Every finding on record at Cedar Hills Center for Nursing and Rehabilitation

Based on observations, record review, staff, and Corporate Nurse Consultant interviews, the facility failed to store medication in its original package with labeling and dispensing instructions (300 hall Medication Cart), failed to remove expired medication (100 hall Medication Cart), and failed to secure two unlocked treatment carts. These failures occurred in 2 of 2 medication carts and 2 of 2 treatment carts (100 and 300 hall) reviewed for medication storage.Findings Included:1). An observation of the 300 hall medication cart was completed on 06/24/2026 at 1:27 PM accompanied by Nurse #2. During this observation five pills were observed loose and not in their original package. The five loose pills were observed in the over-the-counter medication drawer of the medication cart. An interview with Nurse #2 on 6/24/2026 at 1:28 PM revealed that she was unaware of where the loose pills came from and she was unable to identify the pills. Nurse #2 stated she was not aware she had pills that were loose in her medication cart. Nurse #2 could not recall seeing the loose pills when she checked her cart at the beginning of her shift or when she was administering medications earlier in the shift. Nurse #2 stated she had been assigned to this medication cart for the day shift on 6/24/2026. The Director of Nursing (DON) was interviewed on 6/25/2026 at 10:44 AM and she stated that she was unsure why there were loose medications on the 300-hall medication cart. The DON stated she had been doing checks weekly of the medication carts. The DON was unable to explain why there were loose medications on the medication cart. An interview was completed with the Corporate Nurse Consultant on 6/25/2026 at 11:25 AM. The Corporate Nurse Consultant stated she had checked the 300-hall medication cart the morning of 6/24/2026 and there were no loose medications in the cart at that time. She was unable to explain why the loose medication was observed in the medication cart. The Corporate Nurse Consultant stated she has helped with the medication cart checks as well as the DON and nurse assigned to the cart. An interview with the Administrator was completed on 6/26/2026 at 1:15 PM and she could not explain why there were loose medications on the 300-hall medication cart. The Administrator stated the medication carts were checked by the DON and Corporate Nurse multiple times a week and there had not been an issue with loose medications that she was aware of. The Administrator stated that with the routine checks of the medication carts there should have been no loose medications observed. 2). An observation on 6/24/2026 at 2:13 PM of the 100-hall medication cart accompanied by Nurse #3 revealed a bottle of opened Vitamin D3 (vitamin supplement) capsules with an expiration date of 5/2026. An Interview with Nurse #3 was completed on 6/24/2026 at 2:15 PM and she confirmed that the bottle of the Vitamin D3 capsules had expired 5/2026 and should have been removed from the medication cart. Nurse #3 stated she had not observed the expired bottle when completing her checks at the start of the shift. The bottle was removed from the medication cart during this interview with Nurse #3. The Director of Nursing (DON) was interviewed on 6/25/2026 at 10:44 AM and stated medication checks were completed weekly by herself and the nurse assigned to the medication cart and the Vitamin D3 capsules should have been removed when they expired. The DON was unsure why the bottle of Vitamin D3 had not been discarded and replaced at the time of expiration. An interview with the Administrator was completed on 6/26/2026 at 1:15 PM. The Administrator stated the medication carts were checked multiple times a week by the DON and other nursing staff at the facility. The Administrator stated that with the weekly checks of the medication carts there should have been no expired medications observed. The Administrator was unable to explain why an expired bottle of Vitamin D3 was on the 100-hall medication cart. The administrator stated the expired medication should have been removed at the time of expiration and replaced with a current date bottle of medication. 3a). On 6/25/2026 at 9:52 AM an observation of Nurse #1 completing wound care was made. Nurse #1 was observed leaving the 300-hall treatment cart unattended and entering a resident's room without locking the cart. The treatment cart contained medication supplies used for wound care treatments. There was one resident in a wheelchair in the hallway approximately three feet from the treatment cart. Nurse #1 returned to the 300-hall treatment cart to lock the treatment cart when the Surveyor brought it to her attention. Nurse #1 again returned to the 300-hall treatment cart at 9:53 AM to get forgotten supplies and returned to the resident's room to complete treatment. When exiting the room after the observation of treatment was completed it was observed that Nurse #1 left the 300-hall treatment cart unlocked from when she had gotten her forgotten supplies to complete the wound care. There were two residents leaving their room in the hallway during this observation. The two residents were approximately three feet from the treatment cart. An interview with Nurse #1 was completed on 6/25/2026 at 10:02 AM and she was unaware she had not locked the treatment cart when getting the bandage she had forgotten. She stated she should have locked it back before going back into the residents' room to complete the wound treatment. 3b). An observation at 10:32 AM on 06/25/2026 of the treatment cart located on the 100-hall at the nurse's station was observed unattended and unlocked. Medicated supplies were being stored on the 100-hall treatment cart at the time of observation. The time that the treatment cart was left unattended and unlocked was unknown. At 10:39 AM the Director of Nursing (DON) confirmed the treatment cart on the 100 hall was unlocked. The DON was interviewed on 6/25/2026 at 10:44 AM and stated she could not explain why the treatment carts were left unlocked and unattended. She stated staff were aware of locking the treatment and medication carts when leaving them unattended. An interview was completed with the Corporate Nurse on 6/25/2026 at 11:25 AM. The Corporate nurse shared that the DON observed the treatment cart unlocked when passing in the hallway and was the one responsible for locking the treatment cart on the 300 hall. A follow up interview was completed with the DON on 6/26/2026 at 1:14 PM and she confirmed that she had observed the treatment cart unlocked on 6/25/26. The exact time was unknown, but she stated when she observed the treatment cart was unlocked, and she locked the treatment cart at that time. The Director of Nurse did not know why the treatment cart was unlocked while unattended. An interview with the Administrator was completed on 6/26/2026 at 1:15 PM. The Administrator stated she could not explain the unlocked treatment carts. The Administrator stated that every time she made rounds on the hallways the medication/treatment carts were always observed to be locked.

Based on observation and staff interviews, the facility failed to protect resident #8's private healthcare information (PHI) by leaving confidential medical information unattended, visible, and accessible to others on a laptop screen for 1 of 2 treatment carts observed (300-hall treatment cart).The findings included:On 6/25/2026 at 9:52 AM an observation of the 300-hall treatment cart revealed the treatment cart was left unattended when the Treatment Nurse left and entered Resident #8's room to complete the treatment ordered. The Treatment nurse left the computer screen open facing the hallway displaying resident #8's personal identifying information including the resident's name, diagnoses, and orders for treatment. Before closing the door to Resident #8's room to complete the ordered treatment, the Treatment Nurse was asked by Surveyor to place privacy screen on to protect Resident #8's PHI from being revealed. There was one resident in a wheelchair in the hallway during this time. During an interview on 6/25/2026 at 9:54 AM with the Treatment Nurse she acknowledged she did not lock the laptop screen on the treatment cart when she walked away. She indicated she knew she should have locked the laptop screen before leaving the area to ensure resident information was not visible to others. An interview on 6/25/2026 at 10:42 AM with the Director of Nursing (DON) revealed the Treatment Nurse should not have walked away and left resident information displayed on screen without locking it. She indicated screens should be locked to protect resident's privacy whenever the treatment cart was left unattended.

Based on record review, staff interviews, and between review and staff the facility failed to ensure 2 of 2 narcotic reconciliation records reviewed were signed and dated when controlled substances were administered (100 and 300 hall).The findings included: The facilities Controlled Substance Administration and Accountability policy dated 12/2022 with a review dated of 12/2025 under Section f ii stated, All controlled substances obtained from non-automated medication cart or cabinet are recorded on the designated usage form. a. A review on 6/24/2026 at 1:58 PM of the 300-hall side B narcotics reconciliation record showed that at the time of review, there was no record indicated in the narcotics reconciliation record of a controlled substance being administered. The last administration of a controlled substance in the in the narcotic reconciliation record for 300-hall B was signed for administration on 6/23/2026. Nurse #2 was interviewed on 6/24/2026 at 2:06 PM and stated she had administered lorazepam 0.5 mg earlier in the shift and had not signed the narcotic reconciliation record for administration of the controlled substance when she administered the lorazepam. Nurse #2 stated she knew she was supposed to sign the narcotic reconciliation record at the time the medication was administered. She stated this was to ensure the count for the medication was correct. Nurse #2 stated she knew if she forgot to go back and sign the record the medication count would not be accurate and the medication administered would not be accounted for. Nurse #2 was observed to sign the narcotic reconciliation record at time of the interview. Nurse #2 stated she was aware it was a careless error. Nurse #2 showed the electronic Medication Administration Record (Mar) during the interview revealing the lorazepam being administered earlier in the shift. b. A review on 6/24/2026 at 2:40 PM of the 100-hall narcotics reconciliation record showed that at the time of review, there was no record indicated in the narcotics reconciliation record of a narcotic medication being administered on 6/24/2026. Nurse #3 was interviewed on 6/24/2026 at 2:44 PM and stated she had not signed the narcotic reconciliation record when she administered the hydromorphone but knew she was supposed to sign the narcotic reconciliation record when the medication was administered earlier in her shift. She stated she was aware that if she did not sign for the administering of the medication, the medication count would be incorrect, and she could be held accountable for the narcotic medication. During the interview Nurse #3 shared the electronic MAR revealing she had administered the hydromorphone earlier in the shift. She was unable to give a reason why she did not sign for administering the medication at the time it was administered. Nurse #3 was observed to sign the narcotic reconciliation record at the time of interview. The Director of Nursing (DON) was interviewed on 6/25/2026 at 10:46 AM and stated she expected the narcotic reconciliation record to be signed when the medication was administered. The DON was unable to explain why the narcotic reconciliation record was not signed at the time the medication was administered. An interview with the Administrator was completed on 6/26/2026 at 1:14 PM and she stated the narcotic reconciliation record should be signed at the time the medication is administered by the nurse that administered the medication. The Administrator was unable to explain why the medications were not signed for at the time they were administered. The Administrator stated she expected nurses to sign the narcotic reconciliation record when a narcotic and controlled substance was administered to ensure the medication count was correct.

Based on record review and staff, family, and resident interviews, the facility failed to provide wound treatments as ordered by a physician for 2 of 5 residents reviewed for the provision of care according to professional standards and the care plan (Residents #5 and #16). Findings included:1. Resident #5 was admitted to the facility on [DATE] and discharged from the facility on 3/9/2026. Resident #5 had a right below-the-knee amputation.Resident #5 had a physician's order dated 3/3/2026 that directed staff to wrap the right below-the-knee amputation site with an abdominal pad and Kerlix daily and as needed, and to monitor the site for signs and symptoms of infection.Resident #5's care plan dated 3/3/2026 had a focus area for a surgical wound to the right lower extremity, with an intervention to follow facility protocols for treatment of the injury. Review of the Treatment Administration Record revealed blank documentation spaces for the ordered wound treatment to the surgical site for Resident #5 on Saturday, 3/7/2026 and Sunday, 3/8/2026. Resident #5 had a Medicare 5-Day Minimum Data Set assessment dated [DATE] documenting a surgical wound with application of non-surgical dressing other than to the feet.During an interview on 4/21/2026 at 10:09 AM, Nurse #1 stated she was assigned to care for Resident #5 on 3/7/2026 and 3/8/2026 for the 7:00 AM to 7:00 PM shift. Nurse #1 reported she was an agency nurse and had recently begun working at the facility at the end of February 2026. Nurse #1 stated that on 3/7/2026 and 3/8/2026 she had not been informed that she was responsible for completing wound treatments in her assigned area over the weekend. Nurse #5 confirmed that if the treatment was not checked off on the Treatment Administration Record on 3/7/2026 and 3/8/2026, then she did not complete the ordered wound care for Resident #5.During an interview on 4/20/2026 at 1:42 PM a family member of Resident #5 reported that wound care was not provided to Resident #5 on the weekend of 3/7/2026 and 3/8/2026. The family member reported that area was bleeding on the sheets, but she could not get the nurse to put the dressing back on. The family member stated she attempted to put the dressing back on Resident #5 herself.The Director of Nursing was interviewed on 4/21/2026 at 12:48 PM and stated it was her expectation that the nurses complete wound care and treatments on the nursing shift it was ordered for on weekends when the treatment nurse was unavailable. The Director of Nursing acknowledged Nurse #1 was a contract agency nurse, but stated Nurse #1 should have known she was responsible for completing the ordered treatments on 3/7/2026 and 3/8/2026. 2. Resident #16 was admitted to the facility on [DATE] and had a diagnosis of bilateral lower extremity lymphedema.The electronic medical record showed Resident #16 had a care plan focus area initiated on 4/14/2026 for the risk for pressure ulcer development related to lymphedema, with an intervention to administer treatments as ordered and monitor for effectiveness.A basic interview for mental status assessment completed on 4/14/2026 indicated Resident #16 was cognitively intact.A physician's order for Resident #16 dated 4/15/2026 directed staff to apply Xeroform gauze to both legs, cover with abdominal pads and Kerlix from behind the toes to below the knees, and apply an ace wrap in the same manner every day shift.Review of the Treatment Administration Record for Resident #16 revealed a blank documentation space for the ordered treatment on Sunday, 4/19/2026 for her bilateral lymphedema. During a telephone interview on 4/21/2026 at 2:12 PM, Nurse #3 confirmed she was assigned to Resident #16 on 4/19/2026 for the 7:00 AM to 7:00 PM shift. Nurse #3 stated that she did not remember whether she administered the treatment and explained that she was a new nurse and not very skilled at wrapping legs. She confirmed that if the treatment was not checked off on the Treatment Administration Record, then she did not complete it. Resident #16 was interviewed on 4/21/2026 at 2:46 PM. Resident #16 confirmed she did not receive her leg treatment on 4/19/2026.During an interview on 4/21/2026 at 2:46 PM, the Director of Nursing stated Nurse #3 should have completed the treatment as ordered on 4/19/2026 for Resident #16 and confirmed that nurses assigned to the hall are responsible for completing treatment orders on weekends when the wound care nurse was not in the building.

Based on record reviews and staff interviews, the facility failed to protect a resident's right to be free from neglect when Resident #6's call light was disconnected by a staff member. This caused the resident to be unable to access assistance, and Resident #6 was found on the next shift to be soiled with urine and feces. This failure affected 1 of 2 residents who were reviewed for call system concerns (Resident #6).Findings included:Resident #6 admitted to the facility on [DATE] with diagnoses of chronic kidney disease and hypertension.Resident #6's admission Minimum Data Set (MDS) dated [DATE] indicated he had severe cognitive impairment. Further review of the MDS revealed Resident #6 needed substantial/maximum assistance with toilet hygiene and was incontinent with bowel and bladder. A telephone interview was conducted on 4/21/26 at 10:30 a.m. with Nursing Assistant (NA) 3 and she reported she had been assigned to Resident #6 on 2/21/26 at 7 p.m. to 7 a.m. on 2/22/26. She explained that Resident #6 had repeatedly pushed his call light throughout the shift. She had entered his room multiple times to provide assistance, though at times he did not require help and continued to hold the call light in his hand. NA #3 reported that around 5:15 a.m. she had removed the call light cord from the wall socket and placed a plastic fork in the socket to prevent the call light from ringing while she completed her last round. She further stated she had informed Nurse #4, who told her she could not do that and instructed her to replace the call light cord. NA #3 said she later returned to Resident #6's room between 5:30 a.m. and 5:45 a.m. to provide incontinence care but forgot to reinsert the call light cord.During a telephone interview on 4/21/26 at 11:13 a.m., Nurse #4 stated that NA #3 had informed her she removed the resident's call light cord because he was continuously pressing it while she attempted to complete her last round. Nurse #4 reported that she had instructed NA #3 to reconnect the call light. She intended to check behind NA #3 to ensure the cord had been reconnected but was called to another resident's room and forgot to follow up.NA #4 was interviewed on 4/22/26 at 9:49 a.m. She stated she had been assigned to Resident #6 for the 7 a.m. to 7 p.m. shift on 2/22/26. She reported arriving at work around 7 a.m. and hearing someone yelling as she walked down the hallway. The yelling came from Resident #6's room. When she entered, she observed a plastic fork in the call light socket. Resident #6 told her someone had removed his call light from the socket, although he could not identify who. NA #4 said the resident was soiled with urine and feces, and she took him to the shower for cleaning. NA #4 indicated she reported the situation to Nurse #1.Nurse #1 was interviewed on 4/21/26 at 1:37 p.m. She stated she had been informed by NA #4 that a plastic fork was lodged in Resident #6's call light socket. Nurse #1 reported that she checked the room, observed the fork in the socket, removed it, reconnected the call light cord, and notified the Director of Nursing (DON).The DON was interviewed on 4/22/26 at 11:43 a.m. She stated she had been informed on 2/22/26 that the resident's call light had been disconnected and a plastic fork had been inserted in the socket. She said she verified Resident #6 was unharmed. She suspended both NA #3 and Nurse #4 pending the investigation. Once the investigation concluded, NA #3 was terminated, and Nurse #4 and other staff members received additional education.During a telephone interview on 4/22/26 at 4:00 p.m., the previous Administrator stated that both Nurse #4 and NA #3 had been suspended pending the investigation. Nurse #4 was reinstated and provided education on rounding responsibilities and ensuring call lights were functioning. Additional education was provided for the rest of the staff, and NA #3 was terminated.

Based on observations, record reviews, and staff interviews, the facility failed to have a medication error rate of less than 5% as evidenced by 2 medication errors out of 33 opportunities, resulting in a medication error rate of 6.06% for 1 of 2 residents observed for medication administration (Resident #12).The findings included:Resident #12 was admitted to the facility on [DATE] with diagnoses that included anemia, iron deficiency, and hyperlipidemia. Resident #12's physician order dated 4/2/26 for polysaccharide iron complex capsule 150 milligrams (mg) give 1 capsule by mouth one time a day for deficiency. There was no order for acidophilus 500 million (acidophilus 500 million refers to a probiotic supplement that contains 500 million active organisms per serving) located in the medical record. On 4/21/26 a continuous observation of medication administration occurred from 8:28 AM through 8:54 AM. Upon observation of Nurse #1's medication cart and the medication storage room during a medication administration pass, Nurse #1 was unable to locate a bottle of the polysaccharide iron complex capsules (150mg). While at her medication cart, Nurse #1 proceeded to pour one acidophilus 500 million tablet into Resident #12's medicine cup and stated since both medications were probiotics, one could be substituted for the other. Nurse #1 administered the acidophilus tablet along with Resident #12's other medications. On 4/21/26 at 9:10 AM, an interview was held with Nurse #1. She stated if a medication was not available in her medication cart, she would see if another cart on her hall had that medication. If the medication was available on that cart, she would get a cup of the capsules or tablets to finish her medication pass. If the medication was not available on either cart, she would look in the medication storage room. If the medication was not in the storage room, she would follow up with Central Supply to place an order for that medication. On 4/21/26 at 9:40 AM, an interview with Unit Manager #2 revealed if a medication was not available on the medication cart, she would check overstock. If the medicine was not in overstock, she would notify the family and provider. If the medication was a house stock medicine (such as a multivitamin, aspirin, Tylenol, vitamin D3, etc.), she would borrow the medicine from another cart. If that cart did not have the medication, she would let management know and request Central Supply to order it. It usually took less than a day to get house stock medications. If the medication was a prescription, she would check the overstock, medication rooms, or pull the medicine from the Pyxis (machine that housed prescription medications). She would also notify the provider to see if any changes were needed. An interview was conducted with Unit Manager #1 on 4/21/26 at 9:54 AM. She stated when a medication was not available, she would see if the medicine was in the Pyxis. She would notify the provider to order the medication or get a prescription. If the medication was an over-the-counter medication, she would exhaust her options by checking every medication cart, medication room, etc. She would notify the provider if the medication was not available to see if they wanted a substitute or to place the medication on hold. On 4/21/26 at 10 AM, an interview with the Director of Nursing (DON) revealed if a medication was not available on the medication cart, she would check all medication carts and medication storage rooms. If the medication was not available, she would follow up with Central Supply. If they could not obtain the medication, they would contact the provider. A follow up interview with the DON on 4/21/26 at 2:10 PM revealed polysaccharide iron complex is a different medication from acidophilus, and they should not be substituted. An interview conducted with the Nurse Practitioner (NP) on 4/22/26 at 10:15 AM revealed if a resident ran out of a medication, staff should notify him. He stated if the medication was not at the facility, they should call him and he could place a hold on that medication until it was received. The NP stated acidophilus probiotic is not the same medication as the polysaccharide iron complex and that staff should not be making that distinction. The NP stated staff should have notified him of the administration of the acidophilus. He also stated getting the acidophilus should not hurt Resident #12 and there was no harm caused. However, Resident #12 was not getting the benefits as he should with taking the acidophilus instead of the polysaccharide iron complex.

Based on observations and staff interviews, the facility failed to store stock medications securely in the original covered and labeled bottles to prevent errors and possible contamination in 1 of 2 medication carts reviewed for medication storage (300 hall medication cart #1).The findings included: A medication administration observation of the medication cart #1 for the 300-hall occurred on 4/21/26 for Resident #12. This was a continuous observation that occurred from 8:28 AM through 8:54 AM. The observation revealed Nurse #1 did not have a bottle of Vitamin D3 (cholecalciferol) 25 micrograms (mcg)/1000 units (supplement) in her medication cart, nor was the medication available in the medication storage room. Nurse #1 obtained the medication from Unit Manager #1's medication cart #2 which was also assigned to the 300-hall. Unit Manager #1 poured 8 tablets of the Vitamin D3 25mcg/1000 units into a medicine cup, labeled the cup as Vit D3, and handed the cup to Nurse #1. Nurse #1 went back to her medication cart and placed the medicine cup into the top drawer of her medication cart. Nurse #1 confirmed she placed the Vitamin D3 in a medicine cup for continued use until she was able to get a bottle for her medication cart. A continuous medication administration observation on 4/21/26 from 8:54 AM through 9:08 AM with Nurse #1 revealed she did not have Acetaminophen 500 milligrams (mg) in medication cart #1 on the 300-hall for Resident #10. Nurse #1 obtained the medication from Unit Manager #1's medication cart #2. Unit Manager #1 poured 12 tablets of the Acetaminophen 500mg into a medicine cup and handed the cup to Nurse #1. Nurse #1 went back to medication cart #1 and placed the medicine cup into the top drawer of her cart. The medicine cup was not labeled. Nurse #1 stated she did not have a pen to write the medication name on the cup. Nurse #1 confirmed she placed the Acetaminophen in a medicine cup for continued use until she was able to get a bottle for her medication cart. On 4/21/26 at 9:10 AM, an interview was held with Nurse #1. She stated if a medication was not available in her medication cart, she would see if another cart on her hall had that medication. If the medication was available on that cart, she would get a cup of the medicines to finish her medication pass. If the medication was not available on either cart, she would look in the medication storage room. If the medication was not in the storage room, she would follow up with Central Supply to place an order for that medication. On 4/21/26 at 10 AM, an interview with the Director of Nursing (DON) revealed if a medication was not available on the medication cart, she would check all medication carts and medication storage rooms. If the medication was not available, she would follow up with Central Supply. If they could not obtain the medication, they would contact the provider. Interview and observation of Nurse #1's medication cart #1 with the Director of Nursing (DON) present on 4/21/26 at 10:15 AM revealed the open medicine cups that contained 12 tablets of Acetaminophen 500mg and 8 tablets of Vitamin D3 (cholecalciferol) 25mcg/1000 units had been discarded. Nurse #1 stated she received a bottle of Acetaminophen 500mg and Vitamin D3 25mcg/1000 units from the Assistant Director of Nursing (ADON). However, during this observation with the DON and Nurse #1, an open medicine cup of white tablets labeled Magnesium was observed in the top drawer of the medication cart. The small medicine cup was observed to be about half full of tablets. The number of tablets in the cup was unknown as Nurse #1 discarded the pills prior to counting. The DON stated medications were not supposed to be stored open (labeled or unlabeled) in a medicine cup in the medication cart.

Based on observation, record review, and resident and staff interviews, the facility failed to provide assistance to the bathroom and incontinence care to a resident upon request for 1 of 5 reviewed for the provision of activity of daily living care (Resident #16).Findings included:Resident #16 was admitted to the facility on [DATE] with diagnoses including non-progressive congenital joint contractures and chronic obstructive pulmonary disease.Review of an admission data collection note dated 4/13/2026 revealed Resident #16 was assessed as incontinent of bladder and bowel.A Brief Interview for Mental Status assessment completed on 4/14/2026 indicated Resident #16 was cognitively intact.A care plan focus area, initiated on 4/16/2026 for Resident #16, documented a self-care performance deficit, with interventions including the need for one-person assistance for toileting and transfers.Documentation in a daily skilled physical therapy note completed on 4/20/2026 revealed Resident #16 performed a transfer from the edge of the bed to a forward wheeled walker. Resident #16 then took a few steps, transferred to the wheelchair and then the commode with moderate assistance with verbal cues for hand positioning and pivoting. Resident #16 was noted to end the session back in the wheelchair.During an interview and observation conducted on 4/21/2026 at 2:22 PM, with a follow-up interview on 4/22/2026 at 9:41 AM, Resident #16 reported that she had received medication earlier that morning to stimulate bowel movement. She stated that at 12:15 PM, she activated her call light, requesting assistance to the bathroom because she felt the medication beginning to work and believed she could reach the bathroom with help. She reported that Nurse Aide (NA #1), whom she did not recognize, responded within five or six minutes. According to Resident #16, she informed NA #1 of her urgent need for assistance and her fear of having a bowel movement in bed. The resident stated that NA #1 turned off the call light and told her she would return, but no one came. The resident reported that she activated her call light again, at which time NA #2 entered the room to deliver her lunch tray. The resident stated she informed NA #2 that she now required incontinence care because no one assisted her to the bathroom. The resident reported that NA #2 also turned off her call light and stated she would return. The resident stated she became angry but waited, activating her call light again at 1:22 PM. Resident #16 reported she was certain of the time because she had both a wall clock and a phone visible and accessible. A clock was observed on the wall, and the resident was holding her phone during the interview. Resident #16 stated that a staff member from the rehabilitation department, identified as the Director of Rehabilitation Services, eventually answered her call light. Resident #16 reported she told this staff member she had been waiting for over an hour and required incontinence care. Resident #16 stated she received assistance only after the rehabilitation staff member notified a nurse aide. She stated that at home, she was able to reach the bathroom independently and did not soil herself in an incontinence brief.During an interview on 4/21/2026 at 4:13 PM, NA #1 stated she did not recall the exact time but confirmed that before meal trays were distributed, Resident #16 activated her call light. NA #1 stated she responded to the call light and turned off the call light. NA #1 reported she was not assigned to Resident #16 that day and was unfamiliar with the resident's care needs because the resident was new. NA #1 stated she informed Nurse #2 and NA #2 at the nurses' desk that Resident #16 reported the medication to move her bowels was beginning to work, and she needed help to the bathroom.During an interview on 4/21/2026 at 3:35 PM, NA #2 confirmed that NA #1 informed her that Resident #16 needed assistance to the bathroom. NA #2 stated that the lunch trays were already in the hallway at that time. She reported that it was a long-standing rule that residents could not receive incontinence care or be assisted to the bathroom while meal trays were in the hallway. NA #2 stated that Resident #16 did not eat her lunch while soiled but waited until trays were passed and NA #2 had finished assisting other residents with eating. NA #2 stated she then provided incontinence care and reheated Resident #16's lunch.During an interview on 4/21/2026 at 3:30 PM, Nurse #2 stated that NA #1 informed her and NA #2 around lunchtime that Resident #16 might need incontinence care. Nurse #2 stated Resident #16's call light may have been on for approximately ten minutes before NA #1 answered it. Nurse #2 reported that meal trays for the adjacent hallway had just been delivered, and trays for her hallway were expected imminently when Resident #16 requested assistance. During an interview on 4/21/2026 at 3:55 PM, the Director of Rehabilitation Services stated she answered Resident #16's call light at lunchtime that day. She reported that Resident #16 stated she needed to be changed and had been waiting. The Director of Rehabilitation Services stated she notified the Assistant Director of Nursing (ADON) of Resident #16's needs.During an interview on 4/21/2026 at 4:08 PM, the ADON confirmed she was informed by the Director of Rehabilitation Services that Resident #16 required assistance at lunchtime that day. The ADON stated she located Nurse #2 and informed her that Resident #16 needed to be changed. The ADON stated Nurse #2 told her she would take care of it.During a second interview on 4/21/2026 at 4:47 PM, Nurse #2 stated the ADON texted her at 1:30 PM that day and informed her that Resident #16 needed to be changed. Nurse #2 stated she was assisting another resident with eating, and when she entered the hallway, NA #2 was already on her way to provide care.During an interview on 4/22/2026 at 10:30 AM, the Director of Nursing stated that NA #2 should have assisted Resident #16 to the bathroom when she was informed of her needs. She stated she taught nurse aide classes and that there had never been a rule prohibiting incontinence care while meal trays were in the hallway.During an interview with the Administrator conducted on 4/22/2026 at 2:45 PM, she reported that residents should receive assistance with toileting and incontinence care even if the meal trays were on the hallway. The Administrator stated that another staff member could have assisted in passing out meal trays while Resident #16 received the needed care.

Based on observation, record review, and resident and staff interviews, the facility failed to respect a resident's right to dignity when Resident #16 requested assistance to the bathroom and then incontinence care. Assistance was not provided to Resident #16 until after all the meal trays were passed out on the hall and other residents were assisted with eating. This affected 1 of 4 residents reviewed for dignity (Resident #16). Findings included:Resident #16 was admitted to the facility on [DATE] with diagnoses including non-progressive congenital joint contractures and chronic obstructive pulmonary disease.A Brief Interview for Mental Status assessment completed on 4/14/2026 indicated Resident #16 was cognitively intact.A care plan focus area, initiated on 4/16/2026 for Resident #16, documented a self-care performance deficit, with interventions including the need for one-person assistance for toileting and transfers.During an interview and observation conducted on 4/21/2026 at 2:22 PM, with a follow-up interview on 4/22/2026 at 9:41 AM, Resident #16 reported that she had received medication earlier that morning to stimulate a bowel movement. She stated that at 12:15 PM, she activated her call light, requesting assistance to the bathroom because she felt the medication beginning to work and believed she could reach the bathroom with help. She reported that Nurse Aide (NA) #1, whom she did not recognize, responded within five or six minutes. According to Resident #16, she informed NA #1 of her urgent need for assistance and her fear of having a bowel movement in bed. The resident stated that NA #1 turned off the call light and told her she would return, but no one came. The resident reported that she activated her call light again, at which time NA #2 entered the room to deliver her lunch tray. The resident stated she informed NA #2 that she now required incontinence care because no one assisted her to the bathroom. The resident reported that NA #2 also turned off her call light and stated she would return. The resident stated she became angry but waited, activating her call light again at 1:22 PM. Resident #16 reported she was certain of the time because she had both a wall clock and a phone visible and accessible. A clock was observed on the wall, and the resident was holding her phone during the interview. Resident #16 stated that a staff member from the rehabilitation department, identified as the Director of Rehabilitation Services, eventually answered her call light. Resident #16 reported she told this staff member she had been waiting for over an hour and required incontinence care. Resident #16 stated she received assistance only after the rehabilitation staff member notified a nurse aide. Resident #16 confirmed NA #2 did provide care for her, but she was so angry at that point that she did not recall the time. Resident #16 also confirmed she waited until after she received incontinence care to eat her lunch. Resident #16 stated she did not like sitting in her feces and felt frustrated and angry that she did not receive assistance when needed. She stated that at home, she was able to reach the bathroom independently and did not soil herself in an incontinence brief.During an interview on 4/21/2026 at 4:13 PM, NA #1 stated she did not recall the exact time but confirmed that before meal trays were distributed, Resident #16 activated her call light. NA #1 stated she responded to the call light and turned off the call light. NA #1 reported she was not assigned to Resident #16 that day and was unfamiliar with the resident's care needs because the resident was new. NA #1 stated she informed Nurse #2 and NA #2 at the nurses' desk that Resident #16 reported the medication to move her bowels was beginning to work, and she needed help to the bathroom.During an interview on 4/21/2026 at 3:35 PM, NA #2 confirmed that NA #1 informed her that Resident #16 needed assistance to the bathroom. NA #2 stated that the lunch trays were already in the hallway at that time. She reported that it was a long-standing rule that residents could not receive incontinence care or be assisted to the bathroom while meal trays were in the hallway. NA #2 stated that Resident #16 did not eat her lunch while soiled but waited until trays were passed and NA #2 had finished assisting other residents with eating. NA #2 stated she then provided incontinence care and reheated Resident #16's lunch.During an interview on 4/21/2026 at 3:30 PM, Nurse #2 stated that NA #1 informed her and NA #2 around lunchtime that Resident #16 might need incontinence care. Nurse #2 stated Resident #16's call light may have been on for approximately ten minutes before NA #1 answered it, and stated the resident tended to exaggerate waiting times. Nurse #2 reported that meal trays for the adjacent hallway had just been delivered, and trays for her hallway were expected imminently when Resident #16 requested assistance. During an interview on 4/21/2026 at 3:55 PM, the Director of Rehabilitation Services stated she answered Resident #16's call light at lunchtime. She reported that Resident #16 stated she needed to be changed and had been waiting. The Director of Rehabilitation Services stated she notified the Assistant Director of Nursing (ADON) of Resident #16's needs.During an interview on 4/21/2026 at 4:08 PM, the ADON confirmed she was informed by the Director of Rehabilitation Services that Resident #16 required assistance at lunchtime. The ADON stated she located Nurse #2 and informed her that Resident #16 needed to be changed. The ADON stated Nurse #2 told her she would take care of it.During a second interview on 4/21/2026 at 4:47 PM, Nurse #2 stated the ADON texted her at 1:30 PM and informed her that Resident #16 needed to be changed. Nurse #2 stated she was assisting another resident with eating, and when she entered the hallway, NA #2 was already on her way to provide care. Nurse #2 stated that call lights were rarely left on for long because the sound was very annoying, and therefore she believed Resident #16's call light was not on for an extended period.During an interview on 4/22/2026 at 10:30 AM, the Director of Nursing stated that NA #2 should have assisted Resident #16 to the bathroom when she was informed of her needs. She stated she teaches nurse aide classes and that there has never been a rule prohibiting incontinence care while meal trays are in the hallway.During an interview with the Administrator conducted on 4/22/2026 at 2:45 PM, she reported that residents should receive assistance with toileting and incontinence care even if the meal trays were in the hallway. The Administrator stated that another staff member could have assisted with passing out meal trays while Resident #16 received needed care. The Administrator stated the incident represented a dignity issue and was unacceptable.

Based on observations, record review and staff interviews, the facility failed to ensure the low temperature dishwasher maintained the wash temperature of 120 degrees Fahrenheit (F). These practices had the potential to affect food served to all residents. Findings included: During the initial tour of the kitchen on 2/9/26 at 9:58 a.m., three observations of the operation of the dishwashing machine by Dietary Staff #1 were conducted. The water temperatures ranged from 90 degrees Fahrenheit to 100 degrees Fahrenheit. Dietary Staff #1 continued to send dishware through the dish machine. The Dietary Manager (DM) was not in the dishwashing area of the kitchen during this observation. During an interview on 2/9/26 at 10:05 a.m., Dietary Staff #1 revealed he was unsure if the dishwasher was a high temperature or low temperature machine, then pointed to the manufacturer's instructions for use of the dishwasher located on the top, front of the machine which revealed the water temperature requirement for the low temperature dish machine was 120 degrees Fahrenheit and 50 ppm (parts per million) chlorine (sanitizer) during rinse cycle. He further revealed the water temperature of the dishwashing machine has had fluctuating water temperatures for approximately one week. He stated he reported the issue to the Dietary Manager (DM) when the water temperature would decrease but did not indicate why he continued washing the dishware in the machine. During an interview on 2/9/26 at 10:20 a.m. the DM stated the dishwashing machine was a high temperature machine. The DM acknowledged she was aware of the fluctuating water temperatures of the dishwasher and had submitted an electronic work order request to the facility's maintenance department concerning the problem. The DM did not supply a copy of this work order for review when requested. During a telephone interview on 2/9/26 at 10:25 a.m., the Regional Food Service Consultant confirmed the facility's dishwasher was a low temperature machine, not a high temperature machine as indicated by the DM. She indicated she was not aware the dishwashing machine was not operating correctly and disposable plates, cups, and plastic utensils would be used until the dishwasher was repaired. On 2/13/26 at 10:20 a.m., an interview was conducted with the Maintenance Director. He stated he first learned of the dishwashing machine not maintaining the proper temperature on 2/9/26, after the initial tour of the kitchen. The Maintenance Director revealed he did not receive a verbal or electronic work order request from the dietary department concerning the dishwashing machine. He stated that on inspection of the dishwashing machine, hot water was not getting to the dishwashing machine. As a result, on 2/12/26 both hot water tanks were replaced.

Based on observations and staff interviews, the facility failed to ensure the side doors to trash dumpsters remained closed, failed to contain waste in dumpsters with lids or coverings and failed to maintain a clean garbage area free from litter for 2 of 2 trash dumpsters and 1 of 1 construction container. These practices had the potential to attract pests and rodents.Upon arrival into the parking area of the facility an observation of the dumpster area on 2/9/26 at 9:15 a.m., revealed a long/large open to air construction-type container overflowing with bags of trash with some of the bags on the ground next to one side of building of the facility. There was no covering/tarp over the container or trash bags. On 2/11/26 at 12:07 p.m., accompanied by the Regional Food Service Consultant, an observation of the facility's dumpster area was completed. The large/long open-to-air construction-type container remained in the same condition with an overflow of bags of trash. There were two trash dumpsters surrounded by an unlocked, gated fence located in the back of the parking lot. The doors to both dumpsters were open with trash visible inside. The surrounding area was littered with cardboard pieces, used plastic gloves, plastic cup lids, paper, an office chair lying on its' side, and an upside-down large planter on the ground. There was also a pungent odor within the gated dumpster area. The Regional Food Service Consultant revealed she also made this observation when she arrived at the facility earlier that morning and requested the area be cleaned; but the area still looked the same. On 2/12/26 at 8:45 a.m., during an observation, the construction-type container remained in the same condition with an overflow of multiple bags of trash. During an interview on 2/13/26 at 1:03 p.m., the Dietary Manager revealed the facility shared the dumpsters with the neighboring facility located next to this facility. She stated she was not sure who was responsible for keeping the doors of the two dumpsters closed and the enclosed, surrounding area clean. She did not comment on the construction-type container utilized as a trash dumpster. During an interview on 2/13/26 at 1:10 p.m., the Administrator indicated the concerns with the trash disposal containers and areas would be taken care of immediately.

Based on facility policy review, record review and staff interviews, the facility failed to implement an antibiotic stewardship program to monitor antibiotic usage in the facility. This practice had the potential to affect 87 of 87 residents in the facility.The findings included:Review of the facility's policy titled, Antibiotic Stewardship Program, effective date 12/2025 revealed the following: The Antibiotic Stewardship Program purpose is to optimize the overall infection prevention program by the treatment of infections while reducing the adverse events associated with antibiotic use. The Infection Preventionist utilizes expertise and data to form strategies to improve antibiotic use to include tracking of antibiotic starts, monitoring adherence to evidence based published criteria during the evaluation and management of treated infections and reviewing antibiotic resistance patterns in the facility to understand which infections are caused by resistant organisms. A review was conducted of the pharmacy services antibiotic user tracking sheets for the months of November 2025, December 2025 and January 2026. The sheet reported for the month of November there were 25 residents on antibiotics, in December there were 37 residents on antibiotics and in January there were 40 residents on antibiotics.During an interview with the Director of Nursing (DON) on 02/13/26 at 12:00 PM, she stated she was responsible for the Infection Prevention and Control program. The DON further stated she had been in the DON position since the end of December 2025, and she was in the process of getting the Antibiotic Stewardship Program in place, but she was unable to locate any information from prior months. When asked had the facility been monitoring and tracking infections within the facility, she stated she was unable to locate any information for the prior months.A telephone interview was conducted on 02/13/26 at 1:17 PM with the previous DON (DON from 9/2025 to 12/2025) and she indicated she did not have an antibiotic stewardship program in place when working in the facility. The previous DON mentioned that nobody provided her with any guidance or instructions.An interview was conducted with the Administrator on 02/13/26 at 4:01 PM and she indicated she expected the antibiotic stewardship program to be in place per the protocol. The Administrator stated they discussed infections during the quality assurance performance Improvement (QAPI) meetings.

Based on record review and staff interviews, the facility failed to develop a baseline care plan within 48 hours of admission for 9 of 30 residents reviewed for baseline care plan (Residents #30, #105, #106, #110, #6, #109, #82, #99, and #72).Findings included: 1. Resident #30 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis that included paraplegia and neuromuscular dysfunction of bladder. A review of the medical record revealed no documented evidence that a baseline care plan was completed for Resident #30. Attempts made to contact the Nurse who admitted Resident #30 were unsuccessful. An interview was conducted on 02/13/26 at 8:45 am with the Unit Manager (UM). She was not aware that a baseline care plan was not completed for Resident #30. The UM attempted to locate the baseline care plan without success and confirmed it had not been completed. She stated that the baseline care plan should have been completed no later than 48 hours after the resident was admitted to the facility. An interview was conducted on 02/13/26 at 9:24 am with the Director of Nursing (DON). The DON was not aware that a baseline care plan was not completed for Resident #30. The DON stated it was the responsibility of the admitting nurse to complete baseline care plans. She stated if the admitting nurse could not complete the baseline care plan, the oncoming nurse should complete it. She stated if the baseline care plan was not completed by the next day, it should be completed by the unit managers. An interview was conducted on 02/13/26 at 3:00 pm with the Administrator. The Administrator was not aware that a baseline care plan was not completed for Resident #30. She stated that the facility's staff turnover rate was high and they were addressing several issues. 2. Resident #6 was admitted to the facility on [DATE] with a diagnosis that included closed fracture, dementia and type 2 diabetes. A review of the medical record revealed no documented evidence that a baseline care plan was completed for Resident #6. Attempts made to contact the Nurse who admitted Resident #6 were unsuccessful. An interview was conducted on 02/13/26 at 8:45 am with the Unit Manager (UM). She was not aware that a baseline care plan was not completed for Resident #6. The UM attempted to locate the baseline care plan without success and confirmed it had not been completed. She stated that the baseline care plan should have been completed no later than 48 hours after the resident was admitted to the facility. An interview was conducted on 02/13/26 at 9:24 am with the Director of Nursing (DON). The DON was not aware that a baseline care plan was not completed for Resident #6. The DON stated it was the responsibility of the admitting nurse to complete baseline care plans. She stated if the admitting nurse could not complete the baseline care plan, the oncoming nurse should complete it. She stated if the baseline care plan was not completed by the next day, it should be completed by the unit managers. An interview was conducted on 02/13/26 at 3:00 pm with the Administrator. The Administrator was not aware that a baseline care plan was not completed for Resident #6. She stated that the facility's staff turnover rate was high and they were addressing several issues. 3. Resident #72 was admitted to the facility on [DATE] with a diagnosis that included hypothyroidism, hypertension, dementia, and history of falls. A review of the medical record revealed no documented evidence that a baseline care plan was completed for Resident #72. Attempts made to contact the Nurse who admitted Resident #72 were unsuccessful. An interview was conducted on 02/13/26 at 8:45 am with the Unit Manager (UM). She was not aware that a baseline care plan was not completed for Resident #72. The UM attempted to locate the baseline care plan without success and confirmed it had not been completed. She stated that the baseline care plan should have been completed no later than 48 hours after the resident was admitted to the facility. An interview was conducted on 02/13/26 at 9:24 am with the Director of Nursing (DON). The DON was not aware that a baseline care plan was not completed for Resident #72. The DON stated it was the responsibility of the admitting nurse to complete baseline care plans. She stated if the admitting nurse could not complete the baseline care plan, the oncoming nurse should complete it. She stated if the baseline care plan was not completed by the next day, it should be completed by the unit managers. An interview was conducted on 02/13/26 at 3:00 pm with the Administrator. The Administrator was not aware that a baseline care plan was not completed for Resident #72. She stated that the facility's staff turnover rate was high and they were addressing several issues. 4. Resident #105 was admitted to the facility on [DATE] with diagnoses that included protein calorie malnutrition and chronic wounds. Review of Resident #105's medical records revealed no baseline care plan had been developed as of 02/11/26. During an interview on 02/11/26 at 11:55 AM with the Director of Nursing (DON), she indicated the baseline care plan should be completed by the admitting nurse and she was not sure why it had not been completed. Attempts to contact Nurse #8 who had admitted Resident #105 were unsuccessful. An interview was conducted on 02/13/26 at 4:08 PM with the Administrator, who indicated she expected the admitting nurse to complete the baseline care plan within 24 to 48 hours of admission to the facility and to follow the regulations. 5. Resident #106 was admitted to the facility on [DATE] with diagnosis that included in part, acute on chronic systolic (congestive) heart failure and acute respiratory failure. A review of Resident #106's medical record revealed no documented evidence that a baseline care plan had been developed. Attempts were made to contact the Nurse who admitted Resident #106 and were unsuccessful. An interview was conducted on 2/11/26 at 12:43 PM with Unit Manager #2. She indicated the baseline care plan was completed by the admitting nurse at the time of admission and was part of the admission process. An interview was conducted with the Director of Nursing (DON) on 2/11/2026 at 1:42 PM. The DON stated that the admitting nurse was to complete the baseline care plan upon admission and it was the Unit Manager and DON's responsibility to review to make sure it was completed in 48 hours. She explained if the baseline care plan was not completed, they would assist with completing it. The DON stated did not know why the baseline care plan had not been completed for Resident #106. An interview with the Administrator was conducted on 2/13/26 at 10:28AM. The Administrator stated she expected baseline care plans to be completed within the required time frame to ensure the needs of the residents were being addressed and met. 6. Resident #110 was admitted [DATE] with diagnosis that included displaced fracture of the left femur and chronic obstructive pulmonary disease. A review of Resident #110's medical record revealed no documented evidence that a baseline care plan had been developed. Attempts were made to contact the Nurse who admitted Resident #106 and were unsuccessful. An interview was conducted on 2/11/26 at 12:43 PM with Unit Manager #2. She indicated the baseline care plan was completed by the admitting nurse at the time of admission and was part of the admission process. An interview was conducted with the Director of Nursing (DON) on 2/11/2026 at 1:42 PM. The DON stated that the admitting nurse was to complete the baseline care plan upon admission and it was the Unit Manager and DON's responsibility to review to make sure it was completed in 48 hours. She explained if the baseline care plan was not completed, they would assist with completing it. The DON stated did not know why the baseline care plan had not been completed for Resident #110. An interview conducted with the Administrator was conducted on 2/13/26 at 10:28AM. The Administrator stated she expected baseline care plans to be completed within the required time frame to ensure the needs of the residents were being addressed and met. 7. Resident #109 was admitted on [DATE] with a diagnosis of influenza virus, pneumonia and chronic obstructive pulmonary disease. A review of Resident #109's medical record revealed no documented evidence that a baseline care plan had been developed. An interview with Nurse #5 who admitted Resident #109 was conducted on 2/12/2026 at 10:06 AM. Nurse #5 explained the baseline care plan was not included in the list of assessments which needed to be completed for new admissions. Nurse #5 stated she was aware that a baseline care plan must be completed within 48 hours, but the Unit Manager would complete these. An interview was conducted on 2/11/26 at 12:43 PM with Unit Manager #2. She indicated that the baseline care plan was completed by the admitting nurse at the time of admission and was part of the admission process. An interview was conducted with the Director of Nursing (DON) on 2/11/2026 at 1:42 PM. The DON stated that the admitting nurse was to complete the baseline care plan upon admission and it was the Unit Manager and DON's responsibility to review to make sure it was completed in 48 hours. She explained if the baseline care plan was not completed, they would assist with completing it. The DON stated did not know why the baseline care plan had not been completed for Resident #109. An interview conducted with the Administrator was conducted on 2/13/26 at 10:28AM. The Administrator stated she expected baseline care plans to be completed within the required time frame to ensure the needs of the residents were being addressed and met. 8. Resident #82 was admitted on [DATE] with diagnoses that included fracture of left hand, pneumonia, diabetes and chronic pain syndrome. Review of Resident #82's record revealed a baseline care plan had not been developed. An interview was conducted on 2/12/26 at 9:34 AM with Minimum Data Set (MDS) Coordinator #1. She stated upon admission, the baseline care plans were completed by the admission nurse. After reviewing Resident #82's record she indicated that the baseline care plan had not been completed and should have been completed by the admitting nurse. An interview with the Director of Nursing (DON) was conducted on 2/13/25 at 2:05 PM. After a review of Resident #82's record the DON stated the baseline care plan for Resident #82 had not been completed and should have been completed by the admitting nurse or by the unit manager and felt this was an oversight. 9. Resident #99 was admitted on [DATE] with diagnoses that included multiple fractures of the pelvis and chronic obstructive pulmonary disease. Review of Resident #99's record revealed a baseline care plan had not been developed. An interview was conducted on 2/12/26 at 9:34 AM with Minimum Data Set (MDS) Coordinator #1. She stated upon admission that the initial care plans were completed by the admitting nurse. After reviewing Resident #99's record she noted it had not been completed. He explained the baseline care plan should have been completed by the admitting nurse. An interview was conducted with Nurse #2 on 2/12/26 at 9:19 AM. Nurse #2 indicated she was the nurse assigned to Resident #99 at the time of her admission but did not complete the baseline care plan and thought the unit manager was responsible for the completion of the baseline care plan. An interview was conducted with Unit Manager #2 who assisted with Resident #99's admission paperwork. She indicated she did not complete the baseline care plan as she had not yet been trained and thought the admission nurse was responsible. An interview with the Director of Nursing (DON) was conducted on 2/13/25 at 2:06 PM. After a review of Resident #99's record the DON stated the baseline care plan for Resident #99 had not been completed and should have been completed by the admitting nurse or by the unit manager and felt this was an oversight.

Based on record review and staff interviews, the facility failed to maintain vaccination consents or declination decisions in the residents' medical record and failed to maintain a record of education of the benefits and potential side effects for the influenza and pneumococcal immunizations for 5 of 5 residents reviewed for immunizations (Resident #21, Resident #20, Resident #9, Resident #72 and Resident #33). The findings included:Findings included:a. Resident #21 was admitted to the facility on [DATE].Review of Resident #21's Minimum Data Set (MDS) assessment dated [DATE] revealed she was cognitively intact. Further review of the MDS revealed Resident #21was not offered the influenza vaccine and was offered but declined the pneumococcal vaccine.An interview was conducted with Resident #21 on 02/12/26 at 8:57 am and she indicated she could not recall if she was offered the influenza or pneumococcal vaccines. Review of the medical record revealed Resident #21 declined to have the pneumococcal vaccine. Resident #21's medical record did not include the date of declination. Further review of the medical record revealed no documentation of the influenza vaccination for the current influenza season.The facility was unable to provide documentation that the influenza or pneumococcal vaccines were offered, that Resident #21 or the Responsible Party had the opportunity to accept or decline the vaccines, or that education on the benefits and potential side effects were provided to Resident #21 or their Responsible Party regarding the influenza and pneumococcal vaccines.b. Resident #20 was admitted to the facility on [DATE].Review of Resident #20's MDS assessment dated [DATE] revealed Resident #20 was severely cognitively impaired. Further review of the MDS indicated Resident #20 was not offered the influenza or pneumococcal vaccines.Review of the medical record revealed Resident #20 declined to have the influenza vaccine and pneumococcal vaccine. Resident # 20's medical record did not include the date of declination for either vaccine.The facility was unable to provide documentation that the influenza or pneumococcal vaccines were offered, that Resident #20 or the Responsible Party had the opportunity to accept or decline the vaccines, or that education on the benefits and potential side effects were provided to Resident #20 or their Responsible Party regarding the influenza and pneumococcal vaccines.c. Resident #9 was admitted to the facility on [DATE].Review of Resident #9's MDS assessment dated [DATE] revealed Resident #9 was severely cognitively impaired. Further review of the MDS indicated Resident #9 was not offered the influenza or pneumococcal vaccines.Review of the medical record revealed Resident #9 did not have any documentation for the pneumococcal or the influenza vaccine. The facility was unable to provide documentation that the influenza or pneumococcal vaccines were offered, that Resident #9 or the Responsible Party had the opportunity to accept or decline the vaccines, or that education on the benefits and potential side effects were provided to Resident #9 or their Responsible Party regarding the influenza and pneumococcal vaccines.d. Resident #72 was admitted to the facility on [DATE].Review of Resident #72's MDS assessment dated [DATE] revealed Resident #72 was severely cognitively impaired. Further review of the MDS indicated Resident #72 was not offered the influenza vaccine and the pneumococcal vaccine was up to date.Review of the medical record revealed Resident #72 was administered the pneumococcal vaccine (pneumovax 23) outside of the facility on 01/02/21 and the influenza vaccine was administered outside of the facility on 10/21/24 (previous influenza season). The medical record revealed no documentation of an influenza vaccine for the current influenza season.The facility was unable to provide documentation that the influenza vaccine was offered, that Resident #72 or the Responsible Party had the opportunity to accept or decline the influenza vaccine, or that education on the benefits and potential side effects were provided to Resident #72 or their Responsible Party regarding the influenza vaccines.e. Resident # 33 was admitted to the facility on [DATE].Review of Resident 33's MDS assessment dated [DATE] revealed Resident #33 had moderate cognitive impairment. Further review of the MDS indicated Resident #33 was not offered the influenza or pneumococcal vaccines.Review of the medical record revealed Resident #33 did not have any documentation for the pneumococcal or the influenza vaccines. The facility was unable to provide documentation that the influenza or pneumococcal vaccines were offered, that Resident #33 or the Responsible Party had the opportunity to accept or decline the vaccines, or that education on the benefits and potential side effects were provided to Resident #33 or their Responsible Party regarding the influenza and pneumococcal vaccines.During an interview with the Director of Nursing (DON) on 02/13/26 at 12:00 PM, she stated she was responsible for the Infection Prevention and Control program. The DON further stated she had been in the DON position since the end of December 2025, and she was in the process of gathering information on the immunizations, however had not started them yet. She indicated she was unable to locate any of the vaccine consents and/or the education provided to the residents for prior months.A telephone interview was conducted with the previous DON on 02/13/26 at 1:17 PM and it was revealed that she had not received guidance or instructions regarding resident immunizations and did not know if they were being done while she was working in the facility.An interview was conducted with the Administrator on 02/13/26 at 4:01 PM and she indicated she was unaware immunizations had not been completed or offered and expected residents to receive education and consent per protocol.

Based on record review and staff interviews, the facility failed to inform and provide written information to a resident regarding the residents' right to accept or refuse medical/surgical treatment and to formulate an advanced directive for 1 of 33 sampled residents reviewed for advanced directives (Residents #105). Findings included: Resident #105 was admitted to the facility on [DATE]. The nursing admission assessment dated [DATE] indicated Resident #105 was cognitively intact. There was no documentation in Resident #105's medical record indicating the resident was informed of his right to accept or decline medical or surgical treatment prior to making an advance directive decision and/or an advance directive formulated for code status. During an interview on 2/11/26 at 11:36 AM, Resident #105 indicated she had not received any paperwork or education on advanced directives and/or been informed of her right to accept or refuse medical/surgical treatment. Resident #105 stated she wanted to be resuscitated if her heart stopped. During an interview on 02/11/26 at 12:11 PM, the Social Worker (SW) acknowledged the facility did not inform and had not provided any documentation indicating Resident #105 had the right to accept or decline medical or surgical treatment or formulate an advance directive. The SW indicated the process in place was she would give residents information on advance directives if they requested it. An interview was conducted on 02/12/26 at 11:06 AM with Nurse #6 and she verified there was no order in Resident #105's physician orders in the electronic medical record or the code status book at the Nurses station indicating Resident #105's code status information. She indicated she was unsure why there was not an order and would check with the Director of Nursing (DON). An attempt to contact Nurse #7 for interview on 02/12/26 at 11:54 AM and was unsuccessful. On 02/13/26 at 9:25 AM an interview was conducted with the DON, and she indicated she expected the admitting nurse to get the code status during admission and get an order from the physician, and the SW would provide the education for advance directive choices with the resident and/or responsible party (RP). During an interview on 02/13/26 at 4:06 PM, the Administrator stated it was her expectation that staff explained to residents their choices concerning advance directives and an order would be in place for code status. The Administrator indicated she was not aware that written documentation needed to be provided to residents concerning advanced directives and was unsure who was responsible for providing the information.

Based on record review and staff interviews, the facility failed to provide a Centers for Medicare and Medicaid Services (CMS) Skilled Nursing Facility Advanced Beneficiary Notice (SNF-ABN) form 10555 (liability notice that informs Medicare Part A beneficiaries of potential Medicare non-coverage before providing custodial care or items that are usually paid for by Medicare) prior to discharge from Medicare Part A skilled services for 2 of 3 residents reviewed for beneficiary protection notification review (Resident #116 and Resident #117).The findings included:1. Resident #116 was admitted to the facility on [DATE]. He was admitted to Medicare Part A skilled services on 11/6/25.Resident #116's Medicare Part A skilled services ended on 11/28/25. He remained in the facility.Record review revealed there was no documentation Resident #116, or his responsible party were issued a CMS SNF-ABN form 10555 prior to discharge from Part A Medicare services. During an interview with the facility Social Worker on 2/12/26 at 3:26 PM she stated it was her job to issue the SNF-ABN. The Social Worker stated that on 11/26/25 she issued Resident #116 the Advance Beneficiary Notice of Non-Coverage form (form specifically used for Medicare Part B items and services) and therefore Resident #116 had not received the correct notification. An interview was conducted with the Administrator on 2/13/26 at 2:07 PM who indicated she was not aware that the Social Worker had been using the wrong form and Resident #116 should have received the CMS SNF-ABN form 10555 as required by Federal guidelines. 2. Resident #117 was admitted to the facility on [DATE]. He was admitted to Medicare Part A skilled services on 11/28/25.Resident #117's Medicare Part A skilled services ended on 12/17/25. He remained in the facility.Record review revealed there was no documentation Resident #117, or his responsible party were issued a CMS SNF-ABN form 10555 prior to discharge from Part A Medicare services. During an interview with the facility Social Worker on 2/12/26 at 3:27 PM she stated it was her job to issue the SNF-ABN. The Social Worker stated that on 12/15/25 she issued Resident #117 the Advance Beneficiary Notice of Non-Coverage form (form specifically used for Medicare Part B items and services) and therefore Resident #117 had not received the correct notification. An interview was conducted with the Administrator on 2/13/26 at 2:07 PM who indicated she was not aware that the Social Worker had been using the wrong form and Resident #117 should have received the CMS SNF-ABN form 10555 as required by Federal guidelines.

Based on record review and staff interviews, the facility failed to develop a comprehensive care plan in the areas of activities of daily living and activities (Resident #13), and discharge goal (Resident #4) for 2 of 30 residents whose care plans were reviewed (Resident #13 and Resident #4). The findings included:1. Resident #13 was admitted to the facility on [DATE] with diagnoses that included neurocognitive disorder with Lewy bodies and muscle weakness.A significant change Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #13 was cognitively impaired, was dependent on staff for personal hygiene, bathing, and toileting and felt it was somewhat important to be included in group activities.A review of Resident #13's comprehensive care plan revised on 12/29/25 revealed that no care plan had been developed for activities of daily living (ADL) or activities.An interview was conducted with MDS Coordinator #1 on 2/12/26 at 9:34 AM. The MDS Coordinator #1 indicated per the MDS assessment, Resident #13 was dependent on staff for ADL and was not care planned as the care area did not trigger on the MDS.An interview was conducted with the Assistant Activities Director on 2/11/26 at 11:50 AM. She indicated that she completed the significant change MDS assessment dated [DATE] and coded Resident #13 as feeling it was somewhat important to do things with groups of people. The Assistant Activities Director further revealed she did not create an activities care plan as she had not been trained yet on how to complete a care plan and agreed a care plan should have been developed for Resident #13 in the area of activities. An interview was conducted with the Administrator on 2/11/26 3:11 PM. The Administrator stated that a care plan should have been developed for Resident #13 in the area of ADL by the MDS Coordinator and in the area of activities by the Assistant Activities Director and was unsure why these areas were omitted. 2. Resident #4 was admitted to the facility on [DATE] with diagnoses that included polyarthritis and metabolic encephalopathy. Resident #4 discharged home on 2/2/26.An admission MDS assessment dated [DATE] revealed Resident #4 was cognitively intact and participated in discharge planning with a goal to return to the community. The comprehensive care plan dated 12/29/25 revealed no interventions or goals related to discharge planning.An attempt was made to interview Resident #4 and his emergency contact, but attempt was not successful. An interview was conducted with the Social Worker on 2/12/26 at 11:30 AM. She indicated she was responsible for discharge planning and developing discharge planning care plans. The Social Worker indicated she was aware of Resident #4's goal to discharge back to the community but had not developed a discharge care plan and felt that this was an oversight.An interview was conducted with the Director of Nursing on 2/13/26 at 11:38 AM and she indicated the Social Worker should have created a discharge care plan for Resident #4 and felt this was an oversight.An interview was conducted with the Administrator on 2/13/26 at 11:40 AM and she indicated the Social Worker should have created a discharge care plan for Resident #4 and felt this was an oversight.

Based on observation, record review, and interview of the staff, residents, and a family member, the facility failed to provide dependent residents nail care (Residents #8 and #10) and facial hair care (Resident #10). The deficient practice affected 2 of 10 residents reviewed for activities of daily living (Residents #8 and #10). Findings included:1. Resident #8 was admitted on [DATE] with a diagnosis of non-Alzheimer's dementia. The quarterly Minimum Data Set, dated [DATE] documented that Resident #8's cognition was moderately impaired. The resident was dependent for bathing, dressing and personal care, and was incontinent of bowel and bladder. The active diagnoses were dementia, anxiety, and muscle weakness. The care plan for Resident #8 dated 12/27/25 documented a self-care deficit due to weakness. The resident required assistance with personal care, including clean and trim nails. On 2/09/26 at 11:51 am, an observation and interview were conducted. Resident #8's 10 fingernails were approximately 1/2 inch long, jagged as if broken, with a small amount of brown debris underneath. The resident expressed that she would like nail care to both hands and held up her hands.On 2/9/26 at 11:53 am, the assigned nurse aide (NA) #7 observed Resident #8's nails and was interviewed. NA #7 stated the nails were long and was not sure why they had not been cut. The NA stated she would provide nail care. On 2/12/2026 at 11:40 am, Resident #8 was observed while her assigned NA #6 was present. The nails had not been trimmed and still had brown debris underneath. The resident again held up her hands. NA #6 stated she had not offered nail care that morning but would provide care now.On 2/12/26 at 12:20 pm, Resident #8 was observed with nails cut and cleaned.On 2/13/26 at 10:30 am, the Director of Nursing (DON) was interviewed. The DON stated the nursing staff was required to provide nail care during bathing and as needed.2. Resident #10 was admitted to the facility on [DATE] with a diagnosis of stroke. Resident #10's quarterly Minimum Data Set, dated [DATE] documented the resident had severely impaired cognition and was sometimes understood. The resident was dependent for activities of daily living (ADL). The active diagnoses were stroke, dementia and a right-hand contracture.Resident #10's physician progress note dated 12/30/25 documented Resident #10 was minimally interactive, calm and cooperative.Resident #10's care plan dated 1/4/26 documented an ADL self-care deficit. The resident required assistance with all bathing and dressing. The intervention for nail care was cleaning and trimming on bath day. Personal and oral care required assistance from staff. Facial hair care was not mentioned. The resident could refuse on occasion.Resident #10's physician progress note dated 1/13/26 documented Resident #10 was stable with no behaviors or refusals reported by nursing or observed by the physician. Resident #10's psychiatry note dated 1/28/26 documented the resident was stable with no changes. There were no refusals reported. On 2/09/26 at 11:41 am, Resident #10 was observed and an interview was attempted. The resident had mild body odor, facial hair on the upper lip, chin and lower cheeks that was approximately 1.5 inches long, and long nails. The resident had a contracture of the right hand, and his right thumb nail was noted to be an inch long and jagged. The resident indicated he wanted a shave but did not respond regarding nail care.On 2/9/26 at 11:59 am, NA #7 was interviewed. NA #7 stated she was assigned to Resident #10 and had not offered nail care during the bath that morning. NA #7 stated she would provide nail and facial hair care.On 2/10/26 at 10:40 am, Resident #10's family member was interviewed by phone. The family member stated he was visiting the resident during the call. He agreed that the resident's facial hair was long, the resident looked ragged and needed a shave. He also commented that this was the longest he had ever seen the resident's facial hair. The family member stated that his nails looked dirty and needed a trim, especially the right thumb nail which looked sharp. The family member stated he was not informed that the resident had refused care and did not know why the hair and nail care had not been provided. On 02/12/2026 at 11:40 am, an observation was done of Resident #10 with the assigned NA #6. The resident's nails and facial hair remained unchanged from the 2/9/26 observation. The NA stated she had not offered nail or hair care this morning but would cut the resident's fingernails and shave him now. The resident was able to state, yes, and touch his facial hair when the NA asked him. On 2/13/26 at 10:30 am, the Director of Nursing was interviewed. The DON stated the nursing staff was required to provide nail care and facial hair care during bathing as needed or when requested. On 2/13/26 at 2:05 pm Resident #10 was observed to have received nail and facial hair care.

Based on record review, observation, and interview of staff, the physician assistant, and the wound nurse practitioner, the facility failed to change the pressure ulcer dressing as ordered (Resident #30). The deficient practice affected 1 of 5 residents reviewed for pressure ulcers. The findings included:Resident #30 was admitted to the facility on [DATE] with diagnosis which included spina bifida with hydrocephalus, paraplegia, and stage 4 pressure ulcer to the sacrum.The care plan initiated on 08/14/25 revealed Resident #30 had a stage 4 pressure ulcer to the sacral area and a potential for pressure ulcer development related to crushing injury, impaired mobility, spina bifida. The goal was Resident #30's pressure ulcer would show signs of healing and remain free from infection. Interventions included administer medication as ordered, administer treatments as ordered, monitor for effectiveness, educate the resident/family/caregiver as to the causes of skin breakdown, and follow facility policies/protocols for the prevention/treatment of skin breakdown.Review of the initial wound progress note dated 08/19/25 revealed Resident #30 had a stage 4 pressure ulcer to the sacrum, with measurements of 5.5 cm x 5 cm x 3 cm, and undermining (extends under the skin) of 3 cm from 3 o'clock to 10 o'clock. The wound bed was noted to have 40% slough tissue and 60% granulation (new tissue that forms on the wound during healing process) tissue and moderate serosanguinous exudate (light red fluid that leaks out of blood vessels). Review of a wound progress noted dated 08/20/25 revealed Resident #30 had a stage 4 pressure ulcer to the sacrum, with measurements of 5.5 cm x 5 cm x 3 cm and undermining of 3 cm from 3 o'clock to 10 o'clock. The wound bed was noted to have 40% slough tissue and 60% granulation tissue and moderate serosanguinous exudate.The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #30 was cognitively intact. Further review of the MDS indicated Resident #30 was dependent on staff for toileting and personal hygiene, toilet transfer, and required substantial/maximal assistance with rolling left and right. The MDS also indicated Resident #30 had a stage 4 pressure ulcer at the time of the review. There was no indication of rejection of care.A physician order dated 12/08/25 Dakins (1/2 strength) external solution 0.25% (Sodium Hypochlorite) apply to sacrum topically every evening shift. Clean with normal saline and pat dry. Apply moistened gauze cover with abdominal pad and secure with tape twice daily and as needed.Review of the Treatment Administration Record (TAR) for December 2025 revealed the treatment was not documented as administered on 12/20/25, 12/21/25, 12/22/25, and 12/29/25. An interview was conducted on 02/13/26 at 3:30 pm with Nurse # 4, the nurse responsible for Resident #30's pressure wound treatment on 12/20/25 and 12/21/25. Nurse #4 was unable to provide an explanation for why Resident #30's treatments were not completed on those days.A physician order dated 12/31/25 Dakins (1/4 strength) external solution 0.125% (Sodium Hypochlorite) apply to sacrum topically every day shift. Clean with normal saline and pat dry. Apply collagen powder followed by Dakin's moistened rolled gauze packing and cover with silicone super absorbent dressing daily and as needed and apply to sacrum topically as needed for soiling or removal. Review of the wound care progress note dated 01/07/26 revealed Resident #30 had a stage 4 pressure ulcer to the sacrum, with measurements of 3.0 cm x 2.5 cm x 0.3 cm and undermining of 2.2 cm from 5 o'clock to 9 o'clock. The wound bed was noted to have 100% granulation tissue and moderate serosanguinous exudate.Review of the TAR for January 2026 revealed the treatment was not documented as administered on 01/17/26, 01/21/26, 01/25/26, and 01/28/26.An interview was conducted on 02/12/26 at 10:10 am with Nurse #1, the nurse responsible for Resident #30's pressure wound treatment on 01/17/26. Nurse #1 stated the licensed nurse was expected to administer treatments on the weekends if there was no wound care nurse. When Nurse #1 was asked about Resident #30's pressure wound treatment not being administered some days during weekends. She stated she could not always administer treatments on the weekend and if not, she would not sign off the TAR indicating that it was complete.Review of the wound care progress note dated 01/21/26 revealed Resident #30's stage 4 pressure ulcer to the sacrum had deteriorated that week, with undermining of 6 cm from 6 o'clock to 12 o'clock. The wound bed had a 100% granulation tissue and moderate serosanguinous exudate. An interview was conducted on 02/12/26 at 10:45 am with the Wound Care Nurse. The Wound Care Nurse stated that Resident #30 indicated her pressure ulcer treatment was not getting done some days on the weekends. She reported Resident #30's concern to the previous DON. She stated she did provide wound care for Resident #30 on 01/21/26 and 01/28/26 and she was not sure why it was not signed off on the TAR. The Wound Care Nurse was able to review her progress notes and confirm Resident #30's treatment was administered on those days. An interview was attempted multiple times with Nurse #7, the nurse responsible for completing Resident #30's pressure wound treatment on 01/25/26. Review of the wound care progress noted dated 02/4/26 revealed Resident #30's stage 4 pressure ulcer to the sacrum had deteriorated that week, with measurements of 2.3 cm x 2.4 cm x 0.5 cm and undermining of 6.7 cm from 6 o'clock to 12 o'clock. The wound bed had a 100% granulation tissue and moderated serosanguinous exudate.Review of the TAR for February 2026 revealed the treatment was not documented as administered on 02/08/26. An interview was conducted on 02/13/26 at 3:30 pm with Nurse # 4, the nurse responsible for Resident #30's pressure wound treatment on 02/08/26. Nurse #4 was unable to provide an explanation for why Resident #30's treatments were not completed on that day.An interview was conducted on 02/09/26 at 12 noon with Resident #30. Resident #30 stated she was concerned her pressure ulcer treatment was not being administered on the weekends sometimes. She stated on 02/07/26 that her pressure ulcer treatment was administered, but it was not administered on 02/08/26. Resident #30 stated she would ask the nurse aides about her treatment, and they would let the nurse know that the treatment needed to be done. She stated the nurse aides would return and let her know that the nurses were aware, and they could see what treatments were due on their computer. An interview was conducted on 02/13/26 at 3:30 pm with Nurse # 4, the nurse responsible for Resident #30's pressure wound treatment on 02/08/26. Nurse #4 was unable to provide an explanation for why Resident #30's treatment was not completed on that day.An interview was conducted on 02/12/26 at 9:15 am with Nurse Aide (NA) #10. Nurse Aide #10 stated if a resident inquired about wound treatment, she would let the nurse know. She stated she would then go back and let the resident know that the nurse was made aware.An observation of wound care on 02/12/26 at 10:45 am with Resident #30 revealed a pressure wound to the sacrum, with granulation tissue, and no foul odor.An interview was conducted on 02/12/26 at 1:30 pm with the Physician Assistant (PA). The PA stated pressure wounds are handled by the Wound Nurse Practitioner (NP) and the Wound Care Nurse. He stated if there was an issue he needed to address the Wound NP or Wound Care Nurse would inform him. He stated he was not aware of wound treatments not being administered for Resident #30. He stated if an order was placed it was put in place for a reason. He would have to assume if an order was put in place, it was necessary. He indicated if wound treatments were not being administered, it could have a negative effect on the wound.An interview was conducted on 02/12/26 at 3:40 pm with the wound NP. The NP stated failure to provide dressing changes as ordered could cause the wound to not progress or get worse.An interview was conducted on 02/13/26 10:10 am with the Director of Nursing (DON). The DON was not aware of Resident #30's pressure wound treatment not being administered on the weekends. She stated if the wound care nurse was not a work it was the licensed staff responsibility to administer pressure wound treatments. She stated her expectation would be for treatments to be administered according to physician's order.An interview was conducted with the Administrator on 02/13/26 at 3:00 pm. The Administrator was not aware that pressure wound treatments were not being administered some days on the weekends. She stated her expectation would be for staff to administer treatments according to physician's order. She stated it was unacceptable for staff not to administer treatments.

Based on record review, resident interview and staff interviews the facility failed to treat a resident in a dignified and respectful manner when Nurse Aide #7 and Nurse Aide #8 were delayed in responding to a resident's call for assistance and told the resident to stop using her call light causing the resident to be upset and mad. The deficient practice affected 1 of 3 residents reviewed for dignity (Resident #82).Findings included:Resident #82 was admitted to the facility on [DATE] with diagnoses that included fracture of left hand, fracture of left radius, muscle weakness, and anxiety. Resident #82 transferred to the hospital on 2/9/26. The admission comprehensive Minimum Data Set (MDS) assessment for Resident #82 dated 1/29/26 revealed she was cognitively intact, had no behaviors, and required assistance of staff with toileting, bed mobility, and transfers. She was coded to use a wheelchair for mobility. A grievance reporting form was initiated by the Social Worker on 2/5/26 and stated C.N.A's (Certified Nursing Assistant) aren't properly changing resident in a timely manner. Aides at night aren't coming in when they do they tell her not to ring out. The grievance was investigated by the Director of Nursing (DON). The result of the investigation dated 2/13/26 was NA #7 and NA #8 were suspended pending investigation, received disciplinary action regarding timeliness of care and customer service and would receive education on customer service and timelines of care. In addition, NA #7 and NA #8 would not be assigned to Resident # 82 in the event of readmission to the facility. An interview was completed with Resident #82 on 2/9/26 at 10:42 AM. Resident #82 indicated that nursing assistants made her wait over 30 minutes to answer her call light for incontinence care needs and told her not to call for help which made her upset and mad. She further revealed she could not recall the date this occurred but that a grievance had been submitted regarding this complaint. During the interview Nurse # 5 came into the room and initiated a transfer to the hospital per Resident #82's family member's request. NA #7 was not available for interview during the survey. NA #8 was not available for interview during the survey. An interview was conducted with the DON and the Administrator on 2/13/26 at 2:08 PM. The DON and Administrator indicated the investigation revealed NA #7 and NA #8 were assigned to Resident #82's hall the night of 2/5/26 from 7:00 PM-7:00 AM and found that the NA's were delayed in providing Resident #82 with care and admitted to telling Resident #82 not to call out for assistance but did so in a joking manner. The DON indicated NA #7 and NA #8 received disciplinary action and felt they did not treat Resident #82 with respect. The Administrator indicated that staff should treat all residents with dignity and respect.

Based on observation, record review, and interviews of staff, the facility failed to provide care in a safe manner when a resident rolled off a bed raised to waist height onto the floor. Resident #7 sustained a laceration to the left side of her head which required 5 staples. This deficient practice affected 1 of 4 residents reviewed for accidents. (Resident #7) Findings included: Resident #7 was admitted to the facility on [DATE] with diagnoses of Alzheimer's dementia and osteoarthritis. A review of Resident #7's record documented she had the diagnoses added on 9/23/21 of adult failure to thrive, severe protein-calorie malnutrition, cognitive communication deficit, repeated falls, and dysphagia. Resident #7's quarterly Minimum Data Set (MDS) dated [DATE] documented Resident #7 was unable to participate in a cognitive assessment. The resident had no behaviors or refusal of care and no falls. The MDS also indicted the resident was receiving hospice services, required extensive assistance with bed mobility, transfers, incontinence care, and bathing. Resident #7's care plan dated 8/9/24 documented she was at high risk for falls due to history of falls, cognitive impairment, and decreased mobility. The interventions were to report any falls to the physician and to refer to physical therapy as needed. The resident required extensive assistance with all activities of daily living. Resident #7's fall incident report dated 11/1/24 written by Nurse #1 documented during care with the Nursing Assistant (NA), the resident became combative. She fell out of bed and sustained a laceration to the left side of her head. The resident was confused and oriented to person. Resident #7's Emergency Department record dated 11/1/24 documented she was seen after a fall at the facility and sustained a laceration to the left side of her head. The laceration was no longer bleeding. The resident had fragile skin, and five staples were used to close the laceration. The resident was confused and non-verbal. The resident returned to the facility after a check of her brain for bleeding and was not admitted . The nurses' note dated 11/04/24 at 1:33 pm was a late entry written by Nurse #1 that documented Resident #7 left the facility at 1:45 pm with Emergency Medical Service (EMS) by stretcher on 11/1/24 due to a laceration to the left side of her head after rolling out of bed and hitting her head on the wall edge when the NA #1 was providing care. On 11/4/24 at 9:40 am an observation was made of Resident #7. She had 5 large staples on her left forehead that had surrounding bruise. An interview was attempted but the Resident was confused and mumbled at times. On 11/4/24 at 10:40 am an interview was conducted with NA #2. NA #2 stated she knew Resident #7 well and was nearby on 11/1/24 when NA #1 called for help after the resident's fall. NA #2 had not seen the fall but observed the resident on the left side of her bed, lying on her left side with a laceration to the left side of her head. NA #1 held pressure with a washcloth on the Resident's head and NA #2 went to find the nurse assigned (Nurse #1) to report. The resident was known to have behaviors during care when moving the resident but was unable to roll off the bed by herself. The NA reported that Resident #7 required one staff member for all care except transfer which required two staff members. On 11/5/24 at 11:20 am an interview was conducted with Nurse #1. Nurse #1 stated she was aware Resident #7 had verbal and physical behaviors when moved during care and believed it was from her dementia. Nurse #1 stated she was assigned to Resident #7 on 11/1/24 when she fell out of bed. At 3:30 pm a follow-up interview was conducted with Nurse #1. Nurse #1 stated she was aware the resident could be combative with her arms and used foul language during personal and incontinence care, and it was believed this behavior was related to her dementia. Nurse #1 stated the resident could not roll herself in the bed or out of the bed. Nurse #1 stated that she was informed by NA #2 that the resident fell out of bed on 11/1/24 during care by NA #1 when the resident was resisting care when turned. Nurse #1 stated upon entry to the resident's room she observed the resident on the floor, left side of bed near the wall, on her left side and was bleeding on the left side of her head from a laceration. NA #1 was holding pressure on the laceration to the head. NA #1 had provided incontinence care to the resident and informed Nurse #1 that the resident was resisting care when rolled. The resident rolled during the behavior while on her left side and fell off the bed. Nurse #1 stated that the staff was responsible for preventing the resident from rolling off the bed during care and the accident could have been avoided by not letting go of the resident while on her side. On 11/6/24 at 8:20 am an interview was conducted with NA #1. NA #1 stated she provided incontinent care to Resident #7 on 11/1/24 when the resident rolled out of bed. The resident frequently had not liked to be rolled during incontinence care. The resident was known to be calm when not touched. The NA had to bend the resident's knee to roll her. The resident's behavior started when rolling her for care. On 11/1/24 during care, the resident was rolled to her left side and the resident started to hit the NA and yell. The NA moved her hand off the resident so she could calm. The resident rolled onto the floor. The bed was elevated to waist height for care. The resident hit the left side of her head on the wall corner and was bleeding. The nurse (Nurse #1) was informed by NA #2 about the incident while NA #1 remained with the resident. NA #1 stated she held pressure on the resident's head to stop a moderate amount of bleeding. EMS was contacted and the resident was transferred to the Emergency Department. On 11/6/24 at 2:10 pm an interview was conducted with the Corporate Nurse. Resident #7's fall was discussed with the Consultant. She stated, it could be possible the resident's pain in her legs with behavior during care contributed to her fall out of bed. On 11/6/24 at 2:40 pm an interview was conducted with the Administrator. The Administrator stated he was aware of Resident #7's fall and the fall was discussed during morning clinical meeting. He further stated he was just made aware (11/6/24) by the Corporate Nurse that the resident's pain could have contributed to her behavior with resulting fall.

Based on record review and interviews with Guardian, staff, Nurse Practitioner and Physician, the facility failed to report a problem with the door latching between the second-floor unit and the ramp leading down to the first-floor unit. Resident #1 who was severely cognitively impaired exited through the second-floor door on her own, lost control of the wheelchair and rolled down a 150-foot ramp to the first floor. Resident #1 collided with an interior wall on the first floor of the facility. She sustained bilateral femur fractures, a pelvic fracture, and a laceration to her head. The hospital determined she would not survive surgery to repair her fractures and she was admitted to a hospice house for palliative care measures. This deficient practice affected one of three residents reviewed for accident hazards. Immediate jeopardy began on 4/19/2023 when Resident #1 exited the second floor through an unlatched door and rolled down the ramp to the first floor resulting in impact with the wall. The immediate jeopardy was removed on 4/27/2023 when the facility provided and implemented a credible allegation of immediate jeopardy removal. The facility remains out of compliance at a lower scope and severity of D (no actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure education and monitoring systems put into place are effective. Findings included: Resident #1 was admitted to the facility on [DATE] and her diagnoses included cognitive deficit and Alzheimer's Disease. A quarterly Minimum Data Set assessment dated [DATE] indicated Resident #1 was unable to complete the brief interview for mental status indicating severe cognitive impairment. The assessment further indicated Resident #1 required extensive assistance with bed mobility and required assistance of staff for locomotion in wheelchair on and off the unit. The assessment did not indicate the resident had any wandering behaviors. A Wandering assessment dated [DATE] indicated Resident #1 did not have wandering behaviors. An interview was conducted by phone with Resident #1's Guardian. She stated she had visited Resident #1 on 4/18/2023, the day before the accident, and when she was leaving the facility, the door to the ramp that leads to the first floor was ajar slightly and had not latched. The Guardian stated she had not seen the door unlatched on her previous visits and when she went through the door, she made sure it latched behind her. Nurse Aide #2 was interviewed by phone on 4/24/2023 at 3:38 pm. She stated she was not assigned to Resident #1 on 4/19/23 but she saw her in the dining room shortly before her accident. Nurse Aide #2 stated she was called to another resident's room and when she returned Resident #1 was not in the dining room. Nurse Aide #2 stated she had seen the door to the second floor that was at the top of the ramp that leads to the first floor stick on the carpet and not latch. She stated she made sure it latched when she went through the door. She had never notified the Maintenance Director of the door not latching. On 4/24/2023 at 2:45 pm Medication Aide #1 was interviewed and stated she cared for Resident #1 on 4/19/2023 when the accident happened. The Medication Aide #1 stated she saw Resident #1 right before the accident in the hallway when she was in another resident's room. Medication Aide #1 stated Resident #1 did wander around the second floor, but she had never seen her attempt to go through the door to the ramp that leads to the first floor. An interview was conducted with Nurse Aide #1 on 4/24/2023 at 3:30 pm by phone and she stated she was assigned to Resident #1 on 4/19/2023 when she went out the door to the second floor and rolled down the ramp to the first floor and hit the wall at the bottom of the ramp. Nurse Aide #1 stated she was usually assigned to Resident #1 when she worked. She confirmed Resident #1 wandered around the second floor in her wheelchair. Nurse Aide #1 stated she did not see Resident #1 leave the unit because she was in a room assisting another resident. On 4/24/2023 at 3:14 pm an interview was conducted with Nurse #1. She stated she was assigned to the first floor on 4/19/2023 when Resident #1 exited the second floor, rolled down the ramp leading to the first floor and hit the wall. Nurse #1 stated she did not see Resident #1 come down the ramp or hit the wall, but she did hear her hit the wall. Nurse #1 stated when she got to Resident #1, she had her head down and there was a small laceration to the right side of her head. She stated the laceration was bleeding and it was hard to tell how big it was, but she stated she knew the laceration would require sutures. Nurse #1 stated Resident #1's wheelchair had not turned over and she was sitting in the wheelchair, and she did not see any other injuries. Nurse #1 stated she and Nurse #2 took Resident #1 up the ramp to the second floor where Resident #1 resided to call emergency services and get copies of the medical record to send with her to the hospital. Nurse #2 was interviewed on 4/26/2023 at 1:10 pm and stated she was working on the first floor on 4/19/2023 when Resident #1 came down the ramp and hit the wall. Nurse #2 stated she did not see Resident #1 come down the ramp or her hitting the wall, but she did hear it and it was a loud crash. Nurse #2 stated Nurse #1 was already with Resident #1 by the time she got to her. She stated Nurse #1 was checking Resident #1 for injuries when she arrived, and she had a laceration to the right side of her head. Nurse #2 stated she assisted Nurse #1 with taking Resident #1 back to the second floor and assisted with calling emergency services and getting copies of the chart to send to the hospital. Nurse #2 stated she had observed the door to the second floor at the top of the ramp stick and not latch before and you had to make sure it would close all the way. She stated she did not tell the Maintenance Director about the door sticking because she made sure it shut behind her. A Nurse's Progress Note dated 4/19/2023 at 11:20 am written by the Director of Nursing which stated she was called to the unit due to Resident #1 rolling down the hallway and obtaining a laceration to the right side of her head and the injury was dressed and neurological checks were initiated. The nurse's progress note further stated Resident #1 was assessed and the Nurse Practitioner and Physician were notified, and Resident #1 was sent to the emergency room for evaluation and treatment. An interview was conducted with the Director of Nursing (DON) on 4/24/2023 at 12:57 pm and she stated Resident #1 was discovered at the bottom of the ramp that led from the second floor where she resided to the first floor of the facility. The DON stated Resident #1 hit the wall and resident room door at the bottom of the ramp but remained upright in the wheelchair. The DON stated she had gone to the facility's conference room for the facility's Morning Meeting when the accident happened and the two first floor nurses, Nurse #1 and Nurse #2, had heard Resident #1 hit the wall and resident room door at the bottom of the ramp. The DON stated Nurse #1 and Nurse #2 took Resident #1 back up the ramp to the second floor, where she resided and called emergency services. The DON stated she assessed Resident #1's injuries. She stated Resident #1 had a nickel sized laceration to the right side of her head, but she did not have bruises or skin tears anywhere else on her arms, legs or body. The DON stated Resident #1 did not appear to be in pain except when she was loaded on the stretcher by emergency services, and she did put her hand to her head. The DON stated after Resident #1 left with emergency services she went around the unit and made sure everyone else was accounted for and checked the door that Resident #1 had gone through to the ramp, and it was locked. The Nurse Practitioner was interviewed on 4/24/2023 at 12:24 pm and stated before the accident Resident #1 was able to propel herself in her wheelchair and went all over the unit when she was out of bed. During an interview with the Physician on 4/24/2023 at 12:32 pm he stated he was Resident #1's physician and he called Resident #1's Guardian when the facility notified him of her injuries. The Physician stated Resident #1 did wander in the unit on the second floor where she resided. He stated Resident #1 was on the first floor until three months ago and was moved to the second floor because she repeatedly went to the outside exit door on the first floor. The Physician stated he had not seen anyone prop the door to the second floor open, but the door did need to be pulled closed or it would not latch. During an interview and observation on 4/24/2023 at 2:00 pm the Maintenance Director measured the length of the ramp leading from the second floor to the first floor and indicated the ramp was 150-feet long. The Maintenance Director stated he had not had any complaints or issues reported about the door and he examined it when the accident happened and did not find any problems with the latch on the door. The Maintenance Director also stated he had never seen the door ajar or propped open. The Maintenance Director stated before the accident he checked the battery in the lock on the door monthly, but they had not done an audit of the door after the accident. On 4/24/2023 at 10:30 am the Administrator stated Resident #1 exited the door leading from the second floor to a ramp that led to the first floor of the facility. She stated Resident #1 was in her wheelchair and rolled down the ramp and hit the wall at the end of the ramp. The Administrator stated she had interviewed the staff that were present when the accident happened and no one saw Resident #1 come down the ramp, but staff did hear her hit the wall and resident door, which caused her injuries. The Administrator stated Resident #1's wheelchair did not turn over and she was still sitting upright when Nurse #1 and Nurse #2 got to her. The Administrator stated Resident #1 was assessed, given care to the laceration on her head, and emergency services were notified and responded. The Administrator indicated Resident #1 had gone from the hospital to a hospice house and had not returned to the facility. The Administrator stated they had investigated the accident but had not been able to identify how Resident #1 had exited the door. The Administrator stated the facility had added a temporary alarm and ordered a better alarm to the door to alert staff when the door was open, and the facility had provided a staff education regarding the importance of keeping the door shut and locked at all times. Clinical Notes dated 4/19/2023 from the hospital indicated Resident #1 had bilateral femur fractures, a pelvis fracture, and a laceration to her head, which required staples to close. The Clinical Notes further stated Resident #1 was moved to intensive care from the emergency room and then the determination was made she would not survive surgical repair of her fractures. The Administrator was notified of the Immediate Jeopardy on 4/25/2023 at 4:50 pm. On 4/26/2023 the facility provided the following plan for immediate jeopardy removal: F689: Identify those residents who have suffered, or likely to suffer, a serious adverse outcome as a result of the noncompliance: Resident #1, who had severe cognitive impairment exited the second floor of the facility through a door on 200 hall which was routinely locked to a ramp which led to the first floor of the facility and rolled down a 150-foot ramp in her wheelchair where she hit an interior wall and resident room door on the first floor of the facility. Resident #1 sustained bilateral femur fractures, a pelvic fracture, and a laceration to her head which resulted in her being hospitalized in critical condition. During her hospitalization it was determined she would not survive surgery and she was admitted to a hospice house from the hospital. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete: The Regional Nurse Consultant reviewed current residents located on 100, 200, and 300 halls to identify if they wander, whether they are in a wheelchair and/or mobile. The residents' cognition was reviewed on 4/25/2023 by the Social Worker to identify current residents with severe cognitive impairment and if the resident had a BIMS (Brief Interview for Mental Status) score of 7 and below along with having the mobility of going through the door located in the hallway leading to 300 hall the resident will be moved to the 300 hall to decrease the likelihood of the residents attempting go down the ramp on 4/26/2023. On 4/26/2023 the Social Worker will call the residents representative party or guardian before the residents identified are moved, to give notification and reason as to why. On 4/25/2023, the Administrator placed a certified nursing assistant at the door located on 200 hall to protect residents that have severe cognitive impairment and mobile, whether they are in a wheelchair and/or mobile, from incidents and accidents. The Certified Nursing assistant will redirect the residents to a safe area located on the unit. The Certified Nursing assistant was provided with a list of residents that have severe cognitive impairment and mobile, whether they are in a wheelchair and/or mobile from the Social Worker. A Certified Nursing Assistant will always remain at the doors until all residents that were identified move to the 300 hall. On 4/24/2023 it was noted the door leading to the ramp was not securely shutting and the maintenance director adjusted the door with a new pin allowing the door to close and lock with ease. On 4/25/2023 the maintenance director tested all operating doors that are to be locked to ensure doors closed securely and locked. Effectively 4/26/2023 the maintenance director will check the doors weekly to ensure doors close securely and lock appropriately. This is to include 6 doors in the facility, one with a mechanical lock and five others with magnetic locks. There were not life safety egress issues noted nor created with the credible allegation. On 4/25/2023, the Maintenance Director educated the Administrator and Director of Nursing on how to keep the mechanical door locked (the mechanical lock on the other side of the keypad should be turned horizontal), that were identified to remain locked and how to identify that the doors close are secured. On 4/26/2023, signage was placed at the doors that were identified to be securely closed and locked. On 4/25/2023, the Director of Nursing and the administrator educated all current staff on how to keep the doors locked that were identified to remain locked and that doors are closed securely. Any staff member that finds a door that is not locking or closing securely, they are to stay with the door and notify the administrator and/or maintenance director immediately. The current staff will continue to ensure the doors are secured. On 4/25/2023, the Regional Nurse Consultant educated the Administrator and Director of Nursing on how to identify residents that are severely cognitively impaired and mobile, whether they are in a wheelchair and/or mobile and that the residents are to be placed on the 300 hall due to decreasing the likelihood of going down the ramp. On 4/25/2023 The Director of Nursing and administrator educated all current staff on residents that have severe cognitive impairment and mobile, whether they are in a wheelchair and/or mobile to ensure they are redirected to a safe area. The Director of Nursing will ensure no staff will work without receiving this education. Any new hires including agency will receive education prior to the beginning of their next shift. Education will be completed on 4/26/23 by the Director of Nursing and Administrator. Effective 04/25/2023, the Administrator will be responsible for ensuring implementation of this IJ removal plan for this alleged non-compliance. The alleged date of IJ removal is 4/27/2023. On 4/27/2023, the facility's credible allegation for immediate jeopardy removal was validated by the following: Review of the facility's audit of current residents to identify wandering behaviors, cognition, and ability to ambulate or move themselves about the facility in a wheelchair. The facility identified 7 residents who were at risk and after notification of their Responsible Parties and explaining to the resident the rationale they moved the residents to the first floor. ON 4/27/2023 at 11:25 am observation of the door to the 2nd floor that opened to the ramp revealed the door was functioning properly. The door closed completely, and the latch engaged. The alarm sounded as soon as the door opened, and the Nurse Aide attendant was just inside the door. The Maintenance Director was interviewed and stated he had adjusted the door to the second floor that opened to the ramp and replaced the pin allowing the door to close and lock easily. The Maintenance Director provided documentation of audits, which will be done weekly, showing he had tested all doors that were to be locked to ensure they closed securely and locked. A sample of staff were interviewed regarding their understanding of which doors in the facility were to be locked; what to do if a door that should be locked does not work properly; and who to report a lock that does not function properly. All staff stated they had the education and verbalized understanding of the education. The immediate jeopardy was removed on 4/27/2023.

Based on record review, observations, and staff, Physician and Wound Care Nurse Practitioner interviews the facility failed to implement fly reduction measures to protect vulnerable residents with wounds from development of maggots and failed to determine a possible point of entry for flies after the infestation to protect all residents at risk, which resulted in 1 of 3 residents (Resident #1) reviewed for wound care from developing maggots in her right foot wound. Resident #1's Family Member was upset and concerned she had not received adequate wound and comfort care to prevent maggots in her wound. Immediate Jeopardy began on 9/12/2022, when Resident #1's right dorsal foot wound was discovered to be infested with maggots. The Immediate Jeopardy was removed on 9/22/2022 when the facility provided and implemented a credible allegation of immediate jeopardy removal. The facility remained out of compliance at a lower scope and severity of D (no actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure monitoring system put into place are effective and education was completed. Findings included: Resident #1 admitted to the facility on [DATE] with diagnoses of dementia, [CONDITION(S)], diabetes, and pulmonary disease. Resident #1 admitted to the facility for palliative care. A Significant Change Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #1 was severely cognitively impaired and required total assistance with transfers. The assessment further indicated Resident #1 had 8 arterial ulcers. On 9/19/2022 at 10:15 am the Family Member was interviewed, and she stated she was very upset and concerned Resident #1 was not receiving adequate wound and comfort care. The Family Member stated when she arrived at the facility on 9/12/2022 the Wound Care Nurse had taken the dressing off Resident #1's right foot and maggots fell out of the dressing and the wound on the top of her foot was full of maggots. The Family Member stated there were also maggots on the bed linens and the floor. The Wound Care Nurse was interviewed on 9/19/2022 at 11:11 am and stated on Monday, 9/12/2022, she was told Resident #1's dressing was stained and went to change the dressing and when she removed the dressing there were maggots in the wound at the top of Resident #1's foot at the base of the resident's right toes and she reported the condition of the wound to the Family Member, the Wound Care Nurse Practitioner, and the Physician. The Wound Nurse stated the Physician instructed her to remove the maggots by irrigating the wound with a saline solution. The Wound Nurse stated she irrigated Resident #1's wound to remove the maggots on 9/12/2022 when they were discovered there were approximately 10 maggots, and after she irrigated the wound 7 to 8 more crawled out after she cleaned the wound. The Wound Care Nurse stated on Tuesday, 9/13/2022, when she changed Resident #1's dressing there were 7 to 8 maggots in the wound and she irrigated the wound again and appling; and on Wednesday, 9/14/2022, there were 3 maggots in the wound, and she irrigated the wound again to remove them. The Wound Care Nurse stated there had not been any more maggots found in the wound since Wednesday, 9/14/2022. During an observation of Resident #1 on 9/19/2022 at 10:25 she was observed in her room, in bed. Resident #1's right foot was covered from the ankle to the toes in a gauze dressing that was dated 9/19/2022 and the dressing was dry and intact. There were no flies visible in her room. During an observation of Resident #1 on 9/20/2022 at 8:08 am she was in bed, lying on her side with her legs over the side of the bed. No flies were visible in the room. Resident #1's dressing to her right foot was intact and there was light pink drainage to the top and lateral foot that did not come completely through the dressing. Resident #1's window shade was pulled down and the window was open approximately 3 inches with no screen in the window, and cobwebs were stretched between the windowsill and the window sash. An interview and observation of Resident #1's room window was conducted with the Maintenance Director on 9/20/2022 at 8:55 am. The Maintenance Director stated he was not aware Resident #1's window was open, or the screen was missing, and did not know how long the screen was missing from the window. The Maintenance Director stated the window was open 3 inches and there should be a screen in place in the window. The Maintenance Director reported later the screen to the window was found on the ground outside Resident #1's window and the staff should have reported the window did not have a screen to him and filled out a maintenance request. On 9/20/2022 at 10:22 am an interview was conducted with the Director of Nursing; and she stated she did not look at Resident #1's wound on 9/12/2022 when the maggots were found in her wound, but she had observed the wound on 9/13/2022 and there were 2 to 3 maggots in the wound, but it had been flushed before she observed the wound. The Director of Nursing stated she Resident #1's room was deep cleaned on 9/12/2022; they had looked at everyone with wounds to ensure there were no other residents that had maggots in their wounds; the nursing staff were educated to notify the Director of Nursing of anything unusual with wounds; and she had tried to schedule a nurse to do wound care on the weekends. The Housekeeper that usually cleans Resident #1's room was interviewed on 9/20/2022 at 10:48 am and she stated she had not observed flies in Resident #1's room, but she mopped the floor daily because Resident #1 spills food in the floor when she eats. The Housekeeper stated when she cleans the room; she cleans the windowsill, and she was aware Resident #1's window was open but did not know how long the window was open. The Housekeeper stated she was not aware the screen was missing from the window. During a second interview with the Maintenance Director on 9/20/2022 at 11:11 am he stated the facility did have issues with fruit flies coming from a drain on the 300 hall, Resident #1 resided on the 100 hall, in July 2022, but he called the exterminator, and they treated the facility and he had not noticed any fruit flies since. The Maintenance Director stated the facility's exterminator treats the facility for roaches, ants and they monitor for any signs of other pests during the monthly visits. The Maintenance Director stated he did a round of the facility when the maggots were discovered in Resident #1's wound and did not see any flies. The Nurse Practitioner (NP) was interviewed by phone on 9/19/2022 at 11:45 am. The NP stated she saw Resident #1 weekly for wound management and saw her on 9/13/2022 and there was a small handful of maggots observed in her dorsal wound at the base of her right toes. The NP stated the wound was necrotic and would continue to get worse due to Resident #1's desire to not have a right leg amputation. An interview was conducted with the Physician on 9/20/2022 at 4:42 pm by phone and he stated Resident #1's wound was most likely imbedded with fly eggs within 24 hours of the maggots hatching. The Physician stated he did not know how the wound became infested with maggots because he has only seen a few flies in the facility. He stated with recent renovations to the facility the doors were probably open more than they usually were which may have allowed flies to enter the facility. Nurse Aide (NA) #1 who cared for Resident #1 on Saturday, 9/10/2022, and Sunday, 9/11/2022, on the 7:00 am to 7:00 pm shift was interviewed on 9/20/2022 at 8:34 pm. NA #1 stated she had not observed Resident #1 without her dressing when she worked on 9/10/2022 or 9/11/2022. She stated you could see drainage in the dressing, but it had not soaked through and there was no drainage on her bedding. NA #1 stated Resident #1 was total care and could not remove her dressing herself or open her window. NA #1 stated she had not seen flies in Resident #1's room and did not know the window was open with the screen missing. On 9/21/2022 at 5:00 pm an interview was conducted with the Regional Director of Operations (RDO), who was serving as the Administrator of the facility, and he stated he had not seen any flies in the facility, but the pest control exterminator inspects for any pests when they visit the facility monthly. The RDO also stated the Nurses should provide ordered treatments, document they were provided or notify their supervisor of any treatments they are not able to provide. The Regional Director of Operations was notified of immediate jeopardy on 9/20/2022 at 5:01 pm. On 9/21/2022 the facility provided the following Credible Allegation of Immediate Jeopardy Removal: F925 Credible Allegation of Immediate Jeopardy Removal: o Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance The facility failed to implement fly reduction measures to protect vulnerable residents with wounds from the development of maggots resulting in Resident #1 having maggots in her right foot wound. The current residents are at risk who have pressure/ non pressure wounds, [CONDITION(S)] tubes, and feeding tubes as a result of this deficient practice. o Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete On 9/12/2022, Resident #1's room was deep cleaned by the housekeeping staff and maggots/pest were removed. On 9/20/22 the Director of Nursing, Assistant Director of Nursing, Wound Care Nurse and Nursing Supervisors assessed all residents with wounds, feeding tubes and [CONDITION(S)] tubes to ensure no signs of maggots or other pests. No concerns were identified as a result of the audit. On 9/20/22 the Maintenance Director and the Regional Director of Operations performed an observational audit to ensure screens are intact in all resident room windows and in all windows throughout the facility. 5 window screens were identified that needed to be repaired and were repaired by the Maintenance Director on 9/21/22. On 9/21/22 the Maintenance Director, Environmental Services Supervisor, and the Regional Director of Operations conducted observational rounds of the facility grounds to determine potential areas and factors that flies are attracted to including dumpsters and standing water. The identified concerns will be corrected by the Maintenance Director and Environmental Service Supervisor by 9/21/22. On 9/21/22 the Dietary Manager and the Regional Director of Operations conducted observational audits of the kitchen to ensure food is being stored properly and to ensure there is no standing water. No concerns were identified as a result of the audit. On 9/20/22 the Maintenance Director contacted the Pest Control Company to schedule service for flies. On 9/21/22 the Pest Control Company will consult with the facility for possible solutions to identified areas of concern as well as treat the facility for flies. On 9/21/22 the Nursing Home Administrator and the Regional Director of Operations educated the Department Managers related to ensuring that during resident room rounds food is being stored in a sealable food storage container. On 9/21/22 a sign was posted at the visitor sign in area requesting that when food is brought to the residents that it is in sealable food storage containers. Currently an air curtain is in place on the outside door in the kitchen. Fly lights will be installed at the front entrance, and other entrances frequently used by staff, residents or visitors on 9/21/2022. On 9/20/22 the Director of Nursing, facility nursing supervisor, and the Social Service Director began education to all staff including agency staff on maggots. The education will continue at the beginning of each shift until each staff member receives the education. No staff member including agency staff and new hires will be permitted to work until the education is received. The all-staff education includes: - The process of flies laying eggs and transitioning to maggots. - The risks of maggot infestation for residents with wounds, feeding tubes, and tracheostomies - Staff education related to ensuring meal trays returned to the kitchen and open food items stored in a resealable container. - Methods to reduce the risk of flies to protect vulnerable residents including window screens on resident room windows and windows in common areas and reporting standing water - Staff education to be vigilant about flies and what action they need to take if they see a fly or flies including attempting to eliminate/ investigate source of flies/pest and logging it in the Maintenance Request Log that is located at each nursing station. Fly swatter will be available at each nursing station. Effective 9/20/22 the Administrator will be responsible to ensure implementation of this immediate jeopardy removal for this alleged non-compliance. Alleged Date of IJ Removal: 9/22/2022 Credible Allegation of IJ Removal: A review on 9/21/2022 of the plan to ensure those affected by the deficient practice revealed the facility had deep cleaned the room of the affected resident and the maggots/pests were removed. The facility had assessed residents with wounds, feeding tubes, and [CONDITION(S)] tubes for any signs of maggots or other pests, and no concerns were identified, and continued to audit for any issues with wounds or feeding tube (the facility did not have any [CONDITION(S)] tubes). The facility's Maintenance Director, Environmental Services Director and Regional Director of Operations conducted a round of the facility to determine potential areas and factors that flies are attracted to and corrected the concerns. The Dietary Manager and Regional Director of Operations conducted an audit of the kitchen and ensured food is stored properly and there was no standing water that could attract flies and there were no concerns identified. The Facility notified the Pest Control Company and the on 9/21/2022 the Pest Control Company identified areas of concern and treated the facility for flies. The nursing staff were interviewed and were able to give verbal understanding of the education regarding what action should be taken if they see flies, what they can do to prevent flies (notify maintenance of window screens missing from windows, wound treatment care, and the process of flies laying eggs and progressing to maggots). The facility will provide the same in-service education to any new nursing employees and agency staff before they are permitted to work. The IJ was removed on 9/22/2022.

Based on observations, record review, staff interviews and physician interview, the facility failed to implement physician orders [REDACTED].#46 pressure ulcer treatments twice a day per physicians orders and (2) implement Resident #62's physician ordered pressure reducing intervention to float heels while in bed. This failure was for 2 of 4 sampled residents reviewed for pressure ulcers. Findings included: 1.Resident #46 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. The quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #46 was cognitively intact and was coded for having a stage 4 pressure ulcer. Resident #46's care plan dated 7-27-20 revealed a goal the resident would not develop a new open pressure ulcer and the resident's pressure ulcer would show signs of healing and remain free from infection. The interventions listed in part were; administer treatments as ordered and monitor for effectiveness, assess/record/monitor wound healing, measure length, width and depth where possible, assess and document status of the wound perimeter, wound bed and healing progress and report improvements and declines to the physician. Resident #46's medical record revealed the resident had a wound vac from 7-17-20 until 8-7-20 where it was documented the wound vac malfunctioned on 8-7-20. Physician order [REDACTED]. Resident #46's Treatment Administration Record (TAR) for the month of August 2020 revealed no documentation of wound care being performed to the resident's sacrum on the evening shift for the following days; 8-10-20, 8-16-20, 8-18-20, 8-21-20, 8-27-20, 8-28-20, 8-29-20, 8-31-20. Resident #46's TAR for August 2020 also revealed no documentation of wound care being completed to the resident's sacrum during the day or evening shift on 8-31-20. The facility's weekly pressure wound observation tool was reviewed for the months of August 2020 to 9-1-2020 and revealed the following results; 8-13-20 the sacrum wound measured 2.2cm(centimeters) long, 2.5cm wide, 2.0cm deep with 1.5cm of tunneling. 8-18-20 the sacrum wound measured 2.0cm long, 2.5cm wide, 2.0cm deep and 2.7cm of tunneling. 8-27-20 the sacrum wound measured 2.3cm long, 3.0cm wide, 3.0cm deep and 3.7cm of tunneling. 9-1-20 the sacrum wound measured 3.0cm long, 3.0cm wide, 4.0cm deep and 3.0cm of tunneling. During an interview with Resident #46 on 9-1-20 at 3:05pm, Resident #46 discussed having a wound on his buttocks that was supposed to be changed twice a day. The resident stated staff was completing his wound care once a day in the mornings, but he was not receiving his wound care in the evenings. Resident #46 said he had not been refusing for the wound care to be completed. Observation of Resident #46's wound care occurred on 9-2-20 at 10:01am with the facility's wound care aid and nursing assistant (NA) #2. The wound care aid was noted to maintain a clean field and provide the wound care per the physician orders. The wound care aid was noted to pack the residents wound with 4x4 gauze squares wet with Dakin solution using her fingers to insert the 4x4 squares into the wounds tunneling area. The residents wound was observed to be clean with no odor or signs of infection. A very small amount of red drainage was noted. The wound care aid was interviewed on 9-2-20 at 10:15am. The wound care aid stated she was not aware Resident #46's wound care was not being completed twice a day and said, I work during the day, so I know it is getting done then. She also commented that the wound care nurse communicates with the physician if there are any issues with the wound. Nurse #3 was interviewed on 9-4-20 at 3:42pm by telephone. Nurse #3 confirmed she was the wound care nurse for Resident #46 and discussed that she worked during the day. The nurse said she reported to the evening shift, the residents' that had wound care to be completed during their shift. She also stated she had realized Resident #46's wound care was not being completed in the evenings (indicated by the resident's TAR) as ordered but was not aware of the frequency. Nurse #3 stated she had reported the incomplete wound care on the evening shift to the Director of Nursing (DON) when she saw the wound care had not been completed on 8-10-20, 8-16-20 and 8-18-20 and any concerns about Resident #46's wound to the physician. The nurse commented Resident #46 was having the wound vac placed on his sacral wound today (9-4-20). An attempt was made to contact the evening shift nurses; however, it was reported by the DON the facility used different agencies and she was not aware which agency the evening nurses came from so she would not be able to provide any phone numbers. The DON also commented, since the survey, she has started handling the scheduling herself so she can have a better understanding on who was working and if staff was from an agency which agency. The facility's physician was interviewed on 9-4-20 at 12:25pm by telephone. The physician stated the wound care nurse changes the resident's dressing during the day and the floor staff was supposed to change it in the evenings. He said he was not aware the wound care was not being completed on the evening shift. The physician commented he was aware the resident's wound was healing with the wound vac but was not aware the wound had deteriorated. He stated he expected staff to follow the physician orders. The physician discussed the wound having the ability to become worse if the wound was not treated as ordered by staff. An interview occurred with the Director of Nursing (DON) on 9-4-20 at 1:40pm by telephone. The DON stated she was not aware of Resident #46's wound care not being completed as ordered but that she would discuss the issue with staff to find out why the wound care was not being completed. She also stated if the wound care could not be completed as scheduled, the nurses were responsible for documenting the reason in the nursing notes. 2. Resident #62 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #62 had severely impaired cognition and was totally dependent on staff for activities of daily living. Resident #62 was at risk for pressure ulcers and had current pressure ulcers. Resident #62 utilized a pressure reducing device to her bed and received pressure ulcer care. A progress note dated 8/18/20 by the wound care physician revealed Resident #62 was seen for a stage 2 pressure ulcer to her sacrum. The wound measured 1 x 1 x 0.1 centimeters. The resident ' s August 2020 physician's order [REDACTED]. The Medication Administration Record [REDACTED]. An observation on 8/19/20 at 3:20 PM revealed Resident #62 lying in bed. Resident #62 ' s heels were lying flat on the mattress and the heels were not floated. An observation on 8/20/20 at 8:10 AM revealed Resident #62 lying in bed. Resident #62 ' s heels were lying flat on the mattress and the heels were not floated. An interview was conducted with Nurse Aide (NA) #3 on 8/20/20 at 10:00 AM. NA #3 provided care to Resident #62 on 8/20/20. She did not know why Resident #62 ' s heels were not floated on 8/20/20. NA #3 reviewed Resident #62 ' s care plan guide and did not find where Resident #62 ' s heels were to be floated. An interview was conducted with Nurse #4 on 8/21/20 at 10:10 AM. Nurse #4 provided care to Resident #62 on 8/19/20 and 8/20/20. She stated she didn ' t know why Resident #62 ' s heels were not floated and that was something the nursing assistants should do. An interview was conducted with the Director of Nursing (DON) on 8/20/20 at 12:45 PM. The DON stated she would look into why Resident #62 ' s heels were not being floated but still being signed as done.

Based on observation, review of the COVID 19 Policy/Plan and Accordius Health Update policies/instructions, record review, staff interviews and physician interviews, the facility failed to prevent an infection control system failure when (1) 47 of 57 employees did not complete the required screening for signs and symptoms of the COVID 19 virus prior to starting their shift and a nursing assistant entering the facility did not monitor his body temperature as part of the screening process prior to reporting to work in a resident care area and (2) two nursing assistants (NA) #6 and NA #5, who were on duty, were wearing facial masks that were not covering their nasal passages. These system failures occurred during the COVID 19 pandemic and had the likelihood to affect all residents residing in the facility. Immediate Jeopardy began on 4-30-20 when observations were made of a nursing assistant entering the facility without monitoring their body temperature as part of the screening process, two nursing assistants were observed wearing their masks below their nose while on resident halls and record review revealed 47 out of 57 employees did not complete the screening process prior to starting their shift which caused or is likely to cause serious injury, serious harm or death. Immediate Jeopardy was removed 5-1-20 when the facility implemented an acceptable credible allegation of Immediate Jeopardy removal. The facility remains out of compliance at a lower scope and severity of E that is not Immediate Jeopardy to ensure monitoring systems put in place are effective. Findings included: 1. The facility's policy and procedure for COVID 19 Policy/Plan dated 4-4-20 was reviewed and revealed in part; temperatures of staff will be taken with no person being permitted to work with a temperature greater than 100.4 and all staff will complete the staff log and be screened for potential concerns prior to entering a resident area. Upon entering the facility on 4-30-20 at 5:30am, the Assistant Director of Nursing (ADON) was noted to be by the employee sign in table which was located at the lower entrance to the facility. The table was observed to contain; the employee sign in log, hand sanitizer, alcohol pads and an oral, ear and forehead thermometers. There were no masks or protective covers noted for the ear and oral thermometers. The ADON guided this surveyor in the screening process which included; signing the sign in log, recording a temperature, placing the time of entrance into the facility, and answering 4 yes/no questions regarding symptoms and contact with anyone who may be sick. When this surveyor attempted to use the forehead thermometer, the thermometer screen was noted to remain blank and not registering a temperature. The ADON was noted to take the thermometer, shake it a few times then had to press the power button 3 times for the thermometer to turn on. The ADON was then able to obtain an accurate temperature for this surveyor. The ADON was interviewed on 4-30-20 at 5:35am. She stated the facility had no positive cases of COVID 19. The ADON confirmed staff and visitors could only enter through the lower level door and it was the responsibility of the staff member to stop at the sign in table to be screened which she stated consisted of; signing their name, taking their temperature and recording it in the sign in log, recording the time they entered the facility and answered 4 yes/no questions regarding if they had any symptoms (sore throat, fever, cough or shortness of breath), if they had traveled outside the U.S. in the last 14 days, if they had any general sickness or not feeling well in the last 72 hours and if the employee/visitor had been around any person who was sick or had COVID 19. The detail labor report and staffing sheets for 4-23-20 through 4-30-20 which showed the days and times the employees worked, were compared to the COVID 19 employee screening log ( where staff placer their name, temperature, time they entered the and answered 4 yes/no questions regarding COVID 19) dated 4-23-20 through 4-30-20. The comparison of these records revealed 47 out of 57 employees failed to complete the screening process and did not document an entry in the COVID 19 employee sign in log when they reported to work. Nurse #1 was interviewed on 4-30-20 at 6:12am. The nurse stated she had not attended an in-service or formal training regarding personal protective equipment (PPE) such as wearing masks while in the facility, hand washing, screening process or COVID 19. Nurse #1 stated we were given information sheets on wearing our mask, hand washing and COVID 19 and told to sign the attendance sheet when we signed the waiver to work back in March. She also stated staff were not monitored when they entered the facility to ensure they were taking their temperature or filling out the employee screening log. Nurse #1 specified they are using the honor system. She said staff were supposed to write their name, take their temperature then record their temperature on the screening log, put what time they entered the facility and answer the yes/no questions. Nurse #1 also stated there was not a staff member to let them in the building for the 7:00pm shift and stated, No we just put the code in and come in. During an interview with nursing assistant (NA) #3 on 4-30-20 at 6:30am, NA #3 stated she had not attended an in-service or training on masks, hand washing, infection control or COVID 19 we were given an information sheets on wearing our mask, hand washing and COVID 19 in March and instructed to sign the attendance sheet saying we received the information. She also discussed entering the building on her own and there was not a staff member monitoring employees' entering the building, taking their temperature or completing the screening log which consisted of writing their name, taking their temperature then recording their temperature on the screening log, put what time they entered the facility and answer the yes/no questions. Observation of staff entering the facility occurred on 4-30-20 at 6:35am through 7:20am. During that time 4 staff members were noted to enter the building on their own and complete the screening process at the screening table. The employee screening table was monitored periodically starting at 6:45am by the ADON and the facility's scheduler to ensure employees had a mask, took their temperature, recorded their temperature and answered the 4 yes/no COVID 19 questions on the screening log. An observation of staff entering the building on 4-30-20 at 6:55am, revealed NA #5 stopped at the employee screening table located at the lower entrance to the facility. The screening table was not monitored at that time by the ADON or the facility's scheduler. NA #5 was observed obtaining a mask, writing down a temperature in the employee screening log, putting what time he entered the facility and answering the 4 yes/no COVID 19 questions. NA #5 was observed writing down a temperature without obtaining his temperature using the oral, ear or forehead thermometers and then proceeded to walk down hall 300. During an interview with NA #5 on 4-30-20 at 8:15am, NA #5 stated he had not taken his temperature on 4-30-20 and stated, I don't know why I just didn't. He also stated he had been educated back in March on the importance of screening employees prior to their shift verbally by the Director of Nursing (DON) and then stated oh wait, I did. I ran that thing (forehead thermometer) across my forehead. During an interview with the Administrator on 4-30-20 at 7:54am, the Administrator discussed staff only being able to enter through the lower level entrance of the facility, that the front door was locked and the employee screening table by the lower level entrance was supplied with the employee screening log, masks, hand sanitizer and thermometers. He also stated he did not know why there were not masks on the table or covers for the oral and ear thermometers when I leave in the evening, I make sure all the supplies are there on the table. I will have to ask what happened to them. The Administrator said the facility had not had issues with their supply of personal protective equipment (PPE). He discussed the 300-hall nurse and the facility's scheduler being responsible for monitoring the 7:00am shift employees entering the building to ensure the employees take their temperature, fill out the employee screening log and needed supplies (masks, hand sanitizer, thermometers and screening log) were on the table. He also added the 300-hall nurse was responsible for monitoring the 7:00pm staff entering the facility. The Administrator stated staff had been in-serviced on COVID 19, infection control and PPE in March 2020 and that the education was also part of the employees yearly training. The facility's physician was interviewed by phone on 5-4-20 at 2:35pm. The physician stated he was not aware of staff not screening prior to starting their shift but stated it needed to be completed. He also discussed educating staff when he was in the building on the importance of good hand hygiene and the importance of the screening process. The physician also said if staff were not following the proper screening process [MEDICAL CONDITION] could spread in the building and affect more than one or two people. Review of the facility training revealed staff received training on improving sign in process dated 4-24-20. The Director of Nursing (DON) was interviewed by phone on 5-5-20 at 10:00am. The DON stated the process for screening employees entering the facility was; the employee stops at the employee screening table, takes their own temperature or if they need help can ask for help to have their temperature taken, sign in on the screening log, record their temperature and answer the 4 yes/no COVID 19 questions. She also stated the employee needed to report any symptoms or if they had been in contact with anyone who had symptoms of COVID 19. The DON discussed auditing the employee screening log daily to assure employees were following the screening process but had not tallied the number of employees who had not followed the screening process and stated when she found discrepancies she would re-educate the employee on the proper procedure. A follow up telephone interview occurred with the DON on 5-6-20 at 4:10pm. The DON said when she found the discrepancies for the screening process, she spoke with the individual person and re-educated them on the screening process. She also stated, the staff that did not complete the sign in process during the 7:00am to 7:00pm shift, she escorted them back to the sign in table and had them take their temperature. The DON said staff entering the facility for the 7:00pm to 7:00am shift were monitored by the 300 hall nurse to ensure staff took their temperature and answered the 4 yes/no COVID 19 questions but the staff that had not completed the sign in process were re-educated, no documentation was provided by the DON. 2. The facility's policy and procedure for COVID 19 Policy/Plan dated 4-4-20 was reviewed and revealed in part; All staff will always be required to wear a surgical mask while in the facility. Review of the facilities Accordius Health Update dated 4-9-20 revealed in part; all staff always wear masks while in the facility. An observation was conducted on 4-30-20 at 8:31am of nursing assistant (NA) #6 wearing her surgical mask below the nose, exposing the nasal passages while she was on a resident hall. During an interview with NA #6 on 4-30-20 at 8:31am, NA #6 stated she was given information on hand washing and personal protective equipment (PPE) in March 2020. She said she thought if the top ridge of the mask was covering the nasal opening it was ok but was able to state the ridge of her mask was not covering the opening of her nasal passage. NA #6 discussed receiving education in March 2020 that the surgical mask must cover her nose and her mouth while in the facility. NA #6 was observed a second time on 4-30-20 at 9:15am on a resident hall with her mask below her nose exposing her nasal passages. During an observation on 4-30-20 at 9:20am, NA #5 was noted to be on a resident hall with his mask below his nose, exposing the opening of his nasal passages. NA #5 was interviewed on 4-30-20 at 9:20am. NA #5 stated he thought it was ok to wear the mask below the nose while he was not in a resident room. He stated he received education in March 2020 on proper use of the surgical mask and the mask needed to cover his nose and mouth while in the facility. An interview with the Administrator and DON was conducted on 4-30-20 at 10:10am. The Administrator and DON both stated staff had been in-serviced on the mask needing to cover their nose and mouth while they were in the building and that they would speak/re-educate the employees on the way masks are to be worn. Follow up documentation was provided of the facility's weekly mask audit starting on 3-24-20 to 4-30-20. The documentation revealed staff not wearing their surgical masks covering their nose and mouth. The weekly audit tool also documented that staff were re-educated immediately on the proper wearing of their surgical masks. The facility's physician was interviewed by phone on 5-4-20 at 2:35pm. The physician stated he was not aware of staff incorrectly wearing their masks while in the facility but stated staff needed to wear their masks correctly. He also discussed educating staff when he was in the building on the importance of good hand hygiene and the importance of the protocols related to wearing surgical masks while in the building. The physician also said if staff were not making sure their masks covered their nose and mouth [MEDICAL CONDITION] could spread in the building and affect more than one or two people. The Director of Nursing (DON) was interviewed by phone on 5-5-20 at 10:00am. The DON discussed staff had received training between 3-11-20 and 3-23-20 on wearing their surgical masks while in the facility which included masks were to cover their nose and mouth and should not be below the nose or chin and not pulled down to speak. The Administrator and DON were notified of the Immediate Jeopardy by phone on 5-5-20 at 11:20am. On 5-8-20 the facility provided the following credible allegation of Immediate Jeopardy removal: Allegation of IJ removal of F880 Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance No residents were directly involved in the cited deficient practice, but all residents are at risk from the failure to adhere with correct and adequate infection control processes as guided by the Centers for Disease Control (CDC) and Centers for Medicare and Medicaid (CMS). The deficient practice occurred due to one employee that failed to take his temperature upon entering the facility and two employees failed to have their mask over their nose while on the nursing units. Also, numerous employees that failed to document their temperature and responses to screening questions upon arrival at the facility from 4/23/20 through 4/30/20. Specify the Action the Facility will take to alter the process or system failure to Prevent a Serious Outcome from occurring or reoccurring and when the Action will be complete. The Director of Nursing re-educated all staff onsite on 4/30/20 from all departments Including nursing, dietary, housekeeping, activities, social work, therapy and administration regarding the requirements for entering through a single point of entry and exit for the facility , the required use of the sign in log upon entry, the requirements of documenting their temperature and disclosure of any contacts or signs and symptoms. This procedure is required for every person who enters the facility, whether in contract capacity or an employee. Any such staff who was not in the facility on 4/30/20 was in-serviced by phone and competency evaluated by return demonstration as they reported for their next assigned shift. All staff is required to complete this training prior to working in the facility. For those who are educated by a trained and competency evaluated staff person is responsible for either taking the individuals' temperature or witnessing the individual properly taking their own temperature, validating the reading and observing the correct entry being made, and completing the screening questions. In addition, the requirements of wearing a mask, provided by the facility, always when in the facility. The re -education included proper donning and doffing of surgical masks, to keep the mask clean and covering the nose and mouth at all times as well as methods of preserving the integrity and cleanliness of the mask including the optional use of a cloth mask that will contain or shield the surgical mask but which must be washed and sanitized in a dryer with high heat. Re- education specified the requirement that employees will secure and leave the surgical mask in paper bag with the employee's name on it when exiting the building for use on their next assigned shift. The policy allows for use of the same surgical mask for up to five (5) shifts unless the mask becomes soiled, wet or torn. To ensure all staff participated in the education and competency evaluation, the Director of Nursing compared these in-services and return demonstrations to a master list of all employees and contract workers, including the therapy, housekeeping and dietary. All such staff have been competency evaluated by return demonstration and have not been permitted to work since 4/30/20 unless the education and check off were completed. To assure all staff fully understand the importance of proper donning and doffing, beginning on 4/30/20 on an ongoing basis, the individual who is charged with screening individuals upon entry is observing each person as they take their mask from the paper bag and don it, providing a continuous opportunity to correct any improper process or understanding of proper donning and wearing of a mask. During the hours of 7a to 7pm there is an employee assigned on a daily basis by the Director of nursing who sits by the table and ensures that all visitors and employees sign in and complete the questionnaire and temperatures are taken, and properly logged and the mask is obtained and donned. After 7pm and before 7am the doorbell is to be utilized and a staff member for unit 3 will allow the visitor/ employee in and ensure the questionnaire is complete and temperatures are taken and logged along with mask being donned. The employee who is assigned to sit at the table from 7a to 7p reports off to the unit 3 charge nurse. In the event the assigned employee from unit 3 is unable to answer the doorbell he or she will send another employee to the door to inform those that are waiting to enter that someone would be able to sign them in momentarily. All new hires will receive this education as part of orientation. The facility alleges the removal of the immediate jeopardy on 5/1/20 The Administrator is responsible for assuring corrective actions are sustained. On 5-13-20 at 10:40am the facility's credible allegation for Immediate Jeopardy removal, with an Immediate Jeopardy removal date of 5-1-20 was validated as evidenced by licensed and non-licensed staff interviews, facility training that included desk monitoring for the employee sign in/ sign out screening and the COVID policy review which included donning and doffing of surgical masks and employee sign in/sign out procedure. Observations of staff working the 7:00pm to 7:00am shift and staff working 7:00am to 7:00pm shift, revealed masks were being worn properly covering the nose and mouth. The observations of the employees signing in and out for their shift revealed a designated staff person present at the door, assisting the employees into the facility, taking their temperature, assuring the employee filled out the sign in log, retrieved the employees mask from a paper bag with the employees name on it and observed the employee placing the mask over their nose and mouth.

Based on record review and interviews with facility staff, Emergency Medical Service (EMS) transporter, physician, radiologist, and x-ray company representative, the facility failed to protect 1 of 3 residents (Resident # 2) from an injury of unknown origin, failed to provide comprehensive assessments, and delayed to initiate medical treatment when x-ray results were positive for a [MEDICAL CONDITION]. Findings included: Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The fall risk assessment dated [DATE] revealed Resident #2 was assessed as high risk for falls. Review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #2 was assessed as having adequate hearing, clear speech and highly impaired vision. The resident was coded as cognitively impaired and being totally dependent with one-person physical assistance with dressing, toileting and personal hygiene and needing extensive one-person assistance with bed mobility, transfer and bathing. The resident was always incontinent of bowel and bladder and had no falls during the look back period. Care plan review for Resident #2 dated 7/9/19 revealed a focus area of at risk for falls related to needing one-person assistance for all safe transfers and mobility. The goal was that the resident would have no falls with major injury. The interventions included to encourage nonskid footwear or socks when out of bed, remind resident that when rising from a lying position, to sit on the side of the bed for a few minutes before transferring /standing. Interventions also included to remind resident to ask for assistance with transfers prior to transferring and to report falls to physician and responsible party. Review of the incident report dated 8/18/19 revealed Resident # 2 had an unwitnessed fall on 8/18/19. The resident was observed on the floor beside his bed. Report also indicated the bed was at the lowest position. No injuries were observed upon assessment. Floor mat was placed as an intervention. Physician and resident guardian were notified. Interview with Nurse aide (NA) #5 on 9/11/19 at 2:11 PM, revealed nursing assistant (NA) # 5 was working on 9/1/19 from 7 AM - 3 PM. NA # 5 stated, around 7:00 AM, when walking down the hallway, she observed Resident # 2 in his room sitting on the bed which was closer to the resident's room door. NA #5 indicated the resident was assisted with dressing. NA # 5 stated while assisting the resident with his pants, he pointed to his left knee and indicated pain in his left knee area. The resident was able to stand up and allowed the NA # 5 to finish dressing him. NA #5 stated, she had informed Nurse #3, about Resident #2's left knee pain. NA # 5 stated NA #4 (who was assigned to the resident on 9/1/19) went into Resident #2's room approximately 30 minutes later and found the resident without his pants. NA # 4 proceeded to redress the resident, when he complained to her of his left knee pain. NA # 4 approached NA # 5 to enquire about Resident # 2's pain and if the Nurse was informed. NA #5 stated NA # 4 also notified Nurse # 3 about Resident# 2's pain. Interview with NA # 4 via phone on 9/11/19 at 3:00 PM revealed NA # 4 was assigned to Resident #2's care on 9/1/19 from 7 AM to 7 PM. NA # 4 stated at around 7:45 AM, the resident was observed sitting in his wheelchair, with no pants and looking at his leg. Resident #2 flinched when his left leg was touched by NA # 4. NA #4 indicated the resident was assisted with the aid of another NA (does not recollect the NA's name). Resident # 2 was later taken in his wheelchair to the nurse's station. NA # 4 notified Nurse # 3 about Resident #2's pain. NA # 4 stated Resident #2 was in his wheelchair most of the day near the nursing station. NA # 4 stated the resident did not appear to be in any pain and no bruising was observed when taken to the bathroom in the afternoon (after lunch - unsure of the time). NA #4 stated Resident #2 was assessed by the Unit Manager (Nurse # 6) and Director of Nursing (DON) later that afternoon. NA # 4 stated she did not receive any report of resident's fall earlier that morning during shift change. Interview with Nurse # 3 via phone on 9/11/19 at 2:00 PM, revealed Nurse # 3 was working on 9/1/19 from 7AM to 7PM. Nurse # 3 stated a NA (unsure of the name) had reported to him in the morning (unsure of the time) that Resident #2 had reported knee pain. The resident was in his wheelchair near the nursing station most of the day and Nurse # 3 indicated he had not observed the resident in pain. Nurse # 3 indicated around lunch he was sitting at the nurse's station and had observed the resident being assessed by the Unit Manager (Nurse # 6) and DON near the nurse's station. Nurse # 3 stated he overheard the DON and Nurse # 6 talking about a bruise and possible X-ray. The resident was not observed in pain when assessed by DON and the Unit Manager. Nurse #3 indicated no orders were given after their assessment. Nurse # 3 stated he thought the DON and Unit Manager were taking care of the issue and he did not assess the resident. Review of nursing notes dated 9/1/19 at 10:33 AM written by Nurse #6, read in part Resident sitting at nurses' station in wheelchair. CNA (Nurse aide) reported to writer and Director of nursing (DON) that resident was complaining of foot hurting. Writer and DON assessed resident's legs bilaterally, resident had no face grimacing, s/s (signs and symptoms) of pain, or bruises at time of observation. Will continue to monitor. During an interview on 9/11/19 at 2:30 PM, Nurse # 6 indicated she was notified about Resident #2 's leg pain on 9/1/19 (unsure of the time). Nurse #6 stated on 9/1/19 (unsure of the time) she and the DON went to assess Resident #2. The resident was assessed at the nurse's station. No pain or bruising were noted during the assessment. Nurse # 6 stated the DON looked at the legs, pressed leg for pain and the resident was moving the legs fine. There were no issues with the resident's range of motion. No falls were reported. During an interview on 9/12/19 at 3:35 PM, the DON stated on 9/1/19, Resident #2 was assessed by him and Nurse #6. The resident was sitting at the nurse's station during the assessment. The resident was assessed physically (by touching his leg, pressing it and moving his leg for range of motion). The DON stated the resident had no bruises, no pain or grimacing. No facial expression of pain was noted. The DON stated no one had reported the resident having a fall. The DON further stated the resident's last fall was on 8/18/19, which was an unwitnessed fall with no injuries. The DON indicated no falls were reported since 8/18/19. Interview with Nurse # 5 was conducted via phone on 9/11/19 at 2:50 PM. Nurse # 5 stated she had worked on 9/1/19 from 7 pm- 7 am and was assigned to Resident# 2. The Nurse indicated she did not recollect much about the resident but stated no report regarding resident's pain or fall was given to her by Nurse # 3 during shift report. Nurse # 5 stated the resident was in bed the entire shift and had not observed the resident to be in any pain. During an interview on 9/11/19 at 5:40 PM, NA# 6 indicated she was assigned to Resident #2 on 9/1/19 from 7 PM to 7 AM. NA # 6 stated Resident # 2 was in bed the entire shift and did not complain of any pain. NA #6 further stated she did not observe any bruising during incontinent care. The pain assessment scale for 9/1/19 at 1:02 AM, at 9:01 AM and at 8:00 PM, was coded as zero (0). No Skin assessment was documented on 9/1/19. Review of the ADL care tracker revealed ADL care on 9/1/19 for bed mobility, transferring, toilet use, personal hygiene and dressing was marked as provided at 2:44 AM and at 2:30 PM. During an interview on 9/11/19 at 9:53 AM, NA # 1 indicated on 9/2/19 prior to breakfast she went into Resident's #2's room to set the bed table for his breakfast. NA #1 stated she observed Resident # 2 was holding his knee, and he stated ouch it hurts. Resident #2 was not touched or moved. NA #1 indicated, when she removed the sheets to see what the issue was, she noticed a big bruise on his inner left thigh. NA #1 stated Nurse #1 was immediately notified. During an interview on 9/11/19 at 2:11 PM, NA # 5 stated on 9/2/19 at around 8:00 AM when she entered Resident# 2's room to feed him breakfast, NA #5 observed Resident #2 was in a fetal position, was screaming when touched, and noticed the bruising on the resident's inner thigh. NA # 5 stated the resident was in pain on 9/2/19 during the entire shift (until 3 PM) and would only allow NA to do incontinent care very slowly. NA # 5 stated the resident's pain had worsened since 9/1/19. NA #5 stated the bruising was large on the inner leg and could not have been missed by any staff. NA #5 indicated she notified Nurse #2 immediately. During an interview on 9/10/19 at 2:44 PM, Nurse # 1 stated on 9/2/19, she was notified about the resident's bruising by NA # 1 around mid-morning after breakfast (unsure of the time). Nurse #1 stated Resident #2 was provided ADL care when NA # 1 noticed the bruises and notified her. Nurse # 1 stated she assessed Resident # 2's bruise, and the on- call physician and resident's guardian were notified of the bruising. The On- call physician ordered X-rays around lunch (time unsure). Nurse # 1 indicated the incoming nurse (around 6 PM) was notified about the bruising and pending X-ray. She further stated Resident #2 was assessed to be in pain and a standing order for Tylenol 650 milligrams was administered. Nurse # 1 indicated the resident was reassessed for pain a few minutes after Tylenol was administered. Nurse stated Resident# 2 's pain was stable, and the physician was not notified. When asked what she meant by pain being stable, Nurse #1 stated it was similar to any person having a fracture, there should be pain when a person has a fracture. When asked did Resident #2 have pain, she stated any patient with fracture will have pain. The pain was stable, and the physician was not informed as it was stable. Interview with Nurse # 2 was conducted via phone on 9/11/19 at 1:18 PM. Nurse # 2 indicated he was working on 9/2/19 from 7 AM to 7 PM. Nurse # 2 stated Resident # 2's bruises were reported to him by a NA (unsure of the name). Nurse # 2 indicated Resident #2 had a large purplish area on his inner thigh, and it appeared bad. Nurse # 2 further indicated the Unit Manager (Nurse #1) was notified about the bruising and he wanted the Unit Manager to reassess the resident. He stated he did not do a complete skin assessment but indicated the details of the bruise in his notes on 9/2/19. Nurse #2 stated Resident #2 was very guarded and did not allow the staff to touch him and was in bed the entire shift. Nurse #2 stated the resident was administered an as needed (PRN) pain medication of Tylenol which was ineffective. Nurse # 2 indicated Nurse #1 was notified about the ineffectiveness of the pain medication and no other pain medication was administered. Nurse #2 stated he was an agency nurse and hence he notified the Unit Manager (Nurse #1). Nurse #2 indicated he was unsure of the pain scale, but recollected Resident #2 being in bed, and calm until touched. Nurse # 2 stated they did receive an order from the on-call physician for an X-ray. The X-ray was completed on 9/2/19 later that afternoon. Results were pending at the end of the shift. Review of the physician order [REDACTED]. Review of the Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. Review of the pain assessment scale for 9/2/19 revealed at 1:48 AM Nurse #5 had indicated the pain scale as zero (0). No other pain assessment was noted on 9/2/19. No Skin assessment was documented on 9/2/19. Electronic Medication Administration Note (eMAR) review dated 9/2/19 at 2:32 PM, read in part PRN (pain medication) Administration was: Ineffective. Review of nursing note dated 9/2/19 at 3:21 PM written by Nurse # 2, read in part follow up large bruise from previous day. Large dark purplish discoloration to inner left thigh, resident appeared in pain, guarding area. As needed (PRN) pain medication was ineffective. Unit coordinator (Nurse #1) notified and new order for X-RAY to rule out fracture. Resting in bed, total care provided. Vital signs (VS) (temperature) 98.6 (heart beat) 76 (respiration) 18 (blood pressure) 145/62. Oxygen (O2) sat 94% on Room air (RA). Interview with Nurse # 4 was conducted via phone on 9/12/19 at 9:28 AM. Nurse # 4 indicated she was working on 9/2/19 from 7 PM to 7 AM and was assigned to the resident. Nurse # 4 stated during the shift report, she was informed that something happened over the weekend. The nurse stated Nurse #2 informed her that the resident had pain over the weekend per NA who reported to him and something must have happened to the resident to have pain and Resident #2 was screaming in pain on the morning of 9/2/19. An X-ray was ordered and completed on 9/2/19 prior to shift change. The results were pending. Nurse #4 further stated, she checked the back-station Fax machine on unit 1 later that evening for any X-ray results and had not received any results. Resident #2 was already in bed during medication administration and did not show any sign of pain during medication administration. During a telephone interview on 9/12/19 at 3:12 PM, NA # 9 stated he was working on 9/2/19 from 3PM to 7AM and was assigned to Resident #2. NA # 9 indicated prior to his shift and during the shift, he was not made aware about Resident# 2's pain, bruising and the resident being due for an X-ray. No falls were reported to him. NA # 9 stated Resident #2 was in bed the entire shift and he did not observe bruising or pain when incontinent care was provided to the resident. Review of the radiology report that was electronically signed by the radiologist on 9/2/19 at 5:36 PM revealed 1) Hip unilateral -There was a displaced left basitrochanteric fracture ([MEDICAL CONDITION]) assumed acute. Consider computed tomography (CT) to further assess extent of fracture and further evaluate the pelvis. 2) Left Knee - Osteophyte, loose body or fracture fragments of unknown age at the anterior tibial articular surface. Consider CT if there is further suspicion. Mild [MEDICAL CONDITION] changes. During an interview on 9/10/19 at 3:00 PM, NA # 2 stated Resident# 2 was assigned to her care on 9/3/19. Resident had a large bruise and was in pain when incontinent care was provided. He was guarded and care had to be provided slowly. The resident indicated pain by pointing to the leg that hurt. Resident # 2 was in bed and did not move much. NA# 2 indicated Resident #2 was able to communicate pain by facial expression and able to answer simple questions. Resident #2 was dependent and needed assistance with ADL care and transfers. Review of nursing note dated 9/3/19 at 10:50 AM written by Nurse # 3, read in part X- RAY results received this AM for left hip and left knee. Conclusion indicates left basitrochanteric fracture assumed acute. (Unit manager Nurse #1) notified. Physician on call was notified and orders received to send resident to emergency room (ER) for further evaluation. Family notified and requested resident be sent to (name) hospital. Arranging transport to hospital at present. During a telephone interview on 9/11/19 at 2:00 PM, Nurse # 3 stated on 9/3/19, someone (unsure name and time) gave him the resident's X-rays results. Nurse # 3 indicated he did review the results and notified the on-call physician about the X-rays results. He further indicated orders were received to send the resident to the hospital. Nurse # 3 stated on 9/3/19, Resident # 2 was in bed and did not complain of any pain. No pain medication was administered. Nurse # 3 also stated he did not recall if resident's bruising and X-ray results were discussed during the shift change and was not aware of the resident's bruising until he read the X-ray results. Review of nursing note dated 9/3/19 at 1:15 PM written by Nurse # 3, revealed the emergency transport service (EMS) transported the resident to the hospital via stretcher. The resident left the facility in a stable condition. Review of the hospital record revealed on 9/3/19, in the Emergency Department, the resident was presented with complaints of left hip pain, received CT scan, which revealed acute left hip intertrochanteric fracture. Trochanteric fracture is a typical bone [MEDICAL CONDITION] (big/long bone of the leg). Comminuted fracture is when the bone breaks into many pieces - could be the result of bone structure issue, like osteopenia or from the high-impact trauma (car accident). Other X-rays findings showed osteopenia (poor bone structure) and multiple moderate [MEDICAL CONDITION] changes of hip, pelvis and knee (most likely severe arthritis). Assessment in the hospital included: significant bruising over the left inner thigh with anterior and lateral hip. Tender to palpation (touch) diffusely. An orthopedic specialist was consulted and recommended operative management. The resident received IM (intramedullary) nailing (type of surgery) on 9/3/19 without complications. Patient was evaluated by physical therapy and the resident was weight bearing as tolerated. During a telephone interview on 9/11/19 at 11:08 AM, the physician stated it was the expectation that the nursing staff notify the on-call doctors about any pain that was not controlled or managed with PRN pain medication. The physician also stated that the nurse should notify the physician immediately when the X-ray results were received, so appropriate decision can be made at the right time. During a telephone interview on 9/11/19 at 3:15 PM, the X-ray company district sales manager indicated their company received orders for Resident # 2's X-ray on 9/2/19 at 12:57 PM. On 9/2/19 at 4:31 PM, the technician had completed the X-rays. On 9/2/19 at 5:40 PM the results were faxed to the facility at 2 Fax numbers indicated in their file as Station 1 and All routes. The sales manager also stated as the resident's results were positive, an email and a text alert were sent to the email id and phone number that the facility had provided and was on their file. During an interview on 9/12/19 at 1:50 PM and on 9/12/19 at 3:35 PM, DON stated that Station 1 Fax was not in working order. DON indicated, he was responsible for notifying X- ray company when a Fax number was not working. DON stated it was the expectations that the nursing staff also check the main fax in the administrative suite copy room, when any results were pending. He stated if a report was given to the Nurse that the X-ray results were pending then the receiving nurse should be on the lookout for the results. DON added if the nurse does not receive the results, then he should be notified. The DON indicated it was the expectation that the staff notify the physician when pain was not managed by PRN medication. A pain scale should be included to verify the effectiveness of pain and a follow up pain evaluation should be completed. The DON stated Resident #2 was severely cognitively impaired and it was hard to assess the resident's pain. The DON further stated staff should be using a pain scale when the pain medication was documented as ineffective. The DON indicated he had not observed the resident 9/2/19 and was not notified about the pain. Upon follow up around 3- 4 PM on 9/2/19 he was notified by the Unit Manager (Nurse #1) that the X-rays were completed, and results were pending. On 9/3/19 between 9 AM and 10 AM, Unit Manager (Nurse #1) had notified him of the X-rays results, which indicated the resident had a fracture and that the on-call physician was notified about the X-ray results. During an interview on 9/11/19 at 5:30 PM and a telephone interview on 9/13/19 at 10: 30 AM, the Administrator stated the physician was notified about the bruises and X-ray was ordered. Resident #2 had a history of [REDACTED]. The Administrator indicated on 9/3/19, staff observed the resident in his wheelchair, able to wheel himself to the nurse's station and was not observed to be in any pain. He indicated the pain assessment on 9/1/19, 9/2/19 and 9/3/19 indicated a pain score of zero (0). He stated the resident did not have any pain based on the pain scale. The administrator further stated there was only one progress note that stated the pain medication was ineffective. The administrator indicated that the facility did not receive any phone calls from the X-ray company for any alerts indicated on the report. He added an alert was emailed to the DON, however the DON did not receive the alert or the reports as his email was spelled incorrectly. During a telephone interview on 9/16/19 at 12:26 PM, the EMS Transporter stated when the EMS transporters entered Resident #2 's room on 9/3/19 at around 13:02 PM, the resident was observed lying on the floor on a mattress with no sheets on it. EMS transporters attempted to get the resident up, but he had no abdominal strength to stand up. The EMS transporters stated they did not want to pull the resident up by his arms, so they used a sheet to pull him to the stretcher. Resident did not show any pain during the process. Resident was then pulled from the stretcher to the hospital bed using a sheet. An interview with the Radiology medical director via phone was conducted on 9/27/19 at 11:52 AM. The medical director indicated it was hard to predict the exact date of the fracture. He further indicted it could be recent, possibly the date of exam or the day when the resident had a fall and had pain. He stated based on the radiology report there was no specific reason how the fracture could have occurred. But this kind of fracture was generally related to a fall.

Based on record review, observations, and staff interviews, the facility failed to provide supervision to prevent a cognitively impaired resident from exiting the facility for 1 of 3 residents (Resident #1) reviewed for supervision. Resident #1 exited the facility and was found approximately 24 feet away from the door in 45 degree Fahrenheit weather. Findings included: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident #1's most recent Minimum Data Set (MDS), coded as a quarterly assessment and dated 11/21/18, revealed the resident was cognitively impaired. Active [DIAGNOSES REDACTED]. The MDS coded Resident #1 under the behavior section as wandering daily. A review of Resident #1's care plan dated 8/26/18 revealed the resident had a care plan for wandering. The care plan reported the resident had a wander guard in place and the staff would monitor the wander guard daily for the resident's safety. Interventions included that Resident #1 would not leave the facility unattended, the staff would offer activities and distractions when exit seeking, and the staff would check the wander guard placement and function as ordered. A review of Resident #1's MAR (Medication Administration Record) for (MONTH) (YEAR) revealed an order that read 'prior to checking placement of wander guard make sure red light is coming on the brown watch box. If the red light isn't coming on, the box isn't working properly and notify the administrator immediately.' It was documented on all three shifts on the (MONTH) (YEAR) MAR that the wander guard was working. The nurse that documented on the MAR on 12/3/18 was not available for interview. A review of the nighttime temperature per AccuWeather for 12/3/18 revealed the temperature was 45 degrees Fahrenheit between 8pm and 10pm. A review of the facility incident report dated 12/3/18 at 10:10pm involving Resident #1 revealed a NA (Nursing Assistant) observed the resident exiting the building to the parking lot and immediately escorted the resident back inside. According to the incident report, there were no injuries noted. A review of Resident #1's medical record revealed a nursing note dated 12/4/18 at 12:20pm which read NP (Nurse Practitioner) (was) called about resident leaving the unit. She wants the exits (doors) monitored closely. Staff will pass this on to am nurse. Currently resident is still up in his w/c (wheelchair) rolling around the unit. Staff will continue to monitor resident closely for safety. A review of Resident #1's medical record revealed a wandering assessment dated [DATE] that indicated the resident was at high risk for wandering. This wandering assessment was the only one noted in the medical record. An interview was conducted on 12/7/18 at 3:44pm with NA #1. She reported Resident #1 was usually docile but did get anxious at times. She reported when he got anxious, she would redirect him. She reported Resident #1 had never attempted to exit building while she was caring for him. NA #1 stated Resident #1's wander guard was in place on his right ankle whenever she cared for him but she stated she was not working on 12/3/18. An interview was conducted on 12/7/18 at 3:55pm with Nurse #1. She reported Resident #1 wandered the halls of the locked unit all second shift every day. She reported the resident never attempted to leave the building when she was working but would state I want to get out of here. Nurse #1 reported Resident #1 had on wander guard and she checked it on shift to make sure it was working. She reported that she took the wander guard box and put it up to the resident's wander guard. She reported a green light would then come on and that meant it was working. She reported if the green light didn't come on she reported it to her supervisor. She reported she did not have Resident #1 on the night of 12/3/18. An interview was conducted with the administrator on 12/7/18 at 4:25pm. He reported that staff texted him around 10:10pm on 12/3/18 to report Resident #1 had eloped but was back in the building. He reported the staff performed a safety check on all the windows and doors and saw the emergency release box plexiglass was broken and the switch turned off at the door leading to the outside near the front parking lot from the locked unit. He reported the staff made frequent checks on the residents and doors throughout the night. He reported the door was referred to as the bird door due to a painting of a bird on it. The administrator reported the maintenance supervisor came in the facility around 6:00 am on 12/4/18 and repaired the emergency box and added another, louder alarm to the outside door. The administrator reported that the former DON (Director of Nursing) informed him on 12/4/18 that Resident #1 did not have on his wander guard because the facility was attempting to wean him off it. He reported he did not know when the wander guard weaning was initiated. He reported there was no documentation of the resident without the wander guard. An interview was conducted on 12/7/18 at 5:00pm with Nurse #2. She reported she worked 3pm - 11pm on the locked unit on 12/3/18. She reported she normally worked the 200 hall but due to renovations, she and the residents had been moved to the locked unit. Nurse #2 stated she did not have Resident #1 to care for on 12/3/18. She reported that prior to Resident #1 leaving the building, she noticed him going to all the doors and shaking them. She reported at one point, she noticed Resident #1 was sitting in a chair by the outside bird door pushing buttons on the keypad. Nurse #2 reported she mentioned it to one of the aides who normally worked on the locked unit but does not remember which one. She reported the aide told her that Resident #1 did that all the time but would get tired of it and move on to something else. She reported it was probably between 8:00pm and 9:00pm on 12/3/18 that NA #2 came through the main door on the unit (the interior door going into the rest of the facility) with Resident #1. Nurse #2 reported that the NA told the staff he saw the resident come through the outside door but didn't know who it was until he walked up to Resident #1 in the parking lot. A telephone interview was conducted on 12/8/18 at 10:00am with NA #3. She reported she was the NA who cared for Resident #1 on 12/3/18 from 7:00am until 11:00pm. NA #3 reported she did her rounds after supper on 12/3/18 but unsure of time. She reported she cleaned up Resident #1 as he had come out of his room carrying a brief. She reported she applied a clean brief, pajama bottoms and a long sleeve grey t-shirt. She reported Resident #1 then laid down in the bed and she went to the next room to take care of her next resident. She reported she did not remember seeing a wander guard on Resident #1 when she put him to bed. NA #3 reported she thought that the resident normally had a wander guard because she remembered hearing it go off when he got near a door. She reported when she came out of the next resident's room, another NA was bringing Resident #1 back in from outside. She reported he was still in his pajama bottoms, long sleeve shirt and was wearing brown slippers. NA #3 reported she was told the resident went outside because the side door was unlocked. She reported it was only 10-15 minutes from the time she left Resident #1 in bed and finished up the next resident. An interview was conducted on 12/8/18 at 11:30am with Nurse #3 and Medication aide #1. Both reported they only work as needed and neither worked on 12/3/18. They both stated that when they worked, Resident #1 always had on his wander guard. A telephone interview was conducted on 12/8/18 at 12:20pm with NA #2. He reported that on the evening on 12/3/18, he was outside at the building where smoking was allowed for the staff. This building was located across the street from the facility and was approximately 142 feet from the facility door Resident #1 eloped from. NA #2 reported he was standing outside of the building and had a direct view of the facility door near the front parking lot. He reported he saw the door open and knew no one should be coming out of that door so he ran back across the street. He reported Resident #1 was standing outside next to the door and the door had just shut. NA #2 reported he then escorted Resident #1 back into the facility through the front door. He took the resident back to the locked unit and left him with the staff there. He reported he wasn't sure what time the incident occurred, but it was before 11:00pm. The front door and the door from inside the facility to the locked unit did not have a wander guard system. A telephone interview was conducted on 12/8/18 at 12:25pm with Nurse #4 who was the former DON (Director of Nursing). She reported she was called by Nurse #5 on 12/3/18 sometime after 9:00pm. She reported the nurse called to inform her that Resident #1 had walked out of the bird door - the door going to the outside front parking lot from the locked unit. Nurse #4 reported she spoke to the nurse that did the incident report and was told one of the NAs was out in the parking lot and saw the resident in the parking lot and brought him back in. Nurse #4 reported Resident #1 was supposed to be wearing a wander guard but during the stand-up meeting on 12/4/18, someone reported he needed one. She reported the staff told her the batteries were almost dead in the alarm on the bird door and no one could hear the alarm sound. Nurse #4 reported she was told maintenance was going to replace the alarm on the bird door on 12/4/18. She reported she did not interview the NA that found Resident #1 as the Administrator was going to talk to him. She reported she had no knowledge that Resident #1 was being weaned off the wander guard. An interview was conducted with the Maintenance Supervisor on 12/8/18 at 12:40pm. He reported he was told on 12/4/18 that the alarm on the bird door - the door going outside to the front parking lot from the locked unit - was difficult to hear. He reported he replaced the alarm with a louder alarm on 12/4/18. He reported he checked the doors and alarms monthly and all were functioning correctly in November. He reported he was told about the plexiglass being broken on 12/4/18 around 6:00am and repaired the plexiglass around 6:40am on 12/4/18. Numerous unsuccessful attempts were made to contact Nurse #5 who cared for Resident #1 on the evening of 12/3/18 and filed the incident report. An observation was made of Resident #1 on 12/7/18 at 3:44pm. The resident was ambulating in the hall near the nurses area. It was observed that Resident #1 went to the locked door leading to the main facility and tried to open the door. The staff redirected him to the dining area where there was a craft being done. It was noted Resident #1 had a wander guard on right ankle. An observation was made on 12/8/18 at 10:30am with the maintenance supervisor of the distance from the outside door where Resident #1 went out to the parking lot. It measured 22 feet. The distance from the outside door to the road on that side of the building was 67 feet. The measurement from the outside door to the road in front of the facility was 123 feet. The smoking building was located on the other side of the side road and was measured at 75 feet from the building to the parking lot. It was observed sitting on the bench inside the building on the right side or standing outside the building gave a direct view of the outside door. An observation was made on 12/8/18 at 11:15am of the outside doors on the locked unit with the maintenance supervisor. He demonstrated when the emergency switch was turned off the outside door was able to be opened but the alarm went off. If the emergency switch was on, the door would not budge. The emergency alarm was a switch which was enclosed by a red metal box with plexiglass window on the front. The only way to disable the alarm was to break the plexiglass and flip the switch to the off position. The maintenance supervisor demonstrated that a wander guard alarms loudly 6 feet from all outside exit doors and the kitchen door. It was noted the replaced alarm at the outside door that Resident #1 went out was much louder than the other outside door alarms but all could be heard throughout the locked unit. On 12/8/18 at 1:00pm the observation was made through demonstration with the Administrator, DON, and the surveyors that it would take approximately 14 seconds to run from the smoking building to the parking lot. The facility implemented the following corrective action: Resident #1 was admitted to the facility on [DATE]. His current BIMS (Brief Interview for Mental Status) score is 6 as of 11/21/18. The most recent wandering assessment was completed on 12/12/17. At 9:45PM on 12/3/18, Resident #1 exited the building via unit 1 and was immediately spotted by a male CNA (nursing assistant) who was smoking across the street. According to his statement, the male CNA first saw the light from the opening door, then saw the resident, and ran across the street, and assisted the resident back to the secure unit. Resident #1 had been placed in bed approximately ten minutes prior to being brought back to the secure unit. Upon Resident #1's return, Nurse K checked all exit doors and found that alarms were functioning, though the alarm on the bird door was not very loud. This alarm is a magnetic alarm intended for back-up purposes and is not the primary safety feature as the door is equipped with the emergency switch and wander guard. Nurse K noted that the switch cover on the emergency switch was now broken which allowed access to the switch that releases the lock on the side door. The door emergency switch is housed in a plexi glass paneled box designed to be pushed in/broken in an emergency allowing for the switch to be manipulated releasing the door. When intact, the switch remains engaged and the door cannot be opened. As part of the facility's response the secondary alarm on that door was replaced with a much louder alarm to support the backup alarm function. The alarm was replaced on 12/4/18 by the Maintenance Director. Earlier in the evening, the 3-11 nurse had checked the position and function of Resident #1's wanderguard bracelet and it was intact per the medication administration record dated 12/3/18. However, when he returned, Resident #1 did not have his wander guard on. Although it was not found, Resident #1 appears to have removed his wanderguard by sliding it down his arm as Nurse S states he has done in the past. All Wander guard bracelets are checked daily by nurses using the wand to assure they are properly placed on residents and functioning. Additionally, wander guard doors and all door alarms had been checked weekly and the side door was working on 11/30/18 by the Maintenance Director. Doors are now verified as working and documented as such on a daily basis effective 12/4/18. Nurse J immediately completed a head to toe assessment on Resident #1, with no injury noted. An updated wandering assessment was completed by the DON (the Director of Nursing), on 12/4/18. The care plan for Resident #1 was reviewed and updated by the DON, on 12/4/18 to include reviewing the current interventions and the use of a wander guard. Nurse J, Nurse T and Nurse K initiated increased supervision for Resident #1 to include constant knowledge of whereabouts through hall monitoring as well as every 15 min checks to document his location per the Administrator's instruction on 12/3/18. These checks were completed by the CNAs, nurses and documented on a log for 72 hours following the incident. Post event at approximately 9:55pm on 12/3/18, a head count of all residents on the secure unit was conducted by Nurse J, and Nurse T. All residents were present and accounted for. Nurse T notified Resident #1's responsible party, FNP (family nurse practitioner), on 12/3/18 at 10:00pm regarding Resident #1 exiting the facility, physical assessment following the event and plan for increased monitoring. No new physician orders [REDACTED]. On 12/4/18 at 6:40am, the Administrator completed an additional head to toe assessment finding no signs of injury. The Administrator also noted that resident had no recollection of the events of the previous evening and exhibited no signs of distress. It was determined on 12/4/2018 during an Interdisciplinary team meeting and Quality Improvement Process improvement impromptu meeting (DON, Assistant Director of Nursing, Staff Development Coordinator, the MDS nurse, the Maintenance Director and the Administrator) that Resident #1 was able to open the exit door on the short hall of the secure unit. The exit door was checked, and the alarm was working but the emergency release switch for that exit door had been broken and was uncovered. All exit doors were checked and secured immediately. All exit doors on secure unit were checked hourly until 8:00am on 12/4/18. On 12/4/18 the Maintenance Director checked all doors and alarms, replaced the secure panel for release switch for exit door on short hall of secure unit. During the above QAPI meeting, the process and policy were also reviewed and updated. A review identifying residents that have exit-seeking-behaviors (Gates Wandering Assessment) was initiated for the entire facility was completed by the DON, ADON, and Supervisors on 12/4/18 to ensure they have a wandering risk assessment and care plan is reflective of interventions. Exit seeking Risk books containing face sheets with photographs of each resident who was at risk, were updated by the DON, ADON and Supervisors on 12/4/18 and placed on each unit. The Gates scale breaks risk in to low (0-4), moderate (5-10) and high risk (11 and up). Each resident was then reviewed on 12/4/18 by the nursing management team (DON, ADON, Night Supervisor and Administrator) to discuss the triggers that caused the score to be high or low and each was then assigned a validated score. For residents who were at high risk, wander guards were placed by the DON and Social Worker on 12/4/18. For those at moderate risk, wander guards were placed by the Social Worker and DON on 12/4/18 if the risk suggested the resident had the motivation and the ability to wander, and those who were at low risk did not receive new wandering-related interventions. The DON will review residents at moderate and high risk for elopement weekly for 12 weeks to ensure interventions remain in place and are effective. Residents exhibiting new behaviors of wandering or exit seeking will be reviewed by the Interdisciplinary Team (DON, ADON, Nursing Supervisor, Social Worker, Administrator) to ensure the Gates Wandering Assessment is accurate and interventions are in place. In addition, the risk team (DON, ADON, House Supervisor, Social Worker, MDS Nurse, CNA) will ask the direct care staff and then discuss during weekly risk meetings, beginning with the risk team meeting on 12/4/18, and weekly thereafter, about new potential wandering behaviors including exit seeking, requests to go home or to other locations, increased agitation or restlessness, and similar behaviors. For those identified through this process, new Gates Wandering Assessments will be completed and recorded. In addition direct care staff has been in-serviced on 12/4/18 to alert a nurse supervisor anytime they observe behavior that suggests an increased potential for wandering with instruction to stay with the resident until the nursing supervisor can implement immediate interventions as well as to notify the DON/ADON to complete a new Gates Wandering Assessment, and if appropriate, add the resident to the At Risk for Wandering book and update the care plan. Any residents the team may consider trialing for reduction of level of intervention, including removing the wander guard bracelet, will have their plan of care adjusted to reflect close supervision for brief but potentially extending periods, and monitoring for signs of increased wandering behavior risks. At this time, Resident #1 is not a candidate for reduced interventions. On 12/4/18 the Maintenance Director, re-checked all exit doors on the secure unit and documented on the exit door check log. Current staff from all departments, including contract housekeeping and laundry staff, were re-educated on 12/4/18 by staff development coordinator. Education includes the facility policy on elopements and wandering/unsafe residents. It also included recognition of exit seeking behaviors in residents and what intervention strategies could be put into place along with the supervision required. Re-education was conducted by the regional nurse consultant with the maintenance staff on 12/4/18 regarding expectations for frequency in monitoring of exit doors and alarms. Exit doors are checked daily by maintenance or nursing staff to ensure they are functioning properly and a tool was created for this to be logged effective 12/4/18. The administrator will check all exit doors weekly for 12 weeks to ensure the doors and wanderguard and secondary alarms are functioning properly. Results of door checks, wanderguard checks, wandering assessments and At Risk for Wandering books will be presented to QAPI on a monthly basis for 6 months then quarterly for 1 year to assure sustained compliance. The credible allegation was verified on 12/11/18 at 4:00pm as evidenced by staff interviews. Staff education was initiated on 12/4/18 regarding resident who have been identified to be at risk for wandering or may start to display behaviors which would place the resident at risk for wandering. All staff interviewed (nursing and non-nursing staff, administrative staff) stated they were to respond to exit door alarms by immediately going to the door which triggered the alarm and investigate to see if a resident had exited or attempted to exit which would have triggered the alarm. Verification of education for staff regarding wandering residents was completed on 12/11/18.

Based on record review, staff interviews, resident interview, family interview and review of the facility's video footage the facility failed to protect 2 of 3 residents (Resident #1 and Resident #2) from staff physical abuse. This resulted in Resident #1 being hit and pushed into a glass door by an employee. In addition, Resident #2 was hit in the head with a cookie which was thrown at him by an employee. Immediate Jeopardy began on 10-13-18 when Resident #1 was in the dining room and Nursing Assistant (NA) #1 hit the resident in the face then pushed him into a glass door. No physical injuries were assessed. Immediate Jeopardy was removed on 11-3-18 when the facility provided and implemented acceptable creditable allegation of Immediate Jeopardy removal. The facility remains out of compliance at a lower scope and severity of D (no harm with the potential for more than minimal harm that is not Immediate Jeopardy) to ensure monitoring systems put in place are effective. Example #2 (Resident #2) was cited at a scope and severity of a D where a plan of correction is required. Findings included: 1. Resident #1 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. The quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #1 was severely cognitively impaired and rejected care 1 to 3 days a week. Resident #1 was also coded as needing supervision with one person for bed mobility, transfers and locomotion, extensive assistance with one person for dressing, toileting and personal hygiene and supervision with set up help for eating. He was also coded as being on Hospice Care. Resident #1's care plan dated 9-11-18 revealed a goal that he would demonstrate effective coping skills and verbalize understanding for the need to control physically aggressive behavior. The interventions for that goal were as followed; administer medication as ordered, approach resident with question instead of a demand, provide physical and verbal cues to alleviate anxiety, give positive feedback, staff to approach resident in a calm manner, staff will allow resident down time in the evenings to help resident cope with sundowners. A review of the incident report dated 10-13-18 at 6:01pm with a revision date of 10-17-18 at 1:08pm revealed that during dinner Resident #1 was trying to eat another resident's dinner and when she tried to redirect resident he swung at her. The NA stated she put her arm up to deflect the resident from hitting her in the face and the resident fell back into the glass door. Another NA who was in the room and saw the altercation stated that the NA involved pushed the resident. The NA involved was sent home and it will be investigated. Resident unable to give description. The report also revealed there were no injuries to Resident #1 and the Director of Nursing (DON) was notified as well as the resident's family member. An observation and interview with Resident #1 occurred on 10-31-18 at 5:27pm. The resident was noted to be sitting at a table with 3 other male residents eating his supper quietly with no agitation noted. Resident #1 was unable to recall the physical altercation with the NA but stated he did remember the NA being rude and verbally abusive. He was unable to remember what the NA said to him but stated I know it wasn't very nice. A review of the facility's video footage from 10-13-18 occurred on 10-31-18 at 6:10pm. The video was reviewed by the surveyor, Administrator and the DON at that time. The video footage revealed Resident #1 leaning over a table in the dining room and beginning to lift the lid off one of the dinner plates when NA #1 came over and removed the tray from Resident #1. NA #1 was seen putting the tray on another table and returning to Resident #1 who was still standing at the table and engaging in a conversation. Resident #1 was seen turning towards NA #1 with his arm raised and NA #1 hitting the resident in his face and then pushing him into a glass door. The video also revealed a witness, NA #2 who caught Resident #1 from falling to the floor and NA #1 walking away from the situation. During an interview with NA #2 on 10-31-18 at 6:23pm she stated she had walked into the dining room and witnessed NA #1 and the resident discussing something and Resident #1 became angry and went to hit NA #1. She stated the resident's finger tips brushed NA #1's face and NA #1 grabbed the residents arm and pushed him into the glass door. NA #2 denied seeing NA #1 hit the resident. She also stated Resident #1 had been agitated that evening but had not been aggressive towards anyone till the altercation. NA #1 was interviewed on 10-31-18 at 6:45pm. She stated she was trying to keep Resident #1 from eating food off of another resident's tray and the resident threatened to hit her and then swung at her but NA #1 denied Resident #1 ever made contact with her. She also stated when Resident #1 swung at her she grabbed his arm to stop him but denied ever pushing him or hitting him. NA #1 stated the resident had been agitated all evening but that she was able to redirect him with food and activities. She denied having contact with the resident after the altercation. A review of NA #1's training record revealed she received abuse training on 6-28-18. An interview was conducted on 10-31-18 at 7:31pm with nurse #3 who stated she was informed of the altercation by NA #2 around 6:00pm and she immediately went and assessed Resident #1 for any injuries. She denied seeing any marks or bruises on the resident, so she then called the DON who told nurse #3 to send NA #1 home immediately until an investigation could be done. Nurse #3 stated she removed NA #1 from another resident's room where she was providing care with another NA and informed her she would need to leave the building. The nurse denied NA #1 had any further contact with Resident #1 and denied any conversation with the DON about calling law enforcement. During an interview with Resident #1's family member on 11-1-18 at 8:19am he stated he was informed of an incident where my father was trying to eat food off another tray and the nurse confronted him and he swung at the nurse and when she put her arm up to protect herself my father pushed her arm into her face bruising it. The family member denied being told of Resident #1 being hit or pushed into a glass door. An interview with NA #4 occurred on 11-1-18 at 8:52am who stated she could not help the surveyor because she did not know anything. NA #4 stated she did not work on hall 100 and if she was in the dining room it was because she was waiting on trays for the hall she was working. During an interview with the DON on 11-1-18 at 9:05am she stated she was contacted by nurse #3 around 6:00pm on 10-13-18 about the incident between NA #1 and Resident #1. The DON stated Nurse #3 told her NA #1 pushed Resident #1 into the glass door and that she informed Nurse #3 to have NA #1 punch out and go home till an investigation can be completed. She also stated she told the nurse to assess the resident for injuries and notify the resident's power of attorney. The DON stated she then called the Administrator and informed her of the incident and that they did discuss calling law enforcement but since the NA had left the building they did not think it was necessary. An interview with the Administrator occurred on 11-1-18 at 9:32am. The Administrator stated she was informed of the incident by the DON on 10-13-18 and that they discussed calling law enforcement but felt since the NA left the building there was not a need to call them. She stated she came to the facility the next day and reviewed the video sometime before 2:00pm. During an interview with the Corporate Compliance Officer on 11-2-18 at 8:50am she stated the facility had been using the wrong Abuse Policy. She stated there was an updated policy distributed at the end of (MONTH) (YEAR) explaining the federal requirements for reporting abuse and did not know why the Administrator had not in serviced staff on the correct policy. The Compliance Officer stated the process when there was an incident was that the DON or the Administrator would call the regional or corporate compliance office and email risk management who would respond within 30 minutes of the email and guide the DON or Administrator through the process of filing a report with the state. The Administrator and the Corporate Compliance Officer were notified of the immediate jeopardy on 11-1-18 at 5:25pm. On 11-2-18 at 3:50pm the facility provided the following credible allegation of Immediate Jeopardy removal: 1. On 10-13-2018 at approximately 6:00pm NA #2 walked into the dining hall on Unit 1 and saw Resident #1 slap NA #1 in the face. NA #1 then grabbed at Resident #1's hand (wrist) and pushed him away into the door possibly making contact with his face at the same time. NA #2 states that she caught Resident #1 to keep him from falling, then told NA #1 you can't do that and redirected NA #1 away from the resident and assuring another NA was present between them. NA #2 then went to get the assistance of the nurse. Nurse #1 came to the dining room, noting NA #1 was no longer in the room. Nurse #1 then assessed Resident #1 who was uninjured and did not appear to be in distress or upset. Nurse #1 then called the DON who instructed her to assess and observe the resident, immediately suspend the NA forcing her to leave the facility, contact the family and contact the physician. Nurse #1 then suspended NA #1 pending an investigation. The DON then contacted the Administrator reaching her about 6:15pm. According to Nurse #1, Resident #1 continued to walk through the unit without apparent effect, uninjured and seemingly unaffected. The Administrator arrived at the facility on 10-14-18 at approximately 12:00 noon, viewed the video footage, interviewed NA #2 and determined that the event had occurred as reported. The 24-hour report was submitted by facsimile at 2:19pm on 10-14-18. Along with the DON, Administrator contacted NA #1 and terminated her on 10-15-18 at approximately 2:00pm. 2. The facility is responsible for providing all residents with a consistently safe and nurturing environment. In servicing on the Abuse Prevention Program and the Abuse and Neglect: Clinical Protocol began on 10-16-18 with all of Unit 1 nursing staff who were present, then continued with all available nursing staff in the building on days and afternoons through 10-19-18. The staff development coordinator met with night shift staff early in the morning and addressed staff who had been unavailable on a face to face basis by telephone. In servicing resumed on 10-22-18 and has continued and expanded to all individuals who have contact with residents from every department and will include volunteers and contract staff. Employee, volunteer and contract staff lists are being used to validate attendance and in servicing will continue until all are checked off with this process completed no later than 11-2-18. In addition, on 11-2-18 all interview able residents are being interviewed by the Social Worker or her designee using the critical element pathway resident interview for abuse as a guide to determine this was an isolated incident. In accordance with CMS non-interview able abuse critical pathway, staff interviews regarding non-interview able residents will focus on changes in demeanor or mood to be completed on 11-2-18. Data from these interviews will be reviewed by the Regional Director of Clinical Services. On 11-2-18 all data collected through these interviews will be provided to QAPI for review by the committee and evaluation of opportunities to improve care during the upcoming (MONTH) meeting. 3. All staff receives the Abuse policy training at the time of orientation. Effective immediately, all staff will be in serviced on a monthly basis for the next 6 months then quarterly for one year to ensure staff has internalized the standards of care to which residents are entitled. All staff retraining began on 11-1-2018 and will continue through 11-2-18 with no staff being permitted to work with residents until they have completed training. Training includes the definitions of/understanding abuse, neglect, misappropriation, exploitation; the required response to any observed or reported occurrences focused on assuring the safety of any and all involved residents and providing medical and psychological intervention to residents involved and importantly, the importance of a hands-off response to any resident situation. In addition, the staff on the low stimulation unit will receive Hand in Hand training on dementia and managing difficult behavior, beginning on 11-2-18 which will become part of orientation for staff working on that unit assignment as well as having a module shown each month to reinforce training throughout the year. Modules one through six will be presented to current unit staff over the next week. The Social Worker was in serviced on 11-2-18 by the Vice President of Clinical Services to provide support to staff who are caring for residents and encouraging them to express and debrief regarding their challenges and to strategize solutions for managing difficult situations along with the staff person beginning on 11-2-18. While debriefing sessions will remain individually confidential, Social Worker will collect statistics about the number and kind of sessions held and bring these to QAPI to evaluate opportunities to improve care and communication beginning with the (MONTH) QAPI session. This will include any incidences of verbal or physical contact between residents, staff and residents or other situations for the purpose of recognizing situations that suggest risk and require intervention as well as results from trainings and debriefing will be submitted to QAPI for review on a monthly basis for 6 months then quarterly for an additional 6 months. The QAPI team will establish this plan during an ad-hoc QAPI meeting held on 11-2-18. Beginning with the (MONTH) (YEAR) meeting. At that time, the QAPI team will review all data and findings and determine the frequency of reporting for the upcoming year. The first session is being held on 11-2-18. 4. The Regional Director of Clinical Services is responsible for assuring compliance with this plan of corrective action, which will be fully implemented beginning on 11-3-2018. The credible allegation for Immediate Jeopardy removal was validated on 11-5-18 at 10:55am which removed the Immediate Jeopardy on 11-3-18 as evidenced by staff interviews, in service record reviews and observations. The in service included information on the definition of abuse, who needed to be notified, keeping the resident safe and making sure the incident is reported to the state within 2 hours. 2. Resident #2 was initially admitted to the facility on [DATE] and then readmitted on [DATE] with multiple [DIAGNOSES REDACTED]. The 30-day Minimum Data Set ((MDS) dated [DATE] revealed Resident #2 was moderately cognitively impaired and had physical behaviors towards others 1-3 days and verbal behaviors towards others 1-3 days. He was coded as needing extensive assistance with 2 people for bed mobility and transfers, total assistance with 2 people for dressing, extensive assistance with one person for eating, toileting and personal hygiene. Resident #2's care plan dated 9-24-18 revealed a goal that he would have fewer episodes of problem behaviors. The interventions for that goal were as followed; offer snacks such as yogurt, applesauce and pudding, offer food before and after care, psych referral as needed, review medications, A review of the incident report dated 10-10-18 with a revision date of 11-1-18 at 1:36pm revealed nursing assistant (NA) #5 was assisting NA #2 with providing activities of daily living (ADL) care to Resident #2. NA #2 gave the resident a cookie while he was facing her and handed NA #5 a cookie when they turned the resident towards NA #5 and when they turned the resident, the resident swung at NA #5 and in response NA #5 hit the resident in the head with the cookie. No injuries were reported. An interview with NA #2 occurred on 11-1-18 at 1:12pm. During the interview NA #2 stated she was providing ADL care to Resident #2 with NA #5 and while the resident was facing her she had handed him a cookie to eat and that the resident was calm and cooperative but when NA #2 and NA #5 turned the resident towards NA #5 the resident swung at NA #5 and NA #1 then threw a cookie at Resident #2 hitting him in the head and left the room. NA #2 denied Resident #2 ever made physical contact with NA #5. The NA stated nurse #4 came into the room to assist in completing Resident #2's ADL care and NA #2 informed the nurse of the incident when they were finished with the resident's care. During an interview with nurse #4 on 11-1-18 at 4:05pm she stated on 10-10-18 she had come out of another residents room and had heard NA #5 say nobody's gonna beat on me but did not know what the NA was talking about and when nurse #4 was walking to her medication cart she saw NA #2 in Resident #2's room performing ADL care by herself so she went in to help. She stated once the care was completed, NA #2 told her that NA #5 had thrown a cookie and hit the resident in the head and when she assessed the resident he stated, NA #5 had hit him in the face with a cookie. NA #5 was interviewed on 11-1-18 at 4:35pm. NA #5 stated on 10-10-18 while she and another NA were providing ADL care to Resident #2, they had turned him towards her and he balled up his fist and hit her in the right breast. She also stated she put her arm up to protect herself from getting hit again and when she did the cookie flew out of her hand and landed on the resident's neck. NA #5 stated she left the room and was trying to find help for NA #2 but could not find anyone. During the interview NA #5 stated he can be violent. I didn't sign up for all this. I just signed up to work the rehab. During an interview with nurse #3 on 11-1-18 at 11:30am she stated Resident #2 could be combative and that he had dementia. The nurse stated she would offer the resident food or milkshakes to help decrease his agitation, so staff could provide care and if that did not work staff would leave and return later. She also stated most of the time Resident #2 is sweet and friendly. Nurse #3 denied that Resident #2 ever tried to hit her. A review of the investigation revealed in part at approximately 10:00pm on 10-10-18 a call was received to the Administrator that there had been an incident on the hall. NA #5 and NA #2 were both in Resident #2's room to provide care. Resident #2 had swung at NA #5 while providing care and as a response NA #5 had thrown a cookie at the resident due to her frustration. Immediately NA #5 was asked to leave the unit and go home pending an investigation. During the investigation NA #5 was interviewed and stated she had flung' the cookie at the resident but did not realize that it had hit him in the head. The resident was assessed for any signs of pain or discomfort by the nurse and care was completed by the nurse and NA #2. The resident was unhappy about the situation but was able to calm down. He did not show any [MEDICATION NAME] mental anguish due to this situation. NA #5 is no longer an employee for the facility. An interview with the Administrator was conducted on 11-5-18 at 12:11pm. The Administrator stated she felt the new abuse policy was clearer and that she expected her staff to be trained sufficiently and follow the new policy. The Administrator also stated NA #5 was suspended immediately on 10-10-18 and subsequently terminated after the investigation was completed.

Based on observations, staff interviews, and record reviews, the facility failed to follow the van lift manufacturer ' s recommendations for lowering a resident who is wheel chair bound to the ground with the Transportation Aide on the ground and the resident ' s wheel chair in the correct position with the wheel chair brakes locked for 1 of 4 sampled residents (Resident #1) reviewed for accidents. While being assisted to exit the facility ' s transport van, Resident #1 fell backwards in the wheel chair onto the platform of the van ' s lift. Resident #1 was immediately transported to the hospital where she was diagnosed with [REDACTED].#2) reviewed for accidents. Immediate jeopardy began on 10/1/18 when Resident #1 fell backwards in her wheel chair while staff assisted her to exit the facility ' s transport van using the van ' s lift and she hit her head on the lift ' s platform. Immediate jeopardy was removed on 10/5/18 when the facility implemented a credible allegation of Immediate Jeopardy removal. The facility remains out of compliance at a lower scope and severity of D (no actual harm with the potential for more than minimal harm that is not immediate jeopardy) for finding #2 and for the facility to complete staff training and monitor its corrective action to ensure appropriate interventions are put into place to safely transport residents. Findings included: A review of the manufacturer ' s van lift manual included the following statements (page 23): The attendant must always be certain the wheelchair passenger or standee is properly positioned on the platform (fully inside yellow boundaries) and the wheelchair brakes are locked when a passenger is on the lift platform. The lift passenger must keep hands, arms and all other body parts within the lift occupant area and clear of all moving parts. Page 23 of the lift manual also included the following statement: The passenger must be positioned in the center of the platform to prevent side-to-side load imbalance. The lift attendant (operator) should not ride on the platform with the passenger. Page 24 of the lift manual included a black boxed Warning which read: Whenever a passenger is on the platform, the: · Passenger must be positioned fully inside yellow boundaries · Wheelchair brakes must be locked · Inner roll stop and outer barrier must be UP Failure to follow these rules may result in serious bodily injury and/or property damage. 1. Resident #1 was admitted to the facility on [DATE] from another nursing home or swing bed. Her cumulative [DIAGNOSES REDACTED]. A review of Resident #1 ' s most recent quarterly Minimum Data Set ((MDS) dated [DATE] revealed the resident had intact cognitive skills for daily decision making. No behaviors nor rejection of care were reported. Section G of the MDS indicated the resident required extensive assistance for all of her Activities of Daily Living (ADLs), with the exception of being totally dependent on staff for locomotion off the unit (with physical assist of one) and requiring supervision only for eating. The resident used a wheelchair for mobility. Review of an Incident Report (last revised on 10/3/18 at 11:08 AM) detailed an incident which occurred out of the facility during transport on 10/1/18. It reported Transportation Aide #1 called the facility ' s Administrator and stated Resident #1 had fallen off of the van lift when the transportation aide tripped and fell off of the back of the van lift. The report indicated no injuries were observed at the time of the incident; no witnesses were found to the incident. Resident #1 was taken to the hospital Emergency Department (ED) immediately after the fall. A review of the Hospital Records for Resident #1 revealed she was brought to the hospital by an ambulance service and seen at the ED on 10/1/18 at 12:04 PM for triage. The initial ED notes indicated the resident presented less than one hour after having a fall her from wheelchair. At the time of the evaluation, Resident #1 complained of moderate pain in her left shoulder. The resident was diagnosed with [REDACTED]. An interview was conducted on 10/3/18 at 12:20 PM with Transportation Aide #1. Transportation Aide #1 was identified as the staff member who transported Resident #1 to the [MEDICAL TREATMENT] center on 10/1/18 and was involved in the incident when the resident fell on the lift. This transportation aide reported she began working at the facility in the spring of (YEAR) as a Nursing Assistant (NA). She reported having previous work experience transporting residents and transitioned over to working with transportation at this facility approximately two months ago. The transportation aide reported she initially began driving an older facility van belonging to the facility before a new van was put into service 6 weeks ago (on 8/17/18). Transportation Aide #1 stated she picked up this new van from a sister facility and drove it back to the facility. The transportation aide reported the only training she received on the new van was, I got the key and they showed me where the brake was. The interview conducted on 10/3/18 at 12:20 PM with Transportation Aide #1 continued as she detailed events surrounding Resident #1 ' s fall on 10/1/18. The transportation aide reported she had transported Resident #1 and Resident #2 together in the van to the [MEDICAL TREATMENT] unit around 10:30 AM on 10/1/18. She stated both of the residents were transported in wheelchairs, with Resident #1 using a bariatric wheelchair. Each wheelchair was fastened with 4 floor anchors to the floor of the van. Resident #1 rode on the left side (driver ' s side) of the van and was also secured with a safety shoulder and safety lap belt. Resident #2 rode on the right side of the van. After arriving at the [MEDICAL TREATMENT] center, Resident #2 was taken off of the van using the van lift and brought into the [MEDICAL TREATMENT] center by Transportation Aide #1. To unload Resident #1, the transportation aide unfastened the resident ' s safety shoulder and safety lap belt and released the floor anchors for the wheel chair. Transportation Aide #1 then proceeded to back the resident ' s wheelchair onto the lift while standing behind the wheelchair on the van ' s lift platform. Once on the platform, she locked the resident ' s wheelchair brakes. The transportation aide began to lower the lift as she stood on the platform behind Resident #1 ' s wheelchair. She stated the van lift stopped when the resident ' s left foot applied pressure onto the inner roll stop on the lift (a safety feature of the lift which prohibits operation of the lift when it senses weight). Transportation Aide #1 reported she then released the brakes on Resident #1 ' s wheelchair so she could pull the wheelchair back further to ensure the resident ' s foot was no longer triggering this safety sensor. As she did this so, she tripped over the back flap on the end of the lift (the outer barrier). Transportation Aide #1 reported she was able to stay on her feet as she hit the ground and continued to hang onto the resident ' s wheel chair. The transportation aide reported the wheel chair tipped backwards with the resident still seated in the chair. She stated both the resident and the wheel chair landed on the lift, kinda hanging over. After landing, Resident #1 ' s head was reported to be on the edge of the lift and she was on her back while still partially sitting in the wheel chair. The transportation aide stated an unidentified man was in the parking lot loading up people on another transport van. This man responded when she called out for help and he went into the [MEDICAL TREATMENT] center to get help for her. When asked, the resident stated she hurt at the base of her neck. Staff from the [MEDICAL TREATMENT] center called 911 for an ambulance and Transportation Aide #1 reported she called the facility to inform them of the accident. When the ambulance came, the paramedics transferred the resident to a stretcher and transported her to the hospital for evaluation and treatment. Transportation Aide #1 reported the facility ' s Administrator called and told her to wait for someone to come and bring the van back to the facility. The transportation aide reported she has not driven the facility ' s van since that time because the Administrator told her she had to be oriented before she could drive again. Transportation Aide #1 stated, That should have been done before I started driving. The transportation aide reported this morning (10/3/18) the facility initiated a transportation orientation for her with the Maintenance Director as her trainer. Among other activities that morning, the transportation aide stated she watched a video for the first time on the use of the new van lift. An interview was conducted on 10/3/18 at 1:19 PM with the Maintenance Director. During the interview, the Maintenance Director reported the facility ' s other maintenance employee (the maintenance assistant) usually provided training on the transportation of residents. However, since the maintenance assistant was off on this date, the Maintenance Director began the training for Transportation Aide #1 himself. When asked who trained him on the new van and the van lift, he stated no one had trained him on this van. However, the Maintenance Director reported the new van was basically the same as their old van except the lift was on the back of the van instead of on the side. He reported the straps (referring to the safety shoulder and safety lap belts) were the same. Upon inquiry, the Maintenance Director stated he had reviewed the details of Resident #1 ' s fall on the van lift with Transportation Aide #1. The Maintenance Director was asked if there were differences between how the lift was supposed to be used and how the transportation aide reported using it when Resident #1 fell on [DATE]. Upon this inquiry, the Maintenance Director stated the transportation aide was not supposed to be standing on the lift platform when it was being operated. He also reported that from what he understood, the resident ' s wheelchair brakes were not locked at the time of the fall. The Maintenance Director stated, That ' s an accident waiting to happen. A demonstration was conducted on 10/3/18 at 1:38 PM by Transportation Aide #1 of Resident #1 ' s fall on the transportation van lift. Resident #1 ' s bariatric wheelchair was used for the demonstration conducted by the transportation aide. Transportation Aide #1 demonstrated how she was standing on the van lift platform while she operated it and began to lower the wheelchair passenger to the ground. When the safety sensor on the inner roll stop was triggered by a foot touching this floor panel, the lift stopped (approximately 16 above ground level). Transportation Aide #1 released the brakes on the wheelchair to move the chair further back on the lift and re-enacted how she tripped on the outer barrier of the lift while holding on to the wheelchair. The wheelchair was again described as having landed on the lift with the passenger coming to rest on her back while still in the wheelchair. An interview was conducted on 10/3/18 at 1:57 PM with the facility ' s Administrator. During the interview, the Administrator reported a re-enactment of the incident was done on 10/1/18 with Transportation Aide #1 and the van was been checked over by maintenance. She reported there were with no operational issues/concerns found with the van itself. She stated, It was clearly an accident to us because she (Transportation Aide #1) tripped over backwards when trying to help the resident. The Administrator stated the facility has not used the facility ' s van since Resident #1 ' s fall occurred on 10/1/18. She reported the facility was temporarily using a transportation service to meet the residents ' transportation needs. The Administrator also stated, We are making sure before the drivers go back on the van we have an evaluation check list that we are in the process of creating. A follow-up interview was conducted on 10/3/18 at 2:27 PM with the Administrator. During the interview, the Administrator was asked how Transportation Aide #1 was trained to provide transportation for residents prior to the incident on 10/1/18. The Administrator responded by stating that every driver was trained, on manufacturer instructions. When asked what this included, the Administrator reported the written vehicle manual was in the van for review. The Administrator added that Transportation Aide #1 received two days of training when she first started driving the facility ' s van. The first day of this training involved Transportation Aide #1 observing Transportation Aide #2, and the second day involved Transportation Aide #3 observing Transportation Aide #1. The Administrator stated she utilized a basic sign off that the driver is comfortable. This sign off consisted of asking both the trainee and the person who observed her if they were comfortable before the trainee began transporting people on her own. Telephone interviews were conducted on 10/3/18 at 3:46 PM and 10/4/18 at 12:17 PM with Transportation Aide #2. During the interviews, Transportation Aide #2 stated he began working with transportation at the facility in (MONTH) (YEAR) and currently worked on an as needed (PRN) basis. When asked what training he received prior to transporting residents, he stated he did a ride along on 3 occasions with Transportation Aide #3. When asked, Transportation Aide #2 reported he was trained to stand on the ground when operating the van lift for a wheelchair resident. Multiple unsuccessful attempts were made to contact Transportation Aide #3 for a telephone interview. There was no answer and no message could be left to request a return phone call. Transportation Aide #3 was reported to be a PRN staff member, but has not worked with the new van since it was put into service at the facility on 8/17/18. A video from the manufacturer of the van lift was viewed on 10/3/18 at 5:10 PM. The video depicted wheelchair passengers being lowered from the van to the ground with the lift operator standing on the ground. The video provided instructions to position the wheelchair in the center of the lift platform (with the brakes locked) prior to lowering the lift. Follow-up telephone interviews were conducted on 10/3/18 at 6:19 PM and 10/4/18 at 4:40 PM with Transportation Aide #1. During the interviews, the transportation aide was asked to detail the transportation training (specifically related to the ride-alongs) provided at the facility. Transportation Aide #1 stated she rode with Transportation Aide #3 on one trip in the old van (approximately 15 minutes long). Two or three days later, she reported going on one ride along (one trip only) with Transportation Aide #2 for approximately 15-30 minutes. She reported she drove the old van back to the facility on that day but had no hands on training with the residents. From that point on, Transportation Aide #1 stated she transported residents on her own. When the transportation aide was asked if she was observed to load and/or unload a resident from the transport van prior to assuming the transportation responsibilities, she stated she was not. When asked if she signed any paperwork related to training upon starting the transport position, she stated she did not. The transportation aide reported she did not have a transportation check off training sheet until today (10/3/18). An interview was conducted on 10/4/18 at 9:42 AM with the Vice President (VP) of Clinical Operations. The VP reported Transportation Aide #1 had extensive training on transportation in a previous job. However, when asked if the facility should have verified the transportation aide ' s competency prior to her transporting residents, the VP stated, Absolutely .and she should have done a return demo (demonstration). When asked if there was any documentation of Transportation Aide #1 ' s training conducted prior to the incident on 10/1/18, the VP pointed to the documentation provided by the facility and stated, Obviously not. A telephone interview was conducted on 10/4/18 at 3:50 PM with a representative of the van lift ' s manufacturer. Upon inquiry, the representative stated the lift manufacturer did not recommend anyone stand on the lift with a wheelchair passenger during operation of the lift. The representative reported this information was included in the lift manual and an electronic copy of the lift manual was provided by the manufacturer for review. On 10/4/18 at 5:45 PM, the Administrator was informed of the immediate jeopardy. The facility provided a credible allegation on 10/5/18 at 6:23 PM. The allegation of compliance indicated: Credible Allegation for F689: Accordius Health at Clemmons 10/5/2018 Credible Allegation of Removal of Immediate Jeopardy Part One: The facility acknowledges that on (MONTH) 1, (YEAR) at approximately 10:15 am, resident number one (1) was injured during an accident that occurred while disembarking resident number 1 from the facility ' s transport van. The probable citation identifies 1) improper use of seatbelts and safety harnesses and 2) the allowance of having a second person on the lift gate potentially creating a positioning issue that contributed to the accident and inconsistent with manufacturer ' s recommendations. Resident number 1 was immediately transported to and treated at Wake Forest Baptist Hospital where she was discharged several hours later with a contusion but well appearing according to the hospital ' s discharge note. At the time she was discharged from the hospital she was accompanied by her family to a different nursing facility. Immediate and subsequent investigation began on (MONTH) 1, (YEAR) at approximately 11:00 am, when the administrator dispatched Richard, Maintenance Supervisor, to the [MEDICAL TREATMENT] center where the fall had occurred. The initial investigation included checking the integrity of the van and its components, and returning the van in lock out tag out to the facility. Once back at the facility, the investigation evolved including statements and reenactments of the event. The transporter placed herself on the end of the ramp between the wheelchair and the panel and attempted to lower the lift. When it would not move the transporter checked and realized the resident ' s foot was making contact with the inner panel. In order to move the chair back she stepped out, released the brake and as she was moving the chair back enough to remove contact, she tripped over the real panel and, without losing her balance, landed at ground level. In the process the chair went with her. The transporter was able to control the speed and velocity of the tipping to a point, but the chair did overturn and the resident did land on the ramp. During a conversation on 10/4/18 between corporate clinical with the manufacturer about having a second person on the ramp, the representative said they cannot recommend a second person because of weight variations as the lift gate holds a maximum of 800 pounds safely. However, though she expressed that they know it happens frequently and the restriction is related to weight on the lift, she declined to offer anything in writing. The allegation around improper use of seatbelts is not connected to this event. During the surveyors investigation a statement was made that there were only enough seatbelts to properly secure one passenger. Because there were occasions during which two passengers were transported, the deduction is that passengers were transported without complete seat belt. Management was unaware the seatbelts were missing or that anyone was being transported incompletely secured. It should be noted that the 4 point seat restraints and the shoulder harness were present for a second passenger but the lap belt portion was not there. The Maintenance Supervisor replaced these as of 10/4/18. Part Two: All residents who are transported on the facility ' s van are at risk of similar events. To assure no such event will occur the facility has instituted the following plan: · The facility immediately, at 12:30 pm on 10/1/18, stopped transporting residents and took the van out of commission to abate the immediate jeopardy assuring that no resident was still at risk and allowing the facility to begin the process of evaluating, revising and implementing a revised company policy. Our contracted licensed medical transporter, (Company Name), will continue to provide all resident non-emergency transportation until the facility has completed the process and the plan is fully implemented. (Company Name), representative (Name) has reported to the Administrator that (Company Name) meets the safety standards for driving and has provided the facility with their safety check sheets on 10/5/18. Each has been reviewed by the Administrator and corporate clinical director on 10/5/18. · At the time of the incident (10/1/18 approximately 10:15 am), the Transportation Aide was instructed to wait for assistance from the Maintenance assistant who was sent from the facility to check the van to make sure there were no operational issues with the van or the lift. The maintenance assistant brought the van and the aid back to the facility arriving shortly after 12:30 pm. The maintenance assistant found all mechanical and functional aspects of the van and the lift system to be in working order. · An analysis of the incident was initiated immediately and included a thorough inspection of the scene, re-enactment of the Transportation Aide ' s account of what transpired. The transport vehicle was locked-out/tagged out until checked by the Maintenance Director who arrived at the facility approximately 6:30 pm. Equipment failure was ruled out as a contributing factor to the fall. Even so, lock-out/tag out continues through this investigation and implementation of the quality improvement plan. · The Transportation aide was immediately removed from her transport duties. · All equipment in the van was checked for function on 10/1/18 by the maintenance director. Involved staff in the incident was interviewed by the Administrator, The Regional Director of Clinical Services and the Regional Director of Reimbursement beginning on 10/1/18 and continuing through 10/3/18. Follow up documentation of the injured resident was received. · An Emergency QAPI meeting was held on 10/2/18 to review findings of the investigation which began on 10/1/18, the moment the event took place; and to evaluate the transportation process. Participants of the QAPI meeting included: The Director of Nursing, the Business Office Manager, the Dietary Manager, the Housekeeping Supervisor, the MDS Coordinator, an RN Supervisor and the Administrator. The meeting included discussion about the facts and circumstances of the accident with the QAPI committee decided 1) retraining of the transport driver/C NA, 2) looking for potential contributing factors such as footwear or clothing items, 3) assuring that all drivers understand the special parameters and requirements for proper wheelchair placement on the lift, 4) Discussion of whether anti-tippers might have stabilized the chair, and 5) residents be interviewed about their own experiences while being transported and whether or not they felt fearful 6) to keep the van out of commission until a plan could be fully revised and implemented. · Evaluation and revision of the Facility Transportation Vehicle policy and procedure by the Vice President of Clinical Services was begun on 10/1/18. The plan was finalized at 11:30 am on 10/4/18 with a specific plan for full implementation prior to again transporting residents utilizing the facility van. Implementation was underway as of 10/1/18. Based on new training and credentialing requirements included in this plan as well as additional equipment which has been ordered, the facility intends to resume use of the facility van on or about 10/15/18 if all standards have been met and the Corporate Compliance team has reviewed and approved the status of the plan. To assure the facility does not place any resident at risk, Triad Safe Choice remains in place. · Policy revisions include: 1) no transport aid (facility staff) will ride the lift gate with the resident either up or down and will be trained to stand next to the gate (on the ground unless otherwise indicated by manufacturer ' s instructions to provide support and stability as may be needed during operation. 2) All safety harnesses and seat belts have been evaluated for safety, effectiveness and compliance with operation manual instructions. Additional equipment has been added to the van allowing the full securing of any individual who would be transported 3) additional individual wraparound belts have been ordered for use on each individual wheelchair during transport and onboarding and off-boarding. This belt will secure the resident to the chair while on the lift gate during the time when the vehicle wall and floor mounted securing devices cannot be used. · The revised policy includes additional background information to be collected and verified for each driver, use of both the manufacturer ' s lift operations manual and the manufacturer ' s videos for training, a Transport Driver Skills Assessment, a Transport Safety Observation protocol and both Daily and Monthly Safety Check protocols (checklists). · To assure training is conducted accurately, a team of two specific trainers have been assigned. Both are experienced Maintenance Directors who have worked with van transport extensively. Each is using the manufacturer ' s operations manual and training videos as well as policy and its components to establish a train the trainer format. Each building will have a trainer who has been through training with this team so that procedures are consistent and policy is adhered to. · As the facility may use two different vans of vastly different size and capability, the large transport vehicles such as the one involved in this accident will be staffed by two persons for the purpose of safe on-boarding and off-boarding of residents. The facility ' s transport van will remain out of commission until the entire plan is fully implemented (on or about 10/15/18 and the full approval of the Corporate Compliance team.) · No resident will be transported on the facility van until the Compliance team has declared the plan is complete (on or about 10/15/18). No person will drive or operate the van until the Compliance team has determined the implementation is complete. Part Three: On 10/3/18, the maintenance director began re-training the transporter C NA on the safe and proper use of the lift gate including proper onboarding and off-boarding, proper placement of the chair on the lift gate, proper positioning of the transport aide, proper securing of the wheelchair, proper use of the vehicle mounted securing system, the new element of using a wraparound seatbelt for each wheelchair occupant. Effective 10/1/18, and ongoing, Individual training will be completed by the Maintenance Director including Transport Driver Skills Assessment, prior to any individual being permitted to operate the van and will require completion of the Transportation Safety Observation Report prior to any resident being transported. Full training and competency evaluation by the Maintenance Director will be completed then on an annual basis thereafter and anytime there is a change in process, a risk is identified, or a change in condition occurs. On 10/4/18 the Maintenance Director began training the transporter(s) on the use of the Pre-Trip Inspection, the Transportation Vehicle Monthly Safety Inspection. Before the facility van is brought back into use, proposed drivers will receive, study and sign for the Facility Transportation Vehicle Policy and Procedure Accordius Health. This is the policy that guides the process to be followed. It is expected that each potential driver will understand this policy and be prepared to follow it in its entirety. Part Four: The safety committee (The Maintenance Director, Housekeeping Supervisor, Dietary Manager, Staff Development, DON and Administrator) will review the Pre-Trip Inspections and the Transportation Vehicle Monthly Safety Inspection forms (see addendum included at the end of this document) as well as driver Skills Assessments and Transport Observation Reports (see addendum included at the end of this document) on a monthly basis. The committee will review as well any and all close-calls, incidents or events that occur related to the use of the facility van as they occur and on at least a monthly basis. The report of this review will be presented at QAPI on an ongoing basis beginning with the (MONTH) QAPI meeting. The purpose of this presentation is to seek opportunities to improve the process and the safe operation of the facility van. The Regional and Corporate Team will review all reports of events and occurrences to ensure policies and procedures are adhered to as well as to look for opportunities to continue process improvement for the safety of residents. The Corporate Compliance Committee and the Regional Team will oversee this plan and its implementation to support ongoing success. Prior to allowing the van back into service and the driver to load or transport, the maintenance director will complete a Transportation Safety Observation Record and a Pre-Trip Inspection and observe on-boarding and off-boarding. The maintenance director will review at random three times each week for 6 weeks then at random 2 times per week for 3 months. Thereafter the maintenance director will observe at random on a weekly basis ongoing. All data collected during these observations will be recorded on an audit tool which will be presented during QAPI for review. Date of Removal Request: Accordius Health at Clemmons requests consideration for removal of Immediate Jeopardy effective 10/5/2018 at 12:30 pm, the time the van was taken out of service for transportation of residents. The facility ' s credible allegation of Immediate Jeopardy removal was validated on 10/5/18 at 5:20 PM. On 10/3/18 from 12:40 PM through 10/5/18 at 5:20 PM, transportation aides and the Maintenance Director working at the facility were interviewed in regards to the training initiated at the facility. An outside transportation vehicle was observed on multiple occasions as it was utilized to transport the facility ' s residents. The Facility Transportation Vehicle Policy and Procedure Accordius Health, Transport Driver Skills Assessment, a Transport Safety Observation protocol and both Daily and Monthly Safety Check protocols (checklists) initiated by the facility were reviewed as part of the validation process. 2. Resident #2 was admitted to the facility on [DATE] from the hospital. Her cumulative [DIAGNOSES REDACTED]. A review of Resident #2 ' s admission MDS dated [DATE] revealed the resident had severely impaired cognitive skills for daily decision making. No behaviors nor rejection of care were reported. Section G of the MDS indicated the resident required extensive assistance for all of her ADLs, with the exception of being totally dependent on staff for locomotion. The resident used a wheelchair for mobility. A review of Resident #2 ' s medical record revealed no incidents/accidents were reported for this resident since her admission to the facility. An interview was conducted on 10/3/18 at 12:20 PM with Transportation Aide #1. Transportation Aide #1 was identified as the staff member who transported Resident #1 and Resident #2 to the [MEDICAL TREATMENT] center on 10/1/18. The transportation a

Based on observations, record reviews and staff interviews, the facility failed to prevent 1 of 7 cognitively impaired residents ( Resident #1) from exiting the facility without the knowledge of staff. Resident #1 was found across the street from the facility, crossing a two lane road with a speed limit of 45 miles per hour. The immediate jeopardy began on 9/9/13 for Resident #1. The immediate jeopardy was identified on 9/18/13 at 5:28 PM and removed 9/19/13 at 7:00 PM. The facility remains out of compliance at a lower scope and severity of D (an isolated deficiency, no actual harm with potential for more than minimal harm that is not immediate jeopardy) to complete implementation of system changes and monitoring the corrective action stated in the credible allegation. The findings included: Review of policy and procedure dated 9/17/13 and named Elopement Response, included general information as follows: Unsafe Wandering: When a resident wanders into an unsafe, unsupervised area of the facility such as a stairway, courtyard, on the premises yet outside the building or services area. Although the resident has not left the premises, unsafe wandering can be just as dangerous as elopement. Resident #1 was originally admitted on [DATE] and readmitted [DATE] with [DIAGNOSES REDACTED]. Review of the Elopement/Unsafe Wandering Risk assessment dated [DATE] revealed that Resident #1 was not considered to be at risk for elopement. Review of physician orders [REDACTED]. Review of the nurse ' s notes written by Nurse #2 dated 4/30/13 at 1:15 PM revealed that Resident #1 was noted in the courtyard ( courtyard was observed on 9/17/13 at 3:00 PM to be enclosed with a ramp going down from dining room door to the yard) and a wanderguard was ordered and placed. A physician ' s telephone order was written on 4/30/13 by Nurse #2. During an interview with Nurse #2 on 9/18/13 at 12:17 PM revealed that she could not remember writing the order, her position at the facility was Minimum Data Set (MDS) Coordinator and Quality Assurance and could have written the order during a chart review. Nurse #2 further indicated that Resident #1 needed 1:1 supervision because he was unsafe and tried to get out of his wheelchair. The MDS dated [DATE] revealed that Resident #1 required extensive assistance to complete activities of daily living. The MDS further identified Resident #1 as being moderately cognitively impaired for daily decision making. Resident #1 did not exhibit wandering during the assessment period. Review of Resident #1 ' s care plan dated 7/2/13 indicated a problem of wandering and approaches included attempt to re-direct resident when undesirable or unsafe behaviors are observed and prior to administration of psychoactive medications, offer to ambulate or change location, offer activity of interest, offer rest period, apply safety alert device per order, check presence and and function. See Treatment Adminstration Record (TAR). The September 2013 (TAR) indicated to Apply Wanderguard- check placement and functioning every shift. There was no documentation for placement and functioning six times during the first 10 days of September to include 9/9/13 during the 7am-3pm shift. Review of nurse ' s notes written by Nurse #3 dated 7/7/13 at 7:48 PM revealed that the physician was notified of Resident #1 ' s increasing sundowners, resident had been very agitated, constantly on the move, wandering around the unit attempting to elope, going into other residents ' rooms and continuously getting out of chair. Resident taking clothes off and unable to sit still and nursing notes on 7/25/13 further indicated that Resident #1 ' s wandering behaviors increased, pulling self in wheelchair into other residents ' rooms, even with their doors closed. An interview with the Staffing Coordinator on 9/18/13 at 1:00 PM revealed that she started her position on August 15, 2013 and at that time Resident #1 was requiring 1:1 monitoring. She had a verbal agreement with NA #7 and Housekeeper #1 to provide the 1:1 with Resident #1. NA #7 was to sit from 8:00 AM to 6:00 PM and Housekeeper #1 was to sit with Resident #1 from 6:00 PM to 9:00 PM. The Staffing Coordinator further indicated that 1:1 was not assigned after 9:00 PM because Resident #1 slept through the night. Review of the staffing assignment sheet dated 9/9/13 indicated that Resident #1 was to have a sitter 1:1 from 8:00 AM to 9:00 PM An interview with Housekeeper #1 on 9/17/13 at 2:30 PM revealed that he did not sit with Resident #1 on 9/9/13 at 6:00 PM because he was working in housekeeping and he reported that to the staffing coordinator. He further indicated that Resident #1 was very mobile in his wheelchair and a couple months ago, he could not remember the date, he found Resident #1 in the kitchen at the exit door going toward the back dock that drops off about 4 feet. Housekeeper #1 revealed that Resident #1 would go through the dining room, through the kitchen doors that would not lock and to the exit doors. Housekeeper #1 happened to be checking all the doors and heard something in the kitchen and it was Resident #1 and he reported this to Nurse #1. Housekeeper #1 further indicated that he found Resident #1 in the courtyard going down a ramp to the court yard and had been outside about six times and management was aware. Review of nurse ' s notes written by Nurse #4 dated 9/9/13 revealed that Resident #1 was found outside the facility alone at 7:40 PM. A visitor reported that the resident was across the two lane road in front of the facility standing in the grass near the subdivision and Nursing Aide (NA) #1 and (NA) #2 quickly went to Resident #1. Nurse #4 was alerted and went to grassy area to transport Resident #1 back into building. Resident #1 had a wanderguard on and it tested active. The nurse ' s note further indicated that Nurse #4 assigned NA #2 to do 1:1 sitter care with Resident #1 during remainder of the shift. Nurse #4 contacted the Administrator and Acting Director of Nurses at 7:50 PM on 9/9/13. Nurse #4 further documented that no staff member saw Resident #1 leave the building and Nurse #4 did not hear the door alarm. During an interview with Nurse #4 on 9/23/13 at 5:00 PM revealed that on 9/9/13 she last saw Resident #1 in the dining room at dinner, he had a 1:1 sitter until 6:00 PM. She further revealed that there were no 1:1 sitter assigned after 6:00 PM. She understood that the 1:1 sitter was to give the staff a break because Resident #1 was a fall risk. Nurse #4 also indicated that on 9/9/13 at approximately 7:40 PM she was alerted that Resident #1 was outside across the street, when she responded he was across the street standing behind his wheelchair. Nurse #4 could not recall if the door alarm sounded when they came back into the facility, but after she did her assessment she checked Resident #1 wanderguard bracelet and it was functioning and indicated that Resident #1 had no injury, his clothes were clean and he was not frightened. Nurse #4 further revealed that she received no orientation or education on the wanderguard system and did not know the code for a missing resident or how to check the wanderguard bracelet for function. Interview with NA #5 on 9/18/13 at 4:15 PM who was assigned to Resident #1 on 9/9/13 revealed that it was reported to her that Resident #1 was outside across the street. She did not hear the wanderguard alarm sound. She indicated that she last saw Resident #1 around 6:00 PM in the dining room when picking up supper trays. NA #5 revealed that Resident #1 did not have a 1:1 sitter that evening, but he did have 1:1 the day before. She recalled the wandeguard bracelet being on Resident #1 ' s left wrist. NA #5 indicated she was aware of the elopement protocol and had recent education regarding the elopement protocol. Interview with Nurse #1 on 9/18/13 at 9:15 AM revealed that a couple months ago it was reported to him by Housekeeper #1 that Resident #1 was in the kitchen and at the exit doors to the back dock. Nurse #1 indicated that he redirected Resident #1 but did not document the behavior, he reported it to his assigned nurse, Nurse #4. Nurse #1 further indicated that Resident #1 was very quick in his wheelchair and had to be placed on 1:1 supervision. He liked to sit in the dining room across from the front lobby door. He further revealed that at night it is very busy with visitors and kids and then demonstrated that when the door is opened it closes very slowly and observation revealed that it took 5-6 seconds for the door to close. Nurse #1 indicated that the night that Resident #1 went out of the facility he did not hear the wanderguard alarm. A phone interview with the Medical Director on 9/18/13 at 4:58 PM revealed that Resident #1 was on 1:1 supervision for his safety and he was aware that the 1:1 was discontinued on 3/20/13 because Resident #1 ' s behavior improved with medication adjustments and didn ' t need it anymore. The Medical Director further indicated that he was aware of the order for the wanderguard on 4/30/13, he recalled that Resident #1 was always into something, could not think of anything specifically, but would try and go out the front door. He also revealed that he was notified of Resident #1 ' s elopement on 9/9/13. Observation on 9/18/13 at 9:30 AM revealed that the dining room door where Resident #1 had his meals was approximately 12 feet from the front lobby door. The door was approximately 5 feet wide and when opened wide closed slowly taking approximately 6 seconds to close. On 9/18/13 at 3:37 PM the Unit Manager was observed checking all 7 doors that had a wanderguard alarm which included an alarm on each hall, the 100, 200, 300 hall and both dining room doors to the outside secured courtyard and the front lobby door. She indicated that she checks all the alarms on all the doors. All the doors alarmed and locked down except for the front lobby door, the front lobby door was not set up to lock down. The door was tested with a resident that had a wanderguard on and the door did not lock, it only alarmed. The Unit Manager indicated that the front lobby door did not lock down when it alarms. An interview with the Administrator on 9/17/13 at 10:20 AM revealed that Resident #1 had 1:1 care not for exit seeking, but due to Resident #1 ' s wandering into other resident rooms and for whatever reason the night of 9/9/13 the 1:1 assignment messed up and Resident #1 eloped. The Administrator further indicated that after the elopement the facility validated that Resident #1 wanderguard was functioning, all doors with wanderguards were tested and functioning, all residents identified with wanderguards were also checked. He further indicated that all residents had an Elopement Risk Assessment completed. The policy and procedure for elopement was reviewed and updated and an emergency Quality Assurance meeting was held on 9/11/13 to review the Quality Improvement plan. The Administrator further indicated that we have agency nurses and not all the in-services are complete. The Administrator and Director of Nurses were notified of immediate jeopardy on 9/18/13 at 5:28 PM. The allegation of compliance was received on 9/19/13 at 4:35 PM. The allegation of compliance was accepted on 9/19/13 at 7:00 PM. Credible Allegation: A. Address how corrective action will be accomplished for those resident found to have been affected by the deficient practice. On 9/9/13 at 7:40 PM Resident #1 discovered outside the facility unsupervised and in an unsafe location off the premises. The last " confirmed " observation of Res#1 was by HK#1 at 7:05 PM while sitting at Unit Two nurses station prior to being discovered missing. CNA#2 recalls seeing Res#1 at that nurse station while performing her rounds, but cannot recall clearly enough to confirm those observations were between 7:05 PM and 7:40 PM. The Interim Director of Nurses and Administrator were notified at 7:50 PM, 9/9/13, and they ensured the following actions were accomplished: ? The resident was redirected by two Nurse Aides and returned to the facility at 7:40 PM, 9/9/13. ? The Charge Nurse (RN#1) completed and documented a head-to-toe physical assessment tool upon reentering the facility to rule out any physical or mental harm. Resident #1 was assessed as unharmed and in good spirits as well as showing no signs of being scared. ? RN#1 also completed an assessment upon Res#1 ' s return to include vital signs. ? Resident #1 ' s WanderGuard bracelet was checked by RN#1 on 9/9/2013 at approximately 8:00 PM and validated that it functioned properly. ? The resident ' s family and the physician were contacted at 7:55 PM on 9/9/13 and notified of the incident. ? It was also validated by a Restorative Aide on 9/9/2013 at approximately 2:00 PM that all exit doors and associated alarms were functioning properly. ? On 9/9/2013 at 8:00 PM, RN#1 assigned CNA#1to perform one-on-one supervision to directly and continuously monitor resident #1 ' s location and safety until he was asleep in his bed. RN#1 documented this activity in her nurse note. 1-on-1 monitoring ceased when Res#1 was assisted to bed at 10:30 pm on 9/9/2013. ? LPN#1 personally conducted 30-minute documented observations commencing at 11:00 PM on 9/9/13 and during resident #1 ' s period of sleep through 7:15 AM on 9/10/13. All these checks confirmed his safety in the facility. ? Res#1 woke up at approximately 7:15 AM on 9/10/13, and was monitored by LPN#1 until the designated 1-on-1 Staff arrived at 8:00 AM to begin Res#1 ' s one-on-one. ? The Social Worker immediately began on 9/10/13 at 10:00 AM a search for a SNF with an open bed on a secured and locked unit. That was located at 11:30 AM on 9/10/13, necessary transfer forms were exchanged, Res#1 ' s family was consulted at 1:00 PM on 9/10/13 and granted permission for Res#1 to be transferred to a SNF with a secured and locked unit. ? The 1-on-1 Staff remained constantly with Res#1 until he loaded onto the transportation van at 3:30 PM on 9/10/13 for his discharge to a local SNF with an appropriate secured unit capable of providing him with adequate security and safety. ? Facility Incident Report completed on 9/9/13 at approximately 8:00 PM by RN#1. The facility ' s investigation into how Res#1 was able to exit the building and an alarm not be heard has not been determined. B. Address how corrective action will be accomplished for those residents having the potential to be affected by the same deficient practice. ? On 11-7 shift on 9/9/13 and 9/10/13, a 100% resident head count was completed by 4:30 AM (the 10th) by LPN#1 for units 1&2 and RN#2 for unit 3 that " all " residents are present and accounted for inside the facility. This 100% headcount confirmed and validated that all residents were accounted for in the facility. ? A new Elopement Risk Assessment was initiated and completed on 9/10/13 for every resident in the facility by the Interim DON assisted by a new RN Unit Manager and LPN#2 to identify any other residents in the facility that might be at risk for elopement. ? The Assessments were evaluated and six Residents (#2, 3, 4, 5, 6, & 7) were initially identified on 9/11/13 by LPN#2. Resident #5 previously had had a WanderGuard bracelet placed on her, and Residents #3 and #4 refused to allow the bracelet to be placed on 9/11/13, and Residents #2, #6 and #7 had their bracelets placed on 9/17/13. New WanderGuard bracelets were placed by the RN Unit Manager assisted by the Central Supply Clerk. ? The Social Worker wrote a note in each of the six resident ' s medical records. This was completed by September 12, 2013 referencing elopement risk status. ? All current residents as of 9/10/13 with WanderGuard bracelets (#1, #5, #9, #10, #11) were checked on 9/10/13 by the Central Supply Clerk for functionality and expiration dates, and those checks were documented on a spreadsheet. All were determined to be properly functioning, and within the expiration dates. ? All facility exit doors with WanderGuard locks and alarms were also checked by the Central Supply Clerk on 9/10/13. All doors checked and validated that they function properly, and those checks are documented. ? Elopement risk for all residents being established on 6:00 PM on 9/11/13 by the Interim DON and her nurse team, and on 9/17/13 at 6:15 PM, a clinical team consisting of the RN Director of Nursing, RN Staff Development Coordinator, RN Unit Manager, RN MDS Coordinator, and Director of Operations (an RN) reviewed and re-evaluated the designated seven residents alleged to be an elopement risk. For Residents #1, #2, #3, #4, #5, #6, #7 affected the following was to be initiated: a. Resident #1 is discharged on [DATE], and Residents #9, #10, #11 bracelets were removed by 6:00 PM on 9/11/13 by the Central Supply Clerk since their Elopement Risk status was downgraded to safe in the facility. a. Placement of a WanderGuard bracelet on each affected resident. Resident #5 previously had had a WanderGuard bracelet placed on her and as of 9/11/13 remained unchanged, Residents #3 and #4 refused to allow the bracelet to be placed on 9/17/13 so none was placed, and Residents #2, #6 and #7 had their bracelets placed on 9/17/13 by 6:00 PM. New WanderGuard bracelets were placed by the RN Unit Manager assisted by the Central Supply Clerk. Residents #3 & #4 had not special handling and on 9/17/13 were evaluated as not being an elopement risk. b. Telephone orders written for Residents #2, #3, #4, #5, #6, #7 to be placed on the TAR by the RN Unit Manager and RN DON at 8:30 AM on 9/17/13 for q-shift checks for placement and functioning of bracelet and doors. Residents #3 & #4 refused placement and their telephone orders were d/c ' d by 9:30 PM on 9/17/13. No alternate management of Residents #3 & #4. Residents #3, #4, #7 were re-assessed on 9/19/13 for elopement risk by the DON & Unit Mgr and found to not be at risk. c. Telephone orders d/c ' ing WanderGuard bracelets for Residents #2, #5, #6, #7 on 9/18/13 by 11:30 AM by RN Unit Manager. The d/c order was written after confirmation none of these residents were evaluated as being a risk for elopement. d. Placement checks documented q-shift on the TAR by the Charge Nurse began on 9/17/13 and ended 9/18/13. e. Unit Elopement Risk Binders are updated by the Medical Records Clerk with each resident being included whose elopement risk scores support their being placed in the binder. These binders are in place on each nurse station, Reception Desk, Social Work office, DON office and Therapy office the latest update is on 9/19/13. AS of 9/19/13 there are no residents determined to be at-risk and the binders reflect that status. f. For residents #2, #3, #4, #5, #6, and #7 evaluated as at risk for elopement, Care Plan updates were completed by the RN MDS Coordinator to reflect wander/elopement risk and appropriate interventions by 8:30 PM on 9/17/13. Those care plans are now d/c ' s on 9/19/13 at 11:30 AM by the RN MDS Coordinator. ? On 9/18/13 at 10:00 AM Res#8 was further evaluated for elopement risk by the RN Director of Nursing and the RN Unit Manager. Res#8 is a new admission whose admission assessment was reviewed in greater detail. Res#8 was classified as a safe wanderer in the facility who exhibited no elopement risk on 9/18/13. ? The Social Worker completed social notes on 9/18/13 that reflects their updated and true elopement status that reflected they are not an elopement risk. ? The Elopement Response Policy and Procedure will be updated by the Administrator by 9/19/13 to reflect any changes recommended by the QAPI Committee to include a change in who checks the functionality of door alarms. ? 100% of working staff (including all temporary agency staff) will be in-serviced by the RN SDC, RN DON or DON Designee to educate them on the proper procedures to follow should any resident be found to have eloped or attempted an elopement or be found in an unsafe location on the premises. This training begins on 9/19/13 with staff present (permanent and agency) and for all new employees in orientation on 9/19/13 and future orientations. Other employees not having received this training will be in-serviced at the beginning of their next work shift and prior to their beginning work. The credible allegation was verified on 9/19/13 at 7:00 PM as evidence by staff interviews of the understanding of the policy and procedure on Elopement and the understanding of the policy and procedure for Elopement response, elopement drills, how to check placement and functioning of the wanderguard bracelet.