Every finding on record at College Pines Health and Rehabilitation

Based on record review and staff interviews, the facility failed to code the Minimum Data Set (MDS) assessment accurately in the area of medications for 1 of 5 sampled residents (Resident #6). The findings included:Resident #6 was admitted to the facility on [DATE] with diagnoses which included type 2 diabetes mellitus with hyperglycemia (high blood sugar).A review of Resident #6's physician admission orders dated 02/16/26 revealed an order for Lantus Solostar U-100 insulin (long-acting insulin and hypoglycemic medication used to manage blood glucose levels) 100 units per milliliter. Inject 10 units subcutaneously (under the skin) daily in the morning for diabetes.A review of Resident #6's February 2026 Medication Administration Record (MAR) revealed Resident #6 received insulin injections daily as ordered. Resident #6's quarterly Minimum Data Set (MDS) dated [DATE] was reviewed and did not indicate insulin injections or hypoglycemic medications had been received. An interview with the MDS Coordinator was conducted on 04/28/26 at 11:56 AM. The MDS Coordinator confirmed she completed the 02/20/26 MDS for Resident #6. The MDS Coordinator stated Resident #6 received insulin daily and the MDS assessment should have included both insulin injections and the use of hypoglycemic medication. She stated the insulin injections and hypoglycemic medication had been overlooked and the MDS had been coded incorrectly.An interview with the Corporate MDS Coordinator was conducted on 04/28/26 at 11:44 AM. The Corporate MDS Coordinator stated that all MDS assessments should be coded correctly for relevant medications.An interview conducted with the Director of Nursing on 04/29/26 at 2:35 PM revealed Resident #6 had received daily insulin injections and the MDS should be coded correctly for relevant medications.

Based on observations and staff interviews, the facility failed to maintain window screens in resident's room in good condition (Resident #44, #31, #49, #54, #4, #19, #3, #15, #108, #32, #48, #92, #58, #73, #83, #7, #64, #106, #14,#94, #29, #38, #72, #53). The deficient practice affected 18 of 65 rooms on 6 of 6 halls observed for environmental concerns. Findings included:Observations of the window screen in room [ROOM NUMBER] on 04/27/2026 at 1:45 PM and 04/28/2026 at 11:32 AM revealed the window screen's metal frame was out of the track at the bottom of the window frame. The unsecured screen would make it possible for flying insects to enter if the window was open. On 4/29/26 a walking tour of the outside of the facility was conducted with the Maintenance Director from 2:00 to 2:50 PM and revealed the following 18 window screens that needed repair:room [ROOM NUMBER] showed the window screen's metal frame was bent and out of the track.room [ROOM NUMBER] did not have a window screen in place.room [ROOM NUMBER] showed the window screen to have a tear approximately 2 inches by 3 inches.room [ROOM NUMBER] had a tear approximately 4 inches by 2inches in the bottom of the window screen.Rooms #206, #210, #302, and #416 revealed the window screen's metal frame was out of the metal track.room [ROOM NUMBER] revealed a tear approximately 4 inches by 3 inches in the window screen.room [ROOM NUMBER] showed the window screen's metal frame was out of the metal track and revealed a tear approximately 2 inches by 2 inches in the bottom of the screen.room [ROOM NUMBER] showed the window screen to have a tear approximately 3 inches by 3 inches.room [ROOM NUMBER] showed the window screen's metal frame was out of the track at the bottom of the window frame.room [ROOM NUMBER] showed the screen missing from the window. room [ROOM NUMBER] showed a tear approximately 1 inch by 7 inches in the window screen. room [ROOM NUMBER] revealed a tear approximately 1 inch by 3 inches in the window screen. room [ROOM NUMBER] had a tear approximately 3 inches by 6 inches in the window screen.room [ROOM NUMBER] revealed no window screen on the window.room [ROOM NUMBER] revealed a tear approximately 4 inches by 2 inches in the window screen. An interview with Resident #14 in room [ROOM NUMBER] on 4/29/26 at 1:25 PM indicated he had no concerns with the window screen and had not opened his window since his admission. An interview with the Maintenance Director on 4/29/26 at 2:30 PM revealed he had only been employed with the facility for about two and a half months and had not yet established a good monitoring program of the windows. He reported he was aware of only two window screens that needed replacement and they were both in his office awaiting the new screen for the frames. He indicated all staff members could put in a work order if they noticed something in the building that required his attention, but he had not received any work orders for screen repairs. An interview with the Administrator on 4/29/26 at 3:18 PM revealed she expected all staff to alert maintenance staff to any issue and to fill out work orders for the concern. She reported that she was unaware there were that many screens that needed repairing. She stated the previous Maintenance Director had done an assessment of the window screens in early fall of 2025 and had repaired any that were damaged at the time.

Based on record review and Medical Doctor (MD) and staff interviews, the facility failed to notify the MD or on-call provider when Resident #1, who was on anticoagulant medication and had a history of brain bleeds, had an unwitnessed fall with obvious head injury for 1 of 3 residents reviewed for accidents and notification. On 02/13/24 at approximately 1:30 AM Resident #1 was found lying on the floor of her room in between the bed and wall with her head next to the nightstand. Upon assessment by Nurse #1, Resident #1 had a laceration to the right eyebrow area, a quarter-sized hematoma to the right forehead, and bruising to the right hand. Resident #1 exhibited no signs of respiratory distress. Neurological checks were initiated (refers to an assessment of motor and sensory responses, such as reflexes, to determine if the nervous system is impaired), vital signs were obtained, and all were noted within normal limits. Resident #1 was assisted back to bed and monitored throughout the remainder of the shift with continued neurological checks and vital signs that were noted within normal limits. Between 7:30 AM and 7:40 AM Resident #1 was observed having trouble breathing and Emergency Medical Services (EMS) were called to transport her to a local hospital. Resident #1 was diagnosed with a subdural hematoma (buildup of blood on the surface of the brain) with shift (displacement of brain tissue along the center of the brain) and left-sided pneumothorax (when air leaks into the space between the lung and chest causing the lung to collapse). Resident #1 was intubated (procedure where a flexible tube is placed through the mouth or nose into the trachea to aid with breathing), Eliquis (anticoagulant) was reversed (refers to the administration of medication to rapidly reverse the anticoagulant effect), and a chest tube was placed for the pneumothorax. Resident #1's injury was nonsurvivable, her family elected hospice care and Resident #1 passed away on 02/15/24. The findings included: Resident #1 was admitted to the facility on [DATE] with diagnoses that included left hip fracture, hypotension (low blood pressure), paroxysmal atrial fibrillation (type of irregular heartbeat), and fatigue. A physician order dated 02/02/24 for Resident #1 read, Eliquis 2.5 milligrams (mg) twice a day at 8:00 AM and 8:00 PM. The Medical Doctor (MD) history and physical progress note dated 02/05/24 revealed in part, Resident #1's past medical history included frontal hematoma. A nurse progress note dated 02/13/24 at 2:00 AM written by Nurse #1 read in part, Resident #1 had an unwitnessed fall at approximately 1:30 AM and was found lying on her right side on the floor between the bed and wall with her head positioned at the nightstand. Resident #1 was assessed and had a laceration above the outer portion of the right eye, bruise to the right side of the right thumb, a small red area to her right shoulder, and a hematoma approximately the size of a quarter to the top right side of the head. Ice pack and steri-strips were applied. Neurological checks were initiated and initial vital signs were blood pressure (BP) 127/82, pulse 79, respiratory (breathing) rate 18, temperature 97.7, and oxygen saturation 93% on room air. During a telephone interview on 03/05/24 at 12:31 PM, Nurse #1 confirmed she was Resident #1's assigned nurse on 02/13/24 during the hours of 11:00 PM to 7:00 AM. Nurse #1 recalled around 1:30 AM she was sitting at the Nurses' station and Nurse Aide (NA) #1 had just walked past headed down the hallway Resident #1 resided when they heard a loud noise. NA #1 looked into Resident #1's room and informed Nurse #1 she was on the floor. Nurse #1 stated upon immediately entering the room, Resident #1 was observed lying on her right side on the floor in-between the wall and bed with her head near the nightstand. She noticed blood on the floor and upon assessment, Resident #1 had a cut in the eyebrow area of the right eye, bruising to the right hand, and a small hematoma on the top right side of her head with no other injuries or obvious fractures. The eye area was cleaned with steri-strips applied and staff held ice packs to her forehead due to the swelling. Nurse #1 recalled Resident #1 denied any pain other than pointing to the right eye area and Tylenol (over the counter pain medication) was administered per standing order. Nurse #1 recalled Resident #1 stating she was reaching for the water pitcher on the nightstand when she fell out of bed and the best she could determine was Resident #1 must have missed or lost her balance when reaching over to the nightstand. Nurse #1 confirmed Resident #1 was on an anticoagulant medication and although she had obvious head injury, she used her nursing judgement when making the decision not to send Resident #1 out to the hospital for an evaluation at the time of her fall. Nurse #1 added from the time Resident #1 was found on the floor and up until her (Nurse #1) shift ended, Resident #1 was talking normal, displayed no respiratory distress, neurological checks were completed per facility protocol and her vital signs and neurological checks were normal. Resident #1 was assisted back into bed with a fall mat placed on the floor in-between the bed and wall as a safety precaution and monitored the remainder of the shift. Nurse #1 explained based on her assessment of Resident #1, she did not feel that Resident #1 was in any immediate danger as Resident #1 was alert and talking with no altered level of consciousness or uncontrolled bleeding and confirmed she did not call the MD or on-call provider at the time of the fall but did place a note in the physician communication book. A nurse progress note dated 02/13/24 at 8:03 AM written by Nurse #3 read in part, NA went into Resident #1's room and noted she was having slow, struggled respirations. Vitals obtained and noted a blood pressure of 130/74, respiratory rate 7, pulse 100, and oxygen saturation at 88%. Ice placed on Resident #1's head and new orders obtained to send her to the Emergency Department (ED) for evaluation. During an interview on 03/05/24 at 1:45 PM, Nurse #3 recalled on the morning of 02/13/24 right around shift change between 7:30 AM and 7:40 AM, she was notified by NA #2 that something was wrong with Resident #1 and she was not breathing right. Upon entering the room, Nurse #3 stated Resident #1's head was tilted to the right side, as she normally did when she slept, and when she straightened Resident #1's head, Resident #1 had a hematoma to the forehead which she described as a big pump knot (refers to a lump or swelling on the head) that covered the right side of the forehead and eye. In addition, Resident #1 was drooling from the right side of the mouth and breathing with gasps which she described as Cheyne-Stokes (breathing pattern that involves a period of fast, shallow breathing followed by slow, heavier breathing). Nurse #1 explained Resident #1 was a full code so oxygen was provided at 15 liters per minute (LPM) via a non-rebreather mask (device used to assist in the delivery of higher concentrations of oxygen), she obtained physician orders to send Resident #1 to the ED, EMS was notified, ice was placed on the hematoma to reduce the swelling, and she started sternal rubs to keep Resident #1 awake and breathing until EMS arrived to transport her to the hospital. During an interview on 03/06/24 at 1:20 PM, Nurse #4 recalled on the morning of 02/13/24 sometime around the start of the shift, NA #2 stated Resident #1 wasn't breathing right and she went with Nurse #3 to Resident #1's room to assess. Upon entering the room, Nurse #4 recalled Resident #1 was breathing with small gasps, had bruising to her right side around the eye area with steri-strips in place and appeared gray-looking. Resident #1 was non-verbal and able to open her eyes but her pupils were fixed straight ahead. Nurse #4 stated they got the crash cart ready just in case it was needed but Nurse #3 was able to keep Resident #1 alert and breathing with sternal rubs until EMS arrived at the facility, took over and transported her to the hospital. Review of the hospital records dated 02/13/24 revealed Resident #1 presented to the ED for evaluation following a fall at the skilled nursing facility with obvious head trauma and was on anticoagulant medication. Resident #1 was diagnosed with a subdural hematoma (buildup of blood on the surface of the brain) with shift (displacement of brain tissue along the center of the brain). Resident #1 was intubated (procedure where a flexible tube is placed through the mouth or nose into the trachea to aid with breathing), she was on anticoagulant medication that was reversed (refers to the administration of medication to rapidly reverse the anticoagulant effect) and also found to have left-sided pneumothorax (when air leaks into the space between the lung and chest causing the lung to collapse) and a chest tube was placed for the pneumothorax. Resident #1's injury was nonsurvivable, her family elected hospice care and Resident #1 passed away on 02/15/24. During an interview on 03/05/24 at 2:38 PM, the Director of Nursing (DON) confirmed she was notified by Nurse #1 of Resident #1's fall during third shift on 02/13/24. The DON explained they did not automatically notify the MD/provider or send a resident on anticoagulant medication out to the hospital for an evaluation following a fall, even with obvious head injury, but rather went by the nurse's judgement and if neurological checks were normal, they continued to monitor unless the resident had an acute change in condition. The DON stated Nurse #1 used her nursing judgement and following the fall, Resident #1 was monitored frequently, her vital signs and neurological checks remained normal and she had no acute change in condition throughout the remainder of the shift. The DON stated it wasn't until first shift when NA #2 started rounds that Resident #1 was noticed to appear different than she had been earlier. Resident #1 was assessed by Nurse #3 who noticed Resident #1's oxygen saturation was low, she was given a non-rebreather mask, and EMS was notified for an emergent hospital transfer. During an interview on 03/06/24 at 11:00 AM, the Administrator recalled on 02/13/24 when she arrived at the facility between 6:30 AM and 7:00 AM, she was informed by staff that Resident #1 had fallen during the night but was doing fine and her vitals signs and neurological checks were normal. The Administrator explained sometime just after the start of first shift, she was in the area when NA #2 reported Resident #1 was not breathing right. The Administrator went into the room with the nurse and recalled Resident #1 was lying in bed, she had a pump knot on her forehead with steri-strips applied to the cut and she was difficult to arouse but her eyes would flutter when you called her name. The Administrator went out to the nurses' station to check Resident #1's code and transfer status and when she returned to the room, Resident #1's breathing was very shallow and the nurse stated EMS had already been notified. EMS arrived pretty quickly and transported Resident #1 to the hospital. The Administrator explained prior to this incident, they had never had a statement in their fall policy or fall protocol about immediately notifying the MD when a resident on anticoagulant medication had a fall. She further explained the expectation was for the nurse to initiate neurological checks, assess the resident and the decision to call the MD/on-call provider and/or send the resident out to the hospital was based on the clinical assessment and nurses' judgement. During a telephone interview on 03/05/24 at 1:12 PM, the Medical Doctor (MD) confirmed he was not notified on 02/13/24 when Resident #1, who was on anticoagulant medication, fell at 1:30 AM and sustained a head injury. The MD could not recall the date but stated when he was notified of Resident #1's fall, he was told the nurse did not call the provider or send Resident #1 out to the hospital for evaluation and decided to monitor her with neurological checks. Then around 6:30 AM Resident #1 started showing acute changes, she was sent out to the hospital for an evaluation and from what he had heard, the outcome was not positive. The MD stated he was unaware Resident #1 was also diagnosed with pneumothorax and felt that would be more of an issue than a fall with head trauma and if she had symptoms of pneumothorax while at the facility following her fall, he would have expected her to have some respiratory difficulties but she didn't. He explained since Resident #1's respiratory, vital signs and neurological checks were normal, even if she had gone to the hospital immediately following her fall, it was likely a Computerized Tomography (abbreviated as CT and refers to an imaging technique that produces detailed internal images of the body) scan would not have detected anything and the hospital may have just sent her back to the facility. He stated the symptoms could have definitely progressed over a few hours and when Resident #1 did show an acute change in condition, he restated staff recognized the acute change and sent Resident #1 to the hospital. The MD explained stated at the time, the facility did not have a policy or fall protocol for notifying the provider when a resident on anticoagulant medication had a fall. The MD stated he could not say for sure if Resident #1 had been sent to the hospital immediately after her fall there would have been a different outcome but had he been notified, he would have erred on the side of caution and given orders for her to be sent to the hospital for an evaluation. The Administrator was informed of Immediate Jeopardy on 03/06/24 at 11:10 AM. The facility provided the following Corrective Action Plan with a compliance date of 03/05/24: Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice: 1. The facility failed to notify the physician when Resident #1 who was on Eliquis, an anticoagulant medication, had an unwitnessed fall on 2/13/24 at approximately 1:30 AM. The Resident was found lying on her right side on the floor between her bed and the wall with her head positioned at the nightstand. Resident #1 has a bruise to the top portion of the right wrist approximately the size of a quarter, a bruise to the right side of right thumb, a small red area to her right shoulder, and a hematoma approximately the size of a quarter to the top right side of the head. Address how the facility will identify other residents having the potential to be affected by the same deficient practice: 2. All residents have the potential to be affected by this practice. On 2/14/24 the Director of Nursing (DON) and the Unit Managers reviewed residents who had a fall during the last 30 days and were on anticoagulant medications. The falls were reviewed to ensure the Medical Director/Nurse Practitioner (NP)/on-call provider were notified of falls and told the resident was on an anticoagulant. No new concerns were found. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur: 3. The measures that have been put in place to ensure the deficient practice does not recur are as follows: On 2/13/24 the Interdisciplinary Team met to start an investigation into Resident #1's unwitnessed fall. An Ad Hoc QAPI meeting was held on 2/13/24 to develop the plan of correction, audits, and inclusion in QAPI process and meetings. On 2/14/24 the Regional Operations Manager educated the Administrator, DON, Assistant Director of Nursing, and Nursing Leadership on notifying the physician/NP or on-call when a resident on an anticoagulant has an unwitnessed fall or a fall with a head injury immediately. On 2/13/24 an Ad Hoc QAPI meeting was held to discuss Resident #1's unwitnessed fall, the corrective action plan, audits and inclusion in QAPI. Beginning 2/14/24 The Director of Nursing, Assistant Director of Nursing and Nursing Leadership provided education to the nurses regarding notifying the physician/NP or on-call immediately when a resident on an anticoagulant has an unwitnessed fall or a fall with a head injury. The Director of Nursing was educated by the Administrator on 2/14/24 that she would be in charge of tracking all staff to ensure they received education and ensuring no staff will work without receiving this education. Any new hires will receive education prior to the start of their shift, it will be the responsibility of the Director of Nursing to ensure this is completed. On 3/4/24 The Director of Regulatory Compliance educated the Administrator and Director of Nursing on notifying the physician/NP/on-call immediately when a resident has an unwitnessed fall or a fall with a head injury. On 3/4/24 The Director of Nursing and the Staff Development Nurse provided education to all Nursing Staff in person and over the phone with the Staff giving the trainer verbal feedback to ensure education was understood, to immediately call the MD/NP/on-call if a resident has a unwitnessed fall or a fall with a head injury. The Director of Nursing was educated by the Administrator on 3/4/24 that she would be in charge of tracking all staff to ensure they received education and ensuring no staff will work without receiving this education. Any new hires will receive education prior to the start of their shift, it will be the responsibility of the Director of Nursing to ensure this is completed. Education will be completed by 3/4/24. On 3/4/24 the policy for Notification of Change was updated to say: when a resident has an unwitnessed fall or a fall with a head injury the physician/NP/on-call provider should be notified immediately. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained: 4. The DON or designee will audit five (5) residents twice weekly for 4 weeks, then weekly for 8 weeks to ensure physician and NP are notified of any unwitnessed falls or falls with head injury who are on an anticoagulant immediately. The facility will monitor the corrective actions to ensure that the deficient practice is corrected and will not recur by reviewing information collected during audits and reporting to Quality Assurance Performance Improvement committee (QAPI) by the DON monthly for three (3) months. At that time, the QAPI committee will evaluate the effectiveness of the interventions to determine if continued auditing or adjustments to the plan of correction are necessary. Date of compliance 3/5/24. The Corrective Action plan was validated on 03/06/24 as evidenced by facility documentation and staff interviews. Review of the in-service sign-in sheets dated 02/14/24 revealed all staff/all departments received education that a resident on anticoagulant medication who had fall must be assessed by the nurse and the MD/provider must be immediately notified. Interviews with facility staff revealed they received in-service education regarding the facility's fall protocol and were able to verbalize what to do when a resident had a fall and who to notify of the fall. Interviews with nurses revealed they received additional education on 03/04/24 regarding the change to the facility's fall protocol and verbalized they were to call the MD/provider immediately anytime a resident had a fall with or without injury and regardless if the resident was on anticoagulant medication. Review of the facility's monitoring tools dated 02/15/24 through 03/05/24 revealed they were completed as outlined in the corrective action plan with no concerns identified. Inclusion in QAPI was confirmed through review of QAPI documents and interview with the Administrator. The Administrator stated the the corrective action plan and audits would be discussed during the March QAPI meeting and would be on-going. The compliance date of 3/5/24 was validated.

Based on record review and Medical Doctor (MD) and staff interviews, the facility failed to recognize the seriousness of a head injury following a fall and seek medical treatment for a resident on Eliquis (anticoagulant medication) with a history of brain bleeds for 1 of 3 residents reviewed for accidents (Resident #1). On 02/13/24 at approximately 1:30 AM Resident #1 was found lying on the floor of her room in between the bed and wall with her head next to the nightstand. Upon assessment by Nurse #1, Resident #1 had a laceration to the right eyebrow area, a quarter-sized hematoma to the right forehead, and bruising to the right hand. Resident #1 exhibited no signs of respiratory distress. Neurological checks (refers to an assessment of motor and sensory responses, such as reflexes, to determine if the nervous system is impaired) were initiated, vital signs were obtained, and all were noted within normal limits. Resident #1 was assisted back to bed and monitored throughout the remainder of the shift with continued neuro checks and vital signs that were noted within normal limits. Between 7:30 AM and 7:40 AM Resident #1 was observed having trouble breathing and Emergency Medical Services (EMS) were called to transport her to a local hospital. Resident #1 was diagnosed with a subdural hematoma (buildup of blood on the surface of the brain) with shift (displacement of brain tissue along the center of the brain) and left-sided pneumothorax (when air leaks into the space between the lung and chest causing the lung to collapse). Resident #1 was intubated (procedure where a flexible tube is placed through the mouth or nose into the trachea to aid with breathing), anticoagulant medication was reversed (refers to the administration of medication to rapidly reverse the anticoagulant effect), and a chest tube was placed for the pneumothorax. Resident #1's injury was nonsurvivable, her family elected hospice care and Resident #1 passed away on 02/15/24. The findings included: Resident #1 was admitted to the facility on [DATE] with diagnoses that included left hip fracture, hypotension (low blood pressure), paroxysmal atrial fibrillation (type of irregular heartbeat), and fatigue. A nursing admission observation assessment dated [DATE] revealed Resident #1 was oriented to person, place, time and situation. She was able to stand and pivot from the wheelchair with one-person physical assistance and had weakness in all extremities with no functional limitations in range of motion. A physician order dated 02/02/24 for Resident #1 read, Eliquis 2.5 milligrams (mg) twice a day at 8:00 AM and 8:00 PM. The Medical Doctor (MD) history and physical progress note dated 02/05/24 revealed in part, Resident #1's past medical history included frontal hematoma. The discharge Minimum Data Set (MDS) dated [DATE] revealed Resident #1's cognition was not assessed. She required partial/moderate staff assistance with rolling left and right and total staff assistance with transfers. Resident #1 received antianxiety, antidepressant, anticoagulant and opioid medications during the MDS assessment period. A nurse progress note dated 02/13/24 at 2:00 AM written by Nurse #1 read in part, Resident #1 had an unwitnessed fall at approximately 1:30 AM and was found lying on her right side on the floor between the bed and wall with her head positioned at the nightstand. Resident #1 was assessed and had a laceration above the outer portion of the right eye, bruise to the right side of the right thumb, a small red area to her right shoulder, and a hematoma approximately the size of a quarter to the top right side of the head. Ice pack and steri-strips were applied. Neurological checks were initiated and initial vital signs were blood pressure (BP) 127/82, pulse 79, respiratory (breathing) rate 18, temperature 97.7, and oxygen saturation 93% on room air. During a telephone interview on 03/05/24 at 12:31 PM, Nurse #1 confirmed she was Resident #1's assigned nurse on 02/13/24 during the hours of 11:00 PM to 7:00 AM. Nurse #1 recalled around 1:30 AM she was sitting at the Nurses' station, Nurse Aide (NA) #1 had just walked past the nurses' station and was headed down the hallway Resident #1 resided when they heard a loud noise. NA #1 looked into Resident #1's room and informed Nurse #1 she was on the floor. Nurse #1 stated upon immediately entering the room, she noticed Resident #1's bed was in a low position and Resident #1 was lying on her right side on the floor in-between the wall and bed with her head near the nightstand. She noticed blood on the floor and upon assessment, Resident #1 had a cut in the eyebrow area of the right eye, bruising to the right hand, and a small hematoma on the top right side of her head with no other injuries or obvious fractures. The eye area was cleaned with steri-strips applied and staff held ice packs to her forehead due to the swelling. Nurse #1 recalled Resident #1 denied any pain other than pointing to the right eye area and Tylenol (over the counter pain medication) was administered per standing order. Nurse #1 recalled Resident #1 stating she was reaching for the water pitcher on the nightstand when she fell out of bed and the best she could determine was Resident #1 must have missed or lost her balance when reaching over to the nightstand. Nurse #1 confirmed Resident #1 was on an anticoagulant medication and although she had obvious head injury, she used her nursing judgement when making the decision not to send Resident #1 out to the hospital for an evaluation at the time of her fall. Nurse #1 added from the time Resident #1 was found on the floor and up until her (Nurse #1) shift ended, Resident #1 was talking normal, displayed no respiratory distress, neurological checks were completed per facility protocol and her vital signs and neurological checks were normal. Resident #1 was assisted back into bed with a fall mat placed on the floor in-between the bed and wall as a safety precaution and monitored the remainder of the shift. Nurse #1 confirmed she did not call the MD or on-call provider at the time of the fall but did place a note in the physician communication book. Nurse #1 explained based on her assessment of Resident #1, she did not feel that Resident #1 was in any immediate danger as Resident #1 was alert and talking with no altered level of consciousness or uncontrolled bleeding. During a joint telephone interview with Nurse #2 on 03/06/24 at 5:33 AM, NA #1 recalled on 02/13/24 sometime between 1:00 AM and 2:00 AM, she was walking down the hall and happened to look inside Resident #1's room and found her lying on the floor beside her bed. NA #1 stated she was not sure how Resident #1 fell out of bed onto the floor and stated Resident #1 must have fallen while she was trying to reach for something. NA #1 stated she immediately notified Nurse #1 who came to the room to assess Resident #1. NA #1 recalled Resident #1 had a cut above her eye and was talking but did not recall if she had any bumps, hematomas or any other injury. NA #1 explained after Resident #1 was assisted back into bed, she (NA #1) obtained Resident #1's vital signs periodically throughout the remainder of the shift and did not recall Resident #1 displaying any signs of distress. During a joint telephone interview with NA #1 on 03/06/24 at 5:33 AM, Nurse #2 stated she had gone into Resident #1's room with Nurse #1 after being notified Resident #1 was on the floor. Upon entering the room, Nurse #2 observed Resident #1 lying on the floor between the bed and wall and Resident #1 had stated she fell out of bed while trying to reach for the water pitcher. Nurse #2 stated Resident #1 had a cut right above her eyebrow but did not recall seeing any hematomas and explained Nurse #1 did most of the assessment. Nurse #2 stated while in the room, Resident #1 was talking and asking for a drink of water and displayed no signs of distress. Review of the neurological checklist revealed Resident #1's vital signs were monitored every 15 minutes for the first hour, every 30 minutes for the second hour, then hourly up until she was sent out to the hospital for evaluation. The last neurological check was documented at 5:30 AM and revealed Resident #1 had a BP of 132/69, pulse of 84, and respiratory rate of 17. Resident #1 was oriented to person only, opened her eyes spontaneously and purposefully, her pupils were 3 millimeters (normal range in adults varies from 2 mm to 4 mm in bright light and 4 mm to 8 mm in the dark) equal in size and reactive, and she had normal hand, arm and leg movement. A nurse progress note dated 02/13/24 at 8:03 AM written by Nurse #3 read in part, NA went into Resident #1's room and noted she was having slow, struggled respirations. Vitals obtained and noted a blood pressure of 130/74, respiratory rate 7, pulse 100, and oxygen saturation at 88%. Ice placed on Resident #1's head and new orders obtained to send her to the Emergency Department (ED) for evaluation. During an interview on 03/05/24 at 1:45 PM, Nurse #3 recalled on the morning of 02/13/24, right around shift change between 7:30 AM and 7:40 AM, she was notified by NA #2 that something was wrong with Resident #1 and she was not breathing right. Upon entering the room, Nurse #3 stated Resident #1's head was tilted to the right side, as she normally did when she slept, and when she straightened Resident #1's head, Resident #1 had a hematoma to the forehead which she described as a big pump knot (refers to a lump or swelling on the head) that covered the right side of the forehead and eye. In addition, Resident #1 was drooling from the right side of the mouth and breathing with gasps which she described as Cheyne-Stokes (breathing pattern that involves a period of fast, shallow breathing followed by slow, heavier breathing). Nurse #1 explained Resident #1 was a full code so oxygen was provided at 15 liters per minute (LPM) via a non-rebreather mask (device used to assist in the delivery of higher concentrations of oxygen), she obtained physician orders to send Resident #1 to the ED for evaluation, EMS was notified, ice was placed on the hematoma to reduce the swelling, and she started sternal rubs to keep Resident #1 awake and breathing until EMS arrived to transport her to the hospital. During an interview on 03/05/24 at 2:02 PM, NA #2 confirmed she was assigned to provide care to Resident #1 on 02/13/24 during the hours of 7:00 AM to 3:00 PM. NA #2 explained at the start of her shift, she did rounds with NA #1 for shift report and NA #1 had informed her that Resident #1 fell out of bed during the night, bumped her head and had some bruising that would likely get darker. NA #1 also reported to NA #2 that neurological checks and vital signs were completed on Resident #1 throughout the shift and everything was fine. NA #2 recalled as they were talking and she looked into the room, Resident #1 lying in bed with her head tilted to the right, which was how she normally slept, and she could see somewhat of a knot/bruising to Resident #1's forehead and Resident #1 appeared to be breathing fine at that time. Around 7:15 AM when she was assisting another resident to the dining room for breakfast, NA #2 looked into Resident #1's room as she passed by and it looked like she had a little tremor. She assisted the other resident to the dining room and went straight back to Resident #1's room and noticed it wasn't a tremor but rather Resident #1 was breathing with small gasps. NA #2 stated she immediately notified Nurse #3 and Nurse #4 who came to the room to assess Resident #1. During an interview on 03/06/24 at 1:20 PM, Nurse #4 recalled on the morning of 02/13/24 sometime around the start of the shift, NA #2 stated Resident #1 wasn't breathing right and she went with Nurse #3 to Resident #1's room to assess. Upon entering the room, Nurse #4 recalled Resident #1 was breathing with small gasps, had bruising to her right side around the eye area with steri-strips in place and appeared gray-looking. Resident #1 was non-verbal and able to open her eyes but her pupils were fixed straight ahead. Nurse #4 stated they got the crash cart ready just in case it was needed but Nurse #3 was able to keep Resident #1 alert and breathing with sternal rubs until EMS arrived at the facility, took over and transported her to the hospital. The Emergency Medical Services (EMS) report dated 02/13/14 noted a call was received at 7:59 AM and at 8:01 AM they were with Resident #1 at the facility. The EMS report indicated that upon arrival, Resident #1 was unconscious and was receiving supplemental oxygen at 15 LPM via a non-rebreather mask which was continued throughout care. Resident #1 had a large hematoma over her right eye that was swelling outward and Cushing's Triad (low heart rate, irregular respirations and a widened pulse pressure indicative on increased pressure in the brain), hypertension and bradycardia (low heart rate) alongside abnormal breathing were noted with a strong suspicion of intracranial hemorrhage (brain bleeding). During transport to the hospital, Resident #1 continued to display shallow breathing with increasing periods of irregularity and the hospital was notified to prepare for Diffuse Axonal Injury (abbreviated as [NAME] and refers to a type of traumatic brain injury resulting from a blunt injury to the brain) upon arrival. Telephone attempt on 03/06/24 at 11:21 AM for an interview with the EMS Responder was unsuccessful. The hospital radiology report dated 02/13/24 confirmed Resident #1 had an acute left large subdural hemorrhage with at least 1.5 centimeters rightward midline shift with subfalcine herniation (displaced brain tissue that moves under the falx cerebri which is the membrane that divides the two cerebral hemispheres of the brain), right supratentorial subarachnoid hemorrhage (bleeding in the space that surrounds the brain), hemorrhage along the falx, right and left tentorium, and left temporal horn and fourth ventricle intraventricular hemorrhage (bleeding inside or around the spaces in the brain that contain the cerebral spinal fluid), subarachnoid hemorrhage along the brainstem, and an anterior right scalp hematoma. Review of the hospital records dated 02/13/24 revealed Resident #1 presented to the ED for evaluation following a fall at the skilled nursing facility with obvious head trauma and was on anticoagulant medication. Resident #1 was diagnosed with a subdural hematoma (buildup of blood on the surface of the brain) with shift (displacement of brain tissue along the center of the brain). Resident #1 was intubated (procedure where a flexible tube is placed through the mouth or nose into the trachea to aid with breathing), she was on anticoagulant medication that was reversed (refers to the administration of medication to rapidly reverse the anticoagulant effect) and also found to have left-sided pneumothorax (when air leaks into the space between the lung and chest causing the lung to collapse) and a chest tube was placed. Resident #1's injury was nonsurvivable, her family elected hospice care and Resident #1 passed away on 02/15/24. During an interview on 03/05/24 at 2:38 PM, the Director of Nursing (DON) was unable to recall the exact time she was notified by Nurse #1 of Resident #1's fall on 02/13/24 but stated it was sometime early morning shortly after Resident #1 had fallen. The DON recalled Nurse #1 had reported they had just completed first rounds, which was usually around 1:00 AM, and after providing care, Resident #1 asked for a drink of water which was provided by NA #1 before leaving the room. The DON stated she seemed to recall NA #1 walked down the hall to answer another resident's call light after leaving Resident #1's room and she was walking back up the hall, she looked into Resident #1's room and observed her lying on the floor in between the bed and wall with her head near the nightstand. NA #1 immediately called for Nurse #1 who went to the room and upon assessment, Resident #1 had a cut above her eye and a small hematoma upon on her forehead with no other deformities or obvious fractures identified. The DON explained they did not automatically send a resident on anticoagulant medication out to the hospital for an evaluation following a fall, even with obvious head injury, but rather went by the nurse's judgement and if neurological checks were normal, they continued to monitor unless the resident had an acute change in condition. The DON stated Nurse #1 used her nursing judgement and following the fall, Resident #1 was monitored frequently, her vital signs and neurological checks remained normal and she had no acute change in condition throughout the remainder of the shift. The DON stated it wasn't until first shift when NA #2 started rounds that Resident #1 was noticed to appear different than she had been earlier. Resident #1 was assessed by Nurse #3 who noticed Resident #1's oxygen saturation was low, she was given a non-rebreather mask, and EMS was notified for an emergent hospital transfer. During an interview on 03/06/24 at 11:00 AM, the Administrator recalled on 02/13/24 when she arrived at the facility between 6:30 AM and 7:00 AM, she was informed by staff that Resident #1 had fallen during the night but was doing fine and her vitals signs and neurological checks were normal. The Administrator explained when she questioned staff about what happened, staff reported they heard a noise and when they went into Resident #1's room to check, she was lying on the floor between the bed and wall with her head near the nightstand. Staff also reported at the time of the fall, Resident #1 was alert, talking and told Nurse #1 she had knocked the water pitcher off the nightstand and fell out of bed trying to grab it. Nurse #1 stated Resident #1 was monitored throughout the shift with no acute change in condition. Then sometime just after the start of first shift, the Administrator was in the area when NA #2 reported Resident #1 was not breathing right. The Administrator went into the room with the nurse and recalled Resident #1 was lying in bed, she had a pump knot on her forehead with steri-strips applied to the cut and she was difficult to arouse but her eyes would flutter when you called her name. The Administrator went out to the nurses' station to check Resident #1's code and transfer status and when she returned to the room, Resident #1's breathing was very shallow and the nurse stated EMS had already been notified. EMS arrived pretty quickly and transported Resident #1 to the hospital. The Administrator explained prior to his incident, they had never had a statement in their fall policy or fall protocol about immediately notifying the MD when a resident on anticoagulant medication had a fall. She further explained the expectation was for the nurse to initiate neurological checks, assess the resident and the decision to call the MD/on-call provider and/or send the resident out to the hospital was based on the clinical assessment and nurses' judgement. During a telephone interview on 03/05/24 at 1:12 PM, the Medical Doctor (MD) confirmed he was not notified on 02/13/24 when Resident #1, who was on anticoagulant medication, fell at 1:30 AM and sustained a head injury. The MD could not recall the date but stated when he was notified of Resident #1's fall, he was told the nurse did not call the provider or send Resident #1 out to the hospital for evaluation and decided to monitor her with neurological checks. Then around 6:30 AM Resident #1 started showing acute changes, she was sent out to the hospital for an evaluation and from what he had heard, the outcome was not positive. The MD stated he was unaware Resident #1 was also diagnosed with pneumothorax and felt that would be more of an issue than a fall with head trauma and if she had symptoms of pneumothorax while at the facility following her fall, he would have expected her to have some respiratory difficulties but she didn't. He explained since Resident #1's respiratory, vital signs and neurological checks were normal, even if she had gone to the hospital immediately following her fall, it was likely a Computerized Tomography (abbreviated as CT and refers to an imaging technique that produces detailed internal images of the body) scan would not have detected anything and the hospital may have just sent her back to the facility. He stated the symptoms could have definitely progressed over a few hours and when Resident #1 did show an acute change in condition, he restated staff recognized the acute change and sent Resident #1 to the hospital. The MD stated at the time, the facility did not have a policy or fall protocol for notifying the provider when a resident on anticoagulant medication had a fall. The MD stated he could not say for sure if Resident #1 had been sent to the hospital immediately after her fall there would have been a different outcome but had he been notified, he would have erred on the side of caution and given orders for her to be sent to the hospital for an evaluation. The Administrator was informed of Immediate Jeopardy on 03/06/24 at 11:10 AM. The facility provided the following Corrective Action Plan with a compliance date of 03/05/24: Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice: 1. The facility failed to notify the Medical Director (MD)/Nurse Practitioner (NP) or on-call provider when Resident #1 had an unwitnessed fall on 2/13/24 immediately. Resident #1 was on Eliquis, an anticoagulant medication. Nurse #1 assessed the resident; initiated neuro checks with all vital signs noted to be within normal limits. Address how the facility will identify other residents having the potential to be affected by the same deficient practice: 2. An audit of current residents with falls during the last 30 days was completed by the Director of Nursing and the Staff Development Nurse on 2/14/24 to identify any other residents possibly affected by the same practice. There were no negative findings. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur: 3. On 2/13/24 the Interdisciplinary Team met to start an investigation into Resident #1's unwitnessed fall. An Ad Hoc QAPI meeting was held on 2/13/24 to develop the plan of correction, audits, and inclusion in QAPI process and meetings. Beginning 2/14/24 all staff in all departments were trained by the Director of Nursing and Staff Development Nurse on the following: residents must always be assessed after falls and if the resident is on an anticoagulant the MD/NP/on-call should be notified immediately. Staff were educated to review all residents with falls and medication record to verify if they are receiving an anticoagulant and to ensure the provider is notified immediately of a fall. The Director of Nursing was educated by the Administrator on 2/14/24 that she would be in charge of tracking all staff to ensure they received education and ensuring no staff will work without receiving this education. Any new hires will receive education prior to the start of their shift, it will be the responsibility of the Director of Nursing to ensure this is completed. Education to be completed by 3/4/24. On 3/4/24 the policy for Notification of Change was updated to say: when a resident has an unwitnessed fall or a fall with a head injury the MD/NP/on-call should be notified immediately. On 3/4/24 The Director of Regulatory Compliance educated the Administrator and Director of Nursing on notifying the physician/NP/on-call immediately when a resident has an unwitnessed fall or a fall with a head injury. On 3/4/24 The Director of Nursing and the Staff Development Nurse provided education to all Nursing Staff to immediately call the MD/NP/on-call if a resident has an unwitnessed fall or a fall with a head injury. Staff will not be allowed to work before training is completed. The education will be added to the new hire orientation training. Staff will give the trainer verbal feedback to ensure education was understood. The Director of Nursing was educated by the Administrator on 3/4/24 that she would be in charge of tracking all staff to ensure they received education and ensuring no staff will work without receiving this education. Any new hires will receive education prior to the start of their shift, it will be the responsibility of the Director of Nursing to ensure this is completed. Education will be completed by 3/4/24. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained: 4. The Director of Nursing and/or designee will review the daily fall report to ensure all unwitnessed falls and falls with a head injury were reported to the physician immediately for 4 weeks, then 4 falls a week for 4 weeks, and then 3 falls a week for one month. The Director of Nursing or designee will bring these audits to 3 consecutive QAPI meetings. At that time the QAPI committee will evaluate the effectiveness of the interventions to determine if continued auditing is necessary to maintain compliance. Date of compliance 3/5/24. The Corrective Action plan was validated on 03/06/24 as evidenced by facility documentation and staff interviews. Review of the in-service sign-in sheets dated 02/14/24 revealed all staff/all departments received education that a resident on anticoagulant medication who had a fall must be assessed by the nurse and the MD/provider must be immediately notified. Interviews with facility staff revealed they received in-service education regarding the facility's fall protocol and were able to verbalize what to do when a resident had a fall and who to notify of the fall. Interviews with nurses revealed they received additional education on 03/04/24 regarding the change to the facility's fall protocol and verbalized they were to call the MD/provider immediately anytime a resident had a fall with or without injury and regardless if the resident was on anticoagulant medication. Review of the facility's monitoring tools dated 02/15/24 through 03/05/24 revealed they were completed as outlined in the corrective action plan with no concerns identified. Inclusion in QAPI was confirmed through review of QAPI documents and interview with the Administrator. The Administrator stated the the corrective action plan and audits would be discussed during the March QAPI meeting and would be on-going. The compliance date of 3/5/24 was validated.

Based on observations, record review, and staff interviews, the facility's Quality Assessment and Assurance (QAA) Committee failed to maintain implemented procedures and monitor the interventions that the committee put into place following the recertification and complaint investigation survey completed on 03/26/21. This was for two repeat deficiencies in the areas of quality of care and notification that were originally cited during the recertification and complaint investigation survey completed on 03/26/21 and subsequently recited during the complaint investigation completed on 03/06/24. The continued failure of the facility during two federal surveys of record shows a pattern of the facility's inability to sustain an effective QAA Program. The findings included: This tag is cross referenced to: F580: Based on record review and Medical Doctor (MD) and staff interviews, the facility failed to notify the MD or on-call provider when Resident #1, who was on anticoagulant medication and had a history of brain bleeds, had an unwitnessed fall with obvious head injury for 1 of 3 residents reviewed for accidents and notification. During the recertification and complaint investigation survey of 03/26/21, the facility failed to notify the Physician when a resident's Computerized Tomography (CT) scan had been cancelled by the facility. F684: Based on record review and Medical Doctor (MD) and staff interviews, the facility failed to recognize the seriousness of a head injury following a fall and seek medical treatment for a resident on Eliquis (anticoagulant medication) with a history of brain bleeds for 1 of 3 residents reviewed for accidents (Resident #1). During the recertification and complaint investigation survey of 03/26/21, the failed to ensure a resident who had an unwitnessed fall with head injury resulting in hematomas and bruising received a Computerized Tomography (CT) scan as ordered by the Nurse Practitioner. During an interview on 03/06/24 at 3:10 PM, the Administrator revealed it was hard to determine where the breakdown occurred regarding the repeat deficiencies. She explained following the incident with Resident #1 on 02/13/24, they implemented an internal plan of correction and the QA committee would be reviewing and discussing how the monitoring/audits were going when they met later this month (March 2024). The Administrator added she planned to continue with the processes that were put into place indefinitely.

Based on record review and staff interviews the facility failed to ensure a Preadmission Screening and Resident Review (PASRR), level II was completed after new mental health diagnoses for 1 of 3 residents (Resident # 80) reviewed for PASRR. The findings include: Review of Resident #60's medical record revealed the resident was admitted to the facility on [DATE]and a PASRR level I was completed. The resident was diagnosed with adjustment disorder with depressed mood on 05/30/23 and bipolar disorder on 06/19/23. No PASRR level II was completed. During an interview on 11/30/23 at 11:07 AM with the Social Worker (SW) she revealed a PASRR level II should be completed upon admission for residents with a mental health diagnosis and when a resident has had a change of condition or a newly added mental health diagnosis. She stated Resident #60 had been admitted to the facility from the hospital with a past diagnosis of bipolar disorder and assumed this diagnosis had been included in the preadmission Level I PASRR completed by the hospital. The SW revealed she was not aware the facility physician had made Resident #60 bipolar diagnosis active on 06/19/23 or her diagnosis of adjustment disorder with depressed mood on 05/30/23. She stated based on Resident #60's recent diagnosis of adjustment disorder and bipolar disorder a PASRR level II should have been completed. During an interview on 11/30/23 at 11:15 AM with the Administrator she revealed a PASRR level II should be completed in a timely manner upon admission for a resident with a mental health diagnosis or anytime a resident has had a change of condition or a newly added mental health diagnosis. She stated based on Resident #60's diagnosis of adjustment disorder and bipolar disorder a PASRR level II should have been completed.

Based on record review, observations, resident and staff interviews, the facility failed to prevent a latex urinary catheter from being inserted into a resident using latex gloves with a latex allergy and failed to assess the situation for 1 of 3 residents (Resident #76) reviewed for urinary catheters. Resident #76 told a total of 4 staff members before her catheter was changed that she was experiencing symptoms of an allergic reaction. As a result, Resident #76 experienced burning, itching, pain and swelling for a 28-hour period. The findings included: Resident #76 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident #76's face sheet revealed her allergies listed were latex and tape. A previous reaction to latex was not included in Resident #76's chart. The annual Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #76 was cognitively intact and had an indwelling urinary catheter. Resident #76's care plan initiated on 1/27/20 and last revised on 2/12/21 indicated Resident #76 had a urinary catheter related to urinary retention. The goals listed were for Resident #76 to have no harmful impaction, obstruction, or urinary retention through the next review date. The following interventions were listed: monitor for any signs or symptoms, urinary retention, or a urinary tract infection and to assist to the restroom for the highest continence possible. The review revealed Resident #76 did not have a care plan related to her latex allergy. A review of a Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . An interview conducted on 3/15/21 at 9:42 AM with Resident #76 revealed on 3/11/21 the facility staff had placed a latex indwelling catheter into her instead of using a hypoallergenic catheter which was what she required due to her latex allergy. She stated she did not sleep on the night of 3/11/21 due to this and was experiencing symptoms such as pain, itching, burning, and swelling on 3/11/21 and 3/12/21. The interview revealed the latex catheter was inserted by Nurse Aide (NA) #1 on 3/11/21 around 3:00 PM. She stated she had complained of burning and pain to Nurse #3 who worked the 7:00 to 11:00 PM shift when she was administering the medication [MEDICATION(S)] (an acid solution used to irrigate the bladder). She stated she had received the medication prior to this occurrence and had experienced no symptoms. The interview revealed Nurse #2 came on shift at 11:00 PM and she expressed to her that she was uncomfortable and experiencing burning at her catheter insertion site. She stated Nurse #2 came in her room a flushed her catheter with normal saline which helped the burning a little until she woke back up a few hours later urinating on herself. She stated Nurse #2 then came back into the room and resituated her indwelling catheter. The interview revealed on Friday 3/12/21 the latex catheter remained in place when Nurse #4 came on shift from 7:00 AM to 7:00 PM. She stated the catheter was very uncomfortable, even hurting with position change which normally did not happen. She stated Nurse #4 came into her room and she told him she was in pain and burning. Nurse #4 stated he did not want to change her catheter because it had already been changed. Resident #76 stated she had to lay still and try not to change positions so the pain wouldn't be as bad. She stated Nurse #1 came on shift on 3/12/21 at 7:00 PM and Nurse #4 told her she was experiencing trouble with her catheter. The interview revealed Nurse #1 immediately asked if she had a latex catheter inserted or a hypoallergenic catheter. Resident #76 stated Nurse #4 entered her room to check her catheter and said, it is a latex catheter. She stated Nurse #1 then stated, get that out of her. The interview revealed Nurse #1 immediately changed the catheter and told her she was so swollen in her vagina that it was hard to place the second catheter. Resident #76 stated the burning and pain she was experiencing decreased significantly when the latex catheter was removed. An observation conducted on 3/15/21 at 9:42 AM revealed latex free gloves placed in Resident #76's room for facility staff. On 3/16/21 at 2:55 PM an interview was conducted with Nurse #5. She stated she had taken care of Resident #76 on 3/11/21 from the 7:00 AM to 7:00 PM shift. The interview revealed she had an order to obtain a urine specimen and to change Resident #76's indwelling catheter. She stated she knew Resident #76 had an allergy to latex but had forgotten about it. The interview revealed she had asked NA #1 to change Resident #76's foley catheter and did not tell her the resident had an allergy to latex. On 3/16/21 at 3:05 PM an interview was conducted with NA #1. She stated she had placed Resident #76's indwelling catheter on 3/11/21 and obtained a urine specimen for Nurse #5. NA #1 stated when she went to the supply room, she had obtained a regular latex catheter with latex gloves and inserted it because she was not told Resident #76 had an allergy. She stated she wouldn't normally look at a resident's chart or allergies prior to inserting a catheter because the nurse would usually let her know if a resident had an allergy. She stated she knew Resident #76 was experiencing pain the next day on 3/12/21 because the resident had stated it to her. On 3/18/21 at 3:15 PM an interview was conducted with Nurse #3. During the interview she stated she was Resident #76's nurse from 7:00 PM to 11:00 PM on 3/11/21. She stated Resident #76 had complained of burning at her catheter site when she flushed her bladder with the medication [MEDICATION(S)] (an acid solution used to irrigate the bladder), but she felt it was due to trauma with the insertion. The interview revealed she remembered Resident #76 had a latex catheter, brown in color inserted when she was on duty, but she was only there for 4 hours and gave report to Nurse #2. On 3/17/21 at 3:26 PM an interview was conducted with Nurse #2. She stated she was Resident #76's nurse from 11:00 PM to 7:00 AM on 3/11/21. The interview revealed Resident #76 was complaining of cramping and burning at her catheter site, so she deflated the catheter bulb and tried to reinsert the same latex indwelling catheter. She stated she reinserted the catheter, inflated the bulb and flushed it with normal saline. The interview revealed she was not aware Resident #76 had an allergy to latex. On 3/17/21 at 9:30 AM an interview was conducted with NA #2. She stated she was working on 3/12/21 from 7:00 AM to 7:00 PM. The interview revealed Resident #76 had told her she was having problems with her catheter and complaining of pain. She stated she told Nurse #4 a couple of times during her shift. NA #2 stated the nurses had to eventually change Resident #76's catheter due to it being latex and she had a latex allergy. On 3/16/21 at 3:47 PM an interview was conducted with Nurse #4. Nurse #4 stated he was responsible for Resident #76 on 3/12/21 for the 7:00 AM to 7:00 PM shift. Nurse #4 stated Resident #76 was complaining of burning and discomfort during his shift, but he felt it could have been caused from trauma having a new catheter inserted and reinserted the night prior. He stated he told Nurse #1 the resident was experiencing issues with her catheter when he gave her report at 7:00 PM. The interview revealed he was unaware Resident #76 had an allergy to latex. Nurse #4 stated Nurse #1 asked him if the resident had a hypoallergenic catheter in when she received report. He stated he went into the residents room to verify the catheter was latex. Nurse #1 stated to Nurse #4 that she was going to change the catheter. On 3/16/21 at 3:21 PM an interview was conducted with Nurse #1. She stated she had worked on 3/12/21 from 7:00 PM to 7:00 AM on the 100/200 hall in which Resident #76 resided. She stated when she received report from Nurse #4, he stated Resident #76 was experiencing discomfort and pain related to her catheter. The interview revealed she immediately went into Resident #76's room and realized she had a latex catheter in which was causing her discomfort. She stated a lot of the nurses did not realize Resident #76 had a latex allergy, but she did because she was normally the nurse who changed her catheter and knew she needed a hypoallergenic catheter. Nurse #1 stated the facility did not have the correct size catheter Resident #76 had orders for in hypoallergenic catheters, so she had to place a size 18 French hypoallergenic catheter and notified the Director of Nursing. Nurse #1 stated the resident was having symptoms such as burning, swelling, itching and bladder spasms but nobody thought it would be due to the latex catheter prior to her coming on shift. The interview revealed after the changed Resident #76's catheter the resident stated she had some symptom relief. Nurse #1 then amended the Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Nurse #1 stated the order did not specify resident #76's allergy prior to 3/15/21. A review of a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . *Latex allergy! Use hypoallergenic silicone coated catheter only*. On 3/18/21 at 10:59 an interview was conducted with the Director of Nursing (DON). The DON stated she was notified by Nurse #1 on 3/13/21 that a latex catheter was placed into Resident #76. The interview revealed the DON had just conducted a catheter audit on 3/9/21. She stated the facility had two kinds of catheters one being 100% silicone clear in color and the other being latex, brown in color. She stated Nurse #1 told her the catheter was brown in color and Resident #76 had complained of burning. The interview revealed on 3/16/21 the DON completed a medication error on the incident and the order had been amended to include Resident #76 had a latex allergy. She stated she started conducting an in-service with all staff on education of resident allergies which began on 3/16/21. During the interview she stated the resident had latex free gloves placed in her room and was also receiving the medication [MEDICATION(S)] (an acidic solution used to irrigate the bladder) which could have caused some of the burning she experienced. The medication was used as needed prior to 3/11/21 but was changed to twice daily on 3/11/21. Resident #76 received the first dose on the 7:00 AM to 7:00 PM shift and the second dose on the 7:00 PM to 11:00 PM shift when she began complaining of burning. The DON stated Resident #76's allergies were listed on her face sheet in the computer charting system which was visible to all nursing staff. She pulled up the residents Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of an event report dated 3/16/21 revealed on 3/11/21 Resident #76 had stated she started hurting and felt like the wrong catheter was placed and it was not latex free. The type of error was documented as other-latex catheter. The resolution included an evaluation by the Nurse Practitioner. Review of an in-service log dated 3/16/21 revealed the DON had initiated an in-service regarding education for allergies. The education was provided via in person to those who were working in the facility and via text message to staff who were not in the facility. On 3/17/21 at 10:42 AM an interview was conducted with the Nurse Practitioner. During the interview she stated Resident #76 had a chronic indwelling catheter in which she refused to have removed due to incontinence. She stated an allergic reaction to latex could cause swelling in the vagina, burning, itching or redness. The interview revealed when she evaluated Resident #76 this week the resident had stated to her that staff had placed a latex catheter instead of a hypoallergenic catheter and she had experienced discomfort as a result. She stated Resident #76 was receiving [MEDICATION(S)] (acid solution used to irrigate the bladder) twice a day starting on 3/11/21 which could have caused some of the burning the resident had experienced due to the trauma of receiving a new indwelling catheter. On 3/18/21 at 11:48 AM an interview was conducted with the Medical Director. During the interview he stated a reaction to a latex allergy would include swelling, redness, itching and discomfort. He stated he wasn't notified of the incident occurring it would have been the Nurse Practitioner who would be responsible for evaluating the resident. On 3/19/21 at 2:52 PM an interview was conducted with the Administrator. During the interview she stated her expectation was for the orders on Resident #76's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on record reviews, family member, staff and Hospice Representative interviews, the facility failed to promote compassionate care visits for a resident (Resident #255) with overall declining condition for 1 of 3 resident reviewed for falls. The findings included: Resident #255 was admitted to the facility on [DATE] following a hospitalization for repair of left [CONDITION(S)] after a fall. The resident's admitting diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #255's admission Minimum Data Set (MDS) dated [DATE] revealed she was severely cognitively impaired for daily decision making but was able to make her needs known and required extensive assistance of 1 to 2 staff for most activities of daily living (ADL). Review of a fall event report dated 08/30/2020 revealed Resident #255 had an unwitnessed fall in her room around 2:02AM resulting in bilateral hematomas to her head and bruising to her face and a skin tear to her left shoulder with bruising. The resident was assessed by Nurse #1 and neurological checks and vital signs showed no abnormalities for the resident. Review of a Nurse Practitioner progress note dated 08/31/2020 revealed Resident #255 was seen after 2 falls and was described as lethargic today. Review of the Nurse progress notes revealed the following: 09/02/2020 at 12:22AM revealed resident had a fall out of bed but was alert and responsive with confusion which has been noted as increased since previous falls on 08/29/2020 and 08/30/2020. 09/02/2020 at 5:36AM revealed Resident #255 was out of bed in a recliner, restless and throwing her legs over the side of the chair, requiring frequent repositioning and reminders to keep legs on pillows to keep pressure off heels, resident refused AM meds spit them out. 09/02/2020 at 6:39AM revealed Nurse #3 spoke with family related to fall, resident noted with increased restlessness, confusion, with agitation fighting staff, yelling at staff for positioning her, resident has not slept this shift. 09/03/2020 at 12:48AM revealed Nurse #3 wrote remains with confusion and agitation when awake. Interview on 03/16/2021 at 1:52PM with Resident #255's family member revealed the family member had called the Administrator numerous times with no response. She stated she finally found a number for their corporate office and talked with someone there and they gave her the Administrator's email address. According to the family member, she emailed the Administrator with no response about visiting Resident #255. The family member stated she later emailed her again about billing concerns and stated the Administrator had responded to her email about her billing concerns. The family member stated she had finally on 09/03/2020 requested Hospice for Resident #255 because she wanted to be able to spend time with her as she continued to decline. According to the family member it was not until 09/02/2020 when she talked with the Nurse Practitioner (NP) that she had been offered the opportunity to visit Resident #255. She stated the NP told her she would be able to visit the resident on 09/03/2020. Interview on 03/17/2021 at 5:20PM with the Administrator revealed she had checked her emails and phone logs and only had one email from Resident #255's family member. She stated in September of 2020 they were in a COVID outbreak and visitation was limited to compassionate care only. The Administrator could not recall any time the family member had made a request to her to visit Resident #255. She stated she was having the corporate office check their phone logs and emails to see if there had been a contact by the family member to them. The Administrator stated even during their outbreak they were still doing compassionate care visits. Review of a Hospice note dated 09/03/2021 revealed a Social Worker (SW) interviewed the family member of Resident #255 and the family member told her I just want to be able to visit with Resident #255 and I want to make sure that she is comfortable and not suffering because she has been through so much. Review of a Hospice note dated 09/04/2021 revealed a Social Worker (SW) had contacted the family member who shared with her Resident #255 had had numerous falls recently and her head was injured. The family member stated the resident had become less responsive each day and declined rapidly since the fall. The SW documented the family member tearfully described the resident's face as severely bruised with knots on her forehead. According to the report the family member had contacted Administration at the facility regarding visiting her mom and was waiting to hear back for approval. The family member stated if she was not allowed to visit Resident #255 at the facility, she would like for the resident to be moved to Inpatient Hospice. Interview on 03/24/2021 at 1:27PM with the Hospice SW revealed she had talked with Resident #255's family member and had met with her in person. She stated when she talked with the family member on the phone on 09/03/2020 her main concern was she had not been able to visit the resident at the facility. The family member told the SW she was awaiting a call back from the facility to give her permission to see Resident #255. The family member further stated to the SW if she was not going to be able to visit the resident, she wanted her moved to inpatient Hospice where she could spend more time with her. The SW stated they were able to complete the admission process and get the resident transferred on 09/06/2020.

Based on record reviews, staff, Nurse Practitioner and facility Physician interviews, the facility failed to notify the Physician when a resident's (Resident #255) Computerized Tomography (CT) scan had been cancelled by the facility for 1 of 3 residents reviewed for falls. The findings included: Resident #255 was admitted to the facility on [DATE] following a hospitalization for repair of left [CONDITION(S)] after a fall. The resident's admitting diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #255's admission Minimum Data Set (MDS) dated [DATE] revealed she was severely cognitively impaired for daily decision making but was able to make her needs known and required extensive assistance of 1 to 2 staff for most activities of daily living (ADL). Review of a fall event report dated 08/30/2020 revealed Resident #255 had an unwitnessed fall in her room at around 2:02AM resulting in bilateral hematomas to her head and bruising to her face and skin tear to her left shoulder with bruising. The resident was assessed by Nurse #1 and neurological checks and vital signs showed no abnormalities for the resident. Review of a nursing progress note dated 08/30/2020 at 4:35AM written by Nurse #1 revealed Resident #255 Noted to have 2 hematomas bilaterally on forehead. Skin tear noted to left shoulder with bruising already present. SBAR (Situation, Background, Assessment and Recommendation) placed in MD (Medical Doctor) book for notification. Neurochecks initiated and within normal limits at this time. Review of a Nurse Practitioner progress note dated 08/31/2020 revealed Resident #255 was being seen related to Fall, among other concerns. The note stated seen today after a 2 falls. Staff report that Resident #255 was found on the floor beside her bed. Resident is lethargic today. Obtain CT scan of the head without contrast for possible bleed, post fall, and lethargy. Review of the Transportation Aide's appointment calendar for 2020 revealed the CT scan for Resident #255 had been scheduled to be done on 09/01/2020 at the local hospital. The appointment book also revealed the CT scan had been cancelled by the Administrator due to COVID in the building. Interview on 03/17/2021 at 10:30AM with the NP revealed she recalled Resident #255 and stated she had dementia, heart failure and other diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The NP further stated she had ordered a CT scan on 08/31/2020 and stated it had been scheduled for 09/01/2020. The NP indicated she had not seen the results of the scan and had not been notified the scan was not done on 09/01/2020. The NP stated if the CT scan was cancelled, she would have expected to be notified. Interview on 03/17/2021 at 3:00PM with the Transportation Aide (TA) revealed she was responsible for scheduling appointments and stated she had scheduled an appointment for Resident #255 to have a CT scan at the local hospital to be done on 09/01/2020. The TA further stated the CT scan had been cancelled by the Administrator according to her note but stated she did not remember why but in her note she had documented it was due to COVID in the building. Interview on 03/17/2021 at 5:08PM with the facility Physician revealed he recalled the resident but did not recall her specific falls. The Physician indicated he was not aware the CT scan had been cancelled for Resident #255 and stated he would have expected the facility to have contacted the NP to let her know the scan had been cancelled. Interview on 03/17/2020 at 5:20PM with the Administrator revealed she could not recall why she would have cancelled Resident #255's CT scan unless she had been told to do so by the hospital or a physician practice. She stated she did not know why she had cancelled the appointment. A follow up interview on 03/19/2021 at 9:30AM with the Nurse Practitioner (NP) revealed the normal process at the facility would have been for the NP to have been notified the CT scan had been cancelled. She stated if she had been notified, she would have ordered the resident to have been sent out to the local hospital emergency department for the CT scan.

Based on record reviews, staff, Nurse Practitioner and Physician interviews, the facility failed to ensure a resident who was on antiplatelet therapy, had an unwitnessed fall with head injury resulting in hematomas and bruising received a Computerized Tomography (CT) scan as ordered by the Nurse Practitioner for 1 of 3 residents reviewed for falls (Resident #255). The findings included: Resident #255 was admitted to the facility on [DATE] following a hospitalization for repair of left [CONDITION(S)] after a fall. The resident's admitting diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #255's admission Minimum Data Set (MDS) dated [DATE] revealed she was severely cognitively impaired for daily decision making but was able to make her needs known and required extensive assistance of 1 to 2 staff for most activities of daily living (ADL). Review of Resident #255's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The [MEDICATION(S)] was discontinued effective 09/03/2020. Review of a fall event report dated 08/30/2020 revealed Resident #255 had an unwitnessed fall in her room at around 2:02AM resulting in bilateral hematomas to her head and bruising to her face and skin tear to her left shoulder with bruising. The resident was assessed by Nurse #1 and Resident #255's neurological checks and vital signs showed no abnormalities for the resident. Review of a nursing progress note dated 08/30/2020 at 4:35AM written by Nurse #1 revealed Resident #255 noted to be in floor at bedside. Claims she was trying to get up and fell . ROM (range of motion) x 4 without difficulty. Noted to have 2 hematomas bilaterally on forehead. Skin tear noted to left shoulder with bruising already present. SBAR (Situation, Background, Assessment and Recommendation) placed in MD (Medical Doctor) book for notification. Neurochecks initiated and within normal limits at this time. No acute distress noted. Call light within reach. Will continue to monitor. Review of a Nurse Practitioner progress noted dated 08/31/2020 revealed Resident #255 was being seen related to Fall, among other concerns. The note stated seen today after a 2 falls. Staff report that Resident #255 was found on the floor beside her bed. Resident is lethargic today. Obtain CT scan of the head without contrast for possible bleed, post fall, and lethargy. Review of the Transportation Aide's appointment calendar for 2020 revealed the CT scan for Resident #255 had been scheduled to be done on 09/01/2020 at the local hospital. The appointment book also revealed the CT scan had been cancelled by the Administrator due to COVID in the building. Phone interview on 03/16/2021 at 1:52PM with Resident #255's family member revealed when Nurse #1 contacted her on 08/30/2020 early AM (could not remember exact time), Nurse #1 told her Resident #255 had fallen during the night and hit her head and had two pump knots on her head that looked like devil [NAME]. The family member stated she said to Nurse #1, I assume you will be sending her out for a CT scan and stated she told Nurse #1 she wanted Resident #255 sent out for a CT scan. The family member indicated she had spoken with the NP on 08/31/2020 after she had evaluated her mother and the NP told her she had ordered a CT scan of her head without contrast. Interview on 03/17/2021 at 10:30AM with the NP revealed she recalled Resident #255 and stated she had dementia, heart failure and other diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The NP further stated she had ordered a CT scan on 08/31/2020. The NP indicated she had not seen the results of the scan and after looking could not locate the results and stated it must not have been done. The NP further indicated she had not been notified the scan was not done. Phone interview on 03/17/2021 at 11:38AM with Nurse #1 revealed she had taken care of Resident #255 when she had fallen and hit her head on 08/30/2020. She stated after the resident fell , she had two large hematomas on her head but stated her neurological checks and vital signs were normal. Interview on 03/17/2021 at 3:00PM with the Transportation Aide (TA) revealed she was responsible for scheduling appointments and stated she had scheduled an appointment on 08/31/2020 for Resident #255 to have a CT scan at the local hospital to be done on 09/01/2020. The TA further stated the CT scan had been cancelled by the Administrator according to her note but stated she did not remember why except in her note she had documented it was due to COVID in the building. Interview on 03/17/2021 at 5:08PM with the Physician revealed he recalled the resident but did not recall her specific falls. The Physician indicated he was not aware the CT scan had been cancelled for Resident #255 and stated he would have expected the facility to have contacted the NP to let her know the scan had been cancelled and then she could have sent the resident out to the hospital to have it done. Interview on 03/17/2020 at 5:20PM with the Administrator revealed she could not recall why she would have cancelled Resident #255's CT scan unless she had been told to do so by the hospital or a physician practice. She stated she did not know why she had cancelled the appointment. Follow up interview on 03/19/2021 at 9:30AM with the Nurse Practitioner (NP) revealed the normal process at the facility would have been for the NP to have been notified the CT scan had been cancelled but stated she had not been notified the scan was cancelled. She stated if she had been notified, she would have ordered the resident to have been sent out to the local hospital emergency department for the CT scan.

Based on observation and staff interviews, the facility failed to record the refrigerator temperatures for 1 of 2 nourishment rooms. Findings included: An observation with nursing staff, was made on 03/18/21 at 12:15 pm of the nourishment room located on the 500 and 600 halls. The temperature record sheet located on the side of the fridge did not have temperatures logged for dates 03/12/21 and 03/15/21. An interview on 03/19/21 at 2:00 pm with the Dietary Aide revealed she oversees nutritional rooms in the facility and was responsible for checking refrigerator temperatures daily. The Dietary Aide revealed that on dates 3/12/21 and 03/15/21 that she was on vacation and the temperatures should have been checked by other kitchen staff. She indicated she did not know who was assigned to check the temperatures the days of 03/12/21 and 03/15/21 and stated the refrigerator temperatures should be checked and logged daily. An interview on 03/19/21 at 11:24 am with the Dietary Manager revealed the Dietary Aide checks nourishment room refrigerator temperatures daily. She stated she was not aware of the temperatures not being recorded for dates 03/12/21 and 03/15/21 and she did not recall who was assigned to cover for those dates. The Dietary Manager revealed she expected the temperatures to be checked and logged daily. An interview on 03/19/21 at 2:51 pm with the Administrator revealed she could not recall why the temperatures were not checked on 3/12/21 and 3/15/21. The Administrator indicated there should have been a replacement to check refrigerator temperatures if the Dietary Aide was out of the building.

Based on record reviews, observations and staff interviews, the facility failed to implement the Centers for Disease Control and Prevention (CDC) guidelines when they continued to quarantine a previously COVID-19 positive, [CONDITION(S)] resident (Resident #66) after the resident met criteria to come off of isolation and placed a newly-admitted resident (Resident #253) with a resident (Resident #66) that qualified as general population. The facility also failed to implement the CDC guidelines for the use of Personal Protective Equipment (PPE) when 1 of 3 dietary staff members (Cook #1) was observed wearing a KN95 mask under the chin with the nose and mouth uncovered while handling food. These failures occurred during a COVID-19 pandemic. The findings included: 1. The Centers for Disease Control and Prevention (CDC) guideline entitled, Responding to Coronavirus (COVID-19) in Nursing Homes, updated on [DATE] indicated the following statements: * Create a plan for managing new admissions and readmissions whose COVID-19 status is unknown. Options include placement in a single room or in a separate observation area so the resident can be monitored for evidence of COVID-19. * New residents could be transferred out of the observation area or from a single to a multi-resident room if they remain afebrile and without symptoms for 14 days after their last exposure (e.g., date of admission). The facility's COVID-19 policy entitled, Residents out of facility for medically necessary appointments, dated [DATE] read, in part: [CONDITION(S)] residents are at increased risk for COVID-19, these residents will be placed on PUI (persons under investigation) unit upon return to the facility due to high risk. During the entrance conference with the Administrator on [DATE] at 9:22 AM, the Administrator indicated that the newly admitted and readmitted residents were placed on 500 hall which was considered as the PUI unit. She also stated that they placed their [CONDITION(S)] resident on the PUI unit per facility policy. A review of the facility census indicated room [ROOM NUMBER] on the PUI unit and 8 of 9 rooms on 600 hall were empty for [DATE]. Resident #66 was admitted to the facility on [DATE] to room [ROOM NUMBER] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . She was moved to room [ROOM NUMBER] on [DATE] and then to room [ROOM NUMBER] on [DATE]. She had not received any COVID-19 vaccine. Resident #253 was admitted to the facility on [DATE] to room [ROOM NUMBER] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . She had not received any COVID-19 vaccine. An observation of the PUI unit was made on [DATE] at 12:29 PM and revealed Resident #66 and Resident #253 were in room [ROOM NUMBER] and were separated by a screen. Their room door had a posted enhanced droplet isolation sign and a plastic bin was located outside the door which contained PPE such as gowns and gloves. An interview with the Infection Preventionist (IP) on [DATE] at 12:35 PM revealed Resident #66 was in the PUI unit because she went to [CONDITION(S)] three times a week and they treated her like she was positive for COVID-19. The IP stated Resident #66 had just been moved to the room with Resident #253 but had been previously in another room in the PUI unit with another resident. The IP stated that it had not been her decision and was not sure why Resident #66 and Resident #253 were in the same room together in the PUI unit. An interview with the Director of Nursing (DON) on [DATE] at 12:43 PM indicated that she did not have a clue why Resident #66 did not get moved to a private room except for the facility not having a private room available. The DON revealed a resident who had been in room [ROOM NUMBER] had recently died which was why it was currently empty. They had two semi-private rooms in the PUI unit and had always placed two residents in the semi-private rooms. The DON stated she thought this practice was acceptable. She also explained they considered Resident #66 as presumptive positive for COVID-19 because she went to [CONDITION(S)] three times a week and had decided to place her in the PUI unit. Another observation of the PUI unit on [DATE] at 8:35 AM revealed Resident #66 and Resident #253 were still in room [ROOM NUMBER]. An interview was conducted on [DATE] at 9:06 AM with the Administrator who stated that Resident #66 had previously tested positive for COVID-19 last December and Resident #253 had never tested positive for COVID-19. The Administrator explained that they did not move one of them out of the room the day before because they did not have a room available due to 600 hall still having one COVID-19 positive resident. She added that they wanted to sanitize the whole hall first before moving either Resident #66 or Resident #253 to 600 hall. An observation on the 600 hall on [DATE] at 8:24 AM revealed a plastic barrier was set up separating the last four rooms from the rest of the hall while a resident still occupied room [ROOM NUMBER] which was behind the plastic barrier. Further observation of the 600 hall on [DATE] at 1:58 PM revealed Resident #66 had been moved to room [ROOM NUMBER]. 2. The Centers for Disease Control and Prevention (CDC) guideline entitled, Preparing for COVID-19 in Nursing Homes, which was last updated on [DATE] indicated that HCP (healthcare personnel) should wear a facemask at all times while they are in the facility. The CDC guideline entitled, How to Wear Masks, last updated on [DATE] indicated: * Wear a mask over your nose and mouth to help prevent getting and spreading COVID-19. * Wear a mask correctly for maximum protection. * Don't put the mask around your neck or up on your forehead. A review of the facility's COVID-19 policy entitled, Masks, dated [DATE] read, in part: Masks must be worn in/around the facility at all times. The mask must cover your mouth and your nose. During an observation of the facility's kitchen on [DATE] at 1:15 PM, Cook #1 was seen with her mask pulled down underneath her chin. Cook #1's nose and mouth were both exposed. She was observed turning from the sink to the prep table where she was noted to be preparing a sandwich. Nurse Aide (NA) #1 was observed waiting by the open door to the kitchen. An interview with NA #1 on [DATE] at 1:15 PM indicated she had been waiting by the kitchen door because Cook #1 was making one of her residents a sandwich. NA #1 stated she had been waiting about five minutes, but she did not notice whether Cook #1 had her mask down below her chin while fixing the sandwich because Cook #1 had her back turned to her. An interview with Cook #1 on [DATE] at 1:20 PM revealed she knew that she was supposed to wear her mask over her nose and mouth but she had been having such a hard time breathing with a KN95 mask on and that she couldn't wear it over her nose and mouth for a long time. Cook #1 stated that she had tried wearing a surgical mask, but she couldn't breathe through it either. Cook #1 admitted that she had to pull her mask down several times while working in the kitchen and that she had just been preparing a sandwich with her mask down and her mouth and nose exposed. Cook #1 further stated that she had told the Director of Nursing (DON) and the Administrator that she had a problem about not being able to breathe with a mask on but she was told that she should wear a mask anyway. She added that she tried to get her doctor to write her a note that she couldn't wear a mask but her doctor refused to do so and told her that a mask was supposed to protect her from COVID-19. An interview with the Infection Preventionist (IP) on [DATE] at 1:45 PM indicated she expected Cook #1 to wear a mask properly to cover both her nose and mouth while in the kitchen and while handling food for the residents. The IP stated everyone had a hard time breathing through a mask, but it was not an excuse to pull her mask down below her chin. An interview with the Director of Nursing (DON) on [DATE] at 1:47 PM revealed Cook #1 had been educated on how to wear a mask properly and she should have worn her mask to cover both her nose and mouth. The DON stated she had been aware that Cook #1 had been having issues with wearing a mask and her difficulty with breathing through it but she should still have worn her mask properly especially while working in the kitchen and preparing a resident's food. An interview was conducted on [DATE] at 3:00 PM with the Administrator who stated that there was no excuse for Cook #1 to not wear her mask properly and that she had been educated several times previously. The Administrator revealed that this had not been the first time Cook #1 had pulled her mask down while working in the kitchen. She added that Cook #1 should have worn her mask to cover both nose and mouth the whole time while she was in the facility unless she was on break.

Based on record review and staff interviews, the facility failed to include procedures for outdoor visitation screening in their COVID-19 policy and failed to screen visitors prior to an outdoor resident visitation for 1 of 6 residents (Resident #6) reviewed for infection control. These failures occurred during the COVID-19 pandemic. The findings included: A review of the facility's COVID-19 policy entitled Visitation Policy updated on 7/24/20 did not include screening for outdoor resident visitation. The facility's Visitor Screening Log for 8/28/20 indicated one visitor had been screened upon entry to the facility on [DATE] at 2:50 PM to go to room [ROOM NUMBER] which was not Resident #6's room. The visitor signed out at 3:13 PM. On 9/23/20 at 10:59 AM, a phone interview was conducted with the facility's Director of Marketing (DM) who stated the facility had an outdoor visitation for Resident #6 with her family members on 8/28/20. The DM could not say how many people were present at the visitation, but she emphasized that there were not a lot of people who gathered to visit with Resident #6. She stated that nobody touched Resident #6 and all the people present wore masks. The DM said all the visitors including Resident #6's family members were not screened because none of them entered the facility. The DM stated she spoke with Resident #6's family members and educated them prior to the event not to come if they were sick. On 9/22/20 at 1:37 PM, an interview was conducted with the Director of Nursing (DON) who was also responsible for Infection Control. The DON stated she was present when Resident #6 had outdoor visitation from family members on 8/28/20. Resident #6 and all her visitors wore masks. The DON stated all the visitors did not get screened because they did not go into the building. None of Resident #6's visitors had their temperatures checked before the visitation. She counted at least five visitors stood outside while visiting Resident #6. She knew that the Administrator had asked Resident #6's family members not to come if they had been sick or if they had been around other people who were sick before the visit. The DON also confirmed that the visitor who had been screened on 8/28/20 was not one of Resident #6's visitors. On 9/22/20 at 2:57 PM, an interview conducted with the Administrator confirmed the facility had an outdoor visitation for Resident #6 on 8/28/20. All visitors wore masks and stayed outside of the 6-feet marked area. The Administrator could not say how many visitors came because she was not present during the entire visit. She stated some visitors came out of their cars, waved to Resident #6, handed Resident #6's family member a card and left. She said there were no more than five people who stood outside at one time. The Administrator stated they did not check the temperatures of all visitors because nobody went inside the building but she had asked Resident #6's family member not to come and told other family members not to come if they had been sick or if they had been around anyone who had been sick. On 9/24/20 at 2:06 PM, a follow-up interview with the Administrator revealed that the reason why they did not think about screening the visitors prior to the outdoor visitation for Resident #6 on 8/28/20 was that they had planned for none of the visitors to be within 6 feet of Resident #6. The Administrator also stated that the facility policy did not specify screening for outdoor visitation as well and she had thought that they did the right thing at that time and followed the safety precautions to prevent transmission of COVID-19.

Based on resident, physician and staff interviews and record review the facility failed to ensure information staff were to reference about a residents' elected advanced directives was available and accurate. This practice affected for 2 of 4 sampled residents reviewed for advanced directives (Resident #69 and #73). The findings included: 1. Resident #69 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The hospital discharge summary dated [DATE] read in part, CODE STATUS: limited code blue for [MEDICAL CONDITION]. No advanced directive documents available. The physician document titled History and Physical dated [DATE] specified CODE STATUS: DNR (Do Not Resuscitate) limited resuscitation, no intubation, no feeding tube. The admission Minimum Data Set ((MDS) dated [DATE] specified the resident's cognition was intact, she had clear speech, made herself understood and had the ability to understand others. Review of Resident #69's care plan did not address the resident's advanced directives. Review of Resident #69's medical record and a notebook containing advanced directives for residents revealed there was no physician signed documentation of the resident's desire to be a DNR. On [DATE] at 10:34 AM Resident #69 was interviewed and she stated that she had talked with her brother and if she stopped breathing she wanted to go ahead and die. She said she had not spoken with anyone at the facility and no one had asked her about her advanced directives. On [DATE] at 9:21 AM the Social Worker (SW) was interviewed and explained the admission process for determining advanced directives. She stated that she or another staff member assisted families and/or residents with advanced directives on admission and documented the wishes on a MOST (Medical Orders for Scope of Treatment) form, signed by the physician or nurse practitioner. She added that resident advanced directives were kept in a notebook for staff to reference. The SW added that if there was no MOST form in the notebook then a resident was presumed to be FULL CODE and would receive CPR (cardiac [MEDICAL CONDITION] resuscitation). The SW explained that she had not met with Resident #69 to review advanced directives and wasn't sure if anyone had met with the resident because the process allowed various staff members the ability to meet with a new admitted resident to determine advanced directives. She stated she thought the Unit Manager was supposed to audit advanced directives to ensure they were available and up-to-date. On [DATE] at 9:56 AM Unit Manager #2 was interviewed about the process for determining a resident's advanced directives and stated she was not real sure about the process but thought all residents were supposed to have a MOST form kept in a notebook. Unit Manager #2 reviewed the notebook for Resident #69 and found that the notebook contained a Face Sheet and nothing else. Unit Manager #2 confirmed that Resident #69's Face Sheet specified there were no advanced directives selected and there was no MOST form on file. She added that Resident #69 would be consider FULL CODE. She also reviewed the electronic medical record for Resident #69 and noted the hospital discharge summary (dated [DATE]) and physician history and physical (dated [DATE]) specified the resident was DNR. She offered no explanation for the discrepancy. She added that advanced directives were supposed to be audited by the SW to ensure they were up-to-date and accurate. On [DATE] at 10:09 AM the Director of Nursing (DON) was interviewed and explained that the facility's policy was to document advanced directives on a MOST form signed by the physician. She added that without a MOST form, a resident would be considered FULL CODE. She was unaware why advanced directives for Resident #69 were not correctly documented. She explained that ideally within 24 hours of admission, advanced directives should be determined and in place. She also added the facility had realized there was a problem with ensuring advanced directives were being completed on admission. On [DATE] at 11:42 AM the Physician was interviewed and stated he expected advanced directives to be determined and documented as soon as possible. He added that his note was not considered a legal document and advanced directives should be documented and signed by a physician on a legally recognized document, such as a MOST form. The Physician was made aware of his History and Physical assessment dated [DATE] that specified Resident #69 preferred DNR status and added that the facility would need to follow-up with completing a MOST form for him to sign to honor the resident's wishes. On [DATE] at 12:43 PM the Administrator reported that the Unit Managers should audit the advanced directives notebook to ensure advanced directives were in place for all new admissions and that either the SW, Admissions Director or nursing staff had discussed and attempted to obtain advanced directive preferences with all new resident admissions. 2. Resident #73 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the admission Minimum Data Set ((MDS) dated [DATE] revealed that Resident # 73 had severe cognitive impairment and required extensive assistance with most activities of daily living. A review of the electronic and hard copy medical records for Resident #73 revealed there was no Advance Directive (AD) form for a full code or Do Not Resuscitate (DNR) order on file. An interview was conducted with Unit Manager (UM) #1 on [DATE] at 10:35 AM. She indicated that all AD forms should be filed in the AD notebook located at the nursing station. She stated that it was a team effort to make sure the AD forms were completed and on file and no one was assigned. UM #1 explained the form should be completed at the time of admission or as soon as possible, and that if no form was on file in the notebook that it was understood that cardio [MEDICAL CONDITION] resuscitation (CPR) would be initiated and the family and physician would be contacted for continued guidance. UM #1 checked the notebook and verified that Resident #73 had no AD form on file. She stated that the family representative visited daily, and staff would get something completed and on file. The Social Worker (SW) was interviewed on [DATE] at 9:55 AM. She indicated the Admissions Coordinator, SW, or nursing staff could complete the AD forms and the responsibility was not assigned to one specific person. Once the form was completed it should be placed in the AD notebook at the nursing station for easy access when needed. An interview was conducted with the Director of Nursing (DON) on [DATE] at 10:09 AM and she reported she wanted AD forms to be completed and on file within 24 hours of admission. She said they had recently identified problems with the current process and an audit had been initiated to complete forms. The DON reported the family representative for Resident #73 had a hard time making a decision and staff had talked with the family multiple times although it had not been documented. An interview with the Admissions Coordinator on [DATE] at 12:11 PM indicated that the AD forms were addressed at the time of admission and completed at that time if possible. She stated that if it was a late admission it was the responsibility of nursing staff to address and complete the AD forms. The Admissions Coordinator was not sure if there was a process to double check and see if the form was completed. She said the family representative for Resident #73 had not returned the form to the facility until [DATE]. An interview was conducted with the Administrator on [DATE] at 12:44 PM. She said it was a collective effort to make sure AD forms were completed and the Unit Manager's responsibility to make sure the forms were on file in the AD notebook. She reported the family representative for Resident #73 was forgetful and had great difficulty in making this decision on behalf of the resident and the MOST form for Resident #73 had been returned this week. The Administrator indicated that although it was sometimes difficult for families to make decisions at the time of admission, that she would have expected something to have already been on file for a resident that was admitted in (MONTH) 2019. The interview further revealed staff had identified this as an issue recently and that an audit had been initiated and she knew this was an area that needed improvement.

Based on observations and resident and staff interviews the facility failed to assess 1 of 1 resident for self-administration of over the counter medications (Resident # 61). Findings included: Resident #61 was originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set ((MDS) dated [DATE] revealed Resident #61 was cognitively intact. Review of Resident #61's medical record revealed there were no Physician's orders for eye lubricant or eye drops. An observation of Resident #61's over bed table on 01/14/19 at 2:49 PM revealed a tube of eye lubricant and a bottle of eye drops sitting on top. An interview with Resident #61 on 01/14/19 at 2:49 PM revealed he did not use the eye lubricant or eye drops himself and that staff did not administer them to him. An observation of Resident #61's over bed table on 01/15/19 at 1:17 PM revealed a tube of eye lubricant and a bottle of eye drops sitting on top. An observation of Resident #61's bedside table on 01/16/19 at 8:32 AM revealed a clear container sitting on top of the table with a tube of eye lubricant and a bottle of eye drops inside. An observation of Resident #61's bedside on 01/17/19 at 9:11 AM revealed a clear container sitting on top of the table with a tube of eye lubricant and a bottle of eye drops inside. An interview with Resident #61's Nurse #1 on 01/17/19 at 1:09 PM revealed Resident #61 did not self-administer any medications. An observation of Resident #61's bedside table on 01/17/19 at 1:24 PM revealed a clear container sitting on top of the table with a tube of eye lubricant and a bottle of eye drops inside. An interview with Nurse #1 on 01/17/19 at 1:27 PM revealed she was not aware Resident #61 had a tube of eye lubricant and a bottle of eye drops in a container on top of the bedside table. Nurse #1 removed the tube of eye lubricant and bottle of eye drops from Resident #61's room. An interview with the Director of Nursing (DON) on 01/17/19 at 3:16 PM revealed she was not sure where the tube of eye lubricant and bottle of eye drops came from. The DON stated the tube of eye lubricant and bottle of eye drops could have been left at Resident #61's bedside if he had been deemed safe to keep them at the bedside and if Resident #61 had a Physician's order to leave those medications at the bedside. The DON stated Resident #61 did not have a Physician's order to administer the eye lubricant or the eye drops and they should not have been left at the bedside.

Based on observations, record review and staff interviews the facility failed to implement a care planned intervention to off load heels while in bed for 1 of 5 residents reviewed for pressure ulcers (Resident #52). The Findings Included: Resident #52 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident #52's significant change Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #52 to be severely impaired cognitively with no behaviors or rejection of care noted. Resident #52 required extensive assistance with bed mobility. This assessment also identified that Resident #52 was at risk for developing pressure ulcers and was utilizing pressure reducing devices to her chairs and bed. A review of Resident #52's care plan for skin impairment risk related to limited mobility and weakness last revised 12/07/18 revealed with a goal of preventing skin breakdown. Interventions included off load heels on pillows while in bed. A review of Resident #52's physician order [REDACTED]. A review of a facility document entitled N.A. (Nursing Assistant) Worksheet dated 01/17/19 revealed Resident #52 had special needs that included: float heels, and safety air mattress. An observation on 01/15/19 at 3:43 PM revealed Resident #52 was observed to be in bed resting. Resident #52 was observed lying flat on her back with a thin blanket over her body. Further observation at this time revealed Resident #52's heels were not off loaded on pillows per the care plan and there were no pillows observed under the blanket. Resident #52 was noted to be on an air mattress at this time. An additional observation of Resident #52 was completed on 01/16/19 at 1:43 PM. Resident #52 was observed at this time to be in bed lying flat on her back, on an air mattress with her heels resting on the bed. There were no pillows observed under the blanket. During an interview with Nurse #2 on 01/17/19 at 11:25 AM it was revealed it was the responsibility of the nurse aides to make sure that treatments assigned to them remained in place. Nurse #2 stated she signed off on the Treatment Administration Record (TAR) that Resident # 52's heels were off loaded on pillows but she did not go in after nurse aides (NAs) provided care to verify Resident #52's heels were off loaded on pillows while she was in bed. She also stated that it was difficult at times to keep pillows under Resident #52's heels due to Resident #52 occasionally drawing her knees up, especially during care. An interview conducted on 01/17/19 at 1:21 PM with NA #1 revealed she provided care for Resident #52 often and was assigned to Resident #52 on 01/15/19 and 01/16/19. She also reported there were days when there were no pillows under Resident #52's heels. NA #1 reported she was made aware of the special needs of each resident on her hall by looking at a document called the NA Worksheet. NA #1 reported she was made aware the previous day (1/16/19) by the MDS Nurse #1 to make sure Resident # 52 had pillows under her heels while in bed. An interview with the Director of Nursing (DON) on 01/17/19 at 3:04 PM revealed the nurse who had worked on Resident #52's hall had reported to her that pillows were placed in the bed with her but that Resident #52 moved around a lot and that it was difficult to keep them underneath her heels. She continued, stating that Resident #52 was on an air bed and reported the air bed should be better than pillows for off-loading of Resident #52's heels. The DON reported it was expected that care outlined on the NA Worksheet be followed.

Based on observations, record review and staff interviews the facility failed to document a physician ordered intervention had been completed on the treatment administration record and failed to document a medication had been administered on the Medication Administration Record [REDACTED]. The Findings Included: 1a. Resident #52 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident #52's significant change Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #52 to be severely impaired cognitively with no behaviors or rejection of care noted. Resident #52 required extensive assistance with bed mobility, transfer locomotion on the unit, dressing, toilet use and personal hygiene. This assessment also identified that Resident #52 did not have a pressure ulcer but was at risk for developing pressure ulcers and was utilizing pressure reducing devices to her chairs and bed along with the application of ointments or medications. A review of Resident #52's physician order [REDACTED]. A review of Resident #52's care plan revealed a care plan area for skin impairment risk related to limited mobility and weakness. Interventions included moisturizing cream to bilateral heels for dryness and off load heels on pillows while in bed. A Review of Resident #52's Treatment Administration Record (TAR) for (MONTH) 2019 revealed no initials to indicate that a nurse signed off 1/9/19, 1/11/19, 1/14/19, 1/15/19, and 1/16/19 on the 7:00 AM to 7:00 PM time frame for the treatment of [REDACTED]. An interview with Nurse #1 on 01/17/19 at 7:35 AM revealed she was working on the hall where Resident #52 resided on 01/11/19. She reported she remembered ensuring Resident #52's heels were floated on pillows as ordered but forgot to sign off on it. She reported she should have signed off on the TAR. She reported there were times when she couldn't see the forest because of the trees when asked why she had forgotten to sign off on the treatment. An interview with Nurse #2 on 01/17/19 at 11:25 AM revealed she was working on the hall where resident #52 resided on 01/14/19, 10/15/19, 01/16/19. She reported Resident #52 had begun to decline and had spent most of her time in bed. She reported on the 01/14/19, 01/15/19, and 01/16/19 Resident #52 had not gotten out of bed. She continued, stating that she ensured Resident #52's heels were floated but must have missed signing off on the TAR for floating Resident #52's heels on pillows while she was in bed. She stated she should have signed off on the treatment record. An interview with Nurse Manager #1 on 01/16/19 at 1:57 PM revealed if the TAR was initialed then it indicated the treatment had been provided. She reported if the TAR was not initialed then it did not necessarily mean that it was not given. She continued, stating it should be signed off on and reported if the TAR was not signed off on then it would be difficult to determine if the medication or treatment had been provided. An interview with the Director of Nursing on 01/17/19 at 3:04 PM revealed she expected if a treatment was provided, then the nurse should have signed off on the TAR. She reported she could not speak to whether or not Resident #52's heels were floated on the days there was no sign off on TAR. She reported the nursing standard would be that a nurse would sign off on TAR for treatments provided. b. Review of Resident #52's Medication Administration Record [REDACTED]. During an interview with Nurse #3 on 01/17/19 at 3:54 PM it was revealed she was working on 01/01/19 and was responsible for giving Resident #52 her dose of [MEDICATION NAME] at 6:30 AM. She reported she had given Resident #52 her dose of [MEDICATION NAME] but had forgotten to sign off on the MAR indicated [REDACTED]. A phone call was attempted on 01/17/19 at 9:27 AM to reach Nurse #4, who was determined to have worked on 01/03/19, 01/04/19, and 01/05/19 as the medication nurse and did not sign off as administering the [MEDICATION NAME] to Resident #52. It was reported by the Director of Nursing (DON) that Nurse #4 was on a leave of absence from the facility due to illness. Nurse #4 was unable to be reached for an interview. An interview with Nurse Manager #1 on 01/16/19 at 1:57 PM revealed if the MAR indicated [REDACTED]. She reported if the MAR indicated [REDACTED]. She continued, stating technically it should be signed off on and reported if the MAR indicated [REDACTED]. An interview with the Director of Nursing on 01/17/19 at 3:04 PM revealed she expected if a medication was given, the nurse should have signed off on the MAR. She reported she could not speak to whether or not the [MEDICATION NAME] was given where there was no sign off on the MAR indicated [REDACTED].

Based on record review and staff interviews the facility failed to accurately assess 1 of 9 sampled residents utilizing the Minimum Data Set (MDS) reviewed for accidents to reflect active diagnoses (Resident #31) and 1 of 3 sampled residents in the area of isolation (Resident #10). Findings included: 1. Resident #31 was admitted to the facility on [DATE]. A review of the physician's orders [REDACTED].#31 had diagnoses of anxiety, depression, and hypertension and was receiving medication to treat anxiety, depression, and hypertension. A review of Resident #31's quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #31 had been coded under Section I Active Diagnoses as having no diagnoses. On 12/01/17 at 8:42 AM an interview was conducted with MDS Coordinator #2 who stated she coded Section I Active Diagnoses on Resident #31's quarterly MDS dated [DATE]. The MDS Coordinator #2 stated Resident #31 had been coded as having no diagnoses and should have been coded as having active diagnoses of anxiety disorder, depression, and hypertension and was an error in coding. The MDS Coordinator #2 stated she would need to submit a modification to Resident #31's quarterly MDS dated [DATE] to reflect active diagnoses of anxiety disorder, depression, and hypertension. On 12/1/17 at 8:48 AM an interview was conducted with the MDS Manager who verified that Resident #31's quarterly MDS dated [DATE] had been inaccurately coded under Section I to reflect active diagnoses. The MDS Manager stated Resident #31 should have been coded on the quarterly MDS dated [DATE] to reflect active diagnoses of anxiety disorder, depression, and hypertension. The MDS Manager stated her expectation was that the quarterly MDS dated [DATE] would be modified and submitted to reflect active diagnoses. On 12/01/17 at 8:56 AM an interview was conducted with the Director of Nursing (DON) who stated her expectation was that Resident #31's quarterly MDS assessment dated [DATE] would have been accurately coded under Section I active diagnoses to reflect active diagnoses of anxiety disorder, depression, and anxiety. The DON stated her expectation was that the quarterly MDS assessment dated [DATE] would be modified and submitted to accurately reflect active diagnoses of anxiety disorder, depression, and hypertension for Resident #31. On 12/01/17 at 11:35 AM an interview was conducted with the Administrator who stated her expectation was that the quarterly MDS assessment dated [DATE] would have been accurately coded to reflect active diagnoses of anxiety disorder, depression, and hypertension for Resident #31. The Administrator stated her expectation was the quarterly MDS assessment 10/15/17 would be modified and submitted to accurately reflect Resident #31's active diagnoses. 2. Resident #10 was admitted to the facility on [DATE]. A review of the quarterly MDS assessment dated [DATE] indicated Resident #10 had been coded under Section O Special Treatments, Procedures, and Programs as being on isolation or quarantine for active infectious disease. On 11/29/17 at 9:37 AM an interview was conducted with the MDS Manager who stated the quarterly assessment dated [DATE] had been incorrectly coded under Section O to indicate Resident #10 was on isolation. The MDS Manager stated Resident #10 had not been on isolation during the look back period from 09/11/17 to 09/17/17. The MDS Manager stated MDS Coordinator #1 had been clicking on different sections of the MDS while under Section O and had inaccurately coded isolation for Resident #10. The MDS Manager stated her expectation was that the quarterly assessment dated [DATE] would have been accurately coded to reflect Resident #10 had not been on isolation during the look back period 09/11/17 to 09/17/17. The MDS Manager stated her expectation was that the quarterly MDS assessment dated [DATE] would be modified and submitted to accurately reflect Resident #10 had not been on isolation during the look back period 09/11/17 to 09/17/17. On 11/29/17 at 09:45 AM an interview was conducted with the Director of Nursing (DON) who stated her expectation was that MDS Coordinator #1 would have accurately coded the quarterly MDS assessment dated [DATE] to reflect Resident #10 had not been on isolation during the look back period 9/11/17 to 9/17/17. The DON stated her expectation was that the quarterly MDS assessment dated [DATE] would be modified and submitted to accurately reflect Resident #10 had not been on isolation during the look back period 09/11/17 to 09/17/17. On 11/29/17 at 2:44 PM an interview was conducted with MDS Coordinator #1 who stated she coded the quarterly MDS assessment dated [DATE] and incorrectly indicated Resident #10 was on isolation. The MDS Coordinator #1 stated Resident #10 had not been on isolation during the look back period 09/11/17 to 09/17/17. The MDS Coordinator #1 stated she had clicked on the wrong box under Section O that indicated Resident #10 was on isolation. The MDS Coordinator #1 stated the quarterly MDS assessment dated [DATE] would be modified and submitted to indicate Resident #10 had not been on isolation. On 11/29/17 at 3:11 PM an interview was conducted with the Administrator who stated her expectation was that MDS Coordinator #1 would have accurately coded the quarterly MDS assessment dated [DATE] to indicate Resident #10 had not been on isolation during the look back period 9/11/17 to 9/17/17. The administrator stated that Resident #10 had never been on isolation. The administrator stated her expectation was that Resident #10's quarterly MDS assessment dated [DATE] would be modified and submitted to accurately reflect Resident #10 had not been on isolation during the look back period 9/11/17 to 9/17/17.

Based on observations and staff interviews the facility failed to repair 21 resident doors with broken and splintered laminate and wood on 5 of 6 resident hallways (Resident room #102, #103, #201,#203, #204, #205, #207, #208, #210, #301, #304, #305, #308, #402, #403, #404, #409, #411, #603, #605 and #609 and failed to repair damaged wood and laminate on the edges of 4 of 4 sets of smoke prevention doors in the skilled nursing unit (100 hall, 200 Hall, 300 hall and 400 hall). The findings included: 1. a. Observations of Room #102 on 09/13/16 at 9:17 AM revealed the door of the resident's room had broken and splintered laminate on the edges of the bottom half of the door. Observations on 09/14/16 at 10:09 AM revealed the door of resident room #102 had broken and splintered laminate on the edges of the bottom half of the door. Observations on 09/15/16 4:02 PM revealed the door of resident room #102 had broken and splintered laminate on the edges of the bottom half of the door. b. Observations of Room #103 on 09/13/16 at 9:18 AM revealed the door of the resident's room had broken and splintered laminate on the edges of the bottom half of the door. Observations on 09/14/16 at 10:10 AM revealed the door of resident room #103 had broken and splintered laminate on the edges of the bottom half of the door. Observations on 09/15/16 4:03 PM revealed the door of resident room #103 had broken and splintered laminate on the edges of the bottom half of the door. c. Observations of Room #201 on 09/13/16 at 9:19 AM revealed the door of the resident's room had broken and splintered laminate on the edges of the bottom half of the door. Observations on 09/14/16 at 10:11 AM revealed the door of resident room #201 had broken and splintered laminate on the edges of the bottom half of the door. Observations on 09/15/16 4:04 PM revealed the door of resident room #201 had broken and splintered laminate on the edges of the bottom half of the door. d. Observations of Room #203 on 09/13/16 at 9:20 AM revealed the door of the resident's room had broken and splintered laminate on the edges of the bottom half of the door. Observations on 09/14/16 at 10:12 AM revealed the door of resident room #203 had broken and splintered laminate on the edges of the bottom half of the door. Observations on 09/15/16 4:05 PM revealed the door of resident room #203 had broken and splintered laminate on the edges of the bottom half of the door. e. Observations of Room #204 on 09/13/16 at 9:21 AM revealed the door of the resident's room had broken and splintered laminate on the edges of the bottom half of the door. Observations on 09/14/16 at 10:13 AM revealed the door of resident room #204 had broken and splintered laminate on the edges of the bottom half of the door. Observations on 09/15/16 4:06 PM revealed the door of resident room #204 had broken and splintered laminate on the edges of the bottom half of the door. f. Observations of Room #205 on 09/13/16 at 9:22 AM revealed the door of the resident's room had broken and splintered laminate on the edges of the bottom half of the door. Observations on 09/14/16 at 10:14 AM revealed the door of resident room #205 had broken and splintered laminate on the edges of the bottom half of the door. Observations on 09/15/16 4:07 PM revealed the door of resident room #205 had broken and splintered laminate on the edges of the bottom half of the door. g. Observations of Room #207 on 09/13/16 at 9:23 AM revealed the door of the resident's room had broken and splintered laminate on the edges of the bottom half of the door. Observations on 09/14/16 at 10:15 AM revealed the door of resident room #207 had broken and splintered laminate on the edges of the bottom half of the door. Observations on 09/15/16 4:08 PM revealed the door of resident room #207 had broken and splintered laminate on the edges of the bottom half of the door. h. Observations of Room #208 on 09/13/16 at 9:24 AM revealed the door of the resident's room had broken and splintered laminate on the edges of the bottom half of the door. Observations on 09/14/16 at 10:16 AM revealed the door of resident room #208 had broken and splintered laminate on the edges of the bottom half of the door. Observations on 09/15/16 4:09 PM revealed the door of resident room #208 had broken and splintered laminate on the edges of the bottom half of the door. i. Observations of Room #210 on 09/13/16 at 9:25 AM revealed the door of the resident's room had broken and splintered laminate on the edges of the bottom half of the door. Observations on 09/14/16 at 10:17 AM revealed the door of resident room #210 had broken and splintered laminate on the edges of the bottom half of the door. Observations on 09/15/16 4:10 PM revealed the door of resident room #210 had broken and splintered laminate on the edges of the bottom half of the door. j. Observations of Room #301 on 09/13/16 at 9:27 AM revealed the door of the resident's room had broken and splintered laminate on the edges of the bottom half of the door. Observations on 09/14/16 at 10:19 AM revealed the door of resident room #301 had broken and splintered laminate on the edges of the bottom half of the door. Observations on 09/15/16 4:12 PM revealed the door of resident room #301 had broken and splintered laminate on the edges of the bottom half of the door. k. Observations of Room #304 on 09/13/16 at 9:28 AM revealed the door of the resident's room had broken and splintered laminate on the edges of the bottom half of the door. Observations on 09/14/16 at 10:20 AM revealed the door of resident room #304 had broken and splintered laminate on the edges of the bottom half of the door. Observations on 09/15/16 4:13 PM revealed the door of resident room #304 had broken and splintered laminate on the edges of the bottom half of the door. l. Observations of Room #305 on 09/13/16 at 9:29 AM revealed the door of the resident's room had broken and splintered laminate on the edges of the bottom half of the door. Observations on 09/14/16 at 10:21 AM revealed the door of resident room #305 had broken and splintered laminate on the edges of the bottom half of the door. Observations on 09/15/16 4:14 PM revealed the door of resident room #305 had broken and splintered laminate on the edges of the bottom half of the door. m. Observations of Room #308 on 09/13/16 at 9:30 AM revealed the door of the resident's room had broken and splintered laminate on the edges of the bottom half of the door. Observations on 09/14/16 at 10:22 AM revealed the door of resident room #308 had broken and splintered laminate on the edges of the bottom half of the door. Observations on 09/15/16 4:15 PM revealed the door of resident room #308 had broken and splintered laminate on the edges of the bottom half of the door. n. Observations of Room #402 on 09/13/16 at 9:33 AM revealed the door of the resident's room had broken and splintered laminate on the edges of the bottom half of the door. Observations on 09/14/16 at 10:25 AM revealed the door of resident room #402 had broken and splintered laminate on the edges of the bottom half of the door. Observations on 09/15/16 4:25 PM revealed the door of resident room #402 had broken and splintered laminate on the edges of the bottom half of the door. o. Observations of Room #403 on 09/13/16 at 9:34 AM revealed the door of the resident's room had broken and splintered laminate on the edges of the bottom half of the door. Observations on 09/14/16 at 10:26 AM revealed the door of resident room #403 had broken and splintered laminate on the edges of the bottom half of the door. Observations on 09/15/16 4:27 PM revealed the door of resident room #403 had broken and splintered laminate on the edges of the bottom half of the door. p. Observations of Room #404 on 09/13/16 at 9:35 AM revealed the door of the resident's room had broken and splintered laminate on the edges of the bottom half of the door. Observations on 09/14/16 at 10:27 AM revealed the door of resident room #404 had broken and splintered laminate on the edges of the bottom half of the door. Observations on 09/15/16 4:29 PM revealed the door of resident room #404 had broken and splintered laminate on the edges of the bottom half of the door. q. Observations of Room #409 on 09/13/16 at 9:36 AM revealed the door of the resident's room had broken and splintered laminate on the edges of the bottom half of the door. Observations on 09/14/16 at 10:28 AM revealed the door of resident room #409 had broken and splintered laminate on the edges of the bottom half of the door. Observations on 09/15/16 4:32 PM revealed the door of resident room #409 had broken and splintered laminate on the edges of the bottom half of the door. r. Observations of Room #411 on 09/13/16 at 9:37 AM revealed the door of the resident's room had broken and splintered laminate on the edges of the bottom half of the door. Observations on 09/14/16 at 10:29 AM revealed the door of resident room #411 had broken and splintered laminate on the edges of the bottom half of the door. Observations on 09/15/16 4:33 PM revealed the door of resident room #411 had broken and splintered laminate on the edges of the bottom half of the door. s. Observations of Room #603 on 09/13/16 at 9:40 AM revealed the door of the resident's room had broken and splintered laminate on the edges of the bottom half of the door. Observations on 09/14/16 at 10:35 AM revealed the door of resident room #603 had broken and splintered laminate on the edges of the bottom half of the door. Observations on 09/15/16 4:35 PM revealed the door of resident room #603 had broken and splintered laminate on the edges of the bottom half of the door. t. Observations of Room #605 on 09/13/16 at 9:42 AM revealed the door of the resident's room had broken and splintered laminate on the edges of the bottom half of the door. Observations on 09/14/16 at 10:37 AM revealed the door of resident room #605 had broken and splintered laminate on the edges of the bottom half of the door. Observations on 09/15/16 4:36 PM revealed the door of resident room #605 had broken and splintered laminate on the edges of the bottom half of the door. u. Observations of Room #609 on 09/13/16 at 9:43 AM revealed the door of the resident's room had broken and splintered laminate on the edges of the bottom half of the door. Observations on 09/14/16 at 10:43 AM revealed the door of resident room #609 had broken and splintered laminate on the edges of the bottom half of the door. Observations on 09/15/16 4:43 PM revealed the door of resident room #609 had broken and splintered laminate on the edges of the bottom half of the door. 2 a. Observations on 09/13/16 at 9:50 AM of the smoke prevention doors on 100 hall revealed double doors with broken and splintered laminate on the edges of the bottom half of the door. Observations on 09/14/16 at 10:45 AM of smoke prevention doors on 100 hall revealed a set of double doors with broken and splintered laminate on the edges of the bottom half of the doors. Observations on 09/15/16 at 4:45 PM of smoke prevention doors on 100 hall revealed a set of double doors with broken and splintered laminate on the edges of the bottom half of the doors. b. Observations on 09/13/16 at 9:51 AM of the smoke prevention doors on 200 hall revealed double doors with broken and splintered laminate on the edges of the bottom half of the door. Observations on 09/14/16 at 10:46 AM of smoke prevention doors on 200 hall revealed a set of double doors with broken and splintered laminate on the edges of the bottom half of the doors. Observations on 09/15/16 at 4:46 PM of smoke prevention doors on 200 hall revealed a set of double doors with broken and splintered laminate on the edges of the bottom half of the doors. c. Observations on 09/13/16 at 9:52 AM of the smoke prevention doors on 300 hall on revealed double doors with broken and splintered laminate on the edges of the bottom half of the door. Observations on 09/14/16 at 10:47 AM of smoke prevention doors on 300 hall revealed a set of double doors with broken and splintered laminate on the edges of the bottom half of the doors. Observations on 09/15/16 at 4:47 PM of smoke prevention doors on 300 hall revealed a set of double doors with broken and splintered laminate on the edges of the bottom half of the doors. d. Observations on 09/13/16 at 9:53 AM of the smoke prevention doors on 400 hall revealed double doors with broken and splintered laminate on the edges of the bottom half of the door. Observations on 09/14/16 at 10:48 AM of smoke prevention doors on 400 hall revealed double doors with broken and splintered laminate on the edges of the bottom half of the doors. Observations on 09/15/16 at 4:48 PM of smoke prevention doors on 400 hall revealed double doors with broken and splintered laminate on the edges of the bottom half of the doors. During an interview and environmental tour on 09/16/16 at 12:09 PM with the Supervisor of Maintenance he explained they used a work order system for repairs. He stated any staff could fill out a work order in the computer system and staff reported to him any repairs that were needed as he made his routine rounds. He further stated he preferred and expected for staff to complete work orders in the computer system because then he could track and keep records of the repairs he completed. He confirmed the resident doors had broken and splintered laminate on the edges of the doors and he verified staff had not reported the damage to the doors and he had not noticed the damage to the doors. He stated he expected for staff to report damage to doors as they saw them and the doors needed to be sanded to remove splinters or rough edges and some doors with gouged out areas needed to be filled and smoothed. During an interview and environmental tour on 09/16/16 at 12:27 PM with the Administrator she confirmed resident doors had broken and splintered laminate and needed to be repaired and she was not aware the doors were so badly damaged. She stated it was her expectation when staff observed something that needed to be repaired, they should complete a work order for the Maintenance Supervisor. She explained they discussed maintenance concerns as part of the morning meetings every day and it was her expectation for staff to send maintenance concerns to the Maintenance Supervisor so they could be repaired and discussed. She stated the work order system was explained during orientation for all new employees and she expected for staff to follow the work order process.

Based on observation, record reviews, and staff interviews the facility failed to complete the Care Area Assessment (CAA) that addressed underlying causes, contributing factors, and risk factors for 4 of 4 residents sampled for nutrition (Resident #39, Resident #7, Resident #162,and Resident #15). The findings included: 1. Resident #39 was admitted to the facility on [DATE] and discharged from the facility on 06/08/16 with [DIAGNOSES REDACTED]. Review of the most recent comprehensive minimum data set ((MDS) dated [DATE] revealed that Resident #39 was cognitively intact and required set up assistance with eating. Review of the Care Area Assessment (CAA) titled Nutritional CAA was blank except for under the Analysis of Findings it stated See RD Note. The CAA did not specify any nutritional risk factors, contributing factors, or need for referrals. Interview with the MDS Coordinator on 09/15/16 at 11:47 AM revealed that the dietician completed most of the dietary section of the MDS and would be responsible for any nutritional CAA's that triggered. The MDS Coordinator stated that the dietician does not complete the CAA and that she goes into the CAA and typed See RD Note so that she could lock the MDS. The MDS coordinator stated that the dietician completed some type of other assessment but does not complete the CAA because that would be double documenting. The MDS nurse stated that when she completed CAA's that she triggered from the MDS that she summarized the findings, under lying causes and then determines from those findings whether or not to proceed to care plan. Interview with dietician on 09/15/16 at 2:28 PM revealed that she had completed the MDS for Resident #39 but did not complete the CAA. The dietician stated that she completed the nutritional assessment instead of completing the CAA. 2. Resident #7 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the most recent comprehensive minimum data set ((MDS) dated [DATE] revealed that Resident #7 was cognitively intact and required set up assistance of one staff member for eating. Review of the Care Area Assessment (CAA) dated 08/07/16 was blank except for under the Analysis of Findings it stated SEE RD NOTE. The CAA did not specify any nutritional risk factors, contributing factors, or need for referrals. Interview with the MDS Coordinator on 09/15/16 at 11:47 AM revealed that the dietician completed most of the dietary section of the MDS and would be responsible for any nutritional CAA's that triggered. The MDS Coordinator stated that the dietician does not complete the CAA and that she goes into the CAA and types See RD Note so that she could lock the MDS. The MDS coordinator stated that the dietician completed some type of other assessment but does not complete the CAA because that would be double documenting. The MDS nurse stated that when she completed CAA's that she triggered from the MDS that she summarized the findings, under lying causes and then determines from those findings whether or not to proceed to care plan. Interview with dietician on 09/15/16 at 2:28 PM revealed that she had completed the MDS for Resident #39 but did not complete the CAA. The dietician stated that she completed the nutritional assessment instead of completing the CAA. 3. Resident #162 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the most recent quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #162 has short term memory problems, no long term memory problems and was moderately impaired in cognition for daily decision making. The MDS also revealed Resident #162 required supervision and set up for eating. Review of the Care Area Assessment (CAA) titled Nutritional CAA was blank except for under the Analysis of Findings it stated See RD Note. The CAA did not specify any nutritional risk factors, contributing factors, or need for referrals. Interview with the MDS Coordinator on 09/15/16 at 11:47 AM revealed that the dietician completed most of the dietary section of the MDS and would be responsible for any nutritional CAA's that triggered. The MDS Coordinator stated that the dietician does not complete the CAA and that she goes into the CAA and typed See RD Note so that she could lock the MDS. The MDS coordinator stated that the dietician completed some type of other assessment but does not complete the CAA because that would be double documenting. The MDS nurse stated that when she completed CAA's that she triggered from the MDS that she summarized the findings, under lying causes and then determines from those findings whether or not to proceed to care plan. Interview with dietician on 09/15/16 at 2:28 PM revealed she routinely completed the MDS for residents but did not complete the CAA. The dietician explained she completed the nutritional assessment instead of completing the CAA. 4. Resident #15 was admitted to the facility on [DATE] and discharged from the facility on 08/25/16 with [DIAGNOSES REDACTED]. A review of an admission Minimum Data Set ((MDS) dated [DATE] revealed Resident #15 was cognitively intact for daily decision making. The MDS also indicated Resident #15 was independent with set up help only for eating. Interview with the MDS Coordinator on 09/15/16 at 11:47 AM revealed that the dietician completed most of the dietary section of the MDS and would be responsible for any nutritional CAA's that triggered. The MDS Coordinator stated that the dietician does not complete the CAA and that she goes into the CAA and typed See RD Note so that she could lock the MDS. The MDS coordinator stated that the dietician completed some type of other assessment but does not complete the CAA because that would be double documenting. The MDS nurse stated that when she completed CAA's that she triggered from the MDS that she summarized the findings, under lying causes and then determines from those findings whether or not to proceed to care plan. Interview with dietician on 09/15/16 at 2:28 PM revealed she had completed the MDS for residents but did not complete the CAA. The dietician explained she completed the nutritional assessment instead of completing the CAA.

Based on observations, record review, and staff interviews the facility failed to have interventions in place to prevent 1 of 3 residents (Resident #13) that was cognitively impaired with wandering behaviors from exiting unsupervised from the facility. On 5/30/15 Resident #13 was found outside in the parking lot by a visitor of the facility approximately 98 feet from the exit door. Immediate Jeopardy began on 5/30/15. Immediate Jeopardy was removed 8/6/15 at 4:30pm when the facility provided a credible allegation of compliance. The facility will remain out of compliance at a scope and severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy (D), to ensure monitoring of the systems put in place and 100% of employee training. The finding included: Resident #13 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Plan of Care dated 1/1/2015 listed the following under Social Work: · History of wandering with a goal that resident will remain safe while wandering as evidenced by no reports of injuries acquired due to wandering behavior. Intervention for wandering were listed as redirect when wandering occurs to assure safety, report wandering behaviors, report any elopement risks. Quarterly Minimum Data Set ((MDS) dated [DATE] indicated that Resident #13 was severely cognitively impaired and had exhibited wandering behaviors 1 to 3 days during assessment reference period. Her activities of daily living (ADL's) indicated that Resident #13 required extensive assistance of two persons with transfers and walking in corridor and required extensive assistance of one person with bed mobility, locomotion on unit, dressing, toileting, and personal hygiene. Review of nurse's notes from March 7, 2015 at 9:51 am revealed resident was found outside making her way toward the front parking lot from living room A. She has been up all night. Resident has been agitated/combative on this shift also. Resident stated she was going outside to get her pocketbook out of her car. Resident has been accusing various staff members of stealing 100 dollars from her also. She begins to get agitated and combative when staff attempts to talk to her about this. Resident was brought back inside and started on q (every) 15 minute monitoring. PRN (as needed) Ativan was also administered to try to help with resident anxiousness & combativeness. Will continue to monitor. Review of email (official communication from weekend to nursing administration/management) sent March 08, 2015 at 6:43 pm from Nurse #4 to administrative/management staff read in part: 100 hall Resident #13 Saturday confused, agitated, awake all night, packed belongings, 3rd reported removing several butter knives out of night stand as she was packing, went out the door from Living Room A at 9:30 am, rolling wheelchair down sidewalk headed straight to parking lot, door alarm sounded, placed on Q (every) 15 min monitoring x 24 hours, then q 30 min. DON notified. The most recent MDS which was a significant change assessment dated [DATE] indicated that Resident #13 was severely cognitively impaired but had not exhibited wandering during the assessment reference period. Her ADL' s indicated that Resident #13 required extensive assistance of two persons with bed mobility, walking in corridor and required extensive assist of one person with transfers, locomotion on/off unit, dressing, toileting, and personal hygiene. Review of the nurse's notes indicated: May 30, 2015 Resident noted to be wandering today. Resident witnessed by staff to be attempting to open doors to outside. At 2pm resident reported by a visitor to be out in the parking lot. Resident found outside of facility in parking lot. Resident states I was just going home Nurse Manager (Nurse 1) notified. Resident placed on Q15 min monitoring. Resident has becoming increased agitation with staff. MD (medical doctor) notified. Will monitor. This nursing note was signed by Nurse#2. A review of a facility document entitled: Subject Profile Of Incident dated 5/30/15 included a description of incident, written by Nurse #2 which indicated that at 2pm a visitor reported that resident was outside the building heading towards parking lot and that the resident exited the door after a visitor. Nurse #2 and Nurse #3 went outside to investigate. Resident was observed to be propelling wheelchair outside in the parking lot attempting to roll up a slight incline. Resident stated I was just going home. Resident was reoriented and taken back inside. No injuries were noted. Nurse #1 notified. MD notified. Family notified. Resident placed on q 15 min monitoring. Attached to the facility document entitled: Subject Profile of Incident dated 5/30/15 was an additional paper that was a SBAR that is a Situation, background, assessment recommended report that is used by the facility: S (situation) - Visitor came to this RN (Nurse #1). She voiced Resident #13 was in the parking lot. Voiced that another visitor let her out the door. No door alarm sounding. B (background) - Alert and oriented to self at baseline. Poor short term memory/recall. History of elopement. No attempts at elopement since 3-7-15. History of agitation with combative behaviors. [DIAGNOSES REDACTED]. A (assessment) - As soon as reported by visitor Nurse #2 went to intervene and get resident back in facility. Per Nurse #2 resident was going towards her car. Nurse #2 reported that she was near the handicap parking. Resident came back with staff without difficulty. Resident was visibly anxious and slightly agitated. R (recommended) - Implemented q 15 monitoring immediately and monitor closely for continued attempts on elopement or for behaviors. Doctor #1 emailed by Nurse #2, new orders received to increase Depakote to 250 mg by mouth twice a day. Doctor #1 voiced to involve her in activities. Care plan was revised on 5/30/15, and the revision indicated Update: Resident elopement attempted on 5/30/15. No further interventions were added to the care plan at that time. Review of email (official communication from weekend to nursing administration/management) sent May 31, 2015 from Nurse #1 to administration/management team read in part: 100 hall per report Resident #13 did not sleep Friday night. Saturday was up to wheelchair, wanting to find a way out. SHE DID .got out the door with a guest that was coming in. Started on increased monitoring. She was very anxious/slightly agitated. Doctor #1 did not want to change anxiolytics, increased Depakote to 250 mg by mouth twice a day, encourage her to participate in activities. Interview with the Assistant Director of Nursing (ADON) on 8/5/15 at 5:26PM, revealed that she was aware of the elopement with Resident #13 on 5/30/15 She indicated that the door handle could be held down for 15 seconds and the door will open, but that an alarm will sound. She additionally indicated that she was not aware if the alarm sounded on 5/30/15. She further stated that the door to living room A was equipped with a key pad for entry/exit, and once the code was entered into the keypad the door would open without an alarm sounding. A follow-up interview with the ADON at 6:35pm revealed that the alarm was not sounding off on the 5/30/15 incident and that Resident #13 left out of the door as it was opened by a visitor. She additionally stated that the door in living room A that Resident #13 eloped from was still used daily by visitors and staff. Interview with Nurse #1 who communicated the elopement of Resident #13 (of 5/30/15) to supervisory staff was conducted at 6:50PM on 8/5/2015. During this interview, the Nurse#1 indicated that a visitor reported to her that Resident #13 was in the parking lot and was let out of the building by another visitor. She stated that on 5/30/15 Resident #13 got out of the building and into the parking lot and was located towards the end of the sidewalk . She stated that the door alarm was not sounding off and that no staff observed the resident to leave out of the door and no staff was aware that Resident #13 was out of the building. Nurse #1 indicated she did not remember what visitor reported the resident in the parking lot. She additionally indicated that the door in living room A was used daily by staff and visitors until 8:00PM. An additional interview at 6:58PM on 8/5/15 with Nurse #1, ADON and the Director of Nursing (DON) revealed that the door through which Resident #13 left out of on 5/30/15 was open for visitor use until 8:00PM. They all additionally indicated that the only changes that were made to Resident #13' s plan of care after the elopement, was to put the resident on every 15 minutes monitoring x 24 hours and a medication change. Observation of Resident #13 at 7:00pm on 8/5/15 revealed Resident #13 sitting in her room in wheelchair at bedside watching TV. The DON, ADON, and Quality Management Staff were notified of the immediate jeopardy on 8/5/15 at 7:40pm. The facility presented a credible allegation of compliance on 8/6/15 at 3:40 pm which included: Corrective action was accomplished by placing Resident #13 on 1:1 (a staff member assigned to the resident at all times) monitoring at 6:25 p.m. on 8/5/15. Staff were instructed by the DON on 8/5/15 at 6:20 p.m. that without exception the resident had to be in visual sight at all times. A 1:1 tracking sign-in form was implemented to provide documentation of who was assigned and who provided relief and the times of the observation. The other two residents who have the potential for elopement do not have the ability to transfer or ambulate independently so they are only at risk when they are up in their wheelchairs, at which time they will be placed on 1:1 monitoring until they are again returned to their beds. All residents who were at risk for wandering had the potential to be affected by the alleged deficient practice. Corrective action was accomplished on 8/6/15 at 10:30 a.m. for those residents by limiting all traffic to enter and exit only through the front door, and closing access to all other doors (except for emergency egress which will then sound an alarm). Signs were also placed at all doors to alert visitors not to let residents out without staff knowledge. Additionally, the 1:1 observations on the three residents were lifted at 8/6/15 at 10:30 a.m. after determining all the doors were locked. The following systemic changes have been put into place: An in-service about the change in entry and exit through only the front door was provided to all staff beginning on 8/6/15. Any unavailable full-time, part-time or PRN staff will not be allowed to work in the facility until they have completed the in-service. This in-service for all staff included: a. Information that Resident #13 exited the facility with a visitor b. Notice that all traffic into and out of the building will be through the front door only c. The front door will be monitored to assure residents identified as an elopement risk are safe and not allowed outside unsupervised d. Emergency egress is possible through the locked door and an alarm will sound when opened e. Staff nearest a door sounding an alarm will be expected to respond immediately An observation of Resident #13 8/6/15 at 10:04 am revealed resident was bed with eyes closed. Staff providing 1:1 was present at bedside. An observation of Resident #13 8/6/15 at 11:14 am revealed resident was in bed with eyes closed. 1:1 staff that present an hour earlier was no longer at bedside. Observation of Living Room A door on 8/6/15 at 1:15 pm revealed a visitor that had exited thru this door. The door alarm was sounding and staff promptly responded to alarm. There was a posted sign on door that said Enter and Exit Front Door only and a sign that read ATTENTION: please check with staff before allowing any resident outside. Immediate Jeopardy was removed on 8/6/15 at 4:30 pm. Observations revealed the living Room doors were not able to be opened (unless for emergency egress).Review of facilities Monitoring Log revealed Resident #13 had 1:1 staff from 8/5/15 at 6:25pm to 8/6/15 at 10:40 am. Interviews with direct care staff and licensed staff confirmed that they had received in-servicing on responding to residents with exist seeking behaviors. Observations of staff monitoring the front door was observed. Signs were observed posted at entrance/exit doors.

Based on observations, staff interviews and record review the facility failed to implement effective interventions to prevent reoccurrence of sexually inappropriate behavior for 1 of 1 resident with sexually inappropriate behaviors (Resident # 126) toward 1 of 1 residents (Resident #108). Immediate jeopardy began on 01/07/13 when staff became aware Resident #126 acted sexually inappropriate toward Resident #108. The administrator was notified of the immediate jeopardy on 05/09/13 at 4:05 PM. Immediate jeopardy was removed on 05/10/13 at 4:37 PM when the facility provided and implemented an acceptable credible allegation of compliance. The facility will remain out of compliance at a scope and severity level D (no actual harm with potential for more than minimal harm that is not immediate jeopardy) to complete employee education and ensure monitoring systems put in place are effective. The findings included: 1. Resident #126 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] specified the resident had moderately impaired cognitive skills but no documented behaviors. The MDS also specified the resident required limited assistance with activities of daily living (ADL) and used a walker or wheelchair for mobility. Resident #108 was admitted to the facility 11/16/11 with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] specified the resident had severely impaired cognitive skills and required extensive assistance with activities of daily living (ADL). a. On 05/09/13 at 11:10 AM Nurse Aide (NA) #3 was interviewed and reported that she was trained to report any concerns with resident to resident behavior to the nurse. She stated that on a Saturday or Sunday "several months ago, right after Christmas" she observed Resident #126 sitting in the hallway fondling Resident #108's breasts. She called NA #1 for assistance and together the aides approached Resident #126 and separated the residents. She stated she reported the incident to Nurse #3. She added that she also reported the incident to the Weekend Supervisor. On 05/10/13 at 2:55 PM NA #1 was interviewed and reported that she had observed Resident #126 fondling Resident #108's breasts. She stated the incident happened on a weekend when she worked with NA #3, Nurse #3 and the Weekend Supervisor. She added that the incident was reported to Nurse #3. On 05/10/13 at 8:05 AM Nurse #3 was interviewed and reported that she was trained to report all allegations or suspicion of abuse to her immediate supervisor. She stated she recalled being notified by NA #3 that Resident #126 had fondled Resident #108. Nurse #3 explained that she could not recall the date of the incident but confirmed it was a weekend in January. She added that the incident occurred in the early part of January because after the incident she was made aware of 2 additional incidents of Resident #126 being sexually inappropriate with Resident #108. Nurse #3 reported that she asked Resident #108 if she had been touched inappropriately by Resident #126 because she felt the resident was alert and oriented. She added that Resident #108 denied the incident had occurred. She stated she told the nurse aides to monitor Resident #126. Nurse #3 stated that she reported the incident to the Weekend Supervisor. On 05/09/13 at 11:40 AM the Weekend Supervisor was interviewed and reported that she recalled an incident (date unknown) where NA #3 reported she had observed Resident #126 fondling Resident #108's breasts. She stated that she was trained to separate residents and then report the incident to the Director of Nursing (DON). She added that she would have documented the incident in the medical record. She was unable to recall if she had notified the DON of the incident and was unable to provide documentation of the incident. The Weekend Supervisor explained that she asked staff on the hall to monitor Resident #126 more frequently for the remainder of the shift. On 05/09/13 at 2:10 PM the Director of Nursing (DON) and Assistant Director of Nursing (ADON) were interviewed. The DON and ADON stated they were unaware of the incident and had not received notification from the Weekend Supervisor. The DON stated she would expect the Weekend Supervisor to have notified her immediately of the incident. The DON reported that no additional interventions were implemented to prevent Resident #126 from continuing to act sexually inappropriately toward Resident #108 as result of the incident. The ADON stated had they been aware of the incident the facility would have immediately implemented measures to prevent a recurrence. b. Review of Resident #126's medical record revealed a nurses' entry made by Nurse #1 dated 01/07/13 at 9:23 PM that specified Resident #126 was observed inappropriately touching Resident #108. The nurse's entry documented that Resident #126 was redirected and monitored. On 05/09/13 at 10:57 AM Nurse Aide (NA) #2 was interviewed and reported that on 01/07/13 she had observed Resident #126 with his hand up Resident #108's shirt. She explained that when she approached the residents, Resident #126 removed his hand from Resident #108's breasts. She added that she reported the incident to Nurse #1 who instructed the NA to watch Resident #126 more frequently for the remainder of her shift. On 05/09/13 at 5:20 PM Nurse #1 was interviewed and reported that she was trained to report "anything out of the ordinary" to the Director of Nursing. Nurse #1 stated that on 01/07/13 NA #2 notified her that Resident #126 was touching Resident #108's breasts. Nurse #1 explained that the residents were separated and she instructed NA #2 to monitor Resident #126 more frequently. She added that she considered the behavior to be abusive and inappropriate but did not report the incident to the Director of Nursing or other Administrative staff because she felt she had handled the situation. On 05/09/13 at 2:10 PM the Director of Nursing (DON) and Assistant Director of Nursing (ADON) were interviewed. The DON and ADON stated they were unaware of the incident and not received notification from Nurse #1. The DON stated she would expect Nurse #1 to have notified her immediately of the incident so that interventions could have been implemented to prevent any reoccurrence. The DON reported that no additional interventions were implemented to prevent Resident #126 from continuing to act sexually inappropriate toward Resident #108 as result of the incident on 01/07/13. c. Review of Resident #126's medical record revealed a nurses' entry made by Nurse #2 dated 01/11/13 at 12:00 PM that specified Resident #126 touched Resident #108 inappropriately. The entry also specified Resident #126 was redirected and monitored. Further review of the medical record for Resident #126 revealed a care plan dated 01/14/13 that specified Resident #126 had sexually inappropriate behaviors towards a female resident. Interventions identified on the care plan included: - redirect when adverse behaviors occur - report adverse behaviors immediately - monitor resident's interaction with Resident #108 On 05/09/13 at 11:22 AM the Social Worker (SW) was interviewed and reported that Nurse #2 had notified her that Resident #126 touched Resident #108 inappropriately. The SW explained that Resident #126 was told the behavior was not tolerated by the facility and asked the resident to keep his distance from Resident #108. The SW added that Resident #108 had severely impaired cognition and was unable to give consent to being touched. On 05/09/10 at 2:10 PM the Director of Nursing (DON) and Assistant Director of Nursing (ADON) were interviewed. The DON stated that during this time she was on leave and the ADON had assumed the DON role. The ADON stated she was notified by the SW of the incident on 01/11/13. The ADON was unaware Resident #126 had touched Resident #108's breasts and added that she did not interview Nurse #2 who witnessed the incident. The ADON explained that she was only aware that Resident #126 had been observed with his hand on Resident #108's leg and did not consider the behavior to be sexually inappropriate. The ADON stated that had she known Resident #126 touched Resident #108's breasts she would have made additional interventions to prevent any reoccurrence such as notifying the physician and ordering Resident #126 to be on one to one monitoring. On 05/09/13 at 2:50 PM Nurse #2 was interviewed and reported that she had observed Resident #126 rubbing Resident #108's leg and touching her breasts. She stated that she separated the residents and notified the Social Worker of the incident. She stated that following the incident she would monitor Resident #126 during her shifts to keep him from accessing Resident #108. d. Resident #126's medical record was reviewed and revealed an entry made by the Social Worker dated 04/30/13 that specified Resident #126 was sexually inappropriate with Resident #108. The entry also specified Resident #108 was moved to another hall to reduce Resident #126's access and Resident #126 was referred for psychiatric services. Further review of Resident #126's medical record revealed a care plan updated on 04/30/13 for sexually inappropriate behaviors towards a female resident. Interventions included in the care plan to included: - separate resident from Resident #108 - monitor resident's behavior and report any adverse behaviors immediately - refer to psychiatric services On 05/08/13 at 12:40 PM Nurse Aide (NA) #4 was interviewed and reported that on 04/29/13 she observed Resident #126 fondling Resident #108's breasts. She stated that she and another NA separated the residents and notified the nurse and Director of Nursing (DON). On 05/09/13 at 9:20 AM the DON was interviewed and reported that all staff received yearly training on abuse policy and procedure for identifying and reporting abuse. The DON stated that staff were trained to immediately report any possible suspicion of abuse to their supervisor and the supervisor was responsible for notifying the DON to initiate an investigation. The DON stated that she was in the building when the incident on 04/29/13 occurred and instructed staff to put Resident #108 to bed and to do hourly checks on Resident #126 until he went to bed the night of 04/29/13. The DON added that on 04/30/13 Resident #126 was evaluated by psychiatric services and received an order to start a testosterone reducing medication which could take up to a month for the medication to take effect. She stated that staff were continuing to monitor the resident every 2 hours. She added that Resident #126 was very social and propelled himself throughout the facility and that he was a "touchy-feely" person and friendly to everyone. On 05/09/13 at 3:30 PM the Administrator was interviewed and reported that she was aware of Resident #126 being sexually inappropriate with Resident #108 on 04/29/13. She stated that she had also been notified of a similar incident involving Resident #126 and Resident #108 on 01/11/13. She stated that the facility addressed the incidents and felt they implemented measures to prevent any reoccurrence. The Administrator stated she was not aware of the 2 incidents that occurred on a weekend in January 2013 and on 01/07/13 where Resident #126 was observed by staff to have fondled Resident #108. She stated that had she been notified after the first incident of sexually inappropriate behaviors then the facility would have immediately implemented interventions to prevent the behavior from reoccurring 3 more times. The administrator was notified of the immediate jeopardy on 05/09/13 at 4:05 PM. The facility provided a credible allegation of compliance on 05/10/13 at 4:37 PM. The following interventions were put into place by the facility to remove the Immediate Jeopardy: Corrective action was accomplished by placing Resident #126 on 1:1 (one licensed nurse or nursing assistant assigned to the resident at all times) monitoring at 4:50 PM on 05/09/13. Staff were instructed by the ADON on 05/09/13 at 4:45 PM that without exception, the resident had to be in visual sight at all times. A 1:1 tracking sign-in form was implemented to provide documentation of who was assigned and who provided relief and the times of the observation. Resident #126 started a testosterone inhibiting medication on 04/30/13 which he will remain on. He will also remain on 1:1 observation for a period of 21 days in order to allow the testosterone inhibiting medication to become effective. If there are no further incidents of sexual acting out during that 21 day period, the 1:1 observation will be changed to frequent monitoring. If the resident shows any signs of sexually acting out during the 21 day period, the physician will be notified for medication adjustment. If the resident shows any signs of sexually acting out after being removed from 1:1 observation, 1:1 observation will be resumed immediately and the physician will be notified for medication adjustment. The Medical Director was notified on 05/10/13 of the need to evaluate Resident #126. A physician order [REDACTED]. Resident # 108 was assessed by the Director of Nursing on 05/10/13 and no outward signs of anxiety or emotional distress were evident. Resident #108 was assessed on 05/10/13 by the social worker for any residual effects from the sexual behavior of Resident #126. No concerns were noted. All residents had the potential to be affected by the alleged deficient practice. Corrective action was accomplished for those residents by placing Resident #126 on 1:1 nurse aide observation on 5/9/13. All interviewable residents in the facility were questioned on 05/09/13 by the social worker and the nurse managers and asked the following questions and all reported they felt comfortable and no one had been inappropriately touched: ? Has any resident touched you inappropriately? ? Have you observed inappropriate behaviors from any other residents or between any residents? ? Has any other resident made you feel uncomfortable? These questions will also be asked of the interviewable resident s weekly for three more weeks, every two weeks for one month, then evaluate the need to continue. Residents who were non-interviewable were observed for any nonverbal signs of abuse on 5/9/13. There were no indications or outward signs of abuse. Staff were asked to identify if they were aware of any other residents with sexually inappropriate behavior and they reported there were none. An addendum to the abuse/neglect policy was developed by the facility administrator on 05/09/13 to include immediate separation of the residents involved in inappropriate sexual behaviors, including initiation of 1:1 staffing and immediate reporting of sexual behaviors to the DON and/or Administrator 24/7 by the nurse on duty. The following systemic changes have been put into place: An in-service was immediately developed and conducted on 05/09/13 by the ADON and SW on reporting sexually inappropriate behaviors to DON or Administrator. Staff were asked to identify if they were aware of any other residents with sexually inappropriate behavior and they reported there were none. In-service to all staff began on 05/09/13 at 5:05 PM. Any full-time, part-time or PRN staff that were unavailable will not be allowed to work in the facility until they have completed the in-service. This in-service to all staff on the prevention and identification of sexually inappropriate behaviors included: A) Recognizing sexual behaviors. B) Preventing, identifying and reporting of sexual behaviors immediately by phone to the DON or Administrator 24 hours a day, 7 days a week. The telephone numbers are posted at each nursing station. C) Staff response to include immediate separation of residents and initiating 1:1 staffing 24/7 until further notice. D) Expectations of staff responsibility to ensure that resident is monitored until management receives notification of behaviors and implements appropriate safety interventions, notifying the medical provider by phone or in person of incidents. E) Prevention and how to supervise residents on any unit for inappropriate sexual behaviors. F) Admission process for reviewing behaviors and determining if facility can meet the needs of potential admission candidates. G) Licensed nursing staff are responsible for documenting any sexually inappropriate behavior in the facility ' s computer incident reporting program. This documentation must be completed by the end of shift of the day of the incident occurrence. A daily audit will be conducted by the ADON (back-up will be Nurse in Charge) Monday through Friday and the Nurse in Charge (back-up is Manager on Duty) on the weekend to review incident reports of inappropriate sexual behaviors. During these audits, the ADON and/or the Nurse in Charge (weekends) will also verbally question staff of any other concerns related to sexual behaviors. These daily audits and any other staff concerns related to sexual behaviors will be reported to the DON immediately. Any weekend audits or other staff concerns related to sexual behaviors will be called directly to the DON by the Nurse in Charge for further review. These audits will be done on a continual basis. Reporting of the sexual behavior incident reports, audit findings, and any investigative interventions implemented will be reported by the Social Worker to the Quality Assurance Performance Improvement Team each month on a continual basis, with any further recommendations for interventions from the Quality Assurance Performance Improvement Team to be implemented by the Team at that time to ensure compliance. The Immediate Jeopardy was lifted on 05/10/13 at 4:37 PM. The facility provided evidence of in-service training for all staff on the prevention of inappropriate resident behavior. Interviews with the staff revealed they were aware of new changes that included implementing supervision for a resident with identified inappropriate behaviors.

Based on staff interviews and record review the facility failed to develop policies and procedures for reporting abuse allegations to the administrator and/or Director of Nursing and failed to implement protective measures to protect 1 of 1 resident (#108) from 1 of 1 resident (#126) from sexually inappropriate behavior. Immediate jeopardy began on 01/07/13 when staff became aware Resident #126 acted sexually inappropriately toward Resident #108. The administrator was notified of the immediate jeopardy on 05/09/13 at 4:05 PM. Immediate jeopardy was removed on 05/10/13 at 4:37 PM when the facility provided and implemented an acceptable credible allegation of compliance. The facility will remain out of compliance at a scope and severity level D (no actual harm with potential for more than minimal harm that is not immediate jeopardy) to complete employee education and ensure monitoring systems put in place are effective. The findings included: A document titled "Abuse Prohibition" updated on 11/21/11 read in part: "The facility shall develop and operationalize procedures that prohibit abuse for all residents. The facility shall simultaneously develop and operationalize a policy of reporting abuse." The document also read in part the processes in which the facility would implement their abuse prohibition included: - The facility shall train employees through orientation and on-going session about how staff should report their knowledge related to allegations of abuse. - The facility shall assure residents are protected from harm during the investigation. Further review of the document revealed that there was no policy related to reporting abuse allegations to the Administrator and/or Director of Nursing. Resident #126 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] specified the resident had moderately impaired cognitive skills but no documented behaviors. The MDS also specified the resident required limited assistance with activities of daily living (ADL) and used a walker or wheelchair for mobility. Resident #108 was admitted to the facility 11/16/11 with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] specified the resident had severely impaired cognitive skills and required extensive assistance with activities of daily living (ADL). a. On 05/09/13 at 11:10 AM Nurse Aide (NA) #3 was interviewed and reported that she was trained to report any concerns with resident to resident behavior to the nurse. She stated that on a Saturday or Sunday "several months ago, right after Christmas" she observed Resident #126 sitting in the hallway fondling Resident #108's breasts. She called NA #1 for assistance and together the aides approached Resident #126 and separated the residents. She added that she reported the incident to Nurse #3. NA #3 stated that following the incident she monitored Resident #126's location for the remainder of her shift. She stated that following the incident she was not made aware of changes in the level of supervision for Resident #126 and added that he was mobile throughout the facility. The NA explained that Resident #126's room remained near Resident #108 and commented that Resident #126 had a fondness for Resident #108 because she reminded him of his wife. On 05/10/13 at 2:55 PM NA #1 was interviewed and reported that she had observed Resident #126 fondling Resident #108's breasts. She stated the incident happened on a weekend when she worked with NA #3, Nurse #3 and the Weekend Supervisor. She added that the incident was reported to Nurse #3. On 05/10/13 at 8:05 AM Nurse #3 was interviewed and reported that she was trained to report all allegations or suspicion of abuse to her immediate supervisor. She stated she recalled being notified by NA #3 that Resident #126 had fondled Resident #108. Nurse #3 explained that she could not recall the date of the incident but confirmed it was a weekend in January. She added that the incident occurred in the early part of January because after the incident she was made aware of 2 additional incidents of Resident #126 being sexually inappropriate with Resident #108. Nurse #3 reported that she asked Resident #108 if she had been touched inappropriately by Resident #126 because she felt the resident was alert and oriented. She added that Resident #108 denied the incident had occurred. She stated she told the nurse aides to monitor Resident #126. Nurse #3 stated that she reported the incident to the Weekend Supervisor. On 05/09/13 at 11:40 AM the Weekend Supervisor was interviewed and reported that she recalled an incident (date unknown) where NA #3 reported she had observed Resident #126 fondling Resident #108's breasts. She stated that she was trained to separate residents and then report the incident to the Director of Nursing (DON). She added that she would have documented the incident in the medical record. She was unable to recall if she had notified the DON of the incident and was unable to provide documentation of the incident. The Weekend Supervisor explained that she asked staff on the hall to monitor Resident #126 more frequently for the remainder of the shift. She stated that following the incident she was unaware of changes made to Resident #126's accessibility to Resident #108. On 05/09/13 at 2:10 PM the Director of Nursing (DON) and Assistant Director of Nursing (ADON) were interviewed. The DON and ADON stated they were unaware of the incident. The DON stated she would expect the Weekend Supervisor to have notified her immediately of the incident. The DON reported that no additional interventions were implemented to prevent Resident #126 from continuing to act sexually inappropriately toward Resident #108. The DON reported that following the incident no changes had been made to prevent reoccurrences because staff failed to report the incident to the Director of Nursing or Administrator. The DON stated that she would have immediately implemented measures to prevent the behavior from reoccurring such as notifying the physician and monitoring the resident with one to one supervision. b. Review of Resident #126's medical record revealed a nurses' entry made by Nurse #1 dated 01/07/13 at 9:23 PM that specified Resident #126 was observed inappropriately touching Resident #108. The nurse's entry documented that Resident #126 was redirected and monitored. On 05/09/13 at 10:57 AM Nurse Aide (NA) #2 was interviewed and reported that on 01/07/13 she had observed Resident #126 with his hand up Resident #108's shirt. She explained that when she approached the residents, Resident #126 removed his hand from Resident #108's breasts. She added that she reported the incident to Nurse #1 who instructed the NA to watch Resident #126 more frequently for the remained of her shift. NA #2 stated that the residents were allowed to remain on the same hall in close proximity to each other. She added that Resident #108 was dependant on staff to care for her needs and would spend time in the hallway. She stated she was not made aware of changes to level of supervision Resident #126 required. On 05/09/13 at 5:20 PM Nurse #1 was interviewed and reported that she was trained to report "anything out of the ordinary" to the Director of Nursing. Nurse #1 stated that on 01/07/13 NA #2 notified her that resident #126 was touching Resident #108's breasts. Nurse #1 explained that the residents were separated and she instructed NA #2 to monitor Resident #126 more frequently for the remainder of the shift. She added that she considered the behavior to be abusive and inappropriate but did not report the incident to the Director of Nursing or other Administrative staff because she felt she had handled the situation. On 05/09/13 at 2:10 PM the Director of Nursing (DON) and Assistant Director of Nursing (ADON) were interviewed. They stated they were unaware of the incident. The DON stated she would expect Nurse #1 to have notified her immediately of the incident. The DON reported that no additional interventions were implemented to prevent Resident #126 from continuing to act sexually inappropriately toward Resident #108 as result of the incident on 01/07/13 because staff failed to report the incident to the DON and/or Administrator. The DON stated that she would have immediately implemented measures to prevent the behavior from reoccurring such as notifying the physician and monitoring the resident with one to one supervision. On 05/09/13 at 3:30 PM the Administrator was interviewed and reported that she was unaware of Resident #126 being sexually inappropriate with Resident #108 prior to 01/11/13. She added that no interventions were developed or implemented to prevent reoccurrences or to protect Resident #108 prior to 01/11/13 because staff failed to report the incidents to the DON and/or Administrator. She added that after the 01/11/13 incident the facility offered a room change to Resident #108 but her family declined so the staff continued to monitor Resident #126 more frequently. c. Review of Resident #126's medical record revealed a nurses' entry made by Nurse #2 dated 01/11/13 at 12:00 PM that specified Resident #126 touched Resident #108 inappropriately. The entry also specified Resident #126 was redirected and monitored. Further review of the medical record for Resident #126 revealed a care plan dated 01/14/13 that specified Resident #126 had sexually inappropriate behaviors towards a female resident. Interventions identified on the care plan included: - redirect when adverse behaviors occur - report adverse behaviors immediately - monitor resident's interaction with Resident #108 On 05/09/13 at 11:22 AM the Social Worker (SW) was interviewed and reported that Nurse #2 had notified her that Resident #126 touched Resident #108 inappropriately. The SW explained that Resident #126 was told the behavior was not tolerated by the facility and asked the resident to keep his distance from Resident #108. The SW added that Resident #108 had severely impaired cognition and was unable to give consent to being touched. On 05/09/10 at 2:10 PM the Director of Nursing (DON) and Assistant Director of Nursing (ADON) were interviewed. The DON stated that during this time she was on leave and the ADON had assumed the DON role. The ADON stated she was notified by the SW of the incident on 01/11/13. The ADON was unaware Resident #126 had touched Resident #108's breasts and added that she did not interview Nurse #2 who witnessed the incident. The ADON explained that she was only aware that Resident #126 had been observed with his hand on Resident #108's leg and did not consider the behavior to be sexually inappropriate. The ADON stated that had she known Resident #126 touched Resident #108's breasts she would have made additional interventions to prevent any reoccurrence such as notifying the physician and ordering Resident #126 to be on one to one monitoring. She added that Resident #108 was offered a room change but the family declined. On 05/09/13 at 2:50 PM Nurse #2 was interviewed and reported that she had observed Resident #126 rubbing Resident #108's leg and touching her breasts. She stated that she separated the residents and notified the Social Worker of the incident. She stated that following the incident she would monitor Resident #126 during her shifts to keep him from accessing Resident #108. d. Resident #126's medical record was reviewed and revealed an entry made by the Social Worker dated 04/30/13 that specified Resident #126 was sexually inappropriate with Resident #108. The entry also specified Resident #108 was moved to another hall to reduce Resident #126's access to her and Resident #126 was referred for psychiatric services. Further review of Resident #126's medical record revealed a care plan updated on 04/30/13 for sexually inappropriate behaviors towards a female resident. Interventions in the care plan included: - separate resident from Resident #108 - monitor resident's behavior and report any adverse behaviors immediately - refer to psychiatric services On 05/08/13 at 12:40 PM Nurse Aide (NA) #4 was interviewed and reported that on 04/29/13 she observed Resident #126 fondling Resident #108's breasts. She stated that she and another NA separated the residents and notified the nurse and Director of Nursing (DON). On 05/09/13 at 9:20 AM the DON was interviewed and reported that all staff received yearly training on abuse policy and procedure for identifying and reporting abuse. The DON stated that staff were trained to immediately report any possible suspicion of abuse to their supervisor and the supervisor was responsible for notifying the DON to initiate an investigation. The DON stated that she was in the building when the incident on 04/29/13 occurred and instructed staff to put Resident #108 to bed and to do hourly checks on Resident #126 until he went to bed the night of 04/29/13. The DON added that on 04/30/13 Resident #126 was evaluated by psychiatric services and received an order to start a testosterone reducing medication which could take up to a month for the medication to take effect. She stated that staff were continuing to monitor the resident every 2 hours. She added that Resident #126 was very social and propelled himself throughout the facility and that he was a "touchy-feely" person and friendly to everyone. On 05/09/13 at 3:30 PM the Administrator was interviewed and reported that she was aware of Resident #126 being sexually inappropriate with Resident #108 on 04/29/13. She stated that she had also been notified of a similar incident involving Resident #126 and Resident #108 on 01/11/13. She stated that the facility addressed the incidents and felt they implemented measures to prevent any reoccurrence. The Administrator stated she was not aware of the 2 incidents that occurred on a weekend in January 2013 and on 01/07/13 where Resident #126 was observed by staff to have fondled Resident #108. She stated that had she been notified after the first incident of sexually inappropriate behaviors then the facility would have immediately implemented interventions to prevent the behavior from reoccurring 3 more times. The administrator was notified of the immediate jeopardy on 05/09/13 at 4:05 PM. The facility provided a credible allegation of compliance on 05/10/13 at 4:37 PM. The following interventions were put into place by the facility to remove the Immediate Jeopardy: Corrective action was accomplished by placing Resident #126 on 1:1 (one licensed nurse or nursing assistant assigned to the resident at all times) monitoring at 4:50 PM on 05/09/13. Staff were instructed by the ADON on 05/09/13 at 4:45 PM that without exception, the resident had to be in visual sight at all times. A 1:1 tracking sign-in form was implemented to provide documentation of who was assigned and who provided relief and the times of the observation. Resident #126 started a testosterone inhibiting medication on 04/30/13 which he will remain on. He will also remain on 1:1 observation for a period of 21 days in order to allow the testosterone inhibiting medication to become effective. If there are no further incidents of sexual acting out during that 21 day period, the 1:1 observation will be changed to frequent monitoring. If the resident shows any signs of sexually acting out during the 21 day period, the physician will be notified for medication adjustment. If the resident shows any signs of sexually acting out after being removed from 1:1 observation, 1:1 observation will be resumed immediately and the physician will be notified for medication adjustment. The Medical Director was notified on 05/10/13 of the need to evaluate Resident #126. A physician order [REDACTED]. Resident #108 was assessed on 05/10/13 by the social worker for any residual effects from the sexual behavior of Resident #126. No concerns were noted. All residents had the potential to be affected by the alleged deficient practice. Corrective action was accomplished for those residents by placing Resident #126 on 1:1 nurse aide observation on 05/09/13. All interviewable residents in the facility were questioned on 05/09/13 by the social worker and the nurse managers and asked the following questions and all reported they felt comfortable and no one had been inappropriately touched: ? Has any resident touched you inappropriately? ? Have you observed inappropriate behaviors from any other residents or between any residents? ? Has any other resident made you feel uncomfortable? These questions will also be asked of the interviewable residents weekly for three more weeks, every two weeks for one month, then evaluate the need to continue. Residents who were non-interviewable were observed for any nonverbal signs of abuse on 05/09/13. There were no indications or outward signs of abuse. Staff were asked to identify if they were aware of any other residents with sexually inappropriate behavior and they reported there were none. An addendum to the abuse/neglect policy was developed by the facility administrator on 05/09/13 to include immediate separation of the residents involved in inappropriate sexual behaviors, including initiation of 1:1 staffing and immediate reporting of sexual behaviors to the DON and/or Administrator 24/7 by the nurse on duty. Additionally, the following systemic changes have been put into place: An in-service about resident protection and reporting of sexually inappropriate behaviors to the DON or Administrator was immediately developed and conducted on 05/09/13 by the ADON and SW. In-service to all staff began on 05/09/13 at 5:05 pm. Any full-time, part-time or PRN staff that were unavailable will not be allowed to work in the facility until they have completed the in-service. This in-service for all staff included: A) Recognizing sexual behaviors. B) Identifying and reporting of sexual behaviors immediately by phone to the DON or Administrator 24 hours a day, 7 days a week. The telephone numbers are posted at each nursing station. C) Staff response to include ensuring resident protection with immediate separation of residents and initiating 1:1 staffing 24/7 until further notice. D) It is staff responsibility to ensure that resident is monitored 1:1 until management receives notification of behaviors and implements appropriate safety interventions, notifying the medical provider by phone or in person of incidents. E) Prevention and how to supervise residents on any unit for inappropriate sexual behaviors. F) Admission process for reviewing behaviors and determining if facility can meet the needs of potential admission candidates. Additional in-service specific to licensed staff included: G) Licensed nursing staff are responsible for documenting any sexually inappropriate behavior in the facility ' s computer incident reporting program. This documentation must be completed by the end of shift of the day of the incident occurrence. A daily audit will be conducted by the ADON (back-up will be Nurse in Charge) Monday through Friday and the Nurse in Charge (back-up is Manager on Duty) on the weekend to review incident reports of inappropriate sexual behaviors. During these audits, the ADON and/or the Nurse in Charge (weekends) will also verbally question staff of any other concerns related to sexual behaviors. These daily audits and any other staff concerns related to sexual behaviors will be reported to the DON immediately. Any weekend audits or other staff concerns related to sexual behaviors will be called directly to the DON by the Nurse in Charge for further review. These audits will be done on a continual basis. Reporting of the sexual behavior incident reports, audit findings, and any investigative interventions implemented will be reported by the Social Worker to the Quality Assurance Performance Improvement Team each month on a continual basis, with any further recommendations for interventions from the Quality Assurance Performance Improvement Team to be implemented by the Team at that time to ensure compliance. Immediate Jeopardy was lifted on 05/10/13 at 4:37 PM. The facility provided evidence of in-service training for all staff related to reporting allegations of abuse to the Director of Nursing and/or Administrator and protecting residents from abuse by providing supervision to residents who were observed with abusive behaviors. Interviews with staff revealed they were aware of the new policy for reporting and protecting residents.