Every finding on record at Cherry Point Bay Nursing and Rehabilitation Center

Based on observation and staff interviews the facility failed to label and date foods stored in 1 of 1 nourishment refrigerator located at the central nurse's station. This practice had the potential to affect food served to residents. Findings included: During an observation of the nourishment refrigerator located at the central nurse's station on 7/9/24 at 2:30 pm with the Certified Dietary Manager (CDM) present multiple food items were observed unlabeled without open or discard date. In addtion, a typed sign was observed on the outside of the refrigerator that read in part: label and date food items with date opened and discard 3 days after opening of non-consumed foods. a. One white fast food paper bag with a partially consumed wrapped sandwich that was hard to the touch. It did not contain an open or discard date. b. One approximately 8-ounce clear plastic food storage container with a red lid noted with an a grayish-brown food with an unidentifiable white substance floating on top. It did not contain an open or discard date. c. One plastic produce bag that contained two plums, which did not contain an open or discard date. d. One opened 32-ounce 1/2 full bottle of a dairy based creamer with an expiration date of 10/8/24 from the manufacturer. It did not contain an open or discard date. e. One clear gallon sized plastic storage bag that contained an approximately 8-ounce size block of orange cheese with a creamy white substance noted on the edges of the cheese. Droplets of water were noted to adhere to the bag. It did not contain an open or discard date, f. One opened bottle of cranberry juice was noted to be 1/2 full with a best by date from the manufacturer of 7/30/24 stamped on the container. It did not contain an open. g. One opened, partially empty clear plastic container of kosher dill pickles with a sell by date from the manufacturer of 1/23/24 stamped on the container. It did not contain an open. h. One opened 16-ounce 1/2 full bottle of mayonnaise with an expiration date from the manufacturer of 12/26/24. It did not contain an open. During the refrigerator observation the CDM discarded all unlabeled undated foods. In an interview with Nurse Aide (NA) # 1 on 7/09/24 at 02:35 she stated any food placed in the nourishment refrigerator should be dated with the date it had been put in the refrigerator and uneaten food should be discarded after 3 days. She stated that she received training when she was hired and annually. In an interview with Tray Aide #1 on 7/10/24 at 9:28 am she stated that she sometimes stocked the nourishment refrigerator, and she labeled the foods that she stocked with the date that it was placed in the refrigerator and removed food that was not labeled with a date. She stated pull dates differed based on the on the food type, and if it was prepackaged or had been opened, like pudding. She stated foods that were opened had a pull date of 3 days after it was opened. In an interview with Nurse #2 on 7/09/24 at 2:40 pm she stated that anything that is put into the nourishment refrigerator should be dated with the date it was put in the refrigerator and discarded after 3 days if not consumed. She stated that she was trained by the Staff Development Coordinator. In an interview with Nurse #1 on 7/11/24 at 9:14 am she stated that it was everyone's responsibility to maintain the nourishment refrigerator and that dietary stocked it with pudding and juices. She stated that if anyone saw foods that were outdated or unlabeled that they should have discarded them. The interview further revealed that personal foods should be labeled by staff with the date that it was put in the refrigerator. She further indicated that the unit manager maintained the refrigerator but that she no longer worked at the facility, so everyone worked together to keep it maintained and clean. During an interview with the Staff Development Coordinator on 7/09/24 at 3:10 pm she stated that food in the nourishment refrigerator should be dated with an open date and thrown out after 24 to 48 hours but was unsure. The interview further revealed there was a little magnetized basket stuck to the nourishment refrigerator with labels and markers so staff could label items with dates. During an interview with the CDM on 7/9/24 at 2:38 pm she indicated that dietary was responsible for monitoring the nutrition refrigerator daily and that she had checked that refrigerator on the morning of 7/9/24. She stated that she looked for discard dates for foods that she stocked the refrigerator with like juices, puddings, and prepackaged dietary supplements. She further stated that when she was not available her staff would check the refrigerator. She further stated that nursing also had a responsibility to check the refrigerator for outdated foods that belonged to residents, and they should have put the date opened or if it was a food brought in from restaurant it should be labeled with the date it was placed in the refrigerator and discarded within 3 days and referred to the sign on the refrigerator door. In a follow-up interview with the CDM on 7/10/24 at 9:20 am she stated that she had a list of use by dates that she followed in the kitchen. She stated that any kitchen rules should have applied to the nourishment refrigerator. During the interview she stated that different foods had different discard dates that applied to them. In an interview with the Director of Nursing on 7/10/24 at12:55 pm she stated that food in the nourishment refrigerator should have been labeled and dated with the open date or the date it had been put in the refrigerator. She further indicated that the facility policy was not specific, and the facility followed kitchen policy and guidelines for food storage. In an interview with the Administrator on 7/10/24 at 8:32 am she stated the policy used in the kitchen for labeling of foods stored in the refrigerator applied to the nourishment refrigerator at the nurse's station. She stated that any food stored in the nourishment refrigerator should have been labeled with resident names, dates opened, or date that the food was placed in the refrigerator. She stated the discard dates were the same as for the kitchen.

Based on records review, and staff interviews, the facility failed to ensure advance directives were accurate throughout the medical record (Resident #5) and that a copy of the resident's advanced directive was in the medical record (Resident #31) for 2 of 2 residents reviewed for advance directives. 1. Resident #5 was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #5's physical chart was observed to contain a completed Medical Orders for Scope of Treatment (MOST) (advance directive) document dated [DATE] signed by the resident's representative and the attending physician that indicated the resident desired for cardiopulmonary resuscitation (CPR) to be performed if she stopped breathing and her heart stopped beating. The physical chart was further observed to contain a Do Not Resuscitate (DNR) document that indicated that CPR would not be performed if Resident #5 stopped breathing and her heart stopped beating. The DNR was dated [DATE] and contained an illegible signature on the line specified for a physician signature. A review of Resident #5's electronic medical record (EMR) and an order dated [DATE] revealed Resident's #5's code status was a full code. A review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed that Resident #5 was severely cognitively impaired. A review of Resident #5's care plan dated [DATE] revealed that she had an advance directive of full code in place with a revision date of [DATE]. The goal was that the advance directive would be honored by staff. In an interview with Nurse #1 on [DATE] at 2:40 pm she stated that both the MOST form with the full code (perform CPR) directive and the Do Not Resuscitate (DNR) form should not both be on the physical chart at the same time because they contradicted one another. She indicated that she thought the DNR would be correct form because it had the more current date of [DATE]. She then checked the electronic medical record for Resident #5 and stated that Resident #5 was listed as a full code in the electronic medical record and clarified that Resident #5 was a full code and not a DNR. She went on to explain that when Resident #5 returned from the hospital on [DATE] that the DNR had been generated by the hospital because they automatically made everyone a DNR and that when she readmitted to the facility that the DNR should not have been placed in the physical chart. She further stated the DNR on the physical medical record had been signed by a hospital doctor and not by the facility doctor, and the facility did not honor a hospital DNR. She confirmed Resident #5 was a full code not a DNR. She was observed to remove the DNR document from the physical chart. In an interview with Resident #5 on [DATE] at 11:28 am she indicated that she was a full code and desired CPR to be performed should she become without a pulse, or her breathing stopped. In an interview with the Social Worker on [DATE] at 1:31 pm she stated she met with residents or their representatives within 24 hours after they were admitted , and they filled out MOST (advance directive) form. She stated that she did not meet with Resident #5 or her representative when she was readmitted on [DATE] because she was not employed by the facility at that time. She further indicated that if a resident were readmitted from the hospital that all documents were given to the admitting nurse who would have determined if the code status were accurate. She stated that the facility did not honor DNRs from the hospital and that the form should not have been in Resident #5's physical chart. During an interview with the DON on [DATE] at 12:26 pm she stated that Resident #5 should not have had a DNR and Full Code status on the physical chart at the same time. She further stated that the DNR form should not have been placed on the physical chart. In a follow-up interview with Nurse #1 on [DATE] at 9:09 am she stated that when Resident #5 had been readmitted from the hospital in May of 2024 that the admitting nurse should have placed all medical records that were sent with Resident #5 in a box for the Medical Records department and they would have reviewed and scanned the records and placed them in the EMR, but that did not happen for Resident #5 when she returned from the hospital on [DATE]. She further indicated that the MOST document was already on the physical chart when Resident #5 was readmitted and that the DNR had been added to the physical chart in error. She stated that she had been the admitting nurse for Resident #5, and she may have placed the DNR on the physical chart in error. During an interview with the Administrator on [DATE] at 8:37 am she stated the DNR document should not have been on Resident #5's chart if she was a full code. She stated the documents contradicted one another. 48230 2. Resident #31 was admitted to the facility on [DATE]. A review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed that Resident #31 was severely cognitively impaired. A review of Resident #31's care plan dated [DATE] revealed that he had an advance directive of full code in place with a start date of [DATE]. A review of Resident #31's electronic medical record (EMR) revealed an active order dated [DATE] for full code (cardiopulmonary resuscitation [CPR] should be performed in the event his heart should stop). A review of Resident #31's physical chart revealed no advanced directives or code status orders. In an interview with Nurse #1 on [DATE] at 11:50 AM she stated that she checked the EMR for code status when a resident's health declined. Nurse #1 accessed Resident #31's EMR and the information indicated Resident #31 was a full code. She then checked Resident #31's physical chart under advance directives, and it contained no advanced directives. She then checked the orders and was unable to locate a code status order. Nurse #1 stated it was the responsibility of the Social Worker (SW) to update the physical charts with advanced directives. During an interview with the SW on [DATE] at 8:17 AM she stated she was responsible for ensuring the residents' physical charts had the correct advanced directives. The SW further stated she had been in the position for about 5 weeks and had checked resident charts that had been admitted since she started but had not checked the physical charts of residents that had been admitted before she started. During an interview with the Director of Nursing (DON) on [DATE] at 1:08 PM she stated Resident #31 should have had advanced directives in the physical chart that matched the code status on the EMR. During an interview with the Administrator on [DATE] at 1:35 PM she stated Resident #31 should have had advanced directives in the physical chart that matched the code status in the EMR.

Based on record review and staff, Nurse Practitioner (NP) and Physician interviews the facility failed to notify the physician immediately when Resident #1 had a fall from the shower bed (a bed utilized for the provision of personal care for residents who are immobile or who have reduced mobility) headfirst to the floor of the shower room on 2/01/24 at approximately 2:50 AM. Resident #1 sustained a small bruise to the back of her head and an abrasion to her lower back area and was at risk for further injury from head trauma due to a history left hemicraniectomy (surgical procedure where a large flap of the skull is removed) and seizures. On 2/01/24 at approximately 10:00 AM the resident had a change in neurological status with nystagmus (repetitive, uncontrolled eye movement) observed. The NP was notified and ordered for the resident to be sent to the Emergency Department (ED) for evaluation. At the hospital on 2/02/24, the resident had a breakthrough seizure. This deficient practice affected 1 of 1 residents reviewed for notification of significant changes. Immediate jeopardy began on 2/01/24 when the facility failed to immediately notify the physician of Resident #1's fall. The immediate jeopardy was removed on 2/03/24 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 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] with diagnoses which included non-traumatic brain dysfunction, seizure disorder, and history of a left hemicraniectomy. Resident #1's quarterly Minimum Data Set, dated dated dated [DATE] revealed she was in a chronic vegetative state. Review of Resident #1's fall event report dated 2/01/24 at 2:50 AM completed by Nurse #1 read, in part, that the shower bed hit an uneven area in the floor in the shower room and when the bed jarred the head of the bed folded down and the resident slid to the floor. The immediate action taken read, in part, that a small bruise was noted to the lower back and small reddened bump to the back of the head. The notification section stated that the physician was notified on 2/01/24 at 6:30 AM. An interview with Nurse #1 on 2/27/24 at 10:11 AM revealed that she was on duty and assigned to Resident #1 on 2/01/24 at 2:50 AM when the resident fell from the shower bed to the shower room floor. She observed Resident #1 lying face up on the shower floor. She stated that she assessed the resident and noted an abrasion to her lower back area and a small bruise to the back of her head. She started neurological checks (a neurological check consists of a physical examination to identify signs of disorders affecting your brain, spinal cord, and nervous system) per protocol (every 15 minutes x 4, every 30 minutes x 4, every hour x 4, every 2 hours x 2, and every 4 hours x 2, and every shift x 3 shifts). Nurse #1 stated she had not called the on-call physician until later in the morning as the resident had no neurological changes for the rest of her shift. She indicated she received no new orders when she made the physician notification. A progress note dated 2/01/24 at 10:00 AM by Nurse #2 read in part that the neurological observation for the pupil check noted nystagmus (repetitive, uncontrolled eye movement). An interview with Nurse #2 on 3/04/24 at 9:50 AM revealed that she was on duty and assigned to Resident #1 on 2/01/24 day shift (7am-3pm). She stated that she received a shift report from Nurse #1 that the resident had fallen from the shower bed and had no neurological changes. She stated that she continued the neurological checks per protocol. Nurse #2 stated that Resident #1 had a neurological change of nystagmus at 10:00 AM and she notified the Nurse Practitioner who requested that the resident be sent to the hospital. Review of the hospital discharge summary dated 2/09/24 indicated Computerized Tomography (CT) scans revealed the resident had no acute changes. Discharge was recommended back to the facility. Prior to discharge, Resident #1 was observed with a lateral gaze and she lost the ability to follow commands. She had a breakthrough seizure on 2/02/24 for 2 minutes, Neurology was consulted, and the Levetiracetam medication was increased to 1500 mg twice a day. Resident #1 was noted with unrelated medical issues while at the hospital. She was discharged back to the facility on [DATE]. An interview with the NP on 2/28/24 at 9:34 AM revealed that she was notified of Resident #1's fall the morning of 2/01/24 at 8:30 AM when she went to the facility. She stated that she assessed the resident and requested she be sent to the hospital. She revealed that the physician on call should have been notified immediately and the resident sent to hospital right away for evaluation due to Resident #1 hitting her head during the fall and the resident's history of hemicraniectomy. The NP added that the resident had a history of seizures and was on antiseizure medication. She stated that the resident had not had a seizure at the facility (admitted [DATE]). The resident had a seizure at the hospital which she felt could have been related to the fall and hitting her head. An interview with the Physician on 2/28/24 at 10:00 AM revealed that she believed the on-call physician should have been notified immediately and sent to the hospital after Resident #1's fall due to her head trauma caused by falling off the shower bed. She stated that the resident had a left hemicraniectomy (missing a portion of her skull on the left side of her head) from a brain bleed in 2020. She could not say whether Resident #1's seizure was related to her fall or not. She stated that it was a bad judgement call and the nurse should have been educated on timely notification of the physician if the resident had a fall and hit their head. An interview with the Administrator on 2/27/24 at 10:54 AM revealed that she believed the on-call physician should have been notified immediately of Resident #1's fall. She stated that the staff had been immediately educated on when to notify the physician. The Administrator was notified of Immediate Jeopardy on 2/28/24 at 11:15 AM. The facility provided a corrective action plan that was not acceptable to the State Survey Agency. The plan did not demonstrate a sufficient monitoring plan to ensure compliance was sustained. The facility provided the following credible allegation of Immediate Jeopardy removal: - Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance: On 2/1/24 at 02:50 am, Nursing Assistant #1 took Resident #1 to the shower room via the shower bed. The head of the shower bed was in an elevated position, and the foot of the shower bed was not in an elevated position. While entering the shower room, the wheel of the shower bed hit the drain in the floor, causing the bed to become unsteady and begin to tip to the side. The shower bed jarred, and the head of the bed (HOB) support fell . NA #1 prevented the shower bed from completely tipping to the side. However, the resident's body slid off the shower bed onto the floor. NA #1 called for assistance. The nurse completed a head-to-toe assessment of Resident #1 and noted a hematoma to the back of the head and a bruise on the lower back. The resident was assisted up from the floor via mechanical lift onto the shower bed and returned to the room. Neuro checks were completed from 3:00 am to 9:00 am with no negative findings. At 8:05 am, the facility Nurse Practitioner (NP) was updated on the status of the resident with no new orders. At 10:00 am, during a neuro check, the nurse noted nystagmus (repetitive, uncontrolled eye movement) and reported this to the NP. The NP assessed the resident with a new order to send to the emergency room for further evaluation and treatment. While at the hospital, the resident had a 2-minute breakthrough seizure and was treated for seizure-like activity. Additionally, the resident was admitted for a persistent vegetative state, and a small area of cerebral parenchymal hemorrhage chronic in nature, all unrelated to the fall. All residents who had falls, including those with injury, had the potential to be affected. The Quality Assurance Nurse identified these residents utilizing an incident audit tool on 2/1/24. On 2/1/24, a root cause analysis was completed by the Administrator and Director of Nursing. The root cause was determined to be that the nurse became distracted and inadvertently failed to notify the on-call provider of the resident's fall per facility protocol. On 2/1/2024, a 100% audit of incident reports from 1/1/2024 to 2/1/2024 was completed by the Quality Assurance Nurse to ensure the provider was immediately notified of all incidents including falls with a potential head injury. There were no other identified areas of concern. - 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: An in-service was initiated on 2/1/24 by the Quality Assurance nurse with all nurses regarding Notification of the Physician, with emphasis on how to avoid distractions and delay in notification of the physician including (1) immediately notifying the physician of all incidents including falls with a potential head injury (2) if unable to reach the attending, notifying the on-call physician and (3) documentation in the electronic record following notification of the physician. In-service was completed by 2/2/24. After 2/2/24, The Staff Development Nurse monitored staff completion and any nurse who had not completed the in-service will complete it before working their next scheduled shift. Any newly hired nurses will be educated by the Staff Development Nurse during orientation regarding Notification of the Physician with emphasis on how to avoid distractions and delay in notification of the physician including (1) immediately notifying the physician of all incidents including falls with a potential head injury (2) if unable to reach the attending, notifying the on-call physician and (3) documentation in the electronic record following notification of the physician. The Staff Development Nurse was notified of this responsibility by the Administrator on 2/1/24. Date of Jeopardy Removal 2/3/24. The credible allegation of immediate jeopardy removal was verified on 3/05/24. Interviews were conducted with a sample of Nurses to verify education was conducted for Nurses regarding notification of the physician. Documentation of in-service records was reviewed. In an interview on 3/05/24 at 10:28 AM with the Staff Development Coordinator, she stated that all Nurses had been in-serviced on the policy and procedure to notify the physician. She stated that she was responsible for orienting new nurses on the procedure for notification of the physician. The facility's immediate jeopardy removal date of 2/03/24 was validated.

Based on record review, observation, and staff, Nurse Practitioner (NP), and Physician interviews, the facility failed to follow the manufacturer's instructions for the use of a mobile shower bed (a bed utilized for the provision of personal care for residents who are immobile or who have reduced mobility) and to provide care safely for 1 of 1 resident reviewed for supervision to prevent accidents. On 2/01/24 Nursing Assistant (NA) #1 transported Resident #1 to the shower room via the shower bed without utilizing the locking pins that secured the head and the foot of the bed in place. While transporting the resident to the shower room the foot of the shower bed released and dropped toward to the floor. NA #1 did not cease the transport. She continued to push the resident in the shower bed to the shower room. Once arriving in the shower room when the shower bed was wheeled over the drain in the floor, the bed became unsteady, began to tip to the side and the head of the bed released dropping toward the floor resulting in the resident falling off of the shower bed headfirst onto the floor. The resident sustained a small bruise to the back of her head and an abrasion to her lower back area. The resident was transported to the hospital on 2/01/24 at 11:01 AM. At the hospital on 2/02/24, the resident had a breakthrough seizure. Immediate jeopardy began on 2/01/24 when NA #1 failed to provide care safely to Resident #1. The immediate jeopardy was removed on 3/02/24 when the facility provided an acceptable 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: A product website for purchasing of the shower bed utilized by the facility indicated the bed was made of PVC (Polyvinyl chloride) pipe material with a water resistant foam pad across the horizontal surface area of the platform where an individual would lay. It was foldable and mobile. The bed had four casters (wheels that were attached to the bed at the four corners and that were able to lock into position). It was 38.5 (inches) in height x 32 diameter x 76.5 length. To fold the bed, the head of the bed and the foot of the bed folded down towards the casters with the center portion of the bed remaining in a horizontal plane with the folded length measuring 41.5. The operating instructions (undated) indicated the purpose of this bed was to transport a person in a horizontal position and to use as a platform for showering. The shower bed folded down at each end for easy storage by unpinning and lifting up on either end until the section disengaged. Resident #1 was admitted to the facility on [DATE] with diagnoses which included non-traumatic brain dysfunction, seizure disorder, and history of a left hemicraniectomy (surgical procedure where a large flap of the skill is removed). Review of Resident #1's physician's orders revealed an order dated 2/02/23 for Levetiracetam (an antiseizure) 750 milligrams twice a day for seizures. Resident #1's quarterly Minimum Data Set assessment dated [DATE] revealed she was in a chronic vegetative state and was dependent on staff for activities of daily living. She was not prescribed an anticoagulant. Resident #1's care plan last revised 5/24/23 revealed a focus area for activities of daily living with an intervention for total dependence for bathing. There was also an intervention to keep the head of the bed elevated. Review of Resident #1's fall event report dated 2/01/24 at 2:50 AM completed by Nurse #1 read, in part, that the shower bed hit an uneven area in the floor and when the bed jarred the head of the bed folded down and the resident slid to the floor. The immediate action taken read, in part, that a small bruise was noted to the lower back and small reddened bump to the back of the head. An interview with NA #1 on 2/27/24 at 3:15 PM revealed that she regularly provided care for Resident #1 and had given her showers previously using the shower bed. She stated she and NA #2 had transferred Resident #1 from her bed to the shower bed via the mechanical lift. Then NA #1 stated she transported Resident #1 down the hallway toward the shower room. There were side rails on each side of the shower bed that were able to be locked in place with locking pins. She stated the side rails were in an upright and locked position (with the locking pins in place) when she transported Resident #1 down the hallway. The head of the shower bed was elevated, and the foot was not elevated. She stated that the resident care guide intervention was to keep the head of the bed elevated at all times, so she kept the head of the shower bed elevated as well. Part of the way down the hallway, the foot section of the shower bed (a portion that was capable of folding down toward the casters), released which caused it to be in a downward position toward the ground while the center of the bed remained on the horizontal plane. She did not know why this happened. She stated that no part of the resident was off the shower bed and she did not believe the resident was in danger of failing off of the bed so she continued pushing the shower bed towards the shower room. NA #1 stated that after she entered the shower room, the head of the shower bed (a portion of the bed that was capable of folding down toward the casters) released and fell toward the ground. The resident slid off the shower bed headfirst into the floor. The resident was lying face up flat on the shower room floor. NA #1 stated she went to the shower room door and called for help. The nurse (Nurse #1) came to assess the resident. After the resident was assessed, they used the mechanical lift to put the resident on the shower bed and transport her to her room. She stated that she was unaware there were locking pins for the head and foot of the shower bed. (These locking pins for the folding mechanism were separate from the locking pins utilized for the side rail securement). She stated she had not been trained on what the manufacturer's instructions were. NA #1 stated the training she had received for the shower bed was from another NA about the locking pins which held the side rails in an upright, locked and secured position on each side. An interview with Nurse #1 on 2/27/24 at 10:11 AM revealed that she was on duty and assigned to Resident #1 on 2/01/24 at 2:50 AM when the resident fell from the shower bed to the shower room floor. She stated that NA #1 had called out and she responded. She observed Resident #1 lying face up flat on the shower room floor. She stated that she observed the head of the shower bed had folded down. She stated that she assessed the resident and noted an abrasion to her lower back area and a small bruise to the back of her head. Nurse #1 stated that they used the mechanical lift to transfer Resident #1 to the shower bed and transported her back to her room. She started neurological checks (a neurological check consists of a physical examination to identify signs of disorders affecting you brain, spinal cord, and nervous system) per protocol (every 15 minutes x 4, every 30 minutes x 4, every hour x 4, every 2 hours x 2, and every 4 hours x 2, and every shift x 3 shifts). Nurse #1 stated that the resident had no neurological changes for the rest of her shift, and she called the on-call physician the next morning. She indicated she received no new orders when she made the physician notification. A progress note dated 2/01/24 at 10:00 AM by Nurse #2 read in part that the neurological observation for the pupil check noted nystagmus (repetitive, uncontrolled eye movement). An interview with Nurse #2 on 3/04/24 at 9:50 AM revealed that she was on duty and assigned to Resident #1 on 2/01/24 day shift (7am-3pm). She stated that she received a shift report from Nurse #1 that the resident had fallen from the shower bed and had no neurological changes. She stated that she continued the neurological checks per protocol. Nurse #2 stated that Resident #1 had neurological change of nystagmus at 10:00 AM and she notified the Nurse Practitioner who requested that the resident be sent to the hospital. Review of the hospital discharge summary dated 2/09/24 indicated Computerized Tomography (CT) scans revealed the resident had no acute changes. Discharge was recommended back to the facility. Prior to discharge, Resident #1 was observed with a lateral gaze and she lost the ability to follow commands. She had a breakthrough seizure on 2/02/24 for 2 minutes, Neurology was consulted, and the Levetiracetam medication was increased to 1500 mg twice a day. Resident #1 was noted with unrelated medical issues while at the hospital. She was discharged back to the facility on [DATE]. An interview on 2/27/24 at 1:38 PM with the Maintenance Director revealed the facility had one shower bed and he did not have a procedure in place to regularly check the shower bed for mechanical safety. He stated that he was aware of the locking pins which were used to transition the bed from a folded position by securing the head and foot of the shower bed in a horizontal position. He stated there were also locking pins on the side rails of the shower bed to hold them in an upright position. He stated that he usually checked the shower bed weekly to ensure all the locking pins (the side rail pins and the pins that secured the head and the foot of the shower bed preventing them from folding down) were in place because the pins went missing sometimes and he had to replace them. He also stated that he was out of the facility the week before Resident #1 fell and when he was out there was only emergency maintenance coverage. The Maintenance Director stated that when he checked the bed after returning to work on 2/01/24, the locking pins for the head and foot of the bed were missing. He stated that shower bed had been discarded after the accident and was no longer in the facility and the new shower bed did not have locking pins on the bottom. An interview with the Nurse Practitioner (NP) on 2/28/24 at 8:15 AM revealed that she was notified of Resident #1's fall. She stated that she assessed the resident and requested that she be sent to the hospital. She also stated that since the resident had hit her head, she should have been transported to the hospital right away for evaluation because of the resident's history of the hemicraniectomy. The NP stated that the resident had a history of seizures and was on antiseizure medication. She also stated that the resident had not had a seizure at the facility (admitted [DATE]). The resident had a seizure at the hospital which she felt could have been related to the fall and hitting her head. An interview with the Physician on 2/28/24 at 10:00 AM revealed that she believed that Resident #1 should have been sent to the hospital immediately after her fall due to her head trauma caused by falling off the shower bed. She stated that the resident had a left hemicraniectomy (missing a portion of her skull on the left side of her head) from a brain bleed in 2020. She could not say whether Resident #1's seizure was related to her fall or not. She stated that she did not know if the resident's fall had caused any negative consequences as the resident was in a chronic vegetative state. An interview with the Administrator on 2/27/24 at 10:54 AM revealed that she believed the cause of Resident #1's fall from the shower bed was caused by the shower bed failure due to the missing locking pins on the head and foot of the bed and the lack of staff education to check the pins were in place. She stated that the shower bed had been removed from use immediately. She indicated they did not have a system in place for training the staff on the shower bed. The Administrator was notified of immediate jeopardy on 2/28/24 at 11:15 AM. The facility provided a credible allegation of immediate jeopardy removal and the State Survey Agency returned to the facility on [DATE] to validate. The immediate jeopardy removal plan could not be validated as the facility failed to have sufficient evidence that education was completed for staff. Multiple staff working had not received education. The facility was asked to provide a revised credible allegation of immediate jeopardy removal. The facility provided the following revised credible allegation of immediate jeopardy removal: - Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance: On 2/1/24 at 02:50 am, Nursing Assistant #1 took Resident #1 to the shower room via the shower bed. The head of the shower bed was in an elevated position, and the foot of the shower bed was not in an elevated position. While entering the shower room, the wheel of the shower bed hit the drain in the floor, causing the bed to become unsteady and begin to tip to the side. The shower bed jarred, and the head of the bed (HOB) support fell . NA #1 prevented the shower bed from completely tipping to the side. However, the resident's body slid off the shower bed onto the floor. NA #1 called for assistance. The nurse completed a head-to-toe assessment of Resident #1 and noted a hematoma to the back of the head and a bruise on the lower back. The resident was assisted up from the floor via mechanical lift onto the shower bed and returned to the room. Neuro checks were completed from 3:00 am to 9:00 am with no negative findings. At 8:05 am, the facility Nurse Practitioner (NP) was notified of the status of the resident with no new orders. At 10:00 am, during a neuro check, the nurse noted nystagmus (repetitive, uncontrolled eye movement) and reported this to the NP. The NP assessed the resident with a new order to send to the emergency room for further evaluation and treatment. While at the hospital, the resident had a 2-minute breakthrough seizure and was treated for seizure-like activity. Additionally, the resident was admitted for a persistent vegetative state, and a small area of cerebral parenchymal hemorrhage chronic in nature, all unrelated to the fall. All residents who are transported via shower beds have the potential to be affected. The Director of Nursing identified these residents utilizing a census sheet on 2/2/24. On 2/1/24, a root cause analysis was completed by the Administrator and Director of Nursing. The root cause of the fall was that the footrest was not in the up position, and the locking pins were not in place per the manufacturer's specifications. On 2/1/2024, a 100% audit of incident reports from 1/1/2024 to 2/1/2024 was completed by the Quality Assurance Nurse (QA) to ensure no incident resulted from falls during shower transport by gurney or chair. There were no other identified areas of concern. On 2/1/24, a 100% audit was completed by the Maintenance Director to ensure that no other shower beds required locking pins. There were no other beds identified. The identified shower bed was immediately removed from service by the Maintenance Director. On 2/1/2024, questionnaires were initiated by the Staff Development Nurse with alert/oriented residents regarding concerns during shower chairs/bed transport. The questionnaires were completed on 2/1/24. There were no identified areas of concern. - 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 2/1/2024, a 100% audit of all shower beds/chairs was completed by the Maintenance Director to ensure no needed repairs were required including locking pins and to ensure safe operations. There were no other identified areas of concern. On 2/1/2024, a 100% audit of all shower rooms was completed by the Maintenance Director to ensure no safety hazards. There were no other identified concerns. On 2/1/24, the Administrator decided to not utilize the shower bed/chairs with pins. An in-service was completed by the Administrator on 2/1/24 with the supply clerk regarding not ordering any shower equipment requiring locking pins. An in-service was completed on 2/2/24 by the Administrator with the maintenance director regarding notifying the Administrator of any equipment that needs frequent attention/repairs and monitoring of shower beds/chairs weekly. An in-service was initiated on 2/1/2024 by the Staff Development Nurse with all nurses and nursing assistants regarding safety hazards and operational procedures when transporting residents in shower beds. This in-service emphasized (1) inspecting equipment for function and missing parts before transport, (2) immediately reporting to maintenance staff and/or supervisor safety hazards to prevent the risk of falls, (3) ensuring the resident is properly positioned in the shower bed, (4) not using the shower bed if equipment is not fully functional with all parts and (5) if repairs are needed, red tag the shower transport device and place outside maintenance office for repairs. In-service was completed by 2/2/2024. The Staff Development Nurse monitored staff completion of the in-service and ensured any nurse or nurse aide who had not completed the in-service will complete it before working their next scheduled shift. An in-service was initiated on 3/1/2024 by the Staff Development Nurse with all nurses and nursing assistants regarding safety hazards and operational procedures when transporting residents in shower chairs. This in-service emphasized (1) inspecting equipment for function and missing parts before transport, (2) immediately reporting to maintenance staff and/or supervisor safety hazards to prevent the risk of falls, (3) ensuring the resident is properly positioned in the shower chair, (4) not using the shower chair if equipment is not fully functional with all parts and (5) if repairs are needed, red tag the shower transport device and place outside maintenance office for repairs. In-service was completed by 3/1/2024. The Staff Development Nurse monitored staff completion of the in-service and ensured any nurse or nurse aide who had not completed the in-service will complete it before working their next scheduled shift. The Director of Nursing will provide oversight of staff education to validate staff knowledge and understanding of the education provided. Any newly hired nurses and nurse assistants will be educated by the Staff Development Nurse during orientation regarding safe operational procedures during shower chair/bed transport. The Staff Development Nurse was notified of this responsibility by the Administrator on 2/1/24. On 3/1/24, the Staff Development Nurse was instructed by the Administrator on the responsibility to include both shower chairs and beds with the education of all newly hired staff. Date of Immediate Jeopardy Removal: 3/2/24 The credible allegation of immediate jeopardy removal was verified on 3/05/24. Interviews were conducted with a sample of Nursing Assistants and Nurses to verify education was conducted for Nurses and NAs regarding shower bed/chair safety. Documentation of in-service records was reviewed. In an interview on 3/05/24 at 9:08 AM with the Maintenance Director, he stated that he had received education on the process that was put in place to monitor the shower beds/chairs weekly for safety. In an interview on 3/05/24 at 10:28 AM with the Staff Development Coordinator, she stated that all Nurses and Nursing Assistants had been in-serviced on the shower bed/chair for safety. She stated that she was responsible for orienting new nurses and nursing assistants on the safe operational procedure during shower bed/chair transport and use. An observation of the shower room revealed the current shower bed had no locking pins on the bottom of the bed. The shower chairs were observed and appeared to be in good condition. Three shower chairs were observed to be located on the maintenance hall with out of order tags attached to them. The facility's immediate jeopardy removal date of 3/2/24 was validated.

Based on observations, record review, staff, Nurse Practitioner (NP), and Physician interviews the facility failed to train Nursing Assistants (NAs) and verify competency for the safe operation of a foldable shower bed (a bed utilized for the provision of personal care for residents who are immobile or who have reduced mobility) for 1 of 1 NA (NA #1) reviewed. NA #1 was unaware that the shower bed required locking pins to be inserted to secure the head of the bed and the foot of bed to prevent the shower bed from folding. On 2/01/24 NA #1 transported Resident #1 to the shower room via the shower bed without utilizing the locking pins. While transporting the resident to the shower room the foot of the shower bed released and dropped toward to the floor. She continued to push the resident in the shower bed to the shower room. Once arriving in the shower room the shower bed was wheeled over the drain in the floor, the bed became unsteady, began to tip to the side and the head of the bed released dropping toward the floor resulting in the resident falling off of the shower bed headfirst onto the floor. The resident sustained a small bruise to the back of her head and an abrasion to her lower back area. The resident was transported to the hospital on 2/01/24 at 11:01 AM. At the hospital on 2/02/24, the resident had a breakthrough seizure. Immediate jeopardy began on 2/01/24 when the failure to train and verify competency of NAs to safely operate a shower bed resulted in Resident #1 falling from the shower bed to the floor headfirst. The immediate jeopardy was removed on 3/02/24 when the facility provided an acceptable 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: This tag is cross-referenced to: F689: Based on record review, observation, staff, nurse practitioner, and physician interviews, the facility failed to follow the manufacturer's instructions for the use of a mobile shower bed (a bed utilized for the provision of personal care for residents who are immobile or who have reduced mobility) and to provide care safely for 1 of 1 resident reviewed for supervision to prevent accidents. On 2/01/24 Nursing Assistant (NA) #1 transported Resident #1 to the shower room via the shower bed without utilizing the locking pins that secured the head and the foot of the bed in place. While transporting the resident to the shower room the foot of the shower bed released and dropped toward to the floor. NA #1 did not cease the transport. She continued to push the resident in the shower bed to the shower room. Once arriving in the shower room when the shower bed was wheeled over the drain in the floor, the bed became unsteady, began to tip to the side and the head of the bed released dropping toward the floor resulting in the resident falling off of the shower bed headfirst onto the floor. The resident sustained a small bruise to the back of her head and an abrasion to her lower back area. The resident was transported to the hospital on 2/01/24 at 11:01 AM. At the hospital on 2/02/24, the resident had a breakthrough seizure. An interview on 2/27/24 at 1:13 PM with the Staff Development Coordinator (SDC) revealed that she had been SDC for about one year and had not provided training for the safe operation of the shower bed for nursing assistants or nurses. She stated that the skills checklists do not include training for shower beds. The Administrator was notified of Immediate Jeopardy on 2/28/24 at 11:15 AM. The facility provided a credible allegation of immediate jeopardy removal and the State Survey Agency returned to the facility on [DATE] to validate. The immediate jeopardy removal plan could not be validated as the facility failed to have sufficient evidence that education was completed for staff. Multiple staff working had not received education. The facility was asked to provide a revised credible allegation of immediate jeopardy removal. The facility provided the following revised credible allegation of immediate jeopardy removal: - Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance; On 2/1/24 at 02:50 am, Nursing Assistant #1 took Resident #1 to the shower room via the shower bed. The head of the shower bed was in an elevated position, and the foot of the shower bed was not in an elevated position. While entering the shower room, the wheel of the shower bed hit the drain in the floor, causing the bed to become unsteady and begin to tip to the side. The shower bed jarred, and the head of the bed (HOB) support fell . NA #1 prevented the shower bed from completely tipping to the side. However, the resident's body slid off the shower bed onto the floor. NA #1 called for assistance. The nurse completed a head-to-toe assessment of Resident #1 and noted a hematoma to the back of the head and a bruise on the lower back. The resident was assisted up from the floor via mechanical lift onto the shower bed and returned to the room. Neuro checks were completed from 3:00 am to 9:00 am with no negative findings. At 8:05 am, the facility Nurse Practitioner (NP) was notified of the status of the resident with no new orders. At 10:00 am, during a neuro check, the nurse noted nystagmus (repetitive, uncontrolled eye movement) and reported this to the NP. The NP assessed the resident with a new order to send to the emergency room for further evaluation and treatment. While at the hospital, the resident had a 2-minute breakthrough seizure and was treated for seizure-like activity. Additionally, the resident was admitted for a persistent vegetative state, and a small area of cerebral parenchymal hemorrhage chronic in nature, all unrelated to the fall. All residents who are transported via shower beds have the potential to be affected. The Director of Nursing identified these residents utilizing a census sheet on 2/2/24. On 2/1/24, a root cause analysis was completed by the Administrator and Director of Nursing. The root cause of the fall was that the nursing assistant transported the resident to the shower room without being properly educated on the safe operation procedures for using the shower bed with locking pins prior to using it. - 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 2/1/2024, questionnaires were initiated by the Quality Assurance Nurse (QA) with all nursing staff regarding observations of any concerns during residents' shower bed/chair transports. Questionnaires were completed by 2/2/2024. After 2/2/24, the Staff Development Nurse monitored staff completion and any nurse or nurse aide who has not completed the questionnaire will complete these before working their next scheduled shift. On 2/1/24, the Staff Development Nurse initiated return demonstrations of shower bed transport with all nurses and nursing assistants. The purpose of the return demonstration is to ensure staff demonstrate a successful knowledge of safe operational procedures during shower bed transport. For any identified concerns during the return demonstration, staff will be immediately retrained and only allowed to operate shower transport equipment once they pass the return demonstration. The return demonstrations were completed by 2/2/2024. After 2/2/24, the Staff Development Nurse monitored staff completion and any nurse or nurse aide who has not completed the return demonstration will complete it before working their next scheduled shift. On 3/1/24, the Staff Development Nurse initiated return demonstrations of shower chair transport with all nurses and nursing assistants. The purpose of the return demonstration is to ensure staff demonstrate a successful knowledge of safe operational procedures during shower chair transport. For any identified concerns during the return demonstration, staff will be immediately retrained and only allowed to operate shower transport equipment once they pass the return demonstration. The return demonstrations were completed by 3/1/2024. After 3/1/24, the Staff Development Nurse monitored staff completion and any nurse or nurse aide who has not completed the return demonstration will complete it before working their next scheduled shift. The Director of Nursing will provide oversight of the education and return demonstrations of all staff to validate staff knowledge and understanding of education. Any newly hired nurses and nurse assistants will be educated by the Staff Development Nurse during orientation regarding safe operational procedures during shower chair/bed transport with the completion of a return demonstration before using the equipment. The Staff Development Nurse was notified of this responsibility by the Administrator on 2/1/24. On 3/1/24, the Staff Development Nurse was instructed by the Administrator on the responsibility to include return demonstrations of both the shower chair and shower bed with the education of all newly hired staff. Immediate Jeopardy Removal Date: 3/2/24 The credible allegation of immediate jeopardy removal was verified on 3/05/24. Interviews were conducted with a sample of Nursing Assistants and Nurses to verify education was conducted for Nurses and NAs regarding shower bed/chair safety. Documentation of in-service records was reviewed. In an interview on 3/05/24 at 10:28 AM with the Staff Development Coordinator, she stated that all Nurses and Nursing Assistants had been in-serviced on the shower bed/chair for safety. She stated that she was responsible for orienting new nurses and nursing assistants on the safe operational procedure during shower bed/chair transport and use. The facility's immediate jeopardy removal date of 3/02/24 was validated.

Based on observations, record review, and staff interviews the facility failed to 1) follow procedure for gastrostomy tube (g-tube) care by Nurse #2 pushing water with the plunger through the syringe into the g-tube and 2) failed to store a tube feeding syringe with the plunger separated from the barrel. This was for 1 of 1 resident reviewed for enteral feeding management (Resident #1). Findings included: Resident #1 was admitted to the facility on [DATE] with diagnoses which included cerebrovascular accident and Diabetes Mellitus. Resident #1's quarterly Minimum Data Set, dated dated dated [DATE] revealed she was dependent on staff for activities of daily living. An observation on 2/27/24 at 11:38 AM revealed that Nurse #2 injected 30 cubic centimeters (cc) into Resident #1's g-tube using the plunger instead of allowing the water to flow in the syringe by gravity through the g-tube to prevent discomfort in the abdomen and potential damage to the g-tube. Nurse #2 then placed the syringe with the plunger inside the barrel in the storage bag. An interview on 2/27/24 at 11:47 AM with Nurse #2 revealed that she had been taught to push the water into the g-tube instead of allowing it to flow in by gravity. She also stated that she had been taught to store the syringe barrel and plunger separately in the bag but had not done so due to nervousness. An interview on 2/27/24 at 11:54 AM with the Director of Nursing (DON) revealed that she did not know why Nurse #2 pushed the water into the g-tube with the plunger instead of allowing it to flow by gravity or why she had stored the syringe plunger and barrel together.

Based on record review, observation, nurse practitioner, physician, and staff interviews, the facility's Quality Assessment and Assurance (QAA) committee failed to maintain implemented procedures and monitor interventions that the committee put into place following the recertification and complaint investigation survey of 4/20/23. This was for the deficiency in the area of Free of Accident hazards/Supervision/Devices (F689) that was subsequently recited on the current complaint investigation survey of 3/05/24. The continued failure of the facility during 2 federal surveys of record showed a pattern of the facility's inability to sustain an effective Quality Assurance Program. Findings included: This tag is cross-referenced to: F689: Based on record review, observation, staff, nurse practitioner, and physician interviews, the facility failed to follow the manufacturer's instructions for the use of a mobile shower bed (a bed utilized for the provision of personal care for residents who are immobile or who have reduced mobility) and to provide care safely for 1 of 1 resident reviewed for supervision to prevent accidents. On 2/01/24 Nursing Assistant (NA) #1 transported Resident #1 to the shower room via the shower bed without utilizing the locking pins that secured the head and the foot of the bed in place. While transporting the resident to the shower room the foot of the shower bed released and dropped toward to the floor. NA #1 did not cease the transport. She continued to push the resident in the shower bed to the shower room. Once arriving in the shower room when the shower bed was wheeled over the drain in the floor, the bed became unsteady, began to tip to the side and the head of the bed released dropping toward the floor resulting in the resident falling off of the shower bed headfirst onto the floor. The resident sustained a small bruise to the back of her head and an abrasion to her lower back area. The resident was transported to the hospital on 2/01/24 at 11:01 AM. At the hospital on 2/02/24, the resident had a breakthrough seizure. During the recertification and complaint investigation survey of 4/20/23, the facility was cited for failure to provide a safe transfer by mechanical lift for a dependent resident. The facility also failed to prevent a cognitively impaired resident with known exit seeking behaviors from exiting the facility unsupervised. An interview with the Administrator on 3/05/24 at 8:10 AM revealed that she believed that 1 month of monitoring was not sufficient to ensure the changes were sustained. She stated that moving forward the QAA committee will monitor longer than one month and evaluate whether the changes were sustained.

Based on observations, record review, staff and Physician interviews the facility failed to provide a safe transfer by mechanical lift for a dependent resident (Resident #33) on 04/07/23 when Nurse Aide (NA) #11 used an extra-large sling instead of the medium sized sling the resident was assessed to require. The resident fell out of the sling during the transfer hitting her head on the lift and on the floor. She sustained a laceration to the back of her head with bleeding, she required hospital treatment and 3 staples for the laceration, and she suffered pain from the injury. The facility also failed to prevent a cognitively impaired resident (Resident #39) with known exit seeking behaviors from exiting the facility unsupervised. On 04/14/23 Maintenance Staff #1 thought Resident #39 was a family member of another resident and he let her out of the front door of the facility. She had no staff supervision. She was found approximately 205 feet away from the entrance door to the facility at the bottom edge of the curb where it meets the street level of a highly traveled roadway. This had a high likelihood of resulting in serious harm to Resident #39. This was for 2 of 3 residents reviewed for accidents. Findings included: 1. Resident #33 was admitted to the facility on [DATE]. Diagnoses included, in part, dementia, severe degenerative joint disease with bilateral knee contractures, and osteoarthritis of knee. The Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #33 was moderately cognitively impaired and required total dependence with one staff physical assistance with transfers, and extensive assistance with one staff physical assistance with bed mobility, dressing, toileting, and personal hygiene. She had impairment to both sides to upper extremities and lower extremities. She was coded as having no falls during this assessment and weight was recorded as 106 pounds (lbs.) and 63 inches in height. A review of the care plan updated on 03/05/23 revealed Resident #33 had a plan of care in place for Activities of Daily Living/Personal Care with a goal that care would be completed with staff support as appropriate to maintain or achieve highest practical level of functioning with interventions to include, in part, mechanical lift with assistance of one. Review of the active Resident Care Guide for Resident #33 revealed, in part, the resident was non ambulatory and was to use the medium sized sling (yellow) when transferring with the mechanical lift. A review of the manufacturer's recommended lift slings by size and patient weight revealed the following: Color/Size/Weight - Gray/ Medium Slim (slender adult)/66-121 lbs. - Yellow/Medium/88-176 lbs. - Blue/Large/154-265 lbs. - Black/Extra-Large/265-551 lbs. - White/Extra, Extra, Large/441 lbs. or greater An incident note written by Nurse #9 on 04/07/23 at 6:00 AM revealed the Nurse Aide (NA #11) called this nurse to Resident #33's room to assess a head injury. Nurse Aide reported the resident slipped out of sling and fell to the floor during a transfer from the bed to a shower bed. Resident was responsive, alert to self and current situation. Small laceration noted to back of head with bleeding noted. No other injuries were noted at this time. Vital Signs were temperature 98.1, heart rate was 74 beats per minute (bpm), respiration rate was 18 breaths per minute (bpm), blood pressure was 109/62 millimeters of mercury (mm/hg), and oxygen saturation was 97%. Ice pack placed to injury and neurological (neuro) checks (an assessment to monitor neurological signs and symptoms) started. A progress note written by Nurse #9 on 04/07/23 at 6:15 AM revealed Emergency Medical Services (EMS) were called in to transport Resident #33 for laceration and swelling at back of head. Resident told EMS she did not want to go to hospital. EMS completed their assessment and stated that if condition worsened or Resident's caseworker stated she must go, to call them and they would come back. A progress note written by the Director of Nursing on 04/07/23 at 8:00 AM revealed she spoke with the Nurse Practitioner (NP) via phone to update the condition of resident. Informed the NP that EMS was notified and declined to take the resident to the Emergency Department (ED) due to her verbal refusal to go. Notified the NP of injuries (laceration to head). The NP had no new orders and stated to call back with any change in condition. Neurological checks to continue per protocol. A phone interview was conducted with Nurse Aide (NA) #11 on 04/19/23 at 6:42 PM. NA #11 reported she had been a nurse aide for 2 years and had knowledge of how to operate the mechanical lift. NA #11 stated if a resident was care planned for two staff members for transfers with a mechanical lift, then two staff members would need to be present during the transfer and if the resident was care planned for one staff member to assist with transfers with a mechanical lift then only one staff member would need to be present. NA #11 stated she would access the Resident Care Guide to know what a resident was care planned for via the computer system. She stated the Resident Care Guide for Resident #33 indicated the resident required a mechanical lift with one staff assistance with transfers and to use a medium sling. NA #11 stated on the morning of 04/07/23, she was preparing to give Resident #33 a shower. She stated she was unable to find a medium sized sling that was meant for the resident, so she grabbed an extra-large one that was available in the clean laundry area. She stated she secured the straps between her legs, and she seemed secured and as she was transferring Resident #33 from her bed to the shower bed. NA #11 stated the resident's leg and buttocks slipped out of the bottom of the sling, and she fell backwards, hitting her head on the leg of the lift and the floor. She stated she called for the nurse. Nurse #9 assessed her, and she called EMS because the back of the resident's head was bleeding. NA #11 reported she could not find a medium sized sling and there were no other sizes available except for the extra-large. She stated she did not let the nurse know or ask any other aides to assist with locating a medium sized sling. She stated she should have asked for help finding one because the fall could have been avoided if the resident was in the correct size sling during the transfer. NA #11 stated at times it was difficult to find the right sized slings to use for residents but she had not informed any other staff of this issue. She stated most of the times, the sling size assigned to the resident would be located in their rooms, but she was unable to find it and assumed it was sent to be laundered. A phone interview was conducted with Nurse #9 on 04/20/23 at 9:36 AM. Nurse #9 reported NA #11 informed her Resident #33 slipped out of the sling on 04/07/23. Nurse #9 reported when she went into the room, she assessed Resident #33, and she was bleeding in the back of her head, so she called 911 and notified the Director of Nursing (DON). When EMS arrived, they refused to transport Resident #33 because the resident told him she did not want to go. Nurse #9 stated she notified the DON of the resident's refusal. She stated Resident #33 complained that her head hurt but she was okay, but it was obvious to her that Resident #33 needed sutures. Nurse #9 reported she started neuro checks immediately and there were no neurological changes, applied pressure to the back of the head and applied an ice pack. Nurse #9 stated NA #11 told her the resident had slipped out of the sling and she had not been able to locate a proper size sling and she had used a size larger. Nurse #9 stated she informed the NA if that ever happened, she needed to let her know. Nurse #9 stated no nurse aide had ever notified her that they could not locate a certain size sling. Nurse #9 added, if the nurse aides had trouble finding one, they would come to a nurse. She stated usually if the slings were clean, they were kept in the resident's rooms in the closet, and if they were sent to be cleaned, they would be stored in the clean linen area in the laundry room. Nurse #9 stated she was not aware of any aides having difficulty locating medium sized slings for transfers with the mechanical lift. A progress note written by the Treatment Nurse on 04/07/23 at 9:00 AM revealed she was asked to assess the back of the Resident #33's head. She entered the resident's room and noted the resident to be lying in bed with a towel behind her head with bright red blood. A contusion (bruise) to the upper part of the back of the resident's head was noted and her hair was noted to be matted to the contusion area. The Treatment Nurse indicated she used a towel and normal saline (sterile water) to remove the matted hair from the contusion area in which a scalp laceration approximately 4 centimeters (cm) horizontally was noted in middle of the contusion. The scalp laceration was noted to be open and bleeding. The resident was made aware of the scalp laceration and that the area was still bleeding. The Treatment Nurse exited the room and made a phone call to the NP making her aware of the resident's scalp laceration and that it was still bleeding. The NP made decision for Resident #33 to be sent to ED for evaluation. A progress note written by Nurse #2 on 04/07/2023 at 9:10 AM revealed the NP was contacted via phone due to the laceration and contusion to back of Residents #33's head assessed by Treatment Nurse. Resident #33 was bleeding from the laceration. Neuro checks remained within normal limits. Resident #33 had no change in cognition from baseline and denied pain. The NP provided an order to send the resident to the ED for evaluation. Nurse #2 contacted EMS and they arrived at the facility at 9:10 AM. Resident #33 agreed to ED transfer and treatment. Resident #33 left facility at 9:15 AM via stretcher with the assistance of 2 EMS personnel. Review of the hospital emergency room records on 04/07/23 revealed, in part, Resident #33 presented to ED for evaluation after a fall. The resident had a diagnosis of dementia and could not offer much history. The resident was noted to have laceration to the back of her head. The resident had hit her head when she fell . A CAT (CT) Scan (a computerized x-ray imaging machine) of the head and neck were obtained as this was suspicious for acute intracranial abnormality such as subdural or epidural hematoma (a solid swelling of clotted blood) and cervical fracture. The CT scan was read by radiology and the physician and there were no acute fractures nor intracranial abnormality. The laceration required repair. Resident tolerated procedure well and was advised to have the sutures removed in 7 - 10 days by her primary care provider. Review of the Procedure Note for Resident #33 dated 04/07/23 in the ED revealed, in part, Laceration Repair: Laceration of scalp 1.5 centimeters in length was anesthetized locally using 2% lidocaine (a numbing agent) with epinephrine (a medication used to relax blood vessels). Laceration was cleaned using antiseptic with copious (abundant) saline irrigation. Exploration of the wound did not show evidence of foreign body and did not show evidence of tendon injury. The laceration was closed with 2 staples. A progress note written on 04/07/23 at 2:45 PM by Nurse #2 revealed Resident #33 returned from the ED via ambulance/stretcher accompanied by an EMS attendant. The resident was transferred to bed by EMS. A full body assessment was completed. No new injuries were noted. Resident #33 expressed pain to her head but could not verbalize on numerical pain scale. Resident #33 kept saying ouch my head really hurts when it touches the pillow. The resident returned with an order to not scrub/wash scalp for 2-3 days but may rinse and pat dry laceration in back of head with 3 staples. A physician's order for Resident #33 written on 04/07/23 revealed remove staples in 7 - 10 days, do not scrub or wash scalp for 2 - 3 days, may rinse and pat dry. A Progress note written by the Nurse Practitioner on 04/13/23 revealed, in part, Resident #33 had a fall with head injury, and this was a follow up from ED visit. Resident #33 slipped out of the sling during a transfer to the shower and hit the back of her head causing a 1.5 cm laceration that was bleeding. Resident #33 initially refused transfer to the ED but the laceration kept bleeding and staff called EMS. Upon arrival to the ED, the resident denied any pain, and her vital signs were stable with a blood pressure of 110/68 mm/hg and heart rate of 88 bpm. Her laceration required repair with 3 staples and she tolerated this well. The resident returned to the facility in stable condition. The Nurse Practitioner's exam of her head revealed 1.5 cm well approximated superficial laceration to posterior (back) head repaired with 3 staples and no underlying swelling or bruising. Resident was sitting up in her recliner in no acute distress or complaints of pain. An observation and interview were conducted with Resident #33 on 04/17/23 at 12:45 PM. Resident #33 was alert and pleasantly confused. She was sitting on the edge of the bed eating her lunch and had no complaints of pain. She denied ever having any falls. An interview with Nurse #2 on 04/19/23 at 2:30 PM revealed Resident #33 sustained a fall on 04/07/23 on the night shift when an aide used the wrong size sling, and she slipped out of the sling while being transferred with a mechanical lift. Nurse #2 stated Resident #33 was care planned to be transferred with one staff assist. Nurse #2 stated the sling size was determined by a nurse based on the resident's height and weight. Nurse #2 confirmed Resident #33's weight was 106 lbs., and a medium sized sling was correct. An observation on 04/19/23 at 4:30 PM of the clean laundry area for availability of mechanical lift slings revealed there were several slings hanging on the wall upon entry. There were noted to be 4 medium slings (indicated by the color yellow stripe on the sling and a tag insert indicating it was a size medium) hanging in the clean laundry section. An interview was conducted with NA #3 on 04/20/23 at 10:35 AM. NA #3 revealed if she needed a mechanical lift sling she would go to the clean laundry section where they were hanging and get the size she needed. She stated there were usually enough available in all sizes including medium. She stated the medium slings had a yellow stripe on them. She stated many times the slings the resident used were located in their rooms. She stated the nurses had to select the right size sling to use based on the resident's weight and height. She stated she would not make that decision and that it was decided by a nurse, and it would be documented in the care plan and Resident Care Guide. An interview with the Director of Nursing on 04/20/23 revealed she had been notified via phone on 04/07/23 that Resident #33 had a fall from the mechanical lift, sustained an injury to her head and refused to go to the hospital with EMS. She stated when she came in that morning, she notified the NP about Resident #33's refusal and the NP stated to monitor the resident for any change of condition. Shortly after she notified the NP, Nurse #2 reported Resident #33 had increased bleeding and the treatment nurse assessed her and cleaned her up. The DON stated at that point, the NP was notified again, and she gave the order to send the resident to the ED for further evaluation. The DON stated the resident agreed to go with EMS to the hospital and when she returned she had 3 staples to the back of her head. The DON confirmed there were 3 staples used to close the laceration and not 2 staples as indicated on the ED report. The Nurse Practitioner was not available for an interview. 40044 2. Resident #39 was admitted to the facility on [DATE] with diagnoses including Intracranial injury, history of fractures, repeated falls, and dementia with behavioral disturbance. A care plan dated 10/26/22 revealed Resident #39 had a plan of care in place due to wandering and was at risk for unsupervised exits from the facility related to cognitive impairment. The goal of care was for Resident #39 to have no episodes of unsupervised exits from the facility through the next review. Interventions included administering medications as ordered. Implementing the at-risk wandering protocol which included to ensure the resident's picture and name were on the wandering resident board, to post the residents name on their door as allowed and placing a wander guard alarm bracelet to Resident #39's left ankle. A physician's order dated 12/14/22 for Resident # 39 revealed to ensure wander guard was in place to left ankle and to check every shift due to frontal lobe and executive function deficit. The Minimum Data Set quarterly assessment dated [DATE] revealed Resident #39 had moderately impaired cognition. She required limited one person assistance with transfers and walking in room and corridor and extensive one person assistance with locomotion off and on the unit. Resident #39 had no impaired range of motion and used a walker for mobility and used a wander guard alarm daily. Resident #39 had no wandering behaviors at the time of the assessment. A progress note dated 03/31/23 at 02:51 AM written by Nurse #6 revealed in part; Resident #39 remained at baseline cognitive function and was oriented to person only. Resident continued to ask for bible study and continued to attempt to walk out to the door to catch my ride. Resident #39 continued to believe that someone was coming to pick them up for church. Nurse #6 indicated Resident #39 would continue to be monitored and reassessed. A progress note dated 04/14/23 written by Nurse #1 revealed Resident #39 had an unwitnessed exit from the building. Resident #39 was assisted back to the building by staff and taken to her room where a head-to-toe body assessment was performed with no injury identified. Vital signs were within normal limits, neurologic checks were done, and one-to-one supervision was provided. Resident #39 stated, I was going to bible study. She was smiling and laughing. She was wearing a white tank top with a green button-up shirt over it, purple pants and sneakers. The weather outside during the time of the occurrence was approximately 70 degrees and sunny. An investigation summary completed by the Administrator dated 04/14/23 revealed Resident #39 approached the front entrance door at approximately 4:40 PM without an assistive device and asked Maintenance Staff #1 from a sister facility if she could go outside to which he replied yes. Maintenance Staff #1 was not familiar with Resident #39 and believed her to be a family member when he told her she could go outside. Resident #39 exited the building, stepped off the front porch, turned to the right to walk across the parking lot and into the street that runs parallel to the building. Once Resident #39 crossed the street she wound up on the sidewalk in front of a housing development beside the building. A van passing by the facility pulled into the parking lot and notified the Social Worker that one of their residents might be standing across the street. The Social Worker looked across the street and realized it was Resident #39 and asked the receptionist to please call a code orange (elopement) while the Social Worker went to assist the resident back to the building. Resident #39 was given her walker and assisted back to the building safely without injuries. The timeline of events included in the investigation summary that was completed by the Administrator on 04/14/23 included: At approximately 3:30 PM Resident #39 was in her room with no exit seeking behavior observed. At approximately 3:35 PM Resident #39 was observed ambulating in the hallway without a walker. The staff went to get her walker and found her in the charting room. Resident was provided her walker and began ambulating down the hallway. At approximately 4:00 PM another resident (Resident #2) was sitting outside on the front porch. At approximately 4:40 PM a nurse aide returning from break observed Resident #39 seated in the lobby. At approximately 4:40 PM Resident #39 was observed in the lobby by the Activities Director sitting in a chair looking at a magazine. Maintenance Staff #1 was observed working on the front entrance door code. Resident #39 asked Maintenance Staff #1 if she could go outside. Resident #39 did not have an assistive device and was able to walk up to the entrance door without assistance. Maintenance Staff #1 believing that Resident #39 was a visitor answered yes. Resident #39 then proceeded to exit the front entrance into the parking lot. The door did not alarm or lock when the resident exited the facility. Resident #39 had a wander guard in place to her left ankle at the time of the event and it had previously been noted to have been working properly. At approximately 4:45 PM Resident #2 was sitting outside on the front patio and observed Resident #39 exit the front door walking very fast. A transport van pulled into the parking lot at approximately the same time and the driver notified the Social Worker that a person was outside and may be a resident of the facility. The Social Worker observed Resident #39 on the far side sidewalk walking along the sidewalk with a magazine in her hand. The Social Worker immediately assisted Resident #39 back to the facility. Upon entering the facility, the door alarm was triggered by the resident's wander guard. At approximately 4:50 PM Resident #39 was assessed by Nurse #1 with no negative findings. Resident #39 stated I was going to bible study. Resident #39 was immediately placed on one-to-one observation. At approximately 4:48 PM the Quality Assurance (QA) Nurse was returning to the building and observed Resident #2 sitting on the front porch of the facility. Resident #2 informed the QA Nurse that Resident #39 had gotten out the front door and pointed to the right side of the building. The QA Nurse observed the Social Worker with Resident #39 in the parking lot driveway heading back to the building. The QA Nurse entered the building to get assistance. At approximately 4:55 PM the Director of Nursing (DON) was returning to the facility, while walking up to the building the QA Nurse informed her that Resident #39 had exited the building. The DON observed the Social Worker walking Resident #39 back to the building. The DON immediately instructed staff to complete a 100% head count to ensure all residents were accounted for. The DON asked Resident #39's primary nurse (Nurse #1) to initiate vital signs and a full head to toe assessment with neurological checks. When the DON asked Resident #39 where she was going, she stated to bible study, and I wanted my husband to go with me, but he was asleep. The investigation summary completed by the Administrator dated 04/14/23 revealed Resident #39 was care planned for being at risk for wandering since July 2022 and wore a wander guard. Resident #39 resided in her room with her spouse and generally spent most of the day in her room. Resident #39 ambulated with a walker or independently in the hallway and was easily redirected by staff. Resident #39 had no prior unsupervised exits. Per staff report Resident #39 was last seen approximately 10 minutes before exiting the facility sitting in the lobby with no exit seeking behaviors. The resident was out of the facility for approximately 10 minutes and was observed by an alert and oriented resident exiting the facility. A witness statement from Maintenance Staff #1 dated 04/14/23 revealed that at approximately 4:40 PM, he was standing at the entrance door in the lobby getting ready to change the door code when Resident #39 approached the front door and asked if she could go outside. He replied yes believing that she was visiting a family member. The resident did not have an assistive device and was able to walk up to the front door without assistance. Resident #39 proceeded to exit the front entrance out into the parking lot. He was later notified that the resident wore a wander guard and was at risk of wandering. At the time of her exit the door alarm did not sound and the door did not lock. After the resident went outside, he changed the door code and went to report this to the Administrator. He had no further interactions with this resident. No other employees were present the receptionist had left her desk to make copies. No other residents or visitors were present in the lobby. Attempts were made to contact Maintenance Staff #1 during the investigation with no response. During an interview conducted on 04/20/23 at 2:58 PM the Social Worker stated on 04/14/23 around 4:45 PM she was leaving for the day and as she walked out of the front door a random lady came up to her and stated she wanted to know if that was one of their residents over in the neighborhood next to the facility. She stated she looked over and saw Resident #39 in the adjacent neighborhood and she ran toward the resident while calling the facility with her cell phone to have them call a code orange. She stated Resident #39 started walking towards her from the street in the neighborhood and told her she was going to bible study and stated she returned Resident #39 back to the building and the nurses took over from there. She stated she observed no visible injuries on Resident #39. She stated she received education on wandering behaviors and preventing resident elopements following the incident. During an interview conducted on 04/19/23 at 4:40 PM the DON stated she had just returned from a training event on 04/14/23 and came into the parking lot when she saw the Social Worker escorting Resident #39 back into the facility and she was informed of what had just occurred. She stated she was told by the QA Nurse Resident #39 was seen by someone passing by on the highway and that person thought she could be one of their residents, so she came and notified the facility. She stated she was told by the QA Nurse Resident #39 was in the street in the adjacent neighborhood. Resident #39 stated she was going to bible study and stated Maintenance Staff #1 was working on the door code and thought the resident was a visitor and allowed her to go out. She stated a full assessment of Resident #39 was completed by the nurse (Nurse #1) and no injuries were identified. She indicated a plan of correction was implemented on 04/14/23 including a complete head count of residents, checking wander guards and door alarms, wandering assessments were completed, and staff education was initiated. An observation was conducted along with the DON on 04/19/23 at 4:40 PM through 4:45 PM of the area of the street in the adjacent neighborhood where Resident #39 was found unsupervised outside of the facility on 04/14/23. There were sidewalks noted on each side of the neighborhood street, beyond each sidewalk there was a small grassy area that ended at the curb on the edge of the street. There were no posted speed limit signs in the neighborhood. Three cars passed by driving into the neighborhood during the observation. The observed area of the street where the DON indicated Resident #39 was found was a short distance from the entrance to the neighborhood which led to a highly traveled street. There were no visible speed limit signs. During an interview conducted on 04/20/23 at 3:04 PM Nurse #1 stated she was the assigned nurse for Resident #39 on 04/14/23 and saw her at the medication cart earlier that day and in the alcove where the nurse aides sit, and a nurse aide assisted her back into the hallway. She stated Resident #39 normally roamed the halls so that was not out of her normal behavior. She stated as the evening went on, she was told Resident #39 was missing and then she heard the code orange on the intercom. She stated another staff member told her the resident was outside next door to the facility, so she ran outside and assisted the Social Worker with bringing her back inside the building. She stated by that time, Resident #39 and the Social Worker were already walking back toward the building, so she was unsure of her location when the Social Worker got to her. She stated Resident #39 was talking and saying she was going to bible study. She asked her if she was okay, and the resident stated yes. She stated she assisted her inside and did a full head to toe assessment and there were no injuries. She stated Resident #39 was placed on one-to-one observation at that time and stated her wander guard was in place when the incident occurred. She stated her wander guard was checked earlier that day and was functioning properly and it was checked again after the incident for functioning, and it worked. She stated she received in-service training on wandering behaviors, and elopement over the weekend of 4/15/23 and again this week. An observation was conducted along with Maintenance Staff #2 on 04/20/23 at 3:00 PM of the area of the street in the adjacent neighborhood where Resident #39 was found on 04/14/23 unsupervised outside of the facility. Maintenance Staff #2 measured the distance from the front door of the facility to the approximate area of the street where Resident #39 was found. The distance measured 205 feet. An observation was conducted along with the Social Worker on 04/20/23 at 4:15 PM of the area of the street in the adjacent neighborhood where Resident #39 was found unsupervised outside of the facility on 04/14/23. The Social Worker stated when she got to Resident #39, she was standing in the curb on the edge of the street in the neighborhood. An interview was conducted 04/20/23 at 4:25 PM with Resident #2 who was sitting on the front porch during the incident. Resident #2 was alert and oriented and stated he was sitting on the front porch that day and saw her (Resident #39) walk out the front door and walk down the sidewalk. He stated he thought she was going behind the building then the next thing he knew someone pulled into the parking lot and came and asked if that was a resident here. He stated the Social Worker came out and went to get her (Resident #39), and stated he saw her over there on the street and pointed to the street in the adjacent neighborhood. He indicated he was not sure of how long she was outside unsupervised. An observation conducted on 04/19/23 at 5:05 PM revealed Resident #39 was lying in bed with no signs of exit seeking behaviors observed. A nurse aide was observed sitting in the resident's room for one-to-one supervision. A wander guard was in place on Resident #39's left ankle. During a follow up interview on 04/20/23 at 4:40 PM the DON stated Resident #39 had not exited the building unsupervised prior to the incident on 04/14/23. She indicated Resident #39 was care planned for exit seeking behaviors prior to this incident and measures were already in place such as using a wander guard and checking alarms. She indicated all staff had been educated from 04/14/23 through 04/16/23 on interventions for wandering behaviors and preventing elopement and any staff that had not worked must complete in-service training prior to their next shift. During an interview on 04/20/23 at 6:00 PM the Administrator indicated they had measures in place to prevent residents from exiting the building unsupervised. She indicated this incident was due to human error and Maintenance Staff #1 who was not familiar with their residents mistakenly thought Resident #39 was a visitor. She stated interventions have been implemented such as the receptionist must notify the supervisor to find coverage before leaving the front desk to help prevent reoccurrence and education had been provided to all staff including Maintenance Staff #1. The Administrator was notified of immediate jeopardy on 04/20/23 at 12:04 PM The facility submitted the following corrective action: F689 Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice. 1) Resident #33 is alert but confused with a Brief Interview for Mental Status (BIMS) of 9. The resid [TRUNCATED]

Based on record review and staff interviews the facility failed to notify the Ombudsman within 30 days and in writing when 2 of 2 sampled residents were discharged to the hospital (Resident #30 and Resident #44). Findings included. 1. Resident # 30 was admitted to the facility on [DATE]. Resident #30 was discharged to the hospital on 03/04/23 and readmitted to the facility on [DATE], then discharged to the hospital again on 03/25/23 and readmitted [DATE] with diagnoses including hematuria, and urinary tract infection. A nursing progress note dated 03/04/23 at 7:03 PM indicated Resident #30 experienced a change in condition. Resident #30's Responsible Party (RP) was notified. The primary care provider was notified, and a recommendation was made to send resident to the hospital for further evaluation. A nursing progress note dated 03/25/23 at 5:55 PM indicated Resident #30 experienced a change in condition. Resident #30's Responsible Party (RP) was notified. The primary care provider was notified, and a recommendation was made to send resident to the hospital for further evaluation. Interview with the Social Worker on 04/20/23 at 8:18 AM indicated she did not send a list of discharges to the Ombudsman. She stated she had never been told to do this and had never heard of it. She stated she was not aware of a regulation regarding notification of the Ombudsman of residents discharged from the facility. Interview with the Director of Nursing (DON) on 04/20/23 at 8:46 AM indicated when a resident was sent to the hospital, the resident or RP was informed verbally of the transfer to the hospital. The DON did not know if anyone notified the Ombudsman of discharges. A follow up interview on 04/20/23 at 8:57 AM with the Social Worker revealed she did not inform the Ombudsman of the facility initiated or resident initiated discharges. She stated she had never been informed to send the Ombudsman a list of discharges. She stated the business office, and the Quality Assurance nurse kept lists of the residents that were discharged but she did not know if either of them sent the lists to the Ombudsman. Interview on 04/20/23 at 9:10 AM with the Quality Assurance nurse indicated she did not inform the Ombudsman of discharges and she had not been informed to do that. Interview on 04/20/23 at 9:11 AM with the Business Office Manger revealed she did not inform the Ombudsman of discharges. Interview with the Administrator on 04/20/23 at 4:45 PM revealed she was not aware of a regulation regarding notification of the Ombudsman of discharges. The Administrator stated the facility would implement a system of sending the Ombudsman written notification of facility discharges. 45711 2. Resident #44 was originally admitted to the facility on [DATE]. Resident #44 was discharged to the hospital on 2/22/23 and was readmitted to the facility on [DATE] with diagnoses of aspiration pneumonia and acute respiratory failure. Nursing progress note on 2/22/2023 at 2:50 PM indicated Resident #44 experienced a change in condition. Resident #44's primary care physician was notified, and recommendation was made to send resident to the hospital for evaluation. Resident #44 was his own responsible party. Resident #44 was discharged to the hospital via emergency medical services (EMS) for evaluation and treatment. Interview with the Social Worker (SW) on 4/20/23 at 8:18 AM indicated she did not send a list of discharges to the Ombudsman. SW stated she had never been told to do this and had never heard of it. SW was not aware of a regulation regarding notification of the Ombudsman of residents discharged from the facility. Interview with the Director of Nursing (DON) on 4/20/23 at 8:46 AM indicated when a resident was sent to the hospital, the resident or responsible party was informed verbally of the transfer to the hospital. DON did not know if anyone notified the Ombudsman of discharges. Follow up interview on 4/20/23 at 8:57 AM with the Social Worker revealed she did not inform the Ombudsman of facility initiated or resident initiated discharges. SW stated she had never been informed to send the Ombudsman a list of discharges. SW stated the business office, and the Quality Assurance nurse kept lists of the residents that were discharged but she did not know if either of them sent the lists to the Ombudsman. Interview on 4/20/23 at 9:10 AM with the Quality Assurance nurse indicated she did not inform the Ombudsman of discharges and she had not been informed to do that. Interview on 4/20/23 at 9:11 AM with the Business Office Manager revealed she did not inform the Ombudsman of discharges. Interview with the Administrator on 4/20/23 at 4:45 PM revealed she was not aware of a regulation regarding notification of the Ombudsman of discharges. Administrator stated the facility would implement a system of sending the Ombudsman written notification of facility discharges.

Based on observation and staff interviews the facility failed to label and date food items stored in the resident nourishment refrigerator. This was for 1 of 1 resident nourishment refrigerators reviewed for food storage. This practice had the potential to affect food served to residents. Finding included: On 11/18/2021 at 11:32 AM an observation of the resident nourishment refrigerator with Nurse #1 revealed one brown paper takeout food bag with no name or date containing individually wrapped takeout food items that were unlabeled and undated, one white plastic bag with two white cardboard takeout food containers with metal handles with no name or date, one white plastic bag with two clear plastic food storage containers with red lids containing food, labeled with a resident's name but undated, and one white cardboard takeout food container with a metal handle with no name or date. An interview with Nurse #1 at that time indicated this nourishment refrigerator was for the storage of resident items only. She stated all resident food items placed in this nourishment refrigerator should be labeled with the resident's name and dated when placed in the refrigerator. Nurse #1 stated these items should be discarded within 3 days. She further indicated she could not say for sure how long the items had been in the refrigerator, because they were undated. On 11/18/2021 at 11:49 an interview with the Dietary Manager (DM) indicated the facility had one nourishment refrigerator for the storage of resident food items. She stated all resident food items placed in this refrigerator should be labeled with the resident's name and dated when placed in the refrigerator. The DM went on to say these items should then be discarded within 3 days due to the potential for spoilage and nutrient loss. On 11/18/2021 at 12:49 PM an interview with the Director of Nursing (DON) indicated the facility had one nourishment refrigerator for the storage of resident food items. She stated this refrigerator was only accessible by facility staff. She went on to say staff should label food items with the resident's name and the date when the items were placed in the refrigerator. She stated this refrigerator was accessed multiple times daily by staff and any staff accessing the refrigerator should be monitoring for unlabeled, undated food items. The DON further indicated unlabeled, undated food items food items should not be in the resident nourishment refrigerator. She went on to say food items placed in the resident nourishment refrigerator should be discarded within three days. On 11/18/2021 at 12:57 PM an interview with the Administrator indicated any food items placed in the resident nourishment refrigerator should be labeled with the residents name and dated. He stated food items placed in the resident nourishment refrigerator should be discarded within 3 days.

Based on record review and staff interviews, the facility failed to complete and document a resident self-administration of medications for 1 of 1 resident reviewed for self-administration of medications (Resident #61). Findings included: Resident #61 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #61's admission Minimum Data Set, dated dated dated [DATE] revealed she was cognitively intact and required extensive assistance with most activities of daily living. Record review indicated Resident #61 had no self-administration of medication assessment. Review of physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . An observation on 11/15/21 at 3:32 PM revealed Resident #61 had tubes of over the counter medications lying on top of the bedside table. These tubes were: [MEDICATION(S)] (anti itch cream), [MEDICATION(S)] (anti itch cream), and Preparation H (hemorrhoid cream). An interview on 11/15/21 at 3:35 PM with the Director of Nursing revealed she was unaware of any resident at the facility who self-administered medications. She stated a self-administration assessment must be completed before a resident could keep medications at the bedside. An interview on 11/19/21 at 11:35 AM with the Administrator revealed that residents should be evaluated for self-administration of medications before they could be kept at bedside and he did not know why Resident #61 had medications in her room.

Based on observation, record review and staff interview, the facility failed to develop a comprehensive person-centered care plan for 1 of 1 resident (Resident #12) reviewed for respiratory care, who was diagnosed with [CONDITION(S)] and was receiving oxygen. Findings included: Resident #12 was admitted to the facility on [DATE] with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #12 was severely cognitively impaired and was coded for oxygen use. Resident #12's care plan dated 9-8-21 revealed no goals or interventions for the resident's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #12's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation of Resident #12 occurred on 11-15-21 at 12:23pm. Resident #12 was observed receiving oxygen at 2 liters per minute by nasal canula. Observation of Resident #12 on 11-16-21 at 12:48pm revealed the resident was receiving oxygen at 2 liters by nasal canula. The MDS Nurse was interviewed on 11-16-21 at 4:00pm. The MDS nurse discussed usually care planning [CONDITION(S)] and stated she did not know why she had not for Resident #12. She further said, I guess I missed it by accident. The MDS nurse stated she would not care plan oxygen unless the resident had been receiving oxygen on a continuous basis. Nurse #1 was interviewed on 11-17-21 at 9:18am. The nurse stated Resident #12 had her oxygen on at 2 liters per minute all the time to maintain her oxygen level above 90%. Nurse #1 said she was aware the order read as needed and that she would discuss having the order changed with the physician. The Corporate Nurse Consultant was interviewed on 11-18-21 at 4:51pm. The Nurse Consultant stated she expected care plans to be accurate and Resident #12's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on record review and staff and resident interviews, the facility failed to update a care plan for 1 of 1 resident (Resident #9) reviewed for smoking. Findings included: Resident #9 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An admission smoking evaluation assessment dated [DATE] indicated Resident #9 was a safe and independent smoker. The reassessment evaluation dated 7/30/2021 indicated Resident #9 was an unsafe smoker and required supervision. The annual Minimum Data Set assessment dated [DATE] indicated Resident #9 was mildly cognitively impaired. The assessment revealed she had no behaviors and was a current tobacco user. She required limited assistance with transfers and used a wheelchair for mobility. It indicated Resident #9 had a functional limitation in range of motion on one side of the upper extremity. The current care plan reviewed on 8/23/2021 addressed Resident #9 was an independent and safe smoker or user of tobacco/tobacco substitute product. The interventions included provide resident education on smoking policy, provide with a smoking apron, assist resident in obtaining smoking materials from secured storage area upon request, and may smoke independently without supervision. During an interview with the MDS Nurse on 11/16/2021 at 4:17 pm she stated she was unaware a new smoking evaluation had been completed for Resident #9. She then stated the Director of Nursing completed the evaluation and could have updated the care plan. She further stated the care plan should have been updated to reflect Resident #9' s need for smoking supervision. On 11/19/2021 at 10:30 am the Director of Nursing stated Resident #9's care plan should have been updated to supervised smoker. She then stated anyone could update the care plan, but the MDS Nurse was ultimately responsible for the care plan updates.

Based on observation, record review, resident and staff interviews, the facility failed to provide Activities of Daily Living (ADL) care for 1 of 6 residents (Resident #1) who was dependent on facility staff for ADL care. Findings included: Resident #1 was admitted to the facility on [DATE] with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The admission Minimum Data Set (MDS) dated [DATE] revealed Resident #1 was cognitively intact and needed extensive assistance with one person for toileting and personal hygiene. MDS also coded Resident #1 with adequate vision with corrective lenses. Resident #1's care plan dated 11-18-21 revealed a goal that the resident's ADL's/personal care would be completed with staff support as appropriate to maintain or achieve highest practical level of functioning. The interventions for the goal were in part; bathing-total dependance with one-person, personal hygiene/grooming extensive assistance. Resident #1 was interviewed on 11-15-21 at 10:20am. The resident stated he was not doing well. He explained he had been laying in his urine for almost 2.5 hours and had requested incontinence care at 8:00am. He stated the nursing assistant had come into his room and explained the facility was short staffed today (11-15-21) and that she would be back when she could. Resident #1 discussed therapy had been in to see him but would not perform his therapy because he was soiled, and he is now afraid he had missed his therapy. He explained he had looked at the clock on the wall when he had asked the nursing assistant for help and that was how he knew how long ago it had been. He continued to discuss the facility's staffing and he stated, this happens almost everyday but yesterday and today have been the worst. On 11-15-21 at 10:35am, this surveyor informed the Corporate Nurse Consultant of the situation with Resident #1. She explained she would inform the resident's nursing assistant. On 11-15-21 at 11:15am, this surveyor informed the Administrator of Resident #1's situation and prior conversation with the Corporate Nurse Consultant. The Administrator was observed requesting the nursing assistant care for Resident #1. Observation of incontinence care occurred on 11-15-21 at 11:20am with nursing assistant (NA) #1. Resident #1's brief was noted to be over saturated and had leaked onto the under pad beneath the resident. Resident #1 was noted to have redness to his peri area and buttocks that was blanchable. NA#1 was observed applying barrier cream to the resident's peri area and buttocks. NA #1 was interviewed on 11-15-21 at 11:38am. NA #1 confirmed Resident #1's brief had been soiled for several hours and the urine had leaked through to the under pad. She also confirmed the reddened areas on Resident #1's peri area and buttocks were not new. The NA discussed there were 3 nursing assistants today (11-15-21) and she was trying to do the best she could, and she stated, I really can't provide the care the resident's need when we are so short staffed. Resident #1 was further interviewed on 11-16-21 at 12:53pm. The resident stated he had not received a bath or able to get out of bed on 11-15-21 but stated he had received incontinence care. Resident #1 further said he had received a bath and incontinence care right after breakfast this morning (11-16-21). During an interview with NA #2 on 11-16-21 at 1:15pm, the NA confirmed Resident #1 had not received a bath or placed in his chair on 11-15-21. She explained Resident #1 and 2 other residents were not able to receive a bath, get out of bed and had to wait more than an hour to receive incontinence care on 11-15-21. The Therapy Manager was interviewed on 11-18-21 at 3:41pm. The Therapy Manager stated Resident #1 had not missed any therapy sessions but that the physical therapist had to return several times before Resident #1 had been cleaned. She also stated the occupational therapist would be incorporating incontinence care into the therapy session. An interview with the Corporate Nurse Consultant occurred on 11-18-21 at 4:51pm. The Corporate Nurse Consultant stated the facility was not able to recuperate from the call outs on 11-15-21.

Based on observation, record review, resident, staff and physician interviews, the facility failed to follow the facility's wound care protocol for 1 of 5 residents (Resident #12) by not providing wound care treatments to a skin tear for 4 days. Findings included: The facility's Wound Care Manual dated February of 2021 revealed a procedure for dressing application to a skin tear. The procedures read as follows; cleanse wound with normal saline or appropriate wound cleanser, apply a layer of Xeroform petroleum gauze or Hydrogel, cover with a dry dressing, wrap in place with gauze wrap if applicable, change every day or as physician indicated and as needed. Resident #12 was admitted to the facility on [DATE] with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #12 was severely cognitively impaired and had no impairments to the skin. Resident #12's care plan dated 9-8-21 did not include goals and interventions for skin impairment. Resident #12's medical record was reviewed and revealed an incident report dated 11-12-21 documenting Resident #12 had a fall and sustained a skin injury to her left forearm but did not have any interventions for the skin injury documented. Review of Resident #12's emergency room report dated 11-13-21 revealed no orders for the skin injury to Resident #12's forearm. Resident #12's medical record had a nursing note dated 11-13-21 documenting Resident #12's return from the emergency room and the nurse's assessment of the resident. The documentation did not address Resident #12's left forearm. Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation of Resident #12 occurred on 11-15-21 at 10:48 am. Resident #12 was observed to be non-communicative, laying on her back in the bed. A bandage was noted to be on Resident #12's left forearm with a date of 11-12-21. The bandage was intact but was observed to be blood soaked with dry brown edges on the bandage. A second observation of Resident #12 occurred on 11-16-21 at 12:48pm. The observation revealed Resident #12 had a bandage on her left forearm dated 11-12-21. The bandage was observed to be red in the middle with brown coloration over the rest of the bandage. Nurse #3 was interviewed by telephone on 11-17-21 at 9:32am. Nurse #3 stated she was working the evening of 11-12-21 when Resident #12 fell and received a skin injury to her left forearm. She explained the Wound Care (WC) Nurse at the facility had bandaged the residents left forearm prior to the resident going to the emergency roiagnom on [DATE]. Nurse #2 was interviewed by telephone on 11-16-21 at 5:50pm. The nurse confirmed she was the re-admitting nurse to the facility for Resident #12 on 11-13-21. She stated the resident did not come from the emergency room with any orders. Nurse #2 stated she assessed the resident and saw the bandage on the residents left forearm and thought she had documented it in her nursing note. She also explained she did not call the emergency room for orders or contact the facility physician for orders. She stated she left a communication for the physician in the physician's communication book to follow up with Resident #12 the next day. Nurse #1 was interviewed on 11-17-21 at 9:18am. The nurse confirmed she was aware of a bandage on Resident #12's forearm but was not aware of any orders. She explained, if a nurse was alerted by a nursing assistant or the nurse saw a new wound, the nurse would open a flow sheet or leave a note at the nursing station for the Wound Care Nurse to assess. Nurse #1 further explained the Wound Care Nurse was responsible for writing the wound care orders. A further observation of Resident #12 occurred on 11-17-21 at 9:25am. The observation revealed Resident #12 had a bandage on her left forearm dated 11-16-21. The bandage was observed to be clean with no red or brown areas observed. The Wound Care (WC) Nurse was interviewed on 11-17-21 at 11:40am. The WC nurse confirmed she had dressed Resident #12's skin injury to her left forearm on 11-12-21 prior to the resident going to the emergency room . She stated she used the skin tear protocol dressing Resident #12's injury with petroleum gauze and covering with a dry dressing. The nurse said she did not contact the physician or write an order because it was time for her to go home. She further added the nurse receiving Resident #12 back from the emergency room should have received an order. The WC nurse confirmed she changed Resident #12's dressing to her left forearm yesterday (11-16-21) without a physician order. The nurse explained Resident #12 should have had her dressing changed on 11-15-21 but stated since there was not an order written [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility's physician was interviewed by telephone on 11-18-21 at 4:32pm. The physician discussed nursing staff having wound care protocols that they follow but was unaware of what wound care was completed for Resident #12. She also said she was not aware of wound care treatments not being completed on time due to a lack of orders but expected nursing to write orders per the wound care protocol. The Corporate Nurse Consultant was interviewed on 11-18-21 at 4:51pm. The Corporate Nurse Consultant stated she expected orders to be obtained prior to wound care being completed.

Based on record review, staff interviews, and physician interview, the facility failed to: 1) provide a redistribution/pressure relief mattress as indicated on the resident's care plan and failed to change wound treatment orders per facility protocol and 2) follow the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings included: 1. Resident #4 was most recently readmitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #4 was out of the facility and in the hospital on 8/01/21 through 8/05/21 and 10/31/21 through 11/05/21. Resident #4's quarterly Minimum Data Set, dated dated dated [DATE] revealed she was cognitively intact and required extensive assistance or total dependent for most activities of daily living. Further review revealed it was coded for 1 unstageable pressure ulcer. Review of wound ulcer flowsheet dated 8/06/21 revealed an unstageable right gluteal fold pressure ulcer with the current treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #4's care plan last revised on 11/10/21 revealed a focus for skin breakdown which included an intervention to place the resident on pressure relieving products such as pressure relieving mattress. Review of Resident #4's Treatment Administration Record (TAR) for August, September, October, and November 2021 revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . This treatment was signed as completed except when the resident was out of the facility. Review of the facility's wound care manual with the version date of February 2021 read in part that if there is no improvement in skin and wound problems in two weeks to a month, the patient should be reevaluated for a change in intervention. The manual further read that unstageable ulcer procedures for treatment included packing or covering the wound with debridement agents such as Santyl, antimicrobial impregnated gauze, or antibacterial agents. An interview on 11/17/21 at 12:04 PM with Resident #4 revealed she refused to have her wound care observed. She stated she was uncomfortable with people seeing the private areas of her body. An interview on 11/17/21 at 3:25 PM with the Wound Treatment Nurse revealed Resident #4's right gluteal fold wound was first noted on 12/28/20 and was previously resolved on 4/27/21 and subsequently reopened on 5/11/21. She stated the right gluteal pressure ulcer got better and then got worse and the resident had been in and out of the hospital. She stated she had tried other wound care treatments in the past but had not changed the current treatment since August 6, 2021. She stated she had not considered the wound clinic and that she should have referred the resident to the wound care clinic. An observation and interview with Nurse #1 on 11/18/21 at 2:52 PM revealed that Resident #4 was on a regular mattress. Nurse #1 confirmed Resident #4 was on a regular mattress. An interview on 11/18/21 at 4:30 PM with the Physician revealed she was aware that Resident #4 had a right gluteal fold pressure ulcer since December 2020. She stated the wound 'comes and goes'. She stated she did not know if the resident had a pressure relieving mattress or not and she was not involved in the decision for the resident to have a specialty mattress. The Physician stated the facility could have tried other treatments to heal her right gluteal fold pressure ulcer. An interview on 11/18/21 at 10:52 AM with the Director of Nursing revealed she was aware that Resident #4 had a right gluteal fold pressure but was unaware of why she did not have a specialty mattress or why her wound care treatment had not been changed since August 6, 2021. An interview on 11/19/21 at 10:14 AM with the Staffing Development Coordinator (SDC) revealed she was unable to locate any documentation that Resident #4 had ever tried or refused a specialty mattress. She also stated the facility had a specialty mattress and it would be placed on the resident's bed that afternoon. An interview on 11/19/21 at 11:35 AM with the Administrator who stated the facility should provide the appropriate equipment and wound care protocols to ensure the resident had the necessary care for wound healing. 2. Resident #58 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] The care plan initiated on 1/28/2021 and last revised on 11/02/2021 addressed a potential for skin break down related to incontinence and high risk for pressure ulcer. The interventions included place on pressure relieving devices as appropriate, staff to report to nurse any reddened or open areas, do not massage over any bony areas, if nutritional status deteriorates, arrange a dietary consult, inspect skin, and notify nurse of abnormal changes, lubricate skin with moisturizing lotion, and air mattress. Another care plan initiated on 11/2/2021 addressed interference with structural integrity of layers of the skin. The interventions included turn and reposition routinely, bridge heels, heel pillow to heels and feet, and ensure specialty mattress is in place. The current significant change Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #58 was severely cognitively impaired. She required extensive assistance with all activities of daily living and had no functional limitation in range of motion. The assessment was not coded for pressure ulcers. A review of the progress note dated 10/28/2021 revealed a significant change was completed due to decrease in functional mobility and weight loss. A review of a nursing note dated 11/1/2021 revealed a darkened area was observed on Resident #58's right heel. The review of the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Another order dated 11/1/2021 revealed heel pillow to bilateral feet while in bed for pressure reduction and barrier film to right heel pressure ulcer every day shift. The Resident care guide intervention that was initiated on 11/2/2021 revealed for heel protection use a heel pillow. A review of the dietician note dated 11/4/2021 revealed Resident #58 weight was stable for the last month, down 10 pounds (lbs.) within the last 3 months, and down 13 lbs. within the last 6 months. The note indicated she had a decreased intake of 25 percent per nursing documentation and an evaluation was requested for speech therapy. It revealed Resident #58 received a nutritional supplement twice a day, vitamins, and a protein supplement to aid in healing of her right heel suspected deep tissue injury (SDTI). Observations on 11/15/2021 at 10:00 am, and 2:46 pm revealed Resident #58 was resting in bed with her eyes closed. The heel pillow was on the wheelchair during the observations. Her heels were on the bed mattress. Observations on 11/16/2021 at 9:00 am, 12:00 pm, and 2:30 pm revealed Resident #58 was resting in bed and did not have the heel pillow under her feet. The heel pillow was on the chair in her room. During an interview with nurse aide #7 at 11/16/2021 at 2:30 pm she stated she did not work with Resident #58 on a regular basis and was unaware she needed to have a heel pillow. She stated she could look at the care guide in the computer to find out if a resident needed special equipment or the nurse would inform her of any special needs. She further stated she did not look at the care guide for Resident #58 and Nurse #6 did not report that she needed a heel pillow. An interview with Nurse #6 on 11/16/2021 at 2:40 pm revealed she was aware Resident #58 was to have a heel pillow while in bed. She further stated she had not been in the room lately and did not notice that the heel pillow was not under her feet. A review of the Treatment Administration Record for the month of November 2021 revealed for heel pillow to bilateral feet while in bed and air mattress pressure checks were initialed up to the current date of 11/16/2021. All the blanks for heel treatment were also initialed daily. On 11/19/2021 at 10:00 am during an interview with the Director of Nursing she stated Resident #58's heel pillow should have been under her feet while she was in the bed as ordered. She further stated the nurse aides were aware to check the care guide daily for changes.

Based on record review and resident and staff interviews the facility failed to provide ambulation (walking) as specified in the comprehensive plan of care for 1 of 3 residents reviewed for range of motion (Resident #53). This placed Resident #53 at risk for a decline in his ability to ambulate. Findings included: Resident #53 was admitted to the facility on [DATE] a diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] The annual Minimum Data Set (MDS) assessment for Resident #53 dated 10/22/2021 revealed he was cognitively intact. He required the extensive assistance of one person for transfers. Walking in his room and the corridor with one person assistance occurred only once or twice during the assessment period. He was not steady during walking and was only able to stabilize with staff assistance. He used a walker and a wheelchair (WC) for mobility. The current comprehensive care plan for Resident #53 revealed a focus area initiated on 11/17/2020 of requires assistance to maintain maximum function of self-sufficiency for mobility related to at risk for decline in ability to ambulate. The goals last revised on 11/08/2021 were for Resident #53 to maintain the ability to ambulate up to 300 feet on even surfaces using a rolling walker and for him to participate in the restorative program through the next review. An intervention was ambulation program: ambulate up to 75 feet on even surfaces using rolling walker with limited assistance 6 x week, document the reason if he did not participate in the restorative ambulation program, and report to the nurse any changes in his abilities. A review of the nursing restorative summary for Resident #53 dated 10/21/2021 at 4:02 PM revealed he was ambulating 75ft with contact guard assist and a rolling walker with a WC to follow. The goal in restorative was to maintain the ability to walk 75 feet. Resident #53 maintained his ability to ambulate the required distance during the review period. No decline in endurance was noted. A review of the Restorative Nursing flowsheet documentation for Resident #53 from 11/4/2021 though 11/17/2021 revealed no documentation he participated in the restorative ambulation program on 11/5/2021, 11/9/2021, 11/10/2021, 11/12/2021, 11/13/2021, 11/14/2021, 11/15/2021, and 11/17/2021. A review of Resident #53's medical record did not reveal any refusals of restorative ambulation from 11/4/2021 through 11/17/2021. On 11/15/2021 at 12:11 PM an interview with Resident #53 indicated he was not receiving the walking assistance he should be. He stated staff were supposed walk with him several times a week and they were not. He went on to say he hadn't asked about this because staff were supposed to know to walk with him. He stated he did not think his ability to walk had declined but he worried if staff continued not walking with him, it would. On 11/17/2021 at 2:41 PM an interview with the MDS nurse indicated she coordinated the restorative nursing program. She stated Resident #53 was not receiving restorative ambulation 6 times weekly as recommended because when there were not enough nursing assistants (NA) available, either no one was assigned to work as the restorative aide or the restorative aide was pulled off that assignment to provide care to residents. She went on to say this had been an ongoing issue in the facility. On 11/17/2021 at 2:56 PM a telephone interview with NA #4 indicated she was frequently assigned as the restorative aide including on 11/09/2021. She stated she was pulled off her assignment as the restorative aide when there were not enough NA's to provide care to residents and no one replaced her. On 11/18/2021 at 2:49 PM an interview with Nurse #1 revealed she was familiar with Resident #53 and frequently assigned to his care on the 7AM-3PM shift. She stated restorative ambulation often did not get done because when there were not enough nursing assistants (NA) to provide care to residents no one was assigned as restorative aide or the restorative aide was pulled off that assignment to work on the floor. She went on to say it had been an ongoing issue in the facility. Nurse #1 stated she could do things like apply splints for residents when she was administering medication but something like ambulation just was not going to happen. On 11/18/2021 at 5:31 PM an interview with the director of nursing (DON) indicated she was aware there were days from 11/04/2021 through 11/17/2021 when no one was assigned as the restorative aide. She stated she was also aware there were days during that same period when the assigned restorative aide was pulled off the restorative aide assignment to provide care to residents. The DON went on to say there had not been enough staff to provide Resident #53 with restorative ambulation during this period because NA's were busy providing other care to residents. She further indicated on the hierarchy of needs restorative ambulation just did not get done. On 11/19/2021 at 8:28 AM an interview with the administrator indicated it was unacceptable that Resident #53 was not receiving his restorative ambulation as recommended because the facility did not have enough staff to provide this.

Based on record review and resident and staff interviews the facility failed to provide sufficient staffing to assist a resident out of bed as requested (Resident #53) , provide showers as preferred and scheduled (Resident #53 and Resident #23) , provide ambulation as specified in the comprehensive plan of care (Resident #53) and provide Activities of Daily Living (ADL) care for a resident (Resident #1) who was dependent on facility staff for ADL care. This affected 3 of 23 residents reviewed for staffing. Findings included: This tag is cross referenced to: F561 Based on record review and resident and staff interviews the facility failed to assist a resident out of bed as requested and failed to provide showers as preferred and scheduled for 2 of 3 residents reviewed for choices (Resident #53 and Resident #23). F677 Based on observation, record review, resident and staff interviews, the facility failed to provide Activities of Daily Living (ADL) care for 1 of 6 residents (Resident #1) who was dependent on facility staff for ADL care. F688 Based on record review and resident and staff interviews the facility failed to provide ambulation (walking) as specified in the comprehensive plan of care for 1 of 3 residents reviewed for range of motion (Resident #53). This placed Resident #53 at risk for a decline in his ability to ambulate. On 11/19/2021 at 8:10 AM an interview with Nurse #6 indicated prior to 10/28/2021 she served as the NA scheduler. She stated she used the budgeted NA hours table to create the schedule 30 days in advance. She stated she would then manage call outs and needs daily and update the schedule. Nurse #6 further indicated facility staff were required to call out 2 hours before their scheduled shifts but agency staff were not. She stated she would do her best to fill vacant shifts and call outs but it was sometimes not possible. She stated it was also very difficult to get an agency staff replacement the same day. She went on to say the facility was having staffing issues and at times did not have the staff they needed based on the census. She stated the facility had been offering a significant financial bonus for staff to pick up extra shifts but staff were getting burned out. On 11/19/2021 at 9:31 AM an interview with the NA #8 indicated she began serving as the NA scheduler on 10/28/2021. She stated she used the budgeted NA hours table to create the 30 day schedule. She went on to say at times it was very stressful. NA #8 stated that on 11/14/2021 the census was 62 residents which called for 8 NA's, however, the facility only had 3 from 7AM-3PM. She further indicated when she was not able to find anyone else to come in, she put herself down to work the shift. NA #8 went on to say she did not work that 7AM-3PM shift because she needed to work from 3PM-11PM that day. She stated the 3PM-11PM shift called for 6 NA's and there was only 1 available. She further indicated she and the second NA had been able to meet only the basic needs of the residents that shift. NA #8 stated now call outs were oftentimes not replaced. She further indicated she provided the director of nursing and the administrator a list of staff needs for each staffing schedule and posted this needs list at the time clock and in the staff break room. On 11/19/2021 at 9:59 AM an interview with the DON indicated staffing was a daily struggle. She stated the facility currently had 4 full time 7AM-3PM NA vacancies, 4 full time 3PM-11PM NA vacancies, 1 full time 11PM-7AM vacancies, and 4 part time NA vacancies for each shift. She went on to say the facility had a performance improvement plan (PIP) in place to address the issue. She further indicated the facility was still not meeting its daily staffing targets which were based on budgeted staff hours and the facility census. The DON went on to say the facility had not reevaluated the PIP. On 11/19/2021 at 8:02 AM an interview with the administrator indicated the facility utilized the facility assessment, daily census, and budgeted NA hours table to determine staffing needs. He stated the facility had a PIP in place to address the staffing problem. He went on to say the facility was also utilizing agency staff. He further indicated the facility was still not meeting it's targeted staffing numbers even with agency staff. The administrator stated the facility had not reevaluated the PIP.

Based on record review, observations, staff and physician interviews, the facility failed to (1) document wound care treatments, (2) discontinue wound care treatment orders after the wound was resolved and (3) staff continued to document treatment was provided to a wound that was healed. This occurred for 2 of 5 residents (Resident #12 and Resident #26) reviewed for wound care. Findings included: 1.Resident #12 was admitted to the facility on [DATE] with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #12 was severely cognitively impaired. The MDS did not indicate coding for skin issues. Resident #12's care plan dated 9-8-21 did not include goals and interventions for skin impairment. Observation of Resident #12 occurred on 11-15-21 at 10:48am. Resident #12 was observed to be non-communicative, laying on her back in the bed. A bandage was noted to be on Resident #12's left forearm with a date of 11-12-21. The bandage was intact but was observed to be blood soaked with dry brown edges on the bandage. Resident #12's medical record was reviewed and revealed an incident report dated 11-12-21 documenting Resident #12 had a fall and sustained a skin injury to her left forearm. The medical record did not have any assessment or nursing notes documenting what type of skin injury or what treatment was rendered. Review of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #12's Treatment Administration Record (TAR) was reviewed for the month of November 2021 and revealed no documentation of a treatment being performed on Resident #12's left forearm. Observation of Resident #12 on 11-17-21 at 9:25am revealed the bandage on Resident #12's left forearm had been changed with a date on the bandage of 11-16-21. The Wound Care (WC) Nurse was interviewed on 11-17-21 at 11:40am. The WC Nurse explained she was present on 11-12-21 when Resident #12 fell , and she had applied petroleum gauze (wound dressing) covered with a dry dressing to Resident #12's left forearm. She confirmed she did not document Resident #12's injury in the medical record but stated she had followed the facility's wound care protocol. The nurse also confirmed she had changed Resident #12's bandage on 11-16-21 using petroleum gauze covered with a dry dressing. The WC nurse stated she had not contacted the physician to obtain an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility's Medical Director was interviewed by telephone on 11-18-21 at 4:32pm. The Medical Director stated she was not aware that Resident #12 had a wound on her forearm until 11-18-21 when the WC Nurse had called her for further wound care orders. She also said she expected the nurse caring for Resident #12 to have received and written the wound care orders. 2. Resident #26 was most recently readmitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #26's quarterly Minimum Data Set, dated dated dated [DATE] revealed she had moderately impaired cognition and required extensive assistance or totally dependent for most activities of daily living. She was coded to have 3 stage 2 pressure ulcers and 1 deep tissue injury present on readmission. Review of Resident #26's wound ulcer flowsheets dated 11/11/21 revealed the lower coccyx stage 2 pressure ulcer was resolved. Review of the November 2021 Treatment Administration Record (TAR) for Resident #26 revealed an order which read to apply barrier cream to lower coccyx pressure ulcer daily and with perineal care every day shift. This order was signed as completed on November 12 through 16, 2021 by the Wound Treatment Nurse (on 11/12 and 11/16), Nurse #5 (on 11/13 and 11/14) and Nurse #3 (on 11/15). An interview on 11/17/21 at 3:55 PM with the Wound Treatment Nurse revealed she was responsible for wound care orders. She stated Resident #26's lower coccyx stage 2 pressure wound had healed, and the treatment order should have been discontinued on 11/11/21. She stated she was too busy and had forgotten to discontinue this order. She confirmed she had signed Resident #26's lower coccyx pressure ulcer wound care as completed on November 12 and 16. She confirmed she had not completed this order and stated she did not know why she had signed that she completed it. An interview on 11/18/21 at 10:10 AM with Nurse #5 revealed she was responsible for providing wound care treatments. She confirmed she had not completed the wound care treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . An interview on 11/18/21 at 10:52 AM with the Director of Nursing revealed she was unaware that Resident #26's wound care orders had not been discontinued when the wound was resolved or why the nurse had signed wound care orders as completed when they had not completed the treatment. She stated she was concerned to learn that the wound care nurses had signed orders as completed without doing them after the wound had been documented as resolved. An interview on 11/19/21 at 11:35 AM with the Administrator revealed that he believed nurses should not sign orders as completed unless they had performed them.

Based on record review and resident and staff interviews the facility failed to assist a resident out of bed as requested and failed to provide showers as preferred and scheduled for 2 of 3 residents reviewed for choices (Resident #53 and Resident #23). Findings included: 1. Resident #53 was admitted to the facility on [DATE] with a diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] The annual Minimum Data Set (MDS) assessment for Resident #53 dated 10/22/2021 revealed he was cognitively intact. He required the extensive assistance of one person for transfers. He was dependent for bathing with one person assistance. It was somewhat important for him to choose between a tub bath, shower, bed bath or sponge bath. A review of the current care plan for Resident #53 revealed a focus area initiated on 10/22/2018 of daily and activity preferences related to glasses, bathing, snacks between meals, family involvement in care discussions, keeping up with the news revealed a goal last revised on 11/08/2021 of daily and activities preferences will be provided through next review. An intervention dated 10/22/2018 was bathing preference- evening shower. On 11/15/2021 at 12:11 PM an interview with Resident #53 indicated he had not been able to get out of bed when he wanted to on 11/14/2021. He stated this made him feel frustrated. He went on to say he asked his nursing assistant (NA #5) three times on 11/14/2021 to assist him with getting out of bed. Resident #53 further indicated each time he asked, his NA told him he was too busy and could not assist him. He went on to say after that, he just quit asking. A review of the November 2021 Documentation Survey Report for Resident #53 revealed transfers did not occur on 11/14/2021. On 11/17/2021 at 2:16 PM a telephone interview with NA #5 indicated he was assigned to care for Resident #53 on 11/14/2021 on the 7AM-3PM shift. He went on to say he did recall Resident #53 asking him for assistance to get out of bed. NA #5 stated he told Resident #53 he did not have time. He stated he was one of 3 NA's that day and he was assigned 20 residents to care for. NA #5 further indicated while he was able to provide incontinence care and feeding assistance for residents, he had not had time to assist Resident #53 out of bed. On 11/16/2021 at 4:14 PM a follow up interview with Resident #53 indicated he had not been able to get a shower on the evening of 11/15/2021. He stated he waited and when no one came to assist him to shower he asked his nursing assistant (NA #6) about it. Resident #53 went on to say the NA told him she didn't have time because there weren't enough staff. A review of the November 2021 Documentation Survey Report revealed Resident #53 received a partial bed bath on 11/15/2021. On 11/17/2021 at 4:59 PM an interview with NA #6 indicated she provided care to Resident #53 on 11/15/2021 on the 3pm-11pm shift. She stated Resident #53 was scheduled for a shower that shift but she was assigned to care for 21 residents that day and she did not have time to provide a shower to Resident #53. She stated she assisted him with a partial bed bath instead. On 11/18/2021 at 10:58 AM an interview with Nurse #4 indicated she was working on 11/15/2021 on the 3PM-11PM shift. She stated there were 3 NA's that shift providing care to residents. She stated the NA's had 20 residents each to care for. She went on to say while Resident #53 had been assisted with a bed bath, the NA had not been able to provide his shower. Nurse #4 further indicated this had been an ongoing problem in the facility. She stated the facility had been trying to work with staffing agencies to get more help but it did not always work. On 11/18/2021 at 2:11 PM an interview with the Corporate Nurse Consultant (CNC) indicated the facility was aware residents had not been getting showers according to their preference. She stated on 10/20/2021 the facility put a performance improvement plan (PIP) in place to address the issue. The CNC went on to say since 10/21/2021 the facility had been in the monitoring phase of this PIP. On 11/18/2021 at 2:27 PM an interview with the DON indicated the facility was aware that residents were not receiving showers according to their preference. She stated she was using the shower audit tool weekly according to the PIP to ensure showers were being done. She went on to say she had not completed the auditing for the week of 11/6/2021 through 11/13/2021 as she had not had time. The DON stated when the audits determined a resident had not received a shower per their preference, she addressed it with staff immediately. On 11/19/2021 at 8:02 AM an interview with the administrator indicated residents should be receiving their showers according to their preference and assistance with getting out of bed when they wanted to because this was their right. 2. Resident #23 was admitted to the facility on [DATE] with chronic [CONDITION(S)]. The current care plan revised on 8/17/2021 addressed Resident #23's activities of daily living (ADL). The goal was all ADLs would be completed with staff support. The interventions included one person to provide physical assistance with bathing. The Minimum Data Set assessment dated [DATE] indicated Resident #23 was mildly cognitively impaired. The assessment revealed he required one-person physical assistance for baths. It further indicated there was no rejections of care during the look back assessment period. During an interview with Resident #23 on 11/16/2021 at 10:00 am he stated he was not getting his showers like he was supposed to due to staffing. He further stated it happened in August 2021 and also on the previous Friday (11/12/2021) because the nurse aide (NA) was too busy. A review of the shower schedule revealed Resident #23's showers were scheduled on Tuesdays and Fridays. The shower documentation on the nurse aide ADL flowsheet for August 2021 was reviewed. The documentation indicated on 8/3/2021, 8/6/2021, 8/10/2021, and 8/13/2021 Resident #23 received partial baths. The November 2021 shower documentation indicate he had a partial bath on 11/12/2021 day shift and a full bath on the evening shift. A review of the progress notes revealed there was no documentation in the progress notes about the shower not being provided on 11/12/2021. During an interview with NA #2 on 11/16/2021 at 10:08 am she stated she was assigned to Resident #23 on 11/12/2021. She then stated she was unable to assist Resident #23 with his shower because she did not have enough time to help him because of low staffing. NA #2 stated she had informed Nurse #1 that he did not receive a shower. On 11/16/2021 at 2:23 pm Nurse #1 stated she did not recall being told Resident #23 was not able to get a shower. She then stated she would have documented the reason in the progress notes. NA #2 worked with Resident #23 in August 2021 on the dates that he did not receive a shower. She stated during a telephone interview on 11/19/2021 at 8:18 am as far as she knew Resident #23 never refused a shower. She then stated if it was not documented on the NA activities of daily living flowsheet, he did not get the shower. NA #2 further stated staffing was low and she was unable to do the showers. She said Resident #23 really enjoyed his showers and would be very vocal when he did not receive it. The Director of Nursing stated on 11/19/2021 at 10:20 am the NA should have reported to the nurse that Resident #23 did not get his shower so the next shift could have assisted him with the shower. She further stated the facility was aware of the staffing issues.