Every finding on record at Carolina Rehab Center of Cumberland

Based on observation, record review, and staff interviews the facility failed to ensure their medication error rate was less than 5%. Two (2) medication administration errors were detected out of 38 opportunities. The medication errors occurred for 2 of 3 residents observed during medication administration (Resident #8 and Resident #9). This resulted in a 5.26% medication error rate.The findings included:1a. On 1/21/26 at 9:12 AM Nurse #1 was observed as she prepared and administered morning medications to Resident #8. Nurse #1 was observed to remove two docusate sodium (stool softener) 100 mg (milligrams) capsules from a stock bottle and place them in a cup of medications she was preparing to administer for Resident #8. Nurse # 1 was observed to administer the two docusate sodium capsules to Resident #8. Nurse # 1 was not observed to administer any other type of stool softener to the resident.Resident #8's orders were reviewed following the medication administration observation for reconciliation purposes. Resident #8 did not have an order for docusate sodium 100 mg. Resident #8 had an order, dated 5/29/25, for two tablets of sennosides docusate sodium (a combination medication with a bowel stimulant and a stool softener) 8.6-50 mg daily. On 1/21/26 at 10:35 AM orders were reviewed with Nurse #1, and Nurse #1 was interviewed about giving docusate sodium rather than the ordered sennosides docusate sodium to Resident #8. Nurse #1 reported she had not realized she had administered the wrong type of stool softener.1b. On 1/21/26 at 9:16 AM Nurse #1 was observed as she prepared and administered medications for Resident #9. Nurse #1 was observed to remove one tablet containing Calcium 600 mg with Vitamin D 5 micrograms (a calcium and vitamin supplement) from a stock medication bottle and place it in a medication cup. Nurse #1 was observed to administer the Calcium 600 mg with Vitamin D5 micrograms to Resident #9.Resident #9's orders were reviewed following medication observations for reconciliation purposes. Resident #9 had an order, dated 1/8/26, for calcium citrate 950 mg (200) one tab every day (The 200 indicates the amount of elemental calcium available for usage by the body which is separate from the weight of the calcium pill).On 1/21/26 at 10:35 AM orders were reviewed with Nurse #1, and she was interviewed about the difference in calcium supplement she had administered to Resident #9 versus the prescribed calcium supplement. Nurse # 1 reported the facility had only one dosage of calcium stocked and therefore she had given what the facility had in stock.An interview with the DON (Director of Nursing) on 1/21/26 at 2:35 PM revealed the following information. She (the DON) had reviewed Resident #9's record and it appeared Resident #9 took the prescribed dosage of Calcium at home prior to being hospitalized for supplementation and not for a specific diagnosis. The DON explained the daily calcium citrate 950 mg (200) one tab had then been ordered at the hospital and then also at the facility when the resident was admitted . The DON stated there had been no verification prior to the morning of 1/21/26 with the physician about the ordered calcium dosage versus what the facility had in stock with the physician.

Based on observations and staff interviews, the facility failed to discard expired food items stored in 3 of 4 nourishment room refrigerators (Unit 1, Unit 2 and Unit 3) . This practice had the potential to cause foodborne illnesses. Findings included: Observations of the nourishment room refrigerators with the facility's Dietary Manager (DM) on 6/25/25 revealed the following: a. An unopened pack of chicken breast strips and green beans with the use by date of 5/13/25 was observed in the freezer of Unit 1 nourishment refrigerator at 11:53 AM. The DM placed the food item in the trashcan. b. A 10-pack box of prepacked store-bought sandwiches with the best if used by date of 4/27/25 was observed in the freezer of Unit 3 nourishment refrigerator at 12:01 PM. The box was approximately half full. The DM placed the food items in the trashcan. c. Two bottles of nutritional shake with the expiration date of 5/6/25 were observed in Unit 2 nourishment refrigerator at 12:10 PM. The DM placed the food items in the trashcan. The Dietary Manager, who was present during the observations, stated that dietary and nursing staff were supposed to ensure that expired food items in the nourishment refrigerator were discarded. During an interview on 6/25/25 at 2:30 PM with the Director of Nursing (DON), she stated that she expected dietary and nursing staff to inspect the nourishment room refrigerators to ensure expired food items were not left in the refrigerator or freezer. During an interview with the facility Administrator on 6/27/25 at 8:25 AM she indicated her expectation was to have no outdated food items in the refrigerator or freezer and that any expired food items should have been thrown out.

Based on record review, and staff, Wound Care Nurse Practitioner and Podiatrist interviews, the facility failed to obtain orders to coordinate care with the resident's Podiatrist to ensure care needs were met when a resident was admitted with no orders regarding care to a surgical incision site of the right heel. The surgical dressing was not removed, and no treatment was provided. At the Podiatrist visit on 1/13/25 the wound was significantly macerated (skin had become soft and broken down due to prolonged moisture) that had extended laterally out of the incision. Podiatrist #1 saw Resident #4 on 1/13/25 and started oral antibiotics and treatment orders to the incision site. Podiatrist #2 saw Resident #4 on 1/15/25 and changed the treatment orders to the incision site. Podiatrist #1 saw Resident #4 again on 1/24/25 and started him on another antibiotic along with continuing the first antibiotic. On 1/27/25 Resident #4 was seen by Podiatrist #1 and sent him to the emergency room for admittance into the hospital for a bone biopsy and possible surgery due to infection at the surgical site. Resident #4 required two surgeries to remove all of the hardware from the right ankle and intravenous antibiotics for the infection. This was for 1 of 2 residents reviewed for wound care (Resident #4). Findings included: A review of Resident #4's hospital discharge orders 12/27/24 noted an order for non-weight bearing to his right lower extremity, a follow-up appointment with podiatry scheduled for 1/2/25, and no orders noted regarding care of the surgical incision or soft cast. A review of Resident #4's facility admission orders revealed an order dated 12/27/24 for a wound consultation as needed. Resident #4 was admitted into the facility on [DATE] with diagnoses of a right calcaneus comminuted fracture (a severe break of the heel bone that shatters into multiple pieces) status post open reduction internal fixation surgery with primary subtalar arthrodesis (permanently joining the joint that connects the ankle bone to the heel bone), diabetes and peripheral vascular disease. A review of Resident #4's comprehensive care plan dated 12/28/24 included a focus problem of skin impairment with interventions of notify physician as indicated, observe area for signs of improvement or decline, and treatment as ordered. A focus problem of a risk for pressure ulcers related to chronic health conditions and incontinence with interventions of assessing resident for risk of skin breakdown, keep skin clean and dry as possible, and skin assessments as indicated. On 12/30/24 A focus problem of a surgical wound to his right lower extremity and is at risk for infection and complications was added with interventions of notify physician as indicated, observe surgical site for signs and symptoms of redness/infection, surgeon follow-up as indicated, and treatment as ordered. On 1/2/25 a focus problem of noncompliance related to weight bearing status and getting up unassisted was added with interventions of listen to resident and try to calm, provide repeat education of risk and benefits of following weight bearing status. A review of Resident #4's electronic medical record included progress notes by the Wound Care Nurse Practitioner dated 12/30/24 noted Resident #4 had a full thickness surgical area on right lower leg and documented per Surgeon's request, monitor for signs/symptoms of increased drainage or infection and notify Surgeon of any changes right away and to keep post op wrap in place and there was no evidence of infection noted today upon assessment. A review of Resident #4's admission Minimum Data Set, dated dated dated [DATE] indicated he had clear speech, was understood and able to understand and was cognitively intact. He had no behaviors, no rejection of care, had impairment on one side of a lower extremity, and used a wheelchair for mobility. He had one fall since admission with injury, had recent surgical repair of a fracture, a surgical wound, and had received physical therapy for 6 days and occupational therapy for 5 days. A review of Resident #4's electronic medical record included progress notes by the Wound Care Nurse Practitioner dated 1/6/25, noted Resident #4 had a full thickness surgical area on right lower leg and documented per Surgeon's request, monitor for signs/symptoms of increased drainage or infection and notify Surgeon of any changes right away and to keep post operative wrap in place and there was no evidence of infection noted today upon assessment. A review of Resident #4's electronic medical record included progress notes by the Wound Care Nurse Practitioner dated 1/15/25, 1/24/25, and 1/27/25 indicated she did not see Resident #4 due to him being out of the building. A telephone interview with the Wound Care Nurse Practitioner on 3/4/25 at 3:31 PM revealed that she had not removed the soft cast to inspect the incision because she does not carry supplies to replace an orthopedic cast and she had no direction to remove the cast, so she defaulted, due to previous experience, to not removing the soft cast until Resident #4 was seen by the podiatrist. She stated she was aware there were no orders to remove the soft cast, and she further revealed that she had not spoken to the podiatrist in regard to the care of the surgical incision or the removal of the soft cast. The Wound Care Nurse Practitioner further indicated that in her experience a soft cast was kept in place until the resident was seen by the surgeon, so she did not find the lack of treatment orders concerning. She further stated that while she did not speak to the podiatrist, she always used the general terminology of surgeon request in all of her notes. An interview was conducted on 3/4/25 at 2:00 PM with Nurse #1, who admitted Resident #4, stated that he received the order to not change the hospital dressing to the right ankle from the Wound Care Nurse Practitioner on 12/29/24. He explained that after the Wound Care Nurse Practitioner sees a Resident he receives via email the Wound Nurse Practitioner orders which he then transcribes onto the physician order sheet after making the resident's physician aware and gets approval to implement the orders. He further revealed he was notified of the 1/2/25 Podiatrist appointment at the time of the resident's admission. Nurse #1 indicated he was notified by the family member on 1/2/25 of the appointment being rescheduled for 1/13/25 due to insurance issues as the fracture was from a motor vehicle accident and she was still working with the person who caused the accident insurance to ensure payment. A review of the spreadsheet received by Nurse #1 from the Wound Care Nurse Practitioner on 12/30/24 noted an order from the Wound Care Nurse Practitioner to keep the post operative wrap in place. A review of Resident #4's physician orders indicated an order dated 1/1/25 to keep the post operative. wrap in place. A review of Resident #4's Podiatrist #1 progress note dated 1/13/25 revealed Resident #4 stated the facility had completed no dressing changes since the surgical intervention. Podiatrist #1 noted there was significant maceration (skin had become soft and broken down due to prolonged moisture) noted to the lateral extends out of incision and a pressure area on the heel. The incision was cleaned with saline and a topical antiseptic solution-soaked gauze was applied as well as a compressive dressing. Resident #4 was to be strictly non-weightbearing. The note included an order for an antibiotic one tablet twice a day for 10 days and wound care orders were placed for the facility to change the dressing daily. Podiatrist #1 wrote that out of an abundance of caution Resident #4 was to follow up with his colleague on Wednesday for a wound check and dressing change. A review of Resident #4's facility electronic medical record revealed a treatment order dated 1/13/25 for the right heel incision to be cleansed with saline and a topical antiseptic solution-soaked gauze apply abdominal pad and wrap with gauze and compressive dressing three times weekly. A review of Resident #4's treatment administration record noted a treatment dated 1/13/25 for the right heel incision to be cleansed with saline and a topical antiseptic solution-soaked gauze apply abdominal pad and wrap with gauze and compressive dressing daily was completed as ordered. A review of Resident #4's facility electronic medical record revealed a medication order dated 1/13/25 for an antibiotic tablet twice a day for 10 days. A review of Resident #4's medication administration record revealed he received the ordered antibiotic medication twice a day as ordered. A review of Resident #4's Podiatrist #2's progress note dated 1/15/25 indicated Resident #4 complained of pain to the right foot which was sharp with Resident #4 rating the pain as severe. Podiatrist #2 noted there was mild maceration along the central portion of the incision with no incision dehiscence (splitting or bursting open). The sutures were intact and a bullae (fluid filled sac) extended plantarly (sole of the foot). Podiatrist #2 noted edema and erythema (swelling and redness) to the right foot. Podiatrist #2 cleansed the surgical site with saline and a topical antiseptic solution-soaked gauze. Podiatrist #2 wrote Resident #4 has maceration to the incision and recommended a topical antiseptic solution dressing change every 2 days to prevent dehiscence and Resident #4 was to remain absolutely non-weightbearing to the right foot. Podiatrist also wrote Resident #4 was to see Podiatrist #1 next week. A review of Resident #4's facility electronic medical record revealed a treatment order dated 1/15/25 for the right heel incision to be cleansed with saline and a topical antiseptic solution-soaked gauze apply abdominal pad and wrap with gauze and compressive dressing every 2 days. A review of Resident #4's treatment administration record noted a dated 1/15/25 treatment for the right heel incision to be cleansed with saline and a topical antiseptic solution-soaked gauze apply abdominal pad and wrap with gauze and compressive dressing every two days was completed as ordered. A review of Resident #4's Podiatrist #1's progress note dated 1/24/25 revealed Resident #4 complained of severe pain to the right foot and confirmed he was taking the prescribed antibiotic. On examination of the incision to the right foot Podiatrist #1 noted the sutures were intact with maceration along the central portion of the incision. Podiatrist #1 noted the wound did probe (a tool used to determine the extent and depth) but not to bone or hardware, and no dehiscence. Podiatrist #1 also noted edema and erythema to the right foot. Podiatrist #1 cleansed the surgical site with saline and a topical antiseptic solution bandage was applied. Podiatrist #1 sent recommendations for the site to be cleansed with saline and a topical antiseptic solution dressing to be changed daily to prevent dehiscence. Podiatrist #1 also ordered two different antibiotics to be administered orally. A review of Resident #4's facility electronic medical record revealed a treatment order dated 1/24/25 for the right heel incision to be cleansed with saline and a topical antiseptic solution-soaked gauze apply abdominal pad and wrap with gauze and compressive dressing daily. A review of Resident #4's treatment administration record noted a treatment dated 1/24/25 for the right heel incision to be cleansed with saline and a topical antiseptic solution-soaked gauze apply abdominal pad and wrap with gauze and compressive dressing daily was completed as ordered. A telephone interview with Podiatrist #1 on 3/4/25 at 2:15 PM indicated that Resident #4 should have been discharged from the hospital with orders for daily dressing changes to the surgical site. He stated that he was not on duty when Resident #4 was discharged and was unaware that the facility had not received any orders regarding dressing changes. He further indicated that the facility should have called and clarified what wound care was required. Podiatrist #1 further stated that when he saw Resident #4 on 1/13/25 there was serosanguinous drainage and significant maceration on the side of the incision line, and he prescribed an antibiotic for 10 days and orders to clean the incision site daily with saline and a topical antiseptic solution to be done daily. On 1/15/25 Resident #4 was seen by his colleague who changed the wound care orders to clean incision site with saline and a topical antiseptic solution every two days to prevent incision dehiscence. The Podiatrist further indicated he saw Resident #4 again on 1/24/25 and noted there was maceration along the central portion of the incision and noted edema erythema and sent new orders to the facility for two different antibiotics and changed the treatment to the surgical site to cleanse the incision site with saline and a topical antiseptic solution back to daily. When he saw Resident #4 on 1/27/25 he sent him to the emergency room , he was admitted and had two surgeries to remove all of the hardware from the right ankle and intravenous antibiotics for the infection. The Podiatrist further stated that in his opinion if the facility had called for treatment orders when Resident #4 was admitted the infection would have been caught earlier. The Podiatrist said that he could not definitively say that the lack of dressing changes caused the infection but that the changes in the incision would have been caught earlier and treated sooner if the facility had called for orders. A review of the emergency room Physician's provider's note dated 1/27/25 included Resident #4 was being followed by the podiatry clinic after surgery had been performed to the area of the right heel. Resident #4 was sent from Podiatrist office for admission for a bone biopsy and possible surgery due to infection at the surgical site. The focus exam noted swelling, tenderness along the heel and the wound was present with some drainage noted. The emergency room Physician also noted that the podiatry team was in the triage area evaluating and placing orders. An interview with the Director of Nursing on 3/5/25 at 10:26 AM revealed the facility followed the wound care provider's orders which were to keep the soft cast on. The order was noted on the spreadsheet sent by email on 12/30/24 from the Wound Care Nurse Practitioner to the Director of Nursing and Nurse #1. She further stated that she had not received any orders from the Medical Director after he saw Resident #4 on 12/27/24 regarding removing the soft cast. She further revealed that maybe the facility should have questioned the wound care provider after the second time she saw Resident #4 and did not reach out to the Podiatrist and unfortunately with the Wound Care Nurse Practitioner writing per surgeon the facility did not question it. She stated that she was aware of the family member contacting the facility regarding the cancellation of the podiatry appointment on 1/2/25 and rescheduling it for 1/13/25. An interview with the Administrator on 3/5/25 at 8:15 AM indicated that all appointments were discussed at the morning meeting Monday through Friday. This discussion included if the resident made it to the appointment and if the resident had not, was it rescheduled, was paperwork received by the facility from the visit and if not the facility attempted to contact the physician for the information. The units and administration were informed by admissions of any scheduled appointments on the discharge paperwork from the hospital which are then placed on the unit calendar. She further indicated the facility was aware the family member had changed the podiatrist appointment from 1/2/25 to 1/13/25 which was discussed in the morning meeting on 1/3/25 and had called the family member to ensure she would be taking him to the appointment. An interview with the Administrator on 3/5/25 at 10:02 AM indicated that when the Wound Care Nurse Practitioner sees a resident with any type of surgical wound and there were no orders, the wound care provider was responsible for clarifying what orders the surgeon wanted. She further indicated that the facility had a telephone discussion with the wound care company about Resident #4 and the provider stated that orders for wound care needed to be clearly stated on the hospital discharge orders or the Wound Care Nurse Practitioner would be responsible for obtaining and clarifying orders from the surgeon. A telephone interview with the Medical Director on 3/5/25 at 9:05 AM indicated that he made a judgement call to not remove the soft cast and that he did not see an issue with the decision to leave the soft cast in place when he saw Resident #4 on 12/27/24. He further indicated that in hindsight the facility probably should have called and received clarification from the Podiatrist regarding the care of the incision but again he did not see an issue with the soft cast remaining in place. He stated that there was a lack of communication from the hospital and while the Podiatrist may have wanted the soft cast removed and daily dressing changes, this did not mean the discharging physician did. He further stated that it was unusual for the facility to remove a soft cast and start daily treatments. Also, the delay in seeing the Podiatrist due to Resident #4's family member cancelling the 1/2/25 appointment could have played a role in the state of the incision when Resident #4 went to his podiatry appointment.

Based on observation of a recorded video, record review and interviews with resident, staff, and a van transportation company, the facility failed to ensure a resident was safely transported to a physician's visit. The facility's contracted transportation company's Van Driver failed to ensure the lift platform was level with the van before rolling Resident # 7 out of the van. The resident fell backwards out of the transport van to a lift platform that was located on the ground approximately 3 feet below the level of the van. Review of the van company's recorded video of the incident revealed the resident could be heard crying and yelling loudly when she hit the ground. Failure to ensure safety when assisting residents onto mechanical van lifts has a high likelihood of resulting in serious resident harm. This was for one (Resident # 7) of three residents reviewed for accidents. The findings included: Resident # 7 was admitted to the facility on [DATE]. The resident's diagnoses in part included a history of stroke. Resident # 7's annual Minimum Data Assessment, dated 8/7/24, coded the resident as cognitively intact. The resident was coded to use a wheelchair, and as needing substantial to maximum assistance to wheel at least 150 feet. Review of Resident # 7's nursing notes revealed an entry on 8/20/24 at 2:58 PM noting It was reported that during transport from an appointment that the resident had a fall. Resident is being transported by EMS (emergency medical services) to the ER (emergency room ) for evaluation. A review of hospital records for the dates of 8/20/24 and 8/21/24 revealed the following information. Resident # 7 was seen in theER on [DATE] following the incident. The physician noted the resident was in no acute distress at the time of the physician's assessment. The physician noted the resident's speech was hard to understand. When she slowed down her speech was not slurred, and she was able to report she had landed on her back inside her wheelchair during a fall from a transport van. The caregiver (transport driver) landed on top of her. The physician further noted, She denies any complaints at this time, no neck pain, no headache, nausea, vomiting, chest pain, reports legs are less painful than they were prior to arrival. A CT (computerized tomography) of her head and cervical spine were ordered and were negative for injury. The resident was discharged back to the facility from theER on [DATE]. The resident was interviewed on 10/29/24 at 10:47 AM and again on 10/31/24 at 2:40 PM. The resident was observed to talk very fast making it difficult to discern every word. She clearly reported the following information. In August 2024 she had been transported to a doctor's appointment and the Van Driver pushed her out of the van onto the concrete. Before the incident, the Van Driver complained to her that she (the resident) was heavy. Then she fell out of the van. It hurt when she fell , and she had to go to the hospital. An interview was conducted with the Administrator and NA# 1 on 10/31/24 at 3:15 PM. NA (Nurse Aide) # 1 reported and demonstrated the following. NA # 1 had ridden in the van with the contract company to Resident # 7's appointment. Once they arrived at the physician's appointment, she (NA # 1) went into the office to check the resident into the office. She (NA # 1) then came out the door and stood at the doorway while the Van Driver was unlocking and getting Resident # 7 out of the van. She could see the back of the van. The resident and the Van Driver both fell backwards out of the van, and they landed on the lift platform. The wheelchair flipped all the way upside down on top of the resident so that the bottom of the wheelchair seat was facing up in the air and the top of the wheelchair backrest was on the surface of the lift platform. The accident happened very quickly, and she thought the Van Driver had tripped some way and the lift platform was still up in the air when the resident fell backwards. The physician's office staff came to assist with the incident. 911 was called. She called and reported the incident to the facility. She had not observed anything about the Van Driver before the incident which would indicate the Van Driver was not a safe driver. The Administrator reported the facility had used the contracted van company many times and they had given safe and reliable services. The van company had reviewed the incident with her and reported that the Van Driver had not put the lift platform even with the van before rolling the resident out of the van. Instead, the Van Driver had lowered the lift platform all the way to the ground. The van company had reported to the Administrator that there were safety mechanisms in place at the rear of the van, and the Van Driver should have recognized when she met resistance getting the resident out of the van over one of them that there was a possible problem. The Van Company's Director was interviewed on 10/31/24 at 4:53 PM and reported the following information. Their Van Driver had made a mistake and Resident # 7 had fallen out of the transport van. They were very sorry about the incident. They went to check the van at the time of the incident and found nothing mechanically wrong with the lift or the van which led to the incident. The lift was damaged due to the impact of the fall, and it was taken out of service for repair following the incident. She had worked closely with the facility Administrator to try to determine what had happened. There was a video recording from inside of the van which they had watched multiple times to determine what had happened. She and her husband owned the transportation company, and the Director put her husband on the phone call with the surveyor during the interview. Together they reported the following information. The video recorder was facing the rear of the van and therefore the video showed the incident from that angle only. From reviewing the video, they saw NA # 1 had ridden with the resident and the Van Driver. Once they arrived, NA # 1 left the van to go into the doctor's office, and the angle of the video did not pick NA # 1 up until after the incident occurred. After the fall, the video's angle picked up NA # 1 rushing to the back of the van. Upon arrival to the doctor's office, the Van Driver could be seen exiting the van, walking to the rear of the van and letting the lift platform down. The Van Driver then returned inside the van, unlocked the resident's wheelchair's security devices and rolled the resident backwards. While conducting their investigation, they had viewed other transport videos where there had been no incidents. From viewing and comparing the videos where transports were done correctly versus the video where Resident # 7 fell , they were able to see that when the lift platform was even with the van in a safe position to roll residents out, then safety arms on the lift would be visible in all the videos. In viewing the video of Resident # 7's transport, they saw when the Van Driver lowered the lift platform, the safety arms disappeared almost completely. Only a small portion could be seen. This indicated to them that the lift platform had been all the way to the ground instead of level with the back of the van when the resident was rolled backwards. In the video they saw the resident and the Van Driver fall out of the van towards the ground. They estimated that the drop was about 36 inches. They reported they would share the video with the surveyor and a statement from the Van Driver. On 11/1/24 the van company's video was viewed, and the following was observed. Resident # 7 could be seen seated in the rear of the van in a wheelchair. The Van Driver was seated in front and NA # 1 was in the front passenger seat. They came to a stop. NA # 1 stepped out of the van and exited from sight. The video camera no longer was able to capture NA # 1 as she walked into the physician's office to check the resident in. The Van Driver exited the front of the van and opened the back doors of the van. A lift platform could be seen going down at the rear of the van. The arms of the lift faded away from sight as it lowered. There did not appear to be anything in the rear of the van where the lift platform should be. The Van Driver reentered the van and removed the security belts and ties that had kept the resident's wheelchair in place during the transport. She and the resident appeared to be talking. The resident was facing the front of the van and thereby her back was facing the rear of the van. Therefore, the resident could not see where she was headed as she was being rolled backwards in her wheelchair. The Van Driver backed the resident towards the rear of the van. When the Van Driver got to the rear, she appeared to have trouble getting the wheelchair to roll and appeared to be meeting resistance. She readjusted the wheelchair several times pulling it towards her and back again. Then with the last push backwards toward the open rear of the van, the resident fell backwards out of the van in her wheelchair. The Van Driver fell forward out of the van also with the resident. The resident could be heard yelling and crying loudly. After the fall, the resident was out of view from the camera angle. NA # 1 was seen coming into view of the video camera and asking what happened. A gentleman came from one side of the van and physician office staff members were seen coming from the other side to the rear of the van to offer assistance. The wheelchair could be seen lifted up and away. Someone was heard telling the resident they were calling EMS. Someone in the video was heard saying she is on the ground. Once multiple people were attending to the resident, the Van Driver could be seen reentering the front seat of the van and making a phone call to someone. She was heard explaining the incident and stated to the person to whom she was talking that she (the Van Driver) was trying to get Resident # 7 on the lift and couldn't get her. The Van Driver commented, She is so heavy. I was trying to push a little harder. I couldn't rock her because she was so heavy. She then said she tried to rock again and push back again, and the resident fell out of the van and they both hit the ground. The van company also provided a statement from the Van Driver which was in an email from the Van Driver to the Director of the van company on 8/22/24. The emailed statement read as typed, On Tuesday August 20th I [name of van driver] had transported [Resident # 7] to her destination. Once we arrived I locked my breaks, got of my vehicle to go through the proper steps to remove {Resident #7} from the vehicle. The second step was to unfold the lifter and level it so that {Resident # 7} could be placed on the lifter so that I could bring her down to ground level. At the time I didn't realize that I dropped the lifter all the way to the ground instead of keeping it leveled up so that can roll her onto the lifter. Then proceed to unbuckle her restraints so that I could put her onto the lifter upon moving her, not realizing that the lift was ground level, I then proceeded to push her what I thought was on the lifter. Once I started pushing her wheelchair still not realizing that the lifter was down ground level I ended up falling on top of her all the way to the ground. In my mind, I had leveled the lifter but it evident that I didn't, and I fell on top of her going backwards, and we both hit the ground. The van driver ended her statement by saying she had not done anything intentionally to hurt anyone, it had been an unfortunate accident, and she had been properly trained. Interview with the Administrator on 10/31/24 at 3:15 PM revealed the facility identified the incident as needing a plan of correction and they implemented one to ensure residents were safe. The Administrator provided the facility's plan of correction. On 11/1/24 at 11:00 AM the Administrator was notified of immediate jeopardy. The facility's completed corrective action plan was as follows: 1. Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice; On 8/20/2024 resident #7 was being transported by a contracted company to an appointment. During the unloading process, the driver proceeded to lower lift pad to the ground and not level to the van bumper. When the driver proceeded to wheel resident #7 onto lift pad she tripped on safety mechanism and toppled onto resident. This force pushed resident #7 and chair out of the van resulting in a fall in which resident #7 landed on the lift gate landing. On 8/20/2024 resident #7 was not moved until EMS arrived staff helped provide pillows and blankets for dignity until EMS arrived. EMS assisted lowering resident #7 to the ground on the lift gate. Resident #7 was transported to the hospital for further medical treatment. The Driver was suspended on 8/20/2024. The lift gate was damaged during the incident and therefore the van was removed from service until repaired. The driver was drug and alcohol tested on [DATE] with no findings. The driver was interviewed on 8/20/2024 by the contract transport company and maintained that a flap on the van used to keep patients in place failed to drop as expected therefore causing her to trip. On 8/20/2024 the aide who went on transport provided a statement and recollection of the events. She stated she was checking resident #7 into her appointment at the office and was coming out at the time the incident occurred. She stated she saw the driver trip and move forward onto resident #7 at which time the wheelchair tipped backwards and the resident fell . The aide stated that the lift gate was up in the air and that EMS had to assist further lowering it to the ground. On 8/21/2024 the transportation contract company owners came to the facility and brought the van that was part of the incident. The administrator, assistant administrator and owners discussed their findings. The owners stated the van was equipped with video camera that was on the dash and pointed toward the back. They reviewed the video footage however stated it was difficult to fully understand what was happening with the lift gate due to resident #7 and her chair being in the center. They stated they also reviewed footage of her earlier transportations for the day and noticed that the sides of the lift gate were not in visible sight as they had been on her earlier transports for the day. The owners maintain that those flaps only stay up if the lift gate is not level. The driver had received certification upon hire on safety as it relates to ensuring the lift gate is even with the van bumper prior to unrestraining a patient and proceeding with unloading. The owners had implemented a remediation plan of their own after reviewing the tapes starting 8/21/2024. All transports that have a single driver must call dispatch prior to removing the patient from the van to confirm all safety techniques including having the lift gate level are in place prior to unloading a patient. Resident #7 returned to the facility on [DATE] with no injuries. Resident #7 statement was obtained on 8/21/2024 and she stated she remembered talking to the driver and the driver tripped on something causing her to fall backward with the driver on top of her. On 8/21/2024 a trauma screen was performed on resident #7 and she reported no concerns from the incident. On 8/23/2024 during care resident #7 reported the incident again and another trauma screen was completed and she was concerned about future transportation. On 9/12/2024 resident #7 had her first appointment out of the facility since the incident the aide went with her and provided support of her safety during the transport process. Resident #7 expressed no further concern related to transport. The facility failed to ensure resident #7 was safe during the unloading process of transport resulting in fall from the van. 2. Address how the facility will identify other residents having the potential to be affected by the same deficient practice; Any residents receiving transports are affected by this practice. The transport company implemented 8/21/2024 that when working alone all drivers will be required to confirm the lift is floor level by walking on the lift and notifying their administration, prior to unloading all residents, that lift is level and safe. 3. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur; All drivers received education by the transport company owners on Passenger Assistance Safety which includes lift operating procedures and safety harnesses. This was completed 8/22/2024. This was supplied to the facility by the transport company on 8/22/2024. Any new driver will receive education by the transport company in orientation and will be sent to administrator as needed. The center contracts with no other transportation company and therefore no further education was required from other companies. 4. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained; The Quality Assurance Committee (Regional Director of Clinical Services, administrator, Director of Nursing, Assistant Director of Nursing) met on 8/22/2024 to review the findings and initiated a plan. Unit secretary or designee will ride on transport for an audit of 2 transports weekly x 4 weeks, weekly x 8 weeks to ensure the lift gate is level prior to wheeling patient off the van and driver has made all safety checks prior to unloading a patient. The audits will be reported to Quality Assurance for further review quarterly x 2. Include dates when corrective action will be completed. Completion date: 8/23/2024 The facility's corrective action plan was validated by the following: Beginning on 10/29/24 at 9:54 AM a tour of the facility was conducted. Multiple residents, who were interviewed, did not report a problem with safety or transportation. The facility provided documentation they had communicated and worked with their contracted van company to implement their plan of correction. There was documentation the van company provided education to their van drivers and the drivers completed a two day course entitled Passenger Assistance Safety and Sensitivity driver certification program, which included instruction on lift operating procedures, wheelchair and occupant securement training. The van drivers had a certificate of completion awarded from the Community Transportation Association of America. The facility provided evidence of their audits as outlined in their plan of correction. Their audits included checking for ramp and boarding safety, patient securement, and patient assistance. Resident # 7 was part of their audits, and the audit showed the resident had been transported safely following the incident to another office visit. It was confirmed with the Administrator that they only used this transportation company currently for transportation needs, and there had been no further incidents. The facility's correction date of 8/23/24 was validated on 11/1/24.

Based on observation, record review, and interviews with resident and staff the facility failed to afford privacy when a Nurse Aide used a cell phone by video chat in the vicinity of an unclothed resident receiving a shower. This was for one (Resident # 5) of four sampled residents who were interviewed about care. The findings included: Resident # 5 was admitted to the facility on [DATE]. The resident's diagnoses in part included depression and anxiety. Resident # 5's significant change Minimum Data Set assessment, dated 9/11/24, coded the resident as cognitively intact and totally dependent on staff for bathing and showering. Resident # 5's care plan, dated 9/20/24, included information that the resident exhibited manipulative behaviors and had been known to make false statements regarding staff. One of the care plan interventions was to ensure two staff members were in the resident's room when providing care services. This intervention had been added to the care plan on 6/25/24 and remained part of the active care plan. Resident # 5 was interviewed on 10/29/24 at 11:40 AM and again on 10/30/24 at 2:00 PM. Resident # 5 reported the following information. In recent weeks there had been an incident when NA # 3 had been using a cell phone in the shower room while she (Resident # 5) was being showered by NA # 2. At the time she (Resident # 5) was not clothed and was lying on a shower bed while NA # 2 showered her. There was a curtain pulled lengthwise down the long side of the shower bed which afforded privacy if anyone entered the shower room. At the bottom of the shower bed (near her feet), there was a gerichair recliner. During the first part of the shower, NA # 3 was outside of the privacy curtain. She (Resident # 5) could hear NA # 3 using her phone from the other side of the privacy curtain but the privacy curtain was protecting Resident # 5 from being viewed initially when NA # 3 was on the phone. While she was still being showered, NA # 3 came around the privacy curtain and took a seat in the gerichair at the foot of the shower bed while still talking on the phone. She (Resident # 5) lifted her neck and looked down towards the foot of the shower bed where NA # 3 was. NA # 3 had people on her phone and was face timing them while talking to them. The phone was angled so that it was pointed more at her (Resident # 5) than it was at NA # 3. She (Resident # 5) could see heads on the screen of the phone and felt that whoever was on the phone could see her naked on the shower chair. She yelled at NA # 3 to get out of the shower room, and she left. A review of the facility's investigation into the incident revealed the incident date was 9/23/24. The DON (Director of Nursing) and Unit Manager were interviewed on 10/29/24 at 1:00 PM and reported the following. On the date of the incident NA # 3 had been in the shower room as the care planned second staff member for Resident # 5 due to her false accusations. NA # 3 had reported the incident herself when Resident # 5 yelled at her. She had reported she received an emergency phone call about a sick child in her family and reported that was why she took the phone call. The DON reported NA # 3 should have momentarily stepped out of the shower room to afford privacy for Resident # 5, but NA # 3 reported she did not want to leave NA # 2 alone with the resident because that would have placed NA # 2 at risk of having false accusations made against her. On 10/30/24 at 10:20 AM NA # 2 and the DON were accompanied to the shower room where NA # 2 demonstrated and reported the following information she had observed on the incident date. The privacy curtain was pulled down the long length of the shower bed. The other long length of the shower bed was against the wall. She (NA #2) was behind the privacy curtain with Resident # 5 standing at the side of the shower bed near the foot. The bottom privacy curtain was open, enabling her to maneuver around the long shower bed as she worked to shower the resident and shave the resident's legs. Privacy was still afforded with the bottom of the shower curtain open as long as no one came around to the foot of the bed. There was a gerichair near the foot of the shower bed approximately 2 to 3 feet away. It was not facing the shower bed. The left arm of the gerichair would have been towards the shower bed. While she (NA #2) was working to shave Resident # 5's legs, she had her back to the gerichair. She heard Resident # 5 yell at NA # 3. She turned around and saw that NA # 3 had come around the privacy curtain and sat in the gerichair. NA # 3 was not facing or looking at Resident # 5 while doing so. NA # 3 had a cell phone holding it in front of her and looking into the screen of the cell phone. She was talking to someone on the phone while holding it in front of her. She (NA # 2) had not noticed when NA # 3 had received a phone call or what she was doing prior to that because she was shaving Resident # 5's legs and was concentrated on that so as not to cut the resident. She never saw NA # 3 turn the phone towards Resident # 5. When the resident yelled, NA # 3 left. An attempt was made to reach NA # 3 during the survey and she could not be reached for interview. The DON and Administrator were interviewed on 10/30/24 at 5:00 PM. The Administrator reported Resident # 5 did have a history of falsely accusing staff members and that was why NA # 3 had been present. The DON reported NA # 3 was a very good Nurse Aide who had no other problems prior to the incident. Both of the administrative staff members felt the Nurse Aide had taken the call because of an emergency and did not intend to invade Resident # 5's privacy. They had taken corrective action and provided the following plan of correction. 1. Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice; On 9/23/2024 Resident # 5 was receiving a shower by two CNAs when one of them received a personal call from children via video chat and remained in the shower room during the call. The facility failed to provide privacy while the resident was being showered when a staff member used a cell phone in a patient care area. The CNA no longer works in the facility. A trauma screen was performed on 9/24/24 by the Social Worker with no new trauma triggers identified. 2. Address how the facility will identify other residents having the potential to be affected by the same deficient practice; The Quality Assurance Committee (Regional Director of Clinical Services, Administrator, Therapy Manager, Director of Nursing, Assistant Director of Nursing, Medical Director, and Staff Development Coordinator) met on 9/25/2024 to review the findings and initiated a plan. The Administrator reviewed care concerns for the last 30 days on 9/24/24. There were no other concerns regarding cell phone use in patient care areas. 3. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur; The Administrator educated all staff on customer service as it relates to patient care and patient rights to include not using cell phones in resident care areas and privacy. This was completed on 9/26/2024. All newly hired employees will receive this education in orientation prior to assignment. No employee will be allowed to work until they have received this education. 4. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained; When the Quality Assurance Committee (Regional Director of Clinical Services, Administrator, Therapy Manager, Director of Nursing, Assistant Director of Nursing, Medical Director, and Staff Development Coordinator) met on 9/25/2024 to review the findings and initiated a plan, the Quality Assurance Committee also devised a monitoring plan. The DON and nurse managers will ensure cell phones are not being used in resident care areas through rounding, once in the morning and once in the afternoon on every hallway. This will occur 5x/week x 2 weeks, 3x/week x 2 weeks and 2x/week and 4 weeks. The results will be reported to the monthly QAPI committee for review and discussion to ensure substantial compliance. Once the QA Committee determines the problem no longer exists, then review will be completed on a random basis. Compliance: 9/27/24 The facility's plan of correction was validated by the following: Beginning on 10/29/24 at 9:54 AM a tour of the facility was conducted. Multiple residents were interviewed and did not report privacy issues. Staff were observed closing doors during care. There were no staff observed in resident care areas utilizing cell phones. During the interview, which was conducted with Resident # 5 on 10/29/24 at 11:40 AM the resident stated she had reported the 9/23/24 incident and since she had done so she had not experienced staff using their cell phones while providing care or in the vicinity of where care was provided to her. The facility provided documentation of inservice education and audits per the plan of correction. The facility's plan of correction date of 9/27/24 was validated on 10/30/24.

Based on record review and interviews with resident, staff, physician, and pharmacist the facility failed to administer a daily intravenous antibiotic on two consecutive days. This was for one (Resident # 6) of one sampled resident whose medications were reviewed. The findings included: Resident # 6 was admitted to the facility on [DATE]. Review of a hospital discharge summary, dated 10/24/24, revealed the following information. Resident # 6 had a stage 4 pressure sore and osteomyelitis. While hospitalized a culture of the sacral pressure sore grew bacteria. One of the bacteria was extended spectrum beta lactamase (ESBL) Escherichia Coli (A type of bacteria which is resistant to several antibiotics). She had also been diagnosed with a urinary tract infection due to (ESBL) Escherichia Coli. A PICC (peripherally inserted central catheterization) was placed for Intravenous antibiotics. According to the discharge summary the resident was scheduled to receive Ertapenem (an antibiotic) for a total of 6 weeks. The course of treatment was to run from 10/6/24 through 11/17/24. Review of Resident # 6's facility admission orders revealed on 10/24/24 Resident # 6 was ordered to receive Ertapenem 1 gram intravenously daily through 11/17/24. Review of Resident # 6's October 2024 Medication Administration Record (MAR) revealed Resident # 6 was not documented as receiving the Ertapenem on 10/26/24 and 10/27/24. Nurse # 1 did not document a check mark on the MAR indicating the IV antibiotic was administered. Resident # 6 was interviewed on 10/29/24 at 10:05 AM and reported the facility had missed giving her antibiotics over the weekend of 10/26/24 and 10/27/24. Nurse # 1 was interviewed on 10/30/24 at 3:41 PM and reported the following information. She confirmed she had not given Resident # 6 the antibiotic Ertapenem on 10/26/24 and 10/27/24. She could not find the antibiotic and had looked for it multiple places. She called the pharmacy and thought there was a problem with processing the medication order. She had let the physician know and spoken to the Director of Nursing. The DON (Director of Nursing) was interviewed on 10/30/24 at 11:55 AM and reported the following information. She had checked with the pharmacy, and they had sent the antibiotic. It would have been at the facility for administration over the weekend of 10/26/24 and 10/27/24. When the issue had first been brought to her attention, she had thought that the missed doses were due to something that had happened on the pharmacy's end. It had just recently been brought to her attention that the antibiotic was actually in the facility and had not been given. She did not know why Nurse # 1 had not administered the antibiotic or why Nurse # 1 was saying that it was a pharmacy issue. A pharmacist from the facility's pharmacy was interviewed on 10/30/24 at 1:15 PM and reported they had sent a four -day supply of Resident # 6's IV Ertapenem to the facility on [DATE] at 5:16 AM. Therefore, the facility would have had antibiotic doses through 10/28/24. Then they sent more doses on 10/29/24. They had no record of a nurse calling over the weekend of 10/26/24 and 10/27/24 about the antibiotic not being at the facility. There had been no processing issues for the delivery of the antibiotic. Resident # 6's physician was interviewed on 10/31/24 at 12:00 PM and reported the following information. He did not recall whether the staff had mentioned to him over the weekend about Resident # 6 missing her antibiotic on 10/26/24 and 10/27/24. He knew staff had mentioned it on Monday (10/28/24) and he had extended the order to include two additional doses to be given at the end of the resident's antibiotic therapy to adjust for the missed doses. He did not feel the two missed doses had adversely affected Resident #6.

Based on record review, and interviews with staff and a prosthetic company employee, the facility failed to facilitate replacement of a lost prosthetic liner so the resident could use his prosthesis and walk. This was for one (Resident # 4) of one sampled resident who had a prosthesis. The findings included: Resident # 4 was admitted to the facility on [DATE] with diagnoses which in part included diabetes, chronic kidney disease, and left below knee amputation. The resident's quarterly Minimum Data Set assessment, dated 7/27/24, coded the resident as cognitively intact and as not using a prosthesis during the assessment period. The resident was also coded to have moderate impairment of his vision. Review of physical therapy documentation from 7/21/24 through 8/5/24 revealed the following information. Resident # 4 was certified to receive therapy services during the dates of 7/21/24 to 7/31/24. One of his precautions was that he was blind. On 7/29/24 Physical Therapist # 1 documented unable to perform static stand or ambulate for the last 3 days due to inability to locate gel sleeve for prosthesis. DOR (Director of Rehab) notified. On 7/30/24 Physical Therapist # 1 documented treatment time spent on continued search for gel sleeve for prosthesis; therapist searched room again as well as laundry. Unable to locate. Notified DOR again and requested to order another gel sleeve. On 8/5/24 Physical Therapist # 1 completed a discharge summary noting the resident was being discharged from therapy. His ambulation goal had been noted to be 250 feet with forward wheel walker (FWW) and contact guard assistance. At time of discharge, he had not met that goal. The resident was walking 60 to 100 feet with FWW and periods of minimal assistance at time of discharge. Physical Therapist # 1 was interviewed on 10/10/24 at 3:00 PM and reported the following information. The resident needed the gel sleeve (liner) in order to use his prosthesis. It allowed suction between the resident's stump and the prosthetic device so that it would fit correctly. It also prevented the resident from having shearing on his stump. She had looked for the gel sleeve/liner and could not find it. Without it, he could not continue to wear the prosthesis and continue with gait training. She had told the DOR. Not having the liner in order to utilize the prosthesis had hindered his progress with gait training. He also had not made a lot of progress with transfers, and that had not been related to not having the prosthesis liner. He also could not see objects well, and that had also hindered his progress. On 9/3/24 at 12:50 PM Nurse # 2 documented the following information. Resident # 4 called 911 to report his missing prosthetic sleeve/liner. The 911 responders informed the resident that no crime had been committed and to allow the facility to have one delivered for him. On 9/3/24 a facility service concern report for Resident # 4 was completed that noted, Pt. (patient) reports liner to left prosthetic leg has been missing for 30 days. Pt called police to inform them it was missing. 2 officers, DOR, UM (Unit Manager) met with patient officers assured patient that facility directors were on top of the issue and were working to replace the liner as it has not been located. On the service form there was an area noted as action taken. On this part of the form, there was documentation that the DOR contacted a prosthetic company employee who stated they would check to see if the sleeve was in stock. The form further included documentation, awaiting delivery. Resident # 4 was interviewed on 10/9/24 at 12:40 PM and again on 10/10/24 at 5:35 PM and reported the following information. He thought he had two liners for his prosthesis at one time and now he had none. It had been several months since he had a prosthesis liner, and no one had helped him get another one. They had stopped therapy, and he wanted to use the prosthesis and walk. They would tell him his vision was poor, but he could see some things. During one of the interviews the resident pointed out to the surveyor the fire alarm on the wall. He also pointed out the clock, but stated he could not make out the time. He could also see whether the surveyor was wearing white or dark clothing but could not see details of clothing. On 10/10/24 at 11:50 PM the DOR was interviewed and reported the following information. She recalled the resident reporting his liner had been stolen on 9/3/24. She knew the liner had to be ordered. When the resident had the prosthetic liner, he had walked with therapy but was unsteady. He also had visual deficits that contributed to not making progress. During the interview, the DOR reported she would check on the status of the replacement prosthetic liner which had been ordered. On 10/10/24 at 2:40 PM a follow- up interview was conducted with the DOR who reported the following information. The liner had not yet been delivered. It would be delivered later that day (10/10/24). Regarding the lost prosthetic liner, the resident was not able to take off the liner himself and would have needed help. The facility did his laundry, and she did not know what had happened to his last prosthetic liner. The DON (Director of Nursing) was interviewed and reported she first became aware of the issue during a clinical meeting after the resident had called 911 on 9/3/24. She had not been made aware of the problem in July 2024 when the prosthetic liner was lost. An employee at the orthotic's and prosthetics company was interviewed on 10/10/24 at 3:10 PM and reported the following information. The first call they received from the facility requesting the prosthetic liner was on 9/4/24. The company told the facility staff a prescription was needed for the liner. The prescription was sent to the prosthetic company on that afternoon (9/4/24). The liner was not in stock, and it was ordered by the prosthetic company. The facility was notified on 9/19/24 that the prosthetic liner had arrived. A voice mail was left with the DOR on that date. On 10/3/24 the prosthetic company received a call from the facility saying they would call with payment for the liner the next week. They heard nothing further until the current day of 10/10/24 at 1:33 PM when the staff called and submitted payment. According to the prosthetic company employee, delivery was slated for that evening (10/10/24).

Based on record review and staff interviews the facility failed to maintain an accurate record regarding medical diagnoses. This was for one (Resident # 1) of one sampled resident reviewed for accurate diagnoses. The findings included: Resident # 1 resided at the facility from 7/15/24 until her discharge on 9/29/24. The resident's diagnoses in part included respiratory failure with tracheostomy placement. The resident's hospital discharge summary, dated 7/15/24, noted the resident had MRSA (methicillin resistant staphylococcus aureus) pneumonia while hospitalized and had received treatment. A review of the facility's record revealed a list of cumulative diagnoses. MRSA pneumonia was listed as one of the resident's diagnoses while she had been hospitalized . There was an accompanying ICD code (International Statistical Classification of Disease) by the diagnosis of MRSA. (This medical classification system assigns a code for different diagnoses.) A review of the resident's record revealed the resident had three chest x-rays performed while she resided at the facility. These were on 7/21/24, 8/15/24, and 8/29/24. All of the x-rays were negative for pneumonia. On 9/7/24 at 12:11 AM Nurse # 1 documented in a nursing note that Resident # 1 had yellow/green tinged tracheal secretions, and the physician was notified. On 9/7/24 at 12:19 AM Nurse # 1 documented in a nursing note that the physician had ordered the resident to be given Ciprofloxacin 500 milligrams twice per day for 10 days for an upper respiratory infection. (Ciprofloxacin is an antibiotic.) On 9/7/24 Nurse # 1 entered into the resident's medical record, the verbal order for the Ciprofloxacin. The order included the information that Ciprofloxacin was for yellow/green tracheal secretions. It also included an accompanying diagnosis. The diagnosis was listed as MRSA pneumonia. On 9/9/24 the resident' s care plan was updated to reflect the resident had developed pneumonia and was receiving antibiotics for pneumonia. A review of physician notes revealed the resident was seen by the physician on 9/19/24. The physician noted the resident had recently completed the antibiotics secondary to a possible upper respiratory infection and her lungs were clear. The facility's care plan nurse was interviewed on 10/11/24 at 12:43 PM and reported the following information. When verbal orders are entered by a nurse, there is a drop-down box in the electronic system that allows the nurse to tie an order to an ICD diagnostic code in the resident's record. When Nurse # 1 entered the antibiotic order, she had checked the ICD code for MRSA pneumonia which had been entered upon admission to reflect the resident's history of pneumonia while hospitalized . Instead, she should have just entered the order to read that the antibiotic had been ordered for the discolored sputum and concluded the order with that alone. When the care plan nurse looked at the record, it appeared as if the resident was being treated for pneumonia, but she had not been. She (the care plan) nurse had then inaccurately placed on the care plan that the resident had pneumonia. There had been no diagnosis of pneumonia, and it was an error in the record. Resident # 1's Responsible Party (RP) was interviewed on 10/9/24 at 11:34 AM and expressed concern that Resident # 1's facility medical record had inaccurately reflected whether the resident had pneumonia again while she resided at the facility. The RP reported she had talked to facility staff members about Resident # 1 and her status. During conversations staff referenced the resident's medical record to provide her (the RP) information. At one point she had been told Resident # 1 had pneumonia and at another point she had been told the resident did not have pneumonia while she was at the facility. Resident # 1's physician was interviewed on 10/10/24 at 2:00 PM and reported the following information. The resident's RP had been concerned about the color of the resident's mucous and the resident had been placed on antibiotics because of the concern of the color. The resident had not been identified to have pneumonia while she resided at the facility.

Based on record review, and interviews with staff and physician, the facility failed to ensure a Nurse Aide followed a resident's plan of care while transferring the resident. This was for one (Resident # 2) of six sampled residents. The findings included: Record review revealed Resident # 2 was admitted to the facility on [DATE]. The resident's diagnoses in part included Alzheimer's disease, contractures, and failure to thrive. Resident # 2's quarterly Minimum Data Set assessment, dated 7/9/24, coded the resident as severely cognitively impaired and as being totally dependent on staff for transfers. Resident # 2's care plan, dated 7/7/24, directed staff to use two staff members and transfer the resident with a mechanical lift. This had been originally added to the care plan on 4/17/24 and remained part of the resident's active care plan. Resident # 2's weight records included documentation on 8/7/24 that the resident weighed 78 pounds. On 7/18/24 Nurse # 1 noted in a nursing entry that Resident # 2's foot was bluish and swollen. There were no abrasions or outward injuries noted. The physician was notified and an order for x-ray obtained. On 7/19/24 Resident # 2's x-ray of her right ankle was completed. The x-ray report included the notation that Resident # 2's bony structures are osteoporotic. At that time there was no fracture or dislocation identified on the x-ray per the documented report. Nurse # 1 was interviewed on 8/20/24 at 2:10 PM and reported the following information. She had worked with Resident # 1 on 7/18/24 from 7 AM to 7 PM. The resident had not been having problems with her foot in prior days of which she was aware. The assigned Nurse Aide (NA) asked her to look at Resident # 2's foot during the shift. At the time the resident was in bed. The foot appeared reddish and swollen. The physician ordered an x-ray. The resident did not appear to be in any pain. On 8/6/24 at 7:37 PM Nurse # 1 documented the following information. Resident # 2's NA had reported a lump to the resident's right lower extremity. When assessed, the affected area of the leg appeared bluish, swollen, and warm to the touch. The Nurse Practitioner (NP) was notified and ordered an x-ray. After an hour passed, the lump had appeared to increase in size. The NP was again notified and ordered the extremity be elevated. Review of Resident # 2's 8/7/24 x-ray report revealed the resident was identified to have a mildly displaced oblique fracture of the distal diaphysis of the tibia and fibula. (The diaphysis is the long part of a bone. The distal diaphysis of the tibia fibula is the part of the long bone that is closest to the ankle). On 8/8/24 Resident # 2 was ordered to have a splint to the fractured leg for treatment. During the interview with Nurse # 1 on 8/20/24 at 2:10 PM, Nurse # 1 further reported the following information. She had also cared for Resident # 2 on the date of 8/6/24. Earlier on 8/6/24 Resident # 2 had been up in a geri chair. Later in the day, NA # 1 asked her (Nurse # 1) to look at Resident # 2's leg. At that time, Resident # 2 was in bed. There was some swelling in the middle of the resident's right lower leg. NA # 1 did not know how the swelling had happened. When she (Nurse # 1) palpated around the swollen area, the resident did not appear to be in pain. She (Nurse # 1) notified the physician. NA # 1 was interviewed on 8/20/24 at 2:24 PM and reported the following information. She had not noticed anything wrong with Resident # 2 until after she had placed her in bed on the evening of 8/6/24. She (NA # 1) could not find anyone to help her use the mechanical lift to put Resident # 2 back in bed. Resident # 2 was so tiny that she had at other times lifted the resident back in the bed by cradling her in her arms. She also knew other Nurse Aides had lifted her into bed. On the evening of 8/6/24 that was the way she transferred Resident # 2. While doing so, she had put the geri chair right beside the bed and gently lifted her into the bed. None of Resident # 2's extremities hit against anything, and she (NA # 1) did not think lifting her into the bed had anything to do with her leg being broken. She further reported she sincerely cared for Resident # 2 and had taken care of her for a long time. She would never have done anything she thought would have hurt the resident and was always very careful. NA # 1 also further reported the following information. Prior to putting Resident # 2 back to bed, the resident had been sitting in the television room. When NA # 1 had placed Resident # 2 in the television room initially, there were no stacked chairs around her. When she returned later to roll the resident back to her room and place her back to bed, she found several rows of stacked chairs in the television room in the vicinity of the resident. NA # 1 reported that at times Resident # 2 would dangle one of her feet off the side of the geri chair and questioned if the resident's leg could have inadvertently been hit at some time while she was up in the geri chair. Interview with Unit Manager # 1 on 8/20/24 at 3:15 PM revealed NA # 1 should have used a mechanical lift per the resident's plan of care when transferring Resident # 2 to bed on 8/6/24 and there had been staff available that day. Care Plan Nurse # 1 and Care Plan Nurse # 2 were interviewed simultaneously on 8/21/24 at 3:12 PM and reported the following information. The care plan is devised from an interdisciplinary team and the mode of transfer that is placed on a resident's care plan originates from recommendations made by therapy staff. The care plan then generates the Kardex which Nurse Aides reference so they will know specific directions for the resident. The facility's rehabilitation director was interviewed on 8/21/24 at 2:40 PM and reported the following information. By profession she (the rehab director) was a licensed occupational therapist. Due to Resident # 2's small size/weight she (the rehab director) would not say that lifting and cradling a resident could be considered an incorrect transfer. At times firemen do a lift and carry for individuals in that manner and it can be done safely. With Resident # 2 she was in a semi- fetal position which might indicate the lift could be done. In developing care plans for transfers, the therapy staff take into consideration what is easiest and safest for both the staff performing the transfer and for the resident who is being transferred. Resident # 2's physician, who also serves as the facility's medical director, was interviewed on 8/21/24 at 11:10 AM and reported the following information. Resident # 2 was advanced in age and her bones were brittle due to osteoporosis. There was not anyway to know how the fracture actually occurred. Her legs crossed over due to contractures and just in turning she could have sustained a fracture even if staff were providing correct care. According to the physician something could have happened in July 2024 when the resident's foot was swollen. The tibia and fibula connect into the ankle joint where the resident initially had swelling in July 2024. Therefore, it could not be determined that any trauma on 8/6/24 definitively contributed to the fracture. The fracture may have further manifested itself on that date. The resident had not needed any further treatment other than splinting, and it was a mild fracture. The Administrator was interviewed on 8/20/24 at 11:05 AM and again on 8/21/24 at 2:15 PM and reported the following information. They had completed an investigation into the fracture. It had been determined that NA # 1 had not followed the care plan and transferred Resident # 1 with a mechanical lift, but it could not be definitively proven that this caused her fracture. Staff had been trained to follow the care plan generated Kardex for all transfers prior to 8/6/24. The Administrator provided documentation that NA # 1 had been trained to follow the care plan and had ignored her training prior to the incident. According to the Administrator, the administrative staff randomly and unannounced did observations of transfers prior to the incident occurring. It was her policy that any staff who were not transferring residents according to the care plan would no longer be employed by the facility. Following the identification of Resident # 2's fracture, the facility completed a plan of correction. On 8/21/24 the Administrator presented the facility had completed a corrective action plan. The corrective action plan included the following: How corrective action will be accomplished for those residents found to have been affected by the deficient practice; The facility failed to ensure Nursing Assistant #1 followed the care plan related to transfers for resident #2 on 8/6/2024. Resident # 2 skin was assessed 8/6/2024 by charge nurse, MD and RP were notified. The care plan was reviewed on 8/6/2024 and was found to be correct with no changes made to transfers. Staff were educated on 8/6/2024 to ensure they understood resident # 2's transfer needs. How the facility will identify other residents having the potential to be affected by the same deficient practice; Skin assessments for all current residents were completed 8/9/2024 by unit managers. Any residents found to have bruising were investigated and linked to a known origin. Care Plans were reviewed for accuracy of how to transfer a resident including mode of transfer and how many staff members it requires on all current residents 8/12/2024. This was completed by the unit manager with the input of the therapy manager. All residents are at risk for this deficient practice of not following the care plan. The measures that will be put into place or systemic changes made to ensure that the deficient practice will not recur. The Quality Assurance Committee (Regional Director of Clinical Services, Assistant Administrator, Therapy Manager, Director of Nursing and medical director) met on 8/9/2024 to review the findings and initiated a plan. All nursing staff were educated on checking the care plan generated Kardex prior to transfer. This was completed 8/12/2024 by Director of Nursing or designee. All new hires will receive this education in orientation by the staff development coordinator during training. Any employee who has not received the education will not work until completed. How the facility plans to monitor its performance to make sure that solutions are sustained. The unit manager or designee will observe 3 transfers daily Monday-Friday x 4 weeks, 2 transfers 3x a week x 4 weeks, and then 1 transfer weekly x 4 weeks to ensure they are following the care plan. Results will be reported monthly to Quality Assurance committee for review and compliance. Once the Quality Assurance committee determines the problem no longer exists then review will be completed on a random basis. Date of compliance is August 13th 2024 The following was done to validate the facility's corrective action plan. During an initial tour of the facility which began on 8/20/24 at 10:00 AM, residents were interviewed and multiple residents reported no problems with staff following their plan of care. These interviews included interviews with residents who required assistance with transfers. The facility presented documentation to validate they had completed inservice training and audits per their plan of correction. Staff interviews were conducted and validated that staff attended training and were aware they were always to follow a resident's plan of care. On 8/21/24 the facility's plan of correction date of 8/13/24 was validated.

Based on record review, staff and physician interviews, the facility failed to provide care safely to a dependent resident (Resident #216) when the resident sustained a facial fracture when her face hit the bed side rail during care for 1 of 5 residents reviewed for accidents. Findings included: Resident #216 was admitted to the facility on [DATE] with diagnoses which included cerebral infarct and vascular dementia. The quarterly Minimum Data Set, dated dated dated [DATE] indicated that she had severely impaired cognition and was dependent on staff for all activities of daily living (ADL). She was coded to have no behaviors or rejection of care. Resident #216's care plan last revised 3/11/24 had a focus on risk for falls with an intervention for assistance for turning and repositioning in bed. Her care plan also had a focus on ADL care with an intervention for assistance for bathing, hygiene, and dressing. Nursing progress note by Nurse #5 dated 4/08/24 at 11:20 PM revealed Nursing Assistant (NA) #3 called for help when she noted that Resident #216 had blood under and in her mouth. Nurse #5 noted that the resident had a 0.5 centimeter (cm) laceration above her upper lip. Nursing progress note by Nurse #5 dated 4/09/24 at 2:12 AM indicated that Resident #216 had bruising to her chin and side of left check and nose. An interview on 5/01/24 at 6:36 AM with Nurse #5 revealed that on 4/08/24 she was assigned to the hall where Resident #216 resided. She stated that around 11:20 PM on 4/08/24, NA #3 notified her that the resident was bleeding. She assessed the resident and noted a small laceration above her upper lip. She stated that later that night she noted that Resident #216 had developed bruising on her chin and around her left eye. She stated that she notified the Physician of the resident's injury. Nurse #5 stated that Resident #216 was nonverbal and could not turn or reposition herself independently. She also stated that the resident did not have any changes in behavior during the rest of her shift. An interview on 4/30/24 at 9:34 AM with NA #3 revealed that she was assigned to provide care for Resident #216 on 4/08/24. She stated that when she went into the room to provide care, she found the resident with the left side of her face against the left bed side rail around 10:00 PM. She stated that she turned the resident onto her back, and she observed no laceration or blood on the resident's face. NA #3 stated that she started Resident #216's bed bath and when she washed her face, she observed the resident had blood coming from her mouth. She immediately notified the nurse. NA #3 stated she did not know where the blood came from or what caused the laceration. She stated the resident did not use the bed rail or turn herself in bed but sometimes when she coughed it caused her head to move. A Physician's progress note dated 4/09/24 at 9:28 AM revealed that the Physician assessed Resident #216. He noted that she appeared to be in no apparent distress. His physical exam note read in part that the resident had a contusion to the lower eye and left jaw area with no bleeding noted. His plan of care read in part that the resident possibly hit her face on the sidebar rail during treatment and that a facial x-ray would be obtained. A mobile facial x-ray was ordered and completed on 4/09/24. The x-ray impression read there was no acute osseous (bone) or soft tissue abnormality. A nurse's progress note dated 4/10/24 at 4:46 AM revealed that Resident #216 was showing signs of shortness of breath with wheezing and was transported to the hospital. The hospital records for Resident #216's hospitalization were requested during the survey but were not received at the time of exit. The medical record indicated Resident #216 did not return to the facility. A facility investigation report completed by the Administrator on 4/17/24 indicated that on 4/9/24 Resident #216 was identified with bruising to the left side of her face after hitting her face on the side rail during care on 4/08/24. The resident was hospitalized for shortness of breath on 4/10/24 and on 4/11/24 the facility became aware of a right zygomatic arch fracture (facial bone fracture) which was consistent with her face impacting with the bed side rail. Upon initial interview with NA #3 she stated on 4/08/24 Resident #216 coughed and hit the side rail with her face. The investigation resulted in a plan of correction initiated to ensure that bed side rails were only in use after resident assessment of functional capabilities. An interview on 4/30/24 at 3:35 PM with the Physician revealed he had been notified of Resident #216's facial injury and assessed her on 4/09/24. He stated that the resident had light facial swelling and he ordered a facial x-ray. The facial x-ray was completed on 4/09/24 and the results showed no fracture. He stated that Resident #216 was sent to the hospital on 4/10/24 for an unrelated medical condition and the hospital facial x-ray on 4/11/24 revealed a zygomatic arch fracture of unknown age. The Physician stated that he thought there was a low likelihood that the resident turned her head or hit the bed rail by herself. An interview on 5/02/24 at 11:27 AM with the Director of Nursing (DON) and Corporate Nurse Consultant revealed that when Resident #216 was moved from one room to another in the past year, her new bed had side rails. She stated that the bed rails weren't removed from the new bed and they should have been. An interview on 5/01/24 at 8:32 AM with the Administrator revealed that Resident #216 was not supposed to have bed side rails and she felt this was what caused the resident's accident. She stated that last year, the resident's room and bed had changed. She stated there was a process breakdown and the resident had not been assessed for bed rails.

Based on observations, record review, staff and Physician interviews, the facility failed to ensure a bedrail device assessment was completed prior to the use of bedrails for 2 of 3 residents (Resident #216 and Resident #66) and failed to ensure bedrails were maintained securely for 1 of 3 residents (Resident #66) reviewed for bedrail use. Resident #216 sustained a facial fracture when her face hit the bedrail during care. Findings included: 1a. Resident #216 was admitted to the facility on [DATE] with diagnoses which included cerebral infarct and vascular dementia. The discharge Minimum Data Set, dated dated dated [DATE] indicated that she had severely impaired cognition and was dependent on staff for all activities of daily living. A facility investigation report was completed by the Administrator on 4/17/24 indicated that on 4/9/24 Resident #216 was identified with bruising to the left side of her face after hitting her face on the bedrail during care on 4/08/24. The resident was hospitalized for shortness of breath on 4/10/24 and on 4/11/24 the facility became aware of a right zygomatic arch fracture (facial bone fracture) which was consistent with her face impacting with the bedrail. Upon initial interview with NA #3 she stated on 4/08/24 Resident #216 coughed and hit the bedrail with her face. The investigation resulted in a plan of correction initiated to ensure that bed side rails were only in use after resident assessment of functional capabilities. Review of Resident #216's device assessment dated [DATE] revealed no bedrail device assessment was completed. An interview on 4/30/24 at 3:35 PM with the Physician revealed he had been notified of Resident #216's facial injury and assessed her on 4/09/24. He stated that the resident had light facial swelling and he ordered a facial x-ray. The mobile facial x-ray was completed on 4/09/24 and the results showed no fracture. He stated that Resident #216 was sent to the hospital on 4/10/24 for an unrelated medical condition and the hospital facial x-ray on 4/11/24 revealed a zygomatic arch fracture of unknown age. The Physician stated that he thought it a low likelihood that the resident turned her head or hit the bedrail by herself. A Physician's progress note dated 4/09/24 at 9:28 AM revealed that the Physician assessed Resident #216. He noted that she appeared to be in no apparent distress. His physical exam note read in part that the resident had a contusion to the lower eye and left jaw area with no bleeding noted. His plan of care read in part that the patient possible hit her face on the sidebar rail during treatment and that a facial xray would be obtained. A mobile facial xray was ordered and completed on 4/09/24. The xray impression read there was no acute osseous (bone) or soft tissue abnormality. An interview on 4/30/24 at 9:34 AM with Nursing Assistant (NA) #3 revealed that she was assigned to provide care for Resident #216 on 4/08/24. She stated that when she went into the room to provide care, she found the resident with her face against the left bedrail around 10:00 PM. She stated that when she turned the resident onto her back she observed no laceration or blood on the resident's face. NA #3 stated that she started Resident #216's bed bath and when she washed her face, she observed the resident had blood coming from her mouth. She immediately notified the nurse. NA #3 stated she did not know where the blood came from or what caused the laceration. She stated the resident did not use the bed rail or turn herself in bed but sometimes when she coughed it caused her head to move. Nursing progress note by Nurse #5 dated 4/08/24 at 11:20 PM revealed Nursing Assistant (NA) #3 called for help when she noted that Resident #216 had blood under and in her mouth. Nurse #5 noted that the resident had a 0.5-centimeter (cm) laceration above her upper lip. Nursing progress note by Nurse #5 dated 4/09/24 at 2:12 AM indicated that Resident #216 had bruising to her chin and side of left check and nose. An interview on 5/01/24 at 6:36 AM with Nurse #5 revealed that on 4/08/24 she was assigned to the hall where Resident #216 resided. She stated that around 11:20 PM on 4/08/24, NA #3 notified her that the resident was bleeding. She assessed the resident and noted a small laceration above her upper lip. She stated that later that night she noted that Resident #216 had developed bruising on her chin and around her left eye. She stated that she notified the Physician of the resident's injury. Nurse #5 stated that Resident #216 was nonverbal and could not turn or reposition herself independently. She also stated that the resident did not have any changes in behavior during the rest of her shift. A nurse's progress note dated 4/10/24 at 4:46 AM revealed that Resident #216 showed signs of shortness of breath with wheezing and was transported to the hospital. An interview on 5/01/24 at 8:05 AM with the Maintenance Director revealed that he did not participate in the nursing bedrail assessment process. He stated that he installed or removed bedrails for resident beds based on work orders initiated by staff. An interview on 5/02/24 at 11:27 AM with the Director of Nursing (DON) and Corporate Nurse Consultant revealed that when Resident #216 was moved from one room to another in the past year, her new bed had side rails. She stated that Resident #216 had not been assessed for the use of bedrails and there should not have been bedrails on her bed. An interview on 5/01/24 at 8:32 AM with the Administrator revealed that Resident #216 was not assessed to have bedrails and was not supposed to have bedrails. She stated she felt this was what caused the resident's accident. She stated that last year, the resident's room and bed had changed. She stated there was a process breakdown and the resident had not been assessed for bedrails. 41009 2. Resident #66 was admitted to the facility on [DATE] with a diagnosis of muscle weakness. A review of Resident #66's admission Minimum Data Set (MDS) assessment dated [DATE] revealed in part he was cognitively intact. He was independent with rolling from left to right and from sitting on the side of the bed to lying flat in bed. He required supervision to move from lying to sitting on the side of the bed. He required partial assistance to move from sitting to standing. He was 71 inches tall and weighed 368 pounds. A review of a Bed Side Rail Tool for Resident #66 dated 4/24/24 completed by Nurse #1 revealed in part Resident #66 needed siderails to assist with mobility and positioning. Siderails were his preference. The risk versus the benefits of siderails were discussed with Resident #66 and his consent was obtained. He used 1/8 partial siderails bilaterally. These did not restrict his movement. A review of Resident #66's care plan revealed in part a focus area initiated on 4/29/24 for bilateral side rails. The goal was for Resident #66 to use side rails to assist with turning and repositioning in bed with no incidents through the next review. An intervention was to inform the nurse immediately of any safety concerns while using side rails. On 4/29/24 at 2:49 PM an interview with Resident #66 indicated he had 1/8 siderails on both sides of his bed since his admission to the facility on [DATE]. He stated these were already on his bed when he came. He went on to say he had problems with the left siderail from the start, as it was loose and swung outward from the bed when he tried to use it. He further indicated the siderail on the right was secure and didn't do this. Resident #66 stated he had been bracing the left siderail with his dresser, so it would be secure and not move when he used it. He went on to say this worked okay, but he knew this wasn't how it was supposed to be. He further indicated he had told an administrative nurse when she came to talk with him and had also told another staff member, but he couldn't recall their names. He stated the Maintenance Director had been in his room recently to repair his bed control, but he had not fixed the side rail. Resident #66 stated no one really came to check the side rails on a regular basis. An observation of Resident #66's 1/8 siderails at the time of the interview revealed the left side rail was attached to the bed with a post at the head of Resident #66's bed that fit onto a hole near the bedframe. The side rail swung freely outward until it was at a 90-degree angle to the bed. There was observed to be a latch pin near the foot side on the rail. One black plastic latch secured near the head of the bed at the bedframe that allowed the side rail to be locked into place with the latch pin when the rail was oriented towards the head of the bed. There was no black plastic latch secured near the foot of the bed on this siderail to allow the rail to be latched into place when oriented towards the foot of the bed. This prevented the side rail on the left from being latched securely in place when oriented towards the foot of the bed in the position that allowed Resident #66 to use the side rail as an assist. The right side rail was observed to be securely latched with the pin into the black plastic latch near the foot of the bed. The right side rail was also observed to have a black plastic latch secured near the head of the bed at the bedframe. On 4/30/24 at 2:10 PM an interview with Nurse #1 indicated she had spoken with Resident #66 around 4/6/24 in his room. She stated Resident #66 had his 1/8 side rails in place at the time. She went on to say Resident #66 had not mentioned any concerns with his side rails to her then, and she herself checked them and they were secure. Nurse #1 stated she completed the Bed Rail Assessment Tool for Resident #66 on 4/24/24, because she was doing an audit to ensure all residents on her unit who had side rails had the correct assessments for them, found Resident #66 did not have one, and completed one. She went on to say normally residents would not have side rails when they were admitted , but at the first assessment meeting at 24 to 48 hours with the resident and/or family, if these were requested or indicated, an assessment would first be done and then maintenance would apply them to the bed. She further indicated Resident #66 should not have had siderails without this assessment in place first. On 5/1/24 at 10:04 AM an interview with Resident #66 indicated he was surprised that the Maintenance Director came in last evening and fixed his left side rail, so it was secure like his right. He stated the Maintenance Director put some nuts and screws in, but it was still the same and not secure. An observation of Resident #66's left side rail at the time of the interview indicated the left side rail to be the same as the observation on 4/29/24, however there was a broken black plastic latch on the floor under the bed. On 5/1/24 at 10:16 AM an observation of Resident #66's left side rail was conducted with the Maintenance Director. A broken black plastic latch was observed on Resident #66's floor under the bed on the left side. The Maintenance Director stated last evening he was passing by Resident #66's room and Resident #66 called him over to ask him to look at his side rail. He went on to say he noticed a black plastic latch was missing, and so he attached one. He further indicated this latch allowed Resident #66's side rail to be secured in a position that allowed Resident #66 to use the side rail as an assist device. He stated he asked Resident #66 if he knew where the black plastic latch had gone, but Resident #66 told him he did not. The Maintenance Director stated there had already been one black plastic latch near the head of the bed, but if the side rail latch pin was secured in this position, it would be too high for Resident #66 to use it. He went on to say the replacement latch he installed last evening had broken. He further indicated he felt Resident #66 must have put too much weight on it. The Maintenance Director stated he had never seen these break before. He went on to say the process for iinitially nstalling side rails was a Nurse would put through a work order for their installation, he would ensure the correct assessments had been done, apply the rails and then check to make sure they were safe and secure. He stated he checked all bed rails in the facility weekly to ensure they were functioning correctly. He went on to say he did not keep a log of the weekly checks but had last checked Resident #66's side rails last week Thursday (4/25/24) and found them to be secure. He further indicated he was not able to find the work order for the initial placement of Resident #66's side rails. The Maintenance Director stated he would not install side rails if there wasn't an assessment in place first. He went on to say he had been trained on the installation of side rails when he started at the facility in August 2023. He further indicated he had extra parts available for the rails in the Maintenance Department. He stated he would have to apply another latch to Resident #66's left side rail. On 5/3/24 at 8:32 AM a follow-up interview with the Maintenance Director indicated he recalled fixing Resident #66's bed a while back, but he did not recall exactly when. He stated Resident #66 did not say anything to him about his side rail at that time. On 5/3/24 at 8:39 AM a review of the work order log provided by the Administrator for Resident #66's room revealed in part on 3/11/24 and on 3/28/24 his electric bed was serviced by the Maintenance Director. There was no record on this log of the initial placement of Resident #66's side rails, or any subsequent service to them. An interview with the Administrator indicated this was a complete listing of all the work orders for Resident #66 since his admission to the facility. A review of the Manufacturer's User Service Manual for Resident #66's bed provided by the Administrator revealed in part the weight capacity for Resident #66's bed was 500 pounds. The Manufacturer's User Service Manual Operation Instructions for Resident #66's side rails revealed in part they were compatible with his bed. The instructions further revealed there was no weight capacity provided in the manual for the side rails. This side rail instruction manual indicated 2 black plastic latches, one near the head of the bed and one near the foot, were to be used to allow the latch pin to lock the side rail, which could rotate 90 degrees either towards the head or the foot of the bed, into place. It further instructed to verify that the side rail was locked prior to leaving any resident unattended. On 5/3/24 at 8:50 AM an interview with Nurse Aide (NA) #6 indicated she regularly cared for Resident #66 since his admission to the facility. She stated he usually had his dresser placed up against the left side rail. She went on to say he never mentioned to her there was any concern about the left side rail not being secure and she had never noticed any concerns. On 5/3/24 at 10:11 AM a telephone interview with Housekeeper #1 indicated she was the regular Housekeeper for Resident #66's unit. She stated more than 2 weeks ago Resident #66 mentioned to her that his side rail was loose, and she noticed there was no black piece holding it in place. She went on to say she asked her supervisor and was told maintenance handled this. She further indicated she let Resident #66's aide that day know about his side rail. Housekeeper #1stated she did not recall which aide, and she did not follow-up to see if Resident #66's side rail got fixed. On 5/3/24 at 9:21 AM an interview with the Administrator indicated Resident #66's side rails were compatible for his bed. She stated there was nothing in the manufacturer's instructions that indicated the side rails had a weight limit, and his bed weight limit was 500 pounds. She went on to say she didn't think Resident #66's side rail should have to be repaired twice in one week, and she would have to contact the manufacturer to get more information about why it failed.

Based on observations, record review, and interviews with the physician and staff, the facility's Quality Assessment and Assurance (QAA) committee failed to maintain implemented procedures and monitor interventions that the committee put into place in order to sustain compliance. This included a recited deficiency in the area of Supervision to Prevent Accidents (F689) as evidenced by repeat citations resulting in harm or immediate jeopardy for a high likelihood of harm to residents. During the 6/11/21 recertification and complaint investigation survey, deficient practice at F689 was identified as immediate jeopardy for a high likelihood of harm when a resident was found smoking in their room with oxygen in use on three occasions. During the 11/10/21 complaint investigation survey, deficient practice at F689 was cited for failing to prevent a resident from rolling off the bed during care resulting in right frontal hematoma (a pool of mostly clotted blood that forms in an organ, tissue, or body space), laceration, and right periorbital (around the eyes) swelling. During the 3/25/24 complaint investigation survey, deficient practice at F689 was cited for failing to provide a safe transfer resulting in a leg fracture. On the current recertification and complaint investigation survey of 5/3/24, deficient practice at F689 resulted in the resident sustaining a facial fracture. In addition to the repeat deficiency at F689, the facility had 2 other repeat deficiencies in the areas of Activities of Daily Living Care Provided for Dependent Residents (F677) and Posted Nurse Staffing Information (F732) that were originally cited on the 6/11/21 recertification and complaint investigation survey. The continued failure of the facility during 4 federal surveys of record showed a pattern of the facility's inability to sustain an effective Quality Assurance Program. Findings included: This tag is cross referenced to: F677: Based on observations, staff interviews, and record review the facility failed to ensure peri-care was postponed until the last phase of bathing for 1 of 6 residents reviewed for activities of daily living care. (Resident #49) During the recertification and complaint investigation survey on 6/11/21 the facility failed to shave 2 of 2 dependent male residents. F689: Based on record review, staff and physician interviews, the facility failed to provide care safely to a dependent resident (Resident #216) when the resident sustained a facial fracture when her face hit the bed side rail during care for 1 of 5 residents reviewed for accidents. During the recertification and complaint investigation survey on 6/11/21 the facility was cited for failing to supervise and monitor a resident who was not compliant with the smoking policy and was found smoking in room with oxygen via nasal cannula on three occasions. There was also no system or interventions in place to prevent recurrent noncompliance with the smoking policy by residents. During the complaint investigation survey on 11/10/21 the facility was cited for failing to prevent a resident from rolling off the bed during care which resulted in a right frontal hematoma and laceration, and right periorbital swelling from a fall and hospitalization . During the complaint investigation survey on 3/25/24 facility was citing for failing to ensure transfer a resident safely when the resident sustained a fractured leg when two nursing staff members used a sliding board to transfer for the resident after therapy had determined she did not have the functional ability to use the sliding board safely. F732: Based on staff interviews and record review the facility failed to post accurate Registered Nurse (RN) staffing each shift for 2 of 30 days of posting reviewed. During the recertification and complaint investigation survey on 6/11/21 the facility failed to post the resident census on the daily nursing staffing sheets for 1 of 4 days of the recertification survey. An interview with the Administrator on 5/02/24 at 11:01 AM revealed the facility met monthly and made a good faith attempt to identify areas of concern. She stated the committee members included herself, the Director of Nursing, the Medical Director, the Infection Preventionist as well as other staff members. She also revealed the facility had contacted an independent company to help the facility determine the root causes of their repeat accidents. She stated they had determined the cause to be the lack of Nursing Assistant competency due to the lack of hands-on training during the Covid pandemic. She stated they had increased their training and monitoring program for new hires.

Based on observations, record review, and resident, staff and physician interviews the facility failed to ensure the urine collection bag remained below the level of the resident's bladder by removing a urinary leg bag and applying a urinary drainage bag while the resident remained in bed (Resident #267) and failed to ensure a urinary drainage bag did not come into contact with the floor (Resident #98) for 2 of 3 residents reviewed for indwelling urinary catheters. Findings included: 1. Resident #267 was admitted to the facility on [DATE] with a diagnosis of overactive bladder. A review of a physician's medical note for Resident #267 dated 4/26/24 at 10:21 AM revealed in part Resident #267 was having urinary retention. An indwelling urinary catheter was present. This would have to remain in place for at least 7 to 10 days and then a voiding (urination) trial would occur. A review of Resident #267's admission Minimum Data Set (MDS) assessment dated [DATE] revealed in part she was cognitively intact. She had an indwelling bladder catheter. On 4/30/24 at 7:52 AM an observation of Resident #267 revealed she was lying on her back in bed with the head of her bed elevated at approximately 30 degrees. She had an indwelling urinary catheter attached to a leg bag secured to her left thigh. An interview with Resident #267 at that time indicated her indwelling urinary catheter had been attached to a leg bag for a few days including while she slept at night. She stated she had been told they were out of the hanging drainage bags. On 4/30/24 at 4:00 PM a follow-up observation of Resident #267 revealed she was lying on her back in bed with the head of her bed elevated at approximately 30 degrees. Her indwelling urinary catheter remained attached to a leg bag secured to her left thigh. This leg bag was observed to be approximately half full of clear yellow urine. An interview with Resident #267 at that time indicated she slept with her indwelling urinary catheter attached to her leg bag last night. She stated she had to call for assistance in the middle of the night to have this bag emptied as it was so full she was afraid it would pop. On 4/30/24 at 8:30 PM Resident #267 was observed lying in her bed on her back with the head of her bed at approximately 30 degrees. Her indwelling urinary catheter was observed to be connected to a drainage bag with a privacy cover that was hanging from the bedframe below the level of her bladder. On 4/30/24 at 4:06 PM an interview with Nurse #4 indicated Resident #267 had her indwelling urinary catheter attached to a leg back since she saw her at 7:00 AM that morning. She stated she did not know whether Resident #267 had her urinary catheter attached to a leg bag all night, because she wasn't at the facility. On 4/30/24 at 4:16 PM an interview with the Director of Nursing (DON) indicated for residents who had indwelling urinary catheters, a leg bag was something they would wear during the day to collect their urine while they were up and about. She stated when residents were lying in bed through the night while they slept, this should be changed over to a drainage bag. She stated there were plenty of drainage bags available. On 5/3/24 at 9:17 AM a follow up interview with the DON indicated she had not become aware of the difficulty locating a drainage beg for Resident #267 until 4/30/24 at 4:16 PM. She stated she did not think Resident #267 sleeping in a leg bag would be a good thing because this could cause back flow of urine into the bladder and place Resident #267 at increased risk for a urinary tract infection. On 5/1/24 at 2:58 PM a telephone interview with Nurse #6 indicated she cared for Resident #267 on 4/27/24 from 7PM until 7AM on 4/28/24, and on 4/28/24 from 7PM until 7AM on 4/29/24. She stated on 4/27/24 Resident #267's indwelling urinary catheter was connected to a drainage bag that was hanging below the level of her bladder on the bedframe. She went on to say at some point during the evening, the drainage bag began leaking. She further indicated she had gone to look for another drainage bag but had been unable to find one. Nurse #6 stated she let the Assistant Director of Nursing (ADON) know. She went on to say the ADON told her she also looked but had not been able to find a drainage bag either and the ADON gave her a leg bag to place on Resident #267. She further indicated Resident #267 had her indwelling urinary catheter connected to a leg bag the remainder of her shift on 4/27/24 and 4/28/24 and her entire shift on 4/28/24 through 4/29/24. Nurse #6 stated this had happened once before back in June 2024 although she couldn't recall the name of the resident. She went on to say that time they got more drainage bags in a day or so. On 5/1/24 at 8:31 AM a telephone interview with Nurse #5 indicated she cared for Resident #267 from 4/29/24 at 11PM until 4/30/24 at 7:00 AM. She stated Resident #267 had her indwelling urinary catheter attached to a leg bag all night while she slept in bed. Nurse #5 went on to say she had gone to the supply room to try to find a drainage bag to change Resident #267 from her leg bag that shift but had not been able to find one. She further indicated she had not let anyone know she had been unable to find a urinary drainage bag for Resident #267. On 5/2/24 at 8:17 AM an interview with the ADON indicated she wasn't really familiar with Resident #267. She stated usually residents who were mobile and got up during the day preferred the leg bag for their indwelling urinary catheter as it let them be up and around. She went on to say with a leg bag, when residents were lying down there wasn't much gravity and the collection bag was smaller. She further indicated it was better for residents to wear a drainage bag at night for infection control purposes to prevent the backflow of urine into the bladder. The ADON stated the backflow of urine into the bladder put residents at risk for urinary tract infection and damage to the nerves in the bladder. She went on to say she did recall last Saturday night (4/27/24) a nurse asked her to help find a drainage bag. She further indicated she checked the medication rooms and central supply as these were where the bags would normally be kept found and couldn't find one. The ADON stated she had given the nurse a leg bag instead. She went on to say on Monday (4/29/24) she attempted to determine the reason she could not locate any drainage bags. She further indicated she found out there was a resident who had been requesting their drainage bag be changed daily so more bags were being used than normal. The ADON stated the Central Supply Clerk had since contacted her supplier and an additional shipment of drainage bags was requested. She went on to say she was not aware of this ever happening before. On 5/2/24 at 1:44 PM an interview with the Central Supply Clerk indicated on 4/30/24 she heard about an issue with catheter drainage bags. She stated she went looking and was able to locate one in a medication room under a cabinet. She went on to say this was the only drainage bag she was able to find in the facility. She further indicated this issue with a low supply happened because there was a resident who was requesting their drainage bag be changed daily, so more were being used than had been allotted for. The Central Supply Clerk stated her supplier had a list of all the catheters in the building and allotted the drainage bag supply based on this number, which was updated weekly. She went on to say now she had requested an extra shipment of drainage bags in addition to the usual shipment. She further indicated when a drainage bag was taken from Central Supply, it was supposed to be signed out on the inventory log by the person taking it. The Central Supply Manager stated this kept track of the inventory on hand. She went on to say she monitored this log periodically, although she could not say when she last checked it. She further indicated when she looked at the log after becoming aware of this issue only 2 had been signed out of the facility's usual allotment of 12 per month. The Central Supply Clerk stated she was not aware of this ever being an issue before. On 5/2/24 at 10:09 AM a telephone interview with Resident #267's Physician indicated while Resident #267 wearing a leg bag from 4/27/24 until 4/30/24 including while she slept laying in bed through the night would not be an ideal situation, Resident #267 had not had any negative effects from this. He stated Resident #267 did not currently have a urinary tract infection. On 5/3/24 at 11:21 AM an interview with the Administrator indicated Resident #267 had a leg bag on all throughout the day and at night while she slept, and she shouldn't have. She stated while a drainage bag had eventually been found in the facility for Resident #267, these should be readily available for residents. 48295 Resident #98 was admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included obstructive and reflux uropathy (a condition in which the flow of urine is blocked and can cause urine to back up and injure one or both kidneys). Review of the care plan dated 4/10/24 indicated the resident required a urinary catheter related to obstructive uropathy with a goal that Resident #98 would be free of complications related to urinary catheter use through the next review period. Review of nurse progress notes on 4/23/24 written by Nurse #7 indicated Resident #98 continued on an antibiotic for a UTI. A review of Resident #98's significant change Minimum Data Set (MDS) dated [DATE] revealed Resident #98 was cognitively impaired. He required substantial maximum assistance for toileting, bathing, and transfers. The resident was dependent on staff for Activities of Daily Living (ADLs). The MDS assessment indicated Resident #98 had an indwelling urinary catheter. Review of the facility policy entitled Urinary/Catheter Care item #3 under Procedure read in part that licensed nurses would follow manufacturer's guidelines when preparing and maintaining indwelling urinary catheters. Review of the manufacturer's guidelines directions for use for the urinary drainage bag used for Resident #98 read in part Hang bag utilizing the hanger. Do not place on the floor. Multiple observations were conducted of Resident #98's urinary catheter drainage bag either touching or partially lying on the floor of the resident's room. The urinary catheter bag had a built in non-removable privacy cover. These observations were as follows: --On 4/29/24 at 10:23 AM, an observation was made of Resident #98 as he was lying in bed. The bottom of his urinary catheter drainage bag was observed to touch the floor. The urinary catheter drainage tubing was observed come out of the bottom of Resident #98's pant leg and the drainage bag hanger was not attached to anything. --On 4/29/24 at 2:15 PM, the resident's urinary catheter drainage bag was observed to touch the floor and the bag hanger was not attached to anything. --On 5/2/24 at 9:31 AM, the resident's urinary catheter drainage bag was observed to be partially in contact with the floor of the resident's room as he was lying in bed. Approximately four inches of the bottom of the urinary catheter drainage bag was observed to be lying on the floor. In an interview with the Infection Preventionist (IP) Nurse on 04/29/24 2:17 PM, she stated that orders for indwelling urinary catheters are placed on the MAR for nurses to check the catheter every shift and when they checked it they would ensure the catheter tubing was secured with a catheter anchor (to prevent movement from causing the tubing to tug on the urinary meatus (urethral opening to the outside of the body). She further indicated that the urinary collection bag should be checked to ensure it is not on the floor because this could increase the risk of a UTI. The IP nurse further indicated that nursing staff were educated to ensure a urinary catheter collection bag was not on the floor and the bag should be hung on a section of the bed frame to ensure it did not touch the floor, but that it was difficult with Resident #98 because he was in a low bed. During an observation of Resident #98's urinary catheter drainage bag on 4/29/24 at 2:24 AM an interview with the IP nurse was conducted simultaneously. At this time, the bed was noted to be in a higher position than previously observed on 4/29/24 at 2:17 PM and the urinary catheter drainage bag no longer touched the floor however, the urinary catheter drainage bag hanger was not attached to anything and dangled from Resident #98's pant leg. During the observation, the IP nurse assessed the tubing and urinary catheter drainage bag and discovered that the urinary catheter drainage tubing's anchor had come loose. She attached the urinary catheter drainage bag to the bed frame, retrieved supplies and replaced the urinary catheter anchor on Resident #98's upper thigh. The interview further revealed that Resident #98's bed was in a low position to prevent injury because he was a high fall risk and he tried to get out of bed unassisted. She stated that his urinary catheter drainage bag touched the floor earlier because of the low position of the bed. She stated that to keep the bag off the floor staff would attach the bag to a mattress bracket used to prevent the mattress from sliding and that this kept the bag off the floor and kept the bag below the level of the bladder so it would drain properly. The interview further indicated that Resident #98 recently completed a course of antibiotics for a UTI. Review of the April 2024 Medication Administration Record (MAR) revealed that Resident #98 was prescribed and received an antibiotic twice a day for 10 days from 4/20/24 through 4/29/24 for a UTI as evidenced by nurse's initials being placed in each box on the MAR for every day that the medication was administered. During an observation of indwelling urinary catheter care for Resident #98 on 4/30/24 at 12:45 PM by Nurse #8 and Nurse #9 it was observed that incontinence care was provided prior to urinary catheter care being provided. After care was completed the urinary catheter anchor was changed and the urinary catheter drainage bag was positioned off the floor by attaching the hanger to the mattress bracket on the bed. The bed was placed in a low position. In an interview with Nurse #8 on 04/30/24 at 2:46 PM it was revealed that the catheter urinary drainage bag should not touch the floor. She stated that Resident #98 was in a low bed, and she had not seen an issue where the bag touched the floor. She further indicated that staff were trained on how to perform catheter care monthly by the facility and were taught that the urinary catheter drainage bag should not touch the floor. Nurse #8 stated that if the urinary catheter drainage bag touched the floor that it put the resident at risk for a urinary tract infection. During an interview with NA #1 on 05/01/24 at 8:52 AM it was revealed that NA's complete urinary catheter care and that included keeping the urinary catheter drainage bag off the floor. She indicated that urinary catheter care was done with ADL care each day and as needed. Care included hanging the urinary catheter drainage bag on the metal frame part of the bed so that it did not touch the floor and if it touched the floor that created a risk for infection for the resident. She further indicated she had received training for urinary catheter care and infection control. In an interview with Nurse #7 on 05/01/24 at 3:55 PM she stated that she had never seen the urinary catheter drainage bag touch the floor and she always noted it to be attached to the WC when Resident #98 was out of bed or attached to a metal bar on the bed frame when he was in bed. She indicated that there was a concern for infection for the resident if the drainage bag touched the floor. In an interview with the DON on 05/02/24 at 8:29 AM she stated that the urinary catheter drainage bag should not be in contact with the floor at any time. She indicated it was difficult to keep the urinary catheter drainage bag off the floor for Resident #98 because he was in a low bed. She further stated that the bag should be hung so that it did not touch the floor. She stated if the bag touched the floor the bag could become contaminated and increased the risk of infection for the resident. The interview further indicated that Resident #98 would pull on his catheter and could readjust the position of the catheter himself. She further stated that the IP nurse did the training with nursing staff on infection control related to indwelling urinary catheters. During an observation of Resident #98's urinary catheter drainage bag on 5/2/24 at 9:31 AM an interview with the IP nurse was conducted simultaneously. The urinary catheter drainage bag was noted to be attached to the bed frame and in contact with the floor. The IP nurse stated that the drainage bag should not be in contact with the floor and the drainage bag had not been attached to the correct part of the bed frame. She removed and re-attached the bag to a higher part of the bed frame but the bag remained in contact with the floor. She then raised the bed a few inches until the bag no longer rested on the floor and stated that they could not leave the bed at that height because Resident #98 was at risk for falls and required a low bed. She stated she would speak with other team members to see if they could find a solution. In an interview with the facility Administrator on 05/2/24 at 12:37 PM she stated she was not previously aware of the urinary catheter drainage bag for Resident #98 being on floor, but she has since been made aware. She stated the urinary drainage bag should not have been on the floor. She further indicated that Resident #98's bed was maintained in a low position for his safety and that put the catheter at risk of touching the floor. During an interview with Nurse Practitioner #1 on 05/02/24 at 12:51 PM he stated his concern with catheter drainage bags being in contact with the floor was the urinary catheter drainage bag could become contaminated, and infection was a concern. He further stated that it may or may not contribute to recurrent UTI's because the urinary catheter bag itself was a barrier to prevent infection from anything it comes in contact with. In an interview with NA #2 on 5/3/24 at 10:40 AM revealed that she had worked for the facility for 4 years and cared for Resident #98 on a routine basis. She further indicated she placed the catheter tubing through his pant leg to keep it in place so he could not manipulate the tubing and pull it loose. She further indicated that he would often manipulate his tubing, so she ensured that he had a urinary catheter tubing anchor in place as well. She stated that she kept the bag off the floor and hung it on the bed frame because if it touched the floor, it could become contaminated and lead to an infection for Resident #98.

Based on staff and physician interviews and record review the facility failed to administer prednisone per the resident's hospital discharge summary for 23 days for 1 of 1 resident reviewed for medication reconciliation. (Resident #166) Findings included: Review of Resident #166's discharge medication list from the hospital dated 6/9/23 revealed he was ordered to continue taking prednisone 5 milligrams by mouth once daily. Resident #166 was admitted to the facility on [DATE]. His active diagnoses included encounter for orthopedic aftercare following surgical amputation, peripheral vascular disease or peripheral arterial disease, asthma (COPD) or chronic lung disease, pulmonary fibrosis, and interstitial pulmonary disease. Review of Resident #166's minimum data set assessment dated [DATE] revealed he was assessed as cognitively intact. Review of Resident #166's medication orders during his stay in the facility revealed he was not ordered prednisone 5 milligrams daily until 7/2/23. Review of a nursing note dated 7/3/23 revealed on 7/2/23 Resident #166's family member called and asked if Resident #166 had been taking prednisone and asked to restart this medication. The resident was made aware, and the physician was notified and gave an order to start Resident #166 on prednisone 5 milligrams daily. The family member was called back and notified of the changes. Review of a nursing note dated 7/4/23 revealed the pulmonary physician for Resident #166 updated the order for prednisone to be 10 mg give 3 tablets by mouth one time a day for 28 days then give 2 tablets by mouth one time a day for 14 days then give 1.5 tablets by mouth one time a day. During an interview on 4/30/24 at 3:47 PM the Physician stated Resident #166 was diagnosed with cryptogenic pneumonia, and he was on steroids in the hospital to treat this. The Physician further stated Resident #166 should have been on prednisone since his admission on 6/9/23 as it was on the discharge summary from the hospital as well as the after-visit sheet provided to the facility from the hospital upon admission. He did not know why the admitting nurse missed this. He stated at some point during the resident's stay the family questioned if prednisone was being given to the resident and at that point, the nurse called him, and he restarted the medication. The Physician stated, in his opinion, the missed prednisone doses did not cause any harm or deterioration to Resident #166. During an interview on 4/30/24 at 4:22 PM with the Director of Nursing she did not recall being made aware of Resident #166 not having his prednisone 5 milligrams per day carried over from his hospital medication list. She stated did not know what medication list was provided from the hospital and was used for medication reconciliation upon admission. She stated the admitting nurse reconciled the medication orders upon admission from the hospital. She concluded prednisone 5 milligrams once a day was documented by the hospital to be continued in the facility on his discharge summary and should have been continued at the facility, but it was missed until the family brought it to their attention in July 2023. Nurse #11 who admitted Resident #166 was unavailable for interview.

Based on record review and Physician, resident, and staff interviews the facility failed to document the Pneumococcal and Influenza vaccines were offered and declined, and the reason. The facility further failed to document that the resident or the resident's representative was provided education regarding the benefits and potential side effects of the vaccine for resident for 5 of 5 residents reviewed (Resident #14, Resident #55, Resident #59, Resident #92, and Resident #96). Findings included: a. Resident #14 was admitted to the facility on [DATE]. She was [AGE] years old. Her active diagnoses included hypertension (high blood pressure) and Parkinson's Disease. Resident #14's quarterly minimum data set assessment (MDS) dated [DATE] revealed she was assessed as not cognitively intact. The immunization record of Resident #14 revealed that the 2023 influenza vaccine was refused, and the pneumococcal 23 vaccine was marked as refused but there was no documented proof of the refusals, reasons refused, or that education was provided regarding the benefits or potential side effects of the vaccines. Review of vaccine consent forms for Resident #14 revealed that she had no pneumococcal or influenza vaccine consent forms on file. Resident #14 was not interviewable and her responsible representative was unable to be reached by phone. b. Resident #55 was admitted to the facility on [DATE]. He was [AGE] years old. His active diagnoses included Diabetes Mellitus, pressure ulcers, and heart failure. Resident #55's admission minimum data set assessment (MDS) dated [DATE] revealed he was assessed as cognitively intact. The immunization record of Resident #55 revealed that he refused the 2023 influenza and the pneumococcal Prevnar 13 vaccine. The vaccines were marked as refused but there was no documented proof of the refusals, reasons refused, or that education was provided regarding the benefits or potential side effects of the vaccines. Review of vaccine consent forms for Resident #55 revealed that he had no influenza or pneumococcal vaccine consent forms on file. Interview with Resident #55 on 5/5/24 at 9:33 am revealed that he was never offered a pneumonia or influenza vaccine and he recalled that he received the influenza vaccine at a local pharmacy before he was admitted to the facility, he was unsure of the date but recalled it was recent. He further stated that he received the pneumococcal vaccine last year and it was good for 5 years. He stated that he takes all recommended vaccines, and he would have remembered if they had offered it to him. c. Resident #59 was admitted to the facility on [DATE]. She was [AGE] years old. Her active diagnoses included cancer of the thorax (the portion of the body between the neck and abdomen) and hypertension (high blood pressure). Resident #59's quarterly minimum data set assessment (MDS) dated [DATE] revealed she was assessed as not cognitively intact. The immunization record of Resident #59 revealed that the pneumovax vaccine was refused but there was no documented proof of the refusal or reason refused and no documented proof that education was provided regarding the benefits or potential side effects of the vaccine. Review of the vaccine consent forms for Resident #59 revealed that she had no pneumococcal vaccine consent form on file. Resident #59 was not interviewable and her responsible representative was unable to be reached by phone. d. Resident #92 was admitted to the facility on [DATE]. She was [AGE] years old. Her active diagnoses included Chronic Kidney Disease, Hypertension (high blood pressure), and Diabetes Mellitus. Resident #92's quarterly minimum data set assessment (MDS) dated [DATE] revealed she was assessed as cognitively intact. The immunization record of Resident #92 revealed that she had not received a pneumococcal vaccine and there was no documented proof of a refusal or reason refused and no documented proof that education was provided regarding the benefits or potential side effects of the vaccine. Review of vaccine consent forms for Resident #92 revealed that she had no pneumococcal vaccine consent form on file. Interview with Resident #92 on 5/3/24 at 10:52 am revealed that she always took vaccines that were offered to her since she had COVID and pneumonia at the same time in the past. She further indicated that she was not offered a pneumonia vaccine and she had not declined to take one while at the facility. She stated that she would not have declined to take a vaccine if it was offered to her. e. Resident #96 was admitted to the facility on [DATE]. He was [AGE] years old. His active diagnoses included Atherosclerosis (the buildup of plaque in the artery walls), Hypertension (high blood pressure), and Cardiomyopathy (a disorder that affects the heart muscle). Resident #96's quarterly minimum data set assessment (MDS) dated [DATE] revealed he was assessed as cognitively intact. The immunization record of Resident #96 revealed that the 2023 influenza vaccine was refused but there was no documented proof of the refusal or reason refused and no documented proof that education was provided regarding the benefits or potential side effects of the vaccine. Review of vaccine consent forms for Resident #96 revealed that he had no pneumococcal vaccine consent form on file. Interview with Resident #96 on 5/3/24 at 9:48 am revealed that he was not offered an influenza vaccine by the facility and he would have taken it if he was offered. In an interview with the Infection Preventionist on 5/1/24 at 2:18 PM she stated she could not determine whether Resident #14, Resident #55, Resident #59, Resident #92, and Resident #96 had consented or refused the influenza and/or pneumococcal vaccines because there was no documented record of a consent or refusal, reason for refusal, or proof that a Vaccine Information Sheet (VIS) was provided to each resident and/or RP regarding the vaccines. She stated she had been in the IP position since 2/19/24 and her process was she offered vaccine to residents and if they declined she got them to sign the VIS to indicate that education was provided on the risks and benefits of the vaccines and she kept the signed VIS consent/declination in a book, but that she did not have a signed VIS consent/declination for Resident #14, Resident #55, Resident #59, Resident #92, or Resident #96. In an interview with the facility Nurse Consultant on 05/01/24 02:27 PM she stated a written refusal should have been signed and kept on file or that an immunization refusal should have been documented in the electronic medical record under the immunization assessment tab. She further indicated that a recent change in the immunization process was they had the resident or RP initial or sign the VIS and the signed VIS was uploaded to the electronic medical record to prove they received education on the risks and benefits of the vaccines. She stated that this had not been done for Resident #14, Resident #55, Resident #59, Resident #92, or Resident #96. During an interview with the Director of Nursing (DON) on 5/2/24 at 8:37 AM it was revealed she was unaware there was no documentation that Resident #14, Resident #55, Resident #59, Resident #92, or Resident #96 were offered and declined vaccination, no documentation of reason for refusal, and no proof education was provided on the risks and benefits of the vaccines. She stated the facility had a new IP and the prior IP no longer was employed by the facility. She stated the current process for immunizations was the IP reviewed newly admitted residents to determine vaccine status, offered vaccines, and educated the resident using the VIS. The resident signed a copy of the VIS to indicate they consented or declined a vaccine and received the education. She further indicated they would write the word declined or refused on the VIS if the resident declined a vaccine and the resident or RP signed the VIS as proof they declined. The interview further revealed the process prior to the employment of the current IP was that the refusal or consent was entered under the immunizations tab in the electronic medical record and there was a notes box where they entered the refusal and reason refused. The DON stated Resident #14, Resident #55, Resident #59, Resident #92, or Resident #96 should have received a VIS and there should have been proof if they declined a vaccine and the reason why. In an interview with the facility Administrator on 5/2/24 at 10:40 AM she stated newly admitted residents were screened for vaccine status through the North Carolina Immunization Registry and the facility provided the VIS to the resident or RP and reviewed it with them. She stated the resident or RP could decline a vaccine but the facility was not required to get a signed declination or consent because it was not required in the regulations. She further indicated it should be documented that a resident consented to or refused a vaccination in the electronic medical record or somewhere and that would be the proof a resident consented or refused. In an interview with Nurse Practitioner on 5/2/24 at 12:53 PM he stated that he recommended residents become vaccinated if it was not contraindicated. He stated he encouraged vaccinations for all residents because most had preexisting conditions that put them at risk of contracting an infection. He stated residents should be offered vaccinations and staff should educate residents or resident representatives on the risks and benefits of the vaccine and if a resident declined that should documented in the medical record they declined and why.

Based on observations, record review, and resident, staff, responsible party (RP), nurse practitioner (NP), and Physician interviews the facility failed obtain the permission of the RP prior to opening a Resident Trust Fund account with the facility which allowed for the direct deposit of the resident's Social Security and Veterans Administration benefits and automatically transferred care cost payments to the facility. This was for 1 of 5 residents (Resident #49) reviewed for personal funds. Findings included: A review of Resident #49's Hospital Discharge Summary dated 12/21/23 revealed in part Resident #49 understood only basic conversations or simple direct phrases. He frequently required cues to understand. Resident #49 was admitted to the facility on [DATE] with a diagnosis of cerebral infarction (disrupted blood supply to the brain sometimes called a stroke). A review of a Discharge Planning Psychosocial Assessment form for Resident #49 dated 12/22/23 and signed by Social Worker (SW) #2 revealed in part Resident #49's expected length of stay at the facility would be short term as stated by his Responsible Party (RP). It further revealed Resident #49 had a stroke and was unable to communicate. He depended on his RP and another family member to make his decisions for him. A review of Resident #49's admission Minimum Data Set (MDS) assessment dated [DATE] revealed in part his hearing was adequate. He had no speech. His Brief Interview of Mental Status (BIMS) score was 99. He was severely cognitively impaired. A review of a form titled: Resident Fund Management Service Authorization and Agreement to Handle Resident Funds revealed in part the account type was transferring (automatic transfer of care costs due the facility with a 30.00-dollar monthly allowance). The direct deposit boxes (please enroll my indicated recurring benefit payments for direct deposit) for social security, veterans administration, railroad retirement, supplemental security income, civil service benefits, and [NAME]/black lung were all checked. Above the signature line of the form was a statement that read: Resident's illegible signature or mark (X) requires two witnesses. There was an illegible signature on the resident signature line. There were no witness signatures. The form was dated 2/7/24. A review of Resident #49's medical record on 5/1/24 revealed his family member was his Responsible Party (RP). On 5/1/24 at 2:00 PM an interview with Social Worker (SW) #1 indicated she was familiar with Resident #49. She further indicated Resident #49 was pretty cognitively impaired. She stated although there was no Power of Attorney (POA) paperwork for the resident, his family member was his Responsible Party (RP) and his surrogate decision maker as he was unable to do this for himself. She went on to say Resident #49's initial discharge planning on 12/22/23 was completed by SW #2 who no longer worked at the facility. She further indicated she would not be involved in an application for Medicaid for Resident #49, that would be the Business Office. SW #1 stated she was currently working with Resident #49's family to have him transferred to a Veteran's Administration (VA) facility. On 5/1/24 at 2:16 PM an interview with the Business Office Manager (BOM) indicated when Resident #49 was first admitted to the facility the plan was for him to be there short term. She stated she looked at Resident #49's BIMS score. She stated it was 99 and she thought this high score meant that Resident #49 could understand and sign things for himself. She stated although Resident #49 had not been able to speak to her when she talked with him about signing Medicaid application forms, he nodded his head when she explained it all to him. The BOM went on to say now she understood that a BIMS score of 99 meant that Resident #49 might not capable be of understanding and signing forms giving her permission to be his designated representative in the Medicaid application process, and that she should have reached out to nursing or administration for help determining what to do. On 5/2/24 at 2:14 PM in a follow-up interview the BOM indicated she had Resident #49 sign the Resident Fund management Account agreement on 2/7/24 when she had him sign the Medicaid paperwork. She stated she explained to him that whenever someone is in a Long-Term Care facility and had Medicaid, their income minus 30.00 dollars was paid to their bill in the facility. She stated she read the whole form to him, he nodded, and signed it. She went on to say she took this as him understanding what she read to him. She further indicated the signature of the form was Resident #49's. The BOM stated she had not had Resident #49's RP or other family member sign the forms, because she couldn't get them to come in and do it. She further indicated she thought she let Resident #49's family member know on 4/17/24 when she came to the facility that Resident #49 had a Trust Account with the facility. She went on to say the account had been closed on 4/26/24 when Resident #49's family member came to the facility and let her know Resident #49 would be going to the Veteran's Administration (VA) facility, and she would privately pay until then. The BOM stated Resident #49 would not have had a quarterly statement yet at that time. A review of Resident #49's Resident Statement landscape on 5/2/24 provided by the BOM revealed in part the account was opened on 2/21/24. The account type was transferring. The current balance was zero. The account was closed on 4/26/24. On 5/1/24 a VA Treasury payment of $5232.64 was rejected. On 5/1/23 an Office of Personnel Management (OPM is a retirement benefit paid to retired federal employees) payment of $1507.58 was rejected. There were no transactions on the account. On 5/1/24 at 2:48 PM an interview with the Administrator indicated if a resident had a BIMS score of 99 that would indicate they did not have the cognitive ability to understand and consent allowing the BOM to be his designated representative. She stated if there were issues that required this type of signature, and the resident had no POA then the facility would need to seek guardianship. On 5/1/24 at 7:16 PM a telephone interview with Resident #49's family member indicated she and Resident #49's RP had been making both financial and medical decisions for Resident #49 since his admission to the facility as he was not able to do this for himself. She stated she was not aware Resident #49 had a Resident Trust Account with the facility, she had never given her permission for that, and no one from the facility asked her if this was okay. She went on to say a few weeks ago she got an automated text message that Resident #49's social security and veterans administration funds direct deposit destination changed. She further indicated she had asked the Business Office Manager (BOM) if she knew anything about this when she brought a check to the facility to pay for Resident #49's care, and the BOM told her she didn't know anything about it. On 5/1/24 at 7:26 PM a telephone interview with Resident #49's RP indicated she did not know anything about Resident #49 having a Resident Trust account with the facility. She stated no one from the facility ever asked her about this, and she had not given her permission. She went on to say she and Resident #49's family member were responsible for making all financial and medical decisions for Resident #49, as he was unable to do this himself. She further indicated she had a clear conversation about this with the facility when Resident #49 was first admitted . On 5/2/24 at 9:37 AM an interview with Nurse #10 indicated she was familiar with Resident #49 and cared for him often since January 2024. She stated he had a family member who was his RP, and another family member involved in his care. She went on to say she had never had any trouble getting in touch with Resident #49's family to report a fall or other concerns. She further indicated she did not feel Resident #49 had the cognitive ability to make medical or financial decisions for himself. On 5/2/24 at 9:44 AM an interview with Nurse Aide (NA) #5 indicated she was familiar with Resident #49 and cared for him often since January 2024. She stated she did not think Resident 349 would have the cognitive ability to make medical or financial decisions for himself. On 5/2/24 at 10:09 PM a telephone interview with Resident #49's Physician indicated in February 2024, he felt Resident #49 would have been at his baseline cognition level. He stated if he was making financial and health care decisions for himself prior to this, then he felt Resident #49 would have been capable of doing this in February 2024. On 5/2/24 at 12:33 PM a telephone interview with SW #2 indicated she completed Resident #49's initial discharge planning meeting on 12/22/23. She stated he was not capable of making medical or financial decisions for himself and his RP and another family member were doing that for him. On 5/2/24 at 2:09 PM a telephone interview with Resident #49's psychiatric Nurse Practitioner indicated she was familiar with Resident #49. She stated at her assessment of him on 2/15/24 she did not feel he would be capable of making financial or medical decisions for himself. She went on to say because Resident #49 was not verbal, there really would be no way of completing the cognition assessments that would be required to decide that he was.

Based on observations, record review, and resident, staff, resident representative (RR), and nurse practitioner (NP) interviews the facility failed to allow a resident's designated representative to decide whether an application for Medicaid would be completed for the resident. This was for 1 of 5 residents (Resident #49) reviewed for personal funds. A reasonable person would feel distressed related to the potential financial consequences to their estate if an application for Medicaid was completed without their consent. Findings included: A review of Resident #49's Hospital Discharge Summary dated 12/21/23 revealed in part Resident #49 understood only basic conversations or simple direct phrases. He frequently required cues to understand. Resident #49 was admitted to the facility on [DATE] with a diagnosis of cerebral infarction (disrupted blood supply to the brain sometimes called a stroke). A review of Resident #49's medical record revealed his family members were his RR#1 and RR#2. A review of a Discharge Planning Psychosocial Assessment form for Resident #49 dated 12/22/23 and signed by Social Worker (SW) #2 revealed in part Resident #49's expected length of stay at the facility would be short term. It further revealed Resident #49 had a stroke and was unable to communicate. He depended on his RR #1 and RR #2 to make his decisions for him. A review of Resident #49's admission Minimum Data Set (MDS) assessment dated [DATE] revealed in part his hearing was adequate. He had no speech. His Brief Interview of Mental Status (BIMS) score was 99 (indicating the BIMS was incomplete and the staff assessment for mental status was completed). The staff assessment indicated Resident #49 was severely cognitively impaired. A review of a Division of Social Services (DSS) form titled Division of Health Benefits (DHB) Appendix C Designation of Authorized Representative for Resident #49 dated 2/7/24 revealed in part the name of the applicant was {Resident #49}. The name of the authorized representative was {the facility's Business Office Manager (BOM)}. It further revealed in part: I understand that by signing this authorization, I am allowing the above-named individual to sign my application, complete my re-enrollment/re-determination, get official information about my case status, and act for me on all future matters with this agency. The form was signed by Resident #49 and the BOM. A further review of additional forms dated 2/7/24 including a form titled DHB 5028 Authorization to Disclose Information, Authorization to Release Information, Consumer Consent and Authorization for Access to Financial Records, a form that listed Resident #49's income and resources including a joint checking and savings account with his family member, and a notice that advised Resident #49 his estate was subject to Medicaid Recovery were signed only by the BOM. On 5/1/24 at 2:00 PM an interview with Social Worker (SW) #1 indicated she was familiar with Resident #49. She further indicated Resident #49 was cognitively impaired. She stated although there was no Power of Attorney (POA) paperwork for the resident, his family member was his RR#1 and his surrogate decision maker as he was unable to do this for himself. She went on to say Resident #49's initial discharge planning on 12/22/23 was completed by SW #2 who no longer worked at the facility. She further indicated she would not be involved in an application for Medicaid for Resident #49, that would be the Business Office. On 5/1/24 at 2:16 PM an interview with the Business Office Manger (BOM) indicated when Resident #49 was first admitted to the facility the plan was for him to be there short term. She stated when that plan changed, she reached out to his RR #1 and RR#2 trying to get the process started for an application for Medicaid to pay for his stay at the facility as the process took a long time. She went on to say she was not getting a response back quickly enough, so she asked the Assistant BOM to talk with Resident #49 about signing the paperwork for this himself. The BOM stated the Assistant BOM had difficulty talking with Resident #49, so she looked at Resident #49's BIMS score. She stated it was 99 and she thought the high score meant that Resident #49 could understand and sign paperwork for himself. She stated although Resident #49 had not been able to speak to her when she talked with him about this, he nodded his head when she explained it all to him and signed the form making her the designated representative to start the Medicaid application process. She stated she just wanted Resident #49 to get the financial assistance he was entitled to. She went on to say Resident #49 and RR#2 had a good relationship and shared a bank account. She further indicated when Resident #49's RR#2 brought in a check to pay for Resident #49's March 2024 bill, she let her know she had gotten Resident #49's signature to apply for Medicaid. She stated she had not spoken with Resident #49's RR #1 or RR#2 prior to obtaining his signature. The BOM went on to say now she understood that a BIMS score of 99 meant that Resident #49 might not be capable of understanding and signing the form giving her permission to be his designated representative in the Medicaid application process, and that she should have reached out to nursing or administration for help determining what to do. On 5/2/24 at 2:14 PM a follow up interview with the BOM indicated when she approached Resident #49 to have him sign the Medicaid application paperwork, she explained to him that whenever someone is in a Long-Term Care facility and had Medicaid, their income minus 30.00 dollars was paid to their bill in the facility. She stated she read the whole application form to him, he nodded, and signed it. She went on to say she took this as him understanding what she read to him. On 5/1/24 at 2:23 PM an interview with the Assistant Business Office Manager (BOM) indicated she had gone to see Resident #49 about signing some paperwork for Medicaid including designating a representative and for access to his banking and other financial information documents, but Resident #49 had not been having a good day. She stated she left telephone messages for his RP and his other family member but hadn't heard back. She went on to say the BOM told her that Resident #49's BIMS score was 99 and so he could sign for himself. She further indicated she had not known you could do that, so the BOM went to have Resident #49 sign the forms. On 5/2/24 at 9:13 AM Resident #49 was observed sitting in his room. During an attempt at interview with Resident #49 regarding his giving the facility permission to apply for Medicaid on his behalf he did not respond verbally but shrugged his shoulders. On 5/1/24 at 3:52 PM a telephone interview with Resident #49's RR#2 indicated when Resident #49 was first admitted to the facility she let them know she had Power of Attorney. She stated they asked her to bring in a copy of the form, but she had not been able to locate this. She went on to say she and Resident #49's RR#1 were responsible for making both financial and health care decisions for Resident #49, as he was not capable of doing this for himself. She further indicated the facility called her when Resident #49 fell , or had other issues, but no one ever called to ask for permission to have him sign an application for Medicaid prior to or even to let her know after they completed his Medicaid application. Resident #49's RR#2 stated while Resident #49 could understand simple things, there was no way he could understand and give permission for an application to Medicaid and the complicated financial things this involved. She went on to say she had called to the facility to ask about Resident #49's bill and had been told by the Assistant BOM that the facility already had him sign an application for Medicaid. She further indicated she had been very upset by this. Resident #49's RR#2 stated when she found out it was the BOM who had him sign the form she spoke with her. She went on to say the BOM told her that a resident who had a BIMS score of 10 could sign things for themselves and because the resident had a score of 9 that was almost a 10 so the BOM had Resident #49 sign the form himself. On 5/2/24 at 1:20 PM a follow up telephone interview with Resident #49's RR#2 indicated she had managed Resident #49's financial affairs since prior to his admission to the facility as he had not been capable of financial management. She stated she and Resident #49 shared a bank account. On 5/1/24 at 4:03 PM a telephone interview with Resident #49's RR#1 indicated she and RR#2 were both Resident #49's representatives. She stated together they had made all Resident #49's financial and heath care decisions since his admission to the facility because he was not able to do this for himself. She went on to say when she found out the facility had Resident #49 sign an application for Medicaid, she was so upset she immediately drove to the facility. She further indicated when she got there, the BOM told her she made a mistake having Resident #49 sign the forms because she thought his BIMS score was higher than it was. Resident #49's RR#1 stated she understood that a BIMS score was an indication of someone's ability to understand and make decisions. She went on to say she had clear conversations with the facility since Resident #49's admission that she and Resident #49's RR#2 were his decision makers. She further indicated the facility did not even call her or Resident #49's RR#2 to ask if they wanted to apply for Medicaid for Resident #49 prior to having him sign the form. On 5/2/24 at 9:37 AM an interview with Nurse #10 indicated she was familiar with Resident #49 and cared for him often since January 2024. She stated he had a family member (RR#1) who was Representative, and another family member (RR#2) involved in his care. She went on to say she had never had any trouble getting in touch with Resident #49's RR#1 or RR#2 to report a fall or other concerns. She further indicated she did not feel Resident #49 had the cognitive ability to make medical or financial decisions for himself. Nurse #10 stated Resident #49 had some negative and inappropriate behaviors that reflected his impaired cognition. On 5/2/24 at 9:44 AM an interview with Nurse Aide (NA) #5 indicated she was familiar with Resident #49 and cared for him often since January 2024. She stated she did not think Resident #49 had the cognitive ability to make medical or financial decisions for himself. She went on to say he understood simple things, but she didn't feel he could understand complicated things like finances. On 5/2/24 at 12:33 PM a telephone interview with SW #2 indicated she completed Resident #49's initial discharge planning meeting on 12/22/23. She stated he was not capable of making medical or financial decisions for himself because of his cognitive status and RR#1 and RR#2 were doing that for him. On 5/1/24 at 2:48 PM an interview with the Administrator indicated if a resident had a BIMS score of 99 that would indicate they did not have the cognitive ability to understand and consent allowing the BOM to be his designated representative. She stated if there were issues that required this type of signature, and the resident had no POA then the facility would need to seek guardianship. On 5/2/24 at 8:58 AM a follow-up interview with the Administrator indicated the facility did not have any signed admission paperwork for Resident #49. She stated Resident #49 was not able to sign it himself when he was admitted to the facility, and RR#2 had not been communicative. On 5/2/24 at 2:09 PM a telephone interview with Resident #49's psychiatric Nurse Practitioner indicated she was familiar with Resident #49. She stated at her assessment of him on 2/15/24 she did not feel he would be capable of making financial or medical decisions for himself. She went on to say because Resident #49 was not verbal, there really would be no way of completing the cognition assessments that would be required to decide that he was.

Based on record review and staff interviews, The facility failed to notify law enforcement and Adult Protective Services (APS) for an allegation of staff to resident abuse for 1 of 3 residents (Resident #316) reviewed for abuse. Findings included: A review of the initial report sent to the state regulatory agency by the Administrator revealed the facility became aware of the abuse allegation on 1/30/24 at 10:52 AM. The report further revealed that local law enforcement was not contacted regarding the allegation of staff to resident abuse and did not indicate if APS was notified. The initial report further revealed Resident #316 stated that Nurse Aide #5 was rough with his legs during care. In an interview with the Administrator on 5/1/24 The Administrator revealed she did not notify law enforcement or APS because she thought she had the five days of the investigation to notify them, and Resident #316 retracted his allegation on day 5.

Based on observations, staff interviews, and record review the facility failed to ensure peri-care was postponed until the last phase of bathing for 1 of 6 residents reviewed for activities of daily living care. (Resident #49) Findings included: Resident #49 was admitted to the facility on [DATE]. Resident #49's Minimum Data Set assessment dated [DATE] revealed he was assessed as severely cognitively impaired. He required maximal assistance with bathing and toileting hygiene. Resident #49's care plan dated 3/23/24 revealed he was care planned for activities of daily living care. The interventions included 1 person assist with toileting, check and change briefs frequently as needed, and provide toileting hygiene with brief changes. During observation on 5/1/24 at 2:08 PM Nurse Aide #5 was observed providing activities of daily living care for Resident #49. Resident #49 was lying on his left side and the nurse aide was cleaning the resident with a washcloth. The nurse aide was observed to wipe the crack of Resident #49's buttock and a slight smear of stool was observed on the washcloth. The nurse aide was observed to then wipe the small of Resident #49's back, both buttocks, and hamstrings with the same washcloth. There was feces visible on the washcloth. The nurse aide then dried Resident #49 and placed a new brief on Resident #49. During an interview on 5/1/24 at 2:24 PM Nurse Aide #5 stated she did not see that there was feces on the washcloth after she wiped between his buttocks. Had she noted the feces on the washcloth she would not have washed the small of his back, buttocks, and hamstrings with the same washcloth. During an interview on 5/1/24 at 2:27 PM the Director of Nursing stated the Nurse Aide should have discarded the washcloth following washing a dirty area (crack of the buttock) and not returned to the cleaner areas of Resident #49's body with the washcloth. This would have prevented the feces from then being spread during care.

Based on observation, record review, and interviews with staff, family, residents, the physician and the facility's psychiatric provider, the facility failed to protect a cognitively impaired and dependent resident (Resident # 3) from abuse by another cognitively impaired resident (Resident # 2). Resident # 2 was known by staff to display behaviors which included paranoia, delusions, aggression with staff, and exit seeking behaviors. Resident # 2 entered Resident # 3's room while staff were attending to other residents during an evening meal and assaulted Resident # 3 by pulling Resident # 3's wheelchair over on the floor resulting in Resident # 3 landing on the floor; hitting and kicking Resident # 3 in the head; beating Resident # 3 with a meal tray and; hitting Resident # 3 with the door by swinging a door back and forth onto Resident # 3's body while Resident # 3 was on the floor. Resident # 3 sustained a laceration near his eye, multiple areas of bruising, and fear that the incident would occur again. This was for one of three residents sampled for abuse. The findings included: Resident # 2 was admitted to the facility on [DATE] following a hospitalization from [DATE] to 9/18/23. According to the hospital discharge summary, dated 9/18/23, Resident # 2's diagnoses included hypertension, coronary artery disease, heart failure, atrial fibrillation, history of prostate cancer, failure to thrive with moderate malnutrition. The hospital discharge summary also noted the following. Prior to hospital admission on 8/28/23 Resident # 2 had resided at home and a neighbor had found Resident # 2 to be confused. He was also febrile. During hospitalization Resident # 2 was determined to have pneumonia which was treated and resolved. Also, while hospitalized Resident # 2 displayed behavioral problems. It was documented Resident # 2 had removed his clothing and barricaded himself and his wife in the hospital room with a trashcan. He was physically restrained at one point and started on antipsychotic medications during hospitalization . On the hospital discharge summary, the physician noted Resident # 2 could have possible dementia, and his antipsychotic medications were to be continued after his hospital discharge. According to facility room assignment reviews, Resident # 2 was admitted to a room in the facility where he resided with his wife. Physician orders revealed Resident # 2 was prescribed Seroquel 25 mg (milligrams) at bedtime for agitation on 9/18/23. (Seroquel is an antipsychotic medication.) Review of the facility record revealed on 9/19/23 Resident # 2 was seen by the facility medical physician who noted Resident # 2 seemed to have delirium while hospitalized , and antipsychotics were started. The physician noted he would try to wean the resident off antipsychotics over the next few days. Resident # 2's admission Minimum Data Set assessment, dated 9/24/23, coded Resident # 2 as severely cognitively impaired. Resident # 2 was assessed to be ambulatory with a walker and displayed the behavior of refusing care. Resident # 2's care plan, reviewed on 10/2/23, included information that Resident # 2 was at risk for complications related to cognitive impairment secondary to his advanced age. Staff were directed to observe for changes in his cognition over time. The care plan also noted he received antipsychotic medications, was at risk for elopement, and that psychiatric services would be provided as needed. On 10/4/23 the physician noted in a progress note that he was following up on Resident # 2's medical issues and his psychosis. The physician further noted there had been no recent agitation issues with the resident. Per physician orders, on 10/7/23 Resident # 2's Seroquel dosage was changed to 1/2 tablet (12.5 mg) at bedtime. This indicated a dose reduction. Per physician orders on 10/16/23 the dosage was increased back to 25 mg at bedtime. (This dosage amount remaining ordered through 3/9/24). Resident #2's physician noted in a progress note, dated 10/17/23, the following. He was seeing Resident # 2 because of severe agitation in the last couple of days. The resident had a urinalysis completed which was negative, and Resident # 2 had known dementia. The physician directed the resident's daily Seroquel dosage be administered at 6:00 PM rather than at bedtime. On 11/6/23, the Director of Nursing (DON) noted in a nursing note Resident # 2 had stated suicidal ideations but had no plan or means to carry out his ideation. The DON further noted a psych referral would be sent. Interview on 3/21/24 at 4:45 PM with the DON revealed at the time of 11/6/23 Resident # 2 refused to see a psychiatrist, and therefore the psychiatric evaluation did not take place at that time. Resident # 2's physician noted in a progress note, dated 11/19/23, that he was seeing Resident # 2 for a two- month post hospitalization visit for senile dementia and other medical reasons. The physician noted Resident # 2 had an appropriate affect and was in no apparent distress. The physician further documented Resident # 2 would be maintained on Seroquel. Resident # 2's physician noted in a progress note, dated 12/19/23, In follow up of dementia, he does get agitated quite frequently and sometimes have outburst where he resists on seeing the doctor, but today he does not remember anything at all and has really no concerns or complaints while I am in the room. The physician further noted, I will continue Seroquel at this time for agitation. On 12/23/23 a quarterly Minimum Data Set assessment was completed showing the following assessment. Resident # 2 was moderately cognitively impaired, wandered and rejected care 1 to three days during the assessment period, and was ambulatory. Review of physician orders revealed an order on 1/11/24 for a geriatric psychiatric consult for Resident # 2. Review of Resident # 2's medical record revealed a document noting a hearing had been held and Resident # 2 had been deemed incompetent. This document was stamped as filed on 2/2/24. On 2/2/24 the facility's Social Services Director noted there had been a court appointed guardian arranged for Resident # 2. On 2/3/24 at 1:48 AM Nurse # 1 documented in a nursing note the following about Resident # 2. Around 2300 (11:00 PM) resident came up to the nurses' station and started yelling at another nurse and getting in her face. Resident was yelling that it was all the other nurse's fault. Writer got in between resident and nurse and was attempting to calm down the resident. Resident stated the girl he murdered was alive and her and her boyfriend are trying to murder him. Resident stated we needed to call the highway patrol to come protect him. Resident was eventually able to be redirected and clamed down. MD (Medical Doctor) was made aware and PRN (as needed) one time order for Haldol IM (intramuscular) was put in place in case of any more agitation. Resident is now resting in bed. (Haldol is an antipsychotic medication) Nurse # 1 was interviewed on 3/20/24 at 11:00 AM and reported the following. Resident # 2 was not always agitated. Every once in a while he would become confused. She thought Resident # 2 had a history of being in the military police. Routinely he was pleasant around other residents. He knew where his room was and never wandered into other residents' rooms. She never feared for other residents' safety because of any of Resident # 2's behaviors, and he was typically easily redirected if he became confused. On 2/3/24 he had been yelling at another nurse while telling her it was her fault that someone was trying to come kill him. She intervened and gave him a snack. He calmed down and went to bed. She never had to administer the Haldol that was ordered. On 2/11/24 at 4:21 AM Nurse # 2 documented in a nursing note the following about Resident # 2. Resident came to nursing station to use phone to call police. 'I killed my wife.' CNA (certified nursing assistant and I checked and {resident's wife] is asleep. On 2/12/24 at 10:19 PM Nurse # 3 noted the following in a nursing note about Resident # 2. Resident noted with increased confusion this evening refusing medication and ranting of someone coming go kill him, and his wife. Resident was easily redirected. MD notified. Safety measures in place. Nurse # 3 was interviewed on 3/20/24 at 7:30 PM and reported the following. She did not often care for Resident # 2. Initially when she did care for him, he seemed pleasant. One day he was ranting that someone was trying to kill him and stealing his money. She placed a note in the chart, talked to the physician who instructed to monitor Resident # 2. Resident # 2 had refused his medications that day. There was another episode which occurred during the first two weeks of March, 2024 during which he was ranting and trying to leave the facility. He was easily redirected. She would take him by his hand and walk him to his room. Based on his behaviors, she never feared he would hurt another resident. She had never witnessed him hurt or touch any resident. She was not aware of any psychiatric referrals ordered and not completed for the resident. On 2/13/24 at 1:53 AM Nurse # 1 noted the following in a nursing note about Resident # 2. Resident confused said he got a emergency call that stated the jets are on the way to murder him and his wife. Able to calm resident down by talking to him. Resident calm but refusing to go back to his room or bed stated he will leave [his wife] down there alone to get murdered. Resident calm sitting nurses station eating a snack. Resident # 2's physician noted in a progress note, dated 2/19/24, Baseline, very confused and paranoid, in no apparent distress. He has times where he thinks somebody has to murder him and his wife. He can ambulate with a walker Under the physician's plan for the date of 2/19/24, the physician noted he would continue the Seroquel for his behaviors and psychosis and refer to psychiatry. Review of Resident # 2's facility medical record revealed no documentation Resident # 2 was ever seen for a psychiatric consult. On 2/23/24 at 9:29 AM Nurse # 4 noted the following in a nursing note about Resident # 2. Resident complied with medication administration. Increasingly more agitated as the morning goes on. He is unable to verbalize what we can help him with. He wants to leave to find the 'hotel.' Asked how to contact police. Nurse # 4 further noted the physician was contacted and resident was being redirected. On 2/23/24 at 11:32 AM Nurse # 4 noted the physician had ordered lab work for the resident. On 2/26/24 at 1 PM a nursing note was entered documenting the staff had talked with Resident # 2's guardian and informed the guardian Resident # 2 was continuing to refuse lab work to be done. On 2/26/24 at 3:16 PM Nurse # 4 noted the following in a nursing note about Resident # 2. Resident had been exit seeking. Continuing to redirect with very little effect. Resident has continued to refuse to give a urine sample for UA (urinalysis). Change of shift report communicated that we are to re-attempt once the resident has calmed down. During last exit seeking attempt resident stated when he gets back, he will come back with a 'gun.' Resident was returned to room. Put music on for resident that seemed to calm resident. Safety measures in place. Nurse # 4 was interviewed on 3/20/24 at 11:10 AM and reported the following. She worked part time and worked with Resident # 2 about one time per week. At times he appeared frustrated as if he could not say what he wanted to convey. When he mentioned the gun, she knew he had past military experience. He indicated he would not do anything with a gun if he had one. His confusion did not occur on a daily occurrence, and generally he was easy to redirect. She would allow him to voice concerns, deescalate and play music for him. That seemed to help. He never gave any indication he would harm anyone. She never saw him threaten anyone. He never wandered into other residents' rooms or tried to hurt them. She never thought anyone was in danger based on Resident # 2's behaviors. On 2/27/24 at 1:11 PM Nurse # 5 noted in a nursing note that Resident # 2 had been agitated, confrontation, and had lifted his walker and attempted to throw out the glass door. Nurse # 5 further noted diversional conversation was provided and Ativan 1 mg per a one time order was administered and was effective. The resident became calm. Nurse # 5 was interviewed on 3/20/24 at 12:57 PM and reported the following. Resident # 2 was not agitated on a daily basis. He was in the dayroom on 2/27/24 when he became upset on that date. He was typically redirectable. On that day, he took medication and was okay. He calmed down. She had never seen him threaten anyone or harm anyone. He never gave any indication he would hurt anyone. She was not aware of why a psychiatric evaluation had not been done for Resident # 2. Review of physician orders revealed on 2/27/24 Resident # 2 was started on Depakote extended release 250 milligrams twice per day. (Depakote is a medication used as a mood stabilizer). On 3/1/24 Nurse # 6 completed a SBAR communication form (a situation, backgroumd assessment, and recommendation request form). The nurse checked on the form Resident # 2 was having increased verbal and physical aggression, and a danger to self or others. According to the record, after the completion of the form Resident # 2 was sent to the hospital for evaluation. Nurse # 6 was interviewed on 3/21/24 at 11:49 AM and reported the following. She was the staff development coordinator for the facility. Her office was on a different unit than the unit on which Resident # 2 resided. On 3/1/24 she had been in her office when Resident # 2 came walking down the unit where she worked. He was dressed in his coat and toboggan to leave, and his wife was following him. The nurse talked to him and he commented, We are getting out of here. He then told his wife, If you are not coming with me then you are going to pay for this. She knew around the date of 2/28/24 there had been an incident where he had had thrown his walker at an exit door and held his walker up towards staff who were trying to intervene. It had taken about 10 minutes to get him calmed down on that day. She was also aware he had refused lab work to be done. Therefore, she called EMS (Emergency Medical Services) to transfer him to the hospital on 3/1/24. It was her hope that they could medically find if something was causing his confusion and agitation. At the time she did not feel he posed a danger to others, but only to himself because he wanted to leave the facility. She had never seen him threaten or harm another resident when he was agitated. Review of hospital emergency department records, dated 3/1/24, revealed the following. The physician noted Resident # 2 presented for aggressive behavior. Patient was noted to be throwing his walker and furniture at staff attempting to take his wife and leave the facility. On exam patient is moderately confused, oriented to self, reports his wife was being attacked by hospital staff. The physician further noted during his assessment Resident # 2 was calm and cooperative, labs had been done without any significant abnormalities. According to the record, he was returned to the facility with no changes in orders or a psychiatric consult being done. On 3/6/24 Resident # 2's care plan was updated to reflect that Resident # 2 had behaviors related to dementia with psychosis. Some of the interventions included to assign staff that were familiar with the resident when possible and to assure Resident # 2 he was safe if he became distressed. Review of physician orders revealed on 3/9/24 an order for Seroquel 25 milligrams every 12 hours. This indicated an increased dosage. Resident # 2's physician noted in a progress note, dated 3/11/24, Resident # 2 had experienced some syncope episodes. The physician noted that Seroquel was one medication that could contribute to orthostatic hypotension. He further noted Resident # 2 did not respond well to Lorazepam and he would be a good candidate for a lockdown unit. The physician further noted, continue with a referral for psychiatry for further monitoring. On 3/11/24 Resident # 2's Seroquel was discontinued. On 3/12/24 at 7:40 PM Nurse # 7 noted, Late Entry, Resident became aggressive and had an altercation with another resident. Resident was sent to local ER per MD order. RP notified. Review of the facility's investigation into Resident # 2's altercation revealed Resident # 3 was the other Resident involved in the 3/12/24 altercation. A review of Resident # 3's record revealed his diagnoses included in part stroke with hemiplegia/ hemiparesis, dysphagia, and intellectual disability. Resident # 3's quarterly Minimum Data Set assessment, dated 3/2/24, included the information that he was totally dependent on staff for transfers and required substantial to maximum assistance to roll in bed. He was assessed to reject care from staff at times but had no other behaviors on the assessment. According to the record, Resident # 3 resided in the room diagonally across from Resident # 2's room. According to staffing sheets, Nurse # 5 had cared for Resident # 2 from 7 AM to 3 PM on 3/12/24 before the altercation occurred. Nurse # 5 was interviewed on 3/20/24 at 12:57 PM and reported the following. She had also cared for Resident # 2 on the previous day of 3/11/24 and he had been fine on 3/11/24. On 3/12/24 he was also fine all day until he had a moment at the end of the shift. She did not recall the incident in its entirety, and it was brief. She had been seated at the nursing station at the time. Both Resident # 2 and Resident # 3 were in the dayroom which was located adjacent to the nursing station. The dayroom could not be viewed if a staff member was seated. She had been charting and she heard a noise. She stood up and saw that Resident # 2 had moved Resident # 3's wheelchair. Resident # 2 had also said something, but she did not recall what he had said. To her knowledge, Resident # 3 had not done anything, and Resident # 3 was okay. Resident # 3 had just been moved up from where his wheelchair had been. Resident # 2 did seem agitated at the time. She thought she recalled either the Activity Director or the Facility Scheduler had been present at the time and separated Resident # 2 and Resident # 3. She recalled the Activity Director saying Resident # 2 needed his walker. She had gone to Resident # 2's room, obtained his walker, and then walked with Resident # 2 back to his room. He calmed down while she walked with him back to his room. She recalled him saying, I like you because you have a dog. He had not given any indication that he would hurt anyone or become volatile. That was the last time she saw him. She did not report anything to the oncoming Nurse (Nurse # 7) because she recalled Nurse # 7 was standing at the medication cart when the incident moment occurred. The NA (Nurse Aide # 1), who had cared for Resident # 2 during the day shift of 3/12/24, was interviewed on 3/20/24 at 1:30 PM and reported the following. She was familiar with Resident # 2 and knew that at times he felt someone was out to get him. He had never hurt another resident or indicated he would. He never went into other residents' rooms. At times he had stopped in the doorway at the room adjacent to his own and spoken to the residents who resided there in a friendly manner to tell them hello. There were times he would say he felt trapped and would pull on the exit doors to get out. On 3/12/24 during the day shift he had been in the dayroom at one time and was trying to get out. She gave him some cookies and he calmed down. She had never witnessed any incident in the dayroom with Resident # 3. The Activity Director was interviewed on 3/20/24 at 2:10 PM and reported the following. Resident # 2 participated in activities and would talk to other residents in a pleasant manner. He never showed aggression to any residents. On occasion he would say he could not go outside because there was someone out there who was going to get him and his wife. He was not agitated when he mentioned it, and the remark would just seem to come from nowhere. She did not recall an incident at the change of day shift to evening shift on 3/12/24. She did recall Resident # 2 did not have his walker and mentioned this to the nurse. The Scheduler was interviewed on 3/20/24 at 2:18 PM and reported the following. She had been in an office which was near the nursing station at the change of day shift and evening shift on 3/12/24. She recalled Nurse # 5 saying Resident # 2's name and saw her stand up. She (the Scheduler) did not see anything that happened. She left her office when she heard Nurse # 5 say Resident # 2's name to check on things. Resident # 3 was in his wheelchair a couple feet away from Resident # 2 in the dayroom. They were not interacting, and she did not recall Resident # 2 not being calm. Resident # 3's roommate (Resident # 5) was interviewed on 3/20/24 at 9 AM. According to Resident # 5's Minimum Data Set assessment, dated 3/2/24, Resident # 5 was cognitively intact. Resident # 5 reported the following about the evening of 3/12/24 during the interview. Supper meal trays had been served on 3/12/24. He (Resident # 5) was in his bed. Resident # 3 was in his wheelchair watching television when Resident # 2 came into their room. Resident # 2 grabbed Resident # 3's wheelchair and pulled it backwards onto the floor. Resident # 3 fell out of the wheelchair. The intruding resident hit, kicked, and stomped Resident # 3's head. Resident # 2 took Resident # 3's meal tray and beat the heck out of him (Resident # 3). Resident # 2 also took the door to the entrance of their room and hit Resident # 3 with it while Resident # 3 was on the floor. Resident # 2 did this by swinging the door back and forth on Resident # 3's body. Resident # 2 then used the bathroom door to do the same thing. Resident # 2 threw the lid of Resident # 3's supper plate at Resident # 5, but it had missed him and hit the bed. He (Resident # 5) had never seen Resident # 2 before. He (Resident # 5) could not get out of bed by himself to help. He had used his call bell. It seemed like it took 10 to 15 minutes for the staff to come. The nurses did get there and took Resident # 2 away and Resident # 3 was sent to the hospital. On 3/20/24 at 10:00 AM the speech therapist accompanied the surveyor to interview Resident # 3, who was observed to speak in short phrases and at times had unclear words due to his stroke. According to the speech therapist, she had worked with Resident # 3 and was effectively able to communicate with him. Resident # 3 was observed at the time to have a bruised right eye and a small scar where a laceration had healed to the right of his eye. He spoke in short sentences and conveyed the following. The resident, who attacked him, had never been in his room before. He had seen him in a room across the hall from his before the incident. The resident had come in his room and started kicking and hitting him in the face. Resident # 3 pointed to his face as he spoke and to his bruised eye. The resident, who attacked him, used the door to hit his head and it hurt his head. He was afraid now because he worried it could happen again. After the interview, it was confirmed with Resident # 3 and the speech therapist that Resident # 3's comments were understood correctly by the surveyor. Both indicated they had been understood correctly. NA # 2 had been assigned to care for both Resident # 2 and Resident # 3 on the evening shift of 3/12/24. NA # 2 was interviewed on 3/20/24 at 10:15 AM and reported the following. She usually cared for Resident # 3 and described him as a very sweet man. On 3/12/24 she had worked from 7 AM to 7 PM. She had cared for Resident # 3 all during the day and at 3:00 PM assignments were changed for the evening. Resident # 2 was also added to her assignment. She did not consistently care for Resident # 2. To her knowledge Resident # 2 had never threatened or hurt another resident prior. Around 4:00 PM she had seen Resident # 2 walking around the nursing desk. At supper time on 3/12/24 she had been in another resident's room helping them eat their meal. While assisting to help this other resident eat, she thought she heard Resident # 3's voice. Then she heard a noise as if something was falling. She went to look to see what had occurred and found Resident # 2 in Resident # 3's room. Resident # 3 was on the floor curled up in a fetal position. Resident # 2 was swinging the bathroom door back and forth and using the door to hit Resident # 3 in the back. Resident # 3 was crying and there was blood everywhere. She yelled, stop-stop. Resident # 3 raised his arm to swing at her and then exited the room. She looked down the hall and did not see anyone, so she screamed for help. A Nurse Aide on the adjacent hall heard the scream and alerted her nurse. Then other staff came and helped. Nurse # 7 had been assigned to care for Resident # 2 on the evening shift of 3/12/24. Nurse # 7 was interviewed on 3/20/23 at 12:38 PM and reported the following. She routinely worked with Resident # 2 and he was confused every day and would become agitated. He would talk about needing a gun and needing to protect the place where he was. He talked about being in the special military police. He would tell the Nurse Aides at night not to come into his room to care for his wife. He saw himself as the caregiver for his wife and that he was in charge. He had been known to say he would hurt those girls (meaning the aides) if they didn't stop coming into his room. She (Nurse # 7) would have to talk to him and convince him to allow for the staff to care for his wife. Although he would talk to staff about guns, he would not talk to residents about them, and she never knew him to hurt or threaten to hurt another resident prior to 3/12/24. She did not recall anything that had occurred happening between Resident # 2 and Resident # 3 at the beginning of the evening shift or where Resident # 2 was at the beginning of the shift. At the time of the incident, she had been in another resident's room providing care with the door closed. She heard yelling. When she got to the room, other nurses had already arrived. Resident # 2's wife was wandering, and she redirected her and then stayed with Resident # 3 until he was taken to the hospital. NA # 3 was interviewed on 3/21/24 at 10:20 AM and reported the following. She had been working on an adjacent hall to Resident # 2's hall on the evening of 3/12/24 when she heard NA # 2 screaming. She ran to the room and saw NA # 2 trying to get Resident # 2 out of Resident # 3's room. Resident # 2 was agitated when she (NA # 3) arrived but when he saw her (NA # 3), he calmed down and said, There's my sweet heart. She then took him calmly by the hand and led him to his room without a problem, sat him down with his meal tray before him and closed the door. She went back to help with Resident # 3 and try to stop the bleeding while NA # 2 got multiple nurses. They came right away. Nurse # 8 was a nurse who had responded on the date of the incident of 3/12/24 and had been working on the adjacent unit. Nurse # 8 was interviewed on 3/21/24 at 2:30 PM and reported when she heard the call for help, she responded and found Resident # 3 crying on the floor. There was blood in his eyes and his ears . She was familiar with Resident # 2 and was shocked he had attacked Resident # 3. She did not think he had the strength to do what he had done. Nurse # 9, who had been working on another unit and had responded on 3/12/24, was interviewed on 3/21/24 at 3:00 PM. Nurse # 9 reported the following. She heard that they were calling all the nurses to Resident # 2's unit. She ran to Resident # 3's room and saw he had blood in his eyes, ears, and on his arm. One of the Nurse Aides reported he had been beaten. She called 911 for the police and EMS to be dispatched. The facility Social Worker came and stayed with Resident # 2 while she was making calls and getting the paperwork ready for transfer for both residents. Then she took over staying with Resident # 2 until emergency services arrived. At the point where she started watching Resident # 2, he was agitated again and asking if she was going to shoot him while telling her she was an idiot and no good. She had worked with Resident # 2 previously and never known him to be paranoid or have behaviors when she had worked with him previously. He had always been pleasant. Resident # 2's guardian was interviewed on 3/21/24 at 9 AM and reported the following. She had known Resident # 2 and his wife for [AGE] years and knew them well. He and his wife were very active prior to his September 2023 hospitalization . She described Resident # 2 as very sweet and charitable towards others. He had no history of violent behavior. Historically he had worked for the military police and analyzed spy photographs. In September 2023 he was hospitalized and then he and his wife were placed in the facility. It was during the hospitalization that she first became aware of any confusion. The hospital physician had talked to her and informed her that Resident # 2 was hallucinating and thinking that he and his wife were being kidnapped. She was appointed his guardian in February 2024. She visited two to three times per week. She noticed he was becoming more and more confused, and to her, it appeared to be happening rapidly. He was having a harder time completing sentences. Some days she visited, and he was completely fine. Other days he was paranoid and would talk about being under surveillance through his clock, the smoke detector, or television. She felt as if his memories were becoming mixed up in his head. He never appeared aggressive to her. He appeared fearful. On the day of the incident, she had talked to him about two hours before the altercation. He had been in a great mood and had given no indication he could hurt anyone. She was totally shocked and felt as if he could be placed on the right medications, then he could be helped. She did not recall anyone at the facility talking to her about a psychiatric consult until after the incident. Review of hospital records for Resident # 2 revealed he had a psychiatry consult on 3/13/24 after he was hospitalized . The psychiatric NP (Nurse Practitioner) noted, Patient currently reports he doesn't know where he is or why he is not home. He states they took him out after he had to beat somebody up .He appears confused discussing enemies, traitors, and enemy cots. At the time of the survey, Resident # 2 remained hospitalized . Review of Resident # 3's 3/12/24 emergency department records revealed he was assessed to have a small laceration lateral to the right eye which was closed with skin glue and steri- strips, a skin tear to the elbow, and several abrasions and bruises to the forehead. A CT of Resident # 3's head revealed no fracture or hemorrhage. After treatment, he returned to the facility. The facility Social Service Director was interviewed on 3/20/24 at 4:50 PM and reported the following. She had never witnessed Resident # 2 be aggressive with another resident prior to 3/12/24 or wander into another resident's room. She confirmed a psychiatric consult had never been obtained for Resident # 2 and the referral had been inadvertently missed, but she was unsure how it had been missed. Resident # 2's physician was interviewed on 3/21/24 at 9:45 AM and reported the following. From Resident # 2's initial entry into the facility he had made crazy statements. Although Resident # 2 never received a psychiatric consultation, he (the medical physician) was seeing him and overseeing his medications. The highest likelihood of his psychosis was from dementia. Maybe in the last month his behaviors had increased some, but he always had some behaviors. They had sent Resident # 2 to the hospital on 3/1/24 and the hospital had not given any new orders, which validated to the physician that the facility's tr [TRUNCATED]

Based on observation, record review, resident interview, and staff interview the facility failed to ensure a resident was transferred safely. Resident # 1 sustained a fractured leg when two nursing staff members transferred Resident # 1 using a sliding board after therapy had determined Resident # 1 did not have the functional ability to use the sliding board safely. This was for one (Resident # 1) of three sampled residents reviewed for supervision to prevent accidents. The findings included: Resident # 1 was admitted to the facility on [DATE] and had a diagnosis of paraplegia and incomplete quadriplegia. Review of a physical therapy evaluation, which was completed on 2/2/24, revealed Resident # 1 was documented to have impaired strength in all her extremities. Resident # 1's mobility function score was documented as a 2 on a scale of 1 to 12, with the therapist noting that 12 indicated the highest level of mobility functioning. Resident # 1's quarterly Minimum Data Set assessment, dated 2/7/24, coded Resident # 1 as cognitively intact and as totally dependent on staff for transfers. Review of physical therapy progress notes revealed the therapist attempted to work with Resident # 1 with a sliding board for transfers and it was determined not to be an appropriate transfer technique. Specifically, on 2/22/24 Physical Therapist # 1 documented, Due to patient requiring 2-3 persons and total dependence, a slide board transfer is not appropriate at this time and should no longer be used. PT strongly recommends use of mechanical lift for patient safety. Resident # 1's care plan, updated on 2/22/24, noted Resident # 1 exhibited manipulative behavior and was at risk for falls. One of the interventions added to the care plan on 2/22/24 read, Resident often requests slide board to be used for transfer, [mechanical lift] is recommended by therapy for safety, resident aware. On 2/23/24 at 3:22 PM the ADON (Assistant Director of Nursing) entered a nursing entry labeled as late entry. The entry read Resident insisted on the use of the slide board for her transfer from bed to chair, that is what she has used for the last 5 years Physical therapist was asked to come to room. Together we discussed the importance of using [mechanical lift] for safety on all transfers, resident was then transferred to chair from bed with myself and PT. Therapy also repeated the importance of the use of [mechanical lift] for safety. The ADON was interviewed on 3/20/24 at 10:30 AM and reported the following. Around the date of 2/23/24 she was assisting Resident # 1. Resident # 1 wanted the ADON to help her use the sliding board to transfer. The ADON knew Resident # 1 needed a mechanical lift for safety purposes, and this was on Resident # 1's Kardex instructions as the mode of transfer for nursing staff to use. She (the ADON) asked a therapist to come talk to Resident # 1 about safety. The therapist explained safety concerns to Resident # 1, and Resident # 1 was agreeable to using the mechanical lift. Physical therapist # 1 and Physical therapist # 2 were interviewed on 3/19/24 at 3:00 PM and reported the following. They had both worked with Resident # 1 in therapy. Part of their treatment addressed the evaluation of transfers. Resident # 1 wanted to use a sliding board, and according to the therapists, in order to use a sliding board an individual needed to have enough core body strength that he/or she could sit without leaning. The individual also needed to be able to scoot along with the transfer. Resident # 1 did not physically have this capability. In her right leg she had no movement at all. In her left leg she had a trace of movement and could clench/contract a muscle in her left leg only. The therapists had given her a strap for leg support when they attempted to use the sliding board, and it had taken multiple people to help with the transfer. After working with her on the sliding board, they did not think it was safe because of her limited mobility. Therefore, it had been discussed with Resident # 1 that she needed to use the mechanical lift for safety reasons. That was her established plan of care for transfers. Review of nursing notes revealed on 2/25/24 at 10:45 PM Nurse # 10 documented a nursing entry noting the following information. Resident states her right knee was hurting worse after transferring into the bed. Palpated knee with no signs of swelling or pain. Informed MD (Medical Doctor). New order received to obtain knee x-ray. Resident informed knee x-ray will be done tomorrow. The results of the x-ray, completed on 2/26/24, revealed Resident # 1 had an oblique, moderately displaced fracture of the distal diaphysis of the right femur (leg bone). Review of hospital records revealed Resident # 1 was admitted to the hospital on 2/26/24 and underwent surgery on 2/27/24 for her femur fracture. On 2/28/24 she was transferred back to the facility for care. Resident # 1 was interviewed on 3/19/24 at 11:22 AM and reported the following. On the evening when she sustained the fracture, a nurse and a NA (Nuse Aide) were helping transfer her with the sliding board. Her right leg got caught between the bed and the chair. She (Resident # 1) thought she heard something make a noise when her leg caught, and she told the nurse and NA that they had broken her leg. Nurse # 11 was the nurse who had helped with the transfer on 2/25/24. Nurse # 11 was interviewed on 3/19/24 at 3:43 PM and reported the following. She had been at the nursing desk when NA # 4 approached the nursing desk and asked for help transferring Resident # 1 from her wheelchair to the bed. She went to Resident # 1's room with NA # 4 to help. Resident # 1 was not assigned to her, and she was not familiar with what the Kardex/care plan instructions were for Resident # 1. From looking at Resident # 1, Nurse # 11 thought Resident # 1 would require a mechanical lift transfer. She (Nurse # 11) asked NA # 4 how they were going to do the transfer. Resident # 1 was wanting to use the sliding board, and NA # 4 positioned a sliding board, which had been in Resident # 1's room, in the position to use it for a transfer. She and NA # 4 used a draw sheet to move Resident # 1 on the sliding board from her wheelchair into the bed. NA # 4 showed her (Nurse # 11) how to do this. She (the nurse) was on the other side of the bed pulling Resident # 1 with the drawsheet along on the sliding board. NA # 4 was positioned beside Resident # 1's wheelchair. NA # 4 was pushing Resident # 1 along on the sliding board towards the bed and towards Nurse # 11. He was also using the drawsheet on the sliding board to do this. She (Nurse # 11) did not hear a noise or see that Resident # 1's leg got caught during the transfer. When they got Resident # 1 on the bed, they noticed her upper body was not aligned with her legs at the hip area. Resident # 1 called out my leg. They tried to straighten her legs to see if the poor alignment would help her pain. Nurse # 11 was interviewed regarding who had been supporting Resident # 1's legs during the slide and reported her legs did not dangle and no one supported them. Nurse # 11 further reported that once they got her in bed, and the resident was complaining, then she (Nurse # 11) went to obtain Resident # 1's assigned nurse (who was Nurse # 10). NA # 4 was interviewed on 3/19/24 at 5:05 PM and reported the following. He had taken care of Resident # 1 before the date of 2/25/24 and she always wanted to use the sliding board. He did not think it was the greatest idea, but she did not like the mechanical lift. If they did not use the sliding board then Resident # 1 would put up a big fuss about it. He was not aware physical therapy thought the sliding board was unsafe to use or what the instructions were on the Kardex. Resident # 1 directed her care. On 2/25/24 he and Nurse # 11 used a draw sheet and the sliding board to place Resident # 1 back in the bed from her wheelchair. He had been at the side of the wheelchair pushing Resident # 1 along on the sliding board towards the bed with the draw sheet. Nurse # 11, who was standing on the other side of the bed, was pulling Resident # 1 along on the board using the draw sheet. When Resident # 1 was in the bed, Resident # 1 said she believed her knee was broken. NA # 4 was interviewed regarding who had been supporting Resident # 1's legs as the resident was being slid on the board. NA # 4 reported her legs had not dangled. She was in a wheelchair, which could be put in a reclining position about the same level of the bed. Therefore, they had just scooted her whole body on the draw sheet. NA # 4 further reported that after the transfer, then Nurse # 10 came to check Resident # 1. Nurse # 10 was interviewed on 3/19/24 at 4:30 PM and reported the following. On the night of the incident, NA # 4 and Nurse # 11 had informed her Resident # 1 was in pain after they had transferred her to the bed. She had not been in the room and did not know what had occurred during the transfer. She was not aware physical therapy thought the sliding board was not safe for Resident # 1 to use. After she (Nurse # 10) was informed Resident # 1 was hurting, she went to assess Resident # 1. She palpated Resident # 1's leg, and the resident did not flinch. She saw no physical abnormalities. Resident # 1 normally complained of some pain and muscle spasms, and the resident was ordered PRN (as needed) pain medications. Resident # 1's pain did not seem worse than her usual complaints. Nurse # 10 medicated Resident # 1 per the PRN order as she usually did, and the pain medication was effective. Nurse # 12 had cared for Resident # 1 on the day shift of 2/26/24. Nurse # 12 was interviewed on 3/19/24 at 4:44 PM and reported the following. On 2/26/24 during morning shift, she had been told Resident # 1's leg was hurting, and a mobile x-ray was scheduled. She medicated Resident # 1 for pain. The pain medication seemed to help, and she slept part of the day. She talked to Resident # 1 about the option of going to the hospital or waiting for the mobile x-ray. Resident # 1 opted to wait for the x-ray. When the x-ray was performed, it showed Resident #1 had a fracture. The technician let them know onsite when the x-ray was done that the fracture could be seen, and they transferred Resident # 1 to the hospital. Nurse # 12 further reported the following. The day shift staff nursing staff used a mechanical lift to transfer Resident # 1. Resident # 1 could be manipulative and try to get the staff to use a sliding board, but she (Nurse # 12) was aware that therapy did not allow them to do use it. Nurse # 12 stated a sliding board had not been in her care plan. The Administrator was interviewed on 3/20/24 at 3:20 PM and confirmed that Resident # 1 was to always have been a mechanical lift transfer for safety reasons. That had always been on the Kardex. The Administrator further reported the following. Resident # 1 was alert and oriented, and her staff always considered residents rights when caring for residents. She thought that had contributed to the incident occurring because her staff members were trying to do what the resident wanted although it was not safe. Following the incident, the facility had implemented a plan of correction. Part of their plan was to educate staff that if a resident insisted on a transfer that was not part of their Kardex/plan of care, then the staff member was to notify a supervisor. On 3/20/24 the Administrator presented the facility had completed a corrective action plan. The corrective action plan included the following: How corrective action will be accomplished for those residents found to have been affected by the deficient practice; On 2/25/2024 Resident # 1 convinced nursing staff to assist with an unsafe transfer from powerchair to bed using a slide board resulting in a fractured femur. Per resident care plan and Kardex resident is a two person assist via mechanical lift for transfers. Resident transferred to hospital on 2/26/2024. How the facility will identify other residents having the potential to be affected by the same deficient practice; All residents have the potential to be affected due to staff not following the Kardex. Care Plans and Kardex were reviewed for accuracy of how to transfer a resident including mode of transfer and how many staff members it requires for transfers on all current residents 2/28/2024. This was completed by the unit manager with the input of the therapy manager. The measures that will be put into place of systemic changes made to ensure the deficient practice will not recur; DON or designee will provide education to all nursing staff to review the Kardex for appropriate transfer status and to notify a supervisor if a resident insists on transferring in a route other than what is on the Kardex by 3/1/2024 Regional Director of Clinical services, Administrator, Therapy Manager and Director of Nursing met on 3/1/2024 and decided to implement QI safe transfer monitoring tool. Nurse managers or designee will perform observation of staff transfers to ensure accuracy according to the Kardex; this began on 3/4/2024 with 3 transfers 3x per week for x4 weeks, 3 transfers per week x 4 weeks and monthly x 1 month. All new hires after 3/1/2024 will receive training during orientation by the Staff Development Coordinator. How the facility plans to monitor its performance to make sure that solutions are sustained; Part of the Quality Assurance Plan Improvement Committee (Regional Director of Clinical Services, Administrator, Therapy Manager and Director of Nursing) met on 3/1/2024 and decided to audit and monitor transfers as part of Quality Assurance. This Quality Assurance subcommittee introduced the plan to the entire Quality Assurance Committee on 3/5/2024. Results of audits will be reviewed at Quality Assurance Plan Improvement Committee meeting x2 for analysis of patterns, trends or need for further systemic changes. Date of Compliance: 3/2/2024 The following was done to validate the facility's corrective action plan. During an initial tour of the facility, which began on 3/19/24 at 9:42 AM, multiple residents were interviewed. Residents did not report any problems with accidents occurring during care. A sampled dependent resident was observed as two staff members completed a transfer via a mechanical lift on 3/21/24 at 10:10 AM. Prior to the transfer the Nurse Aide located the Kardex and validated the type of transfer needed. The Nurse Aide validated there had been recent training about transferring residents. The Nurse Aide was interviewed about what she would do if a resident insisted on a transfer other than noted in a resident's plan of care. The Nurse Aide stated she would never do a transfer that was not included in a resident's plan of care. The sampled dependent resident was observed to be safely transferred by use of a mechanical lift per his plan of care. NA # 4 validated during his interview on 3/19/24 at 5:05 PM that following the incident he had received training about transfers. The facility presented documentation of staff inservice education and audits per their plan of correction. On 3/21/24 the facility's plan of correction date of 3/2/24 was validated.

Based on record review and staff interviews, the facility failed to prevent a resident from rolling off the bed during care which resulted in a right frontal hematoma and laceration, and right periorbital swelling from a fall and hospitalization for 1 of 3 sampled residents reviewed for supervision to prevent accidents (Resident #3). The findings included: Resident #3 was admitted to the facility on [DATE]. The resident diagnoses included fracture of T11-T12 vertebra, cerebral infarction and generalized muscle weakness. Resident #3's care plan dated 8/25/21 indicated she was at risk for falls related to gait/balance problems and psychoactive drug use. Interventions included: anticipate and meet needs, call light within reach and encourage the resident to use it, educate the resident/family/caregivers about safety reminders and what to do if a fall occurs. The admission Minimum Data Set (MDS) dated [DATE] indicated Resident #3 was severely impaired and required extensive assistance with bed mobility. She was coded for one-person physical assist with bed mobility. An incident note written by Nurse #1 dated 9/26/21 indicated Resident #3 was rolled onto her side getting linen changed and went over the other side of the bed. She had a hematoma on right eyebrow and eyelid and laceration to right forehead. Resident #3's post fall assessment dated [DATE] indicated she had a fall during bed linen change. She had a history of falls. The assessment indicated immediate action taken to prevent further falls was extra staff during rolling resident. During an interview on 11/9/21 at 9:10 am, Nursing Assistant #1 (NA #1) indicated she was changing resident #3's linen when she fell off the bed. She turned Resident #3 away from her so that she could take off the linen and she rolled out of bed hitting her head. She tried to hold onto Resident #3, but she slipped and hit the floor. She verbalized she had been trained to turn the resident toward her if she was providing care by herself. An interview on 11/9/21 at 10:26 am with Nurse #1 revealed she was the primary nurse for Resident #3 when she fell off the bed on 9/26/21. She indicated she became aware of the fall after NA #1 called for assistance from Resident #3's doorway. When she walked into the room Resident #3 was on the floor, she was bleeding from forehead and had swelling around her right eye. She was sent to the Emergency Department (ED) for evaluation. During an interview on 11/10/21 at 11:36 am with the Director of Nursing (DON), she indicated Resident #3 fell while being turned in bed. One NA was positioning Resident #3 when she fell . The DON stated NA #1 should have turned Resident #3 toward her instead of away from her. She stated NA #1 had been trained to turn the resident toward the staff instead of away from the staff when utilizing one-person physical assist. The DON indicated Resident #3's care plan was updated on 9/27/21 to 2-person physical assist with bed mobility to include rolling and repositioning. An ED consult note dated 9/26/21 revealed Resident #3 was seen at the ED on 9/26/21 for a fall. Resident #3 had a right frontal hematoma and laceration, and right periorbital swelling. A hospital Physician note dated 10/1/21 revealed Resident #3 was discharged from inpatient on 10/1/21. The discharge diagnosis was subdural hematoma. She was evaluated for a fall from bed on 9/26/21 and admitted through 10/1/21. Computerized Tomography (CT) scan of head/C-spine revealed 3 mm subdural hematoma, right temporal parietal region with soft tissue swelling/hematoma overlying the right frontal and periorbital region. No skull or cervical fractures were noted. General surgery, neurosurgery and trauma were consulted for subdural hematoma with no surgical intervention needed. The hospital physician note also indicated there was no focal deficit and mental status was at baseline. An interview was conducted on 11/10/21 at 12:00 pm with the Administrator. She stated NA#1 should have turned Resident #3 toward her because she was providing care by herself. She stated all the nursing staff were retrained, after Resident #3's fall, on turning residents toward staff if utilizing one-person physical assist. The Administrator indicated the facility had completed a plan of correction related to the fall. The facility's corrective actions implemented after the accident to prevent a reoccurrence included the following: 1. Resident #3 was transferred to the hospital post fall on 9/26/21 for evaluation. 2. Resident #3's care plan was revised on 9/27/21 to include two-person assist with turning and positioning and on 10/1/21 to include fall mats at bedside. 3. On 9/29/21 NA #1 was provided with education related to ensuring you turn the patient toward you, not away from you during care 4. On 9/29/21 education to nurses and nursing assistants was provided to ensure you turn a person toward you, not away from you when using one person assist during turning and repositioning 5. Staff educated if any resident is noted with abnormal or involuntary movements, they are to make resident two person assist until evaluated 6. Any nurse or nursing assistant who did not receive the education by the compliance date will be removed from schedule until completed. All new nursing staff would receive education during the orientation process. 7. QAPI committee met on 10/1/21 to review findings from 9/26/21 and education. POC was finalized. 8. DON/designee will perform audits of 5 random staff members to ensure they turn residents toward them during care. The audits will be performed daily x2 weeks, 3x a week for 2 weeks, weekly x4 weeks, then monthly x1. 9. DON is responsible for daily monitoring of audits and will report to Administrator daily in morning meetings any residents found to have abnormal movements. Administrator will report results to QAPI monthly x3 for compliance/changes if needed to the plan. On 11/10/21 the facility's Plan of correction was validated by the following: Audits conducted by the facility were reviewed and were found to be completed according to the plan of correction. Auditing started 10/1/21 and was expected to be completed by 12/15/21. All nurses and nursing assistants were educated on turning and repositioning. The training content stated, Will ensure you turn a person toward you not away from you when using one person assist during turning and repositioning according to Mosby's textbook for long term care nursing assistants, 8th edition chapter 15 Body Mechanics page 198. Facility Administrator conducted the initial training and Staff Development Coordinator(SDC) was responsible for tracking and training those who had not been trained. The SDC trained new nurses/nursing assistants as well as agency nurses/nursing assistants. SDC stated she was responsible for training new hires and turning/positioning training was part of the new employee orientation. On 11/8/21 at 2:01 pm nursing staff were observed turning Resident #3 using two - person assist as indicated in her care plan revised 9/27/21. During survey a nursing assistant was observed turning a resident toward the NA when utilizing one-person assist according to the in-service material. Interviews were conducted with nurses and nursing assistants who verbalized they had received training related to turning residents toward staff personnel if using one person assist.

Based on record review, observation and staff interviews, the facility failed to supervise and monitor a resident who was not compliant with the smoking policy and was found smoking in room with oxygen via nasal cannula on three occasions for one of five sampled residents (Resident #87) reviewed for smoking compliance. There was also no system or interventions in place to prevent recurrent noncompliance with the smoking policy by residents. The immediate jeopardy (IJ) began on 10/1/20 when Resident # 87 was found to be smoking in his room with oxygen present and no effective interventions were implemented to prevent reoccurrence. Immediate Jeopardy was removed 6/9/21 when the facility submitted an acceptable credible allegation of immediate jeopardy removal. The facility will remain out of compliance with a scope and severity D (isolated, not actual harm with potential for more than minimal harm) to complete educations and ensure monitoring systems put into place are effective related to supervision to prevent accidents. The findings included: The facility's smoking policy dated 01/23/2020 read in part: use of tobacco products and other electronic smoking paraphernalia was not permitted within the health and rehabilitation center by patients, staff, or visitors. If the administrator chose to designate on ground area approved for tobacco use by patients, family's visitors and employees, the administrator was to establish an administrative review of the campus-free smoking plan with the regional vice president of operations prior to implementation. The policy also included that patients who desired to smoke in the administratively designated grounds area must be assessed by the interdisciplinary team for their ability to safely smoke in the designated areas. Patients smoking in the designated grounds areas were to be supervised as deemed appropriate through their individual safe smoking evaluations. During an interview 6/7/21 at 4:40 PM, the Admissions Director stated the facility's Patient Smoking Acknowledgement Policy was used to inform new residents that it was a non-smoking facility and smoking in the facility was not allowed. If they smoke, admissions educated them on the process of telling the nurse they were leaving the floor and then sign out at receptions. Residents had to leave the property to smoke. All residents signed the policy at admission. Resident #87 was admitted [DATE] with diagnoses that included kidney failure receiving [CONDITION(S)], heart failure, and [CONDITION(S)]. His admission Minimum Data Set (MDS) dated [DATE] indicated he was cognitively intact and was dependent on staff to push wheelchair. The MDS indicated he used oxygen. He was not indicated to be a tobacco user. Record review of Resident #87's doctor's orders found an order dated 9/10/20 for continuous oxygen therapy 3 liters per minute via nasal cannula every shift, every day. Resident #87's Care Plan dated 9/23/20 indicated he had oxygen therapy as needed with interventions that included monitor for signs of respiratory distress and oxygen via nasal cannula as ordered. During an interview on 6/8/21 At 5:30 PM, Resident #87 reported he was aware the facility is non-smoking. He stated he usually had the nurse take his oxygen off in the room, went outside to smoke, and staff would come check up on him. He stated on the occasions he was smoking in his room, he was completely out of it and had just woken from sleep and lit his cigarette not realizing he was not outside nor in his own home. When he became more alert, he put the cigarette out and staff entered. He stated his cigarettes and lighter were at bedside. He stated his Responsible Party (RP) provided the cigarettes to the front desk and he picked them up from there. Resident #87 further stated he always used oxygen at night via nasal cannula and a concentrator but on these occasions the oxygen was off. He knew the oxygen was off because he could not feel it in coming out. He stated he was aware it was dangerous to smoke while on oxygen. During an interview 6/10/21 at 3:30 PM, Resident #87's RP stated she was unaware of the smoking policy and Resident #87 would go out whenever he wanted to smoke. She provided cigarettes to reception or gave it directly to Resident #87 because their were no restrictions. She stated he usually would not bring oxygen tank outside with him to smoke. She further stated she was not aware of him smoking in his room. A social work progress note dated 9/25/20 documented the resident was upset about not being able to go outside to smoke. The note explained due to COVID-19 restrictions, the residents were encouraged to stay in their rooms. The resident stated he will smoke in the bathroom if he must. The social worker notified Resident #87 and his Responsible Party (RP) he would be immediately discharged if caught smoking in the room. During an interview 6/7/21 at 3:50 PM, the social worker stated she was not aware of Resident #87 smoking in his room while on oxygen. She stated if she had been aware, she would have discussed with the administrator and started discharge proceeding. Record review of a Safe Smoking Evaluation dated 9/29/20 completed by Director of Nursing (DON) #2 indicated Resident #87 was safe to smoke without supervision. The question Does resident need facility to store lighter and cigarettes? was answered no. The Safe Smoking Evaluation did not include a question about oxygen use. A Care Plan dated 9/29/20 indicated he was a smoker and non-compliant with COVID-19 precautions to stay in room. The inventions included instruct resident about facility smoking policy, notify charge nurse immediately if it is suspected resident has violated facility smoking policy, and resident can smoke unsupervised. A behavior progress note written by Nurse #7 and dated 10/1/20 indicated resident was smoking in his room while on oxygen on night shift. When confronted by staff, he was noted to be angry and cursing at the nurse. It was documented he forgot. During an interview 6/7/21 at 5:00 PM, Nurse #7 recalled charting at the nurse's station when she smelled smoke. Resident #87 was in the bathroom on oxygen and denied smoking. She stated she reported this to her unit manager and the director of nursing. She stated they removed Resident #87's cigarettes and lighter and put them in a drawer at the nurse's station. She further stated the policy is if someone is caught smoking in their room, they were supposed to be discharged from the facility. A behavior progress note written by Nurse #8 and dated 4/14/21 indicated Resident #87 was smoking in his room while on oxygen on night shift. Intervention noted by the nurse was educated resident on effects of smoking indoors with oxygen on and encourage resident to refrain from smoking indoors. A behavior progress note dated 5/21/21 indicated Resident #87 was smoking in the bathroom on night shift. He stated to Nurse #8 he forgot where he was and that he was not supposed to smoke inside. Intervention was to educate resident on effects of smoking indoors with oxygen on and encourage resident to refrain from smoking indoors. During an interview 6/7/21 at 6:00 PM, Nurse #8 stated in April she smelled smoke coming from Resident #87's room and confiscated his lighter and cigarettes. She stated she wrote a progress note and notified the oncoming nurse. Nurse #8 stated the event in May was similar and that she believed Resident #87 was aware of what he was doing. She stated she did not notify management because she wrote it on the 24-hour report, entered a behavior progress note, and told the oncoming nurse. Written 24-hour reports were not available for review. During an interview on 6/7/21 at 6:25 PM, the DON #2 did not recall staff notifying her about a resident smoking in his room while on oxygen and she was unaware that this occurred. She stated she completed the Safe Smoking Evaluation 9/25/20 and updated the care plan because she was aware Resident #87 was smoking outside in the designated area. During an interview 6/11/21 at 1:30 PM, the DON #1 stated staff should have notified the DON or the administrator when the resident was found smoking in his room while on oxygen. Residents should have to ask for smoking materials and not have them in their room. Residents should understand the smoking policy at admission. During interviews on 6/7/21 at 2:40 PM and 5:20 PM, the Administrator stated she was not aware of any residents smoking in their room. She further stated if she had been aware, the resident would have been immediately discharged . She further stated there was no designated smoking area on the property, they went to an area off campus to smoke, and the residents signed out at reception. She further stated staff would confiscate smoking materials if residents were unsafe to smoke. She stated she was unaware of the policy that stated materials must be locked up. During an interview on 6/11/21 at 2:30 PM, the Administrator stated staff should notify management of any residents smoking in their room or while using oxygen. The Administrator was notified of the immediate jeopardy on 6/8/21 at 9:06 AM. On 6/9/21 the facility provided the following credible allegation of IJ removal: Plan for removing the immediate jeopardy: The department managers completed education to all staff on 6/8/2021 regarding immediately notifying administrator and/or DON at the time of occurrence for any resident caught smoking out of the designated area. Consequences of smoking with oxygen on can result in serious injury. Nurse management (director of nursing, assistant director of nursing, unit managers and/or staff development coordinator) will remove any employee that did not receive the education from the schedule until education is completed. All future employees will be educated by staff development coordinator on the above in-services during new hire orientation. This was completed on 6/8/2021 All nurses were educated to screen new admissions. Smoking assessments must be completed on all smokers and all smoking materials confiscated at time of admission and locked behind closed doors. This was completed 6/8/2021. Resident #87's smoking assessment was completed by Assistant Director of Nursing and was deemed to be unsafe to smoke unsupervised. This was completed on 6/7/2021 Resident #87 was immediately notified he would be moved to a private room due to safety risks by discharge planning director on 6/7/2021. Resident # 87 was reeducated by Administrator, Director of Nursing and Assistant Director of Nurse on facility smoking procedures and seriousness of consequences of smoking with oxygen. Resident was agitated initially however did understand the risk and reeducation on 6/7/2021. Family was notified of facility smoking procedures and seriousness of consequences of smoking with oxygen on 6/8/2021 Resident # 87 was placed on one-on-one observation on 6/7/2021 due to increased agitation/risk from room move and reeducation conversation this was reassessed on 6/8/2021 and resident was no longer agitated. He was pleasant and understanding of changes made to ensure resident safety. All smoking residents' rooms and persons were searched by unit manager and all smoking materials were confiscated and placed behind locked doors. Unit manager provided education to smokers on risks of having smoking materials in room and on person. This was completed 6/7/2021 Administrator will ensure all residents will receive updated smoking plan letter in person and all families will have the letter mailed postmarked on 6/8/2021 Resident # 87's social worker at [CONDITION(S)] center was notified by discharge planning director of concerns related to smoking indoors on 6/8/2021. Receptionist was educated by administrator on searching resident # 87's person and belongings at the time of returning from any outings including [CONDITION(S)] days which are Monday Wednesday and Friday to ensure any smoking materials are removed and locked away starting 6/7/2021 Resident #87 will be checked hourly from the hours of 11pm - 7am daily by a designated staff member assigned by the administrator to ensure resident is not smoking in his room this will begin 6/8/2021 The administrator will ensure implementation of ongoing surveillance of resident #87 's compliance of not having smoking materials on the person or in his belongings beginning 6/8/2021 Alleged date of IJ removal is June 8th Person responsible for implementation is the Administrator Validation: The validation of the immediate jeopardy removal was on 6/9/21. Validation of the credible allegation for IJ removal was completed as evidenced by interviews with nursing staff related to in-service on completing Safe Smoking Evaluations, interviews with various staff regarding new smoking policy, interview with resident and responsible parties about smoking procedures and interview with [CONDITION(S)] social worker about smoking concerns. Observations were made of Resident #87 in private room with and without supervision, smoking in designated area with supervision, and of smoking material location in locked medication room. Record review was completed for all listed smokers' Safe Smoking Evaluation. The immediate jeopardy was removed on 6/9/21.

Based on observation, record review and resident, staff, Consultant Registered Pharmacist (RPh), Physician Assistant (PA), and Physician interviews the facility failed to have an as needed pain medication available as ordered for a resident who verbalized a pain level of 9 on a 0-10 pain scale for 1 of 1 residents (Resident #261) who was reviewed for pain. Findings included: Resident #261 was admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Care Plan created on 05/12/21 revealed that Resident #261 had acute and chronic pain with an intervention to administer [MEDICATION(S)] per order. Another intervention listed was that Resident #261 preferred to have pain controlled by [MEDICATION(S)] (an opioid pain medication) 50mg (milligrams) every 8 hours as needed. The Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The order continued with instructions to hold the medication if an altered mental status or increased sedation was noted. The Controlled Medication Utilization Record revealed that 10 doses of [MEDICATION(S)] 50mg were received in the facility on 05/13/21. The 10th dose of [MEDICATION(S)] was dispensed on 05/21/21 at 5:19 AM. The admission Minimum Data Set (MDS) dated [DATE] revealed that Resident #261 was cognitively intact and did not receive scheduled pain medications but did receive as needed pain medications. Resident #261 had been in almost constant pain during the 5 day look back period. Resident #261's pain level was listed as 10 on a 1-10 scale. In an interview on 06/08/21 at 10:00 AM Nurse #1 stated that Resident #261 had complained of pain and when she went to get pain medication for her she discovered there was none on the medication cart. She indicated she went to the Emergency Medication Supply and discovered they did not carry [MEDICATION(S)] in the supply. She indicated that she approached the Unit Manager (UM) who instructed her to print out a prescription and to locate the PA who was in the building and have him sign it. She indicated she was waiting for the [MEDICATION(S)] to be delivered and had not provided any other pharmacologic intervention for pain to Resident #261. In an observation and interview on 06/08/21 at 10:10 AM Resident #261 stated that the pain in her left leg was a 9 on a 0-10 pain scale. She indicated that she also felt uncomfortable because she felt constipated. Resident #261 was making small adjustments in her position in the bed and stated that she was unsure if she could participate in therapy due to the pain. She indicated that she had not received any type of pain medication although she had requested them. She stated that she usually received [MEDICATION(S)] for her pain. The Order Note dated 06/08/21 at 10:51 AM and written by Nurse #1 revealed that Resident #261 had requested pain medication for leg pain of 6 out of 10. The provider was notified and an order for [MEDICAL RECORD OR PHYSICIAN ORDER] The Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The June 2021 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . In an interview on 06/08/21 at 11:02 AM Nurse #1 stated she had spoken to Resident #261's provider and he did not want to order any other narcotic for the resident's pain. She indicated he had ordered Tylenol instead. Nurse #1 stated that the prescription for [MEDICATION(S)] had been sent to the pharmacy and she had requested it be filled stat. The Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . In an interview on 06/08/21 at 11:08 AM the Occupational Therapist (OT) and the Physical Therapy Assistant (PTA) stated they had worked with Resident #261 that morning. They indicated that it took about 15 minutes of encouragement and motivation to get Resident #261 to agree to participate in therapy. The OT and PTA indicated that Resident #261 complained of constipation and left leg pain and told her that getting up and moving would help both. They indicated that when Resident #261 took pain medication it made her drowsy and that she still complained of pain. In an observation and interview on 06/08/21 at 11:47 AM Resident #261 presented with facial grimacing. She indicated that she had received a stool softener to help with her constipation and Tylenol for her leg pain but that her pain was still at a level of 9. She indicated that the leg pain and the uncomfortable feeling of constipation were different, and she could distinguish between the two. She indicated that her left leg hurt all the way down to her foot. Resident #261 stated she had agreed to go to therapy but could hardly participate due to the pain. Resident #261 stated that coffee or prune juice could help with her constipation and her request was passed on to Nurse #1. In an observation and interview on 06/08/21 at 1:05 PM Nurse #2 looked through the controlled medications on the 600 Hall medication cart where Resident #261 resided until 06/03/21. She confirmed there was no [MEDICATION(S)] on the cart for Resident #261 and there was no controlled medication sign off sheet in the 600 Hall narcotic book. In an observation and interview on 06/08/21 at 1:09 PM Nurse #1 looked through the controlled medications on the 700 Hall medication cart where Resident #261 now resided. She confirmed there was no [MEDICATION(S)] on the cart for Resident #261 and there was no controlled medication sign off sheet in the 600 Hall narcotic book. In an interview on 06/08/21 at 2:15 PM the Director of Nursing (DON) #1 stated that she had not known about the missing [MEDICATION(S)]. She indicated that the nurse should have informed her, and they could have ordered the pain medication from the local back-up pharmacy. She indicated that the [MEDICATION(S)] should be here from the pharmacy any minute. The June 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] #261 at 2:30 PM. In an observation and interview on 06/08/21 at 3:22 PM Resident #261 was lying on her back in bed. Her left leg was shaking up and down. She indicated she had received some brown pills but had not received the [MEDICATION(S)] yet. She indicated that the pain in her leg had not changed and was just as bad. In an observation and interview on 06/08/21 at 3:25 PM Nurse #3 accompanied the surveyor to the Emergency Medication Supply dispenser. He confirmed that there was no [MEDICATION(S)] stocked in the machine. He indicated that the facility had requested that [MEDICATION(S)] be placed in the machine but that the medication had not been stocked yet. In an interview on 06/08/21 at 3:28 PM the DON stated that Resident #261's [MEDICATION(S)] was enroute from the pharmacy. The Health Status Note dated 06/08/21 at 3:53 PM and written by Unit Manager (UM) #1 revealed that Resident #261 had complaints of leg pain. When she went to assess the resident, she was on the phone talking and laughing. Resident #261 told UM #1 that she felt much better now that she had some pain medication. Resident #261's pain level was at an 8. The note revealed that per the DON the resident was offered non-pharmacological pain interventions that were refused. In an interview on 06/08/21 at 4:08 PM Resident #261 stated she wanted a hot cup of coffee to help with her constipation. She indicated that she did not receive any prune juice earlier, but she did receive Milk of Magnesia (MOM). She stated she had been told her [MEDICATION(S)] was on its way to the facility. In an interview on 06/08/21 at 4:09 PM Nurse #1 stated that she had tried non-pharmacological interventions to help with Resident #261's pain throughout the day. She indicated that she elevated Resident #261's head for approximately 10 minutes. She offered to place a pillow under Resident #261's leg, offered to reposition her, and offered her an ice pack. Nurse #1 indicated that these interventions were refused by Resident #261. In an interview on 06/08/21 at 4:13 PM DON #1 stated she had offered to reposition Resident #261 and had offered a pillow for her leg. She indicated that the nurse was calling the provider to get an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . DON #1 stated that the nurse was getting a cold pack for Resident #261's leg and that she had received prune juice and coffee. The June 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] #261 at 4:32 PM. The Skilled Note dated 06/08/21 at 8:52 PM and written by Nurse #1, revealed that Resident #261 had complained of pain that morning and was out of her prescription [MEDICATION(S)]. Nurse #1 printed out a hard copy of the prescription and the provider signed it, and it was faxed to the pharmacy. A stat order was placed on the prescription. The resident said her pain was an 8 on the 0-10 pain scale and Nurse #1 checked the Emergency Medication Supply but there was no [MEDICATION(S)] available. The provider was notified but did not want to give anything stronger than [MEDICATION(S)] and ordered Tylenol. The resident's pain was assessed after an hour and was an 8 on the 0-10 scale. Non-pharmacological interventions were offered. an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #261 received MOM and the provider also ordered [MEDICATION(S)] and [MEDICATION(S)] for her constipation. The resident was reassessed after the [MEDICATION(S)] and her pain was still at an 8 on the 0-10 scale. The [MEDICATION(S)] arrived at the facility and it was administered at approximately 4:30 PM. Resident #261's pain level was assessed after an hour and her pain level was 5. Resident #261 had a small bowel movement but still felt constipated. In a telephone interview on 06/09/21 at 6:30 AM Nurse #4 stated that if there were 10 doses left of a medication, she would re-order them. She indicated that the facility should never run out of a resident's pain medication. Nurse #4 stated that if the medication was not on the medication cart the nurse should check the Emergency Medication Supply machine, and if not there, should notify the provider that something else was needed. Nurse #4 indicated that a stat order should take between 1-2 hours to arrive at the facility. The Health Status Note dated 06/09/21 at 7:06 AM and written by Nurse #4, revealed Resident #261 had two large bowel movements overnight and that she felt much better. In an observation and interview on 06/09/21 at 8:40 AM Resident #261 indicated that her pain level was an 8 on the 0-10 pain scale. She stated that she felt better, and her pain was easing down. Resident #261 stated that her constipation was also better. The Skilled Note dated 06/09/21 at 8:43 AM and written by UM #1 revealed that Resident #261's pain was at a 7 on the 1-10 pain scale and that the pain medication was gradually working. Non-pharmacological interventions were offered and refused. Resident #261 showed no outward signs of pain. The Health Status Note dated 06/09/21 at 10:15 AM and written by Nurse #6, revealed that Resident #261's pain level was now a 5 on the 0-10 pain scale. In a telephone interview on 06/09/21 at 8:55 AM the RPh stated that the [MEDICATION(S)] prescription had been filled on 06/08/21. He stated that controlled medications were not automatically refilled and needed to be ordered by the facility prior to running out of the medication. He indicated that there was a prescription on file in the pharmacy prior to 06/08/21 and that all the facility needed to do was call to order it. The RPh indicated there were multiple ways that the facility could reorder medications including electronically ordering, faxing the order, or calling the order to the pharmacy. He stated that the stat order for the [MEDICATION(S)] was received at 12:19 PM and that the pharmacist needed to check it and fill it and the order was ready to go out at 1:30 PM. The RPh stated that the pharmacy had up to 3 hours from the time filled to dispense the medication. He indicated that another faster option would have been to have the local pharmacy fill the prescription. The RPh stated that another option would be to stock [MEDICATION(S)] in the Emergency Medication Supply machine. He stated that it was not acceptable that the resident had to wait that long for pain medication and that the facility should have utilized the local back-up pharmacy. In an interview on 06/09/21 at 9:14 AM Nurse #5 who provided [MEDICATION(S)] to Resident #261 when there were two doses left, stated that when a resident got down to two doses of medications the nurse needed to reorder them. She stated that she should have reordered Resident #261's [MEDICATION(S)] and that she did not. Nurse #5 stated that the pharmacy did not automatically refill controlled medications and that the nurse needed to request them. She stated that it was not acceptable that Resident #261 did not have pain medications because the facility ran out of the medication and that she should have called the pharmacy to reorder them. In an interview on 06/09/21 at 11:09 AM UM #1 stated she was told by Nurse #1 that Resident #261 was in pain and that they were out of her [MEDICATION(S)]. She indicated that she did not know why the [MEDICATION(S)] was not available, but it should have been. UM #1 indicated that Resident #261 received Tylenol and [MEDICATION(S)] and that non-pharmacological interventions were also offered but they were refused. She stated that Resident #261's complaints of constipation were also addressed and that the medications had worked overnight. She stated that the nurses needed to call the pharmacy to reorder controlled medications because they were not refilled automatically by the pharmacy. UM #1 stated that Resident #261 was resting and had no signs or symptoms of pain and that her pain level had decreased to a 7. She indicated that the medication should have been requested from the local backup pharmacy so the pain medication could have been given sooner. In a telephone interview on 06/10/21 at 3:36 PM Physician Assistant (PA) #1 stated that he had been notified that no [MEDICATION(S)] was available for Resident #261's pain. He indicated that he did not want to order anything stronger than [MEDICATION(S)] because he wanted to wean the resident off the medication. He indicated he ordered Tylenol to be given while the facility waited for the [MEDICATION(S)] to be delivered. He stated the facility was to call him back if the Tylenol was not effective and when they called back, he ordered [MEDICATION(S)]. He stated that he wanted to try and get the pain under control without using addicting pain medications. PA #1 stated that he did not remember if he had been told of Resident #261's constipation but on review of the record he indicated that she had been treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . He indicated that medications should be reordered when there were 7-10 doses left to make sure they got to the facility in time to be administered. PA #1 stated that it was not acceptable for the facility to not have ordered medication on hand and that wasn't the way it was supposed to work. In a telephone interview on 06/11/21 at 1:05 PM Physician #1 confirmed that she was Resident #261's physician. She stated that it was not acceptable for the facility to run out of any medications. She indicated that the PA was there every weekday and they should be checking to see if any medications were needed on Thursdays so they could be ordered. She stated again that medications should be in the facility and available for resident use as ordered. Physician #1 stated that the facility should have requested the [MEDICATION(S)] from the local pharmacy so that Resident #261 could have received the pain medication more quickly and that it was unacceptable that they had not. She stated that Resident #261 should not have had to be in pain as long as she was because the facility had not reordered the [MEDICATION(S)]. Physician #1 stated the facility should not run out of any medications at all and not just pain medications. She stated there was no excuse for the facility not to have medications ordered by the providers in the facility for administration to the residents. In a telephone interview on 06/11/21 at 2:06 PM DON #1 stated that a resident's pain should be addressed immediately. She indicated that a resident should never have to wait as long as Resident #261 had to wait to receive her pain medication. The DON stated that if she had known the medication would take so long to arrive, she would have gone to the local pharmacy to get it herself. She indicated that it was her expectation that pain control be provided to the residents and that what happened to Resident #261 was unacceptable.

Based on observation, record review and staff, Consultant Registered Pharmacist (RPh), Physician Assistant (PA), and Physician interviews the facility failed to reorder medications which caused a delay in medication administration for 1 of 1 residents (Resident #261) who was reviewed for pain. Findings included: Resident #261 was admitted to the facility on [DATE] and had diagnoses of diabetes, a non-displaced fracture of the left foot, and a wedge compression fracture of the [MEDICATION(S)] vertebra. The admission Minimum Data Set (MDS) dated [DATE] revealed that Resident #261 was cognitively intact and received as needed pain medications. In an interview on 06/08/21 at 10:00 AM Nurse #1 stated that Resident #261 had complained of pain and when she went to get pain medication for her she discovered there was none on the medication cart. She indicated she went to the Emergency Medication Supply and discovered they did not carry the medication in the dispenser. She indicated that she approached Unit Manager (UM) #1 who instructed her to print out a prescription and to locate the PA who was in the building and have him sign it. She indicated she was waiting for the medication to be delivered. In an interview on 06/08/21 at 11:02 AM Nurse #1 stated that the prescription for the medication had been sent to the pharmacy and she had requested it be filled stat. In an observation and interview on 06/08/21 at 1:05 PM Nurse #2 looked through the controlled medications on the 600 Hall medication cart where Resident #261 resided until 06/03/21. She confirmed there was no pain medication on the cart for Resident #261 and there was no controlled medication sign off sheet in the 600 Hall narcotic book. In an observation and interview on 06/08/21 at 1:09 PM Nurse #1 looked through the controlled medications on the 700 Hall medication cart where Resident #261 now resided. She confirmed there was no pain medication on the cart for Resident #261 and there was no controlled medication sign off sheet in the 600 Hall narcotic book. In a telephone interview on 06/09/21 at 6:30 AM Nurse #4 stated that if there were 10 doses left of a medication, she would re-order them. She indicated that the facility should never run out of a resident's medication. Nurse #4 stated that if the medication was not on the medication cart the nurse should check the Emergency Medication Supply machine, and if not there, should notify the provider that something else was needed. Nurse #4 indicated that a stat order should take between 1-2 hours to arrive at the facility. In a telephone interview on 06/09/21 at 8:55 AM the RPh stated controlled medications were not automatically refilled and needed to be ordered by the facility prior to running out of the medication. The RPh indicated there were multiple ways that the facility could reorder medications including electronically ordering, faxing the order, or calling the order to the pharmacy. The RPh stated that the pharmacy had up to 3 hours from the time filled to dispense the medication. He indicated that another faster option would have been to have the local pharmacy fill the prescription. The RPh stated that another option would be to stock the medication in the Emergency Medication Supply dispenser. He stated that it was not acceptable that the resident had to wait for medication and that the facility should have utilized the local back-up pharmacy. In an interview on 06/09/21 at 9:14 AM Nurse #5 who provided the missing medication to Resident #261 when there were two doses left, stated that when a resident got down to two doses of medication the nurse needed to reorder them. She stated that she should have reordered Resident #261's medication and that she did not. Nurse #5 stated that the pharmacy did not automatically refill controlled medications and that the nurse needed to request them. She stated that it was not acceptable that Resident #261 did not have medication because the facility ran out of the medication and that she should have called the pharmacy to reorder them. In a telephone interview on 06/10/21 at 3:36 PM Physician Assistant (PA) #1 stated that he had been notified that the medication was not available in the facility for Resident #261. He stated that the facility should not run out of medications that were ordered for the residents. He indicated that medications should be reordered when there were 7-10 doses left to make sure they got to the facility in time to be administered. PA #1 stated that it was not acceptable for the facility to run out of resident's medications. In a telephone interview on 06/11/21 at 1:05 PM Physician #1 confirmed that she was Resident #261's physician. She stated that it was not acceptable for the facility to run out of any medications. She indicated that the PA was there every weekday and they should be checking to see if any medications were needed on Thursdays so they could be ordered. She stated again that medications should be in the facility and available for resident use as ordered. She stated there was no excuse for the facility not to have medications ordered by the providers in the facility for administration to the residents. In a telephone interview on 06/11/21 at 2:06 PM Director of Nursing (DON) #1 stated that she expected the nurses to reorder medications when they got down to the seven-day level. She indicated that even if it was too early, the pharmacy would send it out at the correct time. DON #1 stated that a nurse should never use the last dose of a medication without reordering the medication. She stated it was important that medications be in the facility so they could be administered as ordered by the physician.

Based on observations, record review, resident, family, Physician and staff interviews the facility's contracted transportation driver (Van Driver #1) failed to secure the resident with the seat belt before transporting her back to the facility after her [MEDICAL TREATMENT] appointment for 1 of 4 sampled residents (Resident #1). Resident #1 fell out of her wheelchair and landed on the floor of the transportation van after Van Driver #1 had to stop suddenly to avoid being hit by another vehicle. As a result of not using the seat belt, she sustained right maxillary (face) contusions, fractures of the right inferior and superior pubic ramus (pelvis bone), questionable Hematoma (localized bleeding outside of blood vessels, due to either disease or trauma, including injury or surgery) to right wrist, and nondisplaced fracture at the proximal shaft of the fourth metacarpal (ring finger). Findings included: Review of Van driver #1's signed transportations safety policy dated 09/08/2020 read, Each driver must complete the training video before locking down anyone to the vehicle for transport. Clients must be restrained to the vehicle and chairs properly, according to the training video, at all times during transport. All drivers must check off safety checklist with each transport. Review of the safety checklist/verification form listed a space to document the Resident/client name, date, time, facility employee and drivers initial. The checklist required a checkmark for: wheelchair straps, seatbelt, leg-rest and wheelchair pad for each resident/client. Resident #1 was admitted [DATE] with [DIAGNOSES REDACTED]. The annual Minimum Data Set ((MDS) dated [DATE] had Resident #1 coded as moderately cognitively impaired needing extensive assistance with activities of daily living (ADL). The resident was also coded as having had [MEDICAL TREATMENT]. During a telephone interview with Resident #1 on 12/11/2020 at 8:13 PM, Resident #1 stated all she remembered was the van stopping and her falling out of her wheelchair onto the floor of the van. Resident#1 also stated her seat belt was not buckled and she was in a lot of pain. During a telephone interview with Family Member #1 on 12/11/2020 at 7:32 PM, Family Member #1 stated on 12/02/2020, she was at the [MEDICAL TREATMENT] center after Resident #1 received her treatment and saw Van Driver #1 having problems trying to buckle her seatbelt. Van driver #1 stated he was having a hard time buckling her seatbelt. Family Member #1 also stated she did not see if the seat belt was fastened when she left the [MEDICAL TREATMENT] center. She left, went home and received a call from the DON stating Resident #1 was in an accident, fell out of her wheelchair and would be going to the Emergency Department (ED) because her right side was hurting. Family member #1 also stated the Director of Nursing (DON) told her Van driver #1 said he had to slam on the brakes to avoid getting hit by another vehicle and Resident #1 fell out of the wheelchair. Family member #1 further stated Family member #2 went to the facility on [DATE] for a meeting with the Administrator, Van driver #1 and others to discuss what happened and how it happened and at that time, Van driver #1 stated Resident #1 slipped out of the wheelchair. During an interview with the Admissions Coordinator (AC) on 12/11/2020 at 4:01 PM, the AC stated she saw the transport van, at the entrance of the facility at approximately, 4:10 PM, on 12/02/2020, parked on the side where the bricks are for about 4-5 minutes. The AC also stated she was making copies and looked out the window and watched him then pull up to the front door and he asked the Receptionist if he can get some help. During an interview with Receptionist on 12/11/2020 at 4:07 PM, the Receptionist stated at 4:15 PM she saw the driver pulled up in the transportation white van and stated he needed help, right away. The Receptionist stated she reported it to the Director of Nursing (DON). A progress note written by the DON dated 12/02/2020 read, Resident was observed lying flat on her back in the transport van. Wheelchair was located behind her. Upon assessment, resident was calm and able to state name, date of birth, and family members' names. Stated she had pain in her right leg and unable to move at this time. No visible injury to her right leg. Swelling noted to the right side of her forehead. Resident was able to move upper extremities. No open areas noted. Emergency Medical Services (EMS) called immediately to transfer to Emergency Department (ED) for evaluation. Dr. notified. During an interview with the DON on 12/11/2020 at 3:47 PM, the DON stated on 12/02/2020 at approximately 4:15-4:30 PM the Receptionist told her that Van driver #1 needed help with Resident #1 because she had fallen on the van floor, due to him having to stop fast to avoid another vehicle hitting him at the light in front of the facility. When the DON arrived at the van, she found Resident #1 on her back, with redness noted to her right side of her face. Resident #1 was assessed, and members of her nursing staff came out to assist. The DON asked them to stay with Resident#1, so she could call 911 and the family. Resident #1 was not moved because she was a mechanical lift resident and they suspected her head was hit in the accident. The Emergency Medical Services (EMS) came but could not get her on the stretcher, so the fire department came and were able to get her in the ambulance and she was taken to the ED. The DON stated the van driver reported to her, Resident #1's seat belt popped off. During an interview with Nurse #1 on 12/11/2020 at 4:14 PM, Nurse #1 stated she was alerted by one of the people that worked in the front office on 12/02/2020. She was told Van driver #1 was outside stating Resident #1 had been hurt, there was some sort of accident and they needed nurses outside. So, she went outside to the transportation van and found Resident #1 laying on her back, her head was facing towards the back of the van. She was complaining of some right-sided pain. She noticed some swelling to the right cheek. Van driver#1 said somebody had pulled out in front of him, he had to slam on the brakes, and she fell out of her wheelchair. Nurse #1 also stated she stayed with her until EMS arrived. During an interview with UM on 12/11/2020 at 4:33PM, the UM stated he arrived at the incident about 4:30 PM. He got a call in his office stating they needed some assistance up front and asking if he can come outside. The UM stated when he arrived at the transportation van, he found Resident #1 lying on her back and complaining of pain to her right side of her body. The DON had assessed her and asked if he would stay with her so she could call EMS and the family. The UM further stated EMS arrived shortly after and she was taken to the hospital. During an interview with the Administrator on 12/11/2020 at 3:28 PM, the Administrator stated she received a report on the phone from the Director of Nursing (DON) son 12/02/2020 approximately 4:30 PM, stating Resident #1 was in the van at the facility, had a fall and was calling 911. Resident #1 was transported to the emergency room . She did have some swelling in her face, she had pain in her right leg. The Van driver #1 stated that one of the seat belts must have popped off because he had strapped the patient in, and he thought because of her weight, the seat belt popped. The Administrator also stated she scheduled a meeting the next day with Family member #2, the supervisor of the contract transportation company, and Van driver #1. The next day at 10:00 AM, they met outside, with the van that was used in the accident. Van driver #1 reenacted the incident and stated Resident #1 was in her wheelchair and she was wearing her safety belt. Van driver #1 also stated because of her weight, the belt popped. There were no issues found concerning the safety belts. They also, brought out the wheelchair that was being used for the transport and they had him show them how it should be done. Van driver #1 then said the seat belt didn't pop the patient slid under the seat belt. The Administrator told him the injuries are not consistent with the resident sliding out. The Administrator also stated she was trying to explain to the manager, her injuries were not consistent with the story because she had a contusion right under her cheek and the huge hematoma mean some [MEDICATION NAME] trauma occurred. The next day, the Administrator had a conversation with Family member #1. Family member #1 stated she was at the [MEDICAL TREATMENT] center with her mom and that she had actually saw him load her up into the van and that he could not get the seat belt buckled. Van driver #1 told her she was fine. Family member #1 also stated the ED had indicated it was a force trauma and there were questions as to how she ended on her back when she had front facing injuries and none to her back. The Administrator acknowledged Resident #1's fall in the contracted transportation van was because Van Driver #1 failed to secure Resident #1 in her wheelchair with the seatbelt before transporting her back to the facility after her [MEDICAL TREATMENT] appointment. During an interview with the Contract Transportation Supervisor (TS) on 12/11/2020 at 5:02 PM, the TS stated Van Driver #1 was on administrative suspension until the investigation was completed concerning the incident on 12/02/2020. They were gathering information about the incident. The TS stated Van Driver #1 stated he was avoiding an accident and as he hit the brakes, Resident #1 came out of the wheelchair. The TS also stated they are investigating because he had two different stories. The first was the seat belt popped open due to the client's weight and the second was Resident #1 slid out of the wheelchair. On 12/03/2020, the TS visited the facility with the van used in the incident with Van driver #1 for a meeting with the Administrator and Resident #1's family member. They discussed the incident from 12/02/2020. Van Driver#1 stated as he was at the stop light in front of the facility. He was preparing to make a right turn and was cut off by a car and had to hit the brakes to avoid a collision with the vehicle. While at the facility, the adjustable seatbelts, the adjustable shoulder strap and restraints were checked and there were not any problems noted. The seatbelts are adjustable, so the size of a client would not cause the seatbelt to pop open unless there was a malfunction. There were not any malfunctions found with the seatbelt. The TS also stated before any transport, the drivers must have their passengers safely buckled in their safety belt and are required to perform a safety check using their safety checklist before they begin their transport. The TS stated he has not been able to get in contact with Van driver #1 since the meeting. The TS further stated Van driver#1 did not have a safety checklist completed for 12/02/2020. Van Driver #1 was not available to be interviewed. Family member #2 was not available to be interviewed. During a telephone interview with the attending Physician at the hospital on [DATE] at 12:43 PM, the Physician stated Resident #1 was still admitted in the hospital and had been Resident #1's attending Physician since 11/08/2020. Resident #1 was admitted on [DATE] from the ED due to an accident on a transportation van on 12/02/2020. She had [DIAGNOSES REDACTED]. The Physician stated he cannot say what the circumstances were that occurred before the fall to cause the injuries to Resident #1. The ED notes read: 12/02/2020, Patient arriving via EMS. Patient was on her way back from [MEDICAL TREATMENT], wasn't secured properly, fell out of her wheelchair onto her right side sustaining pain to the hip as well as swelling and bruising to the right side of the face, pain in her right face, right shoulder swollen and tender and right arm swollen and tender. Resident #1's [DIAGNOSES REDACTED]. Resident #1 remained in the hospital at the time of the survey. The facility's investigation and root cause summary completed by the Administrator dated 12/02/2020 read: Resident #1 fell out of her wheelchair in the transport van. Resident was able to answer all questions appropriately, however, did not know what happened in the incident. Nursing staff did notice injury to the right side of her face of redness and swelling. She also complained of right leg pain. The patient was supported in the van by staff until EMS arrived then she was transferred to the hospital for further evaluation. Van driver #1 was interviewed. He stated he was making the turn at the stop light directly in front of the facility when a car pulled out in front of him and he had to brake suddenly at the top of the driveway. He stated that the resident was properly seat belted and locked in and that the seat belt must have popped off due to her weight because he had placed it on her. On 12/03/2020, the TS from the contract transportation company was Informed that until further investigation was completed, we did not want the driver of the accident conducting any transports. On 12/03/2020 the Administrator, DON and ADON met with the Family Member #2, the TS of the transportation company and Van Driver#1 outside with the van used during the transport. They also brought out the wheelchair used during the accident. Van Driver #1 and the TS demonstrated to everyone how the patient was secured in the van. During that time, the driver changed his story and stated the resident was properly secured in and that she slid out from under the seat belt. The DON spoke to Family Member #1 via telephone on 12/03/2020 who indicated she was at the [MEDICAL TREATMENT] center with Resident#1 when the driver was loading her in and he was having a difficult time trying to get her buckled in and that she communicated to him if everything would be okay for her transport. He told her everything was fine. She stated she left and did not see if he was able to get the seat belt working. During the investigation the DON obtained statements of what transpired. It was also noted, from the Admissions Coordinator whose office overlooks the facility' s driveway, that Van driver #1 turned in and parked at the top of the drive for a few minutes before pulling into the facility and notified staff of the accident. The facility performed an investigation on 12/02/2020 and put a corrective action plan in place. On 12/12/20, the facility provided an acceptable Plan of Correction with a correction date of 12/07/2020. The Plan of Correction included: Resident #1 sustained a fall on the transportation van 12/02/2020 at the stop light in front of the facility at approximately 4:15 PM. Resident#1 was being transported in a van driven by the contracted transportation company and her seatbelt was not fastened. Van driver #1 stopped suddenly, and she fell from her wheelchair causing injuries and was sent to the hospital. She assessed onsite by the DON and she was transported by EMS to the ED. Upon discussing with family, the hospital' s evaluation of her injuries her facial injury was consistent with frontal injury and nothing was noted to the back of the head. This was not consistent with the van driver's new story that she slid off the chair because the resident was lying flat on her back and wouldn't have sustained facial hematoma as noted by hospital. The resident sustained [REDACTED]. It was also noted that resident is larger in body mass and that she would have been found entangled in seat belt not flat on her back on the floor. During the investigation the DON obtained statements of what transpired. It was noted from the admissions coordinator whose office overlooks the facility' s driveway, that the driver had turned in and parked at the top of the drive for a few minutes before pulling into the facility and notifying staff of the incident. Statements for incident on 12/02/2020 involving Resident#1 read: Van driver #1 on 12/02/2020: He was turning into Carolina Rehab, a car came out of traffic and accelerated rapidly in front of him, almost hitting him which caused him to break. While breaking to avoid the accident. Resident#1 slid from under seatbelt restraint feet first on the floor of van. ADON: On 12/02/2020 she was called outside because Van driver #1 stated Resident #1 fell out of her wheelchair in the van. As she approached the van, Resident#1 was lying flat on her back with the wheelchair at her head. She stated her face hurt and her ankle hurt. The ADON continued to assess the resident. Resident #1 asked her to move her right leg. She informed her that she did not think that was a good idea, in case something was fractured. She informed Resident #1 that EMS was called. Her right hand was [MEDICAL CONDITION]. The ADON stayed with patient until Fayetteville fire dept arrived. The Admission Coordinator statement dated 12/04/2020 read: On December 2, 2020, she witnessed the contract transportation van parked towards the end of the driveway of the facility. The driver was parked for approximately 4 minutes. He then proceeded to pull up to the front door. As he came to the front door to let the receptionist know that the resident had fallen out of her wheelchair in the back of van. All while he was on his cellphone, his sense of urgency was not there at all. The DON's statement dated 12/02/2020 read: On 12/02/2020, she was alerted that a resident fell out of her wheelchair in the contract company's van. She immediately went to assess the resident with Nurse#1. Resident #1 was lying flat on her back, front of the wheelchair. Upon physical assessment, resident stated her right leg was in pain. We did not move her at all. She was able to state her name, daughters' names and date of birth, the wheelchair was still restrained on the bottom left side of the wheelchair. Nurse#1 and the Van Driver #1 unbuckled the left restraint to remove the wheelchair. EMS was called to assist with transfer to the hospital. Nurse#1 and The Unit Manager stayed with resident to wait for EMS while she called to inform family. Family member #1 cell phone had a voicemail that was full. The statement from Nurse#1 dated 12/02/2020 read: At approximately 1615/1630 on 12/02/2020 she was asked by the front admissions department to go outside to assist with a patient who had a fall in the contract transportation van. She found the resident laying on her back, feet towards the front of the van and her head facing towards the back. There weren't any signs of respiratory distress. Resident was alert and oriented x4. She stated that her right leg was hurt, and it was noted that she had a contusion to her right cheek. No signs of bleeding. Resident was kept in Supine position. DON notified. EMS called. The statement from the Unit Manager on 2/02/2020 read: Writer was called to the front of the building, upon arrival found staff members inside of transport van with resident also in laying in van supine on the center of the floor. When asked what happened resident stated, She didn't know, they stopped suddenly, and she fell out. Resident #1 was noted to have right side facial swelling and also swelling to her right upper extremity. Resident complained of right-side discomfort. Determination was made to call EMS for further evaluation and to transport to hospital. On December 2, 2020, therapy did an evaluation on the wheelchair of Resident #1 was using and determined that the wheelchair was in working condition. However, it was not her usual wheelchair. On December 2, 2020, the rehab department assessed the other resident's wheelchairs that are going to [MEDICAL TREATMENT] to ensure they are in the correct wheelchair with proper functioning parts. All [MEDICAL TREATMENT] resident's wheelchairs have been assessed and no issues with the wheelchair, brakes, or cushion were noted. Residents being transferred by contract transportation company services had their wheelchairs assessed and are appropriate for each resident for transport. On 12/03/2020, 100% audits were performed to validate that residents were properly secured before departing the facility. On 12/4/2020 operations manager sent over in-services done on 12/4/2020 for all drivers. On December 4, 2020 during an interview with Family member #1 via telephone, she indicated that Resident #1 was now able to converse with them and did not recall specifics about the accident, however, did know she did not have a seat belt on during the transport. At that time the TS at contract transportation company of the new finding. At that time, it was also discussed that education would need to be provided to all drivers to safely pullover at the scene of an accident that results in a fall or injury, to immediately call for help and not move the resident and for seatbelt safety. The in-service of all staff was be completed on 12/07/2020. The QAPI committee met on 12/07/2020 to ensure compliance/changes were met. As part of the validation process on 12/14/2020, the entire plan of correction was reviewed including the re-education of van drivers for safe transport of clients. An observation of the wheelchair inspections on 12/12/2020, performed by Therapy Director. An observation of a transport van on 12/14/2020 found Resident #3 safely being loaded onto the contract transportation van by Van Driver #3 using 4 restraints for the wheels, an adjustable lap belt and an adjustable seatbelt. On 12/14/2020, Resident#3 was interviewed, he stated the contract transportation drivers safely transports him using his lap belt and seatbelt. On 12/14/2020, Van Driver #2 was interviewed, he stated he received re-education for seatbelt safety and always follows his checklist and uses the 4 restraints to the wheelchair chassis, the lap belt and the seatbelt which are adjusted to fit all of his clients and has transported Resident #1 and has never had trouble with her size or her seatbelts. A review of the contracted transportation company's plan of correction revealed 100% of staff were trained on safe transportation for clients in wheelchairs by 12/04/2020. A review of the facility's 12/02/2020 data collection audit tool for transportation safety revealed they completed the audits as indicated. The facility wheelchair audit was reviewed and was completed on 12/07/2020. The facility had completed a QAPI meeting on 12/07/2020 which included the Interdisciplinary staff to ensure all safety measures were in place. The facility's correction date of 12/07/20 was validated.

Based on record reviews, observations, emergency room Physician, Physician interview, and staff interviews, the facility failed to provide 2 person assistance when using a mechanical lift for 1 of 3 sampled residents reviewed for accidents (Resident #1). As a result of not using 2 persons when using the mechanical lift, the resident fell from the lift and hit her head on the floor. The resident sustained [REDACTED]. The resident had [MEDICAL CONDITION] while emergency medical services attended to her, was diagnosed with [REDACTED]. The findings included: Resident #1 was admitted on [DATE] with [DIAGNOSES REDACTED]. The annual Minimum Data Set (MDS), dated [DATE], indicated Resident 1#'s cognition was intact, and she required extensive assistance with help of 2 persons for bed mobility, transfer, dressing, personal hygiene and toileting. The MDS also indicated Resident #1 had upper extremity impairment on one side. The MDS and the Care Area Assessment (CAA) did not indicate Resident #1 exhibited any behaviors of resisting care. Resident #1's care plan, updated on [DATE] indicated Resident #1 had problems which included, activity of daily living (ADL) self- care performance deficit due to impaired mobility, resistive to care as the resident will refuse care/showers/medication due to adjustment to environment and verbally aggressive to staff due to ineffective coping skills, mental /emotional illness and poor impulse. The interventions included. Resident # 1 required maximum staff assistance with transfers (a mechanical lift with 2-person transfer), and if resident resisted assistance with ADLs, then reassure resident, document observed behavior and attempted interventions. The incident report dated [DATE] completed by Nurse #1 documented Resident #1 fell out of a mechanical lift while being transferred from a shower bed to bed. Resident #1 was being transferred by NA #1 using a mechanical lift without a second person to assist with the transfer. The report indicated Resident #1 fell out of a mechanical lift and hit the back of her head. The assessment of the resident revealed she sustained 2 lacerations on the back of her head in the shape of a horse shoe and the resident was bleeding from back of head. The report further indicated Nurse #1 and Nurse #2 placed gauze on resident's head and wrapped around head to stop the bleeding. Resident #1 was alert to person. Pupils equal round and reactive to light with accommodation. The report also indicated Resident #1 was able to follow simple commands. Did not remember what happened. Repeatedly asked what happened to her and was awake the whole time. The report further revealed 3 other personnel helped lift resident from floor to bed. The resident's vital signs were then taken. Blood Pressure (BP) ,[DATE], Heart Rate (HR) 93, temperature 97.3, Respiration (R) 20, Oxygen (O2) saturation 96%. 911 was called for resident to be transported to the hospital. The recommendation was documented as following: In-service done with all staff on transferring residents with mechanical lift and to always have 2 people when transferring residents. During the interview on [DATE] at 10:30 AM, NA #1 reported she had been assigned to Resident #1 before [DATE] and normally the resident would be verbally abusive when she is given ADL care. NA #1 reported on [DATE] after she had given Resident #1 a shower, on the way back to the room she started yelling at her about her shower. She reported there was no staff members in the hallway to assist her with the mechanical lift transfer. She added since no one was available she did not ask for help so she proceeded to transfer Resident #1 from the shower bed to her bed. While transferring the resident, she started yelling saying the lift pad which was the right size for the resident was too tight and she started to shift on one side and the lift pad twisted under her. NA #1 lowered the lift trying to prevent the fall, but the Resident fell anyway. She added Nurse #1 was immediately notified about the fall. NA #1 further reported she did not try to get help because they were short of staff on that day because she looked in the hallway and no staff could be seen to ask for assistance. NA #1 reported she was aware that she needed a second person for transfer. She further reported she was trained on the proper use of a mechanical lift when she was first hired at the facility. During the interview on [DATE] at 10:48 AM, NA #2 reported she assisted NA #1 to transfer Resident #1 from her bed to the shower bed before getting her shower. NA #2 reported she did not recall NA #1 requesting assistance to transfer Resident #1 back to bed from the shower bed after getting her shower. NA #1 reported Resident #1's pad was correct size and they had no problems transferred the resident from her bed to the shower bed. NA#2 also reported they had enough staff at the facility on [DATE]. During the interview on [DATE] at 12:15 PM, Nurse #2 reported NA #1 reported to her on [DATE] that Resident #1 fell on the floor during a transfer. She asked NA #1 why she did not ask her to assist her, but NA #1 did not have a reason. Nurse #2 reported after assessing the resident, she took precautions to keep head and neck in-line to maintain C (cervical spine)-spine (vertebral column). Once she realized Resident #1 was bleeding from her head, three additional personnel assisted with lifting resident from floor to bed. Nurse #2 added the Resident was awake the whole time. She reported Resident #1 was alert to herself and could not tell her what happened moments before, and Resident #1 repeatedly asked Nurse #2 what happened to her. Once resident was in the bed, she was able to get the vitals. Nurse #2 also reported prior to Resident #1's fall, she was alert and oriented to herself and her surroundings. She added after the fall, the resident was very confused and asked repeated questions. Nurse #1 reported on [DATE], the facility had enough staffing. She added she did not understand the reason NA #1 did not ask her for assistance to transfer Resident #1. She also reported the resident's lift pad size was correct size during the transfer by NA #1. During the interview on [DATE] at 11:40 AM, Nurse #1 reported unit Nurse #2 came at about 10:00 AM and asked her to come help her in Resident #1's room. When she walked into the room, the resident was lying on the floor and her head was resting on the base leg of a mechanical lift. She reported it appeared to her that the resident may have hit the back of her head on the corner of the lift. She indicated she immediately moved what to keep the resident's head still as possible and put her gloved hand over the bleeding to apply pressure. Nurse #1 reported the resident had the correct size lift pad underneath her. She added, she stayed with the resident the whole time with Nurse #1 until Emergency Medical Services (EMS) arrived to take her out .They relayed any information they could to EMS and told them she was not at her baseline in personality at that time. Nurse #1 reported Resident #1 was upset and could not remember anything they were telling her. Nurse #1 further reported they had no problems with staffing on [DATE]. Emergency Medical Services (EMS) report dated [DATE] documented the EMS personnel arrived at the facility and located the resident lying flat in her bed with a bandage wrap noted to her head. The document indicated Nurse #1 advised the EMS personnel that Resident #1 had fallen out of the mechanical lift into the floor. Nurse #1 advised the EMS personnel that the resident hit her head on the metal leg of mechanical lift. The document further indicated upon the EMS personnel leaving Resident #1's room, they stopped at the nurse's desk to grab the paperwork. The resident was then noted to have [MEDICAL CONDITION] that lasted around 30 seconds the personnel administered the medication and the resident stopped seizing. The document also indicated that after the [MEDICAL CONDITION] the resident was noted to be confused and asked over and over where she was and what was happening. The resident was not noted to have any other [MEDICAL CONDITION] while in route to the hospital. During the interview on [DATE] at 12:30 PM, the Director of Nursing (DON) stated it was reported to her by Nurse #1 that Resident #1 fell on the floor during when NA #1 used a mechanical lift to transfer Resident #1 without the assistance of another staff member. She reported after Resident #1 was sent out to the hospital she did an investigation about the fall incident and NA #1 was terminated due to failure to follow the guidelines, on the use of a mechanical lift with the assistance of another staff member. DON stated her investigation revealed no mechanical problems with the lift and NA #1 used the correct lift pad. DON indicated the facility had enough staff on duty on [DATE] and she concluded NA #1 was negligent because she should have requested for assistance before transferring Resident #1 from shower bed to her bed. During the interview on [DATE] at 12:45 PM, Administrator reported she investigated Resident #1's fall after the resident was sent out to the emergency room . She reported NA #1 was aware Resident #1 required 2 person assistance but chose to use the lift by herself. She reported NA #1 was terminated and an action plan was put in place following the incident. The staff had been educated that a mechanical transfer was to occur with at least two clinical staff members. She further added the staff were educated to use a call light and wait for assistance if they could not find another staff member in the hallway. Did the admin know about staffing and lift pad size? During the interview on [DATE] at 1:13PM, Physician reported he was notified immediately of Resident #1's fall on [DATE]. He reported the resident died at the hospital, but he could not state that the fall caused the resident's death. He added the resident had a lot of comorbidities that included old [MEDICAL CONDITION] infarction and hypertension. Physician stated all residents that fall do not die from a fall. emergency room documentation dated [DATE] indicated: The emergency room department neurosurgeon was consulted. Secondary to a noted head bleed on Computed tomography (CT) scan on Resident #1. A small intraparenchymal (blood pools in the brain) versus subarachnoid hemorrhage (bleeding in the space between the brain and the tissue covering the brain) was noted on CT scan in the right frontal region. The patient had 7 [MEDICAL CONDITION]. She was apneic (a temporary cessation of breathing) during these periods with significant decreased mental status and no active motion. Patient was coded for 4 minutes and Return of Spontaneous Circulation (ROSC). Life saving measures were attempted with no successful ROSC. Patient died on [DATE] at 8:28 AM. During the interview on [DATE] at 3:00 PM, The emergency room Physician reported Resident #1's fall contributed to her death due to her [DIAGNOSES REDACTED]. Death certificate dated [DATE] indicated Resident #1's cause of death was Subarachnoid Hemorrhage. Corrective action for past noncompliance dated [DATE]. How the corrective action will be accomplished for the resident(s) affected. On [DATE] Resident #1 fell from a mechanical lift operated by Nurse Assistant #1. Resident #1 sustained 2 lacerations on the back of her head in the shape of a horse shoe. Resident #1 was bleeding from back of head. Nurse #1and Nurse #2 placed gauze on resident's head and wrapped around head to stop the bleeding after initial assessment was transferred from floor to bed. Resident #1 was alert to person. Pupils equal round and reactive to light with accommodation. Resident #1 was able to follow simple commands. Did not remember what happened. Repeatedly asked what happened to her. Resident awake the whole time. Resident vital signs were then taken BP ,[DATE], HR 93, temp 97.3, R 20, O2 saturation 96% RA. Responsible party was notified and Physician was notified. 911 was called for resident to be transported to the hospital and later expired. How corrective action will be accomplished for those residents with the potential to be affected by the same practice. The center reviewed staffing levels on [DATE] for the day of the incident. The staffing levels were more than adequate to have had two people operate the lift. On [DATE] the lift that was used during the transfer was inspected for safety and functionality. The maintenance director found the lift to be functional. A review of all falls with injury within the last year was conducted on [DATE] related to transfer and found no falls occurred due to inappropriate transfer. The center immediately initiated lift transfer training on [DATE]. Measures in place to ensure practices will not occur. All nursing assistants were in-serviced on proper use of a mechanical lift, referencing manufacturer's guidelines which included: Proper pad position on resident for safety, prior to beginning of transfer. Proper pad position on resident to maximize comfort in the pad, prior to beginning of transfer. Assessing patient behavior prior to transfer and not initiating the transfer should the patient exhibit behaviors. Using two people to operate a mechanical lift. to obtain assistance of second person before initiating the mechanical transfer ways to obtain assistance of a second nursing assistant prior to transfer if not already present, such as verbal request and using the call bell for assistance. Do not adjust lift pad mid transfer. This was completed on [DATE]. Any staff member who did not receive the education on [DATE] did not work until completed. A sample of 5 certified nursing assistants were used for return demonstration post education on [DATE] and successfully completed the transfer. All new nursing assistants will continue to have training on: Proper pad position on resident for safety, prior to beginning of transfer. Proper pad position on resident to maximize comfort in the pad, prior to beginning of transfer. Assessing patient behavior prior to transfer and not initiating the transfer should the patient exhibit behaviors. Using two people to operate a mechanical lift. to obtain assistance of second person before initiating the mechanical transfer ways to obtain assistance of a second nursing assistant prior to transfer if not already present, such as verbal request and using the call bell for assistance. Do not adjust lift pad mid transfer. All certified nursing assistants will continue to complete return demonstration during orientation. How the facility plans to monitor and ensure correction is achieved and sustained. Audit 5 mechanical lift transfers or proper return demonstration weekly x 4, bi weekly x 2 and monthly x 1. These audits will be reviewed in our quarterly quality assurance x 2 for further review. Date of Compliance: [DATE]. As part of the validation process on [DATE], the entire plan of correction was reviewed including re-education of staff and observations of the use of a lift transfer on another resident (Resident # 5 ) at the facility. Interviews of the nurse aides and nurses revealed they were aware of proper usage of the mechanical lift for the transfer of the residents at the facility by asking a second person to assist. A review of the monitoring tools revealed that the facility had completed the 100 % in-service of the use of mechanical lift and return demonstration on [DATE]. The facility's completion date of [DATE] was validated.

Based on record review, resident interview, staff interview, family interview, physician interview, pest control technician interview, entomologist interview, and police officer interview the facility failed to maintain a pest free environment to prevent ants from entering resident rooms for three of three sampled residents reviewed for pest control (Residents #1, #7 and #8). Resident #1 was found in her bed covered with fire ants including her face, mouth and nose. Resident #1 experienced numerous fire ant bites and was transferred to an emergency room for treatment and evaluation. Resident #1 expired while in the hospital. A physician interview revealed fire ant venom could have contributed to her death. The findings include: Immediate Jeopardy began on [DATE] when a police officer and a family member observed ants in the same room that Nurse Aide (NA) #5 found Resident #1 covered with fire ants including in her mouth, nose and all over her body. The immediate jeopardy was removed on [DATE] when the facility provided an acceptable credible allegation of Immediate Jeopardy removal. The facility will remain out of compliance at a scope and severity level of D (not actual harm with the potential for more than minimal harm that is not immediate jeopardy) for the facility to complete staff training and to ensure monitoring systems put in place are effective. Record review revealed Resident # 1 was admitted to the facility from the hospital on [DATE]. Resident #1 resided on the facility's 400 hallway during her stay at the facility. Nursing notes, dated [DATE] at 11:48 AM, included documentation Resident # 1 had been bleeding from her bilateral nostrils intermittently throughout the shift but refused to let the nurse apply pressure to her nose or clean her face and surrounding areas which had blood on them. The resident wore oxygen via a nasal cannula, and the cannula became clotted with blood due to the bleeding. NA # 3 cared for Resident # 1 on [DATE] from 3:00 PM to 11:00 PM. NA # 3 was interviewed on [DATE] at 3:30 PM and reported the following. Usually Resident # 1 was very independent. On the evening of [DATE] she was drowsy. Her family came that evening. She was hot. Therefore, that evening the staff and the family switched the position of Resident # 1's bed to the area in the room where her roommate was so she could be closer to the air conditioning unit. The roommate's bed was put in the position closer to the door. At 11:00 shift change time, she peeked in on Resident # 1 and she was in bed sleeping and appeared okay. She had not seen any ants in the room that day, but she had in previous times; three times total and no more. One time there were five or six ants at one time, and Resident # 1 and the roommate would call her. She would go in, kill the ants, and tell the nurse who was on duty. She did not know what kind of ants they were. They appeared black in color. NA # 5 cared for Resident # 1 on the 11:00 PM to 7:00 AM shift which began at 11:00 PM on [DATE]. NA # 5 had provided a written statement to the facility regarding the incident of [DATE]. NA # 5's statement read, Started passing ice around 12:35 AM, went in (Resident # 1's room) and looked at her and thought she was black and changing colors, then I looked at her again. When I put her cup down and thought it was freckles, but I saw something moving and decided to call the nurse. When called her I said can you come see this lady in (Resident #1's room)? I think she got ants on her face. NA # 5 was interviewed by phone on [DATE] at 4:03 PM and reported the following. When she was making rounds around 1:00 AM she thought the resident was black when she first saw her because she had so many ants on her. (The resident was Caucasian). She got closer to her and realized the black things were moving on her. She got Nurse # 3 and returned to the room with her. The resident's mouth and nose were full of ants. They were all over her upper body. Her mouth was open, and she was breathing. She was not moving or talking. She had seen ants in the room one time before that date but had not reported the ants. Resident # 1's roommate had been messy with food and would drop food on the floor. When Resident # 1 was found with ants on her, they appeared to be coming from the area of the room where the air conditioning unit was located. Nurse # 3 was interviewed on [DATE] at 4:45 PM and again on [DATE] at 3:15 PM. She reported the following. When NA # 5 called her to the room around 1:00 AM, she went into the room, flipped on the light, and found the resident had ants on her face, neck, trunk, bilateral arms, and all over her clothes. They were red ants of various sizes. She and other staff members removed her clothes and took her to the shower. Prior to going to the shower, she stripped the bed linens and clothes and threw them in the bathroom. While in the shower, they were just wiping and wiping ants away from Resident # 1's body. There were too many to estimate the number. The resident stopped breathing while in the shower and CPR (Cardiopulmonary Resuscitation) was begun. Paramedics arrived and took over. Prior to the resident leaving, Nurse # 3 had observed multiple bites on the resident's torso, face, neck, and arms. When she returned to Resident # 1's room, she bagged the linen contained in the bathroom. The rest of the ants in the resident's room were just gone. She could not understand that because there had been a pack of ants going towards the bed earlier when they had walked in. It had looked like they had been coming from behind the resident's oxygen concentrator. She called the Director of Nursing (DON) that night and told her what had occurred. Resident # 1's roommate had not seemed to understand what had happened and had not been bothered by the ants. Resident # 1's roommate was moved that night to another room. Nurse # 4 was interviewed by phone on [DATE] at 6:45 AM. Nurse # 4 reported the following in his interview. He went to Resident # 1's unit when he heard them page there was an emergency on [DATE]. When he entered the resident's room, Nurse # 3 was in the room trying to get the resident in the wheelchair. The resident's eyes were open and she was breathing. She was not moving or talking. He remembered seeing a cluster of ants around her shoulders. NA # 4 was interviewed by phone on [DATE] at 7:00 AM. NA # 4 reported the following in her interview. When she heard the page for STAT help on [DATE] she went also and entered the room to find the nurses trying to get the resident out of bed. The resident was covered with ants from her hair to feet. They were also in her ears, nose, mouth, and private areas. Her eyes were open, but she was not talking nor trying to move and get them off her. Nurse # 5 was interviewed on [DATE] at 6:05 PM. Nurse # 5 reported the following information in the interview. On [DATE] at 1:00 AM she heard a call for stat help. She went to Resident # 1s unit and observed Nurse # 3 taking Resident # 1 to the shower. The resident was not responding. She recalled seeing one or two ants on the resident's face coming from her mouth and nose. emergency room (ER) records for [DATE] revealed the resident entered the ER with [MEDICAL CONDITION] and expired in the ER. The ER physician noted, Multiple small flat [DIAGNOSES REDACTED]tous [MEDICAL CONDITION] on face and trunk. Note occasional ants crawling on patient's skin including head and face. The ER physician was interviewed by phone on [DATE] at 3:15 PM. The ER physician reported the following. When Resident # 1 arrived it was conveyed to him in the report that she had ants on her by the paramedics. At first, he thought it was a rash on her trunk, but then he realized her trunk was literally covered with bites. One ant crawled out of her nose while the ER staff were working with her. According to the ER physician if an individual is covered in ants to the point that someone would mistake a Caucasian resident for a black resident, then there was a good chance the overwhelming fire ant venom did contribute to her death but stated he could not say for sure. According to the ER physician when an individual received hundreds of bites the body can have an overwhelming immune response to the venom which can contribute to death. On [DATE] at 11:00 AM the Administrator was interviewed and reported the following. In investigating the incident of [DATE] she knew there needed to be more clarification because Nurse # 3 referred to them as red ants and the other staff members described them as black ants. They placed a candy bar in the room on [DATE]. They sprayed the room on [DATE] themselves because the pest control company could not come out that day. Ants did come to the candy bar on [DATE], and it was verified with the Pest Control Technician they were fire ants. He treated for [REDACTED]. She had never been made aware of fire ants before [DATE] in the facility although there had been some sugar ants. The facility corporate office had reached out to a professor of Entomology who had some expertise in the area of fire ants. They had learned about the nature of the fire ants, their ability to conglomerate, their habits, and how to prevent problems with them in future. They can travel one to two inches per second. She had wondered if the resident's bloody nose could have attracted them. They had educated their staff on monitoring for ants, reporting ants, and cleaning and practices to avoid ants. They also had created a daily monitoring tool where they checked the rooms for ants. Review of an investigation summary by the Administrator into Resident # 1's incident revealed no mention of ants being problematic prior to the incident with Resident # 1. It noted that exterior and daily room rounds were started on [DATE] to ensure the facility was free of ants. The summary also noted, The facility did an inspection of all resident rooms that could be affected by this issue. The facility has had and continues to receive monthly treatment services for pest control and biyearly treatments specifically designed for ants. Prior to this incident there were no other sightings of fire ants. The summary also noted the facility had a second contractor who came to the facility after their contracted pest control company and treated the facility on [DATE]. The Maintenance Director was interviewed on [DATE] at 9:00 AM and again on [DATE] at 1:25 PM and reported the following. He had just started work in (MONTH) 2019. Sometimes there were some pop ups of sugar ants since he had been there, and the staff would let him know if there were more than one or two. They would clean and get rid of the ants. He was not aware of a reoccurring problem with ants prior to the incident of [DATE], and he had never seen fire ants prior to [DATE] in the building. There had been no records left for him from the previous maintenance director about a problem when he started in July, 2019. They have a maintenance system where they check the AC units themselves and make sure there is nothing in them. He did not recall loose baseboards being pointed out to him since he had started in (MONTH) 2019. The day ([DATE]) after Resident # 1 was sent to the hospital they placed a candy bar in the empty room. They waited for 24 hours and on the date of [DATE] they found about 50 or 60 ants had come to the candy bar. Some of them were black with a little sheen of red on them. The Pest Control Technician came and identified the ants as fire ants, and he treated the entire facility. Resident # 1's room backed up to a courtyard, and they had not observed mounds in the courtyard. They talked to their Pest Control Technician and got a second opinion as well. They thought the ants could be burrowing under the slab foundation of the building and coming in through cracks where the foundation met the building. Because of the glued baseboard in residents' rooms, you could not see all the way to the sheetrock where the wall met the floor. They had ordered new baseboard but had not taken off the baseboard in residents' rooms to look for cracks at the bottom of the sheetrock because the replacement baseboard had not come in. If a staff member had seen more than five or six ants in a room, then he would have wanted to know about it prior to [DATE]. The facility's Pest Control Technician was interviewed on [DATE] at 12:43 PM and at 1:35 PM. He routinely did monthly treatments of the facility which involved placing a granular pesticide solution around the facility which would treat fire ants. Additionally, twice per year he power sprayed a liquid pesticide that was to last for six months around the exterior. Prior to [DATE] he had been called out twice between his monthly maintenance treatments that year. One of these two times was in (MONTH) 2019 and he had identified fire ants in the window sill of a resident's room. He had treated them. He also checked one sixth of the baseboards on his monthly visits and either the former Maintenance Director or current Maintenance Director would accompany him and write down the rooms of any that were loose. He had directed them that loose baseboards would need to be fixed. He did not keep a list of the baseboards himself because the Maintenance Directors took note of them as he checked. He did recall he had identified some loose baseboards but did not recall which rooms and on which dates. He validated that the ants that came to the candy bar test on [DATE] were fire ants. Fire ants secrete pheromones and the pheromones help draw other fire ants. Within a matter of minutes to hours, other fire ants can follow the trail. Also, on the date of [DATE] he did identify two fire ant mounds in the courtyard outside of Resident # 1's room, but they had no activity when he looked at them on [DATE]. On [DATE] at 2:40 PM a follow up interview was conducted with the Pest Control Technician. He had checked his records for the May, 2019 treatment of [REDACTED]. He stated the facility would have kept a record of the room they were identified in. Review of pest control records supplied to the survey team by the facility revealed no documentation of fire ants prior to [DATE]. Interview with a police detective on [DATE] at 6:14 PM revealed the police had responded to a call at the facility in (MONTH) 2019 prior to the incident with Resident # 1. On the date of the (MONTH) 2019 police call another resident's family member had been concerned about ants. The police report, dated [DATE], was obtained and reviewed on [DATE]. It noted police officer # 1 had responded on [DATE] to a call for the same hall to which Resident # 1 was later admitted to. The report noted the police officer received two different stories when she arrived. The nurse was asking for Resident # 8's family member to be removed because the family member was disruptive. When the officer spoke to Resident # 8's family member she found the family member was upset because there were ants in Resident # 8's room. Police Officer # 1 noted in her report that she (the officer) observed ants along the wall near Resident # 8's roommate (Resident #7). The officer noted in her report that she was told by staff there were ants in other resident rooms, maintenance was aware, and they would be in the following day. Police Officer # 1 was interviewed by phone on [DATE] at 7:38 PM. The officer reported the following. She saw about 40 to 50 ants on the floor along the wall which was near the corner of Resident # 7's side of the room (which was near the window side of the room). They looked like sugar ants at first to her, but she did not know for sure. She saw them in Resident # 7's shoes and she moved the shoes. Staff told her there were ants on that wing and maintenance was going to take care of it. A review of Resident #8's record revealed she was admitted on [DATE] to the 400 hall and no longer resided at the facility. According to Resident # 8's admission MDS, dated [DATE], the resident was cognitively impaired and needed total staff assistance. Resident #8's family member was interviewed by phone on [DATE] at 4:30 PM and reported the following. She had witnessed thin black ants on two occasions in Resident #8's room. On the first occasion, they were told there was nothing the staff could do because the key to what they needed was locked up. The ants were in the corner of the room near Resident # 7's side. Then later someone sprayed with ant spray and it seemed to scatter them to Resident #8's side. They were later informed by Resident #7 that after they left that evening, Resident #7 had called for assistance for Resident #8 because the ants had climbed into Resident #8's bed. The family member saw the ants again on [DATE]. The baseboard was not sealed near the AC unit, and they seemed to be coming from that area. She was concerned because Resident # 8 could not call for help. She was not aware Resident #8 got stung by them and she did not know what kind of ants they were. That night after the officer left, they moved Resident #8. Then shortly thereafter Resident # 8 was discharged . A review of Resident #7's record revealed she was admitted on [DATE] to the 400 hall. The Resident's MDS assessment, dated [DATE], indicated Resident #7 was cognitively intact. Resident # 7 was interviewed by phone on [DATE] at 7:34 PM and reported the following. While she resided in her initial room on the 400 hall she had seen brown ants every day. They were all over the room and she kept telling staff about them. The ants would get in her shoes and bite her feet. She did not think they were fire ants but knew they bit her. She was aware to keep her covers off the floor, but her roommate (Resident #8) did not know to do this because she was confused. One night she saw the ants crawl up into Resident #8's bed and she called for help since Resident #8 could not do so. Staff came in and changed the resident's bed linens. Staff sprayed and it slowed them down but it did not stop them. Then one night a police officer came into her room and she was moved to another area. After she was moved, she did not have a problem, and she went home shortly after that. Resident #7's family member was interviewed by phone on [DATE] at 7:25 PM and reported the following. He visited about three to four times a week. After Resident # 7 was initially admitted on [DATE] he did not notice the ants, but then after a few visits he noticed they just came out of nowhere all of the sudden. He would see more than 20 at a time. They were on the walls and the floors and appeared to him to be little black ants. They finally gave the resident a new room and then she went home. The facility's ant monitoring sheets they had started following the incident of [DATE] were reviewed. This review revealed sugar ants had been identified in their audits on [DATE] and [DATE] in room [ROOM NUMBER]. This was the same hall on which Resident #7, Resident # 8, and Resident # 1 resided. The audit contained documentation on [DATE] that the room had been deep cleaned on the window side of the room, sprayed, and the maintenance director and Administrator had been made aware. On [DATE] it was noted the room was sprayed and cleaned with soap and water. An audit for room [ROOM NUMBER] revealed sugar ants had been found in this room on [DATE]. The room and been sprayed and cleaned with soap and water. On [DATE] at 9:43 AM another interview was held by phone with the Administrator to discuss Resident # 7, Resident #8, and the ant monitoring sheets. The Administrator reported she was aware the police responded on [DATE] but she thought it was because of a domestic issue and there was a need to remove the family who was very upset. She was aware Resident #8's family had complained of ants, but it was her understanding they were sugar ants, the residents were moved on the night of [DATE], and the room was sprayed and cleaned. She was not aware of any reports the ants had crawled into Resident # 8's bed. She was not aware Resident # 7 had been experiencing any problems and it was her understanding Resident # 7 had moved also because she got along with her roommate so well. They had not called their pest control company to deal with the [DATE] issue. They would have only done so if it had been a repetitious thing or there were a large number of ants, and it had not been her understanding this was the case. Regarding the audits, the Administrator stated it was her understanding that ants noted on the facility audits were tiny sugar ants. The Administrator stated she would check with her maintenance director and follow back up. On [DATE] at 10:51 AM the Administrator sent information by email to the surveyor. According to the email, the first sighting of ants in room [ROOM NUMBER] was on [DATE]; a day after the pest control company had been in on [DATE]. They had been told there might be sightings of ants up to 24 hours after the spray on [DATE] and therefore they did not reach out to the pest control company. They sprayed with spray the pest control company had left them. The ants had been about 2 dozen tiny black ants in a cup. They did tell the pest control technician when he came for a biweekly visit on [DATE], and he sprayed in the room. On [DATE] in room [ROOM NUMBER] there were a couple black ants. They sprayed and cleaned again, and the Pest Control Technician was scheduled for [DATE]. During a follow up interview with the Pest Control Technician on [DATE] at 12:26 PM the technician validated that prior to the incident of ants in Resident # 8 and Resident #7's room on [DATE], he had last been in the facility on [DATE] and he was not called for an extra service to address the [DATE] incident. The only local ants that bit people were fire ants. When he was in the building on [DATE] he had identified the ants in room [ROOM NUMBER] to be fire ants. There were six or seven of them. He sprayed. While he was in the facility that day ([DATE]) he had identified the baseboards were loose in two rooms. These rooms were 407 and 408. Approximately ¼ to ,[DATE] of the baseboard on the window wall was loose at the corner behind the nightstands. He had been able to detect that there were cracks at the base of the sheetrock where the baseboard was loose by getting down on his hands and knees and using a flashlight. All along as he contracted with them, he had left a particular spray with the facility they could also spray with if needed. He had talked to the maintenance director and informed him if there were a dozen or two dozen ants then he would come out between his monthly services, and for sightings of less than a dozen they could use the spray. He also was always willing to look at a picture of any type of ant they might find in between his monthly visits to help them identify the type of ant. Information provided by the Professor of Entomology, who had been contacted by the facility following the [DATE] incident was reviewed. The information noted the following. Food for fire ants in a facility consist of stained linens, serum and body fluids. When one of these cues is discovered by even a single scout ant, a trail will be laid between the food source and the closest foraging tunnel of the colony. As soon as a scout ant encounters a recruit on the borders of the ant nest, numerous recruits are ready to follow the new scent trail back to the food and repeat the process. The more ants on a trail, the stronger the scent becomes, and the more additional ants recruited. Fire ants are relatively fast at approximately 1 to 2 inches per second. Within ,[DATE] hours (conservatively) hundreds of fire ants could be recruited to a patients' bed. The Professor of Entomology was interviewed on [DATE] at 10:30 AM. He stated he counseled that facilities needed to be very proactive with fire ants. They also need to identify any type of ants that are getting into the building. Fire ants sting and inject a toxin at the site that creates a fiery sensation. The response to their sting is highly individualized. For some individuals, they can have a reaction with one or two bites, whereas other people might be able to withstand a lot of bites. The toxin is intended to be painful in order to ward animals from them. He stated many nursing homes do not understand the gravity of the threat fire ants might pose, and there needs to be better protocols to deal with them. On [DATE] at 7:29 PM the Administrator was informed of the Immediate Jeopardy. The facility provided a credible allegation of Immediate Jeopardy removal on [DATE]. The allegation of Immediate Jeopardy removal indicated: Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance; Deficient practice - During an interview with the facility's pest control technician on [DATE] he stated he treated fire ants in the window sill of a resident's room in (MONTH) 2019. Resident # 7 had seen ants every day in her room (401) up until the date of [DATE]. On that date a police officer came into the room, saw the ants, and she was moved later that night. The resident stated the ants would bite her on her feet and get in her shoes. She observed them crawl into her roommate's bed (Resident # 8) one night before the date of [DATE], and staff had to change the bed linens. Resident #8's family member on [DATE] at 4:30 PM revealed they saw multiple ants in the resident's room on two different occasions and observed the baseboard was not sealed where the ants were coming from. Resident # 1 was found on [DATE] at 1:00 AM with ants on her face, in her mouth, in her nose, and on other parts of her body. According to interviews with NAs # 3 and # 5 during the survey, they had seen ants in Resident #1's room prior to the date of [DATE]. Interview with the facility's pest control technician on [DATE] at 12:26 PM revealed he had seen 6 or 7 fire ants in room [ROOM NUMBER] on [DATE] when he was in the building. He had treated them. Also, the technician stated he had been in the facility on the date of the interview ([DATE]) and identified the baseboards were loose in rooms [ROOM NUMBERS] around the area near the night stand; approximately ¼ to ,[DATE] of the baseboard was loose and he identified this by getting down on his knees with a flashlight. He could see the hole at the bottom of the sheet rock behind the loose baseboard. According to the technician this could contribute to any type of ant getting into the building. Facility Action o Resident # 1 expired on [DATE] o Resident # 7 and 8 were removed from their room on [DATE] and Maintenace sprayed the empty room the next day o All staff education began on [DATE]. Administrator educated department managers who provided education to their respective departments on the following components: Understanding fire ants as per information sheet provided on Red imported fire ants: a threat to nursing homes s, identifying fire ants, removing patients from affected room if suspect fire ants, immediately contact maintenance director if any activity is suspected, when in resident rooms inspect floor, linen and window sill for ant activity proper food storage, availability of storage containers, and removing trash in resident rooms promptly. This education was completed on [DATE]. o On [DATE] the facility's pest control company provided complete exterior treatment for [REDACTED]. Facility also moved services from monthly to bi-weekly ant treatments to reduce ant activity. o On [DATE] Master exterminators came out to center and completed an external ant treatment. o On [DATE] Environmental services director was educated on using soap and water to erase pheromones in room after ant activity noted per the direction of a university entomologist. o All resident rooms and exterior grounds inspected daily by maintenance department or designee that has been initially provided by pest control technician for fire ant activity beginning on ,[DATE] and will continue daily x 4 weeks bi weekly x 4 weeks and monthly x 1. Any pest sightings will be reported to the Maintenance Director for treatment and the facility's pest control services will be called for follow up as needed. All residents have the potential to be affected by these deficient practices. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete; All staff education began on [DATE]. Administrator educated department managers who provided education to their respective departments on the following components: Understanding fire ants as per information sheet provided on Red imported fire ants: a threat to nursing homes, identifying fire ants, removing patients from affected room if suspect fire ants, immediately contact maintenance director if any activity is suspected, when in resident rooms inspect floor, linen and window sill for ant activity this education was completed on [DATE]. On [DATE] a letter was delivered to all residents and mailed to families using the information sheet Red imported fire ants: a threat to nursing homes. The letter highlights important facts about fire ants, how they come in, why they come in, how they can assist with preventing them and what to do if they see ants The education provided also included the resident and family's responsibility in prevention of fire ants by disposing of uneaten food or placing such food in a sealed container that will be provided by the center. Any employee that did not receive the education will be removed from the schedule until education is completed. All new employees will be educated on Understanding fire ants as per information sheet provided on Red imported fire ants: a threat to nursing homes and day care centers, identifying fire ants, removing patients from affected room if suspect fire ants, immediately contact maintenance director if any activity is suspected, when in resident rooms inspect floor, linen and window sill for ant activity by director of nursing or designee during new hire orientation. As per the recommendation of pest control technician Maintenance department began on [DATE] removing all resident room cove base on the wall the leads to the exterior inspecting for cracks/holes and sealing if found. The cove base in all rooms were inspected and ensured no gaps exist. This will be completed [DATE] All resident rooms and exterior grounds inspected daily by maintenance department or designee that has been initially provided by pest control technician for fire ant activity beginning on ,[DATE] and will continue daily x 4 weeks bi weekly x 4 weeks and monthly x 1. Any pest sightings will be reported to the Maintenance Director for treatment and the facility's pest control services will be called for follow up as needed. The facility's pest control company will perform bi-weekly ant treatments until (MONTH) 1 and will resume (MONTH) 1 through the late spring and summer per pest control recommendation. This began on [DATE] Date of compliance is (MONTH) 11th 2019. The Administrator is responsible for implementing the acceptable the immediate jeopardy removal plan. On [DATE] the facility's plan for immediate jeopardy removal was validated by the following. Multiple residents were interviewed and stated they had seen no ants. Residents validated they had received letters from the facility in regards to fire ant education. Random room observations throughout the facility revealed the rooms were clean and without any type of ants. Baseboards were observed to be tight against the floor at the bottom of the sheet rock. Residents reported during their interviews that staff had been in within the past week, removed the baseboard, and caulked before replacing the baseboard at the window side of the room. Staff interviews revealed there had been no sightings of fire ants in the past week within the facility. The facility had documented evidence of daily room audits and ex

Based on record review, resident, staff and family interviews, physician and physician assistant (PA) interviews, paramedic interview, medical examiner interview, emergency telecommunication manager interview, pest control technician interview, police interview, and entomologist interview the facility neglected to prevent ants from entering a resident's rooms, staff neglected to immediately call 911 and keep the resident's oxygen and cardiac vest in place, and neglected to provide complete information about the resident's condition to Emergency Medical Services (EMS) staff who responded to the medical emergency for one (Resident # 1) of three sampled residents whose death was reviewed. Resident #1 was found in her bed covered in fire ants including her face, mouth and nose. Prior to calling 911 staff removed the resident's cardiac vest and oxygen and the resident went into [MEDICAL CONDITION]. Resident #1 experienced numerous fire ant bites and was transferred by EMS to the hospital for evaluation and treatment. Resident #1 expired while in the hospital. A physician interview revealed fire ant venom could have contributed to her death. The findings include: Immediate Jeopardy began on [DATE] when a police officer and a family member observed ants in the same room that Nurse Aide (NA) # 5 found Resident # 1 covered with fire ants in her mouth, nose and all over her body, and when Resident #1 was found staff neglected to call 911 before they removed the resident's cardiac vest, oxygen and provided the resident with a shower. The immediate jeopardy was removed on [DATE] when the facility provided an acceptable credible allegation of Immediate Jeopardy removal. The facility will remain out of compliance at a scope and severity level of D (not actual harm with the potential for more than minimal harm that is not immediate jeopardy) for the facility to complete staff training and to ensure monitoring systems put in place are effective. Resident #1's hospital discharge summary, dated [DATE], revealed she was admitted to the hospital on [DATE] for an exacerbation of her [MEDICAL CONDITIONS]. While hospitalized a cardiac consult and catherization were completed. This showed the resident had no blockages but had experienced a [MEDICAL CONDITION] because of demand ischemia (not enough oxygen). The resident was fitted and given a cardiac vest (a personal device which monitors the heart continuously and delivers a shock treatment if it detects a life threatening abnormal heart rhythm) prior to discharge to the facility where she was to receive therapy for strengthening. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to [DATE] facility admission orders [REDACTED]. During an interview with Facility Nurse Consultant on [DATE] at 10:00 AM, the consultant confirmed Resident #1 had a cardiac vest while she resided at the facility, and the resident was responsible and took care of maintaining the battery and any communication needed regarding it. Therefore, the consultant stated there would not have been an order for [REDACTED]. Resident #1's admission MDS (Minimum Data Set) assessment, dated [DATE], revealed the resident was cognitively intact. She was independent with her dressing, hygiene, and bathing. She needed supervision for ambulating. A nursing note entry written on [DATE] at 11:48 AM specified Resident #1 was alert and oriented with intermittent confusion noted. She was able to make her needs known to staff and utilized a call bell to do so. No complaints or discomfort were noted. Her respirations were even and unlabored with no shortness of breath noted during shift. The resident had been bleeding from her bilateral nostrils intermittently throughout shift but refused to let the nurse apply pressure to the nose or clean up her face and surrounding areas messed with blood. The resident's oxygen nasal cannula was noted to be filled and clotted with blood at one point from her bleeding nose. Her oxygen saturation dropped to 75 percent but when the bloody oxygen cannula tubing was changed her oxygen saturation increased to 91 percent. On [DATE] at 3:00 PM, another nursing entry specified the resident was alert and oriented to person and place, her oxygen saturation levels were 95 percent, and the bleeding from her nose had stopped. The resident was noted to have more labored breathing and an order was obtained for a mobile chest x-ray to be done. Nurse # 1 had cared for Resident # 1 on [DATE] during the 7:00 AM to 3:00 PM shift. Nurse # 1 was interviewed by phone on [DATE] at 2:30 PM and reported the following. The resident bled profusely from the nose that day after breakfast and would not let the nurse pinch her nose or apply ice. There was blood on the sheets and on her clothes. The resident reported she had nose bleeds before and did not want to go to the hospital. After lunch the bleeding stopped. The resident was very alert that day but did have some trouble breathing. She had talked to the PA (Physician Assistant), who had informed her to do what the resident would allow them to do. A chest x-ray was ordered and done. When Nurse # 1 left, the resident was still alert and oriented with no fever, and her blood pressure was fine. Her oxygen level had picked back up after the oxygen cannula change. On [DATE] at 3:15 PM it was noted the chest x-ray order for possible aspiration of blood due to epistaxis was called into the mobile imaging company and the imaging company would be out to perform it that day. Resident # 1's chest x-ray findings, dated [DATE], showed the resident had a minimal infiltrate (a substance denser than air such as pus, blood, or protein in the lung). On [DATE] at 6:45 PM, the Physician Assistant (PA) gave an order for [REDACTED]. On [DATE] at the time of 2:35 AM Nurse # 3 documented, Resident sent out to (hospital) approx. 1:15 AM due to respiratory distress. On [DATE] at 5:45 PM the facility provided written statements regarding the events prior to the resident being transferred to the hospital on [DATE]. Noted below are some of the statements and interviews conducted with staff who cared for Resident # 1 prior to her hospital transfer on [DATE]. Nurse Aide (NA) # 3 cared for Resident # 1 on [DATE] from 3:00 PM to 11:00 PM. NA # 3 was interviewed on [DATE] at 3:30 PM and reported the following. Usually Resident # 1 was very independent. On the evening of [DATE] she was drowsy. Her family came that evening. She was hot. The last time she saw the resident was on walking rounds between 11:00 PM shift change when she and the oncoming nurse aide went around to look in on residents. At that time, they peeked in on her and she was in bed sleeping and appeared okay. She had not seen any ants in the room that day, but she had in previous times; three times total and no more. One time there were five or six ants at one time, and Resident # 1 and the roommate would call her. She would go in, kill the ants, and tell the nurse who was on duty. She did not know what kind of ants they were. They appeared black in color. NA # 5 cared for Resident # 1 on the shift which began at 11:00 PM on [DATE]. NA # 5's statement read, Started passing ice around 12:35 AM, went in (Resident # 1's room) and looked at her and thought she was black and changing colors, then I looked at her again. When I put her cup down and thought it was freckles, but I saw something moving and decided to call the nurse. When called her I said can you come see this lady in (Resident #1's room)? I think she got ants on her face. NA # 5 was interviewed by phone on [DATE] at 4:03 PM and reported the following. When she was making rounds around 1:00 AM she thought the resident was black when she first saw her because she had so many ants on her. (The resident was Caucasian). She got closer to her and realized the black things were moving on her. She got Nurse # 3 and returned to the room with her. The resident's mouth and nose were full of ants. They were all over her upper body. Her mouth was open, and she was breathing. She was not moving or talking. She remembered Nurse # 4 and Nurse # 5 coming to help. They took her to the shower to wash off the ants. They did not take her oxygen with her to the shower. They went to get another bed for her after the shower, and when they put her on the bed the resident had stopped breathing. She had seen ants in the room one time before that date but had not reported the ants. Resident # 1's roommate had been messy with food and would drop food on the floor. Resident # 1's bed position had been swapped at some time to be where the roommate's bed was near the air conditioning unit. When Resident # 1 was found with ants on her, they appeared to be coming from around the air conditioning unit area of the room. Nurse # 3's written statement was dated [DATE] and read, At approximately 0100 (1:00 AM), CNA (#5) reported to me that she 'thought the resident in (Resident # 1's room) may have ants on her face.' I immediately went to room -turned on the light switch and went to bed B to assess resident, (Resident # 1). On this assessment, I observed a significant amount of red ants, of various sizes to be crawling on resident's face, in her nose and mouth, on her neck, upper torso and bilateral upper extremities. There was a clear 'trail' of ants noted on floor, to be coming from the wall next to the air conditioning unit. The ants were coming up the blanket; which was slightly touching the floor. I immediately sent the CNA to 'go get some wash cloths' (to try to remove as many ants as possible). The resident was awake, however was non-verbal. Respirations were shallow-but even & unlabored. CNA arrived back to the room with the wash cloths and was attempting with myself to remove as many ants as possible. I determined at that time that we would need additional help and I instructed CNA to continue removing as many ants as possible, while I ran to the nurse's station and page overhead for (Nurse # 4) to (unit) STAT (right away) then returned back to resident's room and used my scissors to cut her shirt vertically from her neck straight down the middle. Additional staff arrived (Nurse # 4, NA # 4, Nurse #5) and with their assistance we removed the rest of resident's clothing (including the 'Life Vest'). We transferred resident to w/c (wheelchair) and (NA # 4) held her feet up while I pushed the W/C quickly down to the shower room on (unit) hall- Nurse # 4 had ran ahead and cut the shower onto luke warm water. Myself and (Nurse #5) were on either side of resident in the shower stall and we used the handheld shower device to rinse as many ants as possible from resident's body. I took 4X 4 guaze pads and swabbed ants from resident's mouth as well. This process went fairly quick and (Nurse # 5) and I notice resident was starting to have periods of 'not breathing.' I asked Nurse (Nurse # 4) to check her 'code status' and he returned with information that she was a 'full code.' I instructed (Nurse # 4) to bring a bed to the hallway just outside shower room and (Nurse # 5, Nurse #4, Nurse # 2) and I transferred resident to the bed, placed backboard beneath resident and I began chest compressions after determining she was in [MEDICAL CONDITION]/ respiratory arrest. (Nurse # 5 and Nurse #2) were setting up ambu bag with high flow O2 (Oxygen) and Nurse # 4 went to (hall) desk and called 911 emergency services. I continued CPR with (Nurse # 5) giving rescue breath with ambu-bag and (Nurse # 4) printed off resident's paperwork with all pertinent information. I sent a CNA to the front door to allow access for 911 personnel to enter building. Upon their arrival they eventually took over CPR-which is when I instructed the two CNAs who were present to make a check of all of the other residents on (the unit) to ensure there were no additional issues with ants-which after checking-revealed this was an isolated incident. After 911 personnel took over resident's care-I immediately notified DON (Director of Nursing) regarding this situation. 911 personnel were making statements to each other regarding seeing ants coming from resident; however, they did not ask facility staff if we had noticed the ants. CPR continued through their departure from building. Resident's torso remained without clothing and I observed a gross amount of 'bites' on resident's face-neck-torso and bilat. upper extremities. Her skin was very pale white in color and the 'bites' were obvious with dark pink to red in color. After their departure from facility I called and notified resident's daughter via phone that resident had respiratory distress and had been sent via 911 to (hospital). She verbalized her understanding with appreciation for nurse having called. Nurse # 3 was interviewed on [DATE] at 4:45 PM and again on [DATE] at 3:15 PM. Nurse # 3 relayed the above events from her statement and the following information. Prior to 1:00 AM she had last seen Resident # 1 at 11:40 PM. She had looked in on her and, from the light of the hall, could see the rise and fall of her chest which indicated no respiratory distress at that time. She could also see that her oxygen was on. She remembered the time, because she was working a double shift that night. She had left the previous unit and arrived at Resident # 1's unit at 11:40 PM. At that time Nurse # 2 was still there, and she (Nurse # 3) went around to check on her new residents. When NA # 1 called her to the room around 1:00 AM, she went into the room, flipped on the light, and found the resident had ants on her face, neck, trunk, bilateral arms, and all over her clothes. They were red ants of various sizes. The resident opened her eyes and seemed to focus on Nurse # 3 as if she was aware the nurse was talking to her. She was breathing at the time. She was not moving or talking. Nurse # 3 directed NA # 5 to run get washcloths so they could wash the ants off her. While the NA ran for the washcloths, she reached in her pocket to grab her scissors in order to cut away the resident's clothing. When Nurse # 3 reached in her pocket, she felt her phone in the same pocket. It occurred to her that documentation would never describe the amount of ants that had covered Resident # 1, and therefore she grabbed her phone and within a matter of seconds went boom-boom; took two quick pictures for documentation purposes, threw the phone aside, and went to work cutting away the resident's clothing. She continued to tell the resident while she worked, You are going to be okay. We are going to get these off of you. You are going to be okay. When NA # 5 returned to the room with the washcloths, she realized she needed more help and they needed to get the resident in the shower. She paged stat (right away) for Nurse # 4 to come. When she did this, Nurse # 4 arrived with NA # 4, and also Nurse # 5 came. She removed the resident's cardiac vest and all of her clothing. Her oxygen was also removed and they didn't get any portable oxygen because they were working so fast with her. They got her to the wheelchair and ran with her to the hallway shower. Her linens with the ants were thrown into the resident's bathroom to contain the ants in them. While in the shower, they were just wiping and wiping ants away from Resident # 1's body. There were too many to estimate the number. Nurse # 5 said Resident # 1 was crashing and they saw her head had leaned forward. About three to five minutes had passed by while they had been getting her up and showered. She directed staff to get a clean bed. She recalled Nurse # 2 had still been in the facility and was also helping while the resident was in the shower. Nurse # 4 quickly placed a bed by the shower room door and they started CPR. Nurse # 4 went to call 911. EMS arrived and took over. They had been able to get the majority of the ants off in the shower but not all of them. EMS workers did not ask about the ants, and she did not tell them. When she returned to Resident # 1's room, she bagged the linen contained in the bathroom. The rest of the ants in the resident's room were just gone. Nurse #3 stated she could not understand that because there had been a pack of ants going towards the bed earlier when they had walked in. The roommate did not seem cognizant about what had occurred. She called the Director of Nursing (DON) that night and she sent the pictures to her. Her nursing training and experience had prepared her to deal with medical emergencies but she had no training in finding a resident covered with fire ants. She had not seen ants before in the resident's room and was not aware of any ant problem prior to the incident. When she first found Resident # 1, the urgent matter to her had seemed to get the ants off her because she was still breathing, and since she was breathing the nurse did not take her pulse. As the paramedic stepped up on the stretcher to continue CPR while they were rolling Resident # 1 out, the nurse recalled seeing the bites on her torso, face, neck, and arms. She had not realized at the time that the resident's [MEDICAL CONDITION] might have been due to the ants and not to her recently diagnosed pneumonia. She felt taking the pictures had delayed her response by seconds and not longer. Nurse # 2 was interviewed by phone on [DATE] at 2:50 PM. After her second shift ended on [DATE], she had remained to chart and help. She had been with another resident when she heard the page for help. Because she had known Resident # 1 had not been well earlier, she went to the room. When she entered Nurse # 3 was in Resident # 1's room. Resident # 1 looked like she was breathing, and she had insects all over her body; mostly on her abdomen, face, and thighs. She could not recall the number of insects but knew there were multiple ones. She did what Nurse # 3 directed her to do. Nurse # 4 entered in about two or three minutes after she did. They got her into the wheelchair and took her to the hallway shower. Nurse # 3, Nurse # 4, and Nurse # 5 and she were in the shower together with the resident. She did not recall exactly when the resident had no further pulse or respirations. She did recall they got a new bed and placed her in it. She did not recall if there were bites, and she did not know what EMS staff had been told. NA # 4, was interviewed via phone on [DATE] at 7:00 AM. NA # 4 reported the following in her interview. When she heard the page for STAT help, she went also and entered the room to find the nurses trying to get the resident out of bed. The resident was covered with ants from her hair to feet. They were also in her ears, nose, mouth, and private areas. Her eyes were open, but she was not talking nor trying to move and get them off her. Once the resident was in the wheelchair, she picked up her legs and ran backwards as the nurse pushed the wheelchair to the shower room. She remembered Nurse # 3, Nurse # 4, Nurse # 5, and NA # 5 all being there and trying to get the ants off her. She did not recall when the resident stopped breathing but did recall they put her in the bed after the shower and started to perform CPR. She had not worked on that unit in awhile and she had not personally seen any ants in the room. Nurse # 5's, (who worked on the third shift which began on [DATE] at 11:00 PM) written statement read, I (Nurse # 5) was on duty last night on ,[DATE] shift on [DATE]. Around 1 AM or so when I heard over the intercom a page from the nurse to come to (name of unit) STAT. I took the crash cart and ran to the unit. After I have reached and noted (Nurse # 3) with one of the resident who sat in a wheelchair rushed into the shower room. (Nurse # 3) attempted to remove some small black things resembled ants which came from the resident's nares and [MEDICATION NAME] areas (inside the mouth). Then I noticed the resident very lethargic, pale, and unconscious. (Nurse # 3) requested a bed, CPR administered until EMS arrived and took over the situation. Nurse # 5 was interviewed on [DATE] at 6:05 PM. Nurse # 5 reported the following information in the interview. At 1:00 AM she heard a call for stat help which meant code to her. She took the crash cart to Resident # 1's unit. When she got on the unit, Nurse # 3 was taking Resident # 1 to the shower stall. The resident had her eyes closed and was breathing but was not responding otherwise. There was no oxygen on the resident. She had a sheet around her. She recalled seeing one or two ants on the resident's face coming from her mouth and nose. Her mouth and nose were black, and therefore it was hard to see. Once in the shower, Nurse # 3 was showering her. Nurse # 5 was not showering her. Nurse # 5 noticed the resident stopped breathing and told Nurse # 3 they needed to start CPR. A bed was gotten from across the hall, the resident was placed in it, and they started CPR. She did not recall bites. Nurse # 4's, written statement read, At around 0105 (1:05 AM) the intercom system came on asking for me to come to (name of unit). I was in (another room) changing out a patient's tube feed. I immediately left the room and ran to (name of unit). Upon arrival to unit nursing staff was attempting to transfer patient to wheelchair. I assisted with transfer and was instructed to go ahead and cut the shower on luke warm water by (Nurse # 3). I cut the shower on and was instructed to get an empty bed. I was asked to check patient's code status as well. Patient was transferred from wheelchair to bed and became unresponsive. I was instructed to call 911 and to print off patient information. After doing so I returned to patient's side and helped nursing staff perform CPR. EMS and Fire Department arrived on scene and relieved nursing staff. Patient was hooked up to AED (automated external defibrillator) and EKG (electrocardiogram) by EMS and they stated that she had abnormal rhythm. EMS continued CPR while exiting facility. Nurse # 4 was interviewed by phone on [DATE] at 6:45 AM. Nurse # 4 reported the following in his interview. He went to Resident # 1's unit when he heard them page there was an emergency. When he entered the resident's room, Nurse # 3 was in the room trying to get the resident in the wheelchair. The resident's eyes were open and she was breathing. She was not moving or talking. He remembered seeing a cluster of ants around her shoulders. He grabbed around her arms to help lift her into the wheelchair. Nurse # 3 directed him to go turn on the shower, and then he ran to get a new bed. He then went to the nursing desk to view her code status and, while he pulled the code status up on the computer, he hit the print button for paperwork to transfer her out. Then other staff members called to him that the resident had stopped breathing, and he called 911. No more than 5 minutes elapsed while they were working to get the ants off of her and 911 called. He had not seen ants before in Resident # 1's room. During a follow up interview with Nurse # 4 on [DATE] at 6:45 AM, it was verified with him that he printed out the resident's face sheet and medication record prior to calling 911. The nurse stated when he pulled up the code status, he just automatically printed it out to be ready to go. Interview by phone with a police detective on [DATE] at 11:25 AM revealed the police had received the resident's recorded Cardiac Vest information which showed on [DATE] at 12:56:19 the resident was in [MEDICAL CONDITION] with a heartbeat of less than 40 beats per minute. At 1:10 AM on [DATE] the Cardiac Vest was removed from her or turned off. Review of EMS records revealed the 911 call from the facility was received at 1:11:53 AM. EMS was dispatched at 1:13:35 AM. EMS was on scene at 1:16:00 AM. The County Telecommunication's Manager, who oversees the county's 911 call center, was interviewed by phone on [DATE] at 1:50 PM and reported the following. The call center does not have protocol instructions to give a caller for fire ants covering a resident. When the call came into them, the facility staff had reported the resident was non-responsive and CPR had been initiated. There was nothing mentioned about ants. They would have dispatched the crew with the same urgency regardless. If dispatched when the ants were first found, then they would have arrived on the scene sooner. They would not have given instructions about removing oxygen or life vest if asked over the dispatch call. The facility would have been referred to their protocol or physician. As an emergency telecommunications manager, he would think the appropriate response would be to call 911 initially in order to get the paramedics onsite. The Lead Paramedic, who responded to the 911 call, was interviewed by phone on [DATE] at 10:02 AM and reported the following. When EMS arrived Resident # 1 was in the hallway and not in her room. He removed ,[DATE] ants from her, but the staff did not mention anything about the ants. They reported she had been seen about 20 to 30 minutes prior. She had a very, very slow pulseless electrical rhythm (no pulse but slow heart rhythm). Her core was warm, and her extremities were cold and blue. There was a rash from her [MEDICATION NAME] area to her pelvis which appeared to be red dots. If the staff had informed the EMS crew that she had been covered in ants, then he would have used a laryngoscope and opened her airway to look further down. They did not report any information about ants. EMS did give her [MEDICATION NAME] for the [MEDICAL CONDITION], which would have been one of the treatments for ant bites as well. The Paramedic Manager of the responding crew was interviewed by phone on [DATE] at 12:50 PM and reported the following. The call went to the county 911 call center, and then his EMS crew was dispatched. In general, if his crew were to be dispatched and found a resident covered with ants and in distress or cardiac failure, then his paramedics are great multitaskers. They are trained to clean and decontaminate a resident while dealing with a coding or declining resident. emergency room (ER) records for [DATE] revealed the resident entered the ER with [MEDICAL CONDITION] and expired in the ER. The ER physician noted, Multiple small flat [DIAGNOSES REDACTED]tous [MEDICAL CONDITION] on face and trunk. Note occasional ants crawling on patient's skin including head and face. The ER Physician was interviewed by phone on [DATE] at 3:15 PM. The ER Physician reported the following. When Resident # 1 arrived it was conveyed to him in the report that she had ants on her by the paramedics. At first, he also thought it was a rash on her trunk, but then he realized her trunk was literally covered with bites. One ant crawled out of her nose while the ER staff were working with her. According to the ER physician if an individual is covered in ants to the point that someone would mistake a Caucasian resident for a black resident, then there was a good chance the overwhelming fire ant venom did contribute to her death but stated he could not say for sure. According to the ER physician when an individual received hundreds of bites the body can have an overwhelming immune response to the venom which can contribute to death. If he had been told the extent of the ant coverage of her body, he would have used [MEDICATION NAME] or steroids in her treatment. They had used [MEDICATION NAME] to treat the [MEDICAL CONDITION], so she got a drug that would have been used for the ant bites. Review of Resident # 1's death certificate revealed Resident # 1's PA signed on [DATE] that the cause of death was cardiopulmonary arrest with contributing factors of pneumonia, [MEDICAL CONDITION], and chronic [MEDICAL CONDITION]. Resident # 1's Family Member # 1 was interviewed by phone on [DATE] at 10:00 AM and reported the following. He had visited Resident # 1 on [DATE]. He arrived around 2:30 or 3:00 PM and stayed until 4:30 or 5:00 PM. The resident seemed pale and her breathing was more labored, but otherwise okay. He asked her if she wanted to go to see a doctor, and she had not wanted to do so. He helped move the position of her bed to the window side of the room with the roommate's and family's permission to do so. This was because she was hot. It was common for her to have nose bleeds. He usually visited daily and found the room to be clean. Her roommate had kept a lot of sodas but they were always closed. On [DATE] he remembers he brushed a sugar ant from Resident # 1's bed and did not think anything about it. He didn't report it. When he left, he did not expect that Resident # 1 would pass away. He knew her vital signs were okay, and she was coherent. But when they called him later that night to let him know she had passed away, he was not surprised because of her medical history. No one from the facility had mentioned ants had been found on the resident. Resident # 1's Family Member # 2 was interviewed by phone on [DATE] at 11:20 AM. She received a phone call on [DATE] at 11:07 PM (which was 2:07 AM on [DATE] North [NAME]ina time) from someone at the facility. The staff member told her Resident # 1 had been found in the entrance way door to the room on the floor, and they had to push her body away with the door to get to her. She was having trouble breathing and they sent her to the hospital. She called the hospital and the physician told her Resident # 1 had come into the ER in [MEDICAL CONDITION], they tried to do their best, but she had not made it. No one had said anything about ants to her on [DATE]. On [DATE] she received a phone call from the Administrator who told her they were closing the investigation. She had not known there was an investigation and asked, what investigation. She was told Resident # 1 had a couple of ants and she had like two bites. She inquired of the Administrator if this had anything to do with her death and was informed her oxygen level had been low and in the 70's on [DATE], and she had not been doing well. She did not learn about the extent of the ant coverage on Resident # 1's body until a police officer informed the family that week. Interview with the County Medical Examiner on [DATE] at 11:44 AM revealed she was a paramedic by profession. It was her opinion that anytime a resident is found covered in ants, then EMS should be called right away. The DON was interviewed on [DATE] at 9:30 AM and reported the following. She had worked on the date of [DATE] and left the facility around 12:45 AM on [DATE]. She received a phone call around oneish from Nurse # 3 while EMS was still in the building. Nurse # 3 informed her they had found Resident # 1 with ants on her, Nurse # 3 had called for help, and then Nurse # 3 and the staff had showered the resident. After they got her in the shower the resident coded. Nurse # 3 texted pictures at the same time she talked to the DON. The DON really didn't look at the pictures so deeply, and she deleted them right away. She had been aware the resident had not been doing well on the evening shift of [DATE] because Nurse # 2 had informed her of this previously while she had been at the facility on [DATE]. She (the DON) informed Nurse # 3 to make sure Resident # 1's roommate was moved out of the room, and to check all of the resident's room in the facility to make sure there were no more ants. She also told Nurse # 3 to gather statements from staff. She talked to the Administrator that night and informed her of the situation, and the Administrator was to talk to her corporate supervisor. She did not call EMS to convey anything further about the ants herself although Nurse # 3 had not told them. She did talk to Resident # 1's PA on [DATE] and told him there had been a significant amount of ants on Resident #1 and he had responded that he was aware. She turned the statements that were gathered over to the Administrator. She never thought the ants might have been part of the resident's death because the resident had not been doing well on [DATE]. The DON had never been aware of ants in the room before. On [DATE] at 11:00 AM the Administrato

Based on record review and staff interviews, the facility failed to follow the care plan by not keeping 1 of 2 sampled residents in a visible area when in wheelchair, resulting to a left femur fracture. (Resident # 236). Findings included: Resident # 236 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most current Minimum Data Set ((MDS) dated [DATE] revealed the resident's cognition was severely impaired; she needed extensive assistance with 1 person for bed mobility and extensive assistance with 2 persons for transfer. Resident # 236's Care Area Assessment (CAA) worksheet dated 1/4/2017 documented During this look back period, resident has been out of bed at least 4 out of 7 days. Staff to continue to attempt to engage resident in activities of choice. Resident has had falls since admission, but no falls noted during this look back period. Safety precautions being followed per facility protocol. Resident has fall mats beside bed and bed is lowered. Resident # 236's care plan dated 2/28/2017 documented the resident is at risk for falls due to confusion, deconditioning, advanced dementia, history of falls, prefers to sit on the mat. The care plan documented the following interventions: Get resident up before lunch time and in common areas, keep resident in visible area when in wheel chair. On 1/30/2017 a nurse's note at 12:38 PM documented Patient was found on floor mat next to bed during day shift. Patient had pain to right femur, notified doctor. Received order for x- ray. Review of the resident's incident report dated 1/30/2017 revealed under description Patient was found sitting on her floor mat next to her wheelchair. Patient was asked if she put herself there and she nodded yes. I asked the patient if she was hurting anywhere and she said no. Review of the x-ray report dated 1/31/2017 revealed the resident had a left [MEDICAL CONDITION]. During the interview with Nurse Assistant (NA) # 1 on 3/2/2017 at 10:13 AM, she reported she was assigned to take care of the resident on 1/30/2017. She reported after dressing up the resident she took her to the day room and went on a half hour break. She further added when she came back from her break she was told by Resident # 236's roommate that resident # 236 earlier fell on the floor while she was gone on her break. NA#1 further stated she was not aware of the staff member who wheeled the resident back to her room and left her unattended while sitting up on the wheelchair because the resident had no safety awareness and she would stand and try to walk. She added the resident had unsteady gait and was not to transfer herself independently due to her history of falls. NA #1 also reported the resident was to be kept near nurse's station and day room where the staff were to keep an eye on her at all times. She also stated before going on her break she told Nurse # 1 to keep an eye on Resident # 236. During the interview with Nurse # 1 on 3/2/2017 at 1:30 AM, she reported on 1/30/2017 she was passing by the resident's room and saw the resident lying on the floor. She added the resident was sitting earlier on her wheel chair in her room when she fell on the floor and it appeared the resident was attempting to get back on her bed when she fell on the floor. Nurse # 1 reported the resident had history of getting up from the wheel chair and walking but because of unsteady gait she would fall. She also indicated the resident was reminded not to transfer without assistance from wheel chair to bed but the resident was forgetful. During the interview on 3/2/2017 at 2:33 PM, The resident's roommate reported she was in the room on 1/30/2017 when the resident fell to the floor from her wheel chair. She reported the resident was attempting to get back to her bed when she fell on the floor. She added she reported the fall to the staff who was passing by her room to come and help the resident. During the interview on 3/3/2017 at 11:00 PM, the Director of Nursing (DON) reported the resident was found on the floor next to her bed but they were unable to determine the staff that wheeled the resident back to her room from the day room. The DON further reported that her expectation was for the staff not to have left the resident unattended sitting in the wheel chair in her room.

Based on record reviews and staff interviews, the facility failed to keep 1 of 2 sampled residents in a visible area when in wheelchair, resulting to a left femur fracture. (Resident # 236). Findings included: Resident # 236 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most current Minimum Data Set ((MDS) dated [DATE] revealed the resident's cognition was severely impaired; she needed extensive assistance with 1 person for bed mobility and extensive assistance with 2 persons for transfer. Resident # 236's Care Area Assessment (CAA) worksheet dated 1/4/2017 documented During this look back period, resident has been out of bed at least 4 out of 7 days. Staff to continue to attempt to engage resident in activities of choice. Resident has had falls since admission, but no falls noted during this look back period. Safety precautions being followed per facility protocol. Resident has fall mats beside bed and bed is lowered. Resident # 236's care plan dated 2/28/2017 documented the resident is at risk for falls due to confusion, deconditioning, advanced dementia, history of falls, prefers to sit on the mat. The care plan documented the following interventions: Keep environment free of hazards, anticipate and meet the resident's needs, get resident up before lunch time and in common areas, keep resident in visible area when in wheel chair. On 1/30/2017 a nurse's note at 12:38 PM documented Patient was found on floor mat next to bed during day shift. Patient had pain to right femur, notified doctor. Received order for x- ray. Review of the resident's incident report dated 1/30/2017 revealed under description Patient was found sitting on her floor mat next to her wheelchair. Patient was asked if she put herself there and she nodded yes. I asked the patient if she was hurting anywhere and she said no. On 1/31/2017 a nurse's note at 1:39 PM documented Patient complained of hip pain during shift. X- Ray to left hip and femur was ordered. Findings: left hip fracture. Doctor was aware and told me to call the agency that was responsible for taking care of the resident. The nurse practitioner advise to continue giving the patient pain medication. Review of the x-ray report dated 1/31/2017 revealed the resident had a left hip fracture.Orthopedics report dated 2/1/2017 documented The resident presents with pain and fracture on the left side. She states that the symptoms have been acute traumatic and began on 2/1/2017. She indicated the injury occurred at the nursing home. The resident states that the symptoms began as the result of a fall on the hip. The symptoms occur constantly with intermittent worsening. Currently the patient states that the symptoms are severe. The pain is described as discomforting and piercing. She rates her best pain as 10/10. She rates her worst pain as 10/10. She rates her current pain 10/10. The symptoms are aggravated by no specific activity and movement. Resident # 236 states that the symptoms are relieved by no specific activity. Orthopedics report under diagnostics subheading documented displaced intertrochanteric fracture of the left femur with slight superior migration of the femoral shaft. No other acute abnormality noted. During the interview with Nurse Assistant (NA) # 1 on 3/2/2017 at 10:13 AM, she reported she was assigned to take care of the resident on 1/30/2017. She reported after dressing up the resident she took her to the day room and went on a half hour break. She further added when she came back from her break she was told by Resident # 236's roommate that resident # 236 earlier fell on the floor while she was gone on her break. NA#1 further stated she was not aware of the staff member who wheeled the resident back to her room and left her unattended while sitting up on the wheelchair because the resident had no safety awareness and she would stand and try to walk. She added the resident had unsteady gait and was not to transfer herself independently due to her history of falls. NA #1 also reported the resident was to be kept near nurse's station and day room where the staff were to keep an eye on her at all times. She also stated before going on her break she told Nurse # 1 to keep an eye on Resident # 236. During the interview with Nurse # 1 on 3/2/2017 at 1:30 AM, she reported on 1/30/2017 she was passing by the resident's room and saw the resident lying on the floor. She added the resident was sitting earlier on her wheel chair in her room when she fell on the floor and it appeared the resident was attempting to get back on her bed when she fell on the floor. Nurse # 1 reported the resident had history of getting up from the wheel chair and walking but because of unsteady gait she would fall. She also indicated the resident was reminded not to transfer without assistance from wheel chair to bed but the resident was forgetful. During the interview on 3/2/2017 at 2:33 PM, The resident's roommate reported she was in the room on 1/30/2017 when the resident fell to the floor from her wheel chair. She reported the resident was attempting to get back to her bed when she fell on the floor. She added she reported the fall to the staff who was passing by her room to come and help the resident. During the interview on 3/2/2017 at 3:00 PM, the Nurse Practitioner reported the resident was already declining in her health when she fell on [DATE] and sustained a left hip fracture. She also added the orthopedic specialist did not recommend surgery on the resident because of the resident being frail and declining in her health. During the interview on 3/3/2017 at 11:00 PM, the Director of Nursing (DON) reported the resident was found on the floor next to her bed but they were unable to determine the staff that wheeled the resident back to her room from the day room. The DON further reported that her expectation was for the staff not to have left the resident unattended sitting in the wheel chair in her room.

Based on record review, staff interviews and physician interview, the facility staff did not notify the physician about adverse behavioral symptoms, including pulling at her [MEDICAL CONDITION] that jeopardized the safety of one of four residents who had tracheostomies, Resident #1. The Immediate Jeopardy began on [DATE] when Nurse #1 found Resident #1 undressed with her [MEDICAL CONDITION] dislodged completely from her neck, and the efforts to resuscitate her at that time were unsuccessful. The Immediate Jeopardy was removed on [DATE] at 4:05 PM when the facility provided a credible allegation of compliance. The facility will remain out of compliance at a scope and severity of no actual harm with the potential of no more than minimal harm that is not immediate jeopardy (D). The facility was in the process of full implementation of corrective action at that time. Findings included: Resident #1's Discharge Summary from a specialty hospital to the facility dated [DATE] indicated that Resident #1 had a discharge [DIAGNOSES REDACTED]. The same Discharge Summary further indicated that the resident had [MEDICAL CONDITION], and that as a result, her mental status waxed and waned. A review of the admission paperwork which accompanied Resident #1 from the hospital included a Medicaid FL2 Form dated [DATE] which revealed Resident #1 had a [MEDICAL CONDITION] with 28% oxygen therapy, and that the resident wore mittens due to her pulling at the [MEDICAL CONDITION]. An Interdisciplinary Plan of Care Discharge and Barrier Update from the hospital listed a goal to remove Resident #1's mittens without her dislodging her tubes or lines, and that a barrier to this goal was that Resident #1 had a [MEDICAL CONDITION]. A review of the facility's Nursing Admission assessment dated [DATE] revealed Resident #1 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. In addition, the same assessment revealed Resident #1 was totally dependent upon staff assistance for locomotion, dressing, eating, toilet use, personal hygiene, and bathing. Under the category of Extremities, the assessment indicated that right and left arm reflexes were within normal limits. In an interview with the Minimum Data Set (MDS) nurse on [DATE] at 3:35 PM, she stated that from the time of admission on [DATE], Resident #1 was known to have restless behaviors and that she pulled at her [MEDICAL CONDITION]. In addition, she stated that her restless behaviors was discussed in detail in an interdisciplinary meeting and also on daily rounds. The MDS nurse stated she could not recall the exact date and time of the interdisciplinary meeting, but that usually the meetings were held on Thursday mornings, and that Thursday fell on [DATE]. She further explained that it was common knowledge that Resident #1 pulled off her mittens frequently, and that there was discussion about contacting the physician about getting a medication for agitation control. The MDS nurse stated the resident was admitted to the facility wearing the mittens she had from the hospital, and the facility did not have any access to restraints, including mittens, in the facility because the facility was restraint-free. In an interview with Resident #1's physician on [DATE] at 2:00 PM, he stated that in his History and Physical he completed on [DATE], he did not record any combative or restless behavioral problems related to her [MEDICAL CONDITION], such as pulling at her [MEDICAL CONDITION] tubing or device, because Resident #1 did not exhibit such behaviors at the time when he examined her, and he had not received reports of such behavior. The physician stated that he knew that the resident wore mittens upon admission to the facility due to her history of her pulling at the [MEDICAL CONDITION], and that he wrote an order for [REDACTED]. A review of the progress notes revealed a note dated [DATE] at 11:56 PM indicated that mittens continued to be used for [MEDICAL CONDITION] safety for Resident #1. This progress note was signed by Nurse #2. An interview was conducted with one of Resident #1's nurses, Nurse #2, on [DATE] at 2:37 PM. Nurse #2 stated that Resident #1 had tried to get out of bed when she was assigned to her during the first day of her stay in the facility, so she kept the resident up in her chair in the day room across from the nurse ' s station so that she could be monitored. Nurse #2 explained that when the resident was around other people, she did not try to get up or exhibit restless behaviors. She stated that she had seen Resident #1 pull at her oxygen tubing before, but never had seen her actually pull on her [MEDICAL CONDITION]. In addition, Nurse #2 stated that she wasn ' t sure that the mittens were a helpful intervention for Resident #1 because she was very alert and capable of removing them herself. Per the Minimum Data Set (MDS) 5-Day assessment dated [DATE], Resident #1 had no range of motion impairment. Another progress note dated [DATE] at 12:37 AM documented that Resident #1 was observed several times during the shift removing her mittens and grabbing at her [MEDICAL CONDITION]. This note was signed by Nurse #7. In a telephone interview with Nurse #7 on [DATE] at 2:22 PM, she stated that she could not recall many details about what she documented in the progress note on [DATE], but stated if she documented that the resident was observed pulling on her [MEDICAL CONDITION], then it happened. Nurse #7 stated that she worked the 3:00 PM to 11:00 PM shift on [DATE] and that her progress note was written late, after her shift was over. Nurse #7 stated that when the resident was observed pulling off her mittens and pulling at her [MEDICAL CONDITION], it occurred right after her daughter left from a visit. Nurse #7 stated that Resident #1 became fidgety and upset when she left. She added that when she became upset, she removed her mittens and pulled at her [MEDICAL CONDITION], so she (Nurse #7) went to her and replaced her mittens, and explained to her why she had to wear them. Nurse #7 explained that she felt no need to contact the resident ' s physician because the resident seemed to calm down after she explained the need for the mittens. She stated that she was uncertain whether the resident had been known to remove her mittens or pull at her [MEDICAL CONDITION] before then. In addition, she stated that it was not her idea to keep the resident in the day room for observation and that the resident was already in the day room when she came onto her shift at 3:00 PM on [DATE]. A progress noted dated [DATE] at 1:51 AM documented, .trach care provided. Resd (resident) wearing mittens on bilat (bilateral) upper extremities d/t (due to) resident attempting to remove trach. ([MEDICAL CONDITION]) .will continue to monitor. This note was signed by Nurse # 3. In an interview with Resident #1's nursing assistant on [DATE] at 2:40 PM, she stated that when she went to check on Resident #1 on [DATE] between 8:00 AM and 9:00 AM, she found that Resident #1 was not wearing her mittens. She explained she then went to ask the nurse, Nurse #1, if the resident needed to wear the mittens all the time. The nursing assistant stated that Nurse #1 told her the resident needed to wear mittens all the time to keep her from pulling at her [MEDICAL CONDITION], so she returned to the resident's room and applied the mittens per the nurse's direction. A progress note which documented dated [DATE] at 8:32 PM revealed the following: Situation: res (resident) found in bed lying still, not moving or breathing. Background: She continuously pulls her mitts (mittens) off and pulls at O2 (oxygen) hookup and trach ([MEDICAL CONDITION].)CNA (certified nursing assistant) and I had to put mits (mittens) back on mid-shift today and redirect her not to pull [MEDICAL CONDITION]. She stated, I don ' t need it. Assessment: Found laying in bed not breathing, no response to verbal cue or sternal rub. Charge nurse was brought into room along with crash cart, chest compressions and CPR (cardiopulmonary resuscitation) were began. 911 was called and continued to stay on phone until EMS (emergency medical service) arrived. Chest compressions and CPR was performed until EMS arrived. All 3 family members on the responsible party list were called and not reached. (Family member) Ms. ([MEDICAL CONDITION]) called back and I spoke with her about the situation. The other two kids showed up shortly thereafter. This note was signed by Nurse #1. In an interview with Nurse #1 on [DATE] at 11:27 AM, Nurse #1 stated that she was assigned to Resident #1 for just one day on [DATE] on the day shift from 3:00 PM to 11:00 PM, and that she received a report from the previous shift ' s nurse who informed her that the resident needed the mittens to keep her from pulling at her [MEDICAL CONDITION] site. Nurse #1 explained there were no other interventions to keep Resident #1 from pulling at her [MEDICAL CONDITION] other than checking on her frequently, at least every 2 hours. On [DATE] at 1:40 PM, an interview was conducted with Nurse #3, the nurse who was acting as the charge nurse on [DATE]. (Nurse #3 worked the 7:00 to 3:00 PM shift on [DATE].) Nurse #3 stated that if a resident with a [MEDICAL CONDITION] was exhibiting adverse behaviors, such as pulling at her [MEDICAL CONDITION], she would keep the resident in the day room for close monitoring for safety. She also stated that if this intervention was not successful, she would contact the physician to report her behavior. In a second interview with Nurse #1 on [DATE] at 12:33 PM, she stated that the nurse who previously cared for Resident #1 on the night shift reported to her that the resident had tried to pull at her [MEDICAL CONDITION] but did not have a suggestions as to how to keep them on her. Nurse #1 stated that the facility was restraint-free, and that with that in mind, there was not much she could do to keep the resident from pulling off her mittens or pulling at her [MEDICAL CONDITION], and that she would not have contacted the physician about her restless adverse behaviors. On [DATE] at 9:45 AM, an interview was conducted with the unit manager from the unit where Resident #1 resided. The unit manager stated that she was not working on the date when Resident #1 pulled out her [MEDICAL CONDITION], but stated that it would be her expectation that if a resident displayed restless or adverse behaviors which could potentially harm him/her, the assigned nurse should contact the physician to receive guidance. In addition, she stated that if a nurse was unfamiliar with a resident, she should receive a report from the previous shift nurse, and she should review progress notes, the history and physical notes, the discharge summary information from the hospital in order to understand the resident ' s needs and possible behaviors. The administrator, the acting Director of Nursing, and the facility's consultant nurse were notified of the immediate jeopardy in a meeting on [DATE] at 2:40 PM. The facility provided the following credible allegation on [DATE] at 1:09 PM. How the corrective action will be accomplished for those residents found to have been affected by the deficient practice: On [DATE] Nurses documented resident #1 made two attempts to remove [MEDICAL CONDITION]. On [DATE] at approximately 2:00 p.m., based on interview with the nurse and CNA on duty on at the time, Resident #1 was found to be unresponsive and not breathing. CPR was attempted by facility staff and 911 was called. Upon arrival, EMS team continued CPR efforts and later Resident #1 was pronounced dead at the facility. Nurses notes do not reflect MD notification. All LPNs and RNs were in-serviced on [DATE] regarding physician notification. How corrective action will be accomplished for those resident having potential to be affected by the same deficient practice: All Licensed Practical Nurses and Registered Nurses were in-serviced on [DATE] regarding the following policies: 1. Documentation and Notification, which states the Charge Nurse is responsible for notifying the Physician and or the Responsible Party whenever there is a change related to the care of the patient. Included in the in-service was emphasis that anxiety and agitation is reportable to the physician. 2. All Licensed Practical Nurses and Registered Nurses not scheduled on [DATE] will be in- serviced prior to returning to work. 3. The care plans for the three remaining [MEDICAL CONDITION] patients were reviewed by the Corporate Quality Improvement Monitor for accuracy and completeness.On [DATE], all Certified Nurses Assistants were in-serviced on notifying the charge nurse of change in resident condition, using the clinical alerts in the electronic medical record system and verbally. Any Certified Nurses Assistants not scheduled on [DATE] will be in-serviced prior to returning to work. On [DATE] at 3:20 PM, verification of the credible allegation was evidenced via interviews with unit managers, supervising nurses, and other licensed staff who stated they received in-service education regarding the notification of the physician regarding behavioral changes or other adverse behaviors such as pulling at the [MEDICAL CONDITION] which could impact the resident's safety. Interviews with nursing assistants revealed that they had been provided in-service education about the importance of monitoring residents frequently, especially those who exhibited behavioral issues such as removing mittens, and reporting such behaviors to the nurse immediately. The nursing assistants also stated they received in-service education about the importance of keeping resident from harming themselves.

Based on physician interview, staff interviews, visitor interview, and record review, the facility failed to develop an interim care plan to address the [MEDICAL CONDITION] needs and adverse behavioral symptoms related to [MEDICAL CONDITION] safety for one of one resident who was found unresponsive after pulling out her [MEDICAL CONDITION], Resident #1. The Immediate Jeopardy began on [DATE] when Nurse #1 discovered Resident #1 undressed in her bed with her [MEDICAL CONDITION] dislodged completely from her neck, and the efforts to resuscitate her at that time were unsuccessful. The Immediate Jeopardy was removed on [DATE] at 4:05 PM when the facility provided an acceptable credible allegation of compliance. The facility will remain out of compliance at a scope and severity of no actual harm with the potential of no more than minimal harm that is not immediate jeopardy (D). The facility was in the process of full implementation of corrective action at that time. Findings included: Resident #1's Discharge Summary from a specialty hospital to the facility dated [DATE] indicated that Resident #1 had a discharge [DIAGNOSES REDACTED]. The same Discharge Summary further indicated that the resident had [MEDICAL CONDITION], and that as a result, her mental status waxed and waned. A review of the admission paperwork which accompanied Resident #1 from the hospital included a Medicaid FL2 Form dated [DATE] which revealed Resident #1 had a [MEDICAL CONDITION] with 28% oxygen therapy, and that the resident wore mittens due to her pulling at the [MEDICAL CONDITION]. An Interdisciplinary Plan of Care Discharge and Barrier Update from the hospital listed a goal to remove Resident #1's mittens without her dislodging her tubes or lines, and that a barrier to this goal was that Resident #1 had a [MEDICAL CONDITION]. A review of the facility's Nursing Admission assessment dated [DATE] revealed Resident #1 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. In addition, the same assessment revealed Resident #1 was totally dependent upon staff assistance for locomotion, dressing, eating, toilet use, personal hygiene, and bathing. Under the category of Skin the comment box documented, [MEDICAL CONDITION] midline, clean. Under the Motor Control section of the assessment, the resident was documented as having an unsteady gait and poor balance. A review of the facility's Device assessment dated [DATE] revealed that Mittens were not marked as present on the assessment. Review of the progress notes revealed there was a note made upon admission on [DATE] at 2:32 PM which stated, O2 (oxygen) at 4 LPM (liters per minute) [MEDICAL CONDITION] collar. Breathing even, unlabored. Skin warm and dry. Resident able to stand with assist x 1 (with the assistance of one staff member.) Ambulates with assist x 1 (with the assistance of one staff member.) admitted with mittens on both hands . This progress note was signed by Nurse #2. An interview was conducted with Nurse #2 on [DATE] at 2:37 PM. Nurse #2 stated that she was the nurse who worked with Resident #1 on the day she was admitted to the facility on [DATE], and that the resident was wearing her mittens which had been given to her by the hospital. Nurse #2 stated that right after admission, while she was on duty, Resident #1 tried to get out of bed. She explained that she kept Resident #1 in the day room during the day because when she was around other people, she did not try to get out of bed. Nurse #2 also stated that she was monitored by more staff members when she was in her geri-chair in the day room. Nurse #2 stated that she had seen the resident with her mittens off before, but she had not ever seen the resident pull at the [MEDICAL CONDITION] strap. Nurse #2 also stated that she was not even sure that the mittens were helpful in preventing the resident from pulling at her [MEDICAL CONDITION] because the resident was very alert and capable of removing the mittens. She stated the mittens were a soft cotton-like material on the palm of the hand and that there was a Velcro fastener around the wrist to help keep them in place. A review of the medical record revealed there was no interim care plan to address Resident #1's [MEDICAL CONDITION] care or her behavioral tendencies of pulling at the [MEDICAL CONDITION] device or tubing. In an interview with the Minimum Data Set (MDS) nurse (nurse responsible for writing care plans) on [DATE] at 3:35 PM, she stated that from the time of admission on [DATE], Resident #1 was known to have restless behaviors and that she pulled at her [MEDICAL CONDITION]. The MDS nurse explained that an interim care plan to address her [MEDICAL CONDITION] needs and her restless behaviors should have been initiated immediately upon admission after her nursing facility admission assessment. The MDS Nurse stated that the interim care plan would be completed by any of the nurses who were taking care of Resident #1 would have been responsible for completing an interim care plan based upon her [DIAGNOSES REDACTED]. The MDS nurse added that there were three MDS nurses who wrote care plans, and that Resident #1 was not in the facility long enough to have a formal nursing care plan written within 14 days of her admission. She stated that the interim care plan was supposed to be in place to address her care needs regarding the [MEDICAL CONDITION], including her behavior of pulling at her [MEDICAL CONDITION], until the formal care plan could be initiated. In addition, she stated that there was a concern among the nursing staff regarding Resident #1 ' s restless behavior and attempts to pull out her [MEDICAL CONDITION], and that this was discussed in detail in an interdisciplinary meeting and also on daily rounds. The MDS nurse stated she could not recall the exact date and time of the interdisciplinary meeting, but that usually the meetings were held on Thursday mornings, and that Thursday fell on [DATE]. She further explained that it was common knowledge that Resident #1 pulled off her mittens frequently, and that there was discussion about contacting the physician about getting a medication for agitation control. The MDS nurse stated the resident was admitted to the facility wearing the mittens she had from the hospital, and the facility did not have any access to restraints, including mittens, in the facility because the facility was restraint-free. A review of the physician's orders [REDACTED].) There were no other orders regarding the [MEDICAL CONDITION] care for Resident #1. In an interview with Resident #1's physician on [DATE] at 2:00 PM, he stated that in his History and Physical dated [DATE], he did not record any combative behavioral problems related to her [MEDICAL CONDITION], such as pulling at her [MEDICAL CONDITION] tubing or device, because she did not exhibit such behaviors at that time and he had not received reports of such behavior. The physician stated that he knew that the resident wore mittens upon admission to the facility due to her history of her pulling at the [MEDICAL CONDITION], and that he wrote an order for [REDACTED]. Per the Minimum Data Set (MDS) 5-Day assessment dated [DATE], Resident #1 had a partial list of [DIAGNOSES REDACTED]. In addition, the same assessment indicated the resident was receiving [MEDICAL CONDITION] care and was not receiving respiratory therapy. The MDS assessment also there were no behavioral symptoms exhibited, no rejection of care, and no wandering behaviors. There was no range of motion functional impairment for Resident #1, and there were no restraints checked for the resident. A progress note dated [DATE] at 12:37 AM documented, Resident able to verbalize needs to staff, resident was observed several times during shift removing mittens and grabbing [MEDICAL CONDITION]. Resident alert x 2 (oriented to person and place), confusion noted. This note was signed by Nurse #7. In a telephone interview with Nurse #7 on [DATE] at 2:22 PM, she stated that she actually worked on the 3:00 PM to 11:00 PM shift on [DATE], but that she stayed after her shift was over in order to document in the progress notes. She stated that she could not recall many details about what she documented in the progress note on [DATE], but stated if she documented that the resident was observed pulling on her [MEDICAL CONDITION], then it happened. Nurse #7 stated that when she observed Resident #1 pulling off her mittens and pulling at her [MEDICAL CONDITION], it occurred right after her family member left from a visit. Nurse #7 stated that Resident #1 became fidgety and upset when her family member left that day. Nurse #7 stated she went to her and replaced her mittens and explained to her why she had to wear them. She stated that she was uncertain whether the resident had been known to remove her mittens or pull at her [MEDICAL CONDITION] before then. In addition, she stated she was not aware of any other interventions in place to address restless behavior or pulling at the [MEDICAL CONDITION]. A progress noted dated [DATE] at 1:51 AM documented . trach care provided. Resd (resident) wearing mittens on bilat (bilateral) upper extremities d/t (due to) resident attempting to remove trach. ([MEDICAL CONDITION]) .will continue to monitor. This note was signed by Nurse # 3. In an interview with Nurse #1 on [DATE] at 11:27 AM, Nurse #1 stated that she was assigned to Resident #1 for just one day on [DATE] and that she received a report from the previous shift's nurse who informed her that the resident needed the mittens to keep her from pulling at her [MEDICAL CONDITION] site. Nurse #1 explained she had no knowledge of any other interventions being used to keep Resident #1 from pulling at her [MEDICAL CONDITION] other than checking on her frequently, at least every 2 hours. She added that no one reported to her that the resident should be kept in the day room near the nurse ' s station. An interview was conducted on [DATE] at 11:03 AM with the visitor who discovered Resident #1 undressed on [DATE]. During the interview, she stated that she came to visit the resident on [DATE] shortly after 2:00 PM. The visitor stated that when she started to enter the resident ' s room, she noted the resident was wearing no gown or other clothing. She stated that she had not stayed in the entrance of the resident ' s room long enough to determine whether she was breathing and she just assumed the resident was asleep. The visitor stated that she did not want to embarrass the resident, so she backed out of the room and went to report to a staff member that the resident needed to be dressed. The visitor stated that when she went to the nurse's station to notify a staff member that Resident #1 needed to be dressed, there was no one at the nurse's station, so she found a staff member in the hall and reported it to her. She explained that the staff member then went into another resident ' s room for a brief moment, then came back out of that resident's room and got another nursing assistant to assist her with dressing Resident #1. She stated that after the nursing assistants entered the room, they stayed for a few minutes, then one of the nursing assistants came out of the room and ran to get another nurse. An interview was conducted on [DATE] at 2:40 PM with the nursing assistant (NA #1) who was assigned to Resident #1. During the interview, she stated that the last time she saw the resident with her [MEDICAL CONDITION] intact was between 12:35 and 12:40 PM when she heard the resident cough. She explained that she went into the resident ' s room to make certain she was okay, and Resident #1 was breathing without difficulty. NA #1 stated she went back into Resident #1's room after a visitor had reported that she needed to be dressed. She stated that she and another nursing assistant (NA #2) entered Resident #1's room and discovered that the [MEDICAL CONDITION] was not present on the resident throat area, and that the mask that covered the [MEDICAL CONDITION] site was off to the side. She further stated that the resident had one mitten completely off, and that the other was partially in place on her left hand. NA #1 stated the resident had blood on both of her hands, but that the right hand had the most blood present. NA #1 stated she then realized Resident #1 was not breathing, and that she and NA #2 attempted to arouse the resident by tapping on her feet, checking for a pulse, and providing a sternal rub. She stated that she then left the room to get a nurse. NA #1 also stated that the nurse did not tell her how often she should check on Resident #1 during the shift, but that she usually made her rounds every 2 hours. In an interview with the nurse who was in charge on [DATE], Nurse #3, on [DATE] at 1:40 PM, she stated that the resident was cool to touch when she entered the resident ' s room and started CPR. Nurse #3 stated that if she had a resident with a [MEDICAL CONDITION] who had restless or agitated behaviors, she would keep the resident in the day room for close monitoring. A progress note dated [DATE] at 8:32 PM which was signed by Nurse #1 documented the following: (Note: This progress note was not documented as a Late Entry.) Situation: res (resident) found in bed lying still, not moving or breathing. Background: She continuously pulls her mitts (mittens) off and pulls at O2 (oxygen) hookup and trach ([MEDICAL CONDITION].) CNA (certified nursing assistant) and I had to put mits (mittens) back on mid-shift today and redirect her not to pull [MEDICAL CONDITION]. She stated, I don ' t need it. Assessment: Found laying in bed not breathing, no response to verbal cue or sternal rub. Charge nurse was brought into room along with crash cart, chest compressions and CPR (cardiopulmonary resuscitation) were began. 911 was called and continued to stay on phone until EMS (emergency medical service) arrived. Chest compressions and CPR was performed until EMS arrived . A review of the local police department Event Log dated [DATE] revealed that Resident #1's death occurred at 2:41 PM and that the resident ' s body was released to the mortuary at 3:15 PM on [DATE]. In an interview with the acting Director of Nursing on [DATE] at 8:50 AM, she stated that she was not acting as the Director of Nursing when Resident #1 pulled out her [MEDICAL CONDITION] and died on [DATE], but it was an expectation that residents have a care plan to provide direction for nursing care with residents with special needs. The Administrator, acting Director of Nursing, and the facility's consultant nurse were notified of the immediate jeopardy in a meeting on [DATE] at 2:40 PM. The facility provided the following credible allegation on [DATE] at 1:09 PM: Credible Allegation of Compliance for F 309: This allegation of compliance is submitted in compliance with applicable law and regulation. To demonstrate continuing compliance with applicable law, the center has taken or will take the actions set forth in the following allegation of compliance. The following credible allegations constitutes the center's allegation of compliance. All alleged deficiencies have been or will be resolved by the dates indicated. How the corrective action will be accomplished for those residents found to have been affected by the deficient practice: The initial care plan being developed did not fully address the specialized care needs for the [MEDICAL CONDITION]. On [DATE], The MDS nurse conducted an audit of the current (3) three [MEDICAL CONDITION] residents to ensure the Care Plan objectives, care needs, and special needs for [MEDICAL CONDITION] and mittens was accurate and completed. At the time of the audit, there were no new admissions with [MEDICAL CONDITION] needs. How corrective action will be accomplished for those resident having potential to be affected by the same deficient practice: On [DATE], the MDS Nurse conducted an audit to validate the presence of an accurate current Care Plan for the current (3) three [MEDICAL CONDITION] residents which addressed medical and nursing objectives and interventions for [MEDICAL CONDITION] and special needs. On [DATE], the MDS Nurse, Director of Nursing, Unit Manager, and House Supervisors received education by the Staff Development Coordinator on the following Procedure points: the Care Plan will be activated upon admission, the Comprehensive Care plan will be completed within 7 days of the completion of the Comprehensive Assessment, the Care Plan will be updated by each discipline on an ongoing basis as changes in the patient occur and reviewed quarterly. On [DATE], all Licensed Nursing staff were educated by the Staff Development Coordinator on the Care Plan process, objectives, and interventions for patients with [MEDICAL CONDITION] and mittens. All Licensed Nursing staff not scheduled on [DATE] will be in-serviced by the Staff Development Coordinator prior to returning to work. On [DATE] at 3:20 PM, verification of the credible allegation was evidenced via interviews with unit managers, supervising nurses and other licensed staff who stated they received in-service education regarding the importance of interim care plans and the initiation of interventions to provide safety for residents, as well as the importance of assessing residents for changes in condition.

Based on physician interview, visitor interview, staff interviews, and record review, the facility failed to implement effective interventions necessary to prevent one of four residents who had a tracheostomy, Resident #1, from dislodging and removing the tracheostomy tube. The Immediate Jeopardy began on [DATE] when Nurse #1 found Resident #1 undressed with her tracheostomy dislodged completely from her neck, and the efforts to resuscitate her at that time were unsuccessful. The Immediate Jeopardy was removed on [DATE] at 4:05 PM when the facility provided an acceptable credible allegation of compliance. The facility will remain out of compliance at a scope and severity of no actual harm with the potential of no more than minimal harm that is not immediate jeopardy (D). The facility was in the process of full implementation of corrective action at that time. Findings included: Resident #1's Discharge Summary from a specialty hospital to the facility dated [DATE] indicated that Resident #1 had a discharge [DIAGNOSES REDACTED]. The same Discharge Summary further indicated that the resident had [DIAGNOSES REDACTED], and that as a result, her mental status waxed and waned. A review of the admission paperwork which accompanied Resident #1 from the hospital included a Medicaid FL2 Form dated [DATE] which revealed Resident #1 had a tracheostomy with 28% oxygen therapy, and that the resident wore mittens due to her pulling at the tracheostomy tube. An Interdisciplinary Plan of Care Discharge and Barrier Update from the hospital listed a goal to remove Resident #1's mittens without her dislodging her tubes or lines, and that a barrier to this goal was that Resident #1 had a tracheostomy. A review of the facility's Nursing Admission assessment dated [DATE] revealed Resident #1 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. In addition, the same assessment revealed Resident #1 was totally dependent upon staff assistance for locomotion, dressing, eating, toilet use, personal hygiene, and bathing. Under the category of Skin the comment box documented, trach (tracheostomy) midline, clean. Under the Motor Control section of the assessment, the resident was documented as having an unsteady gait and poor balance. A review of the facility's Device assessment dated [DATE] revealed that Mittens were not marked as present on the assessment. Review of the progress notes revealed there was a note made upon admission on [DATE] at 2:32 PM which stated, O2 (oxygen) at 4 LPM (liters per minute) via trach (tracheostomy) collar. Breathing even, unlabored. Skin warm and dry. Resident able to stand with assist x 1 (with the assistance of one staff member.) Ambulates with assist x 1 (with the assistance of one staff member.) admitted with mittens on both hands . This progress note was signed by Nurse #2. An interview was conducted with Nurse #2 on [DATE] at 2:37 PM. Nurse #2 stated that she was the nurse who worked with Resident #1 on the day she was admitted to the facility on [DATE], and that the resident was wearing her mittens which had been given to her by the hospital. Nurse #2 stated that right after admission while she was on duty, Resident #1 tried to get out of bed. She explained that she kept Resident #1 in the day room during the day after that incident because when she was around other people, she did not try to get up unassisted. Nurse #2 also stated that she was monitored by more staff members when she was in her geri-chair in the day room. Nurse #2 stated that she had seen the resident without her mittens on at times, but she had not ever seen the resident pull at the tracheostomy strap. Nurse #2 also stated that she was not even sure that the mittens were helpful in preventing the resident from pulling at her tracheostomy because the resident was very alert and capable of removing the mittens. In an interview with the Minimum Data Set (MDS) nurse (nurse responsible for writing care plans) on [DATE] at 3:35 PM, she stated that from the time of admission on [DATE], Resident #1 was known to have restless behaviors and that she pulled at her tracheostomy. In addition, she stated that there was a concern among the nursing staff regarding Resident #1's restless behavior and attempts to pull out her tracheostomy, and that this was discussed in detail in an interdisciplinary meeting and also on daily rounds. The MDS nurse stated she could not recall the exact date and time of the interdisciplinary meeting, but that usually the meetings were held on Thursday mornings, and that Thursday fell on [DATE]. She further explained that it was common knowledge that Resident #1 pulled off her mittens frequently, and that there was discussion about contacting the physician about getting a medication for agitation control. A review of the physician's orders [REDACTED].) There were no other physician orders [REDACTED]. In an interview with Resident #1's physician on [DATE] at 2:00 PM, he stated that in his History and Physical dated [DATE], he did not record any combative behavioral problems related to her tracheostomy, such as pulling at her tracheostomy tubing or device, because she did not exhibit such behaviors at that time and he had not received reports of such behavior. The physician stated that he knew that the resident wore mittens upon admission to the facility due to her history of her pulling at the tracheostomy, and that he wrote an order for [REDACTED]. The physician stated he did not recall getting a call from a staff member regarding any restless behaviors such as pulling at her tracheostomy or trying to get out of bed. The physician also stated that he did receive a call from a staff member after Resident #1 had expired on [DATE] around mid-afternoon. Per the Minimum Data Set (MDS) 5-Day assessment dated [DATE], Resident #1 displayed no behavioral symptoms, no rejection of care, and no wandering behaviors. There was no range of motion functional impairment for Resident #1, and there were no restraints checked for the resident. A progress note dated [DATE] at 12:37 AM documented, Resident able to verbalize needs to staff, resident was observed several times during shift removing mittens and grabbing at trach (tracheostomy). Resident alert x 2 (oriented to person and place), confusion noted. This note was signed by Nurse #7. In a telephone interview with Nurse #7 on [DATE] at 2:22 PM, she stated that she actually worked on the 3:00 PM to 11:00 PM shift on [DATE], but that she stayed after her shift was over in order to document in the progress notes. She stated that she could not recall many details about what she documented in the progress note on [DATE], but stated if she documented that the resident was observed pulling on her tracheostomy tube, then it happened. Nurse #7 stated Resident #1 was sitting in the day room when she came on to work her 3:00 PM to 11:00 PM shift, and that she received a report from the day nurse regarding the resident ' s needs. She explained that she kept Resident #1 seated in the day room to visit with her family member and to frequently monitor her. Nurse #7 stated that when she observed Resident #1 pulling off her mittens and pulling at her tracheostomy tube, it occurred right after her family member left from a visit. Nurse #7 stated that Resident #1 became fidgety and upset when her family member left that day. Nurse #7 stated she went to her and replaced her mittens and explained to her why she had to wear them. Nurse #7 explained that the resident seemed to calm down after she explained the need for the mittens to her. She stated that she was uncertain whether the resident had been known to remove her mittens or pull at her tracheostomy tube before then. In addition, she stated she was not aware of any other interventions in place to address restless behavior or pulling at the tracheostomy tube. A progress noted dated [DATE] at 1:51 AM documented . trach care provided. Resd (resident) wearing mittens on bilat (bilateral) upper extremities d/t (due to) resident attempting to remove trach. (tracheostomy) .will continue to monitor. This progress note was signed by Nurse # 3. In an interview with Nurse #1 on [DATE] at 11:27 AM, Nurse #1 stated that she was assigned to Resident #1 for just one day on [DATE] and that she received a report from the previous shift ' s nurse who informed her that the resident needed the mittens to keep her from pulling at her tracheostomy site. Nurse #1 explained she had no knowledge of any other interventions being used to keep Resident #1 from pulling at her tracheostomy other than checking on her frequently, at least every 2 hours. In an interview with the facility's consultant nurse on [DATE] at 3:20 PM, she stated that Resident #1 had demonstrated that she was fully capable of removing her mittens and that the mittens were not considered to be a restraint. She added that the facility strived to be restraint-free facility, and that physical or chemical restraints were used only in special circumstances for a short period of time. An interview was conducted on [DATE] at 11:03 AM with the visitor who discovered Resident #1 undressed on [DATE]. During the interview, she stated that she came to visit the resident on [DATE] shortly after 2:00 PM. The visitor stated that when she started to enter the resident's room, she noted the resident was wearing no gown or other clothing. She stated that she had not stayed in the entrance of the resident's room long enough to determine whether she was breathing and she just assumed the resident was asleep. The visitor stated that she did not want to embarrass the resident, so she backed out of the room and went to report to a staff member that the resident needed to be dressed. The visitor stated that when she went to the nurse's station to notify a staff member that Resident #1 needed to be dressed, there was no one at the nurse's station, so she found a staff member in the hall and reported it to her. She explained that the staff member then went into another resident's room for a brief moment, then came back out of that resident ' s room and got another nursing assistant to assist her with dressing Resident #1. She stated that after the nursing assistants entered the room, they stayed for a few minutes, then one of the nursing assistants came out of the room and ran to get another nurse. In an interview with Resident #1's nursing assistant (NA #1) on [DATE] at 2:40 PM, she stated that when she went to check on Resident #1 on [DATE] between 8:00 Am and 9:00 AM, she found that Resident #1 was not wearing her mittens. She explained she then went to ask the nurse, Nurse #1, if the resident needed to wear the mittens all the time. The nursing assistant stated that Nurse #1 told her the resident needed to wear the mittens all the time to keep her from pulling at her tracheostomy tube, so she returned to the resident's room and applied the mittens per the nurse's direction. During the interview, she stated that the last time she saw the resident with her tracheostomy intact was between 12:35 and 12:40 PM when she heard the resident cough. She explained that she went into the resident ' s room to make certain she was okay, and Resident #1 was breathing without difficulty. NA #1 stated she went back into Resident #1 ' s room after a visitor had reported that she was unclothed and needed to be dressed. She stated that she and another nursing assistant (NA #2) entered Resident #1's room and discovered that the tracheostomy tube was not present on the resident throat area, and that the mask that covered the tracheostomy site was off to the side. She further stated that the resident had one mitten completely off, and that the other was partially in place on her left hand. NA #1 stated the resident had blood on both of her hands, but that the right hand had the most blood present. NA #1 stated she then realized Resident #1 was not breathing, and that she and NA #2 attempted to arouse the resident by tapping on her feet, checking for a pulse, and providing a sternal rub. She stated that she then left the room to get a nurse. NA #1 also stated that the nurse did not tell her how often she should check on Resident #1 during the shift, but that she usually made her rounds every 2 hours. In an interview with the nurse who was in charge on [DATE], Nurse #3, on [DATE] at 1:40 PM, she stated that the resident was cool to touch when she entered the resident's room and started CPR. Nurse #3 stated that if she had a resident with a tracheostomy who had restless or agitated behaviors, she would keep the resident in the day room for close monitoring. She also stated that if the restless behaviors or pulling at the tracheostomy tubing could not be controlled effectively, she would contact the physician to consider a possible medication to assist with preventing self-harm. In an interview with Nurse #3 on [DATE] at 1:40 PM, she stated that if a resident displayed restless behaviors or pulled at her tracheostomy tube, she would keep the resident in sight, perhaps in the day room next to the nurse's station. Nurse #3 also stated that if the restless behaviors or pulling at the tracheostomy tubing could not be controlled effectively, she would contact the physician to consider a possible medication to assist with preventing self-harm. A progress note dated [DATE] at 8:32 PM which was signed by Nurse #1 documented the following: (Note: This progress note was not was not indicated as a Late Entry.) Situation: res (resident) found in bed lying still, not moving or breathing. Background: She continuously pulls her mitts (mittens) off and pulls at O2 (oxygen) hookup and trach (tracheostomy.)CNA (certified nursing assistant) and I had to put mits (mittens) back on mid-shift today and redirect her not to pull at trach (tracheostomy). She stated, I don't need it. Assessment: Found laying in bed not breathing, no response to verbal cue or sternal rub. Charge nurse was brought into room along with crash cart, chest compressions and CPR (cardiopulmonary resuscitation) were began. 911 was called and continued to stay on phone until EMS (emergency medical service) arrived. Chest compressions and CPR was performed until EMS arrived . A review of the local police department's Event Log dated [DATE] revealed that Resident #1's death occurred at 2:41 PM and that the resident's body was released to the mortuary at 3:15 PM on [DATE]. The Administrator, acting Director of Nursing, and the facility's consultant nurse were notified of the immediate jeopardy in a meeting on [DATE] at 2:40 PM. The facility provided the following credible allegation on [DATE] at 1:40 PM: This allegation of compliance is submitted in compliance with applicable law and regulation. To demonstrate continuing compliance with applicable law, the center has taken or will take the actions set forth in the following allegation of compliance. The following credible allegations constitutes the center's allegation of compliance. All alleged deficiencies have been or will be resolved by the dates indicated. How the corrective action will be accomplished for those residents found to have been affected by the deficient practice: · Based on documentation, after attempts by resident #1 to remove tracheostomy, no changes in interventions were made. · On [DATE] at approximately 2:15 p.m., based on interview with the nurse and CNA on duty on at the time, Resident #1 was found to be unresponsive and not breathing. CPR was attempted by facility staff and 911 was called. Upon arrival, EMS team continued CPR efforts and later pronounced at the facility. · All LPNs and RNs were in-serviced on [DATE] regarding Change in Condition and Physician Notification utilizing the eINTERACT Model. This model encompasses recognizing a change, reviewing background to clarify change occurred, denoting assessment and/or observation and notifying physician of changes to notify of interventions put in place and further orders the physician may order. · How corrective action will be accomplished for those resident having potential to be affected by the same deficient practice: · On [DATE], all residents in house on this date with a tracheostomy (3 residents with trachs) were reviewed for trach care orders, care plans, and interventions by the Staff Development Coordinator and Unit Managers. All were validated and in place. · MDS Coordinators and Unit Managers were in-serviced by the Staff Development Coordinator [DATE] on initiating the care plan at admission. As a routine practice, the Director of Nursing, Staff Development Coordinator and/or Unit Managers will review all new admissions with trachs and/or mittens on the next business day to ensure that the trach and/or mittens have been care planned and that all special needs have been addressed. · All Licensed Practical Nurses and Registered Nurses were in-serviced on [DATE] regarding the Documentation and Notification policy, which states the Charge Nurse is responsible for notifying the Physician and or the Responsible Party whenever there is a change related to the care of the patient. All Licensed Practical Nurses and Registered Nurses not scheduled on [DATE] will be in-serviced prior to returning to work. · On [DATE], all Certified Nurses Assistants were in-serviced on notifying the charge nurse of change in resident condition, using the clinical alerts in the electronic medical record system and verbally. Any Certified Nurses Assistants not scheduled on [DATE] will be in-serviced prior to returning to work. On [DATE] at 3:20 PM, verification of the credible allegation was evidenced via interviews with unit managers, supervising nurses and other licensed staff who stated they received in-service education regarding the importance of initiation of interventions to provide safety for residents to prevent accidents for residents with tracheostomies, such as frequent monitoring and notification of the physician as needed for other interventions.

Based on record review, observations, resident interview and staff interviews the facility failed to prevent a fall resulting in a hip fracture for 1 of 3 sampled residents. (Resident #1) The findings included: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] indicated Resident #1 was moderately cognitively impaired. The MDS also indicated the resident required extensive assistance consisting of two person staff support with transfers, bed mobility, and hygiene care. The MDS also indicated the resident was totally dependent on staff for all activities of daily living (ADL ' s). Resident #1 ' s care plan dated 5/11/2015 indicated the resident is at risk for falls due to Psycho-active drug use, incontinence, seizure disorder, and contractures. The care plan indicated the goal as the resident will not sustain serious injury through next review. The care plan intervention included - Assist x 2 staff for bed mobility and Assist x 2 staff for bathing. Review of the facility Incident/Accident report for June, 2015 revealed the resident sustained [REDACTED].#1 after an incident of incontinence. The facility report indicated Resident # 1 was assessed and a comprehensive accident report was filled out by a Licensed Practical Nurse (LPN). Review of the facility Accident Report dated 6/22/2015 revealed the following information concerning a fall involving Resident #1 on that date: (NA #1) called for help from resident ' s room. This writer, (LPN #1) came to assist. Resident fell on left side of her bed during patient care and was lying face down and on her left side. Resident said, I fell and my hip hurts. The resident was assessed head to toe. Resident assisted to her back, vitals taken and stable, laceration to forehead cleaned, and ice pack applied as tolerated. The facility physician was called at 7:25 pm, new order to send to the hospital emergency room . 911 called, EMS (Emergency Medical Services) arrived and resident sent to Emergency Department) ED. An Incident Report dated 6/22/2015 at 7:10 pm which related to Resident #1 ' s fall read: Situation - fall on 6/22/2015. Resident was lying on left side holding on to side rail while receiving patient care from (NA #1) and when NA went to reach for wash clothes resident ' s legs began to slip off the bed. When (NA #1) tried to hold her (Resident #1) back her (NA #1 ' s) arm and hand landed in fecal matter and that ' s when she (NA #1) lost her and tried to hold onto the resident ' s gown and she (Resident #1) fell and hit her head on bed side table. Background - Resident unable to voice needs. Incontinent to B&B. Requires one assist with patient care and ADL ' s. Assessment/Appearance - This writer assessed resident head to toe, resident assisted to her back, vitals taken, laceration cleaned and ice pack applied as tolerated. Recommendations - use two assist with patient care and ADL ' s. Author: (LPN #1). LPN #1 was unavailable for an interview. A Progress Note dated 6/22/2015 at 7:40 pm indicated the resident was taken to an acute care hospital emergency department by Emergency Transport Services at 7:45 pm. Resident #1 was diagnosed with [REDACTED]. Resident #1 remained in the hospital at the time of this investigation. In a telephone interview with NA #1 on 7/01/2015 at 12:30 pm, she verified Resident #1 had fallen as described in the incident report. NA #1 stated she was changing Resident #1 when she lost control of her and the resident slid off of the bed onto the floor. NA #1 further stated she had not worked at the facility long and was not familiar with Resident #1 ' s care plan intervention of: two staff to assist with toileting, bathing, and bed mobility. During an interview with the facility Administrator on 7/01/2015 at 12:50 am, she stated she had investigated the circumstances of Resident #1 ' s fall on 6/22/2015 and determined that NA #1 had not followed the care planned interventions of: two staff to assist the resident with bed mobility and bathing. The Administrator stated she had interviewed NA #1 on 6/24/2015 and obtained her statement concerning Resident #1 ' s fall. She stated that NA #1 had stated I did not know the resident needed two people for changing. This information was not relayed to me until after the fall and was not in her Kardex. The Administrator stated that she and the DON reviewed the electronic Kardex which is intended to provide information concerning resident care needs to nurses and NA ' s, She stated that the Kardex was found not to contain information on how many staff were needed to assist the residents in ADL ' s. The administrator stated that she audited several resident ' s electronic Kardex ' s and determined the omission of the number of staff needed to assist resident ' s with ADL ' s was present in all of the audited Kardex ' s. She further stated NA #1 had been suspended from work pending the results of her investigation. The Administrator stated her expectation was for the Nurse ' s Aides and nurses to use the appropriate number of staff to perform resident ADL ' s as outlined in each resident ' s care plan.

Based on record review, observations, resident interview and staff interviews the facility staff failed to follow the care plan for two staff assistance with bed mobility resulting in a [MEDICAL CONDITION] for 1 of 3 sampled residents. (Resident #1) The findings included: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] indicated Resident #1 was moderately cognitively impaired. The MDS also indicated the resident required extensive assistance consisting of two person staff support with transfers, bed mobility, and hygiene care. The MDS also indicated the resident was totally dependent on staff for all activities of daily living (ADL ' s). The resident ' s ADL Care Area Assessment (CAA) dated 5/19/15 documented resident triggered due to inability to independently manage self-care in all ADL ' s. Resident #1 ' s care plan dated 5/11/2015 indicated the resident is unable to provide ADL self-care due to limitations in mobility, range of motion, and disease process of [MEDICAL CONDITION]. The care plan indicated the goal as the resident will maintain current level of function through the next review. The care plan intervention included - Toileting/Changing: Nurses Assistant (NA) will provide toileting and hygiene. Resident #1 ' s care plan dated 5/11/2015 indicated the resident is at risk for falls due to Psycho-active drug use, incontinence, [MEDICAL CONDITION] disorder, and contractures. The care plan indicated the goal as the resident will not sustain serious injury through next review. The care plan intervention included - Assist x 2 staff for bed mobility and Assist x 2 staff for bathing. Review of the facility Accident Report dated 6/22/2015 revealed the following information concerning a fall involving Resident #1 on that date: (NA #1) called for help from resident ' s room. This writer, (LPN #1) came to assist. Resident fell on left side of her bed during patient care and was lying face down and on her left side. Resident said, I fell and my hip hurts. The resident was assessed head to toe. Resident assisted to her back, vitals taken and stable, laceration to forehead cleaned, and ice pack applied as tolerated. The facility physician was called at 7:25 pm, new order to send to the hospital emergency room . 911 called, (Emergency Management System) EMS arrived and resident sent to (Emergency Department) ED. An Accident Report dated 6/22/2015 at 7:10 pm which related to Resident #1 ' s fall read: Situation - fall on 6/22/2015. Resident was lying on left side holding on to side rail while receiving patient care from (NA #1) and when NA went to reach for wash clothes resident ' s legs began to slip off the bed. When (NA #1) tried to hold her (Resident #1) back her (NA #1 ' s) arm and hand landed in fecal matter and that ' s when she (NA #1) lost her and tried to hold onto the resident ' s gown and she (Resident #1) fell and hit her head on bed side table. Background - Resident unable to voice needs. Incontinent to B&B. Requires one assist with patient care and ADL ' s. Assessment/Appearance - This writer assessed resident head to toe, resident assisted to her back, vitals taken, laceration cleaned and ice pack applied as tolerated. Recommendations - use two assist with patient care and ADL ' s. Author: (LPN #1). LPN #1 was unavailable for interview. A Progress Note dated 6/22/2015 at 7:40 pm indicated the resident was taken to an acute care hospital emergency department by Emergency Transport Services at 7:45 pm. Resident #1 was diagnosed with [REDACTED]. Resident #1 remained in the hospital at the time of this investigation. In a telephone interview with NA #1 on 7/01/2015 at 12:30 pm, she verified Resident #1 had fallen as described in the incident report. NA #1 stated she was changing Resident #1 when she lost control of her and the resident slid off of the bed onto the floor. NA #1 further stated she had not worked at the facility long and was not familiar with Resident #1 ' s care plan intervention of: two staff to assist with toileting, bathing, and bed mobility. During an interview with the facility Administrator on 7/01/2015 at 12:50 am, she stated she had investigated the circumstances of Resident #1 ' s fall on 6/22/2015 and determined that NA #1 had not followed the care planned interventions of: two staff to assist the resident with bed mobility and bathing. The Administrator stated she had interviewed NA #1 on 6/24/2015 and obtained her statement concerning Resident #1 ' s fall. She stated that NA #1 had stated I did not know the resident needed two people for changing. This information was not relayed to me until after the fall and was not in her Kardex. The Administrator stated that she and the DON reviewed the electronic Kardex which is intended to provide information concerning resident care needs to nurses and NA ' s, including how many staff are care planned to assist in ADL ' s. She stated that the Kardex was found not to contain information on how many staff are needed to assist the residents in ADL ' s. The administrator stated that she audited several resident ' s electronic Kardex ' s and determined the omission of the number of staff needed to assist resident ' s with ADL ' s was present in all of the audited Kardex ' s. She further stated NA #1 had been suspended from work pending the results of her investigation. The Administrator stated her expectation was for the Nurse ' s Aides and nurses to use the appropriate number of staff to perform resident ADL ' s as outlined in each resident ' s care plan.

Based on observation, record reviews and staff interviews, the facility failed to acknowledge and intervene appropriately for a resident's verbal complaint of pain during a pressure ulcer dressing change for 1 of 3 residents reviewed for pressure ulcers (Resident #1). The findings included: Resident #1 was admitted to the facility on [DATE] with medical [DIAGNOSES REDACTED]. The admission Minimum Data Set (MDS) indicated the resident was severely cognitively impaired. The assessment further indicated Resident #1 was able to understand others and express his needs and wants both verbally and non-verbally. The care plan for Resident #1 dated 2/28/14 revealed the area of pain with interventions which included premedicate in anticipation of potential painful procedure/activity. The care plan also indicated to notify the physician if pain level not reduced to the patient's comfort level. During a dressing change on 3/12/14 at 11:40 am, Nurse #1 asked Resident #1 if his foot was hurting and the resident stated loudly "yes." The nurse proceeded with cleaning the area of the left heel and stated "I will be done in a little bit." While applying the [MEDICATION NAME] to the left heel, the resident yelled out "Oh, oh," with facial grimacing, flushness and arms extended on both sides. The nurse stated "I am almost done." When directed to stop the dressing change for pain management, Nurse #1 stated "It's not going to make a difference. I still have to get this dressing on." Nurse #1 reported to Unit Manager #1 that the resident was exhibiting facial grimacing and complained of pain while he was doing the dressing change. The unit manager directed the nurse to stop until the resident could be medicated for pain. The resident was medicated with Tylenol 650 mg by mouth at 11:53 am. Review of the medical record current physician orders did not reveal an order for [REDACTED]. During an interview on 3/12/14 at 12:02 pm, Nurse #1 stated "Of course I was going to address the pain but my focus was to complete the dressing." The nurse further stated "The textbook would tell you to stop the dressing change and medicate the resident but again my focus was getting the dressing change done for infection control purposes." On 3/13/14 at 11:33 in an interview, Nurse #2 stated the resident complained of pain during the dressing changes on her shift of 3-11. The nurse stated she would normally just try to talk the resident through the dressing change. She then stated the resident would "wince" when she removed the dressing. The nurse described wince as "jerk back and exhibit facial grimacing." After reviewing the medical record, Nurse #2 stated she did not document on assessment or monitoring of pain for Resident #1. In an interview on 3/13/14, the Director of Nursing (DON) stated she expected the nurses to stop the dressing change and address the resident's pain. The DON further stated she expected the nurse to notify the physician if the resident did not have medication ordered for pain or if the medication was not effective in relieving the resident's pain.

Based on observation, staff interviews, resident interviews and record review, the facility failed to prevent one (1) of four (4) cognitively impaired residents (Resident # 2) who exhibited wandering behaviors from eloping from the facility. On February 4, 2011, Resident #2 exited the building unattended by staff. The facility failed to utilize the WanderGuard system according to manufacturers guidelines for 2 of 2 (Resident #6 and #7) sampled residents identified at risk of wandering. Immediate Jeopardy began on 2/4/2011 and was identified on 2/10/2011 at 4:10 p.m. Immediate Jeopardy was removed on 2/11/2011 at 5:00 p.m. when the facility provided a credible allegation of compliance. The facility will remain 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) to ensure monitoring of systems put in place and 100% completion of employee training. Findings include: 1. Resident #2 was admitted to the facility 5/13/2010 and readmitted to the facility 12/16/2010. Cumulative [DIAGNOSES REDACTED]. An annual Minimum Data Set ((MDS) dated [DATE] indicated Resident #2 had short term and long term memory impairment. Cognitive skills for daily decision-making were severely impaired. Resident #2 was dependent on staff for bed mobility. He required extensive assistance with transfers. Ambulation and balance during transitions (moving from seated to standing position, walking, turning around, moving on and off toilet, surface-to-surface transfer) did not occur during the seven day assessment period. Functional limitation in range of motion was noted to both lower extremities. A care plan initiated on June 1, 2010 and updated on 12/23/2010 indicated Resident #2 was at risk for wandering due to dementia. Approaches included the use of a " security alarm bracelet (WanderGuard bracelet) or other sensor system to reduce the risk of elopement from the facility, encourage rest periods as needed; keep same routines and monitor behavior and attempt to determine pattern, frequency and intensity for wandering. " The use of a WanderGuard bracelet was initiated in September, 2010. A Wandering Elopement Risk Assessment done 12/16/2010 indicated Resident #2 did not have a history of wandering/ elopement at home. He did not have a history of leaving the facility without informing staff and had not left the facility without needed supervision. A WanderGuard bracelet continued to be used on Resident #2 in December, 2010. On 2/8/2011 at 9:40 a.m.., Resident #8 revealed she was sitting with Resident #9 smoking under the front shed in the front of building (covered portico outside of the front doors) on 2/4/2011 at 5:30 a.m. She stated she saw Resident #2 coming across the parking lot pushing his wheelchair. It was raining and he did not have a jacket on. She said he told them he had gone home. Resident #9 opened the front lobby door and helped Resident #2 go inside the building. She stated she did not understand how Resident #2 got out of the building because they had alarms on the doors. Resident #8 said they would have seen Resident #2 if he had come out the front door. She did not indicate that she heard the alarm sounding when Resident #2 went into the facility. A review of the weather record for February 4, 2011 in Fayetteville, NC revealed light rain was noted during the hours of 4:53 a.m. through 8:53 a.m. On 2/10/2011 at 4:10 p.m., the Director of Nursing stated she had not interviewed any residents until yesterday (2/9/2011). She stated she had spoken to Resident #8 and, basically, Resident #8 had stated the same information (e.g. Resident #8 and Resident #9 were outside at 5:30 a.m. on 2/4/2011 and saw Resident #2 coming across the parking lot) but said Resident #8 told her Resident #2 was coming across the parking lot as if coming from the store (left side of parking lot). The quarterly MDS dated [DATE] indicated Resident #8 was cognitively intact. Resident #8 ' s name was provided by the facility as a reliable and interviewable resident. On 2/8/2011 at 5:40 p.m., Resident #9 stated she and Resident #8 were smoking outside the front doors on 2/4/2011 early in the morning. She said they saw a black man coming across the parking lot. He was pushing a wheelchair and he was wet. She stated he was not wearing a coat. She opened the front door for Resident #2. She did not indicate if she heard the alarm sounding when Resident #2 entered the facility. The quarterly MDS dated [DATE] indicated Resident #9 was severely cognitively impaired; however, Resident #9 ' s name was provided by the facility as a reliable and interviewable resident. A nursing note dated 2/04/11 at 06:57 a.m. written by Nurse #1 revealed Resident #2 was observed on the front porch of the facility by a dietary employee. Employee brought the resident back inside. Resident #2 was taken back to the unit. He was slightly wet due to the rain. Resident ' s WanderGuard was in place. The investigative report dated 2/4/2011 was reviewed. Staff that had worked on the unit where Resident #2 resided as well as the adjacent unit were interviewed. Staff on the adjacent unit stated they heard the WanderGuard alarm sounding in the front lobby around 6:00 a.m. When they arrived in the lobby, Resident #2 was in the front lobby. They did not see Resident #2 on their unit until he was being returned after he went outside. Nurse #1 stated that she received a phone call at approximately 6:05 a.m. from someone who stated "One of your residents is underneath the tree out in the rain by the gate." Staff from that unit went to the front lobby and observed Resident #2 in the front lobby and the WanderGuard alarm was sounding. Staff reported Resident #2 stated he was going home. Staff noted he had "drizzles" of rain on his sweater and his wheelchair seat was wet. NA #1 stated she assisted the resident out of bed at 5:30 a.m. and had observed him in the dining room at 5:40 a.m. Nurse #1 had documented that a dietary staff member brought the resident back into the building. The Director of Nursing (DON) indicated no staff member was able to validate that a dietary staff member brought Resident #2 in and no staff member actually observed him outside. On 2/8/2011 at 5:15 p.m., Nurse #1 stated, on 2/4/2011, NA #1 got Resident #2 out of bed around 5:45 a.m. She said Resident #2 did not normally get out of bed at this time but he was awake and staff was trying to help the day shift out by getting him up. Nurse #1 stated Resident #2 had a WanderGuard bracelet on his ankle and was sitting in his wheelchair at the nurse ' s station. The WanderGuard alarm system at the dining room door kept alarming every time he tried to go into the dining room and they had to reset the alarm each time it went off. At 6:00 a.m., she was doing her last rounds when someone (person did not identify themselves) called on the telephone and told her one of the patients was outside the facility. She stated her WanderGuard alarm was not sounding at the time of the phone call. She and nursing staff from her unit ran toward the front lobby and someone was bringing him back inside. She did not see who was bringing Resident #2 inside the building and stated she heard a voice that sounded like one of the dietary employees. She indicated the front lobby WanderGuard alarm was sounding when she arrived in the lobby area. She stated, from the Dogwood area (700 and 800 halls), the front door alarm could not be heard. Interviews were conducted with NA #1 and NA #2 on 2/8/2011 between 5:25 p.m. and 5:30 p.m., Both NAs stated Resident #2 was in his wheelchair around 5:30 a.m., He kept rolling in his wheelchair near the dining room door and trying to go in the dining room and caused the Wander Guard alarm to go off. About 6:00 a.m., Nurse #1 asked NA#1 to look for Resident #2 because she had received a phone call about a patient being outside the building. Both NAs went to the front lobby area and found Resident #2 sitting in a regular chair in the front lobby with his wheelchair parked beside him. He had some sprinkles of water on his clothing. A small amount of water (drizzles) was on his wheelchair. Resident # 8 and Resident #9 were outside the front door. NA #2 stated they had the front door open and were coming in the building. When they saw NA #1, they stated Resident #2 had come up walking but did not state he was outside. They stated the alarm was sounding in the front lobby area. On 2/8/2011 at 12:00 p.m., the nurse practitioner stated she received a call from nursing staff on 2/4/2011. Staff informed her that Resident #2 was found outside of the building early in the morning alone. She stated Resident #2 was not known to try to exit the building. He was not known to ambulate but mobilized about the facility in a wheelchair. She examined Resident #2 later that morning, ordered laboratory tests and determined Resident #2 had a urinary tract infection. She stated there were no physical and/or mental changes noted except for verbal responses (Resident #2 had increased verbalizations). On 2/8/2011 at 4:20 p.m., the Director of Nursing (DON) stated Resident #2 was not known to ambulate and/or try to exit the building. She said no one actually verified that Resident #2 was outside and no staff member actually saw him outside of the building. The DON stated NA #1 got Resident #2 up at 5:40 a.m. At 6:00 a.m., he walked in the main lobby door. When he came in the front door, the WanderGuard alarm sounded. Staff from his unit and the adjacent unit came to the lobby area. She indicated staff believed he went out of one of two doors (the day room door or dining room door). Staff had informed her that Resident #2 came in the door by himself and did not mention that there were any other residents in the area at that time. Resident #2 did not usually ambulate. On 2/9/2011 at 12:10 p.m., the DON stated there were nine residents with WanderGuard bracelets and two residents (Resident #2 and Resident #3) had exhibited exit seeking behavior as of 2/9/2011. In November 2010, she stated she had instructed nursing staff to check the WanderGuard bracelets every shift for function and placement and expected the information to be documented on the Medication administration record. Medication administration records (MARS) were reviewed. The following was noted: Resident #2's WanderGuard bracelet checks for function and placement (to be done every shift) was not noted on MARS for November 2010, December 2010 and January 2011. WanderGuard checks for function and placement every shift was documented on February ' s MAR beginning 2/4/2011. The Administrator was notified of the Immediate Jeopardy on 2/10/2011 at 4: 10 p.m. The facility presented a credible allegation of compliance on 2/11/2011 at 5:00 p.m. which included: Address how the corrective action will be accomplished for those residents found to have been affected by the deficient practice: On 2/4/11, Resident # 2, at approximately 6a.m., was reported to be outside. The alarm on the front lobby was going off. Nurse and CNA responded and found Resident #2 sitting in lobby. Approximately 6:30 a.m., Nurse notified DON, Administrator and Unit Manager. Nurse #1 immediately checked the resident ' s wander guard bracelet to confirm that it was operational by walking Resident #2 through interior lobby doors. Door alarm sounded indicating that the bracelet was operational. The maintenance assistant tested all doors alarms with tester at approximately 7am on 2/4/11 and door alarm checks were documented on the computer building engine system as being operational. Fifteen (15) minute checks on dayroom and dining room doors x 24 hrs were initiated to be done by Nurse on unit using tester confirming that door alarms indicating operational. Door alarms were documented as operational. This was documented on the Observation Record; All other door alarms were checked daily by Maintenance assistant and Manager on duty on the weekend (days). Checks were documented on the Building engine system by Maintenance assistant or WanderGuard/door alarm check form. Nurse #1 completed a head to toe assessment of the resident when he was brought back to the unit. Assessment of the resident showed no injury and this was documented in the progress note. Fifteen (15) minutes checks x 24 hrs were initiated for Resident #2 to be done by nursing staff on the unit. After the 24 hrs, Resident #2 was not demonstrating any exit seeking behaviors and fifteen (15) minute checks stopped. . The Nurse Practitioner (NP) was notified 2/4/10 at approximately 8:30a.m. At approximately 9 a.m., NP assessed Resident #2 and gave orders for UA (urinalysis), CBC (complete blood count), CMP (comprehensive metabolic panel), and VS (vital signs) every shift x 3 days and then daily x 7 days. Results received for UA on 2/5/11 with positive results for [DIAGNOSES REDACTED]. Resident #2 had been assessed as a wandering risk on 9/18/10, 12/16/10 and again on 2/4/11 and a WanderGuard bracelet had been placed on resident 9/18/10. Care plan dated 12/23/10 included interventions: Provide program of activities to minimize potential for wandering while meeting need for social/cognitive stimulation, use security alarm bracelet (WanderGuard), praise purposeful movement for non wandering behavior and anticipate resident needs as much as possible. Care plan was updated on 2/4/11 to add Q15 (every fifteen ) minute observation checks on resident by staff for 24 hrs. Care plan was updated on 2/8/11 with a goal evaluation done stating "new DX (diagnosis) UTI with antibiotic therapy which may have influenced desire to leave facility and go home". Change in behavior was thought to be related to UTI 2/5/11 and new [DIAGNOSES REDACTED]. No further attempts by resident #2 to elope. Licensed nurses will continue to check all resident WanderGuard bracelets every shift to verify they are in place, correct placement per manufacturing guidelines, and are operational. Documentation of verification will be on the Medication Administration Record. How corrective action will be accomplished for those resident having potential to be affected by the same deficient practice: DON arrived at the facility 2/4/11 at 6:47 a.m. DON verified location of resident in his room. DON in-serviced the staff on the units in approximate surrounding at the time of elopement (which are Magnolia and Dogwood) on responding to alarms, verifying location of their residents and elopement. In-servicing on wander guard system, response to alarms, and elopement began on 2/4/11, 2/8/11 & 2/9/1. All employees who have not yet been in-serviced will be in-serviced upon arrival for their next shift. Beginning 2/11/11, in-service will include that a minimum of 2 WanderGuard bracelets will be kept in a medication cart on Dogwood and Magnolia units and 1 WanderGuard bracelet on Independence unit (as the majority of these residents are more independent and receiving rehab short term stay) in a medication cart. In the event that there is not a WanderGuard available, the resident at risk will be assigned a staff member to stay with that resident until a wander guard bracelet is placed on resident. In-servicing on WanderGuard system, response to alarms and elopement began on 2/4/11, 2/8/11 & 2/9/11 including how to react. If door alarms are found to be non-functioning, a staff member will be assigned to stay at the door until the door is repaired. All employees who have not yet been in-serviced will be in-serviced upon arrival for their next shift. This was completed 2/14/11. On 2/4/11, the Administrator called (name of environmental services company) at approximately 9 a.m. (Name of environmental services company) verified that they would be at the facility approximately 4:30 to 5p.m. to switch the WanderGuard Door alarm to the outside doors in both the dining room and dayroom. (Name of environmental services company) changed the alarm on the dining room door at approximately 6:30 p.m. The dayroom door was changed on 2/5/11 at approximately 10 a.m. Fifteen minute door checks continued until the door alarms were working properly. On 2/5 & 2/6/11, the manager on duty completed WanderGuard door checks. The maintenance assistant completed WanderGuard door checks daily during the week and the manager on duty completed WanderGuard door checks on weekends previous to 2/4/11. Checks continue daily since 2/4/11. There have been no reports of system not working properly. Signs stating "Do not assist resident outside" were placed on all doors available to exit by visitors by DON. This was completed 2/10/11 All residents currently residing in facility have been assessed for wandering risk using the At risk to Wander assessment form. New admissions will be assessed using the At Risk to Wander Assessment Form on admission and quarterly or as soon as they display s/s of wandering. All residents assessed as wanderers have been, and will continue to be, given a WanderGuard bracelet, a wander risk care plan to include interventions to prevent elopement, and will be communicated via care plan confirm to direct care staff. Their picture will be posted at each nurse ' s station, back door and lobby receptionist area. Address what measures will be put in place or systemic changes made to ensure that the deficient practice will not occur: On 2/9/11 the facility contacted (name of Wander Management Company) and (name of environmental services company) to discuss the possibility of changing the door alarms to alarm when a resident approaches the signal field before a door is opened. All doors currently alarmed when opened by a resident with a WanderGuard and the lobby doors already were set to alarm when a resident with a wander guard approached the signal field before the door was opened. (Name of Wander Management Company) advised how to make the changes and the Regional Maintenance Director changed the door alarms accordingly so that when a resident with a WanderGuard approached the signal field, the alarm sounds before the door was open. This was completed on 2/9/11. On 2/10/11, the Regional Maintenance Director adjusted the system so that the alarm field is expanded to capture the resident ' s signal before reaching the door in an effort to ensure the optimal effectiveness of the system. On 2/10/11, after the system was adjusted, checks were completed x 2 (two) on all doors with alarms and the system was working properly. No other residents have been determined to exit in similar circumstances. DON and unit managers verified that all residents have been assessed for wandering risk using the Wandering Assessment form. This was completed 2/10/11. Residents who had wander guards placed on their chairs have had the WanderGuard removed from the chair and placed in a location acceptable per manufacturer ' s recommendations. This was completed 2/10/11 Indicate how the facility plans to monitor its performance to make sure solutions are sustained. The facility must develop a plan for ensuring that correction is achieved and sustained. The plan must be implemented and the corrective action evaluated for its effectiveness. The POC is integrated into the quality assurance system of the facility: To verify that the system continues to function properly, the maintenance assistant or manager on duty will continue to check all egress doors daily. The maintenance assistant will document on the Building Engine System and the manager on duty will document on the Weekend MOD (manager on duty) wander guard/door check log form. Forms will be audited by the Administrator. The audit will be 5 times a week to include weekend shifts x 1 month. This was completed 2/10/11. In-servicing on WanderGuard system, response to alarms and elopement began on 2/8/11 & 2/9/11 including How to react if door alarms are found to be non-functional. If a WanderGuard is found to be non-functioning, a staff member will be assigned to stay at the door until the door is repaired. All employees who have not yet been in-serviced will be in-serviced upon arrival for their next shift. This has a completion date of 2/14/11. Tests will be done by DON or the unit managers by setting off alarms and timing the response to the door alarm. Findings will be documented on the Door alarm response time audit form. Audit response time to door alarms will be done 5 (five) times weekly x 1(one) month to include weekend shifts, 2 (two) times weekly x 1(one) month to include weekend shifts, and then weekly x 1(one) month to include weekend shifts. Any concerns will be taken to daily stand up meetings and Quarterly Quality Assurance meetings for review and resolution. This was completed 2/10/11. Licensed nurses will continue to check all resident WanderGuard bracelets every shift to ensure that they are in place, correct placement per manufacturing guidelines, and operational. Documentation will be on the Medication Administration Record. Documentation will be audited 5 times a week x 1 month by DON or unit managers. This was completed 2/10/11 The Regional Maintenance Director will continue to complete quarterly inspections of the door alarm system. The Administrator will audit completion. This was completed 2/10/11 with quarterly repeats thereafter. All residents currently residing in facility have been assessed for wandering risk using the At risk to Wander assessment form. New admissions will be assessed using the At Risk to Wander Assessment Form on admission and quarterly. All residents assessed as wanderers have been, and will continue to be, given a WanderGuard bracelet, a wander risk care plan, and their picture will be posted at each nurse ' s station, back door and lobby receptionist area. All Licensed nursing staff have access to residents care plan on the Optimum Clinical system and NAs will have access to care plan interventions for NAs by care plan confirm button on ADL system. This will be audited weekly by DON or unit managers using the Wandering/elopement risk audit form that includes date of last wandering assessment, bracelet placed appropriately, care plan for wandering, and picture. This was completed 2/10/11 In-servicing on WanderGuard system, response to alarms, and elopement began on 2/4/11, 2/8/11 & 2/9/11, including how to react if door alarms are found to be non-functional. If door alarms are found to be non-functioning, a staff member will be assigned to stay at the door until the door alarm is repaired by nursing staff. In the event that there is not a WanderGuard available, a staff member will be assigned to stay with resident until a WanderGuard bracelet is placed on the resident. All employees who have not yet been in-serviced will be in-serviced upon arrival for their next shift. This has a completion date of 2/14/11. All nursing staff will be in-serviced on 2/15/11 by Geriatric Adult Specialty Team from (name of Mental Health Service) to include how to recognize exit seeking behavior. All employees who have not yet been in-serviced will be in-serviced upon arrival for their next shift after 2/15/11. The DON or Staff Development Coordinator will provide education on how to recognize exit seeking behavior to start May 2011 with repeats quarterly. This has a completion date of 2/18/11. A (name of Wander Management Company) technician will test the Wander guard system to ensure that the system is working properly. This was completed 2/10/11. A (Name of Wander Management Company) technician will test the Wander guard system to ensure that the system is working properly monthly times 3 months beginning in March, 2011. This will be audited for completion by Administrator. Resident #2's elopement was addressed in the daily stand up meeting & daily falls committee 2/7/11. Results of door alarm and wander guard checks will be reviewed during Quarterly Assurance Meetings quarterly until compliance is achieved with the committee and recommendations made where appropriate. Between meetings, any elopement incidences will be reviewed by the Falls Committee (DON, Administrator, UM and other attendees) during daily stand up meeting. This will be audited by the Administrator or designee. This was completed 2/7/11 with quarterly reports until compliance achieved. The facility will continue to provide adequate supervision to all of its residents. In particular, where residents are identified as being at risk for elopement, the facility will assess the necessary level and type of supervision that may be required and will provide that supervision based on the individual resident's assessed needs and the risks identified in the environment. Immediate Jeopardy was removed on 2/11/2011 at 5:00 p.m. Observations of residents with WanderGuard bracelets revealed bracelets were appropriately placed on the residents and/or on the wheelchairs. Interviews with direct care staff and licensed staff confirmed they had received in-servicing on responding to the alarm system, monitoring of the WanderGuard alarm bracelets, checking the bracelets for proper function and appropriate documentation and what to do if the system (door alarm and/or bracelet) does not function properly. Licensed staff demonstrated proper Wander Guard function tests. Documentation was provided by the facility that the WanderGuard alarm system had been serviced by the company and functioned properly. Documentation was provided by the facility and observations confirmed staff responded to alarms promptly. Documentation was also provided by the facility of WanderGuard alarm door checks. The maintenance assistant was observed checking the WanderGuard door alarms to determine if they alarmed and functioned properly. Checks were done per policy and there were no problems noted. 2. Wanderguard E departure alert system manufacturer guidelines stated, " Do not place the signaling device on or within 2 " metal, such as wheelchair frames, jewelry, watches etc. or allow it to come in contact with a door or associated hardware such as crash-bars, push-bars, etc. Metal could interfere with the signal sent to the door modules." The wheelchair placement guidelines stated "Mount the signaling device away from the metal frame of a wheelchair at a height of approximately 3 feet from the floor (in the center of the back of the wheelchair). Use only plastic clips or plastic (non-metallic) tape to attach the device." Resident #6 was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. An annual Minimum Data Set assessment, dated 7/21/2010, indicated Resident #6 had short term and long term memory impairment. He was moderately impaired for decision making. He required extensive assistance for transfers and walking in his room. His primary mode of locomotion was his wheelchair. A 10/26/10 care plan included the problem of wandering related to dementia. Approaches included wanderguard bracelet to wheelchair, verify placement every shift, provide diversional activities and encourage rest periods. A Wandering/Elopement risk assessment, dated 1/21/11, indicated Resident #6 was cognitively impaired with poor decision-making skills. He was able to ambulate independently in a wheelchair. He did not have a history of elopement at home or leaving the facility without supervision. A personal alarm safety device was initiated on 3/10. A wanderguard was initiated 12/08. February 2011 Medication Administration Record (MAR) documented checking of the wanderguard bracelet on 2/8/11 and 2/9/11. The December 2010 MAR documented no wanderguard bracelet checks. During an interview, on 2/10/11 at 11:00 am, Nurse #2 indicated the wanderguard was placed on Resident #6's wheelchair due to his history of removing from his wrist and ankle. The wanderguard bracelet should be checked every shift and documented on the MAR. On 2/10/11 at 11:03 am, Resident #6 was in his bed with a personal alarm device in place. His wheelchair had a wanderguard bracelet attached to the metal wheelchair frame within one inch of metal wheel. 3. Wanderguard E departure alert system manufacturer guidelines stated warning "Do not place the signaling device on or within 2" metal, such as wheelchair frames, jewelry, watches etc. or allow it to come in contact with a door or associated hardware such as crash-bars, push-bars, etc. Metal could interfere with the signal sent to the door modules." The wheelchair placement guidelines stated "Mount the signaling device away from the metal frame of a wheelchair at a height of approximately 3 feet from the floor (in the center of the back of the wheelchair). Use only plastic clips or plastic (non-metallic) tape to attach the device." Resident #7 was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. A 12/18/10 annual Minimum Data Set assessment indicated she had short term and long term memory problems. She was moderately impaired in decision making. She required extensive assistance with transfers and locomotion on the unit. Her primary mode of locomotion was a wheelchair. A 12/26/10 care plan included a problem of risk of wandering due to dementia. Approaches included encourage rest periods, provide program of activities, use wanderguard system, wanderguard bracelet to wheelchair. A 2/3/11 Wandering/Elopement assessment indicated Resident #7 was cognitively impaired with poor decision making. She wandered aimlessly and had no history of leaving the facility without supervision. A wanderguard was initiated on 2/2/10 with bed alarm. Review of the November 2010 and December 2010 Medication Administration Record (MAR) documented no check of the wanderguard bracelet. The January 2011 MAR documented no check of the wanderguard bracelet. The February 2011 MAR documented one check of wanderguard bracelet on 2/9/11. On 2/10/11 at 10:25 am, Resident #7 was in the activity room in her wheelchair. The wanderguard bracelet was attached to the metal wheelchair frame by within one inch of the metal wheel. During an interview, on 2/10/11 at 10:53 am, Nurse #2 stated the wanderguard had been placed on Resident #7's wheelchair in 2010 due to her taking the bracelet off her wrist. The wanderguard bracelet should be checked every shift and documented on the MAR 4. On 2/8/2011 at 8:25 a.m., 12:45 p.m. and 4:30 p.m., the Administrator stated, near the end of January 2011, residents from the Memory Care Unit and the unit just outside of that area (400, 500, 600 hall) had relocated to the other side of the building (700, 800 hall). At the time of the move, there were WanderGuard alarms on all of the doors in the facility except the door leading to the service area and the two exterior doors in the dining room and day room/ activity room. Both rooms were adjacent to the nursing station on the 700, 800 halls. The dining room and the day room/activity room had interior doors that had WanderGuard alarms. When the alarm was activated by the Wander Guard bracelet, staff had to manually punch in a code in order to turn the alarm off. The two exterior doors had a magnetic alarm system in place that would sound an alarm or chime when the door was opened. She stated on 1/27/2011, maintenance personnel adjusted the magnetic alarm system on both exterior doors to activate when the door was opened and to remain alarming until someone shut it off. The magnetic alarm was located at the top of the door. There were three settings (continuous alarm, chime alarm, turned off) and the alarm could be placed in any of these three positions. This alarm was not activated by the WanderGuard bracelet. On 2/8/2011 at 12:30 p.m., a visitor exited the exterior dining room door. The alarm sounded when the door was opened and stopped within thirty seconds of the door being closed. On 2/8/2011 at 12:45 p.m. and 4:30 p.m., the Administrator stated on February 5-6, the WanderGuard system was moved from the interior dining room and activity room doors to the exterior doors of both rooms. She indicated the WanderGuard bracelets a