain in left hip. Presented to ED. Was found to have left [MEDICAL CONDITION]. admitted to hospital for further (evaluation) and management. Impression - acute left [MEDICAL CONDITION] secondary to fall at nursing home. Consulting orthopedics for possible surgery tomorrow. Acute worsening of chronic [MEDICAL CONDITION]. Hemoglobin has dropped to 8 from 10.5 4 or 5 days ago. Ordering a cross match and he will likely need a transfusion. Review of the Operative report dated 5/5/15 revealed Resident #148 had a left femoral neck fracture that was repaired by a left hip hemiarthroplasty (an operation to treat a [MEDICAL CONDITION] that replaces the femoral head - the ball part of the hip). During an interview on 5/20/15 at 11:38 am with the Director of Nursing (DON) when asked about the resident ' s fall and any fall investigation she stated, I knew to do an investigation and talked to (Nurse #1). There was a lapse on him falling on Friday to going out Monday. He was able to move without grimacing and didn ' t have external rotation. His wife never said he was in pain. Monday it was reported he was complaining of pain. When asked about monitoring after an unwitnessed fall to included documentation and orthostatic blood pressures she stated, There is a period of monitoring the nurses will do. I have to check how often they are done. We rely on family members to guide and give us insight with the residents, especially the new admissions. During an interview with the Administrator on 5/20/15 at 3:40 pm she stated, (Resident #148) arrived at approximately 3:30 pm on Friday May 1st. I do have an issue that report was not given. The Administrator indicated she expected the nurse who was caring for the resident to have informed the nurse who took over his care of the fall and to tell the supervisor on duty. During an interview on 5/20/15 at 4:26 pm with the Administrator she stated a 72-hour report (summary) is printed Monday morning, the information on the report is triggered by the nurses when notes are written in the electronic medical record, every nurse note written in the 72-hour time frame is on the report, and the report is reviewed by administration on Monday during the stand-up meeting. She further stated the report is used as a means of communication and is the same information that is on the 24-hour report generated every weekend day morning by the weekend supervisor. Record Review of the 72 Hour Summary , that was dated 5/1/15-5/4/15 and printed on 5/4/15 at 7:35 am, indicated there were no nurse ' s notes regarding Resident #148 ' s fall on 5/1/15. During an interview on 5/20/15 at 3:43 pm with the Director of Nursing (DON) she indicated there was a charge nurse on duty at the facility the night of Resident #148 ' s fall and Nurse #1 should have informed the charge nurse of the fall. During an interview on 5/21/15 at 11:08 am with the DON, she produced an undated document titled Acute Episode Monitoring and stated, When there are issues that happen they have to follow those guidelines. They are at every nurse ' s station in the red book. The Acute Episode Monitoring guide, in part, indicated the following: · After a fall, for 3 days, there should be monitoring every shift of the consequences of the fall, pain, shortening/external rotation of the extremity, interventions, and vitals done. · A new admit, for 7 days, there should be monitoring every shift of vitals, pain, alertness, orientation, any complaints, and anything out of the ordinary. During an interview on 5/22/15 at 1:30 pm with Family Member #4, he indicated he visited Resident #148 on Saturday, May 2, 2015, that rehab therapy came in the room to work with Resident #148 and stated, When they tried to move him he yelled out with every attempt. He further indicated he informed the rehab therapist that Resident #148 had a fall on 5/1/15 and therapy stated they ' were not aware of any fall. '