Every finding on record at Compass Healthcare and Rehab Rowan, LLC

Based on observation, record review, Responsible Party (RP), resident, and staff interviews, the facility failed to arrange or coordinate podiatry care for 1 of 1 dependent resident reviewed for foot care (Resident #17).The findings included:Resident #17 was admitted to the facility on [DATE] with diagnoses which included muscle weakness, stroke, diabetes, and lack of coordination. Review of Resident #17's admission Minimum Data Set (MDS) dated [DATE] revealed the resident was severely cognitively impaired and was dependent on staff for assistance with personal hygiene.Review of Resident #17's care plan, revised 10/08/25, revealed the resident had potential for complications related to diabetes. Interventions included inspecting foot for bunions, calluses, cracking, encouraging proper foot care, referring to podiatrist for foot care, and trimming of nails.Review of Resident #17 physician order dated 09/22/25 revealed the resident may use podiatrist services.Review of a progress note dated 10/15/25 documented by the facility Social Worker (SW) revealed Resident #17's Responsible Party (RP) had called the facility with concerns and questions regarding podiatry care. The note further revealed Resident #17 would be added to the next podiatry list for the next visit. The note indicated the Director of Nursing (DON) was notified of concerns.An interview conducted with Resident #17's RP on 11/17/25 at 1:05 PM revealed the RP had requested multiple times since admission that Resident #17 needed to have her toenails trimmed. The RP could not recall who she had spoken to. The RP further revealed the facility had yet to trim Resident #17's toenails since admission and if they could not trim them then she would like Resident #1 to be seen by a podiatrist at an appointment outside of the facility. Review of the facility podiatry list indicated Resident #17 was not on the list to be seen by podiatry during the next scheduled podiatry visit to the facility on [DATE]. An observation with Resident #17 on 11/20/25 at 8:50 AM revealed the free edge of the resident's great toe toenails, on both feet, to be extending beyond the end of her toes, and the nails were thick.An interview and observation were conducted with Nurse Aide #1 on 11/20/25 at 9:00 AM. NA #1 confirmed Resident #17's toenails were long, thick, and needed to be trimmed. NA #1 further revealed she was unable to trim Resident #17's toenails due to the resided being a diabetic. NA #1 stated she had recently notified Nurse #1 that Resident #17's toenails needed to be trimmed.An interview and observation were conducted with Nurse #1, who routinely worked with Resident #17 on 11/20/2 at 9:10 AM. Nurse #1 revealed she did not recall staff, notifying her the resident's toenails needed to be trimmed. Nurse #1 confirmed Resident #17's toenails were long and thick and needed to be trimmed. Nurse #1 indicated she would have Resident #17 added to the list for the next podiatry visit in December because the resident's toenails were thick and needed to be buffed by a podiatrist.An interview conducted with the Facility Scheduler on 11/20/25 at 9:25 AM revealed she handled appointments for residents and assisted with adding residents to in-house services as well. The Facility Scheduler further revealed that she had not been made aware Resident #17 was in need to be seen by podiatry. The Facility Scheduler stated if resident #17's toenails required immediate attention she would have made an appointment with an outside podiatrist.An interview conducted with the Administrator on 11/20/25 at 4:00 PM revealed she was not aware Resident #17's RP had concerns with Resident #17's toenails. It was further revealed she expected residents' toenails to remain trimmed and if there were issues, podiatry would be consulted. The Administrator indicated nursing staff should have communicated the residents' needs and the resident should have been added to the podiatry list.

Based on observations and staff interviews, the facility failed to ensure the food and beverage items stored in the refrigerator/freezer in 1 of 1 nourishment room were dated and labeled and failed to dispose of expired cartons of single serve milk. These practices had the potential to affect food served to residents.The findings included: On 11/19/25 at 2:45 p.m., accompanied by Dietary [NAME] #1, the nourishment room was observed. The refrigerator contained 13 (8-ounce) cartons of whole milk with expiration dates of 11/17/25 and 11/18/25. The refrigerator also contained a small, clear, plastic container of peach cobbler and a blueberry bagel wrapped in foil. These items were not dated or labeled with a resident's name or room number. There were 2 commercially prepared entrees in the freezer section of the refrigerator that were not dated or labeled with a resident's name and room number. Dietary Cook#1 stated the expired cartons of milk should not have been in the refrigerator and the food items without a resident's name, room number and date were not placed in the refrigeration unit by the dietary department. She indicated the nursing staff were responsible for dating and labeling residents' personal food items before storing the items in the refrigerator or freezer. During an interview on 11/20/25 at 9:33 a.m., the Dietary Manager (DM) revealed the dietary department did not supply milk to the nourishment room. He stated the dietary department maintained a list of food items which dietary staff placed in the nourishment room for residents between 1:00 p.m. and 2:00 p.m., every day, including weekends. The DM further explained that if a resident requested extra milk, the nursing staff and/or resident would notify the dietary staff who would supply the milk from the refrigeration unit in the kitchen. He indicated dietary staff were on duty in the kitchen until 8:30 p.m., every night.

Based on record review, and resident, staff, Nurse Practitioner (NP), and physician interviews, the facility failed to protect a resident from a significant medication error when Nurse #1 administered medications prescribed for Resident #26's roommate (Resident #18), as well as Resident #26's own medications, to Resident #26 during the morning medication pass on 08/19/24. The medications administered to Resident #26 included her prescribed dose of carvedilol 3.125 milligram (mg) (a blood pressure medication) and Resident #18's dose of carvedilol 12.5 mg. Resident #26 received her prescribed dose of clopidogrel 75 mg (a blood thinner) and Resident #18's dose of apixaban 5 mg (an anticoagulant). Resident #26 received her prescribed dose of aspirin 81 mg (a nonsteroidal anti-inflammatory drug) and Resident #18's dose of aspirin 81 mg. Resident #26 also received other medications which were not prescribed to her, including Resident #18's dose of hydralazine (a blood pressure medication), Resident #18's dose of levetiracetam (an anticonvulsant), and Resident #18's dose of aripiprazole (an antipsychotic). Resident #26 required an immediate (STAT) electrocardiogram (EKG, a test to record the electrical activity of the heart) and STAT labs including a complete blood count with differential (CBC w/diff), a complete metabolic panel (CMP), a creatinine phosphokinase (CPK), and a prothrombin time/international normalized ratio (PT/INR). Resident #26's vital signs (VS) were monitored hourly for 8 hours, then every 2 hours for 8 hours, then every shift. This was for 1 of 5 residents reviewed for medication errors (Resident #26). The medication error placed Resident #26 at an increased risk of experiencing complications such as hypotension (low blood pressure) and increased anticoagulation (thinning) of her blood. Increased monitoring was required to ensure that in the event of a significant change, Resident #26 would be discharged to a higher level of care. Immediate jeopardy began on 08/19/24 when Resident #26 was administered medications prescribed for another resident. The immediate jeopardy was removed on 08/21/24 when the facility implemented a credible allegation of immediate jeopardy removal. The facility will remain out of compliance at a lower scope and severity D (no actual harm with potential for more than minimal harm) to ensure monitoring systems put into place are effective. The findings included: Resident #26 was admitted to the facility on [DATE], with diagnoses to include cerebrovascular disease, acute ischemic heart disease, hypertension (HTN), bipolar disorder, depression, atrial fibrillation, and convulsions. Resident #26's quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #26 was cognitively intact. A review of the active morning medication orders for Resident #26 included aspirin 81 mg daily, carvedilol 3.125 mg twice a day, and clopidogrel 75 mg daily. A review of the medication administration record (MAR) for 08/19/24 revealed Resident #26 received her prescribed medications at 8:21 am, as evidenced by initials for Nurse #2. Resident #26 received aspirin 81 mg, carvedilol 3.125 mg, and clopidogrel 75 mg. A review of Resident #18's active medication orders included aspirin 81 mg daily, carvedilol 12.5 mg daily, apixaban 5 mg every 12 hours, hydralazine 10 mg every 12 hours, levetiracetam 500 mg every 12 hours, and aripiprazole 10 mg daily. A combined interview was conducted with Nurse #1 and Nurse #2 on 08/19/24 at 9:34 am. Nurse #2 revealed Resident #26 received her roommate's (Resident #18's) medications in addition to Resident #26's own medications. Nurse #1 reported that she went to the wrong bedside when she administered Resident #18's medications to Resident #26. Nurse #1 stated she had not asked Resident #26 her name at the time she administered Resident #18's medications to Resident #26. Nurse #2 reported she (Nurse #2) prepared the medications for Resident #18 and Resident #26 and Nurse #1 administered medications for both residents to Resident #26. Nurse #2 stated she informed Nurse #3 of the error, and Nurse #3 notified the physician. A review of the progress note completed by Nurse #3 on 08/19/24 at 9:00 am stated the physician was made aware of medications given to Resident #26 and provided new orders to include vital signs every hour for the current shift, then every two hours for the next two shifts, then every shift for 24 hours, a STAT EKG, and STAT CBC, CMP, PT/INR, and CPK labs. A review of the medication error report completed by Nurse #3, the charge nurse, on 08/19/24 (with no completion time noted) was reviewed. The report indicated Nurse #2 reported administering incorrect and extra doses of oral medications (including apixaban 5 milligrams, aspirin 81 milligrams, hydralazine 10 milligrams, levetiracetam 500 milligrams, and aripiprazole 10 milligrams to Resident #26 on 08/19/24 at 9 am. An interview with Nurse #3, the Charge Nurse, on 08/19/24 at 9:41 am revealed Nurse #3 was informed of the medication error by Nurse #2 and Nurse #1. Nurse #3 stated she notified the physician immediately, as well as the Administrator and the Director of Nursing (DON). Nurse #3 stated that Resident #26 should have been identified by both Nurse #1 and Nurse #2, and Resident #26 should not have received Resident # 18's medications in addition to Resident #26's own medications. During an interview on 08/19/24 at 9:32 am, Resident #26 stated she received her roommate's (Resident #18's) medications on 08/19/24 at 9:00 am. Resident #26 reported Nurse #1 failed to ask Resident #26 her name before administering Resident #18's medications to her. In addition, Resident #26 stated she informed Nurse #1 that she did not take her medications in pudding, however Nurse #1 instructed Resident #26 to take the medications. During an interview on 08/19/24 at 10:28 am Resident #18 reported she received her prescribed medications on the morning of 08/19/24. A telephone interview with the Physician on 08/19/24 at 10:22 am confirmed she had been informed of the medication error by Nurse #3. The physician stated she ordered a STAT EKG and STAT labs, along with vital signs every hour for 8 hours, then every 2 hours for 8 hours, then every shift - with no end date until further notice. The Physician stated nurses were expected to give the correct medications to the correct residents, to notify the physician of errors (as Nurse #3 did), and to closely monitor Resident #26 due to the medication error. The Physician shared that NP #1 would assess Resident #26 on 08/19/24. In a follow-up discussion with Resident #26 on 08/19/24 at 10:28 am, Resident #26 stated she received Resident #18's medications before Resident #26 received her own medications; she informed Nurse #1 she did not normally take her medications in pudding, and Nurse #1 did not ask her/Resident #26 her name before administering the medications or earlier in Nurse #1's shift. An interview was conducted with NP #1 on 08/19/24 at 1:18 pm, who stated that she was informed of the medication error by the physician. NP #1 shared she had assessed Resident #26, on 08/19/24, who was a little sleepy (but easily awakened), with no shortness of breath or dizziness and at her baseline level cognitively. NP #1 shared that Resident #26's EKG was normal, and the laboratory results remained pending. NP #1 reported Resident #26 was at a risk for bleeding, bruising, and hypotension due to the doses of apixaban 5 milligrams, aspirin 81 milligrams, hydralazine 10 milligrams, levetiracetam 500 milligrams, and aripiprazole 10 milligrams given to her in error. NP #1 stated she provided orders to monitor Resident #26's blood pressure, heart rate, as well as for bleeding and bruising. A review of the Physician's Progress Note dated 08/20/24 at 11:35 am revealed Resident #26 was seen and assessed by the physician following a medication error on 08/19/24. The Physician noted Resident #26 received her roommate's aripiprazole (10 mg), aspirin (81 mg), carvedilol (12.5 mg), apixaban (5 mg), hydralazine (10 mg), levetiracetam (500 mg), in addition to Resident #26's own medications - which included aspirin (81 mg), carvedilol (3.125 mg), and clopidogrel (75 mg),. The physician stated that she was contacted by nursing staff immediately after the medication error occurred, and gave orders for STAT labs to include CBC, CMP, CPK, and PT/INR, as well as an order for a STAT EKG. The physician advised staff to hold Resident #26's evening dose of carvedilol. The physician's assessment revealed that Resident #26, who was without concerns or complaints, appeared to be at her baseline. Resident #26's plan included a repeat of her STAT labs (CBC, CMP, CPK, and PT/INR) in 1 week, VS every shift, and close monitoring. The physician contacted Resident #26's son and explained the plan of care for Resident #26. A follow-up interview with the Physician was conducted on 08/20/24 at 11:40 am, at which time she shared she examined Resident #26 on 08/20/24 at 11:30 am and had no new concerns. The Physician stated she ordered repeat labs (to include STAT CBC w/diff, CMP, PT/INR, and CPK) in 1 week and VS every shift for an additional week for Resident #26. The facility Administrator and DON were notified of Immediate Jeopardy on 08/19/24 at 6:03 pm. The facility implemented the following corrective action plan for immediate jeopardy removal: Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance. On 8/19/24, at approximately 9:00 AM, Nurse #1, administered Resident #26 her prescribed medications, aspirin 81 mg, Coreg 3.125 mg, plavix 75 mg, Trileptal 150 mg. Resident #26 also received Resident #18 medications to include aripiprazole 10 mg, aspirin 81 mg, benztropin 1 mg, coreg 12.5 mg, eliquis 5 mg, hydralazine 10 mg, levetiracetam 500 mg. On 8/19/24 the Medical Director was immediately notified by the Unit Manager and new orders were received for vital signs every hour for first shift, then vital signs every 2 hours for second shift, then every shift for 24 hours. In addition, Stat EKG (electrocardiogram), Stat CBC (complete blood count), CMO (Comprehensive Metabolic panel), PT/INR (Protime/International Normalized Ratio), CPK (Creatine Phosophokinase). The medication Coreg 3.125 mg will be held until tomorrow 8/20/24 until Medical Director can examine Resident #26. A Medication Error report was completed, and family notified. The Nurse Practitioner examined Resident #26 and reported the EKG was reviewed and is normal. Labs were collected and are pending. PT/INR results revealed INR 0.9, normal range 0.9-1.1 and PT 9.7 range 9.9-11.8 . All labs will be repeated on 8/20/24. Nurse #2 was interviewed by the Administrator. It was determined that medications had been administered properly for all other residents on the medication pass. Five other residents had already received medication (rooms 100, 102, 104). No other residents were determined to be at risk. No other residents have suffered a serious adverse outcome as a result of the noncompliance. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete. An in-service was immediately conducted on 8/19/24 by the Director of Nurses on Proper Medication Administration (The 5 Rights) for all nurses and medication aides, and to reinforce medication administration is not to be conducted jointly at any other time. All nurses educated on 8/19/24. Any not educated will be removed from schedule until education is performed. Director of Nursing/Designee will keep in-service records and ensure all staff have received education before returning to work. Joint Medication Administration is not allowed. This topic was included in the in-service mentioned above. The Unit Manager immediately conducted on 8/19/24 a Medication Pass Observation for all nurses on duty and will continue until all nurses have a medication pass skills observation. Nurse #1 was removed from duty until further notice. The root cause analysis is Nurse #1, and the nurse on duty administered medications jointly, causing Resident #26 to receive Resident #18 medications as well. IJ Removal Date: 8/21/24 On 08/21/24, the facility's credible allegation of immediate jeopardy removal was validated on-site by record review, observations, and interviews. Individual interviews with a sample of residents revealed they received their prescribed medications without concerns. A medication administration observation was conducted on 08/21/24. The observation consisted of administration of medications for 4 different residents, by 1 nurse and 1 medication aide. The nurse and the medication aide were observed implementing the rights of medication administration before administering the medications from start to finish. No concerns were identified. Interviews with nurses and the medication aide revealed they were required to complete in-services for the 5 rights of medication administration and the facility's new process for medication administration. A review of the in-service documents dated 08/19/24 and 08/20/24 noted the DON completed the in-person in-services for the 5 rights of medication administration and the facility's new process for medication administration with nurses and medication aides. An interview with the DON on 08/21/24 revealed that the in-services would be provided to Nurse #1 and all other nurses and medication aides that had not worked since the medication error, as well as to any new nurses and medication aides before they were allowed to administer medications. The immediate jeopardy removal date of 08/21/24 was validated.

Based on observations, record review, and staff interviews the facility failed to maintain a clean shower room for 1 of 1 shower room reviewed for a safe, clean, comfortable, and homelike environment. Findings included: An observation of the shower room conducted on 08/18/24 at 1:00 PM revealed a strong odor of feces, brown water and hair sitting in the shower. The walls of the shower appeared to have brown grime. In addition, two wheelchairs were in the shower room, multiple pairs of shoes were on the floor, a used razor was hanging on the sharps container door that was open and unlocked, and multiple body wash and shampoo bottles not labeled, and a used washcloth were sitting beside the sink. An observation and interview conducted with Nurse Aide #4 on 08/19/24 at 9:35 AM revealed the shower room was last used on 08/17/24 and the appearance of the shower room was not considered acceptable to her. Observation included an odor of feces, the sharps container door was open and unlocked, shoes were located on the floor, and the shower had brown grime on the wall and hair and dirt on the shower floor. NA #4 indicated one pair of shoes on the floor belonged to a resident. NA #4 indicated staff had been educated to clean and organize shower room after every shower and it was common for second shift to leave the shower room is disarray. NA #4 stated nursing staff and housekeeping were responsible for cleaning the shower room. During an observation and interview with Nurse Aide (NA) #5 on 08/20/24 at 11:24 AM revealed urine and grime on the walls of the shower room, the sharps container door was open and unlocked. Multiple unlabeled bottles of shampoo and body wash were noted beside the sink. NA #4 stated nursing staff were educated to clean after every shower, but second shift consistently did not clean up. NA #5 further revealed she rarely saw housekeeping in the shower room to assist with cleanliness. NA #5 stated nursing staff and housekeeping were responsible for cleaning the shower room. An observation and interview conducted with the Director of Housekeeping and Regional Housekeeping on 08/20/24 at 11:35 AM. He stated the appearance of the shower room was unacceptable. Urine and grime were observed on the walls, the sharps container door was unlocked and opened, and multiple bottles of unlabeled shampoo and body wash were noted. The Director of Housekeeping revealed he had recently just become the housekeeping director and was not sure if housekeeping had a schedule to clean the shower room. He stated he would have a schedule created to make sure housekeeping was cleaning the shower room. It was indicated that the shower room would need to be deep cleaned and sanitized immediately. An interview conducted with the Administrator on 08/21/24 at 3:00 PM revealed she was not aware the shower room was observed to have environmental concerns. The Administrator further revealed she expected for nursing staff and housekeeping to keep the shower room clean and organized.

Based on record review and interviews with resident and staff, the facility failed to prevent a medication error when Nurse #1 failed to complete the 5 rights of medication administration before she administered medications prescribed for Resident #26's roommate (Resident #18) to Resident #26 during the morning medication pass on 08/19/24. This was for 1 of 5 residents reviewed for professional standards/safe administration of medications (Resident #26). Findings included: Resident #26 was admitted to the facility on [DATE], with diagnoses to include cerebrovascular disease, acute ischemic heart disease, hypertension (HTN), bipolar disorder, depression, atrial fibrillation, and convulsions. Review of Resident #26's quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #26 was cognitively intact. Review of Resident #18's active medication orders included d-mannose 500 mg daily (an antibacterial), benztropine 1 mg (an antitremor medication), docusate 100 mg (a stool softener), fexofenadine 180 mg (an antihistamine), magnesium oxide 400 mg (an antireflux medication), polyethylene glycol 17 grams (a laxative), vitamins a,c,e-zinc-copper 2,148 mc-113 mg-45 mg-17.4 mg (a supplement), lactobacillus acidophilus 1 billion cell-250 mg (a probiotic), and vitamin D3 (a supplement). A combined interview was conducted with Nurse #1 and Nurse #2 on 08/19/24 at 9:34 am. Nurse #2 revealed Resident #26 received her roommate's (Resident #18's) medications in addition to Resident #26's own medications. Nurse #1 stated she went to the wrong bedside when she administered Resident #18's medications to Resident #26. Nurse #1 indicated she had not asked Resident #26 her name at the time she administered Resident #18's medications to Resident #26. Nurse #2 reported she (Nurse #2) prepared the medications for Resident #18 and Resident #26 and Nurse #1 administered medications for both residents to Resident #26. Nurse #2 stated she notified Nurse #3 of the error, and Nurse #3 notified the physician. Review of the medication error report completed by Nurse #3, the charge nurse, on 08/19/24 (with no completion time noted) was reviewed. The report indicated Nurse #2 reported she had administered incorrect to Resident #26 on 08/19/24 at 9:00 am. An interview with Nurse #3, the Charge Nurse, on 08/19/24 at 9:41 am revealed Nurse #3 was notified of the medication error by Nurse #2 and Nurse #1. Nurse #3 stated she notified the physician, the Administrator, and the Director of Nursing (DON) immediately. Nurse #3 stated that Resident #26 should have been identified by both Nurse #1 and Nurse #2 (had they used the 5 rights), and Resident #26 should not have received Resident # 18's medications in addition to Resident #26's own medications. During an interview on 08/19/24 at 9:32 am, Resident #26 stated she received her roommate's (Resident #18's) medications on 08/19/24 at 9:00 am. Resident #26 reported Nurse #1 failed to ask Resident #26 her name before administering Resident #18's medications to her. In addition, Resident #26 stated she informed Nurse #1 that she did not take her medications in pudding, however Nurse #1 instructed Resident #26 to take the medications. A telephone interview with the Physician on 08/19/24 at 10:22 am confirmed she had been informed of the medication error by Nurse #3. In a follow-up interview with Resident #26 on 08/19/24 at 10:28 am, Resident #26 stated she received Resident #18's medications before Resident #26 received her own medications; Resident #26 further revealed she informed Nurse #1 she did not normally take her medications in pudding, and Nurse #1 did not ask Resident #26 her name before administering the medications nor earlier in Nurse #1's shift.

Based on record reviews and staff interviews, the facility failed to use the services of a Registered Nurse (RN) for 8 consecutive hours per day, 7 days per week for 5 of 5 dates reviewed (10/2/2022, 10/30/2022, 11/13/2022, 11/26/2022, and 12/25/2022). The findings included: The Payroll Based Journal (PBJ) data report for fiscal year 2023, quarter 1 from October 2022 to December 2022 was reviewed. The report indicated the facility had 4 or more days within the quarter with no Registered Nurse (RN) hours. The dates provided by the report were 10/2/2022, 10/30/2022, 11/13/2022, 11/26/2022, and 12/25/2022. A. The nursing schedule for 10/2/2022 was reviewed. No RN was scheduled to work on that date. The time sheets for 10/2/2022 were reviewed and no RN had worked any shift on 10/2/2022. B. The nursing schedule for 10/30/2022 was reviewed. No RN was scheduled to work on that date. The time sheets for 10/30/2022 were reviewed and no RN had worked any shift on 10/30/2022. C. The nursing schedule for 11/13/2022 was reviewed. No RN was scheduled to work on that date. The time sheets for 11/13/2022 were reviewed and no RN had worked any shift on 11/13/2022. D. The nursing schedule for 11/26/2022 was reviewed. No RN was scheduled to work on that date. The time sheets for 11/26/2022 were reviewed and no RN had worked any shift on 11/26/2022. E. The nursing schedule for 12/25/2022 was reviewed. No RN was scheduled to work on that date. The time sheets for 12/25/2022 were reviewed and no RN had worked any shift on 12/25/2022. An interview was conducted with the Scheduler on 10/11/2023 at 10:42 AM. The Scheduler said she had been responsible for the nursing schedule for almost 6 years at the facility. The Scheduler reported she was not certain why the facility did not have a RN scheduled for the above dates. The Scheduler reported the facility had 4 available RNs (not counting the Director of Nursing [DON]) and one of those RNs may have been unavailable for those weekends listed as having no RN coverage. The Scheduler reported she had not contacted the DON to inform her there was no RN scheduled for 10/2/2022, 10/30/2022, 11/13/2022, 11/26/2022, or 12/25/2022. During an interview with the DON on 10/11/2023 at 11:39 AM, she reported she was not aware the facility did not have RN coverage on the above listed dates. The DON explained if the Scheduler had notified her, she would have come to the facility to provide the RN coverage for those dates. The DON reported she expected to be aware of when the facility did not have RN coverage for 8 consecutive hours, 7 days per week. The Administrator was interviewed on 10/11/2023 at 2:45 PM. The Administrator explained that the corporate office submitted the PBJ information directly from the time sheets/payroll information. The Administrator reported that the Scheduler should have notified the DON there were no RNs scheduled to work those listed dates and the DON would have provided the 8 hours of coverage.

Based on staff interviews and record reviews, the facility failed to accurately complete a Minimum Data Set (MDS) assessment to reflect a resident's life expectancy for 1 of 3 residents reviewed (Resident #71) who were receiving Hospice services; failed to indicate a resident was admitted to Hospice for 2 of 3 residents reviewed (Resident #71 and Resident #46) who were receiving Hospice services; and failed to accurate report the discharge location for 1 of 3 residents selected for a closed record review (Resident #70). The findings included: 1. Resident #71 was admitted to the facility on [DATE] with a cumulative diagnosis which included a progressive neurological disorder and cancer. A review of Resident #71's physician orders and Nursing Notes revealed the resident began to receive Hospice services on 3/10/23. A significant change Minimum Data Set (MDS) assessment dated [DATE] was completed for Resident #71. A review of this MDS revealed the section on Health Conditions indicated the resident had a life expectancy of less than 6 months. The MDS section on Special Treatments, Procedures and Programs indicated Resident #71 was receiving Hospice services. Review of Resident #71's quarterly MDS assessment dated [DATE] revealed the section on Health Conditions did not indicate the resident had a life expectancy of less than 6 months. Also, the MDS section on Special Treatments, Procedures and Programs did not indicate Resident #71 was receiving Hospice services. An interview conducted on 10/11/23 at 9:01 AM with the facility's Administrator revealed the MDS Coordinator was not available for interview. Upon request, the Administrator reviewed Resident #71's quarterly MDS assessment dated [DATE]. At that time, she confirmed the MDS section on Health Conditions did not indicate the resident had a life expectancy of less than 6 months and the section on Special Treatments, Procedures and Programs did not indicate Resident #71 was receiving Hospice services. She stated the resident was receiving Hospice services, the whole time. 2. Resident #46 was admitted to the facility on [DATE] with reentry on 5/1/23 from a hospital. Her cumulative diagnosis included heart failure and a history of cerebral vascular accident (stroke) and respiratory failure. A review of Resident #46's electronic medical record (EMR) indicated a Hospice Consult was ordered for this resident with a start date of 5/2/23. Further review of Resident #46's paper chart revealed a Consent and Election for Hospice Care was signed by the resident's power of attorney and Hospice Agency Representative on 5/2/23. Resident #46's significant change Minimum Data Set (MDS) assessment dated [DATE] revealed the section on Health Conditions indicated the resident had a life expectancy of less than 6 months. However, the MDS section on Special Treatments, Procedures and Programs reported Resident #46 was only receiving Hospice services while not a resident. A review of Resident #46's quarterly MDS assessment dated [DATE] was also conducted. This MDS revealed the section on Health Conditions continued to indicate the resident had a life expectancy of less than 6 months. However, the MDS section on Special Treatments, Procedures and Programs did not indicate Resident #46 was receiving Hospice services. An interview conducted on 10/11/23 at 9:01 AM with the facility's Administrator revealed the MDS Coordinator was not available for interview. Upon request, the Administrator reviewed Resident #46's significant change MDS dated [DATE] and quarterly MDS assessment dated [DATE]. At that time, the Administrator confirmed the section on Treatments, Procedures and Programs on each of the MDS assessments reviewed did not indicate Resident #46 was receiving Hospice services while she was a resident. 3. Resident #70 was admitted to the facility on [DATE]. A review of the electronic and paper medical record for Resident #70 documented the resident was discharged on [DATE] to an assisted living facility (ALF) within the community. However, a review of Resident #70's discharge Minimum Data Set (MDS) assessment dated [DATE] documented Resident #70 was discharged to an acute care hospital. An interview conducted on 10/11/23 at 9:01 AM with the facility's Administrator revealed the MDS Coordinator was not available for interview. Upon request, the Administrator reviewed Resident #70's discharge MDS dated [DATE]. At that time, the Administrator confirmed the MDS was coded to indicate the resident was discharged to a hospital. The Administrator reported Resident #70 was actually discharged to an ALF.

Based on record review and staff interviews, the facility failed to finalize, and transmit Discharge Minimum Data Set (MDS) assessments within the required time frame for 3 of 3 residents reviewed for submission of MDS assessments (Resident #34, Resident #56, and Resident #66). Findings included: 1.Resident #34 was admitted to the facility 04/19/23. Review of Resident #34's Discharge Return Not Anticipated (DCRNA) MDS assessment on 06/15/23 was not marked as completed and had not been accepted into the Centers for Medicare & Medicaid Services (CMS) Quality Improvement Evaluation System (QIES) Assessment Submission and Processing (ASAP) System within 14 days of completion. 2.Resident #56 was admitted to the facility on [DATE]. Review of Resident #56's DCRNA MDS assessment on 06/06/23 was not marked as completed and had not been accepted into the CMS QIES or ASAP systems within 14 days of completion. 3.Resident #66 was admitted to the facility 04/28/23. Review of the Discharge Return Anticipated (DCRA) MDS assessment on for Resident #66 dated 06/05/23 was not marked as completed and had not been accepted into the CMS QIES or ASAP systems within 14 days of completion. On 10/11/23 an interview with the Administrator at 12:44 PM revealed the MDS Coordinator was not available for interview. The Administrator revealed all MDS assessments were required to be completed and submitted in the time frame required by CMS and the Resident Assessment Instrument (RAI) manual.

Based on record reviews, observations, and staff interviews, the facility failed to post daily accurate staffing information for 9 of 10 posted daily staffing forms reviewed and failed to maintain complete daily nursing staffing sheet daily for 3 of 6 days. The findings included: A. Daily posted nursing staffing sheets for the following dates were reviewed: 10/2/2022, 10/30/2022, 11/13/2022, 11/26/2022, 12/25/2022, 4/8/2023, 4/9/2023, 6/24/2023, 8/15/2023, and 8/16/2023. The following dates were incorrect: The daily posted staffing sheet dated 10/2/2022 indicated 5 Licensed Practical Nurses (LPNs) provide 24 hours of care on the afternoon shift. The schedule for afternoon shift (3:00 PM to 11:00 PM) and the schedule indicated 3.5 LPNs were scheduled to work that date. The daily posted staffing sheet indicated 3 Nursing assistants (NAs) provided 22.5 hours of care for the night shift (11:00 PM to 7:00 AM). The schedule for 10/2/2023 revealed 4 NAs were scheduled to work. The daily posted staffing sheet dated 10/30/2022 indicated 3 NAs provided 22.5 hours of care for the night shift and 5 Licensed Practical Nurses (LPNs) provided 24 hours of care on the afternoon). The schedule for 10/30/2022 revealed 4 NAs were scheduled to work the night shift and 3.5 LPNs were scheduled to work the afternoon shift. The daily posted staffing sheet dated 11/13/2022 indicated 5 NAs provided 26.5 hours of care for the afternoon shift. The nursing schedule dated 11/13/2022 revealed 3.5 NAs were scheduled to work. The daily posted staffing sheet dated 11/26/2022 indicated 4 LPNs provided 16 hours of care for the afternoon shift. The nursing schedule dated 11/26/2022 revealed 2 LPNs were scheduled to work. The daily posted staffing sheet dated 12/25/2022 indicated 7 NAs provided 50 hours of care for the day shift (7:00 AM to 3:00 PM) and 4 LPNs provided 20 hours of care for the afternoon shift. The nursing schedule dated 12/25/2022 revealed 6.5 NAs were scheduled to work the day shift and 3 LPNs were scheduled to work afternoon shift. The daily posted staffing sheet dated 4/8/2023 indicated 3 LPNs provided 24 hours of care on the afternoon shift and 7 NAs provided 34 hours of care on the afternoon shift. The schedule revealed 2.5 LPNs and 4.5 NAs were scheduled to work the afternoon shift. The daily posted staffing sheet dated 4/9/2023 indicated 0 RN was working and 2 LPN provided 16 hours of care for the night shift. The schedule revealed 1 RN and 1 LPN were scheduled to work. The daily posted staffing sheet for afternoon shift on that date indicated 4 NAs provided 20 hours of care. The schedule revealed 2.5 NAs were scheduled to work. The daily posted staffing sheet dated 6/24/2023 indicated 5 NAs provided 37.5 hours of care on day shift. The staffing sheet indicated 1 RN provided 4 hours of care on evening shift, 2 LPNs provided 12 hours of care and 6 NAs provided 42 hours of care on the evening shift. The schedule indicated 4 NAs were scheduled to work the day shift, 0.5 RNs were scheduled to work the afternoon shift, 1.5 LPNs, and 4.5 NAs were scheduled to work the afternoon shift. The daily posted staffing sheet dated 8/16/2023 indicated 3 LPNs provided 21 hours of care and 5 NA provided 44 hours of care during the afternoon shift. The schedule revealed 2.5 LPNs and 4 NAs were scheduled to work. The Scheduler was interviewed on 10/11/2023 at 10:42 AM. The Scheduler reported she was counting both staff members for a split shift (7:00 AM to 7:00 PM) and was not aware she should count those staff members as one licensed person. The Administrator was interviewed on 10/11/2023 at 2:45 PM. The Administrator reported the staffing sheets were to be updated by the charge nurse as staffing changes occurred. The Administrator reported she was not aware the Scheduler was miscalculating the number of staff working per shift. B. The daily posted staffing sheets were observed on the following dates: 10/8/23, 10/9/2023, 10/10/2023, and 10/11/2023. During a tour of the facility on 10/8/2023 at 1:07 PM the posted staffing sheet was located on the nursing unit on a bulletin board beside the nursing station. Pinned to the bulletin board were three copies of the daily posted staffing sheet. The daily posted staffing sheet dated Friday, 10/6/2023 was completed for night shift (11:00 PM to 7:00 PM. There was no information posted for the day shift (7:00 AM to 3:00 PM) or the afternoon shift (3:00 PM to 11:00 PM). The daily posted staffing sheet dated Saturday, 10/7/2023 and the staffing sheet was completed only for night shift. There was no information posted for day or afternoon shift. The daily posted staffing sheet dated Sunday, 10/8/2023 and the staffing sheet was completed only for night shift. There was no information posted for day or afternoon shift. The Scheduler was interviewed on 10/11/2023 at 10:42 AM. The Scheduler reported the night shift nurses posted the new staffing sheet for the facility at midnight and each shift the charge nurse updated the staffing sheet with the census and the staffing. The Scheduler reported she did not know why the staffing sheets were not updated over the weekend. The Scheduler explained that she would complete the staffing sheets if the sheets were incomplete. The Scheduler reported she was not aware the staffing sheets were to be updated as changes occurred with staffing and the census. The Administrator was interviewed on 10/11/2023 at 2:45 PM. The Administrator reported the night shift nurse was to post the new staffing sheet and each shift was responsible for updating the census and the staffing. The Administrator reported she expected the staffing sheet to be updated as changes occurred.

Based on resident and staff interviews and record review, the facility failed to develop a care plan that addressed discharge goals and plans for 5 of 7 residents (Residents #39, #53, #21, #12 and #7) reviewed for discharge planning. Findings included: 1. Resident #39 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #39 was cognitively intact. The assessment further indicated an active discharge plan was not in place for the resident to return to the community. The comprehensive care plan, updated 3/7/22, did not include information that addressed discharge planning. In an interview with Resident #39 on 4/25/22 at 11:34 AM, he stated he had told staff in the past that he wanted to go home. On 4/27/22 at 10:07 AM an interview was completed with the Social Worker (SW). She typically completed the cognitive, mood, behavior, and return to community sections of the MDS assessment and created care plans for the sections in conjunction with the MDS Coordinator. The SW explained if discharge planning/return to community triggered on the MDS assessment, she completed a discharge care plan since the resident indicated a desire to return to the community. If the resident had not expressed a desire to return home or to the community then she had not completed a care plan that specifically addressed discharge plans and goals. She added Resident #39 had expressed a desire to discharge home with his family member. The MDS Coordinator was interviewed on 4/27/22 at 10:29 AM. She explained if a resident was at the facility for long term care, she had not developed a care plan that addressed discharge plans. If a resident came to the facility for short term rehabilitation and expressed a goal of return home, then she added a discharge care plan. She said the SW typically communicated the resident's discharge plan and then she added the information to the comprehensive care plan. The MDS Coordinator shared she and the SW addressed discharge goals in their care plan notes but had not consistently added the information into the comprehensive care plan. She added Resident #39 was at the facility for long term care. During an interview with the Director of Nursing (DON) on 4/27/21 at 11:05 AM she stated facility staff discussed a resident's discharge plans and goals upon admission. She was not aware that discharge planning information needed to be included in the comprehensive care plan. 2. Resident #53 was admitted to the facility on [DATE] with the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The admission assessment dated [DATE] indicated Resident #53 was cognitively intact. The care plan dated 11/4/21 did not include discharge planning for Resident #53. The Physician's Note dated 12/15/22 indicated Resident #53's condition was stable for discharge to the assisted living building. Review of the Director of Nursing's Note dated 2/16/22 documented Resident #53 was initially admitted to the facility for short term rehabilitation with the goal of returning to her home. The note further revealed that after discussion with the physician and the Director of Nursing on 2/15/22 concerning the resident's improvements, the resident agreed to transfer to the assisted living building. The Interdisciplinary Discharge Summary dated 2/16/22 revealed Resident #53 had progressed back to her baseline and was discharged due to a change in level of care. The discharge Minimum Data Set, dated dated dated [DATE] indicated Resident #53's discharge to the community was planned. During an interview on 4/28/22 at 3:50 p.m., the Minimum Data Set Coordinator acknowledged discharge planning was not included in Resident #53's Care Plan. She stated that the error was an oversight. 3. Resident #21 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The admission MDS assessment dated [DATE] revealed Resident #21 had severely impaired cognition. The assessment further indicated the resident's discharge goal was unknown or uncertain. The comprehensive care plan, updated 3/8/22, did not include information that addressed discharge planning. On 4/27/22 at 10:07 AM an interview was completed with the SW. She typically completed the cognitive, mood, behavior, and return to community sections of the MDS assessment and created care plans for the sections in conjunction with the MDS Coordinator. The SW explained if discharge planning/return to community triggered on the MDS assessment, she completed a discharge care plan since the resident indicated a desire to return to the community. If the resident had not expressed a desire to return home or to the community then she had not completed a care plan that specifically addressed discharge plans and goals. The MDS Coordinator was interviewed on 4/27/22 at 10:29 AM. She explained if a resident was at the facility for long term care, she had not developed a care plan that addressed discharge plans. If a resident came to the facility for short term rehabilitation and expressed a goal of return home, then she added a discharge care plan. She said the SW typically communicated the resident's discharge plan and then she added the information to the comprehensive care plan. The MDS Coordinator shared she and the SW addressed discharge goals in their care plan notes but had not consistently added the information into the comprehensive care plan. She added Resident #21's family had not given a clear indication if the resident's stay was short term or if she would be at the facility for long term care. During an interview with the DON on 4/27/21 at 11:05 AM she stated facility staff discussed a resident's discharge plans and goals upon admission. She was not aware that discharge planning information needed to be included in the comprehensive care plan. 4. Resident #12 was admitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] The quarterly MDS assessment dated [DATE] revealed Resident #12 had impaired short term and long term memory and severely impaired daily decision making skills. The comprehensive care plan, updated 3/7/22, did not include information that addressed discharge planning. On 4/27/22 at 10:07 AM an interview was completed with the SW. She typically completed the cognitive, mood, behavior, and return to community sections of the MDS assessment and created care plans for the sections in conjunction with the MDS Coordinator. The SW explained if discharge planning/return to community triggered on the MDS assessment, she completed a discharge care plan since the resident indicated a desire to return to the community. If the resident had not expressed a desire to return home or to the community then she had not completed a care plan that specifically addressed discharge plans and goals. The MDS Coordinator was interviewed on 4/27/22 at 10:29 AM. She explained if a resident was at the facility for long term care, she had not developed a care plan that addressed discharge plans. If a resident came to the facility for short term rehabilitation and expressed a goal of return home, then she added a discharge care plan. She said the SW typically communicated the resident's discharge plan and then she added the information to the comprehensive care plan. The MDS Coordinator shared she and the SW addressed discharge goals in their care plan notes but had not consistently added the information into the comprehensive care plan. She added Resident #12 was at the facility for long term care. During an interview with the DON on 4/27/21 at 11:05 AM she stated facility staff discussed a resident's discharge plans and goals upon admission. She was not aware that discharge planning information needed to be included in the comprehensive care plan. 5. Resident #7 was admitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] The quarterly MDS assessment dated [DATE] revealed Resident #7 was cognitively intact. The comprehensive care plan, updated 2/7/22, did not include information that addressed discharge planning. On 4/27/22 at 10:07 AM an interview was completed with the SW. She typically completed the cognitive, mood, behavior, and return to community sections of the MDS assessment and created care plans for the sections in conjunction with the MDS Coordinator. The SW explained if discharge planning/return to community triggered on the MDS assessment, she completed a discharge care plan since the resident indicated a desire to return to the community. If the resident had not expressed a desire to return home or to the community then she had not completed a care plan that specifically addressed discharge plans and goals. The MDS Coordinator was interviewed on 4/27/22 at 10:29 AM. She explained if a resident was at the facility for long term care, she had not developed a care plan that addressed discharge plans. If a resident came to the facility for short term rehabilitation and expressed a goal of return home, then she added a discharge care plan. She said the SW typically communicated the resident's discharge plan and then she added the information to the comprehensive care plan. The MDS Coordinator shared she and the SW addressed discharge goals in their care plan notes but had not consistently added the information into the comprehensive care plan. She added Resident #7 was at the facility for long term care. During an interview with the DON on 4/27/21 at 11:05 AM she stated facility staff discussed a resident's discharge plans and goals upon admission. She was not aware that discharge planning information needed to be included in the comprehensive care plan.

Based on record review, staff, and family interviews the facility failed to provide written notice of a room change for 1 of 1 resident reviewed for room change (Resident #1). The findings included: Resident #1 was admitted to the facility on [DATE] and was discharged to a local hospital on [DATE]. The resident ' s [DIAGNOSES REDACTED]. Review of Resident #1's most recent Minimum Data Set (MDS) revealed a quarterly assessment with an Assessment Reference Date (ARD) of 3/31/20. Review of the assessment revealed the resident was coded as moderately cognitively impaired. An interview and record review were conducted with the facility Social Worker (SW) on 7/6/20 at 11:38 AM. She stated she was the person responsible for notifying family members and residents about room changes or roommate changes. She stated Resident #1 received a new roommate on 4/8/20. The SW stated she had not remembered notifying the family of Resident #1 about him receiving a new roommate on 4/8/20. The SW reviewed the progress notes for Resident #1 and said she had not documented information regarding Resident #1 receiving a new roommate and she had not documented information regarding having notified the resident ' s family about Resident #1 receiving a new roommate. The SW explained she was unable to provide a reason as to how come she had not notified the family of Resident #1 about him receiving a roommate. The SW further explained she should have notified the resident ' s family and she should have documented the notification in the progress notes. An interviewed was conducted with Resident #1's family member on 7/6/20 at 3:50 PM who stated she had not been notified verbally or through written notification regarding her father receiving a new roommate on 4/8/20. During a second interview with Resident #1's family member on 7/16/20 at 3:50 PM she stated she had not become aware of her father having a new roommate until 4/11/20 when she was notified via a phone call. During an interview with the Administrator on 7/16/20 at 3:01 PM she stated it was her expectation for the resident and/or the resident ' s family member to be made aware of a new roommate coming to a resident ' s room. The Administrator further stated the facility had been conducting several room changes and unfortunately, in this circumstance the proper notification was not completed.

Based on record reviews and staff interviews the facility failed to complete and transmit a discharge tracking MDS assessment form (Resident # 1) and an entry tracking MDS assessment form (Resident # 2) for 2 residents reviewed for MDS tracking assessments (Resident # 1 and Resident # 2). Findings included: 1.Resident # 1 was admitted to the facility on [DATE] and discharged on [DATE]. A review of Resident # 1's transmitted MDS assessments revealed an Entry Tracking assessment dated [DATE] and an admission comprehensive MDS assessment dated [DATE]. The review revealed that a discharge assessment was initiated by the facility dated 04/04/2019, but the assessment had not been transmitted. A review of the face sheet of Resident # 1 revealed that Resident # 1 was discharged return not anticipated on 04/04/2019. Resident # 1's nurse note revealed that Resident # 1 discharged to the community on 04/04/2019. An interview with the MDS nurse conducted on 10/03/2019 at 2:30 PM revealed that a discharge return not anticipated MDS tracking assessment was initiated for Resident # 1 on 04/04/2019 but it was not completed or transmitted to the MDS National Data base. The MDS nurse revealed that this was an over site on her part. A review was completed of the facility's MDS submission report and revealed the MDS dated [DATE] for Resident # 1 was transmitted and accepted on 10/03/2019. The submission report message for the assessment read Assessment completed late: Z0500B (assessment completion date) is more than 14 days after A2300 (Assessment Reference Date (ARD)). The facility administrator was interviewed on 10/03/2019 at 3:48 PM revealed that it was the expectation that all required MDS assessments including discharge tracking assessments be completed and transmitted timely as required by the RAI (Resident Assessment Instrument). 2.Resident # 2 was admitted to the facility on [DATE] and resided in the facility. A review of the transmitted MDS assessments for Resident # 2 included that a comprehensive MDS assessment dated [DATE] was completed and transmitted to the National Data base and quarterly MDS assessments dated 04/04/2019 and 07/02/2019 were also completed and transmitted to the National Data base. There was no record that an entry MDS tracking assessment had been completed or transmitted for Resident #2 dated 02/14/2019. On 10/03/2019 at 2:30 PM an interview was conducted with the MDS nurse. The MDS nurse revealed that the facility failed to complete and transmit an entry MDS tracking form for Resident # 2 dated 02/14/2019 and that this was an over site on her part. A review of the facility's MDS submission report was completed and revealed the MDS dated [DATE] for Resident # 2 was transmitted and accepted into the National Data base on 10/03/2019. The submission report message for the report read Record Submitted Late: The submission is more than 14 days after A1600 on this new (A0050 equals 1) entry tracking record (A0310F equals 01). The facility administrator was interviewed on 10/03/2019 at 3:48 PM revealed that it was the expectation that all required MDS assessments including discharge tracking assessments be completed and transmitted timely as required by the RAI (Resident Assessment Instrument).

Based on record review, observations, resident and staff interviews, the facility failed to correctly code a Minimum Data Set (MDS) assessment for 2 of 23 residents reviewed for MDS accuracy (Resident #53 & #58). Findings included: 1. Resident #53 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. a. The admission MDS dated [DATE] assessed Resident #53 to have a [MEDICAL CONDITION] and that she was always continent of bowels. Resident #53 was interviewed on 9/30/2019 at 11:26 AM and she reported she had a [MEDICAL CONDITION] and she was able to empty the collection bag without assistance from staff. Nursing assistant (NA) #1 was observed documenting on 10/3/2019 at 9:57 AM for Resident #53 and she documented that Resident #53 had a bowel movement and she was continent of her bowels. NA #1 reported she was not aware Resident #53 had a [MEDICAL CONDITION]. An interview was conducted with the MDS nurse on 10/3/2019 at 3:21 PM and she reported because the MDS was coded for Resident #53 to have a [MEDICAL CONDITION], the MDS bowel continence question should have been answered as not rated, resident had an ostomy on the admission MDS assessment. An interview was conducted with the Administrator on 10/3/2019 at 3:42 PM and she reported it was her expectation that the MDS assessment accurately reflected the status of a resident during the assessment period. b. The Quarterly MDS dated [DATE] did not document the presence of a [MEDICAL CONDITION] for Resident #53 and documented that Resident #53 was occasionally incontinent of bowels. The physician orders [REDACTED]. Resident #53 was interviewed on 9/30/2019 at 11:26 AM and she reported she had some skin irritation around her [MEDICAL CONDITION] site and she was seen by the wound clinic for healing of the irritation. Resident #53 went on to explain she was able to provide care to her [MEDICAL CONDITION] without staff assistance. She concluded by reporting the wound clinic changed the [MEDICAL CONDITION] wafer once per week and staff nurses changed it once per week for her. Nursing assistant (NA) #1 was observed documenting on 10/3/2019 at 9:57 AM for Resident #53 and she documented that Resident #53 had a bowel movement and she was continent of her bowels. NA #1 reported she was not aware Resident #53 had a [MEDICAL CONDITION]. An interview was conducted with the MDS nurse on 10/3/2019 at 3:21 PM and she reported she reviewed the NA flowsheet charting before coding the MDS and because the NAs had documented that Resident #53 was occasionally incontinent of bowels, she coded her as occasionally incontinent. The MDS nurse reported she was not aware that Resident #53 had a [MEDICAL CONDITION] and she overlooked her [MEDICAL CONDITION] status when coding the MDS. An interview was conducted with the Administrator on 10/3/2019 at 3:42 PM and she reported it was her expectation that the MDS assessment accurately reflected the status of a resident during the assessment period. 2. Resident # 58 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of a form titled Nurse Admit assessment dated [DATE] included that Resident # 58 had impaired vision and had eye glasses that he did not wear. Resident # 58 was recorded to have few natural teeth and/ or broken natural teeth. Resident # 58 had 3 natural teeth. A review of a comprehensive admission MDS (Minimum Data Set) dated 08/09/2019 revealed that Resident # 58 had moderate cognitive impairment with adequate vision without corrective lenses. Resident # 58 was coded with no dental concerns. On 09/30/2019 at 11:12 AM an interview and observation conducted of Resident # 58 and Resident # 58 revealed that he did not see very well and that he needed to have an eye doctor appointment because he might need eye glasses. Resident # 58 was observed with missing many natural teeth. Resident # 58 revealed that he had not had a dental appointment in many years and that he did want to be seen by the dentist because he had few of his own teeth and he might need dentures or a good oral cleaning. Nurse # 1 was interviewed on 10/02/2019 at 10:57 AM. Nurse # 1 revealed that she was not aware that Resident # 58 had any vision or dental concerns as he had never voiced those concerns to her. Nurse # 1 revealed that she would follow up with the physician and social worker to address concerns of Resident # 58. The facility social worker (SW) was interviewed on 10/02/2019 at 11:46 AM. The SW revealed that she had not been aware that Resident # 58 requested to be seen by the eye doctor or dentist and she (SW) would speak to Resident # 58 and arrange for his appointments as soon as possible. On 10/03/2019 at 3:02 PM an interview was conducted with the MDS nurse. The MDS nurse revealed that the Nurse Admit Assessment data form information dated 08/02/2019 was outside of her review look back period for the admission MDS dated [DATE]. The MDS nurse also stated she used only medical record information when she coded the MDS and that she did not recall that she had performed an interview or observation with Resident # 58 when she completed the MDS dated [DATE]. The facility administrator was interviewed on 10/03/2019 at 3:43 PM. The administrator revealed that it was expected that all MDSs be coded accurately to reflect the resident status during the review period and that MDS accuracy included resident observations and interviews along with medical record documentation reviewed during the MDS review period.

Based on observations, staff interviews, and record review the facility failed to provide an odor free environment for one of three halls, the 200 Hall, and failed to provide clean curtains in 1 of 4 rooms reviewed for environment, room [ROOM NUMBER]. Findings included: An observation of room [ROOM NUMBER] was conducted on 8/15/18 at 4:23 PM at room [ROOM NUMBER]. Prior to entering room [ROOM NUMBER] there was a detectable urine/ammonia odor while standing at the doorway. Upon entering room [ROOM NUMBER] the urine/ammonia odor was more pungent and increased in intensity near the bed closest to the door. An observation of the privacy curtain for both the bed closest to the door and next to the window revealed multiple brown spots on each curtain when they were unfurled. There was no resident observed in the bed closest to the door and resident whose bed was next to the window was in the room. The floor near the bed by the door had a sticky residue around the bed. An observation of room [ROOM NUMBER] was conducted on 8/16/18 at 2:48 PM at room [ROOM NUMBER]. Prior to entering room [ROOM NUMBER] there was a detectable urine/ammonia odor while standing at the doorway. Upon entering room [ROOM NUMBER] the urine/ammonia odor was more pungent and increased in intensity near the bed closest to the door. An observation of the privacy curtain for both the bed closest to the door and next to the window revealed multiple brown spots on each curtain when they were unfurled. Neither the resident at the door nor the resident at the window were present during the time of the observation. An observation of room [ROOM NUMBER] and interview was conducted on 8/16/18 at 2:50 PM with the Nursing Assistant (NA) #1 who had been assigned to room [ROOM NUMBER]. The NA stated there was a strong odor of urine in the room at the time of the observation. The NA stated there usually was an odor of urine in the room, but it was not usually as strong as it was during the time of the observation. The NA stated both residents in the room were incontinent of urine. The NA stated she had provided incontinence care for the resident who was near the door about 15 minutes prior to the observation. The NA stated the resident in the bed near the door would remove her soiled brief and place it in a bag an leave it on the floor and the staff would pick it up later. The NA stated the odor of urine was more intense near the bed closest to the door. The NA stated there were spots on the curtains but was not aware of the spots or where the spots had come from. An observation of room [ROOM NUMBER] and interview was conducted on 8/16/18 at 3:57 PM with the Maintenance Director (MD). The MD stated in addition to supervising maintenance he also oversaw the Housekeeping Department. The MD stated there was a urine odor in room [ROOM NUMBER]. The MD stated he had air fresheners which could be placed in the Packaged Terminal Air Conditioner (PTAC) units. The MD stated there had not been an air freshener placed in the PTAC in room [ROOM NUMBER]. The MD observed the spots on the curtains in room [ROOM NUMBER] and stated the curtains needed to be changed. The MD stated the curtains were taken down and replaced with fresh curtains when the rooms were deep cleaned. The MD stated the curtains which were removed would be laundered. In addition, during the MD stated during deep cleaning the mattresses would be cleaned, the bed frames would have been wiped down, and the rest of the room thoroughly cleaned during a deep clean. The MD stated each resident room was deep cleaned quarterly. A request was made to the MD to provide the deep cleaning schedule and a list of the rooms which had been cleaned during the previous quarter. An interview and record review were conducted with the MD on 8/16/18 at 4:26 PM. The MD stated he was unable to provide a deep cleaning schedule for the resident rooms of the facility which had been completed or were schedule to be completed. The MD provided a checklist which has been most recently completed on 5/28/18 for the 200 Hall. The checklist had each resident room and other rooms on each hall. The tasks listed on the checklist included dust, sweep, mop, trash, toilet paper, paper towels, hand soap, blinds, bed, bedside table, overbed table, deep cleaning. All tasks were marked indicating completion for the 200 hall resident rooms except for blinds, bed, and deep cleaning. Further review of the checklists provided revealed room [ROOM NUMBER] had not checked indicating deep cleaning had been completed back to and including 2/21/18. A Housekeeping Checklist (Nursing) was provided for the 100, 200, and 300 Halls. The Checklist was conducted by the Administrator on 5/16/18 for the 200 Hall. room [ROOM NUMBER] was documented as having been unsatisfactory for Doors and Frames, Overbed Table, Ceiling/Walls (Bathroom), Heat Air Conditioner Unit, and Fan in Bathroom. On the reverse side of the Checklist the Administrator had made the following comments regarding room [ROOM NUMBER]; drawer missing, dust in vent, bathroom ceiling tile stained, dust in light bulbs, and paint door casing. The checklist included no Inspection Element regarding odors detected in the rooms inspected. The MD stated another Housekeeping checklist had been scheduled to have been completed the week of 8/13/18 but the arrival of the survey team did not allow it to be completed. An interview was conducted with the Administrator on 8/16/18 at 4:48 PM. The Administrator stated the housekeeping department cleaned the resident rooms thoroughly. The Administrator stated if there was a urine odor in a resident room there were chemicals the housekeeping department could use to address the odor promptly. The Administrator stated the MD went into detail with the Hall Checklists and she went into detail with Housekeeping Checklist, but they had not completed either since May. The Administrator stated there was not a deep cleaning schedule and as room odors are identified they will deep clean a room, there was no deep cleaning schedule. The Administrator stated it was her expectation for rooms to not smell of urine.

Based on record review and staff interviews, the facility failed to ensure the comprehensive minimum data set (MDS) assessment was complete before submitting the assessment for 1 of 3 residents reviewed (Resident # 54). Resident # 54 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The comprehensive MDS dated [DATE] indicated Resident #54 was severely cognitively impaired. Section F of the assessment contained questions about Resident #54's Preferences for Customary Routine and Activities. None of the questions were answered. During an interview on 8/15/2018 at 3:59 PM, the MDS Coordinator revealed she did not sign the comprehensive MDS in question despite acknowledgment of her signature dated 3/21/2018. The MDS Coordinator further revealed that she is a licensed practical nurse and only a registered nurse could sign the assessment for completion. The MDS Coordinator indicated her signature indicated the assessment was complete. During an interview on 8/16/3018 at 4:50 PM, the Administrator revealed she expected section F of the assessment to be completed and the registered nurse assessment coordinator to submit complete MDS assessments.

Based on observations, staff interviews, and record review the facility failed to assess for the need and remove unnecessary side rails from a bed for 1 of 2 residents reviewed for accidents (Resident #18). Findings included: Resident #18 was admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. Review of Resident #18's most recent Minimum Data Set (MDS) Assessment revealed an admission comprehensive assessment with an Assessment Reference Date (ARD) of 5/30/18. Review of the assessment revealed the resident was coded as having had severe cognitive loss. The resident was coded as having had required extensive or total assistance from one person or more for all Activities of Daily Living (ADLs) including: bed mobility, transfer (such as from the bed to a wheelchair), moving about the facility once in a wheelchair, dressing, eating, toilet use, personal hygiene, and bathing. The use of a bed rail was not coded as a restraint. Review of Resident #18's Device Decision Guide dated 5/23/18 revealed the resident was to have a right side one quarter rail for mobility. A review was completed of Resident #18's care plan, which was most recently updated on 6/8/18. Problem/Need areas on the resident's care plan included: The resident was mainly non-verbal, and she would stare blankly at times and not answer questions, she does not make her needs known. The resident had poor safety awareness related to dementia. The resident required staff assistance with ADLs. She was extensive to total care. She did not feed herself or propel her wheelchair. She was incontinent of bowel and bladder and required incontinence care. She transferred with a stand pivot and 1 assist. She is mainly non-verbal. An approach listed was the resident was to have a one quarter bedrail to the right side to aid in positioning and bed mobility. Discontinued the right bedrail: dated 8/14/18. The resident had a pressure ulcer to her sacrum and one of the approaches listed was to reposition the resident on routine rounds and as needed. There was an update to the Device Decision Guide dated 8/10/18 for Resident #18 which stated one quarter siderail to right side continued to assist in mobility and positioning. An observation of Resident #18 was conducted on 8/13/18 at 11:58 AM. The resident was resting in bed and the resident's family member was at the bedside. The resident was observed to be nonresponsive to questions. The resident's family member stated the resident could not wear clothes on and had to wear robes, and it was easier and better for her to stay in bed. The resident's family member displayed the resident's minimal flexion and contracture in both her right and left arms. The resident's family member stated the resident needed to be turned from right to left side in bed and have a wedge or pillow placed under the resident to keep weight off of the resident's bottom. The resident's bed was observed to have a quarter bedrail at the head of the bed on the resident's right side. A review was completed Resident #18's Departmental Notes of a Nursing Services note dated 8/14/18 and timed 7:04 AM. The note documented the resident was reported by a family member to have had a red area to the right cheek and also a raised area in the middle of her forehead. The Nursing Assistant who had the resident during the 11:00 PM to 7:00 AM shift stated the resident had been lying on her right side and the resident's cheek was a little red. The nurse who had checked the resident's blood sugar prior to the husband's arrival on 8/14/18 stated the resident had not had any raised area to her forehead when she had checked the resident's blood sugar. The note was signed by Nurse #2. A review of a Resident Incident Report for Resident #18 dated 8/14/18 and timed 7:04 AM was completed. The report was completed by the Director of Nursing (DON). The type of injury was listed as an abrasion. The location was listed as the resident's room. The narrative documented the injuries were reported by the resident's family. The resident had a red area to the right cheek and also a raised area in the middle of the forehead. The Nursing Assistant (NA) indicated she had seen the resident had been lying on that side earlier. The physician was notified. The immediate post-incident action was documented as: The resident continued to be repositioned during care rounds and as needed. The Interdepartmental Disciplinary Team (IDT) reviewed the incident. The IDT consisted of the Administrator, the DON, Physical Therapy (PT), Social Work, the Activities Director, the Dietary Manager, and the Unit Manager. The IDT determined the bedrail was removed and the bed control was changed to a hand-held bed control. An observation of Resident #18 was conducted in conjunction with a family interview on 8/14/18 at approximately 5:00 PM. The resident's family member stated when he had come into the facility that morning before 7:00 AM he had observed the resident's face was reddened on the right cheek and the resident had a raised area to the forehead. An observation of the resident revealed the resident's right cheek was reddened and the there was a raised area to the resident's forehead. The raised area was observed to be slightly larger than a grape and had some blueish color to the raised area and around the raised area. Due to the resident's cognitive loss the resident was unable to provide information as to how the injury had occurred. The resident's family stated the resident had had a bedrail at the head of the bed on the right side and it had been removed. The resident's family stated the facility staff had informed him that it had been believed the resident's face had been against the bedrail and the bedrail had caused the injury. A review was completed of the Resident #18's Departmental Notes of a Nursing Services note dated 8/15/18 and timed 5:12 AM. The note documented the resident's right cheek continued to be red but the reddened area was smaller in size than when the 11:00 PM to 7:00 PM shift had began. The note further documented there was no bruising noted to the right side of the face. The note was signed by Nurse #3. A review was completed of Resident #18's Departmental Notes of a Nursing Services note dated 8/16/18 and timed 6:17 AM. The note documented the resident's right cheek remained red and had a small blister like area. The note further documented the resident denied pain or discomfort and had no acute distress noted. The note was signed by Nurse #3. An observation of Resident #18 was conducted at approximately 3:35 PM. The resident was observed to be in her bed. The resident's bed was observed to not have had any bedrails. The raised bruise to the forehead was observed to have no longer been raised but a blue discoloration of the skin remained. The resident's right cheek remained reddened with some of the skin appearing to have been peeling off in a chapped type of manner. An interview was conducted with the Unit Manager (UM) Nurse on 8/16/18 at 3:41 PM. The UM stated the issue of the Resident #18's reddened area on the right cheek and the bruise to the resident's forehead had been investigated. The UM stated the bruise to the resident's forehead and red mark to her face had been determined to have been caused by the bedrail which had been on the resident's bed and the bedrail had been removed. The UM stated the red mark and the bruise were not observed on the resident's face at 6:16 AM when the RN was doing a fingerstick for a blood sugar while the resident was resting in bed. The resident's NA was rounding after 6:16 AM and the NA observed the resident to be resting in bed lying on her right side and her face was on her right cheek. The NA also observed the resident's face and cheek were close to the bedrail. The resident's husband came to the facility at about 6:40 AM and observed the redness to the resident's right cheek and the bruise to her forehead. An interview was conducted with the DON on 8/16/18 at 4:06 PM. The DON stated when she had arrived to the facility on [DATE] in the morning she had went to Resident #18's room to assess her. The DON stated the resident had a bedrail on her bed on the right side at the head of the bed. The DON stated the resident had been a resident at the facility prior to her admitted in (MONTH) and when the resident was readmitted , the resident's family had asked for everything the resident had had prior to her discharge with readmission not anticipated which had occurred on 5/21/18. One of the items the resident's family had requested was the bedrail on her bed. The DON stated she had interviewed the NA who had the resident during night shift and she had went in to check the resident during her last round on her shift and the resident was laying on her right side with her face on the pillow and her face was close to the bedrail. The DON stated she had maintenance remove the bedrail. The bed control for the bed was part of the siderail and maintenance had installed a wired remote bed control in place of the bed control which had been part of the bedrail. The DON stated when she had assessed the resident at approximately 7:00 AM on 8/14/18 the resident's right cheek appeared slightly blistered and the resident had a bruised area to her forehead. The DON stated as a result of an investigation it was determined the resident's right cheek had been on the pillow and the injury to her forehead was from the bed control which was part of the siderail. The DON stated she had a bedrail assessment completed at the time of her readmission and the resident had been able to hold onto the right bedrail which aided in repositioning and care. The DON stated the resident's condition had declined since the bedrail assessment had been completed at the time of her admission. The DON stated the bedrail assessments were completed quarterly. The DON stated if it was determined a change needed to be made to a resident's bedrails from a bedrail assessment, the bedrail(s) would be changed to what was recommended on the assessment on the day of the assessment. An interview was conducted with the Administrator on 8/16/18 at 4:57 PM. The Administrator stated she was made aware of the Resident #18's injury when she had arrived to the facility on [DATE] at 7:40 AM. The Administrator stated it had been determined through the investigation the resident had been lying on the right side of the bed, on her right side, and the resident's forehead was resting on the center of the bedrail where the controls were for the bed. The Administrator stated the bedrail was removed on 8/14/18. The Administrator stated the resident's husband had initially discovered the injury and the resident had been found to be on her right side in the bed with her head against the bedrail. The Administrator also stated the resident's NA from the night shift had also observed the resident to have been lying on her right side and had a positioning wedge under her to position the resident on her right side and her head was against the bedrail. The Administrator stated the resident had only used the bedrail for positioning when she had first arrived to the facility. The Administrator stated bedrail assessments were completed quarterly. She stated there was an assessment completed by nursing for the resident's use of the bedrail and there was an assessment completed quarterly by maintenance for the function and safety of the bedrail. She stated when the resident had first arrived to the facility the resident had been able to use the bedrail and the bedrail remained on the resident's bed due to the bed controls having been located in the bedrail. The Administrator stated the bedrail had been removed and now the resident had a hand held bed control.

Based on record review and staff interviews, the facility failed to provide the Notice of Medicare Non Coverage (NOMNC) Form Centers of Medicare (CMS) prior to discharge from Medicare Part A Services for 2 of 3 residents reviewed (Residents #26 and #61). Findings included: Resident #26 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of records revealed Resident #26 Medicare Part A Services began on 2/25/2018 and terminated on 4/15/2018. Resident #26 was discharged from Medicare Part A Services with benefit days remaining. The NOMNC Form CMS was not provided to Resident # 26 by the facility. Resident # 61 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of records revealed Resident #61 Medicare Part A Services began on 5/25/2018 and terminated on 6/13/2018. Resident #61 was discharged home from Medicare Part A Services with benefit days remaining. The NOMNC Form CMS was not provided to Resident # 61 by the facility. During an interview on 8/16/2018 at 3:39 PM the Business Office Manager (BOM) revealed she was not aware of specifications on when to provide Form CMS . The BOM further revealed if she provided the Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) Form CMS then the NOMNC Form CMS was not necessary for residents discharged from Medicare Part A Services. During an interview on 8/16/2018 at 3:51 PM the Administrator revealed that she expected all residents with benefit days remaining to receive Forms CMS and when discharged from Medicare Part A Services.

Based on observations, interview with facility staff, physician and Administrator and records review the facility failed to prevent an avoidable fall from mechanical lift resulting in injury for 1 of 6 residents reviewed for accidents and falls (Resident # 47). On [DATE] Resident # 47 who was severely cognitive impaired had a fall with injuries while being weighed by mechanical lift, with only one person assist. The resident's care plan and facility policy indicated two (2) person assist for transfer when using a lift. Resident # 47 had a laceration to her head, C1 Jefferson fracture and Type 2 odontoid fracture due to the fall. Resident # 47 expired on [DATE]. Immediate Jeopardy began on [DATE] at 2:30 AM when the sling's four straps were not all unhooked before the sling was removed from the resident. This caused the resident to be pulled into the floor. The immediate jeopardy was removed on [DATE] at 12:30 PM when the facility's acceptable credible allegation of compliance was verified. 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 allow the facility time for therapy or licensed nurse to assess all residents for determination of the safest mechanical lift device using the lift assessment evaluation, Lift assessment evaluation to be completed by the rehab director, resident's care plan and care guide. Findings included: Resident was admitted to the facility on [DATE] and on readmitted on [DATE], with documented [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed admitted [DATE]. Resident was coded as minimum hearing, unclear speech and rarely /never make self-understood. Resident was severely cognitively impaired. Resident was coded as total dependent and needing two person assist with bed mobility, transfer and bathing, one person assist with dressing, eating, toileting and personal hygiene. Resident was having functional limitation impairment for both sides of lower extremity. MDS indicated resident was not on any pain medication. Resident was coded as being on mechanical altered, therapeutic diet. Review of the care plan dated [DATE] revealed problem area with onset date [DATE]- Requires total assist with Activities of Daily living (ADL). Resident has [DIAGNOSES REDACTED]. The goal stated that -will minimize potential for significant decline in ADL status. The interventions stated resident was a two (2) assist transfer with the total lift. Geri sleeves to bilateral arms as orders and resident to wear orthotic and hip abduction braces as ordered with routine skin checks. On Observation and reviewing the manual of the mechanical lift, the lift has the capability to record weights. Review of nursing notes dated [DATE] read in part: resident was been weighted by Nurse Aide (NA). When putting resident on bed, NA undid three (3) loops not all four (4) from lift. Resident was pulled to the floor and bumped her head to the roommate's bed rail when the lift was moved. Resident was sent to emergency room (ER) for treatment and evaluation. Nurse Practitioner (NP) and responsible party was notified. Review of the incident report dated [DATE] read in part - NA #9 was weighing resident when putting the resident on bed undid (3) loops not all four (4) from lift. When NA moved the lift, resident was pulled to floor and bumped head on roommate's bed rail. Resident has laceration to top of head due to amount of blood could not assess wound properly. Pressure applied to the wound on the head. Review of Emergency Medical Services (EMS) report [DATE] at 2:28 PM read in part: Patient on floor lying supine. Nurse reported resident was being transferred from wheelchair to bed, fell and hit head. Neck pain to palpation due to fall from bed 3 feet (ft). Neck pain on palpation and tender spine and paraspine. Immobilized to hospital. Review of ER report dated [DATE] at 3: 05 PM read in part: Patient in ER, lift broke and patient fell , sustained a laceration on top of scalp. Diagnosis: [REDACTED]. Hospital admission note dated [DATE] at 10:18 PM read in part - Resident was admitted to Medical Center. Hospital admission note indicate that resident was transferred from Hospital via EMS with a first cervical vertebra (C1) Fracture. Patient was sent to hospital from her nursing home after sustaining a fall from a mechanical lift. Unknown if there was loss of consciousness (LOC). She fell from a height of 3 to 5 ft and point of impact was the head and neck. Patient makes only incomprehensible sounds and was unable to follow command. Per EMS was her normal mental status. She has a laceration to the top of her head. Point of impact head and neck. Review of ED Provider note dated [DATE] at 10:46 PM read in part- accident occurred 6- 12 hours ago. Fall occurred at Skilled Nursing Facility (SNF) from Mechanical lift. She fell from a height of 3 to 5 ft. and point of impact head and neck. Clinical impression - Closed displaced fracture of first cervical vertebra, unspecified fracture morphology. Review of Orthopedic Note dated [DATE] at 10:48 PM read in part: patient was seen at an outside hospital where she was found to have first cervical vertebra fracture and second cervical vertebra fracture. Assessment and Recommendation indicated C1 Jefferson fracture and C2 type 2 odontoid fracture. Maintain Miami J (MJ) cervical collar at all times; head of bed (HOB) as tolerated; this injury does not have risk of neurological compromise, however risk associated with surgical interventions have high morbidity. Recommend no acute orthopedic surgical intervention. Review of Employee Counseling / Discipline Statement dated [DATE] revealed NA #9 failed to utilize two staff for use of Mechanical lift for weighing a resident. Corrective actions were 1) in-service on Mechanical lift. 2) Return demonstration of use of Mechanical lift. Review of the Medical Discharge Summary dated [DATE] read in part- Resident blood pressure (BP) remained elevated despite home regime. Hemodynamically stable at discharge and at baseline mental status. Recommended maintain MJ collar at all times. Review of nursing note dated [DATE] read in part: Resident arrived to facility via facility transport at 7:17 PM, MJ collar in place on the neck. Resident stable, alert, nonverbal. Vital signs taken. Resident skin dry and intact with some bruising noted to back of both hands and right lower arm at IV site, respiration even and unlabored . Incontinent of Bowel and Bladder, no acute distress noted, will continue to monitor. During an interview with Nurse #2 on [DATE] at 7:05 AM, nurse indicated NA #9 was assigned residents weights the day of the incident. Nurse stated NA #9 came running to her and informed her about Resident #47 fall, unsure of time (may be before or after lunch). Nurse stated Resident #47 was examined by EMS upon arrival and transported her to the hospital in a stretcher. Nurse #2 further stated that two (2) people were required when using the mechanical lift and was unsure why NA #9 was working alone with the mechanical lift while weighing the residents. During an interview with the NA #9 on [DATE] at 11:38 AM, NA indicated she was usually assigned weights for the residents. She indicated on the day of the incident, she was using a mechanical lift to weigh Resident # 47. NA #9 stated the resident was placed on the pad and hooked, lifted up to be weighed. After the weight was taken the resident was lowered down on the bed. NA #9 stated she had unhooked three (3) of the four (4) clips and when the resident's roommate family member walked in, she was distracted. She stated she responded patient care and after he left, NA stated she thought she had removed all of the four (4) hooks from the pad and moved back. NA #9 stated at this point she felt a tug and she could not reach the resident as resident was fallen down. She stated she immediately called the nurse for assessments. NA #9 stated she was working alone with the Mechanical lift that day. She indicated facility had other NA, but she just did not ask for assistance. She also stated she usually works alone with weights and Mechanical lift as she was assigned to that duty for a long time. NA #9 indicated that she only asks for help if the resident was combative or a heavy weight person. During an interview with the administrator on [DATE] at 10:41 AM, Administrator indicated the staff should follow the care plan and by not using two (2) person for Mechanical lift it was a neglect. On [DATE] at 2:30 AM the administrator, corporate nurse consultant, corporate vice president were informed of immediate jeopardy. The Administrator provided an acceptable credible allegation of compliance on [DATE]. Allegation of Compliance: F 224 On [DATE] at 2:15 PM the resident was positioned in the Hoyer lift over her bed at approximately 6 inches above the mattress for the purpose of obtaining her weight. After getting the residents weight the c.n.a. returned the resident to the mattress and started unhooking the 4 hooks that held the pad onto the lift. After unhooking 3 of the 4 hooks a visitor entered the room and the c.n.a. stated out resident care and the visitor left the room. The c.n.a. turned back to the resident she was weighing and at this point started to pull the mechanical back from the bed. The c.n.a. had forgotten that she had not undone the fourth hook and the resident had started to roll and fell from the bed. The c.n.a. was distracted by the visitor coming into the room causing her not to undo the fourth hook. The c.n.a. did not have a second person to assist with the mechanical lift because she stated she was not transferring the resident and this was her common practice for obtaining weight for this resident. The conclusion of the root cause, if following the policy the c.n.a. would have had a second staff while using the mechanical lift per the policy of the facility. The second staff member could have told the first c.n.a. that the fourth hook was still attached prior to moving the mechanical lift and could have prevented the fall. On [DATE] at 2:15 PM while obtaining the residents weight the employee pulled the Hoyer lift without unhooking all 4 hooks causing the resident to fall from the bed hitting her head and obtained a laceration on the top of her head. The physician and family was notified on [DATE] at 2:30 PM and the resident was sent to the emergency room for evaluation and admitted for observation and returned to the facility on [DATE] with a [DIAGNOSES REDACTED]. The resident expired on [DATE]. The involved staff was counseled on [DATE] by the Administrator for not utilizing 2 staff members when using the Hoyer lift while weighing a resident and re-inserviced on use of the Hoyer lift by the Rehab Director, with return demonstration of using a Hoyer lift on [DATE]. On [DATE] and [DATE] the CNAs were re-educated on the use of the Hoyer lift and skills observations completed by the Rehab director. Other residents identified as having the potential to be affected by the use of mechanical lifts, transfer status was reassessed by the DON and MDS coordinator on [DATE] for the need for the Hoyer lift and the care plans and care guides were updated to indicate 2 person assist and transfer for those requiring a Hoyer lift. The transfer status of all residents will be reviewed quarterly with the scheduled MDS and as needed. The Rehab Director will complete the lift assessment on admission and as needed and give to the MDS Coordinator to update the Care Plan and Care Guides. The MDS Coordinator will convey changes to the care guides at morning meeting and the changes will be placed on the 24 hour report for the following shifts each morning after daily morning clinical meeting. The following shifts will then communicate the changes to the c.n.a.'s for their individual residents. The charge nurse will monitor the c.n.a.'s to ensure that the care guides are followed. Any deviation from the care provided according to the care guides will be reported to the DON to be investigated for possible neglect. The Certified Nursing Assistant will be trained by the therapy department on the use of the lifting devices upon hire and annually to show continued competency on the lifting device. On [DATE] all other residents with the potential to be affected for use of a mechanical lift have been identified on their care plans. All staff were re-educated on the use of the mechanical lift policy on [DATE] and [DATE] by the Rehab Director. A 24 hour initial report was completed on [DATE] and sent to N.C. Division of Health and Human Services/Health Care Personnel Investigations by the administrator. The direct care staff was re-educated on [DATE] by the administrator on the importance of reviewing the care guide daily for updates and to understand the expected outcome of the residents care. Care guides for each resident are located on the inside of their closet door. On [DATE] in-services began for all staff in all departments and were re-educated on the facility's abuse/neglect policy by the Administrator and DON and the education included following the care plan and care guide for each individual resident to be completed by [DATE]. The immediate jeopardy was removed on [DATE] at 12:30 PM when interviews with nurse aides confirmed they had received in-service training on the use of mechanical lift, importance of reviewing of care guides and also re-educated on facilities abuse and neglect policy. The facility will remain out of compliance at a lesser scope and severity.

Based on observations, Physician and staff interviews, and records review the facility failed to prevent an avoidable fall from mechanical lift resulting in injury for 1 of 6 residents reviewed for accidents and falls (Resident # 47). On [DATE] Resident # 47 who was severely cognitively impaired had a fall with injuries while being weighed by mechanical lift, with only one person assist. The assigned staff after weighing Resident # 47 had unhooked only three (3) loops not all four (4) from mechanical lift resulting in a fall with injuries. Resident # 47 had a laceration to her head, fracture to the first cervical vertebra (C1 Jefferson fracture) and fracture to the second cervical vertebra (Type 2 odontoid fracture) due to the fall. Immediate Jeopardy began on [DATE] when the sling's four straps were not all unhooked before the sling was removed from the resident. This caused the resident to be pulled into the floor. The immediate jeopardy was removed on [DATE] when the facility's acceptable credible allegation of compliance was verified. 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 allow the facility time to implement a full plan of corrections. Findings included: During an observation on [DATE] at 3:17 PM and reviewing the manual of the mechanical lift, the lift has the capability to record weights. Sling diagram in the manual indicates the sling has 4 loop straps. Two (2) loop straps on the top and 2 loop straps to the bottoms with 3 adjustments. The 2 loop straps in the top together are referred as 1T - 1st loop (smallest) or 2T - 2st loop (middle) or 3T- 3rd loop (longest). Similarly the 2 loop straps in the bottom of the sling are referred to as 1B - 1st loop (smallest) or 2B - 2st loop (middle) or 3B- 3rd loop (longest). Manual also indicates to attach the loops nearest the patient shoulder, to the handle bar hooks of the lift nearest each shoulder using the same length and color of loop strap at each side. The sling leg lying over the left leg is crossed over and to the hook of the hanger bar located on the right side. The similar procedure followed for the right leg. For rigid patients the loops go straight up along the outside of the leg and hooked on the longest loop. Manual indicates to remove the sling after lowering, when the patient's weight is supported by the bed continue to lower the lift to release the tension of the loop, detach the sling from the lift and move the lift away from the patient. Resident was admitted to the facility on [DATE], with documented [DIAGNOSES REDACTED]. Review of Physician orders [REDACTED]. Review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed admitted [DATE]. Resident coded as minimum hearing, unclear speech and rarely /never make self-understood. Resident was severely cognitively impaired. Resident was coded as total dependent and needing two person assist with bed mobility, transfer and bathing, and having functional limitation impairment for both sides of lower extremity. MDS indicated resident was not on any pain medication. Review of the care plan dated [DATE] revealed identification of problem areas 1) requiring total assist with Activities of Daily living (ADL), 2) Potential for injury from fall due to poor trunk control . The goals indicated minimize potential for significant decline in ADL status and minimize potential for injury from fall. The interventions indicate resident a two assist transfer with the total lift. Geri sleeves to bilateral arms as orders and resident to wear orthotic and hip abduction braces as ordered with routine skin checks. Utilize pillows and positioning devices as indicated for assistance with resident's poor truck control. Monitor resident for safety issues/ needs and report to appropriate personnel to prevent falls. Review of Nursing Notes dated [DATE] revealed resident was been weighed by Nurse Aide #9 (NA), when putting resident on bed, NA undid only 3 loops not all 4 from lift. When the lift was moved Resident# 47 was pulled to the floor and bumped her head to her roommate's bed rail. Resident was sent to emergency room (ER) for treatment and evaluation. Nurse Practitioner and responsible party were notified. Review of the incident report dated [DATE] read in part - NA was weighing resident when putting the resident on bed undid 3 loops not all 4 from the lift. When NA moved the lift, resident was pulled to floor and bumped head on roommate's bed rail. Resident has laceration to top of head due to amount of blood could not assess wound properly. Pressure applied to the wound on the head. Physician order [REDACTED]. Review of Emergency Medical Services (EMS) report [DATE] at 2:28 PM read in part: Patient on floor lying supine. Nurse reported resident was being transferred from wheelchair to bed, fell and hit head. Neck pain on palpation due to fall from bed 3 feet (ft.). Neck pain on palpation and tender spine and paraspine. Immobilized to hospital. Review of ER report dated [DATE] at 3: 05 PM read in part: Patient in ER, lift broke and patient fell , sustained a laceration on top of scalp. Diagnosis: [REDACTED]. Hospital admission note dated [DATE] at 10:18 PM read in part - Resident was admitted to Medical Center. Hospital admission note indicate that resident was transferred from Hospital via EMS with a first cervical vertebra (C1) Fracture. Patient was sent to hospital from her nursing home after sustaining a fall from a mechanical lift. Unknown if there was loss of consciousness (LOC). She fell from a height of 3 to 5 ft. and point of impact was the head and neck. Patient makes only incomprehensible sounds and was unable to follow command. Per EMS was her normal mental status. She has a laceration to the top of her head. Point of impact head and neck. Review of ED Provider note dated [DATE] at 10:46 PM read in part- accident occurred 6- 12 hours ago. Fall occurred at Skilled Nursing Facility (SNF) from Mechanical lift. She fell from a height of 3 to 5 ft. and point of impact head and neck. Clinical impression - Closed displaced fracture of first cervical vertebra, unspecified fracture morphology. Review of Orthopedic Note dated [DATE] at 10:48 PM read in part: patient was seen at an outside hospital where she was found to have first cervical vertebra fracture and second cervical vertebra fracture. Assessment and Recommendation indicated C1 Jefferson fracture and C2 type 2 odontoid fracture. Maintain Miami J (MJ) cervical collar at all times; head of bed (HOB) as tolerated; this injury does not have risk of neurologic compromise, however risk associated with surgical interventions have high morbidity. Recommend no acute orthopedic surgical intervention. Review of Employee Counseling / Discipline Statement dated [DATE] revealed NA #9 failed to utilize two staff for use of Mechanical lift for weighing a resident. Corrective actions were 1) in-service on Mechanical lift. 2) Return demonstration of use of Mechanical lift. Review of the Medical Discharge Summary dated [DATE] read in part- Resident blood pressure (BP) remained elevated despite home regime. Hemodynamically stable at discharge and at baseline mental status. Recommended maintain MJ collar at all times. Review of nursing note dated [DATE] read in part: Resident arrived to facility via facility transport at 7:17 PM, MJ collar in place on the neck. Resident stable, alert, nonverbal. Vital signs taken. Resident skin dry and intact with some bruising noted to back of both hands and right lower arm at IV site, respiration even and unlabored . Incontinent of Bowel and Bladder, no acute distress noted, will continue to monitor. Review of Physician orders [REDACTED]. Acetaminophen 325 MG tablet take 2 tablets PO every 6 hours for 7 days. Amlodipine Besylate 10 MG take 1 tablet PO daily for hypertension. Roxicodone 5 MG Tablets take 1 tablet PO 6 hours as needed (PRN). Maintain MJ collar at all times. Reviews of Physician notes dated [DATE] read in part - Follow up after hospital observation stay due to fall from Mechanical lift. Resident diagnosed with [REDACTED]. Orthopedic recommendation: conservative treatment with an MJ collar due to risk of high morbidity with surgery due to baseline function and co-morbidities. Resident can move all extremities, fingers and toes. Resident's BP was elevated from baseline, possibility due to pain and amlodipine has started. Vital Signs stable since return. Review of post incident action report dated [DATE] revealed staff re-educated on use of lift. IDT review for fall with Social worker, administrator, activity director, therapy and MD. Review of Medication Administration Record (MAR) for April and [DATE] revealed: [DATE] through [DATE] - resident did not receive any pain medication. [DATE] through [DATE] - resident received acetaminophen 325 MG 2 tablet Twice a Day (BID) every 6 hours for pain. [DATE] through [DATE] -Resident was administered scheduled Norco ,[DATE] tablet one tablet BID for pain. Resident did not receive any as needed (PRN) Norco ,[DATE] tablet one tablet BID for pain. [DATE] through [DATE]- resident received scheduled Norco ,[DATE] tablet one tablet BID for pain. Resident did not receive any PRN Norco ,[DATE] tablet one tablet BID for pain. [DATE] through [DATE] - Resident was assessed for pain at 6:00 AM, 2:00 PM, 10:00 PM. Pain indicated. Resident was checked for maintaining MJ collar at all times. Review of Certificate of Death dated [DATE] read in part- expired in the facility, Probable aspiration due to dysphagia due to Alzheimer's dementia. During an interview with Nurse #2 on [DATE] at 7:05 AM, nurse indicated NA #9 was assigned residents weights the day of the incident. Nurse stated NA #9 came running to her and informed her about Resident #47 fall, unsure of time (may be before or after lunch). Nurse #2 stated when she entered Resident #47's room, resident was lying against her roommate's bed frame and there was lot of blood. Nurse #2 stated she was unsure if the resident had hit the floor or the bed frame. She indicated she did not move the resident due to blood loss and asked the NA #9 to call the supervisor while she was applying pressure to the head. Nurse #2 further stated supervisor had called EMS. Resident #47 was examined by EMS upon arrival and transported her to the hospital in a stretcher. Nurse #2 further stated that two (2) people were required when using the mechanical lift and was unsure why NA #9 was working alone with the mechanical lift. Nurse #2 also stated prior to the fall resident had poor neck control and would always turn to the right side. She indicated Resident #47 base line was resident was alert and not oriented and was a total assist with her ADL's. Nurse #2 further stated that after the fall resident had a decline in her medical condition, was not eating well, but able to consume some fluids. She stated that the resident had a MJ collar placed in the hospital and this was also hindering the resident comfort. During an interview with NA #8 on [DATE] at 9:41 AM, NA stated there was one resident that had a fall because there was only one NA that used the lift. NA #8 stated that there were 4 NA on duty that day but NA #9 did not ask for help with the lift and used the lift with only one person. She stated the resident hit her head and ended up going to the hospital. During an interview with Nurse #4 on [DATE] at 10:28 AM, Nurse stated she was called to the room by a NA (did not remember the name). Nurse #4 stated that NA had thought all the clips were unhooked and was startled by the roommate's family entered the room, that is when she moved the lift, the resident was pulled out with the lift as one clip was left unhooked. Nurse #4 indicated she had assessed the resident. She stated Resident #47 head was bleeding, resident was alert and talking, laying on her right side in between the beds. She stated Resident #47 was assessed by EMS and transported the resident to the hospital. During an interview with the Nurse Practitioner (NP) on [DATE] at 11:31 AM, NP indicated resident was total dependent, did not move a lot, advanced and progressing dementia, no verbal cues of pain or no verbal response, DNR and on comfort care. NP stated that resident was declining prior to the fall and was on limited interventions for comfort care. NP indicated that on the day of the fall, she was notified and resident was sent to the hospital for evaluation. NP indicated that after resident returned from the hospital, resident was made comfortable with pain medication, not overly sedated. She stated Resident # 47 was consuming less and appetite had decreased. NP indicated she was not present at the time of death, and death was a natural death due to deteriorating conditions. During an interview with the NA #9 on [DATE] at 11:38 AM, NA indicated she was usually assigned weights for the residents. She stated on the day of the incident, she was using a mechanical lift to weigh Resident # 47. NA #9 explained the resident was placed on the pad and hooked, lifted up to be weighed and when the weight was taken the resident was put down on the bed. She stated at this time the resident's roommate family member walked in. NA #9 stated she had removed 3 of the 4 clips and when the family member walked in, she got distracted. NA #9 stated she responded patient care and after he left, NA stated she thought she had removed all of the 4 hooks from the pad and moved back. NA #9 stated at this point she felt a tug and she could not reach the resident as resident was fallen down. She stated she immediately called the nurse for assessments. She stated she was working alone with the mechanical lift that day. She indicated facility had other NA, but she just did not ask for assistance. She also stated she usually works alone with mechanical lift for weights as she was assigned to that duty for a long time. She indicated that she only asks for help if the resident was combative or a heavy weight person. During an interview with Director of Nursing (DON) on [DATE] at 12:15 PM, DON indicated she was in the facility at the time of the fall however not witness it. She indicated NA #9 came running and reported to the nurse about the fall. DON stated when she entered the room, Resident #47's head was lying against the roommate's bed frame. She stated she was unsure why NA #9 was distracted and why NA #9 was working alone with the lift without any assistance. DON stated all the lifts in the facility were 2 person assist. During an interview with the Physician (MD) on [DATE] at 3:38 PM via phone, MD indicated he was working as the Medical Director for the facility during the time frame of the incident. MD stated on the day of the incidence his NP called him and asked him if she could give orders for resident to be transferred to the hospital. MD indicated he was made aware of the incidence from his NP, Acting DON and previous Administrator. He stated it was not appropriate for the resident to be transferred by one person if the care plan indicated 2 person assist for transfer. During an interview with the administrator on [DATE] at 10:41 AM, Administrator indicated the staff should follow the care plan and by not using 2 person for mechanical lift it was a neglect. She further stated that staff did not think she was transferring Resident #47 as she was weighing the resident. Review of the Quality Assurance (QA) Process revealed on [DATE] at 2:15PM, Resident #47 was positioned in the mechanical lift over the bed and approximately 6 inches above the mattress for the purpose of obtaining weights. After getting the resident weights, NA placed the resident on the mattress and started unhooking the 4 clips that held the pad onto the lift. After unhooking 3 of the 4 hooks, the resident's roommate family member came into the room. NA had shouted resident care and they left the room. NA turned and back to the resident she was caring for and at this point started to pull the mechanical lift back to the bed. NA had forgotten she had not unclipped the 4th clip and the resident started to roll and fall from the bed. NA was not able to move fast enough around the mechanical lift to reach or catch the resident from falling. NA got help to assess the resident. Resident #47 was assessed by the nurse and resident had a laceration on the top of her head from hitting her head on her roommate side rails. Physician and responsible party were notified. The QA Process further indicated the NA was reeducated on the use of the mechanical lift with return demonstration to validate skills. All NA's were reeducated on the use of the mechanical Lift and sit to stand with return demonstration to validate skills. All new NA hired will be validated for competency of Mechanical lift and Sit to stand during their orientation period. Random observation will be completed to ensure 2 staff present during use of Mechanical and sit to stand lift, observations will be ongoing to ensure continued quality improvement. QA process did not indicate the facility had identified all the residents that used the mechanical lifts or updated the care guide for the residents using the lift. No monitoring methods were in place. On [DATE] at 2:30 AM the administrator, corporate nurse consultant, corporate vice president were informed of immediate jeopardy. The Administrator provided an acceptable credible allegation of compliance on [DATE]. Credible allegation of Compliance: F 323 On [DATE] at 2:15 PM the resident was positioned in the Hoyer lift over her bed at approximately 6 inches above the mattress for the purpose of obtaining her weight. After getting the residents weight the c.n.a. returned the resident to the mattress and started unhooking the 4 hooks that held the pad onto the lift. After unhooking 3 of the 4 hooks a visitor entered the room and the c.n.a. stated out resident care and the visitor left the room. The c.n.a. turned back to the resident she was weighing and at this point started to pull the mechanical back from the bed. The c.n.a. had forgotten that she had not undone the fourth hook and the resident had started to roll and fell from the bed. The c.n.a. was distracted by the visitor coming into the room causing her not to undo the fourth hook. The c.n.a. did not have a second person to assist with the mechanical lift because she stated she was not transferring the resident and this was her common practice for obtaining weight for this resident. The conclusion of the root cause, if following the policy the c.n.a. would have had a second staff while using the mechanical lift per the policy of the facility. The second staff member could have told the first c.n.a. that the fourth hook was still attached prior to moving the mechanical lift and could have prevented the fall. On [DATE] at 2:15 PM while obtaining the residents weight the employee pulled the Hoyer lift without unhooking all 4 hooks causing the resident to fall from the bed hitting her head and obtained a laceration on the top of her head. The physician and family was notified on [DATE] at 2:30 PM and the resident was sent to the emergency room for evaluation and admitted for observation and returned to the facility on [DATE] with a [DIAGNOSES REDACTED]. The resident expired on [DATE]. The involved staff was counseled on [DATE] by the administrator for not utilizing 2 staff members when using the Hoyer lift while weighing a resident and re-inserviced on use of the Hoyer lift by the Rehab Director, with return demonstration of using a Hoyer lift on [DATE]. On [DATE] and [DATE] the Certified Nursing Assistants were trained by the therapy department on the proper use of 2 people when using the mechanical lifting devices with return demonstration of skill. The training will continue with new hire's and annually to show continued competence. All fulltime certified nursing assistant were trained by the therapy department on [DATE] and [DATE], there are 2 per diem staff that have not had the training and will not be allowed to work until training is completed. Other residents affected were re-assessed on [DATE] for the need for the Hoyer lift and the care plans and care guides were updated to indicate 2 person assist and transfer by the Rehab Director. Since the training on [DATE] and [DATE] there have been no other residents affected by the deficient practice. On [DATE] around the time of the incident the incident log was reviewed and there were no other incidents involving improper use of mechanical lifts. The continued need for the mechanical lift will be reviewed quarterly with the scheduled MDS and as needed by the unit manager. On [DATE] the direct care staff was re-educated on the importance of reviewing the care guide daily for updates and to understand the expected outcome of the residents care. Care guides are located on the inside of each closet door. QIO was contacted [DATE] for assistance with a full plan of correction to achieve and maintain compliance. A QAPI self-assessment was completed today and a visit has not been scheduled at this time. The self-assessment was sent to the facility by the QIO and the assessment was completed on-line. After the QIO reviews they will call the facility and schedule a visit. The validation of the credible allegation was completed on [DATE] at 12:30 PM by doing the following: 1a. On [DATE] at 3:17 PM observed use Mechanical lift to assist a resident transferred from wheel chair to bed. 3 NA were assisting with transfer. One NA operated the mechanical lift while the other 2 assisted with transfer by holding the resident. All loops were unclipped before the mechanical lift was moved. Resident was safely transferred and no issues were noted. 1 b. On [DATE] at 3:22 PM observed use Mechanical lift for weighing a resident laying in her bed. One NA operated the lift while the other NA supported and reassured the resident. Resident was safely weighed. No issues were noted. 2. Review of In-service Education report revealed on [DATE] and [DATE] the facility's direct staff were trained on 2 person assist for the mechanical lift and the sit to stand lift to include 2 person assist for weights; Training included return demonstration. Eighteen (18) NA's were identified on the in- service education sheet. The in-service with return demonstration was completed by the Occupational Therapist. Skills Competency Checklists were completed for the 18 NA's on proper use of gait belt, use of mechanical lifts, and use of sit to stand transfer equipment. During an interview with DON on [DATE] at 12:15 PM, DON stated all direct care staff were re-trained by Physical Therapist (PT) on how to properly use mechanical lifts. She stated the NA's had to demonstrate their understanding skills. 3. Review of Employee Counseling / Discipline Statement dated [DATE] revealed NA #9 was counseled on [DATE] related to failing to utilize 2 staff for use of mechanical lift for weighing a resident. Corrective Actions were 1) Employee was in-serviced on mechanical lift. 2) Return demonstration of use of mechanical lift. 4. On [DATE] the care plan and Care guides of other residents identified for the need for mechanical lift were reviewed. The care plans were updated to indicate sit to stand lift with 2 staff assist or transfers using total lift with 2 assist. Care Guides were updated to indicate sit to stand lift with 2 staff assist or transfers using total lift with 2 assist. 5. Interview with multiple direct staff on [DATE] revealed staff were educated by administrator on [DATE] about reviewing the care guide daily and to understand the expected outcome of the residents care. Direct care staff were able to locate the residents care guide inside of the resident closet door. 6. During an interview with the Administrator on [DATE] at 11:21 AM, Administrator indicated that facility has identify those resident that use the lift. She further stated DON and MDS coordinator will implement the care guide and monitor staff follow the care guide that were placed in the resident's closets. She also stated that rehab director was going to review the need to the lift quarterly with the MDS coordinator and as needed to keep the assessment and care guides current. 7. Reviewed QAPI self-assessment tool. QIO notified on [DATE] at 2:30 PM. Facility waiting for visit to be scheduled. During an interview with the Administrator and Vice President/Director of Operations on [DATE] at 11:56 AM, they indicated that a discussion was held to discuss the significance of Immediate Jeopardy and the expedited protection of other residents with the potential to be affected by the same deficient practice. The immediate jeopardy was removed on [DATE] when the facility's acceptable credible allegation of compliance were verified. The facility will remain out of compliance at a lesser scope and severity.

Based on record review, observation, staff, Nurse Practitioner and Physician interviews, the facility administration failed to provide the leadership and management necessary to ensure resident's needs were met for 1 of 6 residents reviewed for accidents (Resident #47). On [DATE] Resident # 47 who was severely cognitively impaired had a fall with injuries while being weighed by mechanical lift, with only one person assist. The assigned staff after weighing Resident # 47 had unhooked only three (3) loops not all four (4) from mechanical lift resulting in a fall with injuries. Resident # 47 had a laceration to her head, fracture to the first cervical vertebra (C1 Jefferson fracture) and fracture to the second cervical vertebra (Type 2 odontoid fracture) due to the fall. Resident # 47 expired on [DATE] Immediate Jeopardy began on [DATE] when the sling's four straps were not all unhooked before the sling was removed from the resident. This caused the resident to be pulled onto the floor. The immediate jeopardy was removed on [DATE] at 12:30 PM when the facility's acceptable credible allegation of compliance was verified. 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 allow the facility time for to implement full plan of corrections. Findings included: This tag is cross referred to: 1. F323 - Based on observations, Physician and staff interviews, and records review the facility failed to prevent an avoidable fall from mechanical lift resulting in injury for 1 of 6 residents reviewed for accidents and falls (Resident # 47). 2. F224 - Based on observations, interview with facility staff, physician and Administrator and records review the facility failed to prevent an avoidable fall from mechanical lift resulting in injury for 1 of 6 residents reviewed for accidents and falls (Resident # 47). On [DATE] at 2:30 AM the administrator, corporate nurse consultant, corporate vice president were informed of immediate jeopardy. The Administrator provided an acceptable credible allegation of compliance on [DATE]. Allegation of Compliance: F 490 On [DATE] at 2:15 PM the resident was positioned in the Hoyer lift over her bed at approximately 6 inches above the mattress for the purpose of obtaining her weight. After getting the residents weight the c.n.a. returned the resident to the mattress and started unhooking the 4 hooks that held the pad onto the lift. After unhooking 3 of the 4 hooks a visitor entered the room and the c.n.a. stated out resident care and the visitor left the room. The c.n.a. turned back to the resident she was weighing and at this point started to pull the mechanical lift back from the bed. The c.n.a. had forgotten that she had not undone the fourth hook and the resident had started to roll and fell from the bed. The c.n.a. was distracted by the visitor coming into the room causing her not to undo the fourth hook. The c.n.a. did not have a second person to assist with the mechanical lift because she stated she was not transferring the resident and this was her common practice for obtaining weight for this resident. The conclusion of the root cause, if following the policy the c.n.a. would have had a second staff while using the mechanical lift per the policy of the facility. The second staff member could have told the first c.n.a. that the fourth hook was still attached prior to moving the mechanical lift and could have prevented the fall. On [DATE] at 2:15 PM while obtaining the residents weight the employee pulled the Hoyer lift without unhooking all 4 hooks causing the resident to fall from the bed hitting her head and obtained a laceration on the top of her head. The physician and family was notified on [DATE] at 2:30 PM and the resident was sent to the emergency room for evaluation and admitted for observation and returned to the facility on [DATE] with a [DIAGNOSES REDACTED]. On [DATE] and [DATE] the Certified Nursing Assistants were trained by the therapy department on the proper use of 2 people when using the mechanical lifting devices with return demonstration of skill. The training will continue with new hire's and annually to show continued competence. All full-time certified nursing assistants were trained by the therapy department on [DATE] and [DATE], there are 2 per diem staff that have not had the training and will not be allowed to work until training is completed. During the end-of-day meeting with department managers on the afternoon of [DATE] the Director of Clinical Operations re-inserviced the Administrator and Department Managers on the corporation's Abuse and Neglect policy. On [DATE] the Director of Operations and the Director of Clinical Operations met with the Administrator to review the significance of an immediate jeopardy situation and the expedited protection of the facility residents. The Director of Operations and the Director of Clinical Operations will continue to monitor the facility's adherence to corporate policies and regulated guidelines with daily conference calls and weekly on-site visits. On [DATE] the Director of Operations initiated 100% retraining for all Magnolia Estates C.N.A.'s regarding the policy for the use of the mechanical lift requiring 2 staff to operate and use the lift correctly. Other residents with the potential to be affected by this deficient practice were re-assessed on [DATE] for the need for the mechanical lift and the care plans and care guides were updated to indicate 2 person assist and transfer by the Rehab Director. The continued need for the mechanical lift will be reviewed quarterly with the scheduled MDS and as needed. On [DATE] the direct care staff was re-educated by the Administrator on the importance of reviewing the care guide daily for updates and to understand the expected outcome of the residents care. Care guides are located on the inside of each closet door. On [DATE], the Director of Operations inserviced the Administrator regarding the fact that they are the on-site person responsible for planning, organizing, implementing, evaluating, and directing the facility's programs and activities in accordance with the corporation's established policies. Several methods used to accomplish this are Quality Assurance and Performance Improvement committees involving the Medical Director, Social Worker, DON, Pharmacist, Medical Records Director, Dietary Manager and Housekeeping Supervisor to identify issues related to quality assessment and assurance activities as needed and developing and implementing appropriate plans of action for identified facility concerns. In addition, quarterly Satisfaction Surveys are sent to Responsible Parties and Residents, the results of which are presented to QA and modifications made to policies and procedures as required. The Administrator has an open door policy which allows all residents, visitors, and staff members to voice concerns at any time. The charge nurse will monitor the C.N.A.s to ensure that the care guides are followed. Any deviation from the care provided according to the care guides will be reported to the DON to be investigated for possible neglect. As part of the corporation's progressive disciplinary process, employees violating corporate policy and/or regulatory guidelines will be counseled up to and including discharge by the appropriate Department Manager and Administrator. QIO was contacted [DATE] for assistance with a full plan of correction to achieve and maintain compliance. A QAPI self-assessment was completed on [DATE] and returned to the QIO assigned to the facility. After reviewing the self-assessment, the QIO indicated they would call the facility to schedule their first visit. Verification of Credible Allegations: F490 1. When were you last in-serviced on the Abuse/ Neglect Policy? What is the facility policy on related to neglect? During an interview with Nurse #3 on [DATE] at 9:00 AM, Nurse # 3 stated she was in serviced on abuse/neglect yesterday. She also stated she would report neglect to DON and Administrator. During an interview with NA #15 on [DATE] at 9:05 AM, NA stated she underwent abuse and neglect training yesterday. She stated she would report it and indicated she knew when to report it and the steps to take when she sees neglect. During an interview with NA #2 on [DATE] at 9:19 AM, NA stated She was trained this week on Abuse and Neglect. She stated that she would report to the nurse and knew all steps that she would take. During an interview with Nurse #5 on [DATE] at 9:31 AM, she stated she was in-service yesterday on Abuse and Neglect. She further stated that Neglect was when someone doesn't provide care for the resident. During an interview with NA #16 on [DATE] at 9:39 AM, NA indicated that she was trained in Abuse and Neglect. She stated, if she saw a resident being abused, she would not leave the resident and would notify the nurse. During an interview with MDS coordinator on [DATE] at 11:15 AM, MDS Coordinator stated she was in serviced this past week on abuse/neglect. She stated Neglect was one of the 5 forms of abuse. She further stated Neglect would be not doing something that was on the care plan and leaving resident unattended. During an interview with certified occupational therapist assistant (COTA) on [DATE] at 11:52 AM, COTA stated she was trained on abuse and neglect [DATE]. She stated the policy was to report abuse/neglect. She stated that Neglect was care not provided to a resident who needs it. 2. How will you monitor the facility's adherence with Policies and Regulations? During an interview with Vice president / Director of Operations on [DATE] at 11:56 AM, he stated that he and corporate nurse will monitor facility's adherence with daily conference call one of them will be in building at least weekly. 3. When were you last trained on the policy of using mechanical lifts? How many staff are required to use the lift? During an interview with Nurse #3 on [DATE] at 9:00 AM, Nurse # 3 stated that 2 people were required to use the lift. She also stated that she will monitor staff by going into the resident's room and checking for 2 people using the lift. During an interview with NA #15 on 7/ ,[DATE] at 9:05 AM, NA stated 2 people are needed when using the lift. She stated she was in serviced when she first hired and once since then. She further stated that she was also educated on care guide and care plan. She stated that the resident's care guide were located in the resident's closet. During an interviewed with NA #2 on [DATE] at 9:19 AM. She stated that she underwent training about the lift a few weeks ago on how to properly use the lift and that 2 people are required when using a lift. She also indicated care guide were in resident's closets for every resident. During an interview with NA #1 on [DATE] at 9:32 AM. She stated that it takes to use 2 people to use the lift. She stated that care guides were inside the closet on how to provide care for residents. During an interview with NA #16 on [DATE] at 9:39 AM, NA indicated that they have to have 2 peoples to use the lift no matter what and was educated on this. She further stated care guide on the resident closet doors indicated how to provide care for residents. During an interview with NA #5 on 7/ ,[DATE] at 9:40 AM, NA stated she was in serviced early in the week. She further stated that she was also educated on care guide and care plan. 4. How will you monitor NA's that the care guides are being followed: What if there is a deviation from the care guide. What do you do? During an interview with Nurse #3 on [DATE] at 9:00 AM, Nurse #3 stated she would communicate any changes to the care guide to the NA. She further stated that if NA did not follow the care guide, she would counsel the aide. During an interview with Nurse #5 on [DATE] at 9:31 AM, she stated she would checks shower sheets, and do observation of care. She stated that she would counsel the NA if they have missed a care or not providing care. 5. Are Care plans and Care guides for residents with lifts updated? On [DATE] the care plan and care guides of other residents identified for the need for mechanical lift were reviewed. The care plans were updated to indicate sit to stand lift with 2 staff assist or transfers using total lift with 2 assist. Care Guides were updated to indicate sit to stand lift with 2 staff assist or transfers using total lift with 2 assist. 6. Reviewed QAPI self-assessment tool. QIO notified on [DATE] at 2:30 PM. Facility waiting for visit to be scheduled. During an interview with the Administrator and Vice President/Director of Operations on [DATE] at 11:56 AM, they indicated that a discussion was held to discuss the significance of Immediate Jeopardy and the expedited protection of other residents with the potential to be affected by the same deficient practice. The immediate jeopardy was removed on [DATE] when the facility's acceptable credible allegation of compliance were verified. The facility will remain out of compliance at a lesser scope and severity.

Based on observations, staff and physician interviews and record review, the facility failed to notify the physician for a change in condition of a urinary catheter insertion site (urethra) for 1 (Resident #20) of 1 residents reviewed for urinary catheters. The findings included: Resident #20 was admitted on [DATE] with cumulative [DIAGNOSES REDACTED]. A review of Resident #20 ' s skin assessment on admitted d 11/23/16 read no areas of concern to his urethra. A review of Resident #20 ' s weekly skin assessment dated [DATE] read his had been showered and no skin issues noted. There was no mention of any areas of concern to Resident #20 ' s penis or urethra. A nursing note dated 5/16/17 at 10:44 PM read Resident #20 was sent to the hospital and admitted with hematuria and a UTI. He returned to the facility on [DATE]. A review of his re-admission skin assessment dated [DATE] read no areas of concern to his urethra. A review of a PA progress note dated 6/7/17 read Resident #20 was seen for follow up after his course of antibiotics for a UTI. Staff reported a thick milky looking urine. His GU assessment read he had an indwelling urinary catheter with a large amount of sediment but no blood and the urine was described as yellow. There was no mention of staff concerns related his urethra or penis. A review of Resident #20 significant change MDS dated [DATE] indicated his Brief Interview for Mental Status (BIMS) of 2 meaning severe cognitive impairment with no behaviors. He was coded for extensive assistance with all his activities of daily living (ADLs) and coded as having a urinary catheter. The Care Area Assessment for his urinary catheter referred reader to his care plan. A review of Resident #20 ' s care plan dated 6/8/17 read the following problem: *Resident #20 had a urinary catheter due to [MEDICAL CONDITION] and [MEDICAL CONDITION]. Resident #20 had a history of [REDACTED]. He needed staff assistance with his catheter care and urinary bag emptying. He had a history of [REDACTED]. Interventions included: *Observation of Resident #20 ' s skin daily for irritation and redness *Ongoing assessment of the color and clarity of his urine *Assessment of Resident for sign of a UTI *Assistance with his perineal care as needed *Refer Resident #20 to a Urologist as needed *Provide catheter care as ordered and as needed *Change his catheter as ordered * Obtain Urinalysis and give antibiotics as ordered *Ensure the catheter tubing is secured to his thigh A nursing note dated 6/21/17 at 10:13 AM read Resident #20 removed his urinary catheter and it was lying at his bedside. The urinary catheter was replaced without difficulty. There was no documented evidence of trauma of assessment of his urethra or that it was reported to the physician. In an observation and interview on 7/18/17 at 10:23 AM, Nursing Assistant (NA) #13 stated she had worked at the facility for 3 months. NA #13 pulled back Resident #20 ' s sheet. There was no observed anchoring device to either thigh. She stated she was not aware that his urinary catheter should be anchored to his thigh. She stated she was instructed to make sure his urinary bag was attached to his bed but not aware that his urinary bag should not be lying on the floor. NA #13 stated in the past when she was assigned Resident #20 she was only instructed to empty his urinary bag. She was not aware of how to perform his urinary catheter care or what to report to the nurse. In an interview on 07/18/17 at 10:38 AM, Nurse #2 stated she had observed blood in in his urine on occasion. Nurse #2 stated the aides clean his catheter and she assessed his catheter daily to ensure there were no concerns. Nurse #2 stated the aides had not told her that his catheter was not anchored and not told her about any observed concerns to his penis or urethra. Nurse #2 stated if the aides reported or she observed any changes in the appearance of Resident #20 ' s urethra, it should be reported to the physician. In an interview on 07/18/17 at 3:30 PM, Nurse #1 stated she started in January of 2017 and was assigned Resident #20 on 7/17/17 and thought he did not have a leg strap because it irritated his leg. She stated she did not assess his catheter insertion site or penis but expected the aides to report anything unusual to her. Nurse #1 stated if the aides reported or she observed any changes in the appearance of Resident #20 ' s urethra, it should be reported to the physician. In an observation and interview on 07/19/17 at 9:30 AM, NA #2 stated she had worked at the facility for one year and she was assigned Resident #20. During an observation of Resident #20 ' s catheter care, she cleaned around his urethra and cleaning his tubing. She did not attempt to clean the entirety of his penis. NA #2 was asked to further reveal his penis by pushing back his testicles and foreskin. Observed was a penile tear extending from the urethra down the underside of the shaft of his penis measuring approximately 2 inches in length. NA #2 stated his penis was not like that when he was admitted in November 2016 and it should be reported to the nurse. In an interview on 07/19/17 at 9:50 AM, Nurse #2 confirmed she looked at Resident #20 ' s penis daily. She stated she thought he had a small tear on his admission but it did not look like it did today. Nurse #2 stated his catheter was changed monthly on night shift and the penile tear should have been reported to his physician when it was observed during his catheter change. In an interview on 07/19/17 at 10:50 AM, Nurse #3 stated she worked third shift. She stated she thought Resident #20 had a small tear for awhile. She described it as a 2 centimeter ridge on his penis but she had not observed his penis in probably a month. She stated the other nurse who worked nights usually changed his urinary catheter. She confirmed Resident #20 ' s catheter was documented changed by the other night nurse on 7/17/17 on third shift. In a telephone interview on 07/19/17 at 3:10 PM, Nurse #6 confirmed she worked nights and worked third shift on 7/17/17. She stated she had changed Resident #20 ' s urinary catheter in the past but not recently. Nurse #6 was reminded she documented on his TAR she changed his urinary catheter Monday night on 07/17/17. Nurse #6 stated she did not change his catheter on 07/17/17 as documented. She was unable to offer an explanation as to why she initialed off on the TAR that she changed Resident #20 ' s urinary catheter when on interview, she stated she did not. She stated she thought she changed his urinary catheter a month or so ago and had observed pus and blood at his urethra but had not noted the penile tear. She stated if she observed a tear to Resident #20 ' s urethra, it should have been reported to his physician. A review of the facility incident logs on 7/16/17 at 4:00 PM from November 2016 to present included no intakes regarding any injury or change in Resident #20 ' s catheter insertion site at his urethra. In an interview on 7/19/17 at 4:20 PM, NA #14 stated it was her first day back on the 200-hall assignment after a 3-month rotation on another hall. The Director of Nursing (DON) and NA #14 were observed assessing Resident #20 ' s penis. The DON pulled back Resident #20 ' s foreskin and testicles to reveal the penile tear. NA #14 stated it wasn ' t like that 3 months ago. NA #14 stated he may have had some bleeding and maybe a little split but not like what it looks like now. The DON stated she was unable to recall if it had worsened since she last observed it a few weeks ago. She stated it was her expectation that it would have been reported to his physician when it was discovered but she would report it today. There were no nursing notes again until 7/19/17 at 4:59 PM which read Resident #20 ' s urinary catheter was changed without difficulty. In a telephone interview on 07/21/17 at 9:45 AM, Resident #20 ' s physician stated it was her expectation that she be notified of any changes such as trauma or tearing to Resident #20 ' s s penis or urethra. In an interview on 07/21/ at 10:40 AM, the Administrator stated her expectations were the same as Resident #20 ' s physician.

Based on observation, staff interview and record review, the facility failed to ensure a care planned intervention for securing a urinary catheter to prevent injury for 1 of (Resident #20) 1 reviewed for urinary catheters. Findings included: Resident #20 was admitted on [DATE] with cumulative [DIAGNOSES REDACTED]. A review of his re-admission skin assessment dated [DATE] read no areas of concern to his urethra. A review of Resident #20 significant change Minimum Data Set ((MDS) dated [DATE] indicated his Brief Interview for Mental Status (BIMS) of 2 meaning severe cognitive impairment with no behaviors. He was coded for extensive assistance with all his activities of daily living (ADLs) and coded as having a urinary catheter. The Care Area Assessment for his urinary catheter referred reader to his care plan. A review of Resident #20 ' s care plan dated 6/8/17 read the following problem: *Resident #20 had a urinary catheter due to [MEDICAL CONDITION] and [MEDICAL CONDITION]. Resident #20 had a history of [REDACTED]. He needed staff assistance with his catheter care and urinary bag emptying. He had a history of [REDACTED]. Interventions included: *Ensure the catheter tubing is secured to his thigh A review of Resident #20 ' s undated care guide did not include the intervention of ensuring the catheter tubing is secured to his thigh. In an observation on 07/17/17 at 9:00 AM, Resident #20 was lying in a low bed with urinary catheter bag attached to the right side of his bed frame resting on the floor. In an observation on 07/17/17 at 12:10 PM, Resident #20 was lying in a low bed with a sheet partially un-obstructing the view of his right and left thighs. There was no observed catheter securement device to either thigh, the urinary catheter was attached to the right side of the bed frame with the bag resting on the floor. There was no observed blood in the urinary tubing but his urine appeared pale yellow with white sediment. In an observation on 07/18/17 at 10:21 AM, Resident #20 was lying in a low bed. His catheter bag was attached to the left side of his bed frame resting on the floor. There was observed blood tinged urine in his catheter tubing. In an observation and interview on 7/18/17 at 10:23 AM, Nursing Assistant (NA) #13 stated she had worked at the facility for 3 months. NA #13 pulled back Resident #20 ' s sheet. There was no observed anchoring device to either thigh. She stated she was not aware that his urinary catheter should be anchored to his thigh. She stated she was instructed to make sure his urinary bag was attached to his bed but not aware that his urinary bag should not be lying on the floor. NA #13 stated in the past when she was assigned Resident #20 she was only instructed to empty his urinary bag. She stated she used the care guide inside his closet door for how to care for Resident #20. In an interview on 07/18/17 at 10:38 AM, Nurse #2 stated the aides clean his catheter and she assessed his catheter daily to ensure there were no concerns. Nurse #2 stated the aides had not told her that his catheter was not anchored. In an interview on 07/18/17 at 3:30 PM, Nurse #1 stated she started in January of 2017 and was assigned Resident #20 on 7/17/17 and thought he did not have a leg strap because it irritated his leg. In an observation on 7/18/17 at 3:40 PM, Resident #20 was lying in a low bed with his urinary catheter bag attached to the right side of his bed frame resting on the floor In an observation and interview on 07/19/17 at 9:30 AM, NA #2 stated she had worked at the facility for one year and she was assigned Resident #20. During an observation of Resident #20 ' s catheter care, there a leg strap securing his urinary catheter tubing to his right thigh. During an observation of Resident #20 ' s catheter care, she cleaned around his urethra and cleaning his tubing. She did not attempt to clean the entirety of his penis. NA #2 was asked to further reveal his penis by pushing back his testicles and foreskin. Observed was a penile tear extending from the urethra down the underside of the shaft of his penis measuring approximately 2 inches in length. NA #2 stated his penis was not like that when he was admitted in November 2016. In an interview on 07/19/17 at 9:50 AM, Nurse #2 stated she applied a leg strap to Resident #20 ' s leg yesterday around 11:00 AM on 7/18/17. A nursing note dated 7/20/17 at 8:15 AM read Resident #20 ' s urinary catheter tubing was secured in place with a leg strap. In an interview on 7/20/17 at 2:40 PM, the MDS nurse stated she completed Resident #20 ' s last care plan revision on 6/8/17. She stated she did not verify there was an updated care guide in Resident #20 ' s closet including the intervention of securing his urinary catheter was secured to his thigh. In a telephone interview on 7/20/17 at 11:45 AM, the Urologist who saw Resident #20 on 6/26/17 stated some penile erosion was expected from long term urinary catheter however a 2-inch tear would have been the result of trauma or the staff not ensuring the use of a leg strap to prevent the weight of the urinary bag tugging on his catheter. In a telephone interview on 07/21/17 at 9:45 AM, Resident #20 ' s physician stated it was her expectation that Resident #20 ' s urinary catheter be secured to prevent tension and possible trauma or penile erosion. In an interview on 07/21/ at 10:40 AM, the Administrator stated her expectation the staff followed the care plan and the care guide include the intervention of securing his urinary catheter to his thigh using a leg strap to prevent tension or injury.

Based on observations, staff and physician interviews and record review, the facility failed to change a urinary catheter as ordered and failed to assess for changes in the appearance of the urinary catheter insertion site (urethra) for 1 (Resident #20) of 1 residents reviewed for urinary catheters. The findings included: Resident #20 was admitted on [DATE] with cumulative [DIAGNOSES REDACTED]. A review of Resident #20 ' s skin assessment on admitted d 11/23/16 read no areas of concern to his urethra. A review of Resident #20 ' s December 2016 physician orders [REDACTED]. A review of Resident #20 ' s December 2016 treatment administration (TAR) read his urinary catheter was changed on 12/30/16. A review of Resident #20 ' s January 2017 TAR read his urinary catheter was changed on 01/30/17. A review of Resident #20 ' s February 2017 TAR did not indicate that his catheter was changed at any time during the month. A review of Resident #20 ' s March 2017 TAR did not indicate that his catheter was changed at any time during the month. A nursing note dated 4/3/17 at 2:05 AM read Resident #20 was noted to have hematuria (blood in the urine) and a urine sample was obtained. A review of PA progress note dated 04/05/17 read Resident #20 was seen for follow up for a fever and increased confusion. The note referenced his chronic indwelling urinary catheter with hematuria and overall declining health. The PA referenced his GU observation of clear yellow urine. There were no documented staff concerns related to Resident #20 ' s urethra or urinary catheter. A nursing note dated 4/7/17 at 5:28 AM, Resident #20 ' s was leaking. It was changed with Cola colored urine return. He was being treated for [REDACTED]. A review of Resident #20 April physician orders [REDACTED]. A review of Resident #20 ' s weekly skin assessment dated [DATE] read his had been showered and no skin issues noted. There was no mention of any areas of concern to Resident #20 ' s penis or urethra. A nursing note dated 5/16/17 at 10:44 PM read Resident #20 was sent to the hospital and admitted with hematuria and a UTI. He returned to the facility on [DATE]. A review of Resident #20 ' s hospital records dated 5/21/17 indicated he was admitted with a UTI and hematuria. A review of the admitting physician note indicated Resident #20 was not seen by a urologist because the family opted to seek urological care with another urologist in another town. The note read upon discharge, Resident #20 would need to follow with his personal urologist A review of Resident #20 ' s readmission physician orders [REDACTED]. A review of his re-admission skin assessment dated [DATE] read no areas of concern to his urethra. A review of a nurse practitioner (NP) note dated 5/26/17 read the visit was for a follow up for a UTI and hospitalization . The note read Resident #20 was seen by urologist in the hospital with no new orders and staff reported a large amount of sediment in his urinary bag. The GU assessment read his urinary catheter was in place with a large amount of sediment. He was currently on an antibiotic for his UTI. A nursing note dated 6/7/17 at 8:11 AM read his urinary catheter was draining pale yellow milky looking urine with sediment. A note was left for the physician. A review of a PA progress note dated 6/7/17 read Resident #20 was seen for follow up after his course of antibiotics for a UTI. The note read he had an indwelling urinary catheter and saw urology in the hospital. Staff reported a thick milky looking urine. His GU assessment read he had an indwelling urinary catheter with a large amount of sediment but no blood and the urine was described as yellow. There was no mention of staff concerns related his urethra or penis. The PA left orders for staff to change Resident #20 ' s urinary catheter. A review of Resident #20 ' s TAR indicated his catheter was changed on 6/8/17. A review of Resident #20 significant change Minimum (MDS) data set [DATE] indicated his Brief Interview for Mental Status (BIMS) of 2 meaning severe cognitive impairment with no behaviors. He was coded for extensive assistance with all his activities of daily living (ADLs) and coded as having a urinary catheter. The Care Area Assessment for his urinary catheter referred reader to his care plan. A review of Resident #20 ' s care plan dated 6/8/17 read the following problem: *Resident #20 had a urinary catheter due to [MEDICAL CONDITION] and [MEDICAL CONDITION]. Resident #20 had a history of [REDACTED]. He needed staff assistance with his catheter care and urinary bag emptying. He had a history of [REDACTED]. Interventions included: *Observation of Resident #20 ' s skin daily for irritation and redness *Ongoing assessment of the color and clarity of his urine *Assessment of Resident for sign of a UTI *Assistance with his perineal care as needed *Refer Resident #20 to a Urologist as needed *Provide catheter care as ordered and as needed *Change his catheter as ordered * Obtain Urinalysis and give antibiotics as ordered *Ensure the catheter tubing is secured to his thigh A review of Resident #20 ' s June 2017 TAR indicated his urinary catheter was changed on 6/17/17. A nursing note dated 6/21/17 at 10:13 AM read Resident #20 removed his urinary catheter and it was lying at his bedside. The urinary catheter was replaced without difficulty. There was no documented evidence of trauma of assessment of his urethra. A review of the urology note dated 6/26/17 read this was the same urologist who referred Resident #20 to his personal Urologist upon his hospital discharge. He agreed to see Resident #20 on 6/26/17 who was accompanied by his responsible party (RP). The urology note said he last saw Resident #20 in November 2016 during a hospitalization . The note read he had a urinary catheter change monthly by the nursing home staff. The Urologist noted on his physical exam that his catheter was draining clear urine. There were no new orders. A review of Resident #20 ' s July 2017 TAR read his urinary catheter was changed on 7/17/17. In an observation on 07/17/17 at 9:00 AM, Resident #20 was lying in a low bed with urinary catheter bag attached to the right side of his bed frame resting on the floor. In an observation on 07/17/17 at 12:10 PM, Resident #20 was lying in a low bed with a sheet partially un-obstructing the view of his right and left thighs. There was no observed catheter securement device to either thigh, the urinary catheter was attached to the right side of the bed frame with the bag resting on the floor. There was no observed blood in the urinary tubing but his urine appeared pale yellow with white sediment. In an observation on 07/18/17 at 10:21 AM, Resident #20 was lying in a low bed. His catheter bag was attached to the left side of his bed frame resting on the floor. There was observed blood tinged urine in his catheter tubing. In an observation and interview on 7/18/17 at 10:23 AM, Nursing Assistant (NA) #13 stated she had worked at the facility for 3 months. NA #13 pulled back Resident #20 ' s sheet. There was no observed anchoring device to either thigh. She stated she was not aware that his urinary catheter should be anchored to his thigh. She stated she was instructed to make sure his urinary bag was attached to his bed but not aware that his urinary bag should not be lying on the floor. NA #13 stated in the past when she was assigned Resident #20 she was only instructed to empty his urinary bag. She was not aware of how to perform his urinary catheter care or what to report to the nurse. In an interview on 07/18/17 at 10:38 AM, Nurse #2 stated Resident #20 was known to pull on his catheter and he rolled from side to side. She stated she had observed blood in in his urine on occasion. Nurse #2 stated the aides clean his catheter and she assessed his catheter daily to ensure there were no concerns. Nurse #2 stated the aides had not told her that his catheter was not anchored and not told her about any observed concerns to his penis or urethra. In an interview on 07/18/17 at 3:30 PM, Nurse #1 stated she started in January of 2017 and was assigned Resident #20 on 7/17/17 and thought he did not have a leg strap because it irritated his leg. She stated she did not assess his catheter insertion site or penis but expected the aides to report anything unusual to her. In an observation on 7/18/17 at 3:40 PM, Resident #20 was lying in a low bed with his urinary catheter bag attached to the right side of his bed frame resting on the floor In an observation and interview on 07/19/17 at 9:30 AM, NA #2 stated she had worked at the facility for one year and she was assigned Resident #20. During an observation of Resident #20 ' s catheter care, she cleaned around his urethra and cleaning his tubing. She did not attempt to clean the entirety of his penis. NA #2 was asked to further reveal his penis by pushing back his testicles and foreskin. Observed was a penile tear extending from the urethra down the underside of the shaft of his penis measuring approximately 2 inches in length. NA #2 stated his penis was not like that when he was admitted in November 2016. In an interview on 07/19/17 at 9:50 AM, Nurse #2 confirmed she looked at Resident #20 ' s penis daily. She stated she thought he had a small tear on his admission but it did not look like it did today. Nurse #2 stated his catheter was changed monthly on night shift and the penile tear should have been reported when it was observed during his catheter change. In an interview on 07/19/17 at 10:50 AM, Nurse #3 stated she worked third shift. She stated she thought Resident #20 had a small tear for awhile. She described it as a 2 centimeter ridge on his penis but she had not observed his penis in probably a month. She stated the other nurse who worked nights usually changed his urinary catheter. She confirmed Resident #20 ' s catheter was documented changed by the other night nurse on 7/17/17 on third shift. In a telephone interview on 07/19/17 at 3:10 PM, Nurse #6 confirmed she worked nights and worked third shift on 7/17/17. She stated she had changed Resident #20 ' s urinary catheter in the past but not recently. Nurse #6 was reminded she documented on his TAR she changed his urinary catheter Monday night on 07/17/17. Nurse #6 stated she did not change his catheter on 07/17/17 as documented. She was unable to offer an explanation as to why she initialed off on the TAR that she changed Resident #20 ' s urinary catheter when on interview, she stated she did not. She stated she thought she changed his urinary catheter a month or so ago and had observed pus and blood at his urethra but had not noted the penile tear. Nurse #6 stated Resident #20 pulled at his catheter and scratched himself to the genital area. She stated she was not aware he if he was to have a catheter securement device. A review of the facility incident logs on 7/16/17 at 4:00 PM from November 2016 to present included no intakes regarding any injury or change in Resident #20 ' s catheter insertion site at his urethra. In an interview on 7/19/17 at 4:20 PM, NA #14 stated it was her first day back on the 200-hall assignment after a 3-month rotation on another hall. The Director of Nursing (DON) and NA #14 were observed assessing Resident #20 ' s penis. The DON pulled back Resident #20 ' s foreskin and testicles to reveal the penile tear. NA #14 stated it wasn ' t like that 3 months ago. NA #14 stated he may have had some bleeding and maybe a little split but not like what it looks like now. The DON stated she was unable to recall if it had worsened since she last observed it a few weeks ago. There were no nursing notes again until 7/19/17 at 4:59 PM which read Resident #20 ' s urinary catheter was changed without difficulty. A nursing note dated 7/20/17 at 8:15 AM read Resident #20 ' s urinary catheter tubing was secured in place with a leg strap. In a telephone interview on 7/20/17 at 11:45 AM, the Urologist who saw Resident #20 on 6/26/17 stated due to the request of Resident #20 ' s RP, he did not see him in the hospital. The RP wanted him to go another urologist who was not near the facility. He stated he agreed to see Resident #20 on 06/26/17. The Urologist stated during the visit, he did not assess Resident #20 ' s penis, urethra and was not aware of a penile tear. He stated some penile erosion was expected from long term urinary catheter however a 2-inch tear would have been the result of trauma or the staff not ensuring the use of a leg strap to prevent the weight of the urinary bag tugging on his catheter. In a telephone interview on 07/21/17 at 9:45 AM, Resident #20 ' s physician stated it was her expectation that Resident #20 ' s urinary catheter be secured to prevent tension, changed as ordered and needed. She also stated it was her expectation that his catheter and insertion site be assessed daily and she be notified of any changes such as trauma or tearing to his penis or urethra. In an interview on 07/21/ at 10:40 AM, the Administrator stated her expectations were the same as Resident #20 ' s physician.

Based on observations staff interviews, and record review the facility's Quality Assessment and Assurance (QAA) Committee failed to maintain implemented procedures and monitor the interventions that the committee put into place in June, 2016 following a recertification survey and subsequently recited in July 2017 on the current recertification and complaint survey. The recited deficiencies were in the area of notification of change (F157) and provide services according to the care plan (282). The continued failure of the facility during two federal surveys of record show a pattern of the facility's inability to sustain an effective Quality Assurance (QA) Program. The Findings Included: This tag is cross referenced to F157- Based on observations, staff and physician interviews and record review, the facility failed to notify the physician for a change in condition of a urinary catheter insertion site (urethra) for 1 (Resident #20) of 1 residents reviewed for urinary catheters. F282-Based on observation, staff interview and record review, the facility failed to ensure a care planned intervention for securing a urinary catheter to prevent injury for 1 of (Resident #20) 1 reviewed for urinary catheters. The Administrator was interviewed on 7/21/17 at 11:21 AM. She stated that the QA committee met monthly. Her expectation was for the QA committee to meets monthly and identify areas of concern, do a root cause analysis and develop a plan and then audit and monitor that plan and then discuss the outcome.

Based on medical record review and staff interview the facility failed to update the care plan for effective interventions for 2 (Resident #9 and Resident #50) of 4 sampled residents with behaviors to prevent continued resident to resident physical altercations. (Resident #9 had physical altercations with Residents #2, #13, #29 and #67) over a period of 3 months. (Resident #50 had physical altercations with Resident #37 on two consecutive days resulting in injury. The Administrator was notified of Immediate Jeopardy on 4/24/14 at 1:30 PM. The IJ is present and ongoing. The jeopardy started on 1/31/14 with the second physical altercation between resident #50 and #37. The jeopardy started on 3/16/14 when the facility failed to manage Resident #9's behaviors and prevent the physical altercation between Residents #9 and #67. The findings included: 1. Resident #9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #9 required extensive assistance to complete activities of daily living (ADLs). The MDS further indicated Resident #9s physical behavioral symptoms toward others occurred 1 to 3 days. Verbal behavioral symptoms directed at others occurred daily. Resident #9 coded as severely cognitively impaired for daily decision making. The facility could not provide any further quarterly assessment beyond 11/22/13. Review of Resident #9 ' s care plan dated 6/11/13 revealed a problem of " [DIAGNOSES REDACTED]. " The goals included the resident would have no signs and symptoms of depression daily, like crying, refusal to eat etc. times 90 days. The approaches included providing 1 on 1 visits as needed, moving the resident to a different area and re-approaching as needed secondary to the resident cursing and other behaviors which were not easily redirected. Further review of Resident #9 ' s care plan updated 6/11/13 revealed a problem of, " cognition/communication: resident has memory deficits, alert and is able to comprehend simple information, may miss some facts, able to make her needs known to others: unable to make safe appropriate decisions; safety awareness and history of [MEDICAL CONDITION]. " The goals included accept judgment of staff/significant other as appropriate related to clothing and activities x 90 days and resident will be free of injury related to cognitive deficit x 90 days. The approaches included medications as ordered by physician, re-approach as needed, resident frequently resistive and combative to care, use different caregivers as indicated and needed, approach resident warmly and positively and in calm manner, calmly talk with resident and offer reassurance prior to initiating care, provide instruction to resident using clear voice, simple sentences, repeat as needed, monitor and document resident behavior and status, report any change in cognitive status to physician. The facility could not provide any updates or revisions to Resident #9 ' s care plan beyond 6/11/13. physician progress notes [REDACTED]. The nursing staff states that she has for the last month been more agitated and aggressive. She is noted at this time to be moderately agitated and she is upset about her parents who are not living. She is cursing and somewhat aggressive towards other residents however has not physically touched anyone. The note continued with, " the patient is on multiple medications for [MEDICAL CONDITION] disorders. She is on [MEDICATION NAME] (anti-anxiety) 15mg daily and is also on [MEDICATION NAME] (appetite stimulate) 15mg nightly and did increase this to 30mg daily. She is written for [MEDICATION NAME] (anti-anxiety) 0.25 mg every 12 hours PRN (as needed) anxiety and agitation. She is already on Klonopin (anti-anxiety) 1mg three times a day. Will otherwise follow as needed. " Review of Resident #9 ' s physician progress notes [REDACTED].#9 is having a little bit of issue with increased agitation, irritability, and mood and she is having quite a bit of weight gain and due to this, we are going to make some adjustment to her medications and see if we can improve things a little bit for her from that standpoint. " The physician note continued with due to increase mood disorder and weight gain; will decrease [MEDICATION NAME] (appetite Stimulant) from 30mg to 15mg nightly, and increase [MEDICATION NAME] (anti-anxiety) from 15mg to 20mg daily. Reassess and make other adjustments as needed. " Review of Resident #9 ' s physician progress notes [REDACTED]. She had a history of [REDACTED]. She had seen neurology recently who really did not feel that there were any other adjustments that can be made for her. The note continued with, " due to mood issues and weight gain, we adjusted her [MEDICATION NAME] down and [MEDICATION NAME] up and she seems to be doing well with that. " Review of physician progress notes [REDACTED]. " The note continued with, " The patient ' s overall condition is relatively stable except for increased behaviors and recent [MEDICAL CONDITION] found on labs. " Review of Resident #9 ' s physician progress notes [REDACTED]. The nursing staff states that recently she has had an increase in her behaviors with inappropriate language. It was request to repeat a BMP in four weeks, these results are not readily available for review at this time however we will have nursing staff obtain the results and if these are not obtained as of yet, will make sure that is done. " The note continued with, " the patient ' s overall condition relatively stable except for increase in behaviors and recent [MEDICAL CONDITION] found on labs. " Review of Resident #9 ' s medical record revealed a physician order [REDACTED]. " Review of Resident #9 ' s medical record revealed a physician order [REDACTED]. " Further review of Resident #9 ' s medical record revealed no consultation in regards to psychiatry. physician progress notes [REDACTED]. [MEDICATION NAME] was just adjusted within the last 2 to 3 weeks so therefore will hold steady with that. Continue with redirection and make other adjustments as needed. Need to be careful with adjustments on psychiatric medications due to her [MEDICAL CONDITION] medications. " Review of Resident #9 ' s Medication Administration Record [REDACTED]. Review of Resident #9 ' s MAR for the month of February 2014 revealed Resident #9 had received 9 [MEDICATION NAME] for increased anxiety. Further review of Resident #9 ' s medical record revealed a physician progress notes [REDACTED]. She has a history of difficult to control [MEDICAL CONDITION] disorder and is seeing neurology for that. Other issues have been stable. Her depression has been worse and [MEDICATION NAME] was adjusted and she seems to be doing better. " Record review for Resident #9 ' s nursing notes documented episodes of combative behaviors with staff and physical aggressive behaviors directed towards other residents for the dates of 1/13, 1/16, 1/23, 2/17, 2/18, 2/20, 2/21, 2/22, 2/23, ?, 3/11, 3/16 and 3/24/14. Review of Incident report dated 3/16/14 indicated Resident #67 was kicked by Resident #9 during an altercation in the hallway. The description of occurrence indicated Resident #67 was involved in altercation with anther resident in the hall-way. One resident started to kick the other resident, resulting in an injury to resident #67 ' s left lower leg. Review of Resident #9 ' s MAR for the month of March 2014 revealed Resident #9 received [MEDICATION NAME] 12 times for increased anxiety. Interview with the Social Worker on 4/3/14 at 11:10 am revealed she did not update care plans in regards to behaviors or specifics interventions to behaviors. The Social Worker further indicated that she was not aware that Resident #9 was involved in a physical altercation with Resident #67. Interview with the Director of Nursing (DON) on 4/3/14 at 1:18 PM revealed the care plan was updated by a submitted pink slip. The DON further indicated that Resident #9 ' s care plan should have been updated quarterly and should have further indicated specific interventions associated with Resident #9 ' s episodes of aggression toward other residents. The DON indicated she and nursing were responsible for care plan updates. The MDS nurse position was vacant, and the DON was updating the care plans until one was hired. Interview with the Administrator on 4/3/14 at 8:38 am revealed she was unaware of the increase in aggressive behaviors Resident #9 exhibited to other residents within the facility and indicated it was her expectation that new interventions be included to Resident #9 ' s care plan. 2. Resident #50 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the initial Minimum Data Set ((MDS) dated [DATE], indicated Resident #50 was not ambulatory, had no behaviors, and experienced difficulty concentrating some of the time. This MDS indicated she had problems with long and short term memory and was unable to make decisions. The medication used during this assessment period was an antidepressant. The care plan for Resident #50, dated 10/8/13 addressed a problem of " Alteration in cognitive status due to Dementia. " The stated goal included staff would assist in meeting the resident ' s needs related to cognitive status. The approaches for staff to use included redirection when behaviors were exhibited due to confusion and dementia, administer medications as ordered and notify MD of any progressive changes in dementia. There were no updates to this care plan after October for review. Review of a physician ' s progress note for Resident #50, dated 10/16/13 revealed Resident #50 had some "problems with aggression and behaviors mostly in the mornings more so recently. She otherwise was pleasant at times. [MEDICATION NAME] .5mg (milligrams) was ordered to be given every morning. " [MEDICATION NAME] was an antianxiety medication. The next MDS available for review for Resident #50, dated 1/7/14 and was a significant change (SC) MDS. Changes were assessed in the areas of behavior that included physical behavioral symptoms directed toward others that occurred one to three days a week. This MDS assessment of the Impact on Resident " indicated the " identified symptom put the resident at significant risk for physical illness or injury, significantly interfered with the resident ' s care, and put others at significant risk for physical injury " was answered as " Yes. " The SC MDS indicated Resident #50 ' s behaviors were " worse " than the prior MDS assessment. Resident #50 required limited assistance by staff for transfers, extensive assistance with walking in the hallway, locomotion off the unit and bed mobility. She was able to move about the unit with limited assistance by staff. Medications used during the assessment period were an antianxiety and an antidepressant. Review of the Care Area Assessments (CAAS) dated 4/4/14 for cognition included Resident #50 had severe cognitive deficits with a [DIAGNOSES REDACTED]. The resident had short and long term memory impairment with severe impairment with daily decision making abilities. Resident #50 had to be redirected by staff, needed supervision and reminders from staff and had a prior level of care in a secured memory care unit. No wandering episodes were present during that assessment. Review of the CAAS for psychosocial well being included a history of depression and a SC in mood. The family was supportive and visited on regular basis. The resident propelled herself in facility but did not have a self destination. The medications were for depression and anxiety. The care plan for Resident #50 did not address the changes in moods and behaviors after the Significant Change MDS was completed. The nurse ' s note dated 1/30/14 at 10:00 PM indicated Resident #50 had " Some combative (combativeness) this evening. Redirected. " Review of the " Incident/Accident Report for Resident #50 dated 1/31/14 at 1:20 PM revealed an altercation occurred between Residents #50 and #37. The nurse heard noises from the residents ' room and observed the two residents " swatting " at each other. The nurse removed the residents from the situation, Resident (#50) removed from room and gave activity to help. The measures to prevent reoccurrence included " redirected resident to an activity (baby doll). The additional comments included staff to continue frequent rounds and redirect resident to activity such as baby doll. Resident #50 had no injuries noted. The nurse ' s note for dated 2/1/14 at 11:00 AM revealed Resident #50 was up in her wheelchair, saying to her roommate, " You be quiet. " Resident #50 was " agitated at roommate for talking. " (At that time, Resident #50 had been in a new room, on a different hallway from Resident #37 and was yelling at her new roommate.) According to the staff assignment sheet, this nurse ' s note was signed by the nurse on the 100 hall (new location of Resident #50). Interview with the Social Worker on 4/25/14 at 10:21 AM revealed she was not aware of changes in Resident #50 ' s mood and behaviors at the time the significant change MDS was completed. Chart review by the Social Worker revealed she had resisted care, was physically aggressive with staff. Continued interview revealed nothing would be changed on the care plan for moods and behaviors. Further interview revealed the Social Worker completes the mood and behavior section of the MDS, but she does not know there is a significant change MDS until the MDS nurse informs her. The MDS nurse completes a care plan for moods and behaviors. During the interview, the social worker explained her (Resident #50) moods and behaviors have been the same, she is very confused. Resident #50 was moved from memory care unit due to a fall and was admitted to the nursing home after a total hip repair was performed. The Social Worker was not aware what the diagnosis " mental disorder " included. Resident #50 had Alzheimer ' s disease and dementia according to the social worker. Interview with the Director of Nursing (DON) on 4/25/14 at 3:30 PM revealed she was completing the MDS and care plans prior to becoming the DON. In the absence of an MDS nurse, she continued to complete the MDS assessments and do care plan updates. She thought she had included the behaviors of physical aggression of Resident #50 in her note. The explanation provided by the DON was she " missed those behaviors when she went through and tried to update the care plans. "

Based on medical record review, resident interviews, physician assistant and staff interviews the facility failed to manage inappropriate behaviors and implement effective interventions for 2 (Resident #9 and Resident #50) of 4 sampled residents with behaviors to prevent continued resident to resident physical altercations. (Resident #9 had physical altercations with Residents #2, 13, #29 and #67) over a period of 3 months. (Resident #50 had physical altercations with Resident #37) on two consecutive days resulting in injury. The findings included: The Administrator was notified of Immediate Jeopardy on 4/24/14 at 1:30 PM. The IJ is present and ongoing. The jeopardy started on 1/31/14 with the second physical altercation between resident #50 and #37. The jeopardy started on 3/16/14 when the facility failed to manage Resident # 9's behaviors and prevent the physical altercation between Residents #9 and #67. Validation of the facility ' s credible allegation was conducted on 5/12/14. Residents on all halls (100, 200, and 300) in the facility records were reviewed and observations were conducted on those residents who had exhibited aggressive behaviors towards other residents. The observations included interventions associated with behaviors, change in condition, staff reporting/communication process from[***]to shift, staff documentation of observed behaviors resulting in injury in accordance with the facility newly developed policy and procedure, " Resident-to-Resident Altercations " . Record reviews were completed to verify the implantation of the assessment tools and the functional process of staff communication regarding resident to resident altercations. Staff interviews were conducted with all three shifts to verify the implementation of the newly developed policy " Resident-to-Resident Altercations " dated 4/2014 that included guidelines for implementation of interventions specifically related to how to deal with resident to resident alterations and how to deal with resident with aggressive behaviors. The facility executed a contract 4/25/2014 with a consulting psychiatrist to provide in-facility outpatient psychiatric consults. Direct care, and management staff interviews were conducted to verify current staff and agency staff had been in-serviced in the new systemic change and protocols. The completion date for all in-service for nursing and nursing assistance become effective 4/26/14 per the credible allegation. The quality assurance audit reports were reviewed along with all supportive documentation of the credible allegation of compliance, to verify the implementation of the facility ' s credible allegation of compliance. The survey found that immediate jeopardy was removed for the area of preventing resident-to-resident altercations (323) on 5/1/14. The facility remains out of compliance at the E level (the most serious deficiency to be a pattern deficiency that constitutes no actual harm with potential for more than minimal harm that is not immediate jeopardy), to implement monitoring systems and complete employee education. 1. Review of the facilities policy for psychiatric episodes indicated residents who exhibit acute psychiatric symptoms that threatens the well-being of that resident or others, will be evaluated for discharge to a psychiatric crisis center for evaluation. The procedures included 1) the attending physician will be notified once a resident has exhibited behavior that threatens the well-being of himself or others. 3) less severe outbursts may be handled by a psychiatrist on either an in or outpatient basis 4) until a resident who needs immediate discharge can be moved out, move the resident to an area where he is not able to injure himself or others and 8) document the episode. Resident #9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #9 required extensive assistance to complete activities of daily living (ADLs). The MDS further indicated Resident #9 ' s physical behavioral symptoms toward others occurred 1 to 3 days. Verbal behavioral symptoms directed at others occurred daily. Resident #9 coded as severely cognitively impaired for daily decision making. The facility could not provide any further quarterly assessment beyond 11/22/13. Review of Resident #9's care plan dated 6/11/13 revealed a problem of " [DIAGNOSES REDACTED]. " The goals included the resident would have no signs and symptoms of depression daily, like crying, refusal to eat etc. times 90 days. The approaches included providing 1 on 1 visits as needed, moving the resident to a different area and re-approaching as needed secondary to the resident cursing and other behaviors which were not easily redirected. Further review of Resident #9 ' s care plan updated 6/11/13 revealed a problem of, " cognition/communication: resident has memory deficits, alert and is able to comprehend simple information, may miss some facts, able to make her needs known to others: unable to make safe appropriate decisions; safety awareness and history of seizures." The goals included accept judgment of staff/significant other as appropriate related to clothing and activities x 90 days and resident will be free of injury related to cognitive deficit x 90 days. The approaches included medications as ordered by physician, re-approach as needed, resident frequently resistive and combative to care, use different caregivers as indicated and needed, approach resident warmly and positively and in calm manner, calmly talk with resident and offer reassurance prior to initiating care, provide instruction to resident using clear voice, simple sentences, repeat as needed, monitor and document resident behavior and status, report any change in cognitive status to physician. The facility could not provide any updates or revisions to Resident #9's care plan beyond 6/11/13. physician progress notes [REDACTED]. The nursing staff states that she has for the last month been more agitated and aggressive. She is noted at this time to be moderately agitated and she is upset about her parents who are not living. She is cursing and somewhat aggressive towards other residents however has not physically touched anyone. The note continued with, " the patient is on multiple medications for seizure disorders. She is on Lexapro (anti-anxiety) 15mg daily and is also on Remeron (appetite stimulate) 15mg nightly and did increase this to 30mg daily. She is written for Ativan (anti-anxiety) 0.25 mg every 12 hours PRN (as needed) anxiety and agitation. She is already on Klonopin (anti-anxiety) 1mg three times a day. Will otherwise follow as needed. " Review of Resident #9's physician progress notes [REDACTED].#9 is having a little bit of issue with increased agitation, irritability, and mood and she is having quite a bit of weight gain and due to this, we are going to make some adjustment to her medications and see if we can improve things a little bit for her from that standpoint. " The physician note continued with due to increase mood disorder and weight gain; will decrease Remeron (appetite Stimulant) from 30mg to 15mg nightly, and increase Lexapro (anti-anxiety) from 15mg to 20mg daily. Reassess and make other adjustments as needed. " Review of Resident #9's physician progress notes [REDACTED]. She had a history of [REDACTED]. She had seen neurology recently who really did not feel that there were any other adjustments that can be made for her. The note continued with, " due to mood issues and weight gain, we adjusted her Remeron down and Lexapro up and she seems to be doing well with that. " Review of Resident #9's physician progress notes [REDACTED]. The nursing staff states that recently she has had an increase in her behaviors with inappropriate language. It was request to repeat a BMP (basic metabolic panel/lab) in four weeks, these results are not readily available for review at this time however we will have nursing staff obtain the results and if these are not obtained as of yet, will make sure that is done." The note continued with, " the patient's overall condition relatively stable except for increase in behaviors and recent hypernatremia found on labs. " Review of Resident #9's medical record revealed a physician order [REDACTED]. " Review of Resident #9's medical record revealed a physician order [REDACTED]. " Further review of Resident #9 ' s medical record revealed no consultation in regards to psychiatry. A review of Resident #9's nurse's note revealed Resident #9 had episodes of aggression towards other residents in the facility. Nursing note dated 1/13/14 said, " Continues to curse when anyone walks by her in hallway. Starting to kick, PRN (as needed) anxiety med given. Still talking to people not there." Nursing note dated 1/16/14 said, " Remains out in hallway cursing, has continued to try to kick at other residents when they get close to her. " physician progress notes [REDACTED]. Lexapro was just adjusted within the last 2 to 3 weeks so therefore will hold steady with that. Continue with redirection and make other adjustments as needed. Need to be careful with adjustments on psychiatric medications due to her seizure medications. " Nursing note dated 1/23/14 indicated, " Resident currently resting quietly in bed with eyes closed. Earlier in shift attempted to kick another resident stating, " Move out of the way s .... a... " Redirected to another area. " Review of Resident #9's medication administration record (MAR) for the month of January 2014 revealed Resident #9 had received 12 Ativan for increased anxiety. -Nursing note dated 2/17/14 at 8:00 PM said, " Continues with behaviors of cursing and kicking in halls, redirected and environment changes, Unsuccessful. " -Nursing note 2/18/14 at 8:00 PM said, " was cursing in hallway and was going to come in contact with another resident. Environment changed and was redirected. " -Nursing note dated 2/20/14 at 7:00 PM revealed, " One episode of kicking and cursing in hallway. Taken to room to change environment. " -Nursing note dated 2/21/14 at 4:00 PM revealed Resident #9 was cursing and kicking in hallway and had to be brought back to her room. -Nursing note dated 2/22/14 at 6:50 AM said, " resident quiet all shift until arising. After toileting she become abusive to other staff and residents yelling, " you s .... a.., you s ... a.. " over and over attempting to kick another resident rolling by with wheelchair. " Returned to room when she continued to be verbally abusive until taken to dining room for breakfast. " -Nursing note dated 2/23/14 at 1:15 PM indicated, " able to propel self up and down halls. Tries to kick staff and residents. " Review of Resident #9's MAR for the month of February 2014 revealed Resident #9 had received 9 Ativan for increased anxiety. Further review of Resident #9's medical record revealed a physician progress notes [REDACTED]. She has a history of difficult to control seizure disorder and is seeing neurology for that. Other issues have been stable. Her depression has been worse and Lexapro was adjusted and she seems to be doing better. " -Nursing note (Resident #9) dated 3/4/14 at 1:15 PM at said, " patient up in wheelchair in hallway. Has been cursing and hollering all day. Kicked at other patients and staff. Slid down in wheelchair and had to be pulled up several times. " -Nursing note (Resident #9) dated 3/11/14 at 2:40 PM revealed, " Resident #9 very combative this pm, was given prn ativan at pm. She was hitting, kicking and trying to bite other resident and staff. She was redirected to her room where she finally calmed down and took a nap. " -Nursing note (Resident #9) dated 3/16/14 at 2:40 PM said, " Resident #9 involved in a physical altercation of kicking another resident (Resident #67) in hallway. Resident redirect to another activity. " -Nursing note (Resident #9) dated 3/24/14 at 3:00 PM dictated, " alert, confused, place and time and events. Continue to curse at staff at intervals will kick at staff and residents. " Review of incident report dated 3/16/14 indicated Resident #67 was kicked by Resident #9 during an altercation in the hallway. The description of occurrence indicated Resident #67 was involved in altercation with another resident in the hallway. One resident started to kick the other resident, resulting in an injury to resident #67 ' s left lower leg. The measures to prevent further occurrence indicated, Resident #67 will be separated from the resident in question (Resident #9) at all times. Review of Resident #9's MAR for the month of March 2014 revealed Resident #9 received Ativan 12 times for increased anxiety. Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent MDS assessment dated [DATE] indicated Resident #2 required no assistance with locomotion on and off the unit. Resident #2 coded as cognitively intact as evidenced by a (Brief Interview Mental Score) BIM ' s score of 13. Interview with Resident #2 on 4/3/14 at 3:08pm revealed Resident #9 would kick other residents when she was in the hallway. Resident #2 indicated that Resident #9 had been kicked by Resident #9 a couple of times since his admission to include as early as last week. Resident#2 revealed staff (name unknown) did observe Resident #9 kick him. Resident #2 continued that following Resident #9 kicking him, staff moved Resident #9 further down the hall and talked to her for a little bit. Resident #2 stated that he was not hurt as a result of Resident #9 kicking him. Resident #2 indicated that Resident #9 kicked and hit staff as well as other residents that are on the hall without warning. Resident #2 further stated that he was able to propel his own wheelchair and could avoid encounter with Resident #9 by moving out of her way. The facility could not provide any documentation in regards to Resident #9 kicking resident #2. Resident #29 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent MDS assessment dated [DATE] indicated Resident #29 was independent with locomotion off and off the unit. Resident #2 coded as cognitively intact as evidenced by as BIM ' s score of 15. Interview with Resident #29 on 4/3/14 at 3:33 pm revealed Resident #9 would hit and kick residents in the hallway. The resident indicated that the resident #9 had kicked him once before although he could not remember the date. Resident #29 stated staff were aware that the resident kicked and hit at other residents. Resident #9 would become aggressive without warning and it occurred several times weekly. Staff would sometimes observe Resident #9 kick residents and sometimes they did not observe Resident #9 kicking other residents. Resident #29 continued that staff would take Resident #9 to her room when she began kicking and cursing or would move her to another end of the hall away from other residents. Resident #9 would eventually return and continue the same behavior. Resident #29 stated he moves out of Resident #9 ' s way when she passes him in the hallway to prevent Resident #9 from kicking him. Resident #29 stated, " you have to just stay out of kicking distance. " Interview with NA #1 on 4/2/14 at 5:00 pm indicated Resident #9 would become aggressive with other residents in the facility. NA#1 continued that Resident #9 would attempt to kick or hit residents when they passed her by in the hallway. Resident #9 would display aggressive behaviors without warning and not expected. Nursing staff indicated that when resident #9 would become aggressive, staff would attempt to talk to the resident, provide redirection, and remove other residents out of Resident #9 ' s reach. Resident #9's behaviors occurred from 4 to 5 times a week. Resident #9 would occasionally enter other residents ' rooms. NA#1 recalled she had observed Resident #9 having an altercation with Resident # 13 in the doorway of Resident #13 ' s room. Resident #9 was observed to kick Resident #13 about 2 months ago (actual date unknown). NA#1 indicated she recalled separating Resident #9 and Resident #13. NA#1 could not recall if she communicating the incident to nursing. Following the incident NA#1 stated, " I think I took her to her room to calm down. " NA #1 continued with Resident #9 was usually provided an Ativan when attempts to relocating or redirect were unsuccessful. Resident #13 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the most recent MDS assessment dated [DATE] indicated Resident #13 was coded as moderately impaired as evidence of a BIM ' s score of 7. Interview with the Social Worker on 4/3/14 at 11:10 am revealed if an incident was witnessed on the hall the NAs were to report the findings to nursing. The Social Worker indicated that patients at risk are discussed weekly in meetings that include medication changes and behaviors. The social worker indicated that she would only get involved with the resident's behavior concerns in the instance it was an emergency situation involving another resident or in the instance there was an injury. She would also get involved with a resident in the instance the behavior was not improving and inpatient services would be sought. Resident #9 would occasionally kick her feet at anyone who walks by. The social worker revealed she was unaware that Resident #9 had an order for [REDACTED].#9 had an order for [REDACTED]. The social worker further indicated that she was unaware Resident #9 was involved in a physical altercation with Resident #67. In the instance she was aware of the altercation she would have followed up the resident and documented her actions. The Social Worker continued with incident reports were not provided to her for review involving resident to resident aggression. Interview with Nurse #3 on 4/3/14 at 11:19 am indicated Resident #9 had exhibited behaviors that included hitting, kicking, and cursing at staff and residents in the facility. Nurse #3 indicated that in the instance Resident #9 became aggressive with other residents staff would remove the resident to a different activity. Nurse #3 stated that resident #9 could be very aggressive and at times she was difficult to calm. Nurse #3 indicated that Resident #9 ' s triggers for the exhibited behaviors were unknown. Nurse #3 revealed when attempts to calm Resident #9 failed Resident #9 was provide with a PRN (as needed) ativan. Interview with Nurse #4 on 4/3/14 at 1:27 pm revealed she completed an incident report for Resident #67 on 3/16/14. Nurse #4 revealed the incident was communicated by a member of the physical therapy (name unknown). Nurse #4 stated that the PT staff stated Resident #9 had kicked Resident #67. Nurse #4 indicated she completed an incident report on Resident #67 due to resident #67 receiving a skin tear. Nurse #67 indicated the incident occurred after lunch when Resident #9 and Resident #67 were coming back from the dining room after lunch. Nurse #4 described Resident #9's behaviors as verbal and physical. Nurse #4 revealed staff was to retrieve a nurse when Resident #9 was exhibiting behaviors. Nursing staff would normally redirect Resident #9 to another activity or take Resident #9 to another area to talk. Interview with Physical Therapist (PT) #1 on 4/24/14 at 4:02 pm revealed she did communicate Resident #9 and Resident #67 were arguing with each other. PT #1 revealed she heard the two residents when she was headed to the nursing station from the PT department. Resident #9 was observed to be kicking her legs in the direction of Resident #67. It was not known whether the resident was attempting to turn her chair around or if Resident #9 was actually kicking Resident #67. The PT continued that a nurse (name unknown) was coming toward the commotion. At that time the PT#1 indicated that she communicated to the nurse passing her in the hall that it there Resident #9 and Resident #67 were arguing. PT #1 indicated that she was unaware that an injury occurred with Resident #67. PT#1 indicated she does not typically separate residents; she would retrieve nursing staff to deal with behavioral concern. Interview with Nurse #5 on 4/3/14 at 2:53 pm revealed she was made aware of the incident that occurred on 3/16/14 by Nurse #4. Nurse #5 indicated Resident #9 exhibited behaviors such as kicking and cursing at staff and other residents. Nurse #5 revealed staff would move Resident #9 when she would become agitated and attempted to aggress towards other residents. Nurse #5 indicated Resident #9 independently propel her wheelchair and did occasional enter other resident's rooms. Nurse #5 revealed Resident #9 had become aggressive with Resident #13 a couple of times as evidenced by trying to kick her. Nurse #5 indicated that she only does incident reports that result in harm not attempt to harm. Interview with Nurse #6 on 4/24/14 at 3:41 pm revealed a transportation form is provided by nursing to the transportation aide. Nurse #6 indicated she was responsible for ensuring resident ' s physician orders [REDACTED]. Nursing staff would provide a transportation slip to transportation staff and transportation would schedule appointments. Transportation staff would then ensure a consultation report is brought back following the appointment. Nurse #6 revealed she was unsure why there was a laps in the scheduling of Resident #9's psych appointment. Nurse #6 indicated Resident #9 did aggress toward other residents in the facility. Nurse #6 indicated that redirection was not always successful. Nurse #6 further indicated that Resident #9 was moved from the situation, resident #9 would return to the hall and continue the aggressive behaviors. Resident #9 typically " showed out " in the hallways but did occasionally propel her wheelchair in other resident ' s rooms. Interview with the Director of Nursing (DON) on 4/3/14 at 1:18pm revealed Resident #9's behaviors varied at different times of the day. The DON recalled attempting to redirect Resident #9 herself which resulted in Resident #9 attempting to hit the DON. The DON indicated that occasionally Resident #9 could be redirected or diverted. The DON further indicated that she was not aware of the incident dated 3/16/14 in which Resident #9 aggressed towards Resident #67. Interview with the facility Physician Assistant (PA) on 4/3/14 at 3:43 pm indicated that it was communicated to her by facility staff that Resident #9 was exhibiting behaviors such as physical and verbal aggression towards others. The PA further indicated that she had witnessed Resident #9 reach out in an attempt to hit residents in her way. Psychiatric services were recommended due to Resident #9 ' s use of seizure mediations and adjustments to current medications had been attempted. It was the expectation of the PA that Resident #9 be seen as soon as an appointment could be made. The PA was unaware that Resident #9 had not received a consultation from a psychiatrist. The PA was unaware of the incident that occurred on 3/16/14 and further indicated she was not aware of an increase in Resident #9's behaviors. Interview with the administrator on 4/3/14 at 8:38 am revealed it was her expectation that Resident #9's physician order [REDACTED]. Due to the increase in Resident #9's verbal and physical outburst, an appointment should have been followed up with. The Administrator was unaware of the increase in aggressive behaviors Resident #9 exhibited to other residents within the facility and indicated it was her expectation that new interventions be included to Resident #9's care plan. 2. Review of the policy : " Psychiatric Episodes " with a revised date of 10/2006 revealed " Residents who exhibit acute psychiatric symptoms that threatens the well-being of that resident or others, will be evaluated for discharge to a psychiatric crisis center for evaluation. The " Procedure " included ... " 3. Less severe outbursts may be handled by a psychiatrist on either an in or outpatient basis. 4. Until a resident who needs immediate discharge can be moved out, move the resident to an area where he is not able to injure himself or others .... 8. Document episode. " Resident #50 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the initial Minimum Data Set ((MDS) dated [DATE], indicated Resident #50 was not ambulatory, had no behaviors, and experienced difficulty concentrating some of the time. This MDS indicated she had problems with long and short term memory and was unable to make decisions. The medication used during this assessment period was an antidepressant. The care plan for Resident #50, dated 10/8/13 addressed a problem of " Alteration in cognitive status due to Dementia. " The stated goal included staff would assist in meeting the resident ' s needs related to cognitive status. The approaches for staff to use included redirection when behaviors were exhibited due to confusion and dementia, administer medications as ordered and notify MD of any progressive changes in dementia. There were no updates to this care plan after October for review. Review of a physician's progress note for Resident #50, dated 10/16/13 revealed Resident #50 had some "problems with aggression and behaviors mostly in the mornings more so recently. She otherwise was pleasant at times. Ativan .5mg (milligrams) was ordered to be given every morning. " Ativan was an antianxiety medication. The next MDS available for review for Resident #50, dated 1/7/14 and was a significant change (SC) MDS. Changes were assessed in the areas of behavior that included physical behavioral symptoms directed toward others that occurred one to three days a week. This MDS assessment of the Impact on Resident " indicated the " identified symptom put the resident at significant risk for physical illness or injury, significantly interfered with the resident ' s care, and put others at significant risk for physical injury " was answered as " Yes. " The SC MDS indicated Resident #50 ' s behaviors were " worse " than the prior MDS assessment. Resident #50 required limited assistance by staff for transfers, extensive assistance with walking in the hallway, locomotion off the unit and bed mobility. She was able to move about the unit with limited assistance by staff. Medications used during the assessment period were an antianxiety and an antidepressant. Review of the Care Area Assessments (CAAS) dated 4/4/14 for cognition included Resident #50 had severe cognitive deficits with a [DIAGNOSES REDACTED]. The resident had short and long term memory impairment with severe impairment with daily decision making abilities. Resident #50 had to be redirected by staff, needed supervision and reminders from staff and had a prior level of care in a secured memory care unit. No wandering episodes were present during that assessment. Review of the CAAS for psychosocial well being included a history of depression and a SC in mood. The family was supportive and visited on regular basis. The resident propelled herself in facility but did not have a self destination. The medications were for depression and anxiety. The care plan for Resident #50 did not address the changes in moods and behaviors after the Significant Change MDS was completed. Review of a physician ' s note for Resident #50, dated 1/7/14 revealed no mention of problems with behaviors or combativeness. The 1/30/14 incident for Resident #50 was not available for review. The nurse's note dated 1/30/14 at 10:00 PM indicated Resident #50 had " Some combative (combativeness) this evening. Redirected. " Resident #37's initial admission to the facility was on 6/19/13 with [DIAGNOSES REDACTED]. Record review revealed Resident #37 was hosptalized on [DATE]- 9/11/13 secondary to agitation and aggressive behaviors. Her behaviors were described as being aggressive and fighting with nurses. Resident #37 received psychiatric care at the hospital and was discharged back to the facility on [DATE]. Review of the admission MDS dated [DATE]for Resident #37 indicated she had short and long term memory impairment and moderate impairment with daily decision making abilities. Her moods were identified as being short tempered which occurred several days and behaviors were hallucinations, delusions and verbal. This MDS indicated the verbal behaviors did not impact the resident or others. Resident #37 was independent with bed mobility, transfers and eating. She required limited assistance for ambulating and supervision with moving about on and off the unit. Medications used during this assessment period included antipsychotics for the past 7 days and an antidepressant for the past 7 days. The care plan for Resident #37 dated 9/18/13 indicated a problems of dementia and behaviors listed as episodes of becoming combative, hitting staff, threw water on staff, chased staff out of room and frequently cursing at caregivers. Problems of anxiety and depression were also listed. The approaches included staff was to approach warmly, redirect resident when first onset of behavioral problems, consult Paradigm mental Health Services, provide activities, and monitor behavior. The quarterly MDS dated [DATE] for Resident #37 when compared to the admission MDS, indicated no changes in memory, cognition or daily decision making abilities. Behaviors were assessed as hallucinations and delusions. There were no verbal behaviors and no short tempered moods. Resident #37 remained the same with her physical functioning abilities. The medications remained unchanged from the admission MDS with antipsychotic and antidepressant medications received for 7 days during the assessment period. Review of the " Incident/Accident Report for Resident #37 dated 1/30/14 at 6:00 PM revealed an incident had occurred in the room between Residents #37 and #50. The nurse responding heard yelling from the room, entered the room and both residents were yelling at each other. Resident #37 had a skin tear under the right side of the jaw, fingernail marks on the left forearm and a " very pale light purple color under left eye. " Resident #37 was quoted by the nurse as saying " See where she (resident #50) scratched and hit me? " The report indicated the measures to prevent reoccurrence inclu